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