| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
37 |
26 |
$475.36 |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
16 |
12 |
$247.10 |
| A4253 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
28 |
24 |
$38.87 |
| 90694 |
|
35 |
35 |
$27.72 |
| 90686 |
|
17 |
17 |
$7.43 |
| B4150 |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
191 |
130 |
$0.00 |
| 90480 |
|
62 |
62 |
$0.00 |
| G0008 |
Administration of influenza virus vaccine |
67 |
67 |
$0.00 |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
145 |
116 |
$0.00 |
| 91322 |
|
62 |
62 |
$0.00 |