| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T4528 |
Adult size pull-on xl |
1,214 |
810 |
$89K |
| T4526 |
Adult size pull-on med |
340 |
281 |
$24K |
| T4527 |
Adult size pull-on lg |
309 |
232 |
$20K |
| A4239 |
Non-adju cgm supply allow |
56 |
55 |
$3K |
| A6530 |
Compression stocking bk18-30 |
42 |
38 |
$1K |
| T4524 |
Adult size brief/diaper xl |
15 |
12 |
$1K |
| T4535 |
Disposable liner/shield/pad |
17 |
13 |
$1K |
| A4253 |
Blood glucose/reagent strips |
228 |
211 |
$647.08 |
| 0134A |
|
120 |
120 |
$540.65 |
| 90686 |
|
187 |
186 |
$306.02 |
| 91322 |
|
287 |
281 |
$291.84 |
| G0008 |
Admin influenza virus vac |
395 |
385 |
$254.99 |
| 90662 |
|
192 |
184 |
$146.80 |
| 90480 |
|
285 |
279 |
$122.72 |
| 0124A |
|
28 |
28 |
$111.76 |
| Q0513 |
Disp fee inhal drugs/30 days |
15 |
15 |
$72.60 |
| J7620 |
Albuterol ipratrop non-comp |
19 |
12 |
$26.55 |
| 0064A |
|
41 |
41 |
$0.00 |
| 90677 |
|
14 |
13 |
$0.00 |
| M0201 |
Pne flu hepb cov home admin |
97 |
95 |
$0.00 |