| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4927 |
Gloves, non-sterile, per 100 |
566 |
552 |
$22K |
| S9999 |
Sales tax |
2,029 |
1,952 |
$21K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
176 |
175 |
$21K |
| T4541 |
Incontinence product, disposable underpad, large, each |
366 |
354 |
$14K |
| T4537 |
Incontinence product, protective underpad, reusable, bed size, each |
247 |
247 |
$10K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
96 |
96 |
$8K |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
25 |
25 |
$3K |
| 0012A |
|
255 |
255 |
$0.00 |
| 0064A |
|
247 |
247 |
$0.00 |
| 90674 |
|
26 |
26 |
$0.00 |
| 0134A |
|
81 |
81 |
$0.00 |
| 90480 |
|
298 |
298 |
$0.00 |
| 0031A |
|
156 |
156 |
$0.00 |
| 90694 |
|
35 |
35 |
$0.00 |
| G0009 |
Administration of pneumococcal vaccine |
31 |
31 |
$0.00 |
| G0008 |
Administration of influenza virus vaccine |
382 |
382 |
$0.00 |
| 90677 |
|
31 |
31 |
$0.00 |
| 0011A |
|
268 |
268 |
$0.00 |
| 90686 |
|
95 |
95 |
$0.00 |
| 90656 |
|
78 |
78 |
$0.00 |
| 91320 |
|
40 |
40 |
$0.00 |
| 90653 |
|
59 |
59 |
$0.00 |
| 91322 |
|
240 |
240 |
$0.00 |
| 0003A |
|
46 |
46 |
$0.00 |
| 0004A |
|
12 |
12 |
$0.00 |
| 0054A |
|
42 |
42 |
$0.00 |
| 0124A |
|
25 |
25 |
$0.00 |
| 90662 |
|
12 |
12 |
$0.00 |