| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| 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 |
12 |
12 |
$936.66 |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
17 |
12 |
$742.22 |
| A4927 |
Gloves, non-sterile, per 100 |
22 |
12 |
$507.89 |
| 90688 |
|
14 |
14 |
$256.20 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
14 |
14 |
$186.20 |
| 91313 |
|
12 |
12 |
$0.00 |
| 90687 |
|
16 |
16 |
$0.00 |
| 0013A |
|
12 |
12 |
$0.00 |
| 91301 |
|
12 |
12 |
$0.00 |
| G0008 |
Administration of influenza virus vaccine |
17 |
17 |
$0.00 |