| Code | Description | Claims | Beneficiaries | Total Paid |
| G0463 |
Hospital outpt clinic visit |
78,456 |
65,444 |
$12.53M |
| 99213 |
|
65,058 |
59,783 |
$5.21M |
| 90834 |
|
30,150 |
20,306 |
$4.89M |
| 99214 |
|
41,985 |
39,596 |
$3.80M |
| 99284 |
|
18,780 |
17,480 |
$2.66M |
| 99283 |
|
16,442 |
15,783 |
$2.20M |
| 96361 |
|
6,084 |
5,446 |
$1.50M |
| 36415 |
|
47,980 |
42,063 |
$1.47M |
| 45385 |
|
780 |
768 |
$1.26M |
| 70450 |
|
3,767 |
3,678 |
$1.17M |
| 11042 |
|
8,317 |
3,156 |
$1.06M |
| 80048 |
|
21,598 |
18,686 |
$1.05M |
| 74177 |
|
3,943 |
3,849 |
$974K |
| 96365 |
|
3,969 |
3,197 |
$933K |
| 80053 |
|
38,481 |
35,500 |
$907K |
| 99285 |
|
6,191 |
5,908 |
$784K |
| G0397 |
Alcohol/subs interv >30 min |
5,186 |
2,830 |
$724K |
| 45380 |
|
553 |
545 |
$711K |
| 45378 |
|
366 |
356 |
$701K |
| 43239 |
|
825 |
814 |
$674K |
| 99203 |
|
4,894 |
4,840 |
$577K |
| 90832 |
|
3,861 |
2,978 |
$575K |
| 87633 |
|
4,784 |
4,658 |
$574K |
| 99282 |
|
3,172 |
3,105 |
$556K |
| 96366 |
|
2,329 |
1,567 |
$552K |
| 93976 |
|
1,864 |
1,819 |
$536K |
| 71275 |
|
1,596 |
1,573 |
$535K |
| 81025 |
|
2,446 |
2,398 |
$528K |
| 59025 |
|
2,289 |
1,527 |
$525K |
| 87798 |
|
12,672 |
12,135 |
$524K |
| 87486 |
|
11,774 |
11,377 |
$518K |
| U0003 |
Cov-19 amp prb hgh thruput |
6,234 |
6,042 |
$517K |
| 76856 |
|
2,123 |
2,080 |
$495K |
| D9223 |
|
494 |
493 |
$486K |
| 17110 |
|
1,830 |
1,694 |
$485K |
| 96372 |
|
7,119 |
5,904 |
$453K |
| 90791 |
|
2,185 |
2,073 |
$452K |
| H0005 |
Alcohol and/or drug services |
6,853 |
2,054 |
$402K |
| 88305 |
|
9,241 |
8,273 |
$399K |
| 82306 |
|
11,758 |
11,705 |
$392K |
| 11102 |
|
703 |
701 |
$391K |
| 74176 |
|
1,476 |
1,429 |
$379K |
| 86850 |
|
5,206 |
4,962 |
$346K |
| 99204 |
|
2,201 |
2,153 |
$317K |
| 87631 |
|
4,293 |
4,133 |
$314K |
| 80047 |
|
4,835 |
4,663 |
$306K |
| 99212 |
|
2,108 |
1,976 |
$276K |
| 96360 |
|
1,598 |
1,569 |
$268K |
| 97530 |
|
3,697 |
1,225 |
$261K |
| 69436 |
|
107 |
104 |
$257K |
| 87581 |
|
11,776 |
11,378 |
$247K |
| 90792 |
|
1,080 |
886 |
$239K |
| D2930 |
|
319 |
297 |
$233K |
| 90847 |
|
964 |
733 |
$225K |
| G0396 |
Alcohol/subs interv 15-30mn |
2,075 |
1,380 |
$221K |
| 72148 |
|
704 |
704 |
$207K |
| 77067 |
|
4,035 |
3,969 |
$206K |
| 51798 |
|
561 |
553 |
$205K |
| 80307 |
|
5,504 |
5,128 |
$203K |
| 84443 |
|
25,398 |
24,695 |
$195K |
| 80076 |
|
15,459 |
14,337 |
$194K |
| 99395 |
|
1,446 |
1,420 |
$194K |
| 99396 |
|
1,406 |
1,392 |
$175K |
| 93306 |
|
1,174 |
1,173 |
$172K |
| 96413 |
|
1,379 |
918 |
$172K |
| 97110 |
|
3,946 |
1,403 |
$163K |
| 83036 |
|
15,782 |
15,701 |
$150K |
| 80061 |
|
20,098 |
20,011 |
$138K |
| 84439 |
|
13,825 |
13,597 |
$129K |
| 87624 |
|
2,672 |
2,669 |
$122K |
| 85025 |
|
38,848 |
35,340 |
$107K |
| 70551 |
|
349 |
349 |
$102K |
| 76705 |
|
2,073 |
2,022 |
$94K |
| 76801 |
|
954 |
860 |
$91K |
| 97161 |
|
1,036 |
1,020 |
$90K |
| 71250 |
|
1,043 |
1,037 |
$90K |
| 99201 |
|
729 |
546 |
$85K |
| 90715 |
|
2,063 |
2,056 |
$85K |
| 87661 |
|
2,422 |
2,388 |
$85K |
| H0001 |
Alcohol and/or drug assess |
557 |
554 |
$83K |
| 87428 |
|
551 |
535 |
$81K |
| 88142 |
|
3,318 |
3,312 |
$78K |
| 86901 |
|
5,047 |
4,790 |
$77K |
| 83880 |
|
2,212 |
2,114 |
$73K |
| 87389 |
|
4,199 |
4,182 |
$71K |
| 87086 |
|
10,258 |
9,731 |
$71K |
| 93010 |
|
11,052 |
10,471 |
$66K |
| 71260 |
|
587 |
584 |
$64K |
| 82728 |
|
5,099 |
4,979 |
$62K |
| 76815 |
|
868 |
708 |
$61K |
| 90682 |
|
1,966 |
1,962 |
$61K |
| 87070 |
|
7,574 |
7,393 |
$59K |
| 87810 |
|
1,986 |
1,916 |
$59K |
| 92507 |
|
560 |
381 |
$58K |
| 99202 |
|
589 |
572 |
$58K |
| 96415 |
|
97 |
78 |
$57K |
| 76811 |
|
1,203 |
1,186 |
$57K |
| 94010 |
|
2,783 |
2,080 |
$56K |
| 86900 |
|
4,821 |
4,625 |
$56K |
| 97010 |
|
2,284 |
871 |
$55K |
| 82607 |
|
4,298 |
4,256 |
$55K |
| S9480 |
Intensive outpatient psychia |
515 |
96 |
$53K |
| G0378 |
Hospital observation per hr |
669 |
642 |
$53K |
| 93971 |
|
645 |
634 |
$52K |
| 36591 |
|
1,940 |
1,084 |
$51K |
| 76830 |
|
1,541 |
1,517 |
$50K |
| 94726 |
|
511 |
503 |
$49K |
| 90686 |
|
803 |
801 |
$46K |
| 17000 |
|
147 |
147 |
$45K |
| 87491 |
|
1,858 |
1,805 |
$43K |
| 85027 |
|
13,867 |
13,084 |
$43K |
| 86780 |
|
3,625 |
3,593 |
$43K |
| 87502 |
|
905 |
897 |
$42K |
| 86803 |
|
4,585 |
4,551 |
$41K |
| 94060 |
|
532 |
521 |
$41K |
| 71046 |
|
5,998 |
5,879 |
$41K |
| 76775 |
|
865 |
858 |
$41K |
| 87591 |
|
1,860 |
1,805 |
$40K |
| U0002 |
Covid-19 lab test non-cdc |
812 |
784 |
$40K |
| 87507 |
|
244 |
239 |
$39K |
| 42820 |
|
16 |
14 |
$39K |
| 76816 |
|
1,874 |
1,754 |
$38K |
| 87635 |
|
1,219 |
1,132 |
$38K |
| G0123 |
Screen cerv/vag thin layer |
272 |
271 |
$37K |
| 12001 |
|
86 |
85 |
$37K |
| 77063 |
|
3,845 |
3,792 |
$36K |
| 84403 |
|
1,377 |
1,347 |
$36K |
| J1756 |
Iron sucrose injection |
526 |
296 |
$36K |
| 87340 |
|
3,851 |
3,797 |
$36K |
| 73721 |
|
106 |
103 |
$35K |
| 99406 |
|
497 |
487 |
$34K |
| 70553 |
|
105 |
105 |
$34K |
| 87522 |
Neg quan hep c or qual rna |
725 |
706 |
$33K |
| 99394 |
|
229 |
229 |
$31K |
| 76000 |
|
179 |
176 |
$31K |
| 70491 |
|
124 |
124 |
$31K |
| 71271 |
|
1,109 |
1,094 |
$31K |
| 72141 |
|
102 |
102 |
$30K |
| 84153 |
|
1,530 |
1,526 |
$29K |
| 82746 |
|
2,666 |
2,641 |
$29K |
| 87426 |
|
834 |
805 |
$28K |
| 87186 |
|
4,922 |
4,539 |
$28K |
| 11900 |
|
84 |
81 |
$28K |
| 86762 |
|
1,869 |
1,856 |
$27K |
| 99393 |
|
236 |
236 |
$27K |
| 83655 |
|
1,776 |
1,770 |
$27K |
| 83970 |
|
623 |
612 |
$27K |
| 81001 |
|
12,042 |
11,234 |
$26K |
| J1050 |
Medroxyprogesterone acetate |
948 |
946 |
$25K |
| 66984 |
|
13 |
12 |
$24K |
| 72125 |
|
515 |
511 |
$24K |
| 70486 |
|
288 |
288 |
$24K |
| G0480 |
Drug test def 1-7 classes |
1,260 |
1,173 |
$24K |
| 87088 |
|
3,200 |
3,101 |
$24K |
| 93970 |
|
57 |
56 |
$23K |
| 84702 |
|
4,106 |
3,345 |
$23K |
| 82803 |
|
1,174 |
1,029 |
$23K |
| 99460 |
|
503 |
502 |
$22K |
| 86140 |
|
6,257 |
5,963 |
$22K |
| 86480 |
|
361 |
357 |
$21K |
| 87081 |
|
3,974 |
3,938 |
$21K |
| 85610 |
|
5,492 |
4,803 |
$21K |
| D3220 |
|
57 |
54 |
$21K |
| 83550 |
|
4,360 |
4,298 |
$20K |
| 97140 |
|
722 |
267 |
$20K |
| 87077 |
|
2,350 |
2,261 |
$20K |
| 99238 |
|
495 |
494 |
$20K |
| 11045 |
|
18 |
12 |
$18K |
| 76817 |
|
363 |
338 |
$18K |
| C9803 |
Hopd covid-19 spec collect |
1,196 |
1,177 |
$17K |
| 83735 |
|
4,630 |
4,086 |
$17K |
| 77065 |
Tomosynthesis, mammo |
235 |
225 |
$17K |
| 52000 |
|
13 |
13 |
$16K |
| 87850 |
|
1,277 |
1,247 |
$16K |
| 99215 |
Prolong outpt/office vis |
99 |
96 |
$16K |
| 93005 |
|
6,773 |
6,195 |
$15K |
| 76642 |
|
817 |
794 |
$15K |
| 86038 |
|
2,563 |
2,526 |
$14K |
| 86665 |
|
906 |
505 |
$14K |
| 82043 |
|
2,760 |
2,750 |
$14K |
| 73564 |
|
1,558 |
1,529 |
$14K |
| 82784 |
|
1,417 |
1,125 |
$14K |
| 96367 |
|
149 |
103 |
$14K |
| 76820 |
|
1,032 |
798 |
$14K |
| 72110 |
|
860 |
854 |
$13K |
| 94729 |
|
516 |
507 |
$13K |
| 76536 |
|
562 |
551 |
$13K |
| 86617 |
|
869 |
856 |
$13K |
| 87521 |
Neg quan hep c or qual rna |
327 |
320 |
$12K |
| 77066 |
Tomosynthesis, mammo |
214 |
205 |
$12K |
| 88304 |
|
311 |
310 |
$12K |
| 86618 |
|
777 |
768 |
$11K |
| 85652 |
|
6,275 |
6,034 |
$11K |
| 85055 |
|
328 |
218 |
$11K |
| 87505 |
|
147 |
144 |
$11K |
| 86003 |
|
320 |
180 |
$11K |
| 86376 |
|
745 |
741 |
$10K |
| 86431 |
|
2,058 |
2,044 |
$10K |
| H0038 |
Self-help/peer svc per 15min |
176 |
79 |
$10K |
| 99391 |
|
89 |
88 |
$10K |
| 82950 |
|
1,526 |
1,524 |
$10K |
| 99392 |
|
95 |
95 |
$10K |
| 76857 |
|
195 |
195 |
$9K |
| G0399 |
Home sleep test/type 3 porta |
159 |
154 |
$9K |
| 85730 |
|
2,906 |
2,755 |
$9K |
| 99401 |
|
61 |
61 |
$9K |
| 73630 |
|
1,508 |
1,475 |
$8K |
| Q9967 |
Locm 300-399mg/ml iodine,1ml |
2,813 |
2,743 |
$8K |
| 99385 |
|
77 |
77 |
$8K |
| D0220 |
|
109 |
109 |
$8K |
| 73030 |
|
1,111 |
1,085 |
$8K |
| 77080 |
|
154 |
151 |
$8K |
| 73610 |
|
1,435 |
1,372 |
$8K |
| 84591 |
|
80 |
79 |
$8K |
| 11104 |
|
12 |
12 |
$7K |
| 74018 |
|
1,422 |
1,378 |
$7K |
| 83001 |
|
372 |
370 |
$7K |
| 83002 |
|
374 |
364 |
$7K |
| 86705 |
|
746 |
741 |
$6K |
| 73110 |
|
1,038 |
988 |
$6K |
| 73130 |
|
1,182 |
1,148 |
$6K |
| 97803 |
|
267 |
256 |
$6K |
| 88300 |
|
1,226 |
1,215 |
$6K |
| 20552 |
|
138 |
105 |
$6K |
| 86235 |
|
932 |
691 |
$6K |
| 90673 |
|
132 |
132 |
$6K |
| 71045 |
|
2,917 |
2,775 |
$6K |
| 84550 |
|
1,304 |
1,262 |
$6K |
| 76700 |
|
94 |
94 |
$6K |
| 83540 |
|
1,131 |
1,119 |
$6K |
| 70544 |
|
12 |
12 |
$6K |
| 84146 |
|
291 |
289 |
$6K |
| 86664 |
|
446 |
440 |
$5K |
| 86709 |
|
704 |
703 |
$5K |
| 84402 |
|
214 |
214 |
$5K |
| 99442 |
|
63 |
62 |
$5K |
| H0002 |
Alcohol and/or drug screenin |
25 |
24 |
$5K |
| 83690 |
|
5,564 |
5,186 |
$5K |
| D7111 |
|
14 |
14 |
$5K |
| A9576 |
Inj prohance multipack |
412 |
315 |
$5K |
| 82570 |
|
1,000 |
964 |
$5K |
| 87637 |
|
32 |
32 |
$5K |
| 72131 |
|
27 |
27 |
$5K |
| 82550 |
|
4,915 |
4,031 |
$4K |
| 86706 |
|
541 |
536 |
$4K |
| 73502 |
|
677 |
660 |
$4K |
| C8903 |
Mri w/cont, breast, uni |
36 |
36 |
$4K |
| G0297 |
Ldct for lung ca screen |
71 |
71 |
$4K |
| 86160 |
|
401 |
230 |
$4K |
| 87902 |
|
13 |
12 |
$4K |
| 87590 |
|
528 |
524 |
$4K |
| 87490 |
|
528 |
524 |
$4K |
| 84425 |
|
310 |
309 |
$4K |
| 82565 |
|
591 |
579 |
$4K |
| 93000 |
|
394 |
390 |
$4K |
| 87430 |
|
646 |
643 |
$4K |
| 96374 |
|
3,059 |
2,877 |
$4K |
| 84207 |
|
124 |
123 |
$3K |
| 86364 |
|
420 |
381 |
$3K |
| 77062 |
|
50 |
50 |
$3K |
| 10060 |
|
12 |
12 |
$3K |
| 99211 |
|
219 |
217 |
$3K |
| 93242 |
|
27 |
27 |
$3K |
| 77002 |
|
13 |
12 |
$3K |
| G0279 |
Tomosynthesis, mammo |
143 |
138 |
$3K |
| 84156 |
|
877 |
840 |
$3K |
| 83615 |
|
881 |
827 |
$3K |
| 99231 |
|
81 |
41 |
$3K |
| 90732 |
|
66 |
66 |
$3K |
| 84703 |
|
3,455 |
3,285 |
$3K |
| 90734 |
|
90 |
90 |
$3K |
| 99386 |
|
24 |
24 |
$3K |
| 80069 |
|
217 |
212 |
$3K |
| 88307 |
|
40 |
38 |
$3K |
| D0230 |
|
82 |
82 |
$3K |
| H0050 |
Alcohol/drug service 15 min |
47 |
45 |
$2K |
| 82247 |
|
424 |
350 |
$2K |
| 83525 |
|
205 |
204 |
$2K |
| 86800 |
|
184 |
180 |
$2K |
| 11200 |
|
12 |
12 |
$2K |
| 99281 |
|
13 |
13 |
$2K |
| 99239 |
|
25 |
25 |
$2K |
| 81000 |
|
772 |
747 |
$2K |
| 96375 |
|
2,666 |
2,170 |
$2K |
| 84484 |
|
3,754 |
3,296 |
$2K |
| 82150 |
|
704 |
685 |
$2K |
| 81374 |
|
50 |
50 |
$2K |
| 76870 |
|
68 |
64 |
$2K |
| D1208 |
|
36 |
36 |
$2K |
| 90670 |
|
75 |
75 |
$2K |
| 84436 |
|
420 |
418 |
$2K |
| 31575 |
|
33 |
30 |
$2K |
| 87205 |
|
677 |
642 |
$2K |
| 99222 |
|
14 |
14 |
$2K |
| 86255 |
|
293 |
252 |
$2K |
| 84100 |
|
429 |
376 |
$1K |
| 76819 |
|
64 |
42 |
$1K |
| 84165 |
|
201 |
199 |
$1K |
| 81596 |
|
25 |
25 |
$1K |
| 87040 |
|
2,090 |
1,304 |
$1K |
| 93246 |
|
12 |
12 |
$1K |
| 85379 |
|
644 |
633 |
$1K |
| 84481 |
|
160 |
151 |
$1K |
| 82248 |
|
261 |
245 |
$1K |
| J1453 |
Fosaprepitant injection |
21 |
12 |
$1K |
| 77334 |
|
17 |
13 |
$1K |
| 87536 |
|
12 |
12 |
$1K |
| 80164 |
|
124 |
120 |
$1K |
| 83993 |
|
94 |
93 |
$999.96 |
| 86200 |
|
123 |
121 |
$984.71 |
| 82553 |
|
3,591 |
2,841 |
$928.71 |
| 72100 |
|
94 |
93 |
$891.61 |
| 77061 |
|
15 |
15 |
$888.84 |
| 97597 |
|
27 |
13 |
$850.82 |
| 54150 |
|
12 |
12 |
$848.82 |
| 78815 |
|
14 |
14 |
$832.38 |
| 86258 |
|
114 |
113 |
$827.94 |
| 86256 |
|
14 |
14 |
$819.76 |
| 86704 |
|
81 |
80 |
$792.82 |
| 83605 |
|
1,880 |
1,680 |
$769.43 |
| 90648 |
|
42 |
42 |
$749.70 |
| 86308 |
|
319 |
314 |
$731.89 |
| Q9963 |
Hocm 350-399mg/ml iodine,1ml |
210 |
207 |
$718.48 |
| 81002 |
|
1,029 |
1,004 |
$718.47 |
| 73140 |
|
198 |
184 |
$715.37 |
| D1120 |
|
14 |
14 |
$696.57 |
| J0131 |
Inj, acetaminophen (nos) |
1,284 |
1,234 |
$605.58 |
| 86663 |
|
67 |
66 |
$595.55 |
| 72082 |
|
51 |
51 |
$587.78 |
| G0124 |
Screen c/v thin layer by md |
67 |
67 |
$586.36 |
| D1206 |
|
13 |
13 |
$582.09 |
| 84480 |
|
108 |
108 |
$575.76 |
| 86360 |
|
12 |
12 |
$563.76 |
| 84460 |
|
137 |
130 |
$539.63 |
| 82977 |
|
108 |
107 |
$518.66 |
| 73590 |
|
172 |
157 |
$491.73 |
| 84154 |
|
24 |
24 |
$488.88 |
| 94640 |
|
468 |
333 |
$477.43 |
| D0272 |
|
24 |
24 |
$438.83 |
| 86162 |
|
29 |
29 |
$436.90 |
| 84450 |
|
111 |
105 |
$429.41 |
| 90471 |
|
1,771 |
1,734 |
$419.49 |
| 85046 |
|
226 |
223 |
$378.95 |
| 84520 |
|
90 |
90 |
$374.31 |
| 85018 |
|
116 |
113 |
$369.45 |
| 84446 |
|
24 |
24 |
$368.25 |
| 86708 |
|
38 |
38 |
$354.58 |
| 85049 |
|
225 |
150 |
$336.35 |
| 36600 |
|
12 |
12 |
$322.56 |
| 86147 |
|
21 |
12 |
$314.17 |
| 73080 |
|
84 |
83 |
$307.20 |
| 80143 |
|
1,584 |
1,411 |
$298.00 |
| 80503 |
|
13 |
12 |
$277.00 |
| 93041 |
|
3,405 |
3,223 |
$276.69 |
| 82670 |
|
12 |
12 |
$270.63 |
| 74021 |
|
112 |
112 |
$264.00 |
| 82077 |
|
1,916 |
1,718 |
$263.24 |
| 86225 |
|
50 |
50 |
$259.99 |
| 99417 |
Prolong home eval add 15m |
12 |
12 |
$248.99 |
| 82172 |
|
16 |
12 |
$223.02 |
| 70310 |
|
85 |
84 |
$222.24 |
| 72072 |
|
15 |
15 |
$216.00 |
| 90723 |
|
12 |
12 |
$214.20 |
| 88302 |
|
43 |
43 |
$212.16 |
| 86231 |
|
27 |
27 |
$194.50 |
| 82105 |
|
25 |
24 |
$158.99 |
| 87804 |
|
566 |
458 |
$158.05 |
| 90460 |
|
186 |
180 |
$147.09 |
| 90658 |
|
12 |
12 |
$142.92 |
| 82378 |
|
28 |
24 |
$142.31 |
| 83010 |
|
13 |
13 |
$142.09 |
| 99441 |
|
16 |
12 |
$137.72 |
| 83520 |
|
12 |
12 |
$129.14 |
| 86677 |
|
15 |
13 |
$119.95 |
| 84479 |
|
39 |
39 |
$105.12 |
| 82951 |
|
16 |
16 |
$102.60 |
| 87808 |
|
33 |
31 |
$100.71 |
| 87880 |
|
1,605 |
1,578 |
$97.97 |
| 94760 |
|
1,507 |
1,424 |
$97.14 |
| J1885 |
Ketorolac tromethamine inj |
2,118 |
1,972 |
$95.71 |
| 81015 |
|
174 |
169 |
$90.07 |
| G0008 |
Admin influenza virus vac |
15 |
15 |
$87.09 |
| 84155 |
|
28 |
28 |
$80.81 |
| 80178 |
|
13 |
12 |
$70.40 |
| 71101 |
|
13 |
13 |
$52.50 |
| J1100 |
Dexamethasone sodium phos |
2,307 |
1,872 |
$51.15 |
| 82140 |
|
13 |
12 |
$43.71 |
| J3010 |
Fentanyl citrate injection |
1,983 |
1,946 |
$32.39 |
| 87210 |
|
443 |
433 |
$29.11 |
| J1642 |
Inj heparin sodium per 10 u |
121 |
69 |
$26.83 |
| J2405 |
Ondansetron hcl injection |
2,659 |
2,509 |
$21.90 |
| 82952 |
|
15 |
15 |
$19.60 |
| J0690 |
Cefazolin sodium injection |
86 |
73 |
$17.94 |
| J2270 |
Morphine sulfate injection |
172 |
141 |
$13.40 |
| J0665 |
Inj, bupivacaine, nos, 0.5mg |
206 |
197 |
$12.68 |
| J2250 |
Inj midazolam hydrochloride |
1,131 |
1,108 |
$12.48 |
| J0696 |
Ceftriaxone sodium injection |
17 |
12 |
$8.16 |
| J2919 |
Inj, methylpred sod succ 5mg |
12 |
12 |
$6.94 |
| J2765 |
Metoclopramide hcl injection |
252 |
241 |
$6.53 |
| J1200 |
Diphenhydramine hcl injectio |
205 |
172 |
$5.51 |
| Q0162 |
Ondansetron oral |
29 |
29 |
$0.12 |
| 59425 |
|
140 |
107 |
$0.00 |
| 82726 |
|
33 |
33 |
$0.00 |
| 87807 |
|
36 |
35 |
$0.00 |
| 96376 |
|
48 |
38 |
$0.00 |
| J2060 |
Lorazepam injection |
14 |
12 |
$0.00 |