415 B
415 B
| 1 | Member ID | DME Description | DOS | QTY | Insurance | Item Type | Payer ID |
|---|---|---|---|---|---|---|---|
| 2 | PT-1191 | Omnipod | 2024-12-07 | 1 | Medicare | pod | 00019 |
| 3 | PT-1192 | OmniPod 5 | 2024-11-11 | 1 | Medicare | pod | 00019 |
| 4 | PT-1193 | OmniPod 5 | 2025-01-07 | 2 | Medicare | pod | 00019 |
| 5 | PT-1194 | Omnipod 5 | 2024-10-28 | 1 | Medicare | pod | 00019 |
| 6 | PT-1195 | Omnipod 5 | 2024-11-05 | 6 | Medicare | pod | 00019 |
| 7 | PT-1196 | Omnipod | 2024-11-29 | 6 | Medicare | pod | 00019 |
| 8 | PT-1197 | Omnipod | 2024-12-07 | 2 | Medicare | pod | 00019 |