622 B
622 B
| 1 | MRN | Product Name | Dispense Date | Qty Dispensed | Plan Name | Supply Type | Supplier | State |
|---|---|---|---|---|---|---|---|---|
| 2 | PT-1031 | FreestyleLibre3 | 09-Nov-2024 | 6 | Medicare Part B - CGM | sensor | Gaboro DME | PA |
| 3 | PT-1032 | FSL3 | 18-Dec-2024 | 2 | Medicare Part B - CGM | sensor | Gaboro DME | PA |
| 4 | PT-1033 | fs libre 3 | 23-Oct-2024 | 1 | Medicare Part B - CGM | sensor | Gaboro DME | PA |
| 5 | PT-1034 | FreeStyle Libre 3 | 06-Jan-2025 | 2 | Medicare Part B - CGM | sensor | Gaboro DME | PA |
| 6 | PT-1035 | fs libre 3 | 22-Dec-2024 | 9 | Medicare Part B - CGM | sensor | Gaboro DME | PA |
| 7 | PT-1036 | fs libre 3 | 13-Oct-2024 | 9 | Medicare Part B - CGM | sensor | Gaboro DME | PA |
| 8 | PT-1037 | FSL3 | 04-Dec-2024 | 9 | Medicare Part B - CGM | sensor | Gaboro DME | PA |