467 B
467 B
| 1 | Patient ID | Item Description | Service Date | Qty | Insurance Name | Item Type | Prescriber NPI | Branch |
|---|---|---|---|---|---|---|---|---|
| 2 | PT-1011 | FreeStyle Libre 3 | 12/15/2024 | 1 | Aetna Commercial | sensor | 1234567890 | PA-001 |
| 3 | PT-1012 | FSL3 | 12/26/2024 | 1 | Aetna Commercial | sensor | 1234567890 | PA-001 |
| 4 | PT-1013 | FreeStyle Libre 3 | 11/06/2024 | 6 | Aetna Commercial | sensor | 1234567890 | PA-001 |
| 5 | PT-1014 | FSL3 | 11/09/2024 | 2 | Aetna Commercial | sensor | 1234567890 | PA-001 |
| 6 | PT-1015 | Libre 3 | 11/20/2024 | 3 | Aetna Commercial | sensor | 1234567890 | PA-001 |