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Top 20 Benefits
TOP CONDITION
MEMBER PAID
# OF
CLAIM
SERVICE
LINES
PLAN PAID
BENEFIT
BENEFIT
CODE
Cirrhosis, w comp, w comorb, w surg
$3,137.01
228
$123,157.86
Pharmacy, Inpatient
Facility
FPI
Kidney stones, w comp, wo comorb, wo
surg
$92,140.50
254
$108,946.00
Medical Emergency, ER
FME2
Cirrhosis, w comp, w comorb, w surg
$4,463.94
416
$108,706.41
Laboratory Servics,
Inpatient Facility
FLBI
Cholelithiasis, w comp, wo comorb, w surg
$52,999.57
86
$99,132.17
Ambulatory Surgery
FOSF
Cardiovascular disease S&S
$31,769.46
1,360
$86,901.98
Radiology Services, Office
ORDD
Embolism & thrombosis veins, w comp, wo
surg
$6,341.47
16
$86,832.33
Intensive Care
FICU
Thrombocytopenia, w comp, wo comorb,
wo surg
$35,210.45
5,075
$84,181.94
Other - Laboratory
OLO
Other drug dependence, wo comorb
$83,616.47
1,867
$83,387.72
Office - Practitioner Visit
Specialist
VO
Other minor perinatal disorder, w comp
$2,756.52
4
$77,124.97
Nursery, Per-Diem
FNRS
Jt degen -neck, w comp, w comorb, w surg
$40,518.27
231
$75,430.80
ITS Outpatient Surgery -
Exempt
XITS
$951,459.26
29,996
$2,891,897.35
Remaining
Benefits
Page 36 of 41
Incurred: 2/1/2016 to 1/31/2017
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