| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4554 |
Disposable underpads, all sizes |
12,143 |
11,350 |
$569K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
3,863 |
3,662 |
$445K |
| B4150 |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
4,504 |
4,068 |
$438K |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
3,752 |
3,587 |
$379K |
| B4154 |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
2,815 |
2,541 |
$359K |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
2,442 |
2,346 |
$278K |
| A4927 |
Gloves, non-sterile, per 100 |
11,549 |
10,705 |
$215K |
| T4544 |
Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each |
1,188 |
1,073 |
$180K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
2,985 |
2,614 |
$136K |
| T2025 |
Waiver services; not otherwise specified (nos) |
2,257 |
1,929 |
$91K |
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
472 |
433 |
$59K |
| B4152 |
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
187 |
166 |
$21K |
| S5165 |
Home modifications; per service |
28 |
24 |
$14K |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
114 |
105 |
$13K |
| A4928 |
Surgical mask, per 20 |
453 |
400 |
$12K |
| T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
93 |
79 |
$10K |
| 0011A |
|
90 |
70 |
$4K |
| 0012A |
|
55 |
45 |
$3K |
| A4253 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
314 |
304 |
$2K |
| E0570 |
Nebulizer, with compressor |
12 |
12 |
$2K |
| A4670 |
Automatic blood pressure monitor |
26 |
25 |
$2K |
| T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
13 |
13 |
$1K |
| 90686 |
|
65 |
58 |
$862.22 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
88 |
80 |
$857.90 |
| 90674 |
|
24 |
21 |
$371.55 |
| Q0513 |
Pharmacy dispensing fee for inhalation drug(s); per 30 days |
12 |
12 |
$66.00 |
| A5120 |
Skin barrier, wipes or swabs, each |
13 |
12 |
$65.00 |
| 91301 |
|
152 |
114 |
$0.00 |