| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S8101 |
Spacer with mask |
2,821 |
2,821 |
$156K |
| T4524 |
Adult size brief/diaper xl |
748 |
744 |
$103K |
| A4554 |
Disposable underpads |
632 |
624 |
$42K |
| K0553 |
Ther cgm supply allowance |
1,439 |
1,408 |
$40K |
| A6248 |
Hydrogel drsg gel filler |
272 |
271 |
$32K |
| A6196 |
Alginate dressing <=16 sq in |
177 |
177 |
$28K |
| A7005 |
Nondisposable nebulizer set |
971 |
967 |
$16K |
| A6021 |
Collagen dressing <=16 sq in |
157 |
156 |
$15K |
| A4239 |
Non-adju cgm supply allow |
196 |
194 |
$10K |
| A6206 |
Contact layer <= 16 sq in |
168 |
168 |
$8K |
| L0650 |
Lso sc r ant/pos pnl pre ots |
21 |
21 |
$8K |
| A6222 |
Gauze <=16 in no w/sal w/o b |
177 |
177 |
$7K |
| L1833 |
Ko adj jnt pos r sup pre ots |
16 |
12 |
$6K |
| A4450 |
Non-waterproof tape |
315 |
314 |
$6K |
| A4217 |
Sterile water/saline, 500 ml |
315 |
314 |
$5K |
| A4930 |
Sterile, gloves per pair |
246 |
244 |
$3K |
| A6257 |
Transparent film <= 16 sq in |
182 |
182 |
$2K |
| A4927 |
Non-sterile gloves |
298 |
291 |
$1K |
| A6216 |
Non-sterile gauze<=16 sq in |
191 |
191 |
$945.90 |
| T4537 |
Reusable underpad bed size |
26 |
25 |
$688.04 |
| A6449 |
Lt compres band >=3" <5"/yd |
81 |
78 |
$535.40 |
| T4535 |
Disposable liner/shield/pad |
13 |
12 |
$524.90 |
| L2397 |
Suspension sleeve lower ext |
34 |
26 |
$483.60 |
| A6446 |
Conform band s w>=3" <5"/yd |
16 |
15 |
$48.00 |