| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| 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 |
2,330 |
1,901 |
$353K |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
2,411 |
1,856 |
$244K |
| A4554 |
Disposable underpads, all sizes |
2,798 |
2,140 |
$105K |
| A4927 |
Gloves, non-sterile, per 100 |
2,848 |
2,160 |
$39K |
| T4544 |
Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each |
121 |
117 |
$33K |
| 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 |
101 |
75 |
$17K |
| A4335 |
Incontinence supply; miscellaneous |
2,830 |
2,160 |
$15K |
| 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 |
308 |
137 |
$11K |
| T4532 |
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each |
31 |
12 |
$640.80 |