| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| B4161 |
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
4,154 |
3,125 |
$2.18M |
| B4035 |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
10,195 |
8,099 |
$1.71M |
| B4160 |
Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 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 |
6,095 |
5,106 |
$999K |
| E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate |
10,339 |
9,265 |
$546K |
| E0329 |
Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress |
90 |
65 |
$501K |
| B4162 |
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
1,168 |
700 |
$485K |
| E0445 |
Oximeter device for measuring blood oxygen levels non-invasively |
4,687 |
4,325 |
$466K |
| B4158 |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit |
1,283 |
1,041 |
$326K |
| B9002 |
Enteral nutrition infusion pump, any type |
4,083 |
3,702 |
$231K |
| E0619 |
Apnea monitor, with recording feature |
987 |
930 |
$201K |
| T4541 |
Incontinence product, disposable underpad, large, each |
6,099 |
4,738 |
$191K |
| B4034 |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
2,613 |
1,972 |
$186K |
| B4088 |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
2,963 |
2,761 |
$161K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
2,207 |
1,790 |
$148K |
| A4351 |
Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each |
1,674 |
1,293 |
$139K |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
1,699 |
1,346 |
$134K |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
1,790 |
1,532 |
$129K |
| 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 |
1,098 |
753 |
$105K |
| A4624 |
Tracheal suction catheter, any type other than closed system, each |
1,214 |
1,053 |
$103K |
| T4544 |
Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each |
936 |
642 |
$103K |
| B4155 |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit |
1,384 |
1,015 |
$97K |
| E1399 |
Durable medical equipment, miscellaneous |
99 |
41 |
$95K |
| K0001 |
Standard wheelchair |
6,215 |
4,611 |
$92K |
| E0431 |
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
7,038 |
6,319 |
$90K |
| B4149 |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
223 |
158 |
$57K |
| E1236 |
Wheelchair, pediatric size, folding, adjustable, with seating system |
538 |
435 |
$56K |
| E0600 |
Respiratory suction pump, home model, portable or stationary, electric |
2,782 |
2,337 |
$52K |
| K0195 |
Elevating leg rests, pair (for use with capped rental wheelchair base) |
5,856 |
4,531 |
$46K |
| A4606 |
Oxygen probe for use with oximeter device, replacement |
4,032 |
2,683 |
$46K |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
592 |
488 |
$42K |
| E0570 |
Nebulizer, with compressor |
2,755 |
2,389 |
$42K |
| 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 |
505 |
385 |
$39K |
| E1392 |
Portable oxygen concentrator, rental |
2,204 |
1,886 |
$39K |
| A4628 |
Oral and/or oropharyngeal suction catheter, each |
3,596 |
3,371 |
$38K |
| A7000 |
Canister, disposable, used with suction pump, each |
4,354 |
4,100 |
$33K |
| T4524 |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
406 |
380 |
$32K |
| E2611 |
General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware |
207 |
182 |
$29K |
| E1226 |
Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each |
1,018 |
803 |
$29K |
| E0776 |
Iv pole |
3,220 |
2,986 |
$29K |
| T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
483 |
426 |
$26K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
1,265 |
816 |
$24K |
| E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
1,516 |
998 |
$21K |
| A7526 |
Tracheostomy tube collar/holder, each |
405 |
371 |
$20K |
| A7002 |
Tubing, used with suction pump, each |
4,384 |
4,153 |
$16K |
| E2601 |
General use wheelchair seat cushion, width less than 22 inches, any depth |
445 |
382 |
$15K |
| B9998 |
Noc for enteral supplies |
959 |
610 |
$13K |
| A4217 |
Sterile water/saline, 500 ml |
402 |
374 |
$12K |
| A4629 |
Tracheostomy care kit for established tracheostomy |
142 |
128 |
$9K |
| T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
129 |
112 |
$9K |
| E2201 |
Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches |
267 |
228 |
$8K |
| A7509 |
Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each |
309 |
287 |
$8K |
| A4927 |
Gloves, non-sterile, per 100 |
1,380 |
993 |
$7K |
| A4322 |
Irrigation syringe, bulb or piston, each |
390 |
307 |
$6K |
| A7003 |
Administration set, with small volume nonfiltered pneumatic nebulizer, disposable |
2,705 |
2,477 |
$6K |
| A4332 |
Lubricant, individual sterile packet, each |
1,049 |
983 |
$6K |
| E0971 |
Manual wheelchair accessory, anti-tipping device, each |
2,238 |
1,033 |
$6K |
| A4216 |
Sterile water, saline and/or dextrose, diluent/flush, 10 ml |
176 |
152 |
$4K |
| B4082 |
Nasogastric tubing without stylet |
268 |
247 |
$3K |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
253 |
217 |
$2K |
| A5120 |
Skin barrier, wipes or swabs, each |
304 |
259 |
$1K |
| A7015 |
Aerosol mask, used with dme nebulizer |
729 |
675 |
$661.42 |
| A4357 |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
88 |
72 |
$542.11 |
| E0163 |
Commode chair, mobile or stationary, with fixed arms |
17 |
12 |
$458.65 |
| A4450 |
Tape, non-waterproof, per 18 square inches |
143 |
121 |
$213.81 |
| A7525 |
Tracheostomy mask, each |
151 |
126 |
$145.78 |
| A7012 |
Water collection device, used with large volume nebulizer |
12 |
12 |
$45.67 |
| E2208 |
Wheelchair accessory, cylinder tank carrier, each |
34 |
25 |
$0.00 |