| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
2,887 |
2,609 |
$399K |
| 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 |
2,086 |
1,055 |
$143K |
| T4541 |
Incontinence product, disposable underpad, large, each |
1,344 |
1,216 |
$74K |
| A4362 |
Skin barrier; solid, 4 x 4 or equivalent; each |
80 |
66 |
$4K |
| A4385 |
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each |
61 |
56 |
$3K |
| A4414 |
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each |
51 |
40 |
$2K |
| A4394 |
Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce |
95 |
85 |
$2K |
| A5120 |
Skin barrier, wipes or swabs, each |
379 |
300 |
$2K |
| A4424 |
Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each |
18 |
14 |
$1K |
| A4425 |
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each |
28 |
24 |
$988.56 |
| A4217 |
Sterile water/saline, 500 ml |
33 |
26 |
$895.80 |
| 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 |
28 |
16 |
$870.92 |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
14 |
12 |
$287.38 |
| A4456 |
Adhesive remover, wipes, any type, each |
36 |
29 |
$241.14 |