| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4305 |
Disposable drug delivery system, flow rate of 50 ml or greater per hour |
96 |
32 |
$16K |
| A4209 |
Syringe with needle, sterile 5 cc or greater, each |
509 |
179 |
$11K |
| A4221 |
Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately) |
248 |
78 |
$4K |
| 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 |
20 |
12 |
$2K |
| A6209 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
149 |
51 |
$973.38 |
| A4927 |
Gloves, non-sterile, per 100 |
184 |
82 |
$392.19 |
| A6257 |
Transparent film, sterile, 16 sq. in. or less, each dressing |
218 |
78 |
$239.85 |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
220 |
78 |
$118.56 |