| 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 |
2,658 |
2,596 |
$2.13M |
| 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 |
5,993 |
5,849 |
$1.50M |
| B4035 |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
5,379 |
5,141 |
$1.43M |
| E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate |
13,372 |
13,105 |
$1.22M |
| B4153 |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
490 |
486 |
$655K |
| B9998 |
Noc for enteral supplies |
8,243 |
6,834 |
$578K |
| A4554 |
Disposable underpads, all sizes |
12,538 |
12,364 |
$403K |
| 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 |
953 |
920 |
$317K |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
1,623 |
1,594 |
$287K |
| 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 |
694 |
662 |
$268K |
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
2,515 |
2,473 |
$265K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
1,941 |
1,901 |
$260K |
| 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 |
885 |
861 |
$241K |
| E0601 |
Continuous positive airway pressure (cpap) device |
5,147 |
5,095 |
$238K |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
2,272 |
2,241 |
$236K |
| E0570 |
Nebulizer, with compressor |
4,630 |
4,553 |
$228K |
| E0445 |
Oximeter device for measuring blood oxygen levels non-invasively |
1,736 |
1,649 |
$208K |
| E0431 |
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
10,965 |
10,707 |
$185K |
| B9002 |
Enteral nutrition infusion pump, any type |
1,445 |
1,431 |
$178K |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
1,427 |
1,405 |
$148K |
| T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
1,555 |
1,530 |
$147K |
| K0001 |
Standard wheelchair |
2,840 |
2,767 |
$136K |
| T4530 |
Pediatric sized disposable incontinence product, brief/diaper, large size, each |
1,322 |
1,302 |
$120K |
| 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 |
362 |
348 |
$120K |
| A7030 |
Full face mask used with positive airway pressure device, each |
1,567 |
1,525 |
$111K |
| A4335 |
Incontinence supply; miscellaneous |
19,420 |
19,188 |
$96K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
2,283 |
2,197 |
$90K |
| A4351 |
Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each |
459 |
445 |
$78K |
| A4606 |
Oxygen probe for use with oximeter device, replacement |
793 |
730 |
$73K |
| E0562 |
Humidifier, heated, used with positive airway pressure device |
1,752 |
1,736 |
$73K |
| A7031 |
Face mask interface, replacement for full face mask, each |
2,217 |
2,037 |
$63K |
| T4521 |
Adult sized disposable incontinence product, brief/diaper, small, each |
684 |
650 |
$60K |
| A7000 |
Canister, disposable, used with suction pump, each |
1,622 |
1,595 |
$52K |
| A4322 |
Irrigation syringe, bulb or piston, each |
5,438 |
5,334 |
$45K |
| E0277 |
Powered pressure-reducing air mattress |
103 |
103 |
$35K |
| E0143 |
Walker, folding, wheeled, adjustable or fixed height |
537 |
521 |
$29K |
| A7002 |
Tubing, used with suction pump, each |
1,818 |
1,746 |
$24K |
| A4239 |
Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service |
149 |
141 |
$24K |
| E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
196 |
190 |
$23K |
| T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
260 |
259 |
$23K |
| T4532 |
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each |
152 |
151 |
$23K |
| A7005 |
Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable |
1,303 |
1,266 |
$21K |
| A7034 |
Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap |
499 |
481 |
$18K |
| A7035 |
Headgear used with positive airway pressure device |
1,425 |
1,387 |
$18K |
| A7037 |
Tubing used with positive airway pressure device |
901 |
866 |
$16K |
| T1999 |
Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified; identify product in "remarks" |
5,222 |
4,359 |
$15K |
| A4927 |
Gloves, non-sterile, per 100 |
2,577 |
2,536 |
$15K |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
1,507 |
1,481 |
$14K |
| A7038 |
Filter, disposable, used with positive airway pressure device |
3,349 |
3,078 |
$12K |
| E0776 |
Iv pole |
1,122 |
1,114 |
$10K |
| A4628 |
Oral and/or oropharyngeal suction catheter, each |
1,949 |
1,922 |
$10K |
| A7003 |
Administration set, with small volume nonfiltered pneumatic nebulizer, disposable |
3,193 |
3,158 |
$9K |
| K0195 |
Elevating leg rests, pair (for use with capped rental wheelchair base) |
597 |
466 |
$8K |
| T4524 |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
59 |
58 |
$7K |
| A7046 |
Water chamber for humidifier, used with positive airway pressure device, replacement, each |
1,295 |
1,262 |
$7K |
| A6403 |
Gauze, non-impregnated, sterile, pad size more than 16 sq. in. less than or equal to 48 sq. in., without adhesive border, each dressing |
293 |
277 |
$6K |
| A6250 |
Skin sealants, protectants, moisturizers, ointments, any type, any size |
990 |
972 |
$6K |
| A7015 |
Aerosol mask, used with dme nebulizer |
4,752 |
4,615 |
$5K |
| E0114 |
Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips |
180 |
178 |
$5K |
| A7032 |
Cushion for use on nasal mask interface, replacement only, each |
173 |
154 |
$4K |
| A4450 |
Tape, non-waterproof, per 18 square inches |
812 |
793 |
$4K |
| B4103 |
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit |
12 |
12 |
$3K |
| A4604 |
Tubing with integrated heating element for use with positive airway pressure device |
1,185 |
1,168 |
$3K |
| 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 |
13 |
12 |
$3K |
| A4452 |
Tape, waterproof, per 18 square inches |
132 |
122 |
$2K |
| L4361 |
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf |
15 |
15 |
$2K |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
247 |
243 |
$2K |
| E0470 |
Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
12 |
12 |
$1K |
| A7013 |
Filter, disposable, used with aerosol compressor or ultrasonic generator |
2,286 |
2,225 |
$1K |
| E1392 |
Portable oxygen concentrator, rental |
194 |
192 |
$580.48 |
| A7033 |
Pillow for use on nasal cannula type interface, replacement only, pair |
27 |
25 |
$141.51 |
| E1399 |
Durable medical equipment, miscellaneous |
61 |
55 |
$45.10 |