| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A6209 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
103 |
31 |
$730.27 |
| A6457 |
Tubular dressing with or without elastic, any width, per linear yard |
103 |
30 |
$128.89 |
| A6257 |
Transparent film, sterile, 16 sq. in. or less, each dressing |
103 |
31 |
$120.51 |
| A6453 |
Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard |
103 |
31 |
$62.83 |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
103 |
31 |
$58.71 |