| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T4534 |
Youth size pull-on |
455 |
426 |
$87K |
| E1390 |
Oxygen concentrator |
573 |
533 |
$69K |
| K0003 |
Lightweight wheelchair |
1,684 |
1,637 |
$65K |
| B4160 |
Ef ped caloric dense>/=0.7kc |
451 |
297 |
$48K |
| A6197 |
Alginate drsg >16 <=48 sq in |
124 |
114 |
$31K |
| A6252 |
Absorpt drg >16 <=48 w/o bdr |
520 |
459 |
$24K |
| A6196 |
Alginate dressing <=16 sq in |
204 |
166 |
$20K |
| L4361 |
Pneuma/vac walk boot pre ots |
63 |
62 |
$12K |
| A6216 |
Non-sterile gauze<=16 sq in |
1,528 |
1,410 |
$12K |
| E0570 |
Nebulizer with compression |
314 |
294 |
$11K |
| A6260 |
Wound cleanser any type/size |
1,109 |
1,048 |
$10K |
| A6212 |
Foam drg <=16 sq in w/border |
141 |
127 |
$10K |
| A6446 |
Conform band s w>=3" <5"/yd |
402 |
371 |
$8K |
| A6021 |
Collagen dressing <=16 sq in |
30 |
26 |
$7K |
| T4526 |
Adult size pull-on med |
28 |
24 |
$5K |
| E0143 |
Walker folding wheeled w/o s |
67 |
63 |
$3K |
| A4452 |
Waterproof tape |
136 |
133 |
$2K |
| E0431 |
Portable gaseous 02 |
177 |
169 |
$2K |
| T4535 |
Disposable liner/shield/pad |
76 |
64 |
$1K |
| T4521 |
Adult size brief/diaper sm |
12 |
12 |
$1K |
| L3908 |
Who cock-up nonmolde pre ots |
28 |
26 |
$1K |
| A6402 |
Sterile gauze <= 16 sq in |
118 |
113 |
$855.40 |
| A4450 |
Non-waterproof tape |
254 |
219 |
$756.25 |
| A4424 |
Ost pch drain w bar & filter |
12 |
12 |
$725.22 |
| E0260 |
Hosp bed semi-electr w/ matt |
13 |
13 |
$594.06 |