| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
455 |
426 |
$87K |
| E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate |
573 |
533 |
$69K |
| K0003 |
Lightweight wheelchair |
1,684 |
1,637 |
$65K |
| 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 |
451 |
297 |
$48K |
| A6197 |
Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing |
124 |
114 |
$31K |
| A6252 |
Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing |
520 |
459 |
$24K |
| A6196 |
Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing |
204 |
166 |
$20K |
| L4361 |
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf |
63 |
62 |
$12K |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
1,528 |
1,410 |
$12K |
| E0570 |
Nebulizer, with compressor |
314 |
294 |
$11K |
| A6260 |
Wound cleansers, any type, any size |
1,109 |
1,048 |
$10K |
| A6212 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
141 |
127 |
$10K |
| A6446 |
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard |
402 |
371 |
$8K |
| A6021 |
Collagen dressing, sterile, size 16 sq. in. or less, each |
30 |
26 |
$7K |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
28 |
24 |
$5K |
| E0143 |
Walker, folding, wheeled, adjustable or fixed height |
67 |
63 |
$3K |
| A4452 |
Tape, waterproof, per 18 square inches |
136 |
133 |
$2K |
| E0431 |
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
177 |
169 |
$2K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
76 |
64 |
$1K |
| T4521 |
Adult sized disposable incontinence product, brief/diaper, small, each |
12 |
12 |
$1K |
| L3908 |
Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf |
28 |
26 |
$1K |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
118 |
113 |
$855.40 |
| A4450 |
Tape, non-waterproof, per 18 square inches |
254 |
219 |
$756.25 |
| A4424 |
Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each |
12 |
12 |
$725.22 |
| E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
13 |
13 |
$594.06 |