| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4554 |
Disposable underpads |
3,686 |
3,631 |
$177K |
| T4524 |
Adult size brief/diaper xl |
1,576 |
1,555 |
$175K |
| T4535 |
Disposable liner/shield/pad |
2,673 |
2,635 |
$95K |
| L3030 |
Foot arch support remov prem |
1,420 |
697 |
$70K |
| T4523 |
Adult size brief/diaper lg |
642 |
638 |
$59K |
| T4539 |
Reuse diaper/brief any size |
1,662 |
1,618 |
$47K |
| A4239 |
Non-adju cgm supply allow |
724 |
715 |
$31K |
| T4537 |
Reusable underpad bed size |
737 |
721 |
$17K |
| L3001 |
Foot insert remov molded spe |
174 |
86 |
$11K |
| L3215 |
Orthopedic ftwear ladies oxf |
194 |
98 |
$11K |
| T4522 |
Adult size brief/diaper med |
203 |
203 |
$9K |
| L3219 |
Orthopedic mens shoes oxford |
80 |
38 |
$6K |
| L3206 |
Hightop w/ supp/pronator chi |
137 |
69 |
$3K |
| A4927 |
Non-sterile gloves |
565 |
545 |
$2K |
| K0553 |
Ther cgm supply allowance |
27 |
27 |
$1K |
| T4540 |
Reusable underpad chair size |
33 |
32 |
$451.83 |