| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4221 |
Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately) |
1,198 |
423 |
$17K |
| A4222 |
Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) |
153 |
28 |
$11K |
| E0779 |
Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater |
353 |
26 |
$3K |
| 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 |
22 |
12 |
$2K |
| A6209 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
41 |
13 |
$177.25 |
| A6257 |
Transparent film, sterile, 16 sq. in. or less, each dressing |
40 |
13 |
$23.40 |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
40 |
13 |
$11.40 |