| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4927 |
Gloves, non-sterile, per 100 |
179 |
122 |
$54.22 |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
129 |
87 |
$30.16 |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
233 |
159 |
$5.05 |
| A4450 |
Tape, non-waterproof, per 18 square inches |
41 |
30 |
$0.00 |
| A5120 |
Skin barrier, wipes or swabs, each |
18 |
13 |
$0.00 |
| 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 |
15 |
13 |
$0.00 |
| A9270 |
Non-covered item or service |
118 |
84 |
$0.00 |
| A9999 |
Miscellaneous dme supply or accessory, not otherwise specified |
275 |
183 |
$0.00 |
| A6446 |
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard |
84 |
56 |
$0.00 |