| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| Q5104 |
Injection, infliximab-abda, biosimilar, (renflexis), 10 mg |
2,455 |
1,628 |
$12.12M |
| J2357 |
Injection, omalizumab, 5 mg |
2,612 |
1,256 |
$11.96M |
| J1559 |
Injection, immune globulin (hizentra), 100 mg |
2,182 |
1,052 |
$9.71M |
| E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate |
37,846 |
31,914 |
$4.46M |
| S9342 |
Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem |
18,070 |
11,973 |
$3.54M |
| B4161 |
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
5,704 |
4,561 |
$2.53M |
| A4353 |
Intermittent urinary catheter, with insertion supplies |
2,470 |
1,711 |
$2.45M |
| J0585 |
Injection, onabotulinumtoxina, 1 unit |
1,767 |
1,325 |
$2.23M |
| E0601 |
Continuous positive airway pressure (cpap) device |
11,056 |
9,693 |
$1.96M |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
8,493 |
6,557 |
$1.21M |
| A4554 |
Disposable underpads, all sizes |
28,981 |
21,273 |
$1.16M |
| A7034 |
Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap |
17,454 |
13,602 |
$1.04M |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
7,218 |
5,287 |
$1.01M |
| 99601 |
|
14,148 |
6,132 |
$983K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
6,821 |
5,088 |
$974K |
| 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 |
7,776 |
6,153 |
$911K |
| E0465 |
Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) |
1,440 |
1,246 |
$761K |
| A4604 |
Tubing with integrated heating element for use with positive airway pressure device |
21,519 |
16,023 |
$745K |
| E0562 |
Humidifier, heated, used with positive airway pressure device |
11,756 |
10,428 |
$724K |
| E0603 |
Breast pump, electric (ac and/or dc), any type |
5,213 |
3,806 |
$724K |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
5,231 |
3,949 |
$650K |
| 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 |
1,341 |
922 |
$612K |
| A7030 |
Full face mask used with positive airway pressure device, each |
8,760 |
6,928 |
$610K |
| A4351 |
Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each |
3,127 |
2,348 |
$608K |
| T4524 |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
4,603 |
3,395 |
$591K |
| A4624 |
Tracheal suction catheter, any type other than closed system, each |
2,866 |
2,284 |
$580K |
| J2350 |
Injection, ocrelizumab, 1 mg |
17 |
12 |
$524K |
| A6253 |
Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing |
1,522 |
1,123 |
$520K |
| B4035 |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
4,459 |
3,936 |
$493K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
8,914 |
6,740 |
$431K |
| E0431 |
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
19,584 |
15,857 |
$426K |
| B4149 |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
1,539 |
1,231 |
$412K |
| B4153 |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
875 |
731 |
$404K |
| J1950 |
Injection, leuprolide acetate (for depot suspension), per 3.75 mg |
41 |
27 |
$397K |
| A6212 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
1,294 |
908 |
$396K |
| T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
4,204 |
3,343 |
$390K |
| A4927 |
Gloves, non-sterile, per 100 |
27,912 |
20,717 |
$341K |
| A6209 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
1,474 |
1,061 |
$335K |
| 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 |
3,809 |
3,192 |
$325K |
| B4150 |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
4,002 |
3,197 |
$321K |
| K0738 |
Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing |
9,084 |
7,740 |
$318K |
| A7035 |
Headgear used with positive airway pressure device |
14,741 |
12,125 |
$316K |
| E0265 |
Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress |
1,988 |
1,489 |
$309K |
| S9338 |
Home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
6,317 |
1,641 |
$304K |
| A7032 |
Cushion for use on nasal mask interface, replacement only, each |
9,812 |
8,016 |
$300K |
| E0143 |
Walker, folding, wheeled, adjustable or fixed height |
6,817 |
5,937 |
$292K |
| S9366 |
Home infusion therapy, total parenteral nutrition (tpn); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem |
421 |
60 |
$283K |
| S9500 |
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
1,986 |
567 |
$272K |
| B4224 |
Parenteral nutrition administration kit, per day |
1,979 |
470 |
$260K |
| 99602 |
Nursing care in home rn |
3,973 |
2,362 |
$237K |
| A7520 |
Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (pvc), silicone or equal, each |
2,884 |
2,350 |
$237K |
| E1392 |
Portable oxygen concentrator, rental |
6,639 |
5,768 |
$230K |
| A4520 |
Incontinence garment, any type, (e.g., brief, diaper), each |
2,385 |
1,449 |
$227K |
| A4407 |
Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller, each |
1,472 |
855 |
$223K |
| A4385 |
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each |
2,553 |
1,531 |
$207K |
| B4220 |
Parenteral nutrition supply kit; premix, per day |
1,979 |
470 |
$203K |
| A4629 |
Tracheostomy care kit for established tracheostomy |
2,335 |
2,014 |
$194K |
| E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
5,895 |
5,346 |
$193K |
| E0570 |
Nebulizer, with compressor |
7,500 |
6,437 |
$191K |
| K0001 |
Standard wheelchair |
6,937 |
5,580 |
$189K |
| A4623 |
Tracheostomy, inner cannula |
1,692 |
1,367 |
$184K |
| A7031 |
Face mask interface, replacement for full face mask, each |
5,097 |
4,116 |
$182K |
| A7038 |
Filter, disposable, used with positive airway pressure device |
27,752 |
22,333 |
$178K |
| S8120 |
Oxygen contents, gaseous, 1 unit equals 1 cubic foot |
5,423 |
2,482 |
$178K |
| A7526 |
Tracheostomy tube collar/holder, each |
2,672 |
2,303 |
$176K |
| A6266 |
Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard |
732 |
558 |
$174K |
| A4670 |
Automatic blood pressure monitor |
3,722 |
2,700 |
$168K |
| E0470 |
Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
855 |
742 |
$167K |
| S9379 |
Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
2,420 |
1,447 |
$165K |
| A7046 |
Water chamber for humidifier, used with positive airway pressure device, replacement, each |
13,381 |
10,720 |
$162K |
| T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
1,273 |
987 |
$159K |
| L4361 |
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf |
649 |
511 |
$156K |
| A4606 |
Oxygen probe for use with oximeter device, replacement |
1,688 |
1,371 |
$155K |
| A7033 |
Pillow for use on nasal cannula type interface, replacement only, pair |
5,768 |
4,709 |
$145K |
| A4452 |
Tape, waterproof, per 18 square inches |
1,394 |
950 |
$143K |
| 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 |
990 |
688 |
$143K |
| T4532 |
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each |
1,006 |
836 |
$133K |
| A4357 |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
3,501 |
2,169 |
$128K |
| S9374 |
Home infusion therapy, hydration therapy; one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
1,687 |
487 |
$128K |
| B4155 |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit |
1,353 |
1,050 |
$116K |
| Q5121 |
Injection, infliximab-axxq, biosimilar, (avsola), 10 mg |
46 |
38 |
$113K |
| A6021 |
Collagen dressing, sterile, size 16 sq. in. or less, each |
214 |
120 |
$109K |
| B4158 |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit |
875 |
723 |
$108K |
| B4154 |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
542 |
458 |
$105K |
| S9343 |
Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem |
1,199 |
839 |
$96K |
| S9359 |
Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e.g., infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
2,505 |
1,890 |
$94K |
| A4425 |
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each |
1,196 |
873 |
$84K |
| A4221 |
Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately) |
2,685 |
1,470 |
$81K |
| A5061 |
Ostomy pouch, drainable; with barrier attached, (1 piece), each |
982 |
758 |
$71K |
| E0445 |
Oximeter device for measuring blood oxygen levels non-invasively |
194 |
178 |
$70K |
| E0630 |
Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) |
1,700 |
1,464 |
$69K |
| A7037 |
Tubing used with positive airway pressure device |
4,077 |
3,620 |
$69K |
| E0163 |
Commode chair, mobile or stationary, with fixed arms |
1,271 |
1,086 |
$69K |
| K0195 |
Elevating leg rests, pair (for use with capped rental wheelchair base) |
5,904 |
4,804 |
$68K |
| E0600 |
Respiratory suction pump, home model, portable or stationary, electric |
2,155 |
1,868 |
$67K |
| B4103 |
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit |
766 |
600 |
$66K |
| A4483 |
Moisture exchanger, disposable, for use with invasive mechanical ventilation |
657 |
496 |
$63K |
| L3809 |
Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type |
383 |
262 |
$59K |
| K0007 |
Extra heavy duty wheelchair |
498 |
447 |
$58K |
| K0552 |
Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each |
129 |
99 |
$57K |
| A4394 |
Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce |
1,904 |
1,442 |
$55K |
| A7005 |
Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable |
2,634 |
2,205 |
$52K |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
4,165 |
3,196 |
$52K |
| L3908 |
Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf |
1,274 |
849 |
$51K |
| A4406 |
Ostomy skin barrier, pectin-based, paste, per ounce |
1,589 |
1,092 |
$50K |
| A7000 |
Canister, disposable, used with suction pump, each |
4,392 |
3,773 |
$50K |
| K0003 |
Lightweight wheelchair |
993 |
868 |
$49K |
| A4409 |
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each |
555 |
467 |
$49K |
| A5120 |
Skin barrier, wipes or swabs, each |
4,169 |
2,966 |
$49K |
| A7002 |
Tubing, used with suction pump, each |
4,371 |
3,712 |
$46K |
| B4034 |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
1,197 |
1,047 |
$43K |
| A4628 |
Oral and/or oropharyngeal suction catheter, each |
3,456 |
2,879 |
$43K |
| A4553 |
Non-disposable underpads, all sizes |
3,148 |
2,803 |
$43K |
| A4349 |
Male external catheter, with or without adhesive, disposable, each |
569 |
472 |
$39K |
| A6446 |
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard |
764 |
560 |
$37K |
| B4088 |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
588 |
557 |
$34K |
| E0149 |
Walker, heavy duty, wheeled, rigid or folding, any type |
582 |
504 |
$34K |
| A7036 |
Chinstrap used with positive airway pressure device |
2,720 |
2,264 |
$32K |
| A4217 |
Sterile water/saline, 500 ml |
1,676 |
1,224 |
$31K |
| A4456 |
Adhesive remover, wipes, any type, each |
2,111 |
1,532 |
$30K |
| S9502 |
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
327 |
86 |
$29K |
| A4358 |
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each |
1,061 |
613 |
$29K |
| L1820 |
Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
300 |
226 |
$28K |
| A4450 |
Tape, non-waterproof, per 18 square inches |
3,208 |
2,266 |
$28K |
| A4216 |
Sterile water, saline and/or dextrose, diluent/flush, 10 ml |
1,743 |
1,331 |
$27K |
| T4521 |
Adult sized disposable incontinence product, brief/diaper, small, each |
332 |
236 |
$26K |
| A5063 |
Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each |
375 |
331 |
$24K |
| E0156 |
Seat attachment, walker |
1,312 |
1,080 |
$23K |
| L8501 |
Tracheostomy speaking valve |
340 |
299 |
$21K |
| E0973 |
Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each |
1,579 |
732 |
$21K |
| A4402 |
Lubricant, per ounce |
1,225 |
832 |
$20K |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
1,953 |
1,323 |
$17K |
| E0240 |
Bath/shower chair, with or without wheels, any size |
377 |
271 |
$16K |
| A6210 |
Foam 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 |
108 |
101 |
$16K |
| A6260 |
Wound cleansers, any type, any size |
605 |
387 |
$16K |
| A4362 |
Skin barrier; solid, 4 x 4 or equivalent; each |
272 |
187 |
$15K |
| A7003 |
Administration set, with small volume nonfiltered pneumatic nebulizer, disposable |
4,224 |
3,442 |
$14K |
| E0471 |
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
39 |
38 |
$14K |
| A4414 |
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each |
135 |
125 |
$13K |
| J7307 |
Etonogestrel (contraceptive) implant system, including implant and supplies |
33 |
12 |
$12K |
| A4371 |
Ostomy skin barrier, powder, per oz |
1,683 |
1,186 |
$12K |
| E0100 |
Cane, includes canes of all materials, adjustable or fixed, with tip |
607 |
509 |
$11K |
| A7525 |
Tracheostomy mask, each |
1,688 |
1,207 |
$11K |
| A4332 |
Lubricant, individual sterile packet, each |
2,002 |
1,658 |
$11K |
| A7039 |
Filter, non disposable, used with positive airway pressure device |
1,203 |
1,000 |
$10K |
| J3370 |
Injection, vancomycin hcl, 500 mg |
41 |
12 |
$9K |
| A7007 |
Large volume nebulizer, disposable, unfilled, used with aerosol compressor |
1,116 |
893 |
$9K |
| E0114 |
Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips |
178 |
138 |
$8K |
| B9002 |
Enteral nutrition infusion pump, any type |
218 |
193 |
$8K |
| S9375 |
Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
33 |
13 |
$8K |
| S8121 |
Oxygen contents, liquid, 1 unit equals 1 pound |
409 |
126 |
$7K |
| A4310 |
Insertion tray without drainage bag and without catheter (accessories only) |
216 |
142 |
$7K |
| A7012 |
Water collection device, used with large volume nebulizer |
1,172 |
944 |
$7K |
| A7015 |
Aerosol mask, used with dme nebulizer |
2,202 |
1,760 |
$6K |
| A4388 |
Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each |
49 |
36 |
$6K |
| E0434 |
Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing |
209 |
183 |
$6K |
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
39 |
36 |
$6K |
| A7507 |
Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each |
69 |
64 |
$5K |
| E0181 |
Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty |
375 |
344 |
$5K |
| T4537 |
Incontinence product, protective underpad, reusable, bed size, each |
2,579 |
1,691 |
$4K |
| S5501 |
Home infusion therapy, catheter care / maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
37 |
28 |
$4K |
| L1902 |
Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf |
57 |
37 |
$4K |
| A6222 |
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
30 |
14 |
$3K |
| J0696 |
Injection, ceftriaxone sodium, per 250 mg |
38 |
16 |
$3K |
| A6445 |
Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard |
76 |
71 |
$3K |
| S8189 |
Tracheostomy supply, not otherwise classified |
301 |
263 |
$3K |
| A9999 |
Miscellaneous dme supply or accessory, not otherwise specified |
128 |
51 |
$3K |
| A6449 |
Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard |
45 |
28 |
$2K |
| A7018 |
Water, distilled, used with large volume nebulizer, 1000 ml |
785 |
698 |
$2K |
| E0303 |
Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress |
13 |
12 |
$2K |
| E0565 |
Compressor, air power source for equipment which is not self-contained or cylinder driven |
26 |
24 |
$2K |
| T4533 |
Youth sized disposable incontinence product, brief/diaper, each |
13 |
12 |
$1K |
| A6223 |
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing |
13 |
12 |
$1K |
| A4253 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
16 |
15 |
$1K |
| L0625 |
Lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf |
26 |
12 |
$985.32 |
| A4244 |
Alcohol or peroxide, per pint |
22 |
17 |
$933.28 |
| A6248 |
Hydrogel dressing, wound filler, gel, per fluid ounce |
13 |
12 |
$861.89 |
| A6443 |
Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard |
34 |
12 |
$813.98 |
| S9341 |
Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem |
14 |
12 |
$735.60 |
| A4245 |
Alcohol wipes, per box |
270 |
247 |
$643.11 |
| A4367 |
Ostomy belt, each |
52 |
51 |
$526.12 |
| E0443 |
Portable oxygen contents, gaseous, 1 month's supply = 1 unit |
655 |
626 |
$423.21 |
| S9330 |
Home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
18 |
12 |
$400.55 |
| E0165 |
Commode chair, mobile or stationary, with detachable arms |
13 |
12 |
$395.31 |
| A7010 |
Corrugated tubing, disposable, used with large volume nebulizer, 100 feet |
24 |
24 |
$297.19 |
| E1226 |
Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each |
13 |
13 |
$291.41 |
| J9190 |
Injection, fluorouracil, 500 mg |
21 |
14 |
$189.87 |
| A4259 |
Lancets, per box of 100 |
14 |
13 |
$163.21 |