| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| L3217 |
Orthopedic footwear, ladies shoe, hightop, depth inlay, each |
112 |
52 |
$4K |
| L3030 |
Foot, insert, removable, formed to patient foot, each |
576 |
260 |
$3K |
| A4927 |
Gloves, non-sterile, per 100 |
159 |
125 |
$2K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
12 |
12 |
$946.89 |
| 0003A |
|
17 |
17 |
$200.00 |
| A6531 |
Gradient compression stocking, below knee, 30-40 mmhg, used as a surgical dressing, each |
230 |
109 |
$53.52 |
| K0195 |
Elevating leg rests, pair (for use with capped rental wheelchair base) |
54 |
53 |
$17.88 |
| A4253 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
49 |
44 |
$3.33 |
| A4259 |
Lancets, per box of 100 |
37 |
31 |
$2.00 |
| A4258 |
Spring-powered device for lancet, each |
30 |
30 |
$1.04 |
| A5512 |
For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each |
247 |
119 |
$0.00 |
| A5500 |
For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe |
250 |
122 |
$0.00 |
| 91320 |
|
18 |
18 |
$0.00 |
| 0124A |
|
15 |
15 |
$0.00 |
| 90653 |
|
19 |
16 |
$0.00 |
| 0004A |
|
16 |
16 |
$0.00 |
| K1034 |
Provision of covid-19 test, nonprescription self-administered and self-collected use, fda approved, authorized or cleared, one test count |
161 |
159 |
$0.00 |
| 90694 |
|
30 |
30 |
$0.00 |
| G0008 |
Administration of influenza virus vaccine |
98 |
92 |
$0.00 |
| 90677 |
|
13 |
13 |
$0.00 |
| L3002 |
Foot, insert, removable, molded to patient model, plastazote or equal, each |
50 |
22 |
$0.00 |