| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
103 |
101 |
$17K |
| A4554 |
Disposable underpads, all sizes |
135 |
131 |
$11K |
| A5122 |
Skin barrier; solid, 8 x 8 or equivalent, each |
20 |
20 |
$6K |
| A4930 |
Gloves, sterile, per pair |
122 |
120 |
$1K |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
15 |
15 |
$351.00 |
| A6403 |
Gauze, non-impregnated, sterile, pad size more than 16 sq. in. less than or equal to 48 sq. in., without adhesive border, each dressing |
13 |
13 |
$338.00 |
| A6454 |
Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard |
12 |
12 |
$205.20 |