| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4930 |
Gloves, sterile, per pair |
2,189 |
2,171 |
$340K |
| T4541 |
Incontinence product, disposable underpad, large, each |
611 |
606 |
$18K |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
132 |
132 |
$13K |
| A4554 |
Disposable underpads, all sizes |
47 |
47 |
$9K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
24 |
24 |
$2K |
| K0001 |
Standard wheelchair |
170 |
167 |
$2K |
| S5199 |
Personal care item, nos, each |
26 |
25 |
$0.00 |