| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 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 |
88 |
86 |
$55K |
| A9276 |
Sensor; invasive (e.g., subcutaneous), disposable, for use with non-durable medical equipment interstitial continuous glucose monitoring system, one unit = 1 day supply |
77 |
71 |
$39K |
| A4224 |
Supplies for maintenance of insulin infusion catheter, per week |
84 |
81 |
$31K |
| 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 |
232 |
200 |
$29K |
| K0001 |
Standard wheelchair |
406 |
401 |
$15K |
| 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 |
78 |
76 |
$11K |
| 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 |
72 |
59 |
$10K |
| A9274 |
External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories |
13 |
12 |
$7K |
| B9998 |
Noc for enteral supplies |
165 |
149 |
$7K |
| A4225 |
Supplies for external insulin infusion pump, syringe type cartridge, sterile, each |
82 |
80 |
$7K |
| B4035 |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
69 |
66 |
$6K |
| K0003 |
Lightweight wheelchair |
100 |
97 |
$5K |
| K0195 |
Elevating leg rests, pair (for use with capped rental wheelchair base) |
86 |
86 |
$2K |
| B4034 |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
167 |
164 |
$1K |
| E0431 |
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
512 |
508 |
$163.94 |
| E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate |
548 |
544 |
$144.74 |
| A4670 |
Automatic blood pressure monitor |
123 |
123 |
$121.20 |
| T4541 |
Incontinence product, disposable underpad, large, each |
314 |
306 |
$61.00 |
| E0601 |
Continuous positive airway pressure (cpap) device |
777 |
777 |
$0.00 |
| A7038 |
Filter, disposable, used with positive airway pressure device |
128 |
127 |
$0.00 |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
77 |
75 |
$0.00 |
| A4425 |
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each |
27 |
24 |
$0.00 |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
61 |
61 |
$0.00 |
| A7035 |
Headgear used with positive airway pressure device |
188 |
188 |
$0.00 |
| T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
110 |
108 |
$0.00 |
| A4409 |
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each |
35 |
31 |
$0.00 |
| A4385 |
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each |
45 |
43 |
$0.00 |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
23 |
20 |
$0.00 |
| A7000 |
Canister, disposable, used with suction pump, each |
61 |
49 |
$0.00 |
| A7046 |
Water chamber for humidifier, used with positive airway pressure device, replacement, each |
29 |
29 |
$0.00 |
| A7034 |
Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap |
134 |
134 |
$0.00 |
| A4604 |
Tubing with integrated heating element for use with positive airway pressure device |
46 |
46 |
$0.00 |
| A4927 |
Gloves, non-sterile, per 100 |
125 |
115 |
$0.00 |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
80 |
78 |
$0.00 |
| A4357 |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
53 |
45 |
$0.00 |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
139 |
131 |
$0.00 |
| E0295 |
Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress |
90 |
90 |
$0.00 |
| A4452 |
Tape, waterproof, per 18 square inches |
14 |
13 |
$0.00 |
| E0163 |
Commode chair, mobile or stationary, with fixed arms |
15 |
15 |
$0.00 |
| T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
32 |
28 |
$0.00 |
| A7003 |
Administration set, with small volume nonfiltered pneumatic nebulizer, disposable |
16 |
16 |
$0.00 |
| T4524 |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
25 |
22 |
$0.00 |
| E0603 |
Breast pump, electric (ac and/or dc), any type |
142 |
142 |
$0.00 |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
109 |
101 |
$0.00 |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
117 |
117 |
$0.00 |
| A4456 |
Adhesive remover, wipes, any type, each |
77 |
71 |
$0.00 |
| A5120 |
Skin barrier, wipes or swabs, each |
72 |
71 |
$0.00 |
| A7037 |
Tubing used with positive airway pressure device |
130 |
130 |
$0.00 |
| A7030 |
Full face mask used with positive airway pressure device, each |
39 |
39 |
$0.00 |
| A7015 |
Aerosol mask, used with dme nebulizer |
58 |
57 |
$0.00 |
| 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) |
65 |
65 |
$0.00 |
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
15 |
15 |
$0.00 |
| E0271 |
Mattress, innerspring |
91 |
91 |
$0.00 |
| E0144 |
Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat |
12 |
12 |
$0.00 |
| E1392 |
Portable oxygen concentrator, rental |
44 |
42 |
$0.00 |
| A4351 |
Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each |
48 |
42 |
$0.00 |
| E0562 |
Humidifier, heated, used with positive airway pressure device |
882 |
882 |
$0.00 |
| A4217 |
Sterile water/saline, 500 ml |
102 |
94 |
$0.00 |
| E0305 |
Bed side rails, half length |
83 |
83 |
$0.00 |
| E0570 |
Nebulizer, with compressor |
42 |
42 |
$0.00 |
| E0143 |
Walker, folding, wheeled, adjustable or fixed height |
115 |
115 |
$0.00 |
| 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 |
14 |
14 |
$0.00 |
| A7032 |
Cushion for use on nasal mask interface, replacement only, each |
14 |
14 |
$0.00 |
| A4335 |
Incontinence supply; miscellaneous |
12 |
12 |
$0.00 |