| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4554 |
Disposable underpads |
22,336 |
22,308 |
$1.25M |
| T4523 |
Adult size brief/diaper lg |
9,364 |
9,352 |
$940K |
| T4522 |
Adult size brief/diaper med |
7,764 |
7,750 |
$592K |
| T4524 |
Adult size brief/diaper xl |
4,690 |
4,686 |
$546K |
| T4535 |
Disposable liner/shield/pad |
11,108 |
11,085 |
$343K |
| T4537 |
Reusable underpad bed size |
8,474 |
8,458 |
$272K |
| T4543 |
Adult disp brief/diap abv xl |
677 |
676 |
$140K |
| T4540 |
Reusable underpad chair size |
6,226 |
6,211 |
$111K |
| A4927 |
Non-sterile gloves |
18,593 |
18,583 |
$84K |
| L0648 |
Lso sag r an/pos pnl pre ots |
564 |
555 |
$75K |
| L1852 |
Ko double upright prefab ots |
544 |
354 |
$47K |
| T4539 |
Reuse diaper/brief any size |
1,456 |
1,453 |
$40K |
| K0003 |
Lightweight wheelchair |
2,193 |
2,179 |
$38K |
| E0260 |
Hosp bed semi-electr w/ matt |
1,209 |
1,198 |
$21K |
| L3030 |
Foot arch support remov prem |
568 |
285 |
$21K |
| K0823 |
Pwc gp 2 std cap chair |
197 |
195 |
$20K |
| T4521 |
Adult size brief/diaper sm |
200 |
200 |
$13K |
| K0001 |
Standard wheelchair |
841 |
837 |
$11K |
| E1390 |
Oxygen concentrator |
220 |
216 |
$11K |
| K0195 |
Elevating whlchair leg rests |
3,201 |
3,181 |
$8K |
| L3217 |
Ladies shoes hightop depth i |
104 |
52 |
$8K |
| L3216 |
Orthoped ladies shoes dpth i |
143 |
72 |
$6K |
| E0261 |
Hosp bed semi-electr w/o mat |
168 |
167 |
$6K |
| L2397 |
Suspension sleeve lower ext |
480 |
329 |
$5K |
| L3215 |
Orthopedic ftwear ladies oxf |
56 |
28 |
$4K |
| E0143 |
Walker folding wheeled w/o s |
117 |
115 |
$4K |
| L3807 |
Whfo w/o joints pre cst |
20 |
12 |
$2K |
| E0431 |
Portable gaseous 02 |
170 |
167 |
$2K |
| E0849 |
Cervical pneum trac equip |
187 |
184 |
$2K |
| L3020 |
Foot longitud/metatarsal sup |
24 |
12 |
$2K |
| L3221 |
Orthopedic mens shoes dpth i |
29 |
15 |
$1K |
| L1851 |
Ko single upright prefab ots |
23 |
19 |
$1K |
| L3809 |
Whfo w/o joints pre ots |
27 |
14 |
$1K |
| E0990 |
Wheelchair elevating leg res |
50 |
50 |
$1K |
| E0156 |
Walker seat attachment |
106 |
105 |
$860.10 |
| E0240 |
Bath/shower chair |
12 |
12 |
$425.92 |
| E0241 |
Bath tub wall rail |
12 |
12 |
$278.12 |
| E2601 |
Gen w/c cushion wdth < 22 in |
12 |
12 |
$127.45 |