| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| E1399 |
Durable medical equipment, miscellaneous |
1,879 |
408 |
$798K |
| K0108 |
Wheelchair component or accessory, not otherwise specified |
8,033 |
1,814 |
$695K |
| S5165 |
Home modifications; per service |
162 |
120 |
$573K |
| 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 |
780 |
718 |
$215K |
| T2029 |
Specialized medical equipment, not otherwise specified, waiver |
174 |
140 |
$158K |
| E1161 |
Manual adult size wheelchair, includes tilt in space |
1,963 |
1,099 |
$147K |
| E1028 |
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware, other |
10,031 |
3,108 |
$145K |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
1,796 |
1,741 |
$144K |
| T5999 |
Supply, not otherwise specified |
820 |
731 |
$130K |
| B9998 |
Noc for enteral supplies |
727 |
572 |
$122K |
| T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
1,714 |
1,581 |
$110K |
| K0739 |
Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes |
6,252 |
4,099 |
$106K |
| B4100 |
Food thickener, administered orally, per ounce |
741 |
661 |
$94K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
1,224 |
1,190 |
$92K |
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
1,003 |
955 |
$83K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
2,957 |
2,737 |
$79K |
| T4541 |
Incontinence product, disposable underpad, large, each |
3,651 |
3,470 |
$79K |
| B4035 |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
563 |
432 |
$77K |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
945 |
891 |
$72K |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
840 |
800 |
$69K |
| A4927 |
Gloves, non-sterile, per 100 |
3,671 |
3,245 |
$64K |
| 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 |
80 |
$44K |
| E0955 |
Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each |
3,105 |
1,786 |
$42K |
| E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
2,448 |
1,670 |
$40K |
| A4335 |
Incontinence supply; miscellaneous |
868 |
719 |
$21K |
| T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
339 |
312 |
$20K |
| K0823 |
Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds |
571 |
276 |
$19K |
| E0973 |
Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each |
582 |
229 |
$18K |
| 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 |
211 |
167 |
$15K |
| T4521 |
Adult sized disposable incontinence product, brief/diaper, small, each |
237 |
213 |
$13K |
| T4537 |
Incontinence product, protective underpad, reusable, bed size, each |
826 |
770 |
$11K |
| K0040 |
Adjustable angle footplate, each |
541 |
214 |
$11K |
| T4533 |
Youth sized disposable incontinence product, brief/diaper, each |
120 |
116 |
$9K |
| A9286 |
Hygienic item or device, disposable or non-disposable, any type, each |
700 |
427 |
$8K |
| T4530 |
Pediatric sized disposable incontinence product, brief/diaper, large size, each |
72 |
65 |
$8K |
| E0956 |
Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each |
213 |
70 |
$7K |
| E0277 |
Powered pressure-reducing air mattress |
38 |
38 |
$6K |
| B4034 |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
29 |
24 |
$4K |
| E0630 |
Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) |
205 |
164 |
$4K |
| T4524 |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
48 |
43 |
$4K |
| B4088 |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
56 |
39 |
$4K |
| K0004 |
High strength, lightweight wheelchair |
289 |
131 |
$3K |
| E0978 |
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each |
260 |
153 |
$3K |
| E0971 |
Manual wheelchair accessory, anti-tipping device, each |
90 |
40 |
$2K |
| E0265 |
Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress |
14 |
13 |
$2K |
| 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 |
16 |
13 |
$2K |
| E2607 |
Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth |
30 |
12 |
$1K |
| E2211 |
Manual wheelchair accessory, pneumatic propulsion tire, any size, each |
65 |
24 |
$567.40 |
| K0195 |
Elevating leg rests, pair (for use with capped rental wheelchair base) |
375 |
164 |
$489.04 |
| E2213 |
Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each |
37 |
12 |
$263.92 |
| K0001 |
Standard wheelchair |
13 |
12 |
$165.90 |
| A4357 |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
54 |
25 |
$157.88 |
| E0951 |
Heel loop/holder, any type, with or without ankle strap, each |
38 |
12 |
$116.94 |