| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
162,848 |
161,150 |
$12.20M |
| T4537 |
Incontinence product, protective underpad, reusable, bed size, each |
428,584 |
424,214 |
$12.04M |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
187,335 |
185,306 |
$11.94M |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
159,326 |
157,605 |
$9.33M |
| A4927 |
Gloves, non-sterile, per 100 |
302,470 |
299,679 |
$7.60M |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
245,387 |
242,726 |
$6.02M |
| E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate |
112,117 |
110,086 |
$5.66M |
| T4541 |
Incontinence product, disposable underpad, large, each |
383,295 |
379,172 |
$5.54M |
| T4544 |
Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each |
43,944 |
42,103 |
$3.88M |
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
54,795 |
53,847 |
$3.83M |
| E1399 |
Durable medical equipment, miscellaneous |
5,739 |
4,249 |
$2.94M |
| T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
44,752 |
44,097 |
$2.70M |
| A4353 |
Intermittent urinary catheter, with insertion supplies |
5,069 |
4,443 |
$2.50M |
| E0601 |
Continuous positive airway pressure (cpap) device |
71,060 |
70,239 |
$2.31M |
| T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
45,786 |
45,269 |
$2.20M |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
36,429 |
35,981 |
$2.00M |
| T4524 |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
28,390 |
28,052 |
$1.84M |
| T4530 |
Pediatric sized disposable incontinence product, brief/diaper, large size, each |
25,011 |
24,580 |
$1.61M |
| A4351 |
Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each |
23,458 |
21,614 |
$1.61M |
| E0570 |
Nebulizer, with compressor |
57,977 |
57,343 |
$1.58M |
| T4543 |
Adult sized disposable incontinence product, protective brief/diaper, above extra large, each |
11,549 |
11,333 |
$1.34M |
| E0466 |
Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) |
3,483 |
3,440 |
$1.10M |
| E0431 |
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
72,206 |
70,966 |
$931K |
| T4521 |
Adult sized disposable incontinence product, brief/diaper, small, each |
14,995 |
14,808 |
$901K |
| 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) |
12,287 |
12,202 |
$842K |
| A4253 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
78,048 |
67,831 |
$816K |
| E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
15,651 |
15,510 |
$811K |
| A4385 |
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each |
16,160 |
14,334 |
$803K |
| E0465 |
Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) |
1,230 |
1,203 |
$677K |
| E0445 |
Oximeter device for measuring blood oxygen levels non-invasively |
3,253 |
3,213 |
$651K |
| E0562 |
Humidifier, heated, used with positive airway pressure device |
33,046 |
32,587 |
$635K |
| T4532 |
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each |
8,439 |
8,330 |
$601K |
| A7030 |
Full face mask used with positive airway pressure device, each |
15,482 |
15,078 |
$595K |
| L4361 |
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf |
3,601 |
3,592 |
$552K |
| K0001 |
Standard wheelchair |
28,596 |
28,281 |
$545K |
| E0143 |
Walker, folding, wheeled, adjustable or fixed height |
11,909 |
11,804 |
$542K |
| A4409 |
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each |
9,106 |
8,485 |
$506K |
| E0603 |
Breast pump, electric (ac and/or dc), any type |
4,442 |
4,429 |
$456K |
| T4533 |
Youth sized disposable incontinence product, brief/diaper, each |
7,115 |
7,014 |
$427K |
| K0108 |
Wheelchair component or accessory, not otherwise specified |
3,367 |
2,062 |
$424K |
| K0003 |
Lightweight wheelchair |
8,947 |
8,889 |
$368K |
| A4352 |
Intermittent urinary catheter; coude (curved) tip, with or without coating (teflon, silicone, or silicone elastomeric, etc.), each |
1,891 |
1,533 |
$328K |
| L3908 |
Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf |
7,469 |
6,321 |
$313K |
| A4407 |
Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller, each |
4,586 |
4,222 |
$306K |
| A4425 |
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each |
6,940 |
6,409 |
$282K |
| A4362 |
Skin barrier; solid, 4 x 4 or equivalent; each |
8,869 |
8,081 |
$270K |
| E0471 |
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
1,787 |
1,744 |
$261K |
| A4414 |
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each |
5,206 |
4,468 |
$253K |
| A6530 |
Gradient compression stocking, below knee, 18-30 mmhg, each |
6,221 |
4,909 |
$245K |
| A7005 |
Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable |
21,637 |
21,444 |
$243K |
| A7034 |
Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap |
10,062 |
9,792 |
$239K |
| L1820 |
Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
2,725 |
2,637 |
$228K |
| E0630 |
Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) |
6,685 |
6,624 |
$214K |
| B4035 |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
1,445 |
1,379 |
$213K |
| E1392 |
Portable oxygen concentrator, rental |
27,684 |
27,498 |
$211K |
| 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 |
673 |
585 |
$204K |
| A4388 |
Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each |
3,183 |
3,051 |
$195K |
| E1028 |
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware, other |
2,125 |
1,794 |
$188K |
| A4458 |
Enema bag with tubing, reusable |
4,440 |
3,786 |
$180K |
| A7035 |
Headgear used with positive airway pressure device |
18,049 |
17,593 |
$169K |
| K0823 |
Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds |
1,392 |
1,378 |
$164K |
| E2402 |
Negative pressure wound therapy electrical pump, stationary or portable |
609 |
594 |
$160K |
| K0007 |
Extra heavy duty wheelchair |
3,619 |
3,568 |
$159K |
| A4432 |
Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each |
4,884 |
4,398 |
$151K |
| A4624 |
Tracheal suction catheter, any type other than closed system, each |
1,916 |
1,825 |
$151K |
| A7031 |
Face mask interface, replacement for full face mask, each |
8,424 |
8,136 |
$148K |
| A7037 |
Tubing used with positive airway pressure device |
16,527 |
16,154 |
$147K |
| K0004 |
High strength, lightweight wheelchair |
2,350 |
2,329 |
$144K |
| E2617 |
Custom fabricated wheelchair back cushion, any size, including any type mounting hardware |
184 |
169 |
$144K |
| E1161 |
Manual adult size wheelchair, includes tilt in space |
307 |
304 |
$141K |
| A5063 |
Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each |
4,926 |
4,568 |
$138K |
| E0250 |
Hospital bed, fixed height, with any type side rails, with mattress |
10,266 |
10,128 |
$137K |
| A6533 |
Gradient compression stocking, thigh length, 18-30 mmhg, each |
2,517 |
1,893 |
$133K |
| A4424 |
Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each |
2,579 |
2,238 |
$132K |
| E1236 |
Wheelchair, pediatric size, folding, adjustable, with seating system |
331 |
321 |
$129K |
| A4394 |
Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce |
10,241 |
9,624 |
$129K |
| E0149 |
Walker, heavy duty, wheeled, rigid or folding, any type |
5,213 |
5,131 |
$128K |
| E0955 |
Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each |
1,808 |
1,748 |
$120K |
| L3809 |
Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type |
875 |
852 |
$116K |
| E2609 |
Custom fabricated wheelchair seat cushion, any size |
136 |
127 |
$114K |
| E0114 |
Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips |
4,304 |
4,301 |
$111K |
| A6252 |
Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing |
1,853 |
1,718 |
$110K |
| E0303 |
Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress |
1,528 |
1,502 |
$109K |
| E0600 |
Respiratory suction pump, home model, portable or stationary, electric |
2,844 |
2,810 |
$108K |
| A5120 |
Skin barrier, wipes or swabs, each |
18,978 |
16,671 |
$106K |
| E0277 |
Powered pressure-reducing air mattress |
1,495 |
1,474 |
$106K |
| A4629 |
Tracheostomy care kit for established tracheostomy |
2,597 |
2,521 |
$105K |
| A4456 |
Adhesive remover, wipes, any type, each |
14,238 |
12,685 |
$104K |
| E0971 |
Manual wheelchair accessory, anti-tipping device, each |
3,094 |
2,644 |
$104K |
| A5057 |
Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each |
1,100 |
1,020 |
$104K |
| K0739 |
Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes |
2,865 |
2,764 |
$100K |
| A6253 |
Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing |
530 |
489 |
$99K |
| E0607 |
Home blood glucose monitor |
7,108 |
6,399 |
$99K |
| E0730 |
Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation |
2,917 |
2,888 |
$98K |
| L4387 |
Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf |
1,091 |
1,087 |
$98K |
| A7038 |
Filter, disposable, used with positive airway pressure device |
28,193 |
27,809 |
$96K |
| 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 |
918 |
864 |
$93K |
| A4310 |
Insertion tray without drainage bag and without catheter (accessories only) |
7,497 |
6,319 |
$87K |
| K0195 |
Elevating leg rests, pair (for use with capped rental wheelchair base) |
12,452 |
12,281 |
$82K |
| A4357 |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
20,238 |
18,854 |
$81K |
| A7526 |
Tracheostomy tube collar/holder, each |
2,314 |
2,267 |
$81K |
| E0973 |
Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each |
1,211 |
1,089 |
$79K |
| A4452 |
Tape, waterproof, per 18 square inches |
4,908 |
4,640 |
$78K |
| E0163 |
Commode chair, mobile or stationary, with fixed arms |
2,090 |
2,051 |
$75K |
| A4419 |
Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each |
1,752 |
1,560 |
$74K |
| A6446 |
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard |
3,312 |
3,036 |
$72K |
| A4430 |
Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each |
1,138 |
974 |
$72K |
| A4373 |
Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each |
1,205 |
1,044 |
$71K |
| T4540 |
Incontinence product, protective underpad, reusable, chair size, each |
9,573 |
9,425 |
$71K |
| T4531 |
Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each |
1,158 |
1,135 |
$71K |
| K0553 |
Supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service |
1,171 |
1,100 |
$69K |
| E0240 |
Bath/shower chair, with or without wheels, any size |
341 |
333 |
$68K |
| A4259 |
Lancets, per box of 100 |
61,950 |
54,348 |
$68K |
| E0482 |
Cough stimulating device, alternating positive and negative airway pressure |
360 |
343 |
$67K |
| A4389 |
Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each |
830 |
769 |
$67K |
| A4604 |
Tubing with integrated heating element for use with positive airway pressure device |
8,232 |
7,906 |
$66K |
| A4670 |
Automatic blood pressure monitor |
1,256 |
1,252 |
$66K |
| A4332 |
Lubricant, individual sterile packet, each |
13,415 |
11,223 |
$66K |
| A4344 |
Indwelling catheter, foley type, two-way, all silicone or polyurethane, each |
3,017 |
2,507 |
$63K |
| A4349 |
Male external catheter, with or without adhesive, disposable, each |
4,427 |
4,149 |
$63K |
| E0565 |
Compressor, air power source for equipment which is not self-contained or cylinder driven |
1,460 |
1,449 |
$59K |
| A5056 |
Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each |
964 |
928 |
$56K |
| A5500 |
For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe |
905 |
716 |
$56K |
| E0156 |
Seat attachment, walker |
6,350 |
6,302 |
$55K |
| E2601 |
General use wheelchair seat cushion, width less than 22 inches, any depth |
2,507 |
2,410 |
$54K |
| 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 |
584 |
559 |
$54K |
| A4406 |
Ostomy skin barrier, pectin-based, paste, per ounce |
6,660 |
6,362 |
$53K |
| L3670 |
Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf |
867 |
867 |
$52K |
| A7520 |
Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (pvc), silicone or equal, each |
1,894 |
1,847 |
$52K |
| A7032 |
Cushion for use on nasal mask interface, replacement only, each |
2,909 |
2,815 |
$49K |
| E0960 |
Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware |
853 |
831 |
$49K |
| K0040 |
Adjustable angle footplate, each |
765 |
705 |
$44K |
| E0978 |
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each |
2,172 |
2,130 |
$44K |
| T4542 |
Incontinence product, disposable underpad, small size, each |
2,406 |
2,362 |
$44K |
| L1902 |
Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf |
987 |
964 |
$43K |
| A4428 |
Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each |
504 |
463 |
$42K |
| A4239 |
Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service |
727 |
717 |
$41K |
| A4358 |
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each |
8,684 |
8,027 |
$40K |
| A4623 |
Tracheostomy, inner cannula |
550 |
523 |
$38K |
| A7046 |
Water chamber for humidifier, used with positive airway pressure device, replacement, each |
11,990 |
11,845 |
$38K |
| L3020 |
Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each |
198 |
175 |
$38K |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
4,122 |
3,948 |
$36K |
| A4427 |
Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each |
1,355 |
1,276 |
$34K |
| 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 |
287 |
260 |
$33K |
| L4350 |
Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf |
509 |
506 |
$32K |
| A7000 |
Canister, disposable, used with suction pump, each |
2,814 |
2,763 |
$31K |
| A4371 |
Ostomy skin barrier, powder, per oz |
9,820 |
9,247 |
$31K |
| A5512 |
For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each |
332 |
321 |
$30K |
| A4390 |
Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each |
428 |
352 |
$30K |
| A4322 |
Irrigation syringe, bulb or piston, each |
4,969 |
4,063 |
$30K |
| K0006 |
Heavy duty wheelchair |
1,271 |
1,249 |
$30K |
| A4402 |
Lubricant, per ounce |
7,520 |
7,089 |
$29K |
| E0165 |
Commode chair, mobile or stationary, with detachable arms |
2,277 |
2,262 |
$29K |
| T4536 |
Incontinence product, protective underwear/pull-on, reusable, any size, each |
1,412 |
1,389 |
$27K |
| A4335 |
Incontinence supply; miscellaneous |
3,444 |
3,379 |
$27K |
| B9002 |
Enteral nutrition infusion pump, any type |
559 |
542 |
$26K |
| E2611 |
General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware |
476 |
451 |
$26K |
| E0261 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress |
698 |
693 |
$26K |
| A7033 |
Pillow for use on nasal cannula type interface, replacement only, pair |
1,640 |
1,569 |
$26K |
| K0005 |
Ultralightweight wheelchair |
25 |
25 |
$25K |
| A4256 |
Normal, low and high calibrator solution / chips |
19,452 |
17,194 |
$23K |
| E0181 |
Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty |
2,875 |
2,847 |
$22K |
| A4367 |
Ostomy belt, each |
5,228 |
4,935 |
$21K |
| E0100 |
Cane, includes canes of all materials, adjustable or fixed, with tip |
1,878 |
1,874 |
$20K |
| E0951 |
Heel loop/holder, any type, with or without ankle strap, each |
1,540 |
1,280 |
$18K |
| A4320 |
Irrigation tray with bulb or piston syringe, any purpose |
2,849 |
2,653 |
$17K |
| A4520 |
Incontinence garment, any type, (e.g., brief, diaper), each |
787 |
604 |
$17K |
| A4450 |
Tape, non-waterproof, per 18 square inches |
3,702 |
3,527 |
$17K |
| E0956 |
Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each |
109 |
94 |
$17K |
| E1038 |
Transport chair, adult size, patient weight capacity up to and including 300 pounds |
2,534 |
2,526 |
$17K |
| A6212 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
113 |
104 |
$15K |
| E0561 |
Humidifier, non-heated, used with positive airway pressure device |
1,521 |
1,510 |
$15K |
| E0961 |
Manual wheelchair accessory, wheel lock brake extension (handle), each |
895 |
717 |
$15K |
| A4405 |
Ostomy skin barrier, non-pectin based, paste, per ounce |
1,638 |
1,528 |
$14K |
| A7015 |
Aerosol mask, used with dme nebulizer |
16,720 |
16,565 |
$14K |
| A7003 |
Administration set, with small volume nonfiltered pneumatic nebulizer, disposable |
10,697 |
10,573 |
$13K |
| E0135 |
Walker, folding (pickup), adjustable or fixed height |
323 |
321 |
$13K |
| E0245 |
Tub stool or bench |
431 |
421 |
$13K |
| E0168 |
Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each |
1,476 |
1,447 |
$13K |
| E2213 |
Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each |
369 |
345 |
$12K |
| E2211 |
Manual wheelchair accessory, pneumatic propulsion tire, any size, each |
331 |
303 |
$12K |
| E0105 |
Cane, quad or three prong, includes canes of all materials, adjustable or fixed, with tips |
443 |
441 |
$12K |
| S8189 |
Tracheostomy supply, not otherwise classified |
73 |
68 |
$11K |
| A4627 |
Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler |
1,120 |
1,112 |
$10K |
| E1226 |
Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each |
337 |
328 |
$10K |
| A5061 |
Ostomy pouch, drainable; with barrier attached, (1 piece), each |
342 |
303 |
$9K |
| A4338 |
Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each |
3,883 |
3,578 |
$9K |
| A4628 |
Oral and/or oropharyngeal suction catheter, each |
2,203 |
2,151 |
$9K |
| A7036 |
Chinstrap used with positive airway pressure device |
1,909 |
1,873 |
$9K |
| A4333 |
Urinary catheter anchoring device, adhesive skin attachment, each |
2,273 |
1,952 |
$8K |
| E0185 |
Gel or gel-like pressure pad for mattress, standard mattress length and width |
107 |
106 |
$8K |
| A6266 |
Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard |
246 |
235 |
$7K |
| A6539 |
Gradient compression stocking, waist length, 18-30 mmhg, each |
97 |
94 |
$7K |
| B4088 |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
81 |
78 |
$7K |
| A7002 |
Tubing, used with suction pump, each |
2,815 |
2,652 |
$7K |
| A4411 |
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each |
58 |
48 |
$6K |
| E0251 |
Hospital bed, fixed height, with any type side rails, without mattress |
454 |
441 |
$6K |
| A4258 |
Spring-powered device for lancet, each |
12,619 |
10,815 |
$6K |
| B4034 |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
566 |
545 |
$6K |
| E0950 |
Wheelchair accessory, tray, each |
82 |
79 |
$6K |
| E0910 |
Trapeze bars, a/k/a patient helper, attached to bed, with grab bar |
903 |
890 |
$5K |
| A4412 |
Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), without filter, each |
164 |
135 |
$5K |
| A4314 |
Insertion tray with drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) |
1,636 |
1,549 |
$4K |
| A6531 |
Gradient compression stocking, below knee, 30-40 mmhg, used as a surgical dressing, each |
104 |
99 |
$4K |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
765 |
739 |
$4K |
| K0002 |
Standard hemi (low seat) wheelchair |
296 |
293 |
$3K |
| A5513 |
For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each |
31 |
24 |
$3K |
| A6021 |
Collagen dressing, sterile, size 16 sq. in. or less, each |
16 |
16 |
$3K |
| L8000 |
Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type |
88 |
81 |
$3K |
| A7007 |
Large volume nebulizer, disposable, unfilled, used with aerosol compressor |
843 |
831 |
$3K |
| A4315 |
Insertion tray with drainage bag with indwelling catheter, foley type, two-way, all silicone |
420 |
404 |
$2K |
| E1020 |
Residual limb support system for wheelchair, any type |
73 |
65 |
$2K |
| L0642 |
Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf |
12 |
12 |
$2K |
| T1999 |
Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified; identify product in "remarks" |
21 |
12 |
$2K |
| A6550 |
Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories |
14 |
12 |
$2K |
| S5199 |
Personal care item, nos, each |
652 |
649 |
$2K |
| A7012 |
Water collection device, used with large volume nebulizer |
665 |
653 |
$2K |
| A7010 |
Corrugated tubing, disposable, used with large volume nebulizer, 100 feet |
149 |
148 |
$2K |
| A7525 |
Tracheostomy mask, each |
1,555 |
1,483 |
$1K |
| A6223 |
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing |
27 |
25 |
$1K |
| A4334 |
Urinary catheter anchoring device, leg strap, each |
679 |
613 |
$971.88 |
| K0738 |
Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing |
95 |
94 |
$839.11 |
| E0244 |
Raised toilet seat |
31 |
28 |
$827.70 |
| Q0513 |
Pharmacy dispensing fee for inhalation drug(s); per 30 days |
109 |
109 |
$759.00 |
| E0184 |
Dry pressure mattress |
28 |
26 |
$748.56 |
| L3660 |
Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf |
12 |
12 |
$653.91 |
| L1830 |
Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf |
12 |
12 |
$506.76 |
| E0952 |
Toe loop/holder, any type, each |
30 |
27 |
$473.20 |
| E0776 |
Iv pole |
62 |
62 |
$461.27 |
| B9998 |
Noc for enteral supplies |
16 |
12 |
$452.18 |
| A7039 |
Filter, non disposable, used with positive airway pressure device |
311 |
308 |
$440.12 |
| A6222 |
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
12 |
12 |
$426.99 |
| A4426 |
Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each |
31 |
24 |
$375.40 |
| A4595 |
Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) |
26 |
26 |
$352.82 |
| A4364 |
Adhesive, liquid or equal, any type, per oz |
56 |
52 |
$272.29 |
| A6260 |
Wound cleansers, any type, any size |
28 |
26 |
$263.88 |
| A6449 |
Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard |
13 |
12 |
$106.93 |
| A4398 |
Ostomy irrigation supply; bag, each |
14 |
12 |
$99.40 |
| A4233 |
Replacement battery, alkaline (other than j cell), for use with medically necessary home blood glucose monitor owned by patient, each |
128 |
83 |
$21.16 |
| A7018 |
Water, distilled, used with large volume nebulizer, 1000 ml |
16 |
16 |
$13.15 |
| A7013 |
Filter, disposable, used with aerosol compressor or ultrasonic generator |
539 |
532 |
$6.08 |