| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 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 |
38,202 |
36,782 |
$8.55M |
| 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 |
8,468 |
7,917 |
$4.72M |
| B4035 |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
19,762 |
18,419 |
$4.31M |
| 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 |
37,493 |
35,058 |
$3.77M |
| 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 |
13,601 |
11,887 |
$3.48M |
| A6212 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
20,269 |
17,566 |
$2.44M |
| A6253 |
Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing |
15,063 |
13,312 |
$2.36M |
| 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 |
16,824 |
15,956 |
$2.12M |
| B9998 |
Noc for enteral supplies |
20,948 |
17,009 |
$2.08M |
| A6021 |
Collagen dressing, sterile, size 16 sq. in. or less, each |
8,647 |
7,844 |
$1.91M |
| B4154 |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
12,388 |
11,595 |
$1.71M |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
22,517 |
22,237 |
$1.56M |
| A6196 |
Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing |
13,628 |
12,163 |
$1.47M |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
21,826 |
21,456 |
$1.40M |
| B4153 |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
1,895 |
1,750 |
$1.36M |
| T4541 |
Incontinence product, disposable underpad, large, each |
60,441 |
59,248 |
$1.28M |
| B4088 |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
10,596 |
10,216 |
$1.26M |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
16,271 |
15,991 |
$1.25M |
| T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
14,608 |
13,663 |
$1.11M |
| B9002 |
Enteral nutrition infusion pump, any type |
17,531 |
16,298 |
$1.04M |
| A4353 |
Intermittent urinary catheter, with insertion supplies |
1,867 |
1,775 |
$1.01M |
| 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 |
15,654 |
14,181 |
$983K |
| E1399 |
Durable medical equipment, miscellaneous |
2,824 |
2,146 |
$913K |
| A6210 |
Foam 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 |
4,069 |
3,710 |
$862K |
| A4351 |
Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each |
7,137 |
6,803 |
$848K |
| A6446 |
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard |
34,520 |
30,700 |
$848K |
| T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
10,127 |
9,878 |
$756K |
| T4543 |
Adult sized disposable incontinence product, protective brief/diaper, above extra large, each |
3,330 |
3,263 |
$686K |
| B4149 |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
1,629 |
1,514 |
$589K |
| A4927 |
Gloves, non-sterile, per 100 |
48,369 |
45,731 |
$554K |
| T4544 |
Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each |
4,141 |
4,049 |
$554K |
| T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
7,790 |
7,611 |
$553K |
| A4409 |
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each |
7,481 |
7,144 |
$532K |
| L4361 |
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf |
2,508 |
2,472 |
$484K |
| 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 |
9,706 |
8,739 |
$481K |
| A4385 |
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each |
7,466 |
7,095 |
$452K |
| T4524 |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
5,957 |
5,814 |
$449K |
| E0570 |
Nebulizer, with compressor |
6,197 |
6,098 |
$441K |
| T4530 |
Pediatric sized disposable incontinence product, brief/diaper, large size, each |
6,322 |
5,925 |
$431K |
| A6222 |
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
7,880 |
7,277 |
$397K |
| A4452 |
Tape, waterproof, per 18 square inches |
36,653 |
32,872 |
$392K |
| A4216 |
Sterile water, saline and/or dextrose, diluent/flush, 10 ml |
34,725 |
32,091 |
$391K |
| A4425 |
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each |
8,417 |
8,045 |
$369K |
| T4537 |
Incontinence product, protective underpad, reusable, bed size, each |
10,190 |
9,990 |
$367K |
| B4155 |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit |
5,803 |
5,444 |
$367K |
| T4532 |
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each |
5,021 |
4,762 |
$329K |
| A6209 |
Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
3,392 |
3,099 |
$289K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
10,168 |
9,916 |
$284K |
| A4407 |
Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller, each |
2,805 |
2,667 |
$280K |
| T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
4,375 |
4,261 |
$250K |
| A6199 |
Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches |
1,968 |
1,779 |
$226K |
| A4239 |
Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service |
2,361 |
2,220 |
$224K |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
34,219 |
31,111 |
$223K |
| A6452 |
High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard |
1,777 |
1,446 |
$217K |
| A6216 |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
29,094 |
26,962 |
$210K |
| A4670 |
Automatic blood pressure monitor |
3,914 |
3,836 |
$199K |
| A4322 |
Irrigation syringe, bulb or piston, each |
7,149 |
6,673 |
$194K |
| B4158 |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit |
1,029 |
983 |
$184K |
| L1833 |
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf |
413 |
394 |
$178K |
| A6258 |
Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing |
2,573 |
2,136 |
$174K |
| A5056 |
Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each |
2,830 |
2,710 |
$168K |
| A6449 |
Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard |
6,099 |
5,437 |
$166K |
| B4034 |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
1,734 |
1,545 |
$162K |
| B4100 |
Food thickener, administered orally, per ounce |
3,453 |
3,386 |
$147K |
| A6203 |
Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
1,844 |
1,709 |
$135K |
| B4036 |
Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
1,507 |
1,352 |
$133K |
| A4314 |
Insertion tray with drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) |
11,295 |
10,885 |
$132K |
| B4103 |
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit |
2,285 |
2,171 |
$125K |
| A4352 |
Intermittent urinary catheter; coude (curved) tip, with or without coating (teflon, silicone, or silicone elastomeric, etc.), each |
686 |
654 |
$121K |
| E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
2,734 |
2,669 |
$115K |
| A6217 |
Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing |
1,589 |
1,464 |
$109K |
| A6219 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
7,004 |
6,290 |
$106K |
| K0553 |
Supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service |
1,048 |
992 |
$102K |
| A6450 |
Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard |
1,238 |
1,127 |
$101K |
| A5057 |
Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each |
1,027 |
978 |
$100K |
| A4414 |
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each |
1,434 |
1,381 |
$95K |
| A6234 |
Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
2,374 |
2,216 |
$94K |
| A4624 |
Tracheal suction catheter, any type other than closed system, each |
1,661 |
1,287 |
$94K |
| E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate |
1,017 |
992 |
$84K |
| A4394 |
Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce |
5,956 |
5,745 |
$82K |
| L3908 |
Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf |
1,969 |
1,558 |
$78K |
| L3809 |
Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type |
502 |
480 |
$74K |
| A4362 |
Skin barrier; solid, 4 x 4 or equivalent; each |
4,863 |
4,616 |
$73K |
| A4357 |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
11,106 |
10,724 |
$71K |
| A6207 |
Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing |
1,089 |
959 |
$69K |
| A6243 |
Hydrogel 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 |
433 |
401 |
$65K |
| A6266 |
Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard |
1,184 |
1,094 |
$65K |
| A6545 |
Gradient compression wrap, non-elastic, below knee, 30-50 mmhg, used as a surgical dressing, each |
1,034 |
890 |
$65K |
| A4349 |
Male external catheter, with or without adhesive, disposable, each |
3,148 |
3,016 |
$65K |
| A4410 |
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 inches, each |
632 |
612 |
$63K |
| A5120 |
Skin barrier, wipes or swabs, each |
13,394 |
12,875 |
$62K |
| T4521 |
Adult sized disposable incontinence product, brief/diaper, small, each |
962 |
900 |
$60K |
| A4456 |
Adhesive remover, wipes, any type, each |
8,073 |
7,769 |
$55K |
| A6010 |
Collagen based wound filler, dry form, sterile, per gram of collagen |
286 |
241 |
$55K |
| A4419 |
Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each |
988 |
961 |
$54K |
| A4432 |
Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each |
1,212 |
1,179 |
$53K |
| K0001 |
Standard wheelchair |
2,848 |
2,780 |
$48K |
| A6456 |
Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard |
1,396 |
1,215 |
$48K |
| L1902 |
Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf |
861 |
839 |
$47K |
| A6240 |
Hydrocolloid dressing, wound filler, paste, sterile, per ounce |
1,944 |
1,775 |
$46K |
| B9999 |
Noc for parenteral supplies |
271 |
269 |
$45K |
| A6454 |
Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard |
3,056 |
2,655 |
$42K |
| A5063 |
Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each |
1,130 |
1,040 |
$42K |
| E0445 |
Oximeter device for measuring blood oxygen levels non-invasively |
336 |
330 |
$39K |
| E0776 |
Iv pole |
3,349 |
3,237 |
$39K |
| A4333 |
Urinary catheter anchoring device, adhesive skin attachment, each |
6,061 |
5,841 |
$38K |
| A4358 |
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each |
9,113 |
8,831 |
$35K |
| A6248 |
Hydrogel dressing, wound filler, gel, per fluid ounce |
957 |
880 |
$34K |
| A6213 |
Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing |
351 |
290 |
$33K |
| A4253 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
1,110 |
1,104 |
$31K |
| L3670 |
Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf |
354 |
352 |
$30K |
| A4406 |
Ostomy skin barrier, pectin-based, paste, per ounce |
4,902 |
4,693 |
$30K |
| A4320 |
Irrigation tray with bulb or piston syringe, any purpose |
5,681 |
5,498 |
$29K |
| E0277 |
Powered pressure-reducing air mattress |
236 |
229 |
$29K |
| E0143 |
Walker, folding, wheeled, adjustable or fixed height |
736 |
726 |
$27K |
| A6407 |
Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard |
2,233 |
1,966 |
$27K |
| B4102 |
Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit |
408 |
365 |
$27K |
| A6457 |
Tubular dressing with or without elastic, any width, per linear yard |
2,496 |
2,118 |
$26K |
| A6445 |
Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard |
1,422 |
1,350 |
$23K |
| A6441 |
Padding bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than five inches, per yard |
2,290 |
1,806 |
$22K |
| E0240 |
Bath/shower chair, with or without wheels, any size |
844 |
829 |
$22K |
| A4315 |
Insertion tray with drainage bag with indwelling catheter, foley type, two-way, all silicone |
1,131 |
1,094 |
$18K |
| A4450 |
Tape, non-waterproof, per 18 square inches |
6,793 |
6,231 |
$17K |
| 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 |
309 |
297 |
$16K |
| A7000 |
Canister, disposable, used with suction pump, each |
2,356 |
2,289 |
$16K |
| A4427 |
Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each |
547 |
524 |
$16K |
| A7003 |
Administration set, with small volume nonfiltered pneumatic nebulizer, disposable |
6,235 |
6,044 |
$15K |
| E0163 |
Commode chair, mobile or stationary, with fixed arms |
474 |
463 |
$15K |
| E0431 |
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
994 |
981 |
$14K |
| A4628 |
Oral and/or oropharyngeal suction catheter, each |
1,346 |
1,291 |
$14K |
| A4332 |
Lubricant, individual sterile packet, each |
2,612 |
2,489 |
$14K |
| A4217 |
Sterile water/saline, 500 ml |
307 |
293 |
$13K |
| E0630 |
Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) |
407 |
395 |
$13K |
| A4371 |
Ostomy skin barrier, powder, per oz |
4,792 |
4,609 |
$12K |
| A7002 |
Tubing, used with suction pump, each |
2,483 |
2,350 |
$12K |
| T4533 |
Youth sized disposable incontinence product, brief/diaper, each |
159 |
155 |
$12K |
| A6022 |
Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each |
94 |
82 |
$12K |
| A6530 |
Gradient compression stocking, below knee, 18-30 mmhg, each |
203 |
196 |
$11K |
| A6403 |
Gauze, non-impregnated, sterile, pad size more than 16 sq. in. less than or equal to 48 sq. in., without adhesive border, each dressing |
920 |
716 |
$11K |
| A4367 |
Ostomy belt, each |
2,450 |
2,361 |
$11K |
| A6443 |
Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard |
1,306 |
1,161 |
$11K |
| A4334 |
Urinary catheter anchoring device, leg strap, each |
3,775 |
3,667 |
$11K |
| A6257 |
Transparent film, sterile, 16 sq. in. or less, each dressing |
1,068 |
1,022 |
$10K |
| A4623 |
Tracheostomy, inner cannula |
67 |
65 |
$10K |
| A4398 |
Ostomy irrigation supply; bag, each |
972 |
951 |
$10K |
| L0621 |
Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf |
193 |
190 |
$9K |
| A6251 |
Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
308 |
293 |
$9K |
| A4402 |
Lubricant, per ounce |
2,280 |
2,097 |
$9K |
| E0265 |
Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress |
93 |
91 |
$9K |
| E0973 |
Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each |
1,138 |
1,092 |
$9K |
| A4311 |
Insertion tray without drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) |
849 |
833 |
$9K |
| E0600 |
Respiratory suction pump, home model, portable or stationary, electric |
380 |
374 |
$9K |
| E0635 |
Patient lift, electric with seat or sling |
121 |
116 |
$9K |
| A4310 |
Insertion tray without drainage bag and without catheter (accessories only) |
431 |
409 |
$9K |
| A6259 |
Transparent film, sterile, more than 48 sq. in., each dressing |
49 |
38 |
$8K |
| A6242 |
Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
118 |
109 |
$8K |
| A7015 |
Aerosol mask, used with dme nebulizer |
6,106 |
5,908 |
$8K |
| A4554 |
Disposable underpads, all sizes |
434 |
427 |
$8K |
| A4399 |
Ostomy irrigation supply; cone/catheter, with or without brush |
985 |
965 |
$8K |
| E0978 |
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each |
422 |
410 |
$7K |
| B4087 |
Gastrostomy/jejunostomy tube, standard, any material, any type, each |
303 |
298 |
$7K |
| E0114 |
Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips |
186 |
185 |
$7K |
| A4259 |
Lancets, per box of 100 |
1,058 |
1,053 |
$6K |
| E0156 |
Seat attachment, walker |
808 |
795 |
$6K |
| K0195 |
Elevating leg rests, pair (for use with capped rental wheelchair base) |
753 |
724 |
$6K |
| 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 |
71 |
70 |
$6K |
| E0149 |
Walker, heavy duty, wheeled, rigid or folding, any type |
75 |
69 |
$5K |
| A4424 |
Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each |
75 |
74 |
$5K |
| E2201 |
Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches |
353 |
343 |
$4K |
| A4213 |
Syringe, sterile, 20 cc or greater, each |
1,874 |
1,377 |
$4K |
| E0100 |
Cane, includes canes of all materials, adjustable or fixed, with tip |
341 |
335 |
$3K |
| E0304 |
Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress |
12 |
12 |
$3K |
| K0739 |
Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes |
109 |
107 |
$3K |
| A9270 |
Non-covered item or service |
113 |
107 |
$3K |
| A4389 |
Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each |
37 |
36 |
$3K |
| A6531 |
Gradient compression stocking, below knee, 30-40 mmhg, used as a surgical dressing, each |
44 |
38 |
$2K |
| A4373 |
Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each |
29 |
26 |
$2K |
| A7014 |
Filter, nondisposable, used with aerosol compressor or ultrasonic generator |
996 |
941 |
$2K |
| A7526 |
Tracheostomy tube collar/holder, each |
94 |
91 |
$2K |
| E1238 |
Wheelchair, pediatric size, folding, adjustable, without seating system |
14 |
13 |
$2K |
| E0720 |
Transcutaneous electrical nerve stimulation (tens) device, two lead, localized stimulation |
13 |
12 |
$2K |
| K0006 |
Heavy duty wheelchair |
43 |
43 |
$2K |
| L4397 |
Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf |
13 |
13 |
$2K |
| A4629 |
Tracheostomy care kit for established tracheostomy |
16 |
13 |
$2K |
| A4338 |
Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each |
64 |
62 |
$2K |
| A4660 |
Sphygmomanometer/blood pressure apparatus with cuff and stethoscope |
60 |
60 |
$1K |
| A4397 |
Irrigation supply; sleeve, each |
90 |
89 |
$1K |
| A7005 |
Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable |
69 |
67 |
$1K |
| B4081 |
Nasogastric tubing with stylet |
30 |
24 |
$1K |
| L3660 |
Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf |
12 |
12 |
$980.43 |
| E2103 |
Non-adjunctive, non-implanted continuous glucose monitor or receiver |
16 |
12 |
$891.25 |
| A4606 |
Oxygen probe for use with oximeter device, replacement |
38 |
37 |
$743.43 |
| A6447 |
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five inches, per yard |
25 |
25 |
$720.67 |
| L4350 |
Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf |
12 |
12 |
$702.28 |
| E0181 |
Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty |
88 |
88 |
$675.44 |
| A5061 |
Ostomy pouch, drainable; with barrier attached, (1 piece), each |
12 |
12 |
$671.91 |
| A6224 |
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 sq. in., without adhesive border, each dressing |
17 |
13 |
$579.69 |
| 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 |
12 |
12 |
$568.90 |
| A4340 |
Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.), each |
67 |
64 |
$463.99 |
| A4209 |
Syringe with needle, sterile 5 cc or greater, each |
147 |
143 |
$397.44 |
| E0147 |
Walker, heavy duty, multiple braking system, variable wheel resistance |
13 |
13 |
$391.06 |
| K0052 |
Swingaway, detachable footrests, replacement only, each |
77 |
74 |
$199.33 |
| A4245 |
Alcohol wipes, per box |
107 |
106 |
$190.12 |
| E0971 |
Manual wheelchair accessory, anti-tipping device, each |
25 |
25 |
$91.19 |