| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T4541 |
Large disposable underpad |
2,945 |
2,930 |
$161K |
| T4535 |
Disposable liner/shield/pad |
1,111 |
1,105 |
$55K |
| T4524 |
Adult size brief/diaper xl |
463 |
462 |
$41K |
| T4523 |
Adult size brief/diaper lg |
505 |
502 |
$40K |
| T4526 |
Adult size pull-on med |
545 |
544 |
$33K |
| T4528 |
Adult size pull-on xl |
227 |
227 |
$13K |
| T4527 |
Adult size pull-on lg |
102 |
102 |
$7K |
| T4522 |
Adult size brief/diaper med |
74 |
74 |
$6K |
| K0005 |
Ultralightweight wheelchair |
12 |
12 |
$3K |
| E2611 |
Gen use back cush wdth <22in |
12 |
12 |
$309.21 |
| E0973 |
W/ch access det adj armrest |
12 |
12 |
$213.16 |
| E0971 |
Wheelchair anti-tipping devi |
12 |
12 |
$112.80 |
| E0961 |
Wheelchair brake extension |
12 |
12 |
$83.30 |
| E2601 |
Gen w/c cushion wdth < 22 in |
12 |
12 |
$77.88 |
| E0978 |
W/c acc,saf belt pelv strap |
12 |
12 |
$48.95 |