| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A4554 |
Disposable underpads |
19,128 |
15,534 |
$632K |
| T2029 |
Special med equip, noswaiver |
327 |
229 |
$516K |
| T2028 |
Special supply, nos waiver |
5,439 |
3,467 |
$512K |
| T5999 |
Supply, nos |
41,201 |
26,767 |
$487K |
| T4522 |
Adult size brief/diaper med |
4,858 |
3,277 |
$321K |
| T4523 |
Adult size brief/diaper lg |
4,553 |
3,130 |
$320K |
| X1922 |
|
2,615 |
1,215 |
$296K |
| T4527 |
Adult size pull-on lg |
4,663 |
3,619 |
$277K |
| T4534 |
Youth size pull-on |
2,325 |
1,963 |
$242K |
| T4528 |
Adult size pull-on xl |
3,361 |
2,563 |
$225K |
| T4526 |
Adult size pull-on med |
3,712 |
2,908 |
$196K |
| T4535 |
Disposable liner/shield/pad |
5,786 |
4,945 |
$169K |
| X1915 |
|
1,712 |
1,265 |
$168K |
| T4543 |
Adult disp brief/diap abv xl |
1,192 |
925 |
$160K |
| T4524 |
Adult size brief/diaper xl |
1,769 |
1,214 |
$152K |
| A4927 |
Non-sterile gloves |
14,046 |
8,202 |
$144K |
| T4525 |
Adult size pull-on sm |
942 |
808 |
$68K |
| T4533 |
Youth size brief/diaper |
631 |
367 |
$40K |
| S5161 |
Emer rspns sys serv permonth |
1,251 |
1,140 |
$34K |
| X1916 |
|
32 |
24 |
$29K |
| T4532 |
Ped size pull-on lg |
153 |
153 |
$14K |
| T4530 |
Ped size brief/diaper lg |
25 |
25 |
$3K |
| B4087 |
Gastro/jejuno tube, std |
62 |
24 |
$2K |
| T4521 |
Adult size brief/diaper sm |
12 |
12 |
$1K |