| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| L8000 |
Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type |
665 |
649 |
$15K |
| 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 |
272 |
201 |
$4K |
| 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 |
269 |
201 |
$3K |
| L8020 |
Breast prosthesis, mastectomy form |
80 |
73 |
$1K |
| A4253 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
73 |
73 |
$353.57 |
| E0973 |
Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each |
25 |
12 |
$112.16 |
| A4259 |
Lancets, per box of 100 |
73 |
73 |
$9.64 |