| Code | Description | Total Paid |
|---|
| E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate |
$472K |
| E0601 |
Continuous positive airway pressure (cpap) device |
$288K |
| K0001 |
Standard wheelchair |
$191K |
| A7030 |
Full face mask used with positive airway pressure device, each |
$127K |
| E0260 |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress |
$126K |
| A4604 |
Tubing with integrated heating element for use with positive airway pressure device |
$119K |
| 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 |
$104K |
| E0114 |
Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips |
$94K |
| L4350 |
Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf |
$88K |
| L4361 |
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf |
$88K |