| 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,… | 3 | 20 | 2,010 | $100 | $586.6K |
| T4534 | Youth sized disposable incontinence product, protective underwear/pull-on, each | 2 | 20 | 1,990 | $160 | $525.8K |
| 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… | 6 | 20 | 430 | $170 | $500.3K |
| B4154 | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or… | 2 | 10 | 620 | $110 | $413.3K |
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 14 | 30 | 2,640 | $50 | $313.6K |
| 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… | 1 | 20 | 1,610 | $60 | $282.6K |
| T4532 | Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each | 2 | 10 | 1,410 | $170 | $272.5K |
| B4102 | Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit | 2 | 10 | 4,510 | $60 | $272.3K |
| 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… | 3 | 10 | 1,310 | $70 | $221.2K |
| 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… | 2 | 20 | 1,010 | $60 | $219.6K |