| 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,… | 12 | 20 | 2,220 | $140 | $894.9K |
| E0466 | Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) | 4 | 30 | 1,090 | $300 | $584.9K |
| 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… | 12 | 20 | 830 | $150 | $527.5K |
| E1170 | Amputee wheelchair, fixed full length arms, swing away detachable elevating legrests | 1 | 10 | 1,000 | $490 | $483.9K |
| B4100 | Food thickener, administered orally, per ounce | 10 | 10 | 760 | $90 | $381.1K |
| 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… | 8 | 10 | 600 | $360 | $355.4K |
| E1260 | Lightweight wheelchair, detachable arms (desk or full length) swing away detachable footrest | 1 | 10 | 530 | $630 | $336.5K |
| E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | 1 | 100 | 3,970 | $40 | $297.7K |
| E0240 | Bath/shower chair, with or without wheels, any size | 3 | 10 | 260 | $250 | $264.9K |
| T4526 | Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each | 2 | 60 | 1,500 | $90 | $254.7K |