| 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… | 1 | 10 | 1,270 | $1,150 | $2M |
| A4222 | Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) | 1 | 10 | 6,000 | $160 | $943.5K |
| 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,… | 1 | 10 | 1,100 | $260 | $547K |
| A4223 | Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately) | 1 | 10 | 1,600 | $340 | $544.6K |
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 1 | 10 | 1,560 | $130 | $516.7K |
| B4185 | Parenteral nutrition solution, not otherwise specified, 10 grams lipids | 1 | 10 | 2,750 | $120 | $330K |
| B4224 | Parenteral nutrition administration kit, per day | 1 | 10 | 2,940 | $70 | $206K |
| B4149 | Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral… | 2 | 10 | 1,120 | $180 | $198.5K |
| 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 | 10 | 250 | $70 | $171.8K |
| A4305 | Disposable drug delivery system, flow rate of 50 ml or greater per hour | 1 | 10 | 1,210 | $130 | $158.5K |