| 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… | 13 | 20 | 1,760 | $240 | $807.1K |
| 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,… | 19 | 30 | 1,100 | $100 | $553.7K |
| A4927 | Gloves, non-sterile, per 100 | 13 | 10 | 920 | $10 | $388.1K |
| E0466 | Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) | 8 | 30 | 490 | $320 | $304.5K |
| E0465 | Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) | 2 | 10 | 320 | $500 | $295.2K |
| L1833 | Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf | 3 | 10 | 190 | $400 | $267.4K |
| E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | 2 | 100 | 4,570 | $30 | $261.1K |
| L4361 | Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf | 2 | 20 | 130 | $210 | $207.7K |
| B4149 | Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral… | 11 | 10 | 590 | $180 | $196.6K |
| 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… | 12 | 30 | 920 | $70 | $194K |