| 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 | 30 | 1,790 | $670 | $1.8M |
| A4353 | Intermittent urinary catheter, with insertion supplies | 15 | 20 | 620 | $450 | $1.2M |
| E1399 | Durable medical equipment, miscellaneous | 5 | 50 | 420 | $790 | $880.5K |
| E0465 | Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) | 19 | 30 | 1,450 | $520 | $775K |
| T4527 | Adult sized disposable incontinence product, protective underwear/pull-on, large size, each | 4 | 50 | 1,800 | $60 | $730.4K |
| T4526 | Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each | 4 | 60 | 2,140 | $60 | $601K |
| A4351 | Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each | 19 | 30 | 750 | $90 | $563.1K |
| 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,… | 15 | 50 | 1,820 | $180 | $550K |
| S5199 | Personal care item, nos, each | 10 | 40 | 2,820 | $50 | $547.8K |
| 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… | 12 | 20 | 400 | $690 | $542.2K |