| 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,… | 31 | 40 | 2,610 | $120 | $677.4K |
| T4534 | Youth sized disposable incontinence product, protective underwear/pull-on, each | 20 | 20 | 2,890 | $80 | $601.5K |
| A4351 | Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each | 7 | 30 | 760 | $100 | $480.6K |
| T4544 | Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each | 4 | 20 | 420 | $120 | $378.3K |
| B4154 | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or… | 5 | 40 | 970 | $120 | $343K |
| A4595 | Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) | 5 | 30 | 230 | $20 | $320.8K |
| T4543 | Adult sized disposable incontinence product, protective brief/diaper, above extra large, each | 8 | 40 | 470 | $180 | $300.4K |
| A4414 | Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each | 6 | 10 | 120 | $50 | $298.3K |
| T4526 | Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each | 8 | 80 | 1,240 | $70 | $295.8K |
| T4541 | Incontinence product, disposable underpad, large, each | 7 | 100 | 2,060 | $30 | $295.1K |