| B4087 | Gastrostomy/jejunostomy tube, standard, any material, any type, each | 1 | 10 | 4,830 | $130 | $612.6K |
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 6 | 20 | 440 | $140 | $543.9K |
| 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… | 5 | 10 | 1,030 | $360 | $413.4K |
| B4149 | Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral… | 5 | 10 | 1,130 | $200 | $279.4K |
| B4036 | Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 6 | 10 | 1,860 | $90 | $199.9K |
| B4088 | Gastrostomy/jejunostomy tube, low-profile, any material, any type, each | 7 | 10 | 1,340 | $150 | $196.8K |
| 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… | 4 | 10 | 1,830 | $80 | $158K |
| L2275 | Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined | 6 | 10 | 820 | $80 | $70.6K |
| 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… | 3 | 10 | 140 | $430 | $62K |
| L3202 | Orthopedic shoe, oxford with supinator or pronator, child | 2 | 10 | 840 | $60 | $46.3K |