| 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… | 28 | 30 | 1,790 | $670 | $1.8M |
| A4353 | Intermittent urinary catheter, with insertion supplies | 10 | 20 | 620 | $450 | $1.2M |
| A4351 | Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each | 9 | 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,… | 46 | 50 | 1,820 | $180 | $550K |
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 6 | 60 | 2,250 | $110 | $520.7K |
| B4149 | Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral… | 5 | 20 | 550 | $350 | $501.6K |
| E1236 | Wheelchair, pediatric size, folding, adjustable, with seating system | 1 | 10 | 280 | $180 | $405.9K |
| A4624 | Tracheal suction catheter, any type other than closed system, each | 9 | 30 | 890 | $150 | $340.9K |
| E0445 | Oximeter device for measuring blood oxygen levels non-invasively | 2 | 30 | 1,340 | $80 | $334K |
| E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | 1 | 210 | 3,800 | $50 | $287.1K |