| J1726 | Injection, hydroxyprogesterone caproate, (makena), 10 mg | 2 | 10 | 1,780 | $1,080 | $4.1M |
| 90378 | Immunoglobulin is a very complex protein that is produced by certain cells in the body to protect it from various types of infections and produce passive immunity. RSV–IgIM (respiratory syncytial… | 1 | 10 | 720 | $2,350 | $1.8M |
| B4197 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix | 1 | 10 | 1,910 | $900 | $1.7M |
| 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… | 18 | 30 | 3,220 | $390 | $1.5M |
| S9500 | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and… | 10 | 10 | 2,450 | $140 | $851.9K |
| 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,… | 20 | 40 | 2,610 | $120 | $677.4K |
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 10 | 50 | 4,010 | $80 | $640.4K |
| E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | 26 | 190 | 6,790 | $40 | $579.6K |
| E0445 | Oximeter device for measuring blood oxygen levels non-invasively | 11 | 20 | 630 | $220 | $409.1K |
| 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… | 8 | 20 | 870 | $290 | $368.4K |