| 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,… | 3 | 10 | 420 | $130 | $567.7K |
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 3 | 10 | 2,000 | $130 | $423.1K |
| A4223 | Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately) | 1 | 10 | 200 | $270 | $200K |
| B4152 | Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include… | 6 | 10 | 640 | $120 | $138.5K |
| 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… | 12 | 20 | 310 | $80 | $69.2K |
| B9002 | Enteral nutrition infusion pump, any type | 3 | 10 | 920 | $60 | $68.6K |
| B4088 | Gastrostomy/jejunostomy tube, low-profile, any material, any type, each | 3 | 10 | 620 | $50 | $68.2K |
| B4034 | Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 3 | 10 | 520 | $50 | $29K |
| A4221 | Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately) | 1 | 10 | 1,530 | $20 | $28.1K |
| A4222 | Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) | 1 | 10 | 480 | $50 | $24.5K |