| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 8 | 10 | 850 | $300 | $1M |
| 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… | 3 | 10 | 240 | $540 | $555.1K |
| 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,… | 3 | 10 | 650 | $180 | $533.1K |
| T4530 | Pediatric sized disposable incontinence product, brief/diaper, large size, each | 3 | 10 | 1,000 | $160 | $423.4K |
| T4534 | Youth sized disposable incontinence product, protective underwear/pull-on, each | 2 | 10 | 1,780 | $120 | $345.3K |
| B4154 | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or… | 3 | 10 | 950 | $210 | $250.7K |
| T4522 | Adult sized disposable incontinence product, brief/diaper, medium, each | 4 | 10 | 420 | $150 | $175.3K |
| T4525 | Adult sized disposable incontinence product, protective underwear/pull-on, small size, each | 4 | 10 | 120 | $120 | $168.7K |
| A4351 | Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each | 3 | 10 | 370 | $190 | $161K |
| 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 | 1,080 | $150 | $151.9K |