| B4155 | Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium… | 2 | 20 | 840 | $310 | $871K |
| T4527 | Adult sized disposable incontinence product, protective underwear/pull-on, large size, each | 16 | 40 | 2,280 | $150 | $795.4K |
| B4154 | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or… | 7 | 20 | 1,350 | $240 | $716.5K |
| T4526 | Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each | 13 | 40 | 1,900 | $120 | $627.8K |
| A4554 | Disposable underpads, all sizes | 13 | 60 | 6,090 | $50 | $584.2K |
| T4535 | Disposable liner/shield/guard/pad/undergarment, for incontinence, each | 9 | 50 | 3,480 | $50 | $465.5K |
| T4528 | Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each | 13 | 30 | 1,850 | $120 | $415.4K |
| 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… | 16 | 30 | 1,100 | $120 | $372.6K |
| A6250 | Skin sealants, protectants, moisturizers, ointments, any type, any size | 8 | 40 | 6,690 | $30 | $355.6K |
| T4522 | Adult sized disposable incontinence product, brief/diaper, medium, each | 19 | 20 | 1,980 | $120 | $346.2K |