| A4624 | Tracheal suction catheter, any type other than closed system, each | 4,390 | $130 | $579.3K |
| 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,… | 2,560 | $190 | $474.2K |
| T4534 | Youth sized disposable incontinence product, protective underwear/pull-on, each | 2,580 | $160 | $419.9K |
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 6,780 | $60 | $413.4K |
| E0601 | Continuous positive airway pressure (CPAP) device | 8,160 | $50 | $407.9K |
| E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | 4,400 | $60 | $255K |
| A4605 | Tracheal suction catheter, closed system, each | 1,590 | $160 | $249.6K |
| 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… | 3,620 | $60 | $206.2K |
| A4623 | Tracheostomy, inner cannula | 3,200 | $60 | $182.2K |
| 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… | 2,760 | $60 | $162.9K |