| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 4 | 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… | 5 | 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,… | 5 | 10 | 650 | $180 | $533.1K |
| B4088 | Gastrostomy/jejunostomy tube, low-profile, any material, any type, each | 5 | 10 | 40 | $110 | $207.8K |
| 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… | 10 | 10 | 1,080 | $150 | $151.9K |
| E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | 1 | 60 | 2,220 | $40 | $129K |
| A7030 | Full face mask used with positive airway pressure device, each | 5 | 30 | 720 | $60 | $51.4K |
| A4604 | Tubing with integrated heating element for use with positive airway pressure device | 17 | 30 | 780 | $40 | $40.2K |
| E0601 | Continuous positive airway pressure (CPAP) device | 17 | 50 | 840 | $30 | $40K |
| A7031 | Face mask interface, replacement for full face mask, each | 6 | 30 | 960 | $30 | $36.3K |