Enteral Nutrition Price List - B4149-B4155

ENTERAL NUTRITION PRICE LIST B4149 ? B4155

List updated: 11/07/2022

HCPCS Code

MOD

PRODUCT NAME

B4149 NU B4149 NU B4149 NU B4149 NU B4149 NU

B4149 NU

B4149 NU B4149 NU B4149 NU B4149 NU

B4149 NU B4149 NU B4149 NU

COMPLEAT

COMPLEAT ORGANIC BLENDS PLANTBASED COMPLEAT PED REDUCE COMPLEAT PEDIATRIC

COMPLEAT ORGANIC BLENDS CHICKEN BLENDERIZED TF COMPLEAT

PEDIATRIC ORGANIC BLENDS CHICKEN GARDEN BLENDERIZED TF COMPLEAT

PEDIATRIC ORGANIC BLENDS PLANT-

BASED BLENDERIZED TF

LIQUID HOPE

NOURISH

ORANGE CHICKEN, CARROTS, AND BROWN RICE PUREED FOOD BLEND

REAL FOODS = BEEF POTATOES

REAL FOODS ? CHICKEN LIQ MEALS

REAL FOODS ? SALMON LIQ MEALS

REIMB AMOUNT 1/1/2017 ? 12/31/2017

$3.17 *By-Report

$4.62 $2.78 *By-Report

*By-Report

*By-Report

$5.86 *By-Report

*By-Report

*By-Report $4.70 $4.72

REIMB AMOUNT 1/1/2018 ? 12/31/2019

$3.32 *By-Report

$4.85 $2.90 *By-Report

*By-Report

*By-Report

$5.93 *By-Report

*By-Report

*By-Report $4.66 $4.65

REIMB AMOUNT 1/1/202012/31/2020

$3.52 *By-Report

$5.15 $3.08 *By-Report

*By-Report

*By-Report

$5.82 $6.55

*By-Report

*By-Report *By-Report

$4.73

REIMB AMOUNT 1/1/2021Current

$3.52 *By-Report

$5.15 $3.08 *By-Report

*By-Report

*By-Report

$5.82 $6.55

*By-Report

*By-Report *By-Report

$4.69

HCPCS Code

MOD

PRODUCT NAME

B4149 NU

REAL FOODS QUINOA LIQ MEALS

B4149

NU

REAL FOODS- EGGS, APPLES, AND OATS

REAL FOODS-

B4149 NU

TURKEY, SWEET POTATOES, AND

PEACHES

B4149 NU PEDIASURE HARVEST

REIMB AMOUNT 1/1/2017 ? 12/31/2017

$5.00

*By- Report

*By-Report

*By-Report

REIMB AMOUNT 1/1/2018 ? 12/31/2019

$4.74

*By-Report

*By-Report

*By-Report

REIMB AMOUNT 1/1/202012/31/2020

$4.72

*By-Report

*By-Report

*By-Report

REIMB AMOUNT 1/1/2021Current

$4.69

*By-Report

*By-Report

*By-Report

HCPCS Code MOD B4150 NU

PRODUCT NAME BOOST

REIMB AMOUNT 1/1/2017 ? 12/31/2017

$0.94

B4150 NU BOOST CALORIE SMART *By-Report

B4150 NU BOOST HIGH PROTEIN

$1.36

B4150 NU

CARNATION BREAKFAST ESSENTIALS

*By-Report

B4150 NU

ENSURE

$0.81

B4150 NU

ENSURE ACTIVE HIGH PROTEIN

$0.62

B4150 NU ENSURE IMMUNE HEALTH

$0.66

B4150 NU ENSURE MUSCLE HEALTH

$1.86

B4150 NU

FIBERSOURCE HN

*By-Report

B4150 NU B4150 NU B4150 NU B4150 NU

ISOSOURCE HN

JEVITY 1.0

JEVITY 1.2 KATE FARMS STANDARD

1.4 PLAIN

$0.98 $0.97 $1.53 *By-Report

REIMB AMOUNT 1/1/2018 ? CURRENT

$.80

*By-Report $1.14

*By-Report $.86 $1.05

*By-Report

*By-Report *By-Report

$1.03 $1.17 $1.18 *By-Report

REIMB AMOUNT 1/1/202012/31/2020

$.96

*By-Report $1.44

*By-Report $.78 $.59

*By-Report

*By-Report *By-Report

$1.09 $.96 $1.47 *By-Report

REIMB AMOUNT 1/1/2021Current

$.76

*By-Report $1.44

*By-Report $.80 $.58

*By-Report

*By-Report *By-Report

$1.02 $1.12 $1.32 *By-Report

HCPCS Code MOD

PRODUCT NAME

B4150 NU

KATE FARM STANDARD 1.4 VANILLA

B4150 NU

KATE FARM STANDARD FORMULA 1.0 VANILLA

B4150

NU

KATE FARM STANDARD FORMULA 1.0 CHOCOLATE

B4150 NU

KATE FARM STANDARD FORMULA 1.0 PLAIN

B4150 NU NUTREN 1.0 WITH FIBER

B4150 NU

NUTREN 1.0

B4150 NU B4150 NU

B4150 NU B4150 NU

OPTISOURCE HIGH PROTEIN DRINK

ORGAIN VEGAN ALL-INONE PROTEIN SHAKE CHOCOLATE

ORGAIN VEGAN ALL-INONE PROTEIN SHAKE VANILLA

OSMOLITE 1.0

B4150 NU

OSMOLITE 1.2

REIMB AMOUNT 1/1/2017 ? 12/31/2017 *By-Report *By-Report *By-Report *By-Report

$1.19 $1.08

*By-Report

*By-Report

*By-Report

$1.28

$0.65

B4150 NU B4150 NU

PROMOTE PROMOTE WITH FIBER

$1.60 $1.64

B4150 NU

REPLETE

$1.61

B4150 NU REPLETE WITH FIBER

$1.13

REIMB AMOUNT 1/1/2018 ? CURRENT *By-Report *By-Report *By-Report *By-Report

$1.24 $1.13

*By-Report

*By-Report

*By-Report

$1.27

$1.44 $1.68 $1.27 $1.69 $3.82

REIMB AMOUNT 1/1/202012/31/2020 *By-Report *By-Report *By-Report *By-Report

$1.32 $1.20

*By-Report

*By-Report

*By-Report

$1.28

$1.53 $1.79 $1.64 1.80 1.04

REIMB AMOUNT 1/1/2021Current *By-Report

$1.92 *By-Report *By-Report

$1.32 *By-Report

*By-Report

*By-Report

*By-Report

$1.38

$1.49 $1.76 $1.64 $1.80 $1.85

HCPCS Code MOD B4152 NU B4152 NU B4152 NU B4152 NU

PRODUCT NAME

BOOST PLUS BOOST VHC ENSURE COMPLETE ENSURE ENLIVE

REIMB AMOUNT 1/1/2017 ? 12/31/2017

$0.84

$0.56

$0.46

*By-Report

REIMB AMOUNT 1/1/2018 ? CURRENT

$.87

$.85

$.57

*By-Report

REIMB AMOUNT 1/1/202012/31/2020

$.84

$.84

*By-Report

$.89

REIMB AMOUNT 1/1/2021Current

$.84

$.56

*By-Report

$.90

HCPCS Code MOD

B4152 NU B4152 NU B4152 NU B4152 NU B4152 NU B4152 NU B4152 NU B4152 NU B4152 NU

PRODUCT NAME

ENSURE PLUS ISOSOURCE 1.5

JEVITY 1.5 NUTREN 1.5 NUTREN 2.0 OSMOLITE 1.5 RESOURCE 2.0 SCANDISHAKE TWOCAL HN

REIMB AMOUNT 1/1/2017 ? 12/31/2017

$0.57

$0.92

$1.13

$0.91

$0.79

$0.57

$0.92 *By-Report

$0.85

REIMB AMOUNT 1/1/2018 ? CURRENT

$.73

$.88

$.96

$.96

$.82

$.52

$.70 *By-Report

$.88

REIMB AMOUNT 1/1/202012/31/2020

$.54

$.92

$1.12

$1.03

$.88

$.56

$.72 *By-Report

$.83

REIMB AMOUNT 1/1/2021Current

$.56

$1.00

$1.12

$1.03

$.88

$.56

$.72 *By-Report

$.84

HCPCS Code MOD

PRODUCT NAME

B4153 NU

IMPACT PEPTIDE 1.5

B4153 NU

KATE FARM PEPTIDE FORMULA 1.5 PLAIN

B4153 NU

PEPTAMEN

B4153 NU PEPTAMEN WITH PREBIO

B4153 NU

PEPTAMEN 1.5

B4153

NU

PEPTAMEN 1.5 CAL WITH PREBIO 1 TM

B4153 NU

PEPTAMEN AF

B4153 NU

PEPTAMEN OS

B4153 NU PEPTAMEN INTENSE VHP

B4153 NU

PERATIVE

B4153 NU

TOLEREX

B4153 NU

VITAL 1.0

B4153 NU

VITAL 1.5

B4153 NU

VITAL AF 1.2

B4153 NU

VITAL HIGH PROTEIN

B4153 NU

VIVONEX PLUS

B4153 NU

VIVONEX RTF

B4153 NU

VIVONEX T.E.N.

REIMB AMOUNT 1/1/2017 ? 12/31/2017 *By-Report

*By-Report

7.08 $7.34 $7.01

$7.01

$7.69 *By-Report *By-Report *By-Report

$7.18 $2.84 $5.21 *By-Report *By-Report $8.33 $7.70 $7.97

REIMB AMOUNT 1/1/2018 ? CURRENT

$2.10

*By-Report

$7.41 $7.69 $7.41

$7.41

$8.06 *By-Report *By-Report *By-Report

$7.71 $7.03 $1.86 *By-Report *By-Report $8.72 $8.09 $8.34

REIMB AMOUNT 1/1/202012/31/2020 *By-Report

*By-Report

$7.88 $8.18 $7.88

$5.18

$8.56 *By-Report *By-Report *By-Report *By-Report

$2.74 *By-Report *By-Report *By-Report *By-Report

$8.60 *By-Report

REIMB AMOUNT 1/1/2021Current

$5.91

*By-Report

$7.88 $8.18 $7.88

$6.21

$8.56 *By-Report *By-Report *By-Report *By-Report

$2.74 *By-Report *By-Report *By-Report *By-Report

$8.60 *By-Report

HCPCS Code MOD

B4154 NU

B4154 NU B4154 NU B4154 NU B4154 NU

B4154 NU

B4154 NU B4154 NU B4154 NU B4154 NU

B4154 NU

B4154 NU B4154 NU B4154 NU B4154 NU B4154 NU B4154 NU B4154 NU B4154 NU B4154 NU B4154 NU

B4154 NU B4154 NU

B4154 NU

PRODUCT NAME

BOOST GLUCOSE CONTROL

DIABETISOURCE AC GLUCERNA

GLUCERNA 1.2 CAL GLUCERNA 1.5 CAL GLUCERNA HUNGER

SMART SHAKE GLUCERNA SHAKE

GLYTROL IMPACT IMPACT 1.5 IMPACT ADVANCED RECOVERY IMPACT WITH FIBER KETOCAL 3:1 KETOCAL 4:1 POWDER KETOCAL 4:1 LIQUID KETOVIE VANILLA NEPRO CARB STEADY NOVASOURCE RENAL NUTREN PULMONARY PULMOCARE

RENA START

RENASTEP VANILLA

SIMILIAC PM 60/40 SUPLENA WITH CARB

STEADY

REIMB AMOUNT 1/1/2017 ? 12/31/2017

$1.95

$2.88 $1.01 *By-Report *By-Report

*By-Report

$0.61 $4.91 *By-Report *By-Report

*By-Report

*By-Report $5.39 $5.32

*By-Report *By-Report *By-Report *By-Report *By-Report

$1.05 *By-Report

$1.52

$1.17

REIMB AMOUNT 1/1/2018 ? CURRENT

$1.36

*By-Report $1.24

*By-Report *By-Report

*By-Report

*By-Report *By-Report *By-Report *By-Report

*By-Report

*By-Report *By-Report

$5.91 *By-Report *By-Report *By-Report *By-Report *By-Report

$1.05 *By-Report

$1.66

$.79

REIMB AMOUNT 1/1/202012/31/2020

*By-Report

*By-Report $.80

*By-Report *By-Report

*By-Report

*By-Report *By-Report *By-Report *By-Report

*By-Report

*By-Report *By-Report

$4.72 *By-Report *By-Report

$1.03 *By-Report *By-Report *By-Report *By-Report

*By-Report

*By-Report

REIMB AMOUNT 1/1/2021Current *By-Report

*By-Report $.80

*By-Report *By-Report

*By-Report

$.83 *By-Report *By-Report *By-Report

*By-Report

*By-Report $2.04 $4.23 $6.28

*By-Report $.93

*By-Report *By-Report *By-Report *By-Report

*By-Report $2.86

*By-Report

HCPCS Code

B4155 B4155 B4155 B4155 B4155

B4155

B4155

MOD PRODUCT NAME

NU

ARGINAID

NU

BENECALORIE

NU

BENEPROTEIN

NU CITRULLINE 1000

NU

CITRULLINE 200

CAMINO PRO NU RESTORE?LEMON

LIME

CAMINO-PRO

NU

RESTORE RED

BERRY

REIMB AMOUNT 1/1/2017 ? 12/31/2017 *By-Report

$1.61 $4.15 *By-Report *By-Report

*By-Report

*By-Report

REIMB AMOUNT 1/1/2018 ? CURRENT *By-Report

$1.58 $4.88 *By-Report *By-Report

*By-Report

*By-Report

REIMB AMOUNT 1/1/202012/31/2020 *By-Report

$.68 $5.19 *By-Report *By-Report

*By-Report

*By-Report

REIMB AMOUNT 1/1/2021Current

$7.81 $1.39 $5.19 *By-Report *By-Report

*By-Report

*By-Report

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