Enteral Nutrition Price List - B4157-B4162

ENTERAL NUTRITION PRICE LIST B4157 ? B4162

List updated: 04/28/2021

HCPCS Code B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157

B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157

B4157

B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157

MOD NU NU NU NU NU NU NU NU NU NU NU

NU NU NU NU NU NU NU NU NU NU NU NU NU

NU

NU NU NU NU NU NU NU NU

PRODUCT NAME Acerflex** Camino Pro BetterMilk Camino Pro PKU Complex Essential MSD** Cyclinex-2** EAA Supplement Glutarex-2** Glycosade** Glytactin Bettermilk 15** Glytactin Build 10** Glytactin Build 20/20** Glytactin RTD 10 Chocolate** Glytactin RTD 15 PE** Glytactin RTD Lite 15** Glytactin RTD-Original** Hominex-2** IVA Anamix Next Ketonex-2** Lanaflex Lophlex** MMA/PA Anamix Next ** MMA/PA Cooler 15 Liqd** MMA/PA Express** MSUD Cooler**

MSUD Express 20 **

MSUD Lophlex Liquid** Periflex Advance** Phenex 2 ** Phenyl Free 2** PhenylAde 60 Drink Mix ** PhenylAde Drink Mix ** PhenylAde Essential** PhenylAde GMP**

UPC 49735018842 24359035008 24359031002 00847059722 70074051147

70074051143 70074051141 24359035001 24359035307 24359053101

24359056403 50600005140 24359051403 24539057403 70074051119 49735019471 70074051115 49735012643 49735012169 49735019472 50600056122 50600054371 50600050915

50600051653

49735016749 49735012650 70074051122 00087008041 00847095622 00847095332 00847095012 49735018304

REIMB AMOUNT

$3.34 $9.83 $6.00 *By-Report $2.40 *By-Report $4.70 $2.33 $6.12 *By-Report *By-Report

*By-Report $0.96

*By-Report *by Report

$1.36 *By-Report

$4.70 $12.68

$9.85 $5.65 $10.10 *By-Report $12.67

NOTES

Added 08/01/2015 Added 4/23/2018 Added 10/07/2020

Added 02/25/2016 Added 06/10/2019 Added 07/01/2019 Added 03/08/2021

Added 07/27/2020 Added 03/08/2021 Added 06/10/2019

Added 10/05/2016 Added 09/02/2016 Added 4/23/2018

$4.72

$11.00 $3.93 $2.34 $1.87 $6.37 $2.55 $2.64

*By-Report

Added 06/23/2017 Added 01/20/2017 Added 07/26/2018

HCPCS Code B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157 B4157

B4157

MOD NU NU NU NU NU NU NU NU NU NU NU NU NU NU

PRODUCT NAME Phenyl-Free 2HP ** Phlexy-10** PKU Cooler 15 Purple PKU Express15 Tropical** PKU Express20** PKU Lophlex** PKU Periflex Junior Plus** Propimex-2 ** Tylactin RTD Original** TYR Anamix Next** TYR Cooler** Tyrex-2** UCD Anamix Junior** XMTVI Maxamum**

NU XPHE Maxamum **

HCPCS Code

B4158

B4158 B4158 B4158 B4158

B4158

B4158 B4158

B4158

B4158

B4158 B4158 B4158 B4158 B4158

B4158 B4158 B4158

B4158 B4158 B4158 B4158

MOD

NU

NU NU NU NU

NU

NU NU

NU

NU

NU NU NU NU NU

NU NU NU

NU NU NU NU

PRODUCT NAME Baby's Only Organic Dairy DHA Enfagrow Premium Transit Toddler

Enfamil AR

Enfamil Gentlease Lipil

Enfamil LactoFree Enfamil Lipil with Iron ? concentrated Enfamil Lipil with Iron ? powder

Enfamil NeuroPro Infant Gerber Graduates Soothe Powder Good Start Gentle Plus ? powder Good Start Supreme with Iron

Lipistart

Monogen

Pediasure Sidekicks

Portagen Similac Advance Early Shield with Iron

Similac Advance with Iron

Similac for Spit-Up Similac Go & Grow Soy Based Formula

Similac Pro-Advanced

Similac Pro-Sensitive

Similac Sensitive

UPC 00087008141 49735011914 50600054562 812539020172 50600051639 49735019535 49735019477 70074051134 24359059203 49735019479 50600053992 70074051127 04973501293 49735012342 49735018323

UPC

16514022902

00087020142 00087869342 00087061614

00087127241

00087127341 00087512107

50000023125

50000011125

50000012021 50600050205 49735019708 70074056524 00087038701

70074055958 70074055958 70074050960

70074057712 70074066081

70074057541

REIMB AMOUNT

$3.54 $5.50 *By-Report *By-Report $3.00 $0.51 $3.12 $5.35 $11.25 $2.04 $12.67 $4.70 $2.59 $8.34

$5.90

NOTES

Added 04/16/2019 Added 03/20/2019 Added 11/04/2015 Added 06/23/2017 Added 09/01/2017 Added 12/29/2015

Added 06/01/2016

REIMB AMOUNT

NOTES

$0.64

*By-Report $1.20 $0.93 $0.65

Added 01/21/2021 Added 01/11/2016

$1.07

$0.86 *By-Report

5.19

Added 10/14/2019 Added 09/02/2016

$0.80

$0.50 *By-Report

$2.19 $1.27 $1.02

Added 11/02/2020

$4.43 $1.26 $2.34

$0.72 *By-Report *By-Report

$0.95

HCPCS Code

B4158

MOD NU

PRODUCT NAME

Similac Total Comfort Powder

UPC 70074062600

HCPCS Code B4159

B4159 B4159

MOD NU

NU NU

PRODUCT NAME

Enfamil Prosobee Lipil Gerber Good Start Soypowder

Similac Isomil Advance

UPC 00087121441

50000003530 70074056976

HCPCS Code B4160 B4160 B4160 B4160 B4160 B4160 B4160

B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160 B4160

MOD NU NU NU NU NU NU NU

NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU

PRODUCT NAME Boost Kid Essentials 1.0 Boost Kid Essentials 1.5 Boost Kid Essentials 1.5 with Fiber Bright Beginnings Soy Enfamil Enfacare Lipil Enfamil Premature Lipil Enfaport Lipil Kate Farms Pediatric Standard Formula 1.2 Nutren Junior Nutren Junior w/ Fiber Diet PediaSmart Pediasure Pediasure Berry Pediasure Enteral Formula Pediasure Grow & Gain with Fiber Pediasure with Fiber Pediasure with Fiber Enteral Formula Pediasure 1.5 Cal Pediasure 1.5 Cal with Fiber Similac Expert Care Neosure Similac Neosure Similac Neosure Advance Similac Special Care 24 with Iron

UPC 43900033511 43900033540 43900033500 83744035009 00087001944 00087140642 00008712841

05182300699 00065904370 00065904570 16514088201 70074403730 70074053819 70074051805 70074058062 70074050653 70074051807 70074056410 70074056412 70074057431 70074518510 70074057431 70074059583

REIMB AMOUNT

$2.16

NOTES Added 01/15/2016

REIMB AMOUNT

$0.91

$0.80 $1.70

NOTES Moved from B4158

REIMB AMOUNT

$0.74 $0.66 $0.69 $0.76 $0.94 $2.26 $1.36

*By-Report $2.19 $1.03 $0.65 $1.03 $1.03 $0.98 $0.99 $1.06 $1.06 $1.48 $1.54 $1.94 $0.91 $1.08 $3.56

NOTES

Added 02/26/2019 Added 12/29/2015 Added 09/01/2017

HCPCS Code B4161 B4161 B4161 B4161 B4161

B4161

MOD NU NU NU NU NU

NU

PRODUCT NAME

E028 Splash

Alfamino Junior

Elecare

Elecare DHA/ARA

Elecare Jr Enfamil Nutramigen Lipilliquid

UPC 49735012670 7613034787965/7613034787958 70074059406 70074053511 70074055254

00087049801

REIMB AMOUNT

$1.95 *By-Report

$2.07 $2.07 $2.10

$1.65

NOTES

HCPCS Code

B4161

B4161

B4161 B4161 B4161

B4161

B4161 B4161 B4161 B4161 B4161 B4161 B4161 B4161 B4161 B4161 B4161

B4161

B4161

B4161 B4161 B4161 B4161 B4161

B4161 B4161 B4161 B4161

MOD

NU

NU

NU NU NU

NU

NU NU NU NU NU NU NU NU NU NU NU

PRODUCT NAME Enfamil Nutramigen Lipilpowder Kate Farm Pediactic Peptide 1.0 Vanilla Kate Farm 1.5 C Pediatric Peptide

Keto Peptide

Ketovie Peptide Form Compleat Ped Peptide 1.5 RTF Neocate Infant DHA and ARA

Neocate Junior

Neocate Nutra

Neocate One + Powder

Neocate Splash

Nourish Peptide

Pediasure Peptide 1.0 Cal

Pediasure Peptide 1.5 Cal

Pepdite One+

Peptamen Junior

Peptamen Junior 1.5

NU Peptamen Jr HP Peptamen Junior with

NU Fiber Peptamen Junior with

NU Prebio1

NU Pregestimil Liipil Powder

NU Product 3232A

NU Puramino DHA-ARA

NU Puramino JR Similac Alimentum

NU Advance

NU Vital Jr

NU Vital Peptide 1.5c RTF

NU Vivonex Pediatric

UPC 00087033801

851823006461

24359050203

49735010804/ 49735012595 49735011790 49735012910 49735011047 49735014451 57858000427 70074062122 70074056656 49735011766 00065906970 98716007363 43900046768 00065906871 00065906870 00087036701 00087042541 00087510478 00087512244 70074057664 70074059763

00212713176

REIMB AMOUNT

$1.37

*By-Report

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

*By-Report

$2.19 $1.97 $1.90 $2.28 $2.00 *By-Report $3.46 $3.23 $2.10 $3.50 $2.51

$2.50

$3.68

$3.68 $1.60 $3.07 $1.94 *By-Report

$1.50 $3.45 *By-Report $3.59

NOTES Added 03/02/2021 Added 02/07/2019 Added 04/28/2021 Added 01/13/2021

Added 03/11/2016 Added 11/20/2020

Added 09/21/2017 and Updated 06/07/2018

HCPCS Code B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162

MOD NU NU NU NU NU NU NU NU NU

PRODUCT NAME Acerflex** Calcilo XD Camino Pro MSUD Camino Pro PKU Complex Essential MSD ** Cyclinex-1 Cyclinex-2** EAA Supplement Glutarex-1

UPC 49735018842 70074003780 24359061002 24359031002 00847059722 70074051145 70074051147

70074051141

REIMB AMOUNT

$3.34 $0.82 $7.64 $6.00 *By-Report $0.94 $2.40 *By-Report $2.00

NOTES

Added 04/23/2018 Added 10/04/2020

HCPCS Code B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162 B4162

MOD NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU

PRODUCT NAME Glutarex-2** Glycosade** Glytactin Bettermilk 15** Glytactin Build 10** Glytactin Build 20/20** Glytactin RTD 10 Chocolate** Glytactin RTD ? Original** Glytactin RTD 15 PE** Glytactin RTD Lite 15** Hominex-1 Hominex-2** IVA Anamix Next Ketonex 1 Ketonex-2** Lophlex** MMA/PA Anamix Next MMA/PA Cooler 15 Liqd** MMA-PA Express 15** MSUD Cooler** MSUD Express 20** MSUD Lophlex Liquid** Periflex Advance** Periflex Infant Periflex Junior Phenex 2 ** Phenyl Free 1 (infant) Phenyl Free 2** PhenylAde 60 Drink Mix ** PhenylAde Drink Mix ** PhenylAde Essential** PhenylAde GMP** Phenyl-Free 2HP ** Phlexy-10** PKU Cooler 15 Purple PKU Express15 Tropical** PKU Express20** PKU GEL PKU Lophlex** PKU Periflex Junior Plus** Propimex-1 Propimex-2 ** Tylactin RTD Original** TYR Anamix Next** TYR Cooler** Tyrex-2** UCD Anamix Junior**

UPC 70074051143 70074051141 24359035001 24359035307 24359053101 24359056403 24359057403 506000051400 24359051403 70074051117 70074051119 49735019471 70074051112 70074051115 49735012169 49735019472 50600056122 50600054371 50600050915 50600051653 49735016749 49735012650 49735011880 49735011401 70074051123 00087036842 00087008041 00847095622 00847095332 00847095012 49735018304 00087008141 497350119140 50600054562 812539020172 50600051639 50600051448 49735019535 49735019477 70074051133 70074051134 24359059203 49735019479 50600053992 70074051127 04973501293

REIMB AMOUNT

$4.70 $2.33 $6.12 *By-Report *By-Report *By-Report *By-Report $0.96 *By-Report $2.00 $1.36 *By-Report $2.37 $4.70 $9.85 $5.65 $10.10 *By-Report $12.67 $4.72 $11.00 $3.93 $1.42 $2.90 $2.34 $1.27 $1.87 $6.37 $2.55 $2.64 *By-Report $3.54 $5.50 *By-Report *By-Report $3.00 *By-Report $0.51 $3.12 $2.00 $5.35 $11.25 $2.04 $12.67 $4.70 $2.59

NOTES

Added 02/25/2016 Added 06/10/2019 Added 07/01/2019 Added 03/08/2021 Added 03/08/2021 Added 07/27/2020

Added 06/10/2019

Added 10/05/2016 Added 09/02/2016 Added 04/23/2018

Added 06/23/2017

Added 01/20/2017

Added 07/26/2018

Added 04/16/2019 Added 03/20/2019 Added 11/04/2015 Added 07/26/2018 Added 06/23/2017

Added 09/01/2017 Added 12/29/2015

HCPCS Code B4162 B4162 B4162

B4162

MOD NU NU NU

PRODUCT NAME XLEU Analog XMTVI Maxamum** XPHE Maxamum **

NU XPHE XTYR Analog

UPC 49735011888 49735012342 49735018323 49735018301

**product can be billed under HCPCS B4157 or B4162

REIMB AMOUNT

$3.15

$8.34

$5.90

NOTES Added 11/04/2015

Added 06/01/2016

$3.15

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