Enteral Nutrition Price List - B4157-B4162 - Minnesota

ENTERAL NUTRITION PRICE LIST B4157 ? B4162

List updated: June 26, 2024

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

MODIFIER 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

4-CHARACTER DESCRIPTION

(Optional) ACER BCA2 CAMS CPBK CAPK COME CYC2 EAAS GLU2 GLYC GB15 GLYT GB20 GD10 GD15 GYTA GCOF GRTD HOM2 IVAN IVA2 KET2 LANA LOPH MANT MAXA MMPC MMPA MSUD MS20 MSLL PERA PHX2

PRODUCT NAME Acerflex** BCAD2 Camino Pro MSUD** 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 Chocolate** Glytactin RTD 15 PE** Glytactin RTD Lite 15** Glytactin RTD-Original** Hominex-2** IVA Anamix Next I-Valex-2** Ketonex-2** Lanaflex Lophlex** MMA/PA Anamix Next** Maxamum MMA/PA Cooler 15 Liquid** MMA/PA Express** MSUD Cooler** MSUD Express 20** MSUD Lophlex Liquid** Periflex Advance** Phenex 2**

REIMBURSABLE AMOUNT before

July 1, 2024 $3.34

By-Report $7.64 $9.83 $6.00

By-Report $2.40

By-Report $4.70 $2.33

By-Report By-Report By-Report By-Report By-Report

$0.96 By-Report By Report

$1.36 By-Report By-Report

$4.70 $12.68

$9.85 $5.65 By-Report $10.10 By-Report $12.67 $4.72 $11.00 $3.93 $2.34

REIMBURSABLE AMOUNT July 1,

2024 CURRENT

$3.34 By-Report

$7.64 $9.83 $6.00 By-Report $2.40 By-Report $4.70 $2.33 By-Report By-Report By-Report By-Report By-Report $0.96 By-Report By-Report $1.36 By-Report By-Report $4.70 $12.68 $9.85 $5.65 By-Report $10.10 By-Report $12.67 $4.72 $11.00 $3.93 $2.34

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

MODIFIER NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU NU

4-CHARACTER DESCRIPTION

(Optional) PHF2 PH60 PADM PHAL PGMP P2HP PH10 PRPL TROP PKUP PE20 PKUL PKPJ PKUC PKUR PKLQ PMX2 TRTD TYRA TYRC TRX2 UCDA XMTV XPHM

PRODUCT NAME 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 Cooler 20 Purple** PKU Express20** PKU Lophlex** PKU Periflex Junior Plus** PKU Sphere 20 Chocolate** PKU Sphere 20 Red Berry** PKU Sphere 20 Liquid Vanilla** Propimex-2** Tylactin RTD Original** TYR Anamix Next** TYR Cooler** Tyrex-2** UCD Anamix Junior** XMTVI Maxamum** XPHE Maxamum**

REIMBURSABLE AMOUNT before

July 1, 2024 $1.87 $6.37 $2.55 $2.64

By-Report $3.54 $5.50

By-Report By-Report By-Report

$3.00 $0.51 $3.12 By-Report By-Report By-Report $5.35 $11.25 $2.04 $12.67 $4.70 $2.59 $8.34 $5.90

REIMBURSABLE AMOUNT July 1,

2024 CURRENT

$1.87 $6.37 $2.55 $2.64 By-Report $3.54 $5.50 By-Report By-Report By-Report $3.00 $0.51 $3.12 By-Report By-Report By-Report $5.35 $11.25 $2.04 $12.67 $4.70 $2.59 $8.34 $5.90

HCPCS Code B4158

B4158 B4158

B4158 B4158 B4158 B4158

B4158 B4158 B4158 B4158

B4158

B4158 B4158

MODIFIER NU

NU NU

NU NU NU NU

NU NU NU NU

NU

NU NU

4-CHARACTER DESCRIPTION

(Optional) BODD

EPTT ENAR

EMGL EGTP EMIF EMLF

ELIC ELIP ENPI GGSP

GGSO

GSGP GOST

PRODUCT NAME

Baby's Only Organic Dairy DHA Enfagrow Premium Transit Toddler

Enfamil AR Enfamil Gentlease, Powder, 12.4-oz. Can

Enfamil Gentlease Lipil

Enfamil Infant

Enfamil LactoFree Enfamil Lipil with Iron ? concentrated

Enfamil Lipil with Iron ? powder

Enfamil NeuroPro Infant

Gerber Good Start SoothePro Gerber Graduates Soothe Powder Good Start Gentle Plus ? powder

Good Start Supreme with Iron

REIMBURSABLE AMOUNT before

July 1, 2024

$0.64

REIMBURSABLE AMOUNT July 1, 2024- CURRENT

$0.64

By-Report $1.20

By-Report $1.20

By-Report $0.93

By-Report $0.65

By-Report $0.93

By-Report $0.65

$1.07 $0.86 By-Report By-Report

$1.07 $0.86 By-Report By-Report

$5.19

$5.19

$0.80 $0.50

$0.80 $0.50

HCPCS Code B4158 B4158 B4158 B4158 B4158

B4158 B4158 B4158

B4158 B4158 B4158 B4158 B4158

MODIFIER NU NU NU NU NU

NU NU NU

NU NU NU NU NU

4-CHARACTER DESCRIPTION

(Optional) LIPI

MOGN PRCA PEDS PORT

SAES SAWI SSUP

SGOG SPAD SPEN SENS STCP

PRODUCT NAME Lipistart Monogen PediaSure Reduced Calorie 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 Similac Total Comfort Powder

REIMBURSABLE AMOUNT before

July 1, 2024

By-Report

$2.19

By-Report

$1.27

$1.02

REIMBURSABLE AMOUNT July 1, 2024- CURRENT

By-Report $2.19

By-Report $1.27 $1.02

$4.43 $1.26 $2.34

$4.43 $1.26 $2.34

$0.72 By-Report By-Report

$0.95 $2.16

$0.72 By-Report By-Report

$0.95 $2.16

HCPCS Code B4159 B4159 B4159

MODIFIER NU NU NU

4-CHARACTER DESCRIPTION

(Optional)

ENFA

GGSS

SIMI

PRODUCT NAME Enfamil Prosobee Lipil Gerber Good Start Soy ? powder Similac Isomil Advance

REIMBRSABLE AMOUNT before

July 1, 2024

$0.91

$0.80

$1.70

REIMBURSABLE AMOUNT

July 1, 2024 CURRENT

$0.91

$0.80

$1.70

HCPCS Code B4160 B4160

B4160 B4160 B4160 B4160 B4160 B4160

B4160

B4160

MODIFIER NU NU

NU NU NU NU NU NU

4-CHARACTER DESCRIPTION

(Optional) BK10 BK15

E15F BBGS CPS1 EMFA EPLI ENPO

PRODUCT NAME

REIMBURSABLE AMOUNT before

July 1, 2024

REMIBURSABLE AMOUNT

July 1, 2024 CURRENT

Boost Kid Essentials 1.0

$1.11

$1.59

Boost Kid Essentials 1.5

$0.66

$0.66

Boost Kid Essentials 1.5 with Fiber

$0.69

$0.69

Bright Beginnings Soy Compleat Pediatric Standard 1.0

$0.76 By-Report

$0.76 By-Report

Enfamil Enfacare Lipil

$0.94

$0.94

Enfamil Premature Lipil

$2.26

$2.26

Enfaport Lipil

$1.36

$1.36

Kate Farms Pediatric Standard

NU

KFPS

Formula 1.2, Vanilla

By-Report

$1.22

By-Report

Kate Farms Pediatric Standard

NU

KFPC

Formula 1.2, Chocolate

By-Report

HCPCS Code B4160 B4160 B4160 B4160 B4160 B4160 B4160

B4160 B4160

B4160 B4160 B4160 B4160 B4160 B4160

B4160

MODIFIER NU NU NU NU NU NU NU

NU NU

NU NU NU NU NU NU

NU

4-CHARACTER DESCRIPTION

(Optional) NUTR NJFD OPST PDSR PEDL PBRR PDEF

PGGF

PDFI

PFEF

PS15 PF15

SECN SMNS SMNA

SS24

PRODUCT NAME Nutren Junior Nutren Junior with Fiber Diet PediaSmart PediaSure Pediasure Liquid 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

REIMBURSABLE AMOUNT before

July 1, 2024

$1.38 $1.03 $0.65

$1.54 $0.87 $1.03

$1.47

REMIBURSABLE AMOUNT

July 1, 2024 CURRENT

$2.01 $1.55

$0.65

$2.12 $0.87 $1.03

$2.00

$1.16 $1.54

$1.51 $2.22

$1.59 $2.54 $2.71 $1.94 $0.91 $1.08

$2.30 $2.71 $2.88 $1.94 $0.91 $1.08

$3.56

$3.56

HCPCS Code B4161 B4161 B4161 B4161 B4161 B4161 B4161

MODIFIER NU NU NU NU NU NU NU

4-CHARACTER DESCRIPTION

(Optional) ESPL ALFJ ALFV ELCR ELDA ELJR MINO

PRODUCT NAME E028 Splash Alfamino Junior Alfamino Junior Vanilla Elecare Elecare DHA/ARA Elecare Junior Puramino JR

REIMBURSABLE AMOUNT before

July 1, 2024 $1.95

By-Report

By-Report $2.07 $2.07

$2.10 By-Report

REIMBURSABLE AMOUNT

July 1, 2024 CURRENT $1.95 By-Report

By-Report $2.07 $2.07

$2.10 By-Report

B4161

NU

NTMG

Enfamil Nutramigen Lipil-liquid

$1.65

$1.65

Enfamil Nutramigen Lipil-

B4161

NU

NTMP

powder

$1.37

$1.37

Kate Farms Pediatric Peptide

B4161

NU

KPPV

1.0 Vanilla

Kate Farms 1.5 C Pediatric

B4161

NU

KFPP

Peptide

By-Report By-Report

By-Report By-Report

Kate Farms Pediatric Peptide

B4161

NU

KFPV

1.5 Vanilla

B4161

NU

KEPE

Keto Peptide

By-Report By-Report

By-Report

HCPCS Code MODIFIER

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

B4161

NU

4-CHARACTER DESCRIPTION

(Optional)

KVVN KVIE

LEAT NEOI NCJR NEOC NCOP NESP NRSH

NELI PEPE PP15 PPDO PEPJ PJ15 PPHP PMJR PJWP PHGG PGTM P323 PUDA

PRODUCT NAME

KetoVie 4:1 Plant-Based Protein Vanilla

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

Nutramigen with Enflora LGG Infant

PediaSure Peptide 1.0 Cal

PediaSure Peptide 1.5 Cal Pepdite One+

Peptamen Junior

Peptamen Junior 1.5

Peptamen Junior HP

Peptamen Junior with Fiber

Peptamen Junior with Prebio1 Peptamen Junior PHGG

Pregestimil Lipil Powder Product 3232A

PurAmino DHA-ARA

REIMBURSABLE AMOUNT before

July 1, 2024

REIMBURSABLE AMOUNT

July 1, 2024 CURRENT By-Report

By-Report By-Report

By-Report By-Report

By-Report

$2.19 $2.94 $1.90 $2.28 $2.00 By-Report

By-Report

$2.19 $4.38

$1.90 $2.28 $2.00 By-Report

By-Report $5.14 $3.40 $2.10 $5.16 $3.76 $2.50 $3.68 $3.68

By-Report $1.60 $3.07 $1.94

By-Report $7.28 $5.07 $2.10 $7.25 $5.46 $2.50 $3.68 $3.68

By-Report $1.60 $3.07 $1.94

B4161

NU

SALA

Similac Alimentum Advance

B4161

NU

VITJ

Vital Junior

B4161

NU

VITA

Vital Peptide 1.5c RTF

B4161

NU

VXPD

Vivonex Pediatric

$1.50 $3.45 By-Report $3.59

$1.50 $3.45 By-Report $3.59

HCPCS Code B4162 B4162 B4162

MODIFIER NU NU NU

4-CHARACTER DESCRIPTION

(Optional)

ACER

BCA2

CLXD

PRODUCT NAME Acerflex** BCAD2 Calcilo XD

REIMBURSABLE AMOUNT before

July 1, 2024

$3.34

By-Report

$0.82

REIMBURSABLE AMOUNT

July 1, 2024 CURRENT

$3.34

By-Report

$0.82

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download