Enteral Nutrition Price List - B4149-B4155 - Minnesota

1 Enteral Nutrition Price LIST B4149 B4155 List updated: 04/15/2021 HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 12/31/2019 REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4149 NU COMPLEAT $ $ $ $ B4149 NU COMPLEAT ORGANIC BLENDS PLANT-BASED *By-Report *By-Report *By-Report *By-Report B4149 NU COMPLEAT PED REDUCE $ $ $ $ B4149 NU COMPLEAT PEDIATRIC $ $ $ $ B4149 NU COMPLEAT ORGANIC BLENDS CHICKEN BLENDERIZED TF *By-Report *By-Report *By-Report *By-Report B4149 NU COMPLEAT PEDIATRIC ORGANIC BLENDS CHICKEN GARDEN BLENDERIZED TF *By-Report *By-Report *By-Report *By-Report B4149 NU COMPLEAT PEDIATRIC ORGANIC BLENDS PLANT-BASED BLENDERIZED TF

2 *By-Report *By-Report *By-Report *By-Report B4149 NU LIQUID HOPE $ $ $ $ B4149 NU NOURISH *By-Report *By-Report $ $ B4149 NU ORANGE CHICKEN, CARROTS, AND BROWN RICE PUREED FOOD BLEND *By-Report *By-Report *By-Report *By-Report B4149 NU REAL FOODS = BEEF POTATOES *By-Report *By-Report *By-Report *By-Report B4149 NU REAL FOODS CHICKEN LIQ MEALS $ $ *By-Report *By-Report B4149 NU REAL FOODS SALMON LIQ MEALS $ $ $ $ HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 12/31/2019 REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4149 NU REAL FOODS QUINOA LIQ MEALS $ $ $ $ B4149 NU REAL FOODS- EGGS, APPLES, AND OATS *By- Report *By-Report *By-Report *By-Report B4149 NU REAL FOODS-TURKEY, SWEET POTATOES.

3 AND PEACHES *By-Report *By-Report *By-Report *By-Report B4149 NU PEDIASURE HARVEST *By-Report *By-Report *By-Report *By-Report HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 CURRENT REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4150 NU BOOST $ $.80 $.96 $.76 B4150 NU BOOST CALORIE SMART *By-Report *By-Report *By-Report *By-Report B4150 NU BOOST HIGH PROTEIN $ $ $ $ B4150 NU CARNATION BREAKFAST ESSENTIALS *By-Report *By-Report *By-Report *By-Report B4150 NU ENSURE $ $.86 $.78 $.80 B4150 NU ENSURE ACTIVE HIGH PROTEIN $ $ $.

4 59 $.58 B4150 NU ENSURE IMMUNE HEALTH $ *By-Report *By-Report *By-Report B4150 NU ENSURE MUSCLE HEALTH $ *By-Report *By-Report *By-Report B4150 NU FIBERSOURCE HN *By-Report *By-Report *By-Report *By-Report B4150 NU ISOSOURCE HN $ $ $ $ B4150 NU jevity $ $ $.96 $ B4150 NU jevity $ $ $ $ B4150 NU KATE FARMS STANDARD PLAIN *By-Report *By-Report *By-Report *By-Report HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 CURRENT REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4150 NU KATE FARM STANDARD VANILLA *By-Report *By-Report *By-Report *By-Report B4150 NU KATE FARM STANDARD FORMULA VANILLA *By-Report *By-Report *By-Report $ B4150 NU KATE FARM STANDARD FORMULA CHOCOLATE *By-Report *By-Report *By-Report *By-Report B4150 NU KATE FARM STANDARD FORMULA PLAIN *By-Report *By-Report *By-Report *By-Report B4150 NU NUTREN WITH FIBER $ $ $ $

5 B4150 NU NUTREN $ $ $ *By-Report B4150 NU OPTISOURCE HIGH PROTEIN DRINK *By-Report *By-Report *By-Report *By-Report B4150 NU ORGAIN VEGAN ALL-IN-ONE PROTEIN SHAKE CHOCOLATE *By-Report *By-Report *By-Report *By-Report B4150 NU ORGAIN VEGAN ALL-IN-ONE PROTEIN SHAKE VANILLA *By-Report *By-Report *By-Report *By-Report B4150 NU OSMOLITE $ $ $ $ B4150 NU OSMOLITE $ $ $ $ B4150 NU PROMOTE $ $ $ $ B4150 NU PROMOTE WITH FIBER $ $ $ $ B4150 NU REPLETE $ $ $ B4150 NU REPLETE WITH FIBER $ $ $ HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 CURRENT REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4152 NU BOOST PLUS $ $.

6 87 $.84 $.84 B4152 NU BOOST VHC $ $.85 $.84 $.56 B4152 NU ENSURE COMPLETE $ $.57 *By-Report *By-Report B4152 NU ENSURE ENLIVE *By-Report *By-Report $.89 $.90 HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 CURRENT REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4152 NU ENSURE PLUS $ $.73 $.54 $.56 B4152 NU ISOSOURCE $ $.88 $.92 $ B4152 NU jevity $ $.96 $ $ B4152 NU NUTREN $ $.96 $ $ B4152 NU NUTREN $ $.82 $.88 $.88 B4152 NU OSMOLITE $ $.52 $.56 $.56 B4152 NU RESOURCE $ $.70 $.72 $.72 B4152 NU SCANDISHAKE *By-Report *By-Report *By-Report *By-Report B4152 NU TWOCAL HN $ $.88 $.

7 83 $.84 HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 CURRENT REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4153 NU IMPACT PEPTIDE *By-Report $ *By-Report $ B4153 NU KATE FARM PEPTIDE FORMULA PLAIN *By-Report *By-Report *By-Report *By-Report B4153 NU PEPTAMEN $ $ $ B4153 NU PEPTAMEN WITH PREBIO $ $ $ $ B4153 NU PEPTAMEN $ $ $ $ B4153 NU PEPTAMEN CAL WITH PREBIO 1 TM $ $ $ $ B4153 NU PEPTAMEN AF $ $ $ $ B4153 NU PEPTAMEN OS *By-Report *By-Report *By-Report *By-Report B4153 NU PEPTAMEN INTENSE VHP *By-Report *By-Report *By-Report *By-Report B4153 NU PERATIVE *By-Report

8 *By-Report *By-Report *By-Report B4153 NU TOLEREX $ $ *By-Report *By-Report B4153 NU VITAL $ $ $ $ B4153 NU VITAL $ $ *By-Report *By-Report B4153 NU VITAL AF *By-Report *By-Report *By-Report *By-Report B4153 NU VITAL HIGH PROTEIN *By-Report *By-Report *By-Report *By-Report B4153 NU VIVONEX PLUS $ $ *By-Report *By-Report B4153 NU VIVONEX RTF $ $ $ $ B4153 NU VIVONEX $ $ *By-Report *By-Report HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 CURRENT REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4154 NU BOOST GLUCOSE CONTROL $ $ *By-Report *By-Report B4154 NU DIABETISOURCE AC $ *By-Report *By-Report *By-Report B4154 NU GLUCERNA $ $ $.

9 80 $.80 B4154 NU GLUCERNA CAL *By-Report *By-Report *By-Report *By-Report B4154 NU GLUCERNA CAL *By-Report *By-Report *By-Report *By-Report B4154 NU GLUCERNA HUNGER SMART SHAKE *By-Report *By-Report *By-Report *By-Report B4154 NU GLUCERNA SHAKE $ *By-Report *By-Report $.83 B4154 NU GLYTROL $ *By-Report *By-Report *By-Report B4154 NU IMPACT *By-Report *By-Report *By-Report *By-Report B4154 NU IMPACT *By-Report *By-Report *By-Report *By-Report B4154 NU IMPACT ADVANCED RECOVERY *By-Report *By-Report *By-Report *By-Report B4154 NU IMPACT WITH FIBER *By-Report *By-Report *By-Report *By-Report B4154 NU KETOCAL 3:1 $ *By-Report *By-Report $ B4154 NU KETOCAL 4:1 POWDER $ $ $ $ B4154 NU KETOCAL 4:1 LIQUID *By-Report *By-Report *By-Report $ B4154 NU KETOVIE VANILLA *By-Report *By-Report *By-Report *By-Report B4154 NU NEPRO CARB STEADY *By-Report *By-Report $ $.

10 93 B4154 NU NOVASOURCE RENAL *By-Report *By-Report *By-Report *By-Report B4154 NU NUTREN PULMONARY *By-Report *By-Report *By-Report *By-Report B4154 NU PULMOCARE $ $ *By-Report *By-Report B4154 NU RENA START *By-Report *By-Report *By-Report *By-Report B4154 NU SIMILIAC PM 60/40 $ $ *By-Report $ B4154 NU SUPLENA WITH CARB STEADY $ $.79 *By-Report *By-Report HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 CURRENT REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4155 NU ARGINAID *By-Report *By-Report *By-Report $ B4155 NU BENECALORIE $ $ $.68 $ B4155 NU BENEPROTEIN $ $ $ $ B4155 NU CITRULLINE 1000 *By-Report *By-Report *By-Report *By-Report B4155 NU CITRULLINE 200 *By-Report *By-Report *By-Report *By-Report B4155 NU CAMINO PRO RESTORE LEMON LIME *By-Report *By-Report *By-Report *By-Report B4155 NU CAMINO-PRO RESTORE RED BERRY *By-Report *By-Report *By-Report *By-Report HCPCS Code MOD PRODUCT NAME REIMB AMOUNT 1/1/2017 12/31/2017 REIMB AMOUNT 1/1/2018 CURRENT REIMB AMOUNT 1/1/2020-12/31/2020 REIMB AMOUNT 1/1/2021-Current B4155 NU CAMINO PRO RESTORE TANGERINE *By-Report *By-Report *By-Report *By-Report B4155 NU COMPLETE AMINO ACID MIX $ $ $ $ B4155 NU COMPLEX MSUD AMINO ACID