Transcription of Enteral Nutrition Price List - B4157-B4162 - Minnesota
1 Enteral Nutrition Price LIST B4157 B4162 List updated: 04/28/2021 HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4157 NU Acerflex** 49735018842 $ B4157 NU Camino Pro BetterMilk 24359035008 $ Added 08/01/2015 B4157 NU Camino Pro PKU 24359031002 $ B4157 NU Complex Essential MSD** 00847059722 *By-Report Added 4/23/2018 B4157 NU Cyclinex-2** 70074051147 $ B4157 NU EAA Supplement *By-Report Added 10/07/2020 B4157 NU Glutarex-2** 70074051143 $ B4157 NU Glycosade** 70074051141 $ B4157 NU Glytactin Bettermilk 15** 24359035001 $ Added 02/25/2016 B4157 NU Glytactin Build 10** 24359035307 *By-Report Added 06/10/ 2019 B4157 NU Glytactin Build 20/20** 24359053101 *By-Report Added 07/01/ 2019 B4157 NU Glytactin RTD 10 Chocolate** 24359056403 *By-Report Added 03/08/2021 B4157 NU Glytactin RTD 15 PE** 50600005140 $ B4157 NU Glytactin RTD Lite 15** 24359051403 *By-Report Added 07/27/2020 B4157 NU Glytactin RTD-Original** 24539057403 *by
2 Report Added 03/08/2021 B4157 NU Hominex-2** 70074051119 $ B4157 NU IVA Anamix Next 49735019471 *By-Report Added 06/10/ 2019 B4157 NU Ketonex-2** 70074051115 $ B4157 NU Lanaflex 49735012643 $ B4157 NU Lophlex** 49735012169 $ B4157 NU MMA/PA Anamix Next ** 49735019472 $ Added 10/05/2016 B4157 NU MMA/PA Cooler 15 Liqd** 50600056122 $ Added 09/02/2016 B4157 NU MMA/PA Express** 50600054371 *By-Report Added 4/23/2018 B4157 NU MSUD Cooler** 50600050915 $ B4157 NU MSUD Express 20 ** 50600051653 $ B4157 NU MSUD Lophlex Liquid** 49735016749 $ Added 06/23/2017 B4157 NU Periflex Advance** 49735012650 $ B4157 NU Phenex 2 ** 70074051122 $ B4157 NU Phenyl Free 2** 00087008041 $ B4157 NU PhenylAde 60 Drink Mix ** 00847095622 $ Added 01/20/2017 B4157 NU PhenylAde Drink Mix ** 00847095332 $ B4157 NU PhenylAde Essential** 00847095012 $ B4157 NU PhenylAde GMP** 49735018304 *By-Report Added 07/26/2018 HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4157 NU Phenyl-Free 2HP ** 00087008141 $ B4157 NU Phlexy-10** 49735011914 $ B4157 NU PKU Cooler 15 Purple 50600054562 *By-Report Added 04/16/ 2019 B4157 NU PKU Express15 Tropical** 812539020172 *By-Report Added 03/20/ 2019 B4157 NU PKU Express20** 50600051639 $ Added 11/04/2015 B4157 NU PKU Lophlex** 49735019535 $ B4157 NU PKU Periflex Junior Plus** 49735019477 $ Added 06/23/2017 B4157 NU Propimex-2 ** 70074051134 $ B4157 NU Tylactin RTD Original** 24359059203 $ Added 09/01/2017 B4157 NU TYR Anamix Next** 49735019479 $ Added 12/29/2015 B4157 NU TYR Cooler** 50600053992 $ B4157 NU Tyrex-2** 70074051127 $ B4157 NU UCD Anamix Junior** 04973501293 $ B4157 NU XMTVI Maxamum** 49735012342 $ B4157 NU XPHE Maxamum ** 49735018323 $ Added 06/01/2016 HCPCS Code
3 MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4158 NU Baby s Only Organic Dairy DHA 16514022902 $ B4158 NU Enfagrow Premium Transit Toddler *By-Report Added 01/21/2021 B4158 NU Enfamil AR 00087020142 $ Added 01/11/2016 B4158 NU Enfamil Gentlease Lipil 00087869342 $ B4158 NU Enfamil LactoFree 00087061614 $ B4158 NU Enfamil Lipil with Iron concentrated 00087127241 $ B4158 NU Enfamil Lipil with Iron powder 00087127341 $ B4158 NU Enfamil NeuroPro Infant 00087512107 *By-Report Added 10/14/ 2019 B4158 NU Gerber Graduates Soothe Powder 50000023125 Added 09/02/2016 B4158 NU Good Start Gentle Plus powder 50000011125 $ B4158 NU Good Start Supreme with Iron 50000012021 $ B4158 NU Lipistart 50600050205 *By-Report Added 11/02/2020 B4158 NU Monogen 49735019708 $ B4158 NU Pediasure Sidekicks 70074056524 $ B4158 NU Portagen 00087038701 $ B4158 NU Similac Advance Early Shield with Iron 70074055958 $ B4158 NU Similac Advance with Iron 70074055958 $ B4158 NU Similac for Spit-Up 70074050960 $ B4158 NU Similac Go & Grow Soy Based Formula 70074057712 $ B4158 NU Similac Pro-Advanced 70074066081 *By-Report B4158 NU Similac Pro-Sensitive *By-Report B4158 NU Similac Sensitive 70074057541 $ HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4158 NU Similac Total Comfort Powder 70074062600 $ Added 01/15/2016 HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4159 NU Enfamil Prosobee Lipil 00087121441 $ B4159 NU Gerber Good Start Soy-powder 50000003530 $ Moved from B4158 B4159 NU Similac Isomil Advance 70074056976 $ HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4160 NU Boost Kid Essentials 43900033511 $ B4160 NU Boost Kid Essentials 43900033540 $ B4160 NU Boost Kid
4 Essentials with Fiber 43900033500 $ B4160 NU Bright Beginnings Soy 83744035009 $ B4160 NU Enfamil Enfacare Lipil 00087001944 $ B4160 NU Enfamil Premature Lipil 00087140642 $ B4160 NU Enfaport Lipil 00008712841 $ B4160 NU Kate Farms Pediatric Standard Formula 05182300699 *By-Report Added 02/26/ 2019 B4160 NU Nutren Junior 00065904370 $ B4160 NU Nutren Junior w/ Fiber Diet 00065904570 $ B4160 NU PediaSmart 16514088201 $ B4160 NU Pediasure 70074403730 $ B4160 NU Pediasure Berry 70074053819 $ Added 12/29/2015 B4160 NU Pediasure Enteral Formula 70074051805 $ B4160 NU Pediasure Grow & Gain with Fiber 70074058062 $ Added 09/01/2017 B4160 NU Pediasure with Fiber 70074050653 $ B4160 NU Pediasure with Fiber Enteral Formula 70074051807 $ B4160 NU Pediasure Cal 70074056410 $ B4160 NU Pediasure Cal with Fiber 70074056412 $ B4160 NU Similac Expert Care Neosure 70074057431 $ B4160 NU Similac Neosure 70074518510 $ B4160 NU Similac Neosure Advance 70074057431 $ B4160 NU Similac Special Care 24 with Iron 70074059583 $ HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4161 NU E028 Splash 49735012670 $ B4161 NU Alfamino Junior 7613034787965/7613034787958 *By-Report B4161 NU Elecare 70074059406 $ B4161 NU Elecare DHA/ARA 70074053511 $ B4161 NU Elecare Jr 70074055254 $ B4161 NU Enfamil Nutramigen Lipil-liquid 00087049801 $ HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4161 NU Enfamil Nutramigen Lipil-powder 00087033801 $ B4161 NU Kate Farm Pediactic Peptide Vanilla *By-Report Added 03/02/2021 B4161 NU Kate Farm C Pediatric Peptide 851823006461 *By-Report Added 02/07/ 2019 B4161
5 NU Keto Peptide *By-Report B4161 NU Ketovie Peptide 24359050203 *By-Report Added 04/28/2021 B4161 NU Form Compleat Ped Peptide RTF *By-Report Added 01/13/2021 B4161 NU Neocate Infant DHA and ARA 49735010804/ 49735012595 $ B4161 NU Neocate Junior 49735011790 $ B4161 NU Neocate Nutra 49735012910 $ B4161 NU Neocate One + Powder 49735011047 $ B4161 NU Neocate Splash 49735014451 $ Added 03/11/2016 B4161 NU Nourish Peptide 57858000427 *By-Report Added 11/20/2020 B4161 NU Pediasure Peptide Cal 70074062122 $ B4161 NU Pediasure Peptide Cal 70074056656 $ B4161 NU Pepdite One+ 49735011766 $ B4161 NU Peptamen Junior 00065906970 $ B4161 NU Peptamen Junior 98716007363 $ B4161 NU Peptamen Jr HP 43900046768 $ Added 09/21/2017 and Updated 06/07/2018 B4161 NU Peptamen Junior with Fiber 00065906871 $ B4161 NU Peptamen Junior with Prebio1 00065906870 $ B4161 NU Pregestimil Liipil Powder 00087036701 $ B4161 NU Product 3232A 00087042541 $ B4161 NU Puramino DHA-ARA 00087510478 $ B4161 NU Puramino JR 00087512244 *By-Report B4161 NU Similac Alimentum Advance 70074057664 $ B4161 NU Vital Jr 70074059763 $ B4161 NU Vital Peptide RTF *By-Report B4161 NU Vivonex Pediatric 00212713176 $ HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4162 NU Acerflex** 49735018842 $ B4162 NU Calcilo XD 70074003780 $ B4162 NU Camino Pro MSUD 24359061002 $ B4162 NU Camino Pro PKU 24359031002 $ B4162 NU Complex Essential MSD ** 00847059722 *By-Report Added 04/23/2018 B4162 NU Cyclinex-1 70074051145 $ B4162 NU Cyclinex-2** 70074051147 $ B4162 NU EAA Supplement *By-Report Added 10/04/2020 B4162 NU Glutarex-1 70074051141 $ HCPCS Code
6 MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4162 NU Glutarex-2** 70074051143 $ B4162 NU Glycosade** 70074051141 $ B4162 NU Glytactin Bettermilk 15** 24359035001 $ Added 02/25/2016 B4162 NU Glytactin Build 10** 24359035307 *By-Report Added 06/10/ 2019 B4162 NU Glytactin Build 20/20** 24359053101 *By-Report Added 07/01/ 2019 B4162 NU Glytactin RTD 10 Chocolate** 24359056403 *By-Report Added 03/08/2021 B4162 NU Glytactin RTD Original** 24359057403 *By-Report Added 03/08/2021 B4162 NU Glytactin RTD 15 PE** 506000051400 $ B4162 NU Glytactin RTD Lite 15** 24359051403 *By-Report Added 07/27/2020 B4162 NU Hominex-1 70074051117 $ B4162 NU Hominex-2** 70074051119 $ B4162 NU IVA Anamix Next 49735019471 *By-Report Added 06/10/ 2019 B4162 NU Ketonex 1 70074051112 $ B4162 NU Ketonex-2** 70074051115 $ B4162 NU Lophlex** 49735012169 $ B4162 NU MMA/PA Anamix Next 49735019472 $ Added 10/05/2016 B4162 NU MMA/PA Cooler 15 Liqd** 50600056122 $ Added 09/02/2016 B4162 NU MMA-PA Express 15** 50600054371 *By-Report Added 04/23/2018 B4162 NU MSUD Cooler** 50600050915 $ B4162 NU MSUD Express 20** 50600051653 $ B4162 NU MSUD Lophlex Liquid** 49735016749 $ Added 06/23/2017 B4162 NU Periflex Advance** 49735012650 $ B4162 NU Periflex Infant 49735011880 $ B4162 NU Periflex Junior 49735011401 $ B4162 NU Phenex 2 ** 70074051123 $ B4162 NU Phenyl Free 1 (infant)
7 00087036842 $ B4162 NU Phenyl Free 2** 00087008041 $ B4162 NU PhenylAde 60 Drink Mix ** 00847095622 $ Added 01/20/2017 B4162 NU PhenylAde Drink Mix ** 00847095332 $ B4162 NU PhenylAde Essential** 00847095012 $ B4162 NU PhenylAde GMP** 49735018304 *By-Report Added 07/26/2018 B4162 NU Phenyl-Free 2HP ** 00087008141 $ B4162 NU Phlexy-10** 497350119140 $ B4162 NU PKU Cooler 15 Purple 50600054562 *By-Report Added 04/16/ 2019 B4162 NU PKU Express15 Tropical** 812539020172 *By-Report Added 03/20/ 2019 B4162 NU PKU Express20** 50600051639 $ Added 11/04/2015 B4162 NU PKU GEL 50600051448 *By-Report Added 07/26/2018 B4162 NU PKU Lophlex** 49735019535 $ B4162 NU PKU Periflex Junior Plus** 49735019477 $ Added 06/23/2017 B4162 NU Propimex-1 70074051133 $ B4162 NU Propimex-2 ** 70074051134 $ B4162 NU Tylactin RTD Original** 24359059203 $ Added 09/01/2017 B4162 NU TYR Anamix Next** 49735019479 $ Added 12/29/2015 B4162 NU TYR Cooler** 50600053992 $ B4162 NU Tyrex-2** 70074051127 $ B4162 NU UCD Anamix Junior** 04973501293 $ HCPCS Code MOD PRODUCT NAME UPC REIMB AMOUNT NOTES B4162 NU XLEU Analog 49735011888 $ Added 11/04/2015 B4162 NU XMTVI Maxamum** 49735012342 $ B4162 NU XPHE Maxamum ** 49735018323 $ Added 06/01/2016 B4162 NU XPHE XTYR Analog 49735018301 $ **product can be billed under HCPCS B4157 or B4162
