| Code | Description | States | Median rate |
|---|---|---|---|
| B4034 | Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 43 | $5.37 |
| B4035 | Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 44 | $9.83 |
| B4036 | Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 43 | $7.09 |
| B4081 | Nasogastric tubing with stylet | 43 | $19.93 |
| B4082 | Nasogastric tubing without stylet | 43 | $14.73 |
| B4083 | Stomach tube - levine type | 39 | $2.18 |
| B4087 | Gastrostomy/jejunostomy tube, standard, any material, any type, each | 40 | $33.68 |
| B4088 | Gastrostomy/jejunostomy tube, low-profile, any material, any type, each | 36 | $45.49 |
| B4100 | Food thickener, administered orally, per ounce | 17 | $0.72 |
| B4102 | Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit | 10 | $1.67 |
| B4103 | Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit | 16 | $3.33 |
| B4105 | In-line cartridge containing digestive enzyme(s) for enteral feeding, each | 13 | $120.16 |
| B4148 | Enteral feeding supply kit; elastomeric control fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | 11 | $9.40 |
| B4149 | Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 31 | $1.52 |
| B4150 | Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 32 | $0.65 |
| B4152 | Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 33 | $0.54 |
| B4153 | Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 33 | $1.89 |
| B4154 | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 32 | $1.14 |
| B4155 | Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit | 33 | $0.99 |
| B4157 | Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 14 | $3.31 |
| B4158 | Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit | 21 | $0.84 |
| B4159 | Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit | 19 | $0.80 |
| B4160 | Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 22 | $0.86 |
| B4161 | Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 22 | $2.03 |
| B4162 | Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 14 | $3.59 |
| B4164 | Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix | 28 | $18.89 |
| B4168 | Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix | 27 | $28.45 |
| B4172 | Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix | 17 | $32.87 |
| B4176 | Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix | 25 | $55.05 |
| B4178 | Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit) - home mix | 28 | $68.13 |
| B4180 | Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix | 26 | $27.13 |
| B4185 | Parenteral nutrition solution, not otherwise specified, 10 grams lipids | 32 | $11.72 |
| B4187 | Omegaven, 10 grams lipids | 20 | $16.29 |
| B4189 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix | 30 | $193.80 |
| B4193 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix | 29 | $244.19 |
| B4197 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix | 31 | $297.29 |
| B4199 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix | 30 | $331.01 |
| B4216 | Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes), home mix, per day | 26 | $9.14 |
| B4220 | Parenteral nutrition supply kit; premix, per day | 38 | $8.91 |
| B4222 | Parenteral nutrition supply kit; home mix, per day | 33 | $10.98 |
| B4224 | Parenteral nutrition administration kit, per day | 39 | $27.81 |
Published Medicaid fee-for-service schedule amounts, not a coverage or eligibility guarantee. Managed-care plan rates can differ. Where no prior-authorization flag is shown, the state does not publish one. Descriptions are ProviderSignal's own plain-language labels or public-domain CMS text.