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Alaska rates for HCPCS 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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.59 / $0.70 / $2.78
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.00 / $1.00 / $20.69
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.65 / $1.13 / $3.86
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.87 / $1.17 / $1.17
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.00 / $1.00 / $20.69
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.65 / $0.98 / $5.92
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.42 / $1.96 / $2.94