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Arizona 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
$2.14 / $3.89 / $3.89
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.78 / $77.62 / $79.43
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.91 / $2.45 / $4.47
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.74 / $0.83 / $1.66
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.89 / $5.89 / $5.89
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.56 / $0.91 / $89.13
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.68 / $1.00 / $1.51
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.74 / $0.74 / $0.93
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.63 / $0.95 / $1.51