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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
$0.52 / $0.52 / $2.78
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.92 / $3.61 / $6.02
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.57 / $0.84 / $1.67
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.56 / $1.14 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.67 / $0.97 / $1.53
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.69 / $0.94 / $1.45