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California 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
Facility
Modifier
Low / Median / High Price
$0.40 / $0.40 / $2.78
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.46 / $2.78
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.56 / $1.17 / $3.18
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.62 / $0.80 / $1.43
Blue Shield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.15 / $1.65 / $2.13
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.65 / $0.93 / $1.56
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Contra Costa Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.90 / $0.90 / $0.99
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.11 / $2.54
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.75 / $90.00 / $90.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.56 / $0.90 / $20.69
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.49 / $0.90 / $5.92
Sutter Health Plus
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.81 / $1.81 / $1.81
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.56 / $0.99 / $2.27