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Iowa 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
$1.71 / $1.71 / $1.71
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.46 / $0.78 / $0.92
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.41 / $1.42
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.86 / $1.41 / $2.78
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.83 / $1.71 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.49 / $1.11 / $1.66
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.11 / $1.22 / $1.52
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.03 / $1.39 / $2.29
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.68 / $1.66
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.11 / $1.11 / $1.11
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.11 / $1.11 / $1.11