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Idaho 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
$0.69 / $0.90 / $0.90
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.81 / $0.95 / $23.85
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.93 / $0.98 / $1.03
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.21 / $1.50 / $2.35
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.69 / $0.69 / $0.98
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.34 / $1.07 / $1.60