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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
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.98 / $1.26 / $2.24
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.71 / $0.71 / $1.45
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.89 / $0.89 / $1.29
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.95 / $1.05 / $1.05
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.26 / $1.51 / $2.24
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.71 / $0.71 / $1.00
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.34 / $1.07 / $1.58