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Illinois 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
$0.90 / $0.90 / $1.80
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.60 / $0.78 / $0.91
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.24 / $2.50 / $9.86
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.69 / $0.86 / $0.86
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.86 / $1.20 / $12.25
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.12
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.88 / $1.63