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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
$1.91 / $1.91 / $1.91
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $2.14 / $2.45
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.51 / $0.78 / $79.43
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.17 / $2.40 / $8.91
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.69 / $0.85 / $0.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.89 / $5.89 / $5.89
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.85 / $1.29 / $12.30
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
Facility
Modifier
Low / Median / High Price
$0.69 / $0.69 / $0.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.49 / $1.02 / $1.95