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Indiana 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
$0.86 / $0.90 / $0.90
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.44 / $0.90 / $0.90
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.68 / $0.77 / $0.86
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.62 / $0.72 / $1.85
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.89 / $0.89 / $1.07
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.89 / $0.89 / $0.98
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$17.46 / $17.46 / $17.46
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.95 / $0.95 / $0.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.31 / $0.96 / $1.37