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Kansas 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
$0.70 / $1.71 / $1.71
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.70 / $0.92 / $0.92
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.99 / $1.10 / $1.20
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.12
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.70 / $1.58 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.31 / $1.01 / $1.48
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.31 / $0.99 / $1.48