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Louisiana 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
$0.73 / $0.76 / $0.80
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.73 / $0.80 / $0.80
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.71 / $0.71 / $1.07
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.62 / $0.73 / $0.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.31 / $0.86 / $1.22