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Maryland 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
Professional
Modifier
Low / Median / High Price
$1.00 / $2.14 / $2.45
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.98 / $0.98 / $0.98
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.89 / $5.89 / $5.89
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.63 / $0.95 / $1.35
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.72 / $0.89 / $0.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.78 / $1.58
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.58 / $1.58 / $1.58