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Maine 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
$2.45 / $2.45 / $2.45
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.91 / $1.10 / $1.26
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.72 / $0.72 / $0.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.89 / $5.89 / $5.89
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.42 / $1.23 / $1.55
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.82 / $2.45 / $2.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.42 / $1.23 / $1.55