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Michigan 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
$0.90 / $0.90 / $2.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.61 / $0.90 / $0.90
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.13 / $2.42 / $4.72
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.82 / $0.86 / $0.90
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.68 / $0.68 / $5.92
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.90 / $0.95 / $1.67
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.69 / $0.95 / $1.03
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.78 / $0.78 / $0.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.87 / $1.32