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Missouri 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
$0.80 / $1.80 / $3,281.04
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.70 / $0.80 / $0.92
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.88 / $0.92 / $4.05
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.53 / $0.72 / $0.99
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.13 / $5.92 / $5.92
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.71 / $1.75 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.77 / $1.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.76 / $1.47