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Montana 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
$0.85 / $2.78 / $2.78
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.08 / $1.08 / $1.08
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.17 / $1.17 / $1.17
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.17 / $1.17 / $1.17
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.17 / $1.17 / $1.17
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.81 / $0.81 / $1.17
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.07 / $1.28 / $1.60