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Nebraska 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
$0.92 / $1.71 / $1.71
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.67 / $0.92 / $2.78
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$609.59 / $801.77 / $1,675.75
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.82 / $0.85 / $0.86
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.19 / $1.41
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.92 / $1.58 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.37 / $0.79 / $2.09
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.10 / $1.33 / $1.51
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.30 / $2.29
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.37 / $0.79 / $1.56