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New Hampshire rates for HCPCS B4155

Enteral Formula Nutritionally Incomplete/Modular Nutients Includes Specific Calories = 1 Unit (Special Coverage Instructions A

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.42 / $0.42 / $0.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.42 / $0.45 / $0.47
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.86 / $1.00 / $1.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.72 / $0.72 / $1.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.46 / $1.94 / $2.42
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.33 / $0.50 / $1.39
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $1.47 / $2.42