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New Mexico 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
$0.86 / $0.86 / $0.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.83 / $0.86 / $2.78
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$56,799.99 / $68,899.99 / $81,099.99
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.55 / $0.73 / $0.94
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.34 / $1.34 / $1.34
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.64 / $0.86 / $21.44
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.49 / $0.49 / $0.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.89 / $1.37 / $2.21