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Oregon 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
$3.89 / $3.89 / $3.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.89 / $5.89 / $5.89
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.91 / $2.19 / $2.51
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.91 / $0.98 / $1.74
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.87 / $0.93 / $1.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.89 / $0.98 / $1.07
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.81 / $1.45 / $5.37
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.24 / $5.89 / $79.43
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.91 / $1.38 / $3.89
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.85 / $0.85 / $0.85
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.98 / $1.41 / $2.29