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Pennsylvania 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

Facilitymedian $1 · 10th–90th $1–$8,5110%20%40%10th90th$1Professionalmedian $4 · 10th–90th $1–$60%20%40%10th90th$4$0.5$5.0$50.0$500.0$5.0K$50.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample — interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1.00 / $3.89 / $3.89
Ambetter
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1.86 / $1.86 / $1.86
Capital Blue Cross
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$5,011.87 / $8,511.38 / $77,624.71
Capital Blue Cross
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.87 / $0.87 / $0.87
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$5.89 / $5.89 / $5.89
UPMC Health Plan
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$0.68 / $0.91 / $1.58
UPMC Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.68 / $0.91 / $1.58
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.47 / $0.91 / $1.55