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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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $3.89 / $3.89
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.51 / $1.86 / $79.43
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,011.87 / $8,511.38 / $77,624.71
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.87 / $0.87 / $0.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.89 / $5.89 / $5.89
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $2.14 / $3.89
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.68 / $0.91 / $1.58
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.68 / $0.91 / $1.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.87 / $1.41