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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
Facility
Modifier
Low / Median / High Price
$0.55 / $0.55 / $0.66
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.61 / $2.78
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
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
$5.92 / $5.92 / $5.92
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.55 / $0.55 / $0.66
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.61 / $2.78
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
UPMC Health Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.87 / $0.91 / $0.91
UPMC Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.87 / $0.91 / $0.91
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.86 / $1.59