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South Carolina 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
$0.92 / $0.92 / $0.92
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.60 / $0.84 / $0.92
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.89 / $1.11 / $1.39
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.80 / $0.92 / $2.18
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.49 / $0.49 / $0.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.32 / $0.80 / $1.22