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South Dakota 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
$0.92 / $0.92 / $1.08
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.13 / $1.41
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.13 / $1.54 / $1.83
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.32 / $0.95 / $1.66
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.11 / $1.22 / $1.42
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.05 / $1.26 / $2.29
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.86 / $0.99 / $1.15
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.32 / $0.47 / $1.66
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.11 / $1.11 / $1.11