go back

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
$1.82 / $1.82 / $1.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $2.14
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.41
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.12 / $1.55 / $2.95
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.32 / $0.95 / $1.66
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.23 / $1.23 / $1.23
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.87 / $1.02 / $2.14
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.32 / $0.95 / $1.58