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Texas 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
$0.83 / $0.83 / $0.96
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.61 / $0.84 / $0.96
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.77 / $0.77 / $0.77
Baylor Scott & White
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.64 / $0.64 / $0.64
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.75 / $90.00 / $90.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.80 / $0.92 / $19.05
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.49 / $0.68 / $0.92
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.79 / $0.92 / $17.20
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.49 / $5.92 / $5.92
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.59 / $0.86 / $1.38
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.72 / $0.72 / $1.24