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Utah 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
$0.46 / $0.46 / $0.46
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.46 / $0.46 / $0.81
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.86 / $1.43 / $1.43
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.50 / $1.08 / $1.25