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Virginia 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
$0.53 / $0.53 / $0.91
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.53 / $0.55 / $0.91
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.89 / $0.89 / $0.95
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.72 / $0.72 / $0.72
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6.96 / $6.96 / $6.96
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.77 / $1.02 / $1.64
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.53 / $0.89 / $1.72
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.47 / $0.67
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.57 / $0.92 / $4,845.00
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.50 / $0.91 / $4,845.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.48 / $0.78 / $1.40