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Washington rates for HCPCS B4155

Enteral Formula Nutritionally Incomplete/Modular Nutients Includes Specific Calories = 1 Unit (Special Coverage Instructions A

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.81 / $0.81 / $0.81
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.53 / $0.81 / $0.92
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.00 / $1.61 / $90.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.77 / $0.87 / $1.02
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.90 / $0.98 / $6.96
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.85 / $1.39 / $2.25
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.87 / $0.87 / $1.72
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.25 / $1.50 / $2.85
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.77 / $0.77 / $0.94
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.84 / $1.28 / $2.33