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Wisconsin 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

Facilitymedian $1 · 10th–90th $1$20%50%90th$1Professionalmedian $1 · 10th–90th $1$20%20%40%10th90th$1$0.1$0.5$2.0$10.0$50.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$2.45 / $10.96 / $19.05
Anthem BCBS
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$0.87 / $0.87 / $1.45
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.81 / $0.81 / $0.98
Cigna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$2.69 / $3.16 / $5.01
Cigna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1.12 / $1.45 / $5.89
DeanCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$0.69 / $0.85 / $1.23
DeanCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.54 / $0.54 / $0.54
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$0.69 / $0.85 / $89.13
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.47 / $1.23 / $2.88
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.95 / $64.57 / $89.13
Network Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1.55 / $1.55 / $1.55
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.87 / $1.35 / $3.02
Quartz
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$1.78 / $89.13 / $89.13
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$5.89 / $5.89 / $5.89
Security Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1.12 / $1.12 / $1.12
Security Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1.12 / $1.12 / $1.12
United
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$0.71 / $0.87 / $0.87
United
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$0.34 / $1.10 / $2.82