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Wisconsin 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
$0.69 / $0.69 / $0.69
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.67 / $0.69 / $2.78
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.86 / $0.86 / $1.42
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.80 / $0.80 / $0.94
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.77 / $1.84 / $1.84
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.70 / $3.16 / $4.84
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.43 / $5.92
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.69 / $0.86 / $1.24
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.54 / $0.54 / $0.54
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.69 / $0.86 / $90.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $1.28 / $3.37
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.95 / $65.00 / $90.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.67 / $0.86 / $1.24
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.54 / $0.54 / $0.54
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.86 / $1.31 / $2.38
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.75 / $1.77 / $90.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.92 / $5.92 / $5.92
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.11 / $1.11 / $1.11
Security Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.97 / $0.97 / $0.97
Security Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.11 / $1.11 / $1.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.34 / $1.11 / $2.99