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Montana rates for HCPCS B4154

Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3.47 / $3.47 / $3.47
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.20 / $1.20 / $1.20
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.29 / $1.29 / $1.29
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.29 / $1.29 / $1.29
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.81 / $1.12 / $1.17
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.81 / $1.12 / $1.17
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.29 / $1.29 / $1.29
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.29 / $79.43 / $85.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.05 / $1.32 / $1.95