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Washington 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
$1.00 / $3.16 / $3.47
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.82 / $1.82 / $1.82
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.32 / $1.32 / $75.86
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.81 / $0.83 / $1.20
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.87 / $1.17 / $1.74
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.78 / $0.78 / $0.78
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.83 / $1.00 / $1.91
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.71 / $0.71 / $0.71
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.85 / $1.62 / $2.57
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.71 / $0.71 / $1.26