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Arizona rates for HCPCS B4158

Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.74 / $1.74 / $1.74
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.80 / $3.14 / $5.23
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.55 / $0.80 / $1.60
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.79 / $80.00 / $100.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.40 / $0.40