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Georgia 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
Facility
Modifier
Low / Median / High Price
$0.41 / $0.41 / $0.41
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.41 / $0.41 / $0.41
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.90 / $1.06 / $1.06
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.50 / $1.55 / $3.02
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.26 / $1.52 / $98.34