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Indiana 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
$0.40 / $0.41 / $0.41
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.06 / $1.06 / $2.04
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.70 / $1.06 / $1.50
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.78 / $1.78 / $2.24
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.78 / $1.78 / $2.04
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.40 / $1.40 / $1.40
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.45 / $1.50 / $1.61