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Maryland 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
$0.41 / $0.41 / $0.41
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.21 / $1.21 / $1.21
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
$3.00 / $3.00 / $3.00
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.06 / $1.06 / $1.06