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Michigan 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 / $2.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.41 / $0.41 / $1.74
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.13 / $2.31 / $4.45
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.77 / $0.81 / $0.81
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.56 / $0.56
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $1.42 / $1.75
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.41 / $1.75 / $2.10