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Minnesota 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
$7.08 / $7.08 / $7.08
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $2.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3.31 / $3.39 / $933.25
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.69 / $3.39 / $3.39
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.69 / $3.80 / $8.91
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.32 / $1.45
Health Partners
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.88 / $3.63 / $7.08
Health Partners
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.51
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.69 / $1.78 / $79.43
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.58 / $1.58 / $1.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.89 / $1.12 / $1.58