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Missouri 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 / $1.79 / $1.88
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
$0.70 / $1.06 / $1.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $1.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $80.00 / $100.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.44 / $1.44 / $1.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.44 / $1.44 / $1.52