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New Hampshire 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
$0.40 / $0.40 / $0.48
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.32 / $0.40 / $0.40
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.06 / $1.06 / $1.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.50 / $1.99 / $2.49