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New Mexico 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 / $0.41
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.41 / $0.41 / $0.41
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.10 / $2.10 / $2.10
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.10 / $2.10 / $2.10
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $0.41 / $1.33
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.40 / $0.40