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New York 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
$0.32 / $0.40 / $0.41
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.32 / $0.40 / $0.41
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.06 / $1.36 / $1.59
CDPHP
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.19 / $1.19 / $1.31
CDPHP
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.19 / $1.19 / $1.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.58 / $1.58 / $1.59
Excellus BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.74 / $0.74 / $1.43
Excellus BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.89 / $1.43 / $1.43
MVP Health Care
Facility/Professional
Facility
Modifier
Low / Median / High Price
$555.00 / $597.00 / $74,999.25
MVP Health Care
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $2.21
Univera
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.30 / $1.30 / $1.43
Univera
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.30 / $1.43 / $1.43