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Ohio 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
$1.74 / $1.74 / $6.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.41 / $1.74 / $1.74
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.70 / $1.33 / $2.11
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.78 / $59,499.41 / $61,249.39
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Medical Mutual of Ohio
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.00 / $50.00 / $50.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.34 / $1.34 / $1.61