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Oregon 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
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $2.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $0.87 / $1.95
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $2.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.79 / $0.79 / $0.79
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $1.66 / $3.98
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $79.43
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.00