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Pennsylvania 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
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5,000.00 / $8,639.91 / $79,506.39
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.76 / $0.79 / $0.79
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $0.41 / $0.41
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.41 / $0.41
Priority Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52