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South Dakota 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 / $1.74
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.41
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.59 / $1.79 / $2.94
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.21 / $1.21 / $1.21
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.21 / $1.21 / $2.40
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.35 / $1.35 / $1.35
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.00 / $2.00 / $2.00