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Virginia 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 / $1.29 / $1.29
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.41 / $0.41 / $1.29
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.06 / $1.06 / $1.06
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.61 / $0.61 / $0.61
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3.00 / $3.00 / $4.00
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.43 / $1.29 / $1.77
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.02 / $0.63 / $10,945.00
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $0.63 / $10,945.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.48 / $1.48 / $1.48