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Washington 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
$0.39 / $0.41 / $1.29
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.39 / $4.70 / $100.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.06 / $1.14 / $2.59
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.61 / $0.80 / $79,999.20
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.39 / $3.16 / $4.70