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Wisconsin 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
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.70 / $1.06 / $2.23
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.70 / $3.16 / $4.84
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $1.15 / $1.41
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $1.79 / $1.79
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $1.79 / $100.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.45 / $1.45 / $1.45
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.76 / $55.00 / $90.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.40 / $0.74 / $1.79
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.00 / $85.00 / $100.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.52 / $0.52 / $0.52
Security Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.89 / $1.89 / $1.89
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.45 / $1.45 / $1.45