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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
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $2.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $1.07 / $2.29
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.69 / $3.16 / $5.01
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.26 / $1.45
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $1.78 / $1.78
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $1.78 / $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
$54.95 / $64.57 / $89.13
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.11 / $100.00 / $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
$1.91 / $1.91 / $1.91
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.89 / $1.45 / $1.45