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California rates for HCPCS B4159

Enteral formula, for pediatrics, nutritionally complete soy based 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
$0.40 / $0.40 / $0.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.40 / $0.41
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.80 / $0.85 / $0.96
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.70 / $1.06 / $1.73
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.00 / $40.00 / $40.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.88 / $0.88 / $0.88
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $2.00 / $6.00
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.00 / $100.00 / $100.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.42 / $1.10 / $1.85
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.40 / $0.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5.99 / $5.99 / $5.99