go back

Illinois 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
$0.41 / $0.41 / $1.94
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.41 / $0.41 / $1.47
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.60 / $2.69 / $7.21
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.50 / $0.50 / $0.50
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.88 / $0.88 / $0.88
Hally Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.31 / $2.73 / $150.00
Hally Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$100.00 / $100.00 / $100.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00