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New Mexico 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 / $0.41
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.41 / $0.41 / $0.41
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.70 / $1.70 / $1.70
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $0.41 / $1.45
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.40 / $0.40 / $0.40