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South Dakota 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 / $1.85
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.12 / $1.12 / $1.41
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.59 / $1.85 / $3.13
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.21 / $1.21 / $1.21
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.20 / $1.20 / $1.21
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.48 / $1.48 / $1.48
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.00