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Wisconsin rates for HCPCS B4159

Enternal Formula For Pediatrics Nutritionally Complete Soy Based With Intact

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
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.70 / $1.06 / $1.72
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.70 / $3.16 / $4.84
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.88 / $1.15 / $1.41
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $1.85 / $1.85
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.41 / $1.85 / $100.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.07 / $1.07 / $1.07
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.83 / $55.00 / $90.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.40 / $0.74 / $1.85
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$65.00 / $85.00 / $100.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.88 / $0.88 / $0.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.07 / $1.07 / $1.07