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Wisconsin rates for HCPCS B4161

Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.00 / $1.00 / $1.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.00 / $1.00 / $3.02
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $1.86 / $3.31
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5.37 / $6.31 / $10.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.24 / $2.51 / $2.88
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.12 / $3.24 / $3.24
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.12 / $3.24 / $100.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.14 / $2.14 / $2.14
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.66 / $54.95 / $89.13
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.11 / $100.00 / $100.00
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.74 / $1.74 / $1.74
Security Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.90 / $4.90 / $4.90
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.14 / $2.14 / $2.40