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Enteral Formula, Pediatric, Intact Nutrients

Washington rates for HCPCS B4158

Enteral formula, for pediatrics, nutritionally complete 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

Rates data updated July 2026.

Facilitymedian $1 · 10th–90th $0$40%20%40%10th90th$1Professionalmedian $0 · 10th–90th $0$00%50%10th90th$0$0.5$1.0$2.0$5.0$10.0$20.0$50.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$0.41
Median
$0.41
Typical High
$0.41
Aetna
Setting
Professional
Modifier
Global
Typical Low
$0.39
Median
$0.41
Typical High
$0.41
Cigna
Setting
Professional
Modifier
Global
Typical Low
$0.52
Median
$0.52
Typical High
$0.52
Molina
Setting
Professional
Modifier
Global
Typical Low
$64.57
Median
$64.57
Typical High
$75.86
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$0.79
Median
$0.79
Typical High
$0.79
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$2.29
Median
$3.24
Typical High
$4.47
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$1.26
Median
$1.26
Typical High
$2.19