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Pediatric Enteral Formula, Soy-Based, Intact Nutrients

Pennsylvania 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

Rates data updated July 2026.

Facilitymedian $0 · 10th–90th $0$00%50%$0Professionalmedian $0 · 10th–90th $0$10%50%90th$0$0.5$5.0$50.0$500.0$5.0K$50.0K

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
$0.41
Median
$0.41
Typical High
$1.00
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$8,511.38
Typical High
$77,624.71
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$1.51
Median
$1.58
Typical High
$1.58
Cigna
Setting
Professional
Modifier
Global
Typical Low
$0.87
Median
$0.87
Typical High
$0.87
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$0.41
Median
$0.41
Typical High
$0.41
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$0.41
Median
$0.41
Typical High
$0.41