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Pediatric Enteral Formula, Soy-Based, Intact Nutrients

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

Rates data updated July 2026.

Facilitymedian $2 · 10th–90th $1$30%20%10th90th$2Professionalmedian $1 · 10th–90th $0$20%20%40%10th90th$1$0.5$1.0$2.0$5.0

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

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$1.62
Median
$2.24
Typical High
$2.24
Aetna
Setting
Professional
Modifier
Global
Typical Low
$0.41
Median
$1.86
Typical High
$1.86
Cigna
Setting
Professional
Modifier
Global
Typical Low
$1.12
Median
$1.12
Typical High
$1.41
Medica
Setting
Facility
Modifier
Global
Typical Low
$0.59
Median
$1.86
Typical High
$5.13
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$1.48
Median
$1.48
Typical High
$1.48
United
Setting
Professional
Modifier
Global
Typical Low
$2.40
Median
$2.40
Typical High
$2.40
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$1.00
Median
$1.00
Typical High
$1.00