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Pediatric Enteral Formula, Soy-Based, Intact Nutrients

Wisconsin 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 $3 · 10th–90th $0$1000%10%20%10th90th$3Professionalmedian $0 · 10th–90th $0$10%50%90th$0$0.0$0.1$0.5$2.0$10.0$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. Small sample; interpret with caution. 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
$0.41
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$0.02
Median
$1.07
Typical High
$1.78
Cigna
Setting
Facility
Modifier
Global
Typical Low
$2.69
Median
$3.16
Typical High
$5.01
Cigna
Setting
Professional
Modifier
Global
Typical Low
$0.87
Median
$1.26
Typical High
$1.45
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$0.41
Median
$1.86
Typical High
$1.86
Medica
Setting
Facility
Modifier
Global
Typical Low
$0.41
Median
$1.86
Typical High
$100.00
Medica
Setting
Professional
Modifier
Global
Typical Low
$1.07
Median
$1.07
Typical High
$1.07
Molina
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$64.57
Typical High
$89.13
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$0.41
Median
$1.86
Typical High
$1.86
Quartz
Setting
Facility
Modifier
Global
Typical Low
$85.11
Median
$100.00
Typical High
$100.00
Quartz
Setting
Professional
Modifier
Global
Typical Low
$0.87
Median
$0.87
Typical High
$0.87
United
Setting
Professional
Modifier
Global
Typical Low
$1.07
Median
$1.07
Typical High
$2.00