go back

Utah rates for HCPCS 0117U

Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$758.58 / $4,073.80 / $5,370.32
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$501.19 / $676.08 / $891.25
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$724.44 / $741.31 / $2,290.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$954.99 / $954.99 / $1,202.26
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.20 / $44.67
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$707.95 / $1,000.00 / $3,890.45
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$575.44 / $707.95 / $758.58
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.84 / $831.76 / $2,454.71
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$660.69 / $741.31 / $1,258.93
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$416.87 / $416.87 / $549.54
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$354.81 / $354.81 / $676.08