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Maine rates for HCPCS 0263U

Neurology (autism spectrum disorder [ASD]), quantitative measurements of 16 central carbon metabolites (ie, a-ketoglutarate, alanine, lactate, phenylalanine, pyruvate, succinate, carnitine, citrate, fumarate, hypoxanthine, inosine, malate, S-sulfocysteine, taurine, urate, and xanthine), liquid chromatography tandem mass spectrometry (LC-MS/MS), plasma, algorithmic analysis with result reported as negative or positive (with metabolic subtypes of ASD)

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Aetna
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Facility
Modifier
Low / Median / High Price
$750.00 / $750.00 / $1,593.75
Aetna
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Professional
Modifier
Low / Median / High Price
$750.00 / $750.00 / $750.00
Anthem BCBS
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Modifier
Low / Median / High Price
$4,156.20 / $4,798.05 / $5,592.60
Anthem BCBS
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Professional
Modifier
Low / Median / High Price
$300.00 / $300.00 / $637.50
Cigna
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Professional
Modifier
Low / Median / High Price
$861.93 / $861.93 / $1,077.41
Harvard Pilgrim
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Professional
Modifier
Low / Median / High Price
$750.00 / $750.00 / $908.25
Martin's Point
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Facility
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Low / Median / High Price
$750.00 / $750.00 / $1,215.00
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$750.00 / $750.00 / $750.00
United
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Professional
Modifier
Low / Median / High Price
$450.00 / $450.00 / $1,125.00