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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
$758.58 / $758.58 / $1,202.26
Aetna
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Professional
Modifier
Low / Median / High Price
$524.81 / $588.84 / $758.58
Anthem BCBS
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Low / Median / High Price
$4,168.69 / $4,786.30 / $5,248.07
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$302.00 / $446.68 / $758.58
Cigna
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Facility
Modifier
Low / Median / High Price
$1,698.24 / $1,698.24 / $1,698.24
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$870.96 / $870.96 / $1,071.52
Harvard Pilgrim
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Professional
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Low / Median / High Price
$446.68 / $758.58 / $912.01
Martin's Point
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Facility
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Low / Median / High Price
$758.58 / $758.58 / $758.58
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$524.81 / $724.44 / $758.58
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$446.68 / $446.68 / $1,122.02