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Montana 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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Professional
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Low / Median / High Price
$575.44 / $707.95 / $724.44
Cigna
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Low / Median / High Price
$1,096.48 / $1,096.48 / $1,096.48
Cigna
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Low / Median / High Price
$870.96 / $1,071.52 / $1,096.48
MountainHealth Co-op
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Facility
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Low / Median / High Price
$758.58 / $933.25 / $1,737.80
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.58 / $933.25 / $1,737.80
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,096.48 / $1,096.48 / $1,096.48
Providence
Facility/Professional
Professional
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Low / Median / High Price
$79.43 / $676.08 / $933.25
United
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Professional
Modifier
Low / Median / High Price
$316.23 / $316.23 / $758.58