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New Hampshire 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)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$840.00 / $1,845.75 / $5,250.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$525.00 / $607.50 / $607.50
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,233.75 / $1,371.00 / $2,925.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$300.00 / $487.50 / $576.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,354.28 / $2,741.21 / $3,290.14
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$861.93 / $861.93 / $1,077.41
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,017.90 / $1,332.90 / $2,668.42
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$315.00 / $450.00 / $750.00
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,500.00 / $2,750.00 / $3,500.00