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Utah 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
$675.00 / $3,537.00 / $4,637.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$495.00 / $592.50 / $862.50
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$641.05 / $659.33 / $2,066.51
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$861.93 / $861.93 / $1,077.41
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$750.00 / $862.50 / $900.00
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$574.09 / $586.77 / $637.88
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$315.00 / $315.00 / $450.00