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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
$676.08 / $3,630.78 / $4,786.30
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$446.68 / $602.56 / $794.33
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$645.65 / $660.69 / $2,089.30
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$870.96 / $870.96 / $1,071.52
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.20 / $30.20
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$630.96 / $758.58 / $3,467.37
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$512.86 / $630.96 / $676.08
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$524.81 / $758.58 / $2,187.76
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$588.84 / $660.69 / $1,122.02
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$371.54 / $371.54 / $489.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$316.23 / $316.23 / $602.56