2019 Clinical Diagnostic Laboratory Fee Schedule- Gapfill Preliminary Determinations																																																															
"CPT codes, descriptions and other data only are copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA)."																																																															
"As outlined in Sec 1834A(c)(4); Explanation of payment rates.--In the case of a clinical diagnostic laboratory test for which payment is made under this subsection, the Secretary shall make available to the public an explanation of the payment rate for the test."																																																															
																																																															
HCPCS	Modifier	"National
Limit"	"Mid
Point"	CA1	CA2	HI	NV	AK	ID	OR	WA	AZ	MT	ND	SD	UT	WY	CO	NM	OK	TX	IA	KS	KS	MO2	MO1	NE	IL	MN	WI	AR	LA	MS	IN	MI	FL	PR	AL	GA	TN	SC	VA	WV	NC	DE	DC	MD	NJ	PA	CT	NY2	NY1	NY3	ME	MA	NH	RI	VT	KY	OH	Descriptor	MAC Justifications	
				01112	01182	01212	01312	02102	02202	02302	02402	03102	03202	03302	03402	03502	03602	04112	04212	04312	04412	05102	05202	05202	05302	05302	05402	06102	06202	06302	07102	07202	07302	08102	08202	09102	09202	10102	10202	10302	11202	11302	11402	11502	12102	12202	12302	12402	12502	13102	13202	13282	13292	14112	14212	14312	14412	14512	15102	15202			
				LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 01	LOC 02	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 12	LOC 15	LOC 07	LOC 15	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 20	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00			
0018U		" $3,002.09 "		" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $3,002.09 "	" $3,002.09 "	" $1,921.20 "	" $1,921.20 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $3,002.09 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $1,921.20 "	" $3,002.09 "	" $3,002.09 "	" Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy A3 "	"1. This test is not ordered independently - it is ordered with ThyGenX. This test + ThyGenX gives similar information as the test described by 81545. As such, these two tests together should be assigned a price similar to 81545. The ThyGenX test is currently billed using 81445. The 81545 price minus the 81445 price = $3002.09
2. Allow DNA extraction-$136, RT-PCR- $480 times 2= $960, Pathologist review $68, Operation/Overhead $757.20(60%).  Disallow the reported indirect costs related to collection/shipping/ billing- these should be part of the lab/operation overhead. Allow 100% of overhead and 50% of indirect costs =  $1921.20
"	
0019U		" $3,675.00 "		" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	 $597.91 	 $597.91 	 $597.91 	 $597.91 	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	 $328.45 	 $328.45 	 $328.45 	 $597.91 	 $597.91 	 $597.91 	" $3,675.00 "	" $3,675.00 "	 $597.91 	 $597.91 	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	" $3,675.00 "	 $597.91 	 $597.91 	 $597.91 	 $597.91 	 $597.91 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	" $3,675.00 "	" $3,675.00 "	" Oncology, RNA, gene expression by whole transcriptome sequencing, formalinfixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents.
 "	"1. This test does expression profiling of cancers using RNA sequencing as a proxy measure for the activity of upstream proteins which affect the expression of certain genes.  Therefore, this test has methodological similarities to many tests, though it is quite distinct in how the biological data is applied in the interpretive component from any other test with a price. In the absence of clear resource requirements and a direct crosswalk, the median price of similar tests was used. Therefore, median price of 81504, 81518, 81519, 81520, 81521, 81525, 81540, 81541, 81545, 81595 were used to set a price recommendation. All of these are mRNA or gene expression tests, most of which have prices that are fairly close to the median price. Also, all of these tests use an algorithm, and required a significant amount of R&D beyond usual clinical validation, as is the case with 0019U.
2. Data was not received for this service and therefore MAC used the average payment amount for procedure 81445 as an otherwise relevant test.
"	
0021U		 $760.00 		 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $328.42 	 $328.42 	 $328.42 	 $328.42 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $328.45 	 $328.45 	 $328.45 	 $328.42 	 $328.42 	 $328.42 	 $760.00 	 $760.00 	 $328.42 	 $328.42 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $328.42 	 $328.42 	 $328.42 	 $328.42 	 $328.42 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $328.45 	 $760.00 	 $760.00 	" Oncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5-UTRBMI1, CEP 164, 3-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score. "	"1. Test is not identical to but similar to 4K score (81539) in terms of intended use and sample type (though with a different methodology), so recommend similar price as 81539.
2. Data was not received for this service and therefore MAC used the average payment amount for procedure 88184-88187, 86316 as an otherwise relevant test.
"	
0022U		" $1,950.00 "		" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,950.00 "	" $1,950.00 "	" $1,815.00 "	" $1,815.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,950.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,815.00 "	" $1,950.00 "	" $1,950.00 "	" Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider. "	"1. Price recommendation is based on a combination of information regarding FDA kit price and required resources submitted by the manufacturer.
2. Maintain current fee of $1815.00 which was previously set by the contractor. The information provided by the lab did not contain any information which had not already been considered when this fee was established.
"	
0023U		 $248.51 		 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $248.51 	 $248.51 	 $165.51 	 $165.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $248.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $165.51 	 $248.51 	 $248.51 	" Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 mutation and indication for or against the use of midostaurin. "	"1. This test does what is described by 81245 and 81246. Recommended price is 81245 price plus 81246 price.
2. Data was not received for this service and therefore MAC used the average payment amount for procedure 81245 as an otherwise relevant test.
"	
0029U		 $450.91 		 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	 $450.91 	" Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823). "	"1. Recognize that CYP2D6 or CYP2C19 (though not both simultaneously) are covered. Price based off the more expensive of the two, 81226. Little doubt of clinical validity of association of SNPs with metabolic differences, but clinical use of that information is limited beyond these two genes at the time of the MACs pricing decision.
2. Data was not received for this service and therefore MAC used the average payment amount for procedure 81226 as an otherwise relevant test.
"	
0030U		 $134.13 		 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $149.03 	 $149.03 	 $149.03 	 $149.03 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $149.02 	 $149.02 	 $149.02 	 $149.03 	 $149.03 	 $149.03 	 $134.13 	 $134.13 	 $149.03 	 $149.03 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $134.13 	 $149.03 	 $149.03 	 $149.03 	 $149.03 	 $149.03 	 $149.02 	 $149.02 	 $149.02 	 $149.02 	 $149.02 	 $149.02 	 $149.02 	 $149.02 	 $149.02 	 $134.13 	 $134.13 	" Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823). "	"1. This test would be billed using the code G9143, so recommended price is G9143 price.
2. Data was not received for this service and therefore MAC used the average payment amount for procedure G9143 as an otherwise relevant test.
"	
0035U		 $540.99 		 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $427.23 	 $427.23 	 $427.23 	 $427.23 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $427.33 	 $427.33 	 $427.33 	 $427.23 	 $427.23 	 $427.23 	 $540.99 	 $540.99 	 $427.23 	 $427.23 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $540.99 	 $427.23 	 $427.23 	 $427.23 	 $427.23 	 $427.23 	 $427.33 	 $427.33 	 $427.33 	 $427.33 	 $427.33 	 $427.33 	 $427.33 	 $427.33 	 $427.33 	 $540.99 	 $540.99 	" Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking-induced conformational conversion, qualitative "	"1. The laboratory has submitted information regarding resources required to perform the test and their charge for the test of $540.99. The resources required justify this charge, and they report routinely collecting the charge. As such, we recommend a price of $540.99
2. Allow $134.65 (70%) for reagents/consumables, $11.28 for software/equipment, $32.40 (30%) of indirect/fringe, $0.00 for collection load, non-recouped charges=$178.33. $540.99 Disallow $113.76 therefore pay $427.23.
"	
0041U		 $17.21 		 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $17.21 	 $17.21 	 $68.06 	 $68.06 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $17.21 	 $17.21 	" Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by immunoblot, IgM. "	"1. Provides similar information for similar intended use as 86617, so price taken from this.
2. Allow $50.45 (70%)(manuf./performing cost) $29.62(70%) (indirects)=$80.07-15% for panel run-$68.06
"	
0042U		 $17.21 		 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $17.21 	 $17.21 	 $72.82 	 $72.82 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $17.21 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $72.82 	 $17.21 	 $17.21 	" Borrelia burgdorferi, antibody detection of 12 recombinant protein groups, by immunoblot, IgG. "	"1. Provides similar information for similar intended use as 86617, so price taken from this.
2. Allow $56.05(70%)(manuf./performing cost) $29.62 (70%)(indirects)=$85.67-15% for panel run-$72.82
"	
0043U		 $14.86 		 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $14.86 	 $14.86 	 $68.06 	 $68.06 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $14.86 	 $14.86 	" Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgM. "	"1. Provides similar information for similar intended use as 86619, so price taken from this.
2. Allow $50.45 (70%)(manuf./performing cost) $29.62(70%) (indirects)=$80.07-15% for panel run-$68.06
"	
0044U		 $14.86 		 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $14.86 	 $14.86 	 $68.06 	 $68.06 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $14.86 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $68.06 	 $14.86 	 $14.86 	" Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgG. "	"1. Provides similar information for similar intended use as 86619, so price taken from this.
2. Allow $50.45 (70%)(manuf./performing cost) $29.62(70%) (indirects)=$80.07-15% for panel run-$68.06
"	
0048U		" $2,919.60 "		" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,919.60 "	" $2,919.60 "	" $2,916.60 "	" $2,916.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,919.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,919.60 "	" $2,919.60 "	"Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s)"	"1. Similar test to Foundation One and Foundation One CDx. Price for Foundation One and Foundation One CDx (prior to ADLT status) was same as 81455. Therefore recommend price this test at 81455 price.
2. Data was not received for this service and therefore MAC used the average payment amount for procedure 81455 as an otherwise relevant test.
"	
0050U		" $2,278.59 "		" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,278.59 "	" $2,278.59 "	" $2,916.60 "	" $2,916.60 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,278.59 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,278.59 "	" $2,278.59 "	" Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements "	"1. This test covers not only small variants and indels, but coding and non-coding exons as well as copy number alterations, allelic frequency, and structural variants. Therefore, this test goes above and beyond the requirements to bill for 81455. Based on the typical inputs required to run such an NGS assay, recommend price of 3 TIMES 81450.
2. Data was not received for this service and therefore MAC used the average payment amount for procedure 81455 as an otherwise relevant test.
"	
0053U		" $2,030.00 "		" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	 $760.00 	 $760.00 	 $760.00 	 $760.00 	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	" $2,030.00 "	" $2,030.00 "	 $760.00 	 $760.00 	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	" $2,030.00 "	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	 $760.00 	" $2,030.00 "	" $2,030.00 "	" Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade "	"1. Regarding the information provided by this test, there are a number of tests that have been priced that attempt to further refine the risk stratification following biopsy. This test is methodologically different from all of them, though the intended use is similar. Of the other prostate post-biopsy classifier tests out there, it seems to be most similar to Confirm MDx for prostate cancer in terms of intended use of predicting biopsy and pathology underdiagnoses. Additionally, among the prostate post-biopsy classifiers available, the established price of Confirm MDx is relatively close to the resource requirements reported by Mayo to perform the test.  Therefore, recommend similar price as the price assigned to 81551 (the MAAA code for ConfirmMDx).
2. Data was not received for this service and therefore MAC used the average payment amount for procedure 81539 as an otherwise relevant test.
"	
0055U		" $3,240.00 "		" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,240.00 "	" $3,240.00 "	" $3,209.88 "	" $3,209.88 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,240.00 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,209.88 "	" $3,240.00 "	" $3,240.00 "	" Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma "	"1. Similar intended use with intended information as Allomap. Recommend similar price as 81595 (Allomap CPT code). Should align with Allomap, at present, accept cost data +30%   $3209.88
2. The allowance should align with Allomap. Allow the lab's reported cost of $2469.14 plus an estimate 30% increase for indirect cost =$3209.88
"	
0056U		" $2,515.60 "		" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,516.60 "	" $2,517.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,515.60 "	" $2,515.60 "	" $2,916.60 "	" $2,916.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,515.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,916.60 "	" $2,517.60 "	" $2,518.60 "	" $2,519.60 "	" $2,520.60 "	" $2,521.60 "	" $2,522.60 "	" $2,523.60 "	" $2,524.60 "	" $2,525.60 "	" $2,515.60 "	" $2,515.60 "	" Hematology (acute myelogenous leukemia), DNA, whole genome next generation sequencing to detect gene rearrangement(s), blood or bone marrow, report of specific gene rearrangement(s). "	"1. Similar test as the test described by 0014U, except this test is done for AML rather than hematolymphoid disease. Therefore recommend similar price as 0014U.
Similar coverage concerns as with 0050U pay equal to 0014U, $2515.60
2. Data was not received for this service and therefore MAC used the average payment amount for procedure 81455 as an otherwise relevant test.
"	
0057U		 deleted 																																																											"Oncology (solid organ neoplasia), mRNA, gene expression profiling by massively parallel sequencing for analysis of 51 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as a normalized percentile rank."	"Code is being withdrawn, no price assigned."	
