MOLDX MoPath Tier 2 Fee Schedule, M00005, V10, June 23, 2017

2017 MoPath Tier 2 Fee Schedule (M00005, V10)

     

 

The table below lists the fees established for Tier 2 covered tests. Please note the genes are sorted by CPT code and then by alpha per gene. Multiple genes are listed under a single CPT Tier 2 code. The required DEX Z-code™ assigned and submitted with each test enables MolDX to apply the appropriate fee for the specific test performed.

CPT Code	Descriptor	Allowed
81400	ACE, idv	$82.58
81400	F13B, V34L	$64.52
81400	F2, 1199G>A	$70.20
81400	F5, HR2	$58.84
81400	F7, R353Q	$64.52
81400	FGB, -455G>A	$70.20
81400	HPA, antigen ea	$46.46
81400	HPA, panel	$185.84
81400	IL28B	$55.23
81400	IL28B, rs12979860	$55.23
81400	SERPINE1, 4G	$58.84
81401	ABL1, T315I	$153.01
81401	CYFB_MYH11, cv	$138.82
81401	CCND1_IGH, ta majbp qual qual	$93.94
81401	EML4_ALK, ta or ia	$128.48
81401	EWSR1_WT1, ta qual quan	$203.84
81401	F11, cv	$75.88
81401	FIP1L1_PDGFR, qual quan	$90.82
81401	FOXO1_PAX3, ta, qual quan	$120.75
81401	FOXO1_PAX7, ta, qual quan	$120.75
81401	IGH/BCL2, sbp	$123.36
81401	MUTYH, cv	$105.81
81401	PAX8_PPARG, ta	$54.19
81401	RUNX1_RUNX1T1, ta qual quan	$106.05
81401	TPMT, cv	$111.61
81401	TYMS, trv	$169.10
81401	VWF, cv	$278.18
81401	IGH_BCL2, sbp	$123.36
81402	KIT, cv	$98.13
81402	MPL, cv	$89.04
81403	EPCAM, kfv	$93.94
81403	F8, intron 1 and 22a	$81.05
81403	IDH1, exon 4	$67.70
81403	IDH2, exon 4	$67.70
81403	JAK2, exon 12 and 13	$109.14
81403	MUTYH, kfv	$93.94
81403	VHL , dup_del	$83.60
81403	VWF, tsa	$300.03
81403	CDKN2A, kfv	$93.94
81404	CDKN2A, fgs	$373.14
81404	NRAS, exon 1, 2	$148.04
81404	PRSS1, fgs	$248.76
81404	RET, cv	$94.97
81404	VHL, fgs	$639.96
81405	MEN1, fgs	$426.32
81405	RET, tsa	$379.47
81405	VWF, tsa 2N	$278.18
81406	RET, fgs	$384.51