Prices and CPT codes

Please note: MitoMed Diagnostic Laboratory can only accept institutional or cash / check payments.

Mitochondrial DNA Tests

Test code	Test	Blood Sample	CPT codes
1001	Deafness / Aminoglycoside Sensitivity Screen: mtDNA position1555	$290.00	(83907 if solid tissue) 83891, 83898, 83892, 83894x2, 83912
1004	Neuromuscular Panel (MERRF, MELAS): mtDNA positions 8344, 3243, 3271	$580.00	(83907if solid tissue), 83891, 83898x3, 83892x3, 83894x3, 83912x2
1006	LHON : mt DNA positions 3460, 11778, 14484, 14459	$630.00	(83907 if solid tissue), 83891, 83898x4, 83892x4, 83894x4, 83912x3
1007	mtDNA mutation Screen: 1555, 3460, 3243, 3271, 8344, 8993x2, 11778, 14459, 14484	$1,090.00	(83907 if solid tissue), 83891, 83898x9, 83892x10, 83894x6, 83912x7
1008	Known Familial mutation (RFLP)	$290.00	(83907 if solid tissue), 83891, 83898, 83892, 83894x2, 83912
1009	Southern Blot	$460.00	(83907 if solid tissue), 83891, 83892x4, 83894x1, 83896x1, 83897x1, 83912x1
1010	Full Mitochondrial Genome Sequencing	$2,980.00	(83907 if solid tissue), 83891, 83898x8, 83894x1, 83904x88, 83912x37
1011	Comprehensive Maternally Inherited Hearing Loss Panel, MT-RNR1, MT-TS1,MT-TL1,MT-TK	$690.00	(83907 if solid tissue), 83891, 83898x4, 83894x1, 83904x12, 83912x4
1013	mtDNA complex 1 subunit sequencing	$1,720.00	(83907 if solid tissue), 83891, 83898x8, 83894x1, 83904x34, 83912x7
1014	mtDNA complex 3 subunit sequencing	$515.00	(83907 if solid tissue), 83891, 83898x2, 83894x1, 83904x8, 83912x1
1015	mtDNA complex 4 subunit sequencing	$800.00	(83907 if solid tissue), 83891, 83898x3, 83894x1, 83904x16, 83912x3
1016	mtDNA complex 5 subunit sequencing	$460.00	(83907 if solid tissue), 83891, 83898x1, 83894x1, 83904x4, 83912x2

Nuclear Encoded Genes

Test code	Test	Blood Sample	CPT codes
4006	OPA-1 (Optic Atrophy 1 ) gene Sequencing entire coding region	$2,870.00	(83907 if solid tissue), 83891, 83898 x26, 83894, 83904x52, 83912
4008	OPA-3? (Optic Atrophy 3 ) gene Sequencing entire coding region	$2,870.00	(83907 if solid tissue), 83891, 83898x2, 83894, 83904x4, 83912
2003	ANT-1 (SLC25A4) gene sequencing	$460.00	(83907 if solid tissue), 83891, 83898 x4, 83894, 83904x8, 83912
2005	POLG (Alpers, PEO, SANDO)	$1,720.00	(83907 if solid tissue), 83891, 83898 x18, 83894, 83904x36, 83912
2006	Twinkle (PEO1) gene sequencing	$690.00	(83907 if solid tissue), 83891, 83898 x8, 83894, 83904x16, 83912
2007	Thymidine Kinase TK2 gene sequencing	$1,150.00	(83907 if solid tissue), 83891, 83898 x10, 83894, 83904x20, 83912
2008	POLG2: AD PEO	$860.00	(83907 if solid tissue), 83891, 83898 x9, 83894, 83904x18, 83912
2009	SUCLA2: Mitochondrial Myopathy and Methylmalonic Aciduria	$1,260.00	(83907 if solid tissue), 83891, 83898 x11, 83894, 83904x22, 83912
2010	DGUOK: Hepatocerebral Mitochondrial Depletion Syndrome	$690.00	(83907 if solid tissue), , 83891, 83898 x7, 83894, 83904x14, 83912
2011	RRM2B: Encephalomyopathic Mitochondrial Depletion Syndrome with renal tubulopathy, AD-PEO	$920.00	(83907 if solid tissue), 83891, 83898 x9, 83894, 83904x18, 83912
2012	SURF1: Leigh Syndrome, complex 4 deficiency	$690.00	(83907 if solid tissue), 83891, 83898 x5, 83894, 83904x10, 83912
2014	MPV17: Hepatocerebral Mitochondrial Depletion Syndrome	$690.00	(83907 if solid tissue), 83891, 83898 x6, 83894, 83904x12, 83912
2015	TYMP?: Mingie (TYMP) Sequencing	$1,000.00	(83907 if solid tissue), 83891, 83898 x9, 83894, 83904x18, 83912

IBMPFD/ALS

Test code	Test	Blood Sample	CPT codes
5008	IBMPFD VCP(Valosin containing Protein) gene Sequencing	$1,720.00	(83907 if solid tissue), 83891, 83898 x17, 83894, 83904x34, 83912
	VCP sequencing if 5006 ordered previously	$1,540.00
	VCP sequencing if 5007 ordered previously	$1,300.00
5006	IBMPFD VCP (Valosin containing Protein) exon 5 Sequencing	$340.00	(83907 if solid tissue), 83891, 83898, 83894, 83904x2, 83912
5007	IBMPFD VCP exon 3,5,6,7,10 Sequencing	$800.00	(83907 if solid tissue), 83891, 83898 x5, 83894, 83904x10, 83912
5009	SOD 1 (Superoxide Dismutase 1) gene Sequencing ?	$700.00	(83907 if solid tissue), 83891, 83898x5, 83894, 83904x10, 83912

Mitochondrial Nuclear Gene Panels

Test code	Test	Blood Sample	CPT codes
4001	Leigh Syndrome Panel: mtDNA seq, POLG, Surf1	$4,410.00	(83907 if solid tissue), 83891, 83898x31, 83894x3, 83904x134, 83912x39
4002	mtDNA depletion/multiple deletion panel: POLG1, SUCLA2, DGUOK, TK2	$3.950.00	(83907 if solid tissue), 83891, 83898x46, 83894x4, 83904x92, 83912x4
4003	Myopathic mtDNA instability panel: POLG1, RRM2B, TK2, Twinkle	$3.950.00	(83907 if solid tissue), 83891, 83898x45, 83894x4, 83904x90, 83912x4
4004	Hepato-Cerebral mtDNA Instability panel: POLG1, DGUOK, MPV17, Twinkle	$3,380.00	(83907 if solid tissue), 83891, 83898x39, 83894x4, 83904x78, 83912x4
4005	Encephalomyopathic mtDNA Instability panel: POLG1, SUCLA2, RRM2B	$3,380.00	(83907 if solid tissue), 83891, 83898x34, 83894x2, 83904x140, 83912x38
4007	Ophthalmoplegia/PEO sequencing panel: POLG1, POLG2, Twinkle, ANT1	$2,920.00	(83907 if solid tissue), 83891, 83898x39, 83894x4, 83904x78, 83912x4

Hearing Loss Gene Test Panels

Test code	Test	Blood Sample	CPT codes
6001	Nonsyndromic Hearing Loss GJB2, GJB6 sequencing & GJB6 deletion	$1,600.00	83891, 83898x8, 83894x3, 83904x10, 83912x3
6001a	GJB2 sequencing	$720.00	83891, 83898x3, 83894x1, 83904x6, 83912x1
6001b	GJB6 deletion	$360.00	83891, 83898x4, 83894x1, 83912x1
6001c	Pendred Targeted Mutation Analysis	$500.00	83891, 83898x6, 83894x1, 83904x12, 83912x1
6001d	Mitochondrial Genes 12s rRNA and tRNAser	$540.00	83891, 83898x2, 83894x1, 83904x4, 83912x1
6002	GJB6 sequencing	$540.00	83891, 83898x1, 83894x1, 83904x4, 83912x1
6003	Pendred Syndrome/ DFNB4, SLC26A4 sequencing	$2,500	83891, 83898x21, 83894x1, 83904x42, 83912x1

Cardivascular Gene Test Panels

Test code	Test	Blood Sample	CPT codes
7001	Holt‐Oram Syndrome, TBX5 sequencing	$1,100	83891, 83898x10, 83894x1, 83904x20, 83912x1
7003	Barth Syndrome, G4.5/Tafazzin gene sequencing	$1,100.00	83891, 83898x11, 83894x1, 83904x22, 83912x1
7004	Noncompaction, G4.5/Tafazzin gene sequencing	$1,100.00	83891, 83898x11, 83894x1, 83904x22, 83912x1
7005	Noonan Syndrom, PTPN11 sequencing	$1,350.00	83891, 83898x15, 83894x1, 83904x30, 83912x1
7006	DiGeorge Syndrome / Velocardiofacial Syndrome, TBX1 sequening	$1,100.00	83891, 83898x11, 83894x1, 83904x22, 83912x1
7002	Nonsyndromic Congenital Heart Defect, NKx2.5, GATA4 sequencing	$1,900.00	83891X1, 83898x10, 83894x1, 83904x16, 83912x4
7002a	Nonsyndromic Congenital Heart Defect, NKx2.5 sequencing	$700.00	83891, 83898x3, 83894x1, 83904x6, 83912x1
7002b	Nonsyndromic Congenital Heart Defect, GATA4 sequencing	$1,350.00	83891, 83898x7, 83894x1, 83904x14, 83912x1

Cystinosis

Test code	Test	Blood Sample	CPT codes
5001	CTNS 57kb deletion screen	$350.00	(83907 if solid tissue), 83891, 83898x2, 83894, 83912
5003	CTNS gene Sequencing and 57kb deletion screen	$1,370.00	(83907 if solid tissue), 83891, 83898 x15, 83894x2, 83904x26, 83912

Other Tests

Test code	Test	Blood Sample	CPT codes
8001	Prader-Willi syndrome, Methylation test	$360.00	83891, 83898x5, 83894x1, 83912x1
8002	Angelman syndrome, Methylation test	$360.00	83891, 83898x5, 83894x1, 83912x1
8003	VSX1 (Visual System Homeobox 1) whole gene sequencing	$800.00	83891, 83898x6, 83894x1, 83904x12, 83912x1
8004	MYOC (Myocillin) whole gene sequencing	$600.00	83891, 83898x7, 83894x1, 83904x14, 83912x1
8004	MTTP (Microsomal Triglyceride Transfer Protein) whole gene sequencing	$1,800.00	83891, 83898x20, 83894x1, 83904x40, 83912x1
10001	SRY gene, PCR	$360.00	83891, 83898x4, 83894X1 83912x1
9003	DNA Extraction (research)	$100.00	83891
11001	Known Familial Mutation single point confirmation	$290.00	(83907 if solid tissue) 83891, 83898, 83894, 83904x2, 83912

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Topic revision: r40 - 06 Jan 2012 - 09:50:13 - Main.ShreshthaMadaan

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