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Pricing and CPT Codes

Note: MitoMed Laboratory accepts Urine, Blood, Buccal Swaps or Fresh Muscle (biopsy) as samples for molecular testing.

Mitochondrial DNA Tests

Test Code Test Name Blood Sample CPT Codes 2015 CPT Codes 2013
1001 Deafness / Aminoglycoside Sensitivity Screen: mtDNA position1555 $390.00 81403 81479
1004 mtDNA neuromuscular mutation panel: MERRF and MELAS: mtDNA positions 583 G>A, 3243 A>G, 3256 C>T, 3271 T>C, 3291 T>C, 3697 G>A, 4332 G>A, 8344 A>G, 8356 T>C, 8363 G>A, 12147 G>A, 13513 G>A, and 13514 A>G $720.00 81403 81479
1006 LHON mutation panel: mt DNA positions 3460 G>A, 3635 G>A, 3697 G>A, 3700 G>A, 3733G>A, 4171 C>A, 10197 G>A, 10663 T>C, 11778 G>A, 13513 G>A, 14459 G>A, 14482 C>G, 14482 C>A, 14484 T>C, 14495 A>G, and 14568 C>T $730.00 81402 81479
1007 mtDNA common mutation screen: mtDNA positions: 583 G>A, 1494 C>T, 1555 A>G, 1606 G>A, 3243 A>G, 3256 C>T, 3260 A>G, 3271 T>C, 3291 T>C, 3302 A>G, 3303 C>T, 3460 G>A, 3635 G>A, 3697 G>A, 3700 G>A, 3733 G>A, 4171 C>A, 4298 G>A, 4300 A>G, 4308 G>A, 4332 G>A, 5537 A>AT, 5650 G>A, 5703 G>A, 7445 A>G, 7471C>CC, 7497 G>A, 7511 T>C, 8344A>G, 8356 T>C, 8363 G>A, 8993 T>C, 8993 T>G, 9176 T>C, 9176 T>G, 9185 T>C, 10010 T>C, 10158 T>C, 10191 T>C, 10197 G>A, 10663 T>C, 11777 C>A, 11778 G>A, 12147 G>A, 12315 G>A, 12706 T>C, 13513 G>A, 13514 A>G, 14459 G>A, 14482 C>G, 14482 C>A, 14484 T>C, 14487 T>C, 14495 A>G, 14568 C>T, 14674 T>C, 14709 T>C $1,290.00 81402 81479
1008 Known Familial mutation: Use test code 11001 $290.00 81400 81403
1010 Full Mitochondrial Genome Sequencing: $2,980.00 81460 81479
1011 Comprehensive Maternally Inherited Hearing Loss (include MIDD) Panel: MT-RNR1, MT-TS1,MT-TL1,MT-TK, MT-TE $690.00 81404 81403x2, 81479x2
1013 mtDNA complex 1 subunit sequencing: $1,720.00 81405 81479
1014 mtDNA complex 3 subunit sequencing: $515.00 81403 81403
1015 mtDNA complex 4 subunit sequencing: CYTOCHROME c OXIDASE DEFICIENCY $800.00 81404 81479

Nuclear Encoded Gene Tests

Test Code Test Name Blood Sample CPT Codes 2015 CPT Codes 2013
2003 ANT1 (SLC25A4): gene sequencing $460.00 81404 81404
2005 POLG: (Alpers, PEO, SANDO, POLG-Related Disorders) $1,720.00 81406 81406
2006 Twinkle (PEO1/C10orf2): gene sequencing $690.00 81404 81479
2007 Thymidine Kinase TK2: Gene sequencing $1,150.00 81405 81479
2008 POLG2: AD PEO $860.00 81405 81479
2009 SUCLA2: Mitochondrial Myopathy and Methylmalonic Aciduria $1,260.00 81406 81479
2010 DGUOK: Hepatocerebral Mitochondrial Depletion Syndrome $690.00 81405 81479
2011 RRM2B: Encephalomyopathic Mitochondrial Depletion Syndrome with renal tubulopathy, AD-PEO $920.00 81405 81479
2012 SURF1: Leigh Syndrome, complex 4 deficiency $690.00 81405 81479
2014 MPV17: Hepatocerebral Mitochondrial Depletion Syndrome $690.00 81405 81479
2015 TYMP: Mingie $1,000.00 81405 81479
4006 OPA-1: (Optic Atrophy 1) gene Sequencing entire coding region $2,870.00 81407 81407
4008 OPA-3: (Optic Atrophy 3) gene Sequencing entire coding region $430.00 81404 81479

IBMPFD / ALS

Test Code Test Name Blood Sample CPT Codes 2015 CPT Codes 2013
5006 IBMPFD VCP (Valosin containing Protein): exon 5 Sequencing $340.00 81403 81479
5007 IBMPFD VCP (Valosin containing Protein): VCP exons 3, 5, 6, 7, 10 sequencing $800.00 81404 81479
5008 IBMPFD VCP (Valosin containing Protein): gene Sequencing $1,720.00 81406 81479
5008 VCP sequencing: if 5006 ordered previously $1,540.00
5008 VCP sequencing: if 5007 ordered previously $1,300.00

Mitochondrial Nuclear Gene Panels

Test Code Test Name Blood Sample CPT Codes 2015 CPT Codes 2013
4001 Leigh Syndrome Panel: mtDNA seq, POLG, Surf1 $4,410.00 81460, 81406, 81405 81479x2, 81406
4002 mtDNA depletion/multiple deletion panel: POLG1, SUCLA2, DGUOK, TK2 $3,950.00 81406x2, 81405x2 81406, 81479x3
4003 Myopathic mtDNA instability panel: POLG1, RRM2B, TK2, Twinkle $3,950.00 81406, 81405x3 81406, 81479x3
4004 Hepato-Cerebral mtDNA Instability panel: POLG1, DGUOK, MPV17, Twinkle $3,380.00 81406, 81405x2, 81404 81406, 81479x3
4005 Encephalomyopathic mtDNA Instability panel: POLG1, SUCLA2, RRM2B $3,380.00 81406x2, 81405 81406, 81479x2
4007 Ophthalmoplegia/PEO sequencing panel: POLG1, POLG2, Twinkle, ANT1 $2,920.00 81406, 81405, 81404x2 81406, 81479x2, 81404

Hearing Loss Gene Test Panels

Test Code Test Name Blood Sample CPT Codes 2015 CPT Codes 2013
6001 Nonsyndromic Hearing Loss: GJB2, GJB6 deletion, Pendred Target Mutation Analysis, and 12s rRNA & tRNAser sequencing $1,600.00 81252, 81254, 81404, 81403x2 81252, 81254, 81479, 81403x2
6001a Nonsyndromic Hearing Loss: GJB2 sequencing $720.00 83891, 83898x3, 83894x1, 83904x6, 83912x1 81252
6001a_1 Nonsyndromic Hearing Loss: GJB2 Known Familial variants 81253
6001b Nonsyndromic Hearing Loss: GJB6 deletion $360.00 83891, 83898x4, 83894x1, 83912x1 81254
6001c Nonsyndromic Hearing Loss: Pendred Targeted Mutation Analysis $500.00 81404 81479
6001d Nonsyndromic Hearing Loss: Mitochondrial Genes 12s rRNA and tRNAser $540.00 81403x2 81403x2
6002 Nonsyndromic Hearing Loss: Connexin 30 / GJB6 sequencing $540.00 83891, 83898x8, 83894x3, 83904x10, 83912x3 81254
6003 Pendred Syndrome: SLC26A4 full gene sequencing $25,00.00 81406 81406

Cardiovascular Gene Test Panels

Test Code Test Name Blood Sample CPT Codes 2015 CPT Codes 2013
7006 DiGeorge Syndrome / Velocardiofacial Syndrome: TBX1 sequening $1,100.00 81406 81479

Cystinosis

Test Code Test Name Blood Sample CPT Codes 2015 CPT Codes 2013
5001 CTNS: 57kb deletion screen $350.00 81403 81479
5002 CTNS Tiers II: Full CTNS gene sequencing $1,200.00 81406 81479
5003 CTNS Tiers I and II: 57 kb deleletion screen and CTNS sequencing $1,400.00 81403, 81406 81479x2

Other Tests

Test Code Test Name Blood Sample CPT Codes 2015 CPT Codes 2013
11001 Known Familial mutation : single point confirmation $290.00 81400 81403
8003 VSX1 (Visual System Homeobox 1): $800.00 81404 81479
8005 MTTP (Microsomal Triglyceride Transfer Protein) : whole gene sequencing $1,800.00 81406 81479
9003 DNA Extraction (Clinical/Research): $100.00 81479 81479