Clinical Lab Gap Filled Codes - JF Part B
Clinical Lab Gap Filled Codes
View the Noridian Clinical Lab Gap Filled Codes.
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| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81161 | DMD Dup/Delet Analysis | N | N | N | |||
| 81200 | Canavan Dz | N | N | N | |||
| 81201 | APC, full gene analysis | $749.92 | Y | $749.92 | $749.92 | Y | |
| 81202 | APC, known fam var | $93.94 | Y | $93.94 | $93.94 | Y | |
| 81203 | APC dup/del var | $570.05 | Y | $570.05 | $570.05 | Y | |
| 81205 | Maple Syrup Testing | N | N | N | |||
| 81206 | BCR/ABL1, trans location major break | $108.37 | Y | $225.38 | Y | $225.38 | Y |
| 81207 | BCR/ABL1, trans location minor break | $90.31 | Y | $199.08 | Y | $199.08 | Y |
| 81208 | BCR/ABL1, trans location other break | $150.17 | Y | $221.09 | Y | $221.09 | Y |
| 81209 | Bloom Syndrome | N | N | N | |||
| 81210 | BRAF Gene | $97.45 | Y | $180.60 | Y | $180.60 | Y |
| 81211 | BRCA1/2 full seq | $2,795.09 | Y | $2,795.09 | Y | $2,795.09 | Y |
| 81212 | BRCA1/2, variants | $178.04 | Y | $178.04 | Y | $178.04 | Y |
| 81213 | BRCA1/2 uncommon del/dup | $587.12 | Y | $587.12 | Y | $587.12 | Y |
| 81214 | BRCA1 alone, full seq | $1,449.01 | Y | $1,449.01 | Y | $1,449.01 | Y |
| 81215 | BRCA1 alone, known fam var | $93.94 | Y | $93.94 | Y | $93.94 | Y |
| 81216 | BRCA2 alone, full seq | N | N | N | |||
| 81217 | BRCA2 alone, known fam var | $93.94 | Y | $93.94 | Y | $93.94 | Y |
| 81220 | CF testing | N | N | N | |||
| 81221 | CF testing | N | N | N | |||
| 81222 | CF testing | N | N | N | |||
| 81223 | CF testing | N | N | N | |||
| 81224 | CF testing | N | N | N | |||
| 81225 | Cyp2c19 full Seq | $319.12 | Y | $294.00 | Y | $294.00 | Y |
| 81226 | Cyp2d6 | $426.43 | Y | $455.00 | Y | $455.00 | Y |
| 81227 | Cyp2c9 | $169.50 | Y | $176.40 | Y | $176.40 | Y |
| 81228 | Cytogen microarray copy nmbr | N | N | N | |||
| 81229 | Cytogen microarray copy no&snp | N | N | N | |||
| 81235 | EGFR genr analysis, comm variants | $225.00 | Y | $332.50 | Y | $332.50 | Y |
| 81240 | F2 Gene | $41.41 | Y | $67.64 | Y | $67.64 | Y |
| 81241 | F5 Gene | $78.39 | Y | $84.00 | Y | $84.00 | Y |
| 81242 | Fanconi Gene | N | N | N | |||
| 81243 | Fragile X Gene | N | N | N | |||
| 81244 | Fragile X Gene | N | N | N | |||
| 81245 | Flt3 gene | $112.00 | Y | $167.17 | Y | $167.17 | Y |
| 81246 | Flt3 gene | $82.96 | Y | ||||
| 81250 | Glycogen Storage Gene | N | N | N | |||
| 81251 | Glycogen Storage Gene | N | N | N | |||
| 81252 | GJB2 common var | N | N | N | |||
| 81253 | GJB2, known fam variants | N | N | N | |||
| 81254 | GJB6 common var | N | N | N | |||
| 81255 | Tay Sach Gene | N | N | N | |||
| 81256 | Hfe gene | $70.20 | Y | $89.84 | Y | $89.84 | Y |
| 81257 | Hba1/hba2 gene | N | N | N | |||
| 81260 | familial dysautonomia gene | N | N | N | |||
| 81261 | Igh gene rearrange amp meth | $148.12 | Y | $272.15 | Y | $272.15 | Y |
| 81262 | Igh gene rearrange dir probe | $51.12 | Y | $51.12 | Y | $51.12 | Y |
| 81263 | Igh gene regional mutation | $259.93 | Y | $404.83 | Y | $404.83 | Y |
| 81264 | Igk gene rearrange bn clonal pop | $111.98 | Y | $205.26 | Y | $205.26 | Y |
| 81265 | DSPA/STR Seq | N | N | ||||
| 81266 | DSPA/STR Seq | N | Y | ||||
| 81267 | Chimerism anal no cell sel | $149.72 | Y | $285.17 | Y | $285.17 | Y |
| 81268 | Chimerism anal w/ cell select | $149.72 | Y | $358.47 | Y | $358.47 | Y |
| 81270 | JAK2 gene analysis | $82.88 | Y | $126.00 | Y | $126.00 | Y |
| 81275 | KRAS gene analysis | $246.40 | Y | $179.20 | Y | $179.20 | Y |
| 81280 | Long QT Synd gene | N | N | N | |||
| 81281 | Long QT Synd gene | N | N | N | |||
| 81282 | Long QT Synd gene | N | N | N | |||
| 81287 | MGMT | $83.01 | Y | ||||
| 81288 | MLH promoter methylation | $159.48 | Y | ||||
| 81290 | Mucolipidosis | N | N | N | |||
| 81291 | Mthfr gene | $92.92 | Y | $60.00 | Y | $60.00 | Y |
| 81292 | MLH1 gene analysis, full seq | $803.28 | Y | $651.12 | Y | $651.12 | Y |
| 81293 | MLH1 gene analysis, known fam var | $93.94 | Y | $261.02 | Y | $261.02 | Y |
| 81294 | MLH1 gene analysis, del/dup | $491.96 | Y | $192.12 | Y | $192.12 | Y |
| 81295 | MSH2 gene anal, Full seq | $787.22 | Y | $152.86 | Y | $152.86 | Y |
| 81296 | MSH2 gene anal, known fam var | $93.94 | Y | $130.51 | Y | $130.51 | Y |
| 81297 | MSH2 gene anal, del/dup | $542.77 | Y | $152.86 | Y | $152.86 | Y |
| 81298 | MSH6 gene anal, full seq | $617.61 | Y | $290.01 | Y | $290.01 | Y |
| 81299 | MSH6 gene anal, known fam var | $93.94 | Y | $162.46 | Y | $162.46 | Y |
| 81300 | MSH6 gene anal, dup/del | $505.15 | Y | $162.90 | Y | $162.90 | Y |
| 81301 | Microsatellite instability | $320.84 | Y | $398.03 | Y | $398.03 | Y |
| 81302 | Rett Syndrome gene | N | N | N | |||
| 81303 | Rett Syndrome gene | N | N | N | |||
| 81304 | Rett Syndrome gene | N | N | N | |||
| 81310 | Npm1 gene | $58.84 | Y | $249.01 | Y | $249.01 | Y |
| 81313 | PCA3/KLK3 | N | |||||
| 81315 | PML/RARalpha qual or quant | $117.54 | Y | $284.97 | Y | $284.97 | Y |
| 81316 | PML/RARalpha single brkpoint | NO DATA | Y | $434.65 | Y | $434.65 | Y |
| 81317 | PMS2 full sequence | $642.58 | Y | $787.19 | Y | $787.19 | Y |
| 81318 | PMS2, gene anal, known fam var | $93.94 | Y | $186.01 | Y | $186.01 | Y |
| 81319 | PMS2 gene anal, dup/del | $462.42 | Y | $223.34 | Y | $223.34 | Y |
| 81321 | PTEN gene anal full seq | $605.24 | Y | $605.24 | Y | $605.24 | Y |
| 81322 | PTEN, known familial var | $58.84 | Y | $60.00 | Y | $60.00 | Y |
| 81323 | PTEN, dup/del | $88.26 | Y | $88.26 | Y | $88.26 | Y |
| 81324 | PMP22 gene anal, dup/del | N | N | N | |||
| 81325 | PMP22, full seq | N | N | ||||
| 81326 | PMP22, known familial variants | $93.94 | Y | N | N | ||
| 81330 | Niemann Pick gene | N | N | N | |||
| 81331 | Prader Willis gene | N | N | N | |||
| 81332 | Serpina1 gene | $70.20 | Y | $60.00 | Y | $60.00 | Y |
| 81340 | Trb@ gene rearrange amp | $148.12 | Y | $287.17 | Y | $287.17 | Y |
| 81341 | Trb@ gene rearrange diporbe | $45.44 | Y | $68.16 | Y | $68.16 | Y |
| 81342 | Trg gene rearrangement anal | $148.12 | Y | $276.98 | Y | $276.98 | Y |
| 81350 | UGT1A1 irinotecan gene | N | N | N | |||
| 81355 | Vkorc1 gene | $83.19 | Y | N | N | ||
| 81370 | HLA I Typing, antigen equiv | $552.75 | Y | $552.75 | Y | $552.75 | Y |
| 81371 | 81370 verification | $330.84 | Y | $330.84 | Y | $330.84 | Y |
| 81372 | HLA Class I typing, low res, complete | $303.64 | Y | $303.64 | Y | $303.64 | Y |
| 81373 | HLA Class I typing, low res, one locus | $153.08 | Y | $153.08 | Y | $153.08 | Y |
| 81374 | HLA Class I typing, low res, one antigen | $100.00 | Y | $100.00 | Y | $100.00 | Y |
| 81375 | HLA Class II typing, low res | $303.43 | Y | $303.43 | Y | $303.43 | Y |
| 81376 | HLA Class II typing, low res, one locus | $168.00 | Y | $168.00 | Y | $168.00 | Y |
| 81377 | HLA Class II typing, low res, one antigen equiv | $126.20 | Y | $126.20 | Y | $126.20 | Y |
| 81378 | HLA Class I and II high res, alleles | $475.00 | Y | $475.00 | Y | $475.00 | Y |
| 81379 | HLA Class I and II high res, complete | $461.00 | Y | $461.00 | Y | $461.00 | Y |
| 81380 | HLA Class I and II high res, one locus | $243.64 | Y | $243.64 | Y | $243.64 | Y |
| 81381 | HLA Class I and II high res, one allele or allele grp | $130.00 | Y | $130.00 | Y | $130.00 | Y |
| 81382 | HLA Class II high res, one locus | $170.00 | Y | $170.00 | Y | $170.00 | Y |
| 81383 | HLA Class II high res, one allele or allele grp | $150.00 | Y | $150.00 | Y | $150.00 | Y |
| 81410 | Aortic dysf panel, seq | N | |||||
| 81411 | Aortic dysf panel, dup/del | N | |||||
| 81415 | Exome, seq proband | N | |||||
| 81416 | Exome, seq, parents, sibs | N | |||||
| 81417 | Exome, reeval | N | |||||
| 81420 | Fetal aneuploidy | N | |||||
| 81425 | Genome, seq, proband | N | |||||
| 81426 | Genome, seq, parents, sibs | N | |||||
| 81427 | Genome, reeval | N | |||||
| 81430 | Hearing loss panel, seq 60 genes | N | |||||
| 81431 | Hearing loss panel, dup/del | N | |||||
| 81435 | Hered. colon Ca panel, seq | N | |||||
| 81436 | Hered. colon Ca, dup/del | N | |||||
| 81440 | Mito, seq | N | |||||
| 81445 | Targ seq, solid organ, DNA only 5-50 | Y | |||||
| 81450 | Targ seq immuno-hemat, DNA/RNA 5-50 | Y | |||||
| 81455 | Targ, solid/hemato, DNA/RNA, >51 | N | |||||
| 81460 | Whole mito genome, seq | N | |||||
| 81465 | Whole mito genome, dup/del | N | |||||
| 81470 | X-linked intel disability, seq | N | |||||
| 81471 | X-linked intel disabil, dup/del | N |
81400 Mole Path Level 1
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81400 | A282V variant | N | N | N | |||
| 81400 | ABCC8 | N | N | N | |||
| 81400 | ACADM | N | N | N | |||
| 81400 | ACE | $82.58 | Y | $82.58 | Y | $82.58 | Y |
| 81400 | AGTR1 | N | N | N | |||
| 81400 | CCR5 | N | N | N | |||
| 81400 | CLRN1 | N | N | N | |||
| 81400 | DPYD | $81.70 | Y | $81.70 | Y | $81.70 | Y |
| 81400 | DYT1 | N | N | N | |||
| 81400 | F13B | $70.20 | Y | $70.20 | Y | $70.20 | Y |
| 81400 | F2 | NO DATA | Y | NO DATA | Y | Y | |
| 81400 | F5 | $64.52 | Y | $64.52 | Y | $64.52 | Y |
| 81400 | F7 | $64.52 | Y | $64.52 | Y | $64.52 | Y |
| 81400 | FGB | $70.20 | Y | $70.20 | Y | $70.20 | Y |
| 81400 | FGFR3 | N | N | N | |||
| 81400 | Human Platelet Antigen ANTIGEN 1(HPA-1) | $46.46 | Y | $46.46 | Y | $46.46 | Y |
| 81400 | Human Platelet Antigen ANTIGEN 2(HPA-2) | $46.46 | Y | $46.46 | Y | $46.46 | Y |
| 81400 | Human Platelet Antigen ANTIGEN 3(HPA-3) | $46.46 | Y | $46.46 | Y | $46.46 | Y |
| 81400 | Human Platelet Antigen ANTIGEN 4(HPA-4) | $46.46 | Y | $46.46 | Y | $46.46 | Y |
| 81400 | Human Platelet Antigen ANTIGEN 5(HPA-5) | $46.46 | Y | $46.46 | Y | $46.46 | Y |
| 81400 | Human Platelet Antigen ANTIGEN 6(HPA-6w) | $46.46 | Y | $46.46 | Y | $46.46 | Y |
| 81400 | Human Platelet Antigen ANTIGEN 15 (HPA-15) | $46.46 | Y | $46.46 | Y | $46.46 | Y |
| 81400 | IVD | $46.46 | Y | $46.46 | Y | $46.46 | Y |
| 81400 | IL28B | $55.23 | Y | ||||
| 81400 | SERPINE1 | $58.84 | Y | $58.84 | Y | $58.84 | Y |
| 81400 | SHOC2-NOONAN-LIKE-SYNDROME | N | N | N | |||
| 81400 | SMN1 | N | N | N | |||
| 81400 | SRY | N | N | N | |||
| 81400 | TOR1A | N | N | N | |||
| 81400 | COMT | N | N | N |
81401 Mole Path Level 2
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81401 | ABL1 | $153.01 | Y | $153.01 | Y | $153.01 | Y |
| 81401 | ACADM | NO DATA | N | N | N | ||
| 81401 | ADRB2 | N | NO DATA | N | NO DATA | N | |
| 81401 | APOB | NO DATA | N | N | N | ||
| 81401 | APOE | N | NO DATA | N | NO DATA | N | |
| 81401 | AR (androgen receptor) | NO DATA | N | N | N | ||
| 81401 | ATN1 | N | NO DATA | N | NO DATA | N | |
| 81401 | BCL 1 gene rearrangement | N | |||||
| 81401 | CBFB/MYH11 | NO DATA | N | NO DATA | N | NO DATA | N |
| 81401 | CBS | NO DATA | N | NO DATA | N | NO DATA | N |
| 81401 | CCND1/IGH | $93.94 | Y | $93.94 | Y | $93.94 | Y |
| 81401 | CFH/ARMS2 | N | N | N | |||
| 81401 | CYP3A4 | N | N | N | |||
| 81401 | CYP3A5 | N | N | N | |||
| 81401 | CYFB-MYH11 | $138.82 | Y | $138.82 | Y | $138.82 | Y |
| 81401 | DMPK | N | N | N | |||
| 81401 | E2A/PBX1 | $105.30 | Y | $105.30 | Y | $105.30 | Y |
| 81401 | EML4-ALK | $128.48 | Y | $128.48 | Y | $128.48 | Y |
| 81401 | ETV6-RUNX1 | $90.31 | Y | $90.31 | Y | $90.31 | Y |
| 81401 | EWSR1/ERG | $151.42 | Y | $151.42 | Y | $151.42 | Y |
| 81401 | EWSR1/FLI1 | $162.85 | Y | $162.85 | Y | $162.85 | Y |
| 81401 | EWSR1/WT1 | $203.84 | Y | $203.84 | Y | $203.84 | Y |
| 81401 | F11 coagulation factor XI | $75.88 | Y | $75.88 | Y | $75.88 | N |
| 81401 | FGFR3 | N | N | N | |||
| 81401 | FIP1L1-PDGFR | $90.82 | Y | $90.82 | Y | $90.82 | Y |
| 81401 | FOXO1/PAX3 | $120.75 | Y | $120.75 | Y | $120.75 | Y |
| 81401 | FOXO1/PAX7 | $120.75 | Y | $120.75 | Y | $120.75 | N |
| 81401 | FXN (frataxin) | N | N | N | |||
| 81401 | GALT | N | N | N | |||
| 81401 | GY | N | N | ||||
| 81401 | H19 | N | N | N | |||
| 81401 | HBB | $147.81 | Y | $147.81 | Y | $147.81 | Y |
| 81401 | HTT | N | N | N | |||
| 81401 | KCNQ10T1 | N | N | N | |||
| 81401 | MEG3/DLK1 | N | N | N | |||
| 81401 | MLL/AFF | N | N | N | |||
| 81401 | MLL/MLLT3 | N | N | N | |||
| 81401 | MT-ATP6 | N | N | N | |||
| 81401 | MTN-ND4, MT-ND6 | N | N | N | |||
| 81401 | MT-ND5 | N | N | N | |||
| 81401 | MT-RNR1 | N | N | N | |||
| 81401 | MT-TK | N | N | N | |||
| 81401 | MT-TL1 | N | N | N | |||
| 81401 | MT-TS1 | N | N | N | |||
| 81401 | MUTYH | $82.07 | Y | $82.07 | Y | $82.07 | Y |
| 81401 | NPM/ALK | No Data | Y | No Data | Y | No Data | Y |
| 81401 | PAX8/PPARG | $54.19 | Y | $54.19 | Y | $54.19 | Y |
| 81401 | PPRSS1 | N | N | N | |||
| 81401 | RUNX1/RUNX1T1 | $106.05 | Y | $106.05 | Y | $106.05 | Y |
| 81401 | SEPT9 | N | N | ||||
| 81401 | SMN1/SMN2 | N | N | N | |||
| 81401 | TPMT | $111.61 | Y | $111.61 | Y | $111.61 | Y |
| 81401 | TYMS | $169.10 | Y | $169.10 | Y | $169.10 | Y |
| 81401 | VWF | $278.18 | Y | $278.18 | Y | $278.18 | Y |
81402 Mole Path Level 3
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81402 | CYP21A2 | N | N | N | |||
| 81402 | Chromosone 18q | N | N | N | |||
| 81402 | ESR1/PGR | N | N | N | |||
| 81402 | IGH_BCL2, majbpr_mcrbp qul_qun | ||||||
| 81402 | KIT | $98.13 | Y | $98.13 | Y | $98.13 | Y |
| 81402 | MEFV | N | No Data | Y | No Data | Y | |
| 81402 | MPL | $101.45 | Y | $101.45 | Y | $101.45 | Y |
| 81402 | TRD | N | N | N | |||
| 81402 | Uniparenteral Disomy | N | N | N |
81403 Mole Path Level 4
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81403 | ABL1 (c-abl oncogene 1 | $156.89 | Y | $156.89 | Y | $156.89 | Y |
| 81403 | ANG (angiogenin, ribonuclease, RNase A family, 5 | N | N | N | |||
| 81403 | CEBPA | $235.54 | Y | $235.54 | Y | $235.54 | Y |
| 81403 | CEL (carboxyl ester lipase [bile salt-stimulated lipase | N | N | N | |||
| 81403 | DAZ/SRY | N | N | N | |||
| 81403 | EPCAM | ||||||
| 81403 | F8 (coagulation factor VIII | $81.05 | Y | $81.05 | Y | $81.05 | Y |
| 81403 | FGFR3 (fibroblast growth factor receptor 3 | N | N | N | |||
| 81403 | GJB1 (gap junction protein, beta 1) (eg, Charcot-Marie-Tooth X-linked), full gene sequence | N | N | N | |||
| 81403 | HBB (hemoglobin, beta, beta-globin beta thalassemia | N | N | N | |||
| 81403 | HRAS (v-Ha-ras Harvey rat sarcoma viral oncogene homolog Costello syndrome | N | N | N | |||
| 81403 | HRAS1 | N | N | N | |||
| 81403 | IDH1 | $67.70 | Y | $67.70 | Y | $67.70 | Y |
| 81403 | IDH2 (isocitrate dehydrogenase 2 | $67.70 | Y | $67.70 | Y | $67.70 | Y |
| 81403 | JAK2 (Janus kinase 2) | $109.14 | Y | $109.14 | Y | $109.14 | Y |
| 81403 | KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) | N | N | N | |||
| 81403 | MPL (myeloproliferative leukemia virus oncogene, thrombopoietin receptor, TPOR | $106.32 | Y | $106.32 | Y | $106.32 | Y |
| 81403 | MT-RNR1 (mitochondrially encoded 12S RNA | N | N | N | |||
| 81403 | MT-TS1 (mitochondrially encoded tRNA serine 1 | N | N | N | |||
| 81403 | RET, cv | N | |||||
| 81403 | SMN1 (survival of motor neuron 1, telomeric) | N | N | N | |||
| 81403 | VHL (von Hippel-Lindau tumor suppressor | $83.60 | Y | $83.60 | Y | $83.60 | Y |
| 81403 | VWF (von Willebrand factor | $284.20 | Y | $284.20 | Y | $284.20 | Y |
81404 Mole Path Level 5
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81404 | ACADS (acyl-CoA dehydrogenase | N | N | N | |||
| 81404 | AQP2 (aquaporin 2 [collecting duct]) | N | N | N | |||
| 81404 | ARX (aristaless related homeobox) | N | N | N | |||
| 81404 | BTD (biotinidase | N | N | N | |||
| 81404 | CAV3 (caveolin 3) (eg, CAV3-related distal myopathy, limb-girdle muscular dystrophy type 1C), full gene sequence | N | N | N | |||
| 81404 | CDKN2A (cyclin-dependent kinase inhibitor 2A | $373.14 | Y | $373.14 | Y | $373.14 | Y |
| 81404 | CLRN1 (clarin 1) | N | N | N | |||
| 81404 | CPT2 (carnitine palmitoyltransferase | N | N | N | |||
| 81404 | CYP1B1 (cytochrome P450, family 1, subfamily B, polypeptide 1) | N | N | N | |||
| 81404 | DMPK (dystrophia myotonica-protein kinase | N | N | N | |||
| 81404 | EGR2 (early growth response 2) (eg, Charcot-Marie-Tooth | N | N | N | |||
| 81404 | FGFR2 (fibroblast growth factor receptor 2) | N | N | N | |||
| 81404 | FGFR3 (fibroblast growth factor receptor 3) | N | N | N | |||
| 81404 | FKRP (Fukutin related protein) | N | N | N | |||
| 81404 | FOXG1 (forkhead box G1) | N | N | N | |||
| 81404 | FSHMD1A (facioscapulohumeral muscular dystrophy 1A) | N | N | N | |||
| 81404 | FSHMD1A (facioscapulohumeral muscular dystrophy 1A) | N | N | N | |||
| 81404 | FXN (frataxin) | N | N | N | |||
| 81404 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) | N | N | N | |||
| 81404 | HBB (hemoglobin, beta, beta-globin) | N | N | N | |||
| 81404 | HNF1B (HNF1 homeobox B) (eg, maturity-onset diabetes of the | N | N | N | |||
| 81404 | HRAS (v-Ha-ras Harvey rat sarcoma viral oncogene homolog) | N | N | N | |||
| 81404 | Huntingtons dz mutation | N | N | ||||
| 81404 | KCNJ10 (potassium inwardly-rectifying channel, subfamily J, member 10 | N | N | N | |||
| 81404 | KIT (C-kit) (v-kit Hardy-Zuckerman 4 feline sarcoma | $213.47 | Y | $213.47 | Y | $213.47 | Y |
| 81404 | LITAF (lipopolysaccharide-induced TNF factor) | N | N | N | |||
| 81404 | MEFV (Mediterranean fever | $329.41 | Y | $213.47 | Y | $213.47 | Y |
| 81404 | MEN1 (multiple endocrine neoplasia I | N | N | N | |||
| 81404 | NRAS (neuroblastoma RAS viral oncogene homolog) | $148.04 | Y | $148.04 | Y | $148.04 | Y |
| 81404 | PDGFRA (platelet-derived growth factor receptor alpha polypeptide) | $111.44 | Y | $111.44 | Y | $111.44 | Y |
| 81404 | PDX1 (pancreatic and duodenal homeobox | N | N | N | |||
| 81404 | PRNP (prion protein | N | N | N | |||
| 81404 | PRSS1 (protease, serine, 1 [trypsin 1]) | $248.76 | Y | ||||
| 81404 | RAF1 (v-raf-murine leukemia viral oncogene homolog 1) | N | N | ||||
| 81404 | RET (RET proto-oncogene) | $94.97 | Y | ||||
| 81404 | SDHD (succinate dehydrogenase complex, subunit D, integral membrane protein | N | N | N | |||
| 81404 | SLC25A4 (solute carrier family 25 [mitochondrial carrier; adenine nucleotide translocation], | N | N | N | |||
| 81404 | TP53 (tumor protein 53 | N | N | N | |||
| 81404 | TTR (transthyretin | N | N | N | |||
| 81404 | TYR (tyrosinase [oculocutaneous albinism IA]) | N | N | N | |||
| 81404 | USH1G (Usher syndrome 1G [autosomal recessive]) | N | N | N | |||
| 81404 | VHL (von Hippel-Lindau tumor suppressor) | $639.96 | Y | $639.96 | Y | $639.96 | Y |
| 81404 | VWF (von Willebrand factor) | N | N | N |
81405 Mole Path Level 6
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81405 | ABCD1 (ATP-binding cassette, sub-family D [ALD], | N | N | N | |||
| 81405 | ACADS (acyl-CoA dehydrogenase, C-2 to C-3 short chain) (eg, short chain acyl-CoA | N | N | N | |||
| 81405 | ACTC1 (actin, alpha, cardiac muscle 1) | N | N | N | |||
| 81405 | APTX (aprataxin) | N | N | N | |||
| 81405 | AR (androgen receptor) | N | N | N | |||
| 81405 | CHRNA4 (cholinergic receptor, nicotinic, alpha 4) | N | N | N | |||
| 81405 | CHRNB2 (cholinergic receptor, nicotinic, beta 2 [neuronal | N | N | N | |||
| 81405 | CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide2 | N | N | N | |||
| 81405 | DFNB59 (deafness, autosomal recessive 59) | N | N | N | |||
| 81405 | DHCR7 (7-dehydrocholesterol reductase | N | N | N | |||
| 81405 | EYA1 (eyes absent homolog 1 [Drosophila]) | N | N | N | |||
| 81405 | F9 (coagulation factor IX) | N | N | N | |||
| 81405 | FH (fumarate hydratase | N | N | N | |||
| 81405 | FKTN (fukutin) (eg, limb-girdle muscular dystrophy | N | N | N | |||
| 81405 | GFAP (glial fibrillary acidic protein) | N | N | N | |||
| 81405 | GLA (galactosidase, alpha | N | N | N | |||
| 81405 | HBA1/HBA2 (alpha globin 1 and alpha globin 2 | N | N | N | |||
| 81405 | HNF1A (HNF1 homeobox A | N | N | N | |||
| 81405 | HNF1B (HNF1 homeobox B) | N | N | N | |||
| 81405 | KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog) | N | N | N | |||
| 81405 | LAMP2 (lysosomal-associated membrane protein 2) | N | N | N | |||
| 81405 | MEN1 (multiple endocrine neoplasia I | $426.32 | Y | $426.32 | Y | $426.32 | Y |
| 81405 | MPZ (myelin protein zero) | N | N | N | |||
| 81405 | MYL2 (myosin, light chain 2, regulatory, cardiac, slow) | N | N | N | |||
| 81405 | MYL3 (myosin, light chain 3, alkali, ventricular, skeletal, slow) | N | N | N | |||
| 81405 | MYOT (myotilin) | N | N | N | |||
| 81405 | NEFL (neurofilament, light polypeptide) | N | N | N | |||
| 81405 | NF2 (neurofibromin 2 [merlin]) (e | N | N | N | |||
| 81405 | NSD1 (nuclear receptor binding SET domain protein 1) | N | N | N | |||
| 81405 | OTC (ornithine carbamoyltransferase) | N | N | N | |||
| 81405 | PDHB (pyruvate dehydrogenase [lipoamide] beta) | N | N | N | |||
| 81405 | PSEN1 (presenilin 1) | N | N | N | |||
| 81405 | RET (RET proto-oncogene) (eg, multiple endocrine neoplasia, type 2A and familial medullary thyroid carcinoma) | N | N | $379.47 | Y | ||
| 81405 | SDHB (succinate dehydrogenase complex, subunit B, iron sulfur) (eg, hereditary paragangli | N | N | N | |||
| 81405 | SDHC (succinate dehydrogenase complex, subunit C, integral membrane protein, 15kDa) | N | N | N | |||
| 81405 | SGCA (sarcoglycan, alpha [50kDa dystrophin-associated glycoprotein] | N | N | N | |||
| 81405 | SGCB (sarcoglycan, beta [43kDa dystrophin-associated glycoprotein] | N | N | N | |||
| 81405 | SGCD (sarcoglycan, delta [35kDa dystrophin-associated glycoprotein]) | N | N | N | |||
| 81405 | SGCG (sarcoglycan, gamma [35kDa dystrophin-associated glycoprotein]) | N | N | N | |||
| 81405 | SHOC2 (soc-2 suppressor of clear homolog) | N | N | N | |||
| 81405 | SMN1 (survival of motor neuron 1, telomeric) | N | N | N | |||
| 81405 | SPRED1 (sprouty-related, EVH1 domain containing 1) | N | N | N | |||
| 81405 | TGFBR1 (transforming growth factor, beta receptor 1) ( | N | N | N | |||
| 81405 | TGFBR2 (transforming growth factor, beta receptor 2) | N | N | N | |||
| 81405 | THRB (thyroid hormone receptor, beta) | N | N | N | |||
| 81405 | TNNI3 (troponin 1, type 3 [cardiac]) | N | N | N | |||
| 81405 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome, tumor | N | N | N | |||
| 81405 | TPM1 (tropomyosin 1 [alpha]) | N | N | N | |||
| 81405 | TSC1 (tuberous sclerosis 1 | N | N | N | |||
| 81405 | VWF (von Willebrand factor) | $284.20 | Y | $278.18 | Y | $278.18 | Y |
81406 Mole Path Level 7
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81406 | NOTCH3 (notch 3) | N | N | N | |||
| 81406 | RAF1 (v-raf-1 murine leukemia viral oncogene homolog 1) | N | N | N | |||
| 81406 | ACADVL (acyl-CoA dehydrogenase, very long chain) (eg | N | N | N | |||
| 81406 | ACTN4 (actinin, alpha 4) | N | N | N | |||
| 81406 | ANO5 (anoctamin 5) | N | N | N | |||
| 81406 | APP (amyloid beta [A4] precursor protein) | N | N | N | |||
| 81406 | ATP7B (ATPase, Cu++ transporting, beta polypeptide) | $538.98 | Y | $538.98 | Y | $538.98 | Y |
| 81406 | BRAF (v-raf murine sarcoma viral oncogene homolog B1) | N | N | N | |||
| 81406 | CAPN3 (Calpain 3) | N | N | N | |||
| 81406 | CBS (cystathionine-beta-synthase) | N | N | N | |||
| 81406 | CDH1 (cadherin 1, type 1, E-cadherin [epithelial]) | N | N | N | |||
| 81406 | CDKL5 (cyclin-dependent kinase-like 5) | N | N | N | |||
| 81406 | DLAT (dihydrolipoamide S-acetyltransferase) | N | N | N | |||
| 81406 | DLD (dihydrolipoamide dehydrogenase) | N | N | N | |||
| 81406 | EYA1 (eyes absent homolog 1 [Drosophila]) | N | N | N | |||
| 81406 | F8 (coagulation factor VIII) | N | N | N | |||
| 81406 | GAA (glucosidase, alpha; acid) | N | N | N | |||
| 81406 | GALT (galactose-1-phosphate uridylyltransferase) | N | N | N | |||
| 81406 | GCDH (glutaryl-CoA dehydrogenase) | N | N | N | |||
| 81406 | GCK (glucokinase [hexokinase 4]) | N | N | N | |||
| 81406 | HADHA (hydroxyacyl-CoA dehydrogenase/3-ketoacyl-CoA thiolase/enoyl-CoA hydratase [trifunctional protein] alpha subunit) | N | N | N | |||
| 81406 | HEXA (hexosaminidase A, alpha polypeptide) | N | N | N | |||
| 81406 | HNF4A (hepatocyte nuclear factor 4, alpha) | N | N | N | |||
| 81406 | IVD (isovaleryl-CoA dehydrogenase) | N | N | N | |||
| 81406 | JAG1 (jagged 1) ( | N | N | N | |||
| 81406 | LDB3 (LIM domain binding 3) (eg, familial | N | N | N | |||
| 81406 | LMNA (lamin A/C) | N | N | N | |||
| 81406 | MAP2K1 (mitogen-activated protein kinase 1) | N | N | N | |||
| 81406 | MAP2K2 (mitogen-activated protein kinase 2) ( | N | N | N | |||
| 81406 | MCCC2 (methylcrotonoyl-CoA carboxylase 2 [beta]) | N | N | N | |||
| 81406 | MUTYH (mutY homolog [E. coli]) | N | N | N | |||
| 81406 | NF2 (neurofibromin 2 [merlin]) (eg | N | N | N | |||
| 81406 | NSD1 (nuclear receptor binding SET domain protein 1) | N | N | N | |||
| 81406 | OPA1 (optic atrophy 1) (eg, optic atrophy), | N | N | N | |||
| 81406 | PAH (phenylalanine hydroxylase) | N | N | N | |||
| 81406 | PALB2 (partner and localizer of BRCA2) | N | N | N | |||
| 81406 | PAX2 (paired box 2) | N | N | N | |||
| 81406 | PC (pyruvate carboxylase | N | N | N | |||
| 81406 | PCCB (propionyl CoA carboxylase, beta polypeptide | N | N | N | |||
| 81406 | PDHA1 (pyruvate dehydrogenase [lipoamide] alpha1) | N | N | N | |||
| 81406 | PDHX (pyruvate dehydrogenase complex, component | N | N | N | |||
| 81406 | POLG (polymerase [DNA directed], gamma) | N | N | N | |||
| 81406 | POMGNT1 (protein O-linked mannose beta1, 2-N acetylglucosaminyltransferase) | N | N | N | |||
| 81406 | POMT1 (protein-O-mannosyltransferase 1) | N | N | N | |||
| 81406 | POMT2 (protein-O-mannosyltransferase 2) ( | N | N | N | |||
| 81406 | PRKAG2 (protein kinase, AMP-activated, gamma 2 non-catalytic subunit) | N | N | N | |||
| 81406 | PSEN2 (presenilin 2[Alzheimer's disease 4]) | N | N | N | |||
| 81406 | PTPN11 (protein tyrosine phosphatase, non-receptor type 11) | N | N | N | |||
| 81406 | PYGM (phosphorylase, glycogen, muscle) ( | N | N | N | |||
| 81406 | RET (ret-proto-oncogene | $168.83 | Y | $168.83 | Y | $168.83 | Y |
| 81406 | RYR1 (ryanodine receptor 1, skeletal) | N | N | N | |||
| 81406 | SLC26A4 (solute carrier family 26, member 4) | N | N | N | |||
| 81406 | SLC9A6 (solute carrier family 9 [sodium/hydrogen exchanger] member 6) | N | N | N | |||
| 81406 | SOS1 (son of sevenless homolog 1) | N | N | N | |||
| 81406 | TAZ (tafazzin) | N | N | N | |||
| 81406 | TNNT2 (troponin T, type 2 [cardiac]) | N | N | N | |||
| 81406 | TSC1 (tuberous sclerosis 1) | N | N | N | |||
| 81406 | TSC2 (tuberous sclerosis 2) | N | N | N | |||
| 81406 | UBE3A (ubiquitin protein ligase | N | N | N | |||
| 81406 | VWF (von Willebrand factor) | N | N | N |
81407 Mole Path Level 8
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81407 | ABCC8 (ATP-binding cassette, sub-family C [CFTR/MRP], member 8) | N | N | ||||
| 81407 | CHD7 (chromodomain helicase DNA binding protein 7) | N | N | ||||
| 81407 | F8 (coagulation factor VIII) | N | N | ||||
| 81407 | JAG1 (jagged 1) | N | N | ||||
| 81407 | MYBPC3 (myosin binding protein C, cardiac) | N | N | ||||
| 81407 | MYH6 (myosin, heavy chain 6, cardiac muscle, alpha) | N | N | ||||
| 81407 | MYH7 (myosin, heavy chain 7, cardiac muscle, beta) | N | N | ||||
| 81407 | MYO7A (myosin VIIA) | N | N | ||||
| 81407 | NOTCH1 (notch 1) | N | N | ||||
| 81407 | OPA1 (optic atrophy | N | N | ||||
| 81407 | PCDH15 (protocadherin-related 15) | N | N | ||||
| 81407 | SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) | N | N | ||||
| 81407 | SCN5A (sodium channel, voltage-gated, type V, alpha subunit) | N | N | ||||
| 81407 | TSC2 (tuberous sclerosis 2) | N | N | ||||
| 81407 | USH1C (Usher syndrome 1C [autosomal recessive, severe]) | N | N |
81408 Mole Path Level 9
| CPT Code | CPT Descriptor | 2013 | Noridian Coverage | DOS 10/01/13 | Noridian Coverage | DOS 2014 & 2015 | Noridian Coverage |
|---|---|---|---|---|---|---|---|
| 81408 | ATM (ataxia telangiectasia mutated) | N | N | N | |||
| 81408 | CDH23 (cadherin-related 23) | N | N | N | |||
| 81408 | COL1A1 (collagen, type I, alpha 1) | N | N | N | |||
| 81408 | COL1A2 (collagen, type I, alpha 2) | N | N | N | |||
| 81408 | DYSF (dysferlin, limb girdle muscular dystrophy 2B [autosomal recessive]) | N | N | N | |||
| 81408 | FBN1 (fibrillin 1 | N | N | N | |||
| 81408 | NF1 (neurofibromin 1) | N | N | N | |||
| 81408 | RYR1 (ryanodine receptor 1, skeletal) | N | N | N | |||
| 81408 | USH2A (Usher syndrome 2A [autosomal recessive, mild]) | N | N | N | |||
| 81408 | VWF (von Willebrand factor) (eg, von Willebrand disease types 1 and 3), | N | N | N |
Last Updated Fri, 28 Sep 2018 14:02:14 +0000