| Retinoblastoma Solutions | ||||||
| RATE SHEET | ||||||
| Created 01-Oct-2010, USD fees good to 01-Apr-2012 | ||||||
| Table 1: | CPT | USD Std Rate | USD Inst Rate | |||
| Bilateral Proband or Uni Proband with Pos Fam Hx | Code | Qty | Unit Rate | Total | Unit Rate | Total |
| Isolation of DNA from blood, RNA from blood | 83890 | 2 | $9.90 | 19.80 | $9.00 | 18.00 |
| PCR Amplification (30 primer pairs for QMPCR, 28 for DNA sequencing, 4 for RNA sequencing, 2 to test blood) | 83898 | 64 | 11.00 | 704.00 | 10.00 | 640.00 |
| Separation by agarose gel (1 ASPCR, 14 exon pairs, 2 blood) | 83894 | 31 | 5.50 | 170.50 | 5.00 | 155.00 |
| Separation by acrylamide gel (3 Q groups, 27 exons & Pr,2 blood) | 83894 | 32 | 6.60 | 211.20 | 6.00 | 192.00 |
| QM PCR mutation scanning (27 exons & Pr, 2 blood) | 83903 | 30 | 12.65 | 379.50 | 11.50 | 345.00 |
| Promotor hypermethylation analysis | 83904 | 3 | 22.00 | 66.00 | 20.00 | 60.00 |
| Mutation identification by sequencing (27 exons & Pr, 2 blood) | 83904 | 30 | 14.30 | 429.00 | 13.00 | 390.00 |
| Interpretation and Reporting | 83912 | 40 | 16.50 | 660.00 | 15.00 | 600.00 |
| TOTALS | $2,640.00 | $2,400.00 | ||||
| Table 2: | CPT | USD Std Rate | USD Inst Rate | |||
| Unilateral Proband with Tumor | Code | Qty | Unit Rate | Total | Unit Rate | Total |
| Isolation of DNA from blood and tumor, RNA from blood | 83890 | 3 | $5.50 | 16.50 | $5.00 | 15.00 |
| PCR Amplification (30 primer pairs for QMPCR, 28 for DNA sequencing, 4 for RNA sequencing, 2 to test blood) | 83898 | 64 | 16.50 | 1,056.00 | 15.00 | 960.00 |
| Separation by agarose gel (1 ASPCR, 14 exon pairs, 2 blood) | 83894 | 31 | 8.80 | 272.80 | 8.00 | 248.00 |
| Separation by acrylamide gel (3 Q groups, 27 exons & Pr,2 blood) | 83894 | 20 | 10.01 | 200.20 | 9.10 | 182.00 |
| QM PCR mutation scanning (28 exons, 2 blood) | 83903 | 30 | 15.40 | 462.00 | 14.00 | 420.00 |
| Promotor hypermethylation analysis | 83904 | 3 | 22.00 | 66.00 | 20.00 | 60.00 |
| Mutation identification by sequencing (28 exons, 2 blood) | 83904 | 30 | 16.50 | 495.00 | 15.00 | 450.00 |
| Interpretation and Reporting | 83912 | 40 | 17.60 | 704.00 | 16.00 | 640.00 |
| TOTALS | $3,272.50 | $2,975.00 | ||||
| Table 3: | CPT | USD Std Rate | USD Inst Rate | |||
| Unilateral Proband with NO Tumor | Code | Qty | Unit Rate | Total | Unit Rate | Total |
| Isolation of DNA from blood and tumor, RNA from blood | 83890 | 2 | $9.90 | 19.80 | $9.00 | 18.00 |
| PCR Amplification (30 primer pairs for QMPCR, 28 for DNA sequencing, 4 for RNA sequencing, 2 to test blood) | 83898 | 64 | 18.70 | 1,196.80 | 17.00 | 1,088.00 |
| Separation by agarose gel (1 ASPCR, 14 exon pairs, 2 blood) | 83894 | 31 | 16.50 | 511.50 | 15.00 | 465.00 |
| Separation by acrylamide gel (3 Q groups, 27 exons & Pr,2 blood) | 83894 | 32 | 17.60 | 563.20 | 16.00 | 512.00 |
| QM PCR mutation scanning (28 exons, 2 blood) | 83903 | 30 | 18.70 | 561.00 | 17.00 | 510.00 |
| Promotor hypermethylation analysis | 83904 | 3 | 23.10 | 69.30 | 21.00 | 63.00 |
| Mutation identification by sequencing (28 exons, 2 blood) | 83904 | 30 | 16.50 | 495.00 | 15.00 | 450.00 |
| Interpretation and Reporting | 83912 | 40 | 17.71 | 708.40 | 16.10 | 644.00 |
| TOTALS | $4,125.00 | $3,750.00 | ||||
| Table 4: | CPT | USD Std Rate | USD Inst Rate | |||
| One Relative at risk, test for known mutation | Code | Qty | Unit Rate | Total | Unit Rate | Total |
| Isolation of DNA from blood | 83891 | 1 | $17.89 | 17.89 | $16.27 | 16.27 |
| Amplification (one pair primers/person) | 83898 | 4 | 19.88 | 79.52 | 18.07 | 72.30 |
| PCR Analysis (2 runs for 2 persons) | 83894 | 4 | 9.93 | 39.72 | 9.03 | 36.11 |
| Sequence Analysis - proband | 83903 | 8 | 11.93 | 95.44 | 10.84 | 86.75 |
| Sequence Analysis - family member | 83904 | 8 | 22.86 | 182.88 | 20.78 | 166.28 |
| Interpretation and Reporting | 83912 | 2 | 39.76 | 79.52 | 36.15 | 72.30 |
| TOTALS | $494.97 | $450.00 | ||||
| Table 5: | CPT | USD Std Rate | USD Inst Rate | |||
| Add'l Relatives at risk (batched), test for known mutation | Code | Qty | Unit Rate | Total | Unit Rate | Total |
| Isolation of DNA from blood | 83891 | 1 | $18.37 | 18.37 | 16.697 | $16.70 |
| Amplification (one pair primers/person) | 83898 | 2 | 19.88 | 39.76 | 18.074 | 36.15 |
| PCR Analysis (2 runs for 2 persons) | 83894 | 3 | 9.93 | 29.79 | 9.027 | 27.08 |
| Sequence Analysis - proband | 83903 | 6 | 12.48 | 74.87 | 11.344 | 68.07 |
| Sequence Analysis - family member | 83904 | 6 | 23.41 | 140.48 | 21.285 | 127.71 |
| Interpretation and Reporting | 83912 | 2 | 40.86 | 81.72 | 37.148 | 74.30 |
| TOTALS | $385.00 | $350.00 | ||||
| Table 6: | CPT | USD Std Rate | USD Inst Rate | |||
| Pre-Natal Test for Relative at risk, known mutation | Code | Qty | Unit Rate | Total | Unit Rate | Total |
| Isolation of DNA from blood | 83891 | 1 | 17.893 | $17.89 | 16.267 | $16.27 |
| Amplification (one pair primers/person) | 83898 | 4 | 19.88129 | 79.53 | 18.074 | 72.30 |
| PCR Analysis (2 runs for 2 persons) | 83894 | 4 | 9.92959 | 39.72 | 9.027 | 36.11 |
| Sequence Analysis - proband | 83903 | 8 | 11.92873 | 95.43 | 10.844 | 86.75 |
| Sequence Analysis - family member | 83904 | 8 | 22.86339 | 182.91 | 20.785 | 166.28 |
| Interpretation and Reporting | 83912 | 2 | 39.76247 | 79.52 | 36.148 | 72.30 |
| Prenatal Markers | 83905 | 6 | 55.000 | 330.00 | 50.000 | 300.00 |
| TOTALS | $825.00 | $750.00 | ||||