Medicare genomic sequencing pricing under PAMA is based on anywhere from 200 to 275,000 claims for the "GSP" service type. For Exome and Genome, a large body of claims were paid at about half the Medicare CLFS rate.
Note that none of this data is Medicare data; it's private payer data...the behavior of private payers
###
Goodbye to a myth?
Are CMS CLFS prices a benchmark that strongly drive the market? Well, the data shows that for some codes (from 81408 to 81425) the actual market prices can be skewed or centered quite a distance from the CLFS benchmark at the time.
###
What's Up?
Medicare's public raw data files for PAMA 2026 provide interesting data views. Here, I reveal some more, using simple commands and Chat GPT 6.
Case Study: GeneDx (ticker WGS)
The information is relevant. Over the past year, GeneDx has been battling reimbursement issues, with share price varying in that time from around $33 to around $170. On one day in May, the share price dropped 50%.
PAMA Prices Trend Down for Exome, Genome
Not helping is the downward trend in the latest PAMA data for genomic procedures, including 81415 exome and 81425 genome. Here's some data; I include the $2000 (CLFS) rare gene code 81408.
In each case below, the current CMS CLFS price is in the fourth column. But a lot of the reported payments are cheaper: most of the claims for 81415 (exome, middle row) and 81425 (genome, bottom row) are in the second and third columns. Those are claims at $1400-2800 [second column] and $2800-4200 [third column.]
Note that exome, but not genome, has a significant bump to-the-right (blue bar in column 6). We showed earlier that such behavior, high-paying plans, can really drive free cash flow and profit.
 |
| Star - CLFS price |
The skew to the left is even more prominent for 81408, where many payments populate the far left bar ($0-550, while CMS price, $2000).
So if my market depended on the price of Genome being $5000 or nearby, and the largest bucket was column 2, $1400-2800... eeek.
##
Also in the 814nn series, GSP or Genomic Sequencing Procedures, CMS let us count how many services or claims were reported for about 36 GSP codes. Here is a sample screen shot:
Here's the full table:
Here's the Tier 2 claims, 81400 to 81408 as a bar chart.
