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NATIONAL LIMIT
2025 Clinical Laboratory Fee Schedule1


 CLIA WAIVED
Cartridge Product Code Analytes CPT Code(s)
Medicare Coverage
NATIONAL LIMIT
Medicare1 
Medicaid2
Basic Metabolic Panel 07P02-04 BUN Ca CICRE GLU K+ Na+ tCO2 eGFR* 80048-QW
CCI
MUE
Medically Unlikely Edits for 80048

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 8.46
N/A
Comprehensive Metabolic Panel 07P02-08 ALB ALP ALT AST BUN Ca CICRE GLU K+ Na+ TBIL tCO2 TP eGFR* 80053-QW
CCI
MUE
Medically Unlikely Edits for 80053

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: CMS Policy CMS Policy

$ 10.56
N/A
Metlyte 8 Panel 07P02-03 Electrolyte Panel 80051-QW
CCI
MUE
Medically Unlikely Edits for 80051

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 7.01
N/A
BUN 84520-QW
CCI
MUE
Medically Unlikely Edits for 84520

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.95
N/A
Creatinine 82565-QW
CCI
MUE
Medically Unlikely Edits for 82565

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.12
N/A
CK 82550-QW
CCI
MUE
Medically Unlikely Edits for 82550

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 3 3
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 6.51
N/A
Glucose 82947-QW
CCI
MUE
Medically Unlikely Edits for 82947

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 5 5
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data


NCD
Screening
$ 3.93
N/A
If all tests are ordered, performed, and reported:
$ 26.52
N/A
Liver Panel Plus 07P02-10 Albumin 82040-QW
CCI
MUE
Medically Unlikely Edits for 82040

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 4.95
N/A
Alkaline phosphatase 84075-QW
CCI
MUE
Medically Unlikely Edits for 84075

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.18
N/A
ALT 84460-QW
CCI
MUE
Medically Unlikely Edits for 84460

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.30
N/A
AST 84450-QW
CCI
MUE
Medically Unlikely Edits for 84450

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.18
N/A
Amylase 82150-QW
CCI
MUE
Medically Unlikely Edits for 82150

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 6.48
N/A
GGT 82977-QW
CCI
MUE
Medically Unlikely Edits for 82977

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte


NCD
$ 7.20
N/A
Total bilirubin 82247-QW
CCI
MUE
Medically Unlikely Edits for 82247

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 5.02
N/A
Total protein 84155-QW
CCI
MUE
Medically Unlikely Edits for 84155

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.67
N/A
If all tests are ordered, performed, and reported:
$ 42.98
N/A
General Chemistry 6 07P02-01 ALT 84460-QW
CCI
MUE
Medically Unlikely Edits for 84460

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.30
N/A
AST 84450-QW
CCI
MUE
Medically Unlikely Edits for 84450

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.18
N/A
BUN 84520-QW
CCI
MUE
Medically Unlikely Edits for 84520

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.95
N/A
Creatinine 82565-QW
CCI
MUE
Medically Unlikely Edits for 82565

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.12
N/A
GGT 82977-QW
CCI
MUE
Medically Unlikely Edits for 82977

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte


NCD
$ 7.20
N/A
Glucose 82947-QW
CCI
MUE
Medically Unlikely Edits for 82947

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 5 5
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data


NCD
Screening
$ 3.93
N/A
If all tests are ordered, performed, and reported:
$ 30.68
N/A
General Chemistry 13 07P02-11 Albumin 82040-QW
CCI
MUE
Medically Unlikely Edits for 82040

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 4.95
N/A
Alkaline phosphatase 84075-QW
CCI
MUE
Medically Unlikely Edits for 84075

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.18
N/A
Amylase 82150-QW
CCI
MUE
Medically Unlikely Edits for 82150

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 6.48
N/A
ALT 84460-QW
CCI
MUE
Medically Unlikely Edits for 84460

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.30
N/A
AST 84450-QW
CCI
MUE
Medically Unlikely Edits for 84450

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.18
N/A
BUN 84520-QW
CCI
MUE
Medically Unlikely Edits for 84520

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.95
N/A
Total Calcium 82310-QW
CCI
MUE
Medically Unlikely Edits for 82310

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.16
N/A
Creatinine 82565-QW
CCI
MUE
Medically Unlikely Edits for 82565

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.12
N/A
Glucose 82947-QW
CCI
MUE
Medically Unlikely Edits for 82947

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 5 5
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data


NCD
Screening
$ 3.93
N/A
Total Bilirubin 82247-QW
CCI
MUE
Medically Unlikely Edits for 82247

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 5.02
N/A
Total protein 84155-QW
CCI
MUE
Medically Unlikely Edits for 84155

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.67
N/A
GGT 82977-QW
CCI
MUE
Medically Unlikely Edits for 82977

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte


NCD
$ 7.20
N/A
Uric Acid 84550-QW
CCI
MUE
Medically Unlikely Edits for 84550

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 4.52
N/A
If all tests are ordered, performed, and reported:
$ 65.66
N/A
Lipid Panel 07P02-05 CHOL CHOL/HDL* nHDLc* HDL LDL* TRIG VLDL* 80061-QW
CCI
MUE
Medically Unlikely Edits for 80061

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte


NCD
Screening
$ 13.39
N/A
Lipid Panel Plus 07P02-12 Lipid Panel 80061-QW
CCI
MUE
Medically Unlikely Edits for 80061

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte


NCD
Screening
$ 13.39
N/A
Glucose 82947-QW
CCI
MUE
Medically Unlikely Edits for 82947

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 5 5
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data


NCD
Screening
$ 3.93
N/A
ALT 84460-QW
CCI
MUE
Medically Unlikely Edits for 84460

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.30
N/A
AST 84450-QW
CCI
MUE
Medically Unlikely Edits for 84450

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.18
N/A
If all tests are ordered, performed, and reported:
$ 27.80
N/A
Electrolyte Panel 07P02-02 CIK+ Na+ tCO2 80051-QW
CCI
MUE
Medically Unlikely Edits for 80051

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 7.01
N/A
Renal Function Panel 07P02-07 ALB BUN Ca CICRE GLU K+ Na+ PHOS tCO2 eGFR* 80069-QW
CCI
MUE
Medically Unlikely Edits for 80069

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 8.68
N/A
Kidney Check 07P02-09 BUN 84520-QW
CCI
MUE
Medically Unlikely Edits for 84520

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.95
N/A
Creatinine 82565-QW
CCI
MUE
Medically Unlikely Edits for 82565

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.12
N/A
If all tests are ordered, performed, and reported:
$ 9.07
N/A
 MODERATELY COMPLEX
Cartridge Product Code Analytes CPT Code(s)
Medicare Coverage
NATIONAL LIMIT
Medicare1 
Medicaid2
Basic Metabolic Panel Plus 07P02-13 Basic Metabolic Panel 80048
CCI
MUE
Medically Unlikely Edits for 80048

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 8.46
N/A
LD 83615
CCI
MUE
Medically Unlikely Edits for 83615

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 3
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 6.04
N/A
Magnesium 83735
CCI
MUE
Medically Unlikely Edits for 83735

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 4 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 6.70
N/A
If all tests are ordered, performed, and reported:
$ 21.20
N/A
Metalac 12 07P02-16 Renal Function Panel 80069
CCI
MUE
Medically Unlikely Edits for 80069

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 8.68
N/A
Lactate 83605
CCI
MUE
Medically Unlikely Edits for 83605

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 11.57
N/A
Magnesium 83735
CCI
MUE
Medically Unlikely Edits for 83735

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 4 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 6.70
N/A
If all tests are ordered, performed, and reported:
$ 26.95
N/A
Hepatic Function Panel 07P02-06 ALB ALP ALT AST DBIL TBIL TP 80076
CCI
MUE
Medically Unlikely Edits for 80076

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 8.17
N/A
Metlyte Plus CRP 07P02-14 Electrolyte Panel 80051
CCI
MUE
Medically Unlikely Edits for 80051

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 7.01
N/A
BUN 84520
CCI
MUE
Medically Unlikely Edits for 84520

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.95
N/A
Creatinine 82565
CCI
MUE
Medically Unlikely Edits for 82565

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.12
N/A
CK 82550
CCI
MUE
Medically Unlikely Edits for 82550

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 3 3
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 6.51
N/A
Glucose 82947
CCI
MUE
Medically Unlikely Edits for 82947

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 5 5
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data


NCD
Screening
$ 3.93
N/A
CRP 86140
CCI
MUE
Medically Unlikely Edits for 86140

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 2 Date of Service Edit: Policy 2 Date of Service Edit: Policy
Rationale: Code Descriptor / CPT Instruction Code Descriptor / CPT Instruction

$ 5.18
N/A
If all tests are ordered, performed, and reported:
$ 31.70
N/A
Biochemistry Panel Plus 07P02-15 Albumin 82040
CCI
MUE
Medically Unlikely Edits for 82040

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 4.95
N/A
Alkaline phosphatase 84075
CCI
MUE
Medically Unlikely Edits for 84075

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.18
N/A
Amylase 82150
CCI
MUE
Medically Unlikely Edits for 82150

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 6.48
N/A
ALT 84460
CCI
MUE
Medically Unlikely Edits for 84460

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.30
N/A
AST 84450
CCI
MUE
Medically Unlikely Edits for 84450

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.18
N/A
BUN 84520
CCI
MUE
Medically Unlikely Edits for 84520

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.95
N/A
Total Calcium 82310
CCI
MUE
Medically Unlikely Edits for 82310

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 4
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.16
N/A
Creatinine 82565
CCI
MUE
Medically Unlikely Edits for 82565

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 2 2
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 5.12
N/A
Glucose 82947
CCI
MUE
Medically Unlikely Edits for 82947

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 5 5
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data


NCD
Screening
$ 3.93
N/A
CRP 86140
CCI
MUE
Medically Unlikely Edits for 86140

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 2 Date of Service Edit: Policy 2 Date of Service Edit: Policy
Rationale: Code Descriptor / CPT Instruction Code Descriptor / CPT Instruction

$ 5.18
N/A
Total protein 84155
CCI
MUE
Medically Unlikely Edits for 84155

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Clinical: Data Clinical: Data

$ 3.67
N/A
GGT 82977
CCI
MUE
Medically Unlikely Edits for 82977

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte


NCD
$ 7.20
N/A
Uric Acid 84550
CCI
MUE
Medically Unlikely Edits for 84550

Practitioner
Hospital Outpatient
Allowed Frequency per Day: 1 1
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical
Rationale: Nature of Analyte Nature of Analyte

$ 4.52
N/A
If all tests are ordered, performed, and reported:
$ 65.82
N/A
 ADDITIONAL SERVICES
CPT Code
NATIONAL LIMIT
Medicare1 
Medicaid2
Routine Venipuncture 36415
$ 9.09
N/A


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1Reimbursement information source: Centers for Medicare and Medicaid Clinical Diagnostic Laboratory Fee Schedule (CLFS) 2025, available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html

CLFS does not reflect 2% Payment Adjustment (Sequestration). Click here for more information.



The information contained in this document has been compiled by CodeMap, L.L.C. to assist Abbott customers in preparing and submitting claims to Federal health care programs or other third-party payers. The information provided is for general educational purposes only and may not be conclusive or exhaustive. Recent changes in applicable law, regulations, payer instructions/transmittals and interpretations may not be reflected in the information contained herein. CodeMap, L.L.C. remains solely responsible for its content. Abbott assumes no responsibility for omissions or errors contained in this document.

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Abbott customers rely on the information contained in this document at their own risk and should check with the individual payers to verify coverage, coding and payment. The customer is ultimately responsible for determining the appropriate codes, coverage, and payment policies for individual patients. Abbott customers are encouraged to seek individual legal and/or coding guidance.

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CPT copyright 2024 American Medical Association. All rights reserved.