2024 Laboratory Fee Schedule
Fee schedules do not reflect 2% Payment Adjustment (Sequestration).
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Respiratory Health Test
Visby Medical Respiratory Health Test-Emergency Use Authorization
CPT Code
CPT Code Description
Medicare Coverage
CALIFORNIA
Medicare
Reimbursement
CALIFORNIA
Medicaid
Reimbursement
87636-QW*
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique
  CCI   MUE   A57526 A58720
$142.63
$142.63

*QW should only be used when running this test in a CLIA Waived setting.


STI CT/NG/TV (If all tests are ordered and performed)
CPT Code
CPT Code Description
Medicare Coverage
CALIFORNIA
Medicare
Reimbursement
CALIFORNIA
Medicaid
Reimbursement
87801-QW*
Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique
  CCI   MUE   A55326 A57526 A58720
$ 70.20
$38.80

*QW should only be used when running this test in a CLIA Waived setting.




STI CT/NG/TV (If a single test is ordered and performed)
CPT Code
CPT Code Description
Medicare Coverage
CALIFORNIA
Medicare
Reimbursement
CALIFORNIA
Medicaid
Reimbursement
87491
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
  CCI   MUE   NCD
$ 35.09
$25.59
87591
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique
  CCI   MUE   NCD
$ 35.09
$25.36
87661
Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique
  CCI   MUE   A58720
$ 35.09
$30.54


Medicaid Reimbursement information source: California Medicaid Fee Schedule available at:
https://mcweb.apps.prd.cammis.medi-cal.ca.gov/rates.
Medi-Cal Rates as of 7/15/2024
Last updated by CodeMap on 08/20/2024.

Medicaid coverage and payment amounts are subject to many factors exclusively controlled by each State Medicaid Program. CodeMap® makes no representation, warranty, or guarantee that this compilation of Medicaid information is error-free or that the use of this information will result in coverage and subsequent payment of claims.

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