75880 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 75880

Medicaid fee-for-service

  • AZ: $392.67 (outpatient_hospital), effective Oct 1, 2021
  • CO: $90.43 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $25.20 (radiology), effective Jan 1, 2026
  • IL: $69.58 (practitioner), effective Apr 1, 2024
  • IN: $26.37 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $43.91 (default, Exempt Physician), effective Jan 1, 2024
  • KY: $0.00 (asc), effective Jan 1, 2026
  • LA: $83.05 (lab_radiology), effective Jul 1, 2025
  • MA: $24.90 (physician_radiology), effective May 1, 2024
  • MS: $476.38 (comprehensive), effective Jul 1, 2026
  • ND: $81.48 (physician), effective Aug 1, 2026
  • NE: $114.09 (physician, non-facility), effective Jul 1, 2026
  • NY: $79.79 (ordered_ambulatory), effective Jul 24, 2026
  • OH: $79.61 (physician), effective Jan 1, 2018
  • OK: $90.03 (physician, non-facility), effective Jul 1, 2026
  • TX: $754.17 (hospital_outpatient_imaging_services, Rural Hospitals), effective Mar 1, 2025
  • VA: $28.07 (medical), effective Jul 1, 2026
  • VT: $487.08 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $19.11 (physician, facility), effective Jul 1, 2026
  • WY: $277.42 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.