75889 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 75889

Medicaid fee-for-service

  • AZ: $2074.70 (outpatient_hospital), effective Oct 1, 2021
  • CO: $103.05 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $38.97 (radiology), effective Jan 1, 2026
  • IL: $115.31 (practitioner), effective Apr 1, 2024
  • IN: $95.16 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $74.10 (default, Exempt Physician), effective Jan 1, 2024
  • KY: $0.00 (asc), effective Jan 1, 2026
  • LA: $114.57 (lab_radiology), effective Jul 1, 2012
  • MA: $58.25 (physician_radiology), effective May 1, 2024
  • MS: $55.84 (comprehensive), effective Jul 1, 2026
  • ND: $54.82 (physician), effective Aug 1, 2026
  • NE: $575.19 (physician, non-facility), effective Jul 1, 2026
  • NY: $135.46 (physician_radiology, facility), effective Apr 1, 2026
  • OH: $118.57 (physician), effective Jan 1, 2024
  • OK: $60.25 (physician, non-facility), effective Jul 1, 2026
  • TX: $3826.63 (hospital_outpatient_imaging_services, Rural Hospitals), effective Mar 1, 2025
  • VA: $62.50 (medical), effective Jul 1, 2026
  • VT: $2451.66 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $29.43 (physician, facility), effective Jul 1, 2026
  • WY: $1396.35 (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.