Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

OMPARING AB EST 

PAYMENT RATES: M EDICARE 

COULD ACHIEVE 

SUBSTANTIAL SAVINGS 

Daniel R. Levinson 

Inspector General 

June 2013 

OEI-07-11-00010 

C L T
 

 

EXECUTIVE SUMMARY - COMPARING LAB TEST PAYMENT RATES: 

MEDICARE COULD ACHIEVE SUBSTANTIAL SAVINGS 

OEI-07-11-00010 

WHY WE DID THIS STUDY 

Medicare is the largest payer of clinical laboratory (lab) services in the Nation. It paid 

approximately $8.2 billion for lab tests in 2010, which accounted for 3 percent of all Medicare 

Part B payments. Prior to this evaluation, there had not been a comparison of Medicare 

payment rates to those of other health care service payers. Such a comparison will help ensure 

that Medicare is a prudent purchaser of lab services. 

HOW WE DID THIS STUDY 

We collected payment data from 50 State Medicaid programs and 3 Federal Employees Health 

Benefits (FEHB) plans that pay for lab tests on a fee-for-service basis. We requested the 

payment rates in effect from January 1 through March 31, 2011, for 20 lab tests. For each lab 

test in each geographic area represented on the Medicare Clinical Laboratory Fee Schedule 

(CLFS), we compared Medicare paid claims with the State Medicaid program fee schedule 

amount and FEHB plan median claim payment amounts. We surveyed State Medicaid 

programs and FEHB plans to determine how their lab test fee schedules or payment rates were 

formulated, whether a copayment was charged to the patient, and whether lab test charges 

counted towards a member’s deductible. 

WHAT WE FOUND 

In 2011, Medicare paid between 18 and 30 percent more than other insurers for 

20 high-volume and/or high-expenditure lab tests. Medicare could have saved $910 million, or 

38 percent, on these lab tests if it had paid providers at the lowest established rate in each 

geographic area. State Medicaid programs and 83 percent of FEHB plans use the Medicare 

CLFS as a basis for establishing their own fee schedules and payment rates, although most pay 

less. However, unlike Medicare, FEHB programs incorporate factors such as competitor 

information, changes in technology used in performing lab tests, and provider requests in their 

payment rates. Some State Medicaid programs and FEHB plans required copayments for lab 

tests, which, in effect, lowered the costs of lab tests for the insurer. 

WHAT WE RECOMMEND 

We recommend that the Centers for Medicare & Medicaid Services (CMS) seek legislation that 

would allow it to establish lower payment rates for lab tests and consider seeking legislation to 

institute copayments and deductibles for lab tests. In its comments, CMS stated that it is 

exploring whether it has authority under current statute to revise payments for lab tests 

consistent with OIG’s recommendation and that a proposal to establish “deductibles and 

coinsurance” for lab tests is not included in the fiscal year 2014 President’s Budget. 
 

TABLE OF CONTENTS 

Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings........................................................................................................9 

In 2011, Medicare paid between 18 and 30 percent more for 

20 lab tests than other insurers.........................................................9 

Medicare could have saved $910 million in 2011 if it had paid 

the lowest insurer’s payment rate for 20 lab tests ..........................10 

Medicare’s payment rate methodology does not take into 

account technological and market changes ....................................10 

Unlike other insurers reviewed, Medicare does not require 

copayments and deductibles for lab tests .......................................11
 

Conclusion and Recommendations ............................................................13 

Agency Comments and Office of Inspector General Response .....15 

Appendixes ................................................................................................16 

A: Lab Tests Included in Review ..................................................16 

B: Comparison of Medicare-Allowed Amounts for Lab Tests 

With Rates of Other Insurers .........................................................18 

C: Medicare Clinical Laboratory Fee Schedule, State Medicaid 

Program Fee Schedule, and Federal Employees Health Benefits 

Program Median Payment Rates for Selected Laboratory Test 

Codes..............................................................................................23 

D: Potential Savings to Medicare .................................................44 

E: Agency Comments ...................................................................46 

Acknowledgments......................................................................................48 
 

 

OBJECTIVES 

To determine: 

1.	 the extent to which 2011 Medicare payment rates for 20 selected 

laboratory (lab) tests vary from those of State Medicaid programs and 

Federal Employees Health Benefits (FEHB) plans, 

2.	 the amount Medicare could have saved if it had paid a rate equal to the 

lowest insurer’s payment rate for the 20 selected lab tests, 

3.	 how the methods for establishing Medicare lab test payment rates vary 

from those of State Medicaid programs and FEHB plans, and 

4.	 the extent to which State Medicaid programs and FEHB plans require 

copayments and deductibles for lab tests. 

BACKGROUND 

Medicare is the largest payer of clinical lab services in the Nation. It paid 

approximately $8.2 billion for lab tests in 2010, which accounted for 

3 percent of all Medicare Part B payments.1 Prior to this evaluation, there 

had not been a comparison of Medicare payment rates for clinical lab 

services with payment rates for other health care service payers. Such a 

comparison will help ensure that Medicare is a prudent purchaser of lab 

services. Medicare’s methods for establishing payment rates for lab 

services have remained largely unchanged since 1984. 

Medicare Part B Coverage and Payment for Lab Tests 

Clinical diagnostic lab tests are performed on specimens taken from the 

human body. Lab tests provide information integral to preventing, 

diagnosing, and treating disease. Most lab tests are conducted in hospital, 

physician-office, or independent laboratories. Medicare Part B covers 

most lab tests and pays 100 percent of allowable charges; Medicare 

beneficiaries do not pay copayments or deductibles for lab tests.2 

Each lab submits claims to the Medicare Administrative Contractor 

(MAC) responsible for the area in which it is located. Although 15 MACs 

have largely replaced Medicare Part B claims payment carriers (carriers) 

that corresponded closely to State borders, MACs continue to administer 

the same payment policies created by the former 57 carriers, as explained 

below. 

1

 Centers for Medicare & Medicaid Services (CMS), Data Compendium: Table II.3. 

Accessed at http://www.cms.gov/DataCompendium on June 8, 2012.
 2

 Social Security Act (SSA), §§ 1833(a)(1)(D) and (b)(3) and 1866(a)(2)(A).
 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 1 
 

 

 

 

 

The Clinical Laboratory Fee Schedule 

Initial Establishment. The Deficit Reduction Act of 1984 (DRA) 

mandated that payment rates be established for lab tests on a regional, 

statewide, or carrier basis.3 The DRA also mandated that the Consumer 

Price Index for All Urban Consumers (CPI-U) be used annually to adjust 

rates for inflation. Beginning July 1, 1984, each carrier established its 

own payment rates on the basis of prevailing charges for lab tests in its 

locality. These payment rates are collectively known as the Clinical 

Laboratory Fee Schedule (CLFS). 

National Limitation Amount. The Consolidated Omnibus Budget 

Reconciliation Act of 1985 mandated a national limitation amount (NLA) 

for lab tests.4 Between July 1, 1986, and March 31, 1988, the NLA capped 

carrier rates at 115 percent of the median carrier rate for each lab test.5 For 

example, if the median carrier rate for a particular lab test was $100, the 

NLA capped carrier rates at $115. Carriers could establish rates at or 

below the NLA, but could not exceed it. 

In an effort to contain costs, from 1988 through 1998, Congress 

incrementally lowered the NLA as a percentage of the national median 

carrier rate.6 Since 1998, the NLA has been set at 74 percent of the 

median carrier rate for each lab test.7 Under the CLFS, MACs pay 

laboratories the lower of the laboratories’ actual charges or the carrier rate 

as capped by the NLA.8 

CMS publishes an updated CLFS at least annually containing payment 

rates based on the 57 jurisdictions of the former carriers.9 The 2011 CLFS 

contains the median carrier rate, the NLA, and each carrier’s rate for 

1,140 unique lab tests identified by the Healthcare Common Procedure 

3 P.L. 98-369, § 2303. 

4 P.L. 99-272, § 9303(b). 

5 SSA, § 1833(h)(4)(B)(i).
 6 SSA, § 1833(h)(4)(B).
 7

 SSA, § 1833(h)(4)(B)(viii). For new lab tests for which an NLA was not established 

before January 1, 2001, the NLA is set at 100 percent of the median. 

8 SSA, § 1833(a)(1)(D)(i).
 9

 The 57 jurisdictions include the 50 States, the District of Columbia, and Puerto Rico. 

California, Kansas, and Missouri are each divided into 2 jurisdictions; New York is
 

divided into 3 jurisdictions.
 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 2 
 

 

 

 

 

 

Coding System (HCPCS).10 As an example, HCPCS 82607 represents a 

lab test that checks the level of vitamin B-12 in blood. The median carrier 

rate for this test is $28.66, and the NLA is 74 percent of this figure, or 

$21.21. The payment rate for 51 of the carrier jurisdictions is the NLA 

($21.21). The payment rates for the remaining six carrier jurisdictions are 

less than the NLA, ranging from $14.67 to $21.05. 

Adjustments to the CLFS. Since the establishment of the CLFS, various 

laws have changed the calculation of the payment rates on the CLFS (see 

Table 1). 

Table 1: Adjustments to CLFS Payment Rates for Lab Tests 

Year Legislation Effect on the CLFS 

2003 

Medicare Prescription 

Drug, Improvement, and 

Modernization Act of 2003, 

P.L. 108-173, §§ 628 and 

302(b) 

Eliminated the CPI-U adjustments for 2004 through 2008; 

mandated that CMS implement a demonstration project to 

explore whether competitive bidding could reduce rates for 

lab tests below Medicare’s fee schedule rates. 

2008 

Medicare Improvements 

for Patients and Providers 

Act of 2008, P.L. 110-275, 

§ 145(a) and (b) 

Repealed CMS’s authority for a competitive bidding 

demonstration; lowered the CPI-U adjustment by 

0.5 percentage points from 2009 through 2013. 

2010 

Patient Protection and 

Affordable Care Act, 

P.L. 111-148, § 3401(l) 

Repealed the 0.5-percentage point reduction in the CPI-U 

beginning in 2011 and replaced it with a reduction equal to 

the 10-year moving average of annual multifactor 

productivity, which is determined by the Bureau of Labor 

Statistics; reduced the CLFS by an additional 

1.75 percentage points in years 2011 through 2015. 

CMS has only limited authority to make adjustments to CLFS payment 

rates.11 Any additional changes to the CLFS require legislative action. 

Limits on Medicaid Payment for Lab Tests 

Section 1903(i)(7) of the SSA prohibits State Medicaid program payments 

for lab tests that exceed the Medicare payment amount. Chapter 6, 

10 HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 

when services and procedures involve Medicare beneficiaries (e.g., 70405). The five 

character codes and descriptions included in this report are obtained from Current 

Procedural Terminology (CPT®), copyright 2011 by the American Medical 

Association (AMA). CPT is developed by the AMA as a listing of descriptive terms 

and five character identifying codes and modifiers for reporting medical services 

and procedures. Any use of CPT outside of this report should refer to the most 

current version of the Current Procedural Terminology available from 

AMA. Applicable FARS/DFARS apply. 

11 SSA § 1833(h)(2)(A)(i) provides that the Secretary may make adjustments to CLFS 

payment rates that are justified by technological changes. SSA § 1833(h)(2)(B) provides 

for adjustments or exceptions to the CLFS “to assure adequate reimbursement of 

emergency laboratory tests needed for the provision of bona fide emergency services and 

certain low-volume high-cost tests where highly sophisticated equipment or extremely 

skilled personnel are necessary to assure quality.” 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 3 
 

§ 6300.2, of the CMS State Medicaid Manual states that Medicaid 

reimbursement for clinical diagnostic lab tests may not exceed the amount 

that Medicare recognizes for such tests. The section provides eight 

exceptions that pertain to lab tests furnished by certain types of facilities 

(e.g., hospices) and/or paid for under the end stage renal disease composite 

rate. 

FEHB Payment for Lab Tests 

FEHB plans contract with local plans and provider networks to provide 

services to members, including lab tests. Within these contracts, FEHB 

plans negotiate payment rates. Although Federal regulation limits the 

amount that providers may charge for inpatient hospital and physician 

services to the Medicare amount, no such limits exist for lab tests.12 

Related Reports 

A 2000 Institute of Medicine (IOM) report found that Medicare’s fee 

schedule for lab tests and its methodology for setting payment rates had 

not evolved to account for technological and market changes. IOM 

recommended that Medicare payments for lab tests “be based on a single, 

rational, national fee schedule” adjusted for geographic location to account 

for differences in costs of labor and supplies.13 

In 2009, the Office of Inspector General (OIG) found that 83 percent of 

carrier payment rates were at the NLA.14 OIG found that the variation in 

carrier payment rates did not appear to reflect geographic cost differences 

and that varying methods were used to update carrier payment rates. OIG 

recommended that CMS seek legislation that would allow it to set accurate 

and reasonable payment rates for lab tests. In its response, CMS noted 

that the President’s budget for fiscal year 2010 did not include any 

proposals for amending the payment methodology for lab tests; therefore, 

CMS did not concur with this recommendation. CMS further stated that it 

would consider the recommendation as it continued to monitor the effects 

of its payment policies. CMS staff confirmed in early 2012 that it had no 

initiative underway to revamp the payment rate structure for lab tests. 

METHODOLOGY 

Scope 

We evaluated Medicare paid claims for CLFS lab tests during 2011. For 

CLFS lab tests, we included the top 15 lab tests by volume and by 

12 5 CFR § 890.905. 

13 IOM, Medicare Laboratory Payment Policy: Now and in the Future, January 2000. 

Accessed at http://iom.edu/Reports/2000/ on June 8, 2012. 14 OIG, Variation in the Clinical Laboratory Fee Schedule, OEI-05-08-00400, July 2009.
 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 4 
 

 

 

expenditure in 2010, the most recent data available at the time of our 

evaluation design. Because of overlap between these 2 groups of lab tests, 

a total of 20 tests were included in this evaluation. These tests accounted 

for 47 percent of the volume and 56 percent of the expenditures for CLFS 

lab tests reimbursed by Medicare in 2010. 

To ensure equitable comparisons, we compared the Medicare CLFS 

payment rates only to those under State Medicaid and selected FEHB 

fee-for-service health care programs. We did not compare Medicare 

fee-for-service payment rates to rates paid by managed care plans because 

managed care models typically involve an assumption of financial risk by 

providers. Also, our comparison of lab test prices used the fee schedule 

amounts for Medicaid programs and payment rates for FEHB plans. The 

fee schedule amounts for Medicaid programs and payment rates for FEHB 

plans do not reflect copayments and deductibles because those are factored 

in only when claims are paid. 

Data Collection 

From August through October 2011, we collected data from 50 State 

Medicaid programs and 3 fee-for-service FEHB plans.15 We requested the 

fee schedule amounts or payment rates in effect from January 1 through 

March 31, 2011, for 20 lab tests, as shown in Appendix A. We surveyed 

State Medicaid programs and FEHB plans regarding how their lab test fee 

schedule or payment rates were formulated, whether a copayment was 

charged to the patient, and whether lab test charges counted towards a 

member’s deductible. 

We received fee schedule amounts and survey responses from all 50 State 

Medicaid programs. State Medicaid programs provided their fee 

schedules for lab tests, representing the maximum payment rate allowed 

for each test. (For actual claims, providers could have billed for less than 

the fee schedule amounts.) 

We received payment rates and survey responses from the three selected 

FEHB plans. These three plans provide coverage to 90 percent of 

fee-for-service enrollees in the FEHB program. Each of these national 

plans provides services through local plans and networks. Within a single 

national plan, local plans and networks may have differing payment rates. 

The FEHB plans provided us with first-quarter 2011 median claim 

payment amounts representing all of their local plans and networks by 

15 Staff from the Tennessee Medicaid program stated that 100 percent of recipients are 

enrolled in managed care plans; therefore, Tennessee does not pay for any lab tests on a 

fee-for-service basis. We did not include the Tennessee Medicaid program in our data 

collection. We included the District of Columbia, for a total of 50 State Medicaid 

programs. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 5 
 

 

 

 

 

members’ States of residence. However, they did not provide survey 

responses regarding how lab test payment rates were formulated for each 

individual plan or network. In total, we received surveys from 29 of 

58 FEHB local plans and/or networks. 

Payment Rate Comparisons 

We used the population of Medicare claims for 20 lab test codes for tests 

performed in physician offices and independent laboratories during 2011. 

For each lab test in each geographic area, we compared the 

Medicare-allowed amount with the State Medicaid program fee schedule 

amount and each of the three FEHB plan’s median claim payment rates.16 

Insurers reported State-specific payment rates; therefore, we were able to 

make equitable comparisons across States. 

Our approach provides a conservative estimate of potential savings to the 

Medicare program because using Medicaid claim payment amounts or an 

FEHB plan’s lowest rate could produce greater differences in comparison 

to Medicare-allowed amounts. Table 2 summarizes the data sources used 

for the comparisons. 

Table 2: Data Sources Used in Payment Rate Comparisons 

Insurer Data Source Description 

Medicare CMS National Claims History 

file Allowed paid claims during 2011 

Medicaid 50 State Medicaid programs Fee schedule amounts in effect during the first 

quarter of 2011 

FEHB All local plans and networks 

within three FEHB plans 

Median allowed payment rates for claims with 

dates of service during the first quarter 2011 for 

each of the three FEHB plans 

Source: OIG data collection, 2012. 

We reviewed payment rates for 20 lab tests in each of 56 geographic 

jurisdictions for a total of 1,120 potential comparisons.17 However, not all 

insurers reported a payment rate for every lab test in each geographic 

jurisdiction; therefore, the Medicare-allowed amounts used in the 

comparisons vary by insurer. Table 3 shows the number of tests for which 

insurers reported payment rates. 

16 We excluded Medicare claims submitted by providers in geographic areas other than 

the 50 States and the District of Columbia. To ensure equitable comparisons, we 

excluded claims paid by the contractor that pays claims for the Railroad Retirement 

Board because this contractor pays claims nationwide rather than in a specific geographic 

area. 

17 We did not include Puerto Rico in our analysis; therefore, we compared payment rates 

in 56 of the 57 jurisdictions represented on the Medicare CLFS. 

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Table 3: Number of Lab Test Payment Rates Reported by Insurers and 

Medicare-Allowed Amount 

Insurer 

Number of Lab 

Test Payment 

Rates 

2011 

Medicare-Allowed 

Amount 

Medicaid 1,097 $2,355,233,694 

FEHB 1 1,054 $2,406,800,929 

FEHB 2 1,082 $2,410,847,338 

FEHB 3 1,119 $2,416,397,192 

Source: OIG data collection, 2012. 

Savings Calculation 

We conducted a claim-by-claim analysis to calculate the potential savings 

to Medicare if it had paid providers at the lowest established rate in each 

geographic area for each of the 20 reviewed tests. For example, the 

amount Medicare paid for an iron binding test (HCPCS code 83550) 

performed in Connecticut was compared with the fee schedule rate for the 

Connecticut Medicaid program and with the median allowed claim 

payment rate for each of three FEHB plans for members in Connecticut. 

Neither the Medicaid nor FEHB plan rates reflected copayments or 

deductibles because we were using Medicaid fee schedules and FEHB 

payment rates, not the amounts the program and plans actually paid for 

these tests. We subtracted the lowest available rate from the 

Medicare-allowed amount to calculate the potential savings to Medicare 

for that claim. Table 4 shows this calculation in detail. 

Table 4: Example Savings Calculation for an Iron Binding Test 

HCPCS 

Code Insurer Payment Rate 

Lowest 

Available 

Rate 

Potential 

Savings to 

Medicare 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$11.60 

$16.60 

$12.28 

$7.51 

$7.51 $12.30 minus $7.51 

= $4.79 

Source: OIG data collection, 2012. 

We summed the savings for each of the claims to calculate the total 

potential savings to Medicare. If the Medicare claim was paid at or below 

the lowest available rate, it was not included in the savings calculation. 

Limitations 

On the basis of the timing of our data collection, we collected fee schedule 

amounts and payment rates in effect for the period January 1 through 

March 31, 2011, from State Medicaid and FEHB programs. We applied 

these payment rates to Medicare claims for all of 2011. It is possible that 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 7 
 

 

State Medicaid or FEHB programs obtained different payment rates 

during April 1 through December 31, 2011, which would produce a 

different calculation of Medicare savings. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 8 
 

$2,500,000,000 

$2,000,000,000 

Allowed Dollars 

MedicareAllowed Amount 

$1,500,000,000 

Allowed Amount 

When Insurer 

Had Lower Price 

Than Medicare 

$1,000,000,000 

$2.355 

Billion 

$1.966 

Billion 

$2.407 

Billion 

$2.046 

Billion 

$2.411 

Billion 

$1.854 

Billion 

$2.416 

Billion 

$1.853 

Billion 

Medicaid FEHB 1 FEHB 2 FEHB 3 

(20% More) (18% More) (30% More) (30% More) 

Health Insurers 

 

 

FINDINGS 

In 2011, Medicare paid between 18 and 30 percent 

more for 20 lab tests than other insurers 

We reviewed payment rates for 20 lab tests in each of 56 geographic 

jurisdictions. Figure 1 shows the dollar amounts that Medicare paid for 

lab tests in 2011 compared with the dollar amounts that Medicare would 

have paid if it had paid at the rates that State Medicaid and FEHB plans 

paid for the same tests on the basis of their fee schedule amounts or 

payment rates. 

Figure 1: Comparison of Medicare-Allowed Amounts for Lab Tests With 

Rates of Other Insurers 

Note: Insurers did not report payment rates for all lab tests in all jurisdictions; therefore, we could not make all 

1,120 comparisons for each insurer.
 

Source: OIG data collection, 2012. 

When we compared payment rates for specific tests in specific 

jurisdictions, the smallest price variation in which Medicare paid more 

than State Medicaid programs for lab tests was $0.01 (HCPCS 85025 in 

Montana) and the largest price variation was $34.98 (HCPCS 83970 in 

Kansas). Among FEHB plans, the smallest price variation in which 

Medicare paid more was $0.01 (HCPCS 80048 in Tennessee) and the 

largest was $42.27 (HCPCS 83880 in Texas). Appendix B, Tables B-1 

through B-4, provides more detail on the number of lab tests and allowed 

amount for each of the 20 reviewed tests for each insurer. For a complete 

list of payment rates reported by health insurers for this evaluation, see 

Appendix C. 

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Medicare could have saved $910 million in 2011 if it 

had paid the lowest insurer’s payment rate for 20 lab 

tests 

Of the 4 insurers we reviewed, at least 1 paid a lower rate than Medicare 

on approximately 94 percent of the 1,120 price comparisons we 

performed. Table 5 shows the distribution of lab tests paid by other 

insurers in relation to Medicare. 

Table 5: Lab Tests Paid by Other Insurers in Relation to Medicare 

Insurer 

Number and 

Percentage of 

Tests That 

Insurer Paid 

Above Medicare 

Rates 

Number and 

Percentage of 

Tests That 

Insurer Paid at 

Medicare Rates 

Number and 

Percentage of 

Tests That 

Insurer Paid 

Below Medicare 

Rates 

Number 

of Tests 

Not Paid 

by 

Insurer 

Medicaid 65 6% 95 9% 937 85% 23 

FEHB 1 402 38% 6 1% 646 61% 66 

FEHB 2 486 45% 1 <1% 595 55% 38 

FEHB 3 506 45% 9 1% 604 54% 1 

Note: Insurers did not report payment rates for all lab tests in all jurisdictions; therefore, we could not make all 1,120 

comparisons for each insurer.
 

Source: OIG data collection, 2012. 

If Medicare had paid providers for lab tests at the lowest established rates 

among the insurers we surveyed, it could have paid 38 percent less, saving 

$910 million. For example, Medicare paid approximately $348 million for 

14.8 million commonly performed thyroid function tests (HCPCS Code 

84443) during 2011. If Medicare had paid providers for these tests at the 

lowest established rate among the insurers we surveyed, it could have 

saved approximately $140 million, or 40 percent.18 Appendix D shows the 

potential savings that Medicare could achieve for each of the 20 tests 

reviewed using the lowest rate available. 

Medicare’s payment rate methodology does not take 

into account technological and market changes 

Medicare’s payment rates for lab tests were established in 1984 on the 

basis of prevailing charges for lab tests in each Medicare carrier 

jurisdiction. Since that time, legislation has revised the rates by making 

uniform percentage adjustments to every test on the CLFS. CMS has only 

18 Providers submitted, and Medicare paid, a rate lower than the lowest established rate 

for approximately 296,000 tests. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 10 
 

 

 

 

limited authority to make adjustments to CLFS payment rates.19 Any 

additional changes to the CLFS require legislative action. 

As the largest health insurer in the United States, Medicare has great 

influence on the actions of other health care insurers. For example, 

Federal law prohibits State Medicaid program payments that exceed the 

Medicare payment amount for lab tests.20 Eighty-three percent 

(24 of 29) of responding local FEHB plans and networks reported that 

they use the Medicare CLFS as a basis for establishing their own fee 

schedules and payment rates. 

However, State Medicaid programs and local FEHB plans reported that 

they consider factors when establishing payment rates for lab tests that 

Medicare does not consider. For example, eight Medicaid plans and four 

local FEHB plans reported that technological changes (e.g., benchmarking 

payment rates for new tests to the actual cost of performing them) are 

taken into account when establishing payment rates. Thirteen local FEHB 

plans reported taking into account market considerations, such as 

competitor information, membership size, and market analysis. Other 

factors reported by State Medicaid programs and FEHB plans include 

provider requests to review the adequacy of a payment rate for a certain 

lab test and legislative and/or budgetary changes. 

Unlike other insurers reviewed, Medicare does not 

require copayments and deductibles for lab tests 

Beneficiaries enrolled in fee-for-service Medicare do not pay copayments 

for lab tests as they do for other Medicare Part B services (e.g., physician 

visits), nor are lab tests subject to a deductible.21 In comparison, 11 State 

Medicaid programs reported requiring copayments for lab tests in at least 

1 program or recipient category.22 

The amount of the copayment varied from 50 cents to $10; however, 

certain recipient categories were exempt from the copayment. For 

example, the Colorado and Florida State Medicaid programs reported 

requiring a $1 copayment with exemptions for pregnant women and 

recipients living in nursing facilities. In other States (e.g., Kentucky and 

Missouri), the copayment was inclusive of all services rendered by the 

same provider on a single date of service (e.g., a lab test and a doctor’s 

office visit). 

19 See note 11.
 20 SSA, § 1903(i)(7). 21 SSA, §§ 1833(a)(1)(D) and (b)(3) and 1866(a)(2)(A). 22 The 11 State Medicaid programs were Arkansas, Colorado, Florida, Iowa, Kentucky, 

Maine, Missouri, New Jersey, New York, South Dakota, and Wisconsin. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 11 
 

Each of the three FEHB plans offered multiple coverage options for 

members, with varying copayment amounts among these options. For 

example, one FEHB plan’s “standard” coverage option had a copayment 

of 15 percent of the provider’s allowed charges for lab tests, while another 

plan’s “basic” coverage option had no copayment. For another FEHB 

plan’s “high deductible” coverage option, the copayment was a flat $15 

when the tests were not part of a doctor’s office visit. 

Two of the three FEHB plans had an option to avoid member copayments 

by offering “lab cards,” which are issued to members separately from the 

FEHB plan’s health insurance identification cards. When members went 

to specified lab collection sites or requested that their physicians send their 

lab specimens to the specified laboratories, the members incurred no outof-pocket costs. When members chose to have their lab tests performed 

elsewhere, the tests were subject to copayments and deductibles. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 12 
 

 

CONCLUSION AND RECOMMENDATIONS 

In 2011, Medicare paid between 18 and 30 percent more for 20 lab tests 

than other insurers. Medicare could have saved $910 million, or 38 

percent, in 2011 if it had paid the same rate as the lowest paying insurer 

surveyed for each lab test in each geographic location. Achieving lower 

rates is possible because State Medicaid and FEHB lab test providers 

accepted these lower rates for lab tests. 

State Medicaid programs and FEHB plans use the Medicare CLFS as a 

basis for establishing their own fee schedules and payment rates, but most 

pay less. Unlike Medicare, FEHB programs incorporate factors such as 

competitor information, changes in technology used in performing lab 

tests, and provider requests. Some State Medicaid programs and FEHB 

plans required copayments for lab tests, which, in effect, lowered the costs 

of lab tests for the insurer. 

This report builds on previous OIG evaluations regarding lab test payment 

rates. A 2009 OIG report also recommended changes to the structure of 

lab test payment rates. In that report, OIG found that 83 percent of carrier 

payment rates were at the NLA. The variation in carrier payment rates did 

not appear to reflect geographic cost differences, and varying methods 

were used to update carrier payment rates. OIG recommended that CMS 

seek legislation that would allow it to set accurate and reasonable payment 

rates for lab tests. At that time, CMS did not concur with this 

recommendation but stated that it would consider the recommendation as 

it continued to monitor the effects of its payment policies. This report 

provides further evidence that the lab test payment rate structure is 

outdated and should be changed. 

We recommend that CMS: 

Seek Legislation That Would Allow CMS To Establish Lower 

Payment Rates for Lab Tests 

CMS could seek legislation that would provide for cost-saving measures 

such as: 

 conducting demonstration programs, such as competitive bidding 

(i.e., soliciting bids from lab test providers to obtain market rates) or 

entering into provider agreements (i.e., obtaining discounted rates 

from a small number of providers based on high lab test volume) and 

 including the ability to make adjustments to payment rates on an 

individual test basis to account for cost decreases due to technological 

changes and other factors. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 13 
 

 

Consider Seeking Legislation To Institute Copayments and 

Deductibles for Lab Tests 

Given that 11 State Medicaid programs and all three FEHB plans require 

copayments for lab tests in certain circumstances, CMS may want to 

consider whether copayments and deductibles for lab tests are appropriate 

for Medicare beneficiaries. We understand that Medicaid programs waive 

copayments for certain recipient categories and that two FEHB plans offer 

programs that motivate members to use certain lab test providers to avoid 

copayments. The concept of beneficiary copayments and deductibles is 

used broadly for other types of services in Medicare; requiring them could 

lead to cost savings. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 14 
 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS did not state whether it concurred or nonconcurred with OIG’s 

recommendations. Regarding the first recommendation, CMS stated that 

it is exploring whether it has authority under the current statute to revise 

payments for lab tests consistent with the recommendation. Regarding the 

second recommendation, CMS stated that legislation would be required to 

establish “deductibles and coinsurance” for lab tests and that such a 

proposal is not included in the fiscal year 2014 President’s Budget. We 

ask that in its final management decision, CMS more clearly indicate 

whether it concurs with our recommendations and what steps, if any, it 

will take to implement them. 

We did not make any changes to the report based on CMS’s comments. 

The full text of CMS’s comments is provided in Appendix E. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 15 
 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX A 

Lab Tests Included in Review 

HCPCS* 

Code23 Description 

Number 

of 

MedicareAllowed 

Tests in 

2010 

Percentage 

of All 

MedicareAllowed 

Tests in 

2010 

Total 

MedicareAllowed 

Amount in 

2010 

Percentage 

of Total 

MedicareAllowed 

Amount in 

2010 

2011 

Medicare 

National 

Limitation 

Amount 

per Test 

80048 Metabolic panel, total 

calcium 9,355,762 2.3% $94,325,286 1.9% $11.91 

80053 Comprehensive metabolic 

panel 27,232,042 6.6% $319,935,253 6.5% $14.87 

80061 Lipid panel 20,970,947 5.1% $310,596,151 6.3% $18.85 

81001 Urinalysis, automated, 

with microscopy 6,709,626 1.6% $30,435,748 0.6% $4.45 

81002 Urinalysis, nonautomated, 

without microscopy 4,416,987 1.1% $16,008,487 0.3% $3.60 

81003 Urinalysis, automated, 

without microscopy 4,805,501 1.2% $15,435,365 0.3% $3.16 

82306 Vitamin D, 25 hydroxy 5,333,420 1.3% $223,366,966 4.6% $41.66 

82570 Assay of urine creatinine 4,362,909 1.1% $32,023,975 0.7% $7.28 

82607 Vitamin B-12 3,334,018 0.8% $71,897,559 1.5% $21.21 

82728 Assay of ferritin 4,361,621 1.1% $84,963,813 1.7% $19.17 

83036 Glycosylated hemoglobin 

test 12,652,264 3.0% $175,307,639 3.6% $13.66 

83540 Assay of iron 5,455,091 1.3% $49,960,956 1.0% $9.12 

83550 Iron binding test 4,297,065 1.0% $52,653,538 1.1% $12.30 

83880 Natriuretic peptide 1,135,239 0.3% $54,491,238 1.1% $47.77 

83970 Assay of parathormone 3,582,472 0.9% $211,655,094 4.3% $58.08 

*Healthcare Common Procedure Coding System. continued on next page 

23 HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 

when services and procedures involve Medicare beneficiaries (e.g., 70405). The five 

character codes and descriptions included in this report are obtained from Current 

Procedural Terminology (CPT®), copyright 2011 by the American Medical 

Association (AMA). CPT is developed by the AMA as a listing of descriptive terms 

and five character identifying codes and modifiers for reporting medical services 

and procedures. Any use of CPT outside of this report should refer to the most 

current version of the Current Procedural Terminology available from 

AMA. Applicable FARS/DFARS apply. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 16 
 

 

 

 

 

 

Lab Tests Included in Review (Continued) 

HCPCS 

Code Description 

Number 

of 

MedicareAllowed 

Tests in 

2010 

Percentage 

of All 

MedicareAllowed 

Tests in 

2010 

Total 

MedicareAllowed 

Amount in 

2010 

Percentage 

of Total 

MedicareAllowed 

Amount in 

2010 

2011 

Medicare 

National 

Limitation 

Amount 

per Test 

84153 Assay of prostate-specific 

antigen, total 3,651,490 0.9% $96,028,772 2.0% $25.89 

84443 Thyroid stimulating 

hormone 14,728,086 3.5% $353,395,445 7.2% $23.64 

85025 

Complete blood count 

with automated differential 

white blood cell count 

31,930,801 7.7% $351,630,565 7.2% $10.94 

85610 Prothrombin time 22,020,091 5.3% $123,445,269 2.5% $5.53 

87086 Urine culture colony count 4,610,965 1.1% $53,112,711 1.1% $11.36

 Total 194,946,397 47.0% $2,720,669,830 55.5% N/A 

Source: Centers for Medicare & Medicaid Services National Claims History Part B Carrier File, 2012. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 17 
 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX B 

Comparison of Medicare-Allowed Amounts for Lab Tests With 

Rates of Other Insurers 

Table B-1: Comparison of Medicare-Allowed Amounts for Lab Tests With State 

Medicaid Program Rates 

HCPCS* 

Code24 Description 

2011 

Number of 

Allowed 

Tests 

2011 

MedicareAllowed 

Amount 

Number 

of Tests 

With 

Potential 

for 

Savings 

Allowed 

Amount If 

Medicaid 

Lowest 

Rate Used 

Percentage 

Medicare 

Paid More 

Than 

Medicaid 

80048 Metabolic panel, total 

calcium 8,622,383 $85,612,322 5,668,213 $75,265,426 14% 

80053 Comprehensive 

metabolic panel 26,667,106 $308,060,147 13,365,771 $279,044,002 10% 

80061 Lipid panel 20,096,974 $293,294,006 9,799,707 $254,514,132 15% 

81001 Urinalysis, automated, 

with microscopy 6,636,868 $29,518,138 6,307,849 $25,392,723 16% 

81002 

Urinalysis, 

nonautomated, 

without microscopy 

4,153,597 $14,808,195 3,980,171 $11,481,389 29% 

81003 Urinalysis, automated, 

without microscopy 4,808,096 $15,157,960 4,530,759 $12,590,841 20% 

82306 Vitamin D, 25 hydroxy 5,308,512 $218,018,917 5,200,763 $173,834,730 25% 

82570 Assay of urine 

creatinine 4,432,117 $31,958,084 4,274,416 $26,437,934 21% 

82607 Vitamin B-12 3,283,484 $69,600,580 3,208,218 $54,998,544 27% 

82728 Assay of ferritin 2,343,336 $44,791,773 2,285,840 $36,235,474 24% 

83036 Glycosylated 

hemoglobin test 12,374,324 $168,495,108 11,889,154 $139,534,720 21% 

83540 Assay of iron 2,573,826 $22,783,202 2,416,826 $17,777,978 28% 

83550 Iron binding test 2,001,213 $24,090,743 1,952,675 $18,554,959 30% 

83880 Natriuretic peptide 982,145 $46,274,487 947,719 $38,836,439 19% 

83970 Assay of 

parathormone 1,131,955 $65,699,438 1,103,363 $54,696,192 20% 

84153 Assay of prostatespecific antigen, total 3,530,885 $91,280,209 3,415,111 $78,423,161 16% 

*Healthcare Common Procedure Coding System. continued on next page 

24 HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 

when services and procedures involve Medicare beneficiaries (e.g., 70405). The five 

character codes and descriptions included in this report are obtained from Current 

Procedural Terminology (CPT®), copyright 2011 by the American Medical 

Association (AMA). CPT is developed by the AMA as a listing of descriptive terms 

and five character identifying codes and modifiers for reporting medical services 

and procedures. Any use of CPT outside of this report should refer to the most 

current version of the Current Procedural Terminology available from 

AMA. Applicable FARS/DFARS apply. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 18 
 

 

 

 

 

Table B-1: Comparison of Medicare-Allowed Amounts for Lab Tests With State 

Medicaid Program Rates (Continued) 

HCPCS 

Code Description 

2011 

Number of 

Allowed 

Tests 

2011 

MedicareAllowed 

Amount 

Number 

of Tests 

With 

Potential 

for 

Savings 

Allowed 

Amount If 

Medicaid 

Lowest 

Rate Used 

Percentage 

Medicare 

Paid More 

Than 

Medicaid 

84443 Thyroid stimulating 

hormone 14,431,323 $340,218,728 13,470,738 $278,608,047 22% 

85025 

Complete blood count 

with automated 

differential white blood 

cell count 

29,982,902 $324,139,981 28,708,580 $256,024,097 27% 

85610 Prothrombin time 19,778,756 $109,118,351 18,595,275 $90,002,308 21% 

87086 Urine culture colony 

count 4,622,255 $52,313,325 4,523,417 $43,254,698 21%

 Total 177,762,057 $2,355,233,694 145,644,565 $1,965,507,794 20% 

Dollar amounts are rounded to the nearest $1. 

Source: Centers for Medicare & Medicaid Services (CMS), National Claims History Part B Carrier File, 2012.
 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 19 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table B-2: Comparison of Medicare-Allowed Amounts for Lab Tests With 

Federal Employees Health Benefits Plan 1 Rates 

HCPCS 

Code Description 

2011 

Number of 

Allowed 

Tests 

2011 

MedicareAllowed 

Amount 

Number 

of Tests 

With 

Potential 

for 

Savings 

Allowed 

Amount If 

FEHB* 1 

Lowest Rate 

Used 

Percentage 

Medicare 

Paid More 

Than 

FEHB 1 

80048 Metabolic panel, total 

calcium 8,845,138 $87,510,028 4,014,472 $79,233,694 10% 

80053 Comprehensive 

metabolic panel 27,383,560 $315,644,951 12,603,839 $285,465,515 11% 

80061 Lipid panel 20,582,622 $299,733,323 12,236,042 $264,780,532 13% 

81001 Urinalysis, automated, 

with microscopy 6,745,292 $29,999,388 5,393,503 $21,605,942 39% 

81002 

Urinalysis, 

nonautomated, 

without microscopy 

4,298,157 $15,328,388 858,224 $14,827,898 3% 

81003 Urinalysis, automated, 

without microscopy 5,058,767 $15,955,168 3,097,997 $13,384,927 19% 

82306 Vitamin D, 25 hydroxy 5,375,495 $220,809,451 4,791,414 $195,628,854 13% 

82570 Assay of urine 

creatinine 4,599,040 $33,172,982 4,101,514 $28,388,052 17% 

82607 Vitamin B-12 3,348,724 $70,984,263 3,098,644 $57,669,263 23% 

82728 Assay of ferritin 2,390,169 $45,708,890 1,873,378 $38,683,459 18% 

83036 Glycosylated 

hemoglobin test 12,652,717 $172,332,541 11,637,788 $146,644,964 18% 

83540 Assay of iron 2,610,331 $23,119,240 2,191,250 $19,978,006 16% 

83550 Iron binding test 2,029,047 $24,437,035 1,665,647 $20,793,342 18% 

83880 Natriuretic peptide 1,005,678 $47,600,430 616,946 $46,896,600 2% 

83970 Assay of 

parathormone 1,144,866 $66,449,427 802,171 $57,235,817 16% 

84153 Assay of prostatespecific antigen, total 3,610,064 $93,330,561 3,382,894 $69,756,354 34% 

84443 Thyroid stimulating 

hormone 14,736,021 $347,421,480 11,997,260 $256,475,682 35% 

85025 

Complete blood count 

with automated 

differential white blood 

cell count 

30,778,859 $332,847,257 20,154,289 $277,782,489 20% 

85610 Prothrombin time 20,202,185 $111,459,803 11,817,701 $97,932,459 14% 

87086 Urine culture colony 

count 4,675,245 $52,956,323 249,964 $52,816,302 <1%

 Total 182,071,977 $2,406,800,929 116,584,937 $2,045,980,151 18% 

*Federal Employees Health Benefits Plan. 

Dollar amounts are rounded to the nearest $1. 

Source: CMS National Claims History Part B Carrier File, 2012.
 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 20 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table B-3: Comparison of Medicare-Allowed Amounts for Lab Tests With 

FEHB 2 Rates 

HCPCS 

Code Description 

2011 

Number of 

Allowed 

Tests 

2011 

MedicareAllowed 

Amount 

Number 

of Tests 

With 

Potential 

for 

Savings 

Allowed 

Amount If 

FEHB 2 

Lowest 

Rate Used 

Percentage 

Medicare 

Paid More 

Than 

FEHB 2 

80048 Metabolic panel, total 

calcium 8,868,300 $87,691,704 6,406,107 $56,925,617 54% 

80053 Comprehensive 

metabolic panel 27,406,336 $315,878,919 23,616,591 $190,298,975 66% 

80061 Lipid panel 20,620,917 $300,263,670 17,830,508 $181,050,752 66% 

81001 Urinalysis, automated, 

with microscopy 6,803,822 $30,259,846 5,013,009 $27,272,462 11% 

81002 

Urinalysis, 

nonautomated, 

without microscopy 

4,312,499 $15,380,015 801,000 $14,659,027 5% 

81003 Urinalysis, automated, 

without microscopy 5,071,508 $15,995,094 2,423,151 $15,081,085 6% 

82306 Vitamin D, 25 hydroxy 5,394,422 $221,597,882 1 $221,597,881 <1% 

82570 Assay of urine 

creatinine 4,630,130 $33,399,315 234,400 $33,218,013 1% 

82607 Vitamin B-12 3,354,340 $71,103,569 2,647,056 $67,236,703 6% 

82728 Assay of ferritin 2,388,723 $45,681,170 2,215,722 $39,589,293 15% 

83036 Glycosylated 

hemoglobin test 12,678,817 $172,653,909 10,844,674 $158,505,857 9% 

83540 Assay of iron 2,611,112 $23,123,274 2,377,920 $13,725,941 68% 

83550 Iron binding test 2,030,349 $24,449,112 1,606,576 $24,139,181 1% 

83880 Natriuretic peptide 1,003,642 $47,301,371 37,291 $47,200,413 <1% 

83970 Assay of 

parathormone 1,140,880 $66,217,932 1,033,874 $52,503,547 26% 

84153 Assay of prostatespecific antigen, total 3,616,338 $93,492,483 3,299,294 $75,992,390 23% 

84443 Thyroid stimulating 

hormone 14,761,102 $348,014,395 13,578,188 $238,945,858 46% 

85025 

Complete blood count 

with automated 

differential white blood 

cell count 

30,827,609 $333,380,573 22,581,252 $240,858,678 38% 

85610 Prothrombin time 20,250,842 $111,728,873 9,901,125 $107,226,128 4% 

87086 Urine culture colony 

count 4,703,253 $53,234,232 4,376,383 $47,958,561 11%

 Total 182,474,941 $2,410,847,338 130,824,122 $1,853,986,362 30% 

Dollar amounts are rounded to the nearest $1. 

Source: CMS National Claims History Part B Carrier File, 2012.
 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 21 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table B-4: Comparison of Medicare-Allowed Amounts for Lab Tests With 

FEHB 3 Rates 

HCPCS 

Code Description 

2011 

Number of 

Allowed 

Tests 

2011 

MedicareAllowed 

Amount 

Number 

of Tests 

With 

Potential 

for 

Savings 

Allowed 

Amount If 

FEHB 3 

Lowest 

Rate Used 

Percentage 

Medicare 

Paid More 

Than 

FEHB 3 

80048 Metabolic panel, total 

calcium 8,870,790 $87,715,544 5,395,466 $67,285,713 30% 

80053 Comprehensive 

metabolic panel 27,406,336 $315,878,919 16,006,044 $255,119,055 24% 

80061 Lipid panel 20,620,917 $300,263,670 11,088,845 $250,104,002 20% 

81001 Urinalysis, automated, 

with microscopy 6,804,619 $30,263,393 4,301,384 $25,300,428 20% 

81002 

Urinalysis, 

nonautomated, 

without microscopy 

4,312,499 $15,380,015 2,843,481 $13,316,748 15% 

81003 Urinalysis, automated, 

without microscopy 5,078,609 $16,012,775 3,061,511 $13,696,536 17% 

82306 Vitamin D, 25 hydroxy 5,394,422 $221,597,882 4,916,470 $151,929,883 46% 

82570 Assay of urine 

creatinine 4,649,643 $33,541,369 3,644,077 $25,746,329 30% 

82607 Vitamin B-12 3,363,543 $71,298,574 2,999,341 $50,209,954 42% 

82728 Assay of ferritin 2,401,360 $45,904,070 2,138,522 $32,616,087 41% 

83036 Glycosylated 

hemoglobin test 12,678,817 $172,653,909 9,693,743 $133,570,423 29% 

83540 Assay of iron 2,625,017 $23,249,999 2,261,945 $16,042,910 45% 

83550 Iron binding test 2,043,113 $24,606,097 1,864,244 $17,182,469 43% 

83880 Natriuretic peptide 1,079,500 $50,924,545 929,185 $37,383,509 36% 

83970 Assay of 

parathormone 1,154,873 $67,030,516 1,013,627 $47,853,311 40% 

84153 Assay of prostatespecific antigen, total 3,616,338 $93,492,483 3,061,675 $68,755,732 36% 

84443 Thyroid stimulating 

hormone 14,761,102 $348,014,395 12,759,702 $249,494,146 39% 

85025 

Complete blood count 

with automated 

differential white blood 

cell count 

30,827,609 $333,380,573 24,038,398 $258,080,023 29% 

85610 Prothrombin time 20,291,205 $111,952,080 12,595,842 $97,737,892 15% 

87086 Urine culture colony 

count 4,703,518 $53,236,384 4,222,236 $41,570,728 28%

 Total 182,683,830 $2,416,397,192 128,835,738 $1,852,995,878 30% 

Dollar amounts are rounded to the nearest $1. 

Source: CMS National Claims History Part B Carrier File, 2012.
 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 22 
 

 

APPENDIX C 

Medicare Clinical Laboratory Fee Schedule, State Medicaid 

Program Fee Schedule, and Federal Employees Health Benefits 

Program Median Payment Rates for Selected Laboratory Test 

Codes 

The following table contains the Medicare Clinical Laboratory Fee 

Schedule (CLFS) rates and the payment rates reported to us by State 

Medicaid programs and Federal Employees Health Benefits (FEHB) 

programs by Healthcare Common Procedure Coding System (HCPCS)25 

and geographic area. 

25 HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 

when services and procedures involve Medicare beneficiaries (e.g., 70405). The five 

character codes and descriptions included in this report are obtained from Current 

Procedural Terminology (CPT®), copyright 2011 by the American Medical 

Association (AMA). CPT is developed by the AMA as a listing of descriptive terms 

and five character identifying codes and modifiers for reporting medical services 

and procedures. Any use of CPT outside of this report should refer to the most 

current version of the Current Procedural Terminology available from 

AMA. Applicable FARS/DFARS apply. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 23 
 

 

APPENDIX C 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

AK AL AR AZ CA 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.91 

$12.12 

$7.10 

$4.98 

$11.00 

$11.91 

$11.00 

$12.55 

$15.97 

$7.88 

$11.91 

$12.09 

$18.40 

$14.54 

$15.09 

$11.91 

$11.51 

$9.58 

$4.98 

$7.23 

$11.91 

$9.27 

$9.58 

$4.98 

$10.28 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.87 

$15.14 

$11.56 

$6.19 

$43.00 

$14.87 

$12.00 

$14.00 

$8.19 

$9.84 

$14.87 

$15.10 

$18.17 

$19.32 

$22.16 

$14.87 

$14.38 

$11.56 

$6.19 

$9.03 

$14.87 

$11.57 

$11.56 

$6.19 

$12.83 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.85 

$19.19 

$13.69 

$8.20 

$65.00 

$15.99 

$14.00 

$13.69 

$8.20 

$11.40 

$17.89 

$18.16 

$21.85 

$21.85 

$26.66 

$18.85 

$18.23 

$13.69 

$8.20 

$11.44 

$18.85 

$13.74 

$13.18 

$8.20 

$16.25 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$4.54 

$2.74 

$5.54 

$32.00 

$4.45 

$4.00 

$2.74 

$5.66 

$5.50 

$4.45 

$4.52 

$7.97 

$6.65 

$6.65 

$4.45 

$4.31 

$2.74 

$5.15 

$2.71 

$4.45 

$3.47 

$2.70 

$3.80 

$3.84 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$3.66 

N/A 

$5.61 

$25.00 

$3.60 

$3.00 

$7.00 

$4.82 

$4.50 

$3.60 

$3.66 

$6.73 

$4.39 

$5.36 

$3.60 

$3.48 

$3.75 

$4.15 

$3.43 

$3.60 

$2.80 

$5.86 

$6.00 

$3.11 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$3.22 

$5.21 

$2.85 

$29.00 

$3.16 

$3.00 

$5.00 

$4.24 

$4.50 

$3.16 

$3.20 

$5.65 

$3.86 

$4.71 

$3.16 

$3.06 

$2.11 

$2.85 

$1.96 

$3.16 

$2.46 

$2.19 

$3.77 

$2.73 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$42.40 

$34.86 

$57.73 

$90.00 

$41.66 

$29.00 

$43.88 

$57.73 

$33.92 

$41.66 

$42.27 

$36.21 

$57.73 

$62.04 

$32.59 

$31.51 

$36.21 

$57.73 

$19.77 

$41.66 

$24.54 

$34.86 

$57.73 

$35.92 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$7.28 

$7.41 

$5.79 

$13.03 

$26.87 

$7.28 

$6.00 

$7.67 

$8.02 

$7.59 

$7.28 

$7.39 

$6.68 

$10.85 

$10.85 

$7.28 

$7.04 

$6.02 

$10.13 

$5.19 

$7.28 

$5.27 

$6.02 

$13.03 

$6.28 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$21.59 

$16.03 

$19.71 

$36.70 

$21.21 

$17.00 

$22.34 

$28.00 

$17.27 

$21.21 

$21.52 

$23.17 

$27.13 

$31.59 

$21.21 

$20.51 

$16.65 

$19.71 

$12.75 

$21.21 

$16.49 

$16.65 

$19.71 

$18.29 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$19.51 

N/A 

$16.38 

$20.87 

$19.17 

$13.00 

$20.19 

$16.20 

$15.61 

$19.17 

$19.46 

$23.41 

$23.41 

$28.55 

$19.17 

$18.53 

$15.61 

$16.38 

$11.63 

$19.17 

$14.91 

$15.61 

$16.38 

$16.52 

Note: “N/A” indicates that no price was reported for the test. continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 24 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

AK AL AR AZ CA 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$13.90 

$11.45 

$12.35 

$61.50 

$13.66 

$12.00 

$11.45 

$14.67 

$13.90 

$13.66 

$13.87 

$14.92 

$17.00 

$20.34 

$13.66 

$13.21 

$11.02 

$12.35 

$8.16 

$13.66 

$10.63 

$11.24 

$12.35 

$11.78 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$9.28 

$7.51 

$5.12 

$8.35 

$9.12 

$7.00 

$7.80 

$2.10 

$5.57 

$9.12 

$9.25 

$15.60 

$11.14 

$13.58 

$9.12 

$8.82 

$7.51 

$5.12 

$5.53 

$9.12 

$7.09 

$7.51 

$5.12 

$7.86 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$12.52 

$9.57 

$12.28 

$14.65 

$12.30 

$10.00 

$12.95 

$9.45 

$7.51 

$12.30 

$12.48 

$18.36 

$15.02 

$18.32 

$12.30 

$11.89 

$9.57 

$12.28 

$7.47 

$9.85/$10.39* 

$7.88 

$9.57 

$12.28 

$8.97 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.77 

$48.62 

N/A 

$106.19 

$40.44 

$47.77 

$33.00 

$61.89 

$150.60 

$42.75 

$47.77 

$47.43 

$66.40 

$73.57 

$17.60 

$47.77 

$46.19 

$46.76 

$122.25 

$28.98 

$47.77 

$37.56 

$47.65 

$114.94 

$41.19 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$59.12 

N/A 

$44.63 

$49.16 

$58.08 

$51.00 

$61.18 

$78.68 

$47.30 

$58.08 

$58.94 

$80.88 

$44.63 

$86.51 

$58.08 

$56.16 

$49.47 

$44.63 

$35.88 

$58.08 

$45.17 

$86.27 

$44.63 

$50.09 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$25.89 

$26.34 

$18.73 

$20.48 

$109.00 

$25.89 

$20.00 

$21.85 

$20.48 

$19.76 

$25.89 

$26.27 

$38.55 

$28.79 

$38.55 

$25.89 

$25.02 

$18.73 

$20.48 

$15.70 

$25.89 

$20.14 

$18.03 

$20.48 

$22.32 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$24.06 

$16.16 

$15.36 

$45.00 

$23.64 

$23.64 

$24.90 

$15.36 

$19.25 

$23.64 

$23.98 

$26.47 

$28.87 

$35.21 

$23.64 

$22.86 

$16.16 

$15.36 

$14.28 

$23.64 

$18.38 

$16.16 

$15.36 

$20.39 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.94 

$11.14 

$7.67 

$10.86 

$36.55 

$10.94 

$10.00 

$11.52 

$13.43 

$13.00 

$10.94 

$11.10 

$16.21 

$14.00 

$16.29 

$9.03 

$8.73 

$7.67 

$5.03 

$5.48 

$10.94 

$8.50 

$7.67 

$5.03 

$9.43 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$5.62 

$4.38 

$6.60 

$35.00 

$5.53 

$5.00 

$5.82 

$7.00 

$6.10 

$5.53 

$5.61 

$8.24 

$6.74 

$8.24 

$5.53 

$5.34 

$4.38 

$5.12 

$3.42 

$5.53 

$4.30 

$4.38 

$5.12 

$4.77 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$11.57 

N/A 

$10.45 

$37.00 

$11.36 

$10.00 

$14.46 

$10.45 

$10.99 

$11.36 

$11.53 

$20.68 

$13.88 

$16.92 

$11.36 

$10.99 

$29.51 

$10.45 

$6.89 

$11.36 

$7.52 

$24.50 

$10.45 

$9.80 

continued on next page 

* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions. Each jurisdiction may have a different price for 

some HCPCS codes. In jurisdictions where prices differ, differences are signified using “/” between each jurisdiction’s prices. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 25 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

CO CT DC DE FL 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.91 

$10.52 

$9.58 

$4.98 

$5.26 

$11.91 

$11.24 

$15.84 

$4.98 

$7.27 

$11.91 

$6.00 

$9.23 

$5.92 

$5.04 

$11.91 

$11.67 

$9.23 

$4.98 

$7.08 

$11.91 

$8.00 

$9.58 

$4.98 

$6.86 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.87 

$13.14 

$11.12 

$6.19 

$6.61 

$14.87 

$14.03 

$11.56 

$6.19 

$9.08 

$14.87 

$12.00 

$11.12 

$6.19 

$5.31 

$14.87 

$14.57 

$11.12 

$6.19 

$8.85 

$14.87 

$10.00 

$11.56 

$6.19 

$8.57 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.85 

$16.63 

$13.18 

$8.20 

$8.31 

$18.85 

$17.78 

$13.18 

$8.20 

$11.51 

$18.85 

$16.75 

$13.18 

$8.20 

$8.42 

$18.85 

$18.47 

$13.18 

$8.20 

$10.90 

$18.85 

$9.50 

$13.18 

$8.20 

$10.86 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$3.93 

$2.74 

$3.77 

$2.04 

$4.45 

$4.21 

$2.69 

$3.80 

$2.72 

$4.45 

$2.00 

$2.66 

$3.80 

$1.99 

$4.44 

$4.35 

$2.69 

$3.80 

$2.89 

$4.45 

$3.27 

$2.74 

$3.80 

$2.57 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$3.18 

$4.64 

$2.14 

$3.57 

$3.60 

$3.39 

$5.36 

$4.04 

$2.97 

$3.60 

$2.00 

$2.14 

$2.24 

$2.80 

$3.60 

$3.53 

$2.68 

$2.14 

$2.80 

$3.60 

$2.00 

$3.57 

$3.93 

$2.87 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$2.79 

$2.19 

$1.97 

$2.74 

$3.16 

$2.98 

$4.23 

$3.38 

$2.61 

$3.16 

$1.00 

$2.11 

$2.67 

$1.41 

$3.16 

N/A 

$3.14 

$2.67 

$2.09 

$3.16 

$2.50 

$2.19 

$2.85 

$2.51 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$36.76 

$34.86 

$57.73 

$18.49 

$41.66 

$39.29 

$34.86 

$57.73 

$25.44 

$41.66 

$20.00 

$34.86 

$42.50 

$18.61 

$41.66 

$40.83 

$35.54 

$57.73 

$24.77 

$41.66 

$30.00 

$34.86 

$57.73 

$23.99 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$7.28 

$6.42 

$6.02 

$13.03 

$3.22 

$7.28 

$6.87 

$6.02 

$13.03 

$5.10 

$7.28 

$3.00 

$5.79 

$9.07 

$3.25 

$7.28 

$7.13 

$6.50 

$13.03 

$5.19 

$7.28 

$5.00 

$6.02 

$13.03 

$4.19 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$18.72 

$16.65 

$19.71 

$9.33 

$21.21 

$20.01 

$16.03 

$19.71 

$12.95 

$21.21 

$10.00 

$16.03 

$17.90 

$9.48 

$21.21 

$20.79 

$16.65 

$19.71 

$12.61 

$21.21 

$15.00 

$16.03 

$19.71 

$12.21 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$16.93 

$15.03 

$16.38 

$8.48 

$19.17 

$18.08 

$15.32 

$16.38 

$11.71 

$19.17 

$9.00 

$15.03 

$16.18 

$8.56 

$19.17 

$18.79 

$15.03 

$16.38 

$11.40 

$19.17 

$14.00 

$15.61 

$16.38 

$11.04 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 26 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

CO CT DC DE FL 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$12.07 

$11.02 

$12.35 

$6.11 

$13.66 

$12.88 

$11.24 

$12.35 

$8.34 

$13.66 

$8.80 

$11.02 

$11.53 

$6.10 

$13.66 

$13.39 

$11.02 

$12.35 

$8.12 

$13.66 

$9.50 

$11.02 

$12.35 

$7.86 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$8.05 

$7.51 

$5.12 

$4.07 

$9.12 

$8.60 

$7.51 

$5.12 

$5.57 

$9.12 

$4.00 

$7.51 

$4.53 

$4.07 

$9.12 

$8.94 

$7.51 

$24.89 

$6.50 

$9.12 

$5.00 

$7.80 

$5.12 

$5.25 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$10.86 

$9.57 

$12.28 

$5.43 

$12.30 

$11.60 

$16.60 

$12.28 

$7.51 

$12.30 

$12.00 

$9.57 

$10.38 

$5.49 

$12.30 

$12.05 

$9.76 

$39.87 

$7.32 

$12.30 

$8.50 

$9.95 

$12.28 

$7.08 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$45.89 

$40.94 

$47.65 

$52.04 

$31.99 

$47.77 

$45.06 

N/A 

$142.00 

$29.17 

$47.77 

$46.81 

$46.76 

$40.32 

$26.34 

$47.77 

$46.81 

N/A 

$40.32 

$34.03 

$47.77 

N/A 

$45.87 

$140.58 

$42.75 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$51.27 

$45.27 

$44.63 

$25.61 

$58.08 

$54.79 

$365.90 

$44.63 

$35.47 

$58.08 

$27.00 

$45.27 

$49.02 

$31.72 

$58.08 

$56.92 

$46.15 

N/A 

$34.54 

$58.08 

$40.50 

$47.03 

$44.63 

$33.45 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$25.89 

$22.85 

$18.03 

$20.48 

$11.36 

$25.89 

$24.42 

$18.03 

$20.48 

$15.80 

$25.89 

$30.00 

$18.03 

$20.48 

$11.57 

$25.89 

$25.37 

$18.73 

$20.48 

$15.39 

$25.89 

$21.50 

$18.03 

$20.48 

$14.91 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$20.87 

$15.55 

$15.36 

$10.52 

$23.64 

$22.30 

$15.55 

$15.36 

$14.44 

$23.64 

$13.92 

$16.16 

$15.36 

$10.25 

$23.64 

$23.17 

$15.86 

$15.36 

$14.06 

$23.64 

$17.50 

$15.55 

$15.36 

$13.61 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.94 

$8.77 

$7.67 

$5.03 

$4.41 

$10.94 

$10.32 

$13.03 

$5.03 

$8.69 

$10.94 

$5.30 

$7.38 

$5.43 

$6.52 

$10.94 

$10.72 

$7.53 

$5.03 

$7.10 

$10.94 

$8.00 

$7.67 

$5.03 

$6.52 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$4.88 

$5.82 

$4.42 

$3.73 

$5.53 

$5.22 

$4.38 

$5.12 

$4.38 

$5.53 

$3.00 

$4.22 

$4.67 

$3.29 

$5.53 

$5.42 

$4.38 

$5.12 

$3.93 

$5.53 

$3.50 

$4.38 

$5.31 

$4.38 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$10.03 

$27.50 

$10.45 

$5.09 

$11.36 

$10.72 

$22.50 

$10.45 

$6.94 

$11.36 

$6.00 

$26.16 

$10.45 

$10.15 

$11.36 

$11.13 

$17.00 

$9.59 

$7.37 

$11.36 

$8.00 

$24.50 

$10.45 

$6.54 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 27 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

GA HI IA ID IL 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.91 

$10.65 

$12.55 

$4.98 

$13.01 

$11.91 

$11.70 

$9.40 

$12.93 

$16.10 

$11.91 

$11.31 

$12.31 

$25.84 

$14.50 

$11.91 

$11.83 

$13.61 

$13.12 

$13.33 

$11.91 

$8.28 

$10.85 

$7.28 

$4.50 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.87 

$13.29 

$11.56 

$6.19 

$13.12 

$14.87 

$14.61 

$22.47 

$16.30 

$20.10 

$14.87 

$14.13 

$11.56 

$30.60 

$18.00 

$14.87 

$14.77 

$16.35 

$12.46 

$18.32 

$14.87 

$10.36 

$14.77 

$9.00 

$11.16 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.85 

$16.85 

$13.69 

$8.20 

$18.72 

$18.85 

$18.51 

$13.69 

$20.50 

$35.83 

$18.85 

$17.91 

$13.69 

$33.32 

$23.00 

$15.96 

$15.85 

$19.30 

$18.72 

$19.66 

$18.85 

$6.22 

$13.69 

$8.20 

$17.00 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$3.99 

$4.70 

$5.80 

$4.65 

$4.45 

$4.37 

N/A 

$4.97 

$6.00 

$4.45 

$4.23 

$4.76 

$7.87 

$5.50 

$4.45 

$4.43 

$6.87 

$7.97 

$5.49 

$4.45 

$2.86 

$4.43 

$4.26 

$4.50 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$3.21 

$6.59 

$5.33 

$3.93 

$3.60 

$3.54 

$4.52 

$2.47 

$4.61 

$3.60 

$3.42 

$3.93 

$7.24 

$4.50 

$3.60 

$3.57 

$5.53 

$6.44 

$4.43 

$3.60 

$2.60 

$4.28 

$3.89 

$3.00 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$2.83 

$5.24 

$5.33 

$3.22 

$3.16 

$3.10 

N/A 

$1.88 

$3.86 

$3.16 

$3.00 

$3.85 

$5.58 

$4.00 

$3.16 

$3.14 

$3.86 

$5.65 

$3.90 

$3.16 

$2.18 

$2.19 

$3.02 

$3.22 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$37.22 

$36.21 

$57.73 

$33.09 

$41.66 

$40.91 

$69.90 

$57.73 

$56.25 

$41.66 

$39.58 

$43.30 

$60.41 

$51.00 

$41.66 

$41.36 

$56.11 

$57.73 

$51.30 

$41.66 

$8.86 

$36.21 

$57.73 

$30.00 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$7.28 

$6.51 

$6.02 

$13.03 

$7.41 

$7.28 

$7.15 

N/A 

N/A 

$9.85 

$7.28 

$6.92 

$7.61 

$13.03 

$9.00 

$7.28 

$7.23 

$9.04 

$13.03 

$8.97 

$7.28 

$4.66 

$5.79 

$13.03 

$6.72 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$18.95 

$16.65 

$19.71 

$18.71 

$21.21 

$20.83 

N/A 

N/A 

$28.65 

$21.21 

$20.15 

$21.84 

$28.60 

$26.00 

$21.21 

$21.06 

$31.40 

$19.71 

$26.12 

$21.21 

$12.00 

$21.06 

$19.71 

$15.00 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$17.13 

$15.61 

$16.38 

$16.91 

$16.09 

$15.81 

N/A 

N/A 

$21.75 

$19.17 

$18.21 

$19.86 

$33.89 

$23.00 

$19.17 

$19.03 

$23.79 

$16.38 

$23.61 

$19.17 

$7.16 

$20.56 

$16.38 

$14.00 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 28 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

GA HI IA ID IL 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$12.20 

$11.45 

$12.35 

$13.90 

$13.66 

$13.42 

$11.45 

$15.07 

$18.45 

$13.66 

$12.98 

$14.30 

$24.16 

$16.50 

$9.84 

$9.77 

$14.39 

$14.66 

$12.12 

$13.66 

$6.30 

$11.45 

$12.35 

$13.00 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$8.15 

$7.80 

$5.12 

$7.24 

$9.12 

$8.95 

N/A 

N/A 

$12.30 

$9.12 

$8.66 

$8.67 

$16.11 

$11.00 

$9.12 

$9.05 

$8.15 

$5.12 

$10.03 

$9.12 

$6.38 

$9.12 

$5.47 

$6.00 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$10.99 

$9.95 

$12.28 

$10.85 

$12.30 

$12.08 

N/A 

N/A 

$16.60 

$10.60 

$10.07 

$11.33 

$18.76 

$13.00 

$12.30 

$12.21 

N/A 

$12.28 

$13.53 

$12.30 

$8.56 

$12.30 

$12.28 

$9.00 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.77 

$42.69 

$51.00 

$117.39 

$42.75 

$47.77 

$28.46 

N/A 

N/A 

$28.25 

$47.77 

$45.38 

$49.64 

N/A 

$58.00 

$47.77 

$47.43 

$85.00 

N/A 

$58.83 

$39.91 

$14.86 

N/A 

$142.00 

$4.50 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$51.90 

$47.03 

$44.63 

$45.38 

$58.08 

$57.04 

N/A 

N/A 

$78.45 

$58.08 

$55.18 

$55.94 

$70.72 

$71.00 

$58.08 

$57.67 

$70.94 

$48.27 

$65.62 

$58.08 

$31.12 

$45.27 

$48.27 

$41.00 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$25.89 

$23.13 

$18.73 

$20.48 

$25.70 

$25.89 

$25.42 

$18.73 

$28.79 

$34.95 

$25.89 

$24.60 

$18.73 

$42.46 

$32.00 

$25.89 

$25.70 

$29.14 

$26.85 

$31.87 

$25.89 

$13.20 

$18.73 

$20.48 

$18.00 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$21.12 

$16.16 

$15.36 

$20.85 

$23.64 

$23.21 

$38.48 

$26.39 

$31.90 

$23.64 

$22.46 

$24.62 

$41.78 

$29.00 

$22.14 

$21.98 

$25.99 

$15.36 

$27.26 

$23.64 

$16.42 

$16.16 

$15.36 

$17.00 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.94 

$9.77 

$13.07 

$14.00 

$10.86 

$10.94 

$10.74 

$17.91 

$11.94 

$14.75 

$10.94 

$10.39 

$11.52 

$19.33 

$13.50 

$10.94 

$10.86 

$13.37 

$12.35 

$13.48 

$10.94 

$5.74 

$11.14 

$8.06 

$5.18 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$4.94 

$8.21 

$7.41 

$5.87 

$5.53 

$5.43 

N/A 

N/A 

$7.45 

$4.92 

$4.67 

$6.30 

$11.97 

$6.00 

$5.53 

$5.49 

$4.38 

$9.00 

$6.80 

$5.53 

$3.82 

$5.62 

$6.72 

$4.50 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$10.15 

$24.50 

$10.45 

$10.02 

$11.36 

$11.16 

N/A 

$11.42 

$15.35 

$11.36 

$10.79 

$11.92 

$24.00 

$14.00 

$11.36 

$11.28 

$17.48 

$20.28 

$14.00 

$11.36 

$10.50 

$21.00 

$10.45 

$8.12 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 29 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

IN KS KY LA MA 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$8.99 

$8.83 

$9.58 

$4.98 

$5.60 

$11.91 

$10.50 

$9.23 

$4.98 

$13.32 

$9.43 

$9.43 

$9.58 

$12.00 

$5.11 

$11.91 

$9.61 

$12.55 

$22.23 

$2.58 

$11.91 

$8.83 

$9.58 

$4.98 

$12.26 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.65 

$14.39 

$11.12 

$6.19 

$9.12 

$14.87 

$12.48 

$11.56 

$6.19 

$13.32 

$11.83 

$11.83 

$11.56 

$6.19 

$7.12 

$14.87 

$12.01 

$11.56 

$11.73 

$11.36 

$14.87 

$11.03 

$11.56 

$6.19 

$16.50 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.85 

$18.51 

$13.18 

$8.20 

$13.10 

$18.85 

$15.12 

$13.18 

$8.20 

$30.82 

$16.02 

$16.02 

$13.69 

$8.20 

$7.51 

$16.82 

$12.34 

$13.69 

$8.20 

$12.84 

$18.85 

$13.98 

$13.69 

$8.20 

$19.86 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$4.37 

$5.32 

$4.00 

$3.77 

$4.45 

$4.37 

$2.74 

$3.80 

$6.94 

$4.45 

$4.45 

$5.34 

$4.76 

$3.30 

$4.45 

$3.28 

$4.87 

$7.75 

$5.22 

$4.45 

$3.31 

$2.74 

$4.43 

$4.74 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$3.54 

$4.32 

$4.00 

$3.03 

$3.60 

$3.01 

$2.99 

$3.96 

$5.80 

$3.39 

$3.39 

$4.21 

$3.69 

$2.15 

$3.60 

$2.64 

$4.61 

$6.73 

$4.29 

$3.60 

$2.67 

$5.93 

$3.48 

$3.57 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$3.10 

$3.79 

$3.00 

$2.67 

$3.16 

$1.50 

$2.66 

$3.47 

$6.94 

$3.16 

$3.16 

$4.11 

$4.26 

$1.38 

$3.16 

$2.33 

$3.58 

$5.50 

$3.77 

$3.16 

$2.34 

$3.94 

$3.06 

$3.51 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$40.91 

$35.54 

$57.73 

$25.00 

$41.66 

$10.08 

$35.54 

$57.73 

$43.36 

$38.45 

$38.45 

$36.21 

$57.73 

$19.53 

$41.66 

$30.59 

$36.21 

$57.73 

$31.80 

$41.66 

$30.88 

$34.86 

$57.73 

$46.21 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$7.28 

$7.15 

$6.02 

$10.61 

$4.54 

$7.28 

$6.93 

$6.02 

$13.03 

$8.72 

$7.28 

$7.28 

$7.67 

$10.13 

$3.20 

$7.28 

$5.35 

$6.02 

$13.03 

$6.28 

$7.28 

$5.40 

$6.02 

$13.03 

$7.68 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$20.83 

$16.65 

$19.71 

$13.21 

$21.21 

$20.83 

$16.03 

$19.71 

$22.08 

$21.21 

$21.21 

$16.03 

$19.71 

$10.28 

$21.21 

$15.57 

$16.65 

$19.71 

$16.19 

$21.05 

$15.61 

$16.34 

$20.04 

$23.36 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$18.83 

$15.48 

$16.38 

$11.93 

$19.17 

$18.83 

$15.03 

$16.38 

$19.96 

$19.17 

$19.17 

$15.03 

$16.38 

$9.12 

$19.17 

$14.07 

$21.79 

$16.38 

$14.63 

$19.17 

$14.21 

$15.03 

$16.38 

$20.20 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 30 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

IN KS KY LA MA 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$13.42 

$11.45 

$12.35 

$8.50 

$13.66 

$13.41 

$11.45 

$12.35 

$27.08 

$13.66 

$13.66 

$11.45 

$12.35 

$8.91 

$13.66 

$10.03 

$11.45 

$12.35 

$10.43 

$13.66 

$10.13 

$11.45 

$12.35 

$14.40 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$8.95 

$7.80 

$5.12 

$5.68 

$9.12 

$5.20 

$7.51 

$5.12 

$9.49 

$9.12 

$9.12 

$8.40 

$5.12 

$4.11 

$7.55 

$5.54 

$9.30 

$5.12 

$5.76 

$9.12 

$6.76 

$7.51 

$5.12 

$9.97 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$12.08 

$9.95 

$12.28 

$7.66 

$12.30 

$12.18 

$9.57 

$12.28 

$15.34 

$12.30 

$12.30 

$9.57 

$13.50 

$5.77 

$12.30 

$9.04 

$14.04 

$12.28 

$12.30 

$12.30 

$9.12 

$9.76 

$12.28 

$13.06 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$40.85 

$40.56 

$47.65 

$142.00 

$25.43 

$43.37/$47.77 

$23.10 

$45.87 

$149.10 

$38.07 

$47.77 

$47.77 

$53.47 

$136.60 

$22.45 

$47.77 

$38.97 

$68.43 

$100.80 

$16.00 

$47.77 

$35.42 

$47.65 

$45.50 

$49.70 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$57.04 

$58.08 

$44.63 

$34.85 

$58.08 

$23.10 

$45.27 

$44.63 

$116.76 

$58.08 

$58.08 

$45.27 

$44.63 

$28.37 

$58.08 

$42.65 

$47.03 

$44.63 

$41.07 

$58.08 

$43.06 

$45.27 

$44.63 

$61.22 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$25.89 

$25.42 

$18.03 

$20.48 

$21.85 

$25.89 

$21.61 

$18.73 

$20.48 

$51.19 

$25.89 

$25.89 

$18.73 

$20.48 

$12.00 

$25.89 

$19.00 

$18.73 

$20.48 

$19.76 

$25.89 

$19.19 

$18.73 

$20.48 

$28.72 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$23.21 

$15.55 

$15.36 

$14.72 

$23.64 

$15.75 

$16.16 

$15.36 

$27.00 

$23.64 

$23.64 

$24.90 

$15.36 

$11.32 

$23.64 

$17.36 

$16.16 

$23.00 

$18.05 

$23.64 

$17.53 

$16.16 

$15.36 

$25.77 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.94 

$10.74 

$7.67 

$5.03 

$7.60 

$6.54/$10.94 

$5.00 

$7.67 

$5.03 

$9.55 

$10.94 

$10.94 

$13.58 

$11.14 

$5.18 

$10.94 

$8.03 

$12.38 

$20.41 

$11.52 

$10.94 

$8.11 

$7.67 

$8.00 

$11.53 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$5.43 

$4.22 

$6.18 

$3.44 

$5.53 

$5.25 

$4.38 

$6.08 

$12.11 

$5.53 

$5.53 

$6.86 

$5.62 

$4.31 

$5.53 

$4.07 

$6.37 

$10.32 

$3.79 

$5.53 

$4.10 

$4.38 

$5.67 

$5.84 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$11.16 

$24.50 

$10.45 

$7.95 

$11.36 

$10.50 

$24.50 

$10.45 

$21.68 

$11.36 

$11.36 

$24.50 

$10.45 

$8.54 

$11.36 

$8.34 

$24.50 

$10.45 

$8.68 

$11.36 

$8.42 

$20.00 

$10.72 

$12.60 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 31 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

MD ME MI MN MO 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.91 

$9.01 

$9.23 

$4.98 

$9.30 

$11.91 

$7.02 

$9.58 

$8.09 

$12.69 

$11.91 

$9.31 

$9.41 

$4.98 

$8.68 

$11.91 

$11.91 

$24.86 

$33.30 

$13.94 

$11.91 

$11.12 

$9.58 

$4.98 

$10.28 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.87 

$11.25 

$11.12 

$6.19 

$9.76 

$14.87 

$8.76 

$19.58 

$6.19 

$14.61 

$14.65 

$11.43 

$11.56 

$6.19 

$15.19 

$14.87 

$14.87 

$29.32 

$41.40 

$17.41 

$14.87 

$13.73 

$11.56 

$6.19 

$12.39 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$17.17 

$12.98 

$13.18 

$8.20 

$12.36 

$18.85 

$17.10 

$25.27 

$8.20 

$20.34 

$17.98 

$12.53 

$13.69 

$8.20 

$11.78 

$18.85 

$18.85 

$43.50 

$52.20 

$22.07 

$18.85 

$17.61 

$13.69 

$8.20 

$16.64 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$3.38 

$2.64 

$3.80 

$2.92 

$4.45 

$3.42 

$6.42 

$5.90 

$4.81 

$4.45 

$2.64 

$2.74 

$4.97 

$2.92 

$4.45 

$4.45 

$13.95 

$14.18 

$6.40 

$4.45 

$4.17 

$2.74 

$3.80 

$4.99 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$2.72 

$5.50 

$2.24 

$2.80 

$3.60 

$3.42 

$4.82 

$4.03 

$3.52 

$3.60 

$1.10 

$6.50 

$4.27 

$3.73 

$3.60 

$3.60 

$9.11 

$5.71 

$4.21 

$2.94/$3.60 

$1.83 

$4.28 

$3.96 

$3.36 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$2.39 

$2.20 

$2.67 

$2.50 

$3.16 

$3.18 

$4.24 

$3.54 

$3.09 

$3.16 

$1.10 

$3.22 

$3.50 

$3.28 

$3.16 

$3.16 

$10.93 

$9.00 

$3.70 

$2.94/$3.16 

$1.83 

$3.33 

$3.47 

$3.29 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$31.50 

$34.86 

$57.73 

$18.61 

$41.66 

$41.36 

$66.56 

$57.73 

$42.04 

$41.66 

$32.53 

$36.21 

$57.73 

$27.30 

$41.66 

$41.66 

$43.88 

$105.45 

$59.78 

$41.66 

$38.90 

$34.86 

$57.73 

$33.39 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.78 

$4.19 

$6.02 

$12.75 

$4.82 

$7.28 

$5.40 

$5.91 

$13.03 

$7.14 

$6.54 

$3.42 

$6.02 

$10.85 

$4.29 

$7.22 

$7.22 

$19.40 

$13.03 

$8.45 

$7.28 

$5.50 

$6.02 

$13.03 

$5.85 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$16.03 

$16.03 

$19.71 

$12.21 

$21.05 

$11.16 

$16.65 

$19.71 

$20.68 

$21.21 

$10.92 

$16.65 

$21.56 

$13.90 

$21.21 

$21.21 

$38.00 

$19.71 

$30.44 

$21.21 

$19.81 

$16.65 

$19.71 

$17.66 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$14.49 

$15.03 

$16.20 

$12.57 

$19.17 

$18.90 

$25.69 

N/A 

$18.80 

$19.17 

$14.55 

$15.61 

$16.38 

$12.56 

$19.17 

$19.17 

$55.80 

$43.54 

$27.51 

$19.17 

$17.90 

$15.61 

$16.38 

$15.97 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 32 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

MD ME MI MN MO 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.10 

$9.91 

$11.02 

$12.35 

$8.96 

$13.66 

$11.25 

$18.31 

$12.35 

$13.65 

$13.66 

$8.64 

$11.45 

$12.35 

$8.95 

$13.66 

$13.66 

$35.20 

$37.80 

$15.99 

$13.66 

$12.75 

$11.02 

$12.35 

$13.56 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$6.90 

$7.51 

$5.12 

$4.07 

$9.12 

$5.40 

$7.80 

N/A 

$8.60 

$9.12 

$3.96 

$7.80 

$5.12 

$5.98 

$9.12 

$9.12 

$21.60 

$28.37 

$13.08 

$9.12 

$8.51 

$7.80 

$5.12 

$7.59 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$8.93 

$9.57 

$10.38 

$8.06 

$12.30 

$6.47 

$9.95 

N/A 

$12.06 

$12.13 

$6.36 

$9.57 

$12.28 

$7.96 

$12.30 

$12.30 

$21.24 

$34.20 

$17.65 

$12.30 

$7.70 

$9.95 

$12.28 

$9.86 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.77 

$36.12 

$48.99 

$90.46 

$42.75 

$47.77 

$21.34 

$63.75 

N/A 

$51.85 

$47.77 

$37.70 

$72.25 

N/A 

$31.30 

$47.77 

$47.77 

N/A 

$174.60 

$55.91 

$39.27/$43.37 

$38.99 

$45.87 

$148.75 

$42.75 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$43.92 

$45.27 

$44.63 

$38.10 

$58.08 

$52.65 

$80.72 

N/A 

$58.58 

$58.08 

$45.35 

$46.15 

$44.63 

$38.06 

$58.08 

$58.08 

$61.18 

$230.91 

$83.36 

$58.08 

$51.15 

$46.75 

$44.63 

$60.46 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$25.89 

$19.58 

$18.73 

$20.48 

$16.98 

$25.89 

$25.42 

$34.76 

$20.48 

$26.11 

$25.89 

$19.42 

$18.73 

$20.48 

$16.96 

$25.89 

$25.89 

$47.00 

$135.18 

$30.00 

$25.89 

$24.17 

$18.73 

$20.48 

$21.56 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$17.88 

$16.16 

$15.36 

$15.51 

$23.64 

$20.52 

$31.68 

$15.36 

$23.84 

$23.64 

$8.27 

$16.16 

$15.36 

$15.49 

$23.64 

$23.64 

$62.00 

$65.70 

$27.67 

$23.64 

$22.08 

$16.16 

$15.36 

$22.08 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.94 

$8.28 

$7.67 

$5.03 

$7.17 

$10.94 

$10.74 

$14.66 

$7.13 

$10.86 

$10.93 

$4.96 

$11.52 

$10.56 

$8.12 

$10.94 

$10.94 

$22.45 

$34.38 

$15.71 

$10.94 

$10.22 

$7.67 

$11.73 

$12.00 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.30 

$4.00 

$4.38 

$5.12 

$3.63 

$5.53 

$4.59 

$7.41 

$6.18 

$5.58 

$5.53 

$3.64 

$5.66 

$6.15 

$5.53 

$5.53 

$5.53 

$12.63 

$17.57 

$6.46 

$5.53 

$3.85 

$4.38 

$6.08 

$6.00 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$8.59 

$26.16 

$9.59 

$10.13 

$11.36 

$5.98 

$20.00 

$12.38 

$12.43 

$11.36 

$4.42 

$21.38 

$10.45 

$7.45 

$11.36 

$11.36 

$18.11 

$31.50 

$16.31 

$9.84/$11.36 

$9.77 

$24.50 

$10.45 

$9.11 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 33 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

MS MT NC ND NE 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.91 

$10.91 

$17.35 

$32.00 

$31.00 

$11.91 

$11.91 

$21.23 

$24.84 

$18.18 

$11.28 

$10.19 

$12.55 

$7.56 

$7.28 

$11.91 

$12.12 

$52.11 

$21.29 

$25.86 

$11.91 

$11.91 

$18.01 

$25.82 

$20.60 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.87 

$13.63 

$21.69 

$25.00 

$47.00 

$14.87 

$14.86 

$29.32 

$31.02 

$22.71 

$11.89 

$10.74 

$12.98 

$6.19 

$5.35 

$14.87 

$15.14 

$35.18 

$36.90 

$32.31 

$14.87 

$14.87 

$22.17 

$28.80 

$25.74 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.85 

$17.27 

$19.00 

$21.00 

$42.00 

$18.85 

$18.85 

$43.50 

$32.97 

$28.79 

$18.85 

$17.04 

$18.72 

$8.20 

$8.48 

$17.17 

$17.48 

$81.08 

$46.85 

$37.30 

$18.85 

$18.85 

$27.62 

$34.00 

$32.62 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$4.09 

$11.00 

$11.00 

$10.00 

$4.45 

$4.45 

$11.63 

$9.30 

$6.81 

$4.45 

$4.03 

$3.65 

$4.02 

$6.14 

$4.45 

$4.54 

$25.91 

$13.85 

$9.69 

$4.45 

$4.45 

$6.33 

$6.80 

$7.72 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$3.29 

$9.00 

$9.00 

$9.88 

$3.60 

$3.60 

$6.00 

$7.68 

$5.49 

$3.60 

$3.25 

$7.65 

$3.65 

$5.36 

$3.60 

$3.66 

$9.11 

$11.00 

$7.81 

$3.60 

$3.60 

$5.78 

$7.80 

$6.42 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$2.90 

$6.45 

$9.11 

$7.68 

$3.16 

$3.16 

$9.11 

$4.40 

$4.83 

$3.16 

$2.86 

$4.86 

$3.65 

$4.71 

$3.16 

$3.22 

N/A 

$8.10 

$6.87 

$3.16 

$3.16 

$5.20 

$6.86 

$5.67 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$38.16 

$90.00 

$93.00 

$85.00 

$41.66 

$41.65 

$105.00 

$80.23 

$63.60 

$41.66 

$37.64 

$41.36 

$57.73 

$18.61 

$41.66 

$42.40 

N/A 

$107.45 

$100.00 

$41.66 

$41.66 

$58.73 

$83.00 

$72.08 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$6.54 

$5.99 

$7.67 

$16.00 

$14.00 

$7.28 

$7.27 

$16.17 

$16.00 

$11.12 

$7.28 

$6.58 

$7.23 

$10.13 

$4.70 

$7.28 

$7.41 

$16.17 

$19.80 

$15.81 

$7.28 

$7.28 

$6.75 

$13.03 

$12.60 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$19.43 

$26.33 

$47.00 

$45.00 

$21.21 

$21.21 

$33.70 

$34.00 

$32.39 

$21.21 

$19.16 

$21.06 

$23.17 

$9.48 

$21.21 

$21.59 

$45.00 

$53.00 

$46.08 

$21.21 

$21.21 

$31.90 

$31.86 

$36.70 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$17.56 

$15.61 

$37.00 

$41.00 

$19.17 

$19.17 

$46.50 

$16.38 

$29.27 

$19.17 

$17.32 

$20.19 

$16.38 

$8.56 

$19.17 

$19.51 

$46.50 

$19.03 

$41.63 

$19.17 

$19.17 

$22.19 

$40.00 

$33.17 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 34 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

MS MT NC ND NE 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$12.51 

$11.45 

$26.00 

$29.00 

$13.66 

$13.66 

$29.33 

$29.00 

$20.85 

$13.66 

$12.34 

$13.42 

$12.35 

$8.96 

$13.66 

$13.90 

$59.23 

$32.40 

$29.66 

$13.66 

$13.66 

$21.84 

$25.00 

$23.63 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$8.35 

$16.25 

$13.47 

$19.00 

$6.10 

$6.10 

N/A 

$5.12 

$9.32 

$9.12 

$8.24 

$9.60 

$5.12 

$4.07 

$9.12 

$9.28 

$18.00 

$21.60 

$19.81 

$9.12 

$9.12 

$8.15 

$5.12 

$15.78 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$11.27 

$31.00 

$12.28 

$28.00 

$7.63 

$7.63 

N/A 

$12.28 

$11.66 

$12.30 

$11.11 

$12.95 

$12.21 

$5.49 

$12.30 

$12.52 

$17.70 

$12.21 

$26.72 

$12.30 

$12.31 

$14.23 

$12.28 

$21.28 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.77 

$43.76 

$50.32 

$117.99 

$42.75 

$47.77 

$47.77 

N/A 

N/A 

$72.93 

$47.77 

$43.16 

$56.00 

$66.53 

$42.75 

$47.77 

$48.62 

N/A 

N/A 

$105.83 

$47.77 

$47.77 

N/A 

$98.86 

$82.65 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$53.21 

$45.27 

$136.00 

$139.00 

$58.08 

$58.08 

N/A 

N/A 

$88.68 

$58.08 

$52.48 

$61.18 

$43.25 

$31.72 

$58.08 

$59.12 

N/A 

N/A 

$128.68 

$58.08 

$58.08 

$51.90 

$126.03 

$100.50 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$22.12 

$20.26 

$21.85 

$49.00 

$50.00 

$25.89 

$25.89 

$38.25 

$45.00 

$39.51 

$25.89 

$23.39 

$25.70 

$20.48 

$12.36 

$25.89 

$26.34 

$80.80 

$59.40 

$56.21 

$25.89 

$25.89 

$39.19 

$47.06 

$44.78 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$22.89 

$20.97 

$22.43 

$47.00 

$46.00 

$23.64 

$23.64 

$52.50 

$51.00 

$36.09 

$22.93 

$20.72 

$24.90 

$15.36 

$10.32 

$23.64 

$24.06 

$52.50 

$61.15 

$51.35 

$23.64 

$23.64 

$26.91 

$38.73 

$40.90 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.94 

$10.03 

$21.00 

$25.00 

$21.00 

$10.94 

$10.93 

$18.71 

$22.81 

$16.71 

$10.94 

$9.88 

$11.52 

$10.29 

$9.68 

$10.94 

$11.14 

$22.45 

$31.05 

$23.77 

$6.54 

$6.54 

$17.42 

$14.19 

$11.32 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$5.06 

$13.00 

$13.00 

$14.00 

$5.53 

$5.53 

$8.78 

$8.90 

$8.43 

$5.53 

$5.00 

$6.76 

$5.43 

$5.62 

$5.53 

$5.62 

$48.88 

$15.30 

$11.99 

$5.53 

$5.53 

$9.24 

$11.97 

$9.55 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$10.41 

$21.00 

$21.00 

$23.00 

$11.36 

$11.35 

$28.00 

$11.28 

$17.36 

$11.36 

$10.26 

$19.06 

$8.46 

$10.15 

$11.36 

$11.57 

$25.28 

$86.45 

$24.69 

$11.36 

$11.36 

$16.41 

$20.00 

$19.67 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 35 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

NH NJ NM NV NY 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.91 

$7.27 

$9.23 

$4.98 

$12.69 

$11.91 

$9.53 

$9.30 

$4.98 

$10.00 

$11.91 

$11.91 

$10.10 

$25.16 

$8.31 

$11.91 

$5.92 

$9.41 

$4.98 

$5.68 

$8.99/$11.28 

$7.25 

$9.58 

$4.98 

$6.85 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.87 

$9.08 

$11.12 

$6.19 

$16.50 

$13.45 

$10.76 

$11.12 

$6.19 

$11.30 

$14.87 

$14.87 

$11.12 

$31.41 

$15.14 

$14.87 

$7.39 

$11.12 

$6.19 

$8.85 

$13.45/$14.87 

$10.00 

$11.56 

$6.19 

$8.48 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.85 

$11.51 

$13.18 

$8.20 

$19.43 

$18.85 

$15.08 

$13.18 

$8.20 

$16.12 

$17.27 

$17.27 

$13.18 

$36.49 

$14.59 

$18.85 

$9.36 

$13.18 

$8.20 

$11.21 

$18.85 

$6.04 

$13.69 

$8.20 

$11.74 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$2.72 

$2.64 

$5.27 

$4.27 

$4.45 

$3.56 

$2.64 

$3.80 

$3.74 

$4.45 

$4.45 

$4.76 

$9.40 

$3.77 

$4.45 

$2.22 

$2.64 

$3.80 

$2.65 

$4.45 

$4.00 

$2.64 

$3.80 

$2.78 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$2.20 

$5.52 

$4.03 

$3.57 

$3.60 

$2.88 

$4.00 

$3.74 

$3.21 

$3.60 

$3.60 

$5.36 

$7.61 

$3.66 

$3.60 

$1.79 

$2.50 

$2.66 

$1.67 

$3.60 

$2.00 

$5.00 

$9.96 

$2.52 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$2.51 

$1.53 

$3.49 

$2.85 

$2.40 

$3.16 

$2.53 

$2.11 

$2.85 

$2.70 

$3.16 

$3.16 

$2.19 

$6.09 

$3.22 

$3.16 

$1.58 

$2.11 

$2.85 

$1.50 

$3.16 

$2.00 

$2.20 

$3.61 

$2.51 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$25.44 

$34.86 

$57.73 

$46.21 

$41.66 

$33.33 

$34.86 

$57.73 

$34.99 

$41.66 

$41.66 

$34.86 

$87.96 

$29.09 

$41.24 

$20.47 

$43.88 

$57.73 

$19.38 

$40.85/$41.66 

$36.60 

$34.86 

$57.73 

$25.93 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$7.28 

$4.45 

$5.79 

$13.03 

$6.97 

$7.28 

$5.82 

$5.79 

$13.03 

$6.22 

$7.07 

$7.07 

$6.02 

$14.92 

$4.94 

$7.28 

$3.62 

$5.79 

$13.03 

$4.33 

$6.15/$7.28 

$5.03 

$5.79 

$13.03 

$4.54 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$16.89 

$10.31 

$16.03 

$19.71 

$15.69 

$21.21 

$16.97 

$16.65 

$19.71 

$17.82 

$21.21 

$21.21 

$16.03 

$44.78 

$14.81 

$21.21 

$10.53 

$16.03 

$19.71 

$12.62 

$20.67/$21.21 

$12.50 

$16.03 

$19.71 

$13.21 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$11.71 

$15.03 

$16.38 

$14.20 

$19.17 

$15.34 

$15.07 

$16.38 

$16.10 

$19.17 

$19.17 

$20.93 

$40.48 

$13.38 

$19.17 

$9.52 

$15.03 

$16.38 

$11.40 

$19.17 

$14.75 

$15.34 

$16.38 

$11.93 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 36 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

NH NJ NM NV NY 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$8.34 

$11.02 

$12.35 

$14.20 

$13.66 

$10.93 

$11.02 

$12.35 

$11.47 

$13.66 

$13.66 

$11.02 

$17.00 

$11.54 

$13.66 

$6.79 

$11.02 

$12.35 

$8.12 

$13.66 

$10.64 

$11.45 

$12.35 

$8.50 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$5.57 

$7.51 

$5.12 

$9.24 

$9.12 

$7.30 

$7.51 

$5.12 

$6.50 

$9.12 

$9.12 

$8.40 

$19.24 

$6.37 

$8.02 

$3.99 

$7.51 

$5.12 

$5.42 

$9.12 

$5.03 

$7.51 

$5.12 

$5.68 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$7.51 

$9.57 

$12.13 

$8.76 

$12.30 

$9.84 

$9.81 

$12.28 

$10.33 

$12.30 

$12.30 

$9.57 

$31.45 

$8.59 

$9.85 

$4.89 

$9.57 

$12.28 

$7.32 

$12.30 

$5.03 

$9.95 

$12.28 

$7.66 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.77 

$29.17 

N/A 

N/A 

$52.99 

$47.77 

$38.22 

$47.43 

$149.30 

$42.75 

$47.77 

$47.77 

N/A 

$121.55 

$30.46 

$47.77 

$23.72 

$46.76 

$164.91 

$28.41 

$44.12/$47.77 

$34.07 

$45.87 

$58.38 

$34.03 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$35.47 

$45.27 

$44.63 

$52.83 

$58.08 

$46.46 

$45.27 

$44.63 

$48.79 

$58.08 

$58.08 

$45.27 

$147.90 

$49.07 

$58.08 

$28.84 

$45.27 

$44.63 

$34.54 

$58.08 

$52.32 

$47.03 

$44.63 

$36.16 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$20.43 

$12.47 

$18.03 

$20.48 

$28.31 

$25.89 

$20.71 

$18.03 

$20.48 

$21.75 

$25.89 

$25.89 

$18.03 

$54.65 

$18.07 

$25.89 

$12.86 

$18.03 

$20.48 

$15.39 

$25.89 

$24.35 

$18.73 

$20.48 

$16.11 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$14.44 

$15.55 

$15.36 

$25.85 

$23.64 

$18.91 

$16.16 

$15.36 

$19.86 

$23.64 

$23.64 

$15.55 

$49.90 

$19.97 

$23.64 

$11.74 

$15.55 

$15.36 

$14.06 

$23.64 

$9.00 

$16.16 

$15.36 

$16.08 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.94 

$6.68 

$7.67 

$5.03 

$11.09 

$10.94 

$8.75 

$7.67 

$5.03 

$9.36 

$10.94 

$10.94 

$7.67 

$23.09 

$11.14 

$10.94 

$5.43 

$7.60 

$5.03 

$5.37 

$10.88/$10.94 

$3.17 

$8.60 

$10.97 

$8.06 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$3.37 

$4.38 

$5.65 

$5.59 

$5.53 

$4.42 

$4.38 

$5.12 

$4.72 

$5.53 

$5.53 

$5.74 

$9.35 

$5.62 

$5.53 

$2.75 

$4.22 

$5.12 

$2.68 

$5.53 

$3.91 

$4.38 

$5.56 

$3.47 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.03 

$5.51 

$20.00 

$15.00 

$12.43 

$11.36 

$9.09 

$22.48 

$10.45 

$9.54 

$11.25 

$11.25 

$27.50 

$16.15 

$7.85 

$11.36 

$5.64 

$24.50 

$10.45 

$6.75 

$11.36 

$8.15 

$22.48 

$10.45 

$7.07 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 37 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

OH OK OR PA RI 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.33 

$8.47 

$9.23 

$4.98 

$3.47 

$11.91 

$10.95 

$9.23 

$4.98 

$16.56 

$11.91 

$8.97 

$13.01 

$17.45 

$14.20 

$11.91 

$9.36 

$9.23 

$4.98 

$8.48 

$11.91 

$7.10 

N/A 

$4.98 

$12.36 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.87 

$14.17 

$11.12 

$6.19 

$5.00 

$14.87 

$13.67 

$11.12 

$6.19 

$20.68 

$14.87 

$11.20 

$15.14 

$21.80 

$18.17 

$14.87 

$11.69 

$11.12 

$6.19 

$10.60 

$14.87 

$8.86 

N/A 

$6.19 

$15.44 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$17.89 

$17.04 

$13.18 

$8.20 

$6.02 

$18.85 

$17.33 

$13.69 

$8.20 

$26.21 

$18.85 

$14.20 

$19.30 

$27.63 

$23.03 

$18.85 

$14.00 

$13.18 

$8.20 

$21.62 

$18.85 

$11.23 

N/A 

$8.20 

$19.57 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$4.24 

$2.64 

$3.80 

$3.90 

$4.45 

$4.09 

$4.34 

$2.78 

$6.20 

$4.45 

$3.36 

$9.30 

$6.81 

$5.45 

$4.45 

$4.37 

$2.74 

$3.80 

$3.18 

$4.45 

$2.66 

N/A 

$3.80 

$4.63 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.32 

$3.16 

$2.36 

$2.26 

$2.77 

$3.30 

$3.03 

$3.34 

$2.14 

$4.59 

$3.60 

$2.71 

$5.10 

$5.27 

$4.39 

$3.60 

$3.57 

$4.11 

$4.39 

$2.56 

$3.60 

$2.14 

N/A 

$3.99 

$3.57 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$3.01 

$1.87 

$1.74 

$1.06 

$3.16 

$2.90 

$2.91 

$1.88 

$4.40 

$3.16 

$2.38 

$3.67 

$4.64 

$3.86 

$3.16 

$3.10 

$2.19 

$2.85 

$2.25 

$2.69 

$1.60 

N/A 

$2.85 

$2.67 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$39.68 

$34.86 

$57.73 

$14.00 

$41.66 

$38.29 

$36.21 

$57.73 

$57.90 

$33.77 

$25.43 

$36.21 

$57.73 

$34.37 

$41.66 

$40.91 

$34.86 

$57.73 

$29.68 

$41.66 

$24.82 

N/A 

$57.73 

$43.22 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$7.28 

$6.94 

$5.79 

$6.77 

$2.45 

$7.28 

$6.69 

$5.79 

$6.15 

$10.12 

$7.28 

$5.48 

$7.95 

$12.65 

$7.41 

$7.28 

$7.15 

$5.79 

$13.03 

$5.19 

$7.28 

$4.34 

N/A 

$10.35 

$7.23 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$20.21 

$16.03 

$19.71 

$7.13 

$21.21 

$19.49 

$16.03 

$19.71 

$29.48 

$21.21 

$15.98 

$16.65 

$29.12 

$21.59 

$21.21 

$13.00 

$16.03 

$19.71 

$15.11 

$21.21 

$12.64 

N/A 

$19.71 

$22.01 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$18.27 

$15.03 

$16.38 

$6.44 

$19.17 

$17.62 

$15.03 

$16.38 

$26.64 

$12.31 

$9.27 

$15.03 

$17.88 

$12.53 

$19.17 

$12.00 

$15.61 

$16.38 

$13.66 

$19.17 

$11.42 

N/A 

$29.19 

$19.89 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 38 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

OH OK OR PA RI 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$13.02 

$11.02 

$12.35 

$9.00 

$12.16 

$11.18 

$11.02 

$12.35 

$16.91 

$13.66 

$10.29 

$13.05 

$20.02 

$16.68 

$13.66 

$7.00 

$11.02 

$12.35 

$9.73 

$12.31 

$7.33 

N/A 

$12.35 

$12.77 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$8.68 

$7.51 

$5.12 

$3.06 

$7.84 

$7.21 

$7.51 

$5.12 

$10.89 

$9.12 

$6.87 

$7.80 

$9.12 

$9.28 

$9.12 

$8.45 

$7.80 

$5.12 

$6.50 

$9.12 

$5.43 

N/A 

$10.06 

$9.46 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$11.72 

$9.57 

$12.28 

$4.13 

$12.30 

$11.31 

$9.57 

$12.28 

$18.32 

$12.30 

$9.26 

$9.95 

$12.28 

$12.52 

$12.30 

$5.00 

$9.95 

$12.28 

$8.76 

$12.30 

$7.33 

N/A 

$16.14 

$12.77 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.77 

$46.01 

$45.87 

$65.55 

$16.06 

$47.77 

$43.91 

$45.87 

$142.00 

$57.00 

$47.77 

$35.98 

$56.92 

$140.28 

$48.62 

$47.77 

$37.94 

$45.87 

$156.60 

$34.03 

$47.77 

$28.46 

N/A 

N/A 

$47.43 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$57.04 

$45.27 

$44.63 

$19.53 

$58.08 

$53.38 

$45.27 

$40.99 

$80.74 

$58.08 

$43.75 

$47.03 

$44.63 

$59.12 

$58.08 

$42.50 

$47.03 

$44.63 

$41.38 

$58.08 

$34.60 

N/A 

N/A 

$60.27 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$25.89 

$24.66 

$18.03 

$20.48 

$8.70 

$25.89 

$23.80 

$18.03 

$20.48 

$35.98 

$25.89 

$19.49 

$27.26 

$37.08 

$26.34 

$25.89 

$24.36 

$18.03 

$20.48 

$18.44 

$25.80 

$15.37 

N/A 

$20.48 

$26.77 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$22.51 

$15.55 

$15.36 

$7.95 

$23.64 

$21.73 

$15.65 

$15.36 

$32.86 

$23.64 

$17.80 

$24.90 

$33.68 

$28.16 

$23.64 

$23.21 

$15.55 

$15.36 

$16.84 

$23.64 

$14.08 

N/A 

$15.36 

$24.53 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.94 

$10.42 

$7.38 

$5.03 

$3.68 

$10.94 

$10.06 

$7.38 

$5.03 

$15.20 

$10.94 

$8.24 

$11.95 

$16.04 

$13.37 

$10.94 

$6.00 

$7.67 

$5.03 

$7.80 

$10.94 

$6.52 

N/A 

$8.19 

$11.35 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$5.27 

$4.22 

$4.11 

$5.13 

$5.53 

$5.08 

$4.22 

$5.12 

$7.69 

$5.53 

$4.16 

$6.04 

$8.09 

$6.74 

$5.53 

$4.00 

$4.22 

$5.12 

$3.93 

$5.53 

$3.29 

N/A 

$5.12 

$5.74 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$10.83 

$10.80 

$8.46 

$10.16 

$11.36 

$10.44 

$24.50 

$9.59 

$15.79 

$11.36 

$8.56 

$14.00 

$10.45 

$11.57 

$11.36 

$8.00 

$24.50 

$10.45 

$8.10 

$7.34 

$4.37 

N/A 

$12.38 

$7.61 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 39 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

SC SD TN TX UT 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.91 

$10.63 

$11.83 

$7.56 

$10.00 

$11.91 

$11.70 

$13.01 

$30.40 

$14.50 

$9.71 

N/A 

$9.70 

$19.08 

$9.88 

$11.91 

$11.64 

$9.58 

$8.49 

$5.50 

$11.91 

$7.20 

$9.58 

$5.19 

$12.12 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.45 

$12.01 

$11.56 

$6.19 

$10.52 

$14.87 

$14.61 

$20.68 

$28.80 

$18.00 

$12.13 

N/A 

$11.56 

$20.49 

$12.35 

$14.87 

$14.53 

$11.56 

$6.19 

$8.80 

$14.87 

$8.99 

$11.56 

$6.19 

$15.14 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.79 

$12.31 

$13.69 

$8.20 

$14.98 

$18.85 

$18.51 

$26.21 

$48.45 

$23.00 

$18.85 

N/A 

$13.69 

$29.00 

$19.19 

$18.85 

$18.42 

$13.69 

$8.20 

$11.15 

$18.85 

$18.97 

$13.69 

$8.20 

$19.19 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.44 

$3.96 

$2.74 

$4.52 

$5.00 

$4.45 

$4.37 

$14.73 

$20.70 

$5.50 

$4.45 

N/A 

$6.96 

$10.93 

$4.54 

$4.45 

$4.36 

$2.74 

$3.99 

$3.36 

$4.45 

$4.30 

$3.58 

$2.78 

$4.54 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$3.22 

$4.46 

$3.57 

$5.50 

$3.60 

$3.54 

$4.49 

$6.07 

$4.50 

$3.60 

N/A 

$6.73 

$9.15 

$3.66 

$3.60 

$3.51 

$4.39 

$4.50 

$2.38 

$3.60 

$3.48 

$2.75 

$2.24 

$3.66 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$2.82 

$3.14 

$3.47 

$3.00 

$3.16 

$3.10 

$4.50 

$8.32 

$4.00 

$3.16 

N/A 

$4.94 

$6.20 

$3.22 

$3.16 

$3.09 

$3.00 

$3.14 

$2.09 

$3.16 

$3.06 

$2.42 

$1.97 

$3.22 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$37.17 

$36.21 

$58.01 

$30.00 

$41.66 

$40.91 

$43.88 

$93.93 

$51.00 

$41.66 

N/A 

$36.21 

$59.50 

$29.68 

$38.24 

$37.36 

$36.21 

$57.73 

$22.96 

$41.66 

$40.37 

$34.86 

$57.73 

$42.40 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$7.28 

$6.50 

$6.02 

$10.14 

$6.28 

$7.28 

$7.15 

$7.55 

N/A 

$9.00 

$7.28 

N/A 

$6.15 

$14.30 

$7.41 

$7.28 

$7.11 

$6.02 

$13.03 

$4.31 

$5.78 

$4.63 

$6.02 

$10.85 

$5.88 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$18.93 

$16.03 

$20.00 

$20.00 

$21.21 

$20.83 

$69.97 

$47.70 

$26.00 

$21.21 

N/A 

$16.65 

$28.00 

$21.59 

$21.21 

$20.73 

$16.65 

$19.71 

$12.55 

$21.21 

$20.55 

$16.03 

$19.71 

$21.59 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$17.11 

$15.03 

$16.38 

$9.50 

$19.17 

$18.83 

$31.43 

$21.24 

$23.00 

$19.17 

N/A 

$20.19 

$30.00 

$19.51 

$19.17 

$18.73 

$15.61 

$16.38 

$11.34 

$19.17 

$18.59 

$15.07 

$16.38 

$19.51 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 40 
 

 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

SC SD TN TX UT 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$12.19 

$11.45 

$12.35 

$12.00 

$13.10 

$12.18 

$20.25 

$34.20 

$16.00 

$13.66 

N/A 

$11.45 

$22.81 

$13.90 

$13.66 

$13.34 

$11.45 

$12.35 

$8.08 

$13.66 

$13.23 

$11.02 

$5.95 

$13.90 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$8.14 

$7.51 

$5.12 

$4.35 

$8.73 

$8.12 

$9.00 

$17.10 

$10.50 

$9.12 

N/A 

$7.80 

$14.00 

$9.12 

$9.12 

$8.91 

$7.80 

$5.12 

$5.48 

$9.12 

$7.86 

$7.51 

$5.12 

$9.28 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$10.98 

$9.57 

$12.28 

$5.49 

$12.02 

$11.18 

$8.85 

$26.60 

$14.50 

$12.30 

N/A 

$10.38 

$20.00 

$8.76 

$12.30 

$12.02 

$9.95 

$12.28 

$7.39 

$12.30 

$12.60 

$9.95 

$10.38 

$12.52 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.77 

$42.62 

$45.87 

$44.45 

$42.75 

$47.77 

$47.43 

N/A 

$92.49 

$58.00 

$47.77 

N/A 

$51.00 

$98.00 

$42.75 

$47.77 

$46.68 

$45.87 

$142.00 

$5.50 

$47.77 

N/A 

$47.65 

N/A 

$48.62 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$51.83 

$45.27 

$44.63 

$37.49 

$58.08 

$57.04 

$40.44 

$117.00 

$71.00 

$58.08 

N/A 

$46.15 

$70.80 

$41.38 

$58.08 

$56.76 

$47.03 

$44.63 

$34.35 

$58.08 

$56.29 

$45.27 

$25.31 

$59.12 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$25.89 

$23.09 

$18.73 

$20.48 

$30.00 

$25.89 

$25.42 

$35.98 

$56.79 

$32.00 

$25.89 

N/A 

$18.73 

$43.45 

$26.34 

$25.89 

$25.29 

$18.73 

$20.48 

$15.54 

$25.89 

$25.70 

$18.73 

$20.48 

$26.34 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$21.10 

$16.16 

$15.36 

$15.03 

$23.64 

$23.21 

$32.86 

$48.60 

$29.00 

$23.64 

N/A 

$16.16 

$36.00 

$24.06 

$23.64 

$23.10 

$16.16 

$15.36 

$13.98 

$23.64 

$22.91 

$15.86 

$15.36 

$24.06 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.43 

$9.31 

$10.36 

$10.36 

$9.77 

$10.94 

$10.74 

$17.40 

$26.08 

$13.50 

$10.94 

N/A 

$17.11 

$21.48 

$11.14 

$10.94 

$10.69 

$9.77 

$9.77 

$6.57 

$7.44 

$6.66 

$7.38 

$4.77 

$7.57 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$4.94 

$5.49 

$5.49 

$6.00 

$5.53 

$5.43 

$7.69 

$23.63 

$6.50 

$5.53 

N/A 

$8.44 

$9.33 

$5.62 

$5.53 

$5.40 

$5.66 

$6.00 

$5.50 

$5.53 

$5.37 

$4.34 

$3.44 

$5.62 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$10.14 

$24.50 

$10.45 

$10.04 

$11.36 

$11.16 

$11.95 

$28.05 

$14.00 

$11.36 

N/A 

$24.50 

$10.45 

$10.04 

$11.36 

$11.11 

$24.50 

$10.45 

$6.72 

$11.36 

$9.22 

$16.50 

$9.59 

$11.57 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 41 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

VA VT WA WI WV WY 

80048 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.91 

$11.12 

$9.23 

$4.98 

$9.30 

$11.91 

$19.17 

N/A 

N/A 

$17.90 

$8.99 

$6.95 

$11.07 

$8.93 

$8.54 

$11.91 

$11.82 

$74.80 

$74.80 

$13.94 

$11.91 

$10.72 

$15.15 

$4.98 

$14.85 

$10.82 

$9.67 

$165.75 

$4.98 

$16.00 

80053 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.87 

$13.88 

$11.12 

$6.19 

$9.76 

$14.87 

$14.46 

$10.34 

$11.25 

$23.97 

$12.01 

$9.29 

$13.11 

$11.92 

$11.92 

$14.87 

$14.77 

$58.20 

$56.25 

$17.41 

$14.87 

$13.38 

$14.38 

$6.19 

$18.45 

$14.87 

$13.29 

$15.14 

$6.19 

$30.00 

80061 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.85 

$17.58 

$13.18 

$8.20 

$12.36 

$15.45 

$14.99 

$10.74 

$14.35 

$29.33 

$18.85 

$14.58 

$18.72 

$18.72 

$18.85 

$18.85 

$18.70 

$74.46 

$99.45 

$30.32 

$18.85 

$16.97 

$13.69 

$8.20 

$29.25 

$15.67 

$14.00 

$19.51 

$8.20 

$32.00 

81001 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$4.45 

$3.76 

$2.66 

$3.80 

$3.50 

$4.45 

$4.27 

$19.74 

N/A 

$8.85 

$4.45 

$3.45 

$4.70 

$4.63 

$4.43 

$4.45 

$4.41 

$28.05 

$32.20 

$5.22 

$4.45 

$4.01 

$4.43 

$3.80 

$5.40 

$3.60 

$3.24 

$3.66 

$5.54 

$8.00 

81002 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.60 

$3.36 

$2.14 

$2.14 

$3.15 

$2.51 

$2.44 

$3.38 

$3.93 

$6.85 

$3.60 

$2.78 

$6.00 

$3.57 

$3.60 

$3.60 

$3.57 

$7.65 

$13.80 

$4.03 

$3.31 

$2.98 

$3.29 

$6.11 

$4.50 

$2.89 

$2.58 

$17.10 

$10.00 

$10.00 

81003 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$3.16 

$2.95 

$2.19 

$2.67 

$2.70 

$2.49 

$2.35 

$6.40 

N/A 

$6.80 

$3.16 

$2.45 

$3.77 

$3.18 

$3.16 

$3.16 

$3.13 

$9.72 

$23.80 

$3.84 

$3.16 

$2.84 

$3.33 

$5.74 

$4.05 

$2.89 

$2.60 

$2.53 

$11.32 

$4.00 

82306 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$41.66 

$35.67 

$34.86 

$57.73 

$18.61 

$41.66 

$40.52 

N/A 

$57.73 

$46.21 

$41.66 

$32.22 

$36.88 

$57.00 

$39.58 

$41.66 

$41.32 

$36.21 

$105.45 

$42.40 

$41.66 

$37.49 

$43.88 

$57.73 

$51.75 

$41.66 

$37.22 

N/A 

$57.73 

$53.00 

82570 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$7.28 

$6.79 

$5.79 

$6.15 

$5.70 

$7.28 

$7.06 

$6.47 

$7.67 

$8.22 

$7.28 

$5.63 

$8.50 

$10.13 

$6.92 

$7.28 

$7.22 

$10.85 

$25.30 

$8.87 

$7.28 

$6.55 

$6.02 

$13.03 

$9.00 

$7.28 

$6.51 

$6.02 

N/A 

$9.10 

82607 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$21.21 

$19.79 

$16.65 

$19.71 

$9.48 

$14.67 

$14.21 

$16.03 

$19.71 

$22.03 

$21.21 

$16.41 

$21.59 

$21.06 

$20.15 

$21.21 

$21.04 

$19.58 

$71.60 

$23.75 

$21.21 

$19.09 

$21.06 

$19.71 

$26.10 

$16.09 

$14.38 

$81.00 

N/A 

$21.59 

82728 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.17 

$17.89 

$15.61 

$16.38 

$12.57 

$19.17 

$18.65 

N/A 

N/A 

$25.03 

$19.17 

$14.83 

$20.19 

$19.03 

$18.21 

$19.17 

$19.02 

$52.57 

$140.60 

$42.86 

$19.17 

$17.25 

$19.17 

$21.79 

$23.85 

$19.17 

$17.13 

$19.86 

$16.20 

$29.27 

continued on next page 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 42 
 

Medicare CLFS, State Medicaid Program Fee Schedule, and 

FEHB Program Median Payment Rates for Selected Laboratory 

Test Codes (Continued) 

HCPCS 

Code Insurer State 

VA VT WA WI WV WY 

83036 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$13.66 

$12.75 

$11.02 

$12.35 

$10.50 

$13.66 

$13.25 

$11.02 

$35.00 

$20.53 

$13.66 

$10.56 

$14.00 

$13.56 

$13.66 

$13.66 

$13.55 

$32.73 

$63.75 

$16.63 

$13.66 

$12.29 

$13.80 

$12.35 

$17.10 

$10.69 

$9.55 

$12.38 

$12.35 

$18.00 

83540 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.12 

$8.50 

$7.80 

$5.12 

$5.97 

$9.12 

$8.80 

N/A 

N/A 

$13.69 

$9.12 

$7.05 

$7.80 

$9.05 

$8.66 

$9.12 

$9.04 

$24.00 

$37.96 

$10.67 

$9.12 

$8.21 

$8.97 

$5.12 

$11.25 

$9.12 

$8.15 

N/A 

$2.10 

$9.32 

83550 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.30 

$11.48 

$9.95 

$10.38 

$8.06 

$12.30 

$11.94 

N/A 

N/A 

$18.48 

$12.30 

$9.52 

$9.95 

$12.28 

$11.69 

$12.30 

$12.20 

$28.50 

$57.00 

$14.40 

$12.30 

$11.07 

$12.30 

$16.00 

$15.30 

$12.30 

$10.99 

N/A 

$9.45 

$15.38 

83880 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.77 

$45.06 

$45.87 

$87.73 

$42.75 

$47.77 

$26.14 

N/A 

N/A 

N/A 

$47.77 

$36.95 

$67.55 

$49.56 

$45.38 

$47.77 

$47.43 

$180.24 

$122.88 

$52.29 

$47.77 

$42.99 

$50.32 

$176.80 

$44.03 

$47.77 

$42.69 

N/A 

N/A 

$36.00 

83970 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$58.08 

$54.19 

$61.18 

$44.63 

$31.72 

$58.08 

$56.47 

N/A 

N/A 

$87.27 

$58.08 

$44.93 

$66.35 

$57.67 

$55.18 

$58.08 

$57.61 

$49.47 

$263.15 

$59.12 

$58.08 

$52.27 

$58.08 

$95.00 

$72.00 

$58.08 

$51.90 

N/A 

$44.63 

$73.90 

84153 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$25.89 

$23.28 

$18.03 

$20.48 

$16.98 

$25.89 

$20.92 

N/A 

$28.79 

$38.89 

$25.89 

$20.02 

$27.26 

$25.70 

$24.60 

$25.89 

$25.67 

$77.52 

$114.75 

$39.51 

$25.89 

$23.30 

$18.73 

$20.48 

$31.95 

$25.89 

$23.13 

$26.34 

$54.00 

$40.00 

84443 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.64 

$22.05 

$16.16 

$15.36 

$15.51 

$23.64 

$22.92 

$26.97 

$26.39 

$29.34 

$23.56 

$18.22 

$24.90 

$21.81 

$22.38 

$23.64 

$23.44 

$93.50 

$105.40 

$28.78 

$23.64 

$21.28 

$21.93 

$15.36 

$29.25 

$23.09 

$20.64 

$28.75 

$15.36 

$36.09 

85025 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$10.94 

$10.00 

$7.67 

$5.03 

$8.50 

$10.94 

$10.63 

$7.60 

$10.86 

$16.43 

$10.94 

$8.47 

$12.10 

$10.86 

$10.94 

$10.94 

$10.85 

$52.70 

$60.35 

$12.81 

$10.94 

$9.85 

$11.19 

$5.03 

$13.50 

$10.94 

$9.85 

$13.62 

$18.78 

$24.00 

85610 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.53 

$5.16 

$4.22 

$4.67 

$4.95 

$5.53 

$5.32 

$7.18 

$22.53 

$8.30 

$5.53 

$4.27 

$5.93 

$6.00 

$5.53 

$5.53 

$5.48 

$25.22 

$57.00 

$6.46 

$5.53 

$4.98 

$5.49 

$8.15 

$6.75 

$4.47 

$4.00 

$18.22 

$17.76 

$8.00 

87086 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$11.36 

$9.50 

$26.16 

$9.59 

$10.13 

$8.12 

$7.84 

$28.56 

N/A 

$12.19 

$11.36 

$8.79 

$20.70 

$11.28 

$10.79 

$11.36 

$11.27 

$59.50 

$58.50 

$13.31 

$11.36 

$10.22 

$12.49 

$10.45 

$13.95 

$5.29 

$4.76 

$8.68 

$10.45 

$8.25 

Source: Office of Inspector General analysis of Medicare CLFS, State Medicaid Program, and FEHB plan payment rates, 2012. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 43 
 

 

 

APPENDIX D 

Potential Savings to Medicare 

HCPCS* 

Code26 Description 

2011 

Number of 

Allowed 

Tests 

2011 

MedicareAllowed 

Amount 

Number 

of Tests 

With 

Potential 

for 

Savings 

Amount of 

Potential 

Savings to 

Medicare 

Percentage 

Savings to 

Medicare 

80048 Metabolic panel, total 

calcium 8,870,790 $87,715,544 7,537,056 $36,412,622 42% 

80053 Comprehensive 

metabolic panel 27,406,336 $315,878,919 24,785,107 $130,632,849 41% 

80061 Lipid panel 20,620,917 $300,263,670 18,497,996 $125,993,031 42% 

81001 Urinalysis, automated, 

with microscopy 6,804,619 $30,263,393 6,406,217 $9,801,294 32% 

81002 

Urinalysis, 

nonautomated, 

without microscopy

 4,312,499 $15,380,015 4,045,779 $4,427,415 29% 

81003 Urinalysis, automated, 

without microscopy 5,078,609 $16,012,775 4,673,129 $4,383,224 27% 

82306 Vitamin D, 25 hydroxy 5,394,421 $221,597,882 5,343,831 $87,398,016 39% 

82570 Assay of urine 

creatinine 4,649,643 $33,541,369 4,616,456 $10,457,972 31% 

82607 Vitamin B-12 3,363,543 $71,298,574 3,329,444 $25,252,596 35% 

82728 Assay of ferritin 2,401,360 $45,904,070 2,309,044 $15,613,616 34% 

83036 Glycosylated 

hemoglobin test 12,678,817 $172,653,909 12,377,783 $51,406,983 30% 

83540 Assay of iron 2,625,017 $23,249,999 2,511,258 $10,256,188 44% 

83550 Iron binding test 2,043,112 $24,606,097 2,020,049 $9,228,580 38% 

83880 Natriuretic peptide 1,079,558 $50,927,315 1,054,424 $15,970,434 31% 

83970 Assay of 

parathormone 1,154,872 $67,030,516 1,143,748 $22,934,465 34% 

84153 Assay of prostatespecific antigen, total 3,616,338 $93,492,483 3,545,187 $32,784,887 35% 

84443 Thyroid stimulating 

hormone 14,761,102 $348,014,395 14,465,072 $140,148,947 40% 

*Healthcare Common Procedure Coding System. continued on next page 

26 HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 

when services and procedures involve Medicare beneficiaries (e.g., 70405). The five 

character codes and descriptions included in this report are obtained from Current 

Procedural Terminology (CPT®), copyright 2011 by the American Medical 

Association (AMA). CPT is developed by the AMA as a listing of descriptive terms 

and five character identifying codes and modifiers for reporting medical services 

and procedures. Any use of CPT outside of this report should refer to the most 

current version of the Current Procedural Terminology available from 

AMA. Applicable FARS/DFARS apply. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 44 
 

 

Potential Savings to Medicare (Continued) 

HCPCS 

Code Description 

2011 

Number of 

Allowed 

Tests 

2011 

MedicareAllowed 

Amount 

Number 

of Tests 

With 

Potential 

for 

Savings 

Amount of 

Potential 

Savings to 

Medicare 

Percentage 

Savings to 

Medicare 

85025 

Complete blood count 

with automated 

differential white blood 

cell count

 30,827,609 $333,380,573 29,163,289 $136,848,356 41% 

85610 Prothrombin time 20,291,205 $111,952,080 18,942,447 $24,637,107 22% 

87086 Urine culture colony 

count 4,703,518 $53,236,384 4,642,330 $15,296,087 29%

 Total 182,683,885 $2,416,399,964 171,409,646 $909,884,674 38% 

Dollar amounts are rounded to the nearest $1. 

Source: Centers for Medicare & Medicaid Services, National Claims History Part B Carrier File, 2012.
 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 45 
APPENDIX E 

Agency Comments 

Centers tor Medicare & Medicaid Services 

·--------····--··-­ Administrator 

Washington, DC 20201 

APR 2 6 2013 DATE: 

TO: Daniel R. Levinson 

Inspector General 

FROM: Matil;rn "':avenner 

Actilllg Ad'ministrator 

SUBJECT: Office M' IJY;pector General (DIG) Draft Report: Comparison of Laboratory Test 

Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-I 1-000 I0) 

Thank you for the opportunity to review and comment on this OlG draft report. 1be Centers for 

Medicare & Medicaid Services (CMS) appreciates OIG 's effort to examine the laboratory 

payment rates for different payers. OIG collected payment data from 50 state Medicaid 

programs and three Federal Employees Health Benefits (FE! !B) plans that pay for laboratory 

tests on a fcc-for-service basis. OIG requested the payment rates for 20 laboratory tests and for 

each test compared Medicare paid claims with the state Medicaid program fee schedule amount 

and FEHB plan median claim payment amounts. State Medicaid programs and FEHB plans 

were surveyed to determine how their laboratory test fee schedules or payment rates were 

formulated, whether a copayment was charged to the patient, and whether laboratory test charges 

counted towards a member's deductible. 

The OIG found that in 20 II, Medicare paid between 18 and 30 percent more than other insurers 

for 20 high-volume and/or high-expenditure laboratory tests. State Medicaid programs and 

FEHB plans usc the Medicare clinical laboratory fee schedule as a basis for establishing their 

0\1\>n fee schedules and payment rates, although most pay Jess. However, unlike Medicare, FEHB 

programs incorporate factors such as competitor information, changes in technology used in 

perfom1ing laboratory tests, and provider requests in their payment rates. Some state Medicaid 

programs and FEHB plans required copayments for laboratory tests which, in effect, lowered the 

costs oflaboratory tests for the insurer. CMS's responses to OIG's recommendations arc 

discussed below. 

OJG Recommendation I 

The 010 recommends that CMS seek legislation that would allow CMS to establish lower 

payment rates for lab tests. 

CMS Response 

The CMS appreciates OIG's recommendation and the valuable work reflected in this report. 

CMS is currently exploring whether it has authority under the current statute to revise payment~ 

for clinical diagnostic laboratory services consistent with the OIG's recommendation. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-0001 0) 47 
 

 

Agency Comments (Continued) 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 47 
 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Brian T. Whitley, Acting 

Regional Inspector General for Evaluation and Inspections in the Kansas 

City regional office. 

Tricia Fields served as the team leader for this study. Other Office of 

Evaluation and Inspections staff from the Kansas City regional office who 

conducted the study include Michael P. Barrett and Teresa Dailey. Other 

regional and central office staff who contributed include Kevin Farber, 

Scott Horning, Scott Manley, Brian Pattison, Debra Roush, and Mandy 

Walz. 

Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-00010) 48 
 

Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.