Ambetter · PayerPolicy · AMBETTER-CP-MP-107
Summary of the payer’s published policy. Not a coverage determination — confirm with Ambetter before submitting.
Free account. Policy pages stay open to everyone.
Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.
| Code | Code system | Status in this policy |
|---|---|---|
| A6501 | HCPCS | Covered |
| A6502 | HCPCS | Covered |
| A6503 | HCPCS | Covered |
| A6504 | HCPCS | Covered |
| A6505 | HCPCS | Covered |
| A6506 | HCPCS | Covered |
| A6507 | HCPCS | Covered |
| A6508 | HCPCS | Covered |
| A6509 | HCPCS | Covered |
| A6510 | HCPCS | Covered |
| A6511 | HCPCS | Covered |
| A6512 | HCPCS | Covered |
| A6513 | HCPCS | Covered |
| A9900 | HCPCS | Covered |
| E0130 | HCPCS | Covered |
| E0135 | HCPCS | Covered |
| E0141 | HCPCS | Covered |
| E0143 | HCPCS | Covered |
| E0147 | HCPCS | Covered |
| E0148 | HCPCS | Covered |
| E0149 | HCPCS | Covered |
| E0236 | HCPCS | Covered |
| E0240 | HCPCS | Covered |
| E0316 | HCPCS | Covered |
| E0328 | HCPCS | Covered |
| E0329 | HCPCS | Covered |
| E0445 | HCPCS | Covered |
| E0455 | HCPCS | Covered |
| E0465 | HCPCS | Covered |
| E0500 | HCPCS | Covered |
| E0550 | HCPCS | Covered |
| E0574 | HCPCS | Covered |
| E0575 | HCPCS | Covered |
| E0604 | HCPCS | Covered |
| E0616 | HCPCS | Covered |
| E0617 | HCPCS | Covered |
| E0675 | HCPCS | Covered |
| E0678 | HCPCS | Covered |
| E0679 | HCPCS | Covered |
| E0680 | HCPCS | Covered |
| E0681 | HCPCS | Covered |
| E0691 | HCPCS | Covered |
| E0692 | HCPCS | Covered |
| E0693 | HCPCS | Covered |
| E0694 | HCPCS | Covered |
| E0738 | HCPCS | Covered |
| E0739 | HCPCS | Covered |
| E0780 | HCPCS | Covered |
| E0781 | HCPCS | Covered |
| E0782 | HCPCS | Covered |
| E0783 | HCPCS | Covered |
| E0785 | HCPCS | Covered |
| E0786 | HCPCS | Covered |
| E0849 | HCPCS | Covered |
| E1031 | HCPCS | Covered |
| E1037 | HCPCS | Covered |
| E1050 | HCPCS | Covered |
| E1060 | HCPCS | Covered |
| E1070 | HCPCS | Covered |
| E1083 | HCPCS | Covered |
| E1084 | HCPCS | Covered |
| E1085 | HCPCS | Covered |
| E1086 | HCPCS | Covered |
| E1087 | HCPCS | Covered |
| E1088 | HCPCS | Covered |
| E1089 | HCPCS | Covered |
| E1090 | HCPCS | Covered |
| E1091 | HCPCS | Covered |
| E1092 | HCPCS | Covered |
| E1093 | HCPCS | Covered |
| E1100 | HCPCS | Covered |
| E1110 | HCPCS | Covered |
| E1130 | HCPCS | Covered |
| E1140 | HCPCS | Covered |
| E1150 | HCPCS | Covered |
| E1160 | HCPCS | Covered |
| E1170 | HCPCS | Covered |
| E1171 | HCPCS | Covered |
| E1172 | HCPCS | Covered |
| E1180 | HCPCS | Covered |
| E1190 | HCPCS | Covered |
| E1195 | HCPCS | Covered |
| E1200 | HCPCS | Covered |
| E1221 | HCPCS | Covered |
| E1222 | HCPCS | Covered |
| E1223 | HCPCS | Covered |
| E1224 | HCPCS | Covered |
| E1229 | HCPCS | Covered |
| E1231 | HCPCS | Covered |
| E1232 | HCPCS | Covered |
| E1233 | HCPCS | Covered |
| E1234 | HCPCS | Covered |
| E1235 | HCPCS | Covered |
| E1236 | HCPCS | Covered |
| E1237 | HCPCS | Covered |
| E1238 | HCPCS | Covered |
| E1240 | HCPCS | Covered |
| E1250 | HCPCS | Covered |
| E1260 | HCPCS | Covered |
| E1270 | HCPCS | Covered |
| E1280 | HCPCS | Covered |
| E1285 | HCPCS | Covered |
| E1290 | HCPCS | Covered |
| E1295 | HCPCS | Covered |
| E1310 | HCPCS | Covered |
| E1399 | HCPCS | Covered |
| E2000 | HCPCS | Covered |
| E2100 | HCPCS | Covered |
| E2298 | HCPCS | Covered |
| E2300 | HCPCS | Covered |
| IQ | HCPCS | Covered |
| K0009 | HCPCS | Covered |
| K0108 | HCPCS | Covered |
| K0455 | HCPCS | Covered |
| K0606 | HCPCS | Covered |
| K0739 | HCPCS | Covered |
| K1032 | HCPCS | Covered |
| K1033 | HCPCS | Covered |
| L0170 | HCPCS | Covered |
| L0190 | HCPCS | Covered |
| L0200 | HCPCS | Covered |
| L0450 | HCPCS | Covered |
| L0452 | HCPCS | Covered |
| L0454 | HCPCS | Covered |
| L0455 | HCPCS | Covered |
| L0456 | HCPCS | Covered |
| L0457 | HCPCS | Covered |
| L0458 | HCPCS | Covered |
| L0460 | HCPCS | Covered |
| L0462 | HCPCS | Covered |
| L0464 | HCPCS | Covered |
| L0466 | HCPCS | Covered |
| L0467 | HCPCS | Covered |
| L0468 | HCPCS | Covered |
| L0469 | HCPCS | Covered |
| L0470 | HCPCS | Covered |
| L0472 | HCPCS | Covered |
| L0480 | HCPCS | Covered |
| L0482 | HCPCS | Covered |
| L0484 | HCPCS | Covered |
| L0486 | HCPCS | Covered |
| L0488 | HCPCS | Covered |
| L0490 | HCPCS | Covered |
| L0491 | HCPCS | Covered |
| L0492 | HCPCS | Covered |
| L0621 | HCPCS | Covered |
| L0622 | HCPCS | Covered |
| L0623 | HCPCS | Covered |
| L0624 | HCPCS | Covered |
| L0625 | HCPCS | Covered |
| L0626 | HCPCS | Covered |
| L0627 | HCPCS | Covered |
| L0628 | HCPCS | Covered |
| L0629 | HCPCS | Covered |
| L0630 | HCPCS | Covered |
| L0631 | HCPCS | Covered |
| L0632 | HCPCS | Covered |
| L0633 | HCPCS | Covered |
| L0634 | HCPCS | Covered |
| L0635 | HCPCS | Covered |
| L0636 | HCPCS | Covered |
| L0637 | HCPCS | Covered |
| L0638 | HCPCS | Covered |
| L0639 | HCPCS | Covered |
| L0640 | HCPCS | Covered |
| L0643 | HCPCS | Covered |
| L0648 | HCPCS | Covered |
| L0649 | HCPCS | Covered |
| L0650 | HCPCS | Covered |
| L0651 | HCPCS | Covered |
| L0700 | HCPCS | Covered |
| L0710 | HCPCS | Covered |
| L0720 | HCPCS | Covered |
| L0999 | HCPCS | Covered |
| L1000 | HCPCS | Covered |
| L1001 | HCPCS | Covered |
| L1005 | HCPCS | Covered |
| L1006 | HCPCS | Covered |
| L1640 | HCPCS | Covered |
| L1680 | HCPCS | Covered |
| L1685 | HCPCS | Covered |
| L1686 | HCPCS | Covered |
| L1690 | HCPCS | Covered |
| L1700 | HCPCS | Covered |
| L1710 | HCPCS | Covered |
| L1720 | HCPCS | Covered |
| L1730 | HCPCS | Covered |
| L1755 | HCPCS | Covered |
| L1933 | HCPCS | Covered |
| L1952 | HCPCS | Covered |
| L2006 | HCPCS | Covered |
| L2050 | HCPCS | Covered |
| L2060 | HCPCS | Covered |
| L2090 | HCPCS | Covered |
| L2570 | HCPCS | Covered |
| L2580 | HCPCS | Covered |
| L2627 | HCPCS | Covered |
| L2628 | HCPCS | Covered |
| L3000 | HCPCS | Covered |
| L3001 | HCPCS | Covered |
| L3002 | HCPCS | Covered |
| L3003 | HCPCS | Covered |
| L3010 | HCPCS | Covered |
| L3020 | HCPCS | Covered |
| L3030 | HCPCS | Covered |
| L3031 | HCPCS | Covered |
| L3070 | HCPCS | Covered |
| L3080 | HCPCS | Covered |
| L3230 | HCPCS | Covered |
| L3720 | HCPCS | Covered |
| L3730 | HCPCS | Covered |
| L3740 | HCPCS | Covered |
| L3760 | HCPCS | Covered |
| L3900 | HCPCS | Covered |
| L3901 | HCPCS | Covered |
| L3904 | HCPCS | Covered |
| L3960 | HCPCS | Covered |
| L3962 | HCPCS | Covered |
| L3999 | HCPCS | Covered |
| L4000 | HCPCS | Covered |
| L4010 | HCPCS | Covered |
| L4020 | HCPCS | Covered |
| L4030 | HCPCS | Covered |
| L4130 | HCPCS | Covered |
| L4205 | HCPCS | Covered |
| L5827 | HCPCS | Covered |
| L5990 | HCPCS | Covered |
| L6000 | HCPCS | Covered |
| L6010 | HCPCS | Covered |
| L6020 | HCPCS | Covered |
| L6026 | HCPCS | Covered |
| L6028 | HCPCS | Covered |
| L6029 | HCPCS | Covered |
| L6031 | HCPCS | Covered |
| L6032 | HCPCS | Covered |
| L6033 | HCPCS | Covered |
| L6037 | HCPCS | Covered |
| L6050 | HCPCS | Covered |
| L6055 | HCPCS | Covered |
| L6100 | HCPCS | Covered |
| L6110 | HCPCS | Covered |
| L6120 | HCPCS | Covered |
| L6130 | HCPCS | Covered |
| L6200 | HCPCS | Covered |
| L6205 | HCPCS | Covered |
| L6250 | HCPCS | Covered |
| L6300 | HCPCS | Covered |
| L6310 | HCPCS | Covered |
| L6320 | HCPCS | Covered |
| L6350 | HCPCS | Covered |
| L6360 | HCPCS | Covered |
| L6370 | HCPCS | Covered |
| L6380 | HCPCS | Covered |
| L6382 | HCPCS | Covered |
| L6384 | HCPCS | Covered |
| L6386 | HCPCS | Covered |
| L6388 | HCPCS | Covered |
| L6400 | HCPCS | Covered |
| L6450 | HCPCS | Covered |
| L6500 | HCPCS | Covered |
| L6550 | HCPCS | Covered |
| L6570 | HCPCS | Covered |
| L6580 | HCPCS | Covered |
| L6582 | HCPCS | Covered |
| L6584 | HCPCS | Covered |
| L6586 | HCPCS | Covered |
| L6588 | HCPCS | Covered |
| L6590 | HCPCS | Covered |
| L6623 | HCPCS | Covered |
| L6624 | HCPCS | Covered |
| L6625 | HCPCS | Covered |
| L6628 | HCPCS | Covered |
| L6638 | HCPCS | Covered |
| L6646 | HCPCS | Covered |
| L6647 | HCPCS | Covered |
| L6648 | HCPCS | Covered |
| L6689 | HCPCS | Covered |
| L6690 | HCPCS | Covered |
| L6692 | HCPCS | Covered |
| L6693 | HCPCS | Covered |
| L6700 | HCPCS | Covered |
| L6704 | HCPCS | Covered |
| L6707 | HCPCS | Covered |
| L6708 | HCPCS | Covered |
| L6709 | HCPCS | Covered |
| L6711 | HCPCS | Covered |
| L6712 | HCPCS | Covered |
| L6713 | HCPCS | Covered |
| L6714 | HCPCS | Covered |
| L6715 | HCPCS | Covered |
| L6721 | HCPCS | Covered |
| L6722 | HCPCS | Covered |
| L6885 | HCPCS | Covered |
| L6895 | HCPCS | Covered |
| L6900 | HCPCS | Covered |
| L6905 | HCPCS | Covered |
| L6910 | HCPCS | Covered |
| L6915 | HCPCS | Covered |
| L6920 | HCPCS | Covered |
| L6930 | HCPCS | Covered |
| L6940 | HCPCS | Covered |
| L6950 | HCPCS | Covered |
| L6960 | HCPCS | Covered |
| L6965 | HCPCS | Covered |
| L6970 | HCPCS | Covered |
| L6975 | HCPCS | Covered |
| L7040 | HCPCS | Covered |
| L7170 | HCPCS | Covered |
| L7185 | HCPCS | Covered |
| L7186 | HCPCS | Covered |
| L7405 | HCPCS | Covered |
| L7406 | HCPCS | Covered |
| L7499 | HCPCS | Covered |
| L7900 | HCPCS | Covered |
| L7902 | HCPCS | Covered |
| L8030 | HCPCS | Covered |
| L8035 | HCPCS | Covered |
| L8040 | HCPCS | Covered |
| L8041 | HCPCS | Covered |
| L8042 | HCPCS | Covered |
| L8043 | HCPCS | Covered |
| L8044 | HCPCS | Covered |
| L8045 | HCPCS | Covered |
| L8046 | HCPCS | Covered |
| L8047 | HCPCS | Covered |
| L8499 | HCPCS | Covered |
| L8600 | HCPCS | Covered |
| L8609 | HCPCS | Covered |
| L8610 | HCPCS | Covered |
| L8612 | HCPCS | Covered |
| L8615 | HCPCS | Covered |
| L8631 | HCPCS | Covered |
| L8659 | HCPCS | Covered |
| L8701 | HCPCS | Covered |
| L8702 | HCPCS | Covered |
| Q4111 | HCPCS | Covered |
| T2028 | HCPCS | Covered |
| T2029 | HCPCS | Covered |
| T5001 | HCPCS | Covered |