| Test Number | Test Name | CPT Code(s) | BCBS Avalon Policy | Frequency Applies |
|---|---|---|---|---|
| 8700 | VITAMIN D | 82306 | G2005 | YES |
| 2036 | FERRITIN | 82728 | G2011 | |
| 3126 | IRON | 83540 | G2011 | |
| 3128 | IRON BINDING CAPACITY | 83550 | G2011 | |
| 3798 | IRON AND TIBC | 83540, 83550 | G2011 | |
| 3796 | IRON, TIBC, %TRANSFERRIN SATURATION | 83540, 83550 | G2011 | |
| 2048 | TESTOSTERONE TOTAL | 84403 | G2013 | |
| 3042 | ALBUMIN | 82040 | G2013 | |
| 3302 | SEX HORMONE BINDING GLOBULIN (SHBG) | 84270 | G2013 | |
| 3303 | FREE TESTOSTERONE | 84402 | G2013 | |
| 3304 | BIOAVAILABLE & TOTAL TESTO + SHBG | 84403, 84270, 84402 | G2013 | |
| 3309 | TESTOSTERONE FREE AND TOTAL + SHBG | 84403, 84270, 84402 | G2013 | |
| 3306 | TESTOSTERONE FREE BIOAVAILABLE & TOTAL | 84403, 84270, 84402 | G2013 | |
| 8401 | DNA AUTOANTIBODIES, DOUBLESTRANDED(CRITHIDIA) | 86225 | G2022 | |
| 8402 | RNP/SM IGG | 86235 | G2022 | |
| 8403 | SS-A IGG AUTOAB | 86235 | G2022 | |
| 8404 | SS-B IGG AUTOAB | 86235 | G2022 | |
| 8405 | SM (SMITH) IGG AUTOAB | 86235 | G2022 | |
| 8406 | SCL-70 | 86235 | G2022 | |
| 8407 | ANA PROFILE | 86225, 86235 | G2022 | |
| 8408 | JO-1 AUTOAB | 86235 | G2022 | |
| 8416 | SSA/SSB IGG | 86235 | G2022 | |
| 8600 | ANA IFA REFLEX TO PATTERN/TITER | 86038 | G2022 | |
| 8601 | ANA TITER | 86039 | G2022 | |
| 8603 | ANA IFA W/REFLEX TO TITER/PATTERN/PROFILE | 86038 | G2022 | |
| 8604 | ANA TITER/PATTERN BY IFA | 86039 | G2022 | |
| 9100, 9300 AND 9400 SERIES | ALLERGENS (SPECIFIC IGE) | 86003 | G2031 | YES |
| 9415, 9414, 9179 | ALLERGEN COMPONENTS | 86008 | G2031 | YES |
| 2026 | IGE | 82785 | G2031 | |
| 3778 | IMMUNOGLOBULINS | 82784 | G2031 | |
| 9200 | CELIAC TTG IGA | 83516 | G2031 | |
| 9201 | CELIAC TTG IGG | 83516 | G2031 | |
| 9202 | CELIAC DEAMIDATED GLIADIN IGA | 83516 | G2031 | |
| 9203 | CELIAC DEAMIDATED GLIADIN IGG | 83516 | G2031 | |
| 9207 | CELIAC COMPREHENSIVE PROFILE | 82784, 83516 | G2031 | |
| 9208 | CELIAC TTG IGA/ TOTAL IGA PROFILE | 82784, 83516 | G2031 | |
| 8640 | HEPATITIS C ANTIBODY | 86803 | G2036 | YES |
| 2004 | FREE T3 | 84481 | G2045 | |
| 2050 | TSH | 84443 | G2045 | |
| 3075 | FREE T4 (THYROXINE) | 84439 | G2045 | |
| 3076 | T- UPTAKE | 84479 | G2045 | |
| 3078 | T4, TOTAL | 84436 | G2045 | |
| 3081 | T3, TOTAL | 84480 | G2045 | |
| 3083 | THYROID PEROXIDASE ANTIBODY (TPO) | 86376 | G2045 | |
| 3824 | THYROID PANEL (T7) | 84479, 84436 | G2045 | |
| 3825P | THYROID PANEL II (WITH TSH) | 84443, 84479, 84436 | G2045 | |
| 3992 | CRP | 86140 | G2155 | |
| 4098 | SED RATE (WESTERGREN) | 85652 | G2155 | |
| 3024 | CREATININE | 82565 | G2157 | YES |
| 3755P | CREATININE CLEARANCE PANEL | 82575 | G2157 | YES |
| 2038 | HCG QUANTITATIVE | 84702 | G2157 | YES |
| 2028 | HCG QUALITATIVE | 84703 | G2157 | YES |
| 6028 | RPR | 86592 | G2157 | YES |
| 6030 | RPR TITER | 86593 | G2157 | YES |
| 8701 | HSV-1 IgG | 86695 | G2157 | YES |
| 8702 | HSV-2 IgG | 86696 | G2157 | YES |
| 8561 | HEPATITIS B CORE ANTIBODY (IGM) | 86705 | G2157 | YES |
| 8620 | HEPATITIS B SURFACE ANTIBODY | 86706 | G2157 | YES |
| 8703 | SYPHILIS (TREPONEMA PALLIDIUM) ANTIBODY | 86780 | G2157 | YES |
| 8640 | HEPATITIS C ANTIBODY | 86803 | G2157 | YES |
| 8024 | MRSA (MSSA) SCREENING CULTURE | 87081 | G2157 | YES |
| 8240 | GC CULTURE | 87081 | G2157 | YES |
| 8520 | HEPATITIS B SURFACE AG (HBsAg) | 87340 | G2157 | YES |
| 8333 | CHLAMYDIA (AMPLIFIED) | 87491 | G2157 | YES |
| 8400 | CHLAMYDIA AND GONORRHEA AMP. | 87491, 87591 | G2157 | YES |
| 8290 | HSV 1/2 DNA AMPLIFIED | 87529 | G2157 | YES |
| 8335 | GONORRHEA (AMPLIFIED) | 87591 | G2157 | YES |
| NA | PAP and HPV TESTING | 87623, 87624, 87625, 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175, 0500T, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, G0476, P3000, P3001, Q0091 | G2002 | YES |
| 2021 | PSA | 84153 | G2008 | YES |
