Payer policies › CPT 1726417264 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 17264 Payer coverage policies that name 17264 17264 appears in 6 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Carbon Dioxide Laser (0427) covered if criteria are met (range 17260-17286) Jul 8, 2026 payer document Aetna Cryoablation (0100) listed, no stance (range 17000-17286) Aug 4, 2026 payer document Aetna Dermabrasion, Chemical Peels, and Acne Surgery (0251) listed, no stance (range 17260-17286) Apr 15, 2026 payer document Aetna Interstitial Laser Therapy (0781) listed, no stance (range 17260-17266) Aug 5, 2025 payer document Aetna Pulsed Dye Laser Treatment (0559) covered if criteria are met Sep 18, 2026 payer document Aetna Skin and Soft Tissue Substitutes (0244) not covered (range 10040-19499) Jul 29, 2026 payer document
Medicaid fee-for-service AZ: $71.99 (asc), effective Oct 1, 2026 CO: $169.34 (chp_plus, non-facility), effective Jul 1, 2026 FL: $91.00 (physician, facility), effective Jan 1, 2026 IL: $117.55 (practitioner), effective Jul 1, 2026 IN: $102.13 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $300.00 (asc, facility), effective Aug 1, 1982 KY: $128.44 (asc), effective Jan 1, 2026 LA: $162.84 (professional), effective Jul 1, 2025 MA: $112.28 (asc), effective May 1, 2026 MS: $104.29 (comprehensive, facility), effective Oct 1, 2025 ND: $127.05 (physician, facility), effective Aug 1, 2026 NE: $143.98 (physician, facility), effective Jul 1, 2026 OH: $93.95 (physician, facility), effective Jan 1, 2024 OK: $97.12 (physician, facility), effective Jul 1, 2026 TX: $109.08 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $94.62 (medical, facility), effective Jul 1, 2026 VT: $315.64 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $64.78 (physician, facility), effective Jul 1, 2026 WY: $179.77 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.