39503 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 39503

Medicaid fee-for-service

  • AZ: $5805.36 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025
  • CO: $4452.43 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $6141.83 (pediatric_surgery, pediatric surgeon), effective Jan 1, 2025
  • IL: $4083.95 (practitioner), effective Apr 1, 2024
  • IN: $4255.54 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $2188.75 (default, Exempt Physician), effective Aug 1, 2024
  • KY: $1721.61 (physician, facility), effective Jan 1, 2026
  • LA: $941.26 (professional), effective Jul 1, 2025
  • MA: $4140.57 (physician_surgery), effective May 1, 2024
  • MS: $4492.70 (comprehensive), effective Jul 1, 2026
  • ND: $5420.23 (physician), effective Aug 1, 2026
  • NE: $1630.20 (physician, non-facility), effective Jul 1, 2026
  • NY: $2703.60 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $3315.11 (physician), effective Jan 1, 2024
  • OK: $4733.55 (physician, non-facility), effective Jul 1, 2026
  • TX: $630.54 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Sep 1, 2026
  • VA: $4636.87 (medical), effective Jul 1, 2026
  • VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $3051.68 (physician, facility), effective Jul 1, 2026
  • WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), 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.