40702 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 40702

Payer coverage policies that name 40702

40702 appears in 2 coverage policies from Premera Blue Cross.

PayerPolicyRole in policyReviewedDocument
Premera Blue CrossOrthodontic Services for Treatment of Congenital Craniofacial Anomalies (9.02.500)listed, no stanceJun 22, 2026payer document
Premera Blue CrossOrthognathic Surgery (9.02.501)
Page | 7 of 19 | ∞		listed, no stanceMay 12, 2026payer document

Medicaid fee-for-service

Prior authorization required or conditional in VA.

  • AZ: $1943.46 (asc), effective Oct 1, 2026
  • CO: $798.90 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $699.56 (physician, non-facility), effective Jan 1, 2026
  • IL: $958.60 (practitioner), effective Jul 5, 2019
  • IN: $767.74 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $500.00 (asc, facility), effective Aug 1, 1982
  • KY: $2953.46 (asc), effective Jan 1, 2026
  • LA: $803.91 (professional), effective Jul 1, 2025
  • MA: $1909.57 (asc), effective May 1, 2026
  • MS: $2333.88 (comprehensive, facility), effective Oct 1, 2025
  • ND: $1741.07 (physician, facility), effective Aug 1, 2026
  • NE: $207.14 (physician, non-facility), effective Jul 1, 2026
  • NY: $410.92 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $633.19 (physician), effective Jan 1, 2024
  • OK: $2694.50 (asc), effective Jan 1, 2026
  • TX: $1954.22 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $779.22 (medical), effective Jul 1, 2026
  • VT: $4596.52 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $530.88 (physician, facility), effective Jul 1, 2026
  • WY: $2617.97 (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.