Payer policies › CPT 4080440804 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 40804 1 of 1 payer prior-auth lists that name 40804 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue).
Medicaid fee-for-service AZ: $79.15 (outpatient_hospital, RF133), effective Oct 1, 2025 CO: $97.05 (chp_plus, non-facility), effective Jul 1, 2026 FL: $89.88 (physician, facility), effective Jan 1, 2026 IL: $76.15 (practitioner), effective Apr 1, 2024 IN: $91.75 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $250.00 (asc, facility), effective Aug 1, 1982 KY: $0.00 (asc), effective Jan 1, 2026 LA: $217.00 (asc), effective Jul 1, 2012 MA: $0.00 (asc), effective May 1, 2026 MS: $94.17 (comprehensive), effective Jul 1, 2026 ND: $230.93 (physician), effective Aug 1, 2026 NE: $47.34 (physician, facility), effective Jul 1, 2026 NY: $62.05 (physician_surgery, facility), effective Jul 1, 2026 OH: $96.34 (physician, facility), effective Jan 1, 2024 OK: $100.19 (physician, facility), effective Jul 1, 2026 TX: $89.34 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Sep 1, 2026 VA: $100.12 (medical, facility), effective Jul 1, 2026 VT: $704.24 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $69.94 (physician, facility), effective Jul 1, 2026 WY: $401.10 (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.