42104 CPT® code: payer coverage and prior authorization
Payer policies and prior authorization for 42104
3 of 3 payer prior-auth lists that name 42104 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Neighborhood Health Partnership, UnitedHealthcare.
OH: $94.97 (physician, facility), effective Jan 1, 2024
OK: $139.60 (asc), effective Jan 1, 2026
TX: $126.80 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
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.