42405 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 42405

Medicaid fee-for-service

  • AZ: $396.13 (asc), effective Oct 1, 2026
  • CO: $218.16 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $158.33 (physician, facility), effective Jan 1, 2026
  • IL: $155.19 (practitioner), effective Apr 1, 2024
  • IN: $175.93 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $225.00 (asc, facility), effective Aug 1, 1982
  • KY: $643.45 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $456.11 (asc), effective May 1, 2026
  • MS: $525.90 (comprehensive, facility), effective Oct 1, 2025
  • ND: $379.31 (physician, facility), effective Aug 1, 2026
  • NE: $552.00 (asc), effective Jul 1, 2024
  • NY: $109.70 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $144.22 (physician, facility), effective Jan 1, 2024
  • OK: $587.03 (asc), effective Jan 1, 2026
  • TX: $420.64 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $175.06 (medical, facility), effective Jul 1, 2026
  • VT: $1204.74 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $308.28 (asc), effective Jul 1, 2026
  • WY: $686.17 (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.