Payer policies › CPT 4942849428 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 49428 Medicaid fee-for-service AZ: $442.11 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025 CO: $340.26 (chp_plus, non-facility), effective Jul 1, 2026 FL: $320.04 (physician, non-facility), effective Jan 1, 2026 IN: $324.52 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $300.00 (asc, facility), effective Jan 1, 1995 KY: $91.83 (physician, facility), effective Jan 1, 2026 LA: $351.47 (professional), effective Jul 1, 2025 MA: $318.03 (physician_surgery), effective May 1, 2024 MS: $340.34 (comprehensive), effective Jul 1, 2026 ND: $422.80 (physician), effective Aug 1, 2026 NE: $422.36 (physician, non-facility), effective Jul 1, 2026 NY: $203.43 (physician_surgery, facility), effective Jul 1, 2026 OH: $235.19 (physician), effective Jul 1, 2008 OK: $360.03 (physician, non-facility), effective Jul 1, 2026 TX: $329.32 (physician, Physician, facility), effective Sep 1, 2026 VA: $356.48 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $238.68 (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.