67115 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 67115

Medicaid fee-for-service

  • AZ: $1525.68 (asc), effective Oct 1, 2026
  • CO: $336.72 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $336.14 (physician, non-facility), effective Jan 1, 2026
  • IL: $468.28 (practitioner), effective Apr 1, 2024
  • IN: $383.15 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $400.00 (asc, facility), effective Aug 1, 1982
  • KY: $2151.31 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $1560.46 (asc), effective May 1, 2026
  • MS: $1675.46 (comprehensive, facility), effective Oct 1, 2025
  • MT: $479.12 (optometric, facility), effective Jul 1, 2025
  • ND: $1268.20 (physician, facility), effective Aug 1, 2026
  • NE: $552.00 (asc), effective Jul 1, 2024
  • NY: $210.11 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $285.14 (physician), effective Jan 1, 2000
  • OK: $1962.68 (asc), effective Jan 1, 2026
  • TX: $1533.49 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $374.42 (medical), effective Jul 1, 2026
  • VT: $3209.44 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1827.95 (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.