Payer policies › CPT 9101091010 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 91010 Payer coverage policies that name 91010 91010 appears in 2 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Esophageal and Airway pH Monitoring (0667) listed, no stance Oct 7, 2026 payer document Aetna Gastrointestinal Manometry (0616) covered if criteria are met Sep 3, 2026 payer document
Medicaid fee-for-service AZ: $97.71 (asc), effective Oct 1, 2026 CO: $36.16 (chp_plus, non-facility), effective Jul 1, 2026 FL: $50.12 (physician), effective Jan 1, 2026 IL: $142.04 (practitioner), effective Apr 1, 2024 IN: $165.92 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $225.00 (asc, facility), effective Aug 1, 1982 KY: $174.32 (asc), effective Jan 1, 2026 LA: $182.30 (asc), effective Jul 1, 2012 MA: $174.09 (physician_medicine), effective May 1, 2024 MS: $283.38 (comprehensive), effective Jul 1, 2026 ND: $172.42 (physician, facility), effective Aug 1, 2026 NE: $52.09 (physician, non-facility), effective Jul 1, 2026 NY: $50.50 (ordered_ambulatory), effective Jul 24, 2026 OH: $123.60 (physician), effective Jan 1, 2024 OK: $148.78 (physician, non-facility), effective Jul 1, 2026 TX: $122.43 (miscellaneous_other_professionals_portable_x_ray_radiologica, Miscellaneous Other Professionals - Portable X-Ray, Radiological Lab, Physiological Lab, non-facility), effective Sep 1, 2025 VA: $58.74 (medical), effective Jul 1, 2026 VT: $289.74 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $152.88 (physician, facility), effective Jul 1, 2026 WY: $165.02 (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.