Payer policies › CPT 9250492504 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 92504 Medicaid fee-for-service AZ: $19.53 (outpatient_hospital, RF133), effective Oct 1, 2025 CO: $24.12 (chp_plus, non-facility), effective Jul 1, 2026 FL: $6.44 (physician, facility), effective Jan 1, 2026 IL: $8.74 (practitioner), effective Apr 1, 2024 IN: $7.36 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $16.60 (default, Exempt Physician), effective Aug 1, 2024 KY: $45.00 (asc), effective Jan 1, 2026 MA: $7.02 (physician_medicine, facility), effective May 1, 2024 MS: $22.98 (comprehensive), effective Jul 1, 2026 ND: $31.92 (physician), effective Aug 1, 2026 NE: $9.54 (physician, facility), effective Jul 1, 2026 OH: $4.09 (physician, facility), effective Jan 1, 2024 OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026 TX: $7.86 (physician, Physician, facility), effective Mar 1, 2024 VA: $6.66 (medical, facility), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $4.59 (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.