Immunizations Fee Schedule Rates Effective July 1 ... - Colorado

Immunizations Fee Schedule Rates Effective July 1, 2021-June 30, 2022

Procedure Code

Service Description

Age From

0001A ADM SARSCOV2 30MCG/0.3ML 1ST 12

0002A ADM SARSCOV2 30MCG/0.3ML 2ND 12

0003A FEE COVID-19 VAC 1 BOOSTER

12

0004A ADM SARSCOV2 30MCG/0.3ML BST 12

0011A ADM SARSCOV2 100MCG/0.5ML1ST 18

0012A ADM SARSCOV2 100MCG/0.5ML2ND 18

0013A FEE COVID-19 VAC 2 BOOSTER

18

0031A ADM SARSCOV2 VAC AD26 .5 ML

18

0034A ADM SARSCOV2 VAC AD26 .5ML B

18

0051A

ADM SARSCV2 30MCG TRS-SUCR 1

12

0052A

ADM SARSCV2 30MCG TRS-SUCR 2

12

0053A

ADM SARSCV2 30MCG TRS-SUCR 3

12

0054A

ADM SARSCV2 30MCG TRS-SUCR B

12

0064A

ADM SARSCOV2 50MCG/0.25MLBST

18

0071A

ADM SARSCV2 10MCG TRS-SUCR 1

5

0072A

ADM SARSCV2 10MCG TRS-SUCR 2

5

90281

Human ig im

0

90283

Human ig iv

0

90284

Human ig sc

0

90287

Botulinum antitoxin

0

90288

Botulism ig iv

0

90291

Cmv ig iv

0

90296

Diphtheria antitoxin

0

90371

Hep b ig im

0

90375

Rabies ig im/sc

0

90376

Rabies ig heat treated

0

90378

Rsv mab im 50mg

0

90384

Rh ig full-dose im

0

90385

Rh ig minidose im

0

90386

Rh ig iv

0

90389

Tetanus ig im

0

90393

Vaccina ig im

0

90396

Varicella-zoster ig im

0

90399

Immune globulin

0

90460

Im admin 1st/only component

0

90461 Im admin each addl component

0

90471

Immunization admin

0

90472 Immunization admin each addl

0

90473

Immune admin oral/nasal

0

90474 Immune admin oral/nasal addl

0

90476

Adenovirus vaccine type 4

17

90477

Adenovirus vaccine type 7

0

90619

MENACWY-TT Vaccine IM

0

90619

MENACWY-TT Vaccine IM

19

90620 Meningococcal recombiant vac 2 dose 0

90620 Meningococcal recombiant vac 2 dose 19

90621

MenB 3 dose

0

90621

MenB 3 dose

19

90632

Hepa vaccine adult im

19

90633

Hepa vacc ped/adol 2 dose im

0

90636

Hep a/hep b vacc adult im

18

90647

Hib prp-omp vacc 3 dose im

0

90647

Hib prp-omp vacc 3 dose im

18

90648

Hib prp-t vaccine 4 dose im

0

90649

4vhpv vaccine 3 dose im

9

90649

4vhpv vaccine 3 dose im

19

Age To

999 999 999 999 999 999 999 999 999 999 999 999 999

999 11 11 999 999 999 999 999 999 999 999 999 999 3 999 999 999 999 999 999 999 18 18 999 999 999 999 999 999 18 999 18 999 18 999 999 18 999 18 999 4 18 45

Special Instructions

Rate Effective 7/1/20206/30/2021

$

41.18

New Rate

Effective 7/1/2021-

Notes

6/30/2022

$

61.77 New rate effective 9/1/2021

$

41.18 $

61.77 New rate effective 9/1/2021

$

41.18 $

41.18

$

-$

41.18 New age range effective 1/5/22

$

41.18 $

61.77 New rate effective 9/1/2021

$

41.18 $

61.77 New rate effective 9/1/2021

$

41.18 $

41.18

$

41.18 $

61.77 New rate effective 9/1/2021

$

-$

41.18

$

-$

61.77 New code effective 9/29/2021

$

-$

61.77 New code effective 9/29/2021

$

-$

41.18 New code effective 9/29/2021

$

-$

41.18 New code effective 9/29/2021

$

-$

41.18

$

-$

61.77 New rate effective 11/2/2021

$

-$

61.77 New rate effective 11/2/2021

$

15.78 $

16.17

$

276.36 $

283.27

$

622.24 $

637.80

$

206.78 $

211.95

$

485.65 $

497.79

$

385.50 $

395.14

$

43.53 $

44.62

$

177.28 $

181.71

$

101.97 $

104.52

$

100.88 $

103.40

Refer to Physician Administered Drugs Fee Schedule

$

121.44 $

124.48

$

55.27 $

56.65

$

169.08 $

173.31

$

119.94 $

122.94

$

122.28 $

125.34

$

116.16 $

119.06

$

60.11 $

61.61

$

19.27 $

19.75

$

-$

-

$

19.27 $

19.75

$

11.19 $

11.47

$

19.27 $

19.75

$

11.19 $

11.47

$

36.82 $

37.74

$

36.82 $

37.74

V

$

-$

-

*

$

141.43 $

141.43 New Code, Effective 11/01/20

V

$

-$

-

*

$

169.04 $

191.75

V

$

-$

-

*

$

148.39 $

157.35

*

$

68.88 $

73.75

V

$

-$

-

*

$

102.96 $

112.35

V

$

-$

-

$

25.97 $

27.25

V

$

-$

-

V

$

-$

-

$

167.92 $

172.12

Version: 1.8 Updated: 01/19/2022

Immunizations Fee Schedule Rates Effective July 1, 2021-June 30, 2022

90650

2vhpv vaccine 3 dose im

9

18

90650

2vhpv vaccine 3 dose im

19

45

90651

9vhpv vaccine 3 dose im

9

18

90651

9vhpv vaccine 3 dose im

19

45

90654

Flu vacc iiv3 no preserv id

19

999

90655

Iiv3 vacc no prsv 0.25 ml im

0

18

90656

Flu Vaccine IIV3 im

0

18

90656

Flu Vaccine IIV3 im

19

999

90657

Iiv3 vaccine splt 0.25 ml im

0

18

90658

Iiv3 vaccine splt 0.5 ml im

0

18

90658

Iiv3 vaccine splt 0.5 ml im

19

999

90661

CCiv3 flu vac, im

0

18

90661

CCiv3 flu vac, im

19

999

V9A06C6C2INE FOR INFLUENZA FOR INJECTION INTO MUS6C5LE 999

90670

Pcv13 vaccine im

0

18

90670

Pcv13 vaccine im

19

999

90672

Laiv4 vaccine intranasal

2

18

90672

Laiv4 vaccine intranasal

19

49

90673

Riv3 vaccine no preserv im

19

49

90674 CCIIV4 VAC NO PRSV 0.5 ML IM

0

18

90674 CCIIV4 VAC NO PRSV 0.5 ML IM

19

999

90675

Rabies vaccine im

0

999

90677

PCV20 VACCINE IM

18

18

90677

PCV20 VACCINE IM

19

999

V

$

$

V

$

*

$

F

$

F V

$

F V

$

F

$

V

$

V

$

$

F V

$

F

$

$

V

$

*

$

V

$

$

$

V

$

F

$

$

V

$

-$ 167.92 $

-$ 225.65 $

19.70 $ -$ -$

17.18 $ -$ -$

15.80 $ -$

14.82 $ 55.62 $

-$ 199.98 $

-$ 22.43 $ 34.39 $

-$ 21.52 $ 241.13 $

-$ $

90680

Rv5 vacc 3 dose live oral

8 weeks 32 weeks

V

$

-$

90681

Rotavirus vaccine, line, oral

8 weeks 32 weeks

V

$

90682Influenza virus vaccine for intramuscular use 18

999

$

90685

Iiv4 vacc no prsv 0.25 ml im

19

999

$

90685

Iiv4 vacc no prsv 0.25 ml im 6 months 18

F V

$

90686

Iiv4 vacc no prsv 0.5 ml im

6 months 18

V

$

90686

Iiv4 vacc no prsv 0.5 ml im

19

999

F

$

35

90687

Iiv4 vaccine splt 0.25 ml im

6 months months

F V

$

90688

Iiv4 vaccine splt 0.5 ml im

3

18

F V

$

90688

Iiv4 vaccine splt 0.5 ml im

19

999

F

$

90696

DTaP-IPV vaccine

4

6

V

$

90697

DTaP-IPV-HIB-HEPB im

6 weeks

4

V

$

90698

Dtap-ipv/hib vaccine im

0

4

V

$

90700

Dtap vaccine < 7 yrs im

0

6

V

$

90702

Dt vaccine under 7 yrs im

0

6

V

$

90707

Mmr vaccine sc

0

18

V

$

90707

Mmr vaccine sc

19

999

*

$

90710

Mmrv vaccine sc

1

12

V

$

90713

Poliovirus ipv sc/im

0

18

V

$

90713

Poliovirus ipv sc/im

19

999

*

$

90714

Td vacc no presv 7 yrs+ im

7

18

V

$

90714

Td vacc no presv 7 yrs+ im

19

999

*

$

90715

Tdap vaccine 7 yrs/> im

7

18

V

$

90715

Tdap vaccine 7 yrs/> im

19

999

*

$

90716

Var vaccine live subq

0

18

V

$

90716

Var vaccine live subq

19

999

*

$

90723

Dtap-hep b-ipv vaccine im

0

6

V

$

90732

Ppsv23 vacc 2 yrs+ subq/im

2

18

V

$

90732

Ppsv23 vacc 2 yrs+ subq/im

19

999

*

$

90733

Mpsv4 vaccine subq

0

999

$

90734

Menacwy vaccine im

0

18

V

$

90734

Menacwy vaccine im

19

999

*

$

90736

Hzv vaccine live subq

60

999

$

90739

Hepb vacc 2 dose adult im

0

999

$

-$ 52.84 $

-$ -$ -$ 17.97 $

-$ -$ 16.82 $ -$ -$ -$ -$ -$ -$ 77.89 $ -$ -$ 34.82 $ -$ 25.62 $ -$ 46.33 $ -$ 134.37 $ -$ -$ 104.14 $ 124.43 $ -$ 127.10 $ 212.65 $ 114.59 $

Version: 1.8 Updated: 01/19/2022

172.12

239.29

20.19 -

17.61 -

16.20 -

15.19 57.01

211.86

22.99 35.25

22.06 247.16

- New Code Effective 10/1/2021 211.86 New Code Effective 10/1/2021

-

54.16 17.67

18.42

17.24 82.49 36.89 36.14 48.14 142.47 110.45 127.54 140.01 217.97 117.46

Immunizations Fee Schedule Rates Effective July 1, 2021-June 30, 2022

90740 Hepb vacc 3 dose immunsup im

0

18

90740 Hepb vacc 3 dose immunsup im

0

20

90743

Hepb vacc 2 dose adolesc im

11

15

90744

Hepb vacc 3 dose ped/adol im

0

18

90746

Hepb vaccine 3 dose adult im

18

999

90746

Hepb vaccine 3 dose adult im

19

999

90747 Hepb vacc 4 dose immunsup im

0

18

90747 Hepb vacc 4 dose immunsup im

0

999

90748

Hib-HepB vaccine

0

6

90749

Vaccine toxoid

0

999

90750

Hzv vacc recombinant im

50

999

90756

CCIIV4 VACC ABX FREE IM

2

18

90756

CCIIV4 VACC ABX FREE IM

19

999

90759 HEP B VAC 3AG 10MCG 3 DOS IM

0

999

91300 SARSCOV2 VAC 30MCG/0.3ML IM

12

999

91301 SARSCOV2 VAC 100MCG/0.5ML IM 18

999

91303 ADM SARSCOV2 VAC AD26 .5 ML IM 18

999

91305

SARSCOV2 VAC 30 MCG TRS-SUCR

12

999

91306 SARSCOV2 VAC 50MCG/0.25ML IM 18

999

91307 SARSCOV2 VAC 10 MCG TRS-SUCR

5

11

M0201 COVID-19 VACCINE HOME ADMIN

0

999

V

$

-$

*

$

58.36 $

V

$

-$

V

$

-$

V

$

-$

$

45.69 $

V

$

-$

$

58.36 $

V

$

-$

V

$

-$

*

$

149.90 $

V

$

-$

$

20.31 $

$

$

-$

$

-$

$

-$

$

-$

$

-$

$

-$

-$

* Rate taken from CDC Immunization Price List, May 1, 2021 F See flu immunization special billing manual for details

V May be available through the Vaccinations for Children (VFC) program

61.86

46.83 61.86 162.01 20.82 61.86 - New Code, Effective 9/29/2021 - New Code, Effective 10/20/2021 - New Code, Effective 11/02/2021 35.00 New Code, Effective 9/01/2021

Version: 1.8 Updated: 01/19/2022

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