Payer policies › CPT 9130491304 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 91304 Payer coverage policies that name 91304 91304 appears in 1 coverage policy from Blue Cross & Blue Shield of Rhode Island.
Payer Policy Role in policy Reviewed Document Blue Cross & Blue Shield of Rhode Island COVID-19 VaccinationsVACCINE covered if criteria are met Dec 11, 2020 payer document
Medicaid fee-for-service AZ: $191.92 (outpatient_hospital), effective Oct 1, 2025 CO: $191.20 (chp_plus_immunizations), effective Jul 1, 2026 FL: $191.92 (immunization), effective Jul 1, 2026 IN: $150.25 (professional, Advanced Practice Nurse (85%), non-facility), effective Oct 1, 2025 KS: $232.22 (default), effective Oct 1, 2026 KY: $161.54 (physician, non-facility), effective Jan 1, 2026 LA: $191.92 (immunization_0_18), effective Jul 1, 2026 MD: $191.92 (covid_vaccines), effective Oct 8, 2025 ND: $191.92 (physician), effective Aug 1, 2026 OH: $148.20 (outpatient_hospital_behavioral), effective Oct 1, 2023 OK: $179.69 (physician, non-facility), effective Jul 1, 2026 VA: $191.91 (medical), effective Aug 27, 2025 VT: $182.32 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $2.67 (enhanced_pediatric, facility), effective Jul 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.