Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
RL-A-SELENIUM SRM/PLASMA 25023
Mesa, AZ
See all hospitals reporting CPT 84255 →Price type
Agh Mesa Llc’s median price of $26 is 30% below the median hospital's median price ($37), higher than 24% of the 2,438 hospitals reporting CPT 84255. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 7 payers, 17 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | |||||||
|---|---|---|---|---|---|---|---|
| 1 | UnitedHealthcare commercial|all other plans fee schedule · outpatient | $15 | $15 | — | — | — | $15 – $15 |
| 2 | UnitedHealthcare commercial|navigate fee schedule · outpatient | $15 | $15 | — | — | — | $15 – $15 |
| 3 | UnitedHealthcare commercial|options fee schedule · outpatient | $15 | $15 | — | — | — | $15 – $15 |
| 4 | Humana medicare|all plans fee schedule · outpatient | $26 | $26 | — | — | — | $26 – $26 |
| 5 | WellCare medicare|all plans fee schedule · outpatient | $26 | $26 | — | — | — | $26 – $26 |
| 6 | Blue Cross Blue Shield medicare|all plans fee schedule · outpatient | $26 | $26 | — | — | — | $26 – $26 |
| 7 | UnitedHealthcare medicaid|all plans fee schedule · outpatient | $26 | $26 | — | — | — | $26 – $26 |
| 8 | UnitedHealthcare medicare|all plans fee schedule · outpatient | $26 | $26 | — | — | — | $26 – $26 |
| 9 | MultiPlan commercial|all plans fee schedule · inpatient | $30 | $30 | — | — | — | $30 – $30 |
| 10 | MultiPlan commercial|all plans fee schedule · outpatient | $30 | $30 | — | — | — | $30 – $30 |
| 11 | Blue Cross Blue Shield commercial|maricopafocus fee schedule · outpatient | $53 | $53 | — | — | — | $53 – $53 |
| 12 | Blue Cross Blue Shield commercial|neighborhood fee schedule · outpatient | $53 | $53 | — | — | — | $53 – $53 |
| 13 | Blue Cross Blue Shield commercial|all other plans fee schedule · outpatient | $71 | $71 | — | — | — | $71 – $71 |
| 14 | Cigna commercial|all other plans fee schedule · outpatient | $75 | $75 | — | — | — | $75 – $75 |
| 15 | Cigna commercial|ppo fee schedule · outpatient | $75 | $75 | — | — | — | $75 – $75 |
| 16 | Aetna commercial|all other plans fee schedule · outpatient | $124 | $124 | — | — | — | $124 – $124 |
| 17 | Aetna commercial|ppo fee schedule · outpatient | $124 | $124 | — | — | — | $124 – $124 |
Last updated: Feb 28, 2026
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