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Commissioner Approved Fee Schedule- FY 2017-18 ATTACHMENT 4 40 <br /> Commissioner Approved <br /> Fee Change for Last <br /> Department/Program Description Current Fee FY 2017-18* Revision <br /> 90658 Influetza Split 3 and Above $15.00 2012 <br /> 90660 Influetza Vuus Vaccine Live for hi tznzsal $23.00 2012 <br /> 90662 Influetza-high dose 65+ $40.00 2012 <br /> 90669 Pre-(PCV7-Pneumococcal Vaccine $116.00 2009 <br /> 90670 Prevttar CV13 -P-ococcal Vaccine $167.00 2015 <br /> 90672 Ltranasal administration of live quadrivalent <br /> infuenza vaccine $26.00 2015 <br /> 90675 Rabies $288.00 2016 <br /> 90676 Rabies vaccine,for intrzdennal use $212.00 2015 <br /> 90680 Rotateq(Rotavims Vaccine) $99.00 2009 <br /> 90681 Rotarix $124.00 2015 <br /> 90685 Influenza vac quadrivalent prsry free 6-35 mo IM $16.00 2015 <br /> 90686 Influenza vac 4 valent prsry free 3 yrs plus IM $18.00 2015 <br /> 90696 Kinrlx(DTaP/IPV) $52.00 2012 <br /> 90698 Pentacel(DTaP/IPV/Hlb) $95.00 2015 <br /> 90700 Dtap Vaccine ediatric SelfPay $32.00 2012 <br /> 90702 Di theria tetanus tmoid absorbed>7 yr IM $40.00 2015 <br /> 90707 Adult WAR $66.00 2015 <br /> 90713 Inactived Polio Vaccine(IPV) $31.00 2009 <br /> 90714 Td(pres.Free) $35.00 2015 <br /> 90715 Tdap Vaccine $39.49 2014 <br /> 90716 Varicella vaccine $111.00 2015 <br /> 90723 Pediarix TaP/H B/IPV $91.00 2015 <br /> 90732 Itcurran ation:Pnemnococcal-State $80.00 2015 <br /> 90733 M occccal Vaccine,Subcutaneous/Jet $100.00 2008 <br /> 90734 Menasha Me' occccal Vaccine $127.00 2015 <br /> 90736 Zostavax vaccine $207.00 2015 <br /> 90744 Pediatric Hep B Vaccine Se1fPa $30.00 2012 <br /> 90746 I nacuni.ation:Hep B 20+ $58.00 2007 <br /> 90760 IV Infusion Up to One How $140.00 2007 <br /> 90772 Therapeutic prophylactic/diagonostic injection $23.00 2008 <br /> 90801 Ps chiatric Dia ostic Interview Exam $151.00 2008 <br /> 90802 Ps chiatric Dix IMery E Interactive $161.00 2009 <br /> 90804 Ps chother I div In si 20-30 min. $65.00 2009 <br /> 90806 Ps chothw,I div Insi 45-50 min. $97.00 2007 <br /> 90808 Ps chathw,I div Insight,75-80 min. $146.00 2008 <br /> 90810 Ps chother I div Interac 20-30 min. $70.00 2007 <br /> 90812 Ps chother I div Interac 45-50 min. $103.00 2009 <br /> 90814 Ps chathw hdiv Interac 75-80 min. $152.00 2009 <br /> 90846 Ps chath Famil w/o Patient $95.00 2009 <br /> 90847 Psychotherapy,Famil (Conjoint)W/Pt Present $115.00 2009 <br /> 90853 Psychotherapy,Group $32.00 2009 <br /> 91781 IV infusion Fach Additional How up to Eight $39.00 2009 <br /> 86382 Rabies Titer $100.00 2016 <br /> 99080 Record TB S Form Coun letion $25.00 2016 <br /> TBD Minimum Lab Fee $20.00 2016 <br /> J7297 Liletta $50.00 2016 <br /> 88175 Pap Smear with ln[ retraim $26.50 2016 <br /> 87624 HPV $25.00 2016 <br /> 88141 Pap Smear with Doctor Interpretation $80.00 2016 <br /> 92551 Audiornetry $18.00 2008 <br /> 92587 OAE(Limited) $100.00 2012 <br /> 93000 Electrocardiogram,Cmn lete $33.00 2009 <br /> 93005 Electroc-hograrn,Tracing $22.00 2009 <br /> 94640 Airway Inhalation Treattnent $22.00 2009 <br /> 94664 Aerowl[VaW Inhalation Treatment $22.00 2009 <br /> 94760 Pulse Ox en $8.00 2009 <br /> 96110 IDevelopmental Test $23.00 2012 <br /> 96127 Social-Emotion al Screens $0.00(11) $6.00 NEW <br /> 96152 Health&Bettavior Intervention $55.00 2012 <br /> 96160 lAdoleseent Risk&Strength Screening $0.00(11) $9.20 NEW <br /> 96161 Amaternal Depression Screening $0.00(11) $9.20 NEW <br /> * Any fee changes wi I I be included in this column; <br /> a blank beside each fee means there is no fee change in FY 2017-18 Commissioner Approved Fee Schedule <br />