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Commissioner Approved Fee Schedule - FY 2018-19 <br />* Any fee changes will be included in this column; <br />a blank beside each fee means there is no fee change in FY 2018-19 Commissioner Approved Fee Schedule <br />Department/Program Description Current Fee <br />Commissioner Approved <br />Fee Change for <br />FY 2018-19* <br />Last <br />Revision <br />Recode Employee Rubella Titer $75.00 2009 <br />G0008 Adm of Influenza Vaccine $18.00 2009 <br />G0008 Admin. Influenza Vaccine - Medicare $18.00 2009 <br />G0009 Adm of Pneumococcal Vaccine $18.00 2009 <br />G0009 Admin. Pneumococcal Vaccine - Medicare $18.00 2009 <br />G0108 DSME/DSMT Individual Assessment $22.00 2010 <br />G0109 DSME/DSMT Group Class $12.00 2010 <br />G0270 Additional MD requested MNT indiv - Medicare $25.00 2010 <br />G0271 Additional MD requested MNT group - Medicare $13.00 2010 <br />H0001 Alcohol and/or drug assessment $20.00 2015 <br />H0031 Mental Health assessment, by non-physicaian $22.00 2015 <br />J1055 Depo Provera Injection $25.30 2016 <br />J1050 Injection, medroxyprogesterone acetate, 1 mg $0.16 2015 <br />Medicaid only J1050ud Injection, medroxyprogesterone acetate, 1 mg <br />(10)$0.16 $25.82 2017 <br />J1725 Injection, medroxyprogesterone caproate, 1 mg $3.00 2015 <br />J1200 Diphenhydramine HCL/Benadryl up to 50mg $6.00 2009 <br />J2550 Promethazine _ mg $8.00 2009 <br />J2790 Rhogam Injection $88.00 2012 <br />J7296ud Kyleena (10)$0.00 $249.00 NEW <br />J3420 B-12 Injection $6.00 2009 <br />J3490 17 Alpha-hydroxprogesterone $21.00 2012 <br />J7300 Paragard IUD $264.43 2017 <br />Medicaid only J7300ud Paragard IUD (10)$264.43 $237.14 2017 <br />J7301 Skyla IUD $235.00 2017 <br />Medicaid only J7301ud Skyla IUD (10)$235.00 $375.38 2017 <br />J7298 Mirena IUD $235.00 2017 <br />Medicaid only J7298ud Mirena IUD (10)$235.00 $310.26 2017 <br />J7303 Nuvaring (3pack)$27.92 2017 <br />J7307 Nexplanon $399.00 2017 <br />Medicaid only J7307ud Nexplanon (10)$399.00 $400.50 2017 <br />JO696 Ceftriaxone Sodium/Rocephin per 250mg $22.00 2008 <br />Recoded Sports Physical $44.00 2008 <br />Recoded Camp Physical $44.00 2009 <br />Recoded College Physical $44.00 2009 <br />65