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Commissioner Approved Fee Schedule - FY 2019-20 <br />* Any fee changes will be included in this column; <br />a blank beside each fee means there is no fee change in FY 2019-20 Commissioner Approved Fee Schedule <br />Department/Program Description Current Fee <br />Commissioner Approved <br />Fee Change for <br />FY 2019-20* <br />Last <br />Revision <br />2015 DSME Minimum Fee $20.00 2015 <br />G0108 DSME/DSMT Individual Assessment - Medicare $52.00 2015 <br />G0109 DSME/DSMT Group Class - Medicare $17.00 2015 <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-physician $22.00 2015 <br />J0696 Ceftriaxone Sodium/Rocephin per 250mg $22.00 2008 <br />J1050 Medroxyprogesterone acetate, 1 mg (150 units)$0.17 $0.76 2019 <br />Medicaid only J1050ud Medroxyprogesterone acetate, 1 mg (150 units)$0.17 $0.76 2019 <br />J1200 Diphenhydramine HCL/Benadryl up to 50mg $6.00 2009 <br />J1725 Injection hydroxyprogesterone caproate, 1 mg (250 u$3.00 2015 <br />J2550 Promethazine _ mg $8.00 2009 <br />J2790 Rhogam Injection $88.00 2012 <br />J3420 B-12 Injection $6.00 2009 <br />J7300 Paragard IUD $237.14 $237.54 2019 <br />Medicaid only J7300ud Paragard IUD $237.14 $237.54 2019 <br />J7301 Skyla IUD $375.38 $249.00 2019 <br />Medicaid only J7301ud Skyla IUD $375.38 $249.00 2019 <br />J7297 Liletta IUD $47.04 $50.00 2019 <br />Medicaid only J7297ud Liletta IUD $47.04 $50.00 2019 <br />J7298 Mirena IUD $310.26 $249.00 2019 <br />Medicaid only J7298ud Mirena IUD $310.26 $249.00 2019 <br />J7303 Nuvaring (3 pack)$27.92 2017 <br />J7307 Nexplanon $400.50 $399.00 2019 <br />Medicaid only J7307ud Nexplanon $400.50 $399.00 2019 <br />Q2037 Fluvirin Vacc, 3 yrs & >, IM $31.00 2015 <br />Q2038 Fluzone Vacc, 3 yrs & >, IM $40.00 2015 <br />Medicaid only S0280 PMH Risk Screening $50.00 2015 <br />Medicaid only S0281 Postpartum Risk Screening $150.00 2015 <br />Self-Pay only S4993 Oral Contraceptive Pills $5.00 2012 <br />S5000 Prescription Drug Dispensing $3.00 2012 <br />S9465 Diabetic management program, dietitian visit $35.00 2011 <br />S9470 Nutritional counseling, dietitian visit $35.00 2011 <br />T1002 RN Services up to 15 min.$21.00 2005 <br />S9442 Birthing classes 8.69/ 1 hr block 2013 <br />72