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Commissioner Approved Fee Schedule - FY 2020-21 Attachment 4 <br />* Any fee changes will be included in this column; <br />a blank beside each fee means there is no fee change in FY 2020-21 Commissioner Approved Fee Schedule <br />Department/Program Description Current Fee <br />Commissioner Approved <br />Fee Change for <br />FY 2020-21* <br />Last <br />Revision <br />90685 Influenza vaccine (IIV4), quadrivalent, preservative <br />free, 6 to 35 months - FLUZONE PEDS $19.00 2019 <br />Medicaid only 90685SL Influenza vaccine (IIV4), quadrivalent, preservative <br />free, 6 to 35 months - FLUZONE PEDS $0.00 2019 <br />90686 Influenza vaccine (IIV4), quadrivalent, preservative <br />free, 3 years and above - FLUZONE $18.00 2018 <br />Medicaid only 90686SL Influenza vaccine (IIV4), quadrivalent, preservative <br />free, 3 years and above - FLUZONE $0.00 2019 <br />90682 Influenza vaccine (RIV4), quadrivalent, <br />preservative free, 18 year and above - FLUBLOK $53.00 2019 <br />90696 <br />Diphteria, tetanus toxoid, and acellular pertussis <br />vaccine and inactivated poliovirus accine (DTaP- <br />IPV), for 4 to 6 years of age - KINRIX $57.00 2019 <br />Medicaid only <br />90696SL <br />Diphteria, tetanus toxoid, and acellular pertussis <br />vaccine and inactivated poliovirus accine (DTaP- <br />IPV), for 4 to 6 years of age - KINRIX $0.00 2019 <br />90696 <br />Diphteria, tetanus toxoid, and acellular pertussis <br />vaccine and inactivated poliovirus accine (DTaP- <br />IPV), for 4 to 6 years of age - QUADRACEL $59.00 2019 <br />Medicaid only <br />90696SL <br />Diphteria, tetanus toxoid, and acellular pertussis <br />vaccine and inactivated poliovirus accine (DTaP- <br />IPV), for 4 to 6 years of age - QUADRACEL $0.00 2019 <br />90698 <br />Diphteria, tetanus toxoids, acellular pertussis <br />vaccine, haemophilus influenza Type B, and <br />inactivated poliovirus vaccine (DTaP-IPV/Hib) - $101.00 2019 <br />Medicaid only <br />90698SL <br />Diphteria, tetanus toxoids, acellular pertussis <br />vaccine, haemophilus influenza Type B, and <br />inactivated poliovirus vaccine (DTaP-IPV/Hib) - $0.00 2019 <br />66