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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 />90744 Hepatitis B vaccine (Hep B), pediatric/adolescent <br />dosage, 3 dose - ENGERIX PEDS $30.00 2018 <br />Medicaid only 90744SL Hepatitis B vaccine (Hep B), pediatric/adolescent <br />dosage, 3 dose - ENGERIX PEDS $0.00 2019 <br />90744 Hepatitis B vaccine (Hep B), pediatric/adolescent <br />dosage, 3 dose - RECOMBIVAX HB PEDS $25.00 2019 <br />Medicaid only 90744SL Hepatitis B vaccine (Hep B), pediatric/adolescent <br />dosage, 3 dose - RECOMBIVAX HB PEDS $0.00 2019 <br />90746 Hepatitis B vaccine (Hep B), adult dosage - <br />ENGERIX-B $67.00 2019 <br />Medicaid only 90746SL Hepatitis B vaccine (Hep B), adult dosage - <br />ENGERIX-B $0.00 2019 <br />90739 Hepatitis B vaccine (Hep B), adult dosage, 2 dose - <br />HEPLISAV $132.00 2019 <br />90739SL Hepatitis B vaccine (Hep B), adult dosage, 2 dose - <br />HEPLISAV $0.00 2019 <br />90750 Zoster Vaccine recombinant, adjuvanted, 50 years <br />or older - SHINGRIX $166.00 2019 <br />Medicaid only 90750SL Zoster Vaccine recombinant, adjuvanted, 50 years <br />or older - SHINGRIX $0.00 2019 <br />90772 Therapeutic prophylactic/diagonostic injection $23.00 2008 <br />90846 Psychotherapy, Family, w/o Patient $95.00 2009 <br />90847 Psychotherapy, Family, (Conjoint) W/Pt Present $115.00 2009 <br />90853 Psychotherapy, Group $32.00 2009 <br />92551 Audiometry $18.00 2008 <br />92587 OAE (Limited)$100.00 2012 <br />93000 Electrocardiogram, Complete $33.00 2009 <br />93005 Electrocardiogram, Tracing Only $22.00 2009 <br />94150 Peak Flow $3.25 2018 <br />94640 Airway Inhalation Treatment $22.00 2009 <br />94664 Aerosol Inhalation Treatment - Teaching $22.00 2009 <br />94760 Pulse Oxygen $8.00 2009 <br />96110 Developmental Test $23.00 2012 <br />96125 ASQ - Developmental $78.38 2018 <br />96127 Social-emotional Screens $6.00 2017 <br />96152 Health & Behavior Intervention $55.00 2015 <br />69