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63 <br /> Commissioner Approved <br /> Fee Changes for Last <br /> Department/Program Description Current Fee FY 2021-22* Revision <br /> Meningococcal recombinant protein and outer <br /> 90620SL membrane vesicle vaccine,serogroup B(MenB- <br /> Medicaid only 4C),2 dose schedule-BEXSERO $0.00 2019 <br /> 90621 Meningococcal recombinant lipoprotein vaccine, <br /> serogroup B,2 or 3 dose schedule-TRUMENBA $161.00 2019 <br /> 90621SL Meningococcal recombinant lipoprotein vaccine, <br /> Medicaid only serogroup B,2 or 3 dose schedule-TRUMENBA $0.00 2019 <br /> 90632 Hepatitis A vaccine,adult dose-HAVRIX $79.00 2019 <br /> Medicaid only 90632SL Hepatitis A vaccine,adult dose-HAVRIX $0.00 2019 <br /> 90633 Hepatitis A vaccine,pediatric/adolescent dose,2 <br /> dose-HAVRIX $37.00 2019 <br /> 90633SL Hepatitis A vaccine,pediatric/adolescent dose,2 <br /> Medicaid only dose-HAVRIX $0.00 2019 <br /> 90636 Hepatitis A and Hepatitis B recombinant vaccine,3 <br /> doses-TWINRIX $117.00 2019 <br /> 90636SL Hepatitis A and Hepatitis B recombinant vaccine,3 <br /> Medicaid only doses-TWINRIX $0.00 2019 <br /> 90647 Hemophilus Influenzae B vaccine(Hib),PRP- <br /> OMP conjugate,3 dose-PedVaxHIB $40.00 2018 <br /> 90647SL Hemophilus Influenzae B vaccine(Hib),PRP- <br /> Medicaid only OMP conjugate,3 dose-PedVaxHIB $0.00 2019 <br /> 90648 Hemophilus Influenzae B vaccine(Hib),PRP-T <br /> conjugate,4 dose-ActHIB $26.00 2018 <br /> 90648SL Hemophilus Influenzae B vaccine(Hib),PRP-T <br /> Medicaid only conjugate,4 dose-ActHIB $0.00 2019 <br /> Human Papillomavirus vaccine types 6, 11, 16,18, <br /> 90651 31,33,45,52,58,nonavalent(HPV),2 or 3 dose- <br /> GARDASIL 9 $225.00 2019 <br /> Human Papillomavirus vaccine types 6, 11, 16, 18, <br /> 90651SL 31,33,45,52,58,nonavalent(HPV),2 or 3 dose- <br /> Medicaid only GARDASIL 9 $0.00 2019 <br /> 90662 Influenza vaccine(IIV3-HD),for 65 years of age <br /> and up-FLUZONE HIGH DOSE $53.00 2019 <br /> 90670 Pneumococcal conjugate vaccine, 13 valent <br /> (PCV13)-PREVNAR 13 $217.00 2019 <br />