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64 <br /> Commissioner Approved <br /> Fee Changes for Last <br /> Department/Program Description Current Fee FY 2021-22* Revision <br /> 90670SL Pneumococcal conjugate vaccine, 13 valent <br /> Medicaid only (PCV13)-PREVNAR 13 $0.00 2019 <br /> 90675 Rabies Vaccine-IMOVAX RABIES $357.00 2019 <br /> 90680 Rotavirus vaccine,pentavalent(RV5),3 dose- <br /> ROTATEQ $113.00 2019 <br /> 90680SL Rotavirus vaccine,pentavalent(RV5),3 dose- <br /> Medicaid only IROTATEQ $0.00 2019 <br /> 90681 Rotavirus vaccine,human,attenuated(RVI),live, <br /> oral,2 dose-ROTARIX $138.00 2019 <br /> 90681SL Rotavirus vaccine,human,attenuated(RVI),live, <br /> Medicaid only oral,2 dose-ROTARIX $0.00 2019 <br /> 90685 Influenza vaccine(IIV4),quadrivalent,preservative <br /> free,6 to 35 months-FLUZONE PEDS $19.00 2019 <br /> 90685SL Influenza vaccine(IIV4),quadrivalent,preservative <br /> Medicaid only 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 /> 90686SL Influenza vaccine(IIV4),quadrivalent,preservative <br /> Medicaid only 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 /> Diphteria,tetanus toxoid,and acellular pertussis <br /> 90696 vaccine and inactivated poliovirus accine(DTaP- <br /> IPV),for 4 to 6 years of age-KINRIX $57.00 2019 <br /> Diphteria,tetanus toxoid,and acellular pertussis <br /> 90696SL vaccine and inactivated poliovirus accine(DTaP- <br /> Medicaid only IPV),for 4 to 6 years of age-KINRIX $0.00 2019 <br /> Diphteria,tetanus toxoid,and acellular pertussis <br /> 90696 vaccine and inactivated poliovirus accine(DTaP- <br /> IPV),for 4 to 6 years of age-QUADRACEL $59.00 2019 <br /> Diphteria,tetanus toxoid,and acellular pertussis <br /> 90696SL vaccine and inactivated poliovirus accine(DTaP- <br /> Medicaid only IPV),for 4 to 6 years of age-QUADRACEL J$0.00 1 1 2019 <br />