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66 <br /> Commissioner Approved <br /> Fee Changes for Last <br /> Department/Program Description Current Fee FY 2021-22* Revision <br /> 90716 Varicella virus vaccine(VAR),live-VARIVAX $177.00 2019 <br /> Medicaid only 90716SL Varicella virus vaccine(VAR),live-VARIVAX $0.00 2019 <br /> Diphteria,tetanus toxoids,acellular pertussis <br /> 90723 vaccine,Hepatitis B,and inactivated poliovirus <br /> vaccine(DTaP-Hep B-IPV)-PEDIARIX $91.00 2018 <br /> Diphteria,tetanus toxoids,acellular pertussis <br /> 90723 SL vaccine,Hepatitis B,and inactivated poliovirus <br /> Medicaid only vaccine(DTaP-Hep B-IPV)-PEDIARIX $0.00 2019 <br /> Pneumococcal polysaccharide vaccine,23-valent <br /> 90732 (PPSV23),adult or immunosuppressed patient <br /> dosage,when administered to 2 years or older- <br /> PNEUMOVAX 23 $115.00 2020 <br /> Pneumococcal polysaccharide vaccine,23-valent <br /> 90732SL (PPSV23),adult or immunosuppressed patient <br /> dosage,when administered to 2 years or older- <br /> Medicaid only PNEUMOVAX 23 $0.00 2019 <br /> Meningococcal conjugate vaccine,serogroups <br /> 90734 A,C,Y and W-135 quad(MenACWY or MCV4)- <br /> MENVEO $119.00 2019 <br /> Meningococcal conjugate vaccine,serogroups <br /> 90734SL A,C,Y and W-135 quad(MenACWY or MCV4)- <br /> Medicaid only MENVEO $0.00 2019 <br /> Meningococcal conjugate vaccine,serogroups <br /> 90734 A,C,Y and W-135 quad(MenACWY or MCV4)- <br /> MENACTRA $127.00 2018 <br /> Meningococcal conjugate vaccine,serogroups <br /> 90734SL A,C,Y and W-135 quad(MenACWY or MCV4)- <br /> Medicaid only MENACTRA $0.00 2019 <br /> 90744 Hepatitis B vaccine(Hep B),pediatric/adolescent <br /> dosage,3 dose-ENGERIX PEDS $30.00 2018 <br /> 90744SL Hepatitis B vaccine(Hep B),pediatric/adolescent <br /> Medicaid only 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 /> 90744SL Hepatitis B vaccine(Hep B),pediatric/adolescent <br /> Medicaid only dosage,3 dose-RECOMBIVAX HB PEDS $0.00 2019 <br />