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69 <br /> Commissioner Approved <br /> Fee Changes for Last <br /> Department/Program Description Current Fee FY 2021-22* Revision <br /> 99442 Telephone Evaluation 11-20 min(15) N/A $25.00 New <br /> 99443 Telephone Evaluation 21-30 min(15) N/A $30.00 New <br /> 99499 DOT Physical $100.00 2019 <br /> 99501 Home Visit Postpartum $200.00 2015 <br /> 99502 Home Visit Newborn $200.00 2015 <br /> D0145 Oral Evaluation<3 yrs with counseling $55.00 2012 <br /> D1206 Topical Fluoride Appl $47.00 2012 <br /> G0008 Admin.Influenza Vaccine-Medicare $18.00 2009 <br /> G0009 jAdmin.Pneumococcal Vaccine-Medicare $18.00 2009 <br /> G0010 Hep B.-Admin.-Medicare $18.00 2015 <br /> 2015 DSME Minimum Fee $20.00 2015 <br /> G0108 DSME/DSMT Individual Assessment-Medicare $52.00 2015 <br /> G0109 DSME/DSMT Group Class-Medicare $17.00 2015 <br /> G0270 Additional MD requested MNT indiv-Medicare $25.00 2010 <br /> G0271 Additional MD requested MNT group-Medicare $13.00 2010 <br /> H0001 Alcohol and/or drug assessment $20.00 2015 <br /> H0031 Mental health assessment,by non-physician $22.00 2015 <br /> J0696 Ceftriaxone Sodium/Rocephin per 250mg $22.00 2008 <br /> J1050 Medroxyprogesterone acetate, 1 mg(150 units) $0.23 2020 <br /> Medicaid only J1050ud Medroxyprogesterone acetate, 1 mg(150 units) $0.23 2020 <br /> J1200 IDiphenhydramine HCL/Benadryl up to 50mg $6.00 2009 <br /> J1725 Injection hydroxyprogesterone caproate, 1 mg(250 $3.00 2015 <br /> J2550 Promethazine_mg $8.00 2009 <br /> J2790 Rhogam Injection $88.00 2012 <br /> J3420 B-12 Injection $6.00 2009 <br /> J7300 Para and IUD(16) $251.56 $248.00 2020 <br /> Medicaid only J7300ud Para and IUD(16) $251.56 $248.00 2020 <br /> J7296 K Leena IUD N/A $249.00 New <br /> Medicaid only J7296ud K leena IUD N/A $249.00 New <br /> J7301 Skyla IUD $249.00 2019 <br /> Medicaid only J7301ud Skyla IUD $249.00 2019 <br /> J7297 Liletta IUD(16) $66.67 $100.00 2020 <br /> Medicaid only J7297ud Liletta IUD(16) $66.67 $100.00 2020 <br /> J7298 Mirena IUD $249.00 2019 <br /> Medicaid only J7298ud Mirena IUD $249.00 2019 <br />