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65 <br /> Commissioner Approved <br /> Fee Changes for Last <br /> Department/Program Description Current Fee FY 2021-22* Revision <br /> Diphteria,tetanus toxoids,acellular pertussis <br /> 90698 vaccine,haemophilus influenza Type B,and <br /> inactivated poliovirus vaccine(DTaP-IPV/Hib)- <br /> PENTACEL $101.00 2019 <br /> Diphteria,tetanus toxoids,acellular pertussis <br /> 90698SL vaccine,haemophilus influenza Type B,and <br /> inactivated poliovirus vaccine(DTaP-IPV/Hib)- <br /> Medicaid only PENTACEL $0.00 2019 <br /> Diphteria,tetanus toxoids,and acellular pertussis <br /> 90700 vaccine(DTaP),for 7 years or younger - <br /> DAPTACEL 2019 <br /> Diphteria,tetanus toxoids,and acellular pertussis <br /> 90700SL vaccine(DTaP),for 7 years or younger - <br /> Medicaid only DAPTACEL $0.00 2019 <br /> Diphteria,tetanus toxoids,and acellular pertussis <br /> 90700 vaccine(DTaP),for 7 years or younger - <br /> INFANRIX $32.00 2018 <br /> Diphteria,tetanus toxoids,and acellular pertussis <br /> 90700SL vaccine(DTaP),for 7 years or younger - <br /> Medicaid only INFANRIX $0.00 2019 <br /> 90707 Measles,mumps,and rubella virus vaccine <br /> (MMR),live-M-M-R Il $101.00 2019 <br /> 90707SL Measles,mumps,and rubella virus vaccine <br /> Medicaid only (MMR),live-M-M-R 1I $0.00 2019 <br /> 90710 Measles,mumps,and rubella AND varicella virus <br /> vaccine,live-PROQUAD $260.00 2020 <br /> 90713 Poliovirus vaccine(IPV),inactivated-IPOL $34.00 2019 <br /> Medicaid only 90713SL Poliovirus vaccine(IPV),inactivated-IPOL $0.00 2019 <br /> 90714 Tetatus and diphteria toxoids(Td)adsorbed, <br /> preservative free,for 7 years or older-TENIVAC $35.00 2018 <br /> 90714SL Tetatus and diphteria toxoids(Td)adsorbed, <br /> Medicaid only preservative free,for 7 years or older-TENIVAC $0.00 2019 <br /> 90715 Tetanus,diphteria toxoids and acellular pertussis <br /> vaccine(Tdap),for to 7 years or older-ADACEL $39.49 2018 <br /> 90715SL Tetanus,diphteria toxoids and acellular pertussis <br /> Medicaid only vaccine(Tdap),for to 7 years or older-ADACEL $0.00 2019 <br />