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Manager Recommended Fee Schedule - FY 2022-23 48
<br /> Last
<br /> Department/Program Description Current Fee Revision
<br /> 90474 Immunization Adm.-Intranasal/Oral Additional $20.45 2022
<br /> Meningococcal recombinant protein and outer
<br /> 90620 membrane vesicle vaccine,serogroup B(MenB-4C),2
<br /> dose schedule-BEXSERO $169.72 2022
<br /> 90620SL Meningococcal recombinant protein and outer
<br /> membrane vesicle vaccine,serogroup B(MenB-4C),2
<br /> Medicaid only dose schedule-BEXSERO $0.00 2019
<br /> 90621 Meningococcal recombinant lipoprotein vaccine,
<br /> serogroup B,2 or 3 dose schedule-TRUMENBA $138.93 2022
<br /> 90621 SL 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 $40.70 2022
<br /> Medicaid only 90632SL Hepatitis A vaccine,adult dose-HAVRIX $0.00 2019
<br /> 90633 Hepatitis A vaccine,pediatric/adolescent dose,2 dose
<br /> HAVRIX $28.44 2022
<br /> 90633SL Hepatitis A vaccine,pediatric/adolescent dose,2 dose
<br /> Medicaid only HAVRIX $0.00 2019
<br /> 90636 Hepatitis A and Hepatitis B recombinant vaccine,3
<br /> doses-TWINRIX $87.50 2022
<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-OMP
<br /> conjugate,3 dose-PedVaxHIB $28.80 2022
<br /> 90647SL Hemophilus Influenzae B vaccine(Hib),PRP-OMP
<br /> Medicaid only conjugate,3 dose-PedVaxHIB $0.00 2019
<br /> 90648 Hemophilus Influenzae B vaccine(Hib),PRP-T
<br /> conjugate,4 dose-ActHIB $11.78 2022
<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, 18,31,
<br /> 90651 33,45,52,58,nonavalent(HPV),2 or 3 dose-
<br /> GARDASIL 9 $253.60 2022
<br /> Human Papillomavirus vaccine types 6, 11, 16, 18,31,
<br /> 90651 SL 33,45,52,58,nonavalent(HPV),2 or 3 dose-
<br /> Mcdicaid only GARDASIL 9 $0.00 2019
<br /> 90662 Influenza vaccine(IIV3-HD),for 65 years of age and
<br /> up-FLUZONE HIGH DOSE $59.34 2022
<br /> 90670 Pneumococcal conjugate vaccine, 13 valent(PCV13)-
<br /> PREVNAR 13 $209.61 2022
<br /> 90670SL Pneumococcal conjugate vaccine, 13 valent(PCV13)-
<br /> Medicaid only PREVNAR 13 $0.00 2019
<br /> 90675 Rabies Vaccine-IMOVAX RABIES $364.12 2022
<br /> 90680 Rotavirus vaccine,pentavalent(RV5),3 dose-
<br /> ROTATEQ $90.42 2022
<br /> 90680SL Rotavirus vaccine,pentavalent(RV5),3 dose-
<br /> Medicaid only ROTATEQ $0.00 2019
<br /> 90681 Rotavirus vaccine,human,attenuated(RVI),live,
<br /> oral,2 dose-ROTARIX J$119.89 2022
<br /> 90681SL Rotavirus vaccine,human,attenuated(RVI),live,
<br /> Medicaid only oral,2 dose-ROTARIX $0.00 2019
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