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Manager Recommended Fee Schedule - FY 2022-23 49
<br /> Last
<br /> Department/Program Description Current Fee Revision
<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 $18.42 2022
<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,preservative
<br /> free, 18 year and above-FLUBLOK $59.34 2022
<br /> Diphteria,tetanus toxoid,and acellular pertussis
<br /> 90696 vaccine and inactivated poliovirus accine(DTaP-IPV),
<br /> for 4 to 6 years of age-KINRIX $53.67 2022
<br /> Diphteria,tetanus toxoid,and acellular pertussis
<br /> 90696SL vaccine and inactivated poliovirus accine(DTaP-IPV),
<br /> Medicaid only 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-IPV),
<br /> for 4 to 6 years of age-QUADRACEL $54.50 2022
<br /> Diphteria,tetanus toxoid,and acellular pertussis
<br /> 90696SL vaccine and inactivated poliovirus accine(DTaP-IPV),
<br /> Medicaid only for 4 to 6 years of age-QUADRACEL $0.00 2019
<br /> Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> 90698 haemophilus influenza Type B,and inactivated
<br /> poliovirus vaccine(DTaP-IPV/Hib)-PENTACEL $105.28 2022
<br /> Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> 90698SL haemophilus influenza Type B,and inactivated
<br /> Medicaid only poliovirus vaccine(DTaP-IPV/Hib)-PENTACEL $0.00 2019
<br /> 90700 Diphteria,tetanus toxoids,and acellular pertussis
<br /> vaccine(DTaP),for 7 years or younger -DAPTACEL$26.02 2022
<br /> 90700SL Diphteria,tetanus toxoids,and acellular pertussis
<br /> Medicaid only vaccine(DTaP),for 7 years or younger -DAPTACEL$0.00 2019
<br /> 90700 Diphteria,tetanus toxoids,and acellular pertussis
<br /> vaccine(DTaP),for 7 years or younger -INFANRIX $21.53 2022
<br /> 90700SL Diphteria,tetanus toxoids,and acellular pertussis
<br /> Medicaid only vaccine(DTaP),for 7 years or younger -INFANRIX $0.00 2019
<br /> 90707 Measles,mumps,and rubella virus vaccine(MMR),
<br /> live-M-M-R II $87.31 2022
<br /> 90707SL Measles,mumps,and rubella virus vaccine(MMR),
<br /> Medicaid only live-M-M-R II $0.00 2019
<br /> 90710 Measles,mumps,and rubella AND varicella virus
<br /> vaccine,live-PROQUAD $250.01 2022
<br /> 90713 Poliovirus vaccine(IPV),inactivated-IPOL $36.80 2022
<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 $33.07 2022
<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 $43.12 2022
<br /> 90715SL Tetanus,diphteria toxoids and acellular pertussis
<br /> Medicaid only vaccine(Tdap),for to 7 years or older-ADACEL $0.00 12019
<br /> 90716 Varicella virus vaccine(VAR),live-VARIVAX $177.00 12019
<br /> Medicaid only 90716SL lVaricella virus vaccine(VAR),live-VARIVAX $0.00 12019
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