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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 (MenB4C), 2
<br /> dose schedule - BEXSERO $ 169 . 72 2022
<br /> 90620SL Meningococcal recombinant protein and outer
<br /> membrane vesicle vaccine, serogroup B (MenB4C), 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 $ 138093 2022
<br /> 90621SL 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 $28A4 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 - TVJINRIX $ 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 - PedVaXHM $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 WV), 2 or 3 dose -
<br /> GARDASIL 9 $253660 2022
<br /> Human Papillomavirus vaccine types 6, 11 , 16, 18 , 31 ,
<br /> 90651SL 33, 45 , 52, 58, nonavalent (HPV), 2 or 3 dose -
<br /> Medicaid only GARDASIL 9 $ 0 . 00 2019
<br /> 90662 Influenza vaccine (IIV3 -111)), 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 $209961 2022
<br /> 90670SL Pneumococcal conjugate vaccine, 13 valent (PCV13) -
<br /> Medicaid only PREVNAR 13 $ 0 . 00 2019
<br /> 90675 Rabies Vaccine - IMOVAX RABIES $364012 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 (RV1 ), live,
<br /> oral, 2 dose - ROTARIX J $ 119 . 89 2022
<br /> 90681 SL Rotavirus vaccine, human, attenuated (RV I ), live,
<br /> Medicaid only oral, 2 dose - ROTARIX $ 0 . 00 12019
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