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Manager Recommended Fee Schedule ® F'Y 0 - 3 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 aceme (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 aceme (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 aceme (DT04PV),
<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 $ 105428 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 (MN1IZ),
<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 2019
<br /> 90716 Varicella virus vaccine (VAR), live - VARIVAX $ 177000 12019
<br /> Medicaid only 90716SL Varicella virus vaccine (VAR), live - VARIVAX $ 0 . 00 2019
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