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Manager Recommended Fee Schedule - F 'Y 2022 -23 50
<br /> Last
<br /> Department/Program Description Current Fee Revision
<br /> Diphteria, tetanus toxoids, acellular pertussis vaccine,
<br /> 90723 Hepatitis B , and inactivated poliovirus vaccine (DTaP-
<br /> Hep B -IPV) - PEDIARIX $ 74 . 20 2022
<br /> Diphteria, tetanus toxoids, acellular pertussis vaccine,
<br /> 90723SL Hepatitis B , and inactivated poliovirus vaccine (DTaP -
<br /> Medicaid only Hep B -IPV) - PEDIARIX $ 0 . 00 2019
<br /> Pneumococcal polysaccharide vaccine, 23 -valent
<br /> 90732 (PPSV23 ), adult or immunosuppressed patient dosage,
<br /> when administered to 2 years or older -
<br /> PNEUMOVAX 23 $ 117008 2022
<br /> Pneumococcal polysaccharide vaccine, 23 -valent
<br /> 90732SL (PPSV23 ), adult or immunosuppressed patient dosage,
<br /> when administered to 2 years or older -
<br /> Medicaid only PNEUMOVAX 23 $ 0 . 00 2019
<br /> 90734 Meningococcal conjugate vaccine, serogroups A, C,Y
<br /> and W- 135 quad (MenACWY or MCV4) - MENVEO $ 114630 2022
<br /> 90734SL Meningococcal conjugate vaccine, serogroups A, C,Y
<br /> Medicaid only and W435 quad (MenACWY or MCV4) - MENVEO $ 0 . 00 2019
<br /> Meningococcal conjugate vaccine, serogroups A, C,Y
<br /> 90734 and W- 135 quad (MenACWY or MCV4) -
<br /> MENACTRA $ 141 . 00 2022
<br /> Meningococcal conjugate vaccine, serogroups A, C, Y
<br /> 90734SL and W435 quad (MenACWY or MCV4) -
<br /> Medicaid only MENACTRA $ 0 . 00 2019
<br /> 90744 Hepatitis B vaccine (Hep B), pediatric/adolescent
<br /> dosage, 3 dose - ENGERIX PEDS $ 17 . 06 2022
<br /> 90744SL Hepatitis B vaccine (Hep B), pediatric/adolescent
<br /> Medicaid only dosage, 3 dose - ENGERIX PEDS $ 0 . 00 2019
<br /> 90744 Hepatitis B vaccine (Hep B), pediatric/adolescent
<br /> dosage, 3 dose - RECOMBIVAX BB PEDS $20 . 14 2022
<br /> 90744SL Hepatitis B vaccine (Hep B), pediatric/adolescent
<br /> Medicaid only dosage, 3 dose - RECOMBIVAX BB PEDS $ 0 . 00 2019
<br /> 90746 Hepatitis B vaccine (Hep B), adult dosage -
<br /> ENGERIX-B $43 . 12 2022
<br /> 90746SL Hepatitis B vaccine (Hep B), adult dosage -
<br /> Medicaid only ENGERIX-B $ 0 . 00 2019
<br /> 90739 Hepatitis B vaccine (Hep B), adult dosage, 2 dose -
<br /> HEPLISAV $ 108AI 2022
<br /> 90739SL Hepatitis B vaccine (Hep B), adult dosage, 2 dose -
<br /> HEPLISAV $ 0 . 00 2019
<br /> 90750 Zoster Vaccine recombinant, adjuvanted, 50 years or
<br /> older " SHINGRIX $ 161 . 85 2022
<br /> 90750SL Zoster Vaccine recombinant, adjuvanted, 50 years or
<br /> Medicaid only older - SHINGRIX $ 0 . 00 2019
<br /> 90772 Therapeutic prophylactic/diagonostic injection $23 . 00 2008
<br /> 90846 Psychotherapy, Family, w/o Patient $95 . 00 2009
<br /> 90847 Psychotherapy, Family, (Conjoint) W/Pt Present $ 115000 2009
<br /> 90853 Psychotherapy, Group $32 . 00 2009
<br /> 92551 Audiometry $ 18 . 00 2008
<br /> 92587 OAE (Limited) $ 100000 2012
<br /> 93000 Electrocardiogram, Complete $33 . 00 2009
<br /> 93005 JElectrocardiogram, Tracing Only $22 . 00 12009
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