|
Commissioner Approved Fee Schedule - FY 2023-24 51
<br /> Last
<br /> Department/Program Description Current Fee Revision
<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 $268.77 2023
<br /> Human Papillomavirus vaccine types 6, 11, 16, 18,31,
<br /> 90651 SL 33,45,52,58,nonavalent(HPV),2 or 3 dose-
<br /> Medicaid only GARDASIL 9 $0.00 2019
<br /> 90662 Influenza vaccine(IIV3-HD),for 65 years of age and
<br /> up-FLUZONE HIGH DOSE $62.27 2023
<br /> 90670 Pneumococcal conjugate vaccine,13 valent(PCV13)-
<br /> PREVNAR 13 $224.92 2023
<br /> 90670SL Pneumococcal conjugate vaccine, 13 valent(PCV13)-
<br /> Medicaid only PREVNAR 13 $0.00 2019
<br /> 90671 Pneumoccal 15-valent conjugate vaccine 6 weeks
<br /> through 17 ears-VAXNEUVANCE $216.08 2023
<br /> 90675 Rabies Vaccine-IMOVAX RABIES $382.33 2023
<br /> 90677 Pneumococcal 20 valent conjugate vaccine-
<br /> PREVNAR 20 adults 18 years and older $247.22 2023
<br /> 90680 Rotavirus vaccine,pentavalent(RV5),3 dose-
<br /> ROTATEQ $93.18 2023
<br /> 90680SL Rotavirus vaccine,pentavalent(RV5),3 dose-
<br /> Medicaid only ROTATEQ $0.00 2019
<br /> 90681 Rotavirus vaccine,human,attenuated(RV 1),live,
<br /> oral,2 dose-ROTARIX $127.14 2023
<br /> 90681 SL Rotavirus vaccine,human,attenuated(RV 1),live,
<br /> Medicaid only oral,2 dose-ROTARIX $0.00 2019
<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 $18.49 2023
<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 $62.27 2023
<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 $53.93 2023
<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 $53.36 2023
<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 $106.42 2023
<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 />
|