|
Commissioner Approved Fee Schedule - FY 2023-24 52
<br /> Last
<br /> Department/Program Description Current Fee Revision
<br /> 90700 Diphteria,tetanus toxoids,and acellular pertussis
<br /> vaccine(DTaP),for 7 years or younger -DAPTACEL $26.74 2023
<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 $23.82 2023
<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 H $89.86 2023
<br /> 90707SL Measles,mumps,and rubella virus vaccine(MMR),
<br /> Medicaid only live-M-M-R II $0.00 2019
<br /> 90707 Measles,Mumps and Rubella vaccine,live-PRIORIX $87.24 2023
<br /> 90710 Measles,mumps,and rubella AND varicella virus
<br /> vaccine,live-PROQUAD $262.36 2023
<br /> 90713 Poliovirus vaccine(IPV),inactivated-IPOL $38.60 2023
<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-TENNAC $34.44 2023
<br /> 90714SL Tetatus and diphteria toxoids(Td)adsorbed,
<br /> Medicaid only preservative free,for 7 years or older-TENNAC $0.00 2019
<br /> 90715 Tetanus,diphteria toxoids and acellular pertussis
<br /> vaccine(Tdap),for to 7 years or older-ADACEL $44.36 2023
<br /> 90715SL Tetanus,diphteria toxoids and acellular pertussis
<br /> Medicaid only vaccine(Tdap),for to 7 years or older-ADACEL $0.00 2019
<br /> 90715 Tetanus,diphtheria toxoids and acellular pertussis
<br /> vaccine(Tdap),for to 7 years or older-BOOSTRIX $40.32 2023
<br /> 90716 Varicella virus vaccine(VAR),live-VARIVAX $177.00 2019
<br /> Medicaid only 90716SL Varicella virus vaccine(VAR),live-VARNAX $0.00 2019
<br /> Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> 90723 Hepatitis B,and inactivated poliovirus vaccine(DTaP-
<br /> Hep B-IPV)-PEDIARIX $69.10 2023
<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 $117.08 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 $123.55 2023
<br /> 90734SL Meningococcal conjugate vaccine,serogroups A,C,Y
<br /> Medicaid only and W-135 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 W-135 quad(MenACWY or MCV4)-
<br /> Medicaid only MENACTRA $0.00 2019
<br />
|