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Commissioner Approved Fee Schedule - FY 2024-25 47
<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 $287.53 2024
<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(PCV 13)-
<br /> PREVNAR 13 $224.13 2024
<br /> 90670SL Pneumococcal conjugate vaccine, 13 valent(PCV 13)-
<br /> Medicaid only PREVNAR 13 $0.00 2019
<br /> 90671 Pneumoccal 15-valent conjugate vaccine 6 weeks
<br /> through 17 ears-VAXNEUVANCE $222.54 2024
<br /> 90675 Rabies Vaccine-IMOVAX RABIES $393.80 2024
<br /> 90677 Pneumococcal 20 valent conjugate vaccine-
<br /> PREVNAR 20 adults 18 years and older $251.35 2024
<br /> 90678 ABRYSVO(Respiratory Syncytial Virus vaccine,
<br /> preF,subunit,bivalent,for intramuscular use)0.5 mL
<br /> solution for intramuscular injection $292.05 2024
<br /> 90680 Rotavirus vaccine,pentavalent(RV5),3 dose-
<br /> ROTATEQ $99.95 2024
<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 $130.93 2024
<br /> 90681 SL Rotavirus vaccine,human,attenuated(RV I),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(I1V4),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 $56.23 2024
<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 $58.70 2024
<br /> Diphteria,tetanus toxoid,and acellular pertussis
<br /> 90696SL vaccine and inactivated poliovirus accine(DTaP-IPV),
<br /> Medicaid only I for 4 to 6 years of age-QUADRACEL J$0.00 2019
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