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Commissioner Approved Fee Schedule - FY 2024-25 48
<br /> Last
<br /> Department/Program Description Current Fee Revision
<br /> Diphtheria,tetanus toxoids,acellular pertussis vaccine,
<br /> 90697 haemophilus influenza Type B,inactivated poliovirus
<br /> vaccine and Hep B(DTaP-IPV/Hib)6 weeks through
<br /> 4 years-Vaxelis $134.53 2023
<br /> 90698 Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> haemophilus influenza Type B,and inactivated
<br /> poliovirus vaccine(DTaP-IPV/Hib)-PENTACEL $109.50 2024
<br /> 90698SL Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> 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 $27.71 2024
<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 $24.46 2024
<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 $92.49 2024
<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
<br /> $89.79 2024
<br /> 90710 Measles,mumps,and rubella AND varicella virus
<br /> vaccine,live-PROQUAD $270.14 2024
<br /> 90713 Poliovirus vaccine(IPV),inactivated-IPOL $40.49 2024
<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 $35.75 2024
<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 $46.04 2024
<br /> 90715 SL 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 $41.46 2024
<br /> 90716 Varicella virus vaccine(VAR),live-VARNAX $174.32 2024
<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 $73.01 2024
<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
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