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Commissioner Approved Fee Schedule - FY 2024-25 49 <br /> Last <br /> Department/Program Description Current Fee Revision <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 $130.92 2024 <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 /> 90744 Hepatitis B vaccine(Hep B),pediatric/adolescent <br /> dosage,3 dose-ENGERIX PEDS $19.09 2024 <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 HB PEDS $31.32 2024 <br /> 90744SL Hepatitis B vaccine(Hep B),pediatric/adolescent <br /> Medicaid only dosage,3 dose-RECOMBIVAX HB PEDS $0.00 2019 <br /> 90746 Hepatitis B vaccine(Hep B),adult dosage- <br /> ENGERIX-B $49.69 2024 <br /> 90746SL Hepatitis B vaccine(Hep B),adult dosage- <br /> Medicaid only ENGERIX-B $0.00 2019 <br /> 90746 Hepatitis B vaccine(Hep B),adult 20 years and older, <br /> 3 dose-RECOMBIVAX HB ADULT $55.26 2024 <br /> 90739 Hepatitis B vaccine(Hep B),adult dosage,2 dose- <br /> HEPLISAV $156.30 2024 <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 $197.70 2024 <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 $115.00 2009 <br /> 90853 Psychotherapy,Group $32.00 2009 <br /> 92551 Audiometry $18.00 2008 <br /> 92587 OAE(Limited) $100.00 2012 <br /> 93000 Electrocardiogram,Complete $33.00 2009 <br /> 93005 Electrocardiogram,Tracing Only $22.00 2009 <br /> 94150 Peak Flow $18.00 2024 <br /> 94640 Airway Inhalation Treatment $22.00 2009 <br /> 94664 Aerosol Inhalation Treatment-Teaching $22.00 2009 <br /> 94760 Pulse Oxygen $8.00 2009 <br />