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Commissioner Approved Fee Schedule - FY 2025-26 55
<br /> Last
<br /> Department/Program Description Current Fee Revision
<br /> 90633 Hepatitis
<br /> A atV itis A vaccine,pediatric/adolescent dose,2 dose- $38.38 2025
<br /> 90636SL Hepatitis A and Hepatitis B recombinant vaccine,3 doses- $0.00 2019
<br /> Medicaid Only TWINRIX
<br /> 90636 Hepatitis A and Hepatitis B recombinant vaccine,3 doses- $128.44 2025
<br /> RIX
<br /> 90647 Hemophilus Influenzae B vaccine(Hib),PRP-OMP $30.72 2025
<br /> conjugate,3 dose-PedVaxHIB
<br /> 90647SL Hemophilus Influenzae B vaccine(Hib),PRP-OMP $0.00 2019
<br /> Medicaid Only conjugate,3 dose-PedVaxHIB
<br /> 90648SL Hemophilus Influenzae B vaccine(Hib),PRP-T conjugate,4 $0.00 2019
<br /> Medicaid Only dose-ActHIB
<br /> 90651 Human Papillomavirus vaccine types 6,11,16,18,31 33, $316.07 2025
<br /> 45,52,58,nonavalent(HPV),2 or 3 dose-GARDASIL 9
<br /> Human Papillomavirus vaccine types 6,11,16,18,31,33,
<br /> Medicaid Only 90651SL 45,52,58,nonavalent(HPV),2 or 3 dose-GARDASIL 9 $0.00 2019
<br /> 90670SL Pneumococcal conjugate vaccine,13 valent(PCV 13)- $0.00 2019
<br /> Medicaid Only PREVNAR 13
<br /> 90675 Rabies Vaccine-IMOVAX RABIES $409.55 2025
<br /> 90677 Pneumococcal 20 valent conjugate vaccine-PREVNAR 20 $268.63 2025
<br /> adults 18 years and older
<br /> ABRYSVO(Respiratory Syncytial Virus vaccine,preF,
<br /> 90678 subunit,bivalent,for intramuscular use)0.5 mL solution for $303.85 2025
<br /> intramuscular injection
<br /> Medicaid Only 90680SL Rotavirus vaccine,pentavalent(RV5),3 dose-ROTATEQ $0.00 2019
<br /> 90681 Rotavirus vaccine,human,attenuated(RV1),live,oral,2 $137.99 2025
<br /> dose-ROTARIX
<br /> 90681 SL Rotavirus vaccine,human,attenuated(RV 1),live,oral,2 $0.00 2019
<br /> Medicaid Only dose-ROTARIX
<br /> 90685SL Influenza vaccine(IIV4),quadrivalent,preservative free,6 to$0.00 2019
<br /> Medicaid Only 35 months-FLUZONE PEDS
<br /> 90686SL Influenza vaccine(IIV4),quadrivalent,preservative free,3 $0.00 2019
<br /> Medicaid Only 1years and above-FLUZONE
<br /> Diphteria,tetanus toxoid,and acellular pertussis vaccine and
<br /> 90696 inactivated poliovirus accine(DTaP-IPV),for 4 to 6 years of $59.82 2025
<br /> age-KINRIX
<br /> Diphteria,tetanus toxoid,and acellular pertussis vaccine and
<br /> 90696SL inactivated poliovirus accine(DTaP-IPV),for 4 to 6 years of $0.00 2019
<br /> Medicaid Only age-KINRIX
<br /> Diphteria,tetanus toxoid,and acellular pertussis vaccine and
<br /> 90696SL inactivated poliovirus accine(DTaP-IPV),for 4 to 6 years of $0.00 2019
<br /> Medicaid Only age-QUADRACEL
<br /> Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> 90698 haemophilus influenza Type B,and inactivated poliovirus $105.50 2025
<br /> vaccine(DTaP-IPV/Hib)-PENTACEL
<br /> Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> 90698SL haemophilus influenza Type B,and inactivated poliovirus $0.00 2019
<br /> Medicaid Only vaccine DTaP-IPV/Hib -PENTACEL
<br /> Diphteria,tetanus toxoids,and acellular pertussis vaccine
<br /> 90700 $2771 2024
<br /> (DTaP),for 7 years or younger-DAPTACEL
<br /> 90700SL Diphteria,tetanus toxoids,and acellular pertussis vaccine $0.00 2019
<br /> Medicaid Only (I)Tal?),for 7 years or younger-INFANRIX
<br /> 90700SL Diphteria,tetanus toxoids,and acellular pertussis vaccine $0.00 2019
<br /> Medicaid Only DTaP,for 7 years or younger-DAPTACEL
<br /> 90707 Measles,mumps,and rubella virus vaccine(MMR),live-M-$92.95 2025
<br /> M-R II
<br /> 90707SL Measles,mumps,and rubella virus vaccine(MMR),live-M-$0.00 2019
<br /> Medicaid Only M-R II
<br /> 90713 Poliovirus vaccine(IPV),inactivated-IPOL $40.49 2024
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