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Commissioner Approved Fee Schedule - FY 2025-26 56
<br /> Last
<br /> Department/Program Description Current Fee Revision
<br /> Medicaid Only 90713 SL Poliovirus vaccine(IPV),inactivated-IPOL $0.00 2019
<br /> 90714 Tetatus and diphteria toxoids(Td)adsorbed,preservative $37.20 2025
<br /> free,for 7 years or older-TENIVAC
<br /> 90714SL Tetatus and diphteria toxoids(Td)adsorbed,preservative $0.00 2019
<br /> Medicaid Only free,for 7 years or older-TENIVAC
<br /> 90715 Tetanus,diphtheria toxoids and acellular pertussis vaccine $41.46 2024
<br /> Tda ,for to 7 years or older-BOOSTRIX
<br /> 90715SL Tetanus,diphteria toxoids and acellular pertussis vaccine $0.00 2019
<br /> Medicaid Only (Tdap),for to 7 years or older-ADACEL
<br /> 90716 Varicella virus vaccine(VAR),live-VARIVAX $182.25 2025
<br /> Medicaid Only 90716SL Varicella virus vaccine(VAR),live-VAR IVAX $0.00 2019
<br /> Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> 90723 Hepatitis B,and inactivated poliovirus vaccine(DTaP-Hep $73.42 2025
<br /> B-IP -PEDIARIX
<br /> Diphteria,tetanus toxoids,acellular pertussis vaccine,
<br /> 90723SL Hepatitis B,and inactivated poliovirus vaccine(DTaP-Hep B$0.00 2019
<br /> Medicaid Only IPV)-PEDIARIX
<br /> Pneumococcal polysaccharide vaccine,23-valent(PPSV23),
<br /> 90732SL adult or immunosuppressed patient dosage,when $0.00 2019
<br /> Medicaid Only administered to 2 years or older-PNEUMOVAX 23
<br /> 90734 Meningococcal conjugate vaccine,serogroups A,C,Y and W- $130.92 2024
<br /> 135 quad MenACWY or MCV4 -MENVEO
<br /> 90734SL Meningococcal conjugate vaccine,serogroups A,C,Y and W- $0.00 2019
<br /> Medicaid Only 135 quad MenACWY or MCV4 -MENVEO
<br /> 90734SL Meningococcal conjugate vaccine,serogroups A,C,Y and W- $0.00 2019
<br /> Medicaid Only 135 quad MenACWY or MCV4 -MENACTRA
<br /> 90739SL Hepatitis B vaccine(Hep B),adult dosage,2 dose- $0.00 2019
<br /> Medicaid Only HEPLISAV
<br /> 90744 Hepatitis B vaccine(Hep B),pediatric/adolescent dosage,3 $19.09 2024
<br /> dose-ENGERIX PEDS
<br /> 90744SL Hepatitis B vaccine(Hep B),pediatric/adolescent dosage,3 $0.00 2019
<br /> Medicaid Only dose-ENGERIX PEDS
<br /> 90744SL Hepatitis B vaccine(Hep B),pediatric/adolescent dosage,3 $0.00 2019
<br /> Medicaid Only dose-RECOMBIVAX HB PEDS
<br /> 90746 Hepatitis B vaccine(Hep B),adult dosage-ENGERIX-B $50.89 2025
<br /> Medicaid Only 90746SL Hepatitis B vaccine e B),adult dosage-ENGERIX-B $0.00 2019
<br /> 90750SL Zoster Vaccine recombinant,adjuvanted,50 years or older- $0.00 2019
<br /> Medicaid Only SHINGRIX
<br /> 90772 Therapeutic prophylactic/diagonostic injection $23.00 2008
<br /> 90785 Interactive Complexity(add-on code for psychiatric services)$45.17 2025
<br /> 90791 Integrated Biopsychosocial Assessment $206.16 2025
<br /> 90832 Psychotherapy,30 min $74.01 2025
<br /> 90834 Psychotherapy,45 min $97.83 2025
<br /> 90846 Psychotherapy,Family,w/o Patient $94.08 2025
<br /> 90847 Psychotherapy,Family,(Conjoint)W/Pt Present $98.10 2025
<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 /> 96110 Developmental Test 1$23.00 12012
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