| Code | Description | States | Median rate |
|---|---|---|---|
| 90371 | Hepatitis B immune globulin, intramuscular | 27 | $136.95 |
| 90375 | Rabies immune globulin, intramuscular or wound | 35 | $280.37 |
| 90376 | Rabies immune globulin, heat-treated | 30 | $453.04 |
| 90377 | Rabies immune globulin, heat and solvent-detergent treated | 26 | $243.20 |
| 90378 | RSV monoclonal antibody (palivizumab), 50 mg | 20 | $1,348.54 |
| 90380 | RSV monoclonal antibody (nirsevimab), 0.5 mL | 23 | $537.94 |
| 90381 | RSV monoclonal antibody (nirsevimab), 1 mL | 23 | $519.75 |
| 90384 | Rho(D) immune globulin, full dose, intramuscular | 18 | $85.31 |
| 90385 | Rho(D) immune globulin, mini-dose, intramuscular | 21 | $29.73 |
| 90389 | Tetanus immune globulin, intramuscular | 14 | $497.06 |
| 90396 | Varicella-zoster immune globulin, intramuscular | 20 | $2,166.41 |
| 90460 | Vaccine administration with counseling, first component, through age 18 | 35 | $19.68 |
| 90461 | Vaccine administration with counseling, each added component | 21 | $8.00 |
| 90471 | Vaccine administration, one injection | 40 | $17.94 |
| 90472 | Vaccine administration, each added injection | 39 | $13.08 |
| 90473 | Vaccine administration, nasal or oral, one vaccine | 38 | $14.53 |
| 90474 | Vaccine administration, nasal or oral, each added vaccine | 38 | $10.62 |
| 90480 | COVID-19 vaccine administration | 39 | $34.88 |
| 90581 | Anthrax vaccine | 13 | $99.00 |
| 90585 | BCG vaccine for TB, percutaneous | 22 | $174.90 |
| 90586 | BCG for bladder cancer, intravesical | 23 | $163.97 |
| 90587 | Dengue vaccine | 11 | $66.00 |
| 90611 | Smallpox and mpox vaccine (Jynneos) | 24 | $276.31 |
| 90619 | Meningococcal ACWY conjugate vaccine (MenQuadfi) | 33 | $171.97 |
| 90620 | Meningococcal B vaccine, 4-component (Bexsero) | 36 | $236.76 |
| 90621 | Meningococcal B vaccine, FHbp (Trumenba) | 35 | $206.57 |
| 90625 | Cholera vaccine, live, oral | 15 | $285.96 |
| 90626 | Tick-borne encephalitis vaccine, 0.25 mL | 16 | $319.10 |
| 90627 | Tick-borne encephalitis vaccine, 0.5 mL | 16 | $319.10 |
| 90632 | Hepatitis A vaccine, adult dose | 36 | $75.73 |
| 90633 | Hepatitis A vaccine, pediatric, 2-dose | 27 | $39.13 |
| 90636 | Hepatitis A and B vaccine, adult | 34 | $132.43 |
| 90647 | Hib vaccine (PRP-OMP), 3-dose | 32 | $28.82 |
| 90648 | Hib vaccine (PRP-T), 4-dose | 33 | $13.54 |
| 90649 | HPV vaccine, 4-valent | 21 | $141.38 |
| 90650 | HPV vaccine, 2-valent | 17 | $130.30 |
| 90651 | HPV vaccine, 9-valent | 37 | $307.61 |
| 90653 | Flu vaccine, trivalent, adjuvanted, 65 and older | 34 | $96.84 |
| 90655 | Flu vaccine, trivalent, preservative-free, 6-35 months | 19 | $17.15 |
| 90656 | Flu vaccine, trivalent, preservative-free, 3 and older | 37 | $22.34 |
| 90657 | Flu vaccine, trivalent, 6-35 months | 31 | $10.98 |
| 90658 | Flu vaccine, trivalent, 3 and older | 37 | $21.86 |
| 90660 | Flu vaccine, trivalent, live, nasal spray | 36 | $28.87 |
| 90661 | Flu vaccine, trivalent, cell-culture based | 36 | $46.69 |
| 90662 | Flu vaccine, high-dose, 65 and older | 35 | $91.91 |
| 90670 | Pneumococcal conjugate vaccine, 13-valent | 34 | $257.98 |
| 90671 | Pneumococcal conjugate vaccine, 15-valent | 36 | $252.15 |
| 90672 | Flu vaccine, quadrivalent, live, nasal spray | 27 | $25.44 |
| 90673 | Flu vaccine, trivalent, recombinant | 35 | $90.83 |
| 90674 | Flu vaccine, quadrivalent, cell-culture based, 6 months up | 28 | $32.28 |
| 90675 | Rabies vaccine, intramuscular | 36 | $329.88 |
| 90676 | Rabies vaccine, intradermal | 12 | $123.88 |
| 90677 | Pneumococcal conjugate vaccine, 20-valent | 36 | $306.53 |
| 90680 | Rotavirus vaccine, oral, 3-dose | 27 | $97.06 |
| 90681 | Rotavirus vaccine, 2-dose series, oral | 29 | $140.56 |
| 90682 | Flu vaccine, quadrivalent, recombinant | 27 | $66.95 |
| 90683 | RSV vaccine, mRNA | 22 | $315.81 |
| 90685 | Flu vaccine, quadrivalent, preservative-free, 6-35 months | 23 | $19.25 |
| 90686 | Flu vaccine, quadrivalent, preservative-free, age 3+ | 28 | $20.65 |
| 90687 | Flu vaccine, quadrivalent, 6-35 months | 24 | $10.00 |
| 90688 | Flu vaccine, quadrivalent, multi-dose vial | 27 | $19.84 |
| 90690 | Typhoid vaccine, live, oral | 22 | $68.19 |
| 90691 | Typhoid vaccine, Vi polysaccharide, injection | 28 | $123.68 |
| 90694 | Flu vaccine, quadrivalent, adjuvanted, 0.5 mL | 25 | $73.49 |
| 90696 | DTaP-IPV combination vaccine, age 4-6 | 27 | $61.57 |
| 90697 | Six-in-one pediatric vaccine (DTaP-IPV-Hib-HepB) | 24 | $158.97 |
| 90698 | DTaP-Hib-IPV combination vaccine | 27 | $113.31 |
| 90700 | DTaP vaccine, under age 7 | 27 | $28.00 |
| 90702 | Diphtheria and tetanus (DT) vaccine, child | 23 | $28.86 |
| 90707 | MMR vaccine | 36 | $95.20 |
| 90710 | MMR-varicella combination vaccine | 29 | $271.63 |
| 90713 | Polio vaccine, injectable (IPV) | 34 | $44.73 |
| 90714 | Tetanus and diphtheria (Td) vaccine, preservative-free | 37 | $38.97 |
| 90715 | Tdap vaccine, age 7+ | 38 | $40.05 |
| 90716 | Varicella (chickenpox) vaccine | 36 | $182.25 |
| 90717 | Yellow fever vaccine | 24 | $252.22 |
| 90723 | DTaP-HepB-IPV combination vaccine | 27 | $90.04 |
| 90732 | Pneumococcal polysaccharide vaccine, 23-valent | 38 | $133.47 |
| 90733 | Meningococcal polysaccharide vaccine, 4-valent | 19 | $106.49 |
| 90734 | Meningococcal conjugate vaccine (MenACWY) | 36 | $161.67 |
| 90736 | Shingles vaccine, live (Zostavax) | 19 | $165.59 |
| 90738 | Japanese encephalitis vaccine, intramuscular | 14 | $303.64 |
| 90739 | Hepatitis B vaccine, adult, 2-dose (Heplisav) | 36 | $170.05 |
| 90740 | Hepatitis B vaccine, dialysis or immunosuppressed, 3-dose | 36 | $164.42 |
| 90743 | Hepatitis B vaccine, adolescent, 2-dose | 30 | $70.88 |
| 90744 | Hepatitis B vaccine, pediatric, 3-dose | 34 | $30.51 |
| 90746 | Hepatitis B vaccine, adult | 37 | $72.65 |
| 90747 | Hepatitis B vaccine, dialysis or immunosuppressed, 4-dose | 35 | $144.81 |
| 90748 | Hepatitis B and Hib vaccine | 18 | $42.62 |
| 90750 | Shingles vaccine, recombinant (add-on schedule) | 33 | $215.51 |
| 90756 | Flu vaccine, quadrivalent, cell-culture, antibiotic-free | 26 | $30.67 |
| 90759 | Hepatitis B vaccine, 3-antigen, adult (PreHevbrio) | 26 | $73.81 |
| 90901 | Biofeedback training, any method | 15 | $35.29 |
| 90912 | Biofeedback for pelvic floor muscles, first 15 minutes | 24 | $64.62 |
| 90913 | Biofeedback for pelvic floor muscles, each added 15 min | 24 | $25.92 |
| 90935 | Hemodialysis, single physician evaluation | 47 | $57.80 |
| 90937 | Hemodialysis with repeated physician evaluations | 46 | $92.03 |
| 90945 | Dialysis other than hemodialysis, single evaluation | 47 | $67.52 |
| 90951 | Monthly dialysis care, under age 2, 4+ visits | 44 | $859.48 |
| 90952 | Monthly ESRD care, age 2-11, 2-3 visits | 28 | $520.98 |
| 90953 | Monthly ESRD care, age 2-11, 1 visit | 28 | $374.02 |
| 90954 | Monthly dialysis care, age 2 to 11, 4+ visits | 44 | $755.04 |
| 90955 | Monthly dialysis care, age 2 to 11, 2 to 3 visits | 44 | $409.42 |
| 90956 | Monthly dialysis care, age 2 to 11, 1 visit | 43 | $292.83 |
| 90957 | Monthly dialysis care, age 12 to 19, 4+ visits | 44 | $575.43 |
| 90958 | Monthly dialysis care, age 12 to 19, 2 to 3 visits | 44 | $393.46 |
| 90959 | Monthly dialysis care, age 12 to 19, 1 visit | 44 | $267.66 |
| 90960 | Monthly dialysis management, age 20+, 4+ visits | 44 | $276.63 |
| 90961 | Monthly dialysis management, age 20+, 2-3 visits | 44 | $230.40 |
| 90962 | Monthly dialysis care, age 20 and over, 1 visit | 44 | $171.82 |
| 90963 | Monthly home dialysis care, under age 2 | 42 | $491.60 |
| 90964 | Monthly home dialysis care, age 2 to 11 | 42 | $412.05 |
| 90965 | Monthly home dialysis care, age 12 to 19 | 42 | $390.32 |
| 90966 | Monthly home dialysis management, age 20+ | 42 | $225.63 |
| 90967 | Dialysis-related care, per day, under age 2 | 45 | $15.62 |
| 90968 | Dialysis-related care, per day, age 2 to 11 | 45 | $13.70 |
| 90969 | Dialysis-related care, per day, age 12 to 19 | 45 | $13.63 |
| 90970 | Daily dialysis management, less than a full month | 45 | $7.62 |
| 90989 | Dialysis training, completed course | 29 | $397.17 |
| 90993 | Dialysis training, per session | 27 | $20.20 |
| 90997 | Hemoperfusion (blood filtering through resin or charcoal) | 34 | $78.98 |
| 90999 | Unlisted dialysis procedure | 12 | $145.34 |
Published Medicaid fee-for-service schedule amounts, not a coverage or eligibility guarantee. Managed-care plan rates can differ. Where no prior-authorization flag is shown, the state does not publish one. Descriptions are ProviderSignal's own plain-language labels or public-domain CMS text.