Rates last updated 12/31/2021 "Rehabilitation Hospital of Indiana 4141 Shore Drive, Indianapolis IN 46254 Rehabilitation Hospital of Indiana - Northwest Brain Injury Center 9531 Valparaiso Court, Indianapolis IN 46268 Rehabilitation Hospital of Indiana - RHI Carmel Outpatient Services 12425 Old Meridian Street, Suite B2 Carmel, IN 46032" CMG Revenue Code MS_DRG CPT Modifier HCPCS CDM Public Charge Description NDC (Pharmacy) Claim Gross Charge Amount Effective Date Max Negotiated Allowed Amount Min Negotiated Allowed Amount Amount Generally Billed "Aetna, Coventry, NAP" First Health Aetna Workers Compensation Aetna Medicare Anthem Trad Anthem PPO Anthem HMO/POS Anthem Medicare ASA2 Anthem Medicaid Anthem Healthy Indiana Plan Caresource Marketplace Exchange Community Health Alliance Cigna Corvel Encore Encircle Encircle/Encore Combined THCG Workers' Compensation "Humana Commercial" "Humana Medicare" IU Health Plan Services PHCS Multiplan Sagamore Select & Plus Non DRG SIHO Suburban Health United Healthcare United Healthcare Medicare Advantage United VA "USA MCO PPO" "USA MCO Workers' Comp" NULL 272 NULL NULL NULL NULL 118 ANGIO CATH 22GX1 NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $3.76 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.29 $5.09 $4.96 $3.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.27 $5.27 $4.25 $5.79 100% of Medicare $7.20 $7.65 $7.07 $6.57 $7.20 $7.65 $6.19 100% of Medicare 100% of Medicare $6.75 200% of Medicare NULL 272 NULL NULL NULL NULL 120 ANGIO CATH 24X.75 NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $3.76 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.29 $5.09 $4.96 $3.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.27 $5.27 $4.25 $5.79 100% of Medicare $7.20 $7.65 $7.07 $6.57 $7.20 $7.65 $6.19 100% of Medicare 100% of Medicare $6.75 200% of Medicare NULL 272 NULL NULL NULL NULL 124 IV START KIT NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $2.93 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.12 $3.96 $3.86 $2.93 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.10 $4.10 $3.30 $4.50 100% of Medicare $5.60 $5.95 $5.50 $5.11 $5.60 $5.95 $4.81 100% of Medicare 100% of Medicare $5.25 200% of Medicare NULL 272 NULL NULL NULL NULL 150 DRESSING OPSITE 4X5 NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $6.27 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.82 $8.49 $8.27 $6.27 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.78 $8.78 $7.08 $9.65 100% of Medicare $12.00 $12.75 $11.78 $10.95 $12.00 $12.75 $10.31 100% of Medicare 100% of Medicare $11.25 200% of Medicare NULL 272 NULL NULL NULL NULL 332 Suture Strips 1/2x4 NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.34 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.70 $4.53 $4.41 $3.34 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.68 $4.68 $3.78 $5.15 100% of Medicare $6.40 $6.80 $6.28 $5.84 $6.40 $6.80 $5.50 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 509 20G X 3.5 TOUGHY SPINAL NDL NULL INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $11.70 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.47 $15.85 $15.44 $11.70 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.38 $16.38 $13.22 $18.02 100% of Medicare $22.40 $23.80 $21.98 $20.44 $22.40 $23.80 $19.25 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 272 NULL NULL NULL NULL 513 20G X 4.5 TOUGHY SPINAL NDL NULL INSTITUTIONAL $904.00 1/1/2022-12/31/2022 $904.00 $377.87 $515.28 $664.44 $664.44 200% of Medicare 100% of Medicare $531.64 $511.75 $498.38 $377.87 100% of Medicaid 100% of Medicare 150% of Medicare $723.20 $904.00 195% of Medicare $732.24 $528.84 $528.84 $426.69 $581.63 100% of Medicare $723.20 $768.40 $709.64 $659.83 $723.20 $768.40 $621.50 100% of Medicare 100% of Medicare $678.00 200% of Medicare NULL 272 NULL NULL NULL NULL 522 CUSTOM KIT SILBERT XRAY ONLY NULL INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $8.78 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.35 $11.89 $11.58 $8.78 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.29 $12.29 $9.91 $13.51 100% of Medicare $16.80 $17.85 $16.49 $15.33 $16.80 $17.85 $14.44 100% of Medicare 100% of Medicare $15.75 200% of Medicare NULL 272 NULL NULL NULL NULL 766 25G X 3.5 QUINCKE SPINAL NEEDL NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $6.27 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.82 $8.49 $8.27 $6.27 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.78 $8.78 $7.08 $9.65 100% of Medicare $12.00 $12.75 $11.78 $10.95 $12.00 $12.75 $10.31 100% of Medicare 100% of Medicare $11.25 200% of Medicare NULL 272 NULL NULL NULL NULL 771 CANNISTER VAC FREEDOM NULL INSTITUTIONAL $179.00 1/1/2022-12/31/2022 $179.00 $74.82 $102.03 $131.57 $131.57 200% of Medicare 100% of Medicare $105.27 $101.33 $98.68 $74.82 100% of Medicaid 100% of Medicare 150% of Medicare $143.20 $179.00 195% of Medicare $144.99 $104.72 $104.72 $84.49 $115.17 100% of Medicare $143.20 $152.15 $140.52 $130.65 $143.20 $152.15 $123.06 100% of Medicare 100% of Medicare $134.25 200% of Medicare NULL 272 NULL NULL NULL NULL 773 MEDIUM DRESSING VAC FREEDOM NULL INSTITUTIONAL $257.00 1/1/2022-12/31/2022 $257.00 $107.43 $146.49 $188.90 $188.90 200% of Medicare 100% of Medicare $151.14 $145.49 $141.68 $107.43 100% of Medicaid 100% of Medicare 150% of Medicare $205.60 $257.00 195% of Medicare $208.17 $150.35 $150.35 $121.30 $165.35 100% of Medicare $205.60 $218.45 $201.75 $187.58 $205.60 $218.45 $176.69 100% of Medicare 100% of Medicare $192.75 200% of Medicare NULL 272 NULL NULL NULL NULL 837 IV EXTENSION SET 6 SMALLBORE'' NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $2.93 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.12 $3.96 $3.86 $2.93 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.10 $4.10 $3.30 $4.50 100% of Medicare $5.60 $5.95 $5.50 $5.11 $5.60 $5.95 $4.81 100% of Medicare 100% of Medicare $5.25 200% of Medicare NULL 272 NULL NULL NULL NULL 1029 HEMOSTAT KELLY STRAIGHT NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.34 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.70 $4.53 $4.41 $3.34 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.68 $4.68 $3.78 $5.15 100% of Medicare $6.40 $6.80 $6.28 $5.84 $6.40 $6.80 $5.50 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 1171 CONTINU-FLO SOLUTION SET NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $4.60 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.47 $6.23 $6.06 $4.60 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.44 $6.44 $5.19 $7.08 100% of Medicare $8.80 $9.35 $8.64 $8.03 $8.80 $9.35 $7.56 100% of Medicare 100% of Medicare $8.25 200% of Medicare NULL 272 NULL NULL NULL NULL 1312 DISPOSABLE RF ELECTRODE 10CM NULL INSTITUTIONAL $423.00 1/1/2022-12/31/2022 $423.00 $176.81 $241.11 $310.91 $310.91 200% of Medicare 100% of Medicare $248.77 $239.46 $233.20 $176.81 100% of Medicaid 100% of Medicare 150% of Medicare $338.40 $423.00 195% of Medicare $342.63 $247.46 $247.46 $199.66 $272.16 100% of Medicare $338.40 $359.55 $332.06 $308.75 $338.40 $359.55 $290.81 100% of Medicare 100% of Medicare $317.25 200% of Medicare NULL 272 NULL NULL NULL NULL NULL "ELECTRODE, 10CM RADIO FREQUENCY" NULL INSTITUTIONAL $753.00 1/1/2022-12/31/2022 $753.00 $314.75 $429.21 $553.46 $553.46 200% of Medicare 100% of Medicare $442.84 $426.27 $415.13 $314.75 100% of Medicaid 100% of Medicare 150% of Medicare $602.40 $753.00 195% of Medicare $609.93 $440.51 $440.51 $355.42 $484.48 100% of Medicare $602.40 $640.05 $591.11 $549.61 $602.40 $640.05 $517.69 100% of Medicare 100% of Medicare $564.75 200% of Medicare NULL 272 NULL NULL NULL NULL 1427 23x3.5 Quincke Spinal Needle NULL INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $7.11 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.00 $9.62 $9.37 $7.11 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $9.95 $9.95 $8.02 $10.94 100% of Medicare $13.60 $14.45 $13.35 $12.41 $13.60 $14.45 $11.69 100% of Medicare 100% of Medicare $12.75 200% of Medicare NULL 272 NULL NULL NULL NULL 1448 23G X 6.0 SPINAL NEEDLE NULL INSTITUTIONAL $87.00 1/1/2022-12/31/2022 $87.00 $36.37 $49.59 $63.95 $63.95 200% of Medicare 100% of Medicare $51.16 $49.25 $47.96 $36.37 100% of Medicaid 100% of Medicare 150% of Medicare $69.60 $87.00 195% of Medicare $70.47 $50.90 $50.90 $41.06 $55.98 100% of Medicare $69.60 $73.95 $68.30 $63.50 $69.60 $73.95 $59.81 100% of Medicare 100% of Medicare $65.25 200% of Medicare NULL 272 NULL NULL NULL NULL 1453 23x5 Quincke spinal needle NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $20.90 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.41 $28.31 $27.57 $20.90 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.25 $29.25 $23.60 $32.17 100% of Medicare $40.00 $42.50 $39.25 $36.50 $40.00 $42.50 $34.38 100% of Medicare 100% of Medicare $37.50 200% of Medicare NULL 272 NULL NULL NULL NULL NULL SPINAL NEEDLE 23GX5 NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 200% of Medicare 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 272 NULL NULL NULL NULL 1550 SPINAL NEEDLE 23GX5 NULL INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $36.78 $50.16 $64.68 $64.68 200% of Medicare 100% of Medicare $51.75 $49.82 $48.51 $36.78 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $51.48 $51.48 $41.54 $56.62 100% of Medicare $70.40 $74.80 $69.08 $64.23 $70.40 $74.80 $60.50 100% of Medicare 100% of Medicare $66.00 200% of Medicare NULL 272 NULL NULL NULL NULL 1551 DISPOSABLE RF ELECTRODE 15CM NULL INSTITUTIONAL $507.00 1/1/2022-12/31/2022 $507.00 $211.93 $288.99 $372.65 $372.65 200% of Medicare 100% of Medicare $298.17 $287.01 $279.51 $211.93 100% of Medicaid 100% of Medicare 150% of Medicare $405.60 $507.00 195% of Medicare $410.67 $296.60 $296.60 $239.30 $326.20 100% of Medicare $405.60 $430.95 $398.00 $370.06 $405.60 $430.95 $348.56 100% of Medicare 100% of Medicare $380.25 200% of Medicare NULL 274 NULL NULL NULL L4396 1184 BAXTER SECONDARY TUBING NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.25 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.76 $1.70 $1.65 $1.25 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.76 $1.76 $1.42 $1.93 100% of Medicare $2.40 $2.55 $2.36 $2.19 $2.40 $2.55 $2.06 100% of Medicare 100% of Medicare $2.25 200% of Medicare NULL 420 NULL 97530 NULL NULL 420032 PT Therapeutic Activity Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 424 NULL 97161 NULL NULL 424001 PT Eval Low Complex 30 mins NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL 97162 NULL NULL 424002 PT Eval MOD Complex 30 mins NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $165.95 $226.29 $291.80 $291.80 200% of Medicare 100% of Medicare $233.48 $224.74 $218.87 $165.95 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $232.25 $232.25 $187.38 $255.43 100% of Medicare $317.60 $337.45 $311.65 $289.77 $317.60 $337.45 $272.94 100% of Medicare 100% of Medicare $297.75 200% of Medicare NULL 430 NULL 97110 NULL NULL 430005 OT Therapeutic Exercise Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97530 NULL NULL 430026 OT Therapeutic Activities Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 434 NULL 97166 NULL NULL 434002 OT Eval Mod Complex 45 mins NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 440 NULL 92507 NULL NULL 440001 SLP Auditory Processing Tx Units NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 440 NULL 92523 NULL NULL 440010 SLP Speech Sound Prod w/ Lang Comp/Exp NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 510 NULL 20552 NULL NULL 510004 Injection Single/Multiple Trigger Points 1 or 2 Muscles NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 20553 NULL NULL 510005 Injection Single/Multiple Trigger Points 3 or more Muscles NULL INSTITUTIONAL " $1,578.00 " 1/1/2022-12/31/2022 " $1,500.00 " $659.60 $899.46 " $1,159.83 " " $1,159.83 " 200% of Medicare 100% of Medicare $928.02 $893.31 $869.95 $659.60 100% of Medicaid 100% of Medicare 150% of Medicare " $1,262.40 " " $1,500.00 " 195% of Medicare " $1,278.18 " $923.13 $923.13 $744.82 " $1,015.29 " 100% of Medicare " $1,262.40 " " $1,341.30 " " $1,238.73 " " $1,151.78 " " $1,262.40 " " $1,341.30 " " $1,084.88 " 100% of Medicare 100% of Medicare " $1,183.50 " 200% of Medicare NULL 510 NULL 20605 NULL NULL 510007 Arthrocentesis/Aspiration Injection Intermediate Joint/Bursa NULL INSTITUTIONAL $852.00 1/1/2022-12/31/2022 $852.00 $356.14 $485.64 $626.22 $626.22 200% of Medicare 100% of Medicare $501.06 $482.32 $469.71 $356.14 100% of Medicaid 100% of Medicare 150% of Medicare $681.60 $852.00 195% of Medicare $690.12 $498.42 $498.42 $402.14 $548.18 100% of Medicare $681.60 $724.20 $668.82 $621.87 $681.60 $724.20 $585.75 100% of Medicare 100% of Medicare $639.00 200% of Medicare NULL 510 NULL 20610 NULL NULL 510008 Arthrocentesis/Aspiration Injection Major Joint/Bursa NULL INSTITUTIONAL $852.00 1/1/2022-12/31/2022 $852.00 $356.14 $485.64 $626.22 $626.22 200% of Medicare 100% of Medicare $501.06 $482.32 $469.71 $356.14 100% of Medicaid 100% of Medicare 150% of Medicare $681.60 $852.00 195% of Medicare $690.12 $498.42 $498.42 $402.14 $548.18 100% of Medicare $681.60 $724.20 $668.82 $621.87 $681.60 $724.20 $585.75 100% of Medicare 100% of Medicare $639.00 200% of Medicare NULL 510 NULL 27096 NULL NULL 510009 Injection Sacroiliac Joint NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 62369 NULL NULL 510013 Analysis/Reprogram/Refill Pump NULL INSTITUTIONAL " $1,476.00 " 1/1/2022-12/31/2022 " $1,476.00 " $616.97 $841.32 " $1,084.86 " " $1,084.86 " 200% of Medicare 100% of Medicare $868.04 $835.56 $813.72 $616.97 100% of Medicaid 100% of Medicare 150% of Medicare " $1,180.80 " " $1,476.00 " 195% of Medicare " $1,195.56 " $863.46 $863.46 $696.67 $949.66 100% of Medicare " $1,180.80 " " $1,254.60 " " $1,158.66 " " $1,077.33 " " $1,180.80 " " $1,254.60 " " $1,014.75 " 100% of Medicare 100% of Medicare " $1,107.00 " 200% of Medicare NULL 510 NULL 63650 NULL NULL 510014 Percutaneous Implant Neurostimulator Electrode Array Epidural NULL INSTITUTIONAL " $22,993.00 " 1/1/2022-12/31/2022 " $19,544.05 " " $1,500.00 " " $13,106.01 " " $16,899.86 " " $16,899.86 " 200% of Medicare 100% of Medicare " $13,522.18 " " $13,016.34 " " $12,676.04 " " $9,611.07 " 100% of Medicaid 100% of Medicare 150% of Medicare " $18,394.40 " " $1,500.00 " 195% of Medicare " $18,624.33 " " $13,450.91 " " $13,450.91 " " $10,852.70 " " $14,793.70 " 100% of Medicare " $18,394.40 " " $19,544.05 " " $18,049.51 " " $16,782.59 " " $18,394.40 " " $19,544.05 " " $15,807.69 " 100% of Medicare 100% of Medicare " $17,244.75 " 200% of Medicare NULL 510 NULL 64405 NULL NULL 510015 Injection Anesthetic Agent Greater Occipital Nerve NULL INSTITUTIONAL $318.00 1/1/2022-12/31/2022 $318.00 $132.92 $181.26 $233.73 $233.73 200% of Medicare 100% of Medicare $187.02 $180.02 $175.31 $132.92 100% of Medicaid 100% of Medicare 150% of Medicare $254.40 $318.00 195% of Medicare $257.58 $186.03 $186.03 $150.10 $204.60 100% of Medicare $254.40 $270.30 $249.63 $232.11 $254.40 $270.30 $218.63 100% of Medicare 100% of Medicare $238.50 200% of Medicare NULL 510 NULL 64450 NULL NULL 510022 Injection Anesthetic Agent Other Peripheral Nerve NULL INSTITUTIONAL $509.00 1/1/2022-12/31/2022 $509.00 $212.76 $290.13 $374.12 $374.12 200% of Medicare 100% of Medicare $299.34 $288.14 $280.61 $212.76 100% of Medicaid 100% of Medicare 150% of Medicare $407.20 $509.00 195% of Medicare $412.29 $297.77 $297.77 $240.25 $327.49 100% of Medicare $407.20 $432.65 $399.57 $371.52 $407.20 $432.65 $349.94 100% of Medicare 100% of Medicare $381.75 200% of Medicare NULL 510 NULL 64483 NULL NULL 510025 Injection Transforaminal Epidural Lumbar or Sacral NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64490 NULL NULL 510027 Injection Paravertebral Facet Cervical or Thoracic Single Level NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64491 NULL NULL 510028 Injection Paravertebral Facet Cervical or Thoracic Second Level NULL INSTITUTIONAL " $1,331.00 " 1/1/2022-12/31/2022 " $1,331.00 " $556.36 $758.67 $978.29 $978.29 200% of Medicare 100% of Medicare $782.76 $753.48 $733.78 $556.36 100% of Medicaid 100% of Medicare 150% of Medicare " $1,064.80 " " $1,331.00 " 195% of Medicare " $1,078.11 " $778.64 $778.64 $628.23 $856.37 100% of Medicare " $1,064.80 " " $1,131.35 " " $1,044.84 " $971.50 " $1,064.80 " " $1,131.35 " $915.06 100% of Medicare 100% of Medicare $998.25 200% of Medicare NULL 510 NULL 64492 NULL NULL 510029 Injection Paravertebral Facet Cervical or Thoracic Third Level or Add NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 64493 NULL NULL 510030 Injection Paravertebral Facet Lumbar or Sacral Single Level NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64494 NULL NULL 510031 Injection Paravertebral Facet Lumbar or Sacral Second Level NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 64495 NULL NULL 510032 Injection Paravertebral Facet Lumbar or Sacral Third Level or Add NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 64520 NULL NULL 510033 Injection Paravertebral Lumbar/Thoracic NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64611 NULL NULL 510034 " Chemodenervation Parotid/Submandibluar Salivary Glands, Bilateral" NULL INSTITUTIONAL $477.00 1/1/2022-12/31/2022 $477.00 $199.39 $271.89 $350.60 $350.60 200% of Medicare 100% of Medicare $280.52 $270.03 $262.97 $199.39 100% of Medicaid 100% of Medicare 150% of Medicare $381.60 $477.00 195% of Medicare $386.37 $279.05 $279.05 $225.14 $306.90 100% of Medicare $381.60 $405.45 $374.45 $348.16 $381.60 $405.45 $327.94 100% of Medicare 100% of Medicare $357.75 200% of Medicare NULL 510 NULL 64615 NULL NULL 510038 Chemodenervation Chronic Migraine NULL INSTITUTIONAL $520.00 1/1/2022-12/31/2022 $520.00 $217.36 $296.40 $382.20 $382.20 200% of Medicare 100% of Medicare $305.81 $294.37 $286.68 $217.36 100% of Medicaid 100% of Medicare 150% of Medicare $416.00 $520.00 195% of Medicare $421.20 $304.20 $304.20 $245.44 $334.57 100% of Medicare $416.00 $442.00 $408.20 $379.55 $416.00 $442.00 $357.50 100% of Medicare 100% of Medicare $390.00 200% of Medicare NULL 510 NULL 64616 NULL NULL 510036 Chemodenervation Neck Muscle NULL INSTITUTIONAL " $1,262.00 " 1/1/2022-12/31/2022 " $1,262.00 " $527.52 $719.34 $927.57 $927.57 200% of Medicare 100% of Medicare $742.18 $714.42 $695.74 $527.52 100% of Medicaid 100% of Medicare 150% of Medicare " $1,009.60 " " $1,262.00 " 195% of Medicare " $1,022.22 " $738.27 $738.27 $595.66 $811.97 100% of Medicare " $1,009.60 " " $1,072.70 " $990.67 $921.13 " $1,009.60 " " $1,072.70 " $867.63 100% of Medicare 100% of Medicare $946.50 200% of Medicare NULL 510 NULL 64633 NULL NULL 510039 Destruction Paravertebral Facet Cervical or Thoracic Single Level NULL INSTITUTIONAL " $2,245.00 " 1/1/2022-12/31/2022 " $1,908.25 " $938.41 " $1,279.65 " " $1,650.08 " " $1,650.08 " 200% of Medicare 100% of Medicare " $1,320.28 " " $1,270.89 " " $1,237.67 " $938.41 100% of Medicaid 100% of Medicare 150% of Medicare " $1,796.00 " " $1,500.00 " 195% of Medicare " $1,818.45 " " $1,313.33 " " $1,313.33 " " $1,059.64 " " $1,444.43 " 100% of Medicare " $1,796.00 " " $1,908.25 " " $1,762.33 " " $1,638.63 " " $1,796.00 " " $1,908.25 " " $1,543.44 " 100% of Medicare 100% of Medicare " $1,683.75 " 200% of Medicare NULL 510 NULL 64634 NULL NULL 510040 Destruction Paravertebral Facet Cervical or Thoracic Each Add Level NULL INSTITUTIONAL " $1,124.00 " 1/1/2022-12/31/2022 " $1,124.00 " $469.83 $640.68 $826.14 $826.14 200% of Medicare 100% of Medicare $661.02 $636.30 $619.66 $469.83 100% of Medicaid 100% of Medicare 150% of Medicare $899.20 " $1,124.00 " 195% of Medicare $910.44 $657.54 $657.54 $530.53 $723.18 100% of Medicare $899.20 $955.40 $882.34 $820.41 $899.20 $955.40 $772.75 100% of Medicare 100% of Medicare $843.00 200% of Medicare NULL 510 NULL 64635 NULL NULL 510072 "Destruction Neurolytic Agent, Lumbar or Sacral, Single Facet" NULL INSTITUTIONAL " $4,404.00 " 1/1/2022-12/31/2022 " $3,743.40 " " $1,500.00 " " $2,510.28 " " $3,236.94 " " $3,236.94 " 200% of Medicare 100% of Medicare " $2,589.99 " " $2,493.10 " " $2,427.93 " " $1,840.87 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,523.20 " " $1,500.00 " 195% of Medicare " $3,567.24 " " $2,576.34 " " $2,576.34 " " $2,078.69 " " $2,833.53 " 100% of Medicare " $3,523.20 " " $3,743.40 " " $3,457.14 " " $3,214.48 " " $3,523.20 " " $3,743.40 " " $3,027.75 " 100% of Medicare 100% of Medicare " $3,303.00 " 200% of Medicare NULL 510 NULL 64636 NULL NULL 510073 "Destruction Neurolytic Agent, Lumbar or Sacral, Each Additio" NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64640 NULL NULL 510041 Destruction Neurolytic Peripheral NULL INSTITUTIONAL $801.00 1/1/2022-12/31/2022 $801.00 $334.82 $456.57 $588.74 $588.74 200% of Medicare 100% of Medicare $471.07 $453.45 $441.59 $334.82 100% of Medicaid 100% of Medicare 150% of Medicare $640.80 $801.00 195% of Medicare $648.81 $468.59 $468.59 $378.07 $515.36 100% of Medicare $640.80 $680.85 $628.79 $584.65 $640.80 $680.85 $550.69 100% of Medicare 100% of Medicare $600.75 200% of Medicare NULL 510 NULL 64642 NULL NULL 510037 Chemodenervation Extremity/Trunk Muscle NULL INSTITUTIONAL " $1,448.00 " 1/1/2022-12/31/2022 " $1,448.00 " $605.26 $825.36 " $1,064.28 " " $1,064.28 " 200% of Medicare 100% of Medicare $851.57 $819.71 $798.28 $605.26 100% of Medicaid 100% of Medicare 150% of Medicare " $1,158.40 " " $1,448.00 " 195% of Medicare " $1,172.88 " $847.08 $847.08 $683.46 $931.64 100% of Medicare " $1,158.40 " " $1,230.80 " " $1,136.68 " " $1,056.90 " " $1,158.40 " " $1,230.80 " $995.50 100% of Medicare 100% of Medicare " $1,086.00 " 200% of Medicare NULL 510 NULL 64643 NULL NULL 510076 Chemodenervation extremity/ trunk muscle 1-4 muscles e NULL INSTITUTIONAL $360.00 1/1/2022-12/31/2022 $360.00 $150.48 $205.20 $264.60 $264.60 200% of Medicare 100% of Medicare $211.72 $203.80 $198.47 $150.48 100% of Medicaid 100% of Medicare 150% of Medicare $288.00 $360.00 195% of Medicare $291.60 $210.60 $210.60 $169.92 $231.62 100% of Medicare $288.00 $306.00 $282.60 $262.76 $288.00 $306.00 $247.50 100% of Medicare 100% of Medicare $270.00 200% of Medicare NULL 510 NULL 64644 NULL NULL 510077 Chemodenervation 1 extremity; 5 or more muscles NULL INSTITUTIONAL $761.00 1/1/2022-12/31/2022 $761.00 $318.10 $433.77 $559.34 $559.34 200% of Medicare 100% of Medicare $447.54 $430.80 $419.54 $318.10 100% of Medicaid 100% of Medicare 150% of Medicare $608.80 $761.00 195% of Medicare $616.41 $445.19 $445.19 $359.19 $489.63 100% of Medicare $608.80 $646.85 $597.39 $555.45 $608.80 $646.85 $523.19 100% of Medicare 100% of Medicare $570.75 200% of Medicare NULL 510 NULL 64645 NULL NULL 510078 Chemodenervation 1 extremity; each additional extremit NULL INSTITUTIONAL $380.00 1/1/2022-12/31/2022 $380.00 $158.84 $216.60 $279.30 $279.30 200% of Medicare 100% of Medicare $223.48 $215.12 $209.49 $158.84 100% of Medicaid 100% of Medicare 150% of Medicare $304.00 $380.00 195% of Medicare $307.80 $222.30 $222.30 $179.36 $244.49 100% of Medicare $304.00 $323.00 $298.30 $277.36 $304.00 $323.00 $261.25 100% of Medicare 100% of Medicare $285.00 200% of Medicare NULL 510 NULL 64646 NULL NULL 510079 Chemodenervation trunk muscle; 1-5 muscles NULL INSTITUTIONAL $761.00 1/1/2022-12/31/2022 $761.00 $318.10 $433.77 $559.34 $559.34 200% of Medicare 100% of Medicare $447.54 $430.80 $419.54 $318.10 100% of Medicaid 100% of Medicare 150% of Medicare $608.80 $761.00 195% of Medicare $616.41 $445.19 $445.19 $359.19 $489.63 100% of Medicare $608.80 $646.85 $597.39 $555.45 $608.80 $646.85 $523.19 100% of Medicare 100% of Medicare $570.75 200% of Medicare NULL 510 NULL 64647 NULL NULL 510080 Chemodenervation trunk muscle; 6 or more muscles NULL INSTITUTIONAL $831.00 1/1/2022-12/31/2022 $831.00 $347.36 $473.67 $610.79 $610.79 200% of Medicare 100% of Medicare $488.71 $470.43 $458.13 $347.36 100% of Medicaid 100% of Medicare 150% of Medicare $664.80 $831.00 195% of Medicare $673.11 $486.14 $486.14 $392.23 $534.67 100% of Medicare $664.80 $706.35 $652.34 $606.55 $664.80 $706.35 $571.31 100% of Medicare 100% of Medicare $623.25 200% of Medicare NULL 510 NULL 77002 NULL NULL 510042 Fluroscopic Guidance for Needle Placement NULL INSTITUTIONAL $406.00 1/1/2022-12/31/2022 $406.00 $169.71 $231.42 $298.41 $298.41 200% of Medicare 100% of Medicare $238.77 $229.84 $223.83 $169.71 100% of Medicaid 100% of Medicare 150% of Medicare $324.80 $406.00 195% of Medicare $328.86 $237.51 $237.51 $191.63 $261.22 100% of Medicare $324.80 $345.10 $318.71 $296.34 $324.80 $345.10 $279.13 100% of Medicare 100% of Medicare $304.50 200% of Medicare NULL 510 NULL 77003 NULL NULL 510043 Fluroscopic Guidance/Localization Needle for Spine Injection NULL INSTITUTIONAL $324.00 1/1/2022-12/31/2022 $324.00 $135.43 $184.68 $238.14 $238.14 200% of Medicare 100% of Medicare $190.54 $183.42 $178.62 $135.43 100% of Medicaid 100% of Medicare 150% of Medicare $259.20 $324.00 195% of Medicare $262.44 $189.54 $189.54 $152.93 $208.46 100% of Medicare $259.20 $275.40 $254.34 $236.49 $259.20 $275.40 $222.75 100% of Medicare 100% of Medicare $243.00 200% of Medicare NULL 510 NULL 96374 NULL NULL 510056 Therapeutic Injection Single Intravenous Push NULL INSTITUTIONAL $285.00 1/1/2022-12/31/2022 $285.00 $119.13 $162.45 $209.48 $209.48 200% of Medicare 100% of Medicare $167.61 $161.34 $157.12 $119.13 100% of Medicaid 100% of Medicare 150% of Medicare $228.00 $285.00 195% of Medicare $230.85 $166.73 $166.73 $134.52 $183.37 100% of Medicare $228.00 $242.25 $223.73 $208.02 $228.00 $242.25 $195.94 100% of Medicare 100% of Medicare $213.75 200% of Medicare NULL 510 NULL 96375 NULL NULL 510057 Therapeutic Injection Each Add Sequential Intravenous Push New Drug NULL INSTITUTIONAL $187.00 1/1/2022-12/31/2022 $187.00 $78.17 $106.59 $137.45 $137.45 200% of Medicare 100% of Medicare $109.97 $105.86 $103.09 $78.17 100% of Medicaid 100% of Medicare 150% of Medicare $149.60 $187.00 195% of Medicare $151.47 $109.40 $109.40 $88.26 $120.32 100% of Medicare $149.60 $158.95 $146.80 $136.49 $149.60 $158.95 $128.56 100% of Medicare 100% of Medicare $140.25 200% of Medicare NULL 510 NULL 97605 NULL NULL 510060 Negative Press Wound <50 sq cm NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 510 NULL 97605 NULL NULL 510011 Single Injection Epidural Lumbar/Sacral NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 99202 NULL NULL 510063 "Office/Outpatient Visit, New" NULL INSTITUTIONAL $345.00 1/1/2022-12/31/2022 $345.00 $144.21 $196.65 $253.58 $253.58 200% of Medicare 100% of Medicare $202.89 $195.30 $190.20 $144.21 100% of Medicaid 100% of Medicare 150% of Medicare $276.00 $345.00 195% of Medicare $279.45 $201.83 $201.83 $162.84 $221.97 100% of Medicare $276.00 $293.25 $270.83 $251.82 $276.00 $293.25 $237.19 100% of Medicare 100% of Medicare $258.75 200% of Medicare NULL 510 NULL 99212 NULL NULL 510066 "Office/Outpatient Visit, Est" NULL INSTITUTIONAL $345.00 1/1/2022-12/31/2022 $345.00 $144.21 $196.65 $253.58 $253.58 200% of Medicare 100% of Medicare $202.89 $195.30 $190.20 $144.21 100% of Medicaid 100% of Medicare 150% of Medicare $276.00 $345.00 195% of Medicare $279.45 $201.83 $201.83 $162.84 $221.97 100% of Medicare $276.00 $293.25 $270.83 $251.82 $276.00 $293.25 $237.19 100% of Medicare 100% of Medicare $258.75 200% of Medicare NULL 510 NULL 99213 NULL NULL 510067 "Office/Outpatient Visit, Est" NULL INSTITUTIONAL $433.00 1/1/2022-12/31/2022 $433.00 $180.99 $246.81 $318.26 $318.26 200% of Medicare 100% of Medicare $254.65 $245.12 $238.71 $180.99 100% of Medicaid 100% of Medicare 150% of Medicare $346.40 $433.00 195% of Medicare $350.73 $253.31 $253.31 $204.38 $278.59 100% of Medicare $346.40 $368.05 $339.91 $316.05 $346.40 $368.05 $297.69 100% of Medicare 100% of Medicare $324.75 200% of Medicare NULL 636 NULL NULL NULL NULL 6360011 baclofen 0.5 mg/mL Sol NULL INSTITUTIONAL " $2,065.00 " 1/1/2022-12/31/2022 " $1,755.25 " $863.17 " $1,177.05 " " $1,517.78 " " $1,517.78 " 200% of Medicare 100% of Medicare " $1,214.43 " " $1,169.00 " " $1,138.43 " $863.17 100% of Medicaid 100% of Medicare 150% of Medicare " $1,652.00 " " $1,500.00 " 195% of Medicare " $1,672.65 " " $1,208.03 " " $1,208.03 " $974.68 " $1,328.62 " 100% of Medicare " $1,652.00 " " $1,755.25 " " $1,621.03 " " $1,507.24 " " $1,652.00 " " $1,755.25 " " $1,419.69 " 100% of Medicare 100% of Medicare " $1,548.75 " 200% of Medicare NULL 636 NULL NULL NULL NULL 6360013 baclofen 2 mg/mL Sol NULL INSTITUTIONAL " $5,290.00 " 1/1/2022-12/31/2022 " $4,496.50 " " $1,500.00 " " $3,015.30 " " $3,888.15 " " $3,888.15 " 200% of Medicare 100% of Medicare " $3,111.05 " " $2,994.67 " " $2,916.38 " " $2,211.22 " 100% of Medicaid 100% of Medicare 150% of Medicare " $4,232.00 " " $1,500.00 " 195% of Medicare " $4,284.90 " " $3,094.65 " " $3,094.65 " " $2,496.88 " " $3,403.59 " 100% of Medicare " $4,232.00 " " $4,496.50 " " $4,152.65 " " $3,861.17 " " $4,232.00 " " $4,496.50 " " $3,636.88 " 100% of Medicare 100% of Medicare " $3,967.50 " 200% of Medicare NULL 636 NULL NULL NULL NULL 6360010 baclofen 0.05 mg/mL Sol NULL INSTITUTIONAL $453.00 1/1/2022-12/31/2022 $453.00 $189.35 $258.21 $332.96 $332.96 200% of Medicare 100% of Medicare $266.41 $256.44 $249.74 $189.35 100% of Medicaid 100% of Medicare 150% of Medicare $362.40 $453.00 195% of Medicare $366.93 $265.01 $265.01 $213.82 $291.46 100% of Medicare $362.40 $385.05 $355.61 $330.64 $362.40 $385.05 $311.44 100% of Medicare 100% of Medicare $339.75 200% of Medicare NULL 636 NULL NULL NULL NULL 6360001 onabotulinumtoxinA 100 units REC NULL INSTITUTIONAL " $9,195.00 " 1/1/2022-12/31/2022 " $7,815.75 " " $1,500.00 " " $5,241.15 " " $6,758.33 " " $6,758.33 " 200% of Medicare 100% of Medicare " $5,407.58 " " $5,205.29 " " $5,069.20 " " $3,843.51 " 100% of Medicaid 100% of Medicare 150% of Medicare " $7,356.00 " " $1,500.00 " 195% of Medicare " $7,447.95 " " $5,379.08 " " $5,379.08 " " $4,340.04 " " $5,916.06 " 100% of Medicare " $7,356.00 " " $7,815.75 " " $7,218.08 " " $6,711.43 " " $7,356.00 " " $7,815.75 " " $6,321.56 " 100% of Medicare 100% of Medicare " $6,896.25 " 200% of Medicare NULL 636 NULL NULL NULL NULL 6360006 botulinum toxin type B 5000 units/mL Inj Sol NULL INSTITUTIONAL " $9,800.00 " 1/1/2022-12/31/2022 " $8,330.00 " " $1,500.00 " " $5,586.00 " " $7,203.00 " " $7,203.00 " 200% of Medicare 100% of Medicare " $5,763.38 " " $5,547.78 " " $5,402.74 " " $4,096.40 " 100% of Medicaid 100% of Medicare 150% of Medicare " $7,840.00 " " $1,500.00 " 195% of Medicare " $7,938.00 " " $5,733.00 " " $5,733.00 " " $4,625.60 " " $6,305.32 " 100% of Medicare " $7,840.00 " " $8,330.00 " " $7,693.00 " " $7,153.02 " " $7,840.00 " " $8,330.00 " " $6,737.50 " 100% of Medicare 100% of Medicare " $7,350.00 " 200% of Medicare NULL 636 NULL NULL NULL NULL 2501709 incobotulinumtoxinA 100 units REC NULL INSTITUTIONAL " $6,298.00 " 1/1/2022-12/31/2022 " $5,353.30 " " $1,500.00 " " $3,589.86 " " $4,629.03 " " $4,629.03 " 200% of Medicare 100% of Medicare " $3,703.85 " " $3,565.30 " " $3,472.09 " " $2,632.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $5,038.40 " " $1,500.00 " 195% of Medicare " $5,101.38 " " $3,684.33 " " $3,684.33 " " $2,972.66 " " $4,052.13 " 100% of Medicare " $5,038.40 " " $5,353.30 " " $4,943.93 " " $4,596.91 " " $5,038.40 " " $5,353.30 " " $4,329.88 " 100% of Medicare 100% of Medicare " $4,723.50 " 200% of Medicare NULL 636 NULL NULL NULL NULL 6360009 hylan G-F 20 8 mg/mL intra-articular Sol NULL INSTITUTIONAL $619.00 1/1/2022-12/31/2022 $619.00 $258.74 $352.83 $454.97 $454.97 200% of Medicare 100% of Medicare $364.03 $350.42 $341.25 $258.74 100% of Medicaid 100% of Medicare 150% of Medicare $495.20 $619.00 195% of Medicare $501.39 $362.12 $362.12 $292.17 $398.26 100% of Medicare $495.20 $526.15 $485.92 $451.81 $495.20 $526.15 $425.56 100% of Medicare 100% of Medicare $464.25 200% of Medicare NULL 922 NULL 95874 NULL NULL 510052 Needle Electromyography Conjunction with Chemodenervation NULL INSTITUTIONAL $151.00 1/1/2022-12/31/2022 $151.00 $63.12 $86.07 $110.99 $110.99 200% of Medicare 100% of Medicare $88.80 $85.48 $83.25 $63.12 100% of Medicaid 100% of Medicare 150% of Medicare $120.80 $151.00 195% of Medicare $122.31 $88.34 $88.34 $71.27 $97.15 100% of Medicare $120.80 $128.35 $118.54 $110.21 $120.80 $128.35 $103.81 100% of Medicare 100% of Medicare $113.25 200% of Medicare NULL 272 NULL NULL NULL NULL 374 GAIT BELT (54)'''' NULL INSTITUTIONAL $23.85 1/1/2022-12/31/2022 $23.85 $9.97 $13.59 $17.53 $17.53 200% of Medicare 100% of Medicare $14.03 $13.50 $13.15 $9.97 100% of Medicaid 100% of Medicare 150% of Medicare $19.08 $23.85 195% of Medicare $19.32 $13.95 $13.95 $11.26 $15.35 100% of Medicare $19.08 $20.27 $18.72 $17.41 $19.08 $20.27 $16.40 100% of Medicare 100% of Medicare $17.89 200% of Medicare NULL 272 NULL NULL NULL NULL 375 "POSEY BELT, GAIT (72)''''" NULL INSTITUTIONAL $32.52 1/1/2022-12/31/2022 $32.52 $13.59 $18.54 $23.90 $23.90 200% of Medicare 100% of Medicare $19.13 $18.41 $17.93 $13.59 100% of Medicaid 100% of Medicare 150% of Medicare $26.02 $32.52 195% of Medicare $26.34 $19.02 $19.02 $15.35 $20.92 100% of Medicare $26.02 $27.64 $25.53 $23.74 $26.02 $27.64 $22.36 100% of Medicare 100% of Medicare $24.39 200% of Medicare NULL 272 NULL NULL NULL NULL 1133 STOCKING ANTI-EMBOLISM NULL INSTITUTIONAL $26.56 1/1/2022-12/31/2022 $26.56 $11.10 $15.14 $19.52 $19.52 200% of Medicare 100% of Medicare $15.62 $15.04 $14.64 $11.10 100% of Medicaid 100% of Medicare 150% of Medicare $21.25 $26.56 195% of Medicare $21.51 $15.54 $15.54 $12.54 $17.09 100% of Medicare $21.25 $22.58 $20.85 $19.39 $21.25 $22.58 $18.26 100% of Medicare 100% of Medicare $19.92 200% of Medicare NULL 420 NULL 29520 NULL NULL 420007 PT Strapping Hip Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29530 NULL NULL 420008 PT Strapping Knee Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 95992 NULL NULL 420173 Canalith Repositioning Procedure NULL INSTITUTIONAL $159.00 1/1/2022-12/31/2022 $159.00 $66.46 $90.63 $116.87 $116.87 200% of Medicare 100% of Medicare $93.51 $90.01 $87.66 $66.46 100% of Medicaid 100% of Medicare 150% of Medicare $127.20 $159.00 195% of Medicare $128.79 $93.02 $93.02 $75.05 $102.30 100% of Medicare $127.20 $135.15 $124.82 $116.05 $127.20 $135.15 $109.31 100% of Medicare 100% of Medicare $119.25 200% of Medicare NULL 420 NULL 97012 NULL NULL 420018 PT Mechanical Traction Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 97032 NULL NULL 420022 PT Attended E-Stim Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 420 NULL 97033 NULL NULL 420023 PT Iontophoresis Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 420 NULL 97035 NULL NULL 420025 PT Ultrasound Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97110 NULL NULL 420026 PT Therapeutic Exercise Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97112 NULL NULL 420027 PT Neuromuscular Reeducation Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97113 NULL NULL 420028 PT Aquatic Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97116 NULL NULL 420029 PT Gait Training Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97124 NULL NULL 420030 PT Massage Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97140 NULL NULL 420031 PT Manual Therapy Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97530 NULL NULL 420032 PT Therapeutic Activity Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97535 NULL NULL 420043 "PT Self Care, Home Management Units" NULL INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $84.02 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $118.21 $113.79 $110.81 $84.02 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $117.59 $117.59 $94.87 $129.32 100% of Medicare $160.80 $170.85 $157.79 $146.71 $160.80 $170.85 $138.19 100% of Medicare 100% of Medicare $150.75 200% of Medicare NULL 420 NULL 97542 NULL NULL 420034 PT Wheelchair Management Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 424 NULL 97161 NULL NULL 424001 PT Eval Low Complex 30 mins NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL 97162 NULL NULL 424002 PT Eval MOD Complex 30 mins NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $165.95 $226.29 $291.80 $291.80 200% of Medicare 100% of Medicare $233.48 $224.74 $218.87 $165.95 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $232.25 $232.25 $187.38 $255.43 100% of Medicare $317.60 $337.45 $311.65 $289.77 $317.60 $337.45 $272.94 100% of Medicare 100% of Medicare $297.75 200% of Medicare NULL 424 NULL 97163 NULL NULL 424003 PT Eval High Complex 30 mins NULL INSTITUTIONAL $396.00 1/1/2022-12/31/2022 $396.00 $165.53 $225.72 $291.06 $291.06 200% of Medicare 100% of Medicare $232.89 $224.18 $218.31 $165.53 100% of Medicaid 100% of Medicare 150% of Medicare $316.80 $396.00 195% of Medicare $320.76 $231.66 $231.66 $186.91 $254.79 100% of Medicare $316.80 $336.60 $310.86 $289.04 $316.80 $336.60 $272.25 100% of Medicare 100% of Medicare $297.00 200% of Medicare NULL 424 NULL 97164 NULL NULL 424004 PT ReEval NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 430 NULL 97032 NULL NULL 430020 OT Attended E-Stim Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 430 NULL 97035 NULL NULL 430023 OT Ultrasound Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97110 NULL NULL 430005 OT Therapeutic Exercise Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97112 NULL NULL 430006 OT Neuromuscular Reeducation Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97140 NULL NULL 430025 OT Manual Therapy Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97530 NULL NULL 430026 OT Therapeutic Activities Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97535 NULL NULL 430010 "OT Self Care, Home Management Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97537 NULL NULL 430011 "OT Community, Work Reintegration Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97542 NULL NULL 430012 OT Wheelchair Management Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97763 NULL NULL 97763 OT Orthotic Mgmt/Train Establish Rehab Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97763 NULL NULL 999052 Rehab Driving Lesson NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $16.30 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $22.94 $22.08 $21.50 $16.30 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $22.82 $22.82 $18.41 $25.09 100% of Medicare $31.20 $33.15 $30.62 $28.47 $31.20 $33.15 $26.81 100% of Medicare 100% of Medicare $29.25 200% of Medicare NULL 430 NULL 97763 NULL NULL 999053 Rehab Driving Mileage NULL INSTITUTIONAL $111.23 1/1/2022-12/31/2022 $111.23 $46.49 $63.40 $81.75 $81.75 200% of Medicare 100% of Medicare $65.41 $62.97 $61.32 $46.49 100% of Medicaid 100% of Medicare 150% of Medicare $88.98 $111.23 195% of Medicare $90.10 $65.07 $65.07 $52.50 $71.57 100% of Medicare $88.98 $94.55 $87.32 $81.19 $88.98 $94.55 $76.47 100% of Medicare 100% of Medicare $83.42 200% of Medicare NULL 430 NULL 97763 NULL NULL 999054 Rehab Driving Travel Time NULL INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $30.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $43.52 $41.89 $40.80 $30.93 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $43.29 $43.29 $34.93 $47.61 100% of Medicare $59.20 $62.90 $58.09 $54.01 $59.20 $62.90 $50.88 100% of Medicare 100% of Medicare $55.50 200% of Medicare NULL 430 NULL NULL NULL G0515 G0515 OT Cognitive Function Medicare Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 433 NULL 97150 NULL NULL 430101 OT Double Therapy Units NULL INSTITUTIONAL " $1,107.00 " 1/1/2022-12/31/2022 " $1,107.00 " $462.73 $630.99 $813.65 $813.65 200% of Medicare 100% of Medicare $651.03 $626.67 $610.29 $462.73 100% of Medicaid 100% of Medicare 150% of Medicare $885.60 " $1,107.00 " 195% of Medicare $896.67 $647.60 $647.60 $522.50 $712.24 100% of Medicare $885.60 $940.95 $869.00 $808.00 $885.60 $940.95 $761.06 100% of Medicare 100% of Medicare $830.25 200% of Medicare NULL 434 NULL 97165 NULL NULL 434001 OT Eval Low Complex 30 mins NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 434 NULL 97166 NULL NULL 434002 OT Eval Mod Complex 45 mins NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 434 NULL 97167 NULL NULL 434003 OT EVAL High Complex 60 mins NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 434 NULL 97167 NULL NULL 999050 Rehab Driving Evaluation NULL INSTITUTIONAL $473.00 1/1/2022-12/31/2022 $473.00 $197.71 $269.61 $347.66 $347.66 200% of Medicare 100% of Medicare $278.17 $267.77 $260.76 $197.71 100% of Medicaid 100% of Medicare 150% of Medicare $378.40 $473.00 195% of Medicare $383.13 $276.71 $276.71 $223.26 $304.33 100% of Medicare $378.40 $402.05 $371.31 $345.24 $378.40 $402.05 $325.19 100% of Medicare 100% of Medicare $354.75 200% of Medicare NULL 434 NULL 97167 NULL NULL NULL Rehab Driving Evaluation NULL INSTITUTIONAL $487.86 1/1/2022-12/31/2022 $487.86 $203.93 $278.08 $358.58 $358.58 200% of Medicare 100% of Medicare $286.91 $276.18 $268.96 $203.93 100% of Medicaid 100% of Medicare 150% of Medicare $390.29 $487.86 195% of Medicare $395.17 $285.40 $285.40 $230.27 $313.89 100% of Medicare $390.29 $414.68 $382.97 $356.09 $390.29 $414.68 $335.40 100% of Medicare 100% of Medicare $365.90 200% of Medicare NULL 440 NULL 92507 NULL NULL 440001 SLP Auditory Processing Tx Units NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 440 NULL 92507 NULL NULL NULL SLP Tx of Speech/Lang/Voice/Comm/Aud Proc d/o indiv NULL INSTITUTIONAL $666.19 1/1/2022-12/31/2022 $666.19 $278.47 $379.73 $489.65 $489.65 200% of Medicare 100% of Medicare $391.79 $377.13 $367.27 $278.47 100% of Medicaid 100% of Medicare 150% of Medicare $532.95 $666.19 195% of Medicare $539.61 $389.72 $389.72 $314.44 $428.63 100% of Medicare $532.95 $566.26 $522.96 $486.25 $532.95 $566.26 $458.01 100% of Medicare 100% of Medicare $499.64 200% of Medicare NULL 440 NULL 92508 NULL NULL 440100 SLP Double Therapy Units NULL INSTITUTIONAL " $1,107.00 " 1/1/2022-12/31/2022 " $1,107.00 " $462.73 $630.99 $813.65 $813.65 200% of Medicare 100% of Medicare $651.03 $626.67 $610.29 $462.73 100% of Medicaid 100% of Medicare 150% of Medicare $885.60 " $1,107.00 " 195% of Medicare $896.67 $647.60 $647.60 $522.50 $712.24 100% of Medicare $885.60 $940.95 $869.00 $808.00 $885.60 $940.95 $761.06 100% of Medicare 100% of Medicare $830.25 200% of Medicare NULL 440 NULL 92523 NULL NULL 440010 SLP Sound Prod w/ Lang Comp Eval Units NULL INSTITUTIONAL $612.48 1/1/2022-12/31/2022 $612.48 $256.02 $349.11 $450.17 $450.17 200% of Medicare 100% of Medicare $360.20 $346.72 $337.66 $256.02 100% of Medicaid 100% of Medicare 150% of Medicare $489.98 $612.48 195% of Medicare $496.11 $358.30 $358.30 $289.09 $394.07 100% of Medicare $489.98 $520.61 $480.80 $447.05 $489.98 $520.61 $421.08 100% of Medicare 100% of Medicare $459.36 200% of Medicare NULL 440 NULL 92523 NULL NULL NULL SLP Speech Sound Prod w/ Lang Comp/Exp NULL INSTITUTIONAL $692.96 1/1/2022-12/31/2022 $692.96 $289.66 $394.99 $509.33 $509.33 200% of Medicare 100% of Medicare $407.53 $392.28 $382.03 $289.66 100% of Medicaid 100% of Medicare 150% of Medicare $554.37 $692.96 195% of Medicare $561.30 $405.38 $405.38 $327.08 $445.85 100% of Medicare $554.37 $589.02 $543.97 $505.79 $554.37 $589.02 $476.41 100% of Medicare 100% of Medicare $519.72 200% of Medicare NULL 440 NULL 92526 NULL NULL 440002 SLP Swallow Dysfunction Oral Feed Units NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 440 NULL 92526 NULL NULL NULL SLP Tx Oral & Pharyngeal Sw fxn NULL INSTITUTIONAL $666.19 1/1/2022-12/31/2022 $666.19 $278.47 $379.73 $489.65 $489.65 200% of Medicare 100% of Medicare $391.79 $377.13 $367.27 $278.47 100% of Medicaid 100% of Medicare 150% of Medicare $532.95 $666.19 195% of Medicare $539.61 $389.72 $389.72 $314.44 $428.63 100% of Medicare $532.95 $566.26 $522.96 $486.25 $532.95 $566.26 $458.01 100% of Medicare 100% of Medicare $499.64 200% of Medicare NULL 440 NULL 96125 NULL NULL 440006 "SLP Standardized Cog testing w/ interpret/report, per hour" NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 440 NULL 97127 NULL NULL 97127 SLP Cognitive Function Tx NULL INSTITUTIONAL $665.00 1/1/2022-12/31/2022 $665.00 $277.97 $379.05 $488.78 $488.78 200% of Medicare 100% of Medicare $391.09 $376.46 $366.61 $277.97 100% of Medicaid 100% of Medicare 150% of Medicare $532.00 $665.00 195% of Medicare $538.65 $389.03 $389.03 $313.88 $427.86 100% of Medicare $532.00 $565.25 $522.03 $485.38 $532.00 $565.25 $457.19 100% of Medicare 100% of Medicare $498.75 200% of Medicare NULL 440 NULL 97127 NULL NULL NULL SLP Cognitive Function Units NULL INSTITUTIONAL $665.14 1/1/2022-12/31/2022 $665.14 $278.03 $379.13 $488.88 $488.88 200% of Medicare 100% of Medicare $391.17 $376.54 $366.69 $278.03 100% of Medicaid 100% of Medicare 150% of Medicare $532.11 $665.14 195% of Medicare $538.76 $389.11 $389.11 $313.95 $427.95 100% of Medicare $532.11 $565.37 $522.13 $485.49 $532.11 $565.37 $457.28 100% of Medicare 100% of Medicare $498.86 200% of Medicare NULL 440 NULL NULL NULL G0515 G0515 SLP Cognitive Function Medicare Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 444 NULL 92611 NULL NULL 444009 SLP Fluoroscopic Evaluation NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 444 NULL 92611 NULL NULL NULL SLP Fluoroscopic Evaluation Units NULL INSTITUTIONAL $791.95 1/1/2022-12/31/2022 $791.95 $331.04 $451.41 $582.08 $582.08 200% of Medicare 100% of Medicare $465.75 $448.32 $436.60 $331.04 100% of Medicaid 100% of Medicare 150% of Medicare $633.56 $791.95 195% of Medicare $641.48 $463.29 $463.29 $373.80 $509.54 100% of Medicare $633.56 $673.16 $621.68 $578.04 $633.56 $673.16 $544.47 100% of Medicare 100% of Medicare $593.96 200% of Medicare NULL 999 NULL NULL NULL NULL 999004 Aquatics Program 1 Session NULL INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.09 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.94 $2.83 $2.76 $2.09 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.93 $2.93 $2.36 $3.22 100% of Medicare $4.00 $4.25 $3.93 $3.65 $4.00 $4.25 $3.44 100% of Medicare 100% of Medicare $3.75 200% of Medicare NULL 999 NULL NULL NULL NULL 999005 Aquatics Program Monthly NULL INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $16.72 $22.80 $29.40 $29.40 200% of Medicare 100% of Medicare $23.52 $22.64 $22.05 $16.72 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.40 $23.40 $18.88 $25.74 100% of Medicare $32.00 $34.00 $31.40 $29.20 $32.00 $34.00 $27.50 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999014 ABT SCI Wellness 1 Session NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $4.60 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.47 $6.23 $6.06 $4.60 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.44 $6.44 $5.19 $7.08 100% of Medicare $8.80 $9.35 $8.64 $8.03 $8.80 $9.35 $7.56 100% of Medicare 100% of Medicare $8.25 200% of Medicare NULL 999 NULL NULL NULL NULL 999015 ABT SCI Wellness 12 Session NULL INSTITUTIONAL $377.00 1/1/2022-12/31/2022 $377.00 $157.59 $214.89 $277.10 $277.10 200% of Medicare 100% of Medicare $221.71 $213.42 $207.84 $157.59 100% of Medicaid 100% of Medicare 150% of Medicare $301.60 $377.00 195% of Medicare $305.37 $220.55 $220.55 $177.94 $242.56 100% of Medicare $301.60 $320.45 $295.95 $275.17 $301.60 $320.45 $259.19 100% of Medicare 100% of Medicare $282.75 200% of Medicare NULL 999 NULL NULL NULL NULL 999016 NVA Final Report NULL INSTITUTIONAL " $2,200.00 " 1/1/2022-12/31/2022 " $1,870.00 " $919.60 " $1,254.00 " " $1,617.00 " " $1,617.00 " 200% of Medicare 100% of Medicare " $1,293.82 " " $1,245.42 " " $1,212.86 " $919.60 100% of Medicaid 100% of Medicare 150% of Medicare " $1,760.00 " " $1,500.00 " 195% of Medicare " $1,782.00 " " $1,287.00 " " $1,287.00 " " $1,038.40 " " $1,415.48 " 100% of Medicare " $1,760.00 " " $1,870.00 " " $1,727.00 " " $1,605.78 " " $1,760.00 " " $1,870.00 " " $1,512.50 " 100% of Medicare 100% of Medicare " $1,650.00 " 200% of Medicare NULL 999 NULL NULL NULL NULL 999031 RF Hotel NULL INSTITUTIONAL $96.00 1/1/2022-12/31/2022 $96.00 $40.13 $54.72 $70.56 $70.56 200% of Medicare 100% of Medicare $56.46 $54.35 $52.92 $40.13 100% of Medicaid 100% of Medicare 150% of Medicare $76.80 $96.00 195% of Medicare $77.76 $56.16 $56.16 $45.31 $61.77 100% of Medicare $76.80 $81.60 $75.36 $70.07 $76.80 $81.60 $66.00 100% of Medicare 100% of Medicare $72.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999032 RF Mileage NULL INSTITUTIONAL $0.38 1/1/2022-12/31/2022 $0.38 $0.16 $0.22 $0.28 $0.28 200% of Medicare 100% of Medicare $0.22 $0.22 $0.21 $0.16 100% of Medicaid 100% of Medicare 150% of Medicare $0.30 $0.38 195% of Medicare $0.31 $0.22 $0.22 $0.18 $0.24 100% of Medicare $0.30 $0.32 $0.30 $0.28 $0.30 $0.32 $0.26 100% of Medicare 100% of Medicare $0.29 200% of Medicare NULL 999 NULL NULL NULL NULL 999033 RF Gas Card NULL INSTITUTIONAL $62.34 1/1/2022-12/31/2022 $62.34 $26.06 $35.53 $45.82 $45.82 200% of Medicare 100% of Medicare $36.66 $35.29 $34.37 $26.06 100% of Medicaid 100% of Medicare 150% of Medicare $49.87 $62.34 195% of Medicare $50.50 $36.47 $36.47 $29.42 $40.11 100% of Medicare $49.87 $52.99 $48.94 $45.50 $49.87 $52.99 $42.86 100% of Medicare 100% of Medicare $46.76 200% of Medicare NULL 999 NULL NULL NULL NULL 999072 30 Min Swedish Massage NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $14.63 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.58 $19.81 $19.30 $14.63 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.48 $20.48 $16.52 $22.52 100% of Medicare $28.00 $29.75 $27.48 $25.55 $28.00 $29.75 $24.06 100% of Medicare 100% of Medicare $26.25 200% of Medicare NULL 999 NULL NULL NULL NULL 999073 60 Min Swedish Massage NULL INSTITUTIONAL $65.00 1/1/2022-12/31/2022 $65.00 $27.17 $37.05 $47.78 $47.78 200% of Medicare 100% of Medicare $38.23 $36.80 $35.83 $27.17 100% of Medicaid 100% of Medicare 150% of Medicare $52.00 $65.00 195% of Medicare $52.65 $38.03 $38.03 $30.68 $41.82 100% of Medicare $52.00 $55.25 $51.03 $47.44 $52.00 $55.25 $44.69 100% of Medicare 100% of Medicare $48.75 200% of Medicare NULL 999 NULL NULL NULL NULL 999074 70 Min Deep tissue massage NULL INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $33.44 $45.60 $58.80 $58.80 200% of Medicare 100% of Medicare $47.05 $45.29 $44.10 $33.44 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $46.80 $46.80 $37.76 $51.47 100% of Medicare $64.00 $68.00 $62.80 $58.39 $64.00 $68.00 $55.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999075 Sinus/Migraine release NULL INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $10.45 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.70 $14.15 $13.78 $10.45 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.63 $14.63 $11.80 $16.09 100% of Medicare $20.00 $21.25 $19.63 $18.25 $20.00 $21.25 $17.19 100% of Medicare 100% of Medicare $18.75 200% of Medicare NULL NULL NULL 90832 NULL NULL NULL "Psychotherapy, 30 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 90834 NULL NULL NULL "Psychotherapy, 45 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 90837 NULL NULL NULL "Psychotherapy, 60 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 90846 NULL NULL NULL "Family psychotherapy, not including patient, 50 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 90847 NULL NULL NULL "Family psychotherapy, including patient, 50 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 90853 NULL NULL NULL Group psychotherapy NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 99203 NULL NULL NULL "New patient office or other outpatient visit, typically 30 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 99204 NULL NULL NULL "New patient office of other outpatient visit, typically 45 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 99205 NULL NULL NULL "New patient office of other outpatient visit, typically 60 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 99243 NULL NULL NULL "Patient office consultation, typically 40 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 99244 NULL NULL NULL "Patient office consultation, typically 60 min" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 99385 NULL NULL NULL Initial new patient preventive medicine evaluation (18-39 years) NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 99386 NULL NULL NULL Initial new patient preventive medicine evaluation (40-64 years) NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 80048 NULL NULL NULL Basic metabolic panel NULL INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 200% of Medicare 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL NULL NULL 80053 NULL NULL NULL "Blood test, comprehensive group of blood chemicals" NULL INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $42.95 $51.87 $66.89 $66.89 200% of Medicare 100% of Medicare $54.49 $52.45 $51.08 $58.24 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $54.15 $54.15 $42.95 $91.00 100% of Medicare $72.80 $77.35 $81.90 $66.42 $77.35 $91.00 $91.00 100% of Medicare 100% of Medicare $91.00 200% of Medicare NULL NULL NULL 80055 NULL NULL NULL Obstetric blood test panel NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 80061 NULL NULL NULL "Blood test, lipids (cholesterol and triglycerides)" NULL INSTITUTIONAL $82.00 1/1/2022-12/31/2022 $82.00 $38.70 $46.74 $60.27 $60.27 200% of Medicare 100% of Medicare $49.10 $47.26 $46.03 $52.48 100% of Medicaid 100% of Medicare 150% of Medicare $65.60 $82.00 195% of Medicare $66.42 $48.79 $48.79 $38.70 $82.00 100% of Medicare $65.60 $69.70 $73.80 $59.85 $69.70 $82.00 $82.00 100% of Medicare 100% of Medicare $82.00 200% of Medicare NULL NULL NULL 80069 NULL NULL NULL Kidney function panel test NULL INSTITUTIONAL $73.00 1/1/2022-12/31/2022 $73.00 $34.46 $41.61 $53.66 $53.66 200% of Medicare 100% of Medicare $43.71 $42.08 $40.97 $46.72 100% of Medicaid 100% of Medicare 150% of Medicare $58.40 $73.00 195% of Medicare $59.13 $43.44 $43.44 $34.46 $73.00 100% of Medicare $58.40 $62.05 $65.70 $53.28 $62.05 $73.00 $73.00 100% of Medicare 100% of Medicare $73.00 200% of Medicare NULL NULL NULL 80076 NULL NULL NULL Liver function blood test panel NULL INSTITUTIONAL $68.00 1/1/2022-12/31/2022 $68.00 $32.10 $38.76 $49.98 $49.98 200% of Medicare 100% of Medicare $40.72 $39.20 $38.17 $43.52 100% of Medicaid 100% of Medicare 150% of Medicare $54.40 $68.00 195% of Medicare $55.08 $40.46 $40.46 $32.10 $68.00 100% of Medicare $54.40 $57.80 $61.20 $49.63 $57.80 $68.00 $68.00 100% of Medicare 100% of Medicare $68.00 200% of Medicare NULL NULL NULL 81000 or 81001 NULL NULL NULL Manual urinalysis test with examination using microscope NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL NULL NULL 81002 or 81003 NULL NULL NULL Automated urinalysis test NULL INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL NULL NULL 84153-84154 NULL NULL NULL PSA (prostate specific antigen) NULL INSTITUTIONAL $156.00 1/1/2022-12/31/2022 $156.00 $73.63 $88.92 $114.66 $114.66 200% of Medicare 100% of Medicare $93.41 $89.92 $87.56 $99.84 100% of Medicaid 100% of Medicare 150% of Medicare $124.80 $156.00 195% of Medicare $126.36 $92.82 $92.82 $73.63 $156.00 100% of Medicare $124.80 $132.60 $140.40 $113.86 $132.60 $156.00 $156.00 100% of Medicare 100% of Medicare $156.00 200% of Medicare NULL NULL NULL 84443 NULL NULL NULL "Blood test, thyroid stimulating hormone (TSH)" NULL INSTITUTIONAL $143.00 1/1/2022-12/31/2022 $143.00 $67.50 $81.51 $105.11 $105.11 200% of Medicare 100% of Medicare $85.63 $82.43 $80.27 $91.52 100% of Medicaid 100% of Medicare 150% of Medicare $114.40 $143.00 195% of Medicare $115.83 $85.09 $85.09 $67.50 $143.00 100% of Medicare $114.40 $121.55 $128.70 $104.38 $121.55 $143.00 $143.00 100% of Medicare 100% of Medicare $143.00 200% of Medicare NULL NULL NULL 85025 NULL NULL NULL "Complete blood cell count, with differential white blood cells, automated" NULL INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $31.15 $37.62 $48.51 $48.51 200% of Medicare 100% of Medicare $39.52 $38.04 $37.05 $42.24 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $39.27 $39.27 $31.15 $66.00 100% of Medicare $52.80 $56.10 $59.40 $48.17 $56.10 $66.00 $66.00 100% of Medicare 100% of Medicare $66.00 200% of Medicare NULL NULL NULL 85027 NULL NULL NULL "Complete blood count, automated" NULL INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL NULL NULL 85610 NULL NULL NULL "Blood test, clotting time" NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL NULL NULL 85730 NULL NULL NULL Coagulation assessment blood test NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 70450 NULL NULL NULL "CT scan, head or brain, without contrast" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 70553 NULL NULL NULL MRI scan of brain before and after contrast NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 72110 NULL NULL NULL "X-Ray, lower back, minimum four views" NULL INSTITUTIONAL $218.00 1/1/2022-12/31/2022 $218.00 $102.90 $124.26 $160.23 $160.23 200% of Medicare 100% of Medicare $130.54 $125.66 $122.36 $139.52 100% of Medicaid 100% of Medicare 150% of Medicare $174.40 $218.00 195% of Medicare $176.58 $129.71 $129.71 $102.90 $218.00 100% of Medicare $174.40 $185.30 $196.20 $159.12 $185.30 $218.00 $218.00 100% of Medicare 100% of Medicare $218.00 200% of Medicare NULL NULL NULL 72148 NULL NULL NULL MRI scan of lower spinal canal NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 72193 NULL NULL NULL "CT scan, pelvis, with contrast" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 73721 NULL NULL NULL MRI scan of leg joint NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 74177 NULL NULL NULL CT scan of abdomen and pelvis with contrast NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 76700 NULL NULL NULL Ultrasound of abdomen NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 76805 NULL NULL NULL Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 76830 NULL NULL NULL Ultrasound pelvis through vagina NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 77065 NULL NULL NULL Mammography of one breast NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 77066 NULL NULL NULL Mammography of both breasts NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 77067 NULL NULL NULL "Mammography, screening, bilateral" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL 216 NULL NULL NULL NULL Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL 460 NULL NULL NULL NULL Spinal fusion except cervical without major comorbid conditions or complications (MCC) NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL 470 NULL NULL NULL NULL Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC) NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL 473 NULL NULL NULL NULL Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL 743 NULL NULL NULL NULL Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC) NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 19120 NULL NULL NULL "Removal of 1 or more breast growth, open procedure" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 29826 NULL NULL NULL Shaving of shoulder bone using an endoscope NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 29881 NULL NULL NULL Removal of one knee cartilage using an endoscope NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 42820 NULL NULL NULL Removal of tonsils and adenoid glands patient younger than age 12 NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 43235 NULL NULL NULL "Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 43239 NULL NULL NULL "Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 45378 NULL NULL NULL Diagnostic examination of large bowel using an endoscope NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 45380 NULL NULL NULL Biopsy of large bowel using an endoscope NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 45385 NULL NULL NULL Removal of polyps or growths of large bowel using an endoscope NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 45391 NULL NULL NULL Ultrasound examination of lower large bowel using an endoscope NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 47562 NULL NULL NULL Removal of gallbladder using an endoscope NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 49505 NULL NULL NULL Repair of groin hernia patient age 5 years or older NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 55700 NULL NULL NULL Biopsy of prostate gland NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 55866 NULL NULL NULL Surgical removal of prostate and surrounding lymph nodes using an endoscope NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 59400 NULL NULL NULL "Routine obstetric care for vaginal delivery, including pre-and post-delivery care" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 59510 NULL NULL NULL "Routine obstetric care for cesarean delivery, including pre-and post-delivery care" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 59610 NULL NULL NULL Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 62322-62323 NULL NULL NULL Injection of substance into spinal canal of lower back or sacrum using imaging guidance NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 64483 NULL NULL NULL Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL NULL NULL 66821 NULL NULL NULL Removal of recurring cataract in lens capsule using laser NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 66984 NULL NULL NULL Removal of cataract with insertion of lens NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 93000 NULL NULL NULL "Electrocardiogram, routine, with interpretation and report" NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 93452 NULL NULL NULL Insertion of catheter into left heart for diagnosis NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 95810 NULL NULL NULL Sleep study NULL INSTITUTIONAL RHI Does Not Provide 1/1/2022-12/31/2022 NULL NULL NULL 97110 NULL NULL NULL "Physical therapy, therapeutic exercise" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 73110 RT NULL 320175 XR Wrist 3 Views Min Rt NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL 73110 LT NULL 320174 XR Wrist 3 Views Min Lt NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL 73100 LT NULL 320172 XR Wrist 2 Views Left NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 73100 RT NULL 320173 XR Wrist 2 Views Right NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 74000 NULL NULL 320013 XR Abdomen AP NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 320 NULL 73000 50 NULL 320016 XR AC Joints Bilateral w/ wts NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $51.41 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $72.34 $69.63 $67.81 $51.41 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $71.96 $71.96 $58.06 $79.14 100% of Medicare $98.40 $104.55 $96.56 $89.78 $98.40 $104.55 $84.56 100% of Medicare 100% of Medicare $92.25 200% of Medicare NULL 320 NULL 73000 50 NULL 320017 XR AC Joints Bilateral w/ + w/o wts NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $51.41 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $72.34 $69.63 $67.81 $51.41 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $71.96 $71.96 $58.06 $79.14 100% of Medicare $98.40 $104.55 $96.56 $89.78 $98.40 $104.55 $84.56 100% of Medicare 100% of Medicare $92.25 200% of Medicare NULL 320 NULL 73600 LT NULL 320018 XR Ankle 2 Views Left NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $51.41 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $72.34 $69.63 $67.81 $51.41 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $71.96 $71.96 $58.06 $79.14 100% of Medicare $98.40 $104.55 $96.56 $89.78 $98.40 $104.55 $84.56 100% of Medicare 100% of Medicare $92.25 200% of Medicare NULL 320 NULL 73600 RT NULL 320019 XR Ankle 2 Views Right NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $51.41 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $72.34 $69.63 $67.81 $51.41 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $71.96 $71.96 $58.06 $79.14 100% of Medicare $98.40 $104.55 $96.56 $89.78 $98.40 $104.55 $84.56 100% of Medicare 100% of Medicare $92.25 200% of Medicare NULL 320 NULL 73610 LT NULL 320020 XR Ankle 3 Views Min Lt NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $58.52 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $82.33 $79.25 $77.18 $58.52 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $81.90 $81.90 $66.08 $90.08 100% of Medicare $112.00 $119.00 $109.90 $102.19 $112.00 $119.00 $96.25 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 320 NULL 73610 RT NULL 320021 XR Ankle 3 Views Min Rt NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $58.52 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $82.33 $79.25 $77.18 $58.52 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $81.90 $81.90 $66.08 $90.08 100% of Medicare $112.00 $119.00 $109.90 $102.19 $112.00 $119.00 $96.25 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 320 NULL 77074 NULL NULL 320023 XR Bone Survey Complete NULL INSTITUTIONAL $291.00 1/1/2022-12/31/2022 $291.00 $121.64 $165.87 $213.89 $213.89 200% of Medicare 100% of Medicare $171.14 $164.74 $160.43 $121.64 100% of Medicaid 100% of Medicare 150% of Medicare $232.80 $291.00 195% of Medicare $235.71 $170.24 $170.24 $137.35 $187.23 100% of Medicare $232.80 $247.35 $228.44 $212.40 $232.80 $247.35 $200.06 100% of Medicare 100% of Medicare $218.25 200% of Medicare NULL 320 NULL 72040 NULL NULL 320031 XR Spine Cervical 2 Views NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 72020 NULL NULL 320034 XR Spine Cervical Comp w/ Obliques NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 320 NULL 72020 NULL NULL 320033 XR Spine Cervical Cross-Table Lateral NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 320 NULL 72050 NULL NULL 320037 XR Spine Cervical 5 Views NULL INSTITUTIONAL $223.00 1/1/2022-12/31/2022 $223.00 $93.21 $127.11 $163.91 $163.91 200% of Medicare 100% of Medicare $131.15 $126.24 $122.94 $93.21 100% of Medicaid 100% of Medicare 150% of Medicare $178.40 $223.00 195% of Medicare $180.63 $130.46 $130.46 $105.26 $143.48 100% of Medicare $178.40 $189.55 $175.06 $162.77 $178.40 $189.55 $153.31 100% of Medicare 100% of Medicare $167.25 200% of Medicare NULL 320 NULL 72052 NULL NULL 320038 XR Spine Cerv 5 Views w/ Flex +/or Ext NULL INSTITUTIONAL $287.00 1/1/2022-12/31/2022 $287.00 $119.97 $163.59 $210.95 $210.95 200% of Medicare 100% of Medicare $168.78 $162.47 $158.22 $119.97 100% of Medicaid 100% of Medicare 150% of Medicare $229.60 $287.00 195% of Medicare $232.47 $167.90 $167.90 $135.46 $184.66 100% of Medicare $229.60 $243.95 $225.30 $209.48 $229.60 $243.95 $197.31 100% of Medicare 100% of Medicare $215.25 200% of Medicare NULL 320 NULL 73650 LT NULL 320025 XR Calcaneus Min 2 View Lt NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 320 NULL 73650 RT NULL 320026 XR Calcaneus Min 2 View Rt NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 324 NULL 71020 NULL NULL 324011 XR Chest 1 View Frontal NULL INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $53.50 $72.96 $94.08 $94.08 200% of Medicare 100% of Medicare $75.28 $72.46 $70.57 $53.50 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $74.88 $74.88 $60.42 $82.36 100% of Medicare $102.40 $108.80 $100.48 $93.43 $102.40 $108.80 $88.00 100% of Medicare 100% of Medicare $96.00 200% of Medicare NULL 324 NULL 71020 NULL NULL 324000 XR Chest 2 Views NULL INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $53.50 $72.96 $94.08 $94.08 200% of Medicare 100% of Medicare $75.28 $72.46 $70.57 $53.50 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $74.88 $74.88 $60.42 $82.36 100% of Medicare $102.40 $108.80 $100.48 $93.43 $102.40 $108.80 $88.00 100% of Medicare 100% of Medicare $96.00 200% of Medicare NULL 324 NULL 71021 NULL NULL 324010 XR Chest 2 Views w/ Apical Lordotic NULL INSTITUTIONAL $159.00 1/1/2022-12/31/2022 $159.00 $66.46 $90.63 $116.87 $116.87 200% of Medicare 100% of Medicare $93.51 $90.01 $87.66 $66.46 100% of Medicaid 100% of Medicare 150% of Medicare $127.20 $159.00 195% of Medicare $128.79 $93.02 $93.02 $75.05 $102.30 100% of Medicare $127.20 $135.15 $124.82 $116.05 $127.20 $135.15 $109.31 100% of Medicare 100% of Medicare $119.25 200% of Medicare NULL 320 NULL 73000 LT NULL 320040 XR Clavicle Left NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $51.41 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $72.34 $69.63 $67.81 $51.41 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $71.96 $71.96 $58.06 $79.14 100% of Medicare $98.40 $104.55 $96.56 $89.78 $98.40 $104.55 $84.56 100% of Medicare 100% of Medicare $92.25 200% of Medicare NULL 320 NULL 73000 RT NULL 320041 XR Clavicle Right NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $51.41 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $72.34 $69.63 $67.81 $51.41 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $71.96 $71.96 $58.06 $79.14 100% of Medicare $98.40 $104.55 $96.56 $89.78 $98.40 $104.55 $84.56 100% of Medicare 100% of Medicare $92.25 200% of Medicare NULL 320 NULL 73660 RT NULL 320171 XR Toe(s) 2 Views Min Rt NULL INSTITUTIONAL $125.00 1/1/2022-12/31/2022 $125.00 $52.25 $71.25 $91.88 $91.88 200% of Medicare 100% of Medicare $73.51 $70.76 $68.91 $52.25 100% of Medicaid 100% of Medicare 150% of Medicare $100.00 $125.00 195% of Medicare $101.25 $73.13 $73.13 $59.00 $80.43 100% of Medicare $100.00 $106.25 $98.13 $91.24 $100.00 $106.25 $85.94 100% of Medicare 100% of Medicare $93.75 200% of Medicare NULL 320 NULL 73660 LT NULL 320170 XR Toe(s) 2 Views Min Lt NULL INSTITUTIONAL $125.00 1/1/2022-12/31/2022 $125.00 $52.25 $71.25 $91.88 $91.88 200% of Medicare 100% of Medicare $73.51 $70.76 $68.91 $52.25 100% of Medicaid 100% of Medicare 150% of Medicare $100.00 $125.00 195% of Medicare $101.25 $73.13 $73.13 $59.00 $80.43 100% of Medicare $100.00 $106.25 $98.13 $91.24 $100.00 $106.25 $85.94 100% of Medicare 100% of Medicare $93.75 200% of Medicare NULL 320 NULL 70330 50 NULL 320162 XR TMJ Open and Closed Bilateral NULL INSTITUTIONAL $204.00 1/1/2022-12/31/2022 $204.00 $85.27 $116.28 $149.94 $149.94 200% of Medicare 100% of Medicare $119.97 $115.48 $112.47 $85.27 100% of Medicaid 100% of Medicare 150% of Medicare $163.20 $204.00 195% of Medicare $165.24 $119.34 $119.34 $96.29 $131.25 100% of Medicare $163.20 $173.40 $160.14 $148.90 $163.20 $173.40 $140.25 100% of Medicare 100% of Medicare $153.00 200% of Medicare NULL 320 NULL 73590 RT NULL 320169 XR Tibia +Fibula 2 Views Rt NULL INSTITUTIONAL $116.00 1/1/2022-12/31/2022 $116.00 $48.49 $66.12 $85.26 $85.26 200% of Medicare 100% of Medicare $68.22 $65.67 $63.95 $48.49 100% of Medicaid 100% of Medicare 150% of Medicare $92.80 $116.00 195% of Medicare $93.96 $67.86 $67.86 $54.75 $74.63 100% of Medicare $92.80 $98.60 $91.06 $84.67 $92.80 $98.60 $79.75 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 320 NULL 73590 LT NULL 320168 XR Tibia +Fibula 2 Views Lt NULL INSTITUTIONAL $116.00 1/1/2022-12/31/2022 $116.00 $48.49 $66.12 $85.26 $85.26 200% of Medicare 100% of Medicare $68.22 $65.67 $63.95 $48.49 100% of Medicaid 100% of Medicare 150% of Medicare $92.80 $116.00 195% of Medicare $93.96 $67.86 $67.86 $54.75 $74.63 100% of Medicare $92.80 $98.60 $91.06 $84.67 $92.80 $98.60 $79.75 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 320 NULL 71120 NULL NULL 320160 XR Sternum Min 2 Views NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 71130 NULL NULL 320159 XR Sternoclavicular Joint(s) 3 Views Min NULL INSTITUTIONAL $158.00 1/1/2022-12/31/2022 $158.00 $66.04 $90.06 $116.13 $116.13 200% of Medicare 100% of Medicare $92.92 $89.44 $87.11 $66.04 100% of Medicaid 100% of Medicare 150% of Medicare $126.40 $158.00 195% of Medicare $127.98 $92.43 $92.43 $74.58 $101.66 100% of Medicare $126.40 $134.30 $124.03 $115.32 $126.40 $134.30 $108.63 100% of Medicare 100% of Medicare $118.50 200% of Medicare NULL 320 NULL 72074 NULL NULL 320156 XR Spine Thoracic Min 4 Views NULL INSTITUTIONAL $186.00 1/1/2022-12/31/2022 $186.00 $77.75 $106.02 $136.71 $136.71 200% of Medicare 100% of Medicare $109.39 $105.29 $102.54 $77.75 100% of Medicaid 100% of Medicare 150% of Medicare $148.80 $186.00 195% of Medicare $150.66 $108.81 $108.81 $87.79 $119.67 100% of Medicare $148.80 $158.10 $146.01 $135.76 $148.80 $158.10 $127.88 100% of Medicare 100% of Medicare $139.50 200% of Medicare NULL 320 NULL 72070 NULL NULL 320164 XR Spine Thoracic 2 Views NULL INSTITUTIONAL $141.00 1/1/2022-12/31/2022 $141.00 $58.94 $80.37 $103.64 $103.64 200% of Medicare 100% of Medicare $82.92 $79.82 $77.73 $58.94 100% of Medicaid 100% of Medicare 150% of Medicare $112.80 $141.00 195% of Medicare $114.21 $82.49 $82.49 $66.55 $90.72 100% of Medicare $112.80 $119.85 $110.69 $102.92 $112.80 $119.85 $96.94 100% of Medicare 100% of Medicare $105.75 200% of Medicare NULL 320 NULL NULL NULL NULL 320153 XR Spine Scoliosis NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $100.06 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $126.95 $122.20 $119.00 $135.68 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $126.14 $126.14 $100.06 $212.00 100% of Medicare $169.60 $180.20 $190.80 $154.74 $180.20 $212.00 $212.00 100% of Medicare 100% of Medicare $212.00 200% of Medicare NULL 320 NULL NULL NULL NULL 320155 XR Spine Scoliosis Study Standing NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $100.06 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $126.95 $122.20 $119.00 $135.68 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $126.14 $126.14 $100.06 $212.00 100% of Medicare $169.60 $180.20 $190.80 $154.74 $180.20 $212.00 $212.00 100% of Medicare 100% of Medicare $212.00 200% of Medicare NULL 320 NULL 72110 NULL NULL 320101 XR Spine Lumbar 5 Views NULL INSTITUTIONAL $211.00 1/1/2022-12/31/2022 $211.00 $88.20 $120.27 $155.09 $155.09 200% of Medicare 100% of Medicare $124.09 $119.45 $116.32 $88.20 100% of Medicaid 100% of Medicare 150% of Medicare $168.80 $211.00 195% of Medicare $170.91 $123.44 $123.44 $99.59 $135.76 100% of Medicare $168.80 $179.35 $165.64 $154.01 $168.80 $179.35 $145.06 100% of Medicare 100% of Medicare $158.25 200% of Medicare NULL 320 NULL 72110 NULL NULL 320092 XR Spine Lumbosacral Complete w/ Bending NULL INSTITUTIONAL $211.00 1/1/2022-12/31/2022 $211.00 $88.20 $120.27 $155.09 $155.09 200% of Medicare 100% of Medicare $124.09 $119.45 $116.32 $88.20 100% of Medicaid 100% of Medicare 150% of Medicare $168.80 $211.00 195% of Medicare $170.91 $123.44 $123.44 $99.59 $135.76 100% of Medicare $168.80 $179.35 $165.64 $154.01 $168.80 $179.35 $145.06 100% of Medicare 100% of Medicare $158.25 200% of Medicare NULL 320 NULL 72120 NULL NULL 320151 XR Spine Lumbosacral Bending Only NULL INSTITUTIONAL $185.00 1/1/2022-12/31/2022 $185.00 $77.33 $105.45 $135.98 $135.98 200% of Medicare 100% of Medicare $108.80 $104.73 $101.99 $77.33 100% of Medicaid 100% of Medicare 150% of Medicare $148.00 $185.00 195% of Medicare $149.85 $108.23 $108.23 $87.32 $119.03 100% of Medicare $148.00 $157.25 $145.23 $135.03 $148.00 $157.25 $127.19 100% of Medicare 100% of Medicare $138.75 200% of Medicare NULL 320 NULL 72100 NULL NULL 320094 XR Spine Lumbar 2 Views NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 320 NULL 72070 NULL NULL 320163 XR Spine Thoracic 1 View NULL INSTITUTIONAL $141.00 1/1/2022-12/31/2022 $141.00 $58.94 $80.37 $103.64 $103.64 200% of Medicare 100% of Medicare $82.92 $79.82 $77.73 $58.94 100% of Medicaid 100% of Medicare 150% of Medicare $112.80 $141.00 195% of Medicare $114.21 $82.49 $82.49 $66.55 $90.72 100% of Medicare $112.80 $119.85 $110.69 $102.92 $112.80 $119.85 $96.94 100% of Medicare 100% of Medicare $105.75 200% of Medicare NULL 320 NULL 72100 NULL NULL 320091 XR Spine Lumbar 1 View NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 320 NULL 70260 NULL NULL 320148 XR Skull 4 Views Min NULL INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $84.02 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $118.21 $113.79 $110.81 $84.02 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $117.59 $117.59 $94.87 $129.32 100% of Medicare $160.80 $170.85 $157.79 $146.71 $160.80 $170.85 $138.19 100% of Medicare 100% of Medicare $150.75 200% of Medicare NULL 320 NULL 70260 NULL NULL 320149 XR Skull 2 Views NULL INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $84.02 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $118.21 $113.79 $110.81 $84.02 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $117.59 $117.59 $94.87 $129.32 100% of Medicare $160.80 $170.85 $157.79 $146.71 $160.80 $170.85 $138.19 100% of Medicare 100% of Medicare $150.75 200% of Medicare NULL 320 NULL 70210 NULL NULL 4537961 XR Sinuses Complete NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 70210 NULL NULL 320108 XR Sinuses Paranasal < 3 Views NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 73030 RT NULL 320142 XR Shoulder 2 Views Right NULL INSTITUTIONAL $129.00 1/1/2022-12/31/2022 $129.00 $53.92 $73.53 $94.82 $94.82 200% of Medicare 100% of Medicare $75.86 $73.03 $71.12 $53.92 100% of Medicaid 100% of Medicare 150% of Medicare $103.20 $129.00 195% of Medicare $104.49 $75.47 $75.47 $60.89 $83.00 100% of Medicare $103.20 $109.65 $101.27 $94.16 $103.20 $109.65 $88.69 100% of Medicare 100% of Medicare $96.75 200% of Medicare NULL 320 NULL 73030 LT NULL 320141 XR Shoulder 2 Views Left NULL INSTITUTIONAL $129.00 1/1/2022-12/31/2022 $129.00 $53.92 $73.53 $94.82 $94.82 200% of Medicare 100% of Medicare $75.86 $73.03 $71.12 $53.92 100% of Medicaid 100% of Medicare 150% of Medicare $103.20 $129.00 195% of Medicare $104.49 $75.47 $75.47 $60.89 $83.00 100% of Medicare $103.20 $109.65 $101.27 $94.16 $103.20 $109.65 $88.69 100% of Medicare 100% of Medicare $96.75 200% of Medicare NULL 320 NULL 73020 RT NULL 320138 XR Shoulder 1 View Right NULL INSTITUTIONAL $100.00 1/1/2022-12/31/2022 $100.00 $41.80 $57.00 $73.50 $73.50 200% of Medicare 100% of Medicare $58.81 $56.61 $55.13 $41.80 100% of Medicaid 100% of Medicare 150% of Medicare $80.00 $100.00 195% of Medicare $81.00 $58.50 $58.50 $47.20 $64.34 100% of Medicare $80.00 $85.00 $78.50 $72.99 $80.00 $85.00 $68.75 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 320 NULL 73020 LT NULL 320137 XR Shoulder 1 View Left NULL INSTITUTIONAL $100.00 1/1/2022-12/31/2022 $100.00 $41.80 $57.00 $73.50 $73.50 200% of Medicare 100% of Medicare $58.81 $56.61 $55.13 $41.80 100% of Medicaid 100% of Medicare 150% of Medicare $80.00 $100.00 195% of Medicare $81.00 $58.50 $58.50 $47.20 $64.34 100% of Medicare $80.00 $85.00 $78.50 $72.99 $80.00 $85.00 $68.75 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 320 NULL 73010 RT NULL 320136 XR Scapula Right NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 73010 LT NULL 320135 XR Scapula Left NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 72220 NULL NULL 320133 XR Sacrum/Coccyx Min 2 Views NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $51.41 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $72.34 $69.63 $67.81 $51.41 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $71.96 $71.96 $58.06 $79.14 100% of Medicare $98.40 $104.55 $96.56 $89.78 $98.40 $104.55 $84.56 100% of Medicare 100% of Medicare $92.25 200% of Medicare NULL 320 NULL 72202 NULL NULL 320132 XR Sacroiliac Joints Min 3 Views NULL INSTITUTIONAL $146.00 1/1/2022-12/31/2022 $146.00 $61.03 $83.22 $107.31 $107.31 200% of Medicare 100% of Medicare $85.86 $82.65 $80.49 $61.03 100% of Medicaid 100% of Medicare 150% of Medicare $116.80 $146.00 195% of Medicare $118.26 $85.41 $85.41 $68.91 $93.94 100% of Medicare $116.80 $124.10 $114.61 $106.57 $116.80 $124.10 $100.38 100% of Medicare 100% of Medicare $109.50 200% of Medicare NULL 320 NULL 72200 NULL NULL 320131 XR Sacroiliac Joints 1 or 2 Views NULL INSTITUTIONAL $126.00 1/1/2022-12/31/2022 $126.00 $52.67 $71.82 $92.61 $92.61 200% of Medicare 100% of Medicare $74.10 $71.33 $69.46 $52.67 100% of Medicaid 100% of Medicare 150% of Medicare $100.80 $126.00 195% of Medicare $102.06 $73.71 $73.71 $59.47 $81.07 100% of Medicare $100.80 $107.10 $98.91 $91.97 $100.80 $107.10 $86.63 100% of Medicare 100% of Medicare $94.50 200% of Medicare NULL 320 NULL 71100 RT NULL 320130 XR Ribs w/ PA Chest Right NULL INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $57.68 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $81.16 $78.12 $76.08 $57.68 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $80.73 $80.73 $65.14 $88.79 100% of Medicare $110.40 $117.30 $108.33 $100.73 $110.40 $117.30 $94.88 100% of Medicare 100% of Medicare $103.50 200% of Medicare NULL 320 NULL 71100 LT NULL 320127 XR Ribs w/ PA Chest Left NULL INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $57.68 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $81.16 $78.12 $76.08 $57.68 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $80.73 $80.73 $65.14 $88.79 100% of Medicare $110.40 $117.30 $108.33 $100.73 $110.40 $117.30 $94.88 100% of Medicare 100% of Medicare $103.50 200% of Medicare NULL 320 NULL 71110 50 NULL 320124 XR Ribs w/ PA Chest Bilateral NULL INSTITUTIONAL $170.00 1/1/2022-12/31/2022 $170.00 $71.06 $96.90 $124.95 $124.95 200% of Medicare 100% of Medicare $99.98 $96.24 $93.72 $71.06 100% of Medicaid 100% of Medicare 150% of Medicare $136.00 $170.00 195% of Medicare $137.70 $99.45 $99.45 $80.24 $109.38 100% of Medicare $136.00 $144.50 $133.45 $124.08 $136.00 $144.50 $116.88 100% of Medicare 100% of Medicare $127.50 200% of Medicare NULL 320 NULL 72190 NULL NULL 320112 XR Pelvis 2 or More Views NULL INSTITUTIONAL $179.00 1/1/2022-12/31/2022 $179.00 $74.82 $102.03 $131.57 $131.57 200% of Medicare 100% of Medicare $105.27 $101.33 $98.68 $74.82 100% of Medicaid 100% of Medicare 150% of Medicare $143.20 $179.00 195% of Medicare $144.99 $104.72 $104.72 $84.49 $115.17 100% of Medicare $143.20 $152.15 $140.52 $130.65 $143.20 $152.15 $123.06 100% of Medicare 100% of Medicare $134.25 200% of Medicare NULL 320 NULL 72170 NULL NULL 4537860 XR Pelvis AP NULL INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $46.40 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $65.28 $62.84 $61.19 $46.40 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $64.94 $64.94 $52.39 $71.42 100% of Medicare $88.80 $94.35 $87.14 $81.02 $88.80 $94.35 $76.31 100% of Medicare 100% of Medicare $83.25 200% of Medicare NULL 320 NULL 70200 NULL NULL 320105 XR Orbits Complete Bilateral NULL INSTITUTIONAL $185.00 1/1/2022-12/31/2022 $185.00 $77.33 $105.45 $135.98 $135.98 200% of Medicare 100% of Medicare $108.80 $104.73 $101.99 $77.33 100% of Medicaid 100% of Medicare 150% of Medicare $148.00 $185.00 195% of Medicare $149.85 $108.23 $108.23 $87.32 $119.03 100% of Medicare $148.00 $157.25 $145.23 $135.03 $148.00 $157.25 $127.19 100% of Medicare 100% of Medicare $138.75 200% of Medicare NULL 320 NULL 70360 NULL NULL 320150 XR Neck Soft Tissue NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $47.23 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $66.46 $63.97 $62.30 $47.23 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $66.11 $66.11 $53.34 $72.70 100% of Medicare $90.40 $96.05 $88.71 $82.48 $90.40 $96.05 $77.69 100% of Medicare 100% of Medicare $84.75 200% of Medicare NULL 320 NULL 70160 NULL NULL 320103 XR Nasal Bones Min 3 Views NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $58.52 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $82.33 $79.25 $77.18 $58.52 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $81.90 $81.90 $66.08 $90.08 100% of Medicare $112.00 $119.00 $109.90 $102.19 $112.00 $119.00 $96.25 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 320 NULL 70110 NULL NULL 320102 XR Mandible Complete Min 4 Views NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 73564 RT NULL 320083 XR Knee 4 Views Min Rt NULL INSTITUTIONAL $182.00 1/1/2022-12/31/2022 $182.00 $76.08 $103.74 $133.77 $133.77 200% of Medicare 100% of Medicare $107.03 $103.03 $100.34 $76.08 100% of Medicaid 100% of Medicare 150% of Medicare $145.60 $182.00 195% of Medicare $147.42 $106.47 $106.47 $85.90 $117.10 100% of Medicare $145.60 $154.70 $142.87 $132.84 $145.60 $154.70 $125.13 100% of Medicare 100% of Medicare $136.50 200% of Medicare NULL 320 NULL 73564 LT NULL 320082 XR Knee 4 Views Min Lt NULL INSTITUTIONAL $182.00 1/1/2022-12/31/2022 $182.00 $76.08 $103.74 $133.77 $133.77 200% of Medicare 100% of Medicare $107.03 $103.03 $100.34 $76.08 100% of Medicaid 100% of Medicare 150% of Medicare $145.60 $182.00 195% of Medicare $147.42 $106.47 $106.47 $85.90 $117.10 100% of Medicare $145.60 $154.70 $142.87 $132.84 $145.60 $154.70 $125.13 100% of Medicare 100% of Medicare $136.50 200% of Medicare NULL 320 NULL 73560 RT NULL 320110 XR Knee w/ Patella Right NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 73560 LT NULL 320109 XR Knee w/ Patella Left NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 73060 RT NULL 320075 XR Humerus 2 Views Min Rt NULL INSTITUTIONAL $124.00 1/1/2022-12/31/2022 $124.00 $51.83 $70.68 $91.14 $91.14 200% of Medicare 100% of Medicare $72.92 $70.20 $68.36 $51.83 100% of Medicaid 100% of Medicare 150% of Medicare $99.20 $124.00 195% of Medicare $100.44 $72.54 $72.54 $58.53 $79.78 100% of Medicare $99.20 $105.40 $97.34 $90.51 $99.20 $105.40 $85.25 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 320 NULL 73060 LT NULL 320074 XR Humerus 2 Views Min Lt NULL INSTITUTIONAL $124.00 1/1/2022-12/31/2022 $124.00 $51.83 $70.68 $91.14 $91.14 200% of Medicare 100% of Medicare $72.92 $70.20 $68.36 $51.83 100% of Medicaid 100% of Medicare 150% of Medicare $99.20 $124.00 195% of Medicare $100.44 $72.54 $72.54 $58.53 $79.78 100% of Medicare $99.20 $105.40 $97.34 $90.51 $99.20 $105.40 $85.25 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 320 NULL 72170 RT NULL 320015 XR Hip Operative Right NULL INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $46.40 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $65.28 $62.84 $61.19 $46.40 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $64.94 $64.94 $52.39 $71.42 100% of Medicare $88.80 $94.35 $87.14 $81.02 $88.80 $94.35 $76.31 100% of Medicare 100% of Medicare $83.25 200% of Medicare NULL 320 NULL 72170 LT NULL 320014 XR Hip Operative Left NULL INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $46.40 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $65.28 $62.84 $61.19 $46.40 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $64.94 $64.94 $52.39 $71.42 100% of Medicare $88.80 $94.35 $87.14 $81.02 $88.80 $94.35 $76.31 100% of Medicare 100% of Medicare $83.25 200% of Medicare NULL 320 NULL NULL RT NULL 320073 XR Hip 2 Views Min Rt NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 320 NULL NULL LT NULL 320072 XR Hip 2 Views Min Lt NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 320 NULL 72170 RT NULL 320015 XR Hip 1 View Right NULL INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $46.40 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $65.28 $62.84 $61.19 $46.40 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $64.94 $64.94 $52.39 $71.42 100% of Medicare $88.80 $94.35 $87.14 $81.02 $88.80 $94.35 $76.31 100% of Medicare 100% of Medicare $83.25 200% of Medicare NULL 320 NULL 72170 LT NULL 320014 XR Hip 1 View Left NULL INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $46.40 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $65.28 $62.84 $61.19 $46.40 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $64.94 $64.94 $52.39 $71.42 100% of Medicare $88.80 $94.35 $87.14 $81.02 $88.80 $94.35 $76.31 100% of Medicare 100% of Medicare $83.25 200% of Medicare NULL 320 NULL 73130 RT NULL 320071 XR Hand 3 Views Min Rt NULL INSTITUTIONAL $135.00 1/1/2022-12/31/2022 $135.00 $56.43 $76.95 $99.23 $99.23 200% of Medicare 100% of Medicare $79.39 $76.42 $74.43 $56.43 100% of Medicaid 100% of Medicare 150% of Medicare $108.00 $135.00 195% of Medicare $109.35 $78.98 $78.98 $63.72 $86.86 100% of Medicare $108.00 $114.75 $105.98 $98.54 $108.00 $114.75 $92.81 100% of Medicare 100% of Medicare $101.25 200% of Medicare NULL 320 NULL 73130 LT NULL 320070 XR Hand 3 Views Min Lt NULL INSTITUTIONAL $135.00 1/1/2022-12/31/2022 $135.00 $56.43 $76.95 $99.23 $99.23 200% of Medicare 100% of Medicare $79.39 $76.42 $74.43 $56.43 100% of Medicaid 100% of Medicare 150% of Medicare $108.00 $135.00 195% of Medicare $109.35 $78.98 $78.98 $63.72 $86.86 100% of Medicare $108.00 $114.75 $105.98 $98.54 $108.00 $114.75 $92.81 100% of Medicare 100% of Medicare $101.25 200% of Medicare NULL 320 NULL 73120 RT NULL 320069 XR Hand 2 Views Right NULL INSTITUTIONAL $118.00 1/1/2022-12/31/2022 $118.00 $49.32 $67.26 $86.73 $86.73 200% of Medicare 100% of Medicare $69.40 $66.80 $65.05 $49.32 100% of Medicaid 100% of Medicare 150% of Medicare $94.40 $118.00 195% of Medicare $95.58 $69.03 $69.03 $55.70 $75.92 100% of Medicare $94.40 $100.30 $92.63 $86.13 $94.40 $100.30 $81.13 100% of Medicare 100% of Medicare $88.50 200% of Medicare NULL 320 NULL 73120 LT NULL 320068 XR Hand 2 Views Left NULL INSTITUTIONAL $118.00 1/1/2022-12/31/2022 $118.00 $49.32 $67.26 $86.73 $86.73 200% of Medicare 100% of Medicare $69.40 $66.80 $65.05 $49.32 100% of Medicaid 100% of Medicare 150% of Medicare $94.40 $118.00 195% of Medicare $95.58 $69.03 $69.03 $55.70 $75.92 100% of Medicare $94.40 $100.30 $92.63 $86.13 $94.40 $100.30 $81.13 100% of Medicare 100% of Medicare $88.50 200% of Medicare NULL 320 NULL 73630 RT NULL 320065 XR Foot 3 Views Min Rt NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 73630 LT NULL 320064 XR Foot 3 Views Min Lt NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 73620 RT NULL 320061 XR Foot 2 Views Right NULL INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $47.65 $64.98 $83.79 $83.79 200% of Medicare 100% of Medicare $67.04 $64.54 $62.85 $47.65 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $66.69 $66.69 $53.81 $73.35 100% of Medicare $91.20 $96.90 $89.49 $83.21 $91.20 $96.90 $78.38 100% of Medicare 100% of Medicare $85.50 200% of Medicare NULL 320 NULL 73620 LT NULL 320060 XR Foot 2 Views Left NULL INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $47.65 $64.98 $83.79 $83.79 200% of Medicare 100% of Medicare $67.04 $64.54 $62.85 $47.65 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $66.69 $66.69 $53.81 $73.35 100% of Medicare $91.20 $96.90 $89.49 $83.21 $91.20 $96.90 $78.38 100% of Medicare 100% of Medicare $85.50 200% of Medicare NULL 320 NULL 73140 RT NULL 320059 XR Finger 5th Digit Right NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73140 LT NULL 320058 XR Finger 5th Digit Left NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73140 RT NULL 320057 XR Finger 4th Digit Right NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73140 LT NULL 320056 XR Finger 4th Digit Left NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73140 RT NULL 320055 XR Finger 3rd Digit Right NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73140 LT NULL 320054 XR Finger 3rd Digit Left NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73140 RT NULL 320053 XR Finger 2nd Digit Right NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73140 LT NULL 320052 XR Finger 2nd Digit Left NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL NULL RT NULL 320049 XR Femur 2 Views Rt NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 320 NULL NULL LT NULL 320048 XR Femur 2 Views Lt NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 320 NULL 70150 NULL NULL 320047 XR Facial Bones Min 3 Views NULL INSTITUTIONAL $179.00 1/1/2022-12/31/2022 $179.00 $74.82 $102.03 $131.57 $131.57 200% of Medicare 100% of Medicare $105.27 $101.33 $98.68 $74.82 100% of Medicaid 100% of Medicare 150% of Medicare $143.20 $179.00 195% of Medicare $144.99 $104.72 $104.72 $84.49 $115.17 100% of Medicare $143.20 $152.15 $140.52 $130.65 $143.20 $152.15 $123.06 100% of Medicare 100% of Medicare $134.25 200% of Medicare NULL 320 NULL 73070 RT NULL 320046 XR Elbow 2 Views Right NULL INSTITUTIONAL $122.00 1/1/2022-12/31/2022 $122.00 $51.00 $69.54 $89.67 $89.67 200% of Medicare 100% of Medicare $71.75 $69.06 $67.26 $51.00 100% of Medicaid 100% of Medicare 150% of Medicare $97.60 $122.00 195% of Medicare $98.82 $71.37 $71.37 $57.58 $78.49 100% of Medicare $97.60 $103.70 $95.77 $89.05 $97.60 $103.70 $83.88 100% of Medicare 100% of Medicare $91.50 200% of Medicare NULL 320 NULL 73070 LT NULL 320045 XR Elbow 2 Views Left NULL INSTITUTIONAL $122.00 1/1/2022-12/31/2022 $122.00 $51.00 $69.54 $89.67 $89.67 200% of Medicare 100% of Medicare $71.75 $69.06 $67.26 $51.00 100% of Medicaid 100% of Medicare 150% of Medicare $97.60 $122.00 195% of Medicare $98.82 $71.37 $71.37 $57.58 $78.49 100% of Medicare $97.60 $103.70 $95.77 $89.05 $97.60 $103.70 $83.88 100% of Medicare 100% of Medicare $91.50 200% of Medicare NULL 402 NULL 51798 NULL NULL 001404 Bladder Scan NULL INSTITUTIONAL $225.00 1/1/2022-12/31/2022 $225.00 $94.05 $128.25 $165.38 $165.38 200% of Medicare 100% of Medicare $132.32 $127.37 $124.04 $94.05 100% of Medicaid 100% of Medicare 150% of Medicare $180.00 $225.00 195% of Medicare $182.25 $131.63 $131.63 $106.20 $144.77 100% of Medicare $180.00 $191.25 $176.63 $164.23 $180.00 $191.25 $154.69 100% of Medicare 100% of Medicare $168.75 200% of Medicare NULL 324 NULL 71010 RT NULL 324003 XR Chest Decubitus Right NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 271 NULL NULL NULL E1392 001232 Oxygen Therapy with Exercise NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $47.23 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $66.46 $63.97 $62.30 $47.23 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $66.11 $66.11 $53.34 $72.70 100% of Medicare $90.40 $96.05 $88.71 $82.48 $90.40 $96.05 $77.69 100% of Medicare 100% of Medicare $84.75 200% of Medicare NULL 320 NULL 72040 NULL NULL 320032 XR Spine Cervical Flexion + Extension NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 72100 NULL NULL 320096 XR Spine Lumbar Flexion + Extension NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 320 NULL 70110 50 NULL 320176 XR Zygomatic Arches NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 74000 NULL NULL 320005 XR Abdomen 2 Views NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 320 NULL 92611 NULL NULL 320177 XR BASW Modified NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 410 NULL 94760 NULL NULL 410025 SpO2 NULL INSTITUTIONAL $125.00 1/1/2022-12/31/2022 $125.00 $52.25 $71.25 $91.88 $91.88 200% of Medicare 100% of Medicare $73.51 $70.76 $68.91 $52.25 100% of Medicaid 100% of Medicare 150% of Medicare $100.00 $125.00 195% of Medicare $101.25 $73.13 $73.13 $59.00 $80.43 100% of Medicare $100.00 $106.25 $98.13 $91.24 $100.00 $106.25 $85.94 100% of Medicare 100% of Medicare $93.75 200% of Medicare NULL 324 NULL 71010 LT NULL 324002 XR Chest Decubitus Left NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 320 NULL 73610 LT NULL 320020 XR Ankle 3 Views Left NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $58.52 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $82.33 $79.25 $77.18 $58.52 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $81.90 $81.90 $66.08 $90.08 100% of Medicare $112.00 $119.00 $109.90 $102.19 $112.00 $119.00 $96.25 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 320 NULL 73610 RT NULL 320021 XR Ankle 3 Views Right NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $58.52 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $82.33 $79.25 $77.18 $58.52 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $81.90 $81.90 $66.08 $90.08 100% of Medicare $112.00 $119.00 $109.90 $102.19 $112.00 $119.00 $96.25 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 320 NULL 70150 NULL NULL 320047 XR Facial Bones Minimum 3 Views NULL INSTITUTIONAL $179.00 1/1/2022-12/31/2022 $179.00 $74.82 $102.03 $131.57 $131.57 200% of Medicare 100% of Medicare $105.27 $101.33 $98.68 $74.82 100% of Medicaid 100% of Medicare 150% of Medicare $143.20 $179.00 195% of Medicare $144.99 $104.72 $104.72 $84.49 $115.17 100% of Medicare $143.20 $152.15 $140.52 $130.65 $143.20 $152.15 $123.06 100% of Medicare 100% of Medicare $134.25 200% of Medicare NULL 320 NULL 73630 LT NULL 320064 XR Foot 3 Views Left NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 73630 RT NULL 320065 XR Foot 3 Views Right NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 73130 LT NULL 320070 XR Hand 3 Views Left NULL INSTITUTIONAL $135.00 1/1/2022-12/31/2022 $135.00 $56.43 $76.95 $99.23 $99.23 200% of Medicare 100% of Medicare $79.39 $76.42 $74.43 $56.43 100% of Medicaid 100% of Medicare 150% of Medicare $108.00 $135.00 195% of Medicare $109.35 $78.98 $78.98 $63.72 $86.86 100% of Medicare $108.00 $114.75 $105.98 $98.54 $108.00 $114.75 $92.81 100% of Medicare 100% of Medicare $101.25 200% of Medicare NULL 320 NULL 73130 RT NULL 320071 XR Hand 3 Views Right NULL INSTITUTIONAL $135.00 1/1/2022-12/31/2022 $135.00 $56.43 $76.95 $99.23 $99.23 200% of Medicare 100% of Medicare $79.39 $76.42 $74.43 $56.43 100% of Medicaid 100% of Medicare 150% of Medicare $108.00 $135.00 195% of Medicare $109.35 $78.98 $78.98 $63.72 $86.86 100% of Medicare $108.00 $114.75 $105.98 $98.54 $108.00 $114.75 $92.81 100% of Medicare 100% of Medicare $101.25 200% of Medicare NULL 320 NULL 70110 NULL NULL 320102 XR Mandible Complete Minimum 4 Views NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 70160 NULL NULL 320103 XR Nasal Bones Minimum 3 Views NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $58.52 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $82.33 $79.25 $77.18 $58.52 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $81.90 $81.90 $66.08 $90.08 100% of Medicare $112.00 $119.00 $109.90 $102.19 $112.00 $119.00 $96.25 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 320 NULL 72170 NULL NULL 4537860 XR Pelvis 1 or 2 Views NULL INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $46.40 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $65.28 $62.84 $61.19 $46.40 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $64.94 $64.94 $52.39 $71.42 100% of Medicare $88.80 $94.35 $87.14 $81.02 $88.80 $94.35 $76.31 100% of Medicare 100% of Medicare $83.25 200% of Medicare NULL 320 NULL 72190 NULL NULL 320112 XR Pelvis Complete Minimum 3 Views NULL INSTITUTIONAL $179.00 1/1/2022-12/31/2022 $179.00 $74.82 $102.03 $131.57 $131.57 200% of Medicare 100% of Medicare $105.27 $101.33 $98.68 $74.82 100% of Medicaid 100% of Medicare 150% of Medicare $143.20 $179.00 195% of Medicare $144.99 $104.72 $104.72 $84.49 $115.17 100% of Medicare $143.20 $152.15 $140.52 $130.65 $143.20 $152.15 $123.06 100% of Medicare 100% of Medicare $134.25 200% of Medicare NULL 320 NULL 72202 NULL NULL 320132 XR Sacroiliac Joints Minimum 3 Views NULL INSTITUTIONAL $146.00 1/1/2022-12/31/2022 $146.00 $61.03 $83.22 $107.31 $107.31 200% of Medicare 100% of Medicare $85.86 $82.65 $80.49 $61.03 100% of Medicaid 100% of Medicare 150% of Medicare $116.80 $146.00 195% of Medicare $118.26 $85.41 $85.41 $68.91 $93.94 100% of Medicare $116.80 $124.10 $114.61 $106.57 $116.80 $124.10 $100.38 100% of Medicare 100% of Medicare $109.50 200% of Medicare NULL 320 NULL 72220 NULL NULL 320133 XR Sacrum/Coccyx Minimum 2 Views NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $51.41 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $72.34 $69.63 $67.81 $51.41 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $71.96 $71.96 $58.06 $79.14 100% of Medicare $98.40 $104.55 $96.56 $89.78 $98.40 $104.55 $84.56 100% of Medicare 100% of Medicare $92.25 200% of Medicare NULL 320 NULL 73030 LT NULL 320141 XR Shoulder Complete Left NULL INSTITUTIONAL $129.00 1/1/2022-12/31/2022 $129.00 $53.92 $73.53 $94.82 $94.82 200% of Medicare 100% of Medicare $75.86 $73.03 $71.12 $53.92 100% of Medicaid 100% of Medicare 150% of Medicare $103.20 $129.00 195% of Medicare $104.49 $75.47 $75.47 $60.89 $83.00 100% of Medicare $103.20 $109.65 $101.27 $94.16 $103.20 $109.65 $88.69 100% of Medicare 100% of Medicare $96.75 200% of Medicare NULL 320 NULL 73030 RT NULL 320142 XR Shoulder Complete Right NULL INSTITUTIONAL $129.00 1/1/2022-12/31/2022 $129.00 $53.92 $73.53 $94.82 $94.82 200% of Medicare 100% of Medicare $75.86 $73.03 $71.12 $53.92 100% of Medicaid 100% of Medicare 150% of Medicare $103.20 $129.00 195% of Medicare $104.49 $75.47 $75.47 $60.89 $83.00 100% of Medicare $103.20 $109.65 $101.27 $94.16 $103.20 $109.65 $88.69 100% of Medicare 100% of Medicare $96.75 200% of Medicare NULL 320 NULL 72100 NULL NULL 320091 XR Lumbar Spine 1 View NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 320 NULL 72070 NULL NULL 320163 XR Thoracic Spine 1 View NULL INSTITUTIONAL $141.00 1/1/2022-12/31/2022 $141.00 $58.94 $80.37 $103.64 $103.64 200% of Medicare 100% of Medicare $82.92 $79.82 $77.73 $58.94 100% of Medicaid 100% of Medicare 150% of Medicare $112.80 $141.00 195% of Medicare $114.21 $82.49 $82.49 $66.55 $90.72 100% of Medicare $112.80 $119.85 $110.69 $102.92 $112.80 $119.85 $96.94 100% of Medicare 100% of Medicare $105.75 200% of Medicare NULL 320 NULL 72040 NULL NULL 320031 XR Cervical Spine 2 Views NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 72050 NULL NULL 320037 XR Cervical Spine 5 Views NULL INSTITUTIONAL $223.00 1/1/2022-12/31/2022 $223.00 $93.21 $127.11 $163.91 $163.91 200% of Medicare 100% of Medicare $131.15 $126.24 $122.94 $93.21 100% of Medicaid 100% of Medicare 150% of Medicare $178.40 $223.00 195% of Medicare $180.63 $130.46 $130.46 $105.26 $143.48 100% of Medicare $178.40 $189.55 $175.06 $162.77 $178.40 $189.55 $153.31 100% of Medicare 100% of Medicare $167.25 200% of Medicare NULL 320 NULL 72052 NULL NULL 320038 XR Spine Cervical w/ Flex and/or Ext NULL INSTITUTIONAL $287.00 1/1/2022-12/31/2022 $287.00 $119.97 $163.59 $210.95 $210.95 200% of Medicare 100% of Medicare $168.78 $162.47 $158.22 $119.97 100% of Medicaid 100% of Medicare 150% of Medicare $229.60 $287.00 195% of Medicare $232.47 $167.90 $167.90 $135.46 $184.66 100% of Medicare $229.60 $243.95 $225.30 $209.48 $229.60 $243.95 $197.31 100% of Medicare 100% of Medicare $215.25 200% of Medicare NULL 320 NULL 72100 NULL NULL 320094 XR Lumbar Spine 2 Views NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 320 NULL 72110 NULL NULL 320101 XR Lumbar Spine 5 Views NULL INSTITUTIONAL $211.00 1/1/2022-12/31/2022 $211.00 $88.20 $120.27 $155.09 $155.09 200% of Medicare 100% of Medicare $124.09 $119.45 $116.32 $88.20 100% of Medicaid 100% of Medicare 150% of Medicare $168.80 $211.00 195% of Medicare $170.91 $123.44 $123.44 $99.59 $135.76 100% of Medicare $168.80 $179.35 $165.64 $154.01 $168.80 $179.35 $145.06 100% of Medicare 100% of Medicare $158.25 200% of Medicare NULL 320 NULL 72070 NULL NULL 320164 XR Thoracic Spine 2 Views NULL INSTITUTIONAL $141.00 1/1/2022-12/31/2022 $141.00 $58.94 $80.37 $103.64 $103.64 200% of Medicare 100% of Medicare $82.92 $79.82 $77.73 $58.94 100% of Medicaid 100% of Medicare 150% of Medicare $112.80 $141.00 195% of Medicare $114.21 $82.49 $82.49 $66.55 $90.72 100% of Medicare $112.80 $119.85 $110.69 $102.92 $112.80 $119.85 $96.94 100% of Medicare 100% of Medicare $105.75 200% of Medicare NULL 320 NULL 71130 NULL NULL 320159 XR Sternoclavicular Joint(s) NULL INSTITUTIONAL $158.00 1/1/2022-12/31/2022 $158.00 $66.04 $90.06 $116.13 $116.13 200% of Medicare 100% of Medicare $92.92 $89.44 $87.11 $66.04 100% of Medicaid 100% of Medicare 150% of Medicare $126.40 $158.00 195% of Medicare $127.98 $92.43 $92.43 $74.58 $101.66 100% of Medicare $126.40 $134.30 $124.03 $115.32 $126.40 $134.30 $108.63 100% of Medicare 100% of Medicare $118.50 200% of Medicare NULL 320 NULL 71120 NULL NULL 320160 XR Sternum Minimum 2 Views NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 320 NULL 73110 LT NULL 320174 XR Wrist 3 Views Left NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL 73110 RT NULL 320175 XR Wrist 3 Views Right NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 410 NULL NULL NULL NULL 410030 RESPIRATORY THERAPY CHARGES NULL INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $34.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $44.31 $42.65 $41.54 $47.36 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $44.03 $44.03 $34.93 $74.00 100% of Medicare $59.20 $62.90 $66.60 $54.01 $62.90 $74.00 $74.00 100% of Medicare 100% of Medicare $74.00 200% of Medicare NULL 410 NULL 92950 NULL NULL 410020 RT Cardiopulmonary Resuscitation Charge NULL INSTITUTIONAL $849.00 1/1/2022-12/31/2022 $849.00 $354.88 $483.93 $624.02 $624.02 200% of Medicare 100% of Medicare $499.30 $480.62 $468.05 $354.88 100% of Medicaid 100% of Medicare 150% of Medicare $679.20 $849.00 195% of Medicare $687.69 $496.67 $496.67 $400.73 $546.25 100% of Medicare $679.20 $721.65 $666.47 $619.69 $679.20 $721.65 $583.69 100% of Medicare 100% of Medicare $636.75 200% of Medicare NULL 410 NULL 31500 NULL NULL 410100 Intubation Charge NULL INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $30.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $43.52 $41.89 $40.80 $30.93 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $43.29 $43.29 $34.93 $47.61 100% of Medicare $59.20 $62.90 $58.09 $54.01 $59.20 $62.90 $50.88 100% of Medicare 100% of Medicare $55.50 200% of Medicare NULL 410 NULL 31500 NULL NULL 410036 "RT Intubation, Emergency Charge" NULL INSTITUTIONAL $610.00 1/1/2022-12/31/2022 $610.00 $254.98 $347.70 $448.35 $448.35 200% of Medicare 100% of Medicare $358.74 $345.32 $336.29 $254.98 100% of Medicaid 100% of Medicare 150% of Medicare $488.00 $610.00 195% of Medicare $494.10 $356.85 $356.85 $287.92 $392.47 100% of Medicare $488.00 $518.50 $478.85 $445.24 $488.00 $518.50 $419.38 100% of Medicare 100% of Medicare $457.50 200% of Medicare NULL 410 NULL 94762 NULL NULL 410013 RT Overnight Oximetry Charge NULL INSTITUTIONAL $591.00 1/1/2022-12/31/2022 $591.00 $247.04 $336.87 $434.39 $434.39 200% of Medicare 100% of Medicare $347.57 $334.57 $325.82 $247.04 100% of Medicaid 100% of Medicare 150% of Medicare $472.80 $591.00 195% of Medicare $478.71 $345.74 $345.74 $278.95 $380.25 100% of Medicare $472.80 $502.35 $463.94 $431.37 $472.80 $502.35 $406.31 100% of Medicare 100% of Medicare $443.25 200% of Medicare NULL 270 NULL 94680 NULL NULL 270001 RT Oxygen Per Day Charge NULL INSTITUTIONAL $465.00 1/1/2022-12/31/2022 $465.00 $194.37 $265.05 $341.78 $341.78 200% of Medicare 100% of Medicare $273.47 $263.24 $256.35 $194.37 100% of Medicaid 100% of Medicare 150% of Medicare $372.00 $465.00 195% of Medicare $376.65 $272.03 $272.03 $219.48 $299.18 100% of Medicare $372.00 $395.25 $365.03 $339.40 $372.00 $395.25 $319.69 100% of Medicare 100% of Medicare $348.75 200% of Medicare NULL 410 NULL 89220 NULL NULL 410110 Sputum Induction - RT Charge NULL INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $11.70 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.47 $15.85 $15.44 $11.70 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.38 $16.38 $13.22 $18.02 100% of Medicare $22.40 $23.80 $21.98 $20.44 $22.40 $23.80 $19.25 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 410 NULL 94003 NULL NULL 410029 RT Ventilator Services - Sub Charge NULL INSTITUTIONAL $525.00 1/1/2022-12/31/2022 $525.00 $219.45 $299.25 $385.88 $385.88 200% of Medicare 100% of Medicare $308.75 $297.20 $289.43 $219.45 100% of Medicaid 100% of Medicare 150% of Medicare $420.00 $525.00 195% of Medicare $425.25 $307.13 $307.13 $247.80 $337.79 100% of Medicare $420.00 $446.25 $412.13 $383.20 $420.00 $446.25 $360.94 100% of Medicare 100% of Medicare $393.75 200% of Medicare NULL 410 NULL 94150 NULL NULL 410018 "RT Vital Capacity, Total Charge" NULL INSTITUTIONAL $479.00 1/1/2022-12/31/2022 $479.00 $200.22 $273.03 $352.07 $352.07 200% of Medicare 100% of Medicare $281.70 $271.16 $264.07 $200.22 100% of Medicaid 100% of Medicare 150% of Medicare $383.20 $479.00 195% of Medicare $387.99 $280.22 $280.22 $226.09 $308.19 100% of Medicare $383.20 $407.15 $376.02 $349.62 $383.20 $407.15 $329.31 100% of Medicare 100% of Medicare $359.25 200% of Medicare NULL 460 NULL 94799 NULL NULL 410033 Weaning Negative Inspiratory Force NULL INSTITUTIONAL $439.00 1/1/2022-12/31/2022 $439.00 $183.50 $250.23 $322.67 $322.67 200% of Medicare 100% of Medicare $258.18 $248.52 $242.02 $183.50 100% of Medicaid 100% of Medicare 150% of Medicare $351.20 $439.00 195% of Medicare $355.59 $256.82 $256.82 $207.21 $282.45 100% of Medicare $351.20 $373.15 $344.62 $320.43 $351.20 $373.15 $301.81 100% of Medicare 100% of Medicare $329.25 200% of Medicare NULL 410 NULL 94770 NULL NULL 410026 End Tidal CO2 NULL INSTITUTIONAL $891.00 1/1/2022-12/31/2022 $891.00 $372.44 $507.87 $654.89 $654.89 200% of Medicare 100% of Medicare $524.00 $504.40 $491.21 $372.44 100% of Medicaid 100% of Medicare 150% of Medicare $712.80 $891.00 195% of Medicare $721.71 $521.24 $521.24 $420.55 $573.27 100% of Medicare $712.80 $757.35 $699.44 $650.34 $712.80 $757.35 $612.56 100% of Medicare 100% of Medicare $668.25 200% of Medicare NULL 300 NULL 86850 NULL NULL NULL TB Skin Test NULL INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $27.59 $37.62 $48.51 $48.51 200% of Medicare 100% of Medicare $38.81 $37.36 $36.39 $27.59 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $38.61 $38.61 $31.15 $42.46 100% of Medicare $52.80 $56.10 $51.81 $48.17 $52.80 $56.10 $45.38 100% of Medicare 100% of Medicare $49.50 200% of Medicare NULL 410 NULL 94002 NULL NULL 410028 Ventilator Services Initial NULL INSTITUTIONAL " $1,575.00 " 1/1/2022-12/31/2022 " $1,500.00 " $658.35 $897.75 " $1,157.63 " " $1,157.63 " 200% of Medicare 100% of Medicare $926.26 $891.61 $868.30 $658.35 100% of Medicaid 100% of Medicare 150% of Medicare " $1,260.00 " " $1,500.00 " 195% of Medicare " $1,275.75 " $921.38 $921.38 $743.40 " $1,013.36 " 100% of Medicare " $1,260.00 " " $1,338.75 " " $1,236.38 " " $1,149.59 " " $1,260.00 " " $1,338.75 " " $1,082.81 " 100% of Medicare 100% of Medicare " $1,181.25 " 200% of Medicare NULL 410 NULL 94640 NULL NULL 410040 RT Airway Suction Charge NULL INSTITUTIONAL $904.00 1/1/2022-12/31/2022 $904.00 $377.87 $515.28 $664.44 $664.44 200% of Medicare 100% of Medicare $531.64 $511.75 $498.38 $377.87 100% of Medicaid 100% of Medicare 150% of Medicare $723.20 $904.00 195% of Medicare $732.24 $528.84 $528.84 $426.69 $581.63 100% of Medicare $723.20 $768.40 $709.64 $659.83 $723.20 $768.40 $621.50 100% of Medicare 100% of Medicare $678.00 200% of Medicare NULL 410 NULL 94660 NULL NULL 410009 BiPAP/CPAP Initial NULL INSTITUTIONAL $636.00 1/1/2022-12/31/2022 $636.00 $265.85 $362.52 $467.46 $467.46 200% of Medicare 100% of Medicare $374.03 $360.04 $350.63 $265.85 100% of Medicaid 100% of Medicare 150% of Medicare $508.80 $636.00 195% of Medicare $515.16 $372.06 $372.06 $300.19 $409.20 100% of Medicare $508.80 $540.60 $499.26 $464.22 $508.80 $540.60 $437.25 100% of Medicare 100% of Medicare $477.00 200% of Medicare NULL 410 NULL 94660 NULL NULL 410023 BiPAP/CPAP Subsequent NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $88.62 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $124.68 $120.01 $116.88 $88.62 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $124.02 $124.02 $100.06 $136.40 100% of Medicare $169.60 $180.20 $166.42 $154.74 $169.60 $180.20 $145.75 100% of Medicare 100% of Medicare $159.00 200% of Medicare NULL 410 NULL 94667 NULL NULL 410011 Initial Manipulation chest wall NULL INSTITUTIONAL $359.00 1/1/2022-12/31/2022 $359.00 $150.06 $204.63 $263.87 $263.87 200% of Medicare 100% of Medicare $211.13 $203.23 $197.92 $150.06 100% of Medicaid 100% of Medicare 150% of Medicare $287.20 $359.00 195% of Medicare $290.79 $210.02 $210.02 $169.45 $230.98 100% of Medicare $287.20 $305.15 $281.82 $262.03 $287.20 $305.15 $246.81 100% of Medicare 100% of Medicare $269.25 200% of Medicare NULL 410 NULL 94668 NULL NULL 410012 Subsequent Manipulation chest wall NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 730 NULL 93005 NULL NULL 730001 EKG RT Charge NULL INSTITUTIONAL $187.00 1/1/2022-12/31/2022 $187.00 $78.17 $106.59 $137.45 $137.45 200% of Medicare 100% of Medicare $109.97 $105.86 $103.09 $78.17 100% of Medicaid 100% of Medicare 150% of Medicare $149.60 $187.00 195% of Medicare $151.47 $109.40 $109.40 $88.26 $120.32 100% of Medicare $149.60 $158.95 $146.80 $136.49 $149.60 $158.95 $128.56 100% of Medicare 100% of Medicare $140.25 200% of Medicare NULL 272 NULL 94761 NULL NULL 272008 Oxymizer NULL INSTITUTIONAL $146.00 1/1/2022-12/31/2022 $146.00 $61.03 $83.22 $107.31 $107.31 200% of Medicare 100% of Medicare $85.86 $82.65 $80.49 $61.03 100% of Medicaid 100% of Medicare 150% of Medicare $116.80 $146.00 195% of Medicare $118.26 $85.41 $85.41 $68.91 $93.94 100% of Medicare $116.80 $124.10 $114.61 $106.57 $116.80 $124.10 $100.38 100% of Medicare 100% of Medicare $109.50 200% of Medicare NULL 410 NULL 94010 NULL NULL 410105 Incentive Spirometry Initial NULL INSTITUTIONAL $476.00 1/1/2022-12/31/2022 $476.00 $198.97 $271.32 $349.86 $349.86 200% of Medicare 100% of Medicare $279.94 $269.46 $262.42 $198.97 100% of Medicaid 100% of Medicare 150% of Medicare $380.80 $476.00 195% of Medicare $385.56 $278.46 $278.46 $224.67 $306.26 100% of Medicare $380.80 $404.60 $373.66 $347.43 $380.80 $404.60 $327.25 100% of Medicare 100% of Medicare $357.00 200% of Medicare NULL 410 NULL 94010 NULL NULL 410030 Incentive Spirometry Subsequent NULL INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $30.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $43.52 $41.89 $40.80 $30.93 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $43.29 $43.29 $34.93 $47.61 100% of Medicare $59.20 $62.90 $58.09 $54.01 $59.20 $62.90 $50.88 100% of Medicare 100% of Medicare $55.50 200% of Medicare NULL 412 NULL 94640 NULL NULL 412002 Meter Dose Inhaler (MDI) Initial NULL INSTITUTIONAL $681.00 1/1/2022-12/31/2022 $681.00 $284.66 $388.17 $500.54 $500.54 200% of Medicare 100% of Medicare $400.50 $385.51 $375.44 $284.66 100% of Medicaid 100% of Medicare 150% of Medicare $544.80 $681.00 195% of Medicare $551.61 $398.39 $398.39 $321.43 $438.16 100% of Medicare $544.80 $578.85 $534.59 $497.06 $544.80 $578.85 $468.19 100% of Medicare 100% of Medicare $510.75 200% of Medicare NULL 410 NULL 94640 NULL NULL 410034 Meter Dose Inhaler (MDI) Subsequent NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $88.62 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $124.68 $120.01 $116.88 $88.62 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $124.02 $124.02 $100.06 $136.40 100% of Medicare $169.60 $180.20 $166.42 $154.74 $169.60 $180.20 $145.75 100% of Medicare 100% of Medicare $159.00 200% of Medicare NULL 410 NULL NULL NULL NULL 410103 Peak Flow Rate NULL INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $34.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $44.31 $42.65 $41.54 $47.36 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $44.03 $44.03 $34.93 $74.00 100% of Medicare $59.20 $62.90 $66.60 $54.01 $62.90 $74.00 $74.00 100% of Medicare 100% of Medicare $74.00 200% of Medicare NULL 410 NULL NULL NULL NULL 410101 FVC Actual NULL INSTITUTIONAL $487.00 1/1/2022-12/31/2022 $487.00 $229.86 $277.59 $357.95 $357.95 200% of Medicare 100% of Medicare $291.62 $280.71 $273.35 $311.68 100% of Medicaid 100% of Medicare 150% of Medicare $389.60 $487.00 195% of Medicare $394.47 $289.77 $289.77 $229.86 $487.00 100% of Medicare $389.60 $413.95 $438.30 $355.46 $413.95 $487.00 $487.00 100% of Medicare 100% of Medicare $487.00 200% of Medicare NULL 320 NULL 74000 NULL NULL 320001 XR Abdomen KUB NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 320 NULL 74022 NULL NULL 320002 XR Abdomen Series NULL INSTITUTIONAL $202.00 1/1/2022-12/31/2022 $202.00 $84.44 $115.14 $148.47 $148.47 200% of Medicare 100% of Medicare $118.80 $114.35 $111.36 $84.44 100% of Medicaid 100% of Medicare 150% of Medicare $161.60 $202.00 195% of Medicare $163.62 $118.17 $118.17 $95.34 $129.97 100% of Medicare $161.60 $171.70 $158.57 $147.44 $161.60 $171.70 $138.88 100% of Medicare 100% of Medicare $151.50 200% of Medicare NULL 320 NULL 77074 NULL NULL 320022 XR Bone Survey (metastatic) NULL INSTITUTIONAL $291.00 1/1/2022-12/31/2022 $291.00 $121.64 $165.87 $213.89 $213.89 200% of Medicare 100% of Medicare $171.14 $164.74 $160.43 $121.64 100% of Medicaid 100% of Medicare 150% of Medicare $232.80 $291.00 195% of Medicare $235.71 $170.24 $170.24 $137.35 $187.23 100% of Medicare $232.80 $247.35 $228.44 $212.40 $232.80 $247.35 $200.06 100% of Medicare 100% of Medicare $218.25 200% of Medicare NULL 320 NULL 73562 LT NULL 320080 XR Knee 3 Views Left NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL 73562 RT NULL 320081 XR Knee 3 Views Right NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL NULL NULL NULL 320119 XR Pelvis 1 or 2 Views NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 118 NULL NULL NULL NULL 118001 Private NULL INSTITUTIONAL " $2,187.00 " 1/1/2022-12/31/2022 " $2,187.00 " $975.00 " $1,246.59 " " $1,607.45 " " $1,607.45 " 200% of Medicare 100% of Medicare " $1,309.58 " " $1,260.59 " " $1,227.56 " " $1,399.68 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,749.60 " " $1,500.00 " 195% of Medicare " $1,771.47 " " $1,301.27 " " $1,301.27 " " $1,032.26 " " $1,359.00 " 100% of Medicare " $1,749.60 " " $1,858.95 " " $1,968.30 " " $1,596.29 " " $1,858.95 " " $1,500.00 " " $2,187.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 128 NULL NULL NULL NULL 128001 Semi Private NULL INSTITUTIONAL " $2,187.00 " 1/1/2022-12/31/2022 " $2,187.00 " $975.00 " $1,246.59 " " $1,607.45 " " $1,607.45 " 200% of Medicare 100% of Medicare " $1,309.58 " " $1,260.59 " " $1,227.56 " " $1,399.68 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,749.60 " " $1,500.00 " 195% of Medicare " $1,771.47 " " $1,301.27 " " $1,301.27 " " $1,032.26 " " $1,359.00 " 100% of Medicare " $1,749.60 " " $1,858.95 " " $1,968.30 " " $1,596.29 " " $1,858.95 " " $1,500.00 " " $2,187.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 320 NULL 72110 NULL NULL 320088 XR Spine Lumbar 3 Views NULL INSTITUTIONAL $211.00 1/1/2022-12/31/2022 $211.00 $88.20 $120.27 $155.09 $155.09 200% of Medicare 100% of Medicare $124.09 $119.45 $116.32 $88.20 100% of Medicaid 100% of Medicare 150% of Medicare $168.80 $211.00 195% of Medicare $170.91 $123.44 $123.44 $99.59 $135.76 100% of Medicare $168.80 $179.35 $165.64 $154.01 $168.80 $179.35 $145.06 100% of Medicare 100% of Medicare $158.25 200% of Medicare NULL 320 NULL NULL NULL NULL 320118 XR Pelvis w/lateral Hips NULL INSTITUTIONAL $165.00 1/1/2022-12/31/2022 $165.00 $77.88 $94.05 $121.28 $121.28 200% of Medicare 100% of Medicare $98.80 $95.11 $92.61 $105.60 100% of Medicaid 100% of Medicare 150% of Medicare $132.00 $165.00 195% of Medicare $133.65 $98.18 $98.18 $77.88 $165.00 100% of Medicare $132.00 $140.25 $148.50 $120.43 $140.25 $165.00 $165.00 100% of Medicare 100% of Medicare $165.00 200% of Medicare NULL 320 NULL 72110 NULL NULL 320088 XR Lumbar Spine 3 Views NULL INSTITUTIONAL $211.00 1/1/2022-12/31/2022 $211.00 $88.20 $120.27 $155.09 $155.09 200% of Medicare 100% of Medicare $124.09 $119.45 $116.32 $88.20 100% of Medicaid 100% of Medicare 150% of Medicare $168.80 $211.00 195% of Medicare $170.91 $123.44 $123.44 $99.59 $135.76 100% of Medicare $168.80 $179.35 $165.64 $154.01 $168.80 $179.35 $145.06 100% of Medicare 100% of Medicare $158.25 200% of Medicare NULL 410 NULL 94640 NULL NULL 410040 AIRWAY SUCTION Charge NULL INSTITUTIONAL $904.00 1/1/2022-12/31/2022 $904.00 $377.87 $515.28 $664.44 $664.44 200% of Medicare 100% of Medicare $531.64 $511.75 $498.38 $377.87 100% of Medicaid 100% of Medicare 150% of Medicare $723.20 $904.00 195% of Medicare $732.24 $528.84 $528.84 $426.69 $581.63 100% of Medicare $723.20 $768.40 $709.64 $659.83 $723.20 $768.40 $621.50 100% of Medicare 100% of Medicare $678.00 200% of Medicare NULL 320 NULL 73560 RT NULL 320085 XR Patella Sunrise Right NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 73560 LT NULL 320084 XR Patella Sunrise Left NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 72100 NULL NULL 320097 XR Spine Lumbar Xtl Lateral NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 320 NULL 74020 LT NULL 320007 XR Abdomen Decubitus Left NULL INSTITUTIONAL $169.00 1/1/2022-12/31/2022 $169.00 $70.64 $96.33 $124.22 $124.22 200% of Medicare 100% of Medicare $99.39 $95.67 $93.17 $70.64 100% of Medicaid 100% of Medicare 150% of Medicare $135.20 $169.00 195% of Medicare $136.89 $98.87 $98.87 $79.77 $108.73 100% of Medicare $135.20 $143.65 $132.67 $123.35 $135.20 $143.65 $116.19 100% of Medicare 100% of Medicare $126.75 200% of Medicare NULL 320 NULL 74020 RT NULL 320008 XR Abdomen Decubitus Right NULL INSTITUTIONAL $169.00 1/1/2022-12/31/2022 $169.00 $70.64 $96.33 $124.22 $124.22 200% of Medicare 100% of Medicare $99.39 $95.67 $93.17 $70.64 100% of Medicaid 100% of Medicare 150% of Medicare $135.20 $169.00 195% of Medicare $136.89 $98.87 $98.87 $79.77 $108.73 100% of Medicare $135.20 $143.65 $132.67 $123.35 $135.20 $143.65 $116.19 100% of Medicare 100% of Medicare $126.75 200% of Medicare NULL 324 NULL 71010 NULL NULL 324004 XR Chest Inspiration/Expiration NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 320 NULL 77074 NULL NULL 320024 XR Bone Survey Limited (Mets) NULL INSTITUTIONAL $291.00 1/1/2022-12/31/2022 $291.00 $121.64 $165.87 $213.89 $213.89 200% of Medicare 100% of Medicare $171.14 $164.74 $160.43 $121.64 100% of Medicaid 100% of Medicare 150% of Medicare $232.80 $291.00 195% of Medicare $235.71 $170.24 $170.24 $137.35 $187.23 100% of Medicare $232.80 $247.35 $228.44 $212.40 $232.80 $247.35 $200.06 100% of Medicare 100% of Medicare $218.25 200% of Medicare NULL 320 NULL 77073 NULL NULL 320089 XR Bone Length Studies Scanograms NULL INSTITUTIONAL $162.00 1/1/2022-12/31/2022 $162.00 $67.72 $92.34 $119.07 $119.07 200% of Medicare 100% of Medicare $95.27 $91.71 $89.31 $67.72 100% of Medicaid 100% of Medicare 150% of Medicare $129.60 $162.00 195% of Medicare $131.22 $94.77 $94.77 $76.46 $104.23 100% of Medicare $129.60 $137.70 $127.17 $118.24 $129.60 $137.70 $111.38 100% of Medicare 100% of Medicare $121.50 200% of Medicare NULL 320 NULL 70250 NULL NULL 320146 XR Skull < 4 Views NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL 70130 NULL NULL 320147 XR Skull Complete NULL INSTITUTIONAL $239.00 1/1/2022-12/31/2022 $239.00 $99.90 $136.23 $175.67 $175.67 200% of Medicare 100% of Medicare $140.56 $135.30 $131.76 $99.90 100% of Medicaid 100% of Medicare 150% of Medicare $191.20 $239.00 195% of Medicare $193.59 $139.82 $139.82 $112.81 $153.77 100% of Medicare $191.20 $203.15 $187.62 $174.45 $191.20 $203.15 $164.31 100% of Medicare 100% of Medicare $179.25 200% of Medicare NULL 320 NULL NULL NULL NULL 320042 XR Spine Entire Survey AP/Lat NULL INSTITUTIONAL $324.00 1/1/2022-12/31/2022 $324.00 $152.93 $184.68 $238.14 $238.14 200% of Medicare 100% of Medicare $194.01 $186.75 $181.86 $207.36 100% of Medicaid 100% of Medicare 150% of Medicare $259.20 $324.00 195% of Medicare $262.44 $192.78 $192.78 $152.93 $324.00 100% of Medicare $259.20 $275.40 $291.60 $236.49 $275.40 $324.00 $324.00 100% of Medicare 100% of Medicare $324.00 200% of Medicare NULL 320 NULL NULL NULL NULL 320154 XR Spine Scoliosis Supine + Standing NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $100.06 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $126.95 $122.20 $119.00 $135.68 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $126.14 $126.14 $100.06 $212.00 100% of Medicare $169.60 $180.20 $190.80 $154.74 $180.20 $212.00 $212.00 100% of Medicare 100% of Medicare $212.00 200% of Medicare NULL 320 NULL 72080 NULL NULL 320158 XR Spine Thoracolumbar 2 Views NULL INSTITUTIONAL $152.00 1/1/2022-12/31/2022 $152.00 $63.54 $86.64 $111.72 $111.72 200% of Medicare 100% of Medicare $89.39 $86.05 $83.80 $63.54 100% of Medicaid 100% of Medicare 150% of Medicare $121.60 $152.00 195% of Medicare $123.12 $88.92 $88.92 $71.74 $97.80 100% of Medicare $121.60 $129.20 $119.32 $110.94 $121.60 $129.20 $104.50 100% of Medicare 100% of Medicare $114.00 200% of Medicare NULL 320 NULL 71100 LT NULL 320125 XR Ribs 2 Views Left NULL INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $57.68 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $81.16 $78.12 $76.08 $57.68 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $80.73 $80.73 $65.14 $88.79 100% of Medicare $110.40 $117.30 $108.33 $100.73 $110.40 $117.30 $94.88 100% of Medicare 100% of Medicare $103.50 200% of Medicare NULL 320 NULL 71100 RT NULL 320128 XR Ribs 2 Views Right NULL INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $57.68 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $81.16 $78.12 $76.08 $57.68 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $80.73 $80.73 $65.14 $88.79 100% of Medicare $110.40 $117.30 $108.33 $100.73 $110.40 $117.30 $94.88 100% of Medicare 100% of Medicare $103.50 200% of Medicare NULL 360 NULL 36569 NULL NULL 360001 PICC Line Insertion NULL INSTITUTIONAL " $2,201.00 " 1/1/2022-12/31/2022 " $1,870.85 " $920.02 " $1,254.57 " " $1,617.74 " " $1,617.74 " 200% of Medicare 100% of Medicare " $1,294.41 " " $1,245.99 " " $1,213.41 " $920.02 100% of Medicaid 100% of Medicare 150% of Medicare " $1,760.80 " " $1,500.00 " 195% of Medicare " $1,782.81 " " $1,287.59 " " $1,287.59 " " $1,038.87 " " $1,416.12 " 100% of Medicare " $1,760.80 " " $1,870.85 " " $1,727.79 " " $1,606.51 " " $1,760.80 " " $1,870.85 " " $1,513.19 " 100% of Medicare 100% of Medicare " $1,650.75 " 200% of Medicare NULL 320 NULL 70220 NULL NULL 320107 XR Sinuses Paranasal Complete NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 72020 NULL NULL 320029 XR Spine 1 View Cervical NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 320 NULL 72020 NULL NULL 320036 XR Spine Cervical 2 or 3 Views NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 320 NULL 72020 NULL NULL 320039 XR Spine Cervical Min 4 Views NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 320 NULL 72070 NULL NULL 320165 XR Spine Thoracic 3 Views NULL INSTITUTIONAL $141.00 1/1/2022-12/31/2022 $141.00 $58.94 $80.37 $103.64 $103.64 200% of Medicare 100% of Medicare $82.92 $79.82 $77.73 $58.94 100% of Medicaid 100% of Medicare 150% of Medicare $112.80 $141.00 195% of Medicare $114.21 $82.49 $82.49 $66.55 $90.72 100% of Medicare $112.80 $119.85 $110.69 $102.92 $112.80 $119.85 $96.94 100% of Medicare 100% of Medicare $105.75 200% of Medicare NULL 320 NULL 72100 NULL NULL 320152 XR Spine Lumbosacral 2 or 3 Views NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 320 NULL 73030 LT NULL 320139 XR Shoulder Complete Left NULL INSTITUTIONAL $129.00 1/1/2022-12/31/2022 $129.00 $53.92 $73.53 $94.82 $94.82 200% of Medicare 100% of Medicare $75.86 $73.03 $71.12 $53.92 100% of Medicaid 100% of Medicare 150% of Medicare $103.20 $129.00 195% of Medicare $104.49 $75.47 $75.47 $60.89 $83.00 100% of Medicare $103.20 $109.65 $101.27 $94.16 $103.20 $109.65 $88.69 100% of Medicare 100% of Medicare $96.75 200% of Medicare NULL 320 NULL 73030 RT NULL 320140 XR Shoulder Complete Right NULL INSTITUTIONAL $129.00 1/1/2022-12/31/2022 $129.00 $53.92 $73.53 $94.82 $94.82 200% of Medicare 100% of Medicare $75.86 $73.03 $71.12 $53.92 100% of Medicaid 100% of Medicare 150% of Medicare $103.20 $129.00 195% of Medicare $104.49 $75.47 $75.47 $60.89 $83.00 100% of Medicare $103.20 $109.65 $101.27 $94.16 $103.20 $109.65 $88.69 100% of Medicare 100% of Medicare $96.75 200% of Medicare NULL 320 NULL 73090 LT NULL 320122 XR Forearm 2 Views Left NULL INSTITUTIONAL $116.00 1/1/2022-12/31/2022 $116.00 $48.49 $66.12 $85.26 $85.26 200% of Medicare 100% of Medicare $68.22 $65.67 $63.95 $48.49 100% of Medicaid 100% of Medicare 150% of Medicare $92.80 $116.00 195% of Medicare $93.96 $67.86 $67.86 $54.75 $74.63 100% of Medicare $92.80 $98.60 $91.06 $84.67 $92.80 $98.60 $79.75 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 320 NULL 73090 RT NULL 320123 XR Forearm 2 Views Right NULL INSTITUTIONAL $116.00 1/1/2022-12/31/2022 $116.00 $48.49 $66.12 $85.26 $85.26 200% of Medicare 100% of Medicare $68.22 $65.67 $63.95 $48.49 100% of Medicaid 100% of Medicare 150% of Medicare $92.80 $116.00 195% of Medicare $93.96 $67.86 $67.86 $54.75 $74.63 100% of Medicare $92.80 $98.60 $91.06 $84.67 $92.80 $98.60 $79.75 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 320 NULL 73110 LT NULL 320027 XR Wrist Complete Left NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL 73110 RT NULL 320028 XR Wrist Complete Right NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL 73140 LT NULL 320050 XR Finger Thumb Left NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73140 RT NULL 320051 XR Finger Thumb Right NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 320 NULL 73560 LT NULL 320076 XR Knee 1 or 2 Views Left NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 73560 RT NULL 320077 XR Knee 1 or 2 Views Right NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 72020 NULL NULL 320039 XR Spine Cervical Minimum 4 Views NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 320 NULL NULL RT NULL 320073 XR Hip 2 Views Right NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 440 NULL 92507 GN NULL 440001 "SLP Treatment of speech, language, voice, communic" NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 320 NULL NULL LT NULL 320072 XR Hip 2 Views Left NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 434 NULL 97003 GO NULL 434001 OT Evaluation Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL 97168 GO NULL 434004 OT Re-Evaluation Units NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $165.95 $226.29 $291.80 $291.80 200% of Medicare 100% of Medicare $233.48 $224.74 $218.87 $165.95 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $232.25 $232.25 $187.38 $255.43 100% of Medicare $317.60 $337.45 $311.65 $289.77 $317.60 $337.45 $272.94 100% of Medicare 100% of Medicare $297.75 200% of Medicare NULL 430 NULL 97018 GO NULL 430018 OT Paraffin Bath Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 430 NULL 97022 GO NULL 430019 "OT Whirlpool, Fluidotherapy Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 430 NULL 95831 GO NULL 430014 "OT MMT, Extremity, Trunk Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 430 NULL 95832 GO NULL 430015 "OT MMT, Hand Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 430 NULL 95833 GO NULL 430016 "OT MMT, Total Body Without Hand Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 433 NULL 97150 GO NULL 433001 OT Group Therapy Rehab Units NULL INSTITUTIONAL $566.00 1/1/2022-12/31/2022 $566.00 $236.59 $322.62 $416.01 $416.01 200% of Medicare 100% of Medicare $332.86 $320.41 $312.04 $236.59 100% of Medicaid 100% of Medicare 150% of Medicare $452.80 $566.00 195% of Medicare $458.46 $331.11 $331.11 $267.15 $364.16 100% of Medicare $452.80 $481.10 $444.31 $413.12 $452.80 $481.10 $389.13 100% of Medicare 100% of Medicare $424.50 200% of Medicare NULL 433 NULL 97150 GO NULL 430101 OT Double Therapy Units NULL INSTITUTIONAL " $1,107.00 " 1/1/2022-12/31/2022 " $1,107.00 " $462.73 $630.99 $813.65 $813.65 200% of Medicare 100% of Medicare $651.03 $626.67 $610.29 $462.73 100% of Medicaid 100% of Medicare 150% of Medicare $885.60 " $1,107.00 " 195% of Medicare $896.67 $647.60 $647.60 $522.50 $712.24 100% of Medicare $885.60 $940.95 $869.00 $808.00 $885.60 $940.95 $761.06 100% of Medicare 100% of Medicare $830.25 200% of Medicare NULL 430 NULL 97032 GO NULL 430020 OT Attended E-Stim Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 430 NULL 97033 GO NULL 430021 OT Iontophoresis Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 430 NULL 97034 GO NULL 430022 OT Contrast Bath Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97035 GO NULL 430023 OT Ultrasound Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97110 GO NULL 430005 OT Therapeutic Exercise Rehab Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97112 GO NULL 430006 OT Neuromuscular Reeducation Rehab Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97124 GO NULL 430024 OT Massage Rehab Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97140 GO NULL 430025 OT Manual Therapy Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97530 GO NULL 430026 OT Therapeutic Activities Rehab Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97532 GO NULL 430008 OT Cognitive Skills Development Rehab Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97533 GO NULL 430009 OT Sensory Integrative Techniques Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97535 GO NULL 430010 "OT Self Care, Home Management Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97537 GO NULL 430011 "OT Community, Work Reintegration Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97542 GO NULL 430012 OT Wheelchair Management Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97545 GO NULL 430027 OT Work Hardening-Initial 2 Hours Units NULL INSTITUTIONAL $731.00 1/1/2022-12/31/2022 $731.00 $305.56 $416.67 $537.29 $537.29 200% of Medicare 100% of Medicare $429.90 $413.82 $403.00 $305.56 100% of Medicaid 100% of Medicare 150% of Medicare $584.80 $731.00 195% of Medicare $592.11 $427.64 $427.64 $345.03 $470.33 100% of Medicare $584.80 $621.35 $573.84 $533.56 $584.80 $621.35 $502.56 100% of Medicare 100% of Medicare $548.25 200% of Medicare NULL 430 NULL 97546 GO NULL 430028 OT Work Hardening-Each Addl Hour Units NULL INSTITUTIONAL $365.00 1/1/2022-12/31/2022 $365.00 $152.57 $208.05 $268.28 $268.28 200% of Medicare 100% of Medicare $214.66 $206.63 $201.22 $152.57 100% of Medicaid 100% of Medicare 150% of Medicare $292.00 $365.00 195% of Medicare $295.65 $213.53 $213.53 $172.28 $234.84 100% of Medicare $292.00 $310.25 $286.53 $266.41 $292.00 $310.25 $250.94 100% of Medicare 100% of Medicare $273.75 200% of Medicare NULL 430 NULL 97760 GO NULL 430030 "OT Orthotic Management, Train Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97761 GO NULL 430031 "OT Prosthetic Management, Train Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97755 GO NULL 430013 OT Assistive Technology Eval Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 29240 NULL NULL 430040 "OT Strapping, Shoulder Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 430 NULL 29280 NULL NULL 430038 "OT Strapping, Hand, Finger Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 430 NULL 29260 NULL NULL 430037 "OT Strapping, Elbow, Wrist Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 430 NULL 29799 NULL NULL 430039 "OT Strapping, Low Back Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 424 NULL 97001 GP NULL 424001 PT Evaluation Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL NULL GP NULL 424002 PT Reevaluation Units NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $187.38 $226.29 $291.80 $291.80 200% of Medicare 100% of Medicare $237.72 $228.83 $222.84 $254.08 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $236.22 $236.22 $187.38 $397.00 100% of Medicare $317.60 $337.45 $357.30 $289.77 $337.45 $397.00 $397.00 100% of Medicare 100% of Medicare $397.00 200% of Medicare NULL 420 NULL 97012 GP NULL 420018 PT Mechanical Traction Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 97016 GP NULL 420019 PT Vasopneumatic Devices Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 97018 GP NULL 420020 PT Paraffin Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 97022 GP NULL 420021 "PT Whirlpool, Fluidotherapy Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 90901 GP NULL 420012 PT Biofeedback Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 95831 GP NULL 420013 "PT MMT, Extremity, Trunk Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 95833 GP NULL 420014 "PT MMT, Total Body Exclude Hand Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 95834 GP NULL 420015 "PT MMT, Total Body With Hand Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 95852 GP NULL 420017 PT ROM Measurement Hand Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 423 NULL 97150 GP NULL 423001 PT Group Therapy Units NULL INSTITUTIONAL $566.00 1/1/2022-12/31/2022 $566.00 $236.59 $322.62 $416.01 $416.01 200% of Medicare 100% of Medicare $332.86 $320.41 $312.04 $236.59 100% of Medicaid 100% of Medicare 150% of Medicare $452.80 $566.00 195% of Medicare $458.46 $331.11 $331.11 $267.15 $364.16 100% of Medicare $452.80 $481.10 $444.31 $413.12 $452.80 $481.10 $389.13 100% of Medicare 100% of Medicare $424.50 200% of Medicare NULL 423 NULL 97150 GP NULL 420100 PT Double Therapy Units NULL INSTITUTIONAL " $1,107.00 " 1/1/2022-12/31/2022 " $1,107.00 " $462.73 $630.99 $813.65 $813.65 200% of Medicare 100% of Medicare $651.03 $626.67 $610.29 $462.73 100% of Medicaid 100% of Medicare 150% of Medicare $885.60 " $1,107.00 " 195% of Medicare $896.67 $647.60 $647.60 $522.50 $712.24 100% of Medicare $885.60 $940.95 $869.00 $808.00 $885.60 $940.95 $761.06 100% of Medicare 100% of Medicare $830.25 200% of Medicare NULL 420 NULL 97032 GP NULL 420022 PT Attended E-Stim Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 420 NULL 97033 GP NULL 420023 PT Iontophoresis Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 420 NULL 97034 GP NULL 420024 PT Contrast Bath Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97035 GP NULL 420025 PT Ultrasound Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97110 GP NULL 420026 PT Therapeutic Exercise Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97750 GP NULL 420037 PT Physical Performance Test NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97113 GP NULL 420028 PT Aquatic Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97116 GP NULL 420029 PT Gait Training Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97124 GP NULL 420030 PT Massage Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97112 GP NULL 420027 PT Neuromuscular Reeducation Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97140 GP NULL 420031 PT Manual Therapy Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97530 GP NULL 420032 PT Therapeutic Activity Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97535 GP NULL 420043 "PT Self Care, Home Management Units" NULL INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $84.02 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $118.21 $113.79 $110.81 $84.02 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $117.59 $117.59 $94.87 $129.32 100% of Medicare $160.80 $170.85 $157.79 $146.71 $160.80 $170.85 $138.19 100% of Medicare 100% of Medicare $150.75 200% of Medicare NULL 420 NULL 97542 GP NULL 420034 PT Wheelchair Management Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97545 GP NULL 420035 PT Work Hardening Initial 2 Hours Units NULL INSTITUTIONAL $731.00 1/1/2022-12/31/2022 $731.00 $305.56 $416.67 $537.29 $537.29 200% of Medicare 100% of Medicare $429.90 $413.82 $403.00 $305.56 100% of Medicaid 100% of Medicare 150% of Medicare $584.80 $731.00 195% of Medicare $592.11 $427.64 $427.64 $345.03 $470.33 100% of Medicare $584.80 $621.35 $573.84 $533.56 $584.80 $621.35 $502.56 100% of Medicare 100% of Medicare $548.25 200% of Medicare NULL 420 NULL 97546 GP NULL 420036 PT Work Hardening-Each Addl Hour Units NULL INSTITUTIONAL $365.00 1/1/2022-12/31/2022 $365.00 $152.57 $208.05 $268.28 $268.28 200% of Medicare 100% of Medicare $214.66 $206.63 $201.22 $152.57 100% of Medicaid 100% of Medicare 150% of Medicare $292.00 $365.00 195% of Medicare $295.65 $213.53 $213.53 $172.28 $234.84 100% of Medicare $292.00 $310.25 $286.53 $266.41 $292.00 $310.25 $250.94 100% of Medicare 100% of Medicare $273.75 200% of Medicare NULL 420 NULL 97760 GP NULL 420039 "PT Orthotic Management, Train Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97761 GP NULL 420040 "PT Prosthetic Management, Train Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97755 GP NULL 420038 PT Assistive Technology Eval Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 29240 NULL NULL 420004 PT Strapping Shoulder Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29260 NULL NULL 420005 "PT Strapping Elbow, Wrist Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29280 NULL NULL 420006 "PT Strapping Hand, Finger Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29799 NULL NULL 420002 PT Strapping Low Back Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29520 NULL NULL 420007 PT Strapping Hip Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29530 NULL NULL 420008 PT Strapping Knee Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29540 NULL NULL 420009 "PT Strapping Ankle, Foot Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29550 NULL NULL 420010 PT Strapping Toes Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 440 NULL 92507 GN NULL 440001 SLP Auditory Processing Tx Units NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 440 NULL 92526 GN NULL 440002 SLP Swallow Dysfunction Oral Feed Units NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 440 NULL 92606 GN NULL 440007 SLP Non-Speech AAC Device Tx Units NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 440 NULL 92609 GN NULL 440004 SLP Tx Generating Device Units NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 443 NULL 92508 GN NULL 443001 SLP Group Therapy Units NULL INSTITUTIONAL $566.00 1/1/2022-12/31/2022 $566.00 $236.59 $322.62 $416.01 $416.01 200% of Medicare 100% of Medicare $332.86 $320.41 $312.04 $236.59 100% of Medicaid 100% of Medicare 150% of Medicare $452.80 $566.00 195% of Medicare $458.46 $331.11 $331.11 $267.15 $364.16 100% of Medicare $452.80 $481.10 $444.31 $413.12 $452.80 $481.10 $389.13 100% of Medicare 100% of Medicare $424.50 200% of Medicare NULL 440 NULL 92508 GN NULL 440100 SLP Double Therapy Units NULL INSTITUTIONAL " $1,107.00 " 1/1/2022-12/31/2022 " $1,107.00 " $462.73 $630.99 $813.65 $813.65 200% of Medicare 100% of Medicare $651.03 $626.67 $610.29 $462.73 100% of Medicaid 100% of Medicare 150% of Medicare $885.60 " $1,107.00 " 195% of Medicare $896.67 $647.60 $647.60 $522.50 $712.24 100% of Medicare $885.60 $940.95 $869.00 $808.00 $885.60 $940.95 $761.06 100% of Medicare 100% of Medicare $830.25 200% of Medicare NULL 440 NULL 97532 GN NULL 440003 SLP Cognitive Skills Development Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 440 NULL 97533 GN NULL 440005 SLP Sensory Integrative Techniques Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 444 NULL NULL GN NULL 444004 SLP Auditory Processing Eval Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $373.82 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $474.25 $456.51 $444.55 $506.88 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $471.24 $471.24 $373.82 $792.00 100% of Medicare $633.60 $673.20 $712.80 $578.08 $673.20 $792.00 $792.00 100% of Medicare 100% of Medicare $792.00 200% of Medicare NULL 444 NULL 92610 GN NULL 444002 SLP Pharyngeal Swallow Eval Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 444 NULL 92611 GN NULL 444009 SLP Fluoroscopic Evaluation Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 444 NULL 92597 GN NULL 444003 "SLP Use,Fit Speech Prosthetic Eval Units" NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 444 NULL 92605 GN NULL 444006 SLP Non-Speech AAC Device Eval Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 444 NULL 92607 GN NULL 444007 SLP Speech AAC Eval First Hour Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 444 NULL 96105 GN NULL 444001 SLP Assessment of Aphasia Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 444 NULL 92608 GN NULL 444008 SLP Speech AAC Eval Addl Half Hour Units NULL INSTITUTIONAL $396.00 1/1/2022-12/31/2022 $396.00 $165.53 $225.72 $291.06 $291.06 200% of Medicare 100% of Medicare $232.89 $224.18 $218.31 $165.53 100% of Medicaid 100% of Medicare 150% of Medicare $316.80 $396.00 195% of Medicare $320.76 $231.66 $231.66 $186.91 $254.79 100% of Medicare $316.80 $336.60 $310.86 $289.04 $316.80 $336.60 $272.25 100% of Medicare 100% of Medicare $297.00 200% of Medicare NULL 410 NULL 94003 NULL NULL 410017 Ventilator Management Protocol initial NULL INSTITUTIONAL " $1,573.00 " 1/1/2022-12/31/2022 " $1,500.00 " $657.51 $896.61 " $1,156.16 " " $1,156.16 " 200% of Medicare 100% of Medicare $925.08 $890.48 $867.19 $657.51 100% of Medicaid 100% of Medicare 150% of Medicare " $1,258.40 " " $1,500.00 " 195% of Medicare " $1,274.13 " $920.21 $920.21 $742.46 " $1,012.07 " 100% of Medicare " $1,258.40 " " $1,337.05 " " $1,234.81 " " $1,148.13 " " $1,258.40 " " $1,337.05 " " $1,081.44 " 100% of Medicare 100% of Medicare " $1,179.75 " 200% of Medicare NULL 320 NULL 71100 LT NULL 320126 XR Ribs min 3 views/PA Chest Left NULL INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $57.68 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $81.16 $78.12 $76.08 $57.68 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $80.73 $80.73 $65.14 $88.79 100% of Medicare $110.40 $117.30 $108.33 $100.73 $110.40 $117.30 $94.88 100% of Medicare 100% of Medicare $103.50 200% of Medicare NULL 320 NULL 71100 RT NULL 320129 XR Ribs min 3 views/PA Chest Right NULL INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $57.68 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $81.16 $78.12 $76.08 $57.68 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $80.73 $80.73 $65.14 $88.79 100% of Medicare $110.40 $117.30 $108.33 $100.73 $110.40 $117.30 $94.88 100% of Medicare 100% of Medicare $103.50 200% of Medicare NULL 430 NULL 97113 GO NULL 430100 OT Aquatic Exercise Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL NULL NULL NULL 320115 XR Hips Bilat Min 2 Views w/ AP Pelvis NULL INSTITUTIONAL $165.00 1/1/2022-12/31/2022 $165.00 $77.88 $94.05 $121.28 $121.28 200% of Medicare 100% of Medicare $98.80 $95.11 $92.61 $105.60 100% of Medicaid 100% of Medicare 150% of Medicare $132.00 $165.00 195% of Medicare $133.65 $98.18 $98.18 $77.88 $165.00 100% of Medicare $132.00 $140.25 $148.50 $120.43 $140.25 $165.00 $165.00 100% of Medicare 100% of Medicare $165.00 200% of Medicare NULL 320 NULL 72074 NULL NULL 320156 XR Spine Thoracic Minimum 4 Views NULL INSTITUTIONAL $186.00 1/1/2022-12/31/2022 $186.00 $77.75 $106.02 $136.71 $136.71 200% of Medicare 100% of Medicare $109.39 $105.29 $102.54 $77.75 100% of Medicaid 100% of Medicare 150% of Medicare $148.80 $186.00 195% of Medicare $150.66 $108.81 $108.81 $87.79 $119.67 100% of Medicare $148.80 $158.10 $146.01 $135.76 $148.80 $158.10 $127.88 100% of Medicare 100% of Medicare $139.50 200% of Medicare NULL 402 NULL 51798 NULL NULL 402001 Measurement Of Post-VoidingResid Urine/Bladder NULL INSTITUTIONAL $225.00 1/1/2022-12/31/2022 $225.00 $94.05 $128.25 $165.38 $165.38 200% of Medicare 100% of Medicare $132.32 $127.37 $124.04 $94.05 100% of Medicaid 100% of Medicare 150% of Medicare $180.00 $225.00 195% of Medicare $182.25 $131.63 $131.63 $106.20 $144.77 100% of Medicare $180.00 $191.25 $176.63 $164.23 $180.00 $191.25 $154.69 100% of Medicare 100% of Medicare $168.75 200% of Medicare NULL 444 NULL 92608 GN NULL 444008 Speech Generating Device Eval Additional 30 Min NULL INSTITUTIONAL $396.00 1/1/2022-12/31/2022 $396.00 $165.53 $225.72 $291.06 $291.06 200% of Medicare 100% of Medicare $232.89 $224.18 $218.31 $165.53 100% of Medicaid 100% of Medicare 150% of Medicare $316.80 $396.00 195% of Medicare $320.76 $231.66 $231.66 $186.91 $254.79 100% of Medicare $316.80 $336.60 $310.86 $289.04 $316.80 $336.60 $272.25 100% of Medicare 100% of Medicare $297.00 200% of Medicare NULL 410 NULL 94760 NULL NULL 410025 "RT POX, Single Determination Charge" NULL INSTITUTIONAL $125.00 1/1/2022-12/31/2022 $125.00 $52.25 $71.25 $91.88 $91.88 200% of Medicare 100% of Medicare $73.51 $70.76 $68.91 $52.25 100% of Medicaid 100% of Medicare 150% of Medicare $100.00 $125.00 195% of Medicare $101.25 $73.13 $73.13 $59.00 $80.43 100% of Medicare $100.00 $106.25 $98.13 $91.24 $100.00 $106.25 $85.94 100% of Medicare 100% of Medicare $93.75 200% of Medicare NULL 320 NULL 74000 NULL NULL 320011 XR Barium Enema Regular w/ or w/o KUB NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 324 NULL 71020 NULL NULL 324011 XR Chest 1 View NULL INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $53.50 $72.96 $94.08 $94.08 200% of Medicare 100% of Medicare $75.28 $72.46 $70.57 $53.50 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $74.88 $74.88 $60.42 $82.36 100% of Medicare $102.40 $108.80 $100.48 $93.43 $102.40 $108.80 $88.00 100% of Medicare 100% of Medicare $96.00 200% of Medicare NULL 320 NULL 73620 LT NULL 320066 XR Foot 1 View Lt NULL INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $47.65 $64.98 $83.79 $83.79 200% of Medicare 100% of Medicare $67.04 $64.54 $62.85 $47.65 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $66.69 $66.69 $53.81 $73.35 100% of Medicare $91.20 $96.90 $89.49 $83.21 $91.20 $96.90 $78.38 100% of Medicare 100% of Medicare $85.50 200% of Medicare NULL 320 NULL 73620 RT NULL 320067 XR Foot 1 View Rt NULL INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $47.65 $64.98 $83.79 $83.79 200% of Medicare 100% of Medicare $67.04 $64.54 $62.85 $47.65 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $66.69 $66.69 $53.81 $73.35 100% of Medicare $91.20 $96.90 $89.49 $83.21 $91.20 $96.90 $78.38 100% of Medicare 100% of Medicare $85.50 200% of Medicare NULL 320 NULL 74000 NULL NULL 320012 XR GI Tube Long Intro Fluoro and Film NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 320 NULL 73560 LT NULL 320078 XR Knee 1 View Lt NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 73560 RT NULL 320079 XR Knee 1 View Rt NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $54.34 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $76.45 $73.59 $71.67 $54.34 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $76.05 $76.05 $61.36 $83.64 100% of Medicare $104.00 $110.50 $102.05 $94.89 $104.00 $110.50 $89.38 100% of Medicare 100% of Medicare $97.50 200% of Medicare NULL 320 NULL 77073 NULL NULL 320090 XR Long Alignment Legs NULL INSTITUTIONAL $162.00 1/1/2022-12/31/2022 $162.00 $67.72 $92.34 $119.07 $119.07 200% of Medicare 100% of Medicare $95.27 $91.71 $89.31 $67.72 100% of Medicaid 100% of Medicare 150% of Medicare $129.60 $162.00 195% of Medicare $131.22 $94.77 $94.77 $76.46 $104.23 100% of Medicare $129.60 $137.70 $127.17 $118.24 $129.60 $137.70 $111.38 100% of Medicare 100% of Medicare $121.50 200% of Medicare NULL 324 NULL 71020 NULL NULL 324011 XR Chest 1 View NULL INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $53.50 $72.96 $94.08 $94.08 200% of Medicare 100% of Medicare $75.28 $72.46 $70.57 $53.50 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $74.88 $74.88 $60.42 $82.36 100% of Medicare $102.40 $108.80 $100.48 $93.43 $102.40 $108.80 $88.00 100% of Medicare 100% of Medicare $96.00 200% of Medicare NULL 300 NULL 36600 NULL NULL 410014 RT ABG W/Direct Meas O2 Sat Charge NULL INSTITUTIONAL $341.00 1/1/2022-12/31/2022 $341.00 $142.54 $194.37 $250.64 $250.64 200% of Medicare 100% of Medicare $200.54 $193.04 $187.99 $142.54 100% of Medicaid 100% of Medicare 150% of Medicare $272.80 $341.00 195% of Medicare $276.21 $199.49 $199.49 $160.95 $219.40 100% of Medicare $272.80 $289.85 $267.69 $248.90 $272.80 $289.85 $234.44 100% of Medicare 100% of Medicare $255.75 200% of Medicare NULL 320 NULL 74000 NULL NULL 320006 XR Abdomen Multi Views NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 320 NULL 73620 LT NULL 320062 XR Manual Stress Application to Joint Lt NULL INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $47.65 $64.98 $83.79 $83.79 200% of Medicare 100% of Medicare $67.04 $64.54 $62.85 $47.65 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $66.69 $66.69 $53.81 $73.35 100% of Medicare $91.20 $96.90 $89.49 $83.21 $91.20 $96.90 $78.38 100% of Medicare 100% of Medicare $85.50 200% of Medicare NULL 320 NULL 73620 RT NULL 320063 XR Manual Stress Application to Joint Rt NULL INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $47.65 $64.98 $83.79 $83.79 200% of Medicare 100% of Medicare $67.04 $64.54 $62.85 $47.65 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $66.69 $66.69 $53.81 $73.35 100% of Medicare $91.20 $96.90 $89.49 $83.21 $91.20 $96.90 $78.38 100% of Medicare 100% of Medicare $85.50 200% of Medicare NULL 410 NULL NULL NULL NULL 410111 Ed-Postural Education NULL INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $52.39 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $66.47 $63.98 $62.30 $71.04 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $66.05 $66.05 $52.39 $111.00 100% of Medicare $88.80 $94.35 $99.90 $81.02 $94.35 $111.00 $111.00 100% of Medicare 100% of Medicare $111.00 200% of Medicare NULL 440 NULL 96125 GN NULL 440006 SLP Cognitive Test Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 940 NULL 97597 NULL NULL 940001 Selective Debridement (<20cm) NULL INSTITUTIONAL $528.00 1/1/2022-12/31/2022 $528.00 $220.70 $300.96 $388.08 $388.08 200% of Medicare 100% of Medicare $310.52 $298.90 $291.09 $220.70 100% of Medicaid 100% of Medicare 150% of Medicare $422.40 $528.00 195% of Medicare $427.68 $308.88 $308.88 $249.22 $339.72 100% of Medicare $422.40 $448.80 $414.48 $385.39 $422.40 $448.80 $363.00 100% of Medicare 100% of Medicare $396.00 200% of Medicare NULL 940 NULL 97598 NULL NULL 940002 Selective Debridement (>20cm) NULL INSTITUTIONAL $528.00 1/1/2022-12/31/2022 $528.00 $220.70 $300.96 $388.08 $388.08 200% of Medicare 100% of Medicare $310.52 $298.90 $291.09 $220.70 100% of Medicaid 100% of Medicare 150% of Medicare $422.40 $528.00 195% of Medicare $427.68 $308.88 $308.88 $249.22 $339.72 100% of Medicare $422.40 $448.80 $414.48 $385.39 $422.40 $448.80 $363.00 100% of Medicare 100% of Medicare $396.00 200% of Medicare NULL 420 NULL 97026 GP NULL 420042 PT Infrared Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 320 NULL NULL LT NULL 320116 XR Pelvis 1 or 2 Views + Hip 1 View Lt NULL INSTITUTIONAL $165.00 1/1/2022-12/31/2022 $165.00 $77.88 $94.05 $121.28 $121.28 200% of Medicare 100% of Medicare $98.80 $95.11 $92.61 $105.60 100% of Medicaid 100% of Medicare 150% of Medicare $132.00 $165.00 195% of Medicare $133.65 $98.18 $98.18 $77.88 $165.00 100% of Medicare $132.00 $140.25 $148.50 $120.43 $140.25 $165.00 $165.00 100% of Medicare 100% of Medicare $165.00 200% of Medicare NULL 320 NULL NULL RT NULL 320117 XR Pelvis 1 or 2 Views + Hip 1 View Rt NULL INSTITUTIONAL $165.00 1/1/2022-12/31/2022 $165.00 $77.88 $94.05 $121.28 $121.28 200% of Medicare 100% of Medicare $98.80 $95.11 $92.61 $105.60 100% of Medicaid 100% of Medicare 150% of Medicare $132.00 $165.00 195% of Medicare $133.65 $98.18 $98.18 $77.88 $165.00 100% of Medicare $132.00 $140.25 $148.50 $120.43 $140.25 $165.00 $165.00 100% of Medicare 100% of Medicare $165.00 200% of Medicare NULL 320 NULL 73080 LT NULL 320043 XR Elbow 3 Views Min Lt NULL INSTITUTIONAL $143.00 1/1/2022-12/31/2022 $143.00 $59.77 $81.51 $105.11 $105.11 200% of Medicare 100% of Medicare $84.10 $80.95 $78.84 $59.77 100% of Medicaid 100% of Medicare 150% of Medicare $114.40 $143.00 195% of Medicare $115.83 $83.66 $83.66 $67.50 $92.01 100% of Medicare $114.40 $121.55 $112.26 $104.38 $114.40 $121.55 $98.31 100% of Medicare 100% of Medicare $107.25 200% of Medicare NULL 320 NULL 73080 RT NULL 320044 XR Elbow 3 Views Min Rt NULL INSTITUTIONAL $143.00 1/1/2022-12/31/2022 $143.00 $59.77 $81.51 $105.11 $105.11 200% of Medicare 100% of Medicare $84.10 $80.95 $78.84 $59.77 100% of Medicaid 100% of Medicare 150% of Medicare $114.40 $143.00 195% of Medicare $115.83 $83.66 $83.66 $67.50 $92.01 100% of Medicare $114.40 $121.55 $112.26 $104.38 $114.40 $121.55 $98.31 100% of Medicare 100% of Medicare $107.25 200% of Medicare NULL 300 NULL 86580 NULL NULL NULL TB SKIN TEST NULL INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $27.59 $37.62 $48.51 $48.51 200% of Medicare 100% of Medicare $38.81 $37.36 $36.39 $27.59 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $38.61 $38.61 $31.15 $42.46 100% of Medicare $52.80 $56.10 $51.81 $48.17 $52.80 $56.10 $45.38 100% of Medicare 100% of Medicare $49.50 200% of Medicare NULL 420 NULL 29515 NULL NULL 420001 PT Application of Short Leg Splint Units NULL INSTITUTIONAL $671.00 1/1/2022-12/31/2022 $671.00 $280.48 $382.47 $493.19 $493.19 200% of Medicare 100% of Medicare $394.62 $379.85 $369.92 $280.48 100% of Medicaid 100% of Medicare 150% of Medicare $536.80 $671.00 195% of Medicare $543.51 $392.54 $392.54 $316.71 $431.72 100% of Medicare $536.80 $570.35 $526.74 $489.76 $536.80 $570.35 $461.31 100% of Medicare 100% of Medicare $503.25 200% of Medicare NULL 410 NULL 94640 NULL NULL 430032 Aerosol Initial NULL INSTITUTIONAL $648.00 1/1/2022-12/31/2022 $648.00 $270.86 $369.36 $476.28 $476.28 200% of Medicare 100% of Medicare $381.09 $366.83 $357.24 $270.86 100% of Medicaid 100% of Medicare 150% of Medicare $518.40 $648.00 195% of Medicare $524.88 $379.08 $379.08 $305.86 $416.92 100% of Medicare $518.40 $550.80 $508.68 $472.98 $518.40 $550.80 $445.50 100% of Medicare 100% of Medicare $486.00 200% of Medicare NULL 410 NULL 94640 NULL NULL 410031 Aerosol Subsequent NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $88.62 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $124.68 $120.01 $116.88 $88.62 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $124.02 $124.02 $100.06 $136.40 100% of Medicare $169.60 $180.20 $166.42 $154.74 $169.60 $180.20 $145.75 100% of Medicare 100% of Medicare $159.00 200% of Medicare NULL 410 NULL 94642 NULL NULL 410106 IPPB Initial NULL INSTITUTIONAL $983.00 1/1/2022-12/31/2022 $983.00 $410.89 $560.31 $722.51 $722.51 200% of Medicare 100% of Medicare $578.10 $556.48 $541.93 $410.89 100% of Medicaid 100% of Medicare 150% of Medicare $786.40 $983.00 195% of Medicare $796.23 $575.06 $575.06 $463.98 $632.46 100% of Medicare $786.40 $835.55 $771.66 $717.49 $786.40 $835.55 $675.81 100% of Medicare 100% of Medicare $737.25 200% of Medicare NULL 410 NULL 94642 NULL NULL 410107 IPPB Subsequent NULL INSTITUTIONAL $636.00 1/1/2022-12/31/2022 $636.00 $265.85 $362.52 $467.46 $467.46 200% of Medicare 100% of Medicare $374.03 $360.04 $350.63 $265.85 100% of Medicaid 100% of Medicare 150% of Medicare $508.80 $636.00 195% of Medicare $515.16 $372.06 $372.06 $300.19 $409.20 100% of Medicare $508.80 $540.60 $499.26 $464.22 $508.80 $540.60 $437.25 100% of Medicare 100% of Medicare $477.00 200% of Medicare NULL 410 NULL 94640 NULL NULL 410021 EZPAP INITIAL NULL INSTITUTIONAL $742.00 1/1/2022-12/31/2022 $742.00 $310.16 $422.94 $545.37 $545.37 200% of Medicare 100% of Medicare $436.37 $420.05 $409.06 $310.16 100% of Medicaid 100% of Medicare 150% of Medicare $593.60 $742.00 195% of Medicare $601.02 $434.07 $434.07 $350.22 $477.40 100% of Medicare $593.60 $630.70 $582.47 $541.59 $593.60 $630.70 $510.13 100% of Medicare 100% of Medicare $556.50 200% of Medicare NULL 410 NULL 94640 NULL NULL 410035 EZPAP SUBSEQUENT NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $88.62 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $124.68 $120.01 $116.88 $88.62 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $124.02 $124.02 $100.06 $136.40 100% of Medicare $169.60 $180.20 $166.42 $154.74 $169.60 $180.20 $145.75 100% of Medicare 100% of Medicare $159.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL albuterol CFC free 90 mcg/inh Inh 00173-0682-24 INSTITUTIONAL $101.00 1/1/2022-12/31/2022 $101.00 $47.67 $57.57 $74.24 $74.24 200% of Medicare 100% of Medicare $60.48 $58.22 $56.69 $64.64 100% of Medicaid 100% of Medicare 150% of Medicare $80.80 $101.00 195% of Medicare $81.81 $60.10 $60.10 $47.67 $101.00 100% of Medicare $80.80 $85.85 $90.90 $73.72 $85.85 $101.00 $101.00 100% of Medicare 100% of Medicare $101.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL albuterol-ipratropium Inh Aer w/Ad 00597-0013-14 INSTITUTIONAL $911.00 1/1/2022-12/31/2022 $911.00 $429.99 $519.27 $669.59 $669.59 200% of Medicare 100% of Medicare $545.51 $525.10 $511.34 $583.04 100% of Medicaid 100% of Medicare 150% of Medicare $728.80 $911.00 195% of Medicare $737.91 $542.05 $542.05 $429.99 $911.00 100% of Medicare $728.80 $774.35 $819.90 $664.94 $774.35 $911.00 $911.00 100% of Medicare 100% of Medicare $911.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone CFC free 110 mcg/inh I 00173-0719-20 INSTITUTIONAL $923.00 1/1/2022-12/31/2022 $923.00 $435.66 $526.11 $678.41 $678.41 200% of Medicare 100% of Medicare $552.69 $532.02 $518.08 $590.72 100% of Medicaid 100% of Medicare 150% of Medicare $738.40 $923.00 195% of Medicare $747.63 $549.19 $549.19 $435.66 $923.00 100% of Medicare $738.40 $784.55 $830.70 $673.70 $784.55 $923.00 $923.00 100% of Medicare 100% of Medicare $923.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone CFC free 220 mcg/inh I 00173-0720-20 INSTITUTIONAL " $1,429.00 " 1/1/2022-12/31/2022 " $1,429.00 " $674.49 $814.53 " $1,050.32 " " $1,050.32 " 200% of Medicare 100% of Medicare $855.69 $823.68 $802.10 $914.56 100% of Medicaid 100% of Medicare 150% of Medicare " $1,143.20 " " $1,429.00 " 195% of Medicare " $1,157.49 " $850.26 $850.26 $674.49 " $1,359.00 " 100% of Medicare " $1,143.20 " " $1,214.65 " " $1,286.10 " " $1,043.03 " " $1,214.65 " " $1,429.00 " " $1,429.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone CFC free 44 mcg/inh In 00173-0718-20 INSTITUTIONAL $489.00 1/1/2022-12/31/2022 $489.00 $230.81 $278.73 $359.42 $359.42 200% of Medicare 100% of Medicare $292.81 $281.86 $274.48 $312.96 100% of Medicaid 100% of Medicare 150% of Medicare $391.20 $489.00 195% of Medicare $396.09 $290.96 $290.96 $230.81 $489.00 100% of Medicare $391.20 $415.65 $440.10 $356.92 $415.65 $489.00 $489.00 100% of Medicare 100% of Medicare $489.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levalbuterol CFC free 45 mcg/inh I 63402-0510-01 INSTITUTIONAL $246.00 1/1/2022-12/31/2022 $246.00 $116.11 $140.22 $180.81 $180.81 200% of Medicare 100% of Medicare $147.30 $141.79 $138.08 $157.44 100% of Medicaid 100% of Medicare 150% of Medicare $196.80 $246.00 195% of Medicare $199.26 $146.37 $146.37 $116.11 $246.00 100% of Medicare $196.80 $209.10 $221.40 $179.56 $209.10 $246.00 $246.00 100% of Medicare 100% of Medicare $246.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mometasone 220 mcg/inh Inh Aer Pwd 00085-1341-04 INSTITUTIONAL $320.00 1/1/2022-12/31/2022 $320.00 $151.04 $182.40 $235.20 $235.20 200% of Medicare 100% of Medicare $191.62 $184.45 $179.62 $204.80 100% of Medicaid 100% of Medicare 150% of Medicare $256.00 $320.00 195% of Medicare $259.20 $190.40 $190.40 $151.04 $320.00 100% of Medicare $256.00 $272.00 $288.00 $233.57 $272.00 $320.00 $320.00 100% of Medicare 100% of Medicare $320.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acebutolol 200 mg Cap 65162-0669-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amantadine 100 mg Cap 51079-0481-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amoxicillin 250 mg Cap 00093-3107-93 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ampicillin 250 mg Cap 00781-2144-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL anagrelide 0.5 mg Cap 00172-5241-60 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ASA/butalbital/caffeine Cap 00591-3219-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atomoxetine 10 mg Cap 00002-3227-30 INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 200% of Medicare 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atomoxetine 18 mg Cap 00002-3238-30 INSTITUTIONAL $34.00 1/1/2022-12/31/2022 $34.00 $16.05 $19.38 $24.99 $24.99 200% of Medicare 100% of Medicare $20.36 $19.60 $19.08 $21.76 100% of Medicaid 100% of Medicare 150% of Medicare $27.20 $34.00 195% of Medicare $27.54 $20.23 $20.23 $16.05 $34.00 100% of Medicare $27.20 $28.90 $30.60 $24.82 $28.90 $34.00 $34.00 100% of Medicare 100% of Medicare $34.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atomoxetine 40 mg Cap 00002-3229-30 INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $30.21 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $38.32 $36.89 $35.92 $40.96 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $38.08 $38.08 $30.21 $64.00 100% of Medicare $51.20 $54.40 $57.60 $46.71 $54.40 $64.00 $64.00 100% of Medicare 100% of Medicare $64.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atomoxetine 60 mg Cap 00002-3239-30 INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $27.85 $33.63 $43.37 $43.37 200% of Medicare 100% of Medicare $35.33 $34.01 $33.12 $37.76 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $35.11 $35.11 $27.85 $59.00 100% of Medicare $47.20 $50.15 $53.10 $43.06 $50.15 $59.00 $59.00 100% of Medicare 100% of Medicare $59.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL balsalazide 750 mg Cap 00378-6750-82 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL benzonatate 100 mg Cap 67877-0105-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcitriol 0.25 mcg Oral Cap 00054-0007-13 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcium acetate 667 mg Cap 00054-0088-26 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cefdinir 300 mg Cap 00781-2176-60 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL celecoxib 100 mg Cap 00025-1520-34 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cephalexin 250 mg Cap 00093-3145-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cephalexin 500 mg Cap 62756-0294-88 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL chlordiazepoxide 5 mg Cap 51079-0374-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL chlordiazepoxide 25 mg Cap 51079-0141-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clindamycin 150 mg Cap 68084-0243-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Coenzyme Q10 30 mg 00904-5015-46 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cycloSPORINE microEmul 100 mg Cap 00172-7312-46 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cycloSPORINE microEmul 25 mg Cap 00591-2222-15 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cycloSPORINE microEmul 100 mg Cap 00078-0248-15 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cycloSPORINE microEmul 25 mg Cap 00078-0246-15 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dabigatran 150 mg Cap UD 00597-0135-60 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dabigatran 75 mg Cap UD 00597-0149-60 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dantrolene 25 mg Cap 00115-4411-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diphenhydrAMINE 25 mg Cap 00904-5306-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diphenhydrAMINE 50 mg Cap 00904-2056-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL docusate sodium 100 mg Cap 00904-2244-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dofetilide 250 mcg Cap 00069-5810-43 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL doxepin 10 mg Cap 51079-0436-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Doxepin Cap 25 mg 51079-0437-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dronabinol 2.5 mg Cap 49884-0867-02 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dutasteride 0.5 mg Cap 00173-0712-15 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL emtricitabine 200 mg Cap 61958-0601-01 INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $39.18 $47.31 $61.01 $61.01 200% of Medicare 100% of Medicare $49.70 $47.84 $46.59 $53.12 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $49.39 $49.39 $39.18 $83.00 100% of Medicare $66.40 $70.55 $74.70 $60.58 $70.55 $83.00 $83.00 100% of Medicare 100% of Medicare $83.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "ergocalciferol 50,000 intl units C" 64980-0157-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Flax seed Oil 1000mg 11845-0131-31 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluoxetine 10 mg Cap 00904-5784-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL FLUoxetine Cap 20 mg 00904-5785-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL formoterol 12 mcg Inh Cap 00085-1402-01 INSTITUTIONAL $261.00 1/1/2022-12/31/2022 $261.00 $123.19 $148.77 $191.84 $191.84 200% of Medicare 100% of Medicare $156.29 $150.44 $146.50 $167.04 100% of Medicaid 100% of Medicare 150% of Medicare $208.80 $261.00 195% of Medicare $211.41 $155.30 $155.30 $123.19 $261.00 100% of Medicare $208.80 $221.85 $234.90 $190.50 $221.85 $261.00 $261.00 100% of Medicare 100% of Medicare $261.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gabapentin 100 mg Cap 00904-6078-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gabapentin 300 mg Cap 68084-0563-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gabapentin 400 mg Cap 00904-6105-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Glucosamine/Chondroitin 500/400mg 00904-5481-52 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrochlorothiazide 12.5 mg Cap 51079-0776-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydroxyurea 500 mg Cap 49884-0724-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrOXYzine pamoate 25 mg Cap 00185-0613-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL indomethacin 25 mg Cap 51079-0190-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL iron polysaccharide 150 mg Cap 00904-5395-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisdexamfetamine 20 mg Cap 59417-0102-10 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisdexamfetamine 30 mg oral capsul 59417-0103-10 INSTITUTIONAL $42.00 1/1/2022-12/31/2022 $42.00 $19.82 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $25.15 $24.21 $23.57 $26.88 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 195% of Medicare $34.02 $24.99 $24.99 $19.82 $42.00 100% of Medicare $33.60 $35.70 $37.80 $30.66 $35.70 $42.00 $42.00 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Lithium Carbonate 150mg 00054-8526-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL loperamide 2 mg Cap 51079-0690-20 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Lubiprostone Cap 24 mCg 64764-0240-60 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lubiprostone 8 mcg Cap 64764-0080-60 INSTITUTIONAL $34.00 1/1/2022-12/31/2022 $34.00 $16.05 $19.38 $24.99 $24.99 200% of Medicare 100% of Medicare $20.36 $19.60 $19.08 $21.76 100% of Medicaid 100% of Medicare 150% of Medicare $27.20 $34.00 195% of Medicare $27.54 $20.23 $20.23 $16.05 $34.00 100% of Medicare $27.20 $28.90 $30.60 $24.82 $28.90 $34.00 $34.00 100% of Medicare 100% of Medicare $34.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mexiletine 150 mg Cap 00093-8739-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mexiletine 200 mg Cap 00093-8740-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL minocycline 100 mg Cap 00591-5695-50 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL minocycline 50 mg Cap 63304-0694-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mycophenolate mofetil 250 mg Cap 51079-0721-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL NIFEdipine 10 mg Cap 43386-0440-24 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nimodipine 30 mg Cap 23155-0108-30 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nitrofurantoin macrocrystals-monoh 51079-0348-20 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nortriptyline 10 mg Cap 00093-0810-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nortriptyline 25 mg Cap 68084-0032-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL omega-3 polyunsaturated fatty acid 00904-4043-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL omeprazole-sodium bicarbonate 40 m 68012-0104-30 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oseltamivir 75 mg Cap 00004-0800-85 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL paricalcitol 1 mcg oral capsule 00074-4317-30 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 200% of Medicare 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL prazosin 1 mg Cap 51079-0630-20 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pregabalin 100 mg oral capsule 00071-1015-68 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pregabalin 150 mg oral capsule 00071-1016-68 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pregabalin 25 mg oral capsule 00071-1012-68 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pregabalin 75 mg oral capsule 00071-1014-68 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Progesterone 100mg 00032-1708-01 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL quinine 324 mg oral capsule 13310-0153-07 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ribavirin 200 mg Cap 00085-1194-03 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rifampin 300 mg Cap 00527-1315-30 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ritonavir 100 mg Cap 00074-6633-30 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rivastigmine 1.5 mg Cap 00781-2614-13 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL saccharomyces boulardii lyo 250 mg 66825-0002-01 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL selegiline 5 mg Cap 67253-0700-06 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Tacrolimus Cap (Prograf) **5 mg** 00469-0657-11 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tacrolimus 1 mg Cap 00469-0617-11 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tacrolimus 1 mg Cap 68084-0450-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tamsulosin 0.4 mg Oral Cap 00904-6156-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL temazepam 15 mg Cap 51079-0418-21 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL temazepam 30 mg Cap 51079-0419-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL temazepam 7.5 mg Cap 00406-9960-01 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL terazosin 1 mg Cap 51079-0936-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ursodiol Cap 300 mg 00904-6221-60 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "vitamin A 10,000 units Cap " 00904-2085-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vitamin B Complex with C and Folic 60258-0162-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL vitamin E 100 intl units Cap 00904-0270-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL vitamin E 200 intl units Cap 00904-0272-60 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL vitamin E 400 intl units Cap 00904-0274-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL zinc sulfate 220 mg Cap 00904-5332-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ziprasidone 20 mg Cap 00904-6269-08 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL zonisamide 100 mg Cap 62756-0260-02 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL didanosine 400 mg Oral EC Cap 00087-6674-17 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL divalproex sodium 125 mg Oral EC C 68084-0313-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL duloxetine 20 mg Cap 00002-3235-60 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL duloxetine 30 mg Cap 00002-3240-33 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL omeprazole 20 mg Oral EC Cap 68084-0128-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "pancrelipase 60,000 units-12,000 u" 00032-1212-01 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amphetamine-dextroamphetamine 5 mg 00115-1328-01 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL aspirin-dipyridamole 25 mg-200 mg 00597-0001-60 INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL budesonide 3 mg ERCap 51079-0020-03 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diltiazem 120 mg/24 hours ERCap 63739-0283-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Diltiazem Cap CD 180 mg 62584-0975-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diltiazem 240 mg/24 hours ERCap 63739-0285-10 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL niacin 250 mg ERCap 00904-0629-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL niacin 500 mg ERCap 00904-0631-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nitroglycerin 6.5 mg ERCap 00904-0644-60 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenytoin 100 mg ERCap 51079-0905-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium chloride 10 mEq ERCap 68084-0419-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propranolol 60 mg ERCap 43478-0900-88 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propranolol 80 mg ERCap 43478-0901-88 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL theophylline 100 mg/24 hours Oral 50474-0100-01 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL venlafaxine 150 mg ERCap 68084-0486-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Venlafaxine Cap XR 75 mg 00904-6247-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL verapamil 180 mg ERCap 00378-6380-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vitamin B Complex Cap 00536-4787-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vitamin B12/B6/FA 68308-0324-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL haloperidol 2 mg/mL Oral Conc 00121-0581-04 INSTITUTIONAL " $1,252.00 " 1/1/2022-12/31/2022 " $1,252.00 " $590.94 $713.64 $920.22 $920.22 200% of Medicare 100% of Medicare $749.70 $721.65 $702.75 $801.28 100% of Medicaid 100% of Medicare 150% of Medicare " $1,001.60 " " $1,252.00 " 195% of Medicare " $1,014.12 " $744.94 $744.94 $590.94 " $1,252.00 " 100% of Medicare " $1,001.60 " " $1,064.20 " " $1,126.80 " $913.83 " $1,064.20 " " $1,252.00 " " $1,252.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lorazepam 2 mg/mL Oral Conc 00054-3532-44 INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $34.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $44.31 $42.65 $41.54 $47.36 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $44.03 $44.03 $34.93 $74.00 100% of Medicare $59.20 $62.90 $66.60 $54.01 $62.90 $74.00 $74.00 100% of Medicare 100% of Medicare $74.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL magnesium hydroxide 24% Oral Conc 00121-0527-10 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sertraline 20 mg/mL Oral Conc 59762-4940-01 INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $75.99 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $96.41 $92.80 $90.37 $103.04 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $95.80 $95.80 $75.99 $161.00 100% of Medicare $128.80 $136.85 $144.90 $117.51 $136.85 $161.00 $161.00 100% of Medicare 100% of Medicare $161.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL azelaic acid Top 20% Crm 00023-8694-30 INSTITUTIONAL $893.00 1/1/2022-12/31/2022 $893.00 $421.50 $509.01 $656.36 $656.36 200% of Medicare 100% of Medicare $534.73 $514.73 $501.24 $571.52 100% of Medicaid 100% of Medicare 150% of Medicare $714.40 $893.00 195% of Medicare $723.33 $531.34 $531.34 $421.50 $893.00 100% of Medicare $714.40 $759.05 $803.70 $651.80 $759.05 $893.00 $893.00 100% of Medicare 100% of Medicare $893.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL betamethasone Top dipropionate 0.0 00168-0055-15 INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $49.09 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $62.28 $59.95 $58.38 $66.56 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $61.88 $61.88 $49.09 $104.00 100% of Medicare $83.20 $88.40 $93.60 $75.91 $88.40 $104.00 $104.00 100% of Medicare 100% of Medicare $104.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcipotriene Top 0.005% Crm 66993-0877-61 INSTITUTIONAL " $1,497.00 " 1/1/2022-12/31/2022 " $1,497.00 " $706.58 $853.29 " $1,100.30 " " $1,100.30 " 200% of Medicare 100% of Medicare $896.40 $862.87 $840.27 $958.08 100% of Medicaid 100% of Medicare 150% of Medicare " $1,197.60 " " $1,497.00 " 195% of Medicare " $1,212.57 " $890.72 $890.72 $706.58 " $1,359.00 " 100% of Medicare " $1,197.60 " " $1,272.45 " " $1,347.30 " " $1,092.66 " " $1,272.45 " " $1,497.00 " " $1,497.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL capsaicin Top 0.025% Crm 00603-0648-88 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL capsaicin Top 0.075% Crm 00603-0649-88 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clobetasol Top 0.05% Crm 51672-1258-02 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clotrimazole Top 1% Crm 45802-0434-11 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL betamethasone-clotrimazole Top 0.0 51672-4048-01 INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $42.95 $51.87 $66.89 $66.89 200% of Medicare 100% of Medicare $54.49 $52.45 $51.08 $58.24 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $54.15 $54.15 $42.95 $91.00 100% of Medicare $72.80 $77.35 $81.90 $66.42 $77.35 $91.00 $91.00 100% of Medicare 100% of Medicare $91.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diphenhydramine-zinc acetate Top 2 45802-0358-03 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL docosanol Top 10% Crm 00135-0200-01 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL econazole Top 1% Crm 51672-1303-01 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL conjugated estrogens 0.625 mg/g Va 00046-0872-21 INSTITUTIONAL " $1,454.00 " 1/1/2022-12/31/2022 " $1,454.00 " $686.29 $828.78 " $1,068.69 " " $1,068.69 " 200% of Medicare 100% of Medicare $870.66 $838.09 $816.13 $930.56 100% of Medicaid 100% of Medicare 150% of Medicare " $1,163.20 " " $1,454.00 " 195% of Medicare " $1,177.74 " $865.13 $865.13 $686.29 " $1,359.00 " 100% of Medicare " $1,163.20 " " $1,235.90 " " $1,308.60 " " $1,061.27 " " $1,235.90 " " $1,454.00 " " $1,454.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluocinonide Top 0.05% Crm 51672-1253-02 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 200% of Medicare 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluocinonide Top 0.05% Crm 51672-1253-03 INSTITUTIONAL $313.00 1/1/2022-12/31/2022 $313.00 $147.74 $178.41 $230.06 $230.06 200% of Medicare 100% of Medicare $187.42 $180.41 $175.69 $200.32 100% of Medicaid 100% of Medicare 150% of Medicare $250.40 $313.00 195% of Medicare $253.53 $186.24 $186.24 $147.74 $313.00 100% of Medicare $250.40 $266.05 $281.70 $228.46 $266.05 $313.00 $313.00 100% of Medicare 100% of Medicare $313.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gentamicin Top 0.1% Crm 45802-0056-35 INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Hydrocortisone 1% 00603-0535-50 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Hydrocortisone 2.5% 00168-0080-31 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone Top 0.5% Crm 00168-0014-31 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone 2.5% Rectal Crm w/A 64980-0301-30 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ketoconazole Top 2% Crm 51672-1298-02 INSTITUTIONAL $179.00 1/1/2022-12/31/2022 $179.00 $84.49 $102.03 $131.57 $131.57 200% of Medicare 100% of Medicare $107.19 $103.18 $100.47 $114.56 100% of Medicaid 100% of Medicare 150% of Medicare $143.20 $179.00 195% of Medicare $144.99 $106.51 $106.51 $84.49 $179.00 100% of Medicare $143.20 $152.15 $161.10 $130.65 $152.15 $179.00 $179.00 100% of Medicare 100% of Medicare $179.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Mafenide Cream 8.5% 57 GM 51079-0623-81 INSTITUTIONAL $149.00 1/1/2022-12/31/2022 $149.00 $70.33 $84.93 $109.52 $109.52 200% of Medicare 100% of Medicare $89.22 $85.88 $83.63 $95.36 100% of Medicaid 100% of Medicare 150% of Medicare $119.20 $149.00 195% of Medicare $120.69 $88.66 $88.66 $70.33 $149.00 100% of Medicare $119.20 $126.65 $134.10 $108.76 $126.65 $149.00 $149.00 100% of Medicare 100% of Medicare $149.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mupirocin Top 2% Crm 00029-1527-22 INSTITUTIONAL $276.00 1/1/2022-12/31/2022 $276.00 $130.27 $157.32 $202.86 $202.86 200% of Medicare 100% of Medicare $165.27 $159.09 $154.92 $176.64 100% of Medicaid 100% of Medicare 150% of Medicare $220.80 $276.00 195% of Medicare $223.56 $164.22 $164.22 $130.27 $276.00 100% of Medicare $220.80 $234.60 $248.40 $201.45 $234.60 $276.00 $276.00 100% of Medicare 100% of Medicare $276.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Muscle Rub 45802-0174-53 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nystatin-triamcinolone Top Crm 51672-1263-02 INSTITUTIONAL $312.00 1/1/2022-12/31/2022 $312.00 $147.26 $177.84 $229.32 $229.32 200% of Medicare 100% of Medicare $186.83 $179.84 $175.13 $199.68 100% of Medicaid 100% of Medicare 150% of Medicare $249.60 $312.00 195% of Medicare $252.72 $185.64 $185.64 $147.26 $312.00 100% of Medicare $249.60 $265.20 $280.80 $227.73 $265.20 $312.00 $312.00 100% of Medicare 100% of Medicare $312.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL permethrin Top 5% Crm 45802-0269-37 INSTITUTIONAL $183.00 1/1/2022-12/31/2022 $183.00 $86.38 $104.31 $134.51 $134.51 200% of Medicare 100% of Medicare $109.58 $105.48 $102.72 $117.12 100% of Medicaid 100% of Medicare 150% of Medicare $146.40 $183.00 195% of Medicare $148.23 $108.89 $108.89 $86.38 $183.00 100% of Medicare $146.40 $155.55 $164.70 $133.57 $155.55 $183.00 $183.00 100% of Medicare 100% of Medicare $183.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pimecrolimus Top Crm 00187-5101-02 INSTITUTIONAL " $1,831.00 " 1/1/2022-12/31/2022 " $1,831.00 " $864.23 " $1,043.67 " " $1,345.79 " " $1,345.79 " 200% of Medicare 100% of Medicare " $1,096.40 " " $1,055.39 " " $1,027.74 " " $1,171.84 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,464.80 " " $1,500.00 " 195% of Medicare " $1,483.11 " " $1,089.45 " " $1,089.45 " $864.23 " $1,359.00 " 100% of Medicare " $1,464.80 " " $1,556.35 " " $1,647.90 " " $1,336.45 " " $1,556.35 " " $1,500.00 " " $1,831.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL silver sulfADIAZINE Top 1% Crm 00591-0810-55 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 200% of Medicare 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL terbinafine Top 1% Crm 51672-2080-02 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tolnaftate Top 1% Crm 45802-0032-03 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL triamcinolone Top 0.1% Crm 00168-0004-80 INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $52.39 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $66.47 $63.98 $62.30 $71.04 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $66.05 $66.05 $52.39 $111.00 100% of Medicare $88.80 $94.35 $99.90 $81.02 $94.35 $111.00 $111.00 100% of Medicare 100% of Medicare $111.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL trolamine salicylate Top 10% Crm 45802-0356-53 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL miconazole 2% Vag Crm w/Appl 00713-0252-37 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL teriparatide 600 mcg/2.4 mL Devi 00002-8400-01 INSTITUTIONAL " $5,040.00 " 1/1/2022-12/31/2022 " $4,536.00 " $975.00 " $2,872.80 " " $3,704.40 " " $3,704.40 " 200% of Medicare 100% of Medicare " $3,017.95 " " $2,905.06 " " $2,828.95 " " $3,225.60 " 100% of Medicaid 100% of Medicare 150% of Medicare " $4,032.00 " " $1,500.00 " 195% of Medicare " $4,082.40 " " $2,998.80 " " $2,998.80 " " $2,378.88 " " $1,359.00 " 100% of Medicare " $4,032.00 " " $4,284.00 " " $4,536.00 " " $3,678.70 " " $4,284.00 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ferrous sulfate 220 mg/5 mL Oral E 00904-1465-16 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-hydrocodone 500 mg-7 00121-0655-15 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenobarbital 20 mg/5 mL Oral Elix 00603-1508-58 INSTITUTIONAL $301.00 1/1/2022-12/31/2022 $301.00 $142.07 $171.57 $221.24 $221.24 200% of Medicare 100% of Medicare $180.24 $173.50 $168.95 $192.64 100% of Medicaid 100% of Medicare 150% of Medicare $240.80 $301.00 195% of Medicare $243.81 $179.10 $179.10 $142.07 $301.00 100% of Medicare $240.80 $255.85 $270.90 $219.70 $255.85 $301.00 $301.00 100% of Medicare 100% of Medicare $301.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL theophylline 80 mg/15 mL Oral Elix 49708-0644-90 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 200% of Medicare 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "emollients, topical - Emul " 00062-0205-02 INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $94.87 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $120.36 $115.86 $112.82 $128.64 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $119.60 $119.60 $94.87 $201.00 100% of Medicare $160.80 $170.85 $180.90 $146.71 $170.85 $201.00 $201.00 100% of Medicare 100% of Medicare $201.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL docusate 283 mg Rectal Enema 17433-9876-03 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mesalamine 4 g/60 mL Rectal Enema 45802-0098-51 INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 200% of Medicare 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mineral oil 100% Rectal Enema 133 00904-5895-78 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium biphosphate-sodium phosphat 00904-3535-78 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine Top 5% film 63481-0687-06 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone-pramoxine Rectal Fo 68220-0144-10 INSTITUTIONAL $886.00 1/1/2022-12/31/2022 $886.00 $418.19 $505.02 $651.21 $651.21 200% of Medicare 100% of Medicare $530.54 $510.69 $497.31 $567.04 100% of Medicaid 100% of Medicare 150% of Medicare $708.80 $886.00 195% of Medicare $717.66 $527.17 $527.17 $418.19 $886.00 100% of Medicare $708.80 $753.10 $797.40 $646.69 $753.10 $886.00 $886.00 100% of Medicare 100% of Medicare $886.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Pramoxine Foam 1% 15 GM 51862-0180-15 INSTITUTIONAL $76.00 1/1/2022-12/31/2022 $76.00 $35.87 $43.32 $55.86 $55.86 200% of Medicare 100% of Medicare $45.51 $43.81 $42.66 $48.64 100% of Medicaid 100% of Medicare 150% of Medicare $60.80 $76.00 195% of Medicare $61.56 $45.22 $45.22 $35.87 $76.00 100% of Medicare $60.80 $64.60 $68.40 $55.47 $64.60 $76.00 $76.00 100% of Medicare 100% of Medicare $76.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL benzocaine Top 20% mucous membrane 10310-0283-40 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL benzoyl peroxide Top 5% Gel 45802-0216-96 INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $40.59 $49.02 $63.21 $63.21 200% of Medicare 100% of Medicare $51.50 $49.57 $48.27 $55.04 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $51.17 $51.17 $40.59 $86.00 100% of Medicare $68.80 $73.10 $77.40 $62.77 $73.10 $86.00 $86.00 100% of Medicare 100% of Medicare $86.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clindamycin Top 1% Gel 00168-0202-30 INSTITUTIONAL $197.00 1/1/2022-12/31/2022 $197.00 $92.98 $112.29 $144.80 $144.80 200% of Medicare 100% of Medicare $117.96 $113.55 $110.58 $126.08 100% of Medicaid 100% of Medicare 150% of Medicare $157.60 $197.00 195% of Medicare $159.57 $117.22 $117.22 $92.98 $197.00 100% of Medicare $157.60 $167.45 $177.30 $143.79 $167.45 $197.00 $197.00 100% of Medicare 100% of Medicare $197.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diclofenac Top 1% gel 63481-0684-47 INSTITUTIONAL $182.00 1/1/2022-12/31/2022 $182.00 $85.90 $103.74 $133.77 $133.77 200% of Medicare 100% of Medicare $108.98 $104.90 $102.16 $116.48 100% of Medicaid 100% of Medicare 150% of Medicare $145.60 $182.00 195% of Medicare $147.42 $108.29 $108.29 $85.90 $182.00 100% of Medicare $145.60 $154.70 $163.80 $132.84 $154.70 $182.00 $182.00 100% of Medicare 100% of Medicare $182.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine Top 2% Gel w/Appl 17478-0711-30 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL MetroNIDAZOLE Gel 0.75% 45 GM 00168-0275-45 INSTITUTIONAL $584.00 1/1/2022-12/31/2022 $584.00 $275.65 $332.88 $429.24 $429.24 200% of Medicare 100% of Medicare $349.70 $336.62 $327.80 $373.76 100% of Medicaid 100% of Medicare 150% of Medicare $467.20 $584.00 195% of Medicare $473.04 $347.48 $347.48 $275.65 $584.00 100% of Medicare $467.20 $496.40 $525.60 $426.26 $496.40 $584.00 $584.00 100% of Medicare 100% of Medicare $584.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metronidazole 0.75% Vag Gel w/Appl 00245-0860-70 INSTITUTIONAL $100.00 1/1/2022-12/31/2022 $100.00 $47.20 $57.00 $73.50 $73.50 200% of Medicare 100% of Medicare $59.88 $57.64 $56.13 $64.00 100% of Medicaid 100% of Medicare 150% of Medicare $80.00 $100.00 195% of Medicare $81.00 $59.50 $59.50 $47.20 $100.00 100% of Medicare $80.00 $85.00 $90.00 $72.99 $85.00 $100.00 $100.00 100% of Medicare 100% of Medicare $100.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Silver Dressing 08327-0309-09 INSTITUTIONAL $87.00 1/1/2022-12/31/2022 $87.00 $41.06 $49.59 $63.95 $63.95 200% of Medicare 100% of Medicare $52.10 $50.15 $48.83 $55.68 100% of Medicaid 100% of Medicare 150% of Medicare $69.60 $87.00 195% of Medicare $70.47 $51.77 $51.77 $41.06 $87.00 100% of Medicare $69.60 $73.95 $78.30 $63.50 $73.95 $87.00 $87.00 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL testosterone 50 mg/5 g TD Gel 00051-8450-30 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 200% of Medicare 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ocular lubricant Gel 00078-0429-97 INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $30.21 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $38.32 $36.89 $35.92 $40.96 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $38.08 $38.08 $30.21 $64.00 100% of Medicare $51.20 $54.40 $57.60 $46.71 $54.40 $64.00 $64.00 100% of Medicare 100% of Medicare $64.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lactobacillus acidophilus and bulg 64980-0146-12 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL erythromycin ethylsuccinate 200 mg 24338-0134-02 INSTITUTIONAL " $1,020.00 " 1/1/2022-12/31/2022 " $1,020.00 " $481.44 $581.40 $749.70 $749.70 200% of Medicare 100% of Medicare $610.78 $587.93 $572.53 $652.80 100% of Medicaid 100% of Medicare 150% of Medicare $816.00 " $1,020.00 " 195% of Medicare $826.20 $606.90 $606.90 $481.44 " $1,020.00 " 100% of Medicare $816.00 $867.00 $918.00 $744.50 $867.00 " $1,020.00 " " $1,020.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nicotine 2 mg Oral transmucosal Gu 00536-1362-23 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nicotine 4 mg Oral transmucosal Gu 00536-3030-06 INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $25.02 $30.21 $38.96 $38.96 200% of Medicare 100% of Medicare $31.74 $30.55 $29.75 $33.92 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.54 $31.54 $25.02 $53.00 100% of Medicare $42.40 $45.05 $47.70 $38.68 $45.05 $53.00 $53.00 100% of Medicare 100% of Medicare $53.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetylcysteine 10% Inh Sol 4 mL 00517-7504-25 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetylcysteine 20% Inh Sol 4 mL 00517-7604-25 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL albuterol 0.5% Inh Sol 00487-9901-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Albuterol-Ipratropium Inh Soln 3 m 00487-0201-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL J7605 NULL arformoterol 15 mcg/2 mL Inh Sol 63402-0911-30 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $10.45 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.70 $14.15 $13.78 $10.45 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.63 $14.63 $11.80 $16.09 100% of Medicare $20.00 $21.25 $19.63 $18.25 $20.00 $21.25 $17.19 100% of Medicare 100% of Medicare $18.75 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cromolyn 10 mg/mL Inh Sol 00172-6406-59 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL racepinephrine 2.25% Soln UD 00487-5901-99 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ipratropium 0.02% Inh Sol 2 mL 00487-9801-30 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levalbuterol 0.63 mg/3 mL Inh Sol 00591-2919-23 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levalbuterol 1.25 mg/3 mL Inh Sol 00591-2920-23 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pentamidine 300 mg Inh Pwdr for Re 63323-0877-15 INSTITUTIONAL $415.00 1/1/2022-12/31/2022 $415.00 $195.88 $236.55 $305.03 $305.03 200% of Medicare 100% of Medicare $248.50 $239.21 $232.94 $265.60 100% of Medicaid 100% of Medicare 150% of Medicare $332.00 $415.00 195% of Medicare $336.15 $246.93 $246.93 $195.88 $415.00 100% of Medicare $332.00 $352.75 $373.50 $302.91 $352.75 $415.00 $415.00 100% of Medicare 100% of Medicare $415.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride 7% Inh Sol 4 mL 83490-0107-60 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Tiotropium Inh Cap 18 mCg #5 00597-0075-75 INSTITUTIONAL $187.00 1/1/2022-12/31/2022 $187.00 $88.26 $106.59 $137.45 $137.45 200% of Medicare 100% of Medicare $111.98 $107.79 $104.96 $119.68 100% of Medicaid 100% of Medicare 150% of Medicare $149.60 $187.00 195% of Medicare $151.47 $111.27 $111.27 $88.26 $187.00 100% of Medicare $149.60 $158.95 $168.30 $136.49 $158.95 $187.00 $187.00 100% of Medicare 100% of Medicare $187.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Enoxaparin Inj 120 mg/0.8 mL 00075-2912-01 INSTITUTIONAL $79.00 1/1/2022-12/31/2022 $79.00 $37.29 $45.03 $58.07 $58.07 200% of Medicare 100% of Medicare $47.31 $45.54 $44.34 $50.56 100% of Medicaid 100% of Medicare 150% of Medicare $63.20 $79.00 195% of Medicare $63.99 $47.01 $47.01 $37.29 $79.00 100% of Medicare $63.20 $67.15 $71.10 $57.66 $67.15 $79.00 $79.00 100% of Medicare 100% of Medicare $79.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL meningococcal polysaccharide vacci 49281-0489-01 INSTITUTIONAL $503.00 1/1/2022-12/31/2022 $503.00 $237.42 $286.71 $369.71 $369.71 200% of Medicare 100% of Medicare $301.20 $289.93 $282.33 $321.92 100% of Medicaid 100% of Medicare 150% of Medicare $402.40 $503.00 195% of Medicare $407.43 $299.29 $299.29 $237.42 $503.00 100% of Medicare $402.40 $427.55 $452.70 $367.14 $427.55 $503.00 $503.00 100% of Medicare 100% of Medicare $503.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Octreotide Acetate 0.2 mg/mL 00781-3165-75 INSTITUTIONAL $283.00 1/1/2022-12/31/2022 $283.00 $133.58 $161.31 $208.01 $208.01 200% of Medicare 100% of Medicare $169.46 $163.12 $158.85 $181.12 100% of Medicaid 100% of Medicare 150% of Medicare $226.40 $283.00 195% of Medicare $229.23 $168.39 $168.39 $133.58 $283.00 100% of Medicare $226.40 $240.55 $254.70 $206.56 $240.55 $283.00 $283.00 100% of Medicare 100% of Medicare $283.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Water Sterile Injection 00409-4887-10 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL insulin glargine 100 units/mL SubQ 00088-2220-33 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL insulin glulisine 100 units/mL SC 00088-2500-33 INSTITUTIONAL $188.00 1/1/2022-12/31/2022 $188.00 $88.74 $107.16 $138.18 $138.18 200% of Medicare 100% of Medicare $112.57 $108.36 $105.52 $120.32 100% of Medicaid 100% of Medicare 150% of Medicare $150.40 $188.00 195% of Medicare $152.28 $111.86 $111.86 $88.74 $188.00 100% of Medicare $150.40 $159.80 $169.20 $137.22 $159.80 $188.00 $188.00 100% of Medicare 100% of Medicare $188.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL insulin lispro 100 units/mL SubQ I 00002-7510-17 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL insulin isophane human recombinant 00002-8315-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL insulin isophane human recombinant 00002-8315-17 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL insulin aspart-insulin aspart prot 00169-3685-12 INSTITUTIONAL $345.00 1/1/2022-12/31/2022 $345.00 $162.84 $196.65 $253.58 $253.58 200% of Medicare 100% of Medicare $206.59 $198.86 $193.65 $220.80 100% of Medicaid 100% of Medicare 150% of Medicare $276.00 $345.00 195% of Medicare $279.45 $205.28 $205.28 $162.84 $345.00 100% of Medicare $276.00 $293.25 $310.50 $251.82 $293.25 $345.00 $345.00 100% of Medicare 100% of Medicare $345.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Insulin NPH/Reg 70/30 100units/mL 00002-8715-01 INSTITUTIONAL $110.00 1/1/2022-12/31/2022 $110.00 $51.92 $62.70 $80.85 $80.85 200% of Medicare 100% of Medicare $65.87 $63.40 $61.74 $70.40 100% of Medicaid 100% of Medicare 150% of Medicare $88.00 $110.00 195% of Medicare $89.10 $65.45 $65.45 $51.92 $110.00 100% of Medicare $88.00 $93.50 $99.00 $80.29 $93.50 $110.00 $110.00 100% of Medicare 100% of Medicare $110.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL insulin lispro-insulin lispro prot 00002-7511-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Insulin Regular 100units/mL 3mL 00002-8215-17 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vaseline Jelly 00521-2311-00 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vaseline Lip Therapy 00521-2750-00 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 636 NULL NULL NULL J0475 NULL baclofen 0.05 mg/mL intrathecal So 58281-0562-01 INSTITUTIONAL $407.00 1/1/2022-12/31/2022 $407.00 $170.13 $231.99 $299.15 $299.15 200% of Medicare 100% of Medicare $239.36 $230.40 $224.38 $170.13 100% of Medicaid 100% of Medicare 150% of Medicare $325.60 $407.00 195% of Medicare $329.67 $238.10 $238.10 $192.10 $261.86 100% of Medicare $325.60 $345.95 $319.50 $297.07 $325.60 $345.95 $279.81 100% of Medicare 100% of Medicare $305.25 200% of Medicare NULL 636 NULL NULL NULL J0475 NULL baclofen 2 mg/mL intrathecal Sol 58281-0563-01 INSTITUTIONAL " $2,938.00 " 1/1/2022-12/31/2022 " $2,497.30 " " $1,228.08 " " $1,674.66 " " $2,159.43 " " $2,159.43 " 200% of Medicare 100% of Medicare " $1,727.84 " " $1,663.20 " " $1,619.72 " " $1,228.08 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,350.40 " " $1,500.00 " 195% of Medicare " $2,379.78 " " $1,718.73 " " $1,718.73 " " $1,386.74 " " $1,890.31 " 100% of Medicare " $2,350.40 " " $2,497.30 " " $2,306.33 " " $2,144.45 " " $2,350.40 " " $2,497.30 " " $2,019.88 " 100% of Medicare 100% of Medicare " $2,203.50 " 200% of Medicare NULL 636 NULL NULL NULL J0475 NULL baclofen 2 mg/mL intrathecal Sol 58281-0563-02 INSTITUTIONAL " $5,794.00 " 1/1/2022-12/31/2022 " $4,924.90 " " $1,500.00 " " $3,302.58 " " $4,258.59 " " $4,258.59 " 200% of Medicare 100% of Medicare " $3,407.45 " " $3,279.98 " " $3,194.23 " " $2,421.89 " 100% of Medicaid 100% of Medicare 150% of Medicare " $4,635.20 " " $1,500.00 " 195% of Medicare " $4,693.14 " " $3,389.49 " " $3,389.49 " " $2,734.77 " " $3,727.86 " 100% of Medicare " $4,635.20 " " $4,924.90 " " $4,548.29 " " $4,229.04 " " $4,635.20 " " $4,924.90 " " $3,983.38 " 100% of Medicare 100% of Medicare " $4,345.50 " 200% of Medicare NULL 636 NULL NULL NULL J0475 NULL baclofen 0.5 mg/mL intrathecal Sol 58281-0560-01 INSTITUTIONAL $796.00 1/1/2022-12/31/2022 $796.00 $332.73 $453.72 $585.06 $585.06 200% of Medicare 100% of Medicare $468.13 $450.62 $438.83 $332.73 100% of Medicaid 100% of Medicare 150% of Medicare $636.80 $796.00 195% of Medicare $644.76 $465.66 $465.66 $375.71 $512.15 100% of Medicare $636.80 $676.60 $624.86 $581.00 $636.80 $676.60 $547.25 100% of Medicare 100% of Medicare $597.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL epinephrine 0.3 mg Inj kit 49502-0500-01 INSTITUTIONAL " $1,343.00 " 1/1/2022-12/31/2022 " $1,343.00 " $633.90 $765.51 $987.11 $987.11 200% of Medicare 100% of Medicare $804.19 $774.11 $753.83 $859.52 100% of Medicaid 100% of Medicare 150% of Medicare " $1,074.40 " " $1,343.00 " 195% of Medicare " $1,087.83 " $799.09 $799.09 $633.90 " $1,343.00 " 100% of Medicare " $1,074.40 " " $1,141.55 " " $1,208.70 " $980.26 " $1,141.55 " " $1,343.00 " " $1,343.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL etanercept 25 mg SubQ Inj 58406-0425-34 INSTITUTIONAL " $1,177.00 " 1/1/2022-12/31/2022 " $1,177.00 " $555.54 $670.89 $865.10 $865.10 200% of Medicare 100% of Medicare $704.79 $678.42 $660.65 $753.28 100% of Medicaid 100% of Medicare 150% of Medicare $941.60 " $1,177.00 " 195% of Medicare $953.37 $700.32 $700.32 $555.54 " $1,177.00 " 100% of Medicare $941.60 " $1,000.45 " " $1,059.30 " $859.09 " $1,000.45 " " $1,177.00 " " $1,177.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glatiramer 20 mg/mL SubQ Sol 68546-0317-30 INSTITUTIONAL $623.00 1/1/2022-12/31/2022 $623.00 $294.06 $355.11 $457.91 $457.91 200% of Medicare 100% of Medicare $373.05 $359.10 $349.69 $398.72 100% of Medicaid 100% of Medicare 150% of Medicare $498.40 $623.00 195% of Medicare $504.63 $370.69 $370.69 $294.06 $623.00 100% of Medicare $498.40 $529.55 $560.70 $454.73 $529.55 $623.00 $623.00 100% of Medicare 100% of Medicare $623.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL interferon beta-1a 30 mcg/0.5 mL I 59627-0002-05 INSTITUTIONAL " $4,136.00 " 1/1/2022-12/31/2022 " $3,722.40 " $975.00 " $2,357.52 " " $3,039.96 " " $3,039.96 " 200% of Medicare 100% of Medicare " $2,476.64 " " $2,383.99 " " $2,321.54 " " $2,647.04 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,308.80 " " $1,500.00 " 195% of Medicare " $3,350.16 " " $2,460.92 " " $2,460.92 " " $1,952.19 " " $1,359.00 " 100% of Medicare " $3,308.80 " " $3,515.60 " " $3,722.40 " " $3,018.87 " " $3,515.60 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-codeine 120 mg-12 mg 00121-0504-16 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcitriol 1 mcg/mL Oral Liq 00054-3120-41 INSTITUTIONAL $351.00 1/1/2022-12/31/2022 $351.00 $165.67 $200.07 $257.99 $257.99 200% of Medicare 100% of Medicare $210.18 $202.32 $197.02 $224.64 100% of Medicaid 100% of Medicare 150% of Medicare $280.80 $351.00 195% of Medicare $284.31 $208.85 $208.85 $165.67 $351.00 100% of Medicare $280.80 $298.35 $315.90 $256.19 $298.35 $351.00 $351.00 100% of Medicare 100% of Medicare $351.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cycloSPORINE microEmul 100 mg/mL O 00078-0274-22 INSTITUTIONAL " $1,364.00 " 1/1/2022-12/31/2022 " $1,364.00 " $643.81 $777.48 " $1,002.54 " " $1,002.54 " 200% of Medicare 100% of Medicare $816.76 $786.21 $765.61 $872.96 100% of Medicaid 100% of Medicare 150% of Medicare " $1,091.20 " " $1,364.00 " 195% of Medicare " $1,104.84 " $811.58 $811.58 $643.81 " $1,359.00 " 100% of Medicare " $1,091.20 " " $1,159.40 " " $1,227.60 " $995.58 " $1,159.40 " " $1,364.00 " " $1,364.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cycloSPORINE microEmul 100 mg/mL O 00074-7269-50 INSTITUTIONAL $859.00 1/1/2022-12/31/2022 $859.00 $405.45 $489.63 $631.37 $631.37 200% of Medicare 100% of Medicare $514.37 $495.13 $482.16 $549.76 100% of Medicaid 100% of Medicare 150% of Medicare $687.20 $859.00 195% of Medicare $695.79 $511.11 $511.11 $405.45 $859.00 100% of Medicare $687.20 $730.15 $773.10 $626.98 $730.15 $859.00 $859.00 100% of Medicare 100% of Medicare $859.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL docusate sodium 150 mg/15 mL Oral 50383-0771-16 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL furosemide 10 mg/mL Oral Liq 00054-3294-50 INSTITUTIONAL $51.00 1/1/2022-12/31/2022 $51.00 $24.07 $29.07 $37.49 $37.49 200% of Medicare 100% of Medicare $30.54 $29.40 $28.63 $32.64 100% of Medicaid 100% of Medicare 150% of Medicare $40.80 $51.00 195% of Medicare $41.31 $30.35 $30.35 $24.07 $51.00 100% of Medicare $40.80 $43.35 $45.90 $37.22 $43.35 $51.00 $51.00 100% of Medicare 100% of Medicare $51.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glycerin compounding Liq 480 mL 00395-1031-16 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Hydrogen Peroxide 3% 37205-0871-34 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydromorphone 1 mg/mL Oral Liq 00074-2452-02 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL loperamide 1 mg/5 mL Oral Liq 00904-0036-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL magnesium citrate 8.85% Oral Liq 3 37205-0110-38 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mineral oil 100% Oral Liq 30 mL 00121-0462-30 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Multiple Vitamins with Minerals Or 54838-0010-70 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium chloride 20 mEq/15 mL Or 00603-1534-58 INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $26.90 $32.49 $41.90 $41.90 200% of Medicare 100% of Medicare $34.13 $32.85 $31.99 $36.48 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.92 $33.92 $26.90 $57.00 100% of Medicare $45.60 $48.45 $51.30 $41.60 $48.45 $57.00 $57.00 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL simethicone 40 mg/0.6 mL Oral Liq 00536-2220-75 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ammonium Lactate Lotion 12% 225 mL 00904-5984-26 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calamine Top 8% Lotion 00904-2533-00 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone Top 1% Lotion 45802-0283-06 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Lubriderm Lotion 52800-0488-26 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL permethrin Top 1% lotion 00472-5242-67 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL selenium sulfide Top 2.5% Lotion 45802-0040-64 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL benzocaine-menthol topical 15 mg-4 63824-0720-16 INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 200% of Medicare 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clotrimazole 10 mg Loz 00574-0107-77 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Mineral Oil (BULK BOTTLE) 37205-0831-43 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acyclovir Top 5% Oint 64455-0993-95 INSTITUTIONAL $501.00 1/1/2022-12/31/2022 $501.00 $236.47 $285.57 $368.24 $368.24 200% of Medicare 100% of Medicare $300.00 $288.78 $281.21 $320.64 100% of Medicaid 100% of Medicare 150% of Medicare $400.80 $501.00 195% of Medicare $405.81 $298.10 $298.10 $236.47 $501.00 100% of Medicare $400.80 $425.85 $450.90 $365.68 $425.85 $501.00 $501.00 100% of Medicare 100% of Medicare $501.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "emollients, Top Oint " 54162-0500-02 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bacitracin Top 500 units/g Oint 00603-0441-50 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bacitracin topical zinc 500 units/ 00168-0011-16 INSTITUTIONAL $73.00 1/1/2022-12/31/2022 $73.00 $34.46 $41.61 $53.66 $53.66 200% of Medicare 100% of Medicare $43.71 $42.08 $40.97 $46.72 100% of Medicaid 100% of Medicare 150% of Medicare $58.40 $73.00 195% of Medicare $59.13 $43.44 $43.44 $34.46 $73.00 100% of Medicare $58.40 $62.05 $65.70 $53.28 $62.05 $73.00 $73.00 100% of Medicare 100% of Medicare $73.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bacitracin/HC/neomycin/polymyxin B 61570-0031-50 INSTITUTIONAL $334.00 1/1/2022-12/31/2022 $334.00 $157.65 $190.38 $245.49 $245.49 200% of Medicare 100% of Medicare $200.00 $192.52 $187.47 $213.76 100% of Medicaid 100% of Medicare 150% of Medicare $267.20 $334.00 195% of Medicare $270.54 $198.73 $198.73 $157.65 $334.00 100% of Medicare $267.20 $283.90 $300.60 $243.79 $283.90 $334.00 $334.00 100% of Medicare 100% of Medicare $334.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bacitracin/neomycin/polymyxin B To 45802-0061-70 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bacitracin/neomycin/polymyxin B To 00904-0734-31 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL balsam Peru/castor oil/trypsin Top 00064-3900-60 INSTITUTIONAL $61.00 1/1/2022-12/31/2022 $61.00 $28.79 $34.77 $44.84 $44.84 200% of Medicare 100% of Medicare $36.53 $35.16 $34.24 $39.04 100% of Medicaid 100% of Medicare 150% of Medicare $48.80 $61.00 195% of Medicare $49.41 $36.30 $36.30 $28.79 $61.00 100% of Medicare $48.80 $51.85 $54.90 $44.52 $51.85 $61.00 $61.00 100% of Medicare 100% of Medicare $61.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL betamethasone Top dipropionate 0.0 00168-0056-15 INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $73.16 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $92.81 $89.34 $87.00 $99.20 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $92.23 $92.23 $73.16 $155.00 100% of Medicare $124.00 $131.75 $139.50 $113.13 $131.75 $155.00 $155.00 100% of Medicare 100% of Medicare $155.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clobetasol Top 0.05% Oint 51672-1259-02 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL collagenase Top 250 units/g Oint 00064-5010-30 INSTITUTIONAL $929.00 1/1/2022-12/31/2022 $929.00 $438.49 $529.53 $682.82 $682.82 200% of Medicare 100% of Medicare $556.29 $535.48 $521.45 $594.56 100% of Medicaid 100% of Medicare 150% of Medicare $743.20 $929.00 195% of Medicare $752.49 $552.76 $552.76 $438.49 $929.00 100% of Medicare $743.20 $789.65 $836.10 $678.08 $789.65 $929.00 $929.00 100% of Medicare 100% of Medicare $929.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dibucaine Top 1% Oint 45802-0050-03 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluocinonide Top 0.05% Oint 00093-0264-30 INSTITUTIONAL $103.00 1/1/2022-12/31/2022 $103.00 $48.62 $58.71 $75.71 $75.71 200% of Medicare 100% of Medicare $61.68 $59.37 $57.81 $65.92 100% of Medicaid 100% of Medicare 150% of Medicare $82.40 $103.00 195% of Medicare $83.43 $61.29 $61.29 $48.62 $103.00 100% of Medicare $82.40 $87.55 $92.70 $75.18 $87.55 $103.00 $103.00 100% of Medicare 100% of Medicare $103.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gentamicin Top 0.1% Oint 45802-0046-35 INSTITUTIONAL $51.00 1/1/2022-12/31/2022 $51.00 $24.07 $29.07 $37.49 $37.49 200% of Medicare 100% of Medicare $30.54 $29.40 $28.63 $32.64 100% of Medicaid 100% of Medicare 150% of Medicare $40.80 $51.00 195% of Medicare $41.31 $30.35 $30.35 $24.07 $51.00 100% of Medicare $40.80 $43.35 $45.90 $37.22 $43.35 $51.00 $51.00 100% of Medicare 100% of Medicare $51.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone Top valerate 0.2% O 51672-1292-01 INSTITUTIONAL $310.00 1/1/2022-12/31/2022 $310.00 $146.32 $176.70 $227.85 $227.85 200% of Medicare 100% of Medicare $185.63 $178.68 $174.00 $198.40 100% of Medicaid 100% of Medicare 150% of Medicare $248.00 $310.00 195% of Medicare $251.10 $184.45 $184.45 $146.32 $310.00 100% of Medicare $248.00 $263.50 $279.00 $226.27 $263.50 $310.00 $310.00 100% of Medicare 100% of Medicare $310.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mupirocin Top 2% Oint 45802-0112-22 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nitroglycerin 2% Top Oint 00281-0326-30 INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $52.86 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $67.07 $64.56 $62.87 $71.68 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $66.64 $66.64 $52.86 $112.00 100% of Medicare $89.60 $95.20 $100.80 $81.75 $95.20 $112.00 $112.00 100% of Medicare 100% of Medicare $112.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "nystatin Top 100,000 units/g Oint" 00168-0007-30 INSTITUTIONAL $61.00 1/1/2022-12/31/2022 $61.00 $28.79 $34.77 $44.84 $44.84 200% of Medicare 100% of Medicare $36.53 $35.16 $34.24 $39.04 100% of Medicaid 100% of Medicare 150% of Medicare $48.80 $61.00 195% of Medicare $49.41 $36.30 $36.30 $28.79 $61.00 100% of Medicare $48.80 $51.85 $54.90 $44.52 $51.85 $61.00 $61.00 100% of Medicare 100% of Medicare $61.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nystatin-triamcinolone Top Oint 51672-1272-02 INSTITUTIONAL $546.00 1/1/2022-12/31/2022 $546.00 $257.71 $311.22 $401.31 $401.31 200% of Medicare 100% of Medicare $326.94 $314.71 $306.47 $349.44 100% of Medicaid 100% of Medicare 150% of Medicare $436.80 $546.00 195% of Medicare $442.26 $324.87 $324.87 $257.71 $546.00 100% of Medicare $436.80 $464.10 $491.40 $398.53 $464.10 $546.00 $546.00 100% of Medicare 100% of Medicare $546.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenylephrine topical 0.25% Oint 00573-2871-10 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL povidone iodine Top 10% Oint 00603-0599-50 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL triamcinolone Top 0.1% Oint 00168-0006-15 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL vitamin A & D Top Oint 00168-0035-01 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL zinc oxide Top 20% Oint 00168-0062-31 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ciprofloxacin Opth 0.3% Oint 00065-0654-35 INSTITUTIONAL $486.00 1/1/2022-12/31/2022 $486.00 $229.39 $277.02 $357.21 $357.21 200% of Medicare 100% of Medicare $291.02 $280.13 $272.79 $311.04 100% of Medicaid 100% of Medicare 150% of Medicare $388.80 $486.00 195% of Medicare $393.66 $289.17 $289.17 $229.39 $486.00 100% of Medicare $388.80 $413.10 $437.40 $354.73 $413.10 $486.00 $486.00 100% of Medicare 100% of Medicare $486.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL erythromycin Opth 0.5% Oint 17478-0070-35 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ocular lubricant Oint 00023-0312-04 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "sodium chloride, hypertonic, Opth" 17478-0622-35 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tobramycin Opth 0.3% Oint 00065-0644-35 INSTITUTIONAL $400.00 1/1/2022-12/31/2022 $400.00 $188.80 $228.00 $294.00 $294.00 200% of Medicare 100% of Medicare $239.52 $230.56 $224.52 $256.00 100% of Medicaid 100% of Medicare 150% of Medicare $320.00 $400.00 195% of Medicare $324.00 $238.00 $238.00 $188.80 $400.00 100% of Medicare $320.00 $340.00 $360.00 $291.96 $340.00 $400.00 $400.00 100% of Medicare 100% of Medicare $400.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone-tobramycin Opth 0.1% 00065-0648-35 INSTITUTIONAL $677.00 1/1/2022-12/31/2022 $677.00 $319.54 $385.89 $497.60 $497.60 200% of Medicare 100% of Medicare $405.39 $390.22 $380.00 $433.28 100% of Medicaid 100% of Medicare 150% of Medicare $541.60 $677.00 195% of Medicare $548.37 $402.82 $402.82 $319.54 $677.00 100% of Medicare $541.60 $575.45 $609.30 $494.14 $575.45 $677.00 $677.00 100% of Medicare 100% of Medicare $677.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fosfomycin 3 g Oral Pwdr 00456-4300-08 INSTITUTIONAL $286.00 1/1/2022-12/31/2022 $286.00 $134.99 $163.02 $210.21 $210.21 200% of Medicare 100% of Medicare $171.26 $164.85 $160.53 $183.04 100% of Medicaid 100% of Medicare 150% of Medicare $228.80 $286.00 195% of Medicare $231.66 $170.17 $170.17 $134.99 $286.00 100% of Medicare $228.80 $243.10 $257.40 $208.75 $243.10 $286.00 $286.00 100% of Medicare 100% of Medicare $286.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium phosphate Oral Pwdr 17314-9313-02 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sevelamer carbonate 0.8 g REC 58468-0132-02 INSTITUTIONAL $52.00 1/1/2022-12/31/2022 $52.00 $24.54 $29.64 $38.22 $38.22 200% of Medicare 100% of Medicare $31.14 $29.97 $29.19 $33.28 100% of Medicaid 100% of Medicare 150% of Medicare $41.60 $52.00 195% of Medicare $42.12 $30.94 $30.94 $24.54 $52.00 100% of Medicare $41.60 $44.20 $46.80 $37.95 $44.20 $52.00 $52.00 100% of Medicare 100% of Medicare $52.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL triamcinolone Top 0.1% Paste 64980-0320-05 INSTITUTIONAL $184.00 1/1/2022-12/31/2022 $184.00 $86.85 $104.88 $135.24 $135.24 200% of Medicare 100% of Medicare $110.18 $106.06 $103.28 $117.76 100% of Medicaid 100% of Medicare 150% of Medicare $147.20 $184.00 195% of Medicare $149.04 $109.48 $109.48 $86.85 $184.00 100% of Medicare $147.20 $156.40 $165.60 $134.30 $156.40 $184.00 $184.00 100% of Medicare 100% of Medicare $184.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clonidine 0.1 mg/24 hr Transderm E 00555-1009-16 INSTITUTIONAL $119.00 1/1/2022-12/31/2022 $119.00 $56.17 $67.83 $87.47 $87.47 200% of Medicare 100% of Medicare $71.26 $68.59 $66.79 $76.16 100% of Medicaid 100% of Medicare 150% of Medicare $95.20 $119.00 195% of Medicare $96.39 $70.81 $70.81 $56.17 $119.00 100% of Medicare $95.20 $101.15 $107.10 $86.86 $101.15 $119.00 $119.00 100% of Medicare 100% of Medicare $119.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clonidine 0.2 mg/24 hr Transderm E 00555-1010-16 INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 200% of Medicare 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clonidine 0.3 mg/24 hr Transderm E 00555-1011-16 INSTITUTIONAL $167.00 1/1/2022-12/31/2022 $167.00 $78.82 $95.19 $122.75 $122.75 200% of Medicare 100% of Medicare $100.00 $96.26 $93.74 $106.88 100% of Medicaid 100% of Medicare 150% of Medicare $133.60 $167.00 195% of Medicare $135.27 $99.37 $99.37 $78.82 $167.00 100% of Medicare $133.60 $141.95 $150.30 $121.89 $141.95 $167.00 $167.00 100% of Medicare 100% of Medicare $167.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diclofenac topical 1.3% ER F 60793-0411-30 INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $75.99 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $96.41 $92.80 $90.37 $103.04 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $95.80 $95.80 $75.99 $161.00 100% of Medicare $128.80 $136.85 $144.90 $117.51 $136.85 $161.00 $161.00 100% of Medicare 100% of Medicare $161.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL estradiol 0.05 mg/24 hours weekly 00378-3350-99 INSTITUTIONAL $75.00 1/1/2022-12/31/2022 $75.00 $35.40 $42.75 $55.13 $55.13 200% of Medicare 100% of Medicare $44.91 $43.23 $42.10 $48.00 100% of Medicaid 100% of Medicare 150% of Medicare $60.00 $75.00 195% of Medicare $60.75 $44.63 $44.63 $35.40 $75.00 100% of Medicare $60.00 $63.75 $67.50 $54.74 $63.75 $75.00 $75.00 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL estradiol 0.1 mg/24 hours weekly T 00378-3352-99 INSTITUTIONAL $852.00 1/1/2022-12/31/2022 $852.00 $402.14 $485.64 $626.22 $626.22 200% of Medicare 100% of Medicare $510.18 $491.09 $478.23 $545.28 100% of Medicaid 100% of Medicare 150% of Medicare $681.60 $852.00 195% of Medicare $690.12 $506.94 $506.94 $402.14 $852.00 100% of Medicare $681.60 $724.20 $766.80 $621.87 $724.20 $852.00 $852.00 100% of Medicare 100% of Medicare $852.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fentanyl 100 mcg/hr Transderm ER F 00591-3214-72 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fentanyl 75 mcg/hr Transderm ER Fi 60505-7003-02 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nitroglycerin 0.3 mg/hr Transderm 00085-3315-35 INSTITUTIONAL $73.00 1/1/2022-12/31/2022 $73.00 $34.46 $41.61 $53.66 $53.66 200% of Medicare 100% of Medicare $43.71 $42.08 $40.97 $46.72 100% of Medicaid 100% of Medicare 150% of Medicare $58.40 $73.00 195% of Medicare $59.13 $43.44 $43.44 $34.46 $73.00 100% of Medicare $58.40 $62.05 $65.70 $53.28 $62.05 $73.00 $73.00 100% of Medicare 100% of Medicare $73.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nitroglycerin 0.4 mg/hr Transderm 49730-0112-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "rivastigmine 4.6 mg/24 hr TD film," 00078-0501-15 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "rivastigmine 9.5 mg/24 hr TD film," 00078-0502-15 INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $25.02 $30.21 $38.96 $38.96 200% of Medicare 100% of Medicare $31.74 $30.55 $29.75 $33.92 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.54 $31.54 $25.02 $53.00 100% of Medicare $42.40 $45.05 $47.70 $38.68 $45.05 $53.00 $53.00 100% of Medicare 100% of Medicare $53.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL scopolamine 1.5 mg Transderm ER Fi 00067-4345-04 INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $30.21 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $38.32 $36.89 $35.92 $40.96 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $38.08 $38.08 $30.21 $64.00 100% of Medicare $51.20 $54.40 $57.60 $46.71 $54.40 $64.00 $64.00 100% of Medicare 100% of Medicare $64.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL testosterone 5 mg/24 hours Transde 52544-0470-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cholestyramine 4 g/5.5 g REC UD 00245-0036-60 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone-salmeterol 100 mcg-50 00173-0695-04 INSTITUTIONAL $399.00 1/1/2022-12/31/2022 $399.00 $188.33 $227.43 $293.27 $293.27 200% of Medicare 100% of Medicare $238.92 $229.98 $223.96 $255.36 100% of Medicaid 100% of Medicare 150% of Medicare $319.20 $399.00 195% of Medicare $323.19 $237.41 $237.41 $188.33 $399.00 100% of Medicare $319.20 $339.15 $359.10 $291.23 $339.15 $399.00 $399.00 100% of Medicare 100% of Medicare $399.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone-salmeterol 250 mcg-50 00173-0696-04 INSTITUTIONAL $426.00 1/1/2022-12/31/2022 $426.00 $201.07 $242.82 $313.11 $313.11 200% of Medicare 100% of Medicare $255.09 $245.55 $239.11 $272.64 100% of Medicaid 100% of Medicare 150% of Medicare $340.80 $426.00 195% of Medicare $345.06 $253.47 $253.47 $201.07 $426.00 100% of Medicare $340.80 $362.10 $383.40 $310.94 $362.10 $426.00 $426.00 100% of Medicare 100% of Medicare $426.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone-salmeterol 500 mcg-50 00173-0697-04 INSTITUTIONAL $820.00 1/1/2022-12/31/2022 $820.00 $387.04 $467.40 $602.70 $602.70 200% of Medicare 100% of Medicare $491.02 $472.65 $460.27 $524.80 100% of Medicaid 100% of Medicare 150% of Medicare $656.00 $820.00 195% of Medicare $664.20 $487.90 $487.90 $387.04 $820.00 100% of Medicare $656.00 $697.00 $738.00 $598.52 $697.00 $820.00 $820.00 100% of Medicare 100% of Medicare $820.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL guar gum oral Pwdr 43900-0976-47 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL magnesium sulfate compounding Pwdr 00869-0602-43 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Miconazole Powder 2% 45 GM 00067-0949-15 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL miconazole Top 2% Pwdr 00145-1501-03 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "nystatin Top 100,000 units/g Pwdr" 68308-0152-15 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium phosphate-sodium phospha 60258-0006-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL polyethylene glycol 3350 Oral Pwdr 00574-0412-07 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL psyllium 100% Oral Pwdr 00224-1801-24 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL salmeterol 50 mcg Inh Pwdr 00173-0520-00 INSTITUTIONAL $477.00 1/1/2022-12/31/2022 $477.00 $225.14 $271.89 $350.60 $350.60 200% of Medicare 100% of Medicare $285.63 $274.94 $267.74 $305.28 100% of Medicaid 100% of Medicare 150% of Medicare $381.60 $477.00 195% of Medicare $386.37 $283.82 $283.82 $225.14 $477.00 100% of Medicare $381.60 $405.45 $429.30 $348.16 $405.45 $477.00 $477.00 100% of Medicare 100% of Medicare $477.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tolnaftate Top 1% Pwdr 00536-5150-26 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluocinolone Top 0.01% Shampoo 00299-5500-04 INSTITUTIONAL " $1,427.00 " 1/1/2022-12/31/2022 " $1,427.00 " $673.54 $813.39 " $1,048.85 " " $1,048.85 " 200% of Medicare 100% of Medicare $854.49 $822.52 $800.98 $913.28 100% of Medicaid 100% of Medicare 150% of Medicare " $1,141.60 " " $1,427.00 " 195% of Medicare " $1,155.87 " $849.07 $849.07 $673.54 " $1,359.00 " 100% of Medicare " $1,141.60 " " $1,212.95 " " $1,284.30 " " $1,041.57 " " $1,212.95 " " $1,427.00 " " $1,427.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ketoconazole Top 2% Shampoo 45802-0465-64 INSTITUTIONAL $42.00 1/1/2022-12/31/2022 $42.00 $19.82 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $25.15 $24.21 $23.57 $26.88 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 195% of Medicare $34.02 $24.99 $24.99 $19.82 $42.00 100% of Medicare $33.60 $35.70 $37.80 $30.66 $35.70 $42.00 $42.00 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Selenium Sulfide 1% 00536-1995-53 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Bismuth Subsalicylate 262mg 00904-5709-09 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clindamycin Top 1% Sol 59762-3728-02 INSTITUTIONAL $229.00 1/1/2022-12/31/2022 $229.00 $108.09 $130.53 $168.32 $168.32 200% of Medicare 100% of Medicare $137.13 $132.00 $128.54 $146.56 100% of Medicaid 100% of Medicare 150% of Medicare $183.20 $229.00 195% of Medicare $185.49 $136.26 $136.26 $108.09 $229.00 100% of Medicare $183.20 $194.65 $206.10 $167.15 $194.65 $229.00 $229.00 100% of Medicare 100% of Medicare $229.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clobetasol Top 0.05% Sol 00168-0269-50 INSTITUTIONAL $143.00 1/1/2022-12/31/2022 $143.00 $67.50 $81.51 $105.11 $105.11 200% of Medicare 100% of Medicare $85.63 $82.43 $80.27 $91.52 100% of Medicaid 100% of Medicare 150% of Medicare $114.40 $143.00 195% of Medicare $115.83 $85.09 $85.09 $67.50 $143.00 100% of Medicare $114.40 $121.55 $128.70 $104.38 $121.55 $143.00 $143.00 100% of Medicare 100% of Medicare $143.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cycloSPORINE 100 mg/mL Oral Sol 00078-0110-22 INSTITUTIONAL " $2,056.00 " 1/1/2022-12/31/2022 " $2,056.00 " $970.43 " $1,171.92 " " $1,511.16 " " $1,511.16 " 200% of Medicare 100% of Medicare " $1,231.13 " " $1,185.08 " " $1,154.03 " " $1,315.84 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,644.80 " " $1,500.00 " 195% of Medicare " $1,665.36 " " $1,223.32 " " $1,223.32 " $970.43 " $1,359.00 " 100% of Medicare " $1,644.80 " " $1,747.60 " " $1,850.40 " " $1,500.67 " " $1,747.60 " " $1,500.00 " " $2,056.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL desmopressin 4 mcg/mL IV Sol 00075-2451-01 INSTITUTIONAL $158.00 1/1/2022-12/31/2022 $158.00 $74.58 $90.06 $116.13 $116.13 200% of Medicare 100% of Medicare $94.61 $91.07 $88.69 $101.12 100% of Medicaid 100% of Medicare 150% of Medicare $126.40 $158.00 195% of Medicare $127.98 $94.01 $94.01 $74.58 $158.00 100% of Medicare $126.40 $134.30 $142.20 $115.32 $134.30 $158.00 $158.00 100% of Medicare 100% of Medicare $158.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL enoxaparin 100 mg/mL SubQ Sol 00075-0623-00 INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $34.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $44.31 $42.65 $41.54 $47.36 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $44.03 $44.03 $34.93 $74.00 100% of Medicare $59.20 $62.90 $66.60 $54.01 $62.90 $74.00 $74.00 100% of Medicare 100% of Medicare $74.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL enoxaparin 30 mg/0.3 mL SC Sol 00075-0624-30 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL enoxaparin 40 mg/0.4 mL SC Sol 00075-0620-40 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL enoxaparin 60 mg/0.6 mL SC Sol 00075-0621-60 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 200% of Medicare 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL enoxaparin 80 mg/0.8 mL SC Sol 00075-0622-80 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ergocalciferol 8000 intl units/mL 39328-0357-60 INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $65.14 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $82.63 $79.54 $77.46 $88.32 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $82.11 $82.11 $65.14 $138.00 100% of Medicare $110.40 $117.30 $124.20 $100.73 $117.30 $138.00 $138.00 100% of Medicare 100% of Medicare $138.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL exenatide 5 mcg/0.02 mL SC Sol 66780-0210-07 INSTITUTIONAL $181.00 1/1/2022-12/31/2022 $181.00 $85.43 $103.17 $133.04 $133.04 200% of Medicare 100% of Medicare $108.38 $104.33 $101.60 $115.84 100% of Medicaid 100% of Medicare 150% of Medicare $144.80 $181.00 195% of Medicare $146.61 $107.70 $107.70 $85.43 $181.00 100% of Medicare $144.80 $153.85 $162.90 $132.11 $153.85 $181.00 $181.00 100% of Medicare 100% of Medicare $181.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL exenatide 10 mcg/0.04 mL SC Sol 66780-0212-01 INSTITUTIONAL " $2,719.00 " 1/1/2022-12/31/2022 " $2,635.00 " $975.00 " $1,549.83 " " $1,998.47 " " $1,998.47 " 200% of Medicare 100% of Medicare " $1,628.14 " " $1,567.23 " " $1,526.17 " " $1,740.16 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,175.20 " " $1,500.00 " 195% of Medicare " $2,202.39 " " $1,617.81 " " $1,617.81 " " $1,283.37 " " $1,359.00 " 100% of Medicare " $2,175.20 " " $2,311.15 " " $2,447.10 " " $1,984.60 " " $2,311.15 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL filgrastim 480 mcg/1.6 mL Inj Sol 55513-0546-10 INSTITUTIONAL " $2,128.00 " 1/1/2022-12/31/2022 " $2,128.00 " $975.00 " $1,212.96 " " $1,564.08 " " $1,564.08 " 200% of Medicare 100% of Medicare " $1,274.25 " " $1,226.58 " " $1,194.45 " " $1,361.92 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,702.40 " " $1,500.00 " 195% of Medicare " $1,723.68 " " $1,266.16 " " $1,266.16 " " $1,004.42 " " $1,359.00 " 100% of Medicare " $1,702.40 " " $1,808.80 " " $1,915.20 " " $1,553.23 " " $1,808.80 " " $1,500.00 " " $2,128.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluoxetine 20 mg/5 mL Oral Sol 54838-0523-40 INSTITUTIONAL $163.00 1/1/2022-12/31/2022 $163.00 $76.94 $92.91 $119.81 $119.81 200% of Medicare 100% of Medicare $97.60 $93.95 $91.49 $104.32 100% of Medicaid 100% of Medicare 150% of Medicare $130.40 $163.00 195% of Medicare $132.03 $96.99 $96.99 $76.94 $163.00 100% of Medicare $130.40 $138.55 $146.70 $118.97 $138.55 $163.00 $163.00 100% of Medicare 100% of Medicare $163.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fondaparinux 2.5 mg/0.5 mL SubQ So 60505-6078-04 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fondaparinux 5 mg/0.4 mL SC Sol 60505-6079-04 INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $65.61 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $83.23 $80.12 $78.02 $88.96 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $82.71 $82.71 $65.61 $139.00 100% of Medicare $111.20 $118.15 $125.10 $101.46 $118.15 $139.00 $139.00 100% of Medicare 100% of Medicare $139.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fondaparinux 7.5 mg/0.6 mL SC Sol 60505-6080-04 INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $75.99 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $96.41 $92.80 $90.37 $103.04 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $95.80 $95.80 $75.99 $161.00 100% of Medicare $128.80 $136.85 $144.90 $117.51 $136.85 $161.00 $161.00 100% of Medicare 100% of Medicare $161.00 200% of Medicare NULL 250 NULL NULL NULL J7606 NULL formoterol 20 mcg/2 mL Inh Sol 49502-0605-61 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.02 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.06 $6.79 $6.62 $5.02 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.02 $7.02 $5.66 $7.72 100% of Medicare $9.60 $10.20 $9.42 $8.76 $9.60 $10.20 $8.25 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gabapentin 250 mg/5 mL Oral Sol 59762-5025-01 INSTITUTIONAL $52.00 1/1/2022-12/31/2022 $52.00 $24.54 $29.64 $38.22 $38.22 200% of Medicare 100% of Medicare $31.14 $29.97 $29.19 $33.28 100% of Medicaid 100% of Medicare 150% of Medicare $41.60 $52.00 195% of Medicare $42.12 $30.94 $30.94 $24.54 $52.00 100% of Medicare $41.60 $44.20 $46.80 $37.95 $44.20 $52.00 $52.00 100% of Medicare 100% of Medicare $52.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "heparin 10,000 units/mL Inj Sol" 00409-1316-32 INSTITUTIONAL $98.00 1/1/2022-12/31/2022 $98.00 $46.26 $55.86 $72.03 $72.03 200% of Medicare 100% of Medicare $58.68 $56.49 $55.01 $62.72 100% of Medicaid 100% of Medicare 150% of Medicare $78.40 $98.00 195% of Medicare $79.38 $58.31 $58.31 $46.26 $98.00 100% of Medicare $78.40 $83.30 $88.20 $71.53 $83.30 $98.00 $98.00 100% of Medicare 100% of Medicare $98.00 200% of Medicare NULL 250 NULL NULL NULL J7323 NULL sodium hyaluronate 10 mg/mL intra- 55566-4100-01 INSTITUTIONAL $670.00 1/1/2022-12/31/2022 $670.00 $280.06 $381.90 $492.45 $492.45 200% of Medicare 100% of Medicare $394.03 $379.29 $369.37 $280.06 100% of Medicaid 100% of Medicare 150% of Medicare $536.00 $670.00 195% of Medicare $542.70 $391.95 $391.95 $316.24 $431.08 100% of Medicare $536.00 $569.50 $525.95 $489.03 $536.00 $569.50 $460.63 100% of Medicare 100% of Medicare $502.50 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-hydrocodone 325 mg-7 66689-0023-50 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 636 NULL NULL NULL J7325 NULL hylan G-F 20 8 mg/mL intra-articul 58468-0090-01 INSTITUTIONAL $440.00 1/1/2022-12/31/2022 $440.00 $183.92 $250.80 $323.40 $323.40 200% of Medicare 100% of Medicare $258.76 $249.08 $242.57 $183.92 100% of Medicaid 100% of Medicare 150% of Medicare $352.00 $440.00 195% of Medicare $356.40 $257.40 $257.40 $207.68 $283.10 100% of Medicare $352.00 $374.00 $345.40 $321.16 $352.00 $374.00 $302.50 100% of Medicare 100% of Medicare $330.00 200% of Medicare NULL 636 NULL NULL NULL J7325 NULL hylan G-F 20 8 mg/mL intra-articul 58468-0090-03 INSTITUTIONAL " $1,319.00 " 1/1/2022-12/31/2022 " $1,319.00 " $551.34 $751.83 $969.47 $969.47 200% of Medicare 100% of Medicare $775.70 $746.69 $727.16 $551.34 100% of Medicaid 100% of Medicare 150% of Medicare " $1,055.20 " " $1,319.00 " 195% of Medicare " $1,068.39 " $771.62 $771.62 $622.57 $848.64 100% of Medicare " $1,055.20 " " $1,121.15 " " $1,035.42 " $962.74 " $1,055.20 " " $1,121.15 " $906.81 100% of Medicare 100% of Medicare $989.25 200% of Medicare NULL 250 NULL NULL NULL NULL NULL iopamidol 41% intrathecal Sol 20 m 00270-1411-25 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL itraconazole 10 mg/mL Oral Sol 50458-0295-15 INSTITUTIONAL $974.00 1/1/2022-12/31/2022 $974.00 $459.73 $555.18 $715.89 $715.89 200% of Medicare 100% of Medicare $583.23 $561.41 $546.71 $623.36 100% of Medicaid 100% of Medicare 150% of Medicare $779.20 $974.00 195% of Medicare $788.94 $579.53 $579.53 $459.73 $974.00 100% of Medicare $779.20 $827.90 $876.60 $710.92 $827.90 $974.00 $974.00 100% of Medicare 100% of Medicare $974.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lamivudine 10 mg/mL Oral Sol 49702-0205-48 INSTITUTIONAL $475.00 1/1/2022-12/31/2022 $475.00 $224.20 $270.75 $349.13 $349.13 200% of Medicare 100% of Medicare $284.43 $273.79 $266.62 $304.00 100% of Medicaid 100% of Medicare 150% of Medicare $380.00 $475.00 195% of Medicare $384.75 $282.63 $282.63 $224.20 $475.00 100% of Medicare $380.00 $403.75 $427.50 $346.70 $403.75 $475.00 $475.00 100% of Medicare 100% of Medicare $475.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levetiracetam 100 mg/mL Oral Sol 60432-0831-16 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine Top 4% Sol 00054-3505-47 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine Top 2% Sol 100 mL 00603-1393-64 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL meningococcal conjugate vaccine IM 49281-0589-01 INSTITUTIONAL $426.00 1/1/2022-12/31/2022 $426.00 $201.07 $242.82 $313.11 $313.11 200% of Medicare 100% of Medicare $255.09 $245.55 $239.11 $272.64 100% of Medicaid 100% of Medicare 150% of Medicare $340.80 $426.00 195% of Medicare $345.06 $253.47 $253.47 $201.07 $426.00 100% of Medicare $340.80 $362.10 $383.40 $310.94 $362.10 $426.00 $426.00 100% of Medicare 100% of Medicare $426.00 200% of Medicare NULL 250 NULL NULL NULL J2270 NULL morphine 1 mg/mL Inj Sol 00074-6023-04 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $5.85 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.23 $7.93 $7.72 $5.85 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.19 $8.19 $6.61 $9.01 100% of Medicare $11.20 $11.90 $10.99 $10.22 $11.20 $11.90 $9.63 100% of Medicare 100% of Medicare $10.50 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pneumococcal 23-valent vaccine Inj 00006-4943-00 INSTITUTIONAL $399.00 1/1/2022-12/31/2022 $399.00 $188.33 $227.43 $293.27 $293.27 200% of Medicare 100% of Medicare $238.92 $229.98 $223.96 $255.36 100% of Medicaid 100% of Medicare 150% of Medicare $319.20 $399.00 195% of Medicare $323.19 $237.41 $237.41 $188.33 $399.00 100% of Medicare $319.20 $339.15 $359.10 $291.23 $339.15 $399.00 $399.00 100% of Medicare 100% of Medicare $399.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium iodide 1 g/mL Oral Sol 00245-0003-31 INSTITUTIONAL $52.00 1/1/2022-12/31/2022 $52.00 $24.54 $29.64 $38.22 $38.22 200% of Medicare 100% of Medicare $31.14 $29.97 $29.19 $33.28 100% of Medicaid 100% of Medicare 150% of Medicare $41.60 $52.00 195% of Medicare $42.12 $30.94 $30.94 $24.54 $52.00 100% of Medicare $41.60 $44.20 $46.80 $37.95 $44.20 $52.00 $52.00 100% of Medicare 100% of Medicare $52.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sirolimus 1 mg/mL Oral Sol 00008-1030-06 INSTITUTIONAL " $5,856.00 " 1/1/2022-12/31/2022 " $5,270.40 " $975.00 " $3,337.92 " " $4,304.16 " " $4,304.16 " 200% of Medicare 100% of Medicare " $3,506.57 " " $3,375.40 " " $3,286.97 " " $3,747.84 " 100% of Medicaid 100% of Medicare 150% of Medicare " $4,684.80 " " $1,500.00 " 195% of Medicare " $4,743.36 " " $3,484.32 " " $3,484.32 " " $2,764.03 " " $1,359.00 " 100% of Medicare " $4,684.80 " " $4,977.60 " " $5,270.40 " " $4,274.29 " " $4,977.60 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride 0.9% Irr Sol 1000 00338-0048-04 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride 0.9% Inh Sol 15 mL 00378-6987-89 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride 3% Inh Sol 15 mL 49502-0640-15 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium hypochlorite Top 0.5% Sol 00436-0946-16 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium hypochlorite Top 0.25% Sol 00436-0936-16 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sterile Water Irrigation 2000mL 00338-0013-06 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tuberculin purified protein deriva 49281-0752-22 INSTITUTIONAL $92.00 1/1/2022-12/31/2022 $92.00 $43.42 $52.44 $67.62 $67.62 200% of Medicare 100% of Medicare $55.09 $53.03 $51.64 $58.88 100% of Medicaid 100% of Medicare 150% of Medicare $73.60 $92.00 195% of Medicare $74.52 $54.74 $54.74 $43.42 $92.00 100% of Medicare $73.60 $78.20 $82.80 $67.15 $78.20 $92.00 $92.00 100% of Medicare 100% of Medicare $92.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acyclovir 50 mg/mL IV Sol 63323-0325-20 INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $53.81 $64.98 $83.79 $83.79 200% of Medicare 100% of Medicare $68.26 $65.71 $63.99 $72.96 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $67.83 $67.83 $53.81 $114.00 100% of Medicare $91.20 $96.90 $102.60 $83.21 $96.90 $114.00 $114.00 100% of Medicare 100% of Medicare $114.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL albumin human 25% IV Sol 50 mL 68516-5216-01 INSTITUTIONAL $231.00 1/1/2022-12/31/2022 $231.00 $109.03 $131.67 $169.79 $169.79 200% of Medicare 100% of Medicare $138.32 $133.15 $129.66 $147.84 100% of Medicaid 100% of Medicare 150% of Medicare $184.80 $231.00 195% of Medicare $187.11 $137.45 $137.45 $109.03 $231.00 100% of Medicare $184.80 $196.35 $207.90 $168.61 $196.35 $231.00 $231.00 100% of Medicare 100% of Medicare $231.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amikacin 250 mg/mL IV Sol 00703-9040-03 INSTITUTIONAL $137.00 1/1/2022-12/31/2022 $137.00 $64.66 $78.09 $100.70 $100.70 200% of Medicare 100% of Medicare $82.04 $78.97 $76.90 $87.68 100% of Medicaid 100% of Medicare 150% of Medicare $109.60 $137.00 195% of Medicare $110.97 $81.52 $81.52 $64.66 $137.00 100% of Medicare $109.60 $116.45 $123.30 $100.00 $116.45 $137.00 $137.00 100% of Medicare 100% of Medicare $137.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amphotericin B liposomal 50 mg IV 00469-3051-30 INSTITUTIONAL $303.00 1/1/2022-12/31/2022 $303.00 $143.02 $172.71 $222.71 $222.71 200% of Medicare 100% of Medicare $181.44 $174.65 $170.07 $193.92 100% of Medicaid 100% of Medicare 150% of Medicare $242.40 $303.00 195% of Medicare $245.43 $180.29 $180.29 $143.02 $303.00 100% of Medicare $242.40 $257.55 $272.70 $221.16 $257.55 $303.00 $303.00 100% of Medicare 100% of Medicare $303.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ampicillin 2 g Inj 00781-3413-92 INSTITUTIONAL $97.00 1/1/2022-12/31/2022 $97.00 $45.78 $55.29 $71.30 $71.30 200% of Medicare 100% of Medicare $58.08 $55.91 $54.45 $62.08 100% of Medicaid 100% of Medicare 150% of Medicare $77.60 $97.00 195% of Medicare $78.57 $57.72 $57.72 $45.78 $97.00 100% of Medicare $77.60 $82.45 $87.30 $70.80 $82.45 $97.00 $97.00 100% of Medicare 100% of Medicare $97.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ampicillin-sulbactam 2 g-1 g Inj 00409-2987-03 INSTITUTIONAL $106.00 1/1/2022-12/31/2022 $106.00 $50.03 $60.42 $77.91 $77.91 200% of Medicare 100% of Medicare $63.47 $61.10 $59.50 $67.84 100% of Medicaid 100% of Medicare 150% of Medicare $84.80 $106.00 195% of Medicare $85.86 $63.07 $63.07 $50.03 $106.00 100% of Medicare $84.80 $90.10 $95.40 $77.37 $90.10 $106.00 $106.00 100% of Medicare 100% of Medicare $106.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atropine 0.4 mg/mL Inj Sol 00517-0401-25 INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 200% of Medicare 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL azelastine Nasal 137 mcg/inh Spry 51525-0294-03 INSTITUTIONAL $186.00 1/1/2022-12/31/2022 $186.00 $87.79 $106.02 $136.71 $136.71 200% of Medicare 100% of Medicare $111.38 $107.21 $104.40 $119.04 100% of Medicaid 100% of Medicare 150% of Medicare $148.80 $186.00 195% of Medicare $150.66 $110.67 $110.67 $87.79 $186.00 100% of Medicare $148.80 $158.10 $167.40 $135.76 $158.10 $186.00 $186.00 100% of Medicare 100% of Medicare $186.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL azithromycin 500 mg IV Inj 00069-3150-83 INSTITUTIONAL $207.00 1/1/2022-12/31/2022 $207.00 $97.70 $117.99 $152.15 $152.15 200% of Medicare 100% of Medicare $123.95 $119.31 $116.19 $132.48 100% of Medicaid 100% of Medicare 150% of Medicare $165.60 $207.00 195% of Medicare $167.67 $123.17 $123.17 $97.70 $207.00 100% of Medicare $165.60 $175.95 $186.30 $151.09 $175.95 $207.00 $207.00 100% of Medicare 100% of Medicare $207.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL betamethasone acetate-betamethason 00085-0566-05 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 636 NULL NULL NULL J0585 NULL onabotulinumtoxinA 100 units REC 00023-1145-01 INSTITUTIONAL " $2,690.00 " 1/1/2022-12/31/2022 " $2,286.50 " " $1,124.42 " " $1,533.30 " " $1,977.15 " " $1,977.15 " 200% of Medicare 100% of Medicare " $1,581.99 " " $1,522.81 " " $1,483.00 " " $1,124.42 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,152.00 " " $1,500.00 " 195% of Medicare " $2,178.90 " " $1,573.65 " " $1,573.65 " " $1,269.68 " " $1,730.75 " 100% of Medicare " $2,152.00 " " $2,286.50 " " $2,111.65 " " $1,963.43 " " $2,152.00 " " $2,286.50 " " $1,849.38 " 100% of Medicare 100% of Medicare " $2,017.50 " 200% of Medicare NULL 636 NULL NULL NULL J0587 NULL botulinum toxin type B 5000 units/ 59075-0711-10 INSTITUTIONAL " $2,346.00 " 1/1/2022-12/31/2022 " $1,994.10 " $980.63 " $1,337.22 " " $1,724.31 " " $1,724.31 " 200% of Medicare 100% of Medicare " $1,379.68 " " $1,328.07 " " $1,293.35 " $980.63 100% of Medicaid 100% of Medicare 150% of Medicare " $1,876.80 " " $1,500.00 " 195% of Medicare " $1,900.26 " " $1,372.41 " " $1,372.41 " " $1,107.31 " " $1,509.42 " 100% of Medicare " $1,876.80 " " $1,994.10 " " $1,841.61 " " $1,712.35 " " $1,876.80 " " $1,994.10 " " $1,612.88 " 100% of Medicare 100% of Medicare " $1,759.50 " 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bupivacaine 0.25% PF Inj Sol 10 mL 63323-0464-17 INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $40.59 $49.02 $63.21 $63.21 200% of Medicare 100% of Medicare $51.50 $49.57 $48.27 $55.04 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $51.17 $51.17 $40.59 $86.00 100% of Medicare $68.80 $73.10 $77.40 $62.77 $73.10 $86.00 $86.00 100% of Medicare 100% of Medicare $86.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bupivacaine 0.75% PF Inj Sol 30 mL 00409-1582-29 INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $46.73 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $59.28 $57.06 $55.57 $63.36 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $58.91 $58.91 $46.73 $99.00 100% of Medicare $79.20 $84.15 $89.10 $72.26 $84.15 $99.00 $99.00 100% of Medicare 100% of Medicare $99.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bupivacaine 0.5% PF Inj Sol 10 mL 00409-1560-10 INSTITUTIONAL $92.00 1/1/2022-12/31/2022 $92.00 $43.42 $52.44 $67.62 $67.62 200% of Medicare 100% of Medicare $55.09 $53.03 $51.64 $58.88 100% of Medicaid 100% of Medicare 150% of Medicare $73.60 $92.00 195% of Medicare $74.52 $54.74 $54.74 $43.42 $92.00 100% of Medicare $73.60 $78.20 $82.80 $67.15 $78.20 $92.00 $92.00 100% of Medicare 100% of Medicare $92.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bupivacaine 0.75% PF Inj Sol 10 mL 63323-0472-17 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 200% of Medicare 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcium gluconate 100 mg/mL Inj So 63323-0311-10 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL caspofungin 50 mg IV Inj 00006-3822-10 INSTITUTIONAL $409.00 1/1/2022-12/31/2022 $409.00 $193.05 $233.13 $300.62 $300.62 200% of Medicare 100% of Medicare $244.91 $235.75 $229.57 $261.76 100% of Medicaid 100% of Medicare 150% of Medicare $327.20 $409.00 195% of Medicare $331.29 $243.36 $243.36 $193.05 $409.00 100% of Medicare $327.20 $347.65 $368.10 $298.53 $347.65 $409.00 $409.00 100% of Medicare 100% of Medicare $409.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cefazolin 1 g Inj 00409-2585-01 INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 200% of Medicare 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cefazolin 1 g Inj 25021-0102-99 INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $50.50 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $64.07 $61.67 $60.06 $68.48 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $63.67 $63.67 $50.50 $107.00 100% of Medicare $85.60 $90.95 $96.30 $78.10 $90.95 $107.00 $107.00 100% of Medicare 100% of Medicare $107.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cefepime 1 g Inj 00781-3222-95 INSTITUTIONAL $93.00 1/1/2022-12/31/2022 $93.00 $43.90 $53.01 $68.36 $68.36 200% of Medicare 100% of Medicare $55.69 $53.61 $52.20 $59.52 100% of Medicaid 100% of Medicare 150% of Medicare $74.40 $93.00 195% of Medicare $75.33 $55.34 $55.34 $43.90 $93.00 100% of Medicare $74.40 $79.05 $83.70 $67.88 $79.05 $93.00 $93.00 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cefepime 2 g Inj 25021-0122-50 INSTITUTIONAL $122.00 1/1/2022-12/31/2022 $122.00 $57.58 $69.54 $89.67 $89.67 200% of Medicare 100% of Medicare $73.05 $70.32 $68.48 $78.08 100% of Medicaid 100% of Medicare 150% of Medicare $97.60 $122.00 195% of Medicare $98.82 $72.59 $72.59 $57.58 $122.00 100% of Medicare $97.60 $103.70 $109.80 $89.05 $103.70 $122.00 $122.00 100% of Medicare 100% of Medicare $122.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ceftazidime 1 g Inj 00173-0378-10 INSTITUTIONAL $132.00 1/1/2022-12/31/2022 $132.00 $62.30 $75.24 $97.02 $97.02 200% of Medicare 100% of Medicare $79.04 $76.08 $74.09 $84.48 100% of Medicaid 100% of Medicare 150% of Medicare $105.60 $132.00 195% of Medicare $106.92 $78.54 $78.54 $62.30 $132.00 100% of Medicare $105.60 $112.20 $118.80 $96.35 $112.20 $132.00 $132.00 100% of Medicare 100% of Medicare $132.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ceftriaxone 1 g Inj 00409-7333-04 INSTITUTIONAL $98.00 1/1/2022-12/31/2022 $98.00 $46.26 $55.86 $72.03 $72.03 200% of Medicare 100% of Medicare $58.68 $56.49 $55.01 $62.72 100% of Medicaid 100% of Medicare 150% of Medicare $78.40 $98.00 195% of Medicare $79.38 $58.31 $58.31 $46.26 $98.00 100% of Medicare $78.40 $83.30 $88.20 $71.53 $83.30 $98.00 $98.00 100% of Medicare 100% of Medicare $98.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ceftriaxone 2 g Inj 00409-7336-04 INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ciprofloxacin 400 mg/200 mL IV Sol 00409-4777-02 INSTITUTIONAL $92.00 1/1/2022-12/31/2022 $92.00 $43.42 $52.44 $67.62 $67.62 200% of Medicare 100% of Medicare $55.09 $53.03 $51.64 $58.88 100% of Medicaid 100% of Medicare 150% of Medicare $73.60 $92.00 195% of Medicare $74.52 $54.74 $54.74 $43.42 $92.00 100% of Medicare $73.60 $78.20 $82.80 $67.15 $78.20 $92.00 $92.00 100% of Medicare 100% of Medicare $92.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clindamycin 150 mg/mL IV Sol 25021-0115-04 INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $42.95 $51.87 $66.89 $66.89 200% of Medicare 100% of Medicare $54.49 $52.45 $51.08 $58.24 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $54.15 $54.15 $42.95 $91.00 100% of Medicare $72.80 $77.35 $81.90 $66.42 $77.35 $91.00 $91.00 100% of Medicare 100% of Medicare $91.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cosyntropin 0.25 mg Inj 00548-5900-00 INSTITUTIONAL $87.00 1/1/2022-12/31/2022 $87.00 $41.06 $49.59 $63.95 $63.95 200% of Medicare 100% of Medicare $52.10 $50.15 $48.83 $55.68 100% of Medicaid 100% of Medicare 150% of Medicare $69.60 $87.00 195% of Medicare $70.47 $51.77 $51.77 $41.06 $87.00 100% of Medicare $69.60 $73.95 $78.30 $63.50 $73.95 $87.00 $87.00 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cyanocobalamin 1000 mcg/mL Inj Sol 00517-0031-25 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 200% of Medicare 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL daptomycin 500 mg IV Inj 67919-0011-01 INSTITUTIONAL $694.00 1/1/2022-12/31/2022 $694.00 $327.57 $395.58 $510.09 $510.09 200% of Medicare 100% of Medicare $415.57 $400.02 $389.54 $444.16 100% of Medicaid 100% of Medicare 150% of Medicare $555.20 $694.00 195% of Medicare $562.14 $412.93 $412.93 $327.57 $694.00 100% of Medicare $555.20 $589.90 $624.60 $506.55 $589.90 $694.00 $694.00 100% of Medicare 100% of Medicare $694.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darbepoetin alfa 100 mcg/mL Inj So 55513-0005-04 INSTITUTIONAL " $1,487.00 " 1/1/2022-12/31/2022 " $1,487.00 " $701.86 $847.59 " $1,092.95 " " $1,092.95 " 200% of Medicare 100% of Medicare $890.42 $857.11 $834.65 $951.68 100% of Medicaid 100% of Medicare 150% of Medicare " $1,189.60 " " $1,487.00 " 195% of Medicare " $1,204.47 " $884.77 $884.77 $701.86 " $1,359.00 " 100% of Medicare " $1,189.60 " " $1,263.95 " " $1,338.30 " " $1,085.36 " " $1,263.95 " " $1,487.00 " " $1,487.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darbepoetin alfa 200 mcg/mL Inj So 55513-0006-01 INSTITUTIONAL " $2,966.00 " 1/1/2022-12/31/2022 " $2,669.40 " $975.00 " $1,690.62 " " $2,180.01 " " $2,180.01 " 200% of Medicare 100% of Medicare " $1,776.04 " " $1,709.60 " " $1,664.82 " " $1,898.24 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,372.80 " " $1,500.00 " 195% of Medicare " $2,402.46 " " $1,764.77 " " $1,764.77 " " $1,399.95 " " $1,359.00 " 100% of Medicare " $2,372.80 " " $2,521.10 " " $2,669.40 " " $2,164.88 " " $2,521.10 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darbepoetin alfa 25 mcg/mL Inj Sol 55513-0002-04 INSTITUTIONAL $450.00 1/1/2022-12/31/2022 $450.00 $212.40 $256.50 $330.75 $330.75 200% of Medicare 100% of Medicare $269.46 $259.38 $252.59 $288.00 100% of Medicaid 100% of Medicare 150% of Medicare $360.00 $450.00 195% of Medicare $364.50 $267.75 $267.75 $212.40 $450.00 100% of Medicare $360.00 $382.50 $405.00 $328.46 $382.50 $450.00 $450.00 100% of Medicare 100% of Medicare $450.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darbepoetin alfa 300 mcg/mL Inj So 55513-0110-01 INSTITUTIONAL " $4,444.00 " 1/1/2022-12/31/2022 " $3,999.60 " $975.00 " $2,533.08 " " $3,266.34 " " $3,266.34 " 200% of Medicare 100% of Medicare " $2,661.07 " " $2,561.52 " " $2,494.42 " " $2,844.16 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,555.20 " " $1,500.00 " 195% of Medicare " $3,599.64 " " $2,644.18 " " $2,644.18 " " $2,097.57 " " $1,359.00 " 100% of Medicare " $3,555.20 " " $3,777.40 " " $3,999.60 " " $3,243.68 " " $3,777.40 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darbepoetin alfa 40 mcg/mL Inj Sol 55513-0003-04 INSTITUTIONAL $716.00 1/1/2022-12/31/2022 $716.00 $337.95 $408.12 $526.26 $526.26 200% of Medicare 100% of Medicare $428.74 $412.70 $401.89 $458.24 100% of Medicaid 100% of Medicare 150% of Medicare $572.80 $716.00 195% of Medicare $579.96 $426.02 $426.02 $337.95 $716.00 100% of Medicare $572.80 $608.60 $644.40 $522.61 $608.60 $716.00 $716.00 100% of Medicare 100% of Medicare $716.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darbepoetin alfa 60 mcg/mL Inj Sol 55513-0004-04 INSTITUTIONAL " $1,027.00 " 1/1/2022-12/31/2022 " $1,027.00 " $484.74 $585.39 $754.85 $754.85 200% of Medicare 100% of Medicare $614.97 $591.96 $576.46 $657.28 100% of Medicaid 100% of Medicare 150% of Medicare $821.60 " $1,027.00 " 195% of Medicare $831.87 $611.07 $611.07 $484.74 " $1,027.00 " 100% of Medicare $821.60 $872.95 $924.30 $749.61 $872.95 " $1,027.00 " " $1,027.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone 10 mg/mL Inj Sol 00641-0367-25 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone 4 mg/mL Inj Sol 63323-0165-01 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 200% of Medicare 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone 4 mg/mL Inj Sol 63323-0165-05 INSTITUTIONAL $93.00 1/1/2022-12/31/2022 $93.00 $43.90 $53.01 $68.36 $68.36 200% of Medicare 100% of Medicare $55.69 $53.61 $52.20 $59.52 100% of Medicaid 100% of Medicare 150% of Medicare $74.40 $93.00 195% of Medicare $75.33 $55.34 $55.34 $43.90 $93.00 100% of Medicare $74.40 $79.05 $83.70 $67.88 $79.05 $93.00 $93.00 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dextrose 5% Sod Chloride 0.45% KCl 00338-0675-04 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glucose 50% IV Sol 50 mL 00409-7517-16 INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 200% of Medicare 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diphenhydrAMINE 50 mg/mL Inj Sol 00641-0376-25 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 200% of Medicare 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL epinephrine 0.1 mg/mL Inj Sol 00409-4921-34 INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $46.73 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $59.28 $57.06 $55.57 $63.36 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $58.91 $58.91 $46.73 $99.00 100% of Medicare $79.20 $84.15 $89.10 $72.26 $84.15 $99.00 $99.00 100% of Medicare 100% of Medicare $99.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ertapenem 1 g Inj 00006-3843-71 INSTITUTIONAL $363.00 1/1/2022-12/31/2022 $363.00 $171.34 $206.91 $266.81 $266.81 200% of Medicare 100% of Medicare $217.36 $209.23 $203.75 $232.32 100% of Medicaid 100% of Medicare 150% of Medicare $290.40 $363.00 195% of Medicare $294.03 $215.99 $215.99 $171.34 $363.00 100% of Medicare $290.40 $308.55 $326.70 $264.95 $308.55 $363.00 $363.00 100% of Medicare 100% of Medicare $363.00 200% of Medicare NULL 250 NULL NULL NULL S0164 NULL esomeprazole 40 mg IV Inj 00186-6040-01 INSTITUTIONAL $267.00 1/1/2022-12/31/2022 $267.00 $111.61 $152.19 $196.25 $196.25 200% of Medicare 100% of Medicare $157.02 $151.15 $147.20 $111.61 100% of Medicaid 100% of Medicare 150% of Medicare $213.60 $267.00 195% of Medicare $216.27 $156.20 $156.20 $126.02 $171.79 100% of Medicare $213.60 $226.95 $209.60 $194.88 $213.60 $226.95 $183.56 100% of Medicare 100% of Medicare $200.25 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fentanyl 0.05 mg/mL Inj Sol 00641-6027-25 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Fluconazole Inj 200mg in Sodium Ch 00409-4688-23 INSTITUTIONAL " $1,461.00 " 1/1/2022-12/31/2022 " $1,461.00 " $689.59 $832.77 " $1,073.84 " " $1,073.84 " 200% of Medicare 100% of Medicare $874.85 $842.12 $820.06 $935.04 100% of Medicaid 100% of Medicare 150% of Medicare " $1,168.80 " " $1,461.00 " 195% of Medicare " $1,183.41 " $869.30 $869.30 $689.59 " $1,359.00 " 100% of Medicare " $1,168.80 " " $1,241.85 " " $1,314.90 " " $1,066.38 " " $1,241.85 " " $1,461.00 " " $1,461.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL flumazenil 0.1 mg/mL IV Sol 00143-9784-10 INSTITUTIONAL $96.00 1/1/2022-12/31/2022 $96.00 $45.31 $54.72 $70.56 $70.56 200% of Medicare 100% of Medicare $57.48 $55.33 $53.88 $61.44 100% of Medicaid 100% of Medicare 150% of Medicare $76.80 $96.00 195% of Medicare $77.76 $57.12 $57.12 $45.31 $96.00 100% of Medicare $76.80 $81.60 $86.40 $70.07 $81.60 $96.00 $96.00 100% of Medicare 100% of Medicare $96.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL furosemide 10 mg/mL Inj Sol 00409-6102-04 INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 200% of Medicare 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gentamicin 40 mg/mL Inj Sol 63323-0010-02 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 200% of Medicare 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glucagon recombinant 1 mg Inj 55390-0004-01 INSTITUTIONAL " $1,072.00 " 1/1/2022-12/31/2022 " $1,072.00 " $505.98 $611.04 $787.92 $787.92 200% of Medicare 100% of Medicare $641.91 $617.90 $601.71 $686.08 100% of Medicaid 100% of Medicare 150% of Medicare $857.60 " $1,072.00 " 195% of Medicare $868.32 $637.84 $637.84 $505.98 " $1,072.00 " 100% of Medicare $857.60 $911.20 $964.80 $782.45 $911.20 " $1,072.00 " " $1,072.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL haloperidol 5 mg/mL Inj Sol 25021-0806-01 INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 200% of Medicare 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL heparin flush 100 units/mL Soln 64253-0333-35 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrALAZINE 20 mg/mL Inj Sol 17478-0934-01 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone 100 mg preservative 00009-0825-01 INSTITUTIONAL $115.00 1/1/2022-12/31/2022 $115.00 $54.28 $65.55 $84.53 $84.53 200% of Medicare 100% of Medicare $68.86 $66.29 $64.55 $73.60 100% of Medicaid 100% of Medicare 150% of Medicare $92.00 $115.00 195% of Medicare $93.15 $68.43 $68.43 $54.28 $115.00 100% of Medicare $92.00 $97.75 $103.50 $83.94 $97.75 $115.00 $115.00 100% of Medicare 100% of Medicare $115.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydromorphone 2 mg/mL Inj Sol 00409-3356-01 INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $40.59 $49.02 $63.21 $63.21 200% of Medicare 100% of Medicare $51.50 $49.57 $48.27 $55.04 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $51.17 $51.17 $40.59 $86.00 100% of Medicare $68.80 $73.10 $77.40 $62.77 $73.10 $86.00 $86.00 100% of Medicare 100% of Medicare $86.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL interferon beta-1a 44 mcg/0.5 mL S 44087-0044-03 INSTITUTIONAL " $1,507.00 " 1/1/2022-12/31/2022 " $1,507.00 " $711.30 $858.99 " $1,107.65 " " $1,107.65 " 200% of Medicare 100% of Medicare $902.39 $868.63 $845.88 $964.48 100% of Medicaid 100% of Medicare 150% of Medicare " $1,205.60 " " $1,500.00 " 195% of Medicare " $1,220.67 " $896.67 $896.67 $711.30 " $1,359.00 " 100% of Medicare " $1,205.60 " " $1,280.95 " " $1,356.30 " " $1,099.96 " " $1,280.95 " " $1,500.00 " " $1,507.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL iopamidol 41% intrathecal Sol 10 m 00270-1411-11 INSTITUTIONAL $87.00 1/1/2022-12/31/2022 $87.00 $41.06 $49.59 $63.95 $63.95 200% of Medicare 100% of Medicare $52.10 $50.15 $48.83 $55.68 100% of Medicaid 100% of Medicare 150% of Medicare $69.60 $87.00 195% of Medicare $70.47 $51.77 $51.77 $41.06 $87.00 100% of Medicare $69.60 $73.95 $78.30 $63.50 $73.95 $87.00 $87.00 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Iopamidol 61% 15ml 00270-1412-15 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL iron sucrose 20 mg/mL IV Sol 00517-2340-10 INSTITUTIONAL $221.00 1/1/2022-12/31/2022 $221.00 $104.31 $125.97 $162.44 $162.44 200% of Medicare 100% of Medicare $132.33 $127.38 $124.05 $141.44 100% of Medicaid 100% of Medicare 150% of Medicare $176.80 $221.00 195% of Medicare $179.01 $131.50 $131.50 $104.31 $221.00 100% of Medicare $176.80 $187.85 $198.90 $161.31 $187.85 $221.00 $221.00 100% of Medicare 100% of Medicare $221.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ketorolac 30 mg/mL Inj Sol 00409-3795-01 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 200% of Medicare 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL labetalol 5 mg/mL IV Sol 00409-2267-20 INSTITUTIONAL $93.00 1/1/2022-12/31/2022 $93.00 $43.90 $53.01 $68.36 $68.36 200% of Medicare 100% of Medicare $55.69 $53.61 $52.20 $59.52 100% of Medicaid 100% of Medicare 150% of Medicare $74.40 $93.00 195% of Medicare $75.33 $55.34 $55.34 $43.90 $93.00 100% of Medicare $74.40 $79.05 $83.70 $67.88 $79.05 $93.00 $93.00 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levetiracetam 100 mg/mL IV Sol 62756-0513-44 INSTITUTIONAL $103.00 1/1/2022-12/31/2022 $103.00 $48.62 $58.71 $75.71 $75.71 200% of Medicare 100% of Medicare $61.68 $59.37 $57.81 $65.92 100% of Medicaid 100% of Medicare 150% of Medicare $82.40 $103.00 195% of Medicare $83.43 $61.29 $61.29 $48.62 $103.00 100% of Medicare $82.40 $87.55 $92.70 $75.18 $87.55 $103.00 $103.00 100% of Medicare 100% of Medicare $103.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine 2% PF Inj Sol 2 mL 63323-0495-27 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine 1% PF Inj Sol 30 mL 00409-4279-02 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine 1% PF Inj Sol 5 mL 63323-0492-57 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine 1% Inj Sol 00409-4276-01 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine 2% PF Inj Sol 5 mL 00409-4903-34 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine 2% Inj Sol 20 mL 00409-4277-01 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL J3475 NULL magnesium sulfate 10 mg/mL-D5W int 00409-6727-23 INSTITUTIONAL $65.00 1/1/2022-12/31/2022 $65.00 $27.17 $37.05 $47.78 $47.78 200% of Medicare 100% of Medicare $38.23 $36.80 $35.83 $27.17 100% of Medicaid 100% of Medicare 150% of Medicare $52.00 $65.00 195% of Medicare $52.65 $38.03 $38.03 $30.68 $41.82 100% of Medicare $52.00 $55.25 $51.03 $47.44 $52.00 $55.25 $44.69 100% of Medicare 100% of Medicare $48.75 200% of Medicare NULL 250 NULL NULL NULL NULL NULL magnesium sulfate 50% Inj Sol 10 m 00517-2610-25 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL meropenem 500 mg IV Inj 00781-3265-95 INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $52.86 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $67.07 $64.56 $62.87 $71.68 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $66.64 $66.64 $52.86 $112.00 100% of Medicare $89.60 $95.20 $100.80 $81.75 $95.20 $112.00 $112.00 100% of Medicare 100% of Medicare $112.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methotrexate 25 mg/mL PF Inj Sol 10139-0062-02 INSTITUTIONAL $125.00 1/1/2022-12/31/2022 $125.00 $59.00 $71.25 $91.88 $91.88 200% of Medicare 100% of Medicare $74.85 $72.05 $70.16 $80.00 100% of Medicaid 100% of Medicare 150% of Medicare $100.00 $125.00 195% of Medicare $101.25 $74.38 $74.38 $59.00 $125.00 100% of Medicare $100.00 $106.25 $112.50 $91.24 $106.25 $125.00 $125.00 100% of Medicare 100% of Medicare $125.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylPREDNISolone 1 g preservativ 00009-0018-20 INSTITUTIONAL $157.00 1/1/2022-12/31/2022 $157.00 $74.10 $89.49 $115.40 $115.40 200% of Medicare 100% of Medicare $94.01 $90.49 $88.12 $100.48 100% of Medicaid 100% of Medicare 150% of Medicare $125.60 $157.00 195% of Medicare $127.17 $93.42 $93.42 $74.10 $157.00 100% of Medicare $125.60 $133.45 $141.30 $114.59 $133.45 $157.00 $157.00 100% of Medicare 100% of Medicare $157.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylPREDNISolone 125 mg preserva 00009-0047-22 INSTITUTIONAL $93.00 1/1/2022-12/31/2022 $93.00 $43.90 $53.01 $68.36 $68.36 200% of Medicare 100% of Medicare $55.69 $53.61 $52.20 $59.52 100% of Medicaid 100% of Medicare 150% of Medicare $74.40 $93.00 195% of Medicare $75.33 $55.34 $55.34 $43.90 $93.00 100% of Medicare $74.40 $79.05 $83.70 $67.88 $79.05 $93.00 $93.00 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylPREDNISolone 40 mg preservat 00009-0039-28 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 200% of Medicare 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylPREDNISolone 500 mg preserva 00009-0003-02 INSTITUTIONAL $147.00 1/1/2022-12/31/2022 $147.00 $69.38 $83.79 $108.05 $108.05 200% of Medicare 100% of Medicare $88.02 $84.73 $82.51 $94.08 100% of Medicaid 100% of Medicare 150% of Medicare $117.60 $147.00 195% of Medicare $119.07 $87.47 $87.47 $69.38 $147.00 100% of Medicare $117.60 $124.95 $132.30 $107.30 $124.95 $147.00 $147.00 100% of Medicare 100% of Medicare $147.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylPREDNISolone 1 g Inj 00009-0698-01 INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $65.61 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $83.23 $80.12 $78.02 $88.96 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $82.71 $82.71 $65.61 $139.00 100% of Medicare $111.20 $118.15 $125.10 $101.46 $118.15 $139.00 $139.00 100% of Medicare 100% of Medicare $139.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoclopramide 5 mg/mL Inj Sol 00409-3414-01 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 200% of Medicare 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL MetroNIDAZOLE Inj 500mg in Sodium 00338-1055-48 INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $60.42 $72.96 $94.08 $94.08 200% of Medicare 100% of Medicare $76.65 $73.78 $71.85 $81.92 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $76.16 $76.16 $60.42 $128.00 100% of Medicare $102.40 $108.80 $115.20 $93.43 $108.80 $128.00 $128.00 100% of Medicare 100% of Medicare $128.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL micafungin 100 mg IV Inj 00469-3211-10 INSTITUTIONAL $393.00 1/1/2022-12/31/2022 $393.00 $185.50 $224.01 $288.86 $288.86 200% of Medicare 100% of Medicare $235.33 $226.53 $220.59 $251.52 100% of Medicaid 100% of Medicare 150% of Medicare $314.40 $393.00 195% of Medicare $318.33 $233.84 $233.84 $185.50 $393.00 100% of Medicare $314.40 $334.05 $353.70 $286.85 $334.05 $393.00 $393.00 100% of Medicare 100% of Medicare $393.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL midazolam 1 mg/mL preservative-fre 00409-2305-17 INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $39.18 $47.31 $61.01 $61.01 200% of Medicare 100% of Medicare $49.70 $47.84 $46.59 $53.12 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $49.39 $49.39 $39.18 $83.00 100% of Medicare $66.40 $70.55 $74.70 $60.58 $70.55 $83.00 $83.00 100% of Medicare 100% of Medicare $83.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL midazolam 5 mg/mL Inj Sol 63323-0412-25 INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 200% of Medicare 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL morphine 10 mg/mL Inj Sol 00409-1893-01 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL morphine 4 mg/mL Inj Sol 00409-1891-01 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nafcillin 2 g Inj 00781-3125-95 INSTITUTIONAL $119.00 1/1/2022-12/31/2022 $119.00 $56.17 $67.83 $87.47 $87.47 200% of Medicare 100% of Medicare $71.26 $68.59 $66.79 $76.16 100% of Medicaid 100% of Medicare 150% of Medicare $95.20 $119.00 195% of Medicare $96.39 $70.81 $70.81 $56.17 $119.00 100% of Medicare $95.20 $101.15 $107.10 $86.86 $101.15 $119.00 $119.00 100% of Medicare 100% of Medicare $119.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL naloxone 0.4 mg/mL Inj Sol 00409-1215-01 INSTITUTIONAL $144.00 1/1/2022-12/31/2022 $144.00 $67.97 $82.08 $105.84 $105.84 200% of Medicare 100% of Medicare $86.23 $83.00 $80.83 $92.16 100% of Medicaid 100% of Medicare 150% of Medicare $115.20 $144.00 195% of Medicare $116.64 $85.68 $85.68 $67.97 $144.00 100% of Medicare $115.20 $122.40 $129.60 $105.11 $122.40 $144.00 $144.00 100% of Medicare 100% of Medicare $144.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL octreotide 100 mcg/mL Inj Sol 62756-0349-44 INSTITUTIONAL $95.00 1/1/2022-12/31/2022 $95.00 $44.84 $54.15 $69.83 $69.83 200% of Medicare 100% of Medicare $56.89 $54.76 $53.32 $60.80 100% of Medicaid 100% of Medicare 150% of Medicare $76.00 $95.00 195% of Medicare $76.95 $56.53 $56.53 $44.84 $95.00 100% of Medicare $76.00 $80.75 $85.50 $69.34 $80.75 $95.00 $95.00 100% of Medicare 100% of Medicare $95.00 200% of Medicare NULL 250 NULL NULL NULL J2354 NULL octreotide 50 mcg/mL Inj Sol 00078-0180-03 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $9.20 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $12.94 $12.45 $12.13 $9.20 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $12.87 $12.87 $10.38 $14.15 100% of Medicare $17.60 $18.70 $17.27 $16.06 $17.60 $18.70 $15.13 100% of Medicare 100% of Medicare $16.50 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ondansetron Inj 2 mg/mL 2 mL (UD) 00781-3010-95 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pantoprazole 40 mg IV Inj 00008-0923-55 INSTITUTIONAL $95.00 1/1/2022-12/31/2022 $95.00 $44.84 $54.15 $69.83 $69.83 200% of Medicare 100% of Medicare $56.89 $54.76 $53.32 $60.80 100% of Medicaid 100% of Medicare 150% of Medicare $76.00 $95.00 195% of Medicare $76.95 $56.53 $56.53 $44.84 $95.00 100% of Medicare $76.00 $80.75 $85.50 $69.34 $80.75 $95.00 $95.00 100% of Medicare 100% of Medicare $95.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phytonadione 10 mg/mL Inj Sol 00409-9158-01 INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $53.81 $64.98 $83.79 $83.79 200% of Medicare 100% of Medicare $68.26 $65.71 $63.99 $72.96 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $67.83 $67.83 $53.81 $114.00 100% of Medicare $91.20 $96.90 $102.60 $83.21 $96.90 $114.00 $114.00 100% of Medicare 100% of Medicare $114.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Piperacillin/Tazobactam 3.375 GM A 00409-3378-13 INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $26.90 $32.49 $41.90 $41.90 200% of Medicare 100% of Medicare $34.13 $32.85 $31.99 $36.48 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.92 $33.92 $26.90 $57.00 100% of Medicare $45.60 $48.45 $51.30 $41.60 $48.45 $57.00 $57.00 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium chloride 2 mEq/mL IV Sol 00409-6651-06 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium chloride 2 mEq/mL IV Sol 00409-6653-05 INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $20.77 $25.08 $32.34 $32.34 200% of Medicare 100% of Medicare $26.35 $25.36 $24.70 $28.16 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $26.18 $26.18 $20.77 $44.00 100% of Medicare $35.20 $37.40 $39.60 $32.12 $37.40 $44.00 $44.00 100% of Medicare 100% of Medicare $44.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL promethazine 25 mg/mL Inj Sol 00641-0928-25 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 200% of Medicare 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ropivacaine 0.2% Inj Sol 20 mL 63323-0285-20 INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $52.86 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $67.07 $64.56 $62.87 $71.68 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $66.64 $66.64 $52.86 $112.00 100% of Medicare $89.60 $95.20 $100.80 $81.75 $95.20 $112.00 $112.00 100% of Medicare 100% of Medicare $112.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium ferric gluconate complex 12 52544-0922-26 INSTITUTIONAL $216.00 1/1/2022-12/31/2022 $216.00 $101.95 $123.12 $158.76 $158.76 200% of Medicare 100% of Medicare $129.34 $124.50 $121.24 $138.24 100% of Medicaid 100% of Medicare 150% of Medicare $172.80 $216.00 195% of Medicare $174.96 $128.52 $128.52 $101.95 $216.00 100% of Medicare $172.80 $183.60 $194.40 $157.66 $183.60 $216.00 $216.00 100% of Medicare 100% of Medicare $216.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium bicarbonate 8.4% IV Sol 50 00409-6637-34 INSTITUTIONAL $62.00 1/1/2022-12/31/2022 $62.00 $29.26 $35.34 $45.57 $45.57 200% of Medicare 100% of Medicare $37.13 $35.74 $34.80 $39.68 100% of Medicaid 100% of Medicare 150% of Medicare $49.60 $62.00 195% of Medicare $50.22 $36.89 $36.89 $29.26 $62.00 100% of Medicare $49.60 $52.70 $55.80 $45.25 $52.70 $62.00 $62.00 100% of Medicare 100% of Medicare $62.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% with KCl 20 m 00338-0691-04 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 200% of Medicare 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% IV Sol 100 mL 00338-0049-18 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% IV Sol 100 mL 00338-0553-18 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% IV Sol 1000 m 00338-0049-04 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% IV Sol 50 mL 00338-0049-11 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% IV Sol 500 mL 00338-0049-03 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride bacteriostatic 0.9 00409-1966-07 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride 0.9% Inj Sol 10 mL 00409-4888-10 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium phosphate 3 mmol/mL Inj Sol 00409-7391-72 INSTITUTIONAL $242.00 1/1/2022-12/31/2022 $242.00 $114.22 $137.94 $177.87 $177.87 200% of Medicare 100% of Medicare $144.91 $139.49 $135.83 $154.88 100% of Medicaid 100% of Medicare 150% of Medicare $193.60 $242.00 195% of Medicare $196.02 $143.99 $143.99 $114.22 $242.00 100% of Medicare $193.60 $205.70 $217.80 $176.64 $205.70 $242.00 $242.00 100% of Medicare 100% of Medicare $242.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sterile Water Inj Bact 30 mL 00409-3977-03 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL testosterone cypionate 200 mg/mL I 00009-0417-01 INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL vancomycin 1 g IV Inj 00409-6533-01 INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $100.06 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $126.95 $122.20 $119.00 $135.68 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $126.14 $126.14 $100.06 $212.00 100% of Medicare $169.60 $180.20 $190.80 $154.74 $180.20 $212.00 $212.00 100% of Medicare 100% of Medicare $212.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL vancomycin 1 g IV Inj 00409-6535-01 INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $72.69 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $92.22 $88.77 $86.44 $98.56 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $91.63 $91.63 $72.69 $154.00 100% of Medicare $123.20 $130.90 $138.60 $112.40 $130.90 $154.00 $154.00 100% of Medicare 100% of Medicare $154.00 200% of Medicare NULL 250 NULL NULL NULL J3370 NULL vancomycin 500 mg IV Inj 00074-4332-49 INSTITUTIONAL $100.00 1/1/2022-12/31/2022 $100.00 $41.80 $57.00 $73.50 $73.50 200% of Medicare 100% of Medicare $58.81 $56.61 $55.13 $41.80 100% of Medicaid 100% of Medicare 150% of Medicare $80.00 $100.00 195% of Medicare $81.00 $58.50 $58.50 $47.20 $64.34 100% of Medicare $80.00 $85.00 $78.50 $72.99 $80.00 $85.00 $68.75 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 636 NULL NULL NULL NULL NULL zoledronic acid 5 mg/100 mL IV Sol 00078-0435-61 INSTITUTIONAL " $2,238.00 " 1/1/2022-12/31/2022 " $2,238.00 " $975.00 " $1,275.66 " " $1,644.93 " " $1,644.93 " 200% of Medicare 100% of Medicare " $1,340.11 " " $1,289.98 " " $1,256.19 " " $1,432.32 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,790.40 " " $1,500.00 " 195% of Medicare " $1,812.78 " " $1,331.61 " " $1,331.61 " " $1,056.34 " " $1,359.00 " 100% of Medicare " $1,790.40 " " $1,902.30 " " $2,014.20 " " $1,633.52 " " $1,902.30 " " $1,500.00 " " $2,238.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride nasal 0.65% Gel 00225-0525-47 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride Nasal 0.65% Spry 00904-3865-75 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atropine Opth 1% Sol 24208-0750-60 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL azithromycin Opth 1% Sol 31357-0040-25 INSTITUTIONAL $391.00 1/1/2022-12/31/2022 $391.00 $184.55 $222.87 $287.39 $287.39 200% of Medicare 100% of Medicare $234.13 $225.37 $219.47 $250.24 100% of Medicaid 100% of Medicare 150% of Medicare $312.80 $391.00 195% of Medicare $316.71 $232.65 $232.65 $184.55 $391.00 100% of Medicare $312.80 $332.35 $351.90 $285.39 $332.35 $391.00 $391.00 100% of Medicare 100% of Medicare $391.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bacitracin Opth 500 units/g Oint 48102-0007-35 INSTITUTIONAL $271.00 1/1/2022-12/31/2022 $271.00 $127.91 $154.47 $199.19 $199.19 200% of Medicare 100% of Medicare $162.27 $156.20 $152.11 $173.44 100% of Medicaid 100% of Medicare 150% of Medicare $216.80 $271.00 195% of Medicare $219.51 $161.25 $161.25 $127.91 $271.00 100% of Medicare $216.80 $230.35 $243.90 $197.80 $230.35 $271.00 $271.00 100% of Medicare 100% of Medicare $271.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bacitracin/neomycin/polymyxin B Op 17478-0235-35 INSTITUTIONAL $194.00 1/1/2022-12/31/2022 $194.00 $91.57 $110.58 $142.59 $142.59 200% of Medicare 100% of Medicare $116.17 $111.82 $108.89 $124.16 100% of Medicaid 100% of Medicare 150% of Medicare $155.20 $194.00 195% of Medicare $157.14 $115.43 $115.43 $91.57 $194.00 100% of Medicare $155.20 $164.90 $174.60 $141.60 $164.90 $194.00 $194.00 100% of Medicare 100% of Medicare $194.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bacitracin-polymyxin B Opth Oint 17478-0238-35 INSTITUTIONAL $34.00 1/1/2022-12/31/2022 $34.00 $16.05 $19.38 $24.99 $24.99 200% of Medicare 100% of Medicare $20.36 $19.60 $19.08 $21.76 100% of Medicaid 100% of Medicare 150% of Medicare $27.20 $34.00 195% of Medicare $27.54 $20.23 $20.23 $16.05 $34.00 100% of Medicare $27.20 $28.90 $30.60 $24.82 $28.90 $34.00 $34.00 100% of Medicare 100% of Medicare $34.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL betaxolol Opth 0.5% Sol 17478-0705-10 INSTITUTIONAL $222.00 1/1/2022-12/31/2022 $222.00 $104.78 $126.54 $163.17 $163.17 200% of Medicare 100% of Medicare $132.93 $127.96 $124.61 $142.08 100% of Medicaid 100% of Medicare 150% of Medicare $177.60 $222.00 195% of Medicare $179.82 $132.09 $132.09 $104.78 $222.00 100% of Medicare $177.60 $188.70 $199.80 $162.04 $188.70 $222.00 $222.00 100% of Medicare 100% of Medicare $222.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bimatoprost 0.03% Opth Sol 00023-9187-03 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL brimonidine Opth 0.2% Sol 17478-0715-10 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL brinzolamide Opth 1% Susp 00065-0275-10 INSTITUTIONAL " $1,150.00 " 1/1/2022-12/31/2022 " $1,150.00 " $542.80 $655.50 $845.25 $845.25 200% of Medicare 100% of Medicare $688.62 $662.86 $645.50 $736.00 100% of Medicaid 100% of Medicare 150% of Medicare $920.00 " $1,150.00 " 195% of Medicare $931.50 $684.25 $684.25 $542.80 " $1,150.00 " 100% of Medicare $920.00 $977.50 " $1,035.00 " $839.39 $977.50 " $1,150.00 " " $1,150.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ciprofloxacin Opth 0.3% Sol 50383-0282-02 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cyclopentolate Opth 2% Sol 00065-0397-02 INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $72.69 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $92.22 $88.77 $86.44 $98.56 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $91.63 $91.63 $72.69 $154.00 100% of Medicare $123.20 $130.90 $138.60 $112.40 $130.90 $154.00 $154.00 100% of Medicare 100% of Medicare $154.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cycloSPORINE Opth 0.05% Emul 00023-9163-30 INSTITUTIONAL $979.00 1/1/2022-12/31/2022 $979.00 $462.09 $558.03 $719.57 $719.57 200% of Medicare 100% of Medicare $586.23 $564.30 $549.51 $626.56 100% of Medicaid 100% of Medicare 150% of Medicare $783.20 $979.00 195% of Medicare $792.99 $582.51 $582.51 $462.09 $979.00 100% of Medicare $783.20 $832.15 $881.10 $714.57 $832.15 $979.00 $979.00 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone Opth 0.1% Susp 00998-0615-05 INSTITUTIONAL $221.00 1/1/2022-12/31/2022 $221.00 $104.31 $125.97 $162.44 $162.44 200% of Medicare 100% of Medicare $132.33 $127.38 $124.05 $141.44 100% of Medicaid 100% of Medicare 150% of Medicare $176.80 $221.00 195% of Medicare $179.01 $131.50 $131.50 $104.31 $221.00 100% of Medicare $176.80 $187.85 $198.90 $161.31 $187.85 $221.00 $221.00 100% of Medicare 100% of Medicare $221.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone/neomycin/polymyxin B 61314-0631-36 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diclofenac Opth 0.1% Sol 17478-0892-25 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dorzolamide Opth 2% Sol 00093-7618-43 INSTITUTIONAL $152.00 1/1/2022-12/31/2022 $152.00 $71.74 $86.64 $111.72 $111.72 200% of Medicare 100% of Medicare $91.02 $87.61 $85.32 $97.28 100% of Medicaid 100% of Medicare 150% of Medicare $121.60 $152.00 195% of Medicare $123.12 $90.44 $90.44 $71.74 $152.00 100% of Medicare $121.60 $129.20 $136.80 $110.94 $129.20 $152.00 $152.00 100% of Medicare 100% of Medicare $152.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dorzolamide-timolol Opth 2%-0.5% S 50383-0233-10 INSTITUTIONAL $807.00 1/1/2022-12/31/2022 $807.00 $380.90 $459.99 $593.15 $593.15 200% of Medicare 100% of Medicare $483.23 $465.15 $452.97 $516.48 100% of Medicaid 100% of Medicare 150% of Medicare $645.60 $807.00 195% of Medicare $653.67 $480.17 $480.17 $380.90 $807.00 100% of Medicare $645.60 $685.95 $726.30 $589.03 $685.95 $807.00 $807.00 100% of Medicare 100% of Medicare $807.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gentamicin Opth 0.3% Sol 17478-0283-10 INSTITUTIONAL $73.00 1/1/2022-12/31/2022 $73.00 $34.46 $41.61 $53.66 $53.66 200% of Medicare 100% of Medicare $43.71 $42.08 $40.97 $46.72 100% of Medicaid 100% of Medicare 150% of Medicare $58.40 $73.00 195% of Medicare $59.13 $43.44 $43.44 $34.46 $73.00 100% of Medicare $58.40 $62.05 $65.70 $53.28 $62.05 $73.00 $73.00 100% of Medicare 100% of Medicare $73.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ketorolac Opth 0.5% Sol 17478-0209-10 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL latanoprost Opth 0.005% Sol 00517-0830-01 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levobunolol Opth 0.5% Sol 24208-0505-05 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL loteprednol Opth 0.5% Susp 24208-0299-05 INSTITUTIONAL $523.00 1/1/2022-12/31/2022 $523.00 $246.86 $298.11 $384.41 $384.41 200% of Medicare 100% of Medicare $313.17 $301.46 $293.56 $334.72 100% of Medicaid 100% of Medicare 150% of Medicare $418.40 $523.00 195% of Medicare $423.63 $311.19 $311.19 $246.86 $523.00 100% of Medicare $418.40 $444.55 $470.70 $381.74 $444.55 $523.00 $523.00 100% of Medicare 100% of Medicare $523.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL moxifloxacin 0.5% Opth Sol 00065-4013-03 INSTITUTIONAL $628.00 1/1/2022-12/31/2022 $628.00 $296.42 $357.96 $461.58 $461.58 200% of Medicare 100% of Medicare $376.05 $361.98 $352.50 $401.92 100% of Medicaid 100% of Medicare 150% of Medicare $502.40 $628.00 195% of Medicare $508.68 $373.66 $373.66 $296.42 $628.00 100% of Medicare $502.40 $533.80 $565.20 $458.38 $533.80 $628.00 $628.00 100% of Medicare 100% of Medicare $628.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Natural Tears 00065-0416-25 INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $25.02 $30.21 $38.96 $38.96 200% of Medicare 100% of Medicare $31.74 $30.55 $29.75 $33.92 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.54 $31.54 $25.02 $53.00 100% of Medicare $42.40 $45.05 $47.70 $38.68 $45.05 $53.00 $53.00 100% of Medicare 100% of Medicare $53.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nepafenac Opth 0.1% Susp 00065-0002-03 INSTITUTIONAL $614.00 1/1/2022-12/31/2022 $614.00 $289.81 $349.98 $451.29 $451.29 200% of Medicare 100% of Medicare $367.66 $353.91 $344.64 $392.96 100% of Medicaid 100% of Medicare 150% of Medicare $491.20 $614.00 195% of Medicare $497.34 $365.33 $365.33 $289.81 $614.00 100% of Medicare $491.20 $521.90 $552.60 $448.16 $521.90 $614.00 $614.00 100% of Medicare 100% of Medicare $614.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ocular lubricant Sol 00065-0431-32 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ocular lubricant preserved Sol 00904-5017-35 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ofloxacin Opth 0.3% Sol 24208-0434-05 INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 200% of Medicare 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL olopatadine Opth 0.1% Sol 00065-0271-05 INSTITUTIONAL $791.00 1/1/2022-12/31/2022 $791.00 $373.35 $450.87 $581.39 $581.39 200% of Medicare 100% of Medicare $473.65 $455.93 $443.99 $506.24 100% of Medicaid 100% of Medicare 150% of Medicare $632.80 $791.00 195% of Medicare $640.71 $470.65 $470.65 $373.35 $791.00 100% of Medicare $632.80 $672.35 $711.90 $577.35 $672.35 $791.00 $791.00 100% of Medicare 100% of Medicare $791.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL polymyxin B-trimethoprim Opth Sol 24208-0315-10 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 200% of Medicare 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL prednisoLONE Opth acetate 1% Susp 61314-0637-05 INSTITUTIONAL $184.00 1/1/2022-12/31/2022 $184.00 $86.85 $104.88 $135.24 $135.24 200% of Medicare 100% of Medicare $110.18 $106.06 $103.28 $117.76 100% of Medicaid 100% of Medicare 150% of Medicare $147.20 $184.00 195% of Medicare $149.04 $109.48 $109.48 $86.85 $184.00 100% of Medicare $147.20 $156.40 $165.60 $134.30 $156.40 $184.00 $184.00 100% of Medicare 100% of Medicare $184.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL prednisoLONE Opth sodium phosphate 24208-0715-10 INSTITUTIONAL $184.00 1/1/2022-12/31/2022 $184.00 $86.85 $104.88 $135.24 $135.24 200% of Medicare 100% of Medicare $110.18 $106.06 $103.28 $117.76 100% of Medicaid 100% of Medicare 150% of Medicare $147.20 $184.00 195% of Medicare $149.04 $109.48 $109.48 $86.85 $184.00 100% of Medicare $147.20 $156.40 $165.60 $134.30 $156.40 $184.00 $184.00 100% of Medicare 100% of Medicare $184.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "sodium chloride, hypertonic, Opth" 24208-0276-15 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sulfacetamide Ophth Soln 10% 15 mL 61314-0701-01 INSTITUTIONAL $196.00 1/1/2022-12/31/2022 $196.00 $92.51 $111.72 $144.06 $144.06 200% of Medicare 100% of Medicare $117.36 $112.97 $110.01 $125.44 100% of Medicaid 100% of Medicare 150% of Medicare $156.80 $196.00 195% of Medicare $158.76 $116.62 $116.62 $92.51 $196.00 100% of Medicare $156.80 $166.60 $176.40 $143.06 $166.60 $196.00 $196.00 100% of Medicare 100% of Medicare $196.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tetrahydrozoline Opth 0.05% Sol 00904-2992-35 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL timolol Opth 0.25% Gel forming Sol 61314-0224-05 INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $65.14 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $82.63 $79.54 $77.46 $88.32 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $82.11 $82.11 $65.14 $138.00 100% of Medicare $110.40 $117.30 $124.20 $100.73 $117.30 $138.00 $138.00 100% of Medicare 100% of Medicare $138.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL timolol Opth 0.5% Gel forming Sol 61314-0225-05 INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $75.99 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $96.41 $92.80 $90.37 $103.04 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $95.80 $95.80 $75.99 $161.00 100% of Medicare $128.80 $136.85 $144.90 $117.51 $136.85 $161.00 $161.00 100% of Medicare 100% of Medicare $161.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL timolol Opth 0.25% Sol 61314-0226-05 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tobramycin Opth 0.3% Sol 24208-0290-05 INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL chlorhexidine Top 0.12% Liq 480 mL 00116-2001-16 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Cyclosporin 100 mg/ml 00591-2224-55 INSTITUTIONAL $543.00 1/1/2022-12/31/2022 $543.00 $256.30 $309.51 $399.11 $399.11 200% of Medicare 100% of Medicare $325.15 $312.99 $304.79 $347.52 100% of Medicaid 100% of Medicare 150% of Medicare $434.40 $543.00 195% of Medicare $439.83 $323.09 $323.09 $256.30 $543.00 100% of Medicare $434.40 $461.55 $488.70 $396.34 $461.55 $543.00 $543.00 100% of Medicare 100% of Medicare $543.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Guaifenesin Soln 100 mg/5 mL Bottl 00603-0857-94 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Mycophenolate Mofetil 200mg/ml 00004-0261-29 INSTITUTIONAL " $5,770.00 " 1/1/2022-12/31/2022 " $5,193.00 " $975.00 " $3,288.90 " " $4,240.95 " " $4,240.95 " 200% of Medicare 100% of Medicare " $3,455.08 " " $3,325.83 " " $3,238.70 " " $3,692.80 " 100% of Medicaid 100% of Medicare 150% of Medicare " $4,616.00 " " $1,500.00 " 195% of Medicare " $4,673.70 " " $3,433.15 " " $3,433.15 " " $2,723.44 " " $1,359.00 " 100% of Medicare " $4,616.00 " " $4,904.50 " " $5,193.00 " " $4,211.52 " " $4,904.50 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Opium Tincture (USP) per Drop 62559-0153-04 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL polyethylene glycol 3350 with elec 62175-0446-01 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Propranolol HCL 20mg/5ml 00054-3727-63 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetylcysteine 10% Inh Sol 10 mL 00054-3027-02 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetic acid Otic 2% Sol 00603-7038-41 INSTITUTIONAL $115.00 1/1/2022-12/31/2022 $115.00 $54.28 $65.55 $84.53 $84.53 200% of Medicare 100% of Medicare $68.86 $66.29 $64.55 $73.60 100% of Medicaid 100% of Medicare 150% of Medicare $92.00 $115.00 195% of Medicare $93.15 $68.43 $68.43 $54.28 $115.00 100% of Medicare $92.00 $97.75 $103.50 $83.94 $97.75 $115.00 $115.00 100% of Medicare 100% of Medicare $115.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL antipyrine-benzocaine Otic Sol 24208-0561-62 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbamide peroxide Otic 6.5% Sol 00904-3220-35 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ciprofloxacin-dexamethasone 0.3%-0 00065-8533-02 INSTITUTIONAL $843.00 1/1/2022-12/31/2022 $843.00 $397.90 $480.51 $619.61 $619.61 200% of Medicare 100% of Medicare $504.79 $485.91 $473.18 $539.52 100% of Medicaid 100% of Medicare 150% of Medicare $674.40 $843.00 195% of Medicare $682.83 $501.59 $501.59 $397.90 $843.00 100% of Medicare $674.40 $716.55 $758.70 $615.31 $716.55 $843.00 $843.00 100% of Medicare 100% of Medicare $843.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ciprofloxacin-hydrocortisone Otic 00065-8531-10 INSTITUTIONAL " $1,235.00 " 1/1/2022-12/31/2022 " $1,235.00 " $582.92 $703.95 $907.73 $907.73 200% of Medicare 100% of Medicare $739.52 $711.85 $693.21 $790.40 100% of Medicaid 100% of Medicare 150% of Medicare $988.00 " $1,235.00 " 195% of Medicare " $1,000.35 " $734.83 $734.83 $582.92 " $1,235.00 " 100% of Medicare $988.00 " $1,049.75 " " $1,111.50 " $901.43 " $1,049.75 " " $1,235.00 " " $1,235.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone/neomycin/polymyxin 61314-0646-10 INSTITUTIONAL $106.00 1/1/2022-12/31/2022 $106.00 $50.03 $60.42 $77.91 $77.91 200% of Medicare 100% of Medicare $63.47 $61.10 $59.50 $67.84 100% of Medicaid 100% of Medicare 150% of Medicare $84.80 $106.00 195% of Medicare $85.86 $63.07 $63.07 $50.03 $106.00 100% of Medicare $84.80 $90.10 $95.40 $77.37 $90.10 $106.00 $106.00 100% of Medicare 100% of Medicare $106.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ofloxacin Otic 0.3% Sol 24208-0410-05 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Acetic Acid 0.25% 00409-6143-09 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Emollient/Skin Cleanser(Cetaphil) 00299-3921-08 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 200% of Medicare 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL balsam Peru/castor oil/trypsin top 51079-0621-82 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcitonin 200 intl units/inh Nasa 60505-0823-06 INSTITUTIONAL $213.00 1/1/2022-12/31/2022 $213.00 $100.54 $121.41 $156.56 $156.56 200% of Medicare 100% of Medicare $127.54 $122.77 $119.56 $136.32 100% of Medicaid 100% of Medicare 150% of Medicare $170.40 $213.00 195% of Medicare $172.53 $126.74 $126.74 $100.54 $213.00 100% of Medicare $170.40 $181.05 $191.70 $155.47 $181.05 $213.00 $213.00 100% of Medicare 100% of Medicare $213.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cromolyn Nasal 5.2 mg/inh Spry 52183-0199-13 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL desmopressin 10 mcg/inh Nasal Spry 24208-0342-05 INSTITUTIONAL $430.00 1/1/2022-12/31/2022 $430.00 $202.96 $245.10 $316.05 $316.05 200% of Medicare 100% of Medicare $257.48 $247.85 $241.36 $275.20 100% of Medicaid 100% of Medicare 150% of Medicare $344.00 $430.00 195% of Medicare $348.30 $255.85 $255.85 $202.96 $430.00 100% of Medicare $344.00 $365.50 $387.00 $313.86 $365.50 $430.00 $430.00 100% of Medicare 100% of Medicare $430.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone Nasal 0.05 mg/inh Spry 60505-0829-01 INSTITUTIONAL $84.00 1/1/2022-12/31/2022 $84.00 $39.65 $47.88 $61.74 $61.74 200% of Medicare 100% of Medicare $50.30 $48.42 $47.15 $53.76 100% of Medicaid 100% of Medicare 150% of Medicare $67.20 $84.00 195% of Medicare $68.04 $49.98 $49.98 $39.65 $84.00 100% of Medicare $67.20 $71.40 $75.60 $61.31 $71.40 $84.00 $84.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ipratropium Nasal 0.06% Spry 00054-0046-41 INSTITUTIONAL $73.00 1/1/2022-12/31/2022 $73.00 $34.46 $41.61 $53.66 $53.66 200% of Medicare 100% of Medicare $43.71 $42.08 $40.97 $46.72 100% of Medicaid 100% of Medicare 150% of Medicare $58.40 $73.00 195% of Medicare $59.13 $43.44 $43.44 $34.46 $73.00 100% of Medicare $58.40 $62.05 $65.70 $53.28 $62.05 $73.00 $73.00 100% of Medicare 100% of Medicare $73.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nitroglycerin 0.4 mg SubL Spry 52536-0300-20 INSTITUTIONAL $768.00 1/1/2022-12/31/2022 $768.00 $362.50 $437.76 $564.48 $564.48 200% of Medicare 100% of Medicare $459.88 $442.68 $431.08 $491.52 100% of Medicaid 100% of Medicare 150% of Medicare $614.40 $768.00 195% of Medicare $622.08 $456.96 $456.96 $362.50 $768.00 100% of Medicare $614.40 $652.80 $691.20 $560.56 $652.80 $768.00 $768.00 100% of Medicare 100% of Medicare $768.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxymetazoline Nasal 0.05% Spry 00904-5711-35 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenylephrine Nasal 0.5% Spry 00024-1353-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Silver Nitrate Applicator 12870-0001-02 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen 650 mg Supp 45802-0730-30 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bisacodyl 10 mg Supp 00713-0109-01 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Glycerin Adult Supp 00713-0101-26 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenylephrine Top 0.25% Supp 00904-7688-22 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone 25 mg Supp 00713-0503-12 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL miconazole 100 mg Vag Supp 00713-0197-57 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL miconazole 200 mg Vag Supp 00472-1738-03 INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 200% of Medicare 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL prochlorperazine 25 mg Supp 00713-0135-12 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL promethazine 25 mg Supp 00574-7234-12 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Terconazole 80 mg 45802-0717-08 INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $73.16 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $92.81 $89.34 $87.00 $99.20 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $92.23 $92.23 $73.16 $155.00 100% of Medicare $124.00 $131.75 $139.50 $113.13 $131.75 $155.00 $155.00 100% of Medicare 100% of Medicare $155.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen 80 mg/0.8 mL Oral Su 00904-5255-35 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atovaquone 750 mg/5 mL Oral Susp 00173-0547-00 INSTITUTIONAL " $1,346.00 " 1/1/2022-12/31/2022 " $1,346.00 " $635.31 $767.22 $989.31 $989.31 200% of Medicare 100% of Medicare $805.98 $775.83 $755.51 $861.44 100% of Medicaid 100% of Medicare 150% of Medicare " $1,076.80 " " $1,346.00 " 195% of Medicare " $1,090.26 " $800.87 $800.87 $635.31 " $1,346.00 " 100% of Medicare " $1,076.80 " " $1,144.10 " " $1,211.40 " $982.45 " $1,144.10 " " $1,346.00 " " $1,346.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL budesonide 0.25 mg/2 mL Inh Susp 00093-6815-73 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL budesonide 0.5 mg/2 mL Inh Susp 00093-6816-73 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbamazepine 100 mg/5 mL Oral Sus 51672-4047-09 INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $33.04 $39.90 $51.45 $51.45 200% of Medicare 100% of Medicare $41.92 $40.35 $39.29 $44.80 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $41.65 $41.65 $33.04 $70.00 100% of Medicare $56.00 $59.50 $63.00 $51.09 $59.50 $70.00 $70.00 100% of Medicare 100% of Medicare $70.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ibuprofen 100 mg/5 mL Oral Susp 00904-5309-20 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "influenza virus vaccine, inactivat" 58160-0879-52 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL medroxyPROGESTERone 150 mg/mL IM S 00009-0746-30 INSTITUTIONAL $199.00 1/1/2022-12/31/2022 $199.00 $93.93 $113.43 $146.27 $146.27 200% of Medicare 100% of Medicare $119.16 $114.70 $111.70 $127.36 100% of Medicaid 100% of Medicare 150% of Medicare $159.20 $199.00 195% of Medicare $161.19 $118.41 $118.41 $93.93 $199.00 100% of Medicare $159.20 $169.15 $179.10 $145.25 $169.15 $199.00 $199.00 100% of Medicare 100% of Medicare $199.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL megestrol 40 mg/mL Oral Susp 00054-3542-58 INSTITUTIONAL $67.00 1/1/2022-12/31/2022 $67.00 $31.62 $38.19 $49.25 $49.25 200% of Medicare 100% of Medicare $40.12 $38.62 $37.61 $42.88 100% of Medicaid 100% of Medicare 150% of Medicare $53.60 $67.00 195% of Medicare $54.27 $39.87 $39.87 $31.62 $67.00 100% of Medicare $53.60 $56.95 $60.30 $48.90 $56.95 $67.00 $67.00 100% of Medicare 100% of Medicare $67.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylPREDNISolone 40 mg/mL Inj Su 00009-3073-03 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylPREDNISolone 80 mg/mL Inj Su 00009-3475-03 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 200% of Medicare 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "nystatin 100,000 units/mL Oral Sus" 51672-4117-04 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenytoin 125 mg/5 mL Oral Susp 51672-4069-01 INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $50.50 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $64.07 $61.67 $60.06 $68.48 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $63.67 $63.67 $50.50 $107.00 100% of Medicare $85.60 $90.95 $96.30 $78.10 $90.95 $107.00 $107.00 100% of Medicare 100% of Medicare $107.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pneumococcal 13-valent conjugate v 00005-1971-02 INSTITUTIONAL $392.00 1/1/2022-12/31/2022 $392.00 $185.02 $223.44 $288.12 $288.12 200% of Medicare 100% of Medicare $234.73 $225.95 $220.03 $250.88 100% of Medicaid 100% of Medicare 150% of Medicare $313.60 $392.00 195% of Medicare $317.52 $233.24 $233.24 $185.02 $392.00 100% of Medicare $313.60 $333.20 $352.80 $286.12 $333.20 $392.00 $392.00 100% of Medicare 100% of Medicare $392.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium polystyrene sulfonate 15 g/ 46287-0006-01 INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 200% of Medicare 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL spinosad topical 0.9% Susp 52246-0929-04 INSTITUTIONAL $843.00 1/1/2022-12/31/2022 $843.00 $397.90 $480.51 $619.61 $619.61 200% of Medicare 100% of Medicare $504.79 $485.91 $473.18 $539.52 100% of Medicaid 100% of Medicare 150% of Medicare $674.40 $843.00 195% of Medicare $682.83 $501.59 $501.59 $397.90 $843.00 100% of Medicare $674.40 $716.55 $758.70 $615.31 $716.55 $843.00 $843.00 100% of Medicare 100% of Medicare $843.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sucralfate 1 g/10 mL Oral Susp 58914-0170-14 INSTITUTIONAL $183.00 1/1/2022-12/31/2022 $183.00 $86.38 $104.31 $134.51 $134.51 200% of Medicare 100% of Medicare $109.58 $105.48 $102.72 $117.12 100% of Medicaid 100% of Medicare 150% of Medicare $146.40 $183.00 195% of Medicare $148.23 $108.89 $108.89 $86.38 $183.00 100% of Medicare $146.40 $155.55 $164.70 $133.57 $155.55 $183.00 $183.00 100% of Medicare 100% of Medicare $183.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sulfamethoxazole-trimethoprim 200 50383-0823-16 INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 200% of Medicare 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL triamcinolone acetonide 40 mg/mL I 00003-0293-05 INSTITUTIONAL $118.00 1/1/2022-12/31/2022 $118.00 $55.70 $67.26 $86.73 $86.73 200% of Medicare 100% of Medicare $70.66 $68.02 $66.23 $75.52 100% of Medicaid 100% of Medicare 150% of Medicare $94.40 $118.00 195% of Medicare $95.58 $70.21 $70.21 $55.70 $118.00 100% of Medicare $94.40 $100.30 $106.20 $86.13 $100.30 $118.00 $118.00 100% of Medicare 100% of Medicare $118.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Valganciclovir 50 mg/mL 00004-0039-09 INSTITUTIONAL " $3,122.00 " 1/1/2022-12/31/2022 " $2,809.80 " $975.00 " $1,779.54 " " $2,294.67 " " $2,294.67 " 200% of Medicare 100% of Medicare " $1,869.45 " " $1,799.52 " " $1,752.38 " " $1,998.08 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,497.60 " " $1,500.00 " 195% of Medicare " $2,528.82 " " $1,857.59 " " $1,857.59 " " $1,473.58 " " $1,359.00 " 100% of Medicare " $2,497.60 " " $2,653.70 " " $2,809.80 " " $2,278.75 " " $2,653.70 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dextromethorphan 30 mg/5 mL Oral S 63824-0172-65 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL betaxolol Opth 0.25% Susp 00065-0246-10 INSTITUTIONAL $702.00 1/1/2022-12/31/2022 $702.00 $331.34 $400.14 $515.97 $515.97 200% of Medicare 100% of Medicare $420.36 $404.63 $394.03 $449.28 100% of Medicaid 100% of Medicare 150% of Medicare $561.60 $702.00 195% of Medicare $568.62 $417.69 $417.69 $331.34 $702.00 100% of Medicare $561.60 $596.70 $631.80 $512.39 $596.70 $702.00 $702.00 100% of Medicare 100% of Medicare $702.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluorometholone Opth 0.1% Susp 60758-0880-05 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone-tobramycin Opth 0.1% 24208-0295-25 INSTITUTIONAL $176.00 1/1/2022-12/31/2022 $176.00 $83.07 $100.32 $129.36 $129.36 200% of Medicare 100% of Medicare $105.39 $101.45 $98.79 $112.64 100% of Medicaid 100% of Medicare 150% of Medicare $140.80 $176.00 195% of Medicare $142.56 $104.72 $104.72 $83.07 $176.00 100% of Medicare $140.80 $149.60 $158.40 $128.46 $149.60 $176.00 $176.00 100% of Medicare 100% of Medicare $176.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Aluminum/Magnesium/Simeth Susp 360 57896-0629-12 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amoxicillin 250 mg/5 mL Oral Liq 00781-6041-46 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amoxicillin-clavulanate 400 mg-57 00143-9982-01 INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $25.02 $30.21 $38.96 $38.96 200% of Medicare 100% of Medicare $31.74 $30.55 $29.75 $33.92 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.54 $31.54 $25.02 $53.00 100% of Medicare $42.40 $45.05 $47.70 $38.68 $45.05 $53.00 $53.00 100% of Medicare 100% of Medicare $53.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Bismuth Subsal 262 mg/15 mL Bottle 00904-1313-09 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cephalexin 250 mg/5 mL Oral Liq 00093-4177-73 INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 200% of Medicare 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL famotidine 40 mg/5 mL Oral Liq 68180-0150-01 INSTITUTIONAL $216.00 1/1/2022-12/31/2022 $216.00 $101.95 $123.12 $158.76 $158.76 200% of Medicare 100% of Medicare $129.34 $124.50 $121.24 $138.24 100% of Medicaid 100% of Medicare 150% of Medicare $172.80 $216.00 195% of Medicare $174.96 $128.52 $128.52 $101.95 $216.00 100% of Medicare $172.80 $183.60 $194.40 $157.66 $183.60 $216.00 $216.00 100% of Medicare 100% of Medicare $216.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Maalox 200/200/20mg 00536-1945-83 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL OXcarbazepine Susp 60 mg/mL Bottle 00078-0357-52 INSTITUTIONAL $564.00 1/1/2022-12/31/2022 $564.00 $266.21 $321.48 $414.54 $414.54 200% of Medicare 100% of Medicare $337.72 $325.09 $316.57 $360.96 100% of Medicaid 100% of Medicare 150% of Medicare $451.20 $564.00 195% of Medicare $456.84 $335.58 $335.58 $266.21 $564.00 100% of Medicare $451.20 $479.40 $507.60 $411.66 $479.40 $564.00 $564.00 100% of Medicare 100% of Medicare $564.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL voriconazole 40 mg/mL Oral Liq 00049-3160-44 INSTITUTIONAL " $3,529.00 " 1/1/2022-12/31/2022 " $3,176.10 " $975.00 " $2,011.53 " " $2,593.82 " " $2,593.82 " 200% of Medicare 100% of Medicare " $2,113.17 " " $2,034.12 " " $1,980.83 " " $2,258.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,823.20 " " $1,500.00 " 195% of Medicare " $2,858.49 " " $2,099.76 " " $2,099.76 " " $1,665.69 " " $1,359.00 " 100% of Medicare " $2,823.20 " " $2,999.65 " " $3,176.10 " " $2,575.82 " " $2,999.65 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% 00409-1078-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amantadine 50 mg/5 mL Oral Syrup 00121-0646-16 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ascorbic Acid 500mg/5ml 50383-0167-16 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cetirizine 1 mg/mL Oral Syrup 00093-6300-16 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL codeine-guaifenesin 10 mg-100 mg/5 00603-1075-54 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lactulose 10 g/15 mL Oral Syrup 00121-4577-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoclopramide 5 mg/5 mL Oral Syru 00121-0576-16 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxybutynin 5 mg/5 mL Oral Syrup 00603-1491-58 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL promethazine 6.25 mg/5 mL Oral Syr 60432-0608-04 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ranitidine 15 mg/mL Oral Syrup 65162-0664-90 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL senna 8.8 mg/5 mL Oral Syrup 00536-1275-59 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL valproic acid 250 mg/5 mL Oral Syr 00121-0675-16 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acarbose 50 mg Tab 16252-0524-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen 325 mg Tab 63739-0440-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen 500 mg Tab 63739-0439-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Acetaminophen-Aspirin-Caffeine Tab 00904-5135-59 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL APAP/butalbital/caffeine 325 mg-50 68084-0396-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-codeine 300 mg-30 mg 00406-0484-62 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL AcetaZOLAMIDE Tab (Diamox) 250 mg 00527-1050-01 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acyclovir 400 mg Tab 00904-6121-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL alendronate 35 mg Tab 16252-0599-44 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL alendronate 70 mg Tab 00093-5171-20 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL aliskiren 300 mg oral tablet 00078-0486-15 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL allopurinol 100 mg Tab 51079-0205-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL allopurinol 300 mg Tab 51079-0206-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL alprazolam 0.25 mg Tab 00904-5858-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amiloride 5 mg Tab 00574-0292-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amiodarone 200 mg Tab 00245-0147-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amitriptyline 10 mg Tab 51079-0131-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amitriptyline 25 mg Tab 51079-0107-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amitriptyline 50 mg Tab 51079-0133-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amlodipine 10 mg Tab 00904-5993-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amlodipine 5 mg Tab 51079-0451-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amoxicillin-clavulanate 875 mg-125 66685-1001-00 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amphetamine-dextroamphetamine 10 m 00555-0972-02 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amphetamine-dextroamphetamine 20 m 00555-0973-02 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL anastrozole 1 mg Tab 00310-0201-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL aripiprazole 10 mg Tab 59148-0008-13 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL aripiprazole 2 mg oral tablet 59148-0006-13 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL aripiprazole 5 mg Tab 59148-0007-35 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ascorbic acid 500 mg Tab 00904-0523-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL aspirin 325 mg Tab 00904-2009-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atenolol 100 mg Tab 51079-0685-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atenolol 25 mg Tab 51079-0759-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atenolol 50 mg Tab 51079-0684-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atorvastatin 10 mg Tab 00591-3774-19 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atorvastatin 20 mg Tab 68084-0565-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atorvastatin 40 mg Tab 68084-0589-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL azithromycin 600 mg Tab 64679-0962-01 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL baclofen 20 mg Tab 00904-5222-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL benztropine 1 mg Tab 68084-0388-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bethanechol 10 mg Tab 00832-0511-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bethanechol 25 mg Tab 00832-0512-00 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bicalutamide 50 mg Tab 41616-0485-83 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bromocriptine 2.5 mg Tab 00574-0106-01 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bumetanide 1 mg Tab 51079-0892-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL buprenorphine-naloxone 2 mg-0.5 mg 12496-1283-02 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL buprenorphine-naloxone 8 mg-2 mg s 12496-1306-02 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL buPROPion 100 mg Tab 51079-0944-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL buPROPion 75 mg Tab 51079-0943-20 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL busPIRone 5 mg Tab 51079-0985-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL J8515 NULL cabergoline 0.5 mg Tab 00093-5420-88 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $18.81 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.46 $25.47 $24.81 $18.81 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.33 $26.33 $21.24 $28.95 100% of Medicare $36.00 $38.25 $35.33 $32.85 $36.00 $38.25 $30.94 100% of Medicare 100% of Medicare $33.75 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Calcium Carbonate 500 mg 00904-1883-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Calcium Carbonate wiith Vitamin D 00904-1882-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Calcium Carbonate/Vitamin D 315mg/ 00904-5272-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcium lactate 650 mg Tab 00536-3422-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcium carbonate 600 mg Tab 00904-3232-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcium-vitamin D 600 mg-400 intl 00904-3233-92 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL captopril 25 mg Tab 00904-5046-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbamazepine 200 mg Tab 51079-0385-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbidopa/entacapone/levodopa 37.5 00078-0409-05 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbidopa-levodopa 10 mg-100 mg Ta 63739-0046-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbidopa-levodopa 25 mg-250 mg Ta 63739-0048-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carvedilol 12.5 mg Tab 51079-0931-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carvedilol 25 mg Tab 51079-0932-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carvedilol 3.125 mg Tab 51079-0771-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cefpodoxime 200 mg Tab 00781-5439-20 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cefuroxime 500 mg Tab 68180-0303-20 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Certa-Vite Tablet 00904-5486-52 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cetirizine 10 mg Tab 51079-0597-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL chlorproMAZINE 25 mg Tab 51079-0519-20 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL chlorthalidone 25 mg Tab 51079-0058-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "Cholecalciferol Tab 1,000 Units (V" 00904-5824-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cholecalciferol 400 intl units Tab 00904-5823-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cinacalcet 30 mg Tab 55513-0073-30 INSTITUTIONAL $97.00 1/1/2022-12/31/2022 $97.00 $45.78 $55.29 $71.30 $71.30 200% of Medicare 100% of Medicare $58.08 $55.91 $54.45 $62.08 100% of Medicaid 100% of Medicare 150% of Medicare $77.60 $97.00 195% of Medicare $78.57 $57.72 $57.72 $45.78 $97.00 100% of Medicare $77.60 $82.45 $87.30 $70.80 $82.45 $97.00 $97.00 100% of Medicare 100% of Medicare $97.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ciprofloxacin 500 mg Tab 51079-0182-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL citalopram 20 mg Tab 00904-6085-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clarithromycin 500 mg Tab 51079-0673-06 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clobazam 10 mg Tab 67386-0311-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clonazepam 0.5 mg Tab 63739-0263-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clonazepam 1 mg Tab 51079-0882-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clonidine 0.1 mg Tab 00904-5656-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clonidine 0.2 mg Tab 00904-5657-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clonidine 0.3 mg Tab 51079-0301-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clopidogrel 75 mg Tab 51079-0557-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clorazepate 3.75 mg Tab 00378-0030-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clozapine 25 mg Tab 51079-0921-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL codeine sulfate 30 mg Tab 00054-0244-24 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL colesevelam 625 mg Tab 65597-0701-18 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL colestipol 1 g Tab 59762-0450-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cyanocobalamin 100 mcg Tab 00536-3542-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cyanocobalamin 1000 mcg Tab 00536-3556-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cyanocobalamin 250 mcg Tab 00904-4218-13 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cyclobenzaprine 10 mg Tab 51079-0644-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cyproheptadine 4 mg Tab 60258-0850-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dapsone 25 mg Tab 49938-0102-30 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darunavir 600 mg Tab 59676-0562-01 INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 200% of Medicare 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL demeclocycline 150 mg Tab 65162-0554-10 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL desmopressin 0.1 mg Tab 00093-7316-01 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone 1 mg Tab 00054-8174-25 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dexamethasone 4 mg Tab 00054-8175-25 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diazepam 2 mg Tab 51079-0284-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diazepam 5 mg Tab 51079-0285-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dicyclomine 20 mg Tab 51079-0119-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL digoxin 125 mcg (0.125 mg) Tab 00904-5921-61 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diltiazem 30 mg Tab 51079-0745-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diltiazem 60 mg Tab 51079-0746-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL atropine-diphenoxylate 0.025 mg-2. 51079-0067-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dipyridamole 25 mg Tab 00904-1086-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dipyridamole 50 mg Tab 00904-1087-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL docusate-senna 50 mg-8.6 mg Tab 00904-5512-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL donepezil 23 mg Tab 62856-0247-30 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL donepezil 5 mg Tab 00904-6242-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL doxazosin 1 mg Tab 51079-0957-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL doxazosin 4 mg Tab 51079-0959-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dronedarone 400 mg Tab 00024-4142-60 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL efavirenz 600 mg Tab 00056-0510-30 INSTITUTIONAL $100.00 1/1/2022-12/31/2022 $100.00 $47.20 $57.00 $73.50 $73.50 200% of Medicare 100% of Medicare $59.88 $57.64 $56.13 $64.00 100% of Medicaid 100% of Medicare 150% of Medicare $80.00 $100.00 195% of Medicare $81.00 $59.50 $59.50 $47.20 $100.00 100% of Medicare $80.00 $85.00 $90.00 $72.99 $85.00 $100.00 $100.00 100% of Medicare 100% of Medicare $100.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL efavirenz/emtricitabine/tenofovir 15584-0101-01 INSTITUTIONAL $366.00 1/1/2022-12/31/2022 $366.00 $172.75 $208.62 $269.01 $269.01 200% of Medicare 100% of Medicare $219.16 $210.96 $205.44 $234.24 100% of Medicaid 100% of Medicare 150% of Medicare $292.80 $366.00 195% of Medicare $296.46 $217.77 $217.77 $172.75 $366.00 100% of Medicare $292.80 $311.10 $329.40 $267.14 $311.10 $366.00 $366.00 100% of Medicare 100% of Medicare $366.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL enalapril 10 mg Tab 00904-5610-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL enalapril 5 mg Tab 51079-0951-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL entacapone 200 mg Tab 00078-0327-05 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL eplerenone 25 mg Tab 59762-1710-02 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL erythromycin 250 mg Tab 24338-0102-13 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL escitalopram 10 mg Tab 00093-5851-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL estradiol 1 mg Tab 00378-1454-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL estradiol topical 10 mcg Tab 00169-5176-03 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL conjugated estrogens 0.625 mg Tab 00046-1102-81 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ethacrynic acid 25 mg Tab 25010-0205-15 INSTITUTIONAL $79.00 1/1/2022-12/31/2022 $79.00 $37.29 $45.03 $58.07 $58.07 200% of Medicare 100% of Medicare $47.31 $45.54 $44.34 $50.56 100% of Medicaid 100% of Medicare 150% of Medicare $63.20 $79.00 195% of Medicare $63.99 $47.01 $47.01 $37.29 $79.00 100% of Medicare $63.20 $67.15 $71.10 $57.66 $67.15 $79.00 $79.00 100% of Medicare 100% of Medicare $79.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ethinyl estradiol-norethindrone 5 00093-3122-98 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL etidronate 200 mg Tab 00378-3286-91 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL etodolac 400 mg Tab 51672-4018-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ezetimibe 10 mg Tab 66582-0414-28 INSTITUTIONAL $52.00 1/1/2022-12/31/2022 $52.00 $24.54 $29.64 $38.22 $38.22 200% of Medicare 100% of Medicare $31.14 $29.97 $29.19 $33.28 100% of Medicaid 100% of Medicare 150% of Medicare $41.60 $52.00 195% of Medicare $42.12 $30.94 $30.94 $24.54 $52.00 100% of Medicare $41.60 $44.20 $46.80 $37.95 $44.20 $52.00 $52.00 100% of Medicare 100% of Medicare $52.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL febuxostat 40 mg Tab 64764-0918-30 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fenofibrate 160 mg Tab 68084-0328-21 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fenofibrate 54 mg Tab 00378-7100-77 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ferrous gluconate 325 mg Tab 00904-2137-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL finasteride 5 mg Tab 47335-0715-83 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL flavoxate 100 mg Tab 51224-0154-50 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Flecainide Tab 100 mg 65162-0642-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluconazole 100 mg Tab 00172-5411-10 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fludrocortisone 0.1 mg Tab 00555-0997-02 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluvoxamine 50 mg Tab 62559-0159-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL folic acid 1 mg Tab 62584-0897-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL furosemide 40 mg Tab 51079-0073-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL furosemide 80 mg Tab 00904-5798-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL galantamine 4 mg Tab 51079-0852-03 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gemfibrozil 600 mg Tab 00904-5379-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glimepiride 2 mg Tab 68084-0326-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glimepiride 4 mg Tab 68084-0327-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glipiZIDE 10 mg Tab 51079-0811-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glipiZIDE 5 mg Tab 51079-0810-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glyBURIDE micronized 3 mg Tab 00378-1125-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glyBURIDE 2.5 mg Tab 51079-0872-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glyBURIDE 5 mg Tab 51079-0873-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL guanfacine 1 mg Tab 00591-0444-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL haloperidol 1 mg Tab 51079-0734-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL haloperidol 5 mg Tab 51079-0736-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrALAZINE 10 mg Tab 51079-0074-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrALAZINE 25 mg Tab 23155-0002-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrALAZINE 50 mg Tab 62584-0734-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Hydrocodone/Acetaminophen 7.5/500m 63739-0141-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-hydrocodone 325 mg-1 53746-0110-05 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-hydrocodone 325 mg-5 00406-0365-62 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-hydrocodone 500 mg-5 00406-0357-62 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydromorphone 2 mg Tab 68084-0423-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydromorphone 4 mg Tab 42858-0302-25 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydroxychloroquine 200 mg Tab 63304-0296-01 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrOXYzine hydrochloride 25 mg Ta 68462-0361-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrOXYzine hydrochloride 10 mg Ta 68084-0253-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hyoscyamine 0.125 mg Tab 76439-0308-10 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ibandronate 150 mg oral tablet 00004-0186-82 INSTITUTIONAL $577.00 1/1/2022-12/31/2022 $577.00 $272.34 $328.89 $424.10 $424.10 200% of Medicare 100% of Medicare $345.51 $332.58 $323.87 $369.28 100% of Medicaid 100% of Medicare 150% of Medicare $461.60 $577.00 195% of Medicare $467.37 $343.32 $343.32 $272.34 $577.00 100% of Medicare $461.60 $490.45 $519.30 $421.15 $490.45 $577.00 $577.00 100% of Medicare 100% of Medicare $577.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ibuprofen 400 mg Tab 63739-0442-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ibuprofen 600 mg Tab 00904-5854-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL imipramine 25 mg Tab 00781-1764-13 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL isoniazid 300 mg Tab 51079-0083-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL isosorbide dinitrate 20 mg Tab 00904-2154-61 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL isosorbide dinitrate 5 mg Tab 00143-1769-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL isosorbide mononitrate 20 mg Tab 00228-2620-11 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ketoconazole 200 mg Tab 51672-4026-06 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ketorolac 10 mg Tab 00093-0314-01 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL labetalol 100 mg Tab 51079-0928-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL labetalol 200 mg Tab 00904-5929-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lacosamide 200 mg Tab 00131-2480-35 INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 200% of Medicare 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lacosamide 50 mg Tab 00131-2477-35 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lactase 3000 units Tab 00904-5224-52 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lamivudine 100 mg Tab 00173-0662-00 INSTITUTIONAL $65.00 1/1/2022-12/31/2022 $65.00 $30.68 $37.05 $47.78 $47.78 200% of Medicare 100% of Medicare $38.92 $37.47 $36.48 $41.60 100% of Medicaid 100% of Medicare 150% of Medicare $52.00 $65.00 195% of Medicare $52.65 $38.68 $38.68 $30.68 $65.00 100% of Medicare $52.00 $55.25 $58.50 $47.44 $55.25 $65.00 $65.00 100% of Medicare 100% of Medicare $65.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lamotrigine 150 mg Tab 51079-0865-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lamotrigine 25 mg Tab 51079-0498-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Lanthanum Carbonate 54092-0252-90 INSTITUTIONAL $58.00 1/1/2022-12/31/2022 $58.00 $27.38 $33.06 $42.63 $42.63 200% of Medicare 100% of Medicare $34.73 $33.43 $32.56 $37.12 100% of Medicaid 100% of Medicare 150% of Medicare $46.40 $58.00 195% of Medicare $46.98 $34.51 $34.51 $27.38 $58.00 100% of Medicare $46.40 $49.30 $52.20 $42.33 $49.30 $58.00 $58.00 100% of Medicare 100% of Medicare $58.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL leflunomide 10 mg Tab 00093-0173-56 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL leflunomide 20 mg Tab 00093-0174-56 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL letrozole 2.5 mg Tab 00093-7620-56 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL leucovorin 5 mg Tab 00054-4496-13 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levetiracetam 500 mg Tab 51079-0821-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levocarnitine 330 mg Tab 64980-0130-09 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL LEVofloxacin Tab 250 mg 00904-6249-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 100 mcg (0.1 mg) Tab 51079-0442-20 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 112 mcg (0.112 mg) T 00527-1346-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 125 mcg (0.125 mg) T 51079-0443-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 137 mcg (0.137 mg) T 00527-1638-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 150 mcg (0.15 mg) Ta 00074-7069-11 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 175 mcg (0.175 mg) T 00456-1326-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 25 mcg (0.025 mg) Ta 51079-0444-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 75 mcg (0.075 mg) Ta 51079-0441-20 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 88 mcg (0.088 mg) Ta 00527-1344-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL linezolid 600 mg Tab 00009-5135-03 INSTITUTIONAL $514.00 1/1/2022-12/31/2022 $514.00 $242.61 $292.98 $377.79 $377.79 200% of Medicare 100% of Medicare $307.78 $296.27 $288.51 $328.96 100% of Medicaid 100% of Medicare 150% of Medicare $411.20 $514.00 195% of Medicare $416.34 $305.83 $305.83 $242.61 $514.00 100% of Medicare $411.20 $436.90 $462.60 $375.17 $436.90 $514.00 $514.00 100% of Medicare 100% of Medicare $514.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL liothyronine 25 mcg Tab 00574-0222-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL liothyronine 5 mcg Tab 00574-0220-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 10 mg Tab 63739-0349-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Lisinopril Tab 20 mg 63739-0350-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL loratadine 10 mg Tab 00904-5728-89 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lorazepam 0.5 mg Tab 00904-5980-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lorazepam 1 mg Tab 51079-0386-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL magnesium gluconate 500 mg Tab 60258-0172-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL magnesium oxide 400 mg Tab 68585-0006-41 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL magnesium amino acids chelate 133 17204-0434-40 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL maraviroc 150 mg oral tablet 00069-0807-60 INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL megestrol 20 mg Tab 49884-0289-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL melatonin 3 mg Tab 00904-5182-52 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL meloxicam 7.5 mg Tab 51079-0457-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL memantine 10 mg Tab 00456-3210-63 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL memantine 5 mg Tab 00456-3205-63 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metformin 500 mg Tab 00904-6090-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metformin 850 mg Tab 00904-6091-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methadone 10 mg Tab 00406-5771-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methocarbamol 500 mg Tab 63739-0166-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methotrexate 2.5 mg Tab 51079-0670-05 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylphenidate 10 mg Tab 00406-1144-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylphenidate 5 mg Tab 00406-1142-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoclopramide 5 mg Tab 51079-0629-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoclopramide 10 mg Tab 68084-0091-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metolazone 2.5 mg Tab 65580-0643-71 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoprolol 100 mg Tab 51079-0802-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoprolol 25 mg Tab 51079-0255-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoprolol 50 mg Tab 51079-0801-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL midodrine 5 mg Tab 00245-0212-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL milnacipran 25 mg Tab 00456-1525-60 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL milnacipran 50 mg Tab 00456-1550-60 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL misoprostol 100 mcg Tab 59762-5007-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL misoprostol 200 mcg Tab 59762-5008-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL montelukast 10 mg Tab 68084-0620-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL morphine 15 mg Tab 00054-0235-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL moxifloxacin 400 mg Tab 00085-1733-02 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 200% of Medicare 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Prenatal Multivitamins with Folic 00904-5313-60 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Multiple Vitamins Tab 00904-0530-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Antioxidant Multiple Vitamins and 00904-7735-52 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Therapeutic Multiple Vitamins with 00904-5492-13 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Multivitamin/Mineral/Lutein 24208-0632-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mycophenolate mofetil 500 mg Tab 51079-0379-20 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nabumetone 500 mg Tab 68462-0358-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nadolol 20 mg Tab 51079-0812-20 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nadolol 40 mg Tab 51079-0813-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL naproxen 250 mg Tab 00904-6069-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nateglinide 120 mg Tab 49884-0985-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Nebivolol Tab 10 mg 00456-1410-30 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL niacinamide 500 mg oral Tab 00536-4069-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nitroglycerin 0.4 mg sublingual Ta 00071-0418-13 INSTITUTIONAL $126.00 1/1/2022-12/31/2022 $126.00 $59.47 $71.82 $92.61 $92.61 200% of Medicare 100% of Medicare $75.45 $72.63 $70.72 $80.64 100% of Medicaid 100% of Medicare 150% of Medicare $100.80 $126.00 195% of Medicare $102.06 $74.97 $74.97 $59.47 $126.00 100% of Medicare $100.80 $107.10 $113.40 $91.97 $107.10 $126.00 $126.00 100% of Medicare 100% of Medicare $126.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL olanzapine 2.5 mg Tab 00093-5767-56 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxandrolone 2.5 mg Tab 00245-0271-11 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxcarbazepine 300 mg Tab 62584-0143-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxycodone 5 mg Tab 00406-0552-62 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-oxycodone 325 mg-5 m 00406-0512-62 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetaminophen-oxycodone 500 mg-7.5 53746-0205-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL paroxetine 10 mg Tab 00378-7001-93 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL paroxetine 20 mg Tab 68084-0045-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Penicillin V Potassium 500 mg Tab 67253-0201-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL perphenazine 4 mg Tab 00781-1047-13 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenazopyridine 100 mg Tab 68084-0292-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenobarbital 15 mg Tab 51079-0094-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium phosphate-sodium phospha 64980-0104-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Phytonadione Tab 5 mg 25010-0405-15 INSTITUTIONAL $199.00 1/1/2022-12/31/2022 $199.00 $93.93 $113.43 $146.27 $146.27 200% of Medicare 100% of Medicare $119.16 $114.70 $111.70 $127.36 100% of Medicaid 100% of Medicare 150% of Medicare $159.20 $199.00 195% of Medicare $161.19 $118.41 $118.41 $93.93 $199.00 100% of Medicare $159.20 $169.15 $179.10 $145.25 $169.15 $199.00 $199.00 100% of Medicare 100% of Medicare $199.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pilocarpine 5 mg Tab 00527-1313-01 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL polycarbophil 625 mg Tab 00536-4306-11 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pramipexole 0.25 mg Tab 68084-0440-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pramipexole 0.5 mg Tab 13668-0093-90 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL prasugrel 10 mg Tab 00002-5123-30 INSTITUTIONAL $72.00 1/1/2022-12/31/2022 $72.00 $33.98 $41.04 $52.92 $52.92 200% of Medicare 100% of Medicare $43.11 $41.50 $40.41 $46.08 100% of Medicaid 100% of Medicare 150% of Medicare $57.60 $72.00 195% of Medicare $58.32 $42.84 $42.84 $33.98 $72.00 100% of Medicare $57.60 $61.20 $64.80 $52.55 $61.20 $72.00 $72.00 100% of Medicare 100% of Medicare $72.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pravastatin 20 mg Tab 68462-0196-90 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Pravastatin Tab 40 mg 68462-0197-90 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL predniSONE 1 mg Tab 00054-8739-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL predniSONE 10 mg Tab 63739-0519-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL predniSONE 5 mg Tab 00054-8724-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL predniSONE 50 mg Tab 00054-0019-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Prenatal Vit/Fe Fumarate 51991-0566-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL primaquine phosphate 26.3 mg (15 m 00024-1596-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL primidone 50 mg Tab 00527-1301-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL probenecid 500 mg Tab 00378-0156-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL prochlorperazine 10 mg Tab 51079-0542-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL prochlorperazine 5 mg Tab 51079-0541-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL Q0169 NULL promethazine 12.5 mg Tab 00008-0019-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.34 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.70 $4.53 $4.41 $3.34 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.68 $4.68 $3.78 $5.15 100% of Medicare $6.40 $6.80 $6.28 $5.84 $6.40 $6.80 $5.50 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL promethazine 25 mg Tab 00904-5840-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propafenone 150 mg Tab 53489-0551-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propantheline 15 mg Tab 00054-4721-25 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propranolol 10 mg Tab 51079-0277-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propranolol 20 mg Tab 51079-0278-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propranolol 40 mg Tab 51079-0279-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propylthiouracil 50 mg Tab 00143-1480-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pseudoephedrine 30 mg Tab 00904-5053-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pyridostigmine 60 mg Tab 00115-3511-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pyridoxine 50 mg Tab 00536-4408-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL quetiapine 100 mg Tab 00904-6279-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Raloxifene Tab 60 mg 00002-4165-30 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL raltegravir 400 mg oral tablet 00006-0227-61 INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $52.86 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $67.07 $64.56 $62.87 $71.68 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $66.64 $66.64 $52.86 $112.00 100% of Medicare $89.60 $95.20 $100.80 $81.75 $95.20 $112.00 $112.00 100% of Medicare 100% of Medicare $112.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ramelteon 8 mg oral tablet 64764-0805-30 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 200% of Medicare 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ranitidine Tab 150 mg 68084-0577-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rasagiline 1 mg oral tablet 68546-0229-56 INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL repaglinide 0.5 mg Tab 00169-0081-81 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL repaglinide 1 mg Tab 00169-0082-81 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL riboflavin 100 mg Tab 74312-0006-40 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rifaximin 200 mg Tab 65649-0301-03 INSTITUTIONAL $75.00 1/1/2022-12/31/2022 $75.00 $35.40 $42.75 $55.13 $55.13 200% of Medicare 100% of Medicare $44.91 $43.23 $42.10 $48.00 100% of Medicaid 100% of Medicare 150% of Medicare $60.00 $75.00 195% of Medicare $60.75 $44.63 $44.63 $35.40 $75.00 100% of Medicare $60.00 $63.75 $67.50 $54.74 $63.75 $75.00 $75.00 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rifaximin 550 mg Tab UD 65649-0303-03 INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $75.99 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $96.41 $92.80 $90.37 $103.04 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $95.80 $95.80 $75.99 $161.00 100% of Medicare $128.80 $136.85 $144.90 $117.51 $136.85 $161.00 $161.00 100% of Medicare 100% of Medicare $161.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL riluzole 50 mg Tab 00075-7700-60 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Risedronate Tab 35 mg 00430-0472-03 INSTITUTIONAL $146.00 1/1/2022-12/31/2022 $146.00 $68.91 $83.22 $107.31 $107.31 200% of Medicare 100% of Medicare $87.42 $84.15 $81.95 $93.44 100% of Medicaid 100% of Medicare 150% of Medicare $116.80 $146.00 195% of Medicare $118.26 $86.87 $86.87 $68.91 $146.00 100% of Medicare $116.80 $124.10 $131.40 $106.57 $124.10 $146.00 $146.00 100% of Medicare 100% of Medicare $146.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL RisperiDONE Tab 0.25 mg 68084-0270-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL risperidone 1 mg Tab 51079-0462-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rivaroxaban 10 mg Tab 50458-0580-30 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL roflumilast 500 mcg Tab 00456-0095-30 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ropinirole 3 mg Tab 64679-0174-02 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ropinirole 0.25 mg Tab 64679-0154-02 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ropinirole 1 mg Tab 68462-0255-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rosuvastatin 10 mg Tab 00310-0751-39 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Selenium 50 mcg 00904-3162-60 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL senna 8.6 mg Tab 00904-5165-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sertraline 100 mg Tab 68084-0182-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sertraline 50 mg Tab 68084-0181-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sevelamer carbonate 800 mg Tab 58468-0130-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sevelamer 800 mg Tab 58468-0021-01 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 200% of Medicare 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sildenafil 20 mg oral tablet 00069-4190-68 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sildenafil 25 mg Tab 00069-4200-30 INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $60.42 $72.96 $94.08 $94.08 200% of Medicare 100% of Medicare $76.65 $73.78 $71.85 $81.92 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $76.16 $76.16 $60.42 $128.00 100% of Medicare $102.40 $108.80 $115.20 $93.43 $108.80 $128.00 $128.00 100% of Medicare 100% of Medicare $128.00 200% of Medicare NULL 250 NULL NULL NULL J7520 NULL sirolimus 0.5 mg Tab UD 00008-1040-10 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $20.06 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.23 $27.17 $26.46 $20.06 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.08 $28.08 $22.66 $30.88 100% of Medicare $38.40 $40.80 $37.68 $35.04 $38.40 $40.80 $33.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sirolimus 1 mg Tab 00008-1041-10 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sitagliptin 50 mg oral tablet 00006-0112-28 INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $26.43 $31.92 $41.16 $41.16 200% of Medicare 100% of Medicare $33.53 $32.28 $31.43 $35.84 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $33.32 $33.32 $26.43 $56.00 100% of Medicare $44.80 $47.60 $50.40 $40.87 $47.60 $56.00 $56.00 100% of Medicare 100% of Medicare $56.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride 1 g Tab 00223-1760-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL solifenacin 5 mg Tab 51248-0150-52 INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $26.43 $31.92 $41.16 $41.16 200% of Medicare 100% of Medicare $33.53 $32.28 $31.43 $35.84 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $33.32 $33.32 $26.43 $56.00 100% of Medicare $44.80 $47.60 $50.40 $40.87 $47.60 $56.00 $56.00 100% of Medicare 100% of Medicare $56.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sotalol 80 mg Tab 00093-1061-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL spironolactone 25 mg Tab 63739-0544-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sucralfate 1 g Tab 51079-0871-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sulfamethoxazole-trimethoprim 800 51079-0128-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sulfamethoxazole-trimethoprim 400 00603-5780-21 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sumatriptan 25 mg Tab 62756-0520-69 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL SUMAtriptan Tab 50 mg 55111-0292-09 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tamoxifen 10 mg Tab 63739-0269-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tenofovir 300 mg Tab 61958-0401-01 INSTITUTIONAL $121.00 1/1/2022-12/31/2022 $121.00 $57.11 $68.97 $88.94 $88.94 200% of Medicare 100% of Medicare $72.45 $69.74 $67.92 $77.44 100% of Medicaid 100% of Medicare 150% of Medicare $96.80 $121.00 195% of Medicare $98.01 $72.00 $72.00 $57.11 $121.00 100% of Medicare $96.80 $102.85 $108.90 $88.32 $102.85 $121.00 $121.00 100% of Medicare 100% of Medicare $121.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL terbinafine 250 mg Tab 67405-0543-03 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL thiamine 100 mg Tab 00904-0544-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL thyroid desiccated 30 mg Tab 00456-0458-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Thyroid Desiccated Tab 60 mg 00456-0459-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ticagrelor 90 mg Tab UD 00186-0777-39 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Tizanidine HCL 2 mg 00378-0722-19 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tizanidine 4 mg Tab 51079-0998-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tolterodine 2 mg Tab 00093-2055-42 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL topiramate 100 mg Tab 00093-7219-06 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL topiramate 25 mg Tab 51079-0726-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL torsemide 20 mg Tab 50111-0917-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tramadol 50 mg Tab 00904-6119-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL trazodone 50 mg Tab 00904-3990-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL trihexyphenidyl 2 mg Tab 00591-5335-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL trimethoprim 100 mg Tab 00093-2158-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ursodiol 500 mg 58914-0790-10 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL valacyclovir 500 mg Tab 45963-0558-30 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL valganciclovir 450 mg Tab 00004-0038-22 INSTITUTIONAL $160.00 1/1/2022-12/31/2022 $160.00 $75.52 $91.20 $117.60 $117.60 200% of Medicare 100% of Medicare $95.81 $92.22 $89.81 $102.40 100% of Medicaid 100% of Medicare 150% of Medicare $128.00 $160.00 195% of Medicare $129.60 $95.20 $95.20 $75.52 $160.00 100% of Medicare $128.00 $136.00 $144.00 $116.78 $136.00 $160.00 $160.00 100% of Medicare 100% of Medicare $160.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL valsartan 40 mg Tab 00078-0423-15 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL varenicline 0.5 mg oral tablet 00069-0468-56 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL venlafaxine 25 mg Tab 00093-0199-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL venlafaxine 37.5 mg Tab 65162-0302-09 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL verapamil 120 mg Tab 00904-2924-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL verapamil 80 mg Tab 00904-2920-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vitamin B Complex with Folic Acid 51991-0084-90 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL voriconazole 200 mg Tab 00049-3180-30 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 10 mg Tab 00832-1219-00 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 1 mg Tab 00832-1211-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 2 mg Tab 00832-1212-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 2.5 mg Tab 00832-1213-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 3 mg Tab 00832-1214-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Warfarin Tab 4 mg (Jantoven) 00832-1215-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 5 mg Tab 00832-1216-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 7.5 mg Tab 00832-1218-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL zolpidem 10 mg Tab 00904-6083-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL zolpidem 5 mg Tab 51079-0724-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Aspirin Tab Chew 81 mg 00904-4040-73 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcium carbonate 500 mg Chew Tab 00904-1258-92 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL calcium carbonate 750 mg Chew Tab 00904-7695-91 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbamazepine 100 mg Chew Tab 51079-0870-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lactobacillus acidophilus and bulg 64980-0129-50 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Multiple Vitamins Chew Tab 00904-2621-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Phenytoin Tab Chew 50 mg 00071-0007-40 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL simethicone 80 mg Chew Tab 63739-0225-10 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lansoprazole 15 mg Dis Tab 64764-0543-11 INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 200% of Medicare 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL aspirin 325 mg Oral EC Tab 00904-2013-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bisacodyl 5 mg Oral EC Tab 00904-7927-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diclofenac sodium 50 mg Oral EC Ta 00781-1787-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diclofenac sodium 75 mg Oral EC Ta 00228-2551-11 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ferrous sulfate 325 mg Oral EC Tab 00245-0108-11 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mycophenolic acid 180 mg Oral EC T 00078-0385-66 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL J7518 NULL mycophenolic acid 360 mg Oral EC T 00078-0386-66 INSTITUTIONAL $42.00 1/1/2022-12/31/2022 $42.00 $17.56 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $24.70 $23.78 $23.15 $17.56 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 195% of Medicare $34.02 $24.57 $24.57 $19.82 $27.02 100% of Medicare $33.60 $35.70 $32.97 $30.66 $33.60 $35.70 $28.88 100% of Medicare 100% of Medicare $31.50 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pantoprazole 40 mg Oral EC Tab 00008-0607-04 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sulfasalazine 500 mg Oral EC Tab 59762-0104-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium bicarbonate 25 mEq Eff T 00904-2720-46 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL alfuzosin 10 mg ER Tab 31722-0302-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL buPROPion 150 mg/24 hours ER Tab 67767-0141-30 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL buPROPion 300 mg/24 hours ER Tab 00591-3332-30 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbamazepine 100 mg ER Tab 00078-0510-05 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbamazepine 200 mg ER Tab 51672-4124-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbamazepine 400 mg ER Tab 51672-4125-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Carbidopa-Levodopa Tab CR 25 mg-10 62756-0461-88 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darifenacin 7.5 mg ER Tab 00430-0170-15 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL desvenlafaxine 50 mg Tab- 00008-1211-14 INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $26.43 $31.92 $41.16 $41.16 200% of Medicare 100% of Medicare $33.53 $32.28 $31.43 $35.84 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $33.32 $33.32 $26.43 $56.00 100% of Medicare $44.80 $47.60 $50.40 $40.87 $47.60 $56.00 $56.00 100% of Medicare 100% of Medicare $56.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL diltiazem 180 mg/24 hours ER Tab 52544-0691-30 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL divalproex sodium 250 mg ER Tab 00904-5990-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL divalproex sodium 500 mg ER Tab 00904-6073-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL docusate-ferrous fumarate 100 mg-1 36652-0267-69 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glipiZIDE 10 mg ER Tab 59762-5033-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glipiZIDE 2.5 mg ER Tab 00591-0900-30 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glipiZIDE 5 mg ER Tab 59762-5032-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL guaifenesin 600 mg ER Tab 63824-0008-15 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL isosorbide mononitrate 30 mg ER Ta 00603-4110-21 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lithium 300 mg ER Tab 00054-0021-25 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL MetFORMIN Tab XR 500 mg 00904-6107-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoprolol 25 mg ER Tab 62037-0830-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL MetoPROLOL Succinate Tab XL 50 mg 62037-0831-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Morphine Tab SA 15 mg 00378-2658-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL niacin 500 mg ER Tab 00074-3074-90 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL NIFEdipine 30 mg ER Tab 00093-0819-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxycodone 10 mg ER Tab 59011-0410-20 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxycodone 20 mg ER Tab 59011-0420-20 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxycodone 40 mg ER Tab 59011-0440-20 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL paliperidone 3 mg oral ER Tab 50458-0550-01 INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $36.82 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $46.71 $44.96 $43.78 $49.92 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $46.41 $46.41 $36.82 $78.00 100% of Medicare $62.40 $66.30 $70.20 $56.93 $66.30 $78.00 $78.00 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pentoxifylline 400 mg ER Tab 51079-0889-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium chloride 10 mEq ER Tab 00245-0041-01 INSTITUTIONAL $1.00 1/1/2022-12/31/2022 $1.00 $0.47 $0.57 $0.74 $0.74 200% of Medicare 100% of Medicare $0.60 $0.58 $0.56 $0.64 100% of Medicaid 100% of Medicare 150% of Medicare $0.80 $1.00 195% of Medicare $0.81 $0.60 $0.60 $0.47 $1.00 100% of Medicare $0.80 $0.85 $0.90 $0.73 $0.85 $1.00 $1.00 100% of Medicare 100% of Medicare $1.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pseudoephedrine 120 mg ER Tab 00904-5803-15 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pyridostigmine 180 mg ER Tab 00187-3013-30 INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 200% of Medicare 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ranolazine 500 mg oral ER Tab 61958-1003-01 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL theophylline 100 mg ER Tab 00904-5887-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL theophylline 300 mg ER Tab 00904-5889-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL verapamil 120 mg ER Tab 51079-0894-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL verapamil 180 mg ER Tab 51079-0899-20 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sorbitol Soln 70% Bottle 54162-0700-16 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Thermacare LRG/XL 00573-3010-03 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Coenzyme Q Cap 100 mg 04746-9002-88 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Cranberry 475 mg 30768-0119-00 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Enlive Berry 70074-0566-43 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Complete Chocolate Clinical 70074-0583-00 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Complete Strawberry Clinica 70074-0620-11 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Complete Vanilla Clinical S 70074-0565-65 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vitamin D 400units 11845-1183-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Mederma 00259-3192-82 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 200% of Medicare 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Pudding ButterScotch 70074-0548-49 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Pudding Vaniila 70074-0548-45 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Benzocaine 10% 00573-0212-25 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Strawberry Muscle Health 70074-0620-13 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Glucerna 1.2 70074-0509-05 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Glucerna 1.5 70074-0535-35 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Glucerna Shake 70074-0560-53 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Jevity 1.2 70074-0531-19 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Jevity 1.5 70074-0573-34 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Clog Zapper 89220-0002-00 INSTITUTIONAL $108.00 1/1/2022-12/31/2022 $108.00 $50.98 $61.56 $79.38 $79.38 200% of Medicare 100% of Medicare $64.67 $62.25 $60.62 $69.12 100% of Medicaid 100% of Medicare 150% of Medicare $86.40 $108.00 195% of Medicare $87.48 $64.26 $64.26 $50.98 $108.00 100% of Medicare $86.40 $91.80 $97.20 $78.83 $91.80 $108.00 $108.00 100% of Medicare 100% of Medicare $108.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vital AF 1.2 Cal 70074-0565-43 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Nepro with Carb Steady Vanilla 70074-0620-95 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dermaide Aloe 80208-0000-04 INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $36.82 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $46.71 $44.96 $43.78 $49.92 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $46.41 $46.41 $36.82 $78.00 100% of Medicare $62.40 $66.30 $70.20 $56.93 $66.30 $78.00 $78.00 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Osmolite 1.2 70074-0531-21 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Promote with Fiber 70074-0518-73 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Proteinex 54859-0515-08 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Twocal HN 70074-0407-29 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vicks Vaporub 37000-0544-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Tucks Pads/Witch Hazel 04200-2302-68 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Pudding Chocolate 70074-0548-47 INSTITUTIONAL $61.00 1/1/2022-12/31/2022 $61.00 $28.79 $34.77 $44.84 $44.84 200% of Medicare 100% of Medicare $36.53 $35.16 $34.24 $39.04 100% of Medicaid 100% of Medicare 150% of Medicare $48.80 $61.00 195% of Medicare $49.41 $36.30 $36.30 $28.79 $61.00 100% of Medicare $48.80 $51.85 $54.90 $44.52 $51.85 $61.00 $61.00 100% of Medicare 100% of Medicare $61.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Vanilla Muscle Health 70074-0565-59 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Camphor/Phenol 04138-8210-41 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Magnesium Chloride Tab SR 64 mg 57896-0635-06 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Juven Unflavored 59781-0540-02 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL Q2022 NULL Antihemophilic Factor VIII (Advate 00944-2944-01 INSTITUTIONAL " $34,358.00 " 1/1/2022-12/31/2022 " $29,204.30 " " $1,500.00 " " $19,584.06 " " $25,253.13 " " $25,253.13 " 200% of Medicare 100% of Medicare " $20,205.94 " " $19,450.06 " " $18,941.57 " " $14,361.64 " 100% of Medicaid 100% of Medicare 150% of Medicare " $27,486.40 " " $1,500.00 " 195% of Medicare " $27,829.98 " " $20,099.43 " " $20,099.43 " " $16,216.98 " " $22,105.94 " 100% of Medicare " $27,486.40 " " $29,204.30 " " $26,971.03 " " $25,077.90 " " $27,486.40 " " $29,204.30 " " $23,621.13 " 100% of Medicare 100% of Medicare " $25,768.50 " 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Saliva Substitute Spray 60 mL 28409-0847-02 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 200% of Medicare 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Azithromycin Susp 40 mg/mL Bottle 00903-7149-31 INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 200% of Medicare 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ciprofloxacin 250 mg Tab 68084-0069-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 128 NULL NULL NULL NULL 128002 Specialty Semi Private NULL INSTITUTIONAL " $2,187.00 " 1/1/2022-12/31/2022 " $2,187.00 " $975.00 " $1,246.59 " " $1,607.45 " " $1,607.45 " 200% of Medicare 100% of Medicare " $1,309.58 " " $1,260.59 " " $1,227.56 " " $1,399.68 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,749.60 " " $1,500.00 " 195% of Medicare " $1,771.47 " " $1,301.27 " " $1,301.27 " " $1,032.26 " " $1,359.00 " 100% of Medicare " $1,749.60 " " $1,858.95 " " $1,968.30 " " $1,596.29 " " $1,858.95 " " $1,500.00 " " $2,187.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 118 NULL NULL NULL NULL 118002 Specialty Private NULL INSTITUTIONAL " $2,187.00 " 1/1/2022-12/31/2022 " $2,187.00 " $975.00 " $1,246.59 " " $1,607.45 " " $1,607.45 " 200% of Medicare 100% of Medicare " $1,309.58 " " $1,260.59 " " $1,227.56 " " $1,399.68 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,749.60 " " $1,500.00 " 195% of Medicare " $1,771.47 " " $1,301.27 " " $1,301.27 " " $1,032.26 " " $1,359.00 " 100% of Medicare " $1,749.60 " " $1,858.95 " " $1,968.30 " " $1,596.29 " " $1,858.95 " " $1,500.00 " " $2,187.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 300 NULL 85610 NULL NULL 14007272 Protime-INR NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $13.79 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.41 $18.68 $18.19 $13.79 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.31 $19.31 $15.58 $21.23 100% of Medicare $26.40 $28.05 $25.91 $24.09 $26.40 $28.05 $22.69 100% of Medicare 100% of Medicare $24.75 200% of Medicare NULL 300 NULL 80048 NULL NULL 14007277 Basic Metabolic Panel NULL INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $28.84 $39.33 $50.72 $50.72 200% of Medicare 100% of Medicare $40.58 $39.06 $38.04 $28.84 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $40.37 $40.37 $32.57 $44.39 100% of Medicare $55.20 $58.65 $54.17 $50.36 $55.20 $58.65 $47.44 100% of Medicare 100% of Medicare $51.75 200% of Medicare NULL 300 NULL 85027 NULL NULL 14007278 Complete Blood Count NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $22.57 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $31.76 $30.57 $29.77 $22.57 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $31.59 $31.59 $25.49 $34.74 100% of Medicare $43.20 $45.90 $42.39 $39.41 $43.20 $45.90 $37.13 100% of Medicare 100% of Medicare $40.50 200% of Medicare NULL 300 NULL 81005 NULL NULL 14007279 Urinalysis NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $7.94 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.17 $10.76 $10.47 $7.94 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.12 $11.12 $8.97 $12.22 100% of Medicare $15.20 $16.15 $14.92 $13.87 $15.20 $16.15 $13.06 100% of Medicare 100% of Medicare $14.25 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Chocolate Muscle Health 70074-0565-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 300 NULL 82728 NULL NULL 14007281 Ferritin NULL INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $46.82 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $65.87 $63.40 $61.75 $46.82 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $65.52 $65.52 $52.86 $72.06 100% of Medicare $89.60 $95.20 $87.92 $81.75 $89.60 $95.20 $77.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 300 NULL 85610 NULL NULL 14007282 aPTT NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $13.79 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.41 $18.68 $18.19 $13.79 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.31 $19.31 $15.58 $21.23 100% of Medicare $26.40 $28.05 $25.91 $24.09 $26.40 $28.05 $22.69 100% of Medicare 100% of Medicare $24.75 200% of Medicare NULL 300 NULL 85025 NULL NULL 14007285 Complete Blood Count w/Differential NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $26.75 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $37.64 $36.23 $35.28 $26.75 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $37.44 $37.44 $30.21 $41.18 100% of Medicare $51.20 $54.40 $50.24 $46.71 $51.20 $54.40 $44.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 300 NULL 86022 NULL NULL 14007290 Heparin Induced Platelet Antibody NULL INSTITUTIONAL $149.00 1/1/2022-12/31/2022 $149.00 $62.28 $84.93 $109.52 $109.52 200% of Medicare 100% of Medicare $87.63 $84.35 $82.14 $62.28 100% of Medicaid 100% of Medicare 150% of Medicare $119.20 $149.00 195% of Medicare $120.69 $87.17 $87.17 $70.33 $95.87 100% of Medicare $119.20 $126.65 $116.97 $108.76 $119.20 $126.65 $102.44 100% of Medicare 100% of Medicare $111.75 200% of Medicare NULL 300 NULL 86900 NULL NULL 14007291 ABO/Rh NULL INSTITUTIONAL $444.00 1/1/2022-12/31/2022 $444.00 $185.59 $253.08 $326.34 $326.34 200% of Medicare 100% of Medicare $261.12 $251.35 $244.78 $185.59 100% of Medicaid 100% of Medicare 150% of Medicare $355.20 $444.00 195% of Medicare $359.64 $259.74 $259.74 $209.57 $285.67 100% of Medicare $355.20 $377.40 $348.54 $324.08 $355.20 $377.40 $305.25 100% of Medicare 100% of Medicare $333.00 200% of Medicare NULL 300 NULL 86904 NULL NULL 14007296 Crossmatch IS NULL INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $32.60 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $45.87 $44.16 $43.00 $32.60 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $45.63 $45.63 $36.82 $50.19 100% of Medicare $62.40 $66.30 $61.23 $56.93 $62.40 $66.30 $53.63 100% of Medicare 100% of Medicare $58.50 200% of Medicare NULL 300 NULL 82040 NULL NULL 14007297 Albumin NULL INSTITUTIONAL $42.00 1/1/2022-12/31/2022 $42.00 $17.56 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $24.70 $23.78 $23.15 $17.56 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 195% of Medicare $34.02 $24.57 $24.57 $19.82 $27.02 100% of Medicare $33.60 $35.70 $32.97 $30.66 $33.60 $35.70 $28.88 100% of Medicare 100% of Medicare $31.50 200% of Medicare NULL 300 NULL 84075 NULL NULL 14007302 Alkaline Phosphatase NULL INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $17.97 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.29 $24.34 $23.71 $17.97 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.16 $25.16 $20.30 $27.67 100% of Medicare $34.40 $36.55 $33.76 $31.39 $34.40 $36.55 $29.56 100% of Medicare 100% of Medicare $32.25 200% of Medicare NULL 300 NULL 80150 NULL NULL 14007306 Amikacin Pre NULL INSTITUTIONAL $124.00 1/1/2022-12/31/2022 $124.00 $51.83 $70.68 $91.14 $91.14 200% of Medicare 100% of Medicare $72.92 $70.20 $68.36 $51.83 100% of Medicaid 100% of Medicare 150% of Medicare $99.20 $124.00 195% of Medicare $100.44 $72.54 $72.54 $58.53 $79.78 100% of Medicare $99.20 $105.40 $97.34 $90.51 $99.20 $105.40 $85.25 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 300 NULL 82140 NULL NULL 14007310 Ammonia NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 300 NULL 82150 NULL NULL 14007315 Amylase NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $22.57 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $31.76 $30.57 $29.77 $22.57 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $31.59 $31.59 $25.49 $34.74 100% of Medicare $43.20 $45.90 $42.39 $39.41 $43.20 $45.90 $37.13 100% of Medicare 100% of Medicare $40.50 200% of Medicare NULL 300 NULL 83880 NULL NULL 14007322 BNP NULL INSTITUTIONAL $277.00 1/1/2022-12/31/2022 $277.00 $115.79 $157.89 $203.60 $203.60 200% of Medicare 100% of Medicare $162.90 $156.81 $152.71 $115.79 100% of Medicaid 100% of Medicare 150% of Medicare $221.60 $277.00 195% of Medicare $224.37 $162.05 $162.05 $130.74 $178.22 100% of Medicare $221.60 $235.45 $217.45 $202.18 $221.60 $235.45 $190.44 100% of Medicare 100% of Medicare $207.75 200% of Medicare NULL 300 NULL 84702 NULL NULL 14007324 Beta hCG Blood NULL INSTITUTIONAL $124.00 1/1/2022-12/31/2022 $124.00 $51.83 $70.68 $91.14 $91.14 200% of Medicare 100% of Medicare $72.92 $70.20 $68.36 $51.83 100% of Medicaid 100% of Medicare 150% of Medicare $99.20 $124.00 195% of Medicare $100.44 $72.54 $72.54 $58.53 $79.78 100% of Medicare $99.20 $105.40 $97.34 $90.51 $99.20 $105.40 $85.25 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 300 NULL 82248 NULL NULL 14007327 Direct Bilirubin NULL INSTITUTIONAL $42.00 1/1/2022-12/31/2022 $42.00 $17.56 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $24.70 $23.78 $23.15 $17.56 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 195% of Medicare $34.02 $24.57 $24.57 $19.82 $27.02 100% of Medicare $33.60 $35.70 $32.97 $30.66 $33.60 $35.70 $28.88 100% of Medicare 100% of Medicare $31.50 200% of Medicare NULL 300 NULL 82247 NULL NULL 14007332 Total Bilirubin NULL INSTITUTIONAL $42.00 1/1/2022-12/31/2022 $42.00 $17.56 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $24.70 $23.78 $23.15 $17.56 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 195% of Medicare $34.02 $24.57 $24.57 $19.82 $27.02 100% of Medicare $33.60 $35.70 $32.97 $30.66 $33.60 $35.70 $28.88 100% of Medicare 100% of Medicare $31.50 200% of Medicare NULL 300 NULL 86160 NULL NULL 14007337 Complement C3 NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 300 NULL 86160 NULL NULL 14007338 Complement C4 NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 300 NULL 82340 NULL NULL 14007345 "Urine Calcium, Random" NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $20.90 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.41 $28.31 $27.57 $20.90 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.25 $29.25 $23.60 $32.17 100% of Medicare $40.00 $42.50 $39.25 $36.50 $40.00 $42.50 $34.38 100% of Medicare 100% of Medicare $37.50 200% of Medicare NULL 300 NULL 80047 NULL NULL 14007349 Calcium Ionized QN NULL INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $28.84 $39.33 $50.72 $50.72 200% of Medicare 100% of Medicare $40.58 $39.06 $38.04 $28.84 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $40.37 $40.37 $32.57 $44.39 100% of Medicare $55.20 $58.65 $54.17 $50.36 $55.20 $58.65 $47.44 100% of Medicare 100% of Medicare $51.75 200% of Medicare NULL 300 NULL 80156 NULL NULL 14007354 Carbamazepine NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 300 NULL 86301 NULL NULL 14007355 CA 19-9 NULL INSTITUTIONAL $170.00 1/1/2022-12/31/2022 $170.00 $71.06 $96.90 $124.95 $124.95 200% of Medicare 100% of Medicare $99.98 $96.24 $93.72 $71.06 100% of Medicaid 100% of Medicare 150% of Medicare $136.00 $170.00 195% of Medicare $137.70 $99.45 $99.45 $80.24 $109.38 100% of Medicare $136.00 $144.50 $133.45 $124.08 $136.00 $144.50 $116.88 100% of Medicare 100% of Medicare $127.50 200% of Medicare NULL 300 NULL 82378 NULL NULL 14007360 CEA NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 300 NULL 82465 NULL NULL 14007365 HDL Cholesterol NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $14.63 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.58 $19.81 $19.30 $14.63 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.48 $20.48 $16.52 $22.52 100% of Medicare $28.00 $29.75 $27.48 $25.55 $28.00 $29.75 $24.06 100% of Medicare 100% of Medicare $26.25 200% of Medicare NULL 300 NULL 83721 NULL NULL 14007366 "LDL, Measured" NULL INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $32.60 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $45.87 $44.16 $43.00 $32.60 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $45.63 $45.63 $36.82 $50.19 100% of Medicare $62.40 $66.30 $61.23 $56.93 $62.40 $66.30 $53.63 100% of Medicare 100% of Medicare $58.50 200% of Medicare NULL 300 NULL 82465 NULL NULL 14007367 Cholesterol NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $14.63 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.58 $19.81 $19.30 $14.63 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.48 $20.48 $16.52 $22.52 100% of Medicare $28.00 $29.75 $27.48 $25.55 $28.00 $29.75 $24.06 100% of Medicare 100% of Medicare $26.25 200% of Medicare NULL 300 NULL 82553 NULL NULL 14007372 CK MB NULL INSTITUTIONAL $95.00 1/1/2022-12/31/2022 $95.00 $39.71 $54.15 $69.83 $69.83 200% of Medicare 100% of Medicare $55.87 $53.78 $52.37 $39.71 100% of Medicaid 100% of Medicare 150% of Medicare $76.00 $95.00 195% of Medicare $76.95 $55.58 $55.58 $44.84 $61.12 100% of Medicare $76.00 $80.75 $74.58 $69.34 $76.00 $80.75 $65.31 100% of Medicare 100% of Medicare $71.25 200% of Medicare NULL 300 NULL 80053 NULL NULL 14007373 Comprehensive Metabolic Panel NULL INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $36.78 $50.16 $64.68 $64.68 200% of Medicare 100% of Medicare $51.75 $49.82 $48.51 $36.78 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $51.48 $51.48 $41.54 $56.62 100% of Medicare $70.40 $74.80 $69.08 $64.23 $70.40 $74.80 $60.50 100% of Medicare 100% of Medicare $66.00 200% of Medicare NULL 300 NULL 82530 NULL NULL 14007382 Cortisol NULL INSTITUTIONAL $138.00 1/1/2022-12/31/2022 $138.00 $57.68 $78.66 $101.43 $101.43 200% of Medicare 100% of Medicare $81.16 $78.12 $76.08 $57.68 100% of Medicaid 100% of Medicare 150% of Medicare $110.40 $138.00 195% of Medicare $111.78 $80.73 $80.73 $65.14 $88.79 100% of Medicare $110.40 $117.30 $108.33 $100.73 $110.40 $117.30 $94.88 100% of Medicare 100% of Medicare $103.50 200% of Medicare NULL 300 NULL 82550 NULL NULL 14007387 CK NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $22.57 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $31.76 $30.57 $29.77 $22.57 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $31.59 $31.59 $25.49 $34.74 100% of Medicare $43.20 $45.90 $42.39 $39.41 $43.20 $45.90 $37.13 100% of Medicare 100% of Medicare $40.50 200% of Medicare NULL 300 NULL 82570 NULL NULL 14007392 "Urine Creatinine, Random" NULL INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $17.97 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.29 $24.34 $23.71 $17.97 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.16 $25.16 $20.30 $27.67 100% of Medicare $34.40 $36.55 $33.76 $31.39 $34.40 $36.55 $29.56 100% of Medicare 100% of Medicare $32.25 200% of Medicare NULL 300 NULL 80158 NULL NULL 14007393 Cyclosporine NULL INSTITUTIONAL $148.00 1/1/2022-12/31/2022 $148.00 $61.86 $84.36 $108.78 $108.78 200% of Medicare 100% of Medicare $87.04 $83.78 $81.59 $61.86 100% of Medicaid 100% of Medicare 150% of Medicare $118.40 $148.00 195% of Medicare $119.88 $86.58 $86.58 $69.86 $95.22 100% of Medicare $118.40 $125.80 $116.18 $108.03 $118.40 $125.80 $101.75 100% of Medicare 100% of Medicare $111.00 200% of Medicare NULL 300 NULL 80162 NULL NULL 14007398 Digoxin NULL INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $44.73 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $62.93 $60.57 $58.99 $44.73 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $62.60 $62.60 $50.50 $68.84 100% of Medicare $85.60 $90.95 $84.00 $78.10 $85.60 $90.95 $73.56 100% of Medicare 100% of Medicare $80.25 200% of Medicare NULL 300 NULL 80299 NULL NULL 14007403 Drug Screen Blood NULL INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $46.82 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $65.87 $63.40 $61.75 $46.82 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $65.52 $65.52 $52.86 $72.06 100% of Medicare $89.60 $95.20 $87.92 $81.75 $89.60 $95.20 $77.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 300 NULL NULL NULL NULL 14030893 Drugs of Abuse Screen Urine NULL INSTITUTIONAL $315.00 1/1/2022-12/31/2022 $315.00 $148.68 $179.55 $231.53 $231.53 200% of Medicare 100% of Medicare $188.62 $181.57 $176.81 $201.60 100% of Medicaid 100% of Medicare 150% of Medicare $252.00 $315.00 195% of Medicare $255.15 $187.43 $187.43 $148.68 $315.00 100% of Medicare $252.00 $267.75 $283.50 $229.92 $267.75 $315.00 $315.00 100% of Medicare 100% of Medicare $315.00 200% of Medicare NULL 300 NULL 83010 NULL NULL 14030903 Haptoglobin NULL INSTITUTIONAL $103.00 1/1/2022-12/31/2022 $103.00 $43.05 $58.71 $75.71 $75.71 200% of Medicare 100% of Medicare $60.57 $58.31 $56.78 $43.05 100% of Medicaid 100% of Medicare 150% of Medicare $82.40 $103.00 195% of Medicare $83.43 $60.26 $60.26 $48.62 $66.27 100% of Medicare $82.40 $87.55 $80.86 $75.18 $82.40 $87.55 $70.81 100% of Medicare 100% of Medicare $77.25 200% of Medicare NULL 300 NULL 83036 NULL NULL 14030911 Hemoglobin A1c NULL INSTITUTIONAL $79.00 1/1/2022-12/31/2022 $79.00 $33.02 $45.03 $58.07 $58.07 200% of Medicare 100% of Medicare $46.46 $44.72 $43.55 $33.02 100% of Medicaid 100% of Medicare 150% of Medicare $63.20 $79.00 195% of Medicare $63.99 $46.22 $46.22 $37.29 $50.83 100% of Medicare $63.20 $67.15 $62.02 $57.66 $63.20 $67.15 $54.31 100% of Medicare 100% of Medicare $59.25 200% of Medicare NULL 300 NULL 85018 NULL NULL 14030916 "Hemoglobin, Free" NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $8.36 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.76 $11.32 $11.03 $8.36 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.70 $11.70 $9.44 $12.87 100% of Medicare $16.00 $17.00 $15.70 $14.60 $16.00 $17.00 $13.75 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 300 NULL 83090 NULL NULL 14030917 Homocysteine NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 300 NULL 83540 NULL NULL 14030924 Iron NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $22.57 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $31.76 $30.57 $29.77 $22.57 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $31.59 $31.59 $25.49 $34.74 100% of Medicare $43.20 $45.90 $42.39 $39.41 $43.20 $45.90 $37.13 100% of Medicare 100% of Medicare $40.50 200% of Medicare NULL 300 NULL 83540 NULL NULL 14030925 Iron and TIBC NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $22.57 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $31.76 $30.57 $29.77 $22.57 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $31.59 $31.59 $25.49 $34.74 100% of Medicare $43.20 $45.90 $42.39 $39.41 $43.20 $45.90 $37.13 100% of Medicare 100% of Medicare $40.50 200% of Medicare NULL 300 NULL 80197 NULL NULL 14030930 FK 506 NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $47.23 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $66.46 $63.97 $62.30 $47.23 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $66.11 $66.11 $53.34 $72.70 100% of Medicare $90.40 $96.05 $88.71 $82.48 $90.40 $96.05 $77.69 100% of Medicare 100% of Medicare $84.75 200% of Medicare NULL 300 NULL 82747 NULL NULL 14030931 "Folate, RBC" NULL INSTITUTIONAL $143.00 1/1/2022-12/31/2022 $143.00 $59.77 $81.51 $105.11 $105.11 200% of Medicare 100% of Medicare $84.10 $80.95 $78.84 $59.77 100% of Medicaid 100% of Medicare 150% of Medicare $114.40 $143.00 195% of Medicare $115.83 $83.66 $83.66 $67.50 $92.01 100% of Medicare $114.40 $121.55 $112.26 $104.38 $114.40 $121.55 $98.31 100% of Medicare 100% of Medicare $107.25 200% of Medicare NULL 300 NULL 82746 NULL NULL 14030932 Folate NULL INSTITUTIONAL $122.00 1/1/2022-12/31/2022 $122.00 $51.00 $69.54 $89.67 $89.67 200% of Medicare 100% of Medicare $71.75 $69.06 $67.26 $51.00 100% of Medicaid 100% of Medicare 150% of Medicare $97.60 $122.00 195% of Medicare $98.82 $71.37 $71.37 $57.58 $78.49 100% of Medicare $97.60 $103.70 $95.77 $89.05 $97.60 $103.70 $83.88 100% of Medicare 100% of Medicare $91.50 200% of Medicare NULL 300 NULL 82977 NULL NULL 14030933 GGT NULL INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $24.66 $33.63 $43.37 $43.37 200% of Medicare 100% of Medicare $34.70 $33.40 $32.53 $24.66 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $34.52 $34.52 $27.85 $37.96 100% of Medicare $47.20 $50.15 $46.32 $43.06 $47.20 $50.15 $40.56 100% of Medicare 100% of Medicare $44.25 200% of Medicare NULL 300 NULL 80170 NULL NULL 14030934 Gentamicin Post NULL INSTITUTIONAL $133.00 1/1/2022-12/31/2022 $133.00 $55.59 $75.81 $97.76 $97.76 200% of Medicare 100% of Medicare $78.22 $75.29 $73.32 $55.59 100% of Medicaid 100% of Medicare 150% of Medicare $106.40 $133.00 195% of Medicare $107.73 $77.81 $77.81 $62.78 $85.57 100% of Medicare $106.40 $113.05 $104.41 $97.08 $106.40 $113.05 $91.44 100% of Medicare 100% of Medicare $99.75 200% of Medicare NULL 300 NULL 80170 NULL NULL 14030935 Gentamicin Pre NULL INSTITUTIONAL $133.00 1/1/2022-12/31/2022 $133.00 $55.59 $75.81 $97.76 $97.76 200% of Medicare 100% of Medicare $78.22 $75.29 $73.32 $55.59 100% of Medicaid 100% of Medicare 150% of Medicare $106.40 $133.00 195% of Medicare $107.73 $77.81 $77.81 $62.78 $85.57 100% of Medicare $106.40 $113.05 $104.41 $97.08 $106.40 $113.05 $91.44 100% of Medicare 100% of Medicare $99.75 200% of Medicare NULL 300 NULL 82948 NULL NULL 14030936 "Gluc-Strip, POC" NULL INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $10.87 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.29 $14.72 $14.33 $10.87 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.21 $15.21 $12.27 $16.73 100% of Medicare $20.80 $22.10 $20.41 $18.98 $20.80 $22.10 $17.88 100% of Medicare 100% of Medicare $19.50 200% of Medicare NULL 300 NULL 82945 NULL NULL 14030937 Spinal Fluid Glucose NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $13.79 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.41 $18.68 $18.19 $13.79 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.31 $19.31 $15.58 $21.23 100% of Medicare $26.40 $28.05 $25.91 $24.09 $26.40 $28.05 $22.69 100% of Medicare 100% of Medicare $24.75 200% of Medicare NULL 300 NULL 82962 NULL NULL 14030938 Glucose NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $8.36 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.76 $11.32 $11.03 $8.36 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.70 $11.70 $9.44 $12.87 100% of Medicare $16.00 $17.00 $15.70 $14.60 $16.00 $17.00 $13.75 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 300 NULL 82947 NULL NULL 14030940 Glucose POC NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $13.79 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.41 $18.68 $18.19 $13.79 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.31 $19.31 $15.58 $21.23 100% of Medicare $26.40 $28.05 $25.91 $24.09 $26.40 $28.05 $22.69 100% of Medicare 100% of Medicare $24.75 200% of Medicare NULL 300 NULL 83615 NULL NULL 14030941 LDH NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $20.90 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.41 $28.31 $27.57 $20.90 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.25 $29.25 $23.60 $32.17 100% of Medicare $40.00 $42.50 $39.25 $36.50 $40.00 $42.50 $34.38 100% of Medicare 100% of Medicare $37.50 200% of Medicare NULL 300 NULL 83690 NULL NULL 14030942 Lipase NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 200% of Medicare 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 300 NULL 80061 NULL NULL 14030943 Lipid Panel NULL INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $33.44 $45.60 $58.80 $58.80 200% of Medicare 100% of Medicare $47.05 $45.29 $44.10 $33.44 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $46.80 $46.80 $37.76 $51.47 100% of Medicare $64.00 $68.00 $62.80 $58.39 $64.00 $68.00 $55.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 300 NULL 80178 NULL NULL 14030944 Lithium NULL INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $22.99 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.35 $31.14 $30.32 $22.99 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.18 $32.18 $25.96 $35.39 100% of Medicare $44.00 $46.75 $43.18 $40.14 $44.00 $46.75 $37.81 100% of Medicare 100% of Medicare $41.25 200% of Medicare NULL 300 NULL 83735 NULL NULL 14030945 Magnesium NULL INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $22.99 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.35 $31.14 $30.32 $22.99 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.18 $32.18 $25.96 $35.39 100% of Medicare $44.00 $46.75 $43.18 $40.14 $44.00 $46.75 $37.81 100% of Medicare 100% of Medicare $41.25 200% of Medicare NULL 300 NULL 89390 NULL NULL 14030946 Osmolality NULL INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $22.99 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.35 $31.14 $30.32 $22.99 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.18 $32.18 $25.96 $35.39 100% of Medicare $44.00 $46.75 $43.18 $40.14 $44.00 $46.75 $37.81 100% of Medicare 100% of Medicare $41.25 200% of Medicare NULL 300 NULL 83935 NULL NULL 14030947 "Urine Osmolality, Random" NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 200% of Medicare 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Non-Formulary Medication 99999-9999-99 INSTITUTIONAL $418.00 1/1/2022-12/31/2022 $418.00 $197.30 $238.26 $307.23 $307.23 200% of Medicare 100% of Medicare $250.30 $240.94 $234.62 $267.52 100% of Medicaid 100% of Medicare 150% of Medicare $334.40 $418.00 195% of Medicare $338.58 $248.71 $248.71 $197.30 $418.00 100% of Medicare $334.40 $355.30 $376.20 $305.10 $355.30 $418.00 $418.00 100% of Medicare 100% of Medicare $418.00 200% of Medicare NULL 300 NULL 83970 NULL NULL 14156523 "PTH, Intact" NULL INSTITUTIONAL $338.00 1/1/2022-12/31/2022 $338.00 $141.28 $192.66 $248.43 $248.43 200% of Medicare 100% of Medicare $198.78 $191.34 $186.34 $141.28 100% of Medicaid 100% of Medicare 150% of Medicare $270.40 $338.00 195% of Medicare $273.78 $197.73 $197.73 $159.54 $217.47 100% of Medicare $270.40 $287.30 $265.33 $246.71 $270.40 $287.30 $232.38 100% of Medicare 100% of Medicare $253.50 200% of Medicare NULL 300 NULL 80185 NULL NULL 14156524 Phenytoin NULL INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $44.73 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $62.93 $60.57 $58.99 $44.73 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $62.60 $62.60 $50.50 $68.84 100% of Medicare $85.60 $90.95 $84.00 $78.10 $85.60 $90.95 $73.56 100% of Medicare 100% of Medicare $80.25 200% of Medicare NULL 300 NULL 84100 NULL NULL 14156526 Phosphorus NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $16.30 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $22.94 $22.08 $21.50 $16.30 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $22.82 $22.82 $18.41 $25.09 100% of Medicare $31.20 $33.15 $30.62 $28.47 $31.20 $33.15 $26.81 100% of Medicare 100% of Medicare $29.25 200% of Medicare NULL 300 NULL 84132 NULL NULL 14156527 Potassium NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $16.30 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $22.94 $22.08 $21.50 $16.30 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $22.82 $22.82 $18.41 $25.09 100% of Medicare $31.20 $33.15 $30.62 $28.47 $31.20 $33.15 $26.81 100% of Medicare 100% of Medicare $29.25 200% of Medicare NULL 300 NULL 84132 NULL NULL 14156528 "Potassium, POC" NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $16.30 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $22.94 $22.08 $21.50 $16.30 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $22.82 $22.82 $18.41 $25.09 100% of Medicare $31.20 $33.15 $30.62 $28.47 $31.20 $33.15 $26.81 100% of Medicare 100% of Medicare $29.25 200% of Medicare NULL 300 NULL 84134 NULL NULL 14156529 Prealbumin NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 300 NULL 84153 NULL NULL 14156530 PSA NULL INSTITUTIONAL $151.00 1/1/2022-12/31/2022 $151.00 $63.12 $86.07 $110.99 $110.99 200% of Medicare 100% of Medicare $88.80 $85.48 $83.25 $63.12 100% of Medicaid 100% of Medicare 150% of Medicare $120.80 $151.00 195% of Medicare $122.31 $88.34 $88.34 $71.27 $97.15 100% of Medicare $120.80 $128.35 $118.54 $110.21 $120.80 $128.35 $103.81 100% of Medicare 100% of Medicare $113.25 200% of Medicare NULL 300 NULL 84156 NULL NULL 14156531 "Urine Protein, Random" NULL INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $12.12 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.05 $16.42 $15.99 $12.12 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $16.97 $16.97 $13.69 $18.66 100% of Medicare $23.20 $24.65 $22.77 $21.17 $23.20 $24.65 $19.94 100% of Medicare 100% of Medicare $21.75 200% of Medicare NULL 300 NULL 80069 NULL NULL 14156532 Renal Function Panel NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 200% of Medicare 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 300 NULL 86430 NULL NULL 14156533 Rheumatoid Factor NULL INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $19.23 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.05 $26.04 $25.36 $19.23 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $26.91 $26.91 $21.71 $29.60 100% of Medicare $36.80 $39.10 $36.11 $33.58 $36.80 $39.10 $31.63 100% of Medicare 100% of Medicare $34.50 200% of Medicare NULL 300 NULL 84295 NULL NULL 14156534 Sodium NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $17.14 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.11 $23.21 $22.60 $17.14 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $23.99 $23.99 $19.35 $26.38 100% of Medicare $32.80 $34.85 $32.19 $29.93 $32.80 $34.85 $28.19 100% of Medicare 100% of Medicare $30.75 200% of Medicare NULL 300 NULL 84300 NULL NULL 14156535 Urine Sodium NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $17.14 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.11 $23.21 $22.60 $17.14 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $23.99 $23.99 $19.35 $26.38 100% of Medicare $32.80 $34.85 $32.19 $29.93 $32.80 $34.85 $28.19 100% of Medicare 100% of Medicare $30.75 200% of Medicare NULL 300 NULL 81003 NULL NULL 14156536 Urine Specific Gravity NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $8.36 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.76 $11.32 $11.03 $8.36 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.70 $11.70 $9.44 $12.87 100% of Medicare $16.00 $17.00 $15.70 $14.60 $16.00 $17.00 $13.75 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 300 NULL 84481 NULL NULL 14156537 "T3, Free" NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 300 NULL 84439 NULL NULL 14156538 "T4, Free, Direct" NULL INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $30.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $43.52 $41.89 $40.80 $30.93 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $43.29 $43.29 $34.93 $47.61 100% of Medicare $59.20 $62.90 $58.09 $54.01 $59.20 $62.90 $50.88 100% of Medicare 100% of Medicare $55.50 200% of Medicare NULL 300 NULL 84403 NULL NULL 14156539 "Testosterone, Total" NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $88.62 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $124.68 $120.01 $116.88 $88.62 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $124.02 $124.02 $100.06 $136.40 100% of Medicare $169.60 $180.20 $166.42 $154.74 $169.60 $180.20 $145.75 100% of Medicare 100% of Medicare $159.00 200% of Medicare NULL 300 NULL 84436 NULL NULL 14156540 T4 NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 200% of Medicare 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 300 NULL 80200 NULL NULL 14156541 Tobramycin Pre NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 300 NULL 84466 NULL NULL 14156547 Transferrin NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 300 NULL 84480 NULL NULL 14156548 "T3, Total" NULL INSTITUTIONAL $116.00 1/1/2022-12/31/2022 $116.00 $48.49 $66.12 $85.26 $85.26 200% of Medicare 100% of Medicare $68.22 $65.67 $63.95 $48.49 100% of Medicaid 100% of Medicare 150% of Medicare $92.80 $116.00 195% of Medicare $93.96 $67.86 $67.86 $54.75 $74.63 100% of Medicare $92.80 $98.60 $91.06 $84.67 $92.80 $98.60 $79.75 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 300 NULL 84512 NULL NULL 14156554 Troponin I NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $26.75 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $37.64 $36.23 $35.28 $26.75 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $37.44 $37.44 $30.21 $41.18 100% of Medicare $51.20 $54.40 $50.24 $46.71 $51.20 $54.40 $44.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 300 NULL 84443 NULL NULL 14156555 "TSH, 3rd Gen" NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 300 NULL 84540 NULL NULL 14156561 Urine Urea Nitrogen NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $16.30 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $22.94 $22.08 $21.50 $16.30 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $22.82 $22.82 $18.41 $25.09 100% of Medicare $31.20 $33.15 $30.62 $28.47 $31.20 $33.15 $26.81 100% of Medicare 100% of Medicare $29.25 200% of Medicare NULL 300 NULL 84550 NULL NULL 14156562 Uric Acid NULL INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $15.88 $21.66 $27.93 $27.93 200% of Medicare 100% of Medicare $22.35 $21.51 $20.95 $15.88 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.23 $22.23 $17.94 $24.45 100% of Medicare $30.40 $32.30 $29.83 $27.74 $30.40 $32.30 $26.13 100% of Medicare 100% of Medicare $28.50 200% of Medicare NULL 300 NULL 80164 NULL NULL 14156563 Valproic Acid NULL INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $46.82 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $65.87 $63.40 $61.75 $46.82 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $65.52 $65.52 $52.86 $72.06 100% of Medicare $89.60 $95.20 $87.92 $81.75 $89.60 $95.20 $77.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 300 NULL 80202 NULL NULL 14156569 Vancomycin Post NULL INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $46.82 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $65.87 $63.40 $61.75 $46.82 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $65.52 $65.52 $52.86 $72.06 100% of Medicare $89.60 $95.20 $87.92 $81.75 $89.60 $95.20 $77.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 300 NULL 80202 NULL NULL 14156575 Vancomycin Pre NULL INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $46.82 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $65.87 $63.40 $61.75 $46.82 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $65.52 $65.52 $52.86 $72.06 100% of Medicare $89.60 $95.20 $87.92 $81.75 $89.60 $95.20 $77.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 300 NULL 82607 NULL NULL 14156593 Vitamin B12 NULL INSTITUTIONAL $124.00 1/1/2022-12/31/2022 $124.00 $51.83 $70.68 $91.14 $91.14 200% of Medicare 100% of Medicare $72.92 $70.20 $68.36 $51.83 100% of Medicaid 100% of Medicare 150% of Medicare $99.20 $124.00 195% of Medicare $100.44 $72.54 $72.54 $58.53 $79.78 100% of Medicare $99.20 $105.40 $97.34 $90.51 $99.20 $105.40 $85.25 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 300 NULL 87040 NULL NULL 14156594 Blood Culture NULL INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $35.95 $49.02 $63.21 $63.21 200% of Medicare 100% of Medicare $50.58 $48.68 $47.41 $35.95 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $50.31 $50.31 $40.59 $55.33 100% of Medicare $68.80 $73.10 $67.51 $62.77 $68.80 $73.10 $59.13 100% of Medicare 100% of Medicare $64.50 200% of Medicare NULL 300 NULL 86904 NULL NULL 14156595 Crossmatch MTS NULL INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $32.60 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $45.87 $44.16 $43.00 $32.60 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $45.63 $45.63 $36.82 $50.19 100% of Medicare $62.40 $66.30 $61.23 $56.93 $62.40 $66.30 $53.63 100% of Medicare 100% of Medicare $58.50 200% of Medicare NULL 300 NULL 86039 NULL NULL 14156596 ANA Ab NULL INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $38.04 $51.87 $66.89 $66.89 200% of Medicare 100% of Medicare $53.52 $51.52 $50.17 $38.04 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $53.24 $53.24 $42.95 $58.55 100% of Medicare $72.80 $77.35 $71.44 $66.42 $72.80 $77.35 $62.56 100% of Medicare 100% of Medicare $68.25 200% of Medicare NULL 300 NULL 87076 NULL NULL 14156597 Specific Organism Culture NULL INSTITUTIONAL $67.00 1/1/2022-12/31/2022 $67.00 $28.01 $38.19 $49.25 $49.25 200% of Medicare 100% of Medicare $39.40 $37.93 $36.94 $28.01 100% of Medicaid 100% of Medicare 150% of Medicare $53.60 $67.00 195% of Medicare $54.27 $39.20 $39.20 $31.62 $43.11 100% of Medicare $53.60 $56.95 $52.60 $48.90 $53.60 $56.95 $46.06 100% of Medicare 100% of Medicare $50.25 200% of Medicare NULL 300 NULL 87207 NULL NULL 14156598 O+P Screen NULL INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $20.48 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $28.82 $27.74 $27.01 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $28.67 $28.67 $23.13 $31.53 100% of Medicare $39.20 $41.65 $38.47 $35.77 $39.20 $41.65 $33.69 100% of Medicare 100% of Medicare $36.75 200% of Medicare NULL 300 NULL 87046 NULL NULL 14156599 Stool Culture NULL INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $32.60 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $45.87 $44.16 $43.00 $32.60 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $45.63 $45.63 $36.82 $50.19 100% of Medicare $62.40 $66.30 $61.23 $56.93 $62.40 $66.30 $53.63 100% of Medicare 100% of Medicare $58.50 200% of Medicare NULL 300 NULL 87086 NULL NULL 14156600 Urine Culture NULL INSTITUTIONAL $67.00 1/1/2022-12/31/2022 $67.00 $28.01 $38.19 $49.25 $49.25 200% of Medicare 100% of Medicare $39.40 $37.93 $36.94 $28.01 100% of Medicaid 100% of Medicare 150% of Medicare $53.60 $67.00 195% of Medicare $54.27 $39.20 $39.20 $31.62 $43.11 100% of Medicare $53.60 $56.95 $52.60 $48.90 $53.60 $56.95 $46.06 100% of Medicare 100% of Medicare $50.25 200% of Medicare NULL 300 NULL 87070 NULL NULL 14156601 Wound Culture and Stain NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 200% of Medicare 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 300 NULL 87070 NULL NULL 14156602 Respiratory Culture and Stain NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 200% of Medicare 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 300 NULL 87077 NULL NULL 14156603 VRE Screen Culture NULL INSTITUTIONAL $67.00 1/1/2022-12/31/2022 $67.00 $28.01 $38.19 $49.25 $49.25 200% of Medicare 100% of Medicare $39.40 $37.93 $36.94 $28.01 100% of Medicaid 100% of Medicare 150% of Medicare $53.60 $67.00 195% of Medicare $54.27 $39.20 $39.20 $31.62 $43.11 100% of Medicare $53.60 $56.95 $52.60 $48.90 $53.60 $56.95 $46.06 100% of Medicare 100% of Medicare $50.25 200% of Medicare NULL 300 NULL 86361 NULL NULL 14156604 CD4 Followup NULL INSTITUTIONAL $219.00 1/1/2022-12/31/2022 $219.00 $91.54 $124.83 $160.97 $160.97 200% of Medicare 100% of Medicare $128.79 $123.98 $120.73 $91.54 100% of Medicaid 100% of Medicare 150% of Medicare $175.20 $219.00 195% of Medicare $177.39 $128.12 $128.12 $103.37 $140.90 100% of Medicare $175.20 $186.15 $171.92 $159.85 $175.20 $186.15 $150.56 100% of Medicare 100% of Medicare $164.25 200% of Medicare NULL 300 NULL 85009 NULL NULL 14156605 Manual Differential NULL INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $12.54 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.64 $16.98 $16.54 $12.54 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.55 $17.55 $14.16 $19.30 100% of Medicare $24.00 $25.50 $23.55 $21.90 $24.00 $25.50 $20.63 100% of Medicare 100% of Medicare $22.50 200% of Medicare NULL 300 NULL 87207 NULL NULL 14156606 Smear Review NULL INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $20.48 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $28.82 $27.74 $27.01 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $28.67 $28.67 $23.13 $31.53 100% of Medicare $39.20 $41.65 $38.47 $35.77 $39.20 $41.65 $33.69 100% of Medicare 100% of Medicare $36.75 200% of Medicare NULL 300 NULL 85652 NULL NULL 14156609 SED Rate NULL INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $9.61 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.53 $13.02 $12.68 $9.61 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.46 $13.46 $10.86 $14.80 100% of Medicare $18.40 $19.55 $18.06 $16.79 $18.40 $19.55 $15.81 100% of Medicare 100% of Medicare $17.25 200% of Medicare NULL 300 NULL 85044 NULL NULL 14156610 Retic Count NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $14.63 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.58 $19.81 $19.30 $14.63 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.48 $20.48 $16.52 $22.52 100% of Medicare $28.00 $29.75 $27.48 $25.55 $28.00 $29.75 $24.06 100% of Medicare 100% of Medicare $26.25 200% of Medicare NULL 300 NULL 86695 NULL NULL 14156611 "HSV IgG, EIA" NULL INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $44.73 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $62.93 $60.57 $58.99 $44.73 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $62.60 $62.60 $50.50 $68.84 100% of Medicare $85.60 $90.95 $84.00 $78.10 $85.60 $90.95 $73.56 100% of Medicare 100% of Medicare $80.25 200% of Medicare NULL 300 NULL 87101 NULL NULL 14156612 Fungus Culture and Stain NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $26.75 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $37.64 $36.23 $35.28 $26.75 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $37.44 $37.44 $30.21 $41.18 100% of Medicare $51.20 $54.40 $50.24 $46.71 $51.20 $54.40 $44.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 300 NULL 81001 NULL NULL 14156616 Urine Microscopic NULL INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $10.87 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.29 $14.72 $14.33 $10.87 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.21 $15.21 $12.27 $16.73 100% of Medicare $20.80 $22.10 $20.41 $18.98 $20.80 $22.10 $17.88 100% of Medicare 100% of Medicare $19.50 200% of Medicare NULL 300 NULL 81002 NULL NULL 14156617 Urinalysis Dipstick only NULL INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $8.78 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.35 $11.89 $11.58 $8.78 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.29 $12.29 $9.91 $13.51 100% of Medicare $16.80 $17.85 $16.49 $15.33 $16.80 $17.85 $14.44 100% of Medicare 100% of Medicare $15.75 200% of Medicare NULL 300 NULL 87205 NULL NULL 14156619 Wright Stain NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $14.63 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.58 $19.81 $19.30 $14.63 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.48 $20.48 $16.52 $22.52 100% of Medicare $28.00 $29.75 $27.48 $25.55 $28.00 $29.75 $24.06 100% of Medicare 100% of Medicare $26.25 200% of Medicare NULL 300 NULL 82271 NULL NULL 14156621 Occult Blood NULL INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $10.87 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.29 $14.72 $14.33 $10.87 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.21 $15.21 $12.27 $16.73 100% of Medicare $20.80 $22.10 $20.41 $18.98 $20.80 $22.10 $17.88 100% of Medicare 100% of Medicare $19.50 200% of Medicare NULL 300 NULL 85018 NULL NULL 14156622 Hemoglobin NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $8.36 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.76 $11.32 $11.03 $8.36 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.70 $11.70 $9.44 $12.87 100% of Medicare $16.00 $17.00 $15.70 $14.60 $16.00 $17.00 $13.75 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 300 NULL 80076 NULL NULL 14156624 Hepatic Function Panel NULL INSTITUTIONAL $68.00 1/1/2022-12/31/2022 $68.00 $28.42 $38.76 $49.98 $49.98 200% of Medicare 100% of Medicare $39.99 $38.49 $37.49 $28.42 100% of Medicaid 100% of Medicare 150% of Medicare $54.40 $68.00 195% of Medicare $55.08 $39.78 $39.78 $32.10 $43.75 100% of Medicare $54.40 $57.80 $53.38 $49.63 $54.40 $57.80 $46.75 100% of Medicare 100% of Medicare $51.00 200% of Medicare NULL 300 NULL 86904 NULL NULL 14156625 Crossmatch Computer NULL INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $32.60 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $45.87 $44.16 $43.00 $32.60 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $45.63 $45.63 $36.82 $50.19 100% of Medicare $62.40 $66.30 $61.23 $56.93 $62.40 $66.30 $53.63 100% of Medicare 100% of Medicare $58.50 200% of Medicare NULL 300 NULL 80299 NULL NULL 14156626 Levetiracetam (Keppra) NULL INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $46.82 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $65.87 $63.40 $61.75 $46.82 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $65.52 $65.52 $52.86 $72.06 100% of Medicare $89.60 $95.20 $87.92 $81.75 $89.60 $95.20 $77.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 300 NULL 82306 NULL NULL 14156628 "Vitamin D, 1,25 Dihydroxy" NULL INSTITUTIONAL $243.00 1/1/2022-12/31/2022 $243.00 $101.57 $138.51 $178.61 $178.61 200% of Medicare 100% of Medicare $142.91 $137.56 $133.97 $101.57 100% of Medicaid 100% of Medicare 150% of Medicare $194.40 $243.00 195% of Medicare $196.83 $142.16 $142.16 $114.70 $156.35 100% of Medicare $194.40 $206.55 $190.76 $177.37 $194.40 $206.55 $167.06 100% of Medicare 100% of Medicare $182.25 200% of Medicare NULL 300 NULL 82232 NULL NULL 14156630 Beta-2 Microglobulin CSF NULL INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $54.76 $74.67 $96.29 $96.29 200% of Medicare 100% of Medicare $77.04 $74.16 $72.22 $54.76 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $76.64 $76.64 $61.83 $84.29 100% of Medicare $104.80 $111.35 $102.84 $95.62 $104.80 $111.35 $90.06 100% of Medicare 100% of Medicare $98.25 200% of Medicare NULL 300 NULL 84126 NULL NULL 14156631 "Hemoccult, POC" NULL INSTITUTIONAL $209.00 1/1/2022-12/31/2022 $209.00 $87.36 $119.13 $153.62 $153.62 200% of Medicare 100% of Medicare $122.91 $118.31 $115.22 $87.36 100% of Medicaid 100% of Medicare 150% of Medicare $167.20 $209.00 195% of Medicare $169.29 $122.27 $122.27 $98.65 $134.47 100% of Medicare $167.20 $177.65 $164.07 $152.55 $167.20 $177.65 $143.69 100% of Medicare 100% of Medicare $156.75 200% of Medicare NULL 300 NULL 86804 NULL NULL 14156632 Hepatitis C (VIRAL LOAD) NULL INSTITUTIONAL $126.00 1/1/2022-12/31/2022 $126.00 $52.67 $71.82 $92.61 $92.61 200% of Medicare 100% of Medicare $74.10 $71.33 $69.46 $52.67 100% of Medicaid 100% of Medicare 150% of Medicare $100.80 $126.00 195% of Medicare $102.06 $73.71 $73.71 $59.47 $81.07 100% of Medicare $100.80 $107.10 $98.91 $91.97 $100.80 $107.10 $86.63 100% of Medicare 100% of Medicare $94.50 200% of Medicare NULL 300 NULL 84479 NULL NULL 14156637 T4 w/T3 Uptake NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $22.57 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $31.76 $30.57 $29.77 $22.57 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $31.59 $31.59 $25.49 $34.74 100% of Medicare $43.20 $45.90 $42.39 $39.41 $43.20 $45.90 $37.13 100% of Medicare 100% of Medicare $40.50 200% of Medicare NULL 300 NULL 87278 NULL NULL 14156638 "L pneumophila Ag, Urine" NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 300 NULL 85014 NULL NULL 14156644 "iSTAT, CHEM8 POC" NULL INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $5.43 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.65 $7.36 $7.17 $5.43 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.61 $7.61 $6.14 $8.36 100% of Medicare $10.40 $11.05 $10.21 $9.49 $10.40 $11.05 $8.94 100% of Medicare 100% of Medicare $9.75 200% of Medicare NULL 300 NULL 81005 NULL NULL 14156646 Urinalysis Complete NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $7.94 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.17 $10.76 $10.47 $7.94 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.12 $11.12 $8.97 $12.22 100% of Medicare $15.20 $16.15 $14.92 $13.87 $15.20 $16.15 $13.06 100% of Medicare 100% of Medicare $14.25 200% of Medicare NULL 300 NULL 84484 NULL NULL 14156647 "Troponin I, POC" NULL INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $33.44 $45.60 $58.80 $58.80 200% of Medicare 100% of Medicare $47.05 $45.29 $44.10 $33.44 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $46.80 $46.80 $37.76 $51.47 100% of Medicare $64.00 $68.00 $62.80 $58.39 $64.00 $68.00 $55.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 300 NULL 86706 NULL NULL 14156648 Hepatitis B Surface Ab NULL INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $37.20 $50.73 $65.42 $65.42 200% of Medicare 100% of Medicare $52.34 $50.38 $49.07 $37.20 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.07 $52.07 $42.01 $57.26 100% of Medicare $71.20 $75.65 $69.87 $64.96 $71.20 $75.65 $61.19 100% of Medicare 100% of Medicare $66.75 200% of Medicare NULL 300 NULL 86689 NULL NULL 14156649 HIV Antigen (non-ICD) NULL INSTITUTIONAL $159.00 1/1/2022-12/31/2022 $159.00 $66.46 $90.63 $116.87 $116.87 200% of Medicare 100% of Medicare $93.51 $90.01 $87.66 $66.46 100% of Medicaid 100% of Medicare 150% of Medicare $127.20 $159.00 195% of Medicare $128.79 $93.02 $93.02 $75.05 $102.30 100% of Medicare $127.20 $135.15 $124.82 $116.05 $127.20 $135.15 $109.31 100% of Medicare 100% of Medicare $119.25 200% of Medicare NULL 300 NULL 80074 NULL NULL 14156650 "Hepatitis Screen (Hep A, B, C Ab/Ag)" NULL INSTITUTIONAL $265.00 1/1/2022-12/31/2022 $265.00 $110.77 $151.05 $194.78 $194.78 200% of Medicare 100% of Medicare $155.85 $150.02 $146.09 $110.77 100% of Medicaid 100% of Medicare 150% of Medicare $212.00 $265.00 195% of Medicare $214.65 $155.03 $155.03 $125.08 $170.50 100% of Medicare $212.00 $225.25 $208.03 $193.42 $212.00 $225.25 $182.19 100% of Medicare 100% of Medicare $198.75 200% of Medicare NULL 300 NULL 87340 NULL NULL 14156651 Hepatitis B Surface Ag NULL INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $35.95 $49.02 $63.21 $63.21 200% of Medicare 100% of Medicare $50.58 $48.68 $47.41 $35.95 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $50.31 $50.31 $40.59 $55.33 100% of Medicare $68.80 $73.10 $67.51 $62.77 $68.80 $73.10 $59.13 100% of Medicare 100% of Medicare $64.50 200% of Medicare NULL 300 NULL 86705 NULL NULL 14156652 "Hepatitis B Core Antibody, IgM" NULL INSTITUTIONAL $98.00 1/1/2022-12/31/2022 $98.00 $40.96 $55.86 $72.03 $72.03 200% of Medicare 100% of Medicare $57.63 $55.48 $54.03 $40.96 100% of Medicaid 100% of Medicare 150% of Medicare $78.40 $98.00 195% of Medicare $79.38 $57.33 $57.33 $46.26 $63.05 100% of Medicare $78.40 $83.30 $76.93 $71.53 $78.40 $83.30 $67.38 100% of Medicare 100% of Medicare $73.50 200% of Medicare NULL 300 NULL 86704 NULL NULL 14156653 Hepatitis B Core Antibody NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 200% of Medicare 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 300 NULL 87081 NULL NULL 14156654 MRSA PCR NULL INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $22.99 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.35 $31.14 $30.32 $22.99 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.18 $32.18 $25.96 $35.39 100% of Medicare $44.00 $46.75 $43.18 $40.14 $44.00 $46.75 $37.81 100% of Medicare 100% of Medicare $41.25 200% of Medicare NULL 300 NULL 86762 NULL NULL 14156656 "Rubella Antibodies, IgG" NULL INSTITUTIONAL $118.00 1/1/2022-12/31/2022 $118.00 $49.32 $67.26 $86.73 $86.73 200% of Medicare 100% of Medicare $69.40 $66.80 $65.05 $49.32 100% of Medicaid 100% of Medicare 150% of Medicare $94.40 $118.00 195% of Medicare $95.58 $69.03 $69.03 $55.70 $75.92 100% of Medicare $94.40 $100.30 $92.63 $86.13 $94.40 $100.30 $81.13 100% of Medicare 100% of Medicare $88.50 200% of Medicare NULL 300 NULL 85380 NULL NULL 14156657 D-Dimer NULL INSTITUTIONAL $82.00 1/1/2022-12/31/2022 $82.00 $34.28 $46.74 $60.27 $60.27 200% of Medicare 100% of Medicare $48.22 $46.42 $45.21 $34.28 100% of Medicaid 100% of Medicare 150% of Medicare $65.60 $82.00 195% of Medicare $66.42 $47.97 $47.97 $38.70 $52.76 100% of Medicare $65.60 $69.70 $64.37 $59.85 $65.60 $69.70 $56.38 100% of Medicare 100% of Medicare $61.50 200% of Medicare NULL 300 NULL 86880 NULL NULL 14156658 Indirect Antiglobulin Test NULL INSTITUTIONAL $137.00 1/1/2022-12/31/2022 $137.00 $57.27 $78.09 $100.70 $100.70 200% of Medicare 100% of Medicare $80.57 $77.56 $75.53 $57.27 100% of Medicaid 100% of Medicare 150% of Medicare $109.60 $137.00 195% of Medicare $110.97 $80.15 $80.15 $64.66 $88.15 100% of Medicare $109.60 $116.45 $107.55 $100.00 $109.60 $116.45 $94.19 100% of Medicare 100% of Medicare $102.75 200% of Medicare NULL 300 NULL 82024 NULL NULL 14156659 Adrenocorticotropic Hormone(ACTH) NULL INSTITUTIONAL $236.00 1/1/2022-12/31/2022 $236.00 $98.65 $134.52 $173.46 $173.46 200% of Medicare 100% of Medicare $138.79 $133.60 $130.11 $98.65 100% of Medicaid 100% of Medicare 150% of Medicare $188.80 $236.00 195% of Medicare $191.16 $138.06 $138.06 $111.39 $151.84 100% of Medicare $188.80 $200.60 $185.26 $172.26 $188.80 $200.60 $162.25 100% of Medicare 100% of Medicare $177.00 200% of Medicare NULL 300 NULL 86901 NULL NULL 14156660 ABO/Rh Verify NULL INSTITUTIONAL $135.00 1/1/2022-12/31/2022 $135.00 $56.43 $76.95 $99.23 $99.23 200% of Medicare 100% of Medicare $79.39 $76.42 $74.43 $56.43 100% of Medicaid 100% of Medicare 150% of Medicare $108.00 $135.00 195% of Medicare $109.35 $78.98 $78.98 $63.72 $86.86 100% of Medicare $108.00 $114.75 $105.98 $98.54 $108.00 $114.75 $92.81 100% of Medicare 100% of Medicare $101.25 200% of Medicare NULL 300 NULL 87493 NULL NULL 14007336 C diff PCR Assay NULL INSTITUTIONAL $214.00 1/1/2022-12/31/2022 $214.00 $89.45 $121.98 $157.29 $157.29 200% of Medicare 100% of Medicare $125.85 $121.15 $117.98 $89.45 100% of Medicaid 100% of Medicare 150% of Medicare $171.20 $214.00 195% of Medicare $173.34 $125.19 $125.19 $101.01 $137.69 100% of Medicare $171.20 $181.90 $167.99 $156.20 $171.20 $181.90 $147.13 100% of Medicare 100% of Medicare $160.50 200% of Medicare NULL 300 NULL 80299 NULL NULL 14156662 Lamotrigine NULL INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $46.82 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $65.87 $63.40 $61.75 $46.82 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $65.52 $65.52 $52.86 $72.06 100% of Medicare $89.60 $95.20 $87.92 $81.75 $89.60 $95.20 $77.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 300 NULL 82180 NULL NULL 14156663 Vitamin C NULL INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $33.44 $45.60 $58.80 $58.80 200% of Medicare 100% of Medicare $47.05 $45.29 $44.10 $33.44 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $46.80 $46.80 $37.76 $51.47 100% of Medicare $64.00 $68.00 $62.80 $58.39 $64.00 $68.00 $55.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 300 NULL 86780 NULL NULL 14156664 Syphilis Treponemal IgG NULL INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $44.73 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $62.93 $60.57 $58.99 $44.73 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $62.60 $62.60 $50.50 $68.84 100% of Medicare $85.60 $90.95 $84.00 $78.10 $85.60 $90.95 $73.56 100% of Medicare 100% of Medicare $80.25 200% of Medicare NULL 300 NULL 86663 NULL NULL 14156665 EBV EA-D IgG NULL INSTITUTIONAL $106.00 1/1/2022-12/31/2022 $106.00 $44.31 $60.42 $77.91 $77.91 200% of Medicare 100% of Medicare $62.34 $60.01 $58.44 $44.31 100% of Medicaid 100% of Medicare 150% of Medicare $84.80 $106.00 195% of Medicare $85.86 $62.01 $62.01 $50.03 $68.20 100% of Medicare $84.80 $90.10 $83.21 $77.37 $84.80 $90.10 $72.88 100% of Medicare 100% of Medicare $79.50 200% of Medicare NULL 300 NULL 87390 NULL NULL 14156666 HIV 1/2 Antibody and Antigen NULL INSTITUTIONAL $144.00 1/1/2022-12/31/2022 $144.00 $60.19 $82.08 $105.84 $105.84 200% of Medicare 100% of Medicare $84.69 $81.52 $79.39 $60.19 100% of Medicaid 100% of Medicare 150% of Medicare $115.20 $144.00 195% of Medicare $116.64 $84.24 $84.24 $67.97 $92.65 100% of Medicare $115.20 $122.40 $113.04 $105.11 $115.20 $122.40 $99.00 100% of Medicare 100% of Medicare $108.00 200% of Medicare NULL 300 NULL 86787 NULL NULL 14156669 Varicella Zoster Antibody (IgG) EIA NULL INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $43.89 $59.85 $77.18 $77.18 200% of Medicare 100% of Medicare $61.75 $59.44 $57.89 $43.89 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $61.43 $61.43 $49.56 $67.56 100% of Medicare $84.00 $89.25 $82.43 $76.64 $84.00 $89.25 $72.19 100% of Medicare 100% of Medicare $78.75 200% of Medicare NULL 300 NULL 86765 NULL NULL 14156673 Measles Antibody (IgG) EIA NULL INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $43.89 $59.85 $77.18 $77.18 200% of Medicare 100% of Medicare $61.75 $59.44 $57.89 $43.89 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $61.43 $61.43 $49.56 $67.56 100% of Medicare $84.00 $89.25 $82.43 $76.64 $84.00 $89.25 $72.19 100% of Medicare 100% of Medicare $78.75 200% of Medicare NULL 300 NULL 86735 NULL NULL 14156674 Mumps Virus Antibody (IgG) EIA NULL INSTITUTIONAL $106.00 1/1/2022-12/31/2022 $106.00 $44.31 $60.42 $77.91 $77.91 200% of Medicare 100% of Medicare $62.34 $60.01 $58.44 $44.31 100% of Medicaid 100% of Medicare 150% of Medicare $84.80 $106.00 195% of Medicare $85.86 $62.01 $62.01 $50.03 $68.20 100% of Medicare $84.80 $90.10 $83.21 $77.37 $84.80 $90.10 $72.88 100% of Medicare 100% of Medicare $79.50 200% of Medicare NULL 300 NULL 82306 NULL NULL 14156675 "Vitamin D, 25-Hydroxy" NULL INSTITUTIONAL $243.00 1/1/2022-12/31/2022 $243.00 $101.57 $138.51 $178.61 $178.61 200% of Medicare 100% of Medicare $142.91 $137.56 $133.97 $101.57 100% of Medicaid 100% of Medicare 150% of Medicare $194.40 $243.00 195% of Medicare $196.83 $142.16 $142.16 $114.70 $156.35 100% of Medicare $194.40 $206.55 $190.76 $177.37 $194.40 $206.55 $167.06 100% of Medicare 100% of Medicare $182.25 200% of Medicare NULL 300 NULL 86803 NULL NULL 14156930 Hepatitis C Antibody NULL INSTITUTIONAL $118.00 1/1/2022-12/31/2022 $118.00 $49.32 $67.26 $86.73 $86.73 200% of Medicare 100% of Medicare $69.40 $66.80 $65.05 $49.32 100% of Medicaid 100% of Medicare 150% of Medicare $94.40 $118.00 195% of Medicare $95.58 $69.03 $69.03 $55.70 $75.92 100% of Medicare $94.40 $100.30 $92.63 $86.13 $94.40 $100.30 $81.13 100% of Medicare 100% of Medicare $88.50 200% of Medicare NULL 300 NULL 86687 NULL NULL 14156931 HIV-1 Antibody NULL INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $28.84 $39.33 $50.72 $50.72 200% of Medicare 100% of Medicare $40.58 $39.06 $38.04 $28.84 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $40.37 $40.37 $32.57 $44.39 100% of Medicare $55.20 $58.65 $54.17 $50.36 $55.20 $58.65 $47.44 100% of Medicare 100% of Medicare $51.75 200% of Medicare NULL 300 NULL 89055 NULL NULL 14156932 Wright Stain Stool NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $14.63 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.58 $19.81 $19.30 $14.63 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.48 $20.48 $16.52 $22.52 100% of Medicare $28.00 $29.75 $27.48 $25.55 $28.00 $29.75 $24.06 100% of Medicare 100% of Medicare $26.25 200% of Medicare NULL 300 NULL 89190 NULL NULL 14156933 Wright Stain Urine NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $16.30 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $22.94 $22.08 $21.50 $16.30 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $22.82 $22.82 $18.41 $25.09 100% of Medicare $31.20 $33.15 $30.62 $28.47 $31.20 $33.15 $26.81 100% of Medicare 100% of Medicare $29.25 200% of Medicare NULL 300 NULL 82272 NULL NULL 14156934 "Occult Blood, Stool, Reflex" NULL INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $10.87 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.29 $14.72 $14.33 $10.87 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.21 $15.21 $12.27 $16.73 100% of Medicare $20.80 $22.10 $20.41 $18.98 $20.80 $22.10 $17.88 100% of Medicare 100% of Medicare $19.50 200% of Medicare NULL 300 NULL 82271 NULL NULL 14156935 "Occult Blood, Stool, Vomitus" NULL INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $10.87 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.29 $14.72 $14.33 $10.87 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.21 $15.21 $12.27 $16.73 100% of Medicare $20.80 $22.10 $20.41 $18.98 $20.80 $22.10 $17.88 100% of Medicare 100% of Medicare $19.50 200% of Medicare NULL 300 NULL 82306 NULL NULL 14156936 "Vitamin D2 +D3, 25-Hydroxy" NULL INSTITUTIONAL $243.00 1/1/2022-12/31/2022 $243.00 $101.57 $138.51 $178.61 $178.61 200% of Medicare 100% of Medicare $142.91 $137.56 $133.97 $101.57 100% of Medicaid 100% of Medicare 150% of Medicare $194.40 $243.00 195% of Medicare $196.83 $142.16 $142.16 $114.70 $156.35 100% of Medicare $194.40 $206.55 $190.76 $177.37 $194.40 $206.55 $167.06 100% of Medicare 100% of Medicare $182.25 200% of Medicare NULL 300 NULL 86140 NULL NULL 14186869 C-Reactive Protein NULL INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $17.97 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.29 $24.34 $23.71 $17.97 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.16 $25.16 $20.30 $27.67 100% of Medicare $34.40 $36.55 $33.76 $31.39 $34.40 $36.55 $29.56 100% of Medicare 100% of Medicare $32.25 200% of Medicare NULL 300 NULL 80051 NULL NULL 14186872 Electrolytes Urine NULL INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $23.83 $32.49 $41.90 $41.90 200% of Medicare 100% of Medicare $33.52 $32.27 $31.42 $23.83 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.35 $33.35 $26.90 $36.67 100% of Medicare $45.60 $48.45 $44.75 $41.60 $45.60 $48.45 $39.19 100% of Medicare 100% of Medicare $42.75 200% of Medicare NULL 250 NULL NULL NULL NULL NULL midodrine 5 mg Tab 00245-0212-11 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ramipril 5 mg Cap 68084-0267-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL furosemide 20 mg Tab 51079-0072-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL albuterol 0.083% Inh Sol 3 mL 00487-9501-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lorazepam 2 mg/mL Inj Sol 00409-6778-02 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 200% of Medicare 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine Top 5% film 63481-0687-01 INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 200% of Medicare 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL budesonide 0.25 mg/2 mL Inh Susp 00093-6815-45 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL indapamide 2.5 mg Tab 51079-0868-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL paroxetine 20 mg Tab 68084-0045-11 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL divalproex sodium 250 mg Oral EC T 00245-0181-89 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 510 NULL 95909 NULL NULL 510074 NERVE CONDUCTION STUDIES 5-6 STUDIES NULL INSTITUTIONAL $581.00 1/1/2022-12/31/2022 $581.00 $242.86 $331.17 $427.04 $427.04 200% of Medicare 100% of Medicare $341.69 $328.90 $320.31 $242.86 100% of Medicaid 100% of Medicare 150% of Medicare $464.80 $581.00 195% of Medicare $470.61 $339.89 $339.89 $274.23 $373.82 100% of Medicare $464.80 $493.85 $456.09 $424.07 $464.80 $493.85 $399.44 100% of Medicare 100% of Medicare $435.75 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ocular lubricant Oint 00078-0473-97 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dextrose 5% in Water IV Sol 500 mL 00338-0017-03 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dextrose 5% Sod Chloride 0.45% KCl 00338-0671-04 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% IV Sol 100 mL 00409-7101-67 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% IV Sol 250 mL 00409-7101-02 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% 50 mL Addv 00409-7101-66 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 0.5 mg Tab 99999-9999-97 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL warfarin 1.5 mg Tab 99999-9999-96 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL emu oil 38779-1969-08 INSTITUTIONAL $673.00 1/1/2022-12/31/2022 $673.00 $317.66 $383.61 $494.66 $494.66 200% of Medicare 100% of Medicare $402.99 $387.92 $377.75 $430.72 100% of Medicaid 100% of Medicare 150% of Medicare $538.40 $673.00 195% of Medicare $545.13 $400.44 $400.44 $317.66 $673.00 100% of Medicare $538.40 $572.05 $605.70 $491.22 $572.05 $673.00 $673.00 100% of Medicare 100% of Medicare $673.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acetylcysteine 600 mg oral capsule 27434-0002-11 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 636 NULL NULL NULL J0588 NULL incobotulinumtoxinA 100 units REC 00259-1610-01 INSTITUTIONAL " $2,159.00 " 1/1/2022-12/31/2022 " $1,835.15 " $902.46 " $1,230.63 " " $1,586.87 " " $1,586.87 " 200% of Medicare 100% of Medicare " $1,269.71 " " $1,222.21 " " $1,190.26 " $902.46 100% of Medicaid 100% of Medicare 150% of Medicare " $1,727.20 " " $1,500.00 " 195% of Medicare " $1,748.79 " " $1,263.02 " " $1,263.02 " " $1,019.05 " " $1,389.10 " 100% of Medicare " $1,727.20 " " $1,835.15 " " $1,694.82 " " $1,575.85 " " $1,727.20 " " $1,835.15 " " $1,484.31 " 100% of Medicare 100% of Medicare " $1,619.25 " 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ketotifen 0.025% Opth Sol 17478-0717-10 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL doxercalciferol 2 mcg/mL Inj Sol 58468-0126-01 INSTITUTIONAL $95.00 1/1/2022-12/31/2022 $95.00 $44.84 $54.15 $69.83 $69.83 200% of Medicare 100% of Medicare $56.89 $54.76 $53.32 $60.80 100% of Medicaid 100% of Medicare 150% of Medicare $76.00 $95.00 195% of Medicare $76.95 $56.53 $56.53 $44.84 $95.00 100% of Medicare $76.00 $80.75 $85.50 $69.34 $80.75 $95.00 $95.00 100% of Medicare 100% of Medicare $95.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL omeprazole 200 mg Susp 99999-9999-95 INSTITUTIONAL $914.00 1/1/2022-12/31/2022 $914.00 $431.41 $520.98 $671.79 $671.79 200% of Medicare 100% of Medicare $547.30 $526.83 $513.03 $584.96 100% of Medicaid 100% of Medicare 150% of Medicare $731.20 $914.00 195% of Medicare $740.34 $543.83 $543.83 $431.41 $914.00 100% of Medicare $731.20 $776.90 $822.60 $667.13 $776.90 $914.00 $914.00 100% of Medicare 100% of Medicare $914.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL GI Cocktail 60 mL Susp 99999-9999-91 INSTITUTIONAL $146.00 1/1/2022-12/31/2022 $146.00 $68.91 $83.22 $107.31 $107.31 200% of Medicare 100% of Medicare $87.42 $84.15 $81.95 $93.44 100% of Medicaid 100% of Medicare 150% of Medicare $116.80 $146.00 195% of Medicare $118.26 $86.87 $86.87 $68.91 $146.00 100% of Medicare $116.80 $124.10 $131.40 $106.57 $124.10 $146.00 $146.00 100% of Medicare 100% of Medicare $146.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL clorpactin irrigation 99999-9999-88 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL acyclovir 200 mg Cap 00093-8940-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amoxicillin 500 mg Cap 65862-0017-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL doxycycline hyclate 100 mg Cap 00591-5440-50 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tetracycline 500 mg Cap 00591-2235-01 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL vancomycin 125 mg Cap 63323-0338-20 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 200% of Medicare 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL vancomycin 250 mg Cap 63323-0339-20 INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $37.76 $45.60 $58.80 $58.80 200% of Medicare 100% of Medicare $47.90 $46.11 $44.90 $51.20 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $47.60 $47.60 $37.76 $80.00 100% of Medicare $64.00 $68.00 $72.00 $58.39 $68.00 $80.00 $80.00 100% of Medicare 100% of Medicare $80.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL venlafaxine 37.5 mg ERCap 68084-0484-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Mineral Oil (BULK BOTTLE) 00869-4206-10 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone Top 1% Oint 00472-0345-56 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "fentanyl 12 mcg/hr TD film, ER" 00781-7240-55 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fentanyl 25 mcg/hr Transderm ER Fi 00591-3198-72 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fentanyl 50 mcg/hr Transderm ER Fi 00591-3212-72 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL polyethylene glycol 3350 Oral Pwdr 00904-6025-61 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL polyethylene glycol 3350 Oral Pwdr 51991-0457-58 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levetiracetam 100 mg/mL Oral Sol 00054-0224-63 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000001 Urethral Red Rubber Catheter - 14 French (each) NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000003 Urethral Red Rubber Catheter - 14 French - Coude NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000022 OP OT ENCOUNTER NOTE MAIN NULL INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 200% of Medicare 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000036 Catheter - 8 French (each) NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000041 TOUCHLESS MALE CATHETER NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000071 "ACE BANDAGE 4""" NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000072 "ACE BANDAGE 6""" NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000078 ADAPTIC DRESSING 3X8 3PLY NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000109 SALINE WOUND WASH NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000118 ANGIO CATH 22GX1 NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000119 ANGIO CATH 20GX1 NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000120 ANGIO CATH 24X.75 NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000124 IV START KIT NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000149 DRESSING OPSITE 2X3 NULL INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 200% of Medicare 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000150 DRESSING OPSITE 4X5 NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000174 DRESSING RESTORE 4X4 NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000187 DRESSING RESTORE 17SQ NULL INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 200% of Medicare 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000229 DRESSING RESTORE IMPREG 4X4 NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000274 STOCKING THIGH MED-LONG NULL INSTITUTIONAL $34.00 1/1/2022-12/31/2022 $34.00 $16.05 $19.38 $24.99 $24.99 200% of Medicare 100% of Medicare $20.36 $19.60 $19.08 $21.76 100% of Medicaid 100% of Medicare 150% of Medicare $27.20 $34.00 195% of Medicare $27.54 $20.23 $20.23 $16.05 $34.00 100% of Medicare $27.20 $28.90 $30.60 $24.82 $28.90 $34.00 $34.00 100% of Medicare 100% of Medicare $34.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000285 CURVED CANNULA 20 G 10 CM NULL INSTITUTIONAL " $2,542.00 " 1/1/2022-12/31/2022 " $2,542.00 " $975.00 " $1,448.94 " " $1,868.37 " " $1,868.37 " 200% of Medicare 100% of Medicare " $1,522.15 " " $1,465.21 " " $1,426.82 " " $1,626.88 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,033.60 " " $1,500.00 " 195% of Medicare " $2,059.02 " " $1,512.49 " " $1,512.49 " " $1,199.82 " " $1,359.00 " 100% of Medicare " $2,033.60 " " $2,160.70 " " $2,287.80 " " $1,855.41 " " $2,160.70 " " $1,500.00 " " $2,542.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000305 CHANGE TRAY NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000322 SUTURE REMOVAL TRAY NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000341 REMEDY SKIN REPAIR CREAM 2 OZ NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000359 "FEEDING, TRANSPORTER BAG" NULL INSTITUTIONAL $386.00 1/1/2022-12/31/2022 $386.00 $182.19 $220.02 $283.71 $283.71 200% of Medicare 100% of Medicare $231.14 $222.49 $216.66 $247.04 100% of Medicaid 100% of Medicare 150% of Medicare $308.80 $386.00 195% of Medicare $312.66 $229.67 $229.67 $182.19 $386.00 100% of Medicare $308.80 $328.10 $347.40 $281.74 $328.10 $386.00 $386.00 100% of Medicare 100% of Medicare $386.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000360 FEEDING BAG FOR USE W/PUMP NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000361 FEEDING BAG/ AMBULATORY NULL INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000362 "Feeding Tube Extension Set - Mic-Key* (12"")-(each)" NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000367 SPLINT AIR CAST RIGHT NULL INSTITUTIONAL $141.00 1/1/2022-12/31/2022 $141.00 $66.55 $80.37 $103.64 $103.64 200% of Medicare 100% of Medicare $84.43 $81.27 $79.14 $90.24 100% of Medicaid 100% of Medicare 150% of Medicare $112.80 $141.00 195% of Medicare $114.21 $83.90 $83.90 $66.55 $141.00 100% of Medicare $112.80 $119.85 $126.90 $102.92 $119.85 $141.00 $141.00 100% of Medicare 100% of Medicare $141.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000368 SPLINT AIR CAST LEFT NULL INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $61.36 $74.10 $95.55 $95.55 200% of Medicare 100% of Medicare $77.84 $74.93 $72.97 $83.20 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $77.35 $77.35 $61.36 $130.00 100% of Medicare $104.00 $110.50 $117.00 $94.89 $110.50 $130.00 $130.00 100% of Medicare 100% of Medicare $130.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000369 KNEE IMMOBILIZER NULL INSTITUTIONAL $384.00 1/1/2022-12/31/2022 $384.00 $181.25 $218.88 $282.24 $282.24 200% of Medicare 100% of Medicare $229.94 $221.34 $215.54 $245.76 100% of Medicaid 100% of Medicare 150% of Medicare $307.20 $384.00 195% of Medicare $311.04 $228.48 $228.48 $181.25 $384.00 100% of Medicare $307.20 $326.40 $345.60 $280.28 $326.40 $384.00 $384.00 100% of Medicare 100% of Medicare $384.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000373 POSEY LIMB HOLDER PR NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000374 "GAIT BELT (54)""" NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000375 "POSEY BELT, GAIT (72)""" NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000378 HEEL PILLOW NULL INSTITUTIONAL $68.00 1/1/2022-12/31/2022 $68.00 $32.10 $38.76 $49.98 $49.98 200% of Medicare 100% of Medicare $40.72 $39.20 $38.17 $43.52 100% of Medicaid 100% of Medicare 150% of Medicare $54.40 $68.00 195% of Medicare $55.08 $40.46 $40.46 $32.10 $68.00 100% of Medicare $54.40 $57.80 $61.20 $49.63 $57.80 $68.00 $68.00 100% of Medicare 100% of Medicare $68.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000385 PLAK VAC ORAL HYG SUCT BRUSH NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000409 DISP GROUNDING PAD WITH PLUG NULL INSTITUTIONAL " $1,917.00 " 1/1/2022-12/31/2022 " $1,917.00 " $904.82 " $1,092.69 " " $1,409.00 " " $1,409.00 " 200% of Medicare 100% of Medicare " $1,147.90 " " $1,104.96 " " $1,076.01 " " $1,226.88 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,533.60 " " $1,500.00 " 195% of Medicare " $1,552.77 " " $1,140.62 " " $1,140.62 " $904.82 " $1,359.00 " 100% of Medicare " $1,533.60 " " $1,629.45 " " $1,725.30 " " $1,399.22 " " $1,629.45 " " $1,500.00 " " $1,917.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000429 WAFFLE MATTRESS NULL INSTITUTIONAL $133.00 1/1/2022-12/31/2022 $133.00 $62.78 $75.81 $97.76 $97.76 200% of Medicare 100% of Medicare $79.64 $76.66 $74.65 $85.12 100% of Medicaid 100% of Medicare 150% of Medicare $106.40 $133.00 195% of Medicare $107.73 $79.14 $79.14 $62.78 $133.00 100% of Medicare $106.40 $113.05 $119.70 $97.08 $113.05 $133.00 $133.00 100% of Medicare 100% of Medicare $133.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000430 WAFFLE FOOT NULL INSTITUTIONAL $169.00 1/1/2022-12/31/2022 $169.00 $79.77 $96.33 $124.22 $124.22 200% of Medicare 100% of Medicare $101.20 $97.41 $94.86 $108.16 100% of Medicaid 100% of Medicare 150% of Medicare $135.20 $169.00 195% of Medicare $136.89 $100.56 $100.56 $79.77 $169.00 100% of Medicare $135.20 $143.65 $152.10 $123.35 $143.65 $169.00 $169.00 100% of Medicare 100% of Medicare $169.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000434 Suction Cath-N-Glove Kit - 10 Fr (each) 44-10 NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000435 Suction Cath-N-Glove Kit - 12 Fr (each) 44-12 NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000436 Suction Cath-N-Glove Kit - 14 Fr (each) 44-14 NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000438 Inner Cannula Extended Length - Shiley 6mm (each) NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000439 Inner Cannula Extended Length - Shiley 7mm (each) NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000441 Inner Cannula Extended Length - Shiley 8mm (each) NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000443 Trach Tube - Bivonia Silicone Adult Mid Range Cuff NULL INSTITUTIONAL $212.00 1/1/2022-12/31/2022 $212.00 $100.06 $120.84 $155.82 $155.82 200% of Medicare 100% of Medicare $126.95 $122.20 $119.00 $135.68 100% of Medicaid 100% of Medicare 150% of Medicare $169.60 $212.00 195% of Medicare $171.72 $126.14 $126.14 $100.06 $212.00 100% of Medicare $169.60 $180.20 $190.80 $154.74 $180.20 $212.00 $212.00 100% of Medicare 100% of Medicare $212.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000447 Trach Tube Cuffless - Shiley 4.0 PED (each) NULL INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000448 "TRACH STRAP, VELCRO" NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000449 Trach Tube Cuffless - Shiley 3.5 PED (each) NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000453 YANKAUER WITH SWITCH NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000454 "TUBE, NG/SALEM 12F" NULL INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 200% of Medicare 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000455 "TUBE, NG/SALEM 14F" NULL INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 200% of Medicare 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000456 "TUBE, NG/SALEM 16F" NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000457 "Nasogastric Sump Tube 12Fr/48"" - Bard (each)" NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000494 SOFTGOODS FOR CPM NULL INSTITUTIONAL $103.00 1/1/2022-12/31/2022 $103.00 $48.62 $58.71 $75.71 $75.71 200% of Medicare 100% of Medicare $61.68 $59.37 $57.81 $65.92 100% of Medicaid 100% of Medicare 150% of Medicare $82.40 $103.00 195% of Medicare $83.43 $61.29 $61.29 $48.62 $103.00 100% of Medicare $82.40 $87.55 $92.70 $75.18 $87.55 $103.00 $103.00 100% of Medicare 100% of Medicare $103.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000506 "23G X 3.5"" SPINAL NEEDLE" NULL INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000509 20G X 3.5 TOUGHY SPINAL NDL NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000512 20G X 6IN TOUGHY SPINAL NDL NULL INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $20.77 $25.08 $32.34 $32.34 200% of Medicare 100% of Medicare $26.35 $25.36 $24.70 $28.16 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $26.18 $26.18 $20.77 $44.00 100% of Medicare $35.20 $37.40 $39.60 $32.12 $37.40 $44.00 $44.00 100% of Medicare 100% of Medicare $44.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000513 20G X 4.5 TOUGHY SPINAL NDL NULL INSTITUTIONAL " $1,162.00 " 1/1/2022-12/31/2022 " $1,162.00 " $548.46 $662.34 $854.07 $854.07 200% of Medicare 100% of Medicare $695.81 $669.78 $652.23 $743.68 100% of Medicaid 100% of Medicare 150% of Medicare $929.60 " $1,162.00 " 195% of Medicare $941.22 $691.39 $691.39 $548.46 " $1,162.00 " 100% of Medicare $929.60 $987.70 " $1,045.80 " $848.14 $987.70 " $1,162.00 " " $1,162.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000522 CUSTOM KIT SILBERT XRAY ONLY NULL INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000523 LOW AIRLOSS SYRINGE LOS NULL INSTITUTIONAL $370.00 1/1/2022-12/31/2022 $370.00 $174.64 $210.90 $271.95 $271.95 200% of Medicare 100% of Medicare $221.56 $213.27 $207.68 $236.80 100% of Medicaid 100% of Medicare 150% of Medicare $296.00 $370.00 195% of Medicare $299.70 $220.15 $220.15 $174.64 $370.00 100% of Medicare $296.00 $314.50 $333.00 $270.06 $314.50 $370.00 $370.00 100% of Medicare 100% of Medicare $370.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000535 KNEE SPREADER MIRROR NULL INSTITUTIONAL $217.00 1/1/2022-12/31/2022 $217.00 $102.42 $123.69 $159.50 $159.50 200% of Medicare 100% of Medicare $129.94 $125.08 $121.80 $138.88 100% of Medicaid 100% of Medicare 150% of Medicare $173.60 $217.00 195% of Medicare $175.77 $129.12 $129.12 $102.42 $217.00 100% of Medicare $173.60 $184.45 $195.30 $158.39 $184.45 $217.00 $217.00 100% of Medicare 100% of Medicare $217.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000537 SUPPOSITORY INSERTER NULL INSTITUTIONAL $239.00 1/1/2022-12/31/2022 $239.00 $112.81 $136.23 $175.67 $175.67 200% of Medicare 100% of Medicare $143.11 $137.76 $134.15 $152.96 100% of Medicaid 100% of Medicare 150% of Medicare $191.20 $239.00 195% of Medicare $193.59 $142.21 $142.21 $112.81 $239.00 100% of Medicare $191.20 $203.15 $215.10 $174.45 $203.15 $239.00 $239.00 100% of Medicare 100% of Medicare $239.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000538 DIGITAL STIMULATOR NULL INSTITUTIONAL $227.00 1/1/2022-12/31/2022 $227.00 $107.14 $129.39 $166.85 $166.85 200% of Medicare 100% of Medicare $135.93 $130.84 $127.42 $145.28 100% of Medicaid 100% of Medicare 150% of Medicare $181.60 $227.00 195% of Medicare $183.87 $135.07 $135.07 $107.14 $227.00 100% of Medicare $181.60 $192.95 $204.30 $165.69 $192.95 $227.00 $227.00 100% of Medicare 100% of Medicare $227.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000539 FLEXIBLE MIRROR NULL INSTITUTIONAL $79.00 1/1/2022-12/31/2022 $79.00 $37.29 $45.03 $58.07 $58.07 200% of Medicare 100% of Medicare $47.31 $45.54 $44.34 $50.56 100% of Medicaid 100% of Medicare 150% of Medicare $63.20 $79.00 195% of Medicare $63.99 $47.01 $47.01 $37.29 $79.00 100% of Medicare $63.20 $67.15 $71.10 $57.66 $67.15 $79.00 $79.00 100% of Medicare 100% of Medicare $79.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000544 Colostomy/Ileostomy Kit - Hollister (each) NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000554 OSTOMY POUCH CLAMP NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000563 HEMI SLING NULL INSTITUTIONAL $93.00 1/1/2022-12/31/2022 $93.00 $43.90 $53.01 $68.36 $68.36 200% of Medicare 100% of Medicare $55.69 $53.61 $52.20 $59.52 100% of Medicaid 100% of Medicare 150% of Medicare $74.40 $93.00 195% of Medicare $75.33 $55.34 $55.34 $43.90 $93.00 100% of Medicare $74.40 $79.05 $83.70 $67.88 $79.05 $93.00 $93.00 100% of Medicare 100% of Medicare $93.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000569 GLOVES SM PAIR NO FINGERTIP NULL INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 200% of Medicare 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000570 GLOVES MED PAIR NO FINGERTIP NULL INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 200% of Medicare 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000571 GLOVES LG PAIR NO FINGERTIPS NULL INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 200% of Medicare 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000572 GLOVES SM PAIR NULL INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 200% of Medicare 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000573 Latex Free Sterile Gloves (pair) NULL INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 200% of Medicare 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000574 GLOVE LG PAIR NULL INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 200% of Medicare 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000596 ABDUCTION PILLOW NULL INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $34.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $44.31 $42.65 $41.54 $47.36 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $44.03 $44.03 $34.93 $74.00 100% of Medicare $59.20 $62.90 $66.60 $54.01 $62.90 $74.00 $74.00 100% of Medicare 100% of Medicare $74.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000600 XEROFORM DRESSING NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000602 CERVICAL COLLAR SM NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000603 CERVICAL COLLAR MED NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000604 CERVICAL COLLAR LG NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000607 KNEE CRYO/CUFF LRG NULL INSTITUTIONAL $357.00 1/1/2022-12/31/2022 $357.00 $168.50 $203.49 $262.40 $262.40 200% of Medicare 100% of Medicare $213.77 $205.77 $200.38 $228.48 100% of Medicaid 100% of Medicare 150% of Medicare $285.60 $357.00 195% of Medicare $289.17 $212.42 $212.42 $168.50 $357.00 100% of Medicare $285.60 $303.45 $321.30 $260.57 $303.45 $357.00 $357.00 100% of Medicare 100% of Medicare $357.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000610 BOOT MULTI PODUS SMALL NULL INSTITUTIONAL $357.00 1/1/2022-12/31/2022 $357.00 $168.50 $203.49 $262.40 $262.40 200% of Medicare 100% of Medicare $213.77 $205.77 $200.38 $228.48 100% of Medicaid 100% of Medicare 150% of Medicare $285.60 $357.00 195% of Medicare $289.17 $212.42 $212.42 $168.50 $357.00 100% of Medicare $285.60 $303.45 $321.30 $260.57 $303.45 $357.00 $357.00 100% of Medicare 100% of Medicare $357.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000611 BOOT MULTI PODUS MEDIUM NULL INSTITUTIONAL $357.00 1/1/2022-12/31/2022 $357.00 $168.50 $203.49 $262.40 $262.40 200% of Medicare 100% of Medicare $213.77 $205.77 $200.38 $228.48 100% of Medicaid 100% of Medicare 150% of Medicare $285.60 $357.00 195% of Medicare $289.17 $212.42 $212.42 $168.50 $357.00 100% of Medicare $285.60 $303.45 $321.30 $260.57 $303.45 $357.00 $357.00 100% of Medicare 100% of Medicare $357.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000612 BOOT MULTI PODUS LARGE NULL INSTITUTIONAL $357.00 1/1/2022-12/31/2022 $357.00 $168.50 $203.49 $262.40 $262.40 200% of Medicare 100% of Medicare $213.77 $205.77 $200.38 $228.48 100% of Medicaid 100% of Medicare 150% of Medicare $285.60 $357.00 195% of Medicare $289.17 $212.42 $212.42 $168.50 $357.00 100% of Medicare $285.60 $303.45 $321.30 $260.57 $303.45 $357.00 $357.00 100% of Medicare 100% of Medicare $357.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000613 BOOT MULTI PODUS XLARGE NULL INSTITUTIONAL $357.00 1/1/2022-12/31/2022 $357.00 $168.50 $203.49 $262.40 $262.40 200% of Medicare 100% of Medicare $213.77 $205.77 $200.38 $228.48 100% of Medicaid 100% of Medicare 150% of Medicare $285.60 $357.00 195% of Medicare $289.17 $212.42 $212.42 $168.50 $357.00 100% of Medicare $285.60 $303.45 $321.30 $260.57 $303.45 $357.00 $357.00 100% of Medicare 100% of Medicare $357.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000617 BACTIFILTERS NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000621 TRAP SPECIMEN NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000630 25G X 2.5IN QUINCKE SPINAL NDL NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000708 UNIVERSAL SHOULDER IMMOBILIZER NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000714 SCD Garment - Knee Length - Small (each) NULL INSTITUTIONAL $305.00 1/1/2022-12/31/2022 $305.00 $143.96 $173.85 $224.18 $224.18 200% of Medicare 100% of Medicare $182.63 $175.80 $171.20 $195.20 100% of Medicaid 100% of Medicare 150% of Medicare $244.00 $305.00 195% of Medicare $247.05 $181.48 $181.48 $143.96 $305.00 100% of Medicare $244.00 $259.25 $274.50 $222.62 $259.25 $305.00 $305.00 100% of Medicare 100% of Medicare $305.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000715 SCD SLEEVE MEDIUM NULL INSTITUTIONAL $321.00 1/1/2022-12/31/2022 $321.00 $151.51 $182.97 $235.94 $235.94 200% of Medicare 100% of Medicare $192.21 $185.02 $180.18 $205.44 100% of Medicaid 100% of Medicare 150% of Medicare $256.80 $321.00 195% of Medicare $260.01 $191.00 $191.00 $151.51 $321.00 100% of Medicare $256.80 $272.85 $288.90 $234.30 $272.85 $321.00 $321.00 100% of Medicare 100% of Medicare $321.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000716 SCD SLEEVE LARGE NULL INSTITUTIONAL $386.00 1/1/2022-12/31/2022 $386.00 $182.19 $220.02 $283.71 $283.71 200% of Medicare 100% of Medicare $231.14 $222.49 $216.66 $247.04 100% of Medicaid 100% of Medicare 150% of Medicare $308.80 $386.00 195% of Medicare $312.66 $229.67 $229.67 $182.19 $386.00 100% of Medicare $308.80 $328.10 $347.40 $281.74 $328.10 $386.00 $386.00 100% of Medicare 100% of Medicare $386.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000723 TED Hose - Knee - XX-Large - Regular (pair) NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000724 TED Hose - Knee - Medium - Long (pair) NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000725 TED Hose - Thigh - Large - Short (pair) NULL INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000739 ADULT LOPEZ VALVE NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000757 "12 MINI BORE EXTENSION""" NULL INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000758 "20 MINIBORE EXTENSION""" NULL INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $20.77 $25.08 $32.34 $32.34 200% of Medicare 100% of Medicare $26.35 $25.36 $24.70 $28.16 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $26.18 $26.18 $20.77 $44.00 100% of Medicare $35.20 $37.40 $39.60 $32.12 $37.40 $44.00 $44.00 100% of Medicare 100% of Medicare $44.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000759 "2 COBAN""" NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000766 25G X 3.5 QUINCKE SPINAL NEEDL NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000771 CANNISTER VAC FREEDOM NULL INSTITUTIONAL $180.00 1/1/2022-12/31/2022 $180.00 $84.96 $102.60 $132.30 $132.30 200% of Medicare 100% of Medicare $107.78 $103.75 $101.03 $115.20 100% of Medicaid 100% of Medicare 150% of Medicare $144.00 $180.00 195% of Medicare $145.80 $107.10 $107.10 $84.96 $180.00 100% of Medicare $144.00 $153.00 $162.00 $131.38 $153.00 $180.00 $180.00 100% of Medicare 100% of Medicare $180.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000772 SMALL DRESSING VAC FREEDOM NULL INSTITUTIONAL $204.00 1/1/2022-12/31/2022 $204.00 $96.29 $116.28 $149.94 $149.94 200% of Medicare 100% of Medicare $122.16 $117.59 $114.51 $130.56 100% of Medicaid 100% of Medicare 150% of Medicare $163.20 $204.00 195% of Medicare $165.24 $121.38 $121.38 $96.29 $204.00 100% of Medicare $163.20 $173.40 $183.60 $148.90 $173.40 $204.00 $204.00 100% of Medicare 100% of Medicare $204.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000773 MEDIUM DRESSING VAC FREEDOM NULL INSTITUTIONAL $257.00 1/1/2022-12/31/2022 $257.00 $121.30 $146.49 $188.90 $188.90 200% of Medicare 100% of Medicare $153.89 $148.13 $144.25 $164.48 100% of Medicaid 100% of Medicare 150% of Medicare $205.60 $257.00 195% of Medicare $208.17 $152.92 $152.92 $121.30 $257.00 100% of Medicare $205.60 $218.45 $231.30 $187.58 $218.45 $257.00 $257.00 100% of Medicare 100% of Medicare $257.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000774 LARGE DRESSING VAC FREEDOM NULL INSTITUTIONAL $274.00 1/1/2022-12/31/2022 $274.00 $129.33 $156.18 $201.39 $201.39 200% of Medicare 100% of Medicare $164.07 $157.93 $153.80 $175.36 100% of Medicaid 100% of Medicare 150% of Medicare $219.20 $274.00 195% of Medicare $221.94 $163.03 $163.03 $129.33 $274.00 100% of Medicare $219.20 $232.90 $246.60 $199.99 $232.90 $274.00 $274.00 100% of Medicare 100% of Medicare $274.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000794 PASSY MUIR VALVE PMV 2001 NULL INSTITUTIONAL $302.00 1/1/2022-12/31/2022 $302.00 $142.54 $172.14 $221.97 $221.97 200% of Medicare 100% of Medicare $180.84 $174.07 $169.51 $193.28 100% of Medicaid 100% of Medicare 150% of Medicare $241.60 $302.00 195% of Medicare $244.62 $179.69 $179.69 $142.54 $302.00 100% of Medicare $241.60 $256.70 $271.80 $220.43 $256.70 $302.00 $302.00 100% of Medicare 100% of Medicare $302.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000797 RESTING HAND SPLINT SMALL RT NULL INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $52.39 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $66.47 $63.98 $62.30 $71.04 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $66.05 $66.05 $52.39 $111.00 100% of Medicare $88.80 $94.35 $99.90 $81.02 $94.35 $111.00 $111.00 100% of Medicare 100% of Medicare $111.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000798 RESTING HAND SPLINT SMALL LFT NULL INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 200% of Medicare 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000799 RESTING HAND SPLINT MED RT NULL INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 200% of Medicare 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000800 RESTING HAND SPLINT MED LEFT NULL INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 200% of Medicare 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000801 RESTING HAND SPLINT LG RIGHT NULL INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 200% of Medicare 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000802 RESTING HAND SPLINT LG LEFT NULL INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 200% of Medicare 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000803 ANTI-SPAS SPLINT SMALL RT NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000804 ANTI-SPAS SPLINT SMALL LEFT NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000805 ANTI-SPAS SPLINT MED RIGHT NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000806 ANTI-SPAS SPLINT MED LEFT NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000807 ANTI-SPAS SPLINT LG RIGHT NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000808 ANTI-SPAS SPLINT LG LEFT NULL INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 200% of Medicare 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000821 TRAC PAD - WOUND VAC NULL INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $42.95 $51.87 $66.89 $66.89 200% of Medicare 100% of Medicare $54.49 $52.45 $51.08 $58.24 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $54.15 $54.15 $42.95 $91.00 100% of Medicare $72.80 $77.35 $81.90 $66.42 $77.35 $91.00 $91.00 100% of Medicare 100% of Medicare $91.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000833 CALAZIME PASTE PROTECTANT NULL INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000837 IV Catheters - BD 22g x 1 (each) NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000840 IV Catheters - BD 24g x 0.75 (each) NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000842 4 IN 1 CLEANSING LOTION NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000867 "DRESSING,MEPILEX 4X4, SILICONE" NULL INSTITUTIONAL $76.00 1/1/2022-12/31/2022 $76.00 $35.87 $43.32 $55.86 $55.86 200% of Medicare 100% of Medicare $45.51 $43.81 $42.66 $48.64 100% of Medicaid 100% of Medicare 150% of Medicare $60.80 $76.00 195% of Medicare $61.56 $45.22 $45.22 $35.87 $76.00 100% of Medicare $60.80 $64.60 $68.40 $55.47 $64.60 $76.00 $76.00 100% of Medicare 100% of Medicare $76.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000899 DRESSING BORDER MEPILEX 3X3 NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000906 XEROFORM DRESS/GAUZE ROLL NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000907 PELVIC HOLDER SMALL NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $30.21 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $38.32 $36.89 $35.92 $40.96 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $38.08 $38.08 $30.21 $64.00 100% of Medicare $51.20 $54.40 $57.60 $46.71 $54.40 $64.00 $64.00 100% of Medicare 100% of Medicare $64.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000908 PELVIC HOLDER MEDIUM NULL INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 200% of Medicare 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000909 PELVIC HOLDER LARGE NULL INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 200% of Medicare 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000925 ASPEN REPLACEMENT PAD NULL INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $37.76 $45.60 $58.80 $58.80 200% of Medicare 100% of Medicare $47.90 $46.11 $44.90 $51.20 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $47.60 $47.60 $37.76 $80.00 100% of Medicare $64.00 $68.00 $72.00 $58.39 $68.00 $80.00 $80.00 100% of Medicare 100% of Medicare $80.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000926 MELGISORB AG 4X4 NULL INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000928 MEPILEX BORDER 4X8 IN NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000948 Drinking System - Hydrant Replacement Parts (each) NULL INSTITUTIONAL $287.00 1/1/2022-12/31/2022 $287.00 $135.46 $163.59 $210.95 $210.95 200% of Medicare 100% of Medicare $171.86 $165.43 $161.09 $183.68 100% of Medicaid 100% of Medicare 150% of Medicare $229.60 $287.00 195% of Medicare $232.47 $170.77 $170.77 $135.46 $287.00 100% of Medicare $229.60 $243.95 $258.30 $209.48 $243.95 $287.00 $287.00 100% of Medicare 100% of Medicare $287.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000965 CATHETER FOLEY 14FR 5CC BARDEX NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000966 CATHETER FOLEY 18FR 2-WAY 5CC NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 271 NULL NULL NULL NULL 000967 CATHETER FOLEY 20FR 2-WAY 5CC NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000968 CATHETER FOLEY 24FR 5CC BARDEX NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000977 CUFF CRYO KNEE MEDIUM WITH NULL INSTITUTIONAL $331.00 1/1/2022-12/31/2022 $331.00 $156.23 $188.67 $243.29 $243.29 200% of Medicare 100% of Medicare $198.20 $190.79 $185.79 $211.84 100% of Medicaid 100% of Medicare 150% of Medicare $264.80 $331.00 195% of Medicare $268.11 $196.95 $196.95 $156.23 $331.00 100% of Medicare $264.80 $281.35 $297.90 $241.60 $281.35 $331.00 $331.00 100% of Medicare 100% of Medicare $331.00 200% of Medicare NULL 274 NULL NULL NULL L3807 000981 DISPOZ-A-BAG FLIP-FLO 32OZ NULL INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $6.69 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.41 $9.06 $8.82 $6.69 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.36 $9.36 $7.55 $10.29 100% of Medicare $12.80 $13.60 $12.56 $11.68 $12.80 $13.60 $11.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 274 NULL NULL NULL L3807 000982 BAG URINE 2000ML SNGL HOOK NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $7.94 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.17 $10.76 $10.47 $7.94 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.12 $11.12 $8.97 $12.22 100% of Medicare $15.20 $16.15 $14.92 $13.87 $15.20 $16.15 $13.06 100% of Medicare 100% of Medicare $14.25 200% of Medicare NULL 274 NULL NULL NULL L3807 000986 THERMOMETER DIGITAL FAHRENHEIT NULL INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $9.61 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.53 $13.02 $12.68 $9.61 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.46 $13.46 $10.86 $14.80 100% of Medicare $18.40 $19.55 $18.06 $16.79 $18.40 $19.55 $15.81 100% of Medicare 100% of Medicare $17.25 200% of Medicare NULL 274 NULL NULL NULL L3807 000992 SPORTSTAPE LEUKOTAPE NULL INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $9.61 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.53 $13.02 $12.68 $9.61 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.46 $13.46 $10.86 $14.80 100% of Medicare $18.40 $19.55 $18.06 $16.79 $18.40 $19.55 $15.81 100% of Medicare 100% of Medicare $17.25 200% of Medicare NULL 274 NULL NULL NULL L3807 000994 TAPE HYTAPE PLASTIC 1INx5YD NULL INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $12.54 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.64 $16.98 $16.54 $12.54 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.55 $17.55 $14.16 $19.30 100% of Medicare $24.00 $25.50 $23.55 $21.90 $24.00 $25.50 $20.63 100% of Medicare 100% of Medicare $22.50 200% of Medicare NULL 274 NULL NULL NULL L3807 000998 BANDAGE COVER ROLL STRETCH NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $13.79 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.41 $18.68 $18.19 $13.79 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.31 $19.31 $15.58 $21.23 100% of Medicare $26.40 $28.05 $25.91 $24.09 $26.40 $28.05 $22.69 100% of Medicare 100% of Medicare $24.75 200% of Medicare NULL 272 NULL NULL NULL NULL 001001 STOCKING KNEE LENGTH MED NULL INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001002 STOCKING KNEE LENGTH LARGE NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001003 STOCKING THIGH LENGTH SMALL NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001004 STOCKING THIGH LENGTH MEDIUM NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001005 STOCKING THIGH LENGTH LARGE-REGULAR NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 274 NULL NULL NULL L3807 001006 STOCKING THIGH LENGTH LARGE-LONG NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $11.29 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $15.88 $15.28 $14.89 $11.29 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $15.80 $15.80 $12.74 $17.37 100% of Medicare $21.60 $22.95 $21.20 $19.71 $21.60 $22.95 $18.56 100% of Medicare 100% of Medicare $20.25 200% of Medicare NULL 274 NULL NULL NULL L3808 001007 STOCKING ANTI-EMBOLISM-ATS XXL NULL INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $12.54 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.64 $16.98 $16.54 $12.54 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.55 $17.55 $14.16 $19.30 100% of Medicare $24.00 $25.50 $23.55 $21.90 $24.00 $25.50 $20.63 100% of Medicare 100% of Medicare $22.50 200% of Medicare NULL 274 NULL NULL NULL L3809 001009 CATHETER SELF CATH FEMALE 14FR NULL INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.84 $1.14 $1.47 $1.47 200% of Medicare 100% of Medicare $1.18 $1.13 $1.10 $0.84 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.17 $1.17 $0.94 $1.29 100% of Medicare $1.60 $1.70 $1.57 $1.46 $1.60 $1.70 $1.38 100% of Medicare 100% of Medicare $1.50 200% of Medicare NULL 274 NULL NULL NULL L3810 001011 DRESSING ALGINATE 1.2x18IN NULL INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $9.20 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $12.94 $12.45 $12.13 $9.20 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $12.87 $12.87 $10.38 $14.15 100% of Medicare $17.60 $18.70 $17.27 $16.06 $17.60 $18.70 $15.13 100% of Medicare 100% of Medicare $16.50 200% of Medicare NULL 274 NULL NULL NULL L3811 001012 MITT FINGER CONTROL PADDED NULL INSTITUTIONAL $67.00 1/1/2022-12/31/2022 $67.00 $28.01 $38.19 $49.25 $49.25 200% of Medicare 100% of Medicare $39.40 $37.93 $36.94 $28.01 100% of Medicaid 100% of Medicare 150% of Medicare $53.60 $67.00 195% of Medicare $54.27 $39.20 $39.20 $31.62 $43.11 100% of Medicare $53.60 $56.95 $52.60 $48.90 $53.60 $56.95 $46.06 100% of Medicare 100% of Medicare $50.25 200% of Medicare NULL 274 NULL NULL NULL L3812 001013 TOWEL OR 17x27IN BLUE NULL INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $9.61 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.53 $13.02 $12.68 $9.61 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.46 $13.46 $10.86 $14.80 100% of Medicare $18.40 $19.55 $18.06 $16.79 $18.40 $19.55 $15.81 100% of Medicare 100% of Medicare $17.25 200% of Medicare NULL 274 NULL NULL NULL E0370 001018 "N-Terface Dressing (12""x12"") - (each)" NULL INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $53.50 $72.96 $94.08 $94.08 200% of Medicare 100% of Medicare $75.28 $72.46 $70.57 $53.50 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $74.88 $74.88 $60.42 $82.36 100% of Medicare $102.40 $108.80 $100.48 $93.43 $102.40 $108.80 $88.00 100% of Medicare 100% of Medicare $96.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001029 HEMOSTAT KELLY STRAIGHT NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001042 STOCKING THIGH LENGTH X-LARGE NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001047 TUBE TRACH DISPOSABLE 4 NULL INSTITUTIONAL $180.00 1/1/2022-12/31/2022 $180.00 $84.96 $102.60 $132.30 $132.30 200% of Medicare 100% of Medicare $107.78 $103.75 $101.03 $115.20 100% of Medicaid 100% of Medicare 150% of Medicare $144.00 $180.00 195% of Medicare $145.80 $107.10 $107.10 $84.96 $180.00 100% of Medicare $144.00 $153.00 $162.00 $131.38 $153.00 $180.00 $180.00 100% of Medicare 100% of Medicare $180.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001049 CANNULA DISPOSABLE INNER SIZE4 NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001056 STOCKING NYLON KNEE SML REGULR NULL INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001061 LEUKOSTRIP 1/4 X 3 NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001063 "Protector, Heel Raiser" NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001064 PROTECTOR LARGE WHITE HEEL AND NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001065 PROTECTOR XLARGE HEEL AND NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001070 TRAY LATEX FREE URETHERAL NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001076 COLLAR CERVICAL LOW CONTOUR NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001083 Foley Catheter - 24 French/5cc - Infection Control NULL INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001113 "BINDER AB 10 SOLID PANEL""" NULL INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001115 TUBE SUCTION CONNECTING NULL INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 200% of Medicare 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL NULL NULL NULL NULL NULL 001119 POWDER 1OZ PUFF BOTTLE OSTOMY NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001120 PASTE 2OZ ADAPT FOR OSTOMY NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001126 IRRIGATION TRAY 60CC PISTON NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001133 STOCKING ANTI-EMBOLISM NULL INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001151 "COBAN 3"" Latex" NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001157 CATHETER COUDE 14FR 16IN LONG NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 274 NULL NULL NULL L4396 001158 BELT SAFETY ROLL COTTON WITH NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $14.63 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.58 $19.81 $19.30 $14.63 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.48 $20.48 $16.52 $22.52 100% of Medicare $28.00 $29.75 $27.48 $25.55 $28.00 $29.75 $24.06 100% of Medicare 100% of Medicare $26.25 200% of Medicare NULL 274 NULL NULL NULL L4396 001160 CLEANSER WOUND SKINTEGRITY 8OZ NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.34 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.70 $4.53 $4.41 $3.34 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.68 $4.68 $3.78 $5.15 100% of Medicare $6.40 $6.80 $6.28 $5.84 $6.40 $6.80 $5.50 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 274 NULL NULL NULL L4396 001163 CURTH KIT - REHAB HOSP NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $2.93 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.12 $3.96 $3.86 $2.93 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.10 $4.10 $3.30 $4.50 100% of Medicare $5.60 $5.95 $5.50 $5.11 $5.60 $5.95 $4.81 100% of Medicare 100% of Medicare $5.25 200% of Medicare NULL 274 NULL NULL NULL L4396 001164 STAPLE REMOVER SKIN NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.25 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.76 $1.70 $1.65 $1.25 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.76 $1.76 $1.42 $1.93 100% of Medicare $2.40 $2.55 $2.36 $2.19 $2.40 $2.55 $2.06 100% of Medicare 100% of Medicare $2.25 200% of Medicare NULL 272 NULL NULL NULL NULL 001168 PHASE II PODUS BOOT-AVERAGE SZ NULL INSTITUTIONAL $687.00 1/1/2022-12/31/2022 $687.00 $324.26 $391.59 $504.95 $504.95 200% of Medicare 100% of Medicare $411.38 $395.99 $385.61 $439.68 100% of Medicaid 100% of Medicare 150% of Medicare $549.60 $687.00 195% of Medicare $556.47 $408.77 $408.77 $324.26 $687.00 100% of Medicare $549.60 $583.95 $618.30 $501.44 $583.95 $687.00 $687.00 100% of Medicare 100% of Medicare $687.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001169 PHASE II PODUS BOOT-LARGE NULL INSTITUTIONAL $687.00 1/1/2022-12/31/2022 $687.00 $324.26 $391.59 $504.95 $504.95 200% of Medicare 100% of Medicare $411.38 $395.99 $385.61 $439.68 100% of Medicaid 100% of Medicare 150% of Medicare $549.60 $687.00 195% of Medicare $556.47 $408.77 $408.77 $324.26 $687.00 100% of Medicare $549.60 $583.95 $618.30 $501.44 $583.95 $687.00 $687.00 100% of Medicare 100% of Medicare $687.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001170 PHASE II PODUS BOOT-XLARGE NULL INSTITUTIONAL $625.00 1/1/2022-12/31/2022 $625.00 $295.00 $356.25 $459.38 $459.38 200% of Medicare 100% of Medicare $374.25 $360.25 $350.81 $400.00 100% of Medicaid 100% of Medicare 150% of Medicare $500.00 $625.00 195% of Medicare $506.25 $371.88 $371.88 $295.00 $625.00 100% of Medicare $500.00 $531.25 $562.50 $456.19 $531.25 $625.00 $625.00 100% of Medicare 100% of Medicare $625.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001171 CONTINU-FLO SOLUTION SET NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001172 Y-TYPE BLOOD/SOLUTION SET NULL INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001182 PLEURX DRAINAGE KIT NULL INSTITUTIONAL $485.00 1/1/2022-12/31/2022 $485.00 $228.92 $276.45 $356.48 $356.48 200% of Medicare 100% of Medicare $290.42 $279.55 $272.23 $310.40 100% of Medicaid 100% of Medicare 150% of Medicare $388.00 $485.00 195% of Medicare $392.85 $288.58 $288.58 $228.92 $485.00 100% of Medicare $388.00 $412.25 $436.50 $354.00 $412.25 $485.00 $485.00 100% of Medicare 100% of Medicare $485.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001183 BAXTER TPN FILTER TUBING NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 274 NULL NULL NULL L4396 001184 BAXTER SECONDARY TUBING NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.25 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.76 $1.70 $1.65 $1.25 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.76 $1.76 $1.42 $1.93 100% of Medicare $2.40 $2.55 $2.36 $2.19 $2.40 $2.55 $2.06 100% of Medicare 100% of Medicare $2.25 200% of Medicare NULL 274 NULL NULL NULL L4397 001186 PINK SLIP NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $7.52 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.59 $10.19 $9.92 $7.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.53 $10.53 $8.50 $11.58 100% of Medicare $14.40 $15.30 $14.13 $13.14 $14.40 $15.30 $12.38 100% of Medicare 100% of Medicare $13.50 200% of Medicare NULL 274 NULL NULL NULL L4398 001191 EXTENSION TUBING FOR LEG BAG NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.25 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.76 $1.70 $1.65 $1.25 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.76 $1.76 $1.42 $1.93 100% of Medicare $2.40 $2.55 $2.36 $2.19 $2.40 $2.55 $2.06 100% of Medicare 100% of Medicare $2.25 200% of Medicare NULL 274 NULL NULL NULL L1930 001194 Urethral Red Rubber Catheter - 16 French - Coude NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.67 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.35 $2.26 $2.21 $1.67 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.34 $2.34 $1.89 $2.57 100% of Medicare $3.20 $3.40 $3.14 $2.92 $3.20 $3.40 $2.75 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL NULL NULL NULL NULL NULL 001200 Trach Tube XLT Cuffless - Shiley 6 (each) NULL INSTITUTIONAL $174.00 1/1/2022-12/31/2022 $174.00 $82.13 $99.18 $127.89 $127.89 200% of Medicare 100% of Medicare $104.19 $100.29 $97.67 $111.36 100% of Medicaid 100% of Medicare 150% of Medicare $139.20 $174.00 195% of Medicare $140.94 $103.53 $103.53 $82.13 $174.00 100% of Medicare $139.20 $147.90 $156.60 $127.00 $147.90 $174.00 $174.00 100% of Medicare 100% of Medicare $174.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001202 COLOSTOMY/ILEOSTOMY KIT 19106 NULL INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001204 Mepilex Border Sacrum REF282055 NULL INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001205 OSTOMY DRAINABLE POUCH 2.5 LNR NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001206 OSTOMY 1PC CTF 2 1/8 DRAINABLE NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001207 OSTOMY 1 3/4 2PC POUCH - DRNBL NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001208 OSTOMY-2PC POUCH 2 1/4 LNR NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001209 OSTOMY 2PC POUCH 2 3/4 LNR NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001210 OSTOMY 2PC DRNBL 1 3/4 POUCH NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001211 OSTOMY 2PC POUCH 2 1/4 CLAMP NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001212 OSTOMY- 2PC DRNBL POUCH 2 3/4 NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001213 UROSTOMY 2PC DRNBL POUCH 1 3/4 NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001214 UROSTOMY 2PC POUCH 2 1/4 NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001215 UROSTOMY 2PC POUCH TNSP 2 3/4 NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001216 "Ostomy - Skin Barrier - floating (2-1/4"") -(box)" NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001217 "Ostomy - Skin Barrier - floating (2-1/4"") -(each)" NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001218 "BARRIER, SKIN FORMAFLEX, 2 3/4" NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001219 "BARRIER, CNVX FT, CTF 1W/TAPE""" NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001220 "BARRIER, CNVX FT, CTF 2W/TAPE""" NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001221 UROSTOMY DRAIN TUBE ADAPTER NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001222 Trach Tube - Bivonia Silicone Ped Cuffless (3.5mm) NULL INSTITUTIONAL $306.00 1/1/2022-12/31/2022 $306.00 $144.43 $174.42 $224.91 $224.91 200% of Medicare 100% of Medicare $183.23 $176.38 $171.76 $195.84 100% of Medicaid 100% of Medicare 150% of Medicare $244.80 $306.00 195% of Medicare $247.86 $182.07 $182.07 $144.43 $306.00 100% of Medicare $244.80 $260.10 $275.40 $223.35 $260.10 $306.00 $306.00 100% of Medicare 100% of Medicare $306.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001223 Trach Tube - Bivonia Silicone Ped Cuffless (3.0mm) NULL INSTITUTIONAL $306.00 1/1/2022-12/31/2022 $306.00 $144.43 $174.42 $224.91 $224.91 200% of Medicare 100% of Medicare $183.23 $176.38 $171.76 $195.84 100% of Medicaid 100% of Medicare 150% of Medicare $244.80 $306.00 195% of Medicare $247.86 $182.07 $182.07 $144.43 $306.00 100% of Medicare $244.80 $260.10 $275.40 $223.35 $260.10 $306.00 $306.00 100% of Medicare 100% of Medicare $306.00 200% of Medicare NULL 271 NULL NULL NULL NULL 001231 POSEY ALARM CHAIR PAD NULL INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 200% of Medicare 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 272 NULL NULL NULL NULL 00.1244 MEPILEX 6X6 LITE NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001245 "DUODERM SIGNAL SCR 8.3X8.7""""" NULL INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001250 CELLERATION MIST THERAPY KITS NULL INSTITUTIONAL $214.00 1/1/2022-12/31/2022 $214.00 $101.01 $121.98 $157.29 $157.29 200% of Medicare 100% of Medicare $128.14 $123.35 $120.12 $136.96 100% of Medicaid 100% of Medicare 150% of Medicare $171.20 $214.00 195% of Medicare $173.34 $127.33 $127.33 $101.01 $214.00 100% of Medicare $171.20 $181.90 $192.60 $156.20 $181.90 $214.00 $214.00 100% of Medicare 100% of Medicare $214.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001254 VISTA COLLAR REPLACEMENT PADS NULL INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $94.87 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $120.36 $115.86 $112.82 $128.64 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $119.60 $119.60 $94.87 $201.00 100% of Medicare $160.80 $170.85 $180.90 $146.71 $170.85 $201.00 $201.00 100% of Medicare 100% of Medicare $201.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001274 IODOFORM PACKING STRIP NULL INSTITUTIONAL $106.00 1/1/2022-12/31/2022 $106.00 $50.03 $60.42 $77.91 $77.91 200% of Medicare 100% of Medicare $63.47 $61.10 $59.50 $67.84 100% of Medicaid 100% of Medicare 150% of Medicare $84.80 $106.00 195% of Medicare $85.86 $63.07 $63.07 $50.03 $106.00 100% of Medicare $84.80 $90.10 $95.40 $77.37 $90.10 $106.00 $106.00 100% of Medicare 100% of Medicare $106.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001284 URINAL HOLDER W/ VELCRO STRAP NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001286 Scalpel #15 (disposable) 372615 (each) NULL INSTITUTIONAL " $2,921.00 " 1/1/2022-12/31/2022 " $2,635.00 " $975.00 " $1,664.97 " " $2,146.94 " " $2,146.94 " 200% of Medicare 100% of Medicare " $1,749.09 " " $1,683.66 " " $1,639.56 " " $1,869.44 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,336.80 " " $1,500.00 " 195% of Medicare " $2,366.01 " " $1,738.00 " " $1,738.00 " " $1,378.71 " " $1,359.00 " 100% of Medicare " $2,336.80 " " $2,482.85 " " $2,628.90 " " $2,132.04 " " $2,482.85 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001311 PROFORE COMPRESSION BANDAGE NULL INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $25.02 $30.21 $38.96 $38.96 200% of Medicare 100% of Medicare $31.74 $30.55 $29.75 $33.92 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.54 $31.54 $25.02 $53.00 100% of Medicare $42.40 $45.05 $47.70 $38.68 $45.05 $53.00 $53.00 100% of Medicare 100% of Medicare $53.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001312 "ELECTRODE, 10CM RADIO FREQUENCY" NULL INSTITUTIONAL $314.00 1/1/2022-12/31/2022 $314.00 $148.21 $178.98 $230.79 $230.79 200% of Medicare 100% of Medicare $188.02 $180.99 $176.25 $200.96 100% of Medicaid 100% of Medicare 150% of Medicare $251.20 $314.00 195% of Medicare $254.34 $186.83 $186.83 $148.21 $314.00 100% of Medicare $251.20 $266.90 $282.60 $229.19 $266.90 $314.00 $314.00 100% of Medicare 100% of Medicare $314.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001317 "InterDry (10""x36"") - (each)" NULL INSTITUTIONAL $243.00 1/1/2022-12/31/2022 $243.00 $114.70 $138.51 $178.61 $178.61 200% of Medicare 100% of Medicare $145.51 $140.07 $136.40 $155.52 100% of Medicaid 100% of Medicare 150% of Medicare $194.40 $243.00 195% of Medicare $196.83 $144.59 $144.59 $114.70 $243.00 100% of Medicare $194.40 $206.55 $218.70 $177.37 $206.55 $243.00 $243.00 100% of Medicare 100% of Medicare $243.00 200% of Medicare NULL 510 NULL 20526 NULL NULL 510001 Carpal Tunnel Therapeutic Injection NULL INSTITUTIONAL $852.00 1/1/2022-12/31/2022 $852.00 $356.14 $485.64 $626.22 $626.22 200% of Medicare 100% of Medicare $501.06 $482.32 $469.71 $356.14 100% of Medicaid 100% of Medicare 150% of Medicare $681.60 $852.00 195% of Medicare $690.12 $498.42 $498.42 $402.14 $548.18 100% of Medicare $681.60 $724.20 $668.82 $621.87 $681.60 $724.20 $585.75 100% of Medicare 100% of Medicare $639.00 200% of Medicare NULL 510 NULL 20550 NULL NULL 510002 Injection Single Tendon Sheath/Ligament Apo NULL INSTITUTIONAL " $1,244.00 " 1/1/2022-12/31/2022 " $1,244.00 " $519.99 $709.08 $914.34 $914.34 200% of Medicare 100% of Medicare $731.60 $704.23 $685.82 $519.99 100% of Medicaid 100% of Medicare 150% of Medicare $995.20 " $1,244.00 " 195% of Medicare " $1,007.64 " $727.74 $727.74 $587.17 $800.39 100% of Medicare $995.20 " $1,057.40 " $976.54 $908.00 $995.20 " $1,057.40 " $855.25 100% of Medicare 100% of Medicare $933.00 200% of Medicare NULL 510 NULL 20551 NULL NULL 510003 Injection Single Tendon Origin/Insertion RH NULL INSTITUTIONAL $352.00 1/1/2022-12/31/2022 $352.00 $147.14 $200.64 $258.72 $258.72 200% of Medicare 100% of Medicare $207.01 $199.27 $194.06 $147.14 100% of Medicaid 100% of Medicare 150% of Medicare $281.60 $352.00 195% of Medicare $285.12 $205.92 $205.92 $166.14 $226.48 100% of Medicare $281.60 $299.20 $276.32 $256.92 $281.60 $299.20 $242.00 100% of Medicare 100% of Medicare $264.00 200% of Medicare NULL 510 NULL 20552 NULL NULL 510004 Injection Single/Multiple Trigger Points 1 NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 20553 NULL NULL 510005 Injection Single/Multiple Trigger Points 3 NULL INSTITUTIONAL " $1,578.00 " 1/1/2022-12/31/2022 " $1,500.00 " $659.60 $899.46 " $1,159.83 " " $1,159.83 " 200% of Medicare 100% of Medicare $928.02 $893.31 $869.95 $659.60 100% of Medicaid 100% of Medicare 150% of Medicare " $1,262.40 " " $1,500.00 " 195% of Medicare " $1,278.18 " $923.13 $923.13 $744.82 " $1,015.29 " 100% of Medicare " $1,262.40 " " $1,341.30 " " $1,238.73 " " $1,151.78 " " $1,262.40 " " $1,341.30 " " $1,084.88 " 100% of Medicare 100% of Medicare " $1,183.50 " 200% of Medicare NULL 510 NULL 20600 NULL NULL 510006 Arthrocentesis/Aspiration Injection Small J NULL INSTITUTIONAL $852.00 1/1/2022-12/31/2022 $852.00 $356.14 $485.64 $626.22 $626.22 200% of Medicare 100% of Medicare $501.06 $482.32 $469.71 $356.14 100% of Medicaid 100% of Medicare 150% of Medicare $681.60 $852.00 195% of Medicare $690.12 $498.42 $498.42 $402.14 $548.18 100% of Medicare $681.60 $724.20 $668.82 $621.87 $681.60 $724.20 $585.75 100% of Medicare 100% of Medicare $639.00 200% of Medicare NULL 510 NULL 20605 NULL NULL 510007 Arthrocentesis/Aspiration Injection Interme NULL INSTITUTIONAL $852.00 1/1/2022-12/31/2022 $852.00 $356.14 $485.64 $626.22 $626.22 200% of Medicare 100% of Medicare $501.06 $482.32 $469.71 $356.14 100% of Medicaid 100% of Medicare 150% of Medicare $681.60 $852.00 195% of Medicare $690.12 $498.42 $498.42 $402.14 $548.18 100% of Medicare $681.60 $724.20 $668.82 $621.87 $681.60 $724.20 $585.75 100% of Medicare 100% of Medicare $639.00 200% of Medicare NULL 510 NULL 20610 NULL NULL 510008 Arthrocentesis/Aspiration Injection Major J NULL INSTITUTIONAL $852.00 1/1/2022-12/31/2022 $852.00 $356.14 $485.64 $626.22 $626.22 200% of Medicare 100% of Medicare $501.06 $482.32 $469.71 $356.14 100% of Medicaid 100% of Medicare 150% of Medicare $681.60 $852.00 195% of Medicare $690.12 $498.42 $498.42 $402.14 $548.18 100% of Medicare $681.60 $724.20 $668.82 $621.87 $681.60 $724.20 $585.75 100% of Medicare 100% of Medicare $639.00 200% of Medicare NULL 510 NULL 27096 NULL NULL 510009 Injection Sacroiliac Joint NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL NULL NULL NULL 510010 Single Injection Epidural Cervical/Thoracic NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,395.00 " $975.00 " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,434.13 " " $1,380.48 " " $1,344.31 " " $1,532.80 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,425.03 " " $1,425.03 " " $1,130.44 " " $1,359.00 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $2,155.50 " " $1,748.11 " " $2,035.75 " " $1,500.00 " " $2,395.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 510 NULL NULL NULL NULL 510011 Single Injection Epidural Lumbar/Sacral NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,395.00 " $975.00 " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,434.13 " " $1,380.48 " " $1,344.31 " " $1,532.80 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,425.03 " " $1,425.03 " " $1,130.44 " " $1,359.00 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $2,155.50 " " $1,748.11 " " $2,035.75 " " $1,500.00 " " $2,395.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 510 NULL 62368 NULL NULL 510012 "Pain Pump Analysis, Reprogramming" NULL INSTITUTIONAL $846.00 1/1/2022-12/31/2022 $846.00 $353.63 $482.22 $621.81 $621.81 200% of Medicare 100% of Medicare $497.53 $478.92 $466.40 $353.63 100% of Medicaid 100% of Medicare 150% of Medicare $676.80 $846.00 195% of Medicare $685.26 $494.91 $494.91 $399.31 $544.32 100% of Medicare $676.80 $719.10 $664.11 $617.50 $676.80 $719.10 $581.63 100% of Medicare 100% of Medicare $634.50 200% of Medicare NULL 510 NULL 62369 NULL NULL 510013 Analysis/Reprogram/Refill Pump NULL INSTITUTIONAL " $1,476.00 " 1/1/2022-12/31/2022 " $1,476.00 " $616.97 $841.32 " $1,084.86 " " $1,084.86 " 200% of Medicare 100% of Medicare $868.04 $835.56 $813.72 $616.97 100% of Medicaid 100% of Medicare 150% of Medicare " $1,180.80 " " $1,476.00 " 195% of Medicare " $1,195.56 " $863.46 $863.46 $696.67 $949.66 100% of Medicare " $1,180.80 " " $1,254.60 " " $1,158.66 " " $1,077.33 " " $1,180.80 " " $1,254.60 " " $1,014.75 " 100% of Medicare 100% of Medicare " $1,107.00 " 200% of Medicare NULL 510 NULL 63650 NULL NULL 510014 Percutaneous Implant Neurostimulator Electr NULL INSTITUTIONAL " $22,993.00 " 1/1/2022-12/31/2022 " $19,544.05 " " $1,500.00 " " $13,106.01 " " $16,899.86 " " $16,899.86 " 200% of Medicare 100% of Medicare " $13,522.18 " " $13,016.34 " " $12,676.04 " " $9,611.07 " 100% of Medicaid 100% of Medicare 150% of Medicare " $18,394.40 " " $1,500.00 " 195% of Medicare " $18,624.33 " " $13,450.91 " " $13,450.91 " " $10,852.70 " " $14,793.70 " 100% of Medicare " $18,394.40 " " $19,544.05 " " $18,049.51 " " $16,782.59 " " $18,394.40 " " $19,544.05 " " $15,807.69 " 100% of Medicare 100% of Medicare " $17,244.75 " 200% of Medicare NULL 510 NULL 64405 NULL NULL 510015 Injection Anesthetic Agent Greater Occipita NULL INSTITUTIONAL $318.00 1/1/2022-12/31/2022 $318.00 $132.92 $181.26 $233.73 $233.73 200% of Medicare 100% of Medicare $187.02 $180.02 $175.31 $132.92 100% of Medicaid 100% of Medicare 150% of Medicare $254.40 $318.00 195% of Medicare $257.58 $186.03 $186.03 $150.10 $204.60 100% of Medicare $254.40 $270.30 $249.63 $232.11 $254.40 $270.30 $218.63 100% of Medicare 100% of Medicare $238.50 200% of Medicare NULL 510 NULL 64418 NULL NULL 510016 Injection Anesthetic Agent Suprascapular Ne NULL INSTITUTIONAL $887.00 1/1/2022-12/31/2022 $887.00 $370.77 $505.59 $651.95 $651.95 200% of Medicare 100% of Medicare $521.64 $502.13 $489.00 $370.77 100% of Medicaid 100% of Medicare 150% of Medicare $709.60 $887.00 195% of Medicare $718.47 $518.90 $518.90 $418.66 $570.70 100% of Medicare $709.60 $753.95 $696.30 $647.42 $709.60 $753.95 $609.81 100% of Medicare 100% of Medicare $665.25 200% of Medicare NULL 510 NULL 64420 NULL NULL 510017 Injection Anesthetic Agent Intercostal Nerv NULL INSTITUTIONAL $473.00 1/1/2022-12/31/2022 $473.00 $197.71 $269.61 $347.66 $347.66 200% of Medicare 100% of Medicare $278.17 $267.77 $260.76 $197.71 100% of Medicaid 100% of Medicare 150% of Medicare $378.40 $473.00 195% of Medicare $383.13 $276.71 $276.71 $223.26 $304.33 100% of Medicare $378.40 $402.05 $371.31 $345.24 $378.40 $402.05 $325.19 100% of Medicare 100% of Medicare $354.75 200% of Medicare NULL 510 NULL 64421 NULL NULL 510018 Injection Anesthetic Agent Intercostal Nerv NULL INSTITUTIONAL " $1,420.00 " 1/1/2022-12/31/2022 " $1,420.00 " $593.56 $809.40 " $1,043.70 " " $1,043.70 " 200% of Medicare 100% of Medicare $835.10 $803.86 $782.85 $593.56 100% of Medicaid 100% of Medicare 150% of Medicare " $1,136.00 " " $1,420.00 " 195% of Medicare " $1,150.20 " $830.70 $830.70 $670.24 $913.63 100% of Medicare " $1,136.00 " " $1,207.00 " " $1,114.70 " " $1,036.46 " " $1,136.00 " " $1,207.00 " $976.25 100% of Medicare 100% of Medicare " $1,065.00 " 200% of Medicare NULL 510 NULL 64425 NULL NULL 510019 Injection Anesthetic Agent Ilioinguinal/Ili NULL INSTITUTIONAL $644.00 1/1/2022-12/31/2022 $644.00 $269.19 $367.08 $473.34 $473.34 200% of Medicare 100% of Medicare $378.74 $364.57 $355.04 $269.19 100% of Medicaid 100% of Medicare 150% of Medicare $515.20 $644.00 195% of Medicare $521.64 $376.74 $376.74 $303.97 $414.35 100% of Medicare $515.20 $547.40 $505.54 $470.06 $515.20 $547.40 $442.75 100% of Medicare 100% of Medicare $483.00 200% of Medicare NULL 510 NULL 64445 NULL NULL 510020 Injection Anesthetic Agent Sciatic Nerve Si NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64447 NULL NULL 510021 Injection Anesthetic Agent Femoral Nerve Si NULL INSTITUTIONAL " $1,239.00 " 1/1/2022-12/31/2022 " $1,239.00 " $517.90 $706.23 $910.67 $910.67 200% of Medicare 100% of Medicare $728.66 $701.40 $683.06 $517.90 100% of Medicaid 100% of Medicare 150% of Medicare $991.20 " $1,239.00 " 195% of Medicare " $1,003.59 " $724.82 $724.82 $584.81 $797.17 100% of Medicare $991.20 " $1,053.15 " $972.62 $904.35 $991.20 " $1,053.15 " $851.81 100% of Medicare 100% of Medicare $929.25 200% of Medicare NULL 510 NULL 64450 NULL NULL 510022 Injection Anesthetic Agent Other Peripheral NULL INSTITUTIONAL $509.00 1/1/2022-12/31/2022 $509.00 $212.76 $290.13 $374.12 $374.12 200% of Medicare 100% of Medicare $299.34 $288.14 $280.61 $212.76 100% of Medicaid 100% of Medicare 150% of Medicare $407.20 $509.00 195% of Medicare $412.29 $297.77 $297.77 $240.25 $327.49 100% of Medicare $407.20 $432.65 $399.57 $371.52 $407.20 $432.65 $349.94 100% of Medicare 100% of Medicare $381.75 200% of Medicare NULL 510 NULL 64479 NULL NULL 510023 Injection Transforaminal Epidural Cervical NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64480 NULL NULL 510024 Injection Transforaminal Epidural Cervical NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 64483 NULL NULL 510025 Injection Transforaminal Epidural Lumbar or NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64484 NULL NULL 510026 Injection Transforaminal Epidural Lumbar or NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 64490 NULL NULL 510027 Injection Paravertebral Facet Cervical or T NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64491 NULL NULL 510028 Injection Paravertebral Facet Cervical or T NULL INSTITUTIONAL " $1,331.00 " 1/1/2022-12/31/2022 " $1,331.00 " $556.36 $758.67 $978.29 $978.29 200% of Medicare 100% of Medicare $782.76 $753.48 $733.78 $556.36 100% of Medicaid 100% of Medicare 150% of Medicare " $1,064.80 " " $1,331.00 " 195% of Medicare " $1,078.11 " $778.64 $778.64 $628.23 $856.37 100% of Medicare " $1,064.80 " " $1,131.35 " " $1,044.84 " $971.50 " $1,064.80 " " $1,131.35 " $915.06 100% of Medicare 100% of Medicare $998.25 200% of Medicare NULL 510 NULL 64492 NULL NULL 510029 Injection Paravertebral Facet Cervical or T NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 64493 NULL NULL 510030 Injection Paravertebral Facet Lumbar or Sac NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64494 NULL NULL 510031 Injection Paravertebral Facet Lumbar or Sac NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 64495 NULL NULL 510032 Injection Paravertebral Facet Lumbar or Sac NULL INSTITUTIONAL " $1,358.00 " 1/1/2022-12/31/2022 " $1,358.00 " $567.64 $774.06 $998.13 $998.13 200% of Medicare 100% of Medicare $798.64 $768.76 $748.67 $567.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,086.40 " " $1,358.00 " 195% of Medicare " $1,099.98 " $794.43 $794.43 $640.98 $873.74 100% of Medicare " $1,086.40 " " $1,154.30 " " $1,066.03 " $991.20 " $1,086.40 " " $1,154.30 " $933.63 100% of Medicare 100% of Medicare " $1,018.50 " 200% of Medicare NULL 510 NULL 64520 NULL NULL 510033 Injection Paravertebral Lumbar/Thoracic NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 510 NULL 64611 NULL NULL 510034 Chemodenervation Parotid/Submandibluar Sali NULL INSTITUTIONAL $477.00 1/1/2022-12/31/2022 $477.00 $199.39 $271.89 $350.60 $350.60 200% of Medicare 100% of Medicare $280.52 $270.03 $262.97 $199.39 100% of Medicaid 100% of Medicare 150% of Medicare $381.60 $477.00 195% of Medicare $386.37 $279.05 $279.05 $225.14 $306.90 100% of Medicare $381.60 $405.45 $374.45 $348.16 $381.60 $405.45 $327.94 100% of Medicare 100% of Medicare $357.75 200% of Medicare NULL 510 NULL 64612 NULL NULL 510035 Chemodenervation Facial Nerve NULL INSTITUTIONAL " $1,133.00 " 1/1/2022-12/31/2022 " $1,133.00 " $473.59 $645.81 $832.76 $832.76 200% of Medicare 100% of Medicare $666.32 $641.39 $624.62 $473.59 100% of Medicaid 100% of Medicare 150% of Medicare $906.40 " $1,133.00 " 195% of Medicare $917.73 $662.81 $662.81 $534.78 $728.97 100% of Medicare $906.40 $963.05 $889.41 $826.98 $906.40 $963.05 $778.94 100% of Medicare 100% of Medicare $849.75 200% of Medicare NULL 510 NULL 64616 NULL NULL 510036 Chemodenervation Neck Muscle NULL INSTITUTIONAL " $1,262.00 " 1/1/2022-12/31/2022 " $1,262.00 " $527.52 $719.34 $927.57 $927.57 200% of Medicare 100% of Medicare $742.18 $714.42 $695.74 $527.52 100% of Medicaid 100% of Medicare 150% of Medicare " $1,009.60 " " $1,262.00 " 195% of Medicare " $1,022.22 " $738.27 $738.27 $595.66 $811.97 100% of Medicare " $1,009.60 " " $1,072.70 " $990.67 $921.13 " $1,009.60 " " $1,072.70 " $867.63 100% of Medicare 100% of Medicare $946.50 200% of Medicare NULL 510 NULL 64642 NULL NULL 510037 Chemodenervation Extremity/Trunk Muscle NULL INSTITUTIONAL " $1,448.00 " 1/1/2022-12/31/2022 " $1,448.00 " $605.26 $825.36 " $1,064.28 " " $1,064.28 " 200% of Medicare 100% of Medicare $851.57 $819.71 $798.28 $605.26 100% of Medicaid 100% of Medicare 150% of Medicare " $1,158.40 " " $1,448.00 " 195% of Medicare " $1,172.88 " $847.08 $847.08 $683.46 $931.64 100% of Medicare " $1,158.40 " " $1,230.80 " " $1,136.68 " " $1,056.90 " " $1,158.40 " " $1,230.80 " $995.50 100% of Medicare 100% of Medicare " $1,086.00 " 200% of Medicare NULL 510 NULL 64615 NULL NULL 510038 Chemodenervation Chronic Migraine NULL INSTITUTIONAL $520.00 1/1/2022-12/31/2022 $520.00 $217.36 $296.40 $382.20 $382.20 200% of Medicare 100% of Medicare $305.81 $294.37 $286.68 $217.36 100% of Medicaid 100% of Medicare 150% of Medicare $416.00 $520.00 195% of Medicare $421.20 $304.20 $304.20 $245.44 $334.57 100% of Medicare $416.00 $442.00 $408.20 $379.55 $416.00 $442.00 $357.50 100% of Medicare 100% of Medicare $390.00 200% of Medicare NULL 510 NULL 64633 NULL NULL 510039 Destruction Paravertebral Facet Cervical or NULL INSTITUTIONAL " $2,245.00 " 1/1/2022-12/31/2022 " $1,908.25 " $938.41 " $1,279.65 " " $1,650.08 " " $1,650.08 " 200% of Medicare 100% of Medicare " $1,320.28 " " $1,270.89 " " $1,237.67 " $938.41 100% of Medicaid 100% of Medicare 150% of Medicare " $1,796.00 " " $1,500.00 " 195% of Medicare " $1,818.45 " " $1,313.33 " " $1,313.33 " " $1,059.64 " " $1,444.43 " 100% of Medicare " $1,796.00 " " $1,908.25 " " $1,762.33 " " $1,638.63 " " $1,796.00 " " $1,908.25 " " $1,543.44 " 100% of Medicare 100% of Medicare " $1,683.75 " 200% of Medicare NULL 510 NULL 64634 NULL NULL 510040 Destruction Paravertebral Facet Cervical or NULL INSTITUTIONAL " $1,124.00 " 1/1/2022-12/31/2022 " $1,124.00 " $469.83 $640.68 $826.14 $826.14 200% of Medicare 100% of Medicare $661.02 $636.30 $619.66 $469.83 100% of Medicaid 100% of Medicare 150% of Medicare $899.20 " $1,124.00 " 195% of Medicare $910.44 $657.54 $657.54 $530.53 $723.18 100% of Medicare $899.20 $955.40 $882.34 $820.41 $899.20 $955.40 $772.75 100% of Medicare 100% of Medicare $843.00 200% of Medicare NULL 510 NULL 64640 NULL NULL 510041 Destruction Neurolytic Peripheral NULL INSTITUTIONAL $801.00 1/1/2022-12/31/2022 $801.00 $334.82 $456.57 $588.74 $588.74 200% of Medicare 100% of Medicare $471.07 $453.45 $441.59 $334.82 100% of Medicaid 100% of Medicare 150% of Medicare $640.80 $801.00 195% of Medicare $648.81 $468.59 $468.59 $378.07 $515.36 100% of Medicare $640.80 $680.85 $628.79 $584.65 $640.80 $680.85 $550.69 100% of Medicare 100% of Medicare $600.75 200% of Medicare NULL 510 NULL 77002 NULL NULL 510042 Fluroscopic Guidance for Needle Placement R NULL INSTITUTIONAL $406.00 1/1/2022-12/31/2022 $406.00 $169.71 $231.42 $298.41 $298.41 200% of Medicare 100% of Medicare $238.77 $229.84 $223.83 $169.71 100% of Medicaid 100% of Medicare 150% of Medicare $324.80 $406.00 195% of Medicare $328.86 $237.51 $237.51 $191.63 $261.22 100% of Medicare $324.80 $345.10 $318.71 $296.34 $324.80 $345.10 $279.13 100% of Medicare 100% of Medicare $304.50 200% of Medicare NULL 510 NULL 77003 NULL NULL 510043 Fluroscopic Guidance/Localization Needle fo NULL INSTITUTIONAL $324.00 1/1/2022-12/31/2022 $324.00 $135.43 $184.68 $238.14 $238.14 200% of Medicare 100% of Medicare $190.54 $183.42 $178.62 $135.43 100% of Medicaid 100% of Medicare 150% of Medicare $259.20 $324.00 195% of Medicare $262.44 $189.54 $189.54 $152.93 $208.46 100% of Medicare $259.20 $275.40 $254.34 $236.49 $259.20 $275.40 $222.75 100% of Medicare 100% of Medicare $243.00 200% of Medicare NULL 510 NULL 77080 NULL NULL 510044 " DXA Bone Density Study, Axial Skeleton" NULL INSTITUTIONAL $525.00 1/1/2022-12/31/2022 $525.00 $219.45 $299.25 $385.88 $385.88 200% of Medicare 100% of Medicare $308.75 $297.20 $289.43 $219.45 100% of Medicaid 100% of Medicare 150% of Medicare $420.00 $525.00 195% of Medicare $425.25 $307.13 $307.13 $247.80 $337.79 100% of Medicare $420.00 $446.25 $412.13 $383.20 $420.00 $446.25 $360.94 100% of Medicare 100% of Medicare $393.75 200% of Medicare NULL 922 NULL 95860 NULL NULL 510045 Needle Electromyography 1 Extremity with/wi NULL INSTITUTIONAL $285.00 1/1/2022-12/31/2022 $285.00 $119.13 $162.45 $209.48 $209.48 200% of Medicare 100% of Medicare $167.61 $161.34 $157.12 $119.13 100% of Medicaid 100% of Medicare 150% of Medicare $228.00 $285.00 195% of Medicare $230.85 $166.73 $166.73 $134.52 $183.37 100% of Medicare $228.00 $242.25 $223.73 $208.02 $228.00 $242.25 $195.94 100% of Medicare 100% of Medicare $213.75 200% of Medicare NULL 922 NULL 95861 NULL NULL 510046 Needle Electromyography 2 Extremities NULL INSTITUTIONAL $406.00 1/1/2022-12/31/2022 $406.00 $169.71 $231.42 $298.41 $298.41 200% of Medicare 100% of Medicare $238.77 $229.84 $223.83 $169.71 100% of Medicaid 100% of Medicare 150% of Medicare $324.80 $406.00 195% of Medicare $328.86 $237.51 $237.51 $191.63 $261.22 100% of Medicare $324.80 $345.10 $318.71 $296.34 $324.80 $345.10 $279.13 100% of Medicare 100% of Medicare $304.50 200% of Medicare NULL 922 NULL 95863 NULL NULL 510047 Needle Electromyography 3 Extremities NULL INSTITUTIONAL $486.00 1/1/2022-12/31/2022 $486.00 $203.15 $277.02 $357.21 $357.21 200% of Medicare 100% of Medicare $285.82 $275.12 $267.93 $203.15 100% of Medicaid 100% of Medicare 150% of Medicare $388.80 $486.00 195% of Medicare $393.66 $284.31 $284.31 $229.39 $312.69 100% of Medicare $388.80 $413.10 $381.51 $354.73 $388.80 $413.10 $334.13 100% of Medicare 100% of Medicare $364.50 200% of Medicare NULL 922 NULL 95864 NULL NULL 510048 Needle Electromyography 4 Extremities NULL INSTITUTIONAL $555.00 1/1/2022-12/31/2022 $555.00 $231.99 $316.35 $407.93 $407.93 200% of Medicare 100% of Medicare $326.40 $314.19 $305.97 $231.99 100% of Medicaid 100% of Medicare 150% of Medicare $444.00 $555.00 195% of Medicare $449.55 $324.68 $324.68 $261.96 $357.09 100% of Medicare $444.00 $471.75 $435.68 $405.09 $444.00 $471.75 $381.56 100% of Medicare 100% of Medicare $416.25 200% of Medicare NULL 922 NULL 95869 NULL NULL 510049 Needle Electromyography Thoracic Paraspinal NULL INSTITUTIONAL $159.00 1/1/2022-12/31/2022 $159.00 $66.46 $90.63 $116.87 $116.87 200% of Medicare 100% of Medicare $93.51 $90.01 $87.66 $66.46 100% of Medicaid 100% of Medicare 150% of Medicare $127.20 $159.00 195% of Medicare $128.79 $93.02 $93.02 $75.05 $102.30 100% of Medicare $127.20 $135.15 $124.82 $116.05 $127.20 $135.15 $109.31 100% of Medicare 100% of Medicare $119.25 200% of Medicare NULL 510 NULL 95870 NULL NULL 510050 Needle Electromyography 1 Muscle Extremity NULL INSTITUTIONAL $168.00 1/1/2022-12/31/2022 $168.00 $70.22 $95.76 $123.48 $123.48 200% of Medicare 100% of Medicare $98.80 $95.10 $92.62 $70.22 100% of Medicaid 100% of Medicare 150% of Medicare $134.40 $168.00 195% of Medicare $136.08 $98.28 $98.28 $79.30 $108.09 100% of Medicare $134.40 $142.80 $131.88 $122.62 $134.40 $142.80 $115.50 100% of Medicare 100% of Medicare $126.00 200% of Medicare NULL 510 NULL 95873 NULL NULL 510051 Electrical Stimulation Conjunction with Che NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 922 NULL 95874 NULL NULL 510052 Needle Electromyography Conjunction with Ch NULL INSTITUTIONAL $151.00 1/1/2022-12/31/2022 $151.00 $63.12 $86.07 $110.99 $110.99 200% of Medicare 100% of Medicare $88.80 $85.48 $83.25 $63.12 100% of Medicaid 100% of Medicare 150% of Medicare $120.80 $151.00 195% of Medicare $122.31 $88.34 $88.34 $71.27 $97.15 100% of Medicare $120.80 $128.35 $118.54 $110.21 $120.80 $128.35 $103.81 100% of Medicare 100% of Medicare $113.25 200% of Medicare NULL 922 NULL 95905 NULL NULL 510053 Motor Nerve Conduction Test NULL INSTITUTIONAL $213.00 1/1/2022-12/31/2022 $213.00 $89.03 $121.41 $156.56 $156.56 200% of Medicare 100% of Medicare $125.27 $120.58 $117.43 $89.03 100% of Medicaid 100% of Medicare 150% of Medicare $170.40 $213.00 195% of Medicare $172.53 $124.61 $124.61 $100.54 $137.04 100% of Medicare $170.40 $181.05 $167.21 $155.47 $170.40 $181.05 $146.44 100% of Medicare 100% of Medicare $159.75 200% of Medicare NULL 510 NULL 96365 NULL NULL 510054 Intravenous Infusion Therapy Initial Hour R NULL INSTITUTIONAL $510.00 1/1/2022-12/31/2022 $510.00 $213.18 $290.70 $374.85 $374.85 200% of Medicare 100% of Medicare $299.93 $288.71 $281.16 $213.18 100% of Medicaid 100% of Medicare 150% of Medicare $408.00 $510.00 195% of Medicare $413.10 $298.35 $298.35 $240.72 $328.13 100% of Medicare $408.00 $433.50 $400.35 $372.25 $408.00 $433.50 $350.63 100% of Medicare 100% of Medicare $382.50 200% of Medicare NULL 510 NULL 96366 NULL NULL 510055 Intravenous Infusion Therapy Initial Each A NULL INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $67.30 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $94.68 $91.14 $88.76 $67.30 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $94.19 $94.19 $75.99 $103.59 100% of Medicare $128.80 $136.85 $126.39 $117.51 $128.80 $136.85 $110.69 100% of Medicare 100% of Medicare $120.75 200% of Medicare NULL 510 NULL 96374 NULL NULL 510056 Therapeutic Injection Single Intravenous Pu NULL INSTITUTIONAL $285.00 1/1/2022-12/31/2022 $285.00 $119.13 $162.45 $209.48 $209.48 200% of Medicare 100% of Medicare $167.61 $161.34 $157.12 $119.13 100% of Medicaid 100% of Medicare 150% of Medicare $228.00 $285.00 195% of Medicare $230.85 $166.73 $166.73 $134.52 $183.37 100% of Medicare $228.00 $242.25 $223.73 $208.02 $228.00 $242.25 $195.94 100% of Medicare 100% of Medicare $213.75 200% of Medicare NULL 510 NULL 96375 NULL NULL 510057 Therapeutic Injection Each Add Sequential I NULL INSTITUTIONAL $187.00 1/1/2022-12/31/2022 $187.00 $78.17 $106.59 $137.45 $137.45 200% of Medicare 100% of Medicare $109.97 $105.86 $103.09 $78.17 100% of Medicaid 100% of Medicare 150% of Medicare $149.60 $187.00 195% of Medicare $151.47 $109.40 $109.40 $88.26 $120.32 100% of Medicare $149.60 $158.95 $146.80 $136.49 $149.60 $158.95 $128.56 100% of Medicare 100% of Medicare $140.25 200% of Medicare NULL 510 NULL 97597 NULL NULL 510058 Selective Debridement < 20 cm NULL INSTITUTIONAL $243.00 1/1/2022-12/31/2022 $243.00 $101.57 $138.51 $178.61 $178.61 200% of Medicare 100% of Medicare $142.91 $137.56 $133.97 $101.57 100% of Medicaid 100% of Medicare 150% of Medicare $194.40 $243.00 195% of Medicare $196.83 $142.16 $142.16 $114.70 $156.35 100% of Medicare $194.40 $206.55 $190.76 $177.37 $194.40 $206.55 $167.06 100% of Medicare 100% of Medicare $182.25 200% of Medicare NULL 510 NULL 97598 NULL NULL 510059 Non-selective Debridement > 20 cm NULL INSTITUTIONAL $316.00 1/1/2022-12/31/2022 $316.00 $132.09 $180.12 $232.26 $232.26 200% of Medicare 100% of Medicare $185.84 $178.89 $174.21 $132.09 100% of Medicaid 100% of Medicare 150% of Medicare $252.80 $316.00 195% of Medicare $255.96 $184.86 $184.86 $149.15 $203.31 100% of Medicare $252.80 $268.60 $248.06 $230.65 $252.80 $268.60 $217.25 100% of Medicare 100% of Medicare $237.00 200% of Medicare NULL 510 NULL 97605 NULL NULL 510060 Negative Press Wound <50 sq cm NULL INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $58.10 $79.23 $102.17 $102.17 200% of Medicare 100% of Medicare $81.75 $78.69 $76.63 $58.10 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $81.32 $81.32 $65.61 $89.43 100% of Medicare $111.20 $118.15 $109.12 $101.46 $111.20 $118.15 $95.56 100% of Medicare 100% of Medicare $104.25 200% of Medicare NULL 510 NULL 97606 NULL NULL 510061 Negative Press Wound >50 sq cm NULL INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $67.30 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $94.68 $91.14 $88.76 $67.30 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $94.19 $94.19 $75.99 $103.59 100% of Medicare $128.80 $136.85 $126.39 $117.51 $128.80 $136.85 $110.69 100% of Medicare 100% of Medicare $120.75 200% of Medicare NULL 510 NULL NULL NULL G0463 510062 " Office/Outpatient Visit, New" NULL INSTITUTIONAL $231.00 1/1/2022-12/31/2022 $231.00 $96.56 $131.67 $169.79 $169.79 200% of Medicare 100% of Medicare $135.85 $130.77 $127.35 $96.56 100% of Medicaid 100% of Medicare 150% of Medicare $184.80 $231.00 195% of Medicare $187.11 $135.14 $135.14 $109.03 $148.63 100% of Medicare $184.80 $196.35 $181.34 $168.61 $184.80 $196.35 $158.81 100% of Medicare 100% of Medicare $173.25 200% of Medicare NULL 510 NULL NULL NULL G0463 510063 " Office/Outpatient Visit, New" NULL INSTITUTIONAL $345.00 1/1/2022-12/31/2022 $345.00 $144.21 $196.65 $253.58 $253.58 200% of Medicare 100% of Medicare $202.89 $195.30 $190.20 $144.21 100% of Medicaid 100% of Medicare 150% of Medicare $276.00 $345.00 195% of Medicare $279.45 $201.83 $201.83 $162.84 $221.97 100% of Medicare $276.00 $293.25 $270.83 $251.82 $276.00 $293.25 $237.19 100% of Medicare 100% of Medicare $258.75 200% of Medicare NULL 510 NULL NULL NULL G0463 510064 " Office/Outpatient Visit, New" NULL INSTITUTIONAL $352.00 1/1/2022-12/31/2022 $352.00 $147.14 $200.64 $258.72 $258.72 200% of Medicare 100% of Medicare $207.01 $199.27 $194.06 $147.14 100% of Medicaid 100% of Medicare 150% of Medicare $281.60 $352.00 195% of Medicare $285.12 $205.92 $205.92 $166.14 $226.48 100% of Medicare $281.60 $299.20 $276.32 $256.92 $281.60 $299.20 $242.00 100% of Medicare 100% of Medicare $264.00 200% of Medicare NULL 510 NULL NULL NULL G0463 510065 " Office/Outpatient Visit, New" NULL INSTITUTIONAL $459.00 1/1/2022-12/31/2022 $459.00 $191.86 $261.63 $337.37 $337.37 200% of Medicare 100% of Medicare $269.94 $259.84 $253.05 $191.86 100% of Medicaid 100% of Medicare 150% of Medicare $367.20 $459.00 195% of Medicare $371.79 $268.52 $268.52 $216.65 $295.32 100% of Medicare $367.20 $390.15 $360.32 $335.02 $367.20 $390.15 $315.56 100% of Medicare 100% of Medicare $344.25 200% of Medicare NULL 510 NULL NULL NULL G0463 510066 " Office/Outpatient Visit, Est" NULL INSTITUTIONAL $345.00 1/1/2022-12/31/2022 $345.00 $144.21 $196.65 $253.58 $253.58 200% of Medicare 100% of Medicare $202.89 $195.30 $190.20 $144.21 100% of Medicaid 100% of Medicare 150% of Medicare $276.00 $345.00 195% of Medicare $279.45 $201.83 $201.83 $162.84 $221.97 100% of Medicare $276.00 $293.25 $270.83 $251.82 $276.00 $293.25 $237.19 100% of Medicare 100% of Medicare $258.75 200% of Medicare NULL 510 NULL NULL NULL G0463 510067 " Office/Outpatient Visit, Est" NULL INSTITUTIONAL $433.00 1/1/2022-12/31/2022 $433.00 $180.99 $246.81 $318.26 $318.26 200% of Medicare 100% of Medicare $254.65 $245.12 $238.71 $180.99 100% of Medicaid 100% of Medicare 150% of Medicare $346.40 $433.00 195% of Medicare $350.73 $253.31 $253.31 $204.38 $278.59 100% of Medicare $346.40 $368.05 $339.91 $316.05 $346.40 $368.05 $297.69 100% of Medicare 100% of Medicare $324.75 200% of Medicare NULL 510 NULL NULL NULL G0463 510068 " Office/Outpatient Visit, Est" NULL INSTITUTIONAL $499.00 1/1/2022-12/31/2022 $499.00 $208.58 $284.43 $366.77 $366.77 200% of Medicare 100% of Medicare $293.46 $282.48 $275.10 $208.58 100% of Medicaid 100% of Medicare 150% of Medicare $399.20 $499.00 195% of Medicare $404.19 $291.92 $291.92 $235.53 $321.06 100% of Medicare $399.20 $424.15 $391.72 $364.22 $399.20 $424.15 $343.06 100% of Medicare 100% of Medicare $374.25 200% of Medicare NULL 510 NULL NULL NULL G0463 510069 " Office/Outpatient Visit, Est" NULL INSTITUTIONAL $459.00 1/1/2022-12/31/2022 $459.00 $191.86 $261.63 $337.37 $337.37 200% of Medicare 100% of Medicare $269.94 $259.84 $253.05 $191.86 100% of Medicaid 100% of Medicare 150% of Medicare $367.20 $459.00 195% of Medicare $371.79 $268.52 $268.52 $216.65 $295.32 100% of Medicare $367.20 $390.15 $360.32 $335.02 $367.20 $390.15 $315.56 100% of Medicare 100% of Medicare $344.25 200% of Medicare NULL 279 NULL NULL NULL C1778 510070 Lead Neurostimulator Implant NULL INSTITUTIONAL " $1,906.00 " 1/1/2022-12/31/2022 " $1,620.10 " $796.71 " $1,086.42 " " $1,400.91 " " $1,400.91 " 200% of Medicare 100% of Medicare " $1,120.92 " " $1,078.99 " " $1,050.78 " $796.71 100% of Medicaid 100% of Medicare 150% of Medicare " $1,524.80 " " $1,500.00 " 195% of Medicare " $1,543.86 " " $1,115.01 " " $1,115.01 " $899.63 " $1,226.32 " 100% of Medicare " $1,524.80 " " $1,620.10 " " $1,496.21 " " $1,391.19 " " $1,524.80 " " $1,620.10 " " $1,310.38 " 100% of Medicare 100% of Medicare " $1,429.50 " 200% of Medicare NULL 510 NULL NULL NULL G0260 510071 Injection Sacroiliac Joint with or without NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levofloxacin 25 mg/mL IV Sol 25021-0130-30 INSTITUTIONAL $143.00 1/1/2022-12/31/2022 $143.00 $67.50 $81.51 $105.11 $105.11 200% of Medicare 100% of Medicare $85.63 $82.43 $80.27 $91.52 100% of Medicaid 100% of Medicare 150% of Medicare $114.40 $143.00 195% of Medicare $115.83 $85.09 $85.09 $67.50 $143.00 100% of Medicare $114.40 $121.55 $128.70 $104.38 $121.55 $143.00 $143.00 100% of Medicare 100% of Medicare $143.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL meropenem 1 g IV Inj 63323-0508-31 INSTITUTIONAL $129.00 1/1/2022-12/31/2022 $129.00 $60.89 $73.53 $94.82 $94.82 200% of Medicare 100% of Medicare $77.25 $74.36 $72.41 $82.56 100% of Medicaid 100% of Medicare 150% of Medicare $103.20 $129.00 195% of Medicare $104.49 $76.76 $76.76 $60.89 $129.00 100% of Medicare $103.20 $109.65 $116.10 $94.16 $109.65 $129.00 $129.00 100% of Medicare 100% of Medicare $129.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Piperacillin-Taz Inj 2.25 GM (UD) 00409-3383-02 INSTITUTIONAL $97.00 1/1/2022-12/31/2022 $97.00 $45.78 $55.29 $71.30 $71.30 200% of Medicare 100% of Medicare $58.08 $55.91 $54.45 $62.08 100% of Medicaid 100% of Medicare 150% of Medicare $77.60 $97.00 195% of Medicare $78.57 $57.72 $57.72 $45.78 $97.00 100% of Medicare $77.60 $82.45 $87.30 $70.80 $82.45 $97.00 $97.00 100% of Medicare 100% of Medicare $97.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL piperacillin-tazobactam 3 g-0.375 00409-3385-13 INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium bicarbonate 8.4% IV Sol 50 00409-6625-02 INSTITUTIONAL $77.00 1/1/2022-12/31/2022 $77.00 $36.34 $43.89 $56.60 $56.60 200% of Medicare 100% of Medicare $46.11 $44.38 $43.22 $49.28 100% of Medicaid 100% of Medicare 150% of Medicare $61.60 $77.00 195% of Medicare $62.37 $45.82 $45.82 $36.34 $77.00 100% of Medicare $61.60 $65.45 $69.30 $56.20 $65.45 $77.00 $77.00 100% of Medicare 100% of Medicare $77.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bromfenac 0.09% Opth Sol 00378-7110-35 INSTITUTIONAL $451.00 1/1/2022-12/31/2022 $451.00 $212.87 $257.07 $331.49 $331.49 200% of Medicare 100% of Medicare $270.06 $259.96 $253.15 $288.64 100% of Medicaid 100% of Medicare 150% of Medicare $360.80 $451.00 195% of Medicare $365.31 $268.35 $268.35 $212.87 $451.00 100% of Medicare $360.80 $383.35 $405.90 $329.18 $383.35 $451.00 $451.00 100% of Medicare 100% of Medicare $451.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pilocarpine Opth 1% Sol 61314-0203-15 INSTITUTIONAL $357.00 1/1/2022-12/31/2022 $357.00 $168.50 $203.49 $262.40 $262.40 200% of Medicare 100% of Medicare $213.77 $205.77 $200.38 $228.48 100% of Medicaid 100% of Medicare 150% of Medicare $285.60 $357.00 195% of Medicare $289.17 $212.42 $212.42 $168.50 $357.00 100% of Medicare $285.60 $303.45 $321.30 $260.57 $303.45 $357.00 $357.00 100% of Medicare 100% of Medicare $357.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Chlorhexidine Gluconate 4% 52380-1272-04 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Phenol Spray 180 mL (Chloraseptic) 00904-6305-21 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL abacavir 300 mg Tab 00378-4105-91 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amoxicillin-clavulanate 500 mg-125 66685-1002-00 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL azathioprine 50 mg Tab 00054-8084-25 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL azithromycin 250 mg Tab 00093-7146-56 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Baclofen Tab 10 mg 00904-3365-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carbidopa-levodopa 25 mg-100 mg Ta 00904-6237-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cilostazol 100 mg Tab 60505-2522-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL colchicine 0.6 mg Tab 64764-0119-07 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL digoxin 250 mcg (0.25 mg) Tab 00115-9822-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL doxycycline hyclate 100 mg Tab 24658-0220-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL escitalopram 10 mg Tab 00904-6314-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluconazole 150 mg Tab 68462-0103-40 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glycopyrrolate 1 mg Tab 00603-3180-21 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Hydrochlorothiazide Tab 25 mg 63739-0128-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrochlorothiazide-triamterene 25 60505-2656-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone 10 mg Tab 64720-0332-10 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydrocortisone 20 mg Tab 00143-1254-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL isosorbide dinitrate 10 mg Tab 00781-1556-13 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 2.5 mg Tab 00603-4209-21 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 5 mg Tab 51079-0981-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL losartan 25 mg Tab 00603-4224-02 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Losartan Tab 50 mg 00093-7365-98 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Lysine 500mg 00536-6731-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL meclizine 12.5 mg Tab 00536-3985-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL meclizine 25 mg Tab 59746-0121-06 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methimazole 5 mg Tab 23155-0070-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Methylcob-Pyridoxal-Metafolin 51991-0813-90 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methylPREDNISolone 4 mg Tab 59762-4440-03 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metronidazole 250 mg Tab 00904-1453-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL minoxidil 10 mg Tab 53489-0387-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL minoxidil 2.5 mg Tab 53489-0386-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mirtazapine 15 mg Tab 51079-0086-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL modafinil 100 mg Tab 51079-0561-03 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL naproxen 500 mg Tab 00904-6297-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL olanzapine 5 mg Tab 55111-0164-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ondansetron 4 mg Tab 45963-0538-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ondansetron Tab 8 mg 45963-0539-30 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxybutynin 5 mg Tab 00904-2821-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenobarbital 100 mg Tab 00143-1458-05 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenobarbital 32.4 mg Tab 63739-0201-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pioglitazone 15 mg Tab 00591-3205-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pioglitazone 30 mg Tab 00591-3206-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL predniSONE 20 mg Tab 00054-0018-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL quetiapine 25 mg Tab 60505-3130-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium bicarbonate 650 mg Tab 64980-0182-10 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL spironolactone 100 mg Tab 65162-0515-10 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL spironolactone 50 mg Tab 63739-0545-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL valsartan 160 mg Tab 00078-0359-34 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL valsartan 80 mg Tab 00078-0358-34 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL aspirin 81 mg Oral EC Tab 00904-7704-18 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL divalproex sodium 500 mg Oral EC T 63739-0554-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL pantoprazole 40 mg Oral EC Tab 64679-0434-04 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL buPROPion 150 mg ER Tab 00185-0415-60 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL etodolac 400 mg ER Tab 51672-4051-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Isosorbide Mononitrate 120mg ER 00603-4112-21 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoprolol 100 mg ER Tab 62037-0832-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL morphine 30 mg ER Tab 00378-2659-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL NIFEdipine Tab ER 60 mg 49884-0678-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL NIFEdipine 90 mg ER Tab 62175-0262-37 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oxybutynin 5 mg ER Tab 00378-6605-01 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL potassium chloride 20 mEq ER Tab 00245-0058-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Povidone Iodine Top Soln 10% 240 m 67618-0150-09 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 430 NULL NULL NULL NULL 999052 Rehab Driving Lesson NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 430 NULL NULL NULL NULL 999054 Rehab Driving Travel Time NULL INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $34.93 $42.18 $54.39 $54.39 200% of Medicare 100% of Medicare $44.31 $42.65 $41.54 $47.36 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $44.03 $44.03 $34.93 $74.00 100% of Medicare $59.20 $62.90 $66.60 $54.01 $62.90 $74.00 $74.00 100% of Medicare 100% of Medicare $74.00 200% of Medicare NULL 430 NULL NULL NULL NULL 999055 Rehab Driving Vehicle Mod NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 430 NULL NULL NULL NULL 999051 Rehab Driving Final Inspection NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 434 NULL NULL NULL NULL 999058 Rehab Van Access Eval NULL INSTITUTIONAL $522.00 1/1/2022-12/31/2022 $522.00 $246.38 $297.54 $383.67 $383.67 200% of Medicare 100% of Medicare $312.57 $300.88 $293.00 $334.08 100% of Medicaid 100% of Medicare 150% of Medicare $417.60 $522.00 195% of Medicare $422.82 $310.59 $310.59 $246.38 $522.00 100% of Medicare $417.60 $443.70 $469.80 $381.01 $443.70 $522.00 $522.00 100% of Medicare 100% of Medicare $522.00 200% of Medicare NULL 430 NULL NULL NULL NULL 999053 Rehab Driving Mileage NULL INSTITUTIONAL $0.40 1/1/2022-12/31/2022 $0.40 $0.19 $0.23 $0.29 $0.29 200% of Medicare 100% of Medicare $0.24 $0.23 $0.22 $0.26 100% of Medicaid 100% of Medicare 150% of Medicare $0.32 $0.40 195% of Medicare $0.32 $0.24 $0.24 $0.19 $0.40 100% of Medicare $0.32 $0.34 $0.36 $0.29 $0.34 $0.40 $0.40 100% of Medicare 100% of Medicare $0.40 200% of Medicare NULL 320 NULL NULL NULL NULL 320120 XR Pelvis Inlet/Outlet Views NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 320 NULL NULL NULL NULL 320121 XR Pelvis Judet Views NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 324 NULL 71022 LT NULL 324012 XR Chest 2 Views w/ Oblique Left NULL INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $84.02 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $118.21 $113.79 $110.81 $84.02 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $117.59 $117.59 $94.87 $129.32 100% of Medicare $160.80 $170.85 $157.79 $146.71 $160.80 $170.85 $138.19 100% of Medicare 100% of Medicare $150.75 200% of Medicare NULL 324 NULL 71022 RT NULL 324013 XR Chest 2 Views w/ Oblique Right NULL INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $84.02 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $118.21 $113.79 $110.81 $84.02 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $117.59 $117.59 $94.87 $129.32 100% of Medicare $160.80 $170.85 $157.79 $146.71 $160.80 $170.85 $138.19 100% of Medicare 100% of Medicare $150.75 200% of Medicare NULL 320 NULL NULL LT NULL 320113 XR Pelvis w/ Hip Left NULL INSTITUTIONAL $165.00 1/1/2022-12/31/2022 $165.00 $77.88 $94.05 $121.28 $121.28 200% of Medicare 100% of Medicare $98.80 $95.11 $92.61 $105.60 100% of Medicaid 100% of Medicare 150% of Medicare $132.00 $165.00 195% of Medicare $133.65 $98.18 $98.18 $77.88 $165.00 100% of Medicare $132.00 $140.25 $148.50 $120.43 $140.25 $165.00 $165.00 100% of Medicare 100% of Medicare $165.00 200% of Medicare NULL 320 NULL NULL RT NULL 320114 XR Pelvis w/ Hip Right NULL INSTITUTIONAL $165.00 1/1/2022-12/31/2022 $165.00 $77.88 $94.05 $121.28 $121.28 200% of Medicare 100% of Medicare $98.80 $95.11 $92.61 $105.60 100% of Medicaid 100% of Medicare 150% of Medicare $132.00 $165.00 195% of Medicare $133.65 $98.18 $98.18 $77.88 $165.00 100% of Medicare $132.00 $140.25 $148.50 $120.43 $140.25 $165.00 $165.00 100% of Medicare 100% of Medicare $165.00 200% of Medicare NULL 320 NULL 70250 NULL NULL 320144 XR Skull 1 View NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 320 NULL 74020 LT NULL 320003 XR Abdomen 1 View w/ Decubitus Left NULL INSTITUTIONAL $169.00 1/1/2022-12/31/2022 $169.00 $70.64 $96.33 $124.22 $124.22 200% of Medicare 100% of Medicare $99.39 $95.67 $93.17 $70.64 100% of Medicaid 100% of Medicare 150% of Medicare $135.20 $169.00 195% of Medicare $136.89 $98.87 $98.87 $79.77 $108.73 100% of Medicare $135.20 $143.65 $132.67 $123.35 $135.20 $143.65 $116.19 100% of Medicare 100% of Medicare $126.75 200% of Medicare NULL 320 NULL 74020 RT NULL 320004 XR Abdomen 1 View w/ Decubitus Right NULL INSTITUTIONAL $169.00 1/1/2022-12/31/2022 $169.00 $70.64 $96.33 $124.22 $124.22 200% of Medicare 100% of Medicare $99.39 $95.67 $93.17 $70.64 100% of Medicaid 100% of Medicare 150% of Medicare $135.20 $169.00 195% of Medicare $136.89 $98.87 $98.87 $79.77 $108.73 100% of Medicare $135.20 $143.65 $132.67 $123.35 $135.20 $143.65 $116.19 100% of Medicare 100% of Medicare $126.75 200% of Medicare NULL 320 NULL 74000 LT NULL 320009 XR Abdomen Lateral Left NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 320 NULL 74000 RT NULL 320010 XR Abdomen Lateral Right NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL NULL NULL 74000 RT NULL 320010 XR Abdomen Lateral Right NULL INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $43.47 $59.28 $76.44 $76.44 200% of Medicare 100% of Medicare $61.16 $58.87 $57.34 $43.47 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $60.84 $60.84 $49.09 $66.91 100% of Medicare $83.20 $88.40 $81.64 $75.91 $83.20 $88.40 $71.50 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mirtazapine 15 mg Tab 51079-0086-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540001 BLS Emergency NULL INSTITUTIONAL $410.00 1/1/2022-12/31/2022 $410.00 $193.52 $233.70 $301.35 $301.35 200% of Medicare 100% of Medicare $245.51 $236.32 $230.13 $262.40 100% of Medicaid 100% of Medicare 150% of Medicare $328.00 $410.00 195% of Medicare $332.10 $243.95 $243.95 $193.52 $410.00 100% of Medicare $328.00 $348.50 $369.00 $299.26 $348.50 $410.00 $410.00 100% of Medicare 100% of Medicare $410.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540002 BLS Non-Emergency NULL INSTITUTIONAL $256.00 1/1/2022-12/31/2022 $256.00 $120.83 $145.92 $188.16 $188.16 200% of Medicare 100% of Medicare $153.29 $147.56 $143.69 $163.84 100% of Medicaid 100% of Medicare 150% of Medicare $204.80 $256.00 195% of Medicare $207.36 $152.32 $152.32 $120.83 $256.00 100% of Medicare $204.80 $217.60 $230.40 $186.85 $217.60 $256.00 $256.00 100% of Medicare 100% of Medicare $256.00 200% of Medicare NULL 801 NULL 90999 NULL NULL 801001 Inpatient Hemodialysis NULL INSTITUTIONAL $697.00 1/1/2022-12/31/2022 $697.00 $291.35 $397.29 $512.30 $512.30 200% of Medicare 100% of Medicare $409.91 $394.57 $384.26 $291.35 100% of Medicaid 100% of Medicare 150% of Medicare $557.60 $697.00 195% of Medicare $564.57 $407.75 $407.75 $328.98 $448.45 100% of Medicare $557.60 $592.45 $547.15 $508.74 $557.60 $592.45 $479.19 100% of Medicare 100% of Medicare $522.75 200% of Medicare NULL 999 NULL NULL NULL NULL 999001 No Show Charge - 1 session NULL INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999002 No Show Charge - 2 sessions NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999003 Massage Therapy Services Per Minute NULL INSTITUTIONAL $1.00 1/1/2022-12/31/2022 $1.00 $0.47 $0.57 $0.74 $0.74 200% of Medicare 100% of Medicare $0.60 $0.58 $0.56 $0.64 100% of Medicaid 100% of Medicare 150% of Medicare $0.80 $1.00 195% of Medicare $0.81 $0.60 $0.60 $0.47 $1.00 100% of Medicare $0.80 $0.85 $0.90 $0.73 $0.85 $1.00 $1.00 100% of Medicare 100% of Medicare $1.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999004 Aquatics Program 1 Session NULL INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999005 Aquatics Program Monthly NULL INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 200% of Medicare 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999006 Resource Facility Initial Intake NULL INSTITUTIONAL $200.55 1/1/2022-12/31/2022 $200.55 $94.66 $114.31 $147.40 $147.40 200% of Medicare 100% of Medicare $120.09 $115.60 $112.57 $128.35 100% of Medicaid 100% of Medicare 150% of Medicare $160.44 $200.55 195% of Medicare $162.45 $119.33 $119.33 $94.66 $200.55 100% of Medicare $160.44 $170.47 $180.50 $146.38 $170.47 $200.55 $200.55 100% of Medicare 100% of Medicare $200.55 200% of Medicare NULL 999 NULL NULL NULL NULL 999007 Resource Facility Services Per 15 M NULL INSTITUTIONAL $12.60 1/1/2022-12/31/2022 $12.60 $5.95 $7.18 $9.26 $9.26 200% of Medicare 100% of Medicare $7.54 $7.26 $7.07 $8.06 100% of Medicaid 100% of Medicare 150% of Medicare $10.08 $12.60 195% of Medicare $10.21 $7.50 $7.50 $5.95 $12.60 100% of Medicare $10.08 $10.71 $11.34 $9.20 $10.71 $12.60 $12.60 100% of Medicare 100% of Medicare $12.60 200% of Medicare NULL 999 NULL NULL NULL NULL 999008 Innovations 1:1 16 Hour Pack NULL INSTITUTIONAL $61.00 1/1/2022-12/31/2022 $61.00 $28.79 $34.77 $44.84 $44.84 200% of Medicare 100% of Medicare $36.53 $35.16 $34.24 $39.04 100% of Medicaid 100% of Medicare 150% of Medicare $48.80 $61.00 195% of Medicare $49.41 $36.30 $36.30 $28.79 $61.00 100% of Medicare $48.80 $51.85 $54.90 $44.52 $51.85 $61.00 $61.00 100% of Medicare 100% of Medicare $61.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999009 Group Class 4 Week Member NULL INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999010 Group Class 12 Week Member NULL INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999011 Group Class 24 Week Member NULL INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999012 Dx Class Month-Month NULL INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999013 Personal Training 1:1 Session NULL INSTITUTIONAL $76.00 1/1/2022-12/31/2022 $76.00 $35.87 $43.32 $55.86 $55.86 200% of Medicare 100% of Medicare $45.51 $43.81 $42.66 $48.64 100% of Medicaid 100% of Medicare 150% of Medicare $60.80 $76.00 195% of Medicare $61.56 $45.22 $45.22 $35.87 $76.00 100% of Medicare $60.80 $64.60 $68.40 $55.47 $64.60 $76.00 $76.00 100% of Medicare 100% of Medicare $76.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL piperacillin-tazobactam 4 g-0.5 g 00409-3379-04 INSTITUTIONAL $115.00 1/1/2022-12/31/2022 $115.00 $54.28 $65.55 $84.53 $84.53 200% of Medicare 100% of Medicare $68.86 $66.29 $64.55 $73.60 100% of Medicaid 100% of Medicare 150% of Medicare $92.00 $115.00 195% of Medicare $93.15 $68.43 $68.43 $54.28 $115.00 100% of Medicare $92.00 $97.75 $103.50 $83.94 $97.75 $115.00 $115.00 100% of Medicare 100% of Medicare $115.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Insulin NPH/Reg 70/30 100units/mL 00002-8715-17 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL busPIRone 5 mg Tab 68084-0028-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Bismuth Subgallate Tab 200 mg 08472-4000-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Bisacodyl suppository (Magic Bulle 57648-0002-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Glucosamine 500mg cap 00904-5293-52 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Clear 70074-0566-04 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 940 NULL 97602 NULL NULL 940003 Non-selective Debridement NULL INSTITUTIONAL $292.00 1/1/2022-12/31/2022 $292.00 $122.06 $166.44 $214.62 $214.62 200% of Medicare 100% of Medicare $171.73 $165.30 $160.98 $122.06 100% of Medicaid 100% of Medicare 150% of Medicare $233.60 $292.00 195% of Medicare $236.52 $170.82 $170.82 $137.82 $187.87 100% of Medicare $233.60 $248.20 $229.22 $213.13 $233.60 $248.20 $200.75 100% of Medicare 100% of Medicare $219.00 200% of Medicare NULL 940 NULL 97605 NULL NULL 940004 Negative Pressure Wound Therapy < 50cm NULL INSTITUTIONAL $292.00 1/1/2022-12/31/2022 $292.00 $122.06 $166.44 $214.62 $214.62 200% of Medicare 100% of Medicare $171.73 $165.30 $160.98 $122.06 100% of Medicaid 100% of Medicare 150% of Medicare $233.60 $292.00 195% of Medicare $236.52 $170.82 $170.82 $137.82 $187.87 100% of Medicare $233.60 $248.20 $229.22 $213.13 $233.60 $248.20 $200.75 100% of Medicare 100% of Medicare $219.00 200% of Medicare NULL 940 NULL 97605 NULL NULL 940005 Negative Pressure Wound Therapy > 50cm NULL INSTITUTIONAL $512.00 1/1/2022-12/31/2022 $512.00 $214.02 $291.84 $376.32 $376.32 200% of Medicare 100% of Medicare $301.11 $289.84 $282.27 $214.02 100% of Medicaid 100% of Medicare 150% of Medicare $409.60 $512.00 195% of Medicare $414.72 $299.52 $299.52 $241.66 $329.42 100% of Medicare $409.60 $435.20 $401.92 $373.71 $409.60 $435.20 $352.00 100% of Medicare 100% of Medicare $384.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Smog Enema 99999-9999-86 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Tacrolimus 0.5 mg/mL Suspension 99999-9999-90 INSTITUTIONAL $589.00 1/1/2022-12/31/2022 $589.00 $278.01 $335.73 $432.92 $432.92 200% of Medicare 100% of Medicare $352.69 $339.50 $330.61 $376.96 100% of Medicaid 100% of Medicare 150% of Medicare $471.20 $589.00 195% of Medicare $477.09 $350.46 $350.46 $278.01 $589.00 100% of Medicare $471.20 $500.65 $530.10 $429.91 $500.65 $589.00 $589.00 100% of Medicare 100% of Medicare $589.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "miscellaneous compounds 1,100 mL S" 99999-9999-85 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dankins 1/2 Strength 99999-9999-84 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dankins 1/4 Strength 99999-9999-83 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dankins 1/8 Strength 99999-9999-82 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Riley Butt Cream 99999-9999-94 INSTITUTIONAL $174.00 1/1/2022-12/31/2022 $174.00 $82.13 $99.18 $127.89 $127.89 200% of Medicare 100% of Medicare $104.19 $100.29 $97.67 $111.36 100% of Medicaid 100% of Medicare 150% of Medicare $139.20 $174.00 195% of Medicare $140.94 $103.53 $103.53 $82.13 $174.00 100% of Medicare $139.20 $147.90 $156.60 $127.00 $147.90 $174.00 $174.00 100% of Medicare 100% of Medicare $174.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Mary's Magic Mouthwash 99999-9999-93 INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $26.90 $32.49 $41.90 $41.90 200% of Medicare 100% of Medicare $34.13 $32.85 $31.99 $36.48 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.92 $33.92 $26.90 $57.00 100% of Medicare $45.60 $48.45 $51.30 $41.60 $48.45 $57.00 $57.00 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Vancomycin 125mg/5ml 99999-9999-83 INSTITUTIONAL $612.00 1/1/2022-12/31/2022 $612.00 $288.86 $348.84 $449.82 $449.82 200% of Medicare 100% of Medicare $366.47 $352.76 $343.52 $391.68 100% of Medicaid 100% of Medicare 150% of Medicare $489.60 $612.00 195% of Medicare $495.72 $364.14 $364.14 $288.86 $612.00 100% of Medicare $489.60 $520.20 $550.80 $446.70 $520.20 $612.00 $612.00 100% of Medicare 100% of Medicare $612.00 200% of Medicare NULL 434 NULL NULL NULL NULL 999050 Rehab Driving Evaluation NULL INSTITUTIONAL $473.00 1/1/2022-12/31/2022 $473.00 $223.26 $269.61 $347.66 $347.66 200% of Medicare 100% of Medicare $283.23 $272.64 $265.49 $302.72 100% of Medicaid 100% of Medicare 150% of Medicare $378.40 $473.00 195% of Medicare $383.13 $281.44 $281.44 $223.26 $473.00 100% of Medicare $378.40 $402.05 $425.70 $345.24 $402.05 $473.00 $473.00 100% of Medicare 100% of Medicare $473.00 200% of Medicare NULL 434 NULL NULL NULL NULL 999057 Rehab Driving Re-Eval NULL INSTITUTIONAL $334.00 1/1/2022-12/31/2022 $334.00 $157.65 $190.38 $245.49 $245.49 200% of Medicare 100% of Medicare $200.00 $192.52 $187.47 $213.76 100% of Medicaid 100% of Medicare 150% of Medicare $267.20 $334.00 195% of Medicare $270.54 $198.73 $198.73 $157.65 $334.00 100% of Medicare $267.20 $283.90 $300.60 $243.79 $283.90 $334.00 $334.00 100% of Medicare 100% of Medicare $334.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carvedilol 6.25 mg Tab 51079-0930-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mesalamine 400 mg Cap 00430-0753-27 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Gentamicin Bladder Irrigation 4.8% 99999-9999-68 INSTITUTIONAL $77.00 1/1/2022-12/31/2022 $77.00 $36.34 $43.89 $56.60 $56.60 200% of Medicare 100% of Medicare $46.11 $44.38 $43.22 $49.28 100% of Medicaid 100% of Medicare 150% of Medicare $61.60 $77.00 195% of Medicare $62.37 $45.82 $45.82 $36.34 $77.00 100% of Medicare $61.60 $65.45 $69.30 $56.20 $65.45 $77.00 $77.00 100% of Medicare 100% of Medicare $77.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Creon-Sodium Bicarbonate Solution 99999-9999-67 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nitroglycerin 0.2 mg/hr Transderm 00904-5495-46 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nicotine 7 mg/24 hr Transderm ER F 00536-5894-88 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nicotine 21 mg/24 hr Transderm ER 00536-5896-88 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Phenol 89% 38779-1938-08 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 250100 Acetaminophen 160mg/5ml 00536-0122-97 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 200% of Medicare 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Phenol 5% Solution 99999-9999-66 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL enoxaparin 40 mg/0.4 mL SC Sol 00075-0620-41 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL famotidine 20 mg Tab 51079-0966-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL alprazolam 0.5 mg Tab 68084-0019-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nicotine 14 mg/24 hr Transderm ER 00067-5125-14 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Chapstick 00573-1925-50 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL heparin 1000 units/mL Inj Sol 25021-0400-01 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL TPN - Charge 99999-9999-50 INSTITUTIONAL " $1,293.00 " 1/1/2022-12/31/2022 " $1,293.00 " $610.30 $737.01 $950.36 $950.36 200% of Medicare 100% of Medicare $774.25 $745.29 $725.76 $827.52 100% of Medicaid 100% of Medicare 150% of Medicare " $1,034.40 " " $1,293.00 " 195% of Medicare " $1,047.33 " $769.34 $769.34 $610.30 " $1,293.00 " 100% of Medicare " $1,034.40 " " $1,099.05 " " $1,163.70 " $943.76 " $1,099.05 " " $1,293.00 " " $1,293.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levothyroxine 50 mcg (0.05 mg) Tab 00074-4552-11 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 420 NULL 29580 GP NULL 420011 PT Application of Paste Boot Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 430 NULL 96125 GO NULL 430003 OT Cognitive Test Units NULL INSTITUTIONAL $557.00 1/1/2022-12/31/2022 $557.00 $232.83 $317.49 $409.40 $409.40 200% of Medicare 100% of Medicare $327.57 $315.32 $307.07 $232.83 100% of Medicaid 100% of Medicare 150% of Medicare $445.60 $557.00 195% of Medicare $451.17 $325.85 $325.85 $262.90 $358.37 100% of Medicare $445.60 $473.45 $437.25 $406.55 $445.60 $473.45 $382.94 100% of Medicare 100% of Medicare $417.75 200% of Medicare NULL 430 NULL 92065 GO NULL 430002 OT Orthoptic/Pleoptic Training Units NULL INSTITUTIONAL $213.00 1/1/2022-12/31/2022 $213.00 $89.03 $121.41 $156.56 $156.56 200% of Medicare 100% of Medicare $125.27 $120.58 $117.43 $89.03 100% of Medicaid 100% of Medicare 150% of Medicare $170.40 $213.00 195% of Medicare $172.53 $124.61 $124.61 $100.54 $137.04 100% of Medicare $170.40 $181.05 $167.21 $155.47 $170.40 $181.05 $146.44 100% of Medicare 100% of Medicare $159.75 200% of Medicare NULL 430 NULL 92060 GO NULL 430001 OT Sensorimotor Examination Units NULL INSTITUTIONAL $213.00 1/1/2022-12/31/2022 $213.00 $89.03 $121.41 $156.56 $156.56 200% of Medicare 100% of Medicare $125.27 $120.58 $117.43 $89.03 100% of Medicaid 100% of Medicare 150% of Medicare $170.40 $213.00 195% of Medicare $172.53 $124.61 $124.61 $100.54 $137.04 100% of Medicare $170.40 $181.05 $167.21 $155.47 $170.40 $181.05 $146.44 100% of Medicare 100% of Medicare $159.75 200% of Medicare NULL 250 NULL NULL NULL NULL NULL benzoyl peroxide Top 10% Gel 00536-4092-56 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL olanzapine 10 mg IM Inj 00517-0955-01 INSTITUTIONAL $143.00 1/1/2022-12/31/2022 $143.00 $67.50 $81.51 $105.11 $105.11 200% of Medicare 100% of Medicare $85.63 $82.43 $80.27 $91.52 100% of Medicaid 100% of Medicare 150% of Medicare $114.40 $143.00 195% of Medicare $115.83 $85.09 $85.09 $67.50 $143.00 100% of Medicare $114.40 $121.55 $128.70 $104.38 $121.55 $143.00 $143.00 100% of Medicare 100% of Medicare $143.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dextrose 5% Sod Chloride 0.9% 1000 00409-7941-09 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 200% of Medicare 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL miconazole Top 2% Crm 00603-7805-50 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Maalox Plus 400/400/40mg 00904-0005-14 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nystatin 100000 units/mL Sus 60432-0537-60 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Triamcinolone Cream 0.1% 15 GM 67877-0251-15 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 200% of Medicare 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Emollient Skin Cleanser(Hydrocerin 46287-0507-04 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dextrose 5% in Water IV Sol 1000 m 00338-0017-04 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 200% of Medicare 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.45% IV Sol 1000 00409-7985-09 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL silver sulfADIAZINE topical 1% Cre 43598-0210-50 INSTITUTIONAL " $15,805.00 " 1/1/2022-12/31/2022 " $14,224.50 " $975.00 " $9,008.85 " " $11,616.68 " " $11,616.68 " 200% of Medicare 100% of Medicare " $9,464.03 " " $9,110.00 " " $8,871.35 " " $10,115.20 " 100% of Medicaid 100% of Medicare 150% of Medicare " $12,644.00 " " $1,500.00 " 195% of Medicare " $12,802.05 " " $9,403.98 " " $9,403.98 " " $7,459.96 " " $1,359.00 " 100% of Medicare " $12,644.00 " " $13,434.25 " " $14,224.50 " " $11,536.07 " " $13,434.25 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL timolol Opth 0.5% Sol 16571-0141-50 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ceftriaxone 1 g Inj 00409-7333-49 INSTITUTIONAL $97.00 1/1/2022-12/31/2022 $97.00 $45.78 $55.29 $71.30 $71.30 200% of Medicare 100% of Medicare $58.08 $55.91 $54.45 $62.08 100% of Medicaid 100% of Medicare 150% of Medicare $77.60 $97.00 195% of Medicare $78.57 $57.72 $57.72 $45.78 $97.00 100% of Medicare $77.60 $82.45 $87.30 $70.80 $82.45 $97.00 $97.00 100% of Medicare 100% of Medicare $97.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Dextrose 5% Sod Chloride 0.45% 100 00264-7612-00 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 200% of Medicare 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lidocaine-prilocaine Top 2.5%-2.5% 50383-0667-30 INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $20.77 $25.08 $32.34 $32.34 200% of Medicare 100% of Medicare $26.35 $25.36 $24.70 $28.16 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $26.18 $26.18 $20.77 $44.00 100% of Medicare $35.20 $37.40 $39.60 $32.12 $37.40 $44.00 $44.00 100% of Medicare 100% of Medicare $44.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ipratropium Nasal 0.03% Spry 24208-0398-30 INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $39.18 $47.31 $61.01 $61.01 200% of Medicare 100% of Medicare $49.70 $47.84 $46.59 $53.12 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $49.39 $49.39 $39.18 $83.00 100% of Medicare $66.40 $70.55 $74.70 $60.58 $70.55 $83.00 $83.00 100% of Medicare 100% of Medicare $83.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dextromethorphan-guaiFENesin 10 mg 00603-0855-94 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL alteplase 2 mg Pow 50242-0041-64 INSTITUTIONAL $330.00 1/1/2022-12/31/2022 $330.00 $155.76 $188.10 $242.55 $242.55 200% of Medicare 100% of Medicare $197.60 $190.21 $185.23 $211.20 100% of Medicaid 100% of Medicare 150% of Medicare $264.00 $330.00 195% of Medicare $267.30 $196.35 $196.35 $155.76 $330.00 100% of Medicare $264.00 $280.50 $297.00 $240.87 $280.50 $330.00 $330.00 100% of Medicare 100% of Medicare $330.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Biotin 1000 mcg tab 30768-6007-30 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 250500 tizanidine 4 mg Tab 68084-0013-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nystatin topical 100000 units/g Cr 00603-7818-78 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 200% of Medicare 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL furosemide 40 mg Tab 00172-2907-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darbepoetin alfa 100 mcg/mL Inj So 55513-0005-01 INSTITUTIONAL " $1,487.00 " 1/1/2022-12/31/2022 " $1,487.00 " $701.86 $847.59 " $1,092.95 " " $1,092.95 " 200% of Medicare 100% of Medicare $890.42 $857.11 $834.65 $951.68 100% of Medicaid 100% of Medicare 150% of Medicare " $1,189.60 " " $1,487.00 " 195% of Medicare " $1,204.47 " $884.77 $884.77 $701.86 " $1,359.00 " 100% of Medicare " $1,189.60 " " $1,263.95 " " $1,338.30 " " $1,085.36 " " $1,263.95 " " $1,487.00 " " $1,487.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sodium Chloride 0.9% 63807-0100-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levalbuterol 0.63 mg/3 mL Inh Sol 66993-0022-27 INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $36.82 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $46.71 $44.96 $43.78 $49.92 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $46.41 $46.41 $36.82 $78.00 100% of Medicare $62.40 $66.30 $70.20 $56.93 $66.30 $78.00 $78.00 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone nasal 50 mcg/inh Spr 00054-3270-99 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metoprolol 50 mg Tab 62584-0266-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 250903 codeine-guaiFENesin 10 mg-100 mg/5 00121-0775-04 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL famotidine 20 mg Tab 61442-0121-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rivaroxaban 20 mg Tab 50458-0579-30 INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL darbepotin alfa 100mcg/0.5ml 100 m 55513-00-2504 INSTITUTIONAL " $1,487.00 " 1/1/2022-12/31/2022 " $1,487.00 " $701.86 $847.59 " $1,092.95 " " $1,092.95 " 200% of Medicare 100% of Medicare $890.42 $857.11 $834.65 $951.68 100% of Medicaid 100% of Medicare 150% of Medicare " $1,189.60 " " $1,487.00 " 195% of Medicare " $1,204.47 " $884.77 $884.77 $701.86 " $1,359.00 " 100% of Medicare " $1,189.60 " " $1,263.95 " " $1,338.30 " " $1,085.36 " " $1,263.95 " " $1,487.00 " " $1,487.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL terazosin 5 mg Cap 00904-6128-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levalbuterol 1.25 mg/3 mL Sol 00093-4148-64 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 200% of Medicare 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL tacrolimus 0.5 mg Cap 68084-0449-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 250902 Darbepoetin 100 mcg/0.5 mL Syringe 55513-0025-04 INSTITUTIONAL $986.00 1/1/2022-12/31/2022 $986.00 $465.39 $562.02 $724.71 $724.71 200% of Medicare 100% of Medicare $590.42 $568.33 $553.44 $631.04 100% of Medicaid 100% of Medicare 150% of Medicare $788.80 $986.00 195% of Medicare $798.66 $586.67 $586.67 $465.39 $986.00 100% of Medicare $788.80 $838.10 $887.40 $719.68 $838.10 $986.00 $986.00 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sodium chloride 0.9% Sol 63807-0100-01 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 25000002 lamiVUDine 150 mg Tab 68084-0578-21 INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 200% of Medicare 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 510 NULL 64635 NULL NULL 510072 "Destruction Neurolytic Agent, Lumbar or Sacral, Si" NULL INSTITUTIONAL " $4,404.00 " 1/1/2022-12/31/2022 " $3,743.40 " " $1,500.00 " " $2,510.28 " " $3,236.94 " " $3,236.94 " 200% of Medicare 100% of Medicare " $2,589.99 " " $2,493.10 " " $2,427.93 " " $1,840.87 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,523.20 " " $1,500.00 " 195% of Medicare " $3,567.24 " " $2,576.34 " " $2,576.34 " " $2,078.69 " " $2,833.53 " 100% of Medicare " $3,523.20 " " $3,743.40 " " $3,457.14 " " $3,214.48 " " $3,523.20 " " $3,743.40 " " $3,027.75 " 100% of Medicare 100% of Medicare " $3,303.00 " 200% of Medicare NULL 510 NULL 64636 NULL NULL 510073 "Destruction Neurolytic Agent, Lumbar or Sacral, Ea" NULL INSTITUTIONAL " $2,395.00 " 1/1/2022-12/31/2022 " $2,035.75 " " $1,001.11 " " $1,365.15 " " $1,760.33 " " $1,760.33 " 200% of Medicare 100% of Medicare " $1,408.50 " " $1,355.81 " " $1,320.36 " " $1,001.11 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,916.00 " " $1,500.00 " 195% of Medicare " $1,939.95 " " $1,401.08 " " $1,401.08 " " $1,130.44 " " $1,540.94 " 100% of Medicare " $1,916.00 " " $2,035.75 " " $1,880.08 " " $1,748.11 " " $1,916.00 " " $2,035.75 " " $1,646.56 " 100% of Medicare 100% of Medicare " $1,796.25 " 200% of Medicare NULL 300 NULL NULL NULL NULL 999014 Oral Drug Screen NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 420 NULL NULL NULL NULL 999015 PreWork Screen NULL INSTITUTIONAL $377.00 1/1/2022-12/31/2022 $377.00 $177.94 $214.89 $277.10 $277.10 200% of Medicare 100% of Medicare $225.75 $217.30 $211.61 $241.28 100% of Medicaid 100% of Medicare 150% of Medicare $301.60 $377.00 195% of Medicare $305.37 $224.32 $224.32 $177.94 $377.00 100% of Medicare $301.60 $320.45 $339.30 $275.17 $320.45 $377.00 $377.00 100% of Medicare 100% of Medicare $377.00 200% of Medicare NULL 250 NULL NULL NULL J1644 2502505 heparin 5000 units/mL Sol 00409-1402-12 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $3.76 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.29 $5.09 $4.96 $3.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.27 $5.27 $4.25 $5.79 100% of Medicare $7.20 $7.65 $7.07 $6.57 $7.20 $7.65 $6.19 100% of Medicare 100% of Medicare $6.75 200% of Medicare NULL 250 NULL NULL NULL NULL 2502506 lidocaine topical 2% Gel 17478-0811-30 INSTITUTIONAL $62.00 1/1/2022-12/31/2022 $62.00 $29.26 $35.34 $45.57 $45.57 200% of Medicare 100% of Medicare $37.13 $35.74 $34.80 $39.68 100% of Medicaid 100% of Medicare 150% of Medicare $49.60 $62.00 195% of Medicare $50.22 $36.89 $36.89 $29.26 $62.00 100% of Medicare $49.60 $52.70 $55.80 $45.25 $52.70 $62.00 $62.00 100% of Medicare 100% of Medicare $62.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL spironolactone 25 mg Tab 68084-0206-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL A4212 NULL NULL NULL CHALGREN NEEDLES 37X26 NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $26.75 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $37.64 $36.23 $35.28 $26.75 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $37.44 $37.44 $30.21 $41.18 100% of Medicare $51.20 $54.40 $50.24 $46.71 $51.20 $54.40 $44.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL LVP solution Sodium Chloride 0.9% 00409-7983-02 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 636 NULL NULL NULL J3490 NULL Phenol 5% Solution 20 mL Soln 99999-9999-66 INSTITUTIONAL $911.00 1/1/2022-12/31/2022 $911.00 $380.80 $519.27 $669.59 $669.59 200% of Medicare 100% of Medicare $535.76 $515.72 $502.23 $380.80 100% of Medicaid 100% of Medicare 150% of Medicare $728.80 $911.00 195% of Medicare $737.91 $532.94 $532.94 $429.99 $586.14 100% of Medicare $728.80 $774.35 $715.14 $664.94 $728.80 $774.35 $626.31 100% of Medicare 100% of Medicare $683.25 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 10 mg Tab 68084-0061-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 10 mg Tab 00172-3759-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL bumetanide 0.5 mg Tab 00185-0128-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL allopurinol 100 mg Tab 00603-2115-21 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 20 mg Tab 51079-0983-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rivastigmine 4.6 mg/24 hr Fil 00078-0501-61 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 200% of Medicare 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL 250501 sodium chloride 0.9% Sol 08881-5701-21 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lactulose 10 g/15 mL Syr 66689-0038-50 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 20 mg Tab 68084-0062-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL menthol-zinc oxide topical 0.44%-2 00799-0001-03 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL docusate-senna 50 mg-8.6 mg Tab 00904-6339-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL glycerin adult Sup 00713-0101-25 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ucose Polymers 1 CAN Powder 70074-06074-6 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 250104 scopolamine 1.5 mg Fil 10019-0553-88 INSTITUTIONAL $149.00 1/1/2022-12/31/2022 $149.00 $70.33 $84.93 $109.52 $109.52 200% of Medicare 100% of Medicare $89.22 $85.88 $83.63 $95.36 100% of Medicaid 100% of Medicare 150% of Medicare $119.20 $149.00 195% of Medicare $120.69 $88.66 $88.66 $70.33 $149.00 100% of Medicare $119.20 $126.65 $134.10 $108.76 $126.65 $149.00 $149.00 100% of Medicare 100% of Medicare $149.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levalbuterol 0.63 mg/3 mL Sol 00093-4146-64 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL 250102 Riley Butt Cream 1 app Cream 99999-9999-94 INSTITUTIONAL $182.00 1/1/2022-12/31/2022 $182.00 $85.90 $103.74 $133.77 $133.77 200% of Medicare 100% of Medicare $108.98 $104.90 $102.16 $116.48 100% of Medicaid 100% of Medicare 150% of Medicare $145.60 $182.00 195% of Medicare $147.42 $108.29 $108.29 $85.90 $182.00 100% of Medicare $145.60 $154.70 $163.80 $132.84 $154.70 $182.00 $182.00 100% of Medicare 100% of Medicare $182.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001412 Granufoam XL Dressing NULL INSTITUTIONAL $162.00 1/1/2022-12/31/2022 $162.00 $76.46 $92.34 $119.07 $119.07 200% of Medicare 100% of Medicare $97.01 $93.38 $90.93 $103.68 100% of Medicaid 100% of Medicare 150% of Medicare $129.60 $162.00 195% of Medicare $131.22 $96.39 $96.39 $76.46 $162.00 100% of Medicare $129.60 $137.70 $145.80 $118.24 $137.70 $162.00 $162.00 100% of Medicare 100% of Medicare $162.00 200% of Medicare NULL 250 NULL NULL NULL NULL 250103 posaconazole 40 mg/mL Sus 00085-1328-01 INSTITUTIONAL " $4,862.00 " 1/1/2022-12/31/2022 " $4,375.80 " $975.00 " $2,771.34 " " $3,573.57 " " $3,573.57 " 200% of Medicare 100% of Medicare " $2,911.37 " " $2,802.46 " " $2,729.04 " " $3,111.68 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,889.60 " " $1,500.00 " 195% of Medicare " $3,938.22 " " $2,892.89 " " $2,892.89 " " $2,294.86 " " $1,359.00 " 100% of Medicare " $3,889.60 " " $4,132.70 " " $4,375.80 " " $3,548.77 " " $4,132.70 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Miscellaneous MAR Items 1 CAN Powd 70074-05-1149 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL "electrolyte replacement solutions," 70074-0621-20 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL divalproex sodium 500 mg Tab 10370-0511-10 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 440 NULL 92522 GN NULL 440009 SLP Sound Production Eval Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 440 NULL 92523 GN NULL 440010 SLP Sound Prod w/ Lang Comp Eval Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 440 NULL 92524 GN NULL 440008 SLP Analysis of Voice & Resonance Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 410 NULL 94668 NULL NULL 410015 RT CPT w/ Vest Subsequent Charge NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 410 NULL 94667 NULL NULL 410016 RT CPT w/ Vest Initial Charge NULL INSTITUTIONAL $359.00 1/1/2022-12/31/2022 $359.00 $150.06 $204.63 $263.87 $263.87 200% of Medicare 100% of Medicare $211.13 $203.23 $197.92 $150.06 100% of Medicaid 100% of Medicare 150% of Medicare $287.20 $359.00 195% of Medicare $290.79 $210.02 $210.02 $169.45 $230.98 100% of Medicare $287.20 $305.15 $281.82 $262.03 $287.20 $305.15 $246.81 100% of Medicare 100% of Medicare $269.25 200% of Medicare NULL 510 NULL 64617 NULL NULL 510075 "Chemodenervation muscles: larynx, unilateral" NULL INSTITUTIONAL $637.00 1/1/2022-12/31/2022 $637.00 $266.27 $363.09 $468.20 $468.20 200% of Medicare 100% of Medicare $374.62 $360.61 $351.18 $266.27 100% of Medicaid 100% of Medicare 150% of Medicare $509.60 $637.00 195% of Medicare $515.97 $372.65 $372.65 $300.66 $409.85 100% of Medicare $509.60 $541.45 $500.05 $464.95 $509.60 $541.45 $437.94 100% of Medicare 100% of Medicare $477.75 200% of Medicare NULL 510 NULL 64643 NULL NULL 510076 Chemodenervation extremity/ trunk muscle 1-4 NULL INSTITUTIONAL $360.00 1/1/2022-12/31/2022 $360.00 $150.48 $205.20 $264.60 $264.60 200% of Medicare 100% of Medicare $211.72 $203.80 $198.47 $150.48 100% of Medicaid 100% of Medicare 150% of Medicare $288.00 $360.00 195% of Medicare $291.60 $210.60 $210.60 $169.92 $231.62 100% of Medicare $288.00 $306.00 $282.60 $262.76 $288.00 $306.00 $247.50 100% of Medicare 100% of Medicare $270.00 200% of Medicare NULL 510 NULL 64644 NULL NULL 510077 Chemodenervation 1 extremity; 5 or more musc NULL INSTITUTIONAL $761.00 1/1/2022-12/31/2022 $761.00 $318.10 $433.77 $559.34 $559.34 200% of Medicare 100% of Medicare $447.54 $430.80 $419.54 $318.10 100% of Medicaid 100% of Medicare 150% of Medicare $608.80 $761.00 195% of Medicare $616.41 $445.19 $445.19 $359.19 $489.63 100% of Medicare $608.80 $646.85 $597.39 $555.45 $608.80 $646.85 $523.19 100% of Medicare 100% of Medicare $570.75 200% of Medicare NULL 510 NULL 64645 NULL NULL 510078 Chemodenervation 1 extremity; each additiona NULL INSTITUTIONAL $380.00 1/1/2022-12/31/2022 $380.00 $158.84 $216.60 $279.30 $279.30 200% of Medicare 100% of Medicare $223.48 $215.12 $209.49 $158.84 100% of Medicaid 100% of Medicare 150% of Medicare $304.00 $380.00 195% of Medicare $307.80 $222.30 $222.30 $179.36 $244.49 100% of Medicare $304.00 $323.00 $298.30 $277.36 $304.00 $323.00 $261.25 100% of Medicare 100% of Medicare $285.00 200% of Medicare NULL 510 NULL 64646 NULL NULL 510079 Chemodenervation trunk muscle; 1-5 muscles R NULL INSTITUTIONAL $761.00 1/1/2022-12/31/2022 $761.00 $318.10 $433.77 $559.34 $559.34 200% of Medicare 100% of Medicare $447.54 $430.80 $419.54 $318.10 100% of Medicaid 100% of Medicare 150% of Medicare $608.80 $761.00 195% of Medicare $616.41 $445.19 $445.19 $359.19 $489.63 100% of Medicare $608.80 $646.85 $597.39 $555.45 $608.80 $646.85 $523.19 100% of Medicare 100% of Medicare $570.75 200% of Medicare NULL 510 NULL 64647 NULL NULL 510080 Chemodenervation trunk muscle; 6 or more mus NULL INSTITUTIONAL $831.00 1/1/2022-12/31/2022 $831.00 $347.36 $473.67 $610.79 $610.79 200% of Medicare 100% of Medicare $488.71 $470.43 $458.13 $347.36 100% of Medicaid 100% of Medicare 150% of Medicare $664.80 $831.00 195% of Medicare $673.11 $486.14 $486.14 $392.23 $534.67 100% of Medicare $664.80 $706.35 $652.34 $606.55 $664.80 $706.35 $571.31 100% of Medicare 100% of Medicare $623.25 200% of Medicare NULL 272 NULL NULL NULL NULL 001423 Press on Prism - 1 Diopter NULL INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 200% of Medicare 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001426 Press on Prism - 15 Diopter NULL INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 200% of Medicare 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001424 Press on Prism - 4 Diopter NULL INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 200% of Medicare 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001425 Press on Prism - 8 Diopter NULL INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 200% of Medicare 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rtificial Tear Solution 1.4 Bottle 30536-19707-27 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001431 5.0 XLT Inner cannula NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001432 6.0 XLT Inner cannula NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001430 8.0 XLT Inner cannula NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carvedilol 3.125 mg Tab 00904-6300-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ciprofloxacin 500 mg Tab 68084-0070-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 5 mg Tab 68084-0060-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999016 NVA Final Report NULL INSTITUTIONAL " $2,200.00 " 1/1/2022-12/31/2022 " $2,200.00 " $975.00 " $1,254.00 " " $1,617.00 " " $1,617.00 " 200% of Medicare 100% of Medicare " $1,317.36 " " $1,268.08 " " $1,234.86 " " $1,408.00 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,760.00 " " $1,500.00 " 195% of Medicare " $1,782.00 " " $1,309.00 " " $1,309.00 " " $1,038.40 " " $1,359.00 " 100% of Medicare " $1,760.00 " " $1,870.00 " " $1,980.00 " " $1,605.78 " " $1,870.00 " " $1,500.00 " " $2,200.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999017 RF Unit 1 NULL INSTITUTIONAL $500.00 1/1/2022-12/31/2022 $500.00 $236.00 $285.00 $367.50 $367.50 200% of Medicare 100% of Medicare $299.40 $288.20 $280.65 $320.00 100% of Medicaid 100% of Medicare 150% of Medicare $400.00 $500.00 195% of Medicare $405.00 $297.50 $297.50 $236.00 $500.00 100% of Medicare $400.00 $425.00 $450.00 $364.95 $425.00 $500.00 $500.00 100% of Medicare 100% of Medicare $500.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999018 RF Unit 2 NULL INSTITUTIONAL " $1,250.00 " 1/1/2022-12/31/2022 " $1,250.00 " $590.00 $712.50 $918.75 $918.75 200% of Medicare 100% of Medicare $748.50 $720.50 $701.63 $800.00 100% of Medicaid 100% of Medicare 150% of Medicare " $1,000.00 " " $1,250.00 " 195% of Medicare " $1,012.50 " $743.75 $743.75 $590.00 " $1,250.00 " 100% of Medicare " $1,000.00 " " $1,062.50 " " $1,125.00 " $912.38 " $1,062.50 " " $1,250.00 " " $1,250.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999019 VOC Placement NULL INSTITUTIONAL $700.00 1/1/2022-12/31/2022 $700.00 $330.40 $399.00 $514.50 $514.50 200% of Medicare 100% of Medicare $419.16 $403.48 $392.91 $448.00 100% of Medicaid 100% of Medicare 150% of Medicare $560.00 $700.00 195% of Medicare $567.00 $416.50 $416.50 $330.40 $700.00 100% of Medicare $560.00 $595.00 $630.00 $510.93 $595.00 $700.00 $700.00 100% of Medicare 100% of Medicare $700.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999020 90 Day Employment NULL INSTITUTIONAL $700.00 1/1/2022-12/31/2022 $700.00 $330.40 $399.00 $514.50 $514.50 200% of Medicare 100% of Medicare $419.16 $403.48 $392.91 $448.00 100% of Medicaid 100% of Medicare 150% of Medicare $560.00 $700.00 195% of Medicare $567.00 $416.50 $416.50 $330.40 $700.00 100% of Medicare $560.00 $595.00 $630.00 $510.93 $595.00 $700.00 $700.00 100% of Medicare 100% of Medicare $700.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000332 Suture Strips 1/2x4 NULL INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 200% of Medicare 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL polyethylene glycol 3350 - Pow 51079-0306-30 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001436 MEPILEX AG 8x8 NULL INSTITUTIONAL $109.00 1/1/2022-12/31/2022 $109.00 $51.45 $62.13 $80.12 $80.12 200% of Medicare 100% of Medicare $65.27 $62.83 $61.18 $69.76 100% of Medicaid 100% of Medicare 150% of Medicare $87.20 $109.00 195% of Medicare $88.29 $64.86 $64.86 $51.45 $109.00 100% of Medicare $87.20 $92.65 $98.10 $79.56 $92.65 $109.00 $109.00 100% of Medicare 100% of Medicare $109.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL phenazopyridine 100 mg Tab 65162-0517-10 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001448 23G X 6.0 SPINAL NEEDLE NULL INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 200% of Medicare 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000614 "23G X 2"" SPINAL NEEDLE" NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000911 "23G X 5"" SPINAL NEEDLE" NULL INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $25.02 $30.21 $38.96 $38.96 200% of Medicare 100% of Medicare $31.74 $30.55 $29.75 $33.92 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.54 $31.54 $25.02 $53.00 100% of Medicare $42.40 $45.05 $47.70 $38.68 $45.05 $53.00 $53.00 100% of Medicare 100% of Medicare $53.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL spironolactone 25 mg Tab 00904-5951-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lisinopril 20 mg Tab 00904-5809-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 510 NULL 95907 NULL NULL 510081 "Nerve Conduction Studies, 1-2" NULL INSTITUTIONAL $375.00 1/1/2022-12/31/2022 $375.00 $156.75 $213.75 $275.63 $275.63 200% of Medicare 100% of Medicare $220.54 $212.29 $206.74 $156.75 100% of Medicaid 100% of Medicare 150% of Medicare $300.00 $375.00 195% of Medicare $303.75 $219.38 $219.38 $177.00 $241.28 100% of Medicare $300.00 $318.75 $294.38 $273.71 $300.00 $318.75 $257.81 100% of Medicare 100% of Medicare $281.25 200% of Medicare NULL 510 NULL 95908 NULL NULL 510082 "Nerve Conduction Studies, 3-4" NULL INSTITUTIONAL $504.00 1/1/2022-12/31/2022 $504.00 $210.67 $287.28 $370.44 $370.44 200% of Medicare 100% of Medicare $296.40 $285.31 $277.86 $210.67 100% of Medicaid 100% of Medicare 150% of Medicare $403.20 $504.00 195% of Medicare $408.24 $294.84 $294.84 $237.89 $324.27 100% of Medicare $403.20 $428.40 $395.64 $367.87 $403.20 $428.40 $346.50 100% of Medicare 100% of Medicare $378.00 200% of Medicare NULL 510 NULL 95909 NULL NULL 510083 "Nerve Conduction Studies, 5-6" NULL INSTITUTIONAL $555.00 1/1/2022-12/31/2022 $555.00 $231.99 $316.35 $407.93 $407.93 200% of Medicare 100% of Medicare $326.40 $314.19 $305.97 $231.99 100% of Medicaid 100% of Medicare 150% of Medicare $444.00 $555.00 195% of Medicare $449.55 $324.68 $324.68 $261.96 $357.09 100% of Medicare $444.00 $471.75 $435.68 $405.09 $444.00 $471.75 $381.56 100% of Medicare 100% of Medicare $416.25 200% of Medicare NULL 510 NULL 95885 NULL NULL 510084 "EMG, in addition to NCS - each extremity, limited" NULL INSTITUTIONAL $229.00 1/1/2022-12/31/2022 $229.00 $95.72 $130.53 $168.32 $168.32 200% of Medicare 100% of Medicare $134.67 $129.64 $126.25 $95.72 100% of Medicaid 100% of Medicare 150% of Medicare $183.20 $229.00 195% of Medicare $185.49 $133.97 $133.97 $108.09 $147.34 100% of Medicare $183.20 $194.65 $179.77 $167.15 $183.20 $194.65 $157.44 100% of Medicare 100% of Medicare $171.75 200% of Medicare NULL 510 NULL 95886 NULL NULL 510085 "EMG, in addition to NCS - each extremity, complete" NULL INSTITUTIONAL $361.00 1/1/2022-12/31/2022 $361.00 $150.90 $205.77 $265.34 $265.34 200% of Medicare 100% of Medicare $212.30 $204.36 $199.02 $150.90 100% of Medicaid 100% of Medicare 150% of Medicare $288.80 $361.00 195% of Medicare $292.41 $211.19 $211.19 $170.39 $232.27 100% of Medicare $288.80 $306.85 $283.39 $263.49 $288.80 $306.85 $248.19 100% of Medicare 100% of Medicare $270.75 200% of Medicare NULL 510 NULL 95905 NULL NULL 510086 NCV: motor and/or sensory using preconfigured elec NULL INSTITUTIONAL $261.00 1/1/2022-12/31/2022 $261.00 $109.10 $148.77 $191.84 $191.84 200% of Medicare 100% of Medicare $153.49 $147.75 $143.89 $109.10 100% of Medicaid 100% of Medicare 150% of Medicare $208.80 $261.00 195% of Medicare $211.41 $152.69 $152.69 $123.19 $167.93 100% of Medicare $208.80 $221.85 $204.89 $190.50 $208.80 $221.85 $179.44 100% of Medicare 100% of Medicare $195.75 200% of Medicare NULL 272 NULL NULL NULL NULL 001449 Hydrofera Blue 4x4 Foam Dressing NULL INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL donepezil 5 mg Tab 00904-6354-61 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001400 Mepitel 4x7 Dressing NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 410 NULL 31502 NULL NULL 410037 Tube changed NULL INSTITUTIONAL $638.00 1/1/2022-12/31/2022 $638.00 $266.68 $363.66 $468.93 $468.93 200% of Medicare 100% of Medicare $375.21 $361.17 $351.73 $266.68 100% of Medicaid 100% of Medicare 150% of Medicare $510.40 $638.00 195% of Medicare $516.78 $373.23 $373.23 $301.14 $410.49 100% of Medicare $510.40 $542.30 $500.83 $465.68 $510.40 $542.30 $438.63 100% of Medicare 100% of Medicare $478.50 200% of Medicare NULL 272 NULL NULL NULL NULL 001443 001443 NULL INSTITUTIONAL $109.00 1/1/2022-12/31/2022 $109.00 $51.45 $62.13 $80.12 $80.12 200% of Medicare 100% of Medicare $65.27 $62.83 $61.18 $69.76 100% of Medicaid 100% of Medicare 150% of Medicare $87.20 $109.00 195% of Medicare $88.29 $64.86 $64.86 $51.45 $109.00 100% of Medicare $87.20 $92.65 $98.10 $79.56 $92.65 $109.00 $109.00 100% of Medicare 100% of Medicare $109.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001455 001455 NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001456 001456 NULL INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $27.85 $33.63 $43.37 $43.37 200% of Medicare 100% of Medicare $35.33 $34.01 $33.12 $37.76 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $35.11 $35.11 $27.85 $59.00 100% of Medicare $47.20 $50.15 $53.10 $43.06 $50.15 $59.00 $59.00 100% of Medicare 100% of Medicare $59.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Tamsulosin 0.4 mg Capsule 01003-51079-294 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 300 NULL 87497 NULL NULL 29028580 CMV QN PCR NULL INSTITUTIONAL $243.00 1/1/2022-12/31/2022 $243.00 $101.57 $138.51 $178.61 $178.61 200% of Medicare 100% of Medicare $142.91 $137.56 $133.97 $101.57 100% of Medicaid 100% of Medicare 150% of Medicare $194.40 $243.00 195% of Medicare $196.83 $142.16 $142.16 $114.70 $156.35 100% of Medicare $194.40 $206.55 $190.76 $177.37 $194.40 $206.55 $167.06 100% of Medicare 100% of Medicare $182.25 200% of Medicare NULL 300 NULL 80195 NULL NULL 29025890 Sirolimus Bl QN NULL INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $32.60 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $45.87 $44.16 $43.00 $32.60 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $45.63 $45.63 $36.82 $50.19 100% of Medicare $62.40 $66.30 $61.23 $56.93 $62.40 $66.30 $53.63 100% of Medicare 100% of Medicare $58.50 200% of Medicare NULL 510 NULL 95910 NULL NULL 510087 "95910 Nerve conduction studies, 7-8" NULL INSTITUTIONAL $731.00 1/1/2022-12/31/2022 $731.00 $305.56 $416.67 $537.29 $537.29 200% of Medicare 100% of Medicare $429.90 $413.82 $403.00 $305.56 100% of Medicaid 100% of Medicare 150% of Medicare $584.80 $731.00 195% of Medicare $592.11 $427.64 $427.64 $345.03 $470.33 100% of Medicare $584.80 $621.35 $573.84 $533.56 $584.80 $621.35 $502.56 100% of Medicare 100% of Medicare $548.25 200% of Medicare NULL 272 NULL NULL NULL NULL 001453 23x5 Quincke spinal needle NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001427 23x3.5 Quincke Spinal Needle NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001467 Transfer Belt NULL INSTITUTIONAL $100.00 1/1/2022-12/31/2022 $100.00 $47.20 $57.00 $73.50 $73.50 200% of Medicare 100% of Medicare $59.88 $57.64 $56.13 $64.00 100% of Medicaid 100% of Medicare 150% of Medicare $80.00 $100.00 195% of Medicare $81.00 $59.50 $59.50 $47.20 $100.00 100% of Medicare $80.00 $85.00 $90.00 $72.99 $85.00 $100.00 $100.00 100% of Medicare 100% of Medicare $100.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL carBAMazepine 100 mg Tab 00904-3854-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fentaNYL 50 mcg/hr Fil 60505-7012-00 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL HYDROmorphone 4 mg Tab 59011-0454-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL latanoprost ophthalmic 0.005% Sol 00013-8303-04 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999021 RF Gas Card NULL INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 300 NULL 86225 NULL NULL 14007317 Anti-dsDNA QN NULL INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $44.73 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $62.93 $60.57 $58.99 $44.73 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $62.60 $62.60 $50.50 $68.84 100% of Medicare $85.60 $90.95 $84.00 $78.10 $85.60 $90.95 $73.56 100% of Medicare 100% of Medicare $80.25 200% of Medicare NULL 250 NULL NULL NULL NULL NULL VITAL 1.5 cal 70074-0562-79 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Osmolite 1.5 cal 70074-0574-70 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ascorbic acid 500 mg/5 mL Liq 00536-0160-97 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL magnesium citrate 1.745 g/30 mL Li 71525-6100-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001481 Declogger NULL INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 200% of Medicare 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001489 "DRESSING, TEGADERM,OVAL, 2.75"" X 3.5""" NULL INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dolutegravir 50 mg Tab 49702-0228-13 INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone-vilanterol 100 mcg-25 00173-0859-14 INSTITUTIONAL $464.00 1/1/2022-12/31/2022 $464.00 $219.01 $264.48 $341.04 $341.04 200% of Medicare 100% of Medicare $277.84 $267.45 $260.44 $296.96 100% of Medicaid 100% of Medicare 150% of Medicare $371.20 $464.00 195% of Medicare $375.84 $276.08 $276.08 $219.01 $464.00 100% of Medicare $371.20 $394.40 $417.60 $338.67 $394.40 $464.00 $464.00 100% of Medicare 100% of Medicare $464.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL apixaban 5 mg Tab 00003-0894-21 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 420 NULL 29581 NULL NULL 420047 Application of multi-layer compression; leg (below NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 29582 NULL NULL 420047420048 Application of multi-layer compression; thigh and NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97530 NULL NULL 420049 "Therapeutic activities, each 15 mins" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 424 NULL NULL NULL NULL 424003 Physical therapy re-evaluation NULL INSTITUTIONAL $396.00 1/1/2022-12/31/2022 $396.00 $186.91 $225.72 $291.06 $291.06 200% of Medicare 100% of Medicare $237.12 $228.25 $222.27 $253.44 100% of Medicaid 100% of Medicare 150% of Medicare $316.80 $396.00 195% of Medicare $320.76 $235.62 $235.62 $186.91 $396.00 100% of Medicare $316.80 $336.60 $356.40 $289.04 $336.60 $396.00 $396.00 100% of Medicare 100% of Medicare $396.00 200% of Medicare NULL 420 NULL NULL NULL NULL 424004 Physical therapy evaluation NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $373.82 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $474.25 $456.51 $444.55 $506.88 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $471.24 $471.24 $373.82 $792.00 100% of Medicare $633.60 $673.20 $712.80 $578.08 $673.20 $792.00 $792.00 100% of Medicare 100% of Medicare $792.00 200% of Medicare NULL 420 NULL 97597 NULL NULL 420050 Debridement - first 20 sq cm or less NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97598 NULL NULL 420051 Debridement - each additional 20 sq cm NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97602 NULL NULL 420052 Non-selective debridement NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97605 NULL NULL 420053 Negative pressure wound therapy - less than or equ NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97606 NULL NULL 420054 Negative pressure wound therapy - greater than 50 NULL INSTITUTIONAL $249.00 1/1/2022-12/31/2022 $249.00 $104.08 $141.93 $183.02 $183.02 200% of Medicare 100% of Medicare $146.44 $140.96 $137.27 $104.08 100% of Medicaid 100% of Medicare 150% of Medicare $199.20 $249.00 195% of Medicare $201.69 $145.67 $145.67 $117.53 $160.21 100% of Medicare $199.20 $211.65 $195.47 $181.75 $199.20 $211.65 $171.19 100% of Medicare 100% of Medicare $186.75 200% of Medicare NULL 272 NULL NULL NULL NULL 001496 Oxymizer NULL INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 200% of Medicare 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001497 001497 NULL INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001498 001498 NULL INSTITUTIONAL $182.00 1/1/2022-12/31/2022 $182.00 $85.90 $103.74 $133.77 $133.77 200% of Medicare 100% of Medicare $108.98 $104.90 $102.16 $116.48 100% of Medicaid 100% of Medicare 150% of Medicare $145.60 $182.00 195% of Medicare $147.42 $108.29 $108.29 $85.90 $182.00 100% of Medicare $145.60 $154.70 $163.80 $132.84 $154.70 $182.00 $182.00 100% of Medicare 100% of Medicare $182.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001501 Posey Bed Alarm Pad NULL INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 200% of Medicare 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001502 VAD Dressing Change Kit NULL INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999022 FES Bike 1 Session NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999023 FES Bike 10 Session NULL INSTITUTIONAL $180.00 1/1/2022-12/31/2022 $180.00 $84.96 $102.60 $132.30 $132.30 200% of Medicare 100% of Medicare $107.78 $103.75 $101.03 $115.20 100% of Medicaid 100% of Medicare 150% of Medicare $144.00 $180.00 195% of Medicare $145.80 $107.10 $107.10 $84.96 $180.00 100% of Medicare $144.00 $153.00 $162.00 $131.38 $153.00 $180.00 $180.00 100% of Medicare 100% of Medicare $180.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999024 FES Electrode Upper NULL INSTITUTIONAL $42.00 1/1/2022-12/31/2022 $42.00 $19.82 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $25.15 $24.21 $23.57 $26.88 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 195% of Medicare $34.02 $24.99 $24.99 $19.82 $42.00 100% of Medicare $33.60 $35.70 $37.80 $30.66 $35.70 $42.00 $42.00 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999025 FES Electrode Lower NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001503 "Needle, Huber 20G x 3/4""" NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ocular lubricant preserved Sol 00536-1970-72 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001504 001504 NULL INSTITUTIONAL $418.00 1/1/2022-12/31/2022 $418.00 $197.30 $238.26 $307.23 $307.23 200% of Medicare 100% of Medicare $250.30 $240.94 $234.62 $267.52 100% of Medicaid 100% of Medicare 150% of Medicare $334.40 $418.00 195% of Medicare $338.58 $248.71 $248.71 $197.30 $418.00 100% of Medicare $334.40 $355.30 $376.20 $305.10 $355.30 $418.00 $418.00 100% of Medicare 100% of Medicare $418.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001511 001511 NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 440 NULL 92507 GN NULL 440001 Tx of Speech/Lang/Voice/Comm/Auditory Chg Medicaid NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 420 NULL 95992 GP NULL 420173 Canalith Repositioning Procedure Units NULL INSTITUTIONAL $159.00 1/1/2022-12/31/2022 $159.00 $66.46 $90.63 $116.87 $116.87 200% of Medicare 100% of Medicare $93.51 $90.01 $87.66 $66.46 100% of Medicaid 100% of Medicare 150% of Medicare $127.20 $159.00 195% of Medicare $128.79 $93.02 $93.02 $75.05 $102.30 100% of Medicare $127.20 $135.15 $124.82 $116.05 $127.20 $135.15 $109.31 100% of Medicare 100% of Medicare $119.25 200% of Medicare NULL 250 NULL NULL NULL NULL NULL sacubitril-valsartan 49 mg-51 mg T 00078-0777-20 INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 200% of Medicare 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ivabradine 7.5 mg Tab 55513-0810-60 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 420 NULL 97610 NULL NULL 420055 "Non-thermal, non-contact ultrasound" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fluticasone-vilanterol 200 mcg-25 00173-0882-14 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL J1595 NULL glatiramer 40 mg/mL Sol 68546-0325-12 INSTITUTIONAL " $1,896.00 " 1/1/2022-12/31/2022 " $1,611.60 " $792.53 " $1,080.72 " " $1,393.56 " " $1,393.56 " 200% of Medicare 100% of Medicare " $1,115.04 " " $1,073.33 " " $1,045.26 " $792.53 100% of Medicaid 100% of Medicare 150% of Medicare " $1,516.80 " " $1,500.00 " 195% of Medicare " $1,535.76 " " $1,109.16 " " $1,109.16 " $894.91 " $1,219.89 " 100% of Medicare " $1,516.80 " " $1,611.60 " " $1,488.36 " " $1,383.89 " " $1,516.80 " " $1,611.60 " " $1,303.50 " 100% of Medicare 100% of Medicare " $1,422.00 " 200% of Medicare NULL 250 NULL NULL NULL NULL NULL balsam Peru-castor oil topical 87 58980-0780-21 INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $52.39 $63.27 $81.59 $81.59 200% of Medicare 100% of Medicare $66.47 $63.98 $62.30 $71.04 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $66.05 $66.05 $52.39 $111.00 100% of Medicare $88.80 $94.35 $99.90 $81.02 $94.35 $111.00 $111.00 100% of Medicare 100% of Medicare $111.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Cholestyramine/Hydrophor 10 % Oint 99999-9991-00 INSTITUTIONAL $334.00 1/1/2022-12/31/2022 $334.00 $157.65 $190.38 $245.49 $245.49 200% of Medicare 100% of Medicare $200.00 $192.52 $187.47 $213.76 100% of Medicaid 100% of Medicare 150% of Medicare $267.20 $334.00 195% of Medicare $270.54 $198.73 $198.73 $157.65 $334.00 100% of Medicare $267.20 $283.90 $300.60 $243.79 $283.90 $334.00 $334.00 100% of Medicare 100% of Medicare $334.00 200% of Medicare NULL 430 NULL NULL NULL NULL 999056 Rehab Night Driving NULL INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 200% of Medicare 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ELVIT/COBIC/EMTRIC/TENOF 1 mg Tab 61958-19010-1 INSTITUTIONAL $367.00 1/1/2022-12/31/2022 $367.00 $173.22 $209.19 $269.75 $269.75 200% of Medicare 100% of Medicare $219.76 $211.54 $206.00 $234.88 100% of Medicaid 100% of Medicare 150% of Medicare $293.60 $367.00 195% of Medicare $297.27 $218.37 $218.37 $173.22 $367.00 100% of Medicare $293.60 $311.95 $330.30 $267.87 $311.95 $367.00 $367.00 100% of Medicare 100% of Medicare $367.00 200% of Medicare NULL 250 NULL NULL NULL J0695 NULL ceftolozane-tazobactam 1 g-0.5 g P 67919-0030-01 INSTITUTIONAL $490.00 1/1/2022-12/31/2022 $490.00 $204.82 $279.30 $360.15 $360.15 200% of Medicare 100% of Medicare $288.17 $277.39 $270.14 $204.82 100% of Medicaid 100% of Medicare 150% of Medicare $392.00 $490.00 195% of Medicare $396.90 $286.65 $286.65 $231.28 $315.27 100% of Medicare $392.00 $416.50 $384.65 $357.65 $392.00 $416.50 $336.88 100% of Medicare 100% of Medicare $367.50 200% of Medicare NULL 420 NULL NULL NULL NULL 424010 Wound Evaluation NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $373.82 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $474.25 $456.51 $444.55 $506.88 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $471.24 $471.24 $373.82 $792.00 100% of Medicare $633.60 $673.20 $712.80 $578.08 $673.20 $792.00 $792.00 100% of Medicare 100% of Medicare $792.00 200% of Medicare NULL 420 NULL NULL NULL NULL 424011 Wound Re-Evaluation NULL INSTITUTIONAL $396.00 1/1/2022-12/31/2022 $396.00 $186.91 $225.72 $291.06 $291.06 200% of Medicare 100% of Medicare $237.12 $228.25 $222.27 $253.44 100% of Medicaid 100% of Medicare 150% of Medicare $316.80 $396.00 195% of Medicare $320.76 $235.62 $235.62 $186.91 $396.00 100% of Medicare $316.80 $336.60 $356.40 $289.04 $336.60 $396.00 $396.00 100% of Medicare 100% of Medicare $396.00 200% of Medicare NULL 274 NULL 0183T NULL NULL 424012 Mist Kit Equipment NULL INSTITUTIONAL $76.00 1/1/2022-12/31/2022 $76.00 $31.77 $43.32 $55.86 $55.86 200% of Medicare 100% of Medicare $44.70 $43.02 $41.90 $31.77 100% of Medicaid 100% of Medicare 150% of Medicare $60.80 $76.00 195% of Medicare $61.56 $44.46 $44.46 $35.87 $48.90 100% of Medicare $60.80 $64.60 $59.66 $55.47 $60.80 $64.60 $52.25 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 420 NULL 97530 NULL NULL 424013 "Wound Therapeutic activities, each 15 mins" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Memantine 28 mg Cap 00456-34283-3 INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $26.90 $32.49 $41.90 $41.90 200% of Medicare 100% of Medicare $34.13 $32.85 $31.99 $36.48 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.92 $33.92 $26.90 $57.00 100% of Medicare $45.60 $48.45 $51.30 $41.60 $48.45 $57.00 $57.00 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Cranberry 500 mg Cap 36652-0916-81 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001520 001520 NULL INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL methenamine hippurate 1 g Tab 64720-0139-10 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001523 001523 NULL INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001524 Coban 2 Compression System NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 200% of Medicare 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001516 Mextra Suberabsorbent 10 CM x 15 CM (4 IN x 6 IN) NULL INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 200% of Medicare 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001518 CovRSite Dressing 6 IN x 6 IN NULL INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 200% of Medicare 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001519 Primapore Specialty Absorbent Dressing 8 IN x 4 IN NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001520 Primapore Specialty Absorbent Dressing 11 - 3/4 IN NULL INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 200% of Medicare 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001521 Allevyn Life Sacrum Small NULL INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $58.06 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $73.65 $70.90 $69.04 $78.72 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $73.19 $73.19 $58.06 $123.00 100% of Medicare $98.40 $104.55 $110.70 $89.78 $104.55 $123.00 $123.00 100% of Medicare 100% of Medicare $123.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001522 Allevyn GB Lite 3 IN x 3 IN NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL OLANZapine 5 mg Tab 00904-6377-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 636 NULL NULL NULL J0476 NULL baclofen 0.05 mg/mL Sol 45945-0151-01 INSTITUTIONAL $439.00 1/1/2022-12/31/2022 $439.00 $183.50 $250.23 $322.67 $322.67 200% of Medicare 100% of Medicare $258.18 $248.52 $242.02 $183.50 100% of Medicaid 100% of Medicare 150% of Medicare $351.20 $439.00 195% of Medicare $355.59 $256.82 $256.82 $207.21 $282.45 100% of Medicare $351.20 $373.15 $344.62 $320.43 $351.20 $373.15 $301.81 100% of Medicare 100% of Medicare $329.25 200% of Medicare NULL 636 NULL NULL NULL J0475 NULL baclofen 0.5 mg/mL Sol 45945-0155-02 INSTITUTIONAL " $1,041.00 " 1/1/2022-12/31/2022 " $1,041.00 " $435.14 $593.37 $765.14 $765.14 200% of Medicare 100% of Medicare $612.21 $589.31 $573.90 $435.14 100% of Medicaid 100% of Medicare 150% of Medicare $832.80 " $1,041.00 " 195% of Medicare $843.21 $608.99 $608.99 $491.35 $669.78 100% of Medicare $832.80 $884.85 $817.19 $759.83 $832.80 $884.85 $715.69 100% of Medicare 100% of Medicare $780.75 200% of Medicare NULL 250 NULL NULL NULL J0475 NULL baclofen 1 mg/mL Sol 45945-0156-02 INSTITUTIONAL " $1,584.00 " 1/1/2022-12/31/2022 " $1,500.00 " $662.11 $902.88 " $1,164.24 " " $1,164.24 " 200% of Medicare 100% of Medicare $931.55 $896.70 $873.26 $662.11 100% of Medicaid 100% of Medicare 150% of Medicare " $1,267.20 " " $1,500.00 " 195% of Medicare " $1,283.04 " $926.64 $926.64 $747.65 " $1,019.15 " 100% of Medicare " $1,267.20 " " $1,346.40 " " $1,243.44 " " $1,156.16 " " $1,267.20 " " $1,346.40 " " $1,089.00 " 100% of Medicare 100% of Medicare " $1,188.00 " 200% of Medicare NULL 636 NULL NULL NULL J0475 NULL baclofen 2 mg/mL Sol 45945-0157-02 INSTITUTIONAL " $2,945.00 " 1/1/2022-12/31/2022 " $2,503.25 " " $1,231.01 " " $1,678.65 " " $2,164.58 " " $2,164.58 " 200% of Medicare 100% of Medicare " $1,731.95 " " $1,667.16 " " $1,623.58 " " $1,231.01 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,356.00 " " $1,500.00 " 195% of Medicare " $2,385.45 " " $1,722.83 " " $1,722.83 " " $1,390.04 " " $1,894.81 " 100% of Medicare " $2,356.00 " " $2,503.25 " " $2,311.83 " " $2,149.56 " " $2,356.00 " " $2,503.25 " " $2,024.69 " 100% of Medicare 100% of Medicare " $2,208.75 " 200% of Medicare NULL 324 NULL 71010 NULL NULL 657590 CHEST X-RAY 1 VIEW FRONTAL NULL INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $53.50 $72.96 $94.08 $94.08 200% of Medicare 100% of Medicare $75.28 $72.46 $70.57 $53.50 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $74.88 $74.88 $60.42 $82.36 100% of Medicare $102.40 $108.80 $100.48 $93.43 $102.40 $108.80 $88.00 100% of Medicare 100% of Medicare $96.00 200% of Medicare NULL 320 NULL 70250 NULL NULL 1405648 X-RAY EXAM OF SKULL NULL INSTITUTIONAL $398.00 1/1/2022-12/31/2022 $398.00 $166.36 $226.86 $292.53 $292.53 200% of Medicare 100% of Medicare $234.06 $225.31 $219.42 $166.36 100% of Medicaid 100% of Medicare 150% of Medicare $318.40 $398.00 195% of Medicare $322.38 $232.83 $232.83 $187.86 $256.07 100% of Medicare $318.40 $338.30 $312.43 $290.50 $318.40 $338.30 $273.63 100% of Medicare 100% of Medicare $298.50 200% of Medicare NULL 320 NULL 72040 NULL NULL 629600 X-RAY EXAM NECK SPINE 2-3 VW NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 320 NULL 74000 NULL NULL 751237 X-RAY EXAM OF ABDOMEN NULL INSTITUTIONAL $202.00 1/1/2022-12/31/2022 $202.00 $84.44 $115.14 $148.47 $148.47 200% of Medicare 100% of Medicare $118.80 $114.35 $111.36 $84.44 100% of Medicaid 100% of Medicare 150% of Medicare $161.60 $202.00 195% of Medicare $163.62 $118.17 $118.17 $95.34 $129.97 100% of Medicare $161.60 $171.70 $158.57 $147.44 $161.60 $171.70 $138.88 100% of Medicare 100% of Medicare $151.50 200% of Medicare NULL 410 NULL 31502 NULL NULL 410037 Tube changed NULL INSTITUTIONAL $638.00 1/1/2022-12/31/2022 $638.00 $266.68 $363.66 $468.93 $468.93 200% of Medicare 100% of Medicare $375.21 $361.17 $351.73 $266.68 100% of Medicaid 100% of Medicare 150% of Medicare $510.40 $638.00 195% of Medicare $516.78 $373.23 $373.23 $301.14 $410.49 100% of Medicare $510.40 $542.30 $500.83 $465.68 $510.40 $542.30 $438.63 100% of Medicare 100% of Medicare $478.50 200% of Medicare NULL 420 NULL 29582 NULL NULL 420048 Multi-layer compression; thigh down NULL INSTITUTIONAL $250.00 1/1/2022-12/31/2022 $250.00 $104.50 $142.50 $183.75 $183.75 200% of Medicare 100% of Medicare $147.03 $141.53 $137.83 $104.50 100% of Medicaid 100% of Medicare 150% of Medicare $200.00 $250.00 195% of Medicare $202.50 $146.25 $146.25 $118.00 $160.85 100% of Medicare $200.00 $212.50 $196.25 $182.48 $200.00 $212.50 $171.88 100% of Medicare 100% of Medicare $187.50 200% of Medicare NULL 420 NULL 29581 NULL NULL 420047 Multi-layer compression; below knee NULL INSTITUTIONAL $221.00 1/1/2022-12/31/2022 $221.00 $92.38 $125.97 $162.44 $162.44 200% of Medicare 100% of Medicare $129.97 $125.11 $121.84 $92.38 100% of Medicaid 100% of Medicare 150% of Medicare $176.80 $221.00 195% of Medicare $179.01 $129.29 $129.29 $104.31 $142.19 100% of Medicare $176.80 $187.85 $173.49 $161.31 $176.80 $187.85 $151.94 100% of Medicare 100% of Medicare $165.75 200% of Medicare NULL 999 NULL NULL NULL NULL 999026 BICS RF NULL INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gabapentin 300 mg Cap 00904-5632-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gabapentin 100 mg Cap 68084-0783-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL hydroCHLOROthiazide 25 mg Tab 68084-0086-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001530 "Bard Tray, Uretheral, Catheterization tray" NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001525 Precise PGX Skin Stapler NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 434 NULL 97165 GO NULL 434001 OT Evaluation Low Complexity Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 434 NULL 97166 GO NULL 434002 OT Evaluation Moderate Complexity Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 434 NULL 97167 GO NULL 434003 OT Evaluation High Complexity Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL 97161 GP NULL 424001 PT Evaluation Low Complexity Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL 97162 GP NULL 424002 PT Evaluation Moderate Complexity Units NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $165.95 $226.29 $291.80 $291.80 200% of Medicare 100% of Medicare $233.48 $224.74 $218.87 $165.95 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $232.25 $232.25 $187.38 $255.43 100% of Medicare $317.60 $337.45 $311.65 $289.77 $317.60 $337.45 $272.94 100% of Medicare 100% of Medicare $297.75 200% of Medicare NULL 424 NULL 97163 GP NULL 424003 PT Evaluation High Complexity Units NULL INSTITUTIONAL $396.00 1/1/2022-12/31/2022 $396.00 $165.53 $225.72 $291.06 $291.06 200% of Medicare 100% of Medicare $232.89 $224.18 $218.31 $165.53 100% of Medicaid 100% of Medicare 150% of Medicare $316.80 $396.00 195% of Medicare $320.76 $231.66 $231.66 $186.91 $254.79 100% of Medicare $316.80 $336.60 $310.86 $289.04 $316.80 $336.60 $272.25 100% of Medicare 100% of Medicare $297.00 200% of Medicare NULL 424 NULL 97164 GP NULL 424004 PT Re-Evaluation Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL 97161 GP NULL 424001 PT Low Complex Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL 97162 GP NULL 424002 PT Moderate Complex Units NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $165.95 $226.29 $291.80 $291.80 200% of Medicare 100% of Medicare $233.48 $224.74 $218.87 $165.95 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $232.25 $232.25 $187.38 $255.43 100% of Medicare $317.60 $337.45 $311.65 $289.77 $317.60 $337.45 $272.94 100% of Medicare 100% of Medicare $297.75 200% of Medicare NULL 424 NULL 97163 GP NULL 424003 PT High Complex Units NULL INSTITUTIONAL $396.00 1/1/2022-12/31/2022 $396.00 $165.53 $225.72 $291.06 $291.06 200% of Medicare 100% of Medicare $232.89 $224.18 $218.31 $165.53 100% of Medicaid 100% of Medicare 150% of Medicare $316.80 $396.00 195% of Medicare $320.76 $231.66 $231.66 $186.91 $254.79 100% of Medicare $316.80 $336.60 $310.86 $289.04 $316.80 $336.60 $272.25 100% of Medicare 100% of Medicare $297.00 200% of Medicare NULL 424 NULL 97164 GP NULL 424004 PT ReEval Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 434 NULL 97167 GO NULL 434003 OT High Complex Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 424 NULL 97168 GO NULL 434004 OT ReEval Units NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $165.95 $226.29 $291.80 $291.80 200% of Medicare 100% of Medicare $233.48 $224.74 $218.87 $165.95 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $232.25 $232.25 $187.38 $255.43 100% of Medicare $317.60 $337.45 $311.65 $289.77 $317.60 $337.45 $272.94 100% of Medicare 100% of Medicare $297.75 200% of Medicare NULL 434 NULL 97165 GO NULL 434001 OT Low Complex Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 434 NULL 97166 GO NULL 434002 OT Moderate Complex Units NULL INSTITUTIONAL $792.00 1/1/2022-12/31/2022 $792.00 $331.06 $451.44 $582.12 $582.12 200% of Medicare 100% of Medicare $465.78 $448.35 $436.63 $331.06 100% of Medicaid 100% of Medicare 150% of Medicare $633.60 $792.00 195% of Medicare $641.52 $463.32 $463.32 $373.82 $509.57 100% of Medicare $633.60 $673.20 $621.72 $578.08 $633.60 $673.20 $544.50 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001512 MEDI-HONEY DRESSING PASTE 1.5 oz NULL INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 636 NULL NULL NULL J0475 NULL baclofen 2 mg/mL Sol 45945-0157-01 INSTITUTIONAL " $3,036.00 " 1/1/2022-12/31/2022 " $2,580.60 " " $1,269.05 " " $1,730.52 " " $2,231.46 " " $2,231.46 " 200% of Medicare 100% of Medicare " $1,785.47 " " $1,718.68 " " $1,673.75 " " $1,269.05 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,428.80 " " $1,500.00 " 195% of Medicare " $2,459.16 " " $1,776.06 " " $1,776.06 " " $1,432.99 " " $1,953.36 " 100% of Medicare " $2,428.80 " " $2,580.60 " " $2,383.26 " " $2,215.98 " " $2,428.80 " " $2,580.60 " " $2,087.25 " 100% of Medicare 100% of Medicare " $2,277.00 " 200% of Medicare NULL 250 NULL NULL NULL J1644 NULL heparin 5000 units/mL Sol 25021-0402-01 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $6.69 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.41 $9.06 $8.82 $6.69 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.36 $9.36 $7.55 $10.29 100% of Medicare $12.80 $13.60 $12.56 $11.68 $12.80 $13.60 $11.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001535 "GASTROSTOMY TUBE TRI FUNNEL 18FR, 20CC" NULL INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 200% of Medicare 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999027 RF3 Unit 3 NULL INSTITUTIONAL " $1,250.00 " 1/1/2022-12/31/2022 " $1,250.00 " $590.00 $712.50 $918.75 $918.75 200% of Medicare 100% of Medicare $748.50 $720.50 $701.63 $800.00 100% of Medicaid 100% of Medicare 150% of Medicare " $1,000.00 " " $1,250.00 " 195% of Medicare " $1,012.50 " $743.75 $743.75 $590.00 " $1,250.00 " 100% of Medicare " $1,000.00 " " $1,062.50 " " $1,125.00 " $912.38 " $1,062.50 " " $1,250.00 " " $1,250.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL metFORMIN 500 mg Tab 68084-0072-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL fenofibrate 54 mg Tab 68084-0827-25 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL torsemide 20 mg Tab 50268-0756-15 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL propranolol 10 mg Tab 00904-6550-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL cyanocobalamin 1000 mcg Tab 50268-0855-15 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL valGANciclovir 450 mg Tab 31722-0832-60 INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $36.82 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $46.71 $44.96 $43.78 $49.92 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $46.41 $46.41 $36.82 $78.00 100% of Medicare $62.40 $66.30 $70.20 $56.93 $66.30 $78.00 $78.00 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 410 NULL NULL NULL G0237 G0237 Respiratory Therapy/ea 15 min NULL INSTITUTIONAL $108.00 1/1/2022-12/31/2022 $108.00 $45.14 $61.56 $79.38 $79.38 200% of Medicare 100% of Medicare $63.51 $61.14 $59.54 $45.14 100% of Medicaid 100% of Medicare 150% of Medicare $86.40 $108.00 195% of Medicare $87.48 $63.18 $63.18 $50.98 $69.49 100% of Medicare $86.40 $91.80 $84.78 $78.83 $86.40 $91.80 $74.25 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL dipyridamole 25 mg Tab 00555-0252-02 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mineral oil 100% Liq 48433-0202-30 INSTITUTIONAL $62.00 1/1/2022-12/31/2022 $62.00 $29.26 $35.34 $45.57 $45.57 200% of Medicare 100% of Medicare $37.13 $35.74 $34.80 $39.68 100% of Medicaid 100% of Medicare 150% of Medicare $49.60 $62.00 195% of Medicare $50.22 $36.89 $36.89 $29.26 $62.00 100% of Medicare $49.60 $52.70 $55.80 $45.25 $52.70 $62.00 $62.00 100% of Medicare 100% of Medicare $62.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001085 Urinary Catheter Insertion - Indwelling ( NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL nystatin 100000 units/mL Sus 00121-4810-00 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001538 Catheter Stabilization Device - Foley NULL INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Ensure Enlive Shake Charge 1 EA So 99999-9999-59 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL QUEtiapine 25 mg Tab 00904-6277-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL J1833 NULL isavuconazonium 372 mg Pow 00469-0420-99 INSTITUTIONAL " $1,110.00 " 1/1/2022-12/31/2022 " $1,110.00 " $463.98 $632.70 $815.85 $815.85 200% of Medicare 100% of Medicare $652.79 $628.37 $611.94 $463.98 100% of Medicaid 100% of Medicare 150% of Medicare $888.00 " $1,110.00 " 195% of Medicare $899.10 $649.35 $649.35 $523.92 $714.17 100% of Medicare $888.00 $943.50 $871.35 $810.19 $888.00 $943.50 $763.13 100% of Medicare 100% of Medicare $832.50 200% of Medicare NULL 272 NULL NULL NULL NULL 000899 "MEPILEX BORDER 3"" X 3"" Charge" NULL INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL megestrol 20 mg Tab 51079-0434-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL NULL NULL NULL NULL NULL NULL GLUCOSE MONITORING CONTINUOUS HENR NULL INSTITUTIONAL $82.00 1/1/2022-12/31/2022 $82.00 $38.70 $46.74 $60.27 $60.27 200% of Medicare 100% of Medicare $49.10 $47.26 $46.03 $52.48 100% of Medicaid 100% of Medicare 150% of Medicare $65.60 $82.00 195% of Medicare $66.42 $48.79 $48.79 $38.70 $82.00 100% of Medicare $65.60 $69.70 $73.80 $59.85 $69.70 $82.00 $82.00 100% of Medicare 100% of Medicare $82.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL docusate 10 mg/mL Liq 00121-0544-10 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL rosuvastatin 10 mg Tab 60687-0245-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL venlafaxine 150 mg Cap 68084-0713-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL levETIRAcetam 100 mg/mL Sol 50383-0241-06 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL amantadine 50 mg/5 mL Syr 00121-0646-10 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL valproic acid 250 mg/5 mL Syr 00121-4675-55 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 940 NULL NULL NULL NULL NULL Pharmacy MTM Charge 1 EA Each 99999-9999-63 INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $27.85 $33.63 $43.37 $43.37 200% of Medicare 100% of Medicare $35.33 $34.01 $33.12 $37.76 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $35.11 $35.11 $27.85 $59.00 100% of Medicare $47.20 $50.15 $53.10 $43.06 $50.15 $59.00 $59.00 100% of Medicare 100% of Medicare $59.00 200% of Medicare NULL 940 NULL NULL NULL NULL NULL Pharmacy MTM Anticoagulation Level 99999-9999-64 INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $31.15 $37.62 $48.51 $48.51 200% of Medicare 100% of Medicare $39.52 $38.04 $37.05 $42.24 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $39.27 $39.27 $31.15 $66.00 100% of Medicare $52.80 $56.10 $59.40 $48.17 $56.10 $66.00 $66.00 100% of Medicare 100% of Medicare $66.00 200% of Medicare NULL 940 NULL NULL NULL NULL NULL Pharmacy MTM Anticoagulation Level 99999-9999-65 INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 200% of Medicare 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL OLANZapine 2.5 mg Tab 60505-3110-00 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001499 001499 NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001545 001545 NULL INSTITUTIONAL $195.00 1/1/2022-12/31/2022 $195.00 $92.04 $111.15 $143.33 $143.33 200% of Medicare 100% of Medicare $116.77 $112.40 $109.45 $124.80 100% of Medicaid 100% of Medicare 150% of Medicare $156.00 $195.00 195% of Medicare $157.95 $116.03 $116.03 $92.04 $195.00 100% of Medicare $156.00 $165.75 $175.50 $142.33 $165.75 $195.00 $195.00 100% of Medicare 100% of Medicare $195.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001544 001544 NULL INSTITUTIONAL $631.00 1/1/2022-12/31/2022 $631.00 $297.83 $359.67 $463.79 $463.79 200% of Medicare 100% of Medicare $377.84 $363.71 $354.18 $403.84 100% of Medicaid 100% of Medicare 150% of Medicare $504.80 $631.00 195% of Medicare $511.11 $375.45 $375.45 $297.83 $631.00 100% of Medicare $504.80 $536.35 $567.90 $460.57 $536.35 $631.00 $631.00 100% of Medicare 100% of Medicare $631.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001543 001543 NULL INSTITUTIONAL $329.00 1/1/2022-12/31/2022 $329.00 $155.29 $187.53 $241.82 $241.82 200% of Medicare 100% of Medicare $197.01 $189.64 $184.67 $210.56 100% of Medicaid 100% of Medicare 150% of Medicare $263.20 $329.00 195% of Medicare $266.49 $195.76 $195.76 $155.29 $329.00 100% of Medicare $263.20 $279.65 $296.10 $240.14 $279.65 $329.00 $329.00 100% of Medicare 100% of Medicare $329.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540003 ALS Emergency NULL INSTITUTIONAL $486.00 1/1/2022-12/31/2022 $486.00 $229.39 $277.02 $357.21 $357.21 200% of Medicare 100% of Medicare $291.02 $280.13 $272.79 $311.04 100% of Medicaid 100% of Medicare 150% of Medicare $388.80 $486.00 195% of Medicare $393.66 $289.17 $289.17 $229.39 $486.00 100% of Medicare $388.80 $413.10 $437.40 $354.73 $413.10 $486.00 $486.00 100% of Medicare 100% of Medicare $486.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540004 ALS Non-Emergency NULL INSTITUTIONAL $308.00 1/1/2022-12/31/2022 $308.00 $145.38 $175.56 $226.38 $226.38 200% of Medicare 100% of Medicare $184.43 $177.53 $172.88 $197.12 100% of Medicaid 100% of Medicare 150% of Medicare $246.40 $308.00 195% of Medicare $249.48 $183.26 $183.26 $145.38 $308.00 100% of Medicare $246.40 $261.80 $277.20 $224.81 $261.80 $308.00 $308.00 100% of Medicare 100% of Medicare $308.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540005 AC Support 2: NULL INSTITUTIONAL $705.00 1/1/2022-12/31/2022 $705.00 $332.76 $401.85 $518.18 $518.18 200% of Medicare 100% of Medicare $422.15 $406.36 $395.72 $451.20 100% of Medicaid 100% of Medicare 150% of Medicare $564.00 $705.00 195% of Medicare $571.05 $419.48 $419.48 $332.76 $705.00 100% of Medicare $564.00 $599.25 $634.50 $514.58 $599.25 $705.00 $705.00 100% of Medicare 100% of Medicare $705.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540006 SA Transport NULL INSTITUTIONAL $832.00 1/1/2022-12/31/2022 $832.00 $392.70 $474.24 $611.52 $611.52 200% of Medicare 100% of Medicare $498.20 $479.56 $467.00 $532.48 100% of Medicaid 100% of Medicare 150% of Medicare $665.60 $832.00 195% of Medicare $673.92 $495.04 $495.04 $392.70 $832.00 100% of Medicare $665.60 $707.20 $748.80 $607.28 $707.20 $832.00 $832.00 100% of Medicare 100% of Medicare $832.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540007 WC Van NULL INSTITUTIONAL $42.00 1/1/2022-12/31/2022 $42.00 $19.82 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $25.15 $24.21 $23.57 $26.88 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 195% of Medicare $34.02 $24.99 $24.99 $19.82 $42.00 100% of Medicare $33.60 $35.70 $37.80 $30.66 $35.70 $42.00 $42.00 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540008 Ambulance Svcs NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 540 NULL NULL NULL NULL 540009 WC Van NULL INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 200% of Medicare 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL polyethylene glycol 3350 - Pow 11523-7268-03 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 636 NULL NULL NULL J0586 NULL abobotulinumtoxinA 500 units Pow 15054-0500-01 INSTITUTIONAL " $3,524.00 " 1/1/2022-12/31/2022 " $2,995.40 " " $1,473.03 " " $2,008.68 " " $2,590.14 " " $2,590.14 " 200% of Medicare 100% of Medicare " $2,072.46 " " $1,994.94 " " $1,942.78 " " $1,473.03 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,819.20 " " $1,500.00 " 195% of Medicare " $2,854.44 " " $2,061.54 " " $2,061.54 " " $1,663.33 " " $2,267.34 " 100% of Medicare " $2,819.20 " " $2,995.40 " " $2,766.34 " " $2,572.17 " " $2,819.20 " " $2,995.40 " " $2,422.75 " 100% of Medicare 100% of Medicare " $2,643.00 " 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Phenol 6% Solution 6 % Soln 99999-9988-88 INSTITUTIONAL $134.00 1/1/2022-12/31/2022 $134.00 $63.25 $76.38 $98.49 $98.49 200% of Medicare 100% of Medicare $80.24 $77.24 $75.21 $85.76 100% of Medicaid 100% of Medicare 150% of Medicare $107.20 $134.00 195% of Medicare $108.54 $79.73 $79.73 $63.25 $134.00 100% of Medicare $107.20 $113.90 $120.60 $97.81 $113.90 $134.00 $134.00 100% of Medicare 100% of Medicare $134.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL gabapentin 300 mg Cap 50268-0348-15 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 410 NULL 94664 NULL NULL 410019 RT Education/Instruction Charge NULL INSTITUTIONAL $636.00 1/1/2022-12/31/2022 $636.00 $265.85 $362.52 $467.46 $467.46 200% of Medicare 100% of Medicare $374.03 $360.04 $350.63 $265.85 100% of Medicaid 100% of Medicare 150% of Medicare $508.80 $636.00 195% of Medicare $515.16 $372.06 $372.06 $300.19 $409.20 100% of Medicare $508.80 $540.60 $499.26 $464.22 $508.80 $540.60 $437.25 100% of Medicare 100% of Medicare $477.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Opium 10mg/ml 10 mg/mL Soln 62559-01530-4 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 200% of Medicare 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Cefazolin 2g/50ml duplex sol 2g 17190-40010-H7L611 INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $52.86 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $67.07 $64.56 $62.87 $71.68 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $66.64 $66.64 $52.86 $112.00 100% of Medicare $89.60 $95.20 $100.80 $81.75 $95.20 $112.00 $112.00 100% of Medicare 100% of Medicare $112.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999031 RF Hotel NULL INSTITUTIONAL $96.00 1/1/2022-12/31/2022 $96.00 $45.31 $54.72 $70.56 $70.56 200% of Medicare 100% of Medicare $57.48 $55.33 $53.88 $61.44 100% of Medicaid 100% of Medicare 150% of Medicare $76.80 $96.00 195% of Medicare $77.76 $57.12 $57.12 $45.31 $96.00 100% of Medicare $76.80 $81.60 $86.40 $70.07 $81.60 $96.00 $96.00 100% of Medicare 100% of Medicare $96.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999032 RF Mileage NULL INSTITUTIONAL $0.38 1/1/2022-12/31/2022 $0.38 $0.18 $0.22 $0.28 $0.28 200% of Medicare 100% of Medicare $0.23 $0.22 $0.21 $0.24 100% of Medicaid 100% of Medicare 150% of Medicare $0.30 $0.38 195% of Medicare $0.31 $0.23 $0.23 $0.18 $0.38 100% of Medicare $0.30 $0.32 $0.34 $0.28 $0.32 $0.38 $0.38 100% of Medicare 100% of Medicare $0.38 200% of Medicare NULL 999 NULL NULL NULL NULL 21060245 RF Bus Passes NULL INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 200% of Medicare 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001312 001312 NULL INSTITUTIONAL $314.00 1/1/2022-12/31/2022 $314.00 $148.21 $178.98 $230.79 $230.79 200% of Medicare 100% of Medicare $188.02 $180.99 $176.25 $200.96 100% of Medicaid 100% of Medicare 150% of Medicare $251.20 $314.00 195% of Medicare $254.34 $186.83 $186.83 $148.21 $314.00 100% of Medicare $251.20 $266.90 $282.60 $229.19 $266.90 $314.00 $314.00 100% of Medicare 100% of Medicare $314.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001551 001551 NULL INSTITUTIONAL $254.00 1/1/2022-12/31/2022 $254.00 $119.89 $144.78 $186.69 $186.69 200% of Medicare 100% of Medicare $152.10 $146.41 $142.57 $162.56 100% of Medicaid 100% of Medicare 150% of Medicare $203.20 $254.00 195% of Medicare $205.74 $151.13 $151.13 $119.89 $254.00 100% of Medicare $203.20 $215.90 $228.60 $185.39 $215.90 $254.00 $254.00 100% of Medicare 100% of Medicare $254.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001550 001550 NULL INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $42.95 $51.87 $66.89 $66.89 200% of Medicare 100% of Medicare $54.49 $52.45 $51.08 $58.24 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $54.15 $54.15 $42.95 $91.00 100% of Medicare $72.80 $77.35 $81.90 $66.42 $77.35 $91.00 $91.00 100% of Medicare 100% of Medicare $91.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001453 001453 NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 272 NULL NULL NULL NULL 000164 000164 NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $26.43 $31.92 $41.16 $41.16 200% of Medicare 100% of Medicare $33.53 $32.28 $31.43 $35.84 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $33.32 $33.32 $26.43 $56.00 100% of Medicare $44.80 $47.60 $50.40 $40.87 $47.60 $56.00 $56.00 100% of Medicare 100% of Medicare $56.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ticagrelor 60 mg Tab 00186-0776-60 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL paliperidone 6 mg Tab 10147-0953-03 INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 200% of Medicare 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001552 001552 NULL INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 200% of Medicare 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL J3010 NULL fentaNYL 50 mcg/mL Sol 00409-9094-25 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $6.69 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.41 $9.06 $8.82 $6.69 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.36 $9.36 $7.55 $10.29 100% of Medicare $12.80 $13.60 $12.56 $11.68 $12.80 $13.60 $11.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 420 NULL 97763 GP NULL 97763 PT Orthotic Mgmt/Train Establish Rehab Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97127 GO NULL 97127 OT Cognitive Function Units NULL INSTITUTIONAL $665.00 1/1/2022-12/31/2022 $665.00 $277.97 $379.05 $488.78 $488.78 200% of Medicare 100% of Medicare $391.09 $376.46 $366.61 $277.97 100% of Medicaid 100% of Medicare 150% of Medicare $532.00 $665.00 195% of Medicare $538.65 $389.03 $389.03 $313.88 $427.86 100% of Medicare $532.00 $565.25 $522.03 $485.38 $532.00 $565.25 $457.19 100% of Medicare 100% of Medicare $498.75 200% of Medicare NULL 430 NULL 97763 GO NULL 97763 OT Orthotic Mgmt/Train Establish Rehab Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 440 NULL NULL GN G0515 G0515 SLP Cognitive Function Medicare Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 440 NULL 97127 GN G0515 G0515 SLP Cognitive Function Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97127 GP NULL 97127 PT Cognitive Function Units NULL INSTITUTIONAL $665.00 1/1/2022-12/31/2022 $665.00 $277.97 $379.05 $488.78 $488.78 200% of Medicare 100% of Medicare $391.09 $376.46 $366.61 $277.97 100% of Medicaid 100% of Medicare 150% of Medicare $532.00 $665.00 195% of Medicare $538.65 $389.03 $389.03 $313.88 $427.86 100% of Medicare $532.00 $565.25 $522.03 $485.38 $532.00 $565.25 $457.19 100% of Medicare 100% of Medicare $498.75 200% of Medicare NULL 420 NULL NULL GP G0515 G0515 PT Cognitive Function Medicare Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL NULL GO G0515 G0515 OT Cognitive Function Medicare Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 272 NULL NULL NULL NULL 002951 NULL NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 050100 NULL NULL INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 272 NULL NULL NULL NULL 020501 NULL NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL mirabegron 25 mg Tab 00469-2601-30 INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $26.90 $32.49 $41.90 $41.90 200% of Medicare 100% of Medicare $34.13 $32.85 $31.99 $36.48 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.92 $33.92 $26.90 $57.00 100% of Medicare $45.60 $48.45 $51.30 $41.60 $48.45 $57.00 $57.00 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL naloxegol 25 mg Tab 00310-1970-30 INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 200% of Medicare 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL oseltamivir 30mg cap 30 mg Cap 34778-14681-32 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL surgicel fibrillar 1 EA Dressin 01207-05031-003122 INSTITUTIONAL $549.00 1/1/2022-12/31/2022 $549.00 $259.13 $312.93 $403.52 $403.52 200% of Medicare 100% of Medicare $328.74 $316.44 $308.15 $351.36 100% of Medicaid 100% of Medicare 150% of Medicare $439.20 $549.00 195% of Medicare $444.69 $326.66 $326.66 $259.13 $549.00 100% of Medicare $439.20 $466.65 $494.10 $400.72 $466.65 $549.00 $549.00 100% of Medicare 100% of Medicare $549.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110040 110040 NULL INSTITUTIONAL $77.00 1/1/2022-12/31/2022 $77.00 $36.34 $43.89 $56.60 $56.60 200% of Medicare 100% of Medicare $46.11 $44.38 $43.22 $49.28 100% of Medicaid 100% of Medicare 150% of Medicare $61.60 $77.00 195% of Medicare $62.37 $45.82 $45.82 $36.34 $77.00 100% of Medicare $61.60 $65.45 $69.30 $56.20 $65.45 $77.00 $77.00 100% of Medicare 100% of Medicare $77.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110039 110039 NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110042 110042 NULL INSTITUTIONAL $126.00 1/1/2022-12/31/2022 $126.00 $59.47 $71.82 $92.61 $92.61 200% of Medicare 100% of Medicare $75.45 $72.63 $70.72 $80.64 100% of Medicaid 100% of Medicare 150% of Medicare $100.80 $126.00 195% of Medicare $102.06 $74.97 $74.97 $59.47 $126.00 100% of Medicare $100.80 $107.10 $113.40 $91.97 $107.10 $126.00 $126.00 100% of Medicare 100% of Medicare $126.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110048 110048 NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110049 110049 NULL INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110041 110041 NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110046 110046 NULL INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110038 110038 NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110043 110043 NULL INSTITUTIONAL $336.00 1/1/2022-12/31/2022 $336.00 $158.59 $191.52 $246.96 $246.96 200% of Medicare 100% of Medicare $201.20 $193.67 $188.60 $215.04 100% of Medicaid 100% of Medicare 150% of Medicare $268.80 $336.00 195% of Medicare $272.16 $199.92 $199.92 $158.59 $336.00 100% of Medicare $268.80 $285.60 $302.40 $245.25 $285.60 $336.00 $336.00 100% of Medicare 100% of Medicare $336.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110044 110044 NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110045 110045 NULL INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110047 110047 NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001486 001486 NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001485 001485 NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001484 001484 NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001483 001483 NULL INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 300 NULL 87633 NULL NULL 49685539 RVP PCR Panel NULL INSTITUTIONAL " $2,262.00 " 1/1/2022-12/31/2022 " $1,922.70 " $945.52 " $1,289.34 " " $1,662.57 " " $1,662.57 " 200% of Medicare 100% of Medicare " $1,330.28 " " $1,280.52 " " $1,247.04 " $945.52 100% of Medicaid 100% of Medicare 150% of Medicare " $1,809.60 " " $1,500.00 " 195% of Medicare " $1,832.22 " " $1,323.27 " " $1,323.27 " " $1,067.66 " " $1,455.37 " 100% of Medicare " $1,809.60 " " $1,922.70 " " $1,775.67 " " $1,651.03 " " $1,809.60 " " $1,922.70 " " $1,555.13 " 100% of Medicare 100% of Medicare " $1,696.50 " 200% of Medicare NULL 272 NULL NULL NULL NULL 118785 118785 NULL INSTITUTIONAL $145.00 1/1/2022-12/31/2022 $145.00 $68.44 $82.65 $106.58 $106.58 200% of Medicare 100% of Medicare $86.83 $83.58 $81.39 $92.80 100% of Medicaid 100% of Medicare 150% of Medicare $116.00 $145.00 195% of Medicare $117.45 $86.28 $86.28 $68.44 $145.00 100% of Medicare $116.00 $123.25 $130.50 $105.84 $123.25 $145.00 $145.00 100% of Medicare 100% of Medicare $145.00 200% of Medicare NULL 272 NULL NULL NULL NULL 114785 114785 NULL INSTITUTIONAL $62.00 1/1/2022-12/31/2022 $62.00 $29.26 $35.34 $45.57 $45.57 200% of Medicare 100% of Medicare $37.13 $35.74 $34.80 $39.68 100% of Medicaid 100% of Medicare 150% of Medicare $49.60 $62.00 195% of Medicare $50.22 $36.89 $36.89 $29.26 $62.00 100% of Medicare $49.60 $52.70 $55.80 $45.25 $52.70 $62.00 $62.00 100% of Medicare 100% of Medicare $62.00 200% of Medicare NULL 272 NULL NULL NULL NULL 113785 113785 NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117570 117570 NULL INSTITUTIONAL $106.00 1/1/2022-12/31/2022 $106.00 $50.03 $60.42 $77.91 $77.91 200% of Medicare 100% of Medicare $63.47 $61.10 $59.50 $67.84 100% of Medicaid 100% of Medicare 150% of Medicare $84.80 $106.00 195% of Medicare $85.86 $63.07 $63.07 $50.03 $106.00 100% of Medicare $84.80 $90.10 $95.40 $77.37 $90.10 $106.00 $106.00 100% of Medicare 100% of Medicare $106.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117789 117789 NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117650 117650 NULL INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117331 117331 NULL INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117310 117310 NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117332 117332 NULL INSTITUTIONAL $182.00 1/1/2022-12/31/2022 $182.00 $85.90 $103.74 $133.77 $133.77 200% of Medicare 100% of Medicare $108.98 $104.90 $102.16 $116.48 100% of Medicaid 100% of Medicare 150% of Medicare $145.60 $182.00 195% of Medicare $147.42 $108.29 $108.29 $85.90 $182.00 100% of Medicare $145.60 $154.70 $163.80 $132.84 $154.70 $182.00 $182.00 100% of Medicare 100% of Medicare $182.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117040 117040 NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $53.34 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $67.66 $65.13 $63.43 $72.32 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $67.24 $67.24 $53.34 $113.00 100% of Medicare $90.40 $96.05 $101.70 $82.48 $96.05 $113.00 $113.00 100% of Medicare 100% of Medicare $113.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117043 117043 NULL INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 200% of Medicare 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 272 NULL NULL NULL NULL 116911 116911 NULL INSTITUTIONAL $125.00 1/1/2022-12/31/2022 $125.00 $59.00 $71.25 $91.88 $91.88 200% of Medicare 100% of Medicare $74.85 $72.05 $70.16 $80.00 100% of Medicaid 100% of Medicare 150% of Medicare $100.00 $125.00 195% of Medicare $101.25 $74.38 $74.38 $59.00 $125.00 100% of Medicare $100.00 $106.25 $112.50 $91.24 $106.25 $125.00 $125.00 100% of Medicare 100% of Medicare $125.00 200% of Medicare NULL 272 NULL NULL NULL NULL 116092 116092 NULL INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL NULL NULL NULL 115879 115879 NULL INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 200% of Medicare 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 272 NULL NULL NULL NULL 114737 114737 NULL INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 272 NULL NULL NULL NULL 118083 118083 NULL INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 272 NULL NULL NULL NULL 113010 113010 NULL INSTITUTIONAL $191.00 1/1/2022-12/31/2022 $191.00 $90.15 $108.87 $140.39 $140.39 200% of Medicare 100% of Medicare $114.37 $110.09 $107.21 $122.24 100% of Medicaid 100% of Medicare 150% of Medicare $152.80 $191.00 195% of Medicare $154.71 $113.65 $113.65 $90.15 $191.00 100% of Medicare $152.80 $162.35 $171.90 $139.41 $162.35 $191.00 $191.00 100% of Medicare 100% of Medicare $191.00 200% of Medicare NULL 272 NULL NULL NULL NULL 112244 112244 NULL INSTITUTIONAL $87.00 1/1/2022-12/31/2022 $87.00 $41.06 $49.59 $63.95 $63.95 200% of Medicare 100% of Medicare $52.10 $50.15 $48.83 $55.68 100% of Medicaid 100% of Medicare 150% of Medicare $69.60 $87.00 195% of Medicare $70.47 $51.77 $51.77 $41.06 $87.00 100% of Medicare $69.60 $73.95 $78.30 $63.50 $73.95 $87.00 $87.00 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117056 117056 NULL INSTITUTIONAL $336.00 1/1/2022-12/31/2022 $336.00 $158.59 $191.52 $246.96 $246.96 200% of Medicare 100% of Medicare $201.20 $193.67 $188.60 $215.04 100% of Medicaid 100% of Medicare 150% of Medicare $268.80 $336.00 195% of Medicare $272.16 $199.92 $199.92 $158.59 $336.00 100% of Medicare $268.80 $285.60 $302.40 $245.25 $285.60 $336.00 $336.00 100% of Medicare 100% of Medicare $336.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110019 110019 NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 113110 113110 NULL INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 272 NULL NULL NULL NULL 113111 113111 NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL meningococcal B vaccine 4 -comp 0.5 58160-09760-6 INSTITUTIONAL $622.00 1/1/2022-12/31/2022 $622.00 $293.58 $354.54 $457.17 $457.17 200% of Medicare 100% of Medicare $372.45 $358.52 $349.13 $398.08 100% of Medicaid 100% of Medicare 150% of Medicare $497.60 $622.00 195% of Medicare $503.82 $370.09 $370.09 $293.58 $622.00 100% of Medicare $497.60 $528.70 $559.80 $454.00 $528.70 $622.00 $622.00 100% of Medicare 100% of Medicare $622.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Alogliptin 12.5 mg Tab 45802-01036-5 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 300 NULL 84681 NULL NULL 49781976 C-Peptide SerPl QN NULL INSTITUTIONAL $127.00 1/1/2022-12/31/2022 $127.00 $53.09 $72.39 $93.35 $93.35 200% of Medicare 100% of Medicare $74.69 $71.89 $70.02 $53.09 100% of Medicaid 100% of Medicare 150% of Medicare $101.60 $127.00 195% of Medicare $102.87 $74.30 $74.30 $59.94 $81.71 100% of Medicare $101.60 $107.95 $99.70 $92.70 $101.60 $107.95 $87.31 100% of Medicare 100% of Medicare $95.25 200% of Medicare NULL 300 NULL 82947 NULL NULL 49781977 Glucose Fasting SerPl QN NULL INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $10.45 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.70 $14.15 $13.78 $10.45 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.63 $14.63 $11.80 $16.09 100% of Medicare $20.00 $21.25 $19.63 $18.25 $20.00 $21.25 $17.19 100% of Medicare 100% of Medicare $18.75 200% of Medicare NULL 300 NULL 86378 NULL NULL 49782076 Thyroid Peroxidase Ab NULL INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $37.20 $50.73 $65.42 $65.42 200% of Medicare 100% of Medicare $52.34 $50.38 $49.07 $37.20 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.07 $52.07 $42.01 $57.26 100% of Medicare $71.20 $75.65 $69.87 $64.96 $71.20 $75.65 $61.19 100% of Medicare 100% of Medicare $66.75 200% of Medicare NULL 300 NULL 84432 NULL NULL 49782077 Thyroglobulin Ser (cpt 84432) NULL INSTITUTIONAL $98.00 1/1/2022-12/31/2022 $98.00 $40.96 $55.86 $72.03 $72.03 200% of Medicare 100% of Medicare $57.63 $55.48 $54.03 $40.96 100% of Medicaid 100% of Medicare 150% of Medicare $78.40 $98.00 195% of Medicare $79.38 $57.33 $57.33 $46.26 $63.05 100% of Medicare $78.40 $83.30 $76.93 $71.53 $78.40 $83.30 $67.38 100% of Medicare 100% of Medicare $73.50 200% of Medicare NULL 300 NULL 86800 NULL NULL 49782078 Anti-Thyroglobulin Antibody QN (86800) NULL INSTITUTIONAL $98.00 1/1/2022-12/31/2022 $98.00 $40.96 $55.86 $72.03 $72.03 200% of Medicare 100% of Medicare $57.63 $55.48 $54.03 $40.96 100% of Medicaid 100% of Medicare 150% of Medicare $78.40 $98.00 195% of Medicare $79.38 $57.33 $57.33 $46.26 $63.05 100% of Medicare $78.40 $83.30 $76.93 $71.53 $78.40 $83.30 $67.38 100% of Medicare 100% of Medicare $73.50 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Atazanavir 300 mg Cap 00093-55285-6 INSTITUTIONAL $123.00 1/1/2022-12/31/2022 $123.00 $58.06 $70.11 $90.41 $90.41 200% of Medicare 100% of Medicare $73.65 $70.90 $69.04 $78.72 100% of Medicaid 100% of Medicare 150% of Medicare $98.40 $123.00 195% of Medicare $99.63 $73.19 $73.19 $58.06 $123.00 100% of Medicare $98.40 $104.55 $110.70 $89.78 $104.55 $123.00 $123.00 100% of Medicare 100% of Medicare $123.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001581 001581 NULL INSTITUTIONAL $574.00 1/1/2022-12/31/2022 $574.00 $270.93 $327.18 $421.89 $421.89 200% of Medicare 100% of Medicare $343.71 $330.85 $322.19 $367.36 100% of Medicaid 100% of Medicare 150% of Medicare $459.20 $574.00 195% of Medicare $464.94 $341.53 $341.53 $270.93 $574.00 100% of Medicare $459.20 $487.90 $516.60 $418.96 $487.90 $574.00 $574.00 100% of Medicare 100% of Medicare $574.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001557 001557 NULL INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 200% of Medicare 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001580 001580 NULL INSTITUTIONAL $574.00 1/1/2022-12/31/2022 $574.00 $270.93 $327.18 $421.89 $421.89 200% of Medicare 100% of Medicare $343.71 $330.85 $322.19 $367.36 100% of Medicaid 100% of Medicare 150% of Medicare $459.20 $574.00 195% of Medicare $464.94 $341.53 $341.53 $270.93 $574.00 100% of Medicare $459.20 $487.90 $516.60 $418.96 $487.90 $574.00 $574.00 100% of Medicare 100% of Medicare $574.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Summers Eve Douche 1 EA Soln 41608-0087-47 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 200% of Medicare 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL emtricitabine-tenofovir 200 mg-25 61958-2002-01 INSTITUTIONAL $264.00 1/1/2022-12/31/2022 $264.00 $124.61 $150.48 $194.04 $194.04 200% of Medicare 100% of Medicare $158.08 $152.17 $148.18 $168.96 100% of Medicaid 100% of Medicare 150% of Medicare $211.20 $264.00 195% of Medicare $213.84 $157.08 $157.08 $124.61 $264.00 100% of Medicare $211.20 $224.40 $237.60 $192.69 $224.40 $264.00 $264.00 100% of Medicare 100% of Medicare $264.00 200% of Medicare NULL 300 NULL 82088 NULL NULL 49802266 Aldosterone Urine Timed NULL INSTITUTIONAL $249.00 1/1/2022-12/31/2022 $249.00 $104.08 $141.93 $183.02 $183.02 200% of Medicare 100% of Medicare $146.44 $140.96 $137.27 $104.08 100% of Medicaid 100% of Medicare 150% of Medicare $199.20 $249.00 195% of Medicare $201.69 $145.67 $145.67 $117.53 $160.21 100% of Medicare $199.20 $211.65 $195.47 $181.75 $199.20 $211.65 $171.19 100% of Medicare 100% of Medicare $186.75 200% of Medicare NULL 300 NULL 82626 NULL NULL 49802267 Dehydroepiandrosterone by TMS NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 200% of Medicare 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 300 NULL 83605 NULL NULL 49802268 Lactate Arterial Pl QN NULL INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $27.59 $37.62 $48.51 $48.51 200% of Medicare 100% of Medicare $38.81 $37.36 $36.39 $27.59 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $38.61 $38.61 $31.15 $42.46 100% of Medicare $52.80 $56.10 $51.81 $48.17 $52.80 $56.10 $45.38 100% of Medicare 100% of Medicare $49.50 200% of Medicare NULL 300 NULL 84445 NULL NULL 49802285 Thyroid Stimulating Immunoglobulin NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $17.14 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.11 $23.21 $22.60 $17.14 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $23.99 $23.99 $19.35 $26.38 100% of Medicare $32.80 $34.85 $32.19 $29.93 $32.80 $34.85 $28.19 100% of Medicare 100% of Medicare $30.75 200% of Medicare NULL 300 NULL 84146 NULL NULL 49802286 Prolactin SerPl QN 3rd IS NULL INSTITUTIONAL $119.00 1/1/2022-12/31/2022 $119.00 $49.74 $67.83 $87.47 $87.47 200% of Medicare 100% of Medicare $69.98 $67.37 $65.60 $49.74 100% of Medicaid 100% of Medicare 150% of Medicare $95.20 $119.00 195% of Medicare $96.39 $69.62 $69.62 $56.17 $76.56 100% of Medicare $95.20 $101.15 $93.42 $86.86 $95.20 $101.15 $81.81 100% of Medicare 100% of Medicare $89.25 200% of Medicare NULL 300 NULL 83001 NULL NULL 49802287 Follicle Stimulating Hormone NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $47.23 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $66.46 $63.97 $62.30 $47.23 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $66.11 $66.11 $53.34 $72.70 100% of Medicare $90.40 $96.05 $88.71 $82.48 $90.40 $96.05 $77.69 100% of Medicare 100% of Medicare $84.75 200% of Medicare NULL 300 NULL 83002 NULL NULL 49802358 Luteinizing Hormone SerPl QN 2nd IS NULL INSTITUTIONAL $113.00 1/1/2022-12/31/2022 $113.00 $47.23 $64.41 $83.06 $83.06 200% of Medicare 100% of Medicare $66.46 $63.97 $62.30 $47.23 100% of Medicaid 100% of Medicare 150% of Medicare $90.40 $113.00 195% of Medicare $91.53 $66.11 $66.11 $53.34 $72.70 100% of Medicare $90.40 $96.05 $88.71 $82.48 $90.40 $96.05 $77.69 100% of Medicare 100% of Medicare $84.75 200% of Medicare NULL 300 NULL 84305 NULL NULL 49802362 IGF-1 Ser QN NULL INSTITUTIONAL $118.00 1/1/2022-12/31/2022 $118.00 $49.32 $67.26 $86.73 $86.73 200% of Medicare 100% of Medicare $69.40 $66.80 $65.05 $49.32 100% of Medicaid 100% of Medicare 150% of Medicare $94.40 $118.00 195% of Medicare $95.58 $69.03 $69.03 $55.70 $75.92 100% of Medicare $94.40 $100.30 $92.63 $86.13 $94.40 $100.30 $81.13 100% of Medicare 100% of Medicare $88.50 200% of Medicare NULL 250 NULL NULL NULL NULL NULL VITAHP 070074-630816 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110038 NULL NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110044 NULL NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110042 NULL NULL INSTITUTIONAL $126.00 1/1/2022-12/31/2022 $126.00 $59.47 $71.82 $92.61 $92.61 200% of Medicare 100% of Medicare $75.45 $72.63 $70.72 $80.64 100% of Medicaid 100% of Medicare 150% of Medicare $100.80 $126.00 195% of Medicare $102.06 $74.97 $74.97 $59.47 $126.00 100% of Medicare $100.80 $107.10 $113.40 $91.97 $107.10 $126.00 $126.00 100% of Medicare 100% of Medicare $126.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110045 NULL NULL INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 200% of Medicare 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 272 NULL NULL NULL NULL 117310 NULL NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110049 NULL NULL INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 200% of Medicare 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110043 NULL NULL INSTITUTIONAL $336.00 1/1/2022-12/31/2022 $336.00 $158.59 $191.52 $246.96 $246.96 200% of Medicare 100% of Medicare $201.20 $193.67 $188.60 $215.04 100% of Medicaid 100% of Medicare 150% of Medicare $268.80 $336.00 195% of Medicare $272.16 $199.92 $199.92 $158.59 $336.00 100% of Medicare $268.80 $285.60 $302.40 $245.25 $285.60 $336.00 $336.00 100% of Medicare 100% of Medicare $336.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110041 NULL NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 200% of Medicare 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110046 NULL NULL INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 410 NULL 94660 NULL NULL 410027 Heated & Humidified High Flow NULL INSTITUTIONAL $670.00 1/1/2022-12/31/2022 $670.00 $280.06 $381.90 $492.45 $492.45 200% of Medicare 100% of Medicare $394.03 $379.29 $369.37 $280.06 100% of Medicaid 100% of Medicare 150% of Medicare $536.00 $670.00 195% of Medicare $542.70 $391.95 $391.95 $316.24 $431.08 100% of Medicare $536.00 $569.50 $525.95 $489.03 $536.00 $569.50 $460.63 100% of Medicare 100% of Medicare $502.50 200% of Medicare NULL 300 NULL 85610 NULL NULL 14007335 PT/INR POC RT NULL INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $13.79 $18.81 $24.26 $24.26 200% of Medicare 100% of Medicare $19.41 $18.68 $18.19 $13.79 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.31 $19.31 $15.58 $21.23 100% of Medicare $26.40 $28.05 $25.91 $24.09 $26.40 $28.05 $22.69 100% of Medicare 100% of Medicare $24.75 200% of Medicare NULL 300 NULL 85014QW NULL NULL 14156644 iSTAT Chem8 POC RT NULL INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $5.43 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.65 $7.36 $7.17 $5.43 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.61 $7.61 $6.14 $8.36 100% of Medicare $10.40 $11.05 $10.21 $9.49 $10.40 $11.05 $8.94 100% of Medicare 100% of Medicare $9.75 200% of Medicare NULL 250 NULL NULL NULL NULL NULL buP100SR 43547-0288-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL lipD 62205-0000-20 INSTITUTIONAL $246.00 1/1/2022-12/31/2022 $246.00 $116.11 $140.22 $180.81 $180.81 200% of Medicare 100% of Medicare $147.30 $141.79 $138.08 $157.44 100% of Medicaid 100% of Medicare 150% of Medicare $196.80 $246.00 195% of Medicare $199.26 $146.37 $146.37 $116.11 $246.00 100% of Medicare $196.80 $209.10 $221.40 $179.56 $209.10 $246.00 $246.00 100% of Medicare 100% of Medicare $246.00 200% of Medicare NULL 250 NULL NULL NULL J0770 NULL col150P 39822-0617-02 INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $22.15 $30.21 $38.96 $38.96 200% of Medicare 100% of Medicare $31.17 $30.00 $29.22 $22.15 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.01 $31.01 $25.02 $34.10 100% of Medicare $42.40 $45.05 $41.61 $38.68 $42.40 $45.05 $36.44 100% of Medicare 100% of Medicare $39.75 200% of Medicare NULL 272 NULL NULL NULL NULL 118084 118084 NULL INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 200% of Medicare 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL J1953 NULL VIMP200I 30131-18106-79 INSTITUTIONAL $286.00 1/1/2022-12/31/2022 $286.00 $119.55 $163.02 $210.21 $210.21 200% of Medicare 100% of Medicare $168.20 $161.90 $157.67 $119.55 100% of Medicaid 100% of Medicare 150% of Medicare $228.80 $286.00 195% of Medicare $231.66 $167.31 $167.31 $134.99 $184.01 100% of Medicare $228.80 $243.10 $224.51 $208.75 $228.80 $243.10 $196.63 100% of Medicare 100% of Medicare $214.50 200% of Medicare NULL 272 NULL NULL NULL NULL 001587 "CATHETER, INTERMITNT, VAPRO, COUDE, 12FR, 16""" NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001586 BLADDER IRRIGATION SET NULL INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL PROLO 99999-9980-99 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 200% of Medicare 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL INCR625 30173-08730-64 INSTITUTIONAL $221.00 1/1/2022-12/31/2022 $221.00 $104.31 $125.97 $162.44 $162.44 200% of Medicare 100% of Medicare $132.33 $127.38 $124.05 $141.44 100% of Medicaid 100% of Medicare 150% of Medicare $176.80 $221.00 195% of Medicare $179.01 $131.50 $131.50 $104.31 $221.00 100% of Medicare $176.80 $187.85 $198.90 $161.31 $187.85 $221.00 $221.00 100% of Medicare 100% of Medicare $221.00 200% of Medicare NULL 300 NULL 87799 NULL NULL 14007273 BK Virus QN NULL INSTITUTIONAL $245.00 1/1/2022-12/31/2022 $245.00 $102.41 $139.65 $180.08 $180.08 200% of Medicare 100% of Medicare $144.08 $138.69 $135.07 $102.41 100% of Medicaid 100% of Medicare 150% of Medicare $196.00 $245.00 195% of Medicare $198.45 $143.33 $143.33 $115.64 $157.63 100% of Medicare $196.00 $208.25 $192.33 $178.83 $196.00 $208.25 $168.44 100% of Medicare 100% of Medicare $183.75 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ENTR24 00078-06592-0 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999014 ABT SCI Well 1 Session NULL INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 200% of Medicare 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999015 ABT SCI Well 12 Session NULL INSTITUTIONAL $377.00 1/1/2022-12/31/2022 $377.00 $177.94 $214.89 $277.10 $277.10 200% of Medicare 100% of Medicare $225.75 $217.30 $211.61 $241.28 100% of Medicaid 100% of Medicare 150% of Medicare $301.60 $377.00 195% of Medicare $305.37 $224.32 $224.32 $177.94 $377.00 100% of Medicare $301.60 $320.45 $339.30 $275.17 $320.45 $377.00 $377.00 100% of Medicare 100% of Medicare $377.00 200% of Medicare NULL 310 NULL 84145 NULL NULL 14186892 Procalcitonin EIA Qn NULL INSTITUTIONAL $142.00 1/1/2022-12/31/2022 $142.00 $59.36 $80.94 $104.37 $104.37 200% of Medicare 100% of Medicare $83.51 $80.39 $78.28 $59.36 100% of Medicaid 100% of Medicare 150% of Medicare $113.60 $142.00 195% of Medicare $115.02 $83.07 $83.07 $67.02 $91.36 100% of Medicare $113.60 $120.70 $111.47 $103.65 $113.60 $120.70 $97.63 100% of Medicare 100% of Medicare $106.50 200% of Medicare NULL 272 NULL NULL NULL NULL 001591 001591 NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 200% of Medicare 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 300 NULL 85384 NULL NULL 14007274 Fibrinogen NULL INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $20.06 $27.36 $35.28 $35.28 200% of Medicare 100% of Medicare $28.23 $27.17 $26.46 $20.06 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.08 $28.08 $22.66 $30.88 100% of Medicare $38.40 $40.80 $37.68 $35.04 $38.40 $40.80 $33.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 300 NULL 86316 NULL NULL 14007275 Chromogranin A Ser QN NULL INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 300 NULL 87324 NULL NULL 14007334 C diff Assay QL NULL INSTITUTIONAL $75.00 1/1/2022-12/31/2022 $75.00 $31.35 $42.75 $55.13 $55.13 200% of Medicare 100% of Medicare $44.11 $42.46 $41.35 $31.35 100% of Medicaid 100% of Medicare 150% of Medicare $60.00 $75.00 195% of Medicare $60.75 $43.88 $43.88 $35.40 $48.26 100% of Medicare $60.00 $63.75 $58.88 $54.74 $60.00 $63.75 $51.56 100% of Medicare 100% of Medicare $56.25 200% of Medicare NULL 300 NULL 87449 NULL NULL 14007333 C difficile Testing Algorithm NULL INSTITUTIONAL $75.00 1/1/2022-12/31/2022 $75.00 $31.35 $42.75 $55.13 $55.13 200% of Medicare 100% of Medicare $44.11 $42.46 $41.35 $31.35 100% of Medicaid 100% of Medicare 150% of Medicare $60.00 $75.00 195% of Medicare $60.75 $43.88 $43.88 $35.40 $48.26 100% of Medicare $60.00 $63.75 $58.88 $54.74 $60.00 $63.75 $51.56 100% of Medicare 100% of Medicare $56.25 200% of Medicare NULL 300 NULL 87799 NULL NULL 14007276 Intrinsic Factor Blocking Ab NULL INSTITUTIONAL $233.00 1/1/2022-12/31/2022 $233.00 $97.39 $132.81 $171.26 $171.26 200% of Medicare 100% of Medicare $137.03 $131.90 $128.45 $97.39 100% of Medicaid 100% of Medicare 150% of Medicare $186.40 $233.00 195% of Medicare $188.73 $136.31 $136.31 $109.98 $149.91 100% of Medicare $186.40 $198.05 $182.91 $170.07 $186.40 $198.05 $160.19 100% of Medicare 100% of Medicare $174.75 200% of Medicare NULL 301 NULL 85290 NULL NULL 49992632 Factor XIII Activity NULL INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $37.20 $50.73 $65.42 $65.42 200% of Medicare 100% of Medicare $52.34 $50.38 $49.07 $37.20 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.07 $52.07 $42.01 $57.26 100% of Medicare $71.20 $75.65 $69.87 $64.96 $71.20 $75.65 $61.19 100% of Medicare 100% of Medicare $66.75 200% of Medicare NULL 301 NULL 83605 NULL NULL 49948273 Lactate Venous Pl Qn NULL INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $24.66 $33.63 $43.37 $43.37 200% of Medicare 100% of Medicare $34.70 $33.40 $32.53 $24.66 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $34.52 $34.52 $27.85 $37.96 100% of Medicare $47.20 $50.15 $46.32 $43.06 $47.20 $50.15 $40.56 100% of Medicare 100% of Medicare $44.25 200% of Medicare NULL 999 NULL NULL NULL NULL 999030 Love your Brain 6 Session NULL INSTITUTIONAL $169.00 1/1/2022-12/31/2022 $169.00 $79.77 $96.33 $124.22 $124.22 200% of Medicare 100% of Medicare $101.20 $97.41 $94.86 $108.16 100% of Medicaid 100% of Medicare 150% of Medicare $135.20 $169.00 195% of Medicare $136.89 $100.56 $100.56 $79.77 $169.00 100% of Medicare $135.20 $143.65 $152.10 $123.35 $143.65 $169.00 $169.00 100% of Medicare 100% of Medicare $169.00 200% of Medicare NULL 300 NULL 81002 NULL NULL 14156618 "Dipstick UA Manuali, POC" NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $6.27 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.82 $8.49 $8.27 $6.27 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.78 $8.78 $7.08 $9.65 100% of Medicare $12.00 $12.75 $11.78 $10.95 $12.00 $12.75 $10.31 100% of Medicare 100% of Medicare $11.25 200% of Medicare NULL 999 NULL NULL NULL NULL 999028 Neuropsych Eval NULL INSTITUTIONAL " $1,856.00 " 1/1/2022-12/31/2022 " $1,856.00 " $876.03 " $1,057.92 " " $1,364.16 " " $1,364.16 " 200% of Medicare 100% of Medicare " $1,111.37 " " $1,069.80 " " $1,041.77 " " $1,187.84 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,484.80 " " $1,500.00 " 195% of Medicare " $1,503.36 " " $1,104.32 " " $1,104.32 " $876.03 " $1,359.00 " 100% of Medicare " $1,484.80 " " $1,577.60 " " $1,670.40 " " $1,354.69 " " $1,577.60 " " $1,500.00 " " $1,856.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ALOG25 34580-21506-53 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 200% of Medicare 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 300 NULL 81002 NULL NULL 14156618 UA Dipstick POC NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $6.27 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.82 $8.49 $8.27 $6.27 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.78 $8.78 $7.08 $9.65 100% of Medicare $12.00 $12.75 $11.78 $10.95 $12.00 $12.75 $10.31 100% of Medicare 100% of Medicare $11.25 200% of Medicare NULL 300 NULL 81002 NULL NULL 14156618 UA Dipstick NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $6.27 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.82 $8.49 $8.27 $6.27 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.78 $8.78 $7.08 $9.65 100% of Medicare $12.00 $12.75 $11.78 $10.95 $12.00 $12.75 $10.31 100% of Medicare 100% of Medicare $11.25 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Sele200 40985-02115-4 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 200% of Medicare 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL GLUT15 00574-00693-0 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL alo6.25T 45802-0087-65 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 310 NULL 86780 NULL NULL 14186889 Syphilis Treponemal Total (IgM/IgG) NULL INSTITUTIONAL $326.00 1/1/2022-12/31/2022 $326.00 $136.27 $185.82 $239.61 $239.61 200% of Medicare 100% of Medicare $191.72 $184.55 $179.72 $136.27 100% of Medicaid 100% of Medicare 150% of Medicare $260.80 $326.00 195% of Medicare $264.06 $190.71 $190.71 $153.87 $209.75 100% of Medicare $260.80 $277.10 $255.91 $237.95 $260.80 $277.10 $224.13 100% of Medicare 100% of Medicare $244.50 200% of Medicare NULL 300 NULL 80299 NULL NULL 14156626 Keppra (Levetiracetam) Level NULL INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $46.82 $63.84 $82.32 $82.32 200% of Medicare 100% of Medicare $65.87 $63.40 $61.75 $46.82 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $65.52 $65.52 $52.86 $72.06 100% of Medicare $89.60 $95.20 $87.92 $81.75 $89.60 $95.20 $77.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL Copp2 27434-0010-17 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 200% of Medicare 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 310 NULL 82533 NULL NULL 14186873 ACTH 1 HR Stimulation Ser QN NULL INSTITUTIONAL $267.00 1/1/2022-12/31/2022 $267.00 $111.61 $152.19 $196.25 $196.25 200% of Medicare 100% of Medicare $157.02 $151.15 $147.20 $111.61 100% of Medicaid 100% of Medicare 150% of Medicare $213.60 $267.00 195% of Medicare $216.27 $156.20 $156.20 $126.02 $171.79 100% of Medicare $213.60 $226.95 $209.60 $194.88 $213.60 $226.95 $183.56 100% of Medicare 100% of Medicare $200.25 200% of Medicare NULL 310 NULL 86255 NULL NULL 14186874 "Aquaporin-4 Receptor AB, S" NULL INSTITUTIONAL $290.00 1/1/2022-12/31/2022 $290.00 $121.22 $165.30 $213.15 $213.15 200% of Medicare 100% of Medicare $170.55 $164.17 $159.88 $121.22 100% of Medicaid 100% of Medicare 150% of Medicare $232.00 $290.00 195% of Medicare $234.90 $169.65 $169.65 $136.88 $186.59 100% of Medicare $232.00 $246.50 $227.65 $211.67 $232.00 $246.50 $199.38 100% of Medicare 100% of Medicare $217.50 200% of Medicare NULL 310 NULL 81241 NULL NULL 14186875 F-V DNA Leiden Bld PCR NULL INSTITUTIONAL $330.00 1/1/2022-12/31/2022 $330.00 $137.94 $188.10 $242.55 $242.55 200% of Medicare 100% of Medicare $194.07 $186.81 $181.93 $137.94 100% of Medicaid 100% of Medicare 150% of Medicare $264.00 $330.00 195% of Medicare $267.30 $193.05 $193.05 $155.76 $212.32 100% of Medicare $264.00 $280.50 $259.05 $240.87 $264.00 $280.50 $226.88 100% of Medicare 100% of Medicare $247.50 200% of Medicare NULL 310 NULL 84478 NULL NULL 14186876 Triglyceride SerPl QN NULL INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $13.38 $18.24 $23.52 $23.52 200% of Medicare 100% of Medicare $18.82 $18.12 $17.64 $13.38 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $18.72 $18.72 $15.10 $20.59 100% of Medicare $25.60 $27.20 $25.12 $23.36 $25.60 $27.20 $22.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999070 Staff Yoga 1 Class NULL INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 200% of Medicare 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999071 Staff Yoga Monthly pkg NULL INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999072 30 Min Swedish Massage NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999073 60 Min Swedish Massage NULL INSTITUTIONAL $65.00 1/1/2022-12/31/2022 $65.00 $30.68 $37.05 $47.78 $47.78 200% of Medicare 100% of Medicare $38.92 $37.47 $36.48 $41.60 100% of Medicaid 100% of Medicare 150% of Medicare $52.00 $65.00 195% of Medicare $52.65 $38.68 $38.68 $30.68 $65.00 100% of Medicare $52.00 $55.25 $58.50 $47.44 $55.25 $65.00 $65.00 100% of Medicare 100% of Medicare $65.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999074 70 Min Deep tissue massage NULL INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $37.76 $45.60 $58.80 $58.80 200% of Medicare 100% of Medicare $47.90 $46.11 $44.90 $51.20 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $47.60 $47.60 $37.76 $80.00 100% of Medicare $64.00 $68.00 $72.00 $58.39 $68.00 $80.00 $80.00 100% of Medicare 100% of Medicare $80.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999075 Sinus/Migraine release NULL INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 200% of Medicare 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999080 HIT - 1 Session NULL INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 200% of Medicare 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999081 HIT - 2x per week/1 Month NULL INSTITUTIONAL $280.00 1/1/2022-12/31/2022 $280.00 $132.16 $159.60 $205.80 $205.80 200% of Medicare 100% of Medicare $167.66 $161.39 $157.16 $179.20 100% of Medicaid 100% of Medicare 150% of Medicare $224.00 $280.00 195% of Medicare $226.80 $166.60 $166.60 $132.16 $280.00 100% of Medicare $224.00 $238.00 $252.00 $204.37 $238.00 $280.00 $280.00 100% of Medicare 100% of Medicare $280.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999082 HIT - 3x per week/1 Month NULL INSTITUTIONAL $440.00 1/1/2022-12/31/2022 $440.00 $207.68 $250.80 $323.40 $323.40 200% of Medicare 100% of Medicare $263.47 $253.62 $246.97 $281.60 100% of Medicaid 100% of Medicare 150% of Medicare $352.00 $440.00 195% of Medicare $356.40 $261.80 $261.80 $207.68 $440.00 100% of Medicare $352.00 $374.00 $396.00 $321.16 $374.00 $440.00 $440.00 100% of Medicare 100% of Medicare $440.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999076 Chair Massage per 15 minutes NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999077 Reality break per 15 minutes NULL INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 310 NULL 83519 NULL NULL 14186881 Parathyroid Hormone-Related Peptide. NULL INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $32.60 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $45.87 $44.16 $43.00 $32.60 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $45.63 $45.63 $36.82 $50.19 100% of Medicare $62.40 $66.30 $61.23 $56.93 $62.40 $66.30 $53.63 100% of Medicare 100% of Medicare $58.50 200% of Medicare NULL 272 NULL NULL NULL NULL 001602 VAC Veralink Cassette NULL INSTITUTIONAL $746.00 1/1/2022-12/31/2022 $746.00 $352.11 $425.22 $548.31 $548.31 200% of Medicare 100% of Medicare $446.70 $429.99 $418.73 $477.44 100% of Medicaid 100% of Medicare 150% of Medicare $596.80 $746.00 195% of Medicare $604.26 $443.87 $443.87 $352.11 $746.00 100% of Medicare $596.80 $634.10 $671.40 $544.51 $634.10 $746.00 $746.00 100% of Medicare 100% of Medicare $746.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110050 110050 NULL INSTITUTIONAL $272.00 1/1/2022-12/31/2022 $272.00 $128.38 $155.04 $199.92 $199.92 200% of Medicare 100% of Medicare $162.87 $156.78 $152.67 $174.08 100% of Medicaid 100% of Medicare 150% of Medicare $217.60 $272.00 195% of Medicare $220.32 $161.84 $161.84 $128.38 $272.00 100% of Medicare $217.60 $231.20 $244.80 $198.53 $231.20 $272.00 $272.00 100% of Medicare 100% of Medicare $272.00 200% of Medicare NULL 310 NULL 86832 NULL NULL 141868777 "HLA LUMINEX HD ABID, CL 1" NULL INSTITUTIONAL " $1,369.00 " 1/1/2022-12/31/2022 " $1,369.00 " $572.24 $780.33 " $1,006.22 " " $1,006.22 " 200% of Medicare 100% of Medicare $805.11 $774.99 $754.73 $572.24 100% of Medicaid 100% of Medicare 150% of Medicare " $1,095.20 " " $1,369.00 " 195% of Medicare " $1,108.89 " $800.87 $800.87 $646.17 $880.81 100% of Medicare " $1,095.20 " " $1,163.65 " " $1,074.67 " $999.23 " $1,095.20 " " $1,163.65 " $941.19 100% of Medicare 100% of Medicare " $1,026.75 " 200% of Medicare NULL 310 NULL 86833 NULL NULL 141868779 "HLA LUMINEX HD ABID, CL 2" NULL INSTITUTIONAL " $1,378.00 " 1/1/2022-12/31/2022 " $1,378.00 " $576.00 $785.46 " $1,012.83 " " $1,012.83 " 200% of Medicare 100% of Medicare $810.40 $780.09 $759.69 $576.00 100% of Medicaid 100% of Medicare 150% of Medicare " $1,102.40 " " $1,378.00 " 195% of Medicare " $1,116.18 " $806.13 $806.13 $650.42 $886.61 100% of Medicare " $1,102.40 " " $1,171.30 " " $1,081.73 " " $1,005.80 " " $1,102.40 " " $1,171.30 " $947.38 100% of Medicare 100% of Medicare " $1,033.50 " 200% of Medicare NULL 310 NULL 86832 NULL NULL 141868777 FSI DTA NULL INSTITUTIONAL " $1,369.00 " 1/1/2022-12/31/2022 " $1,369.00 " $572.24 $780.33 " $1,006.22 " " $1,006.22 " 200% of Medicare 100% of Medicare $805.11 $774.99 $754.73 $572.24 100% of Medicaid 100% of Medicare 150% of Medicare " $1,095.20 " " $1,369.00 " 195% of Medicare " $1,108.89 " $800.87 $800.87 $646.17 $880.81 100% of Medicare " $1,095.20 " " $1,163.65 " " $1,074.67 " $999.23 " $1,095.20 " " $1,163.65 " $941.19 100% of Medicare 100% of Medicare " $1,026.75 " 200% of Medicare NULL 310 NULL 86833 NULL NULL 141868779 FSI DTA NULL INSTITUTIONAL " $1,378.00 " 1/1/2022-12/31/2022 " $1,378.00 " $576.00 $785.46 " $1,012.83 " " $1,012.83 " 200% of Medicare 100% of Medicare $810.40 $780.09 $759.69 $576.00 100% of Medicaid 100% of Medicare 150% of Medicare " $1,102.40 " " $1,378.00 " 195% of Medicare " $1,116.18 " $806.13 $806.13 $650.42 $886.61 100% of Medicare " $1,102.40 " " $1,171.30 " " $1,081.73 " " $1,005.80 " " $1,102.40 " " $1,171.30 " $947.38 100% of Medicare 100% of Medicare " $1,033.50 " 200% of Medicare NULL 310 NULL 86832 NULL NULL 141868778 HLA CLASS I HIGH DEFIN QUAL NULL INSTITUTIONAL " $1,369.00 " 1/1/2022-12/31/2022 " $1,369.00 " $572.24 $780.33 " $1,006.22 " " $1,006.22 " 200% of Medicare 100% of Medicare $805.11 $774.99 $754.73 $572.24 100% of Medicaid 100% of Medicare 150% of Medicare " $1,095.20 " " $1,369.00 " 195% of Medicare " $1,108.89 " $800.87 $800.87 $646.17 $880.81 100% of Medicare " $1,095.20 " " $1,163.65 " " $1,074.67 " $999.23 " $1,095.20 " " $1,163.65 " $941.19 100% of Medicare 100% of Medicare " $1,026.75 " 200% of Medicare NULL 310 NULL 86833 NULL NULL 141868779 HLA CLASS II HIGH DEFIN QUAL NULL INSTITUTIONAL " $1,378.00 " 1/1/2022-12/31/2022 " $1,378.00 " $576.00 $785.46 " $1,012.83 " " $1,012.83 " 200% of Medicare 100% of Medicare $810.40 $780.09 $759.69 $576.00 100% of Medicaid 100% of Medicare 150% of Medicare " $1,102.40 " " $1,378.00 " 195% of Medicare " $1,116.18 " $806.13 $806.13 $650.42 $886.61 100% of Medicare " $1,102.40 " " $1,171.30 " " $1,081.73 " " $1,005.80 " " $1,102.40 " " $1,171.30 " $947.38 100% of Medicare 100% of Medicare " $1,033.50 " 200% of Medicare NULL 250 NULL NULL NULL NULL NULL COCOB 10181-0041-65 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 200% of Medicare 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 310 NULL 86256 NULL NULL 14186880 Mitochondrl Antibody IF Quantitative NULL INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $27.59 $37.62 $48.51 $48.51 200% of Medicare 100% of Medicare $38.81 $37.36 $36.39 $27.59 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $38.61 $38.61 $31.15 $42.46 100% of Medicare $52.80 $56.10 $51.81 $48.17 $52.80 $56.10 $45.38 100% of Medicare 100% of Medicare $49.50 200% of Medicare NULL 430 NULL 97018 GO NULL 430018 OT Paraffin Bath Assistant Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL NULL NULL NULL GO NULL NULL "OT Whirlpool, Fluidotherapy Assist Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $313.41 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $397.60 $382.73 $372.70 $424.96 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $395.08 $395.08 $313.41 $664.00 100% of Medicare $531.20 $564.40 $597.60 $484.65 $564.40 $664.00 $664.00 100% of Medicare 100% of Medicare $664.00 200% of Medicare NULL 430 NULL 97150 GO NULL 433001 OT Group Therapy Assistant Units NULL INSTITUTIONAL $566.00 1/1/2022-12/31/2022 $566.00 $236.59 $322.62 $416.01 $416.01 200% of Medicare 100% of Medicare $332.86 $320.41 $312.04 $236.59 100% of Medicaid 100% of Medicare 150% of Medicare $452.80 $566.00 195% of Medicare $458.46 $331.11 $331.11 $267.15 $364.16 100% of Medicare $452.80 $481.10 $444.31 $413.12 $452.80 $481.10 $389.13 100% of Medicare 100% of Medicare $424.50 200% of Medicare NULL 430 NULL 97026 CO NULL NULL OT Infrared Assistant Units NULL INSTITUTIONAL $643.00 1/1/2022-12/31/2022 $643.00 $268.77 $366.51 $472.61 $472.61 200% of Medicare 100% of Medicare $378.15 $364.00 $354.49 $268.77 100% of Medicaid 100% of Medicare 150% of Medicare $514.40 $643.00 195% of Medicare $520.83 $376.16 $376.16 $303.50 $413.71 100% of Medicare $514.40 $546.55 $504.76 $469.33 $514.40 $546.55 $442.06 100% of Medicare 100% of Medicare $482.25 200% of Medicare NULL 430 NULL 97032 GO NULL 430020 OT Attended E-Stim Assistant Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 430 NULL 97033 GO NULL 430021 OT Iontophoresis Assistant Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 430 NULL 97034 GO NULL 430022 OT Contrast Bath Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97035 GO NULL 430023 OT Ultrasound Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97110 CO NULL 430005 OT Therapeutic Exercise Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97112 GO NULL 430006 OT Neuromuscular Reeducation Assist Unit NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97124 GO NULL 430024 OT Massage Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97140 GO NULL 430025 OT Manual Therapy Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97530 GO NULL 430026 OT Therapeutic Activities Assist Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97535 GO NULL 430010 "OT Self Care, Home Mgmt Assistant Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97537 GO NULL 430011 "OT Comm, Work Reintegration Assist Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97542 GO NULL 430012 OT Wheelchair Management Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97545 GO NULL 430027 OT Work Harden-Initial 2 Hr Assist Units NULL INSTITUTIONAL $731.00 1/1/2022-12/31/2022 $731.00 $305.56 $416.67 $537.29 $537.29 200% of Medicare 100% of Medicare $429.90 $413.82 $403.00 $305.56 100% of Medicaid 100% of Medicare 150% of Medicare $584.80 $731.00 195% of Medicare $592.11 $427.64 $427.64 $345.03 $470.33 100% of Medicare $584.80 $621.35 $573.84 $533.56 $584.80 $621.35 $502.56 100% of Medicare 100% of Medicare $548.25 200% of Medicare NULL 430 NULL 97546 GO NULL 430028 OT Work Harden-Each Addl Hr Assist Units NULL INSTITUTIONAL $365.00 1/1/2022-12/31/2022 $365.00 $152.57 $208.05 $268.28 $268.28 200% of Medicare 100% of Medicare $214.66 $206.63 $201.22 $152.57 100% of Medicaid 100% of Medicare 150% of Medicare $292.00 $365.00 195% of Medicare $295.65 $213.53 $213.53 $172.28 $234.84 100% of Medicare $292.00 $310.25 $286.53 $266.41 $292.00 $310.25 $250.94 100% of Medicare 100% of Medicare $273.75 200% of Medicare NULL 420 NULL 97012 GP NULL 420018 PT Mechanical Traction Assistant Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 97016 GP NULL 420019 PT Vasopneumatic Devices Assistant Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 97018 GP NULL 420020 PT Paraffin Assistant Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 430 NULL 97022 GP NULL 420021 "PT Whirlpool, Fluidotherapy Assist Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 420 NULL 90901 GP NULL 420012 PT Biofeedback Assistant Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 423 NULL 97150 GP NULL 423001 PT Group Therapy Assistant Units NULL INSTITUTIONAL $566.00 1/1/2022-12/31/2022 $566.00 $236.59 $322.62 $416.01 $416.01 200% of Medicare 100% of Medicare $332.86 $320.41 $312.04 $236.59 100% of Medicaid 100% of Medicare 150% of Medicare $452.80 $566.00 195% of Medicare $458.46 $331.11 $331.11 $267.15 $364.16 100% of Medicare $452.80 $481.10 $444.31 $413.12 $452.80 $481.10 $389.13 100% of Medicare 100% of Medicare $424.50 200% of Medicare NULL 420 NULL 97032 GP NULL 420022 PT Attended E-Stim Assistant Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 420 NULL 97033 GP NULL 420023 PT Iontophoresis Assistant Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 420 NULL 97034 GP NULL 420024 PT Contrast Bath Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97035 GP NULL 420025 PT Ultrasound Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97110 GP NULL 420026 PT Therapeutic Exercise Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97750 GP NULL 420037 PT Physical Performance Assistant Test NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97113 GP NULL 420028 PT Aquatic Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97116 GP NULL 420029 PT Gait Training Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97124 GP NULL 420030 PT Massage Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97140 GP NULL 420031 PT Manual Therapy Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97530 GP NULL 420032 PT Therapeutic Activity Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97112 GP NULL 420027 PT Neuromuscular Reeducation Assist Unit NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97535 GP NULL 420043 "PT Self Care, Home Mgmt Assistant Units" NULL INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $84.02 $114.57 $147.74 $147.74 200% of Medicare 100% of Medicare $118.21 $113.79 $110.81 $84.02 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $117.59 $117.59 $94.87 $129.32 100% of Medicare $160.80 $170.85 $157.79 $146.71 $160.80 $170.85 $138.19 100% of Medicare 100% of Medicare $150.75 200% of Medicare NULL 420 NULL 97542 GP NULL 420034 PT Wheelchair Management Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97545 GP NULL 420035 PT Work Harden Initial 2 Hrs Assist Unit NULL INSTITUTIONAL $731.00 1/1/2022-12/31/2022 $731.00 $305.56 $416.67 $537.29 $537.29 200% of Medicare 100% of Medicare $429.90 $413.82 $403.00 $305.56 100% of Medicaid 100% of Medicare 150% of Medicare $584.80 $731.00 195% of Medicare $592.11 $427.64 $427.64 $345.03 $470.33 100% of Medicare $584.80 $621.35 $573.84 $533.56 $584.80 $621.35 $502.56 100% of Medicare 100% of Medicare $548.25 200% of Medicare NULL 420 NULL 97546 GP NULL 420036 PT Work Harden-Each Addl Hr Assist Units NULL INSTITUTIONAL $365.00 1/1/2022-12/31/2022 $365.00 $152.57 $208.05 $268.28 $268.28 200% of Medicare 100% of Medicare $214.66 $206.63 $201.22 $152.57 100% of Medicaid 100% of Medicare 150% of Medicare $292.00 $365.00 195% of Medicare $295.65 $213.53 $213.53 $172.28 $234.84 100% of Medicare $292.00 $310.25 $286.53 $266.41 $292.00 $310.25 $250.94 100% of Medicare 100% of Medicare $273.75 200% of Medicare NULL 420 NULL 97760 GP NULL 420039 "PT Orthotic Mgmt, Train Assistant Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97761 GP NULL 420040 "PT Prosthetic Mgmt,Train Assistant Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97127 GP NULL 97127 PT Cognitive Function Assistant Units NULL INSTITUTIONAL $665.00 1/1/2022-12/31/2022 $665.00 $277.97 $379.05 $488.78 $488.78 200% of Medicare 100% of Medicare $391.09 $376.46 $366.61 $277.97 100% of Medicaid 100% of Medicare 150% of Medicare $532.00 $665.00 195% of Medicare $538.65 $389.03 $389.03 $313.88 $427.86 100% of Medicare $532.00 $565.25 $522.03 $485.38 $532.00 $565.25 $457.19 100% of Medicare 100% of Medicare $498.75 200% of Medicare NULL 420 NULL 97026 GP NULL 420042 PT Infrared Assistant Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 423 NULL 97150 GP NULL 420100 PT Double Therapy Assistant Units NULL INSTITUTIONAL " $1,107.00 " 1/1/2022-12/31/2022 " $1,107.00 " $462.73 $630.99 $813.65 $813.65 200% of Medicare 100% of Medicare $651.03 $626.67 $610.29 $462.73 100% of Medicaid 100% of Medicare 150% of Medicare $885.60 " $1,107.00 " 195% of Medicare $896.67 $647.60 $647.60 $522.50 $712.24 100% of Medicare $885.60 $940.95 $869.00 $808.00 $885.60 $940.95 $761.06 100% of Medicare 100% of Medicare $830.25 200% of Medicare NULL 430 NULL 97113 GO NULL 430100 OT Aquatic Exercise Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 420 NULL 97763 CO NULL NULL Ot Orthotic Mgmt/Train Establish Assistant Units NULL INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $67.30 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $94.68 $91.14 $88.76 $67.30 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $94.19 $94.19 $75.99 $103.59 100% of Medicare $128.80 $136.85 $126.39 $117.51 $128.80 $136.85 $110.69 100% of Medicare 100% of Medicare $120.75 200% of Medicare NULL 430 NULL 97032 CO NULL 430020 OT US/Estim Combo Assistant Units NULL INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $114.11 $155.61 $200.66 $200.66 200% of Medicare 100% of Medicare $160.55 $154.55 $150.50 $114.11 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $159.71 $159.71 $128.86 $175.65 100% of Medicare $218.40 $232.05 $214.31 $199.26 $218.40 $232.05 $187.69 100% of Medicare 100% of Medicare $204.75 200% of Medicare NULL 420 NULL 97035 CO NULL 430023 OT Phonophoresis Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 423 NULL G0515 GO NULL G0515 OT Cognitive Function Medicare Assistant Units NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97150 GO NULL 433001 OT Double Therapy Assistant Units NULL INSTITUTIONAL $566.00 1/1/2022-12/31/2022 $566.00 $236.59 $322.62 $416.01 $416.01 200% of Medicare 100% of Medicare $332.86 $320.41 $312.04 $236.59 100% of Medicaid 100% of Medicare 150% of Medicare $452.80 $566.00 195% of Medicare $458.46 $331.11 $331.11 $267.15 $364.16 100% of Medicare $452.80 $481.10 $444.31 $413.12 $452.80 $481.10 $389.13 100% of Medicare 100% of Medicare $424.50 200% of Medicare NULL 430 NULL 92526 GO NULL 440002 OT Swallow Dysfunction Assistant Units NULL INSTITUTIONAL $666.00 1/1/2022-12/31/2022 $666.00 $278.39 $379.62 $489.51 $489.51 200% of Medicare 100% of Medicare $391.67 $377.02 $367.17 $278.39 100% of Medicaid 100% of Medicare 150% of Medicare $532.80 $666.00 195% of Medicare $539.46 $389.61 $389.61 $314.35 $428.50 100% of Medicare $532.80 $566.10 $522.81 $486.11 $532.80 $566.10 $457.88 100% of Medicare 100% of Medicare $499.50 200% of Medicare NULL 430 NULL 97610 CO NULL NULL OT Non-Thermal/Contact Ultrasound Assistant Units NULL INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $67.30 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $94.68 $91.14 $88.76 $67.30 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $94.19 $94.19 $75.99 $103.59 100% of Medicare $128.80 $136.85 $126.39 $117.51 $128.80 $136.85 $110.69 100% of Medicare 100% of Medicare $120.75 200% of Medicare NULL 430 NULL 29581 CO NULL NULL OT Multi-Layer Compress Below Knee Assistant Units NULL INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $67.30 $91.77 $118.34 $118.34 200% of Medicare 100% of Medicare $94.68 $91.14 $88.76 $67.30 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $94.19 $94.19 $75.99 $103.59 100% of Medicare $128.80 $136.85 $126.39 $117.51 $128.80 $136.85 $110.69 100% of Medicare 100% of Medicare $120.75 200% of Medicare NULL 430 NULL 97127 GO NULL 97127 OT Cognitive Function Assistant Units NULL INSTITUTIONAL $665.00 1/1/2022-12/31/2022 $665.00 $277.97 $379.05 $488.78 $488.78 200% of Medicare 100% of Medicare $391.09 $376.46 $366.61 $277.97 100% of Medicaid 100% of Medicare 150% of Medicare $532.00 $665.00 195% of Medicare $538.65 $389.03 $389.03 $313.88 $427.86 100% of Medicare $532.00 $565.25 $522.03 $485.38 $532.00 $565.25 $457.19 100% of Medicare 100% of Medicare $498.75 200% of Medicare NULL 440 NULL 97129 GN NULL 440164 "SLP Cog Ther Intervent,First 15Min Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 440 NULL 97130 GN NULL 440165 "SLP Cog Ther Intervent, Addl 15Min Units" NULL INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL 430 NULL 97022 CO NULL 430019 OT Whirlpool Therapy Assitant Units NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $277.55 $378.48 $488.04 $488.04 200% of Medicare 100% of Medicare $390.50 $375.89 $366.06 $277.55 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $388.44 $388.44 $313.41 $427.22 100% of Medicare $531.20 $564.40 $521.24 $484.65 $531.20 $564.40 $456.50 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 250 NULL NULL NULL NULL NULL MICO2SP 69502-0001-57 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 200% of Medicare 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001618 1000 ML ASPIRA DRAINAGE BAG NULL INSTITUTIONAL $469.00 1/1/2022-12/31/2022 $469.00 $221.37 $267.33 $344.72 $344.72 200% of Medicare 100% of Medicare $280.84 $270.33 $263.25 $300.16 100% of Medicaid 100% of Medicare 150% of Medicare $375.20 $469.00 195% of Medicare $379.89 $279.06 $279.06 $221.37 $469.00 100% of Medicare $375.20 $398.65 $422.10 $342.32 $398.65 $469.00 $469.00 100% of Medicare 100% of Medicare $469.00 200% of Medicare NULL 999 NULL NULL NULL NULL 999078 Fit and 50 NULL INSTITUTIONAL $200.00 1/1/2022-12/31/2022 $200.00 $94.40 $114.00 $147.00 $147.00 200% of Medicare 100% of Medicare $119.76 $115.28 $112.26 $128.00 100% of Medicaid 100% of Medicare 150% of Medicare $160.00 $200.00 195% of Medicare $162.00 $119.00 $119.00 $94.40 $200.00 100% of Medicare $160.00 $170.00 $180.00 $145.98 $170.00 $200.00 $200.00 100% of Medicare 100% of Medicare $200.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001610 ADAPTABLE RESTING HAND - LARGE LEFT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001609 ADAPTABLE RESTING HAND - MEDIUM RIGHT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001608 ADAPTABLE RESTING HAND - MEDIUM LEFT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001607 ADAPTABLE GERIATRIC HAND - SMALL LEFT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001606 ADAPTABLE GERIATRIC HAND - MEDIUM RIGHT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001605 ADAPTABLE GERIATRIC HAND - MEDIUM LEFT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001604 Phase II Multi Podus Large NULL INSTITUTIONAL $606.00 1/1/2022-12/31/2022 $606.00 $286.03 $345.42 $445.41 $445.41 200% of Medicare 100% of Medicare $362.87 $349.30 $340.15 $387.84 100% of Medicaid 100% of Medicare 150% of Medicare $484.80 $606.00 195% of Medicare $490.86 $360.57 $360.57 $286.03 $606.00 100% of Medicare $484.80 $515.10 $545.40 $442.32 $515.10 $606.00 $606.00 100% of Medicare 100% of Medicare $606.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001603 Phase II Multi Podus Medium NULL INSTITUTIONAL $606.00 1/1/2022-12/31/2022 $606.00 $286.03 $345.42 $445.41 $445.41 200% of Medicare 100% of Medicare $362.87 $349.30 $340.15 $387.84 100% of Medicaid 100% of Medicare 150% of Medicare $484.80 $606.00 195% of Medicare $490.86 $360.57 $360.57 $286.03 $606.00 100% of Medicare $484.80 $515.10 $545.40 $442.32 $515.10 $606.00 $606.00 100% of Medicare 100% of Medicare $606.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001616 ADAPTABLE GERIATRIC HAND - LARGE RIGHT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001615 ADAPTABLE GERIATRIC HAND - LARGE LEFT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001614 ADAPTABLE GERIATRIC HAND - SMALL RIGHT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001613 ADAPTABLE RESTING HAND - SMALL RIGHT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001612 ADAPTABLE RESTING HAND - SMALL LEFT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 272 NULL NULL NULL NULL 001611 ADAPTABLE RESTING HAND - LARGE RIGHT NULL INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 200% of Medicare 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 310 NULL 85301 NULL NULL 14186885 Antithrombin III Ag NULL INSTITUTIONAL $58.00 1/1/2022-12/31/2022 $58.00 $24.24 $33.06 $42.63 $42.63 200% of Medicare 100% of Medicare $34.11 $32.83 $31.98 $24.24 100% of Medicaid 100% of Medicare 150% of Medicare $46.40 $58.00 195% of Medicare $46.98 $33.93 $33.93 $27.38 $37.32 100% of Medicare $46.40 $49.30 $45.53 $42.33 $46.40 $49.30 $39.88 100% of Medicare 100% of Medicare $43.50 200% of Medicare NULL 310 NULL 81240 NULL NULL 14186886 Prothrombin G20210A Mutation PCR NULL INSTITUTIONAL $270.00 1/1/2022-12/31/2022 $270.00 $112.86 $153.90 $198.45 $198.45 200% of Medicare 100% of Medicare $158.79 $152.85 $148.85 $112.86 100% of Medicaid 100% of Medicare 150% of Medicare $216.00 $270.00 195% of Medicare $218.70 $157.95 $157.95 $127.44 $173.72 100% of Medicare $216.00 $229.50 $211.95 $197.07 $216.00 $229.50 $185.63 100% of Medicare 100% of Medicare $202.50 200% of Medicare NULL 310 NULL 85302 NULL NULL 14186883 Protein C Antigen NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $26.75 $36.48 $47.04 $47.04 200% of Medicare 100% of Medicare $37.64 $36.23 $35.28 $26.75 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $37.44 $37.44 $30.21 $41.18 100% of Medicare $51.20 $54.40 $50.24 $46.71 $51.20 $54.40 $44.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 310 NULL 85306 NULL NULL 14186884 Protein S Antigen NULL INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $33.86 $46.17 $59.54 $59.54 200% of Medicare 100% of Medicare $47.64 $45.85 $44.66 $33.86 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $47.39 $47.39 $38.23 $52.12 100% of Medicare $64.80 $68.85 $63.59 $59.12 $64.80 $68.85 $55.69 100% of Medicare 100% of Medicare $60.75 200% of Medicare NULL 310 NULL 87660 NULL NULL 14186891 Trichomonas Prep NULL INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $38.04 $51.87 $66.89 $66.89 200% of Medicare 100% of Medicare $53.52 $51.52 $50.17 $38.04 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $53.24 $53.24 $42.95 $58.55 100% of Medicare $72.80 $77.35 $71.44 $66.42 $72.80 $77.35 $62.56 100% of Medicare 100% of Medicare $68.25 200% of Medicare NULL 310 NULL 87591 NULL NULL 14186887 Gonorrhea PCR Qualitative NULL INSTITUTIONAL $185.00 1/1/2022-12/31/2022 $185.00 $77.33 $105.45 $135.98 $135.98 200% of Medicare 100% of Medicare $108.80 $104.73 $101.99 $77.33 100% of Medicaid 100% of Medicare 150% of Medicare $148.00 $185.00 195% of Medicare $149.85 $108.23 $108.23 $87.32 $119.03 100% of Medicare $148.00 $157.25 $145.23 $135.03 $148.00 $157.25 $127.19 100% of Medicare 100% of Medicare $138.75 200% of Medicare NULL 310 NULL 87491 NULL NULL 14186888 Chlamydia PCR Qualitative NULL INSTITUTIONAL $185.00 1/1/2022-12/31/2022 $185.00 $77.33 $105.45 $135.98 $135.98 200% of Medicare 100% of Medicare $108.80 $104.73 $101.99 $77.33 100% of Medicaid 100% of Medicare 150% of Medicare $148.00 $185.00 195% of Medicare $149.85 $108.23 $108.23 $87.32 $119.03 100% of Medicare $148.00 $157.25 $145.23 $135.03 $148.00 $157.25 $127.19 100% of Medicare 100% of Medicare $138.75 200% of Medicare NULL 310 NULL 86787 NULL NULL 14186881 "Varicella Zoster Virus Antibody, IgM" NULL INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $32.60 $44.46 $57.33 $57.33 200% of Medicare 100% of Medicare $45.87 $44.16 $43.00 $32.60 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $45.63 $45.63 $36.82 $50.19 100% of Medicare $62.40 $66.30 $61.23 $56.93 $62.40 $66.30 $53.63 100% of Medicare 100% of Medicare $58.50 200% of Medicare NULL 310 NULL 86694 NULL NULL 14186882 "Herpes Simplex Type 1 and 2, IgM" NULL INSTITUTIONAL $77.00 1/1/2022-12/31/2022 $77.00 $32.19 $43.89 $56.60 $56.60 200% of Medicare 100% of Medicare $45.28 $43.59 $42.45 $32.19 100% of Medicaid 100% of Medicare 150% of Medicare $61.60 $77.00 195% of Medicare $62.37 $45.05 $45.05 $36.34 $49.54 100% of Medicare $61.60 $65.45 $60.45 $56.20 $61.60 $65.45 $52.94 100% of Medicare 100% of Medicare $57.75 200% of Medicare NULL 310 NULL 87660 NULL NULL 14186895 Trichomonas Exam Wet Prep NULL INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $38.04 $51.87 $66.89 $66.89 200% of Medicare 100% of Medicare $53.52 $51.52 $50.17 $38.04 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $53.24 $53.24 $42.95 $58.55 100% of Medicare $72.80 $77.35 $71.44 $66.42 $72.80 $77.35 $62.56 100% of Medicare 100% of Medicare $68.25 200% of Medicare NULL 310 NULL 80320 NULL NULL 14186893 Ethanol Pl QN NULL INSTITUTIONAL $469.00 1/1/2022-12/31/2022 $469.00 $196.04 $267.33 $344.72 $344.72 200% of Medicare 100% of Medicare $275.82 $265.50 $258.56 $196.04 100% of Medicaid 100% of Medicare 150% of Medicare $375.20 $469.00 195% of Medicare $379.89 $274.37 $274.37 $221.37 $301.75 100% of Medicare $375.20 $398.65 $368.17 $342.32 $375.20 $398.65 $322.44 100% of Medicare 100% of Medicare $351.75 200% of Medicare NULL 272 NULL NULL NULL NULL 110051 110051 NULL INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 200% of Medicare 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110052 110052 NULL INSTITUTIONAL $65.00 1/1/2022-12/31/2022 $65.00 $30.68 $37.05 $47.78 $47.78 200% of Medicare 100% of Medicare $38.92 $37.47 $36.48 $41.60 100% of Medicaid 100% of Medicare 150% of Medicare $52.00 $65.00 195% of Medicare $52.65 $38.68 $38.68 $30.68 $65.00 100% of Medicare $52.00 $55.25 $58.50 $47.44 $55.25 $65.00 $65.00 100% of Medicare 100% of Medicare $65.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110053 110053 NULL INSTITUTIONAL $65.00 1/1/2022-12/31/2022 $65.00 $30.68 $37.05 $47.78 $47.78 200% of Medicare 100% of Medicare $38.92 $37.47 $36.48 $41.60 100% of Medicaid 100% of Medicare 150% of Medicare $52.00 $65.00 195% of Medicare $52.65 $38.68 $38.68 $30.68 $65.00 100% of Medicare $52.00 $55.25 $58.50 $47.44 $55.25 $65.00 $65.00 100% of Medicare 100% of Medicare $65.00 200% of Medicare NULL 272 NULL NULL NULL NULL 110054 110054 NULL INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 200% of Medicare 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 420 NULL 29240 GP NULL 420004 PT Strapping Shoulder Assistant Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29260 GP NULL 420005 "PT Strapping Elbow,Wrist Assistant Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29280 GP NULL 420006 "PT Strapping Hand,Finger Assistant Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29520 GP NULL 420007 PT Strapping Hip Assistant Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29540 GP NULL 420009 "PT Strapping Ankle, Foot Assistant Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 420 NULL 29550 GP NULL 420010 PT Strapping Toes Assistant Units NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 430 NULL 29280 GO NULL 430038 "OT Strapping, Hand, Finger Assist Units" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 430 NULL 29260 GO NULL 430037 "OT Strapping Elbow, Wrist Assistant Unit" NULL INSTITUTIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 195% of Medicare $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL 310 NULL U0004 NULL NULL 14186897 Coronavirus SARS-CoV-2 (COVID-19) NULL INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $64.37 $87.78 $113.19 $113.19 200% of Medicare 100% of Medicare $90.57 $87.18 $84.90 $64.37 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $90.09 $90.09 $72.69 $99.08 100% of Medicare $123.20 $130.90 $120.89 $112.40 $123.20 $130.90 $105.88 100% of Medicare 100% of Medicare $115.50 200% of Medicare NULL 420 NULL NULL GP G2061 988001 PT eVisit Appointment 5-10 minutes NULL INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $6.69 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.41 $9.06 $8.82 $6.69 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.36 $9.36 $7.55 $10.29 100% of Medicare $12.80 $13.60 $12.56 $11.68 $12.80 $13.60 $11.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 420 NULL NULL GP G2062 988002 PT eVisit Appointment 11-20 minutes NULL INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $11.70 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.47 $15.85 $15.44 $11.70 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.38 $16.38 $13.22 $18.02 100% of Medicare $22.40 $23.80 $21.98 $20.44 $22.40 $23.80 $19.25 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 420 NULL NULL GP G2063 988003 PT eVisit Appointment 21 or more minutes NULL INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $18.39 $25.08 $32.34 $32.34 200% of Medicare 100% of Medicare $25.88 $24.91 $24.26 $18.39 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $25.74 $25.74 $20.77 $28.31 100% of Medicare $35.20 $37.40 $34.54 $32.12 $35.20 $37.40 $30.25 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 430 NULL NULL GO G2061 988004 OT eVisit Appointment 5-10 minutes NULL INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $6.69 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.41 $9.06 $8.82 $6.69 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.36 $9.36 $7.55 $10.29 100% of Medicare $12.80 $13.60 $12.56 $11.68 $12.80 $13.60 $11.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 430 NULL NULL GO G2062 988005 OT eVisit Appointment 11-20 minutes NULL INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $11.70 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.47 $15.85 $15.44 $11.70 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.38 $16.38 $13.22 $18.02 100% of Medicare $22.40 $23.80 $21.98 $20.44 $22.40 $23.80 $19.25 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 430 NULL NULL GO G2063 988006 OT eVisit Appointment 21 or more minutes NULL INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $18.39 $25.08 $32.34 $32.34 200% of Medicare 100% of Medicare $25.88 $24.91 $24.26 $18.39 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $25.74 $25.74 $20.77 $28.31 100% of Medicare $35.20 $37.40 $34.54 $32.12 $35.20 $37.40 $30.25 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 440 NULL NULL GN G2061 988007 SLP eVisit Appointment 5-10 minutes NULL INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $6.69 $9.12 $11.76 $11.76 200% of Medicare 100% of Medicare $9.41 $9.06 $8.82 $6.69 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.36 $9.36 $7.55 $10.29 100% of Medicare $12.80 $13.60 $12.56 $11.68 $12.80 $13.60 $11.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 440 NULL NULL GN G2062 988008 SLP eVisit Appointment 11-20 minutes NULL INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $11.70 $15.96 $20.58 $20.58 200% of Medicare 100% of Medicare $16.47 $15.85 $15.44 $11.70 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.38 $16.38 $13.22 $18.02 100% of Medicare $22.40 $23.80 $21.98 $20.44 $22.40 $23.80 $19.25 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 440 NULL NULL GN G2063 988009 SLP eVisit Appointment 21 or more minutes NULL INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $18.39 $25.08 $32.34 $32.34 200% of Medicare 100% of Medicare $25.88 $24.91 $24.26 $18.39 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $25.74 $25.74 $20.77 $28.31 100% of Medicare $35.20 $37.40 $34.54 $32.12 $35.20 $37.40 $30.25 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 310 NULL 87633 NULL NULL 14186900 RVP2 PCR NULL INSTITUTIONAL " $1,897.00 " 1/1/2022-12/31/2022 " $1,612.45 " $792.95 " $1,081.29 " " $1,394.30 " " $1,394.30 " 200% of Medicare 100% of Medicare " $1,115.63 " " $1,073.89 " " $1,045.82 " $792.95 100% of Medicaid 100% of Medicare 150% of Medicare " $1,517.60 " " $1,500.00 " 195% of Medicare " $1,536.57 " " $1,109.75 " " $1,109.75 " $895.38 " $1,220.53 " 100% of Medicare " $1,517.60 " " $1,612.45 " " $1,489.15 " " $1,384.62 " " $1,517.60 " " $1,612.45 " " $1,304.19 " 100% of Medicare 100% of Medicare " $1,422.75 " 200% of Medicare NULL 310 NULL 84260 NULL NULL 14186901 Serotonin-Serum NULL INSTITUTIONAL $142.00 1/1/2022-12/31/2022 $142.00 $59.36 $80.94 $104.37 $104.37 200% of Medicare 100% of Medicare $83.51 $80.39 $78.28 $59.36 100% of Medicaid 100% of Medicare 150% of Medicare $113.60 $142.00 195% of Medicare $115.02 $83.07 $83.07 $67.02 $91.36 100% of Medicare $113.60 $120.70 $111.47 $103.65 $113.60 $120.70 $97.63 100% of Medicare 100% of Medicare $106.50 200% of Medicare NULL 310 NULL 83520 NULL NULL 14186899 Interleukin 6 QN NULL INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $29.68 $40.47 $52.19 $52.19 200% of Medicare 100% of Medicare $41.76 $40.19 $39.14 $29.68 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $41.54 $41.54 $33.51 $45.68 100% of Medicare $56.80 $60.35 $55.74 $51.82 $56.80 $60.35 $48.81 100% of Medicare 100% of Medicare $53.25 200% of Medicare NULL 250 NULL NULL NULL NULL NULL ANOR 01003-01730-869067 INSTITUTIONAL $248.00 1/1/2022-12/31/2022 $248.00 $117.06 $141.36 $182.28 $182.28 200% of Medicare 100% of Medicare $148.50 $142.95 $139.20 $158.72 100% of Medicaid 100% of Medicare 150% of Medicare $198.40 $248.00 195% of Medicare $200.88 $147.56 $147.56 $117.06 $248.00 100% of Medicare $198.40 $210.80 $223.20 $181.02 $210.80 $248.00 $248.00 100% of Medicare 100% of Medicare $248.00 200% of Medicare NULL 310 NULL 87880 NULL NULL 14186896 Rapid Strep A Ag Ql NULL INSTITUTIONAL $68.00 1/1/2022-12/31/2022 $68.00 $28.42 $38.76 $49.98 $49.98 200% of Medicare 100% of Medicare $39.99 $38.49 $37.49 $28.42 100% of Medicaid 100% of Medicare 150% of Medicare $54.40 $68.00 195% of Medicare $55.08 $39.78 $39.78 $32.10 $43.75 100% of Medicare $54.40 $57.80 $53.38 $49.63 $54.40 $57.80 $46.75 100% of Medicare 100% of Medicare $51.00 200% of Medicare NULL 761 NULL 20560 NULL NULL 510088 Needle Insert w/o inj 1-2 muscles NULL INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $14.63 $19.95 $25.73 $25.73 200% of Medicare 100% of Medicare $20.58 $19.81 $19.30 $14.63 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.48 $20.48 $16.52 $22.52 100% of Medicare $28.00 $29.75 $27.48 $25.55 $28.00 $29.75 $24.06 100% of Medicare 100% of Medicare $26.25 200% of Medicare NULL 761 NULL 20561 NULL NULL 510089 Needle Insert w/o inj 3 or more muscles NULL INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $20.90 $28.50 $36.75 $36.75 200% of Medicare 100% of Medicare $29.41 $28.31 $27.57 $20.90 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.25 $29.25 $23.60 $32.17 100% of Medicare $40.00 $42.50 $39.25 $36.50 $40.00 $42.50 $34.38 100% of Medicare 100% of Medicare $37.50 200% of Medicare NULL 761 NULL 64451 NULL NULL 510090 "Inj, anesthetic agent/steriod, nerves/sacroi" NULL INSTITUTIONAL $272.00 1/1/2022-12/31/2022 $272.00 $113.70 $155.04 $199.92 $199.92 200% of Medicare 100% of Medicare $159.96 $153.98 $149.95 $113.70 100% of Medicaid 100% of Medicare 150% of Medicare $217.60 $272.00 195% of Medicare $220.32 $159.12 $159.12 $128.38 $175.00 100% of Medicare $217.60 $231.20 $213.52 $198.53 $217.60 $231.20 $187.00 100% of Medicare 100% of Medicare $204.00 200% of Medicare NULL 761 NULL 64454 NULL NULL 510091 "Inj, anesthetic agent/steriod, genicular ner" NULL INSTITUTIONAL $272.00 1/1/2022-12/31/2022 $272.00 $113.70 $155.04 $199.92 $199.92 200% of Medicare 100% of Medicare $159.96 $153.98 $149.95 $113.70 100% of Medicaid 100% of Medicare 150% of Medicare $217.60 $272.00 195% of Medicare $220.32 $159.12 $159.12 $128.38 $175.00 100% of Medicare $217.60 $231.20 $213.52 $198.53 $217.60 $231.20 $187.00 100% of Medicare 100% of Medicare $204.00 200% of Medicare NULL 761 NULL 64624 NULL NULL 510092 "Destruction by Neurolytic agent, genicular" NULL INSTITUTIONAL $525.00 1/1/2022-12/31/2022 $525.00 $219.45 $299.25 $385.88 $385.88 200% of Medicare 100% of Medicare $308.75 $297.20 $289.43 $219.45 100% of Medicaid 100% of Medicare 150% of Medicare $420.00 $525.00 195% of Medicare $425.25 $307.13 $307.13 $247.80 $337.79 100% of Medicare $420.00 $446.25 $412.13 $383.20 $420.00 $446.25 $360.94 100% of Medicare 100% of Medicare $393.75 200% of Medicare NULL 761 NULL 64625 NULL NULL 510093 "Radiofrequency ablation, nerves sacroiliac j" NULL INSTITUTIONAL $641.00 1/1/2022-12/31/2022 $641.00 $267.94 $365.37 $471.14 $471.14 200% of Medicare 100% of Medicare $376.97 $362.87 $353.38 $267.94 100% of Medicaid 100% of Medicare 150% of Medicare $512.80 $641.00 195% of Medicare $519.21 $374.99 $374.99 $302.55 $412.42 100% of Medicare $512.80 $544.85 $503.19 $467.87 $512.80 $544.85 $440.69 100% of Medicare 100% of Medicare $480.75 200% of Medicare NULL 272 NULL NULL NULL NULL 001629 "Dressing, Kerracel Foam 4x4" NULL INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 200% of Medicare 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 310 NULL U0003 NULL NULL 14186905 "SARS Coronavirus with CoV-2 RNA, QL NAAT" NULL INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $33.44 $45.60 $58.80 $58.80 200% of Medicare 100% of Medicare $47.05 $45.29 $44.10 $33.44 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $46.80 $46.80 $37.76 $51.47 100% of Medicare $64.00 $68.00 $62.80 $58.39 $64.00 $68.00 $55.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare 0101 NULL NULL NULL NULL NULL NULL Stroke with Motor > 72.50 NULL INSTITUTIONAL " $34,858.00 " 1/1/2022-12/31/2022 " $31,372.20 " " $7,800.00 " " $19,869.06 " " $25,620.63 " " $25,620.63 " " $24,167.05 " 100% of Medicare " $20,872.97 " " $20,092.15 " " $19,565.80 " " $22,309.12 " 100% of Medicaid 100% of Medicare 150% of Medicare " $27,886.40 " " $12,000.00 " 195% of Medicare " $28,234.98 " " $20,740.51 " " $20,740.51 " " $16,452.98 " " $10,872.00 " 100% of Medicare " $27,886.40 " " $29,629.30 " " $31,372.20 " " $25,442.85 " " $29,629.30 " " $12,000.00 " " $21,080.00 " 100% of Medicare 100% of Medicare " $7,800.00 " 200% of Medicare 0102 NULL NULL NULL NULL NULL NULL Stroke with Motor > 63.5 & Motor <72.50 NULL INSTITUTIONAL " $58,773.00 " 1/1/2022-12/31/2022 " $52,895.70 " " $11,700.00 " " $33,500.61 " " $43,198.16 " " $43,198.16 " " $40,747.32 " 100% of Medicare " $35,193.27 " " $33,876.76 " " $32,989.28 " " $37,614.72 " 100% of Medicaid 100% of Medicare 150% of Medicare " $47,018.40 " " $18,000.00 " 195% of Medicare " $47,606.13 " " $34,969.94 " " $34,969.94 " " $27,740.86 " " $16,308.00 " 100% of Medicare " $47,018.40 " " $49,957.05 " " $52,895.70 " " $42,898.41 " " $49,957.05 " " $18,000.00 " " $31,620.00 " 100% of Medicare 100% of Medicare " $11,700.00 " 200% of Medicare 0103 NULL NULL NULL NULL NULL NULL Stroke with Motor > 50.50 & Motor <63.50 NULL INSTITUTIONAL " $84,085.00 " 1/1/2022-12/31/2022 " $75,676.50 " " $16,575.00 " " $47,928.45 " " $61,802.48 " " $61,802.48 " " $58,296.13 " 100% of Medicare " $50,350.10 " " $48,466.59 " " $47,196.91 " " $53,814.40 " 100% of Medicaid 100% of Medicare 150% of Medicare " $67,268.00 " " $25,500.00 " 195% of Medicare " $68,108.85 " " $50,030.58 " " $50,030.58 " " $39,688.12 " " $23,103.00 " 100% of Medicare " $67,268.00 " " $71,472.25 " " $75,676.50 " " $61,373.64 " " $71,472.25 " " $25,500.00 " " $44,795.00 " 100% of Medicare 100% of Medicare " $16,575.00 " 200% of Medicare 0104 NULL NULL NULL NULL NULL NULL Stroke with Motor >41.05 & Motor <50.50 NULL INSTITUTIONAL " $102,013.00 " 1/1/2022-12/31/2022 " $91,811.70 " " $21,450.00 " " $58,147.41 " " $74,979.56 " " $74,979.56 " " $70,725.61 " 100% of Medicare " $61,085.38 " " $58,800.29 " " $57,259.90 " " $65,288.32 " 100% of Medicaid 100% of Medicare 150% of Medicare " $81,610.40 " " $33,000.00 " 195% of Medicare " $82,630.53 " " $60,697.74 " " $60,697.74 " " $48,150.14 " " $29,898.00 " 100% of Medicare " $81,610.40 " " $86,711.05 " " $91,811.70 " " $74,459.29 " " $86,711.05 " " $33,000.00 " " $57,970.00 " 100% of Medicare 100% of Medicare " $21,450.00 " 200% of Medicare 0105 NULL NULL NULL NULL NULL NULL Stroke with Motor <41.50 and Age > 84.5 NULL INSTITUTIONAL " $140,502.00 " 1/1/2022-12/31/2022 " $126,451.80 " " $28,275.00 " " $80,086.14 " " $103,268.97 " " $103,268.97 " " $97,410.04 " 100% of Medicare " $84,132.60 " " $80,985.35 " " $78,863.77 " " $89,921.28 " 100% of Medicaid 100% of Medicare 150% of Medicare " $112,401.60 " " $43,500.00 " 195% of Medicare " $113,806.62 " " $83,598.69 " " $83,598.69 " " $66,316.94 " " $39,411.00 " 100% of Medicare " $112,401.60 " " $119,426.70 " " $126,451.80 " " $102,552.41 " " $119,426.70 " " $43,500.00 " " $76,415.00 " 100% of Medicare 100% of Medicare " $28,275.00 " 200% of Medicare 0106 NULL NULL NULL NULL NULL NULL Stroke with Motor <41.50. Age and < 84.5 NULL INSTITUTIONAL " $117,759.00 " 1/1/2022-12/31/2022 " $105,983.10 " " $22,425.00 " " $67,122.63 " " $86,552.87 " " $86,552.87 " " $81,642.31 " 100% of Medicare " $70,514.09 " " $67,876.29 " " $66,098.13 " " $75,365.76 " 100% of Medicaid 100% of Medicare 150% of Medicare " $94,207.20 " " $34,500.00 " 195% of Medicare " $95,384.79 " " $70,066.61 " " $70,066.61 " " $55,582.25 " " $31,257.00 " 100% of Medicare " $94,207.20 " " $100,095.15 " " $105,983.10 " " $85,952.29 " " $100,095.15 " " $34,500.00 " " $60,605.00 " 100% of Medicare 100% of Medicare " $22,425.00 " 200% of Medicare 0201 NULL NULL NULL NULL NULL NULL Traumatic brain injury with Motor >73.50 NULL INSTITUTIONAL " $47,842.00 " 1/1/2022-12/31/2022 " $43,057.80 " " $10,725.00 " " $27,269.94 " " $35,163.87 " " $35,163.87 " " $33,168.86 " 100% of Medicare " $28,647.79 " " $27,576.13 " " $26,853.71 " " $30,618.88 " 100% of Medicaid 100% of Medicare 150% of Medicare " $38,273.60 " " $16,500.00 " 195% of Medicare " $38,752.02 " " $28,465.99 " " $28,465.99 " " $22,581.42 " " $14,949.00 " 100% of Medicare " $38,273.60 " " $40,665.70 " " $43,057.80 " " $34,919.88 " " $40,665.70 " " $16,500.00 " " $28,985.00 " 100% of Medicare 100% of Medicare " $10,725.00 " 200% of Medicare 0202 NULL NULL NULL NULL NULL NULL Traumatic brain injury with Motor >61.50 & Motor <73.50 NULL INSTITUTIONAL " $78,153.00 " 1/1/2022-12/31/2022 " $70,337.70 " " $14,625.00 " " $44,547.21 " " $57,442.46 " " $57,442.46 " " $54,183.47 " 100% of Medicare " $46,798.02 " " $45,047.39 " " $43,867.28 " " $50,017.92 " 100% of Medicaid 100% of Medicare 150% of Medicare " $62,522.40 " " $22,500.00 " 195% of Medicare " $63,303.93 " " $46,501.04 " " $46,501.04 " " $36,888.22 " " $20,385.00 " 100% of Medicare " $62,522.40 " " $66,430.05 " " $70,337.70 " " $57,043.87 " " $66,430.05 " " $22,500.00 " " $39,525.00 " 100% of Medicare 100% of Medicare " $14,625.00 " 200% of Medicare 0203 NULL NULL NULL NULL NULL NULL Traumatic brain injury with Motor >49.50 & Motor <61.50 NULL INSTITUTIONAL " $68,289.00 " 1/1/2022-12/31/2022 " $61,460.10 " " $13,650.00 " " $38,924.73 " " $50,192.42 " " $50,192.42 " " $47,344.76 " 100% of Medicare " $40,891.45 " " $39,361.78 " " $38,330.62 " " $43,704.96 " 100% of Medicaid 100% of Medicare 150% of Medicare " $54,631.20 " " $21,000.00 " 195% of Medicare " $55,314.09 " " $40,631.96 " " $40,631.96 " " $32,232.41 " " $19,026.00 " 100% of Medicare " $54,631.20 " " $58,045.65 " " $61,460.10 " " $49,844.14 " " $58,045.65 " " $21,000.00 " " $36,890.00 " 100% of Medicare 100% of Medicare " $13,650.00 " 200% of Medicare 0204 NULL NULL NULL NULL NULL NULL Traumatic brain injury with Motor >35.50 & Motor <49.50 NULL INSTITUTIONAL " $97,879.00 " 1/1/2022-12/31/2022 " $88,091.10 " " $20,475.00 " " $55,791.03 " " $71,941.07 " " $71,941.07 " " $67,859.51 " 100% of Medicare " $58,609.95 " " $56,417.46 " " $54,939.48 " " $62,642.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $78,303.20 " " $31,500.00 " 195% of Medicare " $79,281.99 " " $58,238.01 " " $58,238.01 " " $46,198.89 " " $28,539.00 " 100% of Medicare " $78,303.20 " " $83,197.15 " " $88,091.10 " " $71,441.88 " " $83,197.15 " " $31,500.00 " " $55,335.00 " 100% of Medicare 100% of Medicare " $20,475.00 " 200% of Medicare 0205 NULL NULL NULL NULL NULL NULL Traumatic brain injury with Motor <35.50 NULL INSTITUTIONAL " $194,914.00 " 1/1/2022-12/31/2022 " $175,422.60 " " $33,150.00 " " $111,100.98 " " $143,261.79 " " $143,261.79 " " $135,133.88 " 100% of Medicare " $116,714.50 " " $112,348.43 " " $109,405.23 " " $124,744.96 " 100% of Medicaid 100% of Medicare 150% of Medicare " $155,931.20 " " $51,000.00 " 195% of Medicare " $157,880.34 " " $115,973.83 " " $115,973.83 " " $91,999.41 " " $46,206.00 " 100% of Medicare " $155,931.20 " " $165,676.90 " " $175,422.60 " " $142,267.73 " " $165,676.90 " " $51,000.00 " " $89,590.00 " 100% of Medicare 100% of Medicare " $33,150.00 " 200% of Medicare 0301 NULL NULL NULL NULL NULL NULL Non-traumatic brain injury with Motor >65.50 NULL INSTITUTIONAL " $58,043.00 " 1/1/2022-12/31/2022 " $52,238.70 " " $10,725.00 " " $33,084.51 " " $42,661.61 " " $42,661.61 " " $40,241.21 " 100% of Medicare " $34,756.15 " " $33,455.99 " " $32,579.54 " " $37,147.52 " 100% of Medicaid 100% of Medicare 150% of Medicare " $46,434.40 " " $16,500.00 " 195% of Medicare " $47,014.83 " " $34,535.59 " " $34,535.59 " " $27,396.30 " " $14,949.00 " 100% of Medicare " $46,434.40 " " $49,336.55 " " $52,238.70 " " $42,365.59 " " $49,336.55 " " $16,500.00 " " $28,985.00 " 100% of Medicare 100% of Medicare " $10,725.00 " 200% of Medicare 0302 NULL NULL NULL NULL NULL NULL Non-traumatic brain injury with Motor >52.50 & Motor <65.50 NULL INSTITUTIONAL " $77,799.00 " 1/1/2022-12/31/2022 " $70,019.10 " " $15,600.00 " " $44,345.43 " " $57,182.27 " " $57,182.27 " " $53,938.05 " 100% of Medicare " $46,586.04 " " $44,843.34 " " $43,668.58 " " $49,791.36 " 100% of Medicaid 100% of Medicare 150% of Medicare " $62,239.20 " " $24,000.00 " 195% of Medicare " $63,017.19 " " $46,290.41 " " $46,290.41 " " $36,721.13 " " $21,744.00 " 100% of Medicare " $62,239.20 " " $66,129.15 " " $70,019.10 " " $56,785.49 " " $66,129.15 " " $24,000.00 " " $42,160.00 " 100% of Medicare 100% of Medicare " $15,600.00 " 200% of Medicare 0303 NULL NULL NULL NULL NULL NULL Non-traumatic brain injury with Motor >42.50 & Motor <52.50 NULL INSTITUTIONAL " $98,797.00 " 1/1/2022-12/31/2022 " $88,917.30 " " $17,550.00 " " $56,314.29 " " $72,615.80 " " $72,615.80 " " $68,495.96 " 100% of Medicare " $59,159.64 " " $56,946.59 " " $55,454.76 " " $63,230.08 " 100% of Medicaid 100% of Medicare 150% of Medicare " $79,037.60 " " $27,000.00 " 195% of Medicare " $80,025.57 " " $58,784.22 " " $58,784.22 " " $46,632.18 " " $24,462.00 " 100% of Medicare " $79,037.60 " " $83,977.45 " " $88,917.30 " " $72,111.93 " " $83,977.45 " " $27,000.00 " " $47,430.00 " 100% of Medicare 100% of Medicare " $17,550.00 " 200% of Medicare 0304 NULL NULL NULL NULL NULL NULL Non-traumatic brain injury with Motor <42.50 and Age >78.5 NULL INSTITUTIONAL " $188,479.00 " 1/1/2022-12/31/2022 " $169,631.10 " " $33,150.00 " " $107,433.03 " " $138,532.07 " " $138,532.07 " " $130,672.49 " 100% of Medicare " $112,861.23 " " $108,639.30 " " $105,793.26 " " $120,626.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $150,783.20 " " $51,000.00 " 195% of Medicare " $152,667.99 " " $112,145.01 " " $112,145.01 " " $88,962.09 " " $46,206.00 " 100% of Medicare " $150,783.20 " " $160,207.15 " " $169,631.10 " " $137,570.82 " " $160,207.15 " " $51,000.00 " " $89,590.00 " 100% of Medicare 100% of Medicare " $33,150.00 " 200% of Medicare 0305 NULL NULL NULL NULL NULL NULL Non-traumatic brain injury M <42.50 and Age <78.5 NULL INSTITUTIONAL " $124,481.00 " 1/1/2022-12/31/2022 " $112,032.90 " " $18,525.00 " " $70,954.17 " " $91,493.54 " " $91,493.54 " " $86,302.68 " 100% of Medicare " $74,539.22 " " $71,750.85 " " $69,871.19 " " $79,667.84 " 100% of Medicaid 100% of Medicare 150% of Medicare " $99,584.80 " " $28,500.00 " 195% of Medicare " $100,829.61 " " $74,066.20 " " $74,066.20 " " $58,755.03 " " $25,821.00 " 100% of Medicare " $99,584.80 " " $105,808.85 " " $112,032.90 " " $90,858.68 " " $105,808.85 " " $28,500.00 " " $50,065.00 " 100% of Medicare 100% of Medicare " $18,525.00 " 200% of Medicare 0402 NULL NULL NULL NULL NULL NULL Traumatic spinal cord injury with Motor >47.50 & Motor <56.50 NULL INSTITUTIONAL " $131,590.00 " 1/1/2022-12/31/2022 " $118,431.00 " " $27,300.00 " " $75,006.30 " " $96,718.65 " " $96,718.65 " " $91,231.35 " 100% of Medicare " $78,796.09 " " $75,848.48 " " $73,861.47 " " $84,217.60 " 100% of Medicaid 100% of Medicare 150% of Medicare " $105,272.00 " " $42,000.00 " 195% of Medicare " $106,587.90 " " $78,296.05 " " $78,296.05 " " $62,110.48 " " $38,052.00 " 100% of Medicare " $105,272.00 " " $111,851.50 " " $118,431.00 " " $96,047.54 " " $111,851.50 " " $42,000.00 " " $73,780.00 " 100% of Medicare 100% of Medicare " $27,300.00 " 200% of Medicare 0403 NULL NULL NULL NULL NULL NULL Traumatic spinal cord injury with Motor >41.50 & Motor <47.50 NULL INSTITUTIONAL " $141,066.00 " 1/1/2022-12/31/2022 " $126,959.40 " " $30,225.00 " " $80,407.62 " " $103,683.51 " " $103,683.51 " " $97,801.06 " 100% of Medicare " $84,470.32 " " $81,310.44 " " $79,180.35 " " $90,282.24 " 100% of Medicaid 100% of Medicare 150% of Medicare " $112,852.80 " " $46,500.00 " 195% of Medicare " $114,263.46 " " $83,934.27 " " $83,934.27 " " $66,583.15 " " $42,129.00 " 100% of Medicare " $112,852.80 " " $119,906.10 " " $126,959.40 " " $102,964.07 " " $119,906.10 " " $46,500.00 " " $81,685.00 " 100% of Medicare 100% of Medicare " $30,225.00 " 200% of Medicare 0404 NULL NULL NULL NULL NULL NULL Traumatic spinal cord injury with Motor <31.50 & Age >61.5 NULL INSTITUTIONAL " $123,068.00 " 1/1/2022-12/31/2022 " $110,761.20 " " $24,375.00 " " $70,148.76 " " $90,454.98 " " $90,454.98 " " $85,323.04 " 100% of Medicare " $73,693.12 " " $70,936.40 " " $69,078.07 " " $78,763.52 " 100% of Medicaid 100% of Medicare 150% of Medicare " $98,454.40 " " $37,500.00 " 195% of Medicare " $99,685.08 " " $73,225.46 " " $73,225.46 " " $58,088.10 " " $33,975.00 " 100% of Medicare " $98,454.40 " " $104,607.80 " " $110,761.20 " " $89,827.33 " " $104,607.80 " " $37,500.00 " " $65,875.00 " 100% of Medicare 100% of Medicare " $24,375.00 " 200% of Medicare 0405 NULL NULL NULL NULL NULL NULL Traumatic spinal cord injury with Motor >31.50 & <41.50 NULL INSTITUTIONAL " $112,730.00 " 1/1/2022-12/31/2022 " $101,457.00 " " $23,400.00 " " $64,256.10 " " $82,856.55 " " $82,856.55 " " $78,155.71 " 100% of Medicare " $67,502.72 " " $64,977.57 " " $63,275.35 " " $72,147.20 " 100% of Medicaid 100% of Medicare 150% of Medicare " $90,184.00 " " $36,000.00 " 195% of Medicare " $91,311.30 " " $67,074.35 " " $67,074.35 " " $53,208.56 " " $32,616.00 " 100% of Medicare " $90,184.00 " " $95,820.50 " " $101,457.00 " " $82,281.63 " " $95,820.50 " " $36,000.00 " " $63,240.00 " 100% of Medicare 100% of Medicare " $23,400.00 " 200% of Medicare 0407 NULL NULL NULL NULL NULL NULL Traumatic spinal cord injury M <24.50 and Age >=61.5 NULL INSTITUTIONAL " $62,889.00 " 1/1/2022-12/31/2022 " $56,600.10 " " $11,700.00 " " $35,846.73 " " $46,223.42 " " $46,223.42 " " $43,600.94 " 100% of Medicare " $37,657.93 " " $36,249.22 " " $35,299.60 " " $40,248.96 " 100% of Medicaid 100% of Medicare 150% of Medicare " $50,311.20 " " $18,000.00 " 195% of Medicare " $50,940.09 " " $37,418.96 " " $37,418.96 " " $29,683.61 " " $16,308.00 " 100% of Medicare " $50,311.20 " " $53,455.65 " " $56,600.10 " " $45,902.68 " " $53,455.65 " " $18,000.00 " " $31,620.00 " 100% of Medicare 100% of Medicare " $11,700.00 " 200% of Medicare 0501 NULL NULL NULL NULL NULL NULL Non-traumatic spinal cord injury with Motor >60.50 NULL INSTITUTIONAL " $58,808.00 " 1/1/2022-12/31/2022 " $52,927.20 " " $11,700.00 " " $33,520.56 " " $43,223.88 " " $43,223.88 " " $40,771.59 " 100% of Medicare " $35,214.23 " " $33,896.93 " " $33,008.93 " " $37,637.12 " 100% of Medicaid 100% of Medicare 150% of Medicare " $47,046.40 " " $18,000.00 " 195% of Medicare " $47,634.48 " " $34,990.76 " " $34,990.76 " " $27,757.38 " " $16,308.00 " 100% of Medicare " $47,046.40 " " $49,986.80 " " $52,927.20 " " $42,923.96 " " $49,986.80 " " $18,000.00 " " $31,620.00 " 100% of Medicare 100% of Medicare " $11,700.00 " 200% of Medicare 0502 NULL NULL NULL NULL NULL NULL Non-traumatic spinal cord injury with Motor >53.50 & Motor <60.50 NULL INSTITUTIONAL " $74,419.00 " 1/1/2022-12/31/2022 " $66,977.10 " " $13,650.00 " " $42,418.83 " " $54,697.97 " " $54,697.97 " " $51,594.69 " 100% of Medicare " $44,562.10 " " $42,895.11 " " $41,771.38 " " $47,628.16 " 100% of Medicaid 100% of Medicare 150% of Medicare " $59,535.20 " " $21,000.00 " 195% of Medicare " $60,279.39 " " $44,279.31 " " $44,279.31 " " $35,125.77 " " $19,026.00 " 100% of Medicare " $59,535.20 " " $63,256.15 " " $66,977.10 " " $54,318.43 " " $63,256.15 " " $21,000.00 " " $36,890.00 " 100% of Medicare 100% of Medicare " $13,650.00 " 200% of Medicare 0503 NULL NULL NULL NULL NULL NULL Non-traumatic spinal cord injury with Motor >48.50 & Motor <53.50 NULL INSTITUTIONAL " $78,067.00 " 1/1/2022-12/31/2022 " $70,260.30 " " $13,650.00 " " $44,498.19 " " $57,379.25 " " $57,379.25 " " $54,123.85 " 100% of Medicare " $46,746.52 " " $44,997.82 " " $43,819.01 " " $49,962.88 " 100% of Medicaid 100% of Medicare 150% of Medicare " $62,453.60 " " $21,000.00 " 195% of Medicare " $63,234.27 " " $46,449.87 " " $46,449.87 " " $36,847.62 " " $19,026.00 " 100% of Medicare " $62,453.60 " " $66,356.95 " " $70,260.30 " " $56,981.10 " " $66,356.95 " " $21,000.00 " " $36,890.00 " 100% of Medicare 100% of Medicare " $13,650.00 " 200% of Medicare 0504 NULL NULL NULL NULL NULL NULL Non-traumatic spinal cord injury with Motor >39.50 & Motor <48.50 NULL INSTITUTIONAL " $110,727.00 " 1/1/2022-12/31/2022 " $99,654.30 " " $21,450.00 " " $63,114.39 " " $81,384.35 " " $81,384.35 " " $76,767.03 " 100% of Medicare " $66,303.33 " " $63,823.04 " " $62,151.07 " " $70,865.28 " 100% of Medicaid 100% of Medicare 150% of Medicare " $88,581.60 " " $33,000.00 " 195% of Medicare " $89,688.87 " " $65,882.57 " " $65,882.57 " " $52,263.14 " " $29,898.00 " 100% of Medicare " $88,581.60 " " $94,117.95 " " $99,654.30 " " $80,819.64 " " $94,117.95 " " $33,000.00 " " $57,970.00 " 100% of Medicare 100% of Medicare " $21,450.00 " 200% of Medicare 0505 NULL NULL NULL NULL NULL NULL Non-traumatic spinal cord injury with Motor <39.50 NULL INSTITUTIONAL " $92,725.00 " 1/1/2022-12/31/2022 " $83,452.50 " " $18,525.00 " " $52,853.25 " " $68,152.88 " " $68,152.88 " " $64,286.24 " 100% of Medicare " $55,523.73 " " $53,446.69 " " $52,046.54 " " $59,344.00 " 100% of Medicaid 100% of Medicare 150% of Medicare " $74,180.00 " " $28,500.00 " 195% of Medicare " $75,107.25 " " $55,171.38 " " $55,171.38 " " $43,766.20 " " $25,821.00 " 100% of Medicare " $74,180.00 " " $78,816.25 " " $83,452.50 " " $67,679.98 " " $78,816.25 " " $28,500.00 " " $50,065.00 " 100% of Medicare 100% of Medicare " $18,525.00 " 200% of Medicare 0601 NULL NULL NULL NULL NULL NULL Neurological with Motor >64.50 NULL INSTITUTIONAL " $46,333.00 " 1/1/2022-12/31/2022 " $41,699.70 " " $7,800.00 " " $26,409.81 " " $34,054.76 " " $34,054.76 " " $32,122.67 " 100% of Medicare " $27,744.20 " " $26,706.34 " " $26,006.71 " " $29,653.12 " 100% of Medicaid 100% of Medicare 150% of Medicare " $37,066.40 " " $12,000.00 " 195% of Medicare " $37,529.73 " " $27,568.14 " " $27,568.14 " " $21,869.18 " " $10,872.00 " 100% of Medicare " $37,066.40 " " $39,383.05 " " $41,699.70 " " $33,818.46 " " $39,383.05 " " $12,000.00 " " $21,080.00 " 100% of Medicare 100% of Medicare " $7,800.00 " 200% of Medicare 0604 NULL NULL NULL NULL NULL NULL Neurological with Motor <43.50 NULL INSTITUTIONAL " $83,184.00 " 1/1/2022-12/31/2022 " $74,865.60 " " $17,550.00 " " $47,414.88 " " $61,140.24 " " $61,140.24 " " $57,671.47 " 100% of Medicare " $49,810.58 " " $47,947.26 " " $46,691.18 " " $53,237.76 " 100% of Medicaid 100% of Medicare 150% of Medicare " $66,547.20 " " $27,000.00 " 195% of Medicare " $67,379.04 " " $49,494.48 " " $49,494.48 " " $39,262.85 " " $24,462.00 " 100% of Medicare " $66,547.20 " " $70,706.40 " " $74,865.60 " " $60,716.00 " " $70,706.40 " " $27,000.00 " " $47,430.00 " 100% of Medicare 100% of Medicare " $17,550.00 " 200% of Medicare 0701 NULL NULL NULL NULL NULL NULL Fracture of lower extremity with Motor >61.50 NULL INSTITUTIONAL " $51,872.00 " 1/1/2022-12/31/2022 " $46,684.80 " " $12,675.00 " " $29,567.04 " " $38,125.92 " " $38,125.92 " " $35,962.86 " 100% of Medicare " $31,060.95 " " $29,899.02 " " $29,115.75 " " $33,198.08 " 100% of Medicaid 100% of Medicare 150% of Medicare " $41,497.60 " " $19,500.00 " 195% of Medicare " $42,016.32 " " $30,863.84 " " $30,863.84 " " $24,483.58 " " $17,667.00 " 100% of Medicare " $41,497.60 " " $44,091.20 " " $46,684.80 " " $37,861.37 " " $44,091.20 " " $19,500.00 " " $34,255.00 " 100% of Medicare 100% of Medicare " $12,675.00 " 200% of Medicare 0702 NULL NULL NULL NULL NULL NULL Fracture of lower extremity with Motor >52.50 & Motor <61.50 NULL INSTITUTIONAL " $55,025.00 " 1/1/2022-12/31/2022 " $49,522.50 " " $12,675.00 " " $31,364.25 " " $40,443.38 " " $40,443.38 " " $38,148.83 " 100% of Medicare " $32,948.97 " " $31,716.41 " " $30,885.53 " " $35,216.00 " 100% of Medicaid 100% of Medicare 150% of Medicare " $44,020.00 " " $19,500.00 " 195% of Medicare " $44,570.25 " " $32,739.88 " " $32,739.88 " " $25,971.80 " " $17,667.00 " 100% of Medicare " $44,020.00 " " $46,771.25 " " $49,522.50 " " $40,162.75 " " $46,771.25 " " $19,500.00 " " $34,255.00 " 100% of Medicare 100% of Medicare " $12,675.00 " 200% of Medicare 0703 NULL NULL NULL NULL NULL NULL Fracture of lower extremity with Motor >41.50 & Motor <52.50 NULL INSTITUTIONAL " $62,360.00 " 1/1/2022-12/31/2022 " $56,124.00 " " $13,650.00 " " $35,545.20 " " $45,834.60 " " $45,834.60 " " $43,234.19 " 100% of Medicare " $37,341.17 " " $35,944.30 " " $35,002.67 " " $39,910.40 " 100% of Medicaid 100% of Medicare 150% of Medicare " $49,888.00 " " $21,000.00 " 195% of Medicare " $50,511.60 " " $37,104.20 " " $37,104.20 " " $29,433.92 " " $19,026.00 " 100% of Medicare " $49,888.00 " " $53,006.00 " " $56,124.00 " " $45,516.56 " " $53,006.00 " " $21,000.00 " " $36,890.00 " 100% of Medicare 100% of Medicare " $13,650.00 " 200% of Medicare 0704 NULL NULL NULL NULL NULL NULL Fracture of lower extremity with Motor <41.50 NULL INSTITUTIONAL " $74,416.00 " 1/1/2022-12/31/2022 " $66,974.40 " " $16,575.00 " " $42,417.12 " " $54,695.76 " " $54,695.76 " " $51,592.61 " 100% of Medicare " $44,560.30 " " $42,893.38 " " $41,769.70 " " $47,626.24 " 100% of Medicaid 100% of Medicare 150% of Medicare " $59,532.80 " " $25,500.00 " 195% of Medicare " $60,276.96 " " $44,277.52 " " $44,277.52 " " $35,124.35 " " $23,103.00 " 100% of Medicare " $59,532.80 " " $63,253.60 " " $66,974.40 " " $54,316.24 " " $63,253.60 " " $25,500.00 " " $44,795.00 " 100% of Medicare 100% of Medicare " $16,575.00 " 200% of Medicare 0802 NULL NULL NULL NULL NULL NULL Replacement of lower extremity joint with Motor >57.50 & Motor <63.50 NULL INSTITUTIONAL " $47,982.00 " 1/1/2022-12/31/2022 " $43,183.80 " " $10,725.00 " " $27,349.74 " " $35,266.77 " " $35,266.77 " " $33,265.92 " 100% of Medicare " $28,731.62 " " $27,656.82 " " $26,932.30 " " $30,708.48 " 100% of Medicaid 100% of Medicare 150% of Medicare " $38,385.60 " " $16,500.00 " 195% of Medicare " $38,865.42 " " $28,549.29 " " $28,549.29 " " $22,647.50 " " $14,949.00 " 100% of Medicare " $38,385.60 " " $40,784.70 " " $43,183.80 " " $35,022.06 " " $40,784.70 " " $16,500.00 " " $28,985.00 " 100% of Medicare 100% of Medicare " $10,725.00 " 200% of Medicare 0901 NULL NULL NULL NULL NULL NULL Other orthopedic with Motor >63.50 NULL INSTITUTIONAL " $48,984.00 " 1/1/2022-12/31/2022 " $44,085.60 " " $10,725.00 " " $27,920.88 " " $36,003.24 " " $36,003.24 " " $33,960.61 " 100% of Medicare " $29,331.62 " " $28,234.38 " " $27,494.72 " " $31,349.76 " 100% of Medicaid 100% of Medicare 150% of Medicare " $39,187.20 " " $16,500.00 " 195% of Medicare " $39,677.04 " " $29,145.48 " " $29,145.48 " " $23,120.45 " " $14,949.00 " 100% of Medicare " $39,187.20 " " $41,636.40 " " $44,085.60 " " $35,753.42 " " $41,636.40 " " $16,500.00 " " $28,985.00 " 100% of Medicare 100% of Medicare " $10,725.00 " 200% of Medicare 0902 NULL NULL NULL NULL NULL NULL Other orthopedic with Motor >51.50 and Motor <63.50 NULL INSTITUTIONAL " $56,129.00 " 1/1/2022-12/31/2022 " $50,516.10 " " $12,675.00 " " $31,993.53 " " $41,254.82 " " $41,254.82 " " $38,914.24 " 100% of Medicare " $33,610.05 " " $32,352.76 " " $31,505.21 " " $35,922.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $44,903.20 " " $19,500.00 " 195% of Medicare " $45,464.49 " " $33,396.76 " " $33,396.76 " " $26,492.89 " " $17,667.00 " 100% of Medicare " $44,903.20 " " $47,709.65 " " $50,516.10 " " $40,968.56 " " $47,709.65 " " $19,500.00 " " $34,255.00 " 100% of Medicare 100% of Medicare " $12,675.00 " 200% of Medicare 0903 NULL NULL NULL NULL NULL NULL Other orthopedic with Motor >44.50 & Motor <51.50 NULL INSTITUTIONAL " $115,910.00 " 1/1/2022-12/31/2022 " $104,319.00 " " $16,575.00 " " $66,068.70 " " $85,193.85 " " $85,193.85 " " $80,360.40 " 100% of Medicare " $69,406.91 " " $66,810.52 " " $65,060.28 " " $74,182.40 " 100% of Medicaid 100% of Medicare 150% of Medicare " $92,728.00 " " $25,500.00 " 195% of Medicare " $93,887.10 " " $68,966.45 " " $68,966.45 " " $54,709.52 " " $23,103.00 " 100% of Medicare " $92,728.00 " " $98,523.50 " " $104,319.00 " " $84,602.71 " " $98,523.50 " " $25,500.00 " " $44,795.00 " 100% of Medicare 100% of Medicare " $16,575.00 " 200% of Medicare 1001 NULL NULL NULL NULL NULL NULL "Amputation, lower extremity with Motor >64.50" NULL INSTITUTIONAL " $45,412.00 " 1/1/2022-12/31/2022 " $40,870.80 " " $10,725.00 " " $25,884.84 " " $33,377.82 " " $33,377.82 " " $31,484.14 " 100% of Medicare " $27,192.71 " " $26,175.48 " " $25,489.76 " " $29,063.68 " 100% of Medicaid 100% of Medicare 150% of Medicare " $36,329.60 " " $16,500.00 " 195% of Medicare " $36,783.72 " " $27,020.14 " " $27,020.14 " " $21,434.46 " " $14,949.00 " 100% of Medicare " $36,329.60 " " $38,600.20 " " $40,870.80 " " $33,146.22 " " $38,600.20 " " $16,500.00 " " $28,985.00 " 100% of Medicare 100% of Medicare " $10,725.00 " 200% of Medicare 1002 NULL NULL NULL NULL NULL NULL " Amputation, lower extremity with Motor >55.50 & Motor <64.50" NULL INSTITUTIONAL " $63,277.00 " 1/1/2022-12/31/2022 " $56,949.30 " " $12,675.00 " " $36,067.89 " " $46,508.60 " " $46,508.60 " " $43,869.94 " 100% of Medicare " $37,890.27 " " $36,472.86 " " $35,517.38 " " $40,497.28 " 100% of Medicaid 100% of Medicare 150% of Medicare " $50,621.60 " " $19,500.00 " 195% of Medicare " $51,254.37 " " $37,649.82 " " $37,649.82 " " $29,866.74 " " $17,667.00 " 100% of Medicare " $50,621.60 " " $53,785.45 " " $56,949.30 " " $46,185.88 " " $53,785.45 " " $19,500.00 " " $34,255.00 " 100% of Medicare 100% of Medicare " $12,675.00 " 200% of Medicare 1003 NULL NULL NULL NULL NULL NULL "Amputation, lower extremity with Motor >47.50., & Motor <55.50" NULL INSTITUTIONAL " $62,522.00 " 1/1/2022-12/31/2022 " $56,269.80 " " $12,675.00 " " $35,637.54 " " $45,953.67 " " $45,953.67 " " $43,346.50 " 100% of Medicare " $37,438.17 " " $36,037.68 " " $35,093.60 " " $40,014.08 " 100% of Medicaid 100% of Medicare 150% of Medicare " $50,017.60 " " $19,500.00 " 195% of Medicare " $50,642.82 " " $37,200.59 " " $37,200.59 " " $29,510.38 " " $17,667.00 " 100% of Medicare " $50,017.60 " " $53,143.70 " " $56,269.80 " " $45,634.81 " " $53,143.70 " " $19,500.00 " " $34,255.00 " 100% of Medicare 100% of Medicare " $12,675.00 " 200% of Medicare 1004 NULL NULL NULL NULL NULL NULL "Amputation, lower extremity with motor score <47.50" NULL INSTITUTIONAL " $44,605.00 " 1/1/2022-12/31/2022 " $40,144.50 " " $8,775.00 " " $25,424.85 " " $32,784.68 " " $32,784.68 " " $30,924.65 " 100% of Medicare " $26,709.47 " " $25,710.32 " " $25,036.79 " " $28,547.20 " 100% of Medicaid 100% of Medicare 150% of Medicare " $35,684.00 " " $13,500.00 " 195% of Medicare " $36,130.05 " " $26,539.98 " " $26,539.98 " " $21,053.56 " " $12,231.00 " 100% of Medicare " $35,684.00 " " $37,914.25 " " $40,144.50 " " $32,557.19 " " $37,914.25 " " $13,500.00 " " $23,715.00 " 100% of Medicare 100% of Medicare " $8,775.00 " 200% of Medicare 1101 NULL NULL NULL NULL NULL NULL " Amputation, other extremity with Motor >58.50" NULL INSTITUTIONAL " $81,565.00 " 1/1/2022-12/31/2022 " $73,408.50 " " $16,575.00 " " $46,492.05 " " $59,950.28 " " $59,950.28 " " $56,549.01 " 100% of Medicare " $48,841.12 " " $47,014.07 " " $45,782.43 " " $52,201.60 " 100% of Medicaid 100% of Medicare 150% of Medicare " $65,252.00 " " $25,500.00 " 195% of Medicare " $66,067.65 " " $48,531.18 " " $48,531.18 " " $38,498.68 " " $23,103.00 " 100% of Medicare " $65,252.00 " " $69,330.25 " " $73,408.50 " " $59,534.29 " " $69,330.25 " " $25,500.00 " " $44,795.00 " 100% of Medicare 100% of Medicare " $16,575.00 " 200% of Medicare 1401 NULL NULL NULL NULL NULL NULL Cardiac with Motor >68.50 NULL INSTITUTIONAL " $42,750.00 " 1/1/2022-12/31/2022 " $38,475.00 " " $8,775.00 " " $24,367.50 " " $31,421.25 " " $31,421.25 " " $29,638.58 " 100% of Medicare " $25,598.70 " " $24,641.10 " " $23,995.58 " " $27,360.00 " 100% of Medicaid 100% of Medicare 150% of Medicare " $34,200.00 " " $13,500.00 " 195% of Medicare " $34,627.50 " " $25,436.25 " " $25,436.25 " " $20,178.00 " " $12,231.00 " 100% of Medicare " $34,200.00 " " $36,337.50 " " $38,475.00 " " $31,203.23 " " $36,337.50 " " $13,500.00 " " $23,715.00 " 100% of Medicare 100% of Medicare " $8,775.00 " 200% of Medicare 1402 NULL NULL NULL NULL NULL NULL Cardiac with Motor >55.50 motor <68.50 NULL INSTITUTIONAL " $75,507.00 " 1/1/2022-12/31/2022 " $67,956.30 " " $11,700.00 " " $43,038.99 " " $55,497.65 " " $55,497.65 " " $52,349.00 " 100% of Medicare " $45,213.59 " " $43,522.23 " " $42,382.08 " " $48,324.48 " 100% of Medicaid 100% of Medicare 150% of Medicare " $60,405.60 " " $18,000.00 " 195% of Medicare " $61,160.67 " " $44,926.67 " " $44,926.67 " " $35,639.30 " " $16,308.00 " 100% of Medicare " $60,405.60 " " $64,180.95 " " $67,956.30 " " $55,112.56 " " $64,180.95 " " $18,000.00 " " $31,620.00 " 100% of Medicare 100% of Medicare " $11,700.00 " 200% of Medicare 1403 NULL NULL NULL NULL NULL NULL Cardiac with Motor >45.50 & Motor <55.50 NULL INSTITUTIONAL " $74,444.00 " 1/1/2022-12/31/2022 " $66,999.60 " " $14,625.00 " " $42,433.08 " " $54,716.34 " " $54,716.34 " " $51,612.03 " 100% of Medicare " $44,577.07 " " $42,909.52 " " $41,785.42 " " $47,644.16 " 100% of Medicaid 100% of Medicare 150% of Medicare " $59,555.20 " " $22,500.00 " 195% of Medicare " $60,299.64 " " $44,294.18 " " $44,294.18 " " $35,137.57 " " $20,385.00 " 100% of Medicare " $59,555.20 " " $63,277.40 " " $66,999.60 " " $54,336.68 " " $63,277.40 " " $22,500.00 " " $39,525.00 " 100% of Medicare 100% of Medicare " $14,625.00 " 200% of Medicare 1404 NULL NULL NULL NULL NULL NULL Cardiac with Motor <45.50 NULL INSTITUTIONAL " $117,154.00 " 1/1/2022-12/31/2022 " $105,438.60 " " $21,450.00 " " $66,777.78 " " $86,108.19 " " $86,108.19 " " $81,222.87 " 100% of Medicare " $70,151.82 " " $67,527.57 " " $65,758.54 " " $74,978.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $93,723.20 " " $33,000.00 " 195% of Medicare " $94,894.74 " " $69,706.63 " " $69,706.63 " " $55,296.69 " " $29,898.00 " 100% of Medicare " $93,723.20 " " $99,580.90 " " $105,438.60 " " $85,510.70 " " $99,580.90 " " $33,000.00 " " $57,970.00 " 100% of Medicare 100% of Medicare " $21,450.00 " 200% of Medicare 1501 NULL NULL NULL NULL NULL NULL Pulmonary with Motor >68.50 NULL INSTITUTIONAL " $48,699.00 " 1/1/2022-12/31/2022 " $43,829.10 " " $6,825.00 " " $27,758.43 " " $35,793.77 " " $35,793.77 " " $33,763.02 " 100% of Medicare " $29,160.96 " " $28,070.10 " " $27,334.75 " " $31,167.36 " 100% of Medicaid 100% of Medicare 150% of Medicare " $38,959.20 " " $10,500.00 " 195% of Medicare " $39,446.19 " " $28,975.91 " " $28,975.91 " " $22,985.93 " " $9,513.00 " 100% of Medicare " $38,959.20 " " $41,394.15 " " $43,829.10 " " $35,545.40 " " $41,394.15 " " $10,500.00 " " $18,445.00 " 100% of Medicare 100% of Medicare " $6,825.00 " 200% of Medicare 1701 NULL NULL NULL NULL NULL NULL Major multiple trauma without brain or spinal cord injury with Motor >57.50 NULL INSTITUTIONAL " $41,205.00 " 1/1/2022-12/31/2022 " $37,084.50 " " $8,775.00 " " $23,486.85 " " $30,285.68 " " $30,285.68 " " $28,567.43 " 100% of Medicare " $24,673.55 " " $23,750.56 " " $23,128.37 " " $26,371.20 " 100% of Medicaid 100% of Medicare 150% of Medicare " $32,964.00 " " $13,500.00 " 195% of Medicare " $33,376.05 " " $24,516.98 " " $24,516.98 " " $19,448.76 " " $12,231.00 " 100% of Medicare " $32,964.00 " " $35,024.25 " " $37,084.50 " " $30,075.53 " " $35,024.25 " " $13,500.00 " " $23,715.00 " 100% of Medicare 100% of Medicare " $8,775.00 " 200% of Medicare 1702 NULL NULL NULL NULL NULL NULL Major multiple trauma without brain or spinal cord injury with Motor >50.50 & Motor <57.50 NULL INSTITUTIONAL " $72,228.00 " 1/1/2022-12/31/2022 " $65,005.20 " " $15,600.00 " " $41,169.96 " " $53,087.58 " " $53,087.58 " " $50,075.67 " 100% of Medicare " $43,250.13 " " $41,632.22 " " $40,541.58 " " $46,225.92 " 100% of Medicaid 100% of Medicare 150% of Medicare " $57,782.40 " " $24,000.00 " 195% of Medicare " $58,504.68 " " $42,975.66 " " $42,975.66 " " $34,091.62 " " $21,744.00 " 100% of Medicare " $57,782.40 " " $61,393.80 " " $65,005.20 " " $52,719.22 " " $61,393.80 " " $24,000.00 " " $42,160.00 " 100% of Medicare 100% of Medicare " $15,600.00 " 200% of Medicare 1703 NULL NULL NULL NULL NULL NULL Major multiple trauma without brain or spinal cord injury with Motor >41.50 & Motor <50.50 NULL INSTITUTIONAL " $57,289.00 " 1/1/2022-12/31/2022 " $51,560.10 " " $11,700.00 " " $32,654.73 " " $42,107.42 " " $42,107.42 " " $39,718.46 " 100% of Medicare " $34,304.65 " " $33,021.38 " " $32,156.32 " " $36,664.96 " 100% of Medicaid 100% of Medicare 150% of Medicare " $45,831.20 " " $18,000.00 " 195% of Medicare " $46,404.09 " " $34,086.96 " " $34,086.96 " " $27,040.41 " " $16,308.00 " 100% of Medicare " $45,831.20 " " $48,695.65 " " $51,560.10 " " $41,815.24 " " $48,695.65 " " $18,000.00 " " $31,620.00 " 100% of Medicare 100% of Medicare " $11,700.00 " 200% of Medicare 1705 NULL NULL NULL NULL NULL NULL Major multiple trauma without brain or spinal cord injury M <36.50 NULL INSTITUTIONAL " $93,387.00 " 1/1/2022-12/31/2022 " $84,048.30 " " $19,500.00 " " $53,230.59 " " $68,639.45 " " $68,639.45 " " $64,745.21 " 100% of Medicare " $55,920.14 " " $53,828.27 " " $52,418.12 " " $59,767.68 " 100% of Medicaid 100% of Medicare 150% of Medicare " $74,709.60 " " $30,000.00 " 195% of Medicare " $75,643.47 " " $55,565.27 " " $55,565.27 " " $44,078.66 " " $27,180.00 " 100% of Medicare " $74,709.60 " " $79,378.95 " " $84,048.30 " " $68,163.17 " " $79,378.95 " " $30,000.00 " " $52,700.00 " 100% of Medicare 100% of Medicare " $19,500.00 " 200% of Medicare 1801 NULL NULL NULL NULL NULL NULL Major multiple trauma with brain or spinal cord injury with Motor >67.50 NULL INSTITUTIONAL " $47,430.00 " 1/1/2022-12/31/2022 " $42,687.00 " " $9,750.00 " " $27,035.10 " " $34,861.05 " " $34,861.05 " " $32,883.22 " 100% of Medicare " $28,401.08 " " $27,338.65 " " $26,622.46 " " $30,355.20 " 100% of Medicaid 100% of Medicare 150% of Medicare " $37,944.00 " " $15,000.00 " 195% of Medicare " $38,418.30 " " $28,220.85 " " $28,220.85 " " $22,386.96 " " $13,590.00 " 100% of Medicare " $37,944.00 " " $40,315.50 " " $42,687.00 " " $34,619.16 " " $40,315.50 " " $15,000.00 " " $26,350.00 " 100% of Medicare 100% of Medicare " $9,750.00 " 200% of Medicare 1802 NULL NULL NULL NULL NULL NULL Major multiple trauma with brain or spinal cord injury with Motor >55.50 & Motor <67.50 NULL INSTITUTIONAL " $86,546.00 " 1/1/2022-12/31/2022 " $77,891.40 " " $17,550.00 " " $49,331.22 " " $63,611.31 " " $63,611.31 " " $60,002.34 " 100% of Medicare " $51,823.74 " " $49,885.11 " " $48,578.27 " " $55,389.44 " 100% of Medicaid 100% of Medicare 150% of Medicare " $69,236.80 " " $27,000.00 " 195% of Medicare " $70,102.26 " " $51,494.87 " " $51,494.87 " " $40,849.71 " " $24,462.00 " 100% of Medicare " $69,236.80 " " $73,564.10 " " $77,891.40 " " $63,169.93 " " $73,564.10 " " $27,000.00 " " $47,430.00 " 100% of Medicare 100% of Medicare " $17,550.00 " 200% of Medicare 1803 NULL NULL NULL NULL NULL NULL Major multiple trauma with brain or spinal cord injury with Motor >D37245.50. & Motor <55.50 NULL INSTITUTIONAL " $55,578.00 " 1/1/2022-12/31/2022 " $50,020.20 " " $11,700.00 " " $31,679.46 " " $40,849.83 " " $40,849.83 " " $38,532.23 " 100% of Medicare " $33,280.11 " " $32,035.16 " " $31,195.93 " " $35,569.92 " 100% of Medicaid 100% of Medicare 150% of Medicare " $44,462.40 " " $18,000.00 " 195% of Medicare " $45,018.18 " " $33,068.91 " " $33,068.91 " " $26,232.82 " " $16,308.00 " 100% of Medicare " $44,462.40 " " $47,241.30 " " $50,020.20 " " $40,566.38 " " $47,241.30 " " $18,000.00 " " $31,620.00 " 100% of Medicare 100% of Medicare " $11,700.00 " 200% of Medicare 1805 NULL NULL NULL NULL NULL NULL Major multiple trauma with brain or spinal cord injury M >=30.50 and M <40.50 NULL INSTITUTIONAL " $115,108.00 " 1/1/2022-12/31/2022 " $103,597.20 " " $17,550.00 " " $65,611.56 " " $84,604.38 " " $84,604.38 " " $79,804.38 " 100% of Medicare " $68,926.67 " " $66,348.25 " " $64,610.12 " " $73,669.12 " 100% of Medicaid 100% of Medicare 150% of Medicare " $92,086.40 " " $27,000.00 " 195% of Medicare " $93,237.48 " " $68,489.26 " " $68,489.26 " " $54,330.98 " " $24,462.00 " 100% of Medicare " $92,086.40 " " $97,841.80 " " $103,597.20 " " $84,017.33 " " $97,841.80 " " $27,000.00 " " $47,430.00 " 100% of Medicare 100% of Medicare " $17,550.00 " 200% of Medicare 1806 NULL NULL NULL NULL NULL NULL Major multiple trauma with brain or spinal cord injury M <30.50 NULL INSTITUTIONAL " $152,179.00 " 1/1/2022-12/31/2022 " $136,961.10 " " $25,350.00 " " $86,742.03 " " $111,851.57 " " $111,851.57 " " $105,505.70 " 100% of Medicare " $91,124.79 " " $87,715.98 " " $85,418.07 " " $97,394.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $121,743.20 " " $39,000.00 " 195% of Medicare " $123,264.99 " " $90,546.51 " " $90,546.51 " " $71,828.49 " " $35,334.00 " 100% of Medicare " $121,743.20 " " $129,352.15 " " $136,961.10 " " $111,075.45 " " $129,352.15 " " $39,000.00 " " $68,510.00 " 100% of Medicare 100% of Medicare " $25,350.00 " 200% of Medicare 1904 NULL NULL NULL NULL NULL NULL Guillain-Barré M <38.50 NULL INSTITUTIONAL " $101,175.00 " 1/1/2022-12/31/2022 " $91,057.50 " " $20,475.00 " " $57,669.75 " " $74,363.63 " " $74,363.63 " " $70,144.63 " 100% of Medicare " $60,583.59 " " $58,317.27 " " $56,789.53 " " $64,752.00 " 100% of Medicaid 100% of Medicare 150% of Medicare " $80,940.00 " " $31,500.00 " 195% of Medicare " $81,951.75 " " $60,199.13 " " $60,199.13 " " $47,754.60 " " $28,539.00 " 100% of Medicare " $80,940.00 " " $85,998.75 " " $91,057.50 " " $73,847.63 " " $85,998.75 " " $31,500.00 " " $55,335.00 " 100% of Medicare 100% of Medicare " $20,475.00 " 200% of Medicare 2001 NULL NULL NULL NULL NULL NULL Miscellaneous with Motor >66.50 NULL INSTITUTIONAL " $47,748.00 " 1/1/2022-12/31/2022 " $42,973.20 " " $8,775.00 " " $27,216.36 " " $35,094.78 " " $35,094.78 " " $33,103.69 " 100% of Medicare " $28,591.50 " " $27,521.95 " " $26,800.95 " " $30,558.72 " 100% of Medicaid 100% of Medicare 150% of Medicare " $38,198.40 " " $13,500.00 " 195% of Medicare " $38,675.88 " " $28,410.06 " " $28,410.06 " " $22,537.06 " " $12,231.00 " 100% of Medicare " $38,198.40 " " $40,585.80 " " $42,973.20 " " $34,851.27 " " $40,585.80 " " $13,500.00 " " $23,715.00 " 100% of Medicare 100% of Medicare " $8,775.00 " 200% of Medicare 2002 NULL NULL NULL NULL NULL NULL Miscellaneous with Motor >55.50 & Motor <66.50 NULL INSTITUTIONAL " $79,096.00 " 1/1/2022-12/31/2022 " $71,186.40 " " $15,600.00 " " $45,084.72 " " $58,135.56 " " $58,135.56 " " $54,837.26 " 100% of Medicare " $47,362.68 " " $45,590.93 " " $44,396.58 " " $50,621.44 " 100% of Medicaid 100% of Medicare 150% of Medicare " $63,276.80 " " $24,000.00 " 195% of Medicare " $64,067.76 " " $47,062.12 " " $47,062.12 " " $37,333.31 " " $21,744.00 " 100% of Medicare " $63,276.80 " " $67,231.60 " " $71,186.40 " " $57,732.17 " " $67,231.60 " " $24,000.00 " " $42,160.00 " 100% of Medicare 100% of Medicare " $15,600.00 " 200% of Medicare 2003 NULL NULL NULL NULL NULL NULL Miscellaneous with Motor >46.50 & Motor <55.50 NULL INSTITUTIONAL " $92,805.00 " 1/1/2022-12/31/2022 " $83,524.50 " " $15,600.00 " " $52,898.85 " " $68,211.68 " " $68,211.68 " " $64,341.71 " 100% of Medicare " $55,571.63 " " $53,492.80 " " $52,091.45 " " $59,395.20 " 100% of Medicaid 100% of Medicare 150% of Medicare " $74,244.00 " " $24,000.00 " 195% of Medicare " $75,172.05 " " $55,218.98 " " $55,218.98 " " $43,803.96 " " $21,744.00 " 100% of Medicare " $74,244.00 " " $78,884.25 " " $83,524.50 " " $67,738.37 " " $78,884.25 " " $24,000.00 " " $42,160.00 " 100% of Medicare 100% of Medicare " $15,600.00 " 200% of Medicare 2005 NULL NULL NULL NULL NULL NULL Miscellaneous M <46.50 and Age <77.5 NULL INSTITUTIONAL " $48,877.00 " 1/1/2022-12/31/2022 " $43,989.30 " " $10,725.00 " " $27,859.89 " " $35,924.60 " " $35,924.60 " " $33,886.42 " 100% of Medicare " $29,267.55 " " $28,172.70 " " $27,434.66 " " $31,281.28 " 100% of Medicaid 100% of Medicare 150% of Medicare " $39,101.60 " " $16,500.00 " 195% of Medicare " $39,590.37 " " $29,081.82 " " $29,081.82 " " $23,069.94 " " $14,949.00 " 100% of Medicare " $39,101.60 " " $41,545.45 " " $43,989.30 " " $35,675.32 " " $41,545.45 " " $16,500.00 " " $28,985.00 " 100% of Medicare 100% of Medicare " $10,725.00 " 200% of Medicare NULL NULL NULL 96156 NULL NULL NULL "H&B Initial or re-assessment, event based" NULL PROFESSIONAL $260.00 1/1/2022-12/31/2022 $260.00 $108.68 $148.20 $191.10 $191.10 200% of Medicare 100% of Medicare $152.91 $147.19 $143.34 $108.68 100% of Medicaid 100% of Medicare 150% of Medicare $208.00 $260.00 $113.60 $210.60 $152.10 $152.10 $122.72 $167.28 100% of Medicare $208.00 $221.00 $204.10 $189.77 $208.00 $221.00 $178.75 100% of Medicare 100% of Medicare $195.00 200% of Medicare NULL NULL NULL 96158 NULL NULL NULL "H&B intervention, 1st 30 mins" NULL PROFESSIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 $114.00 $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL NULL NULL 96159 NULL NULL NULL "H&B intervention, addt'l 15 mins" NULL PROFESSIONAL $120.00 1/1/2022-12/31/2022 $120.00 $50.16 $68.40 $88.20 $88.20 200% of Medicare 100% of Medicare $70.57 $67.93 $66.16 $50.16 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 $114.00 $97.20 $70.20 $70.20 $56.64 $77.21 100% of Medicare $96.00 $102.00 $94.20 $87.59 $96.00 $102.00 $82.50 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL NULL NULL 96164 NULL NULL NULL "H&B group 2+, 1st 30 mins" NULL PROFESSIONAL $42.00 1/1/2022-12/31/2022 $42.00 $17.56 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $24.70 $23.78 $23.15 $17.56 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 $40.00 $34.02 $24.57 $24.57 $19.82 $27.02 100% of Medicare $33.60 $35.70 $32.97 $30.66 $33.60 $35.70 $28.88 100% of Medicare 100% of Medicare $31.50 200% of Medicare NULL NULL NULL 96165 NULL NULL NULL "H&B group 2+, addt'l 15 mins" NULL PROFESSIONAL $42.00 1/1/2022-12/31/2022 $42.00 $17.56 $23.94 $30.87 $30.87 200% of Medicare 100% of Medicare $24.70 $23.78 $23.15 $17.56 100% of Medicaid 100% of Medicare 150% of Medicare $33.60 $42.00 $40.00 $34.02 $24.57 $24.57 $19.82 $27.02 100% of Medicare $33.60 $35.70 $32.97 $30.66 $33.60 $35.70 $28.88 100% of Medicare 100% of Medicare $31.50 200% of Medicare NULL NULL NULL 96167 NULL NULL NULL "H&B intervention w/pt family, 1st 30 mins" NULL PROFESSIONAL $118.00 1/1/2022-12/31/2022 $118.00 $49.32 $67.26 $86.73 $86.73 200% of Medicare 100% of Medicare $69.40 $66.80 $65.05 $49.32 100% of Medicaid 100% of Medicare 150% of Medicare $94.40 $118.00 $66.40 $95.58 $69.03 $69.03 $55.70 $75.92 100% of Medicare $94.40 $100.30 $92.63 $86.13 $94.40 $100.30 $81.13 100% of Medicare 100% of Medicare $88.50 200% of Medicare NULL NULL NULL 96168 NULL NULL NULL "H&B intervention w/pt family, addt'l 15 mins" NULL PROFESSIONAL $118.00 1/1/2022-12/31/2022 $118.00 $49.32 $67.26 $86.73 $86.73 200% of Medicare 100% of Medicare $69.40 $66.80 $65.05 $49.32 100% of Medicaid 100% of Medicare 150% of Medicare $94.40 $118.00 $112.00 $95.58 $69.03 $69.03 $55.70 $75.92 100% of Medicare $94.40 $100.30 $92.63 $86.13 $94.40 $100.30 $81.13 100% of Medicare 100% of Medicare $88.50 200% of Medicare NULL NULL NULL 96170 NULL NULL NULL "H&B intervention w/o family, 1st 30 mins" NULL PROFESSIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 $158.00 $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL NULL NULL 96171 NULL NULL NULL "H&B intervention w/o family, addt'l 15 mins" NULL PROFESSIONAL $166.00 1/1/2022-12/31/2022 $166.00 $69.39 $94.62 $122.01 $122.01 200% of Medicare 100% of Medicare $97.62 $93.97 $91.52 $69.39 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 $158.00 $134.46 $97.11 $97.11 $78.35 $106.80 100% of Medicare $132.80 $141.10 $130.31 $121.16 $132.80 $141.10 $114.13 100% of Medicare 100% of Medicare $124.50 200% of Medicare NULL NULL NULL 96116 NULL NULL NULL "Neurobehavioral status exam per hour, first hour" NULL PROFESSIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 $228.00 $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL NULL NULL 96121 NULL NULL NULL "Neurobehavioral status exam per hour, each addt'l hour" NULL PROFESSIONAL $279.00 1/1/2022-12/31/2022 $279.00 $116.62 $159.03 $205.07 $205.07 200% of Medicare 100% of Medicare $164.08 $157.94 $153.81 $116.62 100% of Medicaid 100% of Medicare 150% of Medicare $223.20 $279.00 $228.00 $225.99 $163.22 $163.22 $131.69 $179.51 100% of Medicare $223.20 $237.15 $219.02 $203.64 $223.20 $237.15 $191.81 100% of Medicare 100% of Medicare $209.25 200% of Medicare NULL NULL NULL 96132 NULL NULL NULL "Neuropsychological testing evaluation services performed by a professional, first hour" NULL PROFESSIONAL $299.00 1/1/2022-12/31/2022 $299.00 $81.60 $170.43 $219.77 $219.77 200% of Medicare 100% of Medicare $175.84 $169.26 $164.84 $124.98 100% of Medicaid 100% of Medicare 150% of Medicare $239.20 $299.00 $81.60 $242.19 $174.92 $174.92 $141.13 $192.38 100% of Medicare $239.20 $254.15 $234.72 $218.24 $239.20 $254.15 $205.56 100% of Medicare 100% of Medicare $224.25 200% of Medicare NULL NULL NULL 96133 NULL NULL NULL "Neuropsychological testing evaluation services performed by a professional, each addt'l hour" NULL PROFESSIONAL $299.00 1/1/2022-12/31/2022 $299.00 $81.60 $170.43 $219.77 $219.77 200% of Medicare 100% of Medicare $175.84 $169.26 $164.84 $124.98 100% of Medicaid 100% of Medicare 150% of Medicare $239.20 $299.00 $81.60 $242.19 $174.92 $174.92 $141.13 $192.38 100% of Medicare $239.20 $254.15 $234.72 $218.24 $239.20 $254.15 $205.56 100% of Medicare 100% of Medicare $224.25 200% of Medicare NULL NULL NULL 96138 NULL NULL NULL "Neuropsychological test administration and scoring by technician, first 30 mins" NULL PROFESSIONAL $107.00 1/1/2022-12/31/2022 $107.00 $44.73 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $62.93 $60.57 $58.99 $44.73 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 $102.00 $86.67 $62.60 $62.60 $50.50 $68.84 100% of Medicare $85.60 $90.95 $84.00 $78.10 $85.60 $90.95 $73.56 100% of Medicare 100% of Medicare $80.25 200% of Medicare NULL NULL NULL 96139 NULL NULL NULL "Neuropsychological test administration and scoring by technician, each addt'l 30 mins" NULL PROFESSIONAL $107.00 1/1/2022-12/31/2022 $107.00 $44.73 $60.99 $78.65 $78.65 200% of Medicare 100% of Medicare $62.93 $60.57 $58.99 $44.73 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 $91.20 $86.67 $62.60 $62.60 $50.50 $68.84 100% of Medicare $85.60 $90.95 $84.00 $78.10 $85.60 $90.95 $73.56 100% of Medicare 100% of Medicare $80.25 200% of Medicare NULL NULL NULL 99990 NULL NULL NULL Legal Consult NULL PROFESSIONAL $420.00 1/1/2022-12/31/2022 $420.00 $91.20 $239.40 $308.70 $308.70 200% of Medicare 100% of Medicare $247.00 $237.76 $231.55 $175.56 100% of Medicaid 100% of Medicare 150% of Medicare $336.00 $420.00 $91.20 $340.20 $245.70 $245.70 $198.24 $270.23 100% of Medicare $336.00 $357.00 $329.70 $306.56 $336.00 $357.00 $288.75 100% of Medicare 100% of Medicare $315.00 200% of Medicare NULL NULL NULL 90832 NULL NULL NULL "Psychotherapy, 30 mins" NULL PROFESSIONAL $149.00 1/1/2022-12/31/2022 $149.00 $32.00 $84.93 $109.52 $109.52 200% of Medicare 100% of Medicare $87.63 $84.35 $82.14 $62.28 100% of Medicaid 100% of Medicare 150% of Medicare $119.20 $149.00 $32.00 $120.69 $87.17 $87.17 $70.33 $95.87 100% of Medicare $119.20 $126.65 $116.97 $108.76 $119.20 $126.65 $102.44 100% of Medicare 100% of Medicare $111.75 200% of Medicare NULL NULL NULL 90834 NULL NULL NULL "Psychotherapy, 40 mins" NULL PROFESSIONAL $227.00 1/1/2022-12/31/2022 $227.00 $32.00 $129.39 $166.85 $166.85 200% of Medicare 100% of Medicare $133.50 $128.50 $125.15 $94.89 100% of Medicaid 100% of Medicare 150% of Medicare $181.60 $227.00 $32.00 $183.87 $132.80 $132.80 $107.14 $146.05 100% of Medicare $181.60 $192.95 $178.20 $165.69 $181.60 $192.95 $156.06 100% of Medicare 100% of Medicare $170.25 200% of Medicare NULL NULL NULL 90837 NULL NULL NULL "Psychotherapy, 60 mins" NULL PROFESSIONAL $342.00 1/1/2022-12/31/2022 $342.00 $89.60 $194.94 $251.37 $251.37 200% of Medicare 100% of Medicare $201.13 $193.61 $188.54 $142.96 100% of Medicaid 100% of Medicare 150% of Medicare $273.60 $342.00 $89.60 $277.02 $200.07 $200.07 $161.42 $220.04 100% of Medicare $273.60 $290.70 $268.47 $249.63 $273.60 $290.70 $235.13 100% of Medicare 100% of Medicare $256.50 200% of Medicare NULL NULL NULL 90846 NULL NULL NULL "Family, No Patient Psychotherapy" NULL PROFESSIONAL $259.00 1/1/2022-12/31/2022 $259.00 $89.60 $147.63 $190.37 $190.37 200% of Medicare 100% of Medicare $152.32 $146.62 $142.79 $108.26 100% of Medicaid 100% of Medicare 150% of Medicare $207.20 $259.00 $89.60 $209.79 $151.52 $151.52 $122.25 $166.64 100% of Medicare $207.20 $220.15 $203.32 $189.04 $207.20 $220.15 $178.06 100% of Medicare 100% of Medicare $194.25 200% of Medicare NULL NULL NULL 90847 NULL NULL NULL "Family, Patient Psychotherapy" NULL PROFESSIONAL $323.00 1/1/2022-12/31/2022 $323.00 $126.40 $184.11 $237.41 $237.41 200% of Medicare 100% of Medicare $189.96 $182.85 $178.07 $135.01 100% of Medicaid 100% of Medicare 150% of Medicare $258.40 $323.00 $126.40 $261.63 $188.96 $188.96 $152.46 $207.82 100% of Medicare $258.40 $274.55 $253.56 $235.76 $258.40 $274.55 $222.06 100% of Medicare 100% of Medicare $242.25 200% of Medicare NULL NULL NULL 90849 NULL NULL NULL Multiple Family Psychotherapy NULL PROFESSIONAL $87.00 1/1/2022-12/31/2022 $87.00 $36.37 $49.59 $63.95 $63.95 200% of Medicare 100% of Medicare $51.16 $49.25 $47.96 $36.37 100% of Medicaid 100% of Medicare 150% of Medicare $69.60 $87.00 $83.00 $70.47 $50.90 $50.90 $41.06 $55.98 100% of Medicare $69.60 $73.95 $68.30 $63.50 $69.60 $73.95 $59.81 100% of Medicare 100% of Medicare $65.25 200% of Medicare NULL NULL NULL 90853 NULL NULL NULL Group Psychotherapy NULL PROFESSIONAL $323.00 1/1/2022-12/31/2022 $323.00 $135.01 $184.11 $237.41 $237.41 200% of Medicare 100% of Medicare $189.96 $182.85 $178.07 $135.01 100% of Medicaid 100% of Medicare 150% of Medicare $258.40 $323.00 $308.00 $261.63 $188.96 $188.96 $152.46 $207.82 100% of Medicare $258.40 $274.55 $253.56 $235.76 $258.40 $274.55 $222.06 100% of Medicare 100% of Medicare $242.25 200% of Medicare NULL 300 NULL 86850 NULL NULL 797672 TB Skin Test NULL INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $27.59 $37.62 $48.51 $48.51 $45.76 100% of Medicare $38.81 $37.36 $36.39 $27.59 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $38.61 $38.61 $31.15 $42.46 100% of Medicare $52.80 $56.10 $51.81 $48.17 $52.80 $56.10 $45.38 100% of Medicare 100% of Medicare $49.50 200% of Medicare NULL 300 NULL 86580 NULL NULL 11601049 TB SKIN TEST NULL INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $27.59 $37.62 $48.51 $48.51 $45.76 100% of Medicare $38.81 $37.36 $36.39 $27.59 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $38.61 $38.61 $31.15 $42.46 100% of Medicare $52.80 $56.10 $51.81 $48.17 $52.80 $56.10 $45.38 100% of Medicare 100% of Medicare $49.50 200% of Medicare NULL 250 NULL NULL NULL NULL 12832704 albuterol CFC free 90 mcg/inh Inh Aer w/Adapt 00173-0682-24 INSTITUTIONAL $201.00 1/1/2022-12/31/2022 $201.00 $94.87 $114.57 $147.74 $147.74 $139.35 100% of Medicare $120.36 $115.86 $112.82 $128.64 100% of Medicaid 100% of Medicare 150% of Medicare $160.80 $201.00 195% of Medicare $162.81 $119.60 $119.60 $94.87 $201.00 100% of Medicare $160.80 $170.85 $180.90 $146.71 $170.85 $201.00 $201.00 100% of Medicare 100% of Medicare $201.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832707 albuterol-ipratropium Inh Aer w/Adapt 00597-0013-14 INSTITUTIONAL $868.00 1/1/2022-12/31/2022 $868.00 $409.70 $494.76 $637.98 $637.98 $601.78 100% of Medicare $519.76 $500.32 $487.21 $555.52 100% of Medicaid 100% of Medicare 150% of Medicare $694.40 $868.00 195% of Medicare $703.08 $516.46 $516.46 $409.70 $868.00 100% of Medicare $694.40 $737.80 $781.20 $633.55 $737.80 $868.00 $868.00 100% of Medicare 100% of Medicare $868.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832712 budesonide-formoterol 160 mcg-4.5 mcg/inh Inh Aer w/adapter 00186-0370-20 INSTITUTIONAL $464.00 1/1/2022-12/31/2022 $464.00 $219.01 $264.48 $341.04 $341.04 $321.69 100% of Medicare $277.84 $267.45 $260.44 $296.96 100% of Medicaid 100% of Medicare 150% of Medicare $371.20 $464.00 195% of Medicare $375.84 $276.08 $276.08 $219.01 $464.00 100% of Medicare $371.20 $394.40 $417.60 $338.67 $394.40 $464.00 $464.00 100% of Medicare 100% of Medicare $464.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832713 budesonide-formoterol 80 mcg-4.5 mcg/inh Inh Aer w/adapter 00186-0372-20 INSTITUTIONAL $464.00 1/1/2022-12/31/2022 $464.00 $219.01 $264.48 $341.04 $341.04 $321.69 100% of Medicare $277.84 $267.45 $260.44 $296.96 100% of Medicaid 100% of Medicare 150% of Medicare $371.20 $464.00 195% of Medicare $375.84 $276.08 $276.08 $219.01 $464.00 100% of Medicare $371.20 $394.40 $417.60 $338.67 $394.40 $464.00 $464.00 100% of Medicare 100% of Medicare $464.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832716 fluticasone CFC free 110 mcg/inh Inh Aer w/adapter 00173-0719-20 INSTITUTIONAL " $1,149.00 " 1/1/2022-12/31/2022 " $1,149.00 " $542.33 $654.93 $844.52 $844.52 $796.60 100% of Medicare $688.02 $662.28 $644.93 $735.36 100% of Medicaid 100% of Medicare 150% of Medicare $919.20 " $1,149.00 " 195% of Medicare $930.69 $683.66 $683.66 $542.33 " $1,149.00 " 100% of Medicare $919.20 $976.65 " $1,034.10 " $838.66 $976.65 " $1,149.00 " " $1,149.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832717 fluticasone CFC free 220 mcg/inh Inh Aer w/adapter 00173-0720-20 INSTITUTIONAL " $1,785.00 " 1/1/2022-12/31/2022 " $1,785.00 " $842.52 " $1,017.45 " " $1,311.98 " " $1,311.98 " " $1,237.54 " 100% of Medicare " $1,068.86 " " $1,028.87 " " $1,001.92 " " $1,142.40 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,428.00 " " $1,500.00 " 195% of Medicare " $1,445.85 " " $1,062.08 " " $1,062.08 " $842.52 " $1,359.00 " 100% of Medicare " $1,428.00 " " $1,517.25 " " $1,606.50 " " $1,302.87 " " $1,517.25 " " $1,500.00 " " $1,785.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832718 fluticasone CFC free 44 mcg/inh Inh Aer w/adapter 00173-0718-20 INSTITUTIONAL $858.00 1/1/2022-12/31/2022 $858.00 $404.98 $489.06 $630.63 $630.63 $594.85 100% of Medicare $513.77 $494.55 $481.60 $549.12 100% of Medicaid 100% of Medicare 150% of Medicare $686.40 $858.00 195% of Medicare $694.98 $510.51 $510.51 $404.98 $858.00 100% of Medicare $686.40 $729.30 $772.20 $626.25 $729.30 $858.00 $858.00 100% of Medicare 100% of Medicare $858.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832723 levalbuterol CFC free 45 mcg/inh Inh Aer w/adapter 63402-0510-01 INSTITUTIONAL $235.00 1/1/2022-12/31/2022 $235.00 $110.92 $133.95 $172.73 $172.73 $162.93 100% of Medicare $140.72 $135.45 $131.91 $150.40 100% of Medicaid 100% of Medicare 150% of Medicare $188.00 $235.00 195% of Medicare $190.35 $139.83 $139.83 $110.92 $235.00 100% of Medicare $188.00 $199.75 $211.50 $171.53 $199.75 $235.00 $235.00 100% of Medicare 100% of Medicare $235.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832725 mometasone 220 mcg/inh Inh Aer Pwdr 00085-1341-04 INSTITUTIONAL $304.00 1/1/2022-12/31/2022 $304.00 $143.49 $173.28 $223.44 $223.44 $210.76 100% of Medicare $182.04 $175.23 $170.64 $194.56 100% of Medicaid 100% of Medicare 150% of Medicare $243.20 $304.00 195% of Medicare $246.24 $180.88 $180.88 $143.49 $304.00 100% of Medicare $243.20 $258.40 $273.60 $221.89 $258.40 $304.00 $304.00 100% of Medicare 100% of Medicare $304.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832728 acebutolol 200 mg Cap 65162-0669-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832737 amantadine 100 mg Cap 51079-0481-20 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832738 amoxicillin 250 mg Cap 00093-3107-93 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832740 ampicillin 250 mg Cap 00781-2144-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832741 anagrelide 1 mg Cap 00172-5241-60 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832745 ASA/butalbital/caffeine Cap 00591-3219-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832750 atomoxetine 10 mg Cap 00002-3227-30 INSTITUTIONAL $101.00 1/1/2022-12/31/2022 $101.00 $47.67 $57.57 $74.24 $74.24 $70.02 100% of Medicare $60.48 $58.22 $56.69 $64.64 100% of Medicaid 100% of Medicare 150% of Medicare $80.80 $101.00 195% of Medicare $81.81 $60.10 $60.10 $47.67 $101.00 100% of Medicare $80.80 $85.85 $90.90 $73.72 $85.85 $101.00 $101.00 100% of Medicare 100% of Medicare $101.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832751 atomoxetine 18 mg Cap 00002-3238-30 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 $22.19 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832753 atomoxetine 40 mg Cap 00002-3229-30 INSTITUTIONAL $61.00 1/1/2022-12/31/2022 $61.00 $28.79 $34.77 $44.84 $44.84 $42.29 100% of Medicare $36.53 $35.16 $34.24 $39.04 100% of Medicaid 100% of Medicare 150% of Medicare $48.80 $61.00 195% of Medicare $49.41 $36.30 $36.30 $28.79 $61.00 100% of Medicare $48.80 $51.85 $54.90 $44.52 $51.85 $61.00 $61.00 100% of Medicare 100% of Medicare $61.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832754 atomoxetine 60 mg Cap 00002-3239-30 INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $26.43 $31.92 $41.16 $41.16 $38.82 100% of Medicare $33.53 $32.28 $31.43 $35.84 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $33.32 $33.32 $26.43 $56.00 100% of Medicare $44.80 $47.60 $50.40 $40.87 $47.60 $56.00 $56.00 100% of Medicare 100% of Medicare $56.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832756 balsalazide 750 mg Cap 00378-6750-82 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832757 benzonatate 100 mg Cap 67877-0105-01 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832761 calcitriol 0.25 mcg Oral Cap 00054-0007-13 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832763 calcium acetate 667 mg Cap 00054-0088-26 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832767 cefdinir 300 mg Cap 00781-2176-60 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832769 celecoxib 100 mg Cap 00025-1520-34 INSTITUTIONAL $62.00 1/1/2022-12/31/2022 $62.00 $29.26 $35.34 $45.57 $45.57 $42.98 100% of Medicare $37.13 $35.74 $34.80 $39.68 100% of Medicaid 100% of Medicare 150% of Medicare $49.60 $62.00 195% of Medicare $50.22 $36.89 $36.89 $29.26 $62.00 100% of Medicare $49.60 $52.70 $55.80 $45.25 $52.70 $62.00 $62.00 100% of Medicare 100% of Medicare $62.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832770 celecoxib 200 mg Cap 00025-1525-34 INSTITUTIONAL $34.00 1/1/2022-12/31/2022 $34.00 $16.05 $19.38 $24.99 $24.99 $23.57 100% of Medicare $20.36 $19.60 $19.08 $21.76 100% of Medicaid 100% of Medicare 150% of Medicare $27.20 $34.00 195% of Medicare $27.54 $20.23 $20.23 $16.05 $34.00 100% of Medicare $27.20 $28.90 $30.60 $24.82 $28.90 $34.00 $34.00 100% of Medicare 100% of Medicare $34.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832774 cephalexin 500 mg Cap 62756-0294-88 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832777 chlordiazepoxide 5 mg Cap 51079-0374-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832783 clindamycin 150 mg Cap 68084-0243-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832785 clomiPRAMINE 50 mg Cap 00078-0317-06 INSTITUTIONAL $67.00 1/1/2022-12/31/2022 $67.00 $31.62 $38.19 $49.25 $49.25 $46.45 100% of Medicare $40.12 $38.62 $37.61 $42.88 100% of Medicaid 100% of Medicare 150% of Medicare $53.60 $67.00 195% of Medicare $54.27 $39.87 $39.87 $31.62 $67.00 100% of Medicare $53.60 $56.95 $60.30 $48.90 $56.95 $67.00 $67.00 100% of Medicare 100% of Medicare $67.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832790 cycloSPORINE microEmul 100 mg Cap 00172-7312-46 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832791 cycloSPORINE microEmul 25 mg Cap 00591-2222-15 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832792 cycloSPORINE microEmul 100 mg Cap 00078-0248-15 INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 $47.84 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832793 cycloSPORINE microEmul 25 mg Cap 00078-0246-15 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832794 dabigatran 150 mg Cap UD 00597-0135-60 INSTITUTIONAL $51.00 1/1/2022-12/31/2022 $51.00 $24.07 $29.07 $37.49 $37.49 $35.36 100% of Medicare $30.54 $29.40 $28.63 $32.64 100% of Medicaid 100% of Medicare 150% of Medicare $40.80 $51.00 195% of Medicare $41.31 $30.35 $30.35 $24.07 $51.00 100% of Medicare $40.80 $43.35 $45.90 $37.22 $43.35 $51.00 $51.00 100% of Medicare 100% of Medicare $51.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832795 dabigatran 75 mg Cap UD 00597-0149-60 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832796 danazol 100 mg Cap 00024-0304-06 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832798 dantrolene 25 mg Cap 00115-4411-01 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832804 diphenhydrAMINE 25 mg Cap 00904-5306-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12832805 diphenhydrAMINE 50 mg Cap 00904-2056-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832810 docusate sodium 100 mg Cap 00904-2244-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12832813 dofetilide 250 mcg Cap 00069-5810-43 INSTITUTIONAL $79.00 1/1/2022-12/31/2022 $79.00 $37.29 $45.03 $58.07 $58.07 $54.77 100% of Medicare $47.31 $45.54 $44.34 $50.56 100% of Medicaid 100% of Medicare 150% of Medicare $63.20 $79.00 195% of Medicare $63.99 $47.01 $47.01 $37.29 $79.00 100% of Medicare $63.20 $67.15 $71.10 $57.66 $67.15 $79.00 $79.00 100% of Medicare 100% of Medicare $79.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832815 doxepin 10 mg Cap 51079-0436-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832817 Doxepin Cap 25 mg 51079-0437-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832824 dronabinol 2.5 mg Cap 49884-0867-02 INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 $26.35 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832826 dutasteride 0.5 mg Cap 00173-0712-15 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832829 emtricitabine 200 mg Cap 61958-0601-01 INSTITUTIONAL $137.00 1/1/2022-12/31/2022 $137.00 $64.66 $78.09 $100.70 $100.70 $94.98 100% of Medicare $82.04 $78.97 $76.90 $87.68 100% of Medicaid 100% of Medicare 150% of Medicare $109.60 $137.00 195% of Medicare $110.97 $81.52 $81.52 $64.66 $137.00 100% of Medicare $109.60 $116.45 $123.30 $100.00 $116.45 $137.00 $137.00 100% of Medicare 100% of Medicare $137.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832831 " ergocalciferol 50,000 intl units Cap" 64980-0157-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832843 Flax seed Oil 1000mg 11845-0131-31 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832846 fluoxetine 10 mg Cap 00904-5784-61 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832847 FLUoxetine Cap 20 mg 00904-5785-61 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832852 formoterol 12 mcg Inh Cap 00085-1402-01 INSTITUTIONAL $248.00 1/1/2022-12/31/2022 $248.00 $117.06 $141.36 $182.28 $182.28 $171.94 100% of Medicare $148.50 $142.95 $139.20 $158.72 100% of Medicaid 100% of Medicare 150% of Medicare $198.40 $248.00 195% of Medicare $200.88 $147.56 $147.56 $117.06 $248.00 100% of Medicare $198.40 $210.80 $223.20 $181.02 $210.80 $248.00 $248.00 100% of Medicare 100% of Medicare $248.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832853 gabapentin 100 mg Cap 00904-6078-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832854 gabapentin 300 mg Cap 68084-0563-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832855 gabapentin 400 mg Cap 00904-6105-61 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832856 Glucosamine/Chondroitin 500/400mg 00904-5481-52 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12832857 hydrochlorothiazide 12.5 mg Cap 51079-0776-20 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832859 hydroxyurea 500 mg Cap 49884-0724-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832860 hydrOXYzine pamoate 25 mg Cap 00185-0613-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832869 indomethacin 25 mg Cap 51079-0190-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12832888 lisdexamfetamine 20 mg Cap 59417-0102-10 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832889 lisdexamfetamine 30 mg oral capsule 59417-0103-10 INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 $27.73 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832890 lisdexamfetamine 50 mg oral capsule 59417-0105-10 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832892 Lithium Carbonate 150mg 00054-8526-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832902 Lubiprostone Cap 24 mCg 64764-0240-60 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832903 lubiprostone 8 mcg Cap 64764-0080-60 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 $32.59 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832910 mexiletine 150 mg Cap 00093-8739-01 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832911 mexiletine 200 mg Cap 00093-8740-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832913 minocycline 100 mg Cap 00591-5695-50 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832914 minocycline 50 mg Cap 63304-0694-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832918 mycophenolate mofetil 250 mg Cap 51079-0721-20 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832919 NIFEdipine 10 mg Cap 43386-0440-24 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832921 nimodipine 30 mg Cap 23155-0108-30 INSTITUTIONAL $122.00 1/1/2022-12/31/2022 $122.00 $57.58 $69.54 $89.67 $89.67 $84.58 100% of Medicare $73.05 $70.32 $68.48 $78.08 100% of Medicaid 100% of Medicare 150% of Medicare $97.60 $122.00 195% of Medicare $98.82 $72.59 $72.59 $57.58 $122.00 100% of Medicare $97.60 $103.70 $109.80 $89.05 $103.70 $122.00 $122.00 100% of Medicare 100% of Medicare $122.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832923 nitrofurantoin macrocrystals-monohydrate 100 mg Cap 51079-0348-20 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832933 omeprazole-sodium bicarbonate 20 mg-1100 mg oral capsule 68012-0104-30 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832935 oseltamivir 75 mg Cap 00004-0800-85 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 $22.19 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832939 paricalcitol 1 mcg oral capsule 00074-4317-30 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 $20.80 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832948 prazosin 1 mg Cap 51079-0630-20 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832951 pregabalin 100 mg oral capsule 00071-1015-68 INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 $37.44 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832952 pregabalin 150 mg oral capsule 00071-1016-68 INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 $43.68 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832955 pregabalin 25 mg oral capsule 00071-1012-68 INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 $43.68 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832957 pregabalin 75 mg oral capsule 00071-1014-68 INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 $47.84 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832959 Progesterone 100mg 00032-1708-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832961 quinine 324 mg oral capsule 13310-0153-07 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832966 ribavirin 200 mg Cap 00085-1194-03 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832969 rifampin 300 mg Cap 00527-1315-30 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832970 ritonavir 100 mg Cap 00074-6633-30 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832971 rivastigmine 1.5 mg Cap 00781-2614-13 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832975 saccharomyces boulardii lyo 250 mg oral capsule 66825-0002-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12832978 selegiline 5 mg Tab 67253-0700-06 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832993 Tacrolimus Cap (Prograf) **5 mg** 00469-0657-11 INSTITUTIONAL $230.00 1/1/2022-12/31/2022 $230.00 $108.56 $131.10 $169.05 $169.05 $159.46 100% of Medicare $137.72 $132.57 $129.10 $147.20 100% of Medicaid 100% of Medicare 150% of Medicare $184.00 $230.00 195% of Medicare $186.30 $136.85 $136.85 $108.56 $230.00 100% of Medicare $184.00 $195.50 $207.00 $167.88 $195.50 $230.00 $230.00 100% of Medicare 100% of Medicare $230.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832995 tacrolimus 1 mg Cap 00469-0617-11 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832998 tacrolimus 1 mg Cap 68084-0450-01 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12832999 tamsulosin 0.4 mg Oral Cap 00904-6156-61 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 $18.72 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833000 temazepam 15 mg Cap 51079-0418-21 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833001 temazepam 30 mg Cap 51079-0419-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833002 temazepam 7.5 mg Cap 00406-9960-01 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833007 terazosin 1 mg Cap 51079-0936-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833028 Ursodiol Cap 300 mg 00904-6221-60 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833032 " vitamin A 10,000 units Cap" 00904-2085-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833034 Vitamin B Complex with C and Folic Acid Cap 60258-0162-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833035 vitamin E 100 intl units Cap 00904-0270-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833036 vitamin E 200 intl units Cap 00904-0272-60 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833041 zinc sulfate 220 mg Cap 00904-5332-60 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833042 ziprasidone 20 mg Cap 00904-6269-08 INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $26.90 $32.49 $41.90 $41.90 $39.52 100% of Medicare $34.13 $32.85 $31.99 $36.48 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.92 $33.92 $26.90 $57.00 100% of Medicare $45.60 $48.45 $51.30 $41.60 $48.45 $57.00 $57.00 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833046 zonisamide 100 mg Cap 62756-0260-02 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833054 didanosine 400 mg Oral EC Cap 00087-6674-17 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833055 divalproex sodium 125 mg Oral EC Cap 68084-0313-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833056 duloxetine 20 mg Cap 00002-3235-60 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833057 duloxetine 30 mg Cap 00002-3240-33 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833065 omeprazole 20 mg Oral EC Cap 68084-0128-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833067 " pancrelipase 60,000 units-12,000 units-38,000 units Cap-" 00032-1212-01 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833085 amphetamine-dextroamphetamine 5 mg ERCap 00115-1328-01 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 $27.04 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833086 aspirin-dipyridamole 25 mg-200 mg ERCap 00597-0001-60 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 $27.04 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833087 budesonide 3 mg ERCap 51079-0020-03 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833103 diltiazem 120 mg/24 hours ERCap 63739-0283-10 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833104 Diltiazem Cap CD 180 mg 62584-0975-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833105 diltiazem 240 mg/24 hours ERCap 63739-0285-10 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833120 indomethacin 75 mg ERCap 00185-0720-60 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833150 niacin 250 mg ERCap 00904-0629-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833151 niacin 500 mg ERCap 00904-0631-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833152 nitroglycerin 6.5 mg ERCap 00904-0644-60 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833162 potassium chloride 10 mEq ERCap 68084-0419-01 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833168 propranolol 60 mg ERCap 43478-0900-88 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833169 propranolol 80 mg ERCap 43478-0901-88 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833170 theophylline 100 mg/24 hours Oral ER Cap 50474-0100-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833179 venlafaxine 150 mg ERCap 68084-0486-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833181 Venlafaxine Cap XR 75 mg 00904-6247-61 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833183 verapamil 180 mg ERCap 00378-6380-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833187 Vitamin B Complex Cap 00536-4787-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833188 Vitamin B12/B6/FA 68308-0324-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833194 haloperidol 2 mg/mL Oral Conc 00121-0581-04 INSTITUTIONAL " $1,193.00 " 1/1/2022-12/31/2022 " $1,193.00 " $563.10 $680.01 $876.86 $876.86 $827.11 100% of Medicare $714.37 $687.65 $669.63 $763.52 100% of Medicaid 100% of Medicare 150% of Medicare $954.40 " $1,193.00 " 195% of Medicare $966.33 $709.84 $709.84 $563.10 " $1,193.00 " 100% of Medicare $954.40 " $1,014.05 " " $1,073.70 " $870.77 " $1,014.05 " " $1,193.00 " " $1,193.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833195 lorazepam 2 mg/mL Oral Conc 00054-3532-44 INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $33.04 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.92 $40.35 $39.29 $44.80 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $41.65 $41.65 $33.04 $70.00 100% of Medicare $56.00 $59.50 $63.00 $51.09 $59.50 $70.00 $70.00 100% of Medicare 100% of Medicare $70.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833196 magnesium hydroxide 24% Oral Conc 10 mL 00121-0527-10 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833201 sertraline 20 mg/mL Oral Conc 59762-4940-01 INSTITUTIONAL $153.00 1/1/2022-12/31/2022 $153.00 $72.22 $87.21 $112.46 $112.46 $106.07 100% of Medicare $91.62 $88.19 $85.88 $97.92 100% of Medicaid 100% of Medicare 150% of Medicare $122.40 $153.00 195% of Medicare $123.93 $91.04 $91.04 $72.22 $153.00 100% of Medicare $122.40 $130.05 $137.70 $111.67 $130.05 $153.00 $153.00 100% of Medicare 100% of Medicare $153.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833205 azelaic acid Top 20% Crm 00023-8694-30 INSTITUTIONAL $851.00 1/1/2022-12/31/2022 $851.00 $401.67 $485.07 $625.49 $625.49 $590.00 100% of Medicare $509.58 $490.52 $477.67 $544.64 100% of Medicaid 100% of Medicare 150% of Medicare $680.80 $851.00 195% of Medicare $689.31 $506.35 $506.35 $401.67 $851.00 100% of Medicare $680.80 $723.35 $765.90 $621.14 $723.35 $851.00 $851.00 100% of Medicare 100% of Medicare $851.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833206 betamethasone Top dipropionate 0.05% Crm 00168-0055-15 INSTITUTIONAL $336.00 1/1/2022-12/31/2022 $336.00 $158.59 $191.52 $246.96 $246.96 $232.95 100% of Medicare $201.20 $193.67 $188.60 $215.04 100% of Medicaid 100% of Medicare 150% of Medicare $268.80 $336.00 195% of Medicare $272.16 $199.92 $199.92 $158.59 $336.00 100% of Medicare $268.80 $285.60 $302.40 $245.25 $285.60 $336.00 $336.00 100% of Medicare 100% of Medicare $336.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833208 calcipotriene Top 0.005% Crm 66993-0877-61 INSTITUTIONAL " $1,426.00 " 1/1/2022-12/31/2022 " $1,426.00 " $673.07 $812.82 " $1,048.11 " " $1,048.11 " $988.65 100% of Medicare $853.89 $821.95 $800.41 $912.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,140.80 " " $1,426.00 " 195% of Medicare " $1,155.06 " $848.47 $848.47 $673.07 " $1,359.00 " 100% of Medicare " $1,140.80 " " $1,212.10 " " $1,283.40 " " $1,040.84 " " $1,212.10 " " $1,426.00 " " $1,426.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833209 capsaicin Top 0.025% Crm 00603-0648-88 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833210 capsaicin Top 0.075% Crm 00603-0649-88 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833212 clobetasol Top 0.05% Crm 51672-1258-02 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 $32.59 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833215 clotrimazole Top 1% Crm 45802-0434-11 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833217 betamethasone-clotrimazole Top 0.05%-1% Crm 51672-4048-01 INSTITUTIONAL $195.00 1/1/2022-12/31/2022 $195.00 $92.04 $111.15 $143.33 $143.33 $135.19 100% of Medicare $116.77 $112.40 $109.45 $124.80 100% of Medicaid 100% of Medicare 150% of Medicare $156.00 $195.00 195% of Medicare $157.95 $116.03 $116.03 $92.04 $195.00 100% of Medicare $156.00 $165.75 $175.50 $142.33 $165.75 $195.00 $195.00 100% of Medicare 100% of Medicare $195.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833225 diphenhydramine-zinc acetate Top 2%-0.1% Crm 45802-0358-03 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 $17.33 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833226 docosanol Top 10% Crm 00135-0200-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833229 econazole Top 1% Crm 51672-1303-01 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833233 conjugated estrogens 0.625 mg/g Vag Crm w/Appl 00046-0872-21 INSTITUTIONAL " $1,385.00 " 1/1/2022-12/31/2022 " $1,385.00 " $653.72 $789.45 " $1,017.98 " " $1,017.98 " $960.22 100% of Medicare $829.34 $798.31 $777.40 $886.40 100% of Medicaid 100% of Medicare 150% of Medicare " $1,108.00 " " $1,385.00 " 195% of Medicare " $1,121.85 " $824.08 $824.08 $653.72 " $1,359.00 " 100% of Medicare " $1,108.00 " " $1,177.25 " " $1,246.50 " " $1,010.91 " " $1,177.25 " " $1,385.00 " " $1,385.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833237 fluocinonide Top 0.05% Crm 51672-1253-02 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833238 fluocinonide Top 0.05% Crm 51672-1253-03 INSTITUTIONAL " $1,159.00 " 1/1/2022-12/31/2022 " $1,159.00 " $547.05 $660.63 $851.87 $851.87 $803.53 100% of Medicare $694.01 $668.05 $650.55 $741.76 100% of Medicaid 100% of Medicare 150% of Medicare $927.20 " $1,159.00 " 195% of Medicare $938.79 $689.61 $689.61 $547.05 " $1,159.00 " 100% of Medicare $927.20 $985.15 " $1,043.10 " $845.95 $985.15 " $1,159.00 " " $1,159.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833243 gentamicin Top 0.1% Crm 45802-0056-35 INSTITUTIONAL $51.00 1/1/2022-12/31/2022 $51.00 $24.07 $29.07 $37.49 $37.49 $35.36 100% of Medicare $30.54 $29.40 $28.63 $32.64 100% of Medicaid 100% of Medicare 150% of Medicare $40.80 $51.00 195% of Medicare $41.31 $30.35 $30.35 $24.07 $51.00 100% of Medicare $40.80 $43.35 $45.90 $37.22 $43.35 $51.00 $51.00 100% of Medicare 100% of Medicare $51.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833247 Hydrocortisone 1% 00603-0535-50 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833248 Hydrocortisone 2.5% 00168-0080-31 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833251 hydrocortisone Top 0.5% Crm 00168-0014-31 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833252 hydrocortisone 2.5% Rectal Crm w/Appl 64980-0301-30 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833256 ketoconazole Top 2% Crm 51672-1298-02 INSTITUTIONAL $773.00 1/1/2022-12/31/2022 $773.00 $364.86 $440.61 $568.16 $568.16 $535.92 100% of Medicare $462.87 $445.56 $433.88 $494.72 100% of Medicaid 100% of Medicare 150% of Medicare $618.40 $773.00 195% of Medicare $626.13 $459.94 $459.94 $364.86 $773.00 100% of Medicare $618.40 $657.05 $695.70 $564.21 $657.05 $773.00 $773.00 100% of Medicare 100% of Medicare $773.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833261 Mafenide Cream 8.5% 57 GM 51079-0623-81 INSTITUTIONAL $462.00 1/1/2022-12/31/2022 $462.00 $218.06 $263.34 $339.57 $339.57 $320.30 100% of Medicare $276.65 $266.30 $259.32 $295.68 100% of Medicaid 100% of Medicare 150% of Medicare $369.60 $462.00 195% of Medicare $374.22 $274.89 $274.89 $218.06 $462.00 100% of Medicare $369.60 $392.70 $415.80 $337.21 $392.70 $462.00 $462.00 100% of Medicare 100% of Medicare $462.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833267 mupirocin Top 2% Crm 00029-1527-22 INSTITUTIONAL $263.00 1/1/2022-12/31/2022 $263.00 $124.14 $149.91 $193.31 $193.31 $182.34 100% of Medicare $157.48 $151.59 $147.62 $168.32 100% of Medicaid 100% of Medicare 150% of Medicare $210.40 $263.00 195% of Medicare $213.03 $156.49 $156.49 $124.14 $263.00 100% of Medicare $210.40 $223.55 $236.70 $191.96 $223.55 $263.00 $263.00 100% of Medicare 100% of Medicare $263.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833268 Muscle Rub 45802-0174-53 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833272 nystatin-triamcinolone Top Crm 51672-1263-02 INSTITUTIONAL $297.00 1/1/2022-12/31/2022 $297.00 $140.18 $169.29 $218.30 $218.30 $205.91 100% of Medicare $177.84 $171.19 $166.71 $190.08 100% of Medicaid 100% of Medicare 150% of Medicare $237.60 $297.00 195% of Medicare $240.57 $176.72 $176.72 $140.18 $297.00 100% of Medicare $237.60 $252.45 $267.30 $216.78 $252.45 $297.00 $297.00 100% of Medicare 100% of Medicare $297.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833274 permethrin Top 5% Crm 45802-0269-37 INSTITUTIONAL $441.00 1/1/2022-12/31/2022 $441.00 $208.15 $251.37 $324.14 $324.14 $305.75 100% of Medicare $264.07 $254.19 $247.53 $282.24 100% of Medicaid 100% of Medicare 150% of Medicare $352.80 $441.00 195% of Medicare $357.21 $262.40 $262.40 $208.15 $441.00 100% of Medicare $352.80 $374.85 $396.90 $321.89 $374.85 $441.00 $441.00 100% of Medicare 100% of Medicare $441.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833275 pimecrolimus Top Crm 00187-5101-02 INSTITUTIONAL " $1,744.00 " 1/1/2022-12/31/2022 " $1,744.00 " $823.17 $994.08 " $1,281.84 " " $1,281.84 " " $1,209.12 " 100% of Medicare " $1,044.31 " " $1,005.24 " $978.91 " $1,116.16 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,395.20 " " $1,500.00 " 195% of Medicare " $1,412.64 " " $1,037.68 " " $1,037.68 " $823.17 " $1,359.00 " 100% of Medicare " $1,395.20 " " $1,482.40 " " $1,569.60 " " $1,272.95 " " $1,482.40 " " $1,500.00 " " $1,744.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833278 silver sulfADIAZINE Top 1% Crm 00591-0810-55 INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $26.90 $32.49 $41.90 $41.90 $39.52 100% of Medicare $34.13 $32.85 $31.99 $36.48 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.92 $33.92 $26.90 $57.00 100% of Medicare $45.60 $48.45 $51.30 $41.60 $48.45 $57.00 $57.00 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833281 terbinafine Top 1% Crm 51672-2080-02 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833284 tolnaftate Top 1% Crm 45802-0032-03 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 $22.19 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833291 triamcinolone Top 0.1% Crm 00168-0004-80 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 $61.70 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833293 trolamine salicylate Top 10% Crm 45802-0356-53 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833297 miconazole 2% Vag Crm w/Appl 00713-0252-37 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833303 teriparatide 600 mcg/2.4 mL Devi 00002-8400-01 INSTITUTIONAL " $4,800.00 " 1/1/2022-12/31/2022 " $4,320.00 " $975.00 " $2,736.00 " " $3,528.00 " " $3,528.00 " " $3,327.84 " 100% of Medicare " $2,874.24 " " $2,766.72 " " $2,694.24 " " $3,072.00 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,840.00 " " $1,500.00 " 195% of Medicare " $3,888.00 " " $2,856.00 " " $2,856.00 " " $2,265.60 " " $1,359.00 " 100% of Medicare " $3,840.00 " " $4,080.00 " " $4,320.00 " " $3,503.52 " " $4,080.00 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833311 ferrous sulfate 220 mg/5 mL Oral Elix 00904-1465-16 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833315 acetaminophen-HYDROcodone 500 mg-7.5 mg/15 mL Oral Elix 15 mL 00121-0655-15 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833319 phenobarbital 20 mg/5 mL Oral Elix 00603-1508-58 INSTITUTIONAL $287.00 1/1/2022-12/31/2022 $287.00 $135.46 $163.59 $210.95 $210.95 $198.98 100% of Medicare $171.86 $165.43 $161.09 $183.68 100% of Medicaid 100% of Medicare 150% of Medicare $229.60 $287.00 195% of Medicare $232.47 $170.77 $170.77 $135.46 $287.00 100% of Medicare $229.60 $243.95 $258.30 $209.48 $243.95 $287.00 $287.00 100% of Medicare 100% of Medicare $287.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833321 theophylline 80 mg/15 mL Oral Elix 49708-0644-90 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833323 " emollients, topical - Emul" 00062-0205-02 INSTITUTIONAL $192.00 1/1/2022-12/31/2022 $192.00 $90.62 $109.44 $141.12 $141.12 $133.11 100% of Medicare $114.97 $110.67 $107.77 $122.88 100% of Medicaid 100% of Medicare 150% of Medicare $153.60 $192.00 195% of Medicare $155.52 $114.24 $114.24 $90.62 $192.00 100% of Medicare $153.60 $163.20 $172.80 $140.14 $163.20 $192.00 $192.00 100% of Medicare 100% of Medicare $192.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833325 docusate 283 mg Rectal Enema 17433-9876-03 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 $17.33 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833327 mesalamine 4 g/60 mL Rectal Enema 45802-0098-51 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 $41.60 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833328 mineral oil 100% Rectal Enema 133 mL 00904-5895-78 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833329 sodium biphosphate-sodium phosphate 19 g-7 g Rectal Enema 135 mL 00904-3535-78 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833337 lidocaine Top 5% film 63481-0687-06 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 $41.60 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833340 hydrocortisone-pramoxine Rectal Foam 68220-0144-10 INSTITUTIONAL $367.00 1/1/2022-12/31/2022 $367.00 $173.22 $209.19 $269.75 $269.75 $254.44 100% of Medicare $219.76 $211.54 $206.00 $234.88 100% of Medicaid 100% of Medicare 150% of Medicare $293.60 $367.00 195% of Medicare $297.27 $218.37 $218.37 $173.22 $367.00 100% of Medicare $293.60 $311.95 $330.30 $267.87 $311.95 $367.00 $367.00 100% of Medicare 100% of Medicare $367.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833341 Pramoxine Foam 1% 15 GM 51862-0180-15 INSTITUTIONAL $72.00 1/1/2022-12/31/2022 $72.00 $33.98 $41.04 $52.92 $52.92 $49.92 100% of Medicare $43.11 $41.50 $40.41 $46.08 100% of Medicaid 100% of Medicare 150% of Medicare $57.60 $72.00 195% of Medicare $58.32 $42.84 $42.84 $33.98 $72.00 100% of Medicare $57.60 $61.20 $64.80 $52.55 $61.20 $72.00 $72.00 100% of Medicare 100% of Medicare $72.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833344 benzocaine Top 20% mucous membrane gel 10310-0283-40 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833347 benzoyl peroxide Top 5% Gel 45802-0216-96 INSTITUTIONAL $82.00 1/1/2022-12/31/2022 $82.00 $38.70 $46.74 $60.27 $60.27 $56.85 100% of Medicare $49.10 $47.26 $46.03 $52.48 100% of Medicaid 100% of Medicare 150% of Medicare $65.60 $82.00 195% of Medicare $66.42 $48.79 $48.79 $38.70 $82.00 100% of Medicare $65.60 $69.70 $73.80 $59.85 $69.70 $82.00 $82.00 100% of Medicare 100% of Medicare $82.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833349 clindamycin Top 1% Gel 00168-0202-30 INSTITUTIONAL $188.00 1/1/2022-12/31/2022 $188.00 $88.74 $107.16 $138.18 $138.18 $130.34 100% of Medicare $112.57 $108.36 $105.52 $120.32 100% of Medicaid 100% of Medicare 150% of Medicare $150.40 $188.00 195% of Medicare $152.28 $111.86 $111.86 $88.74 $188.00 100% of Medicare $150.40 $159.80 $169.20 $137.22 $159.80 $188.00 $188.00 100% of Medicare 100% of Medicare $188.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833352 diclofenac Top 1% gel 63481-0684-47 INSTITUTIONAL $94.00 1/1/2022-12/31/2022 $94.00 $44.37 $53.58 $69.09 $69.09 $65.17 100% of Medicare $56.29 $54.18 $52.76 $60.16 100% of Medicaid 100% of Medicare 150% of Medicare $75.20 $94.00 195% of Medicare $76.14 $55.93 $55.93 $44.37 $94.00 100% of Medicare $75.20 $79.90 $84.60 $68.61 $79.90 $94.00 $94.00 100% of Medicare 100% of Medicare $94.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833359 lidocaine Top 2% Gel w/Appl 17478-0711-30 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833363 MetroNIDAZOLE Gel 0.75% 45 GM 00168-0275-45 INSTITUTIONAL $557.00 1/1/2022-12/31/2022 $557.00 $262.90 $317.49 $409.40 $409.40 $386.17 100% of Medicare $333.53 $321.05 $312.64 $356.48 100% of Medicaid 100% of Medicare 150% of Medicare $445.60 $557.00 195% of Medicare $451.17 $331.42 $331.42 $262.90 $557.00 100% of Medicare $445.60 $473.45 $501.30 $406.55 $473.45 $557.00 $557.00 100% of Medicare 100% of Medicare $557.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833364 metronidazole 0.75% Vag Gel w/Appl 00245-0860-70 INSTITUTIONAL $605.00 1/1/2022-12/31/2022 $605.00 $285.56 $344.85 $444.68 $444.68 $419.45 100% of Medicare $362.27 $348.72 $339.59 $387.20 100% of Medicaid 100% of Medicare 150% of Medicare $484.00 $605.00 195% of Medicare $490.05 $359.98 $359.98 $285.56 $605.00 100% of Medicare $484.00 $514.25 $544.50 $441.59 $514.25 $605.00 $605.00 100% of Medicare 100% of Medicare $605.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833370 Silver Dressing 08327-0309-09 INSTITUTIONAL $194.00 1/1/2022-12/31/2022 $194.00 $91.57 $110.58 $142.59 $142.59 $134.50 100% of Medicare $116.17 $111.82 $108.89 $124.16 100% of Medicaid 100% of Medicare 150% of Medicare $155.20 $194.00 195% of Medicare $157.14 $115.43 $115.43 $91.57 $194.00 100% of Medicare $155.20 $164.90 $174.60 $141.60 $164.90 $194.00 $194.00 100% of Medicare 100% of Medicare $194.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833371 testosterone 50 mg/5 g TD Gel 00051-8450-30 INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $36.82 $44.46 $57.33 $57.33 $54.08 100% of Medicare $46.71 $44.96 $43.78 $49.92 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $46.41 $46.41 $36.82 $78.00 100% of Medicare $62.40 $66.30 $70.20 $56.93 $66.30 $78.00 $78.00 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833374 ocular lubricant Gel 00078-0429-97 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833375 lactobacillus acidophilus and bulgaricus Oral Gran 64980-0146-12 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833379 erythromycin ethylsuccinate 200 mg/5 mL Oral Liq 24338-0134-02 INSTITUTIONAL $972.00 1/1/2022-12/31/2022 $972.00 $458.78 $554.04 $714.42 $714.42 $673.89 100% of Medicare $582.03 $560.26 $545.58 $622.08 100% of Medicaid 100% of Medicare 150% of Medicare $777.60 $972.00 195% of Medicare $787.32 $578.34 $578.34 $458.78 $972.00 100% of Medicare $777.60 $826.20 $874.80 $709.46 $826.20 $972.00 $972.00 100% of Medicare 100% of Medicare $972.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833383 nicotine 2 mg Oral transmucosal Gum 00536-1362-23 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833384 nicotine 4 mg Oral transmucosal Gum 00536-3030-06 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833392 acetylcysteine 10% Inh Sol 4 mL 00517-7504-25 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833393 acetylcysteine 20% Inh Sol 00517-7604-25 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833396 albuterol 0.5% Inh Sol 00487-9901-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833398 Albuterol-Ipratropium Inh Soln 3 mL 00487-0201-01 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833399 arformoterol 15 mcg/2 mL Inh Sol 63402-0911-30 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833401 cromolyn 10 mg/mL Inh Sol 00172-6406-59 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833402 racepinephrine 2.25% Soln UD 00487-5901-99 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833405 ipratropium 0.02% Inh Sol 2 mL 00487-9801-30 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833406 levalbuterol 0.63 mg/3 mL Inh Sol 00591-2919-23 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833408 levalbuterol 1.25 mg/3 mL Inh Sol 00591-2920-23 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833411 pentamidine 300 mg Inh Pwdr for Recon 63323-0877-15 INSTITUTIONAL $395.00 1/1/2022-12/31/2022 $395.00 $186.44 $225.15 $290.33 $290.33 $273.85 100% of Medicare $236.53 $227.68 $221.71 $252.80 100% of Medicaid 100% of Medicare 150% of Medicare $316.00 $395.00 195% of Medicare $319.95 $235.03 $235.03 $186.44 $395.00 100% of Medicare $316.00 $335.75 $355.50 $288.31 $335.75 $395.00 $395.00 100% of Medicare 100% of Medicare $395.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833416 sodium chloride 7% Inh Sol 4 mL 83490-0107-60 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833418 Tiotropium Inh Cap 18 mCg #5 00597-0075-75 INSTITUTIONAL $178.00 1/1/2022-12/31/2022 $178.00 $84.02 $101.46 $130.83 $130.83 $123.41 100% of Medicare $106.59 $102.60 $99.91 $113.92 100% of Medicaid 100% of Medicare 150% of Medicare $142.40 $178.00 195% of Medicare $144.18 $105.91 $105.91 $84.02 $178.00 100% of Medicare $142.40 $151.30 $160.20 $129.92 $151.30 $178.00 $178.00 100% of Medicare 100% of Medicare $178.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833427 Enoxaparin Inj 120 mg/0.8 mL 00075-2912-01 INSTITUTIONAL $181.00 1/1/2022-12/31/2022 $181.00 $85.43 $103.17 $133.04 $133.04 $125.49 100% of Medicare $108.38 $104.33 $101.60 $115.84 100% of Medicaid 100% of Medicare 150% of Medicare $144.80 $181.00 195% of Medicare $146.61 $107.70 $107.70 $85.43 $181.00 100% of Medicare $144.80 $153.85 $162.90 $132.11 $153.85 $181.00 $181.00 100% of Medicare 100% of Medicare $181.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833439 meningococcal polysaccharide vaccine group A/C/Y/W 50 mcg SubQ Inj 49281-0489-01 INSTITUTIONAL " $1,737.00 " 1/1/2022-12/31/2022 " $1,737.00 " $819.86 $990.09 " $1,276.70 " " $1,276.70 " " $1,204.26 " 100% of Medicare " $1,040.12 " " $1,001.21 " $974.98 " $1,111.68 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,389.60 " " $1,500.00 " 195% of Medicare " $1,406.97 " " $1,033.52 " " $1,033.52 " $819.86 " $1,359.00 " 100% of Medicare " $1,389.60 " " $1,476.45 " " $1,563.30 " " $1,267.84 " " $1,476.45 " " $1,500.00 " " $1,737.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833441 Octreotide Acetate 0.2 mg/mL 00781-3165-75 INSTITUTIONAL $269.00 1/1/2022-12/31/2022 $269.00 $126.97 $153.33 $197.72 $197.72 $186.50 100% of Medicare $161.08 $155.05 $150.99 $172.16 100% of Medicaid 100% of Medicare 150% of Medicare $215.20 $269.00 195% of Medicare $217.89 $160.06 $160.06 $126.97 $269.00 100% of Medicare $215.20 $228.65 $242.10 $196.34 $228.65 $269.00 $269.00 100% of Medicare 100% of Medicare $269.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833480 Water Sterile Injection 00409-4887-10 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833492 insulin glargine 100 units/mL SubQ Sol 00088-2220-33 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833493 insulin glulisine 100 units/mL SC Sol 00088-2500-33 INSTITUTIONAL $179.00 1/1/2022-12/31/2022 $179.00 $84.49 $102.03 $131.57 $131.57 $124.10 100% of Medicare $107.19 $103.18 $100.47 $114.56 100% of Medicaid 100% of Medicare 150% of Medicare $143.20 $179.00 195% of Medicare $144.99 $106.51 $106.51 $84.49 $179.00 100% of Medicare $143.20 $152.15 $161.10 $130.65 $152.15 $179.00 $179.00 100% of Medicare 100% of Medicare $179.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833497 insulin lispro 100 units/mL SubQ Inj 3 mL 00002-7510-17 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833498 insulin isophane human recombinant 100 units/mL SubQ Inj 00002-8315-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833500 insulin isophane human recombinant 100 units/mL SubQ Inj 3 mL 00002-8315-17 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833502 insulin aspart-insulin aspart protamine 30 units-70 units/mL SubQ Susp 10 mL 00169-3685-12 INSTITUTIONAL $328.00 1/1/2022-12/31/2022 $328.00 $154.82 $186.96 $241.08 $241.08 $227.40 100% of Medicare $196.41 $189.06 $184.11 $209.92 100% of Medicaid 100% of Medicare 150% of Medicare $262.40 $328.00 195% of Medicare $265.68 $195.16 $195.16 $154.82 $328.00 100% of Medicare $262.40 $278.80 $295.20 $239.41 $278.80 $328.00 $328.00 100% of Medicare 100% of Medicare $328.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833503 Insulin NPH/Reg 70/30 100units/mL 10 mL 00002-8715-01 INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $49.09 $59.28 $76.44 $76.44 $72.10 100% of Medicare $62.28 $59.95 $58.38 $66.56 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $61.88 $61.88 $49.09 $104.00 100% of Medicare $83.20 $88.40 $93.60 $75.91 $88.40 $104.00 $104.00 100% of Medicare 100% of Medicare $104.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833505 insulin lispro-insulin lispro protamine 25 units-75 units/mL SubQ Susp 10 mL 00002-7511-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833508 insulin regular human recombinant 100 units/mL Inj Sol 3 m 00002-8215-17 INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $26.90 $32.49 $41.90 $41.90 $39.52 100% of Medicare $34.13 $32.85 $31.99 $36.48 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.92 $33.92 $26.90 $57.00 100% of Medicare $45.60 $48.45 $51.30 $41.60 $48.45 $57.00 $57.00 100% of Medicare 100% of Medicare $57.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833509 Vaseline Jelly 00521-2311-00 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833510 Vaseline Lip Therapy 00521-2750-00 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12833513 baclofen 0.05 mg/mL intrathecal Sol 58281-0562-01 INSTITUTIONAL $388.00 1/1/2022-12/31/2022 $388.00 $183.14 $221.16 $285.18 $285.18 $269.00 100% of Medicare $232.33 $223.64 $217.78 $248.32 100% of Medicaid 100% of Medicare 150% of Medicare $310.40 $388.00 195% of Medicare $314.28 $230.86 $230.86 $183.14 $388.00 100% of Medicare $310.40 $329.80 $349.20 $283.20 $329.80 $388.00 $388.00 100% of Medicare 100% of Medicare $388.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12833515 baclofen 2 mg/mL intrathecal Sol 58281-0563-01 INSTITUTIONAL " $2,798.00 " 1/1/2022-12/31/2022 " $2,635.00 " $975.00 " $1,594.86 " " $2,056.53 " " $2,056.53 " " $1,939.85 " 100% of Medicare " $1,675.44 " " $1,612.77 " " $1,570.52 " " $1,790.72 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,238.40 " " $1,500.00 " 195% of Medicare " $2,266.38 " " $1,664.81 " " $1,664.81 " " $1,320.66 " " $1,359.00 " 100% of Medicare " $2,238.40 " " $2,378.30 " " $2,518.20 " " $2,042.26 " " $2,378.30 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12833516 baclofen 2 mg/mL intrathecal Sol 58281-0563-02 INSTITUTIONAL " $5,518.00 " 1/1/2022-12/31/2022 " $4,966.20 " $975.00 " $3,145.26 " " $4,055.73 " " $4,055.73 " " $3,825.63 " 100% of Medicare " $3,304.18 " " $3,180.58 " " $3,097.25 " " $3,531.52 " 100% of Medicaid 100% of Medicare 150% of Medicare " $4,414.40 " " $1,500.00 " 195% of Medicare " $4,469.58 " " $3,283.21 " " $3,283.21 " " $2,604.50 " " $1,359.00 " 100% of Medicare " $4,414.40 " " $4,690.30 " " $4,966.20 " " $4,027.59 " " $4,690.30 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12833517 baclofen 0.5 mg/mL intrathecal Sol 58281-0560-01 INSTITUTIONAL $758.00 1/1/2022-12/31/2022 $758.00 $357.78 $432.06 $557.13 $557.13 $525.52 100% of Medicare $453.89 $436.91 $425.47 $485.12 100% of Medicaid 100% of Medicare 150% of Medicare $606.40 $758.00 195% of Medicare $613.98 $451.01 $451.01 $357.78 $758.00 100% of Medicare $606.40 $644.30 $682.20 $553.26 $644.30 $758.00 $758.00 100% of Medicare 100% of Medicare $758.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833530 epinephrine 0.3 mg Inj kit 49502-0500-01 INSTITUTIONAL " $2,098.00 " 1/1/2022-12/31/2022 " $2,098.00 " $975.00 " $1,195.86 " " $1,542.03 " " $1,542.03 " " $1,454.54 " 100% of Medicare " $1,256.28 " " $1,209.29 " " $1,177.61 " " $1,342.72 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,678.40 " " $1,500.00 " 195% of Medicare " $1,699.38 " " $1,248.31 " " $1,248.31 " $990.26 " $1,359.00 " 100% of Medicare " $1,678.40 " " $1,783.30 " " $1,888.20 " " $1,531.33 " " $1,783.30 " " $1,500.00 " " $2,098.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833531 etanercept 25 mg SubQ Inj 58406-0425-34 INSTITUTIONAL " $1,121.00 " 1/1/2022-12/31/2022 " $1,121.00 " $529.11 $638.97 $823.94 $823.94 $777.19 100% of Medicare $671.25 $646.14 $629.22 $717.44 100% of Medicaid 100% of Medicare 150% of Medicare $896.80 " $1,121.00 " 195% of Medicare $908.01 $667.00 $667.00 $529.11 " $1,121.00 " 100% of Medicare $896.80 $952.85 " $1,008.90 " $818.22 $952.85 " $1,121.00 " " $1,121.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833532 glatiramer 20 mg/mL SubQ Sol 68546-0317-30 INSTITUTIONAL $594.00 1/1/2022-12/31/2022 $594.00 $280.37 $338.58 $436.59 $436.59 $411.82 100% of Medicare $355.69 $342.38 $333.41 $380.16 100% of Medicaid 100% of Medicare 150% of Medicare $475.20 $594.00 195% of Medicare $481.14 $353.43 $353.43 $280.37 $594.00 100% of Medicare $475.20 $504.90 $534.60 $433.56 $504.90 $594.00 $594.00 100% of Medicare 100% of Medicare $594.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833535 interferon beta-1a 30 mcg/0.5 mL IM kit 59627-0002-05 INSTITUTIONAL " $3,939.00 " 1/1/2022-12/31/2022 " $3,545.10 " $975.00 " $2,245.23 " " $2,895.17 " " $2,895.17 " " $2,730.91 " 100% of Medicare " $2,358.67 " " $2,270.44 " " $2,210.96 " " $2,520.96 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,151.20 " " $1,500.00 " 195% of Medicare " $3,190.59 " " $2,343.71 " " $2,343.71 " " $1,859.21 " " $1,359.00 " 100% of Medicare " $3,151.20 " " $3,348.15 " " $3,545.10 " " $2,875.08 " " $3,348.15 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833544 acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 473 mL 00121-0504-16 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833553 calcitriol 1 mcg/mL Oral Liq 00054-3120-41 INSTITUTIONAL $334.00 1/1/2022-12/31/2022 $334.00 $157.65 $190.38 $245.49 $245.49 $231.56 100% of Medicare $200.00 $192.52 $187.47 $213.76 100% of Medicaid 100% of Medicare 150% of Medicare $267.20 $334.00 195% of Medicare $270.54 $198.73 $198.73 $157.65 $334.00 100% of Medicare $267.20 $283.90 $300.60 $243.79 $283.90 $334.00 $334.00 100% of Medicare 100% of Medicare $334.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833561 cycloSPORINE microEmul 100 mg/mL Oral Liq 00078-0274-22 INSTITUTIONAL " $1,958.00 " 1/1/2022-12/31/2022 " $1,958.00 " $924.18 " $1,116.06 " " $1,439.13 " " $1,439.13 " " $1,357.48 " 100% of Medicare " $1,172.45 " " $1,128.59 " " $1,099.03 " " $1,253.12 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,566.40 " " $1,500.00 " 195% of Medicare " $1,585.98 " " $1,165.01 " " $1,165.01 " $924.18 " $1,359.00 " 100% of Medicare " $1,566.40 " " $1,664.30 " " $1,762.20 " " $1,429.14 " " $1,664.30 " " $1,500.00 " " $1,958.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833562 cycloSPORINE microEmul 100 mg/mL Oral Liq 00074-7269-50 INSTITUTIONAL $818.00 1/1/2022-12/31/2022 $818.00 $386.10 $466.26 $601.23 $601.23 $567.12 100% of Medicare $489.82 $471.50 $459.14 $523.52 100% of Medicaid 100% of Medicare 150% of Medicare $654.40 $818.00 195% of Medicare $662.58 $486.71 $486.71 $386.10 $818.00 100% of Medicare $654.40 $695.30 $736.20 $597.06 $695.30 $818.00 $818.00 100% of Medicare 100% of Medicare $818.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833566 docusate sodium 100/10 mL Oral Liq 50383-0771-16 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 $2.77 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833570 furosemide 10 mg/mL Oral Liq 00054-3294-50 INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $60.42 $72.96 $94.08 $94.08 $88.74 100% of Medicare $76.65 $73.78 $71.85 $81.92 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $76.16 $76.16 $60.42 $128.00 100% of Medicare $102.40 $108.80 $115.20 $93.43 $108.80 $128.00 $128.00 100% of Medicare 100% of Medicare $128.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833571 glycerin compounding Liq 480 mL 00395-1031-16 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 $27.04 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833580 Hydrogen Peroxide 3% 37205-0871-34 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833581 hydromorphone 1 mg/mL Oral Liq 00074-2452-02 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833582 loperamide 1 mg/5 mL Oral Liq 00904-0036-20 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 $24.96 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833585 magnesium citrate 8.85% Oral Liq 300 mL 37205-0110-38 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833588 mineral oil 100% Oral Liq 30 mL 00121-0462-30 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833592 Multiple Vitamins with Minerals Oral Liq 237 mL 54838-0010-70 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833598 potassium chloride 20 mEq/15 mL Oral Liq 00603-1534-58 INSTITUTIONAL $84.00 1/1/2022-12/31/2022 $84.00 $39.65 $47.88 $61.74 $61.74 $58.24 100% of Medicare $50.30 $48.42 $47.15 $53.76 100% of Medicaid 100% of Medicare 150% of Medicare $67.20 $84.00 195% of Medicare $68.04 $49.98 $49.98 $39.65 $84.00 100% of Medicare $67.20 $71.40 $75.60 $61.31 $71.40 $84.00 $84.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833603 simethicone 40 mg/0.6 mL Oral Liq 00536-2220-75 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 $31.20 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833608 Ammonium Lactate Lotion 12% 225 mL 00904-5984-26 INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 $43.68 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833610 calamine Top 8% Lotion 00904-2533-00 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833615 hydrocortisone Top 1% Lotion 45802-0283-06 INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $30.21 $36.48 $47.04 $47.04 $44.37 100% of Medicare $38.32 $36.89 $35.92 $40.96 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $38.08 $38.08 $30.21 $64.00 100% of Medicare $51.20 $54.40 $57.60 $46.71 $54.40 $64.00 $64.00 100% of Medicare 100% of Medicare $64.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833617 Lubriderm Lotion 52800-0488-26 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833622 permethrin Top 1% lotion 00472-5242-67 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833624 selenium sulfide Top 2.5% Lotion 45802-0040-64 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833627 benzocaine-menthol topical 15 mg-4 mg Loze 63824-0720-16 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833628 clotrimazole 10 mg Loz 00574-0107-77 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833640 Mineral Oil (BULK BOTTLE) 37205-0831-43 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 $20.11 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833642 acyclovir Top 5% Oint 64455-0993-95 INSTITUTIONAL $477.00 1/1/2022-12/31/2022 $477.00 $225.14 $271.89 $350.60 $350.60 $330.70 100% of Medicare $285.63 $274.94 $267.74 $305.28 100% of Medicaid 100% of Medicare 150% of Medicare $381.60 $477.00 195% of Medicare $386.37 $283.82 $283.82 $225.14 $477.00 100% of Medicare $381.60 $405.45 $429.30 $348.16 $405.45 $477.00 $477.00 100% of Medicare 100% of Medicare $477.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833645 AQUAPHOR Top Oint 54162-0500-02 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833649 bacitracin Top 500 units/g Oint 00603-0441-50 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833650 bacitracin topical zinc 500 units/g Oint 00168-0011-16 INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 $47.84 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833651 bacitracin/HC/neomycin/polymyxin B Top Oint 61570-0031-50 INSTITUTIONAL $318.00 1/1/2022-12/31/2022 $318.00 $150.10 $181.26 $233.73 $233.73 $220.47 100% of Medicare $190.42 $183.30 $178.49 $203.52 100% of Medicaid 100% of Medicare 150% of Medicare $254.40 $318.00 195% of Medicare $257.58 $189.21 $189.21 $150.10 $318.00 100% of Medicare $254.40 $270.30 $286.20 $232.11 $270.30 $318.00 $318.00 100% of Medicare 100% of Medicare $318.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833652 bacitracin/neomycin/polymyxin B Top Oint 45802-0061-70 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833657 balsam Peru/castor oil/trypsin Top Oint 00064-3900-60 INSTITUTIONAL $442.00 1/1/2022-12/31/2022 $442.00 $208.62 $251.94 $324.87 $324.87 $306.44 100% of Medicare $264.67 $254.77 $248.09 $282.88 100% of Medicaid 100% of Medicare 150% of Medicare $353.60 $442.00 195% of Medicare $358.02 $262.99 $262.99 $208.62 $442.00 100% of Medicare $353.60 $375.70 $397.80 $322.62 $375.70 $442.00 $442.00 100% of Medicare 100% of Medicare $442.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833658 betamethasone Top dipropionate 0.05% Oint 00168-0056-15 INSTITUTIONAL $148.00 1/1/2022-12/31/2022 $148.00 $69.86 $84.36 $108.78 $108.78 $102.61 100% of Medicare $88.62 $85.31 $83.07 $94.72 100% of Medicaid 100% of Medicare 150% of Medicare $118.40 $148.00 195% of Medicare $119.88 $88.06 $88.06 $69.86 $148.00 100% of Medicare $118.40 $125.80 $133.20 $108.03 $125.80 $148.00 $148.00 100% of Medicare 100% of Medicare $148.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833661 clobetasol Top 0.05% Oint 51672-1259-02 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 $25.65 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833663 collagenase Top 250 units/g Oint 00064-5010-30 INSTITUTIONAL $479.00 1/1/2022-12/31/2022 $479.00 $226.09 $273.03 $352.07 $352.07 $332.09 100% of Medicare $286.83 $276.10 $268.86 $306.56 100% of Medicaid 100% of Medicare 150% of Medicare $383.20 $479.00 195% of Medicare $387.99 $285.01 $285.01 $226.09 $479.00 100% of Medicare $383.20 $407.15 $431.10 $349.62 $407.15 $479.00 $479.00 100% of Medicare 100% of Medicare $479.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833666 dibucaine Top 1% Oint 45802-0050-03 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833671 fluocinonide Top 0.05% Oint 00093-0264-30 INSTITUTIONAL $98.00 1/1/2022-12/31/2022 $98.00 $46.26 $55.86 $72.03 $72.03 $67.94 100% of Medicare $58.68 $56.49 $55.01 $62.72 100% of Medicaid 100% of Medicare 150% of Medicare $78.40 $98.00 195% of Medicare $79.38 $58.31 $58.31 $46.26 $98.00 100% of Medicare $78.40 $83.30 $88.20 $71.53 $83.30 $98.00 $98.00 100% of Medicare 100% of Medicare $98.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833673 gentamicin Top 0.1% Oint 45802-0046-35 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 $33.97 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833682 hydrocortisone Top valerate 0.2% Oint 51672-1292-01 INSTITUTIONAL $295.00 1/1/2022-12/31/2022 $295.00 $139.24 $168.15 $216.83 $216.83 $204.52 100% of Medicare $176.65 $170.04 $165.58 $188.80 100% of Medicaid 100% of Medicare 150% of Medicare $236.00 $295.00 195% of Medicare $238.95 $175.53 $175.53 $139.24 $295.00 100% of Medicare $236.00 $250.75 $265.50 $215.32 $250.75 $295.00 $295.00 100% of Medicare 100% of Medicare $295.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833688 mupirocin Top 2% Oint 45802-0112-22 INSTITUTIONAL $72.00 1/1/2022-12/31/2022 $72.00 $33.98 $41.04 $52.92 $52.92 $49.92 100% of Medicare $43.11 $41.50 $40.41 $46.08 100% of Medicaid 100% of Medicare 150% of Medicare $57.60 $72.00 195% of Medicare $58.32 $42.84 $42.84 $33.98 $72.00 100% of Medicare $57.60 $61.20 $64.80 $52.55 $61.20 $72.00 $72.00 100% of Medicare 100% of Medicare $72.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833690 nitroglycerin 2% Top Oint 00281-0326-30 INSTITUTIONAL $271.00 1/1/2022-12/31/2022 $271.00 $127.91 $154.47 $199.19 $199.19 $187.88 100% of Medicare $162.27 $156.20 $152.11 $173.44 100% of Medicaid 100% of Medicare 150% of Medicare $216.80 $271.00 195% of Medicare $219.51 $161.25 $161.25 $127.91 $271.00 100% of Medicare $216.80 $230.35 $243.90 $197.80 $230.35 $271.00 $271.00 100% of Medicare 100% of Medicare $271.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833691 " nystatin Top 100,000 units/g Oint" 00168-0007-30 INSTITUTIONAL $160.00 1/1/2022-12/31/2022 $160.00 $75.52 $91.20 $117.60 $117.60 $110.93 100% of Medicare $95.81 $92.22 $89.81 $102.40 100% of Medicaid 100% of Medicare 150% of Medicare $128.00 $160.00 195% of Medicare $129.60 $95.20 $95.20 $75.52 $160.00 100% of Medicare $128.00 $136.00 $144.00 $116.78 $136.00 $160.00 $160.00 100% of Medicare 100% of Medicare $160.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833692 nystatin-triamcinolone Top Oint 51672-1272-02 INSTITUTIONAL $592.00 1/1/2022-12/31/2022 $592.00 $279.42 $337.44 $435.12 $435.12 $410.43 100% of Medicare $354.49 $341.23 $332.29 $378.88 100% of Medicaid 100% of Medicare 150% of Medicare $473.60 $592.00 195% of Medicare $479.52 $352.24 $352.24 $279.42 $592.00 100% of Medicare $473.60 $503.20 $532.80 $432.10 $503.20 $592.00 $592.00 100% of Medicare 100% of Medicare $592.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833693 phenylephrine topical 0.25% Oint 00573-2871-10 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833694 povidone iodine Top 10% Oint 00603-0599-50 INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 $28.43 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833700 triamcinolone Top 0.1% Oint 00168-0006-15 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 $24.96 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833703 vitamin A & D Top Oint 00168-0035-01 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833704 zinc oxide Top 20% Oint 00168-0062-31 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833706 ciprofloxacin Opth 0.3% Oint 00065-0654-35 INSTITUTIONAL $954.00 1/1/2022-12/31/2022 $954.00 $450.29 $543.78 $701.19 $701.19 $661.41 100% of Medicare $571.26 $549.89 $535.48 $610.56 100% of Medicaid 100% of Medicare 150% of Medicare $763.20 $954.00 195% of Medicare $772.74 $567.63 $567.63 $450.29 $954.00 100% of Medicare $763.20 $810.90 $858.60 $696.32 $810.90 $954.00 $954.00 100% of Medicare 100% of Medicare $954.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833708 erythromycin Opth 0.5% Oint 17478-0070-35 INSTITUTIONAL $119.00 1/1/2022-12/31/2022 $119.00 $56.17 $67.83 $87.47 $87.47 $82.50 100% of Medicare $71.26 $68.59 $66.79 $76.16 100% of Medicaid 100% of Medicare 150% of Medicare $95.20 $119.00 195% of Medicare $96.39 $70.81 $70.81 $56.17 $119.00 100% of Medicare $95.20 $101.15 $107.10 $86.86 $101.15 $119.00 $119.00 100% of Medicare 100% of Medicare $119.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833711 ocular lubricant Oint 00023-0312-04 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833712 " sodium chloride, hypertonic, Opth 5% Oint" 17478-0622-35 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833715 tobramycin Opth 0.3% Oint 00065-0644-35 INSTITUTIONAL " $1,636.00 " 1/1/2022-12/31/2022 " $1,636.00 " $772.19 $932.52 " $1,202.46 " " $1,202.46 " " $1,134.24 " 100% of Medicare $979.64 $942.99 $918.29 " $1,047.04 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,308.80 " " $1,500.00 " 195% of Medicare " $1,325.16 " $973.42 $973.42 $772.19 " $1,359.00 " 100% of Medicare " $1,308.80 " " $1,390.60 " " $1,472.40 " " $1,194.12 " " $1,390.60 " " $1,500.00 " " $1,636.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833716 dexamethasone-tobramycin Opth 0.1%-0.3% Oint 00065-0648-35 INSTITUTIONAL $908.00 1/1/2022-12/31/2022 $908.00 $428.58 $517.56 $667.38 $667.38 $629.52 100% of Medicare $543.71 $523.37 $509.66 $581.12 100% of Medicaid 100% of Medicare 150% of Medicare $726.40 $908.00 195% of Medicare $735.48 $540.26 $540.26 $428.58 $908.00 100% of Medicare $726.40 $771.80 $817.20 $662.75 $771.80 $908.00 $908.00 100% of Medicare 100% of Medicare $908.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833718 fosfomycin 3 g Oral Pwdr 00456-4300-08 INSTITUTIONAL $367.00 1/1/2022-12/31/2022 $367.00 $173.22 $209.19 $269.75 $269.75 $254.44 100% of Medicare $219.76 $211.54 $206.00 $234.88 100% of Medicaid 100% of Medicare 150% of Medicare $293.60 $367.00 195% of Medicare $297.27 $218.37 $218.37 $173.22 $367.00 100% of Medicare $293.60 $311.95 $330.30 $267.87 $311.95 $367.00 $367.00 100% of Medicare 100% of Medicare $367.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833722 sevelamer carbonate 0.8 g REC 58468-0132-02 INSTITUTIONAL $108.00 1/1/2022-12/31/2022 $108.00 $50.98 $61.56 $79.38 $79.38 $74.88 100% of Medicare $64.67 $62.25 $60.62 $69.12 100% of Medicaid 100% of Medicare 150% of Medicare $86.40 $108.00 195% of Medicare $87.48 $64.26 $64.26 $50.98 $108.00 100% of Medicare $86.40 $91.80 $97.20 $78.83 $91.80 $108.00 $108.00 100% of Medicare 100% of Medicare $108.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833723 triamcinolone Top 0.1% Paste 64980-0320-05 INSTITUTIONAL $513.00 1/1/2022-12/31/2022 $513.00 $242.14 $292.41 $377.06 $377.06 $355.66 100% of Medicare $307.18 $295.69 $287.95 $328.32 100% of Medicaid 100% of Medicare 150% of Medicare $410.40 $513.00 195% of Medicare $415.53 $305.24 $305.24 $242.14 $513.00 100% of Medicare $410.40 $436.05 $461.70 $374.44 $436.05 $513.00 $513.00 100% of Medicare 100% of Medicare $513.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833728 clonidine 0.1 mg/24 hr Transderm ER Film 00555-1009-16 INSTITUTIONAL $211.00 1/1/2022-12/31/2022 $211.00 $99.59 $120.27 $155.09 $155.09 $146.29 100% of Medicare $126.35 $121.62 $118.43 $135.04 100% of Medicaid 100% of Medicare 150% of Medicare $168.80 $211.00 195% of Medicare $170.91 $125.55 $125.55 $99.59 $211.00 100% of Medicare $168.80 $179.35 $189.90 $154.01 $179.35 $211.00 $211.00 100% of Medicare 100% of Medicare $211.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833729 clonidine 0.2 mg/24 hr Transderm ER Film 00555-1010-16 INSTITUTIONAL $355.00 1/1/2022-12/31/2022 $355.00 $167.56 $202.35 $260.93 $260.93 $246.12 100% of Medicare $212.57 $204.62 $199.26 $227.20 100% of Medicaid 100% of Medicare 150% of Medicare $284.00 $355.00 195% of Medicare $287.55 $211.23 $211.23 $167.56 $355.00 100% of Medicare $284.00 $301.75 $319.50 $259.11 $301.75 $355.00 $355.00 100% of Medicare 100% of Medicare $355.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833730 clonidine 0.3 mg/24 hr Transderm ER Film 00555-1011-16 INSTITUTIONAL $493.00 1/1/2022-12/31/2022 $493.00 $232.70 $281.01 $362.36 $362.36 $341.80 100% of Medicare $295.21 $284.17 $276.72 $315.52 100% of Medicaid 100% of Medicare 150% of Medicare $394.40 $493.00 195% of Medicare $399.33 $293.34 $293.34 $232.70 $493.00 100% of Medicare $394.40 $419.05 $443.70 $359.84 $419.05 $493.00 $493.00 100% of Medicare 100% of Medicare $493.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833731 diclofenac topical 1.3% ER F 60793-0411-30 INSTITUTIONAL $85.00 1/1/2022-12/31/2022 $85.00 $40.12 $48.45 $62.48 $62.48 $58.93 100% of Medicare $50.90 $48.99 $47.71 $54.40 100% of Medicaid 100% of Medicare 150% of Medicare $68.00 $85.00 195% of Medicare $68.85 $50.58 $50.58 $40.12 $85.00 100% of Medicare $68.00 $72.25 $76.50 $62.04 $72.25 $85.00 $85.00 100% of Medicare 100% of Medicare $85.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833734 estradiol 0.05 mg/24 hours weekly Transderm ER Film 00378-3350-99 INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 $49.22 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833735 estradiol 0.1 mg Cream 00378-3352-99 INSTITUTIONAL $812.00 1/1/2022-12/31/2022 $812.00 $383.26 $462.84 $596.82 $596.82 $562.96 100% of Medicare $486.23 $468.04 $455.78 $519.68 100% of Medicaid 100% of Medicare 150% of Medicare $649.60 $812.00 195% of Medicare $657.72 $483.14 $483.14 $383.26 $812.00 100% of Medicare $649.60 $690.20 $730.80 $592.68 $690.20 $812.00 $812.00 100% of Medicare 100% of Medicare $812.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833739 fentanyl 100 mcg/hr Transderm ER Film 00591-3214-72 INSTITUTIONAL $34.00 1/1/2022-12/31/2022 $34.00 $16.05 $19.38 $24.99 $24.99 $23.57 100% of Medicare $20.36 $19.60 $19.08 $21.76 100% of Medicaid 100% of Medicare 150% of Medicare $27.20 $34.00 195% of Medicare $27.54 $20.23 $20.23 $16.05 $34.00 100% of Medicare $27.20 $28.90 $30.60 $24.82 $28.90 $34.00 $34.00 100% of Medicare 100% of Medicare $34.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833743 fentanyl 75 mcg/hr Transderm ER Film 60505-7003-02 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833753 nitroglycerin 0.3 mg/hr Transderm ER Film 00085-3315-35 INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $33.04 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.92 $40.35 $39.29 $44.80 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $41.65 $41.65 $33.04 $70.00 100% of Medicare $56.00 $59.50 $63.00 $51.09 $59.50 $70.00 $70.00 100% of Medicare 100% of Medicare $70.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833754 nitroglycerin 0.4 mg/hr Transderm ER Film 49730-0112-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833758 " rivastigmine 4.6 mg/24 hr TD film, ER" 00078-0501-15 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 $32.59 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833759 " rivastigmine 9.5 mg/24 hr TD film, ER" 00078-0502-15 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833763 scopolamine 1.5 mg Transderm ER Film 00067-4345-04 INSTITUTIONAL $61.00 1/1/2022-12/31/2022 $61.00 $28.79 $34.77 $44.84 $44.84 $42.29 100% of Medicare $36.53 $35.16 $34.24 $39.04 100% of Medicaid 100% of Medicare 150% of Medicare $48.80 $61.00 195% of Medicare $49.41 $36.30 $36.30 $28.79 $61.00 100% of Medicare $48.80 $51.85 $54.90 $44.52 $51.85 $61.00 $61.00 100% of Medicare 100% of Medicare $61.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833770 testosterone 5 mg/24 hours Transderm ER Film 52544-0470-30 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833775 cholestyramine 4 g/5.5 g REC UD 00245-0036-60 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833780 fluticasone-salmeterol 100 mcg-50 mcg Inh Pwdr 00173-0695-04 INSTITUTIONAL $258.00 1/1/2022-12/31/2022 $258.00 $121.78 $147.06 $189.63 $189.63 $178.87 100% of Medicare $154.49 $148.71 $144.82 $165.12 100% of Medicaid 100% of Medicare 150% of Medicare $206.40 $258.00 195% of Medicare $208.98 $153.51 $153.51 $121.78 $258.00 100% of Medicare $206.40 $219.30 $232.20 $188.31 $219.30 $258.00 $258.00 100% of Medicare 100% of Medicare $258.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833781 fluticasone-salmeterol 250 mcg-50 mcg Inh Pwdr 00173-0696-04 INSTITUTIONAL $301.00 1/1/2022-12/31/2022 $301.00 $142.07 $171.57 $221.24 $221.24 $208.68 100% of Medicare $180.24 $173.50 $168.95 $192.64 100% of Medicaid 100% of Medicare 150% of Medicare $240.80 $301.00 195% of Medicare $243.81 $179.10 $179.10 $142.07 $301.00 100% of Medicare $240.80 $255.85 $270.90 $219.70 $255.85 $301.00 $301.00 100% of Medicare 100% of Medicare $301.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833782 fluticasone-salmeterol 500 mcg-50 mcg Inh Pwdr 00173-0697-04 INSTITUTIONAL $781.00 1/1/2022-12/31/2022 $781.00 $368.63 $445.17 $574.04 $574.04 $541.47 100% of Medicare $467.66 $450.17 $438.38 $499.84 100% of Medicaid 100% of Medicare 150% of Medicare $624.80 $781.00 195% of Medicare $632.61 $464.70 $464.70 $368.63 $781.00 100% of Medicare $624.80 $663.85 $702.90 $570.05 $663.85 $781.00 $781.00 100% of Medicare 100% of Medicare $781.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833789 magnesium sulfate compounding Pwdr 00869-0602-43 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12833792 Miconazole Powder 2% 45 GM 00067-0949-15 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833793 miconazole Top 2% Pwdr 00145-1501-03 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833795 " nystatin Top 100,000 units/g Pwdr" 68308-0152-15 INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 $97.06 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833796 DONT USE 60258-0006-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833797 Miralax packet1 00574-0412-07 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833802 salmeterol 50 mcg Inh Pwdr 00173-0520-00 INSTITUTIONAL $454.00 1/1/2022-12/31/2022 $454.00 $214.29 $258.78 $333.69 $333.69 $314.76 100% of Medicare $271.86 $261.69 $254.83 $290.56 100% of Medicaid 100% of Medicare 150% of Medicare $363.20 $454.00 195% of Medicare $367.74 $270.13 $270.13 $214.29 $454.00 100% of Medicare $363.20 $385.90 $408.60 $331.37 $385.90 $454.00 $454.00 100% of Medicare 100% of Medicare $454.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833808 tolnaftate Top 1% Pwdr 00536-5150-26 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833814 fluocinolone Top 0.01% Shampoo 00299-5500-04 INSTITUTIONAL " $1,359.00 " 1/1/2022-12/31/2022 " $1,359.00 " $641.45 $774.63 $998.87 $998.87 $942.19 100% of Medicare $813.77 $783.33 $762.81 $869.76 100% of Medicaid 100% of Medicare 150% of Medicare " $1,087.20 " " $1,359.00 " 195% of Medicare " $1,100.79 " $808.61 $808.61 $641.45 " $1,359.00 " 100% of Medicare " $1,087.20 " " $1,155.15 " " $1,223.10 " $991.93 " $1,155.15 " " $1,359.00 " " $1,359.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833815 ketoconazole Top 2% Shampoo 45802-0465-64 INSTITUTIONAL $192.00 1/1/2022-12/31/2022 $192.00 $90.62 $109.44 $141.12 $141.12 $133.11 100% of Medicare $114.97 $110.67 $107.77 $122.88 100% of Medicaid 100% of Medicare 150% of Medicare $153.60 $192.00 195% of Medicare $155.52 $114.24 $114.24 $90.62 $192.00 100% of Medicare $153.60 $163.20 $172.80 $140.14 $163.20 $192.00 $192.00 100% of Medicare 100% of Medicare $192.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833817 Selenium Sulfide 1% 00536-1995-53 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833826 Bismuth Subsalicylate 262mg 00904-5709-09 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833835 clindamycin Top 1% Sol 59762-3728-02 INSTITUTIONAL $218.00 1/1/2022-12/31/2022 $218.00 $102.90 $124.26 $160.23 $160.23 $151.14 100% of Medicare $130.54 $125.66 $122.36 $139.52 100% of Medicaid 100% of Medicare 150% of Medicare $174.40 $218.00 195% of Medicare $176.58 $129.71 $129.71 $102.90 $218.00 100% of Medicare $174.40 $185.30 $196.20 $159.12 $185.30 $218.00 $218.00 100% of Medicare 100% of Medicare $218.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833837 clobetasol Top 0.05% Sol 00168-0269-50 INSTITUTIONAL $136.00 1/1/2022-12/31/2022 $136.00 $64.19 $77.52 $99.96 $99.96 $94.29 100% of Medicare $81.44 $78.39 $76.34 $87.04 100% of Medicaid 100% of Medicare 150% of Medicare $108.80 $136.00 195% of Medicare $110.16 $80.92 $80.92 $64.19 $136.00 100% of Medicare $108.80 $115.60 $122.40 $99.27 $115.60 $136.00 $136.00 100% of Medicare 100% of Medicare $136.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833841 cycloSPORINE 100 mg/mL Oral Sol 00078-0110-22 INSTITUTIONAL " $1,958.00 " 1/1/2022-12/31/2022 " $1,958.00 " $924.18 " $1,116.06 " " $1,439.13 " " $1,439.13 " " $1,357.48 " 100% of Medicare " $1,172.45 " " $1,128.59 " " $1,099.03 " " $1,253.12 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,566.40 " " $1,500.00 " 195% of Medicare " $1,585.98 " " $1,165.01 " " $1,165.01 " $924.18 " $1,359.00 " 100% of Medicare " $1,566.40 " " $1,664.30 " " $1,762.20 " " $1,429.14 " " $1,664.30 " " $1,500.00 " " $1,958.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833848 desmopressin 4 mcg/mL IV Sol 00075-2451-01 INSTITUTIONAL $150.00 1/1/2022-12/31/2022 $150.00 $70.80 $85.50 $110.25 $110.25 $104.00 100% of Medicare $89.82 $86.46 $84.20 $96.00 100% of Medicaid 100% of Medicare 150% of Medicare $120.00 $150.00 195% of Medicare $121.50 $89.25 $89.25 $70.80 $150.00 100% of Medicare $120.00 $127.50 $135.00 $109.49 $127.50 $150.00 $150.00 100% of Medicare 100% of Medicare $150.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833855 enoxaparin 100 mg/mL SubQ Sol 00075-0623-00 INSTITUTIONAL $152.00 1/1/2022-12/31/2022 $152.00 $71.74 $86.64 $111.72 $111.72 $105.38 100% of Medicare $91.02 $87.61 $85.32 $97.28 100% of Medicaid 100% of Medicare 150% of Medicare $121.60 $152.00 195% of Medicare $123.12 $90.44 $90.44 $71.74 $152.00 100% of Medicare $121.60 $129.20 $136.80 $110.94 $129.20 $152.00 $152.00 100% of Medicare 100% of Medicare $152.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833857 enoxaparin 30 mg/0.3 mL SC Sol 00075-0624-30 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833858 enoxaparin 40 mg/0.4 mL SC Sol 00075-0620-40 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833859 enoxaparin 60 mg/0.6 mL SC Sol 00075-0621-60 INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $42.95 $51.87 $66.89 $66.89 $63.09 100% of Medicare $54.49 $52.45 $51.08 $58.24 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $54.15 $54.15 $42.95 $91.00 100% of Medicare $72.80 $77.35 $81.90 $66.42 $77.35 $91.00 $91.00 100% of Medicare 100% of Medicare $91.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833860 enoxaparin 80 mg/0.8 mL SC Sol 00075-0622-80 INSTITUTIONAL $121.00 1/1/2022-12/31/2022 $121.00 $57.11 $68.97 $88.94 $88.94 $83.89 100% of Medicare $72.45 $69.74 $67.92 $77.44 100% of Medicaid 100% of Medicare 150% of Medicare $96.80 $121.00 195% of Medicare $98.01 $72.00 $72.00 $57.11 $121.00 100% of Medicare $96.80 $102.85 $108.90 $88.32 $102.85 $121.00 $121.00 100% of Medicare 100% of Medicare $121.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833861 entecavir 0.05 mg/mL oral Sol 00003-1614-12 INSTITUTIONAL " $4,277.00 " 1/1/2022-12/31/2022 " $3,849.30 " $975.00 " $2,437.89 " " $3,143.60 " " $3,143.60 " " $2,965.24 " 100% of Medicare " $2,561.07 " " $2,465.26 " " $2,400.68 " " $2,737.28 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,421.60 " " $1,500.00 " 195% of Medicare " $3,464.37 " " $2,544.82 " " $2,544.82 " " $2,018.74 " " $1,359.00 " 100% of Medicare " $3,421.60 " " $3,635.45 " " $3,849.30 " " $3,121.78 " " $3,635.45 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833866 ergocalciferol 8000 intl units/mL Oral Sol 39328-0357-60 INSTITUTIONAL $370.00 1/1/2022-12/31/2022 $370.00 $174.64 $210.90 $271.95 $271.95 $256.52 100% of Medicare $221.56 $213.27 $207.68 $236.80 100% of Medicaid 100% of Medicare 150% of Medicare $296.00 $370.00 195% of Medicare $299.70 $220.15 $220.15 $174.64 $370.00 100% of Medicare $296.00 $314.50 $333.00 $270.06 $314.50 $370.00 $370.00 100% of Medicare 100% of Medicare $370.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833870 exenatide 5 mcg/0.02 mL SC Sol 66780-0210-07 INSTITUTIONAL $173.00 1/1/2022-12/31/2022 $173.00 $81.66 $98.61 $127.16 $127.16 $119.94 100% of Medicare $103.59 $99.72 $97.10 $110.72 100% of Medicaid 100% of Medicare 150% of Medicare $138.40 $173.00 195% of Medicare $140.13 $102.94 $102.94 $81.66 $173.00 100% of Medicare $138.40 $147.05 $155.70 $126.27 $147.05 $173.00 $173.00 100% of Medicare 100% of Medicare $173.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833871 exenatide 10 mcg/0.04 mL SC Sol 66780-0212-01 INSTITUTIONAL " $2,589.00 " 1/1/2022-12/31/2022 " $2,589.00 " $975.00 " $1,475.73 " " $1,902.92 " " $1,902.92 " " $1,794.95 " 100% of Medicare " $1,550.29 " " $1,492.30 " " $1,453.21 " " $1,656.96 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,071.20 " " $1,500.00 " 195% of Medicare " $2,097.09 " " $1,540.46 " " $1,540.46 " " $1,222.01 " " $1,359.00 " 100% of Medicare " $2,071.20 " " $2,200.65 " " $2,330.10 " " $1,889.71 " " $2,200.65 " " $1,500.00 " " $2,589.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833876 filgrastim 300 mcg/1ml Inj Sol 55513-0546-10 INSTITUTIONAL " $2,027.00 " 1/1/2022-12/31/2022 " $2,027.00 " $956.74 " $1,155.39 " " $1,489.85 " " $1,489.85 " " $1,405.32 " 100% of Medicare " $1,213.77 " " $1,168.36 " " $1,137.76 " " $1,297.28 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,621.60 " " $1,500.00 " 195% of Medicare " $1,641.87 " " $1,206.07 " " $1,206.07 " $956.74 " $1,359.00 " 100% of Medicare " $1,621.60 " " $1,722.95 " " $1,824.30 " " $1,479.51 " " $1,722.95 " " $1,500.00 " " $2,027.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833879 fluoxetine 20 mg/5 mL Oral Sol 54838-0523-40 INSTITUTIONAL $438.00 1/1/2022-12/31/2022 $438.00 $206.74 $249.66 $321.93 $321.93 $303.67 100% of Medicare $262.27 $252.46 $245.85 $280.32 100% of Medicaid 100% of Medicare 150% of Medicare $350.40 $438.00 195% of Medicare $354.78 $260.61 $260.61 $206.74 $438.00 100% of Medicare $350.40 $372.30 $394.20 $319.70 $372.30 $438.00 $438.00 100% of Medicare 100% of Medicare $438.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833881 fondaparinux 2.5 mg/0.5 mL SubQ Sol 60505-6078-04 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 $33.28 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833882 fondaparinux 5 mg/0.4 mL SC Sol 60505-6079-04 INSTITUTIONAL $132.00 1/1/2022-12/31/2022 $132.00 $62.30 $75.24 $97.02 $97.02 $91.52 100% of Medicare $79.04 $76.08 $74.09 $84.48 100% of Medicaid 100% of Medicare 150% of Medicare $105.60 $132.00 195% of Medicare $106.92 $78.54 $78.54 $62.30 $132.00 100% of Medicare $105.60 $112.20 $118.80 $96.35 $112.20 $132.00 $132.00 100% of Medicare 100% of Medicare $132.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833883 fondaparinux 7.5 mg/0.6 mL SC Sol 60505-6080-04 INSTITUTIONAL $795.00 1/1/2022-12/31/2022 $795.00 $375.24 $453.15 $584.33 $584.33 $551.17 100% of Medicare $476.05 $458.24 $446.23 $508.80 100% of Medicaid 100% of Medicare 150% of Medicare $636.00 $795.00 195% of Medicare $643.95 $473.03 $473.03 $375.24 $795.00 100% of Medicare $636.00 $675.75 $715.50 $580.27 $675.75 $795.00 $795.00 100% of Medicare 100% of Medicare $795.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833884 formoterol 20 mcg/2 mL Inh Sol 49502-0605-61 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833886 gabapentin 250 mg/5 mL Oral Sol 59762-5025-01 INSTITUTIONAL $137.00 1/1/2022-12/31/2022 $137.00 $64.66 $78.09 $100.70 $100.70 $94.98 100% of Medicare $82.04 $78.97 $76.90 $87.68 100% of Medicaid 100% of Medicare 150% of Medicare $109.60 $137.00 195% of Medicare $110.97 $81.52 $81.52 $64.66 $137.00 100% of Medicare $109.60 $116.45 $123.30 $100.00 $116.45 $137.00 $137.00 100% of Medicare 100% of Medicare $137.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833890 " heparin 10,000 units/mL Inj Sol" 00409-1316-32 INSTITUTIONAL $94.00 1/1/2022-12/31/2022 $94.00 $44.37 $53.58 $69.09 $69.09 $65.17 100% of Medicare $56.29 $54.18 $52.76 $60.16 100% of Medicaid 100% of Medicare 150% of Medicare $75.20 $94.00 195% of Medicare $76.14 $55.93 $55.93 $44.37 $94.00 100% of Medicare $75.20 $79.90 $84.60 $68.61 $79.90 $94.00 $94.00 100% of Medicare 100% of Medicare $94.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833894 sodium hyaluronate 10 mg/mL intra-articular Sol 55566-4100-01 INSTITUTIONAL " $1,007.00 " 1/1/2022-12/31/2022 " $1,007.00 " $475.30 $573.99 $740.15 $740.15 $698.15 100% of Medicare $602.99 $580.43 $565.23 $644.48 100% of Medicaid 100% of Medicare 150% of Medicare $805.60 " $1,007.00 " 195% of Medicare $815.67 $599.17 $599.17 $475.30 " $1,007.00 " 100% of Medicare $805.60 $855.95 $906.30 $735.01 $855.95 " $1,007.00 " " $1,007.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833896 acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL Oral Sol 15 mL 66689-0023-50 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12833900 hylan G-F 20 8 mg/mL intra-articular Sol 58468-0090-01 INSTITUTIONAL $291.00 1/1/2022-12/31/2022 $291.00 $137.35 $165.87 $213.89 $213.89 $201.75 100% of Medicare $174.25 $167.73 $163.34 $186.24 100% of Medicaid 100% of Medicare 150% of Medicare $232.80 $291.00 195% of Medicare $235.71 $173.15 $173.15 $137.35 $291.00 100% of Medicare $232.80 $247.35 $261.90 $212.40 $247.35 $291.00 $291.00 100% of Medicare 100% of Medicare $291.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12833901 hylan G-F 20 8 mg/mL intra-articular Sol 58468-0090-03 INSTITUTIONAL " $1,886.00 " 1/1/2022-12/31/2022 " $1,886.00 " $890.19 " $1,075.02 " " $1,386.21 " " $1,386.21 " " $1,307.56 " 100% of Medicare " $1,129.34 " " $1,087.09 " " $1,058.61 " " $1,207.04 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,508.80 " " $1,500.00 " 195% of Medicare " $1,527.66 " " $1,122.17 " " $1,122.17 " $890.19 " $1,359.00 " 100% of Medicare " $1,508.80 " " $1,603.10 " " $1,697.40 " " $1,376.59 " " $1,603.10 " " $1,500.00 " " $1,886.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833904 iopamidol 41% intrathecal Sol 20 mL 00270-1411-25 INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 $28.43 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833905 itraconazole 10 mg/mL Oral Sol 50458-0295-15 INSTITUTIONAL " $1,526.00 " 1/1/2022-12/31/2022 " $1,526.00 " $720.27 $869.82 " $1,121.61 " " $1,121.61 " " $1,057.98 " 100% of Medicare $913.77 $879.59 $856.54 $976.64 100% of Medicaid 100% of Medicare 150% of Medicare " $1,220.80 " " $1,500.00 " 195% of Medicare " $1,236.06 " $907.97 $907.97 $720.27 " $1,359.00 " 100% of Medicare " $1,220.80 " " $1,297.10 " " $1,373.40 " " $1,113.83 " " $1,297.10 " " $1,500.00 " " $1,526.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833908 lamivudine 10 mg/mL Oral Sol 49702-0205-48 INSTITUTIONAL $453.00 1/1/2022-12/31/2022 $453.00 $213.82 $258.21 $332.96 $332.96 $314.06 100% of Medicare $271.26 $261.11 $254.27 $289.92 100% of Medicaid 100% of Medicare 150% of Medicare $362.40 $453.00 195% of Medicare $366.93 $269.54 $269.54 $213.82 $453.00 100% of Medicare $362.40 $385.05 $407.70 $330.64 $385.05 $453.00 $453.00 100% of Medicare 100% of Medicare $453.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833909 levetiracetam 100 mg/mL Oral Sol 60432-0831-16 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833914 lidocaine Top 4% Sol 00054-3505-47 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833916 lidocaine Top 2% Sol 100 mL 00603-1393-64 INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 $62.40 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833917 meningococcal conjugate vaccine IM Sol 49281-0589-01 INSTITUTIONAL $405.00 1/1/2022-12/31/2022 $405.00 $191.16 $230.85 $297.68 $297.68 $280.79 100% of Medicare $242.51 $233.44 $227.33 $259.20 100% of Medicaid 100% of Medicare 150% of Medicare $324.00 $405.00 195% of Medicare $328.05 $240.98 $240.98 $191.16 $405.00 100% of Medicare $324.00 $344.25 $364.50 $295.61 $344.25 $405.00 $405.00 100% of Medicare 100% of Medicare $405.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833923 morphine 1 mg/mL Inj Sol 00074-6023-04 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833937 pneumococcal 23-valent vaccine Inj Sol 0 mL 00006-4943-00 INSTITUTIONAL $990.00 1/1/2022-12/31/2022 $990.00 $467.28 $564.30 $727.65 $727.65 $686.37 100% of Medicare $592.81 $570.64 $555.69 $633.60 100% of Medicaid 100% of Medicare 150% of Medicare $792.00 $990.00 195% of Medicare $801.90 $589.05 $589.05 $467.28 $990.00 100% of Medicare $792.00 $841.50 $891.00 $722.60 $841.50 $990.00 $990.00 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833939 potassium iodide 1 g/mL Oral Sol 00245-0003-31 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 $33.97 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833949 sirolimus 1 mg/mL Oral Sol 00008-1030-06 INSTITUTIONAL " $8,045.00 " 1/1/2022-12/31/2022 " $7,240.50 " $975.00 " $4,585.65 " " $5,913.08 " " $5,913.08 " " $5,577.60 " 100% of Medicare " $4,817.35 " " $4,637.14 " " $4,515.66 " " $5,148.80 " 100% of Medicaid 100% of Medicare 150% of Medicare " $6,436.00 " " $1,500.00 " 195% of Medicare " $6,516.45 " " $4,786.78 " " $4,786.78 " " $3,797.24 " " $1,359.00 " 100% of Medicare " $6,436.00 " " $6,838.25 " " $7,240.50 " " $5,872.05 " " $6,838.25 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833950 sodium chloride 0.9% Irr Sol 1000 mL 00338-0048-04 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833953 sodium chloride 0.9% Inh Sol 15 mL 00378-6987-89 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833955 sodium chloride 3% Inh Sol 15 mL 49502-0640-15 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833956 sodium hypochlorite Top 0.5% Sol 00436-0946-16 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833957 sodium hypochlorite Top 0.25% Sol 00436-0936-16 INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 $61.01 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833958 Sterile Water Irrigation 1000mL 00338-0004-04 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833959 Sterile Water Irrigation 2000mL 00338-0013-06 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833962 tuberculin purified protein derivative 5 TU/0.1 mL ID Sol 49281-0752-22 INSTITUTIONAL $87.00 1/1/2022-12/31/2022 $87.00 $41.06 $49.59 $63.95 $63.95 $60.32 100% of Medicare $52.10 $50.15 $48.83 $55.68 100% of Medicaid 100% of Medicare 150% of Medicare $69.60 $87.00 195% of Medicare $70.47 $51.77 $51.77 $41.06 $87.00 100% of Medicare $69.60 $73.95 $78.30 $63.50 $73.95 $87.00 $87.00 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833970 acyclovir 50 mg/mL IV Sol 63323-0325-20 INSTITUTIONAL $109.00 1/1/2022-12/31/2022 $109.00 $51.45 $62.13 $80.12 $80.12 $75.57 100% of Medicare $65.27 $62.83 $61.18 $69.76 100% of Medicaid 100% of Medicare 150% of Medicare $87.20 $109.00 195% of Medicare $88.29 $64.86 $64.86 $51.45 $109.00 100% of Medicare $87.20 $92.65 $98.10 $79.56 $92.65 $109.00 $109.00 100% of Medicare 100% of Medicare $109.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833977 albumin human 25% IV Sol 50 mL 68516-5216-01 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12833996 amikacin 250 mg/mL IV Sol 00703-9040-03 INSTITUTIONAL $130.00 1/1/2022-12/31/2022 $130.00 $61.36 $74.10 $95.55 $95.55 $90.13 100% of Medicare $77.84 $74.93 $72.97 $83.20 100% of Medicaid 100% of Medicare 150% of Medicare $104.00 $130.00 195% of Medicare $105.30 $77.35 $77.35 $61.36 $130.00 100% of Medicare $104.00 $110.50 $117.00 $94.89 $110.50 $130.00 $130.00 100% of Medicare 100% of Medicare $130.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834005 amphotericin B liposomal 50 mg IV Inj 00469-3051-30 INSTITUTIONAL $289.00 1/1/2022-12/31/2022 $289.00 $136.41 $164.73 $212.42 $212.42 $200.36 100% of Medicare $173.05 $166.58 $162.22 $184.96 100% of Medicaid 100% of Medicare 150% of Medicare $231.20 $289.00 195% of Medicare $234.09 $171.96 $171.96 $136.41 $289.00 100% of Medicare $231.20 $245.65 $260.10 $210.94 $245.65 $289.00 $289.00 100% of Medicare 100% of Medicare $289.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834006 ampicillin 2 g Inj 00781-3413-92 INSTITUTIONAL $92.00 1/1/2022-12/31/2022 $92.00 $43.42 $52.44 $67.62 $67.62 $63.78 100% of Medicare $55.09 $53.03 $51.64 $58.88 100% of Medicaid 100% of Medicare 150% of Medicare $73.60 $92.00 195% of Medicare $74.52 $54.74 $54.74 $43.42 $92.00 100% of Medicare $73.60 $78.20 $82.80 $67.15 $78.20 $92.00 $92.00 100% of Medicare 100% of Medicare $92.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834009 ampicillin-sulbactam 2 g-1 g Inj 00409-2987-03 INSTITUTIONAL $104.00 1/1/2022-12/31/2022 $104.00 $49.09 $59.28 $76.44 $76.44 $72.10 100% of Medicare $62.28 $59.95 $58.38 $66.56 100% of Medicaid 100% of Medicare 150% of Medicare $83.20 $104.00 195% of Medicare $84.24 $61.88 $61.88 $49.09 $104.00 100% of Medicare $83.20 $88.40 $93.60 $75.91 $88.40 $104.00 $104.00 100% of Medicare 100% of Medicare $104.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834032 atropine 0.4 mg/mL Inj Sol 00517-0401-25 INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $40.59 $49.02 $63.21 $63.21 $59.62 100% of Medicare $51.50 $49.57 $48.27 $55.04 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $51.17 $51.17 $40.59 $86.00 100% of Medicare $68.80 $73.10 $77.40 $62.77 $73.10 $86.00 $86.00 100% of Medicare 100% of Medicare $86.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834037 azelastine Nasal 137 mcg/inh Spry 51525-0294-03 INSTITUTIONAL $390.00 1/1/2022-12/31/2022 $390.00 $184.08 $222.30 $286.65 $286.65 $270.39 100% of Medicare $233.53 $224.80 $218.91 $249.60 100% of Medicaid 100% of Medicare 150% of Medicare $312.00 $390.00 195% of Medicare $315.90 $232.05 $232.05 $184.08 $390.00 100% of Medicare $312.00 $331.50 $351.00 $284.66 $331.50 $390.00 $390.00 100% of Medicare 100% of Medicare $390.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834038 azithromycin 500 mg IV Inj 00069-3150-83 INSTITUTIONAL $197.00 1/1/2022-12/31/2022 $197.00 $92.98 $112.29 $144.80 $144.80 $136.58 100% of Medicare $117.96 $113.55 $110.58 $126.08 100% of Medicaid 100% of Medicare 150% of Medicare $157.60 $197.00 195% of Medicare $159.57 $117.22 $117.22 $92.98 $197.00 100% of Medicare $157.60 $167.45 $177.30 $143.79 $167.45 $197.00 $197.00 100% of Medicare 100% of Medicare $197.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834054 betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL 00085-0566-05 INSTITUTIONAL $75.00 1/1/2022-12/31/2022 $75.00 $35.40 $42.75 $55.13 $55.13 $52.00 100% of Medicare $44.91 $43.23 $42.10 $48.00 100% of Medicaid 100% of Medicare 150% of Medicare $60.00 $75.00 195% of Medicare $60.75 $44.63 $44.63 $35.40 $75.00 100% of Medicare $60.00 $63.75 $67.50 $54.74 $63.75 $75.00 $75.00 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12834063 onabotulinumtoxinA 100 units REC 00023-1145-01 INSTITUTIONAL " $2,706.00 " 1/1/2022-12/31/2022 " $2,635.00 " $975.00 " $1,542.42 " " $1,988.91 " " $1,988.91 " " $1,876.07 " 100% of Medicare " $1,620.35 " " $1,559.74 " " $1,518.88 " " $1,731.84 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,164.80 " " $1,500.00 " 195% of Medicare " $2,191.86 " " $1,610.07 " " $1,610.07 " " $1,277.23 " " $1,359.00 " 100% of Medicare " $2,164.80 " " $2,300.10 " " $2,435.40 " " $1,975.11 " " $2,300.10 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12834066 botulinum toxin type B 5000 units/mL Inj Sol 59075-0711-10 INSTITUTIONAL " $2,234.00 " 1/1/2022-12/31/2022 " $2,234.00 " $975.00 " $1,273.38 " " $1,641.99 " " $1,641.99 " " $1,548.83 " 100% of Medicare " $1,337.72 " " $1,287.68 " " $1,253.94 " " $1,429.76 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,787.20 " " $1,500.00 " 195% of Medicare " $1,809.54 " " $1,329.23 " " $1,329.23 " " $1,054.45 " " $1,359.00 " 100% of Medicare " $1,787.20 " " $1,898.90 " " $2,010.60 " " $1,630.60 " " $1,898.90 " " $1,500.00 " " $2,234.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834071 bupivacaine 0.25% PF Inj Sol 10 mL 63323-0464-17 INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $42.95 $51.87 $66.89 $66.89 $63.09 100% of Medicare $54.49 $52.45 $51.08 $58.24 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $54.15 $54.15 $42.95 $91.00 100% of Medicare $72.80 $77.35 $81.90 $66.42 $77.35 $91.00 $91.00 100% of Medicare 100% of Medicare $91.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834074 bupivacaine 0.75% PF Inj Sol 30 mL 00409-1582-29 INSTITUTIONAL $94.00 1/1/2022-12/31/2022 $94.00 $44.37 $53.58 $69.09 $69.09 $65.17 100% of Medicare $56.29 $54.18 $52.76 $60.16 100% of Medicaid 100% of Medicare 150% of Medicare $75.20 $94.00 195% of Medicare $76.14 $55.93 $55.93 $44.37 $94.00 100% of Medicare $75.20 $79.90 $84.60 $68.61 $79.90 $94.00 $94.00 100% of Medicare 100% of Medicare $94.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834076 bupivacaine 0.5% PF Inj Sol 10 mL 00409-1560-10 INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $46.73 $56.43 $72.77 $72.77 $68.64 100% of Medicare $59.28 $57.06 $55.57 $63.36 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $58.91 $58.91 $46.73 $99.00 100% of Medicare $79.20 $84.15 $89.10 $72.26 $84.15 $99.00 $99.00 100% of Medicare 100% of Medicare $99.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834078 bupivacaine 0.75% PF Inj Sol 10 mL 63323-0472-17 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834096 calcium gluconate 100 mg/mL Inj Sol 63323-0311-10 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 $32.59 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834100 caspofungin 50 mg IV Inj 00006-3822-10 INSTITUTIONAL $390.00 1/1/2022-12/31/2022 $390.00 $184.08 $222.30 $286.65 $286.65 $270.39 100% of Medicare $233.53 $224.80 $218.91 $249.60 100% of Medicaid 100% of Medicare 150% of Medicare $312.00 $390.00 195% of Medicare $315.90 $232.05 $232.05 $184.08 $390.00 100% of Medicare $312.00 $331.50 $351.00 $284.66 $331.50 $390.00 $390.00 100% of Medicare 100% of Medicare $390.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834105 cefazolin 1 g Inj 00409-2585-01 INSTITUTIONAL $34.00 1/1/2022-12/31/2022 $34.00 $16.05 $19.38 $24.99 $24.99 $23.57 100% of Medicare $20.36 $19.60 $19.08 $21.76 100% of Medicaid 100% of Medicare 150% of Medicare $27.20 $34.00 195% of Medicare $27.54 $20.23 $20.23 $16.05 $34.00 100% of Medicare $27.20 $28.90 $30.60 $24.82 $28.90 $34.00 $34.00 100% of Medicare 100% of Medicare $34.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834106 cefazolin 1 g Inj 25021-0102-99 INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 $70.72 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834110 cefepime 1 g Inj 00781-3222-95 INSTITUTIONAL $172.00 1/1/2022-12/31/2022 $172.00 $81.18 $98.04 $126.42 $126.42 $119.25 100% of Medicare $102.99 $99.14 $96.54 $110.08 100% of Medicaid 100% of Medicare 150% of Medicare $137.60 $172.00 195% of Medicare $139.32 $102.34 $102.34 $81.18 $172.00 100% of Medicare $137.60 $146.20 $154.80 $125.54 $146.20 $172.00 $172.00 100% of Medicare 100% of Medicare $172.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834111 cefepime 2 g Inj 25021-0122-50 INSTITUTIONAL $127.00 1/1/2022-12/31/2022 $127.00 $59.94 $72.39 $93.35 $93.35 $88.05 100% of Medicare $76.05 $73.20 $71.29 $81.28 100% of Medicaid 100% of Medicare 150% of Medicare $101.60 $127.00 195% of Medicare $102.87 $75.57 $75.57 $59.94 $127.00 100% of Medicare $101.60 $107.95 $114.30 $92.70 $107.95 $127.00 $127.00 100% of Medicare 100% of Medicare $127.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834123 ceftaroline 600 mg REC 00456-0600-10 INSTITUTIONAL $1.00 1/1/2022-12/31/2022 $1.00 $0.47 $0.57 $0.74 $0.74 $0.69 100% of Medicare $0.60 $0.58 $0.56 $0.64 100% of Medicaid 100% of Medicare 150% of Medicare $0.80 $1.00 195% of Medicare $0.81 $0.60 $0.60 $0.47 $1.00 100% of Medicare $0.80 $0.85 $0.90 $0.73 $0.85 $1.00 $1.00 100% of Medicare 100% of Medicare $1.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834124 cefTAZidime 1 g Inj 00173-0378-10 INSTITUTIONAL $125.00 1/1/2022-12/31/2022 $125.00 $59.00 $71.25 $91.88 $91.88 $86.66 100% of Medicare $74.85 $72.05 $70.16 $80.00 100% of Medicaid 100% of Medicare 150% of Medicare $100.00 $125.00 195% of Medicare $101.25 $74.38 $74.38 $59.00 $125.00 100% of Medicare $100.00 $106.25 $112.50 $91.24 $106.25 $125.00 $125.00 100% of Medicare 100% of Medicare $125.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834126 ceftazidime 2 g Inj 00173-0379-34 INSTITUTIONAL $241.00 1/1/2022-12/31/2022 $241.00 $113.75 $137.37 $177.14 $177.14 $167.09 100% of Medicare $144.31 $138.91 $135.27 $154.24 100% of Medicaid 100% of Medicare 150% of Medicare $192.80 $241.00 195% of Medicare $195.21 $143.40 $143.40 $113.75 $241.00 100% of Medicare $192.80 $204.85 $216.90 $175.91 $204.85 $241.00 $241.00 100% of Medicare 100% of Medicare $241.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834128 ceftriaxone 1 g Inj 00409-7333-04 INSTITUTIONAL $94.00 1/1/2022-12/31/2022 $94.00 $44.37 $53.58 $69.09 $69.09 $65.17 100% of Medicare $56.29 $54.18 $52.76 $60.16 100% of Medicaid 100% of Medicare 150% of Medicare $75.20 $94.00 195% of Medicare $76.14 $55.93 $55.93 $44.37 $94.00 100% of Medicare $75.20 $79.90 $84.60 $68.61 $79.90 $94.00 $94.00 100% of Medicare 100% of Medicare $94.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834130 ceftriaxone 2 g Inj 00409-7336-04 INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $61.83 $74.67 $96.29 $96.29 $90.82 100% of Medicare $78.44 $75.51 $73.53 $83.84 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $77.95 $77.95 $61.83 $131.00 100% of Medicare $104.80 $111.35 $117.90 $95.62 $111.35 $131.00 $131.00 100% of Medicare 100% of Medicare $131.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834149 ciprofloxacin 400 mg/200 mL IV Sol 00409-4777-02 INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 $61.01 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834163 clindamycin 150 mg/mL IV Sol 25021-0115-04 INSTITUTIONAL $87.00 1/1/2022-12/31/2022 $87.00 $41.06 $49.59 $63.95 $63.95 $60.32 100% of Medicare $52.10 $50.15 $48.83 $55.68 100% of Medicaid 100% of Medicare 150% of Medicare $69.60 $87.00 195% of Medicare $70.47 $51.77 $51.77 $41.06 $87.00 100% of Medicare $69.60 $73.95 $78.30 $63.50 $73.95 $87.00 $87.00 100% of Medicare 100% of Medicare $87.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834175 cosyntropin 0.25 mg Inj 00548-5900-00 INSTITUTIONAL " $1,085.00 " 1/1/2022-12/31/2022 " $1,085.00 " $512.12 $618.45 $797.48 $797.48 $752.23 100% of Medicare $649.70 $625.39 $609.01 $694.40 100% of Medicaid 100% of Medicare 150% of Medicare $868.00 " $1,085.00 " 195% of Medicare $878.85 $645.58 $645.58 $512.12 " $1,085.00 " 100% of Medicare $868.00 $922.25 $976.50 $791.94 $922.25 " $1,085.00 " " $1,085.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834194 daptomycin 500 mg IV Inj 67919-0011-01 INSTITUTIONAL $567.00 1/1/2022-12/31/2022 $567.00 $267.62 $323.19 $416.75 $416.75 $393.10 100% of Medicare $339.52 $326.82 $318.26 $362.88 100% of Medicaid 100% of Medicare 150% of Medicare $453.60 $567.00 195% of Medicare $459.27 $337.37 $337.37 $267.62 $567.00 100% of Medicare $453.60 $481.95 $510.30 $413.85 $481.95 $567.00 $567.00 100% of Medicare 100% of Medicare $567.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834195 darbepoetin alfa 100 mcg/mL Inj Sol 55513-0005-04 INSTITUTIONAL " $1,416.00 " 1/1/2022-12/31/2022 " $1,416.00 " $668.35 $807.12 " $1,040.76 " " $1,040.76 " $981.71 100% of Medicare $847.90 $816.18 $794.80 $906.24 100% of Medicaid 100% of Medicare 150% of Medicare " $1,132.80 " " $1,416.00 " 195% of Medicare " $1,146.96 " $842.52 $842.52 $668.35 " $1,359.00 " 100% of Medicare " $1,132.80 " " $1,203.60 " " $1,274.40 " " $1,033.54 " " $1,203.60 " " $1,416.00 " " $1,416.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834198 darbepoetin alfa 200 mcg/mL Inj Sol 55513-0006-01 INSTITUTIONAL " $2,824.00 " 1/1/2022-12/31/2022 " $2,635.00 " $975.00 " $1,609.68 " " $2,075.64 " " $2,075.64 " " $1,957.88 " 100% of Medicare " $1,691.01 " " $1,627.75 " " $1,585.11 " " $1,807.36 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,259.20 " " $1,500.00 " 195% of Medicare " $2,287.44 " " $1,680.28 " " $1,680.28 " " $1,332.93 " " $1,359.00 " 100% of Medicare " $2,259.20 " " $2,400.40 " " $2,541.60 " " $2,061.24 " " $2,400.40 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834199 darbepoetin alfa 25 mcg/mL Inj Sol 55513-0002-04 INSTITUTIONAL $986.00 1/1/2022-12/31/2022 $986.00 $465.39 $562.02 $724.71 $724.71 $683.59 100% of Medicare $590.42 $568.33 $553.44 $631.04 100% of Medicaid 100% of Medicare 150% of Medicare $788.80 $986.00 195% of Medicare $798.66 $586.67 $586.67 $465.39 $986.00 100% of Medicare $788.80 $838.10 $887.40 $719.68 $838.10 $986.00 $986.00 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834200 darbepoetin alfa 300 mcg/mL Inj Sol 55513-0110-01 INSTITUTIONAL " $4,233.00 " 1/1/2022-12/31/2022 " $3,809.70 " $975.00 " $2,412.81 " " $3,111.26 " " $3,111.26 " " $2,934.74 " 100% of Medicare " $2,534.72 " " $2,439.90 " " $2,375.98 " " $2,709.12 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,386.40 " " $1,500.00 " 195% of Medicare " $3,428.73 " " $2,518.64 " " $2,518.64 " " $1,997.98 " " $1,359.00 " 100% of Medicare " $3,386.40 " " $3,598.05 " " $3,809.70 " " $3,089.67 " " $3,598.05 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834201 darbepoetin alfa 40 mcg/mL Inj Sol 55513-0003-04 INSTITUTIONAL $682.00 1/1/2022-12/31/2022 $682.00 $321.90 $388.74 $501.27 $501.27 $472.83 100% of Medicare $408.38 $393.10 $382.81 $436.48 100% of Medicaid 100% of Medicare 150% of Medicare $545.60 $682.00 195% of Medicare $552.42 $405.79 $405.79 $321.90 $682.00 100% of Medicare $545.60 $579.70 $613.80 $497.79 $579.70 $682.00 $682.00 100% of Medicare 100% of Medicare $682.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834203 darbepoetin alfa 60 mcg/mL Inj Sol 55513-0004-04 INSTITUTIONAL $979.00 1/1/2022-12/31/2022 $979.00 $462.09 $558.03 $719.57 $719.57 $678.74 100% of Medicare $586.23 $564.30 $549.51 $626.56 100% of Medicaid 100% of Medicare 150% of Medicare $783.20 $979.00 195% of Medicare $792.99 $582.51 $582.51 $462.09 $979.00 100% of Medicare $783.20 $832.15 $881.10 $714.57 $832.15 $979.00 $979.00 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834210 dexamethasone 10 mg/mL Inj Sol 00641-0367-25 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834212 dexamethasone 4 mg/mL Inj Sol 63323-0165-01 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 $56.16 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834213 dexamethasone 4 mg/mL Inj Sol 63323-0165-05 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 $61.70 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834231 Dextrose 5% Sod Chloride 0.45% KCl 40 mEq 1000 mL PREMIX 00338-0675-04 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 $18.72 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834238 glucose 50% IV Sol 50 mL 00409-7517-16 INSTITUTIONAL $112.00 1/1/2022-12/31/2022 $112.00 $52.86 $63.84 $82.32 $82.32 $77.65 100% of Medicare $67.07 $64.56 $62.87 $71.68 100% of Medicaid 100% of Medicare 150% of Medicare $89.60 $112.00 195% of Medicare $90.72 $66.64 $66.64 $52.86 $112.00 100% of Medicare $89.60 $95.20 $100.80 $81.75 $95.20 $112.00 $112.00 100% of Medicare 100% of Medicare $112.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834251 diphenhydrAMINE 50 mg/mL Inj Sol 00641-0376-25 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834289 epinephrine 0.1 mg/mL Inj Sol 00409-4921-34 INSTITUTIONAL $94.00 1/1/2022-12/31/2022 $94.00 $44.37 $53.58 $69.09 $69.09 $65.17 100% of Medicare $56.29 $54.18 $52.76 $60.16 100% of Medicaid 100% of Medicare 150% of Medicare $75.20 $94.00 195% of Medicare $76.14 $55.93 $55.93 $44.37 $94.00 100% of Medicare $75.20 $79.90 $84.60 $68.61 $79.90 $94.00 $94.00 100% of Medicare 100% of Medicare $94.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834301 ertapenem 1 g Inj 00006-3843-71 INSTITUTIONAL $346.00 1/1/2022-12/31/2022 $346.00 $163.31 $197.22 $254.31 $254.31 $239.88 100% of Medicare $207.18 $199.43 $194.21 $221.44 100% of Medicaid 100% of Medicare 150% of Medicare $276.80 $346.00 195% of Medicare $280.26 $205.87 $205.87 $163.31 $346.00 100% of Medicare $276.80 $294.10 $311.40 $252.55 $294.10 $346.00 $346.00 100% of Medicare 100% of Medicare $346.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834307 esomeprazole 40 mg IV Inj 00186-6040-01 INSTITUTIONAL $255.00 1/1/2022-12/31/2022 $255.00 $120.36 $145.35 $187.43 $187.43 $176.79 100% of Medicare $152.69 $146.98 $143.13 $163.20 100% of Medicaid 100% of Medicare 150% of Medicare $204.00 $255.00 195% of Medicare $206.55 $151.73 $151.73 $120.36 $255.00 100% of Medicare $204.00 $216.75 $229.50 $186.12 $216.75 $255.00 $255.00 100% of Medicare 100% of Medicare $255.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834320 famotidine 10 mg/mL IV Sol 55390-0029-10 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834331 fentanyl 0.05 mg/mL Inj Sol 00641-6027-25 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834341 Fluconazole Inj 200mg in Sodium Chloride 0.9% 100mL PREMIX 00409-4688-23 INSTITUTIONAL " $1,391.00 " 1/1/2022-12/31/2022 " $1,391.00 " $656.55 $792.87 " $1,022.39 " " $1,022.39 " $964.38 100% of Medicare $832.93 $801.77 $780.77 $890.24 100% of Medicaid 100% of Medicare 150% of Medicare " $1,112.80 " " $1,391.00 " 195% of Medicare " $1,126.71 " $827.65 $827.65 $656.55 " $1,359.00 " 100% of Medicare " $1,112.80 " " $1,182.35 " " $1,251.90 " " $1,015.29 " " $1,182.35 " " $1,391.00 " " $1,391.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834342 Fluconazole Inj 400mg in Sodium Chloride 0.9% 200mL PREMIX 00409-4688-02 INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $39.18 $47.31 $61.01 $61.01 $57.54 100% of Medicare $49.70 $47.84 $46.59 $53.12 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $49.39 $49.39 $39.18 $83.00 100% of Medicare $66.40 $70.55 $74.70 $60.58 $70.55 $83.00 $83.00 100% of Medicare 100% of Medicare $83.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834345 flumazenil 0.1 mg/mL IV Sol 00143-9784-10 INSTITUTIONAL $92.00 1/1/2022-12/31/2022 $92.00 $43.42 $52.44 $67.62 $67.62 $63.78 100% of Medicare $55.09 $53.03 $51.64 $58.88 100% of Medicaid 100% of Medicare 150% of Medicare $73.60 $92.00 195% of Medicare $74.52 $54.74 $54.74 $43.42 $92.00 100% of Medicare $73.60 $78.20 $82.80 $67.15 $78.20 $92.00 $92.00 100% of Medicare 100% of Medicare $92.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834359 furosemide 10 mg/mL Inj Sol 00409-6102-04 INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $60.42 $72.96 $94.08 $94.08 $88.74 100% of Medicare $76.65 $73.78 $71.85 $81.92 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $76.16 $76.16 $60.42 $128.00 100% of Medicare $102.40 $108.80 $115.20 $93.43 $108.80 $128.00 $128.00 100% of Medicare 100% of Medicare $128.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834378 glucagon recombinant 1 mg Inj 55390-0004-01 INSTITUTIONAL $873.00 1/1/2022-12/31/2022 $873.00 $412.06 $497.61 $641.66 $641.66 $605.25 100% of Medicare $522.75 $503.20 $490.01 $558.72 100% of Medicaid 100% of Medicare 150% of Medicare $698.40 $873.00 195% of Medicare $707.13 $519.44 $519.44 $412.06 $873.00 100% of Medicare $698.40 $742.05 $785.70 $637.20 $742.05 $873.00 $873.00 100% of Medicare 100% of Medicare $873.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834388 haloperidol 5 mg/mL Inj Sol 25021-0806-01 INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $40.59 $49.02 $63.21 $63.21 $59.62 100% of Medicare $51.50 $49.57 $48.27 $55.04 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $51.17 $51.17 $40.59 $86.00 100% of Medicare $68.80 $73.10 $77.40 $62.77 $73.10 $86.00 $86.00 100% of Medicare 100% of Medicare $86.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834405 hydrALAZINE 20 mg/mL Inj Sol 17478-0934-01 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834409 hydrocortisone 100 mg preservative-free REC 00009-0825-01 INSTITUTIONAL $110.00 1/1/2022-12/31/2022 $110.00 $51.92 $62.70 $80.85 $80.85 $76.26 100% of Medicare $65.87 $63.40 $61.74 $70.40 100% of Medicaid 100% of Medicare 150% of Medicare $88.00 $110.00 195% of Medicare $89.10 $65.45 $65.45 $51.92 $110.00 100% of Medicare $88.00 $93.50 $99.00 $80.29 $93.50 $110.00 $110.00 100% of Medicare 100% of Medicare $110.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834417 hydromorphone 2 mg/mL Inj Sol 00409-3356-01 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834476 interferon beta-1a 44 mcg/0.5 mL SubQ Sol 44087-0044-03 INSTITUTIONAL " $1,435.00 " 1/1/2022-12/31/2022 " $1,435.00 " $677.32 $817.95 " $1,054.73 " " $1,054.73 " $994.89 100% of Medicare $859.28 $827.13 $805.47 $918.40 100% of Medicaid 100% of Medicare 150% of Medicare " $1,148.00 " " $1,435.00 " 195% of Medicare " $1,162.35 " $853.83 $853.83 $677.32 " $1,359.00 " 100% of Medicare " $1,148.00 " " $1,219.75 " " $1,291.50 " " $1,047.41 " " $1,219.75 " " $1,435.00 " " $1,435.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834479 iopamidol 41% intrathecal Sol 10 mL 00270-1411-11 INSTITUTIONAL $82.00 1/1/2022-12/31/2022 $82.00 $38.70 $46.74 $60.27 $60.27 $56.85 100% of Medicare $49.10 $47.26 $46.03 $52.48 100% of Medicaid 100% of Medicare 150% of Medicare $65.60 $82.00 195% of Medicare $66.42 $48.79 $48.79 $38.70 $82.00 100% of Medicare $65.60 $69.70 $73.80 $59.85 $69.70 $82.00 $82.00 100% of Medicare 100% of Medicare $82.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834480 Iopamidol 61% 15ml 00270-1412-15 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834489 iron sucrose 20 mg/mL IV Sol 00517-2340-10 INSTITUTIONAL $210.00 1/1/2022-12/31/2022 $210.00 $99.12 $119.70 $154.35 $154.35 $145.59 100% of Medicare $125.75 $121.04 $117.87 $134.40 100% of Medicaid 100% of Medicare 150% of Medicare $168.00 $210.00 195% of Medicare $170.10 $124.95 $124.95 $99.12 $210.00 100% of Medicare $168.00 $178.50 $189.00 $153.28 $178.50 $210.00 $210.00 100% of Medicare 100% of Medicare $210.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834500 ketorolac 30 mg/mL Inj Sol 00409-3795-01 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 $56.16 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834502 labetalol 5 mg/mL IV Sol 00409-2267-20 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834521 levetiracetam 100 mg/mL IV Sol 62756-0513-44 INSTITUTIONAL $73.00 1/1/2022-12/31/2022 $73.00 $34.46 $41.61 $53.66 $53.66 $50.61 100% of Medicare $43.71 $42.08 $40.97 $46.72 100% of Medicaid 100% of Medicare 150% of Medicare $58.40 $73.00 195% of Medicare $59.13 $43.44 $43.44 $34.46 $73.00 100% of Medicare $58.40 $62.05 $65.70 $53.28 $62.05 $73.00 $73.00 100% of Medicare 100% of Medicare $73.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834533 lidocaine 2% PF Inj Sol 2 mL 63323-0495-27 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834535 lidocaine 1% PF Inj Sol 30 mL 00409-4279-02 INSTITUTIONAL $72.00 1/1/2022-12/31/2022 $72.00 $33.98 $41.04 $52.92 $52.92 $49.92 100% of Medicare $43.11 $41.50 $40.41 $46.08 100% of Medicaid 100% of Medicare 150% of Medicare $57.60 $72.00 195% of Medicare $58.32 $42.84 $42.84 $33.98 $72.00 100% of Medicare $57.60 $61.20 $64.80 $52.55 $61.20 $72.00 $72.00 100% of Medicare 100% of Medicare $72.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834536 lidocaine 1% PF Inj Sol 5 mL 63323-0492-57 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834547 lidocaine 2% PF Inj Sol 5 mL 00409-4903-34 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834549 lidocaine 2% Inj Sol 20 mL 00409-4277-01 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834563 linezolid 2 mg/mL IV Sol 00009-5140-01 INSTITUTIONAL $732.00 1/1/2022-12/31/2022 $732.00 $345.50 $417.24 $538.02 $538.02 $507.50 100% of Medicare $438.32 $421.92 $410.87 $468.48 100% of Medicaid 100% of Medicare 150% of Medicare $585.60 $732.00 195% of Medicare $592.92 $435.54 $435.54 $345.50 $732.00 100% of Medicare $585.60 $622.20 $658.80 $534.29 $622.20 $732.00 $732.00 100% of Medicare 100% of Medicare $732.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834568 magnesium sulfate 10 mg/mL-D5W intravenous solution 00409-6727-23 INSTITUTIONAL " $9,410.00 " 1/1/2022-12/31/2022 " $8,469.00 " $975.00 " $5,363.70 " " $6,916.35 " " $6,916.35 " " $6,523.95 " 100% of Medicare " $5,634.71 " " $5,423.92 " " $5,281.83 " " $6,022.40 " 100% of Medicaid 100% of Medicare 150% of Medicare " $7,528.00 " " $1,500.00 " 195% of Medicare " $7,622.10 " " $5,598.95 " " $5,598.95 " " $4,441.52 " " $1,359.00 " 100% of Medicare " $7,528.00 " " $7,998.50 " " $8,469.00 " " $6,868.36 " " $7,998.50 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834574 magnesium sulfate 50% Inj Sol 10 mL 00517-2610-25 INSTITUTIONAL $413.00 1/1/2022-12/31/2022 $413.00 $194.94 $235.41 $303.56 $303.56 $286.33 100% of Medicare $247.30 $238.05 $231.82 $264.32 100% of Medicaid 100% of Medicare 150% of Medicare $330.40 $413.00 195% of Medicare $334.53 $245.74 $245.74 $194.94 $413.00 100% of Medicare $330.40 $351.05 $371.70 $301.45 $351.05 $413.00 $413.00 100% of Medicare 100% of Medicare $413.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834594 meropenem 500 mg IV Inj 00781-3265-95 INSTITUTIONAL $76.00 1/1/2022-12/31/2022 $76.00 $35.87 $43.32 $55.86 $55.86 $52.69 100% of Medicare $45.51 $43.81 $42.66 $48.64 100% of Medicaid 100% of Medicare 150% of Medicare $60.80 $76.00 195% of Medicare $61.56 $45.22 $45.22 $35.87 $76.00 100% of Medicare $60.80 $64.60 $68.40 $55.47 $64.60 $76.00 $76.00 100% of Medicare 100% of Medicare $76.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834600 methotrexate 25 mg/mL PF Inj Sol 10139-0062-02 INSTITUTIONAL $119.00 1/1/2022-12/31/2022 $119.00 $56.17 $67.83 $87.47 $87.47 $82.50 100% of Medicare $71.26 $68.59 $66.79 $76.16 100% of Medicaid 100% of Medicare 150% of Medicare $95.20 $119.00 195% of Medicare $96.39 $70.81 $70.81 $56.17 $119.00 100% of Medicare $95.20 $101.15 $107.10 $86.86 $101.15 $119.00 $119.00 100% of Medicare 100% of Medicare $119.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834606 methylPREDNISolone 1 g preservative-free REC 00009-0018-20 INSTITUTIONAL $150.00 1/1/2022-12/31/2022 $150.00 $70.80 $85.50 $110.25 $110.25 $104.00 100% of Medicare $89.82 $86.46 $84.20 $96.00 100% of Medicaid 100% of Medicare 150% of Medicare $120.00 $150.00 195% of Medicare $121.50 $89.25 $89.25 $70.80 $150.00 100% of Medicare $120.00 $127.50 $135.00 $109.49 $127.50 $150.00 $150.00 100% of Medicare 100% of Medicare $150.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834607 methylPREDNISolone 125 mg preservative-free REC 00009-0047-22 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 $61.70 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834608 methylPREDNISolone 40 mg preservative-free REC 00009-0039-28 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834609 methylPREDNISolone 500 mg preservative-free REC 00009-0003-02 INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 $97.06 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834610 methylPREDNISolone 1 g Inj 00009-0698-01 INSTITUTIONAL $218.00 1/1/2022-12/31/2022 $218.00 $102.90 $124.26 $160.23 $160.23 $151.14 100% of Medicare $130.54 $125.66 $122.36 $139.52 100% of Medicaid 100% of Medicare 150% of Medicare $174.40 $218.00 195% of Medicare $176.58 $129.71 $129.71 $102.90 $218.00 100% of Medicare $174.40 $185.30 $196.20 $159.12 $185.30 $218.00 $218.00 100% of Medicare 100% of Medicare $218.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834615 metoclopramide 5 mg/mL Inj Sol 00409-3414-01 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834617 MetroNIDAZOLE Inj 500mg in Sodium Chloride 0.9% 100mL PREMIX 00338-1055-48 INSTITUTIONAL $122.00 1/1/2022-12/31/2022 $122.00 $57.58 $69.54 $89.67 $89.67 $84.58 100% of Medicare $73.05 $70.32 $68.48 $78.08 100% of Medicaid 100% of Medicare 150% of Medicare $97.60 $122.00 195% of Medicare $98.82 $72.59 $72.59 $57.58 $122.00 100% of Medicare $97.60 $103.70 $109.80 $89.05 $103.70 $122.00 $122.00 100% of Medicare 100% of Medicare $122.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834618 micafungin 100 mg IV Inj 00469-3211-10 INSTITUTIONAL " $2,738.00 " 1/1/2022-12/31/2022 " $2,635.00 " $975.00 " $1,560.66 " " $2,012.43 " " $2,012.43 " " $1,898.26 " 100% of Medicare " $1,639.51 " " $1,578.18 " " $1,536.84 " " $1,752.32 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,190.40 " " $1,500.00 " 195% of Medicare " $2,217.78 " " $1,629.11 " " $1,629.11 " " $1,292.34 " " $1,359.00 " 100% of Medicare " $2,190.40 " " $2,327.30 " " $2,464.20 " " $1,998.47 " " $2,327.30 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834626 midazolam 1 mg/mL preservative-free Inj Sol 00409-2305-17 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834629 midazolam 5 mg/mL Inj Sol 63323-0412-25 INSTITUTIONAL $84.00 1/1/2022-12/31/2022 $84.00 $39.65 $47.88 $61.74 $61.74 $58.24 100% of Medicare $50.30 $48.42 $47.15 $53.76 100% of Medicaid 100% of Medicare 150% of Medicare $67.20 $84.00 195% of Medicare $68.04 $49.98 $49.98 $39.65 $84.00 100% of Medicare $67.20 $71.40 $75.60 $61.31 $71.40 $84.00 $84.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834647 morphine 10 mg/mL Inj Sol 00409-1893-01 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834651 morphine 4 mg/mL Inj Sol 00409-1891-01 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834661 nafcillin 2 g Inj 00781-3125-95 INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $53.81 $64.98 $83.79 $83.79 $79.04 100% of Medicare $68.26 $65.71 $63.99 $72.96 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $67.83 $67.83 $53.81 $114.00 100% of Medicare $91.20 $96.90 $102.60 $83.21 $96.90 $114.00 $114.00 100% of Medicare 100% of Medicare $114.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834666 naloxone 0.4 mg/mL Inj Sol 00409-1215-01 INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $75.99 $91.77 $118.34 $118.34 $111.62 100% of Medicare $96.41 $92.80 $90.37 $103.04 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $95.80 $95.80 $75.99 $161.00 100% of Medicare $128.80 $136.85 $144.90 $117.51 $136.85 $161.00 $161.00 100% of Medicare 100% of Medicare $161.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834683 octreotide 100 mcg/mL Inj Sol 62756-0349-44 INSTITUTIONAL $136.00 1/1/2022-12/31/2022 $136.00 $64.19 $77.52 $99.96 $99.96 $94.29 100% of Medicare $81.44 $78.39 $76.34 $87.04 100% of Medicaid 100% of Medicare 150% of Medicare $108.80 $136.00 195% of Medicare $110.16 $80.92 $80.92 $64.19 $136.00 100% of Medicare $108.80 $115.60 $122.40 $99.27 $115.60 $136.00 $136.00 100% of Medicare 100% of Medicare $136.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834684 octreotide 50 mcg/mL Inj Sol 00078-0180-03 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834695 Ondansetron Inj 2 mg/mL 2 mL (UD) 00781-3010-95 INSTITUTIONAL $77.00 1/1/2022-12/31/2022 $77.00 $36.34 $43.89 $56.60 $56.60 $53.38 100% of Medicare $46.11 $44.38 $43.22 $49.28 100% of Medicaid 100% of Medicare 150% of Medicare $61.60 $77.00 195% of Medicare $62.37 $45.82 $45.82 $36.34 $77.00 100% of Medicare $61.60 $65.45 $69.30 $56.20 $65.45 $77.00 $77.00 100% of Medicare 100% of Medicare $77.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834709 pamidronate 3 mg/mL IV Sol 00517-0745-01 INSTITUTIONAL $119.00 1/1/2022-12/31/2022 $119.00 $56.17 $67.83 $87.47 $87.47 $82.50 100% of Medicare $71.26 $68.59 $66.79 $76.16 100% of Medicaid 100% of Medicare 150% of Medicare $95.20 $119.00 195% of Medicare $96.39 $70.81 $70.81 $56.17 $119.00 100% of Medicare $95.20 $101.15 $107.10 $86.86 $101.15 $119.00 $119.00 100% of Medicare 100% of Medicare $119.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834713 pantoprazole 40 mg IV Inj 00008-0923-55 INSTITUTIONAL $244.00 1/1/2022-12/31/2022 $244.00 $115.17 $139.08 $179.34 $179.34 $169.17 100% of Medicare $146.11 $140.64 $136.96 $156.16 100% of Medicaid 100% of Medicare 150% of Medicare $195.20 $244.00 195% of Medicare $197.64 $145.18 $145.18 $115.17 $244.00 100% of Medicare $195.20 $207.40 $219.60 $178.10 $207.40 $244.00 $244.00 100% of Medicare 100% of Medicare $244.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834737 phytonadione 10 mg/mL Inj Sol 00409-9158-01 INSTITUTIONAL $108.00 1/1/2022-12/31/2022 $108.00 $50.98 $61.56 $79.38 $79.38 $74.88 100% of Medicare $64.67 $62.25 $60.62 $69.12 100% of Medicaid 100% of Medicare 150% of Medicare $86.40 $108.00 195% of Medicare $87.48 $64.26 $64.26 $50.98 $108.00 100% of Medicare $86.40 $91.80 $97.20 $78.83 $91.80 $108.00 $108.00 100% of Medicare 100% of Medicare $108.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834738 Piperacillin/Tazobactam 3.375 GM ADD 00409-3378-13 INSTITUTIONAL $152.00 1/1/2022-12/31/2022 $152.00 $71.74 $86.64 $111.72 $111.72 $105.38 100% of Medicare $91.02 $87.61 $85.32 $97.28 100% of Medicaid 100% of Medicare 150% of Medicare $121.60 $152.00 195% of Medicare $123.12 $90.44 $90.44 $71.74 $152.00 100% of Medicare $121.60 $129.20 $136.80 $110.94 $129.20 $152.00 $152.00 100% of Medicare 100% of Medicare $152.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834754 potassium chloride 2 mEq/mL IV Sol 00409-6651-06 INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $20.77 $25.08 $32.34 $32.34 $30.51 100% of Medicare $26.35 $25.36 $24.70 $28.16 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $26.18 $26.18 $20.77 $44.00 100% of Medicare $35.20 $37.40 $39.60 $32.12 $37.40 $44.00 $44.00 100% of Medicare 100% of Medicare $44.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834755 potassium chloride 2 mEq/mL IV Sol 00409-6653-05 INSTITUTIONAL " $1,150.00 " 1/1/2022-12/31/2022 " $1,150.00 " $542.80 $655.50 $845.25 $845.25 $797.30 100% of Medicare $688.62 $662.86 $645.50 $736.00 100% of Medicaid 100% of Medicare 150% of Medicare $920.00 " $1,150.00 " 195% of Medicare $931.50 $684.25 $684.25 $542.80 " $1,150.00 " 100% of Medicare $920.00 $977.50 " $1,035.00 " $839.39 $977.50 " $1,150.00 " " $1,150.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834765 promethazine 25 mg/mL Inj Sol 00641-0928-25 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 $56.16 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834795 ropivacaine 0.2% Inj Sol 20 mL 63323-0285-20 INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $34.93 $42.18 $54.39 $54.39 $51.30 100% of Medicare $44.31 $42.65 $41.54 $47.36 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $44.03 $44.03 $34.93 $74.00 100% of Medicare $59.20 $62.90 $66.60 $54.01 $62.90 $74.00 $74.00 100% of Medicare 100% of Medicare $74.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834810 sodium ferric gluconate complex 12.5 mg/mL IV Sol 52544-0922-26 INSTITUTIONAL $205.00 1/1/2022-12/31/2022 $205.00 $96.76 $116.85 $150.68 $150.68 $142.13 100% of Medicare $122.75 $118.16 $115.07 $131.20 100% of Medicaid 100% of Medicare 150% of Medicare $164.00 $205.00 195% of Medicare $166.05 $121.98 $121.98 $96.76 $205.00 100% of Medicare $164.00 $174.25 $184.50 $149.63 $174.25 $205.00 $205.00 100% of Medicare 100% of Medicare $205.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834818 sodium bicarbonate 8.4% IV Sol 50 mL 00409-6637-34 INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $27.85 $33.63 $43.37 $43.37 $40.90 100% of Medicare $35.33 $34.01 $33.12 $37.76 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $35.11 $35.11 $27.85 $59.00 100% of Medicare $47.20 $50.15 $53.10 $43.06 $50.15 $59.00 $59.00 100% of Medicare 100% of Medicare $59.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834819 Sodium Chloride 0.9% with KCl 20 mEq/l IV Sol 1000 mL 00338-0691-04 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834820 Sodium Chloride 0.9% IV Sol 100 mL 00338-0049-18 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834821 Sodium Chloride 0.9% IV Sol 100 mL 00338-0553-18 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834823 Sodium Chloride 0.9% IV Sol 1000 mL 00338-0049-04 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834827 Sodium Chloride 0.9% IV Sol 50 mL 00338-0049-11 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834829 Sodium Chloride 0.9% IV Sol 500 mL 00338-0049-03 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834831 sodium chloride bacteriostatic 0.9% Inj Sol 30 mL 00409-1966-07 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834832 sodium chloride 0.9% Inj Sol 10 mL 00409-4888-10 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834836 sodium phosphate 3 mmol/mL Inj Sol 15mL 00409-7391-72 INSTITUTIONAL $185.00 1/1/2022-12/31/2022 $185.00 $87.32 $105.45 $135.98 $135.98 $128.26 100% of Medicare $110.78 $106.63 $103.84 $118.40 100% of Medicaid 100% of Medicare 150% of Medicare $148.00 $185.00 195% of Medicare $149.85 $110.08 $110.08 $87.32 $185.00 100% of Medicare $148.00 $157.25 $166.50 $135.03 $157.25 $185.00 $185.00 100% of Medicare 100% of Medicare $185.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834841 Sterile Water Inj Bact 30 mL 00409-3977-03 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834859 testosterone cypionate 200 mg/mL IM Sol 00009-0417-01 INSTITUTIONAL $182.00 1/1/2022-12/31/2022 $182.00 $85.90 $103.74 $133.77 $133.77 $126.18 100% of Medicare $108.98 $104.90 $102.16 $116.48 100% of Medicaid 100% of Medicare 150% of Medicare $145.60 $182.00 195% of Medicare $147.42 $108.29 $108.29 $85.90 $182.00 100% of Medicare $145.60 $154.70 $163.80 $132.84 $154.70 $182.00 $182.00 100% of Medicare 100% of Medicare $182.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834896 vancomycin 1 g IV Inj 00409-6533-01 INSTITUTIONAL $163.00 1/1/2022-12/31/2022 $163.00 $76.94 $92.91 $119.81 $119.81 $113.01 100% of Medicare $97.60 $93.95 $91.49 $104.32 100% of Medicaid 100% of Medicare 150% of Medicare $130.40 $163.00 195% of Medicare $132.03 $96.99 $96.99 $76.94 $163.00 100% of Medicare $130.40 $138.55 $146.70 $118.97 $138.55 $163.00 $163.00 100% of Medicare 100% of Medicare $163.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834897 vancomycin 1 g IV Inj Addv 00409-6535-01 INSTITUTIONAL $210.00 1/1/2022-12/31/2022 $210.00 $99.12 $119.70 $154.35 $154.35 $145.59 100% of Medicare $125.75 $121.04 $117.87 $134.40 100% of Medicaid 100% of Medicare 150% of Medicare $168.00 $210.00 195% of Medicare $170.10 $124.95 $124.95 $99.12 $210.00 100% of Medicare $168.00 $178.50 $189.00 $153.28 $178.50 $210.00 $210.00 100% of Medicare 100% of Medicare $210.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834898 vancomycin 500 mg IV Inj 00074-4332-49 INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 $70.72 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12834916 zoledronic acid 5 mg/100 mL IV Sol 00078-0435-61 INSTITUTIONAL " $2,131.00 " 1/1/2022-12/31/2022 " $2,131.00 " $975.00 " $1,214.67 " " $1,566.29 " " $1,566.29 " " $1,477.42 " 100% of Medicare " $1,276.04 " " $1,228.31 " " $1,196.13 " " $1,363.84 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,704.80 " " $1,500.00 " 195% of Medicare " $1,726.11 " " $1,267.95 " " $1,267.95 " " $1,005.83 " " $1,359.00 " 100% of Medicare " $1,704.80 " " $1,811.35 " " $1,917.90 " " $1,555.42 " " $1,811.35 " " $1,500.00 " " $2,131.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834919 sodium chloride nasal 0.65% Gel 00225-0525-47 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834920 sodium chloride Nasal 0.65% Spry 00904-3865-75 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834926 atropine Opth 1% Sol 24208-0750-60 INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $50.50 $60.99 $78.65 $78.65 $74.18 100% of Medicare $64.07 $61.67 $60.06 $68.48 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $63.67 $63.67 $50.50 $107.00 100% of Medicare $85.60 $90.95 $96.30 $78.10 $90.95 $107.00 $107.00 100% of Medicare 100% of Medicare $107.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834929 azithromycin Opth 1% Sol 31357-0040-25 INSTITUTIONAL $372.00 1/1/2022-12/31/2022 $372.00 $175.58 $212.04 $273.42 $273.42 $257.91 100% of Medicare $222.75 $214.42 $208.80 $238.08 100% of Medicaid 100% of Medicare 150% of Medicare $297.60 $372.00 195% of Medicare $301.32 $221.34 $221.34 $175.58 $372.00 100% of Medicare $297.60 $316.20 $334.80 $271.52 $316.20 $372.00 $372.00 100% of Medicare 100% of Medicare $372.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834930 bacitracin Opth 500 units/g Oint 48102-0007-35 INSTITUTIONAL $439.00 1/1/2022-12/31/2022 $439.00 $207.21 $250.23 $322.67 $322.67 $304.36 100% of Medicare $262.87 $253.04 $246.41 $280.96 100% of Medicaid 100% of Medicare 150% of Medicare $351.20 $439.00 195% of Medicare $355.59 $261.21 $261.21 $207.21 $439.00 100% of Medicare $351.20 $373.15 $395.10 $320.43 $373.15 $439.00 $439.00 100% of Medicare 100% of Medicare $439.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834932 bacitracin/neomycin/polymyxin B Opth Oint 17478-0235-35 INSTITUTIONAL $351.00 1/1/2022-12/31/2022 $351.00 $165.67 $200.07 $257.99 $257.99 $243.35 100% of Medicare $210.18 $202.32 $197.02 $224.64 100% of Medicaid 100% of Medicare 150% of Medicare $280.80 $351.00 195% of Medicare $284.31 $208.85 $208.85 $165.67 $351.00 100% of Medicare $280.80 $298.35 $315.90 $256.19 $298.35 $351.00 $351.00 100% of Medicare 100% of Medicare $351.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834933 bacitracin-polymyxin B Opth Oint 17478-0238-35 INSTITUTIONAL $164.00 1/1/2022-12/31/2022 $164.00 $77.41 $93.48 $120.54 $120.54 $113.70 100% of Medicare $98.20 $94.53 $92.05 $104.96 100% of Medicaid 100% of Medicare 150% of Medicare $131.20 $164.00 195% of Medicare $132.84 $97.58 $97.58 $77.41 $164.00 100% of Medicare $131.20 $139.40 $147.60 $119.70 $139.40 $164.00 $164.00 100% of Medicare 100% of Medicare $164.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834940 betaxolol Opth 0.5% Sol 17478-0705-10 INSTITUTIONAL $211.00 1/1/2022-12/31/2022 $211.00 $99.59 $120.27 $155.09 $155.09 $146.29 100% of Medicare $126.35 $121.62 $118.43 $135.04 100% of Medicaid 100% of Medicare 150% of Medicare $168.80 $211.00 195% of Medicare $170.91 $125.55 $125.55 $99.59 $211.00 100% of Medicare $168.80 $179.35 $189.90 $154.01 $179.35 $211.00 $211.00 100% of Medicare 100% of Medicare $211.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834941 bimatoprost 0.01% Opth Sol 00023-9187-03 INSTITUTIONAL $432.00 1/1/2022-12/31/2022 $432.00 $203.90 $246.24 $317.52 $317.52 $299.51 100% of Medicare $258.68 $249.00 $242.48 $276.48 100% of Medicaid 100% of Medicare 150% of Medicare $345.60 $432.00 195% of Medicare $349.92 $257.04 $257.04 $203.90 $432.00 100% of Medicare $345.60 $367.20 $388.80 $315.32 $367.20 $432.00 $432.00 100% of Medicare 100% of Medicare $432.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834944 brimonidine Opth 0.2% Sol 17478-0715-10 INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 $37.44 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834945 brinzolamide Opth 1% Susp 00065-0275-10 INSTITUTIONAL " $1,236.00 " 1/1/2022-12/31/2022 " $1,236.00 " $583.39 $704.52 $908.46 $908.46 $856.92 100% of Medicare $740.12 $712.43 $693.77 $791.04 100% of Medicaid 100% of Medicare 150% of Medicare $988.80 " $1,236.00 " 195% of Medicare " $1,001.16 " $735.42 $735.42 $583.39 " $1,236.00 " 100% of Medicare $988.80 " $1,050.60 " " $1,112.40 " $902.16 " $1,050.60 " " $1,236.00 " " $1,236.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834950 ciprofloxacin Opth 0.3% Sol 50383-0282-02 INSTITUTIONAL $158.00 1/1/2022-12/31/2022 $158.00 $74.58 $90.06 $116.13 $116.13 $109.54 100% of Medicare $94.61 $91.07 $88.69 $101.12 100% of Medicaid 100% of Medicare 150% of Medicare $126.40 $158.00 195% of Medicare $127.98 $94.01 $94.01 $74.58 $158.00 100% of Medicare $126.40 $134.30 $142.20 $115.32 $134.30 $158.00 $158.00 100% of Medicare 100% of Medicare $158.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834954 cyclopentolate Opth 2% Sol 00065-0397-02 INSTITUTIONAL $146.00 1/1/2022-12/31/2022 $146.00 $68.91 $83.22 $107.31 $107.31 $101.22 100% of Medicare $87.42 $84.15 $81.95 $93.44 100% of Medicaid 100% of Medicare 150% of Medicare $116.80 $146.00 195% of Medicare $118.26 $86.87 $86.87 $68.91 $146.00 100% of Medicare $116.80 $124.10 $131.40 $106.57 $124.10 $146.00 $146.00 100% of Medicare 100% of Medicare $146.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834956 cycloSPORINE Opth 0.05% Emul 00023-9163-30 INSTITUTIONAL " $1,304.00 " 1/1/2022-12/31/2022 " $1,304.00 " $615.49 $743.28 $958.44 $958.44 $904.06 100% of Medicare $780.84 $751.63 $731.94 $834.56 100% of Medicaid 100% of Medicare 150% of Medicare " $1,043.20 " " $1,304.00 " 195% of Medicare " $1,056.24 " $775.88 $775.88 $615.49 " $1,304.00 " 100% of Medicare " $1,043.20 " " $1,108.40 " " $1,173.60 " $951.79 " $1,108.40 " " $1,304.00 " " $1,304.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834958 dexamethasone Opth 0.1% Susp 00998-0615-05 INSTITUTIONAL $210.00 1/1/2022-12/31/2022 $210.00 $99.12 $119.70 $154.35 $154.35 $145.59 100% of Medicare $125.75 $121.04 $117.87 $134.40 100% of Medicaid 100% of Medicare 150% of Medicare $168.00 $210.00 195% of Medicare $170.10 $124.95 $124.95 $99.12 $210.00 100% of Medicare $168.00 $178.50 $189.00 $153.28 $178.50 $210.00 $210.00 100% of Medicare 100% of Medicare $210.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834959 dexamethasone/neomycin/polymyxin B Opth Susp 61314-0631-36 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834961 diclofenac Opth 0.1% Sol 17478-0892-25 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834963 dorzolamide Opth 2% Sol 00093-7618-43 INSTITUTIONAL $436.00 1/1/2022-12/31/2022 $436.00 $205.79 $248.52 $320.46 $320.46 $302.28 100% of Medicare $261.08 $251.31 $244.73 $279.04 100% of Medicaid 100% of Medicare 150% of Medicare $348.80 $436.00 195% of Medicare $353.16 $259.42 $259.42 $205.79 $436.00 100% of Medicare $348.80 $370.60 $392.40 $318.24 $370.60 $436.00 $436.00 100% of Medicare 100% of Medicare $436.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834964 dorzolamide-timolol Opth 22.3%-6.8% Sol 50383-0233-10 INSTITUTIONAL $455.00 1/1/2022-12/31/2022 $455.00 $214.76 $259.35 $334.43 $334.43 $315.45 100% of Medicare $272.45 $262.26 $255.39 $291.20 100% of Medicaid 100% of Medicare 150% of Medicare $364.00 $455.00 195% of Medicare $368.55 $270.73 $270.73 $214.76 $455.00 100% of Medicare $364.00 $386.75 $409.50 $332.10 $386.75 $455.00 $455.00 100% of Medicare 100% of Medicare $455.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834968 gentamicin Opth 0.3% Sol 17478-0283-10 INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 $47.84 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834984 ketorolac Opth 0.5% Sol 17478-0209-10 INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $187.38 $226.29 $291.80 $291.80 $275.24 100% of Medicare $237.72 $228.83 $222.84 $254.08 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $236.22 $236.22 $187.38 $397.00 100% of Medicare $317.60 $337.45 $357.30 $289.77 $337.45 $397.00 $397.00 100% of Medicare 100% of Medicare $397.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834986 latanoprost Opth 0.005% Sol 00517-0830-01 INSTITUTIONAL $95.00 1/1/2022-12/31/2022 $95.00 $44.84 $54.15 $69.83 $69.83 $65.86 100% of Medicare $56.89 $54.76 $53.32 $60.80 100% of Medicaid 100% of Medicare 150% of Medicare $76.00 $95.00 195% of Medicare $76.95 $56.53 $56.53 $44.84 $95.00 100% of Medicare $76.00 $80.75 $85.50 $69.34 $80.75 $95.00 $95.00 100% of Medicare 100% of Medicare $95.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834988 levobunolol Opth 0.5% Sol 24208-0505-05 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 $17.33 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834990 loteprednol Opth 0.5% Susp 24208-0299-05 INSTITUTIONAL $498.00 1/1/2022-12/31/2022 $498.00 $235.06 $283.86 $366.03 $366.03 $345.26 100% of Medicare $298.20 $287.05 $279.53 $318.72 100% of Medicaid 100% of Medicare 150% of Medicare $398.40 $498.00 195% of Medicare $403.38 $296.31 $296.31 $235.06 $498.00 100% of Medicare $398.40 $423.30 $448.20 $363.49 $423.30 $498.00 $498.00 100% of Medicare 100% of Medicare $498.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834991 moxifloxacin 0.5% Opth Sol 00065-4013-03 INSTITUTIONAL $775.00 1/1/2022-12/31/2022 $775.00 $365.80 $441.75 $569.63 $569.63 $537.31 100% of Medicare $464.07 $446.71 $435.01 $496.00 100% of Medicaid 100% of Medicare 150% of Medicare $620.00 $775.00 195% of Medicare $627.75 $461.13 $461.13 $365.80 $775.00 100% of Medicare $620.00 $658.75 $697.50 $565.67 $658.75 $775.00 $775.00 100% of Medicare 100% of Medicare $775.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834995 Natural Tears 00065-0416-25 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834996 nepafenac Opth 0.1% Susp 00065-0002-03 INSTITUTIONAL $585.00 1/1/2022-12/31/2022 $585.00 $276.12 $333.45 $429.98 $429.98 $405.58 100% of Medicare $350.30 $337.19 $328.36 $374.40 100% of Medicaid 100% of Medicare 150% of Medicare $468.00 $585.00 195% of Medicare $473.85 $348.08 $348.08 $276.12 $585.00 100% of Medicare $468.00 $497.25 $526.50 $426.99 $497.25 $585.00 $585.00 100% of Medicare 100% of Medicare $585.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12834997 ocular lubricant Sol 00065-0431-32 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835000 ocular lubricant preserved Sol 00904-5017-35 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835001 ofloxacin Opth 0.3% Sol 24208-0434-05 INSTITUTIONAL $156.00 1/1/2022-12/31/2022 $156.00 $73.63 $88.92 $114.66 $114.66 $108.15 100% of Medicare $93.41 $89.92 $87.56 $99.84 100% of Medicaid 100% of Medicare 150% of Medicare $124.80 $156.00 195% of Medicare $126.36 $92.82 $92.82 $73.63 $156.00 100% of Medicare $124.80 $132.60 $140.40 $113.86 $132.60 $156.00 $156.00 100% of Medicare 100% of Medicare $156.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835002 olopatadine Opth 0.1% Sol 00065-0271-05 INSTITUTIONAL " $1,294.00 " 1/1/2022-12/31/2022 " $1,294.00 " $610.77 $737.58 $951.09 $951.09 $897.13 100% of Medicare $774.85 $745.86 $726.32 $828.16 100% of Medicaid 100% of Medicare 150% of Medicare " $1,035.20 " " $1,294.00 " 195% of Medicare " $1,048.14 " $769.93 $769.93 $610.77 " $1,294.00 " 100% of Medicare " $1,035.20 " " $1,099.90 " " $1,164.60 " $944.49 " $1,099.90 " " $1,294.00 " " $1,294.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835017 polymyxin B-trimethoprim Opth Sol 24208-0315-10 INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $40.59 $49.02 $63.21 $63.21 $59.62 100% of Medicare $51.50 $49.57 $48.27 $55.04 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $51.17 $51.17 $40.59 $86.00 100% of Medicare $68.80 $73.10 $77.40 $62.77 $73.10 $86.00 $86.00 100% of Medicare 100% of Medicare $86.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835020 prednisoLONE Opth acetate 1% Susp 61314-0637-05 INSTITUTIONAL $352.00 1/1/2022-12/31/2022 $352.00 $166.14 $200.64 $258.72 $258.72 $244.04 100% of Medicare $210.78 $202.89 $197.58 $225.28 100% of Medicaid 100% of Medicare 150% of Medicare $281.60 $352.00 195% of Medicare $285.12 $209.44 $209.44 $166.14 $352.00 100% of Medicare $281.60 $299.20 $316.80 $256.92 $299.20 $352.00 $352.00 100% of Medicare 100% of Medicare $352.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835021 prednisoLONE Opth sodium phosphate 1% Sol 24208-0715-10 INSTITUTIONAL $175.00 1/1/2022-12/31/2022 $175.00 $82.60 $99.75 $128.63 $128.63 $121.33 100% of Medicare $104.79 $100.87 $98.23 $112.00 100% of Medicaid 100% of Medicare 150% of Medicare $140.00 $175.00 195% of Medicare $141.75 $104.13 $104.13 $82.60 $175.00 100% of Medicare $140.00 $148.75 $157.50 $127.73 $148.75 $175.00 $175.00 100% of Medicare 100% of Medicare $175.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835024 " sodium chloride, hypertonic, Opth 2% Sol" 24208-0276-15 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835025 " sodium chloride, hypertonic, Opth 5% Sol" 17478-0623-12 INSTITUTIONAL $77.00 1/1/2022-12/31/2022 $77.00 $36.34 $43.89 $56.60 $56.60 $53.38 100% of Medicare $46.11 $44.38 $43.22 $49.28 100% of Medicaid 100% of Medicare 150% of Medicare $61.60 $77.00 195% of Medicare $62.37 $45.82 $45.82 $36.34 $77.00 100% of Medicare $61.60 $65.45 $69.30 $56.20 $65.45 $77.00 $77.00 100% of Medicare 100% of Medicare $77.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835026 Sulfacetamide Ophth Soln 10% 15 mL 61314-0701-01 INSTITUTIONAL $186.00 1/1/2022-12/31/2022 $186.00 $87.79 $106.02 $136.71 $136.71 $128.95 100% of Medicare $111.38 $107.21 $104.40 $119.04 100% of Medicaid 100% of Medicare 150% of Medicare $148.80 $186.00 195% of Medicare $150.66 $110.67 $110.67 $87.79 $186.00 100% of Medicare $148.80 $158.10 $167.40 $135.76 $158.10 $186.00 $186.00 100% of Medicare 100% of Medicare $186.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835030 tetrahydrozoline Opth 0.05% Sol 00904-2992-35 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835032 timolol Opth 0.25% Gel forming Sol 61314-0224-05 INSTITUTIONAL $131.00 1/1/2022-12/31/2022 $131.00 $61.83 $74.67 $96.29 $96.29 $90.82 100% of Medicare $78.44 $75.51 $73.53 $83.84 100% of Medicaid 100% of Medicare 150% of Medicare $104.80 $131.00 195% of Medicare $106.11 $77.95 $77.95 $61.83 $131.00 100% of Medicare $104.80 $111.35 $117.90 $95.62 $111.35 $131.00 $131.00 100% of Medicare 100% of Medicare $131.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835033 timolol Opth 0.5% Gel forming Sol 61314-0225-05 INSTITUTIONAL $154.00 1/1/2022-12/31/2022 $154.00 $72.69 $87.78 $113.19 $113.19 $106.77 100% of Medicare $92.22 $88.77 $86.44 $98.56 100% of Medicaid 100% of Medicare 150% of Medicare $123.20 $154.00 195% of Medicare $124.74 $91.63 $91.63 $72.69 $154.00 100% of Medicare $123.20 $130.90 $138.60 $112.40 $130.90 $154.00 $154.00 100% of Medicare 100% of Medicare $154.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835034 timolol Opth 0.25% Sol 61314-0226-05 INSTITUTIONAL $95.00 1/1/2022-12/31/2022 $95.00 $44.84 $54.15 $69.83 $69.83 $65.86 100% of Medicare $56.89 $54.76 $53.32 $60.80 100% of Medicaid 100% of Medicare 150% of Medicare $76.00 $95.00 195% of Medicare $76.95 $56.53 $56.53 $44.84 $95.00 100% of Medicare $76.00 $80.75 $85.50 $69.34 $80.75 $95.00 $95.00 100% of Medicare 100% of Medicare $95.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835036 tobramycin Opth 0.3% Sol 24208-0290-05 INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $25.02 $30.21 $38.96 $38.96 $36.74 100% of Medicare $31.74 $30.55 $29.75 $33.92 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.54 $31.54 $25.02 $53.00 100% of Medicare $42.40 $45.05 $47.70 $38.68 $45.05 $53.00 $53.00 100% of Medicare 100% of Medicare $53.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835047 chlorhexidine Top 0.12% Liq 480 mL 00116-2001-16 INSTITUTIONAL $30.00 1/1/2022-12/31/2022 $30.00 $14.16 $17.10 $22.05 $22.05 $20.80 100% of Medicare $17.96 $17.29 $16.84 $19.20 100% of Medicaid 100% of Medicare 150% of Medicare $24.00 $30.00 195% of Medicare $24.30 $17.85 $17.85 $14.16 $30.00 100% of Medicare $24.00 $25.50 $27.00 $21.90 $25.50 $30.00 $30.00 100% of Medicare 100% of Medicare $30.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835048 Cyclosporin 100 mg/ml 00591-2224-55 INSTITUTIONAL " $1,111.00 " 1/1/2022-12/31/2022 " $1,111.00 " $524.39 $633.27 $816.59 $816.59 $770.26 100% of Medicare $665.27 $640.38 $623.60 $711.04 100% of Medicaid 100% of Medicare 150% of Medicare $888.80 " $1,111.00 " 195% of Medicare $899.91 $661.05 $661.05 $524.39 " $1,111.00 " 100% of Medicare $888.80 $944.35 $999.90 $810.92 $944.35 " $1,111.00 " " $1,111.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835051 Guaifenesin Soln 100 mg/5 mL Bottle 00603-0857-94 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835057 Mycophenolate Mofetil 200mg/ml 00004-0261-29 INSTITUTIONAL " $4,200.00 " 1/1/2022-12/31/2022 " $3,780.00 " $975.00 " $2,394.00 " " $3,087.00 " " $3,087.00 " " $2,911.86 " 100% of Medicare " $2,514.96 " " $2,420.88 " " $2,357.46 " " $2,688.00 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,360.00 " " $1,500.00 " 195% of Medicare " $3,402.00 " " $2,499.00 " " $2,499.00 " " $1,982.40 " " $1,359.00 " 100% of Medicare " $3,360.00 " " $3,570.00 " " $3,780.00 " " $3,065.58 " " $3,570.00 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835058 Opium Tincture (USP) per Drop 62559-0153-04 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835060 polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL 62175-0446-01 INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $22.66 $27.36 $35.28 $35.28 $33.28 100% of Medicare $28.74 $27.67 $26.94 $30.72 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.56 $28.56 $22.66 $48.00 100% of Medicare $38.40 $40.80 $43.20 $35.04 $40.80 $48.00 $48.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835064 Propranolol HCL 20mg/5ml 00054-3727-63 INSTITUTIONAL $101.00 1/1/2022-12/31/2022 $101.00 $47.67 $57.57 $74.24 $74.24 $70.02 100% of Medicare $60.48 $58.22 $56.69 $64.64 100% of Medicaid 100% of Medicare 150% of Medicare $80.80 $101.00 195% of Medicare $81.81 $60.10 $60.10 $47.67 $101.00 100% of Medicare $80.80 $85.85 $90.90 $73.72 $85.85 $101.00 $101.00 100% of Medicare 100% of Medicare $101.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835067 acetylcysteine 10% Inh Sol 10 mL 00054-3027-02 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835072 acetic acid Otic 2% Sol 00603-7038-41 INSTITUTIONAL $109.00 1/1/2022-12/31/2022 $109.00 $51.45 $62.13 $80.12 $80.12 $75.57 100% of Medicare $65.27 $62.83 $61.18 $69.76 100% of Medicaid 100% of Medicare 150% of Medicare $87.20 $109.00 195% of Medicare $88.29 $64.86 $64.86 $51.45 $109.00 100% of Medicare $87.20 $92.65 $98.10 $79.56 $92.65 $109.00 $109.00 100% of Medicare 100% of Medicare $109.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835075 antipyrine-benzocaine Otic Sol 24208-0561-62 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835076 carbamide peroxide Otic 6.5% Sol 00904-3220-35 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835078 ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp 00065-8533-02 INSTITUTIONAL " $1,109.00 " 1/1/2022-12/31/2022 " $1,109.00 " $523.45 $632.13 $815.12 $815.12 $768.87 100% of Medicare $664.07 $639.23 $622.48 $709.76 100% of Medicaid 100% of Medicare 150% of Medicare $887.20 " $1,109.00 " 195% of Medicare $898.29 $659.86 $659.86 $523.45 " $1,109.00 " 100% of Medicare $887.20 $942.65 $998.10 $809.46 $942.65 " $1,109.00 " " $1,109.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835079 ciprofloxacin-hydrocortisone Otic Susp 00065-8531-10 INSTITUTIONAL " $1,176.00 " 1/1/2022-12/31/2022 " $1,176.00 " $555.07 $670.32 $864.36 $864.36 $815.32 100% of Medicare $704.19 $677.85 $660.09 $752.64 100% of Medicaid 100% of Medicare 150% of Medicare $940.80 " $1,176.00 " 195% of Medicare $952.56 $699.72 $699.72 $555.07 " $1,176.00 " 100% of Medicare $940.80 $999.60 " $1,058.40 " $858.36 $999.60 " $1,176.00 " " $1,176.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835081 hydrocortisone/neomycin/polymyxin B Otic Sol 61314-0646-10 INSTITUTIONAL $101.00 1/1/2022-12/31/2022 $101.00 $47.67 $57.57 $74.24 $74.24 $70.02 100% of Medicare $60.48 $58.22 $56.69 $64.64 100% of Medicaid 100% of Medicare 150% of Medicare $80.80 $101.00 195% of Medicare $81.81 $60.10 $60.10 $47.67 $101.00 100% of Medicare $80.80 $85.85 $90.90 $73.72 $85.85 $101.00 $101.00 100% of Medicare 100% of Medicare $101.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835082 ofloxacin Otic 0.3% Sol 24208-0410-05 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835090 Acetic Acid 0.25% 00409-6143-09 INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 $27.73 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835092 Emollient/Skin Cleanser(Cetaphil) 00299-3921-08 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835094 balsam Peru/castor oil/trypsin topical 87 mg-788 mg-0.12 mg/g Spra 51079-0621-82 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835101 calcitonin 200 intl units/inh Nasal Spry 60505-0823-06 INSTITUTIONAL $440.00 1/1/2022-12/31/2022 $440.00 $207.68 $250.80 $323.40 $323.40 $305.05 100% of Medicare $263.47 $253.62 $246.97 $281.60 100% of Medicaid 100% of Medicare 150% of Medicare $352.00 $440.00 195% of Medicare $356.40 $261.80 $261.80 $207.68 $440.00 100% of Medicare $352.00 $374.00 $396.00 $321.16 $374.00 $440.00 $440.00 100% of Medicare 100% of Medicare $440.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835102 cromolyn Nasal 5.2 mg/inh Spry 52183-0199-13 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835103 desmopressin 10 mcg/inh Nasal Spry 24208-0342-05 INSTITUTIONAL $914.00 1/1/2022-12/31/2022 $914.00 $431.41 $520.98 $671.79 $671.79 $633.68 100% of Medicare $547.30 $526.83 $513.03 $584.96 100% of Medicaid 100% of Medicare 150% of Medicare $731.20 $914.00 195% of Medicare $740.34 $543.83 $543.83 $431.41 $914.00 100% of Medicare $731.20 $776.90 $822.60 $667.13 $776.90 $914.00 $914.00 100% of Medicare 100% of Medicare $914.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835105 fluticasone Nasal 0.05 mg/inh Spry 60505-0829-01 INSTITUTIONAL $80.00 1/1/2022-12/31/2022 $80.00 $37.76 $45.60 $58.80 $58.80 $55.46 100% of Medicare $47.90 $46.11 $44.90 $51.20 100% of Medicaid 100% of Medicare 150% of Medicare $64.00 $80.00 195% of Medicare $64.80 $47.60 $47.60 $37.76 $80.00 100% of Medicare $64.00 $68.00 $72.00 $58.39 $68.00 $80.00 $80.00 100% of Medicare 100% of Medicare $80.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835107 ipratropium Nasal 0.06% Spry 00054-0046-41 INSTITUTIONAL $355.00 1/1/2022-12/31/2022 $355.00 $167.56 $202.35 $260.93 $260.93 $246.12 100% of Medicare $212.57 $204.62 $199.26 $227.20 100% of Medicaid 100% of Medicare 150% of Medicare $284.00 $355.00 195% of Medicare $287.55 $211.23 $211.23 $167.56 $355.00 100% of Medicare $284.00 $301.75 $319.50 $259.11 $301.75 $355.00 $355.00 100% of Medicare 100% of Medicare $355.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835110 nitroglycerin 0.4 mg SubL Spry 52536-0300-20 INSTITUTIONAL $732.00 1/1/2022-12/31/2022 $732.00 $345.50 $417.24 $538.02 $538.02 $507.50 100% of Medicare $438.32 $421.92 $410.87 $468.48 100% of Medicaid 100% of Medicare 150% of Medicare $585.60 $732.00 195% of Medicare $592.92 $435.54 $435.54 $345.50 $732.00 100% of Medicare $585.60 $622.20 $658.80 $534.29 $622.20 $732.00 $732.00 100% of Medicare 100% of Medicare $732.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835111 oxymetazoline Nasal 0.05% Spry 00904-5711-35 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835114 phenylephrine Nasal 0.5% Spry 00024-1353-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835117 sumatriptan 5 mg Nasal Spry 00781-6524-86 INSTITUTIONAL " $1,369.00 " 1/1/2022-12/31/2022 " $1,369.00 " $646.17 $780.33 " $1,006.22 " " $1,006.22 " $949.13 100% of Medicare $819.76 $789.09 $768.42 $876.16 100% of Medicaid 100% of Medicare 150% of Medicare " $1,095.20 " " $1,369.00 " 195% of Medicare " $1,108.89 " $814.56 $814.56 $646.17 " $1,359.00 " 100% of Medicare " $1,095.20 " " $1,163.65 " " $1,232.10 " $999.23 " $1,163.65 " " $1,369.00 " " $1,369.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835123 Silver Nitrate Applicator 12870-0001-02 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835136 Glycerin Adult Supp 00713-0101-26 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835137 glycerin pediatric Supp 00713-0102-09 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835140 hydrocortisone 25 mg Supp 00713-0503-12 INSTITUTIONAL $144.00 1/1/2022-12/31/2022 $144.00 $67.97 $82.08 $105.84 $105.84 $99.84 100% of Medicare $86.23 $83.00 $80.83 $92.16 100% of Medicaid 100% of Medicare 150% of Medicare $115.20 $144.00 195% of Medicare $116.64 $85.68 $85.68 $67.97 $144.00 100% of Medicare $115.20 $122.40 $129.60 $105.11 $122.40 $144.00 $144.00 100% of Medicare 100% of Medicare $144.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835143 mesalamine 1000 mg Supp 58914-0501-56 INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 $28.43 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835145 miconazole 100 mg Vag Supp 00713-0197-57 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835146 miconazole 200 mg Vag Supp 00472-1738-03 INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $31.15 $37.62 $48.51 $48.51 $45.76 100% of Medicare $39.52 $38.04 $37.05 $42.24 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $39.27 $39.27 $31.15 $66.00 100% of Medicare $52.80 $56.10 $59.40 $48.17 $56.10 $66.00 $66.00 100% of Medicare 100% of Medicare $66.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835148 " Penicillin G Benz 1,200,000 units/2 mL" 60793-0701-10 INSTITUTIONAL $767.00 1/1/2022-12/31/2022 $767.00 $362.02 $437.19 $563.75 $563.75 $531.76 100% of Medicare $459.28 $442.10 $430.52 $490.88 100% of Medicaid 100% of Medicare 150% of Medicare $613.60 $767.00 195% of Medicare $621.27 $456.37 $456.37 $362.02 $767.00 100% of Medicare $613.60 $651.95 $690.30 $559.83 $651.95 $767.00 $767.00 100% of Medicare 100% of Medicare $767.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835149 prochlorperazine 25 mg Supp 00713-0135-12 INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $36.82 $44.46 $57.33 $57.33 $54.08 100% of Medicare $46.71 $44.96 $43.78 $49.92 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $46.41 $46.41 $36.82 $78.00 100% of Medicare $62.40 $66.30 $70.20 $56.93 $66.30 $78.00 $78.00 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835151 promethazine 25 mg Supp 00574-7234-12 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835154 Terconazole 80 mg 45802-0717-08 INSTITUTIONAL $147.00 1/1/2022-12/31/2022 $147.00 $69.38 $83.79 $108.05 $108.05 $101.92 100% of Medicare $88.02 $84.73 $82.51 $94.08 100% of Medicaid 100% of Medicare 150% of Medicare $117.60 $147.00 195% of Medicare $119.07 $87.47 $87.47 $69.38 $147.00 100% of Medicare $117.60 $124.95 $132.30 $107.30 $124.95 $147.00 $147.00 100% of Medicare 100% of Medicare $147.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835155 acetaminophen 80 mg/0.8 mL Oral Susp 00904-5255-35 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835160 atovaquone 750 mg/5 mL Oral Susp 00173-0547-00 INSTITUTIONAL $253.00 1/1/2022-12/31/2022 $253.00 $119.42 $144.21 $185.96 $185.96 $175.40 100% of Medicare $151.50 $145.83 $142.01 $161.92 100% of Medicaid 100% of Medicare 150% of Medicare $202.40 $253.00 195% of Medicare $204.93 $150.54 $150.54 $119.42 $253.00 100% of Medicare $202.40 $215.05 $227.70 $184.66 $215.05 $253.00 $253.00 100% of Medicare 100% of Medicare $253.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835162 budesonide 0.25 mg/2 mL Inh Susp 00093-6815-73 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 $25.65 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835163 budesonide 0.5 mg/2 mL Inh Susp 00093-6816-73 INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 $49.22 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835166 carbamazepine 100 mg/5 mL Oral Susp 51672-4047-09 INSTITUTIONAL $67.00 1/1/2022-12/31/2022 $67.00 $31.62 $38.19 $49.25 $49.25 $46.45 100% of Medicare $40.12 $38.62 $37.61 $42.88 100% of Medicaid 100% of Medicare 150% of Medicare $53.60 $67.00 195% of Medicare $54.27 $39.87 $39.87 $31.62 $67.00 100% of Medicare $53.60 $56.95 $60.30 $48.90 $56.95 $67.00 $67.00 100% of Medicare 100% of Medicare $67.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835193 ibuprofen 100 mg/5 mL Oral Susp 00904-5309-20 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835200 " influenza virus vaccine, inactivated preservative-free Susp" 58160-0879-52 INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 $97.06 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835203 medroxyPROGESTERone 150 mg/mL IM Susp 00009-0746-30 INSTITUTIONAL $189.00 1/1/2022-12/31/2022 $189.00 $89.21 $107.73 $138.92 $138.92 $131.03 100% of Medicare $113.17 $108.94 $106.09 $120.96 100% of Medicaid 100% of Medicare 150% of Medicare $151.20 $189.00 195% of Medicare $153.09 $112.46 $112.46 $89.21 $189.00 100% of Medicare $151.20 $160.65 $170.10 $137.95 $160.65 $189.00 $189.00 100% of Medicare 100% of Medicare $189.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835205 megestrol 40 mg/mL Oral Susp 00054-3542-58 INSTITUTIONAL $534.00 1/1/2022-12/31/2022 $534.00 $252.05 $304.38 $392.49 $392.49 $370.22 100% of Medicare $319.76 $307.80 $299.73 $341.76 100% of Medicaid 100% of Medicare 150% of Medicare $427.20 $534.00 195% of Medicare $432.54 $317.73 $317.73 $252.05 $534.00 100% of Medicare $427.20 $453.90 $480.60 $389.77 $453.90 $534.00 $534.00 100% of Medicare 100% of Medicare $534.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835207 methylPREDNISolone 40 mg/mL Inj Susp 00009-3073-03 INSTITUTIONAL $58.00 1/1/2022-12/31/2022 $58.00 $27.38 $33.06 $42.63 $42.63 $40.21 100% of Medicare $34.73 $33.43 $32.56 $37.12 100% of Medicaid 100% of Medicare 150% of Medicare $46.40 $58.00 195% of Medicare $46.98 $34.51 $34.51 $27.38 $58.00 100% of Medicare $46.40 $49.30 $52.20 $42.33 $49.30 $58.00 $58.00 100% of Medicare 100% of Medicare $58.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835209 methylPREDNISolone 80 mg/mL Inj Susp 00009-3475-03 INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 $97.06 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835214 " nystatin 100,000 units/mL Oral Susp" 51672-4117-04 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835224 phenytoin 125 mg/5 mL Oral Susp 51672-4069-01 INSTITUTIONAL $235.00 1/1/2022-12/31/2022 $235.00 $110.92 $133.95 $172.73 $172.73 $162.93 100% of Medicare $140.72 $135.45 $131.91 $150.40 100% of Medicaid 100% of Medicare 150% of Medicare $188.00 $235.00 195% of Medicare $190.35 $139.83 $139.83 $110.92 $235.00 100% of Medicare $188.00 $199.75 $211.50 $171.53 $199.75 $235.00 $235.00 100% of Medicare 100% of Medicare $235.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835225 pneumococcal 13-valent conjugate vaccine - Susp UD 00005-1971-02 INSTITUTIONAL $374.00 1/1/2022-12/31/2022 $374.00 $176.53 $213.18 $274.89 $274.89 $259.29 100% of Medicare $223.95 $215.57 $209.93 $239.36 100% of Medicaid 100% of Medicare 150% of Medicare $299.20 $374.00 195% of Medicare $302.94 $222.53 $222.53 $176.53 $374.00 100% of Medicare $299.20 $317.90 $336.60 $272.98 $317.90 $374.00 $374.00 100% of Medicare 100% of Medicare $374.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835230 sodium polystyrene sulfonate 15 g/60 mL Oral Susp 46287-0006-01 INSTITUTIONAL $63.00 1/1/2022-12/31/2022 $63.00 $29.74 $35.91 $46.31 $46.31 $43.68 100% of Medicare $37.72 $36.31 $35.36 $40.32 100% of Medicaid 100% of Medicare 150% of Medicare $50.40 $63.00 195% of Medicare $51.03 $37.49 $37.49 $29.74 $63.00 100% of Medicare $50.40 $53.55 $56.70 $45.98 $53.55 $63.00 $63.00 100% of Medicare 100% of Medicare $63.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835231 spinosad topical 0.9% Susp 52246-0929-04 INSTITUTIONAL $802.00 1/1/2022-12/31/2022 $802.00 $378.54 $457.14 $589.47 $589.47 $556.03 100% of Medicare $480.24 $462.27 $450.16 $513.28 100% of Medicaid 100% of Medicare 150% of Medicare $641.60 $802.00 195% of Medicare $649.62 $477.19 $477.19 $378.54 $802.00 100% of Medicare $641.60 $681.70 $721.80 $585.38 $681.70 $802.00 $802.00 100% of Medicare 100% of Medicare $802.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835233 sucralfate 1 g/10 mL Oral Susp 58914-0170-14 INSTITUTIONAL $479.00 1/1/2022-12/31/2022 $479.00 $226.09 $273.03 $352.07 $352.07 $332.09 100% of Medicare $286.83 $276.10 $268.86 $306.56 100% of Medicaid 100% of Medicare 150% of Medicare $383.20 $479.00 195% of Medicare $387.99 $285.01 $285.01 $226.09 $479.00 100% of Medicare $383.20 $407.15 $431.10 $349.62 $407.15 $479.00 $479.00 100% of Medicare 100% of Medicare $479.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835234 sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL 50383-0823-16 INSTITUTIONAL $343.00 1/1/2022-12/31/2022 $343.00 $161.90 $195.51 $252.11 $252.11 $237.80 100% of Medicare $205.39 $197.71 $192.53 $219.52 100% of Medicaid 100% of Medicare 150% of Medicare $274.40 $343.00 195% of Medicare $277.83 $204.09 $204.09 $161.90 $343.00 100% of Medicare $274.40 $291.55 $308.70 $250.36 $291.55 $343.00 $343.00 100% of Medicare 100% of Medicare $343.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835237 triamcinolone acetonide 40 mg/mL Inj Susp 00003-0293-05 INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 $49.22 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835241 Valganciclovir 50 mg/mL 00004-0039-09 INSTITUTIONAL " $4,764.00 " 1/1/2022-12/31/2022 " $4,287.60 " $975.00 " $2,715.48 " " $3,501.54 " " $3,501.54 " " $3,302.88 " 100% of Medicare " $2,852.68 " " $2,745.97 " " $2,674.03 " " $3,048.96 " 100% of Medicaid 100% of Medicare 150% of Medicare " $3,811.20 " " $1,500.00 " 195% of Medicare " $3,858.84 " " $2,834.58 " " $2,834.58 " " $2,248.61 " " $1,359.00 " 100% of Medicare " $3,811.20 " " $4,049.40 " " $4,287.60 " " $3,477.24 " " $4,049.40 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835242 " dextromethorphan 30 mg/5 mL Oral Susp, ER" 63824-0172-65 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 $56.16 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835249 betaxolol Opth 0.25% Susp 00065-0246-10 INSTITUTIONAL " $1,383.00 " 1/1/2022-12/31/2022 " $1,383.00 " $652.78 $788.31 " $1,016.51 " " $1,016.51 " $958.83 100% of Medicare $828.14 $797.16 $776.28 $885.12 100% of Medicaid 100% of Medicare 150% of Medicare " $1,106.40 " " $1,383.00 " 195% of Medicare " $1,120.23 " $822.89 $822.89 $652.78 " $1,359.00 " 100% of Medicare " $1,106.40 " " $1,175.55 " " $1,244.70 " " $1,009.45 " " $1,175.55 " " $1,383.00 " " $1,383.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835250 fluorometholone Opth 0.1% Susp 60758-0880-05 INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 $26.35 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835254 dexamethasone-tobramycin Opth 0.1%-0.3% Susp 24208-0295-25 INSTITUTIONAL $225.00 1/1/2022-12/31/2022 $225.00 $106.20 $128.25 $165.38 $165.38 $155.99 100% of Medicare $134.73 $129.69 $126.29 $144.00 100% of Medicaid 100% of Medicare 150% of Medicare $180.00 $225.00 195% of Medicare $182.25 $133.88 $133.88 $106.20 $225.00 100% of Medicare $180.00 $191.25 $202.50 $164.23 $191.25 $225.00 $225.00 100% of Medicare 100% of Medicare $225.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835257 Aluminum/Magnesium/Simeth Susp 360 mL 57896-0629-12 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835259 amoxicillin 250 mg/5 mL Oral Liq 00781-6041-46 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835262 amoxicillin-clavulanate 400 mg-57 mg/5 mL Oral Liq 100 mL 00143-9982-01 INSTITUTIONAL $111.00 1/1/2022-12/31/2022 $111.00 $52.39 $63.27 $81.59 $81.59 $76.96 100% of Medicare $66.47 $63.98 $62.30 $71.04 100% of Medicaid 100% of Medicare 150% of Medicare $88.80 $111.00 195% of Medicare $89.91 $66.05 $66.05 $52.39 $111.00 100% of Medicare $88.80 $94.35 $99.90 $81.02 $94.35 $111.00 $111.00 100% of Medicare 100% of Medicare $111.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835266 Bismuth Subsal 262 mg/15 mL Bottle 00904-1313-09 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835277 cephalexin 250 mg/5 mL Oral Liq 00093-4177-73 INSTITUTIONAL $183.00 1/1/2022-12/31/2022 $183.00 $86.38 $104.31 $134.51 $134.51 $126.87 100% of Medicare $109.58 $105.48 $102.72 $117.12 100% of Medicaid 100% of Medicare 150% of Medicare $146.40 $183.00 195% of Medicare $148.23 $108.89 $108.89 $86.38 $183.00 100% of Medicare $146.40 $155.55 $164.70 $133.57 $155.55 $183.00 $183.00 100% of Medicare 100% of Medicare $183.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835284 famotidine 40 mg/5 mL Oral Liq 68180-0150-01 INSTITUTIONAL $206.00 1/1/2022-12/31/2022 $206.00 $97.23 $117.42 $151.41 $151.41 $142.82 100% of Medicare $123.35 $118.74 $115.63 $131.84 100% of Medicaid 100% of Medicare 150% of Medicare $164.80 $206.00 195% of Medicare $166.86 $122.57 $122.57 $97.23 $206.00 100% of Medicare $164.80 $175.10 $185.40 $150.36 $175.10 $206.00 $206.00 100% of Medicare 100% of Medicare $206.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835288 Maalox 200/200/20mg 00536-1945-83 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835294 OXcarbazepine Susp 60 mg/mL Bottle 00078-0357-52 INSTITUTIONAL $537.00 1/1/2022-12/31/2022 $537.00 $253.46 $306.09 $394.70 $394.70 $372.30 100% of Medicare $321.56 $309.53 $301.42 $343.68 100% of Medicaid 100% of Medicare 150% of Medicare $429.60 $537.00 195% of Medicare $434.97 $319.52 $319.52 $253.46 $537.00 100% of Medicare $429.60 $456.45 $483.30 $391.96 $456.45 $537.00 $537.00 100% of Medicare 100% of Medicare $537.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835300 voriconazole 40 mg/mL Oral Liq 00049-3160-44 INSTITUTIONAL " $2,248.00 " 1/1/2022-12/31/2022 " $2,248.00 " $975.00 " $1,281.36 " " $1,652.28 " " $1,652.28 " " $1,558.54 " 100% of Medicare " $1,346.10 " " $1,295.75 " " $1,261.80 " " $1,438.72 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,798.40 " " $1,500.00 " 195% of Medicare " $1,820.88 " " $1,337.56 " " $1,337.56 " " $1,061.06 " " $1,359.00 " 100% of Medicare " $1,798.40 " " $1,910.80 " " $2,023.20 " " $1,640.82 " " $1,910.80 " " $1,500.00 " " $2,248.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835304 Sodium Chloride 0.9% 00409-1078-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835306 amantadine 50 mg/5 mL Oral Syrup 00121-0646-16 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835309 Ascorbic Acid 500mg/5ml 50383-0167-16 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835310 cetirizine 1 mg/mL Oral Syrup 00093-6300-16 INSTITUTIONAL $236.00 1/1/2022-12/31/2022 $236.00 $111.39 $134.52 $173.46 $173.46 $163.62 100% of Medicare $141.32 $136.03 $132.47 $151.04 100% of Medicaid 100% of Medicare 150% of Medicare $188.80 $236.00 195% of Medicare $191.16 $140.42 $140.42 $111.39 $236.00 100% of Medicare $188.80 $200.60 $212.40 $172.26 $200.60 $236.00 $236.00 100% of Medicare 100% of Medicare $236.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835320 codeine-guaifenesin 10 mg-100 mg/5 mL Oral Syrup 120 mL 00603-1075-54 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835329 lactulose 10 g/15 mL Oral Syrup 00121-4577-30 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835334 metoclopramide 5 mg/5 mL Oral Syrup 00121-0576-16 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835337 oxybutynin 5 mg/5 mL Oral Syrup 00603-1491-58 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835339 promethazine 6.25 mg/5 mL Oral Syrup 60432-0608-04 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 $32.59 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835340 ranitidine 15 mg/mL Oral Syrup 65162-0664-90 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835342 senna 8.8 mg/5 mL Oral Syrup 00536-1275-59 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 $33.97 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835343 valproic acid 250 mg/5 mL Oral Syrup 00121-0675-16 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835351 acarbose 50 mg Tab 16252-0524-01 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835352 acetaminophen 325 mg Tab 63739-0440-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835354 Acetaminophen-Aspirin-Caffeine Tab 00904-5135-59 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835355 APAP/butalbital/caffeine 300 mg-50 mg-40 mg Tab 68084-0396-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835356 acetaminophen-codeine 300 mg-30 mg Tab 00406-0484-62 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835358 AcetaZOLAMIDE Tab (Diamox) 250 mg 00527-1050-01 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835360 acyclovir 400 mg Tab 00904-6121-61 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835367 alendronate 35 mg Tab 16252-0599-44 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835369 alendronate 70 mg Tab 00093-5171-20 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835372 aliskiren 300 mg oral tablet 00078-0486-15 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835373 allopurinol 100 mg Tab 51079-0205-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835374 allopurinol 300 mg Tab 51079-0206-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835382 amiloride 5 mg Tab 00574-0292-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835385 amiodarone 200 mg Tab 00245-0147-01 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835390 amlodipine 10 mg Tab 00904-5993-61 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835392 amlodipine 5 mg Tab 51079-0451-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835411 amoxicillin-clavulanate 875 mg-125 mg Tab 66685-1001-00 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 $22.19 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835412 amphetamine-dextroamphetamine 10 mg Tab 00555-0972-02 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835413 amphetamine-dextroamphetamine 20 mg Cap 00555-0973-02 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 $27.04 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835414 amphetamine-dextroamphetamine 5 mg Tab 00555-0971-02 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835415 anastrozole 1 mg Tab 00310-0201-30 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835416 aripiprazole 10 mg Tab 59148-0008-13 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835418 aripiprazole 2 mg oral tablet 59148-0006-13 INSTITUTIONAL $103.00 1/1/2022-12/31/2022 $103.00 $48.62 $58.71 $75.71 $75.71 $71.41 100% of Medicare $61.68 $59.37 $57.81 $65.92 100% of Medicaid 100% of Medicare 150% of Medicare $82.40 $103.00 195% of Medicare $83.43 $61.29 $61.29 $48.62 $103.00 100% of Medicare $82.40 $87.55 $92.70 $75.18 $87.55 $103.00 $103.00 100% of Medicare 100% of Medicare $103.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835420 aripiprazole 5 mg oral Tab 59148-0007-35 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835432 atenolol 100 mg Tab 51079-0685-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835436 atorvastatin 10 mg Tab 00591-3774-19 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835437 atorvastatin 20 mg Tab 68084-0565-01 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835438 atorvastatin 40 mg Tab 68084-0589-01 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835447 azithromycin 600 mg Tab 64679-0962-01 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 636 NULL NULL NULL NULL 12835450 baclofen 20 mg Tab 00904-5222-61 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835459 bethanechol 10 mg Tab 00832-0511-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835460 bethanechol 25 mg Tab 00832-0512-00 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835463 bicalutamide 50 mg Tab 41616-0485-83 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835471 bromocriptine 2.5 mg Tab 00574-0106-01 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835473 bumetanide 1 mg Tab 51079-0892-20 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835476 buprenorphine-naloxone 2 mg-0.5 mg sublingual Dis Tab 12496-1283-02 INSTITUTIONAL $37.00 1/1/2022-12/31/2022 $37.00 $17.46 $21.09 $27.20 $27.20 $25.65 100% of Medicare $22.16 $21.33 $20.77 $23.68 100% of Medicaid 100% of Medicare 150% of Medicare $29.60 $37.00 195% of Medicare $29.97 $22.02 $22.02 $17.46 $37.00 100% of Medicare $29.60 $31.45 $33.30 $27.01 $31.45 $37.00 $37.00 100% of Medicare 100% of Medicare $37.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835477 buprenorphine-naloxone 8 mg-2 mg sublingual Dis Tab 12496-1306-02 INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $27.85 $33.63 $43.37 $43.37 $40.90 100% of Medicare $35.33 $34.01 $33.12 $37.76 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $35.11 $35.11 $27.85 $59.00 100% of Medicare $47.20 $50.15 $53.10 $43.06 $50.15 $59.00 $59.00 100% of Medicare 100% of Medicare $59.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835478 buPROPion 100 mg Tab 51079-0944-20 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835480 busPIRone 10 mg Tab 68084-0029-01 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835481 busPIRone 5 mg Tab 51079-0985-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835482 cabergoline 0.5 mg Tab 00093-5420-88 INSTITUTIONAL $343.00 1/1/2022-12/31/2022 $343.00 $161.90 $195.51 $252.11 $252.11 $237.80 100% of Medicare $205.39 $197.71 $192.53 $219.52 100% of Medicaid 100% of Medicare 150% of Medicare $274.40 $343.00 195% of Medicare $277.83 $204.09 $204.09 $161.90 $343.00 100% of Medicare $274.40 $291.55 $308.70 $250.36 $291.55 $343.00 $343.00 100% of Medicare 100% of Medicare $343.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835487 Calcium Carbonate wiith Vitamin D 250mg/125 U 00904-1882-61 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835488 Calcium Carbonate/Vitamin D 315mg/250Units 00904-5272-60 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835490 calcium lactate 650 mg Tab 00536-3422-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835505 captopril 25 mg Tab 00904-5046-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835507 carbamazepine 200 mg Tab 51079-0385-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835514 carbidopa/entacapone/levodopa 37.5 mg-200 mg-150 mg Tab 00078-0409-05 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835515 carbidopa-levodopa 10 mg-100 mg Tab 63739-0046-10 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835517 carbidopa-levodopa 25 mg-250 mg Tab 63739-0048-10 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835519 carvedilol 12.5 mg Tab 51079-0931-20 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835520 carvedilol 25 mg Tab 51079-0932-20 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835521 carvedilol 3.125 mg Tab 51079-0771-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835524 cefpodoxime 200 mg Tab 00781-5439-20 INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 $37.44 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835527 cefuroxime 250 mg Tab 68180-0303-20 INSTITUTIONAL $51.00 1/1/2022-12/31/2022 $51.00 $24.07 $29.07 $37.49 $37.49 $35.36 100% of Medicare $30.54 $29.40 $28.63 $32.64 100% of Medicaid 100% of Medicare 150% of Medicare $40.80 $51.00 195% of Medicare $41.31 $30.35 $30.35 $24.07 $51.00 100% of Medicare $40.80 $43.35 $45.90 $37.22 $43.35 $51.00 $51.00 100% of Medicare 100% of Medicare $51.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835530 cetirizine 10 mg Tab 51079-0597-20 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835537 ChlorproMAZINE Tab 10 mg 51079-0518-20 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835538 chlorproMAZINE 25 mg Tab 51079-0519-20 INSTITUTIONAL $61.00 1/1/2022-12/31/2022 $61.00 $28.79 $34.77 $44.84 $44.84 $42.29 100% of Medicare $36.53 $35.16 $34.24 $39.04 100% of Medicaid 100% of Medicare 150% of Medicare $48.80 $61.00 195% of Medicare $49.41 $36.30 $36.30 $28.79 $61.00 100% of Medicare $48.80 $51.85 $54.90 $44.52 $51.85 $61.00 $61.00 100% of Medicare 100% of Medicare $61.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835542 chlorthalidone 25 mg Tab 51079-0058-20 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835552 cinacalcet 30 mg Tab 55513-0073-30 INSTITUTIONAL $205.00 1/1/2022-12/31/2022 $205.00 $96.76 $116.85 $150.68 $150.68 $142.13 100% of Medicare $122.75 $118.16 $115.07 $131.20 100% of Medicaid 100% of Medicare 150% of Medicare $164.00 $205.00 195% of Medicare $166.05 $121.98 $121.98 $96.76 $205.00 100% of Medicare $164.00 $174.25 $184.50 $149.63 $174.25 $205.00 $205.00 100% of Medicare 100% of Medicare $205.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835555 ciprofloxacin 500 mg Tab 51079-0182-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835558 citalopram 20 mg Tab 00904-6085-61 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835562 clarithromycin 500 mg Tab 51079-0673-06 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 $18.72 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835564 clobazam 10 mg Tab 67386-0311-01 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835577 clorazepate 3.75 mg Tab 00378-0030-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835579 cloZAPine 25 mg Tab 51079-0921-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835582 codeine sulfate 30 mg Tab 00054-0244-24 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835585 colesevelam 625 mg Tab 65597-0701-18 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835586 colestipol 1 g Tab 59762-0450-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835589 cyanocobalamin 1000 mcg Tab 00536-3556-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835590 cyanocobalamin 250 mcg Tab 00904-4218-13 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835592 cyclobenzaprine 10 mg Tab 51079-0644-20 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835596 cyproheptadine 4 mg Tab 60258-0850-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835597 dapsone 100 mg Tab 49938-0101-30 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835598 dapsone 25 mg Tab 49938-0102-30 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835600 darunavir 600 mg Tab 59676-0562-01 INSTITUTIONAL $125.00 1/1/2022-12/31/2022 $125.00 $59.00 $71.25 $91.88 $91.88 $86.66 100% of Medicare $74.85 $72.05 $70.16 $80.00 100% of Medicaid 100% of Medicare 150% of Medicare $100.00 $125.00 195% of Medicare $101.25 $74.38 $74.38 $59.00 $125.00 100% of Medicare $100.00 $106.25 $112.50 $91.24 $106.25 $125.00 $125.00 100% of Medicare 100% of Medicare $125.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835606 demeclocycline 150 mg Tab 65162-0554-10 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835612 desmopressin 0.1 mg Tab 00093-7316-01 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 $32.59 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835618 dexamethasone 4 mg Tab 00054-8175-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835624 diazepam 2 mg Tab 51079-0284-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835625 diazepam 5 mg Tab 51079-0285-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835629 dicyclomine 20 mg Tab 51079-0119-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835631 digoxin 125 mcg (0.125 mg) Tab 00904-5921-61 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835633 diltiazem 30 mg Tab 51079-0745-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835634 diltiazem 60 mg Tab 51079-0746-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835638 dipyridamole 25 mg Tab 00904-1086-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835639 dipyridamole 50 mg Tab 00904-1087-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835641 docusate-senna 50 mg-8.6 mg Tab 00904-5512-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835644 donepezil 23 mg Tab 62856-0247-30 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835645 donepezil 5 mg Tab 00904-6242-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835646 doxazosin 1 mg Tab 51079-0957-20 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835648 doxazosin 4 mg Tab 51079-0959-20 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 $17.33 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835652 dronedarone 400 mg Tab 00024-4142-60 INSTITUTIONAL $84.00 1/1/2022-12/31/2022 $84.00 $39.65 $47.88 $61.74 $61.74 $58.24 100% of Medicare $50.30 $48.42 $47.15 $53.76 100% of Medicaid 100% of Medicare 150% of Medicare $67.20 $84.00 195% of Medicare $68.04 $49.98 $49.98 $39.65 $84.00 100% of Medicare $67.20 $71.40 $75.60 $61.31 $71.40 $84.00 $84.00 100% of Medicare 100% of Medicare $84.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835654 efavirenz 600 mg Tab 00056-0510-30 INSTITUTIONAL $95.00 1/1/2022-12/31/2022 $95.00 $44.84 $54.15 $69.83 $69.83 $65.86 100% of Medicare $56.89 $54.76 $53.32 $60.80 100% of Medicaid 100% of Medicare 150% of Medicare $76.00 $95.00 195% of Medicare $76.95 $56.53 $56.53 $44.84 $95.00 100% of Medicare $76.00 $80.75 $85.50 $69.34 $80.75 $95.00 $95.00 100% of Medicare 100% of Medicare $95.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835655 efavirenz/emtricitabine/tenofovir 600 mg-200 mg-300 mg oral tablet 15584-0101-01 INSTITUTIONAL $348.00 1/1/2022-12/31/2022 $348.00 $164.26 $198.36 $255.78 $255.78 $241.27 100% of Medicare $208.38 $200.59 $195.33 $222.72 100% of Medicaid 100% of Medicare 150% of Medicare $278.40 $348.00 195% of Medicare $281.88 $207.06 $207.06 $164.26 $348.00 100% of Medicare $278.40 $295.80 $313.20 $254.01 $295.80 $348.00 $348.00 100% of Medicare 100% of Medicare $348.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835662 enalapril 10 mg Tab 00904-5610-61 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835665 enalapril 5 mg Tab 51079-0951-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835666 entacapone 200 mg Tab 00078-0327-05 INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $27.85 $33.63 $43.37 $43.37 $40.90 100% of Medicare $35.33 $34.01 $33.12 $37.76 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $35.11 $35.11 $27.85 $59.00 100% of Medicare $47.20 $50.15 $53.10 $43.06 $50.15 $59.00 $59.00 100% of Medicare 100% of Medicare $59.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835668 eplerenone 25 mg Tab 59762-1710-02 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 $18.72 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835679 erythromycin 250 mg Tab 24338-0102-13 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 $61.70 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835681 escitalopram 10 mg Tab 00093-5851-01 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835687 estradiol 1 mg Tab 00378-1454-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835689 estradiol topical 10 mcg Tab 00169-5176-03 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835692 conjugated estrogens 0.625 mg Tab 00046-1102-81 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835702 ethacrynic acid 25 mg Tab 25010-0205-15 INSTITUTIONAL $76.00 1/1/2022-12/31/2022 $76.00 $35.87 $43.32 $55.86 $55.86 $52.69 100% of Medicare $45.51 $43.81 $42.66 $48.64 100% of Medicaid 100% of Medicare 150% of Medicare $60.80 $76.00 195% of Medicare $61.56 $45.22 $45.22 $35.87 $76.00 100% of Medicare $60.80 $64.60 $68.40 $55.47 $64.60 $76.00 $76.00 100% of Medicare 100% of Medicare $76.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835703 ethambutol 100 mg Tab 68850-0010-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835713 ethinyl estradiol-norethindrone 5 mcg-1 mg Tab 00093-3122-98 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835720 etidronate 200 mg Tab 00378-3286-91 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835722 etodolac 400 mg Tab 51672-4018-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835727 ezetimibe 10 mg Tab 66582-0414-28 INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 $61.01 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835737 febuxostat 40 mg Tab 64764-0918-30 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835743 fenofibrate 160 mg Tab 68084-0328-21 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 $31.20 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835747 fenofibrate 54 mg Tab 00378-7100-77 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835755 ferrous gluconate 325 mg Tab 00904-2137-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835761 finasteride 5 mg Tab 47335-0715-83 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835762 flavoxate 100 mg Tab 51224-0154-50 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835763 Flecainide Tab 100 mg 65162-0642-10 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835764 fluconazole 100 mg Tab 00172-5411-10 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835768 fludrocortisone 0.1 mg Tab 00555-0997-02 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835774 fluvoxamine 50 mg Tab 62559-0159-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835775 folic acid 0.8 mg Tab 00536-3843-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835776 folic acid 1 mg Tab 62584-0897-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835782 furosemide 40 mg Tab 51079-0073-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835783 furosemide 80 mg Tab 00904-5798-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835787 galantamine 4 mg Tab 51079-0852-03 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835790 gemfibrozil 600 mg Tab 00904-5379-61 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835792 glimepiride 2 mg Tab 68084-0326-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835793 glimepiride 4 mg Tab 68084-0327-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835794 glipiZIDE 10 mg Tab 51079-0811-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835795 glipiZIDE 5 mg Tab 51079-0810-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835800 glyBURIDE micronized 3 mg Tab 00378-1125-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835803 glyBURIDE 2.5 mg Tab 51079-0872-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835804 glyBURIDE 5 mg Tab 51079-0873-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835810 granisetron 1 mg Tab 51672-4138-06 INSTITUTIONAL $219.00 1/1/2022-12/31/2022 $219.00 $103.37 $124.83 $160.97 $160.97 $151.83 100% of Medicare $131.14 $126.23 $122.92 $140.16 100% of Medicaid 100% of Medicare 150% of Medicare $175.20 $219.00 195% of Medicare $177.39 $130.31 $130.31 $103.37 $219.00 100% of Medicare $175.20 $186.15 $197.10 $159.85 $186.15 $219.00 $219.00 100% of Medicare 100% of Medicare $219.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835812 guanfacine 1 mg Tab 00591-0444-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835815 haloperidol 1 mg Tab 51079-0734-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835818 haloperidol 5 mg Tab 51079-0736-20 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835819 hydrALAZINE 10 mg Tab 51079-0074-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835821 hydrALAZINE 25 mg Tab 23155-0002-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835822 hydrALAZINE 50 mg Tab 62584-0734-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835824 hydrochlorothiazide 50 mg Tab 00172-2089-60 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835827 Hydrocodone/Acetaminophen 7.5/500mg 63739-0141-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835830 acetaminophen-hydrocodone 325 mg-5 mg Tab 00406-0365-62 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835831 acetaminophen-hydrocodone 500 mg-5 mg Tab 00406-0357-62 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835838 hydromorphone 2 mg Tab 68084-0423-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835839 hydromorphone 4 mg Tab 42858-0302-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835840 hydroxychloroquine 200 mg Tab 63304-0296-01 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835841 hydrOXYzine hydrochloride 25 mg Tab 68462-0361-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835843 hydrOXYzine hydrochloride 10 mg Tab 68084-0253-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835844 hyoscyamine 0.125 mg Tab 76439-0308-10 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835845 ibandronate 150 mg oral tablet 00004-0186-82 INSTITUTIONAL $550.00 1/1/2022-12/31/2022 $550.00 $259.60 $313.50 $404.25 $404.25 $381.32 100% of Medicare $329.34 $317.02 $308.72 $352.00 100% of Medicaid 100% of Medicare 150% of Medicare $440.00 $550.00 195% of Medicare $445.50 $327.25 $327.25 $259.60 $550.00 100% of Medicare $440.00 $467.50 $495.00 $401.45 $467.50 $550.00 $550.00 100% of Medicare 100% of Medicare $550.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835848 ibuprofen 400 mg Tab 63739-0442-10 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835849 ibuprofen 600 mg Tab 00904-5854-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12835860 imipramine 25 mg Tab 00781-1764-13 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835871 isoniazid 300 mg Tab 51079-0083-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835873 isosorbide dinitrate 20 mg Tab 00904-2154-61 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835875 isosorbide dinitrate 5 mg Tab 00143-1769-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835879 ketoconazole 200 mg Tab 51672-4026-06 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835880 ketorolac 10 mg Tab 00093-0314-01 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835882 labetalol 200 mg Tab 00904-5929-61 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835886 lacosamide 200 mg Tab 00131-2480-35 INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 $83.20 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835887 lacosamide 50 mg Tab 00131-2477-35 INSTITUTIONAL $72.00 1/1/2022-12/31/2022 $72.00 $33.98 $41.04 $52.92 $52.92 $49.92 100% of Medicare $43.11 $41.50 $40.41 $46.08 100% of Medicaid 100% of Medicare 150% of Medicare $57.60 $72.00 195% of Medicare $58.32 $42.84 $42.84 $33.98 $72.00 100% of Medicare $57.60 $61.20 $64.80 $52.55 $61.20 $72.00 $72.00 100% of Medicare 100% of Medicare $72.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835888 lactase 3000 units Tab 00904-5224-52 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835890 lamivudine 100 mg Tab 00173-0662-00 INSTITUTIONAL $62.00 1/1/2022-12/31/2022 $62.00 $29.26 $35.34 $45.57 $45.57 $42.98 100% of Medicare $37.13 $35.74 $34.80 $39.68 100% of Medicaid 100% of Medicare 150% of Medicare $49.60 $62.00 195% of Medicare $50.22 $36.89 $36.89 $29.26 $62.00 100% of Medicare $49.60 $52.70 $55.80 $45.25 $52.70 $62.00 $62.00 100% of Medicare 100% of Medicare $62.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835893 lamotrigine 150 mg Tab 51079-0865-20 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835895 lamotrigine 25 mg Tab 51079-0498-20 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835896 Lanthanum Carbonate 54092-0252-90 INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 $38.13 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835898 leflunomide 10 mg Tab 00093-0173-56 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835899 leflunomide 20 mg Tab 00093-0174-56 INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 $72.80 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835900 letrozole 2.5 mg Tab 00093-7620-56 INSTITUTIONAL $115.00 1/1/2022-12/31/2022 $115.00 $54.28 $65.55 $84.53 $84.53 $79.73 100% of Medicare $68.86 $66.29 $64.55 $73.60 100% of Medicaid 100% of Medicare 150% of Medicare $92.00 $115.00 195% of Medicare $93.15 $68.43 $68.43 $54.28 $115.00 100% of Medicare $92.00 $97.75 $103.50 $83.94 $97.75 $115.00 $115.00 100% of Medicare 100% of Medicare $115.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835903 leucovorin 5 mg Tab 00054-4496-13 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835905 levetiracetam 500 mg Tab 51079-0821-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835908 LEVofloxacin Tab 250 mg 00904-6249-61 INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 $38.13 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835917 levothyroxine 150 mcg (0.15 mg) Tab 00074-7069-11 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835918 levothyroxine 175 mcg (0.175 mg) Tab 00456-1326-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835926 linezolid 600 mg Tab 00009-5135-03 INSTITUTIONAL $757.00 1/1/2022-12/31/2022 $757.00 $357.30 $431.49 $556.40 $556.40 $524.83 100% of Medicare $453.29 $436.33 $424.90 $484.48 100% of Medicaid 100% of Medicare 150% of Medicare $605.60 $757.00 195% of Medicare $613.17 $450.42 $450.42 $357.30 $757.00 100% of Medicare $605.60 $643.45 $681.30 $552.53 $643.45 $757.00 $757.00 100% of Medicare 100% of Medicare $757.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835927 liothyronine 25 mcg Tab 00574-0222-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835929 lisinopril 10 mg Tab 63739-0349-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835931 Lisinopril Tab 20 mg 63739-0350-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835946 lurasidone 20 mg Tab 63402-0302-30 INSTITUTIONAL $327.00 1/1/2022-12/31/2022 $327.00 $154.34 $186.39 $240.35 $240.35 $226.71 100% of Medicare $195.81 $188.48 $183.55 $209.28 100% of Medicaid 100% of Medicare 150% of Medicare $261.60 $327.00 195% of Medicare $264.87 $194.57 $194.57 $154.34 $327.00 100% of Medicare $261.60 $277.95 $294.30 $238.68 $277.95 $327.00 $327.00 100% of Medicare 100% of Medicare $327.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835953 magnesium amino acids chelate 133 mg oral tablet 17204-0434-40 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835954 maraviroc 150 mg oral tablet 00069-0807-60 INSTITUTIONAL $108.00 1/1/2022-12/31/2022 $108.00 $50.98 $61.56 $79.38 $79.38 $74.88 100% of Medicare $64.67 $62.25 $60.62 $69.12 100% of Medicaid 100% of Medicare 150% of Medicare $86.40 $108.00 195% of Medicare $87.48 $64.26 $64.26 $50.98 $108.00 100% of Medicare $86.40 $91.80 $97.20 $78.83 $91.80 $108.00 $108.00 100% of Medicare 100% of Medicare $108.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835961 megestrol 20 mg Tab 49884-0289-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835965 meloxicam 7.5 mg Tab 51079-0457-20 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835967 memantine 10 mg Tab 00456-3210-63 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835968 memantine 5 mg Tab 00456-3205-63 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835978 metformin 500 mg Tab 00904-6090-61 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835979 metformin 850 mg Tab 00904-6091-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12835990 methotrexate 2.5 mg Tab 51079-0670-05 INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 $27.73 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836005 metolazone 2.5 mg Tab 65580-0643-71 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836010 metoprolol 50 mg Tab 51079-0801-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836013 midodrine 10 mg Tab 00115-4233-01 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836015 midodrine 5 mg Tab 00245-0212-01 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836021 milnacipran 25 mg Tab 00456-1525-60 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836022 milnacipran 50 mg Tab 00456-1550-60 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 $20.11 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836029 misoprostol 100 mcg Tab 59762-5007-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836030 misoprostol 200 mcg Tab 59762-5008-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836036 montelukast 10 mg Tab 68084-0620-01 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836040 moxifloxacin 400 mg Tab 00085-1733-02 INSTITUTIONAL $211.00 1/1/2022-12/31/2022 $211.00 $99.59 $120.27 $155.09 $155.09 $146.29 100% of Medicare $126.35 $121.62 $118.43 $135.04 100% of Medicaid 100% of Medicare 150% of Medicare $168.80 $211.00 195% of Medicare $170.91 $125.55 $125.55 $99.59 $211.00 100% of Medicare $168.80 $179.35 $189.90 $154.01 $179.35 $211.00 $211.00 100% of Medicare 100% of Medicare $211.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836046 Antioxidant Multiple Vitamins and Minerals Tab 00904-7735-52 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836047 Therapeutic Multiple Vitamins with Minerals Tab 00904-5492-13 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836052 mycophenolate mofetil 500 mg Tab 51079-0379-20 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 $17.33 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836054 nabumetone 500 mg Tab 68462-0358-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836058 nadolol 20 mg Tab 51079-0812-20 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836059 nadolol 40 mg Tab 51079-0813-20 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836069 nateglinide 120 mg Tab 49884-0985-01 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836071 Nebivolol Tab 10 mg 00456-1410-30 INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 $26.35 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836085 niacinamide 500 mg oral Tab 00536-4069-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836089 nitroglycerin 0.4 mg sublingual Tab 00071-0418-13 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836091 norethindrone 5 mg Tab 00555-0211-10 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836096 olanzapine 2.5 mg Tab 00093-5767-56 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836107 oxandrolone 2.5 mg Tab 00245-0271-11 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836110 oxcarbazepine 300 mg Tab 62584-0143-01 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836117 acetaminophen-oxycodone 325 mg-5 mg Tab 00406-0512-62 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836119 acetaminophen-oxycodone 500 mg-7.5 mg Tab 53746-0205-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836122 paroxetine 10 mg Tab 00378-7001-93 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836123 paroxetine 20 mg Tab 68084-0045-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836124 paroxetine 30 mg Tab 60505-0084-01 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836132 perphenazine 4 mg Tab 00781-1047-13 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836133 RHIPYRI100 68084-0292-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836140 phenobarbital 15 mg Tab 51079-0094-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836147 Phytonadione Tab 5 mg 25010-0405-15 INSTITUTIONAL $190.00 1/1/2022-12/31/2022 $190.00 $89.68 $108.30 $139.65 $139.65 $131.73 100% of Medicare $113.77 $109.52 $106.65 $121.60 100% of Medicaid 100% of Medicare 150% of Medicare $152.00 $190.00 195% of Medicare $153.90 $113.05 $113.05 $89.68 $190.00 100% of Medicare $152.00 $161.50 $171.00 $138.68 $161.50 $190.00 $190.00 100% of Medicare 100% of Medicare $190.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836148 pilocarpine 5 mg Tab 00527-1313-01 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836157 pramipexole 0.25 mg Tab 68084-0440-01 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836158 pramipexole 0.5 mg Tab 13668-0093-90 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836161 prasugrel 10 mg Tab 00002-5123-30 INSTITUTIONAL $117.00 1/1/2022-12/31/2022 $117.00 $55.22 $66.69 $86.00 $86.00 $81.12 100% of Medicare $70.06 $67.44 $65.67 $74.88 100% of Medicaid 100% of Medicare 150% of Medicare $93.60 $117.00 195% of Medicare $94.77 $69.62 $69.62 $55.22 $117.00 100% of Medicare $93.60 $99.45 $105.30 $85.40 $99.45 $117.00 $117.00 100% of Medicare 100% of Medicare $117.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836163 pravastatin 20 mg Tab 68462-0196-90 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836164 Pravastatin Tab 40 mg 68462-0197-90 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836167 predniSONE 1 mg Tab 00054-8739-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836172 predniSONE 50 mg Tab 00054-0019-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836177 primaquine phosphate 26.3 mg (15 mg base) Tab 00024-1596-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836180 probenecid 500 mg Tab 00378-0156-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836181 prochlorperazine 10 mg Tab 51079-0542-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836183 promethazine 12.5 mg Tab 00008-0019-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836184 promethazine 25 mg Tab 00904-5840-61 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836186 propafenone 150 mg Tab 53489-0551-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836189 propantheline 15 mg Tab 00054-4721-25 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836190 propranolol 10 mg Tab 51079-0277-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836195 propylthiouracil 50 mg Tab 00143-1480-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836201 pyridostigmine 60 mg Tab 00115-3511-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836205 quetiapine 100 mg Tab 00904-6279-61 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836213 quinidine 200 mg Tab 00591-5438-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836215 Raloxifene Tab 60 mg 00002-4165-30 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836216 raltegravir 400 mg oral tablet 00006-0227-61 INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $50.50 $60.99 $78.65 $78.65 $74.18 100% of Medicare $64.07 $61.67 $60.06 $68.48 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $63.67 $63.67 $50.50 $107.00 100% of Medicare $85.60 $90.95 $96.30 $78.10 $90.95 $107.00 $107.00 100% of Medicare 100% of Medicare $107.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836217 ramelteon 8 mg oral tablet 64764-0805-30 INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $46.73 $56.43 $72.77 $72.77 $68.64 100% of Medicare $59.28 $57.06 $55.57 $63.36 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $58.91 $58.91 $46.73 $99.00 100% of Medicare $79.20 $84.15 $89.10 $72.26 $84.15 $99.00 $99.00 100% of Medicare 100% of Medicare $99.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836218 Ranitidine Tab 150 mg 68084-0577-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836219 rasagiline 1 mg oral tablet 68546-0229-56 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 $27.04 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836220 repaglinide 0.5 mg Tab 00169-0081-81 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836221 repaglinide 1 mg Tab 00169-0082-81 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836225 riboflavin 100 mg Tab 74312-0006-40 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836226 rifaximin 200 mg Tab 65649-0301-03 INSTITUTIONAL $71.00 1/1/2022-12/31/2022 $71.00 $33.51 $40.47 $52.19 $52.19 $49.22 100% of Medicare $42.51 $40.92 $39.85 $45.44 100% of Medicaid 100% of Medicare 150% of Medicare $56.80 $71.00 195% of Medicare $57.51 $42.25 $42.25 $33.51 $71.00 100% of Medicare $56.80 $60.35 $63.90 $51.82 $60.35 $71.00 $71.00 100% of Medicare 100% of Medicare $71.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836227 rifaximin 550 mg Tab UD 65649-0303-03 INSTITUTIONAL $325.00 1/1/2022-12/31/2022 $325.00 $153.40 $185.25 $238.88 $238.88 $225.32 100% of Medicare $194.61 $187.33 $182.42 $208.00 100% of Medicaid 100% of Medicare 150% of Medicare $260.00 $325.00 195% of Medicare $263.25 $193.38 $193.38 $153.40 $325.00 100% of Medicare $260.00 $276.25 $292.50 $237.22 $276.25 $325.00 $325.00 100% of Medicare 100% of Medicare $325.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836229 riluzole 50 mg Tab 00075-7700-60 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836232 Risedronate Tab 35 mg 00430-0472-03 INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 $97.06 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836234 RisperiDONE Tab 0.25 mg 68084-0270-01 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 $17.33 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836235 risperidone 1 mg Tab 51079-0462-20 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836237 rivaroxaban 10 mg Tab 50458-0580-30 INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 $83.20 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836242 roflumilast 500 mcg Tab 00456-0095-30 INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $31.15 $37.62 $48.51 $48.51 $45.76 100% of Medicare $39.52 $38.04 $37.05 $42.24 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $39.27 $39.27 $31.15 $66.00 100% of Medicare $52.80 $56.10 $59.40 $48.17 $56.10 $66.00 $66.00 100% of Medicare 100% of Medicare $66.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836243 ropinirole 3 mg Tab 64679-0174-02 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836244 ropinirole 0.25 mg Tab 64679-0154-02 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836246 ropinirole 1 mg Tab 68462-0255-01 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836256 rosuvastatin 10 mg Tab 00310-0751-39 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836267 Selenium 50 mcg 00904-3162-60 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836269 senna 8.6 mg Tab 00904-5165-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836270 sertraline 100 mg Tab 68084-0182-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836272 sertraline 50 mg Tab 68084-0181-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836273 sevelamer carbonate 800 mg Tab 58468-0130-01 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836275 sevelamer 800 mg Tab 58468-0021-01 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836277 sildenafil 20 mg oral tablet 00069-4190-68 INSTITUTIONAL $382.00 1/1/2022-12/31/2022 $382.00 $180.30 $217.74 $280.77 $280.77 $264.84 100% of Medicare $228.74 $220.18 $214.42 $244.48 100% of Medicaid 100% of Medicare 150% of Medicare $305.60 $382.00 195% of Medicare $309.42 $227.29 $227.29 $180.30 $382.00 100% of Medicare $305.60 $324.70 $343.80 $278.82 $324.70 $382.00 $382.00 100% of Medicare 100% of Medicare $382.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836278 sildenafil 25 mg Tab 00069-4200-30 INSTITUTIONAL $121.00 1/1/2022-12/31/2022 $121.00 $57.11 $68.97 $88.94 $88.94 $83.89 100% of Medicare $72.45 $69.74 $67.92 $77.44 100% of Medicaid 100% of Medicare 150% of Medicare $96.80 $121.00 195% of Medicare $98.01 $72.00 $72.00 $57.11 $121.00 100% of Medicare $96.80 $102.85 $108.90 $88.32 $102.85 $121.00 $121.00 100% of Medicare 100% of Medicare $121.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836284 sirolimus 0.5 mg Tab UD 00008-1040-10 INSTITUTIONAL $121.00 1/1/2022-12/31/2022 $121.00 $57.11 $68.97 $88.94 $88.94 $83.89 100% of Medicare $72.45 $69.74 $67.92 $77.44 100% of Medicaid 100% of Medicare 150% of Medicare $96.80 $121.00 195% of Medicare $98.01 $72.00 $72.00 $57.11 $121.00 100% of Medicare $96.80 $102.85 $108.90 $88.32 $102.85 $121.00 $121.00 100% of Medicare 100% of Medicare $121.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836285 sirolimus 1 mg Tab 00008-1041-10 INSTITUTIONAL $241.00 1/1/2022-12/31/2022 $241.00 $113.75 $137.37 $177.14 $177.14 $167.09 100% of Medicare $144.31 $138.91 $135.27 $154.24 100% of Medicaid 100% of Medicare 150% of Medicare $192.80 $241.00 195% of Medicare $195.21 $143.40 $143.40 $113.75 $241.00 100% of Medicare $192.80 $204.85 $216.90 $175.91 $204.85 $241.00 $241.00 100% of Medicare 100% of Medicare $241.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836288 sitagliptin 50 mg oral tablet 00006-0112-28 INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 $83.20 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836290 sodium chloride 1 g Tab 00223-1760-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836294 solifenacin 5 mg Tab 51248-0150-52 INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $25.02 $30.21 $38.96 $38.96 $36.74 100% of Medicare $31.74 $30.55 $29.75 $33.92 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.54 $31.54 $25.02 $53.00 100% of Medicare $42.40 $45.05 $47.70 $38.68 $45.05 $53.00 $53.00 100% of Medicare 100% of Medicare $53.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836299 sotalol 80 mg Tab 00093-1061-01 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836301 spironolactone 25 mg Tab 63739-0544-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836305 sucralfate 1 g Tab 51079-0871-20 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836307 sulfamethoxazole-trimethoprim 800 mg-160 mg Tab 51079-0128-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836308 sulfamethoxazole-trimethoprim 400 mg-80 mg Tab 00603-5780-21 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836312 sumatriptan 25 mg Tab 62756-0520-69 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836313 SUMAtriptan Tab 50 mg 55111-0292-09 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836315 tamoxifen 10 mg Tab 63739-0269-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836328 tenofovir 300 mg Tab 61958-0401-01 INSTITUTIONAL $319.00 1/1/2022-12/31/2022 $319.00 $150.57 $181.83 $234.47 $234.47 $221.16 100% of Medicare $191.02 $183.87 $179.05 $204.16 100% of Medicaid 100% of Medicare 150% of Medicare $255.20 $319.00 195% of Medicare $258.39 $189.81 $189.81 $150.57 $319.00 100% of Medicare $255.20 $271.15 $287.10 $232.84 $271.15 $319.00 $319.00 100% of Medicare 100% of Medicare $319.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836329 terbinafine 250 mg Tab 67405-0543-03 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 $56.16 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836333 thiamine 100 mg Tab 00904-0544-60 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836334 thiamine 50 mg Tab 00536-4678-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836344 thyroid desiccated 30 mg Tab 00456-0458-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836346 Thyroid Desiccated Tab 60 mg 00456-0459-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836351 ticagrelor 90 mg Tab UD 00186-0777-39 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836354 Tizanidine HCL 2 mg 00378-0722-19 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836355 tizanidine 4 mg Tab 51079-0998-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836360 tolterodine 2 mg Tab 00093-2055-42 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836362 topiramate 100 mg Tab 00093-7219-06 INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $20.77 $25.08 $32.34 $32.34 $30.51 100% of Medicare $26.35 $25.36 $24.70 $28.16 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $26.18 $26.18 $20.77 $44.00 100% of Medicare $35.20 $37.40 $39.60 $32.12 $37.40 $44.00 $44.00 100% of Medicare 100% of Medicare $44.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836364 topiramate 25 mg Tab 51079-0726-20 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836367 torsemide 20 mg Tab 50111-0917-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836378 trazodone 50 mg Tab 00904-3990-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836384 trihexyphenidyl 2 mg Tab 00591-5335-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836386 trimethoprim 100 mg Tab 00093-2158-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836388 Ursodiol 500 mg 58914-0790-10 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836390 valacyclovir 500 mg Tab 45963-0558-30 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836391 valganciclovir 450 mg Tab 00004-0038-22 INSTITUTIONAL $152.00 1/1/2022-12/31/2022 $152.00 $71.74 $86.64 $111.72 $111.72 $105.38 100% of Medicare $91.02 $87.61 $85.32 $97.28 100% of Medicaid 100% of Medicare 150% of Medicare $121.60 $152.00 195% of Medicare $123.12 $90.44 $90.44 $71.74 $152.00 100% of Medicare $121.60 $129.20 $136.80 $110.94 $129.20 $152.00 $152.00 100% of Medicare 100% of Medicare $152.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836394 valsartan 40 mg Tab 00078-0423-15 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836401 varenicline 0.5 mg oral tablet 00069-0468-56 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 $41.60 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836404 venlafaxine 25 mg Tab 00093-0199-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836405 venlafaxine 37.5 mg Tab 65162-0302-09 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836408 verapamil 120 mg Tab 00904-2924-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836410 verapamil 80 mg Tab 00904-2920-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836414 Vitamin B Complex with C and Folic Acid Tab 51991-0082-90 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836416 Vitamin B Complex with Folic Acid Tab 51991-0084-90 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836417 voriconazole 200 mg Tab 00049-3180-30 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836419 warfarin 10 mg Tab 00832-1219-00 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836420 warfarin 1 mg Tab 00832-1211-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836421 warfarin 2 mg Tab 00832-1212-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836422 warfarin 2.5 mg Tab 00832-1213-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836423 warfarin 3 mg Tab 00832-1214-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836424 Warfarin Tab 4 mg (Jantoven) 00832-1215-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836425 warfarin 5 mg Tab 00832-1216-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836427 warfarin 7.5 mg Tab 00832-1218-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836433 zolpidem 10 mg Tab 00904-6083-61 INSTITUTIONAL $1.00 1/1/2022-12/31/2022 $1.00 $0.47 $0.57 $0.74 $0.74 $0.69 100% of Medicare $0.60 $0.58 $0.56 $0.64 100% of Medicaid 100% of Medicare 150% of Medicare $0.80 $1.00 195% of Medicare $0.81 $0.60 $0.60 $0.47 $1.00 100% of Medicare $0.80 $0.85 $0.90 $0.73 $0.85 $1.00 $1.00 100% of Medicare 100% of Medicare $1.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836434 zolpidem 5 mg Tab 51079-0724-20 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 $20.11 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836445 calcium carbonate 500 mg Chew Tab 00904-1258-92 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836447 carbamazepine 100 mg Chew Tab 51079-0870-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836456 Multiple Vitamins Chew Tab 00904-2621-60 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836460 Phenytoin Tab Chew 50 mg 00071-0007-40 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836463 simethicone 80 mg Chew Tab 63739-0225-10 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836471 lansoprazole 15 mg Dis Tab 64764-0543-11 INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 $26.35 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836495 diclofenac sodium 50 mg Oral EC Tab 00781-1787-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836496 diclofenac sodium 75 mg Oral EC Tab 00228-2551-11 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836501 ferrous sulfate 325 mg Oral EC Tab 00245-0108-11 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836502 mesalamine 1.2 g oral EC Tab 54092-0476-12 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836504 mycophenolic acid 180 mg Oral EC Tab 00078-0385-66 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836505 mycophenolic acid 360 mg Oral EC Tab 00078-0386-66 INSTITUTIONAL $75.00 1/1/2022-12/31/2022 $75.00 $35.40 $42.75 $55.13 $55.13 $52.00 100% of Medicare $44.91 $43.23 $42.10 $48.00 100% of Medicaid 100% of Medicare 150% of Medicare $60.00 $75.00 195% of Medicare $60.75 $44.63 $44.63 $35.40 $75.00 100% of Medicare $60.00 $63.75 $67.50 $54.74 $63.75 $75.00 $75.00 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836509 pantoprazole 40 mg Oral EC Tab 00008-0607-04 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836511 sulfasalazine 500 mg Oral EC Tab 59762-0104-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836513 alfuzosin 10 mg ER Tab 31722-0302-01 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 $18.72 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836521 buPROPion 150 mg/24 hours ER Tab 67767-0141-30 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836522 buPROPion 300 mg/24 hours ER Tab 00591-3332-30 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836523 carbamazepine 100 mg ER Tab 00078-0510-05 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836524 carbamazepine 200 mg ER Tab 51672-4124-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836525 carbamazepine 400 mg ER Tab 51672-4125-01 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836526 Carbidopa-Levodopa Tab CR 25 mg-100 mg 62756-0461-88 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836528 darifenacin 7.5 mg ER Tab 00430-0170-15 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 $20.11 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836530 desvenlafaxine 50 mg Tab- 00008-1211-14 INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 $72.80 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836532 diltiazem 180 mg/24 hours ER Tab 52544-0691-30 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836535 divalproex sodium 250 mg ER Tab 00904-5990-61 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836536 divalproex sodium 500 mg ER Tab 00904-6073-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836541 docusate-ferrous fumarate 100 mg-150 mg ER Tab 36652-0267-69 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836547 glipiZIDE 10 mg ER Tab 59762-5033-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836548 glipiZIDE 2.5 mg ER Tab 00591-0900-30 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836549 glipiZIDE 5 mg ER Tab 59762-5032-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836550 guaifenesin 600 mg ER Tab 63824-0008-15 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 12836560 isosorbide mononitrate 30 mg ER Tab 00603-4110-21 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836571 MetFORMIN Tab XR 500 mg 00904-6107-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836582 metoprolol 25 mg ER Tab 62037-0830-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836583 MetoPROLOL Succinate Tab XL 50 mg 62037-0831-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836584 morphine 100 mg ER Tab 00378-2661-01 INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $27.85 $33.63 $43.37 $43.37 $40.90 100% of Medicare $35.33 $34.01 $33.12 $37.76 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $35.11 $35.11 $27.85 $59.00 100% of Medicare $47.20 $50.15 $53.10 $43.06 $50.15 $59.00 $59.00 100% of Medicare 100% of Medicare $59.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836589 niacin 1000 mg ER Tab 00074-3080-90 INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $33.04 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.92 $40.35 $39.29 $44.80 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $41.65 $41.65 $33.04 $70.00 100% of Medicare $56.00 $59.50 $63.00 $51.09 $59.50 $70.00 $70.00 100% of Medicare 100% of Medicare $70.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836590 niacin 500 mg Tab 00074-3074-90 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 $27.04 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836595 NIFEdipine 30 mg ER Tab 00093-0819-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836606 oxycodone 10 mg ER Tab 59011-0410-20 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836608 oxycodone 20 mg ER Tab 59011-0420-20 INSTITUTIONAL $62.00 1/1/2022-12/31/2022 $62.00 $29.26 $35.34 $45.57 $45.57 $42.98 100% of Medicare $37.13 $35.74 $34.80 $39.68 100% of Medicaid 100% of Medicare 150% of Medicare $49.60 $62.00 195% of Medicare $50.22 $36.89 $36.89 $29.26 $62.00 100% of Medicare $49.60 $52.70 $55.80 $45.25 $52.70 $62.00 $62.00 100% of Medicare 100% of Medicare $62.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836609 oxycodone 40 mg ER Tab 59011-0440-20 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836614 paliperidone 3 mg oral ER Tab 50458-0550-01 INSTITUTIONAL $75.00 1/1/2022-12/31/2022 $75.00 $35.40 $42.75 $55.13 $55.13 $52.00 100% of Medicare $44.91 $43.23 $42.10 $48.00 100% of Medicaid 100% of Medicare 150% of Medicare $60.00 $75.00 195% of Medicare $60.75 $44.63 $44.63 $35.40 $75.00 100% of Medicare $60.00 $63.75 $67.50 $54.74 $63.75 $75.00 $75.00 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836620 pentoxifylline 400 mg ER Tab 51079-0889-20 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836625 potassium citrate 10 mEq ER Tab 00245-0071-11 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836631 pseudoephedrine 120 mg ER Tab 00904-5803-15 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836632 pyridostigmine 180 mg ER Tab 00187-3013-30 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 $41.60 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836640 ranolazine 500 mg oral ER Tab 61958-1003-01 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836643 Theophylline Anhydrous 600 mg ER 42858-0702-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836644 theophylline 100 mg ER Tab 00904-5887-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836646 theophylline 300 mg ER Tab 00904-5889-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836648 verapamil 120 mg ER Tab 51079-0894-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836649 verapamil 180 mg ER Tab 51079-0899-20 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 12836662 Sorbitol Soln 70% Bottle 54162-0700-16 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13054959 Thermacare LRG/XL 00573-3010-03 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13054962 Coenzyme Q Cap 100 mg 04746-9002-88 INSTITUTIONAL $1.00 1/1/2022-12/31/2022 $1.00 $0.47 $0.57 $0.74 $0.74 $0.69 100% of Medicare $0.60 $0.58 $0.56 $0.64 100% of Medicaid 100% of Medicare 150% of Medicare $0.80 $1.00 195% of Medicare $0.81 $0.60 $0.60 $0.47 $1.00 100% of Medicare $0.80 $0.85 $0.90 $0.73 $0.85 $1.00 $1.00 100% of Medicare 100% of Medicare $1.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055092 Cranberry 475 mg 30768-0119-00 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055096 Enlive Berry 70074-0566-43 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 $2.77 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055098 Ensure Enlive Shake 70074-0583-00 INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 $1.39 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055101 Ensure Complete Strawberry Clinical Str 70074-0620-11 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055107 Ensure Complete Vanilla Clinical Str 70074-0565-65 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055110 Vitamin D 400units 11845-1183-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055121 Mederma 00259-3192-82 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 $56.16 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055132 Ensure Pudding ButterScotch 70074-0548-49 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055135 Ensure Pudding Vaniila 70074-0548-45 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055175 Benzocaine 10% 00573-0212-25 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13055186 Ensure Strawberry Muscle Health 70074-0620-13 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066868 Glucerna 1.2 70074-0509-05 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 $2.77 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066874 Glucerna 1.5 70074-0535-35 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066879 Glucerna Shake 70074-0560-53 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066883 Jevity 1.2 70074-0531-19 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066884 Jevity 1.5 70074-0573-34 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066897 Clog Zapper 89220-0002-00 INSTITUTIONAL $135.00 1/1/2022-12/31/2022 $135.00 $63.72 $76.95 $99.23 $99.23 $93.60 100% of Medicare $80.84 $77.81 $75.78 $86.40 100% of Medicaid 100% of Medicare 150% of Medicare $108.00 $135.00 195% of Medicare $109.35 $80.33 $80.33 $63.72 $135.00 100% of Medicare $108.00 $114.75 $121.50 $98.54 $114.75 $135.00 $135.00 100% of Medicare 100% of Medicare $135.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066898 Vital AF 1.2 Cal 70074-0565-43 INSTITUTIONAL $23.00 1/1/2022-12/31/2022 $23.00 $10.86 $13.11 $16.91 $16.91 $15.95 100% of Medicare $13.77 $13.26 $12.91 $14.72 100% of Medicaid 100% of Medicare 150% of Medicare $18.40 $23.00 195% of Medicare $18.63 $13.69 $13.69 $10.86 $23.00 100% of Medicare $18.40 $19.55 $20.70 $16.79 $19.55 $23.00 $23.00 100% of Medicare 100% of Medicare $23.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066900 Nepro 70074-0620-95 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066906 Dermaide Aloe 80208-0000-04 INSTITUTIONAL $102.00 1/1/2022-12/31/2022 $102.00 $48.14 $58.14 $74.97 $74.97 $70.72 100% of Medicare $61.08 $58.79 $57.25 $65.28 100% of Medicaid 100% of Medicare 150% of Medicare $81.60 $102.00 195% of Medicare $82.62 $60.69 $60.69 $48.14 $102.00 100% of Medicare $81.60 $86.70 $91.80 $74.45 $86.70 $102.00 $102.00 100% of Medicare 100% of Medicare $102.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066917 Osmolite 1.2 70074-0531-21 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066923 Promote with Fiber 70074-0518-73 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066924 Proteinex 54859-0515-08 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066927 Twocal HN 70074-0407-29 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13066935 Vicks Vaporub 37000-0544-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 13068875 Tucks Pads/Witch Hazel 04200-2302-68 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13068889 Ensure Pudding 70074-0548-47 INSTITUTIONAL $1.00 1/1/2022-12/31/2022 $1.00 $0.47 $0.57 $0.74 $0.74 $0.69 100% of Medicare $0.60 $0.58 $0.56 $0.64 100% of Medicaid 100% of Medicare 150% of Medicare $0.80 $1.00 195% of Medicare $0.81 $0.60 $0.60 $0.47 $1.00 100% of Medicare $0.80 $0.85 $0.90 $0.73 $0.85 $1.00 $1.00 100% of Medicare 100% of Medicare $1.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13068892 Ensure Vanilla Muscle Health 70074-0565-59 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13068907 Blistex Camphor/Phenol 04138-8210-41 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13068910 Magnesium Chloride Tab SR 70 mg 57896-0635-06 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13068943 Juven Orange 59781-0225-50 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13068954 Juven Unflavored 59781-0540-02 INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13069034 Antihemophilic Factor VIII Human (Humate-P) 00944-2944-01 INSTITUTIONAL " $32,722.00 " 1/1/2022-12/31/2022 " $29,449.80 " $975.00 " $18,651.54 " " $24,050.67 " " $24,050.67 " " $22,686.16 " 100% of Medicare " $19,593.93 " " $18,860.96 " " $18,366.86 " " $20,942.08 " 100% of Medicaid 100% of Medicare 150% of Medicare " $26,177.60 " " $1,500.00 " 195% of Medicare " $26,504.82 " " $19,469.59 " " $19,469.59 " " $15,444.78 " " $1,359.00 " 100% of Medicare " $26,177.60 " " $27,813.70 " " $29,449.80 " " $23,883.79 " " $27,813.70 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13069098 Saliva Substitute Spray 45 mL 28409-0847-02 INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 $26.35 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13069107 Azithromycin Susp 40 mg/mL Bottle 00903-7149-31 INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $31.15 $37.62 $48.51 $48.51 $45.76 100% of Medicare $39.52 $38.04 $37.05 $42.24 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $39.27 $39.27 $31.15 $66.00 100% of Medicare $52.80 $56.10 $59.40 $48.17 $56.10 $66.00 $66.00 100% of Medicare 100% of Medicare $66.00 200% of Medicare NULL 250 NULL NULL NULL NULL 13088896 ciprofloxacin 250 mg Tab 68084-0069-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14007280 Ensure Chocolate Muscle Health 70074-0565-61 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14036853 Non-Formulary Medication 99999-9999-99 INSTITUTIONAL $398.00 1/1/2022-12/31/2022 $398.00 $187.86 $226.86 $292.53 $292.53 $275.93 100% of Medicare $238.32 $229.41 $223.40 $254.72 100% of Medicaid 100% of Medicare 150% of Medicare $318.40 $398.00 195% of Medicare $322.38 $236.81 $236.81 $187.86 $398.00 100% of Medicare $318.40 $338.30 $358.20 $290.50 $338.30 $398.00 $398.00 100% of Medicare 100% of Medicare $398.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14253091 midodrine 5 mg Tab 00245-0212-11 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14253098 ramipril 5 mg Cap 68084-0267-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14261212 furosemide 20 mg Tab 51079-0072-20 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 14286939 albuterol 0.083% Inh Sol 3 mL 00487-9501-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14286951 lorazepam 2 mg/mL Inj Sol 00409-6778-02 INSTITUTIONAL $74.00 1/1/2022-12/31/2022 $74.00 $34.93 $42.18 $54.39 $54.39 $51.30 100% of Medicare $44.31 $42.65 $41.54 $47.36 100% of Medicaid 100% of Medicare 150% of Medicare $59.20 $74.00 195% of Medicare $59.94 $44.03 $44.03 $34.93 $74.00 100% of Medicare $59.20 $62.90 $66.60 $54.01 $62.90 $74.00 $74.00 100% of Medicare 100% of Medicare $74.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14412945 lidocaine Top 5% film 63481-0687-01 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 $24.96 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14412998 budesonide 0.25 mg/2 mL Inh Susp 00093-6815-45 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 $41.60 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14446857 indapamide 2.5 mg Tab 51079-0868-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14446925 paroxetine 20 mg Tab 68084-0045-11 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14479357 ocular lubricant Oint 00078-0473-97 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14594927 Dextrose 5% in Water IV Sol 500 mL 00338-0017-03 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 $17.33 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14596958 Dextrose 5% Sod Chloride 0.45% KCl 20 mEq 1000 mL PREMIX 00338-0671-04 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14596961 Lactated Ringers IV Sol 1000 mL 00338-0117-04 INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $26.43 $31.92 $41.16 $41.16 $38.82 100% of Medicare $33.53 $32.28 $31.43 $35.84 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $33.32 $33.32 $26.43 $56.00 100% of Medicare $44.80 $47.60 $50.40 $40.87 $47.60 $56.00 $56.00 100% of Medicare 100% of Medicare $56.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14596968 Sodium Chloride 0.45% IV Sol 500 mL 00338-0043-03 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14596969 Sodium Chloride 0.9% IV Sol 100 mL Addv 00409-7101-67 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14596970 Sodium Chloride 0.9% IV Sol 250 mL Addv 00409-7101-02 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 14596971 Sodium Chloride 0.9% 50 mL Addv 00409-7101-66 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 15768885 warfarin 0.5 mg Tab 99999-9999-97 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 15768886 warfarin 1.5 mg Tab 99999-9999-96 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 15768887 emu oil 38779-1969-08 INSTITUTIONAL $641.00 1/1/2022-12/31/2022 $641.00 $302.55 $365.37 $471.14 $471.14 $444.41 100% of Medicare $383.83 $369.47 $359.79 $410.24 100% of Medicaid 100% of Medicare 150% of Medicare $512.80 $641.00 195% of Medicare $519.21 $381.40 $381.40 $302.55 $641.00 100% of Medicare $512.80 $544.85 $576.90 $467.87 $544.85 $641.00 $641.00 100% of Medicare 100% of Medicare $641.00 200% of Medicare NULL 250 NULL NULL NULL NULL 15801033 acetylcysteine 600 mg oral capsule 27434-0002-11 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 636 NULL NULL NULL NULL 15801509 incobotulinumtoxinA 100 units REC 00259-1610-01 INSTITUTIONAL " $3,079.00 " 1/1/2022-12/31/2022 " $2,771.10 " $975.00 " $1,755.03 " " $2,263.07 " " $2,263.07 " " $2,134.67 " 100% of Medicare " $1,843.71 " " $1,774.74 " " $1,728.24 " " $1,970.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,463.20 " " $1,500.00 " 195% of Medicare " $2,493.99 " " $1,832.01 " " $1,832.01 " " $1,453.29 " " $1,359.00 " 100% of Medicare " $2,463.20 " " $2,617.15 " " $2,771.10 " " $2,247.36 " " $2,617.15 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 15802008 ketotifen 0.025% Opth Sol 17478-0717-10 INSTITUTIONAL $78.00 1/1/2022-12/31/2022 $78.00 $36.82 $44.46 $57.33 $57.33 $54.08 100% of Medicare $46.71 $44.96 $43.78 $49.92 100% of Medicaid 100% of Medicare 150% of Medicare $62.40 $78.00 195% of Medicare $63.18 $46.41 $46.41 $36.82 $78.00 100% of Medicare $62.40 $66.30 $70.20 $56.93 $66.30 $78.00 $78.00 100% of Medicare 100% of Medicare $78.00 200% of Medicare NULL 250 NULL NULL NULL NULL 15802043 doxercalciferol 2 mcg/mL Inj Sol 58468-0126-01 INSTITUTIONAL $91.00 1/1/2022-12/31/2022 $91.00 $42.95 $51.87 $66.89 $66.89 $63.09 100% of Medicare $54.49 $52.45 $51.08 $58.24 100% of Medicaid 100% of Medicare 150% of Medicare $72.80 $91.00 195% of Medicare $73.71 $54.15 $54.15 $42.95 $91.00 100% of Medicare $72.80 $77.35 $81.90 $66.42 $77.35 $91.00 $91.00 100% of Medicare 100% of Medicare $91.00 200% of Medicare NULL 250 NULL NULL NULL NULL 15868856 Omeprazole Suspension 99999-9999-95 INSTITUTIONAL $870.00 1/1/2022-12/31/2022 $870.00 $410.64 $495.90 $639.45 $639.45 $603.17 100% of Medicare $520.96 $501.47 $488.33 $556.80 100% of Medicaid 100% of Medicare 150% of Medicare $696.00 $870.00 195% of Medicare $704.70 $517.65 $517.65 $410.64 $870.00 100% of Medicare $696.00 $739.50 $783.00 $635.01 $739.50 $870.00 $870.00 100% of Medicare 100% of Medicare $870.00 200% of Medicare NULL 250 NULL NULL NULL NULL 15868861 GI Cocktail 99999-9999-91 INSTITUTIONAL $139.00 1/1/2022-12/31/2022 $139.00 $65.61 $79.23 $102.17 $102.17 $96.37 100% of Medicare $83.23 $80.12 $78.02 $88.96 100% of Medicaid 100% of Medicare 150% of Medicare $111.20 $139.00 195% of Medicare $112.59 $82.71 $82.71 $65.61 $139.00 100% of Medicare $111.20 $118.15 $125.10 $101.46 $118.15 $139.00 $139.00 100% of Medicare 100% of Medicare $139.00 200% of Medicare NULL 250 NULL NULL NULL NULL 15873186 clorpactin irrigation 99999-9999-88 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16086329 acyclovir 200 mg Cap 00093-8940-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16086336 doxycycline hyclate 100 mg Cap 00591-5440-50 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16086345 tetracycline 500 mg Cap 00591-2235-01 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16086349 vancomycin 125 mg Cap 63323-0338-20 INSTITUTIONAL $221.00 1/1/2022-12/31/2022 $221.00 $104.31 $125.97 $162.44 $162.44 $153.22 100% of Medicare $132.33 $127.38 $124.05 $141.44 100% of Medicaid 100% of Medicare 150% of Medicare $176.80 $221.00 195% of Medicare $179.01 $131.50 $131.50 $104.31 $221.00 100% of Medicare $176.80 $187.85 $198.90 $161.31 $187.85 $221.00 $221.00 100% of Medicare 100% of Medicare $221.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16086350 vancomycin 250 mg Cap 63323-0339-20 INSTITUTIONAL $408.00 1/1/2022-12/31/2022 $408.00 $192.58 $232.56 $299.88 $299.88 $282.87 100% of Medicare $244.31 $235.17 $229.01 $261.12 100% of Medicaid 100% of Medicare 150% of Medicare $326.40 $408.00 195% of Medicare $330.48 $242.76 $242.76 $192.58 $408.00 100% of Medicare $326.40 $346.80 $367.20 $297.80 $346.80 $408.00 $408.00 100% of Medicare 100% of Medicare $408.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16086352 venlafaxine 37.5 mg ERCap 68084-0484-01 INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 $18.72 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16264869 zinc oxide(Desitin) 74300-0003-01 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16265079 Mineral Oil (BULK BOTTLE) 00869-4206-10 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16265080 hydrocortisone Top 1% Oint 00472-0345-56 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16265081 " fentanyl 12 mcg/hr TD film, ER" 00781-7240-55 INSTITUTIONAL $25.00 1/1/2022-12/31/2022 $25.00 $11.80 $14.25 $18.38 $18.38 $17.33 100% of Medicare $14.97 $14.41 $14.03 $16.00 100% of Medicaid 100% of Medicare 150% of Medicare $20.00 $25.00 195% of Medicare $20.25 $14.88 $14.88 $11.80 $25.00 100% of Medicare $20.00 $21.25 $22.50 $18.25 $21.25 $25.00 $25.00 100% of Medicare 100% of Medicare $25.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16265083 fentanyl 25 mcg/hr Transderm ER Film 00591-3198-72 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16265084 fentanyl 50 mcg/hr Transderm ER Film 00591-3212-72 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16265086 Miralax packet1 00904-6025-61 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16265087 polyethylene glycol 3350 Oral Pwdr for Recon 51991-0457-58 INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $20.30 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.75 $24.79 $24.14 $27.52 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.59 $25.59 $20.30 $43.00 100% of Medicare $34.40 $36.55 $38.70 $31.39 $36.55 $43.00 $43.00 100% of Medicare 100% of Medicare $43.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16265088 levetiracetam 100 mg/mL Oral Sol 00054-0224-63 INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $20.77 $25.08 $32.34 $32.34 $30.51 100% of Medicare $26.35 $25.36 $24.70 $28.16 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $26.18 $26.18 $20.77 $44.00 100% of Medicare $35.20 $37.40 $39.60 $32.12 $37.40 $44.00 $44.00 100% of Medicare 100% of Medicare $44.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379584 levofloxacin 25 mg/mL IV Sol 25021-0130-30 INSTITUTIONAL $136.00 1/1/2022-12/31/2022 $136.00 $64.19 $77.52 $99.96 $99.96 $94.29 100% of Medicare $81.44 $78.39 $76.34 $87.04 100% of Medicaid 100% of Medicare 150% of Medicare $108.80 $136.00 195% of Medicare $110.16 $80.92 $80.92 $64.19 $136.00 100% of Medicare $108.80 $115.60 $122.40 $99.27 $115.60 $136.00 $136.00 100% of Medicare 100% of Medicare $136.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379585 meropenem 1 g IV Inj 63323-0508-31 INSTITUTIONAL $105.00 1/1/2022-12/31/2022 $105.00 $49.56 $59.85 $77.18 $77.18 $72.80 100% of Medicare $62.87 $60.52 $58.94 $67.20 100% of Medicaid 100% of Medicare 150% of Medicare $84.00 $105.00 195% of Medicare $85.05 $62.48 $62.48 $49.56 $105.00 100% of Medicare $84.00 $89.25 $94.50 $76.64 $89.25 $105.00 $105.00 100% of Medicare 100% of Medicare $105.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379587 Piperacillin-Taz Inj 2.25 GM (UD) 00409-3383-02 INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 $61.01 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379588 piperacillin-tazobactam 3 g-0.375 g IV Inj 00409-3385-13 INSTITUTIONAL $114.00 1/1/2022-12/31/2022 $114.00 $53.81 $64.98 $83.79 $83.79 $79.04 100% of Medicare $68.26 $65.71 $63.99 $72.96 100% of Medicaid 100% of Medicare 150% of Medicare $91.20 $114.00 195% of Medicare $92.34 $67.83 $67.83 $53.81 $114.00 100% of Medicare $91.20 $96.90 $102.60 $83.21 $96.90 $114.00 $114.00 100% of Medicare 100% of Medicare $114.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379590 sodium bicarbonate 8.4% IV Sol 50 mL 00409-6625-02 INSTITUTIONAL $81.00 1/1/2022-12/31/2022 $81.00 $38.23 $46.17 $59.54 $59.54 $56.16 100% of Medicare $48.50 $46.69 $45.47 $51.84 100% of Medicaid 100% of Medicare 150% of Medicare $64.80 $81.00 195% of Medicare $65.61 $48.20 $48.20 $38.23 $81.00 100% of Medicare $64.80 $68.85 $72.90 $59.12 $68.85 $81.00 $81.00 100% of Medicare 100% of Medicare $81.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379591 bromfenac 0.09% Opth Sol 00378-7110-35 INSTITUTIONAL $430.00 1/1/2022-12/31/2022 $430.00 $202.96 $245.10 $316.05 $316.05 $298.12 100% of Medicare $257.48 $247.85 $241.36 $275.20 100% of Medicaid 100% of Medicare 150% of Medicare $344.00 $430.00 195% of Medicare $348.30 $255.85 $255.85 $202.96 $430.00 100% of Medicare $344.00 $365.50 $387.00 $313.86 $365.50 $430.00 $430.00 100% of Medicare 100% of Medicare $430.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379592 pilocarpine Opth 1% Sol 61314-0203-15 INSTITUTIONAL $366.00 1/1/2022-12/31/2022 $366.00 $172.75 $208.62 $269.01 $269.01 $253.75 100% of Medicare $219.16 $210.96 $205.44 $234.24 100% of Medicaid 100% of Medicare 150% of Medicare $292.80 $366.00 195% of Medicare $296.46 $217.77 $217.77 $172.75 $366.00 100% of Medicare $292.80 $311.10 $329.40 $267.14 $311.10 $366.00 $366.00 100% of Medicare 100% of Medicare $366.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379595 Chlorhexidine Gluconate 4% 52380-1272-04 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379612 Phenol Spray 177 mL (Chloraseptic) 00904-6305-21 INSTITUTIONAL $32.00 1/1/2022-12/31/2022 $32.00 $15.10 $18.24 $23.52 $23.52 $22.19 100% of Medicare $19.16 $18.44 $17.96 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $25.60 $32.00 195% of Medicare $25.92 $19.04 $19.04 $15.10 $32.00 100% of Medicare $25.60 $27.20 $28.80 $23.36 $27.20 $32.00 $32.00 100% of Medicare 100% of Medicare $32.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379614 abacavir 300 mg Tab 00378-4105-91 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379617 amoxicillin-clavulanate 500 mg-125 mg Tab 66685-1002-00 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379618 azathioprine 50 mg Tab 00054-8084-25 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379619 azithromycin 250 mg Tab 00093-7146-56 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 636 NULL NULL NULL NULL 16379621 Baclofen Tab 10 mg 00904-3365-61 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16379630 carbidopa-levodopa 25 mg-100 mg Tab 00904-6237-61 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16380177 cilostazol 100 mg Tab 60505-2522-01 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383942 colchicine 0.6 mg Tab 64764-0119-07 INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 $38.13 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383943 digoxin 250 mcg (0.25 mg) Tab 00115-9822-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383944 doxycycline hyclate 100 mg Tab 24658-0220-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383946 escitalopram 10 mg Tab 00904-6314-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383951 fluconazole 150 mg Tab 68462-0103-40 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 $61.70 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383952 glycopyrrolate 1 mg Tab 00603-3180-21 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 $31.20 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383954 Hydrochlorothiazide Tab 25 mg 63739-0128-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383955 hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab 60505-2656-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 16383956 hydrocortisone 10 mg Tab 64720-0332-10 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 16383957 hydrocortisone 20 mg Tab 00143-1254-01 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383958 isosorbide dinitrate 10 mg Tab 00781-1556-13 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383959 lisinopril 2.5 mg Tab 00603-4209-21 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383960 lisinopril 5 mg Tab 51079-0981-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383961 losartan 25 mg Tab 00603-4224-02 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383962 Losartan Tab 50 mg 00093-7365-98 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383963 Lysine 500mg 00536-6731-01 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383964 meclizine 12.5 mg Tab 00536-3985-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383968 Methylcob-Pyridoxal-Metafolin 51991-0813-90 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383969 methylPREDNISolone 4 mg Tab 59762-4440-03 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383970 metolazone 5 mg Tab 65580-0644-71 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383972 minoxidil 10 mg Tab 53489-0387-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383974 mirtazapine 15 mg Tab 51079-0086-20 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383975 modafinil 100 mg Tab 51079-0561-03 INSTITUTIONAL $35.00 1/1/2022-12/31/2022 $35.00 $16.52 $19.95 $25.73 $25.73 $24.27 100% of Medicare $20.96 $20.17 $19.65 $22.40 100% of Medicaid 100% of Medicare 150% of Medicare $28.00 $35.00 195% of Medicare $28.35 $20.83 $20.83 $16.52 $35.00 100% of Medicare $28.00 $29.75 $31.50 $25.55 $29.75 $35.00 $35.00 100% of Medicare 100% of Medicare $35.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383976 naproxen 500 mg Tab 00904-6297-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383980 olanzapine 5 mg Tab 55111-0164-30 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383982 Ondansetron Tab 8 mg 45963-0539-30 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383987 phenobarbital 100 mg Tab 00143-1458-05 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383988 phenobarbital 32.4 mg Tab 63739-0201-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383990 pioglitazone 15 mg Tab 00591-3205-30 INSTITUTIONAL $45.00 1/1/2022-12/31/2022 $45.00 $21.24 $25.65 $33.08 $33.08 $31.20 100% of Medicare $26.95 $25.94 $25.26 $28.80 100% of Medicaid 100% of Medicare 150% of Medicare $36.00 $45.00 195% of Medicare $36.45 $26.78 $26.78 $21.24 $45.00 100% of Medicare $36.00 $38.25 $40.50 $32.85 $38.25 $45.00 $45.00 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383991 pioglitazone 30 mg Tab 00591-3206-30 INSTITUTIONAL $68.00 1/1/2022-12/31/2022 $68.00 $32.10 $38.76 $49.98 $49.98 $47.14 100% of Medicare $40.72 $39.20 $38.17 $43.52 100% of Medicaid 100% of Medicare 150% of Medicare $54.40 $68.00 195% of Medicare $55.08 $40.46 $40.46 $32.10 $68.00 100% of Medicare $54.40 $57.80 $61.20 $49.63 $57.80 $68.00 $68.00 100% of Medicare 100% of Medicare $68.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16383995 quetiapine 25 mg Tab 60505-3130-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384000 simvastatin 40 mg Tab 00904-5802-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384002 sodium bicarbonate 650 mg Tab 64980-0182-10 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 16384003 spironolactone 100 mg Tab 65162-0515-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384004 spironolactone 50 mg Tab 63739-0545-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384006 valsartan 160 mg Tab 00078-0359-34 INSTITUTIONAL $65.00 1/1/2022-12/31/2022 $65.00 $30.68 $37.05 $47.78 $47.78 $45.06 100% of Medicare $38.92 $37.47 $36.48 $41.60 100% of Medicaid 100% of Medicare 150% of Medicare $52.00 $65.00 195% of Medicare $52.65 $38.68 $38.68 $30.68 $65.00 100% of Medicare $52.00 $55.25 $58.50 $47.44 $55.25 $65.00 $65.00 100% of Medicare 100% of Medicare $65.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384007 valsartan 80 mg Tab 00078-0358-34 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384011 divalproex sodium 500 mg Oral EC Tab 63739-0554-10 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384012 pantoprazole 40 mg Oral EC Tab 64679-0434-04 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384014 buPROPion 150 mg ER Tab 00185-0415-60 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384015 etodolac 400 mg ER Tab 51672-4051-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384019 Isosorbide Mononitrate 120mg ER 00603-4112-21 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384020 metoprolol 100 mg ER Tab 62037-0832-01 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384021 morphine 30 mg ER Tab 00378-2659-01 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384022 NIFEdipine Tab ER 60 mg 49884-0678-01 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384023 NIFEdipine 90 mg ER Tab 62175-0262-37 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384024 oxybutynin 5 mg ER Tab 00378-6605-01 INSTITUTIONAL $21.00 1/1/2022-12/31/2022 $21.00 $9.91 $11.97 $15.44 $15.44 $14.56 100% of Medicare $12.57 $12.10 $11.79 $13.44 100% of Medicaid 100% of Medicare 150% of Medicare $16.80 $21.00 195% of Medicare $17.01 $12.50 $12.50 $9.91 $21.00 100% of Medicare $16.80 $17.85 $18.90 $15.33 $17.85 $21.00 $21.00 100% of Medicare 100% of Medicare $21.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16384028 Povidone Iodine Top Soln 10% 240 mL 67618-0150-09 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 16773403 mirtazapine 15 mg Tab 51079-0086-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17030874 piperacillin-tazobactam 4 g-0.5 g IV Inj 00409-3379-04 INSTITUTIONAL $109.00 1/1/2022-12/31/2022 $109.00 $51.45 $62.13 $80.12 $80.12 $75.57 100% of Medicare $65.27 $62.83 $61.18 $69.76 100% of Medicaid 100% of Medicare 150% of Medicare $87.20 $109.00 195% of Medicare $88.29 $64.86 $64.86 $51.45 $109.00 100% of Medicare $87.20 $92.65 $98.10 $79.56 $92.65 $109.00 $109.00 100% of Medicare 100% of Medicare $109.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17032903 Insulin NPH/Reg 70/30 100units/mL 3 mL 00002-8715-17 INSTITUTIONAL $340.00 1/1/2022-12/31/2022 $340.00 $160.48 $193.80 $249.90 $249.90 $235.72 100% of Medicare $203.59 $195.98 $190.84 $217.60 100% of Medicaid 100% of Medicare 150% of Medicare $272.00 $340.00 195% of Medicare $275.40 $202.30 $202.30 $160.48 $340.00 100% of Medicare $272.00 $289.00 $306.00 $248.17 $289.00 $340.00 $340.00 100% of Medicare 100% of Medicare $340.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17270866 Bismuth Subgallate Tab 200 mg 08472-4000-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17370973 Bisacodyl suppository (Magic Bullet) 10mg sup 57648-0002-01 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17370982 Glucosamine 500mg cap 00904-5293-52 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 17588907 WARFARIN - PHARMACY TO DOSE 99999-9999-57 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 17816895 Ensure Clear 70074-0566-04 INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 $1.39 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880856 Smog Enema 99999-9999-86 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880858 Tacrolimus 0.5 mg/mL Suspension 99999-9999-90 INSTITUTIONAL $561.00 1/1/2022-12/31/2022 $561.00 $264.79 $319.77 $412.34 $412.34 $388.94 100% of Medicare $335.93 $323.36 $314.89 $359.04 100% of Medicaid 100% of Medicare 150% of Medicare $448.80 $561.00 195% of Medicare $454.41 $333.80 $333.80 $264.79 $561.00 100% of Medicare $448.80 $476.85 $504.90 $409.47 $476.85 $561.00 $561.00 100% of Medicare 100% of Medicare $561.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880859 Dakins Full 99999-9999-85 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880860 Dakins 1/2 Strength 99999-9999-84 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880861 Dakins 1/4 Strength 99999-9999-83 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880862 Dakins 1/8 Strength 99999-9999-82 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880863 Riley Butt Cream 99999-9999-94 INSTITUTIONAL $166.00 1/1/2022-12/31/2022 $166.00 $78.35 $94.62 $122.01 $122.01 $115.09 100% of Medicare $99.40 $95.68 $93.18 $106.24 100% of Medicaid 100% of Medicare 150% of Medicare $132.80 $166.00 195% of Medicare $134.46 $98.77 $98.77 $78.35 $166.00 100% of Medicare $132.80 $141.10 $149.40 $121.16 $141.10 $166.00 $166.00 100% of Medicare 100% of Medicare $166.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880864 Mary's Magic Mouthwash 99999-9999-93 INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $25.96 $31.35 $40.43 $40.43 $38.13 100% of Medicare $32.93 $31.70 $30.87 $35.20 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.73 $32.73 $25.96 $55.00 100% of Medicare $44.00 $46.75 $49.50 $40.14 $46.75 $55.00 $55.00 100% of Medicare 100% of Medicare $55.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17880865 Vancomycin 125mg/5ml 99999-9999-83 INSTITUTIONAL $583.00 1/1/2022-12/31/2022 $583.00 $275.18 $332.31 $428.51 $428.51 $404.19 100% of Medicare $349.10 $336.04 $327.24 $373.12 100% of Medicaid 100% of Medicare 150% of Medicare $466.40 $583.00 195% of Medicare $472.23 $346.89 $346.89 $275.18 $583.00 100% of Medicare $466.40 $495.55 $524.70 $425.53 $495.55 $583.00 $583.00 100% of Medicare 100% of Medicare $583.00 200% of Medicare NULL 250 NULL NULL NULL NULL 17908853 Tacrolimus 0.5 mg/mL Suspension 99999-9999-90 INSTITUTIONAL $384.00 1/1/2022-12/31/2022 $384.00 $181.25 $218.88 $282.24 $282.24 $266.23 100% of Medicare $229.94 $221.34 $215.54 $245.76 100% of Medicaid 100% of Medicare 150% of Medicare $307.20 $384.00 195% of Medicare $311.04 $228.48 $228.48 $181.25 $384.00 100% of Medicare $307.20 $326.40 $345.60 $280.28 $326.40 $384.00 $384.00 100% of Medicare 100% of Medicare $384.00 200% of Medicare NULL 250 NULL NULL NULL NULL 18660241 carvedilol 6.25 mg Tab 51079-0930-20 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 18812283 mesalamine 400 mg Cap 00430-0753-27 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 18952251 Gentamicin Bladder Irrigation 4.8% 99999-9999-68 INSTITUTIONAL $73.00 1/1/2022-12/31/2022 $73.00 $34.46 $41.61 $53.66 $53.66 $50.61 100% of Medicare $43.71 $42.08 $40.97 $46.72 100% of Medicaid 100% of Medicare 150% of Medicare $58.40 $73.00 195% of Medicare $59.13 $43.44 $43.44 $34.46 $73.00 100% of Medicare $58.40 $62.05 $65.70 $53.28 $62.05 $73.00 $73.00 100% of Medicare 100% of Medicare $73.00 200% of Medicare NULL 250 NULL NULL NULL NULL 18952256 Creon-Sodium Bicarbonate Solution 99999-9999-67 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19072242 nitroglycerin 0.2 mg/hr Transderm ER Film 00904-5495-46 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19074256 nicotine 7 mg/24 hr Transderm ER Film 00536-5894-88 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19074257 nicotine 21 mg/24 hr Transderm ER Film 00536-5896-88 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19078241 Phenol 89% 38779-1938-08 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19078246 Phenol 5% Solution 99999-9999-66 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19107230 enoxaparin 40 mg/0.4 mL SC Sol 00075-0620-41 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19264513 famotidine 20 mg Tab 51079-0966-20 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19328240 nicotine 14 mg/24 hr Transderm ER Film 00067-5125-14 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19328261 Chapstick 00573-1925-50 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19390242 heparin 1000 units/mL Inj Sol 25021-0400-01 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19390272 TPN - Charge 99999-9999-50 INSTITUTIONAL " $1,232.00 " 1/1/2022-12/31/2022 " $1,232.00 " $581.50 $702.24 $905.52 $905.52 $854.15 100% of Medicare $737.72 $710.12 $691.52 $788.48 100% of Medicaid 100% of Medicare 150% of Medicare $985.60 " $1,232.00 " 195% of Medicare $997.92 $733.04 $733.04 $581.50 " $1,232.00 " 100% of Medicare $985.60 " $1,047.20 " " $1,108.80 " $899.24 " $1,047.20 " " $1,232.00 " " $1,232.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 19509691 levothyroxine 50 mcg (0.05 mg) Tab 00074-4552-11 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20746294 benzoyl peroxide Top 10% Gel 00536-4092-56 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20746370 olanzapine 10 mg IM Inj 00517-0955-01 INSTITUTIONAL $383.00 1/1/2022-12/31/2022 $383.00 $180.78 $218.31 $281.51 $281.51 $265.53 100% of Medicare $229.34 $220.76 $214.98 $245.12 100% of Medicaid 100% of Medicare 150% of Medicare $306.40 $383.00 195% of Medicare $310.23 $227.89 $227.89 $180.78 $383.00 100% of Medicare $306.40 $325.55 $344.70 $279.55 $325.55 $383.00 $383.00 100% of Medicare 100% of Medicare $383.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20746439 Dextrose 5% Sod Chloride 0.9% 1000 mL 00409-7941-09 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 20746461 miconazole Top 2% Crm 00603-7805-50 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20746481 Maalox Plus 400/400/40mg 00904-0005-14 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780880 " nystatin 100,000 units/mL Oral Susp" 60432-0537-60 INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $19.35 $23.37 $30.14 $30.14 $28.43 100% of Medicare $24.55 $23.63 $23.01 $26.24 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $24.40 $24.40 $19.35 $41.00 100% of Medicare $32.80 $34.85 $36.90 $29.93 $34.85 $41.00 $41.00 100% of Medicare 100% of Medicare $41.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780881 Triamcinolone Cream 0.1% 15 GM 67877-0251-15 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 $24.96 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780892 Emollient Skin Cleanser(Hydrocerin) 46287-0507-04 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 $33.97 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780893 Dextrose 5% in Water IV Sol 1000 mL 00338-0017-04 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 $20.11 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780894 Sodium Chloride 0.45% IV Sol 1000 mL 00409-7985-09 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780895 silver sulfADIAZINE Top 1% Crm 43598-0210-50 INSTITUTIONAL " $15,052.00 " 1/1/2022-12/31/2022 " $13,546.80 " $975.00 " $8,579.64 " " $11,063.22 " " $11,063.22 " " $10,435.55 " 100% of Medicare " $9,013.14 " " $8,675.97 " " $8,448.69 " " $9,633.28 " 100% of Medicaid 100% of Medicare 150% of Medicare " $12,041.60 " " $1,500.00 " 195% of Medicare " $12,192.12 " " $8,955.94 " " $8,955.94 " " $7,104.54 " " $1,359.00 " 100% of Medicare " $12,041.60 " " $12,794.20 " " $13,546.80 " " $10,986.45 " " $12,794.20 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780897 timolol Opth 0.5% Sol 16571-0141-50 INSTITUTIONAL $108.00 1/1/2022-12/31/2022 $108.00 $50.98 $61.56 $79.38 $79.38 $74.88 100% of Medicare $64.67 $62.25 $60.62 $69.12 100% of Medicaid 100% of Medicare 150% of Medicare $86.40 $108.00 195% of Medicare $87.48 $64.26 $64.26 $50.98 $108.00 100% of Medicare $86.40 $91.80 $97.20 $78.83 $91.80 $108.00 $108.00 100% of Medicare 100% of Medicare $108.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780898 ceftriaxone 1 g Inj 00409-7333-49 INSTITUTIONAL $67.00 1/1/2022-12/31/2022 $67.00 $31.62 $38.19 $49.25 $49.25 $46.45 100% of Medicare $40.12 $38.62 $37.61 $42.88 100% of Medicaid 100% of Medicare 150% of Medicare $53.60 $67.00 195% of Medicare $54.27 $39.87 $39.87 $31.62 $67.00 100% of Medicare $53.60 $56.95 $60.30 $48.90 $56.95 $67.00 $67.00 100% of Medicare 100% of Medicare $67.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780903 Dextrose 5% Sod Chloride 0.45% 1000 mL 00264-7612-00 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 20780904 lidocaine-prilocaine Top 2.5%-2.5% Crm 50383-0667-30 INSTITUTIONAL $77.00 1/1/2022-12/31/2022 $77.00 $36.34 $43.89 $56.60 $56.60 $53.38 100% of Medicare $46.11 $44.38 $43.22 $49.28 100% of Medicaid 100% of Medicare 150% of Medicare $61.60 $77.00 195% of Medicare $62.37 $45.82 $45.82 $36.34 $77.00 100% of Medicare $61.60 $65.45 $69.30 $56.20 $65.45 $77.00 $77.00 100% of Medicare 100% of Medicare $77.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20780925 ipratropium Nasal 0.03% Spry 24208-0398-30 INSTITUTIONAL $169.00 1/1/2022-12/31/2022 $169.00 $79.77 $96.33 $124.22 $124.22 $117.17 100% of Medicare $101.20 $97.41 $94.86 $108.16 100% of Medicaid 100% of Medicare 150% of Medicare $135.20 $169.00 195% of Medicare $136.89 $100.56 $100.56 $79.77 $169.00 100% of Medicare $135.20 $143.65 $152.10 $123.35 $143.65 $169.00 $169.00 100% of Medicare 100% of Medicare $169.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20785251 Guaifenesin DM Soln 100 mg-10mg/5 mL Bottle 00603-0855-94 INSTITUTIONAL $4.00 1/1/2022-12/31/2022 $4.00 $1.89 $2.28 $2.94 $2.94 $2.77 100% of Medicare $2.40 $2.31 $2.25 $2.56 100% of Medicaid 100% of Medicare 150% of Medicare $3.20 $4.00 195% of Medicare $3.24 $2.38 $2.38 $1.89 $4.00 100% of Medicare $3.20 $3.40 $3.60 $2.92 $3.40 $4.00 $4.00 100% of Medicare 100% of Medicare $4.00 200% of Medicare NULL 250 NULL NULL NULL NULL 20785252 alteplase 2 mg Powder 50242-0041-64 INSTITUTIONAL $341.00 1/1/2022-12/31/2022 $341.00 $160.95 $194.37 $250.64 $250.64 $236.42 100% of Medicare $204.19 $196.55 $191.40 $218.24 100% of Medicaid 100% of Medicare 150% of Medicare $272.80 $341.00 195% of Medicare $276.21 $202.90 $202.90 $160.95 $341.00 100% of Medicare $272.80 $289.85 $306.90 $248.90 $289.85 $341.00 $341.00 100% of Medicare 100% of Medicare $341.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21190248 gadopentetate dimeglumine 46.9% So 50419-0188-01 INSTITUTIONAL $94.00 1/1/2022-12/31/2022 $94.00 $44.37 $53.58 $69.09 $69.09 $65.17 100% of Medicare $56.29 $54.18 $52.76 $60.16 100% of Medicaid 100% of Medicare 150% of Medicare $75.20 $94.00 195% of Medicare $76.14 $55.93 $55.93 $44.37 $94.00 100% of Medicare $75.20 $79.90 $84.60 $68.61 $79.90 $94.00 $94.00 100% of Medicare 100% of Medicare $94.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21192242 " nystatin Top 100,000 units/g Crm" 00603-7818-78 INSTITUTIONAL $167.00 1/1/2022-12/31/2022 $167.00 $78.82 $95.19 $122.75 $122.75 $115.78 100% of Medicare $100.00 $96.26 $93.74 $106.88 100% of Medicaid 100% of Medicare 150% of Medicare $133.60 $167.00 195% of Medicare $135.27 $99.37 $99.37 $78.82 $167.00 100% of Medicare $133.60 $141.95 $150.30 $121.89 $141.95 $167.00 $167.00 100% of Medicare 100% of Medicare $167.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21266541 furosemide 40 mg Tab 00172-2907-10 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 21266553 darbepoetin alfa 100 mcg/mL Inj Sol 55513-0005-01 INSTITUTIONAL " $1,416.00 " 1/1/2022-12/31/2022 " $1,416.00 " $668.35 $807.12 " $1,040.76 " " $1,040.76 " $981.71 100% of Medicare $847.90 $816.18 $794.80 $906.24 100% of Medicaid 100% of Medicare 150% of Medicare " $1,132.80 " " $1,416.00 " 195% of Medicare " $1,146.96 " $842.52 $842.52 $668.35 " $1,359.00 " 100% of Medicare " $1,132.80 " " $1,203.60 " " $1,274.40 " " $1,033.54 " " $1,203.60 " " $1,416.00 " " $1,416.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21266555 Sodium Chloride 0.9% 63807-0100-10 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21266560 levalbuterol 0.63 mg/3 mL Inh Sol 66993-0022-27 INSTITUTIONAL $75.00 1/1/2022-12/31/2022 $75.00 $35.40 $42.75 $55.13 $55.13 $52.00 100% of Medicare $44.91 $43.23 $42.10 $48.00 100% of Medicaid 100% of Medicare 150% of Medicare $60.00 $75.00 195% of Medicare $60.75 $44.63 $44.63 $35.40 $75.00 100% of Medicare $60.00 $63.75 $67.50 $54.74 $63.75 $75.00 $75.00 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21454376 fluticasone Nasal 0.05 mg/inh Spry 00054-3270-99 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 $32.59 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21524240 famotidine 20 mg Tab 61442-0121-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21556941 rivaroxaban 20 mg Ta 50458-0579-30 INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 $83.20 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21758311 darbepotin alfa 100mcg/0.5ml 100 mcg Syringe 55513-00-2504 INSTITUTIONAL " $1,416.00 " 1/1/2022-12/31/2022 " $1,416.00 " $668.35 $807.12 " $1,040.76 " " $1,040.76 " $981.71 100% of Medicare $847.90 $816.18 $794.80 $906.24 100% of Medicaid 100% of Medicare 150% of Medicare " $1,132.80 " " $1,416.00 " 195% of Medicare " $1,146.96 " $842.52 $842.52 $668.35 " $1,359.00 " 100% of Medicare " $1,132.80 " " $1,203.60 " " $1,274.40 " " $1,033.54 " " $1,203.60 " " $1,416.00 " " $1,416.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21792252 terazosin 5 mg Cap 00904-6128-61 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21953112 levalbuterol 1.25 mg/3 mL Inh Sol 00093-4148-64 INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 $24.96 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL 21954025 tacrolimus 0.5 mg Oral Cap 68084-0449-01 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 22066354 sodium chloride 0.9% Inj Sol 10 mL 63807-0100-01 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 22658968 spironolactone 25 mg Tab 68084-0206-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 272 NULL A4212 NULL NULL 22814275 CHALGREN NEEDLES 37X26 NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $26.75 $36.48 $47.04 $47.04 $44.37 100% of Medicare $37.64 $36.23 $35.28 $26.75 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $37.44 $37.44 $30.21 $41.18 100% of Medicare $51.20 $54.40 $50.24 $46.71 $51.20 $54.40 $44.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23024294 Sodium Chloride 0.9% IV Sol 250 mL 00409-7983-02 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 636 NULL NULL NULL NULL 23058262 Phenol 5% Solution 99999-9999-66 INSTITUTIONAL " $1,505.00 " 1/1/2022-12/31/2022 " $1,505.00 " $710.36 $857.85 " $1,106.18 " " $1,106.18 " " $1,043.42 " 100% of Medicare $901.19 $867.48 $844.76 $963.20 100% of Medicaid 100% of Medicare 150% of Medicare " $1,204.00 " " $1,500.00 " 195% of Medicare " $1,219.05 " $895.48 $895.48 $710.36 " $1,359.00 " 100% of Medicare " $1,204.00 " " $1,279.25 " " $1,354.50 " " $1,098.50 " " $1,279.25 " " $1,500.00 " " $1,505.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23310246 lisinopril 10 mg Tab 68084-0061-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23310247 lisinopril 10 mg Tab 00172-3759-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23310248 BuMETAnide Tab 0.5 mg 00185-0128-01 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23310249 allopurinol 100 mg Tab 00603-2115-21 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23410256 Lisinopril Tab 20 mg 51079-0983-20 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23410257 " rivastigmine 4.6 mg/24 hr TD film, ER" 00078-0501-61 INSTITUTIONAL $47.00 1/1/2022-12/31/2022 $47.00 $22.18 $26.79 $34.55 $34.55 $32.59 100% of Medicare $28.14 $27.09 $26.38 $30.08 100% of Medicaid 100% of Medicare 150% of Medicare $37.60 $47.00 195% of Medicare $38.07 $27.97 $27.97 $22.18 $47.00 100% of Medicare $37.60 $39.95 $42.30 $34.31 $39.95 $47.00 $47.00 100% of Medicare 100% of Medicare $47.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23658699 lactulose 10 g/15 mL Oral Syrup 66689-0038-50 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23732628 Lisinopril Tab 20 mg 68084-0062-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23766901 menthol-zinc oxide topical 0.44%-20.625% Oi 00799-0001-03 INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 250 NULL NULL NULL NULL 23846579 docusate-senna 50 mg-8.6 mg Tab 00904-6339-61 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 24166589 Glycerin Adult Supp 00713-0101-25 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 24318663 POLYCOSE 70074060746 - INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 24386377 levalbuterol 0.63 mg/3 mL Inh Sol 00093-4146-64 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 $20.11 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL 25280602 POLY-PHREE 70074-05-1149 INSTITUTIONAL $19.00 1/1/2022-12/31/2022 $19.00 $8.97 $10.83 $13.97 $13.97 $13.17 100% of Medicare $11.38 $10.95 $10.66 $12.16 100% of Medicaid 100% of Medicare 150% of Medicare $15.20 $19.00 195% of Medicare $15.39 $11.31 $11.31 $8.97 $19.00 100% of Medicare $15.20 $16.15 $17.10 $13.87 $16.15 $19.00 $19.00 100% of Medicare 100% of Medicare $19.00 200% of Medicare NULL 250 NULL NULL NULL NULL 25280603 Pediasure Peptide Vanilla 70074-0621-20 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 250 NULL NULL NULL NULL 25712612 divalproex sodium 500 mg ER Tab 10370-0511-10 INSTITUTIONAL $28.00 1/1/2022-12/31/2022 $28.00 $13.22 $15.96 $20.58 $20.58 $19.41 100% of Medicare $16.77 $16.14 $15.72 $17.92 100% of Medicaid 100% of Medicare 150% of Medicare $22.40 $28.00 195% of Medicare $22.68 $16.66 $16.66 $13.22 $28.00 100% of Medicare $22.40 $23.80 $25.20 $20.44 $23.80 $28.00 $28.00 100% of Medicare 100% of Medicare $28.00 200% of Medicare NULL 250 NULL NULL NULL NULL 27406580 Artificial Tear Solution 1.4 Bottle 30536-19707-27 INSTITUTIONAL $5.00 1/1/2022-12/31/2022 $5.00 $2.36 $2.85 $3.68 $3.68 $3.47 100% of Medicare $2.99 $2.88 $2.81 $3.20 100% of Medicaid 100% of Medicare 150% of Medicare $4.00 $5.00 195% of Medicare $4.05 $2.98 $2.98 $2.36 $5.00 100% of Medicare $4.00 $4.25 $4.50 $3.65 $4.25 $5.00 $5.00 100% of Medicare 100% of Medicare $5.00 200% of Medicare NULL 250 NULL NULL NULL NULL 27930593 carvedilol 3.125 mg Tab 00904-6300-61 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 27934579 ciprofloxacin 500 mg Tab 68084-0070-01 INSTITUTIONAL $33.00 1/1/2022-12/31/2022 $33.00 $15.58 $18.81 $24.26 $24.26 $22.88 100% of Medicare $19.76 $19.02 $18.52 $21.12 100% of Medicaid 100% of Medicare 150% of Medicare $26.40 $33.00 195% of Medicare $26.73 $19.64 $19.64 $15.58 $33.00 100% of Medicare $26.40 $28.05 $29.70 $24.09 $28.05 $33.00 $33.00 100% of Medicare 100% of Medicare $33.00 200% of Medicare NULL 250 NULL NULL NULL NULL 28122668 lisinopril 5 mg Tab 68084-0060-01 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 29618209 Miralax packet1 51079-0306-30 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 29965911 RHIPYRI100 65162-0517-10 INSTITUTIONAL $20.00 1/1/2022-12/31/2022 $20.00 $9.44 $11.40 $14.70 $14.70 $13.87 100% of Medicare $11.98 $11.53 $11.23 $12.80 100% of Medicaid 100% of Medicare 150% of Medicare $16.00 $20.00 195% of Medicare $16.20 $11.90 $11.90 $9.44 $20.00 100% of Medicare $16.00 $17.00 $18.00 $14.60 $17.00 $20.00 $20.00 100% of Medicare 100% of Medicare $20.00 200% of Medicare NULL 250 NULL NULL NULL NULL 30419556 spironolactone 25 mg Tab 00904-5951-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 30419557 Lisinopril Tab 20 mg 00904-5809-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 30702711 donepezil 5 mg Tab 00904-6354-61 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 31777333 tamsulosin 0.4 mg Oral Cap 01003-51079-294 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 34369662 fentanyl 50 mcg/hr Transderm ER Film 60505-7012-00 INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $23.13 $27.93 $36.02 $36.02 $33.97 100% of Medicare $29.34 $28.24 $27.50 $31.36 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $29.16 $29.16 $23.13 $49.00 100% of Medicare $39.20 $41.65 $44.10 $35.77 $41.65 $49.00 $49.00 100% of Medicare 100% of Medicare $49.00 200% of Medicare NULL 250 NULL NULL NULL NULL 34883122 hydromorphone 4 mg Tab 59011-0454-01 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 35119945 latanoprost Opth 0.005% Sol 00013-8303-04 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 41196669 VITAL 1.5 cal 70074-0562-79 INSTITUTIONAL $22.00 1/1/2022-12/31/2022 $22.00 $10.38 $12.54 $16.17 $16.17 $15.25 100% of Medicare $13.17 $12.68 $12.35 $14.08 100% of Medicaid 100% of Medicare 150% of Medicare $17.60 $22.00 195% of Medicare $17.82 $13.09 $13.09 $10.38 $22.00 100% of Medicare $17.60 $18.70 $19.80 $16.06 $18.70 $22.00 $22.00 100% of Medicare 100% of Medicare $22.00 200% of Medicare NULL 250 NULL NULL NULL NULL 41196670 Osmolite 1.5 cal 70074-0574-70 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 42825185 Ascorbic Acid 500mg/5ml 00536-0160-97 INSTITUTIONAL $89.00 1/1/2022-12/31/2022 $89.00 $42.01 $50.73 $65.42 $65.42 $61.70 100% of Medicare $53.29 $51.30 $49.96 $56.96 100% of Medicaid 100% of Medicare 150% of Medicare $71.20 $89.00 195% of Medicare $72.09 $52.96 $52.96 $42.01 $89.00 100% of Medicare $71.20 $75.65 $80.10 $64.96 $75.65 $89.00 $89.00 100% of Medicare 100% of Medicare $89.00 200% of Medicare NULL 250 NULL NULL NULL NULL 43426187 magnesium citrate 8.85% Oral Liq 300 mL 71525-6100-01 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 44059265 dolutegravir 50 mg Ta 49702-0228-13 INSTITUTIONAL $465.00 1/1/2022-12/31/2022 $465.00 $219.48 $265.05 $341.78 $341.78 $322.38 100% of Medicare $278.44 $268.03 $261.00 $297.60 100% of Medicaid 100% of Medicare 150% of Medicare $372.00 $465.00 195% of Medicare $376.65 $276.68 $276.68 $219.48 $465.00 100% of Medicare $372.00 $395.25 $418.50 $339.40 $395.25 $465.00 $465.00 100% of Medicare 100% of Medicare $465.00 200% of Medicare NULL 250 NULL NULL NULL NULL 45199642 fluticasone-vilanterol 100 mcg-25 mcg Powder 00173-0859-14 INSTITUTIONAL $306.00 1/1/2022-12/31/2022 $306.00 $144.43 $174.42 $224.91 $224.91 $212.15 100% of Medicare $183.23 $176.38 $171.76 $195.84 100% of Medicaid 100% of Medicare 150% of Medicare $244.80 $306.00 195% of Medicare $247.86 $182.07 $182.07 $144.43 $306.00 100% of Medicare $244.80 $260.10 $275.40 $223.35 $260.10 $306.00 $306.00 100% of Medicare 100% of Medicare $306.00 200% of Medicare NULL 250 NULL NULL NULL NULL 45199643 apixaban 5 mg Tab 00003-0894-21 INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $28.32 $34.20 $44.10 $44.10 $41.60 100% of Medicare $35.93 $34.58 $33.68 $38.40 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.70 $35.70 $28.32 $60.00 100% of Medicare $48.00 $51.00 $54.00 $43.79 $51.00 $60.00 $60.00 100% of Medicare 100% of Medicare $60.00 200% of Medicare NULL 250 NULL NULL NULL NULL 47840423 ocular lubricant preserved Sol 00536-1970-72 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48089743 sacubitril-valsartan 49 mg-51 mg Tab 00078-0777-20 INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 $47.84 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48089744 ivabradine 7.5 mg Tab 55513-0810-60 INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $27.85 $33.63 $43.37 $43.37 $40.90 100% of Medicare $35.33 $34.01 $33.12 $37.76 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $35.11 $35.11 $27.85 $59.00 100% of Medicare $47.20 $50.15 $53.10 $43.06 $50.15 $59.00 $59.00 100% of Medicare 100% of Medicare $59.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48155028 fluticasone-vilanterol 200 mcg-25 mcg/inh Pow 00173-0882-14 INSTITUTIONAL $306.00 1/1/2022-12/31/2022 $306.00 $144.43 $174.42 $224.91 $224.91 $212.15 100% of Medicare $183.23 $176.38 $171.76 $195.84 100% of Medicaid 100% of Medicare 150% of Medicare $244.80 $306.00 195% of Medicare $247.86 $182.07 $182.07 $144.43 $306.00 100% of Medicare $244.80 $260.10 $275.40 $223.35 $260.10 $306.00 $306.00 100% of Medicare 100% of Medicare $306.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48209273 glatiramer 40 mg/mL Sol 68546-0325-12 INSTITUTIONAL " $1,805.00 " 1/1/2022-12/31/2022 " $1,805.00 " $851.96 " $1,028.85 " " $1,326.68 " " $1,326.68 " " $1,251.41 " 100% of Medicare " $1,080.83 " " $1,040.40 " " $1,013.15 " " $1,155.20 " 100% of Medicaid 100% of Medicare 150% of Medicare " $1,444.00 " " $1,500.00 " 195% of Medicare " $1,462.05 " " $1,073.98 " " $1,073.98 " $851.96 " $1,359.00 " 100% of Medicare " $1,444.00 " " $1,534.25 " " $1,624.50 " " $1,317.47 " " $1,534.25 " " $1,500.00 " " $1,805.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48240664 balsam Peru-castor oil topical 87 mg-788 mg/g Oin 58980-0780-21 INSTITUTIONAL $239.00 1/1/2022-12/31/2022 $239.00 $112.81 $136.23 $175.67 $175.67 $165.70 100% of Medicare $143.11 $137.76 $134.15 $152.96 100% of Medicaid 100% of Medicare 150% of Medicare $191.20 $239.00 195% of Medicare $193.59 $142.21 $142.21 $112.81 $239.00 100% of Medicare $191.20 $203.15 $215.10 $174.45 $203.15 $239.00 $239.00 100% of Medicare 100% of Medicare $239.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48249699 Cholestyramine in Hydrophor 10% ointmen 99999-9991-00 INSTITUTIONAL $318.00 1/1/2022-12/31/2022 $318.00 $150.10 $181.26 $233.73 $233.73 $220.47 100% of Medicare $190.42 $183.30 $178.49 $203.52 100% of Medicaid 100% of Medicare 150% of Medicare $254.40 $318.00 195% of Medicare $257.58 $189.21 $189.21 $150.10 $318.00 100% of Medicare $254.40 $270.30 $286.20 $232.11 $270.30 $318.00 $318.00 100% of Medicare 100% of Medicare $318.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48332617 ELVIT/COBIC/EMTRIC/TENOF 150 mg-150 mg-200 mg -10 mg oral tablet 61958190101 - INSTITUTIONAL $350.00 1/1/2022-12/31/2022 $350.00 $165.20 $199.50 $257.25 $257.25 $242.66 100% of Medicare $209.58 $201.74 $196.46 $224.00 100% of Medicaid 100% of Medicare 150% of Medicare $280.00 $350.00 195% of Medicare $283.50 $208.25 $208.25 $165.20 $350.00 100% of Medicare $280.00 $297.50 $315.00 $255.47 $297.50 $350.00 $350.00 100% of Medicare 100% of Medicare $350.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48332805 ceftolozane-tazobactam 1 g-0.5 g Pow 67919-0030-01 INSTITUTIONAL $466.00 1/1/2022-12/31/2022 $466.00 $219.95 $265.62 $342.51 $342.51 $323.08 100% of Medicare $279.04 $268.60 $261.57 $298.24 100% of Medicaid 100% of Medicare 150% of Medicare $372.80 $466.00 195% of Medicare $377.46 $277.27 $277.27 $219.95 $466.00 100% of Medicare $372.80 $396.10 $419.40 $340.13 $396.10 $466.00 $466.00 100% of Medicare 100% of Medicare $466.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48457624 Memantine XR 28mg oral capsule 00456342833 - INSTITUTIONAL $54.00 1/1/2022-12/31/2022 $54.00 $25.49 $30.78 $39.69 $39.69 $37.44 100% of Medicare $32.34 $31.13 $30.31 $34.56 100% of Medicaid 100% of Medicare 150% of Medicare $43.20 $54.00 195% of Medicare $43.74 $32.13 $32.13 $25.49 $54.00 100% of Medicare $43.20 $45.90 $48.60 $39.41 $45.90 $54.00 $54.00 100% of Medicare 100% of Medicare $54.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48477096 methenamine hippurate 1 g Tab 64720-0139-10 INSTITUTIONAL $14.00 1/1/2022-12/31/2022 $14.00 $6.61 $7.98 $10.29 $10.29 $9.71 100% of Medicare $8.38 $8.07 $7.86 $8.96 100% of Medicaid 100% of Medicare 150% of Medicare $11.20 $14.00 195% of Medicare $11.34 $8.33 $8.33 $6.61 $14.00 100% of Medicare $11.20 $11.90 $12.60 $10.22 $11.90 $14.00 $14.00 100% of Medicare 100% of Medicare $14.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48508612 olanzapine 5 mg Tab 00904-6377-61 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 636 NULL NULL NULL NULL 48525576 baclofen 0.05 mg/mL So 45945-0151-01 INSTITUTIONAL $468.00 1/1/2022-12/31/2022 $468.00 $220.90 $266.76 $343.98 $343.98 $324.46 100% of Medicare $280.24 $269.76 $262.69 $299.52 100% of Medicaid 100% of Medicare 150% of Medicare $374.40 $468.00 195% of Medicare $379.08 $278.46 $278.46 $220.90 $468.00 100% of Medicare $374.40 $397.80 $421.20 $341.59 $397.80 $468.00 $468.00 100% of Medicare 100% of Medicare $468.00 200% of Medicare NULL 636 NULL NULL NULL NULL 48525636 baclofen 0.5 mg/mL So 45945-0155-02 INSTITUTIONAL " $1,430.00 " 1/1/2022-12/31/2022 " $1,430.00 " $674.96 $815.10 " $1,051.05 " " $1,051.05 " $991.42 100% of Medicare $856.28 $824.25 $802.66 $915.20 100% of Medicaid 100% of Medicare 150% of Medicare " $1,144.00 " " $1,430.00 " 195% of Medicare " $1,158.30 " $850.85 $850.85 $674.96 " $1,359.00 " 100% of Medicare " $1,144.00 " " $1,215.50 " " $1,287.00 " " $1,043.76 " " $1,215.50 " " $1,430.00 " " $1,430.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 636 NULL NULL NULL NULL 48525653 baclofen 1 mg/mL Sol 45945-0156-02 INSTITUTIONAL " $1,510.00 " 1/1/2022-12/31/2022 " $1,510.00 " $712.72 $860.70 " $1,109.85 " " $1,109.85 " " $1,046.88 " 100% of Medicare $904.19 $870.36 $847.56 $966.40 100% of Medicaid 100% of Medicare 150% of Medicare " $1,208.00 " " $1,500.00 " 195% of Medicare " $1,223.10 " $898.45 $898.45 $712.72 " $1,359.00 " 100% of Medicare " $1,208.00 " " $1,283.50 " " $1,359.00 " " $1,102.15 " " $1,283.50 " " $1,500.00 " " $1,510.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 636 NULL NULL NULL NULL 48525674 baclofen 2 mg/mL So 45945-0157-02 INSTITUTIONAL " $2,804.00 " 1/1/2022-12/31/2022 " $2,635.00 " $975.00 " $1,598.28 " " $2,060.94 " " $2,060.94 " " $1,944.01 " 100% of Medicare " $1,679.04 " " $1,616.23 " " $1,573.89 " " $1,794.56 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,243.20 " " $1,500.00 " 195% of Medicare " $2,271.24 " " $1,668.38 " " $1,668.38 " " $1,323.49 " " $1,359.00 " 100% of Medicare " $2,243.20 " " $2,383.40 " " $2,523.60 " " $2,046.64 " " $2,383.40 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48717819 gabapentin 300 mg Cap 00904-5632-61 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48717896 gabapentin 100 mg Cap 68084-0783-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 250 NULL NULL NULL NULL 48718406 Hydrochlorothiazide Tab 25 mg 68084-0086-01 INSTITUTIONAL $- 1/1/2022-12/31/2022 $- $- $- $- $- $- 100% of Medicare $- $- $- $- 100% of Medicaid 100% of Medicare 150% of Medicare $- $- 195% of Medicare $- $- $- $- $- 100% of Medicare $- $- $- $- $- $- $- 100% of Medicare 100% of Medicare $- 200% of Medicare NULL 636 NULL NULL NULL NULL 48815900 baclofen 2 mg/mL So 45945-0157-01 INSTITUTIONAL " $2,891.00 " 1/1/2022-12/31/2022 " $2,635.00 " $975.00 " $1,647.87 " " $2,124.89 " " $2,124.89 " " $2,004.33 " 100% of Medicare " $1,731.13 " " $1,666.37 " " $1,622.72 " " $1,850.24 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,312.80 " " $1,500.00 " 195% of Medicare " $2,341.71 " " $1,720.15 " " $1,720.15 " " $1,364.55 " " $1,359.00 " 100% of Medicare " $2,312.80 " " $2,457.35 " " $2,601.90 " " $2,110.14 " " $2,457.35 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48816593 heparin 5000 units/mL Sol 25021-0402-01 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48877942 MetFORMIN Tab XR 500 mg 68084-0072-01 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48880003 fenofibrate 54 mg Tab 68084-0827-25 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 48893443 valganciclovir 450 mg Tab 31722-0832-60 INSTITUTIONAL $410.00 1/1/2022-12/31/2022 $410.00 $193.52 $233.70 $301.35 $301.35 $284.25 100% of Medicare $245.51 $236.32 $230.13 $262.40 100% of Medicaid 100% of Medicare 150% of Medicare $328.00 $410.00 195% of Medicare $332.10 $243.95 $243.95 $193.52 $410.00 100% of Medicare $328.00 $348.50 $369.00 $299.26 $348.50 $410.00 $410.00 100% of Medicare 100% of Medicare $410.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49017374 dipyridamole 25 mg Tab 00555-0252-02 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49019069 mineral oil 100% Oral Liq 30 mL 48433-0202-30 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49067264 " nystatin 100,000 units/mL Oral Susp" 00121-4810-00 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49070483 Ensure Enlive Shake-Charge 99999-9999-59 INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49074373 quetiapine 25 mg Tab 00904-6277-61 INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $8.02 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.18 $9.80 $9.54 $10.88 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $10.12 $10.12 $8.02 $17.00 100% of Medicare $13.60 $14.45 $15.30 $12.41 $14.45 $17.00 $17.00 100% of Medicare 100% of Medicare $17.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49090003 isavuconazonium 372 mg Pow 00469-0420-99 INSTITUTIONAL " $1,058.00 " 1/1/2022-12/31/2022 " $1,058.00 " $499.38 $603.06 $777.63 $777.63 $733.51 100% of Medicare $633.53 $609.83 $593.86 $677.12 100% of Medicaid 100% of Medicare 150% of Medicare $846.40 " $1,058.00 " 195% of Medicare $856.98 $629.51 $629.51 $499.38 " $1,058.00 " 100% of Medicare $846.40 $899.30 $952.20 $772.23 $899.30 " $1,058.00 " " $1,058.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49104492 megestrol 20 mg Tab 51079-0434-20 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL NULL NULL NULL NULL NULL 49104565 Glucose Monitoring Continuous HENR NULL INSTITUTIONAL $82.00 1/1/2022-12/31/2022 $82.00 $38.70 $46.74 $60.27 $60.27 $56.85 100% of Medicare $49.10 $47.26 $46.03 $52.48 100% of Medicaid 100% of Medicare 150% of Medicare $65.60 $82.00 195% of Medicare $66.42 $48.79 $48.79 $38.70 $82.00 100% of Medicare $65.60 $69.70 $73.80 $59.85 $69.70 $82.00 $82.00 100% of Medicare 100% of Medicare $82.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49123834 rosuvastatin 10 mg Tab 60687-0245-01 INSTITUTIONAL $66.00 1/1/2022-12/31/2022 $66.00 $31.15 $37.62 $48.51 $48.51 $45.76 100% of Medicare $39.52 $38.04 $37.05 $42.24 100% of Medicaid 100% of Medicare 150% of Medicare $52.80 $66.00 195% of Medicare $53.46 $39.27 $39.27 $31.15 $66.00 100% of Medicare $52.80 $56.10 $59.40 $48.17 $56.10 $66.00 $66.00 100% of Medicare 100% of Medicare $66.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49126096 venlafaxine 150 mg ERCap 68084-0713-01 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 $20.11 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49127642 levetiracetam 100 mg/mL Oral Sol 50383-0241-06 INSTITUTIONAL $44.00 1/1/2022-12/31/2022 $44.00 $20.77 $25.08 $32.34 $32.34 $30.51 100% of Medicare $26.35 $25.36 $24.70 $28.16 100% of Medicaid 100% of Medicare 150% of Medicare $35.20 $44.00 195% of Medicare $35.64 $26.18 $26.18 $20.77 $44.00 100% of Medicare $35.20 $37.40 $39.60 $32.12 $37.40 $44.00 $44.00 100% of Medicare 100% of Medicare $44.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49127647 amantadine 50 mg/5 mL Oral Syrup 00121-0646-10 INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $7.55 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.58 $9.22 $8.98 $10.24 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.52 $9.52 $7.55 $16.00 100% of Medicare $12.80 $13.60 $14.40 $11.68 $13.60 $16.00 $16.00 100% of Medicare 100% of Medicare $16.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49151037 valproic acid 250 mg/5 mL Oral Syrup 00121-4675-55 INSTITUTIONAL $26.00 1/1/2022-12/31/2022 $26.00 $12.27 $14.82 $19.11 $19.11 $18.03 100% of Medicare $15.57 $14.99 $14.59 $16.64 100% of Medicaid 100% of Medicare 150% of Medicare $20.80 $26.00 195% of Medicare $21.06 $15.47 $15.47 $12.27 $26.00 100% of Medicare $20.80 $22.10 $23.40 $18.98 $22.10 $26.00 $26.00 100% of Medicare 100% of Medicare $26.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49187045 olanzapine 2.5 mg Tab 60505-3110-00 INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49259108 polyethylene glycol 3350 - Pow 11523-7268-03 INSTITUTIONAL $12.00 1/1/2022-12/31/2022 $12.00 $5.66 $6.84 $8.82 $8.82 $8.32 100% of Medicare $7.19 $6.92 $6.74 $7.68 100% of Medicaid 100% of Medicare 150% of Medicare $9.60 $12.00 195% of Medicare $9.72 $7.14 $7.14 $5.66 $12.00 100% of Medicare $9.60 $10.20 $10.80 $8.76 $10.20 $12.00 $12.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 636 NULL NULL NULL NULL 49320414 abobotulinumtoxinA 500 units Pow 15054-0500-01 INSTITUTIONAL " $3,356.00 " 1/1/2022-12/31/2022 " $3,020.40 " $975.00 " $1,912.92 " " $2,466.66 " " $2,466.66 " " $2,326.71 " 100% of Medicare " $2,009.57 " " $1,934.40 " " $1,883.72 " " $2,147.84 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,684.80 " " $1,500.00 " 195% of Medicare " $2,718.36 " " $1,996.82 " " $1,996.82 " " $1,584.03 " " $1,359.00 " 100% of Medicare " $2,684.80 " " $2,852.60 " " $3,020.40 " " $2,449.54 " " $2,852.60 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49356729 Phenol 6% Solution 6 % Soln 99999-9988-88 INSTITUTIONAL $128.00 1/1/2022-12/31/2022 $128.00 $60.42 $72.96 $94.08 $94.08 $88.74 100% of Medicare $76.65 $73.78 $71.85 $81.92 100% of Medicaid 100% of Medicare 150% of Medicare $102.40 $128.00 195% of Medicare $103.68 $76.16 $76.16 $60.42 $128.00 100% of Medicare $102.40 $108.80 $115.20 $93.43 $108.80 $128.00 $128.00 100% of Medicare 100% of Medicare $128.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49380871 gabapentin 300 mg Cap 50268-0348-15 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49386355 Opium 10mg/ml 10 mg/mL Soln 62559015304 - INSTITUTIONAL $18.00 1/1/2022-12/31/2022 $18.00 $8.50 $10.26 $13.23 $13.23 $12.48 100% of Medicare $10.78 $10.38 $10.10 $11.52 100% of Medicaid 100% of Medicare 150% of Medicare $14.40 $18.00 195% of Medicare $14.58 $10.71 $10.71 $8.50 $18.00 100% of Medicare $14.40 $15.30 $16.20 $13.14 $15.30 $18.00 $18.00 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49455672 1719040010H7L611 - Cefazolin 2g/50ml duplex sol 2g/50ml Soln-IV NULL INSTITUTIONAL $107.00 1/1/2022-12/31/2022 $107.00 $50.50 $60.99 $78.65 $78.65 $74.18 100% of Medicare $64.07 $61.67 $60.06 $68.48 100% of Medicaid 100% of Medicare 150% of Medicare $85.60 $107.00 195% of Medicare $86.67 $63.67 $63.67 $50.50 $107.00 100% of Medicare $85.60 $90.95 $96.30 $78.10 $90.95 $107.00 $107.00 100% of Medicare 100% of Medicare $107.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49516868 ticagrelor 60 mg Tab 00186-0776-60 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49517006 paliperidone 6 mg Tab 10147-0953-03 INSTITUTIONAL $68.00 1/1/2022-12/31/2022 $68.00 $32.10 $38.76 $49.98 $49.98 $47.14 100% of Medicare $40.72 $39.20 $38.17 $43.52 100% of Medicaid 100% of Medicare 150% of Medicare $54.40 $68.00 195% of Medicare $55.08 $40.46 $40.46 $32.10 $68.00 100% of Medicare $54.40 $57.80 $61.20 $49.63 $57.80 $68.00 $68.00 100% of Medicare 100% of Medicare $68.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49543254 fentaNYL 50 mcg/mL Sol 00409-9094-25 INSTITUTIONAL $15.00 1/1/2022-12/31/2022 $15.00 $7.08 $8.55 $11.03 $11.03 $10.40 100% of Medicare $8.98 $8.65 $8.42 $9.60 100% of Medicaid 100% of Medicare 150% of Medicare $12.00 $15.00 195% of Medicare $12.15 $8.93 $8.93 $7.08 $15.00 100% of Medicare $12.00 $12.75 $13.50 $10.95 $12.75 $15.00 $15.00 100% of Medicare 100% of Medicare $15.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49576770 mirabegron 25 mg Tab 00469-2601-30 INSTITUTIONAL $103.00 1/1/2022-12/31/2022 $103.00 $48.62 $58.71 $75.71 $75.71 $71.41 100% of Medicare $61.68 $59.37 $57.81 $65.92 100% of Medicaid 100% of Medicare 150% of Medicare $82.40 $103.00 195% of Medicare $83.43 $61.29 $61.29 $48.62 $103.00 100% of Medicare $82.40 $87.55 $92.70 $75.18 $87.55 $103.00 $103.00 100% of Medicare 100% of Medicare $103.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49576775 naloxegol 25 mg Tab 00310-1970-30 INSTITUTIONAL $90.00 1/1/2022-12/31/2022 $90.00 $42.48 $51.30 $66.15 $66.15 $62.40 100% of Medicare $53.89 $51.88 $50.52 $57.60 100% of Medicaid 100% of Medicare 150% of Medicare $72.00 $90.00 195% of Medicare $72.90 $53.55 $53.55 $42.48 $90.00 100% of Medicare $72.00 $76.50 $81.00 $65.69 $76.50 $90.00 $90.00 100% of Medicare 100% of Medicare $90.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49587419 oseltamivir 30mg cap 30 mg Cap 34778-14681-32 INSTITUTIONAL $31.00 1/1/2022-12/31/2022 $31.00 $14.63 $17.67 $22.79 $22.79 $21.49 100% of Medicare $18.56 $17.87 $17.40 $19.84 100% of Medicaid 100% of Medicare 150% of Medicare $24.80 $31.00 195% of Medicare $25.11 $18.45 $18.45 $14.63 $31.00 100% of Medicare $24.80 $26.35 $27.90 $22.63 $26.35 $31.00 $31.00 100% of Medicare 100% of Medicare $31.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49591087 0120705031003122 - surgicel fibrillar 1 EA Dressing NULL INSTITUTIONAL $728.00 1/1/2022-12/31/2022 $728.00 $343.62 $414.96 $535.08 $535.08 $504.72 100% of Medicare $435.93 $419.62 $408.63 $465.92 100% of Medicaid 100% of Medicare 150% of Medicare $582.40 $728.00 195% of Medicare $589.68 $433.16 $433.16 $343.62 $728.00 100% of Medicare $582.40 $618.80 $655.20 $531.37 $618.80 $728.00 $728.00 100% of Medicare 100% of Medicare $728.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49772651 Meningococcal B vaccine 4 -comp 0.5 mL Injection 58160097606 - INSTITUTIONAL $593.00 1/1/2022-12/31/2022 $593.00 $279.90 $338.01 $435.86 $435.86 $411.13 100% of Medicare $355.09 $341.81 $332.85 $379.52 100% of Medicaid 100% of Medicare 150% of Medicare $474.40 $593.00 195% of Medicare $480.33 $352.84 $352.84 $279.90 $593.00 100% of Medicare $474.40 $504.05 $533.70 $432.83 $504.05 $593.00 $593.00 100% of Medicare 100% of Medicare $593.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49778241 Alogliptin 12.5 mg Tab 45802010365 - INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49782500 Atazanavir 300 mg Cap 00093552856 - INSTITUTIONAL $117.00 1/1/2022-12/31/2022 $117.00 $55.22 $66.69 $86.00 $86.00 $81.12 100% of Medicare $70.06 $67.44 $65.67 $74.88 100% of Medicaid 100% of Medicare 150% of Medicare $93.60 $117.00 195% of Medicare $94.77 $69.62 $69.62 $55.22 $117.00 100% of Medicare $93.60 $99.45 $105.30 $85.40 $99.45 $117.00 $117.00 100% of Medicare 100% of Medicare $117.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49796314 Summers Eve Douche 1 EA Soln 41608-0087-47 INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49801910 emtricitabine-tenofovir 200 mg-25 mg Tab 61958-2002-01 INSTITUTIONAL $273.00 1/1/2022-12/31/2022 $273.00 $128.86 $155.61 $200.66 $200.66 $189.27 100% of Medicare $163.47 $157.36 $153.23 $174.72 100% of Medicaid 100% of Medicare 150% of Medicare $218.40 $273.00 195% of Medicare $221.13 $162.44 $162.44 $128.86 $273.00 100% of Medicare $218.40 $232.05 $245.70 $199.26 $232.05 $273.00 $273.00 100% of Medicare 100% of Medicare $273.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49805823 " Vital High Protein 1,000 mL Soln" 070074-630816 INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49847987 buPROPion 100 mg/12 hours Tab 43547-0288-10 INSTITUTIONAL $8.00 1/1/2022-12/31/2022 $8.00 $3.78 $4.56 $5.88 $5.88 $5.55 100% of Medicare $4.79 $4.61 $4.49 $5.12 100% of Medicaid 100% of Medicare 150% of Medicare $6.40 $8.00 195% of Medicare $6.48 $4.76 $4.76 $3.78 $8.00 100% of Medicare $6.40 $6.80 $7.20 $5.84 $6.80 $8.00 $8.00 100% of Medicare 100% of Medicare $8.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49850613 lipase - Dev 62205-0000-20 INSTITUTIONAL $445.00 1/1/2022-12/31/2022 $445.00 $210.04 $253.65 $327.08 $327.08 $308.52 100% of Medicare $266.47 $256.50 $249.78 $284.80 100% of Medicaid 100% of Medicare 150% of Medicare $356.00 $445.00 195% of Medicare $360.45 $264.78 $264.78 $210.04 $445.00 100% of Medicare $356.00 $378.25 $400.50 $324.81 $378.25 $445.00 $445.00 100% of Medicare 100% of Medicare $445.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49851183 colistimethate 150 mg (colistin base) Pow 39822-0617-02 INSTITUTIONAL $51.00 1/1/2022-12/31/2022 $51.00 $24.07 $29.07 $37.49 $37.49 $35.36 100% of Medicare $30.54 $29.40 $28.63 $32.64 100% of Medicaid 100% of Medicare 150% of Medicare $40.80 $51.00 195% of Medicare $41.31 $30.35 $30.35 $24.07 $51.00 100% of Medicare $40.80 $43.35 $45.90 $37.22 $43.35 $51.00 $51.00 100% of Medicare 100% of Medicare $51.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49858422 lacosamide injection 200 mg Injection 30131-18106-79 INSTITUTIONAL $793.00 1/1/2022-12/31/2022 $793.00 $374.30 $452.01 $582.86 $582.86 $549.79 100% of Medicare $474.85 $457.09 $445.11 $507.52 100% of Medicaid 100% of Medicare 150% of Medicare $634.40 $793.00 195% of Medicare $642.33 $471.84 $471.84 $374.30 $793.00 100% of Medicare $634.40 $674.05 $713.70 $578.81 $674.05 $793.00 $793.00 100% of Medicare 100% of Medicare $793.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49875447 Prolo Therapy 1 EA Injection 99999-9980-99 INSTITUTIONAL $29.00 1/1/2022-12/31/2022 $29.00 $13.69 $16.53 $21.32 $21.32 $20.11 100% of Medicare $17.37 $16.72 $16.28 $18.56 100% of Medicaid 100% of Medicare 150% of Medicare $23.20 $29.00 195% of Medicare $23.49 $17.26 $17.26 $13.69 $29.00 100% of Medicare $23.20 $24.65 $26.10 $21.17 $24.65 $29.00 $29.00 100% of Medicare 100% of Medicare $29.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49883754 Umeclidinium INH 62.5 mcg Inhaler 30173-08730-64 INSTITUTIONAL $556.00 1/1/2022-12/31/2022 $556.00 $262.43 $316.92 $408.66 $408.66 $385.47 100% of Medicare $332.93 $320.48 $312.08 $355.84 100% of Medicaid 100% of Medicare 150% of Medicare $444.80 $556.00 195% of Medicare $450.36 $330.82 $330.82 $262.43 $556.00 100% of Medicare $444.80 $472.60 $500.40 $405.82 $472.60 $556.00 $556.00 100% of Medicare 100% of Medicare $556.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49912775 Sacubitril-Valsartan 24 mg Tab 00078065920 - INSTITUTIONAL $69.00 1/1/2022-12/31/2022 $69.00 $32.57 $39.33 $50.72 $50.72 $47.84 100% of Medicare $41.32 $39.77 $38.73 $44.16 100% of Medicaid 100% of Medicare 150% of Medicare $55.20 $69.00 195% of Medicare $55.89 $41.06 $41.06 $32.57 $69.00 100% of Medicare $55.20 $58.65 $62.10 $50.36 $58.65 $69.00 $69.00 100% of Medicare 100% of Medicare $69.00 200% of Medicare NULL 250 NULL NULL NULL NULL 49962486 " penicillin G potassium 5,000,000 units Pow" 00049-0520-22 INSTITUTIONAL $103.00 1/1/2022-12/31/2022 $103.00 $48.62 $58.71 $75.71 $75.71 $71.41 100% of Medicare $61.68 $59.37 $57.81 $65.92 100% of Medicaid 100% of Medicare 150% of Medicare $82.40 $103.00 195% of Medicare $83.43 $61.29 $61.29 $48.62 $103.00 100% of Medicare $82.40 $87.55 $92.70 $75.18 $87.55 $103.00 $103.00 100% of Medicare 100% of Medicare $103.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50089359 Alogliptin 25 mg Tab 34580-21506-53 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50115871 Selenium 200 mcg Cap 40985021154 - INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50116170 Dextrose 4 % Gel 00574006930 - INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50118272 Multiple - Quinidine Solution 10 mg/mL Soln NULL INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $21.71 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.54 $26.51 $25.82 $29.44 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $27.37 $27.37 $21.71 $46.00 100% of Medicare $36.80 $39.10 $41.40 $33.58 $39.10 $46.00 $46.00 100% of Medicare 100% of Medicare $46.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50165525 alogliptin 6.25 mg Tab 45802-0087-65 INSTITUTIONAL $50.00 1/1/2022-12/31/2022 $50.00 $23.60 $28.50 $36.75 $36.75 $34.67 100% of Medicare $29.94 $28.82 $28.07 $32.00 100% of Medicaid 100% of Medicare 150% of Medicare $40.00 $50.00 195% of Medicare $40.50 $29.75 $29.75 $23.60 $50.00 100% of Medicare $40.00 $42.50 $45.00 $36.50 $42.50 $50.00 $50.00 100% of Medicare 100% of Medicare $50.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50219440 Copper 2 mg Cap 27434-0010-17 INSTITUTIONAL $3.00 1/1/2022-12/31/2022 $3.00 $1.42 $1.71 $2.21 $2.21 $2.08 100% of Medicare $1.80 $1.73 $1.68 $1.92 100% of Medicaid 100% of Medicare 150% of Medicare $2.40 $3.00 195% of Medicare $2.43 $1.79 $1.79 $1.42 $3.00 100% of Medicare $2.40 $2.55 $2.70 $2.19 $2.55 $3.00 $3.00 100% of Medicare 100% of Medicare $3.00 200% of Medicare NULL 310 NULL 86833 NULL NULL 50319244 Ab ID LEUKOCYTE Ab ADS CLASS 2 NULL INSTITUTIONAL " $1,378.00 " 1/1/2022-12/31/2022 " $1,378.00 " $576.00 $785.46 " $1,012.83 " " $1,012.83 " $955.37 100% of Medicare $810.40 $780.09 $759.69 $576.00 100% of Medicaid 100% of Medicare 150% of Medicare " $1,102.40 " " $1,378.00 " 195% of Medicare " $1,116.18 " $806.13 $806.13 $650.42 $886.61 100% of Medicare " $1,102.40 " " $1,171.30 " " $1,081.73 " " $1,005.80 " " $1,102.40 " " $1,171.30 " $947.38 100% of Medicare 100% of Medicare " $1,033.50 " 200% of Medicare NULL 250 NULL NULL NULL NULL 50335401 Palmer's Cocoa Butter 400 mL Lotion 10181-0041-65 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL NULL NULL NULL GO NULL 50342571 "OT Whirlpool, Fluidotherapy Assistant Units" NULL INSTITUTIONAL $664.00 1/1/2022-12/31/2022 $664.00 $313.41 $378.48 $488.04 $488.04 $460.35 100% of Medicare $397.60 $382.73 $372.70 $424.96 100% of Medicaid 100% of Medicare 150% of Medicare $531.20 $664.00 195% of Medicare $537.84 $395.08 $395.08 $313.41 $664.00 100% of Medicare $531.20 $564.40 $597.60 $484.65 $564.40 $664.00 $664.00 100% of Medicare 100% of Medicare $664.00 200% of Medicare NULL 430 NULL 97026 CO NULL 50342591 OT Infrared Assistant Units NULL INSTITUTIONAL $643.00 1/1/2022-12/31/2022 $643.00 $268.77 $366.51 $472.61 $472.61 $445.79 100% of Medicare $378.15 $364.00 $354.49 $268.77 100% of Medicaid 100% of Medicare 150% of Medicare $514.40 $643.00 195% of Medicare $520.83 $376.16 $376.16 $303.50 $413.71 100% of Medicare $514.40 $546.55 $504.76 $469.33 $514.40 $546.55 $442.06 100% of Medicare 100% of Medicare $482.25 200% of Medicare NULL 420 NULL 97763 CO NULL 50349009 Ot Orthotic Mgmt/Train Establish Assistant Units NULL INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $67.30 $91.77 $118.34 $118.34 $111.62 100% of Medicare $94.68 $91.14 $88.76 $67.30 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $94.19 $94.19 $75.99 $103.59 100% of Medicare $128.80 $136.85 $126.39 $117.51 $128.80 $136.85 $110.69 100% of Medicare 100% of Medicare $120.75 200% of Medicare NULL 430 NULL 97610 CO NULL 50349047 OT Non-Thermal/Contact Ultrasound Assistant Units NULL INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $67.30 $91.77 $118.34 $118.34 $111.62 100% of Medicare $94.68 $91.14 $88.76 $67.30 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $94.19 $94.19 $75.99 $103.59 100% of Medicare $128.80 $136.85 $126.39 $117.51 $128.80 $136.85 $110.69 100% of Medicare 100% of Medicare $120.75 200% of Medicare NULL 430 NULL 29581 CO NULL 50349051 OT Multi-Layer Compress Below Knee Assistant Units NULL INSTITUTIONAL $161.00 1/1/2022-12/31/2022 $161.00 $67.30 $91.77 $118.34 $118.34 $111.62 100% of Medicare $94.68 $91.14 $88.76 $67.30 100% of Medicaid 100% of Medicare 150% of Medicare $128.80 $161.00 195% of Medicare $130.41 $94.19 $94.19 $75.99 $103.59 100% of Medicare $128.80 $136.85 $126.39 $117.51 $128.80 $136.85 $110.69 100% of Medicare 100% of Medicare $120.75 200% of Medicare NULL 250 NULL NULL NULL NULL 50356188 MICONAZOLE 2 % Spray 69502-0001-57 INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 $27.73 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50356247 tadalafil 20 mg Tab 65862-0880-60 INSTITUTIONAL $484.00 1/1/2022-12/31/2022 $484.00 $228.45 $275.88 $355.74 $355.74 $335.56 100% of Medicare $289.82 $278.98 $271.67 $309.76 100% of Medicaid 100% of Medicare 150% of Medicare $387.20 $484.00 195% of Medicare $392.04 $287.98 $287.98 $228.45 $484.00 100% of Medicare $387.20 $411.40 $435.60 $353.27 $411.40 $484.00 $484.00 100% of Medicare 100% of Medicare $484.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50429722 umeclidinium/ vilanterol inh powder 62.5/ 25mcg Inh-Oral Disk 01003-01730-869 INSTITUTIONAL $451.00 1/1/2022-12/31/2022 $451.00 $212.87 $257.07 $331.49 $331.49 $312.68 100% of Medicare $270.06 $259.96 $253.15 $288.64 100% of Medicaid 100% of Medicare 150% of Medicare $360.80 $451.00 195% of Medicare $365.31 $268.35 $268.35 $212.87 $451.00 100% of Medicare $360.80 $383.35 $405.90 $329.18 $383.35 $451.00 $451.00 100% of Medicare 100% of Medicare $451.00 200% of Medicare NULL 310 NULL 85576 NULL NULL 50478335 Platelet Inhibition (P2Y12) NULL INSTITUTIONAL $103.00 1/1/2022-12/31/2022 $103.00 $43.05 $58.71 $75.71 $75.71 $71.41 100% of Medicare $60.57 $58.31 $56.78 $43.05 100% of Medicaid 100% of Medicare 150% of Medicare $82.40 $103.00 195% of Medicare $83.43 $60.26 $60.26 $48.62 $66.27 100% of Medicare $82.40 $87.55 $80.86 $75.18 $82.40 $87.55 $70.81 100% of Medicare 100% of Medicare $77.25 200% of Medicare NULL 636 NULL NULL NULL NULL 50479147 baclofen 2 mg/mL Sol 66794-0157-02 INSTITUTIONAL " $3,009.00 " 1/1/2022-12/31/2022 " $2,708.10 " $975.00 " $1,715.13 " " $2,211.62 " " $2,211.62 " " $2,086.14 " 100% of Medicare " $1,801.79 " " $1,734.39 " " $1,688.95 " " $1,925.76 " 100% of Medicaid 100% of Medicare 150% of Medicare " $2,407.20 " " $1,500.00 " 195% of Medicare " $2,437.29 " " $1,790.36 " " $1,790.36 " " $1,420.25 " " $1,359.00 " 100% of Medicare " $2,407.20 " " $2,557.65 " " $2,708.10 " " $2,196.27 " " $2,557.65 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 310 NULL 87305 NULL NULL 50489894 Aspergillus Galactomannan Antigen EIA NULL INSTITUTIONAL $55.00 1/1/2022-12/31/2022 $55.00 $22.99 $31.35 $40.43 $40.43 $38.13 100% of Medicare $32.35 $31.14 $30.32 $22.99 100% of Medicaid 100% of Medicare 150% of Medicare $44.00 $55.00 195% of Medicare $44.55 $32.18 $32.18 $25.96 $35.39 100% of Medicare $44.00 $46.75 $43.18 $40.14 $44.00 $46.75 $37.81 100% of Medicare 100% of Medicare $41.25 200% of Medicare NULL 310 NULL 80299 NULL NULL 50491575 Voriconazole Level Quantification/LCMS NULL INSTITUTIONAL $77.00 1/1/2022-12/31/2022 $77.00 $32.19 $43.89 $56.60 $56.60 $53.38 100% of Medicare $45.28 $43.59 $42.45 $32.19 100% of Medicaid 100% of Medicare 150% of Medicare $61.60 $77.00 195% of Medicare $62.37 $45.05 $45.05 $36.34 $49.54 100% of Medicare $61.60 $65.45 $60.45 $56.20 $61.60 $65.45 $52.94 100% of Medicare 100% of Medicare $57.75 200% of Medicare NULL 310 NULL 84588 NULL NULL 50491576 Arginine Vasopressin Hormone Pl QN NULL INSTITUTIONAL $155.00 1/1/2022-12/31/2022 $155.00 $64.79 $88.35 $113.93 $113.93 $107.46 100% of Medicare $91.16 $87.75 $85.45 $64.79 100% of Medicaid 100% of Medicare 150% of Medicare $124.00 $155.00 195% of Medicare $125.55 $90.68 $90.68 $73.16 $99.73 100% of Medicare $124.00 $131.75 $121.68 $113.13 $124.00 $131.75 $106.56 100% of Medicare 100% of Medicare $116.25 200% of Medicare NULL 310 NULL 82575 NULL NULL 50494598 Creatinine SerPl QN NULL INSTITUTIONAL $43.00 1/1/2022-12/31/2022 $43.00 $17.97 $24.51 $31.61 $31.61 $29.81 100% of Medicare $25.29 $24.34 $23.71 $17.97 100% of Medicaid 100% of Medicare 150% of Medicare $34.40 $43.00 195% of Medicare $34.83 $25.16 $25.16 $20.30 $27.67 100% of Medicare $34.40 $36.55 $33.76 $31.39 $34.40 $36.55 $29.56 100% of Medicare 100% of Medicare $32.25 200% of Medicare NULL 310 NULL 81050 NULL NULL 50494599 Timed Urine Volume + Period NULL INSTITUTIONAL $16.00 1/1/2022-12/31/2022 $16.00 $6.69 $9.12 $11.76 $11.76 $11.09 100% of Medicare $9.41 $9.06 $8.82 $6.69 100% of Medicaid 100% of Medicare 150% of Medicare $12.80 $16.00 195% of Medicare $12.96 $9.36 $9.36 $7.55 $10.29 100% of Medicare $12.80 $13.60 $12.56 $11.68 $12.80 $13.60 $11.00 100% of Medicare 100% of Medicare $12.00 200% of Medicare NULL 310 NULL 82565 NULL NULL 50494600 Creatinine Clearance Urine Tm NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $10.03 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.11 $13.59 $13.23 $10.03 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.04 $14.04 $11.33 $15.44 100% of Medicare $19.20 $20.40 $18.84 $17.52 $19.20 $20.40 $16.50 100% of Medicare 100% of Medicare $18.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50495944 brivaracetam 100 mg Tab 50474-0770-66 INSTITUTIONAL $86.00 1/1/2022-12/31/2022 $86.00 $40.59 $49.02 $63.21 $63.21 $59.62 100% of Medicare $51.50 $49.57 $48.27 $55.04 100% of Medicaid 100% of Medicare 150% of Medicare $68.80 $86.00 195% of Medicare $69.66 $51.17 $51.17 $40.59 $86.00 100% of Medicare $68.80 $73.10 $77.40 $62.77 $73.10 $86.00 $86.00 100% of Medicare 100% of Medicare $86.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50514489 Suplena 240 mL Soln-Oral 70074067494 - INSTITUTIONAL $6.00 1/1/2022-12/31/2022 $6.00 $2.83 $3.42 $4.41 $4.41 $4.16 100% of Medicare $3.59 $3.46 $3.37 $3.84 100% of Medicaid 100% of Medicare 150% of Medicare $4.80 $6.00 195% of Medicare $4.86 $3.57 $3.57 $2.83 $6.00 100% of Medicare $4.80 $5.10 $5.40 $4.38 $5.10 $6.00 $6.00 100% of Medicare 100% of Medicare $6.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50517865 "Electrolye Solution 1,000 mL Soln-Oral" 09629-51381-60 INSTITUTIONAL $2.00 1/1/2022-12/31/2022 $2.00 $0.94 $1.14 $1.47 $1.47 $1.39 100% of Medicare $1.20 $1.15 $1.12 $1.28 100% of Medicaid 100% of Medicare 150% of Medicare $1.60 $2.00 195% of Medicare $1.62 $1.19 $1.19 $0.94 $2.00 100% of Medicare $1.60 $1.70 $1.80 $1.46 $1.70 $2.00 $2.00 100% of Medicare 100% of Medicare $2.00 200% of Medicare NULL 310 NULL 84165 NULL NULL 50521730 Protein Electrophoresis Ser QN NULL INSTITUTIONAL $49.00 1/1/2022-12/31/2022 $49.00 $20.48 $27.93 $36.02 $36.02 $33.97 100% of Medicare $28.82 $27.74 $27.01 $20.48 100% of Medicaid 100% of Medicare 150% of Medicare $39.20 $49.00 195% of Medicare $39.69 $28.67 $28.67 $23.13 $31.53 100% of Medicare $39.20 $41.65 $38.47 $35.77 $39.20 $41.65 $33.69 100% of Medicare 100% of Medicare $36.75 200% of Medicare NULL 310 NULL 84155 NULL NULL 50521740 Total Protein NULL INSTITUTIONAL $17.00 1/1/2022-12/31/2022 $17.00 $7.11 $9.69 $12.50 $12.50 $11.79 100% of Medicare $10.00 $9.62 $9.37 $7.11 100% of Medicaid 100% of Medicare 150% of Medicare $13.60 $17.00 195% of Medicare $13.77 $9.95 $9.95 $8.02 $10.94 100% of Medicare $13.60 $14.45 $13.35 $12.41 $13.60 $14.45 $11.69 100% of Medicare 100% of Medicare $12.75 200% of Medicare NULL 250 NULL NULL NULL NULL 50551598 gabapentin 250mg/5ml UD 250 mg / 5 mL Soln 35038-33110-58 INSTITUTIONAL $13.00 1/1/2022-12/31/2022 $13.00 $6.14 $7.41 $9.56 $9.56 $9.01 100% of Medicare $7.78 $7.49 $7.30 $8.32 100% of Medicaid 100% of Medicare 150% of Medicare $10.40 $13.00 195% of Medicare $10.53 $7.74 $7.74 $6.14 $13.00 100% of Medicare $10.40 $11.05 $11.70 $9.49 $11.05 $13.00 $13.00 100% of Medicare 100% of Medicare $13.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50551794 Hydroxyprogesterone Caproate 250 mg Vial 00517-1791-01 INSTITUTIONAL $537.00 1/1/2022-12/31/2022 $537.00 $253.46 $306.09 $394.70 $394.70 $372.30 100% of Medicare $321.56 $309.53 $301.42 $343.68 100% of Medicaid 100% of Medicare 150% of Medicare $429.60 $537.00 195% of Medicare $434.97 $319.52 $319.52 $253.46 $537.00 100% of Medicare $429.60 $456.45 $483.30 $391.96 $456.45 $537.00 $537.00 100% of Medicare 100% of Medicare $537.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50558998 Pivot 1.5 1.5 Soln-Oral 70074065007 - INSTITUTIONAL $7.00 1/1/2022-12/31/2022 $7.00 $3.30 $3.99 $5.15 $5.15 $4.85 100% of Medicare $4.19 $4.03 $3.93 $4.48 100% of Medicaid 100% of Medicare 150% of Medicare $5.60 $7.00 195% of Medicare $5.67 $4.17 $4.17 $3.30 $7.00 100% of Medicare $5.60 $5.95 $6.30 $5.11 $5.95 $7.00 $7.00 100% of Medicare 100% of Medicare $7.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50601449 letermovir 240 mg Tab 00006-3075-04 INSTITUTIONAL $917.00 1/1/2022-12/31/2022 $917.00 $432.82 $522.69 $674.00 $674.00 $635.76 100% of Medicare $549.10 $528.56 $514.71 $586.88 100% of Medicaid 100% of Medicare 150% of Medicare $733.60 $917.00 195% of Medicare $742.77 $545.62 $545.62 $432.82 $917.00 100% of Medicare $733.60 $779.45 $825.30 $669.32 $779.45 $917.00 $917.00 100% of Medicare 100% of Medicare $917.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50618733 nutritional supplement 1 packet Packet 59781-0225-57 INSTITUTIONAL $11.00 1/1/2022-12/31/2022 $11.00 $5.19 $6.27 $8.09 $8.09 $7.63 100% of Medicare $6.59 $6.34 $6.17 $7.04 100% of Medicaid 100% of Medicare 150% of Medicare $8.80 $11.00 195% of Medicare $8.91 $6.55 $6.55 $5.19 $11.00 100% of Medicare $8.80 $9.35 $9.90 $8.03 $9.35 $11.00 $11.00 100% of Medicare 100% of Medicare $11.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50642104 Zinc Oxide Spray 25% 25 % Spray-Top 50600-77231-825 INSTITUTIONAL $39.00 1/1/2022-12/31/2022 $39.00 $18.41 $22.23 $28.67 $28.67 $27.04 100% of Medicare $23.35 $22.48 $21.89 $24.96 100% of Medicaid 100% of Medicare 150% of Medicare $31.20 $39.00 195% of Medicare $31.59 $23.21 $23.21 $18.41 $39.00 100% of Medicare $31.20 $33.15 $35.10 $28.47 $33.15 $39.00 $39.00 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 999 NULL NULL NULL NULL 50649762 VR Psychotherapy NULL INSTITUTIONAL $101.00 1/1/2022-12/31/2022 $101.00 $47.67 $57.57 $74.24 $74.24 $70.02 100% of Medicare $60.48 $58.22 $56.69 $64.64 100% of Medicaid 100% of Medicare 150% of Medicare $80.80 $101.00 195% of Medicare $81.81 $60.10 $60.10 $47.67 $101.00 100% of Medicare $80.80 $85.85 $90.90 $73.72 $85.85 $101.00 $101.00 100% of Medicare 100% of Medicare $101.00 200% of Medicare NULL 272 NULL NULL NULL NULL 50651275 Anasept Antimicrobial Wound Cleanser NULL INSTITUTIONAL $27.00 1/1/2022-12/31/2022 $27.00 $12.74 $15.39 $19.85 $19.85 $18.72 100% of Medicare $16.17 $15.56 $15.16 $17.28 100% of Medicaid 100% of Medicare 150% of Medicare $21.60 $27.00 195% of Medicare $21.87 $16.07 $16.07 $12.74 $27.00 100% of Medicare $21.60 $22.95 $24.30 $19.71 $22.95 $27.00 $27.00 100% of Medicare 100% of Medicare $27.00 200% of Medicare NULL 272 NULL NULL NULL NULL 50651276 Kerra Foam Heal Dressing NULL INSTITUTIONAL $38.00 1/1/2022-12/31/2022 $38.00 $17.94 $21.66 $27.93 $27.93 $26.35 100% of Medicare $22.75 $21.90 $21.33 $24.32 100% of Medicaid 100% of Medicare 150% of Medicare $30.40 $38.00 195% of Medicare $30.78 $22.61 $22.61 $17.94 $38.00 100% of Medicare $30.40 $32.30 $34.20 $27.74 $32.30 $38.00 $38.00 100% of Medicare 100% of Medicare $38.00 200% of Medicare NULL 272 NULL NULL NULL NULL 50651277 Below Knee Amputee Rigid Dressing 21 in NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $187.38 $226.29 $291.80 $291.80 $275.24 100% of Medicare $237.72 $228.83 $222.84 $254.08 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $236.22 $236.22 $187.38 $397.00 100% of Medicare $317.60 $337.45 $357.30 $289.77 $337.45 $397.00 $397.00 100% of Medicare 100% of Medicare $397.00 200% of Medicare NULL 272 NULL NULL NULL NULL 50651278 Below Knee Amputee Rigid Dressing 15 in NULL INSTITUTIONAL $397.00 1/1/2022-12/31/2022 $397.00 $187.38 $226.29 $291.80 $291.80 $275.24 100% of Medicare $237.72 $228.83 $222.84 $254.08 100% of Medicaid 100% of Medicare 150% of Medicare $317.60 $397.00 195% of Medicare $321.57 $236.22 $236.22 $187.38 $397.00 100% of Medicare $317.60 $337.45 $357.30 $289.77 $337.45 $397.00 $397.00 100% of Medicare 100% of Medicare $397.00 200% of Medicare NULL 272 NULL NULL NULL NULL 50651279 Brava Barrier Elastic Strip NULL INSTITUTIONAL $10.00 1/1/2022-12/31/2022 $10.00 $4.72 $5.70 $7.35 $7.35 $6.93 100% of Medicare $5.99 $5.76 $5.61 $6.40 100% of Medicaid 100% of Medicare 150% of Medicare $8.00 $10.00 195% of Medicare $8.10 $5.95 $5.95 $4.72 $10.00 100% of Medicare $8.00 $8.50 $9.00 $7.30 $8.50 $10.00 $10.00 100% of Medicare 100% of Medicare $10.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50660419 gadobutrol 1mmol/mL Sol 50419-0325-37 INSTITUTIONAL $120.00 1/1/2022-12/31/2022 $120.00 $56.64 $68.40 $88.20 $88.20 $83.20 100% of Medicare $71.86 $69.17 $67.36 $76.80 100% of Medicaid 100% of Medicare 150% of Medicare $96.00 $120.00 195% of Medicare $97.20 $71.40 $71.40 $56.64 $120.00 100% of Medicare $96.00 $102.00 $108.00 $87.59 $102.00 $120.00 $120.00 100% of Medicare 100% of Medicare $120.00 200% of Medicare NULL 310 NULL 87385 NULL NULL 50688415 Histoplasma Antigen QN NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 310 NULL 80299 NULL NULL 50688416 "Itraconazole, Quantitative/LC-MS" NULL INSTITUTIONAL $106.00 1/1/2022-12/31/2022 $106.00 $44.31 $60.42 $77.91 $77.91 $73.49 100% of Medicare $62.34 $60.01 $58.44 $44.31 100% of Medicaid 100% of Medicare 150% of Medicare $84.80 $106.00 195% of Medicare $85.86 $62.01 $62.01 $50.03 $68.20 100% of Medicare $84.80 $90.10 $83.21 $77.37 $84.80 $90.10 $72.88 100% of Medicare 100% of Medicare $79.50 200% of Medicare NULL 310 NULL 82542 NULL NULL 50688417 PTH Related Peptide NULL INSTITUTIONAL $100.00 1/1/2022-12/31/2022 $100.00 $41.80 $57.00 $73.50 $73.50 $69.33 100% of Medicare $58.81 $56.61 $55.13 $41.80 100% of Medicaid 100% of Medicare 150% of Medicare $80.00 $100.00 195% of Medicare $81.00 $58.50 $58.50 $47.20 $64.34 100% of Medicare $80.00 $85.00 $78.50 $72.99 $80.00 $85.00 $68.75 100% of Medicare 100% of Medicare $75.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50711534 Empagliflozin 10 mg Tab 30597-0152-30 INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 $97.06 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50713560 empagliflozin 25 mg Tab 00597-0153-30 INSTITUTIONAL $140.00 1/1/2022-12/31/2022 $140.00 $66.08 $79.80 $102.90 $102.90 $97.06 100% of Medicare $83.83 $80.70 $78.58 $89.60 100% of Medicaid 100% of Medicare 150% of Medicare $112.00 $140.00 195% of Medicare $113.40 $83.30 $83.30 $66.08 $140.00 100% of Medicare $112.00 $119.00 $126.00 $102.19 $119.00 $140.00 $140.00 100% of Medicare 100% of Medicare $140.00 200% of Medicare NULL 510 NULL 20611 NULL NULL 50716315 "Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, su" NULL INSTITUTIONAL $852.00 1/1/2022-12/31/2022 $852.00 $356.14 $485.64 $626.22 $626.22 $590.69 100% of Medicare $501.06 $482.32 $469.71 $356.14 100% of Medicaid 100% of Medicare 150% of Medicare $681.60 $852.00 195% of Medicare $690.12 $498.42 $498.42 $402.14 $548.18 100% of Medicare $681.60 $724.20 $668.82 $621.87 $681.60 $724.20 $585.75 100% of Medicare 100% of Medicare $639.00 200% of Medicare NULL 310 NULL 87086 NULL NULL 50725191 Urinalysis with Culture Reflex NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $26.75 $36.48 $47.04 $47.04 $44.37 100% of Medicare $37.64 $36.23 $35.28 $26.75 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $37.44 $37.44 $30.21 $41.18 100% of Medicare $51.20 $54.40 $50.24 $46.71 $51.20 $54.40 $44.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 310 NULL 86039 NULL NULL 50730289 Antinuclear Antibody IFA w/Rflex NULL INSTITUTIONAL $52.00 1/1/2022-12/31/2022 $52.00 $21.74 $29.64 $38.22 $38.22 $36.05 100% of Medicare $30.58 $29.44 $28.67 $21.74 100% of Medicaid 100% of Medicare 150% of Medicare $41.60 $52.00 195% of Medicare $42.12 $30.42 $30.42 $24.54 $33.46 100% of Medicare $41.60 $44.20 $40.82 $37.95 $41.60 $44.20 $35.75 100% of Medicare 100% of Medicare $39.00 200% of Medicare NULL 310 NULL 86235 NULL NULL 50730313 EXTRACT NUCL AG RNP NULL INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $34.69 $47.31 $61.01 $61.01 $57.54 100% of Medicare $48.81 $46.99 $45.76 $34.69 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $48.56 $48.56 $39.18 $53.40 100% of Medicare $66.40 $70.55 $65.16 $60.58 $66.40 $70.55 $57.06 100% of Medicare 100% of Medicare $62.25 200% of Medicare NULL 310 NULL 86235 NULL NULL 50730318 EXTRACTABLE NUCL EAR AG SC170 NULL INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $34.69 $47.31 $61.01 $61.01 $57.54 100% of Medicare $48.81 $46.99 $45.76 $34.69 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $48.56 $48.56 $39.18 $53.40 100% of Medicare $66.40 $70.55 $65.16 $60.58 $66.40 $70.55 $57.06 100% of Medicare 100% of Medicare $62.25 200% of Medicare NULL 310 NULL 86235 NULL NULL 50730323 EXTRACT NUCL AG SMITH NULL INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $34.69 $47.31 $61.01 $61.01 $57.54 100% of Medicare $48.81 $46.99 $45.76 $34.69 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $48.56 $48.56 $39.18 $53.40 100% of Medicare $66.40 $70.55 $65.16 $60.58 $66.40 $70.55 $57.06 100% of Medicare 100% of Medicare $62.25 200% of Medicare NULL 310 NULL 86235 NULL NULL 50730324 EXTRACT NUCL AG SS-A NULL INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $34.69 $47.31 $61.01 $61.01 $57.54 100% of Medicare $48.81 $46.99 $45.76 $34.69 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $48.56 $48.56 $39.18 $53.40 100% of Medicare $66.40 $70.55 $65.16 $60.58 $66.40 $70.55 $57.06 100% of Medicare 100% of Medicare $62.25 200% of Medicare NULL 310 NULL 86235 NULL NULL 50730325 EXTRACT NUCL AG SS-B NULL INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $34.69 $47.31 $61.01 $61.01 $57.54 100% of Medicare $48.81 $46.99 $45.76 $34.69 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $48.56 $48.56 $39.18 $53.40 100% of Medicare $66.40 $70.55 $65.16 $60.58 $66.40 $70.55 $57.06 100% of Medicare 100% of Medicare $62.25 200% of Medicare NULL 310 NULL 86225 NULL NULL 50730326 ANTI DBL STRAND DNA C LUCILAE NULL INSTITUTIONAL $64.00 1/1/2022-12/31/2022 $64.00 $26.75 $36.48 $47.04 $47.04 $44.37 100% of Medicare $37.64 $36.23 $35.28 $26.75 100% of Medicaid 100% of Medicare 150% of Medicare $51.20 $64.00 195% of Medicare $51.84 $37.44 $37.44 $30.21 $41.18 100% of Medicare $51.20 $54.40 $50.24 $46.71 $51.20 $54.40 $44.00 100% of Medicare 100% of Medicare $48.00 200% of Medicare NULL 310 NULL 83516 NULL NULL 50730327 IMMUNOASSAY NOT INFECTIOUS AGT NULL INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $22.15 $30.21 $38.96 $38.96 $36.74 100% of Medicare $31.17 $30.00 $29.22 $22.15 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.01 $31.01 $25.02 $34.10 100% of Medicare $42.40 $45.05 $41.61 $38.68 $42.40 $45.05 $36.44 100% of Medicare 100% of Medicare $39.75 200% of Medicare NULL 310 NULL 86256 NULL NULL 50730328 ANTIBODY NEUTROPHIL CYTO TITER NULL INSTITUTIONAL $57.00 1/1/2022-12/31/2022 $57.00 $23.83 $32.49 $41.90 $41.90 $39.52 100% of Medicare $33.52 $32.27 $31.42 $23.83 100% of Medicaid 100% of Medicare 150% of Medicare $45.60 $57.00 195% of Medicare $46.17 $33.35 $33.35 $26.90 $36.67 100% of Medicare $45.60 $48.45 $44.75 $41.60 $45.60 $48.45 $39.19 100% of Medicare 100% of Medicare $42.75 200% of Medicare NULL 310 NULL 86235 NULL NULL 50730329 "PM/ScI-100 Ab, IgG SO" NULL INSTITUTIONAL $83.00 1/1/2022-12/31/2022 $83.00 $34.69 $47.31 $61.01 $61.01 $57.54 100% of Medicare $48.81 $46.99 $45.76 $34.69 100% of Medicaid 100% of Medicare 150% of Medicare $66.40 $83.00 195% of Medicare $67.23 $48.56 $48.56 $39.18 $53.40 100% of Medicare $66.40 $70.55 $65.16 $60.58 $66.40 $70.55 $57.06 100% of Medicare 100% of Medicare $62.25 200% of Medicare NULL 250 NULL NULL NULL NULL 50734743 vancomycin 750 mg/150 mL Sol 70594-0056-03 INSTITUTIONAL " $17,280.00 " 1/1/2022-12/31/2022 " $15,552.00 " $975.00 " $9,849.60 " " $12,700.80 " " $12,700.80 " " $11,980.22 " 100% of Medicare " $10,347.26 " " $9,960.19 " " $9,699.26 " " $11,059.20 " 100% of Medicaid 100% of Medicare 150% of Medicare " $13,824.00 " " $1,500.00 " 195% of Medicare " $13,996.80 " " $10,281.60 " " $10,281.60 " " $8,156.16 " " $1,359.00 " 100% of Medicare " $13,824.00 " " $14,688.00 " " $15,552.00 " " $12,612.67 " " $14,688.00 " " $1,500.00 " " $2,635.00 " 100% of Medicare 100% of Medicare $975.00 200% of Medicare NULL 310 NULL 87305 NULL NULL 50740966 "Aspergillus Galactomannan Ag EIA, Serum" NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 310 NULL 87305 NULL NULL 50740967 "Aspergillus Galactomannan Ag EIA, CSF" NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 310 NULL 87305 NULL NULL 50740968 "Aspergillus Galactomannan Ag EIA, BAL" NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50741394 nutritional supplement 1 EA Soln-Oral 88899-0097-67 INSTITUTIONAL $9.00 1/1/2022-12/31/2022 $9.00 $4.25 $5.13 $6.62 $6.62 $6.24 100% of Medicare $5.39 $5.19 $5.05 $5.76 100% of Medicaid 100% of Medicare 150% of Medicare $7.20 $9.00 195% of Medicare $7.29 $5.36 $5.36 $4.25 $9.00 100% of Medicare $7.20 $7.65 $8.10 $6.57 $7.65 $9.00 $9.00 100% of Medicare 100% of Medicare $9.00 200% of Medicare NULL 310 NULL 87341 NULL NULL 50744774 Hepatitis B Surface Ag Confirmation. NULL INSTITUTIONAL $41.00 1/1/2022-12/31/2022 $41.00 $17.14 $23.37 $30.14 $30.14 $28.43 100% of Medicare $24.11 $23.21 $22.60 $17.14 100% of Medicaid 100% of Medicare 150% of Medicare $32.80 $41.00 195% of Medicare $33.21 $23.99 $23.99 $19.35 $26.38 100% of Medicare $32.80 $34.85 $32.19 $29.93 $32.80 $34.85 $28.19 100% of Medicare 100% of Medicare $30.75 200% of Medicare NULL 310 NULL 87340 NULL NULL 50744780 87340 NULL INSTITUTIONAL $48.00 1/1/2022-12/31/2022 $48.00 $20.06 $27.36 $35.28 $35.28 $33.28 100% of Medicare $28.23 $27.17 $26.46 $20.06 100% of Medicaid 100% of Medicare 150% of Medicare $38.40 $48.00 195% of Medicare $38.88 $28.08 $28.08 $22.66 $30.88 100% of Medicare $38.40 $40.80 $37.68 $35.04 $38.40 $40.80 $33.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 272 NULL NULL NULL NULL 50745560 "TRAY, CNTAL LINE DRESSING KIT" NULL INSTITUTIONAL $40.00 1/1/2022-12/31/2022 $40.00 $18.88 $22.80 $29.40 $29.40 $27.73 100% of Medicare $23.95 $23.06 $22.45 $25.60 100% of Medicaid 100% of Medicare 150% of Medicare $32.00 $40.00 195% of Medicare $32.40 $23.80 $23.80 $18.88 $40.00 100% of Medicare $32.00 $34.00 $36.00 $29.20 $34.00 $40.00 $40.00 100% of Medicare 100% of Medicare $40.00 200% of Medicare NULL 272 NULL NULL NULL NULL 50745561 KERRAFORM SACRUM DRESSING 6X6 NULL INSTITUTIONAL $24.00 1/1/2022-12/31/2022 $24.00 $11.33 $13.68 $17.64 $17.64 $16.64 100% of Medicare $14.37 $13.83 $13.47 $15.36 100% of Medicaid 100% of Medicare 150% of Medicare $19.20 $24.00 195% of Medicare $19.44 $14.28 $14.28 $11.33 $24.00 100% of Medicare $19.20 $20.40 $21.60 $17.52 $20.40 $24.00 $24.00 100% of Medicare 100% of Medicare $24.00 200% of Medicare NULL 272 NULL NULL NULL NULL 50745562 Kerraform 9x10 NULL INSTITUTIONAL $36.00 1/1/2022-12/31/2022 $36.00 $16.99 $20.52 $26.46 $26.46 $24.96 100% of Medicare $21.56 $20.75 $20.21 $23.04 100% of Medicaid 100% of Medicare 150% of Medicare $28.80 $36.00 195% of Medicare $29.16 $21.42 $21.42 $16.99 $36.00 100% of Medicare $28.80 $30.60 $32.40 $26.28 $30.60 $36.00 $36.00 100% of Medicare 100% of Medicare $36.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50750901 entecavir 0.5 mg Tabs 51991-0895-33 INSTITUTIONAL $267.00 1/1/2022-12/31/2022 $267.00 $126.02 $152.19 $196.25 $196.25 $185.11 100% of Medicare $159.88 $153.90 $149.87 $170.88 100% of Medicaid 100% of Medicare 150% of Medicare $213.60 $267.00 195% of Medicare $216.27 $158.87 $158.87 $126.02 $267.00 100% of Medicare $213.60 $226.95 $240.30 $194.88 $226.95 $267.00 $267.00 100% of Medicare 100% of Medicare $267.00 200% of Medicare NULL 310 NULL 86480 NULL NULL 50763318 QuantiFERON-TB Gold NULL INSTITUTIONAL $390.00 1/1/2022-12/31/2022 $390.00 $163.02 $222.30 $286.65 $286.65 $270.39 100% of Medicare $229.36 $220.78 $215.01 $163.02 100% of Medicaid 100% of Medicare 150% of Medicare $312.00 $390.00 195% of Medicare $315.90 $228.15 $228.15 $184.08 $250.93 100% of Medicare $312.00 $331.50 $306.15 $284.66 $312.00 $331.50 $268.13 100% of Medicare 100% of Medicare $292.50 200% of Medicare NULL 310 NULL 86331 NULL NULL 50776384 Hypersensitivity Pneumonitis 2 NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 310 NULL 86331 NULL NULL 50776392 86331 NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 310 NULL 86606 NULL NULL 50776394 86606(a) NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 310 NULL 86606 NULL NULL 50776395 86606(b) NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 310 NULL 86606 NULL NULL 50776396 86606(c) NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 310 NULL 86331 NULL NULL 50776419 86331(a) NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 310 NULL 86331 NULL NULL 50776420 86331(b) NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 310 NULL 86331 NULL NULL 50776421 86331(c) NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 311 NULL 86606 NULL NULL 50776422 86606(d) NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 310 NULL 86606 NULL NULL 50776423 86606(e) NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 310 NULL 86331 NULL NULL 50776424 Hypersensitivity Pneumonitis 1 Ser ID QL NULL INSTITUTIONAL $56.00 1/1/2022-12/31/2022 $56.00 $23.41 $31.92 $41.16 $41.16 $38.82 100% of Medicare $32.93 $31.70 $30.87 $23.41 100% of Medicaid 100% of Medicare 150% of Medicare $44.80 $56.00 195% of Medicare $45.36 $32.76 $32.76 $26.43 $36.03 100% of Medicare $44.80 $47.60 $43.96 $40.87 $44.80 $47.60 $38.50 100% of Medicare 100% of Medicare $42.00 200% of Medicare NULL 250 NULL NULL NULL NULL 50785724 amoxicillin-clavulanate 600 mg-42.9 mg/5 mL Pow 65862-0535-13 INSTITUTIONAL $88.00 1/1/2022-12/31/2022 $88.00 $41.54 $50.16 $64.68 $64.68 $61.01 100% of Medicare $52.69 $50.72 $49.39 $56.32 100% of Medicaid 100% of Medicare 150% of Medicare $70.40 $88.00 195% of Medicare $71.28 $52.36 $52.36 $41.54 $88.00 100% of Medicare $70.40 $74.80 $79.20 $64.23 $74.80 $88.00 $88.00 100% of Medicare 100% of Medicare $88.00 200% of Medicare NULL 310 NULL 86606 NULL NULL 50793143 Aspergillin Antibody GD Qualitative NULL INSTITUTIONAL $70.00 1/1/2022-12/31/2022 $70.00 $29.26 $39.90 $51.45 $51.45 $48.53 100% of Medicare $41.17 $39.63 $38.59 $29.26 100% of Medicaid 100% of Medicare 150% of Medicare $56.00 $70.00 195% of Medicare $56.70 $40.95 $40.95 $33.04 $45.04 100% of Medicare $56.00 $59.50 $54.95 $51.09 $56.00 $59.50 $48.13 100% of Medicare 100% of Medicare $52.50 200% of Medicare NULL 311 NULL 86612 NULL NULL 50793144 Blastomycin Antibody GD Qualitative NULL INSTITUTIONAL $60.00 1/1/2022-12/31/2022 $60.00 $25.08 $34.20 $44.10 $44.10 $41.60 100% of Medicare $35.29 $33.97 $33.08 $25.08 100% of Medicaid 100% of Medicare 150% of Medicare $48.00 $60.00 195% of Medicare $48.60 $35.10 $35.10 $28.32 $38.60 100% of Medicare $48.00 $51.00 $47.10 $43.79 $48.00 $51.00 $41.25 100% of Medicare 100% of Medicare $45.00 200% of Medicare NULL 312 NULL 86635 NULL NULL 50793145 Coccidiodin Ab GD Qualitative NULL INSTITUTIONAL $53.00 1/1/2022-12/31/2022 $53.00 $22.15 $30.21 $38.96 $38.96 $36.74 100% of Medicare $31.17 $30.00 $29.22 $22.15 100% of Medicaid 100% of Medicare 150% of Medicare $42.40 $53.00 195% of Medicare $42.93 $31.01 $31.01 $25.02 $34.10 100% of Medicare $42.40 $45.05 $41.61 $38.68 $42.40 $45.05 $36.44 100% of Medicare 100% of Medicare $39.75 200% of Medicare NULL 310 NULL 86698 NULL NULL 50793146 Histoplasma Antibody GD Qualitative NULL INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $24.66 $33.63 $43.37 $43.37 $40.90 100% of Medicare $34.70 $33.40 $32.53 $24.66 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $34.52 $34.52 $27.85 $37.96 100% of Medicare $47.20 $50.15 $46.32 $43.06 $47.20 $50.15 $40.56 100% of Medicare 100% of Medicare $44.25 200% of Medicare NULL 310 NULL 84425 NULL NULL 50793147 Vitamin B1 Bld QN NULL INSTITUTIONAL $99.00 1/1/2022-12/31/2022 $99.00 $41.38 $56.43 $72.77 $72.77 $68.64 100% of Medicare $58.22 $56.04 $54.58 $41.38 100% of Medicaid 100% of Medicare 150% of Medicare $79.20 $99.00 195% of Medicare $80.19 $57.92 $57.92 $46.73 $63.70 100% of Medicare $79.20 $84.15 $77.72 $72.26 $79.20 $84.15 $68.06 100% of Medicare 100% of Medicare $74.25 200% of Medicare NULL 310 NULL 86698 NULL NULL 50793153 86698 NULL INSTITUTIONAL $59.00 1/1/2022-12/31/2022 $59.00 $24.66 $33.63 $43.37 $43.37 $40.90 100% of Medicare $34.70 $33.40 $32.53 $24.66 100% of Medicaid 100% of Medicare 150% of Medicare $47.20 $59.00 195% of Medicare $47.79 $34.52 $34.52 $27.85 $37.96 100% of Medicare $47.20 $50.15 $46.32 $43.06 $47.20 $50.15 $40.56 100% of Medicare 100% of Medicare $44.25 200% of Medicare NULL 310 NULL 82955 NULL NULL 50794209 Glucose-6-PD Bld QN NULL INSTITUTIONAL $46.00 1/1/2022-12/31/2022 $46.00 $19.23 $26.22 $33.81 $33.81 $31.89 100% of Medicare $27.05 $26.04 $25.36 $19.23 100% of Medicaid 100% of Medicare 150% of Medicare $36.80 $46.00 195% of Medicare $37.26 $26.91 $26.91 $21.71 $29.60 100% of Medicare $36.80 $39.10 $36.11 $33.58 $36.80 $39.10 $31.63 100% of Medicare 100% of Medicare $34.50 200% of Medicare NULL 310 NULL 87536 NULL NULL 50794210 HIV RNA Viral Load NULL INSTITUTIONAL $392.00 1/1/2022-12/31/2022 $392.00 $163.86 $223.44 $288.12 $288.12 $271.77 100% of Medicare $230.54 $221.91 $216.11 $163.86 100% of Medicaid 100% of Medicare 150% of Medicare $313.60 $392.00 195% of Medicare $317.52 $229.32 $229.32 $185.02 $252.21 100% of Medicare $313.60 $333.20 $307.72 $286.12 $313.60 $333.20 $269.50 100% of Medicare 100% of Medicare $294.00 200% of Medicare NULL 310 NULL 87517 NULL NULL 50794460 Hepatitis B DNA Pl QN PCR NULL INSTITUTIONAL $198.00 1/1/2022-12/31/2022 $198.00 $82.76 $112.86 $145.53 $145.53 $137.27 100% of Medicare $116.44 $112.09 $109.16 $82.76 100% of Medicaid 100% of Medicare 150% of Medicare $158.40 $198.00 195% of Medicare $160.38 $115.83 $115.83 $93.46 $127.39 100% of Medicare $158.40 $168.30 $155.43 $144.52 $158.40 $168.30 $136.13 100% of Medicare 100% of Medicare $148.50 200% of Medicare NULL 310 NULL 87522 NULL NULL 50794461 Hepatitis C SerPl QN PCR NULL INSTITUTIONAL $198.00 1/1/2022-12/31/2022 $198.00 $82.76 $112.86 $145.53 $145.53 $137.27 100% of Medicare $116.44 $112.09 $109.16 $82.76 100% of Medicaid 100% of Medicare 150% of Medicare $158.40 $198.00 195% of Medicare $160.38 $115.83 $115.83 $93.46 $127.39 100% of Medicare $158.40 $168.30 $155.43 $144.52 $158.40 $168.30 $136.13 100% of Medicare 100% of Medicare $148.50 200% of Medicare