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Revised October 2013 4th QTR ASC Drug File

Revised: 07.01.14

Effective 10/01/2013

HCPCS Code Status Indicator Amount
A9584 A $2,380.64
C1204 A $223.15
C9121 A $18.15
C9130 A $38.56
C9131 A $29.22
C9132 A $1.92
C9248 A $2.82
C9250 A $26.15
C9257 A $1.62
C9285 A $13.20
C9290 A $1.10
C9292 A $102.11
C9293 A $244.96
C9294 A $31.12
C9295 A $29.29
C9296 A $10.83
C9297 A $2.48
C9298 A $1,046.75
C9358 A $12.43
C9360 A $12.10
C9363 A $29.83
C9399 C $0.00
J0129 A $23.06
J0130 A $651.25
J0131 A $0.13
J0132 A $2.65
J0135 A $515.89
J0152 A $109.38
J0178 A $980.50
J0180 A $146.19
J0205 A $42.03
J0207 A $298.54
J0210 A $42.40
J0215 A $41.64
J0220 A $206.64
J0221 A $153.60
J0256 A $4.02
J0257 A $3.99
J0287 A $11.42
J0288 A $14.00
J0289 A $15.57
J0300 A $152.43
J0348 A $0.85
J0365 A $2.65
J0395 A $86.37
J0475 A $160.30
J0476 A $74.11
J0480 A $2,442.92
J0485 A $3.80
J0490 A $38.25
J0583 A $3.21
J0585 A $5.45
J0586 A $7.05
J0587 A $10.89
J0588 A $4.48
J0594 A $25.18
J0597 A $32.69
J0598 A $49.34
J0600 A $201.40
J0630 A $69.05
J0637 A $13.35
J0638 A $91.02
J0641 A $1.74
J0712 A $0.88
J0716 A $3,672.34
J0718 A $5.18
J0740 A $648.43
J0775 A $38.57
J0795 A $7.78
J0800 A $3,050.44
J0833 A $101.68
J0840 A $2,349.90
J0850 A $1,013.87
J0878 A $0.60
J0881 A $3.61
J0885 A $11.22
J0894 A $34.78
J0897 A $14.15
J0900 A $33.36
J1162 A $1,241.37
J1190 A $139.65
J1205 A $163.98
J1212 A $79.32
J1290 A $355.64
J1300 A $201.12
J1324 A $0.55
J1327 A $28.08
J1410 A $149.57
J1430 A $299.94
J1435 A $1.54
J1438 A $255.10
J1440 A $288.69
J1441 A $458.51
J1451 A $7.17
J1452 A $85.00
J1453 A $1.72
J1458 A $359.70
J1459 A $36.52
J1460 A $23.98
J1557 A $36.78
J1559 A $7.65
J1560 A $239.77
J1561 A $40.47
J1562 A $12.72
J1566 A $35.75
J1568 A $31.49
J1569 A $39.27
J1570 A $73.71
J1571 A $51.03
J1572 A $36.08
J1573 A $51.03
J1590 A $86.33
J1595 A $151.47
J1610 A $127.98
J1620 A $6.06
J1640 A $16.59
J1670 A $272.52
J1725 A $2.70
J1730 A $88.27
J1740 A $155.25
J1742 A $78.93
J1743 A $469.12
J1744 A $254.73
J1745 A $69.96
J1750 A $12.13
J1786 A $42.01
J1830 A $282.70
J1835 A $0.28
J1930 A $37.16
J1931 A $28.31
J1945 A $570.54
J1950 A $747.92
J2020 A $39.71
J2212 A $0.45
J2248 A $0.95
J2265 A $0.58
J2278 A $6.60
J2315 A $2.80
J2323 A $12.99
J2325 A $60.26
J2353 A $136.14
J2355 A $276.60
J2357 A $25.52
J2358 A $2.75
J2425 A $14.37
J2426 A $7.43
J2469 A $19.38
J2503 A $1,026.70
J2504 A $275.88
J2505 A $3,120.23
J2507 A $508.89
J2562 A $297.65
J2597 A $5.63
J2700 A $2.19
J2724 A $14.26
J2725 A $29.74
J2730 A $88.93
J2770 A $194.32
J2778 A $397.26
J2783 A $211.35
J2785 A $53.43
J2788 A $25.15
J2790 A $82.69
J2791 A $4.78
J2792 A $18.67
J2793 A $24.09
J2794 A $5.78
J2796 A $51.12
J2820 A $28.59
J2850 A $27.49
J2941 A $69.13
J2993 A $2,301.91
J2997 A $56.01
J3095 A $2.65
J3101 A $78.99
J3240 A $1,212.34
J3243 A $1.77
J3246 A $8.95
J3262 A $3.70
J3285 A $61.24
J3300 A $3.96
J3315 A $199.09
J3355 A $67.37
J3357 A $142.17
J3365 A $457.73
J3385 A $348.35
J3396 A $10.45
J3465 A $4.49
J7178 A $0.93
J7180 A $6.51
J7183 A $0.91
J7185 A $1.14
J7186 A $0.93
J7187 A $0.90
J7189 A $1.65
J7190 A $0.92
J7192 A $1.13
J7193 A $0.95
J7194 A $1.10
J7195 A $1.38
J7196 A $103.35
J7197 A $3.11
J7198 A $1.64
J7308 A $172.60
J7309 A $83.69
J7310 A $16,960.00
J7311 A $19,345.00
J7312 A $195.91
J7315 A $379.48
J7321 A $88.85
J7323 A $153.41
J7324 A $177.16
J7325 A $12.83
J7326 A $613.28
J7335 A $25.55
J7501 A $83.13
J7504 A $721.06
J7505 A $1,156.08
J7511 A $569.53
J7513 A $526.34
J7525 A $136.89
J7527 A $6.48
J8501 A $6.69
J8510 A $11.03
J8520 A $9.69
J8521 A $32.19
J8560 A $55.68
J8562 A $81.77
J8650 A $27.07
J8700 A $11.56
J8705 A $89.13
J9010 A $623.63
J9015 A $1,423.64
J9017 A $49.40
J9019 A $344.38
J9020 A $64.57
J9025 A $5.74
J9027 A $129.53
J9031 A $120.91
J9033 A $21.06
J9035 A $64.62
J9041 A $44.89
J9042 A $102.65
J9043 A $139.11
J9050 A $870.93
J9055 A $52.56
J9065 A $23.99
J9070 A $39.67
J9098 A $544.54
J9120 A $645.75
J9150 A $30.02
J9151 A $243.80
J9155 A $3.72
J9160 A $1,646.18
J9171 A $4.63
J9178 A $1.18
J9179 A $98.43
J9185 A $84.17
J9200 A $67.08
J9201 A $7.96
J9202 A $194.19
J9207 A $68.65
J9208 A $31.04
J9211 A $35.31
J9212 A $17.06
J9214 A $20.70
J9216 A $2,517.90
J9217 A $202.84
J9218 A $10.25
J9219 A $4,819.82
J9225 A $2,966.80
J9226 A $16,660.71
J9228 A $128.96
J9230 A $154.70
J9245 A $1,293.55
J9261 A $130.63
J9263 A $0.54
J9264 A $9.55
J9266 A $6,007.38
J9268 A $1,419.70
J9280 A $24.54
J9293 A $34.62
J9300 A $2,742.59
J9302 A $46.53
J9303 A $91.38
J9305 A $59.49
J9307 A $182.61
J9310 A $678.70
J9315 A $251.94
J9320 A $274.35
J9328 A $5.03
J9330 A $55.97
J9340 A $630.70
J9351 A $2.20
J9355 A $78.72
J9357 A $1,052.98
J9395 A $89.68
J9600 A $19,325.78
P9041 A $22.63
P9045 A $60.67
P9046 A $30.24
P9047 A $69.20
Q0138 A $0.68
Q0515 A $1.80
Q2017 A $332.62
Q2043 A $32,709.98
Q2049 A $498.26
Q2050 A $545.48
Q2051 A $150.33
Q3025 A $307.14
Q4101 A $41.06
Q4102 A $9.51
Q4103 A $9.51
Q4104 A $25.75
Q4105 A $13.14
Q4106 A $44.43
Q4107 A $98.50
Q4108 A $28.46
Q4110 A $38.59
Q4111 A $6.91
Q4112 A $392.70
Q4113 A $392.70
Q4114 A $1,235.31
Q4115 A $12.68
Q4116 A $32.89
Q4118 A $2.62
Q4119 A $4.28
Q4121 A $23.21
Q4122 A $77.80
Q4123 A $15.45
Q4124 A $11.89
Q4125 A $114.31
Q4126 A $57.99
Q4127 A $13.78
Q4128 A $34.08
Q4131 A $214.09
Q4132 A $128.70
Q4133 A $147.84
Q4134 A $31.48
Q4135 A $0.16
Q4136 A $0.15
Q9968 A $1.91
90371 A $112.03
90375 A $219.82
90376 A $216.54
90378 A $1,240.19
90396 A $675.22
90581 A $94.05
90585 A $120.91
90675 A $232.39
90676 A $155.64
90681 A $108.65
90733 A $106.49
90734 A $92.22
90735 A $102.08
90740 C $0.00
90743 C $0.00
90744 C $0.00
90746 C $0.00
90747 C $0.00

All CPT codes begin with a numeric character and all HCPCS codes begin with an alpha character.

All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2014 by the American Medical Association.

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