October 2014 4th QTR ASC Drug File
Revised: 10.01.15
Effective 10.01.2014
| HCPCS Code | Status Indicator | Amount |
|---|---|---|
| A9520 | A | $240.00 |
| C9021 | A | $54.27 |
| C9022 | A | $222.13 |
| C9023 | A | $1.15 |
| C9025 | A | $54.06 |
| C9026 | A | $17.03 |
| C9121 | A | $15.70 |
| C9132 | A | $1.54 |
| C9133 | A | $1.22 |
| C9134 | A | $134.95 |
| C9135 | A | $3.21 |
| C9250 | A | $132.98 |
| C9257 | A | $1.67 |
| C9290 | A | $1.15 |
| C9293 | A | $257.94 |
| C9399 | C | $0.00 |
| C9497 | A | $153.70 |
| J0129 | A | $32.25 |
| J0130 | A | $739.17 |
| J0132 | A | $2.19 |
| J0135 | A | $570.94 |
| J0178 | A | $980.50 |
| J0180 | A | $152.35 |
| J0207 | A | $310.72 |
| J0215 | A | $41.64 |
| J0220 | A | $206.63 |
| J0221 | A | $153.64 |
| J0256 | A | $4.11 |
| J0257 | A | $3.98 |
| J0287 | A | $10.41 |
| J0289 | A | $16.83 |
| J0300 | A | $194.26 |
| J0365 | A | $3.42 |
| J0401 | A | $3.87 |
| J0475 | A | $162.80 |
| J0476 | A | $76.29 |
| J0480 | A | $2,716.18 |
| J0485 | A | $3.81 |
| J0490 | A | $39.48 |
| J0583 | A | $3.42 |
| J0585 | A | $5.56 |
| J0586 | A | $7.43 |
| J0587 | A | $11.30 |
| J0588 | A | $4.48 |
| J0594 | A | $28.94 |
| J0597 | A | $37.64 |
| J0598 | A | $51.86 |
| J0600 | A | $3,477.51 |
| J0630 | A | $69.29 |
| J0637 | A | $11.84 |
| J0638 | A | $90.96 |
| J0641 | A | $1.77 |
| J0716 | A | $3,635.80 |
| J0717 | A | $6.17 |
| J0740 | A | $588.10 |
| J0775 | A | $38.48 |
| J0795 | A | $7.72 |
| J0800 | A | $3,324.92 |
| J0833 | A | $101.68 |
| J0840 | A | $2,493.12 |
| J0850 | A | $1,013.87 |
| J0878 | A | $0.67 |
| J0881 | A | $3.77 |
| J0885 | A | $11.65 |
| J0894 | A | $28.25 |
| J0897 | A | $14.45 |
| J1162 | A | $2,051.63 |
| J1190 | A | $144.86 |
| J1205 | A | $122.65 |
| J1290 | A | $375.64 |
| J1300 | A | $206.14 |
| J1324 | A | $0.55 |
| J1327 | A | $27.29 |
| J1410 | A | $180.14 |
| J1430 | A | $311.06 |
| J1438 | A | $285.27 |
| J1442 | A | $0.99 |
| J1446 | A | $3.99 |
| J1451 | A | $6.44 |
| J1453 | A | $1.73 |
| J1455 | A | $13.32 |
| J1458 | A | $359.12 |
| J1459 | A | $37.03 |
| J1460 | A | $28.77 |
| J1556 | A | $36.21 |
| J1557 | A | $35.84 |
| J1559 | A | $7.94 |
| J1560 | A | $287.67 |
| J1561 | A | $40.02 |
| J1566 | A | $26.75 |
| J1568 | A | $36.92 |
| J1569 | A | $39.36 |
| J1570 | A | $72.11 |
| J1571 | A | $53.70 |
| J1572 | A | $37.76 |
| J1573 | A | $53.70 |
| J1595 | A | $176.31 |
| J1602 | A | $24.16 |
| J1610 | A | $146.07 |
| J1640 | A | $20.73 |
| J1670 | A | $326.32 |
| J1725 | A | $2.66 |
| J1740 | A | $151.80 |
| J1742 | A | $112.30 |
| J1743 | A | $483.05 |
| J1744 | A | $276.90 |
| J1745 | A | $74.34 |
| J1750 | A | $12.16 |
| J1786 | A | $42.01 |
| J1830 | A | $353.28 |
| J1930 | A | $41.40 |
| J1931 | A | $29.45 |
| J1945 | A | $256.73 |
| J1950 | A | $829.72 |
| J2020 | A | $45.66 |
| J2212 | A | $0.48 |
| J2248 | A | $0.98 |
| J2278 | A | $6.87 |
| J2315 | A | $2.88 |
| J2323 | A | $14.91 |
| J2325 | A | $66.66 |
| J2353 | A | $141.87 |
| J2355 | A | $321.88 |
| J2357 | A | $27.85 |
| J2358 | A | $2.75 |
| J2425 | A | $14.85 |
| J2426 | A | $7.91 |
| J2469 | A | $20.01 |
| J2503 | A | $1,034.02 |
| J2504 | A | $281.40 |
| J2505 | A | $3,387.93 |
| J2507 | A | $856.64 |
| J2515 | A | $35.82 |
| J2562 | A | $301.20 |
| J2597 | A | $5.08 |
| J2670 | A | $40.01 |
| J2724 | A | $14.52 |
| J2730 | A | $89.16 |
| J2760 | A | $113.40 |
| J2770 | A | $245.22 |
| J2778 | A | $396.43 |
| J2783 | A | $218.75 |
| J2791 | A | $4.80 |
| J2792 | A | $18.85 |
| J2793 | A | $24.09 |
| J2794 | A | $6.16 |
| J2796 | A | $53.63 |
| J2820 | A | $30.13 |
| J2850 | A | $34.78 |
| J2993 | A | $2,301.91 |
| J2997 | A | $64.30 |
| J3060 | A | $31.94 |
| J3095 | A | $4.52 |
| J3101 | A | $86.21 |
| J3240 | A | $1,430.43 |
| J3243 | A | $2.00 |
| J3246 | A | $9.17 |
| J3262 | A | $3.68 |
| J3285 | A | $61.24 |
| J3300 | A | $3.73 |
| J3315 | A | $170.77 |
| J3350 | A | $122.40 |
| J3355 | A | $63.11 |
| J3357 | A | $162.29 |
| J3385 | A | $353.35 |
| J3396 | A | $10.79 |
| J3465 | A | $3.97 |
| J3489 | A | $47.48 |
| J7178 | A | $0.97 |
| J7180 | A | $6.74 |
| J7183 | A | $0.95 |
| J7185 | A | $1.17 |
| J7186 | A | $0.94 |
| J7187 | A | $0.95 |
| J7189 | A | $1.73 |
| J7190 | A | $0.93 |
| J7191 | A | $0.20 |
| J7192 | A | $1.14 |
| J7193 | A | $1.01 |
| J7194 | A | $1.12 |
| J7195 | A | $1.35 |
| J7196 | A | $103.35 |
| J7197 | A | $3.27 |
| J7198 | A | $1.70 |
| J7308 | A | $242.30 |
| J7309 | A | $83.69 |
| J7310 | A | $16,960.00 |
| J7311 | A | $19,641.05 |
| J7312 | A | $201.31 |
| J7315 | A | $368.88 |
| J7316 | A | $1,046.75 |
| J7321 | A | $90.81 |
| J7323 | A | $161.12 |
| J7324 | A | $186.89 |
| J7325 | A | $12.50 |
| J7326 | A | $562.08 |
| J7335 | A | $26.50 |
| J7501 | A | $217.30 |
| J7504 | A | $852.69 |
| J7505 | A | $6.62 |
| J7508 | A | $0.40 |
| J7511 | A | $594.74 |
| J7513 | A | $526.34 |
| J7525 | A | $141.10 |
| J8501 | A | $7.68 |
| J8520 | A | $8.67 |
| J8521 | A | $28.63 |
| J8560 | A | $57.09 |
| J8650 | A | $28.42 |
| J8700 | A | $5.39 |
| J8705 | A | $94.74 |
| J9010 | A | $582.30 |
| J9015 | A | $2,110.63 |
| J9017 | A | $53.58 |
| J9019 | A | $354.76 |
| J9020 | A | $64.56 |
| J9025 | A | $3.92 |
| J9027 | A | $134.10 |
| J9031 | A | $121.96 |
| J9033 | A | $22.21 |
| J9035 | A | $66.65 |
| J9041 | A | $46.08 |
| J9042 | A | $110.82 |
| J9043 | A | $142.42 |
| J9047 | A | $29.81 |
| J9050 | A | $1,861.12 |
| J9055 | A | $53.29 |
| J9065 | A | $21.21 |
| J9070 | A | $63.16 |
| J9098 | A | $561.39 |
| J9120 | A | $807.19 |
| J9150 | A | $22.56 |
| J9151 | A | $239.10 |
| J9155 | A | $3.55 |
| J9171 | A | $4.59 |
| J9179 | A | $99.01 |
| J9185 | A | $70.98 |
| J9200 | A | $55.65 |
| J9202 | A | $225.02 |
| J9207 | A | $70.21 |
| J9208 | A | $33.41 |
| J9211 | A | $49.11 |
| J9213 | A | $53.66 |
| J9214 | A | $21.17 |
| J9215 | A | $31.80 |
| J9216 | A | $3,168.87 |
| J9217 | A | $229.26 |
| J9218 | A | $7.18 |
| J9225 | A | $3,001.59 |
| J9226 | A | $18,317.24 |
| J9228 | A | $133.61 |
| J9230 | A | $189.63 |
| J9245 | A | $1,226.63 |
| J9261 | A | $138.87 |
| J9262 | A | $2.48 |
| J9263 | A | $0.58 |
| J9264 | A | $9.70 |
| J9266 | A | $6,220.80 |
| J9268 | A | $1,483.27 |
| J9280 | A | $20.88 |
| J9293 | A | $32.34 |
| J9302 | A | $47.76 |
| J9303 | A | $94.79 |
| J9305 | A | $60.27 |
| J9306 | A | $10.22 |
| J9307 | A | $197.12 |
| J9310 | A | $708.68 |
| J9315 | A | $270.64 |
| J9320 | A | $335.28 |
| J9328 | A | $5.68 |
| J9330 | A | $58.83 |
| J9340 | A | $630.70 |
| J9351 | A | $1.83 |
| J9354 | A | $29.14 |
| J9355 | A | $82.49 |
| J9357 | A | $1,085.29 |
| J9371 | A | $2,148.20 |
| J9395 | A | $91.27 |
| J9400 | A | $8.12 |
| J9600 | A | $20,002.20 |
| P9041 | A | $10.91 |
| P9045 | A | $54.54 |
| P9046 | A | $22.49 |
| P9047 | A | $53.44 |
| Q0138 | A | $0.74 |
| Q2017 | A | $830.00 |
| Q2043 | A | $34,916.42 |
| Q2049 | A | $508.43 |
| Q2050 | A | $490.49 |
| Q3027 | A | $36.37 |
| Q4121 | A | $32.42 |
| Q4122 | A | $80.58 |
| Q4127 | A | $13.78 |
| Q4131 | A | $219.52 |
| Q4132 | A | $118.03 |
| Q4133 | A | $115.18 |
| Q9970 | A | $1.05 |
| 90371 | A | $117.38 |
| 90375 | A | $247.57 |
| 90376 | A | $237.82 |
| 90378 | A | $1,308.40 |
| 90396 | A | $675.22 |
| 90581 | A | $94.05 |
| 90585 | A | $121.96 |
| 90621 | A | $122.70 |
| 90675 | A | $223.78 |
| 90676 | A | $158.42 |
| 90704 | A | $162.34 |
| 90733 | A | $106.49 |
| 90734 | A | $100.46 |
| 90735 | A | $104.13 |
| 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 2015 by the American Medical Association.

