Revised: October 2015 4th QTR ASC Drug File
Revised: 04.04.16
Effective 10.01.2015
| HCPCS Code | Status Indicator | Amount |
|---|---|---|
| A9520 | A | $497.00 |
| A9586 | A | $2,756.00 |
| C9025 | A | $53.97 |
| C9026 | A | $17.03 |
| C9027 | A | $45.69 |
| C9121 | A | $15.14 |
| C9132 | A | $1.62 |
| C9248 | A | $4.32 |
| C9257 | A | $1.74 |
| C9293 | A | $271.24 |
| C9349 | A | $109.18 |
| C9399 | C | $0.00 |
| C9442 | A | $31.64 |
| C9443 | A | $28.55 |
| C9444 | A | $25.07 |
| C9445 | A | $23.29 |
| C9446 | A | $1.21 |
| C9447 | A | $492.90 |
| C9449 | A | $96.00 |
| C9450 | A | $490.95 |
| C9451 | A | $1.68 |
| C9452 | A | $4.25 |
| C9453 | A | $25.38 |
| C9454 | A | $251.26 |
| C9455 | A | $8.90 |
| C9456 | A | $0.68 |
| C9457 | A | $33.06 |
| C9497 | A | $147.34 |
| J0120 | A | $97.97 |
| J0129 | A | $37.33 |
| J0130 | A | $965.13 |
| J0132 | A | $2.00 |
| J0135 | A | $742.96 |
| J0178 | A | $980.50 |
| J0180 | A | $158.04 |
| J0200 | A | $38.86 |
| J0207 | A | $363.93 |
| J0215 | A | $41.64 |
| J0220 | A | $206.64 |
| J0221 | A | $153.60 |
| J0256 | A | $4.45 |
| J0257 | A | $4.11 |
| J0287 | A | $12.38 |
| J0289 | A | $18.23 |
| J0300 | A | $194.26 |
| J0401 | A | $4.10 |
| J0475 | A | $170.03 |
| J0476 | A | $76.07 |
| J0480 | A | $2,851.52 |
| J0485 | A | $3.80 |
| J0490 | A | $40.54 |
| J0583 | A | $3.71 |
| J0585 | A | $5.72 |
| J0586 | A | $8.00 |
| J0587 | A | $11.65 |
| J0588 | A | $4.67 |
| J0594 | A | $33.20 |
| J0597 | A | $40.52 |
| J0598 | A | $54.46 |
| J0600 | A | $5,594.42 |
| J0630 | A | $2,006.85 |
| J0637 | A | $12.75 |
| J0638 | A | $91.78 |
| J0641 | A | $1.92 |
| J0716 | A | $3,635.80 |
| J0717 | A | $6.62 |
| J0725 | A | $22.59 |
| J0740 | A | $650.18 |
| J0775 | A | $38.06 |
| J0795 | A | $7.74 |
| J0800 | A | $3,468.13 |
| J0833 | A | $101.68 |
| J0840 | A | $2,542.98 |
| J0850 | A | $1,064.77 |
| J0878 | A | $0.76 |
| J0881 | A | $4.38 |
| J0885 | A | $12.62 |
| J0894 | A | $22.13 |
| J0897 | A | $15.24 |
| J1162 | A | $2,639.26 |
| J1190 | A | $146.38 |
| J1205 | A | $119.93 |
| J1290 | A | $402.44 |
| J1300 | A | $215.92 |
| J1322 | A | $221.54 |
| J1324 | A | $18.63 |
| J1327 | A | $32.39 |
| J1364 | A | $50.75 |
| J1410 | A | $215.70 |
| J1430 | A | $404.09 |
| J1438 | A | $330.81 |
| J1439 | A | $1.06 |
| J1442 | A | $1.00 |
| J1446 | A | $3.86 |
| J1451 | A | $7.01 |
| J1453 | A | $1.73 |
| J1458 | A | $364.78 |
| J1459 | A | $38.05 |
| J1556 | A | $38.49 |
| J1557 | A | $37.28 |
| J1559 | A | $8.47 |
| J1561 | A | $40.30 |
| J1566 | A | $33.11 |
| J1568 | A | $42.80 |
| J1569 | A | $38.56 |
| J1571 | A | $54.43 |
| J1572 | A | $35.66 |
| J1573 | A | $54.43 |
| J1595 | A | $194.25 |
| J1600 | A | $4.27 |
| J1602 | A | $24.33 |
| J1610 | A | $190.60 |
| J1640 | A | $21.77 |
| J1670 | A | $255.21 |
| J1725 | A | $2.61 |
| J1740 | A | $116.67 |
| J1742 | A | $63.10 |
| J1743 | A | $497.48 |
| J1744 | A | $298.90 |
| J1745 | A | $78.76 |
| J1750 | A | $12.08 |
| J1786 | A | $42.00 |
| J1830 | A | $357.22 |
| J1930 | A | $47.18 |
| J1931 | A | $29.45 |
| J1945 | A | $235.52 |
| J1950 | A | $900.87 |
| J2020 | A | $31.62 |
| J2248 | A | $0.95 |
| J2278 | A | $7.08 |
| J2315 | A | $3.18 |
| J2320 | A | $122.78 |
| J2323 | A | $16.24 |
| J2325 | A | $72.98 |
| J2353 | A | $156.94 |
| J2355 | A | $417.79 |
| J2357 | A | $29.91 |
| J2358 | A | $2.92 |
| J2425 | A | $15.59 |
| J2426 | A | $8.45 |
| J2469 | A | $20.53 |
| J2503 | A | $1,031.85 |
| J2504 | A | $281.12 |
| J2505 | A | $3,772.79 |
| J2507 | A | $1,239.16 |
| J2515 | A | $40.74 |
| J2562 | A | $305.98 |
| J2597 | A | $8.97 |
| J2670 | A | $1,600.40 |
| J2724 | A | $15.12 |
| J2730 | A | $91.90 |
| J2760 | A | $159.00 |
| J2770 | A | $311.04 |
| J2778 | A | $391.41 |
| J2783 | A | $227.61 |
| J2791 | A | $4.75 |
| J2792 | A | $19.40 |
| J2793 | A | $24.09 |
| J2794 | A | $6.91 |
| J2796 | A | $57.47 |
| J2820 | A | $31.68 |
| J2850 | A | $34.78 |
| J2941 | A | $81.59 |
| J2993 | A | $2,301.91 |
| J2997 | A | $73.74 |
| J3060 | A | $36.48 |
| J3070 | A | $121.83 |
| J3095 | A | $4.91 |
| J3101 | A | $93.96 |
| J3145 | A | $1.17 |
| J3240 | A | $1,432.17 |
| J3243 | A | $2.35 |
| J3246 | A | $8.94 |
| J3262 | A | $3.85 |
| J3285 | A | $61.24 |
| J3300 | A | $3.72 |
| J3315 | A | $144.59 |
| J3350 | A | $39.97 |
| J3355 | A | $64.69 |
| J3357 | A | $166.99 |
| J3385 | A | $346.08 |
| J3396 | A | $10.99 |
| J3465 | A | $4.19 |
| J3485 | A | $1.50 |
| J3489 | A | $34.97 |
| J7178 | A | $1.05 |
| J7180 | A | $7.41 |
| J7181 | A | $14.07 |
| J7183 | A | $1.02 |
| J7185 | A | $1.42 |
| J7186 | A | $0.96 |
| J7187 | A | $0.99 |
| J7189 | A | $2.07 |
| J7190 | A | $0.96 |
| J7191 | A | $0.20 |
| J7192 | A | $1.16 |
| J7193 | A | $1.07 |
| J7194 | A | $1.19 |
| J7195 | A | $1.46 |
| J7196 | A | $103.35 |
| J7197 | A | $3.37 |
| J7198 | A | $1.83 |
| J7200 | A | $1.23 |
| J7201 | A | $2.81 |
| J7308 | A | $292.79 |
| J7309 | A | $83.69 |
| J7310 | A | $16,960.00 |
| J7311 | A | $20,138.08 |
| J7312 | A | $201.03 |
| J7315 | A | $372.66 |
| J7316 | A | $1,046.75 |
| J7321 | A | $88.61 |
| J7323 | A | $152.00 |
| J7324 | A | $172.63 |
| J7325 | A | $12.87 |
| J7326 | A | $578.11 |
| J7327 | A | $958.45 |
| J7336 | A | $2.81 |
| J7501 | A | $217.30 |
| J7504 | A | $1,069.33 |
| J7508 | A | $0.39 |
| J7511 | A | $638.49 |
| J7513 | A | $526.34 |
| J7525 | A | $163.25 |
| J8501 | A | $9.54 |
| J8520 | A | $5.53 |
| J8521 | A | $19.50 |
| J8560 | A | $68.74 |
| J8650 | A | $34.10 |
| J8700 | A | $2.66 |
| J8705 | A | $101.36 |
| J9015 | A | $2,667.51 |
| J9017 | A | $59.42 |
| J9019 | A | $376.49 |
| J9020 | A | $64.56 |
| J9025 | A | $3.05 |
| J9027 | A | $138.38 |
| J9031 | A | $122.88 |
| J9033 | A | $24.66 |
| J9035 | A | $69.60 |
| J9041 | A | $46.75 |
| J9042 | A | $119.62 |
| J9043 | A | $148.66 |
| J9047 | A | $31.06 |
| J9050 | A | $2,973.34 |
| J9055 | A | $53.48 |
| J9065 | A | $20.91 |
| J9070 | A | $48.95 |
| J9098 | A | $576.48 |
| J9120 | A | $1,164.57 |
| J9150 | A | $26.45 |
| J9151 | A | $238.86 |
| J9155 | A | $3.59 |
| J9171 | A | $3.49 |
| J9179 | A | $102.53 |
| J9185 | A | $72.85 |
| J9200 | A | $67.69 |
| J9202 | A | $281.05 |
| J9207 | A | $72.08 |
| J9208 | A | $32.20 |
| J9211 | A | $34.88 |
| J9213 | A | $733.57 |
| J9214 | A | $24.05 |
| J9216 | A | $5,265.95 |
| J9217 | A | $242.80 |
| J9225 | A | $3,012.29 |
| J9226 | A | $22,170.84 |
| J9228 | A | $138.83 |
| J9230 | A | $241.99 |
| J9245 | A | $1,285.40 |
| J9261 | A | $148.57 |
| J9262 | A | $2.48 |
| J9263 | A | $0.48 |
| J9264 | A | $9.77 |
| J9266 | A | $6,189.74 |
| J9268 | A | $1,471.48 |
| J9280 | A | $73.03 |
| J9293 | A | $32.12 |
| J9301 | A | $54.21 |
| J9302 | A | $49.47 |
| J9303 | A | $100.91 |
| J9305 | A | $61.21 |
| J9306 | A | $10.22 |
| J9307 | A | $212.80 |
| J9310 | A | $748.70 |
| J9315 | A | $290.84 |
| J9320 | A | $324.02 |
| J9328 | A | $6.84 |
| J9330 | A | $62.50 |
| J9340 | A | $630.70 |
| J9351 | A | $2.05 |
| J9354 | A | $29.21 |
| J9355 | A | $87.36 |
| J9357 | A | $1,117.31 |
| J9371 | A | $2,321.82 |
| J9395 | A | $93.44 |
| J9400 | A | $8.32 |
| J9600 | A | $20,438.61 |
| P9041 | A | $10.91 |
| P9045 | A | $54.54 |
| P9046 | A | $22.49 |
| P9047 | A | $53.44 |
| Q0138 | A | $0.81 |
| Q2017 | A | $3,494.46 |
| Q2043 | A | $36,704.05 |
| Q2049 | A | $508.43 |
| Q2050 | A | $443.83 |
| Q3027 | A | $40.52 |
| Q4121 | A | $36.00 |
| Q4122 | A | $36.36 |
| Q4127 | A | $14.12 |
| Q5101 | A | $0.97 |
| Q9968 | A | $10.80 |
| Q9975 | A | $1.90 |
| Q9978 | A | $474.85 |
| Q9979 | A | $1,743.19 |
| 90371 | A | $110.39 |
| 90375 | A | $285.93 |
| 90376 | A | $252.95 |
| 90378 | A | $1,947.49 |
| 90396 | A | $1,202.24 |
| 90581 | A | $94.05 |
| 90585 | A | $122.88 |
| 90620 | A | $155.70 |
| 90621 | A | $122.70 |
| 90675 | A | $263.54 |
| 90676 | A | $172.30 |
| 90733 | A | $106.49 |
| 90735 | A | $108.29 |
| 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.

