Revised: April 2016 2nd QTR ASC Drug File
Revised: 09.28.16
Effective: 04.01.2016
| HCPCS Code | Status Indicator | Amount |
|---|---|---|
| A9586 | A | $2,756.00 |
| C9121 | A | $12.40 |
| C9132 | A | $1.69 |
| C9137 | A | $1.89 |
| C9138 | A | $1.99 |
| C9248 | A | $2.37 |
| C9257 | A | $1.77 |
| C9293 | A | $270.72 |
| C9349 | A | $121.38 |
| C9399 | C | $0.00 |
| C9447 | A | $487.89 |
| C9458 | A | $2,968.00 |
| C9459 | A | $3,135.00 |
| C9460 | A | $15.53 |
| C9461 | A | $5,700.00 |
| C9470 | A | $2.53 |
| C9471 | A | $19.00 |
| C9472 | A | $46.64 |
| C9473 | A | $26.50 |
| C9474 | A | $39.93 |
| C9475 | A | $5.30 |
| C9497 | A | $144.70 |
| J0120 | A | $97.97 |
| J0129 | A | $41.05 |
| J0132 | A | $1.63 |
| J0135 | A | $796.67 |
| J0178 | A | $980.50 |
| J0180 | A | $159.66 |
| J0202 | A | $1,738.69 |
| J0207 | A | $390.34 |
| J0215 | A | $41.64 |
| J0220 | A | $206.70 |
| J0221 | A | $154.62 |
| J0256 | A | $4.60 |
| J0257 | A | $4.27 |
| J0287 | A | $13.75 |
| J0289 | A | $18.04 |
| J0300 | A | $194.26 |
| J0401 | A | $4.25 |
| J0475 | A | $182.76 |
| J0476 | A | $77.36 |
| J0480 | A | $3,039.87 |
| J0485 | A | $3.80 |
| J0490 | A | $41.49 |
| J0561 | A | $8.38 |
| J0585 | A | $5.72 |
| J0586 | A | $7.77 |
| J0587 | A | $11.67 |
| J0588 | A | $4.82 |
| J0594 | A | $33.16 |
| J0596 | A | $26.75 |
| J0597 | A | $46.32 |
| J0598 | A | $54.51 |
| J0600 | A | $5,594.42 |
| J0630 | A | $2,369.13 |
| J0637 | A | $13.26 |
| J0638 | A | $92.40 |
| J0641 | A | $1.41 |
| J0695 | A | $4.29 |
| J0712 | A | $2.31 |
| J0714 | A | $73.90 |
| J0716 | A | $3,926.66 |
| J0717 | A | $6.49 |
| J0720 | A | $31.74 |
| J0725 | A | $16.22 |
| J0740 | A | $594.16 |
| J0775 | A | $38.50 |
| J0795 | A | $7.71 |
| J0800 | A | $3,578.55 |
| J0833 | A | $101.68 |
| J0840 | A | $2,670.39 |
| J0850 | A | $1,064.77 |
| J0875 | A | $14.70 |
| J0878 | A | $0.83 |
| J0881 | A | $4.14 |
| J0885 | A | $12.37 |
| J0887 | A | $1.65 |
| J0894 | A | $22.97 |
| J0897 | A | $15.61 |
| J1160 | A | $5.02 |
| J1162 | A | $3,039.88 |
| J1190 | A | $163.46 |
| J1205 | A | $109.09 |
| J1212 | A | $315.55 |
| J1290 | A | $400.42 |
| J1300 | A | $215.92 |
| J1322 | A | $221.66 |
| J1324 | A | $18.63 |
| J1327 | A | $32.51 |
| J1330 | A | $91.15 |
| J1364 | A | $49.33 |
| J1410 | A | $228.37 |
| J1430 | A | $404.09 |
| J1438 | A | $379.14 |
| J1439 | A | $1.06 |
| J1442 | A | $1.01 |
| J1447 | A | $0.77 |
| J1451 | A | $7.00 |
| J1453 | A | $1.81 |
| J1458 | A | $364.20 |
| J1459 | A | $38.26 |
| J1556 | A | $39.23 |
| J1557 | A | $37.28 |
| J1559 | A | $9.84 |
| J1561 | A | $40.76 |
| J1566 | A | $33.43 |
| J1568 | A | $45.86 |
| J1569 | A | $38.82 |
| J1571 | A | $54.97 |
| J1572 | A | $38.13 |
| J1573 | A | $54.97 |
| J1575 | A | $11.47 |
| J1595 | A | $186.37 |
| J1602 | A | $24.60 |
| J1610 | A | $196.57 |
| J1640 | A | $21.77 |
| J1670 | A | $403.71 |
| J1725 | A | $2.56 |
| J1740 | A | $104.13 |
| J1742 | A | $109.03 |
| J1743 | A | $522.65 |
| J1744 | A | $314.28 |
| J1745 | A | $81.60 |
| J1750 | A | $12.26 |
| J1786 | A | $41.96 |
| J1830 | A | $373.58 |
| J1833 | A | $0.63 |
| J1930 | A | $48.44 |
| J1931 | A | $29.65 |
| J1945 | A | $235.52 |
| J1950 | A | $934.40 |
| J2020 | A | $17.65 |
| J2278 | A | $7.18 |
| J2315 | A | $3.20 |
| J2320 | A | $122.78 |
| J2323 | A | $17.06 |
| J2325 | A | $73.21 |
| J2353 | A | $160.40 |
| J2355 | A | $439.87 |
| J2357 | A | $31.13 |
| J2358 | A | $2.92 |
| J2407 | A | $24.70 |
| J2425 | A | $16.38 |
| J2426 | A | $8.68 |
| J2469 | A | $22.27 |
| J2502 | A | $239.45 |
| J2503 | A | $1,054.70 |
| J2504 | A | $281.40 |
| J2505 | A | $3,896.81 |
| J2507 | A | $1,379.99 |
| J2510 | A | $22.99 |
| J2547 | A | $1.65 |
| J2562 | A | $308.16 |
| J2597 | A | $14.11 |
| J2670 | A | $1,600.40 |
| J2724 | A | $15.19 |
| J2760 | A | $425.79 |
| J2770 | A | $332.14 |
| J2778 | A | $386.33 |
| J2783 | A | $241.95 |
| J2792 | A | $20.25 |
| J2793 | A | $24.09 |
| J2794 | A | $7.32 |
| J2796 | A | $59.73 |
| J2800 | A | $40.50 |
| J2820 | A | $35.12 |
| J2850 | A | $34.78 |
| J2860 | A | $9.00 |
| J2941 | A | $81.59 |
| J2993 | A | $2,301.91 |
| J2997 | A | $74.66 |
| J3060 | A | $38.56 |
| J3070 | A | $125.46 |
| J3090 | A | $1.21 |
| J3095 | A | $5.22 |
| J3101 | A | $93.98 |
| J3145 | A | $1.19 |
| J3240 | A | $1,457.99 |
| J3243 | A | $2.42 |
| J3246 | A | $9.82 |
| J3262 | A | $3.98 |
| J3285 | A | $61.24 |
| J3300 | A | $3.71 |
| J3315 | A | $234.96 |
| J3355 | A | $120.61 |
| J3357 | A | $169.34 |
| J3365 | A | $262.79 |
| J3380 | A | $17.03 |
| J3385 | A | $342.29 |
| J3396 | A | $10.96 |
| J3465 | A | $4.56 |
| J3489 | A | $21.12 |
| J7178 | A | $1.09 |
| J7180 | A | $7.77 |
| J7181 | A | $13.77 |
| J7183 | A | $0.98 |
| J7185 | A | $1.20 |
| J7186 | A | $0.97 |
| J7187 | A | $1.00 |
| J7188 | A | $4.37 |
| J7189 | A | $1.90 |
| J7190 | A | $0.96 |
| J7191 | A | $0.20 |
| J7192 | A | $1.18 |
| J7193 | A | $1.12 |
| J7194 | A | $1.22 |
| J7195 | A | $1.45 |
| J7196 | A | $103.35 |
| J7197 | A | $3.68 |
| J7198 | A | $1.90 |
| J7200 | A | $1.23 |
| J7201 | A | $2.82 |
| J7205 | A | $1.90 |
| J7308 | A | $327.41 |
| J7309 | A | $83.69 |
| J7310 | A | $16,960.00 |
| J7311 | A | $20,136.40 |
| J7312 | A | $201.11 |
| J7313 | A | $490.95 |
| J7316 | A | $1,046.75 |
| J7321 | A | $88.56 |
| J7323 | A | $156.86 |
| J7324 | A | $167.83 |
| J7325 | A | $12.83 |
| J7326 | A | $571.96 |
| J7327 | A | $934.44 |
| J7336 | A | $2.89 |
| J7340 | A | $2.14 |
| J7501 | A | $217.30 |
| J7503 | A | $1.03 |
| J7504 | A | $1,137.19 |
| J7508 | A | $0.39 |
| J7511 | A | $649.58 |
| J7513 | A | $526.34 |
| J7525 | A | $164.16 |
| J8501 | A | $10.03 |
| J8510 | A | $16.02 |
| J8520 | A | $4.89 |
| J8521 | A | $15.63 |
| J8560 | A | $67.30 |
| J8650 | A | $38.19 |
| J8655 | A | $395.65 |
| J8700 | A | $3.58 |
| J8705 | A | $101.04 |
| J9015 | A | $2,667.51 |
| J9017 | A | $59.24 |
| J9019 | A | $391.01 |
| J9025 | A | $2.94 |
| J9027 | A | $138.21 |
| J9031 | A | $122.99 |
| J9032 | A | $32.41 |
| J9033 | A | $24.63 |
| J9035 | A | $70.96 |
| J9039 | A | $95.10 |
| J9041 | A | $46.82 |
| J9042 | A | $124.24 |
| J9043 | A | $150.25 |
| J9047 | A | $32.09 |
| J9050 | A | $3,860.63 |
| J9055 | A | $54.37 |
| J9065 | A | $21.85 |
| J9070 | A | $43.51 |
| J9098 | A | $576.26 |
| J9120 | A | $1,160.34 |
| J9150 | A | $39.17 |
| J9151 | A | $238.83 |
| J9155 | A | $3.68 |
| J9171 | A | $2.39 |
| J9179 | A | $104.78 |
| J9200 | A | $47.45 |
| J9202 | A | $282.90 |
| J9207 | A | $73.85 |
| J9208 | A | $29.78 |
| J9211 | A | $36.95 |
| J9213 | A | $733.57 |
| J9214 | A | $25.30 |
| J9216 | A | $5,739.88 |
| J9217 | A | $231.79 |
| J9219 | A | $168.48 |
| J9225 | A | $3,052.96 |
| J9226 | A | $24,068.75 |
| J9228 | A | $140.75 |
| J9230 | A | $241.71 |
| J9245 | A | $1,884.07 |
| J9261 | A | $147.94 |
| J9262 | A | $2.58 |
| J9263 | A | $0.37 |
| J9264 | A | $10.00 |
| J9266 | A | $14,275.20 |
| J9268 | A | $1,630.95 |
| J9271 | A | $45.70 |
| J9280 | A | $102.51 |
| J9293 | A | $33.59 |
| J9299 | A | $25.62 |
| J9301 | A | $55.20 |
| J9302 | A | $50.61 |
| J9303 | A | $103.97 |
| J9305 | A | $61.68 |
| J9306 | A | $10.44 |
| J9307 | A | $221.07 |
| J9308 | A | $54.00 |
| J9310 | A | $769.89 |
| J9315 | A | $298.21 |
| J9320 | A | $314.59 |
| J9328 | A | $7.33 |
| J9330 | A | $63.74 |
| J9340 | A | $1,145.19 |
| J9354 | A | $29.22 |
| J9355 | A | $89.67 |
| J9357 | A | $1,134.35 |
| J9371 | A | $2,412.47 |
| J9395 | A | $94.02 |
| J9400 | A | $8.06 |
| J9600 | A | $20,602.26 |
| P9041 | A | $11.32 |
| P9045 | A | $54.72 |
| P9046 | A | $22.49 |
| P9047 | A | $53.44 |
| Q0138 | A | $0.84 |
| Q2017 | A | $2,025.66 |
| Q2043 | A | $38,347.31 |
| Q2049 | A | $508.43 |
| Q2050 | A | $435.93 |
| Q3027 | A | $43.48 |
| Q4121 | A | $39.64 |
| Q5101 | A | $0.97 |
| Q5102 | A | $0.00 |
| Q9950 | A | $24.16 |
| Q9968 | A | $11.41 |
| 90371 | A | $121.92 |
| 90375 | A | $289.83 |
| 90376 | A | $279.13 |
| 90378 | A | $1,947.49 |
| 90396 | A | $1,230.98 |
| 90585 | A | $122.99 |
| 90620 | A | $153.09 |
| 90621 | A | $122.70 |
| 90675 | A | $273.97 |
| 90676 | A | $172.30 |
| 90733 | A | $106.49 |
| 90734 | A | $105.99 |
| 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 2016 by the American Medical Association.

