Revised October 2016 4th QTR ASC Drug File
Effective 10.01.2016
Revised: 10.01.17
| HCPCS Code | Status Indicator | Amount |
|---|---|---|
| A9586 | A | $2,756.00 |
| C9121 | A | $10.70 |
| C9132 | A | $1.77 |
| C9137 | A | $1.55 |
| C9138 | A | $1.50 |
| C9139 | A | $4.18 |
| C9248 | A | $2.89 |
| C9257 | A | $1.81 |
| C9293 | A | $284.27 |
| C9349 | A | $119.12 |
| C9399 | C | $0.00 |
| C9447 | A | $487.12 |
| C9460 | A | $15.48 |
| C9461 | A | $5,700.00 |
| C9470 | A | $2.37 |
| C9471 | A | $16.41 |
| C9472 | A | $46.28 |
| C9473 | A | $25.93 |
| C9474 | A | $39.55 |
| C9475 | A | $5.28 |
| C9476 | A | $46.85 |
| C9477 | A | $6.25 |
| C9478 | A | $530.00 |
| C9479 | A | $30.00 |
| C9480 | A | $283.34 |
| C9481 | A | $8.85 |
| C9482 | A | $9.99 |
| C9483 | A | $76.14 |
| C9497 | A | $153.70 |
| J0120 | A | $97.97 |
| J0129 | A | $44.75 |
| J0132 | A | $1.51 |
| J0135 | A | $861.45 |
| J0178 | A | $980.46 |
| J0180 | A | $164.42 |
| J0202 | A | $1,738.36 |
| J0207 | A | $416.53 |
| J0215 | A | $41.64 |
| J0220 | A | $206.70 |
| J0221 | A | $159.39 |
| J0256 | A | $4.83 |
| J0257 | A | $4.37 |
| J0287 | A | $13.41 |
| J0289 | A | $19.01 |
| J0300 | A | $194.26 |
| J0401 | A | $4.38 |
| J0475 | A | $173.43 |
| J0476 | A | $76.96 |
| J0480 | A | $3,196.11 |
| J0485 | A | $3.84 |
| J0490 | A | $42.02 |
| J0561 | A | $10.31 |
| J0585 | A | $5.93 |
| J0586 | A | $7.90 |
| J0587 | A | $11.71 |
| J0588 | A | $4.91 |
| J0594 | A | $38.37 |
| J0596 | A | $27.95 |
| J0597 | A | $46.52 |
| J0598 | A | $55.55 |
| J0600 | A | $5,594.42 |
| J0630 | A | $2,321.14 |
| J0637 | A | $12.21 |
| J0638 | A | $92.49 |
| J0641 | A | $0.90 |
| J0695 | A | $4.54 |
| J0712 | A | $2.48 |
| J0714 | A | $77.05 |
| J0716 | A | $4,246.69 |
| J0717 | A | $7.11 |
| J0720 | A | $40.36 |
| J0725 | A | $24.62 |
| J0740 | A | $554.48 |
| J0775 | A | $41.42 |
| J0795 | A | $8.12 |
| J0800 | A | $3,555.35 |
| J0833 | A | $101.68 |
| J0840 | A | $2,670.24 |
| J0850 | A | $1,126.55 |
| J0875 | A | $15.22 |
| J0878 | A | $0.90 |
| J0881 | A | $3.93 |
| J0885 | A | $12.59 |
| J0887 | A | $1.48 |
| J0894 | A | $20.83 |
| J0897 | A | $16.23 |
| J1160 | A | $4.82 |
| J1162 | A | $3,039.53 |
| J1190 | A | $184.05 |
| J1205 | A | $86.68 |
| J1212 | A | $481.94 |
| J1290 | A | $399.56 |
| J1300 | A | $221.12 |
| J1322 | A | $221.77 |
| J1324 | A | $18.63 |
| J1327 | A | $31.29 |
| J1330 | A | $91.15 |
| J1364 | A | $59.29 |
| J1410 | A | $261.40 |
| J1430 | A | $404.09 |
| J1438 | A | $404.62 |
| J1439 | A | $1.05 |
| J1442 | A | $1.00 |
| J1447 | A | $0.74 |
| J1451 | A | $7.94 |
| J1453 | A | $1.89 |
| J1458 | A | $364.41 |
| J1459 | A | $37.90 |
| J1556 | A | $39.52 |
| J1557 | A | $37.03 |
| J1559 | A | $9.83 |
| J1561 | A | $38.58 |
| J1566 | A | $33.07 |
| J1568 | A | $35.98 |
| J1569 | A | $40.00 |
| J1571 | A | $56.06 |
| J1572 | A | $36.80 |
| J1573 | A | $56.06 |
| J1575 | A | $12.74 |
| J1595 | A | $198.58 |
| J1602 | A | $24.79 |
| J1610 | A | $199.12 |
| J1640 | A | $22.86 |
| J1670 | A | $433.06 |
| J1725 | A | $2.69 |
| J1740 | A | $101.96 |
| J1742 | A | $186.19 |
| J1743 | A | $522.04 |
| J1744 | A | $325.48 |
| J1745 | A | $82.87 |
| J1750 | A | $12.41 |
| J1786 | A | $41.93 |
| J1830 | A | $390.11 |
| J1833 | A | $0.64 |
| J1930 | A | $51.31 |
| J1931 | A | $30.59 |
| J1945 | A | $235.52 |
| J1950 | A | $1,038.70 |
| J2020 | A | $15.78 |
| J2278 | A | $7.31 |
| J2315 | A | $3.24 |
| J2320 | A | $122.78 |
| J2323 | A | $17.89 |
| J2325 | A | $72.73 |
| J2353 | A | $168.11 |
| J2355 | A | $467.22 |
| J2357 | A | $32.31 |
| J2358 | A | $2.92 |
| J2407 | A | $24.64 |
| J2425 | A | $17.68 |
| J2426 | A | $9.12 |
| J2469 | A | $22.88 |
| J2502 | A | $265.36 |
| J2503 | A | $1,054.70 |
| J2504 | A | $319.67 |
| J2505 | A | $4,040.69 |
| J2507 | A | $1,642.46 |
| J2510 | A | $26.77 |
| J2547 | A | $1.65 |
| J2562 | A | $312.11 |
| J2597 | A | $14.04 |
| J2670 | A | $1,600.40 |
| J2724 | A | $15.23 |
| J2760 | A | $402.51 |
| J2770 | A | $413.52 |
| J2778 | A | $383.23 |
| J2783 | A | $254.11 |
| J2792 | A | $21.33 |
| J2793 | A | $24.09 |
| J2794 | A | $7.82 |
| J2796 | A | $62.14 |
| J2800 | A | $38.57 |
| J2820 | A | $36.23 |
| J2850 | A | $34.78 |
| J2860 | A | $9.00 |
| J2941 | A | $81.59 |
| J2993 | A | $2,301.91 |
| J2997 | A | $80.29 |
| J3060 | A | $40.46 |
| J3070 | A | $140.39 |
| J3090 | A | $1.28 |
| J3095 | A | $5.02 |
| J3101 | A | $102.43 |
| J3145 | A | $1.22 |
| J3240 | A | $1,571.30 |
| J3243 | A | $3.13 |
| J3246 | A | $9.00 |
| J3262 | A | $4.10 |
| J3285 | A | $61.24 |
| J3300 | A | $3.70 |
| J3315 | A | $460.85 |
| J3355 | A | $132.66 |
| J3357 | A | $174.57 |
| J3365 | A | $262.79 |
| J3380 | A | $17.43 |
| J3385 | A | $343.35 |
| J3396 | A | $10.88 |
| J3465 | A | $4.64 |
| J3489 | A | $15.67 |
| J7178 | A | $1.14 |
| J7180 | A | $8.18 |
| J7181 | A | $14.62 |
| J7183 | A | $0.97 |
| J7185 | A | $1.20 |
| J7186 | A | $0.97 |
| J7187 | A | $1.04 |
| J7188 | A | $4.53 |
| J7189 | A | $1.90 |
| J7190 | A | $0.98 |
| J7191 | A | $0.20 |
| J7192 | A | $1.20 |
| J7193 | A | $1.11 |
| J7194 | A | $1.29 |
| J7195 | A | $1.52 |
| J7196 | A | $103.35 |
| J7197 | A | $3.43 |
| J7198 | A | $1.92 |
| J7200 | A | $1.25 |
| J7201 | A | $2.82 |
| J7205 | A | $1.89 |
| J7308 | A | $327.41 |
| J7309 | A | $83.69 |
| J7310 | A | $16,960.00 |
| J7311 | A | $20,126.60 |
| J7312 | A | $200.90 |
| J7313 | A | $490.95 |
| J7316 | A | $1,046.75 |
| J7321 | A | $87.73 |
| J7323 | A | $155.32 |
| J7324 | A | $159.28 |
| J7325 | A | $12.77 |
| J7326 | A | $587.58 |
| J7327 | A | $917.77 |
| J7336 | A | $2.98 |
| J7340 | A | $2.14 |
| J7501 | A | $255.53 |
| J7503 | A | $1.23 |
| J7504 | A | $1,438.74 |
| J7508 | A | $0.39 |
| J7511 | A | $690.84 |
| J7513 | A | $526.34 |
| J7525 | A | $163.77 |
| J8501 | A | $11.11 |
| J8510 | A | $23.69 |
| J8520 | A | $4.12 |
| J8521 | A | $13.78 |
| J8560 | A | $71.61 |
| J8650 | A | $38.19 |
| J8655 | A | $461.97 |
| J8700 | A | $2.66 |
| J8705 | A | $103.85 |
| J9015 | A | $3,067.64 |
| J9017 | A | $64.62 |
| J9019 | A | $402.74 |
| J9025 | A | $2.84 |
| J9027 | A | $152.44 |
| J9031 | A | $123.20 |
| J9032 | A | $33.54 |
| J9033 | A | $27.01 |
| J9035 | A | $72.31 |
| J9039 | A | $98.79 |
| J9041 | A | $46.52 |
| J9042 | A | $129.09 |
| J9043 | A | $154.57 |
| J9047 | A | $31.95 |
| J9050 | A | $3,847.56 |
| J9055 | A | $55.63 |
| J9065 | A | $21.75 |
| J9070 | A | $43.97 |
| J9098 | A | $595.76 |
| J9120 | A | $1,276.38 |
| J9150 | A | $40.03 |
| J9151 | A | $243.67 |
| J9155 | A | $3.62 |
| J9171 | A | $2.72 |
| J9179 | A | $106.08 |
| J9200 | A | $52.80 |
| J9202 | A | $327.12 |
| J9207 | A | $77.87 |
| J9208 | A | $28.18 |
| J9211 | A | $29.76 |
| J9213 | A | $733.57 |
| J9214 | A | $26.86 |
| J9216 | A | $5,739.88 |
| J9217 | A | $225.01 |
| J9219 | A | $168.48 |
| J9225 | A | $3,138.04 |
| J9226 | A | $26,205.50 |
| J9228 | A | $142.65 |
| J9230 | A | $265.89 |
| J9245 | A | $1,871.63 |
| J9261 | A | $152.21 |
| J9262 | A | $2.69 |
| J9263 | A | $0.39 |
| J9264 | A | $10.32 |
| J9266 | A | $13,911.23 |
| J9268 | A | $1,887.77 |
| J9271 | A | $46.50 |
| J9280 | A | $103.17 |
| J9293 | A | $36.75 |
| J9299 | A | $26.06 |
| J9301 | A | $56.20 |
| J9302 | A | $51.87 |
| J9303 | A | $105.60 |
| J9305 | A | $62.78 |
| J9306 | A | $10.65 |
| J9307 | A | $229.72 |
| J9308 | A | $55.93 |
| J9310 | A | $792.92 |
| J9315 | A | $306.79 |
| J9320 | A | $323.60 |
| J9328 | A | $8.24 |
| J9330 | A | $66.67 |
| J9340 | A | $1,035.21 |
| J9354 | A | $29.22 |
| J9355 | A | $92.09 |
| J9357 | A | $1,148.73 |
| J9371 | A | $2,506.49 |
| J9395 | A | $95.77 |
| J9400 | A | $8.45 |
| J9600 | A | $20,910.92 |
| P9041 | A | $11.02 |
| P9045 | A | $54.72 |
| P9046 | A | $22.49 |
| P9047 | A | $53.44 |
| Q0138 | A | $0.88 |
| Q2017 | A | $2,377.68 |
| Q2043 | A | $38,034.65 |
| Q2049 | A | $508.43 |
| Q2050 | A | $435.44 |
| Q3027 | A | $45.37 |
| Q4121 | A | $42.71 |
| Q5101 | A | $0.83 |
| Q9950 | A | $22.33 |
| Q9968 | A | $2.22 |
| Q9981 | A | $12.65 |
| Q9982 | A | $3,135.00 |
| Q9983 | A | $2,968.00 |
| 90371 | A | $111.33 |
| 90375 | A | $305.48 |
| 90376 | A | $294.59 |
| 90378 | A | $1,947.49 |
| 90396 | A | $1,230.98 |
| 90585 | A | $123.20 |
| 90620 | A | $147.37 |
| 90621 | A | $122.70 |
| 90675 | A | $272.49 |
| 90676 | A | $172.30 |
| 90733 | A | $106.49 |
| 90734 | A | $97.49 |
| 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 2017 by the | ||
| American Medical Association. | ||
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 2017 by the American Medical Association.

