Revised October 2020 4th QTR ASC Drug File
Effective 10.01.2020 – Revised 07.01.2021
| HCPCS Code | Status Indicator | Amount |
|---|---|---|
| C9046 | A | $1.23 |
| C9047 | A | $690.68 |
| C9060 | A | $.75 |
| C9062 | A | $43.34 |
| C9064 | A | $275.22 |
| C9065 | A | $329.46 |
| C9066 | A | $28.79 |
| C9067 | A | $8.64 |
| C9122 | A | $10.25 |
| C9132 | A | $2.09 |
| C9250 | A | $156.84 |
| C9257 | A | $1.91 |
| C9290 | A | $1.29 |
| C9399 | C | $0.00 |
| C9460 | A | $15.32 |
| C9462 | A | $.28 |
| C9482 | A | $16.00 |
| C9488 | A | $32.57 |
| J0121 | A | $3.15 |
| J0122 | A | $1.02 |
| J0129 | A | $58.10 |
| J0135 | A | $1430.92 |
| J0178 | A | $928.24 |
| J0179 | A | $311.99 |
| J0180 | A | $188.99 |
| J0185 | A | $1.73 |
| J0202 | A | $1984.32 |
| J0207 | A | $1135.69 |
| J0220 | A | $73.81 |
| J0221 | A | $174.49 |
| J0222 | A | $97.84 |
| J0223 | A | $106.88 |
| J0256 | A | $4.36 |
| J0257 | A | $4.83 |
| J0287 | A | $9.36 |
| J0289 | A | $26.56 |
| J0291 | A | $3.11 |
| J0300 | A | $95.16 |
| J0401 | A | $5.70 |
| J0475 | A | $171.59 |
| J0480 | A | $4005.19 |
| J0485 | A | $3.78 |
| J0490 | A | $46.18 |
| J0517 | A | $170.11 |
| J0558 | A | $12.00 |
| J0561 | A | $15.16 |
| J0565 | A | $39.65 |
| J0567 | A | $95.36 |
| J0570 | A | $1207.16 |
| J0584 | A | $361.90 |
| J0585 | A | $6.08 |
| J0586 | A | $8.15 |
| J0587 | A | $11.93 |
| J0588 | A | $5.02 |
| J0593 | A | $78.65 |
| J0594 | A | $3.41 |
| J0596 | A | $29.11 |
| J0597 | A | $54.13 |
| J0598 | A | $56.20 |
| J0599 | A | $9.92 |
| J0600 | A | $5594.42 |
| J0606 | A | $2.15 |
| J0630 | A | $2839.22 |
| J0638 | A | $113.24 |
| J0641 | A | $.28 |
| J0642 | A | $1.89 |
| J0691 | A | $.72 |
| J0695 | A | $6.49 |
| J0712 | A | $3.32 |
| J0714 | A | $92.00 |
| J0716 | A | $5063.56 |
| J0717 | A | $8.16 |
| J0740 | A | $666.25 |
| J0742 | A | $2.26 |
| J0775 | A | $52.39 |
| J0791 | A | $122.41 |
| J0795 | A | $9.38 |
| J0800 | A | $4013.24 |
| J0840 | A | $3043.75 |
| J0841 | A | $1264.21 |
| J0850 | A | $1496.95 |
| J0875 | A | $15.39 |
| J0878 | A | $.16 |
| J0881 | A | $3.72 |
| J0882 | A | $3.72 |
| J0883 | A | $1.31 |
| J0884 | A | $1.31 |
| J0885 | A | $9.11 |
| J0894 | A | $4.26 |
| J0896 | A | $36.32 |
| J0897 | A | $20.12 |
| J1095 | A | $1.11 |
| J1096 | A | $139.55 |
| J1162 | A | $3972.14 |
| J1190 | A | $199.93 |
| J1201 | A | $15.45 |
| J1212 | A | $635.67 |
| J1267 | A | $1.15 |
| J1290 | A | $494.69 |
| J1300 | A | $230.48 |
| J1301 | A | $19.89 |
| J1303 | A | $226.28 |
| J1322 | A | $246.20 |
| J1327 | A | $4.51 |
| J1410 | A | $325.62 |
| J1428 | A | $167.45 |
| J1429 | A | $166.33 |
| J1430 | A | $444.10 |
| J1438 | A | $736.30 |
| J1439 | A | $1.11 |
| J1442 | A | $.93 |
| J1447 | A | $.47 |
| J1451 | A | $5.33 |
| J1453 | A | $.79 |
| J1454 | A | $695.77 |
| J1455 | A | $82.27 |
| J1458 | A | $405.76 |
| J1459 | A | $41.50 |
| J1460 | A | $42.93 |
| J1555 | A | $14.02 |
| J1557 | A | $53.66 |
| J1558 | A | $14.22 |
| J1559 | A | $10.86 |
| J1560 | A | $429.26 |
| J1561 | A | $42.19 |
| J1566 | A | $68.30 |
| J1568 | A | $41.23 |
| J1569 | A | $43.20 |
| J1571 | A | $63.40 |
| J1572 | A | $40.38 |
| J1573 | A | $65.96 |
| J1575 | A | $14.49 |
| J1595 | A | $157.42 |
| J1602 | A | $19.00 |
| J1610 | A | $211.79 |
| J1628 | A | $93.12 |
| J1632 | A | $76.91 |
| J1640 | A | $24.44 |
| J1670 | A | $476.57 |
| J1726 | A | $15.88 |
| J1729 | A | $10.81 |
| J1738 | A | $3.26 |
| J1740 | A | $51.00 |
| J1742 | A | $316.20 |
| J1743 | A | $542.92 |
| J1744 | A | $276.57 |
| J1745 | A | $47.62 |
| J1746 | A | $63.62 |
| J1750 | A | $15.01 |
| J1786 | A | $43.38 |
| J1826 | A | $2276.61 |
| J1830 | A | $393.83 |
| J1833 | A | $.78 |
| J1930 | A | $68.48 |
| J1931 | A | $33.10 |
| J1943 | A | $2.86 |
| J1944 | A | $2.85 |
| J1950 | A | $1347.56 |
| J2182 | A | $28.70 |
| J2186 | A | $1.78 |
| J2265 | A | $1.99 |
| J2278 | A | $8.17 |
| J2315 | A | $3.26 |
| J2323 | A | $21.63 |
| J2326 | A | $1122.51 |
| J2350 | A | $57.38 |
| J2353 | A | $205.88 |
| J2355 | A | $1.34 |
| J2357 | A | $37.70 |
| J2407 | A | $23.80 |
| J2425 | A | $22.81 |
| J2426 | A | $12.10 |
| J2502 | A | $332.59 |
| J2504 | A | $1471.85 |
| J2505 | A | $3571.68 |
| J2507 | A | $2801.08 |
| J2515 | A | $33.93 |
| J2547 | A | $1.60 |
| J2562 | A | $365.29 |
| J2597 | A | $10.45 |
| J2724 | A | $15.06 |
| J2760 | A | $359.14 |
| J2770 | A | $458.04 |
| J2778 | A | $324.27 |
| J2783 | A | $300.94 |
| J2786 | A | $9.76 |
| J2792 | A | $36.37 |
| J2794 | A | $10.53 |
| J2796 | A | $78.43 |
| J2798 | A | $10.18 |
| J2820 | A | $47.06 |
| J2840 | A | $541.13 |
| J2850 | A | $34.78 |
| J2860 | A | $111.94 |
| J2941 | A | $84.13 |
| J2997 | A | $87.15 |
| J3031 | A | $2.25 |
| J3032 | A | $15.40 |
| J3060 | A | $40.86 |
| J3090 | A | $1.59 |
| J3095 | A | $5.14 |
| J3101 | A | $129.26 |
| J3111 | A | $9.01 |
| J3145 | A | $1.54 |
| J3240 | A | $1740.23 |
| J3241 | A | $315.88 |
| J3243 | A | $1.38 |
| J3245 | A | $135.67 |
| J3246 | A | $2.19 |
| J3262 | A | $5.40 |
| J3285 | A | $62.81 |
| J3304 | A | $18.20 |
| J3315 | A | $385.61 |
| J3316 | A | $3044.01 |
| J3357 | A | $184.36 |
| J3358 | A | $12.03 |
| J3380 | A | $20.30 |
| J3385 | A | $346.15 |
| J3396 | A | $11.23 |
| J3397 | A | $223.01 |
| J3398 | A | $2883.20 |
| J7169 | A | $291.50 |
| J7170 | A | $47.47 |
| J7175 | A | $7.88 |
| J7177 | A | $1.07 |
| J7178 | A | $1.24 |
| J7179 | A | $1.78 |
| J7180 | A | $8.77 |
| J7181 | A | $15.53 |
| J7182 | A | $1.33 |
| J7183 | A | $1.02 |
| J7185 | A | $1.31 |
| J7186 | A | $1.14 |
| J7187 | A | $1.21 |
| J7188 | A | $3.19 |
| J7189 | A | $2.25 |
| J7190 | A | $1.02 |
| J7192 | A | $1.38 |
| J7193 | A | $1.16 |
| J7194 | A | $1.49 |
| J7195 | A | $1.53 |
| J7196 | A | $103.35 |
| J7197 | A | $3.50 |
| J7198 | A | $2.05 |
| J7200 | A | $1.46 |
| J7201 | A | $3.25 |
| J7202 | A | $4.44 |
| J7203 | A | $4.01 |
| J7204 | A | $2.29 |
| J7205 | A | $2.17 |
| J7207 | A | $1.87 |
| J7208 | A | $2.02 |
| J7209 | A | $1.36 |
| J7210 | A | $1.34 |
| J7308 | A | $394.75 |
| J7311 | A | $340.62 |
| J7312 | A | $199.76 |
| J7313 | A | $490.87 |
| J7314 | A | $491.13 |
| J7316 | A | $1046.93 |
| J7318 | A | $17.23 |
| J7320 | A | $16.92 |
| J7322 | A | $31.67 |
| J7323 | A | $140.31 |
| J7324 | A | $128.41 |
| J7325 | A | $10.22 |
| J7326 | A | $1219.00 |
| J7327 | A | $694.58 |
| J7328 | A | $2.18 |
| J7329 | A | $7.20 |
| J7331 | A | $4.39 |
| J7332 | A | $25.92 |
| J7336 | A | $3.25 |
| J7340 | A | $213.10 |
| J7342 | A | $29.97 |
| J7345 | A | $1.53 |
| J7351 | A | $200.85 |
| J7501 | A | $227.93 |
| J7504 | A | $2257.67 |
| J7511 | A | $817.12 |
| J7525 | A | $211.97 |
| J8510 | A | $23.81 |
| J8560 | A | $75.49 |
| J8655 | A | $270.10 |
| J8670 | A | $2.27 |
| J9015 | A | $4964.62 |
| J9017 | A | $22.06 |
| J9019 | A | $427.27 |
| J9022 | A | $78.28 |
| J9023 | A | $84.70 |
| J9025 | A | $.80 |
| J9027 | A | $52.64 |
| J9030 | A | $2.79 |
| J9032 | A | $42.79 |
| J9033 | A | $24.69 |
| J9034 | A | $20.27 |
| J9035 | A | $76.36 |
| J9036 | A | $21.61 |
| J9039 | A | $118.59 |
| J9041 | A | $44.97 |
| J9042 | A | $175.28 |
| J9043 | A | $181.51 |
| J9044 | A | $22.04 |
| J9047 | A | $39.20 |
| J9050 | A | $2016.27 |
| J9055 | A | $64.41 |
| J9057 | A | $78.99 |
| J9065 | A | $19.57 |
| J9070 | A | $29.67 |
| J9098 | A | $492.92 |
| J9119 | A | $27.40 |
| J9120 | A | $1044.53 |
| J9145 | A | $56.29 |
| J9150 | A | $43.84 |
| J9153 | A | $197.79 |
| J9155 | A | $3.84 |
| J9171 | A | $.85 |
| J9173 | A | $76.02 |
| J9176 | A | $6.67 |
| J9177 | A | $27.96 |
| J9179 | A | $117.66 |
| J9202 | A | $503.59 |
| J9203 | A | $205.38 |
| J9204 | A | $203.88 |
| J9205 | A | $54.33 |
| J9207 | A | $101.19 |
| J9210 | A | $441.59 |
| J9213 | A | $407.24 |
| J9214 | A | $34.35 |
| J9217 | A | $224.45 |
| J9225 | A | $4558.13 |
| J9226 | A | $40237.00 |
| J9227 | A | $66.67 |
| J9228 | A | $157.38 |
| J9229 | A | $2341.50 |
| J9230 | A | $328.29 |
| J9245 | A | $260.38 |
| J9246 | A | $26.96 |
| J9261 | A | $152.15 |
| J9262 | A | $2.98 |
| J9264 | A | $13.30 |
| J9266 | A | $19717.76 |
| J9268 | A | $2060.28 |
| J9269 | A | $270.59 |
| J9271 | A | $50.85 |
| J9280 | A | $49.88 |
| J9285 | A | $52.07 |
| J9293 | A | $28.69 |
| J9295 | A | $5.73 |
| J9299 | A | $28.56 |
| J9301 | A | $63.74 |
| J9302 | A | $61.94 |
| J9303 | A | $123.55 |
| J9305 | A | $71.95 |
| J9306 | A | $12.95 |
| J9307 | A | $311.22 |
| J9308 | A | $60.71 |
| J9309 | A | $110.72 |
| J9311 | A | $41.14 |
| J9312 | A | $92.56 |
| J9313 | A | $22.46 |
| J9315 | A | $336.54 |
| J9320 | A | $349.54 |
| J9325 | A | $53.92 |
| J9328 | A | $10.38 |
| J9330 | A | $44.99 |
| J9340 | A | $475.39 |
| J9352 | A | $318.93 |
| J9354 | A | $32.79 |
| J9355 | A | $99.68 |
| J9356 | A | $75.08 |
| J9357 | A | $1403.17 |
| J9358 | A | $24.14 |
| J9371 | A | $3320.17 |
| J9395 | A | $52.74 |
| J9400 | A | $8.07 |
| J9600 | A | $21856.35 |
| P9041 | A | $10.49 |
| P9045 | A | $52.45 |
| P9046 | A | $20.98 |
| P9047 | A | $52.45 |
| Q0138 | A | $.98 |
| Q0139 | A | $.98 |
| Q2009 | A | $1.61 |
| Q2017 | A | $2645.71 |
| Q2026 | A | $222.09 |
| Q2028 | A | $3.19 |
| Q2043 | A | $49671.77 |
| Q2049 | A | $482.06 |
| Q2050 | A | $315.73 |
| Q3027 | A | $54.32 |
| Q5101 | A | $.47 |
| Q5103 | A | $43.72 |
| Q5104 | A | $44.55 |
| Q5105 | A | $.86 |
| Q5106 | A | $8.61 |
| Q5107 | A | $60.94 |
| Q5108 | A | $269.04 |
| Q5110 | A | $.62 |
| Q5111 | A | $286.67 |
| Q5112 | A | $92.30 |
| Q5113 | A | $91.52 |
| Q5114 | A | $76.41 |
| Q5115 | A | $68.80 |
| Q5116 | A | $83.10 |
| Q5117 | A | $78.72 |
| Q5118 | A | $62.24 |
| Q5119 | A | $70.90 |
| Q5120 | A | $305.55 |
| Q5121 | A | $51.50 |
| Q9968 | A | $7.55 |
| Q9991 | A | $1743.48 |
| Q9992 | A | $1743.48 |
| 90296 | A | $2957.76 |
| 90371 | A | $119.09 |
| 90375 | A | $273.04 |
| 90376 | A | $331.80 |
| 90378 | A | $1838.68 |
| 90396 | A | $1703.97 |
| 90675 | A | $303.24 |
| 90676 | A | $227.53 |
| 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 2020 by the American Medical Association.

