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Revised July 2021 3rd Quarter ASC Drug File

Effective 07.01.2021 – Revised 07.01.2022

HCPCS Code Status Indicator Amount
A9591 A $644.83
A9592 A $918.10
C9046 A $1.30
C9047 A $691.06
C9065 A $285.17
C9067 A $8.64
C9075 A $164.80
C9077 A $20.39
C9078 A $4.87
C9079 A $160.94
C9080 A $489.25
C9248 A $2.89
C9250 A $156.84
C9257 A $1.77
C9290 A $1.33
C9399 C $0.00
C9460 A $16.30
C9462 A $0.39
C9482 A $17.58
C9488 A $43.63
J0121 A $3.29
J0129 A $45.32
J0135 A $1,581.57
J0178 A $916.41
J0179 A $310.79
J0180 A $196.22
J0185 A $1.61
J0202 A $2,052.48
J0207 A $1,135.69
J0220 A $117.07
J0221 A $176.95
J0222 A $97.59
J0223 A $106.76
J0224 A $299.74
J0256 A $4.56
J0257 A $4.97
J0287 A $9.42
J0289 A $28.33
J0291 A $3.05
J0300 A $125.22
J0390 A $165.22
J0401 A $5.92
J0475 A $179.42
J0480 A $4,029.23
J0485 A $3.80
J0490 A $47.58
J0517 A $172.61
J0558 A $12.04
J0561 A $15.19
J0565 A $39.75
J0570 A $1,311.75
J0584 A $369.03
J0585 A $6.08
J0586 A $8.20
J0587 A $12.02
J0588 A $5.04
J0594 A $1.95
J0596 A $30.25
J0597 A $57.49
J0598 A $58.21
J0599 A $10.25
J0600 A $5,708.59
J0630 A $3,036.61
J0638 A $115.42
J0641 A $0.00
J0642 A $1.70
J0691 A $0.72
J0693 A $1.01
J0695 A $6.64
J0712 A $3.54
J0714 A $92.46
J0716 A $5,190.15
J0717 A $6.52
J0740 A $589.78
J0742 A $2.30
J0745 A $135.64
J0775 A $54.40
J0791 A $123.28
J0795 A $9.67
J0840 A $2,866.13
J0841 A $1,265.47
J0850 A $1,520.65
J0875 A $15.80
J0881 A $3.20
J0882 A $3.20
J0883 A $1.31
J0884 A $1.31
J0885 A $8.22
J0888 A $1.53
J0894 A $4.17
J0896 A $36.83
J0897 A $20.97
J1095 A $1.04
J1096 A $134.40
J1097 A $101.00
J1162 A $4,128.19
J1190 A $194.98
J1201 A $15.47
J1212 A $637.13
J1290 A $499.51
J1300 A $229.77
J1301 A $20.27
J1303 A $225.56
J1322 A $250.12
J1364 A $78.74
J1410 A $341.77
J1427 A $59.78
J1429 A $166.31
J1430 A $444.10
J1437 A $25.82
J1438 A $790.78
J1439 A $1.13
J1442 A $0.96
J1447 A $0.47
J1451 A $5.16
J1453 A $0.33
J1454 A $594.20
J1455 A $80.62
J1458 A $411.54
J1459 A $43.18
J1460 A $43.38
J1554 A $481.77
J1555 A $14.21
J1556 A $70.49
J1557 A $49.81
J1558 A $13.39
J1559 A $11.23
J1560 A $433.79
J1561 A $47.77
J1566 A $65.89
J1568 A $41.60
J1569 A $47.71
J1571 A $70.05
J1572 A $34.71
J1573 A $70.25
J1575 A $14.83
J1595 A $148.18
J1602 A $16.96
J1610 A $177.45
J1628 A $82.47
J1632 A $76.10
J1640 A $26.44
J1670 A $483.91
J1726 A $13.38
J1729 A $21.54
J1738 A $3.23
J1740 A $37.06
J1742 A $226.10
J1744 A $219.13
J1745 A $41.32
J1746 A $64.37
J1750 A $15.79
J1786 A $43.96
J1823 A $453.32
J1826 A $2,293.85
J1830 A $397.76
J1833 A $0.81
J1930 A $68.50
J1931 A $34.43
J1943 A $2.93
J1944 A $2.90
J1950 A $1,307.48
J1951 A $127.75
J2182 A $28.74
J2186 A $1.75
J2248 A $1.11
J2265 A $2.00
J2278 A $8.66
J2315 A $3.44
J2323 A $23.25
J2326 A $1,122.04
J2350 A $58.58
J2353 A $203.94
J2357 A $37.89
J2358 A $2.92
J2407 A $23.79
J2425 A $23.93
J2426 A $12.55
J2502 A $351.40
J2504 A $4.06
J2505 A $2,469.36
J2507 A $2,900.42
J2515 A $27.62
J2547 A $1.68
J2560 A $44.95
J2562 A $382.64
J2597 A $9.86
J2724 A $15.15
J2760 A $409.55
J2770 A $456.88
J2778 A $306.93
J2783 A $316.06
J2786 A $9.96
J2792 A $30.03
J2794 A $10.96
J2796 A $82.30
J2798 A $10.71
J2820 A $49.51
J2840 A $539.97
J2850 A $34.78
J2860 A $121.92
J2941 A $36.54
J2993 A $2,506.51
J2997 A $87.41
J3031 A $2.37
J3032 A $15.60
J3060 A $41.38
J3090 A $1.58
J3095 A $6.66
J3101 A $134.81
J3111 A $9.31
J3145 A $1.57
J3240 A $1,841.18
J3241 A $315.88
J3243 A $1.00
J3245 A $135.37
J3246 A $3.74
J3262 A $5.53
J3285 A $60.38
J3304 A $18.00
J3315 A $428.22
J3316 A $3,044.01
J3357 A $172.47
J3358 A $11.75
J3380 A $21.02
J3385 A $357.59
J3396 A $11.19
J3398 A $2,950.78
J7168 A $2.23
J7169 A $290.62
J7170 A $48.76
J7175 A $8.20
J7178 A $1.30
J7179 A $1.79
J7180 A $9.13
J7181 A $15.74
J7182 A $1.33
J7183 A $1.14
J7185 A $1.33
J7186 A $1.12
J7187 A $1.26
J7188 A $3.20
J7189 A $2.31
J7190 A $1.12
J7192 A $1.41
J7193 A $1.13
J7194 A $1.49
J7195 A $1.59
J7197 A $3.31
J7198 A $2.15
J7200 A $1.47
J7201 A $3.26
J7202 A $4.61
J7203 A $4.09
J7204 A $2.22
J7205 A $2.12
J7207 A $1.92
J7208 A $2.10
J7209 A $1.23
J7210 A $1.37
J7211 A $1.27
J7212 A $2.19
J7308 A $382.13
J7311 A $340.22
J7312 A $200.07
J7313 A $490.95
J7314 A $507.07
J7316 A $1,046.93
J7318 A $17.23
J7320 A $16.92
J7322 A $31.67
J7323 A $129.16
J7324 A $134.95
J7325 A $10.89
J7326 A $1,219.00
J7327 A $790.58
J7328 A $2.18
J7329 A $19.12
J7331 A $18.02
J7336 A $3.25
J7340 A $211.61
J7342 A $29.98
J7345 A $1.61
J7351 A $206.26
J7352 A $3,218.90
J7402 A $10.56
J7501 A $244.86
J7504 A $2,362.27
J7511 A $845.55
J7525 A $215.74
J8560 A $75.73
J8655 A $316.42
J8670 A $1.75
J9015 A $3,795.26
J9017 A $18.43
J9019 A $427.27
J9022 A $79.79
J9023 A $86.00
J9025 A $1.21
J9027 A $64.94
J9032 A $42.23
J9033 A $23.80
J9034 A $19.65
J9035 A $70.60
J9036 A $21.26
J9037 A $42.91
J9039 A $122.27
J9041 A $44.69
J9042 A $189.16
J9043 A $190.22
J9044 A $19.30
J9047 A $40.48
J9050 A $1,722.02
J9055 A $66.31
J9057 A $80.90
J9065 A $18.68
J9070 A $31.00
J9119 A $27.58
J9120 A $942.72
J9144 A $45.14
J9145 A $57.64
J9150 A $45.24
J9153 A $202.81
J9155 A $3.98
J9173 A $76.76
J9176 A $6.77
J9177 A $29.06
J9179 A $121.29
J9198 A $34.16
J9202 A $531.63
J9203 A $207.99
J9204 A $210.05
J9205 A $56.61
J9207 A $112.09
J9210 A $389.89
J9214 A $33.76
J9217 A $144.46
J9223 A $174.20
J9225 A $5,166.29
J9226 A $41,645.55
J9227 A $67.70
J9228 A $158.84
J9229 A $2,371.62
J9230 A $11.74
J9245 A $224.40
J9246 A $17.77
J9261 A $152.44
J9262 A $3.31
J9264 A $14.10
J9266 A $21,544.13
J9268 A $1,971.00
J9269 A $284.01
J9270 A $115.40
J9271 A $51.35
J9280 A $44.38
J9281 A $282.12
J9285 A $52.07
J9293 A $29.19
J9295 A $5.74
J9299 A $28.90
J9301 A $64.42
J9302 A $63.96
J9303 A $128.58
J9305 A $74.20
J9306 A $13.53
J9307 A $310.19
J9308 A $62.38
J9309 A $113.57
J9311 A $38.27
J9312 A $87.78
J9313 A $23.39
J9315 A $336.84
J9316 A $72.63
J9317 A $30.37
J9320 A $344.94
J9325 A $56.51
J9328 A $10.39
J9330 A $37.63
J9340 A $453.46
J9348 A $524.48
J9349 A $12.64
J9352 A $324.21
J9353 A $42.79
J9354 A $34.16
J9355 A $90.98
J9356 A $72.24
J9357 A $1,382.42
J9358 A $24.29
J9371 A $3,320.42
J9395 A $27.60
J9400 A $8.27
J9600 A $21,856.35
P9041 A $10.49
P9045 A $52.45
P9046 A $20.98
P9047 A $52.45
Q0138 A $0.95
Q0139 A $0.95
Q2017 A $2,645.71
Q2026 A $257.37
Q2028 A $2.49
Q2043 A $51,712.98
Q2049 A $311.04
Q2050 A $257.09
Q3027 A $55.52
Q5101 A $0.35
Q5103 A $40.05
Q5104 A $39.56
Q5105 A $0.86
Q5106 A $8.63
Q5107 A $48.78
Q5108 A $222.26
Q5110 A $0.39
Q5111 A $251.74
Q5112 A $72.08
Q5113 A $66.76
Q5114 A $63.40
Q5115 A $60.84
Q5116 A $64.79
Q5117 A $59.34
Q5118 A $55.19
Q5119 A $62.48
Q5120 A $270.56
Q5121 A $49.15
Q5122 A $314.21
Q5123 A $73.83
Q9968 A $6.66
Q9991 A $1,816.65
Q9992 A $1,816.65
90371 A $131.86
90375 A $297.80
90376 A $309.10
90377 A $243.78
90378 A $1,185.67
90385 A $151.41
90396 A $1,930.25
90675 A $326.61
90676 A $189.63
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 2021 by the American Medical Association.

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