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Revised October 2021 4th Quarter ASC Drug File

Effective 10.01.2021 – Revised 07.01.2022

HCPCS Code Status Indicator Amount
A9590 A $320.12
A9591 A $644.83
A9592 A $918.21
A9593 A $732.86
A9594 A $717.55
C9046 A $1.33
C9047 A $691.29
C9067 A $8.64
C9082 A $2,136.09
C9083 A $87.89
C9084 A $242.05
C9248 A $2.91
C9250 A $156.84
C9257 A $1.76
C9290 A $1.33
C9399 C $0.00
C9460 A $16.32
C9462 A $0.37
C9482 A $17.58
C9488 A $43.94
J0121 A $3.30
J0129 A $45.27
J0135 A $1,581.57
J0178 A $917.94
J0179 A $312.01
J0180 A $198.14
J0185 A $1.69
J0202 A $2,086.32
J0207 A $1,135.69
J0220 A $117.07
J0221 A $180.35
J0222 A $97.75
J0223 A $106.76
J0224 A $302.30
J0256 A $4.54
J0257 A $4.95
J0287 A $9.50
J0289 A $28.75
J0291 A $3.05
J0300 A $125.22
J0390 A $165.22
J0401 A $6.01
J0475 A $177.43
J0480 A $4,013.08
J0485 A $3.80
J0490 A $47.57
J0517 A $170.80
J0558 A $11.79
J0561 A $14.95
J0565 A $39.77
J0570 A $1,311.75
J0584 A $369.11
J0585 A $6.09
J0586 A $8.41
J0587 A $12.05
J0588 A $5.05
J0594 A $1.71
J0596 A $29.97
J0597 A $57.39
J0598 A $58.93
J0599 A $10.25
J0600 A $5,708.59
J0630 A $3,100.79
J0638 A $115.61
J0641 A $0.00
J0642 A $1.86
J0691 A $0.72
J0695 A $6.64
J0699 A $2.01
J0712 A $3.51
J0714 A $92.39
J0716 A $5,190.15
J0717 A $6.27
J0740 A $563.76
J0741 A $20.56
J0742 A $2.32
J0745 A $135.64
J0775 A $56.66
J0791 A $123.29
J0795 A $9.67
J0840 A $2,743.36
J0841 A $1,189.81
J0850 A $1,538.70
J0875 A $15.89
J0881 A $3.15
J0882 A $3.15
J0883 A $1.20
J0884 A $1.20
J0885 A $8.15
J0888 A $1.51
J0894 A $3.45
J0896 A $36.85
J0897 A $21.19
J1095 A $1.04
J1096 A $133.30
J1097 A $102.82
J1162 A $4,128.19
J1190 A $192.33
J1201 A $15.38
J1212 A $637.11
J1290 A $503.88
J1300 A $229.23
J1301 A $20.64
J1303 A $224.68
J1305 A $165.63
J1322 A $250.33
J1364 A $77.75
J1410 A $341.46
J1426 A $166.47
J1427 A $59.05
J1429 A $166.21
J1430 A $444.10
J1437 A $24.87
J1438 A $790.78
J1439 A $1.12
J1442 A $0.97
J1447 A $0.46
J1448 A $4.97
J1451 A $5.98
J1453 A $0.24
J1454 A $571.22
J1455 A $72.86
J1458 A $411.92
J1459 A $44.48
J1460 A $44.13
J1554 A $481.77
J1555 A $14.50
J1556 A $70.49
J1557 A $48.53
J1558 A $13.61
J1559 A $11.58
J1560 A $441.31
J1561 A $48.22
J1566 A $65.49
J1568 A $41.63
J1569 A $44.49
J1571 A $70.94
J1572 A $36.80
J1573 A $71.24
J1575 A $15.16
J1595 A $141.29
J1602 A $16.82
J1610 A $171.74
J1628 A $82.56
J1632 A $74.65
J1640 A $26.64
J1670 A $441.70
J1726 A $16.82
J1729 A $21.54
J1738 A $3.18
J1740 A $37.09
J1742 A $205.06
J1744 A $204.96
J1745 A $39.53
J1746 A $66.39
J1750 A $15.84
J1786 A $44.05
J1823 A $458.21
J1826 A $2,293.85
J1830 A $406.24
J1833 A $0.83
J1930 A $67.64
J1931 A $34.75
J1943 A $3.05
J1944 A $2.99
J1950 A $1,406.37
J1951 A $126.28
J2182 A $28.41
J2186 A $1.76
J2248 A $0.97
J2265 A $2.00
J2278 A $8.69
J2315 A $3.53
J2323 A $23.24
J2326 A $1,122.13
J2350 A $58.29
J2353 A $205.37
J2357 A $37.67
J2358 A $2.91
J2406 A $41.92
J2407 A $23.63
J2425 A $23.93
J2426 A $12.66
J2502 A $359.03
J2504 A $4.06
J2505 A $2,221.63
J2507 A $2,960.91
J2515 A $26.41
J2547 A $1.68
J2560 A $40.22
J2562 A $382.85
J2597 A $9.40
J2724 A $15.13
J2760 A $416.00
J2770 A $444.67
J2778 A $318.47
J2783 A $315.06
J2786 A $10.11
J2792 A $31.42
J2794 A $11.04
J2796 A $83.47
J2798 A $10.69
J2820 A $51.55
J2840 A $539.91
J2850 A $34.78
J2860 A $124.09
J2941 A $36.54
J2993 A $2,506.51
J2997 A $87.75
J3031 A $2.34
J3032 A $15.64
J3060 A $41.32
J3090 A $1.60
J3095 A $6.16
J3101 A $134.74
J3111 A $9.34
J3145 A $1.63
J3240 A $1,837.25
J3241 A $315.88
J3243 A $1.12
J3245 A $134.08
J3246 A $3.83
J3262 A $5.55
J3285 A $59.68
J3304 A $17.75
J3315 A $379.90
J3316 A $3,120.11
J3357 A $176.77
J3358 A $11.68
J3380 A $21.28
J3385 A $359.29
J3396 A $11.25
J3398 A $2,953.71
J7168 A $1.99
J7169 A $289.93
J7170 A $48.88
J7175 A $8.20
J7178 A $1.30
J7179 A $1.85
J7180 A $9.14
J7181 A $15.87
J7182 A $1.51
J7183 A $1.16
J7185 A $1.33
J7186 A $1.14
J7187 A $1.26
J7188 A $3.19
J7189 A $2.33
J7190 A $1.12
J7192 A $1.43
J7193 A $1.17
J7194 A $1.54
J7195 A $1.61
J7197 A $3.20
J7198 A $2.21
J7200 A $1.54
J7201 A $3.28
J7202 A $4.59
J7203 A $4.23
J7204 A $2.23
J7205 A $2.15
J7207 A $1.92
J7208 A $2.10
J7209 A $1.24
J7210 A $1.36
J7211 A $1.24
J7212 A $2.27
J7308 A $392.48
J7311 A $339.00
J7312 A $199.69
J7313 A $490.95
J7314 A $513.16
J7316 A $1,046.93
J7318 A $17.23
J7320 A $16.92
J7322 A $31.67
J7323 A $138.82
J7324 A $148.74
J7325 A $11.24
J7326 A $1,219.00
J7327 A $762.80
J7328 A $2.18
J7329 A $19.12
J7331 A $18.02
J7336 A $3.23
J7340 A $211.70
J7342 A $29.98
J7345 A $1.59
J7351 A $205.63
J7352 A $3,218.90
J7402 A $10.56
J7501 A $245.02
J7504 A $2,355.53
J7511 A $837.42
J7525 A $219.33
J8560 A $75.63
J8655 A $315.59
J8670 A $1.75
J9015 A $3,795.26
J9017 A $13.11
J9019 A $427.27
J9022 A $79.75
J9023 A $86.19
J9025 A $0.93
J9027 A $53.15
J9032 A $42.77
J9033 A $22.01
J9034 A $19.65
J9035 A $70.41
J9036 A $21.47
J9037 A $42.78
J9039 A $123.88
J9041 A $45.16
J9042 A $189.34
J9043 A $189.00
J9044 A $18.31
J9047 A $41.10
J9050 A $1,234.46
J9055 A $66.71
J9057 A $80.96
J9065 A $18.02
J9070 A $29.15
J9119 A $27.54
J9120 A $890.64
J9144 A $45.10
J9145 A $57.55
J9150 A $40.36
J9153 A $202.60
J9155 A $4.12
J9173 A $76.86
J9176 A $6.77
J9177 A $30.17
J9179 A $123.93
J9198 A $34.00
J9202 A $525.21
J9203 A $207.99
J9204 A $210.05
J9205 A $57.20
J9207 A $112.12
J9210 A $376.03
J9214 A $33.24
J9217 A $139.09
J9223 A $174.03
J9225 A $5,166.29
J9226 A $43,467.03
J9227 A $67.60
J9228 A $158.65
J9229 A $2,371.62
J9230 A $11.74
J9245 A $208.41
J9246 A $18.20
J9247 A $499.86
J9261 A $155.90
J9262 A $3.30
J9264 A $14.08
J9266 A $21,561.05
J9268 A $1,880.67
J9269 A $290.37
J9270 A $115.40
J9271 A $52.75
J9280 A $38.63
J9281 A $281.88
J9285 A $52.07
J9293 A $26.29
J9295 A $5.74
J9299 A $28.86
J9301 A $64.54
J9302 A $63.96
J9303 A $130.38
J9305 A $74.93
J9306 A $13.56
J9307 A $314.84
J9308 A $62.69
J9309 A $113.57
J9311 A $37.94
J9312 A $86.94
J9313 A $23.39
J9316 A $72.15
J9317 A $30.35
J9318 A $33.91
J9319 A $33.68
J9320 A $348.51
J9325 A $57.26
J9328 A $10.41
J9330 A $38.25
J9340 A $305.84
J9348 A $539.07
J9349 A $12.62
J9352 A $325.03
J9353 A $43.87
J9354 A $34.18
J9355 A $89.81
J9356 A $71.85
J9357 A $1,425.37
J9358 A $24.27
J9371 A $3,370.23
J9395 A $15.98
J9400 A $8.42
J9600 A $21,856.35
P9041 A $10.49
P9045 A $52.45
P9046 A $20.98
P9047 A $52.45
Q0138 A $1.00
Q0139 A $1.00
Q2017 A $2,645.71
Q2026 A $257.37
Q2028 A $2.49
Q2043 A $53,017.58
Q2049 A $311.04
Q2050 A $234.03
Q3027 A $55.29
Q5101 A $0.32
Q5103 A $41.19
Q5104 A $38.79
Q5106 A $8.66
Q5107 A $44.56
Q5108 A $211.19
Q5110 A $0.33
Q5111 A $222.38
Q5112 A $66.55
Q5113 A $57.30
Q5114 A $59.91
Q5115 A $60.58
Q5116 A $59.93
Q5117 A $53.18
Q5118 A $52.37
Q5119 A $58.80
Q5120 A $245.43
Q5121 A $47.12
Q5122 A $284.69
Q5123 A $72.23
Q9968 A $6.73
Q9991 A $1,796.80
Q9992 A $1,796.80
90371 A $130.31
90375 A $267.30
90376 A $287.38
90377 A $272.34
90378 A $1,185.67
90396 A $1,965.97
90675 A $327.53
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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