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.

