Revised October 2023 4th QTR ASC Drug File
Effective 10/01/2023 – Revised 10/01/2024
| HCPCS Code | Status Indicator | Amount | Coinsurance % |
|---|---|---|---|
| A9590 | A | $338.06 | 20.000 |
| A9592 | A | $1,003.61 | 20.000 |
| A9593 | A | $806.14 | 20.000 |
| A9594 | A | $789.30 | 20.000 |
| A9595 | A | $580.35 | 20.000 |
| A9596 | A | $995.31 | 20.000 |
| A9602 | A | $446.88 | 20.000 |
| A9800 | A | $873.44 | 20.000 |
| C9047 | A | $745.65 | 20.000 |
| C9088 | A | $0.73 | 20.000 |
| C9089 | A | $0.85 | 20.000 |
| C9101 | A | $1.25 | 20.000 |
| C9144 | A | $0.51 | 20.000 |
| C9145 | A | $1.88 | 20.000 |
| C9152 | A | $5.84 | 20.000 |
| C9153 | A | $9.54 | 20.000 |
| C9154 | A | $12.84 | 20.000 |
| C9155 | A | $52.27 | 20.000 |
| C9156 | A | $614.78 | 20.000 |
| C9157 | A | $146.57 | 20.000 |
| C9158 | A | $25.38 | 20.000 |
| C9248 | A | $3.05 | 20.000 |
| C9250 | A | $180.54 | 20.000 |
| C9257 | A | $1.85 | 20.000 |
| C9290 | A | $1.43 | 20.000 |
| C9399 | C | $0.00 | 20.000 |
| C9460 | A | $18.24 | 20.000 |
| C9482 | A | $20.67 | 19.729 |
| C9488 | A | $47.24 | 20.000 |
| J0121 | A | $3.60 | 20.000 |
| J0129 | A | $42.70 | 20.000 |
| J0135 | A | $1,834.49 | 19.997 |
| J0172 | A | $5.98 | 20.000 |
| J0174 | A | $1.35 | 20.000 |
| J0178 | A | $868.24 | 20.000 |
| J0179 | A | $319.25 | 20.000 |
| J0180 | A | $217.60 | 20.000 |
| J0185 | A | $1.74 | 20.000 |
| J0202 | A | $2,292.77 | 20.000 |
| J0208 | A | $96.19 | 20.000 |
| J0218 | A | $377.11 | 20.000 |
| J0219 | A | $75.63 | 20.000 |
| J0220 | A | $122.56 | 20.000 |
| J0221 | A | $197.07 | 20.000 |
| J0222 | A | $100.17 | 20.000 |
| J0223 | A | $112.10 | 20.000 |
| J0224 | A | $319.50 | 20.000 |
| J0225 | A | $4,950.37 | 20.000 |
| J0248 | A | $6.06 | 20.000 |
| J0256 | A | $4.81 | 20.000 |
| J0257 | A | $5.42 | 20.000 |
| J0287 | A | $11.13 | 20.000 |
| J0289 | A | $27.92 | 20.000 |
| J0291 | A | $3.58 | 19.739 |
| J0300 | A | $171.17 | 20.000 |
| J0349 | A | $10.04 | 20.000 |
| J0390 | A | $0.71 | 20.000 |
| J0400 | A | $5.25 | 20.000 |
| J0401 | A | $6.82 | 20.000 |
| J0470 | A | $59.81 | 20.000 |
| J0475 | A | $182.26 | 20.000 |
| J0480 | A | $4,393.54 | 20.000 |
| J0485 | A | $3.79 | 20.000 |
| J0490 | A | $51.97 | 20.000 |
| J0491 | A | $16.60 | 20.000 |
| J0517 | A | $170.56 | 20.000 |
| J0558 | A | $15.74 | 17.741 |
| J0561 | A | $20.16 | 17.484 |
| J0565 | A | $39.84 | 20.000 |
| J0570 | A | $1,311.75 | 20.000 |
| J0584 | A | $433.52 | 19.744 |
| J0585 | A | $6.33 | 20.000 |
| J0586 | A | $8.80 | 20.000 |
| J0587 | A | $13.04 | 20.000 |
| J0588 | A | $5.19 | 20.000 |
| J0594 | A | $1.04 | 20.000 |
| J0596 | A | $33.70 | 20.000 |
| J0597 | A | $64.41 | 20.000 |
| J0598 | A | $60.73 | 20.000 |
| J0600 | A | $5,708.59 | 20.000 |
| J0630 | A | $1,296.36 | 20.000 |
| J0638 | A | $122.06 | 20.000 |
| J0641 | A | $0.06 | 20.000 |
| J0695 | A | $7.48 | 20.000 |
| J0699 | A | $2.17 | 20.000 |
| J0712 | A | $3.86 | 20.000 |
| J0714 | A | $95.44 | 20.000 |
| J0716 | A | $4,710.90 | 20.000 |
| J0717 | A | $4.90 | 20.000 |
| J0740 | A | $550.38 | 20.000 |
| J0741 | A | $22.29 | 20.000 |
| J0742 | A | $2.46 | 20.000 |
| J0745 | A | $31.65 | 20.000 |
| J0775 | A | $66.48 | 18.981 |
| J0791 | A | $126.86 | 20.000 |
| J0801 | A | $3,774.16 | 20.000 |
| J0802 | A | $3,477.54 | 20.000 |
| J0840 | A | $2,076.46 | 20.000 |
| J0841 | A | $1,113.51 | 20.000 |
| J0850 | A | $1,667.59 | 20.000 |
| J0875 | A | $15.21 | 20.000 |
| J0879 | A | $0.20 | 20.000 |
| J0881 | A | $2.95 | 20.000 |
| J0882 | A | $2.95 | 20.000 |
| J0883 | A | $1.21 | 20.000 |
| J0884 | A | $1.21 | 20.000 |
| J0885 | A | $7.09 | 20.000 |
| J0887 | A | $1.71 | 20.000 |
| J0891 | A | $0.37 | 20.000 |
| J0892 | A | $0.37 | 20.000 |
| J0896 | A | $39.21 | 20.000 |
| J0897 | A | $24.22 | 20.000 |
| J0898 | A | $4.13 | 20.000 |
| J0899 | A | $4.13 | 20.000 |
| J1096 | A | $123.51 | 20.000 |
| J1097 | A | $97.78 | 20.000 |
| J1162 | A | $4,593.57 | 20.000 |
| J1190 | A | $123.88 | 20.000 |
| J1201 | A | $15.18 | 20.000 |
| J1212 | A | $681.74 | 20.000 |
| J1290 | A | $532.25 | 20.000 |
| J1300 | A | $225.26 | 20.000 |
| J1301 | A | $21.39 | 20.000 |
| J1302 | A | $17.74 | 20.000 |
| J1303 | A | $221.67 | 20.000 |
| J1305 | A | $179.14 | 20.000 |
| J1306 | A | $12.02 | 20.000 |
| J1322 | A | $280.92 | 20.000 |
| J1364 | A | $83.64 | 20.000 |
| J1410 | A | $372.48 | 20.000 |
| J1426 | A | $166.22 | 20.000 |
| J1427 | A | $58.78 | 20.000 |
| J1429 | A | $166.19 | 20.000 |
| J1430 | A | $469.26 | 20.000 |
| J1437 | A | $20.06 | 20.000 |
| J1438 | A | $790.78 | 20.000 |
| J1439 | A | $1.12 | 20.000 |
| J1440 | A | $62.42 | 20.000 |
| J1442 | A | $0.99 | 20.000 |
| J1447 | A | $0.42 | 20.000 |
| J1448 | A | $5.20 | 20.000 |
| J1449 | A | $31.34 | 20.000 |
| J1451 | A | $6.61 | 20.000 |
| J1454 | A | $528.38 | 20.000 |
| J1455 | A | $59.07 | 20.000 |
| J1459 | A | $47.59 | 20.000 |
| J1460 | A | $48.77 | 20.000 |
| J1551 | A | $14.04 | 20.000 |
| J1554 | A | $491.41 | 20.000 |
| J1555 | A | $15.73 | 20.000 |
| J1556 | A | $72.96 | 20.000 |
| J1557 | A | $57.01 | 20.000 |
| J1558 | A | $13.97 | 20.000 |
| J1559 | A | $12.73 | 20.000 |
| J1560 | A | $487.66 | 20.000 |
| J1561 | A | $49.26 | 20.000 |
| J1566 | A | $76.57 | 20.000 |
| J1568 | A | $44.79 | 20.000 |
| J1569 | A | $44.46 | 20.000 |
| J1571 | A | $62.16 | 20.000 |
| J1572 | A | $56.12 | 20.000 |
| J1573 | A | $62.16 | 20.000 |
| J1575 | A | $16.89 | 20.000 |
| J1576 | A | $65.70 | 20.000 |
| J1595 | A | $153.01 | 20.000 |
| J1602 | A | $12.93 | 20.000 |
| J1610 | A | $187.50 | 20.000 |
| J1611 | A | $110.76 | 20.000 |
| J1627 | A | $5.78 | 20.000 |
| J1628 | A | $74.63 | 20.000 |
| J1632 | A | $72.22 | 20.000 |
| J1640 | A | $31.40 | 19.536 |
| J1670 | A | $584.39 | 19.207 |
| J1726 | A | $13.82 | 20.000 |
| J1729 | A | $8.85 | 20.000 |
| J1740 | A | $24.90 | 20.000 |
| J1742 | A | $224.03 | 20.000 |
| J1743 | A | $542.92 | 20.000 |
| J1744 | A | $146.81 | 20.000 |
| J1745 | A | $32.64 | 20.000 |
| J1746 | A | $74.46 | 20.000 |
| J1747 | A | $60.22 | 20.000 |
| J1750 | A | $17.41 | 20.000 |
| J1786 | A | $44.14 | 20.000 |
| J1823 | A | $473.51 | 20.000 |
| J1826 | A | $1,819.71 | 20.000 |
| J1833 | A | $0.94 | 19.997 |
| J1930 | A | $51.16 | 20.000 |
| J1931 | A | $37.44 | 20.000 |
| J1932 | A | $49.97 | 20.000 |
| J1943 | A | $3.05 | 20.000 |
| J1944 | A | $3.11 | 20.000 |
| J1950 | A | $1,524.34 | 19.895 |
| J1951 | A | $133.64 | 20.000 |
| J1952 | A | $74.35 | 20.000 |
| J1954 | A | $362.05 | 20.000 |
| J1961 | A | $21.79 | 20.000 |
| J2182 | A | $30.17 | 20.000 |
| J2186 | A | $2.08 | 19.554 |
| J2265 | A | $2.47 | 18.828 |
| J2278 | A | $9.04 | 20.000 |
| J2315 | A | $3.96 | 20.000 |
| J2323 | A | $24.60 | 20.000 |
| J2326 | A | $1,169.80 | 20.000 |
| J2327 | A | $15.33 | 20.000 |
| J2329 | A | $67.08 | 20.000 |
| J2350 | A | $60.55 | 20.000 |
| J2353 | A | $207.16 | 20.000 |
| J2356 | A | $18.58 | 20.000 |
| J2357 | A | $39.09 | 20.000 |
| J2403 | A | $0.71 | 20.000 |
| J2406 | A | $40.69 | 20.000 |
| J2407 | A | $27.54 | 20.000 |
| J2425 | A | $26.51 | 20.000 |
| J2426 | A | $14.34 | 20.000 |
| J2427 | A | $12.20 | 20.000 |
| J2502 | A | $455.82 | 17.881 |
| J2506 | A | $74.95 | 20.000 |
| J2507 | A | $3,307.05 | 20.000 |
| J2510 | A | $40.94 | 20.000 |
| J2515 | A | $34.10 | 20.000 |
| J2547 | A | $1.68 | 20.000 |
| J2560 | A | $36.25 | 20.000 |
| J2562 | A | $429.05 | 20.000 |
| J2597 | A | $6.15 | 20.000 |
| J2724 | A | $15.14 | 20.000 |
| J2760 | A | $453.66 | 20.000 |
| J2770 | A | $493.97 | 20.000 |
| J2777 | A | $36.57 | 20.000 |
| J2778 | A | $197.37 | 20.000 |
| J2779 | A | $81.43 | 20.000 |
| J2781 | A | $153.52 | 20.000 |
| J2783 | A | $358.43 | 20.000 |
| J2786 | A | $10.30 | 20.000 |
| J2792 | A | $33.46 | 20.000 |
| J2794 | A | $12.15 | 20.000 |
| J2796 | A | $95.75 | 19.935 |
| J2798 | A | $11.64 | 20.000 |
| J2820 | A | $58.26 | 19.711 |
| J2840 | A | $535.93 | 20.000 |
| J2850 | A | $41.74 | 19.328 |
| J2860 | A | $148.96 | 18.984 |
| J2941 | A | $169.57 | 20.000 |
| J2993 | A | $2,787.99 | 20.000 |
| J2997 | A | $89.16 | 20.000 |
| J2998 | A | $31.80 | 20.000 |
| J3031 | A | $1.97 | 20.000 |
| J3032 | A | $17.43 | 20.000 |
| J3060 | A | $45.18 | 20.000 |
| J3090 | A | $1.74 | 20.000 |
| J3095 | A | $7.15 | 20.000 |
| J3101 | A | $153.10 | 20.000 |
| J3111 | A | $10.35 | 20.000 |
| J3145 | A | $1.74 | 20.000 |
| J3240 | A | $2,011.27 | 20.000 |
| J3241 | A | $328.00 | 20.000 |
| J3245 | A | $135.66 | 20.000 |
| J3262 | A | $6.19 | 20.000 |
| J3285 | A | $56.01 | 20.000 |
| J3299 | A | $48.58 | 20.000 |
| J3304 | A | $17.13 | 20.000 |
| J3315 | A | $401.75 | 20.000 |
| J3316 | A | $3,225.08 | 20.000 |
| J3357 | A | $151.46 | 20.000 |
| J3358 | A | $12.62 | 20.000 |
| J3380 | A | $22.30 | 20.000 |
| J3385 | A | $366.40 | 20.000 |
| J3396 | A | $11.24 | 20.000 |
| J3398 | A | $2,907.93 | 20.000 |
| J7168 | A | $2.28 | 20.000 |
| J7169 | A | $131.38 | 20.000 |
| J7170 | A | $51.22 | 20.000 |
| J7175 | A | $9.11 | 20.000 |
| J7177 | A | $1.10 | 20.000 |
| J7178 | A | $1.38 | 20.000 |
| J7179 | A | $1.83 | 20.000 |
| J7182 | A | $1.31 | 20.000 |
| J7183 | A | $1.30 | 20.000 |
| J7185 | A | $1.31 | 20.000 |
| J7186 | A | $1.22 | 20.000 |
| J7187 | A | $1.35 | 20.000 |
| J7188 | A | $3.22 | 20.000 |
| J7189 | A | $2.41 | 20.000 |
| J7190 | A | $1.19 | 20.000 |
| J7192 | A | $1.50 | 20.000 |
| J7193 | A | $1.32 | 20.000 |
| J7194 | A | $1.61 | 20.000 |
| J7195 | A | $1.74 | 20.000 |
| J7197 | A | $3.71 | 20.000 |
| J7198 | A | $2.30 | 20.000 |
| J7200 | A | $1.60 | 20.000 |
| J7201 | A | $3.47 | 20.000 |
| J7202 | A | $4.93 | 20.000 |
| J7203 | A | $4.40 | 20.000 |
| J7204 | A | $2.06 | 20.000 |
| J7205 | A | $2.18 | 20.000 |
| J7207 | A | $2.03 | 20.000 |
| J7208 | A | $2.35 | 20.000 |
| J7209 | A | $1.30 | 20.000 |
| J7210 | A | $1.45 | 20.000 |
| J7211 | A | $1.43 | 20.000 |
| J7212 | A | $2.02 | 20.000 |
| J7213 | A | $1.76 | 20.000 |
| J7214 | A | $4.73 | 20.000 |
| J7308 | A | $390.56 | 20.000 |
| J7311 | A | $341.40 | 20.000 |
| J7312 | A | $205.69 | 20.000 |
| J7313 | A | $490.95 | 20.000 |
| J7314 | A | $529.06 | 20.000 |
| J7316 | A | $93.02 | 20.000 |
| J7318 | A | $6.27 | 20.000 |
| J7320 | A | $5.78 | 20.000 |
| J7322 | A | $17.30 | 20.000 |
| J7323 | A | $123.14 | 20.000 |
| J7324 | A | $136.26 | 20.000 |
| J7325 | A | $8.77 | 20.000 |
| J7326 | A | $515.30 | 20.000 |
| J7327 | A | $728.29 | 20.000 |
| J7328 | A | $0.54 | 20.000 |
| J7329 | A | $8.56 | 20.000 |
| J7331 | A | $11.83 | 20.000 |
| J7336 | A | $3.27 | 20.000 |
| J7340 | A | $226.80 | 20.000 |
| J7342 | A | $30.02 | 20.000 |
| J7345 | A | $1.66 | 20.000 |
| J7351 | A | $206.23 | 20.000 |
| J7352 | A | $2,873.33 | 20.000 |
| J7402 | A | $11.35 | 20.000 |
| J7501 | A | $237.83 | 20.000 |
| J7504 | A | $3,254.87 | 16.834 |
| J7511 | A | $921.17 | 20.000 |
| J7519 | A | $0.74 | 20.000 |
| J7525 | A | $248.75 | 20.000 |
| J8560 | A | $76.53 | 20.000 |
| J8655 | A | $407.83 | 17.996 |
| J8670 | A | $1.73 | 20.000 |
| J9015 | A | $3,628.26 | 20.000 |
| J9017 | A | $18.50 | 20.000 |
| J9019 | A | $427.27 | 20.000 |
| J9021 | A | $49.71 | 20.000 |
| J9022 | A | $82.62 | 20.000 |
| J9023 | A | $90.89 | 20.000 |
| J9027 | A | $23.29 | 20.000 |
| J9032 | A | $48.39 | 20.000 |
| J9033 | A | $11.42 | 20.000 |
| J9034 | A | $15.86 | 20.000 |
| J9035 | A | $73.81 | 20.000 |
| J9036 | A | $15.03 | 20.000 |
| J9037 | A | $46.78 | 20.000 |
| J9039 | A | $145.31 | 19.517 |
| J9041 | A | $2.29 | 20.000 |
| J9042 | A | $222.11 | 19.754 |
| J9043 | A | $209.34 | 20.000 |
| J9046 | A | $48.55 | 20.000 |
| J9047 | A | $46.90 | 20.000 |
| J9048 | A | $48.55 | 20.000 |
| J9049 | A | $3.09 | 20.000 |
| J9050 | A | $409.70 | 20.000 |
| J9055 | A | $72.28 | 20.000 |
| J9056 | A | $33.18 | 20.000 |
| J9057 | A | $85.71 | 20.000 |
| J9058 | A | $33.06 | 20.000 |
| J9059 | A | $23.13 | 20.000 |
| J9061 | A | $19.99 | 19.908 |
| J9063 | A | $65.75 | 20.000 |
| J9065 | A | $16.76 | 20.000 |
| J9070 | A | $17.94 | 20.000 |
| J9071 | A | $1.95 | 20.000 |
| J9119 | A | $26.92 | 20.000 |
| J9120 | A | $838.46 | 20.000 |
| J9144 | A | $49.31 | 20.000 |
| J9145 | A | $62.13 | 20.000 |
| J9150 | A | $31.64 | 20.000 |
| J9153 | A | $227.94 | 20.000 |
| J9155 | A | $4.13 | 20.000 |
| J9173 | A | $79.74 | 20.000 |
| J9176 | A | $7.22 | 20.000 |
| J9177 | A | $35.06 | 19.229 |
| J9179 | A | $130.87 | 20.000 |
| J9185 | A | $500.46 | 20.000 |
| J9198 | A | $40.28 | 19.669 |
| J9202 | A | $611.35 | 20.000 |
| J9203 | A | $221.84 | 20.000 |
| J9204 | A | $227.34 | 20.000 |
| J9205 | A | $62.49 | 20.000 |
| J9207 | A | $127.57 | 20.000 |
| J9210 | A | $390.16 | 20.000 |
| J9214 | A | $32.57 | 20.000 |
| J9217 | A | $166.69 | 20.000 |
| J9218 | A | $7.88 | 20.000 |
| J9223 | A | $196.82 | 20.000 |
| J9225 | A | $5,166.29 | 20.000 |
| J9227 | A | $74.64 | 20.000 |
| J9228 | A | $168.56 | 20.000 |
| J9229 | A | $2,529.55 | 20.000 |
| J9245 | A | $176.25 | 20.000 |
| J9246 | A | $16.08 | 20.000 |
| J9247 | A | $503.50 | 20.000 |
| J9259 | A | $16.23 | 20.000 |
| J9261 | A | $116.65 | 20.000 |
| J9262 | A | $3.96 | 19.378 |
| J9264 | A | $14.79 | 20.000 |
| J9266 | A | $25,781.46 | 19.382 |
| J9268 | A | $2,336.98 | 19.562 |
| J9269 | A | $324.48 | 20.000 |
| J9271 | A | $56.41 | 20.000 |
| J9272 | A | $230.82 | 20.000 |
| J9273 | A | $168.26 | 20.000 |
| J9274 | A | $203.83 | 20.000 |
| J9280 | A | $95.61 | 20.000 |
| J9281 | A | $294.37 | 20.000 |
| J9293 | A | $41.39 | 20.000 |
| J9294 | A | $4.98 | 20.000 |
| J9295 | A | $5.74 | 20.000 |
| J9296 | A | $9.66 | 20.000 |
| J9297 | A | $2.29 | 20.000 |
| J9298 | A | $183.62 | 20.000 |
| J9299 | A | $30.43 | 20.000 |
| J9301 | A | $70.29 | 20.000 |
| J9302 | A | $63.96 | 20.000 |
| J9303 | A | $149.72 | 19.921 |
| J9304 | A | $66.23 | 20.000 |
| J9305 | A | $3.22 | 20.000 |
| J9306 | A | $15.42 | 20.000 |
| J9307 | A | $298.18 | 20.000 |
| J9308 | A | $69.00 | 20.000 |
| J9309 | A | $121.23 | 20.000 |
| J9311 | A | $37.13 | 20.000 |
| J9312 | A | $80.19 | 20.000 |
| J9313 | A | $23.39 | 20.000 |
| J9314 | A | $19.96 | 13.634 |
| J9316 | A | $67.91 | 20.000 |
| J9317 | A | $33.11 | 20.000 |
| J9318 | A | $33.91 | 19.509 |
| J9319 | A | $30.66 | 20.000 |
| J9320 | A | $370.18 | 20.000 |
| J9323 | A | $7.08 | 20.000 |
| J9325 | A | $66.30 | 19.772 |
| J9328 | A | $10.40 | 20.000 |
| J9330 | A | $29.68 | 20.000 |
| J9331 | A | $107.66 | 20.000 |
| J9332 | A | $32.11 | 20.000 |
| J9340 | A | $260.25 | 20.000 |
| J9345 | A | $29.33 | 20.000 |
| J9347 | A | $136.31 | 20.000 |
| J9348 | A | $579.54 | 20.000 |
| J9349 | A | $13.29 | 20.000 |
| J9350 | A | $629.70 | 20.000 |
| J9352 | A | $338.41 | 20.000 |
| J9353 | A | $45.93 | 20.000 |
| J9354 | A | $38.34 | 20.000 |
| J9355 | A | $80.79 | 20.000 |
| J9356 | A | $66.00 | 20.000 |
| J9357 | A | $1,426.65 | 20.000 |
| J9358 | A | $26.31 | 20.000 |
| J9359 | A | $195.94 | 20.000 |
| J9371 | A | $3,420.78 | 20.000 |
| J9380 | A | $30.90 | 20.000 |
| J9381 | A | $36.23 | 20.000 |
| J9393 | A | $21.20 | 20.000 |
| J9394 | A | $53.00 | 20.000 |
| J9395 | A | $8.36 | 20.000 |
| J9400 | A | $7.81 | 20.000 |
| J9600 | A | $22,490.02 | 20.000 |
| P9041 | A | $10.62 | 20.000 |
| P9045 | A | $53.08 | 20.000 |
| P9046 | A | $21.23 | 20.000 |
| P9047 | A | $53.08 | 20.000 |
| Q0138 | A | $0.50 | 20.000 |
| Q0139 | A | $0.50 | 20.000 |
| Q2026 | A | $167.36 | 20.000 |
| Q2028 | A | $1.02 | 20.000 |
| Q2043 | A | $53,472.87 | 20.000 |
| Q2049 | A | $424.10 | 20.000 |
| Q2050 | A | $144.85 | 20.000 |
| Q3027 | A | $53.88 | 20.000 |
| Q5103 | A | $13.93 | 20.000 |
| Q5104 | A | $32.56 | 20.000 |
| Q5106 | A | $7.25 | 20.000 |
| Q5107 | A | $27.85 | 20.000 |
| Q5108 | A | $96.46 | 20.000 |
| Q5110 | A | $0.30 | 20.000 |
| Q5111 | A | $150.70 | 20.000 |
| Q5112 | A | $41.65 | 20.000 |
| Q5113 | A | $20.18 | 20.000 |
| Q5114 | A | $40.04 | 20.000 |
| Q5115 | A | $37.63 | 20.000 |
| Q5116 | A | $19.62 | 20.000 |
| Q5117 | A | $24.34 | 20.000 |
| Q5118 | A | $23.74 | 20.000 |
| Q5119 | A | $22.30 | 20.000 |
| Q5120 | A | $346.76 | 20.000 |
| Q5121 | A | $26.47 | 20.000 |
| Q5122 | A | $88.98 | 20.000 |
| Q5123 | A | $43.48 | 20.000 |
| Q5124 | A | $199.55 | 20.000 |
| Q5125 | A | $0.53 | 20.000 |
| Q5126 | A | $63.92 | 20.000 |
| Q5127 | A | $349.14 | 20.000 |
| Q5128 | A | $273.26 | 20.000 |
| Q5129 | A | $69.77 | 20.000 |
| Q5130 | A | $208.80 | 20.000 |
| Q9968 | A | $7.49 | 20.000 |
| Q9991 | A | $1,886.98 | 20.000 |
| Q9992 | A | $1,886.98 | 20.000 |
| 90371 | A | $137.58 | 20.000 |
| 90375 | A | $277.74 | 20.000 |
| 90376 | A | $170.90 | 20.000 |
| 90377 | A | $250.49 | 20.000 |
| 90378 | A | $339.68 | 20.000 |
| 90396 | A | $2,049.23 | 20.000 |
| 90476 | A | $357.98 | 20.000 |
| 90675 | A | $328.55 | 20.000 |
| 90676 | A | $255.14 | 20.000 |
| 90740 | C | $0.00 | 20.000 |
| 90743 | C | $0.00 | 20.000 |
| 90744 | C | $0.00 | 20.000 |
| 90746 | C | $0.00 | 20.000 |
| 90747 | C | $0.00 | 20.000 |
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 2023 by the American Medical Association.

