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Revised April 2023 2nd QTR ASC Drug File

Effective 04/01/2023 – Revised 01/01/2024

HCPCS Code Status Indicator Amount Coinsurance %
A9590 A $329.72 20.000
A9591 A $709.32 20.000
A9592 A $970.62 20.000
A9593 A $806.14 20.000
A9594 A $789.30 20.000
A9595 A $580.35 20.000
A9596 A $996.40 20.000
A9602 A $415.52 20.000
A9800 A $873.44 20.000
C9047 A $719.71 20.000
C9067 A $8.64 20.000
C9088 A $0.69 20.000
C9089 A $0.86 20.000
C9101 A $0.39 20.000
C9144 A $0.51 20.000
C9145 A $1.87 20.000
C9146 A $64.07 20.000
C9147 A $199.36 20.000
C9148 A $30.39 20.000
C9149 A $35.66 20.000
C9248 A $2.94 20.000
C9250 A $180.54 20.000
C9257 A $1.78 20.000
C9290 A $1.38 20.000
C9399 C $0.00 20.000
C9460 A $17.19 20.000
C9482 A $18.92 20.000
C9488 A $47.24 20.000
J0121 A $3.62 20.000
J0129 A $42.76 20.000
J0135 A $1,834.49 19.530
J0172 A $5.98 20.000
J0178 A $893.55 20.000
J0179 A $314.86 20.000
J0180 A $208.17 20.000
J0185 A $1.81 20.000
J0202 A $2,235.38 20.000
J0208 A $94.08 20.000
J0218 A $378.53 20.000
J0219 A $72.45 20.000
J0220 A $122.56 20.000
J0221 A $188.25 20.000
J0222 A $100.75 20.000
J0223 A $109.73 20.000
J0224 A $310.77 20.000
J0225 A $4,875.85 20.000
J0256 A $4.78 20.000
J0257 A $5.15 20.000
J0287 A $11.13 19.180
J0289 A $26.85 20.000
J0291 A $3.38 20.000
J0300 A $171.17 20.000
J0390 A $0.71 20.000
J0400 A $5.25 20.000
J0401 A $6.42 20.000
J0470 A $59.81 20.000
J0475 A $178.45 20.000
J0480 A $4,310.97 20.000
J0485 A $3.79 20.000
J0490 A $50.21 20.000
J0491 A $16.23 20.000
J0517 A $167.12 20.000
J0558 A $14.42 18.921
J0561 A $18.59 18.515
J0565 A $39.86 20.000
J0570 A $1,311.75 20.000
J0584 A $414.71 20.000
J0585 A $6.32 20.000
J0586 A $8.70 20.000
J0587 A $12.70 20.000
J0588 A $5.20 20.000
J0594 A $1.87 20.000
J0596 A $31.61 20.000
J0597 A $60.73 20.000
J0598 A $60.74 20.000
J0600 A $5,708.59 20.000
J0630 A $1,328.00 20.000
J0638 A $119.82 20.000
J0641 A $0.35 20.000
J0695 A $6.71 20.000
J0699 A $2.22 20.000
J0712 A $3.77 20.000
J0714 A $90.84 20.000
J0716 A $4,496.08 20.000
J0717 A $4.97 20.000
J0740 A $608.33 20.000
J0741 A $21.56 20.000
J0742 A $2.38 20.000
J0745 A $31.65 20.000
J0775 A $65.00 18.960
J0791 A $125.28 20.000
J0800 A $3,894.40 20.000
J0840 A $2,077.79 20.000
J0841 A $433.19 20.000
J0850 A $1,814.62 18.983
J0875 A $15.32 20.000
J0879 A $0.25 20.000
J0881 A $3.09 20.000
J0882 A $3.09 20.000
J0883 A $1.39 20.000
J0884 A $1.39 20.000
J0885 A $7.93 20.000
J0887 A $1.97 20.000
J0891 A $0.42 20.000
J0892 A $0.42 20.000
J0896 A $38.46 20.000
J0897 A $23.02 20.000
J0898 A $2.03 20.000
J0899 A $2.03 20.000
J1096 A $127.79 20.000
J1097 A $96.23 20.000
J1162 A $4,593.57 20.000
J1190 A $166.92 20.000
J1201 A $15.10 20.000
J1212 A $638.70 20.000
J1290 A $520.50 20.000
J1300 A $226.21 20.000
J1301 A $21.41 20.000
J1302 A $17.01 20.000
J1303 A $222.32 20.000
J1305 A $172.25 20.000
J1306 A $11.94 20.000
J1322 A $262.71 20.000
J1364 A $85.54 20.000
J1410 A $355.78 20.000
J1426 A $166.24 20.000
J1427 A $58.81 20.000
J1429 A $166.24 20.000
J1430 A $458.97 20.000
J1437 A $21.70 20.000
J1438 A $790.78 20.000
J1439 A $1.13 20.000
J1442 A $0.98 20.000
J1447 A $0.39 20.000
J1448 A $5.11 20.000
J1449 A $35.11 20.000
J1451 A $7.25 20.000
J1454 A $392.66 20.000
J1455 A $52.60 20.000
J1459 A $47.19 20.000
J1460 A $48.32 20.000
J1551 A $14.15 20.000
J1554 A $482.27 20.000
J1555 A $14.91 20.000
J1556 A $70.95 20.000
J1557 A $54.01 20.000
J1558 A $13.62 20.000
J1559 A $12.62 20.000
J1560 A $483.20 20.000
J1561 A $47.70 20.000
J1566 A $73.17 20.000
J1568 A $41.82 20.000
J1569 A $46.50 20.000
J1571 A $67.34 20.000
J1572 A $44.54 20.000
J1573 A $67.34 20.000
J1575 A $15.87 20.000
J1595 A $140.93 20.000
J1602 A $13.85 20.000
J1610 A $190.26 20.000
J1611 A $149.04 20.000
J1627 A $5.90 20.000
J1628 A $77.44 20.000
J1640 A $29.03 20.000
J1670 A $545.62 20.000
J1726 A $17.34 20.000
J1729 A $8.85 20.000
J1738 A $3.13 20.000
J1740 A $30.85 20.000
J1742 A $279.39 20.000
J1743 A $542.95 20.000
J1744 A $193.84 20.000
J1745 A $34.04 20.000
J1746 A $69.61 20.000
J1747 A $60.22 20.000
J1750 A $16.57 20.000
J1786 A $44.33 20.000
J1823 A $462.87 20.000
J1826 A $1,819.71 20.000
J1833 A $0.86 20.000
J1930 A $57.42 20.000
J1931 A $36.05 20.000
J1932 A $60.49 20.000
J1943 A $2.95 20.000
J1944 A $2.98 20.000
J1950 A $1,480.89 20.000
J1951 A $132.00 20.000
J1952 A $98.43 20.000
J1954 A $465.24 20.000
J2182 A $29.37 20.000
J2186 A $1.98 20.000
J2265 A $2.35 19.289
J2278 A $9.07 20.000
J2315 A $3.73 20.000
J2323 A $23.99 20.000
J2326 A $1,170.80 20.000
J2327 A $15.73 20.000
J2350 A $58.97 20.000
J2353 A $204.54 20.000
J2356 A $17.80 20.000
J2357 A $37.92 20.000
J2403 A $0.72 20.000
J2406 A $42.13 20.000
J2407 A $26.67 20.000
J2425 A $25.13 20.000
J2426 A $13.65 20.000
J2502 A $432.48 18.406
J2506 A $109.69 20.000
J2507 A $3,201.86 20.000
J2510 A $39.34 20.000
J2515 A $30.03 20.000
J2547 A $1.68 20.000
J2560 A $39.03 20.000
J2562 A $401.58 20.000
J2597 A $7.08 20.000
J2724 A $15.09 20.000
J2760 A $452.42 20.000
J2770 A $493.97 20.000
J2777 A $37.42 20.000
J2778 A $247.65 20.000
J2779 A $81.93 20.000
J2783 A $342.87 20.000
J2786 A $10.16 20.000
J2792 A $34.22 20.000
J2794 A $11.59 20.000
J2796 A $90.61 20.000
J2798 A $11.19 20.000
J2820 A $57.08 19.648
J2840 A $539.38 20.000
J2850 A $38.09 20.000
J2860 A $139.23 19.777
J2941 A $169.57 20.000
J2993 A $2,735.94 20.000
J2997 A $87.57 20.000
J2998 A $30.32 20.000
J3031 A $2.04 20.000
J3032 A $17.01 20.000
J3060 A $42.92 20.000
J3090 A $1.66 20.000
J3095 A $6.95 20.000
J3101 A $143.69 20.000
J3111 A $9.90 20.000
J3145 A $1.85 19.239
J3240 A $1,926.74 20.000
J3241 A $328.00 20.000
J3245 A $137.83 20.000
J3262 A $5.86 20.000
J3285 A $55.31 20.000
J3299 A $47.61 20.000
J3304 A $16.86 20.000
J3315 A $364.64 20.000
J3316 A $3,139.42 20.000
J3357 A $153.77 20.000
J3358 A $12.25 20.000
J3380 A $21.84 20.000
J3385 A $357.35 20.000
J3396 A $11.38 20.000
J3398 A $2,925.75 20.000
J7168 A $2.18 20.000
J7169 A $90.75 20.000
J7170 A $49.95 20.000
J7175 A $8.61 20.000
J7177 A $1.10 20.000
J7178 A $1.38 20.000
J7179 A $1.87 20.000
J7182 A $1.25 20.000
J7183 A $1.26 20.000
J7185 A $1.30 20.000
J7186 A $1.17 20.000
J7187 A $1.35 20.000
J7188 A $3.22 20.000
J7189 A $2.34 20.000
J7190 A $1.13 20.000
J7192 A $1.45 20.000
J7193 A $1.23 20.000
J7194 A $1.58 20.000
J7195 A $1.65 20.000
J7197 A $3.72 20.000
J7198 A $2.24 20.000
J7200 A $1.57 20.000
J7201 A $3.37 20.000
J7202 A $4.95 20.000
J7203 A $4.33 20.000
J7204 A $2.07 20.000
J7205 A $2.18 20.000
J7207 A $1.93 20.000
J7208 A $2.18 20.000
J7209 A $1.35 20.000
J7210 A $1.44 20.000
J7211 A $1.34 20.000
J7212 A $1.91 20.000
J7308 A $391.70 20.000
J7311 A $337.68 20.000
J7312 A $199.84 20.000
J7313 A $490.95 20.000
J7314 A $523.78 20.000
J7316 A $93.02 20.000
J7318 A $6.77 20.000
J7320 A $7.46 20.000
J7322 A $16.66 20.000
J7323 A $129.47 20.000
J7324 A $134.46 20.000
J7325 A $9.65 20.000
J7326 A $522.47 20.000
J7327 A $719.33 20.000
J7328 A $0.75 20.000
J7329 A $9.67 20.000
J7331 A $13.25 20.000
J7336 A $3.28 20.000
J7340 A $219.76 20.000
J7342 A $30.01 20.000
J7345 A $1.65 20.000
J7351 A $206.28 20.000
J7352 A $2,873.33 20.000
J7402 A $11.35 20.000
J7501 A $237.82 20.000
J7504 A $3,001.29 17.83
J7511 A $886.38 20.000
J7525 A $233.92 20.000
J8560 A $76.56 20.000
J8655 A $442.11 16.213
J8670 A $1.80 20.000
J9015 A $3,628.26 20.000
J9017 A $13.70 20.000
J9019 A $427.27 20.000
J9021 A $48.23 20.000
J9022 A $81.06 20.000
J9023 A $89.18 20.000
J9027 A $32.23 20.000
J9032 A $47.12 20.000
J9033 A $14.37 20.000
J9034 A $16.91 20.000
J9035 A $71.35 20.000
J9036 A $15.06 20.000
J9037 A $45.31 20.000
J9039 A $136.07 20.000
J9041 A $6.22 20.000
J9042 A $213.80 20.000
J9043 A $199.58 20.000
J9046 A $8.65 20.000
J9047 A $44.76 20.000
J9048 A $48.55 20.000
J9049 A $5.67 20.000
J9050 A $304.62 20.000
J9055 A $70.14 20.000
J9057 A $84.04 20.000
J9061 A $19.68 19.747
J9065 A $18.88 20.000
J9070 A $21.64 20.000
J9071 A $3.87 20.000
J9119 A $27.15 20.000
J9120 A $546.61 20.000
J9144 A $48.21 20.000
J9145 A $60.77 20.000
J9150 A $37.16 20.000
J9153 A $219.14 20.000
J9155 A $4.06 20.000
J9173 A $78.57 20.000
J9176 A $7.06 20.000
J9177 A $33.81 19.470
J9179 A $126.92 20.000
J9185 A $161.75 20.000
J9198 A $24.67 20.000
J9202 A $561.59 20.000
J9203 A $217.49 20.000
J9204 A $216.26 20.000
J9205 A $59.95 20.000
J9207 A $121.88 20.000
J9210 A $378.12 20.000
J9214 A $32.57 20.000
J9217 A $172.56 20.000
J9218 A $8.01 20.000
J9223 A $188.30 20.000
J9225 A $5,166.29 20.000
J9227 A $71.70 20.000
J9228 A $165.45 20.000
J9229 A $2,479.96 20.000
J9245 A $186.51 20.000
J9246 A $16.80 20.000
J9247 A $503.50 20.000
J9261 A $129.84 20.000
J9262 A $3.66 20.000
J9264 A $11.78 20.000
J9266 A $23,577.01 20.000
J9268 A $2,585.41 17.269
J9269 A $322.18 20.000
J9271 A $55.42 20.000
J9272 A $223.92 20.000
J9273 A $161.96 20.000
J9274 A $198.86 20.000
J9280 A $24.02 20.000
J9281 A $289.51 20.000
J9293 A $49.33 20.000
J9294 A $10.46 20.000
J9295 A $5.74 20.000
J9296 A $9.74 20.000
J9297 A $9.16 20.000
J9298 A $180.34 20.000
J9299 A $29.91 20.000
J9301 A $66.91 20.000
J9302 A $63.96 20.000
J9303 A $142.42 20.000
J9304 A $77.55 20.000
J9305 A $17.14 20.000
J9306 A $14.43 20.000
J9307 A $351.95 20.000
J9308 A $66.85 20.000
J9309 A $118.11 20.000
J9311 A $37.49 20.000
J9312 A $81.19 20.000
J9313 A $23.39 20.000
J9314 A $13.40 20.000
J9316 A $68.44 20.000
J9317 A $32.55 20.000
J9318 A $33.91 20.000
J9319 A $31.49 20.000
J9320 A $370.18 20.000
J9325 A $62.36 20.000
J9328 A $10.42 20.000
J9330 A $32.17 20.000
J9331 A $104.54 20.000
J9332 A $31.52 20.000
J9340 A $297.26 20.000
J9348 A $578.77 20.000
J9349 A $13.15 20.000
J9352 A $331.83 20.000
J9353 A $45.04 20.000
J9354 A $36.25 20.000
J9355 A $80.25 20.000
J9356 A $65.08 20.000
J9357 A $1,442.53 20.000
J9358 A $25.63 20.000
J9359 A $191.42 20.000
J9371 A $3,420.78 20.000
J9393 A $3.07 20.000
J9394 A $3.92 20.000
J9395 A $12.09 20.000
J9400 A $7.39 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 $0.48 20.000
Q0139 A $0.48 20.000
Q2026 A $167.36 20.000
Q2028 A $1.02 20.000
Q2043 A $53,630.37 20.000
Q2049 A $424.10 20.000
Q2050 A $78.06 20.000
Q3027 A $53.08 20.000
Q5103 A $19.98 20.000
Q5104 A $36.43 20.000
Q5106 A $8.38 20.000
Q5107 A $28.57 20.000
Q5108 A $132.52 20.000
Q5110 A $0.33 20.000
Q5111 A $141.17 20.000
Q5112 A $49.85 20.000
Q5113 A $29.53 20.000
Q5114 A $47.13 20.000
Q5115 A $47.80 20.000
Q5116 A $24.98 20.000
Q5117 A $25.93 20.000
Q5118 A $29.48 20.000
Q5119 A $27.59 20.000
Q5120 A $80.06 20.000
Q5121 A $28.46 20.000
Q5122 A $122.66 20.000
Q5123 A $45.21 20.000
Q5124 A $223.17 20.000
Q5125 A $0.59 20.000
Q5126 A $73.71 20.000
Q5127 A $358.35 20.000
Q5128 A $280.16 20.000
Q5130 A $214.58 20.000
Q9968 A $7.40 20.000
Q9991 A $1,793.85 20.000
Q9992 A $1,793.85 20.000
90371 A $131.76 20.000
90375 A $336.20 20.000
90376 A $296.74 20.000
90377 A $232.03 20.000
90378 A $339.68 20.000
90396 A $2,253.22 20.000
90476 A $357.98 20.000
90675 A $342.22 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.

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