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.

