Revised July 2023 3rd Quarter ASC Drug File
Effective 07/01/2023 – Revised 07/01/2024
| HCPCS Code | Status Indicator | Amount | Coinsurance % |
|---|---|---|---|
| A9590 | A | $338.48 | 20.000 |
| A9591 | A | $709.32 | 20.000 |
| A9592 | A | $970.26 | 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 | $871.50 | 20.000 |
| C9047 | A | $744.95 | 20.000 |
| C9067 | A | $8.64 | 20.000 |
| C9088 | A | $0.73 | 20.000 |
| C9089 | A | $0.85 | 20.000 |
| C9101 | A | $1.10 | 20.000 |
| C9144 | A | $0.50 | 20.000 |
| C9145 | A | $1.87 | 20.000 |
| C9151 | A | $150.38 | 20.000 |
| C9248 | A | $3.06 | 20.000 |
| C9250 | A | $180.54 | 20.000 |
| C9257 | A | $1.84 | 20.000 |
| C9290 | A | $1.44 | 20.000 |
| C9399 | C | $0.00 | 20.000 |
| C9460 | A | $18.13 | 20.000 |
| C9482 | A | $20.74 | 20.000 |
| C9488 | A | $47.24 | 20.000 |
| J0121 | A | $3.68 | 20.000 |
| J0129 | A | $43.27 | 20.000 |
| J0135 | A | $1,834.49 | 19.720 |
| J0172 | A | $5.98 | 20.000 |
| J0178 | A | $875.67 | 20.000 |
| J0179 | A | $319.95 | 20.000 |
| J0180 | A | $215.38 | 20.000 |
| J0185 | A | $1.73 | 20.000 |
| J0202 | A | $2,283.73 | 20.000 |
| J0208 | A | $96.28 | 20.000 |
| J0218 | A | $377.51 | 20.000 |
| J0219 | A | $75.04 | 20.000 |
| J0220 | A | $122.56 | 20.000 |
| J0221 | A | $194.92 | 20.000 |
| J0222 | A | $100.47 | 20.000 |
| J0223 | A | $112.49 | 20.000 |
| J0224 | A | $319.00 | 20.000 |
| J0225 | A | $4,940.95 | 20.000 |
| J0256 | A | $4.88 | 20.000 |
| J0257 | A | $5.31 | 20.000 |
| J0287 | A | $11.13 | 19.368 |
| J0289 | A | $27.87 | 20.000 |
| J0291 | A | $3.36 | 20.000 |
| J0300 | A | $171.17 | 20.000 |
| J0390 | A | $0.71 | 20.000 |
| J0400 | A | $5.25 | 20.000 |
| J0401 | A | $6.72 | 20.000 |
| J0470 | A | $59.81 | 20.000 |
| J0475 | A | $182.49 | 20.000 |
| J0480 | A | $4,389.08 | 20.000 |
| J0485 | A | $3.78 | 20.000 |
| J0490 | A | $50.93 | 20.000 |
| J0491 | A | $16.66 | 20.000 |
| J0517 | A | $170.93 | 20.000 |
| J0558 | A | $15.67 | 17.573 |
| J0561 | A | $20.17 | 17.233 |
| J0565 | A | $39.85 | 20.000 |
| J0570 | A | $1,311.75 | 20.000 |
| J0584 | A | $426.07 | 19.812 |
| J0585 | A | $6.35 | 20.000 |
| J0586 | A | $8.60 | 20.000 |
| J0587 | A | $12.72 | 20.000 |
| J0588 | A | $5.20 | 20.000 |
| J0594 | A | $1.38 | 20.000 |
| J0596 | A | $33.02 | 20.000 |
| J0597 | A | $64.45 | 20.000 |
| J0598 | A | $60.73 | 20.000 |
| J0600 | A | $5,708.59 | 20.000 |
| J0630 | A | $1,366.44 | 20.000 |
| J0638 | A | $121.51 | 20.000 |
| J0641 | A | $0.00 | 20.000 |
| J0695 | A | $7.54 | 20.000 |
| J0699 | A | $2.16 | 20.000 |
| J0712 | A | $3.89 | 20.000 |
| J0714 | A | $92.48 | 20.000 |
| J0716 | A | $5,208.66 | 20.000 |
| J0717 | A | $5.07 | 20.000 |
| J0740 | A | $577.03 | 20.000 |
| J0741 | A | $21.84 | 20.000 |
| J0742 | A | $2.49 | 20.000 |
| J0745 | A | $31.65 | 20.000 |
| J0775 | A | $64.04 | 19.432 |
| J0791 | A | $126.61 | 20.000 |
| J0800 | A | $3,819.78 | 20.000 |
| J0840 | A | $2,056.35 | 20.000 |
| J0841 | A | $1,019.46 | 20.000 |
| J0850 | A | $1,814.20 | 19.173 |
| J0875 | A | $14.70 | 20.000 |
| J0879 | A | $0.21 | 20.000 |
| J0881 | A | $2.94 | 20.000 |
| J0882 | A | $2.94 | 20.000 |
| J0883 | A | $1.25 | 20.000 |
| J0884 | A | $1.25 | 20.000 |
| J0885 | A | $6.88 | 20.000 |
| J0887 | A | $1.65 | 20.000 |
| J0891 | A | $0.46 | 20.000 |
| J0892 | A | $0.46 | 20.000 |
| J0896 | A | $39.18 | 20.000 |
| J0897 | A | $24.19 | 19.829 |
| J0898 | A | $1.64 | 20.000 |
| J0899 | A | $1.64 | 20.000 |
| J1096 | A | $126.48 | 20.000 |
| J1097 | A | $97.58 | 20.000 |
| J1162 | A | $4,593.57 | 20.000 |
| J1190 | A | $113.90 | 20.000 |
| J1201 | A | $15.07 | 20.000 |
| J1212 | A | $682.52 | 20.000 |
| J1290 | A | $530.72 | 20.000 |
| J1300 | A | $225.79 | 20.000 |
| J1301 | A | $21.40 | 20.000 |
| J1302 | A | $17.75 | 19.825 |
| J1303 | A | $221.88 | 20.000 |
| J1305 | A | $175.78 | 20.000 |
| J1306 | A | $12.06 | 20.000 |
| J1322 | A | $280.13 | 20.000 |
| J1364 | A | $87.33 | 20.000 |
| J1410 | A | $371.89 | 20.000 |
| J1426 | A | $166.20 | 20.000 |
| J1427 | A | $58.85 | 20.000 |
| J1429 | A | $166.17 | 20.000 |
| J1430 | A | $481.06 | 20.000 |
| J1437 | A | $20.61 | 20.000 |
| J1438 | A | $790.78 | 20.000 |
| J1439 | A | $1.13 | 20.000 |
| J1440 | A | $61.80 | 20.000 |
| J1442 | A | $0.99 | 20.000 |
| J1447 | A | $0.43 | 20.000 |
| J1448 | A | $5.10 | 20.000 |
| J1449 | A | $31.77 | 20.000 |
| J1451 | A | $7.27 | 20.000 |
| J1454 | A | $372.00 | 20.000 |
| J1455 | A | $57.18 | 20.000 |
| J1459 | A | $47.99 | 20.000 |
| J1460 | A | $48.47 | 20.000 |
| J1551 | A | $14.39 | 20.000 |
| J1554 | A | $491.41 | 20.000 |
| J1555 | A | $16.28 | 19.970 |
| J1556 | A | $72.96 | 20.000 |
| J1557 | A | $59.48 | 20.000 |
| J1558 | A | $14.00 | 20.000 |
| J1559 | A | $12.80 | 20.000 |
| J1560 | A | $484.65 | 20.000 |
| J1561 | A | $50.64 | 20.000 |
| J1566 | A | $77.77 | 20.000 |
| J1568 | A | $44.12 | 20.000 |
| J1569 | A | $46.03 | 20.000 |
| J1571 | A | $66.26 | 20.000 |
| J1572 | A | $56.12 | 20.000 |
| J1573 | A | $66.26 | 20.000 |
| J1575 | A | $16.66 | 20.000 |
| J1576 | A | $65.74 | 20.000 |
| J1595 | A | $151.43 | 20.000 |
| J1602 | A | $13.29 | 20.000 |
| J1610 | A | $195.18 | 20.000 |
| J1611 | A | $101.41 | 20.000 |
| J1627 | A | $5.88 | 20.000 |
| J1628 | A | $75.79 | 20.000 |
| J1632 | A | $72.39 | 20.000 |
| J1640 | A | $31.08 | 19.461 |
| J1670 | A | $540.99 | 20.000 |
| J1726 | A | $14.74 | 20.000 |
| J1729 | A | $8.85 | 20.000 |
| J1740 | A | $29.31 | 20.000 |
| J1742 | A | $271.86 | 20.000 |
| J1743 | A | $542.92 | 20.000 |
| J1744 | A | $228.61 | 20.000 |
| J1745 | A | $32.91 | 20.000 |
| J1746 | A | $74.29 | 19.820 |
| J1747 | A | $60.22 | 20.000 |
| J1750 | A | $17.18 | 20.000 |
| J1786 | A | $44.25 | 20.000 |
| J1823 | A | $472.30 | 20.000 |
| J1826 | A | $1,819.71 | 20.000 |
| J1833 | A | $0.91 | 20.000 |
| J1930 | A | $54.18 | 20.000 |
| J1931 | A | $37.04 | 20.000 |
| J1932 | A | $51.38 | 20.000 |
| J1943 | A | $3.06 | 20.000 |
| J1944 | A | $3.07 | 20.000 |
| J1950 | A | $1,543.52 | 19.376 |
| J1951 | A | $138.81 | 20.000 |
| J1952 | A | $78.31 | 20.000 |
| J1954 | A | $425.48 | 20.000 |
| J1961 | A | $21.67 | 20.000 |
| J2182 | A | $29.75 | 20.000 |
| J2186 | A | $2.02 | 19.828 |
| J2265 | A | $2.40 | 19.079 |
| J2278 | A | $9.08 | 20.000 |
| J2315 | A | $3.94 | 19.948 |
| J2323 | A | $24.86 | 20.000 |
| J2326 | A | $1,170.03 | 20.000 |
| J2327 | A | $15.52 | 20.000 |
| J2329 | A | $67.52 | 20.000 |
| J2350 | A | $61.42 | 20.000 |
| J2353 | A | $208.12 | 20.000 |
| J2356 | A | $18.73 | 19.899 |
| J2357 | A | $39.38 | 20.000 |
| J2403 | A | $0.72 | 20.000 |
| J2406 | A | $41.73 | 20.000 |
| J2407 | A | $26.89 | 20.000 |
| J2425 | A | $26.51 | 20.000 |
| J2426 | A | $14.22 | 20.000 |
| J2427 | A | $12.11 | 20.000 |
| J2502 | A | $421.95 | 19.049 |
| J2506 | A | $85.71 | 20.000 |
| J2507 | A | $3,268.45 | 20.000 |
| J2510 | A | $43.38 | 20.000 |
| J2515 | A | $30.33 | 20.000 |
| J2547 | A | $1.68 | 20.000 |
| J2560 | A | $39.38 | 20.000 |
| J2562 | A | $429.36 | 20.000 |
| J2597 | A | $7.27 | 20.000 |
| J2724 | A | $15.11 | 20.000 |
| J2760 | A | $458.18 | 20.000 |
| J2770 | A | $493.97 | 20.000 |
| J2777 | A | $37.09 | 20.000 |
| J2778 | A | $236.58 | 20.000 |
| J2779 | A | $81.02 | 20.000 |
| J2783 | A | $357.36 | 20.000 |
| J2786 | A | $10.20 | 20.000 |
| J2792 | A | $33.71 | 20.000 |
| J2794 | A | $12.02 | 20.000 |
| J2796 | A | $95.47 | 19.718 |
| J2798 | A | $11.67 | 20.000 |
| J2820 | A | $58.31 | 19.422 |
| J2840 | A | $537.81 | 20.000 |
| J2850 | A | $41.74 | 20.000 |
| J2860 | A | $139.22 | 20.000 |
| J2941 | A | $169.57 | 20.000 |
| J2993 | A | $2,791.65 | 20.000 |
| J2997 | A | $89.15 | 20.000 |
| J2998 | A | $30.10 | 20.000 |
| J3031 | A | $2.00 | 20.000 |
| J3032 | A | $17.44 | 20.000 |
| J3060 | A | $44.56 | 20.000 |
| J3090 | A | $1.71 | 20.000 |
| J3095 | A | $6.83 | 20.000 |
| J3101 | A | $152.70 | 20.000 |
| J3111 | A | $10.37 | 20.000 |
| J3145 | A | $1.79 | 20.000 |
| J3240 | A | $2,001.49 | 20.000 |
| J3241 | A | $328.00 | 20.000 |
| J3245 | A | $143.27 | 20.000 |
| J3262 | A | $5.91 | 20.000 |
| J3285 | A | $55.20 | 20.000 |
| J3299 | A | $48.49 | 20.000 |
| J3304 | A | $17.11 | 20.000 |
| J3315 | A | $382.39 | 20.000 |
| J3316 | A | $3,141.98 | 20.000 |
| J3357 | A | $147.65 | 20.000 |
| J3358 | A | $12.59 | 20.000 |
| J3380 | A | $22.68 | 20.000 |
| J3385 | A | $367.18 | 20.000 |
| J3396 | A | $11.42 | 20.000 |
| J3398 | A | $2,926.89 | 20.000 |
| J7168 | A | $2.18 | 20.000 |
| J7169 | A | $95.88 | 20.000 |
| J7170 | A | $51.01 | 20.000 |
| J7175 | A | $9.09 | 20.000 |
| J7177 | A | $1.10 | 20.000 |
| J7178 | A | $1.38 | 20.000 |
| J7179 | A | $1.78 | 20.000 |
| J7182 | A | $1.28 | 20.000 |
| J7183 | A | $1.26 | 20.000 |
| J7185 | A | $1.38 | 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 | $1.03 | 20.000 |
| J7192 | A | $1.51 | 20.000 |
| J7193 | A | $1.30 | 20.000 |
| J7194 | A | $1.62 | 20.000 |
| J7195 | A | $1.76 | 20.000 |
| J7197 | A | $3.35 | 20.000 |
| J7198 | A | $2.23 | 20.000 |
| J7200 | A | $1.61 | 20.000 |
| J7201 | A | $3.46 | 20.000 |
| J7202 | A | $4.93 | 20.000 |
| J7203 | A | $4.41 | 20.000 |
| J7204 | A | $2.11 | 20.000 |
| J7205 | A | $2.17 | 20.000 |
| J7207 | A | $2.11 | 20.000 |
| J7208 | A | $2.35 | 20.000 |
| J7209 | A | $1.36 | 20.000 |
| J7210 | A | $1.44 | 20.000 |
| J7211 | A | $1.44 | 20.000 |
| J7212 | A | $2.01 | 20.000 |
| J7213 | A | $1.75 | 20.000 |
| J7308 | A | $391.23 | 20.000 |
| J7311 | A | $340.23 | 20.000 |
| J7312 | A | $204.68 | 20.000 |
| J7313 | A | $490.95 | 20.000 |
| J7314 | A | $529.27 | 20.000 |
| J7316 | A | $93.02 | 20.000 |
| J7318 | A | $6.06 | 20.000 |
| J7320 | A | $6.11 | 20.000 |
| J7322 | A | $17.02 | 20.000 |
| J7323 | A | $131.42 | 20.000 |
| J7324 | A | $117.38 | 20.000 |
| J7325 | A | $9.62 | 20.000 |
| J7326 | A | $516.73 | 20.000 |
| J7327 | A | $692.75 | 20.000 |
| J7328 | A | $0.62 | 20.000 |
| J7329 | A | $8.80 | 20.000 |
| J7331 | A | $13.25 | 20.000 |
| J7336 | A | $3.27 | 20.000 |
| J7340 | A | $226.83 | 20.000 |
| J7342 | A | $30.02 | 20.000 |
| J7345 | A | $1.65 | 20.000 |
| J7351 | A | $206.41 | 20.000 |
| J7352 | A | $2,873.33 | 20.000 |
| J7402 | A | $11.35 | 20.000 |
| J7501 | A | $240.20 | 20.000 |
| J7504 | A | $2,989.44 | 18.075 |
| J7511 | A | $920.53 | 20.000 |
| J7525 | A | $246.09 | 20.000 |
| J8560 | A | $77.39 | 20.000 |
| J8655 | A | $419.56 | 15.691 |
| J8670 | A | $1.63 | 20.000 |
| J9015 | A | $3,628.26 | 20.000 |
| J9017 | A | $12.97 | 20.000 |
| J9019 | A | $427.27 | 20.000 |
| J9021 | A | $49.53 | 20.000 |
| J9022 | A | $82.68 | 20.000 |
| J9023 | A | $90.57 | 20.000 |
| J9027 | A | $29.42 | 20.000 |
| J9032 | A | $47.62 | 20.000 |
| J9033 | A | $12.28 | 20.000 |
| J9034 | A | $16.51 | 20.000 |
| J9035 | A | $73.58 | 20.000 |
| J9036 | A | $16.72 | 20.000 |
| J9037 | A | $46.78 | 20.000 |
| J9039 | A | $144.68 | 19.331 |
| J9041 | A | $3.03 | 20.000 |
| J9042 | A | $221.96 | 19.494 |
| J9043 | A | $206.03 | 20.000 |
| J9046 | A | $48.55 | 20.000 |
| J9047 | A | $47.04 | 19.685 |
| J9048 | A | $48.55 | 20.000 |
| J9049 | A | $4.03 | 20.000 |
| J9050 | A | $410.96 | 20.000 |
| J9055 | A | $72.08 | 20.000 |
| J9056 | A | $33.33 | 20.000 |
| J9057 | A | $85.68 | 20.000 |
| J9058 | A | $33.06 | 20.000 |
| J9059 | A | $23.96 | 20.000 |
| J9061 | A | $19.63 | 19.990 |
| J9063 | A | $65.80 | 20.000 |
| J9065 | A | $18.30 | 20.000 |
| J9070 | A | $17.09 | 20.000 |
| J9071 | A | $1.19 | 20.000 |
| J9119 | A | $26.92 | 20.000 |
| J9120 | A | $720.16 | 20.000 |
| J9144 | A | $49.12 | 20.000 |
| J9145 | A | $61.78 | 20.000 |
| J9150 | A | $45.62 | 20.000 |
| J9153 | A | $227.23 | 20.000 |
| J9155 | A | $4.19 | 20.000 |
| J9173 | A | $79.76 | 20.000 |
| J9176 | A | $7.19 | 20.000 |
| J9177 | A | $33.82 | 19.658 |
| J9179 | A | $128.78 | 20.000 |
| J9185 | A | $604.75 | 20.000 |
| J9198 | A | $40.28 | 19.397 |
| J9202 | A | $613.57 | 20.000 |
| J9203 | A | $221.84 | 20.000 |
| J9204 | A | $226.71 | 20.000 |
| J9205 | A | $61.96 | 20.000 |
| J9207 | A | $122.55 | 20.000 |
| J9210 | A | $393.72 | 20.000 |
| J9214 | A | $32.57 | 20.000 |
| J9217 | A | $165.86 | 20.000 |
| J9218 | A | $10.06 | 20.000 |
| J9223 | A | $197.18 | 20.000 |
| J9225 | A | $5,166.29 | 20.000 |
| J9227 | A | $74.35 | 20.000 |
| J9228 | A | $167.93 | 20.000 |
| J9229 | A | $2,529.55 | 20.000 |
| J9245 | A | $154.19 | 20.000 |
| J9246 | A | $16.44 | 20.000 |
| J9247 | A | $503.50 | 20.000 |
| J9259 | A | $16.23 | 20.000 |
| J9261 | A | $128.99 | 20.000 |
| J9262 | A | $4.01 | 18.895 |
| J9264 | A | $12.06 | 20.000 |
| J9266 | A | $25,762.46 | 19.129 |
| J9268 | A | $2,387.73 | 18.882 |
| J9269 | A | $322.60 | 20.000 |
| J9271 | A | $54.81 | 20.000 |
| J9272 | A | $226.93 | 20.000 |
| J9273 | A | $162.05 | 20.000 |
| J9274 | A | $203.83 | 20.000 |
| J9280 | A | $79.02 | 20.000 |
| J9281 | A | $296.17 | 20.000 |
| J9293 | A | $29.06 | 20.000 |
| J9294 | A | $10.00 | 20.000 |
| J9295 | A | $5.74 | 20.000 |
| J9296 | A | $9.66 | 20.000 |
| J9297 | A | $1.73 | 20.000 |
| J9298 | A | $183.63 | 20.000 |
| J9299 | A | $30.46 | 20.000 |
| J9301 | A | $70.55 | 20.000 |
| J9302 | A | $63.96 | 20.000 |
| J9303 | A | $149.71 | 19.646 |
| J9304 | A | $64.48 | 20.000 |
| J9305 | A | $7.93 | 20.000 |
| J9306 | A | $15.37 | 20.000 |
| J9307 | A | $356.51 | 19.902 |
| J9308 | A | $68.87 | 20.000 |
| J9309 | A | $121.25 | 20.000 |
| J9311 | A | $37.46 | 20.000 |
| J9312 | A | $81.04 | 20.000 |
| J9313 | A | $23.39 | 20.000 |
| J9314 | A | $12.30 | 20.000 |
| J9316 | A | $68.21 | 20.000 |
| J9317 | A | $33.32 | 20.000 |
| J9318 | A | $33.91 | 20.000 |
| J9319 | A | $30.37 | 20.000 |
| J9320 | A | $370.18 | 20.000 |
| J9323 | A | $7.51 | 20.000 |
| J9325 | A | $66.05 | 19.570 |
| J9328 | A | $10.41 | 20.000 |
| J9330 | A | $33.57 | 20.000 |
| J9331 | A | $107.61 | 20.000 |
| J9332 | A | $31.81 | 20.000 |
| J9340 | A | $259.56 | 20.000 |
| J9347 | A | $136.56 | 20.000 |
| J9348 | A | $579.65 | 20.000 |
| J9349 | A | $13.30 | 20.000 |
| J9350 | A | $611.88 | 20.000 |
| J9352 | A | $337.28 | 20.000 |
| J9353 | A | $45.88 | 20.000 |
| J9354 | A | $38.33 | 20.000 |
| J9355 | A | $81.08 | 20.000 |
| J9356 | A | $65.58 | 20.000 |
| J9357 | A | $1,391.80 | 20.000 |
| J9358 | A | $26.32 | 20.000 |
| J9359 | A | $196.45 | 20.000 |
| J9371 | A | $3,420.78 | 20.000 |
| J9380 | A | $30.94 | 20.000 |
| J9381 | A | $36.27 | 20.000 |
| J9393 | A | $21.20 | 20.000 |
| J9394 | A | $1.65 | 20.000 |
| J9395 | A | $9.47 | 20.000 |
| J9400 | A | $6.81 | 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 | $53,062.44 | 20.000 |
| Q2049 | A | $424.10 | 20.000 |
| Q2050 | A | $87.98 | 20.000 |
| Q3027 | A | $53.15 | 20.000 |
| Q5103 | A | $17.58 | 20.000 |
| Q5104 | A | $35.55 | 20.000 |
| Q5106 | A | $7.22 | 20.000 |
| Q5107 | A | $28.40 | 20.000 |
| Q5108 | A | $111.14 | 20.000 |
| Q5110 | A | $0.33 | 20.000 |
| Q5111 | A | $124.78 | 20.000 |
| Q5112 | A | $46.93 | 20.000 |
| Q5113 | A | $29.87 | 20.000 |
| Q5114 | A | $40.41 | 20.000 |
| Q5115 | A | $39.79 | 20.000 |
| Q5116 | A | $21.93 | 20.000 |
| Q5117 | A | $23.96 | 20.000 |
| Q5118 | A | $26.17 | 20.000 |
| Q5119 | A | $24.72 | 20.000 |
| Q5120 | A | $30.05 | 20.000 |
| Q5121 | A | $28.33 | 20.000 |
| Q5122 | A | $100.48 | 20.000 |
| Q5123 | A | $44.58 | 20.000 |
| Q5124 | A | $220.83 | 20.000 |
| Q5125 | A | $0.59 | 20.000 |
| Q5126 | A | $72.52 | 20.000 |
| Q5127 | A | $358.35 | 20.000 |
| Q5128 | A | $279.50 | 20.000 |
| Q5129 | A | $69.77 | 20.000 |
| Q5130 | A | $220.83 | 20.000 |
| Q9968 | A | $7.72 | 20.000 |
| Q9991 | A | $1,886.37 | 20.000 |
| Q9992 | A | $1,886.37 | 20.000 |
| 90371 | A | $136.74 | 20.000 |
| 90375 | A | $284.68 | 20.000 |
| 90376 | A | $250.09 | 20.000 |
| 90377 | A | $234.09 | 20.000 |
| 90378 | A | $339.68 | 20.000 |
| 90396 | A | $2,257.32 | 19.560 |
| 90476 | A | $357.98 | 20.000 |
| 90675 | A | $329.99 | 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.

