Revised April 2024 2nd Quarter ASC Drug File
Effective 04.01.2024 – Revised 04.01.2025
| HCPCS Code | Status Indicator | Amount | Coinsurance |
|---|---|---|---|
| A9590 | A | $339.61 | 20.000 |
| A9593 | A | $886.76 | 20.000 |
| A9594 | A | $868.23 | 20.000 |
| A9595 | A | $615.12 | 20.000 |
| A9596 | A | $975.48 | 20.000 |
| A9601 | A | $3710.00 | 20.000 |
| A9602 | A | $446.88 | 20.000 |
| A9608 | A | $628.47 | 20.000 |
| A9800 | A | $873.44 | 20.000 |
| C9047 | A | $739.86 | 20.000 |
| C9088 | A | $.73 | 20.000 |
| C9089 | A | $.85 | 20.000 |
| C9101 | A | $1.30 | 20.000 |
| C9144 | A | $.50 | 20.000 |
| C9145 | A | $1.88 | 20.000 |
| C9166 | A | $17.43 | 20.000 |
| C9167 | A | $33.78 | 20.000 |
| C9168 | A | $32.94 | 20.000 |
| C9250 | A | $135.63 | 20.000 |
| C9257 | A | $1.85 | 20.000 |
| C9290 | A | $1.41 | 20.000 |
| C9399 | C | $0.00 | 20.000 |
| C9460 | A | $17.64 | 20.000 |
| C9482 | A | $20.71 | 19.969 |
| C9488 | A | $47.24 | 20.000 |
| J0121 | A | $3.75 | 20.000 |
| J0122 | A | $1.11 | 20.000 |
| J0129 | A | $42.84 | 20.000 |
| J0134 | A | $0.00 | 20.000 |
| J0135 | A | $1834.49 | 20.000 |
| J0136 | A | $0.00 | 20.000 |
| J0137 | A | $0.00 | 20.000 |
| J0172 | A | $5.98 | 20.000 |
| J0173 | A | $1.89 | 20.000 |
| J0174 | A | $1.34 | 20.000 |
| J0177 | A | $341.75 | 20.000 |
| J0178 | A | $841.13 | 20.000 |
| J0179 | A | $325.68 | 20.000 |
| J0180 | A | $218.28 | 20.000 |
| J0184 | A | $9.08 | 20.000 |
| J0185 | A | $1.67 | 20.000 |
| J0202 | A | $2347.58 | 20.000 |
| J0206 | A | $5.43 | 20.000 |
| J0208 | A | $95.85 | 20.000 |
| J0217 | A | $424.00 | 20.000 |
| J0218 | A | $376.58 | 20.000 |
| J0219 | A | $76.00 | 20.000 |
| J0220 | A | $148.86 | 20.000 |
| J0221 | A | $197.30 | 20.000 |
| J0222 | A | $99.20 | 20.000 |
| J0223 | A | $112.02 | 20.000 |
| J0224 | A | $318.10 | 20.000 |
| J0225 | A | $4935.21 | 20.000 |
| J0256 | A | $4.91 | 20.000 |
| J0257 | A | $5.40 | 20.000 |
| J0287 | A | $11.13 | 19.918 |
| J0289 | A | $27.68 | 20.000 |
| J0291 | A | $3.60 | 19.908 |
| J0300 | A | $114.24 | 20.000 |
| J0349 | A | $10.13 | 20.000 |
| J0391 | A | $47.84 | 20.000 |
| J0401 | A | $6.81 | 20.000 |
| J0402 | A | $5.81 | 20.000 |
| J0457 | A | $2.58 | 20.000 |
| J0470 | A | $59.81 | 20.000 |
| J0475 | A | $177.46 | 20.000 |
| J0480 | A | $4487.00 | 20.000 |
| J0485 | A | $3.87 | 20.000 |
| J0490 | A | $54.10 | 20.000 |
| J0491 | A | $17.14 | 20.000 |
| J0517 | A | $165.25 | 20.000 |
| J0558 | A | $17.37 | 16.309 |
| J0561 | A | $22.00 | 16.248 |
| J0565 | A | $39.87 | 20.000 |
| J0570 | A | $1311.75 | 20.000 |
| J0577 | A | $404.09 | 20.000 |
| J0578 | A | $1616.35 | 20.000 |
| J0584 | A | $447.86 | 19.383 |
| J0585 | A | $6.32 | 20.000 |
| J0586 | A | $8.68 | 18.884 |
| J0587 | A | $13.04 | 20.000 |
| J0588 | A | $5.20 | 20.000 |
| J0589 | A | $4.33 | 20.000 |
| J0594 | A | $1.04 | 20.000 |
| J0596 | A | $33.40 | 20.000 |
| J0597 | A | $64.43 | 20.000 |
| J0598 | A | $62.56 | 20.000 |
| J0600 | A | $6353.09 | 20.000 |
| J0606 | A | $2.45 | 20.000 |
| J0612 | A | $0.00 | 20.000 |
| J0613 | A | $0.00 | 20.000 |
| J0630 | A | $1101.74 | 20.000 |
| J0638 | A | $124.48 | 20.000 |
| J0641 | A | $0.05 | 20.000 |
| J0642 | A | $1.71 | 20.000 |
| J0651 | A | $8.42 | 20.000 |
| J0652 | A | $3.97 | 20.000 |
| J0665 | A | $0.00 | 20.000 |
| J0689 | A | $1.24 | 20.000 |
| J0691 | A | $.72 | 20.000 |
| J0695 | A | $7.29 | 20.000 |
| J0699 | A | $2.17 | 20.000 |
| J0701 | A | $5.76 | 20.000 |
| J0703 | A | $4.95 | 20.000 |
| J0712 | A | $3.86 | 20.000 |
| J0714 | A | $95.44 | 20.000 |
| J0716 | A | $4777.57 | 20.000 |
| J0717 | A | $4.62 | 20.000 |
| J0736 | A | $2.27 | 20.000 |
| J0737 | A | $2.21 | 20.000 |
| J0740 | A | $581.06 | 20.000 |
| J0741 | A | $22.62 | 20.000 |
| J0742 | A | $2.45 | 20.000 |
| J0775 | A | $68.97 | 18.556 |
| J0791 | A | $127.35 | 20.000 |
| J0801 | A | $3370.39 | 20.000 |
| J0802 | A | $3365.30 | 20.000 |
| J0840 | A | $1979.87 | 20.000 |
| J0841 | A | $1047.29 | 20.000 |
| J0850 | A | $1808.22 | 19.783 |
| J0875 | A | $15.12 | 20.000 |
| J0877 | A | $0.00 | 20.000 |
| J0881 | A | $2.90 | 20.000 |
| J0882 | A | $2.90 | 20.000 |
| J0883 | A | $.89 | 20.000 |
| J0884 | A | $.89 | 20.000 |
| J0885 | A | $8.27 | 20.000 |
| J0887 | A | $1.44 | 20.000 |
| J0888 | A | $1.38 | 20.000 |
| J0891 | A | $1.82 | 16.762 |
| J0892 | A | $1.82 | 16.762 |
| J0893 | A | $2.12 | 20.000 |
| J0896 | A | $39.98 | 20.000 |
| J0897 | A | $25.19 | 19.586 |
| J0898 | A | $4.13 | 7.466 |
| J0899 | A | $4.13 | 7.466 |
| J1096 | A | $117.01 | 20.000 |
| J1097 | A | $97.12 | 20.000 |
| J1105 | A | $.75 | 20.000 |
| J1162 | A | $4777.44 | 20.000 |
| J1190 | A | $91.09 | 20.000 |
| J1201 | A | $14.97 | 20.000 |
| J1203 | A | $87.55 | 20.000 |
| J1212 | A | $680.16 | 20.000 |
| J1290 | A | $545.62 | 20.000 |
| J1300 | A | $225.70 | 20.000 |
| J1301 | A | $21.83 | 20.000 |
| J1302 | A | $17.77 | 20.000 |
| J1303 | A | $221.75 | 20.000 |
| J1304 | A | $150.84 | 20.000 |
| J1305 | A | $179.14 | 20.000 |
| J1306 | A | $12.12 | 20.000 |
| J1322 | A | $283.22 | 20.000 |
| J1323 | A | $181.67 | 20.000 |
| J1327 | A | $1.99 | 20.000 |
| J1364 | A | $77.85 | 20.000 |
| J1410 | A | $372.37 | 20.000 |
| J1426 | A | $166.23 | 20.000 |
| J1427 | A | $58.78 | 20.000 |
| J1429 | A | $166.21 | 20.000 |
| J1430 | A | $474.44 | 20.000 |
| J1437 | A | $19.94 | 20.000 |
| J1438 | A | $790.78 | 20.000 |
| J1439 | A | $1.09 | 20.000 |
| J1440 | A | $63.21 | 20.000 |
| J1442 | A | $.99 | 20.000 |
| J1447 | A | $.41 | 20.000 |
| J1448 | A | $5.29 | 20.000 |
| J1449 | A | $27.74 | 20.000 |
| J1451 | A | $6.58 | 20.000 |
| J1454 | A | $708.35 | 19.733 |
| J1455 | A | $61.01 | 20.000 |
| J1456 | A | $2.04 | 3.823 |
| J1458 | A | $466.92 | 20.000 |
| J1459 | A | $47.86 | 20.000 |
| J1460 | A | $49.06 | 20.000 |
| J1551 | A | $13.80 | 20.000 |
| J1554 | A | $491.41 | 20.000 |
| J1555 | A | $15.83 | 20.000 |
| J1556 | A | $72.97 | 20.000 |
| J1557 | A | $55.01 | 20.000 |
| J1558 | A | $14.13 | 20.000 |
| J1559 | A | $12.91 | 20.000 |
| J1560 | A | $490.62 | 20.000 |
| J1561 | A | $48.88 | 20.000 |
| J1566 | A | $78.46 | 20.000 |
| J1568 | A | $46.98 | 20.000 |
| J1569 | A | $43.22 | 20.000 |
| J1571 | A | $60.77 | 20.000 |
| J1572 | A | $56.12 | 20.000 |
| J1573 | A | $60.77 | 20.000 |
| J1575 | A | $16.94 | 20.000 |
| J1576 | A | $64.95 | 20.000 |
| J1595 | A | $164.56 | 20.000 |
| J1602 | A | $11.80 | 20.000 |
| J1610 | A | $191.52 | 20.000 |
| J1611 | A | $128.88 | 20.000 |
| J1627 | A | $5.42 | 20.000 |
| J1628 | A | $70.80 | 20.000 |
| J1632 | A | $71.60 | 20.000 |
| J1640 | A | $31.35 | 19.839 |
| J1643 | A | $4.34 | 20.000 |
| J1670 | A | $578.78 | 19.668 |
| J1726 | A | $12.08 | 20.000 |
| J1729 | A | $18.18 | 20.000 |
| J1742 | A | $70.40 | 20.000 |
| J1743 | A | $542.89 | 20.000 |
| J1744 | A | $126.86 | 20.000 |
| J1745 | A | $31.67 | 20.000 |
| J1746 | A | $74.65 | 20.000 |
| J1747 | A | $60.15 | 20.000 |
| J1750 | A | $17.31 | 20.000 |
| J1786 | A | $43.94 | 20.000 |
| J1805 | A | $.22 | 20.000 |
| J1806 | A | $.42 | 20.000 |
| J1811 | A | $7.56 | 20.000 |
| J1813 | A | $15.68 | 20.000 |
| J1823 | A | $473.51 | 20.000 |
| J1826 | A | $1910.69 | 20.000 |
| J1833 | A | $.95 | 20.000 |
| J1836 | A | $0.00 | 20.000 |
| J1920 | A | $.17 | 20.000 |
| J1921 | A | $2.37 | 20.000 |
| J1930 | A | $48.00 | 20.000 |
| J1931 | A | $37.44 | 20.000 |
| J1932 | A | $44.02 | 20.000 |
| J1943 | A | $3.08 | 20.000 |
| J1944 | A | $3.12 | 20.000 |
| J1950 | A | $1576.12 | 19.514 |
| J1951 | A | $131.71 | 20.000 |
| J1952 | A | $60.75 | 20.000 |
| J1954 | A | $281.57 | 20.000 |
| J1961 | A | $22.01 | 20.000 |
| J2021 | A | $16.43 | 20.000 |
| J2182 | A | $30.48 | 20.000 |
| J2184 | A | $2.02 | 9.538 |
| J2186 | A | $2.08 | 19.813 |
| J2212 | A | $1.15 | 20.000 |
| J2247 | A | $.27 | 20.000 |
| J2251 | A | $.26 | 20.000 |
| J2265 | A | $2.47 | 19.088 |
| J2272 | A | $7.28 | 20.000 |
| J2277 | A | $25.22 | 20.000 |
| J2278 | A | $9.04 | 20.000 |
| J2281 | A | $7.49 | 20.000 |
| J2305 | A | $1.44 | 20.000 |
| J2311 | A | $6.29 | 20.000 |
| J2315 | A | $3.97 | 20.000 |
| J2323 | A | $24.23 | 20.000 |
| J2326 | A | $1210.10 | 20.000 |
| J2327 | A | $15.00 | 20.000 |
| J2329 | A | $67.23 | 20.000 |
| J2350 | A | $58.76 | 20.000 |
| J2353 | A | $210.56 | 20.000 |
| J2356 | A | $17.80 | 20.000 |
| J2357 | A | $36.81 | 20.000 |
| J2358 | A | $2.92 | 20.000 |
| J2359 | A | $.96 | 20.000 |
| J2372 | A | $.17 | 20.000 |
| J2401 | A | $0.00 | 20.000 |
| J2403 | A | $.66 | 20.000 |
| J2406 | A | $40.90 | 20.000 |
| J2407 | A | $26.91 | 20.000 |
| J2425 | A | $33.99 | 16.54 |
| J2426 | A | $14.28 | 20.000 |
| J2427 | A | $12.19 | 20.000 |
| J2502 | A | $463.20 | 17.846 |
| J2506 | A | $109.75 | 20.000 |
| J2507 | A | $3391.91 | 20.000 |
| J2508 | A | $219.16 | 20.000 |
| J2510 | A | $40.94 | 20.000 |
| J2547 | A | $1.68 | 20.000 |
| J2562 | A | $123.58 | 20.000 |
| J2597 | A | $6.27 | 20.000 |
| J2598 | A | $1.88 | 20.000 |
| J2599 | A | $.28 | 20.000 |
| J2690 | A | $187.20 | 20.000 |
| J2724 | A | $15.03 | 20.000 |
| J2760 | A | $444.32 | 20.000 |
| J2770 | A | $493.97 | 20.000 |
| J2777 | A | $35.44 | 20.000 |
| J2778 | A | $173.38 | 20.000 |
| J2779 | A | $80.37 | 20.000 |
| J2781 | A | $149.90 | 20.000 |
| J2782 | A | $111.30 | 20.000 |
| J2783 | A | $367.48 | 20.000 |
| J2786 | A | $10.23 | 20.000 |
| J2792 | A | $30.64 | 20.000 |
| J2794 | A | $12.18 | 20.000 |
| J2796 | A | $96.38 | 20.000 |
| J2798 | A | $11.63 | 20.000 |
| J2799 | A | $24.41 | 20.000 |
| J2801 | A | $12.43 | 20.000 |
| J2820 | A | $59.46 | 19.590 |
| J2840 | A | $538.45 | 20.000 |
| J2850 | A | $41.74 | 19.603 |
| J2860 | A | $151.31 | 18.955 |
| J2941 | A | $163.55 | 20.000 |
| J2993 | A | $2889.63 | 20.000 |
| J2997 | A | $88.82 | 20.000 |
| J2998 | A | $31.80 | 20.000 |
| J3031 | A | $1.82 | 20.000 |
| J3032 | A | $18.05 | 20.000 |
| J3055 | A | $67.72 | 20.000 |
| J3060 | A | $45.00 | 20.000 |
| J3090 | A | $1.82 | 20.000 |
| J3095 | A | $7.13 | 20.000 |
| J3101 | A | $153.11 | 20.000 |
| J3111 | A | $10.69 | 20.000 |
| J3145 | A | $1.93 | 19.139 |
| J3240 | A | $2022.37 | 20.000 |
| J3241 | A | $333.40 | 20.000 |
| J3244 | A | $2.65 | 8.828 |
| J3245 | A | $132.09 | 20.000 |
| J3246 | A | $4.10 | 20.000 |
| J3262 | A | $6.04 | 20.000 |
| J3285 | A | $54.55 | 20.000 |
| J3299 | A | $48.58 | 20.000 |
| J3304 | A | $17.49 | 20.000 |
| J3315 | A | $416.69 | 20.000 |
| J3316 | A | $3234.00 | 20.000 |
| J3357 | A | $152.57 | 20.000 |
| J3358 | A | $12.49 | 20.000 |
| J3371 | A | $5.87 | 20.000 |
| J3372 | A | $6.40 | 20.000 |
| J3380 | A | $21.85 | 20.000 |
| J3385 | A | $367.84 | 20.000 |
| J3396 | A | $11.44 | 20.000 |
| J3398 | A | $2924.79 | 20.000 |
| J3401 | A | 1,007.64 | 20.000 |
| J3424 | A | $2,054.28 | 20.000 |
| J7165 | A | $3.25 | 20.000 |
| J7168 | A | $2.28 | 20.000 |
| J7169 | A | $132.18 | 20.000 |
| J7170 | A | $50.84 | 20.000 |
| J7175 | A | $9.11 | 20.000 |
| J7177 | A | $1.42 | 20.000 |
| J7178 | A | $1.45 | 20.000 |
| J7179 | A | $1.87 | 20.000 |
| J7180 | A | $10.15 | 20.000 |
| J7181 | A | $17.10 | 20.000 |
| J7182 | A | $1.38 | 20.000 |
| J7183 | A | $1.26 | 20.000 |
| J7185 | A | $1.37 | 20.000 |
| J7186 | A | $1.19 | 20.000 |
| J7187 | A | $1.40 | 20.000 |
| J7188 | A | $3.22 | 20.000 |
| J7189 | A | $2.45 | 20.000 |
| J7190 | A | $1.11 | 20.000 |
| J7192 | A | $1.51 | 20.000 |
| J7193 | A | $1.32 | 20.000 |
| J7194 | A | $1.61 | 20.000 |
| J7195 | A | $1.75 | 20.000 |
| J7197 | A | $3.74 | 20.000 |
| J7198 | A | $2.29 | 20.000 |
| J7200 | A | $1.53 | 20.000 |
| J7201 | A | $3.47 | 20.000 |
| J7202 | A | $5.09 | 20.000 |
| J7203 | A | $4.47 | 20.000 |
| J7204 | A | $2.11 | 20.000 |
| J7205 | A | $2.21 | 20.000 |
| J7207 | A | $2.05 | 20.000 |
| J7208 | A | $2.34 | 20.000 |
| J7209 | A | $1.25 | 20.000 |
| J7210 | A | $1.46 | 20.000 |
| J7211 | A | $1.42 | 20.000 |
| J7212 | A | $2.15 | 20.000 |
| J7213 | A | $1.84 | 20.000 |
| J7214 | A | $4.63 | 20.000 |
| J7308 | A | $396.53 | 20.000 |
| J7311 | A | $318.11 | 20.000 |
| J7312 | A | $205.60 | 20.000 |
| J7313 | A | $487.54 | 20.000 |
| J7314 | A | $527.08 | 20.000 |
| J7318 | A | $6.55 | 20.000 |
| J7320 | A | $5.16 | 20.000 |
| J7322 | A | $17.51 | 20.000 |
| J7323 | A | $115.57 | 20.000 |
| J7324 | A | $131.56 | 20.000 |
| J7325 | A | $8.88 | 20.000 |
| J7326 | A | $522.37 | 20.000 |
| J7327 | A | $711.54 | 20.000 |
| J7328 | A | $.49 | 20.000 |
| J7329 | A | $7.42 | 20.000 |
| J7331 | A | $10.46 | 20.000 |
| J7332 | A | $10.49 | 20.000 |
| J7336 | A | $3.32 | 20.000 |
| J7340 | A | $228.01 | 20.000 |
| J7342 | A | $30.02 | 20.000 |
| J7345 | A | $1.70 | 20.000 |
| J7351 | A | $206.19 | 20.000 |
| J7352 | A | $2873.33 | 20.000 |
| J7353 | A | 58.31 | 20.000 |
| J7354 | A | $719.97 | 20.000 |
| J7402 | A | $11.35 | 20.000 |
| J7501 | A | $241.53 | 20.000 |
| J7504 | A | $3614.80 | 15.373 |
| J7511 | A | $927.94 | 20.000 |
| J7519 | A | $.71 | 20.000 |
| J7525 | A | $248.77 | 20.000 |
| J8560 | A | $76.49 | 20.000 |
| J8655 | A | $409.05 | 18.197 |
| J8670 | A | $1.63 | 20.000 |
| J8705 | A | $113.24 | 20.000 |
| J9015 | A | $3943.00 | 20.000 |
| J9017 | A | $11.90 | 20.000 |
| J9021 | A | $51.20 | 20.000 |
| J9022 | A | $83.94 | 20.000 |
| J9023 | A | $92.53 | 20.000 |
| J9027 | A | $18.04 | 20.000 |
| J9029 | A | $63505.40 | 20.000 |
| J9032 | A | $48.84 | 20.000 |
| J9033 | A | $8.36 | 20.000 |
| J9034 | A | $13.83 | 20.000 |
| J9035 | A | $74.16 | 20.000 |
| J9036 | A | $8.88 | 20.000 |
| J9037 | A | $46.78 | 20.000 |
| J9039 | A | $145.36 | 19.788 |
| J9041 | A | $2.07 | 20.000 |
| J9042 | A | $230.74 | 19.285 |
| J9043 | A | $211.76 | 20.000 |
| J9046 | A | $48.55 | 20.000 |
| J9047 | A | $47.18 | 20.000 |
| J9048 | A | $48.55 | 20.000 |
| J9049 | A | $1.72 | 20.000 |
| J9050 | A | $280.92 | 20.000 |
| J9052 | A | $0.00 | 20.000 |
| J9055 | A | $73.49 | 20.000 |
| J9056 | A | $34.02 | 20.000 |
| J9057 | A | $87.66 | 20.000 |
| J9058 | A | $24.13 | 20.000 |
| J9059 | A | $24.13 | 20.000 |
| J9061 | A | $19.99 | 20.000 |
| J9063 | A | $65.68 | 20.000 |
| J9065 | A | $16.60 | 20.000 |
| J9071 | A | $1.76 | 20.000 |
| J9072 | A | $3.87 | 20.000 |
| J9073 | A | $.98 | 20.000 |
| J9075 | A | $.92 | 20.000 |
| J9119 | A | $27.58 | 20.000 |
| J9120 | A | $547.80 | 20.000 |
| J9144 | A | $48.80 | 20.000 |
| J9145 | A | $61.13 | 20.000 |
| J9150 | A | $31.50 | 20.000 |
| J9153 | A | $232.80 | 20.000 |
| J9155 | A | $4.35 | 20.000 |
| J9173 | A | $80.52 | 20.000 |
| J9176 | A | $7.40 | 20.000 |
| J9177 | A | $36.20 | 18.886 |
| J9179 | A | $137.79 | 20.000 |
| J9185 | A | $190.90 | 20.000 |
| J9196 | A | $4.24 | 20.000 |
| J9198 | A | $40.28 | 20.000 |
| J9200 | A | $3728.55 | 20.000 |
| J9202 | A | $599.34 | 20.000 |
| J9203 | A | $226.28 | 20.000 |
| J9204 | A | $234.17 | 20.000 |
| J9205 | A | $63.44 | 20.000 |
| J9207 | A | $127.50 | 20.000 |
| J9210 | A | $364.87 | 20.000 |
| J9214 | A | $32.57 | 20.000 |
| J9217 | A | $185.66 | 20.000 |
| J9218 | A | $11.02 | 20.000 |
| J9223 | A | $199.52 | 20.000 |
| J9225 | A | $5166.29 | 20.000 |
| J9226 | A | $44578.75 | 20.000 |
| J9227 | A | $76.42 | 20.000 |
| J9228 | A | $172.71 | 20.000 |
| J9229 | A | $2580.15 | 20.000 |
| J9245 | A | $167.76 | 20.000 |
| J9246 | A | $16.89 | 20.000 |
| J9247 | A | $426.90 | 20.000 |
| J9248 | A | $751.90 | 20.000 |
| J9259 | A | $15.14 | 20.000 |
| J9261 | A | $101.93 | 20.000 |
| J9262 | A | $3.95 | 19.697 |
| J9264 | A | $13.71 | 20.000 |
| J9266 | A | $25781.46 | 19.658 |
| J9268 | A | $2335.72 | 19.851 |
| J9269 | A | $326.65 | 20.000 |
| J9271 | A | $57.31 | 20.000 |
| J9272 | A | $232.55 | 20.000 |
| J9273 | A | $174.80 | 19.849 |
| J9274 | A | $208.93 | 20.000 |
| J9280 | A | $67.03 | 20.000 |
| J9281 | A | $300.59 | 20.000 |
| J9286 | A | $2707.25 | 20.000 |
| J9293 | A | $42.67 | 20.000 |
| J9294 | A | $3.62 | 20.000 |
| J9295 | A | $5.74 | 20.000 |
| J9296 | A | $9.66 | 20.000 |
| J9297 | A | $1.42 | 20.000 |
| J9298 | A | $187.00 | 20.000 |
| J9299 | A | $31.09 | 20.000 |
| J9301 | A | $70.22 | 20.000 |
| J9302 | A | $63.96 | 20.000 |
| J9303 | A | $151.24 | 20.000 |
| J9304 | A | $63.08 | 20.000 |
| J9305 | A | $3.97 | 20.000 |
| J9306 | A | $15.42 | 20.000 |
| J9307 | A | $299.28 | 20.000 |
| J9308 | A | $69.65 | 20.000 |
| J9309 | A | $124.03 | 20.000 |
| J9311 | A | $37.24 | 20.000 |
| J9312 | A | $78.87 | 20.000 |
| J9313 | A | $23.39 | 20.000 |
| J9314 | A | $9.96 | 20.000 |
| J9316 | A | $65.32 | 20.000 |
| J9317 | A | $33.87 | 20.000 |
| J9318 | A | $33.91 | 19.786 |
| J9319 | A | $30.55 | 20.000 |
| J9320 | A | $370.18 | 20.000 |
| J9321 | A | $53.78 | 20.000 |
| J9323 | A | $10.34 | 20.000 |
| J9325 | A | $66.80 | 19.901 |
| J9328 | A | $10.40 | 20.000 |
| J9330 | A | $28.86 | 20.000 |
| J9331 | A | $109.29 | 20.000 |
| J9332 | A | $32.07 | 20.000 |
| J9333 | A | $22.85 | 20.000 |
| J9334 | A | $33.17 | 20.000 |
| J9340 | A | $228.36 | 20.000 |
| J9345 | A | $29.50 | 20.000 |
| J9347 | A | $135.75 | 20.000 |
| J9348 | A | $610.03 | 20.000 |
| J9349 | A | $13.58 | 20.000 |
| J9350 | A | $629.15 | 20.000 |
| J9352 | A | $338.39 | 20.000 |
| J9353 | A | $47.04 | 20.000 |
| J9354 | A | $38.44 | 20.000 |
| J9355 | A | $80.05 | 20.000 |
| J9356 | A | $65.93 | 20.000 |
| J9357 | A | $1347.69 | 20.000 |
| J9358 | A | $27.27 | 20.000 |
| J9359 | A | $200.49 | 20.000 |
| J9371 | A | $3420.78 | 20.000 |
| J9380 | A | $30.76 | 20.000 |
| J9381 | A | $36.38 | 20.000 |
| J9393 | A | $21.20 | 20.000 |
| J9394 | A | $5.29 | 20.000 |
| J9395 | A | $8.17 | 20.000 |
| J9400 | A | $6.68 | 20.000 |
| J9600 | A | $23170.54 | 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 | $.39 | 20.000 |
| Q0139 | A | $.39 | 20.000 |
| Q2004 | A | $146.92 | 20.000 |
| Q2009 | A | $5.51 | 20.000 |
| Q2026 | A | $298.73 | 20.000 |
| Q2028 | A | $1.40 | 20.000 |
| Q2043 | A | $55453.57 | 20.000 |
| Q2049 | A | $391.42 | 20.000 |
| Q2050 | A | $114.94 | 20.000 |
| Q3027 | A | $54.28 | 20.000 |
| Q5101 | A | $.42 | 20.000 |
| Q5103 | A | $11.09 | 20.000 |
| Q5104 | A | $30.58 | 20.000 |
| Q5105 | A | $.75 | 20.000 |
| Q5106 | A | $7.51 | 20.000 |
| Q5107 | A | $26.75 | 20.000 |
| Q5108 | A | $164.04 | 20.000 |
| Q5110 | A | $.29 | 20.000 |
| Q5111 | A | $135.49 | 20.000 |
| Q5112 | A | $34.06 | 20.000 |
| Q5113 | A | $55.80 | 20.000 |
| Q5114 | A | $62.62 | 20.000 |
| Q5115 | A | $30.98 | 20.000 |
| Q5116 | A | $12.77 | 20.000 |
| Q5117 | A | $17.68 | 20.000 |
| Q5118 | A | $20.76 | 20.000 |
| Q5119 | A | $20.28 | 20.000 |
| Q5120 | A | $346.76 | 20.000 |
| Q5121 | A | $24.37 | 20.000 |
| Q5122 | A | $65.51 | 20.000 |
| Q5123 | A | $41.42 | 20.000 |
| Q5124 | A | $175.06 | 20.000 |
| Q5125 | A | $0.45 | 20.000 |
| Q5126 | A | $55.39 | 20.000 |
| Q5127 | A | $344.10 | 20.000 |
| Q5128 | A | $256.17 | 20.000 |
| Q5129 | A | $69.27 | 20.000 |
| Q5130 | A | $199.92 | 20.000 |
| Q9968 | A | $7.72 | 20.000 |
| Q9991 | A | $1874.90 | 20.000 |
| Q9992 | A | $1874.90 | 20.000 |
| 90371 | A | $141.12 | 20.000 |
| 90375 | A | $285.65 | 20.000 |
| 90376 | A | $479.72 | 20.000 |
| 90377 | A | $250.98 | 20.000 |
| 90396 | A | $2254.82 | 20.000 |
| 90476 | A | $46.00 | 20.000 |
| 90675 | A | $322.77 | 20.000 |
| 90676 | A | $279.15 | 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 2025 by the American Medical Association.

