Revised July 2024 3rd Quarter ASC Drug File
Effective 07.01.2024 – Revised 07.01.2025
| HCPCS Code | Status Indicator | Amount | Coinsurance |
|---|---|---|---|
| A9506 | A | $328.60 | 20.000 |
| A9590 | A | $339.16 | 20.000 |
| A9595 | A | $615.12 | 20.000 |
| A9596 | A | $1,017.21 | 20.000 |
| A9601 | A | $3,710.00 | 20.000 |
| A9602 | A | $446.88 | 20.000 |
| A9608 | A | $651.67 | 20.000 |
| A9800 | A | $873.44 | 20.000 |
| C9047 | A | $768.22 | 20.000 |
| C9088 | A | $0.77 | 20.000 |
| C9089 | A | $0.85 | 20.000 |
| C9101 | A | $1.35 | 20.000 |
| C9144 | A | $0.51 | 20.000 |
| C9145 | A | $1.88 | 20.000 |
| C9250 | A | $138.31 | 20.000 |
| C9257 | A | $1.81 | 20.000 |
| C9290 | A | $1.46 | 20.000 |
| C9399 | C | $0.00 | 20.000 |
| C9460 | A | $18.33 | 20.000 |
| C9482 | A | $22.79 | 18.192 |
| C9488 | A | $47.24 | 20.000 |
| J0121 | A | $3.88 | 19.983 |
| J0122 | A | $1.21 | 19.790 |
| J0129 | A | $43.73 | 20.000 |
| J0134 | A | $0.05 | 20.000 |
| J0135 | A | $1,834.49 | 20.000 |
| J0136 | A | $0.05 | 20.000 |
| J0137 | A | $0.05 | 20.000 |
| J0172 | A | $5.98 | 20.000 |
| J0173 | A | $1.86 | 20.000 |
| J0174 | A | $1.34 | 20.000 |
| J0177 | A | $335.71 | 20.000 |
| J0178 | A | $835.40 | 20.000 |
| J0179 | A | $331.23 | 20.000 |
| J0180 | A | $222.93 | 20.000 |
| J0184 | A | $9.07 | 20.000 |
| J0185 | A | $1.72 | 20.000 |
| J0202 | A | $2,348.84 | 20.000 |
| J0206 | A | $5.49 | 20.000 |
| J0208 | A | $95.97 | 20.000 |
| J0211 | A | $2.17 | 20.000 |
| J0217 | A | $444.40 | 20.000 |
| J0218 | A | $381.83 | 20.000 |
| J0219 | A | $77.60 | 20.000 |
| J0220 | A | $148.86 | 20.000 |
| J0221 | A | $201.67 | 20.000 |
| J0222 | A | $99.35 | 20.000 |
| J0223 | A | $112.28 | 20.000 |
| J0224 | A | $318.49 | 20.000 |
| J0225 | A | $4,932.11 | 20.000 |
| J0256 | A | $4.83 | 20.000 |
| J0257 | A | $5.39 | 20.000 |
| J0287 | A | $11.13 | 20.000 |
| J0289 | A | $21.63 | 20.000 |
| J0291 | A | $3.59 | 19.984 |
| J0300 | A | $114.24 | 20.000 |
| J0349 | A | $10.12 | 20.000 |
| J0391 | A | $51.83 | 20.000 |
| J0401 | A | $7.01 | 19.915 |
| J0402 | A | $5.92 | 20.000 |
| J0457 | A | $2.13 | 20.000 |
| J0470 | A | $59.81 | 20.000 |
| J0475 | A | $176.45 | 20.000 |
| J0480 | A | $4,581.22 | 20.000 |
| J0485 | A | $3.87 | 20.000 |
| J0490 | A | $54.13 | 20.000 |
| J0491 | A | $17.33 | 20.000 |
| J0517 | A | $168.22 | 20.000 |
| J0558 | A | $19.52 | 14.544 |
| J0561 | A | $23.97 | 14.946 |
| J0565 | A | $39.89 | 20.000 |
| J0570 | A | $1,311.75 | 20.000 |
| J0577 | A | $426.97 | 20.000 |
| J0578 | A | $1,707.88 | 20.000 |
| J0584 | A | $464.74 | 18.725 |
| J0585 | A | $6.38 | 20.000 |
| J0586 | A | $8.71 | 20.000 |
| J0587 | A | $13.06 | 20.000 |
| J0588 | A | $5.21 | 20.000 |
| J0589 | A | $3.06 | 20.000 |
| J0594 | A | $0.96 | 20.000 |
| J0596 | A | $34.78 | 20.000 |
| J0597 | A | $67.77 | 20.000 |
| J0598 | A | $64.28 | 20.000 |
| J0600 | A | $6,309.65 | 20.000 |
| J0606 | A | $2.51 | 20.000 |
| J0612 | A | $0.04 | 20.000 |
| J0613 | A | $0.09 | 20.000 |
| J0630 | A | $1,071.97 | 20.000 |
| J0638 | A | $126.55 | 20.000 |
| J0641 | A | $0.02 | 20.000 |
| J0642 | A | $1.70 | 20.000 |
| J0651 | A | $2.66 | 20.000 |
| J0652 | A | $5.79 | 20.000 |
| J0665 | A | $0.01 | 20.000 |
| J0687 | A | $1.08 | 20.000 |
| J0689 | A | $1.27 | 20.000 |
| J0691 | A | $0.72 | 20.000 |
| J0695 | A | $8.24 | 18.991 |
| J0699 | A | $2.27 | 20.000 |
| J0701 | A | $5.69 | 7.823 |
| J0703 | A | $5.13 | 8.676 |
| J0712 | A | $4.03 | 20.000 |
| J0714 | A | $100.20 | 20.000 |
| J0716 | A | $4,760.20 | 20.000 |
| J0717 | A | $4.46 | 20.000 |
| J0736 | A | $2.39 | 20.000 |
| J0737 | A | $3.26 | 20.000 |
| J0740 | A | $544.73 | 20.000 |
| J0741 | A | $22.92 | 20.000 |
| J0742 | A | $2.52 | 20.000 |
| J0775 | A | $68.68 | 18.678 |
| J0791 | A | $127.39 | 20.000 |
| J0801 | A | $3,479.53 | 20.000 |
| J0802 | A | $3,480.99 | 20.000 |
| J0840 | A | $1,894.15 | 20.000 |
| J0841 | A | $1,056.39 | 20.000 |
| J0850 | A | $1,812.14 | 19.788 |
| J0872 | A | $0.33 | 20.000 |
| J0875 | A | $15.79 | 20.000 |
| J0877 | A | $0.06 | 20.000 |
| J0881 | A | $3.06 | 20.000 |
| J0882 | A | $3.06 | 20.000 |
| J0883 | A | $0.82 | 20.000 |
| J0884 | A | $0.82 | 20.000 |
| J0885 | A | $8.13 | 20.000 |
| J0887 | A | $1.08 | 20.000 |
| J0888 | A | $1.08 | 20.000 |
| J0891 | A | $4.20 | 20.000 |
| J0892 | A | $4.20 | 20.000 |
| J0893 | A | $2.12 | 20.000 |
| J0896 | A | $40.68 | 20.000 |
| J0897 | A | $26.75 | 18.488 |
| J0898 | A | $1.39 | 20.000 |
| J0899 | A | $1.39 | 20.000 |
| J0911 | A | $0.86 | 20.000 |
| J1096 | A | $115.08 | 20.000 |
| J1097 | A | $97.06 | 20.000 |
| J1105 | A | $0.77 | 20.000 |
| J1162 | A | $4,777.44 | 20.000 |
| J1190 | A | $100.67 | 20.000 |
| J1201 | A | $14.96 | 20.000 |
| J1203 | A | $88.14 | 20.000 |
| J1212 | A | $706.17 | 20.000 |
| J1290 | A | $562.88 | 20.000 |
| J1300 | A | $225.47 | 20.000 |
| J1301 | A | $21.82 | 20.000 |
| J1302 | A | $18.10 | 20.000 |
| J1303 | A | $221.21 | 20.000 |
| J1304 | A | $150.83 | 20.000 |
| J1305 | A | $182.66 | 20.000 |
| J1306 | A | $12.21 | 20.000 |
| J1322 | A | $288.54 | 20.000 |
| J1323 | A | $179.92 | 20.000 |
| J1327 | A | $3.03 | 20.000 |
| J1364 | A | $69.79 | 20.000 |
| J1410 | A | $384.03 | 20.000 |
| J1426 | A | $166.23 | 20.000 |
| J1427 | A | $58.81 | 20.000 |
| J1429 | A | $166.06 | 20.000 |
| J1430 | A | $498.99 | 20.000 |
| J1437 | A | $20.65 | 20.000 |
| J1438 | A | $790.78 | 20.000 |
| J1439 | A | $1.13 | 20.000 |
| J1440 | A | $63.28 | 20.000 |
| J1442 | A | $1.00 | 20.000 |
| J1447 | A | $0.40 | 20.000 |
| J1448 | A | $5.28 | 20.000 |
| J1449 | A | $26.17 | 20.000 |
| J1451 | A | $6.58 | 20.000 |
| J1454 | A | $687.15 | 20.000 |
| J1455 | A | $49.02 | 20.000 |
| J1456 | A | $2.04 | 3.832 |
| J1458 | A | $475.67 | 20.000 |
| J1459 | A | $48.67 | 20.000 |
| J1460 | A | $50.07 | 20.000 |
| J1551 | A | $14.53 | 20.000 |
| J1554 | A | $491.40 | 20.000 |
| J1555 | A | $16.89 | 19.835 |
| J1556 | A | $75.17 | 20.000 |
| J1557 | A | $54.57 | 20.000 |
| J1558 | A | $14.40 | 20.000 |
| J1559 | A | $13.19 | 20.000 |
| J1560 | A | $500.71 | 20.000 |
| J1561 | A | $49.58 | 20.000 |
| J1566 | A | $79.90 | 20.000 |
| J1568 | A | $47.74 | 20.000 |
| J1569 | A | $45.07 | 20.000 |
| J1571 | A | $62.78 | 20.000 |
| J1572 | A | $56.12 | 20.000 |
| J1573 | A | $62.78 | 20.000 |
| J1575 | A | $17.24 | 20.000 |
| J1576 | A | $69.77 | 20.000 |
| J1595 | A | $167.07 | 20.000 |
| J1602 | A | $11.37 | 20.000 |
| J1610 | A | $189.46 | 20.000 |
| J1611 | A | $129.67 | 20.000 |
| J1627 | A | $5.63 | 20.000 |
| J1628 | A | $73.63 | 20.000 |
| J1632 | A | $71.07 | 20.000 |
| J1640 | A | $32.12 | 19.414 |
| J1643 | A | $3.42 | 20.000 |
| J1670 | A | $564.92 | 20.000 |
| J1726 | A | $14.46 | 20.000 |
| J1729 | A | $18.18 | 20.000 |
| J1742 | A | $230.78 | 20.000 |
| J1743 | A | $544.92 | 20.000 |
| J1744 | A | $155.11 | 20.000 |
| J1745 | A | $31.71 | 20.000 |
| J1746 | A | $77.25 | 19.652 |
| J1747 | A | $61.42 | 20.000 |
| J1750 | A | $17.99 | 20.000 |
| J1786 | A | $43.74 | 20.000 |
| J1805 | A | $0.26 | 20.000 |
| J1806 | A | $0.40 | 20.000 |
| J1811 | A | $7.54 | 20.000 |
| J1813 | A | $15.53 | 20.000 |
| J1823 | A | $483.84 | 20.000 |
| J1826 | A | $1,910.69 | 20.000 |
| J1833 | A | $0.98 | 19.603 |
| J1836 | A | $0.03 | 20.000 |
| J1920 | A | $0.17 | 20.000 |
| J1921 | A | $2.13 | 20.000 |
| J1930 | A | $50.03 | 20.000 |
| J1931 | A | $38.63 | 20.000 |
| J1932 | A | $42.34 | 20.000 |
| J1943 | A | $3.14 | 20.000 |
| J1944 | A | $3.22 | 20.000 |
| J1950 | A | $1,673.93 | 18.419 |
| J1951 | A | $140.00 | 20.000 |
| J1952 | A | $55.64 | 20.000 |
| J1954 | A | $306.66 | 20.000 |
| J1961 | A | $21.92 | 20.000 |
| J2021 | A | $14.34 | 20.000 |
| J2182 | A | $30.46 | 20.000 |
| J2186 | A | $2.08 | 19.832 |
| J2212 | A | $1.18 | 20.000 |
| J2247 | A | $0.49 | 20.000 |
| J2265 | A | $2.59 | 18.239 |
| J2267 | A | $34.74 | 20.000 |
| J2277 | A | $25.22 | 20.000 |
| J2278 | A | $9.78 | 20.000 |
| J2281 | A | $7.56 | 20.000 |
| J2305 | A | $1.34 | 20.000 |
| J2311 | A | $7.71 | 20.000 |
| J2315 | A | $4.10 | 19.781 |
| J2323 | A | $24.07 | 20.000 |
| J2326 | A | $1,211.26 | 20.000 |
| J2327 | A | $14.99 | 20.000 |
| J2329 | A | $70.05 | 19.470 |
| J2350 | A | $60.25 | 20.000 |
| J2353 | A | $215.48 | 20.000 |
| J2356 | A | $18.24 | 20.000 |
| J2357 | A | $38.33 | 20.000 |
| J2358 | A | $2.92 | 20.000 |
| J2359 | A | $0.98 | 20.000 |
| J2372 | A | $0.17 | 20.000 |
| J2401 | A | $0.03 | 20.000 |
| J2403 | A | $0.63 | 20.000 |
| J2406 | A | $41.93 | 20.000 |
| J2407 | A | $28.12 | 19.944 |
| J2425 | A | $33.99 | 16.601 |
| J2426 | A | $14.66 | 20.000 |
| J2427 | A | $12.53 | 20.000 |
| J2502 | A | $480.98 | 17.228 |
| J2506 | A | $55.13 | 20.000 |
| J2507 | A | $3,447.06 | 19.841 |
| J2508 | A | $229.53 | 20.000 |
| J2510 | A | $40.94 | 20.000 |
| J2547 | A | $1.68 | 20.000 |
| J2562 | A | $127.41 | 20.000 |
| J2597 | A | $5.56 | 20.000 |
| J2598 | A | $1.93 | 20.000 |
| J2690 | A | $412.74 | 20.000 |
| J2724 | A | $15.01 | 20.000 |
| J2760 | A | $399.33 | 20.000 |
| J2770 | A | $6.23 | 20.000 |
| J2777 | A | $34.82 | 20.000 |
| J2778 | A | $137.63 | 20.000 |
| J2779 | A | $80.49 | 20.000 |
| J2781 | A | $149.07 | 20.000 |
| J2782 | A | $110.46 | 20.000 |
| J2783 | A | $370.90 | 20.000 |
| J2786 | A | $10.09 | 20.000 |
| J2792 | A | $33.72 | 20.000 |
| J2794 | A | $12.16 | 20.000 |
| J2796 | A | $100.81 | 19.249 |
| J2798 | A | $12.21 | 20.000 |
| J2799 | A | $25.08 | 20.000 |
| J2801 | A | $13.03 | 20.000 |
| J2820 | A | $60.00 | 19.461 |
| J2840 | A | $538.56 | 20.000 |
| J2850 | A | $42.57 | 19.265 |
| J2860 | A | $153.16 | 18.772 |
| J2941 | A | $163.55 | 20.000 |
| J2993 | A | $2,685.42 | 20.000 |
| J2997 | A | $91.34 | 20.000 |
| J2998 | A | $34.97 | 20.000 |
| J3031 | A | $1.86 | 20.000 |
| J3032 | A | $18.66 | 19.722 |
| J3055 | A | $67.61 | 20.000 |
| J3060 | A | $44.57 | 20.000 |
| J3090 | A | $1.81 | 20.000 |
| J3095 | A | $7.06 | 20.000 |
| J3101 | A | $157.47 | 20.000 |
| J3111 | A | $11.16 | 19.672 |
| J3145 | A | $1.89 | 19.561 |
| J3240 | A | $2,065.84 | 20.000 |
| J3241 | A | $336.14 | 20.000 |
| J3244 | A | $2.65 | 20.000 |
| J3245 | A | $133.55 | 20.000 |
| J3246 | A | $3.96 | 20.000 |
| J3247 | A | $17.56 | 20.000 |
| J3262 | A | $5.95 | 20.000 |
| J3263 | A | $39.27 | 20.000 |
| J3285 | A | $55.48 | 20.000 |
| J3299 | A | $48.58 | 20.000 |
| J3304 | A | $17.83 | 20.000 |
| J3315 | A | $458.51 | 20.000 |
| J3316 | A | $3,432.75 | 20.000 |
| J3357 | A | $158.16 | 20.000 |
| J3358 | A | $12.88 | 20.000 |
| J3371 | A | $5.94 | 20.000 |
| J3372 | A | $6.48 | 20.000 |
| J3380 | A | $22.88 | 20.000 |
| J3385 | A | $369.48 | 20.000 |
| J3396 | A | $11.52 | 20.000 |
| J3398 | A | $2,874.62 | 20.000 |
| J3401 | A | $996.94 | 20.000 |
| J3424 | A | $5.03 | 20.000 |
| J7165 | A | $2.38 | 20.000 |
| J7168 | A | $2.27 | 20.000 |
| J7169 | A | $132.08 | 20.000 |
| J7170 | A | $52.57 | 20.000 |
| J7171 | A | $34.68 | 20.000 |
| J7175 | A | $9.11 | 20.000 |
| J7177 | A | $1.10 | 20.000 |
| J7178 | A | $1.44 | 20.000 |
| J7179 | A | $1.83 | 20.000 |
| J7180 | A | $10.15 | 20.000 |
| J7181 | A | $17.63 | 20.000 |
| J7182 | A | $1.38 | 20.000 |
| J7183 | A | $1.27 | 20.000 |
| J7185 | A | $1.42 | 20.000 |
| J7186 | A | $1.19 | 20.000 |
| J7187 | A | $1.40 | 20.000 |
| J7188 | A | $3.22 | 20.000 |
| J7189 | A | $2.54 | 20.000 |
| J7190 | A | $1.08 | 20.000 |
| J7192 | A | $1.55 | 20.000 |
| J7193 | A | $1.39 | 20.000 |
| J7194 | A | $1.65 | 20.000 |
| J7195 | A | $1.84 | 20.000 |
| J7197 | A | $3.89 | 20.000 |
| J7198 | A | $2.36 | 20.000 |
| J7200 | A | $1.62 | 20.000 |
| J7201 | A | $3.57 | 20.000 |
| J7202 | A | $5.06 | 20.000 |
| J7203 | A | $4.51 | 20.000 |
| J7204 | A | $2.17 | 20.000 |
| J7205 | A | $2.30 | 20.000 |
| J7207 | A | $2.03 | 20.000 |
| J7208 | A | $2.44 | 20.000 |
| J7209 | A | $1.22 | 20.000 |
| J7210 | A | $1.46 | 20.000 |
| J7211 | A | $1.47 | 20.000 |
| J7212 | A | $2.27 | 20.000 |
| J7213 | A | $1.72 | 20.000 |
| J7214 | A | $4.70 | 20.000 |
| J7308 | A | $395.24 | 20.000 |
| J7311 | A | $316.27 | 20.000 |
| J7312 | A | $205.56 | 20.000 |
| J7313 | A | $488.70 | 20.000 |
| J7314 | A | $527.13 | 20.000 |
| J7318 | A | $6.66 | 20.000 |
| J7320 | A | $5.13 | 20.000 |
| J7322 | A | $17.56 | 20.000 |
| J7323 | A | $121.98 | 20.000 |
| J7324 | A | $119.80 | 20.000 |
| J7325 | A | $8.82 | 20.000 |
| J7326 | A | $520.99 | 20.000 |
| J7327 | A | $651.85 | 20.000 |
| J7328 | A | $0.56 | 20.000 |
| J7329 | A | $7.09 | 20.000 |
| J7331 | A | $10.29 | 20.000 |
| J7332 | A | $10.19 | 20.000 |
| J7336 | A | $3.33 | 20.000 |
| J7340 | A | $234.90 | 20.000 |
| J7342 | A | $30.02 | 20.000 |
| J7345 | A | $1.74 | 20.000 |
| J7351 | A | $208.38 | 20.000 |
| J7352 | A | $2,873.33 | 20.000 |
| J7353 | A | $58.32 | 20.000 |
| J7354 | A | $719.58 | 20.000 |
| J7355 | A | $191.58 | 20.000 |
| J7402 | A | $11.35 | 20.000 |
| J7501 | A | $239.25 | 20.000 |
| J7504 | A | $3,982.59 | 13.987 |
| J7511 | A | $956.01 | 20.000 |
| J7519 | A | $0.54 | 20.000 |
| J7525 | A | $253.61 | 20.000 |
| J8560 | A | $75.76 | 20.000 |
| J8611 | A | $19.36 | 20.000 |
| J8612 | A | $20.26 | 20.000 |
| J8655 | A | $393.86 | 18.944 |
| J8670 | A | $1.76 | 20.000 |
| J8705 | A | $114.31 | 20.000 |
| J9015 | A | $3,943.00 | 20.000 |
| J9017 | A | $10.69 | 20.000 |
| J9021 | A | $52.60 | 19.731 |
| J9022 | A | $85.78 | 20.000 |
| J9023 | A | $94.73 | 20.000 |
| J9027 | A | $9.19 | 20.000 |
| J9029 | A | $63,499.33 | 20.000 |
| J9032 | A | $49.96 | 19.933 |
| J9033 | A | $5.36 | 20.000 |
| J9034 | A | $13.61 | 20.000 |
| J9035 | A | $72.46 | 20.000 |
| J9036 | A | $3.59 | 20.000 |
| J9037 | A | $46.78 | 20.000 |
| J9039 | A | $151.96 | 18.975 |
| J9041 | A | $1.73 | 20.000 |
| J9042 | A | $239.60 | 18.617 |
| J9043 | A | $215.50 | 20.000 |
| J9046 | A | $48.55 | 20.000 |
| J9047 | A | $49.63 | 20.000 |
| J9048 | A | $5.04 | 20.000 |
| J9049 | A | $1.92 | 20.000 |
| J9050 | A | $378.18 | 20.000 |
| J9052 | A | $259.70 | 20.000 |
| J9055 | A | $75.63 | 20.000 |
| J9056 | A | $29.67 | 20.000 |
| J9057 | A | $89.16 | 20.000 |
| J9058 | A | $18.82 | 20.000 |
| J9059 | A | $18.82 | 20.000 |
| J9061 | A | $20.57 | 19.668 |
| J9063 | A | $66.87 | 20.000 |
| J9065 | A | $13.28 | 20.000 |
| J9071 | A | $1.25 | 20.000 |
| J9072 | A | $3.87 | 20.000 |
| J9073 | A | $0.79 | 20.000 |
| J9075 | A | $1.11 | 20.000 |
| J9119 | A | $27.70 | 20.000 |
| J9120 | A | $397.51 | 20.000 |
| J9144 | A | $51.00 | 20.000 |
| J9145 | A | $64.38 | 20.000 |
| J9150 | A | $26.66 | 20.000 |
| J9153 | A | $241.61 | 19.794 |
| J9155 | A | $4.27 | 20.000 |
| J9173 | A | $81.87 | 20.000 |
| J9176 | A | $7.57 | 20.000 |
| J9177 | A | $36.12 | 18.975 |
| J9179 | A | $141.29 | 20.000 |
| J9185 | A | $229.30 | 20.000 |
| J9196 | A | $7.78 | 12.045 |
| J9198 | A | $40.28 | 20.000 |
| J9200 | A | $3,857.12 | 20.000 |
| J9202 | A | $659.53 | 19.008 |
| J9203 | A | $229.67 | 20.000 |
| J9204 | A | $238.53 | 20.000 |
| J9205 | A | $63.38 | 20.000 |
| J9207 | A | $133.16 | 19.848 |
| J9210 | A | $366.67 | 20.000 |
| J9214 | A | $28.66 | 20.000 |
| J9217 | A | $180.54 | 20.000 |
| J9218 | A | $4.65 | 20.000 |
| J9223 | A | $202.76 | 20.000 |
| J9225 | A | $1,567.97 | 20.000 |
| J9226 | A | $44,158.25 | 20.000 |
| J9227 | A | $77.99 | 20.000 |
| J9228 | A | $176.78 | 20.000 |
| J9229 | A | $2,618.85 | 20.000 |
| J9245 | A | $155.33 | 20.000 |
| J9246 | A | $15.06 | 20.000 |
| J9247 | A | $426.90 | 20.000 |
| J9248 | A | $773.80 | 20.000 |
| J9259 | A | $15.40 | 20.000 |
| J9261 | A | $73.32 | 20.000 |
| J9262 | A | $4.03 | 20.000 |
| J9264 | A | $13.24 | 20.000 |
| J9266 | A | $27,014.86 | 19.658 |
| J9268 | A | $2,537.07 | 18.32 |
| J9269 | A | $326.53 | 20.000 |
| J9271 | A | $56.66 | 20.000 |
| J9272 | A | $236.47 | 20.000 |
| J9273 | A | $174.95 | 19.88 |
| J9274 | A | $214.56 | 19.774 |
| J9280 | A | $54.16 | 20.000 |
| J9281 | A | $306.66 | 20.000 |
| J9286 | A | $2,706.61 | 20.000 |
| J9293 | A | $55.11 | 20.000 |
| J9294 | A | $1.97 | 20.000 |
| J9295 | A | $5.74 | 20.000 |
| J9296 | A | $9.66 | 20.000 |
| J9297 | A | $1.12 | 20.000 |
| J9298 | A | $190.50 | 20.000 |
| J9299 | A | $31.60 | 20.000 |
| J9301 | A | $74.15 | 20.000 |
| J9302 | A | $63.96 | 20.000 |
| J9303 | A | $158.69 | 19.108 |
| J9304 | A | $52.95 | 20.000 |
| J9305 | A | $5.62 | 20.000 |
| J9306 | A | $15.95 | 20.000 |
| J9307 | A | $299.13 | 20.000 |
| J9308 | A | $71.26 | 20.000 |
| J9309 | A | $129.96 | 20.000 |
| J9311 | A | $36.53 | 20.000 |
| J9312 | A | $77.68 | 20.000 |
| J9313 | A | $23.39 | 20.000 |
| J9314 | A | $11.00 | 20.000 |
| J9316 | A | $66.32 | 20.000 |
| J9317 | A | $34.69 | 20.000 |
| J9318 | A | $33.91 | 20.000 |
| J9319 | A | $29.77 | 20.000 |
| J9320 | A | $370.18 | 20.000 |
| J9321 | A | $54.44 | 20.000 |
| J9323 | A | $4.69 | 20.000 |
| J9324 | A | $82.30 | 20.000 |
| J9325 | A | $69.96 | 19.049 |
| J9328 | A | $10.40 | 20.000 |
| J9330 | A | $30.75 | 20.000 |
| J9331 | A | $78.26 | 20.000 |
| J9332 | A | $32.12 | 20.000 |
| J9333 | A | $22.83 | 20.000 |
| J9334 | A | $33.13 | 20.000 |
| J9340 | A | $227.26 | 20.000 |
| J9345 | A | $29.36 | 20.000 |
| J9347 | A | $135.56 | 20.000 |
| J9348 | A | $609.17 | 20.000 |
| J9349 | A | $13.78 | 20.000 |
| J9350 | A | $637.19 | 20.000 |
| J9352 | A | $355.36 | 20.000 |
| J9353 | A | $48.14 | 20.000 |
| J9354 | A | $40.04 | 20.000 |
| J9355 | A | $78.08 | 20.000 |
| J9356 | A | $64.61 | 20.000 |
| J9357 | A | $1,453.80 | 20.000 |
| J9358 | A | $27.75 | 20.000 |
| J9359 | A | $206.41 | 20.000 |
| J9380 | A | $31.75 | 20.000 |
| J9381 | A | $36.95 | 20.000 |
| J9393 | A | $21.20 | 20.000 |
| J9394 | A | $12.26 | 20.000 |
| J9395 | A | $8.73 | 20.000 |
| J9400 | A | $7.09 | 20.000 |
| J9600 | A | $23,517.16 | 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 | $0.33 | 20.000 |
| Q0139 | A | $0.33 | 20.000 |
| Q2004 | A | $146.92 | 20.000 |
| Q2009 | A | $3.07 | 20.000 |
| Q2026 | A | $298.73 | 20.000 |
| Q2028 | A | $1.40 | 20.000 |
| Q2043 | A | $55,512.78 | 20.000 |
| Q2049 | A | $391.42 | 20.000 |
| Q2050 | A | $136.23 | 20.000 |
| Q3027 | A | $57.12 | 20.000 |
| Q5101 | A | $0.25 | 20.000 |
| Q5103 | A | $10.66 | 20.000 |
| Q5104 | A | $29.91 | 20.000 |
| Q5105 | A | $0.68 | 20.000 |
| Q5106 | A | $6.82 | 20.000 |
| Q5107 | A | $26.60 | 20.000 |
| Q5108 | A | $147.76 | 20.000 |
| Q5110 | A | $0.28 | 20.000 |
| Q5111 | A | $166.05 | 20.000 |
| Q5112 | A | $32.46 | 20.000 |
| Q5113 | A | $62.63 | 20.000 |
| Q5114 | A | $55.78 | 20.000 |
| Q5115 | A | $33.70 | 20.000 |
| Q5116 | A | $12.64 | 20.000 |
| Q5117 | A | $19.34 | 20.000 |
| Q5118 | A | $20.97 | 20.000 |
| Q5119 | A | $19.25 | 20.000 |
| Q5120 | A | $346.76 | 20.000 |
| Q5121 | A | $21.89 | 20.000 |
| Q5122 | A | $79.60 | 20.000 |
| Q5123 | A | $40.37 | 20.000 |
| Q5124 | A | $157.71 | 20.000 |
| Q5125 | A | $0.41 | 20.000 |
| Q5126 | A | $52.35 | 20.000 |
| Q5127 | A | $335.39 | 20.000 |
| Q5128 | A | $204.57 | 20.000 |
| Q5129 | A | $61.24 | 20.000 |
| Q5130 | A | $189.94 | 20.000 |
| Q9968 | A | $8.45 | 20.000 |
| Q9991 | A | $1,961.56 | 20.000 |
| Q9992 | A | $1,961.56 | 20.000 |
| 90371 | A | $143.77 | 20.000 |
| 90375 | A | $288.38 | 20.000 |
| 90376 | A | $328.18 | 20.000 |
| 90377 | A | $260.44 | 20.000 |
| 90396 | A | $2,252.21 | 20.000 |
| 90476 | A | $46.00 | 20.000 |
| 90675 | A | $338.49 | 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.

