Revised October 2024 4th Quarter ASC Drug File
Effective 10/01/2024 – Revised 10/01/2025
| HCPCS Code | Status Indicator | Amount | Coinsurance |
|---|---|---|---|
| A9506 | A | $328.60 | 20.000 |
| A9590 | A | $339.61 | 20.000 |
| A9595 | A | $615.12 | 20.000 |
| A9596 | A | $998.60 | 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 | $770.68 | 20.000 |
| C9088 | A | $0.77 | 20.000 |
| C9089 | A | $0.85 | 20.000 |
| C9101 | A | $1.23 | 20.000 |
| C9144 | A | $0.50 | 20.000 |
| C9145 | A | $1.86 | 20.000 |
| C9169 | A | $92.19 | 20.000 |
| C9170 | A | $1,545.00 | 20.000 |
| C9171 | A | $37.51 | 20.000 |
| C9250 | A | $138.35 | 20.000 |
| C9257 | A | $1.82 | 20.000 |
| C9290 | A | $1.45 | 20.000 |
| C9399 | C | $0.00 | 20.000 |
| C9460 | A | $18.82 | 20.000 |
| C9482 | A | $22.83 | 18.466 |
| C9488 | A | $47.24 | 20.000 |
| J0121 | A | $3.80 | 20.000 |
| J0122 | A | $1.21 | 20.000 |
| J0129 | A | $43.44 | 20.000 |
| J0134 | A | $0.04 | 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 | $2.01 | 20.000 |
| J0174 | A | $1.34 | 20.000 |
| J0175 | A | $4.09 | 20.000 |
| J0177 | A | $333.70 | 20.000 |
| J0178 | A | $821.98 | 20.000 |
| J0179 | A | $332.57 | 20.000 |
| J0180 | A | $223.52 | 20.000 |
| J0184 | A | $9.06 | 20.000 |
| J0185 | A | $1.77 | 20.000 |
| J0202 | A | $2,337.69 | 20.000 |
| J0206 | A | $5.00 | 20.000 |
| J0208 | A | $96.08 | 20.000 |
| J0211 | A | $2.17 | 20.000 |
| J0217 | A | $442.00 | 20.000 |
| J0218 | A | $382.56 | 20.000 |
| J0219 | A | $77.75 | 20.000 |
| J0220 | A | $148.86 | 20.000 |
| J0221 | A | $201.97 | 20.000 |
| J0222 | A | $98.88 | 20.000 |
| J0223 | A | $112.14 | 20.000 |
| J0224 | A | $317.88 | 20.000 |
| J0225 | A | $4,926.00 | 20.000 |
| J0256 | A | $4.94 | 20.000 |
| J0257 | A | $5.58 | 20.000 |
| J0287 | A | $11.13 | 20.000 |
| J0289 | A | $23.33 | 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 | $7.07 | 20.000 |
| J0402 | A | $5.95 | 20.000 |
| J0457 | A | $1.97 | 20.000 |
| J0470 | A | $59.81 | 20.000 |
| J0475 | A | $174.58 | 20.000 |
| J0480 | A | $4,588.77 | 20.000 |
| J0485 | A | $3.81 | 20.000 |
| J0490 | A | $54.15 | 20.000 |
| J0491 | A | $17.29 | 20.000 |
| J0517 | A | $167.30 | 20.000 |
| J0558 | A | $19.52 | 14.786 |
| J0561 | A | $24.37 | 14.948 |
| J0565 | A | $39.86 | 20.000 |
| J0570 | A | $1,311.75 | 20.000 |
| J0577 | A | $429.16 | 20.000 |
| J0578 | A | $1,716.62 | 20.000 |
| J0584 | A | $469.58 | 18.884 |
| J0585 | A | $6.41 | 20.000 |
| J0586 | A | $8.63 | 20.000 |
| J0587 | A | $12.99 | 20.000 |
| J0588 | A | $5.34 | 20.000 |
| J0589 | A | $3.12 | 20.000 |
| J0594 | A | $1.27 | 20.000 |
| J0596 | A | $34.72 | 20.000 |
| J0597 | A | $68.36 | 20.000 |
| J0598 | A | $64.21 | 20.000 |
| J0600 | A | $6,086.32 | 20.000 |
| J0606 | A | $2.57 | 20.000 |
| J0612 | A | $0.04 | 20.000 |
| J0613 | A | $0.09 | 20.000 |
| J0630 | A | $1,173.06 | 20.000 |
| J0638 | A | $127.81 | 20.000 |
| J0641 | A | $0.21 | 20.000 |
| J0642 | A | $1.38 | 20.000 |
| J0651 | A | $3.75 | 20.000 |
| J0652 | A | $5.14 | 20.000 |
| J0665 | A | $0.01 | 20.000 |
| J0687 | A | $1.04 | 20.000 |
| J0689 | A | $1.26 | 20.000 |
| J0691 | A | $0.72 | 20.000 |
| J0695 | A | $8.23 | 19.333 |
| J0699 | A | $2.28 | 20.000 |
| J0701 | A | $5.83 | 20.000 |
| J0703 | A | $4.97 | 9.043 |
| J0712 | A | $3.94 | 20.000 |
| J0714 | A | $100.58 | 20.000 |
| J0716 | A | $4,804.24 | 20.000 |
| J0717 | A | $4.65 | 20.000 |
| J0736 | A | $2.47 | 20.000 |
| J0737 | A | $2.82 | 20.000 |
| J0740 | A | $528.00 | 20.000 |
| J0741 | A | $22.90 | 20.000 |
| J0742 | A | $2.51 | 20.000 |
| J0775 | A | $71.16 | 18.328 |
| J0791 | A | $128.54 | 20.000 |
| J0801 | A | $3,750.08 | 20.000 |
| J0802 | A | $3,416.97 | 20.000 |
| J0840 | A | $1,762.35 | 20.000 |
| J0841 | A | $1,040.11 | 20.000 |
| J0850 | A | $1,814.94 | 20.000 |
| J0872 | A | $0.04 | 20.000 |
| J0875 | A | $15.61 | 20.000 |
| J0877 | A | $0.06 | 20.000 |
| J0881 | A | $3.04 | 20.000 |
| J0882 | A | $3.04 | 20.000 |
| J0883 | A | $1.26 | 20.000 |
| J0884 | A | $1.26 | 20.000 |
| J0885 | A | $7.53 | 20.000 |
| J0887 | A | $1.21 | 20.000 |
| J0888 | A | $1.16 | 20.000 |
| J0891 | A | $4.20 | 20.000 |
| J0892 | A | $4.20 | 20.000 |
| J0893 | A | $2.12 | 20.000 |
| J0896 | A | $40.62 | 20.000 |
| J0897 | A | $26.96 | 18.649 |
| J0898 | A | $1.49 | 20.000 |
| J0899 | A | $1.49 | 20.000 |
| J0911 | A | $8.58 | 20.000 |
| J1096 | A | $117.14 | 20.000 |
| J1097 | A | $96.59 | 20.000 |
| J1105 | A | $0.78 | 20.000 |
| J1162 | A | $4,888.10 | 20.000 |
| J1190 | A | $87.49 | 20.000 |
| J1201 | A | $14.87 | 20.000 |
| J1203 | A | $88.06 | 20.000 |
| J1212 | A | $715.90 | 20.000 |
| J1290 | A | $565.83 | 20.000 |
| J1300 | A | $224.63 | 20.000 |
| J1301 | A | $22.14 | 20.000 |
| J1302 | A | $18.13 | 20.000 |
| J1303 | A | $220.75 | 20.000 |
| J1304 | A | $153.66 | 20.000 |
| J1305 | A | $186.31 | 20.000 |
| J1306 | A | $12.19 | 20.000 |
| J1322 | A | $293.92 | 20.000 |
| J1323 | A | $178.85 | 20.000 |
| J1327 | A | $4.15 | 20.000 |
| J1364 | A | $65.38 | 20.000 |
| J1410 | A | $382.79 | 20.000 |
| J1426 | A | $166.23 | 20.000 |
| J1427 | A | $58.79 | 20.000 |
| J1429 | A | $166.22 | 20.000 |
| J1430 | A | $491.68 | 20.000 |
| J1434 | A | $3.14 | 20.000 |
| J1437 | A | $21.05 | 20.000 |
| J1438 | A | $790.78 | 20.000 |
| J1439 | A | $1.10 | 20.000 |
| J1440 | A | $63.30 | 20.000 |
| J1442 | A | $1.00 | 20.000 |
| J1447 | A | $0.39 | 20.000 |
| J1448 | A | $5.36 | 20.000 |
| J1449 | A | $22.75 | 20.000 |
| J1451 | A | $6.44 | 20.000 |
| J1454 | A | $679.51 | 20.000 |
| J1455 | A | $50.32 | 20.000 |
| J1456 | A | $2.04 | 3.896 |
| J1458 | A | $484.75 | 20.000 |
| J1459 | A | $48.58 | 20.000 |
| J1460 | A | $49.85 | 20.000 |
| J1551 | A | $14.50 | 20.000 |
| J1554 | A | $491.40 | 20.000 |
| J1555 | A | $16.82 | 20.000 |
| J1556 | A | $75.17 | 20.000 |
| J1557 | A | $57.93 | 20.000 |
| J1558 | A | $14.30 | 20.000 |
| J1559 | A | $13.23 | 20.000 |
| J1560 | A | $498.52 | 20.000 |
| J1561 | A | $48.81 | 20.000 |
| J1566 | A | $82.19 | 20.000 |
| J1568 | A | $49.00 | 20.000 |
| J1569 | A | $49.69 | 20.000 |
| J1571 | A | $68.66 | 20.000 |
| J1572 | A | $56.12 | 20.000 |
| J1573 | A | $68.66 | 20.000 |
| J1575 | A | $17.50 | 20.000 |
| J1576 | A | $67.46 | 20.000 |
| J1595 | A | $172.88 | 20.000 |
| J1602 | A | $11.10 | 20.000 |
| J1610 | A | $192.30 | 20.000 |
| J1611 | A | $108.93 | 20.000 |
| J1627 | A | $5.71 | 20.000 |
| J1628 | A | $74.47 | 20.000 |
| J1632 | A | $72.00 | 20.000 |
| J1640 | A | $32.20 | 20.000 |
| J1643 | A | $3.73 | 20.000 |
| J1670 | A | $581.78 | 19.940 |
| J1726 | A | $14.46 | 20.000 |
| J1729 | A | $18.18 | 20.000 |
| J1742 | A | $241.40 | 20.000 |
| J1743 | A | $537.93 | 20.000 |
| J1744 | A | $151.64 | 20.000 |
| J1745 | A | $32.22 | 20.000 |
| J1746 | A | $77.06 | 20.000 |
| J1747 | A | $61.43 | 20.000 |
| J1750 | A | $17.67 | 20.000 |
| J1786 | A | $43.62 | 20.000 |
| J1805 | A | $0.19 | 20.000 |
| J1806 | A | $0.36 | 20.000 |
| J1811 | A | $7.41 | 20.000 |
| J1813 | A | $15.53 | 20.000 |
| J1823 | A | $484.40 | 20.000 |
| J1826 | A | $1,910.69 | 20.000 |
| J1833 | A | $0.98 | 19.888 |
| J1836 | A | $0.03 | 20.000 |
| J1920 | A | $0.27 | 20.000 |
| J1921 | A | $1.63 | 20.000 |
| J1930 | A | $49.97 | 20.000 |
| J1931 | A | $38.70 | 20.000 |
| J1932 | A | $36.80 | 20.000 |
| J1943 | A | $3.19 | 20.000 |
| J1944 | A | $3.23 | 20.000 |
| J1950 | A | $1,617.65 | 19.377 |
| J1951 | A | $140.62 | 20.000 |
| J1952 | A | $55.00 | 20.000 |
| J1954 | A | $257.70 | 20.000 |
| J1961 | A | $21.99 | 20.000 |
| J2021 | A | $14.76 | 12.009 |
| J2182 | A | $30.44 | 20.000 |
| J2186 | A | $2.09 | 20.000 |
| J2212 | A | $0.94 | 20.000 |
| J2247 | A | $0.35 | 20.000 |
| J2265 | A | $2.59 | 18.543 |
| J2267 | A | $39.54 | 20.000 |
| J2277 | A | $25.22 | 20.000 |
| J2278 | A | $9.65 | 20.000 |
| J2281 | A | $7.22 | 20.000 |
| J2305 | A | $1.41 | 20.000 |
| J2311 | A | $1.50 | 20.000 |
| J2315 | A | $4.12 | 20.000 |
| J2323 | A | $24.15 | 20.000 |
| J2326 | A | $1,231.90 | 20.000 |
| J2327 | A | $14.63 | 20.000 |
| J2329 | A | $69.44 | 19.969 |
| J2350 | A | $59.80 | 20.000 |
| J2353 | A | $214.88 | 20.000 |
| J2356 | A | $18.11 | 20.000 |
| J2357 | A | $38.29 | 20.000 |
| J2358 | A | $2.92 | 20.000 |
| J2359 | A | $0.92 | 20.000 |
| J2372 | A | $0.17 | 20.000 |
| J2401 | A | $0.03 | 20.000 |
| J2403 | A | $0.63 | 20.000 |
| J2406 | A | $42.50 | 20.000 |
| J2407 | A | $28.46 | 20.000 |
| J2425 | A | $33.99 | 16.877 |
| J2426 | A | $14.76 | 20.000 |
| J2427 | A | $12.66 | 20.000 |
| J2502 | A | $479.84 | 17.556 |
| J2506 | A | $31.14 | 20.000 |
| J2507 | A | $3,482.15 | 19.968 |
| J2508 | A | $223.55 | 20.000 |
| J2510 | A | $40.94 | 20.000 |
| J2547 | A | $1.68 | 20.000 |
| J2562 | A | $50.47 | 20.000 |
| J2597 | A | $5.42 | 20.000 |
| J2598 | A | $1.62 | 20.000 |
| J2601 | A | $3.77 | 20.000 |
| J2690 | A | $546.07 | 20.000 |
| J2724 | A | $15.05 | 20.000 |
| J2760 | A | $367.12 | 20.000 |
| J2770 | A | $6.23 | 20.000 |
| J2777 | A | $34.25 | 20.000 |
| J2778 | A | $137.14 | 20.000 |
| J2779 | A | $79.08 | 20.000 |
| J2781 | A | $147.36 | 20.000 |
| J2782 | A | $109.53 | 20.000 |
| J2783 | A | $371.29 | 20.000 |
| J2786 | A | $10.31 | 20.000 |
| J2792 | A | $34.34 | 20.000 |
| J2794 | A | $11.30 | 20.000 |
| J2796 | A | $101.05 | 19.524 |
| J2798 | A | $12.19 | 20.000 |
| J2799 | A | $24.77 | 20.000 |
| J2801 | A | $13.03 | 20.000 |
| J2820 | A | $60.28 | 19.692 |
| J2840 | A | $539.42 | 20.000 |
| J2850 | A | $42.57 | 19.586 |
| J2860 | A | $157.07 | 18.608 |
| J2941 | A | $163.55 | 20.000 |
| J2993 | A | $2,777.14 | 20.000 |
| J2997 | A | $91.47 | 20.000 |
| J2998 | A | $32.55 | 20.000 |
| J3031 | A | $1.85 | 20.000 |
| J3032 | A | $18.69 | 20.000 |
| J3055 | A | $67.65 | 20.000 |
| J3060 | A | $42.58 | 20.000 |
| J3090 | A | $1.81 | 20.000 |
| J3095 | A | $7.23 | 20.000 |
| J3101 | A | $157.72 | 20.000 |
| J3111 | A | $11.17 | 19.973 |
| J3145 | A | $1.95 | 19.304 |
| J3240 | A | $2,073.34 | 20.000 |
| J3241 | A | $343.89 | 20.000 |
| J3244 | A | $2.65 | 20.000 |
| J3245 | A | $135.92 | 20.000 |
| J3246 | A | $3.83 | 20.000 |
| J3247 | A | $17.54 | 20.000 |
| J3262 | A | $5.96 | 20.000 |
| J3263 | A | $38.87 | 20.000 |
| J3285 | A | $55.82 | 20.000 |
| J3299 | A | $48.40 | 20.000 |
| J3304 | A | $17.75 | 20.000 |
| J3315 | A | $466.73 | 20.000 |
| J3316 | A | $3,418.49 | 20.000 |
| J3357 | A | $159.91 | 20.000 |
| J3358 | A | $12.97 | 20.000 |
| J3371 | A | $5.67 | 20.000 |
| J3372 | A | $6.42 | 20.000 |
| J3380 | A | $22.26 | 20.000 |
| J3385 | A | $370.20 | 20.000 |
| J3396 | A | $11.53 | 20.000 |
| J3398 | A | $3,084.46 | 20.000 |
| J3401 | A | $996.96 | 20.000 |
| J3424 | A | $5.03 | 20.000 |
| J7165 | A | $2.00 | 20.000 |
| J7168 | A | $2.24 | 20.000 |
| J7169 | A | $131.99 | 20.000 |
| J7170 | A | $52.60 | 20.000 |
| J7171 | A | $34.60 | 20.000 |
| J7175 | A | $9.11 | 20.000 |
| J7177 | A | $1.11 | 20.000 |
| J7178 | A | $1.45 | 20.000 |
| J7179 | A | $1.87 | 20.000 |
| J7180 | A | $10.16 | 20.000 |
| J7181 | A | $17.26 | 20.000 |
| J7182 | A | $1.38 | 20.000 |
| J7183 | A | $1.28 | 20.000 |
| J7185 | A | $1.48 | 20.000 |
| J7186 | A | $1.23 | 20.000 |
| J7187 | A | $1.40 | 20.000 |
| J7188 | A | $3.22 | 20.000 |
| J7189 | A | $2.52 | 20.000 |
| J7190 | A | $1.17 | 20.000 |
| J7192 | A | $1.55 | 20.000 |
| J7193 | A | $1.41 | 20.000 |
| J7194 | A | $1.65 | 20.000 |
| J7195 | A | $1.85 | 20.000 |
| J7197 | A | $3.85 | 20.000 |
| J7198 | A | $2.34 | 20.000 |
| J7200 | A | $1.67 | 20.000 |
| J7201 | A | $3.59 | 20.000 |
| J7202 | A | $5.05 | 20.000 |
| J7203 | A | $4.57 | 20.000 |
| J7204 | A | $2.17 | 20.000 |
| J7205 | A | $2.34 | 20.000 |
| J7207 | A | $2.10 | 20.000 |
| J7208 | A | $2.44 | 20.000 |
| J7209 | A | $1.24 | 20.000 |
| J7210 | A | $1.46 | 20.000 |
| J7211 | A | $1.48 | 20.000 |
| J7212 | A | $2.30 | 20.000 |
| J7213 | A | $1.81 | 20.000 |
| J7214 | A | $4.69 | 20.000 |
| J7308 | A | $396.97 | 20.000 |
| J7311 | A | $333.48 | 20.000 |
| J7312 | A | $205.62 | 20.000 |
| J7313 | A | $495.38 | 20.000 |
| J7314 | A | $527.97 | 20.000 |
| J7318 | A | $7.00 | 20.000 |
| J7320 | A | $5.90 | 20.000 |
| J7322 | A | $17.45 | 20.000 |
| J7323 | A | $121.31 | 20.000 |
| J7324 | A | $122.91 | 20.000 |
| J7325 | A | $9.16 | 20.000 |
| J7326 | A | $534.48 | 20.000 |
| J7327 | A | $683.17 | 20.000 |
| J7328 | A | $0.58 | 20.000 |
| J7329 | A | $6.67 | 20.000 |
| J7331 | A | $9.58 | 20.000 |
| J7332 | A | $10.36 | 20.000 |
| J7336 | A | $3.33 | 20.000 |
| J7340 | A | $235.06 | 20.000 |
| J7342 | A | $30.02 | 20.000 |
| J7345 | A | $1.72 | 20.000 |
| J7351 | A | $209.86 | 20.000 |
| J7352 | A | $2,873.33 | 20.000 |
| J7353 | A | $58.34 | 20.000 |
| J7354 | A | $711.75 | 20.000 |
| J7355 | A | $197.16 | 20.000 |
| J7402 | A | $11.35 | 20.000 |
| J7501 | A | $235.67 | 20.000 |
| J7504 | A | $3,968.45 | 14.270 |
| J7511 | A | $956.74 | 20.000 |
| J7519 | A | $0.52 | 20.000 |
| J7525 | A | $254.78 | 20.000 |
| J8560 | A | $76.66 | 20.000 |
| J8611 | A | $19.36 | 20.000 |
| J8612 | A | $20.71 | 20.000 |
| J8655 | A | $400.24 | 18.953 |
| J8670 | A | $1.58 | 20.000 |
| J8705 | A | $124.86 | 20.000 |
| J9015 | A | $3,943.00 | 20.000 |
| J9017 | A | $7.20 | 20.000 |
| J9021 | A | $52.79 | 19.986 |
| J9022 | A | $86.24 | 20.000 |
| J9023 | A | $95.18 | 20.000 |
| J9027 | A | $14.38 | 20.000 |
| J9029 | A | $63,354.77 | 20.000 |
| J9032 | A | $50.09 | 20.000 |
| J9033 | A | $2.82 | 20.000 |
| J9034 | A | $12.95 | 20.000 |
| J9035 | A | $72.70 | 20.000 |
| J9036 | A | $15.32 | 20.000 |
| J9037 | A | $46.78 | 20.000 |
| J9039 | A | $152.18 | 19.262 |
| J9041 | A | $1.57 | 20.000 |
| J9042 | A | $239.86 | 18.907 |
| J9043 | A | $216.46 | 20.000 |
| J9046 | A | $48.55 | 20.000 |
| J9047 | A | $49.58 | 19.575 |
| J9048 | A | $5.04 | 20.000 |
| J9049 | A | $1.49 | 20.000 |
| J9050 | A | $330.87 | 20.000 |
| J9052 | A | $259.70 | 20.000 |
| J9055 | A | $75.48 | 20.000 |
| J9056 | A | $27.84 | 20.000 |
| J9057 | A | $92.81 | 20.000 |
| J9058 | A | $15.22 | 20.000 |
| J9061 | A | $20.67 | 19.895 |
| J9063 | A | $66.76 | 20.000 |
| J9065 | A | $14.25 | 20.000 |
| J9071 | A | $1.16 | 20.000 |
| J9073 | A | $0.93 | 20.000 |
| J9074 | A | $4.34 | 20.000 |
| J9075 | A | $1.01 | 20.000 |
| J9119 | A | $28.24 | 20.000 |
| J9120 | A | $282.13 | 20.000 |
| J9144 | A | $51.41 | 20.000 |
| J9145 | A | $65.12 | 20.000 |
| J9150 | A | $24.44 | 20.000 |
| J9153 | A | $242.50 | 20.000 |
| J9155 | A | $4.18 | 20.000 |
| J9172 | A | $50.99 | 20.000 |
| J9173 | A | $81.82 | 20.000 |
| J9176 | A | $7.58 | 20.000 |
| J9177 | A | $36.74 | 18.963 |
| J9179 | A | $135.79 | 20.000 |
| J9185 | A | $134.15 | 20.000 |
| J9196 | A | $8.52 | 11.181 |
| J9198 | A | $40.28 | 20.000 |
| J9200 | A | $3,858.03 | 20.000 |
| J9202 | A | $674.77 | 18.888 |
| J9203 | A | $229.67 | 20.000 |
| J9204 | A | $238.85 | 20.000 |
| J9205 | A | $64.77 | 20.000 |
| J9207 | A | $134.06 | 20.000 |
| J9210 | A | $378.03 | 20.000 |
| J9214 | A | $28.66 | 20.000 |
| J9217 | A | $176.51 | 20.000 |
| J9218 | A | $9.20 | 20.000 |
| J9223 | A | $203.60 | 20.000 |
| J9225 | A | $1,567.97 | 20.000 |
| J9226 | A | $45,350.22 | 20.000 |
| J9227 | A | $78.05 | 20.000 |
| J9228 | A | $176.88 | 20.000 |
| J9229 | A | $2,618.85 | 20.000 |
| J9245 | A | $153.54 | 20.000 |
| J9246 | A | $17.35 | 20.000 |
| J9248 | A | $773.80 | 20.000 |
| J9259 | A | $14.79 | 20.000 |
| J9261 | A | $72.53 | 20.000 |
| J9262 | A | $4.03 | 20.000 |
| J9264 | A | $13.34 | 20.000 |
| J9266 | A | $27,070.53 | 19.079 |
| J9268 | A | $2,541.77 | 18.590 |
| J9269 | A | $339.03 | 20.000 |
| J9271 | A | $58.22 | 20.000 |
| J9272 | A | $236.40 | 20.000 |
| J9273 | A | $181.60 | 19.471 |
| J9274 | A | $214.76 | 20.000 |
| J9280 | A | $42.51 | 20.000 |
| J9281 | A | $307.34 | 20.000 |
| J9286 | A | $2,701.04 | 20.000 |
| J9293 | A | $54.65 | 20.000 |
| J9294 | A | $0.62 | 20.000 |
| J9295 | A | $5.73 | 20.000 |
| J9296 | A | $9.66 | 20.000 |
| J9297 | A | $1.28 | 20.000 |
| J9298 | A | $190.46 | 20.000 |
| J9299 | A | $31.75 | 20.000 |
| J9301 | A | $74.59 | 20.000 |
| J9302 | A | $63.96 | 20.000 |
| J9303 | A | $159.33 | 19.348 |
| J9304 | A | $50.83 | 20.000 |
| J9305 | A | $4.18 | 20.000 |
| J9306 | A | $16.12 | 20.000 |
| J9307 | A | $373.77 | 20.000 |
| J9308 | A | $71.07 | 20.000 |
| J9309 | A | $129.78 | 20.000 |
| J9311 | A | $36.94 | 20.000 |
| J9312 | A | $77.31 | 20.000 |
| J9313 | A | $23.39 | 20.000 |
| J9314 | A | $5.52 | 20.000 |
| J9316 | A | $64.58 | 20.000 |
| J9317 | A | $34.67 | 20.000 |
| J9318 | A | $33.91 | 20.000 |
| J9319 | A | $29.86 | 20.000 |
| J9320 | A | $370.18 | 20.000 |
| J9321 | A | $54.17 | 20.000 |
| J9323 | A | $10.55 | 20.000 |
| J9324 | A | $82.30 | 20.000 |
| J9325 | A | $70.36 | 19.255 |
| J9328 | A | $10.40 | 20.000 |
| J9330 | A | $32.21 | 20.000 |
| J9331 | A | $78.57 | 20.000 |
| J9332 | A | $32.57 | 20.000 |
| J9333 | A | $22.80 | 20.000 |
| J9334 | A | $33.13 | 20.000 |
| J9340 | A | $209.02 | 20.000 |
| J9345 | A | $29.20 | 20.000 |
| J9347 | A | $135.45 | 20.000 |
| J9348 | A | $642.15 | 19.580 |
| J9349 | A | $13.71 | 20.000 |
| J9350 | A | $635.47 | 20.000 |
| J9352 | A | $362.82 | 20.000 |
| J9353 | A | $48.21 | 20.000 |
| J9354 | A | $40.45 | 20.000 |
| J9355 | A | $77.94 | 20.000 |
| J9356 | A | $63.79 | 20.000 |
| J9357 | A | $1,437.08 | 20.000 |
| J9358 | A | $27.81 | 20.000 |
| J9359 | A | $206.38 | 20.000 |
| J9380 | A | $31.98 | 20.000 |
| J9381 | A | $36.90 | 20.000 |
| J9393 | A | $21.20 | 20.000 |
| J9394 | A | $53.00 | 12.482 |
| J9395 | A | $7.51 | 20.000 |
| J9400 | A | $6.50 | 20.000 |
| J9600 | A | $23,870.14 | 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 | $0.34 | 20.000 |
| Q0139 | A | $0.34 | 20.000 |
| Q2004 | A | $146.92 | 20.000 |
| Q2009 | A | $3.20 | 20.000 |
| Q2026 | A | $298.73 | 20.000 |
| Q2028 | A | $1.40 | 20.000 |
| Q2043 | A | $55,015.23 | 20.000 |
| Q2049 | A | $391.42 | 20.000 |
| Q2050 | A | $133.08 | 20.000 |
| Q3027 | A | $56.23 | 20.000 |
| Q5101 | A | $0.36 | 20.000 |
| Q5103 | A | $13.62 | 20.000 |
| Q5104 | A | $27.18 | 20.000 |
| Q5105 | A | $0.76 | 20.000 |
| Q5106 | A | $7.62 | 20.000 |
| Q5107 | A | $26.59 | 20.000 |
| Q5108 | A | $135.53 | 20.000 |
| Q5110 | A | $0.27 | 20.000 |
| Q5111 | A | $143.38 | 20.000 |
| Q5112 | A | $34.17 | 20.000 |
| Q5113 | A | $60.44 | 20.000 |
| Q5114 | A | $54.16 | 20.000 |
| Q5115 | A | $33.59 | 20.000 |
| Q5116 | A | $19.17 | 20.000 |
| Q5117 | A | $24.33 | 20.000 |
| Q5118 | A | $23.59 | 20.000 |
| Q5119 | A | $22.44 | 20.000 |
| Q5120 | A | $346.76 | 20.000 |
| Q5121 | A | $21.29 | 20.000 |
| Q5122 | A | $96.55 | 20.000 |
| Q5123 | A | $38.65 | 20.000 |
| Q5124 | A | $170.80 | 20.000 |
| Q5125 | A | $0.47 | 20.000 |
| Q5126 | A | $48.70 | 20.000 |
| Q5127 | A | $305.66 | 20.000 |
| Q5128 | A | $201.01 | 20.000 |
| Q5129 | A | $56.82 | 20.000 |
| Q5130 | A | $175.77 | 20.000 |
| Q5131 | A | $292.57 | 20.000 |
| Q5133 | A | $5.72 | 20.000 |
| Q5135 | A | $5.04 | 20.000 |
| Q9968 | A | $8.53 | 20.000 |
| Q9991 | A | $1,943.06 | 20.000 |
| Q9992 | A | $1,943.06 | 20.000 |
| 90371 | A | $139.93 | 20.000 |
| 90375 | A | $287.71 | 20.000 |
| 90376 | A | $479.72 | 20.000 |
| 90377 | A | $265.51 | 20.000 |
| 90396 | A | $2,250.71 | 20.000 |
| 90476 | A | $46.00 | 20.000 |
| 90675 | A | $350.14 | 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.

