January 2024 1st Quarter ASC Drug File
Effective 01/01/2024 – Revised 10/01/2024
| HCPCS Code | Status Indicator | Amount | Coinsurance % |
|---|---|---|---|
| A9593 | A | $806.14 | 20.000 |
| A9594 | A | $789.30 | 20.000 |
| A9595 | A | $580.35 | 20.000 |
| A9596 | A | $991.68 | 20.000 |
| A9601 | A | $3,710.00 | 20.000 |
| A9602 | A | $446.88 | 20.000 |
| A9608 | A | $632.69 | 20.000 |
| A9800 | A | $873.44 | 20.000 |
| C9047 | A | $743.35 | 20.000 |
| C9088 | A | $0.73 | 20.000 |
| C9089 | A | $0.85 | 20.000 |
| C9101 | A | $1.19 | 20.000 |
| C9144 | A | $0.51 | 20.000 |
| C9145 | A | $1.88 | 20.000 |
| C9159 | A | $3.25 | 20.000 |
| C9160 | A | $4.45 | 20.000 |
| C9161 | A | $337.97 | 20.000 |
| C9162 | A | $108.15 | 20.000 |
| C9163 | A | $66.69 | 20.000 |
| C9164 | A | $705.55 | 20.000 |
| C9165 | A | $176.87 | 20.000 |
| C9250 | A | $132.73 | 20.000 |
| C9257 | A | $1.85 | 20.000 |
| C9290 | A | $1.42 | 20.000 |
| C9399 | C | $0.00 | 20.000 |
| C9460 | A | $18.25 | 20.000 |
| C9482 | A | $20.71 | 19.843 |
| C9488 | A | $47.24 | 20.000 |
| J0121 | A | $3.66 | 20.000 |
| J0122 | A | $1.13 | 20.000 |
| J0129 | A | $43.16 | 20.000 |
| J0134 | A | $0.00 | 20.000 |
| J0135 | A | $1,834.49 | 20.000 |
| J0136 | A | $0.00 | 20.000 |
| J0137 | A | $0.00 | 20.000 |
| J0172 | A | $5.98 | 20.000 |
| J0173 | A | $1.79 | 20.000 |
| J0174 | A | $1.35 | 20.000 |
| J0178 | A | $862.28 | 20.000 |
| J0179 | A | $325.24 | 20.000 |
| J0180 | A | $218.34 | 20.000 |
| J0184 | A | $9.08 | 20.000 |
| J0185 | A | $1.73 | 20.000 |
| J0202 | A | $2,324.34 | 20.000 |
| J0206 | A | $5.55 | 20.000 |
| J0208 | A | $96.19 | 20.000 |
| J0217 | A | $424.00 | 20.000 |
| J0218 | A | $376.97 | 20.000 |
| J0219 | A | $76.02 | 20.000 |
| J0220 | A | $148.86 | 20.000 |
| J0221 | A | $197.28 | 20.000 |
| J0222 | A | $99.98 | 20.000 |
| J0223 | A | $112.08 | 20.000 |
| J0224 | A | $319.56 | 20.000 |
| J0225 | A | $4,947.38 | 20.000 |
| J0256 | A | $4.88 | 20.000 |
| J0257 | A | $5.35 | 20.000 |
| J0287 | A | $11.13 | 19.790 |
| J0289 | A | $26.66 | 20.000 |
| J0291 | A | $3.60 | 19.775 |
| J0300 | A | $114.24 | 20.000 |
| J0349 | A | $10.04 | 20.000 |
| J0391 | A | $47.62 | 20.000 |
| J0401 | A | $6.81 | 20.000 |
| J0402 | A | $5.88 | 20.000 |
| J0457 | A | $2.54 | 20.000 |
| J0470 | A | $59.81 | 20.000 |
| J0475 | A | $177.80 | 20.000 |
| J0480 | A | $4,476.27 | 20.000 |
| J0485 | A | $3.87 | 20.000 |
| J0490 | A | $52.00 | 20.000 |
| J0491 | A | $17.18 | 20.000 |
| J0517 | A | $169.50 | 20.000 |
| J0558 | A | $17.58 | 16.010 |
| J0561 | A | $21.73 | 16.342 |
| J0565 | A | $39.86 | 20.000 |
| J0570 | A | $1,311.75 | 20.000 |
| J0576 | A | $12.84 | 20.000 |
| J0584 | A | $443.50 | 19.448 |
| J0585 | A | $6.33 | 20.000 |
| J0586 | A | $8.81 | 20.000 |
| J0587 | A | $13.03 | 20.000 |
| J0588 | A | $5.19 | 20.000 |
| J0594 | A | $1.41 | 20.000 |
| J0596 | A | $33.51 | 20.000 |
| J0597 | A | $64.36 | 20.000 |
| J0598 | A | $62.56 | 20.000 |
| J0600 | A | $6,452.50 | 20.000 |
| J0606 | A | $2.61 | 20.000 |
| J0612 | A | $0.00 | 20.000 |
| J0613 | A | $0.00 | 20.000 |
| J0630 | A | $1,069.50 | 20.000 |
| J0638 | A | $124.33 | 20.000 |
| J0641 | A | $0.07 | 20.000 |
| J0642 | A | $1.53 | 20.000 |
| J0665 | A | $0.00 | 20.000 |
| J0689 | A | $1.23 | 20.000 |
| J0691 | A | $0.72 | 20.000 |
| J0695 | A | $7.37 | 20.000 |
| J0699 | A | $2.17 | 20.000 |
| J0701 | A | $5.64 | 7.832 |
| J0703 | A | $5.27 | 8.381 |
| J0712 | A | $3.84 | 20.000 |
| J0714 | A | $95.45 | 20.000 |
| J0716 | A | $4,867.98 | 20.000 |
| J0717 | A | $4.82 | 20.000 |
| J0736 | A | $1.90 | 20.000 |
| J0737 | A | $1.75 | 20.000 |
| J0740 | A | $554.19 | 20.000 |
| J0741 | A | $22.60 | 20.000 |
| J0742 | A | $2.46 | 20.000 |
| J0775 | A | $66.27 | 19.187 |
| J0791 | A | $127.10 | 20.000 |
| J0801 | A | $3,672.33 | 20.000 |
| J0802 | A | $3,348.99 | 20.000 |
| J0840 | A | $1,949.92 | 20.000 |
| J0841 | A | $912.08 | 20.000 |
| J0850 | A | $1,807.87 | 19.659 |
| J0875 | A | $15.29 | 20.000 |
| J0877 | A | $0.00 | 20.000 |
| J0881 | A | $2.93 | 20.000 |
| J0882 | A | $2.93 | 20.000 |
| J0883 | A | $1.22 | 20.000 |
| J0884 | A | $1.22 | 20.000 |
| J0885 | A | $8.89 | 20.000 |
| J0887 | A | $1.62 | 20.000 |
| J0888 | A | $1.62 | 20.000 |
| J0891 | A | $1.82 | 20.000 |
| J0892 | A | $1.82 | 20.000 |
| J0893 | A | $0.78 | 20.000 |
| J0896 | A | $39.97 | 20.000 |
| J0897 | A | $25.20 | 19.453 |
| J0898 | A | $4.13 | 7.418 |
| J0899 | A | $4.13 | 20.000 |
| J1096 | A | $121.50 | 20.000 |
| J1097 | A | $97.61 | 20.000 |
| J1105 | A | $0.72 | 20.000 |
| J1162 | A | $4,777.44 | 20.000 |
| J1190 | A | $108.01 | 20.000 |
| J1201 | A | $15.07 | 20.000 |
| J1212 | A | $680.82 | 20.000 |
| J1290 | A | $539.33 | 20.000 |
| J1300 | A | $225.69 | 20.000 |
| J1301 | A | $21.82 | 20.000 |
| J1302 | A | $17.77 | 20.000 |
| J1303 | A | $221.77 | 20.000 |
| J1304 | A | $150.84 | 20.000 |
| J1305 | A | $179.14 | 20.000 |
| J1306 | A | $12.13 | 20.000 |
| J1322 | A | $280.91 | 20.000 |
| J1327 | A | $3.35 | 20.000 |
| J1364 | A | $80.78 | 20.000 |
| J1410 | A | $372.15 | 20.000 |
| J1426 | A | $166.23 | 20.000 |
| J1427 | A | $58.83 | 20.000 |
| J1429 | A | $166.20 | 20.000 |
| J1430 | A | $473.93 | 20.000 |
| J1437 | A | $18.86 | 20.000 |
| J1438 | A | $790.78 | 20.000 |
| J1439 | A | $1.15 | 20.000 |
| J1440 | A | $62.98 | 20.000 |
| J1442 | A | $0.99 | 20.000 |
| J1447 | A | $0.44 | 20.000 |
| J1448 | A | $5.20 | 20.000 |
| J1449 | A | $29.68 | 20.000 |
| J1451 | A | $6.06 | 20.000 |
| J1454 | A | $694.18 | 20.000 |
| J1455 | A | $59.37 | 20.000 |
| J1456 | A | $0.44 | 17.596 |
| J1458 | A | $462.99 | 20.000 |
| J1459 | A | $48.29 | 20.000 |
| J1460 | A | $50.73 | 19.987 |
| J1551 | A | $13.89 | 20.000 |
| J1554 | A | $491.41 | 20.000 |
| J1555 | A | $15.92 | 20.000 |
| J1556 | A | $72.96 | 20.000 |
| J1557 | A | $55.15 | 20.000 |
| J1558 | A | $14.18 | 20.000 |
| J1559 | A | $12.95 | 20.000 |
| J1560 | A | $507.26 | 19.987 |
| J1561 | A | $49.79 | 20.000 |
| J1566 | A | $78.50 | 20.000 |
| J1568 | A | $44.98 | 20.000 |
| J1569 | A | $44.15 | 20.000 |
| J1571 | A | $59.62 | 20.000 |
| J1572 | A | $56.12 | 20.000 |
| J1573 | A | $59.62 | 20.000 |
| J1575 | A | $17.09 | 20.000 |
| J1576 | A | $66.44 | 20.000 |
| J1595 | A | $155.98 | 20.000 |
| J1602 | A | $12.34 | 20.000 |
| J1610 | A | $188.37 | 20.000 |
| J1611 | A | $123.83 | 20.000 |
| J1627 | A | $5.67 | 20.000 |
| J1628 | A | $72.50 | 20.000 |
| J1632 | A | $72.10 | 20.000 |
| J1640 | A | $31.35 | 19.715 |
| J1643 | A | $4.58 | 20.000 |
| J1670 | A | $578.61 | 19.547 |
| J1726 | A | $12.08 | 20.000 |
| J1729 | A | $18.18 | 20.000 |
| J1742 | A | $190.25 | 20.000 |
| J1743 | A | $542.92 | 20.000 |
| J1744 | A | $170.85 | 20.000 |
| J1745 | A | $32.16 | 20.000 |
| J1746 | A | $74.62 | 20.000 |
| J1747 | A | $60.22 | 20.000 |
| J1750 | A | $17.32 | 20.000 |
| J1786 | A | $44.02 | 20.000 |
| J1805 | A | $0.26 | 20.000 |
| J1806 | A | $0.45 | 20.000 |
| J1811 | A | $6.80 | 20.000 |
| J1813 | A | $15.57 | 20.000 |
| J1823 | A | $473.51 | 20.000 |
| J1826 | A | $1,910.69 | 20.000 |
| J1833 | A | $0.94 | 20.000 |
| J1836 | A | $0.00 | 20.000 |
| J1920 | A | $0.19 | 20.000 |
| J1921 | A | $2.56 | 20.000 |
| J1930 | A | $48.44 | 20.000 |
| J1931 | A | $37.44 | 20.000 |
| J1932 | A | $48.78 | 20.000 |
| J1943 | A | $3.09 | 20.000 |
| J1944 | A | $3.11 | 20.000 |
| J1950 | A | $1,564.60 | 19.532 |
| J1951 | A | $131.82 | 20.000 |
| J1952 | A | $59.80 | 20.000 |
| J1954 | A | $355.28 | 20.000 |
| J1961 | A | $21.93 | 20.000 |
| J2021 | A | $20.06 | 20.000 |
| J2182 | A | $30.51 | 20.000 |
| J2184 | A | $2.11 | 9.059 |
| J2186 | A | $2.08 | 19.713 |
| J2212 | A | $1.20 | 20.000 |
| J2247 | A | $0.34 | 20.000 |
| J2251 | A | $0.28 | 20.000 |
| J2265 | A | $2.47 | 18.973 |
| J2272 | A | $7.43 | 20.000 |
| J2278 | A | $9.04 | 20.000 |
| J2281 | A | $5.81 | 20.000 |
| J2305 | A | $1.29 | 20.000 |
| J2311 | A | $5.76 | 20.000 |
| J2315 | A | $3.96 | 20.000 |
| J2323 | A | $24.45 | 20.000 |
| J2326 | A | $1,171.87 | 20.000 |
| J2327 | A | $15.36 | 20.000 |
| J2329 | A | $67.66 | 20.000 |
| J2350 | A | $59.75 | 20.000 |
| J2353 | A | $210.83 | 20.000 |
| J2356 | A | $18.59 | 20.000 |
| J2357 | A | $39.46 | 20.000 |
| J2358 | A | $2.92 | 20.000 |
| J2359 | A | $0.95 | 20.000 |
| J2372 | A | $0.18 | 20.000 |
| J2401 | A | $0.00 | 20.000 |
| J2403 | A | $0.71 | 20.000 |
| J2406 | A | $40.92 | 20.000 |
| J2407 | A | $27.60 | 20.000 |
| J2425 | A | $26.51 | 20.000 |
| J2426 | A | $14.32 | 20.000 |
| J2427 | A | $12.21 | 20.000 |
| J2502 | A | $449.49 | 18.272 |
| J2506 | A | $50.68 | 20.000 |
| J2507 | A | $3,371.08 | 20.000 |
| J2508 | A | $212.96 | 20.000 |
| J2510 | A | $40.94 | 20.000 |
| J2547 | A | $1.68 | 20.000 |
| J2562 | A | $172.88 | 20.000 |
| J2597 | A | $6.33 | 20.000 |
| J2598 | A | $1.82 | 20.000 |
| J2599 | A | $0.46 | 20.000 |
| J2690 | A | $146.32 | 20.000 |
| J2724 | A | $15.07 | 20.000 |
| J2760 | A | $446.80 | 20.000 |
| J2770 | A | $493.97 | 20.000 |
| J2777 | A | $36.09 | 20.000 |
| J2778 | A | $187.55 | 20.000 |
| J2779 | A | $80.78 | 20.000 |
| J2781 | A | $151.46 | 20.000 |
| J2783 | A | $367.27 | 20.000 |
| J2786 | A | $10.17 | 20.000 |
| J2792 | A | $32.96 | 20.000 |
| J2794 | A | $12.15 | 20.000 |
| J2796 | A | $96.03 | 20.000 |
| J2798 | A | $11.62 | 20.000 |
| J2799 | A | $24.70 | 20.000 |
| J2820 | A | $59.32 | 19.509 |
| J2840 | A | $538.75 | 20.000 |
| J2850 | A | $41.74 | 19.477 |
| J2860 | A | $148.94 | 19.132 |
| J2941 | A | $163.55 | 20.000 |
| J2993 | A | $2,768.37 | 20.000 |
| J2997 | A | $88.97 | 20.000 |
| J2998 | A | $31.80 | 20.000 |
| J3031 | A | $1.84 | 20.000 |
| J3032 | A | $18.06 | 20.000 |
| J3060 | A | $45.03 | 20.000 |
| J3090 | A | $1.78 | 20.000 |
| J3095 | A | $7.05 | 20.000 |
| J3101 | A | $153.11 | 20.000 |
| J3111 | A | $10.73 | 20.000 |
| J3145 | A | $1.84 | 19.266 |
| J3240 | A | $2,021.17 | 20.000 |
| J3241 | A | $328.00 | 20.000 |
| J3244 | A | $2.65 | 20.000 |
| J3245 | A | $132.58 | 20.000 |
| J3246 | A | $4.32 | 19.778 |
| J3262 | A | $6.12 | 20.000 |
| J3285 | A | $56.38 | 20.000 |
| J3299 | A | $48.58 | 20.000 |
| J3304 | A | $17.54 | 20.000 |
| J3315 | A | $413.59 | 20.000 |
| J3316 | A | $3,227.36 | 20.000 |
| J3357 | A | $153.96 | 20.000 |
| J3358 | A | $12.62 | 20.000 |
| J3371 | A | $5.97 | 20.000 |
| J3372 | A | $6.58 | 9.021 |
| J3380 | A | $22.06 | 20.000 |
| J3385 | A | $367.41 | 20.000 |
| J3396 | A | $11.53 | 20.000 |
| J3398 | A | $2,872.28 | 20.000 |
| J3401 | A | $2,497.75 | 20.000 |
| J7168 | A | $2.28 | 20.000 |
| J7169 | A | $132.36 | 20.000 |
| J7170 | A | $50.65 | 20.000 |
| J7175 | A | $9.11 | 20.000 |
| J7177 | A | $1.10 | 20.000 |
| J7178 | A | $1.38 | 20.000 |
| J7179 | A | $1.82 | 20.000 |
| J7180 | A | $9.68 | 20.000 |
| J7181 | A | $17.13 | 20.000 |
| J7182 | A | $1.34 | 20.000 |
| J7183 | A | $1.30 | 20.000 |
| J7185 | A | $1.29 | 20.000 |
| J7186 | A | $1.20 | 20.000 |
| J7187 | A | $1.35 | 20.000 |
| J7188 | A | $3.22 | 20.000 |
| J7189 | A | $2.43 | 20.000 |
| J7190 | A | $1.03 | 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 | $3.87 | 18.100 |
| J7198 | A | $2.27 | 20.000 |
| J7200 | A | $1.55 | 20.000 |
| J7201 | A | $3.47 | 20.000 |
| J7202 | A | $4.94 | 20.000 |
| J7203 | A | $4.41 | 20.000 |
| J7204 | A | $2.08 | 20.000 |
| J7205 | A | $2.19 | 20.000 |
| J7207 | A | $1.98 | 20.000 |
| J7208 | A | $2.34 | 20.000 |
| J7209 | A | $1.28 | 20.000 |
| J7210 | A | $1.44 | 20.000 |
| J7211 | A | $1.43 | 20.000 |
| J7212 | A | $2.03 | 20.000 |
| J7213 | A | $1.82 | 20.000 |
| J7214 | A | $4.63 | 20.000 |
| J7308 | A | $392.32 | 20.000 |
| J7311 | A | $299.05 | 20.000 |
| J7312 | A | $205.61 | 20.000 |
| J7313 | A | $490.95 | 20.000 |
| J7314 | A | $529.00 | 20.000 |
| J7318 | A | $6.14 | 20.000 |
| J7320 | A | $5.74 | 20.000 |
| J7322 | A | $17.26 | 20.000 |
| J7323 | A | $127.30 | 20.000 |
| J7324 | A | $130.64 | 20.000 |
| J7325 | A | $9.12 | 20.000 |
| J7326 | A | $497.29 | 20.000 |
| J7327 | A | $714.37 | 20.000 |
| J7328 | A | $0.49 | 20.000 |
| J7329 | A | $7.91 | 20.000 |
| J7331 | A | $11.34 | 20.000 |
| J7332 | A | $10.27 | 20.000 |
| J7336 | A | $3.27 | 20.000 |
| J7340 | A | $227.76 | 20.000 |
| J7342 | A | $30.02 | 20.000 |
| J7345 | A | $1.65 | 20.000 |
| J7351 | A | $206.21 | 20.000 |
| J7352 | A | $2,873.33 | 20.000 |
| J7353 | A | $60.71 | 20.000 |
| J7402 | A | $11.35 | 20.000 |
| J7501 | A | $239.94 | 20.000 |
| J7504 | A | $3,591.46 | 15.373 |
| J7511 | A | $929.03 | 20.000 |
| J7519 | A | $0.73 | 20.000 |
| J7525 | A | $248.74 | 20.000 |
| J8560 | A | $76.61 | 20.000 |
| J8655 | A | $410.06 | 18.035 |
| J8670 | A | $1.59 | 20.000 |
| J8705 | A | $113.49 | 20.000 |
| J9015 | A | $3,943.00 | 20.000 |
| J9017 | A | $15.78 | 20.000 |
| J9019 | A | $427.27 | 20.000 |
| J9021 | A | $50.96 | 20.000 |
| J9022 | A | $85.01 | 20.000 |
| J9023 | A | $92.37 | 20.000 |
| J9027 | A | $21.39 | 20.000 |
| J9029 | A | $61,800.00 | 20.000 |
| J9032 | A | $48.88 | 20.000 |
| J9033 | A | $9.19 | 20.000 |
| J9034 | A | $14.76 | 20.000 |
| J9035 | A | $74.07 | 20.000 |
| J9036 | A | $13.09 | 20.000 |
| J9037 | A | $46.78 | 20.000 |
| J9039 | A | $145.57 | 19.633 |
| J9041 | A | $1.96 | 20.000 |
| J9042 | A | $230.61 | 19.172 |
| J9043 | A | $210.45 | 20.000 |
| J9046 | A | $48.55 | 9.293 |
| J9047 | A | $47.09 | 20.000 |
| J9048 | A | $48.55 | 9.293 |
| J9049 | A | $1.52 | 20.000 |
| J9050 | A | $271.47 | 20.000 |
| J9052 | A | $18.40 | 20.000 |
| J9055 | A | $73.72 | 20.000 |
| J9056 | A | $33.45 | 20.000 |
| J9057 | A | $87.56 | 20.000 |
| J9058 | A | $20.78 | 20.000 |
| J9059 | A | $20.78 | 20.000 |
| J9061 | A | $19.98 | 20.000 |
| J9063 | A | $65.71 | 20.000 |
| J9065 | A | $15.77 | 20.000 |
| J9070 | A | $20.15 | 20.000 |
| J9071 | A | $1.79 | 20.000 |
| J9072 | A | $3.76 | 20.000 |
| J9119 | A | $27.46 | 20.000 |
| J9120 | A | $668.90 | 20.000 |
| J9144 | A | $49.05 | 20.000 |
| J9145 | A | $61.71 | 20.000 |
| J9150 | A | $35.67 | 20.000 |
| J9153 | A | $231.76 | 20.000 |
| J9155 | A | $4.19 | 20.000 |
| J9173 | A | $80.71 | 20.000 |
| J9176 | A | $7.38 | 20.000 |
| J9177 | A | $35.03 | 19.392 |
| J9179 | A | $134.02 | 20.000 |
| J9185 | A | $173.97 | 20.000 |
| J9196 | A | $8.78 | 10.588 |
| J9198 | A | $40.28 | 20.000 |
| J9200 | A | $3,722.04 | 20.000 |
| J9202 | A | $609.01 | 20.000 |
| J9203 | A | $226.28 | 20.000 |
| J9204 | A | $234.17 | 20.000 |
| J9205 | A | $62.02 | 20.000 |
| J9207 | A | $128.07 | 20.000 |
| J9210 | A | $375.66 | 20.000 |
| J9214 | A | $32.57 | 20.000 |
| J9217 | A | $181.30 | 20.000 |
| J9218 | A | $13.75 | 20.000 |
| J9223 | A | $200.01 | 20.000 |
| J9225 | A | $5,166.29 | 20.000 |
| J9226 | A | $44,575.94 | 20.000 |
| J9227 | A | $76.50 | 20.000 |
| J9228 | A | $172.42 | 20.000 |
| J9229 | A | $2,580.15 | 20.000 |
| J9245 | A | $148.02 | 20.000 |
| J9246 | A | $16.49 | 20.000 |
| J9247 | A | $503.50 | 20.000 |
| J9259 | A | $15.45 | 20.000 |
| J9261 | A | $110.98 | 20.000 |
| J9262 | A | $3.96 | 19.536 |
| J9264 | A | $14.29 | 20.000 |
| J9266 | A | $25,781.46 | 19.531 |
| J9268 | A | $2,273.15 | 20.000 |
| J9269 | A | $325.56 | 20.000 |
| J9271 | A | $55.73 | 20.000 |
| J9272 | A | $233.26 | 20.000 |
| J9273 | A | $168.31 | 20.000 |
| J9274 | A | $208.93 | 20.000 |
| J9280 | A | $63.35 | 20.000 |
| J9281 | A | $300.75 | 20.000 |
| J9286 | A | $2,707.93 | 20.000 |
| J9293 | A | $43.58 | 20.000 |
| J9294 | A | $10.55 | 20.000 |
| J9295 | A | $5.74 | 20.000 |
| J9296 | A | $9.66 | 20.000 |
| J9297 | A | $1.30 | 20.000 |
| J9298 | A | $187.15 | 20.000 |
| J9299 | A | $31.09 | 20.000 |
| J9301 | A | $70.34 | 20.000 |
| J9302 | A | $63.96 | 20.000 |
| J9303 | A | $150.66 | 19.948 |
| J9304 | A | $62.32 | 20.000 |
| J9305 | A | $4.37 | 20.000 |
| J9306 | A | $15.43 | 20.000 |
| J9307 | A | $289.14 | 20.000 |
| J9308 | A | $70.24 | 20.000 |
| J9309 | A | $124.29 | 20.000 |
| J9311 | A | $37.41 | 20.000 |
| J9312 | A | $79.20 | 20.000 |
| J9313 | A | $23.39 | 20.000 |
| J9314 | A | $19.96 | 13.739 |
| J9316 | A | $67.05 | 20.000 |
| J9317 | A | $33.95 | 20.000 |
| J9318 | A | $33.91 | 19.658 |
| J9319 | A | $31.96 | 20.000 |
| J9320 | A | $370.18 | 20.000 |
| J9321 | A | $53.80 | 20.000 |
| J9323 | A | $6.01 | 20.000 |
| J9325 | A | $66.59 | 19.837 |
| J9328 | A | $10.40 | 20.000 |
| J9330 | A | $30.99 | 20.000 |
| J9331 | A | $109.29 | 20.000 |
| J9332 | A | $32.08 | 20.000 |
| J9333 | A | $22.26 | 20.000 |
| J9334 | A | $32.24 | 20.000 |
| J9340 | A | $251.21 | 20.000 |
| J9345 | A | $29.83 | 20.000 |
| J9347 | A | $136.09 | 20.000 |
| J9348 | A | $609.77 | 20.000 |
| J9349 | A | $13.60 | 20.000 |
| J9350 | A | $629.64 | 20.000 |
| J9352 | A | $338.40 | 20.000 |
| J9353 | A | $47.05 | 20.000 |
| J9354 | A | $38.37 | 20.000 |
| J9355 | A | $80.47 | 20.000 |
| J9356 | A | $66.02 | 20.000 |
| J9357 | A | $1,363.85 | 20.000 |
| J9358 | A | $27.31 | 20.000 |
| J9359 | A | $200.63 | 20.000 |
| J9371 | A | $3,420.78 | 20.000 |
| J9380 | A | $30.85 | 20.000 |
| J9381 | A | $36.26 | 20.000 |
| J9393 | A | $21.20 | 20.000 |
| J9394 | A | $53.00 | 12.170 |
| J9395 | A | $8.45 | 20.000 |
| J9400 | A | $7.28 | 20.000 |
| J9600 | A | $22,828.16 | 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 | $0.36 | 20.000 |
| Q0139 | A | $0.36 | 20.000 |
| Q2004 | A | $146.92 | 20.000 |
| Q2009 | A | $4.80 | 20.000 |
| Q2026 | A | $298.73 | 20.000 |
| Q2028 | A | $1.40 | 20.000 |
| Q2043 | A | $53,426.66 | 20.000 |
| Q2049 | A | $391.42 | 20.000 |
| Q2050 | A | $85.48 | 20.000 |
| Q3027 | A | $53.69 | 20.000 |
| Q5101 | A | $0.32 | 20.000 |
| Q5103 | A | $14.29 | 20.000 |
| Q5104 | A | $31.50 | 20.000 |
| Q5105 | A | $0.78 | 20.000 |
| Q5106 | A | $7.82 | 20.000 |
| Q5107 | A | $25.62 | 20.000 |
| Q5108 | A | $122.54 | 20.000 |
| Q5110 | A | $0.29 | 20.000 |
| Q5111 | A | $122.10 | 20.000 |
| Q5112 | A | $38.94 | 20.000 |
| Q5113 | A | $40.31 | 20.000 |
| Q5114 | A | $44.43 | 20.000 |
| Q5115 | A | $35.89 | 20.000 |
| Q5116 | A | $16.37 | 20.000 |
| Q5117 | A | $13.45 | 20.000 |
| Q5118 | A | $21.51 | 20.000 |
| Q5119 | A | $20.45 | 20.000 |
| Q5120 | A | $346.76 | 20.000 |
| Q5121 | A | $25.56 | 20.000 |
| Q5122 | A | $62.38 | 20.000 |
| Q5123 | A | $41.42 | 20.000 |
| Q5124 | A | $187.51 | 20.000 |
| Q5125 | A | $0.54 | 20.000 |
| Q5126 | A | $60.58 | 20.000 |
| Q5127 | A | $328.64 | 20.000 |
| Q5128 | A | $262.08 | 20.000 |
| Q5129 | A | $72.41 | 20.000 |
| Q5130 | A | $201.97 | 20.000 |
| Q9968 | A | $7.95 | 20.000 |
| Q9991 | A | $1,887.11 | 20.000 |
| Q9992 | A | $1,887.11 | 20.000 |
| 90371 | A | $137.89 | 20.000 |
| 90375 | A | $289.98 | 20.000 |
| 90376 | A | $479.72 | 15.060 |
| 90377 | A | $256.31 | 20.000 |
| 90378 | A | $339.68 | 20.000 |
| 90396 | A | $2,255.95 | 19.998 |
| 90476 | A | $46.00 | 20.000 |
| 90675 | A | $324.74 | 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 2024 by the American Medical Association.

