HCPCS Code Master List

Manage HCPCS codes and custom clinic services

J1885

Drug

Injection, ketorolac tromethamine, per 15 mg

Amount: $25.00

J3490

Drug

Unclassified drugs

Amount: $50.00

A4206

Supply

Syringe with needle, sterile, 1 cc or less

Amount: $2.50

J0690

Drug

Injection, cefazolin sodium, 500 mg

Amount: $15.00

A4247

Supply

Bandage, elastic knitted/woven, non-sterile, width >= 3 inches and < 5 inches, per yard

Amount: $3.00

A4253

Supply

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

Amount: $35.00

A4256

Supply

Normal, low, and high calibrator solution/chips

Amount: $15.00

A4258

Supply

Spring-powered device for lancet, each

Amount: $8.00

A4259

Supply

Lancets, per box of 100

Amount: $12.00

E0607

DME

Home blood glucose monitor

Amount: $45.00

E0617

DME

Nebulizer, non-heated, used with positive airway pressure device

Amount: $75.00

E0776

DME

IV pole

Amount: $35.00

E0830

DME

Ambulatory traction device, all types, each

Amount: $125.00

E0935

DME

Continuous passive motion exercise device for use on knee only

Amount: $850.00

E1390

DME

Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

Amount: $350.00

A0425

Transport

Ground mileage, per statute mile

Amount: $3.50

A0426

Transport

Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1)

Amount: $450.00

A0427

Transport

Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency)

Amount: $650.00

G0008

Procedure

Administration of influenza virus vaccine

Amount: $20.00

G0009

Procedure

Administration of pneumococcal vaccine

Amount: $20.00

G0101

Procedure

Cervical or vaginal cancer screening; pelvic and clinical breast examination

Amount: $55.00

G0108

Procedure

Diabetes outpatient self-management training services, individual, per 30 minutes

Amount: $45.00

G0109

Procedure

Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

Amount: $25.00

Q4081

Drug

Injection, epoetin alfa, 100 units (for ESRD on dialysis)

Amount: $35.00

S0012

Drug

Butorphanol tartrate, nasal spray, 25 mg

Amount: $45.00

S0020

Drug

Injection, bupivicaine HCl, 30 ml

Amount: $55.00

J1885

Drug

Injection, ketorolac tromethamine, per 15 mg

Amount: $25.00

J2001

Drug

Injection, lidocaine HCl for intravenous infusion, 10 mg

Amount: $15.00

J3301

Drug

Injection, triamcinolone acetonide, per 10 mg

Amount: $35.00

J0702

Drug

Injection, betamethasone acetate and betamethasone sodium phosphate, per 3 mg

Amount: $40.00

J1100

Drug

Injection, dexamethasone sodium phosphate, 1 mg

Amount: $12.00

J1200

Drug

Injection, diphenhydramine HCl, up to 50 mg

Amount: $18.00

J2550

Drug

Injection, promethazine HCl, up to 50 mg

Amount: $20.00

J0690

Drug

Injection, cefazolin sodium, 500 mg

Amount: $30.00

J1580

Drug

Injection, garamycin, gentamicin, up to 80 mg

Amount: $35.00

J3420

Drug

Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg

Amount: $22.00

J3490

Drug

Unclassified drugs

Amount: $0.00

J7060

Supply

5% dextrose/normal saline (500 ml = 1 unit)

Amount: $10.00

J7030

Supply

Infusion, normal saline solution, 1000 cc

Amount: $12.00

A4206

Supply

Syringe with needle, sterile, 1 cc or less, each

Amount: $1.50

A4212

Supply

Non-coring needle or stylet with or without catheter

Amount: $25.00

A4213

Supply

Syringe, sterile, 20 cc or greater, each

Amount: $2.50

A4215

Supply

Needle, sterile, any size, each

Amount: $0.75

A4244

Supply

Alcohol or peroxide, per pint

Amount: $5.00