TABLE K. — DURABLE MEDICAL EQUIPMENT, SUPPLIES, …

TABLE K. ¡ª DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE

v3.23 (January - December 2018)

PAGE 1 of 95

HCPCS Code

Modifier 1

A0100

A0110

A0120

A0130

A0140

A0160

A0170

A0180

A0190

A0398

A0422

A4206

A4207

A4208

A4209

A4210

A4211

A4212

A4213

A4215

A4216

A4217

A4217

A4218

A4220

A4221

A4222

A4223

A4224

A4225

A4230

A4231

A4232

A4233

A4233

A4234

A4234

A4235

A4235

A4236

A4236

A4244

A4245

A4246

A4247

A4248

A4250

A4252

A4253

A4253

A4255

A4256

A4256

A4257

A4258

A4258

A4259

Blank

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Blank

Blank

Blank

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Blank

Blank

AU

Blank

Blank

Blank

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Blank

Blank

Blank

Blank

Blank

Blank

Blank

NU

Blank

NU

Blank

NU

Blank

NU

Blank

Blank

Blank

Blank

Blank

Blank

Blank

Blank

NU

Blank

Blank

KL

Blank

Blank

KL

Blank

HCPCS Code Description

NONEMERGENCY TRANSPORT TAXI

NONEMERGENCY TRANSPORT BUS

NONER TRANSPORT MINI-BUS

NONER TRANSPORT WHEELCH VAN

NONEMERGENCY TRANSPORT AIR

NONER TRANSPORT CASE WORKER

TRANSPORT PARKING FEES/TOLLS

NONER TRANSPORT LODGNG RECIP

NONER TRANSPORT MEALS RECIP

ALS ROUTINE DISPOSBLE SUPPLS

AMBULANCE 02 LIFE SUSTAINING

1 CC STERILE SYRINGE&NEEDLE

2 CC STERILE SYRINGE&NEEDLE

3 CC STERILE SYRINGE&NEEDLE

5+ CC STERILE SYRINGE&NEEDLE

NONNEEDLE INJECTION DEVICE

SUPP FOR SELF-ADM INJECTIONS

NON CORING NEEDLE OR STYLET

20+ CC SYRINGE ONLY

STERILE NEEDLE

STERILE WATER/SALINE, 10 ML

STERILE WATER/SALINE, 500 ML

STERILE WATER/SALINE, 500 ML

STERILE SALINE OR WATER

INFUSION PUMP REFILL KIT

SUPP NON-INSULIN INF CATH/WK

INFUSION SUPPLIES WITH PUMP

INFUSION SUPPLIES W/O PUMP

SUPPLY INSULIN INF CATH/WK

SUP/EXT INSULIN INF PUMP SYR

INFUS INSULIN PUMP NON NEEDL

INFUSION INSULIN PUMP NEEDLE

SYRINGE W/NEEDLE INSULIN 3CC

ALKALIN BATT FOR GLUCOSE MON

ALKALIN BATT FOR GLUCOSE MON

J-CELL BATT FOR GLUCOSE MON

J-CELL BATT FOR GLUCOSE MON

LITHIUM BATT FOR GLUCOSE MON

LITHIUM BATT FOR GLUCOSE MON

SILVR OXIDE BATT GLUCOSE MON

SILVR OXIDE BATT GLUCOSE MON

ALCOHOL OR PEROXIDE PER PINT

ALCOHOL WIPES PER BOX

BETADINE/PHISOHEX SOLUTION

BETADINE/IODINE SWABS/WIPES

CHLORHEXIDINE ANTISEPT

URINE REAGENT STRIPS/TABLETS

BLOOD KETONE TEST OR STRIP

BLOOD GLUCOSE/REAGENT STRIPS

BLOOD GLUCOSE/REAGENT STRIPS

GLUCOSE MONITOR PLATFORMS

CALIBRATOR SOLUTION/CHIPS

CALIBRATOR SOLUTION/CHIPS

REPLACE LENSSHIELD CARTRIDGE

LANCET DEVICE EACH

LANCET DEVICE EACH

LANCETS PER BOX

1, 2 - See end of the table for notes regarding these fields.

Status/ Usage

Indicator 2

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Blank

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Blank

Blank

Blank

Blank

Blank

Blank

Blank

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Blank

Blank

Blank

Blank

Blank

Blank

Blank

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Blank

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Blank

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Blank

Blank

Blank

Blank

Blank

Blank

Blank

Charge

$20.81

$61.62

$183.09

$85.54

$1,211.38

$2.42

$303.72

$809.69

$181.99

$132.93

$126.28

$0.94

$0.94

$0.94

$0.94

$1,233.33

$57.07

$13.31

$1.88

$1.29

$1.09

$6.97

$6.97

$3.59

$86.92

$111.76

$144.04

$131.27

$111.76

$25.36

$22.52

$9.38

$5.80

$4.98

$4.98

$23.02

$23.02

$9.76

$9.76

$11.32

$11.32

$1.88

$5.45

$5.45

$7.59

$5.40

$26.16

$11.55

$113.18

$113.18

$43.63

$32.97

$28.96

$102.17

$20.68

$17.89

$13.85

GAAF Category

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

HCPCS - Non-Drugs

TABLE K. ¡ª DURABLE MEDICAL EQUIPMENT, SUPPLIES, VISION AND HEARING HARDWARE NATIONWIDE- CHARGES BY HCPCS CODE

v3.23 (January - December 2018)

PAGE 2 of 95

HCPCS Code

Modifier 1

A4259

A4261

A4262

A4263

A4264

A4265

A4266

A4267

A4268

A4269

A4270

A4280

A4281

A4282

A4283

A4284

A4285

A4286

A4290

A4300

A4301

A4305

A4306

A4310

A4311

A4312

A4313

A4314

A4315

A4316

A4320

A4321

A4322

A4326

A4327

A4328

A4330

A4331

A4332

A4333

A4334

A4335

A4336

A4338

A4340

A4344

A4346

A4349

A4351

A4352

A4353

A4354

A4355

A4356

A4357

A4358

A4360

KL

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HCPCS Code Description

LANCETS PER BOX

CERVICAL CAP CONTRACEPTIVE

TEMPORARY TEAR DUCT PLUG

PERMANENT TEAR DUCT PLUG

INTRATUBAL OCCLUSION DEVICE

PARAFFIN

DIAPHRAGM

MALE CONDOM

FEMALE CONDOM

SPERMICIDE

DISPOSABLE ENDOSCOPE SHEATH

BRST PRSTHS ADHSV ATTCHMNT

REPLACEMENT BREASTPUMP TUBE

REPLACEMENT BREASTPUMP ADPT

REPLACEMENT BREASTPUMP CAP

REPLCMNT BREAST PUMP SHIELD

REPLCMNT BREAST PUMP BOTTLE

REPLCMNT BREASTPUMP LOK RING

SACRAL NERVE STIM TEST LEAD

CATH IMPL VASC ACCESS PORTAL

IMPLANTABLE ACCESS SYST PERC

DRUG DELIVERY SYSTEM >=50 ML

DRUG DELIVERY SYSTEM ................
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