S01 — HCPCS Level II Codes

• S0104 Zidovudine, oral, 100 mg billable
• S0106 Bupropion hcl sustained release tablet, 150 mg, per bottle of 60 tablets billable
• S0108 Mercaptopurine, oral, 50 mg billable
• S0109 Methadone, oral, 5 mg billable
• S0117 Tretinoin, topical, 5 grams billable
• S0119 Ondansetron, oral, 4 mg (for circumstances falling under the medicare statute, use hcpcs q code) billable
• S0122 Injection, menotropins, 75 iu billable
• S0126 Injection, follitropin alfa, 75 iu billable
• S0128 Injection, follitropin beta, 75 iu billable
• S0132 Injection, ganirelix acetate, 250 mcg billable
• S0136 Clozapine, 25 mg billable
• S0137 Didanosine (ddi), 25 mg billable
• S0138 Finasteride, 5 mg billable
• S0139 Minoxidil, 10 mg billable
• S0140 Saquinavir, 200 mg billable
• S0142 Colistimethate sodium, inhalation solution administered through dme, concentrated form, per mg billable
• S0145 Injection, pegylated interferon alfa-2a, 180 mcg per ml billable
• S0148 Injection, pegylated interferon alfa-2b, 10 mcg billable
• S0155 Sterile dilutant for epoprostenol, 50 ml billable
• S0156 Exemestane, 25 mg billable
• S0157 Becaplermin gel 0.01%, 0.5 gm billable
• S0160 Dextroamphetamine sulfate, 5 mg billable
• S0169 Calcitrol, 0.25 microgram billable
• S0170 Anastrozole, oral, 1 mg billable
• S0172 Chlorambucil, oral, 2 mg billable
• S0174 Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180) billable
• S0175 Flutamide, oral, 125 mg billable
• S0176 Hydroxyurea, oral, 500 mg billable
• S0177 Levamisole hydrochloride, oral, 50 mg billable
• S0178 Lomustine, oral, 10 mg billable
• S0179 Megestrol acetate, oral, 20 mg billable
• S0182 Procarbazine hydrochloride, oral, 50 mg billable
• S0183 Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164) billable
• S0187 Tamoxifen citrate, oral, 10 mg billable
• S0190 Mifepristone, oral, 200 mg billable
• S0191 Misoprostol, oral, 200 mcg billable
• S0194 Dialysis/stress vitamin supplement, oral, 100 capsules billable
• S0197 Prenatal vitamins, 30-day supply billable
• S0199 Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by hcg, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs billable