Jurisdiction A DME MAC Fee Schedules
1st Quarter
2010 Average Sales Price (ASP) Drug Pricing File
Effective January 01, 2010 through March 31, 2010
NOTE: Inclusion of a fee amount does not
necessarily indicate coverage
|
HCPCS |
Fee |
|
G0333 |
$57.000 |
|
J0133 |
$0.470 |
|
J0285 |
$10.280 |
|
J0287 |
$21.850 |
|
J0288 |
$15.200 |
|
J0289 |
$35.800 |
|
J0882 |
$2.830 |
|
J0886 |
$9.537 |
|
J0895 |
$15.630 |
|
J1170 |
$1.490 |
|
J1250 |
$4.740 |
|
J1265 |
$0.620 |
|
J1325 |
$12.640 |
|
J1455 |
$13.070 |
|
J1459 |
$35.135 |
|
J1561 |
$37.622 |
|
J1562 |
$11.400 |
|
J1566 |
$30.479 |
|
J1568 |
$37.713 |
|
J1569 |
$38.533 |
|
J1570 |
$35.250 |
|
J1572 |
$37.124 |
|
J1644AX |
$0.293 |
|
J1815 |
$0.444 |
|
J1817 |
$2.800 |
|
J2175 |
$0.560 |
|
J2260 |
$51.580 |
|
J2270 |
$0.710 |
|
J2271 |
$11.070 |
|
J2275 |
$4.390 |
|
J2545 |
$46.174 |
|
J2920 |
$2.609 |
|
J2930 |
$3.326 |
|
J3010 |
$0.700 |
|
J3285 |
$61.750 |
|
J7500 |
$0.174 |
|
J7501 |
$95.644 |
|
J7502 |
$3.180 |
|
J7504 |
$465.251 |
|
J7505 |
$1132.928 |
|
J7506 |
$0.047 |
|
J7507 |
$3.638 |
|
J7509 |
$0.076 |
|
J7510 |
$0.023 |
|
J7511 |
$409.658 |
|
J7513 |
$388.511 |
|
J7515 |
$0.828 |
|
J7516 |
$23.819 |
|
J7517 |
$2.600 |
|
J7518 |
$2.976 |
|
J7520 |
$9.653 |
|
J7525 |
$139.644 |
|
J7605KO |
$5.002 |
|
J7606KO |
$4.525 |
|
J7608KO |
$1.826 |
|
J7611 |
$0.084 |
|
J7612 |
$0.213 |
|
J7613KO |
$0.046 |
|
J7614KO |
$0.195 |
|
J7620 |
$0.229 |
|
J7626KO |
$6.430 |
|
J7631KO |
$0.472 |
|
J7639KO |
$23.869 |
|
J7644KO |
$0.211 |
|
J7669KO |
$0.252 |
|
J7682KO |
$69.214 |
|
J8501 |
$5.527 |
|
J8520 |
$6.224 |
|
J8521 |
$20.429 |
|
J8530 |
$0.831 |
|
J8540 |
$0.414 |
|
J8610 |
$0.134 |
|
J9000 |
$12.540 |
|
J9001 |
$393.480 |
|
J9040 |
$289.370 |
|
J9065 |
$61.720 |
|
J9100 |
$8.190 |
|
J9110 |
$8.550 |
|
J9190 |
$2.070 |
|
J9200 |
$136.800 |
|
J9208 |
$150.380 |
|
J9350 |
$798.650 |
|
J9360 |
$4.100 |
|
J9370 |
$33.980 |
|
J9375 |
$67.960 |
|
J9380 |
$169.910 |
|
J9390 |
$109.000 |
|
Q0163 |
$0.021 |
|
Q0164 |
$0.038 |
|
Q0165 |
$0.031 |
|
Q0166 |
$7.309 |
|
Q0167 |
$6.809 |
|
Q0168 |
$13.604 |
|
Q0169 |
$0.420 |
|
Q0170 |
$0.154 |
|
Q0171 |
$0.013 |
|
Q0172 |
$0.034 |
|
Q0173 |
$0.712 |
|
Q0174 |
*TBD |
|
Q0175 |
$0.635 |
|
Q0176 |
$0.612 |
|
Q0177 |
$0.040 |
|
Q0178 |
$0.050 |
|
Q0179 |
$6.809 |
|
Q0180 |
$63.840 |
|
Q0510 |
$50.000 |
|
Q0511 |
$24.000 |
|
Q0512 |
$16.000 |
|
Q0513 |
$33.000 |
|
Q0514 |
$66.000 |
|
Q4074 |
$65.720 |
*To Be Developed
(TBD) is used for HCPCS codes where there was no fee on the ASP file and we
were unable to locate published WAC pricing, therefore we will develop for an
invoice on this drug.