Jurisdiction A DME MAC Fee Schedules

 

1st Quarter 2012 Average Sales Price (ASP) Drug Pricing File

Effective January 1, 2012 through March 31, 2012

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

$3.212

J0886

$9.618

J0895

$15.630

J1170

$1.490

J1250

$4.740

J1265

$0.620

J1325

$12.640

J1455

$13.070

J1459

$35.065

J1559

$14.364

J1561

$37.618

J1561JB

$46.170

J1562

$11.400

J1566

$30.819

J1568

$56.874

J1569

$37.928

J1569JB

$52.497

J1570

$35.250

J1572

$35.076

J1644AX

$0.267

J1815

$0.468

J1817

$2.800

J2175

$0.560

J2260

$51.580

J2270

$0.710

J2271

$11.070

J2275

$4.390

J2545

$55.109

J2920

$1.865

J2930

$2.575

J3010

$0.700

J3285

$61.750

J7500

$0.095

J7501

$119.282

J7502

$3.189

J7504

$616.218

J7505

$1132.960

J7506

$0.023

J7507

$2.560

J7509

$0.884

J7510

$0.020

J7511

$441.660

J7513

$526.343

J7515

$0.838

J7516

$25.937

J7517

$1.311

J7518

$3.300

J7520

$11.000

J7525

$139.591

J7605KO

$5.353

J7606KO

$4.845

J7608KO

$2.152

J7611

$0.106

J7612

$0.210

J7613KO

$0.061

J7614KO

$0.256

J7620

$0.281

J7626KO

$4.633

J7631KO

$0.394

J7639KO

$28.110

J7644KO

$0.269

J7669KO

$0.252

J7682KO

$84.130

J7686KO

$418.153

J8501

$6.166

J8520

$7.833

J8521

$25.852

J8530

$0.817

J8540

$0.348

J8561

$5.787

J8610

$0.127

J8650

$21.499

J9000

$12.540

J9001

$393.480

J9040

$289.370

J9065

$61.720

J9100

$8.190

J9190

$2.070

J9200

$136.800

J9208

$150.380

J9360

$4.100

J9370

$33.980

J9390

$109.000

Q0162

$.078

Q0163

$0.025

Q0164

$0.065

Q0165

$0.043

Q0166

$2.506

Q0167

$5.003

Q0168

$13.986

Q0169

$0.124

Q0170

$0.062

Q0171

$0.594

Q0172

$0.848

Q0173

$0.349

Q0174

*TBD

Q0175

$0.956

Q0176

$1.150

Q0177

$0.082

Q0178

$0.111

Q0180

$66.789

Q0510

$50.000

Q0511

$24.000

Q0512

$16.000

Q0513

$33.000

Q0514

$66.000

Q4074

$68.900

 

*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.