Jurisdiction
A DME MAC Fee Schedules
Average Sales Price (ASP) Drug Pricing File
Effective
April 1, 2006 through June 30, 2006 (Revised October 1, 2006)
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 |
|
J0895 |
$15.630 |
|
J1170 |
$1.490 |
|
J1250 |
$4.740 |
|
J1265 |
$0.620 |
|
J1325 |
$12.640 |
|
J1455 |
$13.070 |
|
J1570 |
$35.250 |
|
J1644AX |
$0.121 |
|
J1815 |
$0.239 |
|
J1817 |
$2.800 |
|
J2175 |
$0.560 |
|
J2260 |
$51.580 |
|
J2270 |
$0.710 |
|
J2271 |
$11.070 |
|
J2275 |
$4.390 |
|
J2545 |
$44.626 |
|
J2920 |
$1.418 |
|
J2930 |
$2.357 |
|
J3010 |
$0.700 |
|
J3285 |
$61.750 |
|
J3370 |
$7.030 |
|
J7500 |
$0.216 |
|
J7501 |
$49.195 |
|
J7502 |
$3.920 |
|
J7506 |
$0.230 |
|
J7507 |
$3.434 |
|
J7509 |
$0.080 |
|
J7510 |
$0.073 |
|
J7513 |
$348.178 |
|
J7515 |
$0.995 |
|
J7517 |
$2.519 |
|
J7518 |
$2.166 |
|
J7520 |
$6.904 |
|
J7525 |
$136.454 |
|
J7608KO |
$2.248 |
|
J7608KP |
$2.248 |
|
J7608KQ |
$2.068 |
|
J7611 |
$0.090 |
|
J7612 |
$0.987 |
|
J7613KO |
$0.073 |
|
J7613KP |
$0.073 |
|
J7613KQ |
$0.090 |
|
J7614KO |
$1.413 |
|
J7614KP |
$1.413 |
|
J7614KQ |
$0.987 |
|
J7622KO |
*TBD |
|
J7622KP |
*TBD |
|
J7622KQ |
*TBD |
|
J7624KO |
*TBD |
|
J7624KP |
*TBD |
|
J7624KQ |
*TBD |
|
J7626KO |
$4.374 |
|
J7626KP |
$4.374 |
|
J7626KQ |
*TBD |
|
J7627KO |
*TBD |
|
J7627KP |
*TBD |
|
J7627KQ |
*TBD |
|
J7628 |
*TBD |
|
J7629KO |
*TBD |
|
J7629KP |
*TBD |
|
J7629KQ |
*TBD |
|
J7631KO |
$0.059 |
|
J7631KP |
$0.059 |
|
J7631KQ |
$0.024 |
|
J7633 |
*TBD |
|
J7635 |
$0.116 |
|
J7636KO |
$0.116 |
|
J7636KP |
$0.116 |
|
J7636KQ |
$0.116 |
|
J7637 |
$0.123 |
|
J7638KO |
$0.159 |
|
J7638KP |
$0.159 |
|
J7638KQ |
$0.159 |
|
J7639KO |
$18.757 |
|
J7639KP |
$18.757 |
|
J7639KQ |
$18.728 |
|
J7641KO |
*TBD |
|
J7641KP |
*TBD |
|
J7641KQ |
*TBD |
|
J7642 |
$1.040 |
|
J7643KO |
$1.040 |
|
J7643KP |
$1.040 |
|
J7643KQ |
$1.040 |
|
J7644KO |
$0.216 |
|
J7644KP |
$0.216 |
|
J7644KQ |
$0.070 |
|
J7648 |
*TBD |
|
J7649KO |
*TBD |
|
J7649KP |
*TBD |
|
J7649KQ |
*TBD |
|
J7658 |
*TBD |
|
J7659KO |
*TBD |
|
J7659KP |
*TBD |
|
J7659KQ |
*TBD |
|
J7668 |
*TBD |
|
J7669KO |
$0.232 |
|
J7669KP |
$0.232 |
|
J7669KQ |
*TBD |
|
J7674 |
$0.389 |
|
J7680 |
*TBD |
|
J7681KO |
*TBD |
|
J7681KP |
*TBD |
|
J7681KQ |
*TBD |
|
J7682KO |
$53.658 |
|
J7682KP |
$53.658 |
|
J7682KQ |
*TBD |
|
J7683 |
*TBD |
|
J7684KO |
*TBD |
|
J7684KP |
*TBD |
|
J7684KQ |
*TBD |
|
J8501 |
$4.634 |
|
J8530 |
$0.971 |
|
J8540 |
$0.073 |
|
J8597 |
*TBD |
|
J8610 |
$0.239 |
|
J9000 |
$12.540 |
|
J9001 |
$393.480 |
|
J9040 |
$289.370 |
|
J9065 |
$61.720 |
|
J9070 |
$5.730 |
|
J9080 |
$10.890 |
|
J9100 |
$8.190 |
|
J9110 |
$8.550 |
|
J9150 |
$74.230 |
|
J9181 |
$1.710 |
|
J9182 |
$17.100 |
|
J9190 |
$2.070 |
|
J9200 |
$136.800 |
|
J9208 |
$150.380 |
|
J9265 |
$162.170 |
|
J9280 |
$127.400 |
|
J9290 |
$323.200 |
|
J9350 |
$798.650 |
|
J9355 |
$58.130 |
|
J9360 |
$4.100 |
|
J9370 |
$33.980 |
|
J9375 |
$67.960 |
|
J9380 |
$169.910 |
|
J9390 |
$109.000 |
|
Q0163 |
$0.036 |
|
Q0164 |
$0.030 |
|
Q0165 |
$0.025 |
|
Q0166 |
$37.409 |
|
Q0167 |
$4.551 |
|
Q0168 |
$9.363 |
|
Q0169 |
$0.310 |
|
Q0170 |
$0.559 |
|
Q0171 |
$0.014 |
|
Q0172 |
$0.037 |
|
Q0173 |
$0.706 |
|
Q0174 |
*TBD |
|
Q0175 |
$0.191 |
|
Q0176 |
$0.207 |
|
Q0177 |
$0.074 |
|
Q0178 |
$0.084 |
|
Q0179 |
$34.534 |
|
Q0180 |
$47.974 |
|
Q4080 |
$31.111 |
|
Q0510 |
$50.000 |
|
Q0511 |
$24.000 |
|
Q0512 |
$16.000 |
|
Q0513 |
$33.000 |
|
Q0514 |
$66.000 |
*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.