Jurisdiction A DME MAC Fee Schedules

April 2008 Quarterly Average Sales Price (ASP) Drug Pricing File

Effective April 1, 2008 through June 30, 2008

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	$2.771
J0886	$9.073
J0895	$15.630
J1170	$1.490
J1250	$4.740
J1265	$0.620
J1325	$12.640
J1455	$13.070
J1561	$33.448
J1566	$28.065
J1568	$34.069
J1569	$31.787
J1570	$35.250
J1644AX	$0.740
J1815	$0.284
J1817	$2.800
J2175	$0.560
J2260	$51.580
J2270	$0.710
J2271	$11.070
J2275	$4.390
J2545	$54.314
J2920	$2.070
J2930	$3.020
J3010	$0.700
J3285	$61.750
J7500	$0.152
J7501	$50.043
J7502	$3.661
J7504	$383.792
J7505	$986.881
J7506	$0.176
J7507	$3.911
J7509	$0.078
J7510	$0.030
J7511	$344.723
J7513	$315.679
J7515	$0.897
J7516	$19.809
J7517	$2.908
J7518	$2.459
J7520	$7.931
J7525	$140.026
J7608KO	$1.729
J7620	$0.830
J7626KO	$5.017
J7631KO	$0.062
J7639KO	$20.865
J7644KO	$0.202
J7669KO	$0.255
J7674	$0.417
J7682KO	$59.754
J8501	$5.267
J8530	$0.822
J8540	$0.248
J8610	$0.162
J9000	$12.540
J9001	$393.480
J9040	$289.370
J9065	$61.720
J9190	$2.070
J9200	$136.800
J9208	$150.380
J9360	$4.100
J9370	$33.980
J9375	$67.960
J9380	$169.910
J9390	$109.000
Q0163	$0.020
Q0164	$0.055
Q0165	$0.080
Q0166	$46.955
Q0167	$5.415
Q0168	$10.835
Q0169	$0.445
Q0170	$0.192
Q0171	$0.013
Q0172	$0.035
Q0173	$0.294
Q0174	*TBD
Q0175	$0.190
Q0176	$0.203
Q0177	$0.049
Q0178	$0.052
Q0179	$4.604
Q0180	$49.168
Q4080	$40.863
Q4096	$0.656
Q4097	$34.185
Q4098	$11.599
Q4099KO	$4.929

*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.