Jurisdiction A DME MAC

January 2007 Quarterly Average Sales Price (ASP) Drug Pricing File

Effective January 1, 2007 through April 30, 2007

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
J0735	$55.157
J0882	$3.354
J0886	$9.283
J0895	$15.630
J1170	$1.490
J1250	$4.740
J1265	$0.620
J1325	$12.640
J1455	$13.070
J1566	$25.605
J1567	$30.443
J1570	$35.250
J1644AX	$0.225
J1815	$0.239
J1817	$2.800
J2175	$0.560
J2260	$51.580
J2270	$0.710
J2271	$11.070
J2275	$4.390
J2545	$44.732
J2920	$1.948
J2930	$2.476
J3010	$0.700
J3285	$61.750
J3370	$7.030
J7500	$0.274
J7501	$49.587
J7502	$3.541
J7504	$317.148
J7505	$876.832
J7506	$0.191
J7507	$3.540
J7509	$0.072
J7510	$0.071
J7511	$331.070
J7513	$314.587
J7515	$0.952
J7516	$20.635
J7517	$2.547
J7518	$2.140
J7520	$7.224
J7525	$140.386
J7607	*TBD
J7608KO	$2.395
J7608KP	$2.395
J7608KQ	$2.215
J7609KO	*TBD
J7609KP	*TBD
J7609KQ	*TBD
J7610	*TBD
J7611	$0.071
J7612	$0.989
J7613KO	$0.065
J7613KP	$0.065
J7613KQ	$0.097
J7614KO	$1.391
J7614KP	$1.391
J7614KQ	$0.989
J7615KO	*TBD
J7615KP	*TBD
J7615KQ	*TBD
J7616	*TBD
J7617	*TBD
J7618	*TBD
J7619KO	*TBD
J7619KP	*TBD
J7619KQ	*TBD
J7620	$1.052
J7621	*TBD
J7622KO	*TBD
J7622KP	*TBD
J7622KQ	*TBD
J7624KO	*TBD
J7624KP	*TBD
J7624KQ	*TBD
J7626KO	$4.590
J7626KP	$4.590
J7626KQ	$4.518
J7627KO	*TBD
J7627KP	*TBD
J7627KQ	*TBD
J7628	*TBD
J7629KO	*TBD
J7629KP	*TBD
J7629KQ	*TBD
J7631KO	$0.069
J7631KP	$0.069
J7631KQ	$0.034
J7633	*TBD
J7634	*TBD
J7635	$0.266
J7636KO	$0.338
J7636KP	$0.338
J7636KQ	$0.266
J7637	$0.123
J7638KO	$0.159
J7638KP	$0.159
J7638KQ	$0.123
J7639KO	$19.864
J7639KP	$19.864
J7639KQ	$19.835
J7640KO	*TBD
J7640KP	*TBD
J7640KQ	*TBD
J7641KO	*TBD
J7641KP	*TBD
J7641KQ	*TBD
J7642	$1.525
J7643KO	$1.705
J7643KP	$1.705
J7643KQ	$1.525
J7644KO	$0.213
J7644KP	$0.213
J7644KQ	$0.070
J7645KO	*TBD
J7645KP	*TBD
J7645KQ	*TBD
J7647	*TBD
J7648	*TBD
J7649KO	*TBD
J7649KP	*TBD
J7649KQ	*TBD
J7650KO	*TBD
J7650KP	*TBD
J7650KQ	*TBD
J7657	*TBD
J7658	*TBD
J7659KO	*TBD
J7659KP	*TBD
J7659KQ	*TBD
J7660KO	*TBD
J7660KP	*TBD
J7660KQ	*TBD
J7667	*TBD
J7668	$0.166
J7669KO	$0.238
J7669KP	$0.238
J7669KQ	$0.166
J7670KO	*TBD
J7670KP	*TBD
J7670KQ	*TBD
J7674	$0.419
J7680	*TBD
J7681KO	*TBD
J7681KP	*TBD
J7681KQ	*TBD
J7682KO	$57.313
J7682KP	$57.313
J7682KQ	$57.241
J7683	$0.113
J7684KO	$0.149
J7684KP	$0.149
J7684KQ	$0.113
J7685KO	*TBD
J7685KP	*TBD
J7685KQ	*TBD
J8501	$5.035
J8530	$0.978
J8540	$0.257
J8610	$0.218
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
J9293	$359.350
J9350	$798.650
J9355	$58.130
J9360	$4.100
J9370	$33.980
J9375	$67.960
J9380	$169.910
J9390	$109.000
Q0163	$0.034
Q0164	$0.029
Q0165	$0.045
Q0166	$44.174
Q0167	$4.646
Q0168	$10.051
Q0169	$0.390
Q0170	$0.394
Q0171	$0.021
Q0172	$0.047
Q0173	$0.326
Q0174	*TBD
Q0175	$0.191
Q0176	$0.213
Q0177	$0.062
Q0178	$0.064
Q0179	$36.829
Q0180	$48.707
Q4080	$34.238

*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.