Jurisdiction A DME MAC

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

Effective January 1, 2008 through March 31, 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	$2.892
J0886	$8.963
J0895	$15.630
J1170	$1.490
J1250	$4.740
J1265	$0.620
J1325	$12.640
J1455	$13.070
J1561	$32.882
J1566	$27.655
J1570	$35.250
J1644AX	$0.218
J1815	$0.276
J1817	$2.800
J2175	$0.560
J2260	$51.580
J2270	$0.710
J2271	$11.070
J2275	$4.390
J2545	$47.297
J2920	$1.975
J2930	$3.489
J3010	$0.700
J3285	$61.750
J7500	$0.257
J7501	$48.537
J7502	$3.512
J7504	$377.061
J7505	$987.061
J7506	$0.176
J7507	$3.869
J7509	$0.059
J7510	$0.018
J7511	$342.285
J7513	$322.123
J7515	$0.888
J7516	$19.532
J7517	$2.814
J7518	$2.468
J7520	$7.580
J7525	$139.697
J7608KO	$2.273
J7620	$0.805
J7626KO	$5.086
J7631KO	$0.072
J7639KO	$20.846
J7644KO	$0.210
J7669KO	$0.270
J7674	$0.417
J7682KO	$60.995
J8501	$5.528
J8530	$0.857
J8540	$0.240
J8610	$0.209
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	$0.031
Q0164	$0.027
Q0165	$0.090
Q0166	$50.224
Q0167	$4.878
Q0168	$10.982
Q0169	$0.440
Q0170	$0.272
Q0171	$0.019
Q0172	$0.042
Q0173	$0.302
Q0174	*TBD
Q0175	$0.183
Q0176	$0.190
Q0177	$0.045
Q0178	$0.055
Q0179	$9.169
Q0180	$47.977
Q4080	$40.863

*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.