Jurisdiction
A DME MAC Fee
Schedules
1st Quarter 2009 Average Sales Price (ASP) Drug Pricing File
Effective
January 1, 2009 through March 31, 2009
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 |
$3.060 |
|
J0886 |
$9.201 |
|
J0895 |
$15.630 |
|
J1170 |
$1.490 |
|
J1250 |
$4.740 |
|
J1265 |
$0.620 |
|
J1325 |
$12.640 |
|
J1455 |
$13.070 |
|
J1561 |
$35.531 |
|
J1562 |
$11.400 |
|
J1566 |
$29.429 |
|
J1568 |
$36.874 |
|
J1569 |
$35.376 |
|
J1570 |
$35.250 |
|
J1572 |
$35.595 |
|
J1644AX |
$0.199 |
|
J1815 |
$0.308 |
|
J1817 |
$2.800 |
|
J2175 |
$0.560 |
|
J2260 |
$51.580 |
|
J2270 |
$0.710 |
|
J2271 |
$11.070 |
|
J2275 |
$4.390 |
|
J2545 |
$49.269 |
|
J2920 |
$2.245 |
|
J2930 |
$3.160 |
|
J3010 |
$0.700 |
|
J3285 |
$61.75 |
|
J7500 |
$0.110 |
|
J7501 |
$90.906 |
|
J7502 |
$3.411 |
|
J7504 |
$463.578 |
|
J7505 |
$1077.024 |
|
J7506 |
$0.030 |
|
J7507 |
$4.045 |
|
J7509 |
$0.085 |
|
J7510 |
$0.023 |
|
J7511 |
$371.678 |
|
J7513 |
$347.648 |
|
J7515 |
$0.809 |
|
J7516 |
$26.007 |
|
J7517 |
$3.190 |
|
J7518 |
$2.703 |
|
J7520 |
$8.518 |
|
J7525 |
$139.485 |
|
J7605KO |
$4.926 |
|
J7608KO |
$2.020 |
|
J7611 |
$0.088 |
|
J7612 |
$0.166 |
|
J7613KO |
$0.044 |
|
J7614KO |
$0.238 |
|
J7620 |
$0.273 |
|
J7626KO |
$5.630 |
|
J7631KO |
$0.125 |
|
J7639KO |
$22.321 |
|
J7644KO |
$0.209 |
|
J7669KO |
$0.220 |
|
J7682KO |
$63.522 |
|
J8501 |
$5.360 |
|
J8520 |
$5.225 |
|
J8521 |
$17.418 |
|
J8530 |
$0.924 |
|
J8540 |
$0.370 |
|
J8610 |
$0.162 |
|
J9000 |
$12.540 |
|
J9001 |
$393.480 |
|
J9040 |
$289.370 |
|
J9065 |
$61.720 |
|
J9100 |
$8.190 |
|
J9110 |
$8.550 |
|
J9190 |
$2.070 |
|
J9200 |
$136.800 |
|
J9208 |
$150.380 |
|
J9350 |
$798.650 |
|
J9360 |
$4.100 |
|
J9370 |
$33.980 |
|
J9375 |
$67.960 |
|
J9380 |
$169.910 |
|
J9390 |
$109.000 |
|
Q0163 |
$0.017 |
|
Q0164 |
$0.048 |
|
Q0165 |
$0.041 |
|
Q0166 |
$16.584 |
|
Q0167 |
$5.822 |
|
Q0168 |
$11.508 |
|
Q0169 |
$0.427 |
|
Q0170 |
$0.135 |
|
Q0171 |
$0.012 |
|
Q0172 |
$0.033 |
|
Q0173 |
$0.624 |
|
Q0174 |
*TBD |
|
Q0175 |
$0.253 |
|
Q0176 |
$0.300 |
|
Q0177 |
$0.047 |
|
Q0178 |
$0.056 |
|
Q0179 |
$3.332 |
|
Q0180 |
$51.795 |
|
Q0510 |
$50.000 |
|
Q0511 |
$24.000 |
|
Q0512 |
$16.000 |
|
Q0513 |
$33.000 |
|
Q0514 |
$66.000 |
|
Q4080 |
$49.820 |
*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.