Jurisdiction
A DME MAC
July 2007 Quarterly
Average Sales Price (ASP) Drug Pricing File
Effective
July 1, 2007 through September 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 |
$3.027 |
|
J0886 |
$9.104 |
|
J0895 |
$15.630 |
|
J1170 |
$1.490 |
|
J1250 |
$4.740 |
|
J1265 |
$0.620 |
|
J1325 |
$12.640 |
|
J1455 |
$13.070 |
|
J1566 |
$26.828 |
|
J1570 |
$35.250 |
|
J1644AX |
$0.210 |
|
J1815 |
$0.251 |
|
J1817 |
$2.800 |
|
J2175 |
$0.560 |
|
J2260 |
$51.580 |
|
J2270 |
$0.710 |
|
J2271 |
$11.070 |
|
J2275 |
$4.390 |
|
J2545 |
$45.121 |
|
J2920 |
$1.992 |
|
J2930 |
$3.650 |
|
J3010 |
$0.700 |
|
J3285 |
$61.750 |
|
J3370 |
$7.030 |
|
J7500 |
$0.192 |
|
J7501 |
$50.392 |
|
J7502 |
$3.536 |
|
J7504 |
$343.347 |
|
J7505 |
$942.340 |
|
J7506 |
$0.159 |
|
J7507 |
$3.738 |
|
J7509 |
$0.086 |
|
J7510 |
$0.290 |
|
J7511 |
$336.009 |
|
J7513 |
$316.686 |
|
J7515 |
$0.916 |
|
J7516 |
$20.151 |
|
J7517 |
$2.629 |
|
J7518 |
$2.269 |
|
J7520 |
$7.563 |
|
J7525 |
$140.545 |
|
J7608KO |
$2.341 |
|
J7620 |
$1.105 |
|
J7626KO |
$4.744 |
|
J7631KO |
$0.069 |
|
J7644KO |
$0.189 |
|
J7668 |
$0.198 |
|
J7669KO |
$0.270 |
|
J7674 |
$0.417 |
|
J7682KO |
$60.739 |
|
J8501 |
$5.059 |
|
J8530 |
$0.984 |
|
J8540 |
$0.252 |
|
J8610 |
$0.251 |
|
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 |
$0.031 |
|
Q0164 |
$0.042 |
|
Q0165 |
$0.052 |
|
Q0166 |
$44.655 |
|
Q0167 |
$5.098 |
|
Q0168 |
$10.830 |
|
Q0169 |
$0.463 |
|
Q0170 |
$0.290 |
|
Q0171 |
$0.023 |
|
Q0172 |
$0.055 |
|
Q0173 |
$0.325 |
|
Q0174 |
*TBD |
|
Q0175 |
$0.205 |
|
Q0176 |
$0.203 |
|
Q0177 |
$0.052 |
|
Q0178 |
$0.059 |
|
Q0179 |
$25.029 |
|
Q0180 |
$47.108 |
|
Q4080 |
$37.991 |
|
Q4091 |
$32.614 |
|
Q4092 |
$31.860 |
|
Q4093 |
$0.127 |
|
Q4094KO |
$0.525 |
|
Q4095 |
$220.806 |
*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.