Jurisdiction
A DME MAC Fee
Schedules
July 2008 Quarterly
Average Sales Price (ASP) Drug Pricing File
Effective
July 1, 2008 through September 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 |
$2.825 |
|
J0886 |
$9.071 |
|
J0895 |
$15.630 |
|
J1170 |
$1.490 |
|
J1250 |
$4.740 |
|
J1265 |
$0.620 |
|
J1325 |
$12.640 |
|
J1455 |
$13.070 |
|
J1561 |
$34.162 |
|
J1562 |
$11.400 |
|
J1566 |
$28.634 |
|
J1568 |
$36.117 |
|
J1569 |
$34.966 |
|
J1570 |
$35.250 |
|
J1572 |
$35.569 |
|
J1644AX |
$0.086 |
|
J1815 |
$0.294 |
|
J1817 |
$2.800 |
|
J2175 |
$0.560 |
|
J2260 |
$51.580 |
|
J2270 |
$0.710 |
|
J2271 |
$11.070 |
|
J2275 |
$4.390 |
|
J2545 |
$45.357 |
|
J2920 |
$2.146 |
|
J2930 |
$3.265 |
|
J3010 |
$0.700 |
|
J3285 |
$61.75 |
|
J7500 |
$0.132 |
|
J7501 |
$61.024 |
|
J7502 |
$3.489 |
|
J7504 |
$410.542 |
|
J7505 |
$1016.964 |
|
J7506 |
$0.037 |
|
J7507 |
$3.904 |
|
J7509 |
$0.075 |
|
J7510 |
$0.010 |
|
J7511 |
$370.406 |
|
J7513 |
$324.667 |
|
J7515 |
$0.839 |
|
J7516 |
$20.157 |
|
J7517 |
$2.962 |
|
J7518 |
$2.588 |
|
J7520 |
$7.954 |
|
J7525 |
$139.475 |
|
J7608KO |
$1.780 |
|
J7611 |
$0.082 |
|
J7612 |
$0.120 |
|
J7613KO |
$0.040 |
|
J7614KO |
$0.169 |
|
J7620 |
$0.581 |
|
J7626KO |
$5.344 |
|
J7631KO |
$0.062 |
|
J7639KO |
$20.865 |
|
J7644KO |
$0.204 |
|
J7669KO |
$0.254 |
|
J7682KO |
$63.077 |
|
J8501 |
$5.312 |
|
J8530 |
$0.807 |
|
J8540 |
$0.321 |
|
J8610 |
$0.155 |
|
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 |
|
J9360 |
$4.100 |
|
J9370 |
$33.980 |
|
J9375 |
$67.960 |
|
J9380 |
$169.910 |
|
J9390 |
$109.000 |
|
Q0163 |
$0.018 |
|
Q0164 |
$0.049 |
|
Q0165 |
$0.051 |
|
Q0166 |
$17.173 |
|
Q0167 |
$5.387 |
|
Q0168 |
$11.711 |
|
Q0169 |
$0.424 |
|
Q0170 |
$0.198 |
|
Q0171 |
$0.011 |
|
Q0172 |
$0.030 |
|
Q0173 |
$0.267 |
|
Q0174 |
*TBD |
|
Q0175 |
$0.179 |
|
Q0176 |
$0.177 |
|
Q0177 |
$0.048 |
|
Q0178 |
$0.054 |
|
Q0179 |
$3.160 |
|
Q0180 |
$55.377 |
|
Q0510 |
$50.000 |
|
Q0511 |
$24.000 |
|
Q0512 |
$16.000 |
|
Q0513 |
$33.000 |
|
Q0514 |
$66.000 |
|
Q4080 |
$43.275 |
|
Q4096 |
$0.656 |
|
Q4097 |
$34.185 |
|
Q4098 |
$11.599 |
|
Q4099KO |
$4.072 |
*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.