Jurisdiction
A DME MAC Fee Schedules
October 2006 Quarterly
Average Sales Price (ASP) Drug Pricing File
Effective
October 1, 2006 through December 31, 2006 (revised 1/1/07)
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 |
$2.991 |
|
J0886 |
$9.446 |
|
J0895 |
$15.630 |
|
J1170 |
$1.490 |
|
J1250 |
$4.740 |
|
J1265 |
$0.620 |
|
J1325 |
$12.640 |
|
J1455 |
$13.070 |
|
J1566 |
$25.266 |
|
J1567 |
$30.327 |
|
J1570 |
$35.250 |
|
J1644AX |
$0.114 |
|
J1815 |
$0.242 |
|
J1817 |
$2.800 |
|
J2175 |
$0.560 |
|
J2260 |
$51.580 |
|
J2270 |
$0.710 |
|
J2271 |
$11.070 |
|
J2275 |
$4.390 |
|
J2545 |
$43.418 |
|
J2920 |
$1.939 |
|
J2930 |
$2.378 |
|
J3010 |
$0.700 |
|
J3285 |
$61.750 |
|
J3370 |
$7.030 |
|
J7500 |
$0.186 |
|
J7501 |
$49.173 |
|
J7502 |
$3.664 |
|
J7504 |
$315.761 |
|
J7505 |
$856.045 |
|
J7506 |
$0.180 |
|
J7507 |
$3.549 |
|
J7509 |
$0.078 |
|
J7510 |
$0.095 |
|
J7511 |
$329.618 |
|
J7513 |
$328.833 |
|
J7515 |
$0.962 |
|
J7516 |
$19.670 |
|
J7517 |
$2.504 |
|
J7518 |
$2.148 |
|
J7520 |
$7.247 |
|
J7525 |
$140.715 |
|
J7608KO |
$3.338 |
|
J7608KP |
$3.338 |
|
J7608KQ |
$3.158 |
|
J7611 |
$0.100 |
|
J7612 |
*TBD |
|
J7613KO |
$0.059 |
|
J7613KP |
$0.059 |
|
J7613KQ |
$0.100 |
|
J7614KO |
$1.359 |
|
J7614KP |
$1.359 |
|
J7614KQ |
*TBD |
|
J7616 |
*TBD |
|
J7620 |
$1.089 |
|
J7622KO |
*TBD |
|
J7622KP |
*TBD |
|
J7622KQ |
*TBD |
|
J7624KO |
*TBD |
|
J7624KP |
*TBD |
|
J7624KQ |
*TBD |
|
J7626KO |
$4.562 |
|
J7626KP |
$4.562 |
|
J7626KQ |
$4.490 |
|
J7627KO |
*TBD |
|
J7627KP |
*TBD |
|
J7627KQ |
*TBD |
|
J7628 |
*TBD |
|
J7629KO |
*TBD |
|
J7629KP |
*TBD |
|
J7629KQ |
*TBD |
|
J7631KO |
$0.053 |
|
J7631KP |
$0.053 |
|
J7631KQ |
$0.014 |
|
J7633 |
*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 |
$18.754 |
|
J7639KP |
$18.754 |
|
J7639KQ |
$18.725 |
|
J7641KO |
*TBD |
|
J7641KP |
*TBD |
|
J7641KQ |
*TBD |
|
J7642 |
$1.525 |
|
J7643KO |
$1.705 |
|
J7643KP |
$1.705 |
|
J7643KQ |
$1.525 |
|
J7644KO |
$0.215 |
|
J7644KP |
$0.215 |
|
J7644KQ |
$0.072 |
|
J7648 |
*TBD |
|
J7649KO |
*TBD |
|
J7649KP |
*TBD |
|
J7649KQ |
*TBD |
|
J7658 |
*TBD |
|
J7659KO |
*TBD |
|
J7659KP |
*TBD |
|
J7659KQ |
*TBD |
|
J7668 |
$0.133 |
|
J7669KO |
$0.205 |
|
J7669KP |
$0.205 |
|
J7669KQ |
$0.133 |
|
J7674 |
$0.409 |
|
J7680 |
*TBD |
|
J7681KO |
*TBD |
|
J7681KP |
*TBD |
|
J7681KQ |
*TBD |
|
J7682KO |
$55.633 |
|
J7682KP |
$55.633 |
|
J7682KQ |
*TBD |
|
J7683 |
$0.113 |
|
J7684KO |
$0.149 |
|
J7684KP |
$0.149 |
|
J7684KQ |
$0.113 |
|
J8501 |
$4.846 |
|
J8530 |
$0.995 |
|
J8540 |
$0.253 |
|
J8610 |
$0.253 |
|
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 |
$0.033 |
|
Q0164 |
$0.053 |
|
Q0165 |
$0.034 |
|
Q0166 |
$41.183 |
|
Q0167 |
$4.921 |
|
Q0168 |
$10.125 |
|
Q0169 |
$0.390 |
|
Q0170 |
$0.406 |
|
Q0171 |
$0.022 |
|
Q0172 |
$0.051 |
|
Q0173 |
$0.244 |
|
Q0174 |
*TBD |
|
Q0175 |
$0.217 |
|
Q0176 |
$0.229 |
|
Q0177 |
$0.059 |
|
Q0178 |
$0.067 |
|
Q0179 |
$36.064 |
|
Q0180 |
$48.912 |
|
Q4080 |
$33.172 |
*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.