Jurisdiction A DME MAC

October 2007 Quarterly Average Sales Price (ASP) Drug Pricing File

Effective October 1, 2007 through December 31, 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	$2.910
J0886	$9.058
J0895	$15.630
J1170	$1.490
J1250	$4.740
J1265	$0.620
J1325	$12.640
J1455	$13.070
J1566	$27.150
J1570	$35.250
J1644AX	$0.213
J1815	$0.252
J1817	$2.800
J2175	$0.560
J2260	$51.580
J2270	$0.710
J2271	$11.070
J2275	$4.390
J2545	$49.417
J2920	$1.973
J2930	$3.970
J3010	$0.700
J3285	$61.750
J7500	$0.144
J7501	$48.336
J7502	$3.550
J7504	$339.300
J7505	$987.061
J7506	$0.176
J7507	$3.726
J7509	$0.075
J7510	$0.033
J7511	$341.034
J7513	$325.346
J7515	$0.906
J7516	$19.300
J7517	$2.684
J7518	$2.437
J7520	$7.569
J7525	$139.962
J7608KO	$2.369
J7620	$1.079
J7626KO	$4.801
J7631KO	$0.067
J7644KO	$0.188
J7668	$0.198
J7669KO	$0.265
J7674	$0.417
J7682KO	$60.995
J8501	$5.041
J8530	$0.965
J8540	$0.246
J8610	$0.234
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	$0.029
Q0164	$0.032
Q0165	$0.046
Q0166	$50.436
Q0167	$5.412
Q0168	$10.999
Q0169	$0.463
Q0170	$0.256
Q0171	$0.018
Q0172	$0.041
Q0173	$0.326
Q0174	*TBD
Q0175	$0.196
Q0176	$0.195
Q0177	$0.047
Q0178	$0.053
Q0179	$18.543
Q0180	$44.188
Q4080	$40.776
Q4091	$32.573
Q4092	$32.364
Q4093	$0.131
Q4094KO	$0.419

*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.