Jurisdiction
A DME MAC Fee
Schedules
October 2008 Quarterly
Average Sales Price (ASP) Drug Pricing File
Effective
October 1, 2008 through December 31, 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 |
$2.963 |
|
J0886 |
$9.097 |
|
J0895 |
$15.630 |
|
J1170 |
$1.490 |
|
J1250 |
$4.740 |
|
J1265 |
$0.620 |
|
J1325 |
$12.640 |
|
J1455 |
$13.070 |
|
J1561 |
$34.798 |
|
J1562 |
$11.400 |
|
J1566 |
$29.236 |
|
J1568 |
$35.915 |
|
J1569 |
$35.006 |
|
J1570 |
$35.250 |
|
J1572 |
$35.699 |
|
J1644AX |
$0.121 |
|
J1815 |
$0.301 |
|
J1817 |
$2.800 |
|
J2175 |
$0.560 |
|
J2260 |
$51.580 |
|
J2270 |
$0.710 |
|
J2271 |
$11.070 |
|
J2275 |
$4.390 |
|
J2545 |
$46.004 |
|
J2920 |
$2.050 |
|
J2930 |
$3.098 |
|
J3010 |
$0.700 |
|
J3285 |
$61.75 |
|
J7500 |
$0.118 |
|
J7501 |
$90.990 |
|
J7502 |
$3.671 |
|
J7504 |
$439.478 |
|
J7505 |
$1104.181 |
|
J7506 |
$0.031 |
|
J7507 |
$3.901 |
|
J7509 |
$0.084 |
|
J7510 |
$0.020 |
|
J7511 |
$372.336 |
|
J7513 |
$344.533 |
|
J7515 |
$0.877 |
|
J7516 |
$19.371 |
|
J7517 |
$3.146 |
|
J7518 |
$2.602 |
|
J7520 |
$8.403 |
|
J7525 |
$139.602 |
|
J7608KO |
$1.906 |
|
J7611 |
$0.084 |
|
J7612 |
$0.155 |
|
J7613KO |
$0.044 |
|
J7614KO |
$0.212 |
|
J7620 |
$0.307 |
|
J7626KO |
$5.392 |
|
J7631KO |
$0.711 |
|
J7639KO |
$21.608 |
|
J7644KO |
$0.212 |
|
J7669KO |
$0.249 |
|
J7682KO |
$63.558 |
|
J8501 |
$5.336 |
|
J8530 |
$0.912 |
|
J8540 |
$0.365 |
|
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 |
|
J9360 |
$4.100 |
|
J9370 |
$33.980 |
|
J9375 |
$67.960 |
|
J9380 |
$169.910 |
|
J9390 |
$109.000 |
|
Q0163 |
$0.019 |
|
Q0164 |
$0.050 |
|
Q0165 |
$0.032 |
|
Q0166 |
$17.877 |
|
Q0167 |
$5.876 |
|
Q0168 |
$11.838 |
|
Q0169 |
$0.421 |
|
Q0170 |
$0.127 |
|
Q0171 |
$0.012 |
|
Q0172 |
$0.032 |
|
Q0173 |
$0.335 |
|
Q0174 |
*TBD |
|
Q0175 |
$0.205 |
|
Q0176 |
$0.221 |
|
Q0177 |
$0.044 |
|
Q0178 |
$0.052 |
|
Q0179 |
$3.938 |
|
Q0180 |
$57.078 |
|
Q0510 |
$50.000 |
|
Q0511 |
$24.000 |
|
Q0512 |
$16.000 |
|
Q0513 |
$33.000 |
|
Q0514 |
$66.000 |
|
Q4080 |
$48.500 |
|
Q4096 |
$0.656 |
|
Q4097 |
$34.185 |
|
Q4098 |
$11.599 |
|
Q4099KO |
$4.292 |
*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.