ASP Drug Pricing - (3rd Quarter)
July 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Jan 2025 (1st Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor processing the claim.
 
Page 32 * Effective Jul 1, 2025 through Sep 30, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4128 - Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 30.698 - - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 89.182 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 136.177 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 100.715 - - - - - -
Q4138 - Biodfence dryflex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 100.401 - - - - - -
Q4140 - Biodfence, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 164.835 - - - - - -
Q4141 - Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 64.746 - - - - - -
Q4143 - Repriza, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 33.92 - - - - - -
Q4145 - Epifix, injectable, 1 mg 1 MG 19.478 - - - - - -
Q4148 - Neox cord 1k, neox cord rt, or clarix cord 1k, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 126.064 - - - - - -
Q4150 - Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 84.858 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 137.192 - - - - - -
Q4152 - Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 45.409 - - - - - -
Q4153 - Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 108.601 - - - - - -
Q4154 - Biovance, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 142.857 - - - - - -
Q4155 - Neoxflo or clarixflo, 1 mg 1 MG 27.31 - - - - - -
Q4156 - Neox 100 or clarix 100, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 66.347 - - - - - -
Q4158 - Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 66.318 - - - - - -
Q4159 - Affinity, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 235.173 - - - - - -
Q4160 - Nushield, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 530 - - - - - -
Q4161 - Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1653.815 - - - - - -
Q4163 - Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 182.181 - - - - - -
Q4164 - Helicoll, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1640.929 - - - - - -
Q4166 - Cytal, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 20.846 - - - - - -
Q4169 - Artacent wound, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2220.572 - - - - - -
* Effective Jul 1, 2025 through Sep 30, 2025

Drugs not otherwise classified - July 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective Jul 1, 2025 through Sep 30, 2025

Drug name Dosage Payment limit Notes
Vasopressin (Long Grove) 1 UNIT 2.796

ASP (Average Sale Price) Drug Pricing History