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 33 * 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
Q4170 - Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 41.552 - - - - - -
Q4171 - Interfyl, 1 mg 1 MG 10.61 - - - - - -
Q4173 - Palingen or palingen xplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 356.554 - - - - - -
Q4175 - Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 67.716 - - - - - -
Q4178 - Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 93.108 - - - - - -
Q4180 - Revita, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1090.07 - - - - - -
Q4184 - Cellesta or cellesta duo, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 80.04 - - - - - -
Q4186 - Epifix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 150.332 - - - - - -
Q4187 - Epicord, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 241.868 - - - - - -
Q4188 - Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 487.586 - - - - - -
Q4190 - Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 129.418 - - - - - -
Q4191 - Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 730.431 - - - - - -
Q4193 - Coll-e-derm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1713.183 - - - - - -
Q4194 - Novachor, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 717.779 - - - - - -
Q4195 - Puraply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 107.917 - - - - - -
Q4196 - Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 98.541 - - - - - -
Q4197 - Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 71.036 - - - - - -
Q4199 - Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 130.255 - - - - - -
Q4201 - Matrion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 79.228 - - - - - -
Q4203 - Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 871.368 - - - - - -
Q4204 - Xwrap, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3774.774 - - - - - -
Q4205 - Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1190.439 - - - - - -
Q4217 - Woundfix, biowound, woundfix plus, biowound plus, woundfix xplus or biowound xplus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 318 - - - - - -
Q4221 - Amniowrap2, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1961 - - - - - -
Q4222 - Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 127.548 - - - - - -
* 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