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 34 * 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
Q4225 - Amniobind or dermabind tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1370.73 - - - - - -
Q4227 - Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1165.388 - - - - - -
Q4229 - Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 330.311 - - - - - -
Q4232 - Corplex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 130.11 - - - - - -
Q4234 - Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 194.829 - - - - - -
Q4235 - Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 80.484 - - - - - -
Q4236 - Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 483.646 - - - - - -
Q4238 - Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1725.041 - - - - - -
Q4239 - Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2038.504 - - - - - -
Q4248 - Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2824.496 - - - - - -
Q4249 - Amniply, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1789.545 - - - - - -
Q4250 - Amnioamp-mp, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2901.655 - - - - - -
Q4252 - Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 53 - - - - - -
Q4253 - Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 83.176 - - - - - -
Q4256 - Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 813.214 - - - - - -
Q4257 - Relese, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 652.664 - - - - - -
Q4258 - Enverse, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 82.413 - - - - - -
Q4259 - Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 941.457 - - - - - -
Q4262 - Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 62.851 - - - - - -
Q4263 - Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1712.999 - - - - - -
Q4264 - Cocoon membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 372.888 - - - - - -
Q4265 - Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1704.026 - - - - - -
Q4266 - Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 560.571 - - - - - -
Q4267 - Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 290.015 - - - - - -
Q4270 - Complete sl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3370.8 - - - - - -
* 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