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 35 * 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
Q4271 - Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1210.484 - - - - - -
Q4274 - Esano ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1832.318 - - - - - -
Q4275 - Esano aca, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2675.479 - - - - - -
Q4276 - Orion, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 261.255 - - - - - -
Q4278 - Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 265.113 - - - - - -
Q4279 - Vendaje ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2385 - - - - - -
Q4280 - Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2892.85 - - - - - -
Q4281 - Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 544.049 - - - - - -
Q4282 - Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 336.763 - - - - - -
Q4283 - Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 457.32 - - - - - -
Q4289 - Revoshield + amniotic barrier, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1468.105 - - - - - -
Q4290 - Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1864.706 - - - - - -
Q4293 - Acesso dl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1584.7 - - - - - -
Q4294 - Amnio quad-core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2915 - - - - - -
Q4295 - Amnio tri-core amniotic, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2565.2 - - - - - -
Q4296 - Rebound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1455.143 - - - - - -
Q4297 - Emerge matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1697.354 - - - - - -
Q4298 - Amniocore pro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2223.168 - - - - - -
Q4299 - Amniocore pro+, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2856.7 - - - - - -
Q4300 - Acesso tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2114.7 - - - - - -
Q4301 - Activate matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1806.335 - - - - - -
Q4302 - Complete aca, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1271.604 - - - - - -
Q4303 - Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3368.001 - - - - - -
Q4304 - Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 613.68 - - - - - -
Q4309 - Via matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1308.554 - - - - - -
* 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