ASP Drug Pricing - (4th Quarter)
October 2025
Payment Allowance Limits for Medicare Part B Drugs

  • Note 1: Payment allowance limits subject to the ASP methodology are based on Apr 2025 (2nd 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 October 1, 2025 - December 31, 2025
HCPCS Code Code Dosage Payment
Limit		 Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
Q4104 - Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 51.003 - - - - - -
Q4105 - Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 26.944 - - - - - -
Q4108 - Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 38.543 - - - - - -
Q4110 - Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 65.405 - - - - - -
Q4111 - Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 7.872 - - - - - -
Q4114 - Integra flowable wound matrix, injectable, 1 cc 1 CC 1494.41 - - - - - -
Q4115 - Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 12.861 - - - - - -
Q4118 - Matristem micromatrix, 1 mg 1 MG 2.544 - - - - - -
Q4121 - Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 52.752 - - - - - -
Q4123 - Alloskin rt, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 71.55 - - - - - -
Q4124 - Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2.486 - - - - - -
Q4126 - Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 62.414 - - - - - -
Q4127 - Talymed, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 68.487 - - - - - -
Q4128 - Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 29.912 - - - - - -
Q4132 - Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 106.7 - - - - - -
Q4133 - Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 138.74 - - - - - -
Q4137 - Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 101.716 - - - - - -
Q4138 - Biodfence dryflex, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 98.107 - - - - - -
Q4140 - Biodfence, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 161.624 - - - - - -
Q4141 - Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 106.968 - - - - - -
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 123.802 - - - - - -
Q4150 - Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 78.169 - - - - - -
Q4151 - Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 134.886 - - - - - -
* Effective October 1, 2025 - December 31, 2025

Drugs not otherwise classified - October 2025

 

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective October 1, 2025 - December 31, 2025

Drug name Dosage Payment limit Notes
Vasopressin (Long Grove) 1 UNIT 2.462

ASP (Average Sale Price) Drug Pricing History