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 36 * 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
Q4289 - Revoshield + amniotic barrier, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1523.045 - - - - - -
Q4290 - Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1867.014 - - - - - -
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 3363.808 - - - - - -
Q4295 - Amnio tri-core amniotic, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2905.453 - - - - - -
Q4296 - Rebound matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 838.471 - - - - - -
Q4297 - Emerge matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1302.299 - - - - - -
Q4298 - Amniocore pro, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2634.149 - - - - - -
Q4299 - Amniocore pro+, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3161.24 - - - - - -
Q4300 - Acesso tl, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2122.737 - - - - - -
Q4301 - Activate matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1798.114 - - - - - -
Q4302 - Complete aca, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1239.897 - - - - - -
Q4303 - Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3368.389 - - - - - -
Q4304 - Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 447.461 - - - - - -
Q4309 - Via matrix, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 880.025 - - - - - -
Q4310 - Procenta, per 100 mg 100 MG 1391.605 - - - - - -
Q4312 - Acesso ac, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2411.764 - - - - - -
Q4313 - Dermabind fm, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3312.515 - - - - - -
Q4314 - Reeva ft, per square cenitmeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2332 - - - - - -
Q4316 - Amchoplast, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 4227.966 - - - - - -
Q4317 - Vitograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 4770 - - - - - -
Q4319 - Sanograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 2809 - - - - - -
Q4320 - Pellograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 103.026 - - - - - -
Q4321 - Renograft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 3816 - - - - - -
Q4322 - Caregraft, per square centimeter (add-on, list separately in addition to primary procedure) 1 SQ CM 1825.619 - - - - - -
* 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