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    HCPCS Details

    HCPC Q4128
    Short Description Flexhd/allopatchhd/sq cm
    Long Description Flex hd, or allopatch hd, per square centimeter
    Pricing indicator 51
    Coverage code C
    ASC payment group code
    BETOS2 code O1E
    Action code N
    Type of service 1
    Effective date 2022-10-01
    Date Added 2012-01-01

    HCPCS/NDC Cross-Walk

    NDC HCPC Description Drug Name Labeler Name HCPCS Dosage PKG Size PKG QTY Bill Units Bill Units PKG
    370205 Q4128 Flexhd/allopatchhd/sq cm ALLOPATCH HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 10 1 10 10
    370408 Q4128 Flexhd/allopatchhd/sq cm ALLOPATCH HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 32 1 32 32
    370505 Q4128 Flexhd/allopatchhd/sq cm ALLOPATCH HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 25 1 25 25
    371404 Q4128 Flexhd/allopatchhd/sq cm Allopatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 16 1 16 16
    371408 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 32 1 32 32
    371505 Q4128 Flexhd/allopatchhd/sq cm ALLOPATCH HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 25 1 25 25
    372404 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 16 1 16 16
    470102 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 2 2
    470204 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 8 8
    470205 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 10 1 10 10
    470307 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 21 21
    470407 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 28 28
    470408 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 32 1 32 32
    470505 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 25 1 25 25
    471016 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 160 160
    471102 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 2 2
    471112 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 12 1 12 12
    471122 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 144 144
    471202 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 400 400
    471204 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 8 8
    471205 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 10 1 10 10
    471208 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 160 160
    471216 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 192 192
    471224 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 288 288
    471225 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 500 500
    471230 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 600 1 600 600
    471307 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 21 21
    471407 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 28 28
    471408 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 32 1 32 32
    471416 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 64 64
    471505 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 25 1 25 25
    471608 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 48 48
    471612 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 72 72
    471616 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 96 96
    471620 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 320 320
    471812 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 96 96
    471816 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 128 128
    472016 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 160 160
    472224 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 288 288
    472225 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 500 500
    472230 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 600 1 600 600
    472407 Q4128 Flexhd/allopatchhd/sq cm Flex Structural MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 28 1 28 28
    472408 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 32 1 32 32
    472505 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 25 1 25 25
    472620 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 320 320
    472812 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 96 96
    473505 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 25 1 25 25
    474404 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 16 16
    474408 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 32 1 32 32
    474505 Q4128 Flexhd/allopatchhd/sq cm AlloPatch HD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 25 1 25 25
    479204 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 8 1 8 8
    479407 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 28 1 28 28
    4D1331 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 660 1 660 660
    4D1335 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 840 1 840 840
    4d2331 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 660 1 660 660
    4D2335 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 840 1 840 840
    FN0816 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MAX MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 128 1 128 128
    HP1102 Q4128 Flexhd/allopatchhd/sq cm FlexHD Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 2 1 2 2
    HP1202 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 400 1 400 400
    HP1204 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 8 1 8 8
    HP1208 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 160 1 160 160
    HP1220 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 240 1 240 240
    HP1407 Q4128 Flexhd/allopatchhd/sq cm FLEX HD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 28 1 28 28
    HP1412 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 48 1 48 48
    HP1416 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 64 1 64 64
    HP1616 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 96 1 96 96
    HP1620 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 320 1 320 320
    HP1816 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 128 1 128 128
    HP2202 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 400 1 400 400
    HP2208 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 160 1 160 160
    HP2616 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 96 1 96 96
    HP2620 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 320 1 320 320
    HP2816 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 128 1 128 128
    NK0816 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MAX MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 128 2 128 256
    PF1202 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 400 1 400 400
    PF1208 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 160 1 160 160
    PF1220 Q4128 Flexhd/allopatchhd/sq cm FlexHD Pliable Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 240 1 240 240
    PF1616 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 96 1 96 96
    PF1620 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 320 1 320 320
    PF1816 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 128 1 128 128
    PF2202 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 400 1 400 400
    PF2220 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 240 1 240 240
    PF2616 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 96 1 96 96
    PF2620 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 320 1 320 320
    PF2816 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 128 1 128 128
    PK1208 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 160 2 160 320
    PK1616 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 96 2 96 192
    PK1816 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 128 2 128 256
    PP0001 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 350 1 350 350
    PP0002 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 389 1 389 389
    PP0003 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 598 1 598 598
    PP1500 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 322 1 322 322
    PP1502 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 418 1 418 418
    PP2001 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 350 1 350 350
    PP2002 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 504 1 504 504
    PP2003 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 598 1 598 598
    RK1208 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 160 2 160 320
    RK1616 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 96 2 96 192
    RK1816 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 128 2 128 256
    SF1000 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 90 1 90 90
    SF1002 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 90 1 90 90
    SF1100 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 90 2 90 180
    SF1500 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 117 1 117 117
    SF1502 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 117 1 117 117
    SF1515 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 117 2 117 234
    SF2000 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 148 1 148 148
    SF2002 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 148 1 148 148
    SF2200 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 148 2 148 296
    SF3000 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 189 1 189 189
    SF3002 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 189 1 189 189
    SF3300 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 189 2 189 378
    SF4000 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 250 1 250 250
    SF4002 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 250 1 250 250
    SF4400 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED Perforated MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 250 2 250 500
    SP0001 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE Shaped - Small MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 90 90
    SP0002 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE Shaped - Medium MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 148 148
    SP0003 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE Shaped - Large MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 189 189
    SP0004 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 250 1 250 250
    SP0011 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 90 2 90 180
    SP0022 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 148 2 148 296
    SP0033 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 189 2 189 378
    SP0044 Q4128 Flexhd/allopatchhd/sq cm FLEXHD PLIABLE MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 360 2 360 720
    sp1500 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 117 1 117 117
    SP1502 Q4128 Flexhd/allopatchhd/sq cm FlexHD Pliable (Shaped) MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 117 1 117 117
    SP1515 Q4128 Flexhd/allopatchhd/sq cm FlexHD MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 117 2 117 234
    SP2001 Q4128 Flexhd/allopatchhd/sq cm Flex Pliable MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 90 1 90 90
    SP2002 Q4128 Flexhd/allopatchhd/sq cm FlexHD Pliable (Shaped) MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 148 1 148 148
    SP2003 Q4128 Flexhd/allopatchhd/sq cm FlexHD PLIABLE SHAPED MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 189 1 189 189
    SP2004 Q4128 Flexhd/allopatchhd/sq cm FlexHD Pliable (Shaped) MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 250 1 250 250
    TD0405 Q4128 Flexhd/allopatchhd/sq cm Matrix HD RTI SURGICAL 1 SQ CM 20 1 20 20
    TD0508 Q4128 Flexhd/allopatchhd/sq cm Matrix HD RTI SURGICAL 1 SQ CM 40 1 40 40
    TD1010 Q4128 Flexhd/allopatchhd/sq cm Matrix HD RTI SURGICAL 1 SQ CM 100 1 100 100
    TD2203 Q4128 Flexhd/allopatchhd/sq cm Matrix HD RTI SURGICAL 1 SQ CM 6 1 6 6
    TDF405 Q4128 Flexhd/allopatchhd/sq cm Matrix HD Fenestrated RTI SURGICAL 1 SQ CM 20 1 20 20
    TDF508 Q4128 Flexhd/allopatchhd/sq cm Matrix HD Fenestrated RTI SURGICAL 1 SQ CM 40 1 40 40
    TDT346 Q4128 Flexhd/allopatchhd/sq cm ACELLULAR DERMAL ALLOGRAFT RTI SURGICAL 1 SQ CM 24 1 24 24
    TDT358 Q4128 Flexhd/allopatchhd/sq cm ACELLULAR DERMAL ALLOGRAFT RTI SURGICAL 1 SQ CM 40 1 40 40
    TDT546 Q4128 Flexhd/allopatchhd/sq cm ACELLULAR DERMAL ALLOGRAFT RTI SURGICAL 1 SQ CM 24 1 24 24
    TDT558 Q4128 Flexhd/allopatchhd/sq cm ACELLULAR DERMAL ALLOGRAFT RTI SURGICAL 1 SQ CM 40 1 40 40
    TDT646 Q4128 Flexhd/allopatchhd/sq cm ACELLULAR DERMAL ALLOGRAFT RTI SURGICAL 1 SQ CM 24 1 24 24
    TDT658 Q4128 Flexhd/allopatchhd/sq cm ACELLULAR DERMAL ALLOGRAFT RTI SURGICAL 1 SQ CM 40 1 40 40
    WC0202 Q4128 Flexhd/allopatchhd/sq cm AlloPatch MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 4 1 4 4
    WC0404 Q4128 Flexhd/allopatchhd/sq cm WC AlloPatch MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 16 16
    WC0418 Q4128 Flexhd/allopatchhd/sq cm WC AlloPatch MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 1 1 32 32
    WC1515 Q4128 Flexhd/allopatchhd/sq cm AlloPatch MUSCULOSKELETAL TRANSPLANT FOUNDATION 1 SQ CM 2.25 1 2.25 2.25
    The ASP crosswalks are maintained by the Division of Data Analysis and Market Based Pricing to support ASP-based Medicare Part B payments only. The crosswalks are intended to help the public (including entities that submit manufacturer ASP data and providers who bill for drugs) understand which drug products (identified by NDCs) are assigned to which HCPCS billing codes. The crosswalks are not intended to be a comprehensive list of all drugs/NDCs available in the United States. The NDC to HCPCS Crosswalk also includes information on the NDC package size and the number of billable units (as defined by the HCPCS code descriptor). Comments on the file may be sent to [email protected].

    HCPCS Billing Calculator

    Dosage given to patient (per dose)
    HCPCS Dosage 1 SQ CM
    HCPCS/CPT Billing Units 1
    Total doses ordered
    Billing Units 1