High Cost/Low Cost Threshold for Packaged Skin Substitutes

CY 2022 HCPCS Code CY 2022 Short Descriptor CY 2021 High/Low Cost Assignment Final CY 2022 High/Low Cost Assignment

Q4167 Truskin, per square centimeter Q4182 Transcyte, per sq centimeter Q4188 Amnioarmor 1 sq cm Q4190 Artacent ac 1 sq cm Q4193 Coll-e-derm 1 sq cm Q4198 Genesis amnio membrane 1 sq cm Q4199 Cygnus matrix, per sq cm Q4200 Skin te 1 sq cm Q4201 Matrion 1 sq cm Q4209 Surgraft per sq cm Q4211 Amnion bio or axobio sq cm Q4219 Surgigraft dual per sq cm Q4222 Progenamatrix, per sq cm Q4227 Amniocore per sq cm Q4232 Corplex, per sq cm Q4237 cryo-cord, per sq cm Q4238 Derm-maxx, per sq cm Q4239 Amnio-maxx or lite per sq cm Q4249 Amniply, per sq cm Low Low Low Low Low Low N/A Low Low Low Low Low Low Low Low Low Low Low Low High High High High High High Low High High High High High High High High High High High High

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