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South Dakota rates for HCPCS G0460

Autologous Platelet Rich Plasma Or Other Blood-Derived Product For Non-Diabetic Chronic Wounds/Ulcers Including As Applicable Phlebotomy Centrifugation Or Mixing And All Other Preparatory Procedures Administration And Dressings Per Treatment (Desc Rvsd 7/1/23)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$800.06 / $800.06 / $800.06
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$123.41 / $800.06 / $847.61
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$126.75 / $217.88 / $272.33
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$847.61 / $1,432.46 / $2,322.44
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$52.13 / $184.37 / $4,977.89
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$328.89 / $1,113.05 / $1,761.42
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$200.41 / $328.89 / $1,304.86
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$261.22 / $261.22 / $326.52
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$64.68 / $372.10 / $992.71
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$401.00 / $490.70 / $490.70