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Utah 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
$103.44 / $103.44 / $103.44
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$91.33 / $449.29 / $728.28
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$630.72 / $630.72 / $630.72
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.00 / $60.00 / $60.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,814.80 / $3,509.81 / $5,038.84
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$114.64 / $277.89 / $878.60
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$56.48 / $204.34 / $443.49