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Idaho rates for HCPCS G0465

Autologous Platelet Rich Plasma (Prp) Or Other Blood-Derived Product For Diabetic Chronic Wounds/Ulcers Using An Fda-Cleared Device For This Indication (Includes As Applicable Administration Dressings Phlebotomy Centrifugation Or Mixing And All Other Preparatory Procedures Per Treatment)  (Desc Rvsd 7/1/23)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$82.87 / $82.87 / $811.85
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$340.75 / $701.43 / $1,071.73
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$818.96 / $818.96 / $818.96
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$340.75 / $654.45 / $919.25
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$144.11 / $174.68 / $1,762.56
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $1,420.74
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,393.56 / $4,697.79 / $5,755.74
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$122.89 / $564.66 / $1,396.19
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$802.89 / $1,032.31 / $1,376.41