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Montana 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)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $776.25 / $1,071.52
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$46,773.51 / $81,283.05 / $95,499.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$812.83 / $812.83 / $812.83
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.83 / $812.83 / $812.83
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Low / Median / High Price
$891.25 / $891.25 / $912.01
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Low / Median / High Price
$891.25 / $891.25 / $912.01
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$83.18 / $724.44 / $1,412.54
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$79.43 / $173.78 / $1,778.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$416.87 / $1,318.26 / $1,479.11