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New Hampshire 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
$87.72 / $782.83 / $939.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$736.71 / $821.32 / $937.70
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.11 / $87.87 / $890.18
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$818.96 / $818.96 / $818.96
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.59 / $355.72 / $2,807.45
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,109.17 / $1,168.33 / $2,901.81
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,500.00 / $2,750.00 / $3,500.00