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Pennsylvania 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
Facility
Modifier
Low / Median / High Price
$891.25 / $891.25 / $891.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$446.68 / $676.08 / $933.25
Ambetter
Facility/Professional
Professional
Modifier
Low / Median / High Price
$70.79 / $74.13 / $1,023.29
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.83 / $812.83 / $812.83
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,288.25 / $1,659.59 / $1,819.70
Geisinger
Facility/Professional
Professional
Modifier
Low / Median / High Price
$933.25 / $1,230.27 / $2,818.38
Highmark BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,398.83 / $2,398.83 / $2,398.83
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$891.25 / $891.25 / $891.25
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$426.58 / $676.08 / $1,000.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,884.03 / $6,025.60 / $7,413.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$467.74 / $831.76 / $1,548.82