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South Carolina 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
$634.38 / $634.38 / $634.38
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$634.38 / $736.71 / $896.54
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,710.85 / $1,749.26 / $2,281.13
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$84.48 / $817.48 / $983.76
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$818.96 / $818.96 / $818.96
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$101.38 / $634.38 / $858.35
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$310.89 / $749.60 / $1,117.67