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South Dakota 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
$537.03 / $537.03 / $537.03
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$100.00 / $537.03 / $1,071.52
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$97.72 / $123.03 / $1,318.26
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$125.89 / $707.95 / $1,318.26
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$467.74 / $1,122.02 / $5,011.87
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$131.83 / $131.83 / $1,348.96
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$147.91 / $1,318.26 / $1,778.28
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$234.42 / $1,230.27 / $2,089.30
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$181.97 / $218.78 / $2,238.72