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Utah 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
$919.25 / $919.25 / $919.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$340.75 / $831.91 / $919.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$818.96 / $818.96 / $818.96
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $60.00
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,814.80 / $3,509.81 / $5,038.84
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$106.51 / $434.70 / $1,081.25
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$225.92 / $802.91 / $1,224.00