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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)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$912.01 / $912.01 / $912.01
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $660.69 / $933.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$812.83 / $812.83 / $812.83
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.20 / $30.20 / $60.26
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,818.38 / $3,311.31 / $7,244.36
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$107.15 / $436.52 / $1,096.48
Select Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$95.50 / $977.24 / $1,479.11
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$602.56 / $741.31 / $1,659.59
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$151.36 / $794.33 / $1,174.90