| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Hally Health
| Facility | $150.00 | $150.00 | $150.00 | |
Wellmark
| Facility | $18,170.00 | $28,440.00 | $40,290.00 |
Other Therapeutic Services (see also 095X, an extension of 094X)-Complex Medical Equipment-Ancillary
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Hally Health
| Facility | $150.00 | $150.00 | $150.00 | |
Wellmark
| Facility | $18,170.00 | $28,440.00 | $40,290.00 |