| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $2,236.00 | $9,774.00 | $14,552.94 | |
Moda Health
| Facility | $876.16 | $3,263.82 | $4,667.26 | |
Providence
| Facility | $876.16 | $3,263.82 | $4,667.26 |
Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; simple (eg, stone[s] up to 2 cm in single location of kidney or renal pelvis, nonbranching stones)
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $2,236.00 | $9,774.00 | $14,552.94 | |
Moda Health
| Facility | $876.16 | $3,263.82 | $4,667.26 | |
Providence
| Facility | $876.16 | $3,263.82 | $4,667.26 |