| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $3,350.22 | $9,813.00 | $17,617.16 | |
Moda Health
| Facility | $1,419.27 | $5,298.37 | $7,576.67 | |
Providence
| Facility | $1,419.27 | $5,298.37 | $7,576.67 |
Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; complex (eg, stone[s] > 2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy)
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $3,350.22 | $9,813.00 | $17,617.16 | |
Moda Health
| Facility | $1,419.27 | $5,298.37 | $7,576.67 | |
Providence
| Facility | $1,419.27 | $5,298.37 | $7,576.67 |