55700
Prostate biopsy, with or without guidance
Our Work > Good Faith Estimates > Prostate Biopsy
Recent regulations require hospitals and health plans to publish prices of a subset of services. The hospital rule requires publication of “shoppable services,” those that can be scheduled in advance by a consumer. The Transparency in Coverage rule requires a list of 500 items and services to be published. Prostate biopsy, with our without guidance appears on both lists, and there is a standard service package available for it. The services that make up this package are fairly standard across all prostate biopsy procedures
A prostate biopsy is a procedure to remove samples of suspicious tissue from the prostate. The prostate is a small, walnut-shaped gland in males that produces fluid that nourishes and transports sperm. During a prostate biopsy a needle is used to collect a number of tissue samples from your prostate gland. Your doctor may recommend a prostate biopsy if results from initial tests, such as a prostate-specific antigen (PSA) blood test or digital rectal exam, suggest that you may have prostate cancer. This procedure may be performed with or without imaging guidance; with guidance is presented in this service package as an optional fee
This service package does not include any of the procedures or tests used to determine whether a prostate biopsy is needed, nor does it include any post-procedure follow-up services. Your service utilization may vary from this service package for a number of reasons, including your unique clinical profile and where you receive your services.
This Service Package was generated using outpatient care setting claims. However, this service package may also be performed in the below care settings. Please confirm with your provider in which care setting you will receive services, as this may affect your cost.
- Inpatient: Discuss with your provider
- Outpatient facility: 60%
- Free standing ASC: 40%
- Office: Discuss with your provider
Item Definitions
Index
Index
this is the fee for the service being defined; note that other codes may be used to define a similar service
Facility Fee
Facility Fee
these fees are most commonly associated with the index event; these may also be
paid to the facility in addition to the index fee
Professional Fee
Professional Fee
these fees are paid to clinicians for the work associated with this service
Optional Fee
Optional Fee
these services are often also billed with the index event, however may vary based on the patient’s individual circumstances
Ancillary Service
Ancillary Service
these are supply codes that identify other services that may be billed with the index event
Proposed Technical Definition
| association | base_code | code_type | estimated_charge | item_type | name |
|---|---|---|---|---|---|
| 1 | 55700 | CPT | 3061 | index | Prostate biopsy |
| 1 | G0416 | ||||
| 76872 | CPT | $180 | facility_fee | Transrectal ultrasound | |
| 1 | 76872 | CPT | 296 | professional_fee | Transrectal ultrasound |
| 1 | 55700 | CPT | 565 | professional_fee | Prostate biopsy |
| 0.832727336 | 76942 | CPT | $180 | optional_fee [facility] | Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation |
| 76942 | CPT | $45 | optional_fee [professional] | ||
| 88305 | CPT | $1,000 | facility_fee | Surgical Pathology Level 4 | |
| 0.672 | 88305 | CPT | 1200 | professional_fee | Surgical Pathology Level 4 |
| 902 | CPT | $430 | professional_fee | Anesthesia | |
| J2704 | HCPCS | $21 | facility_fee | Propofol injection | |
| J3010 | HCPCS | $12 | facility_fee | Fentanyl citrate injection | |
| 0.640037758 | 636 | Revenue Code | facility_fee | Drugs requiring detailed coding | |
| 0.607576128 | 402 | Revenue Code | facility_fee | Ultrasound imaging | |
| 0.554574695 | 360 | Revenue Code | facility_fee | OR services | |
| 0.420637695 | 310 | Revenue Code | facility_fee | Laboratory Pathology | |
| 0.359367898 | 312 | Revenue Code | optional_fee | Laboratory Histology | |
| 0.309180855 | 250 | Revenue Code | ancillary_service | Pharmacy | |
| 710 | Revenue Code | ancillary_service | Recovery Room |
Captured Spending (N=40,000)
| Decile | Base Fee (Facility + Professional) | Base Fee + Optional Fees |
| 1 | 2% | |
| 2 | 0% | |
| 3 | 1% | |
| 4 | 1% | |
| 5 | 1% | |
| 6 | 2% | |
| 7 | 4% | |
| 8 | 8% | |
| 9 | 9% | |
| 10 | 70% |
Our Work > Good Faith Estimates > Prostate Biopsy