BENEDICTINE HOSPITAL
Legal name: HEALTHALLIANCE HOSPITAL MARYS AVENUE CAMPUS
Published Procedure Prices
| Procedure | CPT | Cash Price | Insurance Range |
|---|---|---|---|
| Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH) | 0003M | $828 | N/A |
| TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15) (eg, thiopurine metabolism) gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15 *3, *4, *5) | 0034U | $767 | N/A |
| Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking-induced conformational conversion, qualitative | 0035U | $890 | N/A |
| Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time | 0042T | N/A | N/A |
| Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) | 0055T | N/A | N/A |
| Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected | 0202U | $685 | N/A |
| Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level | 0213T | $1,733 | N/A |
| Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest | 0263T | $9,118 | N/A |
| Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar | 0275T | $13,902 | N/A |
| Hematology (heparin-induced thrombocytopenia), platelet antibody reactivity by flow cytometry, serum | 0275U | $30 | N/A |
| Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | 0402T | $4,540 | N/A |
| Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children | 0479T | $1,191 | N/A |
| Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure) | 0480T | N/A | N/A |
| Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more | 0671T | $10,041 | N/A |
| Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure) | 10004 | N/A | N/A |
| Fine needle aspiration biopsy, including ultrasound guidance; first lesion | 10005 | $1,369 | N/A |
| Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure) | 10006 | N/A | N/A |
| Fine needle aspiration biopsy, including CT guidance; first lesion | 10009 | $1,369 | N/A |
| Fine needle aspiration biopsy, without imaging guidance; first lesion | 10021 | $778 | N/A |
| Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous | 10030 | $1,369 | N/A |
| Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion | 10035 | $1,369 | N/A |
| Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion (List separately in addition to code for primary procedure) | 10036 | N/A | N/A |
| Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single | 10060 | $387 | N/A |
| Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple | 10061 | $778 | N/A |
| Incision and drainage of pilonidal cyst; simple | 10080 | $1,369 | N/A |
| Incision and drainage of pilonidal cyst; complicated | 10081 | $1,369 | N/A |
| Incision and removal of foreign body, subcutaneous tissues; simple | 10120 | $778 | N/A |
| Incision and removal of foreign body, subcutaneous tissues; complicated | 10121 | $3,153 | N/A |
| Incision and drainage of hematoma, seroma or fluid collection | 10140 | $3,153 | N/A |
| Puncture aspiration of abscess, hematoma, bulla, or cyst | 10160 | $778 | N/A |
Prices shown are published rates from hospital chargemaster files and insurer rate data. Your actual cost depends on your insurance plan, deductible status, and services rendered.