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SURGICAL PROCEDURES
INTEGUMENTARY SYSTEM
INCISION AND DRAINAGE
SERVICES DESCRIPTION
SURGERY (MARSUPIALIZATION, OPENING OR
REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, $50.00
PUSTULES).
INCISION AND DRAINAGE OF ABSCESS; SIMPLE OR SINGLE.
INCISION AND DRAINAGE OF ABSCESS; COMPLICATED OR $105.00
MULTIPLE.
INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE.
INCISION
BODY, $60.00
SUBCUTANEOUS TISSUES; SIMPLE.
INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR $70.00
FLUID COLLECTION.
PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA OR CYST.
SERVICES DESCRIPTION
BIOPSY SKIN, SUBCUTANEOUS TISSUE AND/ OR MUCOUS $40.00
MEMBRANE, SINGLE LESION.
EACH SEPARATE / ADDITIONAL LESION.
PUNCTURE ASPIRATION OF CYST OF BREAST.
EACH ADDITIONAL CYST OF BREAST.
REMOVAL OF SKIN TAGS
SERVICES DESCRIPTION
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS $38.00
TAGS, ANY AREA; UP TO AND INCLUDING 5 LESIONS.
EACH ADDITIONAL TEN LESSIONS.
SURGICAL PROCEDURES
INTEGUMENTARY SYSTEM
EXCISION OF BENIGN LESIONS
SERVICES DESCRIPTION
EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, ARM
OR LEGS; LESION DIAMETER 1.0 CM OR LESS.
EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, ARM
OR LEGS; LESION DIAMETER 1.1 TO 3.0 CM.
EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, ARM
OR LEGS; LESION DIAMETER OVER 3.1 CM.
EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP,
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.0 CM $75.00
EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP,
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO $165.00
EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP,
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER $185.00
EXCISION, OTHER BENIGN LESION, FACE, EARS, EYELIDS,
NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.0 CM $85.00
EXCISION, OTHER BENIGN LESION, FACE, EARS, EYELIDS,
NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO $130.00
EXCISION, OTHER BENIGN LESION, FACE, EARS, EYELIDS,
NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER $225.00
SURGICAL PROCEDURES
INTEGUMENTARY SYSTEM
EXCISION OF MALIGNANT LESIONS
SERVICES DESCRIPTION
EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; $80.00
LESION DIAMETER 2.0 CM OR LESS.
EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; $170.00
LESION DIAMETER OVER 2.1 CM.
EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, $110.00
FEET, GENITALIA; LESION DIAMETER 2.0 CM OR LESS.
EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, $220.00
FEET, GENITALIA; LESION DIAMETER OVER 2.1 CM.
EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, $135.00
NOSE, LIPS; LESION DIAMETER 2.0 CM OR LESS.
SERVICES DESCRIPTION
TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER.
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO $15.00
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR $22.00
AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE.
EVACUATION OF SUBUNGUAL HEMATOMA.
EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR $55.00
COMPLETE.
SURGICAL PROCEDURES
INTEGUMENTARY SYSTEM
SERVICES DESCRIPTION
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK,
EXTERNAL
GENITALIA,
OR $80.00
EXTREMITIES (7.5 CM OR LESS)
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK,
EXTERNAL
GENITALIA,
OR $150.00
EXTREMITIES (7.6 CM TO 20 CM)
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK,
EXTERNAL
GENITALIA,
OR $220.00
EXTREMITIES (20.1 CM OR MORE)
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,
EYELIDS, NOSE, LIPS, AND / OR MUCOUS MEMBRANES
(5 CM OR LESS)
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS,
EYELIDS, NOSE, LIPS, AND / OR MUCOUS MEMBRANES
(5.1 CM TO 12.5 CM)
SERVICES DESCRIPTION
INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO $30.00
MORE THAN LOCAL TREATMENT IS REQUIRED.
BURN DRESSING AND/ OR DEBRIDEMENT.
DESTRUCTION OF BENIGN OR PREMALIGNANT LESIONS
SERVICES DESCRIPTION
DESTRUCTION BY ANY METHOD ALL BENIGN OR $38.00
PREMALIGNANT LESIONS; UP TO 3 LESIONS.
DESTRUCTION BY ANY METHOD ALL BENIGN OR $8.00
PREMALIGNANT LESIONS; 4TH THROUGH 14 LESIONS
(EACH).

DESTRUCTION BY ANY METHOD OF FLAT WARTS, $40.00
MOLLUSCUM CONTAGIOSUM, OR MILIA; UP TO 14 LESIONS.
CHEMICALCAUTERIZATION OF GRANULATION TISSUE.
SURGICAL PROCEDURES
MUSCULOSKELETAL SYSTEM
INTRODUCTION
SERVICES DESCRIPTION
INJECTION OF CARPAL TUNNEL
INJECTION, TRIGGER POINT
ARTHROCENTESIS,
ASPIRATION
INJECTION; $47.00
SMALL JOINT, BURSA (eg, FINGERS, TOES)
-INTERMEDIATE JOINT BURSA (eg, TEMPOROMANDIBULAR,
ACROMIOCLAVICULAR,
ANKLE, $52.00
OLECRANON BURSA)
- MAJOR JOINT OR BURSA (eg, SHOULDER, HIP, KNEE JOINT, $63.00
SUBACROMIAL BURSA)
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) $51.00
ANY LOCATION

SMALL JOINT
INTERMEDIATE, JOINT
MAJOR JOINT
NERVE BLOCK
SERVICES DESCRIPTION
SINGLE INJECTION, STEROID, CERVICAL, THORACIC
INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL
SINGLE INTERCOSTAL NERVE
MULTIPLE INTERCOSTAL NERVES
GREATER OCCIPITAL NERVE
PARAVERTEBRAL FACET, CERVICAL/THORACIC
PARAVERTEBRAL FACET, CERVICAL MULT
PARAVERTEBRAL FACET, LUMBAR/SACRAL
PARAVERTEBRAL FACET, LUMBAR/SACRAL MULT.
SCIATIC NERVE
OTHER PERIPHERAL NERVE
CUT NERVE
LUMBAR OR SACRAL, SINGLE LEVEL
LUMBAR OR SACRAL, EACH ADD. LEVEL
64491-64494
SECOND LEVEL
64492-64495
THIRD AND ANY ADD. LEVEL
SURGICAL PROCEDURES
SERVICES DESCRIPTION
CENTRAL SKELETON
PERIPHERICAL SKELETON
BODY COMPOSITION ANALYSIS
RADIOLOGICAL GUIDENCE
GUIDANCE (CPT.FACET.51)
INJECTABLE MEDICATIONS / VACCINATIONS
SERVICES DESCRIPTION
INTRAMUSCULAR OR Q INJECTION
INTRAVENOUS INJECTION / IV PUSH
INTRAMUSCULAR INJECTION OF ANTIBIOTIC
VITAMIN B12 UP TO 1000 MG.
DEPO MEDROL 20 MG.
DEPO MEDROL 40 MG.
DEPO MEDROL 80 MG.
SOLU CORTEF 100 MG.
CELESTONE PER 3 MG. (1/2 CC)
CELESTONE PER 4 MG.
METHOTREXATE SODIUM, 50 MG.
REMICADE
SOLGANOL, UP TO 50 MG.
TIGAN UP TO 200 MG.
TORADOL PER 15 MG.
PENICILLIN G BENZATHINE 1,200,000 UNITS
ROCEPHIN PER 250 MG.
BENADRYL 50 MG. / ML
HEP LOCK FLUSH, PER 10 UNITS
HEPARIN SODIUM, PER 1000 UNITS
CYTOXAN 500 MG.
5% DEXTROSE / WATER, 500 MIL. + 1 UNIT
5% DEXTROSE / NACI, 500 MIL. + 1 UNIT
NORMAL SALINE SOLUTION, 250 ML.
STERILE SALINE OR WATER, 5 ML.
LACTATED RINGERS, UP TO 1000 MIL.
SURGICAL PROCEDURES
MUSCULOSKELETAL SYSTEM
UPPER EXTREMITY
SERVICES DESCRIPTION
SHOULDER TO HAND ( LONG ARM )
ELBOW TO FINGER ( SHORT ARM )
HAND AND LOWER FORE ARM (GAUNTLET)
SERVICES DESCRIPTION
SHOULDER TO HAND ( LONG ARM )
FOREARM TO HAND
STRAPPING
SERVICES DESCRIPTION
SHOULDER (eg, VELPEAU).
ELBOW OR WRIST.
HAND OR FINGER.
SERVICES DESCRIPTION
REMOVAL FULL ARM CAST.
SURGICAL PROCEDURES
MUSCULOSKELETAL SYSTEM
LOWER EXTREMITY
SERVICES DESCRIPTION
APPLICATION OF LONG LEG CAST (THIGH TO TOES).
-WALKER OR AMBULATORY TYPE.
APPLICATION OF CYLINDER CAST (THIGH TO ANKLE).
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES). $55.00
-WALKER OR AMBULATORY TYPE.
ADDING WALKER TO PREVIOUSLY APPLIED CAST.
SERVICES DESCRIPTION
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR $45.00
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT).
STRAPPING
SERVICES DESCRIPTION
STRAPPING; KNEE
STRAPPING; ANKLE
STRAPPING; TOES
UNNA BOOT
SERVICES DESCRIPTION
REMOVAL BOOT CAST
REMOVAL FULL LEG CAST.
SURGICAL PROCEDURES
URINARY & GENITAL SYSTEM
MANIPULATION
SERVICES DESCRIPTION
CATHETERIZATION, URETHRA; SIMPLE
DESTRUCTION
SERVICES DESCRIPTION
DESTRUCTION OF LESION(S), PENIS (eg, CONDYLOMA,
PAPILLOMA,
MOLLUSCUM
CONTGIOSUM,
HERPETIC $40.00
VESICLE), SIMPLE; CHEMICAL
- ELECTRODESICCATION
- CRYOSURGERY
- LASER SURGERY
- SURGICAL EXCISION
INTRODUCTION
SERVICES DESCRIPTION
INSERTION OF INTRAUTERINE DEVICE (IUD)
REMOVAL OF INTRAUTERINE DEVICE (IUD)
SURGICAL PROCEDURES
EAR, NOSE & THROAT
INCISION
SERVICES DESCRIPTION
DRAINAGE EXTERNAL EAR, ABSCESS OR HAMATOMA
DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS
EAR PIERCING
SERVICES DESCRIPTION
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY $30.00
CANAL; WITHOUT GENERAL ANESTHESIA
REMOVAL IMPACTED CERUMEN, ONE OR BOTH EARS
REMOVAL FOREIGN BODY, INTRANASAL
ENDOSCOPY
SERVICES DESCRIPTION
LARINGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC
Health Care Provider
Provider Relations Representative
Signature
Signature

Source: http://www.bestcaremedicalplan.com/Proveedores/MINOR%20SURGERY%20FEE%20SCHEDULE.pdf

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