DSC Financial Assistance Policy

Every patient must pay their part of estimated financial liability on or before the day of service. We may request that your deductible and copay amounts are paid on or before your date of surgery. If the patient is unable to pay the liability portion in full, the Doctors Surgery Center (DSC) may offer a short term repayment schedule after a minimum down payment is made. For extended repayment, the patient will need to secure financing with either CareCredit or an outside financial institution.

DSC bills the facility and the surgeon for all procedures separately. Also, pathology and anesthesia are billed independently. You may receive bills from multiple companies. As a courtesy to our patients, DSC will file an insurance claim on behalf of the patient to their insurance provider. Patients must respond to the insurance plan’s requests for any information promptly to minimize claims processing delays.

The following providers render services to patients of DSC and will bill patients separately. Furthermore, patients should contact the practitioner listed below:

• KF Anesthesia, LLC        800-208-6014

• DermaPath                      407-587-4155

• AmeriPath                       407-932-2159

• Saturn Medical Laser    954-540-7075

All patients should contact the health care practitioners who provide services while under care at DSC, and they should request a personalized estimate, billing practices and participation with the patient’s insurance provider or health maintenance organization (HMO) as the practitioners may not participate with the same health insurers or HMO as the center.

• KF Anesthesia, LLC        800-208-6014

• DermaPath                      407-587-4155

• AmeriPath                       407-932-2159

• Saturn Medical Laser    954-540-7075

Personalized Estimate from DSC

All prospective patients and all patients have the right to request a personalized estimate for all procedures performed at Doctors Surgery Center.

Note to all patients and prospective patients: the service bundle information is a non-personalized estimate of costs that may be incurred by the patient for anticipated services. The actual costs will be based on services actually provided to the patient.

Code	Description	Old Price	New Price	Allowable
20005	I&D Soft Tissue Abscess	$843.00		$516.33
20680	Removal of Implant; Deep	$1,200.00		$1,010.80
20912	Cartilage Graft Nasal Septum	$1,428.00		$1,342.90
21026	Excision of Facial Bone	$2,300.00		$2,037.71
21029	Removal Benign Tumor Face Bone	$1,174.00		$905.62
21138	Forhead Appl of Prosth bone	$2,235.00		$2,037.71
21208	Osteoplasty Facial Bones	$2,250.00		$2,037.71
21210	Graft Bone; Nasal/Maxilla/Mal	$2,563.00		$2,037.71
21280	MEDIAL CANTHOPEXY SEPARATE PROCEDURE	$1,100.00		$905.62
21282	LATERAL CANTHOPEXY	$987.00		$905.62
21320	Closed Txmt Nasal Frac/Stabliz	$987.00		$905.62
21337	Closed Txmt of Nasal Fracture	$987.00		$905.62
21340	Canthal Ligament Nasolacrimal	$2,250.00		$905.62
21356	Open Treatment of Zygomatic	$2,300.00		$2,037.71
21360	Open Treatment Depressed Malar	$2,250.00		$2,037.71
21390	OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/ALLPLSTC	$2,194.00		$2,037.71
21555	Exc Tumor Soft Tissue of Neck	$843.00		$516.33
21556	Exc Deep Sunfascial Instramuscu	$1,097.00		$1,010.80
25111	Excision Ganglion Wrist	$1,035.00		$701.51
26115	Excise Tumor/Vasc Hand/Finger	$724.00		$516.33
26160	Excision Gaglion Cyst	$790.00		$701.51

Code		Description	Old Price	New Price	Allowable
64400		Nerve Block/ Trigeminal Nerve	$149.00		$81.83
64402		Nerve Block Facial Nerve	$130.00
64612		CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV	$88.00		$72.25

Code		Description	Old Price	New Price	Allowable
10060		I&D of Abscess	$88.00		$69.51
10061		I&D Abscess Complicated/Multi	$126.00		$107.17
10140		Incision & Drainage	$120.00		$99.64
10180		I & D Complex	$1,200.00		$1,010.80
11000		Biopsy of Skin Single Lesion	$60.00		$31.16
11042		Debridement/Skin/Sub Tissue	$180.00		$153.98
11043		Debridement/Subcutaneous Tissue	$273.00		$241.87
11100		Biopsy of Skin	$83.00		$71.22
11401		EXC B9 LES MRGN XCP SK TG T/A/L 0.6-1.0 CM	$113.00		$95.87
11403		EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3.0 CM/>	$137.00		$114.70
11404		EXC B9 LES MRGN XCP SK TG T/A/L 3.1-4.0 CM	$600.00		$516.33
11406		EXC B9 LES MRGN XCP SK TG T/A/L > 4.0 CM	$843.00		$516.33
11424		EXC B9 LES MRGN XCP SK TG S/N/H/F/G 3.1-4.0CM	$843.00		$516.33
11426		EXC B9 LES MRGN XCP SK TG S/N/H/F/G > 4.0CM	$1,140.00		$1,010.80
11441		EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM	$126.00		$104.43
11442		EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM	$128.00		$114.02
11443		EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM	$152.00		$126.00
11444		EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 3.1-4.0CM	$600.00		$516.33
11446		EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M > 4.0CM	$1,140.00		$1,010.80
11600		EXCISION MAL LESION TRUNK/ARM/LEG 0.5 CM/<	$145.00		$124.97
11622		EXCISION MALIGNANT LESION S/N/H/F/G 1.1-2.0 CM	$180.00		$155.79
11624		EXCISION MALIGNANT LESION S/N/H/F/G 3.1-4.0 CM	$843.00		$516.33
11626		EXCISION MALIGNANT LESION S/N/H/F/G > 4.0 CM	$1,140.00		$1,010.80
11641		EXCISION MALIGNANT LES F/E/E/N/L 0.6-1.0 CM	$174.00		$146.89
11642		EXCISION MALIGNANT LES F/E/E/N/L 1.1-2.0 CM	$191.00		$161.61
11643		EXCISION MALIGNANT LES F/E/E/N/L 2.1-3.0 CM/>	$200.00		$177.02
11644		EXCISION MALIGNANT LES F/E/E/N/L 3.1-4.0 CM	$600.00		$516.33
11646		EXCISION MALIGNANT LESION F/E/E/N/L > 4.0 CM	$1,175.00		$1,010.80
11900		Intralesional Injection Up To 7	$63.00		$0.00
11901		Intralesional Inj Over 7	$81.00		$0.00
12001		Simple Repr Sprfcl Wound 2.5cm	$55.00		$0.00
12004		Simple Repr Sprfcl Wound 7.6cm	$55.00		$0.00
12005		Simple Repr Sprfcl Wound 12.6cm – 20.0cm	$180.00		$153.98
12011		Repair Laceration 25cm or Less	$55.00		$0.00
12013		Repair Laceration 26 to 50cm	$55.00		$0.00
12014		Repair Laceration 51-75cm	$55.00		$0.00
12037		REPAIR INTERMEDIATE S/A/T/E > 30.0 CM	$1,545.00		$777.07
12052		REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-53.0 CM/>	$180.00		$153.98
13121		REPAIR COMPLEX SCALP/ARM/LEG 2.6 CM-7.5 CM	$270.00		$241.87
13132		REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6 CM-7.5 CM	$270.00		$241.87
13151		REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM	$270.00		$241.87
13152		REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM	$270.00		$241.87
13160		Surgical Wound Dehiscence	$1,362.00		$777.07
14000		ADJACENT TISSUE TRANSFER/REARGMT TRUNK 10 CM/<	$860.00		$777.07
14001		ADJNT TIS TRANSFR/REARRANGE TRUNK 10.1-30.0 SQCM	$860.00		$777.07
14020		ADJT TIS TRNSFR/REARGMT SCALP/ARM/LEG 10 SQ CM/<	$860.00		$777.07
14021		ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM	$860.00		$777.07
14040		ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<	$860.00		$777.07
14041		ADJT/REARGMT F/C/C/M/N/AX/G/H/F 10.1-30.0 SQ CM	$860.00		$777.07
14060		ADJT TIS TRNSFR/REARRGMT E/N/E/L DFCT 10 SQ CM/<	$860.00		$777.07
14061		ADJT TIS REARGMT EYE/NOSE/EAR/LIP 10.1-30.0 SQCM	$860.00		$777.07
14301		Adj Tissue Trans 30.1-60cm	$1,600.00		$1,342.90
14302		ADD’lt Adj Tissue Trans 30 sq cm	$1,001.00		$0.00
15002		Wnd Prep 1st 100sq CM or 1%	$898.00		$777.07
15004		Escisional Prep For Graft	$258.00		$241.87
15220		FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 CM/<	$866.00		$777.07
15221		FTH/GFT FR W/DIR CLSR S/A/L EA ADDL 20 CM<	$300.00
15240		FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F 20 CM/<	$885.00		$777.07
15260		FTH/GFT FREE W/DIRECT CLOSURE N/E/E/L 20 SQ CM/<	$860.00		$777.07
15730		MIDFACE FLAP W/PRESERVATION OF VASCULAR PEDICLES	$1,610.00		$1,342.90
15731		FOREHEAD FLAP W/PRESERVATION VASCULAR PEDICLE	$1,610.00		$1,342.90
15732		MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP HEAD&NCK	$1,362.00		$1,288.24
15733		MUSC MYOQ/FSCQ FLAP HEAD&NECK W/NAMED VASC PEDCL	$1,610.00		$1,342.90
15740		FLAP ISLAND PEDICLE	$860.00		$777.07
15760		GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA	$1,362.00		$777.07
15770		GRAFT DERMA-FAT-FASCIA	$1,600.00		$1,342.90
15821		BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD	$1,362.00		$777.07
15823		BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN	$862.00		$777.07
15824		RHYTIDECTOMY FOREHEAD	$1,362.00		$777.07
15825		RHYTIDECTOMY NECK W/PLATYSMAL TIGHTENING	$1,362.00		$1,342.90
15826		RHYTIDECTOMY GLABELLAR FROWN LINES	$898.00		$1,342.90
15828		RHYTIDECTOMY CHEEK CHIN&NECK	$1,300.00		$1,342.90
15850		REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON	$300.00		$241.87
17000		Destruct Benigh/Premalig Les	$88.00
17106		Destruct Cutaneous Vasc Lesion	$224.00		$153.98

Code Description Old Price New Price Allowable 69005 I&D Abscess External Ear Compl $152.00 $121.89 69200 Removal RB Ear Auditory Canal; w/out general anesthesia $39.00 $28.14 69300 Otoplasty Ear Lobes $987.00 $905.62

Code Description Old Price New Price Allowable 40700 Plastic Repair of Lip/Nasal $2,250.00 $2,037.71 42409 Salivary Gland $987.00 $905.62

Code		Description	Old Price	New Price	Allowable
30000		Drainage Hematoma Nasal Intern	$110.00		$88.43
30100		Biopsy Intranasal	$154.00		$97.93
30117		Excision or Destruction intranasal lesion; Internal	$987.00		$905.62
30120		Planing of Skin of Nose	$987.00		$905.62
30130		EXCISION INFERIOR TURBINATE PARTIAL/COMPLETE	$987.00		$905.62
30140		Nose Submucous Resect Turbinate	$987.00		$905.62
30410		Repair Elevation Nasal	$2,250.00		$2,037.71
30465		Repair Nasal Stenosis	$2,250.00		$2,037.71
30620		Septal/Intranasal Dermatoplasty	$2,340.00		$2,037.71
30903		Control Nasal Bleeding/Anterio	$82.00		$52.04
30930		FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC	$987.00		$905.62
30999		Middle Turbinate	$700.00
31000		Lavage By Cannulatio Maxillary	$201.00		$88.43
31020		Accessory Sinuses Maxillary	$987.00		$905.62
31075		Incision Transorbital Lynch	$2,250.00		$2,037.71
31080		Sinus Open W/outo-plasti Flap	$2,250.00		$2,037.71
31205		Ethmoidectomy; Extranasal, Tot	$987.00		$905.62
31231		Nasal Endoscopy	$94.00		$77.83