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Cosmetic Dermatology - 2014
Welcome to the Cosmetic Dermatology department at Kaiser Permanente Colorado. Listed below are
the cosmetic procedures offered. As discussed during your visit, you are financially responsible for the
cost of the procedures to be performed. The procedures are elective and are not covered by your
benefits. Prices are subject to change.
Member Name: _____________________________
Date of Visit: _______________
Date of Next Visit: _______________________
Your provider will indicate which service(s) you are recommended to receive in advance of your next appointment from the list below.

Code
900133
Cost
$40
Description
Cosmetic Consultation
Blue Light
900174
$250
Blue Light
900175
$400
$200
Blue Light with Levulan
Additional sticks of Levulan
900___
Chemical Peel
900153
900154
900155
$450
$300
$150
Facial Epidermal Peel TCA, Deep
Facial Epidermal Peel TCA, Medium
Facial Epidermal Peel, Salicylic Acid
900156
900791
900797
$175
$400
$300
900087
$250
900088
$300
17110
$128.62
17111
$192.93
900856
$125
Facial Epidermal Peel, Jessner
Chemical Peel, Salicylic package of 4
Microlaser Peels per Site per Session
Destruction of Lesion
Laser Rosacea (face only)
Destruction Cutaneous Vascular Proliferative Lesion (e.g. laser technique);
10 - 50 sq. cm
Laser Rosacea (face and neck)
Destruction Cutaneous Vascular Proliferative Lesion (e.g. laser technique);
over 50 sq. cm
Destruction Benign Lesion Not Skin Tags, Cutaneous Vascular Proliferative Lesion;
up to 14 lesions
Destruction Benign Lesion Not Skin Tags, Cutaneous Vascular Proliferative Lesion;
15 or more lesions
Laser Rosacea (partial face or neck)
Destruction Cutaneous Vascular Proliferative Lesion (e.g. laser technique) < 10 sq. cm
Excision of Benign Lesion
11400
11401
$229.67
$275.96
11402
11403
11420
11421
11422
$306.55
$352.92
$227.78
$291.24
$323.66
Excision Benign Lesion Margin No Skin Tag Trunk Arm/Leg; 0.5 cm/< , [3]
Excision Benign Lesion Margin No Skin Tag Trunk Arm/Leg; 0.6-1.0 cm, [3]
Excision Benign Lesion Margin No Skin Tag Trunk Arm/Leg; 1.1-2.0 cm, [3]
Excision Benign Lesion Margin No Skin Tag Trunk Arm/Leg; 2.1-3.0 cm, [3]
Excision Benign Lesion Margin Scalp, Neck, Hand, Foot, Genital; 0.5 cm/<, [3]
Excision Benign Lesion Margin Scalp, Neck, Hand, Foot, Genital; 0.6-1.0 cm, [3]
Excision Benign Lesion Margin Scalp, Neck, Hand, Foot, Genital; 1.1-2.0 cm, [3]
Excision Benign Lesion Margin Skin Tag Face, Ear, Eye, Neck, Lip, Mucous Membrane;
11440
$251.59 0.5 cm/<, [3]
Excision Benign Lesion Margin Skin Tag Face, Ear, Eye, Neck, Lip, Mucous Membrane;
11441
$310.87 0.6-1.0 cm, [3]
$346.92 Excision Benign Lesion Margin Skin Tag Face, Ear, Eye, Neck, Lip, Mucous Membrane;
11442
(323.66) 1.1-2.0 cm, [3]
*** List Continues on next page(s)***
Please note: For questions about costs related to these procedures, please call 303-850-2115, weekdays, 8:30 a.m. to 5 p.m. For questions
about costs related to care you receive at a Kaiser Permanente medical office, or to inquire about payment options, please call Financial
Counseling at 303-338-3025 (TTY: 1-800-659-2656), weekdays, 8 a.m. to 6 p.m.
1 of 4
Last updated 01/2014
Cosmetic Dermatology -2014
Welcome to the Cosmetic Dermatology department at Kaiser Permanente Colorado. Listed below are
the cosmetic procedures offered. As discussed during your visit, you are financially responsible for the
cost of the procedures to be performed. The procedures are elective and are not covered by your
benefits. Prices are subject to change.
Your provider will indicate which service(s) you are recommended to receive in advance of your next appointment from the list below.

Code
Cost
Description
Ear Lobe Repair
12011
$203.69
Simple Ear Lobe Repair
12031
$441.31
12032
12041
12051
$563.88
$448.10
$478.68
Layered Closure Wounds Scalp, Axillae, Trunk, Extremities (ex: hands, feet); 2.5 cm/<
Layered Closure Wounds Scalp, Axillae, Trunk, Extremities (Ex Hands, Feet); 2.6 To 7.5
cm
Layered Closure Wounds Neck, Hands, Feet, External Genitalia; 2.5 cm/<
Layered Closure Wounds Face, Ears, Eyelids, Nose, Lips, Mucous Membrane; 2.5 cm/<
Injection
J0585
$10/unit
BOTOX
900121
900625
900626
900694
900695
900696
$499
$399
$299
$549
$449
$349
Juvederm Ultra, 1st Syringe
Juvederm Ultra, 2nd Syringe
Juvederm Ultra, 3rd Syringe
Juvederm Ultra Plus, 1st Syringe
Juvederm Ultra Plus, 2nd Syringe
Juvederm Ultra Plus, 3rd Syringe
Layered Closures
Intense Pulsed Light
900881
900882
900883
900884
900886
$225
$350
$300
$350
$325
Intense Pulsed Light Treatment (IPL), Arms (Elbow Down)
Intense Pulsed Light Treatment (IPL), Arms (Full)
Intense Pulsed Light Treatment (IPL), Face
Intense Pulsed Light Treatment (IPL), Face & Neck
Intense Pulsed Light Treatment (IPL), Face & Hands
900887
900888
900890
$400
$350
$250
Intense Pulsed Light Treatment (IPL), Face, Neck & Chest
Intense Pulsed Light Treatment (IPL), Chest
Intense Pulsed Light Treatment (IPL), Hands
Laser
900164
900166
$2,500
$1,000
Laser, Ablative Resurfacing, Full Face Laser Ablative Resurfacing, Lips
900167
$1,000
Laser, Ablative Resurfacing, Eyes
900794
$10/min
$100
Hair Removal by Laser, per Minute
Laser Hair Removal Areola (1 treatment)
*** List Continues on next page(s)***
Please note: For questions about costs related to these procedures, please call 303-850-2115, weekdays, 8:30 a.m. to 5 p.m. For questions
about costs related to care you receive at a Kaiser Permanente medical office, or to inquire about payment options, please call Financial
Counseling at 303-338-3025 (TTY: 1-800-659-2656), weekdays, 8 a.m. to 6 p.m.
2 of 4
Last updated 01/2014
Cosmetic Dermatology -2014
Welcome to the Cosmetic Dermatology department at Kaiser Permanente Colorado. Listed below are
the cosmetic procedures offered. As discussed during your visit, you are financially responsible for the
cost of the procedures to be performed. The procedures are elective and are not covered by your
benefits. Prices are subject to change.
Your provider will indicate which service(s) you are recommended to receive in advance of your next appointment from the list below.

Code
900681
900682
Cost
Description
$80
$130
$250
$100
Laser Hair Removal Brows (between) (1 treatment)
Laser Hair Removal Cheeks (1 treatment)
Laser Hair Removal Chin and Neck (1 treatment)
Laser Hair Removal Chin (1 treatment)
$100
$350
$200
$80
$100
$130
Laser Hair Removal Ears (1 treatment)
Laser Hair Removal Face (full) (1 treatment)
Laser Hair Removal Face (half) (1 treatment)
Laser Hair Removal Fingers (1 treatment)
Laser Hair Removal Hands (1 treatment)
Laser Hair Removal Jawline (1 treatment)
$100
$200
$200
$150
$130
$130
Laser Hair Removal Lip (upper) (1 treatment)
Laser Hair Removal Neck (back) (1 treatment)
Laser Hair Removal Neck (front) (1 treatment)
Laser Hair Removal Peri-oral (1 treatment )
Laser Hair Removal Sideburns (1 treatment prepay)
Laser Hair Removal Under Arms (1 treatment)
Milia Removal
$230
$45
Milia Removal; 15 /<
Milia Removal; Over 15
Shaving of Benign Lesions
11300
11301
$181.80
$222.85
Shave Epidermis/Dermis 1 Lesion Trunk Arms/Legs; 0.5 cm/<
Shave Epidermis/Dermis 1 Lesion Trunk Arms/Legs; 0.6-1.0 cm
11302
11303
11305
11306
$262.91
$289.14
$181.91
$224.80
Shave Epidermis/Dermis 1 Lesion Trunk Arms/Legs; 1.1-2.0 cm
Shave Epidermis/Dermis 1 Lesion Trunk Arms/Legs; Over 2.0 cm
Shave 1 Lesion Scalp, Neck, Hand, Foot, Genital; 0.5 cm/<
Shave 1 Lesion Scalp, Neck, Hand, Foot, Genital; 0.6 To 1.0 cm
*** List Continues on next page(s)***
Please note: For questions about costs related to these procedures, please call 303-850-2115, weekdays, 8:30 a.m. to 5 p.m. For questions
about costs related to care you receive at a Kaiser Permanente medical office, or to inquire about payment options, please call Financial
Counseling at 303-338-3025 (TTY: 1-800-659-2656), weekdays, 8 a.m. to 6 p.m.
3 of 4
Last updated 01/2014
VisitingCosmetic
Cosmetic Dermatology
– Arapahoe-2014
Medical Office
Dermatology
Welcome to the Cosmetic Dermatology department at Kaiser Permanente Colorado.
Welcome
to the the
Cosmetic
Dermatology
department
Kaiser
Colorado.
Listed
below
are
We have listed
following
fee for service
costs to at
your
visit.Permanente
As discussed
during your
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the
cosmetic
procedures
duringtoyour
visit, you are
financially
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financially
responsible
foroffered.
the costAs
of discussed
the procedures
be performed.
The
procedures
are elective
and
cost
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procedures
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are not
covered
by yourtobenefits.
benefits. Prices are subject to change.
Visiting Cosmetic Dermatology – Arapahoe Medical Office
Your provider will indicate which service(s) you are recommended to receive in advance of your next appointment from the list below.

Code
Cost
Description
11307
$265.87
Shave 1 Lesion Scalp, Neck, Hand, Foot, Genital; 1.1 To 2.0 cm
11308
11310
11311
11312
$281.36
$211.21
$205.25
$298.87
Shave 1 Lesion Scalp, Neck, Hand, Foot, Genital; Over 2.0 cm
Shave 1 Lesion Face, Ears, Eyelid, Nose, Lips; 0.5 cm/<
Shave 1 Lesion Face, Ears, Eyelid, Nose, Lips; 0.6 To 1.0 cm
Shave 1 Lesion Face, Ears, Eyelid, Nose, Lips; 1.1 To 2.0 cm
Pathology
88304
$80.87
Level III Surgical Pathology Gross & Microscopic Exam
88305
$127.16 Level IV Surgical Pathology Gross & Microscopic Exam
Please note: For questions about costs related to these procedures, please call 303-850-2115, weekdays, 8:30 a.m. to 5 p.m. For questions
about costs related to care you receive at a Kaiser Permanente medical office, or to inquire about payment options, please call Financial
Counseling at 303-338-3025 (TTY: 1-800-659-2656), weekdays, 8 a.m. to 6 p.m.
4 of 4
Last updated 01/2014