Payments
Good Faith Estimates - ASC Values
LPC Surgery Center
| LPC SURGERY CENTER | CPT Code Billed | Good Faith Estimate |
|---|---|---|
| Lumbar Epidural Steroid Injection (LESI) | 62323 | 401.48 |
| Cervical Epidural Steroid Injection (CESI) | 62321 | 401.48 |
| Thoracic Epidural Steroid Injection (TESI) | 62321 | 401.48 |
| Lumbar Medial Branch Block (LMBB) | 64493, 64494, 64495 | 651.23 |
| Cervical Medial Branch Block (CMBB) | 64490, 64491, 64492 | 651.23 |
| Thoracic Medial Branch Block (TMBB) | 64490, 64491, 64492 | 651.23 |
| Lumbar Neurotomy (LRFA) | 64635, 64636 | 959.64 |
| Cervical Neurotomy (CRFA) | 64633, 64634 | 817.55 |
| Thoracic Neurotomy (TRFA) | 64633, 64634 | 817.55 |
| Transforaminal Epidural Steroid Injection (TFESI) | 64483, add on code-64484 | 584.41 |
| Sacroiliac Joint Injection | 27096 or G0260 (depending on insurance) | 267.96 |
| Stellate Ganglion Nerve Block | 64510 | 410.39 |
| Occipital Nerve Block | 64405 | 194.03 |
| Ilio-Inguinal/Iliohypogastric Nerve Block | 64425 | 221.2 |
| Other Peripheral Nerve Neurotomy | 64640 | 317.75 |
| Other Peripheral Nerve Block | 64450 | 204.9 |
| Celiac Plexus Block | 64530 | 410.39 |
| Intercostal Nerve Block, Single Level | 64420 | 356.18 |
| Lumbar Sympathetic Block | 64520 | 410.39 |
| Sacroiliac Joint Diagnostic Block | 64451 | 355.88 |
| Sacroiliac Joint Neurotomy | 64625 | 637.13 |
| Genicular Nerve Block | 64454 | 222.76 |
| Genicular Nerve Neurotomy | 64624 | 546.99 |
| Spinal Cord Stimulator Trial-1 lead | 63650 | 3,800.64 |
| Spinal Cord Stimulator Trial-2 lead | 63650 x 2 | 6,551.71 |
| Spinal Cord Stimulator Implant- 2 lead | 63650 x 2, 63685 | 24,110.60 |
| Spinal Cord Stimulator Implant w/Laminectomy | 63685, 63655 | 27,612.56 |
| Peripheral Nerve Stimulator Trial-2 lead | 64555 x 2 | 6345.95 |
| Peripheral Nerve Stimulator Implant- 2 lead | 64555 x 2, 64590 | 16,117.24 |
| Stabilink (Lumbar Spine Fusion) | 22612 or 22867 (depending on insurance) | 9,326.88 |
| Sacroiliac Fusion Joint Surgery | 27279 | 8,594.45 |
Kokomo Ambulatory Surgery Center
| KOKOMO AMBULATORY SURGERY CENTER | CPT Code Billed | Good Faith Estimate |
|---|---|---|
| Lumbar Epidural Steroid Injection (LESI) | 62323 | 441.72 |
| Cervical Epidural Steroid Injection (CESI) | 62321 | 441.72 |
| Thoracic Epidural Steroid Injection (TESI) | 62321 | 441.72 |
| Lumbar Medial Branch Block (LMBB) | 64493, 64494, 64495 | 529.47 |
| Cervical Medial Branch Block (CMBB) | 64490, 64491, 64492 | 529.47 |
| Thoracic Medial Branch Block (TMBB) | 64490, 64491, 64492 | 529.47 |
| Lumbar Neurotomy (LRFA) | 64635, 64636 | 978.8 |
| Cervical Neurotomy (CRFA) | 64633, 64634 | 657.13 |
| Thoracic Neurotomy (TRFA) | 64633, 64634 | 657.13 |
| Transforaminal Epidural Steroid Injection (TFESI) | 64483, add on code-64484 | 529.47 |
| Sacroiliac Joint Injection | 27096 or G0260 (depending on insurance) | 159.34 |
| Stellate Ganglion Nerve Block | 64510 | 292.13 |
| Occipital Nerve Block | 64405 | 240.29 |
| Ilio-Inguinal/Iliohypogastric Nerve Block | 64425 | 330.98 |
| Other Peripheral Nerve Neurotomy | 64640 | 345.62 |
| Other Peripheral Nerve Block | 64450 | 242.24 |
| Celiac Plexus Block | 64530 | 292.13 |
| Intercostal Nerve Block, Single Level | 64420 | 269.59 |
| Lumbar Sympathetic Block | 64520 | 292.13 |
| Sacroiliac Joint Diagnostic Block | 64451 | 164.77 |
| Sacroiliac Joint Neurotomy | 64625 | 369.91 |
| Genicular Nerve Block | 64454 | 170.26 |
| Genicular Nerve Neurotomy | 64624 | 425.59 |
| Spinal Cord Stimulator Trial-1 lead | 63650 | 1,842.38 |
| Spinal Cord Stimulator Trial-2 lead | 63650 x 2 | 3,383.49 |
| Spinal Cord Stimulator Implant- 2 lead | 63650 x 2, 63685 | 11,332.95 |
| Spinal Cord Stimulator Implant w/Laminectomy | 63685, 63655 | 13,597.65 |
| Peripheral Nerve Stimulator Trial-2 lead | 64555 x 2 | 3,085.81 |
| Peripheral Nerve Stimulator Implant- 2 lead | 64555 x 2, 64590 | 8,372.49 |
| Stabilink (Lumbar Spine Fusion) | 22612 or 22867 (depending on insurance) | 8,115.11 |
| Sacroiliac Fusion Joint Surgery | 27279 | 6,012.46 |
