Payments

Good Faith Estimates - ASC Values


LPC Surgery Center
LPC SURGERY CENTERCPT Code BilledGood Faith Estimate
Lumbar Epidural Steroid Injection (LESI)62323401.48
Cervical Epidural Steroid Injection (CESI)62321401.48
Thoracic Epidural Steroid Injection (TESI)62321401.48
Lumbar Medial Branch Block (LMBB)64493, 64494, 64495651.23
Cervical Medial Branch Block (CMBB)64490, 64491, 64492651.23
Thoracic Medial Branch Block (TMBB)64490, 64491, 64492651.23
Lumbar Neurotomy (LRFA)64635, 64636959.64
Cervical Neurotomy (CRFA)64633, 64634817.55
Thoracic Neurotomy (TRFA)64633, 64634817.55
Transforaminal Epidural Steroid Injection (TFESI)64483, add on code-64484584.41
Sacroiliac Joint Injection27096 or G0260 (depending on insurance)267.96
Stellate Ganglion Nerve Block64510410.39
Occipital Nerve Block64405194.03
Ilio-Inguinal/Iliohypogastric Nerve Block64425221.2
Other Peripheral Nerve Neurotomy64640317.75
Other Peripheral Nerve Block64450204.9
Celiac Plexus Block64530410.39
Intercostal Nerve Block, Single Level64420356.18
Lumbar Sympathetic Block64520410.39
Sacroiliac Joint Diagnostic Block64451355.88
Sacroiliac Joint Neurotomy64625637.13
Genicular Nerve Block64454222.76
Genicular Nerve Neurotomy64624546.99
Spinal Cord Stimulator Trial-1 lead636503,800.64
Spinal Cord Stimulator Trial-2 lead63650 x 26,551.71
Spinal Cord Stimulator Implant- 2 lead63650 x 2, 6368524,110.60
Spinal Cord Stimulator Implant w/Laminectomy63685, 6365527,612.56
Peripheral Nerve Stimulator Trial-2 lead64555 x 26345.95
Peripheral Nerve Stimulator Implant- 2 lead64555 x 2, 6459016,117.24
Stabilink (Lumbar Spine Fusion)22612 or 22867 (depending on insurance)9,326.88
Sacroiliac Fusion Joint Surgery272798,594.45
Kokomo Ambulatory Surgery Center
KOKOMO AMBULATORY SURGERY CENTERCPT Code BilledGood Faith Estimate
Lumbar Epidural Steroid Injection (LESI)62323441.72
Cervical Epidural Steroid Injection (CESI)62321441.72
Thoracic Epidural Steroid Injection (TESI)62321441.72
Lumbar Medial Branch Block (LMBB)64493, 64494, 64495529.47
Cervical Medial Branch Block (CMBB)64490, 64491, 64492529.47
Thoracic Medial Branch Block (TMBB)64490, 64491, 64492529.47
Lumbar Neurotomy (LRFA)64635, 64636978.8
Cervical Neurotomy (CRFA)64633, 64634657.13
Thoracic Neurotomy (TRFA)64633, 64634657.13
Transforaminal Epidural Steroid Injection (TFESI)64483, add on code-64484529.47
Sacroiliac Joint Injection27096 or G0260 (depending on insurance)159.34
Stellate Ganglion Nerve Block64510292.13
Occipital Nerve Block64405240.29
Ilio-Inguinal/Iliohypogastric Nerve Block64425330.98
Other Peripheral Nerve Neurotomy64640345.62
Other Peripheral Nerve Block64450242.24
Celiac Plexus Block64530292.13
Intercostal Nerve Block, Single Level64420269.59
Lumbar Sympathetic Block64520292.13
Sacroiliac Joint Diagnostic Block64451164.77
Sacroiliac Joint Neurotomy64625369.91
Genicular Nerve Block64454170.26
Genicular Nerve Neurotomy64624425.59
Spinal Cord Stimulator Trial-1 lead636501,842.38
Spinal Cord Stimulator Trial-2 lead63650 x 23,383.49
Spinal Cord Stimulator Implant- 2 lead63650 x 2, 6368511,332.95
Spinal Cord Stimulator Implant w/Laminectomy63685, 6365513,597.65
Peripheral Nerve Stimulator Trial-2 lead64555 x 23,085.81
Peripheral Nerve Stimulator Implant- 2 lead64555 x 2, 645908,372.49
Stabilink (Lumbar Spine Fusion)22612 or 22867 (depending on insurance)8,115.11
Sacroiliac Fusion Joint Surgery272796,012.46
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