New Patient Medical Forms
New patients may click the image below for a printable version of our new patient forms. Please bring the completed packet with you to your first appointment.
Procedure | Performed at Noble Pain Management (Total Cost) | Performed in an Ambulatory Surgery Center (ASC) (Physician Professional Fee and ASC Fee Combined) | Performed in Hospital Outpatient Department (HOPD) Setting (Physician Professional Fee and HOPD Fee Combined) |
---|---|---|---|
Joint Injection eg. Hip, Knee, Shoulder (20610) | $61.92 | $77.04 | $292.56 |
New Patient Visit (99203) | $109.80 | —— | $165.88 |
Sacroiliac Joint Injection (27096) | $163.08 | $369.50 | $629.74 |
Lumbar or Caudal Epidural Steroid Injection with Fluoroscopy (62323) | $250.56 | $385.70 | $645.94 |
Cervical or Thoracic Epidural Steroid Injection with Fluoroscopy (62321) | $253.80 | $393.98 | $654.22 |
Spinal Cord Stimulator Trial (63650) | $1353.23 | $5020.54 | $6481.07 |
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