Ambulatory Surgery Center Fee Schedule - Washington Department ...

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DOC ASC Fee Schedule Effective Dates of Service 7/1/2012 thru 8/31/2012 Refer to the 2012 CPT® and HCPCS coding books for complete code descriptions Procedure Code Allowed Amount Multiple Procedure Discounting 21296 $1,568.46 Y 21299 $72.39 Y 21310 $72.39 Y 21315 $1,079.91 Y 21320 $1,079.91 Y 21325 $1,568.46 Y 21330 $1,568.46 Y 21335 $1,568.46 Y 21336 $1,623.81 Y 21337 $1,079.91 Y 21338 $1,568.46 Y 21339 $1,568.46 Y 21340 $2,700.59 Y 21345 $1,568.46 Y 21355 $2,700.59 Y 21356 $1,568.46 Y 21360 $1,568.46 Y 21365 $2,700.59 Y 21385 $2,700.59 Y 21390 $2,700.59 Y 21400 $478.74 Y 21401 $1,079.91 Y 21406 $2,700.59 Y 21407 $2,700.59 Y 21408 $2,700.59 Y 21421 $1,568.46 Y 21440 $1,568.46 Y 21445 $1,568.46 Y 21450 $215.19 Y 21451 $478.74 Y 21452 $1,079.91 Y 21453 $2,700.59 Y 21454 $1,568.46 Y 21461 $2,700.59 Y 21462 $2,700.59 Y 21465 $2,700.59 Y 21470 $2,700.59 Y 21480 $72.39 Y Procedure Code Allowed Amount Multiple Procedure Discounting 21485 $1,079.91 Y 21490 $2,700.59 Y 21495 $1,079.91 Y 21497 $1,079.91 Y 21499 $72.39 Y 21501 $1,219.29 Y 21502 $1,383.19 Y 21550 $1,099.36 Y 21552 $1,469.46 Y 21554 $1,469.46 Y 21555 $1,099.36 Y 21556 $1,469.46 Y 21557 $1,099.36 Y 21558 $1,469.46 Y 21600 $1,996.21 Y 21610 $1,996.21 Y 21685 $478.74 Y 21700 $1,383.19 Y 21720 $1,383.19 Y 21725 $91.46 Y 21742 $2,926.52 Y 21743 $2,926.52 Y 21800 $104.15 Y 21805 $1,623.81 Y 21820 $104.15 Y 21899 $72.39 Y 21920 $515.38 Y 21925 $1,469.46 Y 21930 $1,099.36 Y 21931 $1,469.46 Y 21932 $1,099.36 Y 21933 $1,469.46 Y 21935 $1,099.36 Y 21936 $1,469.46 Y 22100 $3,092.83 Y 22101 $3,092.83 Y 22102 $3,092.83 Y 22103 $3,092.83 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 14
DOC ASC Fee Schedule Effective Dates of Service 7/1/2012 thru 8/31/2012 Refer to the 2012 CPT® and HCPCS coding books for complete code descriptions Procedure Code Allowed Amount Multiple Procedure Discounting 22206 $3,314.30 Y 22207 $3,271.40 Y 22208 $833.80 Y 22222 $3,092.83 Y 22305 $104.15 Y 22310 $301.24 Y 22315 $1,155.83 Y 22505 $960.81 Y 22520 $1,996.21 Y 22521 $1,996.21 Y 22522 $1,996.21 Y 22554 $3,092.83 Y 22585 $3,092.83 Y 22612 $3,092.83 Y 22614 $3,092.83 Y 22845 $3,092.83 Y 22846 $3,092.83 Y 22851 $1,383.19 Y 22856 By Report N 22861 By Report N 22864 By Report N 22899 $1,383.19 Y 22900 $1,469.46 Y 22901 $1,469.46 Y 22902 $1,099.36 Y 22903 $1,469.46 Y 22904 $1,099.36 Y 22905 $1,469.46 Y 22999 $1,383.19 Y 23000 $1,099.36 Y 23020 $2,926.52 Y 23030 $1,219.29 Y 23031 $1,219.29 Y 23035 $1,383.19 Y 23040 $1,996.21 Y 23044 $1,996.21 Y 23065 $515.38 Y 23066 $1,469.46 Y Procedure Code Allowed Amount Multiple Procedure Discounting 23071 $1,469.46 Y 23073 $1,469.46 Y 23075 $1,099.36 Y 23076 $1,099.36 Y 23077 $1,099.36 Y 23078 $1,469.46 Y 23100 $1,383.19 Y 23101 $1,996.21 Y 23105 $1,996.21 Y 23106 $1,996.21 Y 23107 $1,996.21 Y 23120 $1,996.21 Y 23125 $1,996.21 Y 23130 $2,926.52 Y 23140 $1,383.19 Y 23145 $1,996.21 Y 23146 $1,996.21 Y 23150 $1,996.21 Y 23155 $1,996.21 Y 23156 $1,996.21 Y 23170 $1,996.21 Y 23172 $1,996.21 Y 23174 $1,996.21 Y 23180 $1,996.21 Y 23182 $1,996.21 Y 23184 $1,996.21 Y 23190 $1,996.21 Y 23195 $1,996.21 Y 23330 $515.38 Y 23331 $1,469.46 Y 23350 Packaged N 23395 $2,926.52 Y 23397 $5,569.99 Y 23400 $1,996.21 Y 23405 $1,996.21 Y 23406 $1,996.21 Y 23410 $2,926.52 Y 23412 $2,926.52 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 15
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