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 42808 $1,568.46 Y 42809 $42.05 N 42810 $1,568.46 Y 42815 $2,700.59 Y 42820 $1,568.46 Y 42821 $1,568.46 Y 42825 $1,568.46 Y 42826 $1,568.46 Y 42830 $1,568.46 Y 42831 $1,568.46 Y 42835 $1,568.46 Y 42836 $1,568.46 Y 42842 $1,568.46 Y 42844 $2,700.59 Y 42860 $1,568.46 Y 42870 $1,568.46 Y 42890 $2,700.59 Y 42892 $2,700.59 Y 42900 $478.74 Y 42950 $1,568.46 Y 42955 $1,568.46 Y 42960 $72.39 Y 42962 $2,700.59 Y 42970 $72.39 Y 42972 $1,079.91 Y 42999 $72.39 Y 43020 $478.74 Y 43030 $1,079.91 Y 43130 $2,700.59 Y 43200 $843.71 Y 43201 $549.52 Y 43202 $843.71 Y 43204 $549.52 Y 43205 $549.52 Y 43215 $549.52 Y 43216 $549.52 Y 43217 $549.52 Y 43219 $1,664.44 Y Procedure Code Allowed Amount Multiple Procedure Discounting 43220 $549.52 Y 43226 $549.52 Y 43227 $549.52 Y 43228 $1,524.90 Y 43231 $549.52 Y 43232 $549.52 Y 43234 $549.52 Y 43235 $843.71 Y 43236 $549.52 Y 43237 $549.52 Y 43238 $549.52 Y 43239 $843.71 Y 43240 $549.52 Y 43241 $549.52 Y 43242 $549.52 Y 43243 $843.71 Y 43244 $549.52 Y 43245 $843.71 Y 43246 $549.52 Y 43247 $843.71 Y 43248 $843.71 Y 43249 $843.71 Y 43250 $843.71 Y 43251 $843.71 Y 43255 $843.71 Y 43256 $1,664.44 Y 43258 $549.52 Y 43259 $549.52 Y 43260 $1,420.65 Y 43261 $1,420.65 Y 43262 $1,420.65 Y 43263 $1,420.65 Y 43264 $1,420.65 Y 43265 $1,420.65 Y 43267 $1,420.65 Y 43268 $1,664.44 Y 43269 $1,664.44 Y 43271 $1,420.65 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 38
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 43272 $1,420.65 Y 43273 $2,181.20 N 43279 $1,762.20 Y 43280 $4,583.95 Y 43281 $2,291.30 Y 43282 $2,576.75 Y 43289 $2,390.93 Y 43450 $575.15 Y 43453 $374.60 Y 43456 $374.60 Y 43458 $549.52 Y 43499 $549.52 Y 43510 $549.52 Y 43600 $549.52 Y 43647 $5,435.85 N 43648 $2,390.93 Y 43651 $4,583.95 Y 43652 $4,583.95 Y 43653 $2,942.95 Y 43659 $2,390.93 Y 43752 $79.75 N 43760 $150.50 Y 43761 $549.52 Y 43775 By Report N 43830 $1,524.90 Y 43831 $549.52 Y 43870 $549.52 Y 43999 $549.52 Y 44100 $549.52 Y 44180 $2,942.95 Y 44186 $2,942.95 Y 44206 $4,583.95 Y 44207 $4,583.95 Y 44208 $4,583.95 Y 44213 $2,390.93 Y 44238 $2,390.93 Y 44312 $1,503.62 Y 44340 $1,503.62 Y Procedure Code Allowed Amount Multiple Procedure Discounting 44360 $950.22 Y 44361 $950.22 Y 44363 $618.89 Y 44364 $618.89 Y 44365 $618.89 Y 44366 $618.89 Y 44369 $618.89 Y 44370 $1,664.44 Y 44372 $618.89 Y 44373 $618.89 Y 44376 $618.89 Y 44377 $950.22 Y 44378 $618.89 Y 44379 $1,664.44 Y 44380 $618.89 Y 44382 $618.89 Y 44383 $1,664.44 Y 44385 $572.07 Y 44386 $878.33 Y 44388 $878.33 Y 44389 $878.33 Y 44390 $572.07 Y 44391 $572.07 Y 44392 $572.07 Y 44393 $572.07 Y 44394 $572.07 Y 44397 $1,664.44 Y 44500 $400.49 Y 44701 Packaged N 44799 $1,708.06 Y 44901 $973.88 Y 44970 $2,942.95 Y 44979 $2,390.93 Y 45000 $886.78 Y 45005 $886.78 Y 45020 $886.78 Y 45100 $1,506.05 Y 45108 $1,506.05 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 39
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