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 49205 $2,391.95 Y 49250 $1,708.06 Y 49320 $2,390.93 Y 49321 $2,390.93 Y 49322 $2,390.93 Y 49323 $2,390.93 Y 49324 $2,390.93 Y 49325 $2,390.93 Y 49326 $2,390.93 Y 49329 $2,390.93 Y 49400 Packaged N 49402 $1,708.06 Y 49411 $864.39 Y 49419 $1,946.37 Y 49420 $1,913.81 Y 49421 $1,913.81 Y 49422 $1,441.39 Y 49423 $961.94 Y 49424 Packaged N 49426 $1,708.06 Y 49427 Packaged N 49429 $1,441.39 Y 49435 $961.94 Y 49436 $961.94 Y 49440 $549.52 Y 49441 $549.52 Y 49442 $886.78 Y 49446 $549.52 Y 49450 $400.49 Y 49451 $400.49 Y 49452 $400.49 Y 49460 $400.49 Y 49465 Packaged N 49491 $2,008.56 Y 49492 $2,008.56 Y 49495 $2,008.56 Y 49496 $2,008.56 Y 49500 $2,008.56 Y Procedure Code Allowed Amount Multiple Procedure Discounting 49501 $2,008.56 Y 49505 $2,008.56 Y 49507 $2,008.56 Y 49520 $2,008.56 Y 49521 $2,008.56 Y 49525 $2,008.56 Y 49540 $2,008.56 Y 49550 $2,008.56 Y 49553 $2,008.56 Y 49555 $2,008.56 Y 49557 $2,008.56 Y 49560 $2,008.56 Y 49561 $2,008.56 Y 49565 $2,008.56 Y 49566 $2,008.56 Y 49568 $2,008.56 Y 49570 $2,008.56 Y 49572 $2,008.56 Y 49580 $2,008.56 Y 49582 $2,008.56 Y 49585 $2,008.56 Y 49587 $2,008.56 Y 49590 $2,008.56 Y 49600 $2,008.56 Y 49650 $2,942.95 Y 49651 $2,942.95 Y 49652 $4,583.95 Y 49653 $4,583.95 Y 49654 $4,583.95 Y 49655 $4,583.95 Y 49656 $4,583.95 Y 49657 $4,583.95 Y 49659 $2,390.93 Y 49999 $1,708.06 Y 50020 $1,603.56 Y 50021 $973.88 Y 50080 $2,932.90 Y 50081 $2,932.90 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 42
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 50200 $607.35 Y 50382 $1,603.56 Y 50384 $1,070.27 Y 50385 $1,603.56 Y 50386 $448.24 Y 50387 $961.94 Y 50389 $448.24 Y 50390 $607.35 Y 50391 $68.85 Y 50392 $1,070.27 Y 50393 $1,603.56 Y 50394 Packaged N 50395 $1,603.56 Y 50396 $126.88 Y 50398 $961.94 Y 50541 $2,390.93 Y 50542 $6,906.48 Y 50543 $2,942.95 Y 50544 $2,390.93 Y 50549 $2,390.93 Y 50551 $448.24 Y 50553 $1,603.56 Y 50555 $448.24 Y 50557 $1,603.56 Y 50561 $1,603.56 Y 50562 $448.24 Y 50570 $448.24 Y 50572 $448.24 Y 50574 $448.24 Y 50575 $2,274.50 Y 50576 $1,070.27 Y 50580 $1,070.27 Y 50590 $2,598.80 Y 50593 $3,227.05 Y 50684 Packaged N 50686 $68.85 Y 50688 $961.94 Y 50690 Packaged N Procedure Code Allowed Amount Multiple Procedure Discounting 50945 $2,942.95 Y 50947 $2,942.95 Y 50948 $2,942.95 Y 50949 $2,390.93 Y 50951 $448.24 Y 50953 $448.24 Y 50955 $1,603.56 Y 50957 $1,603.56 Y 50961 $1,603.56 Y 50970 $448.24 Y 50972 $448.24 Y 50974 $1,070.27 Y 50976 $1,070.27 Y 50980 $1,603.56 Y 51020 $1,603.56 Y 51030 $1,603.56 Y 51040 $1,603.56 Y 51045 $448.24 Y 51050 $1,603.56 Y 51065 $1,603.56 Y 51080 $1,219.29 Y 51100 $126.88 Y 51101 $68.85 Y 51102 $1,258.12 Y 51500 $2,008.56 Y 51520 $1,603.56 Y 51535 $1,603.56 Y 51600 Packaged N 51605 Packaged N 51610 Packaged N 51700 $126.88 Y 51701 $42.05 N 51702 $42.05 N 51703 $68.85 Y 51705 $126.88 Y 51710 $400.49 Y 51715 $1,971.41 Y 51720 $189.83 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 43
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