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 51725 $189.83 Y 51726 $189.83 Y 51727 $189.83 Y 51728 $189.83 Y 51729 $189.83 Y 51736 $68.85 Y 51741 $68.85 Y 51784 $68.85 Y 51785 $126.88 Y 51792 $68.85 Y 51797 $126.88 Y 51798 $42.05 N 51880 $1,603.56 Y 51990 $2,942.95 Y 51992 $2,942.95 Y 51999 $2,390.93 Y 52000 $448.24 Y 52001 $1,070.27 Y 52005 $1,603.56 Y 52007 $1,603.56 Y 52010 $448.24 Y 52204 $1,603.56 Y 52214 $1,603.56 Y 52224 $1,603.56 Y 52234 $1,603.56 Y 52235 $1,603.56 Y 52240 $1,603.56 Y 52250 $1,603.56 Y 52260 $1,070.27 Y 52265 $448.24 Y 52270 $1,070.27 Y 52275 $1,603.56 Y 52276 $1,603.56 Y 52277 $1,603.56 Y 52281 $1,070.27 Y 52282 $2,274.50 Y 52283 $1,603.56 Y 52285 $1,070.27 Y Procedure Code Allowed Amount Multiple Procedure Discounting 52290 $1,603.56 Y 52300 $1,603.56 Y 52301 $1,603.56 Y 52305 $1,603.56 Y 52310 $1,070.27 Y 52315 $1,603.56 Y 52317 $1,603.56 Y 52318 $1,603.56 Y 52320 $1,603.56 Y 52325 $1,603.56 Y 52327 $2,274.50 Y 52330 $1,603.56 Y 52332 $1,603.56 Y 52334 $1,603.56 Y 52341 $1,603.56 Y 52342 $1,603.56 Y 52343 $1,603.56 Y 52344 $1,603.56 Y 52345 $1,603.56 Y 52346 $1,603.56 Y 52351 $1,603.56 Y 52352 $1,603.56 Y 52353 $2,274.50 Y 52354 $1,603.56 Y 52355 $1,603.56 Y 52400 $1,603.56 Y 52402 $1,603.56 Y 52450 $1,603.56 Y 52500 $1,603.56 Y 52601 $2,274.50 Y 52630 $2,274.50 Y 52640 $1,603.56 Y 52647 $2,932.90 Y 52648 $2,932.90 Y 52649 $2,932.90 Y 52700 $1,603.56 Y 53000 $1,277.79 Y 53010 $1,277.79 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 44
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 53020 $1,277.79 Y 53025 $1,277.79 Y 53040 $1,277.79 Y 53060 $1,277.79 Y 53080 $1,277.79 Y 53085 $1,277.79 Y 53200 $1,277.79 Y 53210 $1,971.41 Y 53215 $1,277.79 Y 53220 $1,971.41 Y 53230 $1,971.41 Y 53235 $1,277.79 Y 53240 $1,971.41 Y 53250 $1,277.79 Y 53260 $1,277.79 Y 53265 $1,277.79 Y 53270 $1,277.79 Y 53275 $1,277.79 Y 53400 $1,971.41 Y 53405 $1,971.41 Y 53410 $1,971.41 Y 53420 $1,971.41 Y 53425 $1,971.41 Y 53430 $1,971.41 Y 53431 $1,971.41 Y 53440 $6,162.77 N 53442 $1,971.41 Y 53444 $6,162.77 N 53445 $10,324.19 N 53446 $1,971.41 Y 53447 $10,324.19 N 53449 $1,971.41 Y 53450 $1,971.41 Y 53460 $1,277.79 Y 53500 $1,971.41 Y 53502 $1,277.79 Y 53505 $1,971.41 Y 53510 $1,277.79 Y Procedure Code Allowed Amount Multiple Procedure Discounting 53515 $1,971.41 Y 53520 $1,971.41 Y 53600 $189.83 Y 53601 $68.85 Y 53605 $1,070.27 Y 53620 $1,258.12 Y 53621 $126.88 Y 53660 $68.85 Y 53661 $68.85 Y 53665 $1,277.79 Y 53850 $2,932.90 Y 53852 $2,932.90 Y 53855 $126.88 Y 53899 $68.85 Y 54000 $1,277.79 Y 54001 $1,277.79 Y 54015 $1,219.29 Y 54050 $55.22 Y 54055 $1,336.09 Y 54056 $55.22 Y 54057 $1,336.09 Y 54060 $1,336.09 Y 54065 $1,336.09 Y 54100 $1,099.36 Y 54105 $1,469.46 Y 54110 $2,191.74 Y 54111 $2,191.74 Y 54112 $2,191.74 Y 54115 $1,219.29 Y 54120 $2,191.74 Y 54150 $1,462.92 Y 54160 $1,462.92 Y 54161 $1,462.92 Y 54162 $1,462.92 Y 54163 $1,462.92 Y 54164 $1,462.92 Y 54200 $126.88 Y 54205 $2,191.74 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 45
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