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 75733 Packaged N 75736 Packaged N 75741 Packaged N 75743 Packaged N 75746 Packaged N 75756 Packaged N 75774 Packaged N 75791 Packaged N 75801 Packaged N 75803 Packaged N 75805 Packaged N 75807 Packaged N 75809 Packaged N 75810 Packaged N 75820 Packaged N 75822 Packaged N 75825 Packaged N 75827 Packaged N 75831 Packaged N 75833 Packaged N 75840 Packaged N 75842 Packaged N 75860 Packaged N 75870 Packaged N 75872 Packaged N 75880 Packaged N 75885 Packaged N 75887 Packaged N 75889 Packaged N 75891 Packaged N 75893 Packaged N 75894 Packaged N 75896 Packaged N 75898 Packaged N 75901 Packaged N 75902 Packaged N 75940 Packaged N 75945 Packaged N Procedure Code Allowed Amount Multiple Procedure Discounting 75946 Packaged N 75960 Packaged N 75961 Packaged N 75962 Packaged N 75964 Packaged N 75966 Packaged N 75968 Packaged N 75970 Packaged N 75978 Packaged N 75980 Packaged N 75982 Packaged N 75984 Packaged N 75989 Packaged N 75992 Packaged N 75993 Packaged N 75994 Packaged N 75995 Packaged N 75996 Packaged N 76000 Packaged N 76001 Packaged N 76010 $41.85 N 76080 Packaged N 76098 $351.92 N 76100 $70.12 N 76101 $195.98 N 76102 $195.98 N 76120 $79.75 N 76125 Packaged N 76150 $41.85 N 76350 Packaged N 76376 Packaged N 76377 Packaged N 76380 $102.36 N 76496 $79.75 N 76497 $102.36 N 76498 $325.80 N 76499 $41.85 N 76506 $58.22 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 62
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 76510 $283.20 Y 76511 $90.69 N 76512 $90.69 N 76513 $90.69 N 76514 $14.58 N 76516 $58.22 N 76519 $90.69 N 76529 $58.22 N 76536 $90.69 N 76604 $58.22 N 76645 $58.22 N 76700 $90.69 N 76705 $90.69 N 76770 $90.69 N 76775 $90.69 N 76776 $90.69 N 76800 $90.69 N 76801 $90.69 N 76802 $58.22 N 76805 $90.69 N 76810 $90.69 N 76811 $144.54 N 76812 $58.22 N 76813 $58.22 N 76814 $58.22 N 76815 $58.22 N 76816 $58.22 N 76817 $58.22 N 76818 $90.69 N 76819 $90.69 N 76820 $58.22 N 76821 $58.22 N 76825 $555.57 N 76826 $420.35 N 76827 $58.22 N 76828 $58.22 N 76830 $90.69 N 76831 $144.54 N Procedure Code Allowed Amount Multiple Procedure Discounting 76856 $90.69 N 76857 $58.22 N 76870 $90.69 N 76872 $90.69 N 76873 $90.69 N 76880 $90.69 N 76885 $58.22 N 76886 $58.22 N 76930 Packaged N 76932 Packaged N 76936 $101.00 N 76937 Packaged N 76940 Packaged N 76941 Packaged N 76942 Packaged N 76945 Packaged N 76946 Packaged N 76948 Packaged N 76950 Packaged N 76965 Packaged N 76970 $58.22 N 76975 Packaged N 76977 $42.05 N 76998 Packaged N 76999 $58.22 N 77001 Packaged N 77002 Packaged N 77003 Packaged N 77011 Packaged N 77012 Packaged N 77013 Packaged N 77014 Packaged N 77021 Packaged N 77022 Packaged N 77031 Packaged N 77032 Packaged N 77053 Packaged N 77054 Packaged N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 63
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