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 78472 $285.03 N 78473 $285.03 N 78481 $285.03 N 78483 $285.03 N 78491 $1,335.59 N 78492 $1,335.59 N 78494 $285.03 N 78496 Packaged N 78499 $285.03 N 78580 $192.42 N 78584 $301.78 N 78585 $301.78 N 78586 $192.42 N 78587 $192.42 N 78588 $301.78 N 78591 $192.42 N 78593 $192.42 N 78594 $192.42 N 78596 $301.78 N 78599 $192.42 N 78600 $183.34 N 78601 $539.36 N 78605 $183.34 N 78606 $539.36 N 78607 $539.36 N 78608 $966.92 N 78610 $183.34 N 78630 $539.36 N 78635 $539.36 N 78645 $183.34 N 78647 $539.36 N 78650 $539.36 N 78660 $183.34 N 78699 $183.34 N 78700 $302.97 N 78701 $302.97 N 78707 $302.97 N 78708 $302.97 N Procedure Code Allowed Amount Multiple Procedure Discounting 78709 $302.97 N 78710 $302.97 N 78725 $168.49 N 78730 $104.89 N 78740 $302.97 N 78761 $302.97 N 78799 $302.97 N 78800 $270.38 N 78801 $475.76 N 78802 $475.76 N 78803 $475.76 N 78804 $897.67 N 78805 $475.76 N 78806 $475.76 N 78807 $270.38 N 78808 Packaged N 78811 $966.92 N 78812 $966.92 N 78813 $966.92 N 78814 $966.92 N 78815 $966.92 N 78816 $966.92 N 78999 $104.89 N 79005 $203.29 N 79101 $203.29 N 79200 $326.76 N 79300 $203.29 N 79403 $326.76 N 79440 $326.76 N 79445 $203.29 N 79999 $203.29 N 80103 Packaged N 80500 $15.59 N 80502 $9.71 N 85097 $33.31 N 85396 Packaged N 86077 $15.59 N 86078 $33.31 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 66
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 86079 $15.59 N 86485 $5.02 N 86486 $5.02 N 86490 $5.02 N 86510 $5.02 N 86580 $5.02 N 86780 $25.89 N 86825 $106.14 N 86826 $35.38 N 86850 $13.79 N 86860 $23.46 N 86870 $23.46 N 86880 $7.29 N 86885 $7.29 N 86886 $7.29 N 86890 $46.39 N 86891 $13.79 N 86900 $7.29 N 86901 $7.29 N 86903 $13.79 N 86904 $13.79 N 86905 $13.79 N 86906 $13.79 N 86920 $13.79 N 86921 $13.79 N 86922 $23.46 N 86923 $13.79 N 86927 $13.79 N 86930 $46.39 N 86931 $46.39 N 86932 $46.39 N 86945 $13.79 N 86950 $13.79 N 86960 $13.79 N 86965 $23.46 N 86970 $13.79 N 86971 $13.79 N 86972 $13.79 N Procedure Code Allowed Amount Multiple Procedure Discounting 86975 $23.46 N 86976 $13.79 N 86977 $46.39 N 86978 $23.46 N 86985 $13.79 N 86999 $13.79 N 87150 $68.62 N 87153 $225.53 N 87493 $68.62 N 87500 $69.96 N 87809 $23.91 N 87905 $24.35 N 88104 $15.59 N 88106 $15.59 N 88107 $33.31 N 88108 $15.59 N 88112 $33.31 N 88125 $15.59 N 88141 Packaged N 88160 $15.59 N 88161 $15.59 N 88162 $33.31 N 88172 $33.31 N 88173 $33.31 N 88182 $33.31 N 88184 $15.59 N 88185 $15.59 N 88187 $9.71 N 88188 $33.31 N 88189 $33.31 N 88199 $9.71 N 88299 $9.71 N 88300 $15.59 N 88302 $15.59 N 88304 $33.31 N 88305 $33.31 N 88307 $50.44 N 88309 $50.44 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 67
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