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 93291 $22.03 N 93292 $35.69 N 93293 $22.03 N 93294 $22.03 N 93295 $35.69 N 93296 $35.69 N 93297 $35.69 N 93298 $22.03 N 93299 $22.03 N 93303 $555.57 N 93304 $420.35 N 93306 $420.35 N 93307 $246.44 N 93308 $246.44 N 93312 $555.57 N 93313 $420.35 N 93314 Packaged N 93315 $555.57 N 93316 $555.57 N 93317 Packaged N 93318 $555.57 N 93320 Packaged N 93321 Packaged N 93325 Packaged N 93350 $420.35 N 93351 $555.57 N 93352 $58.30 N 93501 $2,501.25 Y 93503 $1,121.11 Y 93505 $1,121.11 Y 93508 $2,501.25 Y 93510 $2,501.25 Y 93511 $2,501.25 Y 93514 $2,501.25 Y 93524 $2,501.25 Y 93526 $2,501.25 Y 93527 $2,501.25 Y 93528 $2,501.25 Y Procedure Code Allowed Amount Multiple Procedure Discounting 93529 $2,501.25 Y 93530 $2,501.25 Y 93531 $2,501.25 Y 93532 $2,501.25 Y 93533 $2,501.25 Y 93539 Packaged N 93540 Packaged N 93541 Packaged N 93542 Packaged N 93543 Packaged N 93544 Packaged N 93545 Packaged N 93555 Packaged N 93556 Packaged N 93561 Packaged N 93562 Packaged N 93571 Packaged N 93572 Packaged N 93580 $9,259.40 Y 93581 $9,259.40 Y 93600 $679.25 N 93602 $679.25 N 93603 $679.25 N 93609 Packaged N 93610 $679.25 N 93612 $679.25 N 93613 Packaged N 93615 $679.25 N 93616 $679.25 N 93618 $679.25 N 93621 Packaged N 93622 Packaged N 93623 Packaged N 93624 $3,291.54 Y 93631 Packaged N 93640 Packaged N 93641 Packaged N 93642 $679.25 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 72
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 93660 $274.60 N 93662 Packaged N 93701 $24.75 N 93721 $53.37 N 93724 $22.03 N 93740 $53.37 N 93745 $35.69 N 93750 $100.53 N 93770 Packaged N 93786 $61.87 N 93788 $61.87 N 93797 $35.76 N 93798 $35.76 N 93799 $61.87 N 93875 $101.00 N 93880 $144.54 N 93882 $144.54 N 93886 $144.54 N 93888 $58.22 N 93890 $90.69 N 93892 $90.69 N 93893 $90.69 N 93922 $61.87 N 93923 $101.00 N 93924 $101.00 N 93925 $144.54 N 93926 $90.69 N 93930 $144.54 N 93931 $90.69 N 93965 $101.00 N 93970 $144.54 N 93971 $90.69 N 93975 $144.54 N 93976 $144.54 N 93978 $144.54 N 93979 $90.69 N 93980 $144.54 N 93981 $144.54 N Procedure Code Allowed Amount Multiple Procedure Discounting 93982 $61.87 N 93990 $90.69 N 94002 $193.92 N 94003 $193.92 N 94010 $53.37 N 94011 $53.37 N 94012 $53.37 N 94013 $164.79 N 94014 $37.50 N 94015 $37.50 N 94060 $88.85 N 94070 $164.79 N 94150 $37.50 N 94200 $37.50 N 94240 $53.37 N 94250 $53.37 N 94260 $53.37 N 94350 $53.37 N 94360 $37.50 N 94370 $14.58 N 94375 $53.37 N 94400 $37.50 N 94450 $53.37 N 94452 $53.37 N 94453 $53.37 N 94610 $25.50 N 94620 $53.37 N 94621 $164.79 N 94640 $25.50 N 94642 $88.85 N 94644 $42.05 N 94645 $42.05 N 94660 $88.85 N 94662 $193.92 N 94664 $25.50 N 94667 $25.50 N 94668 $25.50 N 94680 $164.79 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 73
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