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 A9155 By Report N A9274 By Report N A9276 By Report N A9277 By Report N A9278 By Report N A9283 By Report N A9284 Packaged N A9500 Packaged N A9501 Packaged N A9502 Packaged N A9503 Packaged N A9504 Packaged N A9505 Packaged N A9507 Packaged N A9508 Packaged N A9509 Packaged N A9510 Packaged N A9512 Packaged N A9516 Packaged N A9517 $16.51 N A9521 Packaged N A9524 Packaged N A9526 Packaged N A9527 $35.35 N A9528 Packaged N A9529 Packaged N A9530 $11.02 N A9531 Packaged N A9532 Packaged N A9536 Packaged N A9537 Packaged N A9538 Packaged N A9539 Packaged N A9540 Packaged N A9541 Packaged N A9542 Packaged N A9543 $30,110.81 N A9544 Packaged N Procedure Code Allowed Amount Multiple Procedure Discounting A9545 $22,693.52 N A9546 Packaged N A9547 Packaged N A9548 Packaged N A9550 Packaged N A9551 Packaged N A9552 Packaged N A9553 Packaged N A9554 Packaged N A9555 Packaged N A9556 Packaged N A9557 Packaged N A9558 Packaged N A9559 Packaged N A9560 Packaged N A9561 Packaged N A9562 Packaged N A9563 $196.49 N A9564 $113.44 N A9566 Packaged N A9567 Packaged N A9568 Packaged N A9569 Packaged N A9570 Packaged N A9571 Packaged N A9572 Packaged N A9576 Packaged N A9577 Packaged N A9578 Packaged N A9579 Packaged N A9580 Packaged N A9581 $13.50 N A9582 $2,284.77 N A9583 $12.89 N A9600 $778.98 N A9604 $5,504.70 N A9698 Packaged N A9699 Packaged N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 78
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 C1300 $99.77 N C1713 Packaged N C1714 Packaged N C1715 Packaged N C1716 $39.94 N C1717 $215.67 N C1719 $59.67 N C1721 Packaged N C1722 Packaged N C1724 Packaged N C1725 Packaged N C1726 Packaged N C1727 Packaged N C1728 Packaged N C1729 Packaged N C1730 Packaged N C1731 Packaged N C1732 Packaged N C1733 Packaged N C1750 Packaged N C1751 Packaged N C1752 Packaged N C1753 Packaged N C1754 Packaged N C1755 Packaged N C1756 Packaged N C1757 Packaged N C1758 Packaged N C1759 Packaged N C1760 Packaged N C1762 Packaged N C1763 Packaged N C1764 Packaged N C1765 Packaged N C1766 Packaged N C1767 Packaged N C1768 Packaged N C1769 Packaged N Procedure Code Allowed Amount Multiple Procedure Discounting C1770 Packaged N C1771 Packaged N C1772 Packaged N C1773 Packaged N C1776 Packaged N C1777 Packaged N C1778 Packaged N C1779 Packaged N C1780 Packaged N C1781 Packaged N C1782 Packaged N C1783 Packaged N C1784 Packaged N C1785 Packaged N C1786 Packaged N C1787 Packaged N C1788 Packaged N C1789 Packaged N C1813 Packaged N C1814 Packaged N C1815 Packaged N C1816 Packaged N C1817 Packaged N C1818 Packaged N C1819 Packaged N C1820 Packaged N C1821 Packaged N C1874 Packaged N C1875 Packaged N C1876 Packaged N C1877 Packaged N C1878 Packaged N C1879 Packaged N C1880 Packaged N C1881 Packaged N C1882 Packaged N C1883 Packaged N C1884 Packaged N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 79
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