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 C1885 Packaged N C1887 Packaged N C1888 Packaged N C1891 Packaged N C1892 Packaged N C1893 Packaged N C1894 Packaged N C1895 Packaged N C1896 Packaged N C1897 Packaged N C1898 Packaged N C1899 Packaged N C1900 Packaged N C2614 Packaged N C2615 Packaged N C2616 $14,708.09 N C2617 Packaged N C2618 Packaged N C2619 Packaged N C2620 Packaged N C2621 Packaged N C2622 Packaged N C2625 Packaged N C2626 Packaged N C2627 Packaged N C2628 Packaged N C2629 Packaged N C2630 Packaged N C2631 Packaged N C2634 $55.74 N C2635 $26.65 N C2636 $18.05 N C2638 $39.60 N C2639 $33.73 N C2640 $56.26 N C2641 $53.24 N C2642 $102.38 N C2643 $61.60 N Procedure Code Allowed Amount Multiple Procedure Discounting C2698 $39.60 N C2699 $26.65 N C8900 $395.21 N C8901 $325.80 N C8902 $499.07 N C8903 $395.21 N C8904 $325.80 N C8905 $499.07 N C8906 $395.21 N C8907 $325.80 N C8908 $499.07 N C8909 $395.21 N C8910 $325.80 N C8911 $499.07 N C8912 $395.21 N C8913 $325.80 N C8914 $499.07 N C8918 $395.21 N C8919 $325.80 N C8920 $499.07 N C8921 $606.96 N C8922 $606.96 N C8923 $606.96 N C8924 $606.96 N C8925 $606.96 N C8926 $606.96 N C8927 $606.96 N C8928 $606.96 N C8929 $606.96 N C8930 $606.96 N C8957 $205.03 N C9113 Packaged N C9121 $17.87 N C9250 $135.36 N C9254 $0.18 N C9255 $6.71 N C9256 $196.10 N C9257 $1.41 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 80
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 C9352 Packaged N C9353 Packaged N C9354 Packaged N C9355 Packaged N C9356 $26.37 N C9358 $10.64 N C9359 $61.47 N C9360 $11.14 N C9361 $250.53 N C9362 $63.60 N C9363 $28.30 N C9364 $18.09 N C9399 Packaged N C9716 $2,021.94 N C9724 $1,524.90 Y C9725 $337.08 N C9726 $1,555.14 N C9727 $478.74 N C9728 $864.39 N C9898 Packaged N D0150 $648.57 N D0240 $648.57 N D0250 $648.57 N D0260 $648.57 N D0270 $648.57 N D0272 $648.57 N D0274 $648.57 N D0277 $648.57 N D0417 By Report N D0418 By Report N D0460 $648.57 N D1510 $648.57 N D1515 $648.57 N D1520 $648.57 N D1525 $648.57 N D1550 $648.57 N D2999 $648.57 N D3222 By Report N Procedure Code Allowed Amount Multiple Procedure Discounting D3460 $648.57 N D3999 $648.57 N D4260 $648.57 N D4263 $648.57 N D4264 $648.57 N D4268 $648.57 N D4270 $648.57 N D4271 $648.57 N D4273 $648.57 N D4355 $648.57 N D4381 $648.57 N D5911 $648.57 N D5912 $648.57 N D5983 $648.57 N D5984 $648.57 N D5985 $648.57 N D5987 $648.57 N D5991 By Report N D6920 $648.57 N D7111 $648.57 N D7140 $648.57 N D7210 $648.57 N D7220 $648.57 N D7230 $648.57 N D7240 $648.57 N D7241 $648.57 N D7250 $648.57 N D7260 $648.57 N D7261 $648.57 N D7291 $648.57 N D7940 $648.57 N D9110 Packaged N D9230 Packaged N D9248 Packaged N D9630 $648.57 N D9930 $648.57 N D9940 $648.57 N D9950 $648.57 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 81
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