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 D9951 $648.57 N D9952 $648.57 N E0328 By Report N E0329 By Report N E0433 By Report N E0445 By Report N E0487 Packaged N E0603 Packaged N E0616 Packaged N E0656 By Report N E0657 By Report N E0746 Packaged N E0749 Packaged N E0770 By Report N E0782 Packaged N E0783 Packaged N E0785 Packaged N E0786 Packaged N G0008 $23.93 N G0009 $23.93 N G0102 Packaged N G0104 $233.90 N G0105 $508.37 Y G0106 $78.61 N G0117 $60.02 N G0118 $37.35 N G0120 $78.61 N G0121 $508.37 Y G0127 $27.87 Y G0130 $41.85 N G0166 $97.15 Y G0173 $3,329.29 N G0177 Packaged N G0186 $367.54 Y G0237 $25.50 N G0238 $25.50 N G0239 $25.50 N G0251 $897.26 N Procedure Code Allowed Amount Multiple Procedure Discounting G0257 $428.57 N G0259 Packaged N G0260 $452.39 Y G0268 Packaged N G0269 Packaged N G0275 Packaged N G0278 Packaged N G0288 Packaged N G0289 Packaged N G0290 $6,960.73 Y G0291 $6,960.73 Y G0293 $42.05 N G0294 $42.05 N G0302 $718.24 N G0303 $718.24 N G0304 $151.06 N G0305 $151.06 N G0339 $3,329.29 N G0340 $2,319.17 N G0364 $42.05 Y G0365 $144.54 N G0378 Packaged N G0389 $90.69 N G0390 $777.31 N G0396 By Report N G0397 By Report N G0398 $151.06 N G0399 $151.06 N G0400 $151.06 N G0402 By Report N G0403 By Report N G0404 By Report N G0405 By Report N G0406 By Report N G0407 By Report N G0408 By Report N G0409 By Report N G0410 By Report N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 82
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 G0411 By Report N G0412 By Report N G0413 By Report N G0414 By Report N G0415 By Report N G0416 By Report N G0417 By Report N G0418 By Report N G0419 By Report N G0420 By Report N G0421 By Report N G0422 By Report N G0423 By Report N G0424 By Report N G0425 By Report N G0426 By Report N G0427 By Report N G0430 By Report N G0431 By Report N G3001 $1,618.96 N G9140 By Report N G9141 $23.93 N G9142 Packaged N J0120 Packaged N J0128 By Report N J0129 $19.15 N J0130 $454.71 N J0132 $2.33 N J0133 Packaged N J0135 $359.89 N J0150 $10.01 N J0152 $79.40 N J0170 Packaged N J0180 $133.68 N J0190 Packaged N J0200 Packaged N J0205 $41.20 N J0207 $333.69 N Procedure Code Allowed Amount Multiple Procedure Discounting J0210 $32.60 N J0215 $30.14 N J0220 $124.69 N J0256 $3.67 N J0278 Packaged N J0280 Packaged N J0282 Packaged N J0285 Packaged N J0287 $9.47 N J0288 $13.74 N J0289 $15.51 N J0290 Packaged N J0295 Packaged N J0300 Packaged N J0330 Packaged N J0348 $1.22 N J0350 By Report N J0360 Packaged N J0364 Packaged N J0365 $2.60 N J0380 Packaged N J0390 Packaged N J0395 Packaged N J0400 Packaged N J0456 Packaged N J0461 Packaged N J0470 $26.88 N J0475 $199.42 N J0476 $73.00 N J0480 $1,696.29 N J0500 Packaged N J0515 Packaged N J0520 Packaged N J0559 Packaged N J0560 Packaged N J0570 Packaged N J0580 Packaged N J0583 $2.41 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 83
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