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 J3411 By Report N J3415 By Report N J3420 Packaged N J3430 Packaged N J3465 Packaged N J3470 Packaged N J3471 Packaged N J3472 Packaged N J3473 Packaged N J3475 Packaged N J3480 Packaged N J3485 Packaged N J3486 Packaged N J3487 $215.25 N J3488 $218.49 N J3490 Packaged N J3530 Packaged N J3590 Packaged N J7030 Packaged N J7040 Packaged N J7042 Packaged N J7050 Packaged N J7060 Packaged N J7070 Packaged N J7100 Packaged N J7110 Packaged N J7120 Packaged N J7130 Packaged N J7185 $1.07 N J7186 $0.90 N J7187 $0.86 N J7189 $1.30 N J7190 $0.85 N J7191 $8.21 N J7192 $1.08 N J7193 $0.87 N J7194 $0.86 N J7195 $1.09 N Procedure Code Allowed Amount Multiple Procedure Discounting J7197 $2.28 N J7198 $1.52 N J7307 By Report N J7308 $127.08 N J7310 $16,640.00 N J7311 $18,980.00 N J7321 $90.54 N J7323 $111.88 N J7324 $172.73 N J7325 $11.52 N J7500 Packaged N J7501 $93.84 N J7502 $3.12 N J7504 $456.47 N J7505 $1,111.55 N J7506 Packaged N J7507 $3.57 N J7509 Packaged N J7510 Packaged N J7511 $401.93 N J7513 $381.18 N J7515 $0.81 N J7516 $23.37 N J7517 $2.55 N J7518 Packaged N J7520 $9.47 N J7525 $137.01 N J7599 Packaged N J7604 By Report N J7605 $5.75 N J7606 $5.20 N J7632 By Report N J7674 Packaged N J7676 By Report N J7799 Packaged N J8501 $5.42 N J8510 Packaged N J8520 $6.11 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 88
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 J8521 $20.04 N J8530 Packaged N J8540 Packaged N J8560 $29.69 N J8597 Packaged N J8600 Packaged N J8610 Packaged N J8700 $8.63 N J8705 $73.00 N J9000 Packaged N J9001 $462.49 N J9010 $555.50 N J9015 $830.93 N J9017 $36.83 N J9020 $59.27 N J9025 $4.79 N J9027 $113.36 N J9031 $108.55 N J9033 $18.51 N J9035 $56.37 N J9040 Packaged N J9041 $37.52 N J9045 Packaged N J9050 $173.53 N J9055 $48.79 N J9060 Packaged N J9062 Packaged N J9065 $23.52 N J9070 Bundled N J9080 Bundled N J9090 Bundled N J9091 Bundled N J9092 Bundled N J9093 Bundled N J9094 Bundled N J9095 Packaged N J9096 Packaged N J9097 Packaged N Procedure Code Allowed Amount Multiple Procedure Discounting J9098 $480.16 N J9100 Packaged N J9110 Packaged N J9120 $556.34 N J9130 Packaged N J9140 Packaged N J9150 $16.65 N J9151 $55.33 N J9155 $2.87 N J9160 $1,467.55 N J9165 $3.83 N J9171 $17.29 N J9175 Packaged N J9178 $2.60 N J9181 Packaged N J9185 $158.63 N J9190 Packaged N J9200 $42.85 N J9201 $142.20 N J9202 $200.02 N J9206 $6.81 N J9207 $63.74 N J9208 $29.51 N J9209 $4.55 N J9211 $100.89 N J9212 $4.71 N J9213 $10.60 N J9214 $15.54 N J9215 $17.89 N J9216 $294.03 N J9217 $202.62 N J9218 $4.68 N J9219 $4,728.88 N J9225 $1,462.69 N J9226 $14,841.08 N J9230 $151.24 N J9245 $1,520.24 N J9250 Packaged N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 89
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