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 J9260 Packaged N J9261 $101.35 N J9263 $7.47 N J9264 $9.20 N J9265 Packaged N J9266 $2,695.46 N J9268 $1,318.44 N J9270 Packaged N J9280 $16.83 N J9290 $67.30 N J9291 $134.60 N J9293 $46.87 N J9300 $2,573.49 N J9303 $85.35 N J9305 $49.63 N J9310 $553.12 N J9320 $278.77 N J9328 $4.90 N J9330 $48.90 N J9340 $103.08 N J9350 $1,012.44 N J9355 $63.56 N J9357 $933.57 N J9360 Packaged N J9370 Packaged N J9375 Packaged N J9380 Packaged N J9390 Packaged N J9395 $80.66 N J9600 $2,748.96 N J9999 Packaged N L8600 Packaged N L8603 Packaged N L8604 Packaged N L8606 Packaged N L8609 Packaged N L8610 Packaged N L8612 Packaged N Procedure Code Allowed Amount Multiple Procedure Discounting L8613 Packaged N L8614 Packaged N L8627 By Report N L8628 By Report N L8629 By Report N L8630 Packaged N L8631 Packaged N L8641 Packaged N L8642 Packaged N L8658 Packaged N L8659 Packaged N L8670 Packaged N L8682 Packaged N L8690 By Report N L8692 By Report N L8699 Packaged N L9900 Packaged N P9010 $192.25 N P9011 $81.46 N P9012 $43.42 N P9016 $174.06 N P9017 $70.86 N P9019 $62.09 N P9020 $127.51 N P9021 $132.11 N P9022 $229.30 N P9023 $47.68 N P9031 $97.64 N P9032 $140.24 N P9033 $123.00 N P9034 $437.26 N P9035 $477.34 N P9036 $333.66 N P9037 $630.64 N P9038 $210.47 N P9039 $339.21 N P9040 $228.39 N P9041 $16.89 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 90
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 P9043 $61.28 N P9044 $88.18 N P9045 $60.58 N P9046 $25.67 N P9047 $62.05 N P9048 $100.63 N P9050 $41.87 N P9051 $126.14 N P9052 $686.67 N P9053 $612.14 N P9054 $96.59 N P9055 $390.77 N P9056 $153.95 N P9057 $338.39 N P9058 $273.96 N P9059 $72.20 N P9060 $67.00 N P9615 Packaged N Q0091 $8.29 N Q0092 Packaged N Q0138 $0.82 N Q0163 Packaged N Q0164 Packaged N Q0166 Packaged N Q0167 Packaged N Q0169 Packaged N Q0171 Packaged N Q0173 Packaged N Q0174 Packaged N Q0175 Packaged N Q0177 Packaged N Q0179 Packaged N Q0180 Packaged N Q0515 $1.77 N Q1003 $50.00 N Q2004 $5.11 N Q2009 Packaged N Q2017 $319.21 N Procedure Code Allowed Amount Multiple Procedure Discounting Q3025 $187.31 N Q3031 Packaged N Q4100 Packaged N Q4101 $32.10 N Q4102 $4.30 N Q4103 $4.30 N Q4104 $14.65 N Q4105 $10.57 N Q4106 $39.37 N Q4107 $89.87 N Q4108 $18.78 N Q4109 Packaged N Q4110 $35.09 N Q4111 $7.64 N Q4112 $338.32 N Q4113 $338.32 N Q4114 $910.19 N Q4115 $9.36 N Q4116 $31.78 N Q9951 Packaged N Q9953 Packaged N Q9954 Packaged N Q9955 Packaged N Q9956 Packaged N Q9957 Packaged N Q9958 Packaged N Q9959 Packaged N Q9960 Packaged N Q9961 Packaged N Q9962 Packaged N Q9963 Packaged N Q9964 Packaged N Q9965 Packaged N Q9966 Packaged N Q9967 Packaged N Q9968 $2.46 N V2630 Packaged N V2631 Packaged N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 91
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