2018 2nd Quarter Ambulatory Surgical Center Fee Schedule

Effective: April 1, 2018

Procedure Indicator: S = Surgical Procedure, A = Ancillary Service, C = Carrier Priced

North Carolina

HCPCS Code
MOD
Proc Ind
Price
FC Mod
Red Price
FB Mod Red Price
Pen Price
Pen FC Mod Red Price
Pen FB Mod Red Price
CBSA
C9749
 
S
$1,166.79
$833.34
$499.91
$1,156.91
$823.47
$490.02
34
C9749
 
S
$1,223.56
$873.89
$524.23
$1,213.21
$863.54
$513.87
11700
C9749
 
S
$1,210.52
$864.58
$518.64
$1,200.27
$854.33
$508.39
15500
C9749
 
S
$1,263.69
$902.55
$541.43
$1,252.99
$891.85
$530.72
16740
C9749
 
S
$1,297.91
$926.99
$556.09
$1,286.92
$916.01
$545.09
20500
C9749
 
S
$1,181.08
$843.55
$506.03
$1,171.08
$833.55
$496.03
22180
C9749
 
S
$1,220.42
$871.65
$522.89
$1,210.09
$861.32
$512.55
24140
C9749
 
S
$1,216.88
$869.12
$521.37
$1,206.58
$858.82
$511.06
24660
C9749
 
S
$1,261.79
$901.19
$540.61
$1,251.11
$890.51
$529.92
24780
C9749
 
S
$1,215.89
$868.42
$520.95
$1,205.60
$858.12
$510.65
25860
C9749
 
S
$1,194.91
$853.43
$511.96
$1,184.80
$843.32
$501.83
27340
C9749
 
S
$1,205.54
$861.02
$516.51
$1,195.33
$850.81
$506.30
34820
C9749
 
S
$1,198.59
$856.05
$513.53
$1,188.44
$845.91
$503.38
35100
C9749
 
S
$1,266.51
$904.57
$542.63
$1,255.79
$893.84
$531.90
39580
C9749
 
S
$1,218.52
$870.29
$522.07
$1,208.20
$859.97
$511.75
40580
C9749
 
S
$1,246.25
$890.10
$533.95
$1,235.70
$879.55
$523.39
47260
C9749
 
S
$1,221.20
$872.21
$523.22
$1,210.87
$861.87
$512.88
48900
C9749
 
S
$1,228.55
$877.45
$526.37
$1,218.15
$867.05
$515.96
49180

South Carolina

HCPCS Code
MOD
Proc Ind
Price
FC Mod
Red Price
FB Mod
Red Price
Pen Price
Pen FC Mod Red Price
Pen FB Mod Red Price
CBSA
C9749
 
S
$1,186.52
$847.44
$508.36
$1,176.48
$837.39
$498.31
42
C9749
 
S
$1,249.26
$892.25
$535.25
$1,238.69
$881.67
$524.66
12260
C9749
 
S
$1,245.27
$889.39
$533.53
$1,234.72
$878.85
$522.98
16700
C9749
 
S
$1,263.69
$902.55
$541.43
$1,252.99
$891.85
$530.72
16740
C9749
 
S
$1,198.98
$856.34
$513.70
$1,188.83
$846.19
$503.54
17900
C9749
 
S
$1,177.08
$840.70
$504.32
$1,167.12
$830.73
$494.35
22500
C9749
 
S
$1,261.59
$901.05
$540.53
$1,250.91
$890.37
$529.84
24860
C9749
 
S
$1,185.47
$846.69
$507.91
$1,175.44
$836.65
$497.87
25940
C9749
 
S
$1,205.54
$861.02
$516.51
$1,195.33
$850.81
$506.30
34820
C9749
 
S
$1,224.55
$874.60
$524.66
$1,214.18
$864.23
$514.28
43900
C9749
 
S
$1,105.69
$789.70
$473.73
$1,096.33
$780.34
$464.36
44940

Virginia

HCPCS Code
MOD
Proc Ind
Price
FC Mod
Red Price
FB Mod
Red Price
Pen Price
Pen FC Mod Red Price
Pen FB Mod Red Price
CBSA
C9749
 
S
$1,159.71
$828.29
$496.88
$1,149.89
$818.47
$487.05
49
C9749
 
S
$1,206.26
$861.53
$516.82
$1,196.05
$851.32
$506.60
13980
C9749
 
S
$1,298.04
$927.09
$556.14
$1,287.05
$916.10
$545.15
16820
C9749
 
S
$1,243.95
$888.46
$532.97
$1,233.42
$877.93
$522.43
25500
C9749
 
S
$1,116.37
$797.34
$478.31
$1,106.92
$787.89
$468.85
28700
C9749
 
S
$1,234.91
$882.00
$529.09
$1,224.45
$871.54
$518.63
31340
C9749
 
S
$1,265.00
$903.49
$541.99
$1,254.29
$892.78
$531.27
40060
C9749
 
S
$1,235.76
$882.60
$529.46
$1,225.30
$872.14
$518.99
40220
C9749
 
S
$1,219.43
$870.95
$522.46
$1,209.11
$860.62
$512.13
44420
C9749
 
S
$1,246.25
$890.10
$533.95
$1,235.70
$879.55
$523.39
47260
C9749
 
S
$1,333.97
$952.75
$571.54
$1,322.68
$941.46
$560.23
47894
C9749
 
S
$1,245.07
$889.25
$533.45
$1,234.53
$878.71
$522.90
49020

West Virginia

HCPCS Code
MOD
Proc Ind
Price
FC Mod
Red Price
FB Mod
Red Price
Pen Price
Pen FC Mod Red Price
Pen FB Mod Red Price
CBSA
C9749
 
S
$1,137.48
$812.41
$487.35
$1,127.85
$802.78
$477.71
51
C9749
 
S
$1,167.71
$834.00
$500.30
$1,157.82
$824.11
$490.41
13220
C9749
 
S
$1,197.47
$855.26
$513.05
$1,187.33
$845.12
$502.91
16620
C9749
 
S
$1,205.86
$861.25
$516.65
$1,195.66
$851.04
$506.43
19060
C9749
 
S
$1,238.84
$884.81
$530.78
$1,228.35
$874.32
$520.28
25180
C9749
 
S
$1,218.71
$870.43
$522.16
$1,208.40
$860.11
$511.83
26580
C9749
 
S
$1,174.13
$838.59
$503.05
$1,164.19
$828.65
$493.11
34060
C9749
 
S
$1,111.78
$794.06
$476.34
$1,102.37
$784.65
$466.92
37620
C9749
 
S
$1,333.97
$952.75
$571.54
$1,322.68
$941.46
$560.23
47894
C9749
 
S
$1,165.81
$832.64
$499.49
$1,155.94
$822.77
$489.61
48260
C9749
 
S
$1,095.98
$782.77
$469.57
$1,086.71
$773.50
$460.29
48540
C9749
 
S
$1,245.07
$889.25
$533.45
$1,234.53
$878.71
$522.90
49020

 

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