Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0023

Effective April 1, 2020 Link to medical fee and payment rules

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment70010 packaged 71047 packaged 72285 packaged 74022 packaged70015 packaged 71048 packaged 72295 packaged 74150 $97.6170030 packaged 71100 packaged 73000 packaged 74160 $158.7270100 packaged 71101 packaged 73010 packaged 74170 $158.7270110 packaged 71110 packaged 73020 packaged 74174 $332.5970120 packaged 71111 packaged 73030 packaged 74175 $158.7270130 packaged 71120 packaged 73040 packaged 74176 $195.9570134 packaged 71130 packaged 73050 packaged 74177 $332.5970140 packaged 71250 $97.61 73060 packaged 74178 $332.5970150 packaged 71260 $158.72 73070 packaged 74181 $202.9770160 packaged 71270 $158.72 73080 packaged 74182 $332.5970170 packaged 71275 $158.72 73085 packaged 74183 $332.5970190 packaged 71550 $202.97 73090 packaged 74190 packaged70200 packaged 71551 $592.98 73092 packaged 74210 packaged70210 packaged 71552 $332.59 73100 packaged 74220 packaged70220 packaged 72020 packaged 73110 packaged 74230 $158.7270240 packaged 72040 packaged 73115 packaged 74235 packaged70250 packaged 72050 packaged 73120 packaged 74240 $138.7270260 packaged 72052 packaged 73130 packaged 74246 $158.7270300 packaged 72070 packaged 73140 packaged 74250 $139.3470310 packaged 72072 packaged 73200 $97.61 74251 $158.7270320 packaged 72074 packaged 73201 $286.78 74261 $97.6170328 packaged 72080 packaged 73202 $158.72 74262 $158.7270330 packaged 72081 packaged 73206 $158.72 74270 packaged70332 packaged 72082 packaged 73218 $202.97 74280 packaged70336 $202.97 72083 $97.61 73219 $332.59 74283 $158.7270350 packaged 72084 $97.61 73220 $332.59 74290 packaged70355 packaged 72100 packaged 73221 $202.97 74300 packaged70360 packaged 72110 packaged 73222 $494.55 74301 packaged70370 packaged 72114 packaged 73223 $332.59 74328 packaged70371 packaged 72120 packaged 73501 packaged 74329 packaged70380 packaged 72125 $97.61 73502 packaged 74330 packaged70390 packaged 72126 $233.91 73503 packaged 74340 packaged70450 $97.61 72127 $158.72 73521 packaged 74355 packaged70460 $158.72 72128 $97.61 73522 packaged 74360 packaged70470 $158.72 72129 $158.72 73523 packaged 74363 packaged70480 $97.61 72130 $158.72 73525 packaged 74400 $158.7270481 $158.72 72131 $97.61 73551 packaged 74410 $158.7270482 $158.72 72132 $234.53 73552 packaged 74415 $158.7270486 $97.61 72133 $158.72 73560 packaged 74420 $332.5970487 $158.72 72141 $202.97 73562 packaged 74425 packaged70488 $158.72 72142 $332.59 73564 packaged 74430 packaged70490 $97.61 72146 $202.97 73565 packaged 74440 packaged70491 $158.72 72147 $332.59 73580 packaged 74445 packaged70492 $158.72 72148 $202.97 73590 packaged 74450 packaged70496 $158.72 72149 $332.59 73592 packaged 74455 packaged70498 $158.72 72156 $332.59 73600 packaged 74470 packaged70540 $202.97 72157 $332.59 73610 packaged 74485 packaged70542 $332.59 72158 $332.59 73615 packaged 74710 packaged70543 $332.59 72170 packaged 73620 packaged 74712 $202.9770544 $202.97 72190 packaged 73630 packaged 74713 packaged70545 $332.59 72191 $158.72 73650 packaged 74740 packaged70546 $332.59 72192 $97.61 73660 packaged 74742 packaged70547 $202.97 72193 $158.72 73700 $97.61 74775 $202.9770548 $332.59 72194 $158.72 73701 $158.72 75557 $202.9770549 $332.59 72195 $202.97 73702 $158.72 75559 $419.4570551 $202.97 72196 $332.59 73706 $158.72 75561 $332.5970552 $332.59 72197 $332.59 73718 $202.97 75563 $592.9870553 $332.59 72200 packaged 73719 $332.59 75565 packaged70554 $202.97 72202 packaged 73720 $332.59 75571 packaged70555 $202.97 72220 packaged 73721 $202.97 75572 $158.7270557 $419.45 72240 packaged 73722 $495.79 75573 $158.7270558 $158.72 72255 packaged 73723 $332.59 75574 $158.7270559 $158.72 72265 packaged 74018 packaged 75600 packaged71045 $27.99 72270 packaged 74019 packaged 75605 packaged71046 $37.32 72275 packaged 74021 packaged 75625 packaged

Appendix D for Administrative Order 20-053

Ambulatory Surgery Center Fee Schedule Amounts for Ancillary Services

CPT only copyright 2019 American Medical Association. All rights reserved.

2020 Appendix D Page 1 of 7

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0023

Effective April 1, 2020 Link to medical fee and payment rules

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

Appendix D for Administrative Order 20-053

Ambulatory Surgery Center Fee Schedule Amounts for Ancillary Services

CPT only copyright 2019 American Medical Association. All rights reserved.

75630 packaged 76514 packaged 77003 packaged 77615 $469.3175635 packaged 76516 packaged 77011 packaged 77620 $469.3175705 packaged 76519 packaged 77012 packaged 77750 $205.8675710 packaged 76529 packaged 77013 packaged 77761 $348.3775716 packaged 76536 packaged 77014 packaged 77762 $398.7475726 packaged 76604 packaged 77021 packaged 77763 $514.4675731 $184.15 76641 packaged 77022 packaged 77767 $205.8675733 packaged 76642 packaged 77046 $202.97 77768 $205.8675736 packaged 76700 $97.61 77047 $202.97 77770 $405.5975741 packaged 76705 $97.61 77053 packaged 77771 $644.9875743 packaged 76770 $97.61 77054 packaged 77772 $644.9875746 $154.27 76775 packaged 77071 packaged 77778 $644.9875756 packaged 76776 $97.61 77072 packaged 77789 $106.8775774 packaged 76800 packaged 77073 packaged 77790 packaged75801 packaged 76801 $97.61 77074 packaged 77799 $106.8775803 $999.59 76802 packaged 77075 packaged 78012 $320.6275805 $999.59 76805 $97.61 77076 packaged 78013 $320.6275807 packaged 76810 packaged 77077 packaged 78014 $320.6275809 packaged 76811 $143.71 77078 $69.51 78015 $320.6275810 $999.59 76812 packaged 77080 $51.01 78016 $320.6275820 packaged 76813 packaged 77081 $37.94 78018 $411.0975822 $129.40 76814 packaged 77084 $202.97 78020 packaged75825 packaged 76815 packaged 77085 packaged 78070 $320.6275827 packaged 76816 packaged 77086 packaged 78071 $320.6275831 packaged 76817 packaged 77280 $110.27 78072 $411.0975833 packaged 76818 $97.61 77285 $291.91 78075 $1,108.0375840 packaged 76819 $83.98 77290 $291.91 78099 $320.6275842 packaged 76820 packaged 77293 packaged 78102 $320.6275860 packaged 76821 packaged 77295 $454.11 78103 $320.6275870 $208.40 76825 $333.44 77299 $110.27 78104 $320.6275872 packaged 76826 $202.97 77300 $58.47 78110 $1,108.0375880 packaged 76827 packaged 77301 $1,084.67 78111 $1,108.0375885 packaged 76828 packaged 77306 $130.64 78120 $320.6275887 $141.82 76830 $97.61 77307 $235.77 78121 $411.0975889 packaged 76831 $144.94 77316 $249.45 78122 $411.0975891 packaged 76856 $97.61 77317 $291.91 78130 $320.6275893 packaged 76857 $41.06 77318 $291.91 78135 $320.6275894 packaged 76870 packaged 77321 $75.90 78140 $320.6275898 $999.59 76872 $97.61 77331 $32.36 78185 $320.6275901 packaged 76873 $97.61 77332 $40.44 78191 $320.6275902 packaged 76881 $80.25 77333 $110.27 78195 $411.0975970 packaged 76882 packaged 77334 $115.71 78199 $320.6275984 packaged 76885 packaged 77336 $110.27 78201 $1,108.0375989 packaged 76886 packaged 77338 $291.91 78202 $1,108.0376000 $45.42 76932 packaged 77370 $110.27 78215 $320.6276010 packaged 76936 $220.44 77385 $469.31 78216 $320.6276080 packaged 76937 packaged 77386 $469.31 78226 $320.6276098 packaged 76940 packaged 77387 packaged 78227 $411.0976100 packaged 76941 packaged 77399 $110.27 78230 $320.6276101 $97.61 76942 packaged 77401 $42.30 78231 $320.6276102 $97.61 76945 packaged 77402 $106.87 78232 $320.6276120 packaged 76946 packaged 77407 $205.86 78258 $320.6276125 packaged 76948 packaged 77412 $205.86 78261 $320.6276376 packaged 76965 packaged 77417 packaged 78262 $320.6276377 packaged 76970 packaged 77423 $46.04 78264 $320.6276380 packaged 76975 packaged 77424 $3,314.02 78265 $320.6276391 $202.97 76977 $6.85 77425 $3,314.02 78266 $411.0976496 packaged 76978 $158.72 77435 packaged 78278 $320.6276497 packaged 76979 packaged 77470 $44.16 78282 $320.6276498 $69.51 76981 $97.61 77520 $469.31 78290 $320.6276499 packaged 76982 $97.61 77522 $1,085.88 78291 $320.6276506 packaged 76983 packaged 77523 $1,085.88 78299 $320.6276510 packaged 76998 packaged 77525 $1,085.88 78300 $320.6276511 packaged 76999 packaged 77600 $205.86 78305 $320.6276512 packaged 77001 packaged 77605 $644.98 78306 $320.6276513 packaged 77002 packaged 77610 $469.31 78315 $320.62

2020 Appendix D Page 2 of 7

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0023

Effective April 1, 2020 Link to medical fee and payment rules

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

Appendix D for Administrative Order 20-053

Ambulatory Surgery Center Fee Schedule Amounts for Ancillary Services

CPT only copyright 2019 American Medical Association. All rights reserved.

78399 $320.62 78813 $1,256.95 0394T $205.86 A9584 packaged78414 $411.09 78814 $1,256.95 0395T $644.98 A9585 packaged78428 $320.62 78815 $1,256.95 0422T $69.51 A9586 $5,220.8378429 $1,256.95 78816 $1,256.95 0508T $97.61 A9587 packaged78430 $1,256.95 78830 $1,108.03 0558T $69.51 A9588 packaged78431 $1,960.12 78831 $1,108.03 A9500 packaged A9597 packaged78432 $2,395.59 78832 $1,256.95 A9501 packaged A9598 packaged78433 $2,395.59 78999 $320.62 A9502 packaged A9698 packaged78434 packaged 79005 $87.10 A9503 packaged A9700 packaged78445 $320.62 79101 $88.34 A9504 packaged C1713 packaged78451 $1,108.03 79200 $92.06 A9505 packaged C1714 packaged78452 $1,108.03 79300 $206.76 A9507 packaged C1715 packaged78453 $1,108.03 79403 $141.21 A9508 packaged C1716 $200.7078454 $1,108.03 79440 $68.43 A9509 packaged C1717 $555.0078456 $1,108.03 79445 $206.76 A9510 packaged C1719 $108.5378457 $1,108.03 79999 $206.76 A9512 packaged C1721 packaged78458 $320.62 90371 $190.77 A9515 packaged C1722 packaged78459 $1,108.03 90375 $483.74 A9516 packaged C1724 packaged78466 $320.62 90376 $467.76 A9520 packaged C1725 packaged78468 $411.09 90378 $2,077.15 A9521 packaged C1726 packaged78469 $1,108.03 90396 $2,958.19 A9524 packaged C1727 packaged78472 $320.62 90476 packaged A9526 packaged C1728 packaged78473 $320.62 90630 packaged A9527 $53.88 C1729 packaged78481 $411.09 90632 packaged A9528 packaged C1730 packaged78483 $411.09 90633 packaged A9529 packaged C1731 packaged78491 $1,256.95 90634 packaged A9531 packaged C1732 packaged78492 $1,256.95 90636 packaged A9532 packaged C1733 packaged78494 $320.62 90647 packaged A9536 packaged C1734 80% of billed78496 packaged 90648 packaged A9537 packaged C1749 packaged78499 $320.62 90653 packaged A9538 packaged C1750 packaged78579 $320.62 90654 packaged A9539 packaged C1751 packaged78580 $320.62 90655 packaged A9540 packaged C1752 packaged78582 $411.09 90656 packaged A9541 packaged C1753 packaged78597 $320.62 90657 packaged A9542 packaged C1754 packaged78598 $411.09 90660 packaged A9546 packaged C1755 packaged78599 $320.62 90661 packaged A9547 packaged C1756 packaged78600 $320.62 90662 packaged A9548 packaged C1757 packaged78601 $320.62 90670 packaged A9550 packaged C1758 packaged78605 $411.09 90672 packaged A9551 packaged C1759 packaged78606 $411.09 90673 packaged A9552 packaged C1760 packaged78608 $1,256.95 90674 packaged A9553 packaged C1762 packaged78610 $411.09 90675 $512.96 A9554 packaged C1763 packaged78630 $411.09 90676 $224.10 A9555 packaged C1764 packaged78635 $411.09 90680 packaged A9556 packaged C1765 packaged78645 $411.09 90682 packaged A9557 packaged C1766 packaged78650 $1,108.03 90685 packaged A9558 packaged C1767 packaged78660 $320.62 90686 packaged A9559 packaged C1768 packaged78699 $320.62 90687 packaged A9560 packaged C1769 packaged78700 $320.62 90688 packaged A9561 packaged C1770 packaged78701 $320.62 90689 packaged A9562 packaged C1771 packaged78707 $411.09 90690 packaged A9566 packaged C1772 packaged78708 $411.09 90691 packaged A9567 packaged C1773 packaged78709 $411.09 90696 packaged A9568 packaged C1776 packaged78725 $320.62 90698 packaged A9569 packaged C1777 packaged78730 packaged 90717 packaged A9570 packaged C1778 packaged78740 $320.62 90732 packaged A9571 packaged C1779 packaged78761 $320.62 90740 80% of billed A9572 packaged C1780 packaged78799 $320.62 90743 80% of billed A9575 packaged C1781 packaged78800 $320.62 90744 80% of billed A9576 packaged C1782 packaged78801 $320.62 90746 80% of billed A9577 packaged C1783 packaged78802 $1,108.03 90747 80% of billed A9578 packaged C1784 packaged78803 $1,108.03 90749 packaged A9579 packaged C1785 packaged78804 $1,108.03 90756 packaged A9580 packaged C1786 packaged78808 packaged 91035 $422.95 A9581 packaged C1787 packaged78811 $1,108.03 0331T $1,108.03 A9582 packaged C1788 packaged78812 $1,256.95 0332T $1,108.03 A9583 packaged C1789 packaged

2020 Appendix D Page 3 of 7

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0023

Effective April 1, 2020 Link to medical fee and payment rules

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

Appendix D for Administrative Order 20-053

Ambulatory Surgery Center Fee Schedule Amounts for Ancillary Services

CPT only copyright 2019 American Medical Association. All rights reserved.

C1813 packaged C2636 $62.10 J0121 $6.02 J0598 $98.30C1814 packaged C2638 $59.53 J0122 $1.65 J0599 $16.67C1815 packaged C2639 $61.41 J0129 $93.63 J0600 $9,643.15C1816 packaged C2640 $144.08 J0130 packaged J0606 $4.49C1817 packaged C2641 $119.61 J0131 packaged J0610 packagedC1818 packaged C2642 $132.21 J0132 packaged J0620 packagedC1819 packaged C2643 $164.96 J0133 packaged J0630 $4,586.88C1820 packaged C2645 $8.08 J0135 $2,363.45 J0636 packagedC1821 packaged C2698 $59.53 J0153 packaged J0637 packagedC1822 packaged C2699 $61.41 J0171 packaged J0638 $191.35C1823 80% of billed C8900 $332.59 J0178 $1,641.78 J0640 packagedC1824 80% of billed C8901 $202.97 J0179 $547.41 J0641 $1.00C1830 packaged C8902 $332.59 J0180 $316.18 J0642 $3.52C1839 80% of billed C8903 $158.72 J0185 $3.74 J0670 packagedC1840 packaged C8905 $332.59 J0202 $3,304.42 J0690 packagedC1841 $123,258.12 C8906 $332.59 J0207 $1,729.89 J0692 packagedC1842 $123,258.12 C8908 $332.59 J0210 packaged J0694 packagedC1874 packaged C8909 $332.59 J0220 $243.29 J0695 $9.65C1875 packaged C8910 $202.97 J0221 $294.84 J0696 packagedC1876 packaged C8911 $332.59 J0222 $169.48 J0697 packagedC1877 packaged C8912 $332.59 J0256 $7.84 J0698 packagedC1878 packaged C8913 $202.97 J0257 $8.31 J0702 packagedC1880 packaged C8914 $332.59 J0278 packaged J0706 packagedC1881 packaged C8918 $332.59 J0280 packaged J0712 $5.50C1882 packaged C8919 $202.97 J0282 packaged J0713 packagedC1883 packaged C8920 $332.59 J0285 packaged J0714 $158.67C1884 packaged C8931 $332.59 J0287 $10.65 J0715 packagedC1885 packaged C8932 $202.97 J0289 $44.97 J0716 $8,312.47C1886 packaged C8933 $332.59 J0290 packaged J0717 $13.82C1887 packaged C8934 $332.59 J0291 $5.55 J0720 packagedC1888 packaged C8935 $202.97 J0295 packaged J0725 packagedC1889 packaged C8936 $332.59 J0300 $97.60 J0735 packagedC1890 80% of billed C9041 $502.46 J0330 packaged J0740 $1,074.33C1891 packaged C9046 $1.48 J0348 packaged J0743 packagedC1892 packaged C9047 $1,178.25 J0360 packaged J0744 packagedC1893 packaged C9054 $1.21 J0390 packaged J0745 packagedC1894 packaged C9055 $132.28 J0400 packaged J0770 packagedC1895 packaged C9113 packaged J0401 $9.82 J0775 $84.05C1896 packaged C9132 $3.45 J0456 packaged J0780 packagedC1897 packaged C9248 packaged J0461 packaged J0795 $15.58C1898 packaged C9250 $284.16 J0470 packaged J0800 $6,802.61C1899 packaged C9254 packaged J0475 $292.19 J0834 packagedC1900 packaged C9257 $3.50 J0476 packaged J0840 $5,662.71C1982 80% of billed C9285 packaged J0480 $6,549.97 J0841 $2,179.49C2596 80% of billed C9290 $2.16 J0485 $6.52 J0850 $1,946.33C2613 packaged C9293 packaged J0490 $77.26 J0875 $25.77C2614 packaged C9352 packaged J0500 packaged J0878 $0.57C2615 packaged C9353 packaged J0515 packaged J0881 $6.64C2616 $29,457.60 C9354 packaged J0517 $290.44 J0882 $6.64C2617 packaged C9355 packaged J0558 $18.77 J0883 $2.06C2618 packaged C9356 packaged J0561 $23.82 J0884 $2.06C2619 packaged C9358 packaged J0565 $68.65 J0885 $19.01C2620 packaged C9359 packaged J0567 $161.19 J0887 packagedC2621 packaged C9360 packaged J0570 $2,246.91 J0888 packagedC2622 packaged C9361 packaged J0583 packaged J0894 $12.91C2623 packaged C9362 packaged J0584 $608.83 J0895 packagedC2624 packaged C9363 packaged J0585 $10.55 J0897 $33.24C2625 packaged C9364 packaged J0586 $14.53 J0945 packagedC2626 packaged C9399 80% of billed J0587 $20.67 J1000 packagedC2627 packaged C9460 $26.51 J0588 $8.70 J1020 packagedC2628 packaged C9462 $0.81 J0592 packaged J1030 packagedC2629 packaged C9482 $17.22 J0593 $131.59 J1040 packagedC2630 packaged C9488 $54.40 J0594 $7.89 J1050 packagedC2631 packaged C9738 packaged J0595 packaged J1071 packagedC2634 $313.53 G0130 $41.06 J0596 $48.65 J1094 packagedC2635 $97.17 J0120 packaged J0597 $88.44 J1095 $2.06

2020 Appendix D Page 4 of 7

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0023

Effective April 1, 2020 Link to medical fee and payment rules

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

Appendix D for Administrative Order 20-053

Ambulatory Surgery Center Fee Schedule Amounts for Ancillary Services

CPT only copyright 2019 American Medical Association. All rights reserved.

J1096 $260.99 J1610 $343.49 J2250 packaged J2790 packagedJ1097 $193.66 J1626 packaged J2260 packaged J2791 packagedJ1100 packaged J1627 $4.72 J2265 $3.12 J2792 $51.33J1110 packaged J1628 $172.74 J2270 packaged J2794 $17.31J1120 packaged J1630 packaged J2274 packaged J2795 packagedJ1130 packaged J1631 packaged J2278 $13.63 J2796 $128.04J1160 packaged J1640 $40.88 J2280 packaged J2797 $1.62J1162 $6,515.95 J1642 packaged J2300 packaged J2798 $17.01J1165 packaged J1644 packaged J2310 packaged J2800 packagedJ1170 packaged J1645 packaged J2315 $5.60 J2805 packagedJ1190 $334.99 J1650 packaged J2320 packaged J2810 packagedJ1200 packaged J1652 packaged J2323 $34.88 J2820 $74.88J1205 packaged J1655 packaged J2325 $128.93 J2840 $932.75J1212 $1,010.97 J1670 $745.78 J2326 $1,899.23 J2850 $59.95J1230 packaged J1700 packaged J2350 $98.97 J2860 $177.65J1240 packaged J1710 packaged J2353 $356.06 J2916 packagedJ1245 packaged J1720 packaged J2354 packaged J2920 packagedJ1250 packaged J1726 $38.61 J2355 $282.66 J2930 packagedJ1260 packaged J1729 $18.63 J2357 $63.40 J2941 $2.87J1265 packaged J1740 $74.95 J2358 packaged J2950 packagedJ1267 $1.53 J1741 packaged J2360 packaged J2993 packagedJ1270 packaged J1742 $480.52 J2370 packaged J2997 $151.07J1290 $851.06 J1743 $935.78 J2400 packaged J3000 packagedJ1300 $397.28 J1744 $649.98 J2405 packaged J3010 packagedJ1301 $33.59 J1745 $109.09 J2407 $40.99 J3030 packagedJ1303 $390.04 J1746 $103.70 J2410 packaged J3031 $4.33J1320 packaged J1750 $24.84 J2425 $36.68 J3060 $69.09J1322 $416.19 J1756 packaged J2426 $20.05 J3070 packagedJ1325 packaged J1786 $74.02 J2430 packaged J3090 $2.57J1327 $7.39 J1790 packaged J2440 packaged J3095 $9.89J1335 packaged J1800 packaged J2469 packaged J3101 $210.00J1364 packaged J1815 packaged J2501 packaged J3105 packagedJ1380 packaged J1817 packaged J2502 $522.34 J3111 $15.43J1410 $532.50 J1826 $4,802.20 J2503 packaged J3121 packagedJ1428 $288.48 J1830 $665.77 J2504 $634.25 J3145 $2.53J1430 $765.50 J1833 $1.34 J2505 $7,640.45 J3230 packagedJ1438 $1,181.70 J1840 packaged J2507 $4,330.91 J3240 $2,921.89J1439 $1.90 J1850 packaged J2510 packaged J3243 $2.71J1442 $1.65 J1885 packaged J2515 $63.81 J3245 $235.27J1447 $0.98 J1890 packaged J2540 packaged J3246 $11.92J1450 packaged J1930 $107.42 J2543 packaged J3250 packagedJ1451 $14.72 J1931 $55.40 J2547 $2.83 J3260 packagedJ1453 $3.40 J1940 packaged J2550 packaged J3262 $8.55J1454 $718.57 J1943 $4.93 J2560 packaged J3265 packagedJ1455 $141.81 J1944 $4.79 J2562 $599.35 J3285 $110.06J1458 $685.90 J1950 $2,187.79 J2590 packaged J3300 packagedJ1459 $69.16 J1953 packaged J2597 $20.93 J3301 packagedJ1460 $68.79 J1956 packaged J2650 packaged J3302 packagedJ1555 $23.77 J1960 packaged J2675 packaged J3303 packagedJ1556 packaged J1980 packaged J2680 packaged J3304 $32.54J1557 $78.98 J1990 packaged J2690 packaged J3310 packagedJ1559 $17.99 J2001 packaged J2700 packaged J3315 $446.00J1560 $687.92 J2010 packaged J2704 packaged J3316 $4,994.16J1561 $67.47 J2020 packaged J2710 packaged J3350 packagedJ1566 $105.49 J2060 packaged J2720 packaged J3357 $329.90J1568 $61.50 J2062 packaged J2724 $26.03 J3358 $20.76J1569 $64.58 J2150 packaged J2730 packaged J3360 packagedJ1570 packaged J2170 packaged J2760 $650.82 J3364 packagedJ1571 $103.53 J2175 packaged J2765 packaged J3370 packagedJ1572 $61.34 J2180 packaged J2770 $719.63 J3380 $34.23J1573 $103.53 J2182 $51.23 J2778 $607.03 J3385 $595.57J1575 $25.09 J2185 packaged J2780 packaged J3396 $19.10J1580 packaged J2186 $3.08 J2783 $499.56 J3397 $376.34J1595 $281.66 J2210 packaged J2785 packaged J3398 $5,039.55J1599 packaged J2212 packaged J2786 $16.58 J3410 packagedJ1602 $37.20 J2248 packaged J2788 packaged J3411 packaged

2020 Appendix D Page 5 of 7

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0023

Effective April 1, 2020 Link to medical fee and payment rules

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

Appendix D for Administrative Order 20-053

Ambulatory Surgery Center Fee Schedule Amounts for Ancillary Services

CPT only copyright 2019 American Medical Association. All rights reserved.

J3415 packaged J7318 $29.70 J9034 $39.39 J9269 $446.37J3420 packaged J7320 $29.16 J9035 $139.93 J9270 packagedJ3430 packaged J7321 packaged J9036 $41.99 J9271 $85.13J3465 packaged J7322 $54.59 J9039 $195.47 J9280 $151.26J3470 packaged J7323 $250.07 J9040 packaged J9285 $89.86J3471 packaged J7324 $247.18 J9041 $77.03 J9293 $47.21J3472 packaged J7325 $19.67 J9042 $280.00 J9295 $9.89J3473 packaged J7326 $2,009.84 J9043 $299.35 J9299 $47.94J3475 packaged J7327 $1,326.41 J9044 $43.16 J9301 $108.35J3480 packaged J7328 $3.75 J9045 packaged J9302 $103.58J3485 packaged J7329 $12.41 J9047 $64.81 J9303 $205.24J3486 packaged J7331 $10.57 J9050 $5,238.37 J9305 $119.75J3489 packaged J7332 $43.40 J9055 $106.96 J9306 $21.18J3490 packaged J7336 $5.43 J9057 $136.90 J9307 $502.04J3530 packaged J7340 $378.27 J9060 packaged J9308 $100.70J3590 packaged J7342 $51.66 J9065 $32.75 J9309 $190.23J7030 packaged J7345 $2.50 J9070 $58.84 J9311 $75.04J7040 packaged J7500 packaged J9098 $140.34 J9312 $163.18J7042 packaged J7501 $410.57 J9100 packaged J9313 $38.06J7050 packaged J7502 packaged J9119 $47.31 J9315 $512.96J7060 packaged J7503 packaged J9120 $1,892.98 J9320 $602.78J7070 packaged J7504 $3,561.21 J9130 packaged J9325 $88.72J7100 packaged J7505 packaged J9145 $93.00 J9328 $17.91J7110 packaged J7507 packaged J9150 $80.57 J9330 $91.59J7120 packaged J7508 packaged J9153 $331.49 J9340 $696.86J7121 packaged J7509 packaged J9155 $6.85 J9351 packagedJ7131 packaged J7510 packaged J9171 $1.50 J9352 $539.37J7170 $81.62 J7511 $1,324.77 J9173 $128.66 J9354 $54.05J7175 $12.94 J7512 packaged J9175 packaged J9355 $183.78J7177 $1.97 J7515 packaged J9176 $11.20 J9356 $138.34J7178 $2.06 J7516 packaged J9178 packaged J9357 $2,479.71J7179 $3.15 J7517 packaged J9179 $196.97 J9360 packagedJ7180 $14.60 J7518 packaged J9181 packaged J9370 packagedJ7181 $26.75 J7520 packaged J9185 packaged J9371 $5,309.09J7182 $2.26 J7525 $365.15 J9190 packaged J9390 packagedJ7183 $1.67 J7527 packaged J9200 packaged J9395 $163.53J7185 $2.19 J7599 packaged J9201 packaged J9400 $14.42J7186 $1.83 J7665 packaged J9202 $857.93 J9600 $36,883.70J7187 $2.00 J7674 packaged J9203 $343.42 J9999 packagedJ7188 $5.48 J7799 packaged J9204 $346.24 L8600 packagedJ7189 $3.70 J7999 packaged J9205 $86.03 L8603 packagedJ7190 $1.85 J8501 packaged J9206 packaged L8604 packagedJ7192 $2.15 J8510 $41.68 J9207 $156.98 L8605 packagedJ7193 $1.99 J8520 packaged J9208 packaged L8606 packagedJ7194 $2.53 J8521 packaged J9209 packaged L8607 packagedJ7195 $2.59 J8530 packaged J9210 $1,344.58 L8609 packagedJ7196 $178.15 J8540 packaged J9211 packaged L8610 packagedJ7197 $5.72 J8560 $129.90 J9213 $291.87 L8612 packagedJ7198 $3.27 J8597 packaged J9214 $59.02 L8613 packagedJ7200 $2.27 J8600 packaged J9217 $387.32 L8614 packagedJ7201 $5.36 J8610 packaged J9218 packaged L8630 packagedJ7202 $7.39 J8655 $423.58 J9225 $7,042.40 L8631 packagedJ7203 $6.88 J8670 $3.66 J9226 $63,169.80 L8641 packagedJ7205 $3.59 J8700 packaged J9228 $263.95 L8642 packagedJ7207 $3.00 J8705 packaged J9229 $3,913.35 L8658 packagedJ7208 $3.48 J9000 packaged J9230 $565.88 L8659 packagedJ7209 $2.13 J9015 $8,557.56 J9245 $1,052.98 L8670 packagedJ7210 $2.34 J9017 $76.38 J9250 packaged L8679 packagedJ7211 packaged J9019 $715.05 J9260 packaged L8682 packagedJ7308 $673.94 J9022 $132.74 J9261 $262.83 L8690 packagedJ7311 $588.86 J9023 $143.02 J9262 $5.36 L8699 packagedJ7312 $344.79 J9025 $2.00 J9263 packaged L9900 packagedJ7313 $846.12 J9027 $106.33 J9264 $21.57 P9041 $18.08J7314 $846.57 J9030 $4.86 J9266 $30,280.21 P9045 $90.41J7315 packaged J9032 $69.07 J9267 packaged P9046 $36.16J7316 $1,804.60 J9033 $47.99 J9268 $3,393.31 P9047 $90.41

2020 Appendix D Page 6 of 7

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0023

Effective April 1, 2020 Link to medical fee and payment rules

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

HCPCS

Code

Maximum

Payment

Appendix D for Administrative Order 20-053

Ambulatory Surgery Center Fee Schedule Amounts for Ancillary Services

CPT only copyright 2019 American Medical Association. All rights reserved.

Q0138 $1.72 Q4141 packaged Q5107 $120.26Q0139 $1.72 Q4142 packaged Q5108 $564.36Q0161 packaged Q4143 packaged Q5110 $1.11Q0162 packaged Q4145 packaged Q5111 $598.23Q0163 packaged Q4146 packaged Q5117 $156.29Q0164 packaged Q4147 packaged Q9950 $33.68Q0166 packaged Q4148 packaged Q9951 packagedQ0167 packaged Q4149 packaged Q9953 packagedQ0169 packaged Q4150 packaged Q9954 packagedQ0173 packaged Q4151 packaged Q9955 packagedQ0175 packaged Q4152 packaged Q9956 packagedQ0177 packaged Q4153 packaged Q9957 packagedQ0180 packaged Q4154 packaged Q9958 packagedQ0181 packaged Q4155 packaged Q9959 packagedQ2004 packaged Q4156 packaged Q9960 packagedQ2009 $2.98 Q4157 packaged Q9961 packagedQ2017 $4,560.43 Q4158 packaged Q9962 packagedQ2026 $816.87 Q4159 packaged Q9963 packagedQ2028 $5.65 Q4160 packaged Q9964 packagedQ2034 packaged Q4161 packaged Q9965 packagedQ2035 packaged Q4162 packaged Q9966 packagedQ2036 packaged Q4163 packaged Q9967 packagedQ2037 packaged Q4164 packaged Q9968 $11.04Q2038 packaged Q4165 packaged Q9982 packagedQ2039 packaged Q4166 packaged Q9983 packagedQ2043 $79,935.62 Q4167 packaged Q9991 $2,884.39Q2049 $810.83 Q4168 packaged Q9992 $2,884.39Q2050 $612.03 Q4169 packaged V2630 packagedQ3027 $92.35 Q4170 packaged V2631 packagedQ3031 packaged Q4171 packaged V2632 packagedQ4100 packaged Q4173 packaged V2785 80% of billedQ4101 packaged Q4174 packaged V2790 packagedQ4102 packaged Q4175 packagedQ4103 packaged Q4176 packagedQ4104 packaged Q4177 packagedQ4105 packaged Q4178 packagedQ4106 packaged Q4179 packagedQ4107 packaged Q4180 packagedQ4108 packaged Q4181 packagedQ4110 packaged Q4182 packagedQ4111 packaged Q4183 packagedQ4112 packaged Q4184 packagedQ4113 packaged Q4185 packagedQ4114 packaged Q4186 packagedQ4115 packaged Q4187 packagedQ4116 packaged Q4188 packagedQ4117 packaged Q4189 packagedQ4118 packaged Q4190 packagedQ4121 packaged Q4191 packagedQ4122 packaged Q4192 packagedQ4123 packaged Q4193 packagedQ4124 packaged Q4194 packagedQ4125 packaged Q4195 $154.62Q4126 packaged Q4196 $180.70Q4127 packaged Q4197 packagedQ4128 packaged Q4198 packagedQ4130 packaged Q4200 packagedQ4132 packaged Q4201 packagedQ4133 packaged Q4202 packagedQ4134 packaged Q4203 packagedQ4135 packaged Q4204 packagedQ4136 packaged Q5101 $0.98Q4137 packaged Q5103 $84.90Q4138 packaged Q5104 $92.05Q4139 packaged Q5105 $1.65Q4140 packaged Q5106 $16.60

2020 Appendix D Page 7 of 7