Ohio Bureau of Workers' Compensation ACTION: Original …codes.ohio.gov/pdf/oh/admin/2020/4123-6-37.3_ph_of_a_app2_20200228_1118.pdfThe BWC 2020 Ambulatory Surgical Center Fee Schedule
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
By Report (BR) The procedure or service is not typically covered and will not routinely be reimbursed. Many of the –BR codes are unclassified/unspecified generic codes and are currently assigned a dollar amount of $0.00. Authorization and payment of codes identified as -BR require an individual analysis by the MCO prior to submission to BWC. The MCO analysis shall include researching the appropriateness of the code in relation to the service or procedure. If the pricing is listed at $0.00, the MCO shall perform a cost comparison to determine a reasonable price. The MCO shall utilize the price to negotiate a final reimbursement rate. The provider must submit a report to the MCO for reimbursement consideration.
Bundled (BN) BN indicates that reimbursement for the covered procedure, service or supply is bundled into the payment rate for the associated surgical procedure. No separate payment for these services.
BWC-certified ASC arthroplasty center (AC) These procedures may be reimbursed to ASCs which have been BWC-certified as ASC arthroplasty centers to perform the procedure according to rule OAC 4123-6-02.22. Not reimbursable to ASCs without this certification.
BWC Rate Reimbursement rate for the ASC facility for CPT® and HCPCS Level II codes.
Never Covered (NC) The procedure or service is never covered.
Not Routinely Covered (NRC) The procedure or service is not covered unless application of the Miller criteria requires an exception. See: OAC 4123-6-16.2(B)(1) through (B)(3). Where coverage is required, the pricing is listed on the fee schedule. If the pricing is listed at $0.00, the MCO shall perform a cost comparison to determine a reasonable price. The MCO shall utilize the price to negotiate a final reimbursement rate.
The five character codes included in the Ohio Bureau of Workers’ Compensation (BWC) 2020 Ambulatory Surgical Center Fee Schedule are obtained from Current Procedural Terminology (CPT®), copyright 2019 by the American Medical Association (AMA) and from the Health Care Procedure Coding System (HCPCS) National Level II Medicare codes.
CPT® is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
HCPCS are released by the Center for Medicare and Medicaid Services (CMS) as a listing of five character codes and descriptive terminology used for reporting supplies, materials and services by health care providers.
The responsibility for the content of the BWC 2020 Ambulatory Surgical Center Fee Schedule is with the State of Ohio Bureau of Workers’ Compensation and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the BWC 2020 Ambulatory Surgical Center Fee Schedule. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT®. Any use of CPT® outside of the BWC 2020 Ambulatory Surgical Center Fee Schedule should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT® codes and descriptive terms. Applicable FARS/DFARS apply.
For the purposes of this fee schedule services and/or supplies must be medically necessary for the treatment of the work related injury. The following definitions apply:
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee ScheduleThe BWC 2020 Ambulatory Surgical Center Fee Schedule rates for all covered services other than orthopedic procedures (CPT® range 20100-29999), pain management (CPT® ranges 62280-62282, 62320-62327, 64400-64681) and device-intensive procedures (identified in Addendum AA of the Department of Health and Human Services, Centers for Medicare and Medicaid Services rule specified below with a payment indicator of J8) shall be calculated using the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates published in Addenda AA and BB of the Department of Health and Human Services, Centers for Medicare and Medicaid Services' “42 CFR Parts 405, 410, 412, 414, 416, 419, and 486 Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Revisions of Organ Procurement Organizations Conditions of Coverage; Prior Authorization Process and Requirements for Certain Covered Outpatient Department Services; Potential Changes to the Laboratory Date of Service Policy; Changes to Grandfathered Children’s Hospitals-Within-Hospitals; Notice of Closure of Two Teaching Hospitals and Opportunity to Apply for Available Slots" final rule, Federal Register, Volume 84, Number 218, Pages 61142-61492, November 12, 2019. and correction 85 Fed. Reg. 224 - 230 (2020).
The BWC 2020 Ambulatory Surgical Center Fee Schedule rates for covered orthopedic procedures (CPT® range 20100-29999) shall be calculated using the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates published in Addenda AA and BB of the Department of Health and Human Services, Centers for Medicare and Medicaid Services rule specified above, multiplied by a payment adjustment factor of 1.12.
The BWC 2020 Ambulatory Surgical Center Fee Schedule rates for covered pain management services (CPT® ranges 62280-62282, 62320-62327, 64400-64681) shall be calculated using the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates published in Addenda AA and BB of the Department of Health and Human Services, Centers for Medicare and Medicaid Services rule specified above, multiplied by a payment adjustment factor of 1.10. The BWC 2020 Ambulatory Surgical Center Fee Schedule rates for covered, device-intensive services (payment indicator J8, identified in Addendum AA of the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates) shall be calculated using the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates published in Addenda AA and BB of the Department of Health and Human Services, Centers for Medicare and Medicaid Services rule specified above, multiplied by a payment adjustment factor of 1.14.
Modifiers BWC accepts all industry-standard modifiers as published with CPT codes by the AMA and published by CMS with HCPCS level II codes in effect on the billed date of service. Unless otherwise specified in this document, modifiers will not affect the fee schedule amount calculated for a procedure.
Modifier 50 Bilateral procedure. Reimbursement is 150% of fee schedule amount.
Modifier 52 Reduced services. Reimbursement is 50% of fee schedule amount.
Modifier 73 Discontinued procedure prior to administration of anesthesia. Reimbursement is 50% of fee schedule amount.
Modifier 74 Discontinued procedure after administration of anesthesia. Reimbursement is 100% of fee schedule amount.
Modifier FB Item provided without cost to provider, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples). When this modifier is billed, BWC will subtract the no cost device offset amount from the final fee. Reimbursement when FB modifier is appended to the surgical procedure is listed in Column E of the fee tab.
Modifier FC Partial credit received for replaced device. When this modifier is billed, BWC will subtract the partial cost device offset amount from the final fee. Reimbursement when FC modifier is appended to the surgical procedure is listed in Column F of the fee tab.
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Definitions - Page 2 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
Multiple Procedure Discounting Services eligible for multiple procedure discounting are labeled as “Y” in the column titled “Subject to Multiple Procedure Discounting” of this appendix. When multiple surgical procedures in the same operative session are subject to the multiple procedure discount, reimbursement shall be at 100% of the fee schedule amount for the highest paying surgical procedure on the bill, plus 50% of the applicable fee schedule amount(s) for the other ASC-covered surgical procedures subject to multiple procedure discounting.
Medically Unlikely Edits (MUE) An MUE for a HCPCS/CPT code reflects the number of units of service a provider will use in most circumstances when treating an injured worker. Medical documentation supporting the necessity of additional units of service must be provided to an MCO when additional units of services beyond the listed MUE are necessary.
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Definitions - Page 3 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
10004 N BN10005 Y $75.0710006 N BN10007 Y $232.4210008 N BN10009 Y $308.2310010 N BN10011 Y $308.2310012 N BN10021 Y $59.1910030 Y $308.2310035 Y BN10036 N BN10040 N BN10060 Y $75.4310061 Y $115.4910080 Y NRC $165.2910081 Y NRC $208.6010120 Y $106.8310121 Y $576.3910140 Y $110.0710160 Y $83.3710180 Y $994.3411000 Y $34.2911001 N BN11010 Y $308.2311011 Y $308.2311012 Y $994.3411042 Y $161.4511043 Y $251.1411044 Y $576.3911045 N BN11046 N BN11047 N BN11055 N BN11056 N BN11057 Y $58.1011102 Y $75.7911103 N BN11104 Y $88.2911105 N BN11106 Y $116.2111107 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 4 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
11200 N BN11201 N BN11300 N BN11301 N BN11302 N BN11303 N BN11305 N BN11306 N BN11307 Y $88.2911308 N BN11310 Y $86.6211311 Y $88.2911312 Y $111.1611313 Y $123.0711400 Y NRC $92.3911401 Y NRC $105.3811402 Y NRC $115.1311403 Y NRC $124.8711404 Y NRC $576.3911406 Y NRC $576.3911420 Y NRC $88.7811421 Y NRC $104.3011422 Y NRC $115.4911423 Y NRC $125.2311424 Y NRC $576.3911426 Y NRC $994.3411440 Y NRC $101.4111441 Y NRC $114.0411442 Y NRC $123.4311443 Y NRC $136.7811444 Y NRC $576.3911446 Y NRC $994.3411450 Y NRC $994.3411451 Y NRC $994.3411462 Y NRC $994.3411463 Y NRC $994.3411470 Y NRC $994.3411471 Y NRC $994.3411600 Y $136.0611601 Y $151.5811602 Y $161.4511603 Y $175.4011604 Y $308.23
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 5 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
11606 Y $576.3911620 Y $136.4211621 Y $151.9411622 Y $164.9311623 Y $181.1711624 Y $576.3911626 Y $994.3411640 Y $140.3911641 Y $156.6311642 Y $171.4311643 Y $187.6711644 Y $576.3911646 Y $994.3411719 N BN11720 N BN11721 N BN11730 N BN11732 N BN11740 N BN11750 Y $99.2511755 Y $76.8711760 Y $251.1411762 Y $186.9411765 N BN11770 Y NRC $994.3411771 Y NRC $994.3411772 Y NRC $994.3411900 N BN11901 N BN11920 Y NRC $124.1511921 Y NRC $137.5011922 N BN11950 Y NRC $46.5611951 Y NRC $59.9111952 Y NRC $77.2311954 Y NRC $85.5311960 Y $1,504.3811970 Y $2,803.3611971 N $994.3411976 N NRC $75.4311980 N BN11981 N BN11982 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 6 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
11983 N BN12001 N BN12002 N BN12004 N BN12005 N $161.4512006 N $161.4512007 Y $88.2912011 N BN12013 N BN12014 N BN12015 N $88.2912016 N $161.4512017 N $161.4512018 N $88.2912020 Y $251.1412021 Y $161.4512031 Y $161.4512032 Y $161.4512034 Y $161.4512035 Y $161.4512036 Y $251.1412037 Y $819.9512041 N $161.4512042 Y $161.4512044 Y $251.1412045 Y $251.1412046 Y $161.4512047 Y $819.9512051 Y $161.4512052 Y $161.4512053 Y $161.4512054 N $161.4512055 Y $161.4512056 N $161.4512057 Y $161.4513100 Y $251.1413101 Y $251.1413102 N BN13120 Y $251.1413121 Y $251.1413122 N BN13131 Y $161.4513132 Y $251.14
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 7 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
13133 N BN13151 Y $251.1413152 Y $251.1413153 N BN13160 Y $819.9514000 Y $819.9514001 Y $819.9514020 Y $819.9514021 Y $819.9514040 Y $819.9514041 Y $819.9514060 Y $819.9514061 Y $819.9514301 Y $1,504.3814302 N BN14350 Y $819.9515002 Y $819.9515003 N BN15004 Y $251.1415005 N BN15040 Y $819.9515050 Y $251.1415100 Y $819.9515101 N BN15110 Y $819.9515111 N BN15115 Y $819.9515116 N BN15120 Y $1,504.3815121 N BN15130 Y $819.9515131 N BN15135 Y $1,504.3815136 N BN15150 Y $819.9515151 N BN15152 N BN15155 Y $1,504.3815156 N BN15157 N BN15200 Y $819.9515201 N BN15220 Y $819.95
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 8 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
15221 N BN15240 Y $819.9515241 N BN15260 Y $819.9515261 N BN15271 Y $819.9515272 N BN15273 Y $1,504.3815274 N BN15275 Y $819.9515276 N BN15277 Y $819.9515278 N BN15570 Y $819.9515572 Y $1,504.3815574 Y $819.9515576 Y $819.9515600 Y $1,504.3815610 Y $819.9515620 Y $819.9515630 Y $819.9515650 Y $819.9515730 Y $1,504.3815731 Y $1,504.3815733 Y $1,504.3815734 Y $1,504.3815736 Y $819.9515738 Y $1,504.3815740 Y $819.9515750 Y $1,504.3815760 Y $819.9515769 Y NRC $1,504.3815770 Y $1,504.3815771 Y NRC $1,504.3815773 Y NRC $819.9515775 Y NRC $161.4515776 Y NRC $161.4515777 N BN15780 Y NRC $565.8815781 Y NRC $308.2315782 Y NRC $378.5815783 Y NRC $161.4515786 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 9 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
15787 N BN15788 N BN15789 Y NRC $251.1415792 N BN15793 N BN15819 Y NRC $819.9515820 Y NRC $819.9515821 Y NRC $819.9515822 Y NRC $819.9515823 Y NRC $819.9515838 Y NRC $994.3415839 Y NRC $994.3415840 Y $1,504.3815841 Y $1,504.3815842 Y $819.9515845 Y $1,504.3815847 N BN15850 Y NRC $251.1415851 Y NRC $71.4615852 N BN15860 N BN15933 Y $994.3415934 Y $1,504.3815935 Y $1,504.3815936 Y $819.9515937 Y $819.9515940 Y $994.3415941 Y $994.3415944 Y $1,504.3815945 Y $819.9515946 Y $819.9515950 Y $576.3915951 Y $994.3415952 Y $819.9515953 Y $1,504.3815956 Y $819.9515958 Y $1,504.3816000 N BN16020 N BN16025 Y $88.2916030 Y $161.4516035 Y $161.4517000 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 10 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
17003 N BN17004 Y $107.9117106 Y $161.4517107 Y $251.1417108 Y $353.3217110 N BN17111 N BN17250 N BN17260 N BN17261 N BN17262 N BN17263 N BN17264 Y $132.0917266 Y $145.4417270 Y $88.2917271 Y $88.2917272 N BN17273 Y $130.2817274 Y $146.8817276 Y $161.4517280 N BN17281 Y $112.9617282 Y $127.0417283 Y $143.6417284 Y $158.4317286 Y $188.7517311 Y $251.1417312 N BN17313 Y $251.1417314 N BN17315 N BN17340 N BN17360 N BN19020 Y $576.3919030 N BN19081 Y $576.3919082 N BN19083 Y $576.3919084 N BN19085 Y $576.3919086 N BN19100 Y $576.3919101 Y $1,118.44
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 11 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
19105 Y $1,118.4419110 Y $1,118.4419112 Y $1,118.4419120 Y $1,118.4419125 Y $1,118.4419126 N BN19281 N BN19282 N BN19283 N BN19284 N BN19285 N BN19286 N BN19287 N BN19288 N BN19294 N BN19296 Y $4,760.47 $1,735.72 $3,248.0919297 N BN19298 Y $2,193.2719300 Y NRC $1,118.4419301 Y $1,118.4419302 Y $2,193.2719303 Y $2,193.2719316 Y NRC $2,193.2719318 Y NRC $2,193.2719324 Y NRC $2,679.4719325 Y NRC $2,679.4719328 N NRC $1,118.4419330 N NRC $1,118.4419340 Y NRC $2,193.2719342 Y NRC $2,679.4719350 Y NRC $1,118.4419355 Y NRC $1,118.4419357 Y NRC $5,339.42 $2,937.05 $4,138.2319366 Y NRC $2,193.2719370 Y NRC $1,118.4419371 Y NRC $1,118.4419380 Y NRC $2,193.2719396 Y NRC $1,118.4420103 Y $345.2220150 Y $1,440.6120200 Y $645.5620205 Y $1,113.6620206 Y $645.56
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 12 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
20220 Y $645.5620225 Y $645.5620240 Y $1,113.6620245 Y $1,113.6620250 Y $1,440.6120251 Y $3,139.7620500 Y $74.3720501 N BN20520 Y $155.6120525 Y $1,113.6620526 Y $46.4820527 Y $50.5220550 Y $29.1020551 Y $30.7220552 Y $33.9620553 Y $39.6120555 Y $1,440.6120600 Y $27.8920604 Y $48.1020605 Y $29.1020606 Y $52.1520610 Y $34.7620611 Y $58.6120612 Y $39.2120615 Y $181.4820650 Y $1,440.6120662 Y $798.5620663 Y $1,440.6120665 N $205.7720670 N $645.5620680 N $1,113.6620690 Y $4,282.19 $2,355.91 $3,319.0520692 Y $9,277.61 $4,403.82 $6,840.7120693 Y $3,139.7620694 N $798.5620696 Y $13,532.96 $4,966.25 $9,249.6020697 Y $798.5620822 Y $798.5620900 Y $3,139.7620902 Y $3,139.7620910 Y $281.2820912 Y $1,684.9120920 Y $918.34
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 13 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
20922 Y $918.3420924 Y $3,139.7620930 N BN20931 N BN20932 N BN20933 N BN20934 N BN20936 N BN20937 N BN20938 N BN20939 N BN20950 Y $345.2220972 Y $3,139.7620973 Y $3,139.7620975 N BN20979 N BN20982 Y $3,139.7620983 Y $4,327.57 $2,320.84 $3,324.2020985 N BN21010 Y $1,181.6721011 Y $276.8821012 Y $645.5621013 Y $358.1221014 Y $1,113.6621015 Y $1,113.6621016 Y $1,113.6621025 Y $2,516.1421026 Y $2,516.1421029 Y NRC $1,181.6721030 Y NRC $351.6621031 Y NRC $303.9621032 Y NRC $302.3421034 Y $2,516.1421040 Y NRC $1,181.6721044 Y $2,516.1421046 Y NRC $2,516.1421047 Y NRC $2,516.1421048 Y NRC $2,516.1421050 Y $2,516.1421060 Y $2,516.1421070 Y NRC $2,516.1421073 Y NRC $288.2021076 Y $457.15
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 14 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
21077 Y $1,109.5421079 Y $782.9521080 Y $913.9121081 Y $847.2121082 Y $799.9221083 Y $788.6021084 Y $884.4021085 Y $115.2421086 Y $834.2821087 Y $834.2821088 Y $1,181.6721100 Y $2,516.1421110 N NRC $600.9921116 N BN21120 Y NRC $2,516.1421121 Y NRC $1,181.6721122 Y NRC $2,516.1421123 Y NRC $1,181.6721125 Y NRC $2,516.1421127 Y NRC $2,516.1421137 Y NRC $1,181.6721138 Y NRC $2,516.1421139 Y NRC $2,516.1421150 Y NRC $2,516.1421181 Y NRC $2,516.1421198 Y NRC $2,516.1421199 Y NRC $2,516.1421206 Y NRC $2,516.1421208 Y $3,359.20 $1,944.01 $2,651.6021209 Y NRC $2,516.1421210 Y $2,516.1421215 Y $2,516.1421230 Y $2,516.1421235 Y $2,516.1421240 Y $2,516.1421242 Y $2,516.1421243 Y $13,803.88 $4,756.79 $9,280.3321244 Y $2,516.1421245 Y $2,516.1421246 Y $2,516.1421248 Y $2,516.1421249 Y $2,516.1421260 Y $2,516.14
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 15 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
21267 Y $2,516.1421270 Y $2,516.1421275 Y $2,516.1421280 Y NRC $1,181.6721282 Y NRC $1,181.6721295 Y NRC $600.9921296 Y NRC $1,181.6721310 Y $122.0421315 Y $600.9921320 Y $1,181.6721325 Y $1,181.6721330 Y $2,516.1421335 Y $1,181.6721336 Y $1,440.6121337 Y $1,181.6721338 Y $3,739.09 $1,650.32 $2,694.7021339 Y $2,516.1421340 Y $1,181.6721345 Y $600.9921355 Y $1,181.6721356 Y $2,516.1421360 Y $2,516.1421390 Y $2,516.1421400 Y $249.9721401 Y $600.9921406 Y $2,516.1421407 Y $2,516.1421421 Y $1,181.6721440 Y $571.5521445 Y $2,516.1421450 Y $249.9721451 Y $600.9921452 Y $2,516.1421453 Y $2,516.1421454 Y $2,516.1421461 Y $3,595.15 $1,761.58 $2,678.3621462 Y $3,520.94 $1,818.98 $2,669.9621465 Y $2,516.1421480 Y $122.0421485 Y $600.9921490 Y $1,181.6721497 Y $600.9921501 Y $1,113.66
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 16 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
21502 Y $1,440.6121550 Y $645.5621552 Y $1,113.6621554 Y $1,113.6621555 Y $645.5621556 Y $1,113.6621557 Y $1,113.6621558 Y $1,113.6621600 Y NRC $3,139.7621610 Y NRC $1,440.6121685 Y NRC $2,516.1421700 Y NRC $3,139.7621720 Y NRC $1,440.6121725 Y NRC $345.2221820 Y $122.0421920 Y $199.2721925 Y $645.5621930 Y $645.5621931 Y $645.5621932 Y $1,113.6621933 Y $1,113.6621935 Y $1,113.6621936 Y $1,113.6622102 Y $3,139.7622103 N BN22310 Y $122.0422315 Y $1,440.6122505 Y $798.5622510 Y $1,440.6122511 Y $1,440.6122512 N BN22513 Y $3,139.7622514 Y $3,139.7622515 N BN22551 Y $9,598.49 $4,155.72 $6,877.1022552 N BN22554 Y $9,606.80 $4,149.29 $6,878.0422585 N BN22612 Y $9,812.64 $3,990.16 $6,901.4022614 N BN22840 N BN22842 N BN22845 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 17 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
22853 N BN22854 N BN22856 Y $13,459.70 $5,022.90 $9,241.3022858 N BN22859 N BN22867 Y $13,959.79 $4,636.26 $9,298.0222868 N BN22869 Y $11,257.29 $2,873.24 $7,065.2622870 N BN22900 Y $1,113.6622901 Y $1,113.6622902 Y $645.5622903 Y $1,113.6622904 Y $1,113.6622905 Y $1,113.6623000 Y $1,113.6623020 Y $1,440.6123030 Y $1,113.6623031 Y $1,113.6623035 Y $798.5623040 Y $1,440.6123044 Y $1,440.6123065 Y $152.3923066 Y $1,113.6623071 Y $645.5623073 Y $1,113.6623075 Y $645.5623076 Y $1,113.6623077 Y $1,113.6623078 Y $1,113.6623100 Y $1,440.6123101 Y $1,440.6123105 Y $3,139.7623106 Y $1,440.6123107 Y $3,139.7623120 Y $1,440.6123125 Y $1,440.6123130 Y $1,440.6123140 Y $1,440.6123145 Y $1,440.6123146 Y $3,139.7623150 Y $1,440.6123155 Y $3,139.76
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 18 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
23156 Y $4,950.23 $1,839.44 $3,394.8323170 Y $1,440.6123172 Y $1,440.6123174 Y $3,139.7623180 Y $3,139.7623182 Y $3,139.7623184 Y $3,139.7623190 Y $1,440.6123195 Y $3,139.7623330 Y $345.2223333 Y $1,113.6623334 Y $1,113.6623350 N BN23395 Y $3,139.7623397 Y $3,139.7623400 Y $3,139.7623405 Y $3,139.7623406 Y $4,581.33 $2,124.65 $3,352.9923410 Y $3,139.7623412 Y $3,139.7623415 Y $3,139.7623420 Y $3,139.7623430 Y $3,139.7623440 Y $3,139.7623450 Y $3,139.7623455 Y $3,139.7623460 Y $3,139.7623462 Y $3,139.7623465 Y $3,139.7623466 Y $3,139.7623470 Y AC $9,449.54 $4,269.72 $6,859.6323472 Y AC $9,449.54 $4,269.72 $6,859.6323473 Y AC $9,449.54 $4,269.72 $6,859.6323480 Y $3,139.7623485 Y $8,957.99 $4,650.92 $6,804.4523490 Y $3,139.7623491 Y $9,125.47 $4,521.44 $6,823.4523500 Y $122.0423505 Y $798.5623515 Y $4,385.45 $2,276.08 $3,330.7623520 Y $798.5623525 Y $122.0423530 Y $3,139.76
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 19 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
23532 Y $3,139.7623540 Y $122.0423545 Y $122.0423550 Y $3,139.7623552 Y $4,357.30 $2,297.86 $3,327.5823570 Y $122.0423575 Y $798.5623585 Y $3,139.7623600 Y $122.0423605 Y $798.5623615 Y $9,450.20 $4,270.38 $6,860.2923616 Y $13,304.64 $5,142.77 $9,223.7023620 Y $122.0423625 Y $798.5623630 Y $4,225.56 $2,399.70 $3,312.6323650 Y $122.0423655 Y $798.5623660 Y $3,139.7623665 Y $798.5623670 Y $3,139.7623675 Y $798.5623680 Y $9,544.16 $4,197.73 $6,870.9423700 Y $798.5623800 Y $3,139.7623802 Y $6,414.3923921 Y $918.3423930 Y $1,113.6623931 Y $645.5623935 Y $1,440.6124000 Y $1,440.6124006 Y $1,440.6124065 Y $202.1024066 Y $1,113.6624071 Y $1,113.6624073 Y $1,113.6624075 Y $645.5624076 Y $1,113.6624077 Y $1,113.6624079 Y $1,113.6624100 Y $1,440.6124101 Y $1,440.6124102 Y $1,440.6124105 Y $1,440.61
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 20 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
24110 Y $1,440.6124115 Y $3,139.7624116 Y $3,139.7624120 Y $1,440.6124125 Y $1,440.6124126 Y $4,869.82 $1,901.61 $3,385.7124130 Y $1,440.6124134 Y $3,139.7624136 Y $1,440.6124138 Y $3,139.7624140 Y $1,440.6124145 Y $3,139.7624147 Y $1,440.6124149 Y $3,139.7624152 Y $3,139.7624155 Y $1,440.6124160 N $1,440.6124164 N $1,440.6124200 Y $164.9224201 Y $1,113.6624220 N BN24300 Y $798.5624301 Y $3,139.7624305 Y $1,440.6124310 Y $1,440.6124320 Y $3,139.7624330 Y $3,139.7624331 Y $3,139.7624332 Y $1,440.6124340 Y $3,139.7624341 Y $3,139.7624342 Y $3,139.7624343 Y $1,440.6124344 Y $3,139.7624345 Y $3,139.7624346 Y $6,414.3924357 Y $1,440.6124358 Y $1,440.6124359 Y $1,440.6124360 Y $3,139.7624361 Y $13,924.02 $4,663.93 $9,293.9724362 Y $6,414.3924363 Y $13,913.79 $4,671.83 $9,292.81
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 21 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
24365 Y $9,788.99 $4,008.45 $6,898.7224366 Y $10,407.12 $3,530.55 $6,968.8324370 Y $9,613.84 $4,143.86 $6,878.8524371 Y $12,469.73 $5,788.27 $9,129.0024400 Y $3,139.7624410 Y $6,414.3924420 Y $3,139.7624430 Y $9,147.84 $4,504.14 $6,825.9924435 Y $9,213.67 $4,453.23 $6,833.4524470 Y $1,440.6124495 Y $3,139.7624498 Y $9,020.64 $4,602.49 $6,811.5624500 Y $122.0424505 Y $798.5624515 Y $8,910.05 $4,687.99 $6,799.0224516 Y $9,037.25 $4,589.64 $6,813.4424530 Y $122.0424535 Y $798.5624538 Y $3,139.7624545 Y $9,354.32 $4,344.52 $6,849.4224546 Y $12,504.67 $5,761.27 $9,132.9724560 Y $122.0424565 Y $798.5624566 Y $798.5624575 Y $8,450.44 $5,043.32 $6,746.8824576 Y $122.0424577 Y $798.5624579 Y $8,594.90 $4,931.63 $6,763.2624582 Y $3,139.7624586 Y $6,414.3924587 Y $9,416.96 $4,296.08 $6,856.5224600 Y $122.0424605 Y $798.5624615 Y $3,139.7624620 Y $798.5624635 Y $4,460.24 $2,218.27 $3,339.2524640 Y NRC $62.6524650 Y $122.0424655 Y $798.5624665 Y $3,139.7624666 Y $10,354.06 $3,571.56 $6,962.8124670 Y $122.0424675 Y $798.56
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 22 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
24685 Y $4,198.96 $2,420.26 $3,309.6124800 Y $3,139.7624802 Y $6,414.3924925 Y $1,440.6125000 Y $798.5625001 Y $1,440.6125020 Y $798.5625023 Y $1,440.6125024 Y $1,440.6125025 Y $798.5625028 Y $1,440.6125031 Y $798.5625035 Y $3,139.7625040 Y $1,440.6125065 Y $204.5225066 Y $1,113.6625071 Y $645.5625073 Y $1,113.6625075 Y $645.5625076 Y $645.5625077 Y $1,113.6625078 Y $1,113.6625085 Y $1,440.6125100 Y $1,440.6125101 Y $1,440.6125105 Y $1,440.6125107 Y $1,440.6125109 Y $1,440.6125110 Y $798.5625111 Y $798.5625112 Y $798.5625115 Y $798.5625116 Y $1,440.6125118 Y $798.5625119 Y $1,440.6125120 Y $1,440.6125125 Y $798.5625126 Y $1,440.6125130 Y $1,440.6125135 Y $3,139.7625136 Y $4,234.01 $2,393.17 $3,313.5925145 Y $1,440.6125150 Y $1,440.61
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 23 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
25151 Y $1,440.6125210 Y $1,440.6125215 Y $1,440.6125230 Y $1,440.6125240 Y $1,440.6125246 N BN25248 Y $798.5625250 N $798.5625251 N $1,440.6125259 Y $798.5625260 Y $1,440.6125263 Y $3,139.7625265 Y $1,440.6125270 Y $1,440.6125272 Y $1,440.6125274 Y $1,440.6125275 Y $1,440.6125280 Y $1,440.6125290 Y $1,440.6125295 Y $1,440.6125300 Y $1,440.6125301 Y $1,440.6125310 Y $1,440.6125312 Y $1,440.6125315 Y $3,139.7625316 Y $3,139.7625320 Y $3,139.7625332 Y $1,440.6125335 Y $1,440.6125337 Y $3,139.7625350 Y $4,950.85 $1,838.95 $3,394.9025355 Y $1,440.6125360 Y $3,139.7625365 Y $6,414.3925370 Y $1,440.6125375 Y $1,440.6125390 Y $4,499.66 $2,187.79 $3,343.7225391 Y $9,166.38 $4,489.81 $6,828.0925392 Y $3,139.7625393 Y $3,139.7625394 Y $1,440.6125400 Y $4,508.11 $2,181.26 $3,344.6825405 Y $4,457.73 $2,220.20 $3,338.96
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 24 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
25415 Y $4,612.30 $2,100.70 $3,356.5025420 Y $3,139.7625425 Y $3,139.7625426 Y $1,440.6125430 Y $1,440.6125431 Y $3,139.7625440 Y $3,139.7625441 Y $10,645.55 $3,346.20 $6,995.8725442 Y $14,567.23 $4,166.63 $9,366.9325443 Y $4,455.85 $2,221.65 $3,338.7525444 Y $10,733.12 $3,278.49 $7,005.8025445 Y $4,502.78 $2,185.36 $3,344.0725446 Y $14,652.43 $4,100.76 $9,376.5925447 Y $1,440.6125449 Y $3,139.7625450 Y NRC $1,440.6125455 Y NRC $1,440.6125490 Y NRC $3,139.7625491 Y NRC $6,414.3925492 Y NRC $1,440.6125500 Y $122.0425505 Y $798.5625515 Y $4,289.71 $2,350.11 $3,319.9125520 Y $798.5625525 Y $3,139.7625526 Y $4,248.10 $2,382.29 $3,315.1925530 Y $122.0425535 Y $122.0425545 Y $4,207.73 $2,413.49 $3,310.6125560 Y $122.0425565 Y $798.5625574 Y $4,525.63 $2,167.71 $3,346.6725575 Y $4,400.16 $2,264.72 $3,332.4425600 Y $122.0425605 Y $798.5625606 Y $1,440.6125607 Y $4,602.29 $2,108.44 $3,355.3625608 Y $4,582.58 $2,123.68 $3,353.1325609 Y $4,601.35 $2,109.17 $3,355.2625622 Y $122.0425624 Y $798.5625628 Y $3,139.7625630 Y $122.04
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 25 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
25635 Y $798.5625645 Y $1,440.6125650 Y $122.0425651 Y $1,440.6125652 Y $3,139.7625660 Y $122.0425670 Y $3,139.7625671 Y $1,440.6125675 Y $122.0425676 Y $3,139.7625680 Y $122.0425685 Y $3,139.7625690 Y $798.5625695 Y $3,139.7625800 Y $4,647.35 $2,073.61 $3,360.4825805 Y $4,621.07 $2,093.93 $3,357.5025810 Y $9,066.66 $4,566.91 $6,816.7825820 Y $4,344.15 $2,308.02 $3,326.0825825 Y $4,319.12 $2,327.37 $3,323.2425830 Y $4,235.26 $2,392.20 $3,313.7325907 Y $1,440.6125922 Y $798.5625929 Y $918.3425931 Y $1,440.6126010 Y $98.8826011 Y $645.5626020 Y $1,440.6126025 Y $1,440.6126030 Y $1,440.6126034 Y $798.5626035 Y $1,440.6126037 Y $1,440.6126040 Y $798.5626045 Y $1,440.6126055 Y $798.5626060 Y $798.5626070 Y $798.5626075 Y $1,440.6126080 Y $798.5626100 Y $1,440.6126105 Y $1,440.6126110 Y $798.5626111 Y $645.56
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 26 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
26113 Y $645.5626115 Y $645.5626116 Y $645.5626117 Y $1,113.6626118 Y $1,113.6626121 Y $1,440.6126123 Y $1,440.6126125 N BN26130 Y $1,440.6126135 Y $1,440.6126140 Y $798.5626145 Y $798.5626160 Y $798.5626170 Y $798.5626180 Y $798.5626185 Y $798.5626200 Y $798.5626205 Y $3,139.7626210 Y $798.5626215 Y $1,440.6126230 Y $1,440.6126235 Y $798.5626236 Y $798.5626250 Y $1,440.6126260 Y $1,440.6126262 Y $798.5626320 N $645.5626340 Y $798.5626341 Y $80.0426350 Y $1,440.6126352 Y $3,139.7626356 Y $1,440.6126357 Y $1,440.6126358 Y $3,139.7626370 Y $1,440.6126372 Y $3,139.7626373 Y $1,440.6126390 Y $4,240.58 $2,388.09 $3,314.3326392 Y $3,139.7626410 Y $798.5626412 Y $1,440.6126415 Y $1,440.6126416 Y $1,440.61
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 27 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
26418 Y $798.5626420 Y $1,440.6126426 Y $1,440.6126428 Y $1,440.6126432 Y $798.5626433 Y $1,440.6126434 Y $1,440.6126437 Y $1,440.6126440 Y $798.5626442 Y $1,440.6126445 Y $1,440.6126449 Y $1,440.6126450 Y $1,440.6126455 Y $798.5626460 Y $798.5626471 Y $1,440.6126474 Y $798.5626476 Y $1,440.6126477 Y $1,440.6126478 Y $1,440.6126479 Y $1,440.6126480 Y $1,440.6126483 Y $1,440.6126485 Y $1,440.6126489 Y $1,440.6126490 Y $1,440.6126492 Y $1,440.6126494 Y $1,440.6126496 Y $1,440.6126497 Y $1,440.6126498 Y $1,440.6126499 Y $1,440.6126500 Y $3,139.7626502 Y $1,440.6126508 Y $1,440.6126510 Y $1,440.6126516 Y $1,440.6126517 Y $1,440.6126518 Y $3,139.7626520 Y $1,440.6126525 Y $798.5626530 Y $3,139.7626531 Y $4,584.15 $2,122.48 $3,353.31
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 28 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
26535 Y $1,440.6126536 Y $4,241.84 $2,387.13 $3,314.4826540 Y $1,440.6126541 Y $1,440.6126542 Y $1,440.6126545 Y $1,440.6126546 Y $3,139.7626548 Y $1,440.6126550 Y $1,440.6126555 Y $3,139.7626560 Y $798.5626561 Y $1,440.6126562 Y $1,440.6126565 Y $1,440.6126567 Y $1,440.6126568 Y $3,139.7626580 Y NRC $1,440.6126587 Y NRC $1,440.6126590 Y NRC $798.5626591 Y $1,440.6126593 Y $1,440.6126596 Y $1,440.6126600 Y $122.0426605 Y $122.0426607 Y $1,440.6126608 Y $1,440.6126615 Y $1,440.6126641 Y $122.0426645 Y $798.5626650 Y $1,440.6126665 Y $1,440.6126670 Y $122.0426675 Y $798.5626676 Y $1,440.6126685 Y $1,440.6126686 Y $1,440.6126700 Y $122.0426705 Y $798.5626706 Y $1,440.6126715 Y $1,440.6126720 Y $122.0426725 Y $122.0426727 Y $1,440.61
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 29 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
26735 Y $1,440.6126740 Y $122.0426742 Y $798.5626746 Y $1,440.6126750 Y $122.0426755 Y $122.0426756 Y $1,440.6126765 Y $1,440.6126770 Y $122.0426775 Y $130.0526776 Y $1,440.6126785 Y $1,440.6126820 Y $4,382.64 $2,278.26 $3,330.4526841 Y $3,139.7626842 Y $3,139.7626843 Y $3,139.7626844 Y $3,139.7626850 Y $3,139.7626852 Y $3,139.7626860 Y $1,440.6126861 N BN26862 Y $1,440.6126863 N BN26910 Y $1,440.6126951 Y $1,440.6126952 Y $1,440.6126990 Y $1,440.6126991 Y $798.5627000 Y $798.5627001 Y $1,440.6127003 Y $3,139.7627033 Y $3,139.7627035 Y $1,440.6127040 Y $645.5627041 Y $645.5627043 Y $1,113.6627045 Y $1,113.6627047 Y $1,113.6627048 Y $1,113.6627049 Y $1,113.6627050 Y $798.5627052 Y $798.5627059 Y $1,113.66
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 30 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
27060 Y $3,139.7627062 Y $1,440.6127065 Y $3,139.7627066 Y $1,440.6127067 Y $3,139.7627080 Y $1,440.6127086 Y $645.5627087 Y $1,440.6127093 N BN27095 N BN27097 Y $1,440.6127098 Y $1,440.6127100 Y $3,139.7627105 Y $1,440.6127110 Y $3,139.7627111 Y $1,440.6127125 Y AC $8,818.43 $3,273.89 $6,046.1627130 Y AC $8,818.43 $3,273.89 $6,046.1627132 Y AC $8,818.43 $3,273.89 $6,046.1627197 Y $122.0427198 Y $122.0427200 Y $122.0427202 Y $1,440.6127220 Y $122.0427230 Y $122.0427238 Y $798.5627246 Y $122.0427250 Y $122.0427252 Y $798.5627256 Y $122.0427257 Y $798.5627265 Y $122.0427266 Y $798.5627267 Y $1,440.6127275 Y $798.5627279 Y $14,799.81 $3,986.81 $9,393.3127301 Y $1,113.6627305 Y $1,440.6127306 Y $1,440.6127307 Y $1,440.6127310 Y $1,440.6127323 Y $645.5627324 Y $1,113.66
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 31 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
27325 Y $892.4027326 Y $892.4027327 Y $645.5627328 Y $1,113.6627329 Y $1,113.6627330 Y $1,440.6127331 Y $1,440.6127332 Y $1,440.6127333 Y $1,440.6127334 Y $1,440.6127335 Y $3,139.7627337 Y $1,113.6627339 Y $1,113.6627340 Y $1,440.6127345 Y $1,440.6127347 Y $1,440.6127350 Y $3,139.7627355 Y $1,440.6127356 Y $6,414.3927357 Y $3,139.7627358 N BN27360 Y $1,440.6127364 Y $1,113.6627369 N BN27372 Y $1,113.6627380 Y $3,139.7627381 Y $3,139.7627385 Y $3,139.7627386 Y $3,139.7627390 Y $1,440.6127391 Y $1,440.6127392 Y $1,440.6127393 Y $3,139.7627394 Y $3,139.7627395 Y $1,440.6127396 Y $3,139.7627397 Y $3,139.7627400 Y $3,139.7627403 Y $4,222.13 $2,402.37 $3,312.2527405 Y $3,139.7627407 Y $3,139.7627409 Y $3,139.7627415 Y $10,728.02 $3,282.46 $7,005.24
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 32 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
27416 Y $3,139.7627418 Y $3,139.7627420 Y $3,139.7627422 Y $3,139.7627424 Y $3,139.7627425 Y $1,440.6127427 Y $4,139.20 $2,466.46 $3,302.8327428 Y $8,797.54 $4,774.96 $6,786.2527429 Y $11,529.61 $2,662.72 $7,096.1627430 Y $3,139.7627435 Y $1,440.6127437 Y $3,139.7627438 Y $8,967.58 $4,643.51 $6,805.5427440 Y $9,643.24 $4,121.13 $6,882.1827441 Y $6,414.3927442 Y $9,661.77 $4,106.79 $6,884.2827443 Y $9,423.99 $4,290.64 $6,857.3127445 Y AC $9,814.45 $3,987.44 $6,900.9427446 Y $9,588.27 $4,163.63 $6,875.9527447 Y $9,815.19 $3,988.18 $6,901.6827475 Y NRC $3,139.7627479 Y NRC $3,139.7627496 Y $1,440.6127497 Y $1,440.6127498 Y $798.5627499 Y $3,139.7627500 Y $122.0427501 Y $122.0427502 Y $798.5627503 Y $798.5627508 Y $122.0427509 Y $3,139.7627510 Y $798.5627516 Y $122.0427517 Y $798.5627520 Y $122.0427524 Y $3,139.7627530 Y $122.0427532 Y $1,440.6127538 Y $122.0427550 Y $122.0427552 Y $798.5627560 Y $122.04
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 33 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
27562 Y $122.0427566 Y $3,139.7627570 Y $798.5627594 Y $1,440.6127600 Y $1,440.6127601 Y $1,440.6127602 Y $1,440.6127603 Y $1,113.6627604 Y $1,440.6127605 Y $798.5627606 Y $1,440.6127607 Y $1,440.6127610 Y $1,440.6127612 Y $1,440.6127613 Y $190.7827614 Y $1,113.6627615 Y $1,113.6627616 Y $1,113.6627618 Y $645.5627619 Y $1,113.6627620 Y $1,440.6127625 Y $1,440.6127626 Y $1,440.6127630 Y $1,440.6127632 Y $1,113.6627634 Y $1,113.6627635 Y $1,440.6127637 Y $3,139.7627638 Y $3,139.7627640 Y $1,440.6127641 Y $1,440.6127647 Y $1,440.6127648 N BN27650 Y $3,139.7627652 Y $3,139.7627654 Y $3,139.7627656 Y $1,440.6127658 Y $1,440.6127659 Y $3,139.7627664 Y $3,139.7627665 Y $3,139.7627675 Y $1,440.6127676 Y $3,139.76
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 34 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
27680 Y $1,440.6127681 Y $1,440.6127685 Y $1,440.6127686 Y $1,440.6127687 Y $1,440.6127690 Y $3,139.7627691 Y $3,139.7627692 N BN27695 Y $3,139.7627696 Y $3,139.7627698 Y $3,139.7627700 Y $3,139.7627702 Y AC $9,630.40 $4,129.82 $6,880.1127703 Y AC $9,630.40 $4,129.82 $6,880.1127704 N $1,440.6127705 Y $4,602.92 $2,107.96 $3,355.4427707 Y $1,440.6127709 Y $6,414.3927720 Y $4,386.39 $2,275.36 $3,330.8727726 Y $4,468.37 $2,211.98 $3,340.1727730 Y $1,440.6127732 Y $1,440.6127734 Y $1,440.6127740 Y $1,440.6127742 Y $1,440.6127745 Y $4,452.10 $2,224.56 $3,338.3327750 Y $122.0427752 Y $798.5627756 Y $4,669.25 $2,056.67 $3,362.9627758 Y $9,225.83 $4,443.85 $6,834.8427759 Y $9,108.85 $4,534.29 $6,821.5727760 Y $122.0427762 Y $798.5627766 Y $3,139.7627767 Y $122.0427768 Y $798.5627769 Y $3,139.7627780 Y $122.0427781 Y $798.5627784 Y $3,139.7627786 Y $122.0427788 Y $122.0427792 Y $4,223.69 $2,401.16 $3,312.42
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 35 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
27808 Y $122.0427810 Y $798.5627814 Y $4,290.64 $2,349.38 $3,320.0127816 Y $122.0427818 Y $798.5627822 Y $4,272.49 $2,363.41 $3,317.9527823 Y $4,258.42 $2,374.30 $3,316.3627824 Y $122.0427825 Y $798.5627826 Y $4,463.99 $2,215.37 $3,339.6827827 Y $9,139.53 $4,510.57 $6,825.0527828 Y $9,299.33 $4,387.01 $6,843.1727829 Y $3,139.7627830 Y $122.0427831 Y $1,440.6127832 Y $3,139.7627840 Y $122.0427842 Y $798.5627846 Y $3,139.7627848 Y $4,708.05 $2,026.68 $3,367.3627860 Y $1,440.6127870 Y $9,631.10 $4,130.52 $6,880.8127871 Y $9,282.07 $4,400.35 $6,841.2127884 Y $1,440.6127889 Y $3,139.7627892 Y $1,440.6127893 Y $3,139.7627894 Y $1,440.6128001 Y $202.5128002 Y $798.5628003 Y $1,440.6128005 Y $1,440.6128008 Y $1,440.6128010 Y $139.4528011 Y $798.5628020 Y $1,440.6128022 Y $1,440.6128024 Y $798.5628035 Y $892.4028039 Y $1,113.6628041 Y $1,113.6628043 Y $645.5628045 Y $1,113.66
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 36 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
28046 Y $1,113.6628047 Y $1,113.6628050 Y $1,440.6128052 Y $1,440.6128054 Y $1,440.6128055 Y $892.4028060 Y $1,440.6128062 Y $1,440.6128070 Y $3,139.7628072 Y $1,440.6128080 Y $798.5628086 Y $1,440.6128088 Y $1,440.6128090 Y $798.5628092 Y $798.5628100 Y $1,440.6128102 Y $3,139.7628103 Y $3,139.7628104 Y $1,440.6128106 Y $3,139.7628107 Y $3,139.7628108 Y $798.5628110 Y $1,440.6128111 Y $1,440.6128112 Y $1,440.6128113 Y $1,440.6128114 Y $1,440.6128116 Y $1,440.6128118 Y $1,440.6128119 Y $1,440.6128120 Y $1,440.6128122 Y $1,440.6128124 Y $337.9228126 Y $1,440.6128130 Y $4,769.37 $1,979.26 $3,374.3128140 Y $1,440.6128150 Y $1,440.6128153 Y $1,440.6128160 Y $1,440.6128171 Y $1,440.6128173 Y $1,440.6128175 Y $798.5628190 Y $204.12
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 37 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
28192 Y $645.5628193 Y $645.5628200 Y $1,440.6128202 Y $3,139.7628208 Y $1,440.6128210 Y $3,139.7628220 Y $319.3228222 Y $1,440.6128225 Y $1,440.6128226 Y $1,440.6128230 Y $314.8828232 Y $293.8528234 Y $798.5628238 Y $3,139.7628240 Y $1,440.6128250 Y $1,440.6128260 Y $1,440.6128261 Y $798.5628262 Y $5,054.74 $1,758.64 $3,406.6928264 Y $798.5628270 Y $1,440.6128272 Y $283.7528280 Y NRC $1,440.6128285 Y $1,440.6128286 Y $1,440.6128288 Y $1,440.6128289 Y $1,440.6128291 Y $4,902.67 $1,876.21 $3,389.4428292 Y NRC $1,440.6128295 Y $1,440.6128296 Y NRC $1,440.6128297 Y NRC $4,583.83 $2,122.72 $3,353.2728298 Y NRC $3,139.7628299 Y NRC $3,139.7628300 Y $4,274.37 $2,361.96 $3,318.1628302 Y $3,139.7628304 Y $3,139.7628305 Y $4,602.29 $2,108.44 $3,355.3628306 Y $3,139.7628307 Y $3,139.7628308 Y $1,440.6128309 Y $3,139.7628310 Y $3,139.76
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 38 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
28312 Y $1,440.6128313 Y NRC $1,440.6128315 Y $1,440.6128320 Y $10,120.74 $3,751.95 $6,936.3428322 Y $4,359.17 $2,296.41 $3,327.7928340 Y NRC $1,440.6128341 Y NRC $1,440.6128344 Y NRC $1,440.6128345 Y NRC $798.5628400 Y $122.0428405 Y $122.0428406 Y $3,139.7628415 Y $4,417.37 $2,251.41 $3,334.3928420 Y $9,405.46 $4,304.98 $6,855.2228430 Y $122.0428435 Y $798.5628436 Y $3,139.7628445 Y $4,147.02 $2,460.41 $3,303.7128446 Y $3,139.7628450 Y $122.0428455 Y $187.9628456 Y $3,139.7628465 Y $4,367.61 $2,289.87 $3,328.7428470 Y $122.0428475 Y $122.0428476 Y $1,440.6128485 Y $4,254.35 $2,377.44 $3,315.8928490 Y $110.7628495 Y $122.0428496 Y $1,440.6128505 Y $1,440.6128510 Y $87.7128515 Y $118.4328525 Y $1,440.6128530 Y $84.0828531 Y $3,139.7628540 Y $122.0428545 Y $1,440.6128546 Y $798.5628555 Y $3,139.7628570 Y $122.0428575 Y $1,440.6128576 Y $3,139.76
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 39 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
28585 Y $4,713.36 $2,022.56 $3,367.9628600 Y $122.0428605 Y $122.0428606 Y $1,440.6128615 Y $4,167.36 $2,444.69 $3,306.0228630 Y $99.8428635 Y $798.5628636 Y $1,440.6128645 Y $1,440.6128660 Y $77.2028665 Y $130.0528666 Y $1,440.6128675 Y $1,440.6128705 Y $13,199.85 $5,223.79 $9,211.8228715 Y $10,075.99 $3,786.54 $6,931.2628725 Y $9,255.23 $4,421.11 $6,838.1728730 Y $9,957.74 $3,877.97 $6,917.8528735 Y $10,057.46 $3,800.88 $6,929.1728737 Y $9,560.78 $4,184.88 $6,872.8328740 Y $4,724.95 $2,013.62 $3,369.2828750 Y $4,638.27 $2,080.62 $3,359.4428755 Y $3,139.7628760 Y $3,139.7628810 Y $1,440.6128820 Y $1,440.6128825 Y $1,440.6128890 Y $219.4929000 Y $130.0529010 Y $130.0529015 Y $130.0529035 Y $130.0529040 Y $130.0529044 Y $75.6929046 Y $130.0529049 Y $69.5229055 Y $130.0529058 Y $78.0129065 Y $67.5029075 Y $61.8529085 Y $67.1029086 Y $61.0429105 Y $55.7829125 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 40 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
29126 N BN29130 N BN29131 N BN29200 Y $21.0229240 N BN29260 N BN29280 N BN29305 Y $130.0529325 Y $130.0529345 Y $88.1229355 Y $89.7329358 Y $113.1829365 Y $83.2629405 Y $54.1629425 Y $50.9329435 Y $75.1929440 Y $24.6529445 Y $69.5229450 Y $73.1629505 Y $65.0729515 Y $47.2929520 N BN29530 N BN29540 Y $15.7629550 N BN29580 Y $47.2929581 Y $75.6929584 Y $75.6929700 Y $45.2729705 Y $38.4029710 Y $75.5929720 Y $63.4629730 Y $36.3829740 Y $59.4229750 Y NRC $62.2529800 Y $1,440.6129804 Y $1,440.6129805 Y $1,440.6129806 Y $3,139.7629807 Y $3,139.7629819 Y $1,440.6129820 Y $3,139.7629821 Y $1,440.61
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 41 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
29822 Y $1,440.6129823 Y $1,440.6129824 Y $1,440.6129825 Y $1,440.6129826 N BN29827 Y $3,139.7629828 Y $3,139.7629830 Y $1,440.6129834 Y $1,440.6129835 Y $1,440.6129836 Y $3,139.7629837 Y $1,440.6129838 Y $1,440.6129840 Y $1,440.6129843 Y $1,440.6129844 Y $1,440.6129845 Y $1,440.6129846 Y $1,440.6129847 Y $3,139.7629848 Y $798.5629850 Y $798.5629851 Y $798.5629855 Y $4,905.17 $1,874.27 $3,389.7229856 Y $8,941.37 $4,663.77 $6,802.5729860 Y $3,139.7629861 Y $3,139.7629862 Y $3,139.7629863 Y $1,440.6129866 Y $3,139.7629867 Y $9,673.29 $4,097.90 $6,885.5929870 Y $1,440.6129871 Y $1,440.6129873 Y $1,440.6129874 Y $1,440.6129875 Y $1,440.6129876 Y $1,440.6129877 Y $1,440.6129879 Y $1,440.6129880 Y $1,440.6129881 Y $1,440.6129882 Y $1,440.6129883 Y $1,440.6129884 Y $1,440.61
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 42 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
29885 Y $3,139.7629886 Y $1,440.6129887 Y $3,139.7629888 Y $4,415.49 $2,252.86 $3,334.1729889 Y $8,734.26 $4,823.90 $6,779.0829891 Y $1,440.6129892 Y $3,139.7629893 Y $1,440.6129894 Y $1,440.6129895 Y $1,440.6129897 Y $1,440.6129898 Y $1,440.6129899 Y $4,143.58 $2,463.08 $3,303.3329900 Y $1,440.6129901 Y $1,440.6129902 Y $798.5629904 Y $1,440.6129905 Y $3,139.7629906 Y $1,440.6129907 Y $8,962.46 $4,647.46 $6,804.9629914 Y $3,139.7629915 Y $3,139.7629916 Y $3,139.7630000 Y $102.8930020 Y $200.3030100 Y $107.1930110 Y $176.8430115 Y $1,055.0630117 Y $1,055.0630118 Y $1,055.0630120 Y $1,055.0630124 Y $536.6030125 Y $2,246.5530130 Y $1,055.0630140 Y $1,055.0630150 Y $2,246.5530160 Y $2,246.5530200 Y $82.6530210 Y $106.8330220 Y $536.6030300 N BN30310 Y $1,055.0630320 Y $536.60
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 43 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
30400 Y NRC $2,246.5530410 Y NRC $2,246.5530420 Y $2,246.5530430 Y $2,246.5530435 Y $2,246.5530450 Y $2,246.5530460 Y NRC $2,246.5530462 Y NRC $2,246.5530465 Y $2,246.5530520 Y $1,055.0630540 Y $2,246.5530545 Y NRC $2,246.5530560 Y $223.1930580 Y $2,246.5530600 Y $2,246.5530620 Y $2,246.5530630 Y $1,055.0630801 Y $536.6030802 Y $536.6030901 N BN30903 Y $55.0930905 Y $55.0930906 Y $102.8930915 Y $1,341.2330920 Y $1,341.2330930 Y $1,055.0631000 Y $102.8931002 Y $536.6031020 Y $1,055.0631030 Y $2,246.5531032 Y $2,246.5531040 Y $2,246.5531050 Y $2,246.5531051 Y $2,246.5531070 Y $2,246.5531075 Y $2,246.5531080 Y $2,246.5531081 Y $2,246.5531084 Y $2,246.5531085 Y $2,246.5531086 Y $2,246.5531087 Y $2,246.5531090 Y $2,246.55
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 44 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
31200 Y $2,246.5531201 Y $536.6031205 Y $1,055.0631231 Y NRC $79.1031233 Y NRC $190.9531235 Y NRC $611.6931237 Y NRC $611.6931238 Y $611.6931239 Y NRC $1,237.7131240 Y NRC $611.6931253 Y $1,895.8931254 Y $1,895.8931255 Y $1,895.8931256 Y $1,237.7131257 Y $1,895.8931259 Y $1,895.8931267 Y $1,895.8931276 Y $1,895.8931287 Y $1,895.8931288 Y $1,895.8931295 Y $1,821.4431296 Y $1,831.1931297 Y $1,816.7531298 Y $1,895.8931300 Y $1,055.0631400 Y $2,246.5531420 Y $2,246.5531500 Y $102.8931502 Y $102.8931505 Y $64.2431510 Y $1,237.7131511 Y $79.1031512 Y $1,237.7131513 Y $190.9531515 Y $190.9531520 Y NRC $190.9531525 Y $611.6931526 Y $611.6931527 Y $1,237.7131528 Y $1,237.7131529 Y $1,237.7131530 Y $611.6931531 Y $1,237.71
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 45 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
31535 Y $1,237.7131536 Y $1,237.7131540 Y $1,237.7131541 Y $1,237.7131545 Y $1,237.7131546 Y $1,895.8931551 Y NRC $2,246.5531552 Y $2,246.5531553 Y NRC $2,246.5531554 Y $2,246.5531560 Y $1,895.8931561 Y $1,895.8931570 Y $1,237.7131571 Y $1,237.7131572 Y $1,237.7131573 Y $182.9731574 Y $611.6931575 Y $79.1031576 Y $611.6931577 Y $190.9531578 Y $1,237.7131579 Y $119.8231580 Y $2,246.5531590 Y $2,246.5531591 Y $2,246.5531592 Y $2,246.5531603 Y $536.6031605 Y $102.8931611 Y $1,055.0631612 Y $1,055.0631613 Y $1,055.0631614 Y $2,246.5531615 Y $223.1931622 Y $611.6931623 Y $611.6931624 Y $611.6931625 Y $611.6931626 Y $1,895.8931627 N BN31628 Y $1,237.7131629 Y $1,237.7131630 Y $1,237.7131631 Y $1,895.89
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 46 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
31632 N BN31633 N BN31634 Y $1,895.8931635 Y $611.6931636 Y $3,162.63 $1,387.14 $2,274.8831637 N BN31638 Y $1,895.8931640 Y $1,237.7131641 Y $1,237.7131643 Y $611.6931645 Y $611.6931646 Y $190.9531647 Y $2,817.29 $1,654.14 $2,235.7131648 Y $1,237.7131649 N $611.6931651 N BN31652 Y $1,237.7131653 Y $1,237.7131654 N BN31717 Y $190.9531720 N BN31730 Y $611.6931750 Y $2,246.5531755 Y $2,246.5531820 Y $1,055.0631825 Y $1,055.0631830 Y $1,055.0632400 Y $576.3932405 Y $576.3932550 Y $1,377.2132552 N $318.5932553 N $629.2632554 Y $318.5932555 Y $318.5932556 Y $663.0632557 Y $579.9132960 Y $318.5932994 Y $2,194.0732998 Y $2,194.0733016 Y $579.9133206 Y NRC $8,419.83 $3,066.35 $5,743.0933207 Y NRC $8,702.71 $2,847.64 $5,775.1733208 Y NRC $8,911.57 $2,686.16 $5,798.86
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 47 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
33210 Y NRC $3,802.4733211 Y NRC $6,688.16 $2,515.35 $4,601.7533212 Y NRC $7,069.71 $2,220.37 $4,645.0433213 Y NRC $8,790.49 $2,779.78 $5,785.1333214 Y NRC $8,625.51 $2,907.32 $5,766.4133215 Y NRC $1,341.2333216 Y NRC $6,235.32 $2,865.46 $4,550.3933217 Y NRC $7,607.86 $1,804.30 $4,706.0833218 Y NRC $1,507.7833220 Y NRC $2,424.68 $1,173.19 $1,798.9333221 Y $13,370.02 $3,920.92 $8,645.4733222 Y NRC $819.9533223 Y NRC $819.9533224 Y NRC $8,935.37 $2,667.77 $5,801.5733225 N BN33226 Y NRC $1,341.2333227 Y $6,910.55 $2,343.41 $4,626.9833228 Y $8,703.77 $2,846.82 $5,775.2933229 Y $13,461.35 $3,850.32 $8,655.8333230 Y $22,744.22 $5,432.61 $14,088.4133231 Y $30,372.31 $7,158.74 $18,765.5233233 N NRC $6,102.48 $2,968.17 $4,535.3233234 N NRC $1,507.7833235 N NRC $2,224.76 $1,327.77 $1,776.2633240 Y NRC $22,506.55 $5,616.35 $14,061.4533241 N NRC $1,507.7833249 Y NRC $30,439.98 $7,106.42 $18,773.2033262 Y $22,234.57 $5,826.63 $14,030.6033263 Y $22,548.49 $5,583.92 $14,066.2033264 Y $30,483.98 $7,072.42 $18,778.2033270 Y $30,167.59 $7,317.02 $18,742.3033271 Y $7,136.34 $2,168.85 $4,652.5933273 Y $1,507.7833274 Y NRC $12,686.74 $3,933.35 $8,310.0433275 Y NRC $1,341.2333285 Y NRC $7,587.92 $1,819.73 $4,703.8233286 N NRC $308.2333419 N BN33508 N BN33866 N BN34490 Y NRC $1,341.2334713 N BN34714 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 48 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
34715 N BN34716 N BN35188 Y NRC $2,321.8135207 Y $1,341.2335572 N BN35875 Y NRC $2,321.8135876 Y NRC $2,321.8136000 N BN36002 Y $318.5936005 N BN36010 N BN36011 N BN36012 N BN36013 N BN36014 N BN36015 N BN36100 N BN36140 N BN36160 N BN36200 N BN36215 N BN36216 N BN36217 N BN36218 N BN36221 N BN36222 N BN36223 N BN36224 N BN36225 N BN36226 N BN36227 N BN36228 N BN36245 N BN36246 N BN36247 N BN36248 N BN36251 N BN36252 N BN36253 N BN36254 N BN36260 Y $2,321.8136261 Y $2,996.19 $731.33 $1,863.7636262 N $1,507.78
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 49 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
36400 N BN36405 N BN36406 N BN36410 N BN36416 N BN36420 N BN36425 N BN36430 N $35.0136440 N NRC $196.0736450 N NRC $196.0736455 N $196.0736465 Y NRC $819.9536466 Y NRC $819.9536468 N BN36470 Y NRC $80.1236471 Y NRC $137.5036473 Y $1,308.2536474 N BN36475 Y NRC $1,341.2336476 N BN36478 Y NRC $1,341.2336479 N BN36481 N BN36482 Y NRC $1,799.4336483 N BN36500 N BN36510 N BN36511 N $668.8136512 N $668.8136513 N $196.0736514 N $668.8136516 N $1,929.3736522 N $1,929.3736555 Y NRC $579.9136556 Y $579.9136557 Y NRC $2,321.8136558 Y $1,341.2336560 Y NRC $1,341.2336561 Y $1,341.2336563 Y $2,321.8136565 Y $1,341.2336566 Y $2,321.8136568 Y NRC $318.59
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 50 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
36569 Y $579.9136570 Y NRC $1,341.2336571 Y $1,341.2336573 Y $579.9136575 Y $318.5936576 Y $579.9136578 Y $1,341.2336580 Y $579.9136581 Y $1,341.2336582 Y $1,341.2336583 Y $4,773.16 $1,002.95 $2,888.0536584 Y $579.9136585 Y $1,341.2336589 N $318.5936590 N $318.5936591 N BN36592 N BN36593 Y $31.4036595 Y $1,341.2336596 Y $579.9136597 Y $579.9136598 Y $92.8436600 N BN36620 N BN36625 N BN36640 Y $1,341.2336680 N BN36800 Y NRC $2,321.8136810 Y NRC $1,341.2336815 Y NRC $2,321.8136818 Y NRC $2,321.8136819 Y NRC $2,321.8136820 Y NRC $2,321.8136821 Y NRC $1,341.2336825 Y NRC $2,321.8136830 Y NRC $2,321.8136831 Y NRC $2,321.8136832 Y NRC $2,321.8136833 Y NRC $2,321.8136835 Y NRC $2,279.60 $948.69 $1,614.1436860 Y NRC $318.5936861 Y NRC $2,321.8136901 Y NRC $573.46
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 51 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
36902 Y NRC $2,141.7436903 Y NRC $7,203.77 $2,885.79 $5,044.7836904 Y NRC $3,277.77 $1,795.09 $2,536.4336905 Y NRC $4,182.9436906 Y NRC $11,607.75 $4,767.56 $8,187.6536907 N BN36908 N BN36909 N BN37184 Y $7,329.84 $2,788.34 $5,059.0937185 N BN37186 N BN37187 Y $3,537.39 $1,594.39 $2,565.8937188 Y $1,341.2337197 Y $1,341.2337200 Y $2,321.8137211 Y $2,321.8137212 Y $1,341.2337220 Y NRC $2,141.7437221 Y NRC $7,045.04 $3,008.52 $5,026.7837222 N BN37223 N BN37224 Y NRC $3,556.74 $1,579.41 $2,568.0737225 Y NRC $7,609.96 $2,571.76 $5,090.8637226 Y NRC $7,347.11 $2,774.98 $5,061.0437227 Y NRC $12,473.53 $4,098.20 $8,285.8637228 Y NRC $6,464.24 $3,457.55 $4,960.8937229 Y NRC $11,726.88 $4,675.46 $8,201.1737230 Y NRC $11,515.94 $4,838.55 $8,177.2437231 Y NRC $12,140.42 $4,355.74 $8,248.0837232 N BN37233 N BN37234 N BN37235 N BN37236 Y $6,777.52 $3,215.35 $4,996.4337237 N BN37238 Y $7,061.38 $2,995.89 $5,028.6337239 N BN37241 Y $4,182.9437242 Y $6,950.26 $3,081.79 $5,016.0237243 Y $4,182.9437246 Y NRC $2,141.7437247 N BN37248 Y NRC $2,141.74
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 52 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
37249 N BN37252 N BN37253 N BN37500 Y NRC $2,321.8137607 Y NRC $1,341.2337609 Y $576.3937650 Y NRC $1,341.2337700 Y NRC $1,341.2337718 Y NRC $1,341.2337722 Y NRC $1,341.2337735 Y NRC $1,341.2337760 Y NRC $1,341.2337761 Y NRC $579.9137765 Y NRC $247.9437766 Y NRC $273.2037780 Y NRC $579.9137785 Y NRC $1,341.2337790 Y NRC $1,376.9738200 N BN38204 N BN38206 N NRC $668.8138220 Y $122.3438221 Y $111.8838222 Y $994.3438230 N NRC $668.8138232 N $1,929.3738241 N NRC $668.8138242 N NRC $668.8138243 N $668.8138300 Y $994.3438305 Y $994.3438308 Y NRC $1,118.4438500 Y $1,118.4438505 Y $576.3938510 Y $1,118.4438520 Y $1,118.4438525 Y $1,118.4438530 Y $1,118.4438542 Y $2,194.0738550 Y $1,118.4438555 Y $2,193.2738570 Y $2,194.0738571 Y $3,588.58
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 53 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
38572 Y $3,588.5838573 Y $3,588.5838700 Y $2,193.2738740 Y $2,194.0738745 Y $2,194.0738760 Y $2,193.2738790 N BN38792 N BN38794 N BN38900 N BN40490 Y $80.1240500 Y NRC $1,055.0640510 Y NRC $1,055.0640520 Y NRC $1,055.0640525 Y NRC $1,055.0640527 Y NRC $2,246.5540530 Y NRC $1,055.0640650 Y $223.1940652 Y $223.1940654 Y $536.6040700 Y NRC $2,246.5540701 Y NRC $2,246.5540702 Y NRC $2,246.5540720 Y NRC $1,055.0640761 Y NRC $2,246.5540800 Y $166.3740801 Y $223.1940804 N BN40805 Y $196.6940806 Y NRC $89.5040808 Y $121.9840810 Y $162.0440812 Y $200.6640814 Y $1,055.0640816 Y $1,055.0640818 Y $223.1940819 Y $536.6040820 Y $214.7340830 Y $102.8940831 Y $223.1940840 Y $2,246.5540842 Y $2,246.5540843 Y $2,246.55
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 54 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
40844 Y $2,246.5540845 Y $2,246.5541000 Y $109.7141005 Y $102.8941006 Y $536.6041007 Y $536.6041008 Y $1,055.0641009 Y $223.1941010 Y NRC $536.6041015 Y $223.1941016 Y $2,246.5541017 Y $1,055.0641018 Y $536.6041019 Y $2,246.5541100 Y $122.7041105 Y $122.7041108 Y $115.4941110 Y $163.1241112 Y $1,055.0641113 Y $1,055.0641114 Y $1,055.0641115 Y $188.0341116 Y $1,055.0641120 Y NRC $2,246.5541250 N BN41251 Y $102.8941252 Y $102.8941510 Y NRC $1,055.0641512 Y NRC $2,246.5541520 Y NRC $1,055.0641530 Y NRC $835.1141800 N BN41805 Y $252.2741806 Y $302.7941820 Y NRC $1,055.0641821 Y NRC $536.6041822 Y $254.0741823 Y $365.5941825 Y $167.8241826 Y $227.3641827 Y $2,246.5541828 Y $226.2841830 Y $325.53
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 55 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
41850 Y NRC $536.6041870 Y NRC $536.6041872 Y NRC $334.9141874 Y NRC $277.5342000 Y NRC $102.8942100 Y $97.4442104 Y $154.8242106 Y $189.1142107 Y $2,246.5542120 Y $2,246.5542140 Y $1,055.0642145 Y $2,246.5542160 Y $166.7342180 Y $223.1942182 Y $2,246.5542200 Y NRC $2,246.5542205 Y NRC $1,055.0642210 Y NRC $2,246.5542215 Y NRC $2,246.5542220 Y NRC $2,246.5542225 Y NRC $2,246.5542226 Y NRC $2,246.5542227 Y NRC $2,246.5542235 Y NRC $2,246.5542260 Y NRC $2,246.5542280 Y NRC $121.2642281 Y NRC $2,246.5542300 Y NRC $536.6042305 Y NRC $1,055.0642310 Y NRC $223.1942320 Y NRC $223.1942330 Y NRC $146.8842335 Y NRC $277.1742340 Y NRC $1,055.0642400 Y $75.0742405 Y $536.6042408 Y NRC $1,055.0642409 Y NRC $1,055.0642410 Y $2,246.5542415 Y $2,246.5542420 Y $2,246.5542425 Y $2,246.5542440 Y NRC $2,246.55
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 56 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
42450 Y NRC $2,246.5542500 Y $2,246.5542505 Y $2,246.5542507 Y NRC $2,246.5542509 Y NRC $2,246.5542510 Y NRC $1,055.0642550 N BN42600 Y NRC $1,055.0642650 Y NRC $49.4442660 Y NRC $75.4342665 Y NRC $1,055.0642700 Y NRC $102.8942720 Y NRC $1,055.0642725 Y NRC $2,246.5542800 Y $103.2242804 Y $1,055.0642806 Y $1,055.0642808 Y $1,055.0642809 N BN42810 Y NRC $1,055.0642815 Y NRC $2,246.5542820 Y NRC $2,246.5542821 Y NRC $1,055.0642825 Y NRC $2,246.5542826 Y NRC $1,055.0642830 Y NRC $1,055.0642831 Y NRC $1,055.0642835 Y NRC $1,055.0642836 Y NRC $1,055.0642860 Y NRC $1,055.0642870 Y NRC $2,246.5542890 Y NRC $2,246.5542892 Y NRC $2,246.5542900 Y $536.6042950 Y NRC $2,246.5542955 Y NRC $536.6042960 Y $223.1942962 Y $1,055.0642970 Y $102.8942972 Y $1,055.0643030 Y NRC $2,246.5543130 Y NRC $2,246.5543180 Y $2,246.55
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 57 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
43191 Y $663.0643192 Y $663.0643193 Y $663.0643194 Y $663.0643195 Y $1,306.1443196 Y $1,306.1443197 Y $135.3443198 Y $144.3643200 Y NRC $397.1243201 Y NRC $663.0643202 Y $663.0643204 Y NRC $663.0643205 Y NRC $663.0643206 Y NRC $663.0643210 Y $3,588.5843211 Y $663.0643212 Y $3,562.02 $1,209.12 $2,385.5743213 Y $663.0643214 Y $663.0643215 Y $663.0643216 Y $663.0643217 Y $663.0643220 Y NRC $663.0643226 Y NRC $663.0643227 Y $663.0643229 Y $1,306.1443231 Y NRC $663.0643232 Y $663.0643233 Y $663.0643235 Y $397.1243236 Y NRC $397.1243237 Y NRC $663.0643238 Y $663.0643239 Y $397.1243240 Y NRC $2,243.00 $906.06 $1,574.5343241 Y NRC $663.0643242 Y $663.0643243 Y NRC $663.0643244 Y NRC $663.0643245 Y $663.0643246 Y $663.0643247 Y $397.1243248 Y NRC $397.12
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 58 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
43249 Y NRC $663.0643250 Y $663.0643251 Y $663.0643252 Y NRC $1,306.1443253 Y $663.0643254 Y $663.0643255 Y $663.0643257 Y NRC $1,306.1443259 Y NRC $663.0643260 Y $1,306.1443261 Y $1,306.1443262 Y NRC $1,306.1443263 Y NRC $1,306.1443264 Y NRC $1,306.1443265 Y NRC $1,960.5743266 Y $3,608.42 $1,173.26 $2,390.8443270 Y $663.0643273 N BN43274 Y $1,960.5743275 Y $1,306.1443276 Y $1,960.5743277 Y $1,306.1443278 Y $1,306.1443284 Y NRC $5,838.92 $2,739.59 $4,289.2543285 N NRC $2,194.0743450 Y NRC $397.1243453 Y NRC $663.0643653 Y NRC $2,194.0743752 N $183.7243753 N BN43754 N BN43755 N NRC $69.9143756 N NRC $397.1243757 Y NRC $397.1243761 Y $118.6943762 Y NRC $118.6943763 Y NRC $118.6943870 Y NRC $1,306.1443886 Y NRC $1,504.3843887 N NRC $819.9543888 Y NRC $1,504.3844100 Y $397.1244312 Y NRC $1,504.38
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 59 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
44340 Y NRC $1,504.3844360 Y $663.0644361 Y $663.0644363 Y $663.0644364 Y $663.0644365 Y $663.0644366 Y NRC $663.0644369 Y $663.0644370 Y NRC $3,612.14 $1,170.38 $2,391.2644372 Y $663.0644373 Y $663.0644376 Y $663.0644377 Y $663.0644378 Y NRC $663.0644379 Y NRC $1,960.5744380 Y $397.1244381 Y NRC $663.0644382 Y $397.1244384 Y NRC $1,306.1444385 Y $385.9844386 Y $385.9844388 Y $385.9844389 Y $507.4244390 Y $385.9844391 Y NRC $507.4244392 Y $507.4244394 Y $507.4244401 Y $507.4244402 Y NRC $3,355.67 $1,368.66 $2,362.1644403 Y NRC $507.4244404 Y NRC $507.4244405 Y NRC $507.4244406 Y NRC $507.4244407 Y $507.4244408 Y NRC $385.9844500 Y NRC $397.1244701 N BN45000 Y NRC $507.4245005 Y NRC $507.4245020 Y NRC $1,100.2045100 Y $1,100.2045108 Y $1,100.2045150 Y NRC $507.42
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 60 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
45160 Y $1,100.2045171 Y $1,100.2045172 Y $1,100.2045190 Y $1,100.2045300 Y $94.1945303 Y NRC $507.4245305 Y $507.4245307 Y $1,100.2045308 Y $1,100.2045309 Y $507.4245315 Y $507.4245317 Y NRC $507.4245320 Y $1,100.2045321 Y NRC $1,100.2045327 Y NRC $2,892.64 $1,726.66 $2,309.6545330 Y $145.4445331 Y $385.9845332 Y $507.4245333 Y $385.9845334 Y NRC $507.4245335 Y NRC $385.9845337 Y NRC $385.9845338 Y $507.4245340 Y NRC $507.4245341 Y NRC $385.9845342 Y $507.4245346 Y $507.4245347 Y NRC $3,701.85 $1,101.01 $2,401.4345349 Y NRC $1,100.2045350 Y NRC $507.4245378 Y $385.9845379 Y $507.4245380 Y $507.4245381 Y NRC $507.4245382 Y NRC $507.4245384 Y $507.4245385 Y $507.4245386 Y NRC $507.4245388 Y $507.4245389 Y NRC $3,571.22 $1,202.02 $2,386.6245390 Y NRC $1,100.2045391 Y NRC $507.4245392 Y $507.42
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 61 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
45393 Y NRC $507.4245398 Y NRC $507.4245500 Y NRC $1,100.2045505 Y NRC $1,100.2045520 N BN45541 Y NRC $1,100.2045560 Y NRC $1,100.2045900 Y NRC $385.9845905 Y NRC $507.4245910 Y NRC $507.4245915 Y $507.4245990 Y NRC $1,100.2046020 Y NRC $1,100.2046030 Y NRC $507.4246040 Y $507.4246045 Y $1,100.2046050 Y $385.9846060 Y NRC $1,100.2046070 Y NRC $1,100.2046080 Y NRC $1,100.2046083 Y NRC $118.6946200 Y NRC $1,100.2046220 Y NRC $507.4246221 Y NRC $186.2246230 Y NRC $1,100.2046250 Y NRC $1,100.2046255 Y NRC $1,100.2046257 Y NRC $1,100.2046258 Y NRC $1,100.2046260 Y NRC $1,100.2046261 Y NRC $1,100.2046262 Y NRC $1,100.2046270 Y NRC $1,100.2046275 Y NRC $1,100.2046280 Y NRC $1,100.2046285 Y NRC $1,100.2046288 Y NRC $1,100.2046320 Y NRC $134.6146500 Y NRC $235.6746505 Y NRC $507.4246600 N BN46601 N BN46604 Y NRC $507.42
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 62 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
46606 Y $213.6546607 Y $507.4246608 Y $385.9846610 Y $1,100.2046611 Y NRC $385.9846612 Y $1,100.2046614 Y NRC $110.4346615 Y $1,100.2046700 Y NRC $1,100.2046706 Y NRC $1,100.2046707 Y NRC $1,100.2046750 Y NRC $1,100.2046753 Y NRC $1,100.2046754 Y NRC $1,100.2046760 Y NRC $1,100.2046761 Y NRC $1,100.2046900 Y $161.4546910 Y $186.9446916 Y $88.2946917 Y $1,100.2046922 Y $1,100.2046924 Y $1,100.2046930 Y NRC $154.8246940 Y NRC $158.0746942 Y NRC $157.7146945 Y NRC $1,100.2046946 Y NRC $1,100.2046947 Y NRC $1,100.2046948 Y NRC $1,100.2047000 Y $576.3947001 N BN47382 Y $2,194.0747383 Y $3,536.88 $1,700.55 $2,618.7147531 N BN47532 N BN47533 Y $1,377.2147534 Y $1,377.2147535 Y $1,377.2147536 Y $1,377.2147537 N $397.1247538 Y $3,795.49 $1,500.62 $2,648.0547539 Y $2,194.0747540 Y $3,555.99 $1,685.79 $2,620.89
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 63 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
47541 Y $1,377.2147542 N BN47543 N BN47544 N BN47552 Y NRC $1,377.2147553 Y NRC $1,377.2147554 Y NRC $2,194.0747555 Y NRC $1,377.2147556 Y NRC $3,707.33 $1,568.78 $2,638.0547562 Y NRC $2,194.0747563 Y NRC $2,194.0747564 Y NRC $2,194.0748102 Y $576.3949082 Y $397.1249083 Y $397.1249084 Y $397.1249180 Y $576.3949250 Y NRC $1,377.2149320 Y $2,194.0749321 Y $2,194.0749322 Y NRC $2,194.0749324 Y NRC $2,194.0749325 Y NRC $2,194.0749326 N BN49327 N BN49400 N BN49402 Y $1,377.2149406 Y $576.3949407 Y $576.3949411 N $362.7049418 Y $1,377.2149419 Y NRC $2,321.8149421 Y NRC $1,377.2149422 N NRC $1,341.2349423 Y NRC $663.0649424 N BN49426 Y $1,377.2149427 N BN49429 N $1,341.2349435 N BN49436 Y NRC $663.0649440 Y $663.0649441 Y $663.06
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 64 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
49442 Y $507.4249446 Y $663.0649450 Y $397.1249451 Y $397.1249452 Y $397.1249460 Y $397.1249465 N $117.7549495 Y NRC $1,377.2149496 Y NRC $1,377.2149500 Y NRC $1,377.2149501 Y NRC $1,377.2149505 Y $1,377.2149507 Y $1,377.2149520 Y $1,377.2149521 Y $1,377.2149525 Y $1,377.2149540 Y $2,194.0749550 Y $1,377.2149553 Y $1,377.2149555 Y $1,377.2149557 Y $1,377.2149560 Y $1,377.2149561 Y $1,377.2149565 Y $2,194.0749566 Y $2,194.0749568 N BN49570 Y $1,377.2149572 Y $1,377.2149580 Y NRC $1,377.2149582 Y NRC $1,377.2149585 Y $1,377.2149587 Y $1,377.2149590 Y $1,377.2149600 Y $1,377.2149650 Y $2,194.0749651 Y $2,194.0749652 Y $2,194.0749653 Y $2,194.0749654 Y $3,588.5849655 Y $3,588.5849656 Y $3,588.5849657 Y $3,588.5850080 Y NRC $3,995.65
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 65 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
50081 Y NRC $3,995.6550200 Y $576.3950382 Y NRC $789.7150384 N NRC $789.7150385 Y NRC $789.7150386 N NRC $639.5150387 Y NRC $789.7150389 N NRC $281.2150390 Y $308.2350391 Y NRC $49.0850396 Y NRC $281.2150430 N BN50431 N BN50432 Y $789.7150433 Y $1,376.9750434 Y $1,206.13 $663.80 $934.9650435 Y $789.7150436 Y NRC $789.7150437 Y NRC $1,376.9750551 Y NRC $1,976.2750553 Y NRC $1,976.2750555 Y $3,995.6550557 Y $3,995.6550561 Y NRC $1,976.2750562 Y $3,995.6550570 Y NRC $1,376.9750572 Y NRC $281.2150574 Y $789.7150575 Y NRC $1,976.2750576 Y $1,976.2750580 Y NRC $1,976.2750590 Y NRC $1,376.9750592 Y $2,194.0750593 Y $5,605.00 $2,920.43 $4,262.7150606 N BN50684 N BN50686 N NRC $69.9150688 Y NRC $789.7150690 N BN50693 Y $1,376.9750694 Y $1,376.9750695 Y $1,376.9750705 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 66 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
50706 N BN50727 Y NRC $1,376.9750947 Y NRC $2,194.0750948 Y NRC $3,588.5850951 Y NRC $1,376.9750953 Y NRC $1,376.9750955 Y $1,976.2750957 Y $1,976.2750961 Y NRC $1,976.2750970 Y NRC $1,376.9750972 Y NRC $1,376.9750974 Y $1,976.2750976 Y $1,976.2750980 Y NRC $1,976.2751020 Y NRC $1,376.9751030 Y NRC $1,376.9751040 Y NRC $789.7151045 Y NRC $789.7151050 Y NRC $1,976.2751065 Y NRC $1,376.9751080 Y NRC $994.3451100 Y NRC $38.9851101 N NRC $105.3851102 Y NRC $789.7151500 Y NRC $2,194.0751520 Y $1,376.9751535 Y $1,376.9751600 N BN51605 N BN51610 N BN51700 Y NRC $52.3351701 N BN51702 N BN51703 N $69.9151705 Y $61.3551710 Y $281.2151715 Y NRC $2,081.83 $1,173.82 $1,627.8251720 Y $51.2551725 Y $118.6951726 Y $118.6951727 Y $244.6951728 Y $251.1851729 Y $252.27
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 67 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
51736 N BN51741 N BN51784 N NRC $29.2351785 Y NRC $118.6951792 N BN51797 N BN51798 N BN51880 Y NRC $1,376.9751992 Y NRC $3,333.38 $1,857.89 $2,595.6352000 Y $281.2152001 Y NRC $1,376.9752005 Y $789.7152007 Y $1,376.9752010 Y NRC $281.2152204 Y $789.7152214 Y NRC $789.7152224 Y $789.7152234 Y $1,376.9752235 Y $1,376.9752240 Y $1,976.2752250 Y $1,376.9752260 Y NRC $789.7152265 Y NRC $271.7552270 Y NRC $789.7152275 Y NRC $789.7152276 Y NRC $789.7152277 Y NRC $1,376.9752281 Y $789.7152282 Y NRC $1,376.9752283 Y NRC $789.7152285 Y NRC $281.2152287 Y $789.7152290 Y NRC $789.7152300 Y NRC $1,376.9752301 Y NRC $1,376.9752305 Y NRC $1,976.2752310 Y $789.7152315 Y $789.7152317 Y NRC $1,376.9752318 Y NRC $1,376.9752320 Y NRC $1,376.9752325 Y NRC $1,976.2752327 Y NRC $3,064.24 $1,625.71 $2,344.97
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 68 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
52330 Y NRC $1,376.9752332 Y NRC $1,376.9752334 Y NRC $1,376.9752341 Y NRC $1,376.9752342 Y NRC $1,376.9752343 Y NRC $789.7152344 Y NRC $1,376.9752345 Y NRC $1,376.9752346 Y NRC $1,976.2752351 Y NRC $1,376.9752352 Y NRC $1,376.9752353 Y NRC $1,976.2752354 Y $1,976.2752355 Y $1,976.2752356 Y $1,976.2752400 Y NRC $1,376.9752402 Y NRC $1,376.9752450 Y NRC $1,376.9752500 Y NRC $1,376.9752601 Y NRC $1,976.2752630 Y NRC $1,976.2752640 Y NRC $1,376.9752647 Y NRC $1,976.2752648 Y NRC $1,976.2752649 Y NRC $1,976.2752700 Y NRC $1,376.9753000 Y NRC $789.7153010 Y NRC $1,976.2753020 Y NRC $789.7153025 Y NRC $789.7153040 Y NRC $789.7153060 Y NRC $81.9253080 Y NRC $281.2153085 Y NRC $789.7153200 Y $789.7153210 Y NRC $1,376.9753215 Y NRC $1,976.2753220 Y $1,376.9753230 Y $1,976.2753235 Y $1,976.2753240 Y NRC $1,376.9753250 Y NRC $1,376.9753260 Y $789.71
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 69 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
53265 Y $789.7153270 Y NRC $789.7153275 Y NRC $789.7153400 Y NRC $1,976.2753405 Y NRC $1,976.2753410 Y NRC $1,976.2753420 Y NRC $1,976.2753425 Y NRC $1,976.2753430 Y NRC $1,976.2753431 Y NRC $1,976.2753440 Y NRC $7,463.23 $2,306.63 $4,884.9353442 Y NRC $1,976.2753444 Y NRC $15,619.29 $5,672.66 $10,645.9753445 Y NRC $17,028.56 $4,583.11 $10,805.8353446 N NRC $1,976.2753447 Y NRC $16,511.11 $4,983.17 $10,747.1453449 Y NRC $1,976.2753450 Y NRC $1,376.9753460 Y NRC $1,376.9753502 Y $1,376.9753505 Y $1,976.2753510 Y $1,976.2753515 Y $1,976.2753520 Y NRC $1,976.2753600 Y NRC $39.3453601 N BN53605 Y NRC $789.7153620 Y NRC $87.3453621 Y NRC $89.5053660 N NRC $44.0353661 N BN53665 Y NRC $789.7153850 Y $1,376.9753852 Y $1,314.0253854 Y $789.7153855 Y NRC $695.0953860 Y NRC $789.7154000 Y NRC $1,376.9754001 Y NRC $789.7154015 Y $576.3954050 N BN54055 Y $79.7654056 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 70 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
54057 Y $819.9554060 Y $819.9554065 Y $819.9554100 Y $576.3954105 Y $994.3454110 Y $1,376.9754111 Y $1,976.2754112 Y $3,995.6554115 Y $994.3454120 Y $1,376.9754150 Y NRC $789.7154160 Y NRC $281.2154161 Y NRC $789.7154162 Y $789.7154163 Y NRC $789.7154164 Y NRC $789.7154200 Y $70.0154205 Y $1,976.2754220 Y $118.6954230 N BN54231 Y NRC $64.6054235 Y NRC $43.6754240 N NRC $37.8954250 Y NRC $12.2754300 Y NRC $1,376.9754304 Y NRC $1,376.9754308 Y NRC $1,976.2754312 Y NRC $1,376.9754316 Y NRC $1,976.2754318 Y NRC $1,376.9754322 Y NRC $1,376.9754324 Y NRC $1,376.9754326 Y NRC $789.7154328 Y NRC $1,376.9754340 Y NRC $1,376.9754344 Y NRC $1,976.2754348 Y NRC $1,976.2754352 Y NRC $1,976.2754360 Y NRC $1,376.9754380 Y NRC $789.7154385 Y NRC $789.7154400 N NRC $16,480.73 $5,006.66 $10,743.6954401 N NRC $16,945.26 $4,647.51 $10,796.38
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 71 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
54405 N NRC $17,031.50 $4,580.84 $10,806.1754406 N NRC $1,376.9754408 Y NRC $1,976.2754410 N NRC $16,791.40 $4,766.47 $10,778.9354415 N NRC $1,376.9754416 N NRC $16,684.57 $4,849.05 $10,766.8154420 Y NRC $789.7154435 Y NRC $1,376.9754437 Y $1,376.9754440 Y $1,376.9754450 Y NRC $118.6954500 Y $994.3454505 Y $1,376.9754512 Y $1,376.9754520 Y NRC $1,376.9754522 Y NRC $1,376.9754530 Y $1,377.2154550 Y NRC $1,377.2154560 Y NRC $789.7154600 Y NRC $1,376.9754620 Y NRC $1,376.9754640 Y NRC $1,377.2154660 Y NRC $3,126.01 $1,577.96 $2,351.9854670 Y NRC $789.7154680 Y NRC $1,376.9754690 Y NRC $2,194.0754692 Y NRC $2,194.0754700 Y NRC $789.7154800 Y $576.3954830 Y $789.7154840 Y $789.7154860 Y NRC $789.7154861 Y NRC $1,376.9754865 Y NRC $1,376.9754900 Y NRC $789.7154901 Y NRC $1,376.9755000 Y NRC $64.2455040 Y NRC $1,377.2155041 Y NRC $1,377.2155060 Y NRC $1,376.9755100 Y NRC $576.3955110 Y NRC $1,376.9755120 Y $789.71
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 72 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
55150 Y NRC $1,376.9755175 Y NRC $1,376.9755180 Y NRC $1,976.2755200 Y NRC $1,376.9755250 Y NRC $789.7155300 N BN55400 Y NRC $1,376.9755500 Y NRC $1,376.9755520 Y $1,376.9755530 Y NRC $1,376.9755535 Y NRC $1,377.2155540 Y NRC $1,377.2155550 Y NRC $2,194.0755600 Y NRC $789.7155680 Y $1,376.9755700 Y $789.7155705 Y $789.7155706 Y $1,376.9755720 Y NRC $789.7155725 Y NRC $1,376.9755860 Y $1,976.2755870 Y NRC $77.5955873 Y NRC $7,061.86 $2,616.95 $4,839.4055874 Y NRC $1,976.2755875 N NRC $1,976.2755876 N $81.2055920 Y $1,816.3656405 Y NRC $70.0156420 Y NRC $83.9056440 Y $1,235.3156441 Y $1,235.3156442 Y NRC $1,235.3156501 Y $103.5856515 Y $819.9556605 Y $47.6456606 N BN56620 Y NRC $1,235.3156625 Y NRC $1,235.3156700 Y NRC $1,235.3156740 Y $1,235.3156800 Y NRC $1,235.3156805 Y NRC $1,235.3156810 Y NRC $1,235.31
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 73 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
56820 Y NRC $60.9956821 Y $79.4057000 Y NRC $1,235.3157010 Y NRC $1,235.3157020 Y NRC $1,816.3657022 Y NRC $994.3457023 Y $994.3457061 Y $91.6757065 Y $1,235.3157100 Y $49.8057105 Y $1,235.3157120 Y NRC $1,816.3657130 Y $1,235.3157135 Y $1,235.3157150 N BN57155 Y $1,816.3657156 Y $136.7957160 Y NRC $33.9257170 Y NRC $35.3757180 Y $83.9057200 Y $1,235.3157210 Y NRC $1,235.3157220 Y NRC $1,816.3657230 Y $1,235.3157240 Y NRC $1,816.3657250 Y NRC $1,816.3657260 Y NRC $1,816.3657265 Y NRC $1,816.3657267 N BN57268 Y NRC $1,816.3657287 N NRC $1,235.3157288 Y NRC $2,795.02 $1,510.63 $2,152.8257289 Y NRC $2,730.3357291 Y NRC $1,816.3657295 Y NRC $1,235.3157300 Y NRC $1,235.3157310 Y $2,730.3357320 Y $1,816.3657400 Y NRC $1,235.3157410 Y NRC $1,235.3157415 Y NRC $1,235.3157420 Y $63.1657421 Y $83.37
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 74 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
57426 Y NRC $2,730.3357452 Y $61.7157454 Y $72.5457455 Y $77.2357456 Y $73.6257460 Y $198.8557461 Y $212.2157500 Y $98.1657505 Y NRC $83.7357510 Y NRC $76.8757511 Y NRC $98.8957513 Y NRC $1,235.3157520 Y NRC $1,235.3157522 Y NRC $1,235.3157530 Y NRC $1,816.3657550 Y NRC $1,816.3657556 Y NRC $1,816.3657558 Y NRC $1,235.3157700 Y NRC $1,235.3157720 Y NRC $1,235.3157800 Y NRC $40.4258100 Y $50.5358110 N BN58120 Y NRC $1,235.3158145 Y $1,235.3158260 Y NRC $1,816.3658262 Y NRC $1,816.3658301 N NRC $52.3358321 Y NRC $43.6758322 Y NRC $46.1958323 Y NRC $6.1458340 N BN58345 Y NRC $1,235.3158346 Y $1,816.3658350 Y NRC $1,816.3658353 Y NRC $1,816.3658356 Y NRC $1,610.3258541 Y NRC $2,194.0758542 Y NRC $3,588.5858543 Y NRC $3,588.5858544 Y NRC $3,588.5858545 Y NRC $2,194.0758546 Y NRC $3,588.58
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 75 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
58550 Y NRC $2,194.0758552 Y NRC $3,588.5858553 Y NRC $3,588.5858554 Y NRC $3,588.5858555 Y NRC $1,235.3158558 Y $1,235.3158559 Y NRC $1,816.3658560 Y NRC $1,816.3658561 Y NRC $1,816.3658562 Y NRC $1,235.3158563 Y NRC $1,816.3658565 Y NRC $1,816.3658570 Y NRC $3,588.5858571 Y NRC $3,588.5858572 Y NRC $3,588.5858573 Y NRC $3,588.5858600 Y NRC $1,235.3158615 Y NRC $1,235.3158660 Y NRC $2,194.0758661 Y NRC $2,194.0758662 Y $2,194.0758670 Y NRC $2,194.0758671 Y NRC $2,194.0758672 Y NRC $2,194.0758673 Y NRC $2,194.0758674 Y NRC $3,588.5858800 Y NRC $1,235.3158805 Y NRC $1,235.3158820 Y NRC $1,235.3158900 Y $1,235.3158970 Y NRC $322.6158976 Y NRC $136.7959000 Y NRC $65.6859001 Y NRC $136.7959012 Y NRC $136.7959015 Y $61.7159020 Y NRC $33.2059025 Y NRC $18.7759070 Y NRC $136.7959072 Y NRC $217.99 $107.97 $162.9859074 Y NRC $136.7959076 Y NRC $136.7959100 Y $1,816.36
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 76 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
59150 Y NRC $2,194.0759151 Y NRC $2,194.0759160 Y NRC $1,235.3159200 Y NRC $56.3059300 Y NRC $111.8859320 Y NRC $1,235.3159412 Y NRC $1,235.3159414 Y NRC $1,235.3159812 Y NRC $1,235.3159820 Y NRC $1,235.3159821 Y NRC $1,235.3159840 Y NRC $1,235.3159841 Y NRC $1,235.3159866 Y NRC $136.7959870 Y NRC $1,235.3159871 N NRC $1,235.3160000 Y NRC $536.6060100 Y $53.7760200 Y $2,194.0760210 Y NRC $2,194.0760212 Y NRC $2,194.0760220 Y NRC $2,194.0760225 Y NRC $2,194.0760240 Y NRC $2,194.0760280 Y $2,194.0760281 Y $2,194.0760300 Y NRC $78.6860500 Y NRC $2,246.5561000 Y NRC $315.8361001 Y NRC $315.8361020 Y $410.3261026 Y $315.8361050 Y $132.2761055 Y $132.2761070 Y $315.8361215 Y $2,170.2461330 Y $1,055.0661770 Y $2,170.2461781 N BN61782 N BN61783 N BN61790 Y NRC $796.7961791 Y NRC $796.79
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 77 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
61880 N $1,845.9561885 N $19,730.76 $3,722.40 $11,726.5861886 N $26,860.75 $5,060.68 $15,960.7161888 N $5,105.74 $2,118.45 $3,612.0962160 N BN62194 Y NRC $796.7962225 Y NRC $2,170.2462230 Y NRC $2,170.2462252 N NRC $35.0162263 Y $410.3262264 Y $410.3262267 Y $308.2362268 Y $410.3262269 Y $576.3962270 Y $315.8362272 Y $315.8362273 Y $315.8362280 Y $451.3562281 Y $451.3562282 Y $451.3562284 N BN62287 Y $796.7962290 N BN62291 N BN62292 Y $796.7962294 Y $410.3262302 N BN62303 N BN62304 N BN62305 N BN62320 Y $347.4162321 Y $347.4162322 Y $347.4162323 Y $347.4162324 Y $451.3562325 Y $451.3562326 Y $451.3562327 Y $451.3562328 Y $315.8362329 Y $315.8362350 Y $3,303.71 $1,832.65 $2,568.1862355 N $796.7962360 Y $15,760.45 $3,498.07 $9,629.26
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 78 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
62361 Y $16,235.87 $3,130.51 $9,683.1962362 Y $15,581.20 $3,636.67 $9,608.9362365 N $2,170.2462367 N $13.7162368 N $19.1362369 N $71.1062370 N $66.4062380 Y $2,803.3663001 Y $2,803.3663003 Y $2,803.3663005 Y $2,803.3663020 Y $2,803.3663030 Y $2,803.3663042 Y $2,803.3663044 N BN63045 Y $2,803.3663046 Y $2,803.3663047 Y $2,803.3663055 Y $2,803.3663056 Y $2,803.3663600 Y $796.7963610 Y $1,342.43 $572.74 $957.5863650 N $5,146.94 $2,086.60 $3,616.7763655 N $18,175.74 $4,924.63 $11,550.1863661 N $796.7963662 N $1,845.9563663 N $5,031.38 $2,175.94 $3,603.6663664 N $16,556.81 $6,176.28 $11,366.5463685 N $26,753.79 $5,143.37 $15,948.5863688 N $1,845.9563744 Y NRC $2,170.2463746 N NRC $796.7964400 Y $84.1664405 Y $36.5264408 Y $44.8664415 Y $451.3564416 Y $451.3564417 Y $451.3564418 Y $47.6464420 Y $347.4164421 Y $451.3564425 Y $82.5864430 Y NRC $451.35
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 79 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
64435 Y NRC $48.8364445 Y $98.4564446 Y $451.3564447 Y $53.2064448 Y $451.3564449 Y $451.3564450 Y $53.2064451 Y $347.4164454 Y $173.8864455 Y $22.6364461 Y $347.4164462 N BN64463 Y $347.4164479 Y $451.3564480 N BN64483 Y $451.3564484 N BN64486 N BN64487 N BN64488 N BN64489 N BN64490 Y $451.3564491 N BN64492 N BN64493 Y $451.3564494 N BN64495 N BN64505 Y NRC $78.6164510 Y $451.3564517 Y NRC $451.3564520 Y $451.3564530 Y NRC $451.3564553 N NRC $5,885.82 $1,515.35 $3,700.5864555 N $5,342.21 $1,935.63 $3,638.9264561 N NRC $5,339.52 $1,937.70 $3,638.6164566 Y $115.1364568 N NRC $27,299.99 $4,721.08 $16,010.5364569 N NRC $6,230.46 $1,248.88 $3,739.6764570 N NRC $2,387.2664575 N NRC $17,866.63 $5,163.62 $11,515.1264580 N NRC $19,424.78 $3,958.95 $11,691.8664581 N NRC $5,522.40 $1,796.31 $3,659.3564585 N $2,030.55
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 80 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
64590 N NRC $19,713.99 $3,735.36 $11,724.6764595 N $2,030.5564600 Y $451.3564605 Y $876.4764610 Y $876.4764611 Y NRC $82.9764612 Y $84.9564615 Y $75.0364616 Y $71.8564617 Y $97.6664620 Y $451.3564624 Y $350.5464625 Y $876.4764630 Y NRC $451.3564632 Y $46.8564633 Y $876.4764634 N BN64635 Y $876.4764636 N BN64640 Y $194.1364642 Y $86.9464643 N BN64644 Y $107.1864645 N BN64646 Y $87.3464647 Y $96.0764650 Y NRC $59.1564653 Y NRC $68.2864680 Y NRC $451.3564681 Y NRC $451.3564702 Y $796.7964704 Y $796.7964708 Y $796.7964712 Y $796.7964713 Y $796.7964714 Y $796.7964716 Y $796.7964718 Y $796.7964719 Y $796.7964721 Y $796.7964722 Y $796.7964726 Y $796.7964727 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 81 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
64732 Y $796.7964734 Y $796.7964736 Y $796.7964738 Y $796.7964740 Y $796.7964742 Y $796.7964744 Y $796.7964746 Y $796.7964763 Y $796.7964766 Y $796.7964771 Y $796.7964772 Y $796.7964774 Y $796.7964776 Y $796.7964778 N BN64782 Y $796.7964783 N BN64784 Y $796.7964786 Y $2,170.2464787 N BN64788 Y $796.7964790 Y $796.7964792 Y $2,170.2464795 Y $796.7964802 Y $796.7964820 Y $796.7964821 Y $1,286.2664822 Y $1,286.2664823 Y $1,286.2664831 Y $796.7964832 N BN64834 Y $2,170.2464835 Y $2,170.2464836 Y $2,170.2464837 N BN64840 Y $2,170.2464856 Y $2,170.2464857 Y $2,170.2464858 Y $796.7964859 N BN64861 Y $796.7964862 Y $2,170.2464864 Y $2,170.24
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 82 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
64865 Y $2,170.2464872 N BN64874 N BN64876 N BN64885 Y $2,170.2464886 Y $2,170.2464890 Y $2,170.2464891 Y $3,224.98 $1,893.51 $2,559.2464892 Y $2,170.2464893 Y $2,170.2464895 Y $2,170.2464896 Y $2,170.2464897 Y $2,170.2464898 Y $2,170.2464901 N BN64902 N BN64905 Y $2,170.2464907 Y $2,170.2464910 Y $3,571.37 $1,625.71 $2,598.5464912 Y $3,901.05 $1,370.83 $2,635.9464913 N BN65091 Y $1,355.6365093 Y $1,355.6365101 Y $1,355.6365103 Y $1,355.6365105 Y $1,355.6365110 Y $1,355.6365112 Y $1,355.6365114 Y $1,355.6365125 Y $836.9465130 Y $1,355.6365135 Y $1,355.6365140 Y $1,355.6365150 Y $1,355.6365155 Y $1,355.6365175 Y $1,355.6365205 N BN65210 N BN65220 N BN65222 N BN65235 Y $1,012.7265260 Y $1,012.7265265 Y $1,012.72
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 83 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
65270 Y $836.9465272 Y $836.9465275 Y $1,355.6365280 Y $1,835.8465285 Y $1,835.8465286 Y $462.6765290 Y $1,355.6365400 Y $407.7565410 Y $836.9465420 Y $836.9465426 Y $836.9465430 N BN65435 Y $48.0065436 Y $208.9665450 Y $136.6865600 Y $260.2165710 Y $1,835.8465730 Y $1,835.8465750 Y $1,835.8465755 Y $1,835.8465756 Y $1,835.8465757 N BN65770 Y $10,129.20 $3,516.42 $6,822.8165772 Y $407.7565775 Y $836.9465778 N BN65779 N BN65780 Y NRC $1,355.6365781 Y NRC $1,835.8465782 Y NRC $1,355.6365785 Y $1,835.8465800 Y NRC $1,012.7265810 Y NRC $1,012.7265815 Y $1,012.7265820 Y NRC $1,835.8465850 Y NRC $1,012.7265855 Y NRC $135.7065860 Y $177.2065865 Y $1,012.7265870 Y $1,012.7265875 Y $1,012.7265880 Y $1,835.8465900 Y $1,012.72
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 84 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
65920 Y $1,012.7265930 Y $1,012.7266020 Y $1,012.7266030 Y $1,012.7266130 Y $836.9466150 Y NRC $1,835.8466155 Y NRC $1,835.8466160 Y NRC $1,012.7266170 Y NRC $1,012.7266172 Y NRC $1,012.7266174 Y NRC $1,835.8466175 Y NRC $1,835.8466179 Y $1,835.8466180 Y NRC $2,806.95 $1,540.76 $2,173.8566183 Y $2,954.89 $1,426.38 $2,190.6366184 Y $1,012.7266185 Y NRC $1,012.7266225 Y $1,835.8466250 Y $836.9466500 Y $1,012.7266505 Y $1,012.7266600 Y $1,835.8466605 Y NRC $1,012.7266625 Y NRC $1,012.7266630 Y NRC $1,012.7266635 Y $1,012.7266680 Y $1,012.7266682 Y $1,012.7266700 Y $1,012.7266710 Y $836.9466711 Y $1,012.7266720 Y $836.9466740 Y $836.9466761 Y NRC $189.8366762 Y NRC $256.1466770 Y $256.1466820 Y NRC $1,012.7266821 Y NRC $256.1466825 Y $1,012.7266830 Y $1,012.7266840 Y $1,012.7266850 Y $1,012.7266852 Y NRC $1,835.84
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 85 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
66920 Y NRC $1,012.7266930 Y NRC $1,835.8466940 Y NRC $1,012.7266982 Y NRC $1,012.7266983 Y NRC $1,012.7266984 Y NRC $1,012.7266985 Y NRC $1,012.7266986 Y NRC $1,012.7266987 Y NRC $2,728.07 $1,601.76 $2,164.9166988 Y NRC $2,728.07 $1,601.76 $2,164.9166990 N BN67005 Y $1,012.7267010 Y $1,012.7267015 Y $1,012.7267025 Y $1,012.7267027 Y $1,629.2667028 N $47.2867030 Y NRC $1,012.7267031 Y NRC $256.1467036 Y $1,835.8467039 Y $1,835.8467040 Y $1,835.8467041 Y NRC $1,835.8467042 Y NRC $1,835.8467043 Y NRC $1,835.8467101 Y $202.8267105 Y $171.4367107 Y $1,835.8467108 Y $1,835.8467110 Y $508.5067113 Y $1,835.8467115 Y $1,835.8467120 Y NRC $1,012.7267121 Y NRC $1,012.7267141 Y NRC $136.6867145 Y NRC $256.1467208 Y $136.6867210 Y $256.1467218 Y $1,355.6367220 Y $256.1467221 Y NRC $153.0267225 N BN67227 Y $164.57
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 86 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
67228 Y $179.0067229 Y NRC $256.1467250 Y $836.9467255 Y $1,012.7267311 Y NRC $836.9467312 Y NRC $1,355.6367314 Y NRC $836.9467316 Y NRC $836.9467318 Y NRC $836.9467320 N BN67331 N BN67332 N BN67334 N BN67335 N BN67340 N BN67343 Y NRC $836.9467345 Y $126.3167346 Y $1,355.6367400 Y $1,355.6367405 Y $836.9467412 Y $836.9467413 Y $836.9467414 Y $1,355.6367415 Y NRC $836.9467420 Y $1,355.6367430 Y $1,355.6367440 Y $1,355.6367445 Y $1,355.6367450 Y $1,355.6367500 Y $136.6867505 Y $38.9867515 Y $36.0967550 Y $1,355.6367560 Y $1,355.6367570 Y $1,355.6367700 Y NRC $136.6867710 Y NRC $199.2167715 Y NRC $836.9467800 Y $76.5167801 Y $92.7567805 Y $118.7367808 Y $836.9467810 Y $136.68
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 87 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
67820 N BN67825 Y NRC $80.4867830 Y NRC $407.7567835 Y NRC $836.9467840 Y $204.2767850 Y $153.3867875 Y NRC $407.7567880 Y NRC $836.9467882 Y NRC $836.9467900 Y NRC $836.9467901 Y NRC $836.9467902 Y NRC $1,355.6367903 Y NRC $836.9467904 Y NRC $836.9467906 Y NRC $1,355.6367908 Y NRC $836.9467909 Y NRC $836.9467911 Y NRC $836.9467912 Y NRC $836.9467914 Y NRC $836.9467915 Y NRC $233.8667916 Y NRC $836.9467917 Y NRC $836.9467921 Y NRC $836.9467922 Y NRC $225.9267923 Y NRC $836.9467924 Y NRC $836.9467930 Y $235.3067935 Y $836.9467938 Y $136.6867950 Y $836.9467961 Y $836.9467966 Y $836.9467971 Y $836.9467973 Y $836.9467974 Y $1,355.6367975 Y $836.9468020 Y NRC $68.5768040 Y $31.7668100 Y $129.9268110 Y $168.9068115 Y $836.9468130 Y $836.94
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 88 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
68135 Y $88.0668200 N BN68320 Y NRC $836.9468325 Y NRC $1,355.6368326 Y NRC $1,355.6368328 Y NRC $836.9468330 Y NRC $1,012.7268335 Y NRC $1,355.6368340 Y NRC $836.9468360 Y NRC $1,355.6368362 Y NRC $836.9468371 Y NRC $836.9468400 Y NRC $232.0668420 Y NRC $245.7768440 Y NRC $66.4068500 Y $1,355.6368505 Y $1,355.6368510 Y $836.9468520 Y NRC $1,355.6368525 Y $836.9468530 Y $136.6868540 Y $836.9468550 Y $1,355.6368700 Y NRC $836.9468705 Y NRC $136.6868720 Y NRC $1,355.6368745 Y NRC $1,355.6368750 Y NRC $1,355.6368760 Y NRC $136.6868761 Y NRC $97.4468770 Y NRC $836.9468801 N BN68810 Y NRC $136.6868811 Y NRC $836.9468815 Y NRC $836.9468816 Y NRC $836.9468840 Y NRC $83.3768850 N BN69000 Y $130.2869005 Y $133.8969020 Y $173.2369100 Y $68.2169105 Y $109.71
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 89 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
69110 Y $994.3469120 Y $2,246.5569140 Y $2,246.5569145 Y $994.3469150 Y $2,246.5569200 N BN69205 Y $576.3969209 N BN69210 N BN69220 N BN69222 Y NRC $157.3569300 Y NRC $1,055.0669310 Y $2,246.5569320 Y NRC $2,246.5569420 Y NRC $102.8969421 Y NRC $1,055.0669424 N NRC $96.0069433 Y NRC $138.2269436 Y NRC $536.6069440 Y NRC $1,055.0669450 Y NRC $1,055.0669501 Y NRC $2,246.5569502 Y NRC $2,246.5569505 Y NRC $2,246.5569511 Y NRC $2,246.5569530 Y NRC $2,246.5569540 Y $158.7969550 Y $2,246.5569552 Y $2,246.5569601 Y NRC $2,246.5569602 Y NRC $2,246.5569603 Y NRC $2,246.5569604 Y NRC $2,246.5569605 Y NRC $2,246.5569610 Y $204.2769620 Y NRC $1,055.0669631 Y NRC $2,246.5569632 Y NRC $2,246.5569633 Y NRC $2,246.5569635 Y NRC $2,246.5569636 Y NRC $2,246.5569637 Y NRC $2,246.5569641 Y NRC $2,246.55
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 90 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
69642 Y NRC $2,246.5569643 Y NRC $2,246.5569644 Y NRC $2,246.5569645 Y NRC $2,246.5569646 Y NRC $2,246.5569650 Y NRC $1,055.0669660 Y NRC $2,246.5569661 Y NRC $2,246.5569662 Y NRC $2,246.5569666 Y NRC $1,055.0669667 Y NRC $1,055.0669670 Y NRC $2,246.5569676 Y NRC $1,055.0669700 Y NRC $536.6069711 N NRC $1,055.0669714 Y NRC $10,781.71 $3,240.94 $7,011.3269715 Y NRC $12,278.89 $5,935.81 $9,107.3569717 Y NRC $4,987.77 $1,810.40 $3,399.0869718 Y NRC $5,727.1369720 Y $2,246.5569740 Y $2,246.5569745 Y $2,246.5569801 Y NRC $133.8969805 Y NRC $2,246.5569806 Y NRC $2,246.5569905 Y NRC $2,246.5569910 Y NRC $2,246.5569915 Y $1,055.0669930 Y NRC $34,995.63 $7,314.14 $21,154.8869990 N BN70010 N BN70015 N BN70030 N BN70100 N BN70110 N BN70120 N BN70130 N BN70134 N BN70140 N BN70150 N BN70160 N BN70170 N BN70190 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 91 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
70200 N BN70210 N BN70220 N BN70240 N BN70250 N BN70260 N BN70300 N BN70310 N BN70320 N BN70328 N BN70330 N BN70332 N BN70336 N $117.7570350 N BN70355 N BN70360 N BN70370 N BN70371 N BN70380 N BN70390 N BN70450 N $56.6370460 N $92.0870470 N $92.0870480 N $56.6370481 N $92.0870482 N $92.0870486 N $56.6370487 N $92.0870488 N $92.0870490 N $56.6370491 N $92.0870492 N $92.0870496 N $92.0870498 N $92.0870540 N $117.7570542 N $192.9570543 N $192.9570544 N $117.7570545 N $192.9570546 N $192.9570547 N $117.7570548 N $192.9570549 N $192.95
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 92 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
70551 N $117.7570552 N $192.9570553 N $192.9570554 N $117.7570555 N $117.7570557 N $243.3470558 N $92.0870559 N $92.0871045 N $16.2471046 N $21.6571047 N BN71048 N BN71100 N BN71101 N BN71110 N BN71111 N BN71120 N BN71130 N BN71250 N $56.6371260 N $92.0871270 N $92.0871275 N $92.0871550 N $117.7571551 N $344.0171552 N $192.9572020 N BN72040 N BN72050 N BN72052 N BN72070 N BN72072 N BN72074 N BN72080 N BN72081 N BN72082 N BN72083 N $56.6372084 N $56.6372100 N BN72110 N BN72114 N BN72120 N BN72125 N $56.6372126 N $135.70
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 93 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
72127 N $92.0872128 N $56.6372129 N $92.0872130 N $92.0872131 N $56.6372132 N $136.0672133 N $92.0872141 N $117.7572142 N $192.9572146 N $117.7572147 N $192.9572148 N $117.7572149 N $192.9572156 N $192.9572157 N $192.9572158 N $192.9572170 N BN72190 N BN72191 N $92.0872192 N $56.6372193 N $92.0872194 N $92.0872195 N $117.7572196 N $192.9572197 N $192.9572200 N BN72202 N BN72220 N BN72240 N BN72255 N BN72265 N BN72270 N BN72275 N BN72285 N BN72295 N BN73000 N BN73010 N BN73020 N BN73030 N BN73040 N BN73050 N BN73060 N BN73070 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 94 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
73080 N BN73085 N BN73090 N BN73092 N BN73100 N BN73110 N BN73115 N BN73120 N BN73130 N BN73140 N BN73200 N $56.6373201 N $166.3773202 N $92.0873206 N $92.0873218 N $117.7573219 N $192.9573220 N $192.9573221 N $117.7573222 N $286.9173223 N $192.9573501 N BN73502 N BN73503 N BN73521 N BN73522 N BN73523 N BN73525 N BN73551 N BN73552 N BN73560 N BN73562 N BN73564 N BN73565 N BN73580 N BN73590 N BN73592 N BN73600 N BN73610 N BN73615 N BN73620 N BN73630 N BN73650 N BN73660 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 95 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
73700 N $56.6373701 N $92.0873702 N $92.0873706 N $92.0873718 N $117.7573719 N $192.9573720 N $192.9573721 N $117.7573722 N $287.6373723 N $192.9574018 N BN74019 N BN74021 N BN74022 N BN74150 N $56.6374160 N $92.0874170 N $92.0874174 N $192.9574175 N $92.0874176 N $113.6874177 N $192.9574178 N $192.9574181 N $117.7574182 N $192.9574183 N $192.9574190 N BN74210 N BN74220 N BN74230 N $92.0874235 N BN74240 N $80.4874246 N NRC $92.0874250 N NRC $80.8474251 N NRC $92.0874261 N NRC $56.6374262 N NRC $92.0874270 N BN74280 N BN74283 N NRC $92.0874290 N BN74300 N BN74301 N BN74328 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 96 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
74329 N BN74330 N BN74340 N BN74355 N BN74360 N BN74363 N BN74400 N NRC $92.0874410 N NRC $92.0874415 N NRC $92.0874420 N NRC $192.9574425 N BN74430 N BN74440 N BN74445 N BN74450 N BN74455 N BN74470 N BN74485 N BN74710 N BN74712 N NRC $117.7574713 N BN74740 N BN74742 N BN74775 N NRC $117.7575557 N NRC $117.7575559 N NRC $243.3475561 N NRC $192.9575563 N NRC $344.0175565 N BN75571 N BN75572 N $92.0875573 N NRC $92.0875574 N $92.0875600 N BN75605 N BN75625 N BN75630 N BN75635 N BN75705 N BN75710 N BN75716 N BN75726 N BN75731 N NRC $106.83
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 97 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
75733 N BN75736 N BN75741 N BN75743 N BN75746 N NRC $89.5075756 N BN75774 N BN75801 N BN75803 N NRC $579.9175805 N NRC $579.9175807 N BN75809 N BN75810 N NRC $579.9175820 N BN75822 N NRC $75.0775825 N BN75827 N BN75831 N BN75833 N BN75840 N BN75842 N BN75860 N BN75870 N NRC $120.9075872 N BN75880 N BN75885 N BN75887 N NRC $82.2875889 N BN75891 N BN75893 N BN75894 N BN75898 N NRC $579.9175901 N BN75902 N BN75970 N BN75984 N BN75989 N BN76000 N $26.3576010 N BN76080 N BN76098 N BN76100 N BN76101 N NRC $56.63
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 98 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
76102 N NRC $56.6376120 N BN76125 N BN76376 N BN76377 N BN76380 N BN76391 N $117.7576496 N BN76497 N BN76498 N $40.3376499 N BN76506 N BN76510 N BN76511 N BN76512 N BN76513 N BN76514 N BN76516 N BN76519 N BN76529 N BN76536 N BN76604 N BN76641 N BN76642 N BN76700 N $56.6376705 N $56.6376770 N $56.6376775 N BN76776 N $56.6376800 N BN76801 N NRC $56.6376802 N BN76805 N NRC $56.6376810 N BN76811 N NRC $83.3776812 N BN76813 N BN76814 N BN76815 N BN76816 N BN76817 N BN76818 N NRC $56.6376819 N NRC $48.72
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 99 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
76820 N BN76821 N BN76825 N NRC $193.4476826 N NRC $117.7576827 N BN76828 N BN76830 N NRC $56.6376831 N NRC $84.0976856 N NRC $56.6376857 N NRC $23.8276870 N BN76872 N NRC $56.6376873 N NRC $56.6376881 N NRC $46.5676882 N BN76885 N BN76886 N BN76932 N BN76936 N NRC $127.8976937 N BN76940 N BN76941 N BN76942 N BN76945 N BN76946 N BN76948 N BN76965 N BN76970 N BN76975 N BN76977 N NRC $3.9776978 N $92.0876979 N BN76981 N $56.6376982 N $56.6376983 N BN76998 N BN76999 N BN77001 N BN77002 N BN77003 N BN77011 N BN77012 N BN77013 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 100 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
77014 N BN77021 N BN77022 N BN77046 N $117.7577047 N $117.7577053 N BN77054 N BN77071 N BN77072 N BN77073 N BN77074 N BN77075 N BN77076 N BN77077 N BN77078 N NRC $40.3377080 N NRC $29.5977081 N NRC $22.0177084 N $117.7577085 N BN77086 N BN77280 N $63.9777285 N $169.3577290 N $169.3577293 N BN77295 N $263.4577299 N $63.9777300 N $33.9277301 N $629.2677306 N $75.7977307 N $136.7877316 N $144.7277317 N $169.3577318 N $169.3577321 N $44.0377331 N $18.7777332 N $23.4677333 N $63.9777334 N $67.1377336 N $63.9777338 N $169.3577370 N $63.9777385 N $272.2777386 N $272.27
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 101 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
77387 N BN77399 N $63.9777401 N $24.5477402 N $62.0077407 N $119.4377412 N $119.4377417 N BN77423 N $26.7177424 N $1,922.6177425 N $1,922.6177435 N BN77470 N $25.6277520 N $272.2777522 N $629.9777523 N $629.9777525 N $629.9777600 N NRC $119.4377605 N NRC $374.1877610 N NRC $272.2777615 N NRC $272.2777620 N NRC $272.2777750 N $119.4377761 N $202.1077762 N $231.3377763 N $298.4677767 N $119.4377768 N $119.4377770 N $235.3077771 N $374.1877772 N $374.1877778 N $374.1877789 N $62.0077790 N BN77799 N $62.0078012 N $186.0178013 N $186.0178014 N $186.0178015 N $186.0178016 N $186.0178018 N $238.4978020 N BN78070 N NRC $186.0178071 N $186.01
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 102 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
78072 N NRC $238.4978075 N NRC $642.8278099 N $186.0178102 N $186.0178103 N $186.0178104 N $186.0178110 N NRC $642.8278111 N NRC $642.8278120 N NRC $186.0178121 N NRC $238.4978122 N $238.4978130 N $186.0178135 N $186.0178140 N $186.0178185 N $186.0178191 N $186.0178195 N $238.4978199 N $186.0178201 N $642.8278202 N $642.8278215 N $186.0178216 N $186.0178226 N $186.0178227 N $238.4978230 N NRC $186.0178231 N NRC $186.0178232 N NRC $186.0178258 N NRC $186.0178261 N NRC $186.0178262 N NRC $186.0178264 N NRC $186.0178265 N NRC $186.0178266 N NRC $238.4978278 N $186.0178282 N NRC $186.0178290 N NRC $186.0178291 N NRC $186.0178299 N $186.0178300 N $186.0178305 N $186.0178306 N $186.0178315 N $186.0178399 N $186.01
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 103 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
78414 N NRC $238.4978428 N NRC $186.0178429 N NRC $729.2178430 N NRC $729.2178431 N NRC $1,137.1578432 N NRC $1,389.7978433 N NRC $1,389.7978434 N BN78445 N $186.0178451 N $642.8278452 N $642.8278453 N $642.8278454 N $642.8278456 N $642.8278457 N $642.8278458 N $186.0178459 N NRC $642.8278466 N NRC $186.0178468 N NRC $238.4978469 N NRC $642.8278472 N NRC $186.0178473 N NRC $186.0178481 N NRC $238.4978483 N NRC $238.4978491 N NRC $729.2178492 N NRC $729.2178494 N NRC $186.0178496 N BN78499 N NRC $186.0178579 N $186.0178580 N $186.0178582 N $238.4978597 N $186.0178598 N $238.4978599 N $186.0178600 N $186.0178601 N $186.0178605 N $238.4978606 N $238.4978608 N NRC $729.2178610 N $238.4978630 N $238.4978635 N $238.49
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 104 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
78645 N $238.4978650 N $642.8278660 N $186.0178699 N $186.0178700 N $186.0178701 N $186.0178707 N NRC $238.4978708 N NRC $238.4978709 N NRC $238.4978725 N $186.0178730 N BN78740 N NRC $186.0178761 N NRC $186.0178799 N $186.0178800 N $186.0178801 N $186.0178802 N $642.8278803 N $642.8278804 N $642.8278808 N BN78811 N NRC $642.8278812 N NRC $729.2178813 N NRC $729.2178814 N NRC $729.2178815 N NRC $729.2178816 N NRC $729.2178830 N $642.8278831 N $642.8278832 N $729.2178999 N $186.0179005 N $50.5379101 N $51.2579200 N $53.4179300 N $119.9579403 N NRC $81.9279440 N NRC $39.7079445 N NRC $119.9579999 N $119.9590371 N $110.6790375 N $280.6490376 N $271.3790378 N NRC $1,205.0590396 N NRC $1,716.18
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 105 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
90476 N BN90630 N BN90632 N BN90633 N BN90634 N BN90636 N BN90647 N BN90648 N BN90653 N BN90654 N BN90655 N BN90656 N BN90657 N BN90660 N BN90661 N BN90662 N BN90670 N BN90672 N BN90673 N BN90674 N BN90675 N $297.5990676 N $130.0190680 N BN90682 N BN90685 N BN90686 N BN90687 N BN90688 N BN90689 N BN90690 N BN90691 N BN90696 N BN90698 N BN90717 N BN90732 N BN90740 N BR $0.0090743 N BR $0.0090744 N BR $0.0090746 N BR $0.0090747 N BR $0.0090749 N BN90756 N BN91035 N $245.37
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 106 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
92920 Y $3,444.64 $1,666.10 $2,555.3792921 N BN92928 Y $6,905.90 $3,116.08 $5,010.9992929 N BN93451 Y $1,374.3693452 Y $1,374.3693453 Y $1,374.3693454 Y $1,374.3693455 Y $1,374.3693456 Y $1,374.3693457 Y $1,374.3693458 Y $1,374.3693459 Y $1,374.3693460 Y $1,374.3693461 Y $1,374.3693462 N BN93566 N BN93567 N BN93568 N BN93571 N BN93572 N BN93985 N $117.7593986 N $56.630100T Y NRC $168,500.99 $25,486.02 $96,993.500101T Y NRC $1,286.260102T Y NRC $1,286.260191T Y NRC $3,098.12 $1,315.65 $2,206.880200T Y NRC $4,406.11 $2,260.12 $3,333.110201T Y NRC $2,803.360213T Y NRC $410.320214T N BN0215T N BN0216T Y NRC $410.320217T N BN0218T N BN0228T Y NRC $410.320229T N BN0230T Y NRC $410.320231T N BN0232T N BN0238T Y NRC $11,708.67 $4,689.54 $8,199.100253T Y NRC $2,934.19 $1,442.38 $2,188.280263T N NRC $1,929.37
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 107 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
0264T N NRC $1,929.370265T N NRC $1,929.370269T N NRC $2,170.240270T N NRC $1,845.950271T N NRC $1,845.950274T Y NRC $2,803.360275T Y NRC $2,803.360278T N BN0290T N BN0308T Y NRC $23,570.21 $4,655.61 $14,112.910313T Y NRC $3,938.92 $686.05 $2,312.480314T N NRC $1,845.950315T N NRC $1,845.950316T N NRC $28,000.21 $4,179.70 $16,089.950330T N BN0331T N NRC $642.820332T N NRC $642.820335T Y NRC $4,850.10 $1,916.85 $3,383.470338T N NRC $2,141.740339T N NRC $2,141.740342T N NRC $1,929.370347T N BN0348T N BN0349T N BN0350T N BN0351T N BN0353T N BN0356T N BN0376T N BN0379T N BN0394T N NRC $119.430395T N NRC $374.180396T N BN0397T N BN0400T N BN0401T N BN0402T Y NRC $836.940408T Y NRC $21,122.51 $6,686.40 $13,904.450409T Y NRC $16,920.83 $9,934.89 $13,427.860410T Y NRC $5,650.48 $3,317.62 $4,484.050411T Y NRC $5,650.48 $3,317.62 $4,484.050412T N NRC $1,507.780413T N NRC $1,507.78
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 108 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
0414T Y NRC $16,920.83 $9,934.89 $13,427.860415T Y NRC $318.590416T Y NRC $819.950419T Y NRC $251.140420T Y NRC $251.140421T Y NRC $3,995.650422T N NRC $40.330424T Y NRC $25,197.89 $6,346.30 $15,772.090425T Y NRC $3,000.870426T Y NRC $9,388.140427T Y NRC $12,777.290428T N NRC $1,845.950429T N NRC $1,845.950430T N NRC $1,845.950431T Y NRC $27,144.54 $4,841.26 $15,992.900432T Y NRC $1,845.950433T Y NRC $1,845.950434T N NRC $57.310437T N BN0439T N BN0440T Y NRC $796.790441T Y NRC $796.790442T Y NRC $3,661.24 $1,556.23 $2,608.730443T N BN0444T N BN0445T N BN0446T Y NRC $251.140447T N NRC $88.290448T Y NRC $251.140449T Y NRC $3,217.38 $1,223.45 $2,220.410450T N BN0465T Y NRC $156.440466T N BN0467T N NRC $1,845.950468T N NRC $1,845.950471T N BN0479T Y NRC $161.450480T N BN0487T N BN0491T Y NRC $161.450492T N BN0493T N BN0502T N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 109 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
0503T N BN0508T N NRC $56.630510T N NRC $1,286.260511T Y NRC $4,165.80 $2,445.90 $3,305.850512T N NRC $161.450513T N BN0514T N BN0523T N BN0524T Y NRC $1,341.230525T Y NRC $7,039.77 $4,133.33 $5,586.550526T Y NRC $5,650.48 $3,317.62 $4,484.050527T Y NRC $5,650.48 $3,317.62 $4,484.050530T N NRC $1,507.780531T N NRC $1,507.780532T N NRC $1,507.780548T Y NRC $5,937.55 $3,486.17 $4,711.860549T Y NRC $2,936.75 $1,724.28 $2,330.510550T Y NRC $1,376.970551T Y NRC $118.690558T N NRC $40.330566T Y NRC $132.270587T Y NRC $469.33 $275.56 $372.440588T Y NRC $132.27A9500 N BNA9501 N BNA9502 N BNA9503 N BNA9504 N BNA9505 N BNA9507 N BNA9508 N BNA9509 N BNA9510 N BNA9512 N BNA9515 N BNA9516 N BNA9520 N BNA9521 N BNA9524 N BNA9526 N BNA9527 N NRC $31.26A9528 N BNA9529 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 110 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
A9531 N BNA9532 N BNA9536 N BNA9537 N BNA9538 N BNA9539 N BNA9540 N BNA9541 N BNA9542 N BNA9546 N BNA9547 N BNA9548 N BNA9550 N BNA9551 N BNA9552 N BNA9553 N BNA9554 N BNA9555 N BNA9556 N BNA9557 N BNA9558 N BNA9559 N BNA9560 N BNA9561 N BNA9562 N BNA9566 N BNA9567 N BNA9568 N BNA9569 N BNA9570 N BNA9571 N BNA9572 N BNA9575 N BNA9576 N BNA9577 N BNA9578 N BNA9579 N BNA9580 N BNA9581 N BNA9582 N BNA9583 N BNA9584 N BNA9585 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 111 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
A9586 N $3,028.84A9587 N BNA9588 N BNA9590 N BNA9597 N BNA9598 N BNA9698 N BNA9700 N BNC1713 N BNC1714 N BNC1715 N BNC1716 N NRC $116.44C1717 N NRC $321.98C1719 N NRC $62.96C1721 N BNC1722 N BNC1724 N BNC1725 N BNC1726 N BNC1727 N BNC1728 N BNC1729 N BNC1730 N BNC1731 N BNC1732 N BNC1733 N BNC1734 N BR $0.00C1749 N BNC1750 N BNC1751 N BNC1752 N BNC1753 N BNC1754 N BNC1755 N BNC1756 N BNC1757 N BNC1758 N BNC1759 N BNC1760 N BNC1762 N BNC1763 N BNC1764 N BNC1765 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 112 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
C1766 N BNC1767 N BNC1768 N BNC1769 N BNC1770 N BNC1771 N BNC1772 N BNC1773 N BNC1776 N BNC1777 N BNC1778 N BNC1779 N BNC1780 N BNC1781 N BNC1782 N BNC1783 N BNC1784 N BNC1785 N BNC1786 N BNC1787 N BNC1788 N BNC1789 N BNC1813 N BNC1814 N BNC1815 N BNC1816 N BNC1817 N BNC1818 N BNC1819 N BNC1820 N BNC1821 N BNC1822 N BNC1823 N BR $0.00C1824 N BR $0.00C1830 N BNC1839 N BR $0.00C1840 N BNC1841 N BNC1842 N BNC1874 N BNC1875 N BNC1876 N BNC1877 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 113 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
C1878 N BNC1880 N BNC1881 N BNC1882 N BNC1883 N BNC1884 N BNC1885 N BNC1886 N BNC1887 N BNC1888 N BNC1889 N BNC1890 N BR $0.00C1891 N BNC1892 N BNC1893 N BNC1894 N BNC1895 N BNC1896 N BNC1897 N BNC1898 N BNC1899 N BNC1900 N BNC1982 N BR $0.00C2596 N BR $0.00C2613 N BNC2614 N BNC2615 N BNC2616 N NRC $17,089.66C2617 N BNC2618 N BNC2619 N BNC2620 N BNC2621 N BNC2622 N BNC2623 N BNC2624 N BNC2625 N BNC2626 N BNC2627 N BNC2628 N BNC2629 N BNC2630 N BNC2631 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 114 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
C2634 N NRC $181.89C2635 N NRC $56.37C2636 N NRC $36.03C2638 N NRC $34.54C2639 N NRC $35.63C2640 N NRC $83.59C2641 N NRC $69.39C2642 N NRC $76.70C2643 N NRC $95.70C2645 N NRC $4.69C2698 N NRC $34.54C2699 N NRC $35.63C5271 Y $251.14C5272 N BNC5273 Y $819.95C5274 N BNC5275 Y $251.14C5276 N BNC5277 Y $251.14C5278 N BNC8900 N NRC $192.95C8901 N NRC $117.75C8902 N NRC $192.95C8903 N NRC $92.08C8905 N NRC $192.95C8906 N NRC $192.95C8908 N NRC $192.95C8909 N NRC $192.95C8910 N NRC $117.75C8911 N NRC $192.95C8912 N NRC $192.95C8913 N NRC $117.75C8914 N NRC $192.95C8918 N NRC $192.95C8919 N NRC $117.75C8920 N NRC $192.95C8931 N NRC $192.95C8932 N NRC $117.75C8933 N NRC $192.95C8934 N NRC $192.95C8935 N NRC $117.75C8936 N NRC $192.95C9046 N NRC $0.86
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 115 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
C9047 N NRC $683.55C9054 N $0.70C9055 N $76.74C9113 N BNC9132 N NRC $2.00C9248 N BNC9250 N $164.85C9254 N BNC9257 N NRC $2.03C9285 N BNC9290 N $1.25C9293 N BNC9352 N BNC9353 N BNC9354 N BNC9355 N BNC9356 N BNC9358 N BNC9359 N BNC9360 N BNC9361 N BNC9362 N BNC9363 N BNC9364 N BNC9399 N NRC $0.00C9460 N $15.38C9462 N $0.47C9482 N NRC $9.99C9488 N NRC $31.56C9600 Y $7,055.78 $3,000.22 $5,028.00C9601 N BNC9725 Y NRC $385.98C9726 N BNC9727 Y NRC $536.60C9728 N NRC $629.26C9738 N BNC9739 Y $3,741.20 $1,102.33 $2,421.76C9740 Y $7,876.19 $1,987.34 $4,931.76C9745 Y NRC $3,828.85 $1,580.91 $2,704.88C9747 Y $1,976.27C9749 Y NRC $3,896.55 $1,528.56 $2,712.55C9752 Y NRC $8,510.53 $4,996.87 $6,753.70C9753 N BN
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HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
C9754 Y NRC $10,102.32 $5,931.47 $8,016.89C9755 Y NRC $10,102.32 $5,931.47 $8,016.89C9757 Y $8,510.53 $4,996.87 $6,753.70G0104 Y $145.44G0105 Y $385.98G0121 Y $385.98G0130 N NRC $23.82G0186 Y $256.14G0260 Y $315.83G0276 Y NRC $2,803.36G0429 Y NRC $52.69G0516 N BNG0517 N BNG0518 N BNJ0120 N BNJ0121 N $3.49J0122 N $0.96J0129 N NRC $54.32J0130 N BNJ0131 N BNJ0132 N BNJ0133 N BNJ0135 N NRC $1,371.14J0153 N BNJ0171 N BNJ0178 N $952.47J0179 N NRC $317.58J0180 N NRC $183.43J0185 N $2.17J0202 N NRC $1,917.04J0207 N $1,003.59J0210 N BNJ0220 N NRC $141.14J0221 N $171.05J0222 N NRC $98.32J0256 N NRC $4.55J0257 N $4.82J0278 N BNJ0280 N BNJ0282 N BNJ0285 N BNJ0287 N $6.18J0289 N $26.09
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J0290 N BNJ0291 N NRC $3.22J0295 N BNJ0300 N NRC $56.62J0330 N BNJ0348 N BNJ0360 N BNJ0390 N BNJ0400 N BNJ0401 N NRC $5.70J0456 N BNJ0461 N BNJ0470 N BNJ0475 N $169.51J0476 N BNJ0480 N NRC $3,799.93J0485 N $3.78J0490 N $44.82J0500 N BNJ0515 N BNJ0517 N $168.50J0558 N $10.89J0561 N $13.82J0565 N NRC $39.83J0567 N NRC $93.51J0570 N NRC $1,303.53J0583 N BNJ0584 N NRC $353.21J0585 N $6.12J0586 N $8.43J0587 N $11.99J0588 N $5.05J0592 N BNJ0593 N NRC $76.34J0594 N NRC $4.58J0595 N BNJ0596 N NRC $28.22J0597 N NRC $51.31J0598 N NRC $57.03J0599 N NRC $9.67J0600 N NRC $5,594.42J0606 N NRC $2.60J0610 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 118 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J0620 N BNJ0630 N NRC $2,661.05J0636 N BNJ0637 N BNJ0638 N NRC $111.01J0640 N BNJ0641 N $0.58J0642 N $2.04J0670 N BNJ0690 N BNJ0692 N BNJ0694 N BNJ0695 N $5.60J0696 N BNJ0697 N BNJ0698 N BNJ0702 N BNJ0706 N BNJ0712 N $3.19J0713 N BNJ0714 N $92.05J0715 N BNJ0716 N $4,822.43J0717 N NRC $8.02J0720 N BNJ0725 N BNJ0735 N BNJ0740 N $623.27J0743 N BNJ0744 N BNJ0745 N BNJ0770 N BNJ0775 N NRC $48.76J0780 N BNJ0795 N NRC $9.04J0800 N NRC $3,946.50J0834 N BNJ0840 N $3,285.19J0841 N NRC $1,264.42J0850 N $1,129.15J0875 N $14.95J0878 N $0.33J0881 N $3.85
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J0882 N $3.85J0883 N $1.19J0884 N $1.19J0885 N $11.03J0887 N BNJ0888 N BNJ0894 N $7.49J0895 N BNJ0897 N $19.28J0945 N BNJ1000 N BNJ1020 N BNJ1030 N BNJ1040 N BNJ1050 N BNJ1071 N BNJ1094 N BNJ1095 N $1.19J1096 N NRC $151.41J1097 N NRC $112.35J1100 N BNJ1110 N BNJ1120 N BNJ1130 N BNJ1160 N BNJ1162 N NRC $3,780.19J1165 N BNJ1170 N BNJ1190 N $194.34J1200 N BNJ1205 N BNJ1212 N NRC $586.51J1230 N BNJ1240 N BNJ1245 N BNJ1250 N BNJ1260 N BNJ1265 N BNJ1267 N $0.89J1270 N BNJ1290 N NRC $493.74J1300 N NRC $230.48J1301 N $19.49
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J1303 N NRC $226.28J1320 N BNJ1322 N NRC $241.45J1325 N BNJ1327 N NRC $4.29J1335 N BNJ1364 N BNJ1380 N BNJ1410 N NRC $308.93J1428 N NRC $167.36J1430 N NRC $444.10J1438 N NRC $685.56J1439 N $1.10J1442 N $0.96J1447 N $0.57J1450 N BNJ1451 N NRC $8.54J1453 N $1.97J1454 N $416.87J1455 N NRC $82.27J1458 N NRC $397.92J1459 N NRC $40.12J1460 N $39.91J1555 N NRC $13.79J1556 N BNJ1557 N $45.82J1559 N NRC $10.44J1560 N $399.09J1561 N $39.14J1566 N NRC $61.20J1568 N $35.68J1569 N $37.47J1570 N BNJ1571 N $60.06J1572 N $35.59J1573 N $60.06J1575 N NRC $14.56J1580 N BNJ1595 N NRC $163.40J1599 N BNJ1602 N NRC $21.58J1610 N NRC $199.27J1626 N BN
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J1627 N $2.74J1628 N NRC $100.21J1630 N BNJ1631 N BNJ1640 N NRC $23.72J1642 N BNJ1644 N BNJ1645 N BNJ1650 N BNJ1652 N BNJ1655 N BNJ1670 N $432.66J1700 N BNJ1710 N BNJ1720 N BNJ1726 N NRC $22.40J1729 N NRC $10.81J1740 N NRC $43.48J1741 N BNJ1742 N NRC $278.77J1743 N NRC $542.89J1744 N $377.08J1745 N NRC $63.29J1746 N NRC $60.16J1750 N $14.41J1756 N BNJ1786 N NRC $42.94J1790 N BNJ1800 N BNJ1815 N BNJ1817 N BNJ1826 N $2,785.97J1830 N NRC $386.24J1833 N $0.78J1840 N BNJ1850 N BNJ1885 N BNJ1890 N BNJ1930 N $62.32J1931 N NRC $32.14J1940 N BNJ1943 N NRC $2.86J1944 N NRC $2.78
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J1950 N $1,269.23J1953 N BNJ1956 N BNJ1960 N BNJ1980 N BNJ1990 N BNJ2001 N BNJ2010 N BNJ2020 N BNJ2060 N BNJ2062 N BNJ2150 N BNJ2170 N BNJ2175 N BNJ2180 N BNJ2182 N NRC $29.72J2185 N BNJ2186 N NRC $1.79J2210 N BNJ2212 N BNJ2248 N BNJ2250 N BNJ2260 N BNJ2265 N $1.81J2270 N BNJ2274 N BNJ2278 N $7.91J2280 N BNJ2300 N BNJ2310 N BNJ2315 N NRC $3.25J2320 N BNJ2323 N NRC $20.24J2325 N NRC $74.80J2326 N NRC $1,101.83J2350 N NRC $57.42J2353 N $206.57J2354 N BNJ2355 N NRC $163.98J2357 N $36.78J2358 N BNJ2360 N BNJ2370 N BN
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J2400 N BNJ2405 N BNJ2407 N $23.78J2410 N BNJ2425 N $21.28J2426 N NRC $11.63J2430 N BNJ2440 N BNJ2469 N BNJ2501 N BNJ2502 N $303.03J2503 N BNJ2504 N NRC $367.96J2505 N $4,432.56J2507 N $2,512.55J2510 N BNJ2515 N $37.02J2540 N BNJ2543 N BNJ2547 N NRC $1.64J2550 N BNJ2560 N BNJ2562 N NRC $347.71J2590 N BNJ2597 N NRC $12.14J2650 N BNJ2675 N BNJ2680 N BNJ2690 N BNJ2700 N BNJ2704 N BNJ2710 N BNJ2720 N BNJ2724 N NRC $15.10J2730 N BNJ2760 N NRC $377.57J2765 N BNJ2770 N $417.49J2778 N NRC $352.17J2780 N BNJ2783 N $289.82J2785 N BNJ2786 N NRC $9.62
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J2788 N BNJ2790 N BNJ2791 N BNJ2792 N NRC $29.78J2794 N $10.04J2795 N BNJ2796 N NRC $74.28J2797 N $0.94J2798 N NRC $9.87J2800 N BNJ2805 N BNJ2810 N BNJ2820 N $43.44J2840 N NRC $541.13J2850 N NRC $34.78J2860 N NRC $103.06J2916 N BNJ2920 N BNJ2930 N BNJ2941 N NRC $1.67J2950 N BNJ2993 N BNJ2997 N $87.64J3000 N BNJ3010 N BNJ3030 N BNJ3031 N NRC $2.51J3060 N NRC $40.08J3070 N BNJ3090 N $1.49J3095 N NRC $5.74J3101 N $121.83J3105 N BNJ3111 N NRC $8.95J3121 N BNJ3145 N NRC $1.47J3230 N BNJ3240 N $1,695.12J3243 N $1.57J3245 N NRC $136.49J3246 N $6.92J3250 N BNJ3260 N BN
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J3262 N NRC $4.96J3265 N BNJ3285 N NRC $63.85J3300 N BNJ3301 N BNJ3302 N BNJ3303 N BNJ3304 N NRC $18.88J3310 N BNJ3315 N $258.74J3316 N $2,897.33J3350 N BNJ3357 N NRC $191.39J3358 N NRC $12.04J3360 N BNJ3364 N BNJ3370 N BNJ3380 N NRC $19.86J3385 N NRC $345.52J3396 N NRC $11.08J3397 N NRC $218.33J3398 N NRC $2,923.67J3410 N BNJ3411 N BNJ3415 N BNJ3420 N BNJ3430 N BNJ3465 N BNJ3470 N BNJ3471 N BNJ3472 N BNJ3473 N BNJ3475 N BNJ3480 N BNJ3485 N BNJ3486 N BNJ3489 N BNJ3490 N BNJ3530 N BNJ3590 N BNJ7030 N BNJ7040 N BNJ7042 N BN
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J7050 N BNJ7060 N BNJ7070 N BNJ7100 N BNJ7110 N BNJ7120 N BNJ7121 N BNJ7131 N BNJ7170 N NRC $47.35J7175 N $7.51J7177 N NRC $1.14J7178 N $1.20J7179 N NRC $1.83J7180 N $8.47J7181 N NRC $15.52J7182 N $1.31J7183 N $0.97J7185 N $1.27J7186 N $1.06J7187 N $1.16J7188 N $3.18J7189 N $2.15J7190 N $1.07J7192 N $1.25J7193 N $1.15J7194 N $1.47J7195 N $1.50J7196 N $103.35J7197 N $3.32J7198 N $1.90J7200 N $1.32J7201 N $3.11J7202 N $4.29J7203 N NRC $3.99J7205 N $2.08J7207 N NRC $1.74J7208 N $2.02J7209 N NRC $1.24J7210 N NRC $1.36J7211 N BNJ7308 N NRC $390.98J7311 N NRC $341.62J7312 N $200.03
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J7313 N NRC $490.87J7314 N NRC $491.13J7315 N BNJ7316 N NRC $1,046.93J7318 N $17.23J7320 N $16.92J7321 N BNJ7322 N $31.67J7323 N $145.08J7324 N $143.40J7325 N $11.41J7326 N NRC $1,166.00J7327 N $769.51J7328 N $2.18J7329 N $7.20J7336 N $3.15J7340 N $219.45J7342 N NRC $29.97J7345 N NRC $1.45J7500 N BNJ7501 N NRC $238.19J7502 N BNJ7503 N BNJ7504 N NRC $2,066.02J7505 N BNJ7507 N BNJ7508 N BNJ7509 N BNJ7510 N BNJ7511 N NRC $768.56J7512 N BNJ7515 N BNJ7516 N BNJ7517 N BNJ7518 N BNJ7520 N BNJ7525 N NRC $211.84J7527 N BNJ7599 N BNJ7665 N BNJ7674 N BNJ7799 N BNJ7999 N BN
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J8501 N BNJ8510 N $24.18J8520 N BNJ8521 N BNJ8530 N BNJ8540 N BNJ8560 N $75.36J8597 N BNJ8600 N BNJ8610 N BNJ8655 N $245.74J8670 N $2.12J8700 N BNJ8705 N BNJ9000 N BNJ9015 N $4,964.62J9017 N $44.31J9019 N $414.83J9022 N $77.01J9023 N $82.97J9025 N $1.16J9027 N $61.69J9030 N $2.82J9032 N $40.07J9033 N $27.84J9034 N $22.85J9035 N $81.18J9036 N $24.36J9039 N $113.40J9040 N BNJ9041 N $44.69J9042 N $162.44J9043 N $173.67J9044 N $25.04J9045 N BNJ9047 N $37.60J9050 N $3,039.01J9055 N $62.05J9057 N $79.42J9060 N BNJ9065 N $19.00J9070 N $34.14J9098 N $81.42
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J9100 N BNJ9119 N $27.45J9120 N $1,098.20J9130 N BNJ9145 N $53.95J9150 N $46.74J9153 N $192.31J9155 N $3.97J9171 N $0.87J9173 N $74.64J9175 N BNJ9176 N $6.50J9178 N BNJ9179 N $114.27J9181 N BNJ9185 N BNJ9190 N BNJ9200 N BNJ9201 N BNJ9202 N $497.72J9203 N $199.23J9204 N $200.87J9205 N $49.91J9206 N BNJ9207 N $91.07J9208 N BNJ9209 N BNJ9210 N NRC $780.05J9211 N BNJ9213 N $169.33J9214 N $34.24J9217 N $224.70J9218 N BNJ9225 N $4,085.61J9226 N NRC $36,647.60J9228 N $153.13J9229 N $2,270.31J9230 N $328.29J9245 N $610.88J9250 N BNJ9260 N BNJ9261 N $152.48J9262 N $3.11
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J9263 N BNJ9264 N $12.51J9266 N $17,566.89J9267 N BNJ9268 N $1,968.61J9269 N $258.96J9270 N BNJ9271 N $49.39J9280 N $87.75J9285 N $52.13J9293 N $27.39J9295 N $5.74J9299 N $27.81J9301 N $62.86J9302 N $60.09J9303 N $119.07J9305 N $69.47J9306 N $12.29J9307 N $291.26J9308 N $58.42J9309 N $110.36J9311 N $43.53J9312 N $94.67J9313 N $22.08J9315 N $297.59J9320 N $349.70J9325 N $51.47J9328 N $10.39J9330 N $53.14J9340 N $404.28J9351 N BNJ9352 N $312.91J9354 N $31.36J9355 N $106.62J9356 N $80.26J9357 N $1,438.59J9360 N BNJ9370 N BNJ9371 N $3,080.04J9390 N BNJ9395 N $94.87J9400 N $8.37J9600 N $21,397.87
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 131 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
J9999 N BNL8600 N BNL8603 N BNL8604 N BNL8605 N BNL8606 N BNL8607 N BNL8609 N BNL8610 N BNL8612 N BNL8613 N BNL8614 N BNL8630 N BNL8631 N BNL8641 N BNL8642 N BNL8658 N BNL8659 N BNL8670 N BNL8679 N BNL8682 N BNL8690 N BNL8699 N BNL9900 N BNP9041 N NRC $10.49P9045 N NRC $52.45P9046 N NRC $20.98P9047 N NRC $52.45Q0138 N $1.00Q0139 N NRC $1.00Q0161 N BNQ0162 N BNQ0163 N BNQ0164 N BNQ0166 N BNQ0167 N BNQ0169 N BNQ0173 N BNQ0175 N BNQ0177 N BNQ0180 N BNQ0181 N BNQ2004 N BN
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
Q2009 N $1.73Q2017 N $2,645.71Q2026 N $473.90Q2028 N $3.28Q2034 N BNQ2035 N BNQ2036 N BNQ2037 N BNQ2038 N BNQ2039 N BNQ2043 N NRC $46,374.20Q2049 N $470.40Q2050 N $355.07Q3027 N $53.58Q3031 N BNQ4100 N BNQ4101 N BNQ4102 N BNQ4103 N BNQ4104 N BNQ4105 N BNQ4106 N BNQ4107 N BNQ4108 N BNQ4110 N BNQ4111 N BNQ4112 N BNQ4113 N BNQ4114 N BNQ4115 N BNQ4116 N BNQ4117 N BNQ4118 N BNQ4121 N BNQ4122 N BNQ4123 N BNQ4124 N BNQ4125 N BNQ4126 N BNQ4127 N BNQ4128 N BNQ4130 N BNQ4132 N BN
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
Q4133 N BNQ4134 N BNQ4135 N BNQ4136 N BNQ4137 N BNQ4138 N BNQ4139 N BNQ4140 N BNQ4141 N BNQ4142 N BNQ4143 N BNQ4145 N BNQ4146 N BNQ4147 N BNQ4148 N BNQ4149 N BNQ4150 N BNQ4151 N BNQ4152 N BNQ4153 N BNQ4154 N BNQ4155 N BNQ4156 N BNQ4157 N BNQ4158 N BNQ4159 N BNQ4160 N BNQ4161 N BNQ4162 N BNQ4163 N BNQ4164 N BNQ4165 N BNQ4166 N BNQ4167 N BNQ4168 N BNQ4169 N BNQ4170 N BNQ4171 N BNQ4173 N BNQ4174 N BNQ4175 N BNQ4176 N BNQ4177 N BN
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Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
Q4178 N BNQ4179 N BNQ4180 N BNQ4181 N BNQ4182 N BNQ4183 N BNQ4184 N BNQ4185 N BNQ4186 N BNQ4187 N BNQ4188 N BNQ4189 N BNQ4190 N BNQ4191 N BNQ4192 N BNQ4193 N BNQ4194 N BNQ4195 N $89.70Q4196 N $104.83Q4197 N BNQ4198 N BNQ4200 N BNQ4201 N BNQ4202 N BNQ4203 N BNQ4204 N BNQ5101 N $0.57Q5103 N NRC $49.25Q5104 N NRC $53.40Q5105 N NRC $0.96Q5106 N $9.63Q5107 N $69.77Q5108 N $327.41Q5110 N $0.64Q5111 N $347.06Q5117 N $90.67Q9950 N $19.54Q9951 N BNQ9953 N BNQ9954 N BNQ9955 N BNQ9956 N BNQ9957 N BN
2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 135 of 243
Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule
HCPCS Code
Subject to Multiple
Procedure Discounting
Coverage Status
BWC 2020 final rate
BWC Rate after applying Modifier FB for full device credit
BWC Rate after applying Modifier
FC for partial device credit
Q9958 N BNQ9959 N BNQ9960 N BNQ9961 N BNQ9962 N BNQ9963 N BNQ9964 N BNQ9965 N BNQ9966 N BNQ9967 N BNQ9968 N NRC $6.40Q9982 N BNQ9983 N BNQ9991 N $1,673.36Q9992 N $1,673.36V2630 N BNV2631 N BNV2632 N BNV2785 N BR $0.00V2790 N BN
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STATE NPI 2020 ASCs Determined to Not Meet Quality Requirements Under CMS ASCQR
AK 1205892197ALASKA SURGERY CENTER LIMITED PARTNERSHIP DBA ALASKA SURGERY CENTER HEALTHSOUTH
AK 1912202896 ALASKA EYE SURGERY AND LASER CENTER INCAR 1457379364 JONESBORO SURGERY CENTER LLCAR 1578643607 PAIN CENTER LLCAR 1730132853 OUTPATIENT SURGERY CENTER INCAR 1831182641 MERCY AMBULATORY SURGERY CENTER LLCAZ 1013195569 DESERT MIRAGE SURGERY CENTERAZ 1104957869 AZ PAIN CENTERSAZ 1528284767 MESA SURGICAL CENTER LLCAZ 1598968927 ORTHOPEDIC CLINIC ASSOCIATION AMB SURG CENTER THEAZ 1639431653 DESERT CLIFFS SURGERY CENTER LLCAZ 1811940398 DESERT SUN SURGERY CENTER LLCAZ 1851531248 LASER SURGERY HOLDING COMPANY LTDAZ 1871513705 SQUAW PEAK SURGICAL FACILITY INCCA 1023365913 PACIFIC SURGERY CTRCA 1033368378 MISSION ENDOSCOPY CENTER INCCA 1033448782 ENDOSCOPY SURGERY CENTER OF SILICON VALLEY LLCCA 1073794855 SURGICARE OF LA VETA LTD DBA BARRANCA SURGERY CENTERCA 1093847311 SURGICAL EYE CARE CENTER INCCA 1124439419 RANCHO CORDOVA SURGERY CENTER LLCCA 1154554160 CABRILLO SURGERY CENTERCA 1194913103 LASERVUE EYE CENTER MEDICAL CORPORATIONCA 1215019625 FOUR SEASONS SURGERY CENTERS OF ONTARIO LPCA 1215238076 KNOWLES SURGERY CENTER LLCCA 1225123227 COMPREHENSIVE PAIN MANAGEMENT CENTER INCCA 1225245723 FRESNO ENDOSCOPY CENTERCA 1245393602 PACIFIC COAST SPINE INSTITUTE AND PAIN CENTERCA 1285028803 PALOS VERDES SKIN SURGERY CTR INCCA 1295897585 FOLSOM SIERRA ENDOSCOPY CENTER LPCA 1295918977 WEST COAST CENTER FOR SURGERIESCA 1366485385 WEBSTER SURGERY CENTER LPCA 1366635609 APPLE SURGERY CENTER INCCA 1396005823 LDAC SURGERY CENTER INCCA 1407932619 PACIFIC EYE INSTITUTE A MEDICAL GROUP INCCA 1447352737 SAMARITAN ENDOSCOPY CENTERCA 1497130660 NIVANO AMBULATORY SURGERY CENTER LPCA 1497705883 MISSION AMBULATORY SURGICENTER LTDCA 1528473030 UNICARE SURGERY CENTER A MEDICAL CORPORATIONCA 1558514158 BAKERSFIELD SURGERY CENTER LLCCA 1578505079 TRUXTUN SURGERY CENTER INCCA 1669660817 SPH IRVINE LLCCA 1679913552 SPINE SPORTS SURGERY CENTER LLCCA 1730514027 KY ADVANCED SURGICAL CENTER INCCA 1740318153 PLAZA SURGERY CENTER LP DBA PLAZA SURGERY CENTERCA 1750553376 SAN MATEO SURGERY CENTER LLCCA 1760423180 CENTRAL COAST ENDOSCOPY CENTER INC
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Ohio Bureau of Workers' Compensation 2020 Ambulatory Surgical Center Services
STATE NPI 2020 ASCs Determined to Not Meet Quality Requirements Under CMS ASCQR
CA 1861760670 PAIN CARE PROVIDERS A PROFESSIONAL MEDICAL CORPORATIONCA 1912362955 ST CHARLES SURGICAL CENTERCA 1922027176 SAN DIEGO EYE COR INCCA 1942335468 INNOVATIVE PAIN TREATMENT SURGERY CENTER OF TEMECULA INCCA 1982931465 GARDEN GROVE SURGICAL CENTER INCCO 1215981113 ENGLEWOOD SURGERY CENTER LLCCO 1356610174 CHERRY CREEK SURGERY CENTER LLCCO 1437549359 CENTER OF SURGICAL EXCELLENCE LLCCO 1871602227 THE MOHS CENTERCO 1922005610 EYE SURGERY CENTER OF COLORADO PCCT 1023113701 SURGICAL CENTER OF CONNECTICUT LLCCT 1386794980 NEW VISION CATARACT CENTER LLC DBA NEW VISION CATARACT CENTERCT 1811318785 CONNECTICUT ORTHOPAEDIC SPECIALISTS OUTPATIENT SURGICAL CENTER LLCFL 1164719209 BLUE WATER SURGERY CENTERFL 1265407142 NAPLES DAY SURGERY LLC DBA NAPLES DAY SURGERY SOUTHFL 1265494553 CORAL VIEW SURGERY CENTER LLCFL 1295793974 SANTA LUCIA SURGICAL CENTER LLCFL 1336100189 ST MICHAELS SURGERY CENTER INCFL 1386654630 BERAJA HEALTHCARE CORPORATIONFL 1467405837 PARKCREEK SURGERY CENTER LLLPFL 1467783688 PREMIER SURGICAL CENTER LLCFL 1477526143 UNIVERSITY EYE SURGERY CENTERFL 1578917035 HABANA AMBULATORY SURGERY CENTER LLCFL 1669803391 SURGERY CENTER OF VIERA LLCFL 1750313144 AMBULATORY SURGICAL CARE LLCFL 1770528838 BREVARD SURGERY CENTERFL 1790761393 ST. LUCIE SURGICAL CENTER PAFL 1891184826 SURGICAL CENTER OF NORTH FLORIDA LLCGA 1215204128 MINIMALLY INVASIVE NEUROSPINE AND PAIN INSTITUTE PCGA 1285083477 GEORGIA INTERVENTIONAL PAIN B LLCGA 1326494147 CENTER FOR SPINE AND PAIN MEDICINE PC DBA CSPM GAINESVILLE ASCGA 1356732804 ATHENS DIGESTIVE ENDOSCOPY CENTERGA 1417217183 PAULSEN STREET SUGERY CENTER LLCGA 1437250248 GEORGIA SURGICAL CENTER ON PEACHTREE LLCGA 1508210378 APEX MEDICAL SURGERY CENTER LLCGA 1679894505 AP SURGERY CENTER LLCGA 1700943958 LOWNDES COUNTY AMBULATORY SURGICAL CENTERGA 1801110275 GA PAIN MANAGEMENT CENTER LLCGA 1861491987 THE PLASTIC SURGERY CENTER LAND LLCHI 1952366874 HONOLULU SURGERY CENTER LP DBA SURGICARE OF HAWAIIIA 1386624815 QUALITY CARE CLINIC AND SURGICENTERIL 1205964103 FULLERTON KIMBALL MEDICAL & SURGICAL CENTERIL 1275599086 BELLEVILLE SURGICAL CENTER LTDIL 1275933756 BELLEVILLE SURGICAL CENTER LTDIL 1356412894 ROCKFORD ORTHOPEDIC SURGERY CENTER LLCIL 1487612024 QUAD CITY AMBULATORY SURGERY CENTER LLCIL 1548390081 ADVANCED AMBULATORY SURGICAL CENTER INC
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STATE NPI 2020 ASCs Determined to Not Meet Quality Requirements Under CMS ASCQR
IL 1568426260 PEORIA DAY SURGERY CENTER SCIN 1033190566 RIVERPOINTE SURGERY CENTERIN 1063556421 MEMORIAL SPINE AND NEUROSCIENCE CENTERIN 1700854072 SULLIVAN SURGICENTER LLCIN 1831508357 CLEARVIEW EYE SURGERY CENTER LLCIN 1902134372 METRO SPECIALTY SURGERY CENTER LLCIN 1942637301 MICHIANA SURGERY CENTER LLCKS 1316043631 VIA CHRISTI CLINIC PALA 1851686596 ADVANCED PAIN INSTITUTE TREATMENT CENTER LLCMA 1851491013 NEW ENGLAND AMBULATORY SURGICENTER LLCMD 1033524855 KENT ISLAND SURGERY CENTER LLCMD 1083624225 UNIVERSITY OF MARYLAND UROLOGICAL SURGERY CENTERMD 1124492996 MOHS AND SKIN SURGERY CENTER LLCMD 1336288224 EYE SURGERY CENTER OF WHITE MARSH LLCMD 1346215316 CHESAPEAKE EYE SURGERY CENTER LLCMD 1508813197 ENDOSCOPY CENTER AT TOWSON INCMD 1598756306 YORK GREEN SURGERY CENTER LLCMD 1629016076 UNIVERSITY CENTER FOR AMBULATORY SURGERY LLCMD 1649501073 SHORE HEALTH SYSTEM INCMD 1710959556 SURGERY CENTER OF ROCKVILLE LLCMD 1790871184 MID- ATLANTIC NEUROSURGICAL ASSOCIATES PAIN CENTERMD 1831489335 HAGERSTOWN SURGERY CENTER LLCMD 1851369615 OPHTHALMOLOGY ASSOCIATES LLCMD 1871751859 WESTMINSTER SURGERY CENTERMD 1902220627 FREDERICK FOOT AND ANKLE ASC LLCMD 1902991979 WESTERN MARYLAND EYE SURGICAL CENTERME 1558456459 PORTLAND ENDOSCOPY CENTERMI 1013385046 INTERVENTIONAL PAIN CENTER PLLCMI 1023358116 OAKLAND PHYSICAN SURGERY CENTERMI 1255342366 MILLMANDERR CENTER FOR EYE CARE PCMI 1861947558 MINIMALLY INVASIVE ASC DBA FLINT REGION ASCMO 1003171745 MIDWEST SURGERY CENTER LLCMO 1023428281 HEARTLAND REGIONAL MEDICAL CENTERMO 1811028293 PHYSICIANS SURGERY CENTERMS 1487094058 COMPREHENSIVE PAIN CENTER FOR SURGERYMS 1508922865 INSTITUTE FOR SPINAL PAIN TREATMENTMS 1720161771 EYE CARE SURGERY CENTER OF OLIVE BRANCHLLCMS 1780767673 EYE CARE SURGERY CENTER OF SOUTHAVEN LLCNJ 1255376653 ENDOSCOPY CENTER OF SOUTH JERSEY P CNJ 1356643944 UNION SURGERY CENTER LLCNJ 1437512514 NEW CENTURY SPINE AND OUTPATIENT SURGICAL INSTITUTENJ 1518286681 LIBERTY AMBULATORY SURGERY CENTER LLCNJ 1538199799 MIDDLESEX SURGERY CENTER LLCNJ 1821242488 SPECIALTY SURGICAL CENTER OF NORTH BRUNSWICK LLCNJ 1912909433 CENTENNIAL SURGERY CENTERNJ 1972556900 GLEN RIDGE SURGI CENTERNV 1386004018 COPPEL SURGICAL SOLUTIONS DBA NEVADA SURGICAL SUITES EAST
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STATE NPI 2020 ASCs Determined to Not Meet Quality Requirements Under CMS ASCQR
NV 1942318498 DIGESTIVE DISEASE CENTERNY 1033517263 ISLAND AMBULATORY SURGERY CENTERNY 1104125939 GASTROENTEROLOGY CARE INCNY 1164516084 ENDOSCOPIC AMBULATORY SPECIALTY CENTER OF BAY RIDGE INCNY 1164793725 HUDSON VALLEY CENTER FOR DIGESTIVE HEALTH LLCNY 1477645711 PROGRESSIVE SURGERY CENTER LLCNY 1598039125 ROOSEVELT SURGERY CENTER LLC DBA MANHATTAN SURGERY CENTERNY 1841213923 NORTH SHORE SURGI CENTER INCNY 1841222353 PRO HEALTH DAY OP OF MINEOLANY 1851717383 NYEEQ ASC LLC DBA NORTH QUEENS SURGICAL CENTERNY 1972980415 CENTRAL NEW YORK ASC DBA OMNI OUTPATIENT SURGERY CENTEROH 1104835776 MID OHIO SURGERY CENTEROH 1154412757 SURGICENTER LTDOH 1396812491 VALLEY ENDOSCOPY CENTER INCOH 1407247208 COLONOSCOPY AND ENDOSCOPY CENTER LLCOH 1619257409 ASHTABULA SURGERY CENTER LLCOH 1700815552 SURGCENTER HUDSON LLCOH 1760470942 SAMARITAN NORTH SURGERY CENTER LTDOH 1831287580 CLINTON COUNTY OUTPATIENT SURGERY INCOH 1891793915 NORTHEAST OHIO SURGERY CENTER LLCOR 1437320017 OREGON EYE SURGERY CENTER INCOR 1851520514 CAPITOL SURGERY CENTER LLC DBA WAVERLY LAKE SURGERY CENTEROR 1912045154 CROISAN RIDGE SURGERY CENTER LLCPA 1043281660 UPMC MONROEVILLE SURGERY CTRPA 1053356436 SURGERY CENTER AT EDGEWORTH COMMONSPA 1134241946 BERKS AMBULATORY SURGERY CENTER LLCPA 1366647968 NORTH POINTE SURGERY CENTER LPPA 1467535773 AMBULATORY ENDOSCOPIC SURGICAL CENTER OF BUCKS COUNTY LLCPA 1487699385 BRANDYWINE VALLEY ENDOSCOPY CENTERPA 1629409578 PAIN CENTER OF WYOMING VALLEY LLCRI 1811168164 UROLOGIC SPECIALISTS OF NEW ENGLAND LLCSC 1932132065 THE SURGERY CENTER OF AIKEN LLCTN 1396828323 EYE CARE SURGERY CENTER OF MEMPHIS LLCTN 1538139811 SAINT THOMAS OUTPATIENT NEUROSURGICAL CENTERTN 1619071214 PREMIER RADIOLOGY PAIN MANAGEMENT CENTERTX 1063586105 DKJJ INC DBA REAGAN EYE CENTERTX 1083000715 CLEBURNE ENDOSCOPY CENTER LLCTX 1083038186 FRISCO AMBULATORY SURGERY CENTER LLCTX 1205267341 SURGCENTER OF WESTOVER HILLS LLCTX 1306199757 SONTERRA PROCEDURE CENTER LLCTX 1376540096 DEHAVEN CATARACT SURGICAL CENTER INCTX 1437505948 WATER LEAF SURGERY CENTER LTDTX 1497767149 PEARLAND PREMIER SURGERY CENTER LTDTX 1548374267 DALLAS SURGI CENTER INCTX 1558782268 HOUSTON SURGERY CENTER
TX 1609206614HURST AMBULATORY SURGERY CENTER LLC DBA PRECINCT AMBULATORY SURGERY CENTER LLC
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STATE NPI 2020 ASCs Determined to Not Meet Quality Requirements Under CMS ASCQR
TX 1841397171 SUMMIT ASC LLPTX 1861869869 BLUE STAR SURGERY CENTER LLCVA 1598786477 OSTEOPATHIC SURGICAL CENTERS LLCWA 1083785398 OLYMPIA ORTHOPAEDIC ASSOCIATES PLLCWA 1164976478 THE DOCTORS CLINIC ASC THE FRANCISCAN MEDICAL GROUPWA 1225230634 VALLEY EYE AND LASER CENTER INCPSWA 1528000155 SOUND UROLOGICAL ASSOCIATES PSWA 1588743009 VALLEY GASTROENTEROLOGY PSWA 1720111792 BELLEVUE SPINE SPECIALISTWA 1891722609 EYE MDS OF PUGET SOUND PLLCWV 1447286562 ANWAR EYE CENTER INCWV 1992896310 JERRY N BLACK SURGICAL SUITE