Ambulatory Surgery Center (ASC) Payment Policies

Line item CPT code Maximum Acquisition cost Allowed. on bill modifier payment policy applied amount. 1 27446–SG $3,570.93 $3,570.931. 2 L8699 $9,025.00 $9,025.002. Total allowed amount $12,595.933. 1. Highest valued procedure is paid at 100% of maximum allowed amount. 2. ................
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