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Florida Workersãâ¢ã¤â€°ã¥ã¤â€¹â¢ Compensation Health Care Provider Reimbursement Manual

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FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER REIMBURSEMENT MANUAL 2008 Edition Department of Financial Services Florida Department of Financial Services Division of Workers’ Compensation for incorporation by reference into Rule 69L-7.020, Florida Administrative Code RULE 69L-7.020, F.A.C. Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition CONTENTS SECTION I: ADMINISTRATIVE PURPOSE OF MANUAL ...................................................... 8 SECTION II: BASIC PROGRAM REQUIREMENTS Provider Eligibility .................................................................................................... 8 Authorization ............................................................................................................. 8 Billing ........................................................................................................................ 8 Materials Adopted for Reference............................................................................... 9 Medical Records ...................................................................................................... 10 Reimbursement Information .................................................................................... 11 SECTION III: CLASSIFICATION OF INJURED EMPLOYEE’S STATUS General Guidelines .................................................................................................. 14 Patient Classification Levels.................................................................................... 15 SECTION IV: DENTAL SERVICES.............................................................................................. 15 SECTION V: DISPENSING OF MEDICATION Medicinal Drugs ...................................................................................................... 16 Patent, Proprietary or Over-the-Counter Drugs ....................................................... 17 SECTION VI: MEDICAL SUPPLIER SERVICES ........................................................................ 17 SECTION VII: MEDICAL SERVICES Biofeedback Services............................................................................................... 18 Electrodiagnostic Medicine ..................................................................................... 18 Evaluation and Management Services ..................................................................... 19 Home Health Services ............................................................................................. 20 Impairment Rating ................................................................................................... 20 Independent Medical Examination .......................................................................... 20 Independent Medical Examination, Consensus ....................................................... 20 Injectable Medications ............................................................................................. 20 Medical and Surgical Supplies ................................................................................ 21 Ophthalmological Services ...................................................................................... 22 Psychiatric and Psychological Services ................................................................... 22 Radiology................................................................................................................. 23 Thermography.......................................................................................................... 24 Transcutaneous Neurostimulator ............................................................................. 24 RULE 69L-7.020, F.A.C. 2 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition SECTION VIII: PHYSICAL MEDICINE AND REHABILITATION SERVICES General Information................................................................................................. 25 Physical Medicine Services ..................................................................................... 26 Manipulative Treatment........................................................................................... 27 Physical Reconditioning Services ......................................................................... 29 Interdisciplinary Rehabilitation Programs ............................................................... 31 Functional Capacity Evaluation............................................................................... 32 SECTION IX: SURGICAL SERVICES General Reimbursement .......................................................................................... 33 Surgical Assistants................................................................................................... 34 Multiple Procedures................................................................................................. 35 Bilateral Procedures................................................................................................. 35 SECTION X: ANESTHESIA SERVICES Reimbursement Methodology.................................................................................. 37 Medical Direction of CRNA/AA ............................................................................. 38 Anesthesia Services for Which Time Units Not Allowed ....................................... 39 SECTION XI: SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES General Instructions for Use of Schedule ................................................................ 41 PART A: Anesthesia................................................................................................................ 43 Surgery..................................................................................................................... 45 Radiology................................................................................................................. 81 Pathology ................................................................................................................. 95 Medicine ................................................................................................................ 118 Evaluation and Management ................................................................................. 127 Dental..................................................................................................................... 128 Injections................................................................................................................ 132 PART B: Surgery................................................................................................................... 136 PART C: Radiology............................................................................................................... 245 Pathology ............................................................................................................... 286 Medicine ................................................................................................................ 353 Evaluation and Management ................................................................................. 378 RULE 69L-7.020, F.A.C. 3 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDICES APPENDIX A. DEFINITIONS................................................................................................ 381 APPENDIX B. OFFICIAL SOURCE OF REFERENCES...................................................... 384 APPENDIX C. MODIFIERS ................................................................................................... 387 APPENDIX D. WORKERS’ COMPENSATION UNIQUE CODES ..................................... 389 APPENDIX E. MEDICARE LOCALITY MAP ..................................................................... 391 INDEX ............................................................................................................................................... 393 RULE 69L-7.020, F.A.C. 4 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 69L-7.020 Florida Workers’ Compensation Health Care Provider Reimbursement Manual. (1) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition, is adopted by reference as part of this rule. The manual contains the Maximum Reimbursement Allowances determined by the Three-Member Panel, pursuant to section 440.13 (12), Florida Statutes and establishes reimbursement policies, guidelines, codes and maximum reimbursement allowances for services and supplies provided by health care providers. Also, the manual includes reimbursement policies and payment methodologies for pharmacists and medical suppliers. (2) The CPT® 2009 Current Procedural Terminology Professional Edition, Copyright 2008, American Medical Association; the Current Dental Terminology, CDT-2009/2010, Copyright 2008, American Dental Association; and in part for D codes and for injectable J codes, and for other medical services and supply codes, the “Healthcare Common Procedure Coding System, Medicare’s National Level II Codes, HCPCS 2009”, American Medical Association, Twenty-first Edition, Copyright 2008, Ingenix Publishing Group, are adopted by reference as part of this rule. When a health care provider performs a procedure or service which is not listed in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition incorporated above, the provider must use a code contained in the CPT®-2009, CDT-2009/2010 or HCPCS-2009 as specified in this section. (3) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition incorporated above, is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section, 200 East Gaines Street, Tallahassee, Florida 32399-0311, or via the Department’s web site at http://www.fldfs.com/wc. Specific Authority 440.13(14)(b), 440.591 FS. Law Implemented 440.13(7), (12), (14) FS. History–New 10-182, Amended 3-16-83, 11-6-83, 5-21-85, Formerly 38F-7.20, Amended 4-1-88, 7-20-88, 6-1-91, 4-29-92, 2-1896, 9-1-97, 12-15-97, 9-17-98, 9-30-01, 7-7-02, Formerly 38F-7.020, 4L-7.020, Amended 12-4-03, 1-1-04, 74-04, 5-9-05, 9-4-05, 11-16-06, 10-18-07, 02-04-09. RULE 69L-7.020, F.A.C. 5 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER REIMBURSEMENT MANUAL 2008 EDITION Rule Chapter 69L-7.020, Florida Administrative Code In accordance with section 440.13, Florida Statutes (F.S.), this manual provides reimbursement policies and a schedule of maximum reimbursement allowances, as applicable, for licensed physicians, licensed health care providers, licensed pharmacists and medical suppliers rendering medical services and supplies to Florida’s injured workers. The maximum reimbursement allowances and procedure codes are listed in Section XI. NOTICES AND DISCLAIMERS The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition, provides five-digit codes and two-digit modifiers for reporting medical services and procedures that were selected from the following references by the State of Florida for inclusion in this publication. When a service or procedure is performed that does not have a code listed in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition, the physician or health care provider must use a code listed in the following materials: CPT® 2009 Current Procedural Terminology Professional Edition, Copyright 2008, American Medical Association. Current Dental Terminology, CDT-2009/2010, Copyright 2008, American Dental Association. Healthcare Common Procedure Coding System, Medicare’s National Level II Codes, HCPCS 2009, American Medical Association, Twenty-first Edition, Copyright 2008, Ingenix Publishing Group. The CPT®-2009 and CDT-2009/2010 contain listings of descriptive terms and identifying codes used by physicians and dentists for reporting medical and dental services and procedures. HCPCS-2009 is used in part for the listing of descriptive terms and codes for dental services and procedures performed by dentists. HCPCS-2009 also contains a listing of injectable medications and codes used to report injections administered by physicians as well as other codes used to report medical services and supplies. It is expressly understood and agreed that the American Medical Association’s rights include, but not limited to, common law and statutory rights of literary property in the CPT® and in any update thereto, including all descriptive terms and identifying codes and modifiers for reporting procedures and medical services and/or any other information or materials contained in the CPT® and in any update thereto are not assigned or released as a result of the agreement between the American Medical Association and the State of Florida, but are at all times reserved and retained by the American Medical Association. RULE 69L-7.020, F.A.C. 6 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition The five character codes included in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition are obtained from Current Procedural Terminology (CPT®), copyright 2008 by the American Medical Association (AMA). 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. The responsibility for the content of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition is with the State of Florida Division 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 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition. 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 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 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. This product includes CPT®, which is commercial technical data and/or computer databases and/or commercial computer software and/or commercial software documentation, as applicable, which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. CPT is a registered trademark of the American Medical Association. RULE 69L-7.020, F.A.C. 7 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition SECTION I: ADMINISTRATIVE PURPOSE OF MANUAL. The administrative purpose of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition, is to provide reimbursement guidelines, codes and maximum reimbursement allowances for licensed physicians and health care providers rendering medically necessary services to Florida’s injured employees. This manual also contains reimbursement policies and payment methodologies for pharmacists and medical suppliers. SECTION II: BASIC PROGRAM REQUIREMENTS. A. Provider Eligibility. 1. Florida health care providers must comply with provider certification and eligibility requirements in section 440.13, Florida Statutes (F.S.), in order to qualify for reimbursement for rendering medical services to injured employees. 2. Provider certification information and the required application may be obtained from the Division at the following website http://www.myfloridacfo.com/wc/forms.html (listed under rules and forms): B. Authorization. 1. Florida health care providers, out-of-state providers and federal facilities must be authorized by the employer’s workers’ compensation insurer or a self-insured employer prior to rendering initial and remedial medical services or before referring the injured employee to facilities or other certified health care providers. 2. Insurers must comply with the statutory requirements in section 440.13, F.S., in responding to authorization requests timely and to ensure that providers are eligible to receive reimbursement for the treatment being requested. 3. Neither emergency services and care, defined in section 395.002, F.S., or a provider referral for emergency treatment resulting from emergency care requires authorization by an insurer. These are the only exceptions to the requirements of prior authorization for medical care and treatment. C. Billing. Health care providers, including pharmacists, medical suppliers, out-of-state providers and federal facilities, must report medical services rendered and must bill in accordance with rule 69L-7.602, Florida Administrative Code (F.A.C.) available at the following website: http://www.myfloridacfo.com/wc (listed under rules and forms). RULE 69L-7.020, F.A.C. 8 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition D. Materials Adopted for Reference. 1. The following publications are adopted for reference to the listings of descriptive terms and identifying codes for reporting medical services and procedures provided to injured employees by physicians and other health care providers: a. CPT® 2009 Current Procedural Terminology Professional Edition, Copyright 2008, American Medical Association. b. Current Dental Terminology, CDT-2009/2010, Copyright 2008, American Dental Association. c. Healthcare Common Procedure Coding System, Medicare’s National Level II Codes, HCPCS 2009, American Medical Association, Twenty-first Edition, Copyright 2008, Ingenix Publishing Group, for dental D codes, injectable J codes, and the other medical services or supply codes as specified in this manual. 2. Physicians and providers shall use the codes and descriptions, modifiers, guidelines, definitions and instructions of the referenced CPT®-2009, CDT-2009/2010 and HCPCS-2009 in part for dental codes, injection codes, specific modifiers, and the other medical services or supply codes as specified in this manual. The code descriptors, guidelines, definitions, and instructions of the aforementioned references are not provided in this manual. 3. Any modification to a code descriptor by the workers’ compensation program shall be specified and shall take precedence over any descriptor contained in the referenced CPT®2009, CDT-2009/2010 or HCPCS-2009. 4. The use of HCPCS Level II codes is only allowed when there is not a more specific CPT® code. E. Maintenance and Release of Medical Records. 1. Health Insurance Portability and Accountability Act (HIPAA) and Applicable Licensure Requirements. Health care providers shall create and maintain medical records of workers’ compensation claimants in accordance and compliance with HIPAA, Chapter 456, F.S., and the applicable licensing statute(s) and administrative rules adopted thereunder, including the requirement to provide notice of privacy practices in a manner and form that meets the requirements of 45 C.F.R. § 164.520 advising the claimant that Protected Health Information (PHI) may be used and disclosed without prior authorization as necessary to comply with workers’ compensation laws. Every health care provider shall, except in an emergency treatment situation, make a good faith effort to obtain a written acknowledgement of receipt of notice of privacy practices no later than the first day of providing medical services to a workers’ compensation insured patient, and if not obtained, document its good faith efforts to obtain such acknowledgment and the reason why the acknowledgement was not obtained. In the event a patient, guardian, RULE 69L-7.020, F.A.C. 9 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition curator, or personal representative requests restriction(s) of the use or disclosure of identifiable health information that would prevent disclosure as necessary for treatment or payment for health care services, the hospital shall notify the insurer immediately, if possible, or by close of business on the next regular business day. 2. Carrier Disclosure. Unless instructed otherwise, it is the responsibility of all health care providers to furnish, without charge, the following documentation to the insurer: a. A complete report of the patient’s symptoms, findings and plan of treatment pursuant to reporting requirements in section 440.13, F.S. b. An operative report when a surgical procedure is performed. c. A narrative report when a consultation or an independent medical examination is rendered. d. Any additional written documentation when requested by the employer/carrier or designated claims handling entity in order to determine compensability of the injury or when medical necessity of services must be substantiated in more detail then previously disclosed. Failure of the provider to forward information when requested by the insurer may result in the billed service being disallowed or denied for payment until sufficient documentation is provided to render the necessary determination. 3. Special insurer requests (Code 99080). Insurers may request physicians to prepare special narrative reports. Prior to a provider’s provision of a special report, the insurer and provider shall agree upon reimbursement for completion of the special report. Reimbursement for special requests shall be made by the insurer at the agreed upon reimbursement amount. 4. Copies of medical records. a. Injured Employee. (1) A health care provider, upon request, shall furnish an injured employee or the employee’s attorney a copy of the employee’s office chart, records and reports. Reimbursement for medical records shall be made to a health care provider by the employee or employee’s representative at $.50 per page. (2) A health care provider, upon request, shall furnish the injured employee or the employee’s representative non-written medical records. Reimbursement shall be made to a health care provider by the requesting party at the provider’s actual cost for x-rays, microfilm, or other non-written records. RULE 69L-7.020, F.A.C. 10 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition b. Employer/Insurer. (1) A health care provider shall also furnish to the employer or insurer or its attorney, on demand, a copy of his or her office chart, records and reports. (2) A health care provider, upon request, shall furnish the employer or insurer or its attorney non-written medical records. Reimbursement shall be made to a health care provider by the requesting party at the provider’s actual direct cost for x-rays, microfilm or other non-written records. (3) Reimbursement for copying charges incurred shall be as specified pursuant to Rule Chapter 64B, F.A.C., and section 440.13, F.S. or 456.057, F.S. c. Division. A health care provider, upon request, shall provide medical records to the Division without charge. Failure to forward the requested information shall result in administrative action pursuant to the provisions in section 440.13, F.S. F. Reimbursement Information. All health care providers are subject to the reimbursement guidelines contained in this manual. 1. Provider payment. a. Federal facilities. Federal facilities are exempt from the reimbursement provisions and allowances in this reimbursement manual. An insurer shall reimburse a federal facility its usual charges. b. Florida health care providers. (1) Reimbursement shall be made to a certified Florida health care provider after applying the appropriate reimbursement guidelines contained in this manual. An insurer shall reimburse a provider either the agreed upon contract price (whether agreed upon prior to rendering service(s) or upon submission of bill) or the maximum reimbursement allowance (MRA) in the appropriate schedule pursuant to section 440.13(12) (a), F.S. Reimbursement shall be based on the geographic location and whether the services were rendered in a facility or a non-facility designation. (See Section XI, Maximum Reimbursement Allowances, General Instructions.) (2) Physicians shall be reimbursed the MRAs from Section XI, Part B for surgical procedures or services and from Part C for non-surgical procedures or services. (3) All anesthesia service codes, whether provided by a physician or non-physician, and those services or procedures delineated in the CDT-2009/2010 or D codes in the HCPCS-2009 shall be reimbursed according to Section XI, Part A. RULE 69L-7.020, F.A.C. 11 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition (4) Physical therapists, occupational therapists, audiologists including special otorhinolaryngologic services uniquely provided by qualified speech pathologists and psychologists shall be reimbursed the MRAs from Section XI, Part C. (5) Physician assistants (PAs), and advanced registered nurse practitioners (ARNPs) shall be reimbursed at eighty-five percent (85%) of the MRA in Section XI, Part B for surgical procedures or services and eighty-five percent (85%) of the MRA in Section XI, Part C for non-surgical procedures or services. (6) Licensed Clinical Social Workers shall be reimbursed at seventy-five percent (75%) of the MRA in Section XI, Part C. (7) Dietitians, Nutritionists, or Nutrition Counselors shall be reimbursed at eighty-five percent (85%) of the MRA in Section XI, Part C. (8) Independent clinical laboratories and freestanding imaging/x-ray centers shall be reimbursed at the technical non-facility MRA from Section XI, Part C. (9) All other workers’ compensation certified providers shall be reimbursed the MRA from Section XI, Part A. c. Out-of-state providers. (1) Prior to the delivery of medical services, an insurer and provider may mutually agree upon the amounts of reimbursement for the services; or a. When a reimbursement agreement is not made, the insurer shall reimburse the out-ofstate provider either the greater of the MRA for the services in Part A, Section XI in this manual or the maximum reimbursement allowances under the workers’ compensation program in the state where the services are provided. 2. Reimbursement guidelines. a. Codes paid by MRAs. Reimbursement for codes listed in this manual with MRAs shall be at the maximum reimbursement allowances after the application of any reimbursement policies contained in this manual, except when there is an agreed upon contract. b. Codes paid by report (BR). (1) Reimbursement shall be determined by the insurer for codes paid by report (BR). Payment shall be based on a provider’s documentation submitted to the insurer in a special report containing information on the complete description of the services or procedures, medical necessity, pertinent clinical data, prevailing charges, fees, relative values and reimbursement for similar procedures or cost of the services or supplies. RULE 69L-7.020, F.A.C. 12 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition (2) The provider shall submit the documentation required above when the following occurs: (a) The procedure is listed BR in this manual. (b) There is a valid code that is not listed in this manual, but contained in the materials adopted for reference in Section II D. (c) There is a valid modifier that alters the established MRA. c. Exclusion. Reimbursement shall not be made for failed appointments. This exclusion does not apply to the statutory provisions for independent medical examinations contained in section 440.13, F.S. d. Exceptions. When a provider deems it medically necessary in the treatment of a particular individual’s injury or illness to furnish medical services that exceed the number of services in specific reimbursement policy guidelines, a provider must: (1) Submit documentation to the insurer substantiating the medical necessity for the request. (2) Receive specific written authorization from the insurer to render the requested exceptional services before they are provided. e. Co-payments. (1) A health care provider is entitled to collect a co-payment of $10.00 per visit when providing medical services and care to an injured employee who has reached maximum medical improvement. The co-payment shall not apply to emergency care or service provided to the employee. (2) The co-payment is not in addition to any applicable maximum reimbursement allowance or fee agreement. The reimbursement amount otherwise payable by the insurer shall be reduced by the amount of the co-payment. 3. Insurer reimbursement responsibilities. a. Insurers shall use the codes and descriptions, guidelines, definitions and instructions in the referenced CPT®-2009, CDT-2009/2010 and HCPCS-2009, in part for dental services, injections, and other medical services and supply codes prior to making reimbursement decisions. In addition, where not inconsistent with instructions in this manual or in rule 69L-7.602, F.A.C., insurers may utilize National Correct Coding Initiative (NCCI) edits as part of the bill review process. RULE 69L-7.020, F.A.C. 13 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition b. Insurers shall make available upon request from the state agency a methodology for determining reimbursement for codes that have no established MRAs, including Category III codes, unlisted procedure codes and codes that are paid BR. (1) Insurers shall utilize the expertise of peer review physicians for concurrent review, including the appropriateness and cost of the medical services reported; billing and coding issues; and reimbursement determinations. (2) Insurers shall make reimbursement decisions based on all of the provider’s documentation; the insurer medical claims data; relative value studies; prevailing charges and reimbursement for procedures, services and supplies; and peer physician recommendations. c. Insurers shall reimburse all work-related and medically necessary services provided in a documented medical or dental emergency. 4. Reimbursement Disputes. a. A contested disallowance or adjustment of payment by an insurer may be resolved by petitioning the department pursuant to s. 440.13(7), F.S. b. Where an insurer has disallowed or adjusted payment for services rendered pursuant to an authorized workers’ compensation managed care arrangement, a health care provider may not elect to petition the department pursuant to s. 440.13(7). SECTION III: CLASSIFICATION OF AN INJURED EMPLOYEE’S STATUS. A. General Guidelines Based on the Use of Patient Classification Levels. 1. Providers and insurers are to utilize the workers’ compensation specific patient classification levels, addressed in Part B of this Section, which are neither hierarchical nor severity indicators. (See rule 69L–7.602, F.A.C. for instructions on reporting classification levels.) 2. The classification system, which is criteria based, comprises descriptive categories that are provided as a means to promote decision-making, accountability and responsible medical claims handling practices. Additionally, the classification system enhances communication between the provider and the insurer which facilitates the authorization process and the provision of medically necessary care. Proper classification of the patient is intended to: a. Convey to insurers the complexity of services that may be required for optimal clinical management; b. Distinguish the overall critical differences among cases that influence the intensity, scope, and cost of services provided; RULE 69L-7.020, F.A.C. 14 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition c. Facilitate recognition of three varying clinical configurations that affect the medical treatment plan and treatment progress or other available benefits for an injured employee; d. Assist the insurer in decisions related to authorization of recommended treatment plans or treatment plan revisions; e. Ensure that on-going treatment plans and authorized reimbursable services are consistent with the high intensity, short duration treatment approach which focuses on specific clinical dysfunction before authorization is made to a provider. B. Patient Classification Levels. 1. Level I: Key issue – specific, well-defined medical condition, with clear correlation between objective relevant physical findings and patient’s subjective complaints. Treatment correlates to specific findings. 2. Level II: Key issue – regional or generalized deconditioning (i.e., deficits in strength, flexibility, endurance, and motor control). Treatment includes physical reconditioning or functional restoration. 3. Level III: Key issue – poor correlation between patient’s complaints and objective, relevant physical findings, indicating both somatic and non-somatic clinical factors. Treatment includes interdisciplinary rehabilitation and management. SECTION IV: DENTAL SERVICES. A. All dental services shall be authorized by an insurer before the services are initiated. An insurer shall only reimburse a dentist or an oral surgeon for authorized services. B. Dentists shall use the dental guidelines, codes and descriptors from the CDT-2009/2010 or the D codes in the HCPCS-2009 for dental procedures. C. Dentists shall use the appropriate guidelines, codes and descriptors from the CPT®-2009 and CDT-2009/2010 or D codes in the HCPCS-2009 for temporomandibular joint services. 1. Dentists who provide temporomandibular joint services may use a combination of CPT®2009 codes and dental codes from the CDT-2009/2010 or HCPCS-2009. 2. Dentists shall refer to the physical medicine section of this manual for information on physical medicine reimbursement guidelines. D. Oral surgeons shall use the CPT®-2009 surgical guidelines, codes, descriptors and modifiers for oral and maxillofacial surgical services. 1. Surgeons shall refer to the surgical services section of this manual for information on reimbursement for multiple surgical procedures, as well as other surgical reimbursement guidelines. RULE 69L-7.020, F.A.C. 15 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 2. Surgeons may refer to other sections in this manual and may use CPT®-2009 codes. E. Reimbursement to a provider shall be as follows: 1. Reimbursement to a dentist or oral surgeon for a dental procedure or service shall be either the agreed upon contract price or the listed MRA in the appropriate schedule. 2. Reimbursement to a surgeon for an oral and maxillofacial consultation shall be limited to one (1) consultative visit per date of accident. SECTION V: DISPENSING OF MEDICATION. A. Medicinal drugs. 1. Medicinal drugs, commonly known as legend or prescription drugs, shall be ordered for an injured employee by a licensed practitioner, authorized by the insurer to treat the employee. 2. Medicinal drugs are dispensed, stored and sold only by a pharmacist licensed under Chapter 465, F.S., or a dispensing practitioner according to the provisions in s.465.0276, F.S. 3. Medicinal drugs may be compounded by a pharmacist or physician when the drug formulation prescribed is not commercially available. 4. Federal regulations. a. The Food and Drug Administration requires drug manufacturers to register and list manufactured drug products. The National Drug Code (NDC) is assigned by the manufacturer and placed on all prescription stock packages. b. The Food and Drug Administration considers the “compounding of drugs” to be the practice of pharmacy/medicine. A compounded drug does not have a NDC. 5. Reimbursement limitations. a. Reimbursement shall only be made to a licensed pharmacist or licensed dispensing practitioner for provision of medicinal drugs under the NDC number and reimbursement is calculated according to the formula below. (Providers should refer to rule 69L-7.602, F.A.C. for the option of using the workers’ compensation unique code DSPNS in addition to the NDC. See also Appendix D.) b. Reimbursement for prescription drugs shall be as follows: (1) The pharmaceutical reimbursement formula: Average Wholesale Price (AWP) + $4.18 dispensing fee = Reimbursement; or RULE 69L-7.020, F.A.C. 16 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition (2) The contracted reimbursement amount determined in accordance with the contractual arrangement between the provider and insurer. c. A pharmacist or physician shall be reimbursed for a professional service related to compounding drugs which formulations are not commercially available. (1) The amount of reimbursement to be made by the insurer shall be mutually agreed upon by the provider and insurer prior to the compounding. (2) A physician or pharmacist shall be reimbursed under the workers’ compensation unique code COMPD for compounding drugs furnished to a patient. B. Patent, proprietary or over-the-counter drugs. 1. Reimbursement shall be made to a pharmacist for dispensing over-the-counter drugs at the pharmacist’s usual charge for the drugs. 2. Reimbursement to a dispensing practitioner shall be as follows: a. Reimbursement shall be made to a dispensing practitioner for furnishing over-thecounter drugs. A dispensing practitioner shall use the NDC number and submit an invoice to the insurer that provides the name, dosage, package size and cost of drugs, including manufacturer’s applicable shipping and handling. (Providers should refer to rule 69L-7.602, F.A.C., for the option of using the Workers’ Compensation Unique Code DSPNS in addition to the NDC. See Appendix D.) b. Reimbursement shall be made at the provider’s charge or an amount not to exceed twenty percent (20%) above the actual cost of each drug furnished. c. Reimbursement shall not be made for oral vitamins, nutrient preparations and dietary supplements. SECTION VI: MEDICAL SUPPLIER SERVICES. A. Medical supplies and durable medical equipment (DME) shall be prescribed by a physician and may be provided to an injured employee by a medical supplier through rental or purchase. B. A medical supplier shall obtain written authorization and a payment agreement from the insurer prior to furnishing an injured employee medical supplies or equipment. C. A medical supplier shall provide the insurer with a copy of the physician’s original order with the bill for reimbursement. The medical supplier is not required to provide invoices with the bill to document the actual costs of supplies and equipment. A medical supplier is required to submit HCPCS codes. Where a more specific HCPCS code is not available for medical supplies and DME, reimbursement shall be made under A9999. RULE 69L-7.020, F.A.C. 17 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition D. Reimbursement. 1. Reimbursement shall be made to a medical supplier by the insurer for rental or purchase of medical equipment and supplies. a. The insurer may rent the item from the supplier for the injured employee. The insurer may write a provision in the payment agreement that when the amount received by the supplier from the rental payments equals the purchase price, the item will become the property of the insurer or injured employee. b. The insurer may purchase the item from the supplier. 2. An insurer shall reimburse a medical supplier at the price stated in the payment agreement, upon receipt of a bill and copy of the physician’s original order. SECTION VII: MEDICAL SERVICES. A. Biofeedback Services. 1. Reimbursement to a health care provider for biofeedback training shall be limited to twelve (12) visits per date of accident. This biofeedback training limitation does not include individual psychophysiological therapy incorporating biofeedback training by any modality with psychotherapy. 2. Reimbursement for the collection and interpretation of biofeedback data digitally stored and downloaded shall be included in the reimbursement to the provider for the basic biofeedback service. B. Electrodiagnostic Medicine. The referring physician shall determine the medical necessity of an electromyography (EMG) or a nerve conduction study (NCS). Only a physician shall determine the frequency of testing or the necessity of repeat testing. 1. Needle electromyography (EMG). a. Only a physician or a recognized practitioner specifically qualified by regulations in Florida shall be reimbursed for needle EMG testing. Reimbursement shall include the testing, interpretation of the studies and a report of the findings. b. A physician or a recognized practitioner specifically qualified by regulations in Florida shall determine the muscles to be tested based on specific clinical findings at the time of the study. c. When an initial evaluation and management service and needle EMG testing are performed during a visit, reimbursement shall be made to a physician for both services. RULE 69L-7.020, F.A.C. 18 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition d. When a follow-up evaluation and management service and needle EMG testing are performed on the same day, reimbursement shall be made to a physician for both services if the physician’s documentation validates the medical necessity of the follow-up evaluation and management service. e. When needle EMG testing is performed in a hospital or other facility, reimbursement shall be made to a physician for an interpretation of the testing when modifier 26 is appended to the appropriate code. 2. Nerve conduction studies (NCSs). a. Only a physician or a recognized practitioner specifically qualified by regulations in Florida shall be reimbursed for NCSs. Reimbursement shall include the testing, interpretation of the studies and report of the findings. b. A physician or a recognized practitioner specifically qualified by regulations in Florida shall determine the nerves to be tested based on specific clinical findings during examination at the time of the study. c. When an initial evaluation and management service and NCSs are performed during the same visit, reimbursement shall be made to a physician for both services. d. When a follow-up evaluation and management service and NCSs are performed on the same day, reimbursement shall be made to a physician for both services if the physician’s documentation validates the medical necessity of the follow-up evaluation and management service. e. A technologist under the direct supervision of the physician may perform a NCS. C. Evaluation and Management Services. 1. Office visits. A physician shall be reimbursed by an insurer for evaluation and management services (new patient and established patient visits). Reimbursement is limited to one (1) visit a day at the highest level of care provided by the physician. 2. Consultations, confirmatory consultations and follow-up consultation services. A physician shall be reimbursed for consultations, confirmatory consultations and follow-up consultation services. Reimbursement shall include a review of all submitted medical records, paper and non-paper; an examination of the injured employee; and a written report. 3. Home Services. A physician shall be reimbursed for home visits when authorized by the insurer. A physician shall use the appropriate evaluation and management home visit code to report the service. RULE 69L-7.020, F.A.C. 19 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition D. Home Health Services. A home health agency shall be reimbursed for insurer authorized home health services provided in a patient’s residence based on a signed order from the authorized, treating physician. The insurer shall reimburse a home health agency at the reimbursement amounts agreed upon by the agency and the insurer. (See rule 69L-7.602, F.A.C. for billing instructions.) E. Impairment Rating (Code 99455). 1. A physician shall be reimbursed by the insurer for an impairment rating. 2. Reimbursement shall include an examination to evaluate an injured employee’s condition on the establishment of the date of maximum medical improvement and the assignment of an impairment rating of zero (0) percent or greater; and the completion and submission of the required reporting form to the appropriate parties in accordance with s.440.15, F.S. 3. Reimbursement shall not be made for an evaluation and management code on the same date as code 99455. F. Independent Medical Examination (Code 99456). 1. A physician shall be reimbursed by the party requesting the independent medical examination (IME). 2. Reimbursement for an IME shall include the review of applicable paper and non-paper medical records; an examination of the injured employee; and a written report. G. Independent Medical Examination, Consensus (99457, Workers’ Compensation unique code). 1. A physician shall be reimbursed by the insurer for a consensus independent medical examination (CIME). 2. Reimbursement for a CIME shall include the review of applicable paper and non-paper medical records, an examination of the injured employee, and a written report. 3. Reimbursement for a CIME shall be negotiated between the physician and the insurer prior to rendering the service. H. Injectable Medications. 1. Providers shall refer to the CPT®-2009 reference adopted as part of this manual for reporting the injection procedure, as well as an immune globulin, vaccine or toxoid product (including 90749). 2. Providers shall refer to J codes in the HCPCS-2009 reference as adopted as part of this manual for reporting other injectable medications. RULE 69L-7.020, F.A.C. 20 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 3. When the specific injectable medication is not listed in either of these references, providers shall identify the injectable product under the NDC number for reimbursement. (Providers may use the option of the Workers’ Compensation Unique Code DSPNS in addition to the NDC number. (See Appendix D.) 4. Reimbursement for injectable medications shall be made to health care providers as follows: a. Reimbursement shall be made to a health care provider using CPT® or HCPCS J codes for specific injectable drugs and CPT® codes for the administration of injectable drugs. b. Reimbursement shall be at either the agreed upon contract price or the listed MRA in the appropriate schedule. Note: The MRA for HCPCS J codes is listed in Part A, Section XI of this manual. c. Reimbursement for an injection shall include a local anesthetic, if necessary. d. Reimbursement for multiple medications administered from the same syringe shall be: (1) (2) At either the agreed upon contract price or the listed MRA, in Part A, Section XI of this manual for the first reported drug; and At either the agreed upon contract price or fifty percent (50%) of the listed MRA in the appropriate schedule for each additional drug. Each additional drug shall be reported by appending modifier 51 to the HCPCS or CPT® code. 5. Reimbursement to a physician for codes 90749 or J3490, shall not exceed twenty percent (20%) above the actual cost of the injectable medication based on submission of: a. The name, strength and dosage of the medication, vaccine or toxoid; and b. Documentation verifying the cost of the medication, vaccine or toxoid, including applicable manufacturers shipping and handling. 6. A special provision is allowed for the identification of a loading dose of morphine sulfate administered via infusion pump. a. Providers may utilize HCPCS code S0093 if deemed by the practitioner to be the most appropriate coding option. (Note: No other S codes are acceptable for reporting injectable medications.) b. Reimbursement shall be limited to no more than twenty percent (20%) above the documented cost of the drug, including applicable manufacturer’s shipping and handling. I. Medical and Surgical Supplies (not incidental to a service or procedure). 1. Reimbursement for supplies that are necessary to perform a procedure or provide a service shall be included in the reimbursement for the service and shall not be made separately. 2. Reimbursement for supplies and materials not incidental to a service or procedure shall be RULE 69L-7.020, F.A.C. 21 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition reimbursed under the specific HCPCS Level II supply code. When a more specific HCPCS code is not available for supplies and materials, use HCPCS code A9999. Reimbursement shall be limited to an amount not to exceed twenty percent (20%) above the actual documented cost based on submission of documentation that substantiates the provider’s cost, including applicable manufacturer’s shipping and handling. J. Ophthalmological Services. 1. Reimbursement for ophthalmological services shall be made for all medically necessary services. 2. Reimbursement shall only be made for spectacles, contact lens or frames of comparable quality to the original when they are damaged, lost or required for treatment as a result of an injury. K. Psychiatric and Psychological Services. 1. Reimbursement for psychiatric and psychological services shall be made by the insurer to an authorized, licensed medical doctor, osteopathic physician, a psychologist, mental health practitioner or health professional providing individual psychotherapy services in compliance with state licensure. 2. Only a physician shall be reimbursed for evaluation and management services when CPT®2009 codes 99201-99499 are billed. 3. Only a physician shall be reimbursed for individual psychotherapy in combination with evaluation and management services provided by the physician at a therapy session. Physicians shall refer to the incorporated CPT®-2009 for specific psychiatric procedure codes to identify the combined services. 4. A physician shall not be reimbursed for an evaluation and management service code (CPT® 99201-99499) on the same day that reimbursement is made for a psychiatric procedure code that describes psychotherapy combined with evaluation and management services. 5. When multiple individual psychotherapy sessions are provided on the same day, only the session lasting the longest period of time shall be reimbursed. 6. Reimbursement shall be made for central nervous system assessments/testing authorized by the insurer. a. Reimbursement includes an assessment and administration of a test with interpretation and report. b. The amount of reimbursement for these services shall be determined from the number of hours (units of services) reported by the provider to perform the assessment/test. The procedure code’s descriptor shall indicate if the service is per hour or all-inclusive. Reimbursement shall be made at the agreed upon contract price or the listed MRA in Section XI of this manual. RULE 69L-7.020, F.A.C. 22 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 7. Reimbursement for family psychotherapy, with or without the injured employee present, shall be made if the documentation supports that the purpose is related to the treatment of the injured employee’s compensable injury. Reimbursement shall not be made for psychological services provided directly to members of the injured employee’s family for support and assistance in adjusting to the injured employee’s condition. 8. Reimbursement shall be made for health and behavior assessment/intervention services when authorized by the insurer. Providers shall refer to the incorporated CPT®-2009 reference for specific health and behavior assessment/intervention procedure codes to identify their services. L. Radiology. 1. Reimbursement shall be made for radiology services, including diagnostic radiology (diagnostic imaging), diagnostic ultrasound and nuclear medicine. 2. Radiology procedures consist of two components: technical and professional. a. Technical Component: Modifier TC. HCPCS Level II modifier TC is used to designate the technical component for a procedure or service. (See Appendix C, Modifiers.) b. Professional Component: Modifier 26. When the professional (or physician) component is reported separately, the service may be identified by appending the modifier 26 to the procedure code. 3. Global services may be reported when one physician provides both the technical and the professional components of a procedure or service. The unmodified 5-digit code is used to identify a global service inclusive of the professional service and the technical cost of providing that service. 4. Reimbursement. a. Reimbursement shall not be made for a professional component (modifier 26) billed in the following situations: (1) A professional component billed by a physician for x-rays taken and interpreted by another physician and reviewed by the billing physician during an IME, medical visit or consultation. (2) A professional component billed by a physician for reviewing x-rays during an emergency department or hospital visit when the x-rays were interpreted by the radiologist at the hospital. RULE 69L-7.020, F.A.C. 23 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition b. Reimbursement shall be made to an independent radiology facility for the technical component only when the service is identified by appending modifier TC to the five (5) digit code. M. Thermography. 1. Authorization. The insurer shall not authorize a physician to perform thermography any earlier than fortyfive (45) days after the date of accident unless documentation of medical necessity is submitted to the insurer along with the request for authorization. 2. Reimbursement. a. Reimbursement for thermography shall be limited to one (1) body area, either major or limited. (1) Major body areas. (The following areas include all views.) (a) Head. (b) Cervical spine and upper extremities. (c) Lumbosacral spine and lower extremities. (2) Limited body areas. (The following areas include all views.) (a) Thoracic spine. (b) Any portion of a major area. b. Reimbursement for thermography to a major body area shall be made at either the agreed upon contract price or the listed MRA in the appropriate schedule. c. Reimbursement for thermography to a limited body area, reported by appending modifier 52 to the code shall be made at either the agreed upon contract price or fifty percent (50%) of the MRA in the appropriate schedule. N. Transcutaneous Neurostimulator (TNS). 1. Reimbursement shall be made to an authorized physician or other health care provider for furnishing an injured employee with a transcutaneous (surface) neurostimulator (TNS) prescribed by a physician. a. Authorization and a reimbursement agreement shall be obtained from the insurer for rental or purchase of a TNS prior to a physician or provider furnishing a TNS to the injured employee. b. A reimbursement agreement shall not exceed twenty percent (20%) above the provider’s RULE 69L-7.020, F.A.C. 24 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition documented cost when the TNS is purchased. A copy of the provider’s documentation shall be submitted with the bill substantiating the actual cost, including applicable manufacturer’s shipping and handling. 2. Reimbursement shall be made to an authorized physician or provider for furnishing training to an injured employee on the application of a transcutaneous neurostimulator. Reimbursement is limited to no more than four (4) training sessions. SECTION VIII: PHYSICAL MEDICINE AND REHABILITATION SERVICES. A. General Information. 1. Physical medicine and rehabilitation services shall be considered as covered treatment only when such care is given based on a physician referral or prescription and when the medical necessity for such services is clearly supported in the provider’s evaluation and the specific physical medicine plan of care. The Florida workers’ compensation program shall reimburse authorized providers, as specified in this section, for the following physical medicine and rehabilitation services: a. Modalities and therapeutic procedures applied to acute injuries to reduce symptoms, restore function and return the injured employee to work. b. Physical reconditioning focused on injuries requiring intensive physical reconditioning services to restore the injured employee to pre-injury level of physical health and function. The goal shall be for the employee to return to a job or become physically reconditioned. c. Interdisciplinary rehabilitation programs covering a variety of services that are coordinated, outcome focused and directed at the injured employee’s needs to increase the employee’s functioning or to return the employee to work. 2. Approval for the provision and payment of medically necessary physical medicine services (i.e., modalities and therapeutic procedures, physical reconditioning, or interdisciplinary rehabilitation programs) shall be supported in the evaluation and a specific physical medicine plan of care, regardless of the location of where the services are rendered or the provider type (i.e. physician or licensed therapist). a. If the insurer questions the appropriateness of the therapy listed in the plan of care, the insurer shall contact the physician to obtain the rationale for the ordered therapy, prior to authorization. b. It shall be the responsibility of the physician to provide the documentation of medical necessity for the therapy to the insurer in order to avoid unnecessary delays in obtaining authorization for treatment or in initiating therapy. 3. Approval beyond the guidelines provided in this section must be obtained from the insurer, in RULE 69L-7.020, F.A.C. 25 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition writing, prior to a provider furnishing the service. The unusual circumstances must be documented and forwarded by the provider to the insurer for review before an exception to the guidelines can be considered and a determination made by the insurer to authorize additional services. B. Physical Medicine Services. 1. Authorization. a. Reimbursement shall only be made for insurer authorized physical medicine modalities and procedures up to six (6) months after the date of accident, based on a signed order or referral from an authorized, treating physician. All services shall be authorized prior to initiation of services. Exceptions to the preceding authorization criteria for physical medicine modalities and procedures may occur when the treating physician provides objective relevant medical findings that demonstrate the following: (1) The injured employee has a specifically defined, relevant clinical dysfunction, consistent with the patient classifications outlined in Section III of this reimbursement manual, that is reasonably expected to respond to the requested physical medicine modalities or procedures, and (2) The injured employee does not conform to either the Level II or Level III patient classifications based on specific documentation of the following: (a) No systemic musculoskeletal deficit (strength, flexibility, endurance, coordination) or substantive functional loss requiring an intensive physical reconditioning program; (b) No behavioral or psychological issues that present a substantive factor in the rehabilitation effort or outcome; (c) No significant vocational or return to work issues; and (d) No significant disparity between the injured employee’s subjective complaints, response to intervention, and other relevant clinical indicators when compared with documented objective, relevant findings. b. Reimbursement for physical medicine services shall not exceed one (1) visit per day, unless specifically authorized by the insurer. 2. Initial evaluation. a. Reimbursement for an initial evaluation by a physician shall be made as an evaluation and management service. b. Reimbursement for an initial evaluation by a licensed therapist shall be made when billed by the therapist under code 97001 or 97003. c. Separate reimbursement shall not be made to a physician and to a physician-employed RULE 69L-7.020, F.A.C. 26 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition therapist for an evaluation by each on the same date. d. Reimbursement for an initial evaluation shall include the evaluation and a plan of care or treatment. Documentation of the evaluation and plan of care shall be submitted to the insurer with the claim form. At a minimum, the documentation shall contain: (1) The evaluation findings including any functional limitations. (2) The proposed therapy specifying the frequency and duration of the services. (3) The anticipated degree of restoration of function with measurable goals. 3. Re-evaluation. Reimbursement shall be made for a re-evaluation ordered by a physician and performed by a therapist. A re-evaluation must be billed using either code 97002 or 97004. 4. Revised plan. a. The physician or therapist shall submit to the insurer a revised plan of care or treatment, when appropriate. b. An authorized treating physician or treating therapist has the responsibility of providing documentation of medical necessity for therapy modifications if questioned by the insurer. 5. Modalities and therapeutic procedures. Reimbursement to a provider shall be made for the modalities and therapeutic procedures listed in the plan of care with the limitation that no more than four (4) units of service shall be reimbursed per visit. a. Codes 97010-97028 shall each equal one (1) reimbursable unit of service. The performance of the supervised modality codes is not time-oriented and each code may only be reported once during the visit. b. Codes 97032-97542 shall each equal one (1) reimbursable unit of service for each 15minute increment of service performed. c. Code 97150 shall be restricted to one (1) reimbursable unit of service per visit. 6. Manipulative treatment. a. Reimbursement to a physician for a manipulative treatment shall be limited to one (1) visit a day. b. Reimbursement for manipulative treatment under workers’ compensation shall be limited to two (2) body regions per day. RULE 69L-7.020, F.A.C. 27 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition The entire spine is one (1) region. (2) Each of the following is one (1) region: head; two (2) upper extremities; two (2) lower extremities; one (1) upper and one (1) lower extremity; rib cage; and abdomen. c. Reimbursement for manipulative treatment to the two (2) regions listed in Section VIII.B.6.b. shall be made for workers’ compensation unique codes 97260 and 97261, specifically designated for physicians other than osteopaths and chiropractors. (1) Reimbursement shall be made for code 97260, when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) entity for workers’ compensation, although there are five (5) spinal regions (cervical; thoracic; lumbar; sacral; and pelvic). (2) Reimbursement shall be made for code 97261, when used to bill for a manipulation of the temporomandibular joint; the upper extremities, including the hand and wrist; the lower extremities; and other regions. d. Reimbursement for osteopathic manipulative treatment (OMT) to the two (2) regions listed in Section VIII.B.6.b. shall be made for codes 98926 and 98928. (1) Reimbursement shall be made for code 98926, when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) entity for workers’ compensation, although there are five (5) spinal regions (cervical; thoracic; lumbar; sacral; and pelvic). (2) Reimbursement shall be made for code 98928, when used to bill for a manipulation to the head region; lower extremities; upper extremities; rib cage region; and abdomen and viscera region. e. Reimbursement for chiropractic manipulative treatment (CMT) to the two (2) regions listed in Section VIII.B.6.b., shall be made for codes 98941 and 98943. These manipulation codes are specifically designated for chiropractic physicians. (1) Reimbursement shall be made for code 98941 when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) entity for workers’ compensation, although there are five (5) spinal regions: cervical region (includes atlanto-occipital joint); thoracic region (includes costovertebral and costo-transverse joints); lumbar region; sacral region; and pelvic (sacroiliac joint) region. (2) Reimbursement shall be made for code 98943, when used to bill for a manipulation to an extraspinal region: head (including temporomandibular joint, excluding atlantooccipital); lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen. 7. Acupuncture. a. Reimbursement for acupuncture and/or electro-acupuncture service is based on 15-minute RULE 69L-7.020, F.A.C. 28 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition increments of face-to-face contact with the patient during a session. b. Reimbursement for acupuncture with one (1) or more needles, with or without electrical stimulation, shall be made to a physician or a recognized practitioner specifically licensed by the Florida Department of Health to diagnose and treat. c. Each treatment session consists of only one initial 15-minute increment, either for electrical stimulation or non-electrical stimulation; however, both electrical and nonelectrical codes can be reported during a single session, provided they are performed during separate 15-minute increments and reported using the appropriate add-on code(s). d. Reinsertion of the acupuncture needle(s) is required for the use of acupuncture add-on codes. 8. Fabrication of orthotic or prosthetic devices by a licensed therapist. a. Reimbursement shall only be made to certified licensed occupational and physical therapists for an insurer authorized custom fabricated orthotic or prosthetic device when reported using appropriate Level II HCPCS codes that specifically describe the device, when it is ordered by a physician. b. Reimbursement shall be by report (BR). 9. Tests and measurements. a. Reimbursement to a provider shall be limited to one (1) visit by an injured employee per thirty (30) days for tests and measurements to a selected body area or number of areas unless a different interval is outlined in the patient’s plan of care. A variation to the standard limitation for tests and measurements must be ordered by the treating physician and authorized by the insurer. b. Reimbursement shall be made for the workers’ compensation unique code 97752, specifically designated for both manual and automated testing. Reimbursement shall include a report of the testing results. Manual muscle testing (95831-95834) and range of motion codes (95851-95852) shall not be reimbursed when reported separately with code 97752. c. Reimbursement shall be made for range of motion measurements. Code 95851 may be reported and paid for either manual or computerized range of motion measurements and report. C. Physical Reconditioning Services. 1. Authorization. a. Reimbursement shall only be made for insurer authorized physical reconditioning based on a signed order from the authorized treating physician. Physical reconditioning services shall be authorized prior to initiation and shall not begin any earlier than thirty (30) days RULE 69L-7.020, F.A.C. 29 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition following the employee’s date of accident. b. Reimbursement for physical reconditioning services shall only be made to an authorized occupational or physical therapist. 2. Physical reconditioning assessment. a. Reimbursement for a physical reconditioning assessment and written report shall be determined from the number of hours reported by the provider to perform the assessment and the listed MRA. Reimbursement shall be limited to eight (8) hours. b. Reimbursement shall be made for workers’ compensation unique codes 97850 and 97851, specifically designated to use in reporting a physical reconditioning assessment. (1) Reimbursement shall be made for code 97850 only when used to bill for the initial hour of a physical reconditioning assessment, whether the assessment is performed during a single session or multiple sessions. (2) Reimbursement shall be made for code 97851 only when used to bill each additional thirty (30) minutes of a physical reconditioning assessment subsequent to code 97850. 3. Physical reconditioning program. a. Reimbursement for a physical reconditioning program shall be paid based on the number of hours billed by the provider and the listed MRA. Reimbursement shall be limited to a program lasting no longer than sixty (60) hours during a six (6) week period, including a physical reconditioning assessment. b. Reimbursement shall be made for workers’ compensation unique codes 97852 and 97853, specifically designated to use in reporting a physical reconditioning program. (1) Reimbursement shall be made for code 97852 when used to bill the initial hour per session of physical reconditioning each day. (2) Reimbursement shall be made for code 97853 when used to bill each additional thirty (30) minutes per session of physical reconditioning each day. c. Reimbursement shall be made for a physical reconditioning program when the services are provided alone, concurrently with or subsequent to modalities and procedures by the same authorized occupational or physical therapist. d. Reimbursement shall be made to a therapist for only one (1) physical reconditioning program for an injured employee per date of accident, unless authorized by the insurer for an exacerbation of the injury or surgical intervention, documented by the treating physician. e. Reimbursement for an extension of the program shall be limited to reimbursement for an RULE 69L-7.020, F.A.C. 30 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition additional twenty (20) hours during a two (2) week period. An extension shall be ordered by the physician and authorized by the insurer. 4. Discharge from the physical reconditioning program. a. The treating physician shall determine if the injured employee shall be discharged from the physical reconditioning program before completion. If the injured employee has not completed the program and the treating physician recommends discontinuance of the program, the physician shall provide discharge information to the injured employee, the insurer and the therapist without charge. b. Upon program completion, a report of the following shall be sent by the therapist without charge to the treating physician and the insurer with the final bill: (1) The injured employee’s current clinical status and degree of reconditioning/restoration; and (2) Return to work recommendations. D. Interdisciplinary Rehabilitation Programs. 1. Authorization. a. Reimbursement shall only be made to a facility for insurer authorized interdisciplinary services based on a signed order from the authorized treating physician. All services shall be authorized prior to initiation of services. b. Reimbursement for Interdisciplinary Rehabilitation Programs shall only be made to rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), except for a facility operating pursuant to Chapter 395, F.S., as part of a hospital. Rehabilitation Program services must be provided through a CARF accredited Outpatient Medical Rehabilitation Program, Occupational Rehabilitation Program or Interdisciplinary Pain Rehabilitation Program. 2. Work hardening program. a. Reimbursement for a work hardening program shall be made to a facility for the duration of the recommended individualized program. b. Reimbursement shall be made for codes 97545 and 97546, specifically designated to use exclusively in reporting a work hardening program. (1) Reimbursement shall be made for code 97545 when used to bill the initial two (2) hours of a work hardening program each day. (2) Reimbursement shall be made for code 97546 when used to bill each additional hour of a work hardening program each day. RULE 69L-7.020, F.A.C. 31 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 3. Pain program. a. Reimbursement for an interdisciplinary pain management program shall be made to a facility for the recommended time indicated in the injured employee’s individual program plan. b. Reimbursement shall be made for codes submitted with documentation of the services rendered. The services provided must relate to the physical, psychological, social, functional and vocational goals of the employee’s program plan. c. Reimbursement shall be made for biofeedback; physical and rehabilitation medicine services; pharmacy services; psychological and psychiatric services and testing; musculoskeletal services tests and measurements; neuromuscular services tests and studies and other medically necessary services during the course of the program. 4. Discharge from a CARF accredited program. a. The facility’s program director shall determine if the injured employee shall be discharged from the work hardening or pain program before completion. If the injured employee has not completed the program and the program director recommends discontinuance of the program, the director shall provide discharge information to the injured employee, the insurer and the treating physician without charge. b. Upon program completion, a report shall be sent by the facility’s program director without charge to the treating physician and to the insurer with the final bill. The report shall include: (1) The injured employee’s current clinical status and plan for transition from the program; and (2) Return to work recommendations. E. Functional Capacity Evaluation (FCE). 1. Reimbursement for an authorized FCE shall be made at any time in the clinical continuum (see patient classification system in Section III of this manual), as long as the evaluation protocol matches the scope and specificity of the clinical situation and referral question(s). 2. Reimbursement shall be made for the workers’ compensation unique code 97750, specifically designated for use solely in reporting a FCE. The reimbursement for a FCE includes a written program plan and a written report. The provider shall provide the results of the evaluation and recommendations to the injured employee, the insurer and the treating physician without additional charge. 3. All FCE protocols must be evidence based. Test design and written interpretation must, at a minimum, focus on identifying associated functional loss, limitations or restrictions and the correlation to work-related clinical dysfunction (i.e. correlate impairment with disability). RULE 69L-7.020, F.A.C. 32 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 4. Reimbursement for an FCE shall be made only when a licensed physical therapist or occupational therapist is directly and actively involved with the testing protocol, although additional professional personnel may be involved as well. SECTION IX: SURGICAL SERVICES. A. General reimbursement information. 1. Reimbursement for a surgical package (global reimbursement) shall include the provisions of certain services before and after surgery. The maximum reimbursement allowance to physicians for surgical procedures shall be based on Part B, Section XI in this manual. (See Section XI for complete instructions.) Payment for these services includes: a. The immediate preoperative visit. b. Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia. c. The surgical procedure and operative report. d. The time period for follow-up care listed in the follow-up days (FUD) column in Section XI. (1) Reimbursement for a procedure code with a YYY designation for the global period shall be set by the insurer. (2) Reimbursement for a procedure code with a ZZZ designation for the global period shall be the same as the other procedure code that is billed in conjunction with this “add-on” procedure code. 2. Reimbursement shall be made for other services in addition to the surgical package in the following situations when: a. A preoperative visit is the initial visit, when prolonged detention or evaluation is necessary to prepare an injured employee and when there is a need to establish the reason for a particular type of surgery. b. The preoperative visit is a consultation. c. The preoperative services are not part of the usual preparation for the particular surgical procedure. d. The services are to treat complications, exacerbations, recurrences, or other diseases and injuries. Documentation substantiating the medical necessity of the additional services rendered shall be submitted with the claim form. RULE 69L-7.020, F.A.C. 33 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 3. Reimbursement shall be made for additional surgery performed during the follow-up period. a. Reimbursement for surgical services shall be made when an additional surgery is performed during the postoperative period of another surgical procedure. b. Reimbursement for normal postoperative care shall run concurrently and shall be made according to the separate FUD periods listed in Section XI unless it is a procedure code with a YYY designation. For these codes the FUD period shall be set by the insurer. B. Reimbursement for surgical assistants, two (2) surgeons and surgical team. 1. Surgical assistants. a. Reimbursement for an assistant surgeon shall be twenty-five percent (25%) of the listed MRA, in Part B, Section XI in this manual. The services provided shall be identified by the modifier 80 added to the specific code. b. Reimbursement shall be made to a non-physician surgical assistant for surgical services. Reimbursement by the insurer shall not exceed seventy-five percent (75%) of twenty-five percent (25%) of the MRA listed in Part B when the insurer has: (1) Determined the non-physician surgical assistant meets state licensure requirements and holds current certification, as applicable; and (2) Provided written authorization to the non-physician surgical assistant prior to the surgery; or (3) Verified that during a medical emergency a physician was not available to assist at surgery. c. Non-physician surgical assistants (including physician assistant, nurse practitioner, or registered nurse first assistant) shall append HCPCS Level II modifier AS to the appropriate code to identify services rendered as an assistant at surgery. 2. Two surgeons. a. Reimbursement shall be made to two (2) surgeons at the same operative session for performing distinct parts of a surgical procedure. The services provided shall be identified by the same code with modifier 62 added. Reimbursement to each surgeon shall be made at sixty-two and one-half percent (62.5%) of the listed MRA in Part B, Section XI in this manual or the agreed upon contract price. b. Reimbursement shall be made to two (2) surgeons at the same operative session for rendering separate surgical procedures identified by different, unmodified codes. Reimbursement to each surgeon shall be made at the listed MRA, in Part B, Section XI or the agreed upon contract price. c. Reimbursement shall not be made to either surgeon until the insurer has received and reviewed each surgeon’s bill and individual operative report. RULE 69L-7.020, F.A.C. 34 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition 3. Surgical team. Reimbursement for a surgical team shall be made BR to each team member for each surgeon’s surgical service. Each team member shall identify the specific procedure with modifier 66 added to the code. C. Reimbursement for multiple procedures. 1. Reimbursement shall be made for all medically necessary procedures when more than one (1) procedure is performed during a single operative session. 2. Reimbursement for the primary surgical procedure shall be the MRA in Part B, Section XI in this manual or the agreed upon contract price. 3. Reimbursement for an additional procedure shall be made at fifty percent (50%) of the listed MRA in Part B, Section XI in this manual or the agreed upon contract price. The additional procedure shall be identified when modifier 51 is added to the code to indicate the performance of multiple procedures. D. Reimbursement for bilateral procedures. 1. Reimbursement shall be made for bilateral procedures that are performed during the same operative session. 2. Reimbursement for a bilateral procedure that contains the word “bilateral” in the descriptor shall be made at the listed MRA in Part B, Section XI in this manual or the agreed upon contract price. 3. Reimbursement for a bilateral procedure that does not indicate that it is bilateral shall be made when the procedure is billed twice as follows: a. Reimbursement for the first procedure shall be made at the listed MRA, in Part B, Section XI in this manual or the agreed upon contract price. b. Reimbursement for the second procedure identified by adding modifier 50 to the procedure code, shall be made at fifty percent (50%) of the listed MRA in Part B, Section XI in this manual or the agreed upon contract price. SECTION X: ANESTHESIA SERVICES. A. Reimbursement for anesthesia services shall be made to a physician or to non-physician anesthesia providers limited to certified registered nurse anesthetists (CRNAs) and anesthesia assistants (AAs) rendering services within scope of state licensure. 1. Reimbursement shall be based on application of the following values, physical status modifiers and certain qualifying circumstances. RULE 69L-7.020, F.A.C. 35 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition a. Basic value (BV) or base unit. (1) The usual preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry) are included in the BV. (2) When multiple surgical procedures are performed during an operative session, the BV for the anesthesia procedure with the highest value is billed and reimbursed. (3) The BV units, listed in Part A, Section XI under Anesthesia, for each anesthesia procedure code are used in calculating reimbursement. (4) When a surgeon provides regional or general anesthesia for a surgical procedure that he or she actually performs, modifier 47 is appended to the surgical code to indicate that the operating surgeon performed the anesthesia. Reimbursement shall be at the BV for the anesthesia service rendered. b. Time (TM) units. (1) Anesthesia time begins when the provider starts to prepare the injured employee for anesthesia care in the operating room or in an equivalent area and stops when the provider is no longer in personal attendance. (2) Anesthesia time shall be billed as the total number of minutes of anesthesia. For example, one (1) hour and fifteen (15) minutes of anesthesia must be billed as seventy-five (75) minutes of anesthesia. (3) The minutes of anesthesia must be converted into TM units as follows: (a) For anesthesiologists, each ten (10) minutes of anesthesia time equals one (1) unit of anesthesia and each minute over a unit has a value of one-tenth (1/10) unit. (b) For CRNAs/AAs, each fifteen (15) minutes of anesthesia time equals one (1) unit and each minute over a unit has a value of one-fifteenth (1/15) unit. (c) For codes providing BV + TM, time units shall be calculated and added to the listed BV to determine the reimbursement for the anesthesia services. (d) Only the BV units apply for codes without a TM unit after the base unit. For some anesthesia services, time is not reported additionally. Therefore, additional units of time are not calculated for these codes when determining reimbursement. c. Physical status modifiers. (1) Anesthesia services shall warrant additional reimbursement for units based upon the injured employee’s condition and the complexity of the anesthesia service provided. RULE 69L-7.020, F.A.C. 36 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition (2) A physical status modifier shall be determined to rank the injured employee’s condition. Additional reimbursement shall be based on the unit value for the specific physical status modifier. Physical Status Modifiers P1 P2 P3 P4 P5 P6 Unit Values A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A declared brain-dead patient whose organs are being removed for donor purposes 0 0 1 2 3 0 d. Qualifying circumstances. Anesthesia services, which are provided under particularly difficult circumstances, may warrant additional reimbursement for unit values based on unusual events. This subsection includes a list of important qualifying circumstances that impact the anesthesia service provided. These procedures are not reported alone but are reported as additional procedure numbers qualifying an anesthesia procedure for additional reimbursement. The listed unit value must be added to the basic unit values to obtain the reimbursement. List each of the following codes separately in addition to the procedure code for the primary anesthesia procedure. Qualifying Circumstances 99100 Anesthesia for patient of extreme age, under one year and over seventy 99116 Anesthesia complicated by utilization of total body hypothermia 99135 Anesthesia complicated by utilization of controlled hypotension 99140 Anesthesia complicated by emergency conditions (specify) Unit Values 1 5 5 2 2. Reimbursement for anesthesia services shall be made at the anesthesia reimbursement allowance (ARA) calculated using the BV and TM values listed in Part A, Section XI in this manual or the agreed upon contract price. a. Methodology for calculating the ARA for procedures that are listed basic value (BV) + time (TM). (1) Select the applicable anesthesia procedure code and basic value from the schedule in Section XI. RULE 69L-7.020, F.A.C. 37 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition (2) Determine the time units according to Section X.A.1.b.(3) (ten [10] minutes = one [1] time unit for an anesthesiologist and fifteen [15] minutes = one [1] time unit for a CRNA/AA). (3) Any minutes that exceed a whole unit are counted as partial units (fractions of units), such as one (1) minute is one-tenth (1/10) unit for an anesthesiologist and onefifteenth (1/15) unit for a CRNA/AA. (4) Determine any additional units that are justified by the physical status modifiers or qualifying circumstances addressed above in Section X.A.1.c. and X.A.1.d. (5) Add the basic value, time units, physical status modifier and any applicable qualifying circumstances to determine the total anesthesia value. (6) Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the anesthesia reimbursement allowance. b. Methodology for calculating the ARA for procedures that are listed only basic value (BV) and no time. Multiply the basic value by the conversion factor of $29.49 to obtain the anesthesia reimbursement allowance. c. Methodology for calculating the ARA for monitored anesthesia care. (1) Follow the guidelines, as applicable, in Section X.A.2.a. as though anesthesia was administered (basic value + time). (2) Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the ARA. B. Reimbursement for medical direction of CRNAs/AAs by an anesthesiologist. 1. Reimbursement shall be made to the anesthesiologist only for direct supervision of anesthesia services which are provided by the anesthesiologist and billed under the name and license number of the physician-employer. a. Reimbursement shall be made to an anesthesiologist for providing medical direction, including preoperative and postoperative evaluations or specific consultation to a CRNA/AA when necessitated by a specific procedure or condition(s) previously identified by the parties to the protocol, as required. (1) When medical direction by an anesthesiologist is required, the CRNA/AA shall bill by appending the HCPCS Level II Modifier QX to the anesthesia procedure code. (2) Reimbursement for a CRNA/AA requiring medical direction by an anesthesiologist shall be fifty percent (50%) of the anesthesia reimbursement allowance listed in Part A, Section XI in this manual or the agreed upon contract price. RULE 69L-7.020, F.A.C. 38 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition (3) Medical direction shall be billed by the anesthesiologist by appending the HCPCS Level II modifier QY to the anesthesia procedure code. (4) Reimbursement for medical direction by anesthesiologists shall be fifty percent (50%) of the anesthesia reimbursement allowance listed in Part A, Section XI in this manual or the agreed upon contract price. b. Reimbursement shall not be made to either the anesthesiologist or the anesthetist/anesthesia assistant until the insurer has received and reviewed the bill and anesthesia report from both providers. 2. No additional reimbursement shall be made for general supervisory services rendered by the anesthesiologist or other physician. C. Anesthesia services for which time units are not allowed. CRNAs and AAs who provide anesthesia for which no time units are used to determine the ARA shall be limited to eighty-five percent (85%) of the ARA allowed for an anesthesiologist. RULE 69L-7.020, F.A.C. 39 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition SECTION XI SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES RULE 69L-7.020, F.A.C. 40 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition MAXIMUM REIMBURSEMENT ALLOWANCES General Instructions: I. Part A of Section XI establishes the Maximum Reimbursement Allowances (MRAs) for services and procedures performed by workers’ compensation certified providers not specifically addressed in Section II F of this manual and for out-of-state providers who have not contracted with the insurer for an alternate reimbursement. Part A also includes the basic value (or base unit) on which reimbursement shall be calculated for all anesthesia services according to Section X of this manual. II. Part B of Section XI establishes the MRAs for Florida physician providers of surgical procedures and services. Physician assistants and advanced registered nurse practitioners shall be paid eightyfive percent (85%) of the physician’s MRA when these non-physician providers directly perform a surgical procedure or service. III. Part C of Section XI establishes the MRAs for Florida physicians, physical and occupational therapists, audiologists and speech pathologists and psychologist providers of non-surgical procedures and services. Physician assistants and advanced registered nurse practitioners shall be paid eighty-five percent (85%) of the physician’s MRA when these non-physician providers directly perform a non-surgical procedure or service. Part C also establishes the MRAs for independent clinical laboratories, freestanding imaging/x-ray centers, dietitians, nutritionists, nutrition counselors and licensed clinical social workers. (Refer to Section II F for reimbursement percentages.) IV. To determine the MRA to which a provider is entitled under Part B or Part C: A. Determine the county location of the provider according to the Medicare locality map in Appendix E. B. Determine whether the procedure should be paid according to the non-facility MRA (services rendered in a provider’s office, urgent care center or diagnostic facility) or the facility MRA (services rendered in a hospital setting, ambulatory surgical center, skilled nursing facility, inpatient psychiatric facility, and comprehensive [Level III] outpatient rehabilitation facility). C. Identify the specific CPT® code in the far-left column of the matrix and the correct locality/non-facility or facility column across the top row. D. Locate the point of intersection for the procedure code row and the appropriate nonfacility or facility locality column on the reimbursement matrix. E. Compare the amount allowed at the point of intersection on the matrix to the amount listed in the 2003 MRA column. F. Reimburse the provider the greater of the amount in the 2003 MRA column or the amount in the column at the point of intersection. RULE 69L-7.020, F.A.C. 41 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition PART A SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES RULE 69L-7.020, F.A.C. 42 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Anesthesia CPT Code 00100 00102 00103 00104 00120 00124 00126 00140 00142 00144 00145 00147 00148 00160 00162 00164 00170 00172 00174 00176 00190 00192 00210 00212 00214 00215 00216 00218 00220 00222 00300 00320 00322 00350 00352 00400 00402 00404 00406 00410 00450 00452 00454 00470 00472 00474 00500 00520 00522 00524 BV + TM 5 + TM 6 + TM 5 + TM 4 + TM 5 + TM 4 + TM 4 + TM 5 + TM 6 + TM 6 + TM 6 + TM 6 + TM 4 + TM 5 + TM 7 + TM 4 + TM 5 + TM 6 + TM 6 + TM 7 + TM 5 + TM 7 + TM 11 + TM 5 + TM 9 + TM 9 + TM 15 + TM 13 + TM 10 + TM 6 + TM 5 + TM 6 + TM 3 + TM 10 + TM 5 + TM 3 + TM 5 + TM 5 + TM 13 + TM 4 + TM 5 + TM 6 + TM 3 + TM 6 + TM 10 + TM 13 + TM 15 + TM 6 + TM 4 + TM 4 + TM Anesthesia CPT Code 00528 00529 00530 00532 00534 00537 00539 00540 00541 00542 00546 00548 00550 00560 00562 00563 00566 00580 00600 00604 00620 00622 00630 00632 00634 00635 00640 00670 00700 00702 00730 00740 00750 00752 00754 00756 00770 00790 00792 00794 00796 00797 00800 00802 00810 00820 00830 00832 00840 00842 BV + TM 8 + TM 11 + TM 4 + TM 4 + TM 7 + TM 8 + TM 17 + TM 13 + TM 15 + TM 15 + TM 15 + TM 15 + TM 10 + TM 15 + TM 20 + TM 25 + TM 25 + TM 20 + TM 10 + TM 13 + TM 10 + TM 13 + TM 8 + TM 7 + TM 10 + TM 4 + TM 3 + TM 13 + TM 3 + TM 4 + TM 5 + TM 5 + TM 4 + TM 6 + TM 7 + TM 7 + TM 15 + TM 7 + TM 13 + TM 8 + TM 30 + TM 10 + TM 3 + TM 5 + TM 5 + TM 5 + TM 4 + TM 6 + TM 6 + TM 4 + TM CPT only © 2008 American Medical Association. All Rights Reserved. Anesthesia CPT Code 00844 00846 00848 00851 00860 00862 00864 00865 00866 00868 00870 00872 00873 00880 00882 00902 00904 00906 00908 00910 00912 00914 00916 00918 00920 00921 00922 00924 00926 00928 00930 00932 00934 00936 00938 00940 00942 00944 00948 00950 00952 01112 01120 01130 01140 01150 01160 01170 01173 01180 BV + TM 7 + TM 8 + TM 8 + TM 6 + TM 6 + TM 7 + TM 8 + TM 8 + TM 10 + TM 10 + TM 5 + TM 7 + TM 5 + TM 15 + TM 10 + TM 5 + TM 7 + TM 4 + TM 6 + TM 3 + TM 5 + TM 5 + TM 5 + TM 5 + TM 3 + TM 3 + TM 6 + TM 4 + TM 4 + TM 6 + TM 4 + TM 4 + TM 6 + TM 8 + TM 4 + TM 3 + TM 4 + TM 6 + TM 4 + TM 5 + TM 4 + TM 5 + TM 6 + TM 3 + TM 15 + TM 8 + TM 4 + TM 8 + TM 12 + TM 3 + TM PartA, 43 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Anesthesia CPT Code 01190 01200 01202 01210 01212 01214 01215 01220 01230 01232 01234 01250 01260 01270 01272 01274 01320 01340 01360 01380 01382 01390 01392 01400 01402 01404 01420 01430 01432 01440 01442 01444 01462 01464 01470 01472 01474 01480 01482 01484 01486 01490 01500 01502 01520 01522 01610 01620 01622 01630 BV + TM 4 + TM 4 + TM 4 + TM 6 + TM 10 + TM 8 + TM 10 + TM 4 + TM 6 + TM 5 + TM 8 + TM 4 + TM 3 + TM 8 + TM 4 + TM 6 + TM 4 + TM 4 + TM 5 + TM 3 + TM 3 + TM 3 + TM 4 + TM 4 + TM 7 + TM 5 + TM 3 + TM 3 + TM 6 + TM 5 + TM 8 + TM 8 + TM 3 + TM 3 + TM 3 + TM 5 + TM 5 + TM 3 + TM 4 + TM 4 + TM 7 + TM 3 + TM 8 + TM 6 + TM 3 + TM 5 + TM 5 + TM 4 + TM 4 + TM 5 + TM Anesthesia CPT Code 01632 01634 01636 01638 01650 01652 01654 01656 01670 01680 01682 01710 01712 01714 01716 01730 01732 01740 01742 01744 01756 01758 01760 01770 01772 01780 01782 01810 01820 01829 01830 01832 01840 01842 01844 01850 01852 01860 01916 01920 01922 01924 01925 01926 01930 01931 01932 01933 01935 01936 BV + TM 6 + TM 9 + TM 15 + TM 10 + TM 6 + TM 10 + TM 8 + TM 10 + TM 4 + TM 3 + TM 4 + TM 3 + TM 5 + TM 5 + TM 5 + TM 3 + TM 3 + TM 4 + TM 5 + TM 5 + TM 6 + TM 5 + TM 7 + TM 6 + TM 6 + TM 3 + TM 4 + TM 3 + TM 3 + TM 3 + TM 3 + TM 6 + TM 6 + TM 6 + TM 6 + TM 3 + TM 4 + TM 3 + TM 5 + TM 7 + TM 7 + TM 6 + TM 8 + TM 10 + TM 5 + TM 7 + TM 7 + TM 8 + TM 8 + TM 8 + TM CPT only © 2008 American Medical Association. All Rights Reserved. Anesthesia CPT Code 01952 01953 01960 01961 01962 01963 01967 01968 01969 01990 01991 01992 01996 01999 BV + TM 5 + TM 1 + TM 5 + TM 7 + TM 8 + TM 10 + TM 5 + TM 3 + TM 5 + TM 0 3 + TM 5 + TM 3 BR PartA, 44 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 10021 10022 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180 11000 11001 11004 11005 11006 11008 11010 11011 11012 11040 11041 11042 11043 11044 11055 11056 11057 11100 11101 11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 MRA $90.00 $92.00 $54.00 $53.00 $133.00 $65.00 $203.00 $53.00 $169.00 $53.00 $45.00 $164.00 $45.00 $27.00 $564.00 $768.00 $710.00 $289.00 $348.00 $432.00 $597.00 $43.00 $45.00 $88.00 $210.00 $283.00 $26.00 $35.00 $39.00 $78.00 $41.00 $66.00 $26.00 $59.00 $80.00 $96.00 $119.00 $61.00 $86.00 $100.00 $125.00 $75.00 $95.00 $110.00 $144.00 $81.00 $114.00 $145.00 $178.00 $200.00 FUD 0 0 10 10 10 10 10 10 10 10 10 10 0 ZZZ 0 0 0 ZZZ 10 0 0 0 0 0 10 10 0 0 0 0 ZZZ 10 ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 10 10 10 10 10 Surgery CPT Code 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11450 11451 11462 11463 11470 11471 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11646 11719 11720 11721 11730 11732 11740 11750 11752 11755 11760 11762 11765 11770 MRA $246.00 $98.00 $92.00 $157.00 $163.00 $221.00 $303.00 $105.00 $102.00 $174.00 $221.00 $276.00 $344.00 $282.00 $366.00 $264.00 $351.00 $320.00 $391.00 $148.00 $180.00 $199.00 $226.00 $249.00 $315.00 $150.00 $191.00 $223.00 $259.00 $305.00 $373.00 $168.00 $227.00 $260.00 $305.00 $380.00 $494.00 $22.00 $32.00 $50.00 $62.00 $31.00 $41.00 $156.00 $234.00 $106.00 $131.00 $223.00 $65.00 $275.00 FUD 10 10 10 10 10 10 10 10 10 10 10 10 10 90 90 90 90 90 90 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 0 0 0 ZZZ 0 10 10 0 10 10 10 10 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 11771 11772 11900 11901 11920 11921 11922 11950 11951 11952 11954 11960 11970 11971 11976 12001 12002 12004 12005 12006 12007 12011 12013 12014 12015 12016 12017 12018 12020 12021 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047 12051 12052 12053 12054 12055 12056 12057 13100 MRA $496.00 $585.00 $33.00 $37.00 $147.00 $172.00 $40.00 $107.00 $114.00 $155.00 $165.00 $829.00 $632.00 $280.00 $123.00 $84.00 $98.00 $122.00 $165.00 $203.00 $339.00 $98.00 $141.00 $165.00 $207.00 $268.00 $316.00 $515.00 $211.00 $87.00 $93.00 $110.00 $148.00 $223.00 $356.00 $411.00 $116.00 $141.00 $176.00 $250.00 $341.00 $363.00 $126.00 $148.00 $223.00 $301.00 $380.00 $487.00 $539.00 $178.00 FUD 90 90 0 0 0 0 ZZZ 0 0 0 0 90 90 90 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 Part A, 45 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code MRA 13101 $240.00 13102 $89.00 13120 $223.00 13121 $348.00 13122 $104.00 13131 $252.00 13132 $484.00 13133 $154.00 13150 $260.00 13151 $375.00 13152 $542.00 13153 $169.00 13160 $655.00 14000 $512.00 14001 $695.00 14020 $590.00 14021 $818.00 14040 $701.00 14041 $936.00 14060 $766.00 14061 $1,330.00 14300 $1,040.00 14350 $734.00 15040 $258.00 15050 $349.00 15100 $679.00 15101 $146.00 15110 $815.00 15111 $129.00 15115 $766.00 15116 $167.00 15120 $788.00 15121 $235.00 15130 $677.00 15131 $105.00 15135 $820.00 15136 $98.00 15150 $677.00 15151 $136.00 15152 $167.00 15155 $678.00 15156 $177.00 15157 $196.00 15170 $356.00 15171 $92.00 15175 $503.00 15176 $146.00 15200 $644.00 15201 $126.00 15220 $687.00 FUD 10 ZZZ 10 10 ZZZ 10 10 ZZZ 10 10 10 ZZZ 90 90 90 90 90 90 90 90 90 90 90 0 90 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ ZZZ 90 ZZZ ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 Surgery CPT Code 15221 15240 15241 15260 15261 15300 15301 15320 15321 15330 15331 15335 15336 15340 15341 15360 15361 15365 15366 15400 15401 15420 15421 15430 15570 15572 15574 15576 15600 15610 15620 15630 15650 15731 15732 15734 15736 15738 15740 15750 15756 15757 15758 15760 15770 15775 15776 15780 15781 15782 MRA $114.00 $763.00 $334.00 $841.00 $207.00 $291.00 $61.00 $338.00 $91.00 $291.00 $61.00 $323.00 $88.00 $308.00 $44.00 $333.00 $71.00 $348.00 $88.00 $223.00 $66.00 $372.00 $115.00 $505.00 $748.00 $721.00 $775.00 $457.00 $259.00 $320.00 $506.00 $362.00 $427.00 $990.00 $1,465.00 $1,557.00 $1,862.00 $1,415.00 $913.00 $1,064.00 $2,892.00 $2,892.00 $2,884.00 $810.00 $674.00 $327.00 $475.00 $532.00 $420.00 $314.00 FUD ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 10 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 15783 15786 15787 15788 15789 15792 15793 15819 15820 15821 15822 15823 15824 15825 15826 15828 15829 15830 15832 15833 15834 15835 15836 15837 15838 15839 15840 15841 15842 15845 15850 15851 15852 15860 15876 15877 15878 15879 15920 15922 15931 15933 15934 15935 15936 15937 15940 15941 15944 15945 MRA $340.00 $146.00 $27.00 $194.00 $360.00 $130.00 $232.00 $780.00 $556.00 $607.00 $499.00 $718.00 BR BR BR BR BR $1,072.00 $926.00 $833.00 $837.00 $865.00 $721.00 $696.00 $600.00 $643.00 $1,187.00 $1,859.00 $3,099.00 $1,116.00 $63.00 $40.00 $35.00 $151.00 BR BR BR BR $571.00 $771.00 $638.00 $860.00 $1,064.00 $1,184.00 $1,032.00 $1,223.00 $318.00 $919.00 $954.00 $1,078.00 FUD 90 10 ZZZ 90 90 90 90 90 90 90 90 90 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 46 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 15946 15950 15951 15952 15953 15956 15958 15999 16000 16020 16025 16030 16035 16036 17000 17003 17004 17106 17107 17108 17110 17111 17250 17260 17261 17262 17263 17264 17266 17270 17271 17272 17273 17274 17276 17280 17281 17282 17283 17284 17286 17311 17312 17313 17314 17315 17340 17360 17380 17999 MRA $1,737.00 $549.00 $872.00 $876.00 $1,013.00 $1,382.00 $1,379.00 BR $53.00 $49.00 $67.00 $153.00 $341.00 $81.00 $60.00 $16.00 $233.00 $341.00 $648.00 $1,015.00 $55.00 $83.00 $27.00 $96.00 $117.00 $150.00 $172.00 $189.00 $225.00 $125.00 $143.00 $170.00 $195.00 $240.00 $281.00 $123.00 $165.00 $194.00 $239.00 $282.00 $373.00 $629.00 $380.00 $575.00 $352.00 $74.00 $37.00 $96.00 BR BR FUD 90 90 90 90 90 90 90 YYY 0 0 0 0 0 ZZZ 10 ZZZ 10 90 90 90 10 10 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 ZZZ 0 ZZZ ZZZ 10 10 0 YYY Surgery CPT Code 19000 19001 19020 19030 19100 19101 19102 19103 19105 19110 19112 19120 19125 19126 19260 19271 19272 19290 19291 19295 19296 19297 19298 19300 19301 19302 19303 19304 19305 19306 19307 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368 19369 19370 19371 MRA $74.00 $40.00 $288.00 $98.00 $117.00 $338.00 $263.00 $601.00 $1,878.00 $406.00 $354.00 $429.00 $468.00 $201.00 $1,101.00 $1,561.00 $1,674.00 $101.00 $52.00 $103.00 $4,903.00 $96.00 $1,841.00 $482.00 $367.00 $780.00 $788.00 $487.00 $964.00 $1,003.00 $1,008.00 $954.00 $1,313.00 $440.00 $656.00 $457.00 $569.00 $545.00 $963.00 $853.00 $755.00 $1,449.00 $1,667.00 $2,737.00 $1,676.00 $2,056.00 $2,444.00 $2,317.00 $662.00 $788.00 FUD 0 ZZZ 90 0 0 10 0 0 0 90 90 90 90 ZZZ 90 90 90 0 ZZZ ZZZ 0 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 19380 19396 19499 20000 20005 20100 20101 20102 20103 20150 20200 20205 20206 20220 20225 20240 20245 20250 20251 20500 20501 20520 20525 20526 20550 20551 20552 20553 20555 20600 20605 20610 20612 20615 20650 20660 20661 20662 20663 20665 20670 20680 20690 20692 20693 20694 20802 20805 20808 20816 MRA $780.00 $231.00 BR $45.00 $267.00 $727.00 $261.00 $314.00 $405.00 $1,141.00 $134.00 $243.00 $119.00 $128.00 $215.00 $279.00 $364.00 $447.00 $511.00 $59.00 $60.00 $75.00 $331.00 $64.00 $40.00 $62.00 $62.00 $62.00 $301.00 $41.00 $48.00 $49.00 $56.00 $94.00 $170.00 $320.00 $476.00 $559.00 $465.00 $105.00 $80.00 $332.00 $298.00 $516.00 $477.00 $421.00 $3,363.00 $4,317.00 $5,324.00 $3,060.00 FUD 90 0 YYY 10 10 10 10 10 10 90 0 0 0 0 0 10 10 10 10 10 0 10 10 0 0 0 0 0 0 0 0 0 0 10 10 0 90 90 90 10 10 90 90 90 90 90 90 90 90 90 Part A, 47 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 20822 20824 20827 20838 20900 20902 20910 20912 20920 20922 20924 20926 20930 20931 20936 20937 20938 20950 20955 20956 20957 20962 20969 20970 20972 20973 20974 20975 20979 20982 20985 20999 21010 21015 21025 21026 21029 21030 21031 21032 21034 21040 21044 21045 21046 21047 21048 21049 21050 21060 MRA $2,511.00 $3,027.00 $3,920.00 $3,484.00 $454.00 $658.00 $338.00 $549.00 $460.00 $634.00 $583.00 $444.00 BR $156.00 BR $234.00 $257.00 $123.00 $3,332.00 $3,167.00 $3,074.00 $3,122.00 $3,716.00 $3,650.00 $3,420.00 $3,821.00 $266.00 $334.00 $19.00 $4,231.00 $140.00 BR $854.00 $520.00 $546.00 $413.00 $700.00 $496.00 $310.00 $315.00 $1,140.00 $227.00 $957.00 $1,313.00 $899.00 $1,109.00 $925.00 $1,051.00 $1,026.00 $972.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 0 ZZZ ZZZ 0 90 90 90 90 90 90 90 90 0 0 0 0 ZZZ YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 21070 21073 21076 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21089 21100 21110 21116 21120 21121 21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 21146 21147 21150 21151 21154 21155 21159 21160 21172 21175 21179 21180 21181 21182 21183 21184 21188 21193 21194 MRA $679.00 $337.00 $1,192.00 $3,002.00 $2,086.00 $2,346.00 $2,138.00 $1,855.00 $1,802.00 $2,105.00 $801.00 $2,333.00 $2,217.00 BR BR $297.00 $371.00 $207.00 $500.00 $651.00 $700.00 $903.00 $656.00 $909.00 $797.00 $960.00 $1,168.00 $1,438.00 $1,527.00 $1,511.00 $1,513.00 $1,570.00 $1,639.00 $1,914.00 $2,264.00 $2,364.00 $2,640.00 $3,302.00 $3,500.00 $2,111.00 $2,604.00 $1,826.00 $2,035.00 $813.00 $2,570.00 $2,770.00 $3,150.00 $1,786.00 $1,331.00 $1,540.00 FUD 90 90 10 90 90 90 90 90 90 90 10 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 21195 21196 21198 21199 21206 21208 21209 21210 21215 21230 21235 21240 21242 21243 21244 21245 21246 21247 21248 21249 21255 21256 21260 21261 21263 21267 21268 21270 21275 21280 21282 21295 21296 21299 21310 21315 21320 21325 21330 21335 21336 21337 21338 21339 21340 21343 21344 21345 21346 21347 MRA $1,360.00 $1,764.00 $1,268.00 $1,018.00 $1,112.00 $946.00 $576.00 $930.00 $970.00 $956.00 $707.00 $1,281.00 $1,207.00 $1,501.00 $1,062.00 $1,038.00 $1,010.00 $2,003.00 $1,023.00 $1,525.00 $1,459.00 $1,470.00 $1,372.00 $2,347.00 $2,361.00 $1,539.00 $1,946.00 $890.00 $963.00 $571.00 $360.00 $144.00 $384.00 BR $81.00 $180.00 $235.00 $348.00 $639.00 $852.00 $478.00 $300.00 $550.00 $689.00 $907.00 $1,043.00 $1,450.00 $738.00 $917.00 $1,048.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 48 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 21348 21355 21356 21360 21365 21366 21385 21386 21387 21390 21395 21400 21401 21406 21407 21408 21421 21422 21423 21431 21432 21433 21435 21436 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21470 21480 21485 21490 21495 21497 21499 21501 21502 21510 21550 21555 21556 21557 21600 21610 MRA $1,286.00 $295.00 $372.00 $590.00 $1,239.00 $1,386.00 $810.00 $812.00 $958.00 $920.00 $1,384.00 $143.00 $313.00 $852.00 $736.00 $1,007.00 $528.00 $761.00 $890.00 $598.00 $744.00 $1,981.00 $1,404.00 $2,045.00 $308.00 $533.00 $325.00 $498.00 $195.00 $902.00 $905.00 $769.00 $1,012.00 $923.00 $1,331.00 $82.00 $318.00 $865.00 $500.00 $372.00 BR $315.00 $612.00 $534.00 $165.00 $337.00 $431.00 $794.00 $631.00 $828.00 FUD 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 YYY 90 90 90 10 90 90 90 90 90 Surgery CPT Code 21615 21616 21620 21627 21630 21632 21685 21700 21705 21720 21725 21740 21742 21743 21750 21800 21805 21810 21820 21825 21899 21920 21925 21930 21935 22010 22015 22100 22101 22102 22103 22110 22112 22114 22116 22206 22207 22208 22210 22212 22214 22216 22220 22222 22224 22226 22305 22310 22315 22318 MRA $938.00 $1,042.00 $689.00 $686.00 $1,455.00 $1,514.00 $918.00 $576.00 $746.00 $523.00 $588.00 $1,387.00 BR BR $1,009.00 $84.00 $236.00 $540.00 $143.00 $810.00 BR $165.00 $371.00 $403.00 $1,280.00 $822.00 $815.00 $850.00 $862.00 $781.00 $198.00 $889.00 $1,090.00 $1,062.00 $195.00 $2,153.00 $2,126.00 $545.00 $1,892.00 $1,668.00 $819.00 $492.00 $1,801.00 $1,604.00 $1,731.00 $488.00 $213.00 $272.00 $711.00 $1,755.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 90 ZZZ 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 22319 22325 22326 22327 22328 22505 22520 22521 22522 22523 22524 22525 22526 22527 22532 22533 22534 22548 22554 22556 22558 22585 22590 22595 22600 22610 22612 22614 22630 22632 22800 22802 22804 22808 22810 22812 22818 22819 22830 22840 22841 22842 22843 22844 22845 22846 22847 22848 22849 22850 MRA $1,983.00 $1,407.00 $1,710.00 $1,660.00 $391.00 $174.00 $509.00 $477.00 $231.00 $617.00 $592.00 $283.00 $2,013.00 $1,637.00 $1,618.00 $1,509.00 $381.00 $2,271.00 $1,727.00 $2,054.00 $1,907.00 $473.00 $1,895.00 $1,960.00 $1,567.00 $1,494.00 $1,861.00 $530.00 $1,201.00 $442.00 $1,960.00 $2,633.00 $2,951.00 $2,157.00 $2,356.00 $2,675.00 $2,701.00 $2,968.00 $1,176.00 $943.00 BR $2,352.00 $1,028.00 $1,277.00 $1,853.00 $999.00 $1,077.00 $529.00 $2,235.00 $872.00 FUD 90 90 90 90 ZZZ 10 10 10 ZZZ 10 10 ZZZ 10 ZZZ 90 90 ZZZ 90 90 90 90 ZZZ 90 90 90 90 90 ZZZ 90 ZZZ 90 90 90 90 90 90 90 90 90 ZZZ 0 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 Part A, 49 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 22851 22852 22855 22857 22862 22865 22899 22900 22999 23000 23020 23030 23031 23035 23040 23044 23065 23066 23075 23076 23077 23100 23101 23105 23106 23107 23120 23125 23130 23140 23145 23146 23150 23155 23156 23170 23172 23174 23180 23182 23184 23190 23195 23200 23210 23220 23221 23222 23330 23331 MRA $600.00 $854.00 $1,193.00 $1,386.00 $1,690.00 $1,646.00 BR $446.00 BR $447.00 $807.00 $323.00 $185.00 $861.00 $898.00 $708.00 $171.00 $302.00 $247.00 $613.00 $1,228.00 $616.00 $583.00 $814.00 $581.00 $851.00 $645.00 $865.00 $722.00 $597.00 $889.00 $704.00 $755.00 $945.00 $794.00 $645.00 $638.00 $882.00 $566.00 $865.00 $962.00 $656.00 $902.00 $1,095.00 $1,095.00 $1,307.00 $1,559.00 $1,921.00 $59.00 $520.00 FUD ZZZ 90 90 90 90 90 YYY 90 YYY 90 90 10 10 90 90 90 10 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 Surgery CPT Code 23332 23350 23395 23397 23400 23405 23406 23410 23412 23415 23420 23430 23440 23450 23455 23460 23462 23465 23466 23470 23472 23480 23485 23490 23491 23500 23505 23515 23520 23525 23530 23532 23540 23545 23550 23552 23570 23575 23585 23600 23605 23615 23616 23620 23625 23630 23650 23655 23660 23665 MRA $1,029.00 $74.00 $1,366.00 $1,403.00 $1,196.00 $799.00 $977.00 $1,119.00 $1,229.00 $622.00 $1,276.00 $884.00 $906.00 $1,210.00 $1,340.00 $1,364.00 $1,383.00 $1,398.00 $1,332.00 $1,540.00 $1,570.00 $926.00 $1,181.00 $1,038.00 $1,251.00 $148.00 $293.00 $688.00 $205.00 $320.00 $659.00 $713.00 $148.00 $148.00 $701.00 $753.00 $88.00 $306.00 $809.00 $318.00 $511.00 $900.00 $1,895.00 $286.00 $422.00 $712.00 $296.00 $374.00 $712.00 $440.00 FUD 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 23670 23675 23680 23700 23800 23802 23900 23920 23921 23929 23930 23931 23935 24000 24006 24065 24066 24075 24076 24077 24100 24101 24102 24105 24110 24115 24116 24120 24125 24126 24130 24134 24136 24138 24140 24145 24147 24149 24150 24151 24152 24153 24155 24160 24164 24200 24201 24220 24300 24301 MRA $759.00 $550.00 $1,064.00 $237.00 $1,346.00 $1,368.00 $1,561.00 $1,300.00 $497.00 BR $71.00 $62.00 $630.00 $550.00 $793.00 $166.00 $461.00 $349.00 $529.00 $1,058.00 $467.00 $591.00 $755.00 $360.00 $724.00 $898.00 $1,037.00 $595.00 $663.00 $731.00 $595.00 $966.00 $720.00 $697.00 $963.00 $592.00 $703.00 $1,224.00 $1,265.00 $1,383.00 $829.00 $936.00 $1,019.00 $533.00 $564.00 $58.00 $444.00 $89.00 $352.00 $869.00 FUD 90 90 90 10 90 90 90 90 90 YYY 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 0 90 90 Part A, 50 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 24305 24310 24320 24330 24331 24332 24340 24341 24342 24343 24344 24345 24346 24357 24358 24359 24360 24361 24362 24363 24365 24366 24400 24410 24420 24430 24435 24470 24495 24498 24500 24505 24515 24516 24530 24535 24538 24545 24546 24560 24565 24566 24575 24576 24577 24579 24582 24586 24587 24600 MRA $579.00 $511.00 $944.00 $845.00 $927.00 $487.00 $697.00 $702.00 $950.00 $643.00 $971.00 $643.00 $971.00 $408.00 $478.00 $587.00 $1,125.00 $1,215.00 $1,269.00 $1,663.00 $747.00 $850.00 $991.00 $1,319.00 $1,265.00 $1,209.00 $1,260.00 $774.00 $742.00 $1,076.00 $288.00 $574.00 $1,018.00 $1,029.00 $88.00 $671.00 $850.00 $946.00 $1,273.00 $266.00 $526.00 $705.00 $872.00 $295.00 $575.00 $964.00 $773.00 $1,314.00 $1,278.00 $360.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 24605 24615 24620 24635 24650 24655 24665 24666 24670 24675 24685 24800 24802 24900 24920 24925 24930 24931 24935 24940 24999 25000 25001 25020 25023 25024 25025 25028 25031 25035 25040 25065 25066 25075 25076 25077 25085 25100 25101 25105 25107 25109 25110 25111 25112 25115 25116 25118 25119 25120 MRA $371.00 $836.00 $560.00 $1,329.00 $262.00 $436.00 $749.00 $905.00 $263.00 $490.00 $819.00 $984.00 $1,181.00 $858.00 $851.00 $661.00 $928.00 $1,063.00 $1,327.00 BR BR $381.00 $294.00 $594.00 $1,040.00 $683.00 $1,104.00 $417.00 $266.00 $794.00 $654.00 $164.00 $322.00 $352.00 $544.00 $957.00 $562.00 $420.00 $492.00 $635.00 $600.00 $470.00 $403.00 $356.00 $441.00 $837.00 $807.00 $466.00 $653.00 $712.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 25125 25126 25130 25135 25136 25145 25150 25151 25170 25210 25215 25230 25240 25246 25248 25250 25251 25259 25260 25263 25265 25270 25272 25274 25275 25280 25290 25295 25300 25301 25310 25312 25315 25316 25320 25332 25335 25337 25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25394 25400 MRA $803.00 $781.00 $502.00 $631.00 $546.00 $713.00 $720.00 $771.00 $1,085.00 $561.00 $817.00 $531.00 $567.00 $72.00 $236.00 $616.00 $933.00 $348.00 $728.00 $809.00 $998.00 $549.00 $613.00 $887.00 $620.00 $670.00 $436.00 $562.00 $592.00 $757.00 $865.00 $968.00 $1,004.00 $1,203.00 $834.00 $1,022.00 $1,166.00 $946.00 $913.00 $1,014.00 $468.00 $1,216.00 $1,214.00 $1,280.00 $1,043.00 $1,349.00 $1,294.00 $1,473.00 $723.00 $1,112.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 51 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 25405 25415 25420 25425 25426 25430 25431 25440 25441 25442 25443 25444 25445 25446 25447 25449 25450 25455 25490 25491 25492 25500 25505 25515 25520 25525 25526 25530 25535 25545 25560 25565 25574 25575 25600 25605 25606 25607 25608 25609 25622 25624 25628 25630 25635 25645 25650 25651 25652 25660 MRA $1,388.00 $1,343.00 $1,554.00 $1,403.00 $1,401.00 $638.00 $631.00 $931.00 $1,147.00 $936.00 $970.00 $1,031.00 $959.00 $1,542.00 $952.00 $395.00 $805.00 $899.00 $955.00 $1,006.00 $1,170.00 $200.00 $517.00 $800.00 $644.00 $1,097.00 $1,293.00 $270.00 $516.00 $803.00 $276.00 $590.00 $804.00 $974.00 $312.00 $540.00 $643.00 $645.00 $739.00 $942.00 $148.00 $482.00 $716.00 $148.00 $458.00 $668.00 $185.00 $379.00 $560.00 $378.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 25670 25671 25675 25676 25680 25685 25690 25695 25800 25805 25810 25820 25825 25830 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931 25999 26010 26011 26020 26025 26030 26034 26035 26037 26040 26045 26055 26060 26070 26075 26080 26100 26105 26110 26115 26116 26117 26121 26123 26125 MRA $731.00 $462.00 $404.00 $741.00 $471.00 $887.00 $518.00 $520.00 $703.00 $1,078.00 $1,008.00 $2,276.00 $895.00 $991.00 $871.00 $900.00 $799.00 $849.00 $1,523.00 $771.00 $670.00 $768.00 $830.00 $645.00 $731.00 BR $59.00 $223.00 $484.00 $548.00 $655.00 $601.00 $741.00 $730.00 $367.00 $621.00 $343.00 $293.00 $440.00 $400.00 $382.00 $398.00 $481.00 $282.00 $344.00 $544.00 $806.00 $833.00 $959.00 $342.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code MRA 26130 $629.00 26135 $668.00 26140 $678.00 26145 $660.00 26160 $319.00 26170 $452.00 26180 $444.00 26185 $511.00 26200 $598.00 26205 $788.00 26210 $543.00 26215 $731.00 26230 $624.00 26235 $612.00 26236 $444.00 26250 $814.00 26255 $1,184.00 26260 $758.00 26261 $949.00 26262 $624.00 26320 $414.00 26340 $266.00 26350 $715.00 26352 $855.00 26356 $886.00 26357 $932.00 26358 $979.00 26370 $832.00 26372 $945.00 26373 $904.00 26390 $889.00 26392 $1,123.00 26410 $371.00 26412 $737.00 26415 $846.00 26416 $1,093.00 26418 $444.00 26420 $741.00 26426 $733.00 26428 $790.00 26432 $430.00 26433 $371.00 26434 $656.00 26437 $491.00 26440 $458.00 26442 $548.00 26445 $455.00 26449 $738.00 26450 $353.00 26455 $364.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 52 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 26460 26471 26474 26476 26477 26478 26479 26480 26483 26485 26489 26490 26492 26494 26496 26497 26498 26499 26500 26502 26508 26510 26516 26517 26518 26520 26525 26530 26531 26535 26536 26540 26541 26542 26545 26546 26548 26550 26551 26553 26554 26555 26556 26560 26561 26562 26565 26567 26568 26580 MRA $346.00 $592.00 $586.00 $543.00 $553.00 $608.00 $653.00 $808.00 $986.00 $891.00 $738.00 $496.00 $971.00 $946.00 $949.00 $946.00 $1,317.00 $934.00 $557.00 $715.00 $334.00 $564.00 $630.00 $890.00 $877.00 $583.00 $531.00 $708.00 $877.00 $546.00 $770.00 $726.00 $926.00 $716.00 $722.00 $918.00 $665.00 $1,861.00 $3,901.00 $3,868.00 $4,551.00 $1,567.00 $4,005.00 $576.00 $1,067.00 $1,017.00 $730.00 $622.00 $1,003.00 $1,585.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code MRA 26587 $792.00 26590 $1,609.00 26591 $431.00 26593 $587.00 26596 $809.00 26600 $133.00 26605 $296.00 26607 $334.00 26608 $497.00 26615 $521.00 26641 $71.00 26645 $371.00 26650 $533.00 26665 $693.00 26670 $148.00 26675 $501.00 26676 $527.00 26685 $592.00 26686 $710.00 26700 $88.00 26705 $296.00 26706 $469.00 26715 $526.00 26720 $96.00 26725 $187.00 26727 $187.00 26735 $532.00 26740 $148.00 26742 $148.00 26746 $548.00 26750 $96.00 26755 $133.00 26756 $366.00 26765 $398.00 26770 $79.00 26775 $275.00 26776 $401.00 26785 $408.00 26820 $854.00 26841 $756.00 26842 $901.00 26843 $800.00 26844 $875.00 26850 $704.00 26852 $829.00 26860 $542.00 26861 $151.00 26862 $747.00 26863 $317.00 26910 $747.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 ZZZ 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 26951 26952 26989 26990 26991 26992 27000 27001 27003 27005 27006 27025 27030 27033 27035 27036 27040 27041 27047 27048 27049 27050 27052 27054 27060 27062 27065 27066 27067 27070 27071 27075 27076 27077 27078 27079 27080 27086 27087 27090 27091 27093 27095 27096 27097 27098 27100 27105 27110 27111 MRA $444.00 $608.00 BR $592.00 $466.00 $1,146.00 $421.00 $550.00 $698.00 $738.00 $788.00 $896.00 $1,148.00 $1,173.00 $1,413.00 $1,176.00 $196.00 $699.00 $535.00 $588.00 $1,162.00 $449.00 $624.00 $843.00 $491.00 $499.00 $583.00 $931.00 $1,234.00 $1,040.00 $1,112.00 $1,485.00 $1,859.00 $1,976.00 $1,164.00 $1,170.00 $568.00 $57.00 $555.00 $981.00 $1,482.00 $62.00 $121.00 $491.00 $795.00 $799.00 $987.00 $946.00 $1,174.00 $1,099.00 FUD 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 0 0 0 90 90 90 90 90 90 Part A, 53 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 27120 27122 27125 27130 27132 27134 27137 27138 27140 27146 27147 27151 27156 27158 27161 27165 27170 27175 27176 27177 27178 27179 27181 27185 27187 27193 27194 27200 27202 27215 27216 27217 27218 27220 27222 27226 27227 27228 27230 27232 27235 27236 27238 27240 27244 27245 27246 27248 27250 27252 MRA $1,603.00 $1,406.00 $1,371.00 $1,853.00 $2,128.00 $2,576.00 $2,190.00 $2,025.00 $1,092.00 $1,432.00 $1,744.00 $1,732.00 $2,017.00 $1,588.00 $1,443.00 $1,572.00 $1,453.00 $491.00 $1,024.00 $1,257.00 $1,020.00 $1,107.00 $1,206.00 $676.00 $1,280.00 $425.00 $740.00 $180.00 $776.00 $954.00 $1,085.00 $1,285.00 $1,570.00 $444.00 $973.00 $1,350.00 $1,967.00 $2,195.00 $491.00 $916.00 $1,128.00 $1,421.00 $504.00 $1,043.00 $1,426.00 $1,691.00 $459.00 $980.00 $535.00 $520.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 27253 27254 27256 27257 27258 27259 27265 27266 27267 27268 27269 27275 27280 27282 27284 27286 27290 27295 27299 27301 27303 27305 27306 27307 27310 27323 27324 27325 27326 27327 27328 27329 27330 27331 27332 27333 27334 27335 27340 27345 27347 27350 27355 27356 27357 27358 27360 27365 27370 27372 MRA $1,162.00 $1,478.00 $338.00 $455.00 $1,355.00 $1,803.00 $442.00 $614.00 $382.00 $470.00 $1,117.00 $220.00 $1,179.00 $990.00 $1,435.00 $1,503.00 $2,073.00 $1,594.00 BR $193.00 $520.00 $555.00 $377.00 $503.00 $877.00 $211.00 $433.00 $476.00 $451.00 $400.00 $503.00 $1,249.00 $492.00 $585.00 $786.00 $719.00 $840.00 $959.00 $405.00 $565.00 $394.00 $786.00 $763.00 $882.00 $950.00 $394.00 $977.00 $1,421.00 $75.00 $371.00 FUD 90 90 10 10 90 90 90 90 90 90 90 10 90 90 90 90 90 90 YYY 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 0 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 27380 27381 27385 27386 27390 27391 27392 27393 27394 27395 27396 27397 27400 27403 27405 27407 27409 27412 27415 27416 27418 27420 27422 27424 27425 27427 27428 27429 27430 27435 27437 27438 27440 27441 27442 27443 27445 27446 27447 27448 27450 27454 27455 27457 27465 27466 27468 27470 27472 27475 MRA $698.00 $1,118.00 $753.00 $1,064.00 $506.00 $647.00 $834.00 $608.00 $748.00 $1,093.00 $742.00 $989.00 $832.00 $792.00 $842.00 $918.00 $1,212.00 $1,605.00 $1,340.00 $878.00 $1,596.00 $927.00 $930.00 $927.00 $639.00 $1,118.00 $1,266.00 $2,333.00 $884.00 $501.00 $819.00 $1,065.00 $1,064.00 $1,006.00 $1,117.00 $1,037.00 $1,618.00 $1,764.00 $1,960.00 $1,060.00 $1,311.00 $1,524.00 $1,157.00 $1,209.00 $1,253.00 $1,441.00 $1,613.00 $1,501.00 $1,665.00 $782.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 54 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 27477 27479 27485 27486 27487 27488 27495 27496 27497 27498 27499 27500 27501 27502 27503 27506 27507 27508 27509 27510 27511 27513 27514 27516 27517 27519 27520 27524 27530 27532 27535 27536 27538 27540 27550 27552 27556 27557 27558 27560 27562 27566 27570 27580 27590 27591 27592 27594 27596 27598 MRA $938.00 $1,123.00 $797.00 $1,771.00 $2,352.00 $1,438.00 $1,477.00 $563.00 $652.00 $701.00 $782.00 $520.00 $659.00 $909.00 $911.00 $1,522.00 $1,297.00 $400.00 $649.00 $755.00 $1,281.00 $1,562.00 $1,508.00 $579.00 $820.00 $1,311.00 $266.00 $910.00 $408.00 $641.00 $1,075.00 $1,282.00 $487.00 $1,106.00 $296.00 $619.00 $832.00 $1,479.00 $1,529.00 $88.00 $514.00 $1,047.00 $184.00 $1,644.00 $1,059.00 $1,182.00 $911.00 $600.00 $931.00 $976.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 Surgery CPT Code 27599 27600 27601 27602 27603 27604 27605 27606 27607 27610 27612 27613 27614 27615 27618 27619 27620 27625 27626 27630 27635 27637 27638 27640 27641 27645 27646 27647 27648 27650 27652 27654 27656 27658 27659 27664 27665 27675 27676 27680 27681 27685 27686 27687 27690 27691 27692 27695 27696 27698 MRA BR $517.00 $516.00 $621.00 $412.00 $308.00 $236.00 $362.00 $608.00 $777.00 $701.00 $165.00 $327.00 $1,106.00 $421.00 $730.00 $587.00 $796.00 $863.00 $430.00 $781.00 $921.00 $978.00 $1,122.00 $922.00 $1,302.00 $1,212.00 $1,044.00 $72.00 $869.00 $935.00 $937.00 $458.00 $527.00 $725.00 $504.00 $618.00 $656.00 $762.00 $523.00 $634.00 $565.00 $706.00 $589.00 $757.00 $889.00 $159.00 $658.00 $758.00 $881.00 FUD YYY 90 90 90 90 90 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 27700 27702 27703 27704 27705 27707 27709 27712 27715 27720 27722 27724 27725 27726 27727 27730 27732 27734 27740 27742 27745 27750 27752 27756 27758 27759 27760 27762 27766 27767 27768 27769 27780 27781 27784 27786 27788 27792 27808 27810 27814 27816 27818 27822 27823 27824 27825 27826 27827 27828 MRA $835.00 $1,278.00 $1,337.00 $683.00 $985.00 $484.00 $1,118.00 $1,227.00 $1,285.00 $1,147.00 $1,076.00 $1,402.00 $1,312.00 $823.00 $1,175.00 $647.00 $611.00 $766.00 $1,044.00 $1,045.00 $940.00 $319.00 $614.00 $708.00 $1,115.00 $1,262.00 $223.00 $495.00 $759.00 $233.00 $361.00 $622.00 $244.00 $296.00 $643.00 $223.00 $422.00 $706.00 $332.00 $567.00 $972.00 $386.00 $613.00 $1,201.00 $1,472.00 $384.00 $670.00 $1,080.00 $1,310.00 $1,823.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 55 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 27829 27830 27831 27832 27840 27842 27846 27848 27860 27870 27871 27880 27881 27882 27884 27886 27888 27889 27892 27893 27894 27899 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28035 28043 28045 28046 28050 28052 28054 28055 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 MRA $742.00 $412.00 $415.00 $617.00 $334.00 $373.00 $877.00 $1,224.00 $211.00 $1,269.00 $843.00 $1,015.00 $1,120.00 $854.00 $579.00 $835.00 $911.00 $879.00 $575.00 $574.00 $712.00 BR $185.00 $362.00 $520.00 $520.00 $296.00 $235.00 $340.00 $509.00 $422.00 $371.00 $532.00 $305.00 $456.00 $814.00 $414.00 $402.00 $236.00 $377.00 $495.00 $657.00 $476.00 $445.00 $392.00 $462.00 $414.00 $414.00 $330.00 $571.00 FUD 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code MRA 28102 $700.00 28103 $709.00 28104 $491.00 28106 $632.00 28107 $517.00 28108 $418.00 28110 $421.00 28111 $537.00 28112 $457.00 28113 $481.00 28114 $890.00 28116 $648.00 28118 $568.00 28119 $524.00 28120 $601.00 28122 $622.00 28124 $480.00 28126 $393.00 28130 $727.00 28140 $533.00 28150 $416.00 28153 $400.00 28160 $412.00 28171 $789.00 28173 $747.00 28175 $571.00 28190 $75.00 28192 $326.00 28193 $341.00 28200 $478.00 28202 $613.00 28208 $406.00 28210 $609.00 28220 $435.00 28222 $555.00 28225 $345.00 28226 $334.00 28230 $380.00 28232 $286.00 28234 $178.00 28238 $695.00 28240 $370.00 28250 $535.00 28260 $641.00 28261 $881.00 28262 $1,363.00 28264 $912.00 28270 $266.00 28272 $336.00 28280 $426.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28400 28405 28406 28415 28420 28430 28435 28436 28445 28446 28450 28455 28456 28465 28470 28475 28476 28485 28490 MRA $463.00 $441.00 $452.00 $458.00 $557.00 $666.00 $845.00 $797.00 $832.00 $838.00 $755.00 $829.00 $845.00 $930.00 $776.00 $1,030.00 $530.00 $614.00 $516.00 $955.00 $505.00 $469.00 $436.00 $462.00 $833.00 $667.00 $649.00 $753.00 $414.00 $557.00 $1,197.00 $266.00 $473.00 $616.00 $1,354.00 $1,619.00 $110.00 $371.00 $463.00 $874.00 $1,075.00 $148.00 $321.00 $288.00 $533.00 $178.00 $296.00 $364.00 $521.00 $80.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 56 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code MRA 28495 $133.00 28496 $261.00 28505 $399.00 28510 $75.00 28515 $115.00 28525 $345.00 28530 $120.00 28531 $243.00 28540 $145.00 28545 $208.00 28546 $325.00 28555 $592.00 28570 $189.00 28575 $308.00 28576 $382.00 28585 $742.00 28600 $144.00 28605 $287.00 28606 $487.00 28615 $621.00 28630 $145.00 28635 $189.00 28636 $318.00 28645 $434.00 28660 $106.00 28665 $172.00 28666 $309.00 28675 $348.00 28705 $1,353.00 28715 $1,179.00 28725 $1,015.00 28730 $945.00 28735 $961.00 28737 $873.00 28740 $690.00 28750 $690.00 28755 $466.00 28760 $654.00 28800 $731.00 28805 $731.00 28810 $543.00 28820 $377.00 28825 $339.00 28890 $358.00 28899 BR 29000 $247.00 29010 $271.00 29015 $289.00 29020 $237.00 29025 $188.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 Surgery CPT Code 29035 29040 29044 29046 29049 29055 29058 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29220 29240 29260 29280 29305 29325 29345 29355 29358 29365 29405 29425 29435 29440 29445 29450 29505 29515 29520 29530 29540 29550 29580 29590 29700 29705 29710 29715 29720 29730 29740 29750 29799 MRA $213.00 $260.00 $260.00 $286.00 $45.00 $180.00 $110.00 $88.00 $72.00 $59.00 $54.00 $59.00 $45.00 $53.00 $26.00 $53.00 $29.00 $37.00 $45.00 $26.00 $29.00 $223.00 $260.00 $126.00 $133.00 $241.00 $101.00 $96.00 $101.00 $133.00 $22.00 $214.00 $84.00 $75.00 $59.00 $22.00 $55.00 $41.00 $37.00 $39.00 $32.00 $29.00 $26.00 $29.00 $109.00 $29.00 $29.00 $37.00 $105.00 BR FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 YYY CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 29800 29804 29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827 29828 29830 29834 29835 29836 29837 29838 29840 29843 29844 29845 29846 29847 29848 29850 29851 29855 29856 29860 29861 29862 29863 29866 29867 29868 29870 29871 29873 29874 29875 29876 29877 29879 29880 29881 29882 MRA $557.00 $902.00 $360.00 $1,003.00 $976.00 $756.00 $718.00 $863.00 $749.00 $1,330.00 $611.00 $941.00 $980.00 $1,058.00 $830.00 $524.00 $635.00 $612.00 $680.00 $830.00 $931.00 $501.00 $580.00 $612.00 $931.00 $976.00 $1,277.00 $608.00 $752.00 $1,137.00 $1,007.00 $1,231.00 $658.00 $845.00 $907.00 $880.00 $1,046.00 $1,250.00 $1,694.00 $460.00 $631.00 $489.00 $676.00 $639.00 $809.00 $852.00 $1,064.00 $1,169.00 $745.00 $819.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 57 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 29883 29884 29885 29886 29887 29888 29889 29891 29892 29893 29894 29895 29897 29898 29899 29900 29901 29902 29904 29905 29906 29907 29999 30000 30020 30100 30110 30115 30117 30118 30120 30124 30125 30130 30140 30150 30160 30200 30210 30220 30300 30310 30320 30400 30410 30420 30430 30435 30450 30460 MRA $1,235.00 $721.00 $832.00 $697.00 $949.00 $1,296.00 $1,255.00 $796.00 $835.00 $472.00 $690.00 $679.00 $704.00 $863.00 $973.00 $434.00 $479.00 $514.00 $557.00 $601.00 $633.00 $775.00 BR $96.00 $117.00 $86.00 $157.00 $360.00 $301.00 $819.00 $500.00 $243.00 $599.00 $275.00 $320.00 $790.00 $875.00 $68.00 $75.00 $154.00 $45.00 $170.00 $419.00 $741.00 $1,173.00 $1,424.00 $626.00 $1,005.00 $1,445.00 $857.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 0 10 90 90 90 90 90 90 90 90 90 90 0 10 10 10 10 90 90 90 90 90 90 90 90 Surgery CPT Code 30462 30465 30520 30540 30545 30560 30580 30600 30620 30630 30801 30802 30901 30903 30905 30906 30915 30920 30930 30999 31000 31002 31020 31030 31032 31040 31050 31051 31070 31075 31080 31081 31084 31085 31086 31087 31090 31200 31201 31205 31225 31230 31231 31233 31235 31237 31238 31239 31240 31254 MRA $1,633.00 $803.00 $533.00 $643.00 $981.00 $104.00 $566.00 $466.00 $564.00 $624.00 $88.00 $172.00 $75.00 $110.00 $224.00 $208.00 $596.00 $862.00 $213.00 BR $81.00 $135.00 $281.00 $531.00 $604.00 $772.00 $489.00 $654.00 $410.00 $839.00 $942.00 $1,089.00 $1,210.00 $1,281.00 $1,081.00 $1,075.00 $877.00 $463.00 $716.00 $851.00 $1,683.00 $1,908.00 $122.00 $221.00 $217.00 $266.00 $311.00 $775.00 $224.00 $588.00 FUD 90 90 90 90 90 10 90 90 90 90 10 10 0 0 0 0 90 90 10 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 10 0 0 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 31255 31256 31267 31276 31287 31288 31290 31291 31292 31293 31294 31299 31300 31320 31360 31365 31367 31368 31370 31375 31380 31382 31390 31395 31400 31420 31500 31502 31505 31510 31511 31512 31513 31515 31525 31526 31527 31528 31529 31530 31531 31535 31536 31540 31541 31545 31546 31560 31561 31570 MRA $601.00 $292.00 $453.00 $690.00 $339.00 $396.00 $1,462.00 $1,551.00 $1,235.00 $1,346.00 $1,587.00 BR $1,295.00 $508.00 $1,630.00 $2,238.00 $1,913.00 $2,478.00 $1,891.00 $1,720.00 $1,782.00 $1,822.00 $2,513.00 $2,937.00 $969.00 $969.00 $116.00 $74.00 $62.00 $145.00 $88.00 $197.00 $182.00 $160.00 $234.00 $222.00 $262.00 $202.00 $217.00 $284.00 $311.00 $272.00 $308.00 $357.00 $453.00 $384.00 $587.00 $446.00 $509.00 $369.00 FUD 0 0 0 0 0 0 10 10 10 10 10 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Part A, 58 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 31571 31575 31576 31577 31578 31579 31580 31582 31584 31587 31588 31590 31595 31599 31600 31603 31605 31610 31611 31612 31613 31614 31615 31620 31622 31623 31624 31625 31628 31629 31630 31631 31632 31633 31635 31636 31637 31638 31640 31641 31643 31645 31646 31656 31715 31717 31720 31725 31730 31750 MRA $363.00 $128.00 $186.00 $230.00 $264.00 $219.00 $1,213.00 $1,881.00 $1,616.00 $913.00 $1,206.00 $691.00 $773.00 BR $306.00 $343.00 $297.00 $794.00 $614.00 $99.00 $384.00 $736.00 $213.00 $271.00 $230.00 $225.00 $217.00 $235.00 $269.00 $198.00 $308.00 $252.00 $73.00 $90.00 $298.00 $241.00 $86.00 $268.00 $399.00 $304.00 $208.00 $208.00 $161.00 $127.00 $57.00 $138.00 $89.00 $103.00 $199.00 $1,088.00 FUD 0 0 0 0 0 0 90 90 90 90 90 90 90 YYY 0 0 0 90 90 0 90 90 0 ZZZ 0 0 0 0 0 0 0 0 ZZZ ZZZ 0 0 ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 90 Surgery CPT Code 31755 31760 31766 31770 31775 31780 31781 31785 31786 31800 31805 31820 31825 31830 31899 32035 32036 32095 32100 32110 32120 32124 32140 32141 32150 32151 32160 32200 32201 32215 32220 32225 32310 32320 32400 32402 32405 32420 32421 32422 32440 32442 32445 32480 32482 32484 32486 32488 32491 32500 MRA $1,448.00 $1,648.00 $2,315.00 $1,815.00 $1,973.00 $1,577.00 $1,936.00 $1,320.00 $1,866.00 $628.00 $1,175.00 $458.00 $659.00 $460.00 BR $821.00 $908.00 $848.00 $1,120.00 $1,223.00 $1,077.00 $1,144.00 $1,284.00 $1,267.00 $1,226.00 $1,231.00 $842.00 $1,132.00 $387.00 $1,024.00 $1,680.00 $1,268.00 $1,221.00 $1,787.00 $129.00 $798.00 $159.00 $116.00 $159.00 $194.00 $1,837.00 $2,093.00 $2,093.00 $1,622.00 $1,714.00 $1,771.00 $1,974.00 $2,094.00 $1,784.00 $1,331.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 0 90 0 0 0 0 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 32501 32503 32504 32540 32550 32551 32560 32601 32602 32603 32604 32605 32606 32650 32651 32652 32653 32654 32655 32656 32657 32658 32659 32660 32661 32662 32663 32664 32665 32800 32810 32815 32820 32851 32852 32853 32854 32900 32905 32906 32940 32960 32997 32998 32999 33010 33011 33015 33020 33025 MRA $374.00 $1,875.00 $2,145.00 $1,308.00 $821.00 $171.00 $302.00 $456.00 $494.00 $585.00 $663.00 $550.00 $637.00 $957.00 $1,166.00 $1,615.00 $1,144.00 $1,096.00 $1,213.00 $1,222.00 $1,261.00 $1,142.00 $1,141.00 $1,691.00 $1,165.00 $1,459.00 $1,636.00 $1,197.00 $1,360.00 $1,166.00 $1,085.00 $1,917.00 $1,848.00 $3,100.00 $3,339.00 $3,787.00 $4,038.00 $1,532.00 $1,661.00 $2,100.00 $1,555.00 $126.00 $312.00 $2,809.00 BR $124.00 $125.00 $555.00 $1,178.00 $1,165.00 FUD ZZZ 90 90 90 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 YYY 0 0 90 90 90 Part A, 59 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 33030 33031 33050 33120 33130 33140 33141 33202 33203 33206 33207 33208 33210 33211 33212 33213 33214 33215 33216 33217 33218 33220 33222 33223 33224 33225 33226 33233 33234 33235 33236 33237 33238 33240 33241 33243 33244 33249 33250 33251 33254 33255 33256 33257 33258 33259 33261 33265 33266 33282 MRA $1,786.00 $1,816.00 $1,224.00 $2,358.00 $1,734.00 $1,571.00 $254.00 $749.00 $766.00 $642.00 $753.00 $573.00 $204.00 $210.00 $511.00 $437.00 $532.00 $304.00 $402.00 $428.00 $488.00 $390.00 $471.00 $585.00 $490.00 $434.00 $472.00 $270.00 $598.00 $587.00 $933.00 $1,184.00 $1,235.00 $648.00 $301.00 $1,650.00 $1,081.00 $1,271.00 $1,687.00 $2,071.00 $1,307.00 $1,573.00 $1,879.00 $565.00 $639.00 $839.00 $1,993.00 $1,307.00 $1,789.00 $470.00 FUD 90 90 90 90 90 90 ZZZ 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 0 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ 90 90 90 90 Surgery CPT Code 33284 33300 33305 33310 33315 33320 33321 33322 33330 33332 33335 33400 33401 33403 33404 33405 33406 33410 33411 33412 33413 33414 33415 33416 33417 33420 33422 33425 33426 33427 33430 33460 33463 33464 33465 33468 33470 33471 33472 33474 33475 33476 33478 33496 33500 33501 33502 33503 33504 33505 MRA $365.00 $1,576.00 $1,889.00 $1,577.00 $1,875.00 $1,485.00 $1,890.00 $1,935.00 $1,726.00 $1,915.00 $2,336.00 $2,401.00 $2,228.00 $2,369.00 $2,698.00 $2,745.00 $2,962.00 $2,637.00 $2,981.00 $3,213.00 $3,282.00 $2,904.00 $2,563.00 $2,684.00 $2,756.00 $1,796.00 $2,431.00 $2,509.00 $2,806.00 $3,026.00 $2,891.00 $2,215.00 $2,396.00 $2,547.00 $2,665.00 $2,952.00 $1,749.00 $1,929.00 $2,001.00 $2,173.00 $2,666.00 $2,270.00 $2,544.00 $2,595.00 $2,370.00 $1,546.00 $1,938.00 $1,983.00 $2,416.00 $2,423.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 33506 33507 33508 33510 33511 33512 33513 33514 33516 33517 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33545 33548 33572 33600 33602 33606 33608 33610 33611 33612 33615 33617 33619 33641 33645 33647 33660 33665 33670 33675 33676 33677 33681 33684 33688 33690 33692 33694 33697 MRA $2,448.00 $1,809.00 $17.00 $2,354.00 $2,546.00 $2,732.00 $2,933.00 $3,197.00 $3,404.00 $219.00 $414.00 $607.00 $801.00 $994.00 $1,189.00 $521.00 $2,415.00 $2,654.00 $2,899.00 $3,143.00 $2,693.00 $3,250.00 $2,381.00 $340.00 $2,644.00 $2,556.00 $2,831.00 $2,940.00 $2,871.00 $2,985.00 $3,152.00 $3,051.00 $3,272.00 $3,678.00 $1,981.00 $2,352.00 $2,732.00 $2,444.00 $2,700.00 $2,820.00 $2,085.00 $2,151.00 $2,236.00 $2,657.00 $2,740.00 $2,602.00 $1,884.00 $2,816.00 $2,856.00 $3,064.00 FUD 90 90 ZZZ 90 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 60 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 33702 33710 33720 33722 33724 33726 33730 33732 33735 33736 33737 33750 33755 33762 33764 33766 33767 33768 33770 33771 33774 33775 33776 33777 33778 33779 33780 33781 33786 33788 33800 33802 33803 33813 33814 33820 33822 33824 33840 33845 33851 33852 33853 33860 33861 33863 33864 33870 33875 33877 MRA $2,549.00 $2,731.00 $2,508.00 $2,704.00 $1,491.00 $1,963.00 $2,785.00 $2,622.00 $2,036.00 $2,288.00 $1,977.00 $1,877.00 $1,831.00 $1,900.00 $1,895.00 $2,119.00 $2,173.00 $449.00 $2,954.00 $2,924.00 $2,681.00 $2,654.00 $2,844.00 $2,724.00 $3,199.00 $3,121.00 $3,232.00 $3,057.00 $2,970.00 $2,288.00 $1,546.00 $1,752.00 $1,746.00 $1,935.00 $2,464.00 $1,619.00 $1,559.00 $1,884.00 $2,029.00 $2,129.00 $2,129.00 $2,311.00 $3,057.00 $3,044.00 $3,069.00 $3,183.00 $3,035.00 $3,638.00 $2,876.00 $3,767.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 33880 33881 33883 33884 33886 33889 33891 33910 33915 33916 33917 33920 33922 33924 33925 33926 33935 33945 33960 33961 33967 33968 33970 33971 33973 33974 33975 33976 33977 33978 33979 33980 33999 34001 34051 34101 34111 34151 34201 34203 34401 34421 34451 34471 34490 34501 34502 34510 34520 34530 MRA $1,866.00 $1,603.00 $1,187.00 $441.00 $1,025.00 $882.00 $1,126.00 $1,987.00 $1,588.00 $2,096.00 $2,345.00 $2,981.00 $2,227.00 $421.00 $1,849.00 $2,499.00 $5,415.00 $3,813.00 $1,221.00 $800.00 $258.00 $51.00 $576.00 $578.00 $756.00 $1,095.00 $1,758.00 $2,056.00 $1,561.00 $1,754.00 $2,496.00 $3,212.00 BR $1,012.00 $1,134.00 $800.00 $669.00 $1,288.00 $777.00 $949.00 $953.00 $779.00 $1,117.00 $685.00 $660.00 $910.00 $2,044.00 $1,108.00 $1,077.00 $1,368.00 FUD 90 90 90 ZZZ 90 0 0 90 90 90 90 90 90 ZZZ 90 90 90 90 0 ZZZ 0 0 0 90 0 90 0 0 90 90 0 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 34800 34802 34803 34804 34805 34806 34808 34812 34813 34820 34825 34826 34830 34831 34832 34833 34834 34900 35001 35002 35005 35011 35013 35021 35022 35045 35081 35082 35091 35092 35102 35103 35111 35112 35121 35122 35131 35132 35141 35142 35151 35152 35180 35182 35184 35188 35189 35190 35201 35206 MRA $1,159.00 $1,279.00 $1,372.00 $1,279.00 $1,243.00 $100.00 $220.00 $359.00 $256.00 $519.00 $694.00 $220.00 $1,803.00 $1,950.00 $1,950.00 $650.00 $306.00 $960.00 $1,564.00 $1,547.00 $1,268.00 $1,007.00 $1,376.00 $1,635.00 $1,686.00 $995.00 $2,175.00 $2,661.00 $2,634.00 $2,872.00 $2,346.00 $2,587.00 $1,398.00 $1,351.00 $2,000.00 $2,382.00 $1,495.00 $1,742.00 $1,231.00 $1,339.00 $1,390.00 $1,229.00 $997.00 $1,345.00 $976.00 $1,048.00 $1,380.00 $1,018.00 $852.00 $835.00 FUD 90 90 90 90 90 ZZZ ZZZ 0 ZZZ 0 90 ZZZ 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 61 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 35207 35211 35216 35221 35226 35231 35236 35241 35246 35251 35256 35261 35266 35271 35276 35281 35286 35301 35302 35303 35304 35305 35306 35311 35321 35331 35341 35351 35355 35361 35363 35371 35372 35390 35400 35450 35452 35454 35456 35458 35459 35460 35470 35471 35472 35473 35474 35475 35476 35480 MRA $935.00 $1,833.00 $1,494.00 $1,243.00 $841.00 $1,053.00 $947.00 $1,926.00 $1,701.00 $1,260.00 $1,568.00 $1,008.00 $921.00 $1,814.00 $1,541.00 $1,396.00 $1,036.00 $1,486.00 $1,109.00 $1,218.00 $1,267.00 $1,218.00 $456.00 $1,999.00 $1,031.00 $1,724.00 $1,908.00 $1,555.00 $1,336.00 $1,859.00 $2,006.00 $1,006.00 $1,085.00 $225.00 $224.00 $643.00 $518.00 $520.00 $631.00 $804.00 $736.00 $430.00 $537.00 $626.00 $388.00 $375.00 $456.00 $569.00 $338.00 $935.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Surgery CPT Code 35481 35482 35483 35484 35485 35490 35491 35492 35493 35494 35495 35500 35501 35506 35508 35509 35510 35511 35512 35515 35516 35518 35521 35522 35523 35525 35526 35531 35533 35536 35537 35538 35539 35540 35548 35549 35551 35556 35558 35560 35563 35565 35566 35571 35572 35583 35585 35587 35600 35601 MRA $565.00 $577.00 $696.00 $853.00 $670.00 $691.00 $423.00 $423.00 $523.00 $605.00 $532.00 $423.00 $1,569.00 $1,641.00 $1,564.00 $1,529.00 $1,316.00 $1,256.00 $1,291.00 $1,387.00 $1,391.00 $1,313.00 $1,393.00 $1,253.00 $1,237.00 $1,197.00 $1,527.00 $2,000.00 $1,716.00 $1,888.00 $2,141.00 $2,391.00 $2,248.00 $2,505.00 $1,751.00 $1,902.00 $2,036.00 $1,745.00 $1,219.00 $1,899.00 $1,115.00 $1,312.00 $2,161.00 $1,612.00 $369.00 $1,843.00 $2,277.00 $1,698.00 $273.00 $1,495.00 FUD 0 0 0 0 0 0 0 0 0 0 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 35606 35612 35616 35621 35623 35626 35631 35636 35637 35638 35642 35645 35646 35647 35650 35651 35654 35656 35661 35663 35665 35666 35671 35681 35682 35683 35685 35686 35691 35693 35694 35695 35697 35700 35701 35721 35741 35761 35800 35820 35840 35860 35870 35875 35876 35879 35881 35883 35884 35901 MRA $1,539.00 $1,349.00 $1,346.00 $1,265.00 $1,193.00 $1,921.00 $1,891.00 $1,656.00 $1,704.00 $1,731.00 $1,298.00 $1,304.00 $2,105.00 $1,555.00 $1,236.00 $2,055.00 $1,603.00 $1,589.00 $1,145.00 $1,237.00 $1,333.00 $1,686.00 $1,315.00 $751.00 $627.00 $702.00 $216.00 $178.00 $1,546.00 $1,140.00 $1,353.00 $1,351.00 $166.00 $264.00 $494.00 $500.00 $499.00 $532.00 $567.00 $951.00 $771.00 $496.00 $1,583.00 $827.00 $1,232.00 $1,163.00 $1,275.00 $1,247.00 $1,324.00 $709.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 62 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 35903 35905 35907 36000 36002 36005 36010 36011 36012 36013 36014 36015 36100 36120 36140 36145 36160 36200 36215 36216 36217 36218 36245 36246 36247 36248 36260 36261 36262 36299 36410 36415 36416 36425 36430 36455 36468 36469 36470 36471 36475 36476 36478 36479 36481 36500 36511 36512 36513 36514 MRA $818.00 $1,343.00 $1,335.00 $46.00 $181.00 $68.00 $136.00 $194.00 $186.00 $141.00 $159.00 $186.00 $176.00 $120.00 $106.00 $10.00 $196.00 $240.00 $240.00 $270.00 $325.00 $79.00 $249.00 $272.00 $323.00 $53.00 $749.00 $388.00 $297.00 BR $18.00 BR BR $86.00 $37.00 $141.00 BR BR $76.00 $96.00 $2,216.00 $434.00 $2,041.00 $438.00 $499.00 $159.00 $92.00 $92.00 $92.00 $92.00 FUD 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 0 ZZZ 90 90 90 YYY 0 0 0 0 0 0 0 0 10 10 0 ZZZ 0 ZZZ 0 0 0 0 0 0 Surgery CPT Code 36515 36516 36522 36556 36558 36561 36563 36565 36566 36569 36571 36575 36576 36578 36580 36581 36582 36583 36584 36585 36589 36590 36591 36592 36593 36595 36596 36597 36598 36600 36620 36625 36640 36680 36800 36810 36815 36818 36819 36820 36821 36822 36823 36825 36830 36831 36832 36833 36834 36835 MRA $92.00 $92.00 $305.00 $316.00 $703.00 $1,333.00 $1,679.00 $1,073.00 $1,121.00 $350.00 $1,550.00 $172.00 $429.00 $546.00 $307.00 $646.00 $1,210.00 $708.00 $321.00 $1,525.00 $176.00 $378.00 $21.00 $26.00 $37.00 $880.00 $194.00 $167.00 $130.00 $24.00 $64.00 $133.00 $130.00 $72.00 $159.00 $345.00 $236.00 $736.00 $977.00 $800.00 $721.00 $630.00 $1,461.00 $867.00 $967.00 $488.00 $810.00 $780.00 $761.00 $542.00 FUD 0 0 0 0 10 10 10 10 10 0 10 0 10 10 0 10 10 10 0 10 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 36838 36860 36861 36870 37140 37145 37160 37180 37181 37182 37183 37184 37185 37186 37187 37188 37195 37200 37201 37202 37203 37204 37205 37206 37207 37208 37209 37210 37215 37216 37250 37251 37500 37501 37565 37600 37605 37606 37607 37609 37615 37616 37617 37618 37620 37650 37660 37700 37718 37722 MRA $1,230.00 $166.00 $224.00 $1,755.00 $1,666.00 $1,741.00 $1,681.00 $1,769.00 $1,923.00 $914.00 $425.00 $3,074.00 $1,002.00 $2,076.00 $2,991.00 $2,586.00 $302.00 $232.00 $408.00 $340.00 $287.00 $957.00 $589.00 $288.00 $613.00 $299.00 $116.00 $2,128.00 $1,095.00 $1,055.00 $112.00 $85.00 $739.00 BR $364.00 $414.00 $521.00 $563.00 $456.00 $278.00 $495.00 $1,128.00 $1,132.00 $514.00 $818.00 $430.00 $789.00 $336.00 $416.00 $495.00 FUD 90 0 0 90 90 90 90 90 90 0 0 0 ZZZ ZZZ 0 0 0 0 0 0 0 0 0 ZZZ 0 ZZZ 0 0 90 90 ZZZ ZZZ 90 YYY 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 Part A, 63 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 37735 37760 37765 37766 37780 37785 37788 37790 37799 38100 38101 38102 38115 38120 38129 38200 38205 38206 38220 38221 38230 38240 38241 38242 38300 38305 38308 38380 38381 38382 38500 38505 38510 38520 38525 38530 38542 38550 38555 38562 38564 38570 38571 38572 38589 38700 38720 38724 38740 38745 MRA $847.00 $813.00 $462.00 $561.00 $301.00 $270.00 $1,654.00 $690.00 BR $974.00 $982.00 $332.00 $1,020.00 $1,138.00 BR $180.00 $79.00 $79.00 $212.00 $228.00 $265.00 $128.00 $128.00 $90.00 $104.00 $375.00 $425.00 $628.00 $1,087.00 $798.00 $234.00 $139.00 $349.00 $431.00 $369.00 $517.00 $507.00 $519.00 $1,115.00 $799.00 $831.00 $695.00 $902.00 $1,049.00 BR $863.00 $1,328.00 $1,366.00 $539.00 $770.00 FUD 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 90 YYY 0 0 0 0 0 10 0 0 0 10 90 90 90 90 90 10 0 10 90 90 90 90 90 90 90 90 10 10 10 YYY 90 90 90 90 90 Surgery CPT Code 38746 38747 38760 38765 38770 38780 38790 38792 38794 38999 39000 39010 39200 39220 39400 39499 39501 39502 39503 39520 39530 39531 39540 39541 39545 39560 39561 39599 40490 40500 40510 40520 40525 40527 40530 40650 40652 40654 40700 40701 40702 40720 40761 40799 40800 40801 40804 40805 40806 40808 MRA $312.00 $337.00 $699.00 $1,283.00 $1,111.00 $1,357.00 $158.00 $26.00 $298.00 BR $664.00 $1,148.00 $1,249.00 $1,542.00 $614.00 BR $1,083.00 $1,268.00 $2,726.00 $1,345.00 $1,295.00 $1,243.00 $1,133.00 $1,179.00 $1,102.00 $968.00 $1,328.00 BR $108.00 $422.00 $469.00 $467.00 $714.00 $851.00 $501.00 $368.00 $436.00 $529.00 $1,009.00 $1,452.00 $1,030.00 $1,107.00 $1,202.00 BR $110.00 $208.00 $105.00 $245.00 $38.00 $100.00 FUD ZZZ ZZZ 90 90 90 90 0 0 90 YYY 90 90 90 90 10 YYY 90 90 90 90 90 90 90 90 90 90 90 YYY 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 10 10 0 10 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 40810 40812 40814 40816 40818 40819 40820 40830 40831 40840 40842 40843 40844 40845 40899 41000 41005 41006 41007 41008 41009 41010 41015 41016 41017 41018 41019 41100 41105 41108 41110 41112 41113 41114 41115 41116 41120 41130 41135 41140 41145 41150 41153 41155 41250 41251 41252 41500 41510 41520 MRA $141.00 $202.00 $319.00 $336.00 $249.00 $208.00 $104.00 $140.00 $213.00 $687.00 $684.00 $947.00 $1,232.00 $1,593.00 BR $119.00 $109.00 $237.00 $283.00 $248.00 $319.00 $91.00 $267.00 $357.00 $300.00 $424.00 $444.00 $140.00 $136.00 $110.00 $159.00 $255.00 $301.00 $682.00 $176.00 $242.00 $813.00 $937.00 $1,869.00 $2,005.00 $2,406.00 $1,897.00 $2,091.00 $2,448.00 $168.00 $203.00 $294.00 $334.00 $313.00 $255.00 FUD 10 10 90 90 90 90 10 10 10 90 90 90 90 90 YYY 10 10 90 90 90 90 10 90 90 90 90 0 10 10 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 10 10 10 90 90 90 Part A, 64 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code MRA 41599 BR 41800 $107.00 41805 $115.00 41806 $217.00 41820 BR 41821 BR 41822 $237.00 41823 $312.00 41825 $144.00 41826 $211.00 41827 $322.00 41828 $176.00 41830 $156.00 41850 BR 41870 BR 41872 $249.00 41874 $193.00 41899 BR 42000 $106.00 42100 $122.00 42104 $161.00 42106 $204.00 42107 $409.00 42120 $573.00 42140 $174.00 42145 $741.00 42160 $176.00 42180 $222.00 42182 $324.00 42200 $946.00 42205 $863.00 42210 $1,174.00 42215 $766.00 42220 $586.00 42225 $803.00 42226 $848.00 42227 $762.00 42235 $631.00 42260 $491.00 42280 $148.00 42281 $160.00 42299 BR 42300 $165.00 42305 $448.00 42310 $145.00 42320 $208.00 42330 $184.00 42335 $287.00 42340 $411.00 42400 $94.00 FUD YYY 10 10 10 0 0 10 90 10 10 90 10 10 0 0 90 90 YYY 10 10 10 10 90 90 90 90 10 10 10 90 90 90 90 90 90 90 90 90 90 10 10 YYY 10 90 10 10 10 90 90 0 Surgery CPT Code 42405 42408 42409 42410 42415 42420 42425 42426 42440 42450 42500 42505 42507 42508 42509 42510 42550 42600 42650 42660 42665 42699 42700 42720 42725 42800 42802 42804 42806 42808 42809 42810 42815 42821 42826 42831 42836 42842 42844 42845 42860 42870 42890 42892 42894 42900 42950 42953 42955 42960 MRA $258.00 $377.00 $266.00 $746.00 $1,364.00 $1,577.00 $1,097.00 $1,882.00 $634.00 $395.00 $407.00 $559.00 $522.00 $767.00 $915.00 $711.00 $82.00 $445.00 $67.00 $89.00 $238.00 BR $144.00 $270.00 $720.00 $123.00 $150.00 $136.00 $167.00 $250.00 $152.00 $335.00 $659.00 $378.00 $320.00 $235.00 $286.00 $729.00 $1,173.00 $1,958.00 $207.00 $427.00 $1,047.00 $1,262.00 $1,825.00 $429.00 $745.00 $752.00 $561.00 $178.00 FUD 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 0 0 90 YYY 10 10 90 10 10 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 10 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 42961 42962 42970 42971 42972 42999 43020 43030 43045 43100 43101 43107 43108 43112 43113 43116 43117 43118 43121 43122 43123 43124 43130 43135 43200 43201 43202 43204 43205 43215 43216 43217 43219 43220 43226 43227 43228 43231 43232 43234 43235 43236 43237 43238 43239 43240 43241 43242 43243 43244 MRA $406.00 $602.00 $284.00 $472.00 $562.00 BR $696.00 $712.00 $1,574.00 $744.00 $1,248.00 $2,325.00 $2,664.00 $2,471.00 $2,755.00 $2,509.00 $2,469.00 $2,607.00 $2,350.00 $2,287.00 $2,661.00 $2,242.00 $1,020.00 $1,332.00 $266.00 $245.00 $205.00 $228.00 $207.00 $160.00 $149.00 $176.00 $171.00 $128.00 $142.00 $218.00 $230.00 $182.00 $252.00 $193.00 $239.00 $285.00 $219.00 $271.00 $246.00 $369.00 $157.00 $384.00 $276.00 $268.00 FUD 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Part A, 65 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 43245 43246 43247 43248 43249 43250 43251 43255 43256 43257 43258 43259 43260 43261 43262 43263 43264 43265 43267 43268 43269 43271 43272 43280 43289 43300 43305 43310 43312 43313 43314 43320 43324 43325 43326 43330 43331 43340 43341 43350 43351 43352 43360 43361 43400 43401 43405 43410 43415 43420 MRA $214.00 $485.00 $229.00 $191.00 $175.00 $194.00 $224.00 $343.00 $235.00 $305.00 $276.00 $271.00 $349.00 $362.00 $447.00 $386.00 $522.00 $527.00 $434.00 $446.00 $410.00 $437.00 $401.00 $1,314.00 BR $837.00 $1,428.00 $2,138.00 $2,331.00 $2,632.00 $2,891.00 $1,299.00 $1,280.00 $1,261.00 $1,198.00 $1,236.00 $1,378.00 $1,292.00 $1,351.00 $986.00 $1,180.00 $1,028.00 $2,277.00 $2,596.00 $1,261.00 $1,299.00 $1,330.00 $946.00 $1,382.00 $854.00 FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 43425 43450 43453 43456 43458 43460 43496 43499 43500 43501 43502 43510 43520 43600 43605 43610 43611 43620 43621 43622 43631 43632 43633 43634 43635 43640 43641 43644 43645 43651 43652 43653 43659 43752 43760 43761 43770 43771 43772 43773 43774 43800 43810 43820 43825 43830 43831 43832 43840 43842 MRA $1,338.00 $91.00 $102.00 $149.00 $164.00 $203.00 BR BR $649.00 $1,105.00 $1,247.00 $680.00 $599.00 $96.00 $686.00 $861.00 $1,001.00 $1,691.00 $1,718.00 $1,798.00 $1,445.00 $1,443.00 $1,467.00 $1,786.00 $143.00 $1,119.00 $1,138.00 $1,598.00 $1,724.00 $716.00 $856.00 $617.00 BR $36.00 $81.00 $107.00 $1,009.00 $1,162.00 $885.00 $1,162.00 $888.00 $793.00 $846.00 $896.00 $1,128.00 $592.00 $593.00 $904.00 $893.00 $1,260.00 FUD 90 0 0 0 0 0 90 YYY 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 YYY 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 43843 43845 43846 43847 43848 43850 43855 43860 43865 43870 43880 43886 43887 43888 43999 44005 44010 44015 44020 44021 44025 44050 44055 44100 44110 44111 44120 44121 44125 44126 44127 44128 44130 44133 44136 44139 44140 44141 44143 44144 44145 44146 44147 44150 44151 44155 44156 44157 44158 44160 MRA $1,249.00 $1,738.00 $1,528.00 $1,678.00 $1,795.00 $1,425.00 $1,454.00 $1,435.00 $1,549.00 $590.00 $1,352.00 $280.00 $274.00 $389.00 BR $1,171.00 $809.00 $1,171.00 $891.00 $888.00 $905.00 $862.00 $957.00 $117.00 $784.00 $963.00 $1,078.00 $308.00 $1,135.00 $1,951.00 $2,243.00 $242.00 $938.00 BR BR $154.00 $1,350.00 $1,488.00 $1,536.00 $1,442.00 $1,678.00 $1,840.00 $1,452.00 $1,661.00 $1,499.00 $1,892.00 $1,709.00 $1,952.00 $2,003.00 $1,236.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 90 90 90 90 0 90 90 90 ZZZ 90 90 90 ZZZ 90 0 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 66 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 44180 44186 44187 44188 44202 44203 44204 44205 44206 44207 44208 44210 44211 44212 44213 44227 44238 44300 44310 44312 44314 44316 44320 44322 44340 44345 44346 44360 44361 44363 44364 44365 44366 44369 44370 44372 44373 44376 44377 44378 44379 44380 44382 44383 44385 44386 44388 44389 44390 44391 MRA $853.00 $600.00 $992.00 $1,088.00 $1,603.00 $235.00 $1,353.00 $1,198.00 $1,480.00 $1,620.00 $1,752.00 $1,551.00 $1,926.00 $1,800.00 $196.00 $1,536.00 BR $697.00 $950.00 $453.00 $892.00 $1,229.00 $1,029.00 $1,015.00 $397.00 $816.00 $923.00 $177.00 $195.00 $213.00 $255.00 $226.00 $300.00 $308.00 $253.00 $301.00 $238.00 $305.00 $320.00 $410.00 $396.00 $91.00 $110.00 $165.00 $219.00 $183.00 $326.00 $301.00 $319.00 $376.00 FUD 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 ZZZ 90 YYY 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Surgery CPT Code 44392 44393 44394 44397 44500 44602 44603 44604 44605 44615 44620 44625 44626 44640 44650 44660 44661 44680 44700 44701 44720 44721 44799 44800 44820 44850 44899 44900 44901 44950 44955 44960 44970 44979 45000 45005 45020 45100 45108 45110 45111 45112 45113 45114 45116 45119 45120 45121 45123 45126 MRA $359.00 $413.00 $395.00 $259.00 $28.00 $815.00 $1,041.00 $1,027.00 $1,132.00 $994.00 $741.00 $1,277.00 $1,581.00 $1,036.00 $1,076.00 $1,050.00 $1,326.00 $1,049.00 $1,115.00 $161.00 $268.00 $393.00 BR $791.00 $755.00 $708.00 BR $644.00 $310.00 $643.00 $136.00 $790.00 $631.00 BR $329.00 $197.00 $364.00 $321.00 $419.00 $1,801.00 $1,270.00 $1,904.00 $1,885.00 $1,732.00 $1,485.00 $1,911.00 $1,845.00 $1,870.00 $1,126.00 $2,444.00 FUD 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 0 0 YYY 90 90 90 YYY 90 0 90 ZZZ 90 90 YYY 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 45130 45135 45136 45150 45160 45170 45190 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45327 45330 45331 45332 45333 45334 45335 45337 45338 45339 45340 45341 45342 45345 45355 45378 45379 45380 45381 45382 45383 45384 45385 45386 45387 45391 45392 45395 45397 45400 45402 45500 45505 MRA $1,041.00 $1,354.00 $1,526.00 $475.00 $949.00 $697.00 $623.00 $75.00 $72.00 $102.00 $172.00 $137.00 $174.00 $211.00 $209.00 $230.00 $154.00 $96.00 $87.00 $120.00 $174.00 $176.00 $171.00 $144.00 $144.00 $212.00 $237.00 $328.00 $153.00 $224.00 $164.00 $185.00 $341.00 $415.00 $369.00 $388.00 $481.00 $482.00 $415.00 $479.00 $739.00 $322.00 $283.00 $358.00 $1,813.00 $1,969.00 $1,058.00 $1,435.00 $584.00 $510.00 FUD 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 Part A, 67 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 45520 45540 45541 45550 45560 45562 45563 45800 45805 45820 45825 45900 45905 45910 45915 45990 45999 46020 46030 46040 46045 46050 46060 46080 46083 46200 46210 46211 46220 46221 46230 46250 46255 46257 46258 46260 46261 46262 46270 46275 46280 46285 46288 46320 46500 46505 46600 46604 46606 46608 MRA $46.00 $1,009.00 $888.00 $1,350.00 $618.00 $915.00 $1,412.00 $1,050.00 $1,273.00 $1,066.00 $1,241.00 $120.00 $133.00 $163.00 $142.00 $105.00 BR $230.00 $94.00 $393.00 $312.00 $105.00 $482.00 $246.00 $98.00 $323.00 $196.00 $353.00 $118.00 $124.00 $198.00 $400.00 $501.00 $504.00 $539.00 $598.00 $655.00 $686.00 $328.00 $442.00 $514.00 $335.00 $521.00 $126.00 $109.00 $229.00 $38.00 $92.00 $66.00 $115.00 FUD 0 90 90 90 90 90 90 90 90 90 90 10 10 10 10 0 YYY 10 10 90 90 10 90 10 10 90 90 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 0 0 0 0 Surgery CPT Code 46610 46611 46612 46614 46615 46700 46706 46710 46712 46715 46716 46730 46735 46740 46742 46744 46746 46748 46750 46753 46754 46760 46761 46762 46900 46910 46916 46917 46922 46924 46937 46938 46940 46942 46945 46946 46947 46999 47000 47001 47010 47011 47015 47100 47120 47122 47125 47130 47135 47136 MRA $114.00 $149.00 $196.00 $169.00 $202.00 $585.00 $140.00 $953.00 $1,999.00 $545.00 $906.00 $1,584.00 $1,881.00 $1,671.00 $2,236.00 $2,412.00 $2,725.00 $2,933.00 $636.00 $511.00 $188.00 $846.00 $813.00 $731.00 $128.00 $144.00 $145.00 $228.00 $189.00 $297.00 $268.00 $405.00 $165.00 $145.00 $199.00 $270.00 $328.00 BR $218.00 $141.00 $788.00 $347.00 $755.00 $550.00 $1,663.00 $2,512.00 $2,293.00 $2,482.00 $6,164.00 $4,985.00 FUD 0 0 0 0 0 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 10 10 10 10 10 10 10 90 10 10 90 90 90 YYY 0 ZZZ 90 0 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 47146 47147 47300 47350 47360 47361 47362 47370 47371 47379 47380 47381 47382 47399 47400 47420 47425 47460 47480 47490 47500 47505 47510 47511 47525 47530 47550 47552 47553 47554 47555 47556 47560 47561 47562 47563 47564 47570 47579 47600 47605 47610 47612 47620 47630 47700 47701 47711 47712 47715 MRA $337.00 $393.00 $778.00 $942.00 $1,305.00 $2,129.00 $849.00 $943.00 $889.00 BR $1,107.00 $1,094.00 $660.00 BR $1,435.00 $1,222.00 $1,275.00 $1,039.00 $755.00 $467.00 $103.00 $96.00 $487.00 $627.00 $295.00 $35.00 $209.00 $364.00 $342.00 $594.00 $383.00 $425.00 $345.00 $388.00 $837.00 $900.00 $1,069.00 $961.00 BR $868.00 $935.00 $1,164.00 $1,276.00 $1,295.00 $465.00 $1,111.00 $1,913.00 $1,442.00 $1,793.00 $1,157.00 FUD 0 0 90 90 90 90 90 90 90 YYY 90 90 10 YYY 90 90 90 90 90 90 0 0 90 90 10 90 ZZZ 0 0 0 0 0 0 0 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 Part A, 68 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 47720 47721 47740 47741 47760 47765 47780 47785 47800 47801 47802 47900 47999 48000 48001 48020 48100 48102 48105 48120 48140 48145 48146 48148 48150 48152 48153 48154 48155 48160 48400 48500 48510 48511 48520 48540 48545 48547 48548 48552 48554 48556 48999 49000 49002 49010 49020 49021 49040 49041 MRA $1,040.00 $1,248.00 $1,188.00 $1,425.00 $1,568.00 $1,624.00 $1,635.00 $1,871.00 $1,485.00 $906.00 $1,352.00 $1,331.00 BR $1,053.00 $1,305.00 $983.00 $779.00 $341.00 $2,505.00 $1,083.00 $1,546.00 $1,661.00 $1,830.00 $1,149.00 $3,101.00 $2,888.00 $3,099.00 $2,893.00 $1,855.00 BR $100.00 $1,012.00 $938.00 $286.00 $1,103.00 $1,350.00 $1,170.00 $1,630.00 $1,460.00 $230.00 $2,365.00 $1,117.00 BR $862.00 $784.00 $915.00 $910.00 $290.00 $763.00 $305.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 90 90 0 90 90 90 90 90 0 90 90 YYY 90 90 90 90 0 90 0 Surgery CPT Code 49060 49061 49062 49080 49081 49180 49203 49204 49205 49215 49220 49250 49255 49320 49321 49322 49323 49324 49325 49326 49329 49400 49402 49419 49420 49421 49422 49423 49424 49425 49426 49427 49428 49429 49435 49436 49440 49441 49442 49446 49450 49451 49452 49460 49465 49505 49507 49520 49521 49525 MRA $827.00 $288.00 $892.00 $123.00 $98.00 $212.00 $1,049.00 $1,337.00 $1,530.00 $1,551.00 $1,182.00 $622.00 $591.00 $415.00 $443.00 $460.00 $712.00 $348.00 $374.00 $171.00 BR $127.00 $748.00 $405.00 $162.00 $452.00 $468.00 $106.00 $54.00 $914.00 $725.00 $48.00 $184.00 $522.00 $110.00 $164.00 $1,113.00 $1,319.00 $1,075.00 $1,100.00 $771.00 $817.00 $998.00 $818.00 $170.00 $510.00 $636.00 $631.00 $730.00 $584.00 FUD 90 0 90 0 0 0 90 90 90 90 90 90 90 10 10 10 90 10 10 ZZZ YYY 0 90 90 0 90 10 0 0 90 90 0 10 10 ZZZ 10 10 10 10 0 0 0 0 0 0 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 49540 49550 49553 49555 49557 49560 49561 49565 49566 49568 49570 49572 49585 49587 49590 49600 49605 49606 49610 49611 49650 49651 49659 49900 49904 49905 49906 49999 50010 50020 50021 50040 50045 50060 50065 50070 50075 50080 50081 50100 50120 50125 50130 50135 50200 50205 50220 50225 50230 50234 MRA $668.00 $557.00 $598.00 $621.00 $715.00 $734.00 $856.00 $754.00 $881.00 $339.00 $411.00 $491.00 $444.00 $501.00 $585.00 $774.00 $1,648.00 $1,416.00 $784.00 $770.00 $484.00 $621.00 BR $512.00 $1,394.00 $454.00 BR BR $886.00 $1,084.00 $335.00 $910.00 $1,137.00 $1,394.00 $1,514.00 $1,476.00 $1,839.00 $1,186.00 $1,635.00 $1,250.00 $1,180.00 $1,228.00 $1,301.00 $1,506.00 $151.00 $807.00 $1,316.00 $1,554.00 $1,695.00 $1,671.00 FUD 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 YYY 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 Part A, 69 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 50236 50240 50250 50280 50290 50320 50327 50328 50329 50340 50360 50365 50370 50380 50382 50384 50385 50386 50387 50389 50390 50391 50392 50393 50394 50395 50396 50398 50400 50405 50500 50520 50525 50526 50540 50541 50542 50543 50544 50545 50546 50547 50548 50549 50551 50553 50555 50557 50561 50562 MRA $1,873.00 $1,679.00 $1,157.00 $1,170.00 $1,080.00 $1,680.00 $214.00 $187.00 $179.00 $1,083.00 $2,475.00 $2,941.00 $1,128.00 $1,507.00 $1,594.00 $1,540.00 $1,326.00 $857.00 $772.00 $529.00 $118.00 $139.00 $189.00 $235.00 $64.00 $203.00 $101.00 $99.00 $1,441.00 $1,802.00 $1,471.00 $1,281.00 $1,644.00 $1,639.00 $1,468.00 $1,037.00 $1,093.00 $1,374.00 $1,428.00 $1,273.00 $1,325.00 $1,702.00 $1,555.00 BR $411.00 $447.00 $668.00 $676.00 $755.00 $580.00 FUD 90 90 90 90 90 90 0 0 0 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 90 Surgery CPT Code 50570 50572 50574 50575 50576 50580 50590 50592 50593 50600 50605 50610 50620 50630 50650 50660 50684 50686 50688 50690 50700 50715 50722 50725 50727 50728 50740 50750 50760 50770 50780 50782 50783 50785 50800 50810 50815 50820 50825 50830 50840 50845 50860 50900 50920 50930 50940 50945 50947 50948 MRA $549.00 $728.00 $762.00 $991.00 $801.00 $726.00 $980.00 $5,936.00 $4,692.00 $1,150.00 $1,054.00 $1,209.00 $1,152.00 $1,170.00 $1,297.00 $1,426.00 $74.00 $109.00 $89.00 $85.00 $1,192.00 $1,397.00 $1,211.00 $1,371.00 $640.00 $924.00 $1,386.00 $1,457.00 $1,389.00 $1,485.00 $1,391.00 $1,465.00 $1,515.00 $1,548.00 $1,226.00 $1,527.00 $1,643.00 $1,729.00 $2,351.00 $2,292.00 $1,493.00 $1,513.00 $1,163.00 $1,043.00 $1,075.00 $1,380.00 $1,107.00 $1,096.00 $1,384.00 $1,265.00 FUD 0 0 0 0 0 0 90 10 10 90 90 90 90 90 90 90 0 0 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 50949 50951 50953 50955 50957 50961 50970 50972 50974 50976 50980 51020 51030 51040 51045 51050 51060 51065 51080 51100 51101 51102 51500 51520 51525 51530 51535 51550 51555 51565 51570 51575 51580 51585 51590 51595 51596 51597 51600 51605 51610 51700 51701 51702 51703 51705 51710 51715 51720 51725 MRA BR $414.00 $461.00 $546.00 $546.00 $510.00 $510.00 $408.00 $661.00 $641.00 $443.00 $587.00 $538.00 $439.00 $548.00 $596.00 $768.00 $704.00 $510.00 $63.00 $130.00 $335.00 $775.00 $764.00 $1,069.00 $957.00 $932.00 $1,171.00 $1,514.00 $1,624.00 $1,762.00 $2,284.00 $2,252.00 $2,601.00 $2,441.00 $2,900.00 $3,063.00 $2,914.00 $54.00 $83.00 $45.00 $29.00 $58.00 $92.00 $128.00 $37.00 $119.00 $322.00 $140.00 $116.00 FUD YYY 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 0 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 10 10 0 0 0 Part A, 70 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 51725-26 51725-TC 51726 51726-26 51726-TC 51736 51736-26 51736-TC 51741 51741-26 51741-TC 51772 51772-26 51772-TC 51784 51784-26 51784-TC 51785 51785-26 51785-TC 51792 51792-26 51792-TC 51795 51795-26 51795-TC 51797 51797-26 51797-TC 51798 51800 51820 51840 51841 51845 51860 51865 51880 51900 51920 51925 51940 51960 51980 51990 51992 52000 52001 52005 52007 MRA $79.00 $199.00 $136.00 $90.00 $274.00 $47.00 $32.00 $15.00 $81.00 $59.00 $17.00 $96.00 $86.00 $197.00 $119.00 $80.00 $136.00 $52.00 $80.00 $155.00 $143.00 $60.00 $213.00 $132.00 $80.00 $270.00 $109.00 $84.00 $205.00 $20.00 $1,294.00 $1,236.00 $858.00 $1,040.00 $843.00 $912.00 $1,150.00 $590.00 $1,050.00 $881.00 $1,167.00 $2,082.00 $1,848.00 $858.00 $850.00 $925.00 $190.00 $133.00 $265.00 $230.00 FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ ZZZ ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 Surgery CPT Code MRA 52010 $292.00 52204 $286.00 52214 $367.00 52224 $339.00 52234 $471.00 52235 $546.00 52240 $887.00 52250 $311.00 52260 $262.00 52265 $243.00 52270 $374.00 52275 $446.00 52276 $490.00 52277 $448.00 52281 $259.00 52282 $560.00 52283 $309.00 52285 $375.00 52290 $304.00 52300 $370.00 52301 $382.00 52305 $370.00 52310 $348.00 52315 $553.00 52317 $772.00 52318 $684.00 52320 $369.00 52325 $494.00 52327 $369.00 52330 $507.00 52332 $451.00 52334 $340.00 52341 $317.00 52342 $344.00 52343 $380.00 52344 $407.00 52345 $433.00 52346 $488.00 52351 $297.00 52352 $349.00 52353 $404.00 52354 $372.00 52355 $447.00 52400 $580.00 52402 $279.00 52450 $602.00 52500 $705.00 52601 $1,021.00 52630 $653.00 52640 $573.00 FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 0 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 52647 52648 52649 52700 53000 53010 53020 53040 53060 53080 53085 53200 53210 53215 53220 53230 53235 53240 53250 53260 53265 53270 53275 53400 53405 53410 53415 53420 53425 53430 53431 53440 53442 53444 53445 53446 53447 53448 53449 53450 53460 53500 53502 53505 53510 53515 53520 53600 53601 53605 MRA $858.00 $957.00 $973.00 $517.00 $224.00 $336.00 $153.00 $460.00 $180.00 $567.00 $836.00 $218.00 $904.00 $1,142.00 $546.00 $760.00 $607.00 $506.00 $464.00 $240.00 $295.00 $226.00 $332.00 $929.00 $1,088.00 $1,151.00 $1,381.00 $1,088.00 $1,150.00 $1,116.00 $1,053.00 $1,057.00 $639.00 $755.00 $1,197.00 $699.00 $991.00 $1,259.00 $784.00 $447.00 $494.00 $719.00 $590.00 $586.00 $777.00 $987.00 $661.00 $37.00 $37.00 $81.00 FUD 90 90 90 90 10 90 0 90 10 90 90 0 90 90 90 90 90 90 90 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 Part A, 71 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 53620 53621 53660 53661 53665 53850 53852 53899 54015 54050 54055 54056 54057 54060 54065 54100 54105 54110 54111 54112 54115 54120 54125 54130 54135 54162 54163 54164 54200 54205 54220 54230 54231 54235 54240 54240-26 54240-TC 54250 54250-26 54250-TC 54300 54304 54308 54312 54316 54318 54322 54324 54326 54328 MRA $59.00 $45.00 $49.00 $50.00 $50.00 $741.00 $728.00 BR $348.00 $91.00 $106.00 $100.00 $149.00 $180.00 $281.00 $149.00 $261.00 $775.00 $1,035.00 $1,210.00 $588.00 $777.00 $1,092.00 $1,532.00 $1,945.00 $220.00 $207.00 $182.00 $78.00 $633.00 $189.00 $104.00 $172.00 $81.00 $109.00 $68.00 $24.00 $104.00 $116.00 $9.00 $830.00 $988.00 $881.00 $1,067.00 $1,316.00 $900.00 $974.00 $1,260.00 $1,212.00 $1,201.00 FUD 0 0 0 0 0 90 90 YYY 10 10 10 10 10 10 10 0 10 90 90 90 90 90 90 90 90 10 10 10 10 90 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 54332 54336 54340 54344 54348 54352 54360 54380 54385 54390 54400 54401 54405 54406 54408 54410 54411 54415 54416 54417 54420 54430 54435 54440 54450 54500 54505 54512 54520 54522 54530 54535 54550 54560 54600 54620 54640 54650 54660 54670 54680 54690 54692 54699 54700 54800 54830 54840 54860 54861 MRA $1,327.00 $1,672.00 $727.00 $1,360.00 $1,318.00 $1,820.00 $898.00 $1,054.00 $1,217.00 $1,635.00 $784.00 $892.00 $1,294.00 $687.00 $724.00 $856.00 $933.00 $510.00 $665.00 $819.00 $899.00 $799.00 $503.00 BR $88.00 $102.00 $259.00 $519.00 $445.00 $589.00 $683.00 $922.00 $588.00 $842.00 $524.00 $373.00 $594.00 $861.00 $401.00 $485.00 $948.00 $825.00 $850.00 BR $133.00 $257.00 $411.00 $432.00 $503.00 $696.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 YYY 10 0 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 54865 54900 54901 55000 55040 55041 55060 55100 55110 55120 55150 55175 55180 55200 55250 55300 55400 55450 55500 55520 55530 55535 55540 55550 55559 55600 55605 55650 55680 55700 55705 55720 55725 55801 55810 55812 55815 55821 55831 55840 55842 55845 55860 55862 55865 55866 55870 55873 55875 55876 MRA $333.00 $969.00 $1,340.00 $109.00 $439.00 $634.00 $430.00 $156.00 $223.00 $350.00 $562.00 $426.00 $796.00 $310.00 $349.00 $167.00 $660.00 $391.00 $445.00 $446.00 $467.00 $496.00 $572.00 $486.00 BR $486.00 $609.00 $853.00 $426.00 $183.00 $368.00 $555.00 $670.00 $1,331.00 $1,711.00 $1,989.00 $2,328.00 $1,153.00 $1,252.00 $1,705.00 $1,859.00 $2,222.00 $1,012.00 $1,351.00 $1,890.00 $1,615.00 $166.00 $1,127.00 $729.00 $147.00 FUD 90 90 90 0 90 90 90 10 90 90 90 90 90 90 90 0 90 10 90 90 90 90 90 90 YYY 90 90 90 90 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 0 Part A, 72 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 55899 55920 56405 56420 56440 56441 56442 56501 56515 56605 56606 56620 56625 56630 56631 56632 56633 56634 56637 56640 56700 56740 56800 56805 56810 56820 56821 57000 57010 57020 57022 57023 57061 57065 57100 57105 57106 57107 57109 57110 57111 57112 57120 57130 57135 57150 57155 57160 57170 57180 MRA BR $420.00 $131.00 $130.00 $271.00 $183.00 $45.00 $122.00 $200.00 $96.00 $49.00 $607.00 $735.00 $1,061.00 $1,400.00 $1,636.00 $1,350.00 $1,537.00 $1,806.00 $1,777.00 $227.00 $321.00 $310.00 $1,349.00 $316.00 $119.00 $154.00 $237.00 $429.00 $118.00 $179.00 $290.00 $124.00 $251.00 $90.00 $132.00 $409.00 $1,467.00 $1,787.00 $1,015.00 $1,793.00 $1,907.00 $612.00 $220.00 $231.00 $50.00 $383.00 $67.00 $74.00 $124.00 FUD YYY 0 10 10 10 10 0 10 10 0 ZZZ 90 90 90 90 90 90 90 90 90 10 10 10 90 10 0 0 10 90 0 10 10 10 10 0 10 90 90 90 90 90 90 90 10 10 0 90 0 0 10 Surgery CPT Code MRA 57200 $313.00 57210 $395.00 57220 $378.00 57230 $442.00 57240 $536.00 57250 $485.00 57260 $700.00 57265 $902.00 57267 $284.00 57268 $577.00 57270 $867.00 57280 $1,071.00 57282 $734.00 57283 $673.00 57284 $950.00 57285 $607.00 57287 $685.00 57288 $1,009.00 57289 $879.00 57291 $622.00 57292 $925.00 57295 $485.00 57296 $880.00 57300 $653.00 57305 $995.00 57307 $997.00 57308 $769.00 57310 $517.00 57311 $612.00 57320 $693.00 57330 $916.00 57335 $963.00 57400 $70.00 57410 $57.00 57415 $75.00 57420 $124.00 57421 $162.00 57423 $848.00 57425 $902.00 57452 $96.00 57454 $125.00 57455 $149.00 57456 $141.00 57460 $223.00 57461 $333.00 57500 $89.00 57505 $105.00 57510 $140.00 57511 $159.00 57513 $191.00 FUD 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 0 0 90 90 0 0 0 0 0 0 0 10 10 10 10 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 57520 57522 57530 57531 57540 57545 57550 57555 57556 57558 57700 57720 57800 58100 58110 58120 58140 58145 58146 58150 58152 58180 58200 58210 58240 58260 58262 58263 58267 58270 58275 58280 58285 58290 58291 58292 58293 58294 58300 58301 58321 58322 58323 58340 58345 58346 58350 58353 58356 58400 MRA $359.00 $319.00 $386.00 $2,036.00 $815.00 $700.00 $486.00 $774.00 $718.00 $120.00 $279.00 $328.00 $71.00 $74.00 $53.00 $297.00 $1,010.00 $677.00 $1,089.00 $1,110.00 $1,159.00 $1,118.00 $1,562.00 $2,080.00 $2,898.00 $926.00 $1,026.00 $1,120.00 $1,133.00 $1,019.00 $1,121.00 $1,132.00 $1,360.00 $1,089.00 $1,197.00 $1,268.00 $1,318.00 $1,168.00 $96.00 $71.00 $81.00 $90.00 $24.00 $87.00 $335.00 $408.00 $103.00 $225.00 $531.00 $519.00 FUD 90 90 90 90 90 90 90 90 90 10 90 90 0 0 ZZZ 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 10 90 10 10 10 90 Part A, 73 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 58410 58520 58540 58541 58542 58543 58544 58545 58546 58548 58550 58552 58553 58554 58555 58558 58559 58560 58561 58562 58563 58565 58570 58571 58572 58573 58578 58579 58600 58605 58611 58615 58660 58661 58662 58670 58671 58672 58673 58679 58700 58720 58740 58750 58752 58760 58770 58800 58805 58820 MRA $752.00 $663.00 $923.00 $793.00 $877.00 $891.00 $965.00 $876.00 $1,104.00 $1,688.00 $1,038.00 $853.00 $1,096.00 $1,085.00 $261.00 $340.00 $436.00 $482.00 $677.00 $339.00 $450.00 $2,189.00 $844.00 $922.00 $1,047.00 $1,178.00 BR BR $337.00 $298.00 $47.00 $319.00 $793.00 $804.00 $807.00 $450.00 $463.00 $872.00 $928.00 BR $544.00 $844.00 $508.00 $949.00 $893.00 $769.00 $763.00 $343.00 $509.00 $326.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 90 90 90 90 90 YYY YYY 90 90 ZZZ 10 90 10 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 58822 58823 58825 58900 58920 58925 58940 58943 58950 58951 58952 58953 58954 58956 58957 58958 58960 58999 59000 59001 59012 59015 59020 59020-26 59020-TC 59025 59025-26 59025-TC 59030 59050 59051 59100 59120 59121 59130 59135 59136 59140 59150 59151 59160 59200 59300 59320 59325 59350 59400 59409 59410 59412 MRA $603.00 $216.00 $469.00 $489.00 $571.00 $820.00 $592.00 $1,368.00 $1,170.00 $1,703.00 $1,876.00 $1,839.00 $1,999.00 $1,329.00 $1,365.00 $1,511.00 $1,174.00 BR $123.00 $167.00 $267.00 $168.00 $85.00 $40.00 $23.00 $54.00 $32.00 $10.00 $155.00 $71.00 $47.00 $633.00 $893.00 $768.00 $832.00 $1,083.00 $934.00 $461.00 $543.00 $690.00 $279.00 $79.00 $179.00 $196.00 $316.00 $375.00 $1,816.00 $1,019.00 $1,123.00 $141.00 FUD 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 10 0 0 0 0 0 0 0 0 0 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 59414 59425 59426 59430 59510 59514 59515 59525 59610 59612 59614 59618 59620 59622 59812 59820 59821 59830 59840 59841 59850 59851 59852 59855 59856 59857 59866 59870 59871 59898 59899 60000 60100 60200 60210 60212 60220 60225 60240 60252 60254 60260 60270 60271 60280 60281 60300 60500 60502 60505 MRA $134.00 $414.00 $708.00 $140.00 $2,064.00 $1,199.00 $1,324.00 $591.00 $1,805.00 $1,113.00 $1,208.00 $2,035.00 $1,293.00 $1,397.00 $343.00 $389.00 $398.00 $496.00 $331.00 $443.00 $449.00 $464.00 $642.00 $477.00 $577.00 $711.00 $304.00 $348.00 $192.00 BR BR $114.00 $96.00 $744.00 $872.00 $1,170.00 $851.00 $1,107.00 $1,228.00 $1,427.00 $1,911.00 $1,022.00 $1,468.00 $1,210.00 $546.00 $670.00 $99.00 $1,232.00 $1,475.00 $1,631.00 FUD 0 0 0 0 0 0 0 ZZZ 0 0 0 0 0 0 90 90 90 90 10 10 90 90 90 90 90 90 0 90 0 YYY YYY 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 Part A, 74 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 60512 60520 60521 60522 60540 60545 60600 60605 60650 60659 60699 61020 61026 61050 61055 61070 61105 61107 61108 61120 61140 61150 61151 61154 61156 61210 61215 61250 61253 61304 61305 61312 61313 61314 61315 61316 61320 61321 61322 61323 61330 61332 61333 61334 61340 61343 61345 61440 61450 61458 MRA $310.00 $1,405.00 $1,591.00 $1,820.00 $1,272.00 $1,505.00 $1,477.00 $1,624.00 $1,340.00 BR BR $150.00 $138.00 $106.00 $143.00 $67.00 $503.00 $863.00 $959.00 $733.00 $1,389.00 $1,503.00 $795.00 $1,393.00 $1,473.00 $527.00 $637.00 $888.00 $1,042.00 $2,005.00 $2,419.00 $2,187.00 $2,207.00 $2,200.00 $2,393.00 $88.00 $2,118.00 $2,310.00 $1,779.00 $1,842.00 $1,706.00 $2,307.00 $2,231.00 $1,525.00 $1,584.00 $2,673.00 $2,259.00 $2,110.00 $2,173.00 $2,433.00 FUD ZZZ 90 90 90 90 90 90 90 90 YYY YYY 0 0 0 0 0 90 0 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Surgery CPT Code 61460 61470 61480 61490 61500 61501 61510 61512 61514 61516 61517 61518 61519 61520 61521 61522 61524 61526 61530 61531 61533 61534 61535 61536 61537 61538 61539 61540 61541 61542 61543 61544 61545 61546 61548 61550 61552 61556 61557 61558 61559 61563 61564 61566 61567 61570 61571 61575 61576 61580 MRA $2,426.00 $1,982.00 $1,922.00 $1,687.00 $1,637.00 $1,353.00 $2,506.00 $2,981.00 $2,262.00 $2,253.00 $74.00 $3,163.00 $3,450.00 $4,349.00 $3,667.00 $2,415.00 $2,484.00 $3,918.00 $3,611.00 $1,344.00 $1,712.00 $1,535.00 $958.00 $2,862.00 $1,714.00 $2,466.00 $2,660.00 $2,069.00 $2,363.00 $2,533.00 $2,307.00 $2,271.00 $3,474.00 $2,695.00 $1,964.00 $1,141.00 $1,463.00 $1,760.00 $1,807.00 $2,085.00 $2,700.00 $2,175.00 $2,597.00 $2,048.00 $2,340.00 $1,975.00 $2,140.00 $2,992.00 $3,772.00 $2,383.00 FUD 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 61581 61582 61583 61584 61585 61586 61590 61591 61592 61595 61596 61597 61598 61600 61601 61605 61606 61607 61608 61609 61610 61611 61612 61613 61615 61616 61618 61619 61623 61624 61626 61630 61635 61640 61641 61642 61680 61682 61684 61686 61690 61692 61697 61698 61700 61702 61703 61705 61708 61710 MRA $2,674.00 $2,557.00 $2,972.00 $2,830.00 $3,142.00 $2,097.00 $3,299.00 $3,491.00 $3,245.00 $2,350.00 $2,827.00 $3,046.00 $2,693.00 $2,039.00 $2,279.00 $2,299.00 $3,178.00 $2,961.00 $3,458.00 $798.00 $2,354.00 $584.00 $2,219.00 $3,375.00 $2,576.00 $3,535.00 $1,389.00 $1,682.00 $540.00 $1,073.00 $877.00 $1,245.00 $1,362.00 $555.00 $195.00 $390.00 $2,758.00 $4,798.00 $3,341.00 $5,012.00 $2,556.00 $4,007.00 $3,231.00 $3,103.00 $4,037.00 $4,019.00 $1,444.00 $3,043.00 $2,546.00 $2,129.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ 90 90 90 90 90 0 0 0 90 90 0 ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 75 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 61711 61720 61735 61750 61751 61760 61770 61790 61791 61795 61850 61860 61863 61864 61867 61868 61870 61875 61880 61885 61886 61888 62000 62005 62010 62100 62115 62116 62117 62120 62121 62140 62141 62142 62143 62145 62146 62147 62148 62160 62161 62162 62163 62164 62165 62180 62190 62192 62194 62200 MRA $3,150.00 $1,558.00 $1,664.00 $1,521.00 $1,628.00 $1,670.00 $1,867.00 $952.00 $1,205.00 $371.00 $1,090.00 $1,197.00 $1,231.00 $295.00 $1,863.00 $491.00 $616.00 $984.00 $559.00 $262.00 $678.00 $331.00 $848.00 $1,282.00 $1,754.00 $1,962.00 $1,686.00 $1,928.00 $2,211.00 $1,898.00 $1,822.00 $1,221.00 $1,955.00 $1,011.00 $1,096.00 $1,566.00 $1,327.00 $1,566.00 $120.00 $172.00 $1,229.00 $1,578.00 $999.00 $1,706.00 $1,336.00 $1,695.00 $1,034.00 $1,146.00 $239.00 $1,625.00 FUD 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 ZZZ 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 90 90 90 10 90 Surgery CPT Code 62201 62220 62223 62225 62230 62252 62252-26 62252-TC 62256 62258 62263 62264 62268 62269 62270 62272 62273 62280 62281 62282 62284 62287 62290 62291 62292 62294 62310 62311 62318 62319 62350 62351 62355 62360 62361 62362 62365 62367 62368 63001 63003 63005 63011 63012 63015 63016 63017 63020 63030 63035 MRA $1,200.00 $1,215.00 $1,199.00 $488.00 $935.00 $85.00 $49.00 $42.00 $616.00 $1,308.00 $426.00 $593.00 $285.00 $271.00 $109.00 $137.00 $130.00 $199.00 $186.00 $211.00 $196.00 $784.00 $235.00 $232.00 $1,064.00 $821.00 $200.00 $201.00 $208.00 $203.00 $488.00 $782.00 $402.00 $195.00 $390.00 $517.00 $418.00 $39.00 $53.00 $1,882.00 $1,591.00 $1,390.00 $1,151.00 $1,568.00 $1,862.00 $1,788.00 $1,489.00 $1,395.00 $1,145.00 $280.00 FUD 90 90 90 90 90 0 0 0 90 90 10 10 0 0 0 0 0 10 10 10 0 90 0 0 90 90 0 0 0 0 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 ZZZ CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 63040 63042 63043 63044 63045 63046 63047 63048 63050 63051 63055 63056 63057 63064 63066 63075 63076 63077 63078 63081 63082 63085 63086 63087 63088 63090 63091 63101 63102 63103 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200 63250 63251 63252 63265 63266 MRA $1,764.00 $1,620.00 BR BR $1,647.00 $2,117.00 $1,907.00 $367.00 $1,411.00 $1,605.00 $2,029.00 $1,960.00 $421.00 $2,200.00 $263.00 $1,720.00 $383.00 $1,828.00 $261.00 $2,203.00 $391.00 $2,416.00 $282.00 $2,930.00 $381.00 $2,490.00 $249.00 $2,127.00 $2,127.00 $249.00 $1,788.00 $1,672.00 $1,851.00 $1,486.00 $1,711.00 $1,347.00 $1,610.00 $1,444.00 $1,593.00 $1,603.00 $1,810.00 $1,725.00 $1,956.00 $2,258.00 $1,569.00 $3,182.00 $3,207.00 $3,319.00 $1,940.00 $2,053.00 FUD 90 90 ZZZ ZZZ 90 90 90 ZZZ 90 90 90 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 76 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 63267 63268 63270 63271 63272 63273 63275 63276 63277 63278 63280 63281 63282 63283 63285 63286 63287 63290 63295 63300 63301 63302 63303 63304 63305 63306 63307 63308 63600 63610 63615 63650 63655 63660 63685 63688 63700 63702 63704 63706 63707 63709 63710 63740 63741 63744 63746 64400 64402 64405 MRA $1,651.00 $1,469.00 $2,197.00 $2,401.00 $2,206.00 $2,012.00 $2,166.00 $2,135.00 $1,905.00 $1,877.00 $2,529.00 $2,496.00 $2,305.00 $2,041.00 $2,934.00 $3,003.00 $3,012.00 $3,073.00 $319.00 $2,006.00 $2,209.00 $2,290.00 $2,357.00 $2,513.00 $2,574.00 $2,596.00 $2,522.00 $425.00 $797.00 $476.00 $1,348.00 $819.00 $1,064.00 $707.00 $615.00 $707.00 $1,340.00 $1,512.00 $1,708.00 $1,873.00 $1,041.00 $1,310.00 $1,165.00 $1,062.00 $741.00 $738.00 $529.00 $78.00 $75.00 $103.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 ZZZ 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 Surgery CPT Code 64408 64410 64412 64413 64415 64416 64417 64418 64420 64421 64425 64430 64435 64445 64446 64447 64448 64449 64450 64470 64472 64475 64476 64479 64480 64483 64484 64505 64508 64510 64517 64520 64530 64550 64553 64555 64560 64561 64565 64573 64575 64577 64580 64581 64585 64590 64595 64600 64605 64610 MRA $120.00 $109.00 $89.00 $128.00 $109.00 $159.00 $105.00 $108.00 $89.00 $128.00 $116.00 $130.00 $114.00 $68.00 $165.00 $77.00 $152.00 $152.00 $53.00 $206.00 $166.00 $183.00 $166.00 $224.00 $194.00 $206.00 $183.00 $104.00 $99.00 $103.00 $188.00 $131.00 $135.00 $23.00 $137.00 $131.00 $197.00 $801.00 $121.00 $464.00 $367.00 $381.00 $343.00 $745.00 $37.00 $217.00 $153.00 $228.00 $319.00 $307.00 FUD 0 0 0 0 0 10 0 0 0 0 0 0 0 0 10 0 10 10 0 0 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 0 0 0 0 0 0 0 10 10 10 10 10 90 90 90 90 90 10 10 10 10 10 10 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code MRA 64612 $188.00 64613 $168.00 64614 $200.00 64620 $185.00 64622 $333.00 64623 $113.00 64626 $262.00 64627 $151.00 64630 $202.00 64640 $208.00 64650 $62.00 64653 $71.00 64680 $180.00 64681 $464.00 64702 $383.00 64704 $402.00 64708 $562.00 64712 $678.00 64713 $867.00 64714 $715.00 64716 $523.00 64718 $558.00 64719 $446.00 64721 $439.00 64722 $411.00 64726 $271.00 64727 $261.00 64732 $405.00 64734 $432.00 64736 $388.00 64738 $475.00 64740 $461.00 64742 $517.00 64744 $798.00 64746 $494.00 64752 $560.00 64755 $1,042.00 64760 $578.00 64761 $495.00 64763 $561.00 64766 $713.00 64771 $632.00 64772 $636.00 64774 $392.00 64776 $390.00 64778 $249.00 64782 $482.00 64783 $298.00 64784 $751.00 64786 $1,281.00 FUD 10 10 10 10 10 ZZZ 10 ZZZ 10 10 0 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 ZZZ 90 90 Part A, 77 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 64787 64788 64790 64792 64795 64802 64804 64809 64818 64820 64821 64822 64823 64831 64832 64834 64835 64836 64837 64840 64856 64857 64858 64859 64861 64862 64864 64865 64866 64868 64870 64872 64874 64876 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64901 64902 64905 64907 64910 64911 MRA $458.00 $381.00 $884.00 $1,148.00 $247.00 $711.00 $1,202.00 $1,080.00 $845.00 $838.00 $609.00 $609.00 $703.00 $592.00 $171.00 $711.00 $834.00 $856.00 $480.00 $1,058.00 $1,063.00 $1,137.00 $1,313.00 $341.00 $1,524.00 $1,798.00 $970.00 $1,250.00 $1,238.00 $1,162.00 $1,313.00 $155.00 $230.00 $189.00 $1,382.00 $1,636.00 $1,112.00 $1,243.00 $1,177.00 $1,321.00 $1,500.00 $1,185.00 $1,419.00 $1,549.00 $865.00 $982.00 $1,059.00 $1,472.00 $645.00 $783.00 FUD ZZZ 90 90 90 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 ZZZ 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 Surgery CPT Code 64999 65091 65093 65101 65103 65105 65110 65112 65114 65125 65130 65135 65140 65150 65155 65175 65205 65210 65220 65222 65235 65260 65265 65270 65272 65273 65275 65280 65285 65286 65290 65400 65410 65420 65426 65430 65435 65436 65450 65600 65710 65730 65750 65755 65770 65772 65775 65780 65781 65782 MRA BR $678.00 $712.00 $726.00 $769.00 $846.00 $1,305.00 $1,386.00 $1,456.00 $312.00 $730.00 $678.00 $738.00 $652.00 $862.00 $654.00 $45.00 $53.00 $58.00 $62.00 $627.00 $956.00 $1,104.00 $88.00 $223.00 $376.00 $75.00 $711.00 $1,177.00 $692.00 $519.00 $603.00 $142.00 $448.00 $534.00 $81.00 $88.00 $319.00 $52.00 $325.00 $1,124.00 $1,314.00 $1,381.00 $1,373.00 $1,461.00 $449.00 $595.00 $766.00 $1,169.00 $1,008.00 FUD YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 90 90 90 10 90 90 90 90 90 90 90 90 0 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 65800 65805 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 66250 66500 66505 66600 66605 66625 66630 66635 66680 66682 66700 66710 66711 66720 66740 66761 66762 66770 66820 66821 66825 66830 MRA $88.00 $178.00 $516.00 $327.00 $813.00 $968.00 $441.00 $339.00 $540.00 $572.00 $597.00 $641.00 $945.00 $752.00 $700.00 $164.00 $160.00 $631.00 $798.00 $795.00 $942.00 $769.00 $1,089.00 $1,264.00 $1,313.00 $769.00 $711.00 $1,006.00 $602.00 $359.00 $359.00 $825.00 $1,136.00 $543.00 $623.00 $595.00 $526.00 $627.00 $506.00 $513.00 $507.00 $506.00 $473.00 $506.00 $433.00 $483.00 $433.00 $275.00 $753.00 $651.00 FUD 0 0 90 90 90 90 10 90 90 90 90 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Part A, 78 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 66840 66850 66852 66920 66930 66940 66982 66983 66984 66985 66986 66990 66999 67005 67010 67015 67025 67027 67028 67030 67031 67036 67039 67040 67041 67042 67043 67101 67105 67107 67108 67110 67112 67113 67115 67120 67121 67141 67145 67208 67210 67218 67220 67221 67225 67227 67228 67229 67250 67255 MRA $707.00 $805.00 $878.00 $785.00 $906.00 $819.00 $846.00 $763.00 $898.00 $744.00 $1,038.00 $84.00 BR $639.00 $647.00 $637.00 $774.00 $1,089.00 $338.00 $485.00 $402.00 $1,384.00 $1,490.00 $1,960.00 $1,065.00 $1,218.00 $1,279.00 $767.00 $941.00 $1,350.00 $1,878.00 $1,040.00 $1,500.00 $1,405.00 $496.00 $751.00 $962.00 $536.00 $514.00 $655.00 $779.00 $1,217.00 $894.00 $325.00 $44.00 $652.00 $1,025.00 $926.00 $793.00 $872.00 FUD 90 90 90 90 90 90 90 90 90 90 90 ZZZ YYY 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 90 90 90 90 90 Surgery CPT Code 67299 67311 67312 67314 67316 67318 67320 67331 67332 67334 67335 67340 67343 67345 67346 67399 67400 67405 67412 67413 67414 67415 67420 67430 67440 67445 67450 67500 67505 67515 67550 67560 67570 67599 67700 67710 67715 67800 67801 67805 67808 67810 67820 67825 67830 67835 67840 67850 67875 67880 MRA BR $616.00 $773.00 $688.00 $857.00 $663.00 $602.00 $560.00 $621.00 $447.00 $253.00 $559.00 $628.00 $275.00 $173.00 BR $960.00 $799.00 $976.00 $909.00 $1,023.00 $146.00 $1,729.00 $1,203.00 $1,257.00 $1,269.00 $1,300.00 $75.00 $109.00 $53.00 $946.00 $936.00 $1,148.00 BR $87.00 $117.00 $102.00 $119.00 $189.00 $208.00 $308.00 $133.00 $36.00 $130.00 $239.00 $500.00 $187.00 $143.00 $163.00 $442.00 FUD YYY 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 10 0 YYY 90 90 90 90 90 0 90 90 90 90 90 0 0 0 90 90 90 YYY 10 10 10 10 10 10 90 0 0 10 10 90 10 10 0 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code MRA 67882 $643.00 67900 $487.00 67901 $646.00 67902 $650.00 67903 $657.00 67904 $720.00 67906 $633.00 67908 $550.00 67909 $577.00 67911 $517.00 67912 $983.00 67914 $487.00 67915 $252.00 67916 $675.00 67917 $631.00 67921 $419.00 67922 $243.00 67923 $718.00 67924 $605.00 67930 $280.00 67935 $520.00 67938 $67.00 67950 $584.00 67961 $571.00 67966 $645.00 67971 $875.00 67973 $1,126.00 67974 $1,140.00 67975 $681.00 67999 BR 68020 $106.00 68040 $75.00 68100 $137.00 68110 $172.00 68115 $248.00 68130 $378.00 68135 $146.00 68200 $59.00 68320 $502.00 68325 $672.00 68326 $654.00 68328 $741.00 68330 $488.00 68335 $636.00 68340 $413.00 68360 $449.00 68362 $691.00 68371 $363.00 68399 BR 68400 $154.00 FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 10 90 90 90 90 90 90 90 YYY 10 0 0 10 10 90 10 0 90 90 90 90 90 90 90 90 90 10 YYY 10 Part A, 79 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code 68420 68440 68500 68505 68510 68520 68525 68530 68540 68550 68700 68705 68720 68745 68750 68760 68761 68770 68801 68810 68811 68815 68816 68840 68850 68899 69000 69005 69020 69100 69105 69110 69120 69140 69145 69150 69155 69200 69205 69210 69220 69222 69300 69310 69320 69399 69400 69401 69405 69420 MRA $191.00 $96.00 $882.00 $921.00 $491.00 $687.00 $340.00 $379.00 $875.00 $1,107.00 $628.00 $176.00 $807.00 $704.00 $792.00 $109.00 $130.00 $634.00 $202.00 $290.00 $191.00 $399.00 $592.00 $100.00 $76.00 BR $52.00 $175.00 $109.00 $85.00 $87.00 $294.00 $274.00 $722.00 $248.00 $1,111.00 $1,680.00 $53.00 $110.00 $39.00 $78.00 $123.00 $522.00 $937.00 $1,434.00 BR $76.00 $52.00 $176.00 $117.00 FUD 10 10 90 90 0 90 0 10 90 90 90 10 90 90 90 10 10 90 10 10 10 10 10 10 0 YYY 10 10 10 0 0 90 90 90 90 90 90 0 10 0 0 10 YYY 90 90 YYY 0 0 10 10 Surgery CPT Code 69421 69424 69433 69436 69440 69450 69501 69502 69505 69511 69530 69535 69540 69550 69552 69554 69601 69602 69603 69604 69605 69610 69620 69631 69632 69633 69635 69636 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69710 69711 69714 69715 69717 69718 MRA $155.00 $84.00 $145.00 $182.00 $699.00 $525.00 $829.00 $1,118.00 $1,176.00 $1,221.00 $1,616.00 $2,824.00 $126.00 $998.00 $1,621.00 $2,600.00 $1,195.00 $1,225.00 $1,264.00 $1,263.00 $1,526.00 $41.00 $651.00 $985.00 $1,166.00 $1,110.00 $1,207.00 $1,381.00 $1,370.00 $1,154.00 $1,519.00 $1,389.00 $1,529.00 $1,479.00 $1,620.00 $879.00 $1,072.00 $1,412.00 $1,386.00 $887.00 $887.00 $988.00 $828.00 $702.00 BR $878.00 $961.00 $1,217.00 $996.00 $1,232.00 FUD 10 0 10 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 CPT only © 2008 American Medical Association. All Rights Reserved. Surgery CPT Code 69720 69725 69740 69745 69799 69801 69802 69805 69806 69820 69840 69905 69910 69915 69930 69949 69950 69955 69960 69970 69979 69990 G0127 G0168 G0247 G0289 G0341 G0342 G0343 G0364 G0392 G0393 MRA $1,307.00 $1,922.00 $1,274.00 $1,447.00 BR $785.00 $1,115.00 $1,187.00 $1,123.00 $876.00 $869.00 $1,013.00 $1,228.00 $1,754.00 $1,498.00 BR $2,017.00 $2,185.00 $2,116.00 $2,306.00 BR $262.00 $17.00 $75.00 $38.00 $82.00 $333.00 $622.00 $1,026.00 $12.00 $2,097.00 $1,587.00 FUD 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 YYY ZZZ 0 0 ZZZ ZZZ 0 90 90 ZZZ 0 0 Part A, 80 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 70010 70010-26 70010-TC 70015 70015-26 70015-TC 70030 70030-26 70030-TC 70100 70100-26 70100-TC 70110 70110-26 70110-TC 70120 70120-26 70120-TC 70130 70130-26 70130-TC 70134 70134-26 70134-TC 70140 70140-26 70140-TC 70150 70150-26 70150-TC 70160 70160-26 70160-TC 70170 70170-26 70170-TC 70190 70190-26 70190-TC 70200 70200-26 70200-TC 70210 70210-26 70210-TC 70220 70220-26 70220-TC 70240 70240-26 MRA $70.00 $19.00 $51.00 $58.00 $31.00 $27.00 $24.00 $10.00 $15.00 $29.00 $9.00 $19.00 $36.00 $12.00 $22.00 $32.00 $9.00 $22.00 $46.00 $17.00 $29.00 $45.00 $17.00 $28.00 $33.00 $9.00 $22.00 $42.00 $12.00 $29.00 $29.00 $8.00 $19.00 $52.00 $15.00 $37.00 $34.00 $10.00 $22.00 $43.00 $14.00 $29.00 $32.00 $8.00 $22.00 $42.00 $12.00 $29.00 $26.00 $9.00 Radiology CPT Code 70240-TC 70250 70250-26 70250-TC 70260 70260-26 70260-TC 70300 70300-26 70300-TC 70310 70310-26 70310-TC 70320 70320-26 70320-TC 70328 70328-26 70328-TC 70330 70330-26 70330-TC 70332 70332-26 70332-TC 70336 70336-26 70336-TC 70350 70350-26 70350-TC 70355 70355-26 70355-TC 70360 70360-26 70360-TC 70370 70370-26 70370-TC 70371 70371-26 70371-TC 70373 70373-26 70373-TC 70380 70380-26 70380-TC 70390 MRA $15.00 $35.00 $12.00 $22.00 $50.00 $17.00 $33.00 $15.00 $5.00 $10.00 $24.00 $8.00 $15.00 $40.00 $11.00 $29.00 $28.00 $10.00 $18.00 $43.00 $12.00 $31.00 $107.00 $27.00 $80.00 $497.00 $72.00 $419.00 $24.00 $10.00 $14.00 $32.00 $10.00 $21.00 $24.00 $8.00 $15.00 $65.00 $16.00 $48.00 $122.00 $43.00 $79.00 $90.00 $22.00 $68.00 $34.00 $8.00 $24.00 $87.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 70390-26 70390-TC 70450 70450-26 70450-TC 70460 70460-26 70460-TC 70470 70470-26 70470-TC 70480 70480-26 70480-TC 70481 70481-26 70481-TC 70482 70482-26 70482-TC 70486 70486-26 70486-TC 70487 70487-26 70487-TC 70488 70488-26 70488-TC 70490 70490-26 70490-TC 70491 70491-26 70491-TC 70492 70492-26 70492-TC 70496 70496-26 70496-TC 70498 70498-26 70498-TC 70540 70540-26 70540-TC 70542 70542-26 70542-TC MRA $19.00 $68.00 $221.00 $43.00 $176.00 $271.00 $58.00 $211.00 $332.00 $65.00 $264.00 $244.00 $65.00 $176.00 $284.00 $70.00 $211.00 $340.00 $74.00 $264.00 $236.00 $58.00 $176.00 $279.00 $66.00 $211.00 $339.00 $72.00 $264.00 $244.00 $65.00 $176.00 $284.00 $70.00 $211.00 $340.00 $74.00 $264.00 $366.00 $92.00 $270.00 $366.00 $92.00 $270.00 $482.00 $70.00 $413.00 $579.00 $82.00 $495.00 Part A, 81 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 70543 70543-26 70543-TC 70544 70544-26 70544-TC 70545 70545-26 70545-TC 70546 70546-26 70546-TC 70547 70547-26 70547-TC 70548 70548-26 70548-TC 70549 70549-26 70549-TC 70551 70551-26 70551-TC 70552 70552-26 70552-TC 70553 70553-26 70553-TC 70554 70554-26 70554-TC 70555 70555-26 70555-TC 70557 70557-26 70557-TC 70558 70558-26 70558-TC 70559 70559-26 70559-TC 71010 71010-26 71010-TC 71015 71015-26 MRA $1,029.00 $109.00 $916.00 $481.00 $61.00 $419.00 $481.00 $61.00 $419.00 $914.00 $92.00 $820.00 $481.00 $61.00 $419.00 $481.00 $61.00 $419.00 $914.00 $92.00 $820.00 $497.00 $76.00 $419.00 $596.00 $91.00 $502.00 $1,055.00 $120.00 $931.00 $618.00 $99.00 $520.00 BR $118.00 BR $392.00 $148.00 $349.00 $425.00 $164.00 $376.00 $548.00 $164.00 $499.00 $27.00 $9.00 $17.00 $30.00 $10.00 Radiology CPT Code 71015-TC 71020 71020-26 71020-TC 71021 71021-26 71021-TC 71022 71022-26 71022-TC 71023 71023-26 71023-TC 71030 71030-26 71030-TC 71034 71034-26 71034-TC 71035 71035-26 71035-TC 71040 71040-26 71040-TC 71060 71060-26 71060-TC 71090 71090-26 71090-TC 71100 71100-26 71100-TC 71101 71101-26 71101-TC 71110 71110-26 71110-TC 71111 71111-26 71111-TC 71120 71120-26 71120-TC 71130 71130-26 71130-TC 71250 MRA $19.00 $35.00 $11.00 $22.00 $41.00 $13.00 $28.00 $44.00 $16.00 $28.00 $49.00 $19.00 $29.00 $45.00 $16.00 $29.00 $79.00 $23.00 $54.00 $56.00 $19.00 $38.00 $34.00 $12.00 $22.00 $108.00 $33.00 $75.00 $92.00 $28.00 $64.00 $33.00 $11.00 $21.00 $38.00 $13.00 $24.00 $43.00 $13.00 $29.00 $49.00 $16.00 $33.00 $35.00 $10.00 $24.00 $38.00 $11.00 $26.00 $282.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 71250-26 71250-TC 71260 71260-26 71260-TC 71270 71270-26 71270-TC 71275 71275-26 71275-TC 71550 71550-26 71550-TC 71551 71551-26 71551-TC 71552 71552-26 71552-TC 71555 71555-26 71555-TC 72010 72010-26 72010-TC 72020 72020-26 72020-TC 72040 72040-26 72040-TC 72050 72050-26 72050-TC 72052 72052-26 72052-TC 72069 72069-26 72069-TC 72070 72070-26 72070-TC 72072 72072-26 72072-TC 72074 72074-26 72074-TC MRA $59.00 $220.00 $328.00 $63.00 $264.00 $402.00 $70.00 $330.00 $431.00 $100.00 $328.00 $490.00 $75.00 $415.00 $587.00 $88.00 $496.00 $1,029.00 $114.00 $911.00 $514.00 $92.00 $419.00 $62.00 $22.00 $38.00 $22.00 $7.00 $15.00 $34.00 $11.00 $22.00 $49.00 $16.00 $33.00 $61.00 $18.00 $42.00 $40.00 $17.00 $24.00 $36.00 $11.00 $24.00 $39.00 $11.00 $28.00 $45.00 $11.00 $34.00 Part A, 82 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 72080 72080-26 72080-TC 72090 72090-26 72090-TC 72100 72100-26 72100-TC 72110 72110-26 72110-TC 72114 72114-26 72114-TC 72120 72120-26 72120-TC 72125 72125-26 72125-TC 72126 72126-26 72126-TC 72127 72127-26 72127-TC 72128 72128-26 72128-TC 72129 72129-26 72129-TC 72130 72130-26 72130-TC 72131 72131-26 72131-TC 72132 72132-26 72132-TC 72133 72133-26 72133-TC 72141 72141-26 72141-TC 72142 72142-26 MRA $36.00 $11.00 $24.00 $39.00 $14.00 $24.00 $36.00 $11.00 $24.00 $50.00 $16.00 $34.00 $64.00 $18.00 $44.00 $45.00 $11.00 $33.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $397.00 $65.00 $330.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $397.00 $65.00 $330.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $391.00 $65.00 $323.00 $503.00 $82.00 $419.00 $604.00 $99.00 Radiology CPT Code 72142-TC 72146 72146-26 72146-TC 72147 72147-26 72147-TC 72148 72148-26 72148-TC 72149 72149-26 72149-TC 72156 72156-26 72156-TC 72157 72157-26 72157-TC 72158 72158-26 72158-TC 72159 72159-26 72159-TC 72170 72170-26 72170-TC 72190 72190-26 72190-TC 72191 72191-26 72191-TC 72192 72192-26 72192-TC 72193 72193-26 72193-TC 72194 72194-26 72194-TC 72195 72195-26 72195-TC 72196 72196-26 72196-TC 72197 MRA $502.00 $549.00 $82.00 $465.00 $603.00 $98.00 $502.00 $543.00 $76.00 $465.00 $597.00 $92.00 $502.00 $1,066.00 $131.00 $931.00 $1,066.00 $131.00 $931.00 $1,056.00 $121.00 $931.00 $563.00 $94.00 $465.00 $29.00 $8.00 $19.00 $35.00 $10.00 $24.00 $413.00 $94.00 $315.00 $278.00 $56.00 $220.00 $317.00 $59.00 $256.00 $380.00 $62.00 $317.00 $491.00 $74.00 $415.00 $526.00 $84.00 $442.00 $1,037.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 72197-26 72197-TC 72198 72198-26 72198-TC 72200 72200-26 72200-TC 72202 72202-26 72202-TC 72220 72220-26 72220-TC 72240 72240-26 72240-TC 72255 72255-26 72255-TC 72265 72265-26 72265-TC 72270 72270-26 72270-TC 72275 72275-26 72275-TC 72285 72285-26 72285-TC 72291 72291-26 72291-TC 72292 72292-26 72292-TC 72295 72295-26 72295-TC 73000 73000-26 73000-TC 73010 73010-26 73010-TC 73020 73020-26 73020-TC MRA $114.00 $919.00 $517.00 $95.00 $419.00 $29.00 $9.00 $19.00 $33.00 $9.00 $22.00 $30.00 $8.00 $21.00 $132.00 $26.00 $106.00 $129.00 $28.00 $101.00 $132.00 $28.00 $104.00 $176.00 $39.00 $137.00 $112.00 $34.00 $78.00 $101.00 $15.00 $86.00 $178.00 $66.00 $157.00 BR $67.00 BR $107.00 $13.00 $94.00 $28.00 $8.00 $19.00 $29.00 $8.00 $19.00 $26.00 $7.00 $17.00 Part A, 83 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 73030 73030-26 73030-TC 73040 73040-26 73040-TC 73050 73050-26 73050-TC 73060 73060-26 73060-TC 73070 73070-26 73070-TC 73080 73080-26 73080-TC 73085 73085-26 73085-TC 73090 73090-26 73090-TC 73100 73100-26 73100-TC 73110 73110-26 73110-TC 73115 73115-26 73115-TC 73120 73120-26 73120-TC 73130 73130-26 73130-TC 73140 73140-26 73140-TC 73200 73200-26 73200-TC 73201 73201-26 73201-TC 73202 73202-26 MRA $31.00 $9.00 $21.00 $68.00 $17.00 $51.00 $35.00 $10.00 $24.00 $30.00 $8.00 $21.00 $27.00 $7.00 $19.00 $30.00 $8.00 $21.00 $74.00 $19.00 $55.00 $28.00 $8.00 $19.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $54.00 $17.00 $37.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $22.00 $7.00 $15.00 $242.00 $56.00 $185.00 $282.00 $59.00 $220.00 $342.00 $63.00 Radiology CPT Code 73202-TC 73206 73206-26 73206-TC 73218 73218-26 73218-TC 73219 73219-26 73219-TC 73220 73220-26 73220-TC 73221 73221-26 73221-TC 73222 73222-26 73222-TC 73223 73223-26 73223-TC 73225 73225-26 73225-TC 73500 73500-26 73500-TC 73510 73510-26 73510-TC 73520 73520-26 73520-TC 73525 73525-26 73525-TC 73530 73530-26 73530-TC 73542 73542-26 73542-TC 73550 73550-26 73550-TC 73560 73560-26 73560-TC 73562 MRA $277.00 $375.00 $94.00 $277.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $520.00 $78.00 $442.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00 $513.00 $92.00 $419.00 $27.00 $8.00 $17.00 $32.00 $10.00 $21.00 $38.00 $12.00 $24.00 $84.00 $21.00 $63.00 $34.00 $14.00 $19.00 $108.00 $28.00 $80.00 $30.00 $8.00 $21.00 $29.00 $8.00 $19.00 $31.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 73562-26 73562-TC 73564 73564-26 73564-TC 73565 73565-26 73565-TC 73580 73580-26 73580-TC 73590 73590-26 73590-TC 73600 73600-26 73600-TC 73610 73610-26 73610-TC 73615 73615-26 73615-TC 73620 73620-26 73620-TC 73630 73630-26 73630-TC 73650 73650-26 73650-TC 73660 73660-26 73660-TC 73700 73700-26 73700-TC 73701 73701-26 73701-TC 73702 73702-26 73702-TC 73706 73706-26 73706-TC 73718 73718-26 73718-TC MRA $9.00 $21.00 $35.00 $11.00 $22.00 $28.00 $8.00 $18.00 $84.00 $18.00 $66.00 $29.00 $8.00 $19.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $72.00 $19.00 $53.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $26.00 $8.00 $17.00 $22.00 $7.00 $15.00 $242.00 $56.00 $185.00 $282.00 $61.00 $220.00 $341.00 $62.00 $277.00 $379.00 $98.00 $277.00 $482.00 $68.00 $413.00 Part A, 84 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 73719 73719-26 73719-TC 73720 73720-26 73720-TC 73721 73721-26 73721-TC 73722 73722-26 73722-TC 73723 73723-26 73723-TC 73725 73725-26 73725-TC 74000 74000-26 74000-TC 74010 74010-26 74010-TC 74020 74020-26 74020-TC 74022 74022-26 74022-TC 74150 74150-26 74150-TC 74160 74160-26 74160-TC 74170 74170-26 74170-TC 74175 74175-26 74175-TC 74181 74181-26 74181-TC 74182 74182-26 74182-TC 74183 74183-26 MRA $579.00 $82.00 $495.00 $520.00 $78.00 $442.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00 $515.00 $92.00 $419.00 $29.00 $9.00 $19.00 $33.00 $11.00 $21.00 $37.00 $13.00 $22.00 $44.00 $16.00 $28.00 $274.00 $60.00 $211.00 $322.00 $65.00 $256.00 $390.00 $71.00 $317.00 $418.00 $98.00 $315.00 $498.00 $85.00 $415.00 $587.00 $88.00 $496.00 $1,037.00 $114.00 Radiology CPT Code 74183-TC 74185 74185-26 74185-TC 74190 74190-26 74190-TC 74210 74210-26 74210-TC 74220 74220-26 74220-TC 74230 74230-26 74230-TC 74235 74235-26 74235-TC 74240 74240-26 74240-TC 74241 74241-26 74241-TC 74245 74245-26 74245-TC 74246 74246-26 74246-TC 74247 74247-26 74247-TC 74249 74249-26 74249-TC 74250 74250-26 74250-TC 74251 74251-26 74251-TC 74260 74260-26 74260-TC 74270 74270-26 74270-TC 74280 MRA $919.00 $514.00 $92.00 $419.00 $73.00 $24.00 $49.00 $63.00 $18.00 $44.00 $68.00 $23.00 $44.00 $77.00 $27.00 $48.00 $160.00 $60.00 $100.00 $91.00 $35.00 $55.00 $91.00 $35.00 $56.00 $137.00 $46.00 $89.00 $97.00 $35.00 $61.00 $99.00 $35.00 $63.00 $144.00 $46.00 $96.00 $73.00 $23.00 $48.00 $85.00 $34.00 $48.00 $82.00 $25.00 $56.00 $100.00 $35.00 $64.00 $136.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 74280-26 74280-TC 74283 74283-26 74283-TC 74290 74290-26 74290-TC 74291 74291-26 74291-TC 74300 74300-26 74300-TC 74301 74301-26 74301-TC 74305 74305-26 74305-TC 74320 74320-26 74320-TC 74327 74327-26 74327-TC 74328 74328-26 74328-TC 74329 74329-26 74329-TC 74330 74330-26 74330-TC 74340 74340-26 74340-TC 74355 74355-26 74355-TC 74360 74360-26 74360-TC 74363 74363-26 74363-TC 74400 74400-26 74400-TC MRA $50.00 $84.00 $201.00 $103.00 $95.00 $44.00 $16.00 $28.00 $26.00 $10.00 $15.00 $31.00 $19.00 $104.00 $107.00 $11.00 $104.00 $51.00 $21.00 $30.00 $145.00 $26.00 $119.00 $103.00 $35.00 $68.00 $155.00 $35.00 $120.00 $155.00 $35.00 $120.00 $165.00 $45.00 $120.00 $121.00 $26.00 $95.00 $137.00 $38.00 $99.00 $145.00 $27.00 $118.00 $274.00 $44.00 $230.00 $89.00 $24.00 $63.00 Part A, 85 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 74410 74410-26 74410-TC 74415 74415-26 74415-TC 74420 74420-26 74420-TC 74425 74425-26 74425-TC 74430 74430-26 74430-TC 74440 74440-26 74440-TC 74445 74445-26 74445-TC 74450 74450-26 74450-TC 74455 74455-26 74455-TC 74470 74470-26 74470-TC 74475 74475-26 74475-TC 74480 74480-26 74480-TC 74485 74485-26 74485-TC 74710 74710-26 74710-TC 74740 74740-26 74740-TC 74742 74742-26 74742-TC 74775 74775-26 MRA $98.00 $24.00 $72.00 $105.00 $24.00 $79.00 $117.00 $18.00 $97.00 $68.00 $18.00 $50.00 $48.00 $14.00 $34.00 $62.00 $19.00 $43.00 $101.00 $57.00 $44.00 $60.00 $14.00 $46.00 $75.00 $16.00 $59.00 $74.00 $27.00 $47.00 $181.00 $27.00 $154.00 $181.00 $27.00 $154.00 $146.00 $27.00 $119.00 $57.00 $17.00 $39.00 $68.00 $19.00 $49.00 $150.00 $30.00 $120.00 $88.00 $32.00 Radiology CPT Code 74775-TC 75557 75557-26 75557-TC 75558 75558-26 75558-TC 75559 75559-26 75559-TC 75560 75560-26 75560-TC 75561 75561-26 75561-TC 75562 75562-26 75562-TC 75563 75563-26 75563-TC 75564 75564-26 75564-TC 75600 75600-26 75600-TC 75605 75605-26 75605-TC 75625 75625-26 75625-TC 75630 75630-26 75630-TC 75635 75635-26 75635-TC 75650 75650-26 75650-TC 75658 75658-26 75658-TC 75660 75660-26 75660-TC 75662 MRA $55.00 $462.00 $79.00 $344.00 $87.00 $87.00 $486.00 $495.00 $99.00 $344.00 $101.00 $101.00 $649.00 $656.00 $87.00 $525.00 $96.00 $96.00 $649.00 $683.00 $101.00 $526.00 $112.00 $112.00 $763.00 $497.00 $25.00 $472.00 $183.00 $20.00 $163.00 $143.00 $15.00 $128.00 $239.00 $37.00 $202.00 $445.00 $75.00 $370.00 $218.00 $29.00 $189.00 $540.00 $66.00 $474.00 $540.00 $65.00 $475.00 $560.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 75662-26 75662-TC 75665 75665-26 75665-TC 75671 75671-26 75671-TC 75676 75676-26 75676-TC 75680 75680-26 75680-TC 75685 75685-26 75685-TC 75705 75705-26 75705-TC 75710 75710-26 75710-TC 75716 75716-26 75716-TC 75722 75722-26 75722-TC 75724 75724-26 75724-TC 75726 75726-26 75726-TC 75731 75731-26 75731-TC 75733 75733-26 75733-TC 75736 75736-26 75736-TC 75741 75741-26 75741-TC 75743 75743-26 75743-TC MRA $84.00 $476.00 $540.00 $65.00 $475.00 $219.00 $32.00 $187.00 $540.00 $65.00 $475.00 $207.00 $31.00 $176.00 $160.00 $19.00 $141.00 $587.00 $109.00 $478.00 $194.00 $21.00 $173.00 $293.00 $35.00 $258.00 $206.00 $22.00 $184.00 $214.00 $29.00 $185.00 $530.00 $56.00 $474.00 $530.00 $56.00 $474.00 $540.00 $65.00 $475.00 $530.00 $56.00 $474.00 $540.00 $65.00 $475.00 $253.00 $37.00 $216.00 Part A, 86 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 75746 75746-26 75746-TC 75756 75756-26 75756-TC 75774 75774-26 75774-TC 75790 75790-26 75790-TC 75801 75801-26 75801-TC 75803 75803-26 75803-TC 75805 75805-26 75805-TC 75807 75807-26 75807-TC 75809 75809-26 75809-TC 75810 75810-26 75810-TC 75820 75820-26 75820-TC 75822 75822-26 75822-TC 75825 75825-26 75825-TC 75827 75827-26 75827-TC 75831 75831-26 75831-TC 75833 75833-26 75833-TC 75840 75840-26 MRA $530.00 $56.00 $474.00 $183.00 $20.00 $163.00 $80.00 $3.00 $77.00 $146.00 $93.00 $53.00 $245.00 $41.00 $204.00 $264.00 $58.00 $206.00 $271.00 $40.00 $231.00 $289.00 $58.00 $231.00 $54.00 $24.00 $30.00 $530.00 $56.00 $474.00 $72.00 $35.00 $37.00 $111.00 $54.00 $57.00 $194.00 $21.00 $173.00 $530.00 $56.00 $474.00 $54.00 $6.00 $48.00 $549.00 $74.00 $475.00 $531.00 $57.00 Radiology CPT Code 75840-TC 75842 75842-26 75842-TC 75860 75860-26 75860-TC 75870 75870-26 75870-TC 75872 75872-26 75872-TC 75880 75880-26 75880-TC 75885 75885-26 75885-TC 75887 75887-26 75887-TC 75889 75889-26 75889-TC 75891 75891-26 75891-TC 75893 75893-26 75893-TC 75894 75894-26 75894-TC 75896 75896-26 75896-TC 75898 75898-26 75898-TC 75900 75900-26 75900-TC 75901 75901-26 75901-TC 75902 75902-26 75902-TC 75940 MRA $474.00 $549.00 $73.00 $476.00 $531.00 $57.00 $474.00 $531.00 $57.00 $474.00 $530.00 $56.00 $474.00 $72.00 $35.00 $37.00 $546.00 $71.00 $475.00 $546.00 $71.00 $475.00 $530.00 $56.00 $474.00 $530.00 $56.00 $474.00 $499.00 $26.00 $473.00 $972.00 $65.00 $907.00 $241.00 $18.00 $223.00 $124.00 $84.00 $39.00 $810.00 $24.00 $786.00 $98.00 $23.00 $75.00 $93.00 $19.00 $74.00 $151.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 75940-26 75940-TC 75945 75945-26 75945-TC 75946 75946-26 75946-TC 75952 75952-26 75952-TC 75953 75953-26 75953-TC 75954 75954-26 75954-TC 75956 75956-26 75956-TC 75957 75957-26 75957-TC 75958 75958-26 75958-TC 75959 75959-26 75959-TC 75960 75960-26 75960-TC 75961 75961-26 75961-TC 75962 75962-26 75962-TC 75964 75964-26 75964-TC 75966 75966-26 75966-TC 75968 75968-26 75968-TC 75970 75970-26 75970-TC MRA $8.00 $143.00 $192.00 $21.00 $171.00 $108.00 $21.00 $87.00 BR $254.00 BR BR $98.00 BR BR $132.00 BR BR $394.00 BR BR $338.00 BR BR $225.00 BR BR $197.00 BR $600.00 $41.00 $559.00 $616.00 $213.00 $403.00 $618.00 $27.00 $591.00 $333.00 $18.00 $315.00 $659.00 $66.00 $593.00 $333.00 $18.00 $315.00 $475.00 $42.00 $433.00 Part A, 87 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 75978 75978-26 75978-TC 75980 75980-26 75980-TC 75982 75982-26 75982-TC 75984 75984-26 75984-TC 75989 75989-26 75989-TC 75992 75992-26 75992-TC 75993 75993-26 75993-TC 75994 75994-26 75994-TC 75995 75995-26 75995-TC 75996 75996-26 75996-TC 76000 76000-26 76000-TC 76001 76001-26 76001-TC 76080 76080-26 76080-TC 76098 76098-26 76098-TC 76100 76100-26 76100-TC 76101 76101-26 76101-TC 76102 76102-26 MRA $617.00 $26.00 $591.00 $277.00 $71.00 $206.00 $303.00 $71.00 $232.00 $110.00 $36.00 $74.00 $180.00 $59.00 $121.00 $618.00 $27.00 $591.00 $333.00 $18.00 $315.00 $659.00 $66.00 $593.00 $658.00 $66.00 $592.00 $332.00 $17.00 $315.00 $58.00 $8.00 $48.00 $134.00 $34.00 $97.00 $67.00 $27.00 $40.00 $23.00 $8.00 $15.00 $77.00 $30.00 $46.00 $94.00 $36.00 $59.00 $95.00 $30.00 Radiology CPT Code 76102-TC 76120 76120-26 76120-TC 76125 76125-26 76125-TC 76140 76150 76350 76376 76376-26 76376-TC 76377 76377-26 76377-TC 76380 76380-26 76380-TC 76390 76390-26 76390-TC 76496 76496-26 76496-TC 76497 76497-26 76497-TC 76498 76498-26 76498-TC 76499 76499-26 76499-TC 76506 76506-26 76506-TC 76510 76510-26 76510-TC 76511 76511-26 76511-TC 76512 76512-26 76512-TC 76513 76513-26 76513-TC 76514 MRA $65.00 $157.00 $56.00 $102.00 $49.00 $17.00 $33.00 $31.00 $15.00 BR $144.00 $11.00 $133.00 $185.00 $43.00 $142.00 $182.00 $50.00 $131.00 $493.00 $71.00 $419.00 BR BR $79.00 BR BR $94.00 BR BR $280.00 BR BR BR $88.00 $33.00 $53.00 $171.00 $86.00 $85.00 $96.00 $48.00 $48.00 $96.00 $36.00 $60.00 $96.00 $36.00 $60.00 $12.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 76514-26 76514-TC 76516 76516-26 76516-TC 76519 76519-26 76519-TC 76529 76529-26 76529-TC 76536 76536-26 76536-TC 76604 76604-26 76604-TC 76645 76645-26 76645-TC 76700 76700-26 76700-TC 76705 76705-26 76705-TC 76770 76770-26 76770-TC 76775 76775-26 76775-TC 76776 76776-26 76776-TC 76800 76800-26 76800-TC 76801 76801-26 76801-TC 76802 76802-26 76802-TC 76805 76805-26 76805-TC 76810 76810-26 76810-TC MRA $10.00 $3.00 $99.00 $37.00 $63.00 $88.00 $31.00 $53.00 $86.00 $31.00 $53.00 $83.00 $31.00 $54.00 $78.00 $28.00 $48.00 $69.00 $31.00 $40.00 $116.00 $42.00 $73.00 $84.00 $30.00 $53.00 $112.00 $38.00 $73.00 $84.00 $30.00 $53.00 $124.00 $36.00 $88.00 $112.00 $61.00 $54.00 $93.00 $51.00 $42.00 $73.00 $43.00 $30.00 $131.00 $51.00 $79.00 $252.00 $100.00 $151.00 Part A, 88 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 76811 76811-26 76811-TC 76812 76812-26 76812-TC 76813 76813-26 76813-TC 76814 76814-26 76814-TC 76815 76815-26 76815-TC 76816 76816-26 76816-TC 76817 76817-26 76817-TC 76818 76818-26 76818-TC 76819 76819-26 76819-TC 76820 76820-26 76820-TC 76821 76821-26 76821-TC 76825 76825-26 76825-TC 76826 76826-26 76826-TC 76827 76827-26 76827-TC 76828 76828-26 76828-TC 76830 76830-26 76830-TC 76831 76831-26 MRA $243.00 $100.00 $142.00 $145.00 $94.00 $51.00 $125.00 $55.00 $71.00 $83.00 $46.00 $37.00 $88.00 $33.00 $53.00 $72.00 $30.00 $41.00 $96.00 $39.00 $57.00 $105.00 $40.00 $60.00 $101.00 $40.00 $60.00 $93.00 $27.00 $66.00 $103.00 $38.00 $66.00 $160.00 $65.00 $73.00 $71.00 $46.00 $27.00 $97.00 $35.00 $65.00 $72.00 $29.00 $42.00 $93.00 $35.00 $57.00 $95.00 $37.00 Radiology CPT Code 76831-TC 76856 76856-26 76856-TC 76857 76857-26 76857-TC 76870 76870-26 76870-TC 76872 76872-26 76872-TC 76873 76873-26 76873-TC 76880 76880-26 76880-TC 76930 76930-26 76930-TC 76932 76932-26 76932-TC 76936 76936-26 76936-TC 76937 76937-26 76937-TC 76940 76940-26 76940-TC 76941 76941-26 76941-TC 76942 76942-26 76942-TC 76945 76945-26 76945-TC 76946 76946-26 76946-TC 76948 76948-26 76948-TC 76950 MRA $57.00 $93.00 $35.00 $57.00 $59.00 $19.00 $39.00 $90.00 $33.00 $57.00 $93.00 $36.00 $57.00 $151.00 $68.00 $80.00 $85.00 $32.00 $54.00 $93.00 $34.00 $59.00 $93.00 $34.00 $59.00 $341.00 $102.00 $236.00 $34.00 $17.00 $18.00 $171.00 $104.00 $68.00 $128.00 $69.00 $59.00 $92.00 $24.00 $68.00 $93.00 $34.00 $59.00 $78.00 $19.00 $59.00 $77.00 $19.00 $58.00 $80.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 76950-26 76950-TC 76965 76965-26 76965-TC 76970 76970-26 76970-TC 76975 76975-26 76975-TC 76977 76977-26 76977-TC 76998 76998-26 76998-TC 76999 76999-26 76999-TC 77001 77001-26 77001-TC 77002 77002-26 77002-TC 77003 77003-26 77003-TC 77011 77011-26 77011-TC 77012 77012-26 77012-TC 77013-26 77013-TC 77014 77014-26 77014-TC 77021 77021-26 77021-TC 77022 77022-26 77022-TC 77031 77031-26 77031-TC 77032 MRA $30.00 $48.00 $281.00 $84.00 $208.00 $60.00 $20.00 $39.00 $99.00 $41.00 $58.00 $34.00 $3.00 $31.00 BR $61.00 $96.00 BR BR BR $83.00 $18.00 $64.00 $75.00 $25.00 $50.00 $73.00 $27.00 $45.00 $309.00 $58.00 $251.00 $306.00 $55.00 $251.00 $191.00 $297.00 $135.00 $41.00 $94.00 $353.00 $73.00 $280.00 BR $204.00 $280.00 $258.00 $77.00 $182.00 $70.00 Part A, 89 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 77032-26 77032-TC 77051 77051-26 77051-TC 77052 77052-26 77052-TC 77053 77053-26 77053-TC 77054 77054-26 77054-TC 77055 77055-26 77055-TC 77056 77056-26 77056-TC 77057 77057-26 77057-TC 77058 77058-26 77058-TC 77059 77059-26 77059-TC 77071 77072 77072-26 77072-TC 77073 77073-26 77073-TC 77074 77074-26 77074-TC 77075 77075-26 77075-TC 77077 77077-26 77077-TC 77078 77078-26 77078-TC 77079 77079-26 MRA $27.00 $44.00 $17.00 $3.00 $14.00 $17.00 $3.00 $14.00 $102.00 $17.00 $85.00 $126.00 $22.00 $104.00 $78.00 $33.00 $45.00 $97.00 $41.00 $56.00 $82.00 $33.00 $49.00 $804.00 $78.00 $726.00 $994.00 $78.00 $917.00 $29.00 $22.00 $9.00 $14.00 $42.00 $13.00 $29.00 $64.00 $22.00 $42.00 $89.00 $26.00 $63.00 $54.00 $15.00 $39.00 $84.00 $12.00 $72.00 $103.00 $11.00 Radiology CPT Code 77079-TC 77080 77080-26 77080-TC 77081 77081-26 77081-TC 77082 77082-26 77082-TC 77083 77083-26 77083-TC 77084 77084-26 77084-TC 77261 77262 77263 77280 77280-26 77280-TC 77285 77285-26 77285-TC 77290 77290-26 77290-TC 77295 77295-26 77295-TC 77299 77299-26 77299-TC 77300 77300-26 77300-TC 77301 77301-26 77301-TC 77305 77305-26 77305-TC 77310 77310-26 77310-TC 77315 77315-26 77315-TC 77321 MRA $92.00 $83.00 $11.00 $72.00 $40.00 $11.00 $29.00 $35.00 $8.00 $27.00 $36.00 $10.00 $26.00 $356.00 $77.00 $280.00 $73.00 $110.00 $163.00 $166.00 $36.00 $130.00 $264.00 $53.00 $209.00 $325.00 $79.00 $243.00 $1,287.00 $232.00 $1,046.00 BR BR BR $87.00 $36.00 $52.00 $1,473.00 $415.00 $1,046.00 $106.00 $36.00 $69.00 $142.00 $53.00 $87.00 $181.00 $79.00 $99.00 $200.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 77321-26 77321-TC 77326 77326-26 77326-TC 77327 77327-26 77327-TC 77328 77328-26 77328-TC 77331 77331-26 77331-TC 77332 77332-26 77332-TC 77333 77333-26 77333-TC 77334 77334-26 77334-TC 77336 77370 77371 77372 77373 77399 77399-26 77399-TC 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77418 77421 77421-26 77421-TC 77422 MRA $48.00 $150.00 $137.00 $47.00 $88.00 $202.00 $71.00 $130.00 $295.00 $106.00 $185.00 $64.00 $45.00 $18.00 $78.00 $27.00 $50.00 $115.00 $43.00 $70.00 $187.00 $63.00 $121.00 $111.00 $130.00 $1,151.00 $874.00 $1,630.00 BR BR BR $66.00 $66.00 $66.00 $66.00 $66.00 $78.00 $78.00 $78.00 $78.00 $87.00 $87.00 $87.00 $87.00 $21.00 $609.00 $152.00 $20.00 $131.00 $70.00 Part A, 90 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 77423 77427 77431 77432 77435 77470 77470-26 77470-TC 77499 77499-26 77499-TC 77520 77522 77523 77525 77600 77600-26 77600-TC 77605 77605-26 77605-TC 77610 77610-26 77610-TC 77615 77615-26 77615-TC 77620 77620-26 77620-TC 77750 77750-26 77750-TC 77761 77761-26 77761-TC 77762 77762-26 77762-TC 77763 77763-26 77763-TC 77776 77776-26 77776-TC 77777 77777-26 77777-TC 77778 77778-26 MRA $91.00 $166.00 $95.00 $417.00 $644.00 $527.00 $106.00 $417.00 BR BR BR BR BR BR BR $196.00 $80.00 $113.00 $263.00 $108.00 $151.00 $195.00 $79.00 $113.00 $262.00 $106.00 $151.00 $196.00 $80.00 $113.00 $299.00 $248.00 $49.00 $284.00 $188.00 $93.00 $427.00 $289.00 $135.00 $605.00 $435.00 $167.00 $316.00 $233.00 $82.00 $540.00 $378.00 $158.00 $764.00 $568.00 Radiology CPT Code 77778-TC 77789 77789-26 77789-TC 77790 77790-26 77790-TC 77799 77799-26 77799-TC 78000 78000-26 78000-TC 78001 78001-26 78001-TC 78003 78003-26 78003-TC 78006 78006-26 78006-TC 78007 78007-26 78007-TC 78010 78010-26 78010-TC 78011 78011-26 78011-TC 78015 78015-26 78015-TC 78016 78016-26 78016-TC 78018 78018-26 78018-TC 78020 78020-26 78020-TC 78070 78070-26 78070-TC 78075 78075-26 78075-TC 78099 MRA $192.00 $74.00 $57.00 $16.00 $72.00 $53.00 $18.00 BR BR BR $46.00 $9.00 $36.00 $62.00 $12.00 $48.00 $54.00 $17.00 $36.00 $115.00 $24.00 $89.00 $122.00 $25.00 $96.00 $89.00 $19.00 $68.00 $114.00 $22.00 $90.00 $132.00 $34.00 $96.00 $173.00 $42.00 $130.00 $248.00 $44.00 $202.00 $35.00 $30.00 $5.00 $112.00 $36.00 $68.00 $242.00 $38.00 $202.00 BR CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 78099-26 78099-TC 78102 78102-26 78102-TC 78103 78103-26 78103-TC 78104 78104-26 78104-TC 78110 78110-26 78110-TC 78111 78111-26 78111-TC 78120 78120-26 78120-TC 78121 78121-26 78121-TC 78122 78122-26 78122-TC 78130 78130-26 78130-TC 78135 78135-26 78135-TC 78140 78140-26 78140-TC 78185 78185-26 78185-TC 78190 78190-26 78190-TC 78191 78191-26 78191-TC 78195 78195-26 78195-TC 78199 78199-26 78199-TC MRA BR BR $106.00 $28.00 $77.00 $158.00 $39.00 $118.00 $194.00 $41.00 $152.00 $45.00 $9.00 $35.00 $108.00 $11.00 $96.00 $78.00 $11.00 $65.00 $125.00 $16.00 $108.00 $196.00 $22.00 $171.00 $139.00 $32.00 $106.00 $216.00 $33.00 $182.00 $179.00 $31.00 $147.00 $110.00 $20.00 $88.00 $272.00 $57.00 $214.00 $307.00 $31.00 $274.00 $216.00 $49.00 $152.00 BR BR BR Part A, 91 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 78201 78201-26 78201-TC 78202 78202-26 78202-TC 78205 78205-26 78205-TC 78206 78206-26 78206-TC 78215 78215-26 78215-TC 78216 78216-26 78216-TC 78220 78220-26 78220-TC 78223 78223-26 78223-TC 78230 78230-26 78230-TC 78231 78231-26 78231-TC 78232 78232-26 78232-TC 78258 78258-26 78258-TC 78261 78261-26 78261-TC 78262 78262-26 78262-TC 78264 78264-26 78264-TC 78267 78268 78270 78270-26 78270-TC MRA $112.00 $22.00 $88.00 $135.00 $26.00 $108.00 $259.00 $36.00 $220.00 $265.00 $46.00 $214.00 $135.00 $24.00 $109.00 $160.00 $29.00 $130.00 $165.00 $24.00 $139.00 $181.00 $43.00 $137.00 $106.00 $23.00 $82.00 $146.00 $27.00 $118.00 $157.00 $23.00 $132.00 $146.00 $38.00 $108.00 $190.00 $36.00 $152.00 $195.00 $35.00 $159.00 $195.00 $40.00 $154.00 BR BR $68.00 $10.00 $58.00 Radiology CPT Code 78271 78271-26 78271-TC 78272 78272-26 78272-TC 78278 78278-26 78278-TC 78282 78282-26 78282-TC 78290 78290-26 78290-TC 78291 78291-26 78291-TC 78299 78299-26 78299-TC 78300 78300-26 78300-TC 78305 78305-26 78305-TC 78306 78306-26 78306-TC 78315 78315-26 78315-TC 78320 78320-26 78320-TC 78350 78350-26 78350-TC 78351 78399 78399-26 78399-TC 78414 78414-26 78414-TC 78428 78428-26 78428-TC 78445 MRA $72.00 $10.00 $61.00 $100.00 $14.00 $87.00 $234.00 $50.00 $182.00 $230.00 $19.00 $224.00 $149.00 $35.00 $113.00 $161.00 $45.00 $114.00 BR BR BR $125.00 $32.00 $93.00 $181.00 $42.00 $137.00 $205.00 $44.00 $159.00 $233.00 $52.00 $179.00 $276.00 $53.00 $220.00 $40.00 $11.00 $29.00 $23.00 BR BR BR BR $23.00 BR $126.00 $41.00 $84.00 $97.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 78445-26 78445-TC 78456 78456-26 78456-TC 78457 78457-26 78457-TC 78458 78458-26 78458-TC 78459 78459-26 78459-TC 78460 78460-26 78460-TC 78461 78461-26 78461-TC 78464 78464-26 78464-TC 78465 78465-26 78465-TC 78466 78466-26 78466-TC 78468 78468-26 78468-TC 78469 78469-26 78469-TC 78472 78472-26 78472-TC 78473 78473-26 78473-TC 78478 78478-26 78478-TC 78480 78480-26 78480-TC 78481 78481-26 78481-TC MRA $28.00 $69.00 $205.00 $49.00 $151.00 $140.00 $39.00 $99.00 $198.00 $46.00 $149.00 $755.00 $100.00 $731.00 $134.00 $44.00 $88.00 $294.00 $82.00 $213.00 $322.00 $56.00 $264.00 $519.00 $75.00 $441.00 $135.00 $36.00 $97.00 $180.00 $41.00 $137.00 $244.00 $47.00 $195.00 $259.00 $50.00 $206.00 $387.00 $75.00 $308.00 $91.00 $32.00 $58.00 $91.00 $32.00 $58.00 $248.00 $51.00 $195.00 Part A, 92 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 78483 78483-26 78483-TC 78491 78491-26 78491-TC 78492 78492-26 78492-TC 78494 78494-26 78494-TC 78496 78496-26 78496-TC 78499 78499-26 78499-TC 78580 78580-26 78580-TC 78584 78584-26 78584-TC 78585 78585-26 78585-TC 78586 78586-26 78586-TC 78587 78587-26 78587-TC 78588 78588-26 78588-TC 78591 78591-26 78591-TC 78593 78593-26 78593-TC 78594 78594-26 78594-TC 78596 78596-26 78596-TC 78599 78599-26 MRA $373.00 $77.00 $294.00 $756.00 $85.00 $731.00 $764.00 $100.00 $731.00 $324.00 $59.00 $262.00 $92.00 $24.00 $66.00 BR BR BR $167.00 $38.00 $128.00 $171.00 $50.00 $119.00 $171.00 $36.00 $133.00 $118.00 $20.00 $96.00 $131.00 $24.00 $105.00 $239.00 $53.00 $192.00 $128.00 $20.00 $106.00 $151.00 $24.00 $126.00 $214.00 $27.00 $186.00 $332.00 $65.00 $264.00 BR BR Radiology CPT Code 78599-TC 78600 78600-26 78600-TC 78601 78601-26 78601-TC 78605 78605-26 78605-TC 78606 78606-26 78606-TC 78607 78607-26 78607-TC 78608 78608-26 78608-TC 78609 78609-26 78609-TC 78610 78610-26 78610-TC 78630 78630-26 78630-TC 78635 78635-26 78635-TC 78645 78645-26 78645-TC 78647 78647-26 78647-TC 78650 78650-26 78650-TC 78660 78660-26 78660-TC 78699 78699-26 78699-TC 78700 78700-26 78700-TC 78701 MRA BR $131.00 $22.00 $108.00 $154.00 $26.00 $126.00 $155.00 $27.00 $126.00 $221.00 $45.00 $177.00 $311.00 $64.00 $245.00 $876.00 $78.00 $855.00 $51.00 $78.00 BR $74.00 $15.00 $59.00 $223.00 $35.00 $188.00 $129.00 $32.00 $95.00 $158.00 $29.00 $128.00 $268.00 $46.00 $220.00 $206.00 $31.00 $173.00 $107.00 $27.00 $79.00 BR BR BR $137.00 $22.00 $113.00 $158.00 CPT only © 2008 American Medical Association. All Rights Reserved. Radiology CPT Code 78701-26 78701-TC 78707 78707-26 78707-TC 78708 78708-26 78708-TC 78709 78709-26 78709-TC 78710 78710-26 78710-TC 78725 78725-26 78725-TC 78730 78730-26 78730-TC 78740 78740-26 78740-TC 78761 78761-26 78761-TC 78799 78799-26 78799-TC 78800 78800-26 78800-TC 78801 78801-26 78801-TC 78802 78802-26 78802-TC 78803 78803-26 78803-TC 78804 78804-26 78804-TC 78805 78805-26 78805-TC 78806 78806-26 78806-TC MRA $24.00 $133.00 $217.00 $49.00 $166.00 $231.00 $61.00 $166.00 $241.00 $68.00 $166.00 $256.00 $34.00 $220.00 $87.00 $19.00 $66.00 $73.00 $18.00 $55.00 $109.00 $29.00 $79.00 $157.00 $36.00 $119.00 BR BR BR $162.00 $34.00 $126.00 $199.00 $40.00 $158.00 $252.00 $44.00 $207.00 $303.00 $56.00 $245.00 $227.00 $55.00 $171.00 $166.00 $38.00 $126.00 $286.00 $44.00 $241.00 Part A, 93 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 78807 78807-26 78807-TC 78811 78811-26 78811-TC 78812 78812-26 78812-TC 78813 78813-26 78813-TC 78814 78814-26 78814-TC 78815 78815-26 78815-TC 78816 78816-26 78816-TC 78999 78999-26 78999-TC 79005 79005-26 79005-TC 79101 79101-26 79101-TC 79200 79200-26 79200-TC 79300 79300-26 79300-TC 79403 79403-26 79403-TC 79440 79440-26 79440-TC 79445 79445-26 79445-TC 79999 79999-26 79999-TC G0130 G0130-26 MRA $303.00 $57.00 $245.00 $879.00 $83.00 $855.00 $884.00 $102.00 $855.00 $885.00 $106.00 $855.00 $982.00 $116.00 $950.00 $985.00 $128.00 $950.00 $986.00 $132.00 $950.00 BR BR BR $199.00 $94.00 $105.00 $207.00 $103.00 $105.00 $203.00 $102.00 $97.00 BR $83.00 BR $287.00 $121.00 $165.00 $204.00 $104.00 $97.00 $232.00 $127.00 $105.00 BR BR BR $34.00 $10.00 Radiology CPT Code G0130-TC G0202 G0202-26 G0202-TC G0204 G0204-26 G0204-TC G0206 G0206-26 G0206-TC G0275 G0278 G0288 G0365 G0365-26 G0365-TC G0389 G0389-26 G0389-TC Q0092 MRA G0130-TC G0202 G0202-26 G0202-TC G0204 G0204-26 G0204-TC G0206 G0206-26 G0206-TC G0275 G0278 G0288 G0365 G0365-26 G0365-TC G0389 G0389-26 G0389-TC Q0092 CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 94 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 80048 $23.00 80048-26 $4.00 80048-TC $19.00 80050 $45.00 80050-26 $18.00 80050-TC $26.00 80051 $16.00 80051-26 $6.00 80051-TC $10.00 80053 $29.00 80053-26 $8.00 80053-TC $21.00 80055 $67.00 80055-26 $21.00 80055-TC $43.00 80061 $31.00 80061-26 $11.00 80061-TC $19.00 80069 $26.00 80069-26 $6.00 80069-TC $20.00 80074 $107.00 80074-26 $43.00 80074-TC $64.00 80076 $18.00 80076-26 $7.00 80076-TC $11.00 80100 $38.00 80100-26 $11.00 80100-TC $26.00 80101 $13.00 80101-26 $3.00 80101-TC $9.00 80102 $23.00 80102-26 $6.00 80102-TC $16.00 80103 $12.00 80103-26 $4.00 80103-TC $7.00 80150 $40.00 80150-26 $13.00 80150-TC $26.00 80152 $43.00 80152-26 $14.00 80152-TC $29.00 80154 $49.00 80154-26 $15.00 80154-TC $34.00 80156 $35.00 80156-26 $11.00 Pathology & Laboratory CPT Code MRA 80156-TC $23.00 80157 $22.00 80157-26 $8.00 80157-TC $14.00 80158 $35.00 80158-26 $12.00 80158-TC $22.00 80160 $35.00 80160-26 $12.00 80160-TC $22.00 80162 $13.00 80162-26 $3.00 80162-TC $9.00 80164 $43.00 80164-26 $14.00 80164-TC $29.00 80166 $35.00 80166-26 $10.00 80166-TC $24.00 80168 $43.00 80168-26 $17.00 80168-TC $25.00 80170 $18.00 80170-26 $6.00 80170-TC $11.00 80172 $44.00 80172-26 $13.00 80172-TC $32.00 80173 $33.00 80173-26 $11.00 80173-TC $22.00 80174 $41.00 80174-26 $12.00 80174-TC $29.00 80176 $35.00 80176-26 $11.00 80176-TC $23.00 80178 $17.00 80178-26 $6.00 80178-TC $11.00 80182 $43.00 80182-26 $14.00 80182-TC $29.00 80184 $34.00 80184-26 $10.00 80184-TC $23.00 80185 $36.00 80185-26 $10.00 80185-TC $25.00 80186 $38.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 80186-26 $11.00 80186-TC $26.00 80188 $35.00 80188-26 $11.00 80188-TC $23.00 80190 $41.00 80190-26 $13.00 80190-TC $28.00 80192 $44.00 80192-26 $17.00 80192-TC $26.00 80194 $33.00 80194-26 $10.00 80194-TC $22.00 80196 $13.00 80196-26 $3.00 80196-TC $9.00 80197 $34.00 80197-26 $11.00 80197-TC $22.00 80198 $20.00 80198-26 $5.00 80198-TC $15.00 80200 $24.00 80200-26 $7.00 80200-TC $16.00 80201 $33.00 80201-26 $11.00 80201-TC $21.00 80202 $42.00 80202-26 $14.00 80202-TC $28.00 80299 BR 80299-26 BR 80299-TC BR 80400 $54.00 80400-26 $18.00 80400-TC $36.00 80402 $138.00 80402-26 $42.00 80402-TC $95.00 80406 $138.00 80406-26 $42.00 80406-TC $95.00 80408 $213.00 80408-26 $77.00 80408-TC $136.00 80410 $166.00 80410-26 $54.00 80410-TC $110.00 Part A, 95 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 80412 $533.00 80412-26 $176.00 80412-TC $355.00 80414 $88.00 80414-26 $26.00 80414-TC $59.00 80415 $93.00 80415-26 $28.00 80415-TC $64.00 80416 $256.00 80416-26 $88.00 80416-TC $166.00 80417 $256.00 80417-26 $88.00 80417-TC $166.00 80418 $934.00 80418-26 $266.00 80418-TC $666.00 80420 $107.00 80420-26 $33.00 80420-TC $74.00 80422 $62.00 80422-26 $18.00 80422-TC $43.00 80424 $94.00 80424-26 $26.00 80424-TC $67.00 80426 $232.00 80426-26 $54.00 80426-TC $176.00 80428 $93.00 80428-26 $19.00 80428-TC $73.00 80430 $99.00 80430-26 $24.00 80430-TC $74.00 80432 $243.00 80432-26 $56.00 80432-TC $186.00 80434 $161.00 80434-26 $49.00 80434-TC $110.00 80435 $166.00 80435-26 $49.00 80435-TC $115.00 80436 $119.00 80436-26 $35.00 80436-TC $85.00 80438 $82.00 80438-26 $24.00 Pathology & Laboratory CPT Code MRA 80438-TC $56.00 80439 $176.00 80439-26 $33.00 80439-TC $144.00 80440 $188.00 80440-26 $36.00 80440-TC $151.00 80500 $34.00 80500-26 $34.00 80500-TC BR 80502 $72.00 80502-26 $72.00 80502-TC BR 81000 $7.00 81000-26 $3.00 81000-TC $4.00 81001 $7.00 81001-26 $3.00 81001-TC $4.00 81002 $5.00 81002-26 $3.00 81002-TC $3.00 81003 $5.00 81003-26 $2.00 81003-TC $3.00 81005 $3.00 81005-26 $1.00 81005-TC $3.00 81007 $5.00 81007-26 $2.00 81007-TC $4.00 81015 $5.00 81015-26 $3.00 81015-TC $3.00 81020 $8.00 81020-26 $3.00 81020-TC $5.00 81025 $7.00 81025-26 $4.00 81025-TC $4.00 81050 $33.00 81050-26 $11.00 81050-TC $21.00 81099 BR 81099-26 BR 81099-TC BR 82000 $24.00 82000-26 $7.00 82000-TC $17.00 82003 $36.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 82003-26 $10.00 82003-TC $25.00 82009 $10.00 82009-26 $3.00 82009-TC $6.00 82010 $22.00 82010-26 $7.00 82010-TC $15.00 82013 $24.00 82013-26 $7.00 82013-TC $17.00 82024 $26.00 82024-26 $7.00 82024-TC $18.00 82030 $43.00 82030-26 $17.00 82030-TC $25.00 82040 $11.00 82040-26 $3.00 82040-TC $7.00 82042 $12.00 82042-26 $3.00 82042-TC $8.00 82043 $14.00 82043-26 $4.00 82043-TC $10.00 82044 $12.00 82044-26 $4.00 82044-TC $9.00 82055 $33.00 82055-26 $10.00 82055-TC $22.00 82075 $32.00 82075-26 $10.00 82075-TC $21.00 82085 $24.00 82085-26 $7.00 82085-TC $17.00 82088 $91.00 82088-26 $28.00 82088-TC $62.00 82101 $59.00 82101-26 $18.00 82101-TC $41.00 82103 $21.00 82103-26 $7.00 82103-TC $14.00 82104 $22.00 82104-26 $7.00 82104-TC $15.00 Part A, 96 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 82105 $26.00 82105-26 $8.00 82105-TC $18.00 82106 $26.00 82106-26 $8.00 82106-TC $18.00 82108 $45.00 82108-26 $14.00 82108-TC $32.00 82120 $9.00 82120-26 $3.00 82120-TC $5.00 82127 $33.00 82127-26 $11.00 82127-TC $22.00 82128 $26.00 82128-26 $6.00 82128-TC $19.00 82131 $57.00 82131-26 $13.00 82131-TC $44.00 82135 $41.00 82135-26 $13.00 82135-TC $28.00 82136 $38.00 82136-26 $14.00 82136-TC $23.00 82139 $38.00 82139-26 $14.00 82139-TC $23.00 82140 $40.00 82140-26 $12.00 82140-TC $28.00 82143 $28.00 82143-26 $8.00 82143-TC $19.00 82145 $35.00 82145-26 $10.00 82145-TC $24.00 82150 $16.00 82150-26 $5.00 82150-TC $11.00 82154 $34.00 82154-26 $13.00 82154-TC $20.00 82157 $57.00 82157-26 $17.00 82157-TC $40.00 82160 $67.00 82160-26 $21.00 Pathology & Laboratory CPT Code MRA 82160-TC $43.00 82163 $42.00 82163-26 $12.00 82163-TC $31.00 82164 $32.00 82164-26 $10.00 82164-TC $21.00 82172 $33.00 82172-26 $10.00 82172-TC $22.00 82175 $48.00 82175-26 $15.00 82175-TC $33.00 82180 $25.00 82180-26 $8.00 82180-TC $17.00 82190 $24.00 82190-26 $8.00 82190-TC $16.00 82205 $34.00 82205-26 $10.00 82205-TC $23.00 82232 $43.00 82232-26 $14.00 82232-TC $29.00 82239 $23.00 82239-26 $8.00 82239-TC $15.00 82240 $49.00 82240-26 $15.00 82240-TC $34.00 82247 $10.00 82247-26 $3.00 82247-TC $7.00 82248 $10.00 82248-26 $3.00 82248-TC $7.00 82252 $11.00 82252-26 $3.00 82252-TC $7.00 82261 $38.00 82261-26 $13.00 82261-TC $24.00 82270 $5.00 82270-26 $2.00 82270-TC $3.00 82274 BR 82274-26 BR 82274-TC BR 82286 $12.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 82286-26 $3.00 82286-TC $8.00 82300 $48.00 82300-26 $15.00 82300-TC $33.00 82306 $79.00 82306-26 $25.00 82306-TC $52.00 82307 $57.00 82307-26 $19.00 82307-TC $38.00 82308 $62.00 82308-26 $18.00 82308-TC $43.00 82310 $11.00 82310-26 $3.00 82310-TC $7.00 82330 $37.00 82330-26 $11.00 82330-TC $25.00 82331 $14.00 82331-26 $4.00 82331-TC $10.00 82340 $13.00 82340-26 $4.00 82340-TC $8.00 82355 $31.00 82355-26 $10.00 82355-TC $20.00 82360 $31.00 82360-26 $10.00 82360-TC $20.00 82365 $31.00 82365-26 $8.00 82365-TC $21.00 82370 $22.00 82370-26 $7.00 82370-TC $15.00 82373 $16.00 82373-26 $5.00 82373-TC $11.00 82374 $10.00 82374-26 $3.00 82374-TC $6.00 82375 $26.00 82375-26 $7.00 82375-TC $18.00 82376 $11.00 82376-26 $3.00 82376-TC $7.00 Part A, 97 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 82378 $31.00 82378-26 $8.00 82378-TC $21.00 82379 $38.00 82379-26 $13.00 82379-TC $24.00 82380 $21.00 82380-26 $6.00 82380-TC $15.00 82382 $38.00 82382-26 $12.00 82382-TC $25.00 82383 $62.00 82383-26 $18.00 82383-TC $43.00 82384 $62.00 82384-26 $18.00 82384-TC $43.00 82387 $34.00 82387-26 $10.00 82387-TC $23.00 82390 $24.00 82390-26 $7.00 82390-TC $17.00 82397 $22.00 82397-26 $7.00 82397-TC $15.00 82415 $28.00 82415-26 $8.00 82415-TC $19.00 82435 $8.00 82435-26 $2.00 82435-TC $6.00 82436 $14.00 82436-26 $4.00 82436-TC $10.00 82438 $13.00 82438-26 $4.00 82438-TC $8.00 82441 $16.00 82441-26 $5.00 82441-TC $11.00 82465 $8.00 82465-26 $2.00 82465-TC $6.00 82480 $23.00 82480-26 $6.00 82480-TC $17.00 82482 $23.00 82482-26 $7.00 Pathology & Laboratory CPT Code MRA 82482-TC $15.00 82485 $37.00 82485-26 $8.00 82485-TC $28.00 82486 $42.00 82486-26 $14.00 82486-TC $27.00 82487 $43.00 82487-26 $14.00 82487-TC $29.00 82488 $57.00 82488-26 $19.00 82488-TC $38.00 82489 $47.00 82489-26 $15.00 82489-TC $32.00 82491 $58.00 82491-26 $17.00 82491-TC $41.00 82492 $42.00 82492-26 $13.00 82492-TC $28.00 82495 $48.00 82495-26 $16.00 82495-TC $32.00 82507 $55.00 82507-26 $16.00 82507-TC $39.00 82520 $26.00 82520-26 $8.00 82520-TC $18.00 82523 $43.00 82523-26 $17.00 82523-TC $25.00 82525 $34.00 82525-26 $10.00 82525-TC $23.00 82528 $40.00 82528-26 $13.00 82528-TC $26.00 82530 $38.00 82530-26 $12.00 82530-TC $25.00 82533 $35.00 82533-26 $10.00 82533-TC $24.00 82540 $10.00 82540-26 $3.00 82540-TC $6.00 82541 $42.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 82541-26 $13.00 82541-TC $28.00 82542 $42.00 82542-26 $13.00 82542-TC $28.00 82543 $42.00 82543-26 $13.00 82543-TC $28.00 82544 $42.00 82544-26 $13.00 82544-TC $28.00 82550 $16.00 82550-26 $4.00 82550-TC $12.00 82552 $33.00 82552-26 $10.00 82552-TC $22.00 82553 $16.00 82553-26 $5.00 82553-TC $11.00 82554 $19.00 82554-26 $6.00 82554-TC $13.00 82565 $13.00 82565-26 $2.00 82565-TC $11.00 82570 $10.00 82570-26 $2.00 82570-TC $7.00 82575 $25.00 82575-26 $8.00 82575-TC $17.00 82585 $15.00 82585-26 $3.00 82585-TC $12.00 82595 $31.00 82595-26 $10.00 82595-TC $21.00 82600 $40.00 82600-26 $12.00 82600-TC $28.00 82607 $38.00 82607-26 $10.00 82607-TC $27.00 82608 $40.00 82608-26 $13.00 82608-TC $26.00 82615 $17.00 82615-26 $5.00 82615-TC $12.00 Part A, 98 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 82626 $59.00 82626-26 $19.00 82626-TC $40.00 82627 $37.00 82627-26 $12.00 82627-TC $24.00 82633 $81.00 82633-26 $23.00 82633-TC $56.00 82634 $81.00 82634-26 $23.00 82634-TC $56.00 82638 $23.00 82638-26 $7.00 82638-TC $16.00 82646 $37.00 82646-26 $11.00 82646-TC $25.00 82649 $43.00 82649-26 $17.00 82649-TC $25.00 82651 $43.00 82651-26 $17.00 82651-TC $25.00 82652 $89.00 82652-26 $25.00 82652-TC $62.00 82654 $37.00 82654-26 $11.00 82654-TC $25.00 82657 $42.00 82657-26 $13.00 82657-TC $28.00 82658 $42.00 82658-26 $13.00 82658-TC $28.00 82664 $40.00 82664-26 $13.00 82664-TC $26.00 82666 $58.00 82666-26 $17.00 82666-TC $41.00 82668 $45.00 82668-26 $14.00 82668-TC $32.00 82670 $61.00 82670-26 $18.00 82670-TC $42.00 82671 $61.00 82671-26 $17.00 Pathology & Laboratory CPT Code MRA 82671-TC $43.00 82672 $57.00 82672-26 $16.00 82672-TC $41.00 82677 $52.00 82677-26 $17.00 82677-TC $35.00 82679 $70.00 82679-26 $20.00 82679-TC $48.00 82690 $53.00 82690-26 $21.00 82690-TC $32.00 82693 $23.00 82693-26 $7.00 82693-TC $16.00 82696 $57.00 82696-26 $19.00 82696-TC $38.00 82705 $14.00 82705-26 $6.00 82705-TC $9.00 82710 $42.00 82710-26 $13.00 82710-TC $29.00 82715 $33.00 82715-26 $11.00 82715-TC $21.00 82725 $28.00 82725-26 $8.00 82725-TC $19.00 82726 $42.00 82726-26 $13.00 82726-TC $28.00 82728 $24.00 82728-26 $7.00 82728-TC $17.00 82735 $36.00 82735-26 $12.00 82735-TC $23.00 82742 $42.00 82742-26 $13.00 82742-TC $29.00 82746 $39.00 82746-26 $13.00 82746-TC $25.00 82747 $29.00 82747-26 $10.00 82747-TC $19.00 82757 $36.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 82757-26 $11.00 82757-TC $24.00 82759 $38.00 82759-26 $12.00 82759-TC $25.00 82760 $26.00 82760-26 $8.00 82760-TC $18.00 82775 $47.00 82775-26 $14.00 82775-TC $33.00 82776 $14.00 82776-26 $3.00 82776-TC $11.00 82784 $15.00 82784-26 $5.00 82784-TC $11.00 82785 $33.00 82785-26 $11.00 82785-TC $21.00 82787 $54.00 82787-26 $17.00 82787-TC $37.00 82800 $22.00 82800-26 $6.00 82800-TC $16.00 82803 $53.00 82803-26 $16.00 82803-TC $37.00 82805 $36.00 82805-26 $10.00 82805-TC $24.00 82810 $28.00 82810-26 $8.00 82810-TC $19.00 82820 $16.00 82820-26 $5.00 82820-TC $11.00 82926 $20.00 82926-26 $5.00 82926-TC $15.00 82928 $12.00 82928-26 $4.00 82928-TC $7.00 82938 $48.00 82938-26 $16.00 82938-TC $32.00 82941 $47.00 82941-26 $15.00 82941-TC $32.00 Part A, 99 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 82943 $38.00 82943-26 $12.00 82943-TC $25.00 82945 $9.00 82945-26 $3.00 82945-TC $5.00 82946 $29.00 82946-26 $7.00 82946-TC $21.00 82947 $11.00 82947-26 $3.00 82947-TC $7.00 82948 $5.00 82948-26 $3.00 82948-TC $3.00 82950 $12.00 82950-26 $4.00 82950-TC $7.00 82951 $22.00 82951-26 $7.00 82951-TC $15.00 82952 $11.00 82952-26 $3.00 82952-TC $7.00 82953 $41.00 82953-26 $14.00 82953-TC $26.00 82955 $25.00 82955-26 $7.00 82955-TC $18.00 82960 $14.00 82960-26 $4.00 82960-TC $10.00 82962 $5.00 82962-26 $1.00 82962-TC $4.00 82963 $54.00 82963-26 $17.00 82963-TC $37.00 82965 $16.00 82965-26 $5.00 82965-TC $11.00 82975 $28.00 82975-26 $8.00 82975-TC $19.00 82977 $16.00 82977-26 $4.00 82977-TC $12.00 82978 $25.00 82978-26 $7.00 Pathology & Laboratory CPT Code MRA 82978-TC $18.00 82979 $18.00 82979-26 $5.00 82979-TC $13.00 82980 $15.00 82980-26 $3.00 82980-TC $11.00 82985 $41.00 82985-26 $12.00 82985-TC $29.00 83001 $40.00 83001-26 $12.00 83001-TC $28.00 83002 $42.00 83002-26 $13.00 83002-TC $29.00 83003 $36.00 83003-26 $10.00 83003-TC $25.00 83008 $34.00 83008-26 $10.00 83008-TC $23.00 83010 $26.00 83010-26 $8.00 83010-TC $18.00 83012 $36.00 83012-26 $14.00 83012-TC $21.00 83013 $133.00 83013-26 $38.00 83013-TC $94.00 83014 $19.00 83014-26 $6.00 83014-TC $13.00 83015 $51.00 83015-26 $15.00 83015-TC $36.00 83018 $56.00 83018-26 $16.00 83018-TC $40.00 83020 $24.00 83020-26 $6.00 83020-TC $18.00 83021 $39.00 83021-26 $13.00 83021-TC $25.00 83026 $8.00 83026-26 $5.00 83026-TC $3.00 83030 $18.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 83030-26 $6.00 83030-TC $12.00 83033 $15.00 83033-26 $4.00 83033-TC $11.00 83036 $15.00 83036-26 $5.00 83036-TC $10.00 83045 $13.00 83045-26 $4.00 83045-TC $8.00 83050 $16.00 83050-26 $5.00 83050-TC $11.00 83051 $16.00 83051-26 $5.00 83051-TC $11.00 83055 $13.00 83055-26 $4.00 83055-TC $8.00 83060 $22.00 83060-26 $6.00 83060-TC $16.00 83065 $18.00 83065-26 $6.00 83065-TC $12.00 83068 $20.00 83068-26 $5.00 83068-TC $15.00 83069 $11.00 83069-26 $3.00 83069-TC $7.00 83070 $13.00 83070-26 $4.00 83070-TC $8.00 83071 $18.00 83071-26 $5.00 83071-TC $13.00 83080 $38.00 83080-26 $11.00 83080-TC $26.00 83088 $59.00 83088-26 $18.00 83088-TC $41.00 83090 $38.00 83090-26 $13.00 83090-TC $25.00 83150 $49.00 83150-26 $16.00 83150-TC $33.00 Part A, 100 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 83491 $37.00 83491-26 $11.00 83491-TC $25.00 83497 $35.00 83497-26 $11.00 83497-TC $23.00 83498 $62.00 83498-26 $20.00 83498-TC $41.00 83499 $51.00 83499-26 $15.00 83499-TC $36.00 83500 $69.00 83500-26 $21.00 83500-TC $45.00 83505 $77.00 83505-26 $21.00 83505-TC $54.00 83516 $26.00 83516-26 $8.00 83516-TC $18.00 83518 $21.00 83518-26 $7.00 83518-TC $14.00 83519 $21.00 83519-26 $7.00 83519-TC $14.00 83520 $20.00 83520-26 $6.00 83520-TC $14.00 83525 $31.00 83525-26 $8.00 83525-TC $21.00 83527 $35.00 83527-26 $11.00 83527-TC $23.00 83528 $43.00 83528-26 $14.00 83528-TC $29.00 83540 $16.00 83540-26 $3.00 83540-TC $13.00 83550 $20.00 83550-26 $5.00 83550-TC $15.00 83570 $23.00 83570-26 $7.00 83570-TC $16.00 83582 $34.00 83582-26 $8.00 Pathology & Laboratory CPT Code MRA 83582-TC $24.00 83586 $38.00 83586-26 $13.00 83586-TC $24.00 83593 $59.00 83593-26 $18.00 83593-TC $41.00 83605 $19.00 83605-26 $6.00 83605-TC $13.00 83615 $16.00 83615-26 $5.00 83615-TC $11.00 83625 $23.00 83625-26 $6.00 83625-TC $17.00 83632 $42.00 83632-26 $14.00 83632-TC $28.00 83655 $31.00 83655-26 $8.00 83655-TC $21.00 83670 $18.00 83670-26 $5.00 83670-TC $13.00 83690 $18.00 83690-26 $6.00 83690-TC $12.00 83718 $16.00 83718-26 $5.00 83718-TC $11.00 83719 $42.00 83719-26 $14.00 83719-TC $28.00 83721 $16.00 83721-26 $5.00 83721-TC $11.00 83727 $43.00 83727-26 $14.00 83727-TC $29.00 83735 $15.00 83735-26 $5.00 83735-TC $10.00 83775 $17.00 83775-26 $5.00 83775-TC $12.00 83785 $58.00 83785-26 $17.00 83785-TC $41.00 83788 $39.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 83788-26 $13.00 83788-TC $25.00 83789 $39.00 83789-26 $13.00 83789-TC $25.00 83805 $44.00 83805-26 $15.00 83805-TC $29.00 83825 $34.00 83825-26 $11.00 83825-TC $22.00 83835 $41.00 83835-26 $12.00 83835-TC $29.00 83840 $42.00 83840-26 $14.00 83840-TC $28.00 83857 $26.00 83857-26 $8.00 83857-TC $18.00 83858 $37.00 83858-26 $12.00 83858-TC $24.00 83864 $32.00 83864-26 $8.00 83864-TC $22.00 83866 $26.00 83866-26 $7.00 83866-TC $19.00 83872 $13.00 83872-26 $4.00 83872-TC $8.00 83873 $54.00 83873-26 $18.00 83873-TC $36.00 83874 $25.00 83874-26 $8.00 83874-TC $17.00 83880 BR 83880-26 BR 83880-TC BR 83883 $11.00 83883-26 $3.00 83883-TC $7.00 83885 $45.00 83885-26 $14.00 83885-TC $32.00 83887 $58.00 83887-26 $17.00 83887-TC $41.00 Part A, 101 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 83890 $7.00 83890-26 $2.00 83890-TC $5.00 83891 $7.00 83891-26 $2.00 83891-TC $5.00 83892 $7.00 83892-26 $2.00 83892-TC $5.00 83893 $7.00 83893-26 $2.00 83893-TC $5.00 83894 $7.00 83894-26 $2.00 83894-TC $5.00 83896 $7.00 83896-26 $2.00 83896-TC $5.00 83897 $9.00 83897-26 $3.00 83897-TC $5.00 83898 $43.00 83898-26 $14.00 83898-TC $29.00 83901 $44.00 83901-26 $14.00 83901-TC $29.00 83902 $38.00 83902-26 $13.00 83902-TC $24.00 83903 $44.00 83903-26 $14.00 83903-TC $29.00 83904 $44.00 83904-26 $14.00 83904-TC $29.00 83905 $44.00 83905-26 $14.00 83905-TC $29.00 83906 $44.00 83906-26 $14.00 83906-TC $29.00 83912 $39.00 83912-26 $11.00 83912-TC $28.00 83915 $31.00 83915-26 $10.00 83915-TC $20.00 83916 $54.00 83916-26 $18.00 Pathology & Laboratory CPT Code MRA 83916-TC $36.00 83918 $41.00 83918-26 $12.00 83918-TC $29.00 83919 $42.00 83919-26 $12.00 83919-TC $29.00 83921 $37.00 83921-26 $12.00 83921-TC $25.00 83925 $13.00 83925-26 $3.00 83925-TC $9.00 83930 $11.00 83930-26 $3.00 83930-TC $7.00 83935 $17.00 83935-26 $5.00 83935-TC $12.00 83937 $29.00 83937-26 $10.00 83937-TC $19.00 83945 $32.00 83945-26 $11.00 83945-TC $20.00 83950 BR 83950-26 BR 83950-TC BR 83970 $94.00 83970-26 $31.00 83970-TC $62.00 83986 $8.00 83986-26 $3.00 83986-TC $5.00 83992 $40.00 83992-26 $12.00 83992-TC $28.00 84022 $41.00 84022-26 $13.00 84022-TC $28.00 84030 $11.00 84030-26 $3.00 84030-TC $7.00 84035 $12.00 84035-26 $3.00 84035-TC $8.00 84060 $20.00 84060-26 $6.00 84060-TC $14.00 84061 $14.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 84061-26 $4.00 84061-TC $10.00 84066 $18.00 84066-26 $6.00 84066-TC $12.00 84075 $12.00 84075-26 $3.00 84075-TC $8.00 84078 $19.00 84078-26 $5.00 84078-TC $14.00 84080 $36.00 84080-26 $11.00 84080-TC $24.00 84081 $45.00 84081-26 $15.00 84081-TC $31.00 84085 $15.00 84085-26 $5.00 84085-TC $10.00 84087 $25.00 84087-26 $7.00 84087-TC $18.00 84100 $11.00 84100-26 $3.00 84100-TC $7.00 84105 $11.00 84105-26 $3.00 84105-TC $7.00 84106 $10.00 84106-26 $2.00 84106-TC $7.00 84110 $21.00 84110-26 $6.00 84110-TC $15.00 84119 $21.00 84119-26 $6.00 84119-TC $15.00 84120 $38.00 84120-26 $11.00 84120-TC $26.00 84126 $71.00 84126-26 $20.00 84126-TC $49.00 84127 $18.00 84127-26 $6.00 84127-TC $12.00 84132 $11.00 84132-26 $3.00 84132-TC $7.00 Part A, 102 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 84133 $11.00 84133-26 $3.00 84133-TC $7.00 84134 $24.00 84134-26 $7.00 84134-TC $17.00 84135 $57.00 84135-26 $19.00 84135-TC $38.00 84138 $56.00 84138-26 $18.00 84138-TC $38.00 84140 $41.00 84140-26 $8.00 84140-TC $33.00 84143 $62.00 84143-26 $20.00 84143-TC $41.00 84144 $38.00 84144-26 $7.00 84144-TC $31.00 84146 $53.00 84146-26 $17.00 84146-TC $36.00 84150 $69.00 84150-26 $20.00 84150-TC $47.00 84152 $42.00 84152-26 $14.00 84152-TC $27.00 84153 $33.00 84153-26 $11.00 84153-TC $21.00 84154 $33.00 84154-26 $11.00 84154-TC $21.00 84155 $12.00 84155-26 $4.00 84155-TC $7.00 84160 $5.00 84160-26 $2.00 84160-TC $2.00 84165 $24.00 84165-26 $8.00 84165-TC $16.00 84166 BR 84166-26 $20.00 84166-TC BR 84181 $29.00 84181-26 $10.00 Pathology & Laboratory CPT Code MRA 84181-TC $19.00 84182 $33.00 84182-26 $11.00 84182-TC $21.00 84202 $39.00 84202-26 $13.00 84202-TC $25.00 84203 $16.00 84203-26 $5.00 84203-TC $11.00 84206 $32.00 84206-26 $10.00 84206-TC $21.00 84207 $54.00 84207-26 $16.00 84207-TC $38.00 84210 $24.00 84210-26 $10.00 84210-TC $15.00 84220 $25.00 84220-26 $8.00 84220-TC $17.00 84228 $32.00 84228-26 $10.00 84228-TC $21.00 84233 $116.00 84233-26 $35.00 84233-TC $81.00 84234 $116.00 84234-26 $35.00 84234-TC $81.00 84235 $114.00 84235-26 $34.00 84235-TC $80.00 84238 $97.00 84238-26 $32.00 84238-TC $65.00 84244 $47.00 84244-26 $15.00 84244-TC $32.00 84252 $47.00 84252-26 $14.00 84252-TC $33.00 84255 $58.00 84255-26 $17.00 84255-TC $41.00 84260 $54.00 84260-26 $16.00 84260-TC $38.00 84270 $36.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 84270-26 $11.00 84270-TC $24.00 84275 $37.00 84275-26 $11.00 84275-TC $25.00 84285 $59.00 84285-26 $17.00 84285-TC $42.00 84295 $10.00 84295-26 $3.00 84295-TC $6.00 84300 $10.00 84300-26 $3.00 84300-TC $6.00 84302 BR 84302-26 BR 84302-TC BR 84305 $34.00 84305-26 $11.00 84305-TC $22.00 84307 $26.00 84307-26 $8.00 84307-TC $18.00 84311 $11.00 84311-26 $3.00 84311-TC $7.00 84315 $5.00 84315-26 $2.00 84315-TC $3.00 84375 $37.00 84375-26 $11.00 84375-TC $25.00 84376 $10.00 84376-26 $3.00 84376-TC $7.00 84377 $10.00 84377-26 $3.00 84377-TC $7.00 84378 $25.00 84378-26 $8.00 84378-TC $17.00 84379 $25.00 84379-26 $8.00 84379-TC $17.00 84392 $8.00 84392-26 $2.00 84392-TC $6.00 84402 $72.00 84402-26 $21.00 84402-TC $49.00 Part A, 103 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 84403 $67.00 84403-26 $19.00 84403-TC $45.00 84425 $54.00 84425-26 $17.00 84425-TC $37.00 84430 $31.00 84430-26 $10.00 84430-TC $20.00 84432 $28.00 84432-26 $8.00 84432-TC $19.00 84436 $14.00 84436-26 $3.00 84436-TC $11.00 84437 $13.00 84437-26 $4.00 84437-TC $8.00 84439 $16.00 84439-26 $4.00 84439-TC $12.00 84442 $25.00 84442-26 $6.00 84442-TC $19.00 84443 $32.00 84443-26 $7.00 84443-TC $23.00 84445 $98.00 84445-26 $29.00 84445-TC $69.00 84446 $35.00 84446-26 $11.00 84446-TC $23.00 84449 $38.00 84449-26 $13.00 84449-TC $24.00 84450 $11.00 84450-26 $3.00 84450-TC $7.00 84460 $13.00 84460-26 $4.00 84460-TC $8.00 84466 $22.00 84466-26 $7.00 84466-TC $15.00 84478 $12.00 84478-26 $3.00 84478-TC $8.00 84479 $15.00 84479-26 $5.00 Pathology & Laboratory CPT Code MRA 84479-TC $10.00 84480 $20.00 84480-26 $6.00 84480-TC $14.00 84481 $33.00 84481-26 $10.00 84481-TC $22.00 84482 $45.00 84482-26 $15.00 84482-TC $31.00 84484 $21.00 84484-26 $6.00 84484-TC $15.00 84485 $15.00 84485-26 $4.00 84485-TC $11.00 84488 $15.00 84488-26 $4.00 84488-TC $11.00 84490 $15.00 84490-26 $4.00 84490-TC $11.00 84510 $26.00 84510-26 $8.00 84510-TC $18.00 84512 $17.00 84512-26 $5.00 84512-TC $12.00 84520 $12.00 84520-26 $3.00 84520-TC $8.00 84525 $7.00 84525-26 $2.00 84525-TC $5.00 84540 $13.00 84540-26 $4.00 84540-TC $8.00 84545 $18.00 84545-26 $5.00 84545-TC $13.00 84550 $12.00 84550-26 $4.00 84550-TC $7.00 84560 $12.00 84560-26 $3.00 84560-TC $8.00 84577 $34.00 84577-26 $11.00 84577-TC $22.00 84578 $7.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 84578-26 $2.00 84578-TC $5.00 84580 $17.00 84580-26 $5.00 84580-TC $12.00 84583 $11.00 84583-26 $3.00 84583-TC $7.00 84585 $36.00 84585-26 $11.00 84585-TC $24.00 84586 $42.00 84586-26 $14.00 84586-TC $27.00 84588 $73.00 84588-26 $23.00 84588-TC $47.00 84590 $33.00 84590-26 $11.00 84590-TC $21.00 84591 $26.00 84591-26 $9.00 84591-TC $18.00 84597 $37.00 84597-26 $11.00 84597-TC $25.00 84600 $43.00 84600-26 $13.00 84600-TC $31.00 84620 $29.00 84620-26 $8.00 84620-TC $20.00 84630 $26.00 84630-26 $8.00 84630-TC $18.00 84681 $52.00 84681-26 $17.00 84681-TC $35.00 84702 $38.00 84702-26 $11.00 84702-TC $26.00 84703 $22.00 84703-26 $6.00 84703-TC $15.00 84830 $17.00 84830-26 $5.00 84830-TC $12.00 84999 BR 84999-26 BR 84999-TC BR Part A, 104 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 85002 $10.00 85002-26 $3.00 85002-TC $6.00 85004 BR 85004-26 BR 85004-TC BR 85007 $6.00 85007-26 $3.00 85007-TC $4.00 85008 $5.00 85008-26 $2.00 85008-TC $3.00 85009 $8.00 85009-26 $3.00 85009-TC $5.00 85013 $3.00 85013-26 $1.00 85013-TC $2.00 85014 $4.00 85014-26 $1.00 85014-TC $3.00 85018 $5.00 85018-26 $2.00 85018-TC $3.00 85025 $20.00 85025-26 $6.00 85025-TC $14.00 85027 $15.00 85027-26 $5.00 85027-TC $10.00 85032 BR 85032-26 BR 85032-TC BR 85041 $7.00 85041-26 $3.00 85041-TC $4.00 85044 $10.00 85044-26 $3.00 85044-TC $6.00 85045 $6.00 85045-26 $2.00 85045-TC $4.00 85046 $13.00 85046-26 $4.00 85046-TC $9.00 85048 $7.00 85048-26 $3.00 85048-TC $4.00 85049 BR 85049-26 BR Pathology & Laboratory CPT Code MRA 85049-TC BR 85060 $25.00 85060-26 $7.00 85060-TC $18.00 85097 $59.00 85097-26 $59.00 85097-TC BR 85130 $19.00 85130-26 $6.00 85130-TC $13.00 85170 $7.00 85170-26 $2.00 85170-TC $5.00 85175 $10.00 85175-26 $3.00 85175-TC $6.00 85210 $31.00 85210-26 $8.00 85210-TC $21.00 85220 $47.00 85220-26 $15.00 85220-TC $32.00 85230 $47.00 85230-26 $14.00 85230-TC $33.00 85240 $48.00 85240-26 $15.00 85240-TC $33.00 85244 $49.00 85244-26 $15.00 85244-TC $34.00 85245 $54.00 85245-26 $18.00 85245-TC $36.00 85246 $54.00 85246-26 $18.00 85246-TC $36.00 85247 $54.00 85247-26 $18.00 85247-TC $36.00 85250 $49.00 85250-26 $14.00 85250-TC $35.00 85260 $49.00 85260-26 $14.00 85260-TC $35.00 85270 $49.00 85270-26 $14.00 85270-TC $35.00 85280 $49.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 85280-26 $14.00 85280-TC $35.00 85290 $44.00 85290-26 $13.00 85290-TC $32.00 85291 $20.00 85291-26 $6.00 85291-TC $14.00 85292 $51.00 85292-26 $17.00 85292-TC $34.00 85293 $51.00 85293-26 $17.00 85293-TC $34.00 85300 $35.00 85300-26 $12.00 85300-TC $23.00 85301 $29.00 85301-26 $10.00 85301-TC $19.00 85302 $33.00 85302-26 $11.00 85302-TC $21.00 85303 $26.00 85303-26 $8.00 85303-TC $18.00 85305 $21.00 85305-26 $7.00 85305-TC $14.00 85306 $29.00 85306-26 $10.00 85306-TC $19.00 85307 $35.00 85307-26 $12.00 85307-TC $23.00 85335 $21.00 85335-26 $7.00 85335-TC $14.00 85337 $19.00 85337-26 $6.00 85337-TC $13.00 85345 $10.00 85345-26 $2.00 85345-TC $7.00 85347 $8.00 85347-26 $2.00 85347-TC $6.00 85348 $10.00 85348-26 $3.00 85348-TC $6.00 Part A, 105 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 85360 $16.00 85360-26 $4.00 85360-TC $12.00 85362 $18.00 85362-26 $7.00 85362-TC $11.00 85366 $13.00 85366-26 $3.00 85366-TC $10.00 85370 $20.00 85370-26 $5.00 85370-TC $15.00 85378 $13.00 85378-26 $4.00 85378-TC $8.00 85379 $18.00 85379-26 $6.00 85379-TC $12.00 85380 BR 85380-26 BR 85380-TC BR 85384 $11.00 85384-26 $3.00 85384-TC $7.00 85385 $16.00 85385-26 $5.00 85385-TC $11.00 85390 $10.00 85390-26 $2.00 85390-TC $7.00 85396 $22.00 85400 $12.00 85400-26 $3.00 85400-TC $8.00 85410 $12.00 85410-26 $3.00 85410-TC $8.00 85415 $28.00 85415-26 $10.00 85415-TC $18.00 85420 $16.00 85420-26 $3.00 85420-TC $13.00 85421 $39.00 85421-26 $12.00 85421-TC $26.00 85441 $7.00 85441-26 $2.00 85441-TC $5.00 85445 $16.00 Pathology & Laboratory CPT Code MRA 85445-26 $5.00 85445-TC $11.00 85460 $15.00 85460-26 $4.00 85460-TC $11.00 85461 $12.00 85461-26 $3.00 85461-TC $8.00 85475 $15.00 85475-26 $4.00 85475-TC $11.00 85520 $22.00 85520-26 $6.00 85520-TC $16.00 85525 $20.00 85525-26 $6.00 85525-TC $14.00 85530 $39.00 85530-26 $12.00 85530-TC $26.00 85536 $14.00 85536-26 $4.00 85536-TC $10.00 85540 $24.00 85540-26 $7.00 85540-TC $17.00 85547 $23.00 85547-26 $6.00 85547-TC $17.00 85549 $45.00 85549-26 $15.00 85549-TC $31.00 85555 $17.00 85555-26 $5.00 85555-TC $12.00 85557 $34.00 85557-26 $10.00 85557-TC $23.00 85576 $21.00 85576-26 $5.00 85576-TC $16.00 85597 $32.00 85597-26 $10.00 85597-TC $21.00 85610 $6.00 85610-26 $3.00 85610-TC $4.00 85611 $6.00 85611-26 $2.00 85611-TC $4.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 85612 $22.00 85612-26 $6.00 85612-TC $16.00 85613 $15.00 85613-26 $4.00 85613-TC $11.00 85635 $26.00 85635-26 $8.00 85635-TC $18.00 85651 $8.00 85651-26 $2.00 85651-TC $6.00 85652 $8.00 85652-26 $2.00 85652-TC $6.00 85660 $10.00 85660-26 $3.00 85660-TC $6.00 85670 $13.00 85670-26 $3.00 85670-TC $10.00 85675 $13.00 85675-26 $4.00 85675-TC $8.00 85705 $13.00 85705-26 $4.00 85705-TC $8.00 85730 $11.00 85730-26 $3.00 85730-TC $7.00 85732 $17.00 85732-26 $5.00 85732-TC $12.00 85810 $19.00 85810-26 $4.00 85810-TC $15.00 85999 BR 85999-26 BR 85999-TC BR 86000 $16.00 86000-26 $5.00 86000-TC $11.00 86001 $12.00 86001-26 $4.00 86001-TC $8.00 86003 $6.00 86003-26 $2.00 86003-TC $3.00 86005 $11.00 86005-26 $4.00 Part A, 106 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 86005-TC $6.00 86021 $41.00 86021-26 $12.00 86021-TC $29.00 86022 $57.00 86022-26 $18.00 86022-TC $39.00 86023 $28.00 86023-26 $10.00 86023-TC $18.00 86038 $22.00 86038-26 $7.00 86038-TC $15.00 86039 $19.00 86039-26 $6.00 86039-TC $13.00 86060 $13.00 86060-26 $3.00 86060-TC $10.00 86063 $21.00 86063-26 $6.00 86063-TC $15.00 86077 $91.00 86077-26 $26.00 86077-TC $64.00 86078 $91.00 86078-26 $26.00 86078-TC $64.00 86079 $79.00 86079-26 $25.00 86079-TC $52.00 86140 $14.00 86140-26 $4.00 86140-TC $10.00 86141 BR 86141-26 BR 86141-TC BR 86146 $58.00 86146-26 $19.00 86146-TC $39.00 86147 $53.00 86147-26 $16.00 86147-TC $36.00 86148 $59.00 86148-26 $21.00 86148-TC $38.00 86155 $26.00 86155-26 $8.00 86155-TC $18.00 86156 $11.00 Pathology & Laboratory CPT Code MRA 86156-26 $3.00 86156-TC $7.00 86157 $13.00 86157-26 $4.00 86157-TC $8.00 86160 $21.00 86160-26 $5.00 86160-TC $16.00 86161 $21.00 86161-26 $5.00 86161-TC $16.00 86162 $54.00 86162-26 $18.00 86162-TC $36.00 86171 $25.00 86171-26 $7.00 86171-TC $18.00 86185 $19.00 86185-26 $6.00 86185-TC $13.00 86215 $36.00 86215-26 $12.00 86215-TC $23.00 86225 $36.00 86225-26 $11.00 86225-TC $24.00 86226 $24.00 86226-26 $8.00 86226-TC $16.00 86235 $33.00 86235-26 $10.00 86235-TC $22.00 86243 $50.00 86243-26 $15.00 86243-TC $35.00 86255 $25.00 86255-26 $8.00 86255-TC $17.00 86256 $25.00 86256-26 $8.00 86256-TC $17.00 86277 $41.00 86277-26 $14.00 86277-TC $26.00 86280 $15.00 86280-26 $3.00 86280-TC $12.00 86294 BR 86294-26 BR 86294-TC BR CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 86300 $47.00 86300-26 $15.00 86300-TC $32.00 86301 $47.00 86301-26 $15.00 86301-TC $32.00 86304 $47.00 86304-26 $15.00 86304-TC $32.00 86308 $8.00 86308-26 $3.00 86308-TC $5.00 86309 $12.00 86309-26 $3.00 86309-TC $8.00 86310 $19.00 86310-26 $6.00 86310-TC $13.00 86316 $37.00 86316-26 $11.00 86316-TC $25.00 86317 $31.00 86317-26 $10.00 86317-TC $20.00 86318 $23.00 86318-26 $10.00 86318-TC $14.00 86320 $49.00 86320-26 $19.00 86320-TC $29.00 86325 $49.00 86325-26 $16.00 86325-TC $33.00 86327 $62.00 86327-26 $19.00 86327-TC $42.00 86329 $37.00 86329-26 $12.00 86329-TC $24.00 86331 $22.00 86331-26 $6.00 86331-TC $15.00 86332 $54.00 86332-26 $18.00 86332-TC $36.00 86334 $65.00 86334-26 $18.00 86334-TC $45.00 86335 BR 86335-26 $20.00 Part A, 107 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 86335-TC BR 86336 BR 86336-26 BR 86336-TC BR 86337 $54.00 86337-26 $18.00 86337-TC $36.00 86340 $39.00 86340-26 $13.00 86340-TC $25.00 86341 $38.00 86341-26 $13.00 86341-TC $24.00 86343 $33.00 86343-26 $11.00 86343-TC $21.00 86344 $21.00 86344-26 $7.00 86344-TC $14.00 86353 $102.00 86353-26 $31.00 86353-TC $72.00 86359 $61.00 86359-26 $19.00 86359-TC $41.00 86360 $99.00 86360-26 $33.00 86360-TC $67.00 86361 $66.00 86361-26 $21.00 86361-TC $43.00 86376 $35.00 86376-26 $11.00 86376-TC $23.00 86378 $45.00 86378-26 $15.00 86378-TC $31.00 86382 $45.00 86382-26 $14.00 86382-TC $32.00 86384 $24.00 86384-26 $8.00 86384-TC $16.00 86403 $18.00 86403-26 $3.00 86403-TC $14.00 86406 $21.00 86406-26 $5.00 86406-TC $16.00 86430 $13.00 Pathology & Laboratory CPT Code MRA 86430-26 $4.00 86430-TC $8.00 86431 $17.00 86431-26 $6.00 86431-TC $11.00 86485 $13.00 86485-26 $4.00 86485-TC $8.00 86486 $6.00 86490 $17.00 86490-26 $5.00 86490-TC $12.00 86510 $13.00 86510-26 $4.00 86510-TC $8.00 86580 $13.00 86580-26 $4.00 86580-TC $8.00 86590 $18.00 86590-26 $6.00 86590-TC $12.00 86592 $8.00 86592-26 $2.00 86592-TC $6.00 86593 $11.00 86593-26 $3.00 86593-TC $7.00 86602 $17.00 86602-26 $5.00 86602-TC $12.00 86603 $20.00 86603-26 $6.00 86603-TC $14.00 86606 $24.00 86606-26 $8.00 86606-TC $16.00 86609 $20.00 86609-26 $6.00 86609-TC $14.00 86611 $23.00 86611-26 $8.00 86611-TC $15.00 86612 $21.00 86612-26 $6.00 86612-TC $15.00 86615 $21.00 86615-26 $6.00 86615-TC $15.00 86617 $29.00 86617-26 $10.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 86617-TC $19.00 86618 $26.00 86618-26 $8.00 86618-TC $18.00 86619 $21.00 86619-26 $6.00 86619-TC $15.00 86622 $16.00 86622-26 $5.00 86622-TC $11.00 86625 $21.00 86625-26 $6.00 86625-TC $15.00 86628 $20.00 86628-26 $6.00 86628-TC $14.00 86631 $20.00 86631-26 $6.00 86631-TC $14.00 86632 $20.00 86632-26 $6.00 86632-TC $14.00 86635 $18.00 86635-26 $5.00 86635-TC $13.00 86638 $20.00 86638-26 $6.00 86638-TC $14.00 86641 $21.00 86641-26 $7.00 86641-TC $14.00 86644 $22.00 86644-26 $7.00 86644-TC $15.00 86645 $28.00 86645-26 $10.00 86645-TC $18.00 86648 $24.00 86648-26 $8.00 86648-TC $16.00 86651 $21.00 86651-26 $7.00 86651-TC $14.00 86652 $21.00 86652-26 $7.00 86652-TC $14.00 86653 $21.00 86653-26 $7.00 86653-TC $14.00 86654 $21.00 Part A, 108 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 86654-26 $7.00 86654-TC $14.00 86658 $21.00 86658-26 $7.00 86658-TC $14.00 86663 $21.00 86663-26 $7.00 86663-TC $14.00 86664 $53.00 86664-26 $17.00 86664-TC $36.00 86665 $29.00 86665-26 $10.00 86665-TC $19.00 86666 $23.00 86666-26 $8.00 86666-TC $15.00 86668 $17.00 86668-26 $5.00 86668-TC $12.00 86671 $20.00 86671-26 $6.00 86671-TC $14.00 86674 $23.00 86674-26 $7.00 86674-TC $16.00 86677 $24.00 86677-26 $8.00 86677-TC $16.00 86682 $21.00 86682-26 $7.00 86682-TC $14.00 86684 $24.00 86684-26 $8.00 86684-TC $16.00 86687 $22.00 86687-26 $7.00 86687-TC $16.00 86688 $20.00 86688-26 $7.00 86688-TC $14.00 86689 $25.00 86689-26 $8.00 86689-TC $17.00 86692 $22.00 86692-26 $7.00 86692-TC $15.00 86694 $22.00 86694-26 $7.00 86694-TC $15.00 Pathology & Laboratory CPT Code MRA 86695 $21.00 86695-26 $7.00 86695-TC $14.00 86696 $44.00 86696-26 $14.00 86696-TC $30.00 86698 $20.00 86698-26 $6.00 86698-TC $14.00 86701 $21.00 86701-26 $7.00 86701-TC $15.00 86702 $21.00 86702-26 $7.00 86702-TC $14.00 86703 $22.00 86703-26 $7.00 86703-TC $15.00 86704 $33.00 86704-26 $11.00 86704-TC $21.00 86705 $35.00 86705-26 $11.00 86705-TC $23.00 86706 $24.00 86706-26 $8.00 86706-TC $16.00 86707 $26.00 86707-26 $8.00 86707-TC $18.00 86708 $32.00 86708-26 $10.00 86708-TC $21.00 86709 $29.00 86709-26 $10.00 86709-TC $19.00 86710 $22.00 86710-26 $7.00 86710-TC $15.00 86713 $23.00 86713-26 $7.00 86713-TC $16.00 86717 $20.00 86717-26 $6.00 86717-TC $14.00 86720 $21.00 86720-26 $7.00 86720-TC $14.00 86723 $21.00 86723-26 $7.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 86723-TC $14.00 86727 $20.00 86727-26 $6.00 86727-TC $14.00 86729 $19.00 86729-26 $6.00 86729-TC $13.00 86732 $21.00 86732-26 $7.00 86732-TC $14.00 86735 $21.00 86735-26 $7.00 86735-TC $14.00 86738 $21.00 86738-26 $7.00 86738-TC $14.00 86741 $21.00 86741-26 $7.00 86741-TC $14.00 86744 $21.00 86744-26 $7.00 86744-TC $14.00 86747 $23.00 86747-26 $7.00 86747-TC $16.00 86750 $21.00 86750-26 $7.00 86750-TC $14.00 86753 $20.00 86753-26 $6.00 86753-TC $14.00 86756 $20.00 86756-26 $6.00 86756-TC $14.00 86757 $44.00 86757-26 $14.00 86757-TC $30.00 86759 $21.00 86759-26 $7.00 86759-TC $14.00 86762 $22.00 86762-26 $7.00 86762-TC $15.00 86765 $20.00 86765-26 $6.00 86765-TC $14.00 86768 $21.00 86768-26 $7.00 86768-TC $14.00 86771 $21.00 Part A, 109 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 86771-26 $7.00 86771-TC $14.00 86774 $23.00 86774-26 $7.00 86774-TC $16.00 86777 $22.00 86777-26 $7.00 86777-TC $15.00 86778 $23.00 86778-26 $7.00 86778-TC $16.00 86781 $22.00 86781-26 $7.00 86781-TC $15.00 86784 $21.00 86784-26 $7.00 86784-TC $14.00 86787 $20.00 86787-26 $6.00 86787-TC $14.00 86790 $21.00 86790-26 $7.00 86790-TC $14.00 86793 $21.00 86793-26 $7.00 86793-TC $14.00 86800 $26.00 86800-26 $8.00 86800-TC $18.00 86803 $24.00 86803-26 $8.00 86803-TC $16.00 86804 $26.00 86804-26 $8.00 86804-TC $18.00 86805 $97.00 86805-26 $33.00 86805-TC $64.00 86806 $87.00 86806-26 $28.00 86806-TC $57.00 86807 $74.00 86807-26 $21.00 86807-TC $51.00 86808 $52.00 86808-26 $15.00 86808-TC $37.00 86812 $108.00 86812-26 $32.00 86812-TC $75.00 Pathology & Laboratory CPT Code MRA 86813 $101.00 86813-26 $29.00 86813-TC $71.00 86816 $64.00 86816-26 $18.00 86816-TC $44.00 86817 $134.00 86817-26 $39.00 86817-TC $94.00 86821 $123.00 86821-26 $36.00 86821-TC $86.00 86822 $96.00 86822-26 $32.00 86822-TC $64.00 86849 BR 86849-26 BR 86849-TC BR 86850 $10.00 86850-26 $3.00 86850-TC $6.00 86860 $44.00 86860-26 $15.00 86860-TC $29.00 86870 $17.00 86870-26 $6.00 86870-TC $11.00 86880 $13.00 86880-26 $4.00 86880-TC $8.00 86885 $15.00 86885-26 $4.00 86885-TC $11.00 86886 $14.00 86886-26 $4.00 86886-TC $10.00 86890 $67.00 86890-26 $11.00 86890-TC $54.00 86891 $91.00 86891-26 $26.00 86891-TC $64.00 86900 $10.00 86900-26 $3.00 86900-TC $6.00 86901 $10.00 86901-26 $3.00 86901-TC $6.00 86903 $15.00 86903-26 $5.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 86903-TC $10.00 86904 $19.00 86904-26 $6.00 86904-TC $13.00 86905 $7.00 86905-26 $1.00 86905-TC $6.00 86906 $11.00 86906-26 $3.00 86906-TC $7.00 86910 $83.00 86910-26 $24.00 86910-TC $57.00 86911 $19.00 86911-26 $6.00 86911-TC $13.00 86920 $19.00 86920-26 $3.00 86920-TC $15.00 86921 $23.00 86921-26 $7.00 86921-TC $16.00 86922 $20.00 86922-26 $6.00 86922-TC $14.00 86927 $21.00 86927-26 $5.00 86927-TC $16.00 86930 $155.00 86930-26 $45.00 86930-TC $108.00 86931 $155.00 86931-26 $45.00 86931-TC $108.00 86932 $161.00 86932-26 $48.00 86932-TC $111.00 86940 $18.00 86940-26 $5.00 86940-TC $13.00 86941 $31.00 86941-26 $8.00 86941-TC $21.00 86945 $35.00 86945-26 $11.00 86945-TC $23.00 86950 $99.00 86950-26 $29.00 86950-TC $70.00 86965 $25.00 Part A, 110 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 86965-26 $7.00 86965-TC $18.00 86970 $41.00 86970-26 $12.00 86970-TC $29.00 86971 $20.00 86971-26 $5.00 86971-TC $15.00 86972 $20.00 86972-26 $6.00 86972-TC $14.00 86975 $53.00 86975-26 $16.00 86975-TC $37.00 86976 $53.00 86976-26 $16.00 86976-TC $37.00 86977 $53.00 86977-26 $16.00 86977-TC $37.00 86978 $65.00 86978-26 $19.00 86978-TC $44.00 86985 $35.00 86985-26 $12.00 86985-TC $23.00 86999 BR 86999-26 BR 86999-TC BR 87001 $35.00 87001-26 $11.00 87001-TC $23.00 87003 $40.00 87003-26 $13.00 87003-TC $26.00 87015 $14.00 87015-26 $5.00 87015-TC $9.00 87040 $18.00 87040-26 $6.00 87040-TC $12.00 87045 $18.00 87045-26 $6.00 87045-TC $11.00 87046 $5.00 87046-26 $2.00 87046-TC $3.00 87070 $14.00 87070-26 $4.00 87070-TC $10.00 Pathology & Laboratory CPT Code MRA 87071 $11.00 87071-26 $3.00 87071-TC $8.00 87073 $11.00 87073-26 $3.00 87073-TC $8.00 87075 $18.00 87075-26 $6.00 87075-TC $12.00 87076 $24.00 87076-26 $8.00 87076-TC $16.00 87077 $16.00 87077-26 $5.00 87077-TC $11.00 87081 $12.00 87081-26 $3.00 87081-TC $8.00 87084 $23.00 87084-26 $7.00 87084-TC $16.00 87086 $14.00 87086-26 $3.00 87086-TC $11.00 87088 $18.00 87088-26 $6.00 87088-TC $12.00 87101 $20.00 87101-26 $6.00 87101-TC $14.00 87102 $20.00 87102-26 $6.00 87102-TC $14.00 87103 $32.00 87103-26 $11.00 87103-TC $20.00 87106 $25.00 87106-26 $7.00 87106-TC $18.00 87107 $23.00 87107-26 $8.00 87107-TC $15.00 87109 $26.00 87109-26 $8.00 87109-TC $18.00 87110 $23.00 87110-26 $7.00 87110-TC $15.00 87116 $15.00 87116-26 $3.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 87116-TC $11.00 87118 $28.00 87118-26 $9.00 87118-TC $20.00 87140 $24.00 87140-26 $7.00 87140-TC $17.00 87143 $34.00 87143-26 $11.00 87143-TC $22.00 87147 $26.00 87147-26 $8.00 87147-TC $18.00 87149 $46.00 87149-26 $15.00 87149-TC $31.00 87152 $12.00 87152-26 $4.00 87152-TC $8.00 87158 $5.00 87158-26 $1.00 87158-TC $3.00 87164 $24.00 87164-26 $8.00 87164-TC $16.00 87166 $24.00 87166-26 $7.00 87166-TC $17.00 87168 $10.00 87168-26 $3.00 87168-TC $7.00 87169 $10.00 87169-26 $3.00 87169-TC $7.00 87172 $10.00 87172-26 $3.00 87172-TC $7.00 87176 $16.00 87176-26 $5.00 87176-TC $11.00 87177 $18.00 87177-26 $6.00 87177-TC $12.00 87181 $13.00 87181-26 $3.00 87181-TC $8.00 87184 $13.00 87184-26 $3.00 87184-TC $10.00 87185 $11.00 Part A, 111 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 87185-26 $3.00 87185-TC $8.00 87186 $16.00 87186-26 $4.00 87186-TC $12.00 87187 $20.00 87187-26 $3.00 87187-TC $17.00 87188 $18.00 87188-26 $5.00 87188-TC $13.00 87190 $7.00 87190-26 $2.00 87190-TC $5.00 87197 $29.00 87197-26 $10.00 87197-TC $19.00 87205 $11.00 87205-26 $3.00 87205-TC $7.00 87206 $15.00 87206-26 $3.00 87206-TC $12.00 87207 $10.00 87207-26 $3.00 87207-TC $6.00 87210 $8.00 87210-26 $2.00 87210-TC $6.00 87220 $12.00 87220-26 $4.00 87220-TC $7.00 87230 $35.00 87230-26 $11.00 87230-TC $23.00 87250 $33.00 87250-26 $13.00 87250-TC $19.00 87252 $44.00 87252-26 $14.00 87252-TC $31.00 87253 $33.00 87253-26 $10.00 87253-TC $22.00 87254 $11.00 87254-26 $3.00 87254-TC $8.00 87255 BR 87255-26 BR 87255-TC BR Pathology & Laboratory CPT Code MRA 87260 $26.00 87260-26 $8.00 87260-TC $18.00 87265 $26.00 87265-26 $8.00 87265-TC $18.00 87267 BR 87267-26 BR 87267-TC BR 87270 $26.00 87270-26 $8.00 87270-TC $18.00 87271 BR 87271-26 BR 87271-TC BR 87272 $26.00 87272-26 $8.00 87272-TC $18.00 87273 $27.00 87273-26 $9.00 87273-TC $19.00 87274 $26.00 87274-26 $8.00 87274-TC $18.00 87275 $27.00 87275-26 $9.00 87275-TC $19.00 87276 $26.00 87276-26 $8.00 87276-TC $18.00 87277 $27.00 87277-26 $9.00 87277-TC $19.00 87278 $26.00 87278-26 $8.00 87278-TC $18.00 87279 $27.00 87279-26 $9.00 87279-TC $19.00 87280 $26.00 87280-26 $8.00 87280-TC $18.00 87281 $27.00 87281-26 $9.00 87281-TC $19.00 87283 $27.00 87283-26 $9.00 87283-TC $19.00 87285 $26.00 87285-26 $8.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 87285-TC $18.00 87290 $26.00 87290-26 $8.00 87290-TC $18.00 87299 $26.00 87299-26 $8.00 87299-TC $18.00 87300 $13.00 87300-26 $4.00 87300-TC $9.00 87301 $26.00 87301-26 $8.00 87301-TC $18.00 87320 $26.00 87320-26 $8.00 87320-TC $18.00 87324 $26.00 87324-26 $8.00 87324-TC $18.00 87327 $27.00 87327-26 $9.00 87327-TC $19.00 87328 $26.00 87328-26 $8.00 87328-TC $18.00 87332 $26.00 87332-26 $8.00 87332-TC $18.00 87335 $26.00 87335-26 $8.00 87335-TC $18.00 87336 $27.00 87336-26 $9.00 87336-TC $19.00 87337 $27.00 87337-26 $9.00 87337-TC $19.00 87338 $27.00 87338-26 $7.00 87338-TC $20.00 87339 $27.00 87339-26 $9.00 87339-TC $19.00 87340 $20.00 87340-26 $6.00 87340-TC $14.00 87341 $23.00 87341-26 $8.00 87341-TC $15.00 87350 $20.00 Part A, 112 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 87350-26 $6.00 87350-TC $14.00 87380 $35.00 87380-26 $11.00 87380-TC $23.00 87385 $26.00 87385-26 $8.00 87385-TC $18.00 87390 $38.00 87390-26 $13.00 87390-TC $24.00 87391 $38.00 87391-26 $13.00 87391-TC $24.00 87400 $13.00 87400-26 $4.00 87400-TC $9.00 87420 $26.00 87420-26 $8.00 87420-TC $18.00 87425 $26.00 87425-26 $8.00 87425-TC $18.00 87427 $27.00 87427-26 $9.00 87427-TC $19.00 87430 $26.00 87430-26 $8.00 87430-TC $18.00 87449 $26.00 87449-26 $8.00 87449-TC $18.00 87450 $21.00 87450-26 $6.00 87450-TC $15.00 87451 $19.00 87451-26 $7.00 87451-TC $12.00 87470 $42.00 87470-26 $13.00 87470-TC $28.00 87471 $73.00 87471-26 $23.00 87471-TC $48.00 87472 $88.00 87472-26 $28.00 87472-TC $58.00 87475 $40.00 87475-26 $13.00 87475-TC $26.00 Pathology & Laboratory CPT Code MRA 87476 $73.00 87476-26 $23.00 87476-TC $48.00 87477 $88.00 87477-26 $28.00 87477-TC $58.00 87480 $42.00 87480-26 $13.00 87480-TC $28.00 87481 $73.00 87481-26 $23.00 87481-TC $48.00 87482 $86.00 87482-26 $28.00 87482-TC $56.00 87485 $42.00 87485-26 $13.00 87485-TC $28.00 87486 $73.00 87486-26 $23.00 87486-TC $48.00 87487 $88.00 87487-26 $28.00 87487-TC $58.00 87490 $42.00 87490-26 $13.00 87490-TC $28.00 87491 $73.00 87491-26 $23.00 87491-TC $48.00 87492 $73.00 87492-26 $23.00 87492-TC $48.00 87495 $42.00 87495-26 $13.00 87495-TC $28.00 87496 $73.00 87496-26 $23.00 87496-TC $48.00 87497 $88.00 87497-26 $28.00 87497-TC $58.00 87510 $42.00 87510-26 $13.00 87510-TC $28.00 87511 $73.00 87511-26 $23.00 87511-TC $48.00 87512 $86.00 87512-26 $28.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 87512-TC $56.00 87515 $42.00 87515-26 $13.00 87515-TC $28.00 87516 $73.00 87516-26 $23.00 87516-TC $48.00 87517 $88.00 87517-26 $28.00 87517-TC $58.00 87520 $42.00 87520-26 $13.00 87520-TC $28.00 87521 $73.00 87521-26 $23.00 87521-TC $48.00 87522 $88.00 87522-26 $28.00 87522-TC $58.00 87525 $42.00 87525-26 $13.00 87525-TC $28.00 87526 $73.00 87526-26 $23.00 87526-TC $48.00 87527 $86.00 87527-26 $28.00 87527-TC $56.00 87528 $42.00 87528-26 $13.00 87528-TC $28.00 87529 $73.00 87529-26 $23.00 87529-TC $48.00 87530 $88.00 87530-26 $28.00 87530-TC $58.00 87531 $42.00 87531-26 $13.00 87531-TC $28.00 87532 $73.00 87532-26 $23.00 87532-TC $48.00 87533 $86.00 87533-26 $28.00 87533-TC $56.00 87534 $42.00 87534-26 $13.00 87534-TC $28.00 87535 $73.00 Part A, 113 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 87535-26 $23.00 87535-TC $48.00 87536 $86.00 87536-26 $28.00 87536-TC $56.00 87537 $42.00 87537-26 $13.00 87537-TC $28.00 87538 $73.00 87538-26 $23.00 87538-TC $48.00 87539 $88.00 87539-26 $28.00 87539-TC $58.00 87540 $42.00 87540-26 $13.00 87540-TC $28.00 87541 $73.00 87541-26 $23.00 87541-TC $48.00 87542 $86.00 87542-26 $28.00 87542-TC $56.00 87550 $42.00 87550-26 $13.00 87550-TC $28.00 87551 $73.00 87551-26 $23.00 87551-TC $48.00 87552 $88.00 87552-26 $28.00 87552-TC $58.00 87555 $42.00 87555-26 $13.00 87555-TC $28.00 87556 $73.00 87556-26 $23.00 87556-TC $48.00 87557 $88.00 87557-26 $28.00 87557-TC $58.00 87560 $42.00 87560-26 $13.00 87560-TC $28.00 87561 $73.00 87561-26 $23.00 87561-TC $48.00 87562 $88.00 87562-26 $28.00 87562-TC $58.00 Pathology & Laboratory CPT Code MRA 87580 $42.00 87580-26 $13.00 87580-TC $28.00 87581 $73.00 87581-26 $23.00 87581-TC $48.00 87582 $86.00 87582-26 $28.00 87582-TC $56.00 87590 $42.00 87590-26 $13.00 87590-TC $28.00 87591 $73.00 87591-26 $23.00 87591-TC $48.00 87592 $88.00 87592-26 $28.00 87592-TC $58.00 87620 $42.00 87620-26 $13.00 87620-TC $28.00 87621 $73.00 87621-26 $23.00 87621-TC $48.00 87622 $86.00 87622-26 $28.00 87622-TC $56.00 87650 $42.00 87650-26 $13.00 87650-TC $28.00 87651 $73.00 87651-26 $23.00 87651-TC $48.00 87652 $86.00 87652-26 $28.00 87652-TC $56.00 87797 $42.00 87797-26 $13.00 87797-TC $28.00 87798 $73.00 87798-26 $23.00 87798-TC $48.00 87799 $88.00 87799-26 $28.00 87799-TC $58.00 87800 $46.00 87800-26 $15.00 87800-TC $31.00 87801 $81.00 87801-26 $26.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 87801-TC $54.00 87802 BR 87802-26 BR 87802-TC BR 87803 BR 87803-26 BR 87803-TC BR 87804 BR 87804-26 BR 87804-TC BR 87810 $26.00 87810-26 $8.00 87810-TC $18.00 87850 $26.00 87850-26 $8.00 87850-TC $18.00 87880 $26.00 87880-26 $8.00 87880-TC $18.00 87899 $26.00 87899-26 $8.00 87899-TC $18.00 87901 $594.00 87901-26 $196.00 87901-TC $398.00 87902 BR 87902-26 BR 87902-TC BR 87903 $1,126.00 87903-26 $371.00 87903-TC $755.00 87904 $59.00 87904-26 $20.00 87904-TC $39.00 87999 BR 87999-26 BR 87999-TC BR 88000 $445.00 88000-26 $445.00 88000-TC BR 88005 $500.00 88005-26 $500.00 88005-TC BR 88007 $556.00 88007-26 $556.00 88007-TC BR 88020 $556.00 88020-26 $556.00 88020-TC BR 88025 $610.00 Part A, 114 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 88025-26 $610.00 88025-TC BR 88027 $666.00 88027-26 $666.00 88027-TC BR 88036 $477.00 88036-26 $477.00 88036-TC BR 88037 $389.00 88037-26 $389.00 88037-TC BR 88040 $1,445.00 88040-26 $1,445.00 88040-TC BR 88045 BR 88045-26 BR 88045-TC BR 88099 BR 88099-26 BR 88099-TC BR 88104 $49.00 88104-26 $37.00 88104-TC $10.00 88106 $54.00 88106-26 $16.00 88106-TC $38.00 88107 $74.00 88107-26 $57.00 88107-TC $15.00 88108 $59.00 88108-26 $47.00 88108-TC $11.00 88112 $121.00 88112-26 $65.00 88112-TC $56.00 88125 $70.00 88125-26 $20.00 88125-TC $48.00 88130 $25.00 88130-26 $7.00 88130-TC $18.00 88140 $18.00 88140-26 $5.00 88140-TC $13.00 88141 $33.00 88141-26 BR 88141-TC BR 88142 $82.00 88142-26 $21.00 88142-TC $59.00 Pathology & Laboratory CPT Code MRA 88143 $94.00 88143-26 $33.00 88143-TC $59.00 88147 $82.00 88147-26 BR 88147-TC $82.00 88148 $104.00 88148-26 $21.00 88148-TC $82.00 88150 $13.00 88150-26 $3.00 88150-TC $9.00 88152 $46.00 88152-26 $8.00 88152-TC $38.00 88153 $82.00 88153-26 $21.00 88153-TC $59.00 88154 $104.00 88154-26 $21.00 88154-TC $82.00 88155 $14.00 88155-26 $3.00 88155-TC $10.00 88160 $45.00 88160-26 $14.00 88160-TC $24.00 88161 $64.00 88161-26 $19.00 88161-TC $37.00 88162 $77.00 88162-26 $22.00 88162-TC $53.00 88164 $54.00 88164-26 $21.00 88164-TC $33.00 88165 $72.00 88165-26 $33.00 88165-TC $38.00 88166 $82.00 88166-26 $21.00 88166-TC $59.00 88167 $87.00 88167-26 $26.00 88167-TC $59.00 88172 $70.00 88172-26 $54.00 88172-TC $14.00 88173 $95.00 88173-26 $95.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 88173-TC $26.00 88174 BR 88174-26 BR 88174-TC BR 88175 BR 88175-26 BR 88175-TC BR 88182 $88.00 88182-26 $33.00 88182-TC $54.00 88184 $51.00 88185 $25.00 88187 $69.00 88188 $86.00 88189 $113.00 88199 BR 88199-26 BR 88199-TC BR 88233 $243.00 88233-26 $73.00 88233-TC $170.00 88235 $256.00 88235-26 $76.00 88235-TC $177.00 88240 $21.00 88240-26 $6.00 88240-TC $15.00 88241 $21.00 88241-26 $6.00 88241-TC $15.00 88300 $24.00 88300-26 $19.00 88300-TC $5.00 88302 $53.00 88302-26 $42.00 88302-TC $11.00 88304 $70.00 88304-26 $54.00 88304-TC $14.00 88305 $108.00 88305-26 $86.00 88305-TC $21.00 88307 $210.00 88307-26 $168.00 88307-TC $41.00 88309 $322.00 88309-26 $258.00 88309-TC $64.00 88311 $23.00 88311-26 $19.00 Part A, 115 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 88311-TC $4.00 88312 $23.00 88312-26 $7.00 88312-TC $16.00 88313 $23.00 88313-26 $7.00 88313-TC $16.00 88314 $21.00 88314-26 $6.00 88314-TC $15.00 88318 $33.00 88318-26 $14.00 88318-TC $18.00 88319 $26.00 88319-26 $13.00 88319-TC $14.00 88321 $43.00 88321-26 $43.00 88321-TC BR 88323 $61.00 88323-26 $61.00 88323-TC $32.00 88325 $54.00 88325-26 $54.00 88325-TC BR 88329 $51.00 88329-26 $51.00 88329-TC BR 88331 $102.00 88331-26 $70.00 88331-TC $33.00 88332 $53.00 88332-26 $36.00 88332-TC $17.00 88333 $89.00 88333-26 $67.00 88333-TC $22.00 88334 $47.00 88334-26 $33.00 88334-TC $14.00 88342 $53.00 88342-26 $36.00 88342-TC $17.00 88346 $96.00 88346-26 $66.00 88346-TC $28.00 88347 $133.00 88347-26 $99.00 88347-TC $33.00 88348 $191.00 Pathology & Laboratory CPT Code MRA 88348-26 $145.00 88348-TC $44.00 88349 $191.00 88349-26 $145.00 88349-TC $44.00 88355 $108.00 88355-26 $80.00 88355-TC $26.00 88356 $108.00 88356-26 $80.00 88356-TC $26.00 88358 $108.00 88358-26 $80.00 88358-TC $26.00 88360 $110.00 88360-26 $62.00 88360-TC $49.00 88361 $139.00 88361-26 $55.00 88361-TC $84.00 88362 $251.00 88362-26 $119.00 88362-TC $132.00 88365 $24.00 88365-26 $24.00 88365-TC $68.00 88367 $210.00 88367-26 $72.00 88367-TC $138.00 88368 $190.00 88368-26 $78.00 88368-TC $112.00 88371 $34.00 88371-26 $10.00 88371-TC $23.00 88372 $38.00 88372-26 $11.00 88372-TC $26.00 88380 $159.00 88380-26 $71.00 88380-TC $88.00 88381 $213.00 88381-26 $54.00 88381-TC $159.00 88385 $330.00 88385-26 $84.00 88385-TC $247.00 88386 $344.00 88386-26 $105.00 88386-TC $239.00 CPT only © 2008 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 88399 BR 88399-26 BR 88399-TC BR 89049 $190.00 89050 $10.00 89050-26 $3.00 89050-TC $6.00 89051 $13.00 89051-26 $4.00 89051-TC $8.00 89055 BR 89055-26 BR 89055-TC BR 89060 $13.00 89060-26 $5.00 89060-TC $8.00 89100 $51.00 89100-26 $15.00 89100-TC $36.00 89105 $65.00 89105-26 $19.00 89105-TC $44.00 89125 $14.00 89125-26 $4.00 89125-TC $10.00 89130 $44.00 89130-26 $13.00 89130-TC $32.00 89132 $20.00 89132-26 $6.00 89132-TC $14.00 89135 $37.00 89135-26 $11.00 89135-TC $25.00 89136 $43.00 89136-26 $14.00 89136-TC $29.00 89140 $50.00 89140-26 $16.00 89140-TC $34.00 89141 $56.00 89141-26 $19.00 89141-TC $37.00 89160 $6.00 89160-26 $2.00 89160-TC $4.00 89190 $10.00 89190-26 $3.00 89190-TC $6.00 89220 $17.00 Part A, 116 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code MRA 89230 $5.00 G0124 $24.00 G0141 $24.00 CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 117 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 90471 90472 90473 90474 90632 90636 90675 90703 90718 90746 90749 90801 90802 90804 90805 90806 90807 90808 90809 90810 90811 90812 90813 90814 90815 90816 90817 90818 90819 90821 90822 90823 90824 90826 90827 90828 90829 90845 90846 90847 90849 90853 90857 90862 90865 90870 90875 90876 90880 90882 MRA $4.00 $4.00 $13.00 $9.00 BR BR BR BR BR BR BR $140.00 $143.00 $62.00 $68.00 $94.00 $101.00 $144.00 $149.00 $69.00 $77.00 $101.00 $107.00 $143.00 $149.00 $64.00 $70.00 $96.00 $102.00 $144.00 $149.00 $73.00 $78.00 $103.00 $107.00 $146.00 $150.00 $85.00 $93.00 $110.00 $32.00 $32.00 $31.00 $50.00 $143.00 $94.00 $74.00 $112.00 $112.00 $104.00 Medicine CPT Code 90885 90887 90889 90899 90901 90911 90935 90937 90940 90945 90947 90997 90999 91000 91000-26 91000-TC 91010 91010-26 91010-TC 91011 91011-26 91011-TC 91012 91012-26 91012-TC 91020 91020-26 91020-TC 91022 91022-26 91022-TC 91030 91030-26 91030-TC 91034 91034-26 91034-TC 91035 91035-26 91035-TC 91037 91037-26 91037-TC 91038 91038-26 91038-TC 91040 91040-26 91040-TC 91052 MRA $49.00 $77.00 BR BR $46.00 $82.00 $76.00 $226.00 BR $80.00 $125.00 $115.00 BR $43.00 $40.00 $2.00 $116.00 $76.00 $32.00 $141.00 $89.00 $39.00 $143.00 $95.00 $45.00 $60.00 $49.00 $9.00 $227.00 $77.00 $150.00 $57.00 $47.00 $8.00 $240.00 $52.00 $188.00 $474.00 $84.00 $390.00 $152.00 $52.00 $100.00 $130.00 $59.00 $72.00 $463.00 $52.00 $411.00 $67.00 CPT only © 2008 American Medical Association. All Rights Reserved. Medicine CPT Code 91052-26 91052-TC 91055 91055-26 91055-TC 91065 91065-26 91065-TC 91105 91110 91110-26 91110-TC 91111 91111-26 91111-TC 91120 91120-26 91120-TC 91122 91122-26 91122-TC 91123 91132 91132-26 91132-TC 91133 91133-26 91133-TC 91299 91299-26 91299-TC 92002 92004 92012 92014 92015 92018 92019 92020 92025 92025-26 92025-TC 92060 92060-26 92060-TC 92065 92065-26 92065-TC 92070 92081 MRA $52.00 $12.00 $63.00 $46.00 $11.00 $34.00 $23.00 $14.00 $35.00 $928.00 $185.00 $743.00 $743.00 $53.00 $690.00 $457.00 $52.00 $405.00 $169.00 $122.00 $37.00 BR BR $28.00 BR BR $34.00 BR BR BR BR $63.00 $98.00 $53.00 $75.00 $34.00 $80.00 $70.00 $31.00 $29.00 $17.00 $13.00 $40.00 $32.00 $7.00 $34.00 $19.00 $6.00 $66.00 $32.00 Part A, 118 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 92081-26 92081-TC 92082 92082-26 92082-TC 92083 92083-26 92083-TC 92100 92120 92130 92135 92135-26 92135-TC 92136 92136-26 92136-TC 92140 92225 92226 92230 92235 92235-26 92235-TC 92240 92240-26 92240-TC 92250 92250-26 92250-TC 92260 92265 92265-26 92265-TC 92270 92270-26 92270-TC 92275 92275-26 92275-TC 92283 92283-26 92283-TC 92284 92284-26 92284-TC 92285 92285-26 92285-TC 92286 MRA $19.00 $6.00 $48.00 $24.00 $9.00 $59.00 $31.00 $14.00 $40.00 $32.00 $56.00 $69.00 $18.00 $49.00 $93.00 $29.00 $63.00 $38.00 $45.00 $39.00 $58.00 $104.00 $46.00 $53.00 $132.00 $60.00 $67.00 $40.00 $24.00 $7.00 $20.00 $53.00 $37.00 $10.00 $64.00 $45.00 $19.00 $80.00 $56.00 $17.00 $24.00 $10.00 $5.00 $192.00 $151.00 $46.00 $26.00 $12.00 $6.00 $91.00 Medicine CPT Code 92286-26 92286-TC 92287 92310 92311 92312 92313 92314 92315 92316 92317 92325 92326 92340 92341 92342 92352 92353 92354 92355 92358 92370 92371 92499 92499-26 92499-TC 92502 92504 92506 92507 92508 92511 92512 92516 92520 92526 92531 92532 92533 92534 92541 92541-26 92541-TC 92542 92542-26 92542-TC 92543 92543-26 92543-TC 92544 MRA $53.00 $29.00 $99.00 $86.00 $78.00 $89.00 $70.00 $54.00 $44.00 $59.00 $39.00 $14.00 $44.00 $32.00 $43.00 $43.00 $31.00 $38.00 $221.00 $107.00 $24.00 $35.00 $18.00 BR BR BR $101.00 $24.00 $63.00 $40.00 $42.00 $81.00 $46.00 $36.00 $47.00 $48.00 $10.00 $14.00 $41.00 BR $37.00 $25.00 $9.00 $33.00 $20.00 $10.00 $28.00 $19.00 $10.00 $26.00 CPT only © 2008 American Medical Association. All Rights Reserved. Medicine CPT Code 92544-26 92544-TC 92545 92545-26 92545-TC 92546 92546-26 92546-TC 92547 92548 92548-26 92548-TC 92551 92552 92553 92555 92556 92557 92560 92561 92562 92563 92564 92565 92567 92568 92569 92571 92572 92575 92576 92577 92579 92582 92583 92584 92585 92585-26 92585-TC 92586 92587 92587-26 92587-TC 92588 92588-26 92588-TC 92590 92591 92592 92593 MRA $16.00 $8.00 $22.00 $14.00 $8.00 $29.00 $17.00 $9.00 $21.00 $92.00 $30.00 $59.00 $17.00 $16.00 $24.00 $14.00 $21.00 $46.00 $23.00 $27.00 $15.00 $14.00 $17.00 $15.00 $20.00 $14.00 $15.00 $14.00 $3.00 $11.00 $17.00 $28.00 $28.00 $28.00 $34.00 $94.00 $114.00 $52.00 $70.00 $70.00 $58.00 $8.00 $49.00 $78.00 $20.00 $57.00 $41.00 BR BR BR Part A, 119 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 92594 92595 92596 92597 92603 92604 92605 92606 92607 92608 92609 92610 92611 92612 92613 92614 92615 92616 92617 92620 92621 92625 92626 92627 92640 92700 92950 92953 92960 92961 92970 92971 92973 92974 92975 92977 92978 92978-26 92978-TC 92979 92979-26 92979-TC 92980 92981 92982 92984 92986 92987 92990 92992 MRA BR BR $22.00 $96.00 $88.00 $60.00 BR BR $109.00 $22.00 $59.00 $42.00 $46.00 $173.00 $43.00 $134.00 $39.00 $183.00 $48.00 $45.00 $12.00 $45.00 $86.00 $22.00 $53.00 BR $203.00 $35.00 $162.00 $239.00 $201.00 $100.00 $174.00 $197.00 $400.00 $302.00 $269.00 $95.00 $170.00 $163.00 $76.00 $86.00 $952.00 $268.00 $705.00 $191.00 $1,222.00 $1,271.00 $974.00 BR Medicine CPT Code 92993 92995 92996 92997 92998 93000 93005 93010 93012 93014 93015 93016 93017 93018 93024 93024-26 93024-TC 93025 93025-26 93025-TC 93040 93041 93042 93224 93225 93226 93227 93230 93231 93232 93233 93235 93236 93237 93268 93270 93271 93272 93278 93278-26 93278-TC 93303 93303-26 93303-TC 93304 93304-26 93304-TC 93307 93307-26 93307-TC MRA BR $776.00 $210.00 $765.00 $331.00 $26.00 $16.00 $12.00 $90.00 $28.00 $104.00 $25.00 $63.00 $54.00 $111.00 $71.00 $42.00 $277.00 $40.00 $299.00 $14.00 $31.00 $9.00 $159.00 $46.00 $83.00 $50.00 $168.00 $57.00 $82.00 $55.00 $123.00 $97.00 $28.00 $109.00 $46.00 $90.00 $28.00 $58.00 $24.00 $44.00 $215.00 $70.00 $144.00 $114.00 $43.00 $73.00 $196.00 $56.00 $144.00 CPT only © 2008 American Medical Association. All Rights Reserved. Medicine CPT Code 93308 93308-26 93308-TC 93312 93312-26 93312-TC 93313 93314 93314-26 93314-TC 93315 93315-26 93315-TC 93316 93317 93317-26 93317-TC 93318 93318-26 93318-TC 93320 93320-26 93320-TC 93321 93321-26 93321-TC 93325 93325-26 93325-TC 93350 93350-26 93350-TC 93501 93501-26 93501-TC 93503 93505 93505-26 93505-TC 93508 93508-26 93508-TC 93510 93510-26 93510-TC 93511 93511-26 93511-TC 93514 93514-26 MRA $118.00 $46.00 $75.00 $322.00 $140.00 $182.00 $76.00 $212.00 $65.00 $144.00 $287.00 $144.00 $141.00 $78.00 $236.00 $95.00 $141.00 $412.00 $114.00 $384.00 $86.00 $30.00 $65.00 $50.00 $10.00 $42.00 $114.00 $4.00 $110.00 $216.00 $77.00 $66.00 $674.00 $160.00 $634.00 $187.00 $318.00 $248.00 $74.00 $698.00 $232.00 $469.00 $1,628.00 $247.00 $1,388.00 $1,629.00 $270.00 $1,350.00 $2,208.00 $525.00 Part A, 120 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 93514-TC 93524 93524-26 93524-TC 93526 93526-26 93526-TC 93527 93527-26 93527-TC 93528 93528-26 93528-TC 93529 93529-26 93529-TC 93530 93530-26 93530-TC 93531 93531-26 93531-TC 93532 93532-26 93532-TC 93533 93533-26 93533-TC 93539 93540 93541 93542 93543 93544 93545 93555 93555-26 93555-TC 93556 93556-26 93556-TC 93561 93561-26 93561-TC 93562 93562-26 93562-TC 93571 93571-26 93571-TC MRA $1,683.00 $2,150.00 $392.00 $1,766.00 $2,147.00 $363.00 $1,815.00 $2,186.00 $451.00 $1,766.00 $2,266.00 $482.00 $1,766.00 $2,032.00 $262.00 $1,766.00 $872.00 $250.00 $634.00 $2,268.00 $467.00 $1,815.00 $2,317.00 $569.00 $1,766.00 $2,131.00 $352.00 $1,766.00 $45.00 $49.00 $38.00 $38.00 $213.00 $30.00 $240.00 $278.00 $42.00 $234.00 $414.00 $44.00 $368.00 $59.00 $47.00 $20.00 $46.00 $33.00 $13.00 $270.00 $93.00 $170.00 Medicine CPT Code 93572 93572-26 93572-TC 93580 93581 93600 93600-26 93600-TC 93602 93602-26 93602-TC 93603 93603-26 93603-TC 93609 93609-26 93609-TC 93610 93610-26 93610-TC 93612 93612-26 93612-TC 93613 93615 93615-26 93615-TC 93616 93616-26 93616-TC 93618 93618-26 93618-TC 93619 93619-26 93619-TC 93620 93620-26 93620-TC 93621 93621-26 93621-TC 93622 93622-26 93622-TC 93623 93623-26 93623-TC 93624 93624-26 MRA $222.00 $74.00 $155.00 $974.00 $1,303.00 $198.00 $129.00 $73.00 $159.00 $119.00 $42.00 $187.00 $127.00 $63.00 $578.00 $481.00 $101.00 $214.00 $166.00 $52.00 $224.00 $167.00 $61.00 $377.00 $62.00 $49.00 $12.00 $94.00 $82.00 $12.00 $399.00 $258.00 $148.00 $717.00 $444.00 $290.00 $358.00 $272.00 $91.00 BR $769.00 BR BR $771.00 BR BR $167.00 BR $333.00 $256.00 CPT only © 2008 American Medical Association. All Rights Reserved. Medicine CPT Code 93624-TC 93631 93631-26 93631-TC 93640 93640-26 93640-TC 93641 93641-26 93641-TC 93642 93642-26 93642-TC 93650 93651 93652 93660 93660-26 93660-TC 93662 93662-26 93662-TC 93668 93701 93701-26 93701-TC 93720 93721 93722 93724 93724-26 93724-TC 93740 93740-26 93740-TC 93770 93770-26 93770-TC 93784 93786 93788 93790 93797 93798 93799 93799-26 93799-TC 93875 93875-26 93875-TC MRA $74.00 $651.00 $420.00 $239.00 $467.00 $230.00 $269.00 $613.00 $360.00 $269.00 $549.00 $295.00 $269.00 $639.00 $985.00 $1,044.00 $162.00 $103.00 $61.00 BR $158.00 BR $16.00 $36.00 $9.00 $27.00 $43.00 $27.00 $24.00 $411.00 $259.00 $148.00 $17.00 $12.00 $5.00 NC NC NC NC NC NC NC $17.00 $38.00 BR BR BR $55.00 $17.00 $42.00 Part A, 121 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 93880 93880-26 93880-TC 93882 93882-26 93882-TC 93886 93886-26 93886-TC 93888 93888-26 93888-TC 93890 93890-26 93890-TC 93892 93892-26 93892-TC 93893 93893-26 93893-TC 93922 93922-26 93922-TC 93923 93923-26 93923-TC 93924 93924-26 93924-TC 93925 93925-26 93925-TC 93926 93926-26 93926-TC 93930 93930-26 93930-TC 93931 93931-26 93931-TC 93965 93965-26 93965-TC 93970 93970-26 93970-TC 93971 93971-26 MRA $176.00 $31.00 $144.00 $117.00 $21.00 $95.00 $215.00 $50.00 $162.00 $142.00 $33.00 $109.00 $241.00 $55.00 $185.00 $256.00 $63.00 $193.00 $251.00 $63.00 $188.00 $60.00 $16.00 $44.00 $112.00 $28.00 $85.00 $122.00 $31.00 $92.00 $175.00 $31.00 $144.00 $117.00 $21.00 $96.00 $174.00 $26.00 $150.00 $118.00 $17.00 $101.00 $63.00 $26.00 $42.00 $189.00 $36.00 $154.00 $121.00 $23.00 Medicine CPT Code 93971-TC 93975 93975-26 93975-TC 93976 93976-26 93976-TC 93978 93978-26 93978-TC 93979 93979-26 93979-TC 93980 93980-26 93980-TC 93981 93981-26 93981-TC 93982 93990 93990-26 93990-TC 94002 94003 94004 94005 94010 94010-26 94010-TC 94014 94015 94016 94060 94060-26 94060-TC 94070 94070-26 94070-TC 94150 94150-26 94150-TC 94200 94200-26 94200-TC 94240 94240-26 94240-TC 94250 94250-26 MRA $96.00 $277.00 $89.00 $181.00 $184.00 $59.00 $121.00 $177.00 $34.00 $143.00 $122.00 $23.00 $98.00 $183.00 $65.00 $105.00 $148.00 $25.00 $124.00 $10.00 $110.00 $14.00 $96.00 $84.00 $61.00 $45.00 $80.00 $30.00 $12.00 $16.00 $39.00 $14.00 $26.00 $57.00 $18.00 $36.00 $32.00 $11.00 $19.00 $8.00 $6.00 $3.00 $17.00 $7.00 $9.00 $43.00 $15.00 $26.00 $12.00 $8.00 CPT only © 2008 American Medical Association. All Rights Reserved. Medicine CPT Code 94250-TC 94260 94260-26 94260-TC 94350 94350-26 94350-TC 94360 94360-26 94360-TC 94370 94370-26 94370-TC 94375 94375-26 94375-TC 94400 94400-26 94400-TC 94450 94450-26 94450-TC 94452 94452-26 94452-TC 94453 94453-26 94453-TC 94610 94620 94620-26 94620-TC 94621 94621-26 94621-TC 94640 94642 94644 94645 94660 94662 94664 94667 94668 94680 94680-26 94680-TC 94681 94681-26 94681-TC MRA $5.00 $27.00 $8.00 $18.00 $36.00 $14.00 $20.00 $37.00 $11.00 $26.00 $33.00 $18.00 $12.00 $34.00 $16.00 $17.00 $40.00 $24.00 $14.00 $37.00 $20.00 $15.00 $52.00 $16.00 $36.00 $74.00 $20.00 $53.00 $63.00 $91.00 $38.00 $54.00 $122.00 $71.00 $52.00 $19.00 BR $36.00 $14.00 $54.00 $38.00 $18.00 $23.00 $16.00 $47.00 $23.00 $22.00 $60.00 $12.00 $43.00 Part A, 122 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 94690 94690-26 94690-TC 94720 94720-26 94720-TC 94725 94725-26 94725-TC 94750 94750-26 94750-TC 94760 94761 94762 94770 94770-26 94770-TC 94799 94799-26 94799-TC 95004 95010 95012 95015 95024 95027 95028 95044 95052 95056 95060 95065 95070 95071 95075 95115 95117 95120 95125 95130 95131 95132 95133 95134 95144 95145 95146 95147 95148 MRA $24.00 $4.00 $20.00 $49.00 $15.00 $31.00 $79.00 $14.00 $64.00 $37.00 $14.00 $21.00 $9.00 $20.00 $30.00 $21.00 $9.00 $12.00 BR BR BR $3.00 $11.00 $19.00 $11.00 $3.00 $5.00 $8.00 $7.00 $9.00 $6.00 $13.00 $7.00 $82.00 $105.00 $82.00 $10.00 $9.00 BR BR BR BR BR BR BR $9.00 $17.00 $24.00 $33.00 $32.00 Medicine CPT Code 95149 95165 95170 95180 95199 95250 95251 95805 95805-26 95805-TC 95806 95806-26 95806-TC 95807 95807-26 95807-TC 95808 95808-26 95808-TC 95810 95810-26 95810-TC 95811 95811-26 95811-TC 95812 95812-26 95812-TC 95813 95813-26 95813-TC 95816 95816-26 95816-TC 95819 95819-26 95819-TC 95822 95822-26 95822-TC 95824 95824-26 95824-TC 95827 95827-26 95827-TC 95829 95829-26 95829-TC 95830 MRA $36.00 $7.00 $13.00 $103.00 BR $114.00 $28.00 $334.00 $94.00 $237.00 $232.00 $109.00 $137.00 $367.00 $98.00 $256.00 $456.00 $149.00 $256.00 $521.00 $183.00 $256.00 $644.00 $196.00 $423.00 $137.00 $58.00 $68.00 $177.00 $89.00 $68.00 $133.00 $54.00 $78.00 $115.00 $58.00 $56.00 $120.00 $58.00 $63.00 $51.00 $41.00 $10.00 $145.00 $59.00 $86.00 $328.00 $291.00 $6.00 $133.00 CPT only © 2008 American Medical Association. All Rights Reserved. Medicine CPT Code 95831 95832 95833 95834 95851 95852 95857 95860 95860-26 95860-TC 95861 95861-26 95861-TC 95863 95863-26 95863-TC 95864 95864-26 95864-TC 95865 95865-26 95865-TC 95866 95866-26 95866-TC 95867 95867-26 95867-TC 95868 95868-26 95868-TC 95869 95869-26 95869-TC 95870 95870-26 95870-TC 95872 95872-26 95872-TC 95873 95873-26 95873-TC 95874 95874-26 95874-TC 95875 95875-26 95875-TC 95900 MRA $26.00 $21.00 $34.00 $44.00 $18.00 $14.00 $40.00 $73.00 $53.00 $15.00 $113.00 $86.00 $28.00 $138.00 $102.00 $35.00 $177.00 $114.00 $67.00 $119.00 $92.00 $27.00 $80.00 $71.00 $9.00 $66.00 $43.00 $21.00 $96.00 $71.00 $26.00 $29.00 $21.00 $8.00 $29.00 $21.00 $8.00 $104.00 $81.00 $22.00 $29.00 $21.00 $8.00 $30.00 $21.00 $8.00 $43.00 $34.00 $7.00 $37.00 Part A, 123 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 95900-26 95900-TC 95903 95903-26 95903-TC 95904 95904-26 95904-TC 95920 95920-26 95920-TC 95921 95921-26 95921-TC 95922 95922-26 95922-TC 95923 95923-26 95923-TC 95925 95925-26 95925-TC 95926 95926-26 95926-TC 95927 95927-26 95927-TC 95928 95928-26 95928-TC 95929 95929-26 95929-TC 95930 95930-26 95930-TC 95933 95933-26 95933-TC 95934 95934-26 95934-TC 95936 95936-26 95936-TC 95937 95937-26 95937-TC MRA $24.00 $10.00 $43.00 $33.00 $9.00 $31.00 $20.00 $8.00 $168.00 $118.00 $48.00 $61.00 $46.00 $14.00 $65.00 $50.00 $14.00 $105.00 $47.00 $57.00 $94.00 $53.00 $41.00 $66.00 $34.00 $34.00 $67.00 $34.00 $34.00 $175.00 $84.00 $91.00 $182.00 $84.00 $98.00 $44.00 $25.00 $11.00 $62.00 $33.00 $30.00 $36.00 $28.00 $8.00 $39.00 $30.00 $8.00 $40.00 $31.00 $9.00 Medicine CPT Code 95950 95950-26 95950-TC 95951 95951-26 95951-TC 95953 95953-26 95953-TC 95954 95954-26 95954-TC 95955 95955-26 95955-TC 95956 95956-26 95956-TC 95957 95957-26 95957-TC 95958 95958-26 95958-TC 95961 95961-26 95961-TC 95962 95962-26 95962-TC 95965 95965-26 95965-TC 95966 95966-26 95966-TC 95967 95967-26 95967-TC 95970 95971 95972 95973 95974 95975 95978 95979 95980 95981 95982 MRA $265.00 $84.00 $177.00 $34.00 $14.00 $20.00 $411.00 $165.00 $240.00 $208.00 $134.00 $23.00 $130.00 $59.00 $74.00 $541.00 $166.00 $314.00 $171.00 $104.00 $64.00 $296.00 $230.00 $66.00 $216.00 $166.00 $48.00 $227.00 $176.00 $48.00 BR $420.00 BR BR $210.00 BR BR $184.00 BR $22.00 $39.00 $78.00 $47.00 $155.00 $88.00 $213.00 $98.00 $27.00 $10.00 $22.00 CPT only © 2008 American Medical Association. All Rights Reserved. Medicine CPT Code 95990 95991 95999 96000 96001 96002 96003 96004 96020 96020-26 96020-TC 96040 96101 96102 96103 96105 96110 96111 96116 96118 96119 96120 96125 96150 96151 96152 96153 96154 96155 DSPNS 96401 96402 96405 96406 96409 96411 96413 96415 96416 96417 96420 96422 96423 96425 96440 96445 96450 96521 96522 96523 MRA $57.00 $84.00 BR $93.00 $111.00 $21.00 $20.00 $97.00 BR $156.00 BR $37.00 $97.00 $44.00 $28.00 $68.00 $88.00 $68.00 $109.00 $130.00 $66.00 $48.00 $57.00 $26.00 $25.00 $24.00 $6.00 $24.00 $22.00 see Appx D $53.00 $46.00 $57.00 $86.00 $122.00 $71.00 $173.00 $39.00 $186.00 $85.00 $46.00 $46.00 $17.00 $54.00 $156.00 $157.00 $134.00 $153.00 $111.00 $28.00 Part A, 124 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 96542 96549 96567 96570 96571 96900 96902 96904 96910 96912 96913 96920 96921 96922 96999 97001 97002 97003 97004 97005 97006 97010 97012 97014 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97260 97261 97530 97532 97533 97535 MRA $126.00 BR $62.00 $69.00 $38.00 $17.00 $24.00 $70.00 $21.00 $24.00 $53.00 $152.00 $155.00 $214.00 BR $62.00 $29.00 $62.00 $29.00 BR BR $10.00 $16.00 $14.00 $15.00 $10.00 $15.00 $10.00 $9.00 $10.00 $16.00 $16.00 $13.00 $11.00 $19.00 $15.00 $22.00 $23.00 $24.00 $21.00 $19.00 $15.00 $26.00 $18.00 $23.00 $17.00 $22.00 $22.00 $24.00 $23.00 Medicine CPT Code 97537 97542 97545 97546 97597 97598 97602 97605 97606 97750 97752 97755 97760 97761 97762 97799 97802 97803 97804 97810 97811 97813 97814 97850 97851 97852 97853 98925 98926 98927 98928 98929 98940 98941 98942 98943 98960 98961 98962 98966 98967 98968 99000 99001 99002 99026 99027 99070 99071 99075 MRA $23.00 $17.00 $83.00 $41.00 $49.00 $62.00 BR $34.00 $37.00 BR $48.00 $35.00 $31.00 $28.00 $26.00 BR $26.00 $17.00 $7.00 $35.00 $27.00 $37.00 $30.00 $54.00 $26.00 $54.00 $26.00 NC $32.00 NC $23.00 NC NC $32.00 NC $23.00 $19.00 $9.00 $7.00 $8.00 $17.00 $25.00 $6.00 $4.00 $35.00 BR BR BR NC See 440.13 CPT only © 2008 American Medical Association. All Rights Reserved. Medicine CPT Code 99078 99080 99082 99090 99091 99172 99173 99175 99183 99185 99186 99190 99191 99192 99195 99199 G0101 G0102 G0104 G0105 G0105-53 G0106 G0106-26 G0106-TC G0108 G0109 G0117 G0118 G0120 G0120-26 G0120-TC G0121 G0121-53 G0122 G0122-26 G0122-TC G0128 G0166 G0179 G0180 G0181 G0182 G0237 G0238 G0239 G0248 G0249 G0250 G0268 G0270 MRA NC BR BR BR $49.00 BR $3.00 $53.00 $123.00 $23.00 $78.00 BR BR BR $16.00 NC $32.00 $18.00 $115.00 $344.00 $115.00 $165.00 $46.00 $119.00 $24.00 $14.00 $40.00 $27.00 $179.00 $46.00 $132.00 $344.00 $115.00 $177.00 $45.00 $132.00 $4.00 $138.00 $41.00 $54.00 $99.00 $102.00 $12.00 $13.00 $11.00 $168.00 $124.00 $9.00 $43.00 $22.00 Part A, 125 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code G0271 G0281 G0283 G0308 G0309 G0310 G0311 G0312 G0313 G0314 G0315 G0316 G0317 G0318 G0319 G0320 G0321 G0322 G0323 G0324 G0325 G0326 G0327 G0329 G0332 G0366 G0367 G9041 G9042 G9043 G9044 P3001 Q0035 Q0035-26 Q0035-TC Q0091 MRA $22.00 $13.00 $10.00 $10.00 $678.00 $557.00 $436.00 $476.00 $393.00 $309.00 $417.00 $344.00 $268.00 $262.00 $215.00 $168.00 $532.00 $380.00 $329.00 $206.00 $19.00 $11.00 $13.00 $7.00 $7.00 $66.00 $21.00 $13.00 $22.00 $9.00 $9.00 $8.00 $24.00 $19.00 $8.00 $11.00 CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 126 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Evaluation & Management CPT Code MRA 99201 $35.00 99202 $58.00 99203 $58.00 99204 $84.00 99205 $84.00 99211 $19.00 99212 $31.00 99213 $40.00 99214 $40.00 99215 $65.00 99217 $65.00 99218 $65.00 99219 $109.00 99220 $152.00 99221 $66.00 99222 $109.00 99223 $152.00 99231 $33.00 99232 $54.00 99233 $77.00 99234 $129.00 99235 $173.00 99236 $213.00 99238 $66.00 99239 $88.00 99241 $54.00 99242 $88.00 99243 $117.00 99244 $163.00 99245 $212.00 99251 $54.00 99252 $70.00 99253 $96.00 99254 $138.00 99255 $190.00 99281 $18.00 99282 $28.00 99283 $60.00 99284 $94.00 99285 $103.00 99288 BR 99291 $192.00 99292 $95.00 99304 $66.00 99305 $88.00 99306 $108.00 99307 $34.00 99308 $56.00 99309 $80.00 99310 $100.00 Evaluation & Management CPT Code MRA 99315 $60.00 99316 $77.00 99318 $66.00 99324 $59.00 99325 $86.00 99326 $125.00 99327 $164.00 99328 $203.00 99334 $45.00 99335 $72.00 99336 $111.00 99337 $163.00 99339 $67.00 99340 $93.00 99341 $59.00 99342 $85.00 99343 $109.00 99344 $160.00 99345 $193.00 99347 $46.00 99348 $71.00 99349 $107.00 99350 $156.00 99354 $106.00 99355 $104.00 99356 $87.00 99357 $88.00 99358 $94.00 99359 $45.00 99360 $47.00 99363 $108.00 99364 $38.00 99366 $37.00 99367 $48.00 99368 $31.00 99374 $75.00 99375 $75.00 99377 $75.00 99378 $104.00 99379 $75.00 99380 $104.00 99406 $12.00 99407 $24.00 99408 $29.00 99409 $58.00 99441 $13.00 99442 $23.00 99443 $34.00 99450 NC 99455 $90.00 CPT only © 2008 American Medical Association. All Rights Reserved. Evaluation & Management CPT Code MRA 99456 BR 99457 BR 99499 BR 99600 BR G0245 $58.00 G0246 $34.00 G0337 $62.00 G0344 $86.00 G0368 $8.00 G0372 $13.00 G0396 $29.00 G0397 $56.00 M0064 $34.00 Part A, 127 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Dental D-Code D0120 D0140 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0274 D0277 D0290 D0310 D0320 D0321 D0322 D0330 D0340 D0350 D0415 D0425 D0460 D0470 D0472 D0473 D0474 D0480 D0502 D0999 D1110 D1204 D1205 D1310 D1320 D1330 D1351 D1510 D1515 D1520 D1525 D1550 D2140 D2150 D2160 D2161 HCPCS © 2008 MRA $17.00 $13.00 $20.00 $36.00 $18.00 $20.00 $40.00 $10.00 $5.00 $12.00 $20.00 $14.00 $7.00 $12.00 $20.00 $18.00 $36.00 $50.00 $204.00 $64.00 $105.00 $29.00 $40.00 $10.00 $34.00 $25.00 $13.00 $24.00 $30.00 BR BR BR $54.00 BR $29.00 $10.00 $40.00 $23.00 $48.00 $13.00 $21.00 $81.00 $121.00 $102.00 $143.00 $14.00 $38.00 $44.00 $54.00 $67.00 Dental D-Code D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2410 D2420 D2430 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2799 D2910 D2920 D2930 D2931 MRA $40.00 $61.00 $66.00 $81.00 $57.00 $43.00 $55.00 $63.00 $69.00 $163.00 $203.00 $293.00 $155.00 $259.00 $244.00 $302.00 $318.00 $348.00 $206.00 $266.00 $348.00 $287.00 $328.00 $378.00 $206.00 $266.00 $348.00 $266.00 $328.00 $348.00 $194.00 $410.00 $306.00 $348.00 $410.00 $451.00 $328.00 $368.00 $368.00 $266.00 $306.00 $389.00 $389.00 $287.00 $328.00 $204.00 $29.00 $29.00 $81.00 $121.00 Dental D-Code D2932 D2933 D2940 D2950 D2951 D2952 D2953 D2954 D2955 D2957 D2960 D2961 D2962 D2980 D2999 D3110 D3120 D3220 D3221 D3230 D3240 D3310 D3320 D3330 D3331 D3332 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3430 D3450 D3460 D3470 D3910 D3920 D3950 D3999 D4210 D4211 D4240 D4241 D4245 MRA $77.00 $91.00 $29.00 $81.00 $20.00 $79.00 $133.00 $102.00 $81.00 $71.00 $121.00 $204.00 $294.00 $83.00 BR $25.00 $20.00 $61.00 $81.00 $70.00 $75.00 $206.00 $204.00 $287.00 $102.00 $110.00 $53.00 $225.00 $274.00 $337.00 $102.00 $81.00 $163.00 $179.00 $194.00 $206.00 $77.00 $55.00 $102.00 $318.00 $204.00 $50.00 $102.00 $61.00 BR $114.00 $50.00 $223.00 $63.00 $265.00 Part A, 128 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Dental D-Code D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4268 D4270 D4271 D4273 D4274 D4275 D4276 D4320 D4321 D4341 D4342 D4355 D4381 D4910 D4920 D4999 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 HCPCS © 2008 MRA $208.00 $328.00 $164.00 $195.00 $159.00 $96.00 $285.00 $328.00 $273.00 $155.00 $206.00 $337.00 $208.00 $178.00 $194.00 $77.00 $55.00 $79.00 $55.00 $50.00 $69.00 $40.00 $27.00 BR $513.00 $513.00 $563.00 $563.00 $256.00 $259.00 $614.00 $614.00 $279.00 $27.00 $27.00 $27.00 $27.00 $61.00 $40.00 $61.00 $83.00 $22.00 $53.00 $61.00 $102.00 $305.00 $305.00 $204.00 $204.00 $163.00 Dental D-Code D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862 D5867 D5875 D5899 D5911 D5912 D5913 D5914 D5915 D5916 D5919 D5922 D5923 D5924 D5925 D5926 D5927 D5928 D5929 D5931 D5932 D5933 D5934 D5935 D5936 D5937 D5951 D5953 D5954 D5955 D5958 D5959 D5960 MRA $163.00 $121.00 $121.00 $102.00 $102.00 $132.00 $163.00 $100.00 $163.00 $244.00 $244.00 $194.00 $204.00 $46.00 $50.00 $543.00 $553.00 $181.00 $36.00 $100.00 BR $81.00 $121.00 $2,052.00 $2,052.00 $2,770.00 $2,874.00 BR $1,334.00 $1,641.00 BR BR $1,026.00 $1,026.00 $1,384.00 BR $656.00 $1,539.00 $306.00 $1,539.00 $1,539.00 $563.00 BR $614.00 $614.00 BR $1,334.00 $780.00 $244.00 $163.00 Dental D-Code D5982 D5983 D5984 D5985 D5986 D5987 D5988 D5999 D6010 D6040 D6050 D6053 D6054 D6055 D6056 D6057 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6080 D6090 D6095 D6100 D6199 D6210 D6211 D6212 D6240 D6241 D6242 D6245 MRA $167.00 BR BR $574.00 $61.00 BR $219.00 BR $649.00 $3,016.00 $1,557.00 $82.00 $61.00 $769.00 $265.00 $303.00 $392.00 $418.00 $289.00 $379.00 $365.00 $359.00 $377.00 $513.00 $513.00 $513.00 $365.00 $359.00 $322.00 $326.00 $365.00 $346.00 $350.00 $414.00 $402.00 $447.00 $1,026.00 $884.00 $71.00 $229.00 $247.00 $264.00 BR $410.00 $287.00 $328.00 $451.00 $368.00 $410.00 $309.00 Part A, 129 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Dental D-Code D6250 D6251 D6252 D6253 D6545 D6548 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6793 D6920 D6930 D6940 D6950 D6970 D6971 D6972 D6973 D6975 D6976 D6977 D6980 D6999 HCPCS © 2008 MRA $410.00 $287.00 $368.00 $51.00 $195.00 $281.00 $155.00 $166.00 $172.00 $203.00 $110.00 $141.00 $139.00 $151.00 $170.00 $178.00 $203.00 $217.00 $141.00 $155.00 $151.00 $162.00 $410.00 $233.00 $348.00 $328.00 $356.00 $328.00 $410.00 $389.00 $320.00 $322.00 $324.00 $389.00 $287.00 $348.00 $30.00 $279.00 $40.00 $102.00 $155.00 $163.00 $113.00 $121.00 $111.00 $214.00 $88.00 $46.00 $106.00 BR Dental D-Code D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7260 D7261 D7270 D7272 D7280 D7282 D7285 D7286 D7287 D7290 D7291 D7310 D7320 D7340 D7350 D7410 D7411 D7412 D7413 D7414 D7415 D7440 D7441 D7450 D7451 D7460 D7461 D7465 D7471 D7472 D7473 D7485 D7490 D7510 D7520 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 MRA $45.00 $70.00 $111.00 $139.00 $147.00 $204.00 $81.00 $244.00 BR $147.00 $204.00 $121.00 $41.00 $106.00 $81.00 BR $133.00 $77.00 $85.00 $108.00 $195.00 $410.00 $102.00 $100.00 $139.00 $205.00 $180.00 $291.00 $161.00 $247.00 $139.00 $179.00 $137.00 $195.00 $71.00 $174.00 $143.00 $147.00 $162.00 $2,545.00 $54.00 $121.00 $85.00 $121.00 $143.00 $266.00 $1,189.00 $984.00 $1,354.00 $820.00 Dental D-Code D7650 D7660 D7670 D7671 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7771 D7780 D7810 D7820 D7830 D7840 D7850 D7852 D7854 D7856 D7858 D7860 D7865 D7870 D7871 D7872 D7873 D7874 D7875 D7876 D7877 D7880 D7899 D7910 D7911 D7912 D7920 D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7955 MRA $1,292.00 $780.00 $410.00 $779.00 $1,949.00 $1,415.00 $903.00 $1,580.00 $922.00 $1,334.00 $1,046.00 $533.00 $73.00 $2,504.00 $1,292.00 $110.00 $186.00 $1,764.00 $1,682.00 $2,011.00 $2,052.00 BR $2,298.00 $614.00 $1,723.00 $81.00 BR $533.00 $584.00 $737.00 $789.00 $820.00 $758.00 $291.00 BR $73.00 $110.00 $163.00 $676.00 $841.00 $2,874.00 $2,914.00 $2,298.00 $2,319.00 $2,566.00 $2,566.00 $2,874.00 $4,186.00 $881.00 $922.00 Part A, 130 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Dental D-Code D7960 D7970 D7971 D7972 D7980 D7981 D7982 D7983 D7990 D7991 D7995 D7996 D7997 D7999 D8010 D8020 D8030 D8040 D8050 D8060 D8070 D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8690 D8691 D8692 D8999 D9110 D9210 D9211 D9212 D9215 D9220 D9221 D9230 D9241 D9242 D9248 D9310 D9410 D9420 D9430 D9440 D9450 D9610 MRA $121.00 $137.00 $67.00 BR $169.00 $820.00 $306.00 $244.00 $340.00 $820.00 BR BR BR BR $451.00 $533.00 $718.00 $583.00 $676.00 $758.00 $1,867.00 $1,867.00 $1,949.00 $155.00 $179.00 $73.00 $54.00 $171.00 $71.00 $67.00 $104.00 BR $40.00 $14.00 $14.00 $13.00 $7.00 $111.00 $40.00 $18.00 $122.00 $45.00 $91.00 $41.00 $61.00 $46.00 $23.00 $41.00 BR $20.00 HCPCS © 2008 Dental D-Code D9630 D9910 D9911 D9920 D9930 D9940 D9941 D9950 D9951 D9952 D9970 D9971 D9972 D9973 D9974 D9999 MRA $10.00 $21.00 $21.00 $32.00 $34.00 $204.00 $58.00 $114.00 $46.00 $163.00 $83.00 $55.00 $113.00 $40.00 $50.00 BR Part A, 131 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Injections J-Code J0120 J0130 J0150 J0152 J0170 J0190 J0200 J0205 J0207 J0210 J0215 J0256 J0280 J0282 J0285 J0287 J0288 J0289 J0290 J0295 J0300 J0330 J0350 J0360 J0380 J0390 J0395 J0456 J0460 J0470 J0475 J0476 J0500 J0515 J0520 J0530 J0540 J0550 J0560 J0570 J0580 J0583 J0585 J0587 J0592 J0595 J0600 J0610 J0620 J0630 MRA $12.00 BR $27.00 BR $1.00 $3.00 BR $38.00 BR $7.00 BR $101.00 $1.00 BR BR BR BR BR $2.00 $7.00 $2.00 $1.00 $2,408.00 $6.00 $1.00 $3.00 BR BR $1.00 $11.00 $201.00 BR $3.00 $3.00 $5.00 $4.00 $8.00 $21.00 $6.00 $9.00 $26.00 BR $393.00 BR BR BR $6.00 $1.00 $3.00 $21.00 HCPCS © 2008 Injections J-Code J0636 J0637 J0640 J0670 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0713 J0715 J0720 J0725 J0735 J0740 J0743 J0744 J0745 J0760 J0770 J0780 J0800 J0835 J0850 J0895 J0900 J0945 J0970 J1000 J1020 J1030 J1040 J1055 J1060 J1070 J1080 J1094 J1100 J1110 J1120 J1160 J1165 J1170 J1180 J1190 J1200 MRA BR BR $22.00 BR $3.00 BR $10.00 $11.00 $6.00 $11.00 $4.00 $2.00 $3.00 $8.00 $6.00 $6.00 $3.00 BR BR $14.00 BR $1.00 $3.00 $32.00 $3.00 $18.00 $12.00 $362.00 $10.00 $1.00 $1.00 $1.00 $3.00 $1.00 $2.00 $3.00 BR $1.00 $1.00 $2.00 BR $1.00 $10.00 $35.00 $2.00 $1.00 $1.00 $1.00 BR $1.00 Injections J-Code J1205 J1212 J1230 J1240 J1245 J1250 J1260 J1270 J1320 J1325 J1327 J1330 J1335 J1364 J1380 J1390 J1410 J1435 J1436 J1438 J1440 J1441 J1450 J1455 J1460 J1470 J1480 J1490 J1500 J1510 J1520 J1530 J1540 J1550 J1560 J1565 J1570 J1580 J1590 J1595 J1600 J1610 J1620 J1626 J1630 J1631 J1642 J1644 J1645 J1650 MRA $9.00 $36.00 $1.00 $1.00 $31.00 $49.00 BR BR $1.00 BR BR $2.00 BR $6.00 $1.00 $1.00 $33.00 $1.00 $68.00 BR $158.00 $254.00 BR $12.00 $2.00 $4.00 $7.00 $9.00 $11.00 $13.00 $15.00 $17.00 $20.00 $22.00 BR BR $36.00 $3.00 BR BR $10.00 $27.00 $69.00 BR $4.00 $28.00 $1.00 $1.00 BR $16.00 Part A, 132 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Injections J-Code J1652 J1655 J1670 J1700 J1710 J1720 J1730 J1742 J1745 J1756 J1785 J1790 J1800 J1810 J1815 J1817 J1825 J1830 J1835 J1840 J1850 J1885 J1890 J1940 J1950 J1955 J1956 J1960 J1980 J1990 J2001 J2010 J2020 J2060 J2150 J2175 J2180 J2185 J2210 J2250 J2260 J2270 J2271 J2275 J2280 J2300 J2310 J2320 J2321 J2322 HCPCS © 2008 MRA BR BR $23.00 $1.00 $5.00 $4.00 $94.00 BR BR BR $4.00 $4.00 $10.00 $6.00 BR BR BR $76.00 BR $7.00 $4.00 $7.00 $11.00 $1.00 $411.00 $37.00 BR $2.00 $3.00 $8.00 BR $2.00 BR $12.00 $3.00 $1.00 $3.00 BR $3.00 $2.00 $32.00 $1.00 BR $13.00 BR $2.00 $3.00 $5.00 $6.00 $8.00 Injections J-Code J2353 J2354 J2355 J2360 J2370 J2400 J2405 J2410 J2430 J2440 J2460 J2501 J2505 J2510 J2515 J2540 J2543 J2545 J2550 J2560 J2590 J2597 J2650 J2670 J2680 J2690 J2700 J2710 J2720 J2725 J2730 J2760 J2765 J2770 J2780 J2783 J2790 J2792 J2795 J2800 J2810 J2820 J2910 J2912 J2916 J2920 J2930 J2940 J2941 J2950 MRA BR BR BR $2.00 $3.00 BR $6.00 $3.00 $189.00 $2.00 $1.00 BR BR $1.00 $1.00 $1.00 BR $105.00 $1.00 $5.00 $1.00 $20.00 $1.00 BR $16.00 $7.00 $2.00 $1.00 $1.00 $11.00 $29.00 $29.00 $2.00 BR BR BR $36.00 BR BR $3.00 $3.00 $115.00 $11.00 $1.00 BR $5.00 $13.00 BR BR $1.00 Injections J-Code J2993 J2995 J2997 J3000 J3010 J3030 J3070 J3100 J3105 J3120 J3130 J3140 J3150 J3230 J3240 J3250 J3260 J3265 J3280 J3301 J3302 J3303 J3305 J3310 J3320 J3350 J3360 J3364 J3365 J3370 J3400 J3410 J3411 J3415 J3420 J3430 J3465 J3470 J3475 J3480 J3485 J3486 J3490 J3590 J7030 J7040 J7042 J7050 J7060 J7070 MRA BR BR BR $2.00 $2.00 $34.00 $4.00 BR $2.00 $1.00 $1.00 $1.00 $1.00 $2.00 $214.00 $1.00 $7.00 $2.00 $5.00 $1.00 $1.00 $1.00 $55.00 $5.00 $16.00 $72.00 $1.00 $52.00 $433.00 $9.00 $12.00 $1.00 BR BR $1.00 $2.00 BR $7.00 $1.00 $1.00 BR BR BR BR $11.00 $10.00 $10.00 $10.00 $10.00 $11.00 Part A, 133 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Injections J-Code J7100 J7110 J7120 J7130 J7190 J7191 J7192 J7193 J7194 J7195 J7197 J7198 J7199 J7317 J7350 J7501 J7504 J7505 J7513 J7516 J7599 HCPCS © 2008 MRA $137.00 $93.00 $12.00 $6.00 $241.00 BR $316.00 BR $120.00 BR $284.00 BR BR BR BR $98.00 $282.00 $576.00 BR BR BR Part A, 134 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition PART B SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES RULE 69L-7.020, F.A.C. 135 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 10021 10022 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180 11000 11001 11004 11005 11006 11008 11010 11011 11012 11040 11041 11042 11043 11044 11055 11056 11057 11100 11101 11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 0 0 10 10 10 10 10 10 10 10 10 10 0 ZZZ 0 0 0 ZZZ 10 0 0 0 0 0 10 10 0 0 0 0 ZZZ 10 ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 10 10 10 10 10 $90.00 $92.00 $54.00 $53.00 $133.00 $65.00 $203.00 $53.00 $169.00 $53.00 $45.00 $164.00 $45.00 $27.00 ------------------------$348.00 $432.00 $597.00 $43.00 $45.00 $88.00 $210.00 $283.00 $26.00 $35.00 $39.00 $78.00 $41.00 $66.00 $26.00 $59.00 $80.00 $96.00 $119.00 $61.00 $86.00 $100.00 $125.00 $75.00 $95.00 $110.00 $144.00 $81.00 $114.00 $145.00 $178.00 $200.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $176.00 $183.00 $118.00 $133.00 $232.00 $209.00 $324.00 $170.00 $329.00 $189.00 $154.00 $290.00 $66.00 $29.00 $738.00 $978.00 $937.00 $366.00 $591.00 $670.00 $942.00 $58.00 $71.00 $96.00 $340.00 $459.00 $58.00 $72.00 $88.00 $118.00 $39.00 $97.00 $23.00 $81.00 $109.00 $129.00 $154.00 $85.00 $115.00 $133.00 $155.00 $100.00 $124.00 $145.00 $184.00 $143.00 $173.00 $192.00 $222.00 $253.00 $186.00 $194.00 $124.00 $141.00 $245.00 $222.00 $344.00 $180.00 $350.00 $201.00 $164.00 $310.00 $70.00 $30.00 $767.00 $1,019.00 $985.00 $387.00 $632.00 $716.00 $1,009.00 $62.00 $76.00 $102.00 $361.00 $487.00 $62.00 $77.00 $94.00 $125.00 $41.00 $102.00 $25.00 $85.00 $114.00 $136.00 $162.00 $90.00 $121.00 $140.00 $164.00 $105.00 $131.00 $152.00 $194.00 $151.00 $183.00 $204.00 $235.00 $268.00 $197.00 $204.00 $129.00 $150.00 $261.00 $235.00 $364.00 $191.00 $373.00 $214.00 $174.00 $333.00 $75.00 $33.00 $804.00 $1,071.00 $1,048.00 $416.00 $678.00 $768.00 $1,086.00 $66.00 $82.00 $110.00 $383.00 $518.00 $66.00 $82.00 $100.00 $130.00 $43.00 $107.00 $26.00 $90.00 $120.00 $143.00 $170.00 $96.00 $128.00 $148.00 $174.00 $110.00 $137.00 $159.00 $204.00 $159.00 $193.00 $216.00 $249.00 $285.00 $91.00 $87.00 $104.00 $116.00 $209.00 $120.00 $209.00 $115.00 $240.00 $152.00 $122.00 $229.00 $43.00 $22.00 $738.00 $978.00 $937.00 $366.00 $373.00 $400.00 $588.00 $37.00 $49.00 $65.00 $298.00 $411.00 $31.00 $44.00 $58.00 $59.00 $30.00 $82.00 $21.00 $37.00 $62.00 $77.00 $91.00 $49.00 $72.00 $83.00 $103.00 $53.00 $77.00 $89.00 $120.00 $91.00 $121.00 $134.00 $170.00 $190.00 $95.00 $90.00 $108.00 $123.00 $221.00 $127.00 $220.00 $122.00 $254.00 $161.00 $130.00 $244.00 $46.00 $23.00 $767.00 $1,019.00 $985.00 $387.00 $399.00 $426.00 $630.00 $39.00 $53.00 $69.00 $316.00 $435.00 $33.00 $46.00 $61.00 $61.00 $31.00 $86.00 $22.00 $38.00 $65.00 $79.00 $94.00 $52.00 $75.00 $86.00 $109.00 $55.00 $80.00 $92.00 $125.00 $96.00 $127.00 $141.00 $180.00 $200.00 $100.00 $94.00 $113.00 $130.00 $236.00 $135.00 $234.00 $129.00 $272.00 $173.00 $138.00 $264.00 $49.00 $25.00 $804.00 $1,071.00 $1,048.00 $416.00 $432.00 $462.00 $686.00 $42.00 $57.00 $75.00 $336.00 $462.00 $35.00 $50.00 $66.00 $64.00 $33.00 $90.00 $24.00 $40.00 $67.00 $83.00 $99.00 $55.00 $79.00 $91.00 $115.00 $58.00 $83.00 $96.00 $131.00 $101.00 $135.00 $150.00 $191.00 $213.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 136 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11450 11451 11462 11463 11470 11471 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11646 11719 11720 11721 11730 11732 11740 11750 11752 11755 11760 11762 11765 11770 10 10 10 10 10 10 10 10 10 10 10 10 10 90 90 90 90 90 90 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 0 0 0 ZZZ 0 10 10 0 10 10 10 10 $246.00 $98.00 $92.00 $157.00 $163.00 $221.00 $303.00 $105.00 $102.00 $174.00 $221.00 $276.00 $344.00 $282.00 $366.00 $264.00 $351.00 $320.00 $391.00 $148.00 $180.00 $199.00 $226.00 $249.00 $315.00 $150.00 $191.00 $223.00 $259.00 $305.00 $373.00 $168.00 $227.00 $260.00 $305.00 $380.00 $494.00 $22.00 $32.00 $50.00 $62.00 $31.00 $41.00 $156.00 $234.00 $106.00 $131.00 $223.00 $65.00 $275.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $353.00 $144.00 $185.00 $207.00 $243.00 $279.00 $402.00 $159.00 $199.00 $224.00 $271.00 $342.00 $460.00 $429.00 $571.00 $423.00 $581.00 $467.00 $602.00 $216.00 $258.00 $280.00 $321.00 $355.00 $501.00 $218.00 $260.00 $293.00 $346.00 $393.00 $490.00 $228.00 $279.00 $321.00 $381.00 $475.00 $631.00 $25.00 $38.00 $56.00 $122.00 $57.00 $54.00 $258.00 $367.00 $162.00 $242.00 $329.00 $151.00 $323.00 $373.00 $153.00 $196.00 $220.00 $257.00 $296.00 $425.00 $169.00 $210.00 $237.00 $287.00 $362.00 $486.00 $455.00 $607.00 $450.00 $618.00 $496.00 $641.00 $229.00 $272.00 $295.00 $337.00 $374.00 $527.00 $230.00 $274.00 $309.00 $364.00 $415.00 $518.00 $241.00 $295.00 $340.00 $402.00 $502.00 $668.00 $27.00 $41.00 $59.00 $130.00 $60.00 $58.00 $273.00 $389.00 $172.00 $258.00 $350.00 $161.00 $344.00 $396.00 $162.00 $207.00 $233.00 $273.00 $314.00 $453.00 $178.00 $222.00 $251.00 $304.00 $383.00 $515.00 $484.00 $647.00 $478.00 $659.00 $527.00 $683.00 $240.00 $286.00 $310.00 $354.00 $393.00 $555.00 $241.00 $288.00 $325.00 $383.00 $437.00 $550.00 $254.00 $311.00 $358.00 $424.00 $530.00 $709.00 $28.00 $43.00 $63.00 $139.00 $64.00 $61.00 $289.00 $413.00 $183.00 $275.00 $374.00 $171.00 $367.00 $282.00 $101.00 $135.00 $161.00 $189.00 $219.00 $335.00 $120.00 $157.00 $175.00 $217.00 $279.00 $393.00 $286.00 $383.00 $274.00 $387.00 $326.00 $417.00 $135.00 $172.00 $187.00 $223.00 $245.00 $367.00 $135.00 $174.00 $200.00 $248.00 $285.00 $368.00 $145.00 $191.00 $225.00 $281.00 $354.00 $505.00 $13.00 $23.00 $40.00 $81.00 $41.00 $40.00 $221.00 $335.00 $110.00 $172.00 $266.00 $84.00 $225.00 $297.00 $106.00 $142.00 $171.00 $199.00 $232.00 $354.00 $127.00 $165.00 $185.00 $229.00 $294.00 $414.00 $302.00 $406.00 $290.00 $411.00 $345.00 $442.00 $141.00 $180.00 $195.00 $233.00 $256.00 $384.00 $141.00 $182.00 $210.00 $259.00 $299.00 $388.00 $152.00 $201.00 $236.00 $295.00 $372.00 $532.00 $13.00 $24.00 $42.00 $86.00 $44.00 $43.00 $233.00 $354.00 $117.00 $183.00 $282.00 $89.00 $239.00 $315.00 $112.00 $151.00 $181.00 $212.00 $247.00 $378.00 $133.00 $175.00 $196.00 $243.00 $312.00 $439.00 $322.00 $435.00 $310.00 $441.00 $368.00 $473.00 $148.00 $189.00 $204.00 $244.00 $269.00 $404.00 $148.00 $191.00 $220.00 $272.00 $315.00 $412.00 $160.00 $211.00 $248.00 $311.00 $394.00 $566.00 $14.00 $26.00 $45.00 $92.00 $47.00 $45.00 $247.00 $376.00 $124.00 $196.00 $302.00 $95.00 $257.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 137 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 11771 11772 11900 11901 11920 11921 11922 11950 11951 11952 11954 11960 11970 11971 11976 12001 12002 12004 12005 12006 12007 12011 12013 12014 12015 12016 12017 12018 12020 12021 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047 12051 12052 12053 12054 12055 12056 12057 13100 90 90 0 0 0 0 ZZZ 0 0 0 0 90 90 90 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 $496.00 $585.00 $33.00 $37.00 $147.00 $172.00 $40.00 $107.00 $114.00 $155.00 $165.00 $829.00 $632.00 $280.00 $123.00 $84.00 $98.00 $122.00 $165.00 $203.00 $339.00 $98.00 $141.00 $165.00 $207.00 $268.00 $316.00 $515.00 $211.00 $87.00 $93.00 $110.00 $148.00 $223.00 $356.00 $411.00 $116.00 $141.00 $176.00 $250.00 $341.00 $363.00 $126.00 $148.00 $223.00 $301.00 $380.00 $487.00 $539.00 $178.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $647.00 $799.00 $65.00 $81.00 $246.00 $279.00 $80.00 $95.00 $125.00 $179.00 $213.00 $1,145.00 $760.00 $589.00 $186.00 $185.00 $198.00 $233.00 $290.00 $362.00 $409.00 $197.00 $217.00 $256.00 $322.00 $382.00 $345.00 $415.00 $335.00 $198.00 $270.00 $356.00 $353.00 $455.00 $508.00 $574.00 $287.00 $337.00 $385.00 $461.00 $547.00 $585.00 $317.00 $347.00 $382.00 $412.00 $507.00 $626.00 $672.00 $380.00 $687.00 $849.00 $68.00 $85.00 $263.00 $298.00 $85.00 $100.00 $132.00 $189.00 $227.00 $1,216.00 $808.00 $627.00 $198.00 $196.00 $209.00 $246.00 $307.00 $382.00 $433.00 $209.00 $229.00 $270.00 $340.00 $404.00 $363.00 $439.00 $356.00 $211.00 $285.00 $376.00 $373.00 $483.00 $542.00 $612.00 $304.00 $355.00 $407.00 $490.00 $582.00 $623.00 $335.00 $366.00 $403.00 $436.00 $537.00 $665.00 $711.00 $402.00 $734.00 $907.00 $71.00 $89.00 $281.00 $319.00 $91.00 $105.00 $140.00 $201.00 $243.00 $1,298.00 $868.00 $663.00 $211.00 $207.00 $221.00 $261.00 $325.00 $406.00 $462.00 $221.00 $243.00 $287.00 $360.00 $428.00 $386.00 $470.00 $379.00 $226.00 $301.00 $396.00 $394.00 $514.00 $580.00 $656.00 $321.00 $373.00 $431.00 $521.00 $621.00 $665.00 $354.00 $384.00 $425.00 $461.00 $570.00 $707.00 $754.00 $425.00 $515.00 $676.00 $38.00 $58.00 $149.00 $177.00 $40.00 $63.00 $86.00 $128.00 $148.00 $1,145.00 $760.00 $372.00 $129.00 $130.00 $145.00 $171.00 $213.00 $270.00 $312.00 $135.00 $154.00 $185.00 $233.00 $284.00 $345.00 $415.00 $239.00 $175.00 $184.00 $231.00 $244.00 $299.00 $354.00 $412.00 $200.00 $232.00 $258.00 $312.00 $369.00 $408.00 $217.00 $245.00 $257.00 $279.00 $350.00 $434.00 $492.00 $288.00 $546.00 $717.00 $39.00 $60.00 $159.00 $188.00 $43.00 $66.00 $91.00 $135.00 $158.00 $1,216.00 $808.00 $394.00 $137.00 $136.00 $153.00 $180.00 $224.00 $284.00 $329.00 $142.00 $162.00 $195.00 $244.00 $299.00 $363.00 $439.00 $254.00 $186.00 $193.00 $243.00 $256.00 $316.00 $376.00 $439.00 $210.00 $243.00 $271.00 $330.00 $391.00 $433.00 $228.00 $257.00 $270.00 $293.00 $369.00 $459.00 $518.00 $303.00 $585.00 $768.00 $40.00 $63.00 $172.00 $204.00 $47.00 $69.00 $96.00 $143.00 $170.00 $1,298.00 $868.00 $418.00 $147.00 $144.00 $162.00 $191.00 $238.00 $302.00 $352.00 $150.00 $172.00 $207.00 $259.00 $317.00 $386.00 $470.00 $271.00 $199.00 $204.00 $255.00 $271.00 $338.00 $405.00 $473.00 $221.00 $255.00 $287.00 $353.00 $420.00 $464.00 $241.00 $269.00 $284.00 $310.00 $392.00 $491.00 $550.00 $320.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 138 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 13101 13102 13120 13121 13122 13131 13132 13133 13150 13151 13152 13153 13160 14000 14001 14020 14021 14040 14041 14060 14061 14300 14350 15040 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15157 15170 15171 15175 15176 15200 15201 15220 10 ZZZ 10 10 ZZZ 10 10 ZZZ 10 10 10 ZZZ 90 90 90 90 90 90 90 90 90 90 90 0 90 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ ZZZ 90 ZZZ ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 $240.00 $89.00 $223.00 $348.00 $104.00 $252.00 $484.00 $154.00 $260.00 $375.00 $542.00 $169.00 $655.00 $512.00 $695.00 $590.00 $818.00 $701.00 $936.00 $766.00 $1,330.00 $1,040.00 $734.00 ------$349.00 $679.00 $146.00 ------------------------$788.00 $235.00 ------------------------------------------------------------------------------------$644.00 $126.00 $687.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $470.00 $131.00 $394.00 $513.00 $152.00 $434.00 $675.00 $206.00 $446.00 $492.00 $669.00 $230.00 $1,033.00 $787.00 $1,026.00 $876.00 $1,151.00 $920.00 $1,257.00 $942.00 $1,363.00 $1,331.00 $965.00 $325.00 $661.00 $1,118.00 $254.00 $1,100.00 $162.00 $1,078.00 $213.00 $1,158.00 $352.00 $870.00 $130.00 $1,094.00 $125.00 $914.00 $171.00 $210.00 $942.00 $225.00 $250.00 $521.00 $120.00 $688.00 $192.00 $982.00 $191.00 $931.00 $495.00 $139.00 $416.00 $540.00 $161.00 $457.00 $707.00 $217.00 $472.00 $518.00 $703.00 $244.00 $1,097.00 $832.00 $1,084.00 $926.00 $1,211.00 $970.00 $1,319.00 $992.00 $1,429.00 $1,404.00 $1,024.00 $347.00 $701.00 $1,190.00 $272.00 $1,168.00 $172.00 $1,140.00 $226.00 $1,227.00 $376.00 $927.00 $138.00 $1,160.00 $133.00 $971.00 $182.00 $224.00 $996.00 $239.00 $265.00 $548.00 $127.00 $726.00 $203.00 $1,041.00 $204.00 $988.00 $521.00 $148.00 $439.00 $567.00 $171.00 $481.00 $740.00 $229.00 $499.00 $546.00 $739.00 $259.00 $1,178.00 $880.00 $1,146.00 $978.00 $1,276.00 $1,022.00 $1,383.00 $1,046.00 $1,498.00 $1,486.00 $1,098.00 $368.00 $745.00 $1,273.00 $290.00 $1,248.00 $185.00 $1,212.00 $243.00 $1,305.00 $401.00 $991.00 $149.00 $1,236.00 $143.00 $1,039.00 $196.00 $241.00 $1,060.00 $257.00 $285.00 $582.00 $136.00 $773.00 $217.00 $1,108.00 $219.00 $1,049.00 $347.00 $96.00 $299.00 $385.00 $110.00 $338.00 $558.00 $167.00 $343.00 $393.00 $528.00 $185.00 $1,033.00 $655.00 $879.00 $746.00 $1,013.00 $800.00 $1,103.00 $845.00 $1,194.00 $1,180.00 $965.00 $167.00 $550.00 $921.00 $150.00 $949.00 $143.00 $969.00 $193.00 $987.00 $232.00 $723.00 $115.00 $989.00 $116.00 $832.00 $154.00 $193.00 $887.00 $212.00 $231.00 $449.00 $115.00 $619.00 $183.00 $813.00 $104.00 $774.00 $363.00 $101.00 $315.00 $403.00 $116.00 $355.00 $582.00 $175.00 $361.00 $412.00 $553.00 $195.00 $1,097.00 $691.00 $926.00 $786.00 $1,064.00 $841.00 $1,154.00 $889.00 $1,248.00 $1,243.00 $1,024.00 $177.00 $583.00 $980.00 $160.00 $1,006.00 $152.00 $1,023.00 $205.00 $1,044.00 $247.00 $769.00 $122.00 $1,048.00 $123.00 $883.00 $164.00 $205.00 $937.00 $225.00 $245.00 $471.00 $121.00 $652.00 $193.00 $860.00 $111.00 $819.00 $382.00 $108.00 $332.00 $423.00 $123.00 $373.00 $608.00 $185.00 $383.00 $434.00 $580.00 $208.00 $1,178.00 $731.00 $980.00 $831.00 $1,120.00 $886.00 $1,209.00 $937.00 $1,307.00 $1,316.00 $1,098.00 $190.00 $620.00 $1,051.00 $172.00 $1,077.00 $164.00 $1,089.00 $221.00 $1,112.00 $266.00 $825.00 $132.00 $1,118.00 $133.00 $945.00 $177.00 $221.00 $998.00 $242.00 $264.00 $500.00 $130.00 $695.00 $207.00 $917.00 $120.00 $872.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 139 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 15221 15240 15241 15260 15261 15300 15301 15320 15321 15330 15331 15335 15336 15340 15341 15360 15361 15365 15366 15400 15401 15420 15421 15430 15570 15572 15574 15576 15600 15610 15620 15630 15650 15731 15732 15734 15736 15738 15740 15750 15756 15757 15758 15760 15770 15775 15776 15780 15781 15782 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 10 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 $114.00 $763.00 $334.00 $841.00 $207.00 ------------------------------------------------------------------------------------$223.00 $66.00 ------------------$748.00 $721.00 $775.00 $457.00 $259.00 $320.00 $506.00 $362.00 $427.00 ------$1,465.00 $1,557.00 $1,862.00 $1,415.00 $913.00 $1,064.00 $2,892.00 $2,892.00 $2,884.00 $810.00 $674.00 $327.00 $475.00 $532.00 $420.00 $314.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $177.00 $1,105.00 $230.00 $1,170.00 $263.00 $423.00 $81.00 $483.00 $122.00 $393.00 $82.00 $425.00 $119.00 $401.00 $59.00 $451.00 $92.00 $453.00 $116.00 $468.00 $130.00 $526.00 $149.00 $668.00 $1,111.00 $1,043.00 $1,120.00 $989.00 $436.00 $400.00 $554.00 $565.00 $612.00 $1,359.00 $1,901.00 $1,974.00 $1,780.00 $1,893.00 $1,186.00 $1,158.00 $3,070.00 $3,031.00 $3,038.00 $1,033.00 $826.00 $405.00 $572.00 $1,021.00 $647.00 $696.00 $188.00 $1,168.00 $245.00 $1,229.00 $279.00 $447.00 $86.00 $511.00 $129.00 $417.00 $87.00 $451.00 $126.00 $425.00 $63.00 $479.00 $97.00 $481.00 $122.00 $496.00 $139.00 $558.00 $159.00 $709.00 $1,183.00 $1,108.00 $1,188.00 $1,046.00 $466.00 $427.00 $588.00 $599.00 $648.00 $1,434.00 $2,011.00 $2,101.00 $1,899.00 $2,017.00 $1,244.00 $1,226.00 $3,257.00 $3,201.00 $3,216.00 $1,091.00 $877.00 $431.00 $609.00 $1,079.00 $684.00 $738.00 $201.00 $1,237.00 $261.00 $1,290.00 $295.00 $476.00 $93.00 $544.00 $140.00 $446.00 $94.00 $482.00 $136.00 $452.00 $67.00 $510.00 $105.00 $511.00 $131.00 $528.00 $149.00 $593.00 $171.00 $755.00 $1,267.00 $1,184.00 $1,266.00 $1,108.00 $495.00 $456.00 $623.00 $633.00 $686.00 $1,519.00 $2,137.00 $2,254.00 $2,042.00 $2,168.00 $1,304.00 $1,308.00 $3,496.00 $3,412.00 $3,440.00 $1,154.00 $937.00 $462.00 $652.00 $1,139.00 $720.00 $778.00 $95.00 $971.00 $149.00 $1,037.00 $185.00 $366.00 $76.00 $420.00 $115.00 $335.00 $77.00 $366.00 $110.00 $344.00 $37.00 $384.00 $84.00 $392.00 $108.00 $437.00 $78.00 $470.00 $115.00 $648.00 $902.00 $890.00 $960.00 $838.00 $259.00 $305.00 $392.00 $424.00 $466.00 $1,231.00 $1,666.00 $1,735.00 $1,510.00 $1,647.00 $1,035.00 $1,158.00 $3,070.00 $3,031.00 $3,038.00 $880.00 $826.00 $290.00 $440.00 $822.00 $533.00 $520.00 $101.00 $1,024.00 $158.00 $1,087.00 $195.00 $387.00 $81.00 $444.00 $122.00 $355.00 $82.00 $388.00 $117.00 $364.00 $39.00 $407.00 $89.00 $415.00 $114.00 $463.00 $82.00 $497.00 $122.00 $687.00 $959.00 $943.00 $1,017.00 $884.00 $276.00 $326.00 $415.00 $448.00 $492.00 $1,297.00 $1,759.00 $1,845.00 $1,610.00 $1,754.00 $1,083.00 $1,226.00 $3,257.00 $3,201.00 $3,216.00 $927.00 $877.00 $307.00 $467.00 $865.00 $561.00 $549.00 $109.00 $1,085.00 $169.00 $1,140.00 $207.00 $412.00 $87.00 $474.00 $132.00 $381.00 $89.00 $416.00 $127.00 $388.00 $42.00 $433.00 $96.00 $442.00 $123.00 $493.00 $89.00 $530.00 $132.00 $731.00 $1,031.00 $1,010.00 $1,086.00 $938.00 $295.00 $349.00 $440.00 $473.00 $521.00 $1,375.00 $1,872.00 $1,983.00 $1,737.00 $1,891.00 $1,133.00 $1,308.00 $3,496.00 $3,412.00 $3,440.00 $981.00 $937.00 $332.00 $503.00 $913.00 $590.00 $579.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 140 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 15783 15786 15787 15788 15789 15792 15793 15819 15820 15821 15822 15823 15824 15825 15826 15828 15829 15830 15832 15833 15834 15835 15836 15837 15838 15839 15840 15841 15842 15845 15850 15851 15852 15860 15876 15877 15878 15879 15920 15922 15931 15933 15934 15935 15936 15937 15940 15941 15944 15945 90 10 ZZZ 90 90 90 90 90 90 90 90 90 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 $340.00 $146.00 $27.00 $194.00 $360.00 $130.00 $232.00 $780.00 $556.00 $607.00 $499.00 $718.00 NC NC NC NC NC ------$926.00 $833.00 $837.00 $865.00 $721.00 $696.00 $600.00 $643.00 $1,187.00 $1,859.00 $3,099.00 $1,116.00 $63.00 $40.00 $35.00 $151.00 NC NC NC NC $571.00 $771.00 $638.00 $860.00 $1,064.00 $1,184.00 $1,032.00 $1,223.00 $318.00 $919.00 $954.00 $1,078.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $595.00 $287.00 $67.00 $511.00 $684.00 $499.00 $554.00 $914.00 $651.00 $696.00 $517.00 $802.00 BR BR BR BR BR $1,517.00 $1,141.00 $1,060.00 $1,086.00 $1,112.00 $936.00 $964.00 $713.00 $1,046.00 $1,270.00 $2,122.00 $3,397.00 $1,165.00 $110.00 $121.00 $62.00 $149.00 BR BR BR BR $738.00 $952.00 $848.00 $1,044.00 $1,171.00 $1,385.00 $1,143.00 $1,337.00 $878.00 $1,153.00 $1,125.00 $1,245.00 $629.00 $302.00 $71.00 $543.00 $720.00 $531.00 $585.00 $963.00 $685.00 $732.00 $547.00 $842.00 BR BR BR BR BR $1,626.00 $1,213.00 $1,126.00 $1,155.00 $1,180.00 $994.00 $1,025.00 $748.00 $1,110.00 $1,337.00 $2,237.00 $3,601.00 $1,217.00 $116.00 $128.00 $65.00 $158.00 BR BR BR BR $784.00 $1,014.00 $900.00 $1,109.00 $1,245.00 $1,474.00 $1,216.00 $1,423.00 $932.00 $1,227.00 $1,197.00 $1,325.00 $661.00 $317.00 $75.00 $571.00 $754.00 $560.00 $613.00 $1,022.00 $721.00 $770.00 $577.00 $884.00 BR BR BR BR BR $1,770.00 $1,303.00 $1,208.00 $1,242.00 $1,266.00 $1,067.00 $1,097.00 $788.00 $1,186.00 $1,417.00 $2,379.00 $3,859.00 $1,275.00 $122.00 $134.00 $70.00 $171.00 BR BR BR BR $840.00 $1,091.00 $966.00 $1,192.00 $1,339.00 $1,585.00 $1,309.00 $1,532.00 $1,002.00 $1,319.00 $1,286.00 $1,425.00 $454.00 $169.00 $25.00 $287.00 $512.00 $324.00 $426.00 $914.00 $586.00 $623.00 $455.00 $734.00 BR BR BR BR BR $1,517.00 $1,141.00 $1,060.00 $1,086.00 $1,112.00 $936.00 $862.00 $713.00 $903.00 $1,270.00 $2,122.00 $3,397.00 $1,165.00 $53.00 $59.00 $62.00 $149.00 BR BR BR BR $738.00 $952.00 $848.00 $1,044.00 $1,171.00 $1,385.00 $1,143.00 $1,337.00 $878.00 $1,153.00 $1,125.00 $1,245.00 $478.00 $177.00 $26.00 $302.00 $536.00 $343.00 $447.00 $963.00 $616.00 $654.00 $480.00 $769.00 BR BR BR BR BR $1,626.00 $1,213.00 $1,126.00 $1,155.00 $1,180.00 $994.00 $916.00 $748.00 $957.00 $1,337.00 $2,237.00 $3,601.00 $1,217.00 $55.00 $61.00 $65.00 $158.00 BR BR BR BR $784.00 $1,014.00 $900.00 $1,109.00 $1,245.00 $1,474.00 $1,216.00 $1,423.00 $932.00 $1,227.00 $1,197.00 $1,325.00 $502.00 $185.00 $28.00 $317.00 $560.00 $361.00 $469.00 $1,022.00 $647.00 $688.00 $507.00 $807.00 BR BR BR BR BR $1,770.00 $1,303.00 $1,208.00 $1,242.00 $1,266.00 $1,067.00 $982.00 $788.00 $1,024.00 $1,417.00 $2,379.00 $3,859.00 $1,275.00 $58.00 $64.00 $70.00 $171.00 BR BR BR BR $840.00 $1,091.00 $966.00 $1,192.00 $1,339.00 $1,585.00 $1,309.00 $1,532.00 $1,002.00 $1,319.00 $1,286.00 $1,425.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 141 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 15946 15950 15951 15952 15953 15956 15958 15999 16000 16020 16025 16030 16035 16036 17000 17003 17004 17106 17107 17108 17110 17111 17250 17260 17261 17262 17263 17264 17266 17270 17271 17272 17273 17274 17276 17280 17281 17282 17283 17284 17286 17311 17312 17313 17314 17315 17340 17360 17380 17999 90 90 90 90 90 90 90 YYY 0 0 0 0 0 ZZZ 10 ZZZ 10 90 90 90 10 10 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 ZZZ 0 ZZZ ZZZ 10 10 0 YYY $1,737.00 $549.00 $872.00 $876.00 $1,013.00 $1,382.00 $1,379.00 BR $53.00 $49.00 $67.00 $153.00 $341.00 $81.00 $60.00 $16.00 $233.00 $341.00 $648.00 $1,015.00 $55.00 $83.00 $27.00 $96.00 $117.00 $150.00 $172.00 $189.00 $225.00 $125.00 $143.00 $170.00 $195.00 $240.00 $281.00 $123.00 $165.00 $194.00 $239.00 $282.00 $373.00 ------------------------------$37.00 $96.00 NC BR Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,071.00 $725.00 $1,034.00 $1,077.00 $1,202.00 $1,463.00 $1,493.00 ------$87.00 $104.00 $185.00 $223.00 $282.00 $113.00 $91.00 $9.00 $212.00 $477.00 $836.00 $1,117.00 $120.00 $146.00 $92.00 $114.00 $162.00 $198.00 $218.00 $236.00 $268.00 $170.00 $187.00 $214.00 $239.00 $285.00 $335.00 $159.00 $203.00 $235.00 $286.00 $334.00 $430.00 $845.00 $510.00 $772.00 $471.00 $100.00 $58.00 $155.00 BR ------- $2,201.00 $770.00 $1,099.00 $1,145.00 $1,279.00 $1,556.00 $1,589.00 ------$92.00 $110.00 $196.00 $237.00 $299.00 $120.00 $96.00 $10.00 $224.00 $503.00 $877.00 $1,163.00 $128.00 $154.00 $98.00 $120.00 $171.00 $208.00 $229.00 $248.00 $281.00 $179.00 $196.00 $225.00 $251.00 $299.00 $351.00 $168.00 $213.00 $247.00 $300.00 $350.00 $450.00 $890.00 $538.00 $813.00 $497.00 $105.00 $60.00 $162.00 BR ------- $2,367.00 $827.00 $1,180.00 $1,230.00 $1,375.00 $1,673.00 $1,709.00 ------$98.00 $117.00 $209.00 $252.00 $321.00 $129.00 $101.00 $11.00 $235.00 $530.00 $923.00 $1,211.00 $135.00 $162.00 $104.00 $125.00 $179.00 $217.00 $239.00 $259.00 $293.00 $187.00 $205.00 $235.00 $262.00 $312.00 $368.00 $176.00 $223.00 $258.00 $313.00 $365.00 $471.00 $930.00 $563.00 $851.00 $520.00 $110.00 $63.00 $170.00 BR ------- $2,071.00 $725.00 $1,034.00 $1,077.00 $1,202.00 $1,463.00 $1,493.00 ------$60.00 $72.00 $147.00 $170.00 $282.00 $113.00 $64.00 $6.00 $168.00 $410.00 $741.00 $1,015.00 $75.00 $96.00 $46.00 $81.00 $107.00 $137.00 $152.00 $163.00 $188.00 $116.00 $131.00 $152.00 $171.00 $210.00 $255.00 $106.00 $148.00 $171.00 $215.00 $256.00 $351.00 $463.00 $246.00 $416.00 $228.00 $65.00 $58.00 $119.00 BR ------- $2,201.00 $770.00 $1,099.00 $1,145.00 $1,279.00 $1,556.00 $1,589.00 ------$63.00 $76.00 $156.00 $180.00 $299.00 $120.00 $67.00 $7.00 $176.00 $431.00 $776.00 $1,054.00 $79.00 $101.00 $49.00 $85.00 $112.00 $143.00 $158.00 $169.00 $195.00 $121.00 $136.00 $158.00 $178.00 $218.00 $266.00 $110.00 $154.00 $178.00 $224.00 $266.00 $365.00 $480.00 $256.00 $431.00 $236.00 $67.00 $61.00 $124.00 BR ------- $2,367.00 $827.00 $1,180.00 $1,230.00 $1,375.00 $1,673.00 $1,709.00 ------$67.00 $81.00 $166.00 $193.00 $321.00 $129.00 $70.00 $7.00 $185.00 $454.00 $816.00 $1,095.00 $83.00 $106.00 $52.00 $88.00 $117.00 $149.00 $164.00 $176.00 $203.00 $125.00 $142.00 $164.00 $185.00 $227.00 $277.00 $115.00 $160.00 $185.00 $233.00 $277.00 $382.00 $498.00 $265.00 $448.00 $245.00 $70.00 $64.00 $129.00 BR ------- CPT only © 2008 American Medical Association. All rights reserved. Part B, 142 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 19000 19001 19020 19030 19100 19101 19102 19103 19105 19110 19112 19120 19125 19126 19260 19271 19272 19290 19291 19295 19296 19297 19298 19300 19301 19302 19303 19304 19305 19306 19307 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368 19369 19370 19371 0 ZZZ 90 0 0 10 0 0 0 90 90 90 90 ZZZ 90 90 90 0 ZZZ ZZZ 0 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 $74.00 $40.00 $288.00 $98.00 $117.00 $338.00 $263.00 $601.00 ------$406.00 $354.00 $429.00 $468.00 $201.00 $1,101.00 $1,561.00 $1,674.00 $101.00 $52.00 $103.00 ------------------------------------------------------------------$954.00 $1,313.00 $440.00 $656.00 $457.00 $569.00 $545.00 $963.00 $853.00 $755.00 $1,449.00 $1,667.00 $2,737.00 $1,676.00 $2,056.00 $2,444.00 $2,317.00 $662.00 $788.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $143.00 $35.00 $535.00 $218.00 $176.00 $403.00 $287.00 $737.00 $2,521.00 $546.00 $520.00 $572.00 $631.00 $211.00 $1,528.00 $2,080.00 $2,301.00 $209.00 $91.00 $125.00 $5,483.00 $121.00 $1,919.00 $679.00 $733.00 $1,106.00 $1,130.00 $692.00 $1,364.00 $1,427.00 $1,436.00 $1,007.00 $1,506.00 $613.00 $829.00 $621.00 $794.00 $529.00 $1,175.00 $1,127.00 $907.00 $1,974.00 $2,051.00 $3,629.00 $1,814.00 $2,366.00 $2,941.00 $2,683.00 $867.00 $1,006.00 $152.00 $37.00 $569.00 $230.00 $188.00 $429.00 $304.00 $783.00 $2,695.00 $581.00 $554.00 $608.00 $670.00 $224.00 $1,621.00 $2,207.00 $2,441.00 $221.00 $96.00 $134.00 $5,870.00 $127.00 $2,045.00 $723.00 $768.00 $1,174.00 $1,181.00 $735.00 $1,442.00 $1,510.00 $1,521.00 $1,075.00 $1,618.00 $651.00 $886.00 $662.00 $847.00 $567.00 $1,253.00 $1,206.00 $962.00 $2,104.00 $2,177.00 $3,869.00 $1,935.00 $2,526.00 $3,148.00 $2,859.00 $924.00 $1,075.00 $161.00 $40.00 $606.00 $241.00 $200.00 $457.00 $320.00 $826.00 $2,843.00 $621.00 $591.00 $651.00 $717.00 $241.00 $1,736.00 $2,360.00 $2,612.00 $232.00 $101.00 $142.00 $6,194.00 $136.00 $2,156.00 $773.00 $811.00 $1,263.00 $1,245.00 $791.00 $1,541.00 $1,617.00 $1,629.00 $1,160.00 $1,765.00 $698.00 $957.00 $712.00 $914.00 $617.00 $1,352.00 $1,296.00 $1,024.00 $2,265.00 $2,336.00 $4,182.00 $2,094.00 $2,732.00 $3,420.00 $3,088.00 $995.00 $1,161.00 $60.00 $30.00 $354.00 $105.00 $91.00 $274.00 $138.00 $258.00 $247.00 $398.00 $358.00 $492.00 $546.00 $211.00 $1,528.00 $2,080.00 $2,301.00 $87.00 $43.00 $125.00 $267.00 $121.00 $429.00 $480.00 $733.00 $1,106.00 $1,130.00 $692.00 $1,364.00 $1,427.00 $1,436.00 $1,007.00 $1,506.00 $613.00 $829.00 $621.00 $794.00 $529.00 $1,175.00 $878.00 $700.00 $1,974.00 $2,051.00 $3,629.00 $1,814.00 $2,366.00 $2,941.00 $2,683.00 $867.00 $1,006.00 $63.00 $31.00 $376.00 $109.00 $96.00 $290.00 $144.00 $270.00 $258.00 $423.00 $381.00 $522.00 $579.00 $224.00 $1,621.00 $2,207.00 $2,441.00 $90.00 $45.00 $134.00 $281.00 $127.00 $448.00 $511.00 $768.00 $1,174.00 $1,181.00 $735.00 $1,442.00 $1,510.00 $1,521.00 $1,075.00 $1,618.00 $651.00 $886.00 $662.00 $847.00 $567.00 $1,253.00 $938.00 $740.00 $2,104.00 $2,177.00 $3,869.00 $1,935.00 $2,526.00 $3,148.00 $2,859.00 $924.00 $1,075.00 $67.00 $33.00 $402.00 $114.00 $104.00 $311.00 $152.00 $285.00 $273.00 $455.00 $408.00 $561.00 $621.00 $241.00 $1,736.00 $2,360.00 $2,612.00 $94.00 $47.00 $142.00 $299.00 $136.00 $471.00 $549.00 $811.00 $1,263.00 $1,245.00 $791.00 $1,541.00 $1,617.00 $1,629.00 $1,160.00 $1,765.00 $698.00 $957.00 $712.00 $914.00 $617.00 $1,352.00 $1,014.00 $790.00 $2,265.00 $2,336.00 $4,182.00 $2,094.00 $2,732.00 $3,420.00 $3,088.00 $995.00 $1,161.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 143 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 19380 19396 19499 20000 20005 20100 20101 20102 20103 20150 20200 20205 20206 20220 20225 20240 20245 20250 20251 20500 20501 20520 20525 20526 20550 20551 20552 20553 20555 20600 20605 20610 20612 20615 20650 20660 20661 20662 20663 20665 20670 20680 20690 20692 20693 20694 20802 20805 20808 20816 90 0 YYY 10 10 10 10 10 10 90 0 0 0 0 0 10 10 10 10 10 0 10 10 0 0 0 0 0 0 0 0 0 0 10 10 0 90 90 90 10 10 90 90 90 90 90 90 90 90 90 $780.00 $231.00 BR $45.00 $267.00 $727.00 $261.00 $314.00 $405.00 $1,141.00 $134.00 $243.00 $119.00 $128.00 $215.00 $279.00 $364.00 $447.00 $511.00 $59.00 $60.00 $75.00 $331.00 $64.00 $40.00 $62.00 $62.00 $62.00 ------$41.00 $48.00 $49.00 $56.00 $94.00 $170.00 $320.00 $476.00 $559.00 $465.00 $105.00 $80.00 $332.00 $298.00 $516.00 $477.00 $421.00 $3,363.00 $4,317.00 $5,324.00 $3,060.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $976.00 $266.00 ------$257.00 $382.00 $782.00 $499.00 $585.00 $719.00 $1,214.00 $240.00 $329.00 $345.00 $247.00 $1,016.00 $302.00 $823.00 $501.00 $558.00 $158.00 $171.00 $243.00 $611.00 $99.00 $76.00 $75.00 $67.00 $75.00 $425.00 $70.00 $76.00 $97.00 $76.00 $280.00 $251.00 $348.00 $606.00 $597.00 $580.00 $165.00 $559.00 $745.00 $639.00 $1,174.00 $607.00 $565.00 $3,144.00 $4,093.00 $5,307.00 $3,203.00 $1,040.00 $284.00 ------$273.00 $407.00 $827.00 $533.00 $623.00 $767.00 $1,292.00 $257.00 $352.00 $367.00 $262.00 $1,087.00 $321.00 $879.00 $540.00 $602.00 $168.00 $181.00 $258.00 $653.00 $106.00 $80.00 $79.00 $71.00 $78.00 $443.00 $75.00 $81.00 $103.00 $81.00 $296.00 $267.00 $372.00 $654.00 $629.00 $622.00 $177.00 $598.00 $789.00 $667.00 $1,225.00 $649.00 $605.00 $3,302.00 $4,310.00 $5,611.00 $3,415.00 $1,119.00 $304.00 ------$291.00 $435.00 $887.00 $568.00 $663.00 $821.00 $1,394.00 $275.00 $376.00 $387.00 $276.00 $1,149.00 $345.00 $948.00 $591.00 $659.00 $178.00 $191.00 $274.00 $697.00 $113.00 $86.00 $84.00 $75.00 $82.00 $467.00 $80.00 $86.00 $110.00 $87.00 $313.00 $286.00 $401.00 $715.00 $666.00 $673.00 $189.00 $636.00 $836.00 $701.00 $1,286.00 $702.00 $651.00 $3,502.00 $4,577.00 $5,988.00 $3,673.00 $976.00 $183.00 ------$202.00 $310.00 $782.00 $265.00 $318.00 $463.00 $1,214.00 $123.00 $194.00 $82.00 $103.00 $159.00 $302.00 $823.00 $501.00 $558.00 $128.00 $52.00 $185.00 $326.00 $78.00 $55.00 $57.00 $46.00 $50.00 $425.00 $54.00 $55.00 $67.00 $58.00 $206.00 $205.00 $312.00 $606.00 $597.00 $580.00 $135.00 $199.00 $516.00 $639.00 $1,174.00 $607.00 $443.00 $3,144.00 $4,093.00 $5,307.00 $3,203.00 $1,040.00 $194.00 ------$214.00 $329.00 $827.00 $282.00 $337.00 $494.00 $1,292.00 $131.00 $206.00 $86.00 $107.00 $169.00 $321.00 $879.00 $540.00 $602.00 $135.00 $54.00 $196.00 $348.00 $83.00 $59.00 $60.00 $48.00 $52.00 $443.00 $57.00 $59.00 $71.00 $62.00 $216.00 $218.00 $332.00 $654.00 $629.00 $622.00 $144.00 $213.00 $544.00 $667.00 $1,225.00 $649.00 $474.00 $3,302.00 $4,310.00 $5,611.00 $3,415.00 $1,119.00 $209.00 ------$228.00 $353.00 $887.00 $304.00 $362.00 $532.00 $1,394.00 $143.00 $222.00 $90.00 $112.00 $181.00 $345.00 $948.00 $591.00 $659.00 $144.00 $56.00 $209.00 $375.00 $89.00 $63.00 $64.00 $51.00 $55.00 $467.00 $61.00 $63.00 $76.00 $67.00 $229.00 $235.00 $360.00 $715.00 $666.00 $673.00 $155.00 $230.00 $578.00 $701.00 $1,286.00 $702.00 $513.00 $3,502.00 $4,577.00 $5,988.00 $3,673.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 144 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 20822 20824 20827 20838 20900 20902 20910 20912 20920 20922 20924 20926 20930 20931 20936 20937 20938 20950 20955 20956 20957 20962 20969 20970 20972 20973 20974 20975 20979 20982 20985 20999 21010 21015 21025 21026 21029 21030 21031 21032 21034 21040 21044 21045 21046 21047 21048 21049 21050 21060 90 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 0 ZZZ ZZZ 0 90 90 90 90 90 90 90 90 0 0 0 0 ZZZ YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $2,511.00 $3,027.00 $3,920.00 $3,484.00 $454.00 $658.00 $338.00 $549.00 $460.00 $634.00 $583.00 $444.00 BR $156.00 BR $234.00 $257.00 $123.00 $3,332.00 $3,167.00 $3,074.00 $3,122.00 $3,716.00 $3,650.00 $3,420.00 $3,821.00 $266.00 $334.00 $19.00 ------------BR $854.00 $520.00 $546.00 $413.00 $700.00 $496.00 $310.00 $315.00 $1,140.00 $227.00 $957.00 $1,313.00 $899.00 $1,109.00 $925.00 $1,051.00 $1,026.00 $972.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,815.00 $3,176.00 $2,851.00 $2,995.00 $787.00 $799.00 $554.00 $624.00 $521.00 $754.00 $663.00 $568.00 ------$159.00 ------$237.00 $260.00 $352.00 $3,338.00 $3,607.00 $3,420.00 $3,558.00 $3,692.00 $3,761.00 $3,384.00 $3,629.00 $80.00 $242.00 $72.00 $5,135.00 $205.00 ------$934.00 $551.00 $1,244.00 $725.00 $935.00 $606.00 $468.00 $476.00 $1,689.00 $608.00 $1,117.00 $1,551.00 $1,388.00 $1,691.00 $1,408.00 $1,605.00 $1,100.00 $1,017.00 $3,010.00 $3,387.00 $3,035.00 $3,088.00 $842.00 $855.00 $589.00 $661.00 $553.00 $799.00 $709.00 $606.00 ------$173.00 ------$255.00 $281.00 $377.00 $3,539.00 $3,866.00 $3,661.00 $3,811.00 $3,899.00 $4,012.00 $3,583.00 $3,840.00 $85.00 $260.00 $77.00 $5,491.00 $221.00 ------$986.00 $585.00 $1,322.00 $770.00 $993.00 $644.00 $500.00 $508.00 $1,786.00 $646.00 $1,177.00 $1,631.00 $1,477.00 $1,787.00 $1,495.00 $1,687.00 $1,168.00 $1,080.00 $3,247.00 $3,646.00 $3,255.00 $3,185.00 $905.00 $925.00 $632.00 $704.00 $591.00 $848.00 $766.00 $654.00 ------$192.00 ------$280.00 $310.00 $401.00 $3,795.00 $4,208.00 $3,990.00 $4,139.00 $4,158.00 $4,340.00 $3,844.00 $4,116.00 $92.00 $285.00 $82.00 $5,797.00 $242.00 ------$1,050.00 $626.00 $1,410.00 $818.00 $1,058.00 $685.00 $535.00 $544.00 $1,898.00 $687.00 $1,247.00 $1,725.00 $1,585.00 $1,906.00 $1,599.00 $1,783.00 $1,252.00 $1,157.00 $2,815.00 $3,176.00 $2,851.00 $2,995.00 $610.00 $799.00 $554.00 $624.00 $521.00 $623.00 $663.00 $568.00 ------$159.00 ------$237.00 $260.00 $122.00 $3,338.00 $3,607.00 $3,420.00 $3,558.00 $3,692.00 $3,761.00 $3,384.00 $3,629.00 $64.00 $242.00 $50.00 $537.00 $205.00 ------$934.00 $551.00 $1,077.00 $614.00 $801.00 $511.00 $369.00 $363.00 $1,512.00 $502.00 $1,117.00 $1,551.00 $1,388.00 $1,691.00 $1,408.00 $1,605.00 $1,100.00 $1,017.00 $3,010.00 $3,387.00 $3,035.00 $3,088.00 $653.00 $855.00 $589.00 $661.00 $553.00 $658.00 $709.00 $606.00 ------$173.00 ------$255.00 $281.00 $130.00 $3,539.00 $3,866.00 $3,661.00 $3,811.00 $3,899.00 $4,012.00 $3,583.00 $3,840.00 $68.00 $260.00 $53.00 $565.00 $221.00 ------$986.00 $585.00 $1,143.00 $651.00 $849.00 $542.00 $393.00 $388.00 $1,597.00 $533.00 $1,177.00 $1,631.00 $1,477.00 $1,787.00 $1,495.00 $1,687.00 $1,168.00 $1,080.00 $3,247.00 $3,646.00 $3,255.00 $3,185.00 $705.00 $925.00 $632.00 $704.00 $591.00 $700.00 $766.00 $654.00 ------$192.00 ------$280.00 $310.00 $141.00 $3,795.00 $4,208.00 $3,990.00 $4,139.00 $4,158.00 $4,340.00 $3,844.00 $4,116.00 $74.00 $285.00 $58.00 $601.00 $242.00 ------$1,050.00 $626.00 $1,221.00 $693.00 $905.00 $578.00 $423.00 $416.00 $1,698.00 $568.00 $1,247.00 $1,725.00 $1,585.00 $1,906.00 $1,599.00 $1,783.00 $1,252.00 $1,157.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 145 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 21070 21073 21076 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21089 21100 21110 21116 21120 21121 21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 21146 21147 21150 21151 21154 21155 21159 21160 21172 21175 21179 21180 21181 21182 21183 21184 21188 21193 21194 90 90 10 90 90 90 90 90 90 90 10 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $679.00 ------$1,192.00 $3,002.00 $2,086.00 $2,346.00 $2,138.00 $1,855.00 $1,802.00 $2,105.00 $801.00 $2,333.00 $2,217.00 BR BR $297.00 $371.00 $207.00 $500.00 $651.00 $700.00 $903.00 $656.00 $909.00 $797.00 $960.00 $1,168.00 $1,438.00 $1,527.00 $1,511.00 $1,513.00 $1,570.00 $1,639.00 $1,914.00 $2,264.00 $2,364.00 $2,640.00 $3,302.00 $3,500.00 $2,111.00 $2,604.00 $1,826.00 $2,035.00 $813.00 $2,570.00 $2,770.00 $3,150.00 $1,786.00 $1,331.00 $1,540.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $834.00 $465.00 $1,297.00 $3,188.00 $2,185.00 $2,490.00 $2,260.00 $2,082.00 $1,977.00 $2,211.00 $903.00 $2,380.00 $2,350.00 ------------$901.00 $895.00 $214.00 $787.00 $942.00 $915.00 $1,084.00 $3,543.00 $3,890.00 $959.00 $1,169.00 $1,244.00 $1,730.00 $1,700.00 $1,758.00 $2,008.00 $2,011.00 $2,108.00 $2,256.00 $2,402.00 $2,681.00 $3,222.00 $3,771.00 $3,801.00 $2,288.00 $2,737.00 $1,915.00 $2,182.00 $940.00 $2,606.00 $3,026.00 $3,200.00 $2,077.00 $1,615.00 $1,820.00 $891.00 $496.00 $1,384.00 $3,393.00 $2,329.00 $2,658.00 $2,409.00 $2,222.00 $2,110.00 $2,337.00 $963.00 $2,540.00 $2,503.00 ------------$957.00 $953.00 $227.00 $839.00 $1,001.00 $972.00 $1,151.00 $3,776.00 $4,157.00 $1,020.00 $1,245.00 $1,307.00 $1,835.00 $1,802.00 $1,847.00 $2,128.00 $2,133.00 $2,207.00 $2,381.00 $2,522.00 $2,817.00 $3,467.00 $4,058.00 $3,996.00 $2,427.00 $2,916.00 $2,031.00 $2,321.00 $999.00 $2,739.00 $3,212.00 $3,412.00 $2,181.00 $1,712.00 $1,917.00 $960.00 $529.00 $1,493.00 $3,645.00 $2,505.00 $2,865.00 $2,590.00 $2,395.00 $2,273.00 $2,481.00 $1,035.00 $2,740.00 $2,692.00 ------------$1,009.00 $1,015.00 $240.00 $892.00 $1,067.00 $1,040.00 $1,232.00 $3,982.00 $4,404.00 $1,094.00 $1,339.00 $1,380.00 $1,966.00 $1,930.00 $1,951.00 $2,280.00 $2,291.00 $2,323.00 $2,531.00 $2,664.00 $2,975.00 $3,790.00 $4,445.00 $4,234.00 $2,608.00 $3,152.00 $2,179.00 $2,500.00 $1,072.00 $2,900.00 $3,447.00 $3,693.00 $2,299.00 $1,833.00 $2,035.00 $834.00 $306.00 $1,155.00 $2,890.00 $1,930.00 $2,184.00 $1,975.00 $1,826.00 $1,689.00 $1,896.00 $780.00 $2,161.00 $2,136.00 ------------$498.00 $782.00 $57.00 $635.00 $818.00 $915.00 $1,084.00 $933.00 $1,119.00 $959.00 $1,169.00 $1,244.00 $1,730.00 $1,700.00 $1,758.00 $2,008.00 $2,011.00 $2,108.00 $2,256.00 $2,402.00 $2,681.00 $3,222.00 $3,771.00 $3,801.00 $2,288.00 $2,737.00 $1,915.00 $2,182.00 $940.00 $2,606.00 $3,026.00 $3,200.00 $2,077.00 $1,615.00 $1,820.00 $891.00 $325.00 $1,232.00 $3,074.00 $2,055.00 $2,330.00 $2,102.00 $1,948.00 $1,802.00 $1,999.00 $831.00 $2,305.00 $2,273.00 ------------$525.00 $832.00 $59.00 $675.00 $869.00 $972.00 $1,151.00 $979.00 $1,188.00 $1,020.00 $1,245.00 $1,307.00 $1,835.00 $1,802.00 $1,847.00 $2,128.00 $2,133.00 $2,207.00 $2,381.00 $2,522.00 $2,817.00 $3,467.00 $4,058.00 $3,996.00 $2,427.00 $2,916.00 $2,031.00 $2,321.00 $999.00 $2,739.00 $3,212.00 $3,412.00 $2,181.00 $1,712.00 $1,917.00 $960.00 $349.00 $1,332.00 $3,309.00 $2,216.00 $2,519.00 $2,267.00 $2,106.00 $1,949.00 $2,124.00 $896.00 $2,492.00 $2,449.00 ------------$554.00 $887.00 $62.00 $720.00 $927.00 $1,040.00 $1,232.00 $1,032.00 $1,273.00 $1,094.00 $1,339.00 $1,380.00 $1,966.00 $1,930.00 $1,951.00 $2,280.00 $2,291.00 $2,323.00 $2,531.00 $2,664.00 $2,975.00 $3,790.00 $4,445.00 $4,234.00 $2,608.00 $3,152.00 $2,179.00 $2,500.00 $1,072.00 $2,900.00 $3,447.00 $3,693.00 $2,299.00 $1,833.00 $2,035.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 146 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 21195 21196 21198 21199 21206 21208 21209 21210 21215 21230 21235 21240 21242 21243 21244 21245 21246 21247 21248 21249 21255 21256 21260 21261 21263 21267 21268 21270 21275 21280 21282 21295 21296 21299 21310 21315 21320 21325 21330 21335 21336 21337 21338 21339 21340 21343 21344 21345 21346 21347 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,360.00 $1,764.00 $1,268.00 $1,018.00 $1,112.00 $946.00 $576.00 $930.00 $970.00 $956.00 $707.00 $1,281.00 $1,207.00 $1,501.00 $1,062.00 $1,038.00 $1,010.00 $2,003.00 $1,023.00 $1,525.00 $1,459.00 $1,470.00 $1,372.00 $2,347.00 $2,361.00 $1,539.00 $1,946.00 $890.00 $963.00 $571.00 $360.00 $144.00 $384.00 BR $81.00 $180.00 $235.00 $348.00 $639.00 $852.00 $478.00 $300.00 $550.00 $689.00 $907.00 $1,043.00 $1,450.00 $738.00 $917.00 $1,048.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,714.00 $1,871.00 $1,456.00 $1,308.00 $1,415.00 $1,997.00 $1,002.00 $2,347.00 $3,880.00 $998.00 $890.00 $1,456.00 $1,328.00 $2,177.00 $1,316.00 $1,414.00 $1,119.00 $2,106.00 $1,330.00 $1,881.00 $1,796.00 $1,472.00 $1,553.00 $2,833.00 $2,479.00 $1,991.00 $2,381.00 $1,121.00 $1,032.00 $647.00 $430.00 $217.00 $504.00 ------$138.00 $319.00 $307.00 $605.00 $744.00 $929.00 $809.00 $482.00 $981.00 $1,063.00 $1,015.00 $1,486.00 $1,936.00 $998.00 $1,202.00 $1,442.00 $1,805.00 $1,977.00 $1,536.00 $1,373.00 $1,491.00 $2,124.00 $1,066.00 $2,502.00 $4,148.00 $1,058.00 $942.00 $1,552.00 $1,410.00 $2,316.00 $1,390.00 $1,495.00 $1,182.00 $2,232.00 $1,414.00 $2,002.00 $1,910.00 $1,548.00 $1,624.00 $2,990.00 $2,605.00 $2,099.00 $2,534.00 $1,180.00 $1,092.00 $679.00 $452.00 $229.00 $532.00 ------$147.00 $338.00 $326.00 $641.00 $789.00 $981.00 $855.00 $511.00 $1,045.00 $1,130.00 $1,072.00 $1,574.00 $2,050.00 $1,057.00 $1,274.00 $1,530.00 $1,911.00 $2,102.00 $1,629.00 $1,452.00 $1,578.00 $2,248.00 $1,135.00 $2,653.00 $4,396.00 $1,130.00 $995.00 $1,672.00 $1,510.00 $2,490.00 $1,474.00 $1,584.00 $1,260.00 $2,387.00 $1,511.00 $2,148.00 $2,049.00 $1,638.00 $1,699.00 $3,182.00 $2,757.00 $2,219.00 $2,727.00 $1,242.00 $1,166.00 $712.00 $474.00 $243.00 $560.00 ------$155.00 $357.00 $345.00 $676.00 $837.00 $1,036.00 $904.00 $540.00 $1,112.00 $1,203.00 $1,140.00 $1,673.00 $2,190.00 $1,123.00 $1,355.00 $1,628.00 $1,714.00 $1,871.00 $1,456.00 $1,308.00 $1,415.00 $1,050.00 $813.00 $1,063.00 $1,115.00 $998.00 $707.00 $1,456.00 $1,328.00 $2,177.00 $1,316.00 $1,161.00 $1,119.00 $2,106.00 $1,134.00 $1,627.00 $1,796.00 $1,472.00 $1,553.00 $2,833.00 $2,479.00 $1,991.00 $2,381.00 $880.00 $1,032.00 $647.00 $430.00 $217.00 $504.00 ------$38.00 $186.00 $176.00 $605.00 $744.00 $929.00 $809.00 $354.00 $981.00 $1,063.00 $1,015.00 $1,486.00 $1,936.00 $833.00 $1,202.00 $1,442.00 $1,805.00 $1,977.00 $1,536.00 $1,373.00 $1,491.00 $1,109.00 $864.00 $1,127.00 $1,185.00 $1,058.00 $745.00 $1,552.00 $1,410.00 $2,316.00 $1,390.00 $1,224.00 $1,182.00 $2,232.00 $1,204.00 $1,730.00 $1,910.00 $1,548.00 $1,624.00 $2,990.00 $2,605.00 $2,099.00 $2,534.00 $921.00 $1,092.00 $679.00 $452.00 $229.00 $532.00 ------$39.00 $196.00 $186.00 $641.00 $789.00 $981.00 $855.00 $373.00 $1,045.00 $1,130.00 $1,072.00 $1,574.00 $2,050.00 $881.00 $1,274.00 $1,530.00 $1,911.00 $2,102.00 $1,629.00 $1,452.00 $1,578.00 $1,178.00 $922.00 $1,203.00 $1,271.00 $1,130.00 $787.00 $1,672.00 $1,510.00 $2,490.00 $1,474.00 $1,298.00 $1,260.00 $2,387.00 $1,290.00 $1,861.00 $2,049.00 $1,638.00 $1,699.00 $3,182.00 $2,757.00 $2,219.00 $2,727.00 $969.00 $1,166.00 $712.00 $474.00 $243.00 $560.00 ------$42.00 $207.00 $198.00 $676.00 $837.00 $1,036.00 $904.00 $395.00 $1,112.00 $1,203.00 $1,140.00 $1,673.00 $2,190.00 $937.00 $1,355.00 $1,628.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 147 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 21348 21355 21356 21360 21365 21366 21385 21386 21387 21390 21395 21400 21401 21406 21407 21408 21421 21422 21423 21431 21432 21433 21435 21436 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21470 21480 21485 21490 21495 21497 21499 21501 21502 21510 21550 21555 21556 21557 21600 21610 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 YYY 90 90 90 10 90 90 90 90 90 $1,286.00 $295.00 $372.00 $590.00 $1,239.00 $1,386.00 $810.00 $812.00 $958.00 $920.00 $1,384.00 $143.00 $313.00 $852.00 $736.00 $1,007.00 $528.00 $761.00 $890.00 $598.00 $744.00 $1,981.00 $1,404.00 $2,045.00 $308.00 $533.00 $325.00 $498.00 $195.00 $902.00 $905.00 $769.00 $1,012.00 $923.00 $1,331.00 $82.00 $318.00 $865.00 $500.00 $372.00 BR $315.00 $612.00 $534.00 $165.00 $337.00 $431.00 $794.00 $631.00 $828.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,566.00 $533.00 $610.00 $672.00 $1,409.00 $1,610.00 $906.00 $848.00 $966.00 $962.00 $1,235.00 $213.00 $573.00 $686.00 $812.00 $1,118.00 $875.00 $861.00 $1,022.00 $928.00 $847.00 $2,162.00 $1,693.00 $2,439.00 $613.00 $896.00 $640.00 $865.00 $756.00 $998.00 $701.00 $2,158.00 $2,371.00 $1,172.00 $1,520.00 $116.00 $763.00 $1,198.00 $816.00 $765.00 ------$540.00 $681.00 $610.00 $309.00 $533.00 $522.00 $751.00 $706.00 $1,429.00 $1,668.00 $563.00 $646.00 $711.00 $1,488.00 $1,712.00 $959.00 $896.00 $1,022.00 $1,011.00 $1,302.00 $226.00 $610.00 $725.00 $859.00 $1,183.00 $932.00 $913.00 $1,084.00 $983.00 $894.00 $2,284.00 $1,786.00 $2,574.00 $654.00 $955.00 $681.00 $920.00 $807.00 $1,062.00 $744.00 $2,301.00 $2,529.00 $1,242.00 $1,610.00 $123.00 $812.00 $1,280.00 $862.00 $815.00 ------$574.00 $723.00 $649.00 $327.00 $568.00 $553.00 $796.00 $752.00 $1,539.00 $1,799.00 $594.00 $685.00 $757.00 $1,584.00 $1,843.00 $1,019.00 $953.00 $1,089.00 $1,068.00 $1,385.00 $240.00 $647.00 $770.00 $915.00 $1,264.00 $993.00 $974.00 $1,159.00 $1,040.00 $948.00 $2,435.00 $1,899.00 $2,742.00 $694.00 $1,018.00 $720.00 $978.00 $855.00 $1,129.00 $793.00 $2,436.00 $2,683.00 $1,327.00 $1,720.00 $131.00 $862.00 $1,384.00 $908.00 $865.00 ------$610.00 $777.00 $696.00 $345.00 $606.00 $591.00 $853.00 $808.00 $1,686.00 $1,566.00 $398.00 $472.00 $672.00 $1,409.00 $1,610.00 $906.00 $848.00 $966.00 $962.00 $1,235.00 $176.00 $361.00 $686.00 $812.00 $1,118.00 $768.00 $861.00 $1,022.00 $928.00 $847.00 $2,162.00 $1,693.00 $2,439.00 $525.00 $766.00 $558.00 $758.00 $396.00 $919.00 $701.00 $1,140.00 $1,259.00 $1,172.00 $1,520.00 $43.00 $675.00 $1,198.00 $816.00 $673.00 ------$399.00 $681.00 $610.00 $198.00 $416.00 $522.00 $751.00 $706.00 $1,429.00 $1,668.00 $419.00 $499.00 $711.00 $1,488.00 $1,712.00 $959.00 $896.00 $1,022.00 $1,011.00 $1,302.00 $186.00 $382.00 $725.00 $859.00 $1,183.00 $818.00 $913.00 $1,084.00 $983.00 $894.00 $2,284.00 $1,786.00 $2,574.00 $558.00 $816.00 $592.00 $806.00 $422.00 $978.00 $744.00 $1,211.00 $1,338.00 $1,242.00 $1,610.00 $45.00 $717.00 $1,280.00 $862.00 $716.00 ------$423.00 $723.00 $649.00 $208.00 $442.00 $553.00 $796.00 $752.00 $1,539.00 $1,799.00 $442.00 $530.00 $757.00 $1,584.00 $1,843.00 $1,019.00 $953.00 $1,089.00 $1,068.00 $1,385.00 $198.00 $407.00 $770.00 $915.00 $1,264.00 $872.00 $974.00 $1,159.00 $1,040.00 $948.00 $2,435.00 $1,899.00 $2,742.00 $593.00 $872.00 $627.00 $858.00 $448.00 $1,040.00 $793.00 $1,287.00 $1,427.00 $1,327.00 $1,720.00 $48.00 $762.00 $1,384.00 $908.00 $761.00 ------$451.00 $777.00 $696.00 $219.00 $474.00 $591.00 $853.00 $808.00 $1,686.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 148 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 21615 21616 21620 21627 21630 21632 21685 21700 21705 21720 21725 21740 21742 21743 21750 21800 21805 21810 21820 21825 21899 21920 21925 21930 21935 22010 22015 22100 22101 22102 22103 22110 22112 22114 22116 22206 22207 22208 22210 22212 22214 22216 22220 22222 22224 22226 22305 22310 22315 22318 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 90 ZZZ 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 $938.00 $1,042.00 $689.00 $686.00 $1,455.00 $1,514.00 ------$576.00 $746.00 $523.00 $588.00 $1,387.00 BR BR $1,009.00 $84.00 $236.00 $540.00 $143.00 $810.00 BR $165.00 $371.00 $403.00 $1,280.00 ------------$850.00 $862.00 $781.00 $198.00 $889.00 $1,090.00 $1,062.00 $195.00 ------------------$1,892.00 $1,668.00 $819.00 $492.00 $1,801.00 $1,604.00 $1,731.00 $488.00 $213.00 $272.00 $711.00 $1,755.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $896.00 $1,100.00 $683.00 $714.00 $1,653.00 $1,640.00 $1,251.00 $539.00 $824.00 $505.00 $694.00 $1,426.00 ------------$948.00 $120.00 $324.00 $658.00 $165.00 $742.00 ------$302.00 $524.00 $584.00 $1,512.00 $1,159.00 $1,151.00 $1,070.00 $1,059.00 $1,061.00 $197.00 $1,325.00 $1,310.00 $1,317.00 $200.00 $3,118.00 $3,076.00 $804.00 $2,362.00 $1,927.00 $1,945.00 $522.00 $2,143.00 $1,940.00 $2,083.00 $520.00 $240.00 $358.00 $1,102.00 $2,145.00 $954.00 $1,174.00 $727.00 $761.00 $1,758.00 $1,745.00 $1,312.00 $563.00 $878.00 $540.00 $744.00 $1,516.00 ------------$1,010.00 $128.00 $345.00 $700.00 $176.00 $791.00 ------$319.00 $558.00 $622.00 $1,607.00 $1,234.00 $1,225.00 $1,153.00 $1,136.00 $1,137.00 $212.00 $1,428.00 $1,407.00 $1,417.00 $216.00 $3,339.00 $3,293.00 $870.00 $2,555.00 $2,072.00 $2,092.00 $564.00 $2,320.00 $2,083.00 $2,238.00 $562.00 $258.00 $381.00 $1,184.00 $2,327.00 $1,028.00 $1,269.00 $781.00 $819.00 $1,893.00 $1,879.00 $1,381.00 $588.00 $949.00 $586.00 $807.00 $1,634.00 ------------$1,091.00 $135.00 $369.00 $752.00 $188.00 $852.00 ------$336.00 $597.00 $665.00 $1,731.00 $1,328.00 $1,318.00 $1,260.00 $1,234.00 $1,235.00 $233.00 $1,564.00 $1,533.00 $1,548.00 $239.00 $3,636.00 $3,583.00 $963.00 $2,813.00 $2,264.00 $2,284.00 $623.00 $2,560.00 $2,277.00 $2,442.00 $621.00 $280.00 $409.00 $1,286.00 $2,575.00 $896.00 $1,100.00 $683.00 $714.00 $1,653.00 $1,640.00 $1,251.00 $539.00 $824.00 $505.00 $694.00 $1,426.00 ------------$948.00 $122.00 $324.00 $658.00 $165.00 $742.00 ------$193.00 $426.00 $470.00 $1,512.00 $1,159.00 $1,151.00 $1,070.00 $1,059.00 $1,061.00 $197.00 $1,325.00 $1,310.00 $1,317.00 $200.00 $3,118.00 $3,076.00 $804.00 $2,362.00 $1,927.00 $1,945.00 $522.00 $2,143.00 $1,940.00 $2,083.00 $520.00 $221.00 $334.00 $982.00 $2,145.00 $954.00 $1,174.00 $727.00 $761.00 $1,758.00 $1,745.00 $1,312.00 $563.00 $878.00 $540.00 $744.00 $1,516.00 ------------$1,010.00 $129.00 $345.00 $700.00 $176.00 $791.00 ------$202.00 $453.00 $499.00 $1,607.00 $1,234.00 $1,225.00 $1,153.00 $1,136.00 $1,137.00 $212.00 $1,428.00 $1,407.00 $1,417.00 $216.00 $3,339.00 $3,293.00 $870.00 $2,555.00 $2,072.00 $2,092.00 $564.00 $2,320.00 $2,083.00 $2,238.00 $562.00 $238.00 $356.00 $1,056.00 $2,327.00 $1,028.00 $1,269.00 $781.00 $819.00 $1,893.00 $1,879.00 $1,381.00 $588.00 $949.00 $586.00 $807.00 $1,634.00 ------------$1,091.00 $137.00 $369.00 $752.00 $188.00 $852.00 ------$213.00 $486.00 $536.00 $1,731.00 $1,328.00 $1,318.00 $1,260.00 $1,234.00 $1,235.00 $233.00 $1,564.00 $1,533.00 $1,548.00 $239.00 $3,636.00 $3,583.00 $963.00 $2,813.00 $2,264.00 $2,284.00 $623.00 $2,560.00 $2,277.00 $2,442.00 $621.00 $259.00 $383.00 $1,151.00 $2,575.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 149 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 22319 22325 22326 22327 22328 22505 22520 22521 22522 22523 22524 22525 22526 22527 22532 22533 22534 22548 22554 22556 22558 22585 22590 22595 22600 22610 22612 22614 22630 22632 22800 22802 22804 22808 22810 22812 22818 22819 22830 22840 22841 22842 22843 22844 22845 22846 22847 22848 22849 22850 90 90 90 90 ZZZ 10 10 10 ZZZ 10 10 ZZZ 10 ZZZ 90 90 ZZZ 90 90 90 90 ZZZ 90 90 90 90 90 ZZZ 90 ZZZ 90 90 90 90 90 90 90 90 90 ZZZ 0 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 $1,983.00 $1,407.00 $1,710.00 $1,660.00 $391.00 $174.00 $509.00 $477.00 $231.00 ------------------------------------------------$2,271.00 $1,727.00 $2,054.00 $1,907.00 $473.00 $1,895.00 $1,960.00 $1,567.00 $1,494.00 $1,861.00 $530.00 $1,201.00 $442.00 $1,960.00 $2,633.00 $2,951.00 $2,157.00 $2,356.00 $2,675.00 $2,701.00 $2,968.00 $1,176.00 $943.00 BR $2,352.00 $1,028.00 $1,277.00 $1,853.00 $999.00 $1,077.00 $529.00 $2,235.00 $872.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,365.00 $1,835.00 $1,939.00 $1,898.00 $391.00 $168.00 $3,204.00 $3,054.00 $347.00 $833.00 $796.00 $374.00 $2,712.00 $2,207.00 $2,272.00 $2,085.00 $513.00 $2,475.00 $1,752.00 $2,188.00 $1,964.00 $480.00 $2,053.00 $1,947.00 $1,664.00 $1,638.00 $2,120.00 $556.00 $2,057.00 $454.00 $1,803.00 $2,878.00 $3,328.00 $2,433.00 $2,710.00 $2,953.00 $3,006.00 $3,421.00 $1,080.00 $1,091.00 ------$1,090.00 $1,152.00 $1,403.00 $1,051.00 $1,092.00 $1,190.00 $510.00 $1,753.00 $955.00 $2,569.00 $1,977.00 $2,096.00 $2,043.00 $422.00 $180.00 $3,436.00 $3,275.00 $373.00 $896.00 $855.00 $402.00 $2,909.00 $2,366.00 $2,434.00 $2,214.00 $554.00 $2,672.00 $1,907.00 $2,347.00 $2,089.00 $520.00 $2,222.00 $2,104.00 $1,798.00 $1,767.00 $2,281.00 $602.00 $2,224.00 $492.00 $1,941.00 $3,098.00 $3,578.00 $2,612.00 $2,900.00 $3,154.00 $3,233.00 $3,686.00 $1,166.00 $1,182.00 ------$1,180.00 $1,246.00 $1,511.00 $1,143.00 $1,187.00 $1,288.00 $549.00 $1,891.00 $1,031.00 $2,849.00 $2,165.00 $2,306.00 $2,237.00 $465.00 $197.00 $3,659.00 $3,486.00 $410.00 $979.00 $933.00 $440.00 $3,091.00 $2,507.00 $2,647.00 $2,378.00 $611.00 $2,938.00 $2,116.00 $2,559.00 $2,249.00 $577.00 $2,449.00 $2,315.00 $1,978.00 $1,939.00 $2,497.00 $664.00 $2,448.00 $544.00 $2,124.00 $3,393.00 $3,914.00 $2,851.00 $3,151.00 $3,418.00 $3,540.00 $4,045.00 $1,278.00 $1,309.00 ------$1,305.00 $1,376.00 $1,659.00 $1,271.00 $1,319.00 $1,424.00 $603.00 $2,076.00 $1,131.00 $2,365.00 $1,835.00 $1,939.00 $1,898.00 $391.00 $168.00 $809.00 $763.00 $347.00 $833.00 $796.00 $374.00 $480.00 $223.00 $2,272.00 $2,085.00 $513.00 $2,475.00 $1,752.00 $2,188.00 $1,964.00 $480.00 $2,053.00 $1,947.00 $1,664.00 $1,638.00 $2,120.00 $556.00 $2,057.00 $454.00 $1,803.00 $2,878.00 $3,328.00 $2,433.00 $2,710.00 $2,953.00 $3,006.00 $3,421.00 $1,080.00 $1,091.00 ------$1,090.00 $1,152.00 $1,403.00 $1,051.00 $1,092.00 $1,190.00 $510.00 $1,753.00 $955.00 $2,569.00 $1,977.00 $2,096.00 $2,043.00 $422.00 $180.00 $870.00 $820.00 $373.00 $896.00 $855.00 $402.00 $517.00 $241.00 $2,434.00 $2,214.00 $554.00 $2,672.00 $1,907.00 $2,347.00 $2,089.00 $520.00 $2,222.00 $2,104.00 $1,798.00 $1,767.00 $2,281.00 $602.00 $2,224.00 $492.00 $1,941.00 $3,098.00 $3,578.00 $2,612.00 $2,900.00 $3,154.00 $3,233.00 $3,686.00 $1,166.00 $1,182.00 ------$1,180.00 $1,246.00 $1,511.00 $1,143.00 $1,187.00 $1,288.00 $549.00 $1,891.00 $1,031.00 $2,849.00 $2,165.00 $2,306.00 $2,237.00 $465.00 $197.00 $952.00 $897.00 $410.00 $979.00 $933.00 $440.00 $568.00 $265.00 $2,647.00 $2,378.00 $611.00 $2,938.00 $2,116.00 $2,559.00 $2,249.00 $577.00 $2,449.00 $2,315.00 $1,978.00 $1,939.00 $2,497.00 $664.00 $2,448.00 $544.00 $2,124.00 $3,393.00 $3,914.00 $2,851.00 $3,151.00 $3,418.00 $3,540.00 $4,045.00 $1,278.00 $1,309.00 ------$1,305.00 $1,376.00 $1,659.00 $1,271.00 $1,319.00 $1,424.00 $603.00 $2,076.00 $1,131.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 150 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 22851 22852 22855 22857 22862 22865 22899 22900 22999 23000 23020 23030 23031 23035 23040 23044 23065 23066 23075 23076 23077 23100 23101 23105 23106 23107 23120 23125 23130 23140 23145 23146 23150 23155 23156 23170 23172 23174 23180 23182 23184 23190 23195 23200 23210 23220 23221 23222 23330 23331 ZZZ 90 90 90 90 90 YYY 90 YYY 90 90 10 10 90 90 90 10 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 $600.00 $854.00 $1,193.00 ------------------BR $446.00 BR $447.00 $807.00 $323.00 $185.00 $861.00 $898.00 $708.00 $171.00 $302.00 $247.00 $613.00 $1,228.00 $616.00 $583.00 $814.00 $581.00 $851.00 $645.00 $865.00 $722.00 $597.00 $889.00 $704.00 $755.00 $945.00 $794.00 $645.00 $638.00 $882.00 $566.00 $865.00 $962.00 $656.00 $902.00 $1,095.00 $1,095.00 $1,307.00 $1,559.00 $1,921.00 $59.00 $520.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $580.00 $911.00 $1,491.00 $2,287.00 $2,752.00 $2,679.00 ------$518.00 ------$671.00 $907.00 $549.00 $525.00 $909.00 $944.00 $749.00 $259.00 $634.00 $324.00 $726.00 $1,530.00 $635.00 $588.00 $835.00 $624.00 $871.00 $736.00 $924.00 $792.00 $668.00 $902.00 $807.00 $847.00 $1,036.00 $883.00 $697.00 $713.00 $984.00 $917.00 $881.00 $993.00 $725.00 $983.00 $1,145.00 $1,199.00 $1,418.00 $1,665.00 $2,236.00 $283.00 $769.00 $629.00 $983.00 $1,614.00 $2,431.00 $2,946.00 $2,867.00 ------$549.00 ------$717.00 $971.00 $587.00 $563.00 $972.00 $1,011.00 $801.00 $274.00 $677.00 $346.00 $774.00 $1,625.00 $680.00 $630.00 $895.00 $667.00 $933.00 $788.00 $990.00 $848.00 $714.00 $965.00 $864.00 $904.00 $1,110.00 $946.00 $746.00 $760.00 $1,054.00 $982.00 $942.00 $1,064.00 $775.00 $1,053.00 $1,223.00 $1,281.00 $1,517.00 $1,783.00 $2,388.00 $302.00 $824.00 $696.00 $1,076.00 $1,780.00 $2,614.00 $3,204.00 $3,117.00 ------$589.00 ------$768.00 $1,052.00 $630.00 $602.00 $1,052.00 $1,096.00 $868.00 $290.00 $725.00 $370.00 $835.00 $1,746.00 $737.00 $682.00 $970.00 $722.00 $1,012.00 $854.00 $1,074.00 $919.00 $771.00 $1,044.00 $937.00 $975.00 $1,204.00 $1,025.00 $806.00 $817.00 $1,142.00 $1,063.00 $1,018.00 $1,151.00 $838.00 $1,141.00 $1,322.00 $1,385.00 $1,644.00 $1,936.00 $2,586.00 $321.00 $892.00 $580.00 $911.00 $1,491.00 $2,287.00 $2,752.00 $2,679.00 ------$518.00 ------$464.00 $907.00 $339.00 $290.00 $909.00 $944.00 $749.00 $207.00 $438.00 $227.00 $726.00 $1,530.00 $635.00 $588.00 $835.00 $624.00 $871.00 $736.00 $924.00 $792.00 $668.00 $902.00 $807.00 $847.00 $1,036.00 $883.00 $697.00 $713.00 $984.00 $917.00 $881.00 $993.00 $725.00 $983.00 $1,145.00 $1,199.00 $1,418.00 $1,665.00 $2,236.00 $192.00 $769.00 $629.00 $983.00 $1,614.00 $2,431.00 $2,946.00 $2,867.00 ------$549.00 ------$496.00 $971.00 $363.00 $310.00 $972.00 $1,011.00 $801.00 $218.00 $467.00 $242.00 $774.00 $1,625.00 $680.00 $630.00 $895.00 $667.00 $933.00 $788.00 $990.00 $848.00 $714.00 $965.00 $864.00 $904.00 $1,110.00 $946.00 $746.00 $760.00 $1,054.00 $982.00 $942.00 $1,064.00 $775.00 $1,053.00 $1,223.00 $1,281.00 $1,517.00 $1,783.00 $2,388.00 $204.00 $824.00 $696.00 $1,076.00 $1,780.00 $2,614.00 $3,204.00 $3,117.00 ------$589.00 ------$535.00 $1,052.00 $393.00 $335.00 $1,052.00 $1,096.00 $868.00 $231.00 $503.00 $261.00 $835.00 $1,746.00 $737.00 $682.00 $970.00 $722.00 $1,012.00 $854.00 $1,074.00 $919.00 $771.00 $1,044.00 $937.00 $975.00 $1,204.00 $1,025.00 $806.00 $817.00 $1,142.00 $1,063.00 $1,018.00 $1,151.00 $838.00 $1,141.00 $1,322.00 $1,385.00 $1,644.00 $1,936.00 $2,586.00 $219.00 $892.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 151 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 23332 23350 23395 23397 23400 23405 23406 23410 23412 23415 23420 23430 23440 23450 23455 23460 23462 23465 23466 23470 23472 23480 23485 23490 23491 23500 23505 23515 23520 23525 23530 23532 23540 23545 23550 23552 23570 23575 23585 23600 23605 23615 23616 23620 23625 23630 23650 23655 23660 23665 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,029.00 $74.00 $1,366.00 $1,403.00 $1,196.00 $799.00 $977.00 $1,119.00 $1,229.00 $622.00 $1,276.00 $884.00 $906.00 $1,210.00 $1,340.00 $1,364.00 $1,383.00 $1,398.00 $1,332.00 $1,540.00 $1,570.00 $926.00 $1,181.00 $1,038.00 $1,251.00 $148.00 $293.00 $688.00 $205.00 $320.00 $659.00 $713.00 $148.00 $148.00 $701.00 $753.00 $88.00 $306.00 $809.00 $318.00 $511.00 $900.00 $1,895.00 $286.00 $422.00 $712.00 $296.00 $374.00 $712.00 $440.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,168.00 $207.00 $1,694.00 $1,521.00 $1,292.00 $832.00 $1,042.00 $1,195.00 $1,271.00 $976.00 $1,390.00 $982.00 $1,015.00 $1,273.00 $1,356.00 $1,466.00 $1,435.00 $1,495.00 $1,460.00 $1,630.00 $2,010.00 $1,093.00 $1,285.00 $1,068.00 $1,358.00 $262.00 $434.00 $888.00 $271.00 $426.00 $722.00 $814.00 $269.00 $382.00 $748.00 $864.00 $281.00 $477.00 $1,187.00 $394.00 $587.00 $1,120.00 $1,763.00 $323.00 $475.00 $938.00 $362.00 $481.00 $759.00 $524.00 $1,250.00 $219.00 $1,812.00 $1,628.00 $1,384.00 $891.00 $1,117.00 $1,281.00 $1,363.00 $1,047.00 $1,486.00 $1,053.00 $1,089.00 $1,365.00 $1,454.00 $1,571.00 $1,536.00 $1,603.00 $1,561.00 $1,746.00 $2,151.00 $1,171.00 $1,377.00 $1,133.00 $1,455.00 $279.00 $465.00 $944.00 $290.00 $453.00 $773.00 $872.00 $286.00 $405.00 $801.00 $925.00 $300.00 $509.00 $1,255.00 $422.00 $629.00 $1,191.00 $1,900.00 $346.00 $508.00 $996.00 $382.00 $513.00 $813.00 $560.00 $1,355.00 $231.00 $1,963.00 $1,767.00 $1,502.00 $967.00 $1,214.00 $1,391.00 $1,480.00 $1,136.00 $1,608.00 $1,143.00 $1,183.00 $1,483.00 $1,580.00 $1,707.00 $1,668.00 $1,742.00 $1,690.00 $1,896.00 $2,334.00 $1,271.00 $1,496.00 $1,214.00 $1,581.00 $299.00 $501.00 $1,015.00 $312.00 $484.00 $836.00 $946.00 $305.00 $430.00 $868.00 $1,002.00 $323.00 $546.00 $1,339.00 $453.00 $679.00 $1,280.00 $2,082.00 $372.00 $549.00 $1,066.00 $404.00 $552.00 $882.00 $603.00 $1,168.00 $69.00 $1,694.00 $1,521.00 $1,292.00 $832.00 $1,042.00 $1,195.00 $1,271.00 $976.00 $1,390.00 $982.00 $1,015.00 $1,273.00 $1,356.00 $1,466.00 $1,435.00 $1,495.00 $1,460.00 $1,630.00 $2,010.00 $1,093.00 $1,285.00 $1,068.00 $1,358.00 $255.00 $410.00 $888.00 $270.00 $398.00 $722.00 $814.00 $258.00 $349.00 $748.00 $864.00 $281.00 $450.00 $1,187.00 $359.00 $541.00 $1,120.00 $1,763.00 $301.00 $445.00 $938.00 $325.00 $481.00 $759.00 $494.00 $1,250.00 $71.00 $1,812.00 $1,628.00 $1,384.00 $891.00 $1,117.00 $1,281.00 $1,363.00 $1,047.00 $1,486.00 $1,053.00 $1,089.00 $1,365.00 $1,454.00 $1,571.00 $1,536.00 $1,603.00 $1,561.00 $1,746.00 $2,151.00 $1,171.00 $1,377.00 $1,133.00 $1,455.00 $272.00 $439.00 $944.00 $289.00 $423.00 $773.00 $872.00 $274.00 $370.00 $801.00 $925.00 $301.00 $480.00 $1,255.00 $384.00 $580.00 $1,191.00 $1,900.00 $322.00 $477.00 $996.00 $342.00 $513.00 $813.00 $528.00 $1,355.00 $75.00 $1,963.00 $1,767.00 $1,502.00 $967.00 $1,214.00 $1,391.00 $1,480.00 $1,136.00 $1,608.00 $1,143.00 $1,183.00 $1,483.00 $1,580.00 $1,707.00 $1,668.00 $1,742.00 $1,690.00 $1,896.00 $2,334.00 $1,271.00 $1,496.00 $1,214.00 $1,581.00 $291.00 $474.00 $1,015.00 $311.00 $453.00 $836.00 $946.00 $293.00 $393.00 $868.00 $1,002.00 $323.00 $516.00 $1,339.00 $413.00 $627.00 $1,280.00 $2,082.00 $347.00 $515.00 $1,066.00 $362.00 $552.00 $882.00 $569.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 152 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 23670 23675 23680 23700 23800 23802 23900 23920 23921 23929 23930 23931 23935 24000 24006 24065 24066 24075 24076 24077 24100 24101 24102 24105 24110 24115 24116 24120 24125 24126 24130 24134 24136 24138 24140 24145 24147 24149 24150 24151 24152 24153 24155 24160 24164 24200 24201 24220 24300 24301 90 90 90 10 90 90 90 90 90 YYY 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 0 90 90 $759.00 $550.00 $1,064.00 $237.00 $1,346.00 $1,368.00 $1,561.00 $1,300.00 $497.00 BR $71.00 $62.00 $630.00 $550.00 $793.00 $166.00 $461.00 $349.00 $529.00 $1,058.00 $467.00 $591.00 $755.00 $360.00 $724.00 $898.00 $1,037.00 $595.00 $663.00 $731.00 $595.00 $966.00 $720.00 $697.00 $963.00 $592.00 $703.00 $1,224.00 $1,265.00 $1,383.00 $829.00 $936.00 $1,019.00 $533.00 $564.00 $58.00 $444.00 $89.00 $352.00 $869.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,046.00 $692.00 $1,158.00 $256.00 $1,354.00 $1,603.00 $1,772.00 $1,428.00 $574.00 ------$456.00 $364.00 $653.00 $612.00 $929.00 $296.00 $741.00 $594.00 $610.00 $1,063.00 $517.00 $647.00 $805.00 $431.00 $760.00 $891.00 $1,151.00 $680.00 $764.00 $817.00 $658.00 $998.00 $824.00 $855.00 $954.00 $803.00 $836.00 $1,494.00 $1,290.00 $1,492.00 $946.00 $870.00 $1,110.00 $792.00 $646.00 $253.00 $714.00 $225.00 $505.00 $989.00 $1,107.00 $741.00 $1,232.00 $275.00 $1,449.00 $1,710.00 $1,893.00 $1,525.00 $611.00 ------$487.00 $389.00 $699.00 $655.00 $993.00 $313.00 $792.00 $634.00 $651.00 $1,133.00 $554.00 $692.00 $862.00 $462.00 $814.00 $955.00 $1,233.00 $728.00 $813.00 $870.00 $704.00 $1,068.00 $882.00 $914.00 $1,021.00 $859.00 $895.00 $1,593.00 $1,382.00 $1,595.00 $1,008.00 $908.00 $1,188.00 $847.00 $691.00 $270.00 $764.00 $238.00 $541.00 $1,057.00 $1,182.00 $799.00 $1,325.00 $298.00 $1,570.00 $1,848.00 $2,051.00 $1,650.00 $656.00 ------$520.00 $415.00 $757.00 $708.00 $1,073.00 $331.00 $848.00 $677.00 $702.00 $1,223.00 $600.00 $749.00 $933.00 $498.00 $883.00 $1,038.00 $1,339.00 $787.00 $873.00 $935.00 $761.00 $1,155.00 $955.00 $988.00 $1,103.00 $928.00 $968.00 $1,719.00 $1,501.00 $1,729.00 $1,087.00 $952.00 $1,287.00 $917.00 $748.00 $286.00 $818.00 $251.00 $582.00 $1,145.00 $1,046.00 $642.00 $1,158.00 $256.00 $1,354.00 $1,603.00 $1,772.00 $1,428.00 $574.00 ------$281.00 $205.00 $653.00 $612.00 $929.00 $204.00 $512.00 $397.00 $610.00 $1,063.00 $517.00 $647.00 $805.00 $431.00 $760.00 $891.00 $1,151.00 $680.00 $764.00 $817.00 $658.00 $998.00 $824.00 $855.00 $954.00 $803.00 $836.00 $1,494.00 $1,290.00 $1,492.00 $946.00 $870.00 $1,110.00 $792.00 $646.00 $174.00 $471.00 $90.00 $505.00 $989.00 $1,107.00 $688.00 $1,232.00 $275.00 $1,449.00 $1,710.00 $1,893.00 $1,525.00 $611.00 ------$299.00 $219.00 $699.00 $655.00 $993.00 $214.00 $546.00 $423.00 $651.00 $1,133.00 $554.00 $692.00 $862.00 $462.00 $814.00 $955.00 $1,233.00 $728.00 $813.00 $870.00 $704.00 $1,068.00 $882.00 $914.00 $1,021.00 $859.00 $895.00 $1,593.00 $1,382.00 $1,595.00 $1,008.00 $908.00 $1,188.00 $847.00 $691.00 $184.00 $503.00 $94.00 $541.00 $1,057.00 $1,182.00 $744.00 $1,325.00 $298.00 $1,570.00 $1,848.00 $2,051.00 $1,650.00 $656.00 ------$323.00 $236.00 $757.00 $708.00 $1,073.00 $226.00 $590.00 $455.00 $702.00 $1,223.00 $600.00 $749.00 $933.00 $498.00 $883.00 $1,038.00 $1,339.00 $787.00 $873.00 $935.00 $761.00 $1,155.00 $955.00 $988.00 $1,103.00 $928.00 $968.00 $1,719.00 $1,501.00 $1,729.00 $1,087.00 $952.00 $1,287.00 $917.00 $748.00 $197.00 $543.00 $98.00 $582.00 $1,145.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 153 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 24305 24310 24320 24330 24331 24332 24340 24341 24342 24343 24344 24345 24346 24357 24358 24359 24360 24361 24362 24363 24365 24366 24400 24410 24420 24430 24435 24470 24495 24498 24500 24505 24515 24516 24530 24535 24538 24545 24546 24560 24565 24566 24575 24576 24577 24579 24582 24586 24587 24600 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $579.00 $511.00 $944.00 $845.00 $927.00 $487.00 $697.00 $702.00 $950.00 $643.00 $971.00 $643.00 $971.00 ------------------$1,125.00 $1,215.00 $1,269.00 $1,663.00 $747.00 $850.00 $991.00 $1,319.00 $1,265.00 $1,209.00 $1,260.00 $774.00 $742.00 $1,076.00 $288.00 $574.00 $1,018.00 $1,029.00 $88.00 $671.00 $850.00 $946.00 $1,273.00 $266.00 $526.00 $705.00 $872.00 $295.00 $575.00 $964.00 $773.00 $1,314.00 $1,278.00 $360.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $753.00 $617.00 $1,006.00 $944.00 $1,041.00 $780.00 $805.00 $928.00 $1,041.00 $914.00 $1,428.00 $910.00 $1,423.00 $576.00 $678.00 $838.00 $1,184.00 $1,327.00 $1,314.00 $1,942.00 $841.00 $902.00 $1,087.00 $1,396.00 $1,287.00 $1,358.00 $1,390.00 $866.00 $862.00 $1,159.00 $427.00 $628.00 $1,159.00 $1,147.00 $461.00 $787.00 $980.00 $1,173.00 $1,420.00 $385.00 $653.00 $893.00 $980.00 $404.00 $675.00 $1,104.00 $1,014.00 $1,458.00 $1,444.00 $459.00 $804.00 $660.00 $1,076.00 $1,011.00 $1,114.00 $834.00 $863.00 $990.00 $1,116.00 $977.00 $1,526.00 $974.00 $1,520.00 $616.00 $726.00 $896.00 $1,268.00 $1,417.00 $1,409.00 $2,065.00 $900.00 $965.00 $1,165.00 $1,496.00 $1,376.00 $1,448.00 $1,485.00 $927.00 $919.00 $1,241.00 $456.00 $673.00 $1,242.00 $1,228.00 $493.00 $843.00 $1,050.00 $1,250.00 $1,526.00 $411.00 $699.00 $953.00 $1,055.00 $432.00 $723.00 $1,185.00 $1,083.00 $1,562.00 $1,544.00 $487.00 $868.00 $713.00 $1,166.00 $1,095.00 $1,207.00 $901.00 $935.00 $1,066.00 $1,212.00 $1,056.00 $1,651.00 $1,052.00 $1,644.00 $666.00 $785.00 $969.00 $1,374.00 $1,532.00 $1,535.00 $2,222.00 $975.00 $1,045.00 $1,265.00 $1,626.00 $1,490.00 $1,563.00 $1,605.00 $1,005.00 $988.00 $1,348.00 $489.00 $726.00 $1,347.00 $1,333.00 $530.00 $911.00 $1,137.00 $1,346.00 $1,664.00 $441.00 $754.00 $1,026.00 $1,151.00 $464.00 $779.00 $1,290.00 $1,166.00 $1,697.00 $1,674.00 $519.00 $753.00 $617.00 $1,006.00 $944.00 $1,041.00 $780.00 $805.00 $928.00 $1,041.00 $914.00 $1,428.00 $910.00 $1,423.00 $576.00 $678.00 $838.00 $1,184.00 $1,327.00 $1,314.00 $1,942.00 $841.00 $902.00 $1,087.00 $1,396.00 $1,287.00 $1,358.00 $1,390.00 $866.00 $862.00 $1,159.00 $382.00 $574.00 $1,159.00 $1,147.00 $414.00 $732.00 $980.00 $1,173.00 $1,420.00 $335.00 $603.00 $893.00 $980.00 $360.00 $624.00 $1,104.00 $1,014.00 $1,458.00 $1,444.00 $410.00 $804.00 $660.00 $1,076.00 $1,011.00 $1,114.00 $834.00 $863.00 $990.00 $1,116.00 $977.00 $1,526.00 $974.00 $1,520.00 $616.00 $726.00 $896.00 $1,268.00 $1,417.00 $1,409.00 $2,065.00 $900.00 $965.00 $1,165.00 $1,496.00 $1,376.00 $1,448.00 $1,485.00 $927.00 $919.00 $1,241.00 $408.00 $615.00 $1,242.00 $1,228.00 $442.00 $785.00 $1,050.00 $1,250.00 $1,526.00 $358.00 $646.00 $953.00 $1,055.00 $385.00 $668.00 $1,185.00 $1,083.00 $1,562.00 $1,544.00 $435.00 $868.00 $713.00 $1,166.00 $1,095.00 $1,207.00 $901.00 $935.00 $1,066.00 $1,212.00 $1,056.00 $1,651.00 $1,052.00 $1,644.00 $666.00 $785.00 $969.00 $1,374.00 $1,532.00 $1,535.00 $2,222.00 $975.00 $1,045.00 $1,265.00 $1,626.00 $1,490.00 $1,563.00 $1,605.00 $1,005.00 $988.00 $1,348.00 $438.00 $665.00 $1,347.00 $1,333.00 $477.00 $849.00 $1,137.00 $1,346.00 $1,664.00 $385.00 $698.00 $1,026.00 $1,151.00 $414.00 $721.00 $1,290.00 $1,166.00 $1,697.00 $1,674.00 $465.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 154 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 24605 24615 24620 24635 24650 24655 24665 24666 24670 24675 24685 24800 24802 24900 24920 24925 24930 24931 24935 24940 24999 25000 25001 25020 25023 25024 25025 25028 25031 25035 25040 25065 25066 25075 25076 25077 25085 25100 25101 25105 25107 25109 25110 25111 25112 25115 25116 25118 25119 25120 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $371.00 $836.00 $560.00 $1,329.00 $262.00 $436.00 $749.00 $905.00 $263.00 $490.00 $819.00 $984.00 $1,181.00 $858.00 $851.00 $661.00 $928.00 $1,063.00 $1,327.00 BR BR $381.00 $294.00 $594.00 $1,040.00 $683.00 $1,104.00 $417.00 $266.00 $794.00 $654.00 $164.00 $322.00 $352.00 $544.00 $957.00 $562.00 $420.00 $492.00 $635.00 $600.00 ------$403.00 $356.00 $441.00 $837.00 $807.00 $466.00 $653.00 $712.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $586.00 $943.00 $710.00 $1,103.00 $312.00 $544.00 $848.00 $961.00 $351.00 $574.00 $857.00 $1,049.00 $1,315.00 $930.00 $922.00 $704.00 $972.00 $1,046.00 $1,397.00 ------------$477.00 $421.00 $767.00 $1,462.00 $970.00 $1,471.00 $672.00 $532.00 $933.00 $757.00 $295.00 $519.00 $451.00 $634.00 $1,034.00 $622.00 $458.00 $538.00 $657.00 $795.00 $658.00 $502.00 $411.00 $504.00 $1,103.00 $918.00 $509.00 $679.00 $798.00 $627.00 $1,009.00 $759.00 $1,198.00 $333.00 $582.00 $909.00 $1,029.00 $375.00 $615.00 $921.00 $1,118.00 $1,408.00 $993.00 $986.00 $752.00 $1,039.00 $1,114.00 $1,485.00 ------------$510.00 $449.00 $820.00 $1,560.00 $1,031.00 $1,553.00 $718.00 $568.00 $998.00 $809.00 $312.00 $555.00 $481.00 $677.00 $1,103.00 $664.00 $489.00 $575.00 $702.00 $846.00 $701.00 $537.00 $440.00 $538.00 $1,174.00 $981.00 $544.00 $726.00 $854.00 $677.00 $1,093.00 $818.00 $1,318.00 $358.00 $626.00 $985.00 $1,115.00 $403.00 $663.00 $1,001.00 $1,205.00 $1,529.00 $1,072.00 $1,069.00 $814.00 $1,125.00 $1,204.00 $1,596.00 ------------$547.00 $483.00 $881.00 $1,679.00 $1,106.00 $1,654.00 $771.00 $609.00 $1,075.00 $873.00 $329.00 $596.00 $517.00 $726.00 $1,186.00 $715.00 $526.00 $620.00 $757.00 $906.00 $754.00 $577.00 $473.00 $579.00 $1,257.00 $1,053.00 $585.00 $782.00 $919.00 $586.00 $943.00 $710.00 $1,103.00 $275.00 $496.00 $848.00 $961.00 $310.00 $528.00 $857.00 $1,049.00 $1,315.00 $930.00 $922.00 $704.00 $972.00 $1,046.00 $1,397.00 ------------$477.00 $421.00 $767.00 $1,462.00 $970.00 $1,471.00 $672.00 $532.00 $933.00 $757.00 $203.00 $519.00 $451.00 $634.00 $1,034.00 $622.00 $458.00 $538.00 $657.00 $795.00 $658.00 $502.00 $411.00 $504.00 $1,103.00 $918.00 $509.00 $679.00 $798.00 $627.00 $1,009.00 $759.00 $1,198.00 $294.00 $530.00 $909.00 $1,029.00 $332.00 $565.00 $921.00 $1,118.00 $1,408.00 $993.00 $986.00 $752.00 $1,039.00 $1,114.00 $1,485.00 ------------$510.00 $449.00 $820.00 $1,560.00 $1,031.00 $1,553.00 $718.00 $568.00 $998.00 $809.00 $214.00 $555.00 $481.00 $677.00 $1,103.00 $664.00 $489.00 $575.00 $702.00 $846.00 $701.00 $537.00 $440.00 $538.00 $1,174.00 $981.00 $544.00 $726.00 $854.00 $677.00 $1,093.00 $818.00 $1,318.00 $316.00 $571.00 $985.00 $1,115.00 $357.00 $611.00 $1,001.00 $1,205.00 $1,529.00 $1,072.00 $1,069.00 $814.00 $1,125.00 $1,204.00 $1,596.00 ------------$547.00 $483.00 $881.00 $1,679.00 $1,106.00 $1,654.00 $771.00 $609.00 $1,075.00 $873.00 $226.00 $596.00 $517.00 $726.00 $1,186.00 $715.00 $526.00 $620.00 $757.00 $906.00 $754.00 $577.00 $473.00 $579.00 $1,257.00 $1,053.00 $585.00 $782.00 $919.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 155 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 25125 25126 25130 25135 25136 25145 25150 25151 25170 25210 25215 25230 25240 25246 25248 25250 25251 25259 25260 25263 25265 25270 25272 25274 25275 25280 25290 25295 25300 25301 25310 25312 25315 25316 25320 25332 25335 25337 25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25394 25400 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $803.00 $781.00 $502.00 $631.00 $546.00 $713.00 $720.00 $771.00 $1,085.00 $561.00 $817.00 $531.00 $567.00 $72.00 $236.00 $616.00 $933.00 $348.00 $728.00 $809.00 $998.00 $549.00 $613.00 $887.00 $620.00 $670.00 $436.00 $562.00 $592.00 $757.00 $865.00 $968.00 $1,004.00 $1,203.00 $834.00 $1,022.00 $1,166.00 $946.00 $913.00 $1,014.00 $468.00 $1,216.00 $1,214.00 $1,280.00 $1,043.00 $1,349.00 $1,294.00 $1,473.00 $723.00 $1,112.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $902.00 $930.00 $592.00 $736.00 $657.00 $814.00 $775.00 $909.00 $1,237.00 $648.00 $841.00 $576.00 $595.00 $230.00 $616.00 $677.00 $922.00 $502.00 $957.00 $948.00 $1,119.00 $785.00 $878.00 $1,022.00 $870.00 $882.00 $803.00 $826.00 $895.00 $856.00 $958.00 $1,083.00 $1,159.00 $1,339.00 $1,240.00 $1,110.00 $1,273.00 $1,157.00 $1,045.00 $1,161.00 $1,019.00 $1,367.00 $1,463.00 $1,429.00 $1,169.00 $1,471.00 $1,467.00 $1,669.00 $1,004.00 $1,231.00 $962.00 $996.00 $632.00 $785.00 $704.00 $870.00 $828.00 $971.00 $1,322.00 $691.00 $897.00 $616.00 $636.00 $243.00 $656.00 $723.00 $980.00 $537.00 $1,023.00 $1,013.00 $1,195.00 $839.00 $939.00 $1,092.00 $928.00 $942.00 $858.00 $882.00 $954.00 $915.00 $1,022.00 $1,156.00 $1,237.00 $1,427.00 $1,319.00 $1,187.00 $1,357.00 $1,233.00 $1,119.00 $1,243.00 $1,091.00 $1,464.00 $1,566.00 $1,531.00 $1,250.00 $1,572.00 $1,565.00 $1,788.00 $1,071.00 $1,317.00 $1,031.00 $1,074.00 $680.00 $845.00 $762.00 $935.00 $893.00 $1,045.00 $1,425.00 $743.00 $966.00 $662.00 $684.00 $256.00 $703.00 $779.00 $1,051.00 $578.00 $1,098.00 $1,088.00 $1,284.00 $902.00 $1,009.00 $1,175.00 $1,000.00 $1,011.00 $919.00 $947.00 $1,025.00 $986.00 $1,098.00 $1,242.00 $1,331.00 $1,531.00 $1,414.00 $1,284.00 $1,462.00 $1,326.00 $1,206.00 $1,343.00 $1,176.00 $1,584.00 $1,693.00 $1,657.00 $1,346.00 $1,696.00 $1,685.00 $1,937.00 $1,156.00 $1,422.00 $902.00 $930.00 $592.00 $736.00 $657.00 $814.00 $775.00 $909.00 $1,237.00 $648.00 $841.00 $576.00 $595.00 $100.00 $616.00 $677.00 $922.00 $502.00 $957.00 $948.00 $1,119.00 $785.00 $878.00 $1,022.00 $870.00 $882.00 $803.00 $826.00 $895.00 $856.00 $958.00 $1,083.00 $1,159.00 $1,339.00 $1,240.00 $1,110.00 $1,273.00 $1,157.00 $1,045.00 $1,161.00 $1,019.00 $1,367.00 $1,463.00 $1,429.00 $1,169.00 $1,471.00 $1,467.00 $1,669.00 $1,004.00 $1,231.00 $962.00 $996.00 $632.00 $785.00 $704.00 $870.00 $828.00 $971.00 $1,322.00 $691.00 $897.00 $616.00 $636.00 $104.00 $656.00 $723.00 $980.00 $537.00 $1,023.00 $1,013.00 $1,195.00 $839.00 $939.00 $1,092.00 $928.00 $942.00 $858.00 $882.00 $954.00 $915.00 $1,022.00 $1,156.00 $1,237.00 $1,427.00 $1,319.00 $1,187.00 $1,357.00 $1,233.00 $1,119.00 $1,243.00 $1,091.00 $1,464.00 $1,566.00 $1,531.00 $1,250.00 $1,572.00 $1,565.00 $1,788.00 $1,071.00 $1,317.00 $1,031.00 $1,074.00 $680.00 $845.00 $762.00 $935.00 $893.00 $1,045.00 $1,425.00 $743.00 $966.00 $662.00 $684.00 $109.00 $703.00 $779.00 $1,051.00 $578.00 $1,098.00 $1,088.00 $1,284.00 $902.00 $1,009.00 $1,175.00 $1,000.00 $1,011.00 $919.00 $947.00 $1,025.00 $986.00 $1,098.00 $1,242.00 $1,331.00 $1,531.00 $1,414.00 $1,284.00 $1,462.00 $1,326.00 $1,206.00 $1,343.00 $1,176.00 $1,584.00 $1,693.00 $1,657.00 $1,346.00 $1,696.00 $1,685.00 $1,937.00 $1,156.00 $1,422.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 156 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 25405 25415 25420 25425 25426 25430 25431 25440 25441 25442 25443 25444 25445 25446 25447 25449 25450 25455 25490 25491 25492 25500 25505 25515 25520 25525 25526 25530 25535 25545 25560 25565 25574 25575 25600 25605 25606 25607 25608 25609 25622 25624 25628 25630 25635 25645 25650 25651 25652 25660 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,388.00 $1,343.00 $1,554.00 $1,403.00 $1,401.00 $638.00 $631.00 $931.00 $1,147.00 $936.00 $970.00 $1,031.00 $959.00 $1,542.00 $952.00 $395.00 $805.00 $899.00 $955.00 $1,006.00 $1,170.00 $200.00 $517.00 $800.00 $644.00 $1,097.00 $1,293.00 $270.00 $516.00 $803.00 $276.00 $590.00 $804.00 $974.00 $312.00 $540.00 ------------------------$148.00 $482.00 $716.00 $148.00 $458.00 $668.00 $185.00 $379.00 $560.00 $378.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,538.00 $1,447.00 $1,706.00 $1,550.00 $1,612.00 $910.00 $1,045.00 $1,033.00 $1,235.00 $1,047.00 $1,002.00 $1,078.00 $948.00 $1,550.00 $1,055.00 $1,362.00 $831.00 $968.00 $1,072.00 $1,129.00 $1,349.00 $318.00 $630.00 $880.00 $698.00 $1,091.00 $1,338.00 $309.00 $605.00 $834.00 $321.00 $657.00 $846.00 $1,160.00 $354.00 $761.00 $871.00 $907.00 $1,046.00 $1,334.00 $363.00 $576.00 $922.00 $372.00 $545.00 $743.00 $386.00 $601.00 $796.00 $499.00 $1,644.00 $1,548.00 $1,823.00 $1,657.00 $1,722.00 $967.00 $1,122.00 $1,103.00 $1,320.00 $1,115.00 $1,066.00 $1,151.00 $1,014.00 $1,652.00 $1,125.00 $1,453.00 $891.00 $1,024.00 $1,145.00 $1,208.00 $1,446.00 $339.00 $675.00 $946.00 $747.00 $1,176.00 $1,433.00 $330.00 $648.00 $898.00 $343.00 $703.00 $901.00 $1,238.00 $379.00 $812.00 $931.00 $967.00 $1,120.00 $1,429.00 $388.00 $616.00 $983.00 $398.00 $584.00 $796.00 $412.00 $642.00 $851.00 $530.00 $1,774.00 $1,671.00 $1,967.00 $1,783.00 $1,861.00 $1,039.00 $1,220.00 $1,191.00 $1,429.00 $1,199.00 $1,143.00 $1,243.00 $1,096.00 $1,782.00 $1,213.00 $1,569.00 $965.00 $1,088.00 $1,231.00 $1,302.00 $1,565.00 $363.00 $728.00 $1,029.00 $808.00 $1,286.00 $1,552.00 $354.00 $701.00 $978.00 $367.00 $759.00 $969.00 $1,336.00 $407.00 $872.00 $1,004.00 $1,041.00 $1,215.00 $1,551.00 $416.00 $664.00 $1,058.00 $427.00 $629.00 $861.00 $442.00 $691.00 $918.00 $566.00 $1,538.00 $1,447.00 $1,706.00 $1,550.00 $1,612.00 $910.00 $1,045.00 $1,033.00 $1,235.00 $1,047.00 $1,002.00 $1,078.00 $948.00 $1,550.00 $1,055.00 $1,362.00 $831.00 $968.00 $1,072.00 $1,129.00 $1,349.00 $285.00 $580.00 $880.00 $664.00 $1,091.00 $1,338.00 $274.00 $569.00 $834.00 $281.00 $601.00 $846.00 $1,160.00 $313.00 $718.00 $871.00 $907.00 $1,046.00 $1,334.00 $320.00 $523.00 $922.00 $329.00 $475.00 $743.00 $348.00 $601.00 $796.00 $499.00 $1,644.00 $1,548.00 $1,823.00 $1,657.00 $1,722.00 $967.00 $1,122.00 $1,103.00 $1,320.00 $1,115.00 $1,066.00 $1,151.00 $1,014.00 $1,652.00 $1,125.00 $1,453.00 $891.00 $1,024.00 $1,145.00 $1,208.00 $1,446.00 $304.00 $622.00 $946.00 $711.00 $1,176.00 $1,433.00 $293.00 $610.00 $898.00 $300.00 $643.00 $901.00 $1,238.00 $335.00 $765.00 $931.00 $967.00 $1,120.00 $1,429.00 $342.00 $560.00 $983.00 $351.00 $508.00 $796.00 $371.00 $642.00 $851.00 $530.00 $1,774.00 $1,671.00 $1,967.00 $1,783.00 $1,861.00 $1,039.00 $1,220.00 $1,191.00 $1,429.00 $1,199.00 $1,143.00 $1,243.00 $1,096.00 $1,782.00 $1,213.00 $1,569.00 $965.00 $1,088.00 $1,231.00 $1,302.00 $1,565.00 $326.00 $672.00 $1,029.00 $770.00 $1,286.00 $1,552.00 $315.00 $660.00 $978.00 $322.00 $695.00 $969.00 $1,336.00 $360.00 $823.00 $1,004.00 $1,041.00 $1,215.00 $1,551.00 $367.00 $604.00 $1,058.00 $378.00 $549.00 $861.00 $398.00 $691.00 $918.00 $566.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 157 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 25670 25671 25675 25676 25680 25685 25690 25695 25800 25805 25810 25820 25825 25830 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931 25999 26010 26011 26020 26025 26030 26034 26035 26037 26040 26045 26055 26060 26070 26075 26080 26100 26105 26110 26115 26116 26117 26121 26123 26125 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ $731.00 $462.00 $404.00 $741.00 $471.00 $887.00 $518.00 $520.00 $703.00 $1,078.00 $1,008.00 $2,276.00 $895.00 $991.00 $871.00 $900.00 $799.00 $849.00 $1,523.00 $771.00 $670.00 $768.00 $830.00 $645.00 $731.00 BR $59.00 $223.00 $484.00 $548.00 $655.00 $601.00 $741.00 $730.00 $367.00 $621.00 $343.00 $293.00 $440.00 $400.00 $382.00 $398.00 $481.00 $282.00 $344.00 $544.00 $806.00 $833.00 $959.00 $342.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $797.00 $669.00 $531.00 $826.00 $575.00 $955.00 $590.00 $827.00 $989.00 $1,136.00 $1,134.00 $806.00 $982.00 $1,249.00 $1,030.00 $1,016.00 $900.00 $1,011.00 $1,670.00 $886.00 $776.00 $868.00 $1,031.00 $741.00 $958.00 ------$328.00 $507.00 $544.00 $534.00 $630.00 $683.00 $1,040.00 $736.00 $392.00 $601.00 $759.00 $333.00 $373.00 $401.00 $486.00 $412.00 $421.00 $401.00 $804.00 $613.00 $836.00 $772.00 $1,039.00 $379.00 $852.00 $715.00 $566.00 $884.00 $611.00 $1,022.00 $631.00 $884.00 $1,057.00 $1,214.00 $1,209.00 $863.00 $1,048.00 $1,333.00 $1,098.00 $1,084.00 $960.00 $1,081.00 $1,789.00 $947.00 $828.00 $927.00 $1,099.00 $790.00 $1,023.00 ------$349.00 $542.00 $580.00 $570.00 $672.00 $730.00 $1,105.00 $786.00 $419.00 $644.00 $812.00 $357.00 $397.00 $427.00 $520.00 $440.00 $450.00 $428.00 $860.00 $654.00 $892.00 $825.00 $1,106.00 $405.00 $921.00 $771.00 $605.00 $956.00 $655.00 $1,106.00 $681.00 $955.00 $1,142.00 $1,312.00 $1,301.00 $931.00 $1,128.00 $1,431.00 $1,177.00 $1,166.00 $1,029.00 $1,165.00 $1,941.00 $1,021.00 $892.00 $1,000.00 $1,179.00 $852.00 $1,097.00 ------$371.00 $577.00 $624.00 $614.00 $724.00 $788.00 $1,187.00 $848.00 $452.00 $696.00 $863.00 $384.00 $425.00 $458.00 $559.00 $472.00 $485.00 $460.00 $917.00 $704.00 $961.00 $890.00 $1,187.00 $439.00 $797.00 $669.00 $488.00 $826.00 $575.00 $955.00 $590.00 $827.00 $989.00 $1,136.00 $1,134.00 $806.00 $982.00 $1,249.00 $1,030.00 $1,016.00 $900.00 $1,011.00 $1,670.00 $886.00 $776.00 $868.00 $1,031.00 $741.00 $958.00 ------$166.00 $237.00 $544.00 $534.00 $630.00 $683.00 $1,040.00 $736.00 $392.00 $601.00 $369.00 $333.00 $373.00 $401.00 $486.00 $412.00 $421.00 $401.00 $456.00 $613.00 $836.00 $772.00 $1,039.00 $379.00 $852.00 $715.00 $519.00 $884.00 $611.00 $1,022.00 $631.00 $884.00 $1,057.00 $1,214.00 $1,209.00 $863.00 $1,048.00 $1,333.00 $1,098.00 $1,084.00 $960.00 $1,081.00 $1,789.00 $947.00 $828.00 $927.00 $1,099.00 $790.00 $1,023.00 ------$176.00 $253.00 $580.00 $570.00 $672.00 $730.00 $1,105.00 $786.00 $419.00 $644.00 $394.00 $357.00 $397.00 $427.00 $520.00 $440.00 $450.00 $428.00 $487.00 $654.00 $892.00 $825.00 $1,106.00 $405.00 $921.00 $771.00 $556.00 $956.00 $655.00 $1,106.00 $681.00 $955.00 $1,142.00 $1,312.00 $1,301.00 $931.00 $1,128.00 $1,431.00 $1,177.00 $1,166.00 $1,029.00 $1,165.00 $1,941.00 $1,021.00 $892.00 $1,000.00 $1,179.00 $852.00 $1,097.00 ------$188.00 $272.00 $624.00 $614.00 $724.00 $788.00 $1,187.00 $848.00 $452.00 $696.00 $422.00 $384.00 $425.00 $458.00 $559.00 $472.00 $485.00 $460.00 $523.00 $704.00 $961.00 $890.00 $1,187.00 $439.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 158 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 26130 26135 26140 26145 26160 26170 26180 26185 26200 26205 26210 26215 26230 26235 26236 26250 26255 26260 26261 26262 26320 26340 26350 26352 26356 26357 26358 26370 26372 26373 26390 26392 26410 26412 26415 26416 26418 26420 26426 26428 26432 26433 26434 26437 26440 26442 26445 26449 26450 26455 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $629.00 $668.00 $678.00 $660.00 $319.00 $452.00 $444.00 $511.00 $598.00 $788.00 $543.00 $731.00 $624.00 $612.00 $444.00 $814.00 $1,184.00 $758.00 $949.00 $624.00 $414.00 $266.00 $715.00 $855.00 $886.00 $932.00 $979.00 $832.00 $945.00 $904.00 $889.00 $1,123.00 $371.00 $737.00 $846.00 $1,093.00 $444.00 $741.00 $733.00 $790.00 $430.00 $371.00 $656.00 $491.00 $458.00 $548.00 $455.00 $738.00 $353.00 $364.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $588.00 $713.00 $646.00 $657.00 $737.00 $514.00 $561.00 $656.00 $579.00 $781.00 $561.00 $711.00 $651.00 $637.00 $564.00 $746.00 $1,176.00 $704.00 $848.00 $590.00 $438.00 $391.00 $963.00 $1,089.00 $1,378.00 $1,161.00 $1,233.00 $1,040.00 $1,205.00 $1,142.00 $1,110.00 $1,309.00 $767.00 $923.00 $954.00 $1,097.00 $768.00 $966.00 $824.00 $1,006.00 $668.00 $719.00 $849.00 $831.00 $845.00 $1,236.00 $790.00 $1,052.00 $534.00 $530.00 $630.00 $761.00 $689.00 $702.00 $787.00 $548.00 $598.00 $697.00 $619.00 $834.00 $599.00 $757.00 $696.00 $680.00 $602.00 $795.00 $1,251.00 $751.00 $900.00 $631.00 $467.00 $418.00 $1,029.00 $1,163.00 $1,466.00 $1,242.00 $1,317.00 $1,113.00 $1,289.00 $1,220.00 $1,186.00 $1,399.00 $820.00 $987.00 $1,013.00 $1,159.00 $822.00 $1,033.00 $881.00 $1,075.00 $715.00 $769.00 $908.00 $888.00 $904.00 $1,316.00 $845.00 $1,120.00 $571.00 $567.00 $682.00 $821.00 $742.00 $757.00 $838.00 $589.00 $644.00 $746.00 $668.00 $900.00 $645.00 $813.00 $752.00 $733.00 $648.00 $855.00 $1,343.00 $808.00 $964.00 $680.00 $502.00 $447.00 $1,101.00 $1,245.00 $1,561.00 $1,332.00 $1,412.00 $1,193.00 $1,384.00 $1,307.00 $1,274.00 $1,501.00 $878.00 $1,057.00 $1,080.00 $1,225.00 $878.00 $1,108.00 $945.00 $1,152.00 $765.00 $823.00 $973.00 $952.00 $965.00 $1,404.00 $902.00 $1,195.00 $613.00 $608.00 $588.00 $713.00 $646.00 $657.00 $403.00 $514.00 $561.00 $656.00 $579.00 $781.00 $561.00 $711.00 $651.00 $637.00 $564.00 $746.00 $1,176.00 $704.00 $848.00 $590.00 $438.00 $391.00 $963.00 $1,089.00 $1,378.00 $1,161.00 $1,233.00 $1,040.00 $1,205.00 $1,142.00 $1,110.00 $1,309.00 $767.00 $923.00 $954.00 $1,097.00 $768.00 $966.00 $824.00 $1,006.00 $668.00 $719.00 $849.00 $831.00 $845.00 $1,236.00 $790.00 $1,052.00 $534.00 $530.00 $630.00 $761.00 $689.00 $702.00 $430.00 $548.00 $598.00 $697.00 $619.00 $834.00 $599.00 $757.00 $696.00 $680.00 $602.00 $795.00 $1,251.00 $751.00 $900.00 $631.00 $467.00 $418.00 $1,029.00 $1,163.00 $1,466.00 $1,242.00 $1,317.00 $1,113.00 $1,289.00 $1,220.00 $1,186.00 $1,399.00 $820.00 $987.00 $1,013.00 $1,159.00 $822.00 $1,033.00 $881.00 $1,075.00 $715.00 $769.00 $908.00 $888.00 $904.00 $1,316.00 $845.00 $1,120.00 $571.00 $567.00 $682.00 $821.00 $742.00 $757.00 $461.00 $589.00 $644.00 $746.00 $668.00 $900.00 $645.00 $813.00 $752.00 $733.00 $648.00 $855.00 $1,343.00 $808.00 $964.00 $680.00 $502.00 $447.00 $1,101.00 $1,245.00 $1,561.00 $1,332.00 $1,412.00 $1,193.00 $1,384.00 $1,307.00 $1,274.00 $1,501.00 $878.00 $1,057.00 $1,080.00 $1,225.00 $878.00 $1,108.00 $945.00 $1,152.00 $765.00 $823.00 $973.00 $952.00 $965.00 $1,404.00 $902.00 $1,195.00 $613.00 $608.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 159 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 26460 26471 26474 26476 26477 26478 26479 26480 26483 26485 26489 26490 26492 26494 26496 26497 26498 26499 26500 26502 26508 26510 26516 26517 26518 26520 26525 26530 26531 26535 26536 26540 26541 26542 26545 26546 26548 26550 26551 26553 26554 26555 26556 26560 26561 26562 26565 26567 26568 26580 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $346.00 $592.00 $586.00 $543.00 $553.00 $608.00 $653.00 $808.00 $986.00 $891.00 $738.00 $496.00 $971.00 $946.00 $949.00 $946.00 $1,317.00 $934.00 $557.00 $715.00 $334.00 $564.00 $630.00 $890.00 $877.00 $583.00 $531.00 $708.00 $877.00 $546.00 $770.00 $726.00 $926.00 $716.00 $722.00 $918.00 $665.00 $1,861.00 $3,901.00 $3,868.00 $4,551.00 $1,567.00 $4,005.00 $576.00 $1,067.00 $1,017.00 $730.00 $622.00 $1,003.00 $1,585.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $514.00 $817.00 $788.00 $766.00 $775.00 $837.00 $828.00 $1,016.00 $1,136.00 $1,092.00 $1,130.00 $1,037.00 $1,152.00 $1,058.00 $1,139.00 $1,142.00 $1,524.00 $1,079.00 $834.00 $936.00 $850.00 $794.00 $940.00 $1,095.00 $1,096.00 $884.00 $889.00 $689.00 $801.00 $501.00 $851.00 $882.00 $1,072.00 $908.00 $926.00 $1,270.00 $1,017.00 $2,010.00 $4,138.00 $3,693.00 $5,247.00 $1,798.00 $3,810.00 $734.00 $1,177.00 $1,595.00 $902.00 $907.00 $1,201.00 $1,682.00 $550.00 $874.00 $841.00 $818.00 $829.00 $895.00 $885.00 $1,086.00 $1,213.00 $1,167.00 $1,203.00 $1,106.00 $1,229.00 $1,130.00 $1,217.00 $1,219.00 $1,627.00 $1,153.00 $891.00 $1,001.00 $909.00 $848.00 $1,004.00 $1,171.00 $1,170.00 $945.00 $951.00 $736.00 $854.00 $533.00 $909.00 $942.00 $1,145.00 $970.00 $990.00 $1,354.00 $1,086.00 $2,130.00 $4,429.00 $3,844.00 $5,617.00 $1,918.00 $3,967.00 $785.00 $1,253.00 $1,698.00 $964.00 $970.00 $1,286.00 $1,782.00 $590.00 $936.00 $899.00 $876.00 $888.00 $959.00 $950.00 $1,162.00 $1,301.00 $1,249.00 $1,286.00 $1,186.00 $1,319.00 $1,213.00 $1,307.00 $1,309.00 $1,751.00 $1,238.00 $954.00 $1,076.00 $977.00 $907.00 $1,078.00 $1,260.00 $1,256.00 $1,010.00 $1,016.00 $794.00 $920.00 $573.00 $974.00 $1,011.00 $1,228.00 $1,039.00 $1,061.00 $1,449.00 $1,165.00 $2,274.00 $4,816.00 $4,013.00 $6,096.00 $2,064.00 $4,144.00 $842.00 $1,342.00 $1,825.00 $1,033.00 $1,040.00 $1,383.00 $1,906.00 $514.00 $817.00 $788.00 $766.00 $775.00 $837.00 $828.00 $1,016.00 $1,136.00 $1,092.00 $1,130.00 $1,037.00 $1,152.00 $1,058.00 $1,139.00 $1,142.00 $1,524.00 $1,079.00 $834.00 $936.00 $850.00 $794.00 $940.00 $1,095.00 $1,096.00 $884.00 $889.00 $689.00 $801.00 $501.00 $851.00 $882.00 $1,072.00 $908.00 $926.00 $1,270.00 $1,017.00 $2,010.00 $4,138.00 $3,693.00 $5,247.00 $1,798.00 $3,810.00 $734.00 $1,177.00 $1,595.00 $902.00 $907.00 $1,201.00 $1,682.00 $550.00 $874.00 $841.00 $818.00 $829.00 $895.00 $885.00 $1,086.00 $1,213.00 $1,167.00 $1,203.00 $1,106.00 $1,229.00 $1,130.00 $1,217.00 $1,219.00 $1,627.00 $1,153.00 $891.00 $1,001.00 $909.00 $848.00 $1,004.00 $1,171.00 $1,170.00 $945.00 $951.00 $736.00 $854.00 $533.00 $909.00 $942.00 $1,145.00 $970.00 $990.00 $1,354.00 $1,086.00 $2,130.00 $4,429.00 $3,844.00 $5,617.00 $1,918.00 $3,967.00 $785.00 $1,253.00 $1,698.00 $964.00 $970.00 $1,286.00 $1,782.00 $590.00 $936.00 $899.00 $876.00 $888.00 $959.00 $950.00 $1,162.00 $1,301.00 $1,249.00 $1,286.00 $1,186.00 $1,319.00 $1,213.00 $1,307.00 $1,309.00 $1,751.00 $1,238.00 $954.00 $1,076.00 $977.00 $907.00 $1,078.00 $1,260.00 $1,256.00 $1,010.00 $1,016.00 $794.00 $920.00 $573.00 $974.00 $1,011.00 $1,228.00 $1,039.00 $1,061.00 $1,449.00 $1,165.00 $2,274.00 $4,816.00 $4,013.00 $6,096.00 $2,064.00 $4,144.00 $842.00 $1,342.00 $1,825.00 $1,033.00 $1,040.00 $1,383.00 $1,906.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 160 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 26587 26590 26591 26593 26596 26600 26605 26607 26608 26615 26641 26645 26650 26665 26670 26675 26676 26685 26686 26700 26705 26706 26715 26720 26725 26727 26735 26740 26742 26746 26750 26755 26756 26765 26770 26775 26776 26785 26820 26841 26842 26843 26844 26850 26852 26860 26861 26862 26863 26910 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 ZZZ 90 $792.00 $1,609.00 $431.00 $587.00 $809.00 $133.00 $296.00 $334.00 $497.00 $521.00 $71.00 $371.00 $533.00 $693.00 $148.00 $501.00 $527.00 $592.00 $710.00 $88.00 $296.00 $469.00 $526.00 $96.00 $187.00 $187.00 $532.00 $148.00 $148.00 $548.00 $96.00 $133.00 $366.00 $398.00 $79.00 $275.00 $401.00 $408.00 $854.00 $756.00 $901.00 $800.00 $875.00 $704.00 $829.00 $542.00 $151.00 $747.00 $317.00 $747.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,227.00 $1,749.00 $589.00 $788.00 $945.00 $326.00 $392.00 $602.00 $612.00 $675.00 $434.00 $508.00 $608.00 $760.00 $403.00 $551.00 $641.00 $714.00 $801.00 $380.00 $504.00 $553.00 $683.00 $233.00 $423.00 $601.00 $708.00 $271.00 $460.00 $841.00 $217.00 $385.00 $530.00 $566.00 $324.00 $466.00 $565.00 $614.00 $1,050.00 $982.00 $1,057.00 $974.00 $1,085.00 $926.00 $1,051.00 $750.00 $144.00 $962.00 $320.00 $939.00 $1,296.00 $1,867.00 $629.00 $841.00 $1,010.00 $347.00 $420.00 $644.00 $654.00 $717.00 $459.00 $542.00 $652.00 $806.00 $427.00 $589.00 $686.00 $763.00 $856.00 $401.00 $539.00 $591.00 $726.00 $249.00 $452.00 $643.00 $753.00 $290.00 $492.00 $887.00 $232.00 $410.00 $567.00 $601.00 $342.00 $497.00 $604.00 $649.00 $1,122.00 $1,051.00 $1,131.00 $1,040.00 $1,159.00 $989.00 $1,121.00 $802.00 $154.00 $1,027.00 $341.00 $1,003.00 $1,382.00 $2,015.00 $672.00 $900.00 $1,090.00 $370.00 $452.00 $694.00 $706.00 $768.00 $487.00 $583.00 $706.00 $860.00 $454.00 $636.00 $740.00 $823.00 $924.00 $425.00 $580.00 $637.00 $779.00 $266.00 $486.00 $693.00 $807.00 $311.00 $528.00 $941.00 $247.00 $439.00 $611.00 $641.00 $362.00 $533.00 $650.00 $691.00 $1,206.00 $1,130.00 $1,216.00 $1,116.00 $1,244.00 $1,061.00 $1,201.00 $858.00 $167.00 $1,101.00 $368.00 $1,078.00 $1,227.00 $1,749.00 $589.00 $788.00 $945.00 $293.00 $355.00 $602.00 $612.00 $675.00 $393.00 $466.00 $608.00 $760.00 $356.00 $507.00 $641.00 $714.00 $801.00 $348.00 $461.00 $553.00 $683.00 $208.00 $374.00 $601.00 $708.00 $253.00 $415.00 $841.00 $206.00 $329.00 $530.00 $566.00 $289.00 $413.00 $565.00 $614.00 $1,050.00 $982.00 $1,057.00 $974.00 $1,085.00 $926.00 $1,051.00 $750.00 $144.00 $962.00 $320.00 $939.00 $1,296.00 $1,867.00 $629.00 $841.00 $1,010.00 $312.00 $380.00 $644.00 $654.00 $717.00 $415.00 $498.00 $652.00 $806.00 $376.00 $542.00 $686.00 $763.00 $856.00 $367.00 $492.00 $591.00 $726.00 $222.00 $400.00 $643.00 $753.00 $271.00 $443.00 $887.00 $219.00 $351.00 $567.00 $601.00 $305.00 $440.00 $604.00 $649.00 $1,122.00 $1,051.00 $1,131.00 $1,040.00 $1,159.00 $989.00 $1,121.00 $802.00 $154.00 $1,027.00 $341.00 $1,003.00 $1,382.00 $2,015.00 $672.00 $900.00 $1,090.00 $333.00 $410.00 $694.00 $706.00 $768.00 $440.00 $536.00 $706.00 $860.00 $400.00 $586.00 $740.00 $823.00 $924.00 $390.00 $531.00 $637.00 $779.00 $238.00 $431.00 $693.00 $807.00 $291.00 $477.00 $941.00 $234.00 $376.00 $611.00 $641.00 $323.00 $473.00 $650.00 $691.00 $1,206.00 $1,130.00 $1,216.00 $1,116.00 $1,244.00 $1,061.00 $1,201.00 $858.00 $167.00 $1,101.00 $368.00 $1,078.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 161 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 26951 26952 26989 26990 26991 26992 27000 27001 27003 27005 27006 27025 27030 27033 27035 27036 27040 27041 27047 27048 27049 27050 27052 27054 27060 27062 27065 27066 27067 27070 27071 27075 27076 27077 27078 27079 27080 27086 27087 27090 27091 27093 27095 27096 27097 27098 27100 27105 27110 27111 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 0 0 0 90 90 90 90 90 90 $444.00 $608.00 BR $592.00 $466.00 $1,146.00 $421.00 $550.00 $698.00 $738.00 $788.00 $896.00 $1,148.00 $1,173.00 $1,413.00 $1,176.00 $196.00 $699.00 $535.00 $588.00 $1,162.00 $449.00 $624.00 $843.00 $491.00 $499.00 $583.00 $931.00 $1,234.00 $1,040.00 $1,112.00 $1,485.00 $1,859.00 $1,976.00 $1,164.00 $1,170.00 $568.00 $57.00 $555.00 $981.00 $1,482.00 $62.00 $121.00 $491.00 $795.00 $799.00 $987.00 $946.00 $1,174.00 $1,099.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $795.00 $864.00 ------$800.00 $910.00 $1,270.00 $588.00 $712.00 $756.00 $962.00 $972.00 $1,160.00 $1,257.00 $1,300.00 $1,474.00 $1,319.00 $418.00 $889.00 $787.00 $610.00 $1,293.00 $452.00 $715.00 $889.00 $553.00 $584.00 $643.00 $1,059.00 $1,319.00 $1,105.00 $1,194.00 $3,059.00 $2,116.00 $3,550.00 $1,328.00 $1,294.00 $629.00 $314.00 $824.00 $1,103.00 $2,112.00 $261.00 $317.00 $244.00 $874.00 $806.00 $1,076.00 $1,109.00 $1,248.00 $1,170.00 $846.00 $923.00 ------$855.00 $973.00 $1,358.00 $631.00 $764.00 $806.00 $1,032.00 $1,042.00 $1,237.00 $1,347.00 $1,391.00 $1,564.00 $1,411.00 $443.00 $946.00 $839.00 $650.00 $1,375.00 $480.00 $763.00 $951.00 $589.00 $625.00 $688.00 $1,133.00 $1,400.00 $1,180.00 $1,276.00 $3,266.00 $2,260.00 $3,782.00 $1,418.00 $1,374.00 $669.00 $335.00 $881.00 $1,181.00 $2,258.00 $278.00 $338.00 $258.00 $936.00 $851.00 $1,152.00 $1,182.00 $1,335.00 $1,250.00 $901.00 $989.00 ------$923.00 $1,046.00 $1,471.00 $683.00 $829.00 $868.00 $1,121.00 $1,130.00 $1,334.00 $1,462.00 $1,510.00 $1,678.00 $1,528.00 $469.00 $1,017.00 $900.00 $700.00 $1,480.00 $515.00 $823.00 $1,029.00 $633.00 $676.00 $743.00 $1,227.00 $1,502.00 $1,274.00 $1,379.00 $3,541.00 $2,446.00 $4,086.00 $1,534.00 $1,477.00 $719.00 $357.00 $952.00 $1,282.00 $2,449.00 $295.00 $357.00 $271.00 $1,017.00 $906.00 $1,248.00 $1,275.00 $1,447.00 $1,352.00 $795.00 $864.00 ------$800.00 $673.00 $1,270.00 $588.00 $712.00 $756.00 $962.00 $972.00 $1,160.00 $1,257.00 $1,300.00 $1,474.00 $1,319.00 $254.00 $889.00 $666.00 $610.00 $1,293.00 $452.00 $715.00 $889.00 $553.00 $584.00 $643.00 $1,059.00 $1,319.00 $1,105.00 $1,194.00 $3,059.00 $2,116.00 $3,550.00 $1,328.00 $1,294.00 $629.00 $191.00 $824.00 $1,103.00 $2,112.00 $95.00 $107.00 $88.00 $874.00 $806.00 $1,076.00 $1,109.00 $1,248.00 $1,170.00 $846.00 $923.00 ------$855.00 $720.00 $1,358.00 $631.00 $764.00 $806.00 $1,032.00 $1,042.00 $1,237.00 $1,347.00 $1,391.00 $1,564.00 $1,411.00 $268.00 $946.00 $708.00 $650.00 $1,375.00 $480.00 $763.00 $951.00 $589.00 $625.00 $688.00 $1,133.00 $1,400.00 $1,180.00 $1,276.00 $3,266.00 $2,260.00 $3,782.00 $1,418.00 $1,374.00 $669.00 $203.00 $881.00 $1,181.00 $2,258.00 $100.00 $112.00 $92.00 $936.00 $851.00 $1,152.00 $1,182.00 $1,335.00 $1,250.00 $901.00 $989.00 ------$923.00 $779.00 $1,471.00 $683.00 $829.00 $868.00 $1,121.00 $1,130.00 $1,334.00 $1,462.00 $1,510.00 $1,678.00 $1,528.00 $284.00 $1,017.00 $762.00 $700.00 $1,480.00 $515.00 $823.00 $1,029.00 $633.00 $676.00 $743.00 $1,227.00 $1,502.00 $1,274.00 $1,379.00 $3,541.00 $2,446.00 $4,086.00 $1,534.00 $1,477.00 $719.00 $218.00 $952.00 $1,282.00 $2,449.00 $107.00 $119.00 $96.00 $1,017.00 $906.00 $1,248.00 $1,275.00 $1,447.00 $1,352.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 162 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 27120 27122 27125 27130 27132 27134 27137 27138 27140 27146 27147 27151 27156 27158 27161 27165 27170 27175 27176 27177 27178 27179 27181 27185 27187 27193 27194 27200 27202 27215 27216 27217 27218 27220 27222 27226 27227 27228 27230 27232 27235 27236 27238 27240 27244 27245 27246 27248 27250 27252 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,603.00 $1,406.00 $1,371.00 $1,853.00 $2,128.00 $2,576.00 $2,190.00 $2,025.00 $1,092.00 $1,432.00 $1,744.00 $1,732.00 $2,017.00 $1,588.00 $1,443.00 $1,572.00 $1,453.00 $491.00 $1,024.00 $1,257.00 $1,020.00 $1,107.00 $1,206.00 $676.00 $1,280.00 $425.00 $740.00 $180.00 $776.00 $954.00 $1,085.00 $1,285.00 $1,570.00 $444.00 $973.00 $1,350.00 $1,967.00 $2,195.00 $491.00 $916.00 $1,128.00 $1,421.00 $504.00 $1,043.00 $1,426.00 $1,691.00 $459.00 $980.00 $535.00 $520.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,708.00 $1,469.00 $1,480.00 $1,920.00 $2,245.00 $2,620.00 $1,993.00 $2,074.00 $1,195.00 $1,685.00 $1,943.00 $1,955.00 $2,302.00 $1,795.00 $1,629.00 $1,801.00 $1,570.00 $848.00 $1,207.00 $1,470.00 $1,175.00 $1,293.00 $1,374.00 $999.00 $1,326.00 $600.00 $961.00 $218.00 $968.00 $989.00 $1,416.00 $1,349.00 $1,828.00 $675.00 $1,293.00 $1,342.00 $2,225.00 $2,550.00 $604.00 $1,027.00 $1,209.00 $1,564.00 $580.00 $1,255.00 $1,545.00 $1,897.00 $496.00 $1,009.00 $611.00 $992.00 $1,827.00 $1,572.00 $1,581.00 $2,054.00 $2,400.00 $2,803.00 $2,132.00 $2,219.00 $1,280.00 $1,801.00 $2,079.00 $2,092.00 $2,462.00 $1,916.00 $1,744.00 $1,923.00 $1,679.00 $906.00 $1,294.00 $1,573.00 $1,258.00 $1,384.00 $1,449.00 $1,085.00 $1,420.00 $642.00 $1,028.00 $232.00 $1,034.00 $1,063.00 $1,517.00 $1,444.00 $1,957.00 $722.00 $1,382.00 $1,435.00 $2,380.00 $2,726.00 $647.00 $1,098.00 $1,294.00 $1,671.00 $621.00 $1,342.00 $1,653.00 $2,032.00 $532.00 $1,081.00 $642.00 $1,059.00 $1,982.00 $1,705.00 $1,711.00 $2,229.00 $2,602.00 $3,046.00 $2,314.00 $2,410.00 $1,389.00 $1,952.00 $2,257.00 $2,276.00 $2,672.00 $2,073.00 $1,893.00 $2,082.00 $1,821.00 $981.00 $1,407.00 $1,706.00 $1,364.00 $1,500.00 $1,540.00 $1,200.00 $1,542.00 $694.00 $1,114.00 $250.00 $1,108.00 $1,161.00 $1,648.00 $1,567.00 $2,128.00 $780.00 $1,495.00 $1,557.00 $2,581.00 $2,958.00 $699.00 $1,191.00 $1,403.00 $1,809.00 $670.00 $1,453.00 $1,793.00 $2,208.00 $576.00 $1,174.00 $680.00 $1,145.00 $1,708.00 $1,469.00 $1,480.00 $1,920.00 $2,245.00 $2,620.00 $1,993.00 $2,074.00 $1,195.00 $1,685.00 $1,943.00 $1,955.00 $2,302.00 $1,795.00 $1,629.00 $1,801.00 $1,570.00 $848.00 $1,207.00 $1,470.00 $1,175.00 $1,293.00 $1,374.00 $999.00 $1,326.00 $603.00 $961.00 $220.00 $968.00 $989.00 $1,416.00 $1,349.00 $1,828.00 $670.00 $1,293.00 $1,342.00 $2,225.00 $2,550.00 $591.00 $1,027.00 $1,209.00 $1,564.00 $580.00 $1,255.00 $1,545.00 $1,897.00 $496.00 $1,009.00 $611.00 $992.00 $1,827.00 $1,572.00 $1,581.00 $2,054.00 $2,400.00 $2,803.00 $2,132.00 $2,219.00 $1,280.00 $1,801.00 $2,079.00 $2,092.00 $2,462.00 $1,916.00 $1,744.00 $1,923.00 $1,679.00 $906.00 $1,294.00 $1,573.00 $1,258.00 $1,384.00 $1,449.00 $1,085.00 $1,420.00 $645.00 $1,028.00 $235.00 $1,034.00 $1,063.00 $1,517.00 $1,444.00 $1,957.00 $716.00 $1,382.00 $1,435.00 $2,380.00 $2,726.00 $633.00 $1,098.00 $1,294.00 $1,671.00 $621.00 $1,342.00 $1,653.00 $2,032.00 $532.00 $1,081.00 $642.00 $1,059.00 $1,982.00 $1,705.00 $1,711.00 $2,229.00 $2,602.00 $3,046.00 $2,314.00 $2,410.00 $1,389.00 $1,952.00 $2,257.00 $2,276.00 $2,672.00 $2,073.00 $1,893.00 $2,082.00 $1,821.00 $981.00 $1,407.00 $1,706.00 $1,364.00 $1,500.00 $1,540.00 $1,200.00 $1,542.00 $697.00 $1,114.00 $252.00 $1,108.00 $1,161.00 $1,648.00 $1,567.00 $2,128.00 $774.00 $1,495.00 $1,557.00 $2,581.00 $2,958.00 $685.00 $1,191.00 $1,403.00 $1,809.00 $670.00 $1,453.00 $1,793.00 $2,208.00 $576.00 $1,174.00 $680.00 $1,145.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 163 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 27253 27254 27256 27257 27258 27259 27265 27266 27267 27268 27269 27275 27280 27282 27284 27286 27290 27295 27299 27301 27303 27305 27306 27307 27310 27323 27324 27325 27326 27327 27328 27329 27330 27331 27332 27333 27334 27335 27340 27345 27347 27350 27355 27356 27357 27358 27360 27365 27370 27372 90 90 10 10 90 90 90 90 90 90 90 10 90 90 90 90 90 90 YYY 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 0 90 $1,162.00 $1,478.00 $338.00 $455.00 $1,355.00 $1,803.00 $442.00 $614.00 ------------------$220.00 $1,179.00 $990.00 $1,435.00 $1,503.00 $2,073.00 $1,594.00 BR $193.00 $520.00 $555.00 $377.00 $503.00 $877.00 $211.00 $433.00 ------------$400.00 $503.00 $1,249.00 $492.00 $585.00 $786.00 $719.00 $840.00 $959.00 $405.00 $565.00 $394.00 $786.00 $763.00 $882.00 $950.00 $394.00 $977.00 $1,421.00 $75.00 $371.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,259.00 $1,699.00 $387.00 $440.00 $1,472.00 $2,051.00 $509.00 $759.00 $543.00 $671.00 $1,607.00 $238.00 $1,361.00 $1,092.00 $2,151.00 $2,131.00 $2,072.00 $1,675.00 ------$852.00 $838.00 $612.00 $506.00 $616.00 $950.00 $320.00 $492.00 $668.00 $642.00 $564.00 $541.00 $1,344.00 $525.00 $617.00 $836.00 $758.00 $892.00 $1,009.00 $470.00 $623.00 $653.00 $850.00 $790.00 $966.00 $1,077.00 $396.00 $1,119.00 $1,616.00 $220.00 $766.00 $1,348.00 $1,820.00 $409.00 $467.00 $1,576.00 $2,194.00 $540.00 $813.00 $582.00 $719.00 $1,717.00 $255.00 $1,459.00 $1,168.00 $2,298.00 $2,261.00 $2,206.00 $1,787.00 ------$911.00 $897.00 $656.00 $543.00 $660.00 $1,017.00 $340.00 $525.00 $713.00 $687.00 $602.00 $578.00 $1,430.00 $562.00 $661.00 $896.00 $812.00 $955.00 $1,081.00 $504.00 $667.00 $697.00 $910.00 $846.00 $1,034.00 $1,156.00 $424.00 $1,197.00 $1,727.00 $234.00 $820.00 $1,463.00 $1,978.00 $436.00 $502.00 $1,710.00 $2,381.00 $578.00 $881.00 $629.00 $779.00 $1,861.00 $276.00 $1,587.00 $1,265.00 $2,492.00 $2,426.00 $2,380.00 $1,934.00 ------$979.00 $972.00 $710.00 $590.00 $716.00 $1,101.00 $361.00 $566.00 $770.00 $744.00 $644.00 $623.00 $1,540.00 $609.00 $717.00 $971.00 $879.00 $1,034.00 $1,172.00 $545.00 $722.00 $752.00 $985.00 $916.00 $1,120.00 $1,257.00 $463.00 $1,295.00 $1,869.00 $247.00 $880.00 $1,259.00 $1,699.00 $323.00 $440.00 $1,472.00 $2,051.00 $509.00 $759.00 $543.00 $671.00 $1,607.00 $238.00 $1,361.00 $1,092.00 $2,151.00 $2,131.00 $2,072.00 $1,675.00 ------$640.00 $838.00 $612.00 $506.00 $616.00 $950.00 $223.00 $492.00 $668.00 $642.00 $445.00 $541.00 $1,344.00 $525.00 $617.00 $836.00 $758.00 $892.00 $1,009.00 $470.00 $623.00 $653.00 $850.00 $790.00 $966.00 $1,077.00 $396.00 $1,119.00 $1,616.00 $69.00 $525.00 $1,348.00 $1,820.00 $341.00 $467.00 $1,576.00 $2,194.00 $540.00 $813.00 $582.00 $719.00 $1,717.00 $255.00 $1,459.00 $1,168.00 $2,298.00 $2,261.00 $2,206.00 $1,787.00 ------$684.00 $897.00 $656.00 $543.00 $660.00 $1,017.00 $236.00 $525.00 $713.00 $687.00 $475.00 $578.00 $1,430.00 $562.00 $661.00 $896.00 $812.00 $955.00 $1,081.00 $504.00 $667.00 $697.00 $910.00 $846.00 $1,034.00 $1,156.00 $424.00 $1,197.00 $1,727.00 $72.00 $562.00 $1,463.00 $1,978.00 $365.00 $502.00 $1,710.00 $2,381.00 $578.00 $881.00 $629.00 $779.00 $1,861.00 $276.00 $1,587.00 $1,265.00 $2,492.00 $2,426.00 $2,380.00 $1,934.00 ------$739.00 $972.00 $710.00 $590.00 $716.00 $1,101.00 $251.00 $566.00 $770.00 $744.00 $511.00 $623.00 $1,540.00 $609.00 $717.00 $971.00 $879.00 $1,034.00 $1,172.00 $545.00 $722.00 $752.00 $985.00 $916.00 $1,120.00 $1,257.00 $463.00 $1,295.00 $1,869.00 $76.00 $608.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 164 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 27380 27381 27385 27386 27390 27391 27392 27393 27394 27395 27396 27397 27400 27403 27405 27407 27409 27412 27415 27416 27418 27420 27422 27424 27425 27427 27428 27429 27430 27435 27437 27438 27440 27441 27442 27443 27445 27446 27447 27448 27450 27454 27455 27457 27465 27466 27468 27470 27472 27475 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $698.00 $1,118.00 $753.00 $1,064.00 $506.00 $647.00 $834.00 $608.00 $748.00 $1,093.00 $742.00 $989.00 $832.00 $792.00 $842.00 $918.00 $1,212.00 ------------------$1,596.00 $927.00 $930.00 $927.00 $639.00 $1,118.00 $1,266.00 $2,333.00 $884.00 $501.00 $819.00 $1,065.00 $1,064.00 $1,006.00 $1,117.00 $1,037.00 $1,618.00 $1,764.00 $1,960.00 $1,060.00 $1,311.00 $1,524.00 $1,157.00 $1,209.00 $1,253.00 $1,441.00 $1,613.00 $1,501.00 $1,665.00 $782.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $776.00 $1,059.00 $832.00 $1,100.00 $568.00 $747.00 $927.00 $662.00 $858.00 $1,162.00 $805.00 $1,165.00 $880.00 $844.00 $887.00 $1,024.00 $1,271.00 $2,209.00 $1,884.00 $1,261.00 $1,100.00 $988.00 $985.00 $986.00 $575.00 $946.00 $1,445.00 $1,616.00 $977.00 $1,038.00 $868.00 $1,109.00 $984.00 $1,038.00 $1,156.00 $1,083.00 $1,684.00 $1,500.00 $2,063.00 $1,092.00 $1,357.00 $1,720.00 $1,255.00 $1,294.00 $1,575.00 $1,572.00 $1,781.00 $1,568.00 $1,699.00 $858.00 $831.00 $1,134.00 $891.00 $1,178.00 $608.00 $800.00 $993.00 $709.00 $920.00 $1,245.00 $862.00 $1,242.00 $938.00 $904.00 $950.00 $1,096.00 $1,361.00 $2,370.00 $2,038.00 $1,350.00 $1,177.00 $1,058.00 $1,055.00 $1,056.00 $616.00 $1,013.00 $1,545.00 $1,727.00 $1,047.00 $1,110.00 $930.00 $1,187.00 $1,054.00 $1,111.00 $1,239.00 $1,161.00 $1,803.00 $1,608.00 $2,208.00 $1,170.00 $1,454.00 $1,841.00 $1,345.00 $1,386.00 $1,675.00 $1,682.00 $1,907.00 $1,678.00 $1,819.00 $916.00 $900.00 $1,229.00 $965.00 $1,277.00 $658.00 $866.00 $1,075.00 $768.00 $997.00 $1,351.00 $933.00 $1,340.00 $1,010.00 $980.00 $1,030.00 $1,189.00 $1,476.00 $2,584.00 $2,245.00 $1,466.00 $1,276.00 $1,148.00 $1,144.00 $1,145.00 $667.00 $1,099.00 $1,671.00 $1,869.00 $1,135.00 $1,200.00 $1,009.00 $1,288.00 $1,144.00 $1,206.00 $1,346.00 $1,259.00 $1,958.00 $1,749.00 $2,397.00 $1,270.00 $1,578.00 $1,998.00 $1,460.00 $1,505.00 $1,803.00 $1,823.00 $2,072.00 $1,820.00 $1,975.00 $989.00 $776.00 $1,059.00 $832.00 $1,100.00 $568.00 $747.00 $927.00 $662.00 $858.00 $1,162.00 $805.00 $1,165.00 $880.00 $844.00 $887.00 $1,024.00 $1,271.00 $2,209.00 $1,884.00 $1,261.00 $1,100.00 $988.00 $985.00 $986.00 $575.00 $946.00 $1,445.00 $1,616.00 $977.00 $1,038.00 $868.00 $1,109.00 $984.00 $1,038.00 $1,156.00 $1,083.00 $1,684.00 $1,500.00 $2,063.00 $1,092.00 $1,357.00 $1,720.00 $1,255.00 $1,294.00 $1,575.00 $1,572.00 $1,781.00 $1,568.00 $1,699.00 $858.00 $831.00 $1,134.00 $891.00 $1,178.00 $608.00 $800.00 $993.00 $709.00 $920.00 $1,245.00 $862.00 $1,242.00 $938.00 $904.00 $950.00 $1,096.00 $1,361.00 $2,370.00 $2,038.00 $1,350.00 $1,177.00 $1,058.00 $1,055.00 $1,056.00 $616.00 $1,013.00 $1,545.00 $1,727.00 $1,047.00 $1,110.00 $930.00 $1,187.00 $1,054.00 $1,111.00 $1,239.00 $1,161.00 $1,803.00 $1,608.00 $2,208.00 $1,170.00 $1,454.00 $1,841.00 $1,345.00 $1,386.00 $1,675.00 $1,682.00 $1,907.00 $1,678.00 $1,819.00 $916.00 $900.00 $1,229.00 $965.00 $1,277.00 $658.00 $866.00 $1,075.00 $768.00 $997.00 $1,351.00 $933.00 $1,340.00 $1,010.00 $980.00 $1,030.00 $1,189.00 $1,476.00 $2,584.00 $2,245.00 $1,466.00 $1,276.00 $1,148.00 $1,144.00 $1,145.00 $667.00 $1,099.00 $1,671.00 $1,869.00 $1,135.00 $1,200.00 $1,009.00 $1,288.00 $1,144.00 $1,206.00 $1,346.00 $1,259.00 $1,958.00 $1,749.00 $2,397.00 $1,270.00 $1,578.00 $1,998.00 $1,460.00 $1,505.00 $1,803.00 $1,823.00 $2,072.00 $1,820.00 $1,975.00 $989.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 165 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 27477 27479 27485 27486 27487 27488 27495 27496 27497 27498 27499 27500 27501 27502 27503 27506 27507 27508 27509 27510 27511 27513 27514 27516 27517 27519 27520 27524 27530 27532 27535 27536 27538 27540 27550 27552 27556 27557 27558 27560 27562 27566 27570 27580 27590 27591 27592 27594 27596 27598 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 $938.00 $1,123.00 $797.00 $1,771.00 $2,352.00 $1,438.00 $1,477.00 $563.00 $652.00 $701.00 $782.00 $520.00 $659.00 $909.00 $911.00 $1,522.00 $1,297.00 $400.00 $649.00 $755.00 $1,281.00 $1,562.00 $1,508.00 $579.00 $820.00 $1,311.00 $266.00 $910.00 $408.00 $641.00 $1,075.00 $1,282.00 $487.00 $1,106.00 $296.00 $619.00 $832.00 $1,479.00 $1,529.00 $88.00 $514.00 $1,047.00 $184.00 $1,644.00 $1,059.00 $1,182.00 $911.00 $600.00 $931.00 $976.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $967.00 $1,296.00 $885.00 $1,878.00 $2,376.00 $1,584.00 $1,511.00 $655.00 $713.00 $778.00 $874.00 $660.00 $649.00 $1,044.00 $1,057.00 $1,757.00 $1,318.00 $666.00 $845.00 $916.00 $1,374.00 $1,736.00 $1,448.00 $622.00 $865.00 $1,293.00 $391.00 $1,000.00 $492.00 $793.00 $1,222.00 $1,570.00 $590.00 $1,127.00 $615.00 $811.00 $1,276.00 $1,516.00 $1,660.00 $441.00 $584.00 $1,191.00 $191.00 $1,924.00 $1,083.00 $1,210.00 $915.00 $665.00 $968.00 $982.00 $1,037.00 $1,400.00 $948.00 $2,008.00 $2,542.00 $1,693.00 $1,618.00 $699.00 $761.00 $829.00 $934.00 $706.00 $695.00 $1,116.00 $1,131.00 $1,877.00 $1,411.00 $712.00 $905.00 $979.00 $1,469.00 $1,858.00 $1,563.00 $664.00 $921.00 $1,392.00 $418.00 $1,071.00 $526.00 $849.00 $1,304.00 $1,678.00 $633.00 $1,215.00 $655.00 $869.00 $1,373.00 $1,630.00 $1,779.00 $467.00 $625.00 $1,275.00 $205.00 $2,058.00 $1,150.00 $1,290.00 $973.00 $708.00 $1,031.00 $1,047.00 $1,126.00 $1,537.00 $1,028.00 $2,178.00 $2,760.00 $1,833.00 $1,755.00 $754.00 $821.00 $894.00 $1,011.00 $763.00 $751.00 $1,209.00 $1,227.00 $2,032.00 $1,533.00 $768.00 $979.00 $1,059.00 $1,591.00 $2,016.00 $1,712.00 $714.00 $990.00 $1,520.00 $449.00 $1,162.00 $567.00 $919.00 $1,409.00 $1,818.00 $683.00 $1,330.00 $701.00 $942.00 $1,500.00 $1,779.00 $1,933.00 $496.00 $675.00 $1,385.00 $222.00 $2,231.00 $1,238.00 $1,393.00 $1,047.00 $763.00 $1,111.00 $1,131.00 $967.00 $1,296.00 $885.00 $1,878.00 $2,376.00 $1,584.00 $1,511.00 $655.00 $713.00 $778.00 $874.00 $612.00 $637.00 $1,044.00 $1,057.00 $1,757.00 $1,318.00 $626.00 $845.00 $916.00 $1,374.00 $1,736.00 $1,448.00 $585.00 $865.00 $1,293.00 $349.00 $1,000.00 $455.00 $751.00 $1,222.00 $1,570.00 $551.00 $1,127.00 $570.00 $811.00 $1,276.00 $1,516.00 $1,660.00 $386.00 $584.00 $1,191.00 $191.00 $1,924.00 $1,083.00 $1,210.00 $915.00 $665.00 $968.00 $982.00 $1,037.00 $1,400.00 $948.00 $2,008.00 $2,542.00 $1,693.00 $1,618.00 $699.00 $761.00 $829.00 $934.00 $655.00 $681.00 $1,116.00 $1,131.00 $1,877.00 $1,411.00 $669.00 $905.00 $979.00 $1,469.00 $1,858.00 $1,563.00 $625.00 $921.00 $1,392.00 $373.00 $1,071.00 $487.00 $804.00 $1,304.00 $1,678.00 $591.00 $1,215.00 $606.00 $869.00 $1,373.00 $1,630.00 $1,779.00 $409.00 $625.00 $1,275.00 $205.00 $2,058.00 $1,150.00 $1,290.00 $973.00 $708.00 $1,031.00 $1,047.00 $1,126.00 $1,537.00 $1,028.00 $2,178.00 $2,760.00 $1,833.00 $1,755.00 $754.00 $821.00 $894.00 $1,011.00 $709.00 $737.00 $1,209.00 $1,227.00 $2,032.00 $1,533.00 $723.00 $979.00 $1,059.00 $1,591.00 $2,016.00 $1,712.00 $672.00 $990.00 $1,520.00 $402.00 $1,162.00 $525.00 $871.00 $1,409.00 $1,818.00 $639.00 $1,330.00 $650.00 $942.00 $1,500.00 $1,779.00 $1,933.00 $435.00 $675.00 $1,385.00 $222.00 $2,231.00 $1,238.00 $1,393.00 $1,047.00 $763.00 $1,111.00 $1,131.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 166 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 27599 27600 27601 27602 27603 27604 27605 27606 27607 27610 27612 27613 27614 27615 27618 27619 27620 27625 27626 27630 27635 27637 27638 27640 27641 27645 27646 27647 27648 27650 27652 27654 27656 27658 27659 27664 27665 27675 27676 27680 27681 27685 27686 27687 27690 27691 27692 27695 27696 27698 YYY 90 90 90 90 90 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 BR $517.00 $516.00 $621.00 $412.00 $308.00 $236.00 $362.00 $608.00 $777.00 $701.00 $165.00 $327.00 $1,106.00 $421.00 $730.00 $587.00 $796.00 $863.00 $430.00 $781.00 $921.00 $978.00 $1,122.00 $922.00 $1,302.00 $1,212.00 $1,044.00 $72.00 $869.00 $935.00 $937.00 $458.00 $527.00 $725.00 $504.00 $618.00 $656.00 $762.00 $523.00 $634.00 $565.00 $706.00 $589.00 $757.00 $889.00 $159.00 $658.00 $758.00 $881.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) ------$555.00 $568.00 $685.00 $662.00 $581.00 $489.00 $399.00 $800.00 $862.00 $747.00 $297.00 $702.00 $1,170.00 $610.00 $985.00 $611.00 $793.00 $857.00 $675.00 $785.00 $989.00 $1,040.00 $1,163.00 $934.00 $1,406.00 $1,250.00 $1,097.00 $212.00 $935.00 $998.00 $938.00 $684.00 $510.00 $673.00 $489.00 $559.00 $689.00 $825.00 $578.00 $692.00 $787.00 $752.00 $620.00 $819.00 $973.00 $154.00 $661.00 $791.00 $883.00 ------$592.00 $604.00 $729.00 $707.00 $621.00 $522.00 $427.00 $855.00 $921.00 $796.00 $315.00 $749.00 $1,247.00 $651.00 $1,051.00 $654.00 $847.00 $917.00 $721.00 $840.00 $1,059.00 $1,115.00 $1,242.00 $996.00 $1,505.00 $1,336.00 $1,167.00 $225.00 $999.00 $1,067.00 $1,002.00 $731.00 $545.00 $719.00 $524.00 $599.00 $735.00 $882.00 $618.00 $741.00 $841.00 $804.00 $663.00 $874.00 $1,040.00 $165.00 $707.00 $845.00 $943.00 ------$638.00 $649.00 $787.00 $758.00 $666.00 $557.00 $463.00 $924.00 $995.00 $857.00 $333.00 $801.00 $1,343.00 $697.00 $1,129.00 $707.00 $915.00 $994.00 $773.00 $910.00 $1,146.00 $1,210.00 $1,343.00 $1,075.00 $1,630.00 $1,444.00 $1,257.00 $238.00 $1,082.00 $1,156.00 $1,083.00 $782.00 $588.00 $777.00 $566.00 $647.00 $794.00 $954.00 $668.00 $803.00 $903.00 $870.00 $717.00 $943.00 $1,126.00 $180.00 $764.00 $912.00 $1,020.00 ------$555.00 $568.00 $685.00 $501.00 $451.00 $269.00 $399.00 $800.00 $862.00 $747.00 $208.00 $539.00 $1,170.00 $494.00 $778.00 $611.00 $793.00 $857.00 $491.00 $785.00 $989.00 $1,040.00 $1,163.00 $934.00 $1,406.00 $1,250.00 $1,097.00 $69.00 $935.00 $998.00 $938.00 $456.00 $510.00 $673.00 $489.00 $559.00 $689.00 $825.00 $578.00 $692.00 $637.00 $752.00 $620.00 $819.00 $973.00 $154.00 $661.00 $791.00 $883.00 ------$592.00 $604.00 $729.00 $534.00 $482.00 $287.00 $427.00 $855.00 $921.00 $796.00 $220.00 $574.00 $1,247.00 $526.00 $830.00 $654.00 $847.00 $917.00 $524.00 $840.00 $1,059.00 $1,115.00 $1,242.00 $996.00 $1,505.00 $1,336.00 $1,167.00 $72.00 $999.00 $1,067.00 $1,002.00 $486.00 $545.00 $719.00 $524.00 $599.00 $735.00 $882.00 $618.00 $741.00 $679.00 $804.00 $663.00 $874.00 $1,040.00 $165.00 $707.00 $845.00 $943.00 ------$638.00 $649.00 $787.00 $575.00 $519.00 $309.00 $463.00 $924.00 $995.00 $857.00 $233.00 $617.00 $1,343.00 $566.00 $895.00 $707.00 $915.00 $994.00 $565.00 $910.00 $1,146.00 $1,210.00 $1,343.00 $1,075.00 $1,630.00 $1,444.00 $1,257.00 $76.00 $1,082.00 $1,156.00 $1,083.00 $524.00 $588.00 $777.00 $566.00 $647.00 $794.00 $954.00 $668.00 $803.00 $732.00 $870.00 $717.00 $943.00 $1,126.00 $180.00 $764.00 $912.00 $1,020.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 167 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 27700 27702 27703 27704 27705 27707 27709 27712 27715 27720 27722 27724 27725 27726 27727 27730 27732 27734 27740 27742 27745 27750 27752 27756 27758 27759 27760 27762 27766 27767 27768 27769 27780 27781 27784 27786 27788 27792 27808 27810 27814 27816 27818 27822 27823 27824 27825 27826 27827 27828 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $835.00 $1,278.00 $1,337.00 $683.00 $985.00 $484.00 $1,118.00 $1,227.00 $1,285.00 $1,147.00 $1,076.00 $1,402.00 $1,312.00 ------$1,175.00 $647.00 $611.00 $766.00 $1,044.00 $1,045.00 $940.00 $319.00 $614.00 $708.00 $1,115.00 $1,262.00 $223.00 $495.00 $759.00 ------------------$244.00 $296.00 $643.00 $223.00 $422.00 $706.00 $332.00 $567.00 $972.00 $386.00 $613.00 $1,201.00 $1,472.00 $384.00 $670.00 $1,080.00 $1,310.00 $1,823.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $823.00 $1,337.00 $1,534.00 $742.00 $1,026.00 $515.00 $1,403.00 $1,437.00 $1,415.00 $1,170.00 $1,167.00 $1,718.00 $1,583.00 $1,164.00 $1,369.00 $787.00 $541.00 $828.00 $939.00 $889.00 $1,005.00 $424.00 $684.00 $742.00 $1,174.00 $1,336.00 $407.00 $613.00 $811.00 $322.00 $512.00 $889.00 $361.00 $527.00 $877.00 $386.00 $536.00 $897.00 $403.00 $601.00 $1,033.00 $383.00 $621.00 $1,141.00 $1,299.00 $379.00 $700.00 $1,055.00 $1,451.00 $1,716.00 $876.00 $1,431.00 $1,642.00 $794.00 $1,099.00 $551.00 $1,480.00 $1,536.00 $1,514.00 $1,253.00 $1,249.00 $1,839.00 $1,692.00 $1,228.00 $1,465.00 $852.00 $576.00 $884.00 $1,006.00 $953.00 $1,077.00 $454.00 $732.00 $794.00 $1,257.00 $1,431.00 $435.00 $656.00 $872.00 $343.00 $548.00 $947.00 $386.00 $564.00 $932.00 $413.00 $574.00 $956.00 $431.00 $642.00 $1,109.00 $409.00 $663.00 $1,224.00 $1,393.00 $404.00 $748.00 $1,123.00 $1,554.00 $1,833.00 $943.00 $1,553.00 $1,781.00 $861.00 $1,193.00 $595.00 $1,575.00 $1,664.00 $1,641.00 $1,359.00 $1,355.00 $1,997.00 $1,832.00 $1,306.00 $1,590.00 $937.00 $620.00 $956.00 $1,091.00 $1,039.00 $1,169.00 $489.00 $790.00 $858.00 $1,362.00 $1,553.00 $467.00 $706.00 $948.00 $365.00 $591.00 $1,022.00 $414.00 $608.00 $1,000.00 $443.00 $619.00 $1,028.00 $463.00 $692.00 $1,205.00 $438.00 $712.00 $1,327.00 $1,512.00 $433.00 $806.00 $1,206.00 $1,684.00 $1,982.00 $823.00 $1,337.00 $1,534.00 $742.00 $1,026.00 $515.00 $1,403.00 $1,437.00 $1,415.00 $1,170.00 $1,167.00 $1,718.00 $1,583.00 $1,164.00 $1,369.00 $787.00 $541.00 $828.00 $939.00 $889.00 $1,005.00 $386.00 $638.00 $742.00 $1,174.00 $1,336.00 $365.00 $566.00 $811.00 $323.00 $512.00 $889.00 $323.00 $490.00 $877.00 $342.00 $493.00 $897.00 $358.00 $552.00 $1,033.00 $342.00 $567.00 $1,141.00 $1,299.00 $362.00 $644.00 $1,055.00 $1,451.00 $1,716.00 $876.00 $1,431.00 $1,642.00 $794.00 $1,099.00 $551.00 $1,480.00 $1,536.00 $1,514.00 $1,253.00 $1,249.00 $1,839.00 $1,692.00 $1,228.00 $1,465.00 $852.00 $576.00 $884.00 $1,006.00 $953.00 $1,077.00 $414.00 $683.00 $794.00 $1,257.00 $1,431.00 $390.00 $605.00 $872.00 $344.00 $548.00 $947.00 $345.00 $525.00 $932.00 $366.00 $527.00 $956.00 $383.00 $590.00 $1,109.00 $365.00 $605.00 $1,224.00 $1,393.00 $386.00 $688.00 $1,123.00 $1,554.00 $1,833.00 $943.00 $1,553.00 $1,781.00 $861.00 $1,193.00 $595.00 $1,575.00 $1,664.00 $1,641.00 $1,359.00 $1,355.00 $1,997.00 $1,832.00 $1,306.00 $1,590.00 $937.00 $620.00 $956.00 $1,091.00 $1,039.00 $1,169.00 $446.00 $739.00 $858.00 $1,362.00 $1,553.00 $419.00 $653.00 $948.00 $367.00 $591.00 $1,022.00 $371.00 $567.00 $1,000.00 $394.00 $570.00 $1,028.00 $412.00 $636.00 $1,205.00 $391.00 $651.00 $1,327.00 $1,512.00 $414.00 $743.00 $1,206.00 $1,684.00 $1,982.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 168 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 27829 27830 27831 27832 27840 27842 27846 27848 27860 27870 27871 27880 27881 27882 27884 27886 27888 27889 27892 27893 27894 27899 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28035 28043 28045 28046 28050 28052 28054 28055 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $742.00 $412.00 $415.00 $617.00 $334.00 $373.00 $877.00 $1,224.00 $211.00 $1,269.00 $843.00 $1,015.00 $1,120.00 $854.00 $579.00 $835.00 $911.00 $879.00 $575.00 $574.00 $712.00 BR $185.00 $362.00 $520.00 $520.00 $296.00 $235.00 $340.00 $509.00 $422.00 $371.00 $532.00 $305.00 $456.00 $814.00 $414.00 $402.00 $236.00 ------$495.00 $657.00 $476.00 $445.00 $392.00 $462.00 $414.00 $414.00 $330.00 $571.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $825.00 $435.00 $488.00 $876.00 $440.00 $626.00 $980.00 $1,123.00 $234.00 $1,392.00 $922.00 $1,200.00 $1,189.00 $842.00 $774.00 $879.00 $938.00 $917.00 $722.00 $717.00 $1,092.00 ------$330.00 $611.00 $859.00 $818.00 $524.00 $295.00 $421.00 $629.00 $574.00 $548.00 $625.00 $419.00 $584.00 $1,081.00 $546.00 $509.00 $475.00 $527.00 $618.00 $733.00 $614.00 $599.00 $575.00 $683.00 $550.00 $554.00 $504.00 $735.00 $874.00 $464.00 $522.00 $926.00 $465.00 $669.00 $1,050.00 $1,203.00 $250.00 $1,487.00 $987.00 $1,269.00 $1,269.00 $895.00 $824.00 $936.00 $1,001.00 $975.00 $769.00 $764.00 $1,161.00 ------$350.00 $647.00 $913.00 $868.00 $558.00 $313.00 $449.00 $671.00 $611.00 $584.00 $667.00 $446.00 $622.00 $1,150.00 $582.00 $542.00 $506.00 $559.00 $658.00 $780.00 $655.00 $639.00 $609.00 $731.00 $588.00 $590.00 $537.00 $785.00 $931.00 $498.00 $563.00 $985.00 $494.00 $723.00 $1,139.00 $1,305.00 $271.00 $1,610.00 $1,070.00 $1,358.00 $1,371.00 $962.00 $888.00 $1,009.00 $1,080.00 $1,050.00 $828.00 $823.00 $1,248.00 ------$374.00 $689.00 $977.00 $931.00 $596.00 $335.00 $482.00 $719.00 $653.00 $624.00 $713.00 $477.00 $665.00 $1,232.00 $623.00 $580.00 $540.00 $598.00 $704.00 $833.00 $702.00 $685.00 $647.00 $784.00 $631.00 $631.00 $574.00 $840.00 $825.00 $409.00 $488.00 $876.00 $440.00 $626.00 $980.00 $1,123.00 $234.00 $1,392.00 $922.00 $1,200.00 $1,189.00 $842.00 $774.00 $879.00 $938.00 $917.00 $722.00 $717.00 $1,092.00 ------$244.00 $503.00 $753.00 $818.00 $411.00 $282.00 $402.00 $488.00 $450.00 $430.00 $488.00 $352.00 $445.00 $909.00 $422.00 $386.00 $351.00 $527.00 $489.00 $570.00 $484.00 $469.00 $452.00 $499.00 $408.00 $422.00 $375.00 $551.00 $874.00 $436.00 $522.00 $926.00 $465.00 $669.00 $1,050.00 $1,203.00 $250.00 $1,487.00 $987.00 $1,269.00 $1,269.00 $895.00 $824.00 $936.00 $1,001.00 $975.00 $769.00 $764.00 $1,161.00 ------$259.00 $532.00 $799.00 $868.00 $437.00 $300.00 $428.00 $520.00 $479.00 $457.00 $519.00 $374.00 $473.00 $965.00 $449.00 $411.00 $373.00 $559.00 $520.00 $606.00 $516.00 $500.00 $478.00 $534.00 $436.00 $449.00 $399.00 $587.00 $931.00 $468.00 $563.00 $985.00 $494.00 $723.00 $1,139.00 $1,305.00 $271.00 $1,610.00 $1,070.00 $1,358.00 $1,371.00 $962.00 $888.00 $1,009.00 $1,080.00 $1,050.00 $828.00 $823.00 $1,248.00 ------$277.00 $567.00 $858.00 $931.00 $468.00 $321.00 $461.00 $560.00 $514.00 $490.00 $558.00 $401.00 $508.00 $1,037.00 $483.00 $441.00 $400.00 $598.00 $559.00 $650.00 $555.00 $539.00 $508.00 $576.00 $471.00 $482.00 $428.00 $632.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 169 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175 28190 28192 28193 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234 28238 28240 28250 28260 28261 28262 28264 28270 28272 28280 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $700.00 $709.00 $491.00 $632.00 $517.00 $418.00 $421.00 $537.00 $457.00 $481.00 $890.00 $648.00 $568.00 $524.00 $601.00 $622.00 $480.00 $393.00 $727.00 $533.00 $416.00 $400.00 $412.00 $789.00 $747.00 $571.00 $75.00 $326.00 $341.00 $478.00 $613.00 $406.00 $609.00 $435.00 $555.00 $345.00 $334.00 $380.00 $286.00 $178.00 $695.00 $370.00 $535.00 $641.00 $881.00 $1,363.00 $912.00 $266.00 $336.00 $426.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $727.00 $596.00 $616.00 $633.00 $678.00 $513.00 $540.00 $625.00 $586.00 $686.00 $1,283.00 $907.00 $704.00 $627.00 $710.00 $815.00 $571.00 $457.00 $859.00 $779.00 $516.00 $474.00 $489.00 $835.00 $922.00 $669.00 $295.00 $573.00 $653.00 $566.00 $773.00 $541.00 $711.00 $537.00 $625.00 $468.00 $553.00 $518.00 $457.00 $470.00 $843.00 $527.00 $675.00 $839.00 $1,213.00 $1,732.00 $1,068.00 $570.00 $467.00 $642.00 $775.00 $635.00 $656.00 $673.00 $722.00 $546.00 $576.00 $666.00 $625.00 $728.00 $1,363.00 $962.00 $750.00 $668.00 $757.00 $867.00 $607.00 $487.00 $913.00 $829.00 $550.00 $505.00 $521.00 $888.00 $979.00 $710.00 $314.00 $611.00 $695.00 $603.00 $823.00 $576.00 $756.00 $571.00 $664.00 $498.00 $588.00 $551.00 $487.00 $501.00 $898.00 $561.00 $719.00 $895.00 $1,287.00 $1,850.00 $1,139.00 $607.00 $497.00 $685.00 $836.00 $683.00 $703.00 $724.00 $772.00 $583.00 $615.00 $712.00 $668.00 $774.00 $1,456.00 $1,027.00 $804.00 $714.00 $810.00 $928.00 $648.00 $519.00 $982.00 $887.00 $587.00 $539.00 $556.00 $956.00 $1,047.00 $758.00 $333.00 $653.00 $743.00 $644.00 $881.00 $616.00 $808.00 $610.00 $709.00 $531.00 $628.00 $589.00 $520.00 $534.00 $963.00 $600.00 $771.00 $961.00 $1,377.00 $1,995.00 $1,226.00 $649.00 $529.00 $733.00 $727.00 $596.00 $483.00 $633.00 $519.00 $396.00 $394.00 $462.00 $432.00 $549.00 $1,074.00 $764.00 $558.00 $494.00 $535.00 $684.00 $455.00 $344.00 $859.00 $625.00 $393.00 $351.00 $373.00 $835.00 $759.00 $531.00 $181.00 $440.00 $519.00 $436.00 $609.00 $415.00 $564.00 $423.00 $507.00 $351.00 $436.00 $408.00 $345.00 $356.00 $685.00 $413.00 $544.00 $710.00 $1,072.00 $1,521.00 $947.00 $455.00 $354.00 $504.00 $775.00 $635.00 $514.00 $673.00 $552.00 $420.00 $419.00 $492.00 $460.00 $581.00 $1,140.00 $809.00 $594.00 $525.00 $570.00 $727.00 $483.00 $366.00 $913.00 $664.00 $418.00 $373.00 $397.00 $888.00 $805.00 $562.00 $191.00 $467.00 $551.00 $463.00 $648.00 $442.00 $599.00 $449.00 $538.00 $372.00 $463.00 $434.00 $367.00 $379.00 $728.00 $440.00 $579.00 $756.00 $1,136.00 $1,624.00 $1,010.00 $483.00 $376.00 $537.00 $836.00 $683.00 $552.00 $724.00 $593.00 $450.00 $449.00 $528.00 $494.00 $619.00 $1,221.00 $865.00 $640.00 $563.00 $613.00 $780.00 $517.00 $392.00 $982.00 $713.00 $448.00 $400.00 $425.00 $956.00 $864.00 $602.00 $204.00 $501.00 $591.00 $497.00 $696.00 $474.00 $642.00 $481.00 $576.00 $399.00 $496.00 $465.00 $393.00 $406.00 $784.00 $472.00 $623.00 $815.00 $1,218.00 $1,757.00 $1,090.00 $518.00 $402.00 $577.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 170 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28400 28405 28406 28415 28420 28430 28435 28436 28445 28446 28450 28455 28456 28465 28470 28475 28476 28485 28490 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $463.00 $441.00 $452.00 $458.00 $557.00 $666.00 $845.00 $797.00 $832.00 $838.00 $755.00 $829.00 $845.00 $930.00 $776.00 $1,030.00 $530.00 $614.00 $516.00 $955.00 $505.00 $469.00 $436.00 $462.00 $833.00 $667.00 $649.00 $753.00 $414.00 $557.00 $1,197.00 $266.00 $473.00 $616.00 $1,354.00 $1,619.00 $110.00 $371.00 $463.00 $874.00 ------$148.00 $321.00 $288.00 $533.00 $178.00 $296.00 $364.00 $521.00 $80.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $554.00 $545.00 $688.00 $897.00 $695.00 $927.00 $1,241.00 $914.00 $975.00 $1,027.00 $872.00 $1,126.00 $900.00 $892.00 $974.00 $913.00 $725.00 $879.00 $648.00 $1,209.00 $645.00 $586.00 $610.00 $570.00 $858.00 $969.00 $761.00 $872.00 $547.00 $690.00 $1,291.00 $307.00 $507.00 $699.00 $1,549.00 $1,615.00 $288.00 $402.00 $555.00 $1,448.00 $1,534.00 $265.00 $362.00 $361.00 $802.00 $265.00 $336.00 $438.00 $683.00 $166.00 $590.00 $579.00 $730.00 $954.00 $741.00 $982.00 $1,314.00 $972.00 $1,037.00 $1,095.00 $928.00 $1,196.00 $963.00 $951.00 $1,038.00 $967.00 $774.00 $938.00 $691.00 $1,289.00 $687.00 $625.00 $651.00 $606.00 $916.00 $1,035.00 $808.00 $925.00 $582.00 $735.00 $1,380.00 $328.00 $542.00 $749.00 $1,659.00 $1,728.00 $307.00 $430.00 $595.00 $1,550.00 $1,633.00 $283.00 $385.00 $386.00 $852.00 $283.00 $359.00 $468.00 $724.00 $177.00 $630.00 $618.00 $777.00 $1,020.00 $795.00 $1,044.00 $1,396.00 $1,040.00 $1,110.00 $1,176.00 $994.00 $1,278.00 $1,042.00 $1,026.00 $1,113.00 $1,036.00 $829.00 $1,003.00 $738.00 $1,392.00 $734.00 $669.00 $698.00 $648.00 $991.00 $1,112.00 $862.00 $988.00 $619.00 $787.00 $1,494.00 $352.00 $584.00 $811.00 $1,799.00 $1,872.00 $329.00 $463.00 $642.00 $1,682.00 $1,760.00 $303.00 $413.00 $415.00 $914.00 $304.00 $386.00 $503.00 $773.00 $189.00 $434.00 $420.00 $564.00 $739.00 $551.00 $774.00 $936.00 $729.00 $787.00 $832.00 $699.00 $938.00 $900.00 $892.00 $807.00 $913.00 $545.00 $612.00 $495.00 $1,209.00 $487.00 $437.00 $507.00 $444.00 $858.00 $787.00 $605.00 $715.00 $407.00 $556.00 $1,291.00 $281.00 $483.00 $699.00 $1,549.00 $1,615.00 $253.00 $381.00 $555.00 $1,448.00 $1,534.00 $236.00 $346.00 $361.00 $802.00 $237.00 $318.00 $438.00 $683.00 $146.00 $461.00 $445.00 $598.00 $785.00 $587.00 $818.00 $988.00 $773.00 $835.00 $886.00 $742.00 $994.00 $963.00 $951.00 $859.00 $967.00 $581.00 $652.00 $526.00 $1,289.00 $518.00 $466.00 $540.00 $472.00 $916.00 $840.00 $641.00 $757.00 $432.00 $591.00 $1,380.00 $301.00 $516.00 $749.00 $1,659.00 $1,728.00 $270.00 $407.00 $595.00 $1,550.00 $1,633.00 $252.00 $368.00 $386.00 $852.00 $253.00 $339.00 $468.00 $724.00 $156.00 $495.00 $477.00 $637.00 $841.00 $632.00 $871.00 $1,051.00 $830.00 $897.00 $955.00 $798.00 $1,065.00 $1,042.00 $1,026.00 $925.00 $1,036.00 $626.00 $702.00 $564.00 $1,392.00 $556.00 $500.00 $581.00 $506.00 $991.00 $907.00 $687.00 $810.00 $461.00 $635.00 $1,494.00 $323.00 $557.00 $811.00 $1,799.00 $1,872.00 $290.00 $439.00 $642.00 $1,682.00 $1,760.00 $270.00 $395.00 $415.00 $914.00 $272.00 $365.00 $503.00 $773.00 $166.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 171 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 28495 28496 28505 28510 28515 28525 28530 28531 28540 28545 28546 28555 28570 28575 28576 28585 28600 28605 28606 28615 28630 28635 28636 28645 28660 28665 28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800 28805 28810 28820 28825 28890 28899 29000 29010 29015 29020 29025 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 $133.00 $261.00 $399.00 $75.00 $115.00 $345.00 $120.00 $243.00 $145.00 $208.00 $325.00 $592.00 $189.00 $308.00 $382.00 $742.00 $144.00 $287.00 $487.00 $621.00 $145.00 $189.00 $318.00 $434.00 $106.00 $172.00 $309.00 $348.00 $1,353.00 $1,179.00 $1,015.00 $945.00 $961.00 $873.00 $690.00 $690.00 $466.00 $654.00 $731.00 $731.00 $543.00 $377.00 $339.00 ------BR $247.00 $271.00 $289.00 $237.00 $188.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $208.00 $532.00 $800.00 $144.00 $188.00 $686.00 $138.00 $490.00 $248.00 $292.00 $570.00 $1,046.00 $221.00 $407.00 $471.00 $1,084.00 $259.00 $338.00 $518.00 $999.00 $182.00 $219.00 $371.00 $719.00 $133.00 $193.00 $269.00 $676.00 $1,767.00 $1,304.00 $1,087.00 $1,115.00 $1,069.00 $947.00 $1,067.00 $1,049.00 $610.00 $949.00 $767.00 $971.00 $588.00 $658.00 $567.00 $447.00 ------$312.00 $324.00 $300.00 $296.00 $327.00 $221.00 $569.00 $844.00 $154.00 $200.00 $726.00 $147.00 $523.00 $264.00 $311.00 $610.00 $1,109.00 $236.00 $435.00 $503.00 $1,150.00 $276.00 $360.00 $555.00 $1,060.00 $193.00 $233.00 $396.00 $758.00 $141.00 $206.00 $288.00 $715.00 $1,887.00 $1,392.00 $1,161.00 $1,187.00 $1,138.00 $1,007.00 $1,136.00 $1,118.00 $651.00 $1,007.00 $816.00 $1,022.00 $625.00 $701.00 $605.00 $476.00 ------$335.00 $349.00 $319.00 $316.00 $351.00 $236.00 $606.00 $890.00 $164.00 $213.00 $769.00 $157.00 $557.00 $282.00 $334.00 $652.00 $1,181.00 $252.00 $469.00 $543.00 $1,227.00 $295.00 $386.00 $600.00 $1,135.00 $206.00 $250.00 $425.00 $799.00 $150.00 $221.00 $312.00 $756.00 $2,042.00 $1,504.00 $1,257.00 $1,278.00 $1,226.00 $1,084.00 $1,216.00 $1,196.00 $696.00 $1,075.00 $877.00 $1,085.00 $671.00 $747.00 $645.00 $507.00 ------$362.00 $378.00 $339.00 $337.00 $379.00 $191.00 $295.00 $604.00 $142.00 $178.00 $489.00 $131.00 $257.00 $237.00 $276.00 $396.00 $828.00 $204.00 $389.00 $471.00 $932.00 $239.00 $322.00 $518.00 $999.00 $144.00 $183.00 $281.00 $584.00 $108.00 $181.00 $269.00 $487.00 $1,767.00 $1,304.00 $1,087.00 $1,115.00 $1,069.00 $947.00 $835.00 $796.00 $454.00 $772.00 $767.00 $971.00 $588.00 $462.00 $379.00 $297.00 ------$223.00 $217.00 $214.00 $192.00 $238.00 $203.00 $315.00 $634.00 $152.00 $189.00 $516.00 $140.00 $274.00 $252.00 $295.00 $423.00 $875.00 $218.00 $417.00 $503.00 $987.00 $255.00 $344.00 $555.00 $1,060.00 $152.00 $194.00 $300.00 $613.00 $115.00 $192.00 $288.00 $512.00 $1,887.00 $1,392.00 $1,161.00 $1,187.00 $1,138.00 $1,007.00 $888.00 $847.00 $483.00 $818.00 $816.00 $1,022.00 $625.00 $490.00 $403.00 $315.00 ------$239.00 $235.00 $227.00 $204.00 $256.00 $216.00 $338.00 $669.00 $162.00 $201.00 $546.00 $149.00 $294.00 $269.00 $317.00 $455.00 $934.00 $233.00 $450.00 $543.00 $1,055.00 $273.00 $369.00 $600.00 $1,135.00 $163.00 $209.00 $324.00 $647.00 $122.00 $207.00 $312.00 $542.00 $2,042.00 $1,504.00 $1,257.00 $1,278.00 $1,226.00 $1,084.00 $954.00 $910.00 $519.00 $875.00 $877.00 $1,085.00 $671.00 $525.00 $433.00 $338.00 ------$260.00 $257.00 $243.00 $219.00 $278.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 172 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 29035 29040 29044 29046 29049 29055 29058 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29220 29240 29260 29280 29305 29325 29345 29355 29358 29365 29405 29425 29435 29440 29445 29450 29505 29515 29520 29530 29540 29550 29580 29590 29700 29705 29710 29715 29720 29730 29740 29750 29799 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 YYY $213.00 $260.00 $260.00 $286.00 $45.00 $180.00 $110.00 $88.00 $72.00 $59.00 $54.00 $59.00 $45.00 $53.00 $26.00 $53.00 $29.00 $37.00 $45.00 $26.00 $29.00 $223.00 $260.00 $126.00 $133.00 $241.00 $101.00 $96.00 $101.00 $133.00 $22.00 $214.00 $84.00 $75.00 $59.00 $22.00 $55.00 $41.00 $37.00 $39.00 $32.00 $29.00 $26.00 $29.00 $109.00 $29.00 $29.00 $37.00 $105.00 BR Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $288.00 $276.00 $316.00 $339.00 $112.00 $252.00 $145.00 $118.00 $109.00 $116.00 $86.00 $109.00 $83.00 $97.00 $51.00 $61.00 $67.00 $68.00 $76.00 $65.00 $63.00 $289.00 $312.00 $171.00 $176.00 $189.00 $152.00 $112.00 $121.00 $148.00 $66.00 $189.00 $195.00 $95.00 $87.00 $65.00 $67.00 $53.00 $51.00 $65.00 $70.00 $79.00 $86.00 $150.00 $111.00 $99.00 $83.00 $122.00 $129.00 ------- $308.00 $295.00 $338.00 $364.00 $120.00 $270.00 $155.00 $126.00 $117.00 $124.00 $91.00 $116.00 $88.00 $103.00 $54.00 $64.00 $70.00 $71.00 $81.00 $69.00 $66.00 $309.00 $334.00 $183.00 $188.00 $203.00 $163.00 $120.00 $129.00 $159.00 $71.00 $202.00 $208.00 $101.00 $92.00 $69.00 $70.00 $56.00 $54.00 $69.00 $75.00 $84.00 $92.00 $160.00 $117.00 $107.00 $89.00 $130.00 $138.00 ------- $330.00 $318.00 $363.00 $392.00 $129.00 $291.00 $165.00 $136.00 $126.00 $133.00 $97.00 $124.00 $94.00 $109.00 $58.00 $67.00 $73.00 $75.00 $85.00 $73.00 $70.00 $333.00 $360.00 $197.00 $203.00 $218.00 $176.00 $129.00 $139.00 $171.00 $76.00 $217.00 $223.00 $108.00 $98.00 $72.00 $75.00 $60.00 $58.00 $74.00 $80.00 $90.00 $99.00 $172.00 $124.00 $115.00 $96.00 $140.00 $149.00 ------- $182.00 $204.00 $212.00 $246.00 $80.00 $175.00 $110.00 $89.00 $80.00 $85.00 $61.00 $77.00 $54.00 $65.00 $37.00 $40.00 $51.00 $52.00 $57.00 $47.00 $44.00 $206.00 $229.00 $135.00 $144.00 $137.00 $116.00 $86.00 $94.00 $115.00 $46.00 $151.00 $168.00 $61.00 $64.00 $49.00 $48.00 $44.00 $41.00 $48.00 $56.00 $46.00 $65.00 $110.00 $72.00 $60.00 $62.00 $91.00 $103.00 ------- $194.00 $218.00 $227.00 $264.00 $85.00 $187.00 $117.00 $96.00 $86.00 $91.00 $64.00 $81.00 $57.00 $69.00 $39.00 $42.00 $53.00 $54.00 $60.00 $50.00 $46.00 $221.00 $245.00 $144.00 $154.00 $147.00 $125.00 $92.00 $101.00 $123.00 $49.00 $161.00 $179.00 $65.00 $68.00 $51.00 $51.00 $47.00 $44.00 $51.00 $60.00 $49.00 $69.00 $118.00 $76.00 $64.00 $66.00 $97.00 $111.00 ------- $210.00 $236.00 $246.00 $287.00 $92.00 $203.00 $125.00 $104.00 $93.00 $99.00 $69.00 $88.00 $61.00 $73.00 $42.00 $43.00 $55.00 $57.00 $64.00 $53.00 $48.00 $240.00 $266.00 $157.00 $168.00 $160.00 $135.00 $99.00 $109.00 $133.00 $53.00 $175.00 $192.00 $69.00 $73.00 $54.00 $54.00 $50.00 $47.00 $55.00 $64.00 $53.00 $75.00 $127.00 $81.00 $70.00 $72.00 $106.00 $121.00 ------- CPT only © 2008 American Medical Association. All rights reserved. Part B, 173 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 29800 29804 29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827 29828 29830 29834 29835 29836 29837 29838 29840 29843 29844 29845 29846 29847 29848 29850 29851 29855 29856 29860 29861 29862 29863 29866 29867 29868 29870 29871 29873 29874 29875 29876 29877 29879 29880 29881 29882 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $557.00 $902.00 $360.00 $1,003.00 $976.00 $756.00 $718.00 $863.00 $749.00 $1,330.00 $611.00 $941.00 $980.00 $1,058.00 ------$524.00 $635.00 $612.00 $680.00 $830.00 $931.00 $501.00 $580.00 $612.00 $931.00 $976.00 $1,277.00 $608.00 $752.00 $1,137.00 $1,007.00 $1,231.00 $658.00 $845.00 $907.00 $880.00 ------------------$460.00 $631.00 $489.00 $676.00 $639.00 $809.00 $852.00 $1,064.00 $1,169.00 $745.00 $819.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $685.00 $851.00 $619.00 $1,413.00 $1,377.00 $776.00 $716.00 $782.00 $760.00 $831.00 $878.00 $775.00 $891.00 $1,458.00 $1,192.00 $597.00 $650.00 $668.00 $762.00 $699.00 $782.00 $578.00 $619.00 $651.00 $736.00 $684.00 $707.00 $633.00 $727.00 $1,251.00 $1,046.00 $1,337.00 $853.00 $937.00 $1,047.00 $1,028.00 $1,391.00 $1,681.00 $2,279.00 $534.00 $674.00 $673.00 $700.00 $653.00 $849.00 $802.00 $859.00 $898.00 $836.00 $905.00 $730.00 $910.00 $664.00 $1,513.00 $1,474.00 $831.00 $767.00 $838.00 $815.00 $890.00 $939.00 $831.00 $955.00 $1,563.00 $1,276.00 $640.00 $697.00 $716.00 $815.00 $749.00 $837.00 $617.00 $661.00 $697.00 $783.00 $731.00 $755.00 $674.00 $776.00 $1,343.00 $1,121.00 $1,433.00 $911.00 $1,001.00 $1,117.00 $1,092.00 $1,489.00 $1,795.00 $2,445.00 $572.00 $722.00 $721.00 $748.00 $700.00 $907.00 $857.00 $918.00 $960.00 $893.00 $968.00 $786.00 $984.00 $719.00 $1,641.00 $1,599.00 $901.00 $832.00 $909.00 $883.00 $965.00 $1,016.00 $901.00 $1,036.00 $1,699.00 $1,385.00 $693.00 $755.00 $776.00 $881.00 $812.00 $907.00 $665.00 $712.00 $753.00 $839.00 $789.00 $815.00 $724.00 $840.00 $1,462.00 $1,218.00 $1,556.00 $984.00 $1,084.00 $1,204.00 $1,171.00 $1,614.00 $1,941.00 $2,661.00 $618.00 $783.00 $780.00 $808.00 $759.00 $980.00 $926.00 $992.00 $1,038.00 $965.00 $1,047.00 $685.00 $851.00 $619.00 $1,413.00 $1,377.00 $776.00 $716.00 $782.00 $760.00 $831.00 $878.00 $775.00 $891.00 $1,458.00 $1,192.00 $597.00 $650.00 $668.00 $762.00 $699.00 $782.00 $578.00 $619.00 $651.00 $736.00 $684.00 $707.00 $633.00 $727.00 $1,251.00 $1,046.00 $1,337.00 $853.00 $937.00 $1,047.00 $1,028.00 $1,391.00 $1,681.00 $2,279.00 $534.00 $674.00 $673.00 $700.00 $653.00 $849.00 $802.00 $859.00 $898.00 $836.00 $905.00 $730.00 $910.00 $664.00 $1,513.00 $1,474.00 $831.00 $767.00 $838.00 $815.00 $890.00 $939.00 $831.00 $955.00 $1,563.00 $1,276.00 $640.00 $697.00 $716.00 $815.00 $749.00 $837.00 $617.00 $661.00 $697.00 $783.00 $731.00 $755.00 $674.00 $776.00 $1,343.00 $1,121.00 $1,433.00 $911.00 $1,001.00 $1,117.00 $1,092.00 $1,489.00 $1,795.00 $2,445.00 $572.00 $722.00 $721.00 $748.00 $700.00 $907.00 $857.00 $918.00 $960.00 $893.00 $968.00 $786.00 $984.00 $719.00 $1,641.00 $1,599.00 $901.00 $832.00 $909.00 $883.00 $965.00 $1,016.00 $901.00 $1,036.00 $1,699.00 $1,385.00 $693.00 $755.00 $776.00 $881.00 $812.00 $907.00 $665.00 $712.00 $753.00 $839.00 $789.00 $815.00 $724.00 $840.00 $1,462.00 $1,218.00 $1,556.00 $984.00 $1,084.00 $1,204.00 $1,171.00 $1,614.00 $1,941.00 $2,661.00 $618.00 $783.00 $780.00 $808.00 $759.00 $980.00 $926.00 $992.00 $1,038.00 $965.00 $1,047.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 174 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 29883 29884 29885 29886 29887 29888 29889 29891 29892 29893 29894 29895 29897 29898 29899 29900 29901 29902 29904 29905 29906 29907 29999 30000 30020 30100 30110 30115 30117 30118 30120 30124 30125 30130 30140 30150 30160 30200 30210 30220 30300 30310 30320 30400 30410 30420 30430 30435 30450 30460 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 0 10 90 90 90 90 90 90 90 90 90 90 0 10 10 10 10 90 90 90 90 90 90 90 90 $1,235.00 $721.00 $832.00 $697.00 $949.00 $1,296.00 $1,255.00 $796.00 $835.00 $472.00 $690.00 $679.00 $704.00 $863.00 $973.00 $434.00 $479.00 $514.00 ------------------------BR $96.00 $117.00 $86.00 $157.00 $360.00 $301.00 $819.00 $500.00 $243.00 $599.00 $275.00 $320.00 $790.00 $875.00 $68.00 $75.00 $154.00 $45.00 $170.00 $419.00 $741.00 $1,173.00 $1,424.00 $626.00 $1,005.00 $1,445.00 $857.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,114.00 $799.00 $971.00 $817.00 $966.00 $1,318.00 $1,603.00 $909.00 $938.00 $713.00 $687.00 $669.00 $700.00 $781.00 $1,399.00 $607.00 $671.00 $700.00 $793.00 $853.00 $899.00 $1,108.00 ------$280.00 $264.00 $164.00 $267.00 $532.00 $953.00 $966.00 $630.00 $350.00 $782.00 $465.00 $523.00 $1,018.00 $1,011.00 $132.00 $174.00 $334.00 $279.00 $256.00 $580.00 $1,314.00 $1,599.00 $1,740.00 $1,166.00 $1,551.00 $2,036.00 $998.00 $1,193.00 $854.00 $1,038.00 $873.00 $1,032.00 $1,412.00 $1,715.00 $969.00 $999.00 $756.00 $734.00 $715.00 $749.00 $834.00 $1,495.00 $650.00 $718.00 $748.00 $846.00 $910.00 $959.00 $1,184.00 ------$297.00 $280.00 $174.00 $283.00 $564.00 $1,016.00 $1,018.00 $668.00 $369.00 $826.00 $493.00 $556.00 $1,078.00 $1,067.00 $141.00 $185.00 $355.00 $297.00 $271.00 $614.00 $1,393.00 $1,696.00 $1,837.00 $1,238.00 $1,644.00 $2,155.00 $1,056.00 $1,293.00 $922.00 $1,122.00 $943.00 $1,116.00 $1,534.00 $1,858.00 $1,045.00 $1,075.00 $803.00 $794.00 $773.00 $810.00 $901.00 $1,619.00 $702.00 $776.00 $809.00 $912.00 $981.00 $1,034.00 $1,282.00 ------$314.00 $296.00 $183.00 $299.00 $597.00 $1,072.00 $1,075.00 $708.00 $390.00 $874.00 $522.00 $589.00 $1,144.00 $1,130.00 $148.00 $195.00 $374.00 $313.00 $286.00 $649.00 $1,477.00 $1,801.00 $1,944.00 $1,311.00 $1,743.00 $2,290.00 $1,122.00 $1,114.00 $799.00 $971.00 $817.00 $966.00 $1,318.00 $1,603.00 $909.00 $938.00 $552.00 $687.00 $669.00 $700.00 $781.00 $1,399.00 $607.00 $671.00 $700.00 $793.00 $853.00 $899.00 $1,108.00 ------$146.00 $149.00 $89.00 $164.00 $532.00 $409.00 $966.00 $568.00 $350.00 $782.00 $465.00 $523.00 $1,018.00 $1,011.00 $77.00 $123.00 $157.00 $150.00 $256.00 $580.00 $1,314.00 $1,599.00 $1,740.00 $1,166.00 $1,551.00 $2,036.00 $998.00 $1,193.00 $854.00 $1,038.00 $873.00 $1,032.00 $1,412.00 $1,715.00 $969.00 $999.00 $583.00 $734.00 $715.00 $749.00 $834.00 $1,495.00 $650.00 $718.00 $748.00 $846.00 $910.00 $959.00 $1,184.00 ------$154.00 $157.00 $93.00 $173.00 $564.00 $433.00 $1,018.00 $601.00 $369.00 $826.00 $493.00 $556.00 $1,078.00 $1,067.00 $81.00 $130.00 $165.00 $159.00 $271.00 $614.00 $1,393.00 $1,696.00 $1,837.00 $1,238.00 $1,644.00 $2,155.00 $1,056.00 $1,293.00 $922.00 $1,122.00 $943.00 $1,116.00 $1,534.00 $1,858.00 $1,045.00 $1,075.00 $621.00 $794.00 $773.00 $810.00 $901.00 $1,619.00 $702.00 $776.00 $809.00 $912.00 $981.00 $1,034.00 $1,282.00 ------$163.00 $166.00 $98.00 $183.00 $597.00 $457.00 $1,075.00 $638.00 $390.00 $874.00 $522.00 $589.00 $1,144.00 $1,130.00 $86.00 $138.00 $174.00 $168.00 $286.00 $649.00 $1,477.00 $1,801.00 $1,944.00 $1,311.00 $1,743.00 $2,290.00 $1,122.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 175 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 30462 30465 30520 30540 30545 30560 30580 30600 30620 30630 30801 30802 30901 30903 30905 30906 30915 30920 30930 30999 31000 31002 31020 31030 31032 31040 31050 31051 31070 31075 31080 31081 31084 31085 31086 31087 31090 31200 31201 31205 31225 31230 31231 31233 31235 31237 31238 31239 31240 31254 90 90 90 90 90 10 90 90 90 90 10 10 0 0 0 0 90 90 10 YYY 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 10 0 0 $1,633.00 $803.00 $533.00 $643.00 $981.00 $104.00 $566.00 $466.00 $564.00 $624.00 $88.00 $172.00 $75.00 $110.00 $224.00 $208.00 $596.00 $862.00 $213.00 BR $81.00 $135.00 $281.00 $531.00 $604.00 $772.00 $489.00 $654.00 $410.00 $839.00 $942.00 $1,089.00 $1,210.00 $1,281.00 $1,081.00 $1,075.00 $877.00 $463.00 $716.00 $851.00 $1,683.00 $1,908.00 $122.00 $221.00 $217.00 $266.00 $311.00 $775.00 $224.00 $588.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,019.00 $1,233.00 $726.00 $866.00 $1,250.00 $320.00 $786.00 $721.00 $767.00 $777.00 $270.00 $349.00 $132.00 $233.00 $292.00 $335.00 $720.00 $1,029.00 $151.00 ------$213.00 $251.00 $591.00 $875.00 $713.00 $953.00 $610.00 $801.00 $536.00 $977.00 $1,290.00 $1,587.00 $1,447.00 $1,572.00 $1,401.00 $1,394.00 $1,234.00 $675.00 $918.00 $1,079.00 $2,260.00 $2,547.00 $233.00 $332.00 $383.00 $414.00 $426.00 $843.00 $217.00 $373.00 $2,146.00 $1,301.00 $764.00 $915.00 $1,335.00 $340.00 $837.00 $765.00 $812.00 $821.00 $288.00 $370.00 $139.00 $247.00 $310.00 $355.00 $759.00 $1,082.00 $160.00 ------$227.00 $265.00 $629.00 $929.00 $753.00 $1,005.00 $645.00 $846.00 $567.00 $1,030.00 $1,364.00 $1,702.00 $1,524.00 $1,667.00 $1,475.00 $1,474.00 $1,305.00 $713.00 $971.00 $1,135.00 $2,365.00 $2,662.00 $248.00 $352.00 $407.00 $439.00 $451.00 $884.00 $228.00 $393.00 $2,297.00 $1,377.00 $803.00 $967.00 $1,436.00 $359.00 $895.00 $815.00 $860.00 $868.00 $304.00 $390.00 $147.00 $261.00 $327.00 $375.00 $801.00 $1,140.00 $170.00 ------$239.00 $280.00 $666.00 $985.00 $797.00 $1,065.00 $683.00 $895.00 $600.00 $1,088.00 $1,448.00 $1,842.00 $1,610.00 $1,776.00 $1,555.00 $1,566.00 $1,380.00 $748.00 $1,030.00 $1,192.00 $2,480.00 $2,789.00 $262.00 $373.00 $431.00 $465.00 $476.00 $930.00 $242.00 $418.00 $2,019.00 $1,233.00 $726.00 $866.00 $1,250.00 $172.00 $650.00 $571.00 $767.00 $777.00 $160.00 $231.00 $81.00 $106.00 $137.00 $180.00 $720.00 $1,029.00 $151.00 ------$131.00 $251.00 $432.00 $655.00 $713.00 $953.00 $610.00 $801.00 $536.00 $977.00 $1,290.00 $1,587.00 $1,447.00 $1,572.00 $1,401.00 $1,394.00 $1,234.00 $675.00 $918.00 $1,079.00 $2,260.00 $2,547.00 $100.00 $183.00 $219.00 $244.00 $264.00 $843.00 $217.00 $373.00 $2,146.00 $1,301.00 $764.00 $915.00 $1,335.00 $182.00 $691.00 $605.00 $812.00 $821.00 $170.00 $244.00 $85.00 $111.00 $144.00 $189.00 $759.00 $1,082.00 $160.00 ------$138.00 $265.00 $458.00 $693.00 $753.00 $1,005.00 $645.00 $846.00 $567.00 $1,030.00 $1,364.00 $1,702.00 $1,524.00 $1,667.00 $1,475.00 $1,474.00 $1,305.00 $713.00 $971.00 $1,135.00 $2,365.00 $2,662.00 $105.00 $193.00 $231.00 $257.00 $277.00 $884.00 $228.00 $393.00 $2,297.00 $1,377.00 $803.00 $967.00 $1,436.00 $192.00 $741.00 $646.00 $860.00 $868.00 $179.00 $257.00 $90.00 $117.00 $152.00 $199.00 $801.00 $1,140.00 $170.00 ------$145.00 $280.00 $485.00 $736.00 $797.00 $1,065.00 $683.00 $895.00 $600.00 $1,088.00 $1,448.00 $1,842.00 $1,610.00 $1,776.00 $1,555.00 $1,566.00 $1,380.00 $748.00 $1,030.00 $1,192.00 $2,480.00 $2,789.00 $111.00 $205.00 $245.00 $273.00 $293.00 $930.00 $242.00 $418.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 176 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 31255 31256 31267 31276 31287 31288 31290 31291 31292 31293 31294 31299 31300 31320 31360 31365 31367 31368 31370 31375 31380 31382 31390 31395 31400 31420 31500 31502 31505 31510 31511 31512 31513 31515 31525 31526 31527 31528 31529 31530 31531 31535 31536 31540 31541 31545 31546 31560 31561 31570 0 0 0 0 0 0 10 10 10 10 10 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 $601.00 $292.00 $453.00 $690.00 $339.00 $396.00 $1,462.00 $1,551.00 $1,235.00 $1,346.00 $1,587.00 BR $1,295.00 $508.00 $1,630.00 $2,238.00 $1,913.00 $2,478.00 $1,891.00 $1,720.00 $1,782.00 $1,822.00 $2,513.00 $2,937.00 $969.00 $969.00 $116.00 $74.00 $62.00 $145.00 $88.00 $197.00 $182.00 $160.00 $234.00 $222.00 $262.00 $202.00 $217.00 $284.00 $311.00 $272.00 $308.00 $357.00 $453.00 ------------$446.00 $509.00 $369.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $554.00 $271.00 $437.00 $698.00 $318.00 $369.00 $1,507.00 $1,598.00 $1,304.00 $1,419.00 $1,634.00 ------$1,569.00 $812.00 $2,418.00 $3,047.00 $2,671.00 $3,017.00 $2,528.00 $2,376.00 $2,355.00 $2,567.00 $3,416.00 $3,658.00 $1,261.00 $1,051.00 $147.00 $47.00 $105.00 $266.00 $268.00 $266.00 $176.00 $264.00 $318.00 $211.00 $256.00 $190.00 $217.00 $267.00 $287.00 $255.00 $285.00 $327.00 $359.00 $475.00 $729.00 $422.00 $462.00 $454.00 $585.00 $286.00 $461.00 $737.00 $335.00 $389.00 $1,580.00 $1,680.00 $1,368.00 $1,487.00 $1,713.00 ------$1,652.00 $860.00 $2,519.00 $3,175.00 $2,796.00 $3,163.00 $2,652.00 $2,492.00 $2,473.00 $2,688.00 $3,563.00 $3,823.00 $1,329.00 $1,104.00 $153.00 $49.00 $111.00 $281.00 $283.00 $281.00 $184.00 $280.00 $336.00 $222.00 $269.00 $199.00 $228.00 $280.00 $302.00 $268.00 $300.00 $343.00 $376.00 $495.00 $764.00 $443.00 $485.00 $480.00 $624.00 $304.00 $491.00 $785.00 $357.00 $414.00 $1,666.00 $1,779.00 $1,443.00 $1,567.00 $1,806.00 ------$1,741.00 $908.00 $2,627.00 $3,317.00 $2,932.00 $3,323.00 $2,786.00 $2,617.00 $2,601.00 $2,820.00 $3,725.00 $4,004.00 $1,401.00 $1,163.00 $161.00 $52.00 $117.00 $297.00 $300.00 $297.00 $195.00 $295.00 $354.00 $234.00 $284.00 $211.00 $241.00 $297.00 $319.00 $283.00 $317.00 $363.00 $398.00 $518.00 $807.00 $468.00 $513.00 $507.00 $554.00 $271.00 $437.00 $698.00 $318.00 $369.00 $1,507.00 $1,598.00 $1,304.00 $1,419.00 $1,634.00 ------$1,569.00 $812.00 $2,418.00 $3,047.00 $2,671.00 $3,017.00 $2,528.00 $2,376.00 $2,355.00 $2,567.00 $3,416.00 $3,658.00 $1,261.00 $1,051.00 $147.00 $47.00 $63.00 $159.00 $168.00 $172.00 $176.00 $144.00 $212.00 $211.00 $256.00 $190.00 $217.00 $267.00 $287.00 $255.00 $285.00 $327.00 $359.00 $475.00 $729.00 $422.00 $462.00 $307.00 $585.00 $286.00 $461.00 $737.00 $335.00 $389.00 $1,580.00 $1,680.00 $1,368.00 $1,487.00 $1,713.00 ------$1,652.00 $860.00 $2,519.00 $3,175.00 $2,796.00 $3,163.00 $2,652.00 $2,492.00 $2,473.00 $2,688.00 $3,563.00 $3,823.00 $1,329.00 $1,104.00 $153.00 $49.00 $66.00 $167.00 $177.00 $181.00 $184.00 $151.00 $223.00 $222.00 $269.00 $199.00 $228.00 $280.00 $302.00 $268.00 $300.00 $343.00 $376.00 $495.00 $764.00 $443.00 $485.00 $322.00 $624.00 $304.00 $491.00 $785.00 $357.00 $414.00 $1,666.00 $1,779.00 $1,443.00 $1,567.00 $1,806.00 ------$1,741.00 $908.00 $2,627.00 $3,317.00 $2,932.00 $3,323.00 $2,786.00 $2,617.00 $2,601.00 $2,820.00 $3,725.00 $4,004.00 $1,401.00 $1,163.00 $161.00 $52.00 $70.00 $177.00 $187.00 $191.00 $195.00 $160.00 $235.00 $234.00 $284.00 $211.00 $241.00 $297.00 $319.00 $283.00 $317.00 $363.00 $398.00 $518.00 $807.00 $468.00 $513.00 $340.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 177 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 31571 31575 31576 31577 31578 31579 31580 31582 31584 31587 31588 31590 31595 31599 31600 31603 31605 31610 31611 31612 31613 31614 31615 31620 31622 31623 31624 31625 31628 31629 31630 31631 31632 31633 31635 31636 31637 31638 31640 31641 31643 31645 31646 31656 31715 31717 31720 31725 31730 31750 0 0 0 0 0 0 90 90 90 90 90 90 90 YYY 0 0 0 90 90 0 90 90 0 ZZZ 0 0 0 0 0 0 0 0 ZZZ ZZZ 0 0 ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 90 $363.00 $128.00 $186.00 $230.00 $264.00 $219.00 $1,213.00 $1,881.00 $1,616.00 $913.00 $1,206.00 $691.00 $773.00 BR $306.00 $343.00 $297.00 $794.00 $614.00 $99.00 $384.00 $736.00 $213.00 ------$230.00 $225.00 $217.00 $235.00 $269.00 $198.00 $308.00 $252.00 ------------$298.00 ------------------$399.00 $304.00 $208.00 $208.00 $161.00 $127.00 $57.00 $138.00 $89.00 $103.00 $199.00 $1,088.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $338.00 $149.00 $283.00 $311.00 $358.00 $286.00 $1,502.00 $2,422.00 $1,927.00 $1,234.00 $1,423.00 $1,133.00 $970.00 ------$537.00 $302.00 $249.00 $899.00 $668.00 $103.00 $554.00 $901.00 $235.00 $366.00 $417.00 $456.00 $424.00 $454.00 $542.00 $861.00 $279.00 $311.00 $104.00 $122.00 $474.00 $304.00 $108.00 $335.00 $358.00 $348.00 $236.00 $407.00 $371.00 $438.00 $73.00 $463.00 $70.00 $128.00 $848.00 $1,672.00 $355.00 $158.00 $299.00 $329.00 $379.00 $303.00 $1,580.00 $2,553.00 $2,031.00 $1,291.00 $1,497.00 $1,205.00 $1,023.00 ------$567.00 $318.00 $263.00 $947.00 $704.00 $109.00 $587.00 $948.00 $248.00 $389.00 $441.00 $481.00 $447.00 $479.00 $572.00 $912.00 $292.00 $326.00 $112.00 $129.00 $500.00 $318.00 $113.00 $347.00 $376.00 $363.00 $245.00 $429.00 $391.00 $465.00 $76.00 $492.00 $73.00 $133.00 $904.00 $1,761.00 $375.00 $166.00 $315.00 $348.00 $400.00 $320.00 $1,663.00 $2,694.00 $2,148.00 $1,355.00 $1,577.00 $1,280.00 $1,079.00 ------$606.00 $340.00 $282.00 $1,002.00 $743.00 $116.00 $621.00 $998.00 $262.00 $411.00 $464.00 $504.00 $468.00 $503.00 $599.00 $957.00 $309.00 $344.00 $121.00 $139.00 $526.00 $334.00 $120.00 $360.00 $399.00 $382.00 $256.00 $450.00 $410.00 $490.00 $79.00 $518.00 $77.00 $140.00 $953.00 $1,854.00 $338.00 $100.00 $162.00 $200.00 $223.00 $186.00 $1,502.00 $2,422.00 $1,927.00 $1,234.00 $1,423.00 $1,133.00 $970.00 ------$537.00 $302.00 $249.00 $899.00 $668.00 $64.00 $554.00 $901.00 $167.00 $96.00 $194.00 $194.00 $194.00 $228.00 $253.00 $269.00 $279.00 $311.00 $76.00 $92.00 $255.00 $304.00 $108.00 $335.00 $358.00 $348.00 $236.00 $213.00 $185.00 $152.00 $73.00 $148.00 $70.00 $128.00 $194.00 $1,672.00 $355.00 $106.00 $170.00 $211.00 $234.00 $195.00 $1,580.00 $2,553.00 $2,031.00 $1,291.00 $1,497.00 $1,205.00 $1,023.00 ------$567.00 $318.00 $263.00 $947.00 $704.00 $67.00 $587.00 $948.00 $175.00 $101.00 $202.00 $201.00 $201.00 $236.00 $262.00 $277.00 $292.00 $326.00 $82.00 $97.00 $266.00 $318.00 $113.00 $347.00 $376.00 $363.00 $245.00 $221.00 $192.00 $158.00 $76.00 $155.00 $73.00 $133.00 $202.00 $1,761.00 $375.00 $112.00 $178.00 $223.00 $247.00 $206.00 $1,663.00 $2,694.00 $2,148.00 $1,355.00 $1,577.00 $1,280.00 $1,079.00 ------$606.00 $340.00 $282.00 $1,002.00 $743.00 $71.00 $621.00 $998.00 $184.00 $106.00 $212.00 $209.00 $209.00 $246.00 $272.00 $287.00 $309.00 $344.00 $90.00 $105.00 $279.00 $334.00 $120.00 $360.00 $399.00 $382.00 $256.00 $230.00 $200.00 $166.00 $79.00 $162.00 $77.00 $140.00 $213.00 $1,854.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 178 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 31755 31760 31766 31770 31775 31780 31781 31785 31786 31800 31805 31820 31825 31830 31899 32035 32036 32095 32100 32110 32120 32124 32140 32141 32150 32151 32160 32200 32201 32215 32220 32225 32310 32320 32400 32402 32405 32420 32421 32422 32440 32442 32445 32480 32482 32484 32486 32488 32491 32500 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 0 90 0 0 0 0 90 90 90 90 90 90 90 90 90 90 $1,448.00 $1,648.00 $2,315.00 $1,815.00 $1,973.00 $1,577.00 $1,936.00 $1,320.00 $1,866.00 $628.00 $1,175.00 $458.00 $659.00 $460.00 BR $821.00 $908.00 $848.00 $1,120.00 $1,223.00 $1,077.00 $1,144.00 $1,284.00 $1,267.00 $1,226.00 $1,231.00 $842.00 $1,132.00 $387.00 $1,024.00 $1,680.00 $1,268.00 $1,221.00 $1,787.00 $129.00 $798.00 $159.00 $116.00 ------------$1,837.00 $2,093.00 $2,093.00 $1,622.00 $1,714.00 $1,771.00 $1,974.00 $2,094.00 $1,784.00 $1,331.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,122.00 $1,843.00 $2,476.00 $1,797.00 $1,923.00 $1,552.00 $1,886.00 $1,431.00 $2,019.00 $891.00 $1,108.00 $533.00 $748.00 $540.00 ------$924.00 $1,005.00 $831.00 $1,304.00 $1,952.00 $1,146.00 $1,225.00 $1,310.00 $1,875.00 $1,322.00 $1,349.00 $993.00 $1,472.00 $1,220.00 $1,070.00 $2,145.00 $1,323.00 $1,228.00 $2,139.00 $198.00 $747.00 $133.00 $147.00 $215.00 $265.00 $2,164.00 $3,789.00 $4,203.00 $2,041.00 $2,172.00 $1,953.00 $2,986.00 $3,047.00 $1,991.00 $1,974.00 $2,242.00 $1,955.00 $2,636.00 $1,903.00 $2,038.00 $1,630.00 $1,982.00 $1,504.00 $2,144.00 $943.00 $1,178.00 $563.00 $788.00 $573.00 ------$977.00 $1,064.00 $881.00 $1,387.00 $2,070.00 $1,212.00 $1,298.00 $1,387.00 $1,958.00 $1,400.00 $1,430.00 $1,047.00 $1,557.00 $1,299.00 $1,136.00 $2,280.00 $1,402.00 $1,305.00 $2,271.00 $208.00 $792.00 $139.00 $152.00 $227.00 $279.00 $2,300.00 $3,947.00 $4,363.00 $2,170.00 $2,308.00 $2,068.00 $3,125.00 $3,196.00 $2,108.00 $2,097.00 $2,364.00 $2,101.00 $2,852.00 $2,042.00 $2,188.00 $1,724.00 $2,103.00 $1,592.00 $2,307.00 $1,001.00 $1,270.00 $595.00 $831.00 $607.00 ------$1,044.00 $1,139.00 $944.00 $1,497.00 $2,227.00 $1,297.00 $1,394.00 $1,487.00 $2,063.00 $1,501.00 $1,533.00 $1,114.00 $1,667.00 $1,367.00 $1,222.00 $2,457.00 $1,506.00 $1,404.00 $2,444.00 $218.00 $848.00 $145.00 $159.00 $238.00 $292.00 $2,480.00 $4,148.00 $4,563.00 $2,340.00 $2,488.00 $2,218.00 $3,304.00 $3,389.00 $2,260.00 $2,259.00 $2,122.00 $1,843.00 $2,476.00 $1,797.00 $1,923.00 $1,552.00 $1,886.00 $1,431.00 $2,019.00 $891.00 $1,108.00 $418.00 $616.00 $437.00 ------$924.00 $1,005.00 $831.00 $1,304.00 $1,952.00 $1,146.00 $1,225.00 $1,310.00 $1,875.00 $1,322.00 $1,349.00 $993.00 $1,472.00 $274.00 $1,070.00 $2,145.00 $1,323.00 $1,228.00 $2,139.00 $119.00 $747.00 $132.00 $147.00 $102.00 $165.00 $2,164.00 $3,789.00 $4,203.00 $2,041.00 $2,172.00 $1,953.00 $2,986.00 $3,047.00 $1,991.00 $1,974.00 $2,242.00 $1,955.00 $2,636.00 $1,903.00 $2,038.00 $1,630.00 $1,982.00 $1,504.00 $2,144.00 $943.00 $1,178.00 $440.00 $647.00 $461.00 ------$977.00 $1,064.00 $881.00 $1,387.00 $2,070.00 $1,212.00 $1,298.00 $1,387.00 $1,958.00 $1,400.00 $1,430.00 $1,047.00 $1,557.00 $285.00 $1,136.00 $2,280.00 $1,402.00 $1,305.00 $2,271.00 $123.00 $792.00 $138.00 $152.00 $106.00 $172.00 $2,300.00 $3,947.00 $4,363.00 $2,170.00 $2,308.00 $2,068.00 $3,125.00 $3,196.00 $2,108.00 $2,097.00 $2,364.00 $2,101.00 $2,852.00 $2,042.00 $2,188.00 $1,724.00 $2,103.00 $1,592.00 $2,307.00 $1,001.00 $1,270.00 $465.00 $683.00 $490.00 ------$1,044.00 $1,139.00 $944.00 $1,497.00 $2,227.00 $1,297.00 $1,394.00 $1,487.00 $2,063.00 $1,501.00 $1,533.00 $1,114.00 $1,667.00 $299.00 $1,222.00 $2,457.00 $1,506.00 $1,404.00 $2,444.00 $129.00 $848.00 $144.00 $159.00 $111.00 $179.00 $2,480.00 $4,148.00 $4,563.00 $2,340.00 $2,488.00 $2,218.00 $3,304.00 $3,389.00 $2,260.00 $2,259.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 179 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 32501 32503 32504 32540 32550 32551 32560 32601 32602 32603 32604 32605 32606 32650 32651 32652 32653 32654 32655 32656 32657 32658 32659 32660 32661 32662 32663 32664 32665 32800 32810 32815 32820 32851 32852 32853 32854 32900 32905 32906 32940 32960 32997 32998 32999 33010 33011 33015 33020 33025 ZZZ 90 90 90 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 YYY 0 0 90 90 90 $374.00 ------------$1,308.00 ------------------$456.00 $494.00 $585.00 $663.00 $550.00 $637.00 $957.00 $1,166.00 $1,615.00 $1,144.00 $1,096.00 $1,213.00 $1,222.00 $1,261.00 $1,142.00 $1,141.00 $1,691.00 $1,165.00 $1,459.00 $1,636.00 $1,197.00 $1,360.00 $1,166.00 $1,085.00 $1,917.00 $1,848.00 $3,100.00 $3,339.00 $3,787.00 $4,038.00 $1,532.00 $1,661.00 $2,100.00 $1,555.00 $126.00 $312.00 ------BR $124.00 $125.00 $555.00 $1,178.00 $1,165.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $343.00 $2,511.00 $2,867.00 $2,112.00 $1,102.00 $247.00 $409.00 $430.00 $467.00 $601.00 $673.00 $541.00 $648.00 $931.00 $1,400.00 $2,110.00 $1,360.00 $1,476.00 $1,259.00 $1,117.00 $1,104.00 $1,003.00 $1,017.00 $1,423.00 $1,122.00 $1,260.00 $1,874.00 $1,183.00 $1,596.00 $1,248.00 $1,213.00 $3,338.00 $1,817.00 $3,561.00 $3,968.00 $4,278.00 $4,616.00 $1,832.00 $1,830.00 $2,263.00 $1,675.00 $183.00 $481.00 $3,806.00 ------$162.00 $165.00 $700.00 $1,170.00 $1,089.00 $365.00 $2,670.00 $3,050.00 $2,202.00 $1,175.00 $262.00 $435.00 $458.00 $497.00 $640.00 $717.00 $576.00 $691.00 $992.00 $1,474.00 $2,217.00 $1,434.00 $1,545.00 $1,333.00 $1,190.00 $1,179.00 $1,069.00 $1,081.00 $1,507.00 $1,196.00 $1,343.00 $1,979.00 $1,266.00 $1,681.00 $1,324.00 $1,288.00 $3,474.00 $1,922.00 $3,789.00 $4,220.00 $4,555.00 $4,907.00 $1,941.00 $1,946.00 $2,406.00 $1,781.00 $193.00 $502.00 $4,066.00 ------$168.00 $173.00 $735.00 $1,239.00 $1,157.00 $395.00 $2,883.00 $3,295.00 $2,315.00 $1,243.00 $282.00 $461.00 $496.00 $539.00 $694.00 $775.00 $624.00 $748.00 $1,072.00 $1,570.00 $2,356.00 $1,530.00 $1,632.00 $1,428.00 $1,285.00 $1,278.00 $1,155.00 $1,165.00 $1,614.00 $1,292.00 $1,451.00 $2,116.00 $1,377.00 $1,790.00 $1,424.00 $1,385.00 $3,646.00 $2,055.00 $4,078.00 $4,539.00 $4,913.00 $5,280.00 $2,085.00 $2,099.00 $2,596.00 $1,921.00 $204.00 $529.00 $4,286.00 ------$177.00 $181.00 $775.00 $1,329.00 $1,246.00 $343.00 $2,511.00 $2,867.00 $2,112.00 $308.00 $247.00 $153.00 $430.00 $467.00 $601.00 $673.00 $541.00 $648.00 $931.00 $1,400.00 $2,110.00 $1,360.00 $1,476.00 $1,259.00 $1,117.00 $1,104.00 $1,003.00 $1,017.00 $1,423.00 $1,122.00 $1,260.00 $1,874.00 $1,183.00 $1,596.00 $1,248.00 $1,213.00 $3,338.00 $1,817.00 $3,561.00 $3,968.00 $4,278.00 $4,616.00 $1,832.00 $1,830.00 $2,263.00 $1,675.00 $130.00 $481.00 $395.00 ------$162.00 $165.00 $700.00 $1,170.00 $1,089.00 $365.00 $2,670.00 $3,050.00 $2,202.00 $324.00 $262.00 $161.00 $458.00 $497.00 $640.00 $717.00 $576.00 $691.00 $992.00 $1,474.00 $2,217.00 $1,434.00 $1,545.00 $1,333.00 $1,190.00 $1,179.00 $1,069.00 $1,081.00 $1,507.00 $1,196.00 $1,343.00 $1,979.00 $1,266.00 $1,681.00 $1,324.00 $1,288.00 $3,474.00 $1,922.00 $3,789.00 $4,220.00 $4,555.00 $4,907.00 $1,941.00 $1,946.00 $2,406.00 $1,781.00 $136.00 $502.00 $411.00 ------$168.00 $173.00 $735.00 $1,239.00 $1,157.00 $395.00 $2,883.00 $3,295.00 $2,315.00 $345.00 $282.00 $172.00 $496.00 $539.00 $694.00 $775.00 $624.00 $748.00 $1,072.00 $1,570.00 $2,356.00 $1,530.00 $1,632.00 $1,428.00 $1,285.00 $1,278.00 $1,155.00 $1,165.00 $1,614.00 $1,292.00 $1,451.00 $2,116.00 $1,377.00 $1,790.00 $1,424.00 $1,385.00 $3,646.00 $2,055.00 $4,078.00 $4,539.00 $4,913.00 $5,280.00 $2,085.00 $2,099.00 $2,596.00 $1,921.00 $144.00 $529.00 $431.00 ------$177.00 $181.00 $775.00 $1,329.00 $1,246.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 180 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 33030 33031 33050 33120 33130 33140 33141 33202 33203 33206 33207 33208 33210 33211 33212 33213 33214 33215 33216 33217 33218 33220 33222 33223 33224 33225 33226 33233 33234 33235 33236 33237 33238 33240 33241 33243 33244 33249 33250 33251 33254 33255 33256 33257 33258 33259 33261 33265 33266 33282 90 90 90 90 90 90 ZZZ 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 0 ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ 90 90 90 90 $1,786.00 $1,816.00 $1,224.00 $2,358.00 $1,734.00 $1,571.00 $254.00 ------------$642.00 $753.00 $573.00 $204.00 $210.00 $511.00 $437.00 $532.00 $304.00 $402.00 $428.00 $488.00 $390.00 $471.00 $585.00 $490.00 $434.00 $472.00 $270.00 $598.00 $587.00 $933.00 $1,184.00 $1,235.00 $648.00 $301.00 $1,650.00 $1,081.00 $1,271.00 $1,687.00 $2,071.00 ------------------------------------$1,993.00 ------------$470.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,737.00 $1,927.00 $1,342.00 $2,131.00 $1,855.00 $2,084.00 $233.00 $1,057.00 $1,070.00 $624.00 $669.00 $714.00 $242.00 $249.00 $469.00 $533.00 $668.00 $426.00 $520.00 $519.00 $538.00 $540.00 $483.00 $578.00 $690.00 $617.00 $668.00 $337.00 $673.00 $875.00 $1,073.00 $1,167.00 $1,285.00 $636.00 $316.00 $1,826.00 $1,187.00 $1,229.00 $2,011.00 $2,204.00 $1,861.00 $2,238.00 $2,681.00 $796.00 $903.00 $1,195.00 $2,213.00 $1,861.00 $2,554.00 $445.00 $1,843.00 $2,042.00 $1,424.00 $2,264.00 $1,967.00 $2,194.00 $255.00 $1,122.00 $1,128.00 $654.00 $702.00 $747.00 $252.00 $259.00 $493.00 $558.00 $701.00 $447.00 $545.00 $544.00 $563.00 $565.00 $509.00 $606.00 $719.00 $642.00 $698.00 $354.00 $706.00 $919.00 $1,140.00 $1,235.00 $1,366.00 $664.00 $331.00 $1,919.00 $1,245.00 $1,282.00 $2,131.00 $2,335.00 $1,981.00 $2,379.00 $2,854.00 $838.00 $952.00 $1,268.00 $2,343.00 $1,981.00 $2,721.00 $466.00 $1,982.00 $2,195.00 $1,531.00 $2,442.00 $2,114.00 $2,338.00 $286.00 $1,207.00 $1,200.00 $689.00 $739.00 $784.00 $264.00 $272.00 $520.00 $588.00 $739.00 $471.00 $572.00 $572.00 $591.00 $593.00 $538.00 $638.00 $754.00 $671.00 $734.00 $373.00 $743.00 $968.00 $1,227.00 $1,321.00 $1,469.00 $694.00 $347.00 $2,035.00 $1,310.00 $1,339.00 $2,289.00 $2,510.00 $2,141.00 $2,567.00 $3,087.00 $889.00 $1,012.00 $1,361.00 $2,513.00 $2,141.00 $2,947.00 $487.00 $1,737.00 $1,927.00 $1,342.00 $2,131.00 $1,855.00 $2,084.00 $233.00 $1,057.00 $1,070.00 $624.00 $669.00 $714.00 $242.00 $249.00 $469.00 $533.00 $668.00 $426.00 $520.00 $519.00 $538.00 $540.00 $483.00 $578.00 $690.00 $617.00 $668.00 $337.00 $673.00 $875.00 $1,073.00 $1,167.00 $1,285.00 $636.00 $316.00 $1,826.00 $1,187.00 $1,229.00 $2,011.00 $2,204.00 $1,861.00 $2,238.00 $2,681.00 $796.00 $903.00 $1,195.00 $2,213.00 $1,861.00 $2,554.00 $445.00 $1,843.00 $2,042.00 $1,424.00 $2,264.00 $1,967.00 $2,194.00 $255.00 $1,122.00 $1,128.00 $654.00 $702.00 $747.00 $252.00 $259.00 $493.00 $558.00 $701.00 $447.00 $545.00 $544.00 $563.00 $565.00 $509.00 $606.00 $719.00 $642.00 $698.00 $354.00 $706.00 $919.00 $1,140.00 $1,235.00 $1,366.00 $664.00 $331.00 $1,919.00 $1,245.00 $1,282.00 $2,131.00 $2,335.00 $1,981.00 $2,379.00 $2,854.00 $838.00 $952.00 $1,268.00 $2,343.00 $1,981.00 $2,721.00 $466.00 $1,982.00 $2,195.00 $1,531.00 $2,442.00 $2,114.00 $2,338.00 $286.00 $1,207.00 $1,200.00 $689.00 $739.00 $784.00 $264.00 $272.00 $520.00 $588.00 $739.00 $471.00 $572.00 $572.00 $591.00 $593.00 $538.00 $638.00 $754.00 $671.00 $734.00 $373.00 $743.00 $968.00 $1,227.00 $1,321.00 $1,469.00 $694.00 $347.00 $2,035.00 $1,310.00 $1,339.00 $2,289.00 $2,510.00 $2,141.00 $2,567.00 $3,087.00 $889.00 $1,012.00 $1,361.00 $2,513.00 $2,141.00 $2,947.00 $487.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 181 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 33284 33300 33305 33310 33315 33320 33321 33322 33330 33332 33335 33400 33401 33403 33404 33405 33406 33410 33411 33412 33413 33414 33415 33416 33417 33420 33422 33425 33426 33427 33430 33460 33463 33464 33465 33468 33470 33471 33472 33474 33475 33476 33478 33496 33500 33501 33502 33503 33504 33505 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $365.00 $1,576.00 $1,889.00 $1,577.00 $1,875.00 $1,485.00 $1,890.00 $1,935.00 $1,726.00 $1,915.00 $2,336.00 $2,401.00 $2,228.00 $2,369.00 $2,698.00 $2,745.00 $2,962.00 $2,637.00 $2,981.00 $3,213.00 $3,282.00 $2,904.00 $2,563.00 $2,684.00 $2,756.00 $1,796.00 $2,431.00 $2,509.00 $2,806.00 $3,026.00 $2,891.00 $2,215.00 $2,396.00 $2,547.00 $2,665.00 $2,952.00 $1,749.00 $1,929.00 $2,001.00 $2,173.00 $2,666.00 $2,270.00 $2,544.00 $2,595.00 $2,370.00 $1,546.00 $1,938.00 $1,983.00 $2,416.00 $2,423.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $326.00 $2,926.00 $4,750.00 $1,603.00 $2,014.00 $1,437.00 $1,657.00 $1,866.00 $1,900.00 $1,888.00 $2,572.00 $3,025.00 $2,024.00 $2,145.00 $2,475.00 $3,192.00 $3,838.00 $3,373.00 $4,339.00 $3,478.00 $4,432.00 $2,918.00 $2,704.00 $2,742.00 $2,328.00 $1,826.00 $2,328.00 $3,429.00 $3,247.00 $3,459.00 $3,684.00 $3,019.00 $3,797.00 $3,153.00 $3,489.00 $2,586.00 $1,548.00 $1,875.00 $1,873.00 $2,695.00 $3,136.00 $1,990.00 $2,196.00 $2,319.00 $2,176.00 $1,471.00 $1,767.00 $1,739.00 $2,014.00 $2,676.00 $342.00 $3,037.00 $4,893.00 $1,701.00 $2,135.00 $1,519.00 $1,764.00 $1,974.00 $2,007.00 $2,001.00 $2,727.00 $3,183.00 $2,157.00 $2,283.00 $2,632.00 $3,387.00 $4,043.00 $3,551.00 $4,549.00 $3,705.00 $4,677.00 $3,084.00 $2,854.00 $2,906.00 $2,477.00 $1,906.00 $2,473.00 $3,587.00 $3,434.00 $3,676.00 $3,877.00 $3,153.00 $3,954.00 $3,310.00 $3,655.00 $2,741.00 $1,607.00 $1,999.00 $2,000.00 $2,819.00 $3,316.00 $2,092.00 $2,338.00 $2,466.00 $2,314.00 $1,548.00 $1,879.00 $1,824.00 $2,140.00 $2,781.00 $358.00 $3,177.00 $5,069.00 $1,829.00 $2,296.00 $1,625.00 $1,905.00 $2,116.00 $2,147.00 $2,149.00 $2,933.00 $3,389.00 $2,332.00 $2,462.00 $2,841.00 $3,646.00 $4,313.00 $3,784.00 $4,823.00 $4,010.00 $4,999.00 $3,306.00 $3,054.00 $3,125.00 $2,676.00 $2,006.00 $2,664.00 $3,793.00 $3,680.00 $3,967.00 $4,130.00 $3,327.00 $4,154.00 $3,517.00 $3,873.00 $2,944.00 $1,675.00 $2,163.00 $2,170.00 $2,981.00 $3,555.00 $2,220.00 $2,526.00 $2,664.00 $2,499.00 $1,647.00 $2,027.00 $1,926.00 $2,305.00 $2,909.00 $326.00 $2,926.00 $4,750.00 $1,603.00 $2,014.00 $1,437.00 $1,657.00 $1,866.00 $1,900.00 $1,888.00 $2,572.00 $3,025.00 $2,024.00 $2,145.00 $2,475.00 $3,192.00 $3,838.00 $3,373.00 $4,339.00 $3,478.00 $4,432.00 $2,918.00 $2,704.00 $2,742.00 $2,328.00 $1,826.00 $2,328.00 $3,429.00 $3,247.00 $3,459.00 $3,684.00 $3,019.00 $3,797.00 $3,153.00 $3,489.00 $2,586.00 $1,548.00 $1,875.00 $1,873.00 $2,695.00 $3,136.00 $1,990.00 $2,196.00 $2,319.00 $2,176.00 $1,471.00 $1,767.00 $1,739.00 $2,014.00 $2,676.00 $342.00 $3,037.00 $4,893.00 $1,701.00 $2,135.00 $1,519.00 $1,764.00 $1,974.00 $2,007.00 $2,001.00 $2,727.00 $3,183.00 $2,157.00 $2,283.00 $2,632.00 $3,387.00 $4,043.00 $3,551.00 $4,549.00 $3,705.00 $4,677.00 $3,084.00 $2,854.00 $2,906.00 $2,477.00 $1,906.00 $2,473.00 $3,587.00 $3,434.00 $3,676.00 $3,877.00 $3,153.00 $3,954.00 $3,310.00 $3,655.00 $2,741.00 $1,607.00 $1,999.00 $2,000.00 $2,819.00 $3,316.00 $2,092.00 $2,338.00 $2,466.00 $2,314.00 $1,548.00 $1,879.00 $1,824.00 $2,140.00 $2,781.00 $358.00 $3,177.00 $5,069.00 $1,829.00 $2,296.00 $1,625.00 $1,905.00 $2,116.00 $2,147.00 $2,149.00 $2,933.00 $3,389.00 $2,332.00 $2,462.00 $2,841.00 $3,646.00 $4,313.00 $3,784.00 $4,823.00 $4,010.00 $4,999.00 $3,306.00 $3,054.00 $3,125.00 $2,676.00 $2,006.00 $2,664.00 $3,793.00 $3,680.00 $3,967.00 $4,130.00 $3,327.00 $4,154.00 $3,517.00 $3,873.00 $2,944.00 $1,675.00 $2,163.00 $2,170.00 $2,981.00 $3,555.00 $2,220.00 $2,526.00 $2,664.00 $2,499.00 $1,647.00 $2,027.00 $1,926.00 $2,305.00 $2,909.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 182 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 33506 33507 33508 33510 33511 33512 33513 33514 33516 33517 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33545 33548 33572 33600 33602 33606 33608 33610 33611 33612 33615 33617 33619 33641 33645 33647 33660 33665 33670 33675 33676 33677 33681 33684 33688 33690 33692 33694 33697 90 90 ZZZ 90 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $2,448.00 ------$17.00 $2,354.00 $2,546.00 $2,732.00 $2,933.00 $3,197.00 $3,404.00 $219.00 $414.00 $607.00 $801.00 $994.00 $1,189.00 $521.00 $2,415.00 $2,654.00 $2,899.00 $3,143.00 $2,693.00 $3,250.00 ------$340.00 $2,644.00 $2,556.00 $2,831.00 $2,940.00 $2,871.00 $2,985.00 $3,152.00 $3,051.00 $3,272.00 $3,678.00 $1,981.00 $2,352.00 $2,732.00 $2,444.00 $2,700.00 $2,820.00 ------------------$2,657.00 $2,740.00 $2,602.00 $1,884.00 $2,816.00 $2,856.00 $3,064.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,827.00 $2,413.00 $23.00 $2,719.00 $2,943.00 $3,269.00 $3,367.00 $3,516.00 $3,657.00 $248.00 $529.00 $712.00 $871.00 $1,006.00 $1,157.00 $667.00 $2,667.00 $3,052.00 $3,356.00 $3,591.00 $3,352.00 $3,981.00 $3,939.00 $329.00 $2,383.00 $2,264.00 $2,462.00 $2,540.00 $2,507.00 $2,676.00 $2,870.00 $2,696.00 $3,027.00 $3,764.00 $2,153.00 $2,176.00 $2,304.00 $2,480.00 $2,600.00 $2,807.00 $2,865.00 $2,966.00 $3,084.00 $2,552.00 $2,552.00 $2,556.00 $1,575.00 $2,674.00 $2,692.00 $2,880.00 $2,994.00 $2,560.00 $24.00 $2,883.00 $3,114.00 $3,447.00 $3,552.00 $3,700.00 $3,853.00 $262.00 $554.00 $748.00 $918.00 $1,066.00 $1,228.00 $698.00 $2,835.00 $3,229.00 $3,545.00 $3,793.00 $3,517.00 $4,177.00 $4,148.00 $350.00 $2,539.00 $2,403.00 $2,620.00 $2,708.00 $2,672.00 $2,834.00 $3,058.00 $2,853.00 $3,224.00 $3,998.00 $2,272.00 $2,312.00 $2,436.00 $2,639.00 $2,748.00 $2,976.00 $3,047.00 $3,161.00 $3,287.00 $2,715.00 $2,686.00 $2,715.00 $1,658.00 $2,850.00 $2,869.00 $3,040.00 $3,217.00 $2,756.00 $26.00 $3,099.00 $3,339.00 $3,680.00 $3,794.00 $3,940.00 $4,109.00 $280.00 $589.00 $797.00 $982.00 $1,147.00 $1,325.00 $740.00 $3,057.00 $3,462.00 $3,793.00 $4,059.00 $3,733.00 $4,435.00 $4,422.00 $380.00 $2,750.00 $2,588.00 $2,831.00 $2,934.00 $2,891.00 $3,045.00 $3,309.00 $3,063.00 $3,491.00 $4,309.00 $2,429.00 $2,494.00 $2,606.00 $2,853.00 $2,944.00 $3,201.00 $3,288.00 $3,422.00 $3,559.00 $2,930.00 $2,859.00 $2,934.00 $1,763.00 $3,080.00 $3,113.00 $3,248.00 $2,827.00 $2,413.00 $23.00 $2,719.00 $2,943.00 $3,269.00 $3,367.00 $3,516.00 $3,657.00 $248.00 $529.00 $712.00 $871.00 $1,006.00 $1,157.00 $667.00 $2,667.00 $3,052.00 $3,356.00 $3,591.00 $3,352.00 $3,981.00 $3,939.00 $329.00 $2,383.00 $2,264.00 $2,462.00 $2,540.00 $2,507.00 $2,676.00 $2,870.00 $2,696.00 $3,027.00 $3,764.00 $2,153.00 $2,176.00 $2,304.00 $2,480.00 $2,600.00 $2,807.00 $2,865.00 $2,966.00 $3,084.00 $2,552.00 $2,552.00 $2,556.00 $1,575.00 $2,674.00 $2,692.00 $2,880.00 $2,994.00 $2,560.00 $24.00 $2,883.00 $3,114.00 $3,447.00 $3,552.00 $3,700.00 $3,853.00 $262.00 $554.00 $748.00 $918.00 $1,066.00 $1,228.00 $698.00 $2,835.00 $3,229.00 $3,545.00 $3,793.00 $3,517.00 $4,177.00 $4,148.00 $350.00 $2,539.00 $2,403.00 $2,620.00 $2,708.00 $2,672.00 $2,834.00 $3,058.00 $2,853.00 $3,224.00 $3,998.00 $2,272.00 $2,312.00 $2,436.00 $2,639.00 $2,748.00 $2,976.00 $3,047.00 $3,161.00 $3,287.00 $2,715.00 $2,686.00 $2,715.00 $1,658.00 $2,850.00 $2,869.00 $3,040.00 $3,217.00 $2,756.00 $26.00 $3,099.00 $3,339.00 $3,680.00 $3,794.00 $3,940.00 $4,109.00 $280.00 $589.00 $797.00 $982.00 $1,147.00 $1,325.00 $740.00 $3,057.00 $3,462.00 $3,793.00 $4,059.00 $3,733.00 $4,435.00 $4,422.00 $380.00 $2,750.00 $2,588.00 $2,831.00 $2,934.00 $2,891.00 $3,045.00 $3,309.00 $3,063.00 $3,491.00 $4,309.00 $2,429.00 $2,494.00 $2,606.00 $2,853.00 $2,944.00 $3,201.00 $3,288.00 $3,422.00 $3,559.00 $2,930.00 $2,859.00 $2,934.00 $1,763.00 $3,080.00 $3,113.00 $3,248.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 183 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 33702 33710 33720 33722 33724 33726 33730 33732 33735 33736 33737 33750 33755 33762 33764 33766 33767 33768 33770 33771 33774 33775 33776 33777 33778 33779 33780 33781 33786 33788 33800 33802 33803 33813 33814 33820 33822 33824 33840 33845 33851 33852 33853 33860 33861 33863 33864 33870 33875 33877 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $2,549.00 $2,731.00 $2,508.00 $2,704.00 ------------$2,785.00 $2,622.00 $2,036.00 $2,288.00 $1,977.00 $1,877.00 $1,831.00 $1,900.00 $1,895.00 $2,119.00 $2,173.00 ------$2,954.00 $2,924.00 $2,681.00 $2,654.00 $2,844.00 $2,724.00 $3,199.00 $3,121.00 $3,232.00 $3,057.00 $2,970.00 $2,288.00 $1,546.00 $1,752.00 $1,746.00 $1,935.00 $2,464.00 $1,619.00 $1,559.00 $1,884.00 $2,029.00 $2,129.00 $2,129.00 $2,311.00 $3,057.00 $3,044.00 $3,069.00 $3,183.00 ------$3,638.00 $2,876.00 $3,767.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,142.00 $2,404.00 $2,153.00 $2,079.00 $2,130.00 $2,800.00 $2,765.00 $2,295.00 $1,687.00 $1,978.00 $1,808.00 $1,619.00 $1,727.00 $1,774.00 $1,772.00 $1,896.00 $1,989.00 $582.00 $2,952.00 $2,993.00 $2,534.00 $2,565.00 $2,677.00 $2,669.00 $3,289.00 $2,954.00 $3,156.00 $3,112.00 $3,183.00 $2,105.00 $1,377.00 $1,466.00 $1,605.00 $1,739.00 $2,122.00 $1,349.00 $1,413.00 $1,634.00 $1,658.00 $1,843.00 $1,767.00 $1,965.00 $2,551.00 $4,160.00 $3,404.00 $4,237.00 $4,357.00 $3,549.00 $2,739.00 $4,638.00 $2,277.00 $2,561.00 $2,291.00 $2,155.00 $2,268.00 $2,975.00 $2,941.00 $2,435.00 $1,772.00 $2,099.00 $1,926.00 $1,683.00 $1,840.00 $1,887.00 $1,882.00 $2,026.00 $2,123.00 $621.00 $3,146.00 $3,182.00 $2,704.00 $2,736.00 $2,852.00 $2,854.00 $3,503.00 $3,077.00 $3,307.00 $3,307.00 $3,383.00 $2,243.00 $1,467.00 $1,554.00 $1,715.00 $1,853.00 $2,261.00 $1,436.00 $1,507.00 $1,740.00 $1,748.00 $1,962.00 $1,883.00 $2,066.00 $2,713.00 $4,371.00 $3,625.00 $4,472.00 $4,599.00 $3,779.00 $2,911.00 $4,855.00 $2,455.00 $2,773.00 $2,476.00 $2,243.00 $2,456.00 $3,211.00 $3,178.00 $2,618.00 $1,876.00 $2,255.00 $2,084.00 $1,758.00 $1,992.00 $2,039.00 $2,029.00 $2,201.00 $2,303.00 $674.00 $3,410.00 $3,443.00 $2,933.00 $2,969.00 $3,091.00 $3,107.00 $3,794.00 $3,233.00 $3,499.00 $3,578.00 $3,653.00 $2,431.00 $1,585.00 $1,669.00 $1,865.00 $2,006.00 $2,446.00 $1,551.00 $1,635.00 $1,881.00 $1,862.00 $2,119.00 $2,036.00 $2,189.00 $2,929.00 $4,652.00 $3,925.00 $4,788.00 $4,923.00 $4,090.00 $3,143.00 $5,144.00 $2,142.00 $2,404.00 $2,153.00 $2,079.00 $2,130.00 $2,800.00 $2,765.00 $2,295.00 $1,687.00 $1,978.00 $1,808.00 $1,619.00 $1,727.00 $1,774.00 $1,772.00 $1,896.00 $1,989.00 $582.00 $2,952.00 $2,993.00 $2,534.00 $2,565.00 $2,677.00 $2,669.00 $3,289.00 $2,954.00 $3,156.00 $3,112.00 $3,183.00 $2,105.00 $1,377.00 $1,466.00 $1,605.00 $1,739.00 $2,122.00 $1,349.00 $1,413.00 $1,634.00 $1,658.00 $1,843.00 $1,767.00 $1,965.00 $2,551.00 $4,160.00 $3,404.00 $4,237.00 $4,357.00 $3,549.00 $2,739.00 $4,638.00 $2,277.00 $2,561.00 $2,291.00 $2,155.00 $2,268.00 $2,975.00 $2,941.00 $2,435.00 $1,772.00 $2,099.00 $1,926.00 $1,683.00 $1,840.00 $1,887.00 $1,882.00 $2,026.00 $2,123.00 $621.00 $3,146.00 $3,182.00 $2,704.00 $2,736.00 $2,852.00 $2,854.00 $3,503.00 $3,077.00 $3,307.00 $3,307.00 $3,383.00 $2,243.00 $1,467.00 $1,554.00 $1,715.00 $1,853.00 $2,261.00 $1,436.00 $1,507.00 $1,740.00 $1,748.00 $1,962.00 $1,883.00 $2,066.00 $2,713.00 $4,371.00 $3,625.00 $4,472.00 $4,599.00 $3,779.00 $2,911.00 $4,855.00 $2,455.00 $2,773.00 $2,476.00 $2,243.00 $2,456.00 $3,211.00 $3,178.00 $2,618.00 $1,876.00 $2,255.00 $2,084.00 $1,758.00 $1,992.00 $2,039.00 $2,029.00 $2,201.00 $2,303.00 $674.00 $3,410.00 $3,443.00 $2,933.00 $2,969.00 $3,091.00 $3,107.00 $3,794.00 $3,233.00 $3,499.00 $3,578.00 $3,653.00 $2,431.00 $1,585.00 $1,669.00 $1,865.00 $2,006.00 $2,446.00 $1,551.00 $1,635.00 $1,881.00 $1,862.00 $2,119.00 $2,036.00 $2,189.00 $2,929.00 $4,652.00 $3,925.00 $4,788.00 $4,923.00 $4,090.00 $3,143.00 $5,144.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 184 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 33880 33881 33883 33884 33886 33889 33891 33910 33915 33916 33917 33920 33922 33924 33925 33926 33935 33945 33960 33961 33967 33968 33970 33971 33973 33974 33975 33976 33977 33978 33979 33980 33999 34001 34051 34101 34111 34151 34201 34203 34401 34421 34451 34471 34490 34501 34502 34510 34520 34530 90 90 90 ZZZ 90 0 0 90 90 90 90 90 90 ZZZ 90 90 90 90 0 ZZZ 0 0 0 90 0 90 0 0 90 90 0 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ------------------------------------------$1,987.00 $1,588.00 $2,096.00 $2,345.00 $2,981.00 $2,227.00 $421.00 ------------$5,415.00 $3,813.00 $1,221.00 $800.00 $258.00 $51.00 $576.00 $578.00 $756.00 $1,095.00 $1,758.00 $2,056.00 $1,561.00 $1,754.00 $2,496.00 $3,212.00 BR $1,012.00 $1,134.00 $800.00 $669.00 $1,288.00 $777.00 $949.00 $953.00 $779.00 $1,117.00 $685.00 $660.00 $910.00 $2,044.00 $1,108.00 $1,077.00 $1,368.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,447.00 $2,110.00 $1,563.00 $570.00 $1,352.00 $1,149.00 $1,475.00 $2,252.00 $1,749.00 $2,174.00 $2,030.00 $2,460.00 $1,906.00 $409.00 $2,611.00 $3,404.00 $4,908.00 $5,974.00 $1,373.00 $747.00 $361.00 $47.00 $502.00 $959.00 $739.00 $1,230.00 $1,543.00 $1,718.00 $1,677.00 $1,874.00 $3,415.00 $4,935.00 ------$1,309.00 $1,350.00 $862.00 $861.00 $1,999.00 $1,324.00 $1,380.00 $1,985.00 $1,034.00 $2,160.00 $1,409.00 $865.00 $1,345.00 $2,165.00 $1,538.00 $1,463.00 $1,357.00 $2,560.00 $2,208.00 $1,646.00 $600.00 $1,423.00 $1,221.00 $1,567.00 $2,387.00 $1,819.00 $2,307.00 $2,164.00 $2,612.00 $2,022.00 $436.00 $2,783.00 $3,620.00 $5,231.00 $6,225.00 $1,459.00 $781.00 $378.00 $50.00 $532.00 $1,012.00 $784.00 $1,302.00 $1,643.00 $1,828.00 $1,785.00 $1,997.00 $3,643.00 $5,240.00 ------$1,379.00 $1,433.00 $916.00 $914.00 $2,123.00 $1,382.00 $1,466.00 $2,099.00 $1,094.00 $2,294.00 $1,462.00 $918.00 $1,432.00 $2,298.00 $1,628.00 $1,549.00 $1,428.00 $2,704.00 $2,331.00 $1,753.00 $641.00 $1,516.00 $1,320.00 $1,693.00 $2,566.00 $1,903.00 $2,484.00 $2,342.00 $2,819.00 $2,175.00 $473.00 $3,010.00 $3,912.00 $5,663.00 $6,547.00 $1,579.00 $826.00 $398.00 $54.00 $571.00 $1,079.00 $845.00 $1,393.00 $1,783.00 $1,978.00 $1,926.00 $2,160.00 $3,958.00 $5,649.00 ------$1,471.00 $1,542.00 $985.00 $983.00 $2,292.00 $1,457.00 $1,580.00 $2,250.00 $1,172.00 $2,476.00 $1,528.00 $988.00 $1,546.00 $2,474.00 $1,744.00 $1,662.00 $1,520.00 $2,447.00 $2,110.00 $1,563.00 $570.00 $1,352.00 $1,149.00 $1,475.00 $2,252.00 $1,749.00 $2,174.00 $2,030.00 $2,460.00 $1,906.00 $409.00 $2,611.00 $3,404.00 $4,908.00 $5,974.00 $1,373.00 $747.00 $361.00 $47.00 $502.00 $959.00 $739.00 $1,230.00 $1,543.00 $1,718.00 $1,677.00 $1,874.00 $3,415.00 $4,935.00 ------$1,309.00 $1,350.00 $862.00 $861.00 $1,999.00 $1,324.00 $1,380.00 $1,985.00 $1,034.00 $2,160.00 $1,409.00 $865.00 $1,345.00 $2,165.00 $1,538.00 $1,463.00 $1,357.00 $2,560.00 $2,208.00 $1,646.00 $600.00 $1,423.00 $1,221.00 $1,567.00 $2,387.00 $1,819.00 $2,307.00 $2,164.00 $2,612.00 $2,022.00 $436.00 $2,783.00 $3,620.00 $5,231.00 $6,225.00 $1,459.00 $781.00 $378.00 $50.00 $532.00 $1,012.00 $784.00 $1,302.00 $1,643.00 $1,828.00 $1,785.00 $1,997.00 $3,643.00 $5,240.00 ------$1,379.00 $1,433.00 $916.00 $914.00 $2,123.00 $1,382.00 $1,466.00 $2,099.00 $1,094.00 $2,294.00 $1,462.00 $918.00 $1,432.00 $2,298.00 $1,628.00 $1,549.00 $1,428.00 $2,704.00 $2,331.00 $1,753.00 $641.00 $1,516.00 $1,320.00 $1,693.00 $2,566.00 $1,903.00 $2,484.00 $2,342.00 $2,819.00 $2,175.00 $473.00 $3,010.00 $3,912.00 $5,663.00 $6,547.00 $1,579.00 $826.00 $398.00 $54.00 $571.00 $1,079.00 $845.00 $1,393.00 $1,783.00 $1,978.00 $1,926.00 $2,160.00 $3,958.00 $5,649.00 ------$1,471.00 $1,542.00 $985.00 $983.00 $2,292.00 $1,457.00 $1,580.00 $2,250.00 $1,172.00 $2,476.00 $1,528.00 $988.00 $1,546.00 $2,474.00 $1,744.00 $1,662.00 $1,520.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 185 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 34800 34802 34803 34804 34805 34806 34808 34812 34813 34820 34825 34826 34830 34831 34832 34833 34834 34900 35001 35002 35005 35011 35013 35021 35022 35045 35081 35082 35091 35092 35102 35103 35111 35112 35121 35122 35131 35132 35141 35142 35151 35152 35180 35182 35184 35188 35189 35190 35201 35206 90 90 90 90 90 ZZZ ZZZ 0 ZZZ 0 90 ZZZ 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,159.00 $1,279.00 ------$1,279.00 ------------$220.00 $359.00 $256.00 $519.00 $694.00 $220.00 $1,803.00 $1,950.00 $1,950.00 $650.00 $306.00 $960.00 $1,564.00 $1,547.00 $1,268.00 $1,007.00 $1,376.00 $1,635.00 $1,686.00 $995.00 $2,175.00 $2,661.00 $2,634.00 $2,872.00 $2,346.00 $2,587.00 $1,398.00 $1,351.00 $2,000.00 $2,382.00 $1,495.00 $1,742.00 $1,231.00 $1,339.00 $1,390.00 $1,229.00 $997.00 $1,345.00 $976.00 $1,048.00 $1,380.00 $1,018.00 $852.00 $835.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,613.00 $1,748.00 $1,777.00 $1,743.00 $1,643.00 $146.00 $301.00 $508.00 $346.00 $718.00 $981.00 $291.00 $2,610.00 $2,741.00 $2,823.00 $890.00 $405.00 $1,287.00 $1,626.00 $1,707.00 $1,475.00 $1,428.00 $1,766.00 $1,712.00 $1,965.00 $1,381.00 $2,440.00 $3,102.00 $2,657.00 $3,697.00 $2,655.00 $3,212.00 $1,979.00 $2,398.00 $2,374.00 $2,783.00 $2,020.00 $2,431.00 $1,604.00 $1,907.00 $1,806.00 $2,091.00 $1,114.00 $2,420.00 $1,449.00 $1,226.00 $2,286.00 $1,062.00 $1,334.00 $1,091.00 $1,705.00 $1,839.00 $1,861.00 $1,833.00 $1,724.00 $155.00 $320.00 $545.00 $368.00 $767.00 $1,034.00 $307.00 $2,768.00 $2,906.00 $2,993.00 $947.00 $431.00 $1,362.00 $1,728.00 $1,814.00 $1,551.00 $1,518.00 $1,876.00 $1,816.00 $2,082.00 $1,468.00 $2,581.00 $3,290.00 $2,830.00 $3,917.00 $2,811.00 $3,409.00 $2,101.00 $2,541.00 $2,523.00 $2,948.00 $2,151.00 $2,581.00 $1,706.00 $2,026.00 $1,920.00 $2,220.00 $1,163.00 $2,573.00 $1,540.00 $1,305.00 $2,428.00 $1,128.00 $1,419.00 $1,160.00 $1,826.00 $1,957.00 $1,967.00 $1,950.00 $1,828.00 $169.00 $347.00 $597.00 $398.00 $834.00 $1,101.00 $328.00 $2,983.00 $3,132.00 $3,223.00 $1,026.00 $466.00 $1,461.00 $1,864.00 $1,957.00 $1,646.00 $1,639.00 $2,024.00 $1,956.00 $2,237.00 $1,585.00 $2,771.00 $3,546.00 $3,066.00 $4,216.00 $3,022.00 $3,677.00 $2,265.00 $2,734.00 $2,725.00 $3,172.00 $2,329.00 $2,784.00 $1,844.00 $2,185.00 $2,074.00 $2,392.00 $1,222.00 $2,779.00 $1,661.00 $1,411.00 $2,619.00 $1,216.00 $1,532.00 $1,251.00 $1,613.00 $1,748.00 $1,777.00 $1,743.00 $1,643.00 $146.00 $301.00 $508.00 $346.00 $718.00 $981.00 $291.00 $2,610.00 $2,741.00 $2,823.00 $890.00 $405.00 $1,287.00 $1,626.00 $1,707.00 $1,475.00 $1,428.00 $1,766.00 $1,712.00 $1,965.00 $1,381.00 $2,440.00 $3,102.00 $2,657.00 $3,697.00 $2,655.00 $3,212.00 $1,979.00 $2,398.00 $2,374.00 $2,783.00 $2,020.00 $2,431.00 $1,604.00 $1,907.00 $1,806.00 $2,091.00 $1,114.00 $2,420.00 $1,449.00 $1,226.00 $2,286.00 $1,062.00 $1,334.00 $1,091.00 $1,705.00 $1,839.00 $1,861.00 $1,833.00 $1,724.00 $155.00 $320.00 $545.00 $368.00 $767.00 $1,034.00 $307.00 $2,768.00 $2,906.00 $2,993.00 $947.00 $431.00 $1,362.00 $1,728.00 $1,814.00 $1,551.00 $1,518.00 $1,876.00 $1,816.00 $2,082.00 $1,468.00 $2,581.00 $3,290.00 $2,830.00 $3,917.00 $2,811.00 $3,409.00 $2,101.00 $2,541.00 $2,523.00 $2,948.00 $2,151.00 $2,581.00 $1,706.00 $2,026.00 $1,920.00 $2,220.00 $1,163.00 $2,573.00 $1,540.00 $1,305.00 $2,428.00 $1,128.00 $1,419.00 $1,160.00 $1,826.00 $1,957.00 $1,967.00 $1,950.00 $1,828.00 $169.00 $347.00 $597.00 $398.00 $834.00 $1,101.00 $328.00 $2,983.00 $3,132.00 $3,223.00 $1,026.00 $466.00 $1,461.00 $1,864.00 $1,957.00 $1,646.00 $1,639.00 $2,024.00 $1,956.00 $2,237.00 $1,585.00 $2,771.00 $3,546.00 $3,066.00 $4,216.00 $3,022.00 $3,677.00 $2,265.00 $2,734.00 $2,725.00 $3,172.00 $2,329.00 $2,784.00 $1,844.00 $2,185.00 $2,074.00 $2,392.00 $1,222.00 $2,779.00 $1,661.00 $1,411.00 $2,619.00 $1,216.00 $1,532.00 $1,251.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 186 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 35207 35211 35216 35221 35226 35231 35236 35241 35246 35251 35256 35261 35266 35271 35276 35281 35286 35301 35302 35303 35304 35305 35306 35311 35321 35331 35341 35351 35355 35361 35363 35371 35372 35390 35400 35450 35452 35454 35456 35458 35459 35460 35470 35471 35472 35473 35474 35475 35476 35480 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 $935.00 $1,833.00 $1,494.00 $1,243.00 $841.00 $1,053.00 $947.00 $1,926.00 $1,701.00 $1,260.00 $1,568.00 $1,008.00 $921.00 $1,814.00 $1,541.00 $1,396.00 $1,036.00 $1,486.00 ------------------------------$1,999.00 $1,031.00 $1,724.00 $1,908.00 $1,555.00 $1,336.00 $1,859.00 $2,006.00 $1,006.00 $1,085.00 $225.00 $224.00 $643.00 $518.00 $520.00 $631.00 $804.00 $736.00 $430.00 $537.00 $626.00 $388.00 $375.00 $456.00 $569.00 $338.00 $935.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $976.00 $1,912.00 $2,487.00 $1,970.00 $1,206.00 $1,656.00 $1,390.00 $2,006.00 $2,166.00 $2,354.00 $1,468.00 $1,469.00 $1,218.00 $1,906.00 $2,009.00 $2,245.00 $1,346.00 $1,508.00 $1,581.00 $1,736.00 $1,807.00 $1,736.00 $655.00 $2,145.00 $1,283.00 $2,101.00 $2,003.00 $1,848.00 $1,502.00 $2,275.00 $2,432.00 $1,192.00 $1,432.00 $233.00 $220.00 $735.00 $515.00 $454.00 $549.00 $702.00 $646.00 $449.00 $4,210.00 $4,681.00 $3,167.00 $2,983.00 $4,093.00 $3,113.00 $2,357.00 $823.00 $1,039.00 $2,030.00 $2,594.00 $2,089.00 $1,281.00 $1,761.00 $1,477.00 $2,134.00 $2,303.00 $2,496.00 $1,561.00 $1,562.00 $1,294.00 $2,022.00 $2,136.00 $2,384.00 $1,432.00 $1,603.00 $1,681.00 $1,845.00 $1,921.00 $1,845.00 $697.00 $2,270.00 $1,363.00 $2,235.00 $2,133.00 $1,964.00 $1,595.00 $2,419.00 $2,583.00 $1,268.00 $1,524.00 $248.00 $235.00 $778.00 $547.00 $484.00 $584.00 $745.00 $687.00 $478.00 $4,495.00 $4,996.00 $3,381.00 $3,186.00 $4,372.00 $3,316.00 $2,512.00 $870.00 $1,118.00 $2,186.00 $2,732.00 $2,248.00 $1,379.00 $1,900.00 $1,593.00 $2,304.00 $2,486.00 $2,690.00 $1,686.00 $1,686.00 $1,395.00 $2,176.00 $2,304.00 $2,571.00 $1,545.00 $1,730.00 $1,818.00 $1,995.00 $2,078.00 $1,995.00 $756.00 $2,435.00 $1,471.00 $2,415.00 $2,310.00 $2,121.00 $1,721.00 $2,613.00 $2,787.00 $1,370.00 $1,648.00 $269.00 $254.00 $837.00 $591.00 $524.00 $632.00 $804.00 $743.00 $516.00 $4,743.00 $5,266.00 $3,568.00 $3,362.00 $4,612.00 $3,494.00 $2,645.00 $932.00 $976.00 $1,912.00 $2,487.00 $1,970.00 $1,206.00 $1,656.00 $1,390.00 $2,006.00 $2,166.00 $2,354.00 $1,468.00 $1,469.00 $1,218.00 $1,906.00 $2,009.00 $2,245.00 $1,346.00 $1,508.00 $1,581.00 $1,736.00 $1,807.00 $1,736.00 $655.00 $2,145.00 $1,283.00 $2,101.00 $2,003.00 $1,848.00 $1,502.00 $2,275.00 $2,432.00 $1,192.00 $1,432.00 $233.00 $220.00 $735.00 $515.00 $454.00 $549.00 $702.00 $646.00 $449.00 $629.00 $741.00 $509.00 $447.00 $537.00 $668.00 $425.00 $823.00 $1,039.00 $2,030.00 $2,594.00 $2,089.00 $1,281.00 $1,761.00 $1,477.00 $2,134.00 $2,303.00 $2,496.00 $1,561.00 $1,562.00 $1,294.00 $2,022.00 $2,136.00 $2,384.00 $1,432.00 $1,603.00 $1,681.00 $1,845.00 $1,921.00 $1,845.00 $697.00 $2,270.00 $1,363.00 $2,235.00 $2,133.00 $1,964.00 $1,595.00 $2,419.00 $2,583.00 $1,268.00 $1,524.00 $248.00 $235.00 $778.00 $547.00 $484.00 $584.00 $745.00 $687.00 $478.00 $659.00 $773.00 $534.00 $468.00 $562.00 $696.00 $441.00 $870.00 $1,118.00 $2,186.00 $2,732.00 $2,248.00 $1,379.00 $1,900.00 $1,593.00 $2,304.00 $2,486.00 $2,690.00 $1,686.00 $1,686.00 $1,395.00 $2,176.00 $2,304.00 $2,571.00 $1,545.00 $1,730.00 $1,818.00 $1,995.00 $2,078.00 $1,995.00 $756.00 $2,435.00 $1,471.00 $2,415.00 $2,310.00 $2,121.00 $1,721.00 $2,613.00 $2,787.00 $1,370.00 $1,648.00 $269.00 $254.00 $837.00 $591.00 $524.00 $632.00 $804.00 $743.00 $516.00 $696.00 $812.00 $565.00 $496.00 $593.00 $731.00 $461.00 $932.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 187 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 35481 35482 35483 35484 35485 35490 35491 35492 35493 35494 35495 35500 35501 35506 35508 35509 35510 35511 35512 35515 35516 35518 35521 35522 35523 35525 35526 35531 35533 35536 35537 35538 35539 35540 35548 35549 35551 35556 35558 35560 35563 35565 35566 35571 35572 35583 35585 35587 35600 35601 0 0 0 0 0 0 0 0 0 0 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 $565.00 $577.00 $696.00 $853.00 $670.00 $691.00 $423.00 $423.00 $523.00 $605.00 $532.00 $423.00 $1,569.00 $1,641.00 $1,564.00 $1,529.00 ------$1,256.00 ------$1,387.00 $1,391.00 $1,313.00 $1,393.00 ------------------$1,527.00 $2,000.00 $1,716.00 $1,888.00 ------------------------$1,751.00 $1,902.00 $2,036.00 $1,745.00 $1,219.00 $1,899.00 $1,115.00 $1,312.00 $2,161.00 $1,612.00 $369.00 $1,843.00 $2,277.00 $1,698.00 $273.00 $1,495.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $582.00 $497.00 $610.00 $757.00 $712.00 $823.00 $594.00 $513.00 $618.00 $777.00 $721.00 $467.00 $2,175.00 $1,857.00 $1,896.00 $2,114.00 $1,756.00 $1,695.00 $1,722.00 $1,900.00 $1,674.00 $1,708.00 $1,819.00 $1,679.00 $1,757.00 $1,592.00 $2,429.00 $2,890.00 $2,234.00 $2,506.00 $3,069.00 $3,428.00 $3,216.00 $3,588.00 $1,725.00 $1,882.00 $2,121.00 $1,955.00 $1,753.00 $2,567.00 $1,985.00 $1,893.00 $2,347.00 $1,938.00 $502.00 $2,018.00 $2,390.00 $2,003.00 $368.00 $2,039.00 $621.00 $528.00 $650.00 $801.00 $758.00 $858.00 $625.00 $536.00 $646.00 $809.00 $754.00 $497.00 $2,314.00 $1,961.00 $2,000.00 $2,249.00 $1,841.00 $1,799.00 $1,807.00 $2,004.00 $1,759.00 $1,814.00 $1,931.00 $1,764.00 $1,845.00 $1,675.00 $2,569.00 $3,068.00 $2,370.00 $2,663.00 $3,261.00 $3,642.00 $3,417.00 $3,812.00 $1,832.00 $2,000.00 $2,253.00 $2,066.00 $1,860.00 $2,730.00 $2,109.00 $2,010.00 $2,483.00 $2,059.00 $535.00 $2,132.00 $2,532.00 $2,128.00 $392.00 $2,167.00 $673.00 $570.00 $703.00 $861.00 $821.00 $901.00 $665.00 $563.00 $679.00 $846.00 $794.00 $539.00 $2,504.00 $2,100.00 $2,136.00 $2,432.00 $1,951.00 $1,939.00 $1,916.00 $2,140.00 $1,872.00 $1,957.00 $2,080.00 $1,872.00 $1,956.00 $1,783.00 $2,751.00 $3,310.00 $2,553.00 $2,878.00 $3,525.00 $3,935.00 $3,693.00 $4,122.00 $1,974.00 $2,158.00 $2,432.00 $2,215.00 $2,004.00 $2,952.00 $2,276.00 $2,166.00 $2,664.00 $2,221.00 $580.00 $2,284.00 $2,723.00 $2,296.00 $426.00 $2,342.00 $582.00 $497.00 $610.00 $757.00 $712.00 $823.00 $594.00 $513.00 $618.00 $777.00 $721.00 $467.00 $2,175.00 $1,857.00 $1,896.00 $2,114.00 $1,756.00 $1,695.00 $1,722.00 $1,900.00 $1,674.00 $1,708.00 $1,819.00 $1,679.00 $1,757.00 $1,592.00 $2,429.00 $2,890.00 $2,234.00 $2,506.00 $3,069.00 $3,428.00 $3,216.00 $3,588.00 $1,725.00 $1,882.00 $2,121.00 $1,955.00 $1,753.00 $2,567.00 $1,985.00 $1,893.00 $2,347.00 $1,938.00 $502.00 $2,018.00 $2,390.00 $2,003.00 $368.00 $2,039.00 $621.00 $528.00 $650.00 $801.00 $758.00 $858.00 $625.00 $536.00 $646.00 $809.00 $754.00 $497.00 $2,314.00 $1,961.00 $2,000.00 $2,249.00 $1,841.00 $1,799.00 $1,807.00 $2,004.00 $1,759.00 $1,814.00 $1,931.00 $1,764.00 $1,845.00 $1,675.00 $2,569.00 $3,068.00 $2,370.00 $2,663.00 $3,261.00 $3,642.00 $3,417.00 $3,812.00 $1,832.00 $2,000.00 $2,253.00 $2,066.00 $1,860.00 $2,730.00 $2,109.00 $2,010.00 $2,483.00 $2,059.00 $535.00 $2,132.00 $2,532.00 $2,128.00 $392.00 $2,167.00 $673.00 $570.00 $703.00 $861.00 $821.00 $901.00 $665.00 $563.00 $679.00 $846.00 $794.00 $539.00 $2,504.00 $2,100.00 $2,136.00 $2,432.00 $1,951.00 $1,939.00 $1,916.00 $2,140.00 $1,872.00 $1,957.00 $2,080.00 $1,872.00 $1,956.00 $1,783.00 $2,751.00 $3,310.00 $2,553.00 $2,878.00 $3,525.00 $3,935.00 $3,693.00 $4,122.00 $1,974.00 $2,158.00 $2,432.00 $2,215.00 $2,004.00 $2,952.00 $2,276.00 $2,166.00 $2,664.00 $2,221.00 $580.00 $2,284.00 $2,723.00 $2,296.00 $426.00 $2,342.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 188 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 35606 35612 35616 35621 35623 35626 35631 35636 35637 35638 35642 35645 35646 35647 35650 35651 35654 35656 35661 35663 35665 35666 35671 35681 35682 35683 35685 35686 35691 35693 35694 35695 35697 35700 35701 35721 35741 35761 35800 35820 35840 35860 35870 35875 35876 35879 35881 35883 35884 35901 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,539.00 $1,349.00 $1,346.00 $1,265.00 $1,193.00 $1,921.00 $1,891.00 $1,656.00 ------------$1,298.00 $1,304.00 $2,105.00 $1,555.00 $1,236.00 $2,055.00 $1,603.00 $1,589.00 $1,145.00 $1,237.00 $1,333.00 $1,686.00 $1,315.00 $751.00 $627.00 $702.00 $216.00 $178.00 $1,546.00 $1,140.00 $1,353.00 $1,351.00 ------$264.00 $494.00 $500.00 $499.00 $532.00 $567.00 $951.00 $771.00 $496.00 $1,583.00 $827.00 $1,232.00 $1,163.00 $1,275.00 ------------$709.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,672.00 $1,305.00 $1,576.00 $1,602.00 $1,959.00 $2,245.00 $2,689.00 $2,360.00 $2,430.00 $2,469.00 $1,438.00 $1,466.00 $2,483.00 $2,243.00 $1,541.00 $1,972.00 $1,984.00 $1,566.00 $1,565.00 $1,811.00 $1,703.00 $1,834.00 $1,615.00 $117.00 $521.00 $614.00 $293.00 $244.00 $1,424.00 $1,256.00 $1,488.00 $1,537.00 $217.00 $224.00 $753.00 $648.00 $706.00 $519.00 $666.00 $2,386.00 $869.00 $563.00 $1,827.00 $848.00 $1,360.00 $1,334.00 $1,484.00 $1,761.00 $1,871.00 $717.00 $1,770.00 $1,383.00 $1,659.00 $1,704.00 $2,080.00 $2,388.00 $2,858.00 $2,503.00 $2,581.00 $2,623.00 $1,523.00 $1,558.00 $2,638.00 $2,383.00 $1,637.00 $2,092.00 $2,108.00 $1,664.00 $1,662.00 $1,922.00 $1,809.00 $1,949.00 $1,716.00 $124.00 $555.00 $653.00 $312.00 $259.00 $1,516.00 $1,337.00 $1,583.00 $1,633.00 $231.00 $238.00 $798.00 $689.00 $750.00 $552.00 $705.00 $2,471.00 $921.00 $596.00 $1,935.00 $901.00 $1,445.00 $1,416.00 $1,576.00 $1,873.00 $1,990.00 $764.00 $1,900.00 $1,487.00 $1,768.00 $1,841.00 $2,244.00 $2,581.00 $3,089.00 $2,697.00 $2,787.00 $2,832.00 $1,634.00 $1,681.00 $2,847.00 $2,571.00 $1,767.00 $2,253.00 $2,275.00 $1,797.00 $1,793.00 $2,071.00 $1,952.00 $2,101.00 $1,850.00 $135.00 $601.00 $707.00 $338.00 $280.00 $1,639.00 $1,445.00 $1,712.00 $1,764.00 $250.00 $258.00 $856.00 $742.00 $806.00 $592.00 $755.00 $2,577.00 $989.00 $638.00 $2,079.00 $971.00 $1,559.00 $1,526.00 $1,699.00 $2,023.00 $2,150.00 $823.00 $1,672.00 $1,305.00 $1,576.00 $1,602.00 $1,959.00 $2,245.00 $2,689.00 $2,360.00 $2,430.00 $2,469.00 $1,438.00 $1,466.00 $2,483.00 $2,243.00 $1,541.00 $1,972.00 $1,984.00 $1,566.00 $1,565.00 $1,811.00 $1,703.00 $1,834.00 $1,615.00 $117.00 $521.00 $614.00 $293.00 $244.00 $1,424.00 $1,256.00 $1,488.00 $1,537.00 $217.00 $224.00 $753.00 $648.00 $706.00 $519.00 $666.00 $2,386.00 $869.00 $563.00 $1,827.00 $848.00 $1,360.00 $1,334.00 $1,484.00 $1,761.00 $1,871.00 $717.00 $1,770.00 $1,383.00 $1,659.00 $1,704.00 $2,080.00 $2,388.00 $2,858.00 $2,503.00 $2,581.00 $2,623.00 $1,523.00 $1,558.00 $2,638.00 $2,383.00 $1,637.00 $2,092.00 $2,108.00 $1,664.00 $1,662.00 $1,922.00 $1,809.00 $1,949.00 $1,716.00 $124.00 $555.00 $653.00 $312.00 $259.00 $1,516.00 $1,337.00 $1,583.00 $1,633.00 $231.00 $238.00 $798.00 $689.00 $750.00 $552.00 $705.00 $2,471.00 $921.00 $596.00 $1,935.00 $901.00 $1,445.00 $1,416.00 $1,576.00 $1,873.00 $1,990.00 $764.00 $1,900.00 $1,487.00 $1,768.00 $1,841.00 $2,244.00 $2,581.00 $3,089.00 $2,697.00 $2,787.00 $2,832.00 $1,634.00 $1,681.00 $2,847.00 $2,571.00 $1,767.00 $2,253.00 $2,275.00 $1,797.00 $1,793.00 $2,071.00 $1,952.00 $2,101.00 $1,850.00 $135.00 $601.00 $707.00 $338.00 $280.00 $1,639.00 $1,445.00 $1,712.00 $1,764.00 $250.00 $258.00 $856.00 $742.00 $806.00 $592.00 $755.00 $2,577.00 $989.00 $638.00 $2,079.00 $971.00 $1,559.00 $1,526.00 $1,699.00 $2,023.00 $2,150.00 $823.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 189 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 35903 35905 35907 36000 36002 36005 36010 36011 36012 36013 36014 36015 36100 36120 36140 36145 36160 36200 36215 36216 36217 36218 36245 36246 36247 36248 36260 36261 36262 36299 36410 36415 36416 36425 36430 36455 36468 36469 36470 36471 36475 36476 36478 36479 36481 36500 36511 36512 36513 36514 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ 0 0 0 ZZZ 90 90 90 YYY 0 0 0 0 0 0 0 0 10 10 0 ZZZ 0 ZZZ 0 0 0 0 0 0 $818.00 $1,343.00 $1,335.00 $46.00 $181.00 $68.00 $136.00 $194.00 $186.00 $141.00 $159.00 $186.00 $176.00 $120.00 $106.00 $10.00 $196.00 $240.00 $240.00 $270.00 $325.00 $79.00 $249.00 $272.00 $323.00 $53.00 $749.00 $388.00 $297.00 BR $18.00 BR BR $86.00 $37.00 $141.00 NC NC $76.00 $96.00 ------------------------$499.00 $159.00 $92.00 $92.00 $92.00 $92.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $815.00 $2,516.00 $2,761.00 $35.00 $233.00 $451.00 $890.00 $1,355.00 $1,163.00 $1,141.00 $1,134.00 $1,237.00 $745.00 $603.00 $688.00 $674.00 $765.00 $915.00 $1,565.00 $1,700.00 $2,863.00 $274.00 $1,766.00 $1,713.00 $2,699.00 $233.00 $801.00 $484.00 $370.00 ------$24.00 ------------$51.00 $53.00 $168.00 BR BR $188.00 $231.00 $2,523.00 $523.00 $2,189.00 $532.00 $496.00 $246.00 $120.00 $121.00 $127.00 $774.00 $867.00 $2,671.00 $2,930.00 $37.00 $247.00 $482.00 $949.00 $1,446.00 $1,239.00 $1,220.00 $1,208.00 $1,317.00 $793.00 $642.00 $734.00 $718.00 $816.00 $975.00 $1,667.00 $1,810.00 $3,055.00 $292.00 $1,882.00 $1,825.00 $2,881.00 $248.00 $851.00 $514.00 $393.00 ------$26.00 ------------$53.00 $58.00 $175.00 BR BR $200.00 $246.00 $2,689.00 $553.00 $2,330.00 $562.00 $518.00 $256.00 $125.00 $126.00 $134.00 $826.00 $934.00 $2,881.00 $3,161.00 $39.00 $261.00 $507.00 $1,002.00 $1,527.00 $1,305.00 $1,288.00 $1,273.00 $1,388.00 $838.00 $677.00 $774.00 $756.00 $863.00 $1,029.00 $1,755.00 $1,906.00 $3,221.00 $308.00 $1,984.00 $1,924.00 $3,038.00 $261.00 $916.00 $551.00 $422.00 ------$27.00 ------------$56.00 $63.00 $183.00 BR BR $212.00 $262.00 $2,831.00 $581.00 $2,453.00 $590.00 $547.00 $268.00 $130.00 $131.00 $142.00 $869.00 $815.00 $2,516.00 $2,761.00 $12.00 $151.00 $66.00 $169.00 $221.00 $244.00 $179.00 $210.00 $237.00 $220.00 $136.00 $141.00 $136.00 $186.00 $211.00 $328.00 $369.00 $445.00 $71.00 $339.00 $373.00 $445.00 $71.00 $801.00 $484.00 $370.00 ------$12.00 ------------$51.00 $53.00 $168.00 BR BR $95.00 $134.00 $455.00 $222.00 $459.00 $225.00 $496.00 $246.00 $120.00 $121.00 $127.00 $119.00 $867.00 $2,671.00 $2,930.00 $13.00 $159.00 $69.00 $177.00 $231.00 $255.00 $188.00 $219.00 $247.00 $231.00 $142.00 $147.00 $141.00 $196.00 $221.00 $341.00 $384.00 $465.00 $74.00 $353.00 $389.00 $465.00 $74.00 $851.00 $514.00 $393.00 ------$12.00 ------------$53.00 $58.00 $175.00 BR BR $101.00 $142.00 $473.00 $230.00 $477.00 $233.00 $518.00 $256.00 $125.00 $126.00 $134.00 $123.00 $934.00 $2,881.00 $3,161.00 $13.00 $168.00 $72.00 $188.00 $245.00 $267.00 $200.00 $230.00 $258.00 $245.00 $150.00 $155.00 $148.00 $209.00 $233.00 $357.00 $402.00 $489.00 $78.00 $371.00 $410.00 $490.00 $78.00 $916.00 $551.00 $422.00 ------$13.00 ------------$56.00 $63.00 $183.00 BR BR $107.00 $152.00 $494.00 $240.00 $498.00 $244.00 $547.00 $268.00 $130.00 $131.00 $142.00 $128.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 190 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 36515 36516 36522 36556 36558 36561 36563 36565 36566 36569 36571 36575 36576 36578 36580 36581 36582 36583 36584 36585 36589 36590 36591 36592 36593 36595 36596 36597 36598 36600 36620 36625 36640 36680 36800 36810 36815 36818 36819 36820 36821 36822 36823 36825 36830 36831 36832 36833 36834 36835 0 0 0 0 10 10 10 10 10 0 10 0 10 10 0 10 10 10 0 10 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 $92.00 $92.00 $305.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------$24.00 $64.00 $133.00 $130.00 $72.00 $159.00 $345.00 $236.00 ------$977.00 $800.00 $721.00 $630.00 $1,461.00 $867.00 $967.00 $488.00 $810.00 $780.00 $761.00 $542.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,882.00 $3,403.00 $1,833.00 $344.00 $1,168.00 $1,623.00 $1,604.00 $1,383.00 $3,785.00 $396.00 $1,739.00 $231.00 $487.00 $687.00 $349.00 $1,052.00 $1,448.00 $1,452.00 $345.00 $1,500.00 $228.00 $365.00 $28.00 $34.00 $59.00 $887.00 $196.00 $174.00 $160.00 $41.00 $69.00 $146.00 $164.00 $85.00 $217.00 $297.00 $206.00 $968.00 $1,118.00 $1,121.00 $742.00 $524.00 $1,751.00 $809.00 $929.00 $641.00 $819.00 $925.00 $855.00 $628.00 $3,084.00 $3,644.00 $1,961.00 $364.00 $1,247.00 $1,730.00 $1,715.00 $1,472.00 $4,045.00 $422.00 $1,856.00 $249.00 $515.00 $729.00 $373.00 $1,119.00 $1,538.00 $1,542.00 $369.00 $1,595.00 $242.00 $389.00 $30.00 $37.00 $71.00 $943.00 $208.00 $183.00 $170.00 $43.00 $71.00 $154.00 $173.00 $89.00 $230.00 $314.00 $219.00 $1,035.00 $1,189.00 $1,191.00 $789.00 $559.00 $1,857.00 $860.00 $988.00 $681.00 $871.00 $983.00 $906.00 $667.00 $3,251.00 $3,843.00 $2,069.00 $384.00 $1,322.00 $1,829.00 $1,821.00 $1,557.00 $4,269.00 $446.00 $1,964.00 $268.00 $541.00 $766.00 $396.00 $1,178.00 $1,616.00 $1,619.00 $393.00 $1,676.00 $257.00 $417.00 $32.00 $39.00 $87.00 $992.00 $219.00 $193.00 $179.00 $45.00 $75.00 $166.00 $184.00 $94.00 $244.00 $336.00 $236.00 $1,125.00 $1,283.00 $1,285.00 $850.00 $602.00 $1,997.00 $926.00 $1,067.00 $735.00 $940.00 $1,062.00 $973.00 $718.00 $116.00 $85.00 $136.00 $165.00 $394.00 $467.00 $498.00 $463.00 $494.00 $131.00 $424.00 $60.00 $251.00 $287.00 $97.00 $269.00 $393.00 $396.00 $101.00 $370.00 $191.00 $274.00 $28.00 $34.00 $59.00 $256.00 $63.00 $85.00 $112.00 $21.00 $69.00 $146.00 $164.00 $85.00 $217.00 $297.00 $206.00 $968.00 $1,118.00 $1,121.00 $742.00 $524.00 $1,751.00 $809.00 $929.00 $641.00 $819.00 $925.00 $855.00 $628.00 $120.00 $88.00 $143.00 $172.00 $418.00 $492.00 $529.00 $487.00 $518.00 $138.00 $447.00 $66.00 $262.00 $300.00 $104.00 $280.00 $407.00 $410.00 $107.00 $384.00 $202.00 $291.00 $30.00 $37.00 $71.00 $266.00 $66.00 $88.00 $118.00 $21.00 $71.00 $154.00 $173.00 $89.00 $230.00 $314.00 $219.00 $1,035.00 $1,189.00 $1,191.00 $789.00 $559.00 $1,857.00 $860.00 $988.00 $681.00 $871.00 $983.00 $906.00 $667.00 $125.00 $93.00 $151.00 $181.00 $447.00 $522.00 $570.00 $517.00 $549.00 $148.00 $477.00 $74.00 $275.00 $314.00 $112.00 $293.00 $422.00 $426.00 $117.00 $399.00 $215.00 $313.00 $32.00 $39.00 $87.00 $278.00 $69.00 $93.00 $124.00 $22.00 $75.00 $166.00 $184.00 $94.00 $244.00 $336.00 $236.00 $1,125.00 $1,283.00 $1,285.00 $850.00 $602.00 $1,997.00 $926.00 $1,067.00 $735.00 $940.00 $1,062.00 $973.00 $718.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 191 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 36838 36860 36861 36870 37140 37145 37160 37180 37181 37182 37183 37184 37185 37186 37187 37188 37195 37200 37201 37202 37203 37204 37205 37206 37207 37208 37209 37210 37215 37216 37250 37251 37500 37501 37565 37600 37605 37606 37607 37609 37615 37616 37617 37618 37620 37650 37660 37700 37718 37722 90 0 0 90 90 90 90 90 90 0 0 0 ZZZ ZZZ 0 0 0 0 0 0 0 0 0 ZZZ 0 ZZZ 0 0 90 90 ZZZ ZZZ 90 YYY 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 ------$166.00 $224.00 $1,755.00 $1,666.00 $1,741.00 $1,681.00 $1,769.00 $1,923.00 $914.00 $425.00 ------------------------------$302.00 $232.00 $408.00 $340.00 $287.00 $957.00 $589.00 $288.00 $613.00 $299.00 $116.00 ------------------$112.00 $85.00 $739.00 BR $364.00 $414.00 $521.00 $563.00 $456.00 $278.00 $495.00 $1,128.00 $1,132.00 $514.00 $818.00 $430.00 $789.00 $336.00 ------------- Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,664.00 $232.00 $207.00 $2,611.00 $1,825.00 $2,018.00 $1,740.00 $1,982.00 $2,094.00 $1,186.00 $565.00 $3,491.00 $1,153.00 $2,364.00 $3,378.00 $2,903.00 ------$314.00 $382.00 $460.00 $1,834.00 $1,271.00 $3,247.00 $1,916.00 $619.00 $300.00 $156.00 $4,708.00 $1,481.00 $1,332.00 $153.00 $116.00 $969.00 ------$936.00 $980.00 $1,133.00 $742.00 $522.00 $388.00 $621.00 $1,472.00 $1,776.00 $507.00 $891.00 $698.00 $1,656.00 $348.00 $531.00 $650.00 $1,770.00 $243.00 $219.00 $2,786.00 $1,911.00 $2,139.00 $1,842.00 $2,102.00 $2,216.00 $1,233.00 $588.00 $3,723.00 $1,228.00 $2,523.00 $3,602.00 $3,098.00 ------$327.00 $399.00 $482.00 $1,953.00 $1,331.00 $3,463.00 $2,045.00 $659.00 $319.00 $163.00 $5,020.00 $1,543.00 $1,384.00 $161.00 $123.00 $1,030.00 ------$989.00 $1,037.00 $1,206.00 $791.00 $556.00 $412.00 $653.00 $1,560.00 $1,882.00 $536.00 $934.00 $740.00 $1,749.00 $371.00 $548.00 $687.00 $1,913.00 $255.00 $234.00 $2,935.00 $2,019.00 $2,299.00 $1,978.00 $2,263.00 $2,379.00 $1,291.00 $615.00 $3,923.00 $1,294.00 $2,659.00 $3,796.00 $3,266.00 ------$342.00 $419.00 $508.00 $2,057.00 $1,407.00 $3,652.00 $2,157.00 $713.00 $346.00 $171.00 $5,288.00 $1,614.00 $1,447.00 $172.00 $132.00 $1,108.00 ------$1,058.00 $1,109.00 $1,302.00 $853.00 $599.00 $439.00 $692.00 $1,675.00 $2,025.00 $573.00 $986.00 $793.00 $1,872.00 $399.00 $564.00 $732.00 $1,664.00 $136.00 $207.00 $414.00 $1,825.00 $2,018.00 $1,740.00 $1,982.00 $2,094.00 $1,186.00 $565.00 $615.00 $227.00 $342.00 $571.00 $411.00 ------$314.00 $382.00 $460.00 $362.00 $1,271.00 $611.00 $293.00 $619.00 $300.00 $156.00 $729.00 $1,481.00 $1,332.00 $153.00 $116.00 $969.00 ------$936.00 $980.00 $1,133.00 $742.00 $522.00 $265.00 $621.00 $1,472.00 $1,776.00 $507.00 $891.00 $698.00 $1,656.00 $348.00 $531.00 $650.00 $1,770.00 $141.00 $219.00 $431.00 $1,911.00 $2,139.00 $1,842.00 $2,102.00 $2,216.00 $1,233.00 $588.00 $641.00 $236.00 $356.00 $595.00 $428.00 ------$327.00 $399.00 $482.00 $376.00 $1,331.00 $638.00 $306.00 $659.00 $319.00 $163.00 $757.00 $1,543.00 $1,384.00 $161.00 $123.00 $1,030.00 ------$989.00 $1,037.00 $1,206.00 $791.00 $556.00 $281.00 $653.00 $1,560.00 $1,882.00 $536.00 $934.00 $740.00 $1,749.00 $371.00 $548.00 $687.00 $1,913.00 $147.00 $234.00 $452.00 $2,019.00 $2,299.00 $1,978.00 $2,263.00 $2,379.00 $1,291.00 $615.00 $672.00 $248.00 $374.00 $624.00 $450.00 ------$342.00 $419.00 $508.00 $394.00 $1,407.00 $672.00 $323.00 $713.00 $346.00 $171.00 $792.00 $1,614.00 $1,447.00 $172.00 $132.00 $1,108.00 ------$1,058.00 $1,109.00 $1,302.00 $853.00 $599.00 $300.00 $692.00 $1,675.00 $2,025.00 $573.00 $986.00 $793.00 $1,872.00 $399.00 $564.00 $732.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 192 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 37735 37760 37765 37766 37780 37785 37788 37790 37799 38100 38101 38102 38115 38120 38129 38200 38205 38206 38220 38221 38230 38240 38241 38242 38300 38305 38308 38380 38381 38382 38500 38505 38510 38520 38525 38530 38542 38550 38555 38562 38564 38570 38571 38572 38589 38700 38720 38724 38740 38745 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 90 YYY 0 0 0 0 0 10 0 0 0 10 90 90 90 90 90 10 0 10 90 90 90 90 90 90 90 90 10 10 10 YYY 90 90 90 90 90 $847.00 $813.00 ------------$301.00 $270.00 $1,654.00 $690.00 BR $974.00 $982.00 $332.00 $1,020.00 $1,138.00 BR $180.00 $79.00 $79.00 $212.00 $228.00 $265.00 $128.00 $128.00 $90.00 $104.00 $375.00 $425.00 $628.00 $1,087.00 $798.00 $234.00 $139.00 $349.00 $431.00 $369.00 $517.00 $507.00 $519.00 $1,115.00 $799.00 $831.00 $695.00 $902.00 $1,049.00 BR $863.00 $1,328.00 $1,366.00 $539.00 $770.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $880.00 $861.00 $601.00 $724.00 $355.00 $478.00 $1,797.00 $678.00 ------$1,392.00 $1,413.00 $346.00 $1,541.00 $1,333.00 ------$184.00 $106.00 $106.00 $215.00 $238.00 $423.00 $163.00 $163.00 $123.00 $340.00 $593.00 $566.00 $718.00 $1,096.00 $882.00 $401.00 $164.00 $645.00 $588.00 $530.00 $689.00 $544.00 $603.00 $1,263.00 $897.00 $896.00 $725.00 $1,092.00 $1,269.00 ------$972.00 $1,603.00 $1,734.00 $850.00 $1,085.00 $936.00 $915.00 $628.00 $754.00 $378.00 $509.00 $1,893.00 $710.00 ------$1,464.00 $1,489.00 $368.00 $1,620.00 $1,416.00 ------$191.00 $110.00 $110.00 $227.00 $252.00 $446.00 $169.00 $170.00 $128.00 $361.00 $631.00 $600.00 $756.00 $1,166.00 $937.00 $427.00 $174.00 $682.00 $623.00 $563.00 $733.00 $574.00 $640.00 $1,336.00 $948.00 $948.00 $768.00 $1,143.00 $1,340.00 ------$1,013.00 $1,669.00 $1,804.00 $901.00 $1,150.00 $1,009.00 $987.00 $658.00 $786.00 $406.00 $545.00 $2,013.00 $747.00 ------$1,559.00 $1,589.00 $397.00 $1,723.00 $1,525.00 ------$200.00 $114.00 $115.00 $239.00 $264.00 $474.00 $176.00 $177.00 $133.00 $384.00 $678.00 $644.00 $801.00 $1,258.00 $1,007.00 $457.00 $184.00 $727.00 $668.00 $604.00 $790.00 $610.00 $687.00 $1,429.00 $1,012.00 $1,016.00 $824.00 $1,207.00 $1,435.00 ------$1,060.00 $1,745.00 $1,885.00 $967.00 $1,237.00 $880.00 $861.00 $601.00 $724.00 $355.00 $357.00 $1,797.00 $678.00 ------$1,392.00 $1,413.00 $346.00 $1,541.00 $1,333.00 ------$184.00 $106.00 $106.00 $79.00 $101.00 $423.00 $163.00 $163.00 $123.00 $229.00 $593.00 $566.00 $718.00 $1,096.00 $882.00 $318.00 $98.00 $536.00 $588.00 $530.00 $689.00 $544.00 $603.00 $1,263.00 $897.00 $896.00 $725.00 $1,092.00 $1,269.00 ------$972.00 $1,603.00 $1,734.00 $850.00 $1,085.00 $936.00 $915.00 $628.00 $754.00 $378.00 $380.00 $1,893.00 $710.00 ------$1,464.00 $1,489.00 $368.00 $1,620.00 $1,416.00 ------$191.00 $110.00 $110.00 $82.00 $105.00 $446.00 $169.00 $170.00 $128.00 $243.00 $631.00 $600.00 $756.00 $1,166.00 $937.00 $338.00 $103.00 $566.00 $623.00 $563.00 $733.00 $574.00 $640.00 $1,336.00 $948.00 $948.00 $768.00 $1,143.00 $1,340.00 ------$1,013.00 $1,669.00 $1,804.00 $901.00 $1,150.00 $1,009.00 $987.00 $658.00 $786.00 $406.00 $409.00 $2,013.00 $747.00 ------$1,559.00 $1,589.00 $397.00 $1,723.00 $1,525.00 ------$200.00 $114.00 $115.00 $85.00 $109.00 $474.00 $176.00 $177.00 $133.00 $259.00 $678.00 $644.00 $801.00 $1,258.00 $1,007.00 $363.00 $109.00 $604.00 $668.00 $604.00 $790.00 $610.00 $687.00 $1,429.00 $1,012.00 $1,016.00 $824.00 $1,207.00 $1,435.00 ------$1,060.00 $1,745.00 $1,885.00 $967.00 $1,237.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 193 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 38746 38747 38760 38765 38770 38780 38790 38792 38794 38999 39000 39010 39200 39220 39400 39499 39501 39502 39503 39520 39530 39531 39540 39541 39545 39560 39561 39599 40490 40500 40510 40520 40525 40527 40530 40650 40652 40654 40700 40701 40702 40720 40761 40799 40800 40801 40804 40805 40806 40808 ZZZ ZZZ 90 90 90 90 0 0 90 YYY 90 90 90 90 10 YYY 90 90 90 90 90 90 90 90 90 90 90 YYY 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 10 10 10 10 0 10 $312.00 $337.00 $699.00 $1,283.00 $1,111.00 $1,357.00 $158.00 $26.00 $298.00 BR $664.00 $1,148.00 $1,249.00 $1,542.00 $614.00 BR $1,083.00 $1,268.00 $2,726.00 $1,345.00 $1,295.00 $1,243.00 $1,133.00 $1,179.00 $1,102.00 $968.00 $1,328.00 BR $108.00 $422.00 $469.00 $467.00 $714.00 $851.00 $501.00 $368.00 $436.00 $529.00 $1,009.00 $1,452.00 $1,030.00 $1,107.00 $1,202.00 BR $110.00 $208.00 $105.00 $245.00 $38.00 $100.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $362.00 $354.00 $1,071.00 $1,648.00 $1,079.00 $1,379.00 $109.00 $52.00 $402.00 ------$645.00 $1,102.00 $1,210.00 $1,543.00 $665.00 ------$1,100.00 $1,318.00 $7,493.00 $1,329.00 $1,263.00 $1,334.00 $1,122.00 $1,205.00 $1,192.00 $1,030.00 $1,588.00 ------$153.00 $604.00 $595.00 $626.00 $716.00 $846.00 $684.00 $523.00 $619.00 $717.00 $1,174.00 $1,409.00 $1,111.00 $1,311.00 $1,380.00 ------$236.00 $367.00 $247.00 $394.00 $124.00 $210.00 $386.00 $375.00 $1,136.00 $1,742.00 $1,137.00 $1,455.00 $115.00 $55.00 $422.00 ------$684.00 $1,171.00 $1,286.00 $1,637.00 $702.00 ------$1,167.00 $1,398.00 $7,880.00 $1,413.00 $1,340.00 $1,415.00 $1,189.00 $1,277.00 $1,265.00 $1,091.00 $1,683.00 ------$161.00 $640.00 $631.00 $665.00 $758.00 $895.00 $726.00 $555.00 $659.00 $762.00 $1,230.00 $1,486.00 $1,167.00 $1,391.00 $1,464.00 ------$252.00 $391.00 $263.00 $419.00 $133.00 $224.00 $418.00 $405.00 $1,221.00 $1,865.00 $1,210.00 $1,554.00 $122.00 $59.00 $445.00 ------$732.00 $1,261.00 $1,386.00 $1,759.00 $748.00 ------$1,255.00 $1,503.00 $8,402.00 $1,522.00 $1,443.00 $1,523.00 $1,277.00 $1,371.00 $1,359.00 $1,171.00 $1,807.00 ------$169.00 $677.00 $670.00 $707.00 $808.00 $953.00 $770.00 $589.00 $701.00 $810.00 $1,294.00 $1,579.00 $1,236.00 $1,490.00 $1,569.00 ------$267.00 $416.00 $278.00 $446.00 $140.00 $237.00 $362.00 $354.00 $1,071.00 $1,648.00 $1,079.00 $1,379.00 $109.00 $52.00 $402.00 ------$645.00 $1,102.00 $1,210.00 $1,543.00 $665.00 ------$1,100.00 $1,318.00 $7,493.00 $1,329.00 $1,263.00 $1,334.00 $1,122.00 $1,205.00 $1,192.00 $1,030.00 $1,588.00 ------$90.00 $452.00 $452.00 $461.00 $716.00 $846.00 $520.00 $365.00 $453.00 $540.00 $1,174.00 $1,409.00 $1,111.00 $1,311.00 $1,380.00 ------$158.00 $278.00 $160.00 $290.00 $43.00 $131.00 $386.00 $375.00 $1,136.00 $1,742.00 $1,137.00 $1,455.00 $115.00 $55.00 $422.00 ------$684.00 $1,171.00 $1,286.00 $1,637.00 $702.00 ------$1,167.00 $1,398.00 $7,880.00 $1,413.00 $1,340.00 $1,415.00 $1,189.00 $1,277.00 $1,265.00 $1,091.00 $1,683.00 ------$94.00 $477.00 $478.00 $488.00 $758.00 $895.00 $550.00 $386.00 $481.00 $573.00 $1,230.00 $1,486.00 $1,167.00 $1,391.00 $1,464.00 ------$168.00 $295.00 $170.00 $308.00 $45.00 $139.00 $418.00 $405.00 $1,221.00 $1,865.00 $1,210.00 $1,554.00 $122.00 $59.00 $445.00 ------$732.00 $1,261.00 $1,386.00 $1,759.00 $748.00 ------$1,255.00 $1,503.00 $8,402.00 $1,522.00 $1,443.00 $1,523.00 $1,277.00 $1,371.00 $1,359.00 $1,171.00 $1,807.00 ------$98.00 $505.00 $509.00 $520.00 $808.00 $953.00 $585.00 $410.00 $514.00 $610.00 $1,294.00 $1,579.00 $1,236.00 $1,490.00 $1,569.00 ------$178.00 $315.00 $180.00 $329.00 $48.00 $148.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 194 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 40810 40812 40814 40816 40818 40819 40820 40830 40831 40840 40842 40843 40844 40845 40899 41000 41005 41006 41007 41008 41009 41010 41015 41016 41017 41018 41019 41100 41105 41108 41110 41112 41113 41114 41115 41116 41120 41130 41135 41140 41145 41150 41153 41155 41250 41251 41252 41500 41510 41520 10 10 90 90 90 90 10 10 10 90 90 90 90 90 YYY 10 10 90 90 90 90 10 90 90 90 90 0 10 10 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 10 10 10 90 90 90 $141.00 $202.00 $319.00 $336.00 $249.00 $208.00 $104.00 $140.00 $213.00 $687.00 $684.00 $947.00 $1,232.00 $1,593.00 BR $119.00 $109.00 $237.00 $283.00 $248.00 $319.00 $91.00 $267.00 $357.00 $300.00 $424.00 ------$140.00 $136.00 $110.00 $159.00 $255.00 $301.00 $682.00 $176.00 $242.00 $813.00 $937.00 $1,869.00 $2,005.00 $2,406.00 $1,897.00 $2,091.00 $2,448.00 $168.00 $203.00 $294.00 $334.00 $313.00 $255.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $237.00 $338.00 $460.00 $482.00 $419.00 $364.00 $300.00 $293.00 $388.00 $1,005.00 $1,016.00 $1,285.00 $1,711.00 $1,885.00 ------$193.00 $261.00 $437.00 $434.00 $448.00 $478.00 $239.00 $517.00 $531.00 $535.00 $618.00 $626.00 $204.00 $202.00 $173.00 $248.00 $396.00 $435.00 $812.00 $284.00 $382.00 $1,316.00 $1,604.00 $2,677.00 $2,789.00 $3,451.00 $2,735.00 $2,946.00 $3,610.00 $270.00 $294.00 $375.00 $573.00 $538.00 $412.00 $252.00 $360.00 $490.00 $512.00 $444.00 $387.00 $320.00 $311.00 $414.00 $1,068.00 $1,080.00 $1,362.00 $1,817.00 $1,995.00 ------$205.00 $278.00 $464.00 $461.00 $476.00 $509.00 $254.00 $549.00 $565.00 $570.00 $658.00 $652.00 $217.00 $215.00 $184.00 $263.00 $420.00 $462.00 $857.00 $302.00 $406.00 $1,389.00 $1,685.00 $2,806.00 $2,936.00 $3,622.00 $2,870.00 $3,085.00 $3,766.00 $286.00 $312.00 $398.00 $608.00 $569.00 $438.00 $267.00 $383.00 $522.00 $544.00 $469.00 $412.00 $338.00 $330.00 $440.00 $1,139.00 $1,152.00 $1,451.00 $1,941.00 $2,123.00 ------$217.00 $294.00 $493.00 $488.00 $508.00 $543.00 $267.00 $584.00 $604.00 $609.00 $704.00 $685.00 $231.00 $227.00 $194.00 $278.00 $445.00 $490.00 $910.00 $320.00 $429.00 $1,464.00 $1,769.00 $2,947.00 $3,100.00 $3,810.00 $3,016.00 $3,235.00 $3,938.00 $303.00 $330.00 $421.00 $642.00 $598.00 $464.00 $157.00 $248.00 $384.00 $400.00 $337.00 $293.00 $204.00 $201.00 $285.00 $823.00 $822.00 $1,042.00 $1,453.00 $1,644.00 ------$140.00 $157.00 $332.00 $316.00 $344.00 $376.00 $135.00 $427.00 $442.00 $445.00 $522.00 $626.00 $141.00 $141.00 $114.00 $164.00 $314.00 $350.00 $812.00 $186.00 $274.00 $1,316.00 $1,604.00 $2,677.00 $2,789.00 $3,451.00 $2,735.00 $2,946.00 $3,610.00 $174.00 $208.00 $273.00 $573.00 $538.00 $323.00 $166.00 $264.00 $408.00 $424.00 $357.00 $312.00 $216.00 $213.00 $303.00 $873.00 $872.00 $1,101.00 $1,541.00 $1,737.00 ------$148.00 $167.00 $351.00 $334.00 $365.00 $400.00 $143.00 $453.00 $471.00 $474.00 $555.00 $652.00 $150.00 $149.00 $120.00 $173.00 $332.00 $371.00 $857.00 $197.00 $290.00 $1,389.00 $1,685.00 $2,806.00 $2,936.00 $3,622.00 $2,870.00 $3,085.00 $3,766.00 $184.00 $220.00 $288.00 $608.00 $569.00 $343.00 $177.00 $282.00 $435.00 $451.00 $376.00 $332.00 $229.00 $227.00 $323.00 $934.00 $932.00 $1,176.00 $1,650.00 $1,850.00 ------$157.00 $176.00 $374.00 $354.00 $391.00 $428.00 $150.00 $483.00 $504.00 $507.00 $595.00 $685.00 $160.00 $158.00 $127.00 $183.00 $353.00 $394.00 $910.00 $210.00 $307.00 $1,464.00 $1,769.00 $2,947.00 $3,100.00 $3,810.00 $3,016.00 $3,235.00 $3,938.00 $195.00 $233.00 $306.00 $642.00 $598.00 $363.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 195 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 41599 41800 41805 41806 41820 41821 41822 41823 41825 41826 41827 41828 41830 41850 41870 41872 41874 41899 42000 42100 42104 42106 42107 42120 42140 42145 42160 42180 42182 42200 42205 42210 42215 42220 42225 42226 42227 42235 42260 42280 42281 42299 42300 42305 42310 42320 42330 42335 42340 42400 YYY 10 10 10 0 0 10 90 10 10 90 10 10 0 0 90 90 YYY 10 10 10 10 90 90 90 90 10 10 10 90 90 90 90 90 90 90 90 90 90 10 10 YYY 10 90 10 10 10 90 90 0 BR $107.00 $115.00 $217.00 NC NC $237.00 $312.00 $144.00 $211.00 $322.00 $176.00 $156.00 NC NC $249.00 $193.00 BR $106.00 $122.00 $161.00 $204.00 $409.00 $573.00 $174.00 $741.00 $176.00 $222.00 $324.00 $946.00 $863.00 $1,174.00 $766.00 $586.00 $803.00 $848.00 $762.00 $631.00 $491.00 $148.00 $160.00 BR $165.00 $448.00 $145.00 $208.00 $184.00 $287.00 $411.00 $94.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) ------$251.00 $253.00 $393.00 BR BR $352.00 $508.00 $244.00 $322.00 $506.00 $378.00 $467.00 BR BR $436.00 $445.00 ------$194.00 $182.00 $243.00 $311.00 $552.00 $1,192.00 $295.00 $878.00 $299.00 $296.00 $408.00 $1,154.00 $1,198.00 $1,415.00 $933.00 $740.00 $1,254.00 $1,226.00 $1,208.00 $984.00 $1,072.00 $193.00 $247.00 ------$253.00 $551.00 $198.00 $303.00 $283.00 $447.00 $570.00 $132.00 ------$268.00 $270.00 $419.00 BR BR $376.00 $542.00 $260.00 $343.00 $537.00 $404.00 $498.00 BR BR $463.00 $475.00 ------$206.00 $193.00 $258.00 $331.00 $585.00 $1,248.00 $313.00 $921.00 $318.00 $313.00 $433.00 $1,220.00 $1,270.00 $1,509.00 $996.00 $783.00 $1,329.00 $1,299.00 $1,280.00 $1,042.00 $1,140.00 $205.00 $261.00 ------$268.00 $580.00 $210.00 $321.00 $300.00 $474.00 $604.00 $141.00 ------$283.00 $286.00 $447.00 BR BR $401.00 $578.00 $276.00 $366.00 $569.00 $433.00 $531.00 BR BR $491.00 $508.00 ------$218.00 $204.00 $274.00 $353.00 $620.00 $1,303.00 $330.00 $969.00 $336.00 $330.00 $460.00 $1,298.00 $1,357.00 $1,626.00 $1,072.00 $833.00 $1,406.00 $1,378.00 $1,358.00 $1,103.00 $1,219.00 $219.00 $276.00 ------$283.00 $612.00 $222.00 $340.00 $317.00 $501.00 $639.00 $148.00 ------$152.00 $193.00 $317.00 BR BR $228.00 $401.00 $168.00 $251.00 $379.00 $296.00 $362.00 BR BR $329.00 $330.00 ------$130.00 $138.00 $171.00 $232.00 $436.00 $1,192.00 $193.00 $878.00 $198.00 $234.00 $347.00 $1,154.00 $1,198.00 $1,415.00 $933.00 $740.00 $1,254.00 $1,226.00 $1,208.00 $984.00 $901.00 $138.00 $194.00 ------$193.00 $551.00 $157.00 $228.00 $209.00 $330.00 $437.00 $76.00 ------$161.00 $206.00 $338.00 BR BR $242.00 $427.00 $179.00 $267.00 $400.00 $315.00 $385.00 BR BR $348.00 $352.00 ------$137.00 $146.00 $181.00 $247.00 $461.00 $1,248.00 $204.00 $921.00 $210.00 $246.00 $367.00 $1,220.00 $1,270.00 $1,509.00 $996.00 $783.00 $1,329.00 $1,299.00 $1,280.00 $1,042.00 $957.00 $146.00 $205.00 ------$204.00 $580.00 $166.00 $240.00 $220.00 $348.00 $461.00 $79.00 ------$170.00 $218.00 $361.00 BR BR $260.00 $457.00 $190.00 $286.00 $424.00 $339.00 $413.00 BR BR $370.00 $379.00 ------$145.00 $155.00 $192.00 $263.00 $490.00 $1,303.00 $215.00 $969.00 $222.00 $260.00 $391.00 $1,298.00 $1,357.00 $1,626.00 $1,072.00 $833.00 $1,406.00 $1,378.00 $1,358.00 $1,103.00 $1,026.00 $156.00 $217.00 ------$215.00 $612.00 $175.00 $254.00 $233.00 $368.00 $488.00 $84.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 196 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 42405 42408 42409 42410 42415 42420 42425 42426 42440 42450 42500 42505 42507 42508 42509 42510 42550 42600 42650 42660 42665 42699 42700 42720 42725 42800 42802 42804 42806 42808 42809 42810 42815 42821 42826 42831 42836 42842 42844 42845 42860 42870 42890 42892 42894 42900 42950 42953 42955 42960 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 0 0 90 YYY 10 10 90 10 10 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 10 $258.00 $377.00 $266.00 $746.00 $1,364.00 $1,577.00 $1,097.00 $1,882.00 $634.00 $395.00 $407.00 $559.00 $522.00 $767.00 $915.00 $711.00 $82.00 $445.00 $67.00 $89.00 $238.00 BR $144.00 $270.00 $720.00 $123.00 $150.00 $136.00 $167.00 $250.00 $152.00 $335.00 $659.00 $378.00 $320.00 $235.00 $286.00 $729.00 $1,173.00 $1,958.00 $207.00 $427.00 $1,047.00 $1,262.00 $1,825.00 $429.00 $745.00 $752.00 $561.00 $178.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $376.00 $559.00 $401.00 $806.00 $1,445.00 $1,660.00 $1,094.00 $1,778.00 $594.00 $559.00 $531.00 $696.00 $650.00 $926.00 $1,099.00 $807.00 $202.00 $591.00 $101.00 $130.00 $368.00 ------$228.00 $569.00 $1,031.00 $191.00 $305.00 $250.00 $283.00 $282.00 $212.00 $476.00 $705.00 $393.00 $324.00 $284.00 $312.00 $1,196.00 $1,709.00 $2,785.00 $237.00 $722.00 $1,707.00 $2,221.00 $2,865.00 $452.00 $1,014.00 $1,286.00 $954.00 $217.00 $398.00 $592.00 $426.00 $850.00 $1,516.00 $1,741.00 $1,148.00 $1,865.00 $625.00 $591.00 $563.00 $736.00 $685.00 $981.00 $1,156.00 $850.00 $213.00 $626.00 $107.00 $138.00 $390.00 ------$241.00 $597.00 $1,081.00 $202.00 $324.00 $266.00 $300.00 $298.00 $225.00 $505.00 $743.00 $413.00 $341.00 $299.00 $329.00 $1,255.00 $1,796.00 $2,915.00 $250.00 $764.00 $1,786.00 $2,318.00 $2,994.00 $476.00 $1,073.00 $1,364.00 $1,012.00 $229.00 $420.00 $628.00 $451.00 $903.00 $1,601.00 $1,838.00 $1,212.00 $1,970.00 $661.00 $626.00 $596.00 $779.00 $723.00 $1,046.00 $1,221.00 $898.00 $224.00 $662.00 $114.00 $145.00 $413.00 ------$254.00 $629.00 $1,140.00 $214.00 $342.00 $280.00 $317.00 $315.00 $238.00 $534.00 $786.00 $437.00 $360.00 $316.00 $347.00 $1,317.00 $1,888.00 $3,058.00 $264.00 $807.00 $1,870.00 $2,422.00 $3,135.00 $506.00 $1,135.00 $1,444.00 $1,074.00 $242.00 $292.00 $422.00 $288.00 $806.00 $1,445.00 $1,660.00 $1,094.00 $1,778.00 $594.00 $459.00 $437.00 $588.00 $650.00 $926.00 $1,099.00 $807.00 $86.00 $451.00 $76.00 $100.00 $264.00 ------$171.00 $505.00 $1,031.00 $142.00 $176.00 $148.00 $174.00 $212.00 $165.00 $360.00 $705.00 $393.00 $324.00 $284.00 $312.00 $1,196.00 $1,709.00 $2,785.00 $237.00 $722.00 $1,707.00 $2,221.00 $2,865.00 $452.00 $1,014.00 $1,286.00 $954.00 $217.00 $308.00 $446.00 $304.00 $850.00 $1,516.00 $1,741.00 $1,148.00 $1,865.00 $625.00 $484.00 $462.00 $620.00 $685.00 $981.00 $1,156.00 $850.00 $89.00 $475.00 $80.00 $106.00 $278.00 ------$180.00 $529.00 $1,081.00 $150.00 $186.00 $156.00 $184.00 $223.00 $173.00 $380.00 $743.00 $413.00 $341.00 $299.00 $329.00 $1,255.00 $1,796.00 $2,915.00 $250.00 $764.00 $1,786.00 $2,318.00 $2,994.00 $476.00 $1,073.00 $1,364.00 $1,012.00 $229.00 $325.00 $474.00 $322.00 $903.00 $1,601.00 $1,838.00 $1,212.00 $1,970.00 $661.00 $513.00 $490.00 $657.00 $723.00 $1,046.00 $1,221.00 $898.00 $93.00 $503.00 $85.00 $111.00 $295.00 ------$190.00 $556.00 $1,140.00 $158.00 $196.00 $165.00 $194.00 $236.00 $183.00 $403.00 $786.00 $437.00 $360.00 $316.00 $347.00 $1,317.00 $1,888.00 $3,058.00 $264.00 $807.00 $1,870.00 $2,422.00 $3,135.00 $506.00 $1,135.00 $1,444.00 $1,074.00 $242.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 197 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 42961 42962 42970 42971 42972 42999 43020 43030 43045 43100 43101 43107 43108 43112 43113 43116 43117 43118 43121 43122 43123 43124 43130 43135 43200 43201 43202 43204 43205 43215 43216 43217 43219 43220 43226 43227 43228 43231 43232 43234 43235 43236 43237 43238 43239 43240 43241 43242 43243 43244 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 $406.00 $602.00 $284.00 $472.00 $562.00 BR $696.00 $712.00 $1,574.00 $744.00 $1,248.00 $2,325.00 $2,664.00 $2,471.00 $2,755.00 $2,509.00 $2,469.00 $2,607.00 $2,350.00 $2,287.00 $2,661.00 $2,242.00 $1,020.00 $1,332.00 $266.00 $245.00 $205.00 $228.00 $207.00 $160.00 $149.00 $176.00 $171.00 $128.00 $142.00 $218.00 $230.00 $182.00 $252.00 $193.00 $239.00 $285.00 ------------$246.00 $369.00 $157.00 $384.00 $276.00 $268.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $539.00 $667.00 $495.00 $588.00 $670.00 ------$701.00 $678.00 $1,725.00 $808.00 $1,358.00 $3,344.00 $5,172.00 $3,590.00 $5,113.00 $5,774.00 $3,266.00 $4,348.00 $3,514.00 $3,320.00 $5,220.00 $4,465.00 $1,023.00 $1,861.00 $281.00 $366.00 $368.00 $288.00 $289.00 $202.00 $232.00 $495.00 $223.00 $165.00 $183.00 $271.00 $289.00 $245.00 $342.00 $366.00 $388.00 $481.00 $315.00 $383.00 $447.00 $513.00 $201.00 $545.00 $344.00 $382.00 $567.00 $701.00 $519.00 $618.00 $705.00 ------$741.00 $713.00 $1,826.00 $852.00 $1,444.00 $3,538.00 $5,345.00 $3,803.00 $5,297.00 $5,936.00 $3,455.00 $4,516.00 $3,670.00 $3,516.00 $5,397.00 $4,626.00 $1,077.00 $1,952.00 $299.00 $388.00 $391.00 $302.00 $303.00 $212.00 $244.00 $526.00 $234.00 $173.00 $192.00 $284.00 $304.00 $256.00 $358.00 $388.00 $412.00 $510.00 $332.00 $402.00 $473.00 $538.00 $210.00 $570.00 $360.00 $399.00 $599.00 $740.00 $546.00 $652.00 $745.00 ------$790.00 $755.00 $1,958.00 $905.00 $1,557.00 $3,795.00 $5,562.00 $4,085.00 $5,531.00 $6,126.00 $3,707.00 $4,729.00 $3,871.00 $3,778.00 $5,619.00 $4,829.00 $1,144.00 $2,071.00 $315.00 $409.00 $413.00 $319.00 $319.00 $224.00 $258.00 $556.00 $248.00 $182.00 $203.00 $300.00 $323.00 $269.00 $378.00 $410.00 $435.00 $538.00 $355.00 $426.00 $499.00 $569.00 $222.00 $601.00 $379.00 $421.00 $539.00 $667.00 $495.00 $588.00 $670.00 ------$701.00 $678.00 $1,725.00 $808.00 $1,358.00 $3,344.00 $5,172.00 $3,590.00 $5,113.00 $5,774.00 $3,266.00 $4,348.00 $3,514.00 $3,320.00 $5,220.00 $4,465.00 $1,023.00 $1,861.00 $136.00 $167.00 $148.00 $288.00 $289.00 $202.00 $186.00 $221.00 $223.00 $165.00 $183.00 $271.00 $289.00 $245.00 $342.00 $155.00 $186.00 $225.00 $315.00 $383.00 $221.00 $513.00 $201.00 $545.00 $344.00 $382.00 $567.00 $701.00 $519.00 $618.00 $705.00 ------$741.00 $713.00 $1,826.00 $852.00 $1,444.00 $3,538.00 $5,345.00 $3,803.00 $5,297.00 $5,936.00 $3,455.00 $4,516.00 $3,670.00 $3,516.00 $5,397.00 $4,626.00 $1,077.00 $1,952.00 $143.00 $175.00 $156.00 $302.00 $303.00 $212.00 $196.00 $232.00 $234.00 $173.00 $192.00 $284.00 $304.00 $256.00 $358.00 $163.00 $195.00 $236.00 $332.00 $402.00 $231.00 $538.00 $210.00 $570.00 $360.00 $399.00 $599.00 $740.00 $546.00 $652.00 $745.00 ------$790.00 $755.00 $1,958.00 $905.00 $1,557.00 $3,795.00 $5,562.00 $4,085.00 $5,531.00 $6,126.00 $3,707.00 $4,729.00 $3,871.00 $3,778.00 $5,619.00 $4,829.00 $1,144.00 $2,071.00 $151.00 $185.00 $164.00 $319.00 $319.00 $224.00 $207.00 $246.00 $248.00 $182.00 $203.00 $300.00 $323.00 $269.00 $378.00 $172.00 $206.00 $248.00 $355.00 $426.00 $244.00 $569.00 $222.00 $601.00 $379.00 $421.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 198 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 43245 43246 43247 43248 43249 43250 43251 43255 43256 43257 43258 43259 43260 43261 43262 43263 43264 43265 43267 43268 43269 43271 43272 43280 43289 43300 43305 43310 43312 43313 43314 43320 43324 43325 43326 43330 43331 43340 43341 43350 43351 43352 43360 43361 43400 43401 43405 43410 43415 43420 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $214.00 $485.00 $229.00 $191.00 $175.00 $194.00 $224.00 $343.00 $235.00 ------$276.00 $271.00 $349.00 $362.00 $447.00 $386.00 $522.00 $527.00 $434.00 $446.00 $410.00 $437.00 $401.00 $1,314.00 BR $837.00 $1,428.00 $2,138.00 $2,331.00 $2,632.00 $2,891.00 $1,299.00 $1,280.00 $1,261.00 $1,198.00 $1,236.00 $1,378.00 $1,292.00 $1,351.00 $986.00 $1,180.00 $1,028.00 $2,277.00 $2,596.00 $1,261.00 $1,299.00 $1,330.00 $946.00 $1,382.00 $854.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $243.00 $325.00 $259.00 $243.00 $224.00 $244.00 $281.00 $364.00 $328.00 $395.00 $343.00 $388.00 $447.00 $470.00 $552.00 $545.00 $663.00 $745.00 $544.00 $559.00 $612.00 $552.00 $553.00 $1,374.00 ------$816.00 $1,442.00 $2,037.00 $2,245.00 $3,603.00 $3,880.00 $1,751.00 $1,720.00 $1,691.00 $1,729.00 $1,661.00 $1,800.00 $1,725.00 $1,855.00 $1,449.00 $1,739.00 $1,402.00 $3,017.00 $3,369.00 $1,927.00 $1,955.00 $1,884.00 $1,283.00 $2,217.00 $1,267.00 $255.00 $340.00 $272.00 $254.00 $235.00 $256.00 $295.00 $381.00 $343.00 $412.00 $359.00 $406.00 $467.00 $492.00 $578.00 $570.00 $693.00 $779.00 $569.00 $585.00 $640.00 $577.00 $579.00 $1,457.00 ------$866.00 $1,515.00 $2,166.00 $2,386.00 $3,807.00 $4,110.00 $1,852.00 $1,821.00 $1,788.00 $1,834.00 $1,757.00 $1,910.00 $1,820.00 $1,964.00 $1,516.00 $1,839.00 $1,483.00 $3,197.00 $3,546.00 $2,018.00 $2,067.00 $1,993.00 $1,354.00 $2,348.00 $1,330.00 $269.00 $359.00 $287.00 $268.00 $247.00 $270.00 $311.00 $401.00 $362.00 $433.00 $378.00 $426.00 $492.00 $518.00 $609.00 $600.00 $730.00 $820.00 $599.00 $616.00 $674.00 $608.00 $610.00 $1,567.00 ------$927.00 $1,604.00 $2,339.00 $2,577.00 $4,075.00 $4,422.00 $1,986.00 $1,955.00 $1,915.00 $1,973.00 $1,885.00 $2,054.00 $1,943.00 $2,108.00 $1,597.00 $1,966.00 $1,588.00 $3,436.00 $3,774.00 $2,129.00 $2,215.00 $2,134.00 $1,445.00 $2,522.00 $1,408.00 $243.00 $325.00 $259.00 $243.00 $224.00 $244.00 $281.00 $364.00 $328.00 $395.00 $343.00 $388.00 $447.00 $470.00 $552.00 $545.00 $663.00 $745.00 $544.00 $559.00 $612.00 $552.00 $553.00 $1,374.00 ------$816.00 $1,442.00 $2,037.00 $2,245.00 $3,603.00 $3,880.00 $1,751.00 $1,720.00 $1,691.00 $1,729.00 $1,661.00 $1,800.00 $1,725.00 $1,855.00 $1,449.00 $1,739.00 $1,402.00 $3,017.00 $3,369.00 $1,927.00 $1,955.00 $1,884.00 $1,283.00 $2,217.00 $1,267.00 $255.00 $340.00 $272.00 $254.00 $235.00 $256.00 $295.00 $381.00 $343.00 $412.00 $359.00 $406.00 $467.00 $492.00 $578.00 $570.00 $693.00 $779.00 $569.00 $585.00 $640.00 $577.00 $579.00 $1,457.00 ------$866.00 $1,515.00 $2,166.00 $2,386.00 $3,807.00 $4,110.00 $1,852.00 $1,821.00 $1,788.00 $1,834.00 $1,757.00 $1,910.00 $1,820.00 $1,964.00 $1,516.00 $1,839.00 $1,483.00 $3,197.00 $3,546.00 $2,018.00 $2,067.00 $1,993.00 $1,354.00 $2,348.00 $1,330.00 $269.00 $359.00 $287.00 $268.00 $247.00 $270.00 $311.00 $401.00 $362.00 $433.00 $378.00 $426.00 $492.00 $518.00 $609.00 $600.00 $730.00 $820.00 $599.00 $616.00 $674.00 $608.00 $610.00 $1,567.00 ------$927.00 $1,604.00 $2,339.00 $2,577.00 $4,075.00 $4,422.00 $1,986.00 $1,955.00 $1,915.00 $1,973.00 $1,885.00 $2,054.00 $1,943.00 $2,108.00 $1,597.00 $1,966.00 $1,588.00 $3,436.00 $3,774.00 $2,129.00 $2,215.00 $2,134.00 $1,445.00 $2,522.00 $1,408.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 199 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 43425 43450 43453 43456 43458 43460 43496 43499 43500 43501 43502 43510 43520 43600 43605 43610 43611 43620 43621 43622 43631 43632 43633 43634 43635 43640 43641 43644 43645 43651 43652 43653 43659 43752 43760 43761 43770 43771 43772 43773 43774 43800 43810 43820 43825 43830 43831 43832 43840 43842 90 0 0 0 0 0 90 YYY 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 YYY 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,338.00 $91.00 $102.00 $149.00 $164.00 $203.00 BR BR $649.00 $1,105.00 $1,247.00 $680.00 $599.00 $96.00 $686.00 $861.00 $1,001.00 $1,691.00 $1,718.00 $1,798.00 $1,445.00 $1,443.00 $1,467.00 $1,786.00 $143.00 $1,119.00 $1,138.00 ------------$716.00 $856.00 $617.00 BR BR $81.00 $107.00 ------------------------------$793.00 $846.00 $896.00 $1,128.00 $592.00 $593.00 $904.00 $893.00 $1,260.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,921.00 $207.00 $389.00 $805.00 $502.00 $284.00 ------------$968.00 $1,675.00 $1,907.00 $1,215.00 $886.00 $136.00 $1,032.00 $1,222.00 $1,514.00 $2,479.00 $2,780.00 $2,842.00 $1,826.00 $2,392.00 $2,295.00 $2,525.00 $148.00 $1,457.00 $1,477.00 $2,157.00 $2,316.00 $816.00 $967.00 $690.00 ------$52.00 $251.00 $160.00 $1,390.00 $1,590.00 $1,197.00 $1,590.00 $1,200.00 $1,158.00 $1,250.00 $1,576.00 $1,615.00 $855.00 $711.00 $1,315.00 $1,602.00 $1,539.00 $2,034.00 $219.00 $414.00 $858.00 $532.00 $297.00 ------------$1,023.00 $1,772.00 $2,019.00 $1,281.00 $939.00 $142.00 $1,091.00 $1,293.00 $1,601.00 $2,620.00 $2,926.00 $2,996.00 $1,933.00 $2,504.00 $2,408.00 $2,649.00 $157.00 $1,540.00 $1,561.00 $2,275.00 $2,446.00 $866.00 $1,026.00 $731.00 ------$54.00 $268.00 $167.00 $1,472.00 $1,684.00 $1,268.00 $1,685.00 $1,270.00 $1,225.00 $1,322.00 $1,653.00 $1,708.00 $904.00 $754.00 $1,391.00 $1,681.00 $1,627.00 $2,184.00 $231.00 $436.00 $905.00 $561.00 $314.00 ------------$1,095.00 $1,900.00 $2,168.00 $1,362.00 $1,007.00 $150.00 $1,169.00 $1,387.00 $1,716.00 $2,809.00 $3,121.00 $3,202.00 $2,077.00 $2,652.00 $2,558.00 $2,812.00 $170.00 $1,650.00 $1,672.00 $2,430.00 $2,618.00 $932.00 $1,103.00 $783.00 ------$55.00 $283.00 $175.00 $1,581.00 $1,809.00 $1,362.00 $1,810.00 $1,362.00 $1,314.00 $1,416.00 $1,755.00 $1,831.00 $968.00 $809.00 $1,489.00 $1,784.00 $1,745.00 $1,921.00 $114.00 $123.00 $200.00 $234.00 $284.00 ------------$968.00 $1,675.00 $1,907.00 $1,215.00 $886.00 $136.00 $1,032.00 $1,222.00 $1,514.00 $2,479.00 $2,780.00 $2,842.00 $1,826.00 $2,392.00 $2,295.00 $2,525.00 $148.00 $1,457.00 $1,477.00 $2,157.00 $2,316.00 $816.00 $967.00 $690.00 ------$52.00 $69.00 $139.00 $1,390.00 $1,590.00 $1,197.00 $1,590.00 $1,200.00 $1,158.00 $1,250.00 $1,576.00 $1,615.00 $855.00 $711.00 $1,315.00 $1,602.00 $1,539.00 $2,034.00 $120.00 $129.00 $209.00 $246.00 $297.00 ------------$1,023.00 $1,772.00 $2,019.00 $1,281.00 $939.00 $142.00 $1,091.00 $1,293.00 $1,601.00 $2,620.00 $2,926.00 $2,996.00 $1,933.00 $2,504.00 $2,408.00 $2,649.00 $157.00 $1,540.00 $1,561.00 $2,275.00 $2,446.00 $866.00 $1,026.00 $731.00 ------$54.00 $72.00 $144.00 $1,472.00 $1,684.00 $1,268.00 $1,685.00 $1,270.00 $1,225.00 $1,322.00 $1,653.00 $1,708.00 $904.00 $754.00 $1,391.00 $1,681.00 $1,627.00 $2,184.00 $127.00 $136.00 $221.00 $259.00 $314.00 ------------$1,095.00 $1,900.00 $2,168.00 $1,362.00 $1,007.00 $150.00 $1,169.00 $1,387.00 $1,716.00 $2,809.00 $3,121.00 $3,202.00 $2,077.00 $2,652.00 $2,558.00 $2,812.00 $170.00 $1,650.00 $1,672.00 $2,430.00 $2,618.00 $932.00 $1,103.00 $783.00 ------$55.00 $77.00 $152.00 $1,581.00 $1,809.00 $1,362.00 $1,810.00 $1,362.00 $1,314.00 $1,416.00 $1,755.00 $1,831.00 $968.00 $809.00 $1,489.00 $1,784.00 $1,745.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 200 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 43843 43845 43846 43847 43848 43850 43855 43860 43865 43870 43880 43886 43887 43888 43999 44005 44010 44015 44020 44021 44025 44050 44055 44100 44110 44111 44120 44121 44125 44126 44127 44128 44130 44133 44136 44139 44140 44141 44143 44144 44145 44146 44147 44150 44151 44155 44156 44157 44158 44160 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 90 90 90 90 0 90 90 90 ZZZ 90 90 90 ZZZ 90 0 0 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,249.00 ------$1,528.00 $1,678.00 $1,795.00 $1,425.00 $1,454.00 $1,435.00 $1,549.00 $590.00 $1,352.00 ------------------BR $1,171.00 $809.00 $1,171.00 $891.00 $888.00 $905.00 $862.00 $957.00 $117.00 $784.00 $963.00 $1,078.00 $308.00 $1,135.00 $1,951.00 $2,243.00 $242.00 $938.00 BR BR $154.00 $1,350.00 $1,488.00 $1,536.00 $1,442.00 $1,678.00 $1,840.00 $1,452.00 $1,661.00 $1,499.00 $1,892.00 $1,709.00 ------------$1,236.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,575.00 $2,469.00 $2,032.00 $2,231.00 $2,415.00 $2,032.00 $2,117.00 $2,053.00 $2,142.00 $870.00 $2,009.00 $398.00 $385.00 $547.00 ------$1,366.00 $1,070.00 $190.00 $1,204.00 $1,213.00 $1,224.00 $1,167.00 $1,860.00 $148.00 $1,047.00 $1,225.00 $1,508.00 $320.00 $1,473.00 $3,038.00 $3,547.00 $325.00 $1,536.00 ------------$160.00 $1,688.00 $2,145.00 $2,064.00 $2,130.00 $2,104.00 $2,576.00 $2,266.00 $2,265.00 $2,591.00 $2,536.00 $2,799.00 $2,833.00 $2,907.00 $1,545.00 $1,665.00 $2,614.00 $2,149.00 $2,360.00 $2,555.00 $2,150.00 $2,241.00 $2,171.00 $2,268.00 $920.00 $2,126.00 $416.00 $408.00 $579.00 ------$1,445.00 $1,132.00 $202.00 $1,272.00 $1,282.00 $1,294.00 $1,235.00 $1,965.00 $156.00 $1,105.00 $1,295.00 $1,590.00 $340.00 $1,556.00 $3,206.00 $3,750.00 $346.00 $1,609.00 ------------$169.00 $1,786.00 $2,248.00 $2,178.00 $2,238.00 $2,224.00 $2,709.00 $2,365.00 $2,386.00 $2,728.00 $2,667.00 $2,952.00 $2,994.00 $3,072.00 $1,633.00 $1,785.00 $2,809.00 $2,304.00 $2,531.00 $2,741.00 $2,307.00 $2,407.00 $2,330.00 $2,435.00 $983.00 $2,283.00 $435.00 $437.00 $618.00 ------$1,549.00 $1,212.00 $218.00 $1,363.00 $1,374.00 $1,386.00 $1,326.00 $2,104.00 $165.00 $1,182.00 $1,386.00 $1,699.00 $367.00 $1,666.00 $3,432.00 $4,023.00 $374.00 $1,704.00 ------------$182.00 $1,917.00 $2,380.00 $2,329.00 $2,381.00 $2,383.00 $2,882.00 $2,495.00 $2,542.00 $2,906.00 $2,835.00 $3,151.00 $3,198.00 $3,283.00 $1,748.00 $1,575.00 $2,469.00 $2,032.00 $2,231.00 $2,415.00 $2,032.00 $2,117.00 $2,053.00 $2,142.00 $870.00 $2,009.00 $398.00 $385.00 $547.00 ------$1,366.00 $1,070.00 $190.00 $1,204.00 $1,213.00 $1,224.00 $1,167.00 $1,860.00 $148.00 $1,047.00 $1,225.00 $1,508.00 $320.00 $1,473.00 $3,038.00 $3,547.00 $325.00 $1,536.00 ------------$160.00 $1,688.00 $2,145.00 $2,064.00 $2,130.00 $2,104.00 $2,576.00 $2,266.00 $2,265.00 $2,591.00 $2,536.00 $2,799.00 $2,833.00 $2,907.00 $1,545.00 $1,665.00 $2,614.00 $2,149.00 $2,360.00 $2,555.00 $2,150.00 $2,241.00 $2,171.00 $2,268.00 $920.00 $2,126.00 $416.00 $408.00 $579.00 ------$1,445.00 $1,132.00 $202.00 $1,272.00 $1,282.00 $1,294.00 $1,235.00 $1,965.00 $156.00 $1,105.00 $1,295.00 $1,590.00 $340.00 $1,556.00 $3,206.00 $3,750.00 $346.00 $1,609.00 ------------$169.00 $1,786.00 $2,248.00 $2,178.00 $2,238.00 $2,224.00 $2,709.00 $2,365.00 $2,386.00 $2,728.00 $2,667.00 $2,952.00 $2,994.00 $3,072.00 $1,633.00 $1,785.00 $2,809.00 $2,304.00 $2,531.00 $2,741.00 $2,307.00 $2,407.00 $2,330.00 $2,435.00 $983.00 $2,283.00 $435.00 $437.00 $618.00 ------$1,549.00 $1,212.00 $218.00 $1,363.00 $1,374.00 $1,386.00 $1,326.00 $2,104.00 $165.00 $1,182.00 $1,386.00 $1,699.00 $367.00 $1,666.00 $3,432.00 $4,023.00 $374.00 $1,704.00 ------------$182.00 $1,917.00 $2,380.00 $2,329.00 $2,381.00 $2,383.00 $2,882.00 $2,495.00 $2,542.00 $2,906.00 $2,835.00 $3,151.00 $3,198.00 $3,283.00 $1,748.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 201 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 44180 44186 44187 44188 44202 44203 44204 44205 44206 44207 44208 44210 44211 44212 44213 44227 44238 44300 44310 44312 44314 44316 44320 44322 44340 44345 44346 44360 44361 44363 44364 44365 44366 44369 44370 44372 44373 44376 44377 44378 44379 44380 44382 44383 44385 44386 44388 44389 44390 44391 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 ZZZ 90 YYY 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ------------------------$1,603.00 $235.00 $1,353.00 $1,198.00 $1,480.00 $1,620.00 $1,752.00 $1,551.00 $1,926.00 $1,800.00 ------------BR $697.00 $950.00 $453.00 $892.00 $1,229.00 $1,029.00 $1,015.00 $397.00 $816.00 $923.00 $177.00 $195.00 $213.00 $255.00 $226.00 $300.00 $308.00 $253.00 $301.00 $238.00 $305.00 $320.00 $410.00 $396.00 $91.00 $110.00 $165.00 $219.00 $183.00 $326.00 $301.00 $319.00 $376.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,162.00 $819.00 $1,376.00 $1,517.00 $1,749.00 $319.00 $1,952.00 $1,708.00 $2,209.00 $2,323.00 $2,527.00 $2,251.00 $2,769.00 $2,582.00 $251.00 $2,109.00 ------$1,044.00 $1,306.00 $727.00 $1,252.00 $1,726.00 $1,488.00 $1,181.00 $737.00 $1,302.00 $1,456.00 $202.00 $222.00 $266.00 $283.00 $252.00 $334.00 $340.00 $368.00 $331.00 $265.00 $392.00 $413.00 $532.00 $570.00 $88.00 $106.00 $227.00 $304.00 $448.00 $433.00 $512.00 $591.00 $671.00 $1,231.00 $868.00 $1,455.00 $1,605.00 $1,852.00 $338.00 $2,065.00 $1,807.00 $2,336.00 $2,455.00 $2,670.00 $2,378.00 $2,925.00 $2,726.00 $266.00 $2,231.00 ------$1,104.00 $1,380.00 $766.00 $1,321.00 $1,817.00 $1,573.00 $1,252.00 $778.00 $1,377.00 $1,537.00 $211.00 $232.00 $278.00 $296.00 $263.00 $350.00 $356.00 $385.00 $346.00 $277.00 $411.00 $432.00 $557.00 $598.00 $92.00 $111.00 $237.00 $322.00 $477.00 $459.00 $543.00 $627.00 $711.00 $1,321.00 $932.00 $1,557.00 $1,719.00 $1,990.00 $365.00 $2,215.00 $1,940.00 $2,504.00 $2,631.00 $2,860.00 $2,547.00 $3,131.00 $2,914.00 $286.00 $2,393.00 ------$1,183.00 $1,478.00 $815.00 $1,409.00 $1,936.00 $1,684.00 $1,339.00 $831.00 $1,474.00 $1,643.00 $222.00 $245.00 $294.00 $312.00 $277.00 $368.00 $375.00 $407.00 $366.00 $292.00 $434.00 $455.00 $587.00 $633.00 $97.00 $118.00 $250.00 $340.00 $504.00 $486.00 $574.00 $662.00 $751.00 $1,162.00 $819.00 $1,376.00 $1,517.00 $1,749.00 $319.00 $1,952.00 $1,708.00 $2,209.00 $2,323.00 $2,527.00 $2,251.00 $2,769.00 $2,582.00 $251.00 $2,109.00 ------$1,044.00 $1,306.00 $727.00 $1,252.00 $1,726.00 $1,488.00 $1,181.00 $737.00 $1,302.00 $1,456.00 $202.00 $222.00 $266.00 $283.00 $252.00 $334.00 $340.00 $368.00 $331.00 $265.00 $392.00 $413.00 $532.00 $570.00 $88.00 $106.00 $227.00 $138.00 $163.00 $215.00 $240.00 $290.00 $327.00 $1,231.00 $868.00 $1,455.00 $1,605.00 $1,852.00 $338.00 $2,065.00 $1,807.00 $2,336.00 $2,455.00 $2,670.00 $2,378.00 $2,925.00 $2,726.00 $266.00 $2,231.00 ------$1,104.00 $1,380.00 $766.00 $1,321.00 $1,817.00 $1,573.00 $1,252.00 $778.00 $1,377.00 $1,537.00 $211.00 $232.00 $278.00 $296.00 $263.00 $350.00 $356.00 $385.00 $346.00 $277.00 $411.00 $432.00 $557.00 $598.00 $92.00 $111.00 $237.00 $145.00 $172.00 $226.00 $251.00 $304.00 $343.00 $1,321.00 $932.00 $1,557.00 $1,719.00 $1,990.00 $365.00 $2,215.00 $1,940.00 $2,504.00 $2,631.00 $2,860.00 $2,547.00 $3,131.00 $2,914.00 $286.00 $2,393.00 ------$1,183.00 $1,478.00 $815.00 $1,409.00 $1,936.00 $1,684.00 $1,339.00 $831.00 $1,474.00 $1,643.00 $222.00 $245.00 $294.00 $312.00 $277.00 $368.00 $375.00 $407.00 $366.00 $292.00 $434.00 $455.00 $587.00 $633.00 $97.00 $118.00 $250.00 $153.00 $182.00 $240.00 $266.00 $321.00 $362.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 202 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 44392 44393 44394 44397 44500 44602 44603 44604 44605 44615 44620 44625 44626 44640 44650 44660 44661 44680 44700 44701 44720 44721 44799 44800 44820 44850 44899 44900 44901 44950 44955 44960 44970 44979 45000 45005 45020 45100 45108 45110 45111 45112 45113 45114 45116 45119 45120 45121 45123 45126 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 0 0 YYY 90 90 90 YYY 90 0 90 ZZZ 90 90 YYY 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $359.00 $413.00 $395.00 $259.00 $28.00 $815.00 $1,041.00 $1,027.00 $1,132.00 $994.00 $741.00 $1,277.00 $1,581.00 $1,036.00 $1,076.00 $1,050.00 $1,326.00 $1,049.00 $1,115.00 $161.00 ------------BR $791.00 $755.00 $708.00 BR $644.00 $310.00 $643.00 $136.00 $790.00 $631.00 BR $329.00 $197.00 $364.00 $321.00 $419.00 $1,801.00 $1,270.00 $1,904.00 $1,885.00 $1,732.00 $1,485.00 $1,911.00 $1,845.00 $1,870.00 $1,126.00 $2,444.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $555.00 $633.00 $645.00 $351.00 $34.00 $1,676.00 $1,914.00 $1,329.00 $1,638.00 $1,343.00 $1,065.00 $1,267.00 $2,033.00 $1,768.00 $1,838.00 $1,741.00 $1,977.00 $1,327.00 $1,283.00 $220.00 $338.00 $510.00 ------$949.00 $1,042.00 $925.00 ------$932.00 $1,368.00 $807.00 $111.00 $1,073.00 $736.00 ------$496.00 $315.00 $635.00 $350.00 $430.00 $2,308.00 $1,358.00 $2,376.00 $2,435.00 $2,234.00 $2,014.00 $2,432.00 $1,948.00 $2,145.00 $1,371.00 $3,566.00 $588.00 $671.00 $684.00 $368.00 $35.00 $1,754.00 $2,004.00 $1,405.00 $1,731.00 $1,420.00 $1,122.00 $1,336.00 $2,150.00 $1,868.00 $1,943.00 $1,827.00 $2,082.00 $1,401.00 $1,353.00 $233.00 $353.00 $542.00 ------$1,006.00 $1,103.00 $979.00 ------$983.00 $1,459.00 $855.00 $118.00 $1,134.00 $780.00 ------$521.00 $335.00 $663.00 $371.00 $456.00 $2,437.00 $1,436.00 $2,502.00 $2,567.00 $2,357.00 $2,123.00 $2,561.00 $2,056.00 $2,265.00 $1,442.00 $3,742.00 $622.00 $709.00 $723.00 $389.00 $37.00 $1,858.00 $2,123.00 $1,507.00 $1,854.00 $1,520.00 $1,198.00 $1,428.00 $2,306.00 $2,002.00 $2,084.00 $1,938.00 $2,221.00 $1,499.00 $1,444.00 $250.00 $372.00 $586.00 ------$1,079.00 $1,181.00 $1,048.00 ------$1,050.00 $1,537.00 $919.00 $127.00 $1,214.00 $837.00 ------$551.00 $357.00 $696.00 $396.00 $488.00 $2,605.00 $1,538.00 $2,669.00 $2,740.00 $2,520.00 $2,265.00 $2,728.00 $2,199.00 $2,424.00 $1,536.00 $3,967.00 $286.00 $360.00 $332.00 $351.00 $34.00 $1,676.00 $1,914.00 $1,329.00 $1,638.00 $1,343.00 $1,065.00 $1,267.00 $2,033.00 $1,768.00 $1,838.00 $1,741.00 $1,977.00 $1,327.00 $1,283.00 $220.00 $338.00 $510.00 ------$949.00 $1,042.00 $925.00 ------$932.00 $233.00 $807.00 $111.00 $1,073.00 $736.00 ------$496.00 $193.00 $635.00 $350.00 $430.00 $2,308.00 $1,358.00 $2,376.00 $2,435.00 $2,234.00 $2,014.00 $2,432.00 $1,948.00 $2,145.00 $1,371.00 $3,566.00 $300.00 $378.00 $348.00 $368.00 $35.00 $1,754.00 $2,004.00 $1,405.00 $1,731.00 $1,420.00 $1,122.00 $1,336.00 $2,150.00 $1,868.00 $1,943.00 $1,827.00 $2,082.00 $1,401.00 $1,353.00 $233.00 $353.00 $542.00 ------$1,006.00 $1,103.00 $979.00 ------$983.00 $243.00 $855.00 $118.00 $1,134.00 $780.00 ------$521.00 $205.00 $663.00 $371.00 $456.00 $2,437.00 $1,436.00 $2,502.00 $2,567.00 $2,357.00 $2,123.00 $2,561.00 $2,056.00 $2,265.00 $1,442.00 $3,742.00 $319.00 $400.00 $369.00 $389.00 $37.00 $1,858.00 $2,123.00 $1,507.00 $1,854.00 $1,520.00 $1,198.00 $1,428.00 $2,306.00 $2,002.00 $2,084.00 $1,938.00 $2,221.00 $1,499.00 $1,444.00 $250.00 $372.00 $586.00 ------$1,079.00 $1,181.00 $1,048.00 ------$1,050.00 $255.00 $919.00 $127.00 $1,214.00 $837.00 ------$551.00 $219.00 $696.00 $396.00 $488.00 $2,605.00 $1,538.00 $2,669.00 $2,740.00 $2,520.00 $2,265.00 $2,728.00 $2,199.00 $2,424.00 $1,536.00 $3,967.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 203 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 45130 45135 45136 45150 45160 45170 45190 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45327 45330 45331 45332 45333 45334 45335 45337 45338 45339 45340 45341 45342 45345 45355 45378 45379 45380 45381 45382 45383 45384 45385 45386 45387 45391 45392 45395 45397 45400 45402 45500 45505 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 $1,041.00 $1,354.00 $1,526.00 $475.00 $949.00 $697.00 $623.00 $75.00 $72.00 $102.00 $172.00 $137.00 $174.00 $211.00 $209.00 $230.00 $154.00 $96.00 $87.00 $120.00 $174.00 $176.00 $171.00 $144.00 $144.00 $212.00 $237.00 $328.00 $153.00 $224.00 $164.00 $185.00 $341.00 $415.00 $369.00 $388.00 $481.00 $482.00 $415.00 $479.00 $739.00 $322.00 ------------------------------------$584.00 $510.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,341.00 $1,653.00 $2,274.00 $477.00 $1,219.00 $958.00 $826.00 $127.00 $1,039.00 $213.00 $246.00 $208.00 $246.00 $264.00 $251.00 $254.00 $128.00 $147.00 $172.00 $220.00 $360.00 $359.00 $211.00 $291.00 $184.00 $403.00 $398.00 $511.00 $201.00 $307.00 $222.00 $267.00 $510.00 $644.00 $609.00 $591.00 $806.00 $725.00 $600.00 $687.00 $864.00 $444.00 $387.00 $483.00 $2,493.00 $2,687.00 $1,440.00 $1,931.00 $618.00 $676.00 $1,411.00 $1,743.00 $2,389.00 $503.00 $1,285.00 $1,011.00 $873.00 $135.00 $1,109.00 $226.00 $260.00 $220.00 $263.00 $279.00 $265.00 $270.00 $134.00 $153.00 $182.00 $234.00 $383.00 $382.00 $221.00 $309.00 $193.00 $428.00 $421.00 $544.00 $210.00 $321.00 $232.00 $282.00 $540.00 $682.00 $645.00 $625.00 $853.00 $767.00 $635.00 $726.00 $919.00 $465.00 $405.00 $504.00 $2,633.00 $2,829.00 $1,519.00 $2,036.00 $652.00 $713.00 $1,502.00 $1,861.00 $2,536.00 $537.00 $1,371.00 $1,080.00 $932.00 $141.00 $1,168.00 $239.00 $273.00 $231.00 $281.00 $295.00 $279.00 $285.00 $141.00 $162.00 $192.00 $246.00 $405.00 $403.00 $232.00 $326.00 $204.00 $452.00 $445.00 $574.00 $221.00 $338.00 $245.00 $300.00 $571.00 $720.00 $681.00 $659.00 $899.00 $810.00 $670.00 $766.00 $970.00 $492.00 $429.00 $529.00 $2,815.00 $3,014.00 $1,620.00 $2,174.00 $693.00 $760.00 $1,341.00 $1,653.00 $2,274.00 $477.00 $1,219.00 $958.00 $826.00 $59.00 $99.00 $95.00 $118.00 $99.00 $125.00 $134.00 $141.00 $134.00 $128.00 $147.00 $80.00 $95.00 $142.00 $141.00 $211.00 $117.00 $184.00 $182.00 $242.00 $147.00 $201.00 $307.00 $222.00 $267.00 $280.00 $350.00 $335.00 $316.00 $426.00 $435.00 $351.00 $398.00 $344.00 $444.00 $387.00 $483.00 $2,493.00 $2,687.00 $1,440.00 $1,931.00 $618.00 $676.00 $1,411.00 $1,743.00 $2,389.00 $503.00 $1,285.00 $1,011.00 $873.00 $61.00 $102.00 $100.00 $123.00 $103.00 $134.00 $141.00 $148.00 $141.00 $134.00 $153.00 $84.00 $100.00 $149.00 $148.00 $221.00 $123.00 $193.00 $191.00 $254.00 $154.00 $210.00 $321.00 $232.00 $282.00 $293.00 $367.00 $351.00 $330.00 $446.00 $456.00 $368.00 $417.00 $361.00 $465.00 $405.00 $504.00 $2,633.00 $2,829.00 $1,519.00 $2,036.00 $652.00 $713.00 $1,502.00 $1,861.00 $2,536.00 $537.00 $1,371.00 $1,080.00 $932.00 $64.00 $105.00 $106.00 $129.00 $108.00 $144.00 $149.00 $156.00 $149.00 $141.00 $162.00 $88.00 $106.00 $158.00 $156.00 $232.00 $129.00 $204.00 $202.00 $268.00 $163.00 $221.00 $338.00 $245.00 $300.00 $310.00 $388.00 $371.00 $347.00 $469.00 $482.00 $388.00 $440.00 $382.00 $492.00 $429.00 $529.00 $2,815.00 $3,014.00 $1,620.00 $2,174.00 $693.00 $760.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 204 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 45520 45540 45541 45550 45560 45562 45563 45800 45805 45820 45825 45900 45905 45910 45915 45990 45999 46020 46030 46040 46045 46050 46060 46080 46083 46200 46210 46211 46220 46221 46230 46250 46255 46257 46258 46260 46261 46262 46270 46275 46280 46285 46288 46320 46500 46505 46600 46604 46606 46608 0 90 90 90 90 90 90 90 90 90 90 10 10 10 10 0 YYY 10 10 90 90 10 90 10 10 90 90 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 0 0 0 0 $46.00 $1,009.00 $888.00 $1,350.00 $618.00 $915.00 $1,412.00 $1,050.00 $1,273.00 $1,066.00 $1,241.00 $120.00 $133.00 $163.00 $142.00 ------BR $230.00 $94.00 $393.00 $312.00 $105.00 $482.00 $246.00 $98.00 $323.00 $196.00 $353.00 $118.00 $124.00 $198.00 $400.00 $501.00 $504.00 $539.00 $598.00 $655.00 $686.00 $328.00 $442.00 $514.00 $335.00 $521.00 $126.00 $109.00 ------$38.00 $92.00 $66.00 $115.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $142.00 $1,309.00 $1,127.00 $1,820.00 $890.00 $1,360.00 $2,010.00 $1,509.00 $1,736.00 $1,493.00 $1,793.00 $242.00 $206.00 $243.00 $385.00 $136.00 ------$303.00 $150.00 $597.00 $486.00 $212.00 $537.00 $277.00 $200.00 $447.00 $426.00 $572.00 $221.00 $286.00 $310.00 $515.00 $580.00 $485.00 $529.00 $554.00 $618.00 $642.00 $547.00 $572.00 $535.00 $542.00 $632.00 $204.00 $232.00 $316.00 $103.00 $599.00 $255.00 $277.00 $151.00 $1,378.00 $1,189.00 $1,919.00 $938.00 $1,434.00 $2,127.00 $1,586.00 $1,822.00 $1,563.00 $1,886.00 $255.00 $218.00 $257.00 $408.00 $143.00 ------$320.00 $160.00 $634.00 $512.00 $225.00 $568.00 $294.00 $213.00 $475.00 $453.00 $608.00 $234.00 $303.00 $329.00 $547.00 $616.00 $514.00 $559.00 $586.00 $653.00 $678.00 $579.00 $605.00 $565.00 $571.00 $666.00 $217.00 $247.00 $331.00 $110.00 $641.00 $271.00 $296.00 $160.00 $1,470.00 $1,268.00 $2,049.00 $998.00 $1,528.00 $2,280.00 $1,684.00 $1,930.00 $1,650.00 $2,006.00 $272.00 $233.00 $274.00 $432.00 $152.00 ------$341.00 $170.00 $676.00 $543.00 $239.00 $606.00 $314.00 $226.00 $506.00 $482.00 $646.00 $249.00 $322.00 $351.00 $583.00 $657.00 $549.00 $597.00 $627.00 $695.00 $723.00 $614.00 $642.00 $602.00 $604.00 $710.00 $230.00 $261.00 $346.00 $116.00 $677.00 $286.00 $314.00 $49.00 $1,309.00 $1,127.00 $1,820.00 $890.00 $1,360.00 $2,010.00 $1,509.00 $1,736.00 $1,493.00 $1,793.00 $242.00 $206.00 $243.00 $275.00 $136.00 ------$268.00 $107.00 $485.00 $486.00 $114.00 $537.00 $198.00 $126.00 $359.00 $300.00 $445.00 $139.00 $220.00 $211.00 $370.00 $423.00 $485.00 $529.00 $554.00 $618.00 $642.00 $431.00 $464.00 $535.00 $452.00 $632.00 $134.00 $149.00 $264.00 $48.00 $86.00 $89.00 $104.00 $51.00 $1,378.00 $1,189.00 $1,919.00 $938.00 $1,434.00 $2,127.00 $1,586.00 $1,822.00 $1,563.00 $1,886.00 $255.00 $218.00 $257.00 $290.00 $143.00 ------$283.00 $113.00 $514.00 $512.00 $120.00 $568.00 $209.00 $133.00 $381.00 $319.00 $472.00 $147.00 $232.00 $223.00 $392.00 $448.00 $514.00 $559.00 $586.00 $653.00 $678.00 $455.00 $490.00 $565.00 $475.00 $666.00 $141.00 $158.00 $275.00 $50.00 $91.00 $93.00 $110.00 $54.00 $1,470.00 $1,268.00 $2,049.00 $998.00 $1,528.00 $2,280.00 $1,684.00 $1,930.00 $1,650.00 $2,006.00 $272.00 $233.00 $274.00 $308.00 $152.00 ------$301.00 $121.00 $550.00 $543.00 $129.00 $606.00 $224.00 $141.00 $406.00 $340.00 $503.00 $156.00 $247.00 $239.00 $418.00 $479.00 $549.00 $597.00 $627.00 $695.00 $723.00 $483.00 $520.00 $602.00 $502.00 $710.00 $151.00 $168.00 $287.00 $53.00 $97.00 $98.00 $118.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 205 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 46610 46611 46612 46614 46615 46700 46706 46710 46712 46715 46716 46730 46735 46740 46742 46744 46746 46748 46750 46753 46754 46760 46761 46762 46900 46910 46916 46917 46922 46924 46937 46938 46940 46942 46945 46946 46947 46999 47000 47001 47010 47011 47015 47100 47120 47122 47125 47130 47135 47136 0 0 0 0 0 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 10 10 10 10 10 10 10 90 10 10 90 90 90 YYY 0 ZZZ 90 0 90 90 90 90 90 90 90 90 $114.00 $149.00 $196.00 $169.00 $202.00 $585.00 $140.00 ------------$545.00 $906.00 $1,584.00 $1,881.00 $1,671.00 $2,236.00 $2,412.00 $2,725.00 $2,933.00 $636.00 $511.00 $188.00 $846.00 $813.00 $731.00 $128.00 $144.00 $145.00 $228.00 $189.00 $297.00 $268.00 $405.00 $165.00 $145.00 $199.00 $270.00 ------BR $218.00 $141.00 $788.00 $347.00 $755.00 $550.00 $1,663.00 $2,512.00 $2,293.00 $2,482.00 $6,164.00 $4,985.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $268.00 $222.00 $339.00 $169.00 $202.00 $763.00 $204.00 $1,291.00 $2,723.00 $610.00 $1,369.00 $2,225.00 $2,643.00 $2,474.00 $2,894.00 $4,234.00 $4,780.00 $4,714.00 $922.00 $699.00 $331.00 $1,313.00 $1,137.00 $1,102.00 $259.00 $273.00 $270.00 $553.00 $291.00 $608.00 $292.00 $507.00 $248.00 $228.00 $317.00 $352.00 $462.00 ------$367.00 $137.00 $1,466.00 $254.00 $1,400.00 $1,030.00 $2,922.00 $4,364.00 $3,915.00 $4,209.00 $6,183.00 $5,265.00 $285.00 $238.00 $364.00 $182.00 $218.00 $803.00 $216.00 $1,353.00 $2,868.00 $646.00 $1,441.00 $2,332.00 $2,775.00 $2,586.00 $3,031.00 $4,467.00 $5,056.00 $4,879.00 $969.00 $738.00 $349.00 $1,380.00 $1,196.00 $1,156.00 $274.00 $290.00 $285.00 $590.00 $310.00 $647.00 $307.00 $539.00 $263.00 $241.00 $336.00 $374.00 $492.00 ------$389.00 $146.00 $1,542.00 $264.00 $1,475.00 $1,091.00 $3,093.00 $4,619.00 $4,145.00 $4,455.00 $6,542.00 $5,571.00 $303.00 $254.00 $390.00 $196.00 $237.00 $854.00 $231.00 $1,430.00 $3,055.00 $693.00 $1,529.00 $2,465.00 $2,943.00 $2,723.00 $3,203.00 $4,776.00 $5,425.00 $5,077.00 $1,028.00 $788.00 $367.00 $1,465.00 $1,270.00 $1,223.00 $290.00 $307.00 $300.00 $625.00 $330.00 $684.00 $322.00 $576.00 $279.00 $255.00 $355.00 $397.00 $530.00 ------$410.00 $157.00 $1,638.00 $276.00 $1,570.00 $1,169.00 $3,319.00 $4,961.00 $4,453.00 $4,787.00 $7,020.00 $5,979.00 $102.00 $109.00 $135.00 $97.00 $139.00 $763.00 $204.00 $1,291.00 $2,723.00 $610.00 $1,369.00 $2,225.00 $2,643.00 $2,474.00 $2,894.00 $4,234.00 $4,780.00 $4,714.00 $922.00 $699.00 $247.00 $1,313.00 $1,137.00 $1,102.00 $168.00 $160.00 $171.00 $164.00 $162.00 $223.00 $204.00 $432.00 $181.00 $161.00 $252.00 $269.00 $462.00 ------$132.00 $137.00 $1,466.00 $254.00 $1,400.00 $1,030.00 $2,922.00 $4,364.00 $3,915.00 $4,209.00 $6,183.00 $5,265.00 $108.00 $117.00 $145.00 $104.00 $150.00 $803.00 $216.00 $1,353.00 $2,868.00 $646.00 $1,441.00 $2,332.00 $2,775.00 $2,586.00 $3,031.00 $4,467.00 $5,056.00 $4,879.00 $969.00 $738.00 $259.00 $1,380.00 $1,196.00 $1,156.00 $176.00 $169.00 $179.00 $173.00 $172.00 $234.00 $212.00 $458.00 $191.00 $169.00 $266.00 $285.00 $492.00 ------$137.00 $146.00 $1,542.00 $264.00 $1,475.00 $1,091.00 $3,093.00 $4,619.00 $4,145.00 $4,455.00 $6,542.00 $5,571.00 $116.00 $126.00 $159.00 $114.00 $166.00 $854.00 $231.00 $1,430.00 $3,055.00 $693.00 $1,529.00 $2,465.00 $2,943.00 $2,723.00 $3,203.00 $4,776.00 $5,425.00 $5,077.00 $1,028.00 $788.00 $272.00 $1,465.00 $1,270.00 $1,223.00 $187.00 $180.00 $188.00 $185.00 $184.00 $249.00 $222.00 $491.00 $203.00 $180.00 $282.00 $303.00 $530.00 ------$144.00 $157.00 $1,638.00 $276.00 $1,570.00 $1,169.00 $3,319.00 $4,961.00 $4,453.00 $4,787.00 $7,020.00 $5,979.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 206 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 47146 47147 47300 47350 47360 47361 47362 47370 47371 47379 47380 47381 47382 47399 47400 47420 47425 47460 47480 47490 47500 47505 47510 47511 47525 47530 47550 47552 47553 47554 47555 47556 47560 47561 47562 47563 47564 47570 47579 47600 47605 47610 47612 47620 47630 47700 47701 47711 47712 47715 0 0 90 90 90 90 90 90 90 YYY 90 90 10 YYY 90 90 90 90 90 90 0 0 90 90 10 90 ZZZ 0 0 0 0 0 0 0 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 90 ------------$778.00 $942.00 $1,305.00 $2,129.00 $849.00 $943.00 $889.00 BR $1,107.00 $1,094.00 $660.00 BR $1,435.00 $1,222.00 $1,275.00 $1,039.00 $755.00 $467.00 $103.00 $96.00 $487.00 $627.00 $295.00 $35.00 $209.00 $364.00 $342.00 $594.00 $383.00 $425.00 $345.00 $388.00 $837.00 $900.00 $1,069.00 $961.00 BR $868.00 $935.00 $1,164.00 $1,276.00 $1,295.00 $465.00 $1,111.00 $1,913.00 $1,442.00 $1,793.00 $1,157.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $437.00 $509.00 $1,378.00 $1,696.00 $2,303.00 $3,827.00 $1,748.00 $1,569.00 $1,578.00 ------$1,823.00 $1,860.00 $1,096.00 ------$2,607.00 $1,671.00 $1,687.00 $1,571.00 $1,042.00 $683.00 $135.00 $52.00 $650.00 $806.00 $1,035.00 $1,918.00 $219.00 $438.00 $435.00 $667.00 $521.00 $588.00 $353.00 $382.00 $918.00 $949.00 $1,101.00 $979.00 ------$1,291.00 $1,223.00 $1,565.00 $1,578.00 $1,713.00 $741.00 $1,302.00 $2,188.00 $1,941.00 $2,491.00 $1,629.00 $464.00 $541.00 $1,455.00 $1,793.00 $2,429.00 $4,041.00 $1,844.00 $1,662.00 $1,673.00 ------$1,928.00 $1,966.00 $1,143.00 ------$2,732.00 $1,768.00 $1,784.00 $1,658.00 $1,101.00 $714.00 $141.00 $54.00 $679.00 $840.00 $1,097.00 $2,043.00 $232.00 $457.00 $452.00 $703.00 $541.00 $611.00 $375.00 $405.00 $974.00 $1,008.00 $1,169.00 $1,039.00 ------$1,361.00 $1,296.00 $1,656.00 $1,669.00 $1,813.00 $775.00 $1,380.00 $2,321.00 $2,053.00 $2,634.00 $1,723.00 $502.00 $586.00 $1,555.00 $1,921.00 $2,596.00 $4,324.00 $1,970.00 $1,786.00 $1,800.00 ------$2,068.00 $2,106.00 $1,199.00 ------$2,892.00 $1,897.00 $1,913.00 $1,771.00 $1,175.00 $747.00 $147.00 $56.00 $711.00 $880.00 $1,154.00 $2,152.00 $250.00 $481.00 $473.00 $751.00 $567.00 $640.00 $405.00 $437.00 $1,046.00 $1,085.00 $1,260.00 $1,119.00 ------$1,451.00 $1,391.00 $1,777.00 $1,789.00 $1,945.00 $815.00 $1,483.00 $2,499.00 $2,202.00 $2,824.00 $1,846.00 $437.00 $509.00 $1,378.00 $1,696.00 $2,303.00 $3,827.00 $1,748.00 $1,569.00 $1,578.00 ------$1,823.00 $1,860.00 $1,096.00 ------$2,607.00 $1,671.00 $1,687.00 $1,571.00 $1,042.00 $683.00 $135.00 $52.00 $650.00 $806.00 $424.00 $488.00 $219.00 $438.00 $435.00 $667.00 $521.00 $588.00 $353.00 $382.00 $918.00 $949.00 $1,101.00 $979.00 ------$1,291.00 $1,223.00 $1,565.00 $1,578.00 $1,713.00 $741.00 $1,302.00 $2,188.00 $1,941.00 $2,491.00 $1,629.00 $464.00 $541.00 $1,455.00 $1,793.00 $2,429.00 $4,041.00 $1,844.00 $1,662.00 $1,673.00 ------$1,928.00 $1,966.00 $1,143.00 ------$2,732.00 $1,768.00 $1,784.00 $1,658.00 $1,101.00 $714.00 $141.00 $54.00 $679.00 $840.00 $443.00 $510.00 $232.00 $457.00 $452.00 $703.00 $541.00 $611.00 $375.00 $405.00 $974.00 $1,008.00 $1,169.00 $1,039.00 ------$1,361.00 $1,296.00 $1,656.00 $1,669.00 $1,813.00 $775.00 $1,380.00 $2,321.00 $2,053.00 $2,634.00 $1,723.00 $502.00 $586.00 $1,555.00 $1,921.00 $2,596.00 $4,324.00 $1,970.00 $1,786.00 $1,800.00 ------$2,068.00 $2,106.00 $1,199.00 ------$2,892.00 $1,897.00 $1,913.00 $1,771.00 $1,175.00 $747.00 $147.00 $56.00 $711.00 $880.00 $464.00 $535.00 $250.00 $481.00 $473.00 $751.00 $567.00 $640.00 $405.00 $437.00 $1,046.00 $1,085.00 $1,260.00 $1,119.00 ------$1,451.00 $1,391.00 $1,777.00 $1,789.00 $1,945.00 $815.00 $1,483.00 $2,499.00 $2,202.00 $2,824.00 $1,846.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 207 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 47720 47721 47740 47741 47760 47765 47780 47785 47800 47801 47802 47900 47999 48000 48001 48020 48100 48102 48105 48120 48140 48145 48146 48148 48150 48152 48153 48154 48155 48160 48400 48500 48510 48511 48520 48540 48545 48547 48548 48552 48554 48556 48999 49000 49002 49010 49020 49021 49040 49041 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 90 90 0 90 90 90 90 90 0 90 90 YYY 90 90 90 90 0 90 0 $1,040.00 $1,248.00 $1,188.00 $1,425.00 $1,568.00 $1,624.00 $1,635.00 $1,871.00 $1,485.00 $906.00 $1,352.00 $1,331.00 BR $1,053.00 $1,305.00 $983.00 $779.00 $341.00 ------$1,083.00 $1,546.00 $1,661.00 $1,830.00 $1,149.00 $3,101.00 $2,888.00 $3,099.00 $2,893.00 $1,855.00 BR $100.00 $1,012.00 $938.00 $286.00 $1,103.00 $1,350.00 $1,170.00 $1,630.00 ------------$2,365.00 $1,117.00 BR $862.00 $784.00 $915.00 $910.00 $290.00 $763.00 $305.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,402.00 $1,654.00 $1,600.00 $1,818.00 $2,659.00 $3,397.00 $2,889.00 $3,724.00 $1,962.00 $1,326.00 $1,875.00 $1,701.00 ------$2,329.00 $2,896.00 $1,432.00 $1,092.00 $681.00 $3,552.00 $1,370.00 $1,943.00 $2,017.00 $2,304.00 $1,529.00 $3,911.00 $3,612.00 $3,907.00 $3,632.00 $2,224.00 ------$136.00 $1,383.00 $1,322.00 $1,233.00 $1,350.00 $1,631.00 $1,636.00 $2,211.00 $2,074.00 $292.00 $3,041.00 $1,501.00 ------$969.00 $1,217.00 $1,172.00 $1,970.00 $1,191.00 $1,229.00 $1,192.00 $1,483.00 $1,749.00 $1,691.00 $1,923.00 $2,789.00 $3,530.00 $3,023.00 $3,883.00 $2,076.00 $1,385.00 $1,982.00 $1,800.00 ------$2,457.00 $3,062.00 $1,512.00 $1,154.00 $719.00 $3,751.00 $1,447.00 $2,054.00 $2,132.00 $2,435.00 $1,615.00 $4,139.00 $3,821.00 $4,134.00 $3,843.00 $2,350.00 ------$142.00 $1,461.00 $1,395.00 $1,312.00 $1,426.00 $1,726.00 $1,726.00 $2,335.00 $2,193.00 $304.00 $3,216.00 $1,584.00 ------$1,026.00 $1,273.00 $1,232.00 $2,079.00 $1,269.00 $1,295.00 $1,269.00 $1,588.00 $1,874.00 $1,811.00 $2,062.00 $2,958.00 $3,701.00 $3,198.00 $4,089.00 $2,226.00 $1,455.00 $2,123.00 $1,930.00 ------$2,627.00 $3,286.00 $1,618.00 $1,234.00 $756.00 $4,017.00 $1,550.00 $2,200.00 $2,286.00 $2,608.00 $1,729.00 $4,442.00 $4,101.00 $4,437.00 $4,125.00 $2,513.00 ------$150.00 $1,563.00 $1,489.00 $1,382.00 $1,527.00 $1,852.00 $1,844.00 $2,500.00 $2,351.00 $320.00 $3,438.00 $1,692.00 ------$1,102.00 $1,343.00 $1,310.00 $2,220.00 $1,337.00 $1,381.00 $1,336.00 $1,402.00 $1,654.00 $1,600.00 $1,818.00 $2,659.00 $3,397.00 $2,889.00 $3,724.00 $1,962.00 $1,326.00 $1,875.00 $1,701.00 ------$2,329.00 $2,896.00 $1,432.00 $1,092.00 $338.00 $3,552.00 $1,370.00 $1,943.00 $2,017.00 $2,304.00 $1,529.00 $3,911.00 $3,612.00 $3,907.00 $3,632.00 $2,224.00 ------$136.00 $1,383.00 $1,322.00 $275.00 $1,350.00 $1,631.00 $1,636.00 $2,211.00 $2,074.00 $292.00 $3,041.00 $1,501.00 ------$969.00 $1,217.00 $1,172.00 $1,970.00 $232.00 $1,229.00 $275.00 $1,483.00 $1,749.00 $1,691.00 $1,923.00 $2,789.00 $3,530.00 $3,023.00 $3,883.00 $2,076.00 $1,385.00 $1,982.00 $1,800.00 ------$2,457.00 $3,062.00 $1,512.00 $1,154.00 $352.00 $3,751.00 $1,447.00 $2,054.00 $2,132.00 $2,435.00 $1,615.00 $4,139.00 $3,821.00 $4,134.00 $3,843.00 $2,350.00 ------$142.00 $1,461.00 $1,395.00 $286.00 $1,426.00 $1,726.00 $1,726.00 $2,335.00 $2,193.00 $304.00 $3,216.00 $1,584.00 ------$1,026.00 $1,273.00 $1,232.00 $2,079.00 $241.00 $1,295.00 $286.00 $1,588.00 $1,874.00 $1,811.00 $2,062.00 $2,958.00 $3,701.00 $3,198.00 $4,089.00 $2,226.00 $1,455.00 $2,123.00 $1,930.00 ------$2,627.00 $3,286.00 $1,618.00 $1,234.00 $369.00 $4,017.00 $1,550.00 $2,200.00 $2,286.00 $2,608.00 $1,729.00 $4,442.00 $4,101.00 $4,437.00 $4,125.00 $2,513.00 ------$150.00 $1,563.00 $1,489.00 $299.00 $1,527.00 $1,852.00 $1,844.00 $2,500.00 $2,351.00 $320.00 $3,438.00 $1,692.00 ------$1,102.00 $1,343.00 $1,310.00 $2,220.00 $253.00 $1,381.00 $299.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 208 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 49060 49061 49062 49080 49081 49180 49203 49204 49205 49215 49220 49250 49255 49320 49321 49322 49323 49324 49325 49326 49329 49400 49402 49419 49420 49421 49422 49423 49424 49425 49426 49427 49428 49429 49435 49436 49440 49441 49442 49446 49450 49451 49452 49460 49465 49505 49507 49520 49521 49525 90 0 90 0 0 0 90 90 90 90 90 90 90 10 10 10 90 10 10 ZZZ YYY 0 90 90 0 90 10 0 0 90 90 0 10 10 ZZZ 10 10 10 10 0 0 0 0 0 0 90 90 90 90 90 $827.00 $288.00 $892.00 $123.00 $98.00 $212.00 ------------------$1,551.00 $1,182.00 $622.00 $591.00 $415.00 $443.00 $460.00 $712.00 ------------------BR $127.00 ------$405.00 $162.00 $452.00 $468.00 $106.00 $54.00 $914.00 $725.00 $48.00 $184.00 $522.00 ------------------------------------------------------------------$510.00 $636.00 $631.00 $730.00 $584.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,371.00 $1,175.00 $943.00 $238.00 $204.00 $228.00 $1,502.00 $1,918.00 $2,196.00 $2,784.00 $1,214.00 $720.00 $977.00 $417.00 $439.00 $477.00 $800.00 $492.00 $531.00 $245.00 ------$239.00 $1,062.00 $569.00 $177.00 $491.00 $497.00 $755.00 $209.00 $964.00 $820.00 $63.00 $555.00 $590.00 $159.00 $232.00 $1,487.00 $1,752.00 $1,429.00 $1,457.00 $1,018.00 $1,080.00 $1,323.00 $1,078.00 $226.00 $642.00 $791.00 $787.00 $962.00 $710.00 $1,441.00 $1,251.00 $997.00 $252.00 $216.00 $241.00 $1,587.00 $2,025.00 $2,319.00 $2,943.00 $1,286.00 $762.00 $1,034.00 $443.00 $466.00 $505.00 $847.00 $520.00 $564.00 $260.00 ------$253.00 $1,123.00 $602.00 $186.00 $521.00 $528.00 $806.00 $222.00 $1,022.00 $869.00 $66.00 $588.00 $627.00 $168.00 $245.00 $1,589.00 $1,867.00 $1,522.00 $1,554.00 $1,088.00 $1,153.00 $1,412.00 $1,153.00 $241.00 $682.00 $839.00 $835.00 $1,020.00 $753.00 $1,532.00 $1,317.00 $1,067.00 $265.00 $228.00 $253.00 $1,699.00 $2,168.00 $2,483.00 $3,154.00 $1,379.00 $818.00 $1,106.00 $476.00 $501.00 $541.00 $908.00 $557.00 $606.00 $280.00 ------$267.00 $1,203.00 $644.00 $198.00 $560.00 $569.00 $849.00 $233.00 $1,099.00 $933.00 $69.00 $630.00 $676.00 $181.00 $260.00 $1,682.00 $1,967.00 $1,603.00 $1,637.00 $1,147.00 $1,215.00 $1,488.00 $1,215.00 $253.00 $734.00 $902.00 $898.00 $1,098.00 $810.00 $1,371.00 $254.00 $943.00 $93.00 $89.00 $118.00 $1,502.00 $1,918.00 $2,196.00 $2,784.00 $1,214.00 $720.00 $977.00 $417.00 $439.00 $477.00 $800.00 $492.00 $531.00 $245.00 ------$131.00 $1,062.00 $569.00 $177.00 $491.00 $497.00 $103.00 $54.00 $964.00 $820.00 $63.00 $555.00 $590.00 $159.00 $232.00 $326.00 $347.00 $288.00 $227.00 $92.00 $127.00 $199.00 $65.00 $43.00 $642.00 $791.00 $787.00 $962.00 $710.00 $1,441.00 $264.00 $997.00 $97.00 $93.00 $123.00 $1,587.00 $2,025.00 $2,319.00 $2,943.00 $1,286.00 $762.00 $1,034.00 $443.00 $466.00 $505.00 $847.00 $520.00 $564.00 $260.00 ------$137.00 $1,123.00 $602.00 $186.00 $521.00 $528.00 $107.00 $56.00 $1,022.00 $869.00 $66.00 $588.00 $627.00 $168.00 $245.00 $344.00 $362.00 $300.00 $236.00 $96.00 $132.00 $207.00 $67.00 $44.00 $682.00 $839.00 $835.00 $1,020.00 $753.00 $1,532.00 $277.00 $1,067.00 $102.00 $98.00 $129.00 $1,699.00 $2,168.00 $2,483.00 $3,154.00 $1,379.00 $818.00 $1,106.00 $476.00 $501.00 $541.00 $908.00 $557.00 $606.00 $280.00 ------$145.00 $1,203.00 $644.00 $198.00 $560.00 $569.00 $112.00 $58.00 $1,099.00 $933.00 $69.00 $630.00 $676.00 $181.00 $260.00 $369.00 $379.00 $314.00 $246.00 $100.00 $138.00 $217.00 $70.00 $46.00 $734.00 $902.00 $898.00 $1,098.00 $810.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 209 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 49540 49550 49553 49555 49557 49560 49561 49565 49566 49568 49570 49572 49585 49587 49590 49600 49605 49606 49610 49611 49650 49651 49659 49900 49904 49905 49906 49999 50010 50020 50021 50040 50045 50060 50065 50070 50075 50080 50081 50100 50120 50125 50130 50135 50200 50205 50220 50225 50230 50234 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 YYY 90 90 ZZZ 90 YYY 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 $668.00 $557.00 $598.00 $621.00 $715.00 $734.00 $856.00 $754.00 $881.00 $339.00 $411.00 $491.00 $444.00 $501.00 $585.00 $774.00 $1,648.00 $1,416.00 $784.00 $770.00 $484.00 $621.00 BR $512.00 $1,394.00 $454.00 BR BR $886.00 $1,084.00 $335.00 $910.00 $1,137.00 $1,394.00 $1,514.00 $1,476.00 $1,839.00 $1,186.00 $1,635.00 $1,250.00 $1,180.00 $1,228.00 $1,301.00 $1,506.00 $151.00 $807.00 $1,316.00 $1,554.00 $1,695.00 $1,671.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $842.00 $715.00 $781.00 $744.00 $904.00 $927.00 $1,165.00 $955.00 $1,177.00 $353.00 $503.00 $618.00 $541.00 $642.00 $708.00 $911.00 $6,225.00 $1,445.00 $855.00 $776.00 $533.00 $686.00 ------$1,017.00 $1,932.00 $466.00 ------------$942.00 $1,352.00 $1,243.00 $1,246.00 $1,249.00 $1,551.00 $1,607.00 $1,621.00 $1,992.00 $1,186.00 $1,741.00 $1,334.00 $1,294.00 $1,360.00 $1,404.00 $1,527.00 $198.00 $938.00 $1,396.00 $1,618.00 $1,740.00 $1,770.00 $894.00 $759.00 $828.00 $789.00 $959.00 $984.00 $1,234.00 $1,012.00 $1,247.00 $374.00 $534.00 $653.00 $573.00 $681.00 $751.00 $963.00 $6,564.00 $1,533.00 $901.00 $816.00 $568.00 $730.00 ------$1,081.00 $2,049.00 $492.00 ------------$987.00 $1,415.00 $1,324.00 $1,300.00 $1,307.00 $1,619.00 $1,679.00 $1,693.00 $2,080.00 $1,239.00 $1,817.00 $1,412.00 $1,353.00 $1,426.00 $1,465.00 $1,594.00 $207.00 $990.00 $1,460.00 $1,691.00 $1,815.00 $1,848.00 $961.00 $816.00 $890.00 $849.00 $1,031.00 $1,058.00 $1,326.00 $1,087.00 $1,339.00 $403.00 $573.00 $698.00 $616.00 $731.00 $808.00 $1,031.00 $7,015.00 $1,651.00 $959.00 $863.00 $615.00 $787.00 ------$1,163.00 $2,195.00 $528.00 ------------$1,041.00 $1,491.00 $1,395.00 $1,364.00 $1,378.00 $1,700.00 $1,767.00 $1,778.00 $2,185.00 $1,302.00 $1,908.00 $1,514.00 $1,424.00 $1,507.00 $1,539.00 $1,673.00 $217.00 $1,057.00 $1,538.00 $1,778.00 $1,906.00 $1,941.00 $842.00 $715.00 $781.00 $744.00 $904.00 $927.00 $1,165.00 $955.00 $1,177.00 $353.00 $503.00 $618.00 $541.00 $642.00 $708.00 $911.00 $6,225.00 $1,445.00 $855.00 $776.00 $533.00 $686.00 ------$1,017.00 $1,932.00 $466.00 ------------$942.00 $1,352.00 $232.00 $1,246.00 $1,249.00 $1,551.00 $1,607.00 $1,621.00 $1,992.00 $1,186.00 $1,741.00 $1,334.00 $1,294.00 $1,360.00 $1,404.00 $1,527.00 $198.00 $938.00 $1,396.00 $1,618.00 $1,740.00 $1,770.00 $894.00 $759.00 $828.00 $789.00 $959.00 $984.00 $1,234.00 $1,012.00 $1,247.00 $374.00 $534.00 $653.00 $573.00 $681.00 $751.00 $963.00 $6,564.00 $1,533.00 $901.00 $816.00 $568.00 $730.00 ------$1,081.00 $2,049.00 $492.00 ------------$987.00 $1,415.00 $241.00 $1,300.00 $1,307.00 $1,619.00 $1,679.00 $1,693.00 $2,080.00 $1,239.00 $1,817.00 $1,412.00 $1,353.00 $1,426.00 $1,465.00 $1,594.00 $207.00 $990.00 $1,460.00 $1,691.00 $1,815.00 $1,848.00 $961.00 $816.00 $890.00 $849.00 $1,031.00 $1,058.00 $1,326.00 $1,087.00 $1,339.00 $403.00 $573.00 $698.00 $616.00 $731.00 $808.00 $1,031.00 $7,015.00 $1,651.00 $959.00 $863.00 $615.00 $787.00 ------$1,163.00 $2,195.00 $528.00 ------------$1,041.00 $1,491.00 $253.00 $1,364.00 $1,378.00 $1,700.00 $1,767.00 $1,778.00 $2,185.00 $1,302.00 $1,908.00 $1,514.00 $1,424.00 $1,507.00 $1,539.00 $1,673.00 $217.00 $1,057.00 $1,538.00 $1,778.00 $1,906.00 $1,941.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 210 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 50236 50240 50250 50280 50290 50320 50327 50328 50329 50340 50360 50365 50370 50380 50382 50384 50385 50386 50387 50389 50390 50391 50392 50393 50394 50395 50396 50398 50400 50405 50500 50520 50525 50526 50540 50541 50542 50543 50544 50545 50546 50547 50548 50549 50551 50553 50555 50557 50561 50562 90 90 90 90 90 90 0 0 0 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 90 $1,873.00 $1,679.00 ------$1,170.00 $1,080.00 $1,680.00 ------------------$1,083.00 $2,475.00 $2,941.00 $1,128.00 $1,507.00 ------------------------------------$118.00 ------$189.00 $235.00 $64.00 $203.00 $101.00 $99.00 $1,441.00 $1,802.00 $1,471.00 $1,281.00 $1,644.00 $1,639.00 $1,468.00 $1,037.00 $1,093.00 $1,374.00 $1,428.00 $1,273.00 $1,325.00 $1,702.00 $1,555.00 BR $411.00 $447.00 $668.00 $676.00 $755.00 $580.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,000.00 $1,790.00 $1,663.00 $1,284.00 $1,218.00 $1,807.00 $272.00 $239.00 $231.00 $1,139.00 $3,056.00 $3,437.00 $1,419.00 $2,298.00 $1,847.00 $1,656.00 $1,761.00 $1,139.00 $874.00 $543.00 $135.00 $177.00 $250.00 $304.00 $154.00 $251.00 $162.00 $779.00 $1,572.00 $1,896.00 $1,576.00 $1,414.00 $1,803.00 $1,834.00 $1,565.00 $1,256.00 $1,587.00 $2,027.00 $1,717.00 $1,839.00 $1,634.00 $2,041.00 $1,855.00 ------$512.00 $533.00 $589.00 $593.00 $671.00 $812.00 $2,088.00 $1,868.00 $1,735.00 $1,342.00 $1,279.00 $1,908.00 $283.00 $249.00 $241.00 $1,207.00 $3,214.00 $3,616.00 $1,491.00 $2,412.00 $1,967.00 $1,764.00 $1,877.00 $1,214.00 $932.00 $579.00 $141.00 $186.00 $261.00 $317.00 $163.00 $262.00 $170.00 $832.00 $1,640.00 $1,980.00 $1,658.00 $1,482.00 $1,886.00 $1,916.00 $1,633.00 $1,312.00 $1,657.00 $2,116.00 $1,792.00 $1,921.00 $1,709.00 $2,154.00 $1,937.00 ------$538.00 $559.00 $618.00 $623.00 $704.00 $847.00 $2,193.00 $1,961.00 $1,820.00 $1,412.00 $1,355.00 $2,035.00 $298.00 $263.00 $254.00 $1,293.00 $3,414.00 $3,846.00 $1,581.00 $2,552.00 $2,072.00 $1,858.00 $1,978.00 $1,278.00 $982.00 $611.00 $147.00 $196.00 $273.00 $332.00 $172.00 $275.00 $178.00 $877.00 $1,722.00 $2,083.00 $1,762.00 $1,565.00 $1,989.00 $2,020.00 $1,715.00 $1,378.00 $1,740.00 $2,223.00 $1,884.00 $2,019.00 $1,800.00 $2,297.00 $2,037.00 ------$567.00 $587.00 $650.00 $656.00 $741.00 $890.00 $2,000.00 $1,790.00 $1,663.00 $1,284.00 $1,218.00 $1,807.00 $272.00 $239.00 $231.00 $1,139.00 $3,056.00 $3,437.00 $1,419.00 $2,298.00 $383.00 $348.00 $332.00 $251.00 $138.00 $77.00 $135.00 $137.00 $250.00 $304.00 $71.00 $251.00 $162.00 $103.00 $1,572.00 $1,896.00 $1,576.00 $1,414.00 $1,803.00 $1,834.00 $1,565.00 $1,256.00 $1,587.00 $2,027.00 $1,717.00 $1,839.00 $1,634.00 $2,041.00 $1,855.00 ------$410.00 $432.00 $476.00 $482.00 $550.00 $812.00 $2,088.00 $1,868.00 $1,735.00 $1,342.00 $1,279.00 $1,908.00 $283.00 $249.00 $241.00 $1,207.00 $3,214.00 $3,616.00 $1,491.00 $2,412.00 $399.00 $362.00 $347.00 $262.00 $144.00 $80.00 $141.00 $143.00 $261.00 $317.00 $74.00 $262.00 $170.00 $107.00 $1,640.00 $1,980.00 $1,658.00 $1,482.00 $1,886.00 $1,916.00 $1,633.00 $1,312.00 $1,657.00 $2,116.00 $1,792.00 $1,921.00 $1,709.00 $2,154.00 $1,937.00 ------$428.00 $450.00 $497.00 $503.00 $574.00 $847.00 $2,193.00 $1,961.00 $1,820.00 $1,412.00 $1,355.00 $2,035.00 $298.00 $263.00 $254.00 $1,293.00 $3,414.00 $3,846.00 $1,581.00 $2,552.00 $418.00 $380.00 $363.00 $275.00 $151.00 $84.00 $147.00 $150.00 $273.00 $332.00 $78.00 $275.00 $178.00 $112.00 $1,722.00 $2,083.00 $1,762.00 $1,565.00 $1,989.00 $2,020.00 $1,715.00 $1,378.00 $1,740.00 $2,223.00 $1,884.00 $2,019.00 $1,800.00 $2,297.00 $2,037.00 ------$450.00 $473.00 $522.00 $529.00 $605.00 $890.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 211 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 50570 50572 50574 50575 50576 50580 50590 50592 50593 50600 50605 50610 50620 50630 50650 50660 50684 50686 50688 50690 50700 50715 50722 50725 50727 50728 50740 50750 50760 50770 50780 50782 50783 50785 50800 50810 50815 50820 50825 50830 50840 50845 50860 50900 50920 50930 50940 50945 50947 50948 0 0 0 0 0 0 90 10 10 90 90 90 90 90 90 90 0 0 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $549.00 $728.00 $762.00 $991.00 $801.00 $726.00 $980.00 ------------$1,150.00 $1,054.00 $1,209.00 $1,152.00 $1,170.00 $1,297.00 $1,426.00 $74.00 $109.00 $89.00 $85.00 $1,192.00 $1,397.00 $1,211.00 $1,371.00 $640.00 $924.00 $1,386.00 $1,457.00 $1,389.00 $1,485.00 $1,391.00 $1,465.00 $1,515.00 $1,548.00 $1,226.00 $1,527.00 $1,643.00 $1,729.00 $2,351.00 $2,292.00 $1,493.00 $1,513.00 $1,163.00 $1,043.00 $1,075.00 $1,380.00 $1,107.00 $1,096.00 $1,384.00 $1,265.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $685.00 $748.00 $791.00 $998.00 $788.00 $848.00 $1,241.00 $5,963.00 $6,199.00 $1,269.00 $1,263.00 $1,316.00 $1,230.00 $1,203.00 $1,403.00 $1,556.00 $263.00 $223.00 $111.00 $142.00 $1,274.00 $1,564.00 $1,364.00 $1,484.00 $682.00 $950.00 $1,509.00 $1,575.00 $1,497.00 $1,575.00 $1,492.00 $1,510.00 $1,580.00 $1,638.00 $1,247.00 $1,726.00 $1,655.00 $1,785.00 $2,247.00 $2,460.00 $1,667.00 $1,691.00 $1,293.00 $1,142.00 $1,192.00 $1,479.00 $1,195.00 $1,355.00 $1,925.00 $1,745.00 $716.00 $784.00 $826.00 $1,042.00 $823.00 $886.00 $1,310.00 $6,375.00 $6,624.00 $1,325.00 $1,326.00 $1,381.00 $1,285.00 $1,257.00 $1,465.00 $1,625.00 $280.00 $236.00 $117.00 $150.00 $1,335.00 $1,649.00 $1,439.00 $1,552.00 $715.00 $998.00 $1,589.00 $1,644.00 $1,568.00 $1,646.00 $1,562.00 $1,584.00 $1,663.00 $1,710.00 $1,305.00 $1,820.00 $1,730.00 $1,870.00 $2,346.00 $2,570.00 $1,741.00 $1,769.00 $1,354.00 $1,196.00 $1,245.00 $1,543.00 $1,253.00 $1,419.00 $2,019.00 $1,824.00 $753.00 $829.00 $869.00 $1,097.00 $866.00 $932.00 $1,379.00 $6,722.00 $6,983.00 $1,392.00 $1,404.00 $1,460.00 $1,349.00 $1,321.00 $1,539.00 $1,706.00 $295.00 $249.00 $123.00 $157.00 $1,408.00 $1,758.00 $1,537.00 $1,637.00 $754.00 $1,055.00 $1,691.00 $1,726.00 $1,654.00 $1,731.00 $1,647.00 $1,675.00 $1,768.00 $1,796.00 $1,375.00 $1,940.00 $1,820.00 $1,975.00 $2,466.00 $2,704.00 $1,829.00 $1,861.00 $1,428.00 $1,262.00 $1,307.00 $1,619.00 $1,323.00 $1,496.00 $2,137.00 $1,920.00 $685.00 $748.00 $791.00 $998.00 $788.00 $848.00 $760.00 $501.00 $645.00 $1,269.00 $1,263.00 $1,316.00 $1,230.00 $1,203.00 $1,403.00 $1,556.00 $67.00 $121.00 $111.00 $96.00 $1,274.00 $1,564.00 $1,364.00 $1,484.00 $682.00 $950.00 $1,509.00 $1,575.00 $1,497.00 $1,575.00 $1,492.00 $1,510.00 $1,580.00 $1,638.00 $1,247.00 $1,726.00 $1,655.00 $1,785.00 $2,247.00 $2,460.00 $1,667.00 $1,691.00 $1,293.00 $1,142.00 $1,192.00 $1,479.00 $1,195.00 $1,355.00 $1,925.00 $1,745.00 $716.00 $784.00 $826.00 $1,042.00 $823.00 $886.00 $795.00 $523.00 $672.00 $1,325.00 $1,326.00 $1,381.00 $1,285.00 $1,257.00 $1,465.00 $1,625.00 $70.00 $126.00 $117.00 $101.00 $1,335.00 $1,649.00 $1,439.00 $1,552.00 $715.00 $998.00 $1,589.00 $1,644.00 $1,568.00 $1,646.00 $1,562.00 $1,584.00 $1,663.00 $1,710.00 $1,305.00 $1,820.00 $1,730.00 $1,870.00 $2,346.00 $2,570.00 $1,741.00 $1,769.00 $1,354.00 $1,196.00 $1,245.00 $1,543.00 $1,253.00 $1,419.00 $2,019.00 $1,824.00 $753.00 $829.00 $869.00 $1,097.00 $866.00 $932.00 $836.00 $549.00 $705.00 $1,392.00 $1,404.00 $1,460.00 $1,349.00 $1,321.00 $1,539.00 $1,706.00 $74.00 $133.00 $123.00 $106.00 $1,408.00 $1,758.00 $1,537.00 $1,637.00 $754.00 $1,055.00 $1,691.00 $1,726.00 $1,654.00 $1,731.00 $1,647.00 $1,675.00 $1,768.00 $1,796.00 $1,375.00 $1,940.00 $1,820.00 $1,975.00 $2,466.00 $2,704.00 $1,829.00 $1,861.00 $1,428.00 $1,262.00 $1,307.00 $1,619.00 $1,323.00 $1,496.00 $2,137.00 $1,920.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 212 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 50949 50951 50953 50955 50957 50961 50970 50972 50974 50976 50980 51020 51030 51040 51045 51050 51060 51065 51080 51100 51101 51102 51500 51520 51525 51530 51535 51550 51555 51565 51570 51575 51580 51585 51590 51595 51596 51597 51600 51605 51610 51700 51701 51702 51703 51705 51710 51715 51720 51725 YYY 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 0 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 10 10 0 0 0 BR $414.00 $461.00 $546.00 $546.00 $510.00 $510.00 $408.00 $661.00 $641.00 $443.00 $587.00 $538.00 $439.00 $548.00 $596.00 $768.00 $704.00 $510.00 ------------------$775.00 $764.00 $1,069.00 $957.00 $932.00 $1,171.00 $1,514.00 $1,624.00 $1,762.00 $2,284.00 $2,252.00 $2,601.00 $2,441.00 $2,900.00 $3,063.00 $2,914.00 $54.00 $83.00 $45.00 $29.00 $58.00 $92.00 $128.00 $37.00 $119.00 $322.00 $140.00 $116.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) ------$534.00 $560.00 $644.00 $605.00 $544.00 $519.00 $500.00 $653.00 $649.00 $497.00 $623.00 $628.00 $394.00 $629.00 $632.00 $783.00 $776.00 $548.00 $87.00 $176.00 $460.00 $864.00 $803.00 $1,161.00 $1,049.00 $1,081.00 $1,293.00 $1,716.00 $1,759.00 $2,000.00 $2,480.00 $2,580.00 $2,871.00 $2,624.00 $2,979.00 $3,197.00 $3,099.00 $278.00 $53.00 $160.00 $123.00 $92.00 $117.00 $202.00 $162.00 $231.00 $406.00 $165.00 $329.00 ------$561.00 $588.00 $676.00 $635.00 $570.00 $542.00 $522.00 $682.00 $678.00 $519.00 $652.00 $658.00 $413.00 $658.00 $661.00 $818.00 $811.00 $573.00 $91.00 $187.00 $484.00 $909.00 $840.00 $1,212.00 $1,099.00 $1,136.00 $1,354.00 $1,795.00 $1,838.00 $2,085.00 $2,586.00 $2,691.00 $2,993.00 $2,735.00 $3,105.00 $3,333.00 $3,234.00 $296.00 $55.00 $169.00 $130.00 $98.00 $125.00 $213.00 $171.00 $244.00 $428.00 $175.00 $351.00 ------$590.00 $618.00 $712.00 $668.00 $600.00 $571.00 $550.00 $717.00 $714.00 $545.00 $684.00 $694.00 $435.00 $692.00 $693.00 $859.00 $851.00 $602.00 $96.00 $198.00 $509.00 $965.00 $883.00 $1,273.00 $1,160.00 $1,205.00 $1,428.00 $1,892.00 $1,933.00 $2,186.00 $2,713.00 $2,823.00 $3,140.00 $2,869.00 $3,257.00 $3,496.00 $3,396.00 $312.00 $58.00 $178.00 $137.00 $103.00 $131.00 $224.00 $180.00 $257.00 $452.00 $185.00 $371.00 ------$426.00 $466.00 $508.00 $494.00 $441.00 $519.00 $500.00 $653.00 $649.00 $497.00 $623.00 $628.00 $394.00 $629.00 $632.00 $783.00 $776.00 $548.00 $54.00 $73.00 $341.00 $864.00 $803.00 $1,161.00 $1,049.00 $1,081.00 $1,293.00 $1,716.00 $1,759.00 $2,000.00 $2,480.00 $2,580.00 $2,871.00 $2,624.00 $2,979.00 $3,197.00 $3,099.00 $61.00 $53.00 $87.00 $61.00 $38.00 $41.00 $111.00 $91.00 $128.00 $275.00 $117.00 $329.00 ------$446.00 $487.00 $531.00 $516.00 $460.00 $542.00 $522.00 $682.00 $678.00 $519.00 $652.00 $658.00 $413.00 $658.00 $661.00 $818.00 $811.00 $573.00 $56.00 $77.00 $357.00 $909.00 $840.00 $1,212.00 $1,099.00 $1,136.00 $1,354.00 $1,795.00 $1,838.00 $2,085.00 $2,586.00 $2,691.00 $2,993.00 $2,735.00 $3,105.00 $3,333.00 $3,234.00 $64.00 $55.00 $91.00 $64.00 $39.00 $43.00 $116.00 $95.00 $134.00 $288.00 $123.00 $351.00 ------$469.00 $512.00 $559.00 $543.00 $483.00 $571.00 $550.00 $717.00 $714.00 $545.00 $684.00 $694.00 $435.00 $692.00 $693.00 $859.00 $851.00 $602.00 $59.00 $82.00 $375.00 $965.00 $883.00 $1,273.00 $1,160.00 $1,205.00 $1,428.00 $1,892.00 $1,933.00 $2,186.00 $2,713.00 $2,823.00 $3,140.00 $2,869.00 $3,257.00 $3,496.00 $3,396.00 $67.00 $58.00 $96.00 $67.00 $42.00 $46.00 $122.00 $100.00 $141.00 $304.00 $131.00 $371.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 213 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 51725-26 51725-TC 51726 51726-26 51726-TC 51736 51736-26 51736-TC 51741 51741-26 51741-TC 51772 51772-26 51772-TC 51784 51784-26 51784-TC 51785 51785-26 51785-TC 51792 51792-26 51792-TC 51795 51795-26 51795-TC 51797 51797-26 51797-TC 51798 51800 51820 51840 51841 51845 51860 51865 51880 51900 51920 51925 51940 51960 51980 51990 51992 52000 52001 52005 52007 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ZZZ ZZZ ZZZ 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 ------------$136.00 ------------$47.00 ------------$81.00 ------------$96.00 ------------$119.00 ------------$52.00 ------------$143.00 ------------$132.00 ------------$109.00 ------------$20.00 $1,294.00 $1,236.00 $858.00 $1,040.00 $843.00 $912.00 $1,150.00 $590.00 $1,050.00 $881.00 $1,167.00 $2,082.00 $1,848.00 $858.00 $850.00 $925.00 $190.00 $133.00 $265.00 $230.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $106.00 $223.00 $460.00 $121.00 $339.00 $72.00 $44.00 $28.00 $114.00 $81.00 $33.00 $357.00 $115.00 $242.00 $287.00 $108.00 $179.00 $309.00 $107.00 $202.00 $343.00 $77.00 $266.00 $439.00 $108.00 $331.00 $256.00 $67.00 $189.00 $30.00 $1,416.00 $1,501.00 $896.00 $1,068.00 $801.00 $991.00 $1,209.00 $641.00 $1,127.00 $1,058.00 $1,502.00 $2,197.00 $1,876.00 $963.00 $1,035.00 $1,123.00 $289.00 $539.00 $407.00 $838.00 $111.00 $239.00 $491.00 $126.00 $364.00 $76.00 $46.00 $30.00 $120.00 $85.00 $35.00 $381.00 $121.00 $261.00 $306.00 $113.00 $193.00 $329.00 $112.00 $217.00 $368.00 $80.00 $288.00 $470.00 $113.00 $357.00 $275.00 $72.00 $203.00 $34.00 $1,481.00 $1,578.00 $944.00 $1,123.00 $840.00 $1,043.00 $1,267.00 $675.00 $1,182.00 $1,113.00 $1,591.00 $2,294.00 $1,957.00 $1,007.00 $1,092.00 $1,182.00 $305.00 $567.00 $432.00 $892.00 $118.00 $254.00 $519.00 $133.00 $386.00 $80.00 $48.00 $32.00 $127.00 $89.00 $38.00 $405.00 $128.00 $277.00 $324.00 $119.00 $205.00 $348.00 $118.00 $230.00 $392.00 $84.00 $308.00 $499.00 $119.00 $380.00 $294.00 $78.00 $216.00 $38.00 $1,558.00 $1,673.00 $1,002.00 $1,191.00 $887.00 $1,107.00 $1,338.00 $716.00 $1,251.00 $1,179.00 $1,702.00 $2,414.00 $2,055.00 $1,059.00 $1,164.00 $1,256.00 $321.00 $597.00 $455.00 $940.00 $106.00 $223.00 $460.00 $121.00 $339.00 $72.00 $44.00 $28.00 $114.00 $81.00 $33.00 $357.00 $115.00 $242.00 $287.00 $108.00 $179.00 $309.00 $107.00 $202.00 $343.00 $77.00 $266.00 $439.00 $108.00 $331.00 $256.00 $67.00 $189.00 $30.00 $1,416.00 $1,501.00 $896.00 $1,068.00 $801.00 $991.00 $1,209.00 $641.00 $1,127.00 $1,058.00 $1,502.00 $2,197.00 $1,876.00 $963.00 $1,035.00 $1,123.00 $167.00 $397.00 $181.00 $228.00 $111.00 $239.00 $491.00 $126.00 $364.00 $76.00 $46.00 $30.00 $120.00 $85.00 $35.00 $381.00 $121.00 $261.00 $306.00 $113.00 $193.00 $329.00 $112.00 $217.00 $368.00 $80.00 $288.00 $470.00 $113.00 $357.00 $275.00 $72.00 $203.00 $34.00 $1,481.00 $1,578.00 $944.00 $1,123.00 $840.00 $1,043.00 $1,267.00 $675.00 $1,182.00 $1,113.00 $1,591.00 $2,294.00 $1,957.00 $1,007.00 $1,092.00 $1,182.00 $174.00 $415.00 $190.00 $239.00 $118.00 $254.00 $519.00 $133.00 $386.00 $80.00 $48.00 $32.00 $127.00 $89.00 $38.00 $405.00 $128.00 $277.00 $324.00 $119.00 $205.00 $348.00 $118.00 $230.00 $392.00 $84.00 $308.00 $499.00 $119.00 $380.00 $294.00 $78.00 $216.00 $38.00 $1,558.00 $1,673.00 $1,002.00 $1,191.00 $887.00 $1,107.00 $1,338.00 $716.00 $1,251.00 $1,179.00 $1,702.00 $2,414.00 $2,055.00 $1,059.00 $1,164.00 $1,256.00 $183.00 $437.00 $200.00 $251.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 214 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 52010 52204 52214 52224 52234 52235 52240 52250 52260 52265 52270 52275 52276 52277 52281 52282 52283 52285 52290 52300 52301 52305 52310 52315 52317 52318 52320 52325 52327 52330 52332 52334 52341 52342 52343 52344 52345 52346 52351 52352 52353 52354 52355 52400 52402 52450 52500 52601 52630 52640 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 0 90 90 90 90 90 $292.00 $286.00 $367.00 $339.00 $471.00 $546.00 $887.00 $311.00 $262.00 $243.00 $374.00 $446.00 $490.00 $448.00 $259.00 $560.00 $309.00 $375.00 $304.00 $370.00 $382.00 $370.00 $348.00 $553.00 $772.00 $684.00 $369.00 $494.00 $369.00 $507.00 $451.00 $340.00 $317.00 $344.00 $380.00 $407.00 $433.00 $488.00 $297.00 $349.00 $404.00 $372.00 $447.00 $580.00 ------$602.00 $705.00 $1,021.00 $653.00 $573.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $629.00 $705.00 $1,644.00 $1,553.00 $341.00 $401.00 $702.00 $334.00 $289.00 $676.00 $628.00 $867.00 $367.00 $452.00 $457.00 $466.00 $395.00 $398.00 $338.00 $391.00 $411.00 $388.00 $365.00 $656.00 $1,503.00 $661.00 $342.00 $446.00 $1,119.00 $1,745.00 $603.00 $355.00 $452.00 $487.00 $536.00 $578.00 $613.00 $685.00 $435.00 $510.00 $588.00 $543.00 $648.00 $754.00 $375.00 $630.00 $741.00 $1,117.00 $599.00 $545.00 $668.00 $750.00 $1,754.00 $1,657.00 $357.00 $419.00 $733.00 $350.00 $302.00 $719.00 $666.00 $920.00 $384.00 $472.00 $484.00 $487.00 $416.00 $420.00 $353.00 $408.00 $431.00 $405.00 $386.00 $693.00 $1,597.00 $690.00 $358.00 $466.00 $1,189.00 $1,860.00 $641.00 $371.00 $473.00 $508.00 $560.00 $604.00 $640.00 $715.00 $454.00 $533.00 $614.00 $568.00 $677.00 $788.00 $392.00 $660.00 $774.00 $1,163.00 $626.00 $570.00 $704.00 $790.00 $1,849.00 $1,748.00 $375.00 $441.00 $771.00 $368.00 $318.00 $758.00 $702.00 $970.00 $404.00 $497.00 $510.00 $512.00 $438.00 $442.00 $371.00 $430.00 $456.00 $426.00 $406.00 $730.00 $1,684.00 $726.00 $376.00 $491.00 $1,253.00 $1,961.00 $676.00 $391.00 $497.00 $535.00 $589.00 $635.00 $673.00 $752.00 $478.00 $561.00 $647.00 $597.00 $713.00 $828.00 $413.00 $695.00 $813.00 $1,217.00 $658.00 $600.00 $227.00 $192.00 $273.00 $234.00 $341.00 $401.00 $702.00 $334.00 $289.00 $220.00 $251.00 $344.00 $367.00 $452.00 $213.00 $466.00 $276.00 $269.00 $338.00 $391.00 $411.00 $388.00 $209.00 $381.00 $485.00 $661.00 $342.00 $446.00 $369.00 $367.00 $214.00 $355.00 $452.00 $487.00 $536.00 $578.00 $613.00 $685.00 $435.00 $510.00 $588.00 $543.00 $648.00 $754.00 $375.00 $630.00 $741.00 $1,117.00 $599.00 $545.00 $238.00 $200.00 $286.00 $245.00 $357.00 $419.00 $733.00 $350.00 $302.00 $230.00 $263.00 $360.00 $384.00 $472.00 $223.00 $487.00 $289.00 $281.00 $353.00 $408.00 $431.00 $405.00 $219.00 $398.00 $507.00 $690.00 $358.00 $466.00 $385.00 $384.00 $224.00 $371.00 $473.00 $508.00 $560.00 $604.00 $640.00 $715.00 $454.00 $533.00 $614.00 $568.00 $677.00 $788.00 $392.00 $660.00 $774.00 $1,163.00 $626.00 $570.00 $250.00 $210.00 $301.00 $257.00 $375.00 $441.00 $771.00 $368.00 $318.00 $243.00 $277.00 $378.00 $404.00 $497.00 $235.00 $512.00 $304.00 $296.00 $371.00 $430.00 $456.00 $426.00 $230.00 $419.00 $533.00 $726.00 $376.00 $491.00 $405.00 $404.00 $236.00 $391.00 $497.00 $535.00 $589.00 $635.00 $673.00 $752.00 $478.00 $561.00 $647.00 $597.00 $713.00 $828.00 $413.00 $695.00 $813.00 $1,217.00 $658.00 $600.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 215 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 52647 52648 52649 52700 53000 53010 53020 53040 53060 53080 53085 53200 53210 53215 53220 53230 53235 53240 53250 53260 53265 53270 53275 53400 53405 53410 53415 53420 53425 53430 53431 53440 53442 53444 53445 53446 53447 53448 53449 53450 53460 53500 53502 53505 53510 53515 53520 53600 53601 53605 90 90 90 90 10 90 0 90 10 90 90 0 90 90 90 90 90 90 90 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 $858.00 $957.00 ------$517.00 $224.00 $336.00 $153.00 $460.00 $180.00 $567.00 $836.00 $218.00 $904.00 $1,142.00 $546.00 $760.00 $607.00 $506.00 $464.00 $240.00 $295.00 $226.00 $332.00 $929.00 $1,088.00 $1,151.00 $1,381.00 $1,088.00 $1,150.00 $1,116.00 $1,053.00 $1,057.00 $639.00 $755.00 $1,197.00 $699.00 $991.00 $1,259.00 $784.00 $447.00 $494.00 ------$590.00 $586.00 $777.00 $987.00 $661.00 $37.00 $37.00 $81.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $3,478.00 $3,536.00 $1,359.00 $587.00 $204.00 $392.00 $134.00 $537.00 $251.00 $635.00 $887.00 $213.00 $1,049.00 $1,266.00 $610.00 $819.00 $862.00 $579.00 $532.00 $278.00 $308.00 $286.00 $364.00 $1,089.00 $1,190.00 $1,333.00 $1,524.00 $1,117.00 $1,282.00 $1,298.00 $1,575.00 $1,175.00 $1,034.00 $1,082.00 $1,188.00 $874.00 $1,110.00 $1,745.00 $826.00 $548.00 $617.00 $1,016.00 $659.00 $657.00 $867.00 $1,092.00 $754.00 $121.00 $117.00 $90.00 $3,704.00 $3,764.00 $1,421.00 $614.00 $214.00 $410.00 $140.00 $562.00 $265.00 $667.00 $932.00 $223.00 $1,096.00 $1,322.00 $638.00 $857.00 $902.00 $607.00 $558.00 $293.00 $324.00 $302.00 $381.00 $1,139.00 $1,245.00 $1,392.00 $1,591.00 $1,165.00 $1,339.00 $1,356.00 $1,645.00 $1,227.00 $1,079.00 $1,131.00 $1,242.00 $914.00 $1,160.00 $1,821.00 $864.00 $573.00 $646.00 $1,063.00 $691.00 $687.00 $907.00 $1,144.00 $789.00 $128.00 $124.00 $94.00 $3,902.00 $3,966.00 $1,492.00 $644.00 $225.00 $429.00 $148.00 $591.00 $283.00 $704.00 $985.00 $236.00 $1,151.00 $1,388.00 $670.00 $902.00 $947.00 $640.00 $589.00 $309.00 $342.00 $321.00 $401.00 $1,199.00 $1,310.00 $1,463.00 $1,671.00 $1,223.00 $1,407.00 $1,424.00 $1,728.00 $1,287.00 $1,132.00 $1,188.00 $1,304.00 $960.00 $1,219.00 $1,912.00 $907.00 $602.00 $678.00 $1,118.00 $729.00 $722.00 $954.00 $1,206.00 $828.00 $134.00 $130.00 $99.00 $867.00 $926.00 $1,359.00 $587.00 $204.00 $392.00 $134.00 $537.00 $219.00 $635.00 $887.00 $194.00 $1,049.00 $1,266.00 $610.00 $819.00 $862.00 $579.00 $532.00 $242.00 $252.00 $254.00 $364.00 $1,089.00 $1,190.00 $1,333.00 $1,524.00 $1,117.00 $1,282.00 $1,298.00 $1,575.00 $1,175.00 $1,034.00 $1,082.00 $1,188.00 $874.00 $1,110.00 $1,745.00 $826.00 $548.00 $617.00 $1,016.00 $659.00 $657.00 $867.00 $1,092.00 $754.00 $89.00 $73.00 $90.00 $906.00 $968.00 $1,421.00 $614.00 $214.00 $410.00 $140.00 $562.00 $231.00 $667.00 $932.00 $204.00 $1,096.00 $1,322.00 $638.00 $857.00 $902.00 $607.00 $558.00 $254.00 $264.00 $268.00 $381.00 $1,139.00 $1,245.00 $1,392.00 $1,591.00 $1,165.00 $1,339.00 $1,356.00 $1,645.00 $1,227.00 $1,079.00 $1,131.00 $1,242.00 $914.00 $1,160.00 $1,821.00 $864.00 $573.00 $646.00 $1,063.00 $691.00 $687.00 $907.00 $1,144.00 $789.00 $93.00 $77.00 $94.00 $951.00 $1,016.00 $1,492.00 $644.00 $225.00 $429.00 $148.00 $591.00 $246.00 $704.00 $985.00 $215.00 $1,151.00 $1,388.00 $670.00 $902.00 $947.00 $640.00 $589.00 $269.00 $278.00 $285.00 $401.00 $1,199.00 $1,310.00 $1,463.00 $1,671.00 $1,223.00 $1,407.00 $1,424.00 $1,728.00 $1,287.00 $1,132.00 $1,188.00 $1,304.00 $960.00 $1,219.00 $1,912.00 $907.00 $602.00 $678.00 $1,118.00 $729.00 $722.00 $954.00 $1,206.00 $828.00 $98.00 $81.00 $99.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 216 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 53620 53621 53660 53661 53665 53850 53852 53899 54015 54050 54055 54056 54057 54060 54065 54100 54105 54110 54111 54112 54115 54120 54125 54130 54135 54162 54163 54164 54200 54205 54220 54230 54231 54235 54240 54240-26 54240-TC 54250 54250-26 54250-TC 54300 54304 54308 54312 54316 54318 54322 54324 54326 54328 0 0 0 0 0 90 90 YYY 10 10 10 10 10 10 10 0 10 90 90 90 90 90 90 90 90 10 10 10 10 90 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 $59.00 $45.00 $49.00 $50.00 $50.00 $741.00 $728.00 BR $348.00 $91.00 $106.00 $100.00 $149.00 $180.00 $281.00 $149.00 $261.00 $775.00 $1,035.00 $1,210.00 $588.00 $777.00 $1,092.00 $1,532.00 $1,945.00 $220.00 $207.00 $182.00 $78.00 $633.00 $189.00 $104.00 $172.00 $81.00 $109.00 ------------$104.00 ------------$830.00 $988.00 $881.00 $1,067.00 $1,316.00 $900.00 $974.00 $1,260.00 $1,212.00 $1,201.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $177.00 $168.00 $103.00 $103.00 $53.00 $4,103.00 $3,934.00 ------$424.00 $159.00 $152.00 $165.00 $187.00 $257.00 $273.00 $251.00 $391.00 $851.00 $1,092.00 $1,281.00 $608.00 $850.00 $1,100.00 $1,631.00 $2,070.00 $387.00 $292.00 $257.00 $152.00 $728.00 $306.00 $132.00 $192.00 $121.00 $138.00 $93.00 $45.00 $171.00 $156.00 $16.00 $887.00 $1,040.00 $921.00 $1,169.00 $1,383.00 $952.00 $1,083.00 $1,350.00 $1,304.00 $1,281.00 $187.00 $178.00 $109.00 $108.00 $56.00 $4,376.00 $4,194.00 ------$444.00 $168.00 $161.00 $174.00 $198.00 $271.00 $287.00 $264.00 $412.00 $889.00 $1,141.00 $1,337.00 $637.00 $887.00 $1,149.00 $1,705.00 $2,161.00 $407.00 $306.00 $269.00 $161.00 $761.00 $323.00 $139.00 $202.00 $127.00 $147.00 $97.00 $50.00 $180.00 $162.00 $17.00 $928.00 $1,088.00 $962.00 $1,229.00 $1,446.00 $1,006.00 $1,132.00 $1,410.00 $1,362.00 $1,336.00 $197.00 $187.00 $115.00 $114.00 $59.00 $4,613.00 $4,419.00 ------$467.00 $177.00 $169.00 $182.00 $209.00 $286.00 $301.00 $277.00 $434.00 $934.00 $1,199.00 $1,405.00 $669.00 $931.00 $1,207.00 $1,793.00 $2,271.00 $428.00 $321.00 $283.00 $170.00 $799.00 $340.00 $146.00 $213.00 $134.00 $157.00 $103.00 $54.00 $190.00 $171.00 $19.00 $976.00 $1,143.00 $1,010.00 $1,301.00 $1,520.00 $1,077.00 $1,190.00 $1,481.00 $1,431.00 $1,399.00 $120.00 $100.00 $57.00 $55.00 $53.00 $767.00 $832.00 ------$424.00 $126.00 $115.00 $130.00 $121.00 $169.00 $205.00 $151.00 $294.00 $851.00 $1,092.00 $1,281.00 $564.00 $850.00 $1,100.00 $1,631.00 $2,070.00 $263.00 $292.00 $257.00 $114.00 $728.00 $185.00 $109.00 $162.00 $99.00 $138.00 $93.00 $45.00 $171.00 $156.00 $16.00 $887.00 $1,040.00 $921.00 $1,169.00 $1,383.00 $952.00 $1,083.00 $1,350.00 $1,304.00 $1,281.00 $126.00 $105.00 $59.00 $58.00 $56.00 $801.00 $870.00 ------$444.00 $132.00 $121.00 $137.00 $128.00 $178.00 $214.00 $158.00 $308.00 $889.00 $1,141.00 $1,337.00 $590.00 $887.00 $1,149.00 $1,705.00 $2,161.00 $275.00 $306.00 $269.00 $120.00 $761.00 $193.00 $114.00 $169.00 $103.00 $147.00 $97.00 $50.00 $180.00 $162.00 $17.00 $928.00 $1,088.00 $962.00 $1,229.00 $1,446.00 $1,006.00 $1,132.00 $1,410.00 $1,362.00 $1,336.00 $132.00 $111.00 $62.00 $61.00 $59.00 $842.00 $913.00 ------$467.00 $139.00 $127.00 $143.00 $134.00 $187.00 $224.00 $165.00 $324.00 $934.00 $1,199.00 $1,405.00 $620.00 $931.00 $1,207.00 $1,793.00 $2,271.00 $288.00 $321.00 $283.00 $127.00 $799.00 $203.00 $119.00 $179.00 $109.00 $157.00 $103.00 $54.00 $190.00 $171.00 $19.00 $976.00 $1,143.00 $1,010.00 $1,301.00 $1,520.00 $1,077.00 $1,190.00 $1,481.00 $1,431.00 $1,399.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 217 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 54332 54336 54340 54344 54348 54352 54360 54380 54385 54390 54400 54401 54405 54406 54408 54410 54411 54415 54416 54417 54420 54430 54435 54440 54450 54500 54505 54512 54520 54522 54530 54535 54550 54560 54600 54620 54640 54650 54660 54670 54680 54690 54692 54699 54700 54800 54830 54840 54860 54861 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 YYY 10 0 90 90 90 90 $1,327.00 $1,672.00 $727.00 $1,360.00 $1,318.00 $1,820.00 $898.00 $1,054.00 $1,217.00 $1,635.00 $784.00 $892.00 $1,294.00 $687.00 $724.00 $856.00 $933.00 $510.00 $665.00 $819.00 $899.00 $799.00 $503.00 BR $88.00 $102.00 $259.00 $519.00 $445.00 $589.00 $683.00 $922.00 $588.00 $842.00 $524.00 $373.00 $594.00 $861.00 $401.00 $485.00 $948.00 $825.00 $850.00 BR $133.00 $257.00 $411.00 $432.00 $503.00 $696.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,396.00 $1,622.00 $785.00 $1,348.00 $1,412.00 $2,026.00 $997.00 $1,098.00 $1,326.00 $1,604.00 $730.00 $886.00 $1,102.00 $993.00 $1,065.00 $1,260.00 $1,377.00 $712.00 $950.00 $1,209.00 $964.00 $871.00 $564.00 ------$104.00 $102.00 $294.00 $732.00 $448.00 $808.00 $747.00 $999.00 $662.00 $934.00 $611.00 $413.00 $632.00 $943.00 $483.00 $554.00 $1,091.00 $888.00 $1,068.00 ------$292.00 $181.00 $496.00 $439.00 $562.00 $763.00 $1,459.00 $1,709.00 $821.00 $1,418.00 $1,476.00 $2,128.00 $1,043.00 $1,148.00 $1,383.00 $1,673.00 $764.00 $930.00 $1,151.00 $1,038.00 $1,113.00 $1,316.00 $1,437.00 $745.00 $993.00 $1,262.00 $1,008.00 $911.00 $590.00 ------$109.00 $107.00 $308.00 $766.00 $473.00 $849.00 $782.00 $1,046.00 $694.00 $978.00 $639.00 $432.00 $664.00 $992.00 $508.00 $581.00 $1,145.00 $933.00 $1,124.00 ------$307.00 $190.00 $519.00 $460.00 $588.00 $798.00 $1,532.00 $1,822.00 $863.00 $1,504.00 $1,552.00 $2,254.00 $1,096.00 $1,206.00 $1,445.00 $1,758.00 $804.00 $979.00 $1,209.00 $1,091.00 $1,169.00 $1,383.00 $1,507.00 $783.00 $1,043.00 $1,324.00 $1,059.00 $957.00 $620.00 ------$115.00 $113.00 $325.00 $807.00 $502.00 $900.00 $823.00 $1,101.00 $730.00 $1,031.00 $672.00 $455.00 $701.00 $1,054.00 $536.00 $611.00 $1,211.00 $988.00 $1,194.00 ------$324.00 $202.00 $546.00 $484.00 $617.00 $838.00 $1,396.00 $1,622.00 $785.00 $1,348.00 $1,412.00 $2,026.00 $997.00 $1,098.00 $1,326.00 $1,604.00 $730.00 $886.00 $1,102.00 $993.00 $1,065.00 $1,260.00 $1,377.00 $712.00 $950.00 $1,209.00 $964.00 $871.00 $564.00 ------$82.00 $102.00 $294.00 $732.00 $448.00 $808.00 $747.00 $999.00 $662.00 $934.00 $611.00 $413.00 $632.00 $943.00 $483.00 $554.00 $1,091.00 $888.00 $1,068.00 ------$292.00 $181.00 $496.00 $439.00 $562.00 $763.00 $1,459.00 $1,709.00 $821.00 $1,418.00 $1,476.00 $2,128.00 $1,043.00 $1,148.00 $1,383.00 $1,673.00 $764.00 $930.00 $1,151.00 $1,038.00 $1,113.00 $1,316.00 $1,437.00 $745.00 $993.00 $1,262.00 $1,008.00 $911.00 $590.00 ------$86.00 $107.00 $308.00 $766.00 $473.00 $849.00 $782.00 $1,046.00 $694.00 $978.00 $639.00 $432.00 $664.00 $992.00 $508.00 $581.00 $1,145.00 $933.00 $1,124.00 ------$307.00 $190.00 $519.00 $460.00 $588.00 $798.00 $1,532.00 $1,822.00 $863.00 $1,504.00 $1,552.00 $2,254.00 $1,096.00 $1,206.00 $1,445.00 $1,758.00 $804.00 $979.00 $1,209.00 $1,091.00 $1,169.00 $1,383.00 $1,507.00 $783.00 $1,043.00 $1,324.00 $1,059.00 $957.00 $620.00 ------$90.00 $113.00 $325.00 $807.00 $502.00 $900.00 $823.00 $1,101.00 $730.00 $1,031.00 $672.00 $455.00 $701.00 $1,054.00 $536.00 $611.00 $1,211.00 $988.00 $1,194.00 ------$324.00 $202.00 $546.00 $484.00 $617.00 $838.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 218 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 54865 54900 54901 55000 55040 55041 55060 55100 55110 55120 55150 55175 55180 55200 55250 55300 55400 55450 55500 55520 55530 55535 55540 55550 55559 55600 55605 55650 55680 55700 55705 55720 55725 55801 55810 55812 55815 55821 55831 55840 55842 55845 55860 55862 55865 55866 55870 55873 55875 55876 90 90 90 0 90 90 90 10 90 90 90 90 90 90 90 0 90 10 90 90 90 90 90 90 YYY 90 90 90 90 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 0 ------$969.00 $1,340.00 $109.00 $439.00 $634.00 $430.00 $156.00 $223.00 $350.00 $562.00 $426.00 $796.00 $310.00 $349.00 $167.00 $660.00 $391.00 $445.00 $446.00 $467.00 $496.00 $572.00 $486.00 BR $486.00 $609.00 $853.00 $426.00 $183.00 $368.00 $555.00 $670.00 $1,331.00 $1,711.00 $1,989.00 $2,328.00 $1,153.00 $1,252.00 $1,705.00 $1,859.00 $2,222.00 $1,012.00 $1,351.00 $1,890.00 $1,615.00 $166.00 $1,127.00 ------------- Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $478.00 $1,009.00 $1,484.00 $174.00 $458.00 $684.00 $509.00 $305.00 $517.00 $474.00 $652.00 $484.00 $933.00 $745.00 $658.00 $261.00 $688.00 $540.00 $513.00 $544.00 $480.00 $575.00 $660.00 $574.00 ------$579.00 $678.00 $977.00 $472.00 $327.00 $369.00 $653.00 $789.00 $1,476.00 $1,792.00 $2,186.00 $2,411.00 $1,185.00 $1,285.00 $1,824.00 $1,955.00 $2,238.00 $1,192.00 $1,516.00 $1,816.00 $2,378.00 $234.00 $1,565.00 $1,037.00 $207.00 $501.00 $1,053.00 $1,562.00 $184.00 $481.00 $716.00 $534.00 $322.00 $541.00 $496.00 $683.00 $506.00 $979.00 $790.00 $699.00 $272.00 $721.00 $570.00 $540.00 $576.00 $504.00 $602.00 $699.00 $603.00 ------$609.00 $711.00 $1,023.00 $496.00 $344.00 $386.00 $692.00 $826.00 $1,542.00 $1,871.00 $2,283.00 $2,516.00 $1,237.00 $1,341.00 $1,905.00 $2,040.00 $2,336.00 $1,244.00 $1,587.00 $1,896.00 $2,482.00 $245.00 $1,637.00 $1,084.00 $221.00 $527.00 $1,105.00 $1,661.00 $194.00 $508.00 $754.00 $563.00 $339.00 $569.00 $522.00 $719.00 $531.00 $1,033.00 $833.00 $737.00 $287.00 $760.00 $599.00 $572.00 $616.00 $532.00 $633.00 $747.00 $637.00 ------$646.00 $749.00 $1,078.00 $525.00 $360.00 $406.00 $742.00 $870.00 $1,621.00 $1,965.00 $2,401.00 $2,643.00 $1,299.00 $1,408.00 $2,000.00 $2,143.00 $2,454.00 $1,306.00 $1,672.00 $1,992.00 $2,608.00 $258.00 $1,721.00 $1,139.00 $238.00 $478.00 $1,009.00 $1,484.00 $115.00 $458.00 $684.00 $509.00 $217.00 $517.00 $474.00 $652.00 $484.00 $933.00 $379.00 $307.00 $261.00 $688.00 $340.00 $513.00 $544.00 $480.00 $575.00 $660.00 $574.00 ------$579.00 $678.00 $977.00 $472.00 $179.00 $369.00 $653.00 $789.00 $1,476.00 $1,792.00 $2,186.00 $2,411.00 $1,185.00 $1,285.00 $1,824.00 $1,955.00 $2,238.00 $1,192.00 $1,516.00 $1,816.00 $2,378.00 $197.00 $1,565.00 $1,037.00 $156.00 $501.00 $1,053.00 $1,562.00 $120.00 $481.00 $716.00 $534.00 $228.00 $541.00 $496.00 $683.00 $506.00 $979.00 $398.00 $323.00 $272.00 $721.00 $355.00 $540.00 $576.00 $504.00 $602.00 $699.00 $603.00 ------$609.00 $711.00 $1,023.00 $496.00 $185.00 $386.00 $692.00 $826.00 $1,542.00 $1,871.00 $2,283.00 $2,516.00 $1,237.00 $1,341.00 $1,905.00 $2,040.00 $2,336.00 $1,244.00 $1,587.00 $1,896.00 $2,482.00 $206.00 $1,637.00 $1,084.00 $167.00 $527.00 $1,105.00 $1,661.00 $127.00 $508.00 $754.00 $563.00 $240.00 $569.00 $522.00 $719.00 $531.00 $1,033.00 $419.00 $341.00 $287.00 $760.00 $373.00 $572.00 $616.00 $532.00 $633.00 $747.00 $637.00 ------$646.00 $749.00 $1,078.00 $525.00 $192.00 $406.00 $742.00 $870.00 $1,621.00 $1,965.00 $2,401.00 $2,643.00 $1,299.00 $1,408.00 $2,000.00 $2,143.00 $2,454.00 $1,306.00 $1,672.00 $1,992.00 $2,608.00 $216.00 $1,721.00 $1,139.00 $181.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 219 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 55899 55920 56405 56420 56440 56441 56442 56501 56515 56605 56606 56620 56625 56630 56631 56632 56633 56634 56637 56640 56700 56740 56800 56805 56810 56820 56821 57000 57010 57020 57022 57023 57061 57065 57100 57105 57106 57107 57109 57110 57111 57112 57120 57130 57135 57150 57155 57160 57170 57180 YYY 0 10 10 10 10 0 10 10 0 ZZZ 90 90 90 90 90 90 90 90 90 10 10 10 90 10 0 0 10 90 0 10 10 10 10 0 10 90 90 90 90 90 90 90 10 10 0 90 0 0 10 BR ------$131.00 $130.00 $271.00 $183.00 ------$122.00 $200.00 $96.00 $49.00 $607.00 $735.00 $1,061.00 $1,400.00 $1,636.00 $1,350.00 $1,537.00 $1,806.00 $1,777.00 $227.00 $321.00 $310.00 $1,349.00 $316.00 $119.00 $154.00 $237.00 $429.00 $118.00 $179.00 $290.00 $124.00 $251.00 $90.00 $132.00 $409.00 $1,467.00 $1,787.00 $1,015.00 $1,793.00 $1,907.00 $612.00 $220.00 $231.00 $50.00 $383.00 $67.00 $74.00 $124.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) ------$593.00 $145.00 $174.00 $243.00 $197.00 $64.00 $172.00 $292.00 $112.00 $53.00 $697.00 $782.00 $1,135.00 $1,453.00 $1,675.00 $1,481.00 $1,574.00 $1,870.00 $1,873.00 $245.00 $393.00 $322.00 $1,525.00 $347.00 $147.00 $199.00 $251.00 $563.00 $128.00 $221.00 $410.00 $151.00 $256.00 $119.00 $181.00 $614.00 $1,851.00 $2,119.00 $1,196.00 $2,155.00 $2,238.00 $674.00 $241.00 $258.00 $73.00 $554.00 $101.00 $102.00 $191.00 ------$619.00 $154.00 $185.00 $257.00 $208.00 $68.00 $183.00 $309.00 $119.00 $56.00 $736.00 $826.00 $1,196.00 $1,533.00 $1,769.00 $1,561.00 $1,660.00 $1,973.00 $1,981.00 $259.00 $416.00 $340.00 $1,610.00 $367.00 $156.00 $211.00 $265.00 $595.00 $135.00 $232.00 $434.00 $161.00 $272.00 $126.00 $192.00 $648.00 $1,954.00 $2,240.00 $1,265.00 $2,277.00 $2,357.00 $713.00 $255.00 $273.00 $78.00 $580.00 $107.00 $109.00 $203.00 ------$651.00 $164.00 $196.00 $275.00 $222.00 $72.00 $195.00 $329.00 $127.00 $60.00 $785.00 $881.00 $1,274.00 $1,634.00 $1,891.00 $1,663.00 $1,772.00 $2,105.00 $2,124.00 $276.00 $446.00 $364.00 $1,720.00 $393.00 $167.00 $226.00 $283.00 $634.00 $145.00 $247.00 $464.00 $171.00 $290.00 $134.00 $205.00 $689.00 $2,090.00 $2,398.00 $1,353.00 $2,436.00 $2,511.00 $761.00 $273.00 $292.00 $83.00 $608.00 $114.00 $116.00 $216.00 ------$593.00 $140.00 $124.00 $243.00 $183.00 $64.00 $148.00 $258.00 $82.00 $41.00 $697.00 $782.00 $1,135.00 $1,453.00 $1,675.00 $1,481.00 $1,574.00 $1,870.00 $1,873.00 $245.00 $393.00 $322.00 $1,525.00 $347.00 $114.00 $156.00 $251.00 $563.00 $111.00 $221.00 $410.00 $128.00 $227.00 $89.00 $165.00 $614.00 $1,851.00 $2,119.00 $1,196.00 $2,155.00 $2,238.00 $674.00 $213.00 $230.00 $40.00 $554.00 $65.00 $66.00 $145.00 ------$619.00 $148.00 $132.00 $257.00 $193.00 $68.00 $157.00 $272.00 $87.00 $43.00 $736.00 $826.00 $1,196.00 $1,533.00 $1,769.00 $1,561.00 $1,660.00 $1,973.00 $1,981.00 $259.00 $416.00 $340.00 $1,610.00 $367.00 $121.00 $166.00 $265.00 $595.00 $117.00 $232.00 $434.00 $135.00 $241.00 $94.00 $175.00 $648.00 $1,954.00 $2,240.00 $1,265.00 $2,277.00 $2,357.00 $713.00 $225.00 $243.00 $43.00 $580.00 $68.00 $70.00 $153.00 ------$651.00 $158.00 $141.00 $275.00 $206.00 $72.00 $168.00 $290.00 $93.00 $46.00 $785.00 $881.00 $1,274.00 $1,634.00 $1,891.00 $1,663.00 $1,772.00 $2,105.00 $2,124.00 $276.00 $446.00 $364.00 $1,720.00 $393.00 $130.00 $178.00 $283.00 $634.00 $126.00 $247.00 $464.00 $145.00 $258.00 $100.00 $187.00 $689.00 $2,090.00 $2,398.00 $1,353.00 $2,436.00 $2,511.00 $761.00 $241.00 $260.00 $46.00 $608.00 $73.00 $75.00 $164.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 220 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 57200 57210 57220 57230 57240 57250 57260 57265 57267 57268 57270 57280 57282 57283 57284 57285 57287 57288 57289 57291 57292 57295 57296 57300 57305 57307 57308 57310 57311 57320 57330 57335 57400 57410 57415 57420 57421 57423 57425 57452 57454 57455 57456 57460 57461 57500 57505 57510 57511 57513 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 0 0 90 90 0 0 0 0 0 0 0 10 10 10 10 $313.00 $395.00 $378.00 $442.00 $536.00 $485.00 $700.00 $902.00 ------$577.00 $867.00 $1,071.00 $734.00 ------$950.00 ------$685.00 $1,009.00 $879.00 $622.00 $925.00 ------------$653.00 $995.00 $997.00 $769.00 $517.00 $612.00 $693.00 $916.00 $963.00 $70.00 $57.00 $75.00 $124.00 $162.00 ------------$96.00 $125.00 $149.00 $141.00 $223.00 $333.00 $89.00 $105.00 $140.00 $159.00 $191.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $387.00 $481.00 $417.00 $511.00 $818.00 $803.00 $1,018.00 $1,158.00 $367.00 $626.00 $1,052.00 $1,272.00 $674.00 $901.00 $1,109.00 $849.00 $907.00 $1,070.00 $1,010.00 $720.00 $1,099.00 $649.00 $1,239.00 $690.00 $1,164.00 $1,307.00 $834.00 $619.00 $706.00 $708.00 $1,022.00 $1,507.00 $180.00 $141.00 $207.00 $155.00 $211.00 $1,208.00 $1,273.00 $146.00 $207.00 $193.00 $182.00 $413.00 $460.00 $180.00 $135.00 $179.00 $194.00 $190.00 $409.00 $509.00 $441.00 $537.00 $850.00 $835.00 $1,062.00 $1,214.00 $389.00 $662.00 $1,109.00 $1,341.00 $716.00 $946.00 $1,169.00 $883.00 $951.00 $1,121.00 $1,063.00 $761.00 $1,162.00 $687.00 $1,306.00 $728.00 $1,230.00 $1,383.00 $881.00 $648.00 $739.00 $743.00 $1,072.00 $1,586.00 $190.00 $149.00 $218.00 $164.00 $224.00 $1,273.00 $1,342.00 $155.00 $220.00 $205.00 $193.00 $439.00 $490.00 $191.00 $143.00 $190.00 $206.00 $202.00 $436.00 $543.00 $470.00 $569.00 $888.00 $873.00 $1,116.00 $1,284.00 $420.00 $705.00 $1,183.00 $1,428.00 $769.00 $1,003.00 $1,243.00 $923.00 $1,004.00 $1,184.00 $1,130.00 $812.00 $1,243.00 $735.00 $1,391.00 $775.00 $1,317.00 $1,483.00 $941.00 $683.00 $779.00 $784.00 $1,133.00 $1,686.00 $203.00 $159.00 $232.00 $175.00 $239.00 $1,357.00 $1,431.00 $166.00 $235.00 $219.00 $206.00 $468.00 $522.00 $203.00 $153.00 $203.00 $220.00 $216.00 $387.00 $481.00 $417.00 $511.00 $818.00 $803.00 $1,018.00 $1,158.00 $367.00 $626.00 $1,052.00 $1,272.00 $674.00 $901.00 $1,109.00 $849.00 $907.00 $1,070.00 $1,010.00 $720.00 $1,099.00 $649.00 $1,239.00 $690.00 $1,164.00 $1,307.00 $834.00 $619.00 $706.00 $708.00 $1,022.00 $1,507.00 $180.00 $141.00 $207.00 $121.00 $167.00 $1,208.00 $1,273.00 $122.00 $184.00 $150.00 $140.00 $221.00 $257.00 $98.00 $119.00 $156.00 $174.00 $175.00 $409.00 $509.00 $441.00 $537.00 $850.00 $835.00 $1,062.00 $1,214.00 $389.00 $662.00 $1,109.00 $1,341.00 $716.00 $946.00 $1,169.00 $883.00 $951.00 $1,121.00 $1,063.00 $761.00 $1,162.00 $687.00 $1,306.00 $728.00 $1,230.00 $1,383.00 $881.00 $648.00 $739.00 $743.00 $1,072.00 $1,586.00 $190.00 $149.00 $218.00 $128.00 $177.00 $1,273.00 $1,342.00 $129.00 $195.00 $159.00 $149.00 $234.00 $271.00 $103.00 $127.00 $165.00 $185.00 $186.00 $436.00 $543.00 $470.00 $569.00 $888.00 $873.00 $1,116.00 $1,284.00 $420.00 $705.00 $1,183.00 $1,428.00 $769.00 $1,003.00 $1,243.00 $923.00 $1,004.00 $1,184.00 $1,130.00 $812.00 $1,243.00 $735.00 $1,391.00 $775.00 $1,317.00 $1,483.00 $941.00 $683.00 $779.00 $784.00 $1,133.00 $1,686.00 $203.00 $159.00 $232.00 $137.00 $190.00 $1,357.00 $1,431.00 $139.00 $209.00 $171.00 $159.00 $251.00 $291.00 $110.00 $136.00 $177.00 $198.00 $199.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 221 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 57520 57522 57530 57531 57540 57545 57550 57555 57556 57558 57700 57720 57800 58100 58110 58120 58140 58145 58146 58150 58152 58180 58200 58210 58240 58260 58262 58263 58267 58270 58275 58280 58285 58290 58291 58292 58293 58294 58300 58301 58321 58322 58323 58340 58345 58346 58350 58353 58356 58400 90 90 90 90 90 90 90 90 90 10 90 90 0 0 ZZZ 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 10 90 10 10 10 90 $359.00 $319.00 $386.00 $2,036.00 $815.00 $700.00 $486.00 $774.00 $718.00 ------$279.00 $328.00 $71.00 $74.00 ------$297.00 $1,010.00 $677.00 $1,089.00 $1,110.00 $1,159.00 $1,118.00 $1,562.00 $2,080.00 $2,898.00 $926.00 $1,026.00 $1,120.00 $1,133.00 $1,019.00 $1,121.00 $1,132.00 $1,360.00 $1,089.00 $1,197.00 $1,268.00 $1,318.00 $1,168.00 $96.00 $71.00 $81.00 $90.00 $24.00 $87.00 $335.00 $408.00 $103.00 $225.00 ------$519.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $413.00 $351.00 $452.00 $2,265.00 $1,030.00 $1,088.00 $532.00 $795.00 $744.00 $166.00 $390.00 $403.00 $80.00 $148.00 $67.00 $322.00 $1,213.00 $716.00 $1,544.00 $1,306.00 $1,665.00 $1,249.00 $1,735.00 $2,310.00 $3,519.00 $1,095.00 $1,225.00 $1,321.00 $1,403.00 $1,177.00 $1,305.00 $1,399.00 $1,756.00 $1,541.00 $1,674.00 $1,768.00 $1,839.00 $1,624.00 $108.00 $131.00 $103.00 $118.00 $30.00 $181.00 $365.00 $587.00 $129.00 $1,663.00 $2,983.00 $586.00 $438.00 $372.00 $478.00 $2,393.00 $1,088.00 $1,149.00 $562.00 $840.00 $784.00 $176.00 $412.00 $426.00 $85.00 $157.00 $71.00 $341.00 $1,283.00 $757.00 $1,632.00 $1,378.00 $1,760.00 $1,315.00 $1,833.00 $2,439.00 $3,689.00 $1,157.00 $1,295.00 $1,396.00 $1,483.00 $1,244.00 $1,380.00 $1,478.00 $1,857.00 $1,629.00 $1,770.00 $1,870.00 $1,944.00 $1,715.00 $115.00 $139.00 $109.00 $125.00 $32.00 $193.00 $384.00 $615.00 $137.00 $1,779.00 $3,191.00 $619.00 $468.00 $396.00 $510.00 $2,560.00 $1,164.00 $1,227.00 $599.00 $897.00 $834.00 $188.00 $438.00 $454.00 $91.00 $167.00 $76.00 $364.00 $1,374.00 $808.00 $1,748.00 $1,471.00 $1,883.00 $1,400.00 $1,959.00 $2,607.00 $3,907.00 $1,237.00 $1,386.00 $1,494.00 $1,587.00 $1,332.00 $1,476.00 $1,582.00 $1,990.00 $1,744.00 $1,896.00 $2,002.00 $2,082.00 $1,835.00 $123.00 $148.00 $116.00 $134.00 $34.00 $204.00 $406.00 $648.00 $146.00 $1,882.00 $3,377.00 $660.00 $364.00 $320.00 $452.00 $2,265.00 $1,030.00 $1,088.00 $532.00 $795.00 $744.00 $150.00 $390.00 $403.00 $65.00 $119.00 $56.00 $286.00 $1,213.00 $716.00 $1,544.00 $1,306.00 $1,665.00 $1,249.00 $1,735.00 $2,310.00 $3,519.00 $1,095.00 $1,225.00 $1,321.00 $1,403.00 $1,177.00 $1,305.00 $1,399.00 $1,756.00 $1,541.00 $1,674.00 $1,768.00 $1,839.00 $1,624.00 $72.00 $92.00 $66.00 $80.00 $17.00 $79.00 $365.00 $587.00 $103.00 $295.00 $477.00 $586.00 $386.00 $339.00 $478.00 $2,393.00 $1,088.00 $1,149.00 $562.00 $840.00 $784.00 $159.00 $412.00 $426.00 $69.00 $126.00 $60.00 $302.00 $1,283.00 $757.00 $1,632.00 $1,378.00 $1,760.00 $1,315.00 $1,833.00 $2,439.00 $3,689.00 $1,157.00 $1,295.00 $1,396.00 $1,483.00 $1,244.00 $1,380.00 $1,478.00 $1,857.00 $1,629.00 $1,770.00 $1,870.00 $1,944.00 $1,715.00 $77.00 $97.00 $70.00 $85.00 $18.00 $83.00 $384.00 $615.00 $109.00 $313.00 $506.00 $619.00 $413.00 $362.00 $510.00 $2,560.00 $1,164.00 $1,227.00 $599.00 $897.00 $834.00 $170.00 $438.00 $454.00 $74.00 $135.00 $64.00 $323.00 $1,374.00 $808.00 $1,748.00 $1,471.00 $1,883.00 $1,400.00 $1,959.00 $2,607.00 $3,907.00 $1,237.00 $1,386.00 $1,494.00 $1,587.00 $1,332.00 $1,476.00 $1,582.00 $1,990.00 $1,744.00 $1,896.00 $2,002.00 $2,082.00 $1,835.00 $82.00 $104.00 $75.00 $91.00 $20.00 $88.00 $406.00 $648.00 $117.00 $336.00 $545.00 $660.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 222 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 58410 58520 58540 58541 58542 58543 58544 58545 58546 58548 58550 58552 58553 58554 58555 58558 58559 58560 58561 58562 58563 58565 58570 58571 58572 58573 58578 58579 58600 58605 58611 58615 58660 58661 58662 58670 58671 58672 58673 58679 58700 58720 58740 58750 58752 58760 58770 58800 58805 58820 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 90 90 90 90 90 YYY YYY 90 90 ZZZ 10 90 10 90 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 $752.00 $663.00 $923.00 ------------------------$876.00 $1,104.00 ------$1,038.00 $853.00 $1,096.00 $1,085.00 $261.00 $340.00 $436.00 $482.00 $677.00 $339.00 $450.00 ------------------------------BR BR $337.00 $298.00 $47.00 $319.00 $793.00 $804.00 $807.00 $450.00 $463.00 $872.00 $928.00 BR $544.00 $844.00 $508.00 $949.00 $893.00 $769.00 $763.00 $343.00 $509.00 $326.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,057.00 $1,033.00 $1,203.00 $1,124.00 $1,238.00 $1,259.00 $1,362.00 $1,193.00 $1,514.00 $2,379.00 $1,175.00 $1,290.00 $1,520.00 $1,726.00 $312.00 $412.00 $467.00 $530.00 $750.00 $441.00 $2,683.00 $2,714.00 $1,207.00 $1,315.00 $1,501.00 $1,681.00 ------------$484.00 $439.00 $107.00 $339.00 $897.00 $864.00 $944.00 $484.00 $485.00 $1,005.00 $1,084.00 ------$1,010.00 $949.00 $1,160.00 $1,213.00 $1,197.00 $1,101.00 $1,144.00 $419.00 $527.00 $413.00 $1,116.00 $1,091.00 $1,271.00 $1,188.00 $1,304.00 $1,326.00 $1,435.00 $1,261.00 $1,601.00 $2,513.00 $1,243.00 $1,360.00 $1,608.00 $1,817.00 $331.00 $437.00 $494.00 $561.00 $794.00 $468.00 $2,869.00 $2,908.00 $1,276.00 $1,386.00 $1,586.00 $1,769.00 ------------$512.00 $464.00 $113.00 $360.00 $950.00 $915.00 $999.00 $512.00 $513.00 $1,066.00 $1,148.00 ------$1,069.00 $1,004.00 $1,227.00 $1,284.00 $1,267.00 $1,168.00 $1,211.00 $442.00 $557.00 $437.00 $1,190.00 $1,165.00 $1,361.00 $1,272.00 $1,390.00 $1,414.00 $1,530.00 $1,350.00 $1,716.00 $2,688.00 $1,331.00 $1,449.00 $1,722.00 $1,934.00 $354.00 $468.00 $531.00 $602.00 $853.00 $501.00 $3,035.00 $3,089.00 $1,367.00 $1,478.00 $1,699.00 $1,883.00 ------------$547.00 $496.00 $121.00 $385.00 $1,019.00 $981.00 $1,071.00 $547.00 $549.00 $1,145.00 $1,232.00 ------$1,145.00 $1,074.00 $1,314.00 $1,376.00 $1,357.00 $1,257.00 $1,298.00 $469.00 $595.00 $467.00 $1,057.00 $1,033.00 $1,203.00 $1,124.00 $1,238.00 $1,259.00 $1,362.00 $1,193.00 $1,514.00 $2,379.00 $1,175.00 $1,290.00 $1,520.00 $1,726.00 $257.00 $363.00 $467.00 $530.00 $750.00 $397.00 $468.00 $608.00 $1,207.00 $1,315.00 $1,501.00 $1,681.00 ------------$484.00 $439.00 $107.00 $339.00 $897.00 $864.00 $944.00 $484.00 $485.00 $1,005.00 $1,084.00 ------$1,010.00 $949.00 $1,160.00 $1,213.00 $1,197.00 $1,101.00 $1,144.00 $387.00 $527.00 $413.00 $1,116.00 $1,091.00 $1,271.00 $1,188.00 $1,304.00 $1,326.00 $1,435.00 $1,261.00 $1,601.00 $2,513.00 $1,243.00 $1,360.00 $1,608.00 $1,817.00 $273.00 $384.00 $494.00 $561.00 $794.00 $420.00 $495.00 $651.00 $1,276.00 $1,386.00 $1,586.00 $1,769.00 ------------$512.00 $464.00 $113.00 $360.00 $950.00 $915.00 $999.00 $512.00 $513.00 $1,066.00 $1,148.00 ------$1,069.00 $1,004.00 $1,227.00 $1,284.00 $1,267.00 $1,168.00 $1,211.00 $408.00 $557.00 $437.00 $1,190.00 $1,165.00 $1,361.00 $1,272.00 $1,390.00 $1,414.00 $1,530.00 $1,350.00 $1,716.00 $2,688.00 $1,331.00 $1,449.00 $1,722.00 $1,934.00 $292.00 $412.00 $531.00 $602.00 $853.00 $451.00 $531.00 $709.00 $1,367.00 $1,478.00 $1,699.00 $1,883.00 ------------$547.00 $496.00 $121.00 $385.00 $1,019.00 $981.00 $1,071.00 $547.00 $549.00 $1,145.00 $1,232.00 ------$1,145.00 $1,074.00 $1,314.00 $1,376.00 $1,357.00 $1,257.00 $1,298.00 $433.00 $595.00 $467.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 223 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 58822 58823 58825 58900 58920 58925 58940 58943 58950 58951 58952 58953 58954 58956 58957 58958 58960 58999 59000 59001 59012 59015 59020 59020-26 59020-TC 59025 59025-26 59025-TC 59030 59050 59051 59100 59120 59121 59130 59135 59136 59140 59150 59151 59160 59200 59300 59320 59325 59350 59400 59409 59410 59412 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 YYY 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 10 0 0 0 0 0 0 0 0 0 $603.00 $216.00 $469.00 $489.00 $571.00 $820.00 $592.00 $1,368.00 $1,170.00 $1,703.00 $1,876.00 $1,839.00 $1,999.00 ------------------$1,174.00 BR $123.00 $167.00 $267.00 $168.00 $85.00 ------------$54.00 ------------$155.00 $71.00 $47.00 $633.00 $893.00 $768.00 $832.00 $1,083.00 $934.00 $461.00 $543.00 $690.00 $279.00 $79.00 $179.00 $196.00 $316.00 $375.00 $1,816.00 $1,019.00 $1,123.00 $141.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $901.00 $1,210.00 $920.00 $538.00 $936.00 $964.00 $657.00 $1,484.00 $1,410.00 $1,819.00 $2,055.00 $2,554.00 $2,773.00 $1,854.00 $1,936.00 $2,143.00 $1,219.00 ------$181.00 $259.00 $294.00 $219.00 $98.00 $55.00 $43.00 $64.00 $44.00 $20.00 $161.00 $74.00 $61.00 $1,157.00 $1,097.00 $1,107.00 $1,260.00 $1,266.00 $1,202.00 $515.00 $1,074.00 $1,054.00 $311.00 $105.00 $267.00 $219.00 $344.00 $402.00 $2,430.00 $1,114.00 $1,277.00 $148.00 $949.00 $1,290.00 $972.00 $568.00 $991.00 $1,020.00 $694.00 $1,569.00 $1,490.00 $1,920.00 $2,170.00 $2,698.00 $2,930.00 $1,990.00 $2,045.00 $2,264.00 $1,289.00 ------$196.00 $282.00 $319.00 $237.00 $107.00 $59.00 $48.00 $70.00 $48.00 $21.00 $175.00 $80.00 $66.00 $1,253.00 $1,187.00 $1,198.00 $1,367.00 $1,372.00 $1,302.00 $558.00 $1,165.00 $1,144.00 $336.00 $114.00 $289.00 $238.00 $372.00 $437.00 $2,622.00 $1,212.00 $1,387.00 $161.00 $1,010.00 $1,360.00 $1,040.00 $606.00 $1,063.00 $1,091.00 $742.00 $1,680.00 $1,593.00 $2,052.00 $2,321.00 $2,887.00 $3,136.00 $2,175.00 $2,189.00 $2,424.00 $1,380.00 ------$213.00 $313.00 $355.00 $262.00 $120.00 $66.00 $54.00 $77.00 $54.00 $23.00 $195.00 $89.00 $73.00 $1,387.00 $1,312.00 $1,325.00 $1,517.00 $1,521.00 $1,443.00 $617.00 $1,291.00 $1,267.00 $369.00 $125.00 $318.00 $265.00 $412.00 $488.00 $2,882.00 $1,352.00 $1,542.00 $179.00 $901.00 $234.00 $920.00 $538.00 $936.00 $964.00 $657.00 $1,484.00 $1,410.00 $1,819.00 $2,055.00 $2,554.00 $2,773.00 $1,854.00 $1,936.00 $2,143.00 $1,219.00 ------$116.00 $259.00 $294.00 $191.00 $98.00 $55.00 $43.00 $64.00 $44.00 $20.00 $161.00 $74.00 $61.00 $1,157.00 $1,097.00 $1,107.00 $1,260.00 $1,266.00 $1,202.00 $515.00 $1,074.00 $1,054.00 $261.00 $65.00 $207.00 $219.00 $344.00 $402.00 $2,430.00 $1,114.00 $1,277.00 $148.00 $949.00 $245.00 $972.00 $568.00 $991.00 $1,020.00 $694.00 $1,569.00 $1,490.00 $1,920.00 $2,170.00 $2,698.00 $2,930.00 $1,990.00 $2,045.00 $2,264.00 $1,289.00 ------$126.00 $282.00 $319.00 $207.00 $107.00 $59.00 $48.00 $70.00 $48.00 $21.00 $175.00 $80.00 $66.00 $1,253.00 $1,187.00 $1,198.00 $1,367.00 $1,372.00 $1,302.00 $558.00 $1,165.00 $1,144.00 $283.00 $71.00 $225.00 $238.00 $372.00 $437.00 $2,622.00 $1,212.00 $1,387.00 $161.00 $1,010.00 $257.00 $1,040.00 $606.00 $1,063.00 $1,091.00 $742.00 $1,680.00 $1,593.00 $2,052.00 $2,321.00 $2,887.00 $3,136.00 $2,175.00 $2,189.00 $2,424.00 $1,380.00 ------$140.00 $313.00 $355.00 $230.00 $120.00 $66.00 $54.00 $77.00 $54.00 $23.00 $195.00 $89.00 $73.00 $1,387.00 $1,312.00 $1,325.00 $1,517.00 $1,521.00 $1,443.00 $617.00 $1,291.00 $1,267.00 $313.00 $79.00 $251.00 $265.00 $412.00 $488.00 $2,882.00 $1,352.00 $1,542.00 $179.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 224 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 59414 59425 59426 59430 59510 59514 59515 59525 59610 59612 59614 59618 59620 59622 59812 59820 59821 59830 59840 59841 59850 59851 59852 59855 59856 59857 59866 59870 59871 59898 59899 60000 60100 60200 60210 60212 60220 60225 60240 60252 60254 60260 60270 60271 60280 60281 60300 60500 60502 60505 0 0 0 0 0 0 0 ZZZ 0 0 0 0 0 0 90 90 90 90 10 10 90 90 90 90 90 90 0 90 0 YYY YYY 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 $134.00 $414.00 $708.00 $140.00 $2,064.00 $1,199.00 $1,324.00 $591.00 $1,805.00 $1,113.00 $1,208.00 $2,035.00 $1,293.00 $1,397.00 $343.00 $389.00 $398.00 $496.00 $331.00 $443.00 $449.00 $464.00 $642.00 $477.00 $577.00 $711.00 $304.00 $348.00 $192.00 BR BR $114.00 $96.00 $744.00 $872.00 $1,170.00 $851.00 $1,107.00 $1,228.00 $1,427.00 $1,911.00 $1,022.00 $1,468.00 $1,210.00 $546.00 $670.00 ------$1,232.00 $1,475.00 $1,631.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $133.00 $594.00 $1,059.00 $197.00 $2,752.00 $1,317.00 $1,534.00 $694.00 $2,560.00 $1,247.00 $1,389.00 $2,882.00 $1,438.00 $1,666.00 $423.00 $507.00 $522.00 $605.00 $301.00 $525.00 $522.00 $555.00 $752.00 $580.00 $690.00 $806.00 $338.00 $635.00 $191.00 ------------$196.00 $149.00 $832.00 $893.00 $1,286.00 $977.00 $1,177.00 $1,257.00 $1,683.00 $2,169.00 $1,409.00 $1,763.00 $1,356.00 $555.00 $746.00 $134.00 $1,300.00 $1,637.00 $1,794.00 $144.00 $638.00 $1,136.00 $214.00 $2,970.00 $1,432.00 $1,664.00 $754.00 $2,765.00 $1,357.00 $1,509.00 $3,111.00 $1,564.00 $1,807.00 $457.00 $547.00 $564.00 $655.00 $326.00 $568.00 $564.00 $600.00 $813.00 $629.00 $749.00 $872.00 $366.00 $687.00 $207.00 ------------$207.00 $156.00 $879.00 $943.00 $1,362.00 $1,032.00 $1,244.00 $1,329.00 $1,775.00 $2,281.00 $1,487.00 $1,857.00 $1,429.00 $585.00 $784.00 $142.00 $1,376.00 $1,734.00 $1,897.00 $161.00 $695.00 $1,237.00 $237.00 $3,265.00 $1,597.00 $1,847.00 $838.00 $3,041.00 $1,513.00 $1,680.00 $3,422.00 $1,745.00 $2,007.00 $503.00 $597.00 $617.00 $723.00 $360.00 $626.00 $623.00 $660.00 $898.00 $696.00 $830.00 $964.00 $405.00 $756.00 $230.00 ------------$219.00 $164.00 $935.00 $1,008.00 $1,460.00 $1,101.00 $1,330.00 $1,423.00 $1,893.00 $2,421.00 $1,587.00 $1,978.00 $1,520.00 $620.00 $829.00 $150.00 $1,476.00 $1,860.00 $2,031.00 $133.00 $471.00 $831.00 $181.00 $2,752.00 $1,317.00 $1,534.00 $694.00 $2,560.00 $1,247.00 $1,389.00 $2,882.00 $1,438.00 $1,666.00 $404.00 $470.00 $484.00 $605.00 $295.00 $498.00 $522.00 $555.00 $752.00 $580.00 $690.00 $806.00 $338.00 $635.00 $191.00 ------------$181.00 $107.00 $832.00 $893.00 $1,286.00 $977.00 $1,177.00 $1,257.00 $1,683.00 $2,169.00 $1,409.00 $1,763.00 $1,356.00 $555.00 $746.00 $67.00 $1,300.00 $1,637.00 $1,794.00 $144.00 $506.00 $892.00 $197.00 $2,970.00 $1,432.00 $1,664.00 $754.00 $2,765.00 $1,357.00 $1,509.00 $3,111.00 $1,564.00 $1,807.00 $437.00 $507.00 $522.00 $655.00 $320.00 $539.00 $564.00 $600.00 $813.00 $629.00 $749.00 $872.00 $366.00 $687.00 $207.00 ------------$190.00 $111.00 $879.00 $943.00 $1,362.00 $1,032.00 $1,244.00 $1,329.00 $1,775.00 $2,281.00 $1,487.00 $1,857.00 $1,429.00 $585.00 $784.00 $70.00 $1,376.00 $1,734.00 $1,897.00 $161.00 $556.00 $979.00 $219.00 $3,265.00 $1,597.00 $1,847.00 $838.00 $3,041.00 $1,513.00 $1,680.00 $3,422.00 $1,745.00 $2,007.00 $482.00 $555.00 $574.00 $723.00 $354.00 $596.00 $623.00 $660.00 $898.00 $696.00 $830.00 $964.00 $405.00 $756.00 $230.00 ------------$201.00 $117.00 $935.00 $1,008.00 $1,460.00 $1,101.00 $1,330.00 $1,423.00 $1,893.00 $2,421.00 $1,587.00 $1,978.00 $1,520.00 $620.00 $829.00 $73.00 $1,476.00 $1,860.00 $2,031.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 225 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 60512 60520 60521 60522 60540 60545 60600 60605 60650 60659 60699 61020 61026 61050 61055 61070 61105 61107 61108 61120 61140 61150 61151 61154 61156 61210 61215 61250 61253 61304 61305 61312 61313 61314 61315 61316 61320 61321 61322 61323 61330 61332 61333 61334 61340 61343 61345 61440 61450 61458 ZZZ 90 90 90 90 90 90 90 90 YYY YYY 0 0 0 0 0 90 0 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $310.00 $1,405.00 $1,591.00 $1,820.00 $1,272.00 $1,505.00 $1,477.00 $1,624.00 $1,340.00 BR BR $150.00 $138.00 $106.00 $143.00 $67.00 $503.00 $863.00 $959.00 $733.00 $1,389.00 $1,503.00 $795.00 $1,393.00 $1,473.00 $527.00 $637.00 $888.00 $1,042.00 $2,005.00 $2,419.00 $2,187.00 $2,207.00 $2,200.00 $2,393.00 $88.00 $2,118.00 $2,310.00 $1,779.00 $1,842.00 $1,706.00 $2,307.00 $2,231.00 $1,525.00 $1,584.00 $2,673.00 $2,259.00 $2,110.00 $2,173.00 $2,433.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $321.00 $1,358.00 $1,563.00 $1,879.00 $1,376.00 $1,579.00 $1,843.00 $2,304.00 $1,552.00 ------------$172.00 $173.00 $140.00 $181.00 $109.00 $579.00 $445.00 $1,138.00 $933.00 $1,637.00 $1,752.00 $1,275.00 $1,636.00 $1,640.00 $519.00 $607.00 $1,112.00 $1,218.00 $2,176.00 $2,579.00 $2,673.00 $2,578.00 $2,388.00 $2,743.00 $121.00 $2,533.00 $2,799.00 $3,034.00 $3,112.00 $1,997.00 $2,435.00 $2,393.00 $1,546.00 $1,893.00 $2,914.00 $2,682.00 $2,623.00 $2,464.00 $2,666.00 $340.00 $1,441.00 $1,666.00 $1,999.00 $1,448.00 $1,663.00 $1,934.00 $2,411.00 $1,639.00 ------------$186.00 $186.00 $147.00 $190.00 $117.00 $629.00 $486.00 $1,232.00 $1,009.00 $1,778.00 $1,899.00 $1,380.00 $1,780.00 $1,783.00 $566.00 $656.00 $1,207.00 $1,312.00 $2,364.00 $2,788.00 $2,889.00 $2,795.00 $2,596.00 $2,981.00 $132.00 $2,753.00 $3,037.00 $3,287.00 $3,376.00 $2,101.00 $2,609.00 $2,543.00 $1,625.00 $2,057.00 $3,167.00 $2,914.00 $2,850.00 $2,662.00 $2,898.00 $364.00 $1,550.00 $1,803.00 $2,158.00 $1,540.00 $1,771.00 $2,050.00 $2,545.00 $1,753.00 ------------$203.00 $203.00 $155.00 $201.00 $127.00 $694.00 $543.00 $1,359.00 $1,110.00 $1,970.00 $2,100.00 $1,523.00 $1,975.00 $1,978.00 $633.00 $719.00 $1,337.00 $1,437.00 $2,623.00 $3,072.00 $3,184.00 $3,093.00 $2,883.00 $3,309.00 $147.00 $3,056.00 $3,366.00 $3,636.00 $3,741.00 $2,229.00 $2,841.00 $2,739.00 $1,723.00 $2,281.00 $3,515.00 $3,236.00 $3,165.00 $2,931.00 $3,220.00 $321.00 $1,358.00 $1,563.00 $1,879.00 $1,376.00 $1,579.00 $1,843.00 $2,304.00 $1,552.00 ------------$172.00 $173.00 $140.00 $181.00 $109.00 $579.00 $445.00 $1,138.00 $933.00 $1,637.00 $1,752.00 $1,275.00 $1,636.00 $1,640.00 $519.00 $607.00 $1,112.00 $1,218.00 $2,176.00 $2,579.00 $2,673.00 $2,578.00 $2,388.00 $2,743.00 $121.00 $2,533.00 $2,799.00 $3,034.00 $3,112.00 $1,997.00 $2,435.00 $2,393.00 $1,546.00 $1,893.00 $2,914.00 $2,682.00 $2,623.00 $2,464.00 $2,666.00 $340.00 $1,441.00 $1,666.00 $1,999.00 $1,448.00 $1,663.00 $1,934.00 $2,411.00 $1,639.00 ------------$186.00 $186.00 $147.00 $190.00 $117.00 $629.00 $486.00 $1,232.00 $1,009.00 $1,778.00 $1,899.00 $1,380.00 $1,780.00 $1,783.00 $566.00 $656.00 $1,207.00 $1,312.00 $2,364.00 $2,788.00 $2,889.00 $2,795.00 $2,596.00 $2,981.00 $132.00 $2,753.00 $3,037.00 $3,287.00 $3,376.00 $2,101.00 $2,609.00 $2,543.00 $1,625.00 $2,057.00 $3,167.00 $2,914.00 $2,850.00 $2,662.00 $2,898.00 $364.00 $1,550.00 $1,803.00 $2,158.00 $1,540.00 $1,771.00 $2,050.00 $2,545.00 $1,753.00 ------------$203.00 $203.00 $155.00 $201.00 $127.00 $694.00 $543.00 $1,359.00 $1,110.00 $1,970.00 $2,100.00 $1,523.00 $1,975.00 $1,978.00 $633.00 $719.00 $1,337.00 $1,437.00 $2,623.00 $3,072.00 $3,184.00 $3,093.00 $2,883.00 $3,309.00 $147.00 $3,056.00 $3,366.00 $3,636.00 $3,741.00 $2,229.00 $2,841.00 $2,739.00 $1,723.00 $2,281.00 $3,515.00 $3,236.00 $3,165.00 $2,931.00 $3,220.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 226 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 61460 61470 61480 61490 61500 61501 61510 61512 61514 61516 61517 61518 61519 61520 61521 61522 61524 61526 61530 61531 61533 61534 61535 61536 61537 61538 61539 61540 61541 61542 61543 61544 61545 61546 61548 61550 61552 61556 61557 61558 61559 61563 61564 61566 61567 61570 61571 61575 61576 61580 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $2,426.00 $1,982.00 $1,922.00 $1,687.00 $1,637.00 $1,353.00 $2,506.00 $2,981.00 $2,262.00 $2,253.00 $74.00 $3,163.00 $3,450.00 $4,349.00 $3,667.00 $2,415.00 $2,484.00 $3,918.00 $3,611.00 $1,344.00 $1,712.00 $1,535.00 $958.00 $2,862.00 ------$2,466.00 $2,660.00 ------$2,363.00 $2,533.00 $2,307.00 $2,271.00 $3,474.00 $2,695.00 $1,964.00 $1,141.00 $1,463.00 $1,760.00 $1,807.00 $2,085.00 $2,700.00 $2,175.00 $2,597.00 ------------$1,975.00 $2,140.00 $2,992.00 $3,772.00 $2,383.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $2,668.00 $2,458.00 $2,432.00 $2,536.00 $1,758.00 $1,483.00 $2,863.00 $3,411.00 $2,512.00 $2,454.00 $122.00 $3,665.00 $3,958.00 $4,968.00 $4,262.00 $2,884.00 $2,750.00 $4,392.00 $3,735.00 $1,555.00 $1,992.00 $2,136.00 $1,259.00 $3,454.00 $3,052.00 $3,240.00 $3,128.00 $2,968.00 $2,778.00 $3,054.00 $2,820.00 $2,457.00 $4,190.00 $3,028.00 $1,974.00 $1,117.00 $1,568.00 $2,112.00 $2,229.00 $2,067.00 $3,205.00 $2,450.00 $3,226.00 $2,928.00 $3,242.00 $2,403.00 $2,611.00 $3,027.00 $4,601.00 $3,090.00 $2,876.00 $2,658.00 $2,644.00 $2,763.00 $1,901.00 $1,598.00 $3,109.00 $3,710.00 $2,730.00 $2,665.00 $133.00 $3,983.00 $4,305.00 $5,353.00 $4,634.00 $3,135.00 $2,988.00 $4,664.00 $3,971.00 $1,686.00 $2,164.00 $2,320.00 $1,364.00 $3,756.00 $3,285.00 $3,476.00 $3,401.00 $3,240.00 $3,003.00 $3,319.00 $3,066.00 $2,658.00 $4,544.00 $3,284.00 $2,105.00 $1,165.00 $1,632.00 $2,274.00 $2,425.00 $2,153.00 $3,489.00 $2,632.00 $3,513.00 $3,166.00 $3,479.00 $2,603.00 $2,837.00 $3,227.00 $4,854.00 $3,262.00 $3,159.00 $2,931.00 $2,943.00 $3,077.00 $2,094.00 $1,752.00 $3,448.00 $4,123.00 $3,030.00 $2,957.00 $148.00 $4,424.00 $4,787.00 $5,877.00 $5,151.00 $3,482.00 $3,316.00 $5,019.00 $4,278.00 $1,864.00 $2,399.00 $2,571.00 $1,507.00 $4,175.00 $3,604.00 $3,799.00 $3,779.00 $3,616.00 $3,310.00 $3,686.00 $3,408.00 $2,935.00 $5,032.00 $3,636.00 $2,276.00 $1,222.00 $1,705.00 $2,493.00 $2,693.00 $2,249.00 $3,879.00 $2,877.00 $3,912.00 $3,490.00 $3,795.00 $2,875.00 $3,148.00 $3,489.00 $5,166.00 $3,466.00 $2,668.00 $2,458.00 $2,432.00 $2,536.00 $1,758.00 $1,483.00 $2,863.00 $3,411.00 $2,512.00 $2,454.00 $122.00 $3,665.00 $3,958.00 $4,968.00 $4,262.00 $2,884.00 $2,750.00 $4,392.00 $3,735.00 $1,555.00 $1,992.00 $2,136.00 $1,259.00 $3,454.00 $3,052.00 $3,240.00 $3,128.00 $2,968.00 $2,778.00 $3,054.00 $2,820.00 $2,457.00 $4,190.00 $3,028.00 $1,974.00 $1,117.00 $1,568.00 $2,112.00 $2,229.00 $2,067.00 $3,205.00 $2,450.00 $3,226.00 $2,928.00 $3,242.00 $2,403.00 $2,611.00 $3,027.00 $4,601.00 $3,090.00 $2,876.00 $2,658.00 $2,644.00 $2,763.00 $1,901.00 $1,598.00 $3,109.00 $3,710.00 $2,730.00 $2,665.00 $133.00 $3,983.00 $4,305.00 $5,353.00 $4,634.00 $3,135.00 $2,988.00 $4,664.00 $3,971.00 $1,686.00 $2,164.00 $2,320.00 $1,364.00 $3,756.00 $3,285.00 $3,476.00 $3,401.00 $3,240.00 $3,003.00 $3,319.00 $3,066.00 $2,658.00 $4,544.00 $3,284.00 $2,105.00 $1,165.00 $1,632.00 $2,274.00 $2,425.00 $2,153.00 $3,489.00 $2,632.00 $3,513.00 $3,166.00 $3,479.00 $2,603.00 $2,837.00 $3,227.00 $4,854.00 $3,262.00 $3,159.00 $2,931.00 $2,943.00 $3,077.00 $2,094.00 $1,752.00 $3,448.00 $4,123.00 $3,030.00 $2,957.00 $148.00 $4,424.00 $4,787.00 $5,877.00 $5,151.00 $3,482.00 $3,316.00 $5,019.00 $4,278.00 $1,864.00 $2,399.00 $2,571.00 $1,507.00 $4,175.00 $3,604.00 $3,799.00 $3,779.00 $3,616.00 $3,310.00 $3,686.00 $3,408.00 $2,935.00 $5,032.00 $3,636.00 $2,276.00 $1,222.00 $1,705.00 $2,493.00 $2,693.00 $2,249.00 $3,879.00 $2,877.00 $3,912.00 $3,490.00 $3,795.00 $2,875.00 $3,148.00 $3,489.00 $5,166.00 $3,466.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 227 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 61581 61582 61583 61584 61585 61586 61590 61591 61592 61595 61596 61597 61598 61600 61601 61605 61606 61607 61608 61609 61610 61611 61612 61613 61615 61616 61618 61619 61623 61624 61626 61630 61635 61640 61641 61642 61680 61682 61684 61686 61690 61692 61697 61698 61700 61702 61703 61705 61708 61710 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ 90 90 90 90 90 0 0 0 90 90 0 ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $2,674.00 $2,557.00 $2,972.00 $2,830.00 $3,142.00 $2,097.00 $3,299.00 $3,491.00 $3,245.00 $2,350.00 $2,827.00 $3,046.00 $2,693.00 $2,039.00 $2,279.00 $2,299.00 $3,178.00 $2,961.00 $3,458.00 $798.00 $2,354.00 $584.00 $2,219.00 $3,375.00 $2,576.00 $3,535.00 $1,389.00 $1,682.00 $540.00 $1,073.00 $877.00 ------------------------------$2,758.00 $4,798.00 $3,341.00 $5,012.00 $2,556.00 $4,007.00 $3,231.00 $3,103.00 $4,037.00 $4,019.00 $1,444.00 $3,043.00 $2,546.00 $2,129.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $3,419.00 $3,657.00 $3,809.00 $3,679.00 $3,842.00 $2,758.00 $3,958.00 $4,002.00 $4,150.00 $2,979.00 $3,250.00 $3,771.00 $3,296.00 $2,690.00 $3,055.00 $2,784.00 $3,904.00 $3,584.00 $4,309.00 $869.00 $2,606.00 $636.00 $2,142.00 $4,121.00 $3,149.00 $4,241.00 $1,689.00 $1,945.00 $745.00 $1,455.00 $1,165.00 $1,670.00 $1,828.00 $776.00 $273.00 $546.00 $3,006.00 $5,728.00 $3,826.00 $6,117.00 $2,846.00 $4,917.00 $5,404.00 $5,688.00 $4,697.00 $5,005.00 $1,714.00 $3,426.00 $2,690.00 $2,509.00 $3,610.00 $3,943.00 $4,134.00 $3,977.00 $4,113.00 $2,950.00 $4,188.00 $4,243.00 $4,501.00 $3,158.00 $3,417.00 $4,078.00 $3,522.00 $2,857.00 $3,300.00 $2,930.00 $4,219.00 $3,839.00 $4,677.00 $949.00 $2,844.00 $694.00 $2,287.00 $4,431.00 $3,348.00 $4,551.00 $1,821.00 $2,088.00 $786.00 $1,530.00 $1,217.00 $1,755.00 $1,920.00 $804.00 $283.00 $566.00 $3,269.00 $6,239.00 $4,163.00 $6,658.00 $3,082.00 $5,351.00 $5,831.00 $6,109.00 $5,120.00 $5,375.00 $1,853.00 $3,718.00 $2,808.00 $2,673.00 $3,839.00 $4,311.00 $4,571.00 $4,373.00 $4,465.00 $3,188.00 $4,475.00 $4,545.00 $4,975.00 $3,378.00 $3,618.00 $4,493.00 $3,813.00 $3,064.00 $3,624.00 $3,103.00 $4,644.00 $4,176.00 $5,177.00 $1,062.00 $3,182.00 $776.00 $2,485.00 $4,842.00 $3,598.00 $4,958.00 $1,998.00 $2,278.00 $839.00 $1,628.00 $1,283.00 $1,862.00 $2,037.00 $841.00 $296.00 $591.00 $3,632.00 $6,952.00 $4,631.00 $7,411.00 $3,404.00 $5,955.00 $6,420.00 $6,686.00 $5,709.00 $5,878.00 $2,043.00 $4,123.00 $2,950.00 $2,891.00 $3,419.00 $3,657.00 $3,809.00 $3,679.00 $3,842.00 $2,758.00 $3,958.00 $4,002.00 $4,150.00 $2,979.00 $3,250.00 $3,771.00 $3,296.00 $2,690.00 $3,055.00 $2,784.00 $3,904.00 $3,584.00 $4,309.00 $869.00 $2,606.00 $636.00 $2,142.00 $4,121.00 $3,149.00 $4,241.00 $1,689.00 $1,945.00 $745.00 $1,455.00 $1,165.00 $1,670.00 $1,828.00 $776.00 $273.00 $546.00 $3,006.00 $5,728.00 $3,826.00 $6,117.00 $2,846.00 $4,917.00 $5,404.00 $5,688.00 $4,697.00 $5,005.00 $1,714.00 $3,426.00 $2,690.00 $2,509.00 $3,610.00 $3,943.00 $4,134.00 $3,977.00 $4,113.00 $2,950.00 $4,188.00 $4,243.00 $4,501.00 $3,158.00 $3,417.00 $4,078.00 $3,522.00 $2,857.00 $3,300.00 $2,930.00 $4,219.00 $3,839.00 $4,677.00 $949.00 $2,844.00 $694.00 $2,287.00 $4,431.00 $3,348.00 $4,551.00 $1,821.00 $2,088.00 $786.00 $1,530.00 $1,217.00 $1,755.00 $1,920.00 $804.00 $283.00 $566.00 $3,269.00 $6,239.00 $4,163.00 $6,658.00 $3,082.00 $5,351.00 $5,831.00 $6,109.00 $5,120.00 $5,375.00 $1,853.00 $3,718.00 $2,808.00 $2,673.00 $3,839.00 $4,311.00 $4,571.00 $4,373.00 $4,465.00 $3,188.00 $4,475.00 $4,545.00 $4,975.00 $3,378.00 $3,618.00 $4,493.00 $3,813.00 $3,064.00 $3,624.00 $3,103.00 $4,644.00 $4,176.00 $5,177.00 $1,062.00 $3,182.00 $776.00 $2,485.00 $4,842.00 $3,598.00 $4,958.00 $1,998.00 $2,278.00 $839.00 $1,628.00 $1,283.00 $1,862.00 $2,037.00 $841.00 $296.00 $591.00 $3,632.00 $6,952.00 $4,631.00 $7,411.00 $3,404.00 $5,955.00 $6,420.00 $6,686.00 $5,709.00 $5,878.00 $2,043.00 $4,123.00 $2,950.00 $2,891.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 228 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 61711 61720 61735 61750 61751 61760 61770 61790 61791 61795 61850 61860 61863 61864 61867 61868 61870 61875 61880 61885 61886 61888 62000 62005 62010 62100 62115 62116 62117 62120 62121 62140 62141 62142 62143 62145 62146 62147 62148 62160 62161 62162 62163 62164 62165 62180 62190 62192 62194 62200 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 ZZZ 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 90 90 90 90 10 90 $3,150.00 $1,558.00 $1,664.00 $1,521.00 $1,628.00 $1,670.00 $1,867.00 $952.00 $1,205.00 $371.00 $1,090.00 $1,197.00 ------------------------$616.00 $984.00 $559.00 $262.00 $678.00 $331.00 $848.00 $1,282.00 $1,754.00 $1,962.00 $1,686.00 $1,928.00 $2,211.00 $1,898.00 $1,822.00 $1,221.00 $1,955.00 $1,011.00 $1,096.00 $1,566.00 $1,327.00 $1,566.00 $120.00 $172.00 $1,229.00 $1,578.00 $999.00 $1,706.00 $1,336.00 $1,695.00 $1,034.00 $1,146.00 $239.00 $1,625.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $3,497.00 $1,490.00 $1,793.00 $1,840.00 $1,792.00 $1,993.00 $1,919.00 $1,104.00 $1,417.00 $338.00 $1,267.00 $2,024.00 $2,001.00 $741.00 $2,834.00 $977.00 $1,554.00 $1,350.00 $698.00 $782.00 $985.00 $528.00 $1,062.00 $1,590.00 $1,996.00 $2,105.00 $2,142.00 $2,322.00 $2,389.00 $2,278.00 $2,150.00 $1,377.00 $1,507.00 $1,137.00 $1,346.00 $1,824.00 $1,573.00 $1,866.00 $172.00 $268.00 $2,009.00 $2,459.00 $1,567.00 $2,573.00 $1,952.00 $2,066.00 $1,150.00 $1,253.00 $479.00 $1,808.00 $3,804.00 $1,593.00 $1,901.00 $1,998.00 $1,947.00 $2,168.00 $2,049.00 $1,200.00 $1,534.00 $365.00 $1,377.00 $2,192.00 $2,182.00 $886.00 $3,033.00 $1,127.00 $1,687.00 $1,450.00 $757.00 $844.00 $1,062.00 $575.00 $1,112.00 $1,721.00 $2,168.00 $2,272.00 $2,327.00 $2,525.00 $2,555.00 $2,419.00 $2,308.00 $1,496.00 $1,636.00 $1,232.00 $1,462.00 $1,976.00 $1,699.00 $2,015.00 $187.00 $292.00 $2,184.00 $2,661.00 $1,704.00 $2,765.00 $2,073.00 $2,236.00 $1,247.00 $1,357.00 $512.00 $1,965.00 $4,231.00 $1,729.00 $2,039.00 $2,216.00 $2,159.00 $2,412.00 $2,221.00 $1,331.00 $1,693.00 $401.00 $1,526.00 $2,422.00 $2,432.00 $1,105.00 $3,298.00 $1,351.00 $1,868.00 $1,586.00 $837.00 $925.00 $1,161.00 $637.00 $1,173.00 $1,901.00 $2,405.00 $2,499.00 $2,582.00 $2,804.00 $2,774.00 $2,589.00 $2,516.00 $1,657.00 $1,811.00 $1,362.00 $1,619.00 $2,184.00 $1,869.00 $2,218.00 $208.00 $326.00 $2,424.00 $2,937.00 $1,889.00 $3,022.00 $2,229.00 $2,468.00 $1,379.00 $1,499.00 $557.00 $2,179.00 $3,497.00 $1,490.00 $1,793.00 $1,840.00 $1,792.00 $1,993.00 $1,919.00 $1,104.00 $1,417.00 $338.00 $1,267.00 $2,024.00 $2,001.00 $741.00 $2,834.00 $977.00 $1,554.00 $1,350.00 $698.00 $782.00 $985.00 $528.00 $1,062.00 $1,590.00 $1,996.00 $2,105.00 $2,142.00 $2,322.00 $2,389.00 $2,278.00 $2,150.00 $1,377.00 $1,507.00 $1,137.00 $1,346.00 $1,824.00 $1,573.00 $1,866.00 $172.00 $268.00 $2,009.00 $2,459.00 $1,567.00 $2,573.00 $1,952.00 $2,066.00 $1,150.00 $1,253.00 $479.00 $1,808.00 $3,804.00 $1,593.00 $1,901.00 $1,998.00 $1,947.00 $2,168.00 $2,049.00 $1,200.00 $1,534.00 $365.00 $1,377.00 $2,192.00 $2,182.00 $886.00 $3,033.00 $1,127.00 $1,687.00 $1,450.00 $757.00 $844.00 $1,062.00 $575.00 $1,112.00 $1,721.00 $2,168.00 $2,272.00 $2,327.00 $2,525.00 $2,555.00 $2,419.00 $2,308.00 $1,496.00 $1,636.00 $1,232.00 $1,462.00 $1,976.00 $1,699.00 $2,015.00 $187.00 $292.00 $2,184.00 $2,661.00 $1,704.00 $2,765.00 $2,073.00 $2,236.00 $1,247.00 $1,357.00 $512.00 $1,965.00 $4,231.00 $1,729.00 $2,039.00 $2,216.00 $2,159.00 $2,412.00 $2,221.00 $1,331.00 $1,693.00 $401.00 $1,526.00 $2,422.00 $2,432.00 $1,105.00 $3,298.00 $1,351.00 $1,868.00 $1,586.00 $837.00 $925.00 $1,161.00 $637.00 $1,173.00 $1,901.00 $2,405.00 $2,499.00 $2,582.00 $2,804.00 $2,774.00 $2,589.00 $2,516.00 $1,657.00 $1,811.00 $1,362.00 $1,619.00 $2,184.00 $1,869.00 $2,218.00 $208.00 $326.00 $2,424.00 $2,937.00 $1,889.00 $3,022.00 $2,229.00 $2,468.00 $1,379.00 $1,499.00 $557.00 $2,179.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 229 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 62201 62220 62223 62225 62230 62252 62252-26 62252-TC 62256 62258 62263 62264 62268 62269 62270 62272 62273 62280 62281 62282 62284 62287 62290 62291 62292 62294 62310 62311 62318 62319 62350 62351 62355 62360 62361 62362 62365 62367 62368 63001 63003 63005 63011 63012 63015 63016 63017 63020 63030 63035 90 90 90 90 90 0 0 0 90 90 10 10 0 0 0 0 0 10 10 10 0 90 0 0 90 90 0 0 0 0 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 ZZZ $1,200.00 $1,215.00 $1,199.00 $488.00 $935.00 $85.00 ------------$616.00 $1,308.00 $426.00 $593.00 $285.00 $271.00 $109.00 $137.00 $130.00 $199.00 $186.00 $211.00 $196.00 $784.00 $235.00 $232.00 $1,064.00 $821.00 $200.00 $201.00 $208.00 $203.00 $488.00 $782.00 $402.00 $195.00 $390.00 $517.00 $418.00 BR BR $1,882.00 $1,591.00 $1,390.00 $1,151.00 $1,568.00 $1,862.00 $1,788.00 $1,489.00 $1,395.00 $1,145.00 $280.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,533.00 $1,338.00 $1,342.00 $637.00 $1,090.00 $132.00 $66.00 $67.00 $744.00 $1,477.00 $887.00 $563.00 $712.00 $788.00 $205.00 $246.00 $221.00 $436.00 $383.00 $434.00 $302.00 $709.00 $450.00 $411.00 $678.00 $1,000.00 $294.00 $269.00 $326.00 $291.00 $656.00 $1,090.00 $533.00 $346.00 $572.00 $722.00 $559.00 $51.00 $71.00 $1,603.00 $1,614.00 $1,523.00 $1,441.00 $1,559.00 $1,943.00 $1,979.00 $1,614.00 $1,537.00 $1,276.00 $280.00 $1,662.00 $1,453.00 $1,453.00 $689.00 $1,183.00 $143.00 $72.00 $72.00 $807.00 $1,604.00 $937.00 $593.00 $756.00 $834.00 $217.00 $263.00 $232.00 $465.00 $405.00 $460.00 $321.00 $742.00 $476.00 $436.00 $712.00 $1,053.00 $311.00 $285.00 $345.00 $308.00 $696.00 $1,173.00 $563.00 $365.00 $607.00 $768.00 $594.00 $53.00 $75.00 $1,733.00 $1,744.00 $1,643.00 $1,558.00 $1,683.00 $2,106.00 $2,137.00 $1,743.00 $1,667.00 $1,383.00 $305.00 $1,835.00 $1,609.00 $1,602.00 $758.00 $1,310.00 $156.00 $80.00 $76.00 $890.00 $1,777.00 $985.00 $624.00 $799.00 $880.00 $228.00 $280.00 $243.00 $493.00 $427.00 $485.00 $339.00 $779.00 $503.00 $461.00 $755.00 $1,120.00 $327.00 $300.00 $362.00 $323.00 $748.00 $1,283.00 $601.00 $387.00 $650.00 $828.00 $639.00 $56.00 $79.00 $1,910.00 $1,919.00 $1,804.00 $1,716.00 $1,850.00 $2,328.00 $2,352.00 $1,917.00 $1,842.00 $1,526.00 $340.00 $1,533.00 $1,338.00 $1,342.00 $637.00 $1,090.00 $132.00 $66.00 $67.00 $744.00 $1,477.00 $488.00 $295.00 $355.00 $351.00 $99.00 $111.00 $143.00 $201.00 $188.00 $174.00 $118.00 $709.00 $222.00 $215.00 $678.00 $1,000.00 $129.00 $108.00 $132.00 $123.00 $656.00 $1,090.00 $533.00 $346.00 $572.00 $722.00 $559.00 $30.00 $48.00 $1,603.00 $1,614.00 $1,523.00 $1,441.00 $1,559.00 $1,943.00 $1,979.00 $1,614.00 $1,537.00 $1,276.00 $280.00 $1,662.00 $1,453.00 $1,453.00 $689.00 $1,183.00 $143.00 $72.00 $72.00 $807.00 $1,604.00 $509.00 $307.00 $373.00 $367.00 $103.00 $118.00 $149.00 $213.00 $196.00 $182.00 $124.00 $742.00 $232.00 $225.00 $712.00 $1,053.00 $134.00 $112.00 $137.00 $127.00 $696.00 $1,173.00 $563.00 $365.00 $607.00 $768.00 $594.00 $31.00 $51.00 $1,733.00 $1,744.00 $1,643.00 $1,558.00 $1,683.00 $2,106.00 $2,137.00 $1,743.00 $1,667.00 $1,383.00 $305.00 $1,835.00 $1,609.00 $1,602.00 $758.00 $1,310.00 $156.00 $80.00 $76.00 $890.00 $1,777.00 $534.00 $321.00 $396.00 $386.00 $108.00 $127.00 $156.00 $228.00 $206.00 $191.00 $131.00 $779.00 $245.00 $239.00 $755.00 $1,120.00 $141.00 $117.00 $144.00 $133.00 $748.00 $1,283.00 $601.00 $387.00 $650.00 $828.00 $639.00 $33.00 $53.00 $1,910.00 $1,919.00 $1,804.00 $1,716.00 $1,850.00 $2,328.00 $2,352.00 $1,917.00 $1,842.00 $1,526.00 $340.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 230 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 63040 63042 63043 63044 63045 63046 63047 63048 63050 63051 63055 63056 63057 63064 63066 63075 63076 63077 63078 63081 63082 63085 63086 63087 63088 63090 63091 63101 63102 63103 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200 63250 63251 63252 63265 63266 90 90 ZZZ ZZZ 90 90 90 ZZZ 90 90 90 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 ZZZ 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $1,764.00 $1,620.00 BR BR $1,647.00 $2,117.00 $1,907.00 $367.00 ------------$2,029.00 $1,960.00 $421.00 $2,200.00 $263.00 $1,720.00 $383.00 $1,828.00 $261.00 $2,203.00 $391.00 $2,416.00 $282.00 $2,930.00 $381.00 $2,490.00 $249.00 ------------------$1,788.00 $1,672.00 $1,851.00 $1,486.00 $1,711.00 $1,347.00 $1,610.00 $1,444.00 $1,593.00 $1,603.00 $1,810.00 $1,725.00 $1,956.00 $2,258.00 $1,569.00 $3,182.00 $3,207.00 $3,319.00 $1,940.00 $2,053.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,882.00 $1,760.00 ------------$1,671.00 $1,586.00 $1,452.00 $295.00 $1,989.00 $2,226.00 $2,159.00 $1,997.00 $459.00 $2,369.00 $279.00 $1,859.00 $355.00 $1,981.00 $278.00 $2,356.00 $383.00 $2,459.00 $266.00 $3,152.00 $362.00 $2,540.00 $245.00 $2,953.00 $2,948.00 $387.00 $1,980.00 $1,822.00 $2,247.00 $1,820.00 $1,941.00 $1,438.00 $1,632.00 $1,752.00 $1,864.00 $1,977.00 $2,318.00 $2,043.00 $2,343.00 $2,189.00 $1,980.00 $3,791.00 $4,021.00 $4,013.00 $2,189.00 $2,253.00 $2,041.00 $1,908.00 ------------$1,809.00 $1,712.00 $1,569.00 $318.00 $2,150.00 $2,392.00 $2,339.00 $2,161.00 $498.00 $2,563.00 $302.00 $2,018.00 $386.00 $2,125.00 $300.00 $2,547.00 $415.00 $2,625.00 $286.00 $3,374.00 $389.00 $2,702.00 $262.00 $3,163.00 $3,158.00 $412.00 $2,144.00 $1,975.00 $2,439.00 $1,960.00 $2,108.00 $1,541.00 $1,750.00 $1,939.00 $1,988.00 $2,142.00 $2,514.00 $2,215.00 $2,538.00 $2,268.00 $2,148.00 $4,094.00 $4,365.00 $4,361.00 $2,373.00 $2,441.00 $2,258.00 $2,107.00 ------------$1,996.00 $1,881.00 $1,725.00 $351.00 $2,369.00 $2,615.00 $2,585.00 $2,383.00 $553.00 $2,828.00 $333.00 $2,234.00 $429.00 $2,317.00 $330.00 $2,806.00 $461.00 $2,844.00 $313.00 $3,672.00 $427.00 $2,913.00 $285.00 $3,441.00 $3,436.00 $445.00 $2,368.00 $2,183.00 $2,702.00 $2,148.00 $2,344.00 $1,677.00 $1,907.00 $2,211.00 $2,150.00 $2,368.00 $2,781.00 $2,456.00 $2,817.00 $2,359.00 $2,378.00 $4,509.00 $4,840.00 $4,844.00 $2,625.00 $2,698.00 $1,882.00 $1,760.00 ------------$1,671.00 $1,586.00 $1,452.00 $295.00 $1,989.00 $2,226.00 $2,159.00 $1,997.00 $459.00 $2,369.00 $279.00 $1,859.00 $355.00 $1,981.00 $278.00 $2,356.00 $383.00 $2,459.00 $266.00 $3,152.00 $362.00 $2,540.00 $245.00 $2,953.00 $2,948.00 $387.00 $1,980.00 $1,822.00 $2,247.00 $1,820.00 $1,941.00 $1,438.00 $1,632.00 $1,752.00 $1,864.00 $1,977.00 $2,318.00 $2,043.00 $2,343.00 $2,189.00 $1,980.00 $3,791.00 $4,021.00 $4,013.00 $2,189.00 $2,253.00 $2,041.00 $1,908.00 ------------$1,809.00 $1,712.00 $1,569.00 $318.00 $2,150.00 $2,392.00 $2,339.00 $2,161.00 $498.00 $2,563.00 $302.00 $2,018.00 $386.00 $2,125.00 $300.00 $2,547.00 $415.00 $2,625.00 $286.00 $3,374.00 $389.00 $2,702.00 $262.00 $3,163.00 $3,158.00 $412.00 $2,144.00 $1,975.00 $2,439.00 $1,960.00 $2,108.00 $1,541.00 $1,750.00 $1,939.00 $1,988.00 $2,142.00 $2,514.00 $2,215.00 $2,538.00 $2,268.00 $2,148.00 $4,094.00 $4,365.00 $4,361.00 $2,373.00 $2,441.00 $2,258.00 $2,107.00 ------------$1,996.00 $1,881.00 $1,725.00 $351.00 $2,369.00 $2,615.00 $2,585.00 $2,383.00 $553.00 $2,828.00 $333.00 $2,234.00 $429.00 $2,317.00 $330.00 $2,806.00 $461.00 $2,844.00 $313.00 $3,672.00 $427.00 $2,913.00 $285.00 $3,441.00 $3,436.00 $445.00 $2,368.00 $2,183.00 $2,702.00 $2,148.00 $2,344.00 $1,677.00 $1,907.00 $2,211.00 $2,150.00 $2,368.00 $2,781.00 $2,456.00 $2,817.00 $2,359.00 $2,378.00 $4,509.00 $4,840.00 $4,844.00 $2,625.00 $2,698.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 231 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 63267 63268 63270 63271 63272 63273 63275 63276 63277 63278 63280 63281 63282 63283 63285 63286 63287 63290 63295 63300 63301 63302 63303 63304 63305 63306 63307 63308 63600 63610 63615 63650 63655 63660 63685 63688 63700 63702 63704 63706 63707 63709 63710 63740 63741 63744 63746 64400 64402 64405 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 ZZZ 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 $1,651.00 $1,469.00 $2,197.00 $2,401.00 $2,206.00 $2,012.00 $2,166.00 $2,135.00 $1,905.00 $1,877.00 $2,529.00 $2,496.00 $2,305.00 $2,041.00 $2,934.00 $3,003.00 $3,012.00 $3,073.00 ------$2,006.00 $2,209.00 $2,290.00 $2,357.00 $2,513.00 $2,574.00 $2,596.00 $2,522.00 $425.00 $797.00 $476.00 $1,348.00 $819.00 $1,064.00 $707.00 $615.00 $707.00 $1,340.00 $1,512.00 $1,708.00 $1,873.00 $1,041.00 $1,310.00 $1,165.00 $1,062.00 $741.00 $738.00 $529.00 $78.00 $75.00 $103.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,809.00 $1,768.00 $2,706.00 $2,720.00 $2,501.00 $2,404.00 $2,358.00 $2,344.00 $2,060.00 $2,002.00 $2,798.00 $2,773.00 $2,611.00 $2,481.00 $3,461.00 $3,458.00 $3,623.00 $3,624.00 $431.00 $2,430.00 $2,648.00 $2,637.00 $2,739.00 $2,964.00 $3,025.00 $3,185.00 $2,780.00 $462.00 $1,062.00 $2,318.00 $1,479.00 $550.00 $1,093.00 $560.00 $648.00 $534.00 $1,600.00 $1,757.00 $2,022.00 $2,374.00 $1,176.00 $1,434.00 $1,444.00 $1,211.00 $797.00 $842.00 $698.00 $141.00 $141.00 $134.00 $1,960.00 $1,901.00 $2,935.00 $2,951.00 $2,710.00 $2,601.00 $2,555.00 $2,541.00 $2,232.00 $2,161.00 $3,041.00 $3,012.00 $2,837.00 $2,693.00 $3,763.00 $3,762.00 $3,934.00 $3,925.00 $464.00 $2,632.00 $2,839.00 $2,831.00 $2,915.00 $3,189.00 $3,233.00 $3,459.00 $2,950.00 $503.00 $1,117.00 $2,471.00 $1,583.00 $574.00 $1,181.00 $593.00 $688.00 $569.00 $1,725.00 $1,900.00 $2,182.00 $2,582.00 $1,268.00 $1,546.00 $1,563.00 $1,313.00 $856.00 $910.00 $754.00 $148.00 $149.00 $140.00 $2,165.00 $2,078.00 $3,249.00 $3,268.00 $2,997.00 $2,870.00 $2,824.00 $2,811.00 $2,466.00 $2,376.00 $3,375.00 $3,342.00 $3,149.00 $2,983.00 $4,181.00 $4,182.00 $4,363.00 $4,340.00 $511.00 $2,909.00 $3,095.00 $3,092.00 $3,146.00 $3,494.00 $3,510.00 $3,838.00 $3,172.00 $560.00 $1,191.00 $2,613.00 $1,722.00 $604.00 $1,299.00 $634.00 $741.00 $615.00 $1,894.00 $2,093.00 $2,398.00 $2,869.00 $1,390.00 $1,695.00 $1,724.00 $1,452.00 $936.00 $1,001.00 $828.00 $156.00 $157.00 $147.00 $1,809.00 $1,768.00 $2,706.00 $2,720.00 $2,501.00 $2,404.00 $2,358.00 $2,344.00 $2,060.00 $2,002.00 $2,798.00 $2,773.00 $2,611.00 $2,481.00 $3,461.00 $3,458.00 $3,623.00 $3,624.00 $431.00 $2,430.00 $2,648.00 $2,637.00 $2,739.00 $2,964.00 $3,025.00 $3,185.00 $2,780.00 $462.00 $1,062.00 $571.00 $1,479.00 $550.00 $1,093.00 $560.00 $648.00 $534.00 $1,600.00 $1,757.00 $2,022.00 $2,374.00 $1,176.00 $1,434.00 $1,444.00 $1,211.00 $797.00 $842.00 $698.00 $80.00 $93.00 $92.00 $1,960.00 $1,901.00 $2,935.00 $2,951.00 $2,710.00 $2,601.00 $2,555.00 $2,541.00 $2,232.00 $2,161.00 $3,041.00 $3,012.00 $2,837.00 $2,693.00 $3,763.00 $3,762.00 $3,934.00 $3,925.00 $464.00 $2,632.00 $2,839.00 $2,831.00 $2,915.00 $3,189.00 $3,233.00 $3,459.00 $2,950.00 $503.00 $1,117.00 $600.00 $1,583.00 $574.00 $1,181.00 $593.00 $688.00 $569.00 $1,725.00 $1,900.00 $2,182.00 $2,582.00 $1,268.00 $1,546.00 $1,563.00 $1,313.00 $856.00 $910.00 $754.00 $83.00 $98.00 $96.00 $2,165.00 $2,078.00 $3,249.00 $3,268.00 $2,997.00 $2,870.00 $2,824.00 $2,811.00 $2,466.00 $2,376.00 $3,375.00 $3,342.00 $3,149.00 $2,983.00 $4,181.00 $4,182.00 $4,363.00 $4,340.00 $511.00 $2,909.00 $3,095.00 $3,092.00 $3,146.00 $3,494.00 $3,510.00 $3,838.00 $3,172.00 $560.00 $1,191.00 $639.00 $1,722.00 $604.00 $1,299.00 $634.00 $741.00 $615.00 $1,894.00 $2,093.00 $2,398.00 $2,869.00 $1,390.00 $1,695.00 $1,724.00 $1,452.00 $936.00 $1,001.00 $828.00 $87.00 $103.00 $100.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 232 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 64408 64410 64412 64413 64415 64416 64417 64418 64420 64421 64425 64430 64435 64445 64446 64447 64448 64449 64450 64470 64472 64475 64476 64479 64480 64483 64484 64505 64508 64510 64517 64520 64530 64550 64553 64555 64560 64561 64565 64573 64575 64577 64580 64581 64585 64590 64595 64600 64605 64610 0 0 0 0 0 10 0 0 0 0 0 0 0 0 10 0 10 10 0 0 ZZZ 0 ZZZ 0 ZZZ 0 ZZZ 0 0 0 0 0 0 0 10 10 10 10 10 90 90 90 90 90 10 10 10 10 10 10 $120.00 $109.00 $89.00 $128.00 $109.00 $159.00 $105.00 $108.00 $89.00 $128.00 $116.00 $130.00 $114.00 $68.00 $165.00 $77.00 $152.00 ------$53.00 $206.00 $166.00 $183.00 $166.00 $224.00 $194.00 $206.00 $183.00 $104.00 $99.00 $103.00 ------$131.00 $135.00 $23.00 $137.00 $131.00 $197.00 $801.00 $121.00 $464.00 $367.00 $381.00 $343.00 $745.00 $37.00 $217.00 $153.00 $228.00 $319.00 $307.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $150.00 $185.00 $181.00 $151.00 $182.00 $237.00 $188.00 $180.00 $219.00 $328.00 $166.00 $199.00 $194.00 $185.00 $222.00 $93.00 $202.00 $198.00 $133.00 $372.00 $156.00 $337.00 $132.00 $394.00 $190.00 $391.00 $191.00 $131.00 $192.00 $197.00 $223.00 $263.00 $263.00 $21.00 $260.00 $270.00 $255.00 $1,614.00 $238.00 $770.00 $372.00 $502.00 $380.00 $1,047.00 $543.00 $467.00 $518.00 $559.00 $746.00 $913.00 $157.00 $195.00 $192.00 $159.00 $192.00 $247.00 $199.00 $190.00 $232.00 $348.00 $174.00 $210.00 $206.00 $195.00 $230.00 $96.00 $209.00 $205.00 $141.00 $394.00 $164.00 $358.00 $139.00 $417.00 $201.00 $414.00 $202.00 $138.00 $204.00 $208.00 $234.00 $278.00 $278.00 $22.00 $275.00 $285.00 $270.00 $1,715.00 $252.00 $829.00 $396.00 $543.00 $400.00 $1,095.00 $579.00 $496.00 $553.00 $594.00 $796.00 $985.00 $166.00 $205.00 $202.00 $166.00 $201.00 $261.00 $209.00 $200.00 $244.00 $367.00 $184.00 $222.00 $219.00 $205.00 $240.00 $100.00 $218.00 $213.00 $150.00 $415.00 $173.00 $378.00 $147.00 $438.00 $211.00 $436.00 $212.00 $145.00 $214.00 $218.00 $245.00 $293.00 $293.00 $24.00 $290.00 $301.00 $286.00 $1,808.00 $265.00 $908.00 $427.00 $596.00 $423.00 $1,154.00 $612.00 $523.00 $585.00 $629.00 $852.00 $1,074.00 $113.00 $100.00 $87.00 $96.00 $95.00 $237.00 $96.00 $91.00 $83.00 $114.00 $119.00 $110.00 $112.00 $102.00 $222.00 $93.00 $202.00 $198.00 $94.00 $131.00 $84.00 $104.00 $63.00 $155.00 $102.00 $137.00 $86.00 $107.00 $91.00 $86.00 $151.00 $96.00 $115.00 $12.00 $206.00 $190.00 $193.00 $536.00 $158.00 $770.00 $372.00 $502.00 $380.00 $1,047.00 $224.00 $247.00 $200.00 $272.00 $438.00 $640.00 $118.00 $104.00 $91.00 $100.00 $99.00 $247.00 $101.00 $95.00 $87.00 $118.00 $124.00 $115.00 $118.00 $107.00 $230.00 $96.00 $209.00 $205.00 $99.00 $136.00 $87.00 $109.00 $66.00 $162.00 $106.00 $143.00 $90.00 $112.00 $95.00 $90.00 $157.00 $100.00 $119.00 $12.00 $216.00 $199.00 $203.00 $561.00 $166.00 $829.00 $396.00 $543.00 $400.00 $1,095.00 $237.00 $260.00 $212.00 $286.00 $466.00 $693.00 $125.00 $109.00 $96.00 $105.00 $104.00 $261.00 $106.00 $99.00 $91.00 $124.00 $131.00 $120.00 $126.00 $112.00 $240.00 $100.00 $218.00 $213.00 $106.00 $142.00 $91.00 $114.00 $69.00 $169.00 $111.00 $150.00 $94.00 $118.00 $100.00 $94.00 $163.00 $105.00 $125.00 $13.00 $228.00 $211.00 $215.00 $590.00 $175.00 $908.00 $427.00 $596.00 $423.00 $1,154.00 $251.00 $275.00 $225.00 $304.00 $504.00 $766.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 233 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 64612 64613 64614 64620 64622 64623 64626 64627 64630 64640 64650 64653 64680 64681 64702 64704 64708 64712 64713 64714 64716 64718 64719 64721 64722 64726 64727 64732 64734 64736 64738 64740 64742 64744 64746 64752 64755 64760 64761 64763 64766 64771 64772 64774 64776 64778 64782 64783 64784 64786 10 10 10 10 10 ZZZ 10 ZZZ 10 10 0 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 ZZZ 90 ZZZ 90 90 $188.00 $168.00 $200.00 $185.00 $333.00 $113.00 $262.00 $151.00 $202.00 $208.00 ------------$180.00 ------$383.00 $402.00 $562.00 $678.00 $867.00 $715.00 $523.00 $558.00 $446.00 $439.00 $411.00 $271.00 $261.00 $405.00 $432.00 $388.00 $475.00 $461.00 $517.00 $798.00 $494.00 $560.00 $1,042.00 $578.00 $495.00 $561.00 $713.00 $632.00 $636.00 $392.00 $390.00 $249.00 $482.00 $298.00 $751.00 $1,281.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $203.00 $209.00 $232.00 $359.00 $451.00 $167.00 $508.00 $232.00 $297.00 $319.00 $77.00 $89.00 $412.00 $553.00 $561.00 $430.00 $595.00 $684.00 $973.00 $799.00 $658.00 $720.00 $507.00 $537.00 $411.00 $381.00 $251.00 $483.00 $538.00 $476.00 $611.00 $594.00 $599.00 $552.00 $577.00 $632.00 $1,127.00 $597.00 $564.00 $652.00 $772.00 $754.00 $726.00 $523.00 $504.00 $250.00 $585.00 $295.00 $927.00 $1,421.00 $213.00 $219.00 $243.00 $379.00 $477.00 $177.00 $535.00 $246.00 $312.00 $338.00 $82.00 $94.00 $436.00 $585.00 $593.00 $457.00 $635.00 $724.00 $1,041.00 $844.00 $694.00 $768.00 $542.00 $573.00 $434.00 $404.00 $268.00 $520.00 $576.00 $503.00 $655.00 $630.00 $634.00 $596.00 $613.00 $670.00 $1,194.00 $631.00 $591.00 $692.00 $817.00 $805.00 $779.00 $556.00 $537.00 $267.00 $622.00 $313.00 $985.00 $1,520.00 $223.00 $230.00 $255.00 $399.00 $502.00 $186.00 $561.00 $259.00 $329.00 $359.00 $86.00 $99.00 $459.00 $617.00 $630.00 $491.00 $686.00 $775.00 $1,130.00 $904.00 $736.00 $827.00 $585.00 $617.00 $462.00 $434.00 $290.00 $569.00 $624.00 $534.00 $711.00 $672.00 $675.00 $653.00 $658.00 $718.00 $1,282.00 $673.00 $624.00 $743.00 $873.00 $870.00 $849.00 $596.00 $578.00 $289.00 $667.00 $338.00 $1,059.00 $1,649.00 $168.00 $160.00 $177.00 $211.00 $222.00 $62.00 $291.00 $73.00 $240.00 $235.00 $49.00 $62.00 $203.00 $283.00 $561.00 $430.00 $595.00 $684.00 $973.00 $799.00 $658.00 $720.00 $507.00 $535.00 $411.00 $381.00 $251.00 $483.00 $538.00 $476.00 $611.00 $594.00 $599.00 $552.00 $577.00 $632.00 $1,127.00 $597.00 $564.00 $652.00 $772.00 $754.00 $726.00 $523.00 $504.00 $250.00 $585.00 $295.00 $927.00 $1,421.00 $176.00 $167.00 $184.00 $221.00 $231.00 $64.00 $303.00 $76.00 $252.00 $248.00 $52.00 $65.00 $213.00 $296.00 $593.00 $457.00 $635.00 $724.00 $1,041.00 $844.00 $694.00 $768.00 $542.00 $572.00 $434.00 $404.00 $268.00 $520.00 $576.00 $503.00 $655.00 $630.00 $634.00 $596.00 $613.00 $670.00 $1,194.00 $631.00 $591.00 $692.00 $817.00 $805.00 $779.00 $556.00 $537.00 $267.00 $622.00 $313.00 $985.00 $1,520.00 $184.00 $175.00 $192.00 $232.00 $242.00 $67.00 $316.00 $79.00 $265.00 $264.00 $55.00 $69.00 $224.00 $312.00 $630.00 $491.00 $686.00 $775.00 $1,130.00 $904.00 $736.00 $827.00 $585.00 $615.00 $462.00 $434.00 $290.00 $569.00 $624.00 $534.00 $711.00 $672.00 $675.00 $653.00 $658.00 $718.00 $1,282.00 $673.00 $624.00 $743.00 $873.00 $870.00 $849.00 $596.00 $578.00 $289.00 $667.00 $338.00 $1,059.00 $1,649.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 234 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 64787 64788 64790 64792 64795 64802 64804 64809 64818 64820 64821 64822 64823 64831 64832 64834 64835 64836 64837 64840 64856 64857 64858 64859 64861 64862 64864 64865 64866 64868 64870 64872 64874 64876 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64901 64902 64905 64907 64910 64911 ZZZ 90 90 90 0 90 90 90 90 90 90 90 90 90 ZZZ 90 90 90 ZZZ 90 90 90 90 ZZZ 90 90 90 90 90 90 90 ZZZ ZZZ ZZZ 90 90 90 90 90 90 90 90 90 90 ZZZ ZZZ 90 90 90 90 $458.00 $381.00 $884.00 $1,148.00 $247.00 $711.00 $1,202.00 $1,080.00 $845.00 $838.00 $609.00 $609.00 $703.00 $592.00 $171.00 $711.00 $834.00 $856.00 $480.00 $1,058.00 $1,063.00 $1,137.00 $1,313.00 $341.00 $1,524.00 $1,798.00 $970.00 $1,250.00 $1,238.00 $1,162.00 $1,313.00 $155.00 $230.00 $189.00 $1,382.00 $1,636.00 $1,112.00 $1,243.00 $1,177.00 $1,321.00 $1,500.00 $1,185.00 $1,419.00 $1,549.00 $865.00 $982.00 $1,059.00 $1,472.00 ------------- Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $342.00 $487.00 $1,084.00 $1,363.00 $257.00 $799.00 $1,240.00 $1,125.00 $873.00 $969.00 $877.00 $876.00 $996.00 $935.00 $464.00 $963.00 $1,047.00 $1,046.00 $515.00 $1,154.00 $1,313.00 $1,373.00 $1,604.00 $351.00 $1,842.00 $1,877.00 $1,131.00 $1,494.00 $1,554.00 $1,338.00 $1,319.00 $163.00 $242.00 $275.00 $1,465.00 $1,737.00 $1,413.00 $1,368.00 $1,380.00 $1,481.00 $1,673.00 $1,842.00 $1,636.00 $1,779.00 $810.00 $943.00 $1,250.00 $1,658.00 $897.00 $1,085.00 $363.00 $519.00 $1,163.00 $1,457.00 $276.00 $847.00 $1,318.00 $1,186.00 $924.00 $1,032.00 $933.00 $933.00 $1,062.00 $995.00 $495.00 $1,027.00 $1,118.00 $1,115.00 $550.00 $1,217.00 $1,398.00 $1,462.00 $1,725.00 $375.00 $1,985.00 $2,026.00 $1,192.00 $1,577.00 $1,649.00 $1,413.00 $1,382.00 $173.00 $258.00 $293.00 $1,543.00 $1,832.00 $1,506.00 $1,441.00 $1,475.00 $1,582.00 $1,776.00 $1,963.00 $1,738.00 $1,891.00 $861.00 $1,001.00 $1,329.00 $1,772.00 $958.00 $1,152.00 $391.00 $559.00 $1,266.00 $1,580.00 $300.00 $911.00 $1,422.00 $1,264.00 $991.00 $1,111.00 $1,002.00 $1,004.00 $1,146.00 $1,070.00 $536.00 $1,107.00 $1,207.00 $1,203.00 $597.00 $1,294.00 $1,508.00 $1,576.00 $1,886.00 $407.00 $2,178.00 $2,229.00 $1,265.00 $1,673.00 $1,765.00 $1,500.00 $1,458.00 $188.00 $279.00 $316.00 $1,637.00 $1,950.00 $1,624.00 $1,530.00 $1,599.00 $1,714.00 $1,908.00 $2,121.00 $1,870.00 $2,035.00 $928.00 $1,078.00 $1,431.00 $1,924.00 $1,040.00 $1,243.00 $342.00 $487.00 $1,084.00 $1,363.00 $257.00 $799.00 $1,240.00 $1,125.00 $873.00 $969.00 $877.00 $876.00 $996.00 $935.00 $464.00 $963.00 $1,047.00 $1,046.00 $515.00 $1,154.00 $1,313.00 $1,373.00 $1,604.00 $351.00 $1,842.00 $1,877.00 $1,131.00 $1,494.00 $1,554.00 $1,338.00 $1,319.00 $163.00 $242.00 $275.00 $1,465.00 $1,737.00 $1,413.00 $1,368.00 $1,380.00 $1,481.00 $1,673.00 $1,842.00 $1,636.00 $1,779.00 $810.00 $943.00 $1,250.00 $1,658.00 $897.00 $1,085.00 $363.00 $519.00 $1,163.00 $1,457.00 $276.00 $847.00 $1,318.00 $1,186.00 $924.00 $1,032.00 $933.00 $933.00 $1,062.00 $995.00 $495.00 $1,027.00 $1,118.00 $1,115.00 $550.00 $1,217.00 $1,398.00 $1,462.00 $1,725.00 $375.00 $1,985.00 $2,026.00 $1,192.00 $1,577.00 $1,649.00 $1,413.00 $1,382.00 $173.00 $258.00 $293.00 $1,543.00 $1,832.00 $1,506.00 $1,441.00 $1,475.00 $1,582.00 $1,776.00 $1,963.00 $1,738.00 $1,891.00 $861.00 $1,001.00 $1,329.00 $1,772.00 $958.00 $1,152.00 $391.00 $559.00 $1,266.00 $1,580.00 $300.00 $911.00 $1,422.00 $1,264.00 $991.00 $1,111.00 $1,002.00 $1,004.00 $1,146.00 $1,070.00 $536.00 $1,107.00 $1,207.00 $1,203.00 $597.00 $1,294.00 $1,508.00 $1,576.00 $1,886.00 $407.00 $2,178.00 $2,229.00 $1,265.00 $1,673.00 $1,765.00 $1,500.00 $1,458.00 $188.00 $279.00 $316.00 $1,637.00 $1,950.00 $1,624.00 $1,530.00 $1,599.00 $1,714.00 $1,908.00 $2,121.00 $1,870.00 $2,035.00 $928.00 $1,078.00 $1,431.00 $1,924.00 $1,040.00 $1,243.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 235 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 64999 65091 65093 65101 65103 65105 65110 65112 65114 65125 65130 65135 65140 65150 65155 65175 65205 65210 65220 65222 65235 65260 65265 65270 65272 65273 65275 65280 65285 65286 65290 65400 65410 65420 65426 65430 65435 65436 65450 65600 65710 65730 65750 65755 65770 65772 65775 65780 65781 65782 YYY 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 90 90 90 10 90 90 90 90 90 90 90 90 0 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 BR $678.00 $712.00 $726.00 $769.00 $846.00 $1,305.00 $1,386.00 $1,456.00 $312.00 $730.00 $678.00 $738.00 $652.00 $862.00 $654.00 $45.00 $53.00 $58.00 $62.00 $627.00 $956.00 $1,104.00 $88.00 $223.00 $376.00 $75.00 $711.00 $1,177.00 $692.00 $519.00 $603.00 $142.00 $448.00 $534.00 $81.00 $88.00 $319.00 $52.00 $325.00 $1,124.00 $1,314.00 $1,381.00 $1,373.00 $1,461.00 $449.00 $595.00 ------------------- Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) ------$737.00 $740.00 $845.00 $881.00 $969.00 $1,415.00 $1,692.00 $1,735.00 $552.00 $835.00 $849.00 $921.00 $678.00 $984.00 $751.00 $66.00 $81.00 $69.00 $88.00 $779.00 $1,082.00 $1,214.00 $323.00 $575.00 $427.00 $624.00 $748.00 $1,168.00 $820.00 $552.00 $759.00 $169.00 $608.00 $754.00 $134.00 $93.00 $434.00 $363.00 $440.00 $1,243.00 $1,380.00 $1,402.00 $1,394.00 $1,601.00 $509.00 $620.00 $1,005.00 $1,504.00 $1,301.00 ------$772.00 $776.00 $885.00 $923.00 $1,014.00 $1,481.00 $1,778.00 $1,815.00 $585.00 $873.00 $889.00 $964.00 $711.00 $1,031.00 $787.00 $69.00 $84.00 $72.00 $92.00 $813.00 $1,129.00 $1,266.00 $342.00 $605.00 $445.00 $654.00 $779.00 $1,216.00 $862.00 $576.00 $795.00 $177.00 $642.00 $793.00 $140.00 $97.00 $454.00 $381.00 $461.00 $1,297.00 $1,439.00 $1,462.00 $1,452.00 $1,668.00 $533.00 $647.00 $1,050.00 $1,560.00 $1,352.00 ------$807.00 $812.00 $925.00 $963.00 $1,059.00 $1,550.00 $1,872.00 $1,899.00 $615.00 $912.00 $928.00 $1,007.00 $744.00 $1,079.00 $822.00 $72.00 $88.00 $76.00 $96.00 $847.00 $1,179.00 $1,320.00 $358.00 $633.00 $464.00 $682.00 $812.00 $1,267.00 $902.00 $602.00 $829.00 $186.00 $673.00 $830.00 $146.00 $101.00 $473.00 $399.00 $482.00 $1,352.00 $1,500.00 $1,524.00 $1,514.00 $1,739.00 $556.00 $674.00 $1,096.00 $1,614.00 $1,401.00 ------$737.00 $740.00 $845.00 $881.00 $969.00 $1,415.00 $1,692.00 $1,735.00 $333.00 $835.00 $849.00 $921.00 $678.00 $984.00 $751.00 $51.00 $62.00 $52.00 $67.00 $779.00 $1,082.00 $1,214.00 $162.00 $387.00 $427.00 $505.00 $748.00 $1,168.00 $549.00 $552.00 $664.00 $120.00 $425.00 $534.00 $120.00 $80.00 $416.00 $358.00 $373.00 $1,243.00 $1,380.00 $1,402.00 $1,394.00 $1,601.00 $451.00 $620.00 $1,005.00 $1,504.00 $1,301.00 ------$772.00 $776.00 $885.00 $923.00 $1,014.00 $1,481.00 $1,778.00 $1,815.00 $350.00 $873.00 $889.00 $964.00 $711.00 $1,031.00 $787.00 $53.00 $64.00 $54.00 $69.00 $813.00 $1,129.00 $1,266.00 $169.00 $403.00 $445.00 $526.00 $779.00 $1,216.00 $572.00 $576.00 $693.00 $125.00 $446.00 $557.00 $125.00 $84.00 $434.00 $376.00 $389.00 $1,297.00 $1,439.00 $1,462.00 $1,452.00 $1,668.00 $470.00 $647.00 $1,050.00 $1,560.00 $1,352.00 ------$807.00 $812.00 $925.00 $963.00 $1,059.00 $1,550.00 $1,872.00 $1,899.00 $368.00 $912.00 $928.00 $1,007.00 $744.00 $1,079.00 $822.00 $55.00 $67.00 $57.00 $72.00 $847.00 $1,179.00 $1,320.00 $176.00 $420.00 $464.00 $547.00 $812.00 $1,267.00 $596.00 $602.00 $722.00 $130.00 $466.00 $580.00 $131.00 $87.00 $453.00 $393.00 $406.00 $1,352.00 $1,500.00 $1,524.00 $1,514.00 $1,739.00 $490.00 $674.00 $1,096.00 $1,614.00 $1,401.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 236 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 65800 65805 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 66250 66500 66505 66600 66605 66625 66630 66635 66680 66682 66700 66710 66711 66720 66740 66761 66762 66770 66820 66821 66825 66830 0 0 90 90 90 90 10 90 90 90 90 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $88.00 $178.00 $516.00 $327.00 $813.00 $968.00 $441.00 $339.00 $540.00 $572.00 $597.00 $641.00 $945.00 $752.00 $700.00 $164.00 $160.00 $631.00 $798.00 $795.00 $942.00 $769.00 $1,089.00 $1,264.00 $1,313.00 $769.00 $711.00 $1,006.00 $602.00 $359.00 $359.00 $825.00 $1,136.00 $543.00 $623.00 $595.00 $526.00 $627.00 $506.00 $513.00 ------$506.00 $473.00 $506.00 $433.00 $483.00 $433.00 $275.00 $753.00 $651.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $177.00 $194.00 $519.00 $742.00 $855.00 $963.00 $393.00 $364.00 $546.00 $666.00 $705.00 $744.00 $1,097.00 $881.00 $731.00 $220.00 $196.00 $822.00 $969.00 $964.00 $1,096.00 $946.00 $1,326.00 $1,662.00 $1,320.00 $831.00 $810.00 $1,046.00 $872.00 $405.00 $442.00 $910.00 $1,205.00 $488.00 $634.00 $640.00 $572.00 $693.00 $507.00 $500.00 $704.00 $528.00 $496.00 $510.00 $533.00 $592.00 $460.00 $362.00 $867.00 $796.00 $185.00 $203.00 $542.00 $780.00 $895.00 $1,004.00 $412.00 $381.00 $571.00 $695.00 $737.00 $777.00 $1,145.00 $919.00 $763.00 $232.00 $207.00 $862.00 $1,014.00 $1,007.00 $1,144.00 $989.00 $1,384.00 $1,734.00 $1,374.00 $867.00 $845.00 $1,090.00 $917.00 $424.00 $464.00 $951.00 $1,259.00 $510.00 $662.00 $668.00 $598.00 $725.00 $531.00 $523.00 $735.00 $554.00 $519.00 $534.00 $558.00 $619.00 $484.00 $379.00 $907.00 $829.00 $193.00 $212.00 $565.00 $817.00 $935.00 $1,048.00 $431.00 $399.00 $597.00 $725.00 $768.00 $810.00 $1,195.00 $958.00 $796.00 $244.00 $217.00 $902.00 $1,058.00 $1,050.00 $1,192.00 $1,031.00 $1,442.00 $1,807.00 $1,432.00 $904.00 $882.00 $1,137.00 $959.00 $444.00 $485.00 $992.00 $1,318.00 $534.00 $690.00 $696.00 $624.00 $757.00 $555.00 $547.00 $765.00 $581.00 $543.00 $557.00 $583.00 $647.00 $507.00 $395.00 $947.00 $863.00 $152.00 $152.00 $519.00 $529.00 $855.00 $963.00 $341.00 $296.00 $546.00 $666.00 $705.00 $744.00 $1,097.00 $881.00 $731.00 $150.00 $125.00 $656.00 $969.00 $964.00 $1,096.00 $946.00 $1,326.00 $1,662.00 $1,320.00 $831.00 $810.00 $1,046.00 $617.00 $405.00 $442.00 $910.00 $1,205.00 $488.00 $634.00 $640.00 $572.00 $693.00 $445.00 $442.00 $704.00 $475.00 $445.00 $457.00 $473.00 $536.00 $460.00 $340.00 $867.00 $796.00 $158.00 $158.00 $542.00 $552.00 $895.00 $1,004.00 $356.00 $308.00 $571.00 $695.00 $737.00 $777.00 $1,145.00 $919.00 $763.00 $157.00 $131.00 $684.00 $1,014.00 $1,007.00 $1,144.00 $989.00 $1,384.00 $1,734.00 $1,374.00 $867.00 $845.00 $1,090.00 $644.00 $424.00 $464.00 $951.00 $1,259.00 $510.00 $662.00 $668.00 $598.00 $725.00 $464.00 $461.00 $735.00 $497.00 $465.00 $477.00 $494.00 $559.00 $484.00 $356.00 $907.00 $829.00 $165.00 $165.00 $565.00 $575.00 $935.00 $1,048.00 $372.00 $322.00 $597.00 $725.00 $768.00 $810.00 $1,195.00 $958.00 $796.00 $164.00 $137.00 $714.00 $1,058.00 $1,050.00 $1,192.00 $1,031.00 $1,442.00 $1,807.00 $1,432.00 $904.00 $882.00 $1,137.00 $671.00 $444.00 $485.00 $992.00 $1,318.00 $534.00 $690.00 $696.00 $624.00 $757.00 $485.00 $481.00 $765.00 $521.00 $485.00 $498.00 $516.00 $583.00 $507.00 $370.00 $947.00 $863.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 237 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 66840 66850 66852 66920 66930 66940 66982 66983 66984 66985 66986 66990 66999 67005 67010 67015 67025 67027 67028 67030 67031 67036 67039 67040 67041 67042 67043 67101 67105 67107 67108 67110 67112 67113 67115 67120 67121 67141 67145 67208 67210 67218 67220 67221 67225 67227 67228 67229 67250 67255 90 90 90 90 90 90 90 90 90 90 90 ZZZ YYY 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 ZZZ 90 90 90 90 90 $707.00 $805.00 $878.00 $785.00 $906.00 $819.00 $846.00 $763.00 $898.00 $744.00 $1,038.00 $84.00 BR $639.00 $647.00 $637.00 $774.00 $1,089.00 $338.00 $485.00 $402.00 $1,384.00 $1,490.00 $1,960.00 ------------------$767.00 $941.00 $1,350.00 $1,878.00 $1,040.00 $1,500.00 ------$496.00 $751.00 $962.00 $536.00 $514.00 $655.00 $779.00 $1,217.00 $894.00 $325.00 $44.00 $652.00 $1,025.00 ------$793.00 $872.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $781.00 $888.00 $951.00 $849.00 $963.00 $875.00 $1,217.00 $805.00 $864.00 $850.00 $1,054.00 $107.00 ------$529.00 $613.00 $659.00 $825.00 $964.00 $249.00 $583.00 $435.00 $1,090.00 $1,397.00 $1,612.00 $1,478.00 $1,693.00 $1,777.00 $873.00 $809.00 $1,367.00 $1,820.00 $984.00 $1,498.00 $1,951.00 $548.00 $746.00 $1,017.00 $583.00 $587.00 $672.00 $786.00 $1,592.00 $1,209.00 $359.00 $35.00 $687.00 $1,319.00 $1,283.00 $902.00 $961.00 $815.00 $925.00 $991.00 $885.00 $1,003.00 $912.00 $1,266.00 $831.00 $898.00 $885.00 $1,100.00 $111.00 ------$553.00 $640.00 $690.00 $864.00 $1,005.00 $261.00 $609.00 $455.00 $1,135.00 $1,456.00 $1,679.00 $1,537.00 $1,759.00 $1,847.00 $914.00 $846.00 $1,424.00 $1,895.00 $1,029.00 $1,560.00 $2,029.00 $572.00 $782.00 $1,060.00 $610.00 $614.00 $702.00 $819.00 $1,656.00 $1,260.00 $377.00 $37.00 $718.00 $1,379.00 $1,335.00 $944.00 $1,005.00 $850.00 $965.00 $1,033.00 $923.00 $1,045.00 $950.00 $1,319.00 $855.00 $934.00 $921.00 $1,149.00 $115.00 ------$578.00 $669.00 $721.00 $903.00 $1,048.00 $273.00 $635.00 $475.00 $1,183.00 $1,518.00 $1,750.00 $1,602.00 $1,832.00 $1,924.00 $954.00 $883.00 $1,485.00 $1,975.00 $1,075.00 $1,626.00 $2,113.00 $597.00 $817.00 $1,105.00 $637.00 $641.00 $732.00 $855.00 $1,725.00 $1,315.00 $395.00 $38.00 $749.00 $1,441.00 $1,391.00 $987.00 $1,049.00 $781.00 $888.00 $951.00 $849.00 $963.00 $875.00 $1,217.00 $805.00 $864.00 $850.00 $1,054.00 $107.00 ------$529.00 $613.00 $659.00 $702.00 $964.00 $195.00 $583.00 $394.00 $1,090.00 $1,397.00 $1,612.00 $1,478.00 $1,693.00 $1,777.00 $750.00 $720.00 $1,367.00 $1,820.00 $864.00 $1,498.00 $1,951.00 $548.00 $618.00 $1,017.00 $540.00 $552.00 $646.00 $757.00 $1,592.00 $1,147.00 $257.00 $33.00 $640.00 $1,160.00 $1,283.00 $902.00 $961.00 $815.00 $925.00 $991.00 $885.00 $1,003.00 $912.00 $1,266.00 $831.00 $898.00 $885.00 $1,100.00 $111.00 ------$553.00 $640.00 $690.00 $732.00 $1,005.00 $203.00 $609.00 $412.00 $1,135.00 $1,456.00 $1,679.00 $1,537.00 $1,759.00 $1,847.00 $782.00 $750.00 $1,424.00 $1,895.00 $901.00 $1,560.00 $2,029.00 $572.00 $645.00 $1,060.00 $564.00 $576.00 $673.00 $788.00 $1,656.00 $1,194.00 $268.00 $34.00 $667.00 $1,210.00 $1,335.00 $944.00 $1,005.00 $850.00 $965.00 $1,033.00 $923.00 $1,045.00 $950.00 $1,319.00 $855.00 $934.00 $921.00 $1,149.00 $115.00 ------$578.00 $669.00 $721.00 $763.00 $1,048.00 $212.00 $635.00 $429.00 $1,183.00 $1,518.00 $1,750.00 $1,602.00 $1,832.00 $1,924.00 $816.00 $782.00 $1,485.00 $1,975.00 $939.00 $1,626.00 $2,113.00 $597.00 $672.00 $1,105.00 $588.00 $601.00 $702.00 $822.00 $1,725.00 $1,245.00 $281.00 $35.00 $696.00 $1,262.00 $1,391.00 $987.00 $1,049.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 238 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 67299 67311 67312 67314 67316 67318 67320 67331 67332 67334 67335 67340 67343 67345 67346 67399 67400 67405 67412 67413 67414 67415 67420 67430 67440 67445 67450 67500 67505 67515 67550 67560 67570 67599 67700 67710 67715 67800 67801 67805 67808 67810 67820 67825 67830 67835 67840 67850 67875 67880 YYY 90 90 90 90 90 ZZZ ZZZ ZZZ ZZZ ZZZ ZZZ 90 10 0 YYY 90 90 90 90 90 0 90 90 90 90 90 0 0 0 90 90 90 YYY 10 10 10 10 10 10 90 0 0 10 10 90 10 10 0 90 BR $616.00 $773.00 $688.00 $857.00 $663.00 $602.00 $560.00 $621.00 $447.00 $253.00 $559.00 $628.00 $275.00 ------BR $960.00 $799.00 $976.00 $909.00 $1,023.00 $146.00 $1,729.00 $1,203.00 $1,257.00 $1,269.00 $1,300.00 $75.00 $109.00 $53.00 $946.00 $936.00 $1,148.00 BR $87.00 $117.00 $102.00 $119.00 $189.00 $208.00 $308.00 $133.00 $36.00 $130.00 $239.00 $500.00 $187.00 $143.00 $163.00 $442.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) ------$673.00 $803.00 $751.00 $903.00 $787.00 $368.00 $349.00 $379.00 $343.00 $177.00 $410.00 $733.00 $272.00 $234.00 ------$1,076.00 $910.00 $1,002.00 $1,000.00 $1,478.00 $124.00 $1,897.00 $1,441.00 $1,392.00 $1,613.00 $1,438.00 $103.00 $97.00 $102.00 $1,126.00 $1,137.00 $1,336.00 ------$328.00 $280.00 $293.00 $146.00 $187.00 $231.00 $410.00 $256.00 $63.00 $150.00 $325.00 $504.00 $339.00 $252.00 $211.00 $526.00 ------$703.00 $837.00 $784.00 $941.00 $821.00 $381.00 $360.00 $392.00 $355.00 $184.00 $424.00 $765.00 $285.00 $244.00 ------$1,127.00 $954.00 $1,049.00 $1,048.00 $1,537.00 $129.00 $1,983.00 $1,510.00 $1,457.00 $1,682.00 $1,504.00 $106.00 $101.00 $105.00 $1,182.00 $1,190.00 $1,397.00 ------$349.00 $297.00 $311.00 $153.00 $195.00 $242.00 $428.00 $270.00 $66.00 $157.00 $344.00 $527.00 $358.00 $266.00 $223.00 $553.00 ------$735.00 $873.00 $818.00 $982.00 $857.00 $395.00 $374.00 $407.00 $368.00 $192.00 $440.00 $798.00 $299.00 $255.00 ------$1,180.00 $998.00 $1,096.00 $1,096.00 $1,597.00 $135.00 $2,074.00 $1,583.00 $1,523.00 $1,756.00 $1,570.00 $110.00 $105.00 $108.00 $1,241.00 $1,244.00 $1,460.00 ------$367.00 $313.00 $327.00 $160.00 $204.00 $254.00 $446.00 $284.00 $69.00 $164.00 $361.00 $551.00 $376.00 $279.00 $234.00 $578.00 ------$673.00 $803.00 $751.00 $903.00 $787.00 $368.00 $349.00 $379.00 $343.00 $177.00 $410.00 $733.00 $246.00 $234.00 ------$1,076.00 $910.00 $1,002.00 $1,000.00 $1,478.00 $124.00 $1,897.00 $1,441.00 $1,392.00 $1,613.00 $1,438.00 $90.00 $84.00 $93.00 $1,126.00 $1,137.00 $1,336.00 ------$131.00 $110.00 $124.00 $119.00 $154.00 $190.00 $410.00 $108.00 $63.00 $138.00 $157.00 $504.00 $182.00 $159.00 $113.00 $410.00 ------$703.00 $837.00 $784.00 $941.00 $821.00 $381.00 $360.00 $392.00 $355.00 $184.00 $424.00 $765.00 $257.00 $244.00 ------$1,127.00 $954.00 $1,049.00 $1,048.00 $1,537.00 $129.00 $1,983.00 $1,510.00 $1,457.00 $1,682.00 $1,504.00 $93.00 $87.00 $95.00 $1,182.00 $1,190.00 $1,397.00 ------$137.00 $115.00 $130.00 $124.00 $161.00 $198.00 $428.00 $112.00 $66.00 $144.00 $164.00 $527.00 $190.00 $166.00 $118.00 $428.00 ------$735.00 $873.00 $818.00 $982.00 $857.00 $395.00 $374.00 $407.00 $368.00 $192.00 $440.00 $798.00 $269.00 $255.00 ------$1,180.00 $998.00 $1,096.00 $1,096.00 $1,597.00 $135.00 $2,074.00 $1,583.00 $1,523.00 $1,756.00 $1,570.00 $96.00 $90.00 $98.00 $1,241.00 $1,244.00 $1,460.00 ------$144.00 $121.00 $136.00 $130.00 $168.00 $207.00 $446.00 $116.00 $69.00 $151.00 $172.00 $551.00 $198.00 $173.00 $124.00 $446.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 239 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 67882 67900 67901 67902 67903 67904 67906 67908 67909 67911 67912 67914 67915 67916 67917 67921 67922 67923 67924 67930 67935 67938 67950 67961 67966 67971 67973 67974 67975 67999 68020 68040 68100 68110 68115 68130 68135 68200 68320 68325 68326 68328 68330 68335 68340 68360 68362 68371 68399 68400 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 10 90 90 90 90 90 90 90 YYY 10 0 0 10 10 90 10 0 90 90 90 90 90 90 90 90 90 10 YYY 10 $643.00 $487.00 $646.00 $650.00 $657.00 $720.00 $633.00 $550.00 $577.00 $517.00 ------$487.00 $252.00 $675.00 $631.00 $419.00 $243.00 $718.00 $605.00 $280.00 $520.00 $67.00 $584.00 $571.00 $645.00 $875.00 $1,126.00 $1,140.00 $681.00 BR $106.00 $75.00 $137.00 $172.00 $248.00 $378.00 $146.00 $59.00 $502.00 $672.00 $654.00 $741.00 $488.00 $636.00 $413.00 $449.00 $691.00 ------BR $154.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $645.00 $755.00 $753.00 $797.00 $743.00 $845.00 $595.00 $570.00 $636.00 $617.00 $1,116.00 $466.00 $421.00 $635.00 $693.00 $444.00 $409.00 $666.00 $694.00 $437.00 $707.00 $299.00 $687.00 $683.00 $873.00 $842.00 $1,094.00 $1,090.00 $794.00 ------$136.00 $76.00 $209.00 $271.00 $379.00 $637.00 $180.00 $49.00 $834.00 $746.00 $722.00 $819.00 $704.00 $724.00 $638.00 $616.00 $733.00 $488.00 ------$345.00 $676.00 $794.00 $793.00 $833.00 $784.00 $887.00 $623.00 $599.00 $670.00 $642.00 $1,181.00 $491.00 $443.00 $668.00 $729.00 $468.00 $431.00 $700.00 $730.00 $460.00 $744.00 $317.00 $723.00 $719.00 $913.00 $879.00 $1,143.00 $1,139.00 $830.00 ------$142.00 $80.00 $221.00 $286.00 $400.00 $670.00 $188.00 $51.00 $878.00 $780.00 $753.00 $857.00 $740.00 $755.00 $671.00 $647.00 $764.00 $515.00 ------$365.00 $706.00 $833.00 $835.00 $874.00 $826.00 $930.00 $656.00 $628.00 $703.00 $669.00 $1,239.00 $515.00 $465.00 $700.00 $766.00 $490.00 $451.00 $733.00 $765.00 $482.00 $782.00 $332.00 $760.00 $755.00 $953.00 $920.00 $1,198.00 $1,193.00 $869.00 ------$148.00 $83.00 $232.00 $300.00 $420.00 $702.00 $196.00 $53.00 $918.00 $816.00 $785.00 $899.00 $775.00 $787.00 $702.00 $677.00 $797.00 $545.00 ------$383.00 $527.00 $591.00 $661.00 $797.00 $585.00 $665.00 $595.00 $503.00 $509.00 $617.00 $572.00 $332.00 $295.00 $497.00 $551.00 $310.00 $284.00 $535.00 $516.00 $284.00 $525.00 $130.00 $545.00 $529.00 $727.00 $842.00 $1,094.00 $1,090.00 $794.00 ------$126.00 $63.00 $114.00 $169.00 $211.00 $468.00 $173.00 $40.00 $595.00 $746.00 $722.00 $819.00 $512.00 $724.00 $443.00 $458.00 $733.00 $488.00 ------$163.00 $550.00 $618.00 $694.00 $833.00 $614.00 $695.00 $623.00 $527.00 $533.00 $642.00 $597.00 $347.00 $308.00 $520.00 $577.00 $324.00 $297.00 $559.00 $539.00 $296.00 $549.00 $136.00 $571.00 $554.00 $757.00 $879.00 $1,143.00 $1,139.00 $830.00 ------$132.00 $65.00 $119.00 $177.00 $221.00 $490.00 $180.00 $42.00 $621.00 $780.00 $753.00 $857.00 $535.00 $755.00 $462.00 $478.00 $764.00 $515.00 ------$170.00 $573.00 $647.00 $731.00 $874.00 $647.00 $726.00 $656.00 $552.00 $559.00 $669.00 $623.00 $363.00 $322.00 $544.00 $605.00 $339.00 $310.00 $585.00 $564.00 $309.00 $576.00 $142.00 $599.00 $581.00 $788.00 $920.00 $1,198.00 $1,193.00 $869.00 ------$138.00 $68.00 $124.00 $185.00 $231.00 $512.00 $189.00 $43.00 $647.00 $816.00 $785.00 $899.00 $558.00 $787.00 $482.00 $498.00 $797.00 $545.00 ------$178.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 240 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 68420 68440 68500 68505 68510 68520 68525 68530 68540 68550 68700 68705 68720 68745 68750 68760 68761 68770 68801 68810 68811 68815 68816 68840 68850 68899 69000 69005 69020 69100 69105 69110 69120 69140 69145 69150 69155 69200 69205 69210 69220 69222 69300 69310 69320 69399 69400 69401 69405 69420 10 10 90 90 0 90 0 10 90 90 90 10 90 90 90 10 10 90 10 10 10 10 10 10 0 YYY 10 10 10 0 0 90 90 90 90 90 90 0 10 0 0 10 YYY 90 90 YYY 0 0 10 10 $191.00 $96.00 $882.00 $921.00 $491.00 $687.00 $340.00 $379.00 $875.00 $1,107.00 $628.00 $176.00 $807.00 $704.00 $792.00 $109.00 $130.00 $634.00 $202.00 $290.00 $191.00 $399.00 ------$100.00 $76.00 BR $52.00 $175.00 $109.00 $85.00 $87.00 $294.00 $274.00 $722.00 $248.00 $1,111.00 $1,680.00 $53.00 $110.00 $39.00 $78.00 $123.00 $522.00 $937.00 $1,434.00 BR $76.00 $52.00 $176.00 $117.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $387.00 $133.00 $1,111.00 $1,116.00 $547.00 $780.00 $315.00 $531.00 $1,048.00 $1,287.00 $674.00 $285.00 $862.00 $867.00 $890.00 $242.00 $172.00 $631.00 $142.00 $308.00 $236.00 $532.00 $790.00 $142.00 $80.00 ------$222.00 $262.00 $282.00 $129.00 $170.00 $551.00 $510.00 $1,091.00 $461.00 $1,352.00 $2,150.00 $154.00 $129.00 $63.00 $167.00 $272.00 $744.00 $1,371.00 $1,956.00 ------$169.00 $102.00 $320.00 $234.00 $409.00 $140.00 $1,160.00 $1,165.00 $576.00 $814.00 $327.00 $560.00 $1,093.00 $1,345.00 $702.00 $301.00 $900.00 $907.00 $929.00 $255.00 $181.00 $656.00 $150.00 $323.00 $247.00 $562.00 $840.00 $149.00 $84.00 ------$236.00 $277.00 $299.00 $136.00 $181.00 $585.00 $540.00 $1,155.00 $489.00 $1,427.00 $2,264.00 $164.00 $137.00 $66.00 $178.00 $289.00 $789.00 $1,449.00 $2,065.00 ------$180.00 $108.00 $338.00 $248.00 $429.00 $147.00 $1,210.00 $1,215.00 $603.00 $849.00 $341.00 $587.00 $1,140.00 $1,407.00 $732.00 $315.00 $939.00 $949.00 $969.00 $268.00 $189.00 $683.00 $158.00 $337.00 $259.00 $590.00 $884.00 $156.00 $88.00 ------$249.00 $292.00 $316.00 $143.00 $191.00 $618.00 $572.00 $1,219.00 $516.00 $1,512.00 $2,393.00 $173.00 $144.00 $70.00 $188.00 $305.00 $840.00 $1,530.00 $2,181.00 ------$190.00 $114.00 $357.00 $262.00 $205.00 $111.00 $1,111.00 $1,116.00 $337.00 $780.00 $315.00 $304.00 $1,048.00 $1,287.00 $674.00 $190.00 $862.00 $867.00 $890.00 $166.00 $134.00 $631.00 $122.00 $266.00 $236.00 $296.00 $279.00 $124.00 $72.00 ------$146.00 $200.00 $179.00 $60.00 $83.00 $410.00 $510.00 $1,091.00 $308.00 $1,352.00 $2,150.00 $70.00 $129.00 $43.00 $79.00 $175.00 $606.00 $1,371.00 $1,956.00 ------$78.00 $64.00 $248.00 $151.00 $215.00 $116.00 $1,160.00 $1,165.00 $350.00 $814.00 $327.00 $317.00 $1,093.00 $1,345.00 $702.00 $199.00 $900.00 $907.00 $929.00 $174.00 $140.00 $656.00 $128.00 $278.00 $247.00 $310.00 $292.00 $130.00 $76.00 ------$154.00 $211.00 $189.00 $62.00 $87.00 $433.00 $540.00 $1,155.00 $325.00 $1,427.00 $2,264.00 $74.00 $137.00 $45.00 $84.00 $185.00 $641.00 $1,449.00 $2,065.00 ------$82.00 $68.00 $261.00 $159.00 $224.00 $122.00 $1,210.00 $1,215.00 $365.00 $849.00 $341.00 $331.00 $1,140.00 $1,407.00 $732.00 $207.00 $939.00 $949.00 $969.00 $182.00 $146.00 $683.00 $134.00 $289.00 $259.00 $324.00 $306.00 $136.00 $79.00 ------$162.00 $222.00 $199.00 $64.00 $92.00 $458.00 $572.00 $1,219.00 $343.00 $1,512.00 $2,393.00 $78.00 $144.00 $47.00 $89.00 $196.00 $683.00 $1,530.00 $2,181.00 ------$87.00 $72.00 $275.00 $168.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 241 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 69421 69424 69433 69436 69440 69450 69501 69502 69505 69511 69530 69535 69540 69550 69552 69554 69601 69602 69603 69604 69605 69610 69620 69631 69632 69633 69635 69636 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69710 69711 69714 69715 69717 69718 10 0 10 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 $155.00 $84.00 $145.00 $182.00 $699.00 $525.00 $829.00 $1,118.00 $1,176.00 $1,221.00 $1,616.00 $2,824.00 $126.00 $998.00 $1,621.00 $2,600.00 $1,195.00 $1,225.00 $1,264.00 $1,263.00 $1,526.00 $41.00 $651.00 $985.00 $1,166.00 $1,110.00 $1,207.00 $1,381.00 $1,370.00 $1,154.00 $1,519.00 $1,389.00 $1,529.00 $1,479.00 $1,620.00 $879.00 $1,072.00 $1,412.00 $1,386.00 $887.00 $887.00 $988.00 $828.00 $702.00 BR $878.00 $961.00 $1,217.00 $996.00 $1,232.00 Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $194.00 $158.00 $243.00 $213.00 $853.00 $665.00 $928.00 $1,229.00 $1,529.00 $1,569.00 $2,105.00 $3,451.00 $256.00 $1,317.00 $2,022.00 $3,267.00 $1,325.00 $1,379.00 $1,622.00 $1,413.00 $1,996.00 $499.00 $868.00 $1,098.00 $1,353.00 $1,303.00 $1,540.00 $1,753.00 $1,743.00 $1,313.00 $1,697.00 $1,549.00 $1,890.00 $1,849.00 $1,968.00 $1,004.00 $1,179.00 $1,547.00 $1,483.00 $1,017.00 $1,019.00 $1,193.00 $1,048.00 $890.00 ------$1,089.00 $1,373.00 $1,709.00 $1,450.00 $1,868.00 $205.00 $168.00 $258.00 $225.00 $901.00 $703.00 $978.00 $1,295.00 $1,616.00 $1,657.00 $2,218.00 $3,630.00 $272.00 $1,392.00 $2,132.00 $3,438.00 $1,396.00 $1,453.00 $1,713.00 $1,489.00 $2,106.00 $527.00 $919.00 $1,159.00 $1,427.00 $1,375.00 $1,627.00 $1,851.00 $1,841.00 $1,384.00 $1,789.00 $1,632.00 $1,994.00 $1,952.00 $2,077.00 $1,059.00 $1,242.00 $1,629.00 $1,561.00 $1,072.00 $1,075.00 $1,258.00 $1,107.00 $939.00 ------$1,148.00 $1,445.00 $1,798.00 $1,520.00 $2,001.00 $217.00 $178.00 $273.00 $239.00 $951.00 $742.00 $1,033.00 $1,367.00 $1,706.00 $1,750.00 $2,339.00 $3,831.00 $287.00 $1,470.00 $2,251.00 $3,633.00 $1,474.00 $1,535.00 $1,809.00 $1,573.00 $2,224.00 $556.00 $970.00 $1,223.00 $1,507.00 $1,451.00 $1,718.00 $1,954.00 $1,944.00 $1,462.00 $1,889.00 $1,723.00 $2,106.00 $2,061.00 $2,193.00 $1,118.00 $1,311.00 $1,720.00 $1,649.00 $1,133.00 $1,135.00 $1,328.00 $1,170.00 $992.00 ------$1,212.00 $1,525.00 $1,898.00 $1,594.00 $2,170.00 $194.00 $80.00 $164.00 $213.00 $853.00 $665.00 $928.00 $1,229.00 $1,529.00 $1,569.00 $2,105.00 $3,451.00 $161.00 $1,317.00 $2,022.00 $3,267.00 $1,325.00 $1,379.00 $1,622.00 $1,413.00 $1,996.00 $383.00 $620.00 $1,098.00 $1,353.00 $1,303.00 $1,540.00 $1,753.00 $1,743.00 $1,313.00 $1,697.00 $1,549.00 $1,890.00 $1,849.00 $1,968.00 $1,004.00 $1,179.00 $1,547.00 $1,483.00 $1,017.00 $1,019.00 $1,193.00 $1,048.00 $890.00 ------$1,089.00 $1,373.00 $1,709.00 $1,450.00 $1,868.00 $205.00 $84.00 $173.00 $225.00 $901.00 $703.00 $978.00 $1,295.00 $1,616.00 $1,657.00 $2,218.00 $3,630.00 $170.00 $1,392.00 $2,132.00 $3,438.00 $1,396.00 $1,453.00 $1,713.00 $1,489.00 $2,106.00 $403.00 $654.00 $1,159.00 $1,427.00 $1,375.00 $1,627.00 $1,851.00 $1,841.00 $1,384.00 $1,789.00 $1,632.00 $1,994.00 $1,952.00 $2,077.00 $1,059.00 $1,242.00 $1,629.00 $1,561.00 $1,072.00 $1,075.00 $1,258.00 $1,107.00 $939.00 ------$1,148.00 $1,445.00 $1,798.00 $1,520.00 $2,001.00 $217.00 $88.00 $183.00 $239.00 $951.00 $742.00 $1,033.00 $1,367.00 $1,706.00 $1,750.00 $2,339.00 $3,831.00 $180.00 $1,470.00 $2,251.00 $3,633.00 $1,474.00 $1,535.00 $1,809.00 $1,573.00 $2,224.00 $426.00 $691.00 $1,223.00 $1,507.00 $1,451.00 $1,718.00 $1,954.00 $1,944.00 $1,462.00 $1,889.00 $1,723.00 $2,106.00 $2,061.00 $2,193.00 $1,118.00 $1,311.00 $1,720.00 $1,649.00 $1,133.00 $1,135.00 $1,328.00 $1,170.00 $992.00 ------$1,212.00 $1,525.00 $1,898.00 $1,594.00 $2,170.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 242 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Surgery CPT Code FUD 2003 MRA 69720 69725 69740 69745 69799 69801 69802 69805 69806 69820 69840 69905 69910 69915 69930 69949 69950 69955 69960 69970 69979 69990 G0127 G0168 G0247 G0289 G0341 G0342 G0343 G0364 G0392 G0393 90 90 90 90 YYY 90 90 90 90 90 90 90 90 90 90 YYY 90 90 90 90 YYY ZZZ 0 0 ZZZ ZZZ 0 90 90 ZZZ 0 0 $1,307.00 $1,922.00 $1,274.00 $1,447.00 BR $785.00 $1,115.00 $1,187.00 $1,123.00 $876.00 $869.00 $1,013.00 $1,228.00 $1,754.00 $1,498.00 BR $2,017.00 $2,185.00 $2,116.00 $2,306.00 BR $262.00 ------------------------------------------------------------- Locality 01/02 Locality 03 Locality 04 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $1,490.00 $2,437.00 $1,486.00 $1,507.00 ------$936.00 $1,317.00 $1,341.00 $1,203.00 $1,096.00 $1,161.00 $1,155.00 $1,303.00 $1,981.00 $1,631.00 ------$2,364.00 $2,589.00 $2,494.00 $2,774.00 ------$310.00 $25.00 $112.00 $55.00 $124.00 $490.00 $935.00 $1,529.00 $18.00 $3,113.00 $2,357.00 $1,570.00 $2,567.00 $1,563.00 $1,580.00 ------$988.00 $1,387.00 $1,410.00 $1,267.00 $1,158.00 $1,225.00 $1,218.00 $1,371.00 $2,080.00 $1,715.00 ------$2,486.00 $2,725.00 $2,617.00 $2,912.00 ------$338.00 $26.00 $119.00 $58.00 $134.00 $511.00 $990.00 $1,613.00 $20.00 $3,316.00 $2,512.00 $1,658.00 $2,719.00 $1,649.00 $1,662.00 ------$1,043.00 $1,465.00 $1,488.00 $1,338.00 $1,225.00 $1,292.00 $1,286.00 $1,446.00 $2,193.00 $1,810.00 ------$2,629.00 $2,883.00 $2,758.00 $3,070.00 ------$377.00 $28.00 $125.00 $60.00 $146.00 $537.00 $1,063.00 $1,719.00 $22.00 $3,494.00 $2,645.00 $1,490.00 $2,437.00 $1,486.00 $1,507.00 ------$936.00 $1,317.00 $1,341.00 $1,203.00 $1,096.00 $1,161.00 $1,155.00 $1,303.00 $1,981.00 $1,631.00 ------$2,364.00 $2,589.00 $2,494.00 $2,774.00 ------$310.00 $12.00 $34.00 $34.00 $124.00 $490.00 $935.00 $1,529.00 $14.00 $668.00 $425.00 $1,570.00 $2,567.00 $1,563.00 $1,580.00 ------$988.00 $1,387.00 $1,410.00 $1,267.00 $1,158.00 $1,225.00 $1,218.00 $1,371.00 $2,080.00 $1,715.00 ------$2,486.00 $2,725.00 $2,617.00 $2,912.00 ------$338.00 $12.00 $36.00 $35.00 $134.00 $511.00 $990.00 $1,613.00 $15.00 $696.00 $441.00 $1,658.00 $2,719.00 $1,649.00 $1,662.00 ------$1,043.00 $1,465.00 $1,488.00 $1,338.00 $1,225.00 $1,292.00 $1,286.00 $1,446.00 $2,193.00 $1,810.00 ------$2,629.00 $2,883.00 $2,758.00 $3,070.00 ------$377.00 $13.00 $38.00 $37.00 $146.00 $537.00 $1,063.00 $1,719.00 $17.00 $731.00 $461.00 CPT only © 2008 American Medical Association. All rights reserved. Part B, 243 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition PART C SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES RULE 69L-7.020, F.A.C. 244 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 70010 70010-26 70010-TC 70015 70015-26 70015-TC 70030 70030-26 70030-TC 70100 70100-26 70100-TC 70110 70110-26 70110-TC 70120 70120-26 70120-TC 70130 70130-26 70130-TC 70134 70134-26 70134-TC 70140 70140-26 70140-TC 70150 70150-26 70150-TC 70160 70160-26 70160-TC 70170 70170-26 70170-TC 70190 70190-26 70190-TC 70200 70200-26 70200-TC 70210 70210-26 70210-TC 70220 70220-26 70220-TC 70240 70240-26 $70.00 NC NC $58.00 NC NC $24.00 $10.00 $15.00 $29.00 $9.00 $19.00 $36.00 $12.00 $22.00 $32.00 $9.00 $22.00 $46.00 $17.00 $29.00 $45.00 $17.00 $28.00 $33.00 $9.00 $22.00 $42.00 $12.00 $29.00 $29.00 $8.00 $19.00 $52.00 NC NC $34.00 $10.00 $22.00 $43.00 $14.00 $29.00 $32.00 $8.00 $22.00 $42.00 $12.00 $29.00 $26.00 $9.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $209.00 $63.00 $146.00 $145.00 $65.00 $80.00 $29.00 $9.00 $20.00 $33.00 $10.00 $23.00 $42.00 $13.00 $29.00 $37.00 $10.00 $27.00 $57.00 $18.00 $39.00 $51.00 $18.00 $33.00 $35.00 $10.00 $24.00 $47.00 $13.00 $33.00 $33.00 $9.00 $24.00 $371.00 $15.00 $366.00 $39.00 $11.00 $28.00 $48.00 $15.00 $34.00 $34.00 $9.00 $25.00 $44.00 $13.00 $31.00 $30.00 $10.00 $225.00 $65.00 $160.00 $155.00 $68.00 $87.00 $31.00 $10.00 $22.00 $35.00 $10.00 $25.00 $45.00 $13.00 $31.00 $40.00 $10.00 $30.00 $61.00 $19.00 $42.00 $55.00 $19.00 $36.00 $37.00 $10.00 $27.00 $50.00 $14.00 $37.00 $36.00 $10.00 $26.00 $406.00 $16.00 $401.00 $42.00 $11.00 $30.00 $52.00 $15.00 $37.00 $36.00 $9.00 $27.00 $48.00 $13.00 $34.00 $32.00 $10.00 $242.00 $67.00 $174.00 $165.00 $71.00 $94.00 $34.00 $10.00 $24.00 $37.00 $10.00 $27.00 $48.00 $14.00 $34.00 $43.00 $10.00 $32.00 $66.00 $20.00 $46.00 $59.00 $20.00 $39.00 $40.00 $11.00 $29.00 $54.00 $14.00 $40.00 $38.00 $10.00 $28.00 $445.00 $16.00 $439.00 $45.00 $12.00 $33.00 $56.00 $16.00 $40.00 $39.00 $10.00 $30.00 $52.00 $14.00 $38.00 $34.00 $11.00 $209.00 $63.00 $146.00 $145.00 $65.00 $80.00 $29.00 $9.00 $20.00 $33.00 $10.00 $23.00 $42.00 $13.00 $29.00 $37.00 $10.00 $27.00 $57.00 $18.00 $39.00 $51.00 $18.00 $33.00 $35.00 $10.00 $24.00 $47.00 $13.00 $33.00 $33.00 $9.00 $24.00 $371.00 $15.00 $366.00 $39.00 $11.00 $28.00 $48.00 $15.00 $34.00 $34.00 $9.00 $25.00 $44.00 $13.00 $31.00 $30.00 $10.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $225.00 $65.00 $160.00 $155.00 $68.00 $87.00 $31.00 $10.00 $22.00 $35.00 $10.00 $25.00 $45.00 $13.00 $31.00 $40.00 $10.00 $30.00 $61.00 $19.00 $42.00 $55.00 $19.00 $36.00 $37.00 $10.00 $27.00 $50.00 $14.00 $37.00 $36.00 $10.00 $26.00 $406.00 $16.00 $401.00 $42.00 $11.00 $30.00 $52.00 $15.00 $37.00 $36.00 $9.00 $27.00 $48.00 $13.00 $34.00 $32.00 $10.00 $242.00 $67.00 $174.00 $165.00 $71.00 $94.00 $34.00 $10.00 $24.00 $37.00 $10.00 $27.00 $48.00 $14.00 $34.00 $43.00 $10.00 $32.00 $66.00 $20.00 $46.00 $59.00 $20.00 $39.00 $40.00 $11.00 $29.00 $54.00 $14.00 $40.00 $38.00 $10.00 $28.00 $445.00 $16.00 $439.00 $45.00 $12.00 $33.00 $56.00 $16.00 $40.00 $39.00 $10.00 $30.00 $52.00 $14.00 $38.00 $34.00 $11.00 Part C, 245 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 70240-TC 70250 70250-26 70250-TC 70260 70260-26 70260-TC 70300 70300-26 70300-TC 70310 70310-26 70310-TC 70320 70320-26 70320-TC 70328 70328-26 70328-TC 70330 70330-26 70330-TC 70332 70332-26 70332-TC 70336 70336-26 70336-TC 70350 70350-26 70350-TC 70355 70355-26 70355-TC 70360 70360-26 70360-TC 70370 70370-26 70370-TC 70371 70371-26 70371-TC 70373 70373-26 70373-TC 70380 70380-26 70380-TC 70390 $15.00 $35.00 $12.00 $22.00 $50.00 $17.00 $33.00 $15.00 $5.00 $10.00 $24.00 $8.00 $15.00 $40.00 $11.00 $29.00 $28.00 $10.00 $18.00 $43.00 $12.00 $31.00 $107.00 NC NC $497.00 $72.00 $419.00 $24.00 $10.00 $14.00 $32.00 $10.00 $21.00 $24.00 $8.00 $15.00 $65.00 $16.00 $48.00 $122.00 $43.00 $79.00 $90.00 NC NC $34.00 $8.00 $24.00 $87.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $20.00 $39.00 $12.00 $27.00 $54.00 $18.00 $36.00 $16.00 $6.00 $10.00 $33.00 $9.00 $24.00 $50.00 $12.00 $38.00 $32.00 $10.00 $22.00 $50.00 $13.00 $38.00 $103.00 $28.00 $74.00 $408.00 $78.00 $330.00 $23.00 $9.00 $14.00 $29.00 $11.00 $18.00 $29.00 $9.00 $19.00 $77.00 $16.00 $61.00 $117.00 $44.00 $73.00 $94.00 $23.00 $71.00 $40.00 $9.00 $31.00 $106.00 $22.00 $42.00 $13.00 $29.00 $59.00 $19.00 $40.00 $18.00 $6.00 $11.00 $36.00 $9.00 $26.00 $54.00 $12.00 $42.00 $34.00 $10.00 $24.00 $54.00 $13.00 $41.00 $111.00 $29.00 $81.00 $441.00 $81.00 $360.00 $25.00 $10.00 $16.00 $31.00 $11.00 $20.00 $31.00 $10.00 $21.00 $83.00 $17.00 $66.00 $125.00 $46.00 $80.00 $101.00 $23.00 $78.00 $43.00 $10.00 $34.00 $114.00 $24.00 $45.00 $13.00 $32.00 $63.00 $20.00 $44.00 $19.00 $7.00 $12.00 $38.00 $10.00 $28.00 $58.00 $13.00 $45.00 $36.00 $10.00 $26.00 $58.00 $13.00 $45.00 $119.00 $30.00 $89.00 $475.00 $85.00 $390.00 $27.00 $10.00 $17.00 $34.00 $12.00 $22.00 $33.00 $10.00 $23.00 $89.00 $17.00 $71.00 $135.00 $48.00 $87.00 $109.00 $24.00 $85.00 $47.00 $10.00 $36.00 $123.00 $20.00 $39.00 $12.00 $27.00 $54.00 $18.00 $36.00 $16.00 $6.00 $10.00 $33.00 $9.00 $24.00 $50.00 $12.00 $38.00 $32.00 $10.00 $22.00 $50.00 $13.00 $38.00 $103.00 $28.00 $74.00 $408.00 $78.00 $330.00 $23.00 $9.00 $14.00 $29.00 $11.00 $18.00 $29.00 $9.00 $19.00 $77.00 $16.00 $61.00 $117.00 $44.00 $73.00 $94.00 $23.00 $71.00 $40.00 $9.00 $31.00 $106.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $22.00 $42.00 $13.00 $29.00 $59.00 $19.00 $40.00 $18.00 $6.00 $11.00 $36.00 $9.00 $26.00 $54.00 $12.00 $42.00 $34.00 $10.00 $24.00 $54.00 $13.00 $41.00 $111.00 $29.00 $81.00 $441.00 $81.00 $360.00 $25.00 $10.00 $16.00 $31.00 $11.00 $20.00 $31.00 $10.00 $21.00 $83.00 $17.00 $66.00 $125.00 $46.00 $80.00 $101.00 $23.00 $78.00 $43.00 $10.00 $34.00 $114.00 $24.00 $45.00 $13.00 $32.00 $63.00 $20.00 $44.00 $19.00 $7.00 $12.00 $38.00 $10.00 $28.00 $58.00 $13.00 $45.00 $36.00 $10.00 $26.00 $58.00 $13.00 $45.00 $119.00 $30.00 $89.00 $475.00 $85.00 $390.00 $27.00 $10.00 $17.00 $34.00 $12.00 $22.00 $33.00 $10.00 $23.00 $89.00 $17.00 $71.00 $135.00 $48.00 $87.00 $109.00 $24.00 $85.00 $47.00 $10.00 $36.00 $123.00 Part C, 246 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 70390-26 70390-TC 70450 70450-26 70450-TC 70460 70460-26 70460-TC 70470 70470-26 70470-TC 70480 70480-26 70480-TC 70481 70481-26 70481-TC 70482 70482-26 70482-TC 70486 70486-26 70486-TC 70487 70487-26 70487-TC 70488 70488-26 70488-TC 70490 70490-26 70490-TC 70491 70491-26 70491-TC 70492 70492-26 70492-TC 70496 70496-26 70496-TC 70498 70498-26 70498-TC 70540 70540-26 70540-TC 70542 70542-26 70542-TC NC NC $221.00 $43.00 $176.00 $271.00 $58.00 $211.00 $332.00 $65.00 $264.00 $244.00 $65.00 $176.00 $284.00 $70.00 $211.00 $340.00 $74.00 $264.00 $236.00 $58.00 $176.00 $279.00 $66.00 $211.00 $339.00 $72.00 $264.00 $244.00 $65.00 $176.00 $284.00 $70.00 $211.00 $340.00 $74.00 $264.00 $366.00 $92.00 $270.00 $366.00 $92.00 $270.00 $482.00 $70.00 $413.00 $579.00 $82.00 $495.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $20.00 $85.00 $244.00 $45.00 $199.00 $310.00 $60.00 $250.00 $376.00 $68.00 $309.00 $270.00 $68.00 $202.00 $366.00 $73.00 $293.00 $420.00 $77.00 $344.00 $263.00 $60.00 $203.00 $354.00 $69.00 $285.00 $419.00 $75.00 $344.00 $271.00 $68.00 $203.00 $352.00 $73.00 $278.00 $421.00 $77.00 $344.00 $440.00 $93.00 $347.00 $440.00 $93.00 $347.00 $432.00 $71.00 $360.00 $503.00 $86.00 $417.00 $21.00 $93.00 $264.00 $47.00 $217.00 $335.00 $62.00 $272.00 $407.00 $70.00 $337.00 $290.00 $70.00 $220.00 $394.00 $76.00 $318.00 $453.00 $79.00 $373.00 $283.00 $62.00 $221.00 $382.00 $72.00 $310.00 $452.00 $77.00 $374.00 $291.00 $71.00 $220.00 $379.00 $76.00 $303.00 $453.00 $79.00 $374.00 $473.00 $96.00 $377.00 $474.00 $97.00 $377.00 $464.00 $74.00 $390.00 $541.00 $89.00 $452.00 $22.00 $101.00 $284.00 $49.00 $236.00 $360.00 $65.00 $295.00 $438.00 $73.00 $365.00 $310.00 $73.00 $237.00 $421.00 $79.00 $343.00 $485.00 $82.00 $403.00 $303.00 $64.00 $239.00 $409.00 $75.00 $335.00 $485.00 $80.00 $404.00 $312.00 $74.00 $238.00 $406.00 $79.00 $327.00 $486.00 $82.00 $404.00 $507.00 $100.00 $407.00 $508.00 $101.00 $407.00 $495.00 $77.00 $419.00 $578.00 $92.00 $486.00 $20.00 $85.00 $244.00 $45.00 $199.00 $310.00 $60.00 $250.00 $376.00 $68.00 $309.00 $270.00 $68.00 $202.00 $366.00 $73.00 $293.00 $420.00 $77.00 $344.00 $263.00 $60.00 $203.00 $354.00 $69.00 $285.00 $419.00 $75.00 $344.00 $271.00 $68.00 $203.00 $352.00 $73.00 $278.00 $421.00 $77.00 $344.00 $440.00 $93.00 $347.00 $440.00 $93.00 $347.00 $432.00 $71.00 $360.00 $503.00 $86.00 $417.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $21.00 $93.00 $264.00 $47.00 $217.00 $335.00 $62.00 $272.00 $407.00 $70.00 $337.00 $290.00 $70.00 $220.00 $394.00 $76.00 $318.00 $453.00 $79.00 $373.00 $283.00 $62.00 $221.00 $382.00 $72.00 $310.00 $452.00 $77.00 $374.00 $291.00 $71.00 $220.00 $379.00 $76.00 $303.00 $453.00 $79.00 $374.00 $473.00 $96.00 $377.00 $474.00 $97.00 $377.00 $464.00 $74.00 $390.00 $541.00 $89.00 $452.00 $22.00 $101.00 $284.00 $49.00 $236.00 $360.00 $65.00 $295.00 $438.00 $73.00 $365.00 $310.00 $73.00 $237.00 $421.00 $79.00 $343.00 $485.00 $82.00 $403.00 $303.00 $64.00 $239.00 $409.00 $75.00 $335.00 $485.00 $80.00 $404.00 $312.00 $74.00 $238.00 $406.00 $79.00 $327.00 $486.00 $82.00 $404.00 $507.00 $100.00 $407.00 $508.00 $101.00 $407.00 $495.00 $77.00 $419.00 $578.00 $92.00 $486.00 Part C, 247 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 70543 70543-26 70543-TC 70544 70544-26 70544-TC 70545 70545-26 70545-TC 70546 70546-26 70546-TC 70547 70547-26 70547-TC 70548 70548-26 70548-TC 70549 70549-26 70549-TC 70551 70551-26 70551-TC 70552 70552-26 70552-TC 70553 70553-26 70553-TC 70554 70554-26 70554-TC 70555 70555-26 70555-TC 70557 70557-26 70557-TC 70558 70558-26 70558-TC 70559 70559-26 70559-TC 71010 71010-26 71010-TC 71015 71015-26 $1,029.00 $109.00 $916.00 $481.00 $61.00 $419.00 $481.00 $61.00 $419.00 $914.00 $92.00 $820.00 $481.00 $61.00 $419.00 $481.00 $61.00 $419.00 $914.00 $92.00 $820.00 $497.00 $76.00 $419.00 $596.00 $91.00 $502.00 $1,055.00 $120.00 $931.00 ------------------------------------------------------------------------------------------$27.00 $9.00 $17.00 $30.00 $10.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $667.00 $114.00 $553.00 $427.00 $64.00 $363.00 $483.00 $64.00 $419.00 $645.00 $96.00 $549.00 $426.00 $63.00 $363.00 $483.00 $64.00 $419.00 $645.00 $96.00 $549.00 $441.00 $78.00 $363.00 $515.00 $95.00 $421.00 $685.00 $125.00 $560.00 $741.00 $111.00 $629.00 BR $136.00 BR $418.00 $154.00 $371.00 $480.00 $170.00 $428.00 $621.00 $172.00 $567.00 $27.00 $10.00 $18.00 $32.00 $11.00 $719.00 $118.00 $601.00 $460.00 $66.00 $395.00 $522.00 $66.00 $456.00 $693.00 $99.00 $594.00 $460.00 $65.00 $395.00 $522.00 $66.00 $456.00 $693.00 $99.00 $594.00 $476.00 $81.00 $395.00 $556.00 $98.00 $458.00 $742.00 $129.00 $613.00 $802.00 $115.00 $687.00 BR $141.00 BR $460.00 $159.00 $408.00 $529.00 $176.00 $472.00 $684.00 $178.00 $624.00 $29.00 $10.00 $19.00 $34.00 $11.00 $770.00 $122.00 $648.00 $495.00 $68.00 $426.00 $561.00 $68.00 $493.00 $739.00 $103.00 $636.00 $494.00 $68.00 $426.00 $561.00 $68.00 $492.00 $739.00 $103.00 $636.00 $512.00 $85.00 $427.00 $598.00 $102.00 $497.00 $802.00 $134.00 $668.00 $866.00 $120.00 $746.00 BR $146.00 BR $507.00 $164.00 $450.00 $583.00 $181.00 $519.00 $754.00 $185.00 $688.00 $31.00 $10.00 $21.00 $37.00 $12.00 $667.00 $114.00 $553.00 $427.00 $64.00 $363.00 $483.00 $64.00 $419.00 $645.00 $96.00 $549.00 $426.00 $63.00 $363.00 $483.00 $64.00 $419.00 $645.00 $96.00 $549.00 $441.00 $78.00 $363.00 $515.00 $95.00 $421.00 $685.00 $125.00 $560.00 $741.00 $111.00 $629.00 BR $136.00 BR $418.00 $154.00 $371.00 $480.00 $170.00 $428.00 $621.00 $172.00 $567.00 $27.00 $10.00 $18.00 $32.00 $11.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $719.00 $118.00 $601.00 $460.00 $66.00 $395.00 $522.00 $66.00 $456.00 $693.00 $99.00 $594.00 $460.00 $65.00 $395.00 $522.00 $66.00 $456.00 $693.00 $99.00 $594.00 $476.00 $81.00 $395.00 $556.00 $98.00 $458.00 $742.00 $129.00 $613.00 $802.00 $115.00 $687.00 BR $141.00 BR $460.00 $159.00 $408.00 $529.00 $176.00 $472.00 $684.00 $178.00 $624.00 $29.00 $10.00 $19.00 $34.00 $11.00 $770.00 $122.00 $648.00 $495.00 $68.00 $426.00 $561.00 $68.00 $493.00 $739.00 $103.00 $636.00 $494.00 $68.00 $426.00 $561.00 $68.00 $492.00 $739.00 $103.00 $636.00 $512.00 $85.00 $427.00 $598.00 $102.00 $497.00 $802.00 $134.00 $668.00 $866.00 $120.00 $746.00 BR $146.00 BR $507.00 $164.00 $450.00 $583.00 $181.00 $519.00 $754.00 $185.00 $688.00 $31.00 $10.00 $21.00 $37.00 $12.00 Part C, 248 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 71015-TC 71020 71020-26 71020-TC 71021 71021-26 71021-TC 71022 71022-26 71022-TC 71023 71023-26 71023-TC 71030 71030-26 71030-TC 71034 71034-26 71034-TC 71035 71035-26 71035-TC 71040 71040-26 71040-TC 71060 71060-26 71060-TC 71090 71090-26 71090-TC 71100 71100-26 71100-TC 71101 71101-26 71101-TC 71110 71110-26 71110-TC 71111 71111-26 71111-TC 71120 71120-26 71120-TC 71130 71130-26 71130-TC 71250 $19.00 $35.00 $11.00 $22.00 $41.00 $13.00 $28.00 $44.00 $16.00 $28.00 $49.00 $19.00 $29.00 $45.00 $16.00 $29.00 $79.00 $23.00 $54.00 $56.00 $19.00 $38.00 $34.00 NC NC $108.00 NC NC $92.00 NC NC $33.00 $11.00 $21.00 $38.00 $13.00 $24.00 $43.00 $13.00 $29.00 $49.00 $16.00 $33.00 $35.00 $10.00 $24.00 $38.00 $11.00 $26.00 $282.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $21.00 $36.00 $11.00 $24.00 $44.00 $14.00 $30.00 $49.00 $16.00 $33.00 $66.00 $20.00 $46.00 $50.00 $16.00 $35.00 $96.00 $25.00 $71.00 $35.00 $10.00 $26.00 $101.00 $30.00 $71.00 $146.00 $39.00 $107.00 ------$31.00 BR $36.00 $11.00 $24.00 $43.00 $14.00 $29.00 $46.00 $14.00 $32.00 $57.00 $16.00 $40.00 $37.00 $11.00 $26.00 $41.00 $11.00 $30.00 $265.00 $23.00 $39.00 $12.00 $27.00 $47.00 $15.00 $33.00 $52.00 $16.00 $36.00 $70.00 $21.00 $50.00 $54.00 $16.00 $38.00 $103.00 $26.00 $77.00 $38.00 $10.00 $28.00 $108.00 $31.00 $77.00 $157.00 $40.00 $117.00 ------$32.00 BR $39.00 $12.00 $27.00 $46.00 $15.00 $31.00 $49.00 $15.00 $35.00 $61.00 $17.00 $44.00 $40.00 $11.00 $29.00 $44.00 $12.00 $32.00 $285.00 $25.00 $42.00 $12.00 $29.00 $51.00 $15.00 $36.00 $56.00 $17.00 $39.00 $75.00 $21.00 $54.00 $58.00 $17.00 $41.00 $111.00 $27.00 $83.00 $40.00 $10.00 $30.00 $116.00 $33.00 $83.00 $169.00 $42.00 $127.00 ------$33.00 BR $42.00 $12.00 $29.00 $49.00 $15.00 $34.00 $53.00 $15.00 $38.00 $65.00 $17.00 $48.00 $43.00 $12.00 $32.00 $47.00 $12.00 $35.00 $307.00 $21.00 $36.00 $11.00 $24.00 $44.00 $14.00 $30.00 $49.00 $16.00 $33.00 $66.00 $20.00 $46.00 $50.00 $16.00 $35.00 $96.00 $25.00 $71.00 $35.00 $10.00 $26.00 $101.00 $30.00 $71.00 $146.00 $39.00 $107.00 ------$31.00 BR $36.00 $11.00 $24.00 $43.00 $14.00 $29.00 $46.00 $14.00 $32.00 $57.00 $16.00 $40.00 $37.00 $11.00 $26.00 $41.00 $11.00 $30.00 $265.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $23.00 $39.00 $12.00 $27.00 $47.00 $15.00 $33.00 $52.00 $16.00 $36.00 $70.00 $21.00 $50.00 $54.00 $16.00 $38.00 $103.00 $26.00 $77.00 $38.00 $10.00 $28.00 $108.00 $31.00 $77.00 $157.00 $40.00 $117.00 ------$32.00 BR $39.00 $12.00 $27.00 $46.00 $15.00 $31.00 $49.00 $15.00 $35.00 $61.00 $17.00 $44.00 $40.00 $11.00 $29.00 $44.00 $12.00 $32.00 $285.00 $25.00 $42.00 $12.00 $29.00 $51.00 $15.00 $36.00 $56.00 $17.00 $39.00 $75.00 $21.00 $54.00 $58.00 $17.00 $41.00 $111.00 $27.00 $83.00 $40.00 $10.00 $30.00 $116.00 $33.00 $83.00 $169.00 $42.00 $127.00 ------$33.00 BR $42.00 $12.00 $29.00 $49.00 $15.00 $34.00 $53.00 $15.00 $38.00 $65.00 $17.00 $48.00 $43.00 $12.00 $32.00 $47.00 $12.00 $35.00 $307.00 Part C, 249 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 71250-26 71250-TC 71260 71260-26 71260-TC 71270 71270-26 71270-TC 71275 71275-26 71275-TC 71550 71550-26 71550-TC 71551 71551-26 71551-TC 71552 71552-26 71552-TC 71555 71555-26 71555-TC 72010 72010-26 72010-TC 72020 72020-26 72020-TC 72040 72040-26 72040-TC 72050 72050-26 72050-TC 72052 72052-26 72052-TC 72069 72069-26 72069-TC 72070 72070-26 72070-TC 72072 72072-26 72072-TC 72074 72074-26 72074-TC $59.00 $220.00 $328.00 $63.00 $264.00 $402.00 $70.00 $330.00 $431.00 $100.00 $328.00 $490.00 $75.00 $415.00 $587.00 $88.00 $496.00 $1,029.00 $114.00 $911.00 $514.00 $92.00 $419.00 $62.00 $22.00 $38.00 $22.00 $7.00 $15.00 $34.00 $11.00 $22.00 $49.00 $16.00 $33.00 $61.00 $18.00 $42.00 $40.00 $17.00 $24.00 $36.00 $11.00 $24.00 $39.00 $11.00 $28.00 $45.00 $11.00 $34.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $61.00 $204.00 $359.00 $65.00 $294.00 $418.00 $73.00 $345.00 $448.00 $102.00 $346.00 $438.00 $77.00 $361.00 $509.00 $91.00 $417.00 $670.00 $120.00 $550.00 $516.00 $96.00 $420.00 $71.00 $24.00 $47.00 $26.00 $8.00 $18.00 $39.00 $11.00 $28.00 $56.00 $16.00 $40.00 $70.00 $19.00 $51.00 $36.00 $12.00 $24.00 $38.00 $11.00 $26.00 $42.00 $11.00 $31.00 $50.00 $11.00 $39.00 $63.00 $222.00 $388.00 $67.00 $320.00 $452.00 $76.00 $376.00 $481.00 $106.00 $375.00 $471.00 $80.00 $391.00 $547.00 $95.00 $452.00 $720.00 $124.00 $596.00 $557.00 $100.00 $457.00 $76.00 $24.00 $52.00 $28.00 $8.00 $19.00 $42.00 $12.00 $31.00 $60.00 $16.00 $44.00 $76.00 $20.00 $55.00 $38.00 $12.00 $26.00 $41.00 $12.00 $29.00 $46.00 $12.00 $34.00 $54.00 $12.00 $42.00 $66.00 $241.00 $417.00 $70.00 $347.00 $486.00 $79.00 $408.00 $513.00 $110.00 $403.00 $503.00 $83.00 $420.00 $585.00 $98.00 $486.00 $768.00 $129.00 $639.00 $598.00 $104.00 $494.00 $81.00 $25.00 $56.00 $30.00 $9.00 $21.00 $46.00 $12.00 $33.00 $65.00 $17.00 $48.00 $81.00 $21.00 $60.00 $41.00 $13.00 $28.00 $44.00 $12.00 $32.00 $49.00 $12.00 $37.00 $58.00 $12.00 $46.00 $61.00 $204.00 $359.00 $65.00 $294.00 $418.00 $73.00 $345.00 $448.00 $102.00 $346.00 $438.00 $77.00 $361.00 $509.00 $91.00 $417.00 $670.00 $120.00 $550.00 $516.00 $96.00 $420.00 $71.00 $24.00 $47.00 $26.00 $8.00 $18.00 $39.00 $11.00 $28.00 $56.00 $16.00 $40.00 $70.00 $19.00 $51.00 $36.00 $12.00 $24.00 $38.00 $11.00 $26.00 $42.00 $11.00 $31.00 $50.00 $11.00 $39.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $63.00 $222.00 $388.00 $67.00 $320.00 $452.00 $76.00 $376.00 $481.00 $106.00 $375.00 $471.00 $80.00 $391.00 $547.00 $95.00 $452.00 $720.00 $124.00 $596.00 $557.00 $100.00 $457.00 $76.00 $24.00 $52.00 $28.00 $8.00 $19.00 $42.00 $12.00 $31.00 $60.00 $16.00 $44.00 $76.00 $20.00 $55.00 $38.00 $12.00 $26.00 $41.00 $12.00 $29.00 $46.00 $12.00 $34.00 $54.00 $12.00 $42.00 $66.00 $241.00 $417.00 $70.00 $347.00 $486.00 $79.00 $408.00 $513.00 $110.00 $403.00 $503.00 $83.00 $420.00 $585.00 $98.00 $486.00 $768.00 $129.00 $639.00 $598.00 $104.00 $494.00 $81.00 $25.00 $56.00 $30.00 $9.00 $21.00 $46.00 $12.00 $33.00 $65.00 $17.00 $48.00 $81.00 $21.00 $60.00 $41.00 $13.00 $28.00 $44.00 $12.00 $32.00 $49.00 $12.00 $37.00 $58.00 $12.00 $46.00 Part C, 250 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 72080 72080-26 72080-TC 72090 72090-26 72090-TC 72100 72100-26 72100-TC 72110 72110-26 72110-TC 72114 72114-26 72114-TC 72120 72120-26 72120-TC 72125 72125-26 72125-TC 72126 72126-26 72126-TC 72127 72127-26 72127-TC 72128 72128-26 72128-TC 72129 72129-26 72129-TC 72130 72130-26 72130-TC 72131 72131-26 72131-TC 72132 72132-26 72132-TC 72133 72133-26 72133-TC 72141 72141-26 72141-TC 72142 72142-26 $36.00 $11.00 $24.00 $39.00 $14.00 $24.00 $36.00 $11.00 $24.00 $50.00 $16.00 $34.00 $64.00 $18.00 $44.00 $45.00 $11.00 $33.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $397.00 $65.00 $330.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $397.00 $65.00 $330.00 $282.00 $59.00 $220.00 $328.00 $62.00 $264.00 $391.00 $65.00 $323.00 $503.00 $82.00 $419.00 $604.00 $99.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $39.00 $11.00 $28.00 $49.00 $15.00 $34.00 $41.00 $11.00 $30.00 $58.00 $16.00 $42.00 $75.00 $19.00 $55.00 $52.00 $11.00 $41.00 $265.00 $61.00 $204.00 $358.00 $64.00 $294.00 $413.00 $68.00 $345.00 $265.00 $61.00 $204.00 $358.00 $64.00 $294.00 $413.00 $68.00 $345.00 $265.00 $61.00 $204.00 $358.00 $64.00 $294.00 $413.00 $68.00 $345.00 $449.00 $85.00 $364.00 $523.00 $102.00 $42.00 $12.00 $30.00 $52.00 $15.00 $37.00 $44.00 $12.00 $33.00 $62.00 $16.00 $46.00 $80.00 $20.00 $60.00 $56.00 $12.00 $44.00 $285.00 $63.00 $222.00 $387.00 $66.00 $320.00 $446.00 $70.00 $376.00 $285.00 $63.00 $222.00 $387.00 $67.00 $320.00 $446.00 $70.00 $376.00 $285.00 $63.00 $222.00 $387.00 $66.00 $320.00 $446.00 $70.00 $376.00 $485.00 $88.00 $397.00 $564.00 $106.00 $45.00 $12.00 $33.00 $56.00 $16.00 $40.00 $48.00 $12.00 $36.00 $67.00 $17.00 $50.00 $86.00 $21.00 $65.00 $61.00 $12.00 $48.00 $307.00 $66.00 $241.00 $416.00 $69.00 $347.00 $480.00 $73.00 $408.00 $307.00 $66.00 $241.00 $416.00 $69.00 $347.00 $480.00 $73.00 $408.00 $307.00 $66.00 $241.00 $416.00 $69.00 $347.00 $480.00 $73.00 $408.00 $521.00 $91.00 $430.00 $606.00 $110.00 $39.00 $11.00 $28.00 $49.00 $15.00 $34.00 $41.00 $11.00 $30.00 $58.00 $16.00 $42.00 $75.00 $19.00 $55.00 $52.00 $11.00 $41.00 $265.00 $61.00 $204.00 $358.00 $64.00 $294.00 $413.00 $68.00 $345.00 $265.00 $61.00 $204.00 $358.00 $64.00 $294.00 $413.00 $68.00 $345.00 $265.00 $61.00 $204.00 $358.00 $64.00 $294.00 $413.00 $68.00 $345.00 $449.00 $85.00 $364.00 $523.00 $102.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $42.00 $12.00 $30.00 $52.00 $15.00 $37.00 $44.00 $12.00 $33.00 $62.00 $16.00 $46.00 $80.00 $20.00 $60.00 $56.00 $12.00 $44.00 $285.00 $63.00 $222.00 $387.00 $66.00 $320.00 $446.00 $70.00 $376.00 $285.00 $63.00 $222.00 $387.00 $67.00 $320.00 $446.00 $70.00 $376.00 $285.00 $63.00 $222.00 $387.00 $66.00 $320.00 $446.00 $70.00 $376.00 $485.00 $88.00 $397.00 $564.00 $106.00 $45.00 $12.00 $33.00 $56.00 $16.00 $40.00 $48.00 $12.00 $36.00 $67.00 $17.00 $50.00 $86.00 $21.00 $65.00 $61.00 $12.00 $48.00 $307.00 $66.00 $241.00 $416.00 $69.00 $347.00 $480.00 $73.00 $408.00 $307.00 $66.00 $241.00 $416.00 $69.00 $347.00 $480.00 $73.00 $408.00 $307.00 $66.00 $241.00 $416.00 $69.00 $347.00 $480.00 $73.00 $408.00 $521.00 $91.00 $430.00 $606.00 $110.00 Part C, 251 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 72142-TC 72146 72146-26 72146-TC 72147 72147-26 72147-TC 72148 72148-26 72148-TC 72149 72149-26 72149-TC 72156 72156-26 72156-TC 72157 72157-26 72157-TC 72158 72158-26 72158-TC 72159 72159-26 72159-TC 72170 72170-26 72170-TC 72190 72190-26 72190-TC 72191 72191-26 72191-TC 72192 72192-26 72192-TC 72193 72193-26 72193-TC 72194 72194-26 72194-TC 72195 72195-26 72195-TC 72196 72196-26 72196-TC 72197 $502.00 $549.00 $82.00 $465.00 $603.00 $98.00 $502.00 $543.00 $76.00 $465.00 $597.00 $92.00 $502.00 $1,066.00 $131.00 $931.00 $1,066.00 $131.00 $931.00 $1,056.00 $121.00 $931.00 $563.00 $94.00 $465.00 $29.00 $8.00 $19.00 $35.00 $10.00 $24.00 $413.00 $94.00 $315.00 $278.00 $56.00 $220.00 $317.00 $59.00 $256.00 $380.00 $62.00 $317.00 $491.00 $74.00 $415.00 $526.00 $84.00 $442.00 $1,037.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $421.00 $449.00 $85.00 $364.00 $524.00 $102.00 $422.00 $443.00 $78.00 $364.00 $515.00 $95.00 $421.00 $696.00 $136.00 $560.00 $696.00 $136.00 $561.00 $685.00 $125.00 $560.00 $655.00 $94.00 $560.00 $29.00 $9.00 $20.00 $42.00 $11.00 $31.00 $442.00 $96.00 $346.00 $262.00 $58.00 $204.00 $356.00 $62.00 $295.00 $409.00 $64.00 $345.00 $438.00 $77.00 $361.00 $510.00 $92.00 $418.00 $674.00 $458.00 $485.00 $88.00 $398.00 $566.00 $106.00 $460.00 $479.00 $81.00 $398.00 $556.00 $98.00 $458.00 $753.00 $140.00 $613.00 $754.00 $140.00 $614.00 $742.00 $129.00 $613.00 $708.00 $98.00 $610.00 $31.00 $10.00 $22.00 $45.00 $11.00 $34.00 $475.00 $100.00 $375.00 $282.00 $60.00 $222.00 $385.00 $64.00 $321.00 $442.00 $66.00 $375.00 $471.00 $80.00 $392.00 $549.00 $95.00 $454.00 $726.00 $497.00 $522.00 $91.00 $431.00 $609.00 $110.00 $499.00 $516.00 $85.00 $431.00 $598.00 $102.00 $497.00 $813.00 $146.00 $668.00 $815.00 $146.00 $670.00 $802.00 $134.00 $668.00 $763.00 $102.00 $660.00 $34.00 $10.00 $24.00 $48.00 $12.00 $36.00 $507.00 $104.00 $403.00 $304.00 $62.00 $242.00 $414.00 $66.00 $348.00 $475.00 $69.00 $406.00 $504.00 $83.00 $422.00 $587.00 $99.00 $488.00 $779.00 $421.00 $449.00 $85.00 $364.00 $524.00 $102.00 $422.00 $443.00 $78.00 $364.00 $515.00 $95.00 $421.00 $696.00 $136.00 $560.00 $696.00 $136.00 $561.00 $685.00 $125.00 $560.00 $655.00 $94.00 $560.00 $29.00 $9.00 $20.00 $42.00 $11.00 $31.00 $442.00 $96.00 $346.00 $262.00 $58.00 $204.00 $356.00 $62.00 $295.00 $409.00 $64.00 $345.00 $438.00 $77.00 $361.00 $510.00 $92.00 $418.00 $674.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $458.00 $485.00 $88.00 $398.00 $566.00 $106.00 $460.00 $479.00 $81.00 $398.00 $556.00 $98.00 $458.00 $753.00 $140.00 $613.00 $754.00 $140.00 $614.00 $742.00 $129.00 $613.00 $708.00 $98.00 $610.00 $31.00 $10.00 $22.00 $45.00 $11.00 $34.00 $475.00 $100.00 $375.00 $282.00 $60.00 $222.00 $385.00 $64.00 $321.00 $442.00 $66.00 $375.00 $471.00 $80.00 $392.00 $549.00 $95.00 $454.00 $726.00 $497.00 $522.00 $91.00 $431.00 $609.00 $110.00 $499.00 $516.00 $85.00 $431.00 $598.00 $102.00 $497.00 $813.00 $146.00 $668.00 $815.00 $146.00 $670.00 $802.00 $134.00 $668.00 $763.00 $102.00 $660.00 $34.00 $10.00 $24.00 $48.00 $12.00 $36.00 $507.00 $104.00 $403.00 $304.00 $62.00 $242.00 $414.00 $66.00 $348.00 $475.00 $69.00 $406.00 $504.00 $83.00 $422.00 $587.00 $99.00 $488.00 $779.00 Part C, 252 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 72197-26 72197-TC 72198 72198-26 72198-TC 72200 72200-26 72200-TC 72202 72202-26 72202-TC 72220 72220-26 72220-TC 72240 72240-26 72240-TC 72255 72255-26 72255-TC 72265 72265-26 72265-TC 72270 72270-26 72270-TC 72275 72275-26 72275-TC 72285 72285-26 72285-TC 72291 72291-26 72291-TC 72292 72292-26 72292-TC 72295 72295-26 72295-TC 73000 73000-26 73000-TC 73010 73010-26 73010-TC 73020 73020-26 73020-TC $114.00 $919.00 $517.00 $95.00 $419.00 $29.00 $9.00 $19.00 $33.00 $9.00 $22.00 $30.00 $8.00 $21.00 $132.00 NC NC $129.00 NC NC $132.00 NC NC $176.00 NC NC $112.00 NC NC $101.00 NC NC ------------------------------------$107.00 NC NC $28.00 $8.00 $19.00 $29.00 $8.00 $19.00 $26.00 $7.00 $17.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $119.00 $554.00 $516.00 $96.00 $420.00 $31.00 $9.00 $22.00 $38.00 $10.00 $28.00 $33.00 $9.00 $24.00 $201.00 $48.00 $153.00 $184.00 $47.00 $137.00 $181.00 $44.00 $138.00 $280.00 $70.00 $210.00 $124.00 $38.00 $85.00 $274.00 $60.00 $214.00 BR $73.00 BR BR $75.00 BR $248.00 $45.00 $203.00 $30.00 $8.00 $21.00 $31.00 $9.00 $22.00 $26.00 $8.00 $18.00 $124.00 $603.00 $556.00 $99.00 $457.00 $34.00 $10.00 $24.00 $41.00 $10.00 $31.00 $36.00 $10.00 $26.00 $217.00 $49.00 $168.00 $199.00 $49.00 $151.00 $196.00 $45.00 $151.00 $303.00 $73.00 $230.00 $134.00 $40.00 $95.00 $298.00 $62.00 $236.00 BR $76.00 BR BR $77.00 BR $270.00 $46.00 $224.00 $32.00 $9.00 $23.00 $33.00 $10.00 $24.00 $28.00 $8.00 $20.00 $128.00 $650.00 $597.00 $103.00 $494.00 $36.00 $10.00 $26.00 $44.00 $11.00 $33.00 $39.00 $10.00 $29.00 $235.00 $51.00 $184.00 $215.00 $50.00 $165.00 $212.00 $47.00 $165.00 $327.00 $76.00 $251.00 $147.00 $41.00 $106.00 $325.00 $65.00 $260.00 BR $80.00 BR BR $81.00 BR $296.00 $49.00 $247.00 $34.00 $9.00 $25.00 $35.00 $10.00 $25.00 $30.00 $9.00 $21.00 $119.00 $554.00 $516.00 $96.00 $420.00 $31.00 $9.00 $22.00 $38.00 $10.00 $28.00 $33.00 $9.00 $24.00 $201.00 $48.00 $153.00 $184.00 $47.00 $137.00 $181.00 $44.00 $138.00 $280.00 $70.00 $210.00 $124.00 $38.00 $85.00 $274.00 $60.00 $214.00 BR $73.00 BR BR $75.00 BR $248.00 $45.00 $203.00 $30.00 $8.00 $21.00 $31.00 $9.00 $22.00 $26.00 $8.00 $18.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $124.00 $603.00 $556.00 $99.00 $457.00 $34.00 $10.00 $24.00 $41.00 $10.00 $31.00 $36.00 $10.00 $26.00 $217.00 $49.00 $168.00 $199.00 $49.00 $151.00 $196.00 $45.00 $151.00 $303.00 $73.00 $230.00 $134.00 $40.00 $95.00 $298.00 $62.00 $236.00 BR $76.00 BR BR $77.00 BR $270.00 $46.00 $224.00 $32.00 $9.00 $23.00 $33.00 $10.00 $24.00 $28.00 $8.00 $20.00 $128.00 $650.00 $597.00 $103.00 $494.00 $36.00 $10.00 $26.00 $44.00 $11.00 $33.00 $39.00 $10.00 $29.00 $235.00 $51.00 $184.00 $215.00 $50.00 $165.00 $212.00 $47.00 $165.00 $327.00 $76.00 $251.00 $147.00 $41.00 $106.00 $325.00 $65.00 $260.00 BR $80.00 BR BR $81.00 BR $296.00 $49.00 $247.00 $34.00 $9.00 $25.00 $35.00 $10.00 $25.00 $30.00 $9.00 $21.00 Part C, 253 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 73030 73030-26 73030-TC 73040 73040-26 73040-TC 73050 73050-26 73050-TC 73060 73060-26 73060-TC 73070 73070-26 73070-TC 73080 73080-26 73080-TC 73085 73085-26 73085-TC 73090 73090-26 73090-TC 73100 73100-26 73100-TC 73110 73110-26 73110-TC 73115 73115-26 73115-TC 73120 73120-26 73120-TC 73130 73130-26 73130-TC 73140 73140-26 73140-TC 73200 73200-26 73200-TC 73201 73201-26 73201-TC 73202 73202-26 $31.00 $9.00 $21.00 $68.00 NC NC $35.00 $10.00 $24.00 $30.00 $8.00 $21.00 $27.00 $7.00 $19.00 $30.00 $8.00 $21.00 $74.00 NC NC $28.00 $8.00 $19.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $54.00 NC NC $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $22.00 $7.00 $15.00 $242.00 $56.00 $185.00 $282.00 $59.00 $220.00 $342.00 $63.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $33.00 $10.00 $24.00 $118.00 $29.00 $89.00 $39.00 $11.00 $28.00 $33.00 $9.00 $24.00 $29.00 $8.00 $21.00 $36.00 $9.00 $27.00 $110.00 $29.00 $81.00 $30.00 $8.00 $21.00 $30.00 $8.00 $22.00 $35.00 $9.00 $26.00 $108.00 $28.00 $79.00 $29.00 $8.00 $21.00 $33.00 $9.00 $24.00 $29.00 $7.00 $22.00 $261.00 $58.00 $203.00 $344.00 $61.00 $283.00 $408.00 $64.00 $36.00 $10.00 $26.00 $127.00 $30.00 $97.00 $42.00 $11.00 $31.00 $36.00 $10.00 $26.00 $31.00 $8.00 $23.00 $39.00 $10.00 $30.00 $119.00 $30.00 $89.00 $32.00 $9.00 $23.00 $32.00 $9.00 $24.00 $37.00 $10.00 $28.00 $116.00 $29.00 $86.00 $31.00 $9.00 $23.00 $35.00 $10.00 $26.00 $31.00 $7.00 $24.00 $281.00 $60.00 $221.00 $371.00 $63.00 $308.00 $440.00 $66.00 $39.00 $10.00 $28.00 $137.00 $31.00 $106.00 $46.00 $12.00 $34.00 $39.00 $10.00 $28.00 $34.00 $9.00 $25.00 $43.00 $10.00 $32.00 $128.00 $31.00 $97.00 $34.00 $9.00 $25.00 $35.00 $9.00 $25.00 $40.00 $10.00 $30.00 $124.00 $30.00 $94.00 $34.00 $9.00 $24.00 $38.00 $10.00 $28.00 $33.00 $8.00 $26.00 $301.00 $62.00 $239.00 $399.00 $66.00 $333.00 $473.00 $69.00 $33.00 $10.00 $24.00 $118.00 $29.00 $89.00 $39.00 $11.00 $28.00 $33.00 $9.00 $24.00 $29.00 $8.00 $21.00 $36.00 $9.00 $27.00 $110.00 $29.00 $81.00 $30.00 $8.00 $21.00 $30.00 $8.00 $22.00 $35.00 $9.00 $26.00 $108.00 $28.00 $79.00 $29.00 $8.00 $21.00 $33.00 $9.00 $24.00 $29.00 $7.00 $22.00 $261.00 $58.00 $203.00 $344.00 $61.00 $283.00 $408.00 $64.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $36.00 $10.00 $26.00 $127.00 $30.00 $97.00 $42.00 $11.00 $31.00 $36.00 $10.00 $26.00 $31.00 $8.00 $23.00 $39.00 $10.00 $30.00 $119.00 $30.00 $89.00 $32.00 $9.00 $23.00 $32.00 $9.00 $24.00 $37.00 $10.00 $28.00 $116.00 $29.00 $86.00 $31.00 $9.00 $23.00 $35.00 $10.00 $26.00 $31.00 $7.00 $24.00 $281.00 $60.00 $221.00 $371.00 $63.00 $308.00 $440.00 $66.00 $39.00 $10.00 $28.00 $137.00 $31.00 $106.00 $46.00 $12.00 $34.00 $39.00 $10.00 $28.00 $34.00 $9.00 $25.00 $43.00 $10.00 $32.00 $128.00 $31.00 $97.00 $34.00 $9.00 $25.00 $35.00 $9.00 $25.00 $40.00 $10.00 $30.00 $124.00 $30.00 $94.00 $34.00 $9.00 $24.00 $38.00 $10.00 $28.00 $33.00 $8.00 $26.00 $301.00 $62.00 $239.00 $399.00 $66.00 $333.00 $473.00 $69.00 Part C, 254 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 73202-TC 73206 73206-26 73206-TC 73218 73218-26 73218-TC 73219 73219-26 73219-TC 73220 73220-26 73220-TC 73221 73221-26 73221-TC 73222 73222-26 73222-TC 73223 73223-26 73223-TC 73225 73225-26 73225-TC 73500 73500-26 73500-TC 73510 73510-26 73510-TC 73520 73520-26 73520-TC 73525 73525-26 73525-TC 73530 73530-26 73530-TC 73542 73542-26 73542-TC 73550 73550-26 73550-TC 73560 73560-26 73560-TC 73562 $277.00 $375.00 $94.00 $277.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $520.00 $78.00 $442.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00 $513.00 $92.00 $419.00 $27.00 $8.00 $17.00 $32.00 $10.00 $21.00 $38.00 $12.00 $24.00 $84.00 NC NC $34.00 $14.00 $19.00 $108.00 NC NC $30.00 $8.00 $21.00 $29.00 $8.00 $19.00 $31.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $344.00 $443.00 $96.00 $346.00 $432.00 $71.00 $360.00 $503.00 $86.00 $417.00 $667.00 $114.00 $553.00 $432.00 $71.00 $361.00 $503.00 $86.00 $418.00 $667.00 $114.00 $554.00 $623.00 $91.00 $533.00 $28.00 $9.00 $19.00 $39.00 $11.00 $28.00 $43.00 $14.00 $29.00 $110.00 $29.00 $81.00 ------$15.00 ------$98.00 $30.00 $68.00 $33.00 $9.00 $23.00 $31.00 $9.00 $22.00 $37.00 $374.00 $476.00 $100.00 $376.00 $464.00 $74.00 $390.00 $541.00 $89.00 $452.00 $719.00 $118.00 $601.00 $464.00 $74.00 $391.00 $542.00 $89.00 $453.00 $719.00 $118.00 $601.00 $674.00 $94.00 $580.00 $30.00 $10.00 $21.00 $42.00 $11.00 $30.00 $46.00 $14.00 $32.00 $119.00 $30.00 $89.00 ------$16.00 ------$106.00 $31.00 $75.00 $35.00 $10.00 $26.00 $33.00 $10.00 $24.00 $39.00 $404.00 $508.00 $104.00 $405.00 $495.00 $77.00 $419.00 $578.00 $92.00 $486.00 $771.00 $123.00 $648.00 $496.00 $77.00 $419.00 $579.00 $92.00 $487.00 $771.00 $122.00 $648.00 $726.00 $99.00 $627.00 $32.00 $10.00 $22.00 $45.00 $12.00 $33.00 $49.00 $15.00 $35.00 $128.00 $31.00 $97.00 ------$16.00 ------$114.00 $32.00 $82.00 $38.00 $10.00 $28.00 $35.00 $10.00 $25.00 $43.00 $344.00 $443.00 $96.00 $346.00 $432.00 $71.00 $360.00 $503.00 $86.00 $417.00 $667.00 $114.00 $553.00 $432.00 $71.00 $361.00 $503.00 $86.00 $418.00 $667.00 $114.00 $554.00 $623.00 $91.00 $533.00 $28.00 $9.00 $19.00 $39.00 $11.00 $28.00 $43.00 $14.00 $29.00 $110.00 $29.00 $81.00 ------$15.00 ------$98.00 $30.00 $68.00 $33.00 $9.00 $23.00 $31.00 $9.00 $22.00 $37.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $374.00 $476.00 $100.00 $376.00 $464.00 $74.00 $390.00 $541.00 $89.00 $452.00 $719.00 $118.00 $601.00 $464.00 $74.00 $391.00 $542.00 $89.00 $453.00 $719.00 $118.00 $601.00 $674.00 $94.00 $580.00 $30.00 $10.00 $21.00 $42.00 $11.00 $30.00 $46.00 $14.00 $32.00 $119.00 $30.00 $89.00 ------$16.00 ------$106.00 $31.00 $75.00 $35.00 $10.00 $26.00 $33.00 $10.00 $24.00 $39.00 $404.00 $508.00 $104.00 $405.00 $495.00 $77.00 $419.00 $578.00 $92.00 $486.00 $771.00 $123.00 $648.00 $496.00 $77.00 $419.00 $579.00 $92.00 $487.00 $771.00 $122.00 $648.00 $726.00 $99.00 $627.00 $32.00 $10.00 $22.00 $45.00 $12.00 $33.00 $49.00 $15.00 $35.00 $128.00 $31.00 $97.00 ------$16.00 ------$114.00 $32.00 $82.00 $38.00 $10.00 $28.00 $35.00 $10.00 $25.00 $43.00 Part C, 255 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 73562-26 73562-TC 73564 73564-26 73564-TC 73565 73565-26 73565-TC 73580 73580-26 73580-TC 73590 73590-26 73590-TC 73600 73600-26 73600-TC 73610 73610-26 73610-TC 73615 73615-26 73615-TC 73620 73620-26 73620-TC 73630 73630-26 73630-TC 73650 73650-26 73650-TC 73660 73660-26 73660-TC 73700 73700-26 73700-TC 73701 73701-26 73701-TC 73702 73702-26 73702-TC 73706 73706-26 73706-TC 73718 73718-26 73718-TC $9.00 $21.00 $35.00 $11.00 $22.00 $28.00 $8.00 $18.00 $84.00 NC NC $29.00 $8.00 $19.00 $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $72.00 NC NC $27.00 $8.00 $18.00 $29.00 $8.00 $19.00 $26.00 $8.00 $17.00 $22.00 $7.00 $15.00 $242.00 $56.00 $185.00 $282.00 $61.00 $220.00 $341.00 $62.00 $277.00 $379.00 $98.00 $277.00 $482.00 $68.00 $413.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $10.00 $27.00 $41.00 $11.00 $30.00 $32.00 $9.00 $22.00 $136.00 $29.00 $107.00 $30.00 $9.00 $21.00 $29.00 $8.00 $21.00 $33.00 $9.00 $24.00 $113.00 $29.00 $84.00 $29.00 $8.00 $20.00 $33.00 $9.00 $24.00 $29.00 $8.00 $20.00 $28.00 $7.00 $21.00 $261.00 $58.00 $203.00 $345.00 $62.00 $284.00 $408.00 $64.00 $344.00 $447.00 $101.00 $346.00 $432.00 $71.00 $360.00 $10.00 $29.00 $44.00 $12.00 $33.00 $34.00 $10.00 $24.00 $147.00 $30.00 $117.00 $32.00 $10.00 $23.00 $31.00 $9.00 $23.00 $35.00 $10.00 $26.00 $122.00 $30.00 $92.00 $31.00 $9.00 $22.00 $35.00 $10.00 $26.00 $31.00 $9.00 $22.00 $30.00 $7.00 $23.00 $281.00 $60.00 $221.00 $373.00 $64.00 $309.00 $441.00 $67.00 $374.00 $480.00 $105.00 $375.00 $464.00 $74.00 $390.00 $10.00 $32.00 $48.00 $12.00 $36.00 $36.00 $10.00 $26.00 $158.00 $31.00 $127.00 $35.00 $10.00 $24.00 $34.00 $9.00 $24.00 $38.00 $10.00 $28.00 $132.00 $31.00 $101.00 $33.00 $9.00 $24.00 $38.00 $10.00 $28.00 $33.00 $9.00 $24.00 $32.00 $8.00 $25.00 $301.00 $62.00 $239.00 $400.00 $66.00 $334.00 $473.00 $69.00 $404.00 $512.00 $109.00 $403.00 $495.00 $77.00 $419.00 $10.00 $27.00 $41.00 $11.00 $30.00 $32.00 $9.00 $22.00 $136.00 $29.00 $107.00 $30.00 $9.00 $21.00 $29.00 $8.00 $21.00 $33.00 $9.00 $24.00 $113.00 $29.00 $84.00 $29.00 $8.00 $20.00 $33.00 $9.00 $24.00 $29.00 $8.00 $20.00 $28.00 $7.00 $21.00 $261.00 $58.00 $203.00 $345.00 $62.00 $284.00 $408.00 $64.00 $344.00 $447.00 $101.00 $346.00 $432.00 $71.00 $360.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $10.00 $29.00 $44.00 $12.00 $33.00 $34.00 $10.00 $24.00 $147.00 $30.00 $117.00 $32.00 $10.00 $23.00 $31.00 $9.00 $23.00 $35.00 $10.00 $26.00 $122.00 $30.00 $92.00 $31.00 $9.00 $22.00 $35.00 $10.00 $26.00 $31.00 $9.00 $22.00 $30.00 $7.00 $23.00 $281.00 $60.00 $221.00 $373.00 $64.00 $309.00 $441.00 $67.00 $374.00 $480.00 $105.00 $375.00 $464.00 $74.00 $390.00 $10.00 $32.00 $48.00 $12.00 $36.00 $36.00 $10.00 $26.00 $158.00 $31.00 $127.00 $35.00 $10.00 $24.00 $34.00 $9.00 $24.00 $38.00 $10.00 $28.00 $132.00 $31.00 $101.00 $33.00 $9.00 $24.00 $38.00 $10.00 $28.00 $33.00 $9.00 $24.00 $32.00 $8.00 $25.00 $301.00 $62.00 $239.00 $400.00 $66.00 $334.00 $473.00 $69.00 $404.00 $512.00 $109.00 $403.00 $495.00 $77.00 $419.00 Part C, 256 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 73719 73719-26 73719-TC 73720 73720-26 73720-TC 73721 73721-26 73721-TC 73722 73722-26 73722-TC 73723 73723-26 73723-TC 73725 73725-26 73725-TC 74000 74000-26 74000-TC 74010 74010-26 74010-TC 74020 74020-26 74020-TC 74022 74022-26 74022-TC 74150 74150-26 74150-TC 74160 74160-26 74160-TC 74170 74170-26 74170-TC 74175 74175-26 74175-TC 74181 74181-26 74181-TC 74182 74182-26 74182-TC 74183 74183-26 $579.00 $82.00 $495.00 $520.00 $78.00 $442.00 $482.00 $68.00 $413.00 $579.00 $82.00 $495.00 $1,029.00 $109.00 $916.00 $515.00 $92.00 $419.00 $29.00 $9.00 $19.00 $33.00 $11.00 $21.00 $37.00 $13.00 $22.00 $44.00 $16.00 $28.00 $274.00 $60.00 $211.00 $322.00 $65.00 $256.00 $390.00 $71.00 $317.00 $418.00 $98.00 $315.00 $498.00 $85.00 $415.00 $587.00 $88.00 $496.00 $1,037.00 $114.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $503.00 $86.00 $417.00 $667.00 $114.00 $553.00 $432.00 $71.00 $361.00 $503.00 $86.00 $418.00 $668.00 $114.00 $554.00 $516.00 $96.00 $420.00 $29.00 $10.00 $19.00 $40.00 $12.00 $28.00 $43.00 $14.00 $29.00 $51.00 $17.00 $35.00 $266.00 $63.00 $203.00 $362.00 $68.00 $294.00 $418.00 $74.00 $344.00 $446.00 $100.00 $346.00 $439.00 $77.00 $362.00 $509.00 $92.00 $418.00 $674.00 $119.00 $541.00 $89.00 $452.00 $719.00 $118.00 $601.00 $464.00 $74.00 $391.00 $542.00 $89.00 $453.00 $720.00 $118.00 $601.00 $557.00 $100.00 $457.00 $31.00 $10.00 $21.00 $43.00 $13.00 $30.00 $46.00 $15.00 $31.00 $55.00 $17.00 $38.00 $287.00 $65.00 $222.00 $390.00 $70.00 $320.00 $450.00 $77.00 $374.00 $479.00 $104.00 $375.00 $473.00 $80.00 $393.00 $548.00 $95.00 $453.00 $726.00 $124.00 $578.00 $92.00 $486.00 $770.00 $122.00 $648.00 $496.00 $77.00 $419.00 $579.00 $92.00 $487.00 $771.00 $123.00 $648.00 $598.00 $104.00 $494.00 $33.00 $10.00 $23.00 $46.00 $13.00 $33.00 $49.00 $15.00 $34.00 $59.00 $18.00 $41.00 $308.00 $68.00 $240.00 $419.00 $73.00 $346.00 $483.00 $80.00 $403.00 $510.00 $108.00 $403.00 $507.00 $83.00 $424.00 $586.00 $99.00 $487.00 $779.00 $128.00 $503.00 $86.00 $417.00 $667.00 $114.00 $553.00 $432.00 $71.00 $361.00 $503.00 $86.00 $418.00 $668.00 $114.00 $554.00 $516.00 $96.00 $420.00 $29.00 $10.00 $19.00 $40.00 $12.00 $28.00 $43.00 $14.00 $29.00 $51.00 $17.00 $35.00 $266.00 $63.00 $203.00 $362.00 $68.00 $294.00 $418.00 $74.00 $344.00 $446.00 $100.00 $346.00 $439.00 $77.00 $362.00 $509.00 $92.00 $418.00 $674.00 $119.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $541.00 $89.00 $452.00 $719.00 $118.00 $601.00 $464.00 $74.00 $391.00 $542.00 $89.00 $453.00 $720.00 $118.00 $601.00 $557.00 $100.00 $457.00 $31.00 $10.00 $21.00 $43.00 $13.00 $30.00 $46.00 $15.00 $31.00 $55.00 $17.00 $38.00 $287.00 $65.00 $222.00 $390.00 $70.00 $320.00 $450.00 $77.00 $374.00 $479.00 $104.00 $375.00 $473.00 $80.00 $393.00 $548.00 $95.00 $453.00 $726.00 $124.00 $578.00 $92.00 $486.00 $770.00 $122.00 $648.00 $496.00 $77.00 $419.00 $579.00 $92.00 $487.00 $771.00 $123.00 $648.00 $598.00 $104.00 $494.00 $33.00 $10.00 $23.00 $46.00 $13.00 $33.00 $49.00 $15.00 $34.00 $59.00 $18.00 $41.00 $308.00 $68.00 $240.00 $419.00 $73.00 $346.00 $483.00 $80.00 $403.00 $510.00 $108.00 $403.00 $507.00 $83.00 $424.00 $586.00 $99.00 $487.00 $779.00 $128.00 Part C, 257 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 74183-TC 74185 74185-26 74185-TC 74190 74190-26 74190-TC 74210 74210-26 74210-TC 74220 74220-26 74220-TC 74230 74230-26 74230-TC 74235 74235-26 74235-TC 74240 74240-26 74240-TC 74241 74241-26 74241-TC 74245 74245-26 74245-TC 74246 74246-26 74246-TC 74247 74247-26 74247-TC 74249 74249-26 74249-TC 74250 74250-26 74250-TC 74251 74251-26 74251-TC 74260 74260-26 74260-TC 74270 74270-26 74270-TC 74280 $919.00 $514.00 $92.00 $419.00 $73.00 NC NC $63.00 $18.00 $44.00 $68.00 $23.00 $44.00 $77.00 $27.00 $48.00 $160.00 NC NC $91.00 $35.00 $55.00 $91.00 $35.00 $56.00 $137.00 $46.00 $89.00 $97.00 $35.00 $61.00 $99.00 $35.00 $63.00 $144.00 $46.00 $96.00 $73.00 $23.00 $48.00 $85.00 $34.00 $48.00 $82.00 $25.00 $56.00 $100.00 $35.00 $64.00 $136.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $554.00 $516.00 $96.00 $420.00 $371.00 $25.00 $363.00 $79.00 $19.00 $59.00 $88.00 $25.00 $63.00 $93.00 $28.00 $65.00 ------$64.00 BR $111.00 $37.00 $74.00 $116.00 $36.00 $80.00 $174.00 $48.00 $126.00 $126.00 $37.00 $89.00 $130.00 $37.00 $93.00 $186.00 $48.00 $138.00 $100.00 $25.00 $75.00 $184.00 $37.00 $147.00 $118.00 $26.00 $92.00 $130.00 $37.00 $93.00 $194.00 $603.00 $556.00 $99.00 $457.00 $405.00 $26.00 $397.00 $85.00 $20.00 $65.00 $94.00 $26.00 $69.00 $99.00 $29.00 $71.00 ------$66.00 BR $119.00 $38.00 $81.00 $125.00 $38.00 $87.00 $187.00 $50.00 $137.00 $135.00 $38.00 $97.00 $139.00 $38.00 $101.00 $200.00 $50.00 $150.00 $107.00 $26.00 $82.00 $197.00 $38.00 $158.00 $126.00 $27.00 $99.00 $140.00 $38.00 $102.00 $208.00 $650.00 $597.00 $103.00 $494.00 $441.00 $27.00 $431.00 $91.00 $21.00 $70.00 $101.00 $27.00 $74.00 $106.00 $30.00 $76.00 ------$69.00 BR $127.00 $40.00 $87.00 $133.00 $39.00 $94.00 $200.00 $52.00 $148.00 $144.00 $40.00 $105.00 $149.00 $40.00 $109.00 $214.00 $52.00 $162.00 $115.00 $27.00 $88.00 $208.00 $40.00 $168.00 $134.00 $28.00 $106.00 $149.00 $40.00 $110.00 $222.00 $554.00 $516.00 $96.00 $420.00 $371.00 $25.00 $363.00 $79.00 $19.00 $59.00 $88.00 $25.00 $63.00 $93.00 $28.00 $65.00 ------$64.00 BR $111.00 $37.00 $74.00 $116.00 $36.00 $80.00 $174.00 $48.00 $126.00 $126.00 $37.00 $89.00 $130.00 $37.00 $93.00 $186.00 $48.00 $138.00 $100.00 $25.00 $75.00 $184.00 $37.00 $147.00 $118.00 $26.00 $92.00 $130.00 $37.00 $93.00 $194.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $603.00 $556.00 $99.00 $457.00 $405.00 $26.00 $397.00 $85.00 $20.00 $65.00 $94.00 $26.00 $69.00 $99.00 $29.00 $71.00 ------$66.00 BR $119.00 $38.00 $81.00 $125.00 $38.00 $87.00 $187.00 $50.00 $137.00 $135.00 $38.00 $97.00 $139.00 $38.00 $101.00 $200.00 $50.00 $150.00 $107.00 $26.00 $82.00 $197.00 $38.00 $158.00 $126.00 $27.00 $99.00 $140.00 $38.00 $102.00 $208.00 $650.00 $597.00 $103.00 $494.00 $441.00 $27.00 $431.00 $91.00 $21.00 $70.00 $101.00 $27.00 $74.00 $106.00 $30.00 $76.00 ------$69.00 BR $127.00 $40.00 $87.00 $133.00 $39.00 $94.00 $200.00 $52.00 $148.00 $144.00 $40.00 $105.00 $149.00 $40.00 $109.00 $214.00 $52.00 $162.00 $115.00 $27.00 $88.00 $208.00 $40.00 $168.00 $134.00 $28.00 $106.00 $149.00 $40.00 $110.00 $222.00 Part C, 258 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 74280-26 74280-TC 74283 74283-26 74283-TC 74290 74290-26 74290-TC 74291 74291-26 74291-TC 74300 74300-26 74300-TC 74301 74301-26 74301-TC 74305 74305-26 74305-TC 74320 74320-26 74320-TC 74327 74327-26 74327-TC 74328 74328-26 74328-TC 74329 74329-26 74329-TC 74330 74330-26 74330-TC 74340 74340-26 74340-TC 74355 74355-26 74355-TC 74360 74360-26 74360-TC 74363 74363-26 74363-TC 74400 74400-26 74400-TC $50.00 $84.00 $201.00 $103.00 $95.00 $44.00 $16.00 $28.00 $26.00 $10.00 $15.00 $31.00 NC NC BR NC NC $51.00 NC NC $145.00 NC NC $103.00 NC NC $155.00 NC NC $155.00 NC NC $165.00 NC NC $121.00 NC NC $137.00 NC NC $145.00 NC NC $274.00 NC NC $89.00 $24.00 $63.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $52.00 $142.00 $200.00 $106.00 $93.00 $63.00 $17.00 $46.00 $49.00 $11.00 $39.00 ------$19.00 BR ------$11.00 BR ------$23.00 BR $139.00 $29.00 $110.00 $132.00 $37.00 $95.00 ------$38.00 BR ------$38.00 BR ------$48.00 BR ------$29.00 BR ------$40.00 BR ------$30.00 BR ------$47.00 BR $113.00 $26.00 $87.00 $54.00 $155.00 $212.00 $110.00 $102.00 $68.00 $17.00 $50.00 $53.00 $11.00 $42.00 ------$20.00 BR ------$11.00 BR ------$23.00 BR $151.00 $30.00 $121.00 $142.00 $39.00 $103.00 ------$39.00 BR ------$39.00 BR ------$49.00 BR ------$30.00 BR ------$41.00 BR ------$31.00 BR ------$48.00 BR $122.00 $27.00 $95.00 $56.00 $166.00 $225.00 $114.00 $110.00 $72.00 $18.00 $54.00 $56.00 $12.00 $44.00 ------$21.00 BR ------$12.00 BR ------$24.00 BR $163.00 $31.00 $132.00 $152.00 $40.00 $112.00 ------$40.00 BR ------$40.00 BR ------$51.00 BR ------$31.00 BR ------$43.00 BR ------$32.00 BR ------$50.00 BR $131.00 $28.00 $103.00 $52.00 $142.00 $200.00 $106.00 $93.00 $63.00 $17.00 $46.00 $49.00 $11.00 $39.00 ------$19.00 BR ------$11.00 BR ------$23.00 BR $139.00 $29.00 $110.00 $132.00 $37.00 $95.00 ------$38.00 BR ------$38.00 BR ------$48.00 BR ------$29.00 BR ------$40.00 BR ------$30.00 BR ------$47.00 BR $113.00 $26.00 $87.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $54.00 $155.00 $212.00 $110.00 $102.00 $68.00 $17.00 $50.00 $53.00 $11.00 $42.00 ------$20.00 BR ------$11.00 BR ------$23.00 BR $151.00 $30.00 $121.00 $142.00 $39.00 $103.00 ------$39.00 BR ------$39.00 BR ------$49.00 BR ------$30.00 BR ------$41.00 BR ------$31.00 BR ------$48.00 BR $122.00 $27.00 $95.00 $56.00 $166.00 $225.00 $114.00 $110.00 $72.00 $18.00 $54.00 $56.00 $12.00 $44.00 ------$21.00 BR ------$12.00 BR ------$24.00 BR $163.00 $31.00 $132.00 $152.00 $40.00 $112.00 ------$40.00 BR ------$40.00 BR ------$51.00 BR ------$31.00 BR ------$43.00 BR ------$32.00 BR ------$50.00 BR $131.00 $28.00 $103.00 Part C, 259 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 74410 74410-26 74410-TC 74415 74415-26 74415-TC 74420 74420-26 74420-TC 74425 74425-26 74425-TC 74430 74430-26 74430-TC 74440 74440-26 74440-TC 74445 74445-26 74445-TC 74450 74450-26 74450-TC 74455 74455-26 74455-TC 74470 74470-26 74470-TC 74475 74475-26 74475-TC 74480 74480-26 74480-TC 74485 74485-26 74485-TC 74710 74710-26 74710-TC 74740 74740-26 74740-TC 74742 74742-26 74742-TC 74775 74775-26 $98.00 $24.00 $72.00 $105.00 $24.00 $79.00 $117.00 $18.00 $97.00 $68.00 NC NC $48.00 NC NC $62.00 NC NC $101.00 NC NC $60.00 NC NC $75.00 NC NC $74.00 NC NC $181.00 NC NC $181.00 NC NC $146.00 NC NC $57.00 $17.00 $39.00 $68.00 NC NC $150.00 NC NC $88.00 $32.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $120.00 $26.00 $94.00 $136.00 $26.00 $110.00 $184.00 $20.00 $177.00 $183.00 $20.00 $177.00 $78.00 $17.00 $61.00 $85.00 $20.00 $65.00 $198.00 $62.00 $177.00 $184.00 $18.00 $178.00 $96.00 $18.00 $78.00 $190.00 $28.00 $182.00 $160.00 $29.00 $131.00 $160.00 $29.00 $131.00 $143.00 $29.00 $113.00 $53.00 $18.00 $35.00 $82.00 $20.00 $62.00 ------$32.00 BR $190.00 $33.00 $130.00 $27.00 $103.00 $146.00 $27.00 $120.00 $201.00 $21.00 $194.00 $201.00 $21.00 $193.00 $84.00 $18.00 $66.00 $91.00 $21.00 $70.00 $217.00 $65.00 $194.00 $201.00 $19.00 $194.00 $104.00 $19.00 $85.00 $209.00 $29.00 $199.00 $174.00 $30.00 $144.00 $174.00 $30.00 $144.00 $154.00 $31.00 $124.00 $57.00 $19.00 $38.00 $89.00 $21.00 $68.00 ------$34.00 BR $209.00 $34.00 $139.00 $28.00 $111.00 $157.00 $28.00 $129.00 $219.00 $21.00 $211.00 $218.00 $21.00 $210.00 $90.00 $19.00 $71.00 $97.00 $22.00 $76.00 $237.00 $68.00 $211.00 $219.00 $20.00 $212.00 $112.00 $20.00 $92.00 $228.00 $30.00 $217.00 $189.00 $31.00 $158.00 $189.00 $31.00 $158.00 $167.00 $32.00 $135.00 $62.00 $20.00 $42.00 $95.00 $22.00 $73.00 ------$35.00 BR $231.00 $36.00 $120.00 $26.00 $94.00 $136.00 $26.00 $110.00 $184.00 $20.00 $177.00 $183.00 $20.00 $177.00 $78.00 $17.00 $61.00 $85.00 $20.00 $65.00 $198.00 $62.00 $177.00 $184.00 $18.00 $178.00 $96.00 $18.00 $78.00 $190.00 $28.00 $182.00 $160.00 $29.00 $131.00 $160.00 $29.00 $131.00 $143.00 $29.00 $113.00 $53.00 $18.00 $35.00 $82.00 $20.00 $62.00 ------$32.00 BR $190.00 $33.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $130.00 $27.00 $103.00 $146.00 $27.00 $120.00 $201.00 $21.00 $194.00 $201.00 $21.00 $193.00 $84.00 $18.00 $66.00 $91.00 $21.00 $70.00 $217.00 $65.00 $194.00 $201.00 $19.00 $194.00 $104.00 $19.00 $85.00 $209.00 $29.00 $199.00 $174.00 $30.00 $144.00 $174.00 $30.00 $144.00 $154.00 $31.00 $124.00 $57.00 $19.00 $38.00 $89.00 $21.00 $68.00 ------$34.00 BR $209.00 $34.00 $139.00 $28.00 $111.00 $157.00 $28.00 $129.00 $219.00 $21.00 $211.00 $218.00 $21.00 $210.00 $90.00 $19.00 $71.00 $97.00 $22.00 $76.00 $237.00 $68.00 $211.00 $219.00 $20.00 $212.00 $112.00 $20.00 $92.00 $228.00 $30.00 $217.00 $189.00 $31.00 $158.00 $189.00 $31.00 $158.00 $167.00 $32.00 $135.00 $62.00 $20.00 $42.00 $95.00 $22.00 $73.00 ------$35.00 BR $231.00 $36.00 Part C, 260 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 74775-TC 75557 75557-26 75557-TC 75558 75558-26 75558-TC 75559 75559-26 75559-TC 75560 75560-26 75560-TC 75561 75561-26 75561-TC 75562 75562-26 75562-TC 75563 75563-26 75563-TC 75564 75564-26 75564-TC 75600 75600-26 75600-TC 75605 75605-26 75605-TC 75625 75625-26 75625-TC 75630 75630-26 75630-TC 75635 75635-26 75635-TC 75650 75650-26 75650-TC 75658 75658-26 75658-TC 75660 75660-26 75660-TC 75662 $55.00 ------------------------------------------------------------------------------------------------------------------------------------------------$497.00 NC NC $183.00 NC NC $143.00 NC NC $239.00 NC NC $445.00 NC NC $218.00 NC NC $540.00 NC NC $540.00 NC NC $560.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $180.00 $500.00 $130.00 $370.00 $649.00 $126.00 $523.00 $530.00 $165.00 $365.00 $834.00 $145.00 $690.00 $704.00 $144.00 $561.00 $828.00 $138.00 $690.00 $729.00 $172.00 $557.00 $974.00 $162.00 $812.00 $437.00 $28.00 $410.00 $411.00 $62.00 $348.00 $407.00 $61.00 $346.00 $460.00 $99.00 $361.00 $473.00 $129.00 $344.00 $426.00 $80.00 $346.00 $423.00 $71.00 $353.00 $425.00 $70.00 $355.00 $463.00 $198.00 $542.00 $134.00 $408.00 $705.00 $130.00 $575.00 $569.00 $171.00 $398.00 $901.00 $149.00 $753.00 $762.00 $149.00 $613.00 $896.00 $142.00 $753.00 $786.00 $178.00 $608.00 $1,053.00 $167.00 $886.00 $478.00 $29.00 $449.00 $448.00 $65.00 $383.00 $444.00 $64.00 $380.00 $501.00 $103.00 $398.00 $505.00 $133.00 $372.00 $464.00 $83.00 $381.00 $461.00 $73.00 $388.00 $463.00 $73.00 $390.00 $503.00 $218.00 $588.00 $140.00 $448.00 $767.00 $135.00 $632.00 $609.00 $177.00 $433.00 $971.00 $154.00 $817.00 $824.00 $155.00 $669.00 $966.00 $147.00 $819.00 $843.00 $184.00 $659.00 $1,136.00 $172.00 $964.00 $521.00 $30.00 $491.00 $489.00 $67.00 $421.00 $485.00 $66.00 $418.00 $545.00 $108.00 $438.00 $537.00 $139.00 $399.00 $505.00 $86.00 $419.00 $503.00 $77.00 $426.00 $504.00 $76.00 $429.00 $546.00 $180.00 $500.00 $130.00 $370.00 $649.00 $126.00 $523.00 $530.00 $165.00 $365.00 $834.00 $145.00 $690.00 $704.00 $144.00 $561.00 $828.00 $138.00 $690.00 $729.00 $172.00 $557.00 $974.00 $162.00 $812.00 $437.00 $28.00 $410.00 $411.00 $62.00 $348.00 $407.00 $61.00 $346.00 $460.00 $99.00 $361.00 $473.00 $129.00 $344.00 $426.00 $80.00 $346.00 $423.00 $71.00 $353.00 $425.00 $70.00 $355.00 $463.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $198.00 $542.00 $134.00 $408.00 $705.00 $130.00 $575.00 $569.00 $171.00 $398.00 $901.00 $149.00 $753.00 $762.00 $149.00 $613.00 $896.00 $142.00 $753.00 $786.00 $178.00 $608.00 $1,053.00 $167.00 $886.00 $478.00 $29.00 $449.00 $448.00 $65.00 $383.00 $444.00 $64.00 $380.00 $501.00 $103.00 $398.00 $505.00 $133.00 $372.00 $464.00 $83.00 $381.00 $461.00 $73.00 $388.00 $463.00 $73.00 $390.00 $503.00 $218.00 $588.00 $140.00 $448.00 $767.00 $135.00 $632.00 $609.00 $177.00 $433.00 $971.00 $154.00 $817.00 $824.00 $155.00 $669.00 $966.00 $147.00 $819.00 $843.00 $184.00 $659.00 $1,136.00 $172.00 $964.00 $521.00 $30.00 $491.00 $489.00 $67.00 $421.00 $485.00 $66.00 $418.00 $545.00 $108.00 $438.00 $537.00 $139.00 $399.00 $505.00 $86.00 $419.00 $503.00 $77.00 $426.00 $504.00 $76.00 $429.00 $546.00 Part C, 261 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 75662-26 75662-TC 75665 75665-26 75665-TC 75671 75671-26 75671-TC 75676 75676-26 75676-TC 75680 75680-26 75680-TC 75685 75685-26 75685-TC 75705 75705-26 75705-TC 75710 75710-26 75710-TC 75716 75716-26 75716-TC 75722 75722-26 75722-TC 75724 75724-26 75724-TC 75726 75726-26 75726-TC 75731 75731-26 75731-TC 75733 75733-26 75733-TC 75736 75736-26 75736-TC 75741 75741-26 75741-TC 75743 75743-26 75743-TC NC NC $540.00 NC NC $219.00 NC NC $540.00 NC NC $207.00 NC NC $160.00 NC NC $587.00 NC NC $194.00 NC NC $293.00 NC NC $206.00 NC NC $214.00 NC NC $530.00 NC NC $530.00 NC NC $540.00 NC NC $530.00 NC NC $540.00 NC NC $253.00 NC NC Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $90.00 $373.00 $431.00 $72.00 $359.00 $464.00 $89.00 $376.00 $425.00 $71.00 $355.00 $455.00 $89.00 $366.00 $425.00 $70.00 $355.00 $473.00 $118.00 $354.00 $420.00 $62.00 $357.00 $446.00 $71.00 $375.00 $416.00 $62.00 $354.00 $458.00 $84.00 $374.00 $414.00 $60.00 $354.00 $421.00 $63.00 $359.00 $456.00 $74.00 $382.00 $418.00 $62.00 $356.00 $411.00 $70.00 $341.00 $434.00 $88.00 $346.00 $93.00 $409.00 $470.00 $75.00 $395.00 $504.00 $92.00 $413.00 $463.00 $73.00 $390.00 $494.00 $92.00 $402.00 $463.00 $73.00 $390.00 $513.00 $123.00 $390.00 $458.00 $65.00 $393.00 $485.00 $73.00 $412.00 $454.00 $65.00 $390.00 $497.00 $86.00 $411.00 $452.00 $62.00 $389.00 $460.00 $65.00 $394.00 $496.00 $76.00 $420.00 $455.00 $64.00 $391.00 $448.00 $72.00 $375.00 $472.00 $91.00 $381.00 $97.00 $449.00 $513.00 $79.00 $434.00 $548.00 $95.00 $453.00 $505.00 $77.00 $429.00 $537.00 $96.00 $441.00 $504.00 $76.00 $429.00 $557.00 $129.00 $428.00 $500.00 $68.00 $432.00 $528.00 $77.00 $452.00 $495.00 $67.00 $428.00 $540.00 $89.00 $451.00 $493.00 $65.00 $428.00 $501.00 $68.00 $433.00 $539.00 $79.00 $460.00 $497.00 $67.00 $430.00 $488.00 $75.00 $413.00 $514.00 $95.00 $419.00 $90.00 $373.00 $431.00 $72.00 $359.00 $464.00 $89.00 $376.00 $425.00 $71.00 $355.00 $455.00 $89.00 $366.00 $425.00 $70.00 $355.00 $473.00 $118.00 $354.00 $420.00 $62.00 $357.00 $446.00 $71.00 $375.00 $416.00 $62.00 $354.00 $458.00 $84.00 $374.00 $414.00 $60.00 $354.00 $421.00 $63.00 $359.00 $456.00 $74.00 $382.00 $418.00 $62.00 $356.00 $411.00 $70.00 $341.00 $434.00 $88.00 $346.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $93.00 $409.00 $470.00 $75.00 $395.00 $504.00 $92.00 $413.00 $463.00 $73.00 $390.00 $494.00 $92.00 $402.00 $463.00 $73.00 $390.00 $513.00 $123.00 $390.00 $458.00 $65.00 $393.00 $485.00 $73.00 $412.00 $454.00 $65.00 $390.00 $497.00 $86.00 $411.00 $452.00 $62.00 $389.00 $460.00 $65.00 $394.00 $496.00 $76.00 $420.00 $455.00 $64.00 $391.00 $448.00 $72.00 $375.00 $472.00 $91.00 $381.00 $97.00 $449.00 $513.00 $79.00 $434.00 $548.00 $95.00 $453.00 $505.00 $77.00 $429.00 $537.00 $96.00 $441.00 $504.00 $76.00 $429.00 $557.00 $129.00 $428.00 $500.00 $68.00 $432.00 $528.00 $77.00 $452.00 $495.00 $67.00 $428.00 $540.00 $89.00 $451.00 $493.00 $65.00 $428.00 $501.00 $68.00 $433.00 $539.00 $79.00 $460.00 $497.00 $67.00 $430.00 $488.00 $75.00 $413.00 $514.00 $95.00 $419.00 Part C, 262 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 75746 75746-26 75746-TC 75756 75756-26 75756-TC 75774 75774-26 75774-TC 75790 75790-26 75790-TC 75801 75801-26 75801-TC 75803 75803-26 75803-TC 75805 75805-26 75805-TC 75807 75807-26 75807-TC 75809 75809-26 75809-TC 75810 75810-26 75810-TC 75820 75820-26 75820-TC 75822 75822-26 75822-TC 75825 75825-26 75825-TC 75827 75827-26 75827-TC 75831 75831-26 75831-TC 75833 75833-26 75833-TC 75840 75840-26 $530.00 NC NC $183.00 NC NC $80.00 NC NC $146.00 NC NC $245.00 NC NC $264.00 NC NC $271.00 NC NC $289.00 NC NC $54.00 NC NC $530.00 NC NC $72.00 NC NC $111.00 NC NC $194.00 NC NC $530.00 NC NC $54.00 NC NC $549.00 NC NC $531.00 NC Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $410.00 $60.00 $349.00 $426.00 $64.00 $362.00 $354.00 $20.00 $335.00 $178.00 $97.00 $81.00 $384.00 $45.00 $369.00 $387.00 $62.00 $369.00 $383.00 $43.00 $369.00 $387.00 $62.00 $369.00 $82.00 $24.00 $58.00 $2,003.00 $60.00 $1,985.00 $114.00 $38.00 $76.00 $145.00 $56.00 $89.00 $399.00 $61.00 $338.00 $398.00 $60.00 $339.00 $401.00 $60.00 $340.00 $430.00 $80.00 $350.00 $400.00 $61.00 $447.00 $62.00 $385.00 $465.00 $67.00 $398.00 $389.00 $21.00 $369.00 $189.00 $101.00 $88.00 $423.00 $47.00 $406.00 $427.00 $64.00 $406.00 $422.00 $45.00 $406.00 $427.00 $64.00 $406.00 $88.00 $25.00 $63.00 $2,207.00 $62.00 $2,187.00 $121.00 $39.00 $82.00 $155.00 $58.00 $97.00 $436.00 $64.00 $372.00 $435.00 $62.00 $373.00 $437.00 $62.00 $375.00 $469.00 $83.00 $385.00 $437.00 $63.00 $488.00 $65.00 $423.00 $506.00 $69.00 $437.00 $427.00 $21.00 $406.00 $200.00 $105.00 $95.00 $468.00 $50.00 $448.00 $471.00 $66.00 $448.00 $465.00 $47.00 $448.00 $471.00 $66.00 $448.00 $93.00 $26.00 $67.00 $2,431.00 $64.00 $2,408.00 $129.00 $41.00 $88.00 $165.00 $61.00 $104.00 $477.00 $67.00 $410.00 $475.00 $64.00 $411.00 $478.00 $65.00 $413.00 $511.00 $87.00 $424.00 $477.00 $66.00 $410.00 $60.00 $349.00 $426.00 $64.00 $362.00 $354.00 $20.00 $335.00 $178.00 $97.00 $81.00 $384.00 $45.00 $369.00 $387.00 $62.00 $369.00 $383.00 $43.00 $369.00 $387.00 $62.00 $369.00 $82.00 $24.00 $58.00 $2,003.00 $60.00 $1,985.00 $114.00 $38.00 $76.00 $145.00 $56.00 $89.00 $399.00 $61.00 $338.00 $398.00 $60.00 $339.00 $401.00 $60.00 $340.00 $430.00 $80.00 $350.00 $400.00 $61.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $447.00 $62.00 $385.00 $465.00 $67.00 $398.00 $389.00 $21.00 $369.00 $189.00 $101.00 $88.00 $423.00 $47.00 $406.00 $427.00 $64.00 $406.00 $422.00 $45.00 $406.00 $427.00 $64.00 $406.00 $88.00 $25.00 $63.00 $2,207.00 $62.00 $2,187.00 $121.00 $39.00 $82.00 $155.00 $58.00 $97.00 $436.00 $64.00 $372.00 $435.00 $62.00 $373.00 $437.00 $62.00 $375.00 $469.00 $83.00 $385.00 $437.00 $63.00 $488.00 $65.00 $423.00 $506.00 $69.00 $437.00 $427.00 $21.00 $406.00 $200.00 $105.00 $95.00 $468.00 $50.00 $448.00 $471.00 $66.00 $448.00 $465.00 $47.00 $448.00 $471.00 $66.00 $448.00 $93.00 $26.00 $67.00 $2,431.00 $64.00 $2,408.00 $129.00 $41.00 $88.00 $165.00 $61.00 $104.00 $477.00 $67.00 $410.00 $475.00 $64.00 $411.00 $478.00 $65.00 $413.00 $511.00 $87.00 $424.00 $477.00 $66.00 Part C, 263 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 75840-TC 75842 75842-26 75842-TC 75860 75860-26 75860-TC 75870 75870-26 75870-TC 75872 75872-26 75872-TC 75880 75880-26 75880-TC 75885 75885-26 75885-TC 75887 75887-26 75887-TC 75889 75889-26 75889-TC 75891 75891-26 75891-TC 75893 75893-26 75893-TC 75894 75894-26 75894-TC 75896 75896-26 75896-TC 75898 75898-26 75898-TC 75900 75900-26 75900-TC 75901 75901-26 75901-TC 75902 75902-26 75902-TC 75940 NC $549.00 NC NC $531.00 NC NC $531.00 NC NC $530.00 NC NC $72.00 NC NC $546.00 NC NC $546.00 NC NC $530.00 NC NC $530.00 NC NC $499.00 NC NC $972.00 NC NC $241.00 NC NC $124.00 $84.00 $39.00 $810.00 NC NC $98.00 NC NC $93.00 NC NC $151.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $339.00 $430.00 $79.00 $351.00 $407.00 $62.00 $345.00 $406.00 $61.00 $345.00 $426.00 $67.00 $359.00 $118.00 $38.00 $80.00 $417.00 $76.00 $340.00 $421.00 $77.00 $344.00 $401.00 $60.00 $340.00 $400.00 $60.00 $340.00 $369.00 $29.00 $340.00 ------$70.00 BR ------$70.00 BR $209.00 $88.00 $182.00 ------$26.00 BR $181.00 $26.00 $155.00 $127.00 $21.00 $107.00 ------- $374.00 $468.00 $82.00 $386.00 $444.00 $64.00 $380.00 $442.00 $63.00 $380.00 $465.00 $71.00 $395.00 $126.00 $39.00 $87.00 $454.00 $79.00 $375.00 $459.00 $80.00 $379.00 $437.00 $62.00 $375.00 $437.00 $62.00 $374.00 $405.00 $30.00 $375.00 ------$73.00 BR ------$72.00 BR $229.00 $91.00 $199.00 ------$27.00 BR $206.00 $27.00 $179.00 $149.00 $21.00 $127.00 ------- $411.00 $510.00 $85.00 $425.00 $484.00 $66.00 $418.00 $483.00 $65.00 $417.00 $509.00 $76.00 $433.00 $134.00 $40.00 $93.00 $494.00 $82.00 $413.00 $500.00 $83.00 $417.00 $477.00 $65.00 $413.00 $477.00 $65.00 $412.00 $443.00 $31.00 $413.00 ------$77.00 BR ------$75.00 BR $250.00 $95.00 $216.00 ------$29.00 BR $239.00 $28.00 $211.00 $178.00 $22.00 $156.00 ------- $339.00 $430.00 $79.00 $351.00 $407.00 $62.00 $345.00 $406.00 $61.00 $345.00 $426.00 $67.00 $359.00 $118.00 $38.00 $80.00 $417.00 $76.00 $340.00 $421.00 $77.00 $344.00 $401.00 $60.00 $340.00 $400.00 $60.00 $340.00 $369.00 $29.00 $340.00 ------$70.00 BR ------$70.00 BR $209.00 $88.00 $182.00 ------$26.00 BR $181.00 $26.00 $155.00 $127.00 $21.00 $107.00 ------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $374.00 $468.00 $82.00 $386.00 $444.00 $64.00 $380.00 $442.00 $63.00 $380.00 $465.00 $71.00 $395.00 $126.00 $39.00 $87.00 $454.00 $79.00 $375.00 $459.00 $80.00 $379.00 $437.00 $62.00 $375.00 $437.00 $62.00 $374.00 $405.00 $30.00 $375.00 ------$73.00 BR ------$72.00 BR $229.00 $91.00 $199.00 ------$27.00 BR $206.00 $27.00 $179.00 $149.00 $21.00 $127.00 ------- $411.00 $510.00 $85.00 $425.00 $484.00 $66.00 $418.00 $483.00 $65.00 $417.00 $509.00 $76.00 $433.00 $134.00 $40.00 $93.00 $494.00 $82.00 $413.00 $500.00 $83.00 $417.00 $477.00 $65.00 $413.00 $477.00 $65.00 $412.00 $443.00 $31.00 $413.00 ------$77.00 BR ------$75.00 BR $250.00 $95.00 $216.00 ------$29.00 BR $239.00 $28.00 $211.00 $178.00 $22.00 $156.00 ------- Part C, 264 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 75940-26 75940-TC 75945 75945-26 75945-TC 75946 75946-26 75946-TC 75952 75952-26 75952-TC 75953 75953-26 75953-TC 75954 75954-26 75954-TC 75956 75956-26 75956-TC 75957 75957-26 75957-TC 75958 75958-26 75958-TC 75959 75959-26 75959-TC 75960 75960-26 75960-TC 75961 75961-26 75961-TC 75962 75962-26 75962-TC 75964 75964-26 75964-TC 75966 75966-26 75966-TC 75968 75968-26 75968-TC 75970 75970-26 75970-TC NC NC $192.00 NC NC $108.00 NC NC BR NC NC BR NC NC BR NC NC ------------------------------------------------------------------------$600.00 NC NC $616.00 NC NC $618.00 NC NC $333.00 NC NC $659.00 NC NC $333.00 NC NC $475.00 NC NC Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $30.00 BR $169.00 $23.00 $161.00 ------$23.00 BR ------$247.00 BR ------$75.00 BR ------$120.00 BR BR $391.00 BR BR $335.00 BR BR $223.00 BR BR $195.00 BR $433.00 $45.00 $388.00 $527.00 $224.00 $303.00 $455.00 $29.00 $426.00 $255.00 $20.00 $235.00 $504.00 $72.00 $432.00 $256.00 $20.00 $236.00 ------$44.00 BR $31.00 BR $185.00 $24.00 $176.00 ------$24.00 BR ------$259.00 BR ------$79.00 BR ------$125.00 BR BR $411.00 BR BR $353.00 BR BR $234.00 BR BR $205.00 BR $474.00 $47.00 $427.00 $565.00 $232.00 $333.00 $500.00 $31.00 $469.00 $280.00 $21.00 $259.00 $550.00 $75.00 $475.00 $280.00 $21.00 $259.00 ------$46.00 BR $33.00 BR $202.00 $25.00 $191.00 ------$26.00 BR ------$276.00 BR ------$84.00 BR ------$131.00 BR BR $438.00 BR BR $375.00 BR BR $249.00 BR BR $218.00 BR $520.00 $49.00 $471.00 $607.00 $241.00 $366.00 $549.00 $32.00 $517.00 $306.00 $22.00 $284.00 $601.00 $78.00 $523.00 $307.00 $22.00 $285.00 ------$48.00 BR $30.00 BR $169.00 $23.00 $161.00 ------$23.00 BR ------$247.00 BR ------$75.00 BR ------$120.00 BR BR $391.00 BR BR $335.00 BR BR $223.00 BR BR $195.00 BR $433.00 $45.00 $388.00 $527.00 $224.00 $303.00 $455.00 $29.00 $426.00 $255.00 $20.00 $235.00 $504.00 $72.00 $432.00 $256.00 $20.00 $236.00 ------$44.00 BR CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $31.00 BR $185.00 $24.00 $176.00 ------$24.00 BR ------$259.00 BR ------$79.00 BR ------$125.00 BR BR $411.00 BR BR $353.00 BR BR $234.00 BR BR $205.00 BR $474.00 $47.00 $427.00 $565.00 $232.00 $333.00 $500.00 $31.00 $469.00 $280.00 $21.00 $259.00 $550.00 $75.00 $475.00 $280.00 $21.00 $259.00 ------$46.00 BR $33.00 BR $202.00 $25.00 $191.00 ------$26.00 BR ------$276.00 BR ------$84.00 BR ------$131.00 BR BR $438.00 BR BR $375.00 BR BR $249.00 BR BR $218.00 BR $520.00 $49.00 $471.00 $607.00 $241.00 $366.00 $549.00 $32.00 $517.00 $306.00 $22.00 $284.00 $601.00 $78.00 $523.00 $307.00 $22.00 $285.00 ------$48.00 BR Part C, 265 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 75978 75978-26 75978-TC 75980 75980-26 75980-TC 75982 75982-26 75982-TC 75984 75984-26 75984-TC 75989 75989-26 75989-TC 75992 75992-26 75992-TC 75993 75993-26 75993-TC 75994 75994-26 75994-TC 75995 75995-26 75995-TC 75996 75996-26 75996-TC 76000 76000-26 76000-TC 76001 76001-26 76001-TC 76080 76080-26 76080-TC 76098 76098-26 76098-TC 76100 76100-26 76100-TC 76101 76101-26 76101-TC 76102 76102-26 $617.00 NC NC $277.00 NC NC $303.00 NC NC $110.00 NC NC $180.00 NC NC $618.00 NC NC $333.00 NC NC $659.00 NC NC $658.00 NC NC $332.00 NC NC $58.00 $8.00 $48.00 $134.00 $34.00 $97.00 $67.00 NC NC $23.00 $8.00 $15.00 $77.00 $30.00 $46.00 $94.00 $36.00 $59.00 $95.00 $30.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $450.00 $28.00 $422.00 ------$77.00 BR ------$77.00 BR $123.00 $38.00 $85.00 $172.00 $63.00 $108.00 ------$30.00 BR ------$20.00 BR ------$72.00 BR ------$70.00 BR ------$19.00 BR $92.00 $9.00 $83.00 ------$37.00 ------$71.00 $29.00 $42.00 $23.00 $8.00 $15.00 $109.00 $31.00 $78.00 $167.00 $31.00 $136.00 $208.00 $30.00 $494.00 $29.00 $465.00 ------$79.00 BR ------$79.00 BR $132.00 $39.00 $93.00 $184.00 $65.00 $119.00 ------$31.00 BR ------$21.00 BR ------$75.00 BR ------$72.00 BR ------$20.00 BR $100.00 $9.00 $90.00 ------$39.00 ------$75.00 $30.00 $46.00 $25.00 $9.00 $16.00 $116.00 $32.00 $84.00 $179.00 $32.00 $147.00 $224.00 $31.00 $542.00 $30.00 $512.00 ------$82.00 BR ------$82.00 BR $142.00 $40.00 $101.00 $198.00 $68.00 $130.00 ------$33.00 BR ------$21.00 BR ------$78.00 BR ------$75.00 BR ------$21.00 BR $107.00 $10.00 $97.00 ------$41.00 ------$81.00 $31.00 $50.00 $27.00 $9.00 $17.00 $124.00 $34.00 $90.00 $191.00 $33.00 $158.00 $238.00 $33.00 $450.00 $28.00 $422.00 ------$77.00 BR ------$77.00 BR $123.00 $38.00 $85.00 $172.00 $63.00 $108.00 ------$30.00 BR ------$20.00 BR ------$72.00 BR ------$70.00 BR ------$19.00 BR $92.00 $9.00 $83.00 ------$37.00 ------$71.00 $29.00 $42.00 $23.00 $8.00 $15.00 $109.00 $31.00 $78.00 $167.00 $31.00 $136.00 $208.00 $30.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $494.00 $29.00 $465.00 ------$79.00 BR ------$79.00 BR $132.00 $39.00 $93.00 $184.00 $65.00 $119.00 ------$31.00 BR ------$21.00 BR ------$75.00 BR ------$72.00 BR ------$20.00 BR $100.00 $9.00 $90.00 ------$39.00 ------$75.00 $30.00 $46.00 $25.00 $9.00 $16.00 $116.00 $32.00 $84.00 $179.00 $32.00 $147.00 $224.00 $31.00 $542.00 $30.00 $512.00 ------$82.00 BR ------$82.00 BR $142.00 $40.00 $101.00 $198.00 $68.00 $130.00 ------$33.00 BR ------$21.00 BR ------$78.00 BR ------$75.00 BR ------$21.00 BR $107.00 $10.00 $97.00 ------$41.00 ------$81.00 $31.00 $50.00 $27.00 $9.00 $17.00 $124.00 $34.00 $90.00 $191.00 $33.00 $158.00 $238.00 $33.00 Part C, 266 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 76102-TC 76120 76120-26 76120-TC 76125 76125-26 76125-TC 76140 76150 76350 76376 76376-26 76376-TC 76377 76377-26 76377-TC 76380 76380-26 76380-TC 76390 76390-26 76390-TC 76496 76496-26 76496-TC 76497 76497-26 76497-TC 76498 76498-26 76498-TC 76499 76499-26 76499-TC 76506 76506-26 76506-TC 76510 76510-26 76510-TC 76511 76511-26 76511-TC 76512 76512-26 76512-TC 76513 76513-26 76513-TC 76514 $65.00 $157.00 $56.00 $102.00 $49.00 $17.00 $33.00 $31.00 $15.00 BR ------------------------------------$182.00 $50.00 $131.00 $493.00 $71.00 $419.00 BR BR BR BR BR BR BR BR BR BR BR BR $88.00 $33.00 $53.00 ------------------$96.00 $48.00 $48.00 $96.00 $36.00 $60.00 $96.00 $36.00 $60.00 ------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $178.00 $79.00 $20.00 $59.00 ------$15.00 ------------$23.00 ------$110.00 $12.00 $98.00 $153.00 $45.00 $108.00 $158.00 $51.00 $107.00 $503.00 $72.00 $432.00 ------------$91.00 ------------$109.00 ------------$335.00 ------------------$100.00 $35.00 $64.00 $163.00 $83.00 $81.00 $115.00 $51.00 $64.00 $109.00 $51.00 $58.00 $97.00 $36.00 $62.00 $13.00 $192.00 $85.00 $21.00 $64.00 ------$16.00 ------------$25.00 ------$119.00 $12.00 $107.00 $168.00 $47.00 $121.00 $169.00 $53.00 $116.00 $546.00 $74.00 $472.00 ------------$101.00 ------------$120.00 ------------$369.00 ------------------$107.00 $37.00 $70.00 $172.00 $85.00 $87.00 $123.00 $52.00 $70.00 $116.00 $52.00 $64.00 $104.00 $37.00 $68.00 $14.00 $206.00 $91.00 $22.00 $69.00 ------$16.00 ------------$27.00 ------$128.00 $13.00 $115.00 $186.00 $50.00 $136.00 $181.00 $55.00 $126.00 $590.00 $77.00 $513.00 ------------$111.00 ------------$132.00 ------------$407.00 ------------------$115.00 $40.00 $75.00 $181.00 $87.00 $94.00 $130.00 $54.00 $76.00 $123.00 $53.00 $70.00 $112.00 $38.00 $74.00 $15.00 $178.00 $79.00 $20.00 $59.00 ------$15.00 ------------$23.00 ------$110.00 $12.00 $98.00 $153.00 $45.00 $108.00 $158.00 $51.00 $107.00 $503.00 $72.00 $432.00 ------------$91.00 ------------$109.00 ------------$335.00 ------------------$100.00 $35.00 $64.00 $163.00 $83.00 $81.00 $115.00 $51.00 $64.00 $109.00 $51.00 $58.00 $97.00 $36.00 $62.00 $13.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $192.00 $85.00 $21.00 $64.00 ------$16.00 ------------$25.00 ------$119.00 $12.00 $107.00 $168.00 $47.00 $121.00 $169.00 $53.00 $116.00 $546.00 $74.00 $472.00 ------------$101.00 ------------$120.00 ------------$369.00 ------------------$107.00 $37.00 $70.00 $172.00 $85.00 $87.00 $123.00 $52.00 $70.00 $116.00 $52.00 $64.00 $104.00 $37.00 $68.00 $14.00 $206.00 $91.00 $22.00 $69.00 ------$16.00 ------------$27.00 ------$128.00 $13.00 $115.00 $186.00 $50.00 $136.00 $181.00 $55.00 $126.00 $590.00 $77.00 $513.00 ------------$111.00 ------------$132.00 ------------$407.00 ------------------$115.00 $40.00 $75.00 $181.00 $87.00 $94.00 $130.00 $54.00 $76.00 $123.00 $53.00 $70.00 $112.00 $38.00 $74.00 $15.00 Part C, 267 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 76514-26 76514-TC 76516 76516-26 76516-TC 76519 76519-26 76519-TC 76529 76529-26 76529-TC 76536 76536-26 76536-TC 76604 76604-26 76604-TC 76645 76645-26 76645-TC 76700 76700-26 76700-TC 76705 76705-26 76705-TC 76770 76770-26 76770-TC 76775 76775-26 76775-TC 76776 76776-26 76776-TC 76800 76800-26 76800-TC 76801 76801-26 76801-TC 76802 76802-26 76802-TC 76805 76805-26 76805-TC 76810 76810-26 76810-TC ------------$99.00 $37.00 $63.00 $88.00 $31.00 $53.00 $86.00 $31.00 $53.00 $83.00 $31.00 $54.00 $78.00 $28.00 $48.00 $69.00 $31.00 $40.00 $116.00 $42.00 $73.00 $84.00 $30.00 $53.00 $112.00 $38.00 $73.00 $84.00 $30.00 $53.00 ------------------$112.00 $61.00 $54.00 $93.00 $51.00 $42.00 $73.00 $43.00 $30.00 $131.00 $51.00 $79.00 $252.00 $100.00 $151.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $10.00 $4.00 $77.00 $29.00 $48.00 $81.00 $29.00 $51.00 $77.00 $31.00 $46.00 $111.00 $29.00 $82.00 $91.00 $29.00 $62.00 $91.00 $28.00 $62.00 $142.00 $43.00 $100.00 $106.00 $32.00 $75.00 $137.00 $39.00 $98.00 $107.00 $31.00 $76.00 $148.00 $40.00 $108.00 $130.00 $57.00 $73.00 $143.00 $52.00 $91.00 $86.00 $44.00 $42.00 $153.00 $52.00 $102.00 $112.00 $51.00 $61.00 $10.00 $4.00 $82.00 $30.00 $52.00 $86.00 $30.00 $56.00 $82.00 $32.00 $50.00 $119.00 $30.00 $89.00 $97.00 $30.00 $68.00 $97.00 $29.00 $68.00 $153.00 $44.00 $108.00 $114.00 $33.00 $81.00 $147.00 $40.00 $107.00 $115.00 $32.00 $83.00 $159.00 $41.00 $117.00 $138.00 $59.00 $79.00 $153.00 $53.00 $99.00 $93.00 $46.00 $47.00 $164.00 $53.00 $111.00 $121.00 $53.00 $69.00 $11.00 $5.00 $87.00 $31.00 $57.00 $92.00 $31.00 $61.00 $88.00 $33.00 $55.00 $127.00 $31.00 $96.00 $104.00 $31.00 $73.00 $103.00 $30.00 $73.00 $163.00 $46.00 $117.00 $122.00 $34.00 $88.00 $157.00 $42.00 $115.00 $123.00 $34.00 $89.00 $169.00 $43.00 $126.00 $147.00 $61.00 $85.00 $163.00 $55.00 $108.00 $100.00 $48.00 $53.00 $175.00 $55.00 $120.00 $133.00 $55.00 $78.00 $10.00 $4.00 $77.00 $29.00 $48.00 $81.00 $29.00 $51.00 $77.00 $31.00 $46.00 $111.00 $29.00 $82.00 $91.00 $29.00 $62.00 $91.00 $28.00 $62.00 $142.00 $43.00 $100.00 $106.00 $32.00 $75.00 $137.00 $39.00 $98.00 $107.00 $31.00 $76.00 $148.00 $40.00 $108.00 $130.00 $57.00 $73.00 $143.00 $52.00 $91.00 $86.00 $44.00 $42.00 $153.00 $52.00 $102.00 $112.00 $51.00 $61.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $10.00 $4.00 $82.00 $30.00 $52.00 $86.00 $30.00 $56.00 $82.00 $32.00 $50.00 $119.00 $30.00 $89.00 $97.00 $30.00 $68.00 $97.00 $29.00 $68.00 $153.00 $44.00 $108.00 $114.00 $33.00 $81.00 $147.00 $40.00 $107.00 $115.00 $32.00 $83.00 $159.00 $41.00 $117.00 $138.00 $59.00 $79.00 $153.00 $53.00 $99.00 $93.00 $46.00 $47.00 $164.00 $53.00 $111.00 $121.00 $53.00 $69.00 $11.00 $5.00 $87.00 $31.00 $57.00 $92.00 $31.00 $61.00 $88.00 $33.00 $55.00 $127.00 $31.00 $96.00 $104.00 $31.00 $73.00 $103.00 $30.00 $73.00 $163.00 $46.00 $117.00 $122.00 $34.00 $88.00 $157.00 $42.00 $115.00 $123.00 $34.00 $89.00 $169.00 $43.00 $126.00 $147.00 $61.00 $85.00 $163.00 $55.00 $108.00 $100.00 $48.00 $53.00 $175.00 $55.00 $120.00 $133.00 $55.00 $78.00 Part C, 268 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 76811 76811-26 76811-TC 76812 76812-26 76812-TC 76813 76813-26 76813-TC 76814 76814-26 76814-TC 76815 76815-26 76815-TC 76816 76816-26 76816-TC 76817 76817-26 76817-TC 76818 76818-26 76818-TC 76819 76819-26 76819-TC 76820 76820-26 76820-TC 76821 76821-26 76821-TC 76825 76825-26 76825-TC 76826 76826-26 76826-TC 76827 76827-26 76827-TC 76828 76828-26 76828-TC 76830 76830-26 76830-TC 76831 76831-26 $243.00 $100.00 $142.00 $145.00 $94.00 $51.00 ------------------------------------$88.00 $33.00 $53.00 $72.00 $30.00 $41.00 $96.00 $39.00 $57.00 $105.00 $40.00 $60.00 $101.00 $40.00 $60.00 ------------------------------------$160.00 $65.00 $73.00 $71.00 $46.00 $27.00 $97.00 $35.00 $65.00 $72.00 $29.00 $42.00 $93.00 $35.00 $57.00 $95.00 $37.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $245.00 $100.00 $145.00 $162.00 $94.00 $69.00 $142.00 $62.00 $80.00 $93.00 $51.00 $42.00 $98.00 $34.00 $64.00 $109.00 $45.00 $64.00 $103.00 $39.00 $64.00 $131.00 $55.00 $75.00 $106.00 $41.00 $65.00 $74.00 $27.00 $47.00 $109.00 $37.00 $72.00 $189.00 $88.00 $101.00 $107.00 $43.00 $64.00 $89.00 $30.00 $59.00 $66.00 $30.00 $36.00 $122.00 $36.00 $86.00 $123.00 $37.00 $266.00 $103.00 $162.00 $174.00 $97.00 $77.00 $152.00 $65.00 $88.00 $100.00 $53.00 $48.00 $105.00 $35.00 $70.00 $116.00 $46.00 $70.00 $110.00 $40.00 $70.00 $140.00 $57.00 $82.00 $113.00 $42.00 $71.00 $80.00 $28.00 $52.00 $117.00 $39.00 $79.00 $200.00 $90.00 $110.00 $114.00 $44.00 $69.00 $96.00 $31.00 $65.00 $71.00 $31.00 $40.00 $131.00 $38.00 $94.00 $132.00 $39.00 $290.00 $108.00 $183.00 $189.00 $101.00 $88.00 $163.00 $67.00 $96.00 $109.00 $55.00 $54.00 $113.00 $37.00 $76.00 $123.00 $48.00 $75.00 $117.00 $42.00 $75.00 $149.00 $60.00 $89.00 $121.00 $43.00 $78.00 $88.00 $29.00 $58.00 $126.00 $40.00 $86.00 $212.00 $94.00 $118.00 $120.00 $46.00 $74.00 $104.00 $32.00 $72.00 $76.00 $32.00 $44.00 $141.00 $39.00 $101.00 $141.00 $40.00 $245.00 $100.00 $145.00 $162.00 $94.00 $69.00 $142.00 $62.00 $80.00 $93.00 $51.00 $42.00 $98.00 $34.00 $64.00 $109.00 $45.00 $64.00 $103.00 $39.00 $64.00 $131.00 $55.00 $75.00 $106.00 $41.00 $65.00 $74.00 $27.00 $47.00 $109.00 $37.00 $72.00 $189.00 $88.00 $101.00 $107.00 $43.00 $64.00 $89.00 $30.00 $59.00 $66.00 $30.00 $36.00 $122.00 $36.00 $86.00 $123.00 $37.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $266.00 $103.00 $162.00 $174.00 $97.00 $77.00 $152.00 $65.00 $88.00 $100.00 $53.00 $48.00 $105.00 $35.00 $70.00 $116.00 $46.00 $70.00 $110.00 $40.00 $70.00 $140.00 $57.00 $82.00 $113.00 $42.00 $71.00 $80.00 $28.00 $52.00 $117.00 $39.00 $79.00 $200.00 $90.00 $110.00 $114.00 $44.00 $69.00 $96.00 $31.00 $65.00 $71.00 $31.00 $40.00 $131.00 $38.00 $94.00 $132.00 $39.00 $290.00 $108.00 $183.00 $189.00 $101.00 $88.00 $163.00 $67.00 $96.00 $109.00 $55.00 $54.00 $113.00 $37.00 $76.00 $123.00 $48.00 $75.00 $117.00 $42.00 $75.00 $149.00 $60.00 $89.00 $121.00 $43.00 $78.00 $88.00 $29.00 $58.00 $126.00 $40.00 $86.00 $212.00 $94.00 $118.00 $120.00 $46.00 $74.00 $104.00 $32.00 $72.00 $76.00 $32.00 $44.00 $141.00 $39.00 $101.00 $141.00 $40.00 Part C, 269 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 76831-TC 76856 76856-26 76856-TC 76857 76857-26 76857-TC 76870 76870-26 76870-TC 76872 76872-26 76872-TC 76873 76873-26 76873-TC 76880 76880-26 76880-TC 76930 76930-26 76930-TC 76932 76932-26 76932-TC 76936 76936-26 76936-TC 76937 76937-26 76937-TC 76940 76940-26 76940-TC 76941 76941-26 76941-TC 76942 76942-26 76942-TC 76945 76945-26 76945-TC 76946 76946-26 76946-TC 76948 76948-26 76948-TC 76950 $57.00 $93.00 $35.00 $57.00 $59.00 $19.00 $39.00 $90.00 $33.00 $57.00 $93.00 $36.00 $57.00 $151.00 $68.00 $80.00 $85.00 $32.00 $54.00 $93.00 NC NC $93.00 NC NC $341.00 $102.00 $236.00 ------------------------------------$128.00 NC NC $92.00 NC NC $93.00 NC NC $78.00 NC NC $77.00 NC NC $80.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $86.00 $123.00 $36.00 $86.00 $84.00 $20.00 $64.00 $121.00 $34.00 $87.00 $138.00 $37.00 $101.00 $185.00 $83.00 $102.00 $123.00 $31.00 $92.00 $108.00 $37.00 $70.00 ------$38.00 BR $360.00 $109.00 $251.00 $41.00 $17.00 $24.00 BR $119.00 BR ------$71.00 BR $186.00 $36.00 $151.00 ------$35.00 BR $63.00 $20.00 $43.00 $62.00 $19.00 $43.00 $81.00 $93.00 $132.00 $38.00 $94.00 $90.00 $21.00 $69.00 $130.00 $35.00 $95.00 $149.00 $39.00 $110.00 $198.00 $86.00 $112.00 $132.00 $32.00 $100.00 $115.00 $39.00 $77.00 ------$39.00 BR $388.00 $113.00 $274.00 $45.00 $18.00 $27.00 BR $127.00 BR ------$73.00 BR $200.00 $37.00 $163.00 ------$36.00 BR $68.00 $21.00 $47.00 $67.00 $20.00 $47.00 $86.00 $101.00 $141.00 $39.00 $102.00 $96.00 $22.00 $74.00 $139.00 $37.00 $103.00 $159.00 $41.00 $118.00 $212.00 $90.00 $122.00 $141.00 $34.00 $107.00 $123.00 $40.00 $84.00 ------$40.00 BR $417.00 $119.00 $298.00 $50.00 $19.00 $31.00 BR $138.00 BR ------$76.00 BR $213.00 $38.00 $175.00 ------$37.00 BR $74.00 $21.00 $53.00 $74.00 $21.00 $53.00 $93.00 $86.00 $123.00 $36.00 $86.00 $84.00 $20.00 $64.00 $121.00 $34.00 $87.00 $138.00 $37.00 $101.00 $185.00 $83.00 $102.00 $123.00 $31.00 $92.00 $108.00 $37.00 $70.00 ------$38.00 BR $360.00 $109.00 $251.00 $41.00 $17.00 $24.00 BR $119.00 BR ------$71.00 BR $186.00 $36.00 $151.00 ------$35.00 BR $63.00 $20.00 $43.00 $62.00 $19.00 $43.00 $81.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $93.00 $132.00 $38.00 $94.00 $90.00 $21.00 $69.00 $130.00 $35.00 $95.00 $149.00 $39.00 $110.00 $198.00 $86.00 $112.00 $132.00 $32.00 $100.00 $115.00 $39.00 $77.00 ------$39.00 BR $388.00 $113.00 $274.00 $45.00 $18.00 $27.00 BR $127.00 BR ------$73.00 BR $200.00 $37.00 $163.00 ------$36.00 BR $68.00 $21.00 $47.00 $67.00 $20.00 $47.00 $86.00 $101.00 $141.00 $39.00 $102.00 $96.00 $22.00 $74.00 $139.00 $37.00 $103.00 $159.00 $41.00 $118.00 $212.00 $90.00 $122.00 $141.00 $34.00 $107.00 $123.00 $40.00 $84.00 ------$40.00 BR $417.00 $119.00 $298.00 $50.00 $19.00 $31.00 BR $138.00 BR ------$76.00 BR $213.00 $38.00 $175.00 ------$37.00 BR $74.00 $21.00 $53.00 $74.00 $21.00 $53.00 $93.00 Part C, 270 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 76950-26 76950-TC 76965 76965-26 76965-TC 76970 76970-26 76970-TC 76975 76975-26 76975-TC 76977 76977-26 76977-TC 76998 76998-26 76998-TC 76999 76999-26 76999-TC 77001 77001-26 77001-TC 77002 77002-26 77002-TC 77003 77003-26 77003-TC 77011 77011-26 77011-TC 77012 77012-26 77012-TC 77013-26 77013-TC 77014 77014-26 77014-TC 77021 77021-26 77021-TC 77022 77022-26 77022-TC 77031 77031-26 77031-TC 77032 $30.00 $48.00 $281.00 $84.00 $208.00 $60.00 $20.00 $39.00 $99.00 NC NC $34.00 $3.00 $31.00 ------------------BR BR BR ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $31.00 $50.00 $214.00 $72.00 $141.00 $82.00 $21.00 $61.00 $177.00 $44.00 $163.00 $24.00 $3.00 $21.00 BR $67.00 BR ------------------$102.00 $20.00 $83.00 $79.00 $28.00 $51.00 $72.00 $30.00 $42.00 $642.00 $64.00 $579.00 $288.00 $62.00 $226.00 $212.00 BR $195.00 $45.00 $151.00 $516.00 $81.00 $435.00 BR $228.00 BR $275.00 $85.00 $190.00 $72.00 $32.00 $55.00 $231.00 $75.00 $156.00 $88.00 $21.00 $66.00 $195.00 $45.00 $179.00 $27.00 $3.00 $23.00 BR $71.00 BR ------------------$110.00 $20.00 $90.00 $84.00 $28.00 $56.00 $77.00 $31.00 $46.00 $692.00 $66.00 $626.00 $312.00 $64.00 $249.00 $219.00 BR $210.00 $46.00 $164.00 $558.00 $84.00 $474.00 BR $237.00 BR $298.00 $88.00 $209.00 $77.00 $33.00 $59.00 $251.00 $79.00 $172.00 $94.00 $22.00 $72.00 $214.00 $47.00 $197.00 $30.00 $4.00 $26.00 BR $76.00 BR ------------------$119.00 $21.00 $98.00 $90.00 $29.00 $61.00 $83.00 $32.00 $51.00 $740.00 $68.00 $672.00 $340.00 $66.00 $273.00 $228.00 BR $225.00 $48.00 $177.00 $603.00 $88.00 $515.00 BR $248.00 BR $323.00 $92.00 $230.00 $83.00 $31.00 $50.00 $214.00 $72.00 $141.00 $82.00 $21.00 $61.00 $177.00 $44.00 $163.00 $24.00 $3.00 $21.00 BR $67.00 BR ------------------$102.00 $20.00 $83.00 $79.00 $28.00 $51.00 $72.00 $30.00 $42.00 $642.00 $64.00 $579.00 $288.00 $62.00 $226.00 $212.00 BR $195.00 $45.00 $151.00 $516.00 $81.00 $435.00 BR $228.00 BR $275.00 $85.00 $190.00 $72.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $32.00 $55.00 $231.00 $75.00 $156.00 $88.00 $21.00 $66.00 $195.00 $45.00 $179.00 $27.00 $3.00 $23.00 BR $71.00 BR ------------------$110.00 $20.00 $90.00 $84.00 $28.00 $56.00 $77.00 $31.00 $46.00 $692.00 $66.00 $626.00 $312.00 $64.00 $249.00 $219.00 BR $210.00 $46.00 $164.00 $558.00 $84.00 $474.00 BR $237.00 BR $298.00 $88.00 $209.00 $77.00 $33.00 $59.00 $251.00 $79.00 $172.00 $94.00 $22.00 $72.00 $214.00 $47.00 $197.00 $30.00 $4.00 $26.00 BR $76.00 BR ------------------$119.00 $21.00 $98.00 $90.00 $29.00 $61.00 $83.00 $32.00 $51.00 $740.00 $68.00 $672.00 $340.00 $66.00 $273.00 $228.00 BR $225.00 $48.00 $177.00 $603.00 $88.00 $515.00 BR $248.00 BR $323.00 $92.00 $230.00 $83.00 Part C, 271 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 77032-26 77032-TC 77051 77051-26 77051-TC 77052 77052-26 77052-TC 77053 77053-26 77053-TC 77054 77054-26 77054-TC 77055 77055-26 77055-TC 77056 77056-26 77056-TC 77057 77057-26 77057-TC 77058 77058-26 77058-TC 77059 77059-26 77059-TC 77071 77072 77072-26 77072-TC 77073 77073-26 77073-TC 77074 77074-26 77074-TC 77075 77075-26 77075-TC 77077 77077-26 77077-TC 77078 77078-26 77078-TC 77079 77079-26 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $29.00 $43.00 $16.00 $4.00 $12.00 $16.00 $4.00 $12.00 $102.00 $19.00 $82.00 $137.00 $24.00 $114.00 $89.00 $37.00 $52.00 $112.00 $46.00 $66.00 $90.00 $37.00 $52.00 $904.00 $86.00 $817.00 $1,046.00 $86.00 $959.00 $38.00 $25.00 $10.00 $15.00 $44.00 $15.00 $30.00 $73.00 $24.00 $48.00 $103.00 $29.00 $74.00 $53.00 $16.00 $36.00 $90.00 $13.00 $77.00 $87.00 $11.00 $30.00 $47.00 $17.00 $4.00 $13.00 $17.00 $4.00 $13.00 $110.00 $20.00 $90.00 $149.00 $25.00 $125.00 $95.00 $39.00 $56.00 $120.00 $48.00 $72.00 $96.00 $39.00 $57.00 $979.00 $89.00 $890.00 $1,136.00 $89.00 $1,047.00 $40.00 $27.00 $10.00 $17.00 $48.00 $15.00 $33.00 $78.00 $25.00 $53.00 $111.00 $30.00 $81.00 $57.00 $17.00 $40.00 $97.00 $13.00 $84.00 $94.00 $12.00 $31.00 $51.00 $19.00 $4.00 $14.00 $19.00 $4.00 $14.00 $120.00 $21.00 $99.00 $162.00 $26.00 $136.00 $101.00 $40.00 $61.00 $127.00 $50.00 $78.00 $102.00 $40.00 $62.00 $1,056.00 $93.00 $963.00 $1,230.00 $93.00 $1,137.00 $43.00 $29.00 $11.00 $18.00 $51.00 $16.00 $36.00 $84.00 $26.00 $57.00 $118.00 $31.00 $88.00 $62.00 $18.00 $44.00 $104.00 $14.00 $90.00 $100.00 $12.00 $29.00 $43.00 $16.00 $4.00 $12.00 $16.00 $4.00 $12.00 $102.00 $19.00 $82.00 $137.00 $24.00 $114.00 $89.00 $37.00 $52.00 $112.00 $46.00 $66.00 $90.00 $37.00 $52.00 $904.00 $86.00 $817.00 $1,046.00 $86.00 $959.00 $38.00 $25.00 $10.00 $15.00 $44.00 $15.00 $30.00 $73.00 $24.00 $48.00 $103.00 $29.00 $74.00 $53.00 $16.00 $36.00 $90.00 $13.00 $77.00 $87.00 $11.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $30.00 $47.00 $17.00 $4.00 $13.00 $17.00 $4.00 $13.00 $110.00 $20.00 $90.00 $149.00 $25.00 $125.00 $95.00 $39.00 $56.00 $120.00 $48.00 $72.00 $96.00 $39.00 $57.00 $979.00 $89.00 $890.00 $1,136.00 $89.00 $1,047.00 $40.00 $27.00 $10.00 $17.00 $48.00 $15.00 $33.00 $78.00 $25.00 $53.00 $111.00 $30.00 $81.00 $57.00 $17.00 $40.00 $97.00 $13.00 $84.00 $94.00 $12.00 $31.00 $51.00 $19.00 $4.00 $14.00 $19.00 $4.00 $14.00 $120.00 $21.00 $99.00 $162.00 $26.00 $136.00 $101.00 $40.00 $61.00 $127.00 $50.00 $78.00 $102.00 $40.00 $62.00 $1,056.00 $93.00 $963.00 $1,230.00 $93.00 $1,137.00 $43.00 $29.00 $11.00 $18.00 $51.00 $16.00 $36.00 $84.00 $26.00 $57.00 $118.00 $31.00 $88.00 $62.00 $18.00 $44.00 $104.00 $14.00 $90.00 $100.00 $12.00 Part C, 272 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 77079-TC 77080 77080-26 77080-TC 77081 77081-26 77081-TC 77082 77082-26 77082-TC 77083 77083-26 77083-TC 77084 77084-26 77084-TC 77261 77262 77263 77280 77280-26 77280-TC 77285 77285-26 77285-TC 77290 77290-26 77290-TC 77295 77295-26 77295-TC 77299 77299-26 77299-TC 77300 77300-26 77300-TC 77301 77301-26 77301-TC 77305 77305-26 77305-TC 77310 77310-26 77310-TC 77315 77315-26 77315-TC 77321 ------------------------------------------------------------------------------------------------$73.00 $110.00 $163.00 $166.00 $36.00 $130.00 $264.00 $53.00 $209.00 $325.00 $79.00 $243.00 $1,287.00 $232.00 $1,046.00 BR BR BR $87.00 $36.00 $52.00 $1,473.00 $415.00 $1,046.00 $106.00 $36.00 $69.00 $142.00 $53.00 $87.00 $181.00 $79.00 $99.00 $200.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $76.00 $89.00 $11.00 $78.00 $37.00 $11.00 $26.00 $36.00 $9.00 $27.00 $34.00 $11.00 $24.00 $413.00 $84.00 $330.00 $75.00 $113.00 $168.00 $199.00 $37.00 $162.00 $334.00 $55.00 $279.00 $485.00 $82.00 $403.00 $999.00 $241.00 $758.00 ------------------$83.00 $33.00 $50.00 $2,139.00 $422.00 $1,718.00 $94.00 $37.00 $57.00 $127.00 $55.00 $72.00 $174.00 $82.00 $92.00 $166.00 $82.00 $97.00 $12.00 $86.00 $40.00 $12.00 $29.00 $39.00 $9.00 $30.00 $37.00 $11.00 $26.00 $446.00 $87.00 $359.00 $77.00 $117.00 $174.00 $215.00 $39.00 $176.00 $361.00 $57.00 $304.00 $523.00 $85.00 $438.00 $1,084.00 $250.00 $835.00 ------------------$88.00 $34.00 $55.00 $2,300.00 $437.00 $1,863.00 $101.00 $39.00 $62.00 $136.00 $57.00 $79.00 $186.00 $85.00 $101.00 $180.00 $88.00 $106.00 $12.00 $94.00 $44.00 $12.00 $31.00 $42.00 $10.00 $33.00 $41.00 $11.00 $29.00 $479.00 $90.00 $389.00 $81.00 $122.00 $182.00 $231.00 $41.00 $191.00 $387.00 $59.00 $328.00 $560.00 $89.00 $471.00 $1,180.00 $260.00 $920.00 ------------------$95.00 $35.00 $59.00 $2,460.00 $455.00 $2,004.00 $110.00 $41.00 $69.00 $146.00 $59.00 $87.00 $199.00 $89.00 $110.00 $195.00 $76.00 $89.00 $11.00 $78.00 $37.00 $11.00 $26.00 $36.00 $9.00 $27.00 $34.00 $11.00 $24.00 $413.00 $84.00 $330.00 $75.00 $113.00 $168.00 $199.00 $37.00 $162.00 $334.00 $55.00 $279.00 $485.00 $82.00 $403.00 $999.00 $241.00 $758.00 ------------------$83.00 $33.00 $50.00 $2,139.00 $422.00 $1,718.00 $94.00 $37.00 $57.00 $127.00 $55.00 $72.00 $174.00 $82.00 $92.00 $166.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $82.00 $97.00 $12.00 $86.00 $40.00 $12.00 $29.00 $39.00 $9.00 $30.00 $37.00 $11.00 $26.00 $446.00 $87.00 $359.00 $77.00 $117.00 $174.00 $215.00 $39.00 $176.00 $361.00 $57.00 $304.00 $523.00 $85.00 $438.00 $1,084.00 $250.00 $835.00 ------------------$88.00 $34.00 $55.00 $2,300.00 $437.00 $1,863.00 $101.00 $39.00 $62.00 $136.00 $57.00 $79.00 $186.00 $85.00 $101.00 $180.00 $88.00 $106.00 $12.00 $94.00 $44.00 $12.00 $31.00 $42.00 $10.00 $33.00 $41.00 $11.00 $29.00 $479.00 $90.00 $389.00 $81.00 $122.00 $182.00 $231.00 $41.00 $191.00 $387.00 $59.00 $328.00 $560.00 $89.00 $471.00 $1,180.00 $260.00 $920.00 ------------------$95.00 $35.00 $59.00 $2,460.00 $455.00 $2,004.00 $110.00 $41.00 $69.00 $146.00 $59.00 $87.00 $199.00 $89.00 $110.00 $195.00 Part C, 273 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 77321-26 77321-TC 77326 77326-26 77326-TC 77327 77327-26 77327-TC 77328 77328-26 77328-TC 77331 77331-26 77331-TC 77332 77332-26 77332-TC 77333 77333-26 77333-TC 77334 77334-26 77334-TC 77336 77370 77371 77372 77373 77399 77399-26 77399-TC 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77418 77421 77421-26 77421-TC 77422 $48.00 $150.00 $137.00 $47.00 $88.00 $202.00 $71.00 $130.00 $295.00 $106.00 $185.00 $64.00 $45.00 $18.00 $78.00 $27.00 $50.00 $115.00 $43.00 $70.00 $187.00 $63.00 $121.00 $111.00 $130.00 ------------------BR BR BR $66.00 $66.00 $66.00 $66.00 $66.00 $78.00 $78.00 $78.00 $78.00 $87.00 $87.00 $87.00 $87.00 $21.00 $609.00 ------------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $50.00 $116.00 $156.00 $49.00 $107.00 $224.00 $73.00 $151.00 $313.00 $111.00 $202.00 $67.00 $46.00 $21.00 $86.00 $29.00 $58.00 $93.00 $44.00 $49.00 $185.00 $65.00 $120.00 $91.00 $140.00 $1,190.00 $904.00 $1,683.00 ------------------$51.00 $127.00 $116.00 $124.00 $125.00 $162.00 $150.00 $162.00 $161.00 $187.00 $189.00 $206.00 $206.00 $21.00 $621.00 $137.00 $21.00 $116.00 $147.00 $52.00 $127.00 $168.00 $51.00 $117.00 $240.00 $76.00 $165.00 $336.00 $115.00 $221.00 $70.00 $47.00 $23.00 $93.00 $30.00 $63.00 $100.00 $46.00 $54.00 $198.00 $67.00 $131.00 $100.00 $152.00 $1,277.00 $971.00 $1,806.00 ------------------$56.00 $138.00 $126.00 $135.00 $136.00 $176.00 $163.00 $175.00 $175.00 $203.00 $204.00 $222.00 $222.00 $23.00 $667.00 $147.00 $21.00 $126.00 $159.00 $55.00 $140.00 $180.00 $53.00 $127.00 $257.00 $79.00 $178.00 $359.00 $120.00 $240.00 $74.00 $49.00 $25.00 $99.00 $31.00 $68.00 $107.00 $48.00 $60.00 $213.00 $70.00 $143.00 $110.00 $165.00 $1,351.00 $1,028.00 $1,908.00 ------------------$62.00 $148.00 $135.00 $145.00 $146.00 $188.00 $175.00 $188.00 $188.00 $217.00 $219.00 $238.00 $238.00 $26.00 $707.00 $158.00 $22.00 $136.00 $171.00 $50.00 $116.00 $156.00 $49.00 $107.00 $224.00 $73.00 $151.00 $313.00 $111.00 $202.00 $67.00 $46.00 $21.00 $86.00 $29.00 $58.00 $93.00 $44.00 $49.00 $185.00 $65.00 $120.00 $91.00 $140.00 $1,190.00 $904.00 $1,683.00 ------------------$51.00 $127.00 $116.00 $124.00 $125.00 $162.00 $150.00 $162.00 $161.00 $187.00 $189.00 $206.00 $206.00 $21.00 $621.00 $137.00 $21.00 $116.00 $147.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $52.00 $127.00 $168.00 $51.00 $117.00 $240.00 $76.00 $165.00 $336.00 $115.00 $221.00 $70.00 $47.00 $23.00 $93.00 $30.00 $63.00 $100.00 $46.00 $54.00 $198.00 $67.00 $131.00 $100.00 $152.00 $1,277.00 $971.00 $1,806.00 ------------------$56.00 $138.00 $126.00 $135.00 $136.00 $176.00 $163.00 $175.00 $175.00 $203.00 $204.00 $222.00 $222.00 $23.00 $667.00 $147.00 $21.00 $126.00 $159.00 $55.00 $140.00 $180.00 $53.00 $127.00 $257.00 $79.00 $178.00 $359.00 $120.00 $240.00 $74.00 $49.00 $25.00 $99.00 $31.00 $68.00 $107.00 $48.00 $60.00 $213.00 $70.00 $143.00 $110.00 $165.00 $1,351.00 $1,028.00 $1,908.00 ------------------$62.00 $148.00 $135.00 $145.00 $146.00 $188.00 $175.00 $188.00 $188.00 $217.00 $219.00 $238.00 $238.00 $26.00 $707.00 $158.00 $22.00 $136.00 $171.00 Part C, 274 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 77423 77427 77431 77432 77435 77470 77470-26 77470-TC 77499 77499-26 77499-TC 77520 77522 77523 77525 77600 77600-26 77600-TC 77605 77605-26 77605-TC 77610 77610-26 77610-TC 77615 77615-26 77615-TC 77620 77620-26 77620-TC 77750 77750-26 77750-TC 77761 77761-26 77761-TC 77762 77762-26 77762-TC 77763 77763-26 77763-TC 77776 77776-26 77776-TC 77777 77777-26 77777-TC 77778 77778-26 ------$166.00 $95.00 $417.00 ------$527.00 $106.00 $417.00 BR BR BR BR BR BR BR $196.00 $80.00 $113.00 $263.00 $108.00 $151.00 $195.00 $79.00 $113.00 $262.00 $106.00 $151.00 $196.00 $80.00 $113.00 $299.00 $248.00 $49.00 $284.00 $188.00 $93.00 $427.00 $289.00 $135.00 $605.00 $435.00 $167.00 $316.00 $233.00 $82.00 $540.00 $378.00 $158.00 $764.00 $568.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $199.00 $195.00 $101.00 $426.00 $708.00 $391.00 $111.00 $280.00 ------------------------------------------$343.00 $82.00 $261.00 $556.00 $111.00 $446.00 $494.00 $79.00 $415.00 $699.00 $109.00 $590.00 $356.00 $88.00 $268.00 $349.00 $261.00 $88.00 $356.00 $199.00 $158.00 $498.00 $303.00 $196.00 $703.00 $453.00 $250.00 $416.00 $251.00 $165.00 $600.00 $395.00 $204.00 $860.00 $592.00 $215.00 $202.00 $105.00 $441.00 $735.00 $424.00 $115.00 $309.00 ------------------------------------------$367.00 $85.00 $282.00 $596.00 $116.00 $481.00 $529.00 $82.00 $447.00 $749.00 $113.00 $635.00 $383.00 $93.00 $290.00 $365.00 $270.00 $95.00 $377.00 $206.00 $171.00 $526.00 $314.00 $212.00 $741.00 $469.00 $272.00 $442.00 $264.00 $179.00 $632.00 $410.00 $222.00 $905.00 $614.00 $230.00 $210.00 $109.00 $460.00 $767.00 $462.00 $120.00 $342.00 ------------------------------------------$391.00 $89.00 $302.00 $635.00 $122.00 $513.00 $562.00 $86.00 $476.00 $794.00 $118.00 $676.00 $411.00 $100.00 $310.00 $384.00 $282.00 $102.00 $399.00 $214.00 $184.00 $556.00 $327.00 $229.00 $782.00 $489.00 $293.00 $472.00 $280.00 $192.00 $668.00 $428.00 $240.00 $954.00 $640.00 $199.00 $195.00 $101.00 $426.00 $708.00 $391.00 $111.00 $280.00 ------------------------------------------$343.00 $82.00 $261.00 $556.00 $111.00 $446.00 $494.00 $79.00 $415.00 $699.00 $109.00 $590.00 $356.00 $88.00 $268.00 $349.00 $261.00 $88.00 $356.00 $199.00 $158.00 $498.00 $303.00 $196.00 $703.00 $453.00 $250.00 $416.00 $251.00 $165.00 $600.00 $395.00 $204.00 $860.00 $592.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $215.00 $202.00 $105.00 $441.00 $735.00 $424.00 $115.00 $309.00 ------------------------------------------$367.00 $85.00 $282.00 $596.00 $116.00 $481.00 $529.00 $82.00 $447.00 $749.00 $113.00 $635.00 $383.00 $93.00 $290.00 $365.00 $270.00 $95.00 $377.00 $206.00 $171.00 $526.00 $314.00 $212.00 $741.00 $469.00 $272.00 $442.00 $264.00 $179.00 $632.00 $410.00 $222.00 $905.00 $614.00 $230.00 $210.00 $109.00 $460.00 $767.00 $462.00 $120.00 $342.00 ------------------------------------------$391.00 $89.00 $302.00 $635.00 $122.00 $513.00 $562.00 $86.00 $476.00 $794.00 $118.00 $676.00 $411.00 $100.00 $310.00 $384.00 $282.00 $102.00 $399.00 $214.00 $184.00 $556.00 $327.00 $229.00 $782.00 $489.00 $293.00 $472.00 $280.00 $192.00 $668.00 $428.00 $240.00 $954.00 $640.00 Part C, 275 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 77778-TC 77789 77789-26 77789-TC 77790 77790-26 77790-TC 77799 77799-26 77799-TC 78000 78000-26 78000-TC 78001 78001-26 78001-TC 78003 78003-26 78003-TC 78006 78006-26 78006-TC 78007 78007-26 78007-TC 78010 78010-26 78010-TC 78011 78011-26 78011-TC 78015 78015-26 78015-TC 78016 78016-26 78016-TC 78018 78018-26 78018-TC 78020 78020-26 78020-TC 78070 78070-26 78070-TC 78075 78075-26 78075-TC 78099 $192.00 $74.00 $57.00 $16.00 $72.00 $53.00 $18.00 BR BR BR $46.00 $9.00 $36.00 $62.00 $12.00 $48.00 $54.00 $17.00 $36.00 $115.00 $24.00 $89.00 $122.00 $25.00 $96.00 $89.00 $19.00 $68.00 $114.00 $22.00 $90.00 $132.00 $34.00 $96.00 $173.00 $42.00 $130.00 $248.00 $44.00 $202.00 $35.00 $30.00 $5.00 $112.00 $36.00 $68.00 $242.00 $38.00 $202.00 BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $267.00 $103.00 $61.00 $42.00 $88.00 $55.00 $33.00 ------------------$68.00 $10.00 $58.00 $87.00 $14.00 $73.00 $75.00 $17.00 $58.00 $199.00 $26.00 $174.00 $142.00 $26.00 $116.00 $143.00 $21.00 $122.00 $162.00 $24.00 $138.00 $195.00 $36.00 $160.00 $285.00 $43.00 $242.00 $321.00 $46.00 $274.00 $97.00 $32.00 $66.00 $197.00 $44.00 $154.00 $387.00 $39.00 $348.00 ------- $291.00 $108.00 $63.00 $45.00 $93.00 $57.00 $36.00 ------------------$73.00 $10.00 $63.00 $94.00 $14.00 $80.00 $81.00 $18.00 $63.00 $215.00 $26.00 $188.00 $154.00 $27.00 $126.00 $154.00 $21.00 $133.00 $174.00 $25.00 $150.00 $210.00 $37.00 $173.00 $306.00 $44.00 $262.00 $346.00 $48.00 $299.00 $105.00 $33.00 $73.00 $212.00 $45.00 $166.00 $417.00 $40.00 $377.00 ------- $314.00 $114.00 $66.00 $48.00 $97.00 $59.00 $38.00 ------------------$79.00 $11.00 $68.00 $101.00 $15.00 $86.00 $87.00 $18.00 $68.00 $229.00 $27.00 $202.00 $165.00 $28.00 $137.00 $165.00 $22.00 $143.00 $187.00 $26.00 $161.00 $225.00 $38.00 $187.00 $327.00 $46.00 $281.00 $372.00 $50.00 $323.00 $114.00 $34.00 $80.00 $226.00 $47.00 $178.00 $447.00 $42.00 $406.00 ------- $267.00 $103.00 $61.00 $42.00 $88.00 $55.00 $33.00 ------------------$68.00 $10.00 $58.00 $87.00 $14.00 $73.00 $75.00 $17.00 $58.00 $199.00 $26.00 $174.00 $142.00 $26.00 $116.00 $143.00 $21.00 $122.00 $162.00 $24.00 $138.00 $195.00 $36.00 $160.00 $285.00 $43.00 $242.00 $321.00 $46.00 $274.00 $97.00 $32.00 $66.00 $197.00 $44.00 $154.00 $387.00 $39.00 $348.00 ------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $291.00 $108.00 $63.00 $45.00 $93.00 $57.00 $36.00 ------------------$73.00 $10.00 $63.00 $94.00 $14.00 $80.00 $81.00 $18.00 $63.00 $215.00 $26.00 $188.00 $154.00 $27.00 $126.00 $154.00 $21.00 $133.00 $174.00 $25.00 $150.00 $210.00 $37.00 $173.00 $306.00 $44.00 $262.00 $346.00 $48.00 $299.00 $105.00 $33.00 $73.00 $212.00 $45.00 $166.00 $417.00 $40.00 $377.00 ------- $314.00 $114.00 $66.00 $48.00 $97.00 $59.00 $38.00 ------------------$79.00 $11.00 $68.00 $101.00 $15.00 $86.00 $87.00 $18.00 $68.00 $229.00 $27.00 $202.00 $165.00 $28.00 $137.00 $165.00 $22.00 $143.00 $187.00 $26.00 $161.00 $225.00 $38.00 $187.00 $327.00 $46.00 $281.00 $372.00 $50.00 $323.00 $114.00 $34.00 $80.00 $226.00 $47.00 $178.00 $447.00 $42.00 $406.00 ------- Part C, 276 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 78099-26 78099-TC 78102 78102-26 78102-TC 78103 78103-26 78103-TC 78104 78104-26 78104-TC 78110 78110-26 78110-TC 78111 78111-26 78111-TC 78120 78120-26 78120-TC 78121 78121-26 78121-TC 78122 78122-26 78122-TC 78130 78130-26 78130-TC 78135 78135-26 78135-TC 78140 78140-26 78140-TC 78185 78185-26 78185-TC 78190 78190-26 78190-TC 78191 78191-26 78191-TC 78195 78195-26 78195-TC 78199 78199-26 78199-TC BR BR $106.00 $28.00 $77.00 $158.00 $39.00 $118.00 $194.00 $41.00 $152.00 $45.00 $9.00 $35.00 $108.00 $11.00 $96.00 $78.00 $11.00 $65.00 $125.00 $16.00 $108.00 $196.00 $22.00 $171.00 $139.00 $32.00 $106.00 $216.00 $33.00 $182.00 $179.00 $31.00 $147.00 $110.00 $20.00 $88.00 $272.00 $57.00 $214.00 $307.00 $31.00 $274.00 $216.00 $49.00 $152.00 BR BR BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------$155.00 $29.00 $126.00 $214.00 $40.00 $175.00 $253.00 $42.00 $210.00 $74.00 $10.00 $63.00 $112.00 $12.00 $100.00 $93.00 $12.00 $81.00 $124.00 $17.00 $107.00 $171.00 $24.00 $146.00 $162.00 $33.00 $129.00 $311.00 $34.00 $277.00 $177.00 $33.00 $144.00 $175.00 $21.00 $154.00 $253.00 $58.00 $195.00 $265.00 $33.00 $232.00 $320.00 $64.00 $256.00 ------------------- ------------$167.00 $30.00 $137.00 $231.00 $41.00 $190.00 $272.00 $44.00 $229.00 $79.00 $11.00 $68.00 $121.00 $12.00 $109.00 $101.00 $13.00 $88.00 $134.00 $17.00 $117.00 $186.00 $25.00 $161.00 $175.00 $34.00 $141.00 $336.00 $35.00 $301.00 $191.00 $34.00 $157.00 $189.00 $22.00 $167.00 $272.00 $60.00 $212.00 $288.00 $34.00 $254.00 $344.00 $67.00 $278.00 ------------------- ------------$178.00 $31.00 $148.00 $247.00 $43.00 $205.00 $292.00 $45.00 $247.00 $85.00 $11.00 $74.00 $131.00 $13.00 $119.00 $109.00 $13.00 $96.00 $145.00 $18.00 $127.00 $202.00 $26.00 $176.00 $187.00 $35.00 $152.00 $361.00 $37.00 $324.00 $207.00 $35.00 $172.00 $202.00 $23.00 $179.00 $292.00 $63.00 $229.00 $313.00 $35.00 $278.00 $368.00 $69.00 $299.00 ------------------- ------------$155.00 $29.00 $126.00 $214.00 $40.00 $175.00 $253.00 $42.00 $210.00 $74.00 $10.00 $63.00 $112.00 $12.00 $100.00 $93.00 $12.00 $81.00 $124.00 $17.00 $107.00 $171.00 $24.00 $146.00 $162.00 $33.00 $129.00 $311.00 $34.00 $277.00 $177.00 $33.00 $144.00 $175.00 $21.00 $154.00 $253.00 $58.00 $195.00 $265.00 $33.00 $232.00 $320.00 $64.00 $256.00 ------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------$167.00 $30.00 $137.00 $231.00 $41.00 $190.00 $272.00 $44.00 $229.00 $79.00 $11.00 $68.00 $121.00 $12.00 $109.00 $101.00 $13.00 $88.00 $134.00 $17.00 $117.00 $186.00 $25.00 $161.00 $175.00 $34.00 $141.00 $336.00 $35.00 $301.00 $191.00 $34.00 $157.00 $189.00 $22.00 $167.00 $272.00 $60.00 $212.00 $288.00 $34.00 $254.00 $344.00 $67.00 $278.00 ------------------- ------------$178.00 $31.00 $148.00 $247.00 $43.00 $205.00 $292.00 $45.00 $247.00 $85.00 $11.00 $74.00 $131.00 $13.00 $119.00 $109.00 $13.00 $96.00 $145.00 $18.00 $127.00 $202.00 $26.00 $176.00 $187.00 $35.00 $152.00 $361.00 $37.00 $324.00 $207.00 $35.00 $172.00 $202.00 $23.00 $179.00 $292.00 $63.00 $229.00 $313.00 $35.00 $278.00 $368.00 $69.00 $299.00 ------------------- Part C, 277 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 78201 78201-26 78201-TC 78202 78202-26 78202-TC 78205 78205-26 78205-TC 78206 78206-26 78206-TC 78215 78215-26 78215-TC 78216 78216-26 78216-TC 78220 78220-26 78220-TC 78223 78223-26 78223-TC 78230 78230-26 78230-TC 78231 78231-26 78231-TC 78232 78232-26 78232-TC 78258 78258-26 78258-TC 78261 78261-26 78261-TC 78262 78262-26 78262-TC 78264 78264-26 78264-TC 78267 78268 78270 78270-26 78270-TC $112.00 $22.00 $88.00 $135.00 $26.00 $108.00 $259.00 $36.00 $220.00 $265.00 $46.00 $214.00 $135.00 $24.00 $109.00 $160.00 $29.00 $130.00 $165.00 $24.00 $139.00 $181.00 $43.00 $137.00 $106.00 $23.00 $82.00 $146.00 $27.00 $118.00 $157.00 $23.00 $132.00 $146.00 $38.00 $108.00 $190.00 $36.00 $152.00 $195.00 $35.00 $159.00 $195.00 $40.00 $154.00 BR BR $68.00 $10.00 $58.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $165.00 $23.00 $142.00 $194.00 $27.00 $167.00 $272.00 $38.00 $234.00 $336.00 $51.00 $285.00 $184.00 $26.00 $158.00 $161.00 $30.00 $132.00 $168.00 $26.00 $142.00 $290.00 $45.00 $245.00 $154.00 $24.00 $130.00 $152.00 $27.00 $124.00 $157.00 $25.00 $132.00 $208.00 $39.00 $169.00 $244.00 $37.00 $207.00 $246.00 $36.00 $210.00 $271.00 $41.00 $230.00 ------------$84.00 $11.00 $73.00 $178.00 $24.00 $155.00 $209.00 $28.00 $181.00 $295.00 $39.00 $256.00 $360.00 $53.00 $307.00 $198.00 $27.00 $171.00 $175.00 $31.00 $144.00 $182.00 $26.00 $155.00 $312.00 $46.00 $265.00 $166.00 $25.00 $141.00 $164.00 $28.00 $136.00 $170.00 $26.00 $144.00 $223.00 $41.00 $183.00 $264.00 $38.00 $225.00 $265.00 $37.00 $228.00 $293.00 $43.00 $250.00 ------------$91.00 $11.00 $80.00 $191.00 $25.00 $166.00 $223.00 $29.00 $195.00 $318.00 $40.00 $278.00 $382.00 $55.00 $327.00 $212.00 $28.00 $184.00 $188.00 $32.00 $157.00 $196.00 $27.00 $169.00 $333.00 $48.00 $285.00 $178.00 $26.00 $152.00 $177.00 $29.00 $148.00 $184.00 $27.00 $157.00 $239.00 $42.00 $196.00 $283.00 $40.00 $244.00 $285.00 $38.00 $247.00 $314.00 $44.00 $269.00 ------------$99.00 $12.00 $87.00 $165.00 $23.00 $142.00 $194.00 $27.00 $167.00 $272.00 $38.00 $234.00 $336.00 $51.00 $285.00 $184.00 $26.00 $158.00 $161.00 $30.00 $132.00 $168.00 $26.00 $142.00 $290.00 $45.00 $245.00 $154.00 $24.00 $130.00 $152.00 $27.00 $124.00 $157.00 $25.00 $132.00 $208.00 $39.00 $169.00 $244.00 $37.00 $207.00 $246.00 $36.00 $210.00 $271.00 $41.00 $230.00 ------------$84.00 $11.00 $73.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $178.00 $24.00 $155.00 $209.00 $28.00 $181.00 $295.00 $39.00 $256.00 $360.00 $53.00 $307.00 $198.00 $27.00 $171.00 $175.00 $31.00 $144.00 $182.00 $26.00 $155.00 $312.00 $46.00 $265.00 $166.00 $25.00 $141.00 $164.00 $28.00 $136.00 $170.00 $26.00 $144.00 $223.00 $41.00 $183.00 $264.00 $38.00 $225.00 $265.00 $37.00 $228.00 $293.00 $43.00 $250.00 ------------$91.00 $11.00 $80.00 $191.00 $25.00 $166.00 $223.00 $29.00 $195.00 $318.00 $40.00 $278.00 $382.00 $55.00 $327.00 $212.00 $28.00 $184.00 $188.00 $32.00 $157.00 $196.00 $27.00 $169.00 $333.00 $48.00 $285.00 $178.00 $26.00 $152.00 $177.00 $29.00 $148.00 $184.00 $27.00 $157.00 $239.00 $42.00 $196.00 $283.00 $40.00 $244.00 $285.00 $38.00 $247.00 $314.00 $44.00 $269.00 ------------$99.00 $12.00 $87.00 Part C, 278 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 78271 78271-26 78271-TC 78272 78272-26 78272-TC 78278 78278-26 78278-TC 78282 78282-26 78282-TC 78290 78290-26 78290-TC 78291 78291-26 78291-TC 78299 78299-26 78299-TC 78300 78300-26 78300-TC 78305 78305-26 78305-TC 78306 78306-26 78306-TC 78315 78315-26 78315-TC 78320 78320-26 78320-TC 78350 78350-26 78350-TC 78351 78399 78399-26 78399-TC 78414 78414-26 78414-TC 78428 78428-26 78428-TC 78445 $72.00 $10.00 $61.00 $100.00 $14.00 $87.00 $234.00 $50.00 $182.00 BR $19.00 BR $149.00 $35.00 $113.00 $161.00 $45.00 $114.00 BR BR BR $125.00 $32.00 $93.00 $181.00 $42.00 $137.00 $205.00 $44.00 $159.00 $233.00 $52.00 $179.00 $276.00 $53.00 $220.00 $40.00 $11.00 $29.00 $23.00 BR BR BR BR $23.00 BR $126.00 $41.00 $84.00 $97.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $85.00 $11.00 $75.00 $107.00 $14.00 $93.00 $306.00 $52.00 $254.00 $267.00 $20.00 $261.00 $269.00 $36.00 $233.00 $232.00 $47.00 $185.00 ------------------$169.00 $33.00 $136.00 $230.00 $44.00 $186.00 $257.00 $46.00 $211.00 $310.00 $54.00 $256.00 $289.00 $55.00 $234.00 $38.00 $11.00 $27.00 $15.00 ------------------------$25.00 ------$192.00 $43.00 $149.00 $154.00 $92.00 $11.00 $81.00 $116.00 $14.00 $102.00 $330.00 $54.00 $276.00 $294.00 $21.00 $287.00 $289.00 $38.00 $252.00 $249.00 $48.00 $201.00 ------------------$183.00 $34.00 $148.00 $248.00 $46.00 $202.00 $277.00 $48.00 $229.00 $333.00 $56.00 $278.00 $312.00 $57.00 $255.00 $41.00 $11.00 $30.00 $15.00 ------------------------$26.00 ------$206.00 $45.00 $161.00 $166.00 $100.00 $11.00 $89.00 $125.00 $15.00 $111.00 $353.00 $56.00 $297.00 $324.00 $22.00 $316.00 $309.00 $39.00 $270.00 $266.00 $50.00 $216.00 ------------------$196.00 $36.00 $160.00 $266.00 $48.00 $218.00 $297.00 $50.00 $248.00 $357.00 $58.00 $299.00 $336.00 $59.00 $277.00 $44.00 $12.00 $33.00 $16.00 ------------------------$27.00 ------$220.00 $47.00 $174.00 $177.00 $85.00 $11.00 $75.00 $107.00 $14.00 $93.00 $306.00 $52.00 $254.00 $267.00 $20.00 $261.00 $269.00 $36.00 $233.00 $232.00 $47.00 $185.00 ------------------$169.00 $33.00 $136.00 $230.00 $44.00 $186.00 $257.00 $46.00 $211.00 $310.00 $54.00 $256.00 $289.00 $55.00 $234.00 $38.00 $11.00 $27.00 $15.00 ------------------------$25.00 ------$192.00 $43.00 $149.00 $154.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $92.00 $11.00 $81.00 $116.00 $14.00 $102.00 $330.00 $54.00 $276.00 $294.00 $21.00 $287.00 $289.00 $38.00 $252.00 $249.00 $48.00 $201.00 ------------------$183.00 $34.00 $148.00 $248.00 $46.00 $202.00 $277.00 $48.00 $229.00 $333.00 $56.00 $278.00 $312.00 $57.00 $255.00 $41.00 $11.00 $30.00 $15.00 ------------------------$26.00 ------$206.00 $45.00 $161.00 $166.00 $100.00 $11.00 $89.00 $125.00 $15.00 $111.00 $353.00 $56.00 $297.00 $324.00 $22.00 $316.00 $309.00 $39.00 $270.00 $266.00 $50.00 $216.00 ------------------$196.00 $36.00 $160.00 $266.00 $48.00 $218.00 $297.00 $50.00 $248.00 $357.00 $58.00 $299.00 $336.00 $59.00 $277.00 $44.00 $12.00 $33.00 $16.00 ------------------------$27.00 ------$220.00 $47.00 $174.00 $177.00 Part C, 279 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 78445-26 78445-TC 78456 78456-26 78456-TC 78457 78457-26 78457-TC 78458 78458-26 78458-TC 78459 78459-26 78459-TC 78460 78460-26 78460-TC 78461 78461-26 78461-TC 78464 78464-26 78464-TC 78465 78465-26 78465-TC 78466 78466-26 78466-TC 78468 78468-26 78468-TC 78469 78469-26 78469-TC 78472 78472-26 78472-TC 78473 78473-26 78473-TC 78478 78478-26 78478-TC 78480 78480-26 78480-TC 78481 78481-26 78481-TC $28.00 $69.00 $205.00 $49.00 $151.00 $140.00 $39.00 $99.00 $198.00 $46.00 $149.00 BR $100.00 BR $134.00 $44.00 $88.00 $294.00 $82.00 $213.00 $322.00 $56.00 $264.00 $519.00 $75.00 $441.00 $135.00 $36.00 $97.00 $180.00 $41.00 $137.00 $244.00 $47.00 $195.00 $259.00 $50.00 $206.00 $387.00 $75.00 $308.00 $91.00 $32.00 $58.00 $91.00 $32.00 $58.00 $248.00 $51.00 $195.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $26.00 $128.00 $265.00 $53.00 $211.00 $188.00 $40.00 $148.00 $223.00 $48.00 $175.00 $1,538.00 $82.00 $1,512.00 $186.00 $46.00 $140.00 $245.00 $66.00 $179.00 $327.00 $60.00 $267.00 $562.00 $81.00 $481.00 $182.00 $38.00 $145.00 $235.00 $44.00 $191.00 $286.00 $51.00 $235.00 $290.00 $53.00 $237.00 $409.00 $81.00 $328.00 $77.00 $29.00 $48.00 $67.00 $19.00 $48.00 $265.00 $55.00 $210.00 $27.00 $139.00 $285.00 $55.00 $230.00 $202.00 $41.00 $160.00 $240.00 $49.00 $191.00 $1,694.00 $84.00 $1,665.00 $199.00 $48.00 $152.00 $264.00 $68.00 $196.00 $354.00 $62.00 $292.00 $609.00 $84.00 $525.00 $196.00 $39.00 $157.00 $254.00 $46.00 $208.00 $308.00 $52.00 $256.00 $314.00 $55.00 $259.00 $441.00 $83.00 $358.00 $83.00 $30.00 $53.00 $73.00 $20.00 $53.00 $286.00 $57.00 $229.00 $28.00 $150.00 $306.00 $57.00 $249.00 $216.00 $43.00 $173.00 $258.00 $51.00 $207.00 $1,866.00 $87.00 $1,834.00 $213.00 $50.00 $163.00 $284.00 $70.00 $213.00 $382.00 $64.00 $318.00 $657.00 $87.00 $570.00 $210.00 $40.00 $169.00 $272.00 $47.00 $224.00 $332.00 $54.00 $278.00 $338.00 $57.00 $281.00 $475.00 $87.00 $389.00 $90.00 $31.00 $58.00 $79.00 $21.00 $58.00 $308.00 $59.00 $249.00 $26.00 $128.00 $265.00 $53.00 $211.00 $188.00 $40.00 $148.00 $223.00 $48.00 $175.00 $1,538.00 $82.00 $1,512.00 $186.00 $46.00 $140.00 $245.00 $66.00 $179.00 $327.00 $60.00 $267.00 $562.00 $81.00 $481.00 $182.00 $38.00 $145.00 $235.00 $44.00 $191.00 $286.00 $51.00 $235.00 $290.00 $53.00 $237.00 $409.00 $81.00 $328.00 $77.00 $29.00 $48.00 $67.00 $19.00 $48.00 $265.00 $55.00 $210.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $27.00 $139.00 $285.00 $55.00 $230.00 $202.00 $41.00 $160.00 $240.00 $49.00 $191.00 $1,694.00 $84.00 $1,665.00 $199.00 $48.00 $152.00 $264.00 $68.00 $196.00 $354.00 $62.00 $292.00 $609.00 $84.00 $525.00 $196.00 $39.00 $157.00 $254.00 $46.00 $208.00 $308.00 $52.00 $256.00 $314.00 $55.00 $259.00 $441.00 $83.00 $358.00 $83.00 $30.00 $53.00 $73.00 $20.00 $53.00 $286.00 $57.00 $229.00 $28.00 $150.00 $306.00 $57.00 $249.00 $216.00 $43.00 $173.00 $258.00 $51.00 $207.00 $1,866.00 $87.00 $1,834.00 $213.00 $50.00 $163.00 $284.00 $70.00 $213.00 $382.00 $64.00 $318.00 $657.00 $87.00 $570.00 $210.00 $40.00 $169.00 $272.00 $47.00 $224.00 $332.00 $54.00 $278.00 $338.00 $57.00 $281.00 $475.00 $87.00 $389.00 $90.00 $31.00 $58.00 $79.00 $21.00 $58.00 $308.00 $59.00 $249.00 Part C, 280 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 78483 78483-26 78483-TC 78491 78491-26 78491-TC 78492 78492-26 78492-TC 78494 78494-26 78494-TC 78496 78496-26 78496-TC 78499 78499-26 78499-TC 78580 78580-26 78580-TC 78584 78584-26 78584-TC 78585 78585-26 78585-TC 78586 78586-26 78586-TC 78587 78587-26 78587-TC 78588 78588-26 78588-TC 78591 78591-26 78591-TC 78593 78593-26 78593-TC 78594 78594-26 78594-TC 78596 78596-26 78596-TC 78599 78599-26 $373.00 $77.00 $294.00 BR $85.00 BR BR $100.00 BR $324.00 $59.00 $262.00 $92.00 $24.00 $66.00 BR BR BR $167.00 $38.00 $128.00 $171.00 $50.00 $119.00 $171.00 $36.00 $133.00 $118.00 $20.00 $96.00 $131.00 $24.00 $105.00 $239.00 $53.00 $192.00 $128.00 $20.00 $106.00 $151.00 $24.00 $126.00 $214.00 $27.00 $186.00 $332.00 $65.00 $264.00 BR BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $383.00 $83.00 $300.00 $1,540.00 $83.00 $1,512.00 $1,548.00 $106.00 $1,512.00 $335.00 $66.00 $269.00 $198.00 $28.00 $170.00 ------------------$213.00 $39.00 $174.00 $178.00 $52.00 $126.00 $349.00 $58.00 $292.00 $160.00 $21.00 $139.00 $193.00 $26.00 $167.00 $294.00 $58.00 $237.00 $165.00 $21.00 $144.00 $196.00 $26.00 $170.00 $242.00 $28.00 $214.00 $391.00 $66.00 $325.00 ------------- $413.00 $86.00 $327.00 $1,696.00 $86.00 $1,665.00 $1,706.00 $109.00 $1,665.00 $361.00 $68.00 $293.00 $216.00 $28.00 $187.00 ------------------$230.00 $41.00 $189.00 $192.00 $54.00 $138.00 $377.00 $60.00 $317.00 $173.00 $22.00 $151.00 $208.00 $27.00 $181.00 $316.00 $60.00 $256.00 $178.00 $22.00 $156.00 $212.00 $26.00 $185.00 $262.00 $29.00 $233.00 $422.00 $68.00 $354.00 ------------- $445.00 $89.00 $356.00 $1,868.00 $89.00 $1,834.00 $1,879.00 $113.00 $1,834.00 $388.00 $71.00 $317.00 $235.00 $30.00 $205.00 ------------------$247.00 $42.00 $205.00 $206.00 $56.00 $150.00 $405.00 $62.00 $342.00 $185.00 $23.00 $163.00 $223.00 $28.00 $195.00 $337.00 $62.00 $275.00 $192.00 $23.00 $168.00 $227.00 $27.00 $200.00 $282.00 $30.00 $252.00 $453.00 $71.00 $383.00 ------------- $383.00 $83.00 $300.00 $1,540.00 $83.00 $1,512.00 $1,548.00 $106.00 $1,512.00 $335.00 $66.00 $269.00 $198.00 $28.00 $170.00 ------------------$213.00 $39.00 $174.00 $178.00 $52.00 $126.00 $349.00 $58.00 $292.00 $160.00 $21.00 $139.00 $193.00 $26.00 $167.00 $294.00 $58.00 $237.00 $165.00 $21.00 $144.00 $196.00 $26.00 $170.00 $242.00 $28.00 $214.00 $391.00 $66.00 $325.00 ------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $413.00 $86.00 $327.00 $1,696.00 $86.00 $1,665.00 $1,706.00 $109.00 $1,665.00 $361.00 $68.00 $293.00 $216.00 $28.00 $187.00 ------------------$230.00 $41.00 $189.00 $192.00 $54.00 $138.00 $377.00 $60.00 $317.00 $173.00 $22.00 $151.00 $208.00 $27.00 $181.00 $316.00 $60.00 $256.00 $178.00 $22.00 $156.00 $212.00 $26.00 $185.00 $262.00 $29.00 $233.00 $422.00 $68.00 $354.00 ------------- $445.00 $89.00 $356.00 $1,868.00 $89.00 $1,834.00 $1,879.00 $113.00 $1,834.00 $388.00 $71.00 $317.00 $235.00 $30.00 $205.00 ------------------$247.00 $42.00 $205.00 $206.00 $56.00 $150.00 $405.00 $62.00 $342.00 $185.00 $23.00 $163.00 $223.00 $28.00 $195.00 $337.00 $62.00 $275.00 $192.00 $23.00 $168.00 $227.00 $27.00 $200.00 $282.00 $30.00 $252.00 $453.00 $71.00 $383.00 ------------- Part C, 281 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 78599-TC 78600 78600-26 78600-TC 78601 78601-26 78601-TC 78605 78605-26 78605-TC 78606 78606-26 78606-TC 78607 78607-26 78607-TC 78608 78608-26 78608-TC 78609 78609-26 78609-TC 78610 78610-26 78610-TC 78630 78630-26 78630-TC 78635 78635-26 78635-TC 78645 78645-26 78645-TC 78647 78647-26 78647-TC 78650 78650-26 78650-TC 78660 78660-26 78660-TC 78699 78699-26 78699-TC 78700 78700-26 78700-TC 78701 BR $131.00 $22.00 $108.00 $154.00 $26.00 $126.00 $155.00 $27.00 $126.00 $221.00 $45.00 $177.00 $311.00 $64.00 $245.00 BR ------------BR ------------$74.00 $15.00 $59.00 $223.00 $35.00 $188.00 $129.00 $32.00 $95.00 $158.00 $29.00 $128.00 $268.00 $46.00 $220.00 $206.00 $31.00 $173.00 $107.00 $27.00 $79.00 BR BR BR $137.00 $22.00 $113.00 $158.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------$172.00 $23.00 $148.00 $207.00 $27.00 $180.00 $198.00 $28.00 $169.00 $286.00 $34.00 $253.00 $377.00 $65.00 $312.00 $1,164.00 $79.00 $1,141.00 $78.00 $78.00 BR $184.00 $17.00 $168.00 $317.00 $36.00 $281.00 $260.00 $33.00 $227.00 $245.00 $30.00 $216.00 $345.00 $47.00 $297.00 $303.00 $33.00 $270.00 $157.00 $28.00 $129.00 ------------------$177.00 $24.00 $153.00 $209.00 ------$186.00 $24.00 $161.00 $223.00 $28.00 $196.00 $214.00 $29.00 $184.00 $309.00 $35.00 $274.00 $407.00 $67.00 $340.00 $1,283.00 $81.00 $1,257.00 $81.00 $81.00 BR $198.00 $17.00 $181.00 $343.00 $37.00 $305.00 $279.00 $34.00 $246.00 $264.00 $31.00 $234.00 $372.00 $49.00 $323.00 $327.00 $34.00 $293.00 $169.00 $29.00 $140.00 ------------------$191.00 $25.00 $166.00 $226.00 ------$199.00 $25.00 $174.00 $240.00 $29.00 $211.00 $230.00 $30.00 $199.00 $331.00 $36.00 $294.00 $437.00 $70.00 $368.00 $1,414.00 $84.00 $1,385.00 $84.00 $84.00 BR $211.00 $18.00 $194.00 $368.00 $39.00 $329.00 $298.00 $35.00 $263.00 $282.00 $32.00 $251.00 $400.00 $51.00 $349.00 $351.00 $35.00 $316.00 $181.00 $30.00 $151.00 ------------------$206.00 $26.00 $180.00 $243.00 ------$172.00 $23.00 $148.00 $207.00 $27.00 $180.00 $198.00 $28.00 $169.00 $286.00 $34.00 $253.00 $377.00 $65.00 $312.00 $1,164.00 $79.00 $1,141.00 $78.00 $78.00 BR $184.00 $17.00 $168.00 $317.00 $36.00 $281.00 $260.00 $33.00 $227.00 $245.00 $30.00 $216.00 $345.00 $47.00 $297.00 $303.00 $33.00 $270.00 $157.00 $28.00 $129.00 ------------------$177.00 $24.00 $153.00 $209.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------$186.00 $24.00 $161.00 $223.00 $28.00 $196.00 $214.00 $29.00 $184.00 $309.00 $35.00 $274.00 $407.00 $67.00 $340.00 $1,283.00 $81.00 $1,257.00 $81.00 $81.00 BR $198.00 $17.00 $181.00 $343.00 $37.00 $305.00 $279.00 $34.00 $246.00 $264.00 $31.00 $234.00 $372.00 $49.00 $323.00 $327.00 $34.00 $293.00 $169.00 $29.00 $140.00 ------------------$191.00 $25.00 $166.00 $226.00 ------$199.00 $25.00 $174.00 $240.00 $29.00 $211.00 $230.00 $30.00 $199.00 $331.00 $36.00 $294.00 $437.00 $70.00 $368.00 $1,414.00 $84.00 $1,385.00 $84.00 $84.00 BR $211.00 $18.00 $194.00 $368.00 $39.00 $329.00 $298.00 $35.00 $263.00 $282.00 $32.00 $251.00 $400.00 $51.00 $349.00 $351.00 $35.00 $316.00 $181.00 $30.00 $151.00 ------------------$206.00 $26.00 $180.00 $243.00 Part C, 282 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 78701-26 78701-TC 78707 78707-26 78707-TC 78708 78708-26 78708-TC 78709 78709-26 78709-TC 78710 78710-26 78710-TC 78725 78725-26 78725-TC 78730 78730-26 78730-TC 78740 78740-26 78740-TC 78761 78761-26 78761-TC 78799 78799-26 78799-TC 78800 78800-26 78800-TC 78801 78801-26 78801-TC 78802 78802-26 78802-TC 78803 78803-26 78803-TC 78804 78804-26 78804-TC 78805 78805-26 78805-TC 78806 78806-26 78806-TC $24.00 $133.00 $217.00 $49.00 $166.00 $231.00 $61.00 $166.00 $241.00 $68.00 $166.00 $256.00 $34.00 $220.00 $87.00 $19.00 $66.00 $73.00 $18.00 $55.00 $109.00 $29.00 $79.00 $157.00 $36.00 $119.00 BR BR BR $162.00 $34.00 $126.00 $199.00 $40.00 $158.00 $252.00 $44.00 $207.00 $303.00 $56.00 $245.00 ------------------$166.00 $38.00 $126.00 $286.00 $44.00 $241.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $26.00 $184.00 $254.00 $51.00 $203.00 $226.00 $64.00 $162.00 $341.00 $75.00 $267.00 $270.00 $35.00 $235.00 $106.00 $20.00 $86.00 $82.00 $10.00 $71.00 $187.00 $30.00 $156.00 $205.00 $38.00 $168.00 ------------------$195.00 $35.00 $159.00 $253.00 $43.00 $210.00 $327.00 $46.00 $281.00 $369.00 $58.00 $311.00 $576.00 $56.00 $520.00 $195.00 $39.00 $156.00 $352.00 $46.00 $306.00 $27.00 $199.00 $274.00 $53.00 $221.00 $244.00 $67.00 $177.00 $366.00 $77.00 $289.00 $292.00 $36.00 $256.00 $115.00 $21.00 $94.00 $89.00 $11.00 $78.00 $201.00 $31.00 $169.00 $221.00 $39.00 $182.00 ------------------$210.00 $37.00 $173.00 $273.00 $45.00 $228.00 $353.00 $47.00 $306.00 $399.00 $60.00 $338.00 $620.00 $58.00 $562.00 $210.00 $40.00 $170.00 $381.00 $47.00 $334.00 $28.00 $215.00 $294.00 $55.00 $239.00 $262.00 $69.00 $193.00 $391.00 $80.00 $311.00 $316.00 $37.00 $279.00 $123.00 $22.00 $102.00 $96.00 $12.00 $84.00 $215.00 $33.00 $182.00 $237.00 $40.00 $197.00 ------------------$226.00 $39.00 $188.00 $294.00 $47.00 $247.00 $380.00 $49.00 $331.00 $429.00 $63.00 $366.00 $661.00 $60.00 $601.00 $225.00 $41.00 $184.00 $411.00 $49.00 $361.00 $26.00 $184.00 $254.00 $51.00 $203.00 $226.00 $64.00 $162.00 $341.00 $75.00 $267.00 $270.00 $35.00 $235.00 $106.00 $20.00 $86.00 $82.00 $10.00 $71.00 $187.00 $30.00 $156.00 $205.00 $38.00 $168.00 ------------------$195.00 $35.00 $159.00 $253.00 $43.00 $210.00 $327.00 $46.00 $281.00 $369.00 $58.00 $311.00 $576.00 $56.00 $520.00 $195.00 $39.00 $156.00 $352.00 $46.00 $306.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $27.00 $199.00 $274.00 $53.00 $221.00 $244.00 $67.00 $177.00 $366.00 $77.00 $289.00 $292.00 $36.00 $256.00 $115.00 $21.00 $94.00 $89.00 $11.00 $78.00 $201.00 $31.00 $169.00 $221.00 $39.00 $182.00 ------------------$210.00 $37.00 $173.00 $273.00 $45.00 $228.00 $353.00 $47.00 $306.00 $399.00 $60.00 $338.00 $620.00 $58.00 $562.00 $210.00 $40.00 $170.00 $381.00 $47.00 $334.00 $28.00 $215.00 $294.00 $55.00 $239.00 $262.00 $69.00 $193.00 $391.00 $80.00 $311.00 $316.00 $37.00 $279.00 $123.00 $22.00 $102.00 $96.00 $12.00 $84.00 $215.00 $33.00 $182.00 $237.00 $40.00 $197.00 ------------------$226.00 $39.00 $188.00 $294.00 $47.00 $247.00 $380.00 $49.00 $331.00 $429.00 $63.00 $366.00 $661.00 $60.00 $601.00 $225.00 $41.00 $184.00 $411.00 $49.00 $361.00 Part C, 283 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA 78807 78807-26 78807-TC 78811 78811-26 78811-TC 78812 78812-26 78812-TC 78813 78813-26 78813-TC 78814 78814-26 78814-TC 78815 78815-26 78815-TC 78816 78816-26 78816-TC 78999 78999-26 78999-TC 79005 79005-26 79005-TC 79101 79101-26 79101-TC 79200 79200-26 79200-TC 79300 79300-26 79300-TC 79403 79403-26 79403-TC 79440 79440-26 79440-TC 79445 79445-26 79445-TC 79999 79999-26 79999-TC G0130 G0130-26 $303.00 $57.00 $245.00 ------------------------------------------------------------------------------------------------------------BR BR BR ------------------------------------$203.00 $102.00 $97.00 BR $83.00 BR ------------------$204.00 $104.00 $97.00 ------------------BR BR BR ------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $368.00 $58.00 $310.00 $1,169.00 $85.00 $1,141.00 $1,174.00 $104.00 $1,141.00 $1,175.00 $108.00 $1,141.00 $1,177.00 $118.00 $1,141.00 $1,181.00 $130.00 $1,141.00 $1,182.00 $133.00 $1,141.00 ------------------$180.00 $95.00 $85.00 $193.00 $105.00 $88.00 $196.00 $105.00 $91.00 ------$89.00 ------$257.00 $121.00 $135.00 $189.00 $106.00 $83.00 BR $128.00 BR ------------------$40.00 $11.00 $397.00 $59.00 $338.00 $1,288.00 $88.00 $1,257.00 $1,294.00 $108.00 $1,257.00 $1,295.00 $112.00 $1,257.00 $1,298.00 $122.00 $1,257.00 $1,301.00 $134.00 $1,257.00 $1,302.00 $137.00 $1,257.00 ------------------$192.00 $98.00 $94.00 $205.00 $109.00 $97.00 $209.00 $109.00 $100.00 ------$93.00 ------$273.00 $126.00 $147.00 $200.00 $109.00 $91.00 BR $133.00 BR ------------------$43.00 $12.00 $427.00 $62.00 $366.00 $1,421.00 $93.00 $1,385.00 $1,426.00 $113.00 $1,385.00 $1,428.00 $117.00 $1,385.00 $1,430.00 $127.00 $1,385.00 $1,434.00 $140.00 $1,385.00 $1,435.00 $143.00 $1,385.00 ------------------$204.00 $102.00 $102.00 $219.00 $113.00 $106.00 $222.00 $113.00 $109.00 ------$98.00 ------$289.00 $131.00 $159.00 $213.00 $113.00 $100.00 BR $139.00 BR ------------------$47.00 $12.00 $368.00 $58.00 $310.00 $1,169.00 $85.00 $1,141.00 $1,174.00 $104.00 $1,141.00 $1,175.00 $108.00 $1,141.00 $1,177.00 $118.00 $1,141.00 $1,181.00 $130.00 $1,141.00 $1,182.00 $133.00 $1,141.00 ------------------$180.00 $95.00 $85.00 $193.00 $105.00 $88.00 $196.00 $105.00 $91.00 ------$89.00 ------$257.00 $121.00 $135.00 $189.00 $106.00 $83.00 BR $128.00 BR ------------------$40.00 $11.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $397.00 $59.00 $338.00 $1,288.00 $88.00 $1,257.00 $1,294.00 $108.00 $1,257.00 $1,295.00 $112.00 $1,257.00 $1,298.00 $122.00 $1,257.00 $1,301.00 $134.00 $1,257.00 $1,302.00 $137.00 $1,257.00 ------------------$192.00 $98.00 $94.00 $205.00 $109.00 $97.00 $209.00 $109.00 $100.00 ------$93.00 ------$273.00 $126.00 $147.00 $200.00 $109.00 $91.00 BR $133.00 BR ------------------$43.00 $12.00 $427.00 $62.00 $366.00 $1,421.00 $93.00 $1,385.00 $1,426.00 $113.00 $1,385.00 $1,428.00 $117.00 $1,385.00 $1,430.00 $127.00 $1,385.00 $1,434.00 $140.00 $1,385.00 $1,435.00 $143.00 $1,385.00 ------------------$204.00 $102.00 $102.00 $219.00 $113.00 $106.00 $222.00 $113.00 $109.00 ------$98.00 ------$289.00 $131.00 $159.00 $213.00 $113.00 $100.00 BR $139.00 BR ------------------$47.00 $12.00 Part C, 284 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Radiology CPT Code 2003 MRA G0130-TC G0202 G0202-26 G0202-TC G0204 G0204-26 G0204-TC G0206 G0206-26 G0206-TC G0275 G0278 G0288 G0365 G0365-26 G0365-TC G0389 G0389-26 G0389-TC Q0092 ------------------------------------------------------------------------------------------------------------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $29.00 $142.00 $37.00 $105.00 $160.00 $46.00 $114.00 $128.00 $37.00 $91.00 $15.00 $15.00 $240.00 $174.00 $14.00 $161.00 $123.00 $31.00 $92.00 $16.00 $31.00 $152.00 $38.00 $113.00 $171.00 $48.00 $124.00 $137.00 $38.00 $99.00 $15.00 $15.00 $260.00 $189.00 $14.00 $175.00 $132.00 $32.00 $100.00 $18.00 $34.00 $161.00 $40.00 $122.00 $182.00 $50.00 $132.00 $145.00 $40.00 $106.00 $16.00 $16.00 $279.00 $205.00 $15.00 $190.00 $141.00 $34.00 $107.00 $19.00 $29.00 $142.00 $37.00 $105.00 $160.00 $46.00 $114.00 $128.00 $37.00 $91.00 $15.00 $15.00 $240.00 $174.00 $14.00 $161.00 $123.00 $31.00 $92.00 $16.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $31.00 $152.00 $38.00 $113.00 $171.00 $48.00 $124.00 $137.00 $38.00 $99.00 $15.00 $15.00 $260.00 $189.00 $14.00 $175.00 $132.00 $32.00 $100.00 $18.00 $34.00 $161.00 $40.00 $122.00 $182.00 $50.00 $132.00 $145.00 $40.00 $106.00 $16.00 $16.00 $279.00 $205.00 $15.00 $190.00 $141.00 $34.00 $107.00 $19.00 Part C, 285 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 80048 80048-26 80048-TC 80050 80050-26 80050-TC 80051 80051-26 80051-TC 80053 80053-26 80053-TC 80055 80055-26 80055-TC 80061 80061-26 80061-TC 80069 80069-26 80069-TC 80074 80074-26 80074-TC 80076 80076-26 80076-TC 80100 80100-26 80100-TC 80101 80101-26 80101-TC 80102 80102-26 80102-TC 80103 80103-26 80103-TC 80150 80150-26 80150-TC 80152 80152-26 80152-TC 80154 80154-26 80154-TC 80156 80156-26 $23.00 $4.00 $19.00 $45.00 $18.00 $26.00 $16.00 $6.00 $10.00 $29.00 $8.00 $21.00 $67.00 $21.00 $43.00 $31.00 $11.00 $19.00 $26.00 $6.00 $20.00 $107.00 $43.00 $64.00 $18.00 $7.00 $11.00 $38.00 $11.00 $26.00 $13.00 $3.00 $9.00 $23.00 $6.00 $16.00 $12.00 $4.00 $7.00 $40.00 $13.00 $26.00 $43.00 $14.00 $29.00 $49.00 $15.00 $34.00 $35.00 $11.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 286 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 80156-TC 80157 80157-26 80157-TC 80158 80158-26 80158-TC 80160 80160-26 80160-TC 80162 80162-26 80162-TC 80164 80164-26 80164-TC 80166 80166-26 80166-TC 80168 80168-26 80168-TC 80170 80170-26 80170-TC 80172 80172-26 80172-TC 80173 80173-26 80173-TC 80174 80174-26 80174-TC 80176 80176-26 80176-TC 80178 80178-26 80178-TC 80182 80182-26 80182-TC 80184 80184-26 80184-TC 80185 80185-26 80185-TC 80186 $23.00 $22.00 $8.00 $14.00 $35.00 $12.00 $22.00 $35.00 $12.00 $22.00 $13.00 $3.00 $9.00 $43.00 $14.00 $29.00 $35.00 $10.00 $24.00 $43.00 $17.00 $25.00 $18.00 $6.00 $11.00 $44.00 $13.00 $32.00 $33.00 $11.00 $22.00 $41.00 $12.00 $29.00 $35.00 $11.00 $23.00 $17.00 $6.00 $11.00 $43.00 $14.00 $29.00 $34.00 $10.00 $23.00 $36.00 $10.00 $25.00 $38.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 287 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 80186-26 80186-TC 80188 80188-26 80188-TC 80190 80190-26 80190-TC 80192 80192-26 80192-TC 80194 80194-26 80194-TC 80196 80196-26 80196-TC 80197 80197-26 80197-TC 80198 80198-26 80198-TC 80200 80200-26 80200-TC 80201 80201-26 80201-TC 80202 80202-26 80202-TC 80299 80299-26 80299-TC 80400 80400-26 80400-TC 80402 80402-26 80402-TC 80406 80406-26 80406-TC 80408 80408-26 80408-TC 80410 80410-26 80410-TC $11.00 $26.00 $35.00 $11.00 $23.00 $41.00 $13.00 $28.00 $44.00 $17.00 $26.00 $33.00 $10.00 $22.00 $13.00 $3.00 $9.00 $34.00 $11.00 $22.00 $20.00 $5.00 $15.00 $24.00 $7.00 $16.00 $33.00 $11.00 $21.00 $42.00 $14.00 $28.00 BR BR BR $54.00 $18.00 $36.00 $138.00 $42.00 $95.00 $138.00 $42.00 $95.00 $213.00 $77.00 $136.00 $166.00 $54.00 $110.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 288 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 80412 80412-26 80412-TC 80414 80414-26 80414-TC 80415 80415-26 80415-TC 80416 80416-26 80416-TC 80417 80417-26 80417-TC 80418 80418-26 80418-TC 80420 80420-26 80420-TC 80422 80422-26 80422-TC 80424 80424-26 80424-TC 80426 80426-26 80426-TC 80428 80428-26 80428-TC 80430 80430-26 80430-TC 80432 80432-26 80432-TC 80434 80434-26 80434-TC 80435 80435-26 80435-TC 80436 80436-26 80436-TC 80438 80438-26 $533.00 $176.00 $355.00 $88.00 $26.00 $59.00 $93.00 $28.00 $64.00 $256.00 $88.00 $166.00 $256.00 $88.00 $166.00 $934.00 $266.00 $666.00 $107.00 $33.00 $74.00 $62.00 $18.00 $43.00 $94.00 $26.00 $67.00 $232.00 $54.00 $176.00 $93.00 $19.00 $73.00 $99.00 $24.00 $74.00 $243.00 $56.00 $186.00 $161.00 $49.00 $110.00 $166.00 $49.00 $115.00 $119.00 $35.00 $85.00 $82.00 $24.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 289 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 80438-TC 80439 80439-26 80439-TC 80440 80440-26 80440-TC 80500 80500-26 80500-TC 80502 80502-26 80502-TC 81000 81000-26 81000-TC 81001 81001-26 81001-TC 81002 81002-26 81002-TC 81003 81003-26 81003-TC 81005 81005-26 81005-TC 81007 81007-26 81007-TC 81015 81015-26 81015-TC 81020 81020-26 81020-TC 81025 81025-26 81025-TC 81050 81050-26 81050-TC 81099 81099-26 81099-TC 82000 82000-26 82000-TC 82003 $56.00 $176.00 $33.00 $144.00 $188.00 $36.00 $151.00 $34.00 $34.00 BR $72.00 $72.00 BR $7.00 $3.00 $4.00 $7.00 $3.00 $4.00 $5.00 $3.00 $3.00 $5.00 $2.00 $3.00 $3.00 $1.00 $3.00 $5.00 $2.00 $4.00 $5.00 $3.00 $3.00 $8.00 $3.00 $5.00 $7.00 $4.00 $4.00 $33.00 $11.00 $21.00 BR BR BR $24.00 $7.00 $17.00 $36.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------$22.00 ------------$68.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------$23.00 ------------$70.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------$24.00 ------------$73.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------$20.00 ------------$67.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------$21.00 ------------$69.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------$21.00 ------------$71.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 290 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82003-26 82003-TC 82009 82009-26 82009-TC 82010 82010-26 82010-TC 82013 82013-26 82013-TC 82024 82024-26 82024-TC 82030 82030-26 82030-TC 82040 82040-26 82040-TC 82042 82042-26 82042-TC 82043 82043-26 82043-TC 82044 82044-26 82044-TC 82055 82055-26 82055-TC 82075 82075-26 82075-TC 82085 82085-26 82085-TC 82088 82088-26 82088-TC 82101 82101-26 82101-TC 82103 82103-26 82103-TC 82104 82104-26 82104-TC $10.00 $25.00 $10.00 $3.00 $6.00 $22.00 $7.00 $15.00 $24.00 $7.00 $17.00 $26.00 $7.00 $18.00 $43.00 $17.00 $25.00 $11.00 $3.00 $7.00 $12.00 $3.00 $8.00 $14.00 $4.00 $10.00 $12.00 $4.00 $9.00 $33.00 $10.00 $22.00 $32.00 $10.00 $21.00 $24.00 $7.00 $17.00 $91.00 $28.00 $62.00 $59.00 $18.00 $41.00 $21.00 $7.00 $14.00 $22.00 $7.00 $15.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 291 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82105 82105-26 82105-TC 82106 82106-26 82106-TC 82108 82108-26 82108-TC 82120 82120-26 82120-TC 82127 82127-26 82127-TC 82128 82128-26 82128-TC 82131 82131-26 82131-TC 82135 82135-26 82135-TC 82136 82136-26 82136-TC 82139 82139-26 82139-TC 82140 82140-26 82140-TC 82143 82143-26 82143-TC 82145 82145-26 82145-TC 82150 82150-26 82150-TC 82154 82154-26 82154-TC 82157 82157-26 82157-TC 82160 82160-26 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $45.00 $14.00 $32.00 $9.00 $3.00 $5.00 $33.00 $11.00 $22.00 $26.00 $6.00 $19.00 $57.00 $13.00 $44.00 $41.00 $13.00 $28.00 $38.00 $14.00 $23.00 $38.00 $14.00 $23.00 $40.00 $12.00 $28.00 $28.00 $8.00 $19.00 $35.00 $10.00 $24.00 $16.00 $5.00 $11.00 $34.00 $13.00 $20.00 $57.00 $17.00 $40.00 $67.00 $21.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 292 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82160-TC 82163 82163-26 82163-TC 82164 82164-26 82164-TC 82172 82172-26 82172-TC 82175 82175-26 82175-TC 82180 82180-26 82180-TC 82190 82190-26 82190-TC 82205 82205-26 82205-TC 82232 82232-26 82232-TC 82239 82239-26 82239-TC 82240 82240-26 82240-TC 82247 82247-26 82247-TC 82248 82248-26 82248-TC 82252 82252-26 82252-TC 82261 82261-26 82261-TC 82270 82270-26 82270-TC 82274 82274-26 82274-TC 82286 $43.00 $42.00 $12.00 $31.00 $32.00 $10.00 $21.00 $33.00 $10.00 $22.00 $48.00 $15.00 $33.00 $25.00 $8.00 $17.00 $24.00 $8.00 $16.00 $34.00 $10.00 $23.00 $43.00 $14.00 $29.00 $23.00 $8.00 $15.00 $49.00 $15.00 $34.00 $10.00 $3.00 $7.00 $10.00 $3.00 $7.00 $11.00 $3.00 $7.00 $38.00 $13.00 $24.00 $5.00 $2.00 $3.00 BR BR BR $12.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 293 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82286-26 82286-TC 82300 82300-26 82300-TC 82306 82306-26 82306-TC 82307 82307-26 82307-TC 82308 82308-26 82308-TC 82310 82310-26 82310-TC 82330 82330-26 82330-TC 82331 82331-26 82331-TC 82340 82340-26 82340-TC 82355 82355-26 82355-TC 82360 82360-26 82360-TC 82365 82365-26 82365-TC 82370 82370-26 82370-TC 82373 82373-26 82373-TC 82374 82374-26 82374-TC 82375 82375-26 82375-TC 82376 82376-26 82376-TC $3.00 $8.00 $48.00 $15.00 $33.00 $79.00 $25.00 $52.00 $57.00 $19.00 $38.00 $62.00 $18.00 $43.00 $11.00 $3.00 $7.00 $37.00 $11.00 $25.00 $14.00 $4.00 $10.00 $13.00 $4.00 $8.00 $31.00 $10.00 $20.00 $31.00 $10.00 $20.00 $31.00 $8.00 $21.00 $22.00 $7.00 $15.00 $16.00 $5.00 $11.00 $10.00 $3.00 $6.00 $26.00 $7.00 $18.00 $11.00 $3.00 $7.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 294 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82378 82378-26 82378-TC 82379 82379-26 82379-TC 82380 82380-26 82380-TC 82382 82382-26 82382-TC 82383 82383-26 82383-TC 82384 82384-26 82384-TC 82387 82387-26 82387-TC 82390 82390-26 82390-TC 82397 82397-26 82397-TC 82415 82415-26 82415-TC 82435 82435-26 82435-TC 82436 82436-26 82436-TC 82438 82438-26 82438-TC 82441 82441-26 82441-TC 82465 82465-26 82465-TC 82480 82480-26 82480-TC 82482 82482-26 $31.00 $8.00 $21.00 $38.00 $13.00 $24.00 $21.00 $6.00 $15.00 $38.00 $12.00 $25.00 $62.00 $18.00 $43.00 $62.00 $18.00 $43.00 $34.00 $10.00 $23.00 $24.00 $7.00 $17.00 $22.00 $7.00 $15.00 $28.00 $8.00 $19.00 $8.00 $2.00 $6.00 $14.00 $4.00 $10.00 $13.00 $4.00 $8.00 $16.00 $5.00 $11.00 $8.00 $2.00 $6.00 $23.00 $6.00 $17.00 $23.00 $7.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 295 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82482-TC 82485 82485-26 82485-TC 82486 82486-26 82486-TC 82487 82487-26 82487-TC 82488 82488-26 82488-TC 82489 82489-26 82489-TC 82491 82491-26 82491-TC 82492 82492-26 82492-TC 82495 82495-26 82495-TC 82507 82507-26 82507-TC 82520 82520-26 82520-TC 82523 82523-26 82523-TC 82525 82525-26 82525-TC 82528 82528-26 82528-TC 82530 82530-26 82530-TC 82533 82533-26 82533-TC 82540 82540-26 82540-TC 82541 $15.00 $37.00 $8.00 $28.00 $42.00 $14.00 $27.00 $43.00 $14.00 $29.00 $57.00 $19.00 $38.00 $47.00 $15.00 $32.00 $58.00 $17.00 $41.00 $42.00 $13.00 $28.00 $48.00 $16.00 $32.00 $55.00 $16.00 $39.00 $26.00 $8.00 $18.00 $43.00 $17.00 $25.00 $34.00 $10.00 $23.00 $40.00 $13.00 $26.00 $38.00 $12.00 $25.00 $35.00 $10.00 $24.00 $10.00 $3.00 $6.00 $42.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 296 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82541-26 82541-TC 82542 82542-26 82542-TC 82543 82543-26 82543-TC 82544 82544-26 82544-TC 82550 82550-26 82550-TC 82552 82552-26 82552-TC 82553 82553-26 82553-TC 82554 82554-26 82554-TC 82565 82565-26 82565-TC 82570 82570-26 82570-TC 82575 82575-26 82575-TC 82585 82585-26 82585-TC 82595 82595-26 82595-TC 82600 82600-26 82600-TC 82607 82607-26 82607-TC 82608 82608-26 82608-TC 82615 82615-26 82615-TC $13.00 $28.00 $42.00 $13.00 $28.00 $42.00 $13.00 $28.00 $42.00 $13.00 $28.00 $16.00 $4.00 $12.00 $33.00 $10.00 $22.00 $16.00 $5.00 $11.00 $19.00 $6.00 $13.00 $13.00 $2.00 $11.00 $10.00 $2.00 $7.00 $25.00 $8.00 $17.00 $15.00 $3.00 $12.00 $31.00 $10.00 $21.00 $40.00 $12.00 $28.00 $38.00 $10.00 $27.00 $40.00 $13.00 $26.00 $17.00 $5.00 $12.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 297 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82626 82626-26 82626-TC 82627 82627-26 82627-TC 82633 82633-26 82633-TC 82634 82634-26 82634-TC 82638 82638-26 82638-TC 82646 82646-26 82646-TC 82649 82649-26 82649-TC 82651 82651-26 82651-TC 82652 82652-26 82652-TC 82654 82654-26 82654-TC 82657 82657-26 82657-TC 82658 82658-26 82658-TC 82664 82664-26 82664-TC 82666 82666-26 82666-TC 82668 82668-26 82668-TC 82670 82670-26 82670-TC 82671 82671-26 $59.00 $19.00 $40.00 $37.00 $12.00 $24.00 $81.00 $23.00 $56.00 $81.00 $23.00 $56.00 $23.00 $7.00 $16.00 $37.00 $11.00 $25.00 $43.00 $17.00 $25.00 $43.00 $17.00 $25.00 $89.00 $25.00 $62.00 $37.00 $11.00 $25.00 $42.00 $13.00 $28.00 $42.00 $13.00 $28.00 $40.00 $13.00 $26.00 $58.00 $17.00 $41.00 $45.00 $14.00 $32.00 $61.00 $18.00 $42.00 $61.00 $17.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 298 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82671-TC 82672 82672-26 82672-TC 82677 82677-26 82677-TC 82679 82679-26 82679-TC 82690 82690-26 82690-TC 82693 82693-26 82693-TC 82696 82696-26 82696-TC 82705 82705-26 82705-TC 82710 82710-26 82710-TC 82715 82715-26 82715-TC 82725 82725-26 82725-TC 82726 82726-26 82726-TC 82728 82728-26 82728-TC 82735 82735-26 82735-TC 82742 82742-26 82742-TC 82746 82746-26 82746-TC 82747 82747-26 82747-TC 82757 $43.00 $57.00 $16.00 $41.00 $52.00 $17.00 $35.00 $70.00 $20.00 $48.00 $53.00 $21.00 $32.00 $23.00 $7.00 $16.00 $57.00 $19.00 $38.00 $14.00 $6.00 $9.00 $42.00 $13.00 $29.00 $33.00 $11.00 $21.00 $28.00 $8.00 $19.00 $42.00 $13.00 $28.00 $24.00 $7.00 $17.00 $36.00 $12.00 $23.00 $42.00 $13.00 $29.00 $39.00 $13.00 $25.00 $29.00 $10.00 $19.00 $36.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 299 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82757-26 82757-TC 82759 82759-26 82759-TC 82760 82760-26 82760-TC 82775 82775-26 82775-TC 82776 82776-26 82776-TC 82784 82784-26 82784-TC 82785 82785-26 82785-TC 82787 82787-26 82787-TC 82800 82800-26 82800-TC 82803 82803-26 82803-TC 82805 82805-26 82805-TC 82810 82810-26 82810-TC 82820 82820-26 82820-TC 82926 82926-26 82926-TC 82928 82928-26 82928-TC 82938 82938-26 82938-TC 82941 82941-26 82941-TC $11.00 $24.00 $38.00 $12.00 $25.00 $26.00 $8.00 $18.00 $47.00 $14.00 $33.00 $14.00 $3.00 $11.00 $15.00 $5.00 $11.00 $33.00 $11.00 $21.00 $54.00 $17.00 $37.00 $22.00 $6.00 $16.00 $53.00 $16.00 $37.00 $36.00 $10.00 $24.00 $28.00 $8.00 $19.00 $16.00 $5.00 $11.00 $20.00 $5.00 $15.00 $12.00 $4.00 $7.00 $48.00 $16.00 $32.00 $47.00 $15.00 $32.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 300 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82943 82943-26 82943-TC 82945 82945-26 82945-TC 82946 82946-26 82946-TC 82947 82947-26 82947-TC 82948 82948-26 82948-TC 82950 82950-26 82950-TC 82951 82951-26 82951-TC 82952 82952-26 82952-TC 82953 82953-26 82953-TC 82955 82955-26 82955-TC 82960 82960-26 82960-TC 82962 82962-26 82962-TC 82963 82963-26 82963-TC 82965 82965-26 82965-TC 82975 82975-26 82975-TC 82977 82977-26 82977-TC 82978 82978-26 $38.00 $12.00 $25.00 $9.00 $3.00 $5.00 $29.00 $7.00 $21.00 $11.00 $3.00 $7.00 $5.00 $3.00 $3.00 $12.00 $4.00 $7.00 $22.00 $7.00 $15.00 $11.00 $3.00 $7.00 $41.00 $14.00 $26.00 $25.00 $7.00 $18.00 $14.00 $4.00 $10.00 $5.00 $1.00 $4.00 $54.00 $17.00 $37.00 $16.00 $5.00 $11.00 $28.00 $8.00 $19.00 $16.00 $4.00 $12.00 $25.00 $7.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 301 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 82978-TC 82979 82979-26 82979-TC 82980 82980-26 82980-TC 82985 82985-26 82985-TC 83001 83001-26 83001-TC 83002 83002-26 83002-TC 83003 83003-26 83003-TC 83008 83008-26 83008-TC 83010 83010-26 83010-TC 83012 83012-26 83012-TC 83013 83013-26 83013-TC 83014 83014-26 83014-TC 83015 83015-26 83015-TC 83018 83018-26 83018-TC 83020 83020-26 83020-TC 83021 83021-26 83021-TC 83026 83026-26 83026-TC 83030 $18.00 $18.00 $5.00 $13.00 $15.00 $3.00 $11.00 $41.00 $12.00 $29.00 $40.00 $12.00 $28.00 $42.00 $13.00 $29.00 $36.00 $10.00 $25.00 $34.00 $10.00 $23.00 $26.00 $8.00 $18.00 $36.00 $14.00 $21.00 $133.00 $38.00 $94.00 $19.00 $6.00 $13.00 $51.00 $15.00 $36.00 $56.00 $16.00 $40.00 $24.00 $6.00 $18.00 $39.00 $13.00 $25.00 $8.00 $5.00 $3.00 $18.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------- Part C, 302 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 83030-26 83030-TC 83033 83033-26 83033-TC 83036 83036-26 83036-TC 83045 83045-26 83045-TC 83050 83050-26 83050-TC 83051 83051-26 83051-TC 83055 83055-26 83055-TC 83060 83060-26 83060-TC 83065 83065-26 83065-TC 83068 83068-26 83068-TC 83069 83069-26 83069-TC 83070 83070-26 83070-TC 83071 83071-26 83071-TC 83080 83080-26 83080-TC 83088 83088-26 83088-TC 83090 83090-26 83090-TC 83150 83150-26 83150-TC $6.00 $12.00 $15.00 $4.00 $11.00 $15.00 $5.00 $10.00 $13.00 $4.00 $8.00 $16.00 $5.00 $11.00 $16.00 $5.00 $11.00 $13.00 $4.00 $8.00 $22.00 $6.00 $16.00 $18.00 $6.00 $12.00 $20.00 $5.00 $15.00 $11.00 $3.00 $7.00 $13.00 $4.00 $8.00 $18.00 $5.00 $13.00 $38.00 $11.00 $26.00 $59.00 $18.00 $41.00 $38.00 $13.00 $25.00 $49.00 $16.00 $33.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 303 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 83491 83491-26 83491-TC 83497 83497-26 83497-TC 83498 83498-26 83498-TC 83499 83499-26 83499-TC 83500 83500-26 83500-TC 83505 83505-26 83505-TC 83516 83516-26 83516-TC 83518 83518-26 83518-TC 83519 83519-26 83519-TC 83520 83520-26 83520-TC 83525 83525-26 83525-TC 83527 83527-26 83527-TC 83528 83528-26 83528-TC 83540 83540-26 83540-TC 83550 83550-26 83550-TC 83570 83570-26 83570-TC 83582 83582-26 $37.00 $11.00 $25.00 $35.00 $11.00 $23.00 $62.00 $20.00 $41.00 $51.00 $15.00 $36.00 $69.00 $21.00 $45.00 $77.00 $21.00 $54.00 $26.00 $8.00 $18.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $20.00 $6.00 $14.00 $31.00 $8.00 $21.00 $35.00 $11.00 $23.00 $43.00 $14.00 $29.00 $16.00 $3.00 $13.00 $20.00 $5.00 $15.00 $23.00 $7.00 $16.00 $34.00 $8.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 304 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 83582-TC 83586 83586-26 83586-TC 83593 83593-26 83593-TC 83605 83605-26 83605-TC 83615 83615-26 83615-TC 83625 83625-26 83625-TC 83632 83632-26 83632-TC 83655 83655-26 83655-TC 83670 83670-26 83670-TC 83690 83690-26 83690-TC 83718 83718-26 83718-TC 83719 83719-26 83719-TC 83721 83721-26 83721-TC 83727 83727-26 83727-TC 83735 83735-26 83735-TC 83775 83775-26 83775-TC 83785 83785-26 83785-TC 83788 $24.00 $38.00 $13.00 $24.00 $59.00 $18.00 $41.00 $19.00 $6.00 $13.00 $16.00 $5.00 $11.00 $23.00 $6.00 $17.00 $42.00 $14.00 $28.00 $31.00 $8.00 $21.00 $18.00 $5.00 $13.00 $18.00 $6.00 $12.00 $16.00 $5.00 $11.00 $42.00 $14.00 $28.00 $16.00 $5.00 $11.00 $43.00 $14.00 $29.00 $15.00 $5.00 $10.00 $17.00 $5.00 $12.00 $58.00 $17.00 $41.00 $39.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 305 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 83788-26 83788-TC 83789 83789-26 83789-TC 83805 83805-26 83805-TC 83825 83825-26 83825-TC 83835 83835-26 83835-TC 83840 83840-26 83840-TC 83857 83857-26 83857-TC 83858 83858-26 83858-TC 83864 83864-26 83864-TC 83866 83866-26 83866-TC 83872 83872-26 83872-TC 83873 83873-26 83873-TC 83874 83874-26 83874-TC 83880 83880-26 83880-TC 83883 83883-26 83883-TC 83885 83885-26 83885-TC 83887 83887-26 83887-TC $13.00 $25.00 $39.00 $13.00 $25.00 $44.00 $15.00 $29.00 $34.00 $11.00 $22.00 $41.00 $12.00 $29.00 $42.00 $14.00 $28.00 $26.00 $8.00 $18.00 $37.00 $12.00 $24.00 $32.00 $8.00 $22.00 $26.00 $7.00 $19.00 $13.00 $4.00 $8.00 $54.00 $18.00 $36.00 $25.00 $8.00 $17.00 BR BR BR $11.00 $3.00 $7.00 $45.00 $14.00 $32.00 $58.00 $17.00 $41.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 306 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 83890 83890-26 83890-TC 83891 83891-26 83891-TC 83892 83892-26 83892-TC 83893 83893-26 83893-TC 83894 83894-26 83894-TC 83896 83896-26 83896-TC 83897 83897-26 83897-TC 83898 83898-26 83898-TC 83901 83901-26 83901-TC 83902 83902-26 83902-TC 83903 83903-26 83903-TC 83904 83904-26 83904-TC 83905 83905-26 83905-TC 83906 83906-26 83906-TC 83912 83912-26 83912-TC 83915 83915-26 83915-TC 83916 83916-26 $7.00 $2.00 $5.00 $7.00 $2.00 $5.00 $7.00 $2.00 $5.00 $7.00 $2.00 $5.00 $7.00 $2.00 $5.00 $7.00 $2.00 $5.00 $9.00 $3.00 $5.00 $43.00 $14.00 $29.00 $44.00 $14.00 $29.00 $38.00 $13.00 $24.00 $44.00 $14.00 $29.00 $44.00 $14.00 $29.00 $44.00 $14.00 $29.00 $44.00 $14.00 $29.00 $39.00 $11.00 $28.00 $31.00 $10.00 $20.00 $54.00 $18.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$19.00 ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$19.00 ------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------- Part C, 307 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 83916-TC 83918 83918-26 83918-TC 83919 83919-26 83919-TC 83921 83921-26 83921-TC 83925 83925-26 83925-TC 83930 83930-26 83930-TC 83935 83935-26 83935-TC 83937 83937-26 83937-TC 83945 83945-26 83945-TC 83950 83950-26 83950-TC 83970 83970-26 83970-TC 83986 83986-26 83986-TC 83992 83992-26 83992-TC 84022 84022-26 84022-TC 84030 84030-26 84030-TC 84035 84035-26 84035-TC 84060 84060-26 84060-TC 84061 $36.00 $41.00 $12.00 $29.00 $42.00 $12.00 $29.00 $37.00 $12.00 $25.00 $13.00 $3.00 $9.00 $11.00 $3.00 $7.00 $17.00 $5.00 $12.00 $29.00 $10.00 $19.00 $32.00 $11.00 $20.00 BR BR BR $94.00 $31.00 $62.00 $8.00 $3.00 $5.00 $40.00 $12.00 $28.00 $41.00 $13.00 $28.00 $11.00 $3.00 $7.00 $12.00 $3.00 $8.00 $20.00 $6.00 $14.00 $14.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 308 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 84061-26 84061-TC 84066 84066-26 84066-TC 84075 84075-26 84075-TC 84078 84078-26 84078-TC 84080 84080-26 84080-TC 84081 84081-26 84081-TC 84085 84085-26 84085-TC 84087 84087-26 84087-TC 84100 84100-26 84100-TC 84105 84105-26 84105-TC 84106 84106-26 84106-TC 84110 84110-26 84110-TC 84119 84119-26 84119-TC 84120 84120-26 84120-TC 84126 84126-26 84126-TC 84127 84127-26 84127-TC 84132 84132-26 84132-TC $4.00 $10.00 $18.00 $6.00 $12.00 $12.00 $3.00 $8.00 $19.00 $5.00 $14.00 $36.00 $11.00 $24.00 $45.00 $15.00 $31.00 $15.00 $5.00 $10.00 $25.00 $7.00 $18.00 $11.00 $3.00 $7.00 $11.00 $3.00 $7.00 $10.00 $2.00 $7.00 $21.00 $6.00 $15.00 $21.00 $6.00 $15.00 $38.00 $11.00 $26.00 $71.00 $20.00 $49.00 $18.00 $6.00 $12.00 $11.00 $3.00 $7.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 309 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 84133 84133-26 84133-TC 84134 84134-26 84134-TC 84135 84135-26 84135-TC 84138 84138-26 84138-TC 84140 84140-26 84140-TC 84143 84143-26 84143-TC 84144 84144-26 84144-TC 84146 84146-26 84146-TC 84150 84150-26 84150-TC 84152 84152-26 84152-TC 84153 84153-26 84153-TC 84154 84154-26 84154-TC 84155 84155-26 84155-TC 84160 84160-26 84160-TC 84165 84165-26 84165-TC 84166 84166-26 84166-TC 84181 84181-26 $11.00 $3.00 $7.00 $24.00 $7.00 $17.00 $57.00 $19.00 $38.00 $56.00 $18.00 $38.00 $41.00 $8.00 $33.00 $62.00 $20.00 $41.00 $38.00 $7.00 $31.00 $53.00 $17.00 $36.00 $69.00 $20.00 $47.00 $42.00 $14.00 $27.00 $33.00 $11.00 $21.00 $33.00 $11.00 $21.00 $12.00 $4.00 $7.00 $5.00 $2.00 $2.00 $24.00 $8.00 $16.00 ------------------$29.00 $10.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------BR $20.00 BR ------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------BR $20.00 BR ------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------BR $21.00 BR ------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------BR $20.00 BR ------$20.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------BR $20.00 BR ------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------BR $21.00 BR ------$21.00 Part C, 310 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 84181-TC 84182 84182-26 84182-TC 84202 84202-26 84202-TC 84203 84203-26 84203-TC 84206 84206-26 84206-TC 84207 84207-26 84207-TC 84210 84210-26 84210-TC 84220 84220-26 84220-TC 84228 84228-26 84228-TC 84233 84233-26 84233-TC 84234 84234-26 84234-TC 84235 84235-26 84235-TC 84238 84238-26 84238-TC 84244 84244-26 84244-TC 84252 84252-26 84252-TC 84255 84255-26 84255-TC 84260 84260-26 84260-TC 84270 $19.00 $33.00 $11.00 $21.00 $39.00 $13.00 $25.00 $16.00 $5.00 $11.00 $32.00 $10.00 $21.00 $54.00 $16.00 $38.00 $24.00 $10.00 $15.00 $25.00 $8.00 $17.00 $32.00 $10.00 $21.00 $116.00 $35.00 $81.00 $116.00 $35.00 $81.00 $114.00 $34.00 $80.00 $97.00 $32.00 $65.00 $47.00 $15.00 $32.00 $47.00 $14.00 $33.00 $58.00 $17.00 $41.00 $54.00 $16.00 $38.00 $36.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------$22.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------$22.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 311 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 84270-26 84270-TC 84275 84275-26 84275-TC 84285 84285-26 84285-TC 84295 84295-26 84295-TC 84300 84300-26 84300-TC 84302 84302-26 84302-TC 84305 84305-26 84305-TC 84307 84307-26 84307-TC 84311 84311-26 84311-TC 84315 84315-26 84315-TC 84375 84375-26 84375-TC 84376 84376-26 84376-TC 84377 84377-26 84377-TC 84378 84378-26 84378-TC 84379 84379-26 84379-TC 84392 84392-26 84392-TC 84402 84402-26 84402-TC $11.00 $24.00 $37.00 $11.00 $25.00 $59.00 $17.00 $42.00 $10.00 $3.00 $6.00 $10.00 $3.00 $6.00 BR BR BR $34.00 $11.00 $22.00 $26.00 $8.00 $18.00 $11.00 $3.00 $7.00 $5.00 $2.00 $3.00 $37.00 $11.00 $25.00 $10.00 $3.00 $7.00 $10.00 $3.00 $7.00 $25.00 $8.00 $17.00 $25.00 $8.00 $17.00 $8.00 $2.00 $6.00 $72.00 $21.00 $49.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 312 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 84403 84403-26 84403-TC 84425 84425-26 84425-TC 84430 84430-26 84430-TC 84432 84432-26 84432-TC 84436 84436-26 84436-TC 84437 84437-26 84437-TC 84439 84439-26 84439-TC 84442 84442-26 84442-TC 84443 84443-26 84443-TC 84445 84445-26 84445-TC 84446 84446-26 84446-TC 84449 84449-26 84449-TC 84450 84450-26 84450-TC 84460 84460-26 84460-TC 84466 84466-26 84466-TC 84478 84478-26 84478-TC 84479 84479-26 $67.00 $19.00 $45.00 $54.00 $17.00 $37.00 $31.00 $10.00 $20.00 $28.00 $8.00 $19.00 $14.00 $3.00 $11.00 $13.00 $4.00 $8.00 $16.00 $4.00 $12.00 $25.00 $6.00 $19.00 $32.00 $7.00 $23.00 $98.00 $29.00 $69.00 $35.00 $11.00 $23.00 $38.00 $13.00 $24.00 $11.00 $3.00 $7.00 $13.00 $4.00 $8.00 $22.00 $7.00 $15.00 $12.00 $3.00 $8.00 $15.00 $5.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 313 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 84479-TC 84480 84480-26 84480-TC 84481 84481-26 84481-TC 84482 84482-26 84482-TC 84484 84484-26 84484-TC 84485 84485-26 84485-TC 84488 84488-26 84488-TC 84490 84490-26 84490-TC 84510 84510-26 84510-TC 84512 84512-26 84512-TC 84520 84520-26 84520-TC 84525 84525-26 84525-TC 84540 84540-26 84540-TC 84545 84545-26 84545-TC 84550 84550-26 84550-TC 84560 84560-26 84560-TC 84577 84577-26 84577-TC 84578 $10.00 $20.00 $6.00 $14.00 $33.00 $10.00 $22.00 $45.00 $15.00 $31.00 $21.00 $6.00 $15.00 $15.00 $4.00 $11.00 $15.00 $4.00 $11.00 $15.00 $4.00 $11.00 $26.00 $8.00 $18.00 $17.00 $5.00 $12.00 $12.00 $3.00 $8.00 $7.00 $2.00 $5.00 $13.00 $4.00 $8.00 $18.00 $5.00 $13.00 $12.00 $4.00 $7.00 $12.00 $3.00 $8.00 $34.00 $11.00 $22.00 $7.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 314 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 84578-26 84578-TC 84580 84580-26 84580-TC 84583 84583-26 84583-TC 84585 84585-26 84585-TC 84586 84586-26 84586-TC 84588 84588-26 84588-TC 84590 84590-26 84590-TC 84591 84591-26 84591-TC 84597 84597-26 84597-TC 84600 84600-26 84600-TC 84620 84620-26 84620-TC 84630 84630-26 84630-TC 84681 84681-26 84681-TC 84702 84702-26 84702-TC 84703 84703-26 84703-TC 84830 84830-26 84830-TC 84999 84999-26 84999-TC $2.00 $5.00 $17.00 $5.00 $12.00 $11.00 $3.00 $7.00 $36.00 $11.00 $24.00 $42.00 $14.00 $27.00 $73.00 $23.00 $47.00 $33.00 $11.00 $21.00 $26.00 $9.00 $18.00 $37.00 $11.00 $25.00 $43.00 $13.00 $31.00 $29.00 $8.00 $20.00 $26.00 $8.00 $18.00 $52.00 $17.00 $35.00 $38.00 $11.00 $26.00 $22.00 $6.00 $15.00 $17.00 $5.00 $12.00 BR BR BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 315 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 85002 85002-26 85002-TC 85004 85004-26 85004-TC 85007 85007-26 85007-TC 85008 85008-26 85008-TC 85009 85009-26 85009-TC 85013 85013-26 85013-TC 85014 85014-26 85014-TC 85018 85018-26 85018-TC 85025 85025-26 85025-TC 85027 85027-26 85027-TC 85032 85032-26 85032-TC 85041 85041-26 85041-TC 85044 85044-26 85044-TC 85045 85045-26 85045-TC 85046 85046-26 85046-TC 85048 85048-26 85048-TC 85049 85049-26 $10.00 $3.00 $6.00 BR BR BR $6.00 $3.00 $4.00 $5.00 $2.00 $3.00 $8.00 $3.00 $5.00 $3.00 $1.00 $2.00 $4.00 $1.00 $3.00 $5.00 $2.00 $3.00 $20.00 $6.00 $14.00 $15.00 $5.00 $10.00 BR BR BR $7.00 $3.00 $4.00 $10.00 $3.00 $6.00 $6.00 $2.00 $4.00 $13.00 $4.00 $9.00 $7.00 $3.00 $4.00 BR BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 316 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 85049-TC 85060 85060-26 85060-TC 85097 85097-26 85097-TC 85130 85130-26 85130-TC 85170 85170-26 85170-TC 85175 85175-26 85175-TC 85210 85210-26 85210-TC 85220 85220-26 85220-TC 85230 85230-26 85230-TC 85240 85240-26 85240-TC 85244 85244-26 85244-TC 85245 85245-26 85245-TC 85246 85246-26 85246-TC 85247 85247-26 85247-TC 85250 85250-26 85250-TC 85260 85260-26 85260-TC 85270 85270-26 85270-TC 85280 BR $25.00 $7.00 $18.00 $59.00 $59.00 BR $19.00 $6.00 $13.00 $7.00 $2.00 $5.00 $10.00 $3.00 $6.00 $31.00 $8.00 $21.00 $47.00 $15.00 $32.00 $47.00 $14.00 $33.00 $48.00 $15.00 $33.00 $49.00 $15.00 $34.00 $54.00 $18.00 $36.00 $54.00 $18.00 $36.00 $54.00 $18.00 $36.00 $49.00 $14.00 $35.00 $49.00 $14.00 $35.00 $49.00 $14.00 $35.00 $49.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------$24.00 ------------$99.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------$25.00 ------------$105.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------$26.00 ------------$109.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------$24.00 ------------$51.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------$25.00 ------------$52.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------$26.00 ------------$54.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 317 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 85280-26 85280-TC 85290 85290-26 85290-TC 85291 85291-26 85291-TC 85292 85292-26 85292-TC 85293 85293-26 85293-TC 85300 85300-26 85300-TC 85301 85301-26 85301-TC 85302 85302-26 85302-TC 85303 85303-26 85303-TC 85305 85305-26 85305-TC 85306 85306-26 85306-TC 85307 85307-26 85307-TC 85335 85335-26 85335-TC 85337 85337-26 85337-TC 85345 85345-26 85345-TC 85347 85347-26 85347-TC 85348 85348-26 85348-TC $14.00 $35.00 $44.00 $13.00 $32.00 $20.00 $6.00 $14.00 $51.00 $17.00 $34.00 $51.00 $17.00 $34.00 $35.00 $12.00 $23.00 $29.00 $10.00 $19.00 $33.00 $11.00 $21.00 $26.00 $8.00 $18.00 $21.00 $7.00 $14.00 $29.00 $10.00 $19.00 $35.00 $12.00 $23.00 $21.00 $7.00 $14.00 $19.00 $6.00 $13.00 $10.00 $2.00 $7.00 $8.00 $2.00 $6.00 $10.00 $3.00 $6.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 318 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 85360 85360-26 85360-TC 85362 85362-26 85362-TC 85366 85366-26 85366-TC 85370 85370-26 85370-TC 85378 85378-26 85378-TC 85379 85379-26 85379-TC 85380 85380-26 85380-TC 85384 85384-26 85384-TC 85385 85385-26 85385-TC 85390 85390-26 85390-TC 85396 85400 85400-26 85400-TC 85410 85410-26 85410-TC 85415 85415-26 85415-TC 85420 85420-26 85420-TC 85421 85421-26 85421-TC 85441 85441-26 85441-TC 85445 $16.00 $4.00 $12.00 $18.00 $7.00 $11.00 $13.00 $3.00 $10.00 $20.00 $5.00 $15.00 $13.00 $4.00 $8.00 $18.00 $6.00 $12.00 BR BR BR $11.00 $3.00 $7.00 $16.00 $5.00 $11.00 $10.00 $2.00 $7.00 ------$12.00 $3.00 $8.00 $12.00 $3.00 $8.00 $28.00 $10.00 $18.00 $16.00 $3.00 $13.00 $39.00 $12.00 $26.00 $7.00 $2.00 $5.00 $16.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------$21.00 ------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------$23.00 ------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------$24.00 ------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------$21.00 ------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------$23.00 ------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------$24.00 ------------------------------------------------------------------------------------------------------------------- Part C, 319 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 85445-26 85445-TC 85460 85460-26 85460-TC 85461 85461-26 85461-TC 85475 85475-26 85475-TC 85520 85520-26 85520-TC 85525 85525-26 85525-TC 85530 85530-26 85530-TC 85536 85536-26 85536-TC 85540 85540-26 85540-TC 85547 85547-26 85547-TC 85549 85549-26 85549-TC 85555 85555-26 85555-TC 85557 85557-26 85557-TC 85576 85576-26 85576-TC 85597 85597-26 85597-TC 85610 85610-26 85610-TC 85611 85611-26 85611-TC $5.00 $11.00 $15.00 $4.00 $11.00 $12.00 $3.00 $8.00 $15.00 $4.00 $11.00 $22.00 $6.00 $16.00 $20.00 $6.00 $14.00 $39.00 $12.00 $26.00 $14.00 $4.00 $10.00 $24.00 $7.00 $17.00 $23.00 $6.00 $17.00 $45.00 $15.00 $31.00 $17.00 $5.00 $12.00 $34.00 $10.00 $23.00 $21.00 $5.00 $16.00 $32.00 $10.00 $21.00 $6.00 $3.00 $4.00 $6.00 $2.00 $4.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------------------- Part C, 320 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 85612 85612-26 85612-TC 85613 85613-26 85613-TC 85635 85635-26 85635-TC 85651 85651-26 85651-TC 85652 85652-26 85652-TC 85660 85660-26 85660-TC 85670 85670-26 85670-TC 85675 85675-26 85675-TC 85705 85705-26 85705-TC 85730 85730-26 85730-TC 85732 85732-26 85732-TC 85810 85810-26 85810-TC 85999 85999-26 85999-TC 86000 86000-26 86000-TC 86001 86001-26 86001-TC 86003 86003-26 86003-TC 86005 86005-26 $22.00 $6.00 $16.00 $15.00 $4.00 $11.00 $26.00 $8.00 $18.00 $8.00 $2.00 $6.00 $8.00 $2.00 $6.00 $10.00 $3.00 $6.00 $13.00 $3.00 $10.00 $13.00 $4.00 $8.00 $13.00 $4.00 $8.00 $11.00 $3.00 $7.00 $17.00 $5.00 $12.00 $19.00 $4.00 $15.00 BR BR BR $16.00 $5.00 $11.00 $12.00 $4.00 $8.00 $6.00 $2.00 $3.00 $11.00 $4.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 321 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86005-TC 86021 86021-26 86021-TC 86022 86022-26 86022-TC 86023 86023-26 86023-TC 86038 86038-26 86038-TC 86039 86039-26 86039-TC 86060 86060-26 86060-TC 86063 86063-26 86063-TC 86077 86077-26 86077-TC 86078 86078-26 86078-TC 86079 86079-26 86079-TC 86140 86140-26 86140-TC 86141 86141-26 86141-TC 86146 86146-26 86146-TC 86147 86147-26 86147-TC 86148 86148-26 86148-TC 86155 86155-26 86155-TC 86156 $6.00 $41.00 $12.00 $29.00 $57.00 $18.00 $39.00 $28.00 $10.00 $18.00 $22.00 $7.00 $15.00 $19.00 $6.00 $13.00 $13.00 $3.00 $10.00 $21.00 $6.00 $15.00 $91.00 $26.00 $64.00 $91.00 $26.00 $64.00 $79.00 $25.00 $52.00 $14.00 $4.00 $10.00 BR BR BR $58.00 $19.00 $39.00 $53.00 $16.00 $36.00 $59.00 $21.00 $38.00 $26.00 $8.00 $18.00 $11.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------$52.00 ------------$53.00 ------------$53.00 ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------$54.00 ------------$55.00 ------------$55.00 ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------$55.00 ------------$57.00 ------------$57.00 ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------$50.00 ------------$50.00 ------------$51.00 ------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------$52.00 ------------$52.00 ------------$52.00 ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------$53.00 ------------$54.00 ------------$54.00 ------------------------------------------------------------------------------------------------------------------------------- Part C, 322 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86156-26 86156-TC 86157 86157-26 86157-TC 86160 86160-26 86160-TC 86161 86161-26 86161-TC 86162 86162-26 86162-TC 86171 86171-26 86171-TC 86185 86185-26 86185-TC 86215 86215-26 86215-TC 86225 86225-26 86225-TC 86226 86226-26 86226-TC 86235 86235-26 86235-TC 86243 86243-26 86243-TC 86255 86255-26 86255-TC 86256 86256-26 86256-TC 86277 86277-26 86277-TC 86280 86280-26 86280-TC 86294 86294-26 86294-TC $3.00 $7.00 $13.00 $4.00 $8.00 $21.00 $5.00 $16.00 $21.00 $5.00 $16.00 $54.00 $18.00 $36.00 $25.00 $7.00 $18.00 $19.00 $6.00 $13.00 $36.00 $12.00 $23.00 $36.00 $11.00 $24.00 $24.00 $8.00 $16.00 $33.00 $10.00 $22.00 $50.00 $15.00 $35.00 $25.00 $8.00 $17.00 $25.00 $8.00 $17.00 $41.00 $14.00 $26.00 $15.00 $3.00 $12.00 BR BR BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------$20.00 ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------$21.00 ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------$21.00 ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------$20.00 ------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------$21.00 ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------$21.00 ------------------------------------------------------------- Part C, 323 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86300 86300-26 86300-TC 86301 86301-26 86301-TC 86304 86304-26 86304-TC 86308 86308-26 86308-TC 86309 86309-26 86309-TC 86310 86310-26 86310-TC 86316 86316-26 86316-TC 86317 86317-26 86317-TC 86318 86318-26 86318-TC 86320 86320-26 86320-TC 86325 86325-26 86325-TC 86327 86327-26 86327-TC 86329 86329-26 86329-TC 86331 86331-26 86331-TC 86332 86332-26 86332-TC 86334 86334-26 86334-TC 86335 86335-26 $47.00 $15.00 $32.00 $47.00 $15.00 $32.00 $47.00 $15.00 $32.00 $8.00 $3.00 $5.00 $12.00 $3.00 $8.00 $19.00 $6.00 $13.00 $37.00 $11.00 $25.00 $31.00 $10.00 $20.00 $23.00 $10.00 $14.00 $49.00 $19.00 $29.00 $49.00 $16.00 $33.00 $62.00 $19.00 $42.00 $37.00 $12.00 $24.00 $22.00 $6.00 $15.00 $54.00 $18.00 $36.00 $65.00 $18.00 $45.00 ------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------$20.00 ------------$23.00 ------------------------------------------------------------------$20.00 ------BR $20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------$20.00 ------------$23.00 ------------------------------------------------------------------$20.00 ------BR $20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------$21.00 ------------$24.00 ------------------------------------------------------------------$21.00 ------BR $21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------$20.00 ------------$23.00 ------------------------------------------------------------------$20.00 ------BR $20.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------$20.00 ------------$23.00 ------------------------------------------------------------------$20.00 ------BR $20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------$21.00 ------------$24.00 ------------------------------------------------------------------$21.00 ------BR $21.00 Part C, 324 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86335-TC 86336 86336-26 86336-TC 86337 86337-26 86337-TC 86340 86340-26 86340-TC 86341 86341-26 86341-TC 86343 86343-26 86343-TC 86344 86344-26 86344-TC 86353 86353-26 86353-TC 86359 86359-26 86359-TC 86360 86360-26 86360-TC 86361 86361-26 86361-TC 86376 86376-26 86376-TC 86378 86378-26 86378-TC 86382 86382-26 86382-TC 86384 86384-26 86384-TC 86403 86403-26 86403-TC 86406 86406-26 86406-TC 86430 ------BR BR BR $54.00 $18.00 $36.00 $39.00 $13.00 $25.00 $38.00 $13.00 $24.00 $33.00 $11.00 $21.00 $21.00 $7.00 $14.00 $102.00 $31.00 $72.00 $61.00 $19.00 $41.00 $99.00 $33.00 $67.00 $66.00 $21.00 $43.00 $35.00 $11.00 $23.00 $45.00 $15.00 $31.00 $45.00 $14.00 $32.00 $24.00 $8.00 $16.00 $18.00 $3.00 $14.00 $21.00 $5.00 $16.00 $13.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) BR ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- BR ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- BR ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- BR ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) BR ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- BR ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 325 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86430-26 86430-TC 86431 86431-26 86431-TC 86485 86485-26 86485-TC 86486 86490 86490-26 86490-TC 86510 86510-26 86510-TC 86580 86580-26 86580-TC 86590 86590-26 86590-TC 86592 86592-26 86592-TC 86593 86593-26 86593-TC 86602 86602-26 86602-TC 86603 86603-26 86603-TC 86606 86606-26 86606-TC 86609 86609-26 86609-TC 86611 86611-26 86611-TC 86612 86612-26 86612-TC 86615 86615-26 86615-TC 86617 86617-26 $4.00 $8.00 $17.00 $6.00 $11.00 $13.00 $4.00 $8.00 ------$17.00 $5.00 $12.00 $13.00 $4.00 $8.00 $13.00 $4.00 $8.00 $18.00 $6.00 $12.00 $8.00 $2.00 $6.00 $11.00 $3.00 $7.00 $17.00 $5.00 $12.00 $20.00 $6.00 $14.00 $24.00 $8.00 $16.00 $20.00 $6.00 $14.00 $23.00 $8.00 $15.00 $21.00 $6.00 $15.00 $21.00 $6.00 $15.00 $29.00 $10.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------$6.00 $9.00 ------------$10.00 ------------$9.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------$7.00 $10.00 ------------$11.00 ------------$10.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------$8.00 $12.00 ------------$12.00 ------------$11.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------$6.00 $9.00 ------------$10.00 ------------$9.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------$7.00 $10.00 ------------$11.00 ------------$10.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------$8.00 $12.00 ------------$12.00 ------------$11.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 326 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86617-TC 86618 86618-26 86618-TC 86619 86619-26 86619-TC 86622 86622-26 86622-TC 86625 86625-26 86625-TC 86628 86628-26 86628-TC 86631 86631-26 86631-TC 86632 86632-26 86632-TC 86635 86635-26 86635-TC 86638 86638-26 86638-TC 86641 86641-26 86641-TC 86644 86644-26 86644-TC 86645 86645-26 86645-TC 86648 86648-26 86648-TC 86651 86651-26 86651-TC 86652 86652-26 86652-TC 86653 86653-26 86653-TC 86654 $19.00 $26.00 $8.00 $18.00 $21.00 $6.00 $15.00 $16.00 $5.00 $11.00 $21.00 $6.00 $15.00 $20.00 $6.00 $14.00 $20.00 $6.00 $14.00 $20.00 $6.00 $14.00 $18.00 $5.00 $13.00 $20.00 $6.00 $14.00 $21.00 $7.00 $14.00 $22.00 $7.00 $15.00 $28.00 $10.00 $18.00 $24.00 $8.00 $16.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 327 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86654-26 86654-TC 86658 86658-26 86658-TC 86663 86663-26 86663-TC 86664 86664-26 86664-TC 86665 86665-26 86665-TC 86666 86666-26 86666-TC 86668 86668-26 86668-TC 86671 86671-26 86671-TC 86674 86674-26 86674-TC 86677 86677-26 86677-TC 86682 86682-26 86682-TC 86684 86684-26 86684-TC 86687 86687-26 86687-TC 86688 86688-26 86688-TC 86689 86689-26 86689-TC 86692 86692-26 86692-TC 86694 86694-26 86694-TC $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $53.00 $17.00 $36.00 $29.00 $10.00 $19.00 $23.00 $8.00 $15.00 $17.00 $5.00 $12.00 $20.00 $6.00 $14.00 $23.00 $7.00 $16.00 $24.00 $8.00 $16.00 $21.00 $7.00 $14.00 $24.00 $8.00 $16.00 $22.00 $7.00 $16.00 $20.00 $7.00 $14.00 $25.00 $8.00 $17.00 $22.00 $7.00 $15.00 $22.00 $7.00 $15.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 328 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86695 86695-26 86695-TC 86696 86696-26 86696-TC 86698 86698-26 86698-TC 86701 86701-26 86701-TC 86702 86702-26 86702-TC 86703 86703-26 86703-TC 86704 86704-26 86704-TC 86705 86705-26 86705-TC 86706 86706-26 86706-TC 86707 86707-26 86707-TC 86708 86708-26 86708-TC 86709 86709-26 86709-TC 86710 86710-26 86710-TC 86713 86713-26 86713-TC 86717 86717-26 86717-TC 86720 86720-26 86720-TC 86723 86723-26 $21.00 $7.00 $14.00 $44.00 $14.00 $30.00 $20.00 $6.00 $14.00 $21.00 $7.00 $15.00 $21.00 $7.00 $14.00 $22.00 $7.00 $15.00 $33.00 $11.00 $21.00 $35.00 $11.00 $23.00 $24.00 $8.00 $16.00 $26.00 $8.00 $18.00 $32.00 $10.00 $21.00 $29.00 $10.00 $19.00 $22.00 $7.00 $15.00 $23.00 $7.00 $16.00 $20.00 $6.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 329 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86723-TC 86727 86727-26 86727-TC 86729 86729-26 86729-TC 86732 86732-26 86732-TC 86735 86735-26 86735-TC 86738 86738-26 86738-TC 86741 86741-26 86741-TC 86744 86744-26 86744-TC 86747 86747-26 86747-TC 86750 86750-26 86750-TC 86753 86753-26 86753-TC 86756 86756-26 86756-TC 86757 86757-26 86757-TC 86759 86759-26 86759-TC 86762 86762-26 86762-TC 86765 86765-26 86765-TC 86768 86768-26 86768-TC 86771 $14.00 $20.00 $6.00 $14.00 $19.00 $6.00 $13.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $23.00 $7.00 $16.00 $21.00 $7.00 $14.00 $20.00 $6.00 $14.00 $20.00 $6.00 $14.00 $44.00 $14.00 $30.00 $21.00 $7.00 $14.00 $22.00 $7.00 $15.00 $20.00 $6.00 $14.00 $21.00 $7.00 $14.00 $21.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 330 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86771-26 86771-TC 86774 86774-26 86774-TC 86777 86777-26 86777-TC 86778 86778-26 86778-TC 86781 86781-26 86781-TC 86784 86784-26 86784-TC 86787 86787-26 86787-TC 86790 86790-26 86790-TC 86793 86793-26 86793-TC 86800 86800-26 86800-TC 86803 86803-26 86803-TC 86804 86804-26 86804-TC 86805 86805-26 86805-TC 86806 86806-26 86806-TC 86807 86807-26 86807-TC 86808 86808-26 86808-TC 86812 86812-26 86812-TC $7.00 $14.00 $23.00 $7.00 $16.00 $22.00 $7.00 $15.00 $23.00 $7.00 $16.00 $22.00 $7.00 $15.00 $21.00 $7.00 $14.00 $20.00 $6.00 $14.00 $21.00 $7.00 $14.00 $21.00 $7.00 $14.00 $26.00 $8.00 $18.00 $24.00 $8.00 $16.00 $26.00 $8.00 $18.00 $97.00 $33.00 $64.00 $87.00 $28.00 $57.00 $74.00 $21.00 $51.00 $52.00 $15.00 $37.00 $108.00 $32.00 $75.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 331 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86813 86813-26 86813-TC 86816 86816-26 86816-TC 86817 86817-26 86817-TC 86821 86821-26 86821-TC 86822 86822-26 86822-TC 86849 86849-26 86849-TC 86850 86850-26 86850-TC 86860 86860-26 86860-TC 86870 86870-26 86870-TC 86880 86880-26 86880-TC 86885 86885-26 86885-TC 86886 86886-26 86886-TC 86890 86890-26 86890-TC 86891 86891-26 86891-TC 86900 86900-26 86900-TC 86901 86901-26 86901-TC 86903 86903-26 $101.00 $29.00 $71.00 $64.00 $18.00 $44.00 $134.00 $39.00 $94.00 $123.00 $36.00 $86.00 $96.00 $32.00 $64.00 BR BR BR $10.00 $3.00 $6.00 $44.00 $15.00 $29.00 $17.00 $6.00 $11.00 $13.00 $4.00 $8.00 $15.00 $4.00 $11.00 $14.00 $4.00 $10.00 $67.00 $11.00 $54.00 $91.00 $26.00 $64.00 $10.00 $3.00 $6.00 $10.00 $3.00 $6.00 $15.00 $5.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 332 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86903-TC 86904 86904-26 86904-TC 86905 86905-26 86905-TC 86906 86906-26 86906-TC 86910 86910-26 86910-TC 86911 86911-26 86911-TC 86920 86920-26 86920-TC 86921 86921-26 86921-TC 86922 86922-26 86922-TC 86927 86927-26 86927-TC 86930 86930-26 86930-TC 86931 86931-26 86931-TC 86932 86932-26 86932-TC 86940 86940-26 86940-TC 86941 86941-26 86941-TC 86945 86945-26 86945-TC 86950 86950-26 86950-TC 86965 $10.00 $19.00 $6.00 $13.00 $7.00 $1.00 $6.00 $11.00 $3.00 $7.00 $83.00 $24.00 $57.00 $19.00 $6.00 $13.00 $19.00 $3.00 $15.00 $23.00 $7.00 $16.00 $20.00 $6.00 $14.00 $21.00 $5.00 $16.00 $155.00 $45.00 $108.00 $155.00 $45.00 $108.00 $161.00 $48.00 $111.00 $18.00 $5.00 $13.00 $31.00 $8.00 $21.00 $35.00 $11.00 $23.00 $99.00 $29.00 $70.00 $25.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 333 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 86965-26 86965-TC 86970 86970-26 86970-TC 86971 86971-26 86971-TC 86972 86972-26 86972-TC 86975 86975-26 86975-TC 86976 86976-26 86976-TC 86977 86977-26 86977-TC 86978 86978-26 86978-TC 86985 86985-26 86985-TC 86999 86999-26 86999-TC 87001 87001-26 87001-TC 87003 87003-26 87003-TC 87015 87015-26 87015-TC 87040 87040-26 87040-TC 87045 87045-26 87045-TC 87046 87046-26 87046-TC 87070 87070-26 87070-TC $7.00 $18.00 $41.00 $12.00 $29.00 $20.00 $5.00 $15.00 $20.00 $6.00 $14.00 $53.00 $16.00 $37.00 $53.00 $16.00 $37.00 $53.00 $16.00 $37.00 $65.00 $19.00 $44.00 $35.00 $12.00 $23.00 BR BR BR $35.00 $11.00 $23.00 $40.00 $13.00 $26.00 $14.00 $5.00 $9.00 $18.00 $6.00 $12.00 $18.00 $6.00 $11.00 $5.00 $2.00 $3.00 $14.00 $4.00 $10.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 334 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87071 87071-26 87071-TC 87073 87073-26 87073-TC 87075 87075-26 87075-TC 87076 87076-26 87076-TC 87077 87077-26 87077-TC 87081 87081-26 87081-TC 87084 87084-26 87084-TC 87086 87086-26 87086-TC 87088 87088-26 87088-TC 87101 87101-26 87101-TC 87102 87102-26 87102-TC 87103 87103-26 87103-TC 87106 87106-26 87106-TC 87107 87107-26 87107-TC 87109 87109-26 87109-TC 87110 87110-26 87110-TC 87116 87116-26 $11.00 $3.00 $8.00 $11.00 $3.00 $8.00 $18.00 $6.00 $12.00 $24.00 $8.00 $16.00 $16.00 $5.00 $11.00 $12.00 $3.00 $8.00 $23.00 $7.00 $16.00 $14.00 $3.00 $11.00 $18.00 $6.00 $12.00 $20.00 $6.00 $14.00 $20.00 $6.00 $14.00 $32.00 $11.00 $20.00 $25.00 $7.00 $18.00 $23.00 $8.00 $15.00 $26.00 $8.00 $18.00 $23.00 $7.00 $15.00 $15.00 $3.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 335 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87116-TC 87118 87118-26 87118-TC 87140 87140-26 87140-TC 87143 87143-26 87143-TC 87147 87147-26 87147-TC 87149 87149-26 87149-TC 87152 87152-26 87152-TC 87158 87158-26 87158-TC 87164 87164-26 87164-TC 87166 87166-26 87166-TC 87168 87168-26 87168-TC 87169 87169-26 87169-TC 87172 87172-26 87172-TC 87176 87176-26 87176-TC 87177 87177-26 87177-TC 87181 87181-26 87181-TC 87184 87184-26 87184-TC 87185 $11.00 $28.00 $9.00 $20.00 $24.00 $7.00 $17.00 $34.00 $11.00 $22.00 $26.00 $8.00 $18.00 $46.00 $15.00 $31.00 $12.00 $4.00 $8.00 $5.00 $1.00 $3.00 $24.00 $8.00 $16.00 $24.00 $7.00 $17.00 $10.00 $3.00 $7.00 $10.00 $3.00 $7.00 $10.00 $3.00 $7.00 $16.00 $5.00 $11.00 $18.00 $6.00 $12.00 $13.00 $3.00 $8.00 $13.00 $3.00 $10.00 $11.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------$19.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------$19.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 336 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87185-26 87185-TC 87186 87186-26 87186-TC 87187 87187-26 87187-TC 87188 87188-26 87188-TC 87190 87190-26 87190-TC 87197 87197-26 87197-TC 87205 87205-26 87205-TC 87206 87206-26 87206-TC 87207 87207-26 87207-TC 87210 87210-26 87210-TC 87220 87220-26 87220-TC 87230 87230-26 87230-TC 87250 87250-26 87250-TC 87252 87252-26 87252-TC 87253 87253-26 87253-TC 87254 87254-26 87254-TC 87255 87255-26 87255-TC $3.00 $8.00 $16.00 $4.00 $12.00 $20.00 $3.00 $17.00 $18.00 $5.00 $13.00 $7.00 $2.00 $5.00 $29.00 $10.00 $19.00 $11.00 $3.00 $7.00 $15.00 $3.00 $12.00 $10.00 $3.00 $6.00 $8.00 $2.00 $6.00 $12.00 $4.00 $7.00 $35.00 $11.00 $23.00 $33.00 $13.00 $19.00 $44.00 $14.00 $31.00 $33.00 $10.00 $22.00 $11.00 $3.00 $8.00 BR BR BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------$20.00 ------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------$21.00 ------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 337 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87260 87260-26 87260-TC 87265 87265-26 87265-TC 87267 87267-26 87267-TC 87270 87270-26 87270-TC 87271 87271-26 87271-TC 87272 87272-26 87272-TC 87273 87273-26 87273-TC 87274 87274-26 87274-TC 87275 87275-26 87275-TC 87276 87276-26 87276-TC 87277 87277-26 87277-TC 87278 87278-26 87278-TC 87279 87279-26 87279-TC 87280 87280-26 87280-TC 87281 87281-26 87281-TC 87283 87283-26 87283-TC 87285 87285-26 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 BR BR BR $26.00 $8.00 $18.00 BR BR BR $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $27.00 $9.00 $19.00 $26.00 $8.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 338 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87285-TC 87290 87290-26 87290-TC 87299 87299-26 87299-TC 87300 87300-26 87300-TC 87301 87301-26 87301-TC 87320 87320-26 87320-TC 87324 87324-26 87324-TC 87327 87327-26 87327-TC 87328 87328-26 87328-TC 87332 87332-26 87332-TC 87335 87335-26 87335-TC 87336 87336-26 87336-TC 87337 87337-26 87337-TC 87338 87338-26 87338-TC 87339 87339-26 87339-TC 87340 87340-26 87340-TC 87341 87341-26 87341-TC 87350 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $13.00 $4.00 $9.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $27.00 $9.00 $19.00 $27.00 $7.00 $20.00 $27.00 $9.00 $19.00 $20.00 $6.00 $14.00 $23.00 $8.00 $15.00 $20.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 339 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87350-26 87350-TC 87380 87380-26 87380-TC 87385 87385-26 87385-TC 87390 87390-26 87390-TC 87391 87391-26 87391-TC 87400 87400-26 87400-TC 87420 87420-26 87420-TC 87425 87425-26 87425-TC 87427 87427-26 87427-TC 87430 87430-26 87430-TC 87449 87449-26 87449-TC 87450 87450-26 87450-TC 87451 87451-26 87451-TC 87470 87470-26 87470-TC 87471 87471-26 87471-TC 87472 87472-26 87472-TC 87475 87475-26 87475-TC $6.00 $14.00 $35.00 $11.00 $23.00 $26.00 $8.00 $18.00 $38.00 $13.00 $24.00 $38.00 $13.00 $24.00 $13.00 $4.00 $9.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $27.00 $9.00 $19.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $21.00 $6.00 $15.00 $19.00 $7.00 $12.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $40.00 $13.00 $26.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 340 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87476 87476-26 87476-TC 87477 87477-26 87477-TC 87480 87480-26 87480-TC 87481 87481-26 87481-TC 87482 87482-26 87482-TC 87485 87485-26 87485-TC 87486 87486-26 87486-TC 87487 87487-26 87487-TC 87490 87490-26 87490-TC 87491 87491-26 87491-TC 87492 87492-26 87492-TC 87495 87495-26 87495-TC 87496 87496-26 87496-TC 87497 87497-26 87497-TC 87510 87510-26 87510-TC 87511 87511-26 87511-TC 87512 87512-26 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $73.00 $23.00 $48.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 341 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87512-TC 87515 87515-26 87515-TC 87516 87516-26 87516-TC 87517 87517-26 87517-TC 87520 87520-26 87520-TC 87521 87521-26 87521-TC 87522 87522-26 87522-TC 87525 87525-26 87525-TC 87526 87526-26 87526-TC 87527 87527-26 87527-TC 87528 87528-26 87528-TC 87529 87529-26 87529-TC 87530 87530-26 87530-TC 87531 87531-26 87531-TC 87532 87532-26 87532-TC 87533 87533-26 87533-TC 87534 87534-26 87534-TC 87535 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 342 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87535-26 87535-TC 87536 87536-26 87536-TC 87537 87537-26 87537-TC 87538 87538-26 87538-TC 87539 87539-26 87539-TC 87540 87540-26 87540-TC 87541 87541-26 87541-TC 87542 87542-26 87542-TC 87550 87550-26 87550-TC 87551 87551-26 87551-TC 87552 87552-26 87552-TC 87555 87555-26 87555-TC 87556 87556-26 87556-TC 87557 87557-26 87557-TC 87560 87560-26 87560-TC 87561 87561-26 87561-TC 87562 87562-26 87562-TC $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 343 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87580 87580-26 87580-TC 87581 87581-26 87581-TC 87582 87582-26 87582-TC 87590 87590-26 87590-TC 87591 87591-26 87591-TC 87592 87592-26 87592-TC 87620 87620-26 87620-TC 87621 87621-26 87621-TC 87622 87622-26 87622-TC 87650 87650-26 87650-TC 87651 87651-26 87651-TC 87652 87652-26 87652-TC 87797 87797-26 87797-TC 87798 87798-26 87798-TC 87799 87799-26 87799-TC 87800 87800-26 87800-TC 87801 87801-26 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $86.00 $28.00 $56.00 $42.00 $13.00 $28.00 $73.00 $23.00 $48.00 $88.00 $28.00 $58.00 $46.00 $15.00 $31.00 $81.00 $26.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 344 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 87801-TC 87802 87802-26 87802-TC 87803 87803-26 87803-TC 87804 87804-26 87804-TC 87810 87810-26 87810-TC 87850 87850-26 87850-TC 87880 87880-26 87880-TC 87899 87899-26 87899-TC 87901 87901-26 87901-TC 87902 87902-26 87902-TC 87903 87903-26 87903-TC 87904 87904-26 87904-TC 87999 87999-26 87999-TC 88000 88000-26 88000-TC 88005 88005-26 88005-TC 88007 88007-26 88007-TC 88020 88020-26 88020-TC 88025 $54.00 BR BR BR BR BR BR BR BR BR $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $594.00 $196.00 $398.00 BR BR BR $1,126.00 $371.00 $755.00 $59.00 $20.00 $39.00 BR BR BR $445.00 $445.00 BR $500.00 $500.00 BR $556.00 $556.00 BR $556.00 $556.00 BR $610.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Part C, 345 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 88025-26 88025-TC 88027 88027-26 88027-TC 88036 88036-26 88036-TC 88037 88037-26 88037-TC 88040 88040-26 88040-TC 88045 88045-26 88045-TC 88099 88099-26 88099-TC 88104 88104-26 88104-TC 88106 88106-26 88106-TC 88107 88107-26 88107-TC 88108 88108-26 88108-TC 88112 88112-26 88112-TC 88125 88125-26 88125-TC 88130 88130-26 88130-TC 88140 88140-26 88140-TC 88141 88141-26 88141-TC 88142 88142-26 88142-TC $610.00 BR $666.00 $666.00 BR $477.00 $477.00 BR $389.00 $389.00 BR $1,445.00 $1,445.00 BR BR BR BR BR BR BR $49.00 $37.00 $10.00 $54.00 $16.00 $38.00 $74.00 $57.00 $15.00 $59.00 $47.00 $11.00 ------------------$70.00 $20.00 $48.00 $25.00 $7.00 $18.00 $18.00 $5.00 $13.00 $33.00 NC NC $82.00 $21.00 $59.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------$63.00 $30.00 $33.00 $80.00 $30.00 $50.00 $101.00 $41.00 $60.00 $76.00 $30.00 $46.00 $114.00 $61.00 $53.00 $20.00 $13.00 $7.00 ------------------------------------$27.00 BR BR ------------------- ------------------------------------------------------------------------------------------------------------------------$67.00 $31.00 $36.00 $84.00 $31.00 $54.00 $107.00 $42.00 $64.00 $80.00 $31.00 $50.00 $119.00 $62.00 $57.00 $21.00 $14.00 $8.00 ------------------------------------$28.00 BR BR ------------------- ------------------------------------------------------------------------------------------------------------------------$70.00 $32.00 $39.00 $89.00 $32.00 $57.00 $112.00 $44.00 $68.00 $85.00 $32.00 $53.00 $124.00 $64.00 $61.00 $23.00 $14.00 $8.00 ------------------------------------$29.00 BR BR ------------------- ------------------------------------------------------------------------------------------------------------------------$63.00 $30.00 $33.00 $80.00 $30.00 $50.00 $101.00 $41.00 $60.00 $76.00 $30.00 $46.00 $114.00 $61.00 $53.00 $20.00 $13.00 $7.00 ------------------------------------$27.00 BR BR ------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------------------------------------------------------------------------------------------------------$67.00 $31.00 $36.00 $84.00 $31.00 $54.00 $107.00 $42.00 $64.00 $80.00 $31.00 $50.00 $119.00 $62.00 $57.00 $21.00 $14.00 $8.00 ------------------------------------$28.00 BR BR ------------------- ------------------------------------------------------------------------------------------------------------------------$70.00 $32.00 $39.00 $89.00 $32.00 $57.00 $112.00 $44.00 $68.00 $85.00 $32.00 $53.00 $124.00 $64.00 $61.00 $23.00 $14.00 $8.00 ------------------------------------$29.00 BR BR ------------------- Part C, 346 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 88143 88143-26 88143-TC 88147 88147-26 88147-TC 88148 88148-26 88148-TC 88150 88150-26 88150-TC 88152 88152-26 88152-TC 88153 88153-26 88153-TC 88154 88154-26 88154-TC 88155 88155-26 88155-TC 88160 88160-26 88160-TC 88161 88161-26 88161-TC 88162 88162-26 88162-TC 88164 88164-26 88164-TC 88165 88165-26 88165-TC 88166 88166-26 88166-TC 88167 88167-26 88167-TC 88172 88172-26 88172-TC 88173 88173-26 $94.00 $33.00 $59.00 $82.00 NC $82.00 $104.00 $21.00 $82.00 $13.00 $3.00 $9.00 $46.00 $8.00 $38.00 $82.00 $21.00 $59.00 $104.00 $21.00 $82.00 $14.00 $3.00 $10.00 $45.00 $14.00 $24.00 $64.00 $19.00 $37.00 $77.00 $22.00 $53.00 $54.00 $21.00 $33.00 $72.00 $33.00 $38.00 $82.00 $21.00 $59.00 $87.00 $26.00 $59.00 $70.00 $54.00 $14.00 $95.00 $95.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------BR ------------------------------------------------------------------------------------------------------------------$55.00 $26.00 $29.00 $60.00 $27.00 $33.00 $82.00 $41.00 $41.00 ------------------------------------------------------------------------$55.00 $32.00 $23.00 $140.00 $73.00 ------------------------BR ------------------------------------------------------------------------------------------------------------------$58.00 $27.00 $31.00 $64.00 $28.00 $36.00 $87.00 $42.00 $45.00 ------------------------------------------------------------------------$58.00 $33.00 $25.00 $148.00 $75.00 ------------------------BR ------------------------------------------------------------------------------------------------------------------$62.00 $28.00 $33.00 $67.00 $29.00 $39.00 $91.00 $44.00 $48.00 ------------------------------------------------------------------------$61.00 $34.00 $27.00 $155.00 $78.00 ------------------------BR ------------------------------------------------------------------------------------------------------------------$55.00 $26.00 $29.00 $60.00 $27.00 $33.00 $82.00 $41.00 $41.00 ------------------------------------------------------------------------$55.00 $32.00 $23.00 $140.00 $73.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------BR ------------------------------------------------------------------------------------------------------------------$58.00 $27.00 $31.00 $64.00 $28.00 $36.00 $87.00 $42.00 $45.00 ------------------------------------------------------------------------$58.00 $33.00 $25.00 $148.00 $75.00 ------------------------BR ------------------------------------------------------------------------------------------------------------------$62.00 $28.00 $33.00 $67.00 $29.00 $39.00 $91.00 $44.00 $48.00 ------------------------------------------------------------------------$61.00 $34.00 $27.00 $155.00 $78.00 Part C, 347 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 88173-TC 88174 88174-26 88174-TC 88175 88175-26 88175-TC 88182 88182-26 88182-TC 88184 88185 88187 88188 88189 88199 88199-26 88199-TC 88233 88233-26 88233-TC 88235 88235-26 88235-TC 88240 88240-26 88240-TC 88241 88241-26 88241-TC 88300 88300-26 88300-TC 88302 88302-26 88302-TC 88304 88304-26 88304-TC 88305 88305-26 88305-TC 88307 88307-26 88307-TC 88309 88309-26 88309-TC 88311 88311-26 $26.00 BR BR BR BR BR BR $88.00 $33.00 $54.00 ------------------------------BR BR BR $243.00 $73.00 $170.00 $256.00 $76.00 $177.00 $21.00 $6.00 $15.00 $21.00 $6.00 $15.00 $24.00 $19.00 $5.00 $53.00 $42.00 $11.00 $70.00 $54.00 $14.00 $108.00 $86.00 $21.00 $210.00 $168.00 $41.00 $322.00 $258.00 $64.00 $23.00 $19.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $67.00 ------------------------------------$111.00 $39.00 $72.00 $75.00 $43.00 $67.00 $83.00 $107.00 ------------------------------------------------------------------------------------------$24.00 $5.00 $19.00 $52.00 $7.00 $45.00 $64.00 $11.00 $53.00 $109.00 $40.00 $70.00 $215.00 $85.00 $130.00 $319.00 $144.00 $176.00 $19.00 $13.00 $72.00 ------------------------------------$118.00 $41.00 $77.00 $81.00 $47.00 $69.00 $85.00 $109.00 ------------------------------------------------------------------------------------------$26.00 $5.00 $21.00 $56.00 $8.00 $48.00 $69.00 $12.00 $57.00 $116.00 $41.00 $75.00 $228.00 $88.00 $140.00 $337.00 $148.00 $189.00 $20.00 $13.00 $77.00 ------------------------------------$125.00 $42.00 $83.00 $86.00 $50.00 $70.00 $86.00 $110.00 ------------------------------------------------------------------------------------------$28.00 $5.00 $22.00 $59.00 $8.00 $52.00 $73.00 $12.00 $61.00 $123.00 $43.00 $80.00 $240.00 $91.00 $149.00 $354.00 $152.00 $201.00 $21.00 $13.00 $67.00 ------------------------------------$111.00 $39.00 $72.00 $75.00 $43.00 $67.00 $83.00 $107.00 ------------------------------------------------------------------------------------------$24.00 $5.00 $19.00 $52.00 $7.00 $45.00 $64.00 $11.00 $53.00 $109.00 $40.00 $70.00 $215.00 $85.00 $130.00 $319.00 $144.00 $176.00 $19.00 $13.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $72.00 ------------------------------------$118.00 $41.00 $77.00 $81.00 $47.00 $69.00 $85.00 $109.00 ------------------------------------------------------------------------------------------$26.00 $5.00 $21.00 $56.00 $8.00 $48.00 $69.00 $12.00 $57.00 $116.00 $41.00 $75.00 $228.00 $88.00 $140.00 $337.00 $148.00 $189.00 $20.00 $13.00 $77.00 ------------------------------------$125.00 $42.00 $83.00 $86.00 $50.00 $70.00 $86.00 $110.00 ------------------------------------------------------------------------------------------$28.00 $5.00 $22.00 $59.00 $8.00 $52.00 $73.00 $12.00 $61.00 $123.00 $43.00 $80.00 $240.00 $91.00 $149.00 $354.00 $152.00 $201.00 $21.00 $13.00 Part C, 348 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 88311-TC 88312 88312-26 88312-TC 88313 88313-26 88313-TC 88314 88314-26 88314-TC 88318 88318-26 88318-TC 88319 88319-26 88319-TC 88321 88321-26 88321-TC 88323 88323-26 88323-TC 88325 88325-26 88325-TC 88329 88329-26 88329-TC 88331 88331-26 88331-TC 88332 88332-26 88332-TC 88333 88333-26 88333-TC 88334 88334-26 88334-TC 88342 88342-26 88342-TC 88346 88346-26 88346-TC 88347 88347-26 88347-TC 88348 $4.00 $23.00 $7.00 $16.00 $23.00 $7.00 $16.00 $21.00 $6.00 $15.00 $33.00 $14.00 $18.00 $26.00 $13.00 $14.00 $43.00 $43.00 NC $61.00 $61.00 NC $54.00 $54.00 NC $51.00 $51.00 NC $102.00 $70.00 $33.00 $53.00 $36.00 $17.00 ------------------------------------$53.00 $36.00 $17.00 $96.00 $66.00 $28.00 $133.00 $99.00 $33.00 $191.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $7.00 $97.00 $28.00 $68.00 $73.00 $13.00 $60.00 $98.00 $24.00 $74.00 $108.00 $23.00 $85.00 $153.00 $28.00 $124.00 $93.00 ------BR $150.00 $91.00 $59.00 $201.00 ------BR $52.00 ------BR $95.00 $64.00 $31.00 $43.00 $32.00 $11.00 $97.00 $65.00 $32.00 $56.00 $37.00 $19.00 $102.00 $45.00 $57.00 $103.00 $45.00 $58.00 $86.00 $44.00 $41.00 $606.00 $7.00 $102.00 $29.00 $73.00 $78.00 $13.00 $65.00 $105.00 $25.00 $79.00 $115.00 $23.00 $91.00 $163.00 $29.00 $133.00 $96.00 ------BR $157.00 $93.00 $64.00 $210.00 ------BR $54.00 ------BR $99.00 $66.00 $34.00 $45.00 $33.00 $12.00 $101.00 $67.00 $35.00 $59.00 $39.00 $21.00 $108.00 $46.00 $62.00 $109.00 $47.00 $63.00 $90.00 $46.00 $45.00 $647.00 $8.00 $108.00 $30.00 $77.00 $82.00 $13.00 $69.00 $110.00 $26.00 $84.00 $121.00 $24.00 $97.00 $172.00 $30.00 $141.00 $99.00 ------BR $164.00 $96.00 $68.00 $219.00 ------BR $56.00 ------BR $105.00 $68.00 $36.00 $47.00 $34.00 $13.00 $107.00 $69.00 $38.00 $62.00 $40.00 $22.00 $113.00 $48.00 $66.00 $115.00 $48.00 $67.00 $95.00 $47.00 $48.00 $683.00 $7.00 $97.00 $28.00 $68.00 $73.00 $13.00 $60.00 $98.00 $24.00 $74.00 $108.00 $23.00 $85.00 $153.00 $28.00 $124.00 $83.00 ------BR $150.00 $91.00 $59.00 $129.00 ------BR $35.00 ------BR $95.00 $64.00 $31.00 $43.00 $32.00 $11.00 $97.00 $65.00 $32.00 $56.00 $37.00 $19.00 $102.00 $45.00 $57.00 $103.00 $45.00 $58.00 $86.00 $44.00 $41.00 $606.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $7.00 $102.00 $29.00 $73.00 $78.00 $13.00 $65.00 $105.00 $25.00 $79.00 $115.00 $23.00 $91.00 $163.00 $29.00 $133.00 $86.00 ------BR $157.00 $93.00 $64.00 $132.00 ------BR $36.00 ------BR $99.00 $66.00 $34.00 $45.00 $33.00 $12.00 $101.00 $67.00 $35.00 $59.00 $39.00 $21.00 $108.00 $46.00 $62.00 $109.00 $47.00 $63.00 $90.00 $46.00 $45.00 $647.00 $8.00 $108.00 $30.00 $77.00 $82.00 $13.00 $69.00 $110.00 $26.00 $84.00 $121.00 $24.00 $97.00 $172.00 $30.00 $141.00 $89.00 ------BR $164.00 $96.00 $68.00 $136.00 ------BR $38.00 ------BR $105.00 $68.00 $36.00 $47.00 $34.00 $13.00 $107.00 $69.00 $38.00 $62.00 $40.00 $22.00 $113.00 $48.00 $66.00 $115.00 $48.00 $67.00 $95.00 $47.00 $48.00 $683.00 Part C, 349 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 88348-26 88348-TC 88349 88349-26 88349-TC 88355 88355-26 88355-TC 88356 88356-26 88356-TC 88358 88358-26 88358-TC 88360 88360-26 88360-TC 88361 88361-26 88361-TC 88362 88362-26 88362-TC 88365 88365-26 88365-TC 88367 88367-26 88367-TC 88368 88368-26 88368-TC 88371 88371-26 88371-TC 88372 88372-26 88372-TC 88380 88380-26 88380-TC 88381 88381-26 88381-TC 88385 88385-26 88385-TC 88386 88386-26 88386-TC $145.00 $44.00 $191.00 $145.00 $44.00 $108.00 $80.00 $26.00 $108.00 $80.00 $26.00 $108.00 $80.00 $26.00 ------------------------------------BR BR BR $24.00 $24.00 BR ------------------------------------$34.00 $10.00 $23.00 $38.00 $11.00 $26.00 BR BR BR ------------------------------------------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $80.00 $526.00 $288.00 $41.00 $247.00 $312.00 $95.00 $217.00 $311.00 $155.00 $156.00 $84.00 $52.00 $31.00 $123.00 $59.00 $64.00 $168.00 $65.00 $104.00 $280.00 $115.00 $165.00 $155.00 $62.00 $93.00 $236.00 $66.00 $169.00 $204.00 $72.00 $132.00 ------$19.00 ------------$20.00 ------$171.00 $79.00 $92.00 $224.00 $60.00 $164.00 $507.00 $77.00 $430.00 $521.00 $97.00 $424.00 $83.00 $564.00 $308.00 $42.00 $266.00 $331.00 $98.00 $233.00 $328.00 $160.00 $168.00 $90.00 $55.00 $35.00 $131.00 $61.00 $69.00 $180.00 $68.00 $112.00 $296.00 $119.00 $177.00 $163.00 $64.00 $100.00 $251.00 $69.00 $182.00 $217.00 $75.00 $142.00 ------$20.00 ------------$21.00 ------$181.00 $81.00 $100.00 $238.00 $62.00 $176.00 $541.00 $80.00 $462.00 $556.00 $101.00 $455.00 $86.00 $597.00 $326.00 $44.00 $282.00 $349.00 $102.00 $247.00 $345.00 $166.00 $179.00 $97.00 $59.00 $39.00 $138.00 $64.00 $74.00 $192.00 $72.00 $120.00 $312.00 $123.00 $189.00 $171.00 $66.00 $106.00 $265.00 $71.00 $194.00 $229.00 $77.00 $151.00 ------$20.00 ------------$21.00 ------$191.00 $84.00 $107.00 $251.00 $65.00 $186.00 $571.00 $83.00 $489.00 $587.00 $104.00 $482.00 $80.00 $526.00 $288.00 $41.00 $247.00 $312.00 $95.00 $217.00 $311.00 $155.00 $156.00 $84.00 $52.00 $31.00 $123.00 $59.00 $64.00 $168.00 $65.00 $104.00 $280.00 $115.00 $165.00 $155.00 $62.00 $93.00 $236.00 $66.00 $169.00 $204.00 $72.00 $132.00 ------$19.00 ------------$20.00 ------$171.00 $79.00 $92.00 $224.00 $60.00 $164.00 $507.00 $77.00 $430.00 $521.00 $97.00 $424.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $83.00 $564.00 $308.00 $42.00 $266.00 $331.00 $98.00 $233.00 $328.00 $160.00 $168.00 $90.00 $55.00 $35.00 $131.00 $61.00 $69.00 $180.00 $68.00 $112.00 $296.00 $119.00 $177.00 $163.00 $64.00 $100.00 $251.00 $69.00 $182.00 $217.00 $75.00 $142.00 ------$20.00 ------------$21.00 ------$181.00 $81.00 $100.00 $238.00 $62.00 $176.00 $541.00 $80.00 $462.00 $556.00 $101.00 $455.00 $86.00 $597.00 $326.00 $44.00 $282.00 $349.00 $102.00 $247.00 $345.00 $166.00 $179.00 $97.00 $59.00 $39.00 $138.00 $64.00 $74.00 $192.00 $72.00 $120.00 $312.00 $123.00 $189.00 $171.00 $66.00 $106.00 $265.00 $71.00 $194.00 $229.00 $77.00 $151.00 ------$20.00 ------------$21.00 ------$191.00 $84.00 $107.00 $251.00 $65.00 $186.00 $571.00 $83.00 $489.00 $587.00 $104.00 $482.00 Part C, 350 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 2003 MRA 88399 88399-26 88399-TC 89049 89050 89050-26 89050-TC 89051 89051-26 89051-TC 89055 89055-26 89055-TC 89060 89060-26 89060-TC 89100 89100-26 89100-TC 89105 89105-26 89105-TC 89125 89125-26 89125-TC 89130 89130-26 89130-TC 89132 89132-26 89132-TC 89135 89135-26 89135-TC 89136 89136-26 89136-TC 89140 89140-26 89140-TC 89141 89141-26 89141-TC 89160 89160-26 89160-TC 89190 89190-26 89190-TC 89220 BR BR BR ------$10.00 $3.00 $6.00 $13.00 $4.00 $8.00 BR BR BR $13.00 $5.00 $8.00 $51.00 $15.00 $36.00 $65.00 $19.00 $44.00 $14.00 $4.00 $10.00 $44.00 $13.00 $32.00 $20.00 $6.00 $14.00 $37.00 $11.00 $25.00 $43.00 $14.00 $29.00 $50.00 $16.00 $34.00 $56.00 $19.00 $37.00 $6.00 $2.00 $4.00 $10.00 $3.00 $6.00 ------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------$195.00 ------------------------------------------------------------$20.00 ------$215.00 ------------$218.00 ------------------------------$181.00 ------------$203.00 ------------$242.00 ------------$159.00 ------------$200.00 ------------$213.00 ------------------------------------------------$17.00 ------------------$206.00 ------------------------------------------------------------$21.00 ------$230.00 ------------$232.00 ------------------------------$193.00 ------------$217.00 ------------$258.00 ------------$170.00 ------------$213.00 ------------$227.00 ------------------------------------------------$18.00 ------------------$216.00 ------------------------------------------------------------$21.00 ------$242.00 ------------$244.00 ------------------------------$203.00 ------------$229.00 ------------$272.00 ------------$179.00 ------------$223.00 ------------$238.00 ------------------------------------------------$20.00 ------------------$64.00 ------------------------------------------------------------$20.00 ------$39.00 ------------$32.00 ------------------------------$28.00 ------------$16.00 ------------$50.00 ------------$15.00 ------------$51.00 ------------$49.00 ------------------------------------------------$17.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------$66.00 ------------------------------------------------------------$21.00 ------$40.00 ------------$34.00 ------------------------------$29.00 ------------$17.00 ------------$52.00 ------------$16.00 ------------$53.00 ------------$51.00 ------------------------------------------------$18.00 ------------------$69.00 ------------------------------------------------------------$21.00 ------$42.00 ------------$35.00 ------------------------------$30.00 ------------$18.00 ------------$54.00 ------------$17.00 ------------$55.00 ------------$53.00 ------------------------------------------------$20.00 Part C, 351 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Pathology & Laboratory CPT Code 89230 G0124 G0141 2003 MRA ------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $5.00 $27.00 $27.00 $5.00 $28.00 $28.00 $6.00 $29.00 $29.00 $5.00 $27.00 $27.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $5.00 $28.00 $28.00 $6.00 $29.00 $29.00 Part C, 352 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 90471 90472 90473 90474 90632 90636 90675 90703 90718 90746 90749 90801 90802 90804 90805 90806 90807 90808 90809 90810 90811 90812 90813 90814 90815 90816 90817 90818 90819 90821 90822 90823 90824 90826 90827 90828 90829 90845 90846 90847 90849 90853 90857 90862 90865 90870 90875 90876 90880 90882 2003 MRA $4.00 $4.00 BR BR BR BR BR BR BR BR BR $140.00 $143.00 $62.00 $68.00 $94.00 $101.00 $144.00 $149.00 $69.00 $77.00 $101.00 $107.00 $143.00 $149.00 $64.00 $70.00 $96.00 $102.00 $144.00 $149.00 $73.00 $78.00 $103.00 $107.00 $146.00 $150.00 $85.00 $93.00 $110.00 $32.00 $32.00 $31.00 $50.00 $143.00 $94.00 $74.00 $112.00 $112.00 $104.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $22.00 $11.00 $14.00 $10.00 ------------------------------------------$159.00 $169.00 $67.00 $74.00 $95.00 $105.00 $141.00 $150.00 $72.00 $82.00 $103.00 $113.00 $148.00 $157.00 $63.00 $70.00 $94.00 $101.00 $139.00 $146.00 $68.00 $76.00 $100.00 $105.00 $145.00 $151.00 $88.00 $93.00 $115.00 $35.00 $33.00 $37.00 $56.00 $162.00 $148.00 $75.00 $109.00 $116.00 ------- $23.00 $12.00 $15.00 $10.00 ------------------------------------------$164.00 $174.00 $69.00 $76.00 $98.00 $108.00 $144.00 $154.00 $74.00 $85.00 $106.00 $117.00 $152.00 $161.00 $65.00 $71.00 $96.00 $103.00 $143.00 $150.00 $70.00 $78.00 $103.00 $108.00 $149.00 $154.00 $90.00 $95.00 $119.00 $36.00 $34.00 $38.00 $58.00 $168.00 $154.00 $78.00 $113.00 $119.00 ------- $24.00 $12.00 $15.00 $11.00 ------------------------------------------$169.00 $180.00 $71.00 $78.00 $100.00 $111.00 $148.00 $158.00 $76.00 $87.00 $109.00 $120.00 $156.00 $166.00 $67.00 $73.00 $99.00 $106.00 $147.00 $154.00 $72.00 $80.00 $106.00 $111.00 $153.00 $158.00 $92.00 $98.00 $122.00 $37.00 $34.00 $39.00 $60.00 $174.00 $160.00 $80.00 $116.00 $122.00 ------- $22.00 $9.00 $9.00 $8.00 ------------------------------------------$137.00 $148.00 $58.00 $66.00 $89.00 $97.00 $134.00 $142.00 $64.00 $71.00 $94.00 $102.00 $140.00 $146.00 $63.00 $70.00 $94.00 $101.00 $139.00 $146.00 $68.00 $76.00 $100.00 $105.00 $145.00 $151.00 $86.00 $91.00 $110.00 $32.00 $31.00 $33.00 $48.00 $142.00 $91.00 $61.00 $96.00 $105.00 ------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $23.00 $10.00 $10.00 $8.00 ------------------------------------------$140.00 $152.00 $60.00 $67.00 $91.00 $99.00 $137.00 $145.00 $66.00 $73.00 $96.00 $105.00 $143.00 $150.00 $65.00 $71.00 $96.00 $103.00 $143.00 $150.00 $70.00 $78.00 $103.00 $108.00 $149.00 $154.00 $88.00 $93.00 $112.00 $33.00 $31.00 $34.00 $49.00 $147.00 $93.00 $63.00 $98.00 $108.00 ------- $24.00 $10.00 $10.00 $9.00 ------------------------------------------$144.00 $156.00 $62.00 $69.00 $94.00 $102.00 $141.00 $149.00 $68.00 $75.00 $99.00 $107.00 $147.00 $153.00 $67.00 $73.00 $99.00 $106.00 $147.00 $154.00 $72.00 $80.00 $106.00 $111.00 $153.00 $158.00 $90.00 $96.00 $115.00 $34.00 $32.00 $34.00 $50.00 $152.00 $96.00 $65.00 $101.00 $110.00 ------- Part C, 353 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 90885 90887 90889 90899 90901 90911 90935 90937 90940 90945 90947 90997 90999 91000 91000-26 91000-TC 91010 91010-26 91010-TC 91011 91011-26 91011-TC 91012 91012-26 91012-TC 91020 91020-26 91020-TC 91022 91022-26 91022-TC 91030 91030-26 91030-TC 91034 91034-26 91034-TC 91035 91035-26 91035-TC 91037 91037-26 91037-TC 91038 91038-26 91038-TC 91040 91040-26 91040-TC 91052 $49.00 $77.00 BR BR $46.00 $82.00 $76.00 $226.00 BR $80.00 $125.00 $115.00 BR $43.00 $40.00 $2.00 $116.00 $76.00 $32.00 $141.00 $89.00 $39.00 $143.00 $95.00 $45.00 $60.00 $49.00 $9.00 ------------------$57.00 $47.00 $8.00 ------------------------------------------------------------------------------------------$67.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $49.00 $85.00 ------------$38.00 $94.00 $71.00 $116.00 ------$74.00 $119.00 $94.00 ------$78.00 $38.00 $39.00 $212.00 $69.00 $143.00 $271.00 $84.00 $187.00 $282.00 $81.00 $201.00 $245.00 $79.00 $165.00 $209.00 $80.00 $129.00 $142.00 $51.00 $92.00 $227.00 $54.00 $173.00 $502.00 $87.00 $415.00 $169.00 $55.00 $114.00 $147.00 $62.00 $85.00 $413.00 $52.00 $362.00 $138.00 $50.00 $88.00 ------------$40.00 $99.00 $73.00 $120.00 ------$77.00 $123.00 $97.00 ------$82.00 $39.00 $42.00 $226.00 $72.00 $154.00 $289.00 $87.00 $202.00 $300.00 $84.00 $216.00 $260.00 $82.00 $178.00 $222.00 $83.00 $140.00 $151.00 $52.00 $98.00 $243.00 $57.00 $186.00 $535.00 $90.00 $445.00 $180.00 $57.00 $123.00 $157.00 $65.00 $92.00 $442.00 $54.00 $389.00 $146.00 $51.00 $90.00 ------------$42.00 $105.00 $76.00 $124.00 ------$79.00 $127.00 $100.00 ------$86.00 $41.00 $45.00 $239.00 $75.00 $164.00 $305.00 $91.00 $214.00 $317.00 $87.00 $230.00 $275.00 $86.00 $190.00 $235.00 $86.00 $149.00 $159.00 $54.00 $104.00 $257.00 $59.00 $198.00 $565.00 $93.00 $471.00 $191.00 $60.00 $131.00 $166.00 $67.00 $99.00 $468.00 $56.00 $411.00 $154.00 $49.00 $75.00 ------------$21.00 $48.00 $71.00 $116.00 ------$74.00 $119.00 $94.00 ------$78.00 $38.00 $39.00 $212.00 $69.00 $143.00 $271.00 $84.00 $187.00 $282.00 $81.00 $201.00 $245.00 $79.00 $165.00 $209.00 $80.00 $129.00 $142.00 $51.00 $92.00 $227.00 $54.00 $173.00 $502.00 $87.00 $415.00 $169.00 $55.00 $114.00 $147.00 $62.00 $85.00 $413.00 $52.00 $362.00 $138.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $50.00 $77.00 ------------$22.00 $50.00 $73.00 $120.00 ------$77.00 $123.00 $97.00 ------$82.00 $39.00 $42.00 $226.00 $72.00 $154.00 $289.00 $87.00 $202.00 $300.00 $84.00 $216.00 $260.00 $82.00 $178.00 $222.00 $83.00 $140.00 $151.00 $52.00 $98.00 $243.00 $57.00 $186.00 $535.00 $90.00 $445.00 $180.00 $57.00 $123.00 $157.00 $65.00 $92.00 $442.00 $54.00 $389.00 $146.00 $51.00 $79.00 ------------$23.00 $53.00 $76.00 $124.00 ------$79.00 $127.00 $100.00 ------$86.00 $41.00 $45.00 $239.00 $75.00 $164.00 $305.00 $91.00 $214.00 $317.00 $87.00 $230.00 $275.00 $86.00 $190.00 $235.00 $86.00 $149.00 $159.00 $54.00 $104.00 $257.00 $59.00 $198.00 $565.00 $93.00 $471.00 $191.00 $60.00 $131.00 $166.00 $67.00 $99.00 $468.00 $56.00 $411.00 $154.00 Part C, 354 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 91052-26 91052-TC 91055 91055-26 91055-TC 91065 91065-26 91065-TC 91105 91110 91110-26 91110-TC 91111 91111-26 91111-TC 91120 91120-26 91120-TC 91122 91122-26 91122-TC 91123 91132 91132-26 91132-TC 91133 91133-26 91133-TC 91299 91299-26 91299-TC 92002 92004 92012 92014 92015 92018 92019 92020 92025 92025-26 92025-TC 92060 92060-26 92060-TC 92065 92065-26 92065-TC 92070 92081 $52.00 $12.00 $63.00 $46.00 $11.00 $34.00 $23.00 $14.00 $35.00 ------------------------------------------------------$169.00 $122.00 $37.00 BR BR $28.00 BR BR $34.00 BR BR BR BR $63.00 $98.00 $53.00 $75.00 $34.00 $80.00 $70.00 $31.00 ------------------$40.00 $32.00 $7.00 $34.00 $19.00 $6.00 $66.00 $32.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $44.00 $94.00 $147.00 $49.00 $99.00 $64.00 $11.00 $53.00 $90.00 $985.00 $198.00 $788.00 $780.00 $56.00 $723.00 $433.00 $52.00 $381.00 $263.00 $97.00 $166.00 ------------$29.00 ------------$37.00 ------------------------$71.00 $134.00 $75.00 $109.00 $45.00 $134.00 $68.00 $26.00 $33.00 $18.00 $15.00 $57.00 $37.00 $20.00 $42.00 $19.00 $23.00 $66.00 $52.00 $45.00 $101.00 $157.00 $51.00 $106.00 $69.00 $11.00 $58.00 $96.00 $1,049.00 $204.00 $845.00 $833.00 $58.00 $775.00 $463.00 $54.00 $408.00 $280.00 $102.00 $179.00 ------------$30.00 ------------$39.00 ------------------------$74.00 $139.00 $78.00 $113.00 $48.00 $138.00 $70.00 $27.00 $35.00 $19.00 $16.00 $60.00 $38.00 $21.00 $44.00 $20.00 $25.00 $69.00 $55.00 $47.00 $107.00 $165.00 $53.00 $112.00 $73.00 $12.00 $61.00 $101.00 $1,103.00 $210.00 $893.00 $878.00 $60.00 $818.00 $489.00 $57.00 $432.00 $298.00 $107.00 $191.00 ------------$31.00 ------------$40.00 ------------------------$77.00 $144.00 $81.00 $117.00 $50.00 $143.00 $72.00 $28.00 $37.00 $19.00 $18.00 $62.00 $39.00 $23.00 $47.00 $20.00 $26.00 $72.00 $58.00 $44.00 $94.00 $147.00 $49.00 $99.00 $64.00 $11.00 $53.00 $19.00 $985.00 $198.00 $788.00 $780.00 $56.00 $723.00 $433.00 $52.00 $381.00 $263.00 $97.00 $166.00 ------------$29.00 ------------$37.00 ------------------------$45.00 $94.00 $47.00 $72.00 $19.00 $134.00 $68.00 $20.00 $33.00 $18.00 $15.00 $57.00 $37.00 $20.00 $42.00 $19.00 $23.00 $38.00 $52.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $45.00 $101.00 $157.00 $51.00 $106.00 $69.00 $11.00 $58.00 $20.00 $1,049.00 $204.00 $845.00 $833.00 $58.00 $775.00 $463.00 $54.00 $408.00 $280.00 $102.00 $179.00 ------------$30.00 ------------$39.00 ------------------------$47.00 $96.00 $48.00 $74.00 $20.00 $138.00 $70.00 $21.00 $35.00 $19.00 $16.00 $60.00 $38.00 $21.00 $44.00 $20.00 $25.00 $39.00 $55.00 $47.00 $107.00 $165.00 $53.00 $112.00 $73.00 $12.00 $61.00 $21.00 $1,103.00 $210.00 $893.00 $878.00 $60.00 $818.00 $489.00 $57.00 $432.00 $298.00 $107.00 $191.00 ------------$31.00 ------------$40.00 ------------------------$48.00 $99.00 $50.00 $76.00 $20.00 $143.00 $72.00 $21.00 $37.00 $19.00 $18.00 $62.00 $39.00 $23.00 $47.00 $20.00 $26.00 $40.00 $58.00 Part C, 355 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 92081-26 92081-TC 92082 92082-26 92082-TC 92083 92083-26 92083-TC 92100 92120 92130 92135 92135-26 92135-TC 92136 92136-26 92136-TC 92140 92225 92226 92230 92235 92235-26 92235-TC 92240 92240-26 92240-TC 92250 92250-26 92250-TC 92260 92265 92265-26 92265-TC 92270 92270-26 92270-TC 92275 92275-26 92275-TC 92283 92283-26 92283-TC 92284 92284-26 92284-TC 92285 92285-26 92285-TC 92286 $19.00 $6.00 $48.00 $24.00 $9.00 $59.00 $31.00 $14.00 $40.00 $32.00 $56.00 $69.00 $18.00 $49.00 $93.00 $29.00 $63.00 $38.00 $45.00 $39.00 $58.00 $104.00 $46.00 $53.00 $132.00 $60.00 $67.00 $40.00 $24.00 $7.00 $20.00 $53.00 $37.00 $10.00 $64.00 $45.00 $19.00 $80.00 $56.00 $17.00 $24.00 $10.00 $5.00 $192.00 $151.00 $46.00 $26.00 $12.00 $6.00 $91.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $19.00 $33.00 $67.00 $23.00 $44.00 $77.00 $27.00 $51.00 $86.00 $71.00 $79.00 $45.00 $19.00 $27.00 $86.00 $29.00 $56.00 $56.00 $23.00 $21.00 $67.00 $131.00 $44.00 $87.00 $204.00 $60.00 $144.00 $73.00 $23.00 $50.00 $18.00 $82.00 $42.00 $40.00 $89.00 $43.00 $46.00 $126.00 $54.00 $72.00 $43.00 $9.00 $34.00 $69.00 $12.00 $57.00 $44.00 $11.00 $32.00 $127.00 $20.00 $35.00 $71.00 $24.00 $48.00 $82.00 $27.00 $55.00 $90.00 $74.00 $83.00 $48.00 $19.00 $29.00 $91.00 $30.00 $61.00 $59.00 $24.00 $22.00 $70.00 $139.00 $45.00 $94.00 $217.00 $62.00 $155.00 $77.00 $24.00 $53.00 $18.00 $87.00 $44.00 $43.00 $94.00 $44.00 $50.00 $133.00 $56.00 $77.00 $46.00 $10.00 $37.00 $74.00 $13.00 $61.00 $47.00 $12.00 $35.00 $135.00 $20.00 $38.00 $75.00 $25.00 $50.00 $86.00 $28.00 $58.00 $93.00 $77.00 $87.00 $50.00 $20.00 $30.00 $97.00 $31.00 $66.00 $61.00 $25.00 $23.00 $73.00 $147.00 $47.00 $100.00 $228.00 $64.00 $164.00 $81.00 $25.00 $57.00 $19.00 $92.00 $46.00 $46.00 $98.00 $46.00 $53.00 $140.00 $58.00 $82.00 $49.00 $10.00 $39.00 $78.00 $13.00 $65.00 $49.00 $12.00 $37.00 $142.00 $19.00 $33.00 $67.00 $23.00 $44.00 $77.00 $27.00 $51.00 $48.00 $42.00 $44.00 $45.00 $19.00 $27.00 $86.00 $29.00 $56.00 $26.00 $20.00 $18.00 $31.00 $131.00 $44.00 $87.00 $204.00 $60.00 $144.00 $73.00 $23.00 $50.00 $11.00 $82.00 $42.00 $40.00 $89.00 $43.00 $46.00 $126.00 $54.00 $72.00 $43.00 $9.00 $34.00 $69.00 $12.00 $57.00 $44.00 $11.00 $32.00 $127.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $20.00 $35.00 $71.00 $24.00 $48.00 $82.00 $27.00 $55.00 $49.00 $43.00 $45.00 $48.00 $19.00 $29.00 $91.00 $30.00 $61.00 $27.00 $21.00 $18.00 $32.00 $139.00 $45.00 $94.00 $217.00 $62.00 $155.00 $77.00 $24.00 $53.00 $12.00 $87.00 $44.00 $43.00 $94.00 $44.00 $50.00 $133.00 $56.00 $77.00 $46.00 $10.00 $37.00 $74.00 $13.00 $61.00 $47.00 $12.00 $35.00 $135.00 $20.00 $38.00 $75.00 $25.00 $50.00 $86.00 $28.00 $58.00 $50.00 $44.00 $46.00 $50.00 $20.00 $30.00 $97.00 $31.00 $66.00 $28.00 $21.00 $19.00 $33.00 $147.00 $47.00 $100.00 $228.00 $64.00 $164.00 $81.00 $25.00 $57.00 $12.00 $92.00 $46.00 $46.00 $98.00 $46.00 $53.00 $140.00 $58.00 $82.00 $49.00 $10.00 $39.00 $78.00 $13.00 $65.00 $49.00 $12.00 $37.00 $142.00 Part C, 356 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 92286-26 92286-TC 92287 92310 92311 92312 92313 92314 92315 92316 92317 92325 92326 92340 92341 92342 92352 92353 92354 92355 92358 92370 92371 92499 92499-26 92499-TC 92502 92504 92506 92507 92508 92511 92512 92516 92520 92526 92531 92532 92533 92534 92541 92541-26 92541-TC 92542 92542-26 92542-TC 92543 92543-26 92543-TC 92544 $53.00 $29.00 $99.00 $86.00 $78.00 $89.00 $70.00 $54.00 $44.00 $59.00 $39.00 $14.00 $44.00 $32.00 $43.00 $43.00 $31.00 $38.00 $221.00 $107.00 $24.00 $35.00 $18.00 BR BR BR $101.00 $24.00 $63.00 $40.00 $42.00 $81.00 $46.00 $36.00 $47.00 $48.00 $10.00 $14.00 $41.00 BR $37.00 $25.00 $9.00 $33.00 $20.00 $10.00 $28.00 $19.00 $10.00 $26.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $35.00 $92.00 $115.00 $88.00 $88.00 $98.00 $84.00 $67.00 $60.00 $76.00 $61.00 $25.00 $50.00 $37.00 $41.00 $45.00 $39.00 $46.00 $186.00 $94.00 $27.00 $31.00 $18.00 ------------------$98.00 $29.00 $153.00 $66.00 $31.00 $159.00 $63.00 $64.00 $58.00 $87.00 ------------------------$60.00 $22.00 $38.00 $62.00 $18.00 $44.00 $29.00 $6.00 $23.00 $50.00 $36.00 $99.00 $121.00 $92.00 $92.00 $102.00 $88.00 $70.00 $63.00 $80.00 $65.00 $27.00 $55.00 $39.00 $43.00 $47.00 $41.00 $48.00 $201.00 $101.00 $29.00 $33.00 $20.00 ------------------$102.00 $31.00 $163.00 $70.00 $33.00 $169.00 $67.00 $68.00 $60.00 $92.00 ------------------------$64.00 $23.00 $41.00 $66.00 $18.00 $47.00 $31.00 $6.00 $25.00 $53.00 $38.00 $105.00 $127.00 $96.00 $96.00 $106.00 $91.00 $73.00 $66.00 $84.00 $68.00 $29.00 $59.00 $40.00 $45.00 $48.00 $42.00 $50.00 $215.00 $107.00 $32.00 $35.00 $21.00 ------------------$106.00 $32.00 $171.00 $73.00 $34.00 $177.00 $70.00 $71.00 $63.00 $96.00 ------------------------$68.00 $24.00 $44.00 $70.00 $19.00 $51.00 $33.00 $7.00 $26.00 $56.00 $35.00 $92.00 $42.00 $60.00 $55.00 $65.00 $47.00 $34.00 $23.00 $37.00 $22.00 $25.00 $50.00 $19.00 $23.00 $27.00 $19.00 $26.00 $186.00 $94.00 $27.00 $17.00 $18.00 ------------------$98.00 $10.00 $47.00 $28.00 $15.00 $61.00 $28.00 $24.00 $42.00 $28.00 ------------------------$60.00 $22.00 $38.00 $62.00 $18.00 $44.00 $29.00 $6.00 $23.00 $50.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $36.00 $99.00 $44.00 $62.00 $56.00 $67.00 $48.00 $35.00 $23.00 $38.00 $23.00 $27.00 $55.00 $19.00 $24.00 $28.00 $19.00 $26.00 $201.00 $101.00 $29.00 $18.00 $20.00 ------------------$102.00 $10.00 $49.00 $29.00 $15.00 $64.00 $29.00 $24.00 $43.00 $29.00 ------------------------$64.00 $23.00 $41.00 $66.00 $18.00 $47.00 $31.00 $6.00 $25.00 $53.00 $38.00 $105.00 $45.00 $64.00 $58.00 $69.00 $50.00 $36.00 $24.00 $39.00 $24.00 $29.00 $59.00 $20.00 $25.00 $28.00 $20.00 $27.00 $215.00 $107.00 $32.00 $18.00 $21.00 ------------------$106.00 $11.00 $50.00 $30.00 $16.00 $66.00 $30.00 $25.00 $45.00 $30.00 ------------------------$68.00 $24.00 $44.00 $70.00 $19.00 $51.00 $33.00 $7.00 $26.00 $56.00 Part C, 357 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 92544-26 92544-TC 92545 92545-26 92545-TC 92546 92546-26 92546-TC 92547 92548 92548-26 92548-TC 92551 92552 92553 92555 92556 92557 92560 92561 92562 92563 92564 92565 92567 92568 92569 92571 92572 92575 92576 92577 92579 92582 92583 92584 92585 92585-26 92585-TC 92586 92587 92587-26 92587-TC 92588 92588-26 92588-TC 92590 92591 92592 92593 $16.00 $8.00 $22.00 $14.00 $8.00 $29.00 $17.00 $9.00 $21.00 $92.00 $30.00 $59.00 $17.00 $16.00 $24.00 $14.00 $21.00 $46.00 $23.00 $27.00 $15.00 $14.00 $17.00 $15.00 $20.00 $14.00 $15.00 $14.00 $3.00 $11.00 $17.00 $28.00 $28.00 $28.00 $34.00 $94.00 $114.00 $52.00 $70.00 $70.00 $58.00 $8.00 $49.00 $78.00 $20.00 $57.00 $41.00 BR BR BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $14.00 $35.00 $46.00 $13.00 $33.00 $87.00 $15.00 $72.00 $7.00 $106.00 $28.00 $78.00 $10.00 $23.00 $32.00 $18.00 $25.00 $59.00 ------$32.00 $23.00 $21.00 $22.00 $15.00 $24.00 $23.00 $19.00 $19.00 $14.00 $30.00 $23.00 $24.00 $51.00 $41.00 $37.00 $88.00 $111.00 $27.00 $83.00 $73.00 $52.00 $7.00 $45.00 $76.00 $20.00 $57.00 ------------------------- $15.00 $38.00 $49.00 $13.00 $36.00 $93.00 $16.00 $77.00 $9.00 $114.00 $28.00 $86.00 $11.00 $25.00 $35.00 $20.00 $28.00 $63.00 ------$35.00 $25.00 $23.00 $24.00 $17.00 $26.00 $24.00 $21.00 $21.00 $15.00 $32.00 $26.00 $26.00 $54.00 $45.00 $41.00 $98.00 $120.00 $28.00 $91.00 $81.00 $57.00 $8.00 $49.00 $83.00 $20.00 $63.00 ------------------------- $15.00 $41.00 $52.00 $14.00 $38.00 $99.00 $16.00 $82.00 $11.00 $123.00 $30.00 $94.00 $12.00 $28.00 $38.00 $22.00 $31.00 $69.00 ------$38.00 $27.00 $25.00 $27.00 $19.00 $29.00 $26.00 $23.00 $23.00 $16.00 $35.00 $28.00 $30.00 $57.00 $49.00 $45.00 $109.00 $130.00 $30.00 $100.00 $89.00 $63.00 $8.00 $55.00 $90.00 $21.00 $70.00 ------------------------- $14.00 $35.00 $46.00 $13.00 $33.00 $87.00 $15.00 $72.00 $7.00 $106.00 $28.00 $78.00 $10.00 $23.00 $32.00 $18.00 $25.00 $57.00 ------$32.00 $23.00 $21.00 $22.00 $15.00 $23.00 $23.00 $19.00 $19.00 $14.00 $30.00 $23.00 $24.00 $49.00 $41.00 $37.00 $88.00 $111.00 $27.00 $83.00 $73.00 $52.00 $7.00 $45.00 $76.00 $20.00 $57.00 ------------------------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $15.00 $38.00 $49.00 $13.00 $36.00 $93.00 $16.00 $77.00 $9.00 $114.00 $28.00 $86.00 $11.00 $25.00 $35.00 $20.00 $28.00 $61.00 ------$35.00 $25.00 $23.00 $24.00 $17.00 $25.00 $24.00 $21.00 $21.00 $15.00 $32.00 $26.00 $26.00 $51.00 $45.00 $41.00 $98.00 $120.00 $28.00 $91.00 $81.00 $57.00 $8.00 $49.00 $83.00 $20.00 $63.00 ------------------------- $15.00 $41.00 $52.00 $14.00 $38.00 $99.00 $16.00 $82.00 $11.00 $123.00 $30.00 $94.00 $12.00 $28.00 $38.00 $22.00 $31.00 $66.00 ------$38.00 $27.00 $25.00 $27.00 $19.00 $27.00 $26.00 $23.00 $23.00 $16.00 $35.00 $28.00 $30.00 $54.00 $49.00 $45.00 $109.00 $130.00 $30.00 $100.00 $89.00 $63.00 $8.00 $55.00 $90.00 $21.00 $70.00 ------------------------- Part C, 358 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 92594 92595 92596 92597 92603 92604 92605 92606 92607 92608 92609 92610 92611 92612 92613 92614 92615 92616 92617 92620 92621 92625 92626 92627 92640 92700 92950 92953 92960 92961 92970 92971 92973 92974 92975 92977 92978 92978-26 92978-TC 92979 92979-26 92979-TC 92980 92981 92982 92984 92986 92987 92990 92992 BR BR $22.00 $96.00 $88.00 $60.00 BR BR $109.00 $22.00 $59.00 $42.00 $46.00 $173.00 BR $134.00 BR $183.00 BR ------------------------------------BR $203.00 $35.00 $162.00 $239.00 $201.00 $100.00 $174.00 $197.00 $400.00 $302.00 $269.00 $95.00 $170.00 $163.00 $76.00 $86.00 $952.00 $268.00 $705.00 $191.00 $1,222.00 $1,271.00 $974.00 BR Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------$35.00 $106.00 $153.00 $92.00 ------------$155.00 $31.00 $82.00 $106.00 $111.00 $162.00 $42.00 $146.00 $37.00 $202.00 $46.00 $64.00 $17.00 $64.00 $86.00 $21.00 $53.00 ------$303.00 $12.00 $297.00 $276.00 $189.00 $107.00 $195.00 $179.00 $429.00 $221.00 ------$103.00 ------------$83.00 ------$889.00 $247.00 $659.00 $177.00 $1,465.00 $1,519.00 $1,158.00 ------- ------------$39.00 $112.00 $159.00 $96.00 ------------$166.00 $34.00 $88.00 $115.00 $120.00 $171.00 $44.00 $154.00 $39.00 $212.00 $48.00 $70.00 $19.00 $69.00 $93.00 $23.00 $57.00 ------$319.00 $13.00 $313.00 $288.00 $196.00 $111.00 $204.00 $187.00 $449.00 $244.00 ------$107.00 ------------$86.00 ------$930.00 $258.00 $689.00 $185.00 $1,533.00 $1,590.00 $1,212.00 ------- ------------$42.00 $117.00 $165.00 $101.00 ------------$177.00 $38.00 $94.00 $123.00 $128.00 $178.00 $46.00 $161.00 $41.00 $222.00 $51.00 $75.00 $22.00 $75.00 $100.00 $24.00 $61.00 ------$337.00 $14.00 $328.00 $302.00 $203.00 $115.00 $215.00 $197.00 $472.00 $269.00 ------$111.00 ------------$90.00 ------$978.00 $272.00 $725.00 $194.00 $1,611.00 $1,672.00 $1,274.00 ------- ------------$35.00 $48.00 $144.00 $85.00 ------------$155.00 $31.00 $82.00 $106.00 $111.00 $71.00 $42.00 $71.00 $37.00 $105.00 $46.00 $64.00 $17.00 $64.00 $86.00 $21.00 $53.00 ------$192.00 $12.00 $139.00 $276.00 $189.00 $107.00 $195.00 $179.00 $429.00 $221.00 ------$103.00 ------------$83.00 ------$889.00 $247.00 $659.00 $177.00 $1,465.00 $1,519.00 $1,158.00 ------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------$39.00 $50.00 $149.00 $89.00 ------------$166.00 $34.00 $88.00 $115.00 $120.00 $73.00 $44.00 $73.00 $39.00 $108.00 $48.00 $70.00 $19.00 $69.00 $93.00 $23.00 $57.00 ------$200.00 $13.00 $144.00 $288.00 $196.00 $111.00 $204.00 $187.00 $449.00 $244.00 ------$107.00 ------------$86.00 ------$930.00 $258.00 $689.00 $185.00 $1,533.00 $1,590.00 $1,212.00 ------- ------------$42.00 $52.00 $155.00 $93.00 ------------$177.00 $38.00 $94.00 $123.00 $128.00 $75.00 $46.00 $75.00 $41.00 $112.00 $51.00 $75.00 $22.00 $75.00 $100.00 $24.00 $61.00 ------$210.00 $14.00 $149.00 $302.00 $203.00 $115.00 $215.00 $197.00 $472.00 $269.00 ------$111.00 ------------$90.00 ------$978.00 $272.00 $725.00 $194.00 $1,611.00 $1,672.00 $1,274.00 ------- Part C, 359 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 92993 92995 92996 92997 92998 93000 93005 93010 93012 93014 93015 93016 93017 93018 93024 93024-26 93024-TC 93025 93025-26 93025-TC 93040 93041 93042 93224 93225 93226 93227 93230 93231 93232 93233 93235 93236 93237 93268 93270 93271 93272 93278 93278-26 93278-TC 93303 93303-26 93303-TC 93304 93304-26 93304-TC 93307 93307-26 93307-TC BR $776.00 $210.00 $765.00 $331.00 $26.00 $16.00 $12.00 $90.00 $28.00 $104.00 $25.00 $63.00 $54.00 $111.00 $71.00 $42.00 $277.00 ------------$14.00 $31.00 $9.00 $159.00 $46.00 $83.00 $50.00 $168.00 $57.00 $82.00 $55.00 $123.00 $97.00 $28.00 $109.00 $46.00 $90.00 $28.00 $58.00 $24.00 $44.00 $215.00 $70.00 $144.00 $114.00 $43.00 $73.00 $196.00 $56.00 $144.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------$725.00 $186.00 $672.00 $340.00 $25.00 $15.00 $9.00 $211.00 $29.00 $113.00 $26.00 $70.00 $17.00 $128.00 $66.00 $63.00 $263.00 $43.00 $220.00 $15.00 $7.00 $8.00 $151.00 $46.00 $75.00 $30.00 $157.00 $51.00 $78.00 $29.00 ------------$25.00 $296.00 $35.00 $233.00 $28.00 $53.00 $14.00 $39.00 $238.00 $70.00 $168.00 $142.00 $40.00 $102.00 $206.00 $52.00 $154.00 ------$758.00 $192.00 $694.00 $353.00 $26.00 $17.00 $10.00 $229.00 $30.00 $121.00 $27.00 $77.00 $17.00 $136.00 $68.00 $68.00 $282.00 $44.00 $237.00 $16.00 $7.00 $9.00 $164.00 $51.00 $83.00 $31.00 $171.00 $56.00 $85.00 $30.00 ------------$26.00 $320.00 $39.00 $252.00 $29.00 $58.00 $14.00 $44.00 $255.00 $72.00 $183.00 $152.00 $41.00 $111.00 $222.00 $53.00 $169.00 ------$798.00 $199.00 $719.00 $368.00 $28.00 $18.00 $10.00 $246.00 $31.00 $130.00 $28.00 $84.00 $18.00 $145.00 $70.00 $74.00 $300.00 $46.00 $253.00 $17.00 $8.00 $9.00 $178.00 $56.00 $91.00 $32.00 $186.00 $62.00 $93.00 $31.00 ------------$27.00 $344.00 $43.00 $271.00 $30.00 $64.00 $15.00 $49.00 $274.00 $74.00 $200.00 $163.00 $43.00 $120.00 $240.00 $55.00 $184.00 ------$725.00 $186.00 $672.00 $340.00 $25.00 $15.00 $9.00 $211.00 $29.00 $113.00 $26.00 $70.00 $17.00 $128.00 $66.00 $63.00 $263.00 $43.00 $220.00 $15.00 $7.00 $8.00 $151.00 $46.00 $75.00 $30.00 $157.00 $51.00 $78.00 $29.00 ------------$25.00 $296.00 $35.00 $233.00 $28.00 $53.00 $14.00 $39.00 $238.00 $70.00 $168.00 $142.00 $40.00 $102.00 $206.00 $52.00 $154.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------$758.00 $192.00 $694.00 $353.00 $26.00 $17.00 $10.00 $229.00 $30.00 $121.00 $27.00 $77.00 $17.00 $136.00 $68.00 $68.00 $282.00 $44.00 $237.00 $16.00 $7.00 $9.00 $164.00 $51.00 $83.00 $31.00 $171.00 $56.00 $85.00 $30.00 ------------$26.00 $320.00 $39.00 $252.00 $29.00 $58.00 $14.00 $44.00 $255.00 $72.00 $183.00 $152.00 $41.00 $111.00 $222.00 $53.00 $169.00 ------$798.00 $199.00 $719.00 $368.00 $28.00 $18.00 $10.00 $246.00 $31.00 $130.00 $28.00 $84.00 $18.00 $145.00 $70.00 $74.00 $300.00 $46.00 $253.00 $17.00 $8.00 $9.00 $178.00 $56.00 $91.00 $32.00 $186.00 $62.00 $93.00 $31.00 ------------$27.00 $344.00 $43.00 $271.00 $30.00 $64.00 $15.00 $49.00 $274.00 $74.00 $200.00 $163.00 $43.00 $120.00 $240.00 $55.00 $184.00 Part C, 360 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 93308 93308-26 93308-TC 93312 93312-26 93312-TC 93313 93314 93314-26 93314-TC 93315 93315-26 93315-TC 93316 93317 93317-26 93317-TC 93318 93318-26 93318-TC 93320 93320-26 93320-TC 93321 93321-26 93321-TC 93325 93325-26 93325-TC 93350 93350-26 93350-TC 93501 93501-26 93501-TC 93503 93505 93505-26 93505-TC 93508 93508-26 93508-TC 93510 93510-26 93510-TC 93511 93511-26 93511-TC 93514 93514-26 $118.00 $46.00 $75.00 $322.00 $140.00 $182.00 $76.00 $212.00 $65.00 $144.00 $287.00 $144.00 $141.00 $78.00 $236.00 $95.00 $141.00 BR $114.00 BR $86.00 $30.00 $65.00 $50.00 $10.00 $42.00 $114.00 $4.00 $110.00 $216.00 $77.00 $66.00 $674.00 $160.00 $634.00 $187.00 $318.00 $248.00 $74.00 $698.00 $232.00 $469.00 $1,628.00 $247.00 $1,388.00 $1,629.00 $270.00 $1,350.00 $2,208.00 $525.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $122.00 $30.00 $93.00 $339.00 $121.00 $218.00 $46.00 $292.00 $69.00 $223.00 $616.00 $154.00 $565.00 $48.00 ------$96.00 ------$600.00 $116.00 $565.00 $91.00 $21.00 $70.00 $46.00 $9.00 $37.00 $87.00 $4.00 $83.00 $211.00 $83.00 $128.00 $913.00 $178.00 $735.00 $120.00 $672.00 $258.00 $415.00 $1,064.00 $252.00 $812.00 $1,643.00 $265.00 $1,378.00 ------$307.00 ------------$410.00 $132.00 $31.00 $101.00 $363.00 $125.00 $238.00 $47.00 $314.00 $71.00 $243.00 $678.00 $159.00 $622.00 $50.00 ------$100.00 ------$662.00 $121.00 $622.00 $99.00 $22.00 $77.00 $50.00 $9.00 $41.00 $96.00 $5.00 $92.00 $225.00 $86.00 $139.00 $990.00 $186.00 $804.00 $124.00 $716.00 $269.00 $447.00 $1,144.00 $263.00 $880.00 $1,790.00 $278.00 $1,512.00 ------$321.00 ------------$428.00 $142.00 $32.00 $110.00 $388.00 $129.00 $259.00 $50.00 $338.00 $73.00 $264.00 $747.00 $164.00 $685.00 $52.00 ------$104.00 ------$731.00 $127.00 $685.00 $107.00 $23.00 $85.00 $55.00 $10.00 $45.00 $107.00 $5.00 $102.00 $239.00 $89.00 $150.00 $1,071.00 $196.00 $876.00 $130.00 $759.00 $283.00 $476.00 $1,222.00 $277.00 $945.00 $1,948.00 $292.00 $1,656.00 ------$338.00 ------------$450.00 $122.00 $30.00 $93.00 $339.00 $121.00 $218.00 $46.00 $292.00 $69.00 $223.00 $616.00 $154.00 $565.00 $48.00 ------$96.00 ------$600.00 $116.00 $565.00 $91.00 $21.00 $70.00 $46.00 $9.00 $37.00 $87.00 $4.00 $83.00 $211.00 $83.00 $128.00 $913.00 $178.00 $735.00 $120.00 $672.00 $258.00 $415.00 $1,064.00 $252.00 $812.00 $1,643.00 $265.00 $1,378.00 ------$307.00 ------------$410.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $132.00 $31.00 $101.00 $363.00 $125.00 $238.00 $47.00 $314.00 $71.00 $243.00 $678.00 $159.00 $622.00 $50.00 ------$100.00 ------$662.00 $121.00 $622.00 $99.00 $22.00 $77.00 $50.00 $9.00 $41.00 $96.00 $5.00 $92.00 $225.00 $86.00 $139.00 $990.00 $186.00 $804.00 $124.00 $716.00 $269.00 $447.00 $1,144.00 $263.00 $880.00 $1,790.00 $278.00 $1,512.00 ------$321.00 ------------$428.00 $142.00 $32.00 $110.00 $388.00 $129.00 $259.00 $50.00 $338.00 $73.00 $264.00 $747.00 $164.00 $685.00 $52.00 ------$104.00 ------$731.00 $127.00 $685.00 $107.00 $23.00 $85.00 $55.00 $10.00 $45.00 $107.00 $5.00 $102.00 $239.00 $89.00 $150.00 $1,071.00 $196.00 $876.00 $130.00 $759.00 $283.00 $476.00 $1,222.00 $277.00 $945.00 $1,948.00 $292.00 $1,656.00 ------$338.00 ------------$450.00 Part C, 361 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 93514-TC 93524 93524-26 93524-TC 93526 93526-26 93526-TC 93527 93527-26 93527-TC 93528 93528-26 93528-TC 93529 93529-26 93529-TC 93530 93530-26 93530-TC 93531 93531-26 93531-TC 93532 93532-26 93532-TC 93533 93533-26 93533-TC 93539 93540 93541 93542 93543 93544 93545 93555 93555-26 93555-TC 93556 93556-26 93556-TC 93561 93561-26 93561-TC 93562 93562-26 93562-TC 93571 93571-26 93571-TC $1,683.00 $2,150.00 $392.00 $1,766.00 $2,147.00 $363.00 $1,815.00 $2,186.00 $451.00 $1,766.00 $2,266.00 $482.00 $1,766.00 $2,032.00 $262.00 $1,766.00 $872.00 $250.00 $634.00 $2,268.00 $467.00 $1,815.00 $2,317.00 $569.00 $1,766.00 $2,131.00 $352.00 $1,766.00 $45.00 $49.00 $38.00 $38.00 $213.00 $30.00 $240.00 $278.00 $42.00 $234.00 $414.00 $44.00 $368.00 $59.00 $47.00 $20.00 $46.00 $33.00 $13.00 $270.00 $93.00 $170.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------$422.00 ------$2,126.00 $364.00 $1,762.00 ------$441.00 ------------$537.00 ------------$293.00 ------------$248.00 ------------$484.00 ------------$567.00 ------------$393.00 ------$67.00 $189.00 $17.00 $116.00 $65.00 $48.00 $133.00 $194.00 $46.00 $148.00 $282.00 $47.00 $235.00 ------$26.00 ------------$8.00 ------------$103.00 ------- ------------$441.00 ------$2,316.00 $381.00 $1,935.00 ------$461.00 ------------$561.00 ------------$306.00 ------------$259.00 ------------$506.00 ------------$592.00 ------------$411.00 ------$71.00 $201.00 $17.00 $123.00 $69.00 $51.00 $142.00 $211.00 $48.00 $163.00 $308.00 $49.00 $259.00 ------$26.00 ------------$8.00 ------------$106.00 ------- ------------$464.00 ------$2,522.00 $401.00 $2,121.00 ------$485.00 ------------$590.00 ------------$322.00 ------------$273.00 ------------$532.00 ------------$622.00 ------------$432.00 ------$74.00 $212.00 $18.00 $130.00 $73.00 $53.00 $149.00 $231.00 $50.00 $181.00 $338.00 $51.00 $287.00 ------$27.00 ------------$9.00 ------------$110.00 ------- ------------$422.00 ------$2,126.00 $364.00 $1,762.00 ------$441.00 ------------$537.00 ------------$293.00 ------------$248.00 ------------$484.00 ------------$567.00 ------------$393.00 ------$23.00 $24.00 $17.00 $17.00 $17.00 $15.00 $23.00 $194.00 $46.00 $148.00 $282.00 $47.00 $235.00 ------$26.00 ------------$8.00 ------------$103.00 ------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------$441.00 ------$2,316.00 $381.00 $1,935.00 ------$461.00 ------------$561.00 ------------$306.00 ------------$259.00 ------------$506.00 ------------$592.00 ------------$411.00 ------$23.00 $25.00 $17.00 $17.00 $17.00 $15.00 $23.00 $211.00 $48.00 $163.00 $308.00 $49.00 $259.00 ------$26.00 ------------$8.00 ------------$106.00 ------- ------------$464.00 ------$2,522.00 $401.00 $2,121.00 ------$485.00 ------------$590.00 ------------$322.00 ------------$273.00 ------------$532.00 ------------$622.00 ------------$432.00 ------$24.00 $26.00 $18.00 $18.00 $18.00 $16.00 $24.00 $231.00 $50.00 $181.00 $338.00 $51.00 $287.00 ------$27.00 ------------$9.00 ------------$110.00 ------- Part C, 362 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 93572 93572-26 93572-TC 93580 93581 93600 93600-26 93600-TC 93602 93602-26 93602-TC 93603 93603-26 93603-TC 93609 93609-26 93609-TC 93610 93610-26 93610-TC 93612 93612-26 93612-TC 93613 93615 93615-26 93615-TC 93616 93616-26 93616-TC 93618 93618-26 93618-TC 93619 93619-26 93619-TC 93620 93620-26 93620-TC 93621 93621-26 93621-TC 93622 93622-26 93622-TC 93623 93623-26 93623-TC 93624 93624-26 $222.00 $74.00 $155.00 $974.00 $1,303.00 $198.00 $129.00 $73.00 $159.00 $119.00 $42.00 $187.00 $127.00 $63.00 $578.00 $481.00 $101.00 $214.00 $166.00 $52.00 $224.00 $167.00 $61.00 $377.00 $62.00 $49.00 $12.00 $94.00 $82.00 $12.00 $399.00 $258.00 $148.00 $717.00 $444.00 $290.00 $358.00 $272.00 $91.00 BR $769.00 BR BR $771.00 BR BR $167.00 BR $333.00 $256.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------$80.00 ------$1,071.00 $1,419.00 ------$126.00 ------------$125.00 ------------$126.00 ------------$296.00 ------------$178.00 ------------$178.00 ------$415.00 ------$54.00 ------------$74.00 ------------$253.00 ------------$440.00 ------------$691.00 ------------$125.00 ------------$183.00 ------------$169.00 ------------$292.00 ------$83.00 ------$1,119.00 $1,482.00 ------$132.00 ------------$131.00 ------------$132.00 ------------$309.00 ------------$186.00 ------------$186.00 ------$434.00 ------$56.00 ------------$77.00 ------------$264.00 ------------$460.00 ------------$722.00 ------------$130.00 ------------$191.00 ------------$176.00 ------------$305.00 ------$85.00 ------$1,177.00 $1,560.00 ------$139.00 ------------$139.00 ------------$140.00 ------------$325.00 ------------$197.00 ------------$197.00 ------$457.00 ------$58.00 ------------$81.00 ------------$278.00 ------------$484.00 ------------$760.00 ------------$137.00 ------------$201.00 ------------$185.00 ------------$321.00 ------$80.00 ------$1,071.00 $1,419.00 ------$126.00 ------------$125.00 ------------$126.00 ------------$296.00 ------------$178.00 ------------$178.00 ------$415.00 ------$54.00 ------------$74.00 ------------$253.00 ------------$440.00 ------------$691.00 ------------$125.00 ------------$183.00 ------------$169.00 ------------$292.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------$83.00 ------$1,119.00 $1,482.00 ------$132.00 ------------$131.00 ------------$132.00 ------------$309.00 ------------$186.00 ------------$186.00 ------$434.00 ------$56.00 ------------$77.00 ------------$264.00 ------------$460.00 ------------$722.00 ------------$130.00 ------------$191.00 ------------$176.00 ------------$305.00 ------$85.00 ------$1,177.00 $1,560.00 ------$139.00 ------------$139.00 ------------$140.00 ------------$325.00 ------------$197.00 ------------$197.00 ------$457.00 ------$58.00 ------------$81.00 ------------$278.00 ------------$484.00 ------------$760.00 ------------$137.00 ------------$201.00 ------------$185.00 ------------$321.00 Part C, 363 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 93624-TC 93631 93631-26 93631-TC 93640 93640-26 93640-TC 93641 93641-26 93641-TC 93642 93642-26 93642-TC 93650 93651 93652 93660 93660-26 93660-TC 93662 93662-26 93662-TC 93668 93701 93701-26 93701-TC 93720 93721 93722 93724 93724-26 93724-TC 93740 93740-26 93740-TC 93770 93770-26 93770-TC 93784 93786 93788 93790 93797 93798 93799 93799-26 93799-TC 93875 93875-26 93875-TC $74.00 $651.00 $420.00 $239.00 $467.00 $230.00 $269.00 $613.00 $360.00 $269.00 $549.00 $295.00 $269.00 $639.00 $985.00 $1,044.00 $162.00 $103.00 $61.00 BR $158.00 BR BR $36.00 $9.00 $27.00 $43.00 $27.00 $24.00 $411.00 $259.00 $148.00 $17.00 $12.00 $5.00 NC NC NC NC NC NC NC $17.00 $38.00 BR BR BR $55.00 $17.00 $42.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------$449.00 ------------$207.00 ------------$350.00 ------------$284.00 $261.00 $634.00 $961.00 $1,047.00 $181.00 $107.00 $74.00 ------$160.00 ------$17.00 $41.00 $10.00 $31.00 $49.00 $40.00 $9.00 $383.00 $273.00 $110.00 $11.00 $8.00 $3.00 NC NC NC NC NC NC NC $19.00 $29.00 ------------------$111.00 $11.00 $100.00 ------------$476.00 ------------$216.00 ------------$366.00 ------------$294.00 $286.00 $663.00 $1,004.00 $1,094.00 $190.00 $110.00 $80.00 ------$165.00 ------$18.00 $43.00 $10.00 $33.00 $53.00 $44.00 $9.00 $404.00 $282.00 $122.00 $12.00 $8.00 $4.00 NC NC NC NC NC NC NC $21.00 $30.00 ------------------$120.00 $12.00 $109.00 ------------$512.00 ------------$227.00 ------------$385.00 ------------$304.00 $312.00 $697.00 $1,056.00 $1,151.00 $199.00 $114.00 $85.00 ------$171.00 ------$19.00 $46.00 $11.00 $35.00 $57.00 $48.00 $10.00 $426.00 $292.00 $135.00 $13.00 $9.00 $4.00 NC NC NC NC NC NC NC $22.00 $32.00 ------------------$130.00 $12.00 $118.00 ------------$449.00 ------------$207.00 ------------$350.00 ------------$284.00 $261.00 $634.00 $961.00 $1,047.00 $181.00 $107.00 $74.00 ------$160.00 ------$17.00 $41.00 $10.00 $31.00 $49.00 $40.00 $9.00 $383.00 $273.00 $110.00 $11.00 $8.00 $3.00 NC NC NC NC NC NC NC $10.00 $16.00 ------------------$111.00 $11.00 $100.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------$476.00 ------------$216.00 ------------$366.00 ------------$294.00 $286.00 $663.00 $1,004.00 $1,094.00 $190.00 $110.00 $80.00 ------$165.00 ------$18.00 $43.00 $10.00 $33.00 $53.00 $44.00 $9.00 $404.00 $282.00 $122.00 $12.00 $8.00 $4.00 NC NC NC NC NC NC NC $11.00 $16.00 ------------------$120.00 $12.00 $109.00 ------------$512.00 ------------$227.00 ------------$385.00 ------------$304.00 $312.00 $697.00 $1,056.00 $1,151.00 $199.00 $114.00 $85.00 ------$171.00 ------$19.00 $46.00 $11.00 $35.00 $57.00 $48.00 $10.00 $426.00 $292.00 $135.00 $13.00 $9.00 $4.00 NC NC NC NC NC NC NC $11.00 $17.00 ------------------$130.00 $12.00 $118.00 Part C, 364 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 93880 93880-26 93880-TC 93882 93882-26 93882-TC 93886 93886-26 93886-TC 93888 93888-26 93888-TC 93890 93890-26 93890-TC 93892 93892-26 93892-TC 93893 93893-26 93893-TC 93922 93922-26 93922-TC 93923 93923-26 93923-TC 93924 93924-26 93924-TC 93925 93925-26 93925-TC 93926 93926-26 93926-TC 93930 93930-26 93930-TC 93931 93931-26 93931-TC 93965 93965-26 93965-TC 93970 93970-26 93970-TC 93971 93971-26 $176.00 $31.00 $144.00 $117.00 $21.00 $95.00 $215.00 $50.00 $162.00 $142.00 $33.00 $109.00 ------------------------------------------------------$60.00 $16.00 $44.00 $112.00 $28.00 $85.00 $122.00 $31.00 $92.00 $175.00 $31.00 $144.00 $117.00 $21.00 $96.00 $174.00 $26.00 $150.00 $118.00 $17.00 $101.00 $63.00 $26.00 $42.00 $189.00 $36.00 $154.00 $121.00 $23.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $194.00 $33.00 $162.00 $181.00 $22.00 $159.00 $212.00 $51.00 $161.00 $99.00 $34.00 $65.00 $158.00 $55.00 $103.00 $164.00 $61.00 $103.00 $164.00 $61.00 $103.00 $132.00 $14.00 $119.00 $204.00 $25.00 $179.00 $248.00 $28.00 $219.00 $191.00 $31.00 $160.00 $123.00 $21.00 $102.00 $187.00 $26.00 $161.00 $120.00 $17.00 $102.00 $136.00 $19.00 $117.00 $200.00 $38.00 $162.00 $127.00 $25.00 $211.00 $34.00 $177.00 $197.00 $23.00 $173.00 $229.00 $53.00 $176.00 $107.00 $36.00 $71.00 $170.00 $57.00 $113.00 $176.00 $64.00 $112.00 $176.00 $64.00 $112.00 $144.00 $14.00 $129.00 $221.00 $26.00 $195.00 $269.00 $30.00 $239.00 $207.00 $33.00 $174.00 $133.00 $23.00 $111.00 $203.00 $27.00 $177.00 $130.00 $18.00 $112.00 $146.00 $19.00 $127.00 $218.00 $39.00 $178.00 $138.00 $26.00 $228.00 $36.00 $192.00 $214.00 $25.00 $189.00 $248.00 $56.00 $192.00 $115.00 $38.00 $77.00 $183.00 $60.00 $124.00 $189.00 $66.00 $123.00 $189.00 $66.00 $123.00 $155.00 $15.00 $140.00 $239.00 $28.00 $212.00 $290.00 $32.00 $259.00 $223.00 $34.00 $189.00 $144.00 $24.00 $120.00 $221.00 $28.00 $193.00 $141.00 $19.00 $122.00 $158.00 $20.00 $137.00 $237.00 $42.00 $195.00 $150.00 $27.00 $194.00 $33.00 $162.00 $181.00 $22.00 $159.00 $212.00 $51.00 $161.00 $99.00 $34.00 $65.00 $158.00 $55.00 $103.00 $164.00 $61.00 $103.00 $164.00 $61.00 $103.00 $132.00 $14.00 $119.00 $204.00 $25.00 $179.00 $248.00 $28.00 $219.00 $191.00 $31.00 $160.00 $123.00 $21.00 $102.00 $187.00 $26.00 $161.00 $120.00 $17.00 $102.00 $136.00 $19.00 $117.00 $200.00 $38.00 $162.00 $127.00 $25.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $211.00 $34.00 $177.00 $197.00 $23.00 $173.00 $229.00 $53.00 $176.00 $107.00 $36.00 $71.00 $170.00 $57.00 $113.00 $176.00 $64.00 $112.00 $176.00 $64.00 $112.00 $144.00 $14.00 $129.00 $221.00 $26.00 $195.00 $269.00 $30.00 $239.00 $207.00 $33.00 $174.00 $133.00 $23.00 $111.00 $203.00 $27.00 $177.00 $130.00 $18.00 $112.00 $146.00 $19.00 $127.00 $218.00 $39.00 $178.00 $138.00 $26.00 $228.00 $36.00 $192.00 $214.00 $25.00 $189.00 $248.00 $56.00 $192.00 $115.00 $38.00 $77.00 $183.00 $60.00 $124.00 $189.00 $66.00 $123.00 $189.00 $66.00 $123.00 $155.00 $15.00 $140.00 $239.00 $28.00 $212.00 $290.00 $32.00 $259.00 $223.00 $34.00 $189.00 $144.00 $24.00 $120.00 $221.00 $28.00 $193.00 $141.00 $19.00 $122.00 $158.00 $20.00 $137.00 $237.00 $42.00 $195.00 $150.00 $27.00 Part C, 365 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 93971-TC 93975 93975-26 93975-TC 93976 93976-26 93976-TC 93978 93978-26 93978-TC 93979 93979-26 93979-TC 93980 93980-26 93980-TC 93981 93981-26 93981-TC 93982 93990 93990-26 93990-TC 94002 94003 94004 94005 94010 94010-26 94010-TC 94014 94015 94016 94060 94060-26 94060-TC 94070 94070-26 94070-TC 94150 94150-26 94150-TC 94200 94200-26 94200-TC 94240 94240-26 94240-TC 94250 94250-26 $96.00 $277.00 $89.00 $181.00 $184.00 $59.00 $121.00 $177.00 $34.00 $143.00 $122.00 $23.00 $98.00 $183.00 $65.00 $105.00 $148.00 $25.00 $124.00 ------$110.00 $14.00 $96.00 ------------------------$30.00 $12.00 $16.00 $39.00 $14.00 $26.00 $57.00 $18.00 $36.00 $32.00 $11.00 $19.00 $8.00 $6.00 $3.00 $17.00 $7.00 $9.00 $43.00 $15.00 $26.00 $12.00 $8.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $103.00 $260.00 $99.00 $161.00 $227.00 $64.00 $163.00 $199.00 $36.00 $162.00 $127.00 $24.00 $103.00 $196.00 $68.00 $128.00 $149.00 $23.00 $126.00 $43.00 $116.00 $14.00 $102.00 $92.00 $67.00 $48.00 $87.00 $36.00 $9.00 $27.00 $52.00 $25.00 $26.00 $62.00 $15.00 $47.00 $66.00 $30.00 $35.00 $22.00 $4.00 $18.00 $25.00 $6.00 $19.00 $42.00 $13.00 $29.00 $28.00 $6.00 $113.00 $279.00 $103.00 $176.00 $245.00 $66.00 $179.00 $216.00 $38.00 $178.00 $138.00 $25.00 $112.00 $214.00 $71.00 $143.00 $164.00 $24.00 $140.00 $45.00 $126.00 $15.00 $111.00 $95.00 $69.00 $50.00 $90.00 $39.00 $9.00 $29.00 $55.00 $27.00 $27.00 $67.00 $15.00 $52.00 $71.00 $31.00 $39.00 $24.00 $4.00 $20.00 $26.00 $6.00 $20.00 $46.00 $13.00 $32.00 $30.00 $6.00 $124.00 $300.00 $108.00 $192.00 $265.00 $69.00 $196.00 $236.00 $40.00 $195.00 $149.00 $26.00 $123.00 $234.00 $74.00 $160.00 $181.00 $25.00 $155.00 $48.00 $136.00 $16.00 $120.00 $99.00 $72.00 $52.00 $93.00 $41.00 $10.00 $32.00 $57.00 $29.00 $28.00 $72.00 $16.00 $56.00 $77.00 $33.00 $44.00 $26.00 $5.00 $21.00 $28.00 $7.00 $22.00 $49.00 $14.00 $35.00 $32.00 $7.00 $103.00 $260.00 $99.00 $161.00 $227.00 $64.00 $163.00 $199.00 $36.00 $162.00 $127.00 $24.00 $103.00 $196.00 $68.00 $128.00 $149.00 $23.00 $126.00 $43.00 $116.00 $14.00 $102.00 $92.00 $67.00 $48.00 $87.00 $36.00 $9.00 $27.00 $52.00 $25.00 $26.00 $62.00 $15.00 $47.00 $66.00 $30.00 $35.00 $22.00 $4.00 $18.00 $25.00 $6.00 $19.00 $42.00 $13.00 $29.00 $28.00 $6.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $113.00 $279.00 $103.00 $176.00 $245.00 $66.00 $179.00 $216.00 $38.00 $178.00 $138.00 $25.00 $112.00 $214.00 $71.00 $143.00 $164.00 $24.00 $140.00 $45.00 $126.00 $15.00 $111.00 $95.00 $69.00 $50.00 $90.00 $39.00 $9.00 $29.00 $55.00 $27.00 $27.00 $67.00 $15.00 $52.00 $71.00 $31.00 $39.00 $24.00 $4.00 $20.00 $26.00 $6.00 $20.00 $46.00 $13.00 $32.00 $30.00 $6.00 $124.00 $300.00 $108.00 $192.00 $265.00 $69.00 $196.00 $236.00 $40.00 $195.00 $149.00 $26.00 $123.00 $234.00 $74.00 $160.00 $181.00 $25.00 $155.00 $48.00 $136.00 $16.00 $120.00 $99.00 $72.00 $52.00 $93.00 $41.00 $10.00 $32.00 $57.00 $29.00 $28.00 $72.00 $16.00 $56.00 $77.00 $33.00 $44.00 $26.00 $5.00 $21.00 $28.00 $7.00 $22.00 $49.00 $14.00 $35.00 $32.00 $7.00 Part C, 366 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 94250-TC 94260 94260-26 94260-TC 94350 94350-26 94350-TC 94360 94360-26 94360-TC 94370 94370-26 94370-TC 94375 94375-26 94375-TC 94400 94400-26 94400-TC 94450 94450-26 94450-TC 94452 94452-26 94452-TC 94453 94453-26 94453-TC 94610 94620 94620-26 94620-TC 94621 94621-26 94621-TC 94640 94642 94644 94645 94660 94662 94664 94667 94668 94680 94680-26 94680-TC 94681 94681-26 94681-TC $5.00 $27.00 $8.00 $18.00 $36.00 $14.00 $20.00 $37.00 $11.00 $26.00 $33.00 $18.00 $12.00 $34.00 $16.00 $17.00 $40.00 $24.00 $14.00 $37.00 $20.00 $15.00 ------------------------------------------$91.00 $38.00 $54.00 $122.00 $71.00 $52.00 $19.00 BR ------------$54.00 $38.00 $18.00 $23.00 $16.00 $47.00 $23.00 $22.00 $60.00 $12.00 $43.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $22.00 $34.00 $6.00 $27.00 $40.00 $13.00 $27.00 $46.00 $13.00 $33.00 $37.00 $13.00 $24.00 $39.00 $15.00 $24.00 $57.00 $21.00 $36.00 $53.00 $20.00 $33.00 $59.00 $16.00 $43.00 $80.00 $20.00 $60.00 $72.00 $96.00 $32.00 $64.00 $168.00 $73.00 $95.00 $15.00 ------$39.00 $15.00 $59.00 $38.00 $17.00 $24.00 $20.00 $71.00 $13.00 $58.00 $86.00 $10.00 $76.00 $24.00 $36.00 $7.00 $30.00 $43.00 $13.00 $29.00 $50.00 $13.00 $36.00 $40.00 $13.00 $26.00 $42.00 $15.00 $26.00 $62.00 $22.00 $40.00 $57.00 $21.00 $36.00 $63.00 $16.00 $46.00 $85.00 $21.00 $64.00 $78.00 $103.00 $34.00 $70.00 $179.00 $76.00 $103.00 $16.00 ------$42.00 $16.00 $62.00 $39.00 $18.00 $26.00 $22.00 $77.00 $13.00 $63.00 $94.00 $10.00 $83.00 $26.00 $40.00 $7.00 $32.00 $46.00 $14.00 $32.00 $54.00 $14.00 $40.00 $42.00 $14.00 $28.00 $44.00 $16.00 $28.00 $67.00 $23.00 $44.00 $60.00 $21.00 $39.00 $66.00 $17.00 $49.00 $90.00 $22.00 $68.00 $87.00 $111.00 $35.00 $76.00 $190.00 $79.00 $111.00 $17.00 ------$45.00 $18.00 $65.00 $41.00 $21.00 $29.00 $24.00 $82.00 $14.00 $68.00 $102.00 $11.00 $91.00 $22.00 $34.00 $6.00 $27.00 $40.00 $13.00 $27.00 $46.00 $13.00 $33.00 $37.00 $13.00 $24.00 $39.00 $15.00 $24.00 $57.00 $21.00 $36.00 $53.00 $20.00 $33.00 $59.00 $16.00 $43.00 $80.00 $20.00 $60.00 $72.00 $96.00 $32.00 $64.00 $168.00 $73.00 $95.00 $15.00 ------$39.00 $15.00 $39.00 $38.00 $17.00 $24.00 $20.00 $71.00 $13.00 $58.00 $86.00 $10.00 $76.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $24.00 $36.00 $7.00 $30.00 $43.00 $13.00 $29.00 $50.00 $13.00 $36.00 $40.00 $13.00 $26.00 $42.00 $15.00 $26.00 $62.00 $22.00 $40.00 $57.00 $21.00 $36.00 $63.00 $16.00 $46.00 $85.00 $21.00 $64.00 $78.00 $103.00 $34.00 $70.00 $179.00 $76.00 $103.00 $16.00 ------$42.00 $16.00 $40.00 $39.00 $18.00 $26.00 $22.00 $77.00 $13.00 $63.00 $94.00 $10.00 $83.00 $26.00 $40.00 $7.00 $32.00 $46.00 $14.00 $32.00 $54.00 $14.00 $40.00 $42.00 $14.00 $28.00 $44.00 $16.00 $28.00 $67.00 $23.00 $44.00 $60.00 $21.00 $39.00 $66.00 $17.00 $49.00 $90.00 $22.00 $68.00 $87.00 $111.00 $35.00 $76.00 $190.00 $79.00 $111.00 $17.00 ------$45.00 $18.00 $42.00 $41.00 $21.00 $29.00 $24.00 $82.00 $14.00 $68.00 $102.00 $11.00 $91.00 Part C, 367 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 94690 94690-26 94690-TC 94720 94720-26 94720-TC 94725 94725-26 94725-TC 94750 94750-26 94750-TC 94760 94761 94762 94770 94770-26 94770-TC 94799 94799-26 94799-TC 95004 95010 95012 95015 95024 95027 95028 95044 95052 95056 95060 95065 95070 95071 95075 95115 95117 95120 95125 95130 95131 95132 95133 95134 95144 95145 95146 95147 95148 $24.00 $4.00 $20.00 $49.00 $15.00 $31.00 $79.00 $14.00 $64.00 $37.00 $14.00 $21.00 $9.00 $20.00 $30.00 $21.00 $9.00 $12.00 BR BR BR $3.00 $11.00 ------$11.00 $3.00 $5.00 $8.00 $7.00 $9.00 $6.00 $13.00 $7.00 $82.00 $105.00 $82.00 $10.00 $9.00 BR BR BR BR BR BR BR $9.00 $17.00 $24.00 $33.00 $32.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $65.00 $4.00 $61.00 $56.00 $13.00 $43.00 $94.00 $13.00 $81.00 $72.00 $11.00 $61.00 $3.00 $7.00 $32.00 $41.00 $8.00 $33.00 ------------------$6.00 $19.00 $20.00 $13.00 $7.00 $6.00 $11.00 $8.00 $8.00 $29.00 $22.00 $18.00 $62.00 $78.00 $67.00 $13.00 $17.00 ------------------------------------------$12.00 $16.00 $25.00 $24.00 $33.00 $71.00 $4.00 $66.00 $61.00 $13.00 $47.00 $102.00 $13.00 $89.00 $78.00 $12.00 $66.00 $4.00 $9.00 $36.00 $45.00 $8.00 $37.00 ------------------$7.00 $20.00 $21.00 $14.00 $8.00 $6.00 $12.00 $8.00 $9.00 $31.00 $24.00 $20.00 $67.00 $84.00 $69.00 $15.00 $18.00 ------------------------------------------$13.00 $17.00 $26.00 $26.00 $36.00 $76.00 $5.00 $71.00 $65.00 $14.00 $52.00 $110.00 $14.00 $97.00 $83.00 $12.00 $71.00 $4.00 $11.00 $41.00 $49.00 $8.00 $41.00 ------------------$7.00 $21.00 $23.00 $15.00 $9.00 $7.00 $13.00 $9.00 $10.00 $33.00 $26.00 $21.00 $71.00 $89.00 $72.00 $16.00 $20.00 ------------------------------------------$13.00 $18.00 $28.00 $27.00 $38.00 $65.00 $4.00 $61.00 $56.00 $13.00 $43.00 $94.00 $13.00 $81.00 $72.00 $11.00 $61.00 $3.00 $7.00 $32.00 $41.00 $8.00 $33.00 ------------------$6.00 $19.00 $20.00 $13.00 $7.00 $6.00 $11.00 $8.00 $8.00 $29.00 $22.00 $18.00 $62.00 $78.00 $50.00 $13.00 $17.00 ------------------------------------------$4.00 $4.00 $4.00 $4.00 $4.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $71.00 $4.00 $66.00 $61.00 $13.00 $47.00 $102.00 $13.00 $89.00 $78.00 $12.00 $66.00 $4.00 $9.00 $36.00 $45.00 $8.00 $37.00 ------------------$7.00 $20.00 $21.00 $14.00 $8.00 $6.00 $12.00 $8.00 $9.00 $31.00 $24.00 $20.00 $67.00 $84.00 $51.00 $15.00 $18.00 ------------------------------------------$4.00 $4.00 $4.00 $4.00 $4.00 $76.00 $5.00 $71.00 $65.00 $14.00 $52.00 $110.00 $14.00 $97.00 $83.00 $12.00 $71.00 $4.00 $11.00 $41.00 $49.00 $8.00 $41.00 ------------------$7.00 $21.00 $23.00 $15.00 $9.00 $7.00 $13.00 $9.00 $10.00 $33.00 $26.00 $21.00 $71.00 $89.00 $53.00 $16.00 $20.00 ------------------------------------------$4.00 $4.00 $4.00 $4.00 $4.00 Part C, 368 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 95149 95165 95170 95180 95199 95250 95251 95805 95805-26 95805-TC 95806 95806-26 95806-TC 95807 95807-26 95807-TC 95808 95808-26 95808-TC 95810 95810-26 95810-TC 95811 95811-26 95811-TC 95812 95812-26 95812-TC 95813 95813-26 95813-TC 95816 95816-26 95816-TC 95819 95819-26 95819-TC 95822 95822-26 95822-TC 95824 95824-26 95824-TC 95827 95827-26 95827-TC 95829 95829-26 95829-TC 95830 $36.00 $7.00 $13.00 $103.00 BR $114.00 ------$334.00 $94.00 $237.00 $232.00 $109.00 $137.00 $367.00 $98.00 $256.00 $456.00 $149.00 $256.00 $521.00 $183.00 $256.00 $644.00 $196.00 $423.00 $137.00 $58.00 $68.00 $177.00 $89.00 $68.00 $133.00 $54.00 $78.00 $115.00 $58.00 $56.00 $120.00 $58.00 $63.00 $51.00 $41.00 $10.00 $145.00 $59.00 $86.00 $328.00 $291.00 $6.00 $133.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $44.00 $12.00 $9.00 $149.00 ------$150.00 $41.00 $573.00 $98.00 $475.00 $228.00 $86.00 $142.00 $567.00 $85.00 $482.00 $700.00 $138.00 $563.00 $858.00 $181.00 $676.00 $942.00 $195.00 $747.00 $246.00 $58.00 $187.00 $303.00 $92.00 $210.00 $226.00 $58.00 $168.00 $229.00 $58.00 $170.00 $250.00 $58.00 $192.00 ------$40.00 ------$331.00 $57.00 $274.00 $1,355.00 $339.00 $1,016.00 $193.00 $47.00 $13.00 $10.00 $155.00 ------$161.00 $42.00 $616.00 $101.00 $514.00 $246.00 $89.00 $157.00 $610.00 $88.00 $523.00 $752.00 $142.00 $610.00 $919.00 $188.00 $731.00 $1,008.00 $201.00 $807.00 $263.00 $61.00 $202.00 $323.00 $96.00 $227.00 $242.00 $61.00 $181.00 $245.00 $61.00 $184.00 $268.00 $61.00 $208.00 ------$41.00 ------$355.00 $59.00 $296.00 $1,443.00 $354.00 $1,089.00 $204.00 $50.00 $13.00 $11.00 $161.00 ------$170.00 $43.00 $657.00 $105.00 $551.00 $267.00 $93.00 $174.00 $654.00 $91.00 $563.00 $802.00 $148.00 $654.00 $978.00 $195.00 $782.00 $1,072.00 $210.00 $862.00 $280.00 $63.00 $216.00 $342.00 $100.00 $242.00 $257.00 $63.00 $194.00 $260.00 $63.00 $197.00 $286.00 $63.00 $222.00 ------$43.00 ------$377.00 $61.00 $316.00 $1,523.00 $374.00 $1,150.00 $214.00 $4.00 $4.00 $4.00 $110.00 ------$150.00 $41.00 $573.00 $98.00 $475.00 $228.00 $86.00 $142.00 $567.00 $85.00 $482.00 $700.00 $138.00 $563.00 $858.00 $181.00 $676.00 $942.00 $195.00 $747.00 $246.00 $58.00 $187.00 $303.00 $92.00 $210.00 $226.00 $58.00 $168.00 $229.00 $58.00 $170.00 $250.00 $58.00 $192.00 ------$40.00 ------$331.00 $57.00 $274.00 $1,355.00 $339.00 $1,016.00 $92.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $4.00 $4.00 $4.00 $113.00 ------$161.00 $42.00 $616.00 $101.00 $514.00 $246.00 $89.00 $157.00 $610.00 $88.00 $523.00 $752.00 $142.00 $610.00 $919.00 $188.00 $731.00 $1,008.00 $201.00 $807.00 $263.00 $61.00 $202.00 $323.00 $96.00 $227.00 $242.00 $61.00 $181.00 $245.00 $61.00 $184.00 $268.00 $61.00 $208.00 ------$41.00 ------$355.00 $59.00 $296.00 $1,443.00 $354.00 $1,089.00 $96.00 $4.00 $4.00 $4.00 $116.00 ------$170.00 $43.00 $657.00 $105.00 $551.00 $267.00 $93.00 $174.00 $654.00 $91.00 $563.00 $802.00 $148.00 $654.00 $978.00 $195.00 $782.00 $1,072.00 $210.00 $862.00 $280.00 $63.00 $216.00 $342.00 $100.00 $242.00 $257.00 $63.00 $194.00 $260.00 $63.00 $197.00 $286.00 $63.00 $222.00 ------$43.00 ------$377.00 $61.00 $316.00 $1,523.00 $374.00 $1,150.00 $101.00 Part C, 369 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 95831 95832 95833 95834 95851 95852 95857 95860 95860-26 95860-TC 95861 95861-26 95861-TC 95863 95863-26 95863-TC 95864 95864-26 95864-TC 95865 95865-26 95865-TC 95866 95866-26 95866-TC 95867 95867-26 95867-TC 95868 95868-26 95868-TC 95869 95869-26 95869-TC 95870 95870-26 95870-TC 95872 95872-26 95872-TC 95873 95873-26 95873-TC 95874 95874-26 95874-TC 95875 95875-26 95875-TC 95900 $26.00 $21.00 $34.00 $44.00 $18.00 $14.00 $40.00 $73.00 $53.00 $15.00 $113.00 $86.00 $28.00 $138.00 $102.00 $35.00 $177.00 $114.00 $67.00 ------------------------------------$66.00 $43.00 $21.00 $96.00 $71.00 $26.00 $29.00 $21.00 $8.00 $29.00 $21.00 $8.00 $104.00 $81.00 $22.00 ------------------------------------$43.00 $34.00 $7.00 $37.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $28.00 $26.00 $40.00 $47.00 $19.00 $15.00 $44.00 $91.00 $53.00 $37.00 $125.00 $85.00 $41.00 $150.00 $101.00 $48.00 $181.00 $108.00 $73.00 $120.00 $88.00 $33.00 $93.00 $69.00 $24.00 $75.00 $43.00 $32.00 $103.00 $64.00 $39.00 $44.00 $21.00 $23.00 $43.00 $21.00 $22.00 $171.00 $141.00 $30.00 $43.00 $21.00 $22.00 $43.00 $21.00 $22.00 $105.00 $61.00 $44.00 $61.00 $29.00 $27.00 $42.00 $49.00 $20.00 $16.00 $46.00 $96.00 $55.00 $40.00 $132.00 $88.00 $44.00 $158.00 $105.00 $53.00 $192.00 $112.00 $80.00 $127.00 $91.00 $36.00 $98.00 $72.00 $26.00 $79.00 $44.00 $35.00 $109.00 $66.00 $42.00 $47.00 $21.00 $25.00 $46.00 $21.00 $24.00 $177.00 $145.00 $33.00 $46.00 $22.00 $24.00 $45.00 $22.00 $24.00 $111.00 $63.00 $48.00 $65.00 $31.00 $29.00 $43.00 $51.00 $21.00 $16.00 $48.00 $101.00 $58.00 $43.00 $140.00 $91.00 $48.00 $167.00 $109.00 $57.00 $204.00 $116.00 $87.00 $133.00 $95.00 $38.00 $103.00 $75.00 $28.00 $83.00 $46.00 $38.00 $115.00 $69.00 $46.00 $49.00 $22.00 $27.00 $49.00 $22.00 $26.00 $185.00 $149.00 $36.00 $49.00 $23.00 $26.00 $48.00 $23.00 $25.00 $118.00 $65.00 $52.00 $68.00 $15.00 $16.00 $25.00 $33.00 $9.00 $6.00 $28.00 $91.00 $53.00 $37.00 $125.00 $85.00 $41.00 $150.00 $101.00 $48.00 $181.00 $108.00 $73.00 $120.00 $88.00 $33.00 $93.00 $69.00 $24.00 $75.00 $43.00 $32.00 $103.00 $64.00 $39.00 $44.00 $21.00 $23.00 $43.00 $21.00 $22.00 $171.00 $141.00 $30.00 $43.00 $21.00 $22.00 $43.00 $21.00 $22.00 $105.00 $61.00 $44.00 $61.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $16.00 $17.00 $26.00 $34.00 $9.00 $7.00 $29.00 $96.00 $55.00 $40.00 $132.00 $88.00 $44.00 $158.00 $105.00 $53.00 $192.00 $112.00 $80.00 $127.00 $91.00 $36.00 $98.00 $72.00 $26.00 $79.00 $44.00 $35.00 $109.00 $66.00 $42.00 $47.00 $21.00 $25.00 $46.00 $21.00 $24.00 $177.00 $145.00 $33.00 $46.00 $22.00 $24.00 $45.00 $22.00 $24.00 $111.00 $63.00 $48.00 $65.00 $16.00 $18.00 $27.00 $36.00 $10.00 $7.00 $30.00 $101.00 $58.00 $43.00 $140.00 $91.00 $48.00 $167.00 $109.00 $57.00 $204.00 $116.00 $87.00 $133.00 $95.00 $38.00 $103.00 $75.00 $28.00 $83.00 $46.00 $38.00 $115.00 $69.00 $46.00 $49.00 $22.00 $27.00 $49.00 $22.00 $26.00 $185.00 $149.00 $36.00 $49.00 $23.00 $26.00 $48.00 $23.00 $25.00 $118.00 $65.00 $52.00 $68.00 Part C, 370 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 95900-26 95900-TC 95903 95903-26 95903-TC 95904 95904-26 95904-TC 95920 95920-26 95920-TC 95921 95921-26 95921-TC 95922 95922-26 95922-TC 95923 95923-26 95923-TC 95925 95925-26 95925-TC 95926 95926-26 95926-TC 95927 95927-26 95927-TC 95928 95928-26 95928-TC 95929 95929-26 95929-TC 95930 95930-26 95930-TC 95933 95933-26 95933-TC 95934 95934-26 95934-TC 95936 95936-26 95936-TC 95937 95937-26 95937-TC $24.00 $10.00 $43.00 $33.00 $9.00 $31.00 $20.00 $8.00 $168.00 $118.00 $48.00 $61.00 $46.00 $14.00 $65.00 $50.00 $14.00 $105.00 $47.00 $57.00 $94.00 $53.00 $41.00 $66.00 $34.00 $34.00 $67.00 $34.00 $34.00 ------------------------------------$44.00 $25.00 $11.00 $62.00 $33.00 $30.00 $36.00 $28.00 $8.00 $39.00 $30.00 $8.00 $40.00 $31.00 $9.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $23.00 $38.00 $69.00 $33.00 $36.00 $53.00 $19.00 $34.00 $170.00 $119.00 $52.00 $74.00 $47.00 $27.00 $87.00 $52.00 $35.00 $121.00 $49.00 $73.00 $109.00 $30.00 $79.00 $107.00 $29.00 $78.00 $111.00 $31.00 $80.00 $198.00 $80.00 $117.00 $208.00 $81.00 $127.00 $111.00 $19.00 $92.00 $70.00 $33.00 $37.00 $46.00 $28.00 $19.00 $44.00 $30.00 $14.00 $60.00 $38.00 $22.00 $24.00 $41.00 $73.00 $34.00 $39.00 $57.00 $20.00 $37.00 $181.00 $124.00 $57.00 $78.00 $49.00 $29.00 $91.00 $54.00 $38.00 $129.00 $51.00 $78.00 $117.00 $31.00 $85.00 $115.00 $31.00 $84.00 $119.00 $32.00 $87.00 $209.00 $83.00 $126.00 $220.00 $83.00 $137.00 $119.00 $20.00 $98.00 $75.00 $34.00 $41.00 $49.00 $28.00 $21.00 $46.00 $31.00 $15.00 $64.00 $40.00 $24.00 $25.00 $44.00 $77.00 $35.00 $41.00 $60.00 $21.00 $40.00 $192.00 $131.00 $62.00 $82.00 $50.00 $31.00 $96.00 $56.00 $40.00 $136.00 $53.00 $83.00 $125.00 $33.00 $92.00 $122.00 $32.00 $90.00 $127.00 $34.00 $93.00 $220.00 $86.00 $134.00 $231.00 $87.00 $145.00 $125.00 $21.00 $104.00 $81.00 $36.00 $45.00 $52.00 $30.00 $22.00 $49.00 $32.00 $16.00 $69.00 $43.00 $26.00 $23.00 $38.00 $69.00 $33.00 $36.00 $53.00 $19.00 $34.00 $170.00 $119.00 $52.00 $74.00 $47.00 $27.00 $87.00 $52.00 $35.00 $121.00 $49.00 $73.00 $109.00 $30.00 $79.00 $107.00 $29.00 $78.00 $111.00 $31.00 $80.00 $198.00 $80.00 $117.00 $208.00 $81.00 $127.00 $111.00 $19.00 $92.00 $70.00 $33.00 $37.00 $46.00 $28.00 $19.00 $44.00 $30.00 $14.00 $60.00 $38.00 $22.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $24.00 $41.00 $73.00 $34.00 $39.00 $57.00 $20.00 $37.00 $181.00 $124.00 $57.00 $78.00 $49.00 $29.00 $91.00 $54.00 $38.00 $129.00 $51.00 $78.00 $117.00 $31.00 $85.00 $115.00 $31.00 $84.00 $119.00 $32.00 $87.00 $209.00 $83.00 $126.00 $220.00 $83.00 $137.00 $119.00 $20.00 $98.00 $75.00 $34.00 $41.00 $49.00 $28.00 $21.00 $46.00 $31.00 $15.00 $64.00 $40.00 $24.00 $25.00 $44.00 $77.00 $35.00 $41.00 $60.00 $21.00 $40.00 $192.00 $131.00 $62.00 $82.00 $50.00 $31.00 $96.00 $56.00 $40.00 $136.00 $53.00 $83.00 $125.00 $33.00 $92.00 $122.00 $32.00 $90.00 $127.00 $34.00 $93.00 $220.00 $86.00 $134.00 $231.00 $87.00 $145.00 $125.00 $21.00 $104.00 $81.00 $36.00 $45.00 $52.00 $30.00 $22.00 $49.00 $32.00 $16.00 $69.00 $43.00 $26.00 Part C, 371 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 95950 95950-26 95950-TC 95951 95951-26 95951-TC 95953 95953-26 95953-TC 95954 95954-26 95954-TC 95955 95955-26 95955-TC 95956 95956-26 95956-TC 95957 95957-26 95957-TC 95958 95958-26 95958-TC 95961 95961-26 95961-TC 95962 95962-26 95962-TC 95965 95965-26 95965-TC 95966 95966-26 95966-TC 95967 95967-26 95967-TC 95970 95971 95972 95973 95974 95975 95978 95979 95980 95981 95982 $265.00 $84.00 $177.00 $34.00 $14.00 $20.00 $411.00 $165.00 $240.00 $208.00 $134.00 $23.00 $130.00 $59.00 $74.00 $541.00 $166.00 $314.00 $171.00 $104.00 $64.00 $296.00 $230.00 $66.00 $216.00 $166.00 $48.00 $227.00 $176.00 $48.00 BR $420.00 BR BR $210.00 BR BR $184.00 BR $22.00 $39.00 $78.00 $47.00 $155.00 $88.00 ------------------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $261.00 $82.00 $180.00 ------$324.00 ------$451.00 $176.00 $275.00 $271.00 $127.00 $144.00 $151.00 $53.00 $98.00 $773.00 $166.00 $607.00 $252.00 $107.00 $145.00 $378.00 $228.00 $150.00 $256.00 $183.00 $73.00 $239.00 $184.00 $55.00 ------$438.00 ------------$216.00 ------------$181.00 ------$53.00 $58.00 $110.00 $60.00 $182.00 $102.00 $215.00 $97.00 $44.00 $29.00 $45.00 $284.00 $85.00 $199.00 ------$336.00 ------$484.00 $183.00 $301.00 $287.00 $132.00 $155.00 $162.00 $55.00 $107.00 $829.00 $172.00 $657.00 $268.00 $111.00 $157.00 $399.00 $236.00 $163.00 $275.00 $196.00 $79.00 $254.00 $193.00 $60.00 ------$455.00 ------------$224.00 ------------$188.00 ------$56.00 $61.00 $116.00 $63.00 $190.00 $107.00 $224.00 $101.00 $46.00 $31.00 $48.00 $310.00 $88.00 $222.00 ------$351.00 ------$520.00 $190.00 $329.00 $303.00 $138.00 $165.00 $175.00 $57.00 $118.00 $884.00 $180.00 $704.00 $285.00 $116.00 $169.00 $421.00 $246.00 $175.00 $298.00 $213.00 $85.00 $271.00 $206.00 $66.00 ------$476.00 ------------$233.00 ------------$195.00 ------$59.00 $65.00 $124.00 $66.00 $198.00 $112.00 $234.00 $105.00 $48.00 $33.00 $50.00 $261.00 $82.00 $180.00 ------$324.00 ------$451.00 $176.00 $275.00 $271.00 $127.00 $144.00 $151.00 $53.00 $98.00 $773.00 $166.00 $607.00 $252.00 $107.00 $145.00 $378.00 $228.00 $150.00 $256.00 $183.00 $73.00 $239.00 $184.00 $55.00 ------$438.00 ------------$216.00 ------------$181.00 ------$24.00 $41.00 $82.00 $49.00 $161.00 $94.00 $186.00 $88.00 $44.00 $17.00 $34.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $284.00 $85.00 $199.00 ------$336.00 ------$484.00 $183.00 $301.00 $287.00 $132.00 $155.00 $162.00 $55.00 $107.00 $829.00 $172.00 $657.00 $268.00 $111.00 $157.00 $399.00 $236.00 $163.00 $275.00 $196.00 $79.00 $254.00 $193.00 $60.00 ------$455.00 ------------$224.00 ------------$188.00 ------$25.00 $43.00 $86.00 $51.00 $168.00 $98.00 $193.00 $91.00 $46.00 $18.00 $36.00 $310.00 $88.00 $222.00 ------$351.00 ------$520.00 $190.00 $329.00 $303.00 $138.00 $165.00 $175.00 $57.00 $118.00 $884.00 $180.00 $704.00 $285.00 $116.00 $169.00 $421.00 $246.00 $175.00 $298.00 $213.00 $85.00 $271.00 $206.00 $66.00 ------$476.00 ------------$233.00 ------------$195.00 ------$26.00 $46.00 $92.00 $54.00 $175.00 $103.00 $201.00 $95.00 $48.00 $18.00 $38.00 Part C, 372 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 95990 95991 95999 96000 96001 96002 96003 96004 96020 96020-26 96020-TC 96040 96101 96102 96103 96105 96110 96111 96116 96118 96119 96120 96125 96150 96151 96152 96153 96154 96155 DSPNS 96401 96402 96405 96406 96409 96411 96413 96415 96416 96417 96420 96422 96423 96425 96440 96445 96450 96521 96522 96523 $57.00 ------BR $93.00 $111.00 $21.00 $20.00 $97.00 ------------------------------------------$68.00 $88.00 $68.00 ------------------------------------------------------------------see formula ------------$57.00 $86.00 ------------------------------------$46.00 $46.00 $17.00 $54.00 $156.00 $157.00 $134.00 ------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) (Facility MRA) (Facility MRA) $65.00 $93.00 ------$92.00 $109.00 $21.00 $19.00 $117.00 BR $179.00 BR $39.00 $91.00 $54.00 $42.00 $78.00 $18.00 $141.00 $107.00 $124.00 $81.00 $68.00 $103.00 $25.00 $24.00 $23.00 $6.00 $22.00 $23.00 See Appx D $67.00 $43.00 $141.00 $161.00 $125.00 $72.00 $169.00 $39.00 $183.00 $84.00 $118.00 $194.00 $84.00 $191.00 $367.00 $354.00 $297.00 $147.00 $118.00 $29.00 $71.00 $99.00 ------$96.00 $113.00 $22.00 $20.00 $121.00 BR $186.00 BR $42.00 $94.00 $56.00 $44.00 $87.00 $22.00 $147.00 $112.00 $130.00 $88.00 $71.00 $108.00 $25.00 $24.00 $23.00 $6.00 $23.00 $24.00 See Appx D $72.00 $45.00 $150.00 $171.00 $134.00 $78.00 $182.00 $43.00 $197.00 $91.00 $127.00 $209.00 $90.00 $205.00 $389.00 $376.00 $315.00 $158.00 $126.00 $31.00 $76.00 $104.00 ------$100.00 $118.00 $23.00 $21.00 $126.00 BR $193.00 BR $45.00 $97.00 $59.00 $46.00 $96.00 $28.00 $155.00 $119.00 $138.00 $97.00 $75.00 $115.00 $26.00 $25.00 $24.00 $6.00 $24.00 $25.00 See Appx D $76.00 $48.00 $158.00 $180.00 $142.00 $83.00 $193.00 $47.00 $209.00 $97.00 $136.00 $222.00 $95.00 $218.00 $410.00 $396.00 $332.00 $168.00 $135.00 $33.00 $65.00 $39.00 ------$92.00 $109.00 $21.00 $19.00 $117.00 BR $179.00 BR $39.00 $91.00 $24.00 $26.00 $78.00 $18.00 $139.00 $100.00 $99.00 $37.00 $25.00 $87.00 $24.00 $23.00 $23.00 $5.00 $22.00 $23.00 See Appx D $67.00 $43.00 $31.00 $43.00 $125.00 $72.00 $169.00 $39.00 $183.00 $84.00 $118.00 $194.00 $84.00 $191.00 $141.00 $132.00 $104.00 $147.00 $118.00 $29.00 $71.00 $76.00 $41.00 $43.00 ------------$96.00 $100.00 $113.00 $118.00 $22.00 $23.00 $20.00 $21.00 $121.00 $126.00 BR BR $186.00 $193.00 BR BR $42.00 $45.00 $93.00 $96.00 $25.00 $25.00 $26.00 $27.00 $87.00 $96.00 $22.00 $28.00 $145.00 $152.00 $105.00 $112.00 $104.00 $110.00 $41.00 $47.00 $26.00 $27.00 $92.00 $97.00 $25.00 $25.00 $24.00 $24.00 $23.00 $24.00 $5.00 $6.00 $23.00 $23.00 $24.00 $25.00 See Appx D See Appx D $72.00 $76.00 $45.00 $48.00 $32.00 $33.00 $45.00 $46.00 $134.00 $142.00 $78.00 $83.00 $182.00 $193.00 $43.00 $47.00 $197.00 $209.00 $91.00 $97.00 $127.00 $136.00 $209.00 $222.00 $90.00 $95.00 $205.00 $218.00 $148.00 $156.00 $138.00 $145.00 $109.00 $114.00 $158.00 $168.00 $126.00 $135.00 $31.00 $33.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 Part C, 373 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 96542 96549 96567 96570 96571 96900 96902 96904 96910 96912 96913 96920 96921 96922 96999 97001 97002 97003 97004 97005 97006 97010 97012 97014 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97260 97261 97530 97532 97533 97535 2003 MRA $126.00 BR $62.00 $69.00 $38.00 $17.00 $24.00 ------$21.00 $24.00 $53.00 $152.00 $155.00 $214.00 BR $62.00 $29.00 $62.00 $29.00 NC NC $10.00 $16.00 $14.00 $15.00 $10.00 $15.00 $10.00 $9.00 $10.00 $16.00 $16.00 $13.00 $11.00 $19.00 $15.00 $22.00 $23.00 $24.00 $21.00 $19.00 $15.00 $26.00 $18.00 $23.00 $17.00 $22.00 $22.00 $24.00 $23.00 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $185.00 ------$114.00 $62.00 $29.00 $21.00 $22.00 $75.00 $61.00 $78.00 $107.00 $164.00 $162.00 $239.00 ------$75.00 $40.00 $80.00 $47.00 BR BR $5.00 $15.00 $14.00 $16.00 $8.00 $18.00 $5.00 $5.00 $7.00 $17.00 $24.00 $15.00 $12.00 $26.00 ------$29.00 $30.00 $35.00 $25.00 $23.00 ------$27.00 $19.00 ------------$31.00 $25.00 $27.00 $31.00 $197.00 ------$123.00 $66.00 $31.00 $23.00 $22.00 $81.00 $66.00 $85.00 $116.00 $173.00 $171.00 $252.00 ------$78.00 $42.00 $84.00 $50.00 BR BR $5.00 $16.00 $15.00 $16.00 $8.00 $18.00 $6.00 $5.00 $7.00 $18.00 $26.00 $16.00 $13.00 $27.00 ------$31.00 $31.00 $37.00 $26.00 $24.00 ------$28.00 $19.00 ------------$32.00 $26.00 $28.00 $32.00 $209.00 ------$131.00 $70.00 $32.00 $24.00 $23.00 $85.00 $71.00 $91.00 $125.00 $180.00 $178.00 $262.00 ------$81.00 $43.00 $88.00 $52.00 BR BR $6.00 $17.00 $16.00 $17.00 $9.00 $19.00 $6.00 $6.00 $8.00 $18.00 $27.00 $16.00 $13.00 $28.00 ------$32.00 $33.00 $38.00 $27.00 $25.00 ------$29.00 $20.00 ------------$33.00 $27.00 $29.00 $33.00 $51.00 ------$114.00 $62.00 $29.00 $21.00 $21.00 $75.00 $61.00 $78.00 $107.00 $66.00 $66.00 $113.00 ------$75.00 $40.00 $80.00 $47.00 BR BR $5.00 $15.00 $14.00 $16.00 $8.00 $18.00 $5.00 $5.00 $7.00 $17.00 $24.00 $15.00 $12.00 $26.00 ------$29.00 $30.00 $35.00 $25.00 $23.00 ------$27.00 $19.00 ------------$31.00 $25.00 $27.00 $31.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $54.00 ------$123.00 $66.00 $31.00 $23.00 $21.00 $81.00 $66.00 $85.00 $116.00 $68.00 $68.00 $116.00 ------$78.00 $42.00 $84.00 $50.00 BR BR $5.00 $16.00 $15.00 $16.00 $8.00 $18.00 $6.00 $5.00 $7.00 $18.00 $26.00 $16.00 $13.00 $27.00 ------$31.00 $31.00 $37.00 $26.00 $24.00 ------$28.00 $19.00 ------------$32.00 $26.00 $28.00 $32.00 $57.00 ------$131.00 $70.00 $32.00 $24.00 $22.00 $85.00 $71.00 $91.00 $125.00 $69.00 $71.00 $119.00 ------$81.00 $43.00 $88.00 $52.00 BR BR $6.00 $17.00 $16.00 $17.00 $9.00 $19.00 $6.00 $6.00 $8.00 $18.00 $27.00 $16.00 $13.00 $28.00 ------$32.00 $33.00 $38.00 $27.00 $25.00 ------$29.00 $20.00 ------------$33.00 $27.00 $29.00 $33.00 Part C, 374 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 97537 97542 97545 97546 97597 97598 97602 97605 97606 97750 97752 97755 97760 97761 97762 97799 97802 97803 97804 97810 97811 97813 97814 97850 97851 97852 97853 98925 98926 98927 98928 98929 98940 98941 98942 98943 98960 98961 98962 98966 98967 98968 99000 99001 99002 99026 99027 99070 99071 99075 $23.00 $17.00 $83.00 $41.00 ------------BR ------------BR $48.00 ------------------------BR $26.00 $17.00 $7.00 ------------------------$54.00 $26.00 $54.00 $26.00 NC $32.00 NC $23.00 NC NC $32.00 NC $23.00 ------------------------------------$6.00 $4.00 $35.00 BR BR BR NC See 440.13 Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $28.00 $28.00 ------------$59.00 $73.00 ------$36.00 $39.00 BR ------$35.00 $34.00 $30.00 $33.00 ------$29.00 $26.00 $15.00 $37.00 $28.00 $39.00 $31.00 ------------------------NC $41.00 NC $62.00 NC NC $36.00 NC $24.00 $23.00 $12.00 $8.00 $13.00 $25.00 $37.00 ------------------------------------NC ------- $29.00 $29.00 ------------$63.00 $77.00 ------$37.00 $41.00 BR ------$36.00 $35.00 $31.00 $35.00 ------$30.00 $27.00 $16.00 $38.00 $29.00 $40.00 $33.00 ------------------------NC $43.00 NC $65.00 NC NC $37.00 NC $24.00 $25.00 $13.00 $9.00 $14.00 $26.00 $39.00 ------------------------------------NC ------- $30.00 $30.00 ------------$66.00 $81.00 ------$39.00 $42.00 BR ------$38.00 $37.00 $32.00 $37.00 ------$31.00 $28.00 $16.00 $40.00 $31.00 $42.00 $34.00 ------------------------NC $45.00 NC $67.00 NC NC $38.00 NC $25.00 $27.00 $14.00 $10.00 $14.00 $27.00 $40.00 ------------------------------------NC ------- $28.00 $28.00 ------------$40.00 $51.00 ------$28.00 $31.00 BR ------$35.00 $34.00 $30.00 $33.00 ------$29.00 $25.00 $15.00 $31.00 $26.00 $34.00 $29.00 ------------------------NC $34.00 NC $52.00 NC NC $31.00 NC $20.00 $23.00 $12.00 $8.00 $12.00 $24.00 $36.00 ------------------------------------NC ------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $29.00 $29.00 ------------$42.00 $54.00 ------$29.00 $32.00 BR ------$36.00 $35.00 $31.00 $35.00 ------$30.00 $26.00 $15.00 $32.00 $27.00 $35.00 $30.00 ------------------------NC $35.00 NC $54.00 NC NC $32.00 NC $21.00 $25.00 $13.00 $9.00 $13.00 $25.00 $37.00 ------------------------------------NC ------- $30.00 $30.00 ------------$44.00 $56.00 ------$30.00 $34.00 BR ------$38.00 $37.00 $32.00 $37.00 ------$31.00 $27.00 $16.00 $34.00 $28.00 $36.00 $31.00 ------------------------NC $37.00 NC $56.00 NC NC $33.00 NC $22.00 $27.00 $14.00 $10.00 $13.00 $26.00 $39.00 ------------------------------------NC ------- Part C, 375 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA 99078 99080 99082 99090 99091 99172 99173 99175 99183 99185 99186 99190 99191 99192 99195 99199 G0101 G0102 G0104 G0105 G0105-53 G0106 G0106-26 G0106-TC G0108 G0109 G0117 G0118 G0120 G0120-26 G0120-TC G0121 G0121-53 G0122 G0122-26 G0122-TC G0128 G0166 G0179 G0180 G0181 G0182 G0237 G0238 G0239 G0248 G0249 G0250 G0268 G0270 NC BR BR BR BR BR BR $53.00 $123.00 $23.00 $78.00 BR BR BR $16.00 NC ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) NC ------------------$53.00 ------$3.00 $40.00 $211.00 $48.00 $95.00 ------------------$60.00 NC $38.00 $21.00 $135.00 $401.00 $135.00 $194.00 $52.00 $142.00 $29.00 $16.00 $46.00 $31.00 $191.00 $52.00 $139.00 $401.00 $135.00 $209.00 $51.00 $158.00 $4.00 $162.00 $47.00 $62.00 $113.00 $117.00 $15.00 $15.00 $14.00 $197.00 $145.00 $10.00 $49.00 $26.00 NC ------------------$54.00 ------$3.00 $45.00 $222.00 $52.00 $109.00 ------------------$65.00 NC $39.00 $22.00 $143.00 $425.00 $143.00 $208.00 $54.00 $155.00 $31.00 $18.00 $49.00 $33.00 $204.00 $54.00 $151.00 $425.00 $143.00 $224.00 $53.00 $171.00 $5.00 $173.00 $50.00 $65.00 $117.00 $122.00 $16.00 $17.00 $15.00 $212.00 $156.00 $10.00 $52.00 $27.00 NC ------------------$56.00 ------$4.00 $50.00 $234.00 $56.00 $127.00 ------------------$69.00 NC $41.00 $23.00 $151.00 $448.00 $151.00 $222.00 $56.00 $166.00 $33.00 $19.00 $51.00 $35.00 $218.00 $56.00 $162.00 $448.00 $151.00 $239.00 $55.00 $184.00 $5.00 $183.00 $52.00 $68.00 $122.00 $127.00 $17.00 $18.00 $16.00 $223.00 $164.00 $11.00 $54.00 $28.00 NC ------------------$53.00 ------$3.00 $40.00 $122.00 $48.00 $95.00 ------------------$60.00 NC $38.00 $9.00 $63.00 $220.00 $63.00 $194.00 $52.00 $142.00 $29.00 $16.00 $46.00 $31.00 $191.00 $52.00 $139.00 $220.00 $63.00 $209.00 $51.00 $158.00 $4.00 $162.00 $47.00 $62.00 $113.00 $117.00 $15.00 $15.00 $14.00 $197.00 $145.00 $10.00 $33.00 $25.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) NC ------------------$54.00 ------$3.00 $45.00 $127.00 $52.00 $109.00 ------------------$65.00 NC $39.00 $10.00 $66.00 $230.00 $66.00 $208.00 $54.00 $155.00 $31.00 $18.00 $49.00 $33.00 $204.00 $54.00 $151.00 $230.00 $66.00 $224.00 $53.00 $171.00 $5.00 $173.00 $50.00 $65.00 $117.00 $122.00 $16.00 $17.00 $15.00 $212.00 $156.00 $10.00 $34.00 $26.00 NC ------------------$56.00 ------$4.00 $50.00 $133.00 $56.00 $127.00 ------------------$69.00 NC $41.00 $10.00 $70.00 $243.00 $70.00 $222.00 $56.00 $166.00 $33.00 $19.00 $51.00 $35.00 $218.00 $56.00 $162.00 $243.00 $70.00 $239.00 $55.00 $184.00 $5.00 $183.00 $52.00 $68.00 $122.00 $127.00 $17.00 $18.00 $16.00 $223.00 $164.00 $11.00 $35.00 $27.00 Part C, 376 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C. Medicine CPT Code 2003 MRA G0271 G0281 G0283 G0308 G0309 G0310 G0311 G0312 G0313 G0314 G0315 G0316 G0317 G0318 G0319 G0320 G0321 G0322 G0323 G0324 G0325 G0326 G0327 G0329 G0332 G0366 G0367 G9041 G9042 G9043 G9044 P3001 Q0035 Q0035-26 Q0035-TC Q0091 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Locality 01/02 Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $15.00 $12.00 $12.00 $773.00 $635.00 $497.00 $542.00 $447.00 $351.00 $475.00 $392.00 $305.00 $299.00 $245.00 $192.00 $606.00 $433.00 $375.00 $234.00 $21.00 $13.00 $15.00 $8.00 $9.00 $77.00 $25.00 $15.00 $25.00 $11.00 $11.00 $9.00 $27.00 $23.00 $9.00 $14.00 $43.00 $16.00 $13.00 $13.00 $802.00 $658.00 $515.00 $561.00 $462.00 $362.00 $492.00 $405.00 $314.00 $309.00 $254.00 $198.00 $627.00 $447.00 $387.00 $242.00 $22.00 $13.00 $16.00 $9.00 $9.00 $83.00 $26.00 $17.00 $26.00 $11.00 $11.00 $10.00 $28.00 $24.00 $9.00 $15.00 $45.00 $16.00 $13.00 $13.00 $831.00 $682.00 $533.00 $581.00 $479.00 $375.00 $509.00 $419.00 $325.00 $321.00 $263.00 $205.00 $649.00 $463.00 $400.00 $250.00 $23.00 $14.00 $16.00 $9.00 $10.00 $87.00 $28.00 $18.00 $26.00 $12.00 $12.00 $11.00 $29.00 $26.00 $10.00 $16.00 $48.00 $15.00 $12.00 $12.00 $773.00 $635.00 $497.00 $542.00 $447.00 $351.00 $475.00 $392.00 $305.00 $299.00 $245.00 $192.00 $606.00 $433.00 $375.00 $234.00 $21.00 $13.00 $15.00 $8.00 $9.00 $77.00 $25.00 $15.00 $25.00 $11.00 $11.00 $9.00 $27.00 $23.00 $9.00 $14.00 $20.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $15.00 $13.00 $13.00 $802.00 $658.00 $515.00 $561.00 $462.00 $362.00 $492.00 $405.00 $314.00 $309.00 $254.00 $198.00 $627.00 $447.00 $387.00 $242.00 $22.00 $13.00 $16.00 $9.00 $9.00 $83.00 $26.00 $17.00 $26.00 $11.00 $11.00 $10.00 $28.00 $24.00 $9.00 $15.00 $21.00 $16.00 $13.00 $13.00 $831.00 $682.00 $533.00 $581.00 $479.00 $375.00 $509.00 $419.00 $325.00 $321.00 $263.00 $205.00 $649.00 $463.00 $400.00 $250.00 $23.00 $14.00 $16.00 $9.00 $10.00 $87.00 $28.00 $18.00 $26.00 $12.00 $12.00 $11.00 $29.00 $26.00 $10.00 $16.00 $21.00 Part C, 377 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition Evaluation and Management Locality 01/02 CPT Code 2003 MRA 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99281 99282 99283 99284 99285 99288 99291 99292 99304 99305 99306 99307 99308 99309 99310 $35.00 $58.00 $58.00 $84.00 $84.00 $19.00 $31.00 $40.00 $40.00 $65.00 $65.00 $65.00 $109.00 $152.00 $66.00 $109.00 $152.00 $33.00 $54.00 $77.00 $129.00 $173.00 $213.00 $66.00 $88.00 $54.00 $88.00 $117.00 $163.00 $212.00 $54.00 $70.00 $96.00 $138.00 $190.00 $18.00 $28.00 $60.00 $94.00 $103.00 BR $192.00 $95.00 ------------------------------------------- RULE 69L-7.020, F.A.C. Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $39.00 $67.00 $99.00 $151.00 $190.00 $21.00 $40.00 $64.00 $97.00 $132.00 $71.00 $67.00 $111.00 $155.00 $94.00 $129.00 $189.00 $39.00 $69.00 $99.00 $135.00 $178.00 $221.00 $71.00 $102.00 $52.00 $97.00 $133.00 $195.00 $241.00 $51.00 $81.00 $120.00 $172.00 $212.00 $22.00 $41.00 $66.00 $121.00 $182.00 ------$274.00 $123.00 $83.00 $116.00 $149.00 $41.00 $63.00 $85.00 $124.00 $41.00 $70.00 $104.00 $158.00 $198.00 $22.00 $42.00 $67.00 $101.00 $137.00 $74.00 $70.00 $114.00 $161.00 $96.00 $133.00 $194.00 $40.00 $71.00 $102.00 $140.00 $184.00 $228.00 $73.00 $105.00 $55.00 $102.00 $140.00 $204.00 $252.00 $52.00 $84.00 $124.00 $178.00 $220.00 $22.00 $42.00 $69.00 $126.00 $188.00 ------$285.00 $128.00 $86.00 $119.00 $153.00 $43.00 $65.00 $88.00 $128.00 $43.00 $74.00 $109.00 $165.00 $207.00 $23.00 $45.00 $70.00 $105.00 $143.00 $77.00 $72.00 $119.00 $167.00 $100.00 $138.00 $201.00 $42.00 $73.00 $105.00 $146.00 $191.00 $237.00 $76.00 $109.00 $58.00 $108.00 $147.00 $213.00 $264.00 $55.00 $88.00 $129.00 $184.00 $229.00 $23.00 $43.00 $72.00 $131.00 $197.00 ------$297.00 $133.00 $89.00 $123.00 $158.00 $44.00 $68.00 $91.00 $132.00 $25.00 $47.00 $73.00 $120.00 $156.00 $9.00 $25.00 $46.00 $72.00 $103.00 $71.00 $67.00 $111.00 $155.00 $94.00 $129.00 $189.00 $39.00 $69.00 $99.00 $135.00 $178.00 $221.00 $71.00 $102.00 $35.00 $74.00 $103.00 $161.00 $202.00 $51.00 $81.00 $120.00 $172.00 $212.00 $22.00 $41.00 $66.00 $121.00 $182.00 ------$226.00 $113.00 $83.00 $116.00 $149.00 $41.00 $63.00 $85.00 $124.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $26.00 $49.00 $76.00 $125.00 $162.00 $10.00 $26.00 $47.00 $74.00 $107.00 $74.00 $70.00 $114.00 $161.00 $96.00 $133.00 $194.00 $40.00 $71.00 $102.00 $140.00 $184.00 $228.00 $73.00 $105.00 $37.00 $77.00 $108.00 $167.00 $210.00 $52.00 $84.00 $124.00 $178.00 $220.00 $22.00 $42.00 $69.00 $126.00 $188.00 ------$233.00 $117.00 $86.00 $119.00 $153.00 $43.00 $65.00 $88.00 $128.00 $27.00 $51.00 $80.00 $130.00 $169.00 $10.00 $27.00 $49.00 $77.00 $111.00 $77.00 $72.00 $119.00 $167.00 $100.00 $138.00 $201.00 $42.00 $73.00 $105.00 $146.00 $191.00 $237.00 $76.00 $109.00 $39.00 $82.00 $113.00 $174.00 $219.00 $55.00 $88.00 $129.00 $184.00 $229.00 $23.00 $43.00 $72.00 $131.00 $197.00 ------$242.00 $122.00 $89.00 $123.00 $158.00 $44.00 $68.00 $91.00 $132.00 Part C, 378 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition Evaluation and Management Locality 01/02 CPT Code 2003 MRA 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99339 99340 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99355 99356 99357 99358 99359 99360 99363 99364 99366 99367 99368 99374 99375 99377 99378 99379 99380 99406 99407 99408 99409 99441 99442 99443 99450 99455 $60.00 $77.00 ------------------------------------------------------------------------$59.00 $85.00 $109.00 $160.00 $193.00 $46.00 $71.00 $107.00 $156.00 $106.00 $104.00 $87.00 $88.00 BR BR BR ------------------------------$75.00 $75.00 $75.00 $104.00 $75.00 $104.00 ------------------------------------------NC $90.00 RULE 69L-7.020, F.A.C. Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) $62.00 $81.00 $87.00 $58.00 $85.00 $138.00 $179.00 $211.00 $58.00 $90.00 $128.00 $183.00 $73.00 $101.00 $58.00 $85.00 $134.00 $176.00 $211.00 $55.00 $84.00 $122.00 $171.00 $98.00 $96.00 $90.00 $90.00 $103.00 $50.00 $59.00 $116.00 $40.00 $42.00 $54.00 $35.00 $68.00 $113.00 $68.00 $121.00 $67.00 $102.00 $13.00 $26.00 $32.00 $63.00 $14.00 $25.00 $37.00 NC ------- $64.00 $83.00 $90.00 $61.00 $88.00 $142.00 $184.00 $218.00 $60.00 $93.00 $132.00 $189.00 $75.00 $105.00 $60.00 $88.00 $139.00 $181.00 $218.00 $57.00 $86.00 $126.00 $177.00 $102.00 $100.00 $93.00 $93.00 $106.00 $51.00 $60.00 $121.00 $42.00 $44.00 $55.00 $36.00 $71.00 $118.00 $71.00 $126.00 $70.00 $105.00 $14.00 $27.00 $33.00 $65.00 $15.00 $26.00 $39.00 NC ------- $67.00 $87.00 $92.00 $63.00 $92.00 $147.00 $191.00 $226.00 $63.00 $96.00 $136.00 $195.00 $79.00 $109.00 $63.00 $92.00 $144.00 $188.00 $226.00 $60.00 $89.00 $131.00 $183.00 $106.00 $103.00 $96.00 $97.00 $110.00 $53.00 $62.00 $126.00 $44.00 $46.00 $57.00 $37.00 $74.00 $123.00 $74.00 $132.00 $73.00 $109.00 $14.00 $28.00 $33.00 $66.00 $15.00 $27.00 $40.00 NC ------- $62.00 $81.00 $87.00 $58.00 $85.00 $138.00 $179.00 $211.00 $58.00 $90.00 $128.00 $183.00 $73.00 $101.00 $58.00 $85.00 $134.00 $176.00 $211.00 $55.00 $84.00 $122.00 $171.00 $93.00 $91.00 $90.00 $90.00 $103.00 $50.00 $59.00 $80.00 $31.00 $41.00 $54.00 $35.00 $57.00 $106.00 $57.00 $114.00 $56.00 $88.00 $13.00 $25.00 $30.00 $61.00 $13.00 $24.00 $36.00 NC ------- CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) $64.00 $83.00 $90.00 $61.00 $88.00 $142.00 $184.00 $218.00 $60.00 $93.00 $132.00 $189.00 $75.00 $105.00 $60.00 $88.00 $139.00 $181.00 $218.00 $57.00 $86.00 $126.00 $177.00 $96.00 $94.00 $93.00 $93.00 $106.00 $51.00 $60.00 $83.00 $32.00 $43.00 $55.00 $36.00 $59.00 $110.00 $59.00 $119.00 $58.00 $91.00 $13.00 $26.00 $31.00 $63.00 $13.00 $25.00 $37.00 NC ------- $67.00 $87.00 $92.00 $63.00 $92.00 $147.00 $191.00 $226.00 $63.00 $96.00 $136.00 $195.00 $79.00 $109.00 $63.00 $92.00 $144.00 $188.00 $226.00 $60.00 $89.00 $131.00 $183.00 $100.00 $97.00 $96.00 $97.00 $110.00 $53.00 $62.00 $86.00 $34.00 $45.00 $57.00 $37.00 $61.00 $115.00 $61.00 $124.00 $60.00 $94.00 $13.00 $26.00 $32.00 $64.00 $14.00 $26.00 $39.00 NC ------- Part C, 379 Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition Evaluation and Management Locality 01/02 CPT Code 2003 MRA 99456 99457 99499 99600 G0245 G0246 G0337 G0344 G0368 G0372 G0396 G0397 M0064 BR BR BR BR ------------------------------------------------------- RULE 69L-7.020, F.A.C. Locality 03 Locality 04 (Non-Facility MRA) (Non-Facility MRA) (Non-Facility MRA) (Facility MRA) ------------------------$67.00 $40.00 $71.00 $100.00 $9.00 $16.00 $32.00 $63.00 $39.00 ------------------------$70.00 $42.00 $74.00 $105.00 $10.00 $16.00 $33.00 $65.00 $41.00 ------------------------$73.00 $43.00 $78.00 $110.00 $10.00 $17.00 $33.00 $66.00 $42.00 ------------------------$47.00 $24.00 $71.00 $73.00 $9.00 $9.00 $30.00 $61.00 $18.00 CPT only © 2008 American Medical Association. All rights reserved. Locality 01/02 Locality 03 Locality 04 (Facility MRA) (Facility MRA) ------------------------$48.00 $25.00 $74.00 $77.00 $10.00 $9.00 $31.00 $62.00 $18.00 ------------------------$50.00 $26.00 $78.00 $81.00 $10.00 $10.00 $32.00 $64.00 $19.00 Part C, 380 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDIX A DEFINITIONS RULE 69L-7.020, F.A.C. 381 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDIX A. DEFINITIONS. (1) “AA” means an anesthesiologist assistant licensed pursuant to Chapter 458, F.S. (2) “Agency” means the Agency for Health Care Administration as defined in s.440.02 (3), F.S. (3) “Anesthesia Reimbursement Allowance (ARA)” means the maximum reimbursement allowance paid to a provider for an anesthesia procedure. (4) “Authorization” means the approval given to a health care provider by the insurer or selfinsured employer for the provision of medical services to an employee. (5) “Basic Value (BV) or base unit” means the value of all usual anesthesia services, except the values of time units actually spent in anesthesia care and the value of any additional modifiers. (6) “Billing” means the completion and submission of a form to the insurer in order to receive reimbursement for health care services provided to an injured employee. (7) “Commission on Accreditation of Rehabilitation Facilities (CARF)” is a not-for-profit organization whose mission is to promote the quality, value and optimal outcomes of services through a consultative accreditation process that centers on enhancing the lives of people in need of rehabilitation and served by CARF accredited organizations and rehabilitation programs. (8) “CRNA” means a certified registered nurse anesthetist licensed by Chapter 464, F.S. (9) “Division” means the Division of Workers’ Compensation of the Department of Financial Services as defined in s.440.02 (14), F.S. (10) “Durable medical equipment (DME)” means articles of a permanent nature which are prescribed for prolonged or continuous use. (11) “Exception” means payment may be made for services or supplies exceeding reimbursement guidelines if documented and authorized by the insurer. (12) “Exclusion” means a procedure, service or supply that is not reimbursable under the workers’ compensation program. (13) “Health care provider” means a provider as defined in s.440.13 (1), F.S. (14) “Limitations” means the restrictions placed on the reimbursement of medical services. (15) “Maximum Reimbursement Allowance (MRA)” means the specifically listed maximum dollar amount in the schedule adopted by the three-member panel for reimbursement of medical service(s) rendered to an injured employee by a health care provider. (16) “Medically Necessary or Medical Necessity” means any medical service or medical supply which meets the definition of the terms according to s.440.13 (1) (l), F.S. RULE 69L-7.020, F.A.C. 382 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition (17) “Medical record” means the medical file that contains information that identifies the patient, supports the diagnosis, justifies the treatment and documents the care provided as required under Chapter 395, F.S. (18) “Medical supplier” means a supplier who furnishes medical equipment, supplies, appliances, devices, transcutaneous neurostimulators, ocular and hearing aids, prosthetics or orthotics as prescribed by a physician. (19) “National Correct Coding Initiative” or “Correct Coding Initiative” refers to the Centers for Medicare and Medicaid Services (CMS) plan to promote national correct coding methodologies and to control improper coding. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). (20) “Non-physician surgical assistant” means a physician assistant licensed pursuant to s.458.347, F.S., or s.459.022, F.S., or a licensed registered nurse certified pursuant to s.464, F.S. (21) “Not covered or non-covered (NC)” means a service or supply that is not reimbursable under the workers’ compensation program. These services and supplies are identified by “NC” in the MRA column in the schedule of maximum reimbursement allowances. (22) “Orthotics” means mechanical appliances that are used to support and correct deformities. (23) “Peer review” means an evaluation as defined in s.440.13, F.S. (24) “Physician” means a physician as defined in s.440.13, F.S. (25) “Professional component” means that portion of a diagnostic procedure that consists of the physician’s professional services. This includes examination of the patient when indicated; the performance, supervision and interpretation of the procedure; and the provision of a written report. (26) “Prosthetics” means artificial substitutes that are used to replace missing parts or devices to augment performance of a natural function. (27) “Technical component” means the portion of certain diagnostic procedures that includes the provision of personnel, materials and equipment to perform the procedures or studies. (28) “Time (TM) Units” means the number of units of time that a procedure requires, which is calculated by dividing the total anesthesia time (total minutes) by either ten (10) minute intervals for anesthesiologists, or fifteen (15) minute intervals for CRNAs/AAs. (29) “Unlisted procedure” means a procedure code that is not listed in this schedule, but is contained in the CPT® 2009 Current Procedural Terminology Professional Edition, Copyright 2008, American Medical Association; the Current Dental Terminology, CDT2009/2010, Copyright 2008, American Dental Association; or the Healthcare Common Procedure Coding System, Medicare’s National Level II Codes, HCPCS 2009, American Medical Association, Twenty-first Edition, Copyright 2008, Ingenix Publishing Group. RULE 69L-7.020, F.A.C. 383 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDIX B OFFICIAL SOURCE OF REFERENCES DIRECTORY OFFICIAL S RULE 69L-7.020, F.A.C. 384 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDIX B. OFFICIAL SOURCE OF REFERENCES. As medical information pertaining to coding systems and guidelines are evolving, users of this manual seeking up-to-date information should use the appropriate listed reference address, telephone/fax number or web site for specific answers to questions, inquiries and products. ♦ 2009 Relative Value Guide: A Guide for Anesthesia Values American Society of Anesthesiologists 520 N. Northwest Highway Park Ridge, Il. 60068-2573 (847) 825-5586 Web Site: www.asahq.org/ ♦ Complete Global Service Data for Orthopaedic Surgery, Vol. 1 & 2 American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, Illinois 60018-4262 (847) 823-7186 (800) 626-6726 (847) 823-8125 Fax (800) 823-8025 Fax Web site: www.aaos.org/ ♦ Current Dental Terminology (CDT-2009/2010) American Dental Association 211 East Chicago Avenue, 6th Floor Chicago, Illinois 60611-2678 (312) 440-2653 (800) 621-8099 (312) 440-7494 Fax Web site: www.ada.org ADA Order Department American Dental Association Post Office Box 776 St. Charles, Illinois 60174 (800) 947-4746 (888) 476-1880 Fax Web site: www.adacatalog.org/ ♦ Drug Topics Red Book Medical Economics Company, Inc. Five Paragon Drive Montvale, New Jersey 07645-1742 (201) 358-7200 (800) 232-7379 (201) 722-2680 Fax Web site: www.pdr.net. RULE 69L-7.020, F.A.C. 385 OU RC E OF RE FE RE NC ES Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition ♦ ♦ ♦ ♦ ♦ Current Procedural Terminology, (CPT®) CPT Assistant® Guide To The Evaluation of Permanent Impairment, 5th Edition HCPCS ICD-9-CM American Medical Association (AMA) – MAIN OFFICE 515 North State Street Chicago, Illinois 60610 (312) 464-5000 (312) 464-4184 Fax Web site: www.ama-assn.org AMA Order Department P.O. Box 930876 Atlanta, Georgia 31193-0876 (800) 621–8335 (800) 262-3211 (312) 464-5600 Fax For questions regarding the use of CPT® codes, please contact the American Medical Association CPT® Information and Education Services at 1-800-634-6922. ♦ 1996 Florida Uniform Permanent Impairment Rating Schedule Florida Workers’ Compensation Institute P. O. Box 200 Tallahassee, Florida 32302 (850) 425-8156 (850) 222-9766 Fax Web site: www.fwciweb.org ♦ National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual) Visit http://www.cms.hhs.gov/NationalCorrectCodInitEd/ for an overview of the Coding Policy Manual and for information on how to obtain the manual. Comments or concerns about specific NCCI edits may be submitted in writing to: National Correct Coding Initiative Correct Coding Solutions LLC P.O. Box 907 Carmel, IN 46082-0907 Attention: Niles R. Rosen, M.D., Medical Director and Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist (317) 571-1745 Fax RULE 69L-7.020, F.A.C. 386 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDIX C MODIFIERS RULE 69L-7.020, F.A.C. 387 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDIX C. MODIFIERS. 1. Modifiers change the basic services reported and require different reimbursements from the MRAs listed for the unmodified basic services. Modifiers are two (2) characters: alpha, numeric or an alphanumeric combination. 2. The CPT®-2009 has a two-digit numeric modifier series. The modifier, when appropriate, must be added to the procedure code of the basic procedure. a. Reimbursement shall be made for all of the two-digit numeric modifiers provided in the CPT®2009, when the service is medically necessary. (1) The guidelines in the CPT®-2009 must be followed for each modifier reported by the provider. (2) In some situations, it may be necessary for the provider to submit a report with the bill to explain the circumstances in order for an insurer to determine payment. 3. In addition to the CPT® modifiers, there are HCPCS Level II modifiers for reporting a change to the basic service. HCPCS Level II modifiers specifically required by this manual are the following: a. Modifier TC (Technical Component) When the technical component of a procedure (personnel, materials, equipment, space and supplies) is rendered by a health care provider other than the physician performing the professional component of the procedure, the provider shall bill the technical component by adding modifier TC to the appropriate procedure code. b. Modifiers used specifically for CRNA services: Modifier QX is appended to the appropriate anesthesia CPT® code by a CRNA to identify services provided with medical direction of a physician. The reimbursement for a CRNA requiring medical direction of a physician shall be fifty percent (50%) of the anesthesia reimbursement allowance listed in Part A, Section XI in this manual or the agreed upon contract price. Modifier QY is used by an anesthesiologist to report medical directions of a CRNA. When an anesthesiologist/physician is not personally administering the anesthesia but is providing medical direction for the anesthesia services provided by a nurse anesthetist, not employed by the anesthesiologist, the physician shall bill for the medical direction service by adding one of the appropriate modifiers to the anesthesia procedure code. The medical direction service includes the preoperative and postoperative anesthesia care. Reimbursement for medical direction services by an anesthesiologist shall be fifty percent (50%) of the anesthesia reimbursement allowance or the agreed-upon contracted price. c. Modifier AS is used by a physician assistant, nurse practitioner or registered nurse first assistant to report services for assistant at surgery. RULE 69L-7.020, F.A.C. 388 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDIX D WORKERS’ COMPENSATION UNIQUE CODES RULE 69L-7.020, F.A.C. 389 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition APPENDIX D. WORKERS’ COMPENSATION UNIQUE CODES DSPNS Legend, prescription, and over-the-counter drugs dispensed by a licensed practitioner. (See Section V: Dispensing of Medication and rule 69L-7.602, F.A.C. for specific limitations on the use of this code.) Page 16 COMPD Compounded drugs dispensed. Page 17 97260 Manipulation of spine by a physician other than an osteopathic or chiropractic physician. Page 28 97261 Manipulation of the temporomandibular joint; upper extremities including the hand and wrist; the lower extremities; and other regions by a physician other than an osteopathic or chiropractic physician. Page 28 97750 Functional capacity evaluation (FCE) with written report. Page 32 97752 Muscle testing manually or by automated equipment with written report. Page 29 97850 Physical reconditioning assessment; per hour. Page 23 97851 Physical reconditioning assessment; additional thirty (30) minutes. Page 23 97852 Physical reconditioning program; per hour. Page 30 97853 Physical reconditioning program; additional thirty (30) minutes. Page 30 99457 Consensus Independent Medical Examination (CIME). Page 20 RULE 69L-7.020, F.A.C. 390 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition COMPENSATION UN APPENDIX E MEDICARE LOCALITY MAP RULE 69L-7.020, F.A.C. 391 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition Medicare Payment Localities (Counties) Locality 01 / Locality 02: Alachua Baker Bay Bradford Brevard Calhoun Charlotte Citrus Clay Columbia De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Jackson Jefferson Lafayette Lake Leon Levy Liberty Madison Manatee Marion Nassau Okaloosa Okeechobee Orange Osceola Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington Locality 03: Broward Collier Martin Indian River Lee Palm Beach St. Lucie Locality 04: Dade Monroe RULE 69L-7.020, F.A.C. 392 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition INDEX RULE 69L-7.020, F.A.C. 393 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition INDEX A E Acupuncture, 28 Anesthesia, 35 Anesthesia Reimbursement Allowance (ARA), 37 Basic value (BV), 36 Conversion factor, 38 Physical status modifiers, 37 Qualifying circumstances, 37 Reimbursement methodology, 38 Time (TM) Units, 36 Authorization, 8 Average Wholesale Price (AWP), 16 Electrodiagnostic medicine, 18 Electromyography, 18 Eligibility, 8 Evaluation and management services, 19 B G Biofeedback, 18 By Report (BR), 12 Global reimbursement, 33 F Failed appointments, 13 Federal facilities, 11 Follow-up days (FUD), 33 Functional capacity evaluation (FCE), 32 H C Health care provider(s), 382 Home health agency, 20 Home health services, 20 Chiropractic manipulative treatment (CMT), 28 Commission on Accreditation of Rehabilitation Facilities (CARF), 382 Compounding drugs, 16 Consensus Independent Medical Examination (CIME), 20 Consultations, 19 I Impairment rating, 20 Independent Medical Examination (IME), 20 Independent Medical Examination, Consensus (CIME), 20 Individual psychotherapy, 22 Injectable medications, 20 Injured employee status (Classification), 14 Interdisciplinary pain management program, 31 Interdisciplinary pain rehabilitation program, 32 D Dental services, 15 Oral and maxillofacial surgery, 15 Temporomandibular joint services, 15 Drugs, 16 Average Wholesale Price (AWP), 16 Compounded, 17 National Drug Code (NDC), 16, 17 Over-the-counter drugs, 17 Medicinal drugs, 16 Reimbursement formula, 16 Durable medical equipment (DME), 17 J J codes, 20 L Level I: Classification (defined), 15 RULE 69L-7.020, F.A.C. 394 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition Level II: Classification (defined), 15 Level III: Classification (defined), 15 Psychological services, 22 Psychotherapy, 22 Q M Qualifying circumstances, 37 Manipulative treatment, 27 Maximum reimbursement allowance (MRA), 382 Medical records, 9 Medical supplier services, 17 Medical and surgical supplies, 21 Medicare Locality Map, 392 Medicinal drugs, 16 Modifiers, 388 R Radiology, 23 Professional component modifier, 23 Technical component modifier, 23 Reference materials, 385 Reimbursement information, 11 N S National Correct Coding Initiative (NCCI), 13, 383, 386 National Drug Code (NDC), 16, 17 Nerve conduction studies (NCS), 19 Section XI Schedule of MRA’s, 40 Instructions, 41 Part A, 42 Part B, 135 Part C, 244 Supplies, 17 Surgical services, 33 Bilateral procedures, 35 Follow-up day period, 33 General reimbursement information, 33 Global reimbursement, 33 Multiple procedures, 35 Non-physician surgical assistant, 34 Surgical assistants, 34 Surgical team, 35 Two surgeons, 34 O Office visits, 19 Ophthalmological services, 22 Osteopathic manipulative treatment (OMT), 28 Out-of-state providers, 12 P Pain program, 32 Pharmaceutical reimbursement formula, 16 Physical medicine and rehabilitation, 25 General information, 25 Initial evaluation and plan of care, 26 Manipulative treatment, 27 Medical supplies, 17 Modalities and therapeutic procedures, 27 Physical reconditioning assessment, 30 Physical reconditioning program, 30 Rehabilitation program, 31 Revised plan of care, 27 Tests and measurements, 29 Therapy re-evaluation, 27 Work hardening program, 31 Professional component, 23, 383 Provider eligibility, 8 Psychiatric services, 22 RULE 69L-7.020, F.A.C. T Technical component, 23, 383 Temporomandibular joint services, 15 Thermography, 24 Transcutaneous neurostimulator (TNS), 24 U Unique codes, 390 Unlisted procedures, 383 V Visit(s), 19 Consultation, 19 395 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition Confirmatory consultation, 19 Office visit, 19 Postoperative, 33 Preoperative, 33 W Work hardening program, 31 Workers’ compensation unique codes, 390 X X-rays, 23 Y YYY Follow-up designation, 33 Z ZZZ Follow-up designation, 33 RULE 69L-7.020, F.A.C. 396

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Florida Workersãâ¢ã¤â€°ã¥ã¤â€¹â¢ Compensation Health Care Provider Reimbursement Manual