florida workers’ compensation health care provider reimbursement manual 2008 edition ·...

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RULE 69L-7.020, F.A.C. 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

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Page 1: FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER REIMBURSEMENT MANUAL 2008 Edition · 2009-03-27 · Florida Workers’ Compensation Health Care Provider Reimbursement Manual,

RULE 69L-7.020, F.A.C.

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

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition

RULE 69L-7.020, F.A.C. 2

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

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition

RULE 69L-7.020, F.A.C. 3

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

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition

RULE 69L-7.020, F.A.C. 4

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

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition

RULE 69L-7.020, F.A.C. 5

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 10-1-82, 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, 2-18-96, 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, 7-4-04, 5-9-05, 9-4-05, 11-16-06, 10-18-07, 02-04-09.

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition

RULE 69L-7.020, F.A.C. 6

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.

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RULE 69L-7.020, F.A.C. 7

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.

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RULE 69L-7.020, F.A.C. 8

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).

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RULE 69L-7.020, F.A.C. 9

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,

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RULE 69L-7.020, F.A.C. 10

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.

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RULE 69L-7.020, F.A.C. 11

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.

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RULE 69L-7.020, F.A.C. 12

(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-of-

state 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.

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RULE 69L-7.020, F.A.C. 13

(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.

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RULE 69L-7.020, F.A.C. 14

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;

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RULE 69L-7.020, F.A.C. 15

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.

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RULE 69L-7.020, F.A.C. 16

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

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RULE 69L-7.020, F.A.C. 17

(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-the-counter 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.

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RULE 69L-7.020, F.A.C. 18

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.

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RULE 69L-7.020, F.A.C. 19

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.

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RULE 69L-7.020, F.A.C. 20

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.

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RULE 69L-7.020, F.A.C. 21

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) 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 (2) 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

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RULE 69L-7.020, F.A.C. 22

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.

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RULE 69L-7.020, F.A.C. 23

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.

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RULE 69L-7.020, F.A.C. 24

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 forty-

five (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

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RULE 69L-7.020, F.A.C. 25

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

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RULE 69L-7.020, F.A.C. 26

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

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RULE 69L-7.020, F.A.C. 27

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 15- minute 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.

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RULE 69L-7.020, F.A.C. 28

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 atlanto-occipital); 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

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RULE 69L-7.020, F.A.C. 29

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 non-electrical 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

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RULE 69L-7.020, F.A.C. 30

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

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RULE 69L-7.020, F.A.C. 31

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.

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RULE 69L-7.020, F.A.C. 32

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).

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RULE 69L-7.020, F.A.C. 33

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.

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RULE 69L-7.020, F.A.C. 34

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.

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RULE 69L-7.020, F.A.C. 35

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.

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RULE 69L-7.020, F.A.C. 36

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.

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RULE 69L-7.020, F.A.C. 37

(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 Unit Values

P1 A normal healthy patient 0 P2 A patient with mild systemic disease 0 P3 A patient with severe systemic disease 1 P4 A patient with severe systemic disease that is a constant threat to life 2 P5 A moribund patient who is not expected to survive without the operation 3 P6 A declared brain-dead patient whose organs

are being removed for donor purposes 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 Unit Values

99100 Anesthesia for patient of extreme age, under one year and over seventy 1 99116 Anesthesia complicated by utilization of total body hypothermia 5 99135 Anesthesia complicated by utilization of controlled hypotension 5 99140 Anesthesia complicated by emergency conditions (specify) 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.

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RULE 69L-7.020, F.A.C. 38

(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 one-fifteenth (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.

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RULE 69L-7.020, F.A.C. 39

(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.

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RULE 69L-7.020, F.A.C. 40

SECTION XI

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

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RULE 69L-7.020, F.A.C. 41

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 eighty-five 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 non- facility 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.

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RULE 69L-7.020, F.A.C. 42

PART A

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

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Anesthesia Anesthesia AnesthesiaCPT Code BV + TM CPT Code BV + TM CPT Code BV + TM

00100 5 + TM 00528 8 + TM 00844 7 + TM00102 6 + TM 00529 11 + TM 00846 8 + TM00103 5 + TM 00530 4 + TM 00848 8 + TM00104 4 + TM 00532 4 + TM 00851 6 + TM00120 5 + TM 00534 7 + TM 00860 6 + TM00124 4 + TM 00537 8 + TM 00862 7 + TM00126 4 + TM 00539 17 + TM 00864 8 + TM00140 5 + TM 00540 13 + TM 00865 8 + TM00142 6 + TM 00541 15 + TM 00866 10 + TM00144 6 + TM 00542 15 + TM 00868 10 + TM00145 6 + TM 00546 15 + TM 00870 5 + TM00147 6 + TM 00548 15 + TM 00872 7 + TM00148 4 + TM 00550 10 + TM 00873 5 + TM00160 5 + TM 00560 15 + TM 00880 15 + TM00162 7 + TM 00562 20 + TM 00882 10 + TM00164 4 + TM 00563 25 + TM 00902 5 + TM00170 5 + TM 00566 25 + TM 00904 7 + TM00172 6 + TM 00580 20 + TM 00906 4 + TM00174 6 + TM 00600 10 + TM 00908 6 + TM00176 7 + TM 00604 13 + TM 00910 3 + TM00190 5 + TM 00620 10 + TM 00912 5 + TM00192 7 + TM 00622 13 + TM 00914 5 + TM00210 11 + TM 00630 8 + TM 00916 5 + TM00212 5 + TM 00632 7 + TM 00918 5 + TM00214 9 + TM 00634 10 + TM 00920 3 + TM00215 9 + TM 00635 4 + TM 00921 3 + TM00216 15 + TM 00640 3 + TM 00922 6 + TM00218 13 + TM 00670 13 + TM 00924 4 + TM00220 10 + TM 00700 3 + TM 00926 4 + TM00222 6 + TM 00702 4 + TM 00928 6 + TM00300 5 + TM 00730 5 + TM 00930 4 + TM00320 6 + TM 00740 5 + TM 00932 4 + TM00322 3 + TM 00750 4 + TM 00934 6 + TM00350 10 + TM 00752 6 + TM 00936 8 + TM00352 5 + TM 00754 7 + TM 00938 4 + TM00400 3 + TM 00756 7 + TM 00940 3 + TM00402 5 + TM 00770 15 + TM 00942 4 + TM00404 5 + TM 00790 7 + TM 00944 6 + TM00406 13 + TM 00792 13 + TM 00948 4 + TM00410 4 + TM 00794 8 + TM 00950 5 + TM00450 5 + TM 00796 30 + TM 00952 4 + TM00452 6 + TM 00797 10 + TM 01112 5 + TM00454 3 + TM 00800 3 + TM 01120 6 + TM00470 6 + TM 00802 5 + TM 01130 3 + TM00472 10 + TM 00810 5 + TM 01140 15 + TM00474 13 + TM 00820 5 + TM 01150 8 + TM00500 15 + TM 00830 4 + TM 01160 4 + TM00520 6 + TM 00832 6 + TM 01170 8 + TM00522 4 + TM 00840 6 + TM 01173 12 + TM00524 4 + TM 00842 4 + TM 01180 3 + TM

CPT only © 2008 American Medical Association. All Rights Reserved. PartA, 43

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Anesthesia Anesthesia AnesthesiaCPT Code BV + TM CPT Code BV + TM CPT Code BV + TM

01190 4 + TM 01632 6 + TM 01952 5 + TM01200 4 + TM 01634 9 + TM 01953 1 + TM01202 4 + TM 01636 15 + TM 01960 5 + TM01210 6 + TM 01638 10 + TM 01961 7 + TM01212 10 + TM 01650 6 + TM 01962 8 + TM01214 8 + TM 01652 10 + TM 01963 10 + TM01215 10 + TM 01654 8 + TM 01967 5 + TM01220 4 + TM 01656 10 + TM 01968 3 + TM01230 6 + TM 01670 4 + TM 01969 5 + TM01232 5 + TM 01680 3 + TM 01990 001234 8 + TM 01682 4 + TM 01991 3 + TM01250 4 + TM 01710 3 + TM 01992 5 + TM01260 3 + TM 01712 5 + TM 01996 301270 8 + TM 01714 5 + TM 01999 BR01272 4 + TM 01716 5 + TM01274 6 + TM 01730 3 + TM01320 4 + TM 01732 3 + TM01340 4 + TM 01740 4 + TM01360 5 + TM 01742 5 + TM01380 3 + TM 01744 5 + TM01382 3 + TM 01756 6 + TM01390 3 + TM 01758 5 + TM01392 4 + TM 01760 7 + TM01400 4 + TM 01770 6 + TM01402 7 + TM 01772 6 + TM01404 5 + TM 01780 3 + TM01420 3 + TM 01782 4 + TM01430 3 + TM 01810 3 + TM01432 6 + TM 01820 3 + TM01440 5 + TM 01829 3 + TM01442 8 + TM 01830 3 + TM01444 8 + TM 01832 6 + TM01462 3 + TM 01840 6 + TM01464 3 + TM 01842 6 + TM01470 3 + TM 01844 6 + TM01472 5 + TM 01850 3 + TM01474 5 + TM 01852 4 + TM01480 3 + TM 01860 3 + TM01482 4 + TM 01916 5 + TM01484 4 + TM 01920 7 + TM01486 7 + TM 01922 7 + TM01490 3 + TM 01924 6 + TM01500 8 + TM 01925 8 + TM01502 6 + TM 01926 10 + TM01520 3 + TM 01930 5 + TM01522 5 + TM 01931 7 + TM01610 5 + TM 01932 7 + TM01620 4 + TM 01933 8 + TM01622 4 + TM 01935 8 + TM01630 5 + TM 01936 8 + TM

CPT only © 2008 American Medical Association. All Rights Reserved. PartA, 44

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD10021 $90.00 0 11406 $246.00 10 11771 $496.00 9010022 $92.00 0 11420 $98.00 10 11772 $585.00 9010040 $54.00 10 11421 $92.00 10 11900 $33.00 010060 $53.00 10 11422 $157.00 10 11901 $37.00 010061 $133.00 10 11423 $163.00 10 11920 $147.00 010080 $65.00 10 11424 $221.00 10 11921 $172.00 010081 $203.00 10 11426 $303.00 10 11922 $40.00 ZZZ10120 $53.00 10 11440 $105.00 10 11950 $107.00 010121 $169.00 10 11441 $102.00 10 11951 $114.00 010140 $53.00 10 11442 $174.00 10 11952 $155.00 010160 $45.00 10 11443 $221.00 10 11954 $165.00 010180 $164.00 10 11444 $276.00 10 11960 $829.00 9011000 $45.00 0 11446 $344.00 10 11970 $632.00 9011001 $27.00 ZZZ 11450 $282.00 90 11971 $280.00 9011004 $564.00 0 11451 $366.00 90 11976 $123.00 011005 $768.00 0 11462 $264.00 90 12001 $84.00 1011006 $710.00 0 11463 $351.00 90 12002 $98.00 1011008 $289.00 ZZZ 11470 $320.00 90 12004 $122.00 1011010 $348.00 10 11471 $391.00 90 12005 $165.00 1011011 $432.00 0 11600 $148.00 10 12006 $203.00 1011012 $597.00 0 11601 $180.00 10 12007 $339.00 1011040 $43.00 0 11602 $199.00 10 12011 $98.00 1011041 $45.00 0 11603 $226.00 10 12013 $141.00 1011042 $88.00 0 11604 $249.00 10 12014 $165.00 1011043 $210.00 10 11606 $315.00 10 12015 $207.00 1011044 $283.00 10 11620 $150.00 10 12016 $268.00 1011055 $26.00 0 11621 $191.00 10 12017 $316.00 1011056 $35.00 0 11622 $223.00 10 12018 $515.00 1011057 $39.00 0 11623 $259.00 10 12020 $211.00 1011100 $78.00 0 11624 $305.00 10 12021 $87.00 1011101 $41.00 ZZZ 11626 $373.00 10 12031 $93.00 1011200 $66.00 10 11640 $168.00 10 12032 $110.00 1011201 $26.00 ZZZ 11641 $227.00 10 12034 $148.00 1011300 $59.00 0 11642 $260.00 10 12035 $223.00 1011301 $80.00 0 11643 $305.00 10 12036 $356.00 1011302 $96.00 0 11644 $380.00 10 12037 $411.00 1011303 $119.00 0 11646 $494.00 10 12041 $116.00 1011305 $61.00 0 11719 $22.00 0 12042 $141.00 1011306 $86.00 0 11720 $32.00 0 12044 $176.00 1011307 $100.00 0 11721 $50.00 0 12045 $250.00 1011308 $125.00 0 11730 $62.00 0 12046 $341.00 1011310 $75.00 0 11732 $31.00 ZZZ 12047 $363.00 1011311 $95.00 0 11740 $41.00 0 12051 $126.00 1011312 $110.00 0 11750 $156.00 10 12052 $148.00 1011313 $144.00 0 11752 $234.00 10 12053 $223.00 1011400 $81.00 10 11755 $106.00 0 12054 $301.00 1011401 $114.00 10 11760 $131.00 10 12055 $380.00 1011402 $145.00 10 11762 $223.00 10 12056 $487.00 1011403 $178.00 10 11765 $65.00 10 12057 $539.00 1011404 $200.00 10 11770 $275.00 10 13100 $178.00 10

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 45

Page 46: FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER REIMBURSEMENT MANUAL 2008 Edition · 2009-03-27 · Florida Workers’ Compensation Health Care Provider Reimbursement Manual,

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD13101 $240.00 10 15221 $114.00 ZZZ 15783 $340.00 9013102 $89.00 ZZZ 15240 $763.00 90 15786 $146.00 1013120 $223.00 10 15241 $334.00 ZZZ 15787 $27.00 ZZZ13121 $348.00 10 15260 $841.00 90 15788 $194.00 9013122 $104.00 ZZZ 15261 $207.00 ZZZ 15789 $360.00 9013131 $252.00 10 15300 $291.00 90 15792 $130.00 9013132 $484.00 10 15301 $61.00 ZZZ 15793 $232.00 9013133 $154.00 ZZZ 15320 $338.00 90 15819 $780.00 9013150 $260.00 10 15321 $91.00 ZZZ 15820 $556.00 9013151 $375.00 10 15330 $291.00 90 15821 $607.00 9013152 $542.00 10 15331 $61.00 ZZZ 15822 $499.00 9013153 $169.00 ZZZ 15335 $323.00 90 15823 $718.00 9013160 $655.00 90 15336 $88.00 ZZZ 15824 BR 014000 $512.00 90 15340 $308.00 10 15825 BR 014001 $695.00 90 15341 $44.00 ZZZ 15826 BR 014020 $590.00 90 15360 $333.00 90 15828 BR 014021 $818.00 90 15361 $71.00 ZZZ 15829 BR 014040 $701.00 90 15365 $348.00 90 15830 $1,072.00 9014041 $936.00 90 15366 $88.00 ZZZ 15832 $926.00 9014060 $766.00 90 15400 $223.00 90 15833 $833.00 9014061 $1,330.00 90 15401 $66.00 ZZZ 15834 $837.00 9014300 $1,040.00 90 15420 $372.00 90 15835 $865.00 9014350 $734.00 90 15421 $115.00 ZZZ 15836 $721.00 9015040 $258.00 0 15430 $505.00 90 15837 $696.00 9015050 $349.00 90 15570 $748.00 90 15838 $600.00 9015100 $679.00 90 15572 $721.00 90 15839 $643.00 9015101 $146.00 ZZZ 15574 $775.00 90 15840 $1,187.00 9015110 $815.00 90 15576 $457.00 90 15841 $1,859.00 9015111 $129.00 ZZZ 15600 $259.00 90 15842 $3,099.00 9015115 $766.00 90 15610 $320.00 90 15845 $1,116.00 9015116 $167.00 ZZZ 15620 $506.00 90 15850 $63.00 015120 $788.00 90 15630 $362.00 90 15851 $40.00 015121 $235.00 ZZZ 15650 $427.00 90 15852 $35.00 015130 $677.00 90 15731 $990.00 90 15860 $151.00 015131 $105.00 ZZZ 15732 $1,465.00 90 15876 BR 015135 $820.00 90 15734 $1,557.00 90 15877 BR 015136 $98.00 ZZZ 15736 $1,862.00 90 15878 BR 015150 $677.00 90 15738 $1,415.00 90 15879 BR 015151 $136.00 ZZZ 15740 $913.00 90 15920 $571.00 9015152 $167.00 ZZZ 15750 $1,064.00 90 15922 $771.00 9015155 $678.00 90 15756 $2,892.00 90 15931 $638.00 9015156 $177.00 ZZZ 15757 $2,892.00 90 15933 $860.00 9015157 $196.00 ZZZ 15758 $2,884.00 90 15934 $1,064.00 9015170 $356.00 90 15760 $810.00 90 15935 $1,184.00 9015171 $92.00 ZZZ 15770 $674.00 90 15936 $1,032.00 9015175 $503.00 90 15775 $327.00 0 15937 $1,223.00 9015176 $146.00 ZZZ 15776 $475.00 0 15940 $318.00 9015200 $644.00 90 15780 $532.00 90 15941 $919.00 9015201 $126.00 ZZZ 15781 $420.00 90 15944 $954.00 9015220 $687.00 90 15782 $314.00 90 15945 $1,078.00 90

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 46

Page 47: FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER REIMBURSEMENT MANUAL 2008 Edition · 2009-03-27 · Florida Workers’ Compensation Health Care Provider Reimbursement Manual,

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD15946 $1,737.00 90 19000 $74.00 0 19380 $780.00 9015950 $549.00 90 19001 $40.00 ZZZ 19396 $231.00 015951 $872.00 90 19020 $288.00 90 19499 BR YYY15952 $876.00 90 19030 $98.00 0 20000 $45.00 1015953 $1,013.00 90 19100 $117.00 0 20005 $267.00 1015956 $1,382.00 90 19101 $338.00 10 20100 $727.00 1015958 $1,379.00 90 19102 $263.00 0 20101 $261.00 1015999 BR YYY 19103 $601.00 0 20102 $314.00 1016000 $53.00 0 19105 $1,878.00 0 20103 $405.00 1016020 $49.00 0 19110 $406.00 90 20150 $1,141.00 9016025 $67.00 0 19112 $354.00 90 20200 $134.00 016030 $153.00 0 19120 $429.00 90 20205 $243.00 016035 $341.00 0 19125 $468.00 90 20206 $119.00 016036 $81.00 ZZZ 19126 $201.00 ZZZ 20220 $128.00 017000 $60.00 10 19260 $1,101.00 90 20225 $215.00 017003 $16.00 ZZZ 19271 $1,561.00 90 20240 $279.00 1017004 $233.00 10 19272 $1,674.00 90 20245 $364.00 1017106 $341.00 90 19290 $101.00 0 20250 $447.00 1017107 $648.00 90 19291 $52.00 ZZZ 20251 $511.00 1017108 $1,015.00 90 19295 $103.00 ZZZ 20500 $59.00 1017110 $55.00 10 19296 $4,903.00 0 20501 $60.00 017111 $83.00 10 19297 $96.00 ZZZ 20520 $75.00 1017250 $27.00 0 19298 $1,841.00 0 20525 $331.00 1017260 $96.00 10 19300 $482.00 90 20526 $64.00 017261 $117.00 10 19301 $367.00 90 20550 $40.00 017262 $150.00 10 19302 $780.00 90 20551 $62.00 017263 $172.00 10 19303 $788.00 90 20552 $62.00 017264 $189.00 10 19304 $487.00 90 20553 $62.00 017266 $225.00 10 19305 $964.00 90 20555 $301.00 017270 $125.00 10 19306 $1,003.00 90 20600 $41.00 017271 $143.00 10 19307 $1,008.00 90 20605 $48.00 017272 $170.00 10 19316 $954.00 90 20610 $49.00 017273 $195.00 10 19318 $1,313.00 90 20612 $56.00 017274 $240.00 10 19324 $440.00 90 20615 $94.00 1017276 $281.00 10 19325 $656.00 90 20650 $170.00 1017280 $123.00 10 19328 $457.00 90 20660 $320.00 017281 $165.00 10 19330 $569.00 90 20661 $476.00 9017282 $194.00 10 19340 $545.00 ZZZ 20662 $559.00 9017283 $239.00 10 19342 $963.00 90 20663 $465.00 9017284 $282.00 10 19350 $853.00 90 20665 $105.00 1017286 $373.00 10 19355 $755.00 90 20670 $80.00 1017311 $629.00 0 19357 $1,449.00 90 20680 $332.00 9017312 $380.00 ZZZ 19361 $1,667.00 90 20690 $298.00 9017313 $575.00 0 19364 $2,737.00 90 20692 $516.00 9017314 $352.00 ZZZ 19366 $1,676.00 90 20693 $477.00 9017315 $74.00 ZZZ 19367 $2,056.00 90 20694 $421.00 9017340 $37.00 10 19368 $2,444.00 90 20802 $3,363.00 9017360 $96.00 10 19369 $2,317.00 90 20805 $4,317.00 9017380 BR 0 19370 $662.00 90 20808 $5,324.00 9017999 BR YYY 19371 $788.00 90 20816 $3,060.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD20822 $2,511.00 90 21070 $679.00 90 21195 $1,360.00 9020824 $3,027.00 90 21073 $337.00 90 21196 $1,764.00 9020827 $3,920.00 90 21076 $1,192.00 10 21198 $1,268.00 9020838 $3,484.00 90 21077 $3,002.00 90 21199 $1,018.00 9020900 $454.00 90 21079 $2,086.00 90 21206 $1,112.00 9020902 $658.00 90 21080 $2,346.00 90 21208 $946.00 9020910 $338.00 90 21081 $2,138.00 90 21209 $576.00 9020912 $549.00 90 21082 $1,855.00 90 21210 $930.00 9020920 $460.00 90 21083 $1,802.00 90 21215 $970.00 9020922 $634.00 90 21084 $2,105.00 90 21230 $956.00 9020924 $583.00 90 21085 $801.00 10 21235 $707.00 9020926 $444.00 90 21086 $2,333.00 90 21240 $1,281.00 9020930 BR 0 21087 $2,217.00 90 21242 $1,207.00 9020931 $156.00 ZZZ 21088 BR 90 21243 $1,501.00 9020936 BR 0 21089 BR 90 21244 $1,062.00 9020937 $234.00 ZZZ 21100 $297.00 90 21245 $1,038.00 9020938 $257.00 ZZZ 21110 $371.00 90 21246 $1,010.00 9020950 $123.00 0 21116 $207.00 0 21247 $2,003.00 9020955 $3,332.00 90 21120 $500.00 90 21248 $1,023.00 9020956 $3,167.00 90 21121 $651.00 90 21249 $1,525.00 9020957 $3,074.00 90 21122 $700.00 90 21255 $1,459.00 9020962 $3,122.00 90 21123 $903.00 90 21256 $1,470.00 9020969 $3,716.00 90 21125 $656.00 90 21260 $1,372.00 9020970 $3,650.00 90 21127 $909.00 90 21261 $2,347.00 9020972 $3,420.00 90 21137 $797.00 90 21263 $2,361.00 9020973 $3,821.00 90 21138 $960.00 90 21267 $1,539.00 9020974 $266.00 0 21139 $1,168.00 90 21268 $1,946.00 9020975 $334.00 0 21141 $1,438.00 90 21270 $890.00 9020979 $19.00 0 21142 $1,527.00 90 21275 $963.00 9020982 $4,231.00 0 21143 $1,511.00 90 21280 $571.00 9020985 $140.00 ZZZ 21145 $1,513.00 90 21282 $360.00 9020999 BR YYY 21146 $1,570.00 90 21295 $144.00 9021010 $854.00 90 21147 $1,639.00 90 21296 $384.00 9021015 $520.00 90 21150 $1,914.00 90 21299 BR YYY21025 $546.00 90 21151 $2,264.00 90 21310 $81.00 021026 $413.00 90 21154 $2,364.00 90 21315 $180.00 1021029 $700.00 90 21155 $2,640.00 90 21320 $235.00 1021030 $496.00 90 21159 $3,302.00 90 21325 $348.00 9021031 $310.00 90 21160 $3,500.00 90 21330 $639.00 9021032 $315.00 90 21172 $2,111.00 90 21335 $852.00 9021034 $1,140.00 90 21175 $2,604.00 90 21336 $478.00 9021040 $227.00 90 21179 $1,826.00 90 21337 $300.00 9021044 $957.00 90 21180 $2,035.00 90 21338 $550.00 9021045 $1,313.00 90 21181 $813.00 90 21339 $689.00 9021046 $899.00 90 21182 $2,570.00 90 21340 $907.00 9021047 $1,109.00 90 21183 $2,770.00 90 21343 $1,043.00 9021048 $925.00 90 21184 $3,150.00 90 21344 $1,450.00 9021049 $1,051.00 90 21188 $1,786.00 90 21345 $738.00 9021050 $1,026.00 90 21193 $1,331.00 90 21346 $917.00 9021060 $972.00 90 21194 $1,540.00 90 21347 $1,048.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD21348 $1,286.00 90 21615 $938.00 90 22319 $1,983.00 9021355 $295.00 10 21616 $1,042.00 90 22325 $1,407.00 9021356 $372.00 10 21620 $689.00 90 22326 $1,710.00 9021360 $590.00 90 21627 $686.00 90 22327 $1,660.00 9021365 $1,239.00 90 21630 $1,455.00 90 22328 $391.00 ZZZ21366 $1,386.00 90 21632 $1,514.00 90 22505 $174.00 1021385 $810.00 90 21685 $918.00 90 22520 $509.00 1021386 $812.00 90 21700 $576.00 90 22521 $477.00 1021387 $958.00 90 21705 $746.00 90 22522 $231.00 ZZZ21390 $920.00 90 21720 $523.00 90 22523 $617.00 1021395 $1,384.00 90 21725 $588.00 90 22524 $592.00 1021400 $143.00 90 21740 $1,387.00 90 22525 $283.00 ZZZ21401 $313.00 90 21742 BR 90 22526 $2,013.00 1021406 $852.00 90 21743 BR 90 22527 $1,637.00 ZZZ21407 $736.00 90 21750 $1,009.00 90 22532 $1,618.00 9021408 $1,007.00 90 21800 $84.00 90 22533 $1,509.00 9021421 $528.00 90 21805 $236.00 90 22534 $381.00 ZZZ21422 $761.00 90 21810 $540.00 90 22548 $2,271.00 9021423 $890.00 90 21820 $143.00 90 22554 $1,727.00 9021431 $598.00 90 21825 $810.00 90 22556 $2,054.00 9021432 $744.00 90 21899 BR YYY 22558 $1,907.00 9021433 $1,981.00 90 21920 $165.00 10 22585 $473.00 ZZZ21435 $1,404.00 90 21925 $371.00 90 22590 $1,895.00 9021436 $2,045.00 90 21930 $403.00 90 22595 $1,960.00 9021440 $308.00 90 21935 $1,280.00 90 22600 $1,567.00 9021445 $533.00 90 22010 $822.00 90 22610 $1,494.00 9021450 $325.00 90 22015 $815.00 90 22612 $1,861.00 9021451 $498.00 90 22100 $850.00 90 22614 $530.00 ZZZ21452 $195.00 90 22101 $862.00 90 22630 $1,201.00 9021453 $902.00 90 22102 $781.00 90 22632 $442.00 ZZZ21454 $905.00 90 22103 $198.00 ZZZ 22800 $1,960.00 9021461 $769.00 90 22110 $889.00 90 22802 $2,633.00 9021462 $1,012.00 90 22112 $1,090.00 90 22804 $2,951.00 9021465 $923.00 90 22114 $1,062.00 90 22808 $2,157.00 9021470 $1,331.00 90 22116 $195.00 ZZZ 22810 $2,356.00 9021480 $82.00 0 22206 $2,153.00 90 22812 $2,675.00 9021485 $318.00 90 22207 $2,126.00 90 22818 $2,701.00 9021490 $865.00 90 22208 $545.00 ZZZ 22819 $2,968.00 9021495 $500.00 90 22210 $1,892.00 90 22830 $1,176.00 9021497 $372.00 90 22212 $1,668.00 90 22840 $943.00 ZZZ21499 BR YYY 22214 $819.00 90 22841 BR 021501 $315.00 90 22216 $492.00 ZZZ 22842 $2,352.00 ZZZ21502 $612.00 90 22220 $1,801.00 90 22843 $1,028.00 ZZZ21510 $534.00 90 22222 $1,604.00 90 22844 $1,277.00 ZZZ21550 $165.00 10 22224 $1,731.00 90 22845 $1,853.00 ZZZ21555 $337.00 90 22226 $488.00 ZZZ 22846 $999.00 ZZZ21556 $431.00 90 22305 $213.00 90 22847 $1,077.00 ZZZ21557 $794.00 90 22310 $272.00 90 22848 $529.00 ZZZ21600 $631.00 90 22315 $711.00 90 22849 $2,235.00 9021610 $828.00 90 22318 $1,755.00 90 22850 $872.00 90

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 49

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD22851 $600.00 ZZZ 23332 $1,029.00 90 23670 $759.00 9022852 $854.00 90 23350 $74.00 0 23675 $550.00 9022855 $1,193.00 90 23395 $1,366.00 90 23680 $1,064.00 9022857 $1,386.00 90 23397 $1,403.00 90 23700 $237.00 1022862 $1,690.00 90 23400 $1,196.00 90 23800 $1,346.00 9022865 $1,646.00 90 23405 $799.00 90 23802 $1,368.00 9022899 BR YYY 23406 $977.00 90 23900 $1,561.00 9022900 $446.00 90 23410 $1,119.00 90 23920 $1,300.00 9022999 BR YYY 23412 $1,229.00 90 23921 $497.00 9023000 $447.00 90 23415 $622.00 90 23929 BR YYY23020 $807.00 90 23420 $1,276.00 90 23930 $71.00 1023030 $323.00 10 23430 $884.00 90 23931 $62.00 1023031 $185.00 10 23440 $906.00 90 23935 $630.00 9023035 $861.00 90 23450 $1,210.00 90 24000 $550.00 9023040 $898.00 90 23455 $1,340.00 90 24006 $793.00 9023044 $708.00 90 23460 $1,364.00 90 24065 $166.00 1023065 $171.00 10 23462 $1,383.00 90 24066 $461.00 9023066 $302.00 90 23465 $1,398.00 90 24075 $349.00 9023075 $247.00 10 23466 $1,332.00 90 24076 $529.00 9023076 $613.00 90 23470 $1,540.00 90 24077 $1,058.00 9023077 $1,228.00 90 23472 $1,570.00 90 24100 $467.00 9023100 $616.00 90 23480 $926.00 90 24101 $591.00 9023101 $583.00 90 23485 $1,181.00 90 24102 $755.00 9023105 $814.00 90 23490 $1,038.00 90 24105 $360.00 9023106 $581.00 90 23491 $1,251.00 90 24110 $724.00 9023107 $851.00 90 23500 $148.00 90 24115 $898.00 9023120 $645.00 90 23505 $293.00 90 24116 $1,037.00 9023125 $865.00 90 23515 $688.00 90 24120 $595.00 9023130 $722.00 90 23520 $205.00 90 24125 $663.00 9023140 $597.00 90 23525 $320.00 90 24126 $731.00 9023145 $889.00 90 23530 $659.00 90 24130 $595.00 9023146 $704.00 90 23532 $713.00 90 24134 $966.00 9023150 $755.00 90 23540 $148.00 90 24136 $720.00 9023155 $945.00 90 23545 $148.00 90 24138 $697.00 9023156 $794.00 90 23550 $701.00 90 24140 $963.00 9023170 $645.00 90 23552 $753.00 90 24145 $592.00 9023172 $638.00 90 23570 $88.00 90 24147 $703.00 9023174 $882.00 90 23575 $306.00 90 24149 $1,224.00 9023180 $566.00 90 23585 $809.00 90 24150 $1,265.00 9023182 $865.00 90 23600 $318.00 90 24151 $1,383.00 9023184 $962.00 90 23605 $511.00 90 24152 $829.00 9023190 $656.00 90 23615 $900.00 90 24153 $936.00 9023195 $902.00 90 23616 $1,895.00 90 24155 $1,019.00 9023200 $1,095.00 90 23620 $286.00 90 24160 $533.00 9023210 $1,095.00 90 23625 $422.00 90 24164 $564.00 9023220 $1,307.00 90 23630 $712.00 90 24200 $58.00 1023221 $1,559.00 90 23650 $296.00 90 24201 $444.00 9023222 $1,921.00 90 23655 $374.00 90 24220 $89.00 023330 $59.00 10 23660 $712.00 90 24300 $352.00 9023331 $520.00 90 23665 $440.00 90 24301 $869.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD24305 $579.00 90 24605 $371.00 90 25125 $803.00 9024310 $511.00 90 24615 $836.00 90 25126 $781.00 9024320 $944.00 90 24620 $560.00 90 25130 $502.00 9024330 $845.00 90 24635 $1,329.00 90 25135 $631.00 9024331 $927.00 90 24650 $262.00 90 25136 $546.00 9024332 $487.00 90 24655 $436.00 90 25145 $713.00 9024340 $697.00 90 24665 $749.00 90 25150 $720.00 9024341 $702.00 90 24666 $905.00 90 25151 $771.00 9024342 $950.00 90 24670 $263.00 90 25170 $1,085.00 9024343 $643.00 90 24675 $490.00 90 25210 $561.00 9024344 $971.00 90 24685 $819.00 90 25215 $817.00 9024345 $643.00 90 24800 $984.00 90 25230 $531.00 9024346 $971.00 90 24802 $1,181.00 90 25240 $567.00 9024357 $408.00 90 24900 $858.00 90 25246 $72.00 024358 $478.00 90 24920 $851.00 90 25248 $236.00 9024359 $587.00 90 24925 $661.00 90 25250 $616.00 9024360 $1,125.00 90 24930 $928.00 90 25251 $933.00 9024361 $1,215.00 90 24931 $1,063.00 90 25259 $348.00 9024362 $1,269.00 90 24935 $1,327.00 90 25260 $728.00 9024363 $1,663.00 90 24940 BR 90 25263 $809.00 9024365 $747.00 90 24999 BR YYY 25265 $998.00 9024366 $850.00 90 25000 $381.00 90 25270 $549.00 9024400 $991.00 90 25001 $294.00 90 25272 $613.00 9024410 $1,319.00 90 25020 $594.00 90 25274 $887.00 9024420 $1,265.00 90 25023 $1,040.00 90 25275 $620.00 9024430 $1,209.00 90 25024 $683.00 90 25280 $670.00 9024435 $1,260.00 90 25025 $1,104.00 90 25290 $436.00 9024470 $774.00 90 25028 $417.00 90 25295 $562.00 9024495 $742.00 90 25031 $266.00 90 25300 $592.00 9024498 $1,076.00 90 25035 $794.00 90 25301 $757.00 9024500 $288.00 90 25040 $654.00 90 25310 $865.00 9024505 $574.00 90 25065 $164.00 10 25312 $968.00 9024515 $1,018.00 90 25066 $322.00 90 25315 $1,004.00 9024516 $1,029.00 90 25075 $352.00 90 25316 $1,203.00 9024530 $88.00 90 25076 $544.00 90 25320 $834.00 9024535 $671.00 90 25077 $957.00 90 25332 $1,022.00 9024538 $850.00 90 25085 $562.00 90 25335 $1,166.00 9024545 $946.00 90 25100 $420.00 90 25337 $946.00 9024546 $1,273.00 90 25101 $492.00 90 25350 $913.00 9024560 $266.00 90 25105 $635.00 90 25355 $1,014.00 9024565 $526.00 90 25107 $600.00 90 25360 $468.00 9024566 $705.00 90 25109 $470.00 90 25365 $1,216.00 9024575 $872.00 90 25110 $403.00 90 25370 $1,214.00 9024576 $295.00 90 25111 $356.00 90 25375 $1,280.00 9024577 $575.00 90 25112 $441.00 90 25390 $1,043.00 9024579 $964.00 90 25115 $837.00 90 25391 $1,349.00 9024582 $773.00 90 25116 $807.00 90 25392 $1,294.00 9024586 $1,314.00 90 25118 $466.00 90 25393 $1,473.00 9024587 $1,278.00 90 25119 $653.00 90 25394 $723.00 9024600 $360.00 90 25120 $712.00 90 25400 $1,112.00 90

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 51

Page 52: FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER REIMBURSEMENT MANUAL 2008 Edition · 2009-03-27 · Florida Workers’ Compensation Health Care Provider Reimbursement Manual,

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD25405 $1,388.00 90 25670 $731.00 90 26130 $629.00 9025415 $1,343.00 90 25671 $462.00 90 26135 $668.00 9025420 $1,554.00 90 25675 $404.00 90 26140 $678.00 9025425 $1,403.00 90 25676 $741.00 90 26145 $660.00 9025426 $1,401.00 90 25680 $471.00 90 26160 $319.00 9025430 $638.00 90 25685 $887.00 90 26170 $452.00 9025431 $631.00 90 25690 $518.00 90 26180 $444.00 9025440 $931.00 90 25695 $520.00 90 26185 $511.00 9025441 $1,147.00 90 25800 $703.00 90 26200 $598.00 9025442 $936.00 90 25805 $1,078.00 90 26205 $788.00 9025443 $970.00 90 25810 $1,008.00 90 26210 $543.00 9025444 $1,031.00 90 25820 $2,276.00 90 26215 $731.00 9025445 $959.00 90 25825 $895.00 90 26230 $624.00 9025446 $1,542.00 90 25830 $991.00 90 26235 $612.00 9025447 $952.00 90 25900 $871.00 90 26236 $444.00 9025449 $395.00 90 25905 $900.00 90 26250 $814.00 9025450 $805.00 90 25907 $799.00 90 26255 $1,184.00 9025455 $899.00 90 25909 $849.00 90 26260 $758.00 9025490 $955.00 90 25915 $1,523.00 90 26261 $949.00 9025491 $1,006.00 90 25920 $771.00 90 26262 $624.00 9025492 $1,170.00 90 25922 $670.00 90 26320 $414.00 9025500 $200.00 90 25924 $768.00 90 26340 $266.00 9025505 $517.00 90 25927 $830.00 90 26350 $715.00 9025515 $800.00 90 25929 $645.00 90 26352 $855.00 9025520 $644.00 90 25931 $731.00 90 26356 $886.00 9025525 $1,097.00 90 25999 BR YYY 26357 $932.00 9025526 $1,293.00 90 26010 $59.00 10 26358 $979.00 9025530 $270.00 90 26011 $223.00 10 26370 $832.00 9025535 $516.00 90 26020 $484.00 90 26372 $945.00 9025545 $803.00 90 26025 $548.00 90 26373 $904.00 9025560 $276.00 90 26030 $655.00 90 26390 $889.00 9025565 $590.00 90 26034 $601.00 90 26392 $1,123.00 9025574 $804.00 90 26035 $741.00 90 26410 $371.00 9025575 $974.00 90 26037 $730.00 90 26412 $737.00 9025600 $312.00 90 26040 $367.00 90 26415 $846.00 9025605 $540.00 90 26045 $621.00 90 26416 $1,093.00 9025606 $643.00 90 26055 $343.00 90 26418 $444.00 9025607 $645.00 90 26060 $293.00 90 26420 $741.00 9025608 $739.00 90 26070 $440.00 90 26426 $733.00 9025609 $942.00 90 26075 $400.00 90 26428 $790.00 9025622 $148.00 90 26080 $382.00 90 26432 $430.00 9025624 $482.00 90 26100 $398.00 90 26433 $371.00 9025628 $716.00 90 26105 $481.00 90 26434 $656.00 9025630 $148.00 90 26110 $282.00 90 26437 $491.00 9025635 $458.00 90 26115 $344.00 90 26440 $458.00 9025645 $668.00 90 26116 $544.00 90 26442 $548.00 9025650 $185.00 90 26117 $806.00 90 26445 $455.00 9025651 $379.00 90 26121 $833.00 90 26449 $738.00 9025652 $560.00 90 26123 $959.00 90 26450 $353.00 9025660 $378.00 90 26125 $342.00 ZZZ 26455 $364.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD26460 $346.00 90 26587 $792.00 90 26951 $444.00 9026471 $592.00 90 26590 $1,609.00 90 26952 $608.00 9026474 $586.00 90 26591 $431.00 90 26989 BR YYY26476 $543.00 90 26593 $587.00 90 26990 $592.00 9026477 $553.00 90 26596 $809.00 90 26991 $466.00 9026478 $608.00 90 26600 $133.00 90 26992 $1,146.00 9026479 $653.00 90 26605 $296.00 90 27000 $421.00 9026480 $808.00 90 26607 $334.00 90 27001 $550.00 9026483 $986.00 90 26608 $497.00 90 27003 $698.00 9026485 $891.00 90 26615 $521.00 90 27005 $738.00 9026489 $738.00 90 26641 $71.00 90 27006 $788.00 9026490 $496.00 90 26645 $371.00 90 27025 $896.00 9026492 $971.00 90 26650 $533.00 90 27030 $1,148.00 9026494 $946.00 90 26665 $693.00 90 27033 $1,173.00 9026496 $949.00 90 26670 $148.00 90 27035 $1,413.00 9026497 $946.00 90 26675 $501.00 90 27036 $1,176.00 9026498 $1,317.00 90 26676 $527.00 90 27040 $196.00 1026499 $934.00 90 26685 $592.00 90 27041 $699.00 9026500 $557.00 90 26686 $710.00 90 27047 $535.00 9026502 $715.00 90 26700 $88.00 90 27048 $588.00 9026508 $334.00 90 26705 $296.00 90 27049 $1,162.00 9026510 $564.00 90 26706 $469.00 90 27050 $449.00 9026516 $630.00 90 26715 $526.00 90 27052 $624.00 9026517 $890.00 90 26720 $96.00 90 27054 $843.00 9026518 $877.00 90 26725 $187.00 90 27060 $491.00 9026520 $583.00 90 26727 $187.00 90 27062 $499.00 9026525 $531.00 90 26735 $532.00 90 27065 $583.00 9026530 $708.00 90 26740 $148.00 90 27066 $931.00 9026531 $877.00 90 26742 $148.00 90 27067 $1,234.00 9026535 $546.00 90 26746 $548.00 90 27070 $1,040.00 9026536 $770.00 90 26750 $96.00 90 27071 $1,112.00 9026540 $726.00 90 26755 $133.00 90 27075 $1,485.00 9026541 $926.00 90 26756 $366.00 90 27076 $1,859.00 9026542 $716.00 90 26765 $398.00 90 27077 $1,976.00 9026545 $722.00 90 26770 $79.00 90 27078 $1,164.00 9026546 $918.00 90 26775 $275.00 90 27079 $1,170.00 9026548 $665.00 90 26776 $401.00 90 27080 $568.00 9026550 $1,861.00 90 26785 $408.00 90 27086 $57.00 1026551 $3,901.00 90 26820 $854.00 90 27087 $555.00 9026553 $3,868.00 90 26841 $756.00 90 27090 $981.00 9026554 $4,551.00 90 26842 $901.00 90 27091 $1,482.00 9026555 $1,567.00 90 26843 $800.00 90 27093 $62.00 026556 $4,005.00 90 26844 $875.00 90 27095 $121.00 026560 $576.00 90 26850 $704.00 90 27096 $491.00 026561 $1,067.00 90 26852 $829.00 90 27097 $795.00 9026562 $1,017.00 90 26860 $542.00 90 27098 $799.00 9026565 $730.00 90 26861 $151.00 ZZZ 27100 $987.00 9026567 $622.00 90 26862 $747.00 90 27105 $946.00 9026568 $1,003.00 90 26863 $317.00 ZZZ 27110 $1,174.00 9026580 $1,585.00 90 26910 $747.00 90 27111 $1,099.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD27120 $1,603.00 90 27253 $1,162.00 90 27380 $698.00 9027122 $1,406.00 90 27254 $1,478.00 90 27381 $1,118.00 9027125 $1,371.00 90 27256 $338.00 10 27385 $753.00 9027130 $1,853.00 90 27257 $455.00 10 27386 $1,064.00 9027132 $2,128.00 90 27258 $1,355.00 90 27390 $506.00 9027134 $2,576.00 90 27259 $1,803.00 90 27391 $647.00 9027137 $2,190.00 90 27265 $442.00 90 27392 $834.00 9027138 $2,025.00 90 27266 $614.00 90 27393 $608.00 9027140 $1,092.00 90 27267 $382.00 90 27394 $748.00 9027146 $1,432.00 90 27268 $470.00 90 27395 $1,093.00 9027147 $1,744.00 90 27269 $1,117.00 90 27396 $742.00 9027151 $1,732.00 90 27275 $220.00 10 27397 $989.00 9027156 $2,017.00 90 27280 $1,179.00 90 27400 $832.00 9027158 $1,588.00 90 27282 $990.00 90 27403 $792.00 9027161 $1,443.00 90 27284 $1,435.00 90 27405 $842.00 9027165 $1,572.00 90 27286 $1,503.00 90 27407 $918.00 9027170 $1,453.00 90 27290 $2,073.00 90 27409 $1,212.00 9027175 $491.00 90 27295 $1,594.00 90 27412 $1,605.00 9027176 $1,024.00 90 27299 BR YYY 27415 $1,340.00 9027177 $1,257.00 90 27301 $193.00 90 27416 $878.00 9027178 $1,020.00 90 27303 $520.00 90 27418 $1,596.00 9027179 $1,107.00 90 27305 $555.00 90 27420 $927.00 9027181 $1,206.00 90 27306 $377.00 90 27422 $930.00 9027185 $676.00 90 27307 $503.00 90 27424 $927.00 9027187 $1,280.00 90 27310 $877.00 90 27425 $639.00 9027193 $425.00 90 27323 $211.00 10 27427 $1,118.00 9027194 $740.00 90 27324 $433.00 90 27428 $1,266.00 9027200 $180.00 90 27325 $476.00 90 27429 $2,333.00 9027202 $776.00 90 27326 $451.00 90 27430 $884.00 9027215 $954.00 90 27327 $400.00 90 27435 $501.00 9027216 $1,085.00 90 27328 $503.00 90 27437 $819.00 9027217 $1,285.00 90 27329 $1,249.00 90 27438 $1,065.00 9027218 $1,570.00 90 27330 $492.00 90 27440 $1,064.00 9027220 $444.00 90 27331 $585.00 90 27441 $1,006.00 9027222 $973.00 90 27332 $786.00 90 27442 $1,117.00 9027226 $1,350.00 90 27333 $719.00 90 27443 $1,037.00 9027227 $1,967.00 90 27334 $840.00 90 27445 $1,618.00 9027228 $2,195.00 90 27335 $959.00 90 27446 $1,764.00 9027230 $491.00 90 27340 $405.00 90 27447 $1,960.00 9027232 $916.00 90 27345 $565.00 90 27448 $1,060.00 9027235 $1,128.00 90 27347 $394.00 90 27450 $1,311.00 9027236 $1,421.00 90 27350 $786.00 90 27454 $1,524.00 9027238 $504.00 90 27355 $763.00 90 27455 $1,157.00 9027240 $1,043.00 90 27356 $882.00 90 27457 $1,209.00 9027244 $1,426.00 90 27357 $950.00 90 27465 $1,253.00 9027245 $1,691.00 90 27358 $394.00 ZZZ 27466 $1,441.00 9027246 $459.00 90 27360 $977.00 90 27468 $1,613.00 9027248 $980.00 90 27365 $1,421.00 90 27470 $1,501.00 9027250 $535.00 90 27370 $75.00 0 27472 $1,665.00 9027252 $520.00 90 27372 $371.00 90 27475 $782.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD27477 $938.00 90 27599 BR YYY 27700 $835.00 9027479 $1,123.00 90 27600 $517.00 90 27702 $1,278.00 9027485 $797.00 90 27601 $516.00 90 27703 $1,337.00 9027486 $1,771.00 90 27602 $621.00 90 27704 $683.00 9027487 $2,352.00 90 27603 $412.00 90 27705 $985.00 9027488 $1,438.00 90 27604 $308.00 90 27707 $484.00 9027495 $1,477.00 90 27605 $236.00 10 27709 $1,118.00 9027496 $563.00 90 27606 $362.00 10 27712 $1,227.00 9027497 $652.00 90 27607 $608.00 90 27715 $1,285.00 9027498 $701.00 90 27610 $777.00 90 27720 $1,147.00 9027499 $782.00 90 27612 $701.00 90 27722 $1,076.00 9027500 $520.00 90 27613 $165.00 10 27724 $1,402.00 9027501 $659.00 90 27614 $327.00 90 27725 $1,312.00 9027502 $909.00 90 27615 $1,106.00 90 27726 $823.00 9027503 $911.00 90 27618 $421.00 90 27727 $1,175.00 9027506 $1,522.00 90 27619 $730.00 90 27730 $647.00 9027507 $1,297.00 90 27620 $587.00 90 27732 $611.00 9027508 $400.00 90 27625 $796.00 90 27734 $766.00 9027509 $649.00 90 27626 $863.00 90 27740 $1,044.00 9027510 $755.00 90 27630 $430.00 90 27742 $1,045.00 9027511 $1,281.00 90 27635 $781.00 90 27745 $940.00 9027513 $1,562.00 90 27637 $921.00 90 27750 $319.00 9027514 $1,508.00 90 27638 $978.00 90 27752 $614.00 9027516 $579.00 90 27640 $1,122.00 90 27756 $708.00 9027517 $820.00 90 27641 $922.00 90 27758 $1,115.00 9027519 $1,311.00 90 27645 $1,302.00 90 27759 $1,262.00 9027520 $266.00 90 27646 $1,212.00 90 27760 $223.00 9027524 $910.00 90 27647 $1,044.00 90 27762 $495.00 9027530 $408.00 90 27648 $72.00 0 27766 $759.00 9027532 $641.00 90 27650 $869.00 90 27767 $233.00 9027535 $1,075.00 90 27652 $935.00 90 27768 $361.00 9027536 $1,282.00 90 27654 $937.00 90 27769 $622.00 9027538 $487.00 90 27656 $458.00 90 27780 $244.00 9027540 $1,106.00 90 27658 $527.00 90 27781 $296.00 9027550 $296.00 90 27659 $725.00 90 27784 $643.00 9027552 $619.00 90 27664 $504.00 90 27786 $223.00 9027556 $832.00 90 27665 $618.00 90 27788 $422.00 9027557 $1,479.00 90 27675 $656.00 90 27792 $706.00 9027558 $1,529.00 90 27676 $762.00 90 27808 $332.00 9027560 $88.00 90 27680 $523.00 90 27810 $567.00 9027562 $514.00 90 27681 $634.00 90 27814 $972.00 9027566 $1,047.00 90 27685 $565.00 90 27816 $386.00 9027570 $184.00 10 27686 $706.00 90 27818 $613.00 9027580 $1,644.00 90 27687 $589.00 90 27822 $1,201.00 9027590 $1,059.00 90 27690 $757.00 90 27823 $1,472.00 9027591 $1,182.00 90 27691 $889.00 90 27824 $384.00 9027592 $911.00 90 27692 $159.00 ZZZ 27825 $670.00 9027594 $600.00 90 27695 $658.00 90 27826 $1,080.00 9027596 $931.00 90 27696 $758.00 90 27827 $1,310.00 9027598 $976.00 90 27698 $881.00 90 27828 $1,823.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD27829 $742.00 90 28102 $700.00 90 28285 $463.00 9027830 $412.00 90 28103 $709.00 90 28286 $441.00 9027831 $415.00 90 28104 $491.00 90 28288 $452.00 9027832 $617.00 90 28106 $632.00 90 28289 $458.00 9027840 $334.00 90 28107 $517.00 90 28290 $557.00 9027842 $373.00 90 28108 $418.00 90 28292 $666.00 9027846 $877.00 90 28110 $421.00 90 28293 $845.00 9027848 $1,224.00 90 28111 $537.00 90 28294 $797.00 9027860 $211.00 10 28112 $457.00 90 28296 $832.00 9027870 $1,269.00 90 28113 $481.00 90 28297 $838.00 9027871 $843.00 90 28114 $890.00 90 28298 $755.00 9027880 $1,015.00 90 28116 $648.00 90 28299 $829.00 9027881 $1,120.00 90 28118 $568.00 90 28300 $845.00 9027882 $854.00 90 28119 $524.00 90 28302 $930.00 9027884 $579.00 90 28120 $601.00 90 28304 $776.00 9027886 $835.00 90 28122 $622.00 90 28305 $1,030.00 9027888 $911.00 90 28124 $480.00 90 28306 $530.00 9027889 $879.00 90 28126 $393.00 90 28307 $614.00 9027892 $575.00 90 28130 $727.00 90 28308 $516.00 9027893 $574.00 90 28140 $533.00 90 28309 $955.00 9027894 $712.00 90 28150 $416.00 90 28310 $505.00 9027899 BR YYY 28153 $400.00 90 28312 $469.00 9028001 $185.00 10 28160 $412.00 90 28313 $436.00 9028002 $362.00 10 28171 $789.00 90 28315 $462.00 9028003 $520.00 90 28173 $747.00 90 28320 $833.00 9028005 $520.00 90 28175 $571.00 90 28322 $667.00 9028008 $296.00 90 28190 $75.00 10 28340 $649.00 9028010 $235.00 90 28192 $326.00 90 28341 $753.00 9028011 $340.00 90 28193 $341.00 90 28344 $414.00 9028020 $509.00 90 28200 $478.00 90 28345 $557.00 9028022 $422.00 90 28202 $613.00 90 28360 $1,197.00 9028024 $371.00 90 28208 $406.00 90 28400 $266.00 9028035 $532.00 90 28210 $609.00 90 28405 $473.00 9028043 $305.00 90 28220 $435.00 90 28406 $616.00 9028045 $456.00 90 28222 $555.00 90 28415 $1,354.00 9028046 $814.00 90 28225 $345.00 90 28420 $1,619.00 9028050 $414.00 90 28226 $334.00 90 28430 $110.00 9028052 $402.00 90 28230 $380.00 90 28435 $371.00 9028054 $236.00 90 28232 $286.00 90 28436 $463.00 9028055 $377.00 90 28234 $178.00 90 28445 $874.00 9028060 $495.00 90 28238 $695.00 90 28446 $1,075.00 9028062 $657.00 90 28240 $370.00 90 28450 $148.00 9028070 $476.00 90 28250 $535.00 90 28455 $321.00 9028072 $445.00 90 28260 $641.00 90 28456 $288.00 9028080 $392.00 90 28261 $881.00 90 28465 $533.00 9028086 $462.00 90 28262 $1,363.00 90 28470 $178.00 9028088 $414.00 90 28264 $912.00 90 28475 $296.00 9028090 $414.00 90 28270 $266.00 90 28476 $364.00 9028092 $330.00 90 28272 $336.00 90 28485 $521.00 9028100 $571.00 90 28280 $426.00 90 28490 $80.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD28495 $133.00 90 29035 $213.00 0 29800 $557.00 9028496 $261.00 90 29040 $260.00 0 29804 $902.00 9028505 $399.00 90 29044 $260.00 0 29805 $360.00 9028510 $75.00 90 29046 $286.00 0 29806 $1,003.00 9028515 $115.00 90 29049 $45.00 0 29807 $976.00 9028525 $345.00 90 29055 $180.00 0 29819 $756.00 9028530 $120.00 90 29058 $110.00 0 29820 $718.00 9028531 $243.00 90 29065 $88.00 0 29821 $863.00 9028540 $145.00 90 29075 $72.00 0 29822 $749.00 9028545 $208.00 90 29085 $59.00 0 29823 $1,330.00 9028546 $325.00 90 29086 $54.00 0 29824 $611.00 9028555 $592.00 90 29105 $59.00 0 29825 $941.00 9028570 $189.00 90 29125 $45.00 0 29826 $980.00 9028575 $308.00 90 29126 $53.00 0 29827 $1,058.00 9028576 $382.00 90 29130 $26.00 0 29828 $830.00 9028585 $742.00 90 29131 $53.00 0 29830 $524.00 9028600 $144.00 90 29200 $29.00 0 29834 $635.00 9028605 $287.00 90 29220 $37.00 0 29835 $612.00 9028606 $487.00 90 29240 $45.00 0 29836 $680.00 9028615 $621.00 90 29260 $26.00 0 29837 $830.00 9028630 $145.00 10 29280 $29.00 0 29838 $931.00 9028635 $189.00 10 29305 $223.00 0 29840 $501.00 9028636 $318.00 10 29325 $260.00 0 29843 $580.00 9028645 $434.00 90 29345 $126.00 0 29844 $612.00 9028660 $106.00 10 29355 $133.00 0 29845 $931.00 9028665 $172.00 10 29358 $241.00 0 29846 $976.00 9028666 $309.00 10 29365 $101.00 0 29847 $1,277.00 9028675 $348.00 90 29405 $96.00 0 29848 $608.00 9028705 $1,353.00 90 29425 $101.00 0 29850 $752.00 9028715 $1,179.00 90 29435 $133.00 0 29851 $1,137.00 9028725 $1,015.00 90 29440 $22.00 0 29855 $1,007.00 9028730 $945.00 90 29445 $214.00 0 29856 $1,231.00 9028735 $961.00 90 29450 $84.00 0 29860 $658.00 9028737 $873.00 90 29505 $75.00 0 29861 $845.00 9028740 $690.00 90 29515 $59.00 0 29862 $907.00 9028750 $690.00 90 29520 $22.00 0 29863 $880.00 9028755 $466.00 90 29530 $55.00 0 29866 $1,046.00 9028760 $654.00 90 29540 $41.00 0 29867 $1,250.00 9028800 $731.00 90 29550 $37.00 0 29868 $1,694.00 9028805 $731.00 90 29580 $39.00 0 29870 $460.00 9028810 $543.00 90 29590 $32.00 0 29871 $631.00 9028820 $377.00 90 29700 $29.00 0 29873 $489.00 9028825 $339.00 90 29705 $26.00 0 29874 $676.00 9028890 $358.00 90 29710 $29.00 0 29875 $639.00 9028899 BR YYY 29715 $109.00 0 29876 $809.00 9029000 $247.00 0 29720 $29.00 0 29877 $852.00 9029010 $271.00 0 29730 $29.00 0 29879 $1,064.00 9029015 $289.00 0 29740 $37.00 0 29880 $1,169.00 9029020 $237.00 0 29750 $105.00 0 29881 $745.00 9029025 $188.00 0 29799 BR YYY 29882 $819.00 90

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 57

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD29883 $1,235.00 90 30462 $1,633.00 90 31255 $601.00 029884 $721.00 90 30465 $803.00 90 31256 $292.00 029885 $832.00 90 30520 $533.00 90 31267 $453.00 029886 $697.00 90 30540 $643.00 90 31276 $690.00 029887 $949.00 90 30545 $981.00 90 31287 $339.00 029888 $1,296.00 90 30560 $104.00 10 31288 $396.00 029889 $1,255.00 90 30580 $566.00 90 31290 $1,462.00 1029891 $796.00 90 30600 $466.00 90 31291 $1,551.00 1029892 $835.00 90 30620 $564.00 90 31292 $1,235.00 1029893 $472.00 90 30630 $624.00 90 31293 $1,346.00 1029894 $690.00 90 30801 $88.00 10 31294 $1,587.00 1029895 $679.00 90 30802 $172.00 10 31299 BR YYY29897 $704.00 90 30901 $75.00 0 31300 $1,295.00 9029898 $863.00 90 30903 $110.00 0 31320 $508.00 9029899 $973.00 90 30905 $224.00 0 31360 $1,630.00 9029900 $434.00 90 30906 $208.00 0 31365 $2,238.00 9029901 $479.00 90 30915 $596.00 90 31367 $1,913.00 9029902 $514.00 90 30920 $862.00 90 31368 $2,478.00 9029904 $557.00 90 30930 $213.00 10 31370 $1,891.00 9029905 $601.00 90 30999 BR YYY 31375 $1,720.00 9029906 $633.00 90 31000 $81.00 10 31380 $1,782.00 9029907 $775.00 90 31002 $135.00 10 31382 $1,822.00 9029999 BR YYY 31020 $281.00 90 31390 $2,513.00 9030000 $96.00 10 31030 $531.00 90 31395 $2,937.00 9030020 $117.00 10 31032 $604.00 90 31400 $969.00 9030100 $86.00 0 31040 $772.00 90 31420 $969.00 9030110 $157.00 10 31050 $489.00 90 31500 $116.00 030115 $360.00 90 31051 $654.00 90 31502 $74.00 030117 $301.00 90 31070 $410.00 90 31505 $62.00 030118 $819.00 90 31075 $839.00 90 31510 $145.00 030120 $500.00 90 31080 $942.00 90 31511 $88.00 030124 $243.00 90 31081 $1,089.00 90 31512 $197.00 030125 $599.00 90 31084 $1,210.00 90 31513 $182.00 030130 $275.00 90 31085 $1,281.00 90 31515 $160.00 030140 $320.00 90 31086 $1,081.00 90 31525 $234.00 030150 $790.00 90 31087 $1,075.00 90 31526 $222.00 030160 $875.00 90 31090 $877.00 90 31527 $262.00 030200 $68.00 0 31200 $463.00 90 31528 $202.00 030210 $75.00 10 31201 $716.00 90 31529 $217.00 030220 $154.00 10 31205 $851.00 90 31530 $284.00 030300 $45.00 10 31225 $1,683.00 90 31531 $311.00 030310 $170.00 10 31230 $1,908.00 90 31535 $272.00 030320 $419.00 90 31231 $122.00 0 31536 $308.00 030400 $741.00 90 31233 $221.00 0 31540 $357.00 030410 $1,173.00 90 31235 $217.00 0 31541 $453.00 030420 $1,424.00 90 31237 $266.00 0 31545 $384.00 030430 $626.00 90 31238 $311.00 0 31546 $587.00 030435 $1,005.00 90 31239 $775.00 10 31560 $446.00 030450 $1,445.00 90 31240 $224.00 0 31561 $509.00 030460 $857.00 90 31254 $588.00 0 31570 $369.00 0

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 58

Page 59: FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER REIMBURSEMENT MANUAL 2008 Edition · 2009-03-27 · Florida Workers’ Compensation Health Care Provider Reimbursement Manual,

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD31571 $363.00 0 31755 $1,448.00 90 32501 $374.00 ZZZ31575 $128.00 0 31760 $1,648.00 90 32503 $1,875.00 9031576 $186.00 0 31766 $2,315.00 90 32504 $2,145.00 9031577 $230.00 0 31770 $1,815.00 90 32540 $1,308.00 9031578 $264.00 0 31775 $1,973.00 90 32550 $821.00 031579 $219.00 0 31780 $1,577.00 90 32551 $171.00 031580 $1,213.00 90 31781 $1,936.00 90 32560 $302.00 031582 $1,881.00 90 31785 $1,320.00 90 32601 $456.00 031584 $1,616.00 90 31786 $1,866.00 90 32602 $494.00 031587 $913.00 90 31800 $628.00 90 32603 $585.00 031588 $1,206.00 90 31805 $1,175.00 90 32604 $663.00 031590 $691.00 90 31820 $458.00 90 32605 $550.00 031595 $773.00 90 31825 $659.00 90 32606 $637.00 031599 BR YYY 31830 $460.00 90 32650 $957.00 9031600 $306.00 0 31899 BR YYY 32651 $1,166.00 9031603 $343.00 0 32035 $821.00 90 32652 $1,615.00 9031605 $297.00 0 32036 $908.00 90 32653 $1,144.00 9031610 $794.00 90 32095 $848.00 90 32654 $1,096.00 9031611 $614.00 90 32100 $1,120.00 90 32655 $1,213.00 9031612 $99.00 0 32110 $1,223.00 90 32656 $1,222.00 9031613 $384.00 90 32120 $1,077.00 90 32657 $1,261.00 9031614 $736.00 90 32124 $1,144.00 90 32658 $1,142.00 9031615 $213.00 0 32140 $1,284.00 90 32659 $1,141.00 9031620 $271.00 ZZZ 32141 $1,267.00 90 32660 $1,691.00 9031622 $230.00 0 32150 $1,226.00 90 32661 $1,165.00 9031623 $225.00 0 32151 $1,231.00 90 32662 $1,459.00 9031624 $217.00 0 32160 $842.00 90 32663 $1,636.00 9031625 $235.00 0 32200 $1,132.00 90 32664 $1,197.00 9031628 $269.00 0 32201 $387.00 0 32665 $1,360.00 9031629 $198.00 0 32215 $1,024.00 90 32800 $1,166.00 9031630 $308.00 0 32220 $1,680.00 90 32810 $1,085.00 9031631 $252.00 0 32225 $1,268.00 90 32815 $1,917.00 9031632 $73.00 ZZZ 32310 $1,221.00 90 32820 $1,848.00 9031633 $90.00 ZZZ 32320 $1,787.00 90 32851 $3,100.00 9031635 $298.00 0 32400 $129.00 0 32852 $3,339.00 9031636 $241.00 0 32402 $798.00 90 32853 $3,787.00 9031637 $86.00 ZZZ 32405 $159.00 0 32854 $4,038.00 9031638 $268.00 0 32420 $116.00 0 32900 $1,532.00 9031640 $399.00 0 32421 $159.00 0 32905 $1,661.00 9031641 $304.00 0 32422 $194.00 0 32906 $2,100.00 9031643 $208.00 0 32440 $1,837.00 90 32940 $1,555.00 9031645 $208.00 0 32442 $2,093.00 90 32960 $126.00 031646 $161.00 0 32445 $2,093.00 90 32997 $312.00 031656 $127.00 0 32480 $1,622.00 90 32998 $2,809.00 031715 $57.00 0 32482 $1,714.00 90 32999 BR YYY31717 $138.00 0 32484 $1,771.00 90 33010 $124.00 031720 $89.00 0 32486 $1,974.00 90 33011 $125.00 031725 $103.00 0 32488 $2,094.00 90 33015 $555.00 9031730 $199.00 0 32491 $1,784.00 90 33020 $1,178.00 9031750 $1,088.00 90 32500 $1,331.00 90 33025 $1,165.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD33030 $1,786.00 90 33284 $365.00 90 33506 $2,448.00 9033031 $1,816.00 90 33300 $1,576.00 90 33507 $1,809.00 9033050 $1,224.00 90 33305 $1,889.00 90 33508 $17.00 ZZZ33120 $2,358.00 90 33310 $1,577.00 90 33510 $2,354.00 9033130 $1,734.00 90 33315 $1,875.00 90 33511 $2,546.00 9033140 $1,571.00 90 33320 $1,485.00 90 33512 $2,732.00 9033141 $254.00 ZZZ 33321 $1,890.00 90 33513 $2,933.00 9033202 $749.00 90 33322 $1,935.00 90 33514 $3,197.00 9033203 $766.00 90 33330 $1,726.00 90 33516 $3,404.00 9033206 $642.00 90 33332 $1,915.00 90 33517 $219.00 ZZZ33207 $753.00 90 33335 $2,336.00 90 33518 $414.00 ZZZ33208 $573.00 90 33400 $2,401.00 90 33519 $607.00 ZZZ33210 $204.00 0 33401 $2,228.00 90 33521 $801.00 ZZZ33211 $210.00 0 33403 $2,369.00 90 33522 $994.00 ZZZ33212 $511.00 90 33404 $2,698.00 90 33523 $1,189.00 ZZZ33213 $437.00 90 33405 $2,745.00 90 33530 $521.00 ZZZ33214 $532.00 90 33406 $2,962.00 90 33533 $2,415.00 9033215 $304.00 90 33410 $2,637.00 90 33534 $2,654.00 9033216 $402.00 90 33411 $2,981.00 90 33535 $2,899.00 9033217 $428.00 90 33412 $3,213.00 90 33536 $3,143.00 9033218 $488.00 90 33413 $3,282.00 90 33542 $2,693.00 9033220 $390.00 90 33414 $2,904.00 90 33545 $3,250.00 9033222 $471.00 90 33415 $2,563.00 90 33548 $2,381.00 9033223 $585.00 90 33416 $2,684.00 90 33572 $340.00 ZZZ33224 $490.00 0 33417 $2,756.00 90 33600 $2,644.00 9033225 $434.00 ZZZ 33420 $1,796.00 90 33602 $2,556.00 9033226 $472.00 0 33422 $2,431.00 90 33606 $2,831.00 9033233 $270.00 90 33425 $2,509.00 90 33608 $2,940.00 9033234 $598.00 90 33426 $2,806.00 90 33610 $2,871.00 9033235 $587.00 90 33427 $3,026.00 90 33611 $2,985.00 9033236 $933.00 90 33430 $2,891.00 90 33612 $3,152.00 9033237 $1,184.00 90 33460 $2,215.00 90 33615 $3,051.00 9033238 $1,235.00 90 33463 $2,396.00 90 33617 $3,272.00 9033240 $648.00 90 33464 $2,547.00 90 33619 $3,678.00 9033241 $301.00 90 33465 $2,665.00 90 33641 $1,981.00 9033243 $1,650.00 90 33468 $2,952.00 90 33645 $2,352.00 9033244 $1,081.00 90 33470 $1,749.00 90 33647 $2,732.00 9033249 $1,271.00 90 33471 $1,929.00 90 33660 $2,444.00 9033250 $1,687.00 90 33472 $2,001.00 90 33665 $2,700.00 9033251 $2,071.00 90 33474 $2,173.00 90 33670 $2,820.00 9033254 $1,307.00 90 33475 $2,666.00 90 33675 $2,085.00 9033255 $1,573.00 90 33476 $2,270.00 90 33676 $2,151.00 9033256 $1,879.00 90 33478 $2,544.00 90 33677 $2,236.00 9033257 $565.00 ZZZ 33496 $2,595.00 90 33681 $2,657.00 9033258 $639.00 ZZZ 33500 $2,370.00 90 33684 $2,740.00 9033259 $839.00 ZZZ 33501 $1,546.00 90 33688 $2,602.00 9033261 $1,993.00 90 33502 $1,938.00 90 33690 $1,884.00 9033265 $1,307.00 90 33503 $1,983.00 90 33692 $2,816.00 9033266 $1,789.00 90 33504 $2,416.00 90 33694 $2,856.00 9033282 $470.00 90 33505 $2,423.00 90 33697 $3,064.00 90

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 60

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD33702 $2,549.00 90 33880 $1,866.00 90 34800 $1,159.00 9033710 $2,731.00 90 33881 $1,603.00 90 34802 $1,279.00 9033720 $2,508.00 90 33883 $1,187.00 90 34803 $1,372.00 9033722 $2,704.00 90 33884 $441.00 ZZZ 34804 $1,279.00 9033724 $1,491.00 90 33886 $1,025.00 90 34805 $1,243.00 9033726 $1,963.00 90 33889 $882.00 0 34806 $100.00 ZZZ33730 $2,785.00 90 33891 $1,126.00 0 34808 $220.00 ZZZ33732 $2,622.00 90 33910 $1,987.00 90 34812 $359.00 033735 $2,036.00 90 33915 $1,588.00 90 34813 $256.00 ZZZ33736 $2,288.00 90 33916 $2,096.00 90 34820 $519.00 033737 $1,977.00 90 33917 $2,345.00 90 34825 $694.00 9033750 $1,877.00 90 33920 $2,981.00 90 34826 $220.00 ZZZ33755 $1,831.00 90 33922 $2,227.00 90 34830 $1,803.00 9033762 $1,900.00 90 33924 $421.00 ZZZ 34831 $1,950.00 9033764 $1,895.00 90 33925 $1,849.00 90 34832 $1,950.00 9033766 $2,119.00 90 33926 $2,499.00 90 34833 $650.00 033767 $2,173.00 90 33935 $5,415.00 90 34834 $306.00 033768 $449.00 ZZZ 33945 $3,813.00 90 34900 $960.00 9033770 $2,954.00 90 33960 $1,221.00 0 35001 $1,564.00 9033771 $2,924.00 90 33961 $800.00 ZZZ 35002 $1,547.00 9033774 $2,681.00 90 33967 $258.00 0 35005 $1,268.00 9033775 $2,654.00 90 33968 $51.00 0 35011 $1,007.00 9033776 $2,844.00 90 33970 $576.00 0 35013 $1,376.00 9033777 $2,724.00 90 33971 $578.00 90 35021 $1,635.00 9033778 $3,199.00 90 33973 $756.00 0 35022 $1,686.00 9033779 $3,121.00 90 33974 $1,095.00 90 35045 $995.00 9033780 $3,232.00 90 33975 $1,758.00 0 35081 $2,175.00 9033781 $3,057.00 90 33976 $2,056.00 0 35082 $2,661.00 9033786 $2,970.00 90 33977 $1,561.00 90 35091 $2,634.00 9033788 $2,288.00 90 33978 $1,754.00 90 35092 $2,872.00 9033800 $1,546.00 90 33979 $2,496.00 0 35102 $2,346.00 9033802 $1,752.00 90 33980 $3,212.00 90 35103 $2,587.00 9033803 $1,746.00 90 33999 BR YYY 35111 $1,398.00 9033813 $1,935.00 90 34001 $1,012.00 90 35112 $1,351.00 9033814 $2,464.00 90 34051 $1,134.00 90 35121 $2,000.00 9033820 $1,619.00 90 34101 $800.00 90 35122 $2,382.00 9033822 $1,559.00 90 34111 $669.00 90 35131 $1,495.00 9033824 $1,884.00 90 34151 $1,288.00 90 35132 $1,742.00 9033840 $2,029.00 90 34201 $777.00 90 35141 $1,231.00 9033845 $2,129.00 90 34203 $949.00 90 35142 $1,339.00 9033851 $2,129.00 90 34401 $953.00 90 35151 $1,390.00 9033852 $2,311.00 90 34421 $779.00 90 35152 $1,229.00 9033853 $3,057.00 90 34451 $1,117.00 90 35180 $997.00 9033860 $3,044.00 90 34471 $685.00 90 35182 $1,345.00 9033861 $3,069.00 90 34490 $660.00 90 35184 $976.00 9033863 $3,183.00 90 34501 $910.00 90 35188 $1,048.00 9033864 $3,035.00 90 34502 $2,044.00 90 35189 $1,380.00 9033870 $3,638.00 90 34510 $1,108.00 90 35190 $1,018.00 9033875 $2,876.00 90 34520 $1,077.00 90 35201 $852.00 9033877 $3,767.00 90 34530 $1,368.00 90 35206 $835.00 90

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 61

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD35207 $935.00 90 35481 $565.00 0 35606 $1,539.00 9035211 $1,833.00 90 35482 $577.00 0 35612 $1,349.00 9035216 $1,494.00 90 35483 $696.00 0 35616 $1,346.00 9035221 $1,243.00 90 35484 $853.00 0 35621 $1,265.00 9035226 $841.00 90 35485 $670.00 0 35623 $1,193.00 9035231 $1,053.00 90 35490 $691.00 0 35626 $1,921.00 9035236 $947.00 90 35491 $423.00 0 35631 $1,891.00 9035241 $1,926.00 90 35492 $423.00 0 35636 $1,656.00 9035246 $1,701.00 90 35493 $523.00 0 35637 $1,704.00 9035251 $1,260.00 90 35494 $605.00 0 35638 $1,731.00 9035256 $1,568.00 90 35495 $532.00 0 35642 $1,298.00 9035261 $1,008.00 90 35500 $423.00 ZZZ 35645 $1,304.00 9035266 $921.00 90 35501 $1,569.00 90 35646 $2,105.00 9035271 $1,814.00 90 35506 $1,641.00 90 35647 $1,555.00 9035276 $1,541.00 90 35508 $1,564.00 90 35650 $1,236.00 9035281 $1,396.00 90 35509 $1,529.00 90 35651 $2,055.00 9035286 $1,036.00 90 35510 $1,316.00 90 35654 $1,603.00 9035301 $1,486.00 90 35511 $1,256.00 90 35656 $1,589.00 9035302 $1,109.00 90 35512 $1,291.00 90 35661 $1,145.00 9035303 $1,218.00 90 35515 $1,387.00 90 35663 $1,237.00 9035304 $1,267.00 90 35516 $1,391.00 90 35665 $1,333.00 9035305 $1,218.00 90 35518 $1,313.00 90 35666 $1,686.00 9035306 $456.00 ZZZ 35521 $1,393.00 90 35671 $1,315.00 9035311 $1,999.00 90 35522 $1,253.00 90 35681 $751.00 ZZZ35321 $1,031.00 90 35523 $1,237.00 90 35682 $627.00 ZZZ35331 $1,724.00 90 35525 $1,197.00 90 35683 $702.00 ZZZ35341 $1,908.00 90 35526 $1,527.00 90 35685 $216.00 ZZZ35351 $1,555.00 90 35531 $2,000.00 90 35686 $178.00 ZZZ35355 $1,336.00 90 35533 $1,716.00 90 35691 $1,546.00 9035361 $1,859.00 90 35536 $1,888.00 90 35693 $1,140.00 9035363 $2,006.00 90 35537 $2,141.00 90 35694 $1,353.00 9035371 $1,006.00 90 35538 $2,391.00 90 35695 $1,351.00 9035372 $1,085.00 90 35539 $2,248.00 90 35697 $166.00 ZZZ35390 $225.00 ZZZ 35540 $2,505.00 90 35700 $264.00 ZZZ35400 $224.00 ZZZ 35548 $1,751.00 90 35701 $494.00 9035450 $643.00 0 35549 $1,902.00 90 35721 $500.00 9035452 $518.00 0 35551 $2,036.00 90 35741 $499.00 9035454 $520.00 0 35556 $1,745.00 90 35761 $532.00 9035456 $631.00 0 35558 $1,219.00 90 35800 $567.00 9035458 $804.00 0 35560 $1,899.00 90 35820 $951.00 9035459 $736.00 0 35563 $1,115.00 90 35840 $771.00 9035460 $430.00 0 35565 $1,312.00 90 35860 $496.00 9035470 $537.00 0 35566 $2,161.00 90 35870 $1,583.00 9035471 $626.00 0 35571 $1,612.00 90 35875 $827.00 9035472 $388.00 0 35572 $369.00 ZZZ 35876 $1,232.00 9035473 $375.00 0 35583 $1,843.00 90 35879 $1,163.00 9035474 $456.00 0 35585 $2,277.00 90 35881 $1,275.00 9035475 $569.00 0 35587 $1,698.00 90 35883 $1,247.00 9035476 $338.00 0 35600 $273.00 ZZZ 35884 $1,324.00 9035480 $935.00 0 35601 $1,495.00 90 35901 $709.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD35903 $818.00 90 36515 $92.00 0 36838 $1,230.00 9035905 $1,343.00 90 36516 $92.00 0 36860 $166.00 035907 $1,335.00 90 36522 $305.00 0 36861 $224.00 036000 $46.00 0 36556 $316.00 0 36870 $1,755.00 9036002 $181.00 0 36558 $703.00 10 37140 $1,666.00 9036005 $68.00 0 36561 $1,333.00 10 37145 $1,741.00 9036010 $136.00 0 36563 $1,679.00 10 37160 $1,681.00 9036011 $194.00 0 36565 $1,073.00 10 37180 $1,769.00 9036012 $186.00 0 36566 $1,121.00 10 37181 $1,923.00 9036013 $141.00 0 36569 $350.00 0 37182 $914.00 036014 $159.00 0 36571 $1,550.00 10 37183 $425.00 036015 $186.00 0 36575 $172.00 0 37184 $3,074.00 036100 $176.00 0 36576 $429.00 10 37185 $1,002.00 ZZZ36120 $120.00 0 36578 $546.00 10 37186 $2,076.00 ZZZ36140 $106.00 0 36580 $307.00 0 37187 $2,991.00 036145 $10.00 0 36581 $646.00 10 37188 $2,586.00 036160 $196.00 0 36582 $1,210.00 10 37195 $302.00 036200 $240.00 0 36583 $708.00 10 37200 $232.00 036215 $240.00 0 36584 $321.00 0 37201 $408.00 036216 $270.00 0 36585 $1,525.00 10 37202 $340.00 036217 $325.00 0 36589 $176.00 10 37203 $287.00 036218 $79.00 ZZZ 36590 $378.00 10 37204 $957.00 036245 $249.00 0 36591 $21.00 0 37205 $589.00 036246 $272.00 0 36592 $26.00 0 37206 $288.00 ZZZ36247 $323.00 0 36593 $37.00 0 37207 $613.00 036248 $53.00 ZZZ 36595 $880.00 0 37208 $299.00 ZZZ36260 $749.00 90 36596 $194.00 0 37209 $116.00 036261 $388.00 90 36597 $167.00 0 37210 $2,128.00 036262 $297.00 90 36598 $130.00 0 37215 $1,095.00 9036299 BR YYY 36600 $24.00 0 37216 $1,055.00 9036410 $18.00 0 36620 $64.00 0 37250 $112.00 ZZZ36415 BR 0 36625 $133.00 0 37251 $85.00 ZZZ36416 BR 0 36640 $130.00 0 37500 $739.00 9036425 $86.00 0 36680 $72.00 0 37501 BR YYY36430 $37.00 0 36800 $159.00 0 37565 $364.00 9036455 $141.00 0 36810 $345.00 0 37600 $414.00 9036468 BR 0 36815 $236.00 0 37605 $521.00 9036469 BR 0 36818 $736.00 90 37606 $563.00 9036470 $76.00 10 36819 $977.00 90 37607 $456.00 9036471 $96.00 10 36820 $800.00 90 37609 $278.00 1036475 $2,216.00 0 36821 $721.00 90 37615 $495.00 9036476 $434.00 ZZZ 36822 $630.00 90 37616 $1,128.00 9036478 $2,041.00 0 36823 $1,461.00 90 37617 $1,132.00 9036479 $438.00 ZZZ 36825 $867.00 90 37618 $514.00 9036481 $499.00 0 36830 $967.00 90 37620 $818.00 9036500 $159.00 0 36831 $488.00 90 37650 $430.00 9036511 $92.00 0 36832 $810.00 90 37660 $789.00 9036512 $92.00 0 36833 $780.00 90 37700 $336.00 9036513 $92.00 0 36834 $761.00 90 37718 $416.00 9036514 $92.00 0 36835 $542.00 90 37722 $495.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD37735 $847.00 90 38746 $312.00 ZZZ 40810 $141.00 1037760 $813.00 90 38747 $337.00 ZZZ 40812 $202.00 1037765 $462.00 90 38760 $699.00 90 40814 $319.00 9037766 $561.00 90 38765 $1,283.00 90 40816 $336.00 9037780 $301.00 90 38770 $1,111.00 90 40818 $249.00 9037785 $270.00 90 38780 $1,357.00 90 40819 $208.00 9037788 $1,654.00 90 38790 $158.00 0 40820 $104.00 1037790 $690.00 90 38792 $26.00 0 40830 $140.00 1037799 BR YYY 38794 $298.00 90 40831 $213.00 1038100 $974.00 90 38999 BR YYY 40840 $687.00 9038101 $982.00 90 39000 $664.00 90 40842 $684.00 9038102 $332.00 ZZZ 39010 $1,148.00 90 40843 $947.00 9038115 $1,020.00 90 39200 $1,249.00 90 40844 $1,232.00 9038120 $1,138.00 90 39220 $1,542.00 90 40845 $1,593.00 9038129 BR YYY 39400 $614.00 10 40899 BR YYY38200 $180.00 0 39499 BR YYY 41000 $119.00 1038205 $79.00 0 39501 $1,083.00 90 41005 $109.00 1038206 $79.00 0 39502 $1,268.00 90 41006 $237.00 9038220 $212.00 0 39503 $2,726.00 90 41007 $283.00 9038221 $228.00 0 39520 $1,345.00 90 41008 $248.00 9038230 $265.00 10 39530 $1,295.00 90 41009 $319.00 9038240 $128.00 0 39531 $1,243.00 90 41010 $91.00 1038241 $128.00 0 39540 $1,133.00 90 41015 $267.00 9038242 $90.00 0 39541 $1,179.00 90 41016 $357.00 9038300 $104.00 10 39545 $1,102.00 90 41017 $300.00 9038305 $375.00 90 39560 $968.00 90 41018 $424.00 9038308 $425.00 90 39561 $1,328.00 90 41019 $444.00 038380 $628.00 90 39599 BR YYY 41100 $140.00 1038381 $1,087.00 90 40490 $108.00 0 41105 $136.00 1038382 $798.00 90 40500 $422.00 90 41108 $110.00 1038500 $234.00 10 40510 $469.00 90 41110 $159.00 1038505 $139.00 0 40520 $467.00 90 41112 $255.00 9038510 $349.00 10 40525 $714.00 90 41113 $301.00 9038520 $431.00 90 40527 $851.00 90 41114 $682.00 9038525 $369.00 90 40530 $501.00 90 41115 $176.00 1038530 $517.00 90 40650 $368.00 90 41116 $242.00 9038542 $507.00 90 40652 $436.00 90 41120 $813.00 9038550 $519.00 90 40654 $529.00 90 41130 $937.00 9038555 $1,115.00 90 40700 $1,009.00 90 41135 $1,869.00 9038562 $799.00 90 40701 $1,452.00 90 41140 $2,005.00 9038564 $831.00 90 40702 $1,030.00 90 41145 $2,406.00 9038570 $695.00 10 40720 $1,107.00 90 41150 $1,897.00 9038571 $902.00 10 40761 $1,202.00 90 41153 $2,091.00 9038572 $1,049.00 10 40799 BR YYY 41155 $2,448.00 9038589 BR YYY 40800 $110.00 10 41250 $168.00 1038700 $863.00 90 40801 $208.00 10 41251 $203.00 1038720 $1,328.00 90 40804 $105.00 10 41252 $294.00 1038724 $1,366.00 90 40805 $245.00 10 41500 $334.00 9038740 $539.00 90 40806 $38.00 0 41510 $313.00 9038745 $770.00 90 40808 $100.00 10 41520 $255.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD41599 BR YYY 42405 $258.00 10 42961 $406.00 9041800 $107.00 10 42408 $377.00 90 42962 $602.00 9041805 $115.00 10 42409 $266.00 90 42970 $284.00 9041806 $217.00 10 42410 $746.00 90 42971 $472.00 9041820 BR 0 42415 $1,364.00 90 42972 $562.00 9041821 BR 0 42420 $1,577.00 90 42999 BR YYY41822 $237.00 10 42425 $1,097.00 90 43020 $696.00 9041823 $312.00 90 42426 $1,882.00 90 43030 $712.00 9041825 $144.00 10 42440 $634.00 90 43045 $1,574.00 9041826 $211.00 10 42450 $395.00 90 43100 $744.00 9041827 $322.00 90 42500 $407.00 90 43101 $1,248.00 9041828 $176.00 10 42505 $559.00 90 43107 $2,325.00 9041830 $156.00 10 42507 $522.00 90 43108 $2,664.00 9041850 BR 0 42508 $767.00 90 43112 $2,471.00 9041870 BR 0 42509 $915.00 90 43113 $2,755.00 9041872 $249.00 90 42510 $711.00 90 43116 $2,509.00 9041874 $193.00 90 42550 $82.00 0 43117 $2,469.00 9041899 BR YYY 42600 $445.00 90 43118 $2,607.00 9042000 $106.00 10 42650 $67.00 0 43121 $2,350.00 9042100 $122.00 10 42660 $89.00 0 43122 $2,287.00 9042104 $161.00 10 42665 $238.00 90 43123 $2,661.00 9042106 $204.00 10 42699 BR YYY 43124 $2,242.00 9042107 $409.00 90 42700 $144.00 10 43130 $1,020.00 9042120 $573.00 90 42720 $270.00 10 43135 $1,332.00 9042140 $174.00 90 42725 $720.00 90 43200 $266.00 042145 $741.00 90 42800 $123.00 10 43201 $245.00 042160 $176.00 10 42802 $150.00 10 43202 $205.00 042180 $222.00 10 42804 $136.00 10 43204 $228.00 042182 $324.00 10 42806 $167.00 10 43205 $207.00 042200 $946.00 90 42808 $250.00 10 43215 $160.00 042205 $863.00 90 42809 $152.00 10 43216 $149.00 042210 $1,174.00 90 42810 $335.00 90 43217 $176.00 042215 $766.00 90 42815 $659.00 90 43219 $171.00 042220 $586.00 90 42821 $378.00 90 43220 $128.00 042225 $803.00 90 42826 $320.00 90 43226 $142.00 042226 $848.00 90 42831 $235.00 90 43227 $218.00 042227 $762.00 90 42836 $286.00 90 43228 $230.00 042235 $631.00 90 42842 $729.00 90 43231 $182.00 042260 $491.00 90 42844 $1,173.00 90 43232 $252.00 042280 $148.00 10 42845 $1,958.00 90 43234 $193.00 042281 $160.00 10 42860 $207.00 90 43235 $239.00 042299 BR YYY 42870 $427.00 90 43236 $285.00 042300 $165.00 10 42890 $1,047.00 90 43237 $219.00 042305 $448.00 90 42892 $1,262.00 90 43238 $271.00 042310 $145.00 10 42894 $1,825.00 90 43239 $246.00 042320 $208.00 10 42900 $429.00 10 43240 $369.00 042330 $184.00 10 42950 $745.00 90 43241 $157.00 042335 $287.00 90 42953 $752.00 90 43242 $384.00 042340 $411.00 90 42955 $561.00 90 43243 $276.00 042400 $94.00 0 42960 $178.00 10 43244 $268.00 0

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD43245 $214.00 0 43425 $1,338.00 90 43843 $1,249.00 9043246 $485.00 0 43450 $91.00 0 43845 $1,738.00 9043247 $229.00 0 43453 $102.00 0 43846 $1,528.00 9043248 $191.00 0 43456 $149.00 0 43847 $1,678.00 9043249 $175.00 0 43458 $164.00 0 43848 $1,795.00 9043250 $194.00 0 43460 $203.00 0 43850 $1,425.00 9043251 $224.00 0 43496 BR 90 43855 $1,454.00 9043255 $343.00 0 43499 BR YYY 43860 $1,435.00 9043256 $235.00 0 43500 $649.00 90 43865 $1,549.00 9043257 $305.00 0 43501 $1,105.00 90 43870 $590.00 9043258 $276.00 0 43502 $1,247.00 90 43880 $1,352.00 9043259 $271.00 0 43510 $680.00 90 43886 $280.00 9043260 $349.00 0 43520 $599.00 90 43887 $274.00 9043261 $362.00 0 43600 $96.00 0 43888 $389.00 9043262 $447.00 0 43605 $686.00 90 43999 BR YYY43263 $386.00 0 43610 $861.00 90 44005 $1,171.00 9043264 $522.00 0 43611 $1,001.00 90 44010 $809.00 9043265 $527.00 0 43620 $1,691.00 90 44015 $1,171.00 ZZZ43267 $434.00 0 43621 $1,718.00 90 44020 $891.00 9043268 $446.00 0 43622 $1,798.00 90 44021 $888.00 9043269 $410.00 0 43631 $1,445.00 90 44025 $905.00 9043271 $437.00 0 43632 $1,443.00 90 44050 $862.00 9043272 $401.00 0 43633 $1,467.00 90 44055 $957.00 9043280 $1,314.00 90 43634 $1,786.00 90 44100 $117.00 043289 BR YYY 43635 $143.00 ZZZ 44110 $784.00 9043300 $837.00 90 43640 $1,119.00 90 44111 $963.00 9043305 $1,428.00 90 43641 $1,138.00 90 44120 $1,078.00 9043310 $2,138.00 90 43644 $1,598.00 90 44121 $308.00 ZZZ43312 $2,331.00 90 43645 $1,724.00 90 44125 $1,135.00 9043313 $2,632.00 90 43651 $716.00 90 44126 $1,951.00 9043314 $2,891.00 90 43652 $856.00 90 44127 $2,243.00 9043320 $1,299.00 90 43653 $617.00 90 44128 $242.00 ZZZ43324 $1,280.00 90 43659 BR YYY 44130 $938.00 9043325 $1,261.00 90 43752 $36.00 0 44133 BR 043326 $1,198.00 90 43760 $81.00 0 44136 BR 043330 $1,236.00 90 43761 $107.00 0 44139 $154.00 ZZZ43331 $1,378.00 90 43770 $1,009.00 90 44140 $1,350.00 9043340 $1,292.00 90 43771 $1,162.00 90 44141 $1,488.00 9043341 $1,351.00 90 43772 $885.00 90 44143 $1,536.00 9043350 $986.00 90 43773 $1,162.00 90 44144 $1,442.00 9043351 $1,180.00 90 43774 $888.00 90 44145 $1,678.00 9043352 $1,028.00 90 43800 $793.00 90 44146 $1,840.00 9043360 $2,277.00 90 43810 $846.00 90 44147 $1,452.00 9043361 $2,596.00 90 43820 $896.00 90 44150 $1,661.00 9043400 $1,261.00 90 43825 $1,128.00 90 44151 $1,499.00 9043401 $1,299.00 90 43830 $592.00 90 44155 $1,892.00 9043405 $1,330.00 90 43831 $593.00 90 44156 $1,709.00 9043410 $946.00 90 43832 $904.00 90 44157 $1,952.00 9043415 $1,382.00 90 43840 $893.00 90 44158 $2,003.00 9043420 $854.00 90 43842 $1,260.00 90 44160 $1,236.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD44180 $853.00 90 44392 $359.00 0 45130 $1,041.00 9044186 $600.00 90 44393 $413.00 0 45135 $1,354.00 9044187 $992.00 90 44394 $395.00 0 45136 $1,526.00 9044188 $1,088.00 90 44397 $259.00 0 45150 $475.00 9044202 $1,603.00 90 44500 $28.00 0 45160 $949.00 9044203 $235.00 ZZZ 44602 $815.00 90 45170 $697.00 9044204 $1,353.00 90 44603 $1,041.00 90 45190 $623.00 9044205 $1,198.00 90 44604 $1,027.00 90 45300 $75.00 044206 $1,480.00 90 44605 $1,132.00 90 45303 $72.00 044207 $1,620.00 90 44615 $994.00 90 45305 $102.00 044208 $1,752.00 90 44620 $741.00 90 45307 $172.00 044210 $1,551.00 90 44625 $1,277.00 90 45308 $137.00 044211 $1,926.00 90 44626 $1,581.00 90 45309 $174.00 044212 $1,800.00 90 44640 $1,036.00 90 45315 $211.00 044213 $196.00 ZZZ 44650 $1,076.00 90 45317 $209.00 044227 $1,536.00 90 44660 $1,050.00 90 45320 $230.00 044238 BR YYY 44661 $1,326.00 90 45321 $154.00 044300 $697.00 90 44680 $1,049.00 90 45327 $96.00 044310 $950.00 90 44700 $1,115.00 90 45330 $87.00 044312 $453.00 90 44701 $161.00 ZZZ 45331 $120.00 044314 $892.00 90 44720 $268.00 0 45332 $174.00 044316 $1,229.00 90 44721 $393.00 0 45333 $176.00 044320 $1,029.00 90 44799 BR YYY 45334 $171.00 044322 $1,015.00 90 44800 $791.00 90 45335 $144.00 044340 $397.00 90 44820 $755.00 90 45337 $144.00 044345 $816.00 90 44850 $708.00 90 45338 $212.00 044346 $923.00 90 44899 BR YYY 45339 $237.00 044360 $177.00 0 44900 $644.00 90 45340 $328.00 044361 $195.00 0 44901 $310.00 0 45341 $153.00 044363 $213.00 0 44950 $643.00 90 45342 $224.00 044364 $255.00 0 44955 $136.00 ZZZ 45345 $164.00 044365 $226.00 0 44960 $790.00 90 45355 $185.00 044366 $300.00 0 44970 $631.00 90 45378 $341.00 044369 $308.00 0 44979 BR YYY 45379 $415.00 044370 $253.00 0 45000 $329.00 90 45380 $369.00 044372 $301.00 0 45005 $197.00 10 45381 $388.00 044373 $238.00 0 45020 $364.00 90 45382 $481.00 044376 $305.00 0 45100 $321.00 90 45383 $482.00 044377 $320.00 0 45108 $419.00 90 45384 $415.00 044378 $410.00 0 45110 $1,801.00 90 45385 $479.00 044379 $396.00 0 45111 $1,270.00 90 45386 $739.00 044380 $91.00 0 45112 $1,904.00 90 45387 $322.00 044382 $110.00 0 45113 $1,885.00 90 45391 $283.00 044383 $165.00 0 45114 $1,732.00 90 45392 $358.00 044385 $219.00 0 45116 $1,485.00 90 45395 $1,813.00 9044386 $183.00 0 45119 $1,911.00 90 45397 $1,969.00 9044388 $326.00 0 45120 $1,845.00 90 45400 $1,058.00 9044389 $301.00 0 45121 $1,870.00 90 45402 $1,435.00 9044390 $319.00 0 45123 $1,126.00 90 45500 $584.00 9044391 $376.00 0 45126 $2,444.00 90 45505 $510.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD45520 $46.00 0 46610 $114.00 0 47146 $337.00 045540 $1,009.00 90 46611 $149.00 0 47147 $393.00 045541 $888.00 90 46612 $196.00 0 47300 $778.00 9045550 $1,350.00 90 46614 $169.00 0 47350 $942.00 9045560 $618.00 90 46615 $202.00 0 47360 $1,305.00 9045562 $915.00 90 46700 $585.00 90 47361 $2,129.00 9045563 $1,412.00 90 46706 $140.00 10 47362 $849.00 9045800 $1,050.00 90 46710 $953.00 90 47370 $943.00 9045805 $1,273.00 90 46712 $1,999.00 90 47371 $889.00 9045820 $1,066.00 90 46715 $545.00 90 47379 BR YYY45825 $1,241.00 90 46716 $906.00 90 47380 $1,107.00 9045900 $120.00 10 46730 $1,584.00 90 47381 $1,094.00 9045905 $133.00 10 46735 $1,881.00 90 47382 $660.00 1045910 $163.00 10 46740 $1,671.00 90 47399 BR YYY45915 $142.00 10 46742 $2,236.00 90 47400 $1,435.00 9045990 $105.00 0 46744 $2,412.00 90 47420 $1,222.00 9045999 BR YYY 46746 $2,725.00 90 47425 $1,275.00 9046020 $230.00 10 46748 $2,933.00 90 47460 $1,039.00 9046030 $94.00 10 46750 $636.00 90 47480 $755.00 9046040 $393.00 90 46753 $511.00 90 47490 $467.00 9046045 $312.00 90 46754 $188.00 10 47500 $103.00 046050 $105.00 10 46760 $846.00 90 47505 $96.00 046060 $482.00 90 46761 $813.00 90 47510 $487.00 9046080 $246.00 10 46762 $731.00 90 47511 $627.00 9046083 $98.00 10 46900 $128.00 10 47525 $295.00 1046200 $323.00 90 46910 $144.00 10 47530 $35.00 9046210 $196.00 90 46916 $145.00 10 47550 $209.00 ZZZ46211 $353.00 90 46917 $228.00 10 47552 $364.00 046220 $118.00 10 46922 $189.00 10 47553 $342.00 046221 $124.00 10 46924 $297.00 10 47554 $594.00 046230 $198.00 10 46937 $268.00 10 47555 $383.00 046250 $400.00 90 46938 $405.00 90 47556 $425.00 046255 $501.00 90 46940 $165.00 10 47560 $345.00 046257 $504.00 90 46942 $145.00 10 47561 $388.00 046258 $539.00 90 46945 $199.00 90 47562 $837.00 9046260 $598.00 90 46946 $270.00 90 47563 $900.00 9046261 $655.00 90 46947 $328.00 90 47564 $1,069.00 9046262 $686.00 90 46999 BR YYY 47570 $961.00 9046270 $328.00 90 47000 $218.00 0 47579 BR YYY46275 $442.00 90 47001 $141.00 ZZZ 47600 $868.00 9046280 $514.00 90 47010 $788.00 90 47605 $935.00 9046285 $335.00 90 47011 $347.00 0 47610 $1,164.00 9046288 $521.00 90 47015 $755.00 90 47612 $1,276.00 9046320 $126.00 10 47100 $550.00 90 47620 $1,295.00 9046500 $109.00 10 47120 $1,663.00 90 47630 $465.00 9046505 $229.00 10 47122 $2,512.00 90 47700 $1,111.00 9046600 $38.00 0 47125 $2,293.00 90 47701 $1,913.00 9046604 $92.00 0 47130 $2,482.00 90 47711 $1,442.00 9046606 $66.00 0 47135 $6,164.00 90 47712 $1,793.00 9046608 $115.00 0 47136 $4,985.00 90 47715 $1,157.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD47720 $1,040.00 90 49060 $827.00 90 49540 $668.00 9047721 $1,248.00 90 49061 $288.00 0 49550 $557.00 9047740 $1,188.00 90 49062 $892.00 90 49553 $598.00 9047741 $1,425.00 90 49080 $123.00 0 49555 $621.00 9047760 $1,568.00 90 49081 $98.00 0 49557 $715.00 9047765 $1,624.00 90 49180 $212.00 0 49560 $734.00 9047780 $1,635.00 90 49203 $1,049.00 90 49561 $856.00 9047785 $1,871.00 90 49204 $1,337.00 90 49565 $754.00 9047800 $1,485.00 90 49205 $1,530.00 90 49566 $881.00 9047801 $906.00 90 49215 $1,551.00 90 49568 $339.00 ZZZ47802 $1,352.00 90 49220 $1,182.00 90 49570 $411.00 9047900 $1,331.00 90 49250 $622.00 90 49572 $491.00 9047999 BR YYY 49255 $591.00 90 49585 $444.00 9048000 $1,053.00 90 49320 $415.00 10 49587 $501.00 9048001 $1,305.00 90 49321 $443.00 10 49590 $585.00 9048020 $983.00 90 49322 $460.00 10 49600 $774.00 9048100 $779.00 90 49323 $712.00 90 49605 $1,648.00 9048102 $341.00 10 49324 $348.00 10 49606 $1,416.00 9048105 $2,505.00 90 49325 $374.00 10 49610 $784.00 9048120 $1,083.00 90 49326 $171.00 ZZZ 49611 $770.00 9048140 $1,546.00 90 49329 BR YYY 49650 $484.00 9048145 $1,661.00 90 49400 $127.00 0 49651 $621.00 9048146 $1,830.00 90 49402 $748.00 90 49659 BR YYY48148 $1,149.00 90 49419 $405.00 90 49900 $512.00 9048150 $3,101.00 90 49420 $162.00 0 49904 $1,394.00 9048152 $2,888.00 90 49421 $452.00 90 49905 $454.00 ZZZ48153 $3,099.00 90 49422 $468.00 10 49906 BR 9048154 $2,893.00 90 49423 $106.00 0 49999 BR YYY48155 $1,855.00 90 49424 $54.00 0 50010 $886.00 9048160 BR 0 49425 $914.00 90 50020 $1,084.00 9048400 $100.00 ZZZ 49426 $725.00 90 50021 $335.00 048500 $1,012.00 90 49427 $48.00 0 50040 $910.00 9048510 $938.00 90 49428 $184.00 10 50045 $1,137.00 9048511 $286.00 0 49429 $522.00 10 50060 $1,394.00 9048520 $1,103.00 90 49435 $110.00 ZZZ 50065 $1,514.00 9048540 $1,350.00 90 49436 $164.00 10 50070 $1,476.00 9048545 $1,170.00 90 49440 $1,113.00 10 50075 $1,839.00 9048547 $1,630.00 90 49441 $1,319.00 10 50080 $1,186.00 9048548 $1,460.00 90 49442 $1,075.00 10 50081 $1,635.00 9048552 $230.00 0 49446 $1,100.00 0 50100 $1,250.00 9048554 $2,365.00 90 49450 $771.00 0 50120 $1,180.00 9048556 $1,117.00 90 49451 $817.00 0 50125 $1,228.00 9048999 BR YYY 49452 $998.00 0 50130 $1,301.00 9049000 $862.00 90 49460 $818.00 0 50135 $1,506.00 9049002 $784.00 90 49465 $170.00 0 50200 $151.00 049010 $915.00 90 49505 $510.00 90 50205 $807.00 9049020 $910.00 90 49507 $636.00 90 50220 $1,316.00 9049021 $290.00 0 49520 $631.00 90 50225 $1,554.00 9049040 $763.00 90 49521 $730.00 90 50230 $1,695.00 9049041 $305.00 0 49525 $584.00 90 50234 $1,671.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD50236 $1,873.00 90 50570 $549.00 0 50949 BR YYY50240 $1,679.00 90 50572 $728.00 0 50951 $414.00 050250 $1,157.00 90 50574 $762.00 0 50953 $461.00 050280 $1,170.00 90 50575 $991.00 0 50955 $546.00 050290 $1,080.00 90 50576 $801.00 0 50957 $546.00 050320 $1,680.00 90 50580 $726.00 0 50961 $510.00 050327 $214.00 0 50590 $980.00 90 50970 $510.00 050328 $187.00 0 50592 $5,936.00 10 50972 $408.00 050329 $179.00 0 50593 $4,692.00 10 50974 $661.00 050340 $1,083.00 90 50600 $1,150.00 90 50976 $641.00 050360 $2,475.00 90 50605 $1,054.00 90 50980 $443.00 050365 $2,941.00 90 50610 $1,209.00 90 51020 $587.00 9050370 $1,128.00 90 50620 $1,152.00 90 51030 $538.00 9050380 $1,507.00 90 50630 $1,170.00 90 51040 $439.00 9050382 $1,594.00 0 50650 $1,297.00 90 51045 $548.00 9050384 $1,540.00 0 50660 $1,426.00 90 51050 $596.00 9050385 $1,326.00 0 50684 $74.00 0 51060 $768.00 9050386 $857.00 0 50686 $109.00 0 51065 $704.00 9050387 $772.00 0 50688 $89.00 10 51080 $510.00 9050389 $529.00 0 50690 $85.00 0 51100 $63.00 050390 $118.00 0 50700 $1,192.00 90 51101 $130.00 050391 $139.00 0 50715 $1,397.00 90 51102 $335.00 1050392 $189.00 0 50722 $1,211.00 90 51500 $775.00 9050393 $235.00 0 50725 $1,371.00 90 51520 $764.00 9050394 $64.00 0 50727 $640.00 90 51525 $1,069.00 9050395 $203.00 0 50728 $924.00 90 51530 $957.00 9050396 $101.00 0 50740 $1,386.00 90 51535 $932.00 9050398 $99.00 0 50750 $1,457.00 90 51550 $1,171.00 9050400 $1,441.00 90 50760 $1,389.00 90 51555 $1,514.00 9050405 $1,802.00 90 50770 $1,485.00 90 51565 $1,624.00 9050500 $1,471.00 90 50780 $1,391.00 90 51570 $1,762.00 9050520 $1,281.00 90 50782 $1,465.00 90 51575 $2,284.00 9050525 $1,644.00 90 50783 $1,515.00 90 51580 $2,252.00 9050526 $1,639.00 90 50785 $1,548.00 90 51585 $2,601.00 9050540 $1,468.00 90 50800 $1,226.00 90 51590 $2,441.00 9050541 $1,037.00 90 50810 $1,527.00 90 51595 $2,900.00 9050542 $1,093.00 90 50815 $1,643.00 90 51596 $3,063.00 9050543 $1,374.00 90 50820 $1,729.00 90 51597 $2,914.00 9050544 $1,428.00 90 50825 $2,351.00 90 51600 $54.00 050545 $1,273.00 90 50830 $2,292.00 90 51605 $83.00 050546 $1,325.00 90 50840 $1,493.00 90 51610 $45.00 050547 $1,702.00 90 50845 $1,513.00 90 51700 $29.00 050548 $1,555.00 90 50860 $1,163.00 90 51701 $58.00 050549 BR YYY 50900 $1,043.00 90 51702 $92.00 050551 $411.00 0 50920 $1,075.00 90 51703 $128.00 050553 $447.00 0 50930 $1,380.00 90 51705 $37.00 1050555 $668.00 0 50940 $1,107.00 90 51710 $119.00 1050557 $676.00 0 50945 $1,096.00 90 51715 $322.00 050561 $755.00 0 50947 $1,384.00 90 51720 $140.00 050562 $580.00 90 50948 $1,265.00 90 51725 $116.00 0

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD51725-26 $79.00 0 52010 $292.00 0 52647 $858.00 9051725-TC $199.00 0 52204 $286.00 0 52648 $957.00 9051726 $136.00 0 52214 $367.00 0 52649 $973.00 9051726-26 $90.00 0 52224 $339.00 0 52700 $517.00 9051726-TC $274.00 0 52234 $471.00 0 53000 $224.00 1051736 $47.00 0 52235 $546.00 0 53010 $336.00 9051736-26 $32.00 0 52240 $887.00 0 53020 $153.00 051736-TC $15.00 0 52250 $311.00 0 53040 $460.00 9051741 $81.00 0 52260 $262.00 0 53060 $180.00 1051741-26 $59.00 0 52265 $243.00 0 53080 $567.00 9051741-TC $17.00 0 52270 $374.00 0 53085 $836.00 9051772 $96.00 0 52275 $446.00 0 53200 $218.00 051772-26 $86.00 0 52276 $490.00 0 53210 $904.00 9051772-TC $197.00 0 52277 $448.00 0 53215 $1,142.00 9051784 $119.00 0 52281 $259.00 0 53220 $546.00 9051784-26 $80.00 0 52282 $560.00 0 53230 $760.00 9051784-TC $136.00 0 52283 $309.00 0 53235 $607.00 9051785 $52.00 0 52285 $375.00 0 53240 $506.00 9051785-26 $80.00 0 52290 $304.00 0 53250 $464.00 9051785-TC $155.00 0 52300 $370.00 0 53260 $240.00 1051792 $143.00 0 52301 $382.00 0 53265 $295.00 1051792-26 $60.00 0 52305 $370.00 0 53270 $226.00 1051792-TC $213.00 0 52310 $348.00 0 53275 $332.00 1051795 $132.00 0 52315 $553.00 0 53400 $929.00 9051795-26 $80.00 0 52317 $772.00 0 53405 $1,088.00 9051795-TC $270.00 0 52318 $684.00 0 53410 $1,151.00 9051797 $109.00 ZZZ 52320 $369.00 0 53415 $1,381.00 9051797-26 $84.00 ZZZ 52325 $494.00 0 53420 $1,088.00 9051797-TC $205.00 ZZZ 52327 $369.00 0 53425 $1,150.00 9051798 $20.00 0 52330 $507.00 0 53430 $1,116.00 9051800 $1,294.00 90 52332 $451.00 0 53431 $1,053.00 9051820 $1,236.00 90 52334 $340.00 0 53440 $1,057.00 9051840 $858.00 90 52341 $317.00 0 53442 $639.00 9051841 $1,040.00 90 52342 $344.00 0 53444 $755.00 9051845 $843.00 90 52343 $380.00 0 53445 $1,197.00 9051860 $912.00 90 52344 $407.00 0 53446 $699.00 9051865 $1,150.00 90 52345 $433.00 0 53447 $991.00 9051880 $590.00 90 52346 $488.00 0 53448 $1,259.00 9051900 $1,050.00 90 52351 $297.00 0 53449 $784.00 9051920 $881.00 90 52352 $349.00 0 53450 $447.00 9051925 $1,167.00 90 52353 $404.00 0 53460 $494.00 9051940 $2,082.00 90 52354 $372.00 0 53500 $719.00 9051960 $1,848.00 90 52355 $447.00 0 53502 $590.00 9051980 $858.00 90 52400 $580.00 90 53505 $586.00 9051990 $850.00 90 52402 $279.00 0 53510 $777.00 9051992 $925.00 90 52450 $602.00 90 53515 $987.00 9052000 $190.00 0 52500 $705.00 90 53520 $661.00 9052001 $133.00 0 52601 $1,021.00 90 53600 $37.00 052005 $265.00 0 52630 $653.00 90 53601 $37.00 052007 $230.00 0 52640 $573.00 90 53605 $81.00 0

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD53620 $59.00 0 54332 $1,327.00 90 54865 $333.00 9053621 $45.00 0 54336 $1,672.00 90 54900 $969.00 9053660 $49.00 0 54340 $727.00 90 54901 $1,340.00 9053661 $50.00 0 54344 $1,360.00 90 55000 $109.00 053665 $50.00 0 54348 $1,318.00 90 55040 $439.00 9053850 $741.00 90 54352 $1,820.00 90 55041 $634.00 9053852 $728.00 90 54360 $898.00 90 55060 $430.00 9053899 BR YYY 54380 $1,054.00 90 55100 $156.00 1054015 $348.00 10 54385 $1,217.00 90 55110 $223.00 9054050 $91.00 10 54390 $1,635.00 90 55120 $350.00 9054055 $106.00 10 54400 $784.00 90 55150 $562.00 9054056 $100.00 10 54401 $892.00 90 55175 $426.00 9054057 $149.00 10 54405 $1,294.00 90 55180 $796.00 9054060 $180.00 10 54406 $687.00 90 55200 $310.00 9054065 $281.00 10 54408 $724.00 90 55250 $349.00 9054100 $149.00 0 54410 $856.00 90 55300 $167.00 054105 $261.00 10 54411 $933.00 90 55400 $660.00 9054110 $775.00 90 54415 $510.00 90 55450 $391.00 1054111 $1,035.00 90 54416 $665.00 90 55500 $445.00 9054112 $1,210.00 90 54417 $819.00 90 55520 $446.00 9054115 $588.00 90 54420 $899.00 90 55530 $467.00 9054120 $777.00 90 54430 $799.00 90 55535 $496.00 9054125 $1,092.00 90 54435 $503.00 90 55540 $572.00 9054130 $1,532.00 90 54440 BR 90 55550 $486.00 9054135 $1,945.00 90 54450 $88.00 0 55559 BR YYY54162 $220.00 10 54500 $102.00 0 55600 $486.00 9054163 $207.00 10 54505 $259.00 10 55605 $609.00 9054164 $182.00 10 54512 $519.00 90 55650 $853.00 9054200 $78.00 10 54520 $445.00 90 55680 $426.00 9054205 $633.00 90 54522 $589.00 90 55700 $183.00 054220 $189.00 0 54530 $683.00 90 55705 $368.00 1054230 $104.00 0 54535 $922.00 90 55720 $555.00 9054231 $172.00 0 54550 $588.00 90 55725 $670.00 9054235 $81.00 0 54560 $842.00 90 55801 $1,331.00 9054240 $109.00 0 54600 $524.00 90 55810 $1,711.00 9054240-26 $68.00 0 54620 $373.00 10 55812 $1,989.00 9054240-TC $24.00 0 54640 $594.00 90 55815 $2,328.00 9054250 $104.00 0 54650 $861.00 90 55821 $1,153.00 9054250-26 $116.00 0 54660 $401.00 90 55831 $1,252.00 9054250-TC $9.00 0 54670 $485.00 90 55840 $1,705.00 9054300 $830.00 90 54680 $948.00 90 55842 $1,859.00 9054304 $988.00 90 54690 $825.00 90 55845 $2,222.00 9054308 $881.00 90 54692 $850.00 90 55860 $1,012.00 9054312 $1,067.00 90 54699 BR YYY 55862 $1,351.00 9054316 $1,316.00 90 54700 $133.00 10 55865 $1,890.00 9054318 $900.00 90 54800 $257.00 0 55866 $1,615.00 9054322 $974.00 90 54830 $411.00 90 55870 $166.00 054324 $1,260.00 90 54840 $432.00 90 55873 $1,127.00 9054326 $1,212.00 90 54860 $503.00 90 55875 $729.00 9054328 $1,201.00 90 54861 $696.00 90 55876 $147.00 0

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD55899 BR YYY 57200 $313.00 90 57520 $359.00 9055920 $420.00 0 57210 $395.00 90 57522 $319.00 9056405 $131.00 10 57220 $378.00 90 57530 $386.00 9056420 $130.00 10 57230 $442.00 90 57531 $2,036.00 9056440 $271.00 10 57240 $536.00 90 57540 $815.00 9056441 $183.00 10 57250 $485.00 90 57545 $700.00 9056442 $45.00 0 57260 $700.00 90 57550 $486.00 9056501 $122.00 10 57265 $902.00 90 57555 $774.00 9056515 $200.00 10 57267 $284.00 ZZZ 57556 $718.00 9056605 $96.00 0 57268 $577.00 90 57558 $120.00 1056606 $49.00 ZZZ 57270 $867.00 90 57700 $279.00 9056620 $607.00 90 57280 $1,071.00 90 57720 $328.00 9056625 $735.00 90 57282 $734.00 90 57800 $71.00 056630 $1,061.00 90 57283 $673.00 90 58100 $74.00 056631 $1,400.00 90 57284 $950.00 90 58110 $53.00 ZZZ56632 $1,636.00 90 57285 $607.00 90 58120 $297.00 1056633 $1,350.00 90 57287 $685.00 90 58140 $1,010.00 9056634 $1,537.00 90 57288 $1,009.00 90 58145 $677.00 9056637 $1,806.00 90 57289 $879.00 90 58146 $1,089.00 9056640 $1,777.00 90 57291 $622.00 90 58150 $1,110.00 9056700 $227.00 10 57292 $925.00 90 58152 $1,159.00 9056740 $321.00 10 57295 $485.00 90 58180 $1,118.00 9056800 $310.00 10 57296 $880.00 90 58200 $1,562.00 9056805 $1,349.00 90 57300 $653.00 90 58210 $2,080.00 9056810 $316.00 10 57305 $995.00 90 58240 $2,898.00 9056820 $119.00 0 57307 $997.00 90 58260 $926.00 9056821 $154.00 0 57308 $769.00 90 58262 $1,026.00 9057000 $237.00 10 57310 $517.00 90 58263 $1,120.00 9057010 $429.00 90 57311 $612.00 90 58267 $1,133.00 9057020 $118.00 0 57320 $693.00 90 58270 $1,019.00 9057022 $179.00 10 57330 $916.00 90 58275 $1,121.00 9057023 $290.00 10 57335 $963.00 90 58280 $1,132.00 9057061 $124.00 10 57400 $70.00 0 58285 $1,360.00 9057065 $251.00 10 57410 $57.00 0 58290 $1,089.00 9057100 $90.00 0 57415 $75.00 10 58291 $1,197.00 9057105 $132.00 10 57420 $124.00 0 58292 $1,268.00 9057106 $409.00 90 57421 $162.00 0 58293 $1,318.00 9057107 $1,467.00 90 57423 $848.00 90 58294 $1,168.00 9057109 $1,787.00 90 57425 $902.00 90 58300 $96.00 057110 $1,015.00 90 57452 $96.00 0 58301 $71.00 057111 $1,793.00 90 57454 $125.00 0 58321 $81.00 057112 $1,907.00 90 57455 $149.00 0 58322 $90.00 057120 $612.00 90 57456 $141.00 0 58323 $24.00 057130 $220.00 10 57460 $223.00 0 58340 $87.00 057135 $231.00 10 57461 $333.00 0 58345 $335.00 1057150 $50.00 0 57500 $89.00 0 58346 $408.00 9057155 $383.00 90 57505 $105.00 10 58350 $103.00 1057160 $67.00 0 57510 $140.00 10 58353 $225.00 1057170 $74.00 0 57511 $159.00 10 58356 $531.00 1057180 $124.00 10 57513 $191.00 10 58400 $519.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD58410 $752.00 90 58822 $603.00 90 59414 $134.00 058520 $663.00 90 58823 $216.00 0 59425 $414.00 058540 $923.00 90 58825 $469.00 90 59426 $708.00 058541 $793.00 90 58900 $489.00 90 59430 $140.00 058542 $877.00 90 58920 $571.00 90 59510 $2,064.00 058543 $891.00 90 58925 $820.00 90 59514 $1,199.00 058544 $965.00 90 58940 $592.00 90 59515 $1,324.00 058545 $876.00 90 58943 $1,368.00 90 59525 $591.00 ZZZ58546 $1,104.00 90 58950 $1,170.00 90 59610 $1,805.00 058548 $1,688.00 90 58951 $1,703.00 90 59612 $1,113.00 058550 $1,038.00 90 58952 $1,876.00 90 59614 $1,208.00 058552 $853.00 90 58953 $1,839.00 90 59618 $2,035.00 058553 $1,096.00 90 58954 $1,999.00 90 59620 $1,293.00 058554 $1,085.00 90 58956 $1,329.00 90 59622 $1,397.00 058555 $261.00 0 58957 $1,365.00 90 59812 $343.00 9058558 $340.00 0 58958 $1,511.00 90 59820 $389.00 9058559 $436.00 0 58960 $1,174.00 90 59821 $398.00 9058560 $482.00 0 58999 BR YYY 59830 $496.00 9058561 $677.00 0 59000 $123.00 0 59840 $331.00 1058562 $339.00 0 59001 $167.00 0 59841 $443.00 1058563 $450.00 0 59012 $267.00 0 59850 $449.00 9058565 $2,189.00 90 59015 $168.00 0 59851 $464.00 9058570 $844.00 90 59020 $85.00 0 59852 $642.00 9058571 $922.00 90 59020-26 $40.00 0 59855 $477.00 9058572 $1,047.00 90 59020-TC $23.00 0 59856 $577.00 9058573 $1,178.00 90 59025 $54.00 0 59857 $711.00 9058578 BR YYY 59025-26 $32.00 0 59866 $304.00 058579 BR YYY 59025-TC $10.00 0 59870 $348.00 9058600 $337.00 90 59030 $155.00 0 59871 $192.00 058605 $298.00 90 59050 $71.00 0 59898 BR YYY58611 $47.00 ZZZ 59051 $47.00 0 59899 BR YYY58615 $319.00 10 59100 $633.00 90 60000 $114.00 1058660 $793.00 90 59120 $893.00 90 60100 $96.00 058661 $804.00 10 59121 $768.00 90 60200 $744.00 9058662 $807.00 90 59130 $832.00 90 60210 $872.00 9058670 $450.00 90 59135 $1,083.00 90 60212 $1,170.00 9058671 $463.00 90 59136 $934.00 90 60220 $851.00 9058672 $872.00 90 59140 $461.00 90 60225 $1,107.00 9058673 $928.00 90 59150 $543.00 90 60240 $1,228.00 9058679 BR YYY 59151 $690.00 90 60252 $1,427.00 9058700 $544.00 90 59160 $279.00 10 60254 $1,911.00 9058720 $844.00 90 59200 $79.00 0 60260 $1,022.00 9058740 $508.00 90 59300 $179.00 0 60270 $1,468.00 9058750 $949.00 90 59320 $196.00 0 60271 $1,210.00 9058752 $893.00 90 59325 $316.00 0 60280 $546.00 9058760 $769.00 90 59350 $375.00 0 60281 $670.00 9058770 $763.00 90 59400 $1,816.00 0 60300 $99.00 058800 $343.00 90 59409 $1,019.00 0 60500 $1,232.00 9058805 $509.00 90 59410 $1,123.00 0 60502 $1,475.00 9058820 $326.00 90 59412 $141.00 0 60505 $1,631.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD60512 $310.00 ZZZ 61460 $2,426.00 90 61581 $2,674.00 9060520 $1,405.00 90 61470 $1,982.00 90 61582 $2,557.00 9060521 $1,591.00 90 61480 $1,922.00 90 61583 $2,972.00 9060522 $1,820.00 90 61490 $1,687.00 90 61584 $2,830.00 9060540 $1,272.00 90 61500 $1,637.00 90 61585 $3,142.00 9060545 $1,505.00 90 61501 $1,353.00 90 61586 $2,097.00 9060600 $1,477.00 90 61510 $2,506.00 90 61590 $3,299.00 9060605 $1,624.00 90 61512 $2,981.00 90 61591 $3,491.00 9060650 $1,340.00 90 61514 $2,262.00 90 61592 $3,245.00 9060659 BR YYY 61516 $2,253.00 90 61595 $2,350.00 9060699 BR YYY 61517 $74.00 ZZZ 61596 $2,827.00 9061020 $150.00 0 61518 $3,163.00 90 61597 $3,046.00 9061026 $138.00 0 61519 $3,450.00 90 61598 $2,693.00 9061050 $106.00 0 61520 $4,349.00 90 61600 $2,039.00 9061055 $143.00 0 61521 $3,667.00 90 61601 $2,279.00 9061070 $67.00 0 61522 $2,415.00 90 61605 $2,299.00 9061105 $503.00 90 61524 $2,484.00 90 61606 $3,178.00 9061107 $863.00 0 61526 $3,918.00 90 61607 $2,961.00 9061108 $959.00 90 61530 $3,611.00 90 61608 $3,458.00 9061120 $733.00 90 61531 $1,344.00 90 61609 $798.00 ZZZ61140 $1,389.00 90 61533 $1,712.00 90 61610 $2,354.00 ZZZ61150 $1,503.00 90 61534 $1,535.00 90 61611 $584.00 ZZZ61151 $795.00 90 61535 $958.00 90 61612 $2,219.00 ZZZ61154 $1,393.00 90 61536 $2,862.00 90 61613 $3,375.00 9061156 $1,473.00 90 61537 $1,714.00 90 61615 $2,576.00 9061210 $527.00 0 61538 $2,466.00 90 61616 $3,535.00 9061215 $637.00 90 61539 $2,660.00 90 61618 $1,389.00 9061250 $888.00 90 61540 $2,069.00 90 61619 $1,682.00 9061253 $1,042.00 90 61541 $2,363.00 90 61623 $540.00 061304 $2,005.00 90 61542 $2,533.00 90 61624 $1,073.00 061305 $2,419.00 90 61543 $2,307.00 90 61626 $877.00 061312 $2,187.00 90 61544 $2,271.00 90 61630 $1,245.00 9061313 $2,207.00 90 61545 $3,474.00 90 61635 $1,362.00 9061314 $2,200.00 90 61546 $2,695.00 90 61640 $555.00 061315 $2,393.00 90 61548 $1,964.00 90 61641 $195.00 ZZZ61316 $88.00 ZZZ 61550 $1,141.00 90 61642 $390.00 ZZZ61320 $2,118.00 90 61552 $1,463.00 90 61680 $2,758.00 9061321 $2,310.00 90 61556 $1,760.00 90 61682 $4,798.00 9061322 $1,779.00 90 61557 $1,807.00 90 61684 $3,341.00 9061323 $1,842.00 90 61558 $2,085.00 90 61686 $5,012.00 9061330 $1,706.00 90 61559 $2,700.00 90 61690 $2,556.00 9061332 $2,307.00 90 61563 $2,175.00 90 61692 $4,007.00 9061333 $2,231.00 90 61564 $2,597.00 90 61697 $3,231.00 9061334 $1,525.00 90 61566 $2,048.00 90 61698 $3,103.00 9061340 $1,584.00 90 61567 $2,340.00 90 61700 $4,037.00 9061343 $2,673.00 90 61570 $1,975.00 90 61702 $4,019.00 9061345 $2,259.00 90 61571 $2,140.00 90 61703 $1,444.00 9061440 $2,110.00 90 61575 $2,992.00 90 61705 $3,043.00 9061450 $2,173.00 90 61576 $3,772.00 90 61708 $2,546.00 9061458 $2,433.00 90 61580 $2,383.00 90 61710 $2,129.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD61711 $3,150.00 90 62201 $1,200.00 90 63040 $1,764.00 9061720 $1,558.00 90 62220 $1,215.00 90 63042 $1,620.00 9061735 $1,664.00 90 62223 $1,199.00 90 63043 BR ZZZ61750 $1,521.00 90 62225 $488.00 90 63044 BR ZZZ61751 $1,628.00 90 62230 $935.00 90 63045 $1,647.00 9061760 $1,670.00 90 62252 $85.00 0 63046 $2,117.00 9061770 $1,867.00 90 62252-26 $49.00 0 63047 $1,907.00 9061790 $952.00 90 62252-TC $42.00 0 63048 $367.00 ZZZ61791 $1,205.00 90 62256 $616.00 90 63050 $1,411.00 9061795 $371.00 ZZZ 62258 $1,308.00 90 63051 $1,605.00 9061850 $1,090.00 90 62263 $426.00 10 63055 $2,029.00 9061860 $1,197.00 90 62264 $593.00 10 63056 $1,960.00 9061863 $1,231.00 90 62268 $285.00 0 63057 $421.00 ZZZ61864 $295.00 ZZZ 62269 $271.00 0 63064 $2,200.00 9061867 $1,863.00 90 62270 $109.00 0 63066 $263.00 ZZZ61868 $491.00 ZZZ 62272 $137.00 0 63075 $1,720.00 9061870 $616.00 90 62273 $130.00 0 63076 $383.00 ZZZ61875 $984.00 90 62280 $199.00 10 63077 $1,828.00 9061880 $559.00 90 62281 $186.00 10 63078 $261.00 ZZZ61885 $262.00 90 62282 $211.00 10 63081 $2,203.00 9061886 $678.00 90 62284 $196.00 0 63082 $391.00 ZZZ61888 $331.00 10 62287 $784.00 90 63085 $2,416.00 9062000 $848.00 90 62290 $235.00 0 63086 $282.00 ZZZ62005 $1,282.00 90 62291 $232.00 0 63087 $2,930.00 9062010 $1,754.00 90 62292 $1,064.00 90 63088 $381.00 ZZZ62100 $1,962.00 90 62294 $821.00 90 63090 $2,490.00 9062115 $1,686.00 90 62310 $200.00 0 63091 $249.00 ZZZ62116 $1,928.00 90 62311 $201.00 0 63101 $2,127.00 9062117 $2,211.00 90 62318 $208.00 0 63102 $2,127.00 9062120 $1,898.00 90 62319 $203.00 0 63103 $249.00 ZZZ62121 $1,822.00 90 62350 $488.00 90 63170 $1,788.00 9062140 $1,221.00 90 62351 $782.00 90 63172 $1,672.00 9062141 $1,955.00 90 62355 $402.00 90 63173 $1,851.00 9062142 $1,011.00 90 62360 $195.00 90 63180 $1,486.00 9062143 $1,096.00 90 62361 $390.00 90 63182 $1,711.00 9062145 $1,566.00 90 62362 $517.00 90 63185 $1,347.00 9062146 $1,327.00 90 62365 $418.00 90 63190 $1,610.00 9062147 $1,566.00 90 62367 $39.00 0 63191 $1,444.00 9062148 $120.00 ZZZ 62368 $53.00 0 63194 $1,593.00 9062160 $172.00 ZZZ 63001 $1,882.00 90 63195 $1,603.00 9062161 $1,229.00 90 63003 $1,591.00 90 63196 $1,810.00 9062162 $1,578.00 90 63005 $1,390.00 90 63197 $1,725.00 9062163 $999.00 90 63011 $1,151.00 90 63198 $1,956.00 9062164 $1,706.00 90 63012 $1,568.00 90 63199 $2,258.00 9062165 $1,336.00 90 63015 $1,862.00 90 63200 $1,569.00 9062180 $1,695.00 90 63016 $1,788.00 90 63250 $3,182.00 9062190 $1,034.00 90 63017 $1,489.00 90 63251 $3,207.00 9062192 $1,146.00 90 63020 $1,395.00 90 63252 $3,319.00 9062194 $239.00 10 63030 $1,145.00 90 63265 $1,940.00 9062200 $1,625.00 90 63035 $280.00 ZZZ 63266 $2,053.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD63267 $1,651.00 90 64408 $120.00 0 64612 $188.00 1063268 $1,469.00 90 64410 $109.00 0 64613 $168.00 1063270 $2,197.00 90 64412 $89.00 0 64614 $200.00 1063271 $2,401.00 90 64413 $128.00 0 64620 $185.00 1063272 $2,206.00 90 64415 $109.00 0 64622 $333.00 1063273 $2,012.00 90 64416 $159.00 10 64623 $113.00 ZZZ63275 $2,166.00 90 64417 $105.00 0 64626 $262.00 1063276 $2,135.00 90 64418 $108.00 0 64627 $151.00 ZZZ63277 $1,905.00 90 64420 $89.00 0 64630 $202.00 1063278 $1,877.00 90 64421 $128.00 0 64640 $208.00 1063280 $2,529.00 90 64425 $116.00 0 64650 $62.00 063281 $2,496.00 90 64430 $130.00 0 64653 $71.00 063282 $2,305.00 90 64435 $114.00 0 64680 $180.00 1063283 $2,041.00 90 64445 $68.00 0 64681 $464.00 1063285 $2,934.00 90 64446 $165.00 10 64702 $383.00 9063286 $3,003.00 90 64447 $77.00 0 64704 $402.00 9063287 $3,012.00 90 64448 $152.00 10 64708 $562.00 9063290 $3,073.00 90 64449 $152.00 10 64712 $678.00 9063295 $319.00 ZZZ 64450 $53.00 0 64713 $867.00 9063300 $2,006.00 90 64470 $206.00 0 64714 $715.00 9063301 $2,209.00 90 64472 $166.00 ZZZ 64716 $523.00 9063302 $2,290.00 90 64475 $183.00 0 64718 $558.00 9063303 $2,357.00 90 64476 $166.00 ZZZ 64719 $446.00 9063304 $2,513.00 90 64479 $224.00 0 64721 $439.00 9063305 $2,574.00 90 64480 $194.00 ZZZ 64722 $411.00 9063306 $2,596.00 90 64483 $206.00 0 64726 $271.00 9063307 $2,522.00 90 64484 $183.00 ZZZ 64727 $261.00 ZZZ63308 $425.00 ZZZ 64505 $104.00 0 64732 $405.00 9063600 $797.00 90 64508 $99.00 0 64734 $432.00 9063610 $476.00 0 64510 $103.00 0 64736 $388.00 9063615 $1,348.00 90 64517 $188.00 0 64738 $475.00 9063650 $819.00 90 64520 $131.00 0 64740 $461.00 9063655 $1,064.00 90 64530 $135.00 0 64742 $517.00 9063660 $707.00 90 64550 $23.00 0 64744 $798.00 9063685 $615.00 90 64553 $137.00 10 64746 $494.00 9063688 $707.00 90 64555 $131.00 10 64752 $560.00 9063700 $1,340.00 90 64560 $197.00 10 64755 $1,042.00 9063702 $1,512.00 90 64561 $801.00 10 64760 $578.00 9063704 $1,708.00 90 64565 $121.00 10 64761 $495.00 9063706 $1,873.00 90 64573 $464.00 90 64763 $561.00 9063707 $1,041.00 90 64575 $367.00 90 64766 $713.00 9063709 $1,310.00 90 64577 $381.00 90 64771 $632.00 9063710 $1,165.00 90 64580 $343.00 90 64772 $636.00 9063740 $1,062.00 90 64581 $745.00 90 64774 $392.00 9063741 $741.00 90 64585 $37.00 10 64776 $390.00 9063744 $738.00 90 64590 $217.00 10 64778 $249.00 ZZZ63746 $529.00 90 64595 $153.00 10 64782 $482.00 9064400 $78.00 0 64600 $228.00 10 64783 $298.00 ZZZ64402 $75.00 0 64605 $319.00 10 64784 $751.00 9064405 $103.00 0 64610 $307.00 10 64786 $1,281.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD64787 $458.00 ZZZ 64999 BR YYY 65800 $88.00 064788 $381.00 90 65091 $678.00 90 65805 $178.00 064790 $884.00 90 65093 $712.00 90 65810 $516.00 9064792 $1,148.00 90 65101 $726.00 90 65815 $327.00 9064795 $247.00 0 65103 $769.00 90 65820 $813.00 9064802 $711.00 90 65105 $846.00 90 65850 $968.00 9064804 $1,202.00 90 65110 $1,305.00 90 65855 $441.00 1064809 $1,080.00 90 65112 $1,386.00 90 65860 $339.00 9064818 $845.00 90 65114 $1,456.00 90 65865 $540.00 9064820 $838.00 90 65125 $312.00 90 65870 $572.00 9064821 $609.00 90 65130 $730.00 90 65875 $597.00 9064822 $609.00 90 65135 $678.00 90 65880 $641.00 9064823 $703.00 90 65140 $738.00 90 65900 $945.00 9064831 $592.00 90 65150 $652.00 90 65920 $752.00 9064832 $171.00 ZZZ 65155 $862.00 90 65930 $700.00 9064834 $711.00 90 65175 $654.00 90 66020 $164.00 1064835 $834.00 90 65205 $45.00 0 66030 $160.00 1064836 $856.00 90 65210 $53.00 0 66130 $631.00 9064837 $480.00 ZZZ 65220 $58.00 0 66150 $798.00 9064840 $1,058.00 90 65222 $62.00 0 66155 $795.00 9064856 $1,063.00 90 65235 $627.00 90 66160 $942.00 9064857 $1,137.00 90 65260 $956.00 90 66165 $769.00 9064858 $1,313.00 90 65265 $1,104.00 90 66170 $1,089.00 9064859 $341.00 ZZZ 65270 $88.00 10 66172 $1,264.00 9064861 $1,524.00 90 65272 $223.00 90 66180 $1,313.00 9064862 $1,798.00 90 65273 $376.00 90 66185 $769.00 9064864 $970.00 90 65275 $75.00 90 66220 $711.00 9064865 $1,250.00 90 65280 $711.00 90 66225 $1,006.00 9064866 $1,238.00 90 65285 $1,177.00 90 66250 $602.00 9064868 $1,162.00 90 65286 $692.00 90 66500 $359.00 9064870 $1,313.00 90 65290 $519.00 90 66505 $359.00 9064872 $155.00 ZZZ 65400 $603.00 90 66600 $825.00 9064874 $230.00 ZZZ 65410 $142.00 0 66605 $1,136.00 9064876 $189.00 ZZZ 65420 $448.00 90 66625 $543.00 9064885 $1,382.00 90 65426 $534.00 90 66630 $623.00 9064886 $1,636.00 90 65430 $81.00 0 66635 $595.00 9064890 $1,112.00 90 65435 $88.00 0 66680 $526.00 9064891 $1,243.00 90 65436 $319.00 90 66682 $627.00 9064892 $1,177.00 90 65450 $52.00 90 66700 $506.00 9064893 $1,321.00 90 65600 $325.00 90 66710 $513.00 9064895 $1,500.00 90 65710 $1,124.00 90 66711 $507.00 9064896 $1,185.00 90 65730 $1,314.00 90 66720 $506.00 9064897 $1,419.00 90 65750 $1,381.00 90 66740 $473.00 9064898 $1,549.00 90 65755 $1,373.00 90 66761 $506.00 9064901 $865.00 ZZZ 65770 $1,461.00 90 66762 $433.00 9064902 $982.00 ZZZ 65772 $449.00 90 66770 $483.00 9064905 $1,059.00 90 65775 $595.00 90 66820 $433.00 9064907 $1,472.00 90 65780 $766.00 90 66821 $275.00 9064910 $645.00 90 65781 $1,169.00 90 66825 $753.00 9064911 $783.00 90 65782 $1,008.00 90 66830 $651.00 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD66840 $707.00 90 67299 BR YYY 67882 $643.00 9066850 $805.00 90 67311 $616.00 90 67900 $487.00 9066852 $878.00 90 67312 $773.00 90 67901 $646.00 9066920 $785.00 90 67314 $688.00 90 67902 $650.00 9066930 $906.00 90 67316 $857.00 90 67903 $657.00 9066940 $819.00 90 67318 $663.00 90 67904 $720.00 9066982 $846.00 90 67320 $602.00 ZZZ 67906 $633.00 9066983 $763.00 90 67331 $560.00 ZZZ 67908 $550.00 9066984 $898.00 90 67332 $621.00 ZZZ 67909 $577.00 9066985 $744.00 90 67334 $447.00 ZZZ 67911 $517.00 9066986 $1,038.00 90 67335 $253.00 ZZZ 67912 $983.00 9066990 $84.00 ZZZ 67340 $559.00 ZZZ 67914 $487.00 9066999 BR YYY 67343 $628.00 90 67915 $252.00 9067005 $639.00 90 67345 $275.00 10 67916 $675.00 9067010 $647.00 90 67346 $173.00 0 67917 $631.00 9067015 $637.00 90 67399 BR YYY 67921 $419.00 9067025 $774.00 90 67400 $960.00 90 67922 $243.00 9067027 $1,089.00 90 67405 $799.00 90 67923 $718.00 9067028 $338.00 0 67412 $976.00 90 67924 $605.00 9067030 $485.00 90 67413 $909.00 90 67930 $280.00 1067031 $402.00 90 67414 $1,023.00 90 67935 $520.00 9067036 $1,384.00 90 67415 $146.00 0 67938 $67.00 1067039 $1,490.00 90 67420 $1,729.00 90 67950 $584.00 9067040 $1,960.00 90 67430 $1,203.00 90 67961 $571.00 9067041 $1,065.00 90 67440 $1,257.00 90 67966 $645.00 9067042 $1,218.00 90 67445 $1,269.00 90 67971 $875.00 9067043 $1,279.00 90 67450 $1,300.00 90 67973 $1,126.00 9067101 $767.00 90 67500 $75.00 0 67974 $1,140.00 9067105 $941.00 90 67505 $109.00 0 67975 $681.00 9067107 $1,350.00 90 67515 $53.00 0 67999 BR YYY67108 $1,878.00 90 67550 $946.00 90 68020 $106.00 1067110 $1,040.00 90 67560 $936.00 90 68040 $75.00 067112 $1,500.00 90 67570 $1,148.00 90 68100 $137.00 067113 $1,405.00 90 67599 BR YYY 68110 $172.00 1067115 $496.00 90 67700 $87.00 10 68115 $248.00 1067120 $751.00 90 67710 $117.00 10 68130 $378.00 9067121 $962.00 90 67715 $102.00 10 68135 $146.00 1067141 $536.00 90 67800 $119.00 10 68200 $59.00 067145 $514.00 90 67801 $189.00 10 68320 $502.00 9067208 $655.00 90 67805 $208.00 10 68325 $672.00 9067210 $779.00 90 67808 $308.00 90 68326 $654.00 9067218 $1,217.00 90 67810 $133.00 0 68328 $741.00 9067220 $894.00 90 67820 $36.00 0 68330 $488.00 9067221 $325.00 0 67825 $130.00 10 68335 $636.00 9067225 $44.00 ZZZ 67830 $239.00 10 68340 $413.00 9067227 $652.00 90 67835 $500.00 90 68360 $449.00 9067228 $1,025.00 90 67840 $187.00 10 68362 $691.00 9067229 $926.00 90 67850 $143.00 10 68371 $363.00 1067250 $793.00 90 67875 $163.00 0 68399 BR YYY67255 $872.00 90 67880 $442.00 90 68400 $154.00 10

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD68420 $191.00 10 69421 $155.00 10 69720 $1,307.00 9068440 $96.00 10 69424 $84.00 0 69725 $1,922.00 9068500 $882.00 90 69433 $145.00 10 69740 $1,274.00 9068505 $921.00 90 69436 $182.00 10 69745 $1,447.00 9068510 $491.00 0 69440 $699.00 90 69799 BR YYY68520 $687.00 90 69450 $525.00 90 69801 $785.00 9068525 $340.00 0 69501 $829.00 90 69802 $1,115.00 9068530 $379.00 10 69502 $1,118.00 90 69805 $1,187.00 9068540 $875.00 90 69505 $1,176.00 90 69806 $1,123.00 9068550 $1,107.00 90 69511 $1,221.00 90 69820 $876.00 9068700 $628.00 90 69530 $1,616.00 90 69840 $869.00 9068705 $176.00 10 69535 $2,824.00 90 69905 $1,013.00 9068720 $807.00 90 69540 $126.00 10 69910 $1,228.00 9068745 $704.00 90 69550 $998.00 90 69915 $1,754.00 9068750 $792.00 90 69552 $1,621.00 90 69930 $1,498.00 9068760 $109.00 10 69554 $2,600.00 90 69949 BR YYY68761 $130.00 10 69601 $1,195.00 90 69950 $2,017.00 9068770 $634.00 90 69602 $1,225.00 90 69955 $2,185.00 9068801 $202.00 10 69603 $1,264.00 90 69960 $2,116.00 9068810 $290.00 10 69604 $1,263.00 90 69970 $2,306.00 9068811 $191.00 10 69605 $1,526.00 90 69979 BR YYY68815 $399.00 10 69610 $41.00 10 69990 $262.00 ZZZ68816 $592.00 10 69620 $651.00 90 G0127 $17.00 068840 $100.00 10 69631 $985.00 90 G0168 $75.00 068850 $76.00 0 69632 $1,166.00 90 G0247 $38.00 ZZZ68899 BR YYY 69633 $1,110.00 90 G0289 $82.00 ZZZ69000 $52.00 10 69635 $1,207.00 90 G0341 $333.00 069005 $175.00 10 69636 $1,381.00 90 G0342 $622.00 9069020 $109.00 10 69637 $1,370.00 90 G0343 $1,026.00 9069100 $85.00 0 69641 $1,154.00 90 G0364 $12.00 ZZZ69105 $87.00 0 69642 $1,519.00 90 G0392 $2,097.00 069110 $294.00 90 69643 $1,389.00 90 G0393 $1,587.00 069120 $274.00 90 69644 $1,529.00 9069140 $722.00 90 69645 $1,479.00 9069145 $248.00 90 69646 $1,620.00 9069150 $1,111.00 90 69650 $879.00 9069155 $1,680.00 90 69660 $1,072.00 9069200 $53.00 0 69661 $1,412.00 9069205 $110.00 10 69662 $1,386.00 9069210 $39.00 0 69666 $887.00 9069220 $78.00 0 69667 $887.00 9069222 $123.00 10 69670 $988.00 9069300 $522.00 YYY 69676 $828.00 9069310 $937.00 90 69700 $702.00 9069320 $1,434.00 90 69710 BR 069399 BR YYY 69711 $878.00 9069400 $76.00 0 69714 $961.00 9069401 $52.00 0 69715 $1,217.00 9069405 $176.00 10 69717 $996.00 9069420 $117.00 10 69718 $1,232.00 90

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Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA70010 $70.00 70240-TC $15.00 70390-26 $19.0070010-26 $19.00 70250 $35.00 70390-TC $68.0070010-TC $51.00 70250-26 $12.00 70450 $221.0070015 $58.00 70250-TC $22.00 70450-26 $43.0070015-26 $31.00 70260 $50.00 70450-TC $176.0070015-TC $27.00 70260-26 $17.00 70460 $271.0070030 $24.00 70260-TC $33.00 70460-26 $58.0070030-26 $10.00 70300 $15.00 70460-TC $211.0070030-TC $15.00 70300-26 $5.00 70470 $332.0070100 $29.00 70300-TC $10.00 70470-26 $65.0070100-26 $9.00 70310 $24.00 70470-TC $264.0070100-TC $19.00 70310-26 $8.00 70480 $244.0070110 $36.00 70310-TC $15.00 70480-26 $65.0070110-26 $12.00 70320 $40.00 70480-TC $176.0070110-TC $22.00 70320-26 $11.00 70481 $284.0070120 $32.00 70320-TC $29.00 70481-26 $70.0070120-26 $9.00 70328 $28.00 70481-TC $211.0070120-TC $22.00 70328-26 $10.00 70482 $340.0070130 $46.00 70328-TC $18.00 70482-26 $74.0070130-26 $17.00 70330 $43.00 70482-TC $264.0070130-TC $29.00 70330-26 $12.00 70486 $236.0070134 $45.00 70330-TC $31.00 70486-26 $58.0070134-26 $17.00 70332 $107.00 70486-TC $176.0070134-TC $28.00 70332-26 $27.00 70487 $279.0070140 $33.00 70332-TC $80.00 70487-26 $66.0070140-26 $9.00 70336 $497.00 70487-TC $211.0070140-TC $22.00 70336-26 $72.00 70488 $339.0070150 $42.00 70336-TC $419.00 70488-26 $72.0070150-26 $12.00 70350 $24.00 70488-TC $264.0070150-TC $29.00 70350-26 $10.00 70490 $244.0070160 $29.00 70350-TC $14.00 70490-26 $65.0070160-26 $8.00 70355 $32.00 70490-TC $176.0070160-TC $19.00 70355-26 $10.00 70491 $284.0070170 $52.00 70355-TC $21.00 70491-26 $70.0070170-26 $15.00 70360 $24.00 70491-TC $211.0070170-TC $37.00 70360-26 $8.00 70492 $340.0070190 $34.00 70360-TC $15.00 70492-26 $74.0070190-26 $10.00 70370 $65.00 70492-TC $264.0070190-TC $22.00 70370-26 $16.00 70496 $366.0070200 $43.00 70370-TC $48.00 70496-26 $92.0070200-26 $14.00 70371 $122.00 70496-TC $270.0070200-TC $29.00 70371-26 $43.00 70498 $366.0070210 $32.00 70371-TC $79.00 70498-26 $92.0070210-26 $8.00 70373 $90.00 70498-TC $270.0070210-TC $22.00 70373-26 $22.00 70540 $482.0070220 $42.00 70373-TC $68.00 70540-26 $70.0070220-26 $12.00 70380 $34.00 70540-TC $413.0070220-TC $29.00 70380-26 $8.00 70542 $579.0070240 $26.00 70380-TC $24.00 70542-26 $82.0070240-26 $9.00 70390 $87.00 70542-TC $495.00

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Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA70543 $1,029.00 71015-TC $19.00 71250-26 $59.0070543-26 $109.00 71020 $35.00 71250-TC $220.0070543-TC $916.00 71020-26 $11.00 71260 $328.0070544 $481.00 71020-TC $22.00 71260-26 $63.0070544-26 $61.00 71021 $41.00 71260-TC $264.0070544-TC $419.00 71021-26 $13.00 71270 $402.0070545 $481.00 71021-TC $28.00 71270-26 $70.0070545-26 $61.00 71022 $44.00 71270-TC $330.0070545-TC $419.00 71022-26 $16.00 71275 $431.0070546 $914.00 71022-TC $28.00 71275-26 $100.0070546-26 $92.00 71023 $49.00 71275-TC $328.0070546-TC $820.00 71023-26 $19.00 71550 $490.0070547 $481.00 71023-TC $29.00 71550-26 $75.0070547-26 $61.00 71030 $45.00 71550-TC $415.0070547-TC $419.00 71030-26 $16.00 71551 $587.0070548 $481.00 71030-TC $29.00 71551-26 $88.0070548-26 $61.00 71034 $79.00 71551-TC $496.0070548-TC $419.00 71034-26 $23.00 71552 $1,029.0070549 $914.00 71034-TC $54.00 71552-26 $114.0070549-26 $92.00 71035 $56.00 71552-TC $911.0070549-TC $820.00 71035-26 $19.00 71555 $514.0070551 $497.00 71035-TC $38.00 71555-26 $92.0070551-26 $76.00 71040 $34.00 71555-TC $419.0070551-TC $419.00 71040-26 $12.00 72010 $62.0070552 $596.00 71040-TC $22.00 72010-26 $22.0070552-26 $91.00 71060 $108.00 72010-TC $38.0070552-TC $502.00 71060-26 $33.00 72020 $22.0070553 $1,055.00 71060-TC $75.00 72020-26 $7.0070553-26 $120.00 71090 $92.00 72020-TC $15.0070553-TC $931.00 71090-26 $28.00 72040 $34.0070554 $618.00 71090-TC $64.00 72040-26 $11.0070554-26 $99.00 71100 $33.00 72040-TC $22.0070554-TC $520.00 71100-26 $11.00 72050 $49.0070555 BR 71100-TC $21.00 72050-26 $16.0070555-26 $118.00 71101 $38.00 72050-TC $33.0070555-TC BR 71101-26 $13.00 72052 $61.0070557 $392.00 71101-TC $24.00 72052-26 $18.0070557-26 $148.00 71110 $43.00 72052-TC $42.0070557-TC $349.00 71110-26 $13.00 72069 $40.0070558 $425.00 71110-TC $29.00 72069-26 $17.0070558-26 $164.00 71111 $49.00 72069-TC $24.0070558-TC $376.00 71111-26 $16.00 72070 $36.0070559 $548.00 71111-TC $33.00 72070-26 $11.0070559-26 $164.00 71120 $35.00 72070-TC $24.0070559-TC $499.00 71120-26 $10.00 72072 $39.0071010 $27.00 71120-TC $24.00 72072-26 $11.0071010-26 $9.00 71130 $38.00 72072-TC $28.0071010-TC $17.00 71130-26 $11.00 72074 $45.0071015 $30.00 71130-TC $26.00 72074-26 $11.0071015-26 $10.00 71250 $282.00 72074-TC $34.00

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Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA72080 $36.00 72142-TC $502.00 72197-26 $114.0072080-26 $11.00 72146 $549.00 72197-TC $919.0072080-TC $24.00 72146-26 $82.00 72198 $517.0072090 $39.00 72146-TC $465.00 72198-26 $95.0072090-26 $14.00 72147 $603.00 72198-TC $419.0072090-TC $24.00 72147-26 $98.00 72200 $29.0072100 $36.00 72147-TC $502.00 72200-26 $9.0072100-26 $11.00 72148 $543.00 72200-TC $19.0072100-TC $24.00 72148-26 $76.00 72202 $33.0072110 $50.00 72148-TC $465.00 72202-26 $9.0072110-26 $16.00 72149 $597.00 72202-TC $22.0072110-TC $34.00 72149-26 $92.00 72220 $30.0072114 $64.00 72149-TC $502.00 72220-26 $8.0072114-26 $18.00 72156 $1,066.00 72220-TC $21.0072114-TC $44.00 72156-26 $131.00 72240 $132.0072120 $45.00 72156-TC $931.00 72240-26 $26.0072120-26 $11.00 72157 $1,066.00 72240-TC $106.0072120-TC $33.00 72157-26 $131.00 72255 $129.0072125 $282.00 72157-TC $931.00 72255-26 $28.0072125-26 $59.00 72158 $1,056.00 72255-TC $101.0072125-TC $220.00 72158-26 $121.00 72265 $132.0072126 $328.00 72158-TC $931.00 72265-26 $28.0072126-26 $62.00 72159 $563.00 72265-TC $104.0072126-TC $264.00 72159-26 $94.00 72270 $176.0072127 $397.00 72159-TC $465.00 72270-26 $39.0072127-26 $65.00 72170 $29.00 72270-TC $137.0072127-TC $330.00 72170-26 $8.00 72275 $112.0072128 $282.00 72170-TC $19.00 72275-26 $34.0072128-26 $59.00 72190 $35.00 72275-TC $78.0072128-TC $220.00 72190-26 $10.00 72285 $101.0072129 $328.00 72190-TC $24.00 72285-26 $15.0072129-26 $62.00 72191 $413.00 72285-TC $86.0072129-TC $264.00 72191-26 $94.00 72291 $178.0072130 $397.00 72191-TC $315.00 72291-26 $66.0072130-26 $65.00 72192 $278.00 72291-TC $157.0072130-TC $330.00 72192-26 $56.00 72292 BR72131 $282.00 72192-TC $220.00 72292-26 $67.0072131-26 $59.00 72193 $317.00 72292-TC BR72131-TC $220.00 72193-26 $59.00 72295 $107.0072132 $328.00 72193-TC $256.00 72295-26 $13.0072132-26 $62.00 72194 $380.00 72295-TC $94.0072132-TC $264.00 72194-26 $62.00 73000 $28.0072133 $391.00 72194-TC $317.00 73000-26 $8.0072133-26 $65.00 72195 $491.00 73000-TC $19.0072133-TC $323.00 72195-26 $74.00 73010 $29.0072141 $503.00 72195-TC $415.00 73010-26 $8.0072141-26 $82.00 72196 $526.00 73010-TC $19.0072141-TC $419.00 72196-26 $84.00 73020 $26.0072142 $604.00 72196-TC $442.00 73020-26 $7.0072142-26 $99.00 72197 $1,037.00 73020-TC $17.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 83

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Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA73030 $31.00 73202-TC $277.00 73562-26 $9.0073030-26 $9.00 73206 $375.00 73562-TC $21.0073030-TC $21.00 73206-26 $94.00 73564 $35.0073040 $68.00 73206-TC $277.00 73564-26 $11.0073040-26 $17.00 73218 $482.00 73564-TC $22.0073040-TC $51.00 73218-26 $68.00 73565 $28.0073050 $35.00 73218-TC $413.00 73565-26 $8.0073050-26 $10.00 73219 $579.00 73565-TC $18.0073050-TC $24.00 73219-26 $82.00 73580 $84.0073060 $30.00 73219-TC $495.00 73580-26 $18.0073060-26 $8.00 73220 $520.00 73580-TC $66.0073060-TC $21.00 73220-26 $78.00 73590 $29.0073070 $27.00 73220-TC $442.00 73590-26 $8.0073070-26 $7.00 73221 $482.00 73590-TC $19.0073070-TC $19.00 73221-26 $68.00 73600 $27.0073080 $30.00 73221-TC $413.00 73600-26 $8.0073080-26 $8.00 73222 $579.00 73600-TC $18.0073080-TC $21.00 73222-26 $82.00 73610 $29.0073085 $74.00 73222-TC $495.00 73610-26 $8.0073085-26 $19.00 73223 $1,029.00 73610-TC $19.0073085-TC $55.00 73223-26 $109.00 73615 $72.0073090 $28.00 73223-TC $916.00 73615-26 $19.0073090-26 $8.00 73225 $513.00 73615-TC $53.0073090-TC $19.00 73225-26 $92.00 73620 $27.0073100 $27.00 73225-TC $419.00 73620-26 $8.0073100-26 $8.00 73500 $27.00 73620-TC $18.0073100-TC $18.00 73500-26 $8.00 73630 $29.0073110 $29.00 73500-TC $17.00 73630-26 $8.0073110-26 $8.00 73510 $32.00 73630-TC $19.0073110-TC $19.00 73510-26 $10.00 73650 $26.0073115 $54.00 73510-TC $21.00 73650-26 $8.0073115-26 $17.00 73520 $38.00 73650-TC $17.0073115-TC $37.00 73520-26 $12.00 73660 $22.0073120 $27.00 73520-TC $24.00 73660-26 $7.0073120-26 $8.00 73525 $84.00 73660-TC $15.0073120-TC $18.00 73525-26 $21.00 73700 $242.0073130 $29.00 73525-TC $63.00 73700-26 $56.0073130-26 $8.00 73530 $34.00 73700-TC $185.0073130-TC $19.00 73530-26 $14.00 73701 $282.0073140 $22.00 73530-TC $19.00 73701-26 $61.0073140-26 $7.00 73542 $108.00 73701-TC $220.0073140-TC $15.00 73542-26 $28.00 73702 $341.0073200 $242.00 73542-TC $80.00 73702-26 $62.0073200-26 $56.00 73550 $30.00 73702-TC $277.0073200-TC $185.00 73550-26 $8.00 73706 $379.0073201 $282.00 73550-TC $21.00 73706-26 $98.0073201-26 $59.00 73560 $29.00 73706-TC $277.0073201-TC $220.00 73560-26 $8.00 73718 $482.0073202 $342.00 73560-TC $19.00 73718-26 $68.0073202-26 $63.00 73562 $31.00 73718-TC $413.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 84

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA73719 $579.00 74183-TC $919.00 74280-26 $50.0073719-26 $82.00 74185 $514.00 74280-TC $84.0073719-TC $495.00 74185-26 $92.00 74283 $201.0073720 $520.00 74185-TC $419.00 74283-26 $103.0073720-26 $78.00 74190 $73.00 74283-TC $95.0073720-TC $442.00 74190-26 $24.00 74290 $44.0073721 $482.00 74190-TC $49.00 74290-26 $16.0073721-26 $68.00 74210 $63.00 74290-TC $28.0073721-TC $413.00 74210-26 $18.00 74291 $26.0073722 $579.00 74210-TC $44.00 74291-26 $10.0073722-26 $82.00 74220 $68.00 74291-TC $15.0073722-TC $495.00 74220-26 $23.00 74300 $31.0073723 $1,029.00 74220-TC $44.00 74300-26 $19.0073723-26 $109.00 74230 $77.00 74300-TC $104.0073723-TC $916.00 74230-26 $27.00 74301 $107.0073725 $515.00 74230-TC $48.00 74301-26 $11.0073725-26 $92.00 74235 $160.00 74301-TC $104.0073725-TC $419.00 74235-26 $60.00 74305 $51.0074000 $29.00 74235-TC $100.00 74305-26 $21.0074000-26 $9.00 74240 $91.00 74305-TC $30.0074000-TC $19.00 74240-26 $35.00 74320 $145.0074010 $33.00 74240-TC $55.00 74320-26 $26.0074010-26 $11.00 74241 $91.00 74320-TC $119.0074010-TC $21.00 74241-26 $35.00 74327 $103.0074020 $37.00 74241-TC $56.00 74327-26 $35.0074020-26 $13.00 74245 $137.00 74327-TC $68.0074020-TC $22.00 74245-26 $46.00 74328 $155.0074022 $44.00 74245-TC $89.00 74328-26 $35.0074022-26 $16.00 74246 $97.00 74328-TC $120.0074022-TC $28.00 74246-26 $35.00 74329 $155.0074150 $274.00 74246-TC $61.00 74329-26 $35.0074150-26 $60.00 74247 $99.00 74329-TC $120.0074150-TC $211.00 74247-26 $35.00 74330 $165.0074160 $322.00 74247-TC $63.00 74330-26 $45.0074160-26 $65.00 74249 $144.00 74330-TC $120.0074160-TC $256.00 74249-26 $46.00 74340 $121.0074170 $390.00 74249-TC $96.00 74340-26 $26.0074170-26 $71.00 74250 $73.00 74340-TC $95.0074170-TC $317.00 74250-26 $23.00 74355 $137.0074175 $418.00 74250-TC $48.00 74355-26 $38.0074175-26 $98.00 74251 $85.00 74355-TC $99.0074175-TC $315.00 74251-26 $34.00 74360 $145.0074181 $498.00 74251-TC $48.00 74360-26 $27.0074181-26 $85.00 74260 $82.00 74360-TC $118.0074181-TC $415.00 74260-26 $25.00 74363 $274.0074182 $587.00 74260-TC $56.00 74363-26 $44.0074182-26 $88.00 74270 $100.00 74363-TC $230.0074182-TC $496.00 74270-26 $35.00 74400 $89.0074183 $1,037.00 74270-TC $64.00 74400-26 $24.0074183-26 $114.00 74280 $136.00 74400-TC $63.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA74410 $98.00 74775-TC $55.00 75662-26 $84.0074410-26 $24.00 75557 $462.00 75662-TC $476.0074410-TC $72.00 75557-26 $79.00 75665 $540.0074415 $105.00 75557-TC $344.00 75665-26 $65.0074415-26 $24.00 75558 $87.00 75665-TC $475.0074415-TC $79.00 75558-26 $87.00 75671 $219.0074420 $117.00 75558-TC $486.00 75671-26 $32.0074420-26 $18.00 75559 $495.00 75671-TC $187.0074420-TC $97.00 75559-26 $99.00 75676 $540.0074425 $68.00 75559-TC $344.00 75676-26 $65.0074425-26 $18.00 75560 $101.00 75676-TC $475.0074425-TC $50.00 75560-26 $101.00 75680 $207.0074430 $48.00 75560-TC $649.00 75680-26 $31.0074430-26 $14.00 75561 $656.00 75680-TC $176.0074430-TC $34.00 75561-26 $87.00 75685 $160.0074440 $62.00 75561-TC $525.00 75685-26 $19.0074440-26 $19.00 75562 $96.00 75685-TC $141.0074440-TC $43.00 75562-26 $96.00 75705 $587.0074445 $101.00 75562-TC $649.00 75705-26 $109.0074445-26 $57.00 75563 $683.00 75705-TC $478.0074445-TC $44.00 75563-26 $101.00 75710 $194.0074450 $60.00 75563-TC $526.00 75710-26 $21.0074450-26 $14.00 75564 $112.00 75710-TC $173.0074450-TC $46.00 75564-26 $112.00 75716 $293.0074455 $75.00 75564-TC $763.00 75716-26 $35.0074455-26 $16.00 75600 $497.00 75716-TC $258.0074455-TC $59.00 75600-26 $25.00 75722 $206.0074470 $74.00 75600-TC $472.00 75722-26 $22.0074470-26 $27.00 75605 $183.00 75722-TC $184.0074470-TC $47.00 75605-26 $20.00 75724 $214.0074475 $181.00 75605-TC $163.00 75724-26 $29.0074475-26 $27.00 75625 $143.00 75724-TC $185.0074475-TC $154.00 75625-26 $15.00 75726 $530.0074480 $181.00 75625-TC $128.00 75726-26 $56.0074480-26 $27.00 75630 $239.00 75726-TC $474.0074480-TC $154.00 75630-26 $37.00 75731 $530.0074485 $146.00 75630-TC $202.00 75731-26 $56.0074485-26 $27.00 75635 $445.00 75731-TC $474.0074485-TC $119.00 75635-26 $75.00 75733 $540.0074710 $57.00 75635-TC $370.00 75733-26 $65.0074710-26 $17.00 75650 $218.00 75733-TC $475.0074710-TC $39.00 75650-26 $29.00 75736 $530.0074740 $68.00 75650-TC $189.00 75736-26 $56.0074740-26 $19.00 75658 $540.00 75736-TC $474.0074740-TC $49.00 75658-26 $66.00 75741 $540.0074742 $150.00 75658-TC $474.00 75741-26 $65.0074742-26 $30.00 75660 $540.00 75741-TC $475.0074742-TC $120.00 75660-26 $65.00 75743 $253.0074775 $88.00 75660-TC $475.00 75743-26 $37.0074775-26 $32.00 75662 $560.00 75743-TC $216.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 86

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA75746 $530.00 75840-TC $474.00 75940-26 $8.0075746-26 $56.00 75842 $549.00 75940-TC $143.0075746-TC $474.00 75842-26 $73.00 75945 $192.0075756 $183.00 75842-TC $476.00 75945-26 $21.0075756-26 $20.00 75860 $531.00 75945-TC $171.0075756-TC $163.00 75860-26 $57.00 75946 $108.0075774 $80.00 75860-TC $474.00 75946-26 $21.0075774-26 $3.00 75870 $531.00 75946-TC $87.0075774-TC $77.00 75870-26 $57.00 75952 BR75790 $146.00 75870-TC $474.00 75952-26 $254.0075790-26 $93.00 75872 $530.00 75952-TC BR75790-TC $53.00 75872-26 $56.00 75953 BR75801 $245.00 75872-TC $474.00 75953-26 $98.0075801-26 $41.00 75880 $72.00 75953-TC BR75801-TC $204.00 75880-26 $35.00 75954 BR75803 $264.00 75880-TC $37.00 75954-26 $132.0075803-26 $58.00 75885 $546.00 75954-TC BR75803-TC $206.00 75885-26 $71.00 75956 BR75805 $271.00 75885-TC $475.00 75956-26 $394.0075805-26 $40.00 75887 $546.00 75956-TC BR75805-TC $231.00 75887-26 $71.00 75957 BR75807 $289.00 75887-TC $475.00 75957-26 $338.0075807-26 $58.00 75889 $530.00 75957-TC BR75807-TC $231.00 75889-26 $56.00 75958 BR75809 $54.00 75889-TC $474.00 75958-26 $225.0075809-26 $24.00 75891 $530.00 75958-TC BR75809-TC $30.00 75891-26 $56.00 75959 BR75810 $530.00 75891-TC $474.00 75959-26 $197.0075810-26 $56.00 75893 $499.00 75959-TC BR75810-TC $474.00 75893-26 $26.00 75960 $600.0075820 $72.00 75893-TC $473.00 75960-26 $41.0075820-26 $35.00 75894 $972.00 75960-TC $559.0075820-TC $37.00 75894-26 $65.00 75961 $616.0075822 $111.00 75894-TC $907.00 75961-26 $213.0075822-26 $54.00 75896 $241.00 75961-TC $403.0075822-TC $57.00 75896-26 $18.00 75962 $618.0075825 $194.00 75896-TC $223.00 75962-26 $27.0075825-26 $21.00 75898 $124.00 75962-TC $591.0075825-TC $173.00 75898-26 $84.00 75964 $333.0075827 $530.00 75898-TC $39.00 75964-26 $18.0075827-26 $56.00 75900 $810.00 75964-TC $315.0075827-TC $474.00 75900-26 $24.00 75966 $659.0075831 $54.00 75900-TC $786.00 75966-26 $66.0075831-26 $6.00 75901 $98.00 75966-TC $593.0075831-TC $48.00 75901-26 $23.00 75968 $333.0075833 $549.00 75901-TC $75.00 75968-26 $18.0075833-26 $74.00 75902 $93.00 75968-TC $315.0075833-TC $475.00 75902-26 $19.00 75970 $475.0075840 $531.00 75902-TC $74.00 75970-26 $42.0075840-26 $57.00 75940 $151.00 75970-TC $433.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 87

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA75978 $617.00 76102-TC $65.00 76514-26 $10.0075978-26 $26.00 76120 $157.00 76514-TC $3.0075978-TC $591.00 76120-26 $56.00 76516 $99.0075980 $277.00 76120-TC $102.00 76516-26 $37.0075980-26 $71.00 76125 $49.00 76516-TC $63.0075980-TC $206.00 76125-26 $17.00 76519 $88.0075982 $303.00 76125-TC $33.00 76519-26 $31.0075982-26 $71.00 76140 $31.00 76519-TC $53.0075982-TC $232.00 76150 $15.00 76529 $86.0075984 $110.00 76350 BR 76529-26 $31.0075984-26 $36.00 76376 $144.00 76529-TC $53.0075984-TC $74.00 76376-26 $11.00 76536 $83.0075989 $180.00 76376-TC $133.00 76536-26 $31.0075989-26 $59.00 76377 $185.00 76536-TC $54.0075989-TC $121.00 76377-26 $43.00 76604 $78.0075992 $618.00 76377-TC $142.00 76604-26 $28.0075992-26 $27.00 76380 $182.00 76604-TC $48.0075992-TC $591.00 76380-26 $50.00 76645 $69.0075993 $333.00 76380-TC $131.00 76645-26 $31.0075993-26 $18.00 76390 $493.00 76645-TC $40.0075993-TC $315.00 76390-26 $71.00 76700 $116.0075994 $659.00 76390-TC $419.00 76700-26 $42.0075994-26 $66.00 76496 BR 76700-TC $73.0075994-TC $593.00 76496-26 BR 76705 $84.0075995 $658.00 76496-TC $79.00 76705-26 $30.0075995-26 $66.00 76497 BR 76705-TC $53.0075995-TC $592.00 76497-26 BR 76770 $112.0075996 $332.00 76497-TC $94.00 76770-26 $38.0075996-26 $17.00 76498 BR 76770-TC $73.0075996-TC $315.00 76498-26 BR 76775 $84.0076000 $58.00 76498-TC $280.00 76775-26 $30.0076000-26 $8.00 76499 BR 76775-TC $53.0076000-TC $48.00 76499-26 BR 76776 $124.0076001 $134.00 76499-TC BR 76776-26 $36.0076001-26 $34.00 76506 $88.00 76776-TC $88.0076001-TC $97.00 76506-26 $33.00 76800 $112.0076080 $67.00 76506-TC $53.00 76800-26 $61.0076080-26 $27.00 76510 $171.00 76800-TC $54.0076080-TC $40.00 76510-26 $86.00 76801 $93.0076098 $23.00 76510-TC $85.00 76801-26 $51.0076098-26 $8.00 76511 $96.00 76801-TC $42.0076098-TC $15.00 76511-26 $48.00 76802 $73.0076100 $77.00 76511-TC $48.00 76802-26 $43.0076100-26 $30.00 76512 $96.00 76802-TC $30.0076100-TC $46.00 76512-26 $36.00 76805 $131.0076101 $94.00 76512-TC $60.00 76805-26 $51.0076101-26 $36.00 76513 $96.00 76805-TC $79.0076101-TC $59.00 76513-26 $36.00 76810 $252.0076102 $95.00 76513-TC $60.00 76810-26 $100.0076102-26 $30.00 76514 $12.00 76810-TC $151.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 88

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA76811 $243.00 76831-TC $57.00 76950-26 $30.0076811-26 $100.00 76856 $93.00 76950-TC $48.0076811-TC $142.00 76856-26 $35.00 76965 $281.0076812 $145.00 76856-TC $57.00 76965-26 $84.0076812-26 $94.00 76857 $59.00 76965-TC $208.0076812-TC $51.00 76857-26 $19.00 76970 $60.0076813 $125.00 76857-TC $39.00 76970-26 $20.0076813-26 $55.00 76870 $90.00 76970-TC $39.0076813-TC $71.00 76870-26 $33.00 76975 $99.0076814 $83.00 76870-TC $57.00 76975-26 $41.0076814-26 $46.00 76872 $93.00 76975-TC $58.0076814-TC $37.00 76872-26 $36.00 76977 $34.0076815 $88.00 76872-TC $57.00 76977-26 $3.0076815-26 $33.00 76873 $151.00 76977-TC $31.0076815-TC $53.00 76873-26 $68.00 76998 BR76816 $72.00 76873-TC $80.00 76998-26 $61.0076816-26 $30.00 76880 $85.00 76998-TC $96.0076816-TC $41.00 76880-26 $32.00 76999 BR76817 $96.00 76880-TC $54.00 76999-26 BR76817-26 $39.00 76930 $93.00 76999-TC BR76817-TC $57.00 76930-26 $34.00 77001 $83.0076818 $105.00 76930-TC $59.00 77001-26 $18.0076818-26 $40.00 76932 $93.00 77001-TC $64.0076818-TC $60.00 76932-26 $34.00 77002 $75.0076819 $101.00 76932-TC $59.00 77002-26 $25.0076819-26 $40.00 76936 $341.00 77002-TC $50.0076819-TC $60.00 76936-26 $102.00 77003 $73.0076820 $93.00 76936-TC $236.00 77003-26 $27.0076820-26 $27.00 76937 $34.00 77003-TC $45.0076820-TC $66.00 76937-26 $17.00 77011 $309.0076821 $103.00 76937-TC $18.00 77011-26 $58.0076821-26 $38.00 76940 $171.00 77011-TC $251.0076821-TC $66.00 76940-26 $104.00 77012 $306.0076825 $160.00 76940-TC $68.00 77012-26 $55.0076825-26 $65.00 76941 $128.00 77012-TC $251.0076825-TC $73.00 76941-26 $69.00 77013-26 $191.0076826 $71.00 76941-TC $59.00 77013-TC $297.0076826-26 $46.00 76942 $92.00 77014 $135.0076826-TC $27.00 76942-26 $24.00 77014-26 $41.0076827 $97.00 76942-TC $68.00 77014-TC $94.0076827-26 $35.00 76945 $93.00 77021 $353.0076827-TC $65.00 76945-26 $34.00 77021-26 $73.0076828 $72.00 76945-TC $59.00 77021-TC $280.0076828-26 $29.00 76946 $78.00 77022 BR76828-TC $42.00 76946-26 $19.00 77022-26 $204.0076830 $93.00 76946-TC $59.00 77022-TC $280.0076830-26 $35.00 76948 $77.00 77031 $258.0076830-TC $57.00 76948-26 $19.00 77031-26 $77.0076831 $95.00 76948-TC $58.00 77031-TC $182.0076831-26 $37.00 76950 $80.00 77032 $70.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 89

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA77032-26 $27.00 77079-TC $92.00 77321-26 $48.0077032-TC $44.00 77080 $83.00 77321-TC $150.0077051 $17.00 77080-26 $11.00 77326 $137.0077051-26 $3.00 77080-TC $72.00 77326-26 $47.0077051-TC $14.00 77081 $40.00 77326-TC $88.0077052 $17.00 77081-26 $11.00 77327 $202.0077052-26 $3.00 77081-TC $29.00 77327-26 $71.0077052-TC $14.00 77082 $35.00 77327-TC $130.0077053 $102.00 77082-26 $8.00 77328 $295.0077053-26 $17.00 77082-TC $27.00 77328-26 $106.0077053-TC $85.00 77083 $36.00 77328-TC $185.0077054 $126.00 77083-26 $10.00 77331 $64.0077054-26 $22.00 77083-TC $26.00 77331-26 $45.0077054-TC $104.00 77084 $356.00 77331-TC $18.0077055 $78.00 77084-26 $77.00 77332 $78.0077055-26 $33.00 77084-TC $280.00 77332-26 $27.0077055-TC $45.00 77261 $73.00 77332-TC $50.0077056 $97.00 77262 $110.00 77333 $115.0077056-26 $41.00 77263 $163.00 77333-26 $43.0077056-TC $56.00 77280 $166.00 77333-TC $70.0077057 $82.00 77280-26 $36.00 77334 $187.0077057-26 $33.00 77280-TC $130.00 77334-26 $63.0077057-TC $49.00 77285 $264.00 77334-TC $121.0077058 $804.00 77285-26 $53.00 77336 $111.0077058-26 $78.00 77285-TC $209.00 77370 $130.0077058-TC $726.00 77290 $325.00 77371 $1,151.0077059 $994.00 77290-26 $79.00 77372 $874.0077059-26 $78.00 77290-TC $243.00 77373 $1,630.0077059-TC $917.00 77295 $1,287.00 77399 BR77071 $29.00 77295-26 $232.00 77399-26 BR77072 $22.00 77295-TC $1,046.00 77399-TC BR77072-26 $9.00 77299 BR 77401 $66.0077072-TC $14.00 77299-26 BR 77402 $66.0077073 $42.00 77299-TC BR 77403 $66.0077073-26 $13.00 77300 $87.00 77404 $66.0077073-TC $29.00 77300-26 $36.00 77406 $66.0077074 $64.00 77300-TC $52.00 77407 $78.0077074-26 $22.00 77301 $1,473.00 77408 $78.0077074-TC $42.00 77301-26 $415.00 77409 $78.0077075 $89.00 77301-TC $1,046.00 77411 $78.0077075-26 $26.00 77305 $106.00 77412 $87.0077075-TC $63.00 77305-26 $36.00 77413 $87.0077077 $54.00 77305-TC $69.00 77414 $87.0077077-26 $15.00 77310 $142.00 77416 $87.0077077-TC $39.00 77310-26 $53.00 77417 $21.0077078 $84.00 77310-TC $87.00 77418 $609.0077078-26 $12.00 77315 $181.00 77421 $152.0077078-TC $72.00 77315-26 $79.00 77421-26 $20.0077079 $103.00 77315-TC $99.00 77421-TC $131.0077079-26 $11.00 77321 $200.00 77422 $70.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 90

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA77423 $91.00 77778-TC $192.00 78099-26 BR77427 $166.00 77789 $74.00 78099-TC BR77431 $95.00 77789-26 $57.00 78102 $106.0077432 $417.00 77789-TC $16.00 78102-26 $28.0077435 $644.00 77790 $72.00 78102-TC $77.0077470 $527.00 77790-26 $53.00 78103 $158.0077470-26 $106.00 77790-TC $18.00 78103-26 $39.0077470-TC $417.00 77799 BR 78103-TC $118.0077499 BR 77799-26 BR 78104 $194.0077499-26 BR 77799-TC BR 78104-26 $41.0077499-TC BR 78000 $46.00 78104-TC $152.0077520 BR 78000-26 $9.00 78110 $45.0077522 BR 78000-TC $36.00 78110-26 $9.0077523 BR 78001 $62.00 78110-TC $35.0077525 BR 78001-26 $12.00 78111 $108.0077600 $196.00 78001-TC $48.00 78111-26 $11.0077600-26 $80.00 78003 $54.00 78111-TC $96.0077600-TC $113.00 78003-26 $17.00 78120 $78.0077605 $263.00 78003-TC $36.00 78120-26 $11.0077605-26 $108.00 78006 $115.00 78120-TC $65.0077605-TC $151.00 78006-26 $24.00 78121 $125.0077610 $195.00 78006-TC $89.00 78121-26 $16.0077610-26 $79.00 78007 $122.00 78121-TC $108.0077610-TC $113.00 78007-26 $25.00 78122 $196.0077615 $262.00 78007-TC $96.00 78122-26 $22.0077615-26 $106.00 78010 $89.00 78122-TC $171.0077615-TC $151.00 78010-26 $19.00 78130 $139.0077620 $196.00 78010-TC $68.00 78130-26 $32.0077620-26 $80.00 78011 $114.00 78130-TC $106.0077620-TC $113.00 78011-26 $22.00 78135 $216.0077750 $299.00 78011-TC $90.00 78135-26 $33.0077750-26 $248.00 78015 $132.00 78135-TC $182.0077750-TC $49.00 78015-26 $34.00 78140 $179.0077761 $284.00 78015-TC $96.00 78140-26 $31.0077761-26 $188.00 78016 $173.00 78140-TC $147.0077761-TC $93.00 78016-26 $42.00 78185 $110.0077762 $427.00 78016-TC $130.00 78185-26 $20.0077762-26 $289.00 78018 $248.00 78185-TC $88.0077762-TC $135.00 78018-26 $44.00 78190 $272.0077763 $605.00 78018-TC $202.00 78190-26 $57.0077763-26 $435.00 78020 $35.00 78190-TC $214.0077763-TC $167.00 78020-26 $30.00 78191 $307.0077776 $316.00 78020-TC $5.00 78191-26 $31.0077776-26 $233.00 78070 $112.00 78191-TC $274.0077776-TC $82.00 78070-26 $36.00 78195 $216.0077777 $540.00 78070-TC $68.00 78195-26 $49.0077777-26 $378.00 78075 $242.00 78195-TC $152.0077777-TC $158.00 78075-26 $38.00 78199 BR77778 $764.00 78075-TC $202.00 78199-26 BR77778-26 $568.00 78099 BR 78199-TC BR

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 91

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA78201 $112.00 78271 $72.00 78445-26 $28.0078201-26 $22.00 78271-26 $10.00 78445-TC $69.0078201-TC $88.00 78271-TC $61.00 78456 $205.0078202 $135.00 78272 $100.00 78456-26 $49.0078202-26 $26.00 78272-26 $14.00 78456-TC $151.0078202-TC $108.00 78272-TC $87.00 78457 $140.0078205 $259.00 78278 $234.00 78457-26 $39.0078205-26 $36.00 78278-26 $50.00 78457-TC $99.0078205-TC $220.00 78278-TC $182.00 78458 $198.0078206 $265.00 78282 $230.00 78458-26 $46.0078206-26 $46.00 78282-26 $19.00 78458-TC $149.0078206-TC $214.00 78282-TC $224.00 78459 $755.0078215 $135.00 78290 $149.00 78459-26 $100.0078215-26 $24.00 78290-26 $35.00 78459-TC $731.0078215-TC $109.00 78290-TC $113.00 78460 $134.0078216 $160.00 78291 $161.00 78460-26 $44.0078216-26 $29.00 78291-26 $45.00 78460-TC $88.0078216-TC $130.00 78291-TC $114.00 78461 $294.0078220 $165.00 78299 BR 78461-26 $82.0078220-26 $24.00 78299-26 BR 78461-TC $213.0078220-TC $139.00 78299-TC BR 78464 $322.0078223 $181.00 78300 $125.00 78464-26 $56.0078223-26 $43.00 78300-26 $32.00 78464-TC $264.0078223-TC $137.00 78300-TC $93.00 78465 $519.0078230 $106.00 78305 $181.00 78465-26 $75.0078230-26 $23.00 78305-26 $42.00 78465-TC $441.0078230-TC $82.00 78305-TC $137.00 78466 $135.0078231 $146.00 78306 $205.00 78466-26 $36.0078231-26 $27.00 78306-26 $44.00 78466-TC $97.0078231-TC $118.00 78306-TC $159.00 78468 $180.0078232 $157.00 78315 $233.00 78468-26 $41.0078232-26 $23.00 78315-26 $52.00 78468-TC $137.0078232-TC $132.00 78315-TC $179.00 78469 $244.0078258 $146.00 78320 $276.00 78469-26 $47.0078258-26 $38.00 78320-26 $53.00 78469-TC $195.0078258-TC $108.00 78320-TC $220.00 78472 $259.0078261 $190.00 78350 $40.00 78472-26 $50.0078261-26 $36.00 78350-26 $11.00 78472-TC $206.0078261-TC $152.00 78350-TC $29.00 78473 $387.0078262 $195.00 78351 $23.00 78473-26 $75.0078262-26 $35.00 78399 BR 78473-TC $308.0078262-TC $159.00 78399-26 BR 78478 $91.0078264 $195.00 78399-TC BR 78478-26 $32.0078264-26 $40.00 78414 BR 78478-TC $58.0078264-TC $154.00 78414-26 $23.00 78480 $91.0078267 BR 78414-TC BR 78480-26 $32.0078268 BR 78428 $126.00 78480-TC $58.0078270 $68.00 78428-26 $41.00 78481 $248.0078270-26 $10.00 78428-TC $84.00 78481-26 $51.0078270-TC $58.00 78445 $97.00 78481-TC $195.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 92

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA78483 $373.00 78599-TC BR 78701-26 $24.0078483-26 $77.00 78600 $131.00 78701-TC $133.0078483-TC $294.00 78600-26 $22.00 78707 $217.0078491 $756.00 78600-TC $108.00 78707-26 $49.0078491-26 $85.00 78601 $154.00 78707-TC $166.0078491-TC $731.00 78601-26 $26.00 78708 $231.0078492 $764.00 78601-TC $126.00 78708-26 $61.0078492-26 $100.00 78605 $155.00 78708-TC $166.0078492-TC $731.00 78605-26 $27.00 78709 $241.0078494 $324.00 78605-TC $126.00 78709-26 $68.0078494-26 $59.00 78606 $221.00 78709-TC $166.0078494-TC $262.00 78606-26 $45.00 78710 $256.0078496 $92.00 78606-TC $177.00 78710-26 $34.0078496-26 $24.00 78607 $311.00 78710-TC $220.0078496-TC $66.00 78607-26 $64.00 78725 $87.0078499 BR 78607-TC $245.00 78725-26 $19.0078499-26 BR 78608 $876.00 78725-TC $66.0078499-TC BR 78608-26 $78.00 78730 $73.0078580 $167.00 78608-TC $855.00 78730-26 $18.0078580-26 $38.00 78609 $51.00 78730-TC $55.0078580-TC $128.00 78609-26 $78.00 78740 $109.0078584 $171.00 78609-TC BR 78740-26 $29.0078584-26 $50.00 78610 $74.00 78740-TC $79.0078584-TC $119.00 78610-26 $15.00 78761 $157.0078585 $171.00 78610-TC $59.00 78761-26 $36.0078585-26 $36.00 78630 $223.00 78761-TC $119.0078585-TC $133.00 78630-26 $35.00 78799 BR78586 $118.00 78630-TC $188.00 78799-26 BR78586-26 $20.00 78635 $129.00 78799-TC BR78586-TC $96.00 78635-26 $32.00 78800 $162.0078587 $131.00 78635-TC $95.00 78800-26 $34.0078587-26 $24.00 78645 $158.00 78800-TC $126.0078587-TC $105.00 78645-26 $29.00 78801 $199.0078588 $239.00 78645-TC $128.00 78801-26 $40.0078588-26 $53.00 78647 $268.00 78801-TC $158.0078588-TC $192.00 78647-26 $46.00 78802 $252.0078591 $128.00 78647-TC $220.00 78802-26 $44.0078591-26 $20.00 78650 $206.00 78802-TC $207.0078591-TC $106.00 78650-26 $31.00 78803 $303.0078593 $151.00 78650-TC $173.00 78803-26 $56.0078593-26 $24.00 78660 $107.00 78803-TC $245.0078593-TC $126.00 78660-26 $27.00 78804 $227.0078594 $214.00 78660-TC $79.00 78804-26 $55.0078594-26 $27.00 78699 BR 78804-TC $171.0078594-TC $186.00 78699-26 BR 78805 $166.0078596 $332.00 78699-TC BR 78805-26 $38.0078596-26 $65.00 78700 $137.00 78805-TC $126.0078596-TC $264.00 78700-26 $22.00 78806 $286.0078599 BR 78700-TC $113.00 78806-26 $44.0078599-26 BR 78701 $158.00 78806-TC $241.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 93

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Radiology RadiologyCPT Code MRA CPT Code MRA78807 $303.00 G0130-TC G0130-TC78807-26 $57.00 G0202 G020278807-TC $245.00 G0202-26 G0202-2678811 $879.00 G0202-TC G0202-TC78811-26 $83.00 G0204 G020478811-TC $855.00 G0204-26 G0204-2678812 $884.00 G0204-TC G0204-TC78812-26 $102.00 G0206 G020678812-TC $855.00 G0206-26 G0206-2678813 $885.00 G0206-TC G0206-TC78813-26 $106.00 G0275 G027578813-TC $855.00 G0278 G027878814 $982.00 G0288 G028878814-26 $116.00 G0365 G036578814-TC $950.00 G0365-26 G0365-2678815 $985.00 G0365-TC G0365-TC78815-26 $128.00 G0389 G038978815-TC $950.00 G0389-26 G0389-2678816 $986.00 G0389-TC G0389-TC78816-26 $132.00 Q0092 Q009278816-TC $950.0078999 BR78999-26 BR78999-TC BR79005 $199.0079005-26 $94.0079005-TC $105.0079101 $207.0079101-26 $103.0079101-TC $105.0079200 $203.0079200-26 $102.0079200-TC $97.0079300 BR79300-26 $83.0079300-TC BR79403 $287.0079403-26 $121.0079403-TC $165.0079440 $204.0079440-26 $104.0079440-TC $97.0079445 $232.0079445-26 $127.0079445-TC $105.0079999 BR79999-26 BR79999-TC BRG0130 $34.00G0130-26 $10.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 94

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA80048 $23.00 80156-TC $23.00 80186-26 $11.0080048-26 $4.00 80157 $22.00 80186-TC $26.0080048-TC $19.00 80157-26 $8.00 80188 $35.0080050 $45.00 80157-TC $14.00 80188-26 $11.0080050-26 $18.00 80158 $35.00 80188-TC $23.0080050-TC $26.00 80158-26 $12.00 80190 $41.0080051 $16.00 80158-TC $22.00 80190-26 $13.0080051-26 $6.00 80160 $35.00 80190-TC $28.0080051-TC $10.00 80160-26 $12.00 80192 $44.0080053 $29.00 80160-TC $22.00 80192-26 $17.0080053-26 $8.00 80162 $13.00 80192-TC $26.0080053-TC $21.00 80162-26 $3.00 80194 $33.0080055 $67.00 80162-TC $9.00 80194-26 $10.0080055-26 $21.00 80164 $43.00 80194-TC $22.0080055-TC $43.00 80164-26 $14.00 80196 $13.0080061 $31.00 80164-TC $29.00 80196-26 $3.0080061-26 $11.00 80166 $35.00 80196-TC $9.0080061-TC $19.00 80166-26 $10.00 80197 $34.0080069 $26.00 80166-TC $24.00 80197-26 $11.0080069-26 $6.00 80168 $43.00 80197-TC $22.0080069-TC $20.00 80168-26 $17.00 80198 $20.0080074 $107.00 80168-TC $25.00 80198-26 $5.0080074-26 $43.00 80170 $18.00 80198-TC $15.0080074-TC $64.00 80170-26 $6.00 80200 $24.0080076 $18.00 80170-TC $11.00 80200-26 $7.0080076-26 $7.00 80172 $44.00 80200-TC $16.0080076-TC $11.00 80172-26 $13.00 80201 $33.0080100 $38.00 80172-TC $32.00 80201-26 $11.0080100-26 $11.00 80173 $33.00 80201-TC $21.0080100-TC $26.00 80173-26 $11.00 80202 $42.0080101 $13.00 80173-TC $22.00 80202-26 $14.0080101-26 $3.00 80174 $41.00 80202-TC $28.0080101-TC $9.00 80174-26 $12.00 80299 BR80102 $23.00 80174-TC $29.00 80299-26 BR80102-26 $6.00 80176 $35.00 80299-TC BR80102-TC $16.00 80176-26 $11.00 80400 $54.0080103 $12.00 80176-TC $23.00 80400-26 $18.0080103-26 $4.00 80178 $17.00 80400-TC $36.0080103-TC $7.00 80178-26 $6.00 80402 $138.0080150 $40.00 80178-TC $11.00 80402-26 $42.0080150-26 $13.00 80182 $43.00 80402-TC $95.0080150-TC $26.00 80182-26 $14.00 80406 $138.0080152 $43.00 80182-TC $29.00 80406-26 $42.0080152-26 $14.00 80184 $34.00 80406-TC $95.0080152-TC $29.00 80184-26 $10.00 80408 $213.0080154 $49.00 80184-TC $23.00 80408-26 $77.0080154-26 $15.00 80185 $36.00 80408-TC $136.0080154-TC $34.00 80185-26 $10.00 80410 $166.0080156 $35.00 80185-TC $25.00 80410-26 $54.0080156-26 $11.00 80186 $38.00 80410-TC $110.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 95

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA80412 $533.00 80438-TC $56.00 82003-26 $10.0080412-26 $176.00 80439 $176.00 82003-TC $25.0080412-TC $355.00 80439-26 $33.00 82009 $10.0080414 $88.00 80439-TC $144.00 82009-26 $3.0080414-26 $26.00 80440 $188.00 82009-TC $6.0080414-TC $59.00 80440-26 $36.00 82010 $22.0080415 $93.00 80440-TC $151.00 82010-26 $7.0080415-26 $28.00 80500 $34.00 82010-TC $15.0080415-TC $64.00 80500-26 $34.00 82013 $24.0080416 $256.00 80500-TC BR 82013-26 $7.0080416-26 $88.00 80502 $72.00 82013-TC $17.0080416-TC $166.00 80502-26 $72.00 82024 $26.0080417 $256.00 80502-TC BR 82024-26 $7.0080417-26 $88.00 81000 $7.00 82024-TC $18.0080417-TC $166.00 81000-26 $3.00 82030 $43.0080418 $934.00 81000-TC $4.00 82030-26 $17.0080418-26 $266.00 81001 $7.00 82030-TC $25.0080418-TC $666.00 81001-26 $3.00 82040 $11.0080420 $107.00 81001-TC $4.00 82040-26 $3.0080420-26 $33.00 81002 $5.00 82040-TC $7.0080420-TC $74.00 81002-26 $3.00 82042 $12.0080422 $62.00 81002-TC $3.00 82042-26 $3.0080422-26 $18.00 81003 $5.00 82042-TC $8.0080422-TC $43.00 81003-26 $2.00 82043 $14.0080424 $94.00 81003-TC $3.00 82043-26 $4.0080424-26 $26.00 81005 $3.00 82043-TC $10.0080424-TC $67.00 81005-26 $1.00 82044 $12.0080426 $232.00 81005-TC $3.00 82044-26 $4.0080426-26 $54.00 81007 $5.00 82044-TC $9.0080426-TC $176.00 81007-26 $2.00 82055 $33.0080428 $93.00 81007-TC $4.00 82055-26 $10.0080428-26 $19.00 81015 $5.00 82055-TC $22.0080428-TC $73.00 81015-26 $3.00 82075 $32.0080430 $99.00 81015-TC $3.00 82075-26 $10.0080430-26 $24.00 81020 $8.00 82075-TC $21.0080430-TC $74.00 81020-26 $3.00 82085 $24.0080432 $243.00 81020-TC $5.00 82085-26 $7.0080432-26 $56.00 81025 $7.00 82085-TC $17.0080432-TC $186.00 81025-26 $4.00 82088 $91.0080434 $161.00 81025-TC $4.00 82088-26 $28.0080434-26 $49.00 81050 $33.00 82088-TC $62.0080434-TC $110.00 81050-26 $11.00 82101 $59.0080435 $166.00 81050-TC $21.00 82101-26 $18.0080435-26 $49.00 81099 BR 82101-TC $41.0080435-TC $115.00 81099-26 BR 82103 $21.0080436 $119.00 81099-TC BR 82103-26 $7.0080436-26 $35.00 82000 $24.00 82103-TC $14.0080436-TC $85.00 82000-26 $7.00 82104 $22.0080438 $82.00 82000-TC $17.00 82104-26 $7.0080438-26 $24.00 82003 $36.00 82104-TC $15.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 96

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA82105 $26.00 82160-TC $43.00 82286-26 $3.0082105-26 $8.00 82163 $42.00 82286-TC $8.0082105-TC $18.00 82163-26 $12.00 82300 $48.0082106 $26.00 82163-TC $31.00 82300-26 $15.0082106-26 $8.00 82164 $32.00 82300-TC $33.0082106-TC $18.00 82164-26 $10.00 82306 $79.0082108 $45.00 82164-TC $21.00 82306-26 $25.0082108-26 $14.00 82172 $33.00 82306-TC $52.0082108-TC $32.00 82172-26 $10.00 82307 $57.0082120 $9.00 82172-TC $22.00 82307-26 $19.0082120-26 $3.00 82175 $48.00 82307-TC $38.0082120-TC $5.00 82175-26 $15.00 82308 $62.0082127 $33.00 82175-TC $33.00 82308-26 $18.0082127-26 $11.00 82180 $25.00 82308-TC $43.0082127-TC $22.00 82180-26 $8.00 82310 $11.0082128 $26.00 82180-TC $17.00 82310-26 $3.0082128-26 $6.00 82190 $24.00 82310-TC $7.0082128-TC $19.00 82190-26 $8.00 82330 $37.0082131 $57.00 82190-TC $16.00 82330-26 $11.0082131-26 $13.00 82205 $34.00 82330-TC $25.0082131-TC $44.00 82205-26 $10.00 82331 $14.0082135 $41.00 82205-TC $23.00 82331-26 $4.0082135-26 $13.00 82232 $43.00 82331-TC $10.0082135-TC $28.00 82232-26 $14.00 82340 $13.0082136 $38.00 82232-TC $29.00 82340-26 $4.0082136-26 $14.00 82239 $23.00 82340-TC $8.0082136-TC $23.00 82239-26 $8.00 82355 $31.0082139 $38.00 82239-TC $15.00 82355-26 $10.0082139-26 $14.00 82240 $49.00 82355-TC $20.0082139-TC $23.00 82240-26 $15.00 82360 $31.0082140 $40.00 82240-TC $34.00 82360-26 $10.0082140-26 $12.00 82247 $10.00 82360-TC $20.0082140-TC $28.00 82247-26 $3.00 82365 $31.0082143 $28.00 82247-TC $7.00 82365-26 $8.0082143-26 $8.00 82248 $10.00 82365-TC $21.0082143-TC $19.00 82248-26 $3.00 82370 $22.0082145 $35.00 82248-TC $7.00 82370-26 $7.0082145-26 $10.00 82252 $11.00 82370-TC $15.0082145-TC $24.00 82252-26 $3.00 82373 $16.0082150 $16.00 82252-TC $7.00 82373-26 $5.0082150-26 $5.00 82261 $38.00 82373-TC $11.0082150-TC $11.00 82261-26 $13.00 82374 $10.0082154 $34.00 82261-TC $24.00 82374-26 $3.0082154-26 $13.00 82270 $5.00 82374-TC $6.0082154-TC $20.00 82270-26 $2.00 82375 $26.0082157 $57.00 82270-TC $3.00 82375-26 $7.0082157-26 $17.00 82274 BR 82375-TC $18.0082157-TC $40.00 82274-26 BR 82376 $11.0082160 $67.00 82274-TC BR 82376-26 $3.0082160-26 $21.00 82286 $12.00 82376-TC $7.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 97

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA82378 $31.00 82482-TC $15.00 82541-26 $13.0082378-26 $8.00 82485 $37.00 82541-TC $28.0082378-TC $21.00 82485-26 $8.00 82542 $42.0082379 $38.00 82485-TC $28.00 82542-26 $13.0082379-26 $13.00 82486 $42.00 82542-TC $28.0082379-TC $24.00 82486-26 $14.00 82543 $42.0082380 $21.00 82486-TC $27.00 82543-26 $13.0082380-26 $6.00 82487 $43.00 82543-TC $28.0082380-TC $15.00 82487-26 $14.00 82544 $42.0082382 $38.00 82487-TC $29.00 82544-26 $13.0082382-26 $12.00 82488 $57.00 82544-TC $28.0082382-TC $25.00 82488-26 $19.00 82550 $16.0082383 $62.00 82488-TC $38.00 82550-26 $4.0082383-26 $18.00 82489 $47.00 82550-TC $12.0082383-TC $43.00 82489-26 $15.00 82552 $33.0082384 $62.00 82489-TC $32.00 82552-26 $10.0082384-26 $18.00 82491 $58.00 82552-TC $22.0082384-TC $43.00 82491-26 $17.00 82553 $16.0082387 $34.00 82491-TC $41.00 82553-26 $5.0082387-26 $10.00 82492 $42.00 82553-TC $11.0082387-TC $23.00 82492-26 $13.00 82554 $19.0082390 $24.00 82492-TC $28.00 82554-26 $6.0082390-26 $7.00 82495 $48.00 82554-TC $13.0082390-TC $17.00 82495-26 $16.00 82565 $13.0082397 $22.00 82495-TC $32.00 82565-26 $2.0082397-26 $7.00 82507 $55.00 82565-TC $11.0082397-TC $15.00 82507-26 $16.00 82570 $10.0082415 $28.00 82507-TC $39.00 82570-26 $2.0082415-26 $8.00 82520 $26.00 82570-TC $7.0082415-TC $19.00 82520-26 $8.00 82575 $25.0082435 $8.00 82520-TC $18.00 82575-26 $8.0082435-26 $2.00 82523 $43.00 82575-TC $17.0082435-TC $6.00 82523-26 $17.00 82585 $15.0082436 $14.00 82523-TC $25.00 82585-26 $3.0082436-26 $4.00 82525 $34.00 82585-TC $12.0082436-TC $10.00 82525-26 $10.00 82595 $31.0082438 $13.00 82525-TC $23.00 82595-26 $10.0082438-26 $4.00 82528 $40.00 82595-TC $21.0082438-TC $8.00 82528-26 $13.00 82600 $40.0082441 $16.00 82528-TC $26.00 82600-26 $12.0082441-26 $5.00 82530 $38.00 82600-TC $28.0082441-TC $11.00 82530-26 $12.00 82607 $38.0082465 $8.00 82530-TC $25.00 82607-26 $10.0082465-26 $2.00 82533 $35.00 82607-TC $27.0082465-TC $6.00 82533-26 $10.00 82608 $40.0082480 $23.00 82533-TC $24.00 82608-26 $13.0082480-26 $6.00 82540 $10.00 82608-TC $26.0082480-TC $17.00 82540-26 $3.00 82615 $17.0082482 $23.00 82540-TC $6.00 82615-26 $5.0082482-26 $7.00 82541 $42.00 82615-TC $12.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 98

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA82626 $59.00 82671-TC $43.00 82757-26 $11.0082626-26 $19.00 82672 $57.00 82757-TC $24.0082626-TC $40.00 82672-26 $16.00 82759 $38.0082627 $37.00 82672-TC $41.00 82759-26 $12.0082627-26 $12.00 82677 $52.00 82759-TC $25.0082627-TC $24.00 82677-26 $17.00 82760 $26.0082633 $81.00 82677-TC $35.00 82760-26 $8.0082633-26 $23.00 82679 $70.00 82760-TC $18.0082633-TC $56.00 82679-26 $20.00 82775 $47.0082634 $81.00 82679-TC $48.00 82775-26 $14.0082634-26 $23.00 82690 $53.00 82775-TC $33.0082634-TC $56.00 82690-26 $21.00 82776 $14.0082638 $23.00 82690-TC $32.00 82776-26 $3.0082638-26 $7.00 82693 $23.00 82776-TC $11.0082638-TC $16.00 82693-26 $7.00 82784 $15.0082646 $37.00 82693-TC $16.00 82784-26 $5.0082646-26 $11.00 82696 $57.00 82784-TC $11.0082646-TC $25.00 82696-26 $19.00 82785 $33.0082649 $43.00 82696-TC $38.00 82785-26 $11.0082649-26 $17.00 82705 $14.00 82785-TC $21.0082649-TC $25.00 82705-26 $6.00 82787 $54.0082651 $43.00 82705-TC $9.00 82787-26 $17.0082651-26 $17.00 82710 $42.00 82787-TC $37.0082651-TC $25.00 82710-26 $13.00 82800 $22.0082652 $89.00 82710-TC $29.00 82800-26 $6.0082652-26 $25.00 82715 $33.00 82800-TC $16.0082652-TC $62.00 82715-26 $11.00 82803 $53.0082654 $37.00 82715-TC $21.00 82803-26 $16.0082654-26 $11.00 82725 $28.00 82803-TC $37.0082654-TC $25.00 82725-26 $8.00 82805 $36.0082657 $42.00 82725-TC $19.00 82805-26 $10.0082657-26 $13.00 82726 $42.00 82805-TC $24.0082657-TC $28.00 82726-26 $13.00 82810 $28.0082658 $42.00 82726-TC $28.00 82810-26 $8.0082658-26 $13.00 82728 $24.00 82810-TC $19.0082658-TC $28.00 82728-26 $7.00 82820 $16.0082664 $40.00 82728-TC $17.00 82820-26 $5.0082664-26 $13.00 82735 $36.00 82820-TC $11.0082664-TC $26.00 82735-26 $12.00 82926 $20.0082666 $58.00 82735-TC $23.00 82926-26 $5.0082666-26 $17.00 82742 $42.00 82926-TC $15.0082666-TC $41.00 82742-26 $13.00 82928 $12.0082668 $45.00 82742-TC $29.00 82928-26 $4.0082668-26 $14.00 82746 $39.00 82928-TC $7.0082668-TC $32.00 82746-26 $13.00 82938 $48.0082670 $61.00 82746-TC $25.00 82938-26 $16.0082670-26 $18.00 82747 $29.00 82938-TC $32.0082670-TC $42.00 82747-26 $10.00 82941 $47.0082671 $61.00 82747-TC $19.00 82941-26 $15.0082671-26 $17.00 82757 $36.00 82941-TC $32.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 99

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA82943 $38.00 82978-TC $18.00 83030-26 $6.0082943-26 $12.00 82979 $18.00 83030-TC $12.0082943-TC $25.00 82979-26 $5.00 83033 $15.0082945 $9.00 82979-TC $13.00 83033-26 $4.0082945-26 $3.00 82980 $15.00 83033-TC $11.0082945-TC $5.00 82980-26 $3.00 83036 $15.0082946 $29.00 82980-TC $11.00 83036-26 $5.0082946-26 $7.00 82985 $41.00 83036-TC $10.0082946-TC $21.00 82985-26 $12.00 83045 $13.0082947 $11.00 82985-TC $29.00 83045-26 $4.0082947-26 $3.00 83001 $40.00 83045-TC $8.0082947-TC $7.00 83001-26 $12.00 83050 $16.0082948 $5.00 83001-TC $28.00 83050-26 $5.0082948-26 $3.00 83002 $42.00 83050-TC $11.0082948-TC $3.00 83002-26 $13.00 83051 $16.0082950 $12.00 83002-TC $29.00 83051-26 $5.0082950-26 $4.00 83003 $36.00 83051-TC $11.0082950-TC $7.00 83003-26 $10.00 83055 $13.0082951 $22.00 83003-TC $25.00 83055-26 $4.0082951-26 $7.00 83008 $34.00 83055-TC $8.0082951-TC $15.00 83008-26 $10.00 83060 $22.0082952 $11.00 83008-TC $23.00 83060-26 $6.0082952-26 $3.00 83010 $26.00 83060-TC $16.0082952-TC $7.00 83010-26 $8.00 83065 $18.0082953 $41.00 83010-TC $18.00 83065-26 $6.0082953-26 $14.00 83012 $36.00 83065-TC $12.0082953-TC $26.00 83012-26 $14.00 83068 $20.0082955 $25.00 83012-TC $21.00 83068-26 $5.0082955-26 $7.00 83013 $133.00 83068-TC $15.0082955-TC $18.00 83013-26 $38.00 83069 $11.0082960 $14.00 83013-TC $94.00 83069-26 $3.0082960-26 $4.00 83014 $19.00 83069-TC $7.0082960-TC $10.00 83014-26 $6.00 83070 $13.0082962 $5.00 83014-TC $13.00 83070-26 $4.0082962-26 $1.00 83015 $51.00 83070-TC $8.0082962-TC $4.00 83015-26 $15.00 83071 $18.0082963 $54.00 83015-TC $36.00 83071-26 $5.0082963-26 $17.00 83018 $56.00 83071-TC $13.0082963-TC $37.00 83018-26 $16.00 83080 $38.0082965 $16.00 83018-TC $40.00 83080-26 $11.0082965-26 $5.00 83020 $24.00 83080-TC $26.0082965-TC $11.00 83020-26 $6.00 83088 $59.0082975 $28.00 83020-TC $18.00 83088-26 $18.0082975-26 $8.00 83021 $39.00 83088-TC $41.0082975-TC $19.00 83021-26 $13.00 83090 $38.0082977 $16.00 83021-TC $25.00 83090-26 $13.0082977-26 $4.00 83026 $8.00 83090-TC $25.0082977-TC $12.00 83026-26 $5.00 83150 $49.0082978 $25.00 83026-TC $3.00 83150-26 $16.0082978-26 $7.00 83030 $18.00 83150-TC $33.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 100

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA83491 $37.00 83582-TC $24.00 83788-26 $13.0083491-26 $11.00 83586 $38.00 83788-TC $25.0083491-TC $25.00 83586-26 $13.00 83789 $39.0083497 $35.00 83586-TC $24.00 83789-26 $13.0083497-26 $11.00 83593 $59.00 83789-TC $25.0083497-TC $23.00 83593-26 $18.00 83805 $44.0083498 $62.00 83593-TC $41.00 83805-26 $15.0083498-26 $20.00 83605 $19.00 83805-TC $29.0083498-TC $41.00 83605-26 $6.00 83825 $34.0083499 $51.00 83605-TC $13.00 83825-26 $11.0083499-26 $15.00 83615 $16.00 83825-TC $22.0083499-TC $36.00 83615-26 $5.00 83835 $41.0083500 $69.00 83615-TC $11.00 83835-26 $12.0083500-26 $21.00 83625 $23.00 83835-TC $29.0083500-TC $45.00 83625-26 $6.00 83840 $42.0083505 $77.00 83625-TC $17.00 83840-26 $14.0083505-26 $21.00 83632 $42.00 83840-TC $28.0083505-TC $54.00 83632-26 $14.00 83857 $26.0083516 $26.00 83632-TC $28.00 83857-26 $8.0083516-26 $8.00 83655 $31.00 83857-TC $18.0083516-TC $18.00 83655-26 $8.00 83858 $37.0083518 $21.00 83655-TC $21.00 83858-26 $12.0083518-26 $7.00 83670 $18.00 83858-TC $24.0083518-TC $14.00 83670-26 $5.00 83864 $32.0083519 $21.00 83670-TC $13.00 83864-26 $8.0083519-26 $7.00 83690 $18.00 83864-TC $22.0083519-TC $14.00 83690-26 $6.00 83866 $26.0083520 $20.00 83690-TC $12.00 83866-26 $7.0083520-26 $6.00 83718 $16.00 83866-TC $19.0083520-TC $14.00 83718-26 $5.00 83872 $13.0083525 $31.00 83718-TC $11.00 83872-26 $4.0083525-26 $8.00 83719 $42.00 83872-TC $8.0083525-TC $21.00 83719-26 $14.00 83873 $54.0083527 $35.00 83719-TC $28.00 83873-26 $18.0083527-26 $11.00 83721 $16.00 83873-TC $36.0083527-TC $23.00 83721-26 $5.00 83874 $25.0083528 $43.00 83721-TC $11.00 83874-26 $8.0083528-26 $14.00 83727 $43.00 83874-TC $17.0083528-TC $29.00 83727-26 $14.00 83880 BR83540 $16.00 83727-TC $29.00 83880-26 BR83540-26 $3.00 83735 $15.00 83880-TC BR83540-TC $13.00 83735-26 $5.00 83883 $11.0083550 $20.00 83735-TC $10.00 83883-26 $3.0083550-26 $5.00 83775 $17.00 83883-TC $7.0083550-TC $15.00 83775-26 $5.00 83885 $45.0083570 $23.00 83775-TC $12.00 83885-26 $14.0083570-26 $7.00 83785 $58.00 83885-TC $32.0083570-TC $16.00 83785-26 $17.00 83887 $58.0083582 $34.00 83785-TC $41.00 83887-26 $17.0083582-26 $8.00 83788 $39.00 83887-TC $41.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 101

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA83890 $7.00 83916-TC $36.00 84061-26 $4.0083890-26 $2.00 83918 $41.00 84061-TC $10.0083890-TC $5.00 83918-26 $12.00 84066 $18.0083891 $7.00 83918-TC $29.00 84066-26 $6.0083891-26 $2.00 83919 $42.00 84066-TC $12.0083891-TC $5.00 83919-26 $12.00 84075 $12.0083892 $7.00 83919-TC $29.00 84075-26 $3.0083892-26 $2.00 83921 $37.00 84075-TC $8.0083892-TC $5.00 83921-26 $12.00 84078 $19.0083893 $7.00 83921-TC $25.00 84078-26 $5.0083893-26 $2.00 83925 $13.00 84078-TC $14.0083893-TC $5.00 83925-26 $3.00 84080 $36.0083894 $7.00 83925-TC $9.00 84080-26 $11.0083894-26 $2.00 83930 $11.00 84080-TC $24.0083894-TC $5.00 83930-26 $3.00 84081 $45.0083896 $7.00 83930-TC $7.00 84081-26 $15.0083896-26 $2.00 83935 $17.00 84081-TC $31.0083896-TC $5.00 83935-26 $5.00 84085 $15.0083897 $9.00 83935-TC $12.00 84085-26 $5.0083897-26 $3.00 83937 $29.00 84085-TC $10.0083897-TC $5.00 83937-26 $10.00 84087 $25.0083898 $43.00 83937-TC $19.00 84087-26 $7.0083898-26 $14.00 83945 $32.00 84087-TC $18.0083898-TC $29.00 83945-26 $11.00 84100 $11.0083901 $44.00 83945-TC $20.00 84100-26 $3.0083901-26 $14.00 83950 BR 84100-TC $7.0083901-TC $29.00 83950-26 BR 84105 $11.0083902 $38.00 83950-TC BR 84105-26 $3.0083902-26 $13.00 83970 $94.00 84105-TC $7.0083902-TC $24.00 83970-26 $31.00 84106 $10.0083903 $44.00 83970-TC $62.00 84106-26 $2.0083903-26 $14.00 83986 $8.00 84106-TC $7.0083903-TC $29.00 83986-26 $3.00 84110 $21.0083904 $44.00 83986-TC $5.00 84110-26 $6.0083904-26 $14.00 83992 $40.00 84110-TC $15.0083904-TC $29.00 83992-26 $12.00 84119 $21.0083905 $44.00 83992-TC $28.00 84119-26 $6.0083905-26 $14.00 84022 $41.00 84119-TC $15.0083905-TC $29.00 84022-26 $13.00 84120 $38.0083906 $44.00 84022-TC $28.00 84120-26 $11.0083906-26 $14.00 84030 $11.00 84120-TC $26.0083906-TC $29.00 84030-26 $3.00 84126 $71.0083912 $39.00 84030-TC $7.00 84126-26 $20.0083912-26 $11.00 84035 $12.00 84126-TC $49.0083912-TC $28.00 84035-26 $3.00 84127 $18.0083915 $31.00 84035-TC $8.00 84127-26 $6.0083915-26 $10.00 84060 $20.00 84127-TC $12.0083915-TC $20.00 84060-26 $6.00 84132 $11.0083916 $54.00 84060-TC $14.00 84132-26 $3.0083916-26 $18.00 84061 $14.00 84132-TC $7.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 102

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA84133 $11.00 84181-TC $19.00 84270-26 $11.0084133-26 $3.00 84182 $33.00 84270-TC $24.0084133-TC $7.00 84182-26 $11.00 84275 $37.0084134 $24.00 84182-TC $21.00 84275-26 $11.0084134-26 $7.00 84202 $39.00 84275-TC $25.0084134-TC $17.00 84202-26 $13.00 84285 $59.0084135 $57.00 84202-TC $25.00 84285-26 $17.0084135-26 $19.00 84203 $16.00 84285-TC $42.0084135-TC $38.00 84203-26 $5.00 84295 $10.0084138 $56.00 84203-TC $11.00 84295-26 $3.0084138-26 $18.00 84206 $32.00 84295-TC $6.0084138-TC $38.00 84206-26 $10.00 84300 $10.0084140 $41.00 84206-TC $21.00 84300-26 $3.0084140-26 $8.00 84207 $54.00 84300-TC $6.0084140-TC $33.00 84207-26 $16.00 84302 BR84143 $62.00 84207-TC $38.00 84302-26 BR84143-26 $20.00 84210 $24.00 84302-TC BR84143-TC $41.00 84210-26 $10.00 84305 $34.0084144 $38.00 84210-TC $15.00 84305-26 $11.0084144-26 $7.00 84220 $25.00 84305-TC $22.0084144-TC $31.00 84220-26 $8.00 84307 $26.0084146 $53.00 84220-TC $17.00 84307-26 $8.0084146-26 $17.00 84228 $32.00 84307-TC $18.0084146-TC $36.00 84228-26 $10.00 84311 $11.0084150 $69.00 84228-TC $21.00 84311-26 $3.0084150-26 $20.00 84233 $116.00 84311-TC $7.0084150-TC $47.00 84233-26 $35.00 84315 $5.0084152 $42.00 84233-TC $81.00 84315-26 $2.0084152-26 $14.00 84234 $116.00 84315-TC $3.0084152-TC $27.00 84234-26 $35.00 84375 $37.0084153 $33.00 84234-TC $81.00 84375-26 $11.0084153-26 $11.00 84235 $114.00 84375-TC $25.0084153-TC $21.00 84235-26 $34.00 84376 $10.0084154 $33.00 84235-TC $80.00 84376-26 $3.0084154-26 $11.00 84238 $97.00 84376-TC $7.0084154-TC $21.00 84238-26 $32.00 84377 $10.0084155 $12.00 84238-TC $65.00 84377-26 $3.0084155-26 $4.00 84244 $47.00 84377-TC $7.0084155-TC $7.00 84244-26 $15.00 84378 $25.0084160 $5.00 84244-TC $32.00 84378-26 $8.0084160-26 $2.00 84252 $47.00 84378-TC $17.0084160-TC $2.00 84252-26 $14.00 84379 $25.0084165 $24.00 84252-TC $33.00 84379-26 $8.0084165-26 $8.00 84255 $58.00 84379-TC $17.0084165-TC $16.00 84255-26 $17.00 84392 $8.0084166 BR 84255-TC $41.00 84392-26 $2.0084166-26 $20.00 84260 $54.00 84392-TC $6.0084166-TC BR 84260-26 $16.00 84402 $72.0084181 $29.00 84260-TC $38.00 84402-26 $21.0084181-26 $10.00 84270 $36.00 84402-TC $49.00

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA84403 $67.00 84479-TC $10.00 84578-26 $2.0084403-26 $19.00 84480 $20.00 84578-TC $5.0084403-TC $45.00 84480-26 $6.00 84580 $17.0084425 $54.00 84480-TC $14.00 84580-26 $5.0084425-26 $17.00 84481 $33.00 84580-TC $12.0084425-TC $37.00 84481-26 $10.00 84583 $11.0084430 $31.00 84481-TC $22.00 84583-26 $3.0084430-26 $10.00 84482 $45.00 84583-TC $7.0084430-TC $20.00 84482-26 $15.00 84585 $36.0084432 $28.00 84482-TC $31.00 84585-26 $11.0084432-26 $8.00 84484 $21.00 84585-TC $24.0084432-TC $19.00 84484-26 $6.00 84586 $42.0084436 $14.00 84484-TC $15.00 84586-26 $14.0084436-26 $3.00 84485 $15.00 84586-TC $27.0084436-TC $11.00 84485-26 $4.00 84588 $73.0084437 $13.00 84485-TC $11.00 84588-26 $23.0084437-26 $4.00 84488 $15.00 84588-TC $47.0084437-TC $8.00 84488-26 $4.00 84590 $33.0084439 $16.00 84488-TC $11.00 84590-26 $11.0084439-26 $4.00 84490 $15.00 84590-TC $21.0084439-TC $12.00 84490-26 $4.00 84591 $26.0084442 $25.00 84490-TC $11.00 84591-26 $9.0084442-26 $6.00 84510 $26.00 84591-TC $18.0084442-TC $19.00 84510-26 $8.00 84597 $37.0084443 $32.00 84510-TC $18.00 84597-26 $11.0084443-26 $7.00 84512 $17.00 84597-TC $25.0084443-TC $23.00 84512-26 $5.00 84600 $43.0084445 $98.00 84512-TC $12.00 84600-26 $13.0084445-26 $29.00 84520 $12.00 84600-TC $31.0084445-TC $69.00 84520-26 $3.00 84620 $29.0084446 $35.00 84520-TC $8.00 84620-26 $8.0084446-26 $11.00 84525 $7.00 84620-TC $20.0084446-TC $23.00 84525-26 $2.00 84630 $26.0084449 $38.00 84525-TC $5.00 84630-26 $8.0084449-26 $13.00 84540 $13.00 84630-TC $18.0084449-TC $24.00 84540-26 $4.00 84681 $52.0084450 $11.00 84540-TC $8.00 84681-26 $17.0084450-26 $3.00 84545 $18.00 84681-TC $35.0084450-TC $7.00 84545-26 $5.00 84702 $38.0084460 $13.00 84545-TC $13.00 84702-26 $11.0084460-26 $4.00 84550 $12.00 84702-TC $26.0084460-TC $8.00 84550-26 $4.00 84703 $22.0084466 $22.00 84550-TC $7.00 84703-26 $6.0084466-26 $7.00 84560 $12.00 84703-TC $15.0084466-TC $15.00 84560-26 $3.00 84830 $17.0084478 $12.00 84560-TC $8.00 84830-26 $5.0084478-26 $3.00 84577 $34.00 84830-TC $12.0084478-TC $8.00 84577-26 $11.00 84999 BR84479 $15.00 84577-TC $22.00 84999-26 BR84479-26 $5.00 84578 $7.00 84999-TC BR

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 104

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA85002 $10.00 85049-TC BR 85280-26 $14.0085002-26 $3.00 85060 $25.00 85280-TC $35.0085002-TC $6.00 85060-26 $7.00 85290 $44.0085004 BR 85060-TC $18.00 85290-26 $13.0085004-26 BR 85097 $59.00 85290-TC $32.0085004-TC BR 85097-26 $59.00 85291 $20.0085007 $6.00 85097-TC BR 85291-26 $6.0085007-26 $3.00 85130 $19.00 85291-TC $14.0085007-TC $4.00 85130-26 $6.00 85292 $51.0085008 $5.00 85130-TC $13.00 85292-26 $17.0085008-26 $2.00 85170 $7.00 85292-TC $34.0085008-TC $3.00 85170-26 $2.00 85293 $51.0085009 $8.00 85170-TC $5.00 85293-26 $17.0085009-26 $3.00 85175 $10.00 85293-TC $34.0085009-TC $5.00 85175-26 $3.00 85300 $35.0085013 $3.00 85175-TC $6.00 85300-26 $12.0085013-26 $1.00 85210 $31.00 85300-TC $23.0085013-TC $2.00 85210-26 $8.00 85301 $29.0085014 $4.00 85210-TC $21.00 85301-26 $10.0085014-26 $1.00 85220 $47.00 85301-TC $19.0085014-TC $3.00 85220-26 $15.00 85302 $33.0085018 $5.00 85220-TC $32.00 85302-26 $11.0085018-26 $2.00 85230 $47.00 85302-TC $21.0085018-TC $3.00 85230-26 $14.00 85303 $26.0085025 $20.00 85230-TC $33.00 85303-26 $8.0085025-26 $6.00 85240 $48.00 85303-TC $18.0085025-TC $14.00 85240-26 $15.00 85305 $21.0085027 $15.00 85240-TC $33.00 85305-26 $7.0085027-26 $5.00 85244 $49.00 85305-TC $14.0085027-TC $10.00 85244-26 $15.00 85306 $29.0085032 BR 85244-TC $34.00 85306-26 $10.0085032-26 BR 85245 $54.00 85306-TC $19.0085032-TC BR 85245-26 $18.00 85307 $35.0085041 $7.00 85245-TC $36.00 85307-26 $12.0085041-26 $3.00 85246 $54.00 85307-TC $23.0085041-TC $4.00 85246-26 $18.00 85335 $21.0085044 $10.00 85246-TC $36.00 85335-26 $7.0085044-26 $3.00 85247 $54.00 85335-TC $14.0085044-TC $6.00 85247-26 $18.00 85337 $19.0085045 $6.00 85247-TC $36.00 85337-26 $6.0085045-26 $2.00 85250 $49.00 85337-TC $13.0085045-TC $4.00 85250-26 $14.00 85345 $10.0085046 $13.00 85250-TC $35.00 85345-26 $2.0085046-26 $4.00 85260 $49.00 85345-TC $7.0085046-TC $9.00 85260-26 $14.00 85347 $8.0085048 $7.00 85260-TC $35.00 85347-26 $2.0085048-26 $3.00 85270 $49.00 85347-TC $6.0085048-TC $4.00 85270-26 $14.00 85348 $10.0085049 BR 85270-TC $35.00 85348-26 $3.0085049-26 BR 85280 $49.00 85348-TC $6.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 105

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA85360 $16.00 85445-26 $5.00 85612 $22.0085360-26 $4.00 85445-TC $11.00 85612-26 $6.0085360-TC $12.00 85460 $15.00 85612-TC $16.0085362 $18.00 85460-26 $4.00 85613 $15.0085362-26 $7.00 85460-TC $11.00 85613-26 $4.0085362-TC $11.00 85461 $12.00 85613-TC $11.0085366 $13.00 85461-26 $3.00 85635 $26.0085366-26 $3.00 85461-TC $8.00 85635-26 $8.0085366-TC $10.00 85475 $15.00 85635-TC $18.0085370 $20.00 85475-26 $4.00 85651 $8.0085370-26 $5.00 85475-TC $11.00 85651-26 $2.0085370-TC $15.00 85520 $22.00 85651-TC $6.0085378 $13.00 85520-26 $6.00 85652 $8.0085378-26 $4.00 85520-TC $16.00 85652-26 $2.0085378-TC $8.00 85525 $20.00 85652-TC $6.0085379 $18.00 85525-26 $6.00 85660 $10.0085379-26 $6.00 85525-TC $14.00 85660-26 $3.0085379-TC $12.00 85530 $39.00 85660-TC $6.0085380 BR 85530-26 $12.00 85670 $13.0085380-26 BR 85530-TC $26.00 85670-26 $3.0085380-TC BR 85536 $14.00 85670-TC $10.0085384 $11.00 85536-26 $4.00 85675 $13.0085384-26 $3.00 85536-TC $10.00 85675-26 $4.0085384-TC $7.00 85540 $24.00 85675-TC $8.0085385 $16.00 85540-26 $7.00 85705 $13.0085385-26 $5.00 85540-TC $17.00 85705-26 $4.0085385-TC $11.00 85547 $23.00 85705-TC $8.0085390 $10.00 85547-26 $6.00 85730 $11.0085390-26 $2.00 85547-TC $17.00 85730-26 $3.0085390-TC $7.00 85549 $45.00 85730-TC $7.0085396 $22.00 85549-26 $15.00 85732 $17.0085400 $12.00 85549-TC $31.00 85732-26 $5.0085400-26 $3.00 85555 $17.00 85732-TC $12.0085400-TC $8.00 85555-26 $5.00 85810 $19.0085410 $12.00 85555-TC $12.00 85810-26 $4.0085410-26 $3.00 85557 $34.00 85810-TC $15.0085410-TC $8.00 85557-26 $10.00 85999 BR85415 $28.00 85557-TC $23.00 85999-26 BR85415-26 $10.00 85576 $21.00 85999-TC BR85415-TC $18.00 85576-26 $5.00 86000 $16.0085420 $16.00 85576-TC $16.00 86000-26 $5.0085420-26 $3.00 85597 $32.00 86000-TC $11.0085420-TC $13.00 85597-26 $10.00 86001 $12.0085421 $39.00 85597-TC $21.00 86001-26 $4.0085421-26 $12.00 85610 $6.00 86001-TC $8.0085421-TC $26.00 85610-26 $3.00 86003 $6.0085441 $7.00 85610-TC $4.00 86003-26 $2.0085441-26 $2.00 85611 $6.00 86003-TC $3.0085441-TC $5.00 85611-26 $2.00 86005 $11.0085445 $16.00 85611-TC $4.00 86005-26 $4.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 106

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA86005-TC $6.00 86156-26 $3.00 86300 $47.0086021 $41.00 86156-TC $7.00 86300-26 $15.0086021-26 $12.00 86157 $13.00 86300-TC $32.0086021-TC $29.00 86157-26 $4.00 86301 $47.0086022 $57.00 86157-TC $8.00 86301-26 $15.0086022-26 $18.00 86160 $21.00 86301-TC $32.0086022-TC $39.00 86160-26 $5.00 86304 $47.0086023 $28.00 86160-TC $16.00 86304-26 $15.0086023-26 $10.00 86161 $21.00 86304-TC $32.0086023-TC $18.00 86161-26 $5.00 86308 $8.0086038 $22.00 86161-TC $16.00 86308-26 $3.0086038-26 $7.00 86162 $54.00 86308-TC $5.0086038-TC $15.00 86162-26 $18.00 86309 $12.0086039 $19.00 86162-TC $36.00 86309-26 $3.0086039-26 $6.00 86171 $25.00 86309-TC $8.0086039-TC $13.00 86171-26 $7.00 86310 $19.0086060 $13.00 86171-TC $18.00 86310-26 $6.0086060-26 $3.00 86185 $19.00 86310-TC $13.0086060-TC $10.00 86185-26 $6.00 86316 $37.0086063 $21.00 86185-TC $13.00 86316-26 $11.0086063-26 $6.00 86215 $36.00 86316-TC $25.0086063-TC $15.00 86215-26 $12.00 86317 $31.0086077 $91.00 86215-TC $23.00 86317-26 $10.0086077-26 $26.00 86225 $36.00 86317-TC $20.0086077-TC $64.00 86225-26 $11.00 86318 $23.0086078 $91.00 86225-TC $24.00 86318-26 $10.0086078-26 $26.00 86226 $24.00 86318-TC $14.0086078-TC $64.00 86226-26 $8.00 86320 $49.0086079 $79.00 86226-TC $16.00 86320-26 $19.0086079-26 $25.00 86235 $33.00 86320-TC $29.0086079-TC $52.00 86235-26 $10.00 86325 $49.0086140 $14.00 86235-TC $22.00 86325-26 $16.0086140-26 $4.00 86243 $50.00 86325-TC $33.0086140-TC $10.00 86243-26 $15.00 86327 $62.0086141 BR 86243-TC $35.00 86327-26 $19.0086141-26 BR 86255 $25.00 86327-TC $42.0086141-TC BR 86255-26 $8.00 86329 $37.0086146 $58.00 86255-TC $17.00 86329-26 $12.0086146-26 $19.00 86256 $25.00 86329-TC $24.0086146-TC $39.00 86256-26 $8.00 86331 $22.0086147 $53.00 86256-TC $17.00 86331-26 $6.0086147-26 $16.00 86277 $41.00 86331-TC $15.0086147-TC $36.00 86277-26 $14.00 86332 $54.0086148 $59.00 86277-TC $26.00 86332-26 $18.0086148-26 $21.00 86280 $15.00 86332-TC $36.0086148-TC $38.00 86280-26 $3.00 86334 $65.0086155 $26.00 86280-TC $12.00 86334-26 $18.0086155-26 $8.00 86294 BR 86334-TC $45.0086155-TC $18.00 86294-26 BR 86335 BR86156 $11.00 86294-TC BR 86335-26 $20.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 107

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA86335-TC BR 86430-26 $4.00 86617-TC $19.0086336 BR 86430-TC $8.00 86618 $26.0086336-26 BR 86431 $17.00 86618-26 $8.0086336-TC BR 86431-26 $6.00 86618-TC $18.0086337 $54.00 86431-TC $11.00 86619 $21.0086337-26 $18.00 86485 $13.00 86619-26 $6.0086337-TC $36.00 86485-26 $4.00 86619-TC $15.0086340 $39.00 86485-TC $8.00 86622 $16.0086340-26 $13.00 86486 $6.00 86622-26 $5.0086340-TC $25.00 86490 $17.00 86622-TC $11.0086341 $38.00 86490-26 $5.00 86625 $21.0086341-26 $13.00 86490-TC $12.00 86625-26 $6.0086341-TC $24.00 86510 $13.00 86625-TC $15.0086343 $33.00 86510-26 $4.00 86628 $20.0086343-26 $11.00 86510-TC $8.00 86628-26 $6.0086343-TC $21.00 86580 $13.00 86628-TC $14.0086344 $21.00 86580-26 $4.00 86631 $20.0086344-26 $7.00 86580-TC $8.00 86631-26 $6.0086344-TC $14.00 86590 $18.00 86631-TC $14.0086353 $102.00 86590-26 $6.00 86632 $20.0086353-26 $31.00 86590-TC $12.00 86632-26 $6.0086353-TC $72.00 86592 $8.00 86632-TC $14.0086359 $61.00 86592-26 $2.00 86635 $18.0086359-26 $19.00 86592-TC $6.00 86635-26 $5.0086359-TC $41.00 86593 $11.00 86635-TC $13.0086360 $99.00 86593-26 $3.00 86638 $20.0086360-26 $33.00 86593-TC $7.00 86638-26 $6.0086360-TC $67.00 86602 $17.00 86638-TC $14.0086361 $66.00 86602-26 $5.00 86641 $21.0086361-26 $21.00 86602-TC $12.00 86641-26 $7.0086361-TC $43.00 86603 $20.00 86641-TC $14.0086376 $35.00 86603-26 $6.00 86644 $22.0086376-26 $11.00 86603-TC $14.00 86644-26 $7.0086376-TC $23.00 86606 $24.00 86644-TC $15.0086378 $45.00 86606-26 $8.00 86645 $28.0086378-26 $15.00 86606-TC $16.00 86645-26 $10.0086378-TC $31.00 86609 $20.00 86645-TC $18.0086382 $45.00 86609-26 $6.00 86648 $24.0086382-26 $14.00 86609-TC $14.00 86648-26 $8.0086382-TC $32.00 86611 $23.00 86648-TC $16.0086384 $24.00 86611-26 $8.00 86651 $21.0086384-26 $8.00 86611-TC $15.00 86651-26 $7.0086384-TC $16.00 86612 $21.00 86651-TC $14.0086403 $18.00 86612-26 $6.00 86652 $21.0086403-26 $3.00 86612-TC $15.00 86652-26 $7.0086403-TC $14.00 86615 $21.00 86652-TC $14.0086406 $21.00 86615-26 $6.00 86653 $21.0086406-26 $5.00 86615-TC $15.00 86653-26 $7.0086406-TC $16.00 86617 $29.00 86653-TC $14.0086430 $13.00 86617-26 $10.00 86654 $21.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 108

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.

Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA86654-26 $7.00 86695 $21.00 86723-TC $14.0086654-TC $14.00 86695-26 $7.00 86727 $20.0086658 $21.00 86695-TC $14.00 86727-26 $6.0086658-26 $7.00 86696 $44.00 86727-TC $14.0086658-TC $14.00 86696-26 $14.00 86729 $19.0086663 $21.00 86696-TC $30.00 86729-26 $6.0086663-26 $7.00 86698 $20.00 86729-TC $13.0086663-TC $14.00 86698-26 $6.00 86732 $21.0086664 $53.00 86698-TC $14.00 86732-26 $7.0086664-26 $17.00 86701 $21.00 86732-TC $14.0086664-TC $36.00 86701-26 $7.00 86735 $21.0086665 $29.00 86701-TC $15.00 86735-26 $7.0086665-26 $10.00 86702 $21.00 86735-TC $14.0086665-TC $19.00 86702-26 $7.00 86738 $21.0086666 $23.00 86702-TC $14.00 86738-26 $7.0086666-26 $8.00 86703 $22.00 86738-TC $14.0086666-TC $15.00 86703-26 $7.00 86741 $21.0086668 $17.00 86703-TC $15.00 86741-26 $7.0086668-26 $5.00 86704 $33.00 86741-TC $14.0086668-TC $12.00 86704-26 $11.00 86744 $21.0086671 $20.00 86704-TC $21.00 86744-26 $7.0086671-26 $6.00 86705 $35.00 86744-TC $14.0086671-TC $14.00 86705-26 $11.00 86747 $23.0086674 $23.00 86705-TC $23.00 86747-26 $7.0086674-26 $7.00 86706 $24.00 86747-TC $16.0086674-TC $16.00 86706-26 $8.00 86750 $21.0086677 $24.00 86706-TC $16.00 86750-26 $7.0086677-26 $8.00 86707 $26.00 86750-TC $14.0086677-TC $16.00 86707-26 $8.00 86753 $20.0086682 $21.00 86707-TC $18.00 86753-26 $6.0086682-26 $7.00 86708 $32.00 86753-TC $14.0086682-TC $14.00 86708-26 $10.00 86756 $20.0086684 $24.00 86708-TC $21.00 86756-26 $6.0086684-26 $8.00 86709 $29.00 86756-TC $14.0086684-TC $16.00 86709-26 $10.00 86757 $44.0086687 $22.00 86709-TC $19.00 86757-26 $14.0086687-26 $7.00 86710 $22.00 86757-TC $30.0086687-TC $16.00 86710-26 $7.00 86759 $21.0086688 $20.00 86710-TC $15.00 86759-26 $7.0086688-26 $7.00 86713 $23.00 86759-TC $14.0086688-TC $14.00 86713-26 $7.00 86762 $22.0086689 $25.00 86713-TC $16.00 86762-26 $7.0086689-26 $8.00 86717 $20.00 86762-TC $15.0086689-TC $17.00 86717-26 $6.00 86765 $20.0086692 $22.00 86717-TC $14.00 86765-26 $6.0086692-26 $7.00 86720 $21.00 86765-TC $14.0086692-TC $15.00 86720-26 $7.00 86768 $21.0086694 $22.00 86720-TC $14.00 86768-26 $7.0086694-26 $7.00 86723 $21.00 86768-TC $14.0086694-TC $15.00 86723-26 $7.00 86771 $21.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 109

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA86771-26 $7.00 86813 $101.00 86903-TC $10.0086771-TC $14.00 86813-26 $29.00 86904 $19.0086774 $23.00 86813-TC $71.00 86904-26 $6.0086774-26 $7.00 86816 $64.00 86904-TC $13.0086774-TC $16.00 86816-26 $18.00 86905 $7.0086777 $22.00 86816-TC $44.00 86905-26 $1.0086777-26 $7.00 86817 $134.00 86905-TC $6.0086777-TC $15.00 86817-26 $39.00 86906 $11.0086778 $23.00 86817-TC $94.00 86906-26 $3.0086778-26 $7.00 86821 $123.00 86906-TC $7.0086778-TC $16.00 86821-26 $36.00 86910 $83.0086781 $22.00 86821-TC $86.00 86910-26 $24.0086781-26 $7.00 86822 $96.00 86910-TC $57.0086781-TC $15.00 86822-26 $32.00 86911 $19.0086784 $21.00 86822-TC $64.00 86911-26 $6.0086784-26 $7.00 86849 BR 86911-TC $13.0086784-TC $14.00 86849-26 BR 86920 $19.0086787 $20.00 86849-TC BR 86920-26 $3.0086787-26 $6.00 86850 $10.00 86920-TC $15.0086787-TC $14.00 86850-26 $3.00 86921 $23.0086790 $21.00 86850-TC $6.00 86921-26 $7.0086790-26 $7.00 86860 $44.00 86921-TC $16.0086790-TC $14.00 86860-26 $15.00 86922 $20.0086793 $21.00 86860-TC $29.00 86922-26 $6.0086793-26 $7.00 86870 $17.00 86922-TC $14.0086793-TC $14.00 86870-26 $6.00 86927 $21.0086800 $26.00 86870-TC $11.00 86927-26 $5.0086800-26 $8.00 86880 $13.00 86927-TC $16.0086800-TC $18.00 86880-26 $4.00 86930 $155.0086803 $24.00 86880-TC $8.00 86930-26 $45.0086803-26 $8.00 86885 $15.00 86930-TC $108.0086803-TC $16.00 86885-26 $4.00 86931 $155.0086804 $26.00 86885-TC $11.00 86931-26 $45.0086804-26 $8.00 86886 $14.00 86931-TC $108.0086804-TC $18.00 86886-26 $4.00 86932 $161.0086805 $97.00 86886-TC $10.00 86932-26 $48.0086805-26 $33.00 86890 $67.00 86932-TC $111.0086805-TC $64.00 86890-26 $11.00 86940 $18.0086806 $87.00 86890-TC $54.00 86940-26 $5.0086806-26 $28.00 86891 $91.00 86940-TC $13.0086806-TC $57.00 86891-26 $26.00 86941 $31.0086807 $74.00 86891-TC $64.00 86941-26 $8.0086807-26 $21.00 86900 $10.00 86941-TC $21.0086807-TC $51.00 86900-26 $3.00 86945 $35.0086808 $52.00 86900-TC $6.00 86945-26 $11.0086808-26 $15.00 86901 $10.00 86945-TC $23.0086808-TC $37.00 86901-26 $3.00 86950 $99.0086812 $108.00 86901-TC $6.00 86950-26 $29.0086812-26 $32.00 86903 $15.00 86950-TC $70.0086812-TC $75.00 86903-26 $5.00 86965 $25.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 110

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA86965-26 $7.00 87071 $11.00 87116-TC $11.0086965-TC $18.00 87071-26 $3.00 87118 $28.0086970 $41.00 87071-TC $8.00 87118-26 $9.0086970-26 $12.00 87073 $11.00 87118-TC $20.0086970-TC $29.00 87073-26 $3.00 87140 $24.0086971 $20.00 87073-TC $8.00 87140-26 $7.0086971-26 $5.00 87075 $18.00 87140-TC $17.0086971-TC $15.00 87075-26 $6.00 87143 $34.0086972 $20.00 87075-TC $12.00 87143-26 $11.0086972-26 $6.00 87076 $24.00 87143-TC $22.0086972-TC $14.00 87076-26 $8.00 87147 $26.0086975 $53.00 87076-TC $16.00 87147-26 $8.0086975-26 $16.00 87077 $16.00 87147-TC $18.0086975-TC $37.00 87077-26 $5.00 87149 $46.0086976 $53.00 87077-TC $11.00 87149-26 $15.0086976-26 $16.00 87081 $12.00 87149-TC $31.0086976-TC $37.00 87081-26 $3.00 87152 $12.0086977 $53.00 87081-TC $8.00 87152-26 $4.0086977-26 $16.00 87084 $23.00 87152-TC $8.0086977-TC $37.00 87084-26 $7.00 87158 $5.0086978 $65.00 87084-TC $16.00 87158-26 $1.0086978-26 $19.00 87086 $14.00 87158-TC $3.0086978-TC $44.00 87086-26 $3.00 87164 $24.0086985 $35.00 87086-TC $11.00 87164-26 $8.0086985-26 $12.00 87088 $18.00 87164-TC $16.0086985-TC $23.00 87088-26 $6.00 87166 $24.0086999 BR 87088-TC $12.00 87166-26 $7.0086999-26 BR 87101 $20.00 87166-TC $17.0086999-TC BR 87101-26 $6.00 87168 $10.0087001 $35.00 87101-TC $14.00 87168-26 $3.0087001-26 $11.00 87102 $20.00 87168-TC $7.0087001-TC $23.00 87102-26 $6.00 87169 $10.0087003 $40.00 87102-TC $14.00 87169-26 $3.0087003-26 $13.00 87103 $32.00 87169-TC $7.0087003-TC $26.00 87103-26 $11.00 87172 $10.0087015 $14.00 87103-TC $20.00 87172-26 $3.0087015-26 $5.00 87106 $25.00 87172-TC $7.0087015-TC $9.00 87106-26 $7.00 87176 $16.0087040 $18.00 87106-TC $18.00 87176-26 $5.0087040-26 $6.00 87107 $23.00 87176-TC $11.0087040-TC $12.00 87107-26 $8.00 87177 $18.0087045 $18.00 87107-TC $15.00 87177-26 $6.0087045-26 $6.00 87109 $26.00 87177-TC $12.0087045-TC $11.00 87109-26 $8.00 87181 $13.0087046 $5.00 87109-TC $18.00 87181-26 $3.0087046-26 $2.00 87110 $23.00 87181-TC $8.0087046-TC $3.00 87110-26 $7.00 87184 $13.0087070 $14.00 87110-TC $15.00 87184-26 $3.0087070-26 $4.00 87116 $15.00 87184-TC $10.0087070-TC $10.00 87116-26 $3.00 87185 $11.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 111

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA87185-26 $3.00 87260 $26.00 87285-TC $18.0087185-TC $8.00 87260-26 $8.00 87290 $26.0087186 $16.00 87260-TC $18.00 87290-26 $8.0087186-26 $4.00 87265 $26.00 87290-TC $18.0087186-TC $12.00 87265-26 $8.00 87299 $26.0087187 $20.00 87265-TC $18.00 87299-26 $8.0087187-26 $3.00 87267 BR 87299-TC $18.0087187-TC $17.00 87267-26 BR 87300 $13.0087188 $18.00 87267-TC BR 87300-26 $4.0087188-26 $5.00 87270 $26.00 87300-TC $9.0087188-TC $13.00 87270-26 $8.00 87301 $26.0087190 $7.00 87270-TC $18.00 87301-26 $8.0087190-26 $2.00 87271 BR 87301-TC $18.0087190-TC $5.00 87271-26 BR 87320 $26.0087197 $29.00 87271-TC BR 87320-26 $8.0087197-26 $10.00 87272 $26.00 87320-TC $18.0087197-TC $19.00 87272-26 $8.00 87324 $26.0087205 $11.00 87272-TC $18.00 87324-26 $8.0087205-26 $3.00 87273 $27.00 87324-TC $18.0087205-TC $7.00 87273-26 $9.00 87327 $27.0087206 $15.00 87273-TC $19.00 87327-26 $9.0087206-26 $3.00 87274 $26.00 87327-TC $19.0087206-TC $12.00 87274-26 $8.00 87328 $26.0087207 $10.00 87274-TC $18.00 87328-26 $8.0087207-26 $3.00 87275 $27.00 87328-TC $18.0087207-TC $6.00 87275-26 $9.00 87332 $26.0087210 $8.00 87275-TC $19.00 87332-26 $8.0087210-26 $2.00 87276 $26.00 87332-TC $18.0087210-TC $6.00 87276-26 $8.00 87335 $26.0087220 $12.00 87276-TC $18.00 87335-26 $8.0087220-26 $4.00 87277 $27.00 87335-TC $18.0087220-TC $7.00 87277-26 $9.00 87336 $27.0087230 $35.00 87277-TC $19.00 87336-26 $9.0087230-26 $11.00 87278 $26.00 87336-TC $19.0087230-TC $23.00 87278-26 $8.00 87337 $27.0087250 $33.00 87278-TC $18.00 87337-26 $9.0087250-26 $13.00 87279 $27.00 87337-TC $19.0087250-TC $19.00 87279-26 $9.00 87338 $27.0087252 $44.00 87279-TC $19.00 87338-26 $7.0087252-26 $14.00 87280 $26.00 87338-TC $20.0087252-TC $31.00 87280-26 $8.00 87339 $27.0087253 $33.00 87280-TC $18.00 87339-26 $9.0087253-26 $10.00 87281 $27.00 87339-TC $19.0087253-TC $22.00 87281-26 $9.00 87340 $20.0087254 $11.00 87281-TC $19.00 87340-26 $6.0087254-26 $3.00 87283 $27.00 87340-TC $14.0087254-TC $8.00 87283-26 $9.00 87341 $23.0087255 BR 87283-TC $19.00 87341-26 $8.0087255-26 BR 87285 $26.00 87341-TC $15.0087255-TC BR 87285-26 $8.00 87350 $20.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 112

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA87350-26 $6.00 87476 $73.00 87512-TC $56.0087350-TC $14.00 87476-26 $23.00 87515 $42.0087380 $35.00 87476-TC $48.00 87515-26 $13.0087380-26 $11.00 87477 $88.00 87515-TC $28.0087380-TC $23.00 87477-26 $28.00 87516 $73.0087385 $26.00 87477-TC $58.00 87516-26 $23.0087385-26 $8.00 87480 $42.00 87516-TC $48.0087385-TC $18.00 87480-26 $13.00 87517 $88.0087390 $38.00 87480-TC $28.00 87517-26 $28.0087390-26 $13.00 87481 $73.00 87517-TC $58.0087390-TC $24.00 87481-26 $23.00 87520 $42.0087391 $38.00 87481-TC $48.00 87520-26 $13.0087391-26 $13.00 87482 $86.00 87520-TC $28.0087391-TC $24.00 87482-26 $28.00 87521 $73.0087400 $13.00 87482-TC $56.00 87521-26 $23.0087400-26 $4.00 87485 $42.00 87521-TC $48.0087400-TC $9.00 87485-26 $13.00 87522 $88.0087420 $26.00 87485-TC $28.00 87522-26 $28.0087420-26 $8.00 87486 $73.00 87522-TC $58.0087420-TC $18.00 87486-26 $23.00 87525 $42.0087425 $26.00 87486-TC $48.00 87525-26 $13.0087425-26 $8.00 87487 $88.00 87525-TC $28.0087425-TC $18.00 87487-26 $28.00 87526 $73.0087427 $27.00 87487-TC $58.00 87526-26 $23.0087427-26 $9.00 87490 $42.00 87526-TC $48.0087427-TC $19.00 87490-26 $13.00 87527 $86.0087430 $26.00 87490-TC $28.00 87527-26 $28.0087430-26 $8.00 87491 $73.00 87527-TC $56.0087430-TC $18.00 87491-26 $23.00 87528 $42.0087449 $26.00 87491-TC $48.00 87528-26 $13.0087449-26 $8.00 87492 $73.00 87528-TC $28.0087449-TC $18.00 87492-26 $23.00 87529 $73.0087450 $21.00 87492-TC $48.00 87529-26 $23.0087450-26 $6.00 87495 $42.00 87529-TC $48.0087450-TC $15.00 87495-26 $13.00 87530 $88.0087451 $19.00 87495-TC $28.00 87530-26 $28.0087451-26 $7.00 87496 $73.00 87530-TC $58.0087451-TC $12.00 87496-26 $23.00 87531 $42.0087470 $42.00 87496-TC $48.00 87531-26 $13.0087470-26 $13.00 87497 $88.00 87531-TC $28.0087470-TC $28.00 87497-26 $28.00 87532 $73.0087471 $73.00 87497-TC $58.00 87532-26 $23.0087471-26 $23.00 87510 $42.00 87532-TC $48.0087471-TC $48.00 87510-26 $13.00 87533 $86.0087472 $88.00 87510-TC $28.00 87533-26 $28.0087472-26 $28.00 87511 $73.00 87533-TC $56.0087472-TC $58.00 87511-26 $23.00 87534 $42.0087475 $40.00 87511-TC $48.00 87534-26 $13.0087475-26 $13.00 87512 $86.00 87534-TC $28.0087475-TC $26.00 87512-26 $28.00 87535 $73.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 113

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA87535-26 $23.00 87580 $42.00 87801-TC $54.0087535-TC $48.00 87580-26 $13.00 87802 BR87536 $86.00 87580-TC $28.00 87802-26 BR87536-26 $28.00 87581 $73.00 87802-TC BR87536-TC $56.00 87581-26 $23.00 87803 BR87537 $42.00 87581-TC $48.00 87803-26 BR87537-26 $13.00 87582 $86.00 87803-TC BR87537-TC $28.00 87582-26 $28.00 87804 BR87538 $73.00 87582-TC $56.00 87804-26 BR87538-26 $23.00 87590 $42.00 87804-TC BR87538-TC $48.00 87590-26 $13.00 87810 $26.0087539 $88.00 87590-TC $28.00 87810-26 $8.0087539-26 $28.00 87591 $73.00 87810-TC $18.0087539-TC $58.00 87591-26 $23.00 87850 $26.0087540 $42.00 87591-TC $48.00 87850-26 $8.0087540-26 $13.00 87592 $88.00 87850-TC $18.0087540-TC $28.00 87592-26 $28.00 87880 $26.0087541 $73.00 87592-TC $58.00 87880-26 $8.0087541-26 $23.00 87620 $42.00 87880-TC $18.0087541-TC $48.00 87620-26 $13.00 87899 $26.0087542 $86.00 87620-TC $28.00 87899-26 $8.0087542-26 $28.00 87621 $73.00 87899-TC $18.0087542-TC $56.00 87621-26 $23.00 87901 $594.0087550 $42.00 87621-TC $48.00 87901-26 $196.0087550-26 $13.00 87622 $86.00 87901-TC $398.0087550-TC $28.00 87622-26 $28.00 87902 BR87551 $73.00 87622-TC $56.00 87902-26 BR87551-26 $23.00 87650 $42.00 87902-TC BR87551-TC $48.00 87650-26 $13.00 87903 $1,126.0087552 $88.00 87650-TC $28.00 87903-26 $371.0087552-26 $28.00 87651 $73.00 87903-TC $755.0087552-TC $58.00 87651-26 $23.00 87904 $59.0087555 $42.00 87651-TC $48.00 87904-26 $20.0087555-26 $13.00 87652 $86.00 87904-TC $39.0087555-TC $28.00 87652-26 $28.00 87999 BR87556 $73.00 87652-TC $56.00 87999-26 BR87556-26 $23.00 87797 $42.00 87999-TC BR87556-TC $48.00 87797-26 $13.00 88000 $445.0087557 $88.00 87797-TC $28.00 88000-26 $445.0087557-26 $28.00 87798 $73.00 88000-TC BR87557-TC $58.00 87798-26 $23.00 88005 $500.0087560 $42.00 87798-TC $48.00 88005-26 $500.0087560-26 $13.00 87799 $88.00 88005-TC BR87560-TC $28.00 87799-26 $28.00 88007 $556.0087561 $73.00 87799-TC $58.00 88007-26 $556.0087561-26 $23.00 87800 $46.00 88007-TC BR87561-TC $48.00 87800-26 $15.00 88020 $556.0087562 $88.00 87800-TC $31.00 88020-26 $556.0087562-26 $28.00 87801 $81.00 88020-TC BR87562-TC $58.00 87801-26 $26.00 88025 $610.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 114

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA88025-26 $610.00 88143 $94.00 88173-TC $26.0088025-TC BR 88143-26 $33.00 88174 BR88027 $666.00 88143-TC $59.00 88174-26 BR88027-26 $666.00 88147 $82.00 88174-TC BR88027-TC BR 88147-26 BR 88175 BR88036 $477.00 88147-TC $82.00 88175-26 BR88036-26 $477.00 88148 $104.00 88175-TC BR88036-TC BR 88148-26 $21.00 88182 $88.0088037 $389.00 88148-TC $82.00 88182-26 $33.0088037-26 $389.00 88150 $13.00 88182-TC $54.0088037-TC BR 88150-26 $3.00 88184 $51.0088040 $1,445.00 88150-TC $9.00 88185 $25.0088040-26 $1,445.00 88152 $46.00 88187 $69.0088040-TC BR 88152-26 $8.00 88188 $86.0088045 BR 88152-TC $38.00 88189 $113.0088045-26 BR 88153 $82.00 88199 BR88045-TC BR 88153-26 $21.00 88199-26 BR88099 BR 88153-TC $59.00 88199-TC BR88099-26 BR 88154 $104.00 88233 $243.0088099-TC BR 88154-26 $21.00 88233-26 $73.0088104 $49.00 88154-TC $82.00 88233-TC $170.0088104-26 $37.00 88155 $14.00 88235 $256.0088104-TC $10.00 88155-26 $3.00 88235-26 $76.0088106 $54.00 88155-TC $10.00 88235-TC $177.0088106-26 $16.00 88160 $45.00 88240 $21.0088106-TC $38.00 88160-26 $14.00 88240-26 $6.0088107 $74.00 88160-TC $24.00 88240-TC $15.0088107-26 $57.00 88161 $64.00 88241 $21.0088107-TC $15.00 88161-26 $19.00 88241-26 $6.0088108 $59.00 88161-TC $37.00 88241-TC $15.0088108-26 $47.00 88162 $77.00 88300 $24.0088108-TC $11.00 88162-26 $22.00 88300-26 $19.0088112 $121.00 88162-TC $53.00 88300-TC $5.0088112-26 $65.00 88164 $54.00 88302 $53.0088112-TC $56.00 88164-26 $21.00 88302-26 $42.0088125 $70.00 88164-TC $33.00 88302-TC $11.0088125-26 $20.00 88165 $72.00 88304 $70.0088125-TC $48.00 88165-26 $33.00 88304-26 $54.0088130 $25.00 88165-TC $38.00 88304-TC $14.0088130-26 $7.00 88166 $82.00 88305 $108.0088130-TC $18.00 88166-26 $21.00 88305-26 $86.0088140 $18.00 88166-TC $59.00 88305-TC $21.0088140-26 $5.00 88167 $87.00 88307 $210.0088140-TC $13.00 88167-26 $26.00 88307-26 $168.0088141 $33.00 88167-TC $59.00 88307-TC $41.0088141-26 BR 88172 $70.00 88309 $322.0088141-TC BR 88172-26 $54.00 88309-26 $258.0088142 $82.00 88172-TC $14.00 88309-TC $64.0088142-26 $21.00 88173 $95.00 88311 $23.0088142-TC $59.00 88173-26 $95.00 88311-26 $19.00

CPT only © 2008 American Medical Association. All Rights Reserved. Part A, 115

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Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA88311-TC $4.00 88348-26 $145.00 88399 BR88312 $23.00 88348-TC $44.00 88399-26 BR88312-26 $7.00 88349 $191.00 88399-TC BR88312-TC $16.00 88349-26 $145.00 89049 $190.0088313 $23.00 88349-TC $44.00 89050 $10.0088313-26 $7.00 88355 $108.00 89050-26 $3.0088313-TC $16.00 88355-26 $80.00 89050-TC $6.0088314 $21.00 88355-TC $26.00 89051 $13.0088314-26 $6.00 88356 $108.00 89051-26 $4.0088314-TC $15.00 88356-26 $80.00 89051-TC $8.0088318 $33.00 88356-TC $26.00 89055 BR88318-26 $14.00 88358 $108.00 89055-26 BR88318-TC $18.00 88358-26 $80.00 89055-TC BR88319 $26.00 88358-TC $26.00 89060 $13.0088319-26 $13.00 88360 $110.00 89060-26 $5.0088319-TC $14.00 88360-26 $62.00 89060-TC $8.0088321 $43.00 88360-TC $49.00 89100 $51.0088321-26 $43.00 88361 $139.00 89100-26 $15.0088321-TC BR 88361-26 $55.00 89100-TC $36.0088323 $61.00 88361-TC $84.00 89105 $65.0088323-26 $61.00 88362 $251.00 89105-26 $19.0088323-TC $32.00 88362-26 $119.00 89105-TC $44.0088325 $54.00 88362-TC $132.00 89125 $14.0088325-26 $54.00 88365 $24.00 89125-26 $4.0088325-TC BR 88365-26 $24.00 89125-TC $10.0088329 $51.00 88365-TC $68.00 89130 $44.0088329-26 $51.00 88367 $210.00 89130-26 $13.0088329-TC BR 88367-26 $72.00 89130-TC $32.0088331 $102.00 88367-TC $138.00 89132 $20.0088331-26 $70.00 88368 $190.00 89132-26 $6.0088331-TC $33.00 88368-26 $78.00 89132-TC $14.0088332 $53.00 88368-TC $112.00 89135 $37.0088332-26 $36.00 88371 $34.00 89135-26 $11.0088332-TC $17.00 88371-26 $10.00 89135-TC $25.0088333 $89.00 88371-TC $23.00 89136 $43.0088333-26 $67.00 88372 $38.00 89136-26 $14.0088333-TC $22.00 88372-26 $11.00 89136-TC $29.0088334 $47.00 88372-TC $26.00 89140 $50.0088334-26 $33.00 88380 $159.00 89140-26 $16.0088334-TC $14.00 88380-26 $71.00 89140-TC $34.0088342 $53.00 88380-TC $88.00 89141 $56.0088342-26 $36.00 88381 $213.00 89141-26 $19.0088342-TC $17.00 88381-26 $54.00 89141-TC $37.0088346 $96.00 88381-TC $159.00 89160 $6.0088346-26 $66.00 88385 $330.00 89160-26 $2.0088346-TC $28.00 88385-26 $84.00 89160-TC $4.0088347 $133.00 88385-TC $247.00 89190 $10.0088347-26 $99.00 88386 $344.00 89190-26 $3.0088347-TC $33.00 88386-26 $105.00 89190-TC $6.0088348 $191.00 88386-TC $239.00 89220 $17.00

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Pathology & LaboratoryCPT Code MRA89230 $5.00G0124 $24.00G0141 $24.00

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Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA90471 $4.00 90885 $49.00 91052-26 $52.0090472 $4.00 90887 $77.00 91052-TC $12.0090473 $13.00 90889 BR 91055 $63.0090474 $9.00 90899 BR 91055-26 $46.0090632 BR 90901 $46.00 91055-TC $11.0090636 BR 90911 $82.00 91065 $34.0090675 BR 90935 $76.00 91065-26 $23.0090703 BR 90937 $226.00 91065-TC $14.0090718 BR 90940 BR 91105 $35.0090746 BR 90945 $80.00 91110 $928.0090749 BR 90947 $125.00 91110-26 $185.0090801 $140.00 90997 $115.00 91110-TC $743.0090802 $143.00 90999 BR 91111 $743.0090804 $62.00 91000 $43.00 91111-26 $53.0090805 $68.00 91000-26 $40.00 91111-TC $690.0090806 $94.00 91000-TC $2.00 91120 $457.0090807 $101.00 91010 $116.00 91120-26 $52.0090808 $144.00 91010-26 $76.00 91120-TC $405.0090809 $149.00 91010-TC $32.00 91122 $169.0090810 $69.00 91011 $141.00 91122-26 $122.0090811 $77.00 91011-26 $89.00 91122-TC $37.0090812 $101.00 91011-TC $39.00 91123 BR90813 $107.00 91012 $143.00 91132 BR90814 $143.00 91012-26 $95.00 91132-26 $28.0090815 $149.00 91012-TC $45.00 91132-TC BR90816 $64.00 91020 $60.00 91133 BR90817 $70.00 91020-26 $49.00 91133-26 $34.0090818 $96.00 91020-TC $9.00 91133-TC BR90819 $102.00 91022 $227.00 91299 BR90821 $144.00 91022-26 $77.00 91299-26 BR90822 $149.00 91022-TC $150.00 91299-TC BR90823 $73.00 91030 $57.00 92002 $63.0090824 $78.00 91030-26 $47.00 92004 $98.0090826 $103.00 91030-TC $8.00 92012 $53.0090827 $107.00 91034 $240.00 92014 $75.0090828 $146.00 91034-26 $52.00 92015 $34.0090829 $150.00 91034-TC $188.00 92018 $80.0090845 $85.00 91035 $474.00 92019 $70.0090846 $93.00 91035-26 $84.00 92020 $31.0090847 $110.00 91035-TC $390.00 92025 $29.0090849 $32.00 91037 $152.00 92025-26 $17.0090853 $32.00 91037-26 $52.00 92025-TC $13.0090857 $31.00 91037-TC $100.00 92060 $40.0090862 $50.00 91038 $130.00 92060-26 $32.0090865 $143.00 91038-26 $59.00 92060-TC $7.0090870 $94.00 91038-TC $72.00 92065 $34.0090875 $74.00 91040 $463.00 92065-26 $19.0090876 $112.00 91040-26 $52.00 92065-TC $6.0090880 $112.00 91040-TC $411.00 92070 $66.0090882 $104.00 91052 $67.00 92081 $32.00

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Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA92081-26 $19.00 92286-26 $53.00 92544-26 $16.0092081-TC $6.00 92286-TC $29.00 92544-TC $8.0092082 $48.00 92287 $99.00 92545 $22.0092082-26 $24.00 92310 $86.00 92545-26 $14.0092082-TC $9.00 92311 $78.00 92545-TC $8.0092083 $59.00 92312 $89.00 92546 $29.0092083-26 $31.00 92313 $70.00 92546-26 $17.0092083-TC $14.00 92314 $54.00 92546-TC $9.0092100 $40.00 92315 $44.00 92547 $21.0092120 $32.00 92316 $59.00 92548 $92.0092130 $56.00 92317 $39.00 92548-26 $30.0092135 $69.00 92325 $14.00 92548-TC $59.0092135-26 $18.00 92326 $44.00 92551 $17.0092135-TC $49.00 92340 $32.00 92552 $16.0092136 $93.00 92341 $43.00 92553 $24.0092136-26 $29.00 92342 $43.00 92555 $14.0092136-TC $63.00 92352 $31.00 92556 $21.0092140 $38.00 92353 $38.00 92557 $46.0092225 $45.00 92354 $221.00 92560 $23.0092226 $39.00 92355 $107.00 92561 $27.0092230 $58.00 92358 $24.00 92562 $15.0092235 $104.00 92370 $35.00 92563 $14.0092235-26 $46.00 92371 $18.00 92564 $17.0092235-TC $53.00 92499 BR 92565 $15.0092240 $132.00 92499-26 BR 92567 $20.0092240-26 $60.00 92499-TC BR 92568 $14.0092240-TC $67.00 92502 $101.00 92569 $15.0092250 $40.00 92504 $24.00 92571 $14.0092250-26 $24.00 92506 $63.00 92572 $3.0092250-TC $7.00 92507 $40.00 92575 $11.0092260 $20.00 92508 $42.00 92576 $17.0092265 $53.00 92511 $81.00 92577 $28.0092265-26 $37.00 92512 $46.00 92579 $28.0092265-TC $10.00 92516 $36.00 92582 $28.0092270 $64.00 92520 $47.00 92583 $34.0092270-26 $45.00 92526 $48.00 92584 $94.0092270-TC $19.00 92531 $10.00 92585 $114.0092275 $80.00 92532 $14.00 92585-26 $52.0092275-26 $56.00 92533 $41.00 92585-TC $70.0092275-TC $17.00 92534 BR 92586 $70.0092283 $24.00 92541 $37.00 92587 $58.0092283-26 $10.00 92541-26 $25.00 92587-26 $8.0092283-TC $5.00 92541-TC $9.00 92587-TC $49.0092284 $192.00 92542 $33.00 92588 $78.0092284-26 $151.00 92542-26 $20.00 92588-26 $20.0092284-TC $46.00 92542-TC $10.00 92588-TC $57.0092285 $26.00 92543 $28.00 92590 $41.0092285-26 $12.00 92543-26 $19.00 92591 BR92285-TC $6.00 92543-TC $10.00 92592 BR92286 $91.00 92544 $26.00 92593 BR

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Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA92594 BR 92993 BR 93308 $118.0092595 BR 92995 $776.00 93308-26 $46.0092596 $22.00 92996 $210.00 93308-TC $75.0092597 $96.00 92997 $765.00 93312 $322.0092603 $88.00 92998 $331.00 93312-26 $140.0092604 $60.00 93000 $26.00 93312-TC $182.0092605 BR 93005 $16.00 93313 $76.0092606 BR 93010 $12.00 93314 $212.0092607 $109.00 93012 $90.00 93314-26 $65.0092608 $22.00 93014 $28.00 93314-TC $144.0092609 $59.00 93015 $104.00 93315 $287.0092610 $42.00 93016 $25.00 93315-26 $144.0092611 $46.00 93017 $63.00 93315-TC $141.0092612 $173.00 93018 $54.00 93316 $78.0092613 $43.00 93024 $111.00 93317 $236.0092614 $134.00 93024-26 $71.00 93317-26 $95.0092615 $39.00 93024-TC $42.00 93317-TC $141.0092616 $183.00 93025 $277.00 93318 $412.0092617 $48.00 93025-26 $40.00 93318-26 $114.0092620 $45.00 93025-TC $299.00 93318-TC $384.0092621 $12.00 93040 $14.00 93320 $86.0092625 $45.00 93041 $31.00 93320-26 $30.0092626 $86.00 93042 $9.00 93320-TC $65.0092627 $22.00 93224 $159.00 93321 $50.0092640 $53.00 93225 $46.00 93321-26 $10.0092700 BR 93226 $83.00 93321-TC $42.0092950 $203.00 93227 $50.00 93325 $114.0092953 $35.00 93230 $168.00 93325-26 $4.0092960 $162.00 93231 $57.00 93325-TC $110.0092961 $239.00 93232 $82.00 93350 $216.0092970 $201.00 93233 $55.00 93350-26 $77.0092971 $100.00 93235 $123.00 93350-TC $66.0092973 $174.00 93236 $97.00 93501 $674.0092974 $197.00 93237 $28.00 93501-26 $160.0092975 $400.00 93268 $109.00 93501-TC $634.0092977 $302.00 93270 $46.00 93503 $187.0092978 $269.00 93271 $90.00 93505 $318.0092978-26 $95.00 93272 $28.00 93505-26 $248.0092978-TC $170.00 93278 $58.00 93505-TC $74.0092979 $163.00 93278-26 $24.00 93508 $698.0092979-26 $76.00 93278-TC $44.00 93508-26 $232.0092979-TC $86.00 93303 $215.00 93508-TC $469.0092980 $952.00 93303-26 $70.00 93510 $1,628.0092981 $268.00 93303-TC $144.00 93510-26 $247.0092982 $705.00 93304 $114.00 93510-TC $1,388.0092984 $191.00 93304-26 $43.00 93511 $1,629.0092986 $1,222.00 93304-TC $73.00 93511-26 $270.0092987 $1,271.00 93307 $196.00 93511-TC $1,350.0092990 $974.00 93307-26 $56.00 93514 $2,208.0092992 BR 93307-TC $144.00 93514-26 $525.00

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Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA93514-TC $1,683.00 93572 $222.00 93624-TC $74.0093524 $2,150.00 93572-26 $74.00 93631 $651.0093524-26 $392.00 93572-TC $155.00 93631-26 $420.0093524-TC $1,766.00 93580 $974.00 93631-TC $239.0093526 $2,147.00 93581 $1,303.00 93640 $467.0093526-26 $363.00 93600 $198.00 93640-26 $230.0093526-TC $1,815.00 93600-26 $129.00 93640-TC $269.0093527 $2,186.00 93600-TC $73.00 93641 $613.0093527-26 $451.00 93602 $159.00 93641-26 $360.0093527-TC $1,766.00 93602-26 $119.00 93641-TC $269.0093528 $2,266.00 93602-TC $42.00 93642 $549.0093528-26 $482.00 93603 $187.00 93642-26 $295.0093528-TC $1,766.00 93603-26 $127.00 93642-TC $269.0093529 $2,032.00 93603-TC $63.00 93650 $639.0093529-26 $262.00 93609 $578.00 93651 $985.0093529-TC $1,766.00 93609-26 $481.00 93652 $1,044.0093530 $872.00 93609-TC $101.00 93660 $162.0093530-26 $250.00 93610 $214.00 93660-26 $103.0093530-TC $634.00 93610-26 $166.00 93660-TC $61.0093531 $2,268.00 93610-TC $52.00 93662 BR93531-26 $467.00 93612 $224.00 93662-26 $158.0093531-TC $1,815.00 93612-26 $167.00 93662-TC BR93532 $2,317.00 93612-TC $61.00 93668 $16.0093532-26 $569.00 93613 $377.00 93701 $36.0093532-TC $1,766.00 93615 $62.00 93701-26 $9.0093533 $2,131.00 93615-26 $49.00 93701-TC $27.0093533-26 $352.00 93615-TC $12.00 93720 $43.0093533-TC $1,766.00 93616 $94.00 93721 $27.0093539 $45.00 93616-26 $82.00 93722 $24.0093540 $49.00 93616-TC $12.00 93724 $411.0093541 $38.00 93618 $399.00 93724-26 $259.0093542 $38.00 93618-26 $258.00 93724-TC $148.0093543 $213.00 93618-TC $148.00 93740 $17.0093544 $30.00 93619 $717.00 93740-26 $12.0093545 $240.00 93619-26 $444.00 93740-TC $5.0093555 $278.00 93619-TC $290.00 93770 NC93555-26 $42.00 93620 $358.00 93770-26 NC93555-TC $234.00 93620-26 $272.00 93770-TC NC93556 $414.00 93620-TC $91.00 93784 NC93556-26 $44.00 93621 BR 93786 NC93556-TC $368.00 93621-26 $769.00 93788 NC93561 $59.00 93621-TC BR 93790 NC93561-26 $47.00 93622 BR 93797 $17.0093561-TC $20.00 93622-26 $771.00 93798 $38.0093562 $46.00 93622-TC BR 93799 BR93562-26 $33.00 93623 BR 93799-26 BR93562-TC $13.00 93623-26 $167.00 93799-TC BR93571 $270.00 93623-TC BR 93875 $55.0093571-26 $93.00 93624 $333.00 93875-26 $17.0093571-TC $170.00 93624-26 $256.00 93875-TC $42.00

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Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA93880 $176.00 93971-TC $96.00 94250-TC $5.0093880-26 $31.00 93975 $277.00 94260 $27.0093880-TC $144.00 93975-26 $89.00 94260-26 $8.0093882 $117.00 93975-TC $181.00 94260-TC $18.0093882-26 $21.00 93976 $184.00 94350 $36.0093882-TC $95.00 93976-26 $59.00 94350-26 $14.0093886 $215.00 93976-TC $121.00 94350-TC $20.0093886-26 $50.00 93978 $177.00 94360 $37.0093886-TC $162.00 93978-26 $34.00 94360-26 $11.0093888 $142.00 93978-TC $143.00 94360-TC $26.0093888-26 $33.00 93979 $122.00 94370 $33.0093888-TC $109.00 93979-26 $23.00 94370-26 $18.0093890 $241.00 93979-TC $98.00 94370-TC $12.0093890-26 $55.00 93980 $183.00 94375 $34.0093890-TC $185.00 93980-26 $65.00 94375-26 $16.0093892 $256.00 93980-TC $105.00 94375-TC $17.0093892-26 $63.00 93981 $148.00 94400 $40.0093892-TC $193.00 93981-26 $25.00 94400-26 $24.0093893 $251.00 93981-TC $124.00 94400-TC $14.0093893-26 $63.00 93982 $10.00 94450 $37.0093893-TC $188.00 93990 $110.00 94450-26 $20.0093922 $60.00 93990-26 $14.00 94450-TC $15.0093922-26 $16.00 93990-TC $96.00 94452 $52.0093922-TC $44.00 94002 $84.00 94452-26 $16.0093923 $112.00 94003 $61.00 94452-TC $36.0093923-26 $28.00 94004 $45.00 94453 $74.0093923-TC $85.00 94005 $80.00 94453-26 $20.0093924 $122.00 94010 $30.00 94453-TC $53.0093924-26 $31.00 94010-26 $12.00 94610 $63.0093924-TC $92.00 94010-TC $16.00 94620 $91.0093925 $175.00 94014 $39.00 94620-26 $38.0093925-26 $31.00 94015 $14.00 94620-TC $54.0093925-TC $144.00 94016 $26.00 94621 $122.0093926 $117.00 94060 $57.00 94621-26 $71.0093926-26 $21.00 94060-26 $18.00 94621-TC $52.0093926-TC $96.00 94060-TC $36.00 94640 $19.0093930 $174.00 94070 $32.00 94642 BR93930-26 $26.00 94070-26 $11.00 94644 $36.0093930-TC $150.00 94070-TC $19.00 94645 $14.0093931 $118.00 94150 $8.00 94660 $54.0093931-26 $17.00 94150-26 $6.00 94662 $38.0093931-TC $101.00 94150-TC $3.00 94664 $18.0093965 $63.00 94200 $17.00 94667 $23.0093965-26 $26.00 94200-26 $7.00 94668 $16.0093965-TC $42.00 94200-TC $9.00 94680 $47.0093970 $189.00 94240 $43.00 94680-26 $23.0093970-26 $36.00 94240-26 $15.00 94680-TC $22.0093970-TC $154.00 94240-TC $26.00 94681 $60.0093971 $121.00 94250 $12.00 94681-26 $12.0093971-26 $23.00 94250-26 $8.00 94681-TC $43.00

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Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA94690 $24.00 95149 $36.00 95831 $26.0094690-26 $4.00 95165 $7.00 95832 $21.0094690-TC $20.00 95170 $13.00 95833 $34.0094720 $49.00 95180 $103.00 95834 $44.0094720-26 $15.00 95199 BR 95851 $18.0094720-TC $31.00 95250 $114.00 95852 $14.0094725 $79.00 95251 $28.00 95857 $40.0094725-26 $14.00 95805 $334.00 95860 $73.0094725-TC $64.00 95805-26 $94.00 95860-26 $53.0094750 $37.00 95805-TC $237.00 95860-TC $15.0094750-26 $14.00 95806 $232.00 95861 $113.0094750-TC $21.00 95806-26 $109.00 95861-26 $86.0094760 $9.00 95806-TC $137.00 95861-TC $28.0094761 $20.00 95807 $367.00 95863 $138.0094762 $30.00 95807-26 $98.00 95863-26 $102.0094770 $21.00 95807-TC $256.00 95863-TC $35.0094770-26 $9.00 95808 $456.00 95864 $177.0094770-TC $12.00 95808-26 $149.00 95864-26 $114.0094799 BR 95808-TC $256.00 95864-TC $67.0094799-26 BR 95810 $521.00 95865 $119.0094799-TC BR 95810-26 $183.00 95865-26 $92.0095004 $3.00 95810-TC $256.00 95865-TC $27.0095010 $11.00 95811 $644.00 95866 $80.0095012 $19.00 95811-26 $196.00 95866-26 $71.0095015 $11.00 95811-TC $423.00 95866-TC $9.0095024 $3.00 95812 $137.00 95867 $66.0095027 $5.00 95812-26 $58.00 95867-26 $43.0095028 $8.00 95812-TC $68.00 95867-TC $21.0095044 $7.00 95813 $177.00 95868 $96.0095052 $9.00 95813-26 $89.00 95868-26 $71.0095056 $6.00 95813-TC $68.00 95868-TC $26.0095060 $13.00 95816 $133.00 95869 $29.0095065 $7.00 95816-26 $54.00 95869-26 $21.0095070 $82.00 95816-TC $78.00 95869-TC $8.0095071 $105.00 95819 $115.00 95870 $29.0095075 $82.00 95819-26 $58.00 95870-26 $21.0095115 $10.00 95819-TC $56.00 95870-TC $8.0095117 $9.00 95822 $120.00 95872 $104.0095120 BR 95822-26 $58.00 95872-26 $81.0095125 BR 95822-TC $63.00 95872-TC $22.0095130 BR 95824 $51.00 95873 $29.0095131 BR 95824-26 $41.00 95873-26 $21.0095132 BR 95824-TC $10.00 95873-TC $8.0095133 BR 95827 $145.00 95874 $30.0095134 BR 95827-26 $59.00 95874-26 $21.0095144 $9.00 95827-TC $86.00 95874-TC $8.0095145 $17.00 95829 $328.00 95875 $43.0095146 $24.00 95829-26 $291.00 95875-26 $34.0095147 $33.00 95829-TC $6.00 95875-TC $7.0095148 $32.00 95830 $133.00 95900 $37.00

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Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA95900-26 $24.00 95950 $265.00 95990 $57.0095900-TC $10.00 95950-26 $84.00 95991 $84.0095903 $43.00 95950-TC $177.00 95999 BR95903-26 $33.00 95951 $34.00 96000 $93.0095903-TC $9.00 95951-26 $14.00 96001 $111.0095904 $31.00 95951-TC $20.00 96002 $21.0095904-26 $20.00 95953 $411.00 96003 $20.0095904-TC $8.00 95953-26 $165.00 96004 $97.0095920 $168.00 95953-TC $240.00 96020 BR95920-26 $118.00 95954 $208.00 96020-26 $156.0095920-TC $48.00 95954-26 $134.00 96020-TC BR95921 $61.00 95954-TC $23.00 96040 $37.0095921-26 $46.00 95955 $130.00 96101 $97.0095921-TC $14.00 95955-26 $59.00 96102 $44.0095922 $65.00 95955-TC $74.00 96103 $28.0095922-26 $50.00 95956 $541.00 96105 $68.0095922-TC $14.00 95956-26 $166.00 96110 $88.0095923 $105.00 95956-TC $314.00 96111 $68.0095923-26 $47.00 95957 $171.00 96116 $109.0095923-TC $57.00 95957-26 $104.00 96118 $130.0095925 $94.00 95957-TC $64.00 96119 $66.0095925-26 $53.00 95958 $296.00 96120 $48.0095925-TC $41.00 95958-26 $230.00 96125 $57.0095926 $66.00 95958-TC $66.00 96150 $26.0095926-26 $34.00 95961 $216.00 96151 $25.0095926-TC $34.00 95961-26 $166.00 96152 $24.0095927 $67.00 95961-TC $48.00 96153 $6.0095927-26 $34.00 95962 $227.00 96154 $24.0095927-TC $34.00 95962-26 $176.00 96155 $22.0095928 $175.00 95962-TC $48.00 DSPNS see Appx D95928-26 $84.00 95965 BR 96401 $53.0095928-TC $91.00 95965-26 $420.00 96402 $46.0095929 $182.00 95965-TC BR 96405 $57.0095929-26 $84.00 95966 BR 96406 $86.0095929-TC $98.00 95966-26 $210.00 96409 $122.0095930 $44.00 95966-TC BR 96411 $71.0095930-26 $25.00 95967 BR 96413 $173.0095930-TC $11.00 95967-26 $184.00 96415 $39.0095933 $62.00 95967-TC BR 96416 $186.0095933-26 $33.00 95970 $22.00 96417 $85.0095933-TC $30.00 95971 $39.00 96420 $46.0095934 $36.00 95972 $78.00 96422 $46.0095934-26 $28.00 95973 $47.00 96423 $17.0095934-TC $8.00 95974 $155.00 96425 $54.0095936 $39.00 95975 $88.00 96440 $156.0095936-26 $30.00 95978 $213.00 96445 $157.0095936-TC $8.00 95979 $98.00 96450 $134.0095937 $40.00 95980 $27.00 96521 $153.0095937-26 $31.00 95981 $10.00 96522 $111.0095937-TC $9.00 95982 $22.00 96523 $28.00

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Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA96542 $126.00 97537 $23.00 99078 NC96549 BR 97542 $17.00 99080 BR96567 $62.00 97545 $83.00 99082 BR96570 $69.00 97546 $41.00 99090 BR96571 $38.00 97597 $49.00 99091 $49.0096900 $17.00 97598 $62.00 99172 BR96902 $24.00 97602 BR 99173 $3.0096904 $70.00 97605 $34.00 99175 $53.0096910 $21.00 97606 $37.00 99183 $123.0096912 $24.00 97750 BR 99185 $23.0096913 $53.00 97752 $48.00 99186 $78.0096920 $152.00 97755 $35.00 99190 BR96921 $155.00 97760 $31.00 99191 BR96922 $214.00 97761 $28.00 99192 BR96999 BR 97762 $26.00 99195 $16.0097001 $62.00 97799 BR 99199 NC97002 $29.00 97802 $26.00 G0101 $32.0097003 $62.00 97803 $17.00 G0102 $18.0097004 $29.00 97804 $7.00 G0104 $115.0097005 BR 97810 $35.00 G0105 $344.0097006 BR 97811 $27.00 G0105-53 $115.0097010 $10.00 97813 $37.00 G0106 $165.0097012 $16.00 97814 $30.00 G0106-26 $46.0097014 $14.00 97850 $54.00 G0106-TC $119.0097016 $15.00 97851 $26.00 G0108 $24.0097018 $10.00 97852 $54.00 G0109 $14.0097022 $15.00 97853 $26.00 G0117 $40.0097024 $10.00 98925 NC G0118 $27.0097026 $9.00 98926 $32.00 G0120 $179.0097028 $10.00 98927 NC G0120-26 $46.0097032 $16.00 98928 $23.00 G0120-TC $132.0097033 $16.00 98929 NC G0121 $344.0097034 $13.00 98940 NC G0121-53 $115.0097035 $11.00 98941 $32.00 G0122 $177.0097036 $19.00 98942 NC G0122-26 $45.0097039 $15.00 98943 $23.00 G0122-TC $132.0097110 $22.00 98960 $19.00 G0128 $4.0097112 $23.00 98961 $9.00 G0166 $138.0097113 $24.00 98962 $7.00 G0179 $41.0097116 $21.00 98966 $8.00 G0180 $54.0097124 $19.00 98967 $17.00 G0181 $99.0097139 $15.00 98968 $25.00 G0182 $102.0097140 $26.00 99000 $6.00 G0237 $12.0097150 $18.00 99001 $4.00 G0238 $13.0097260 $23.00 99002 $35.00 G0239 $11.0097261 $17.00 99026 BR G0248 $168.0097530 $22.00 99027 BR G0249 $124.0097532 $22.00 99070 BR G0250 $9.0097533 $24.00 99071 NC G0268 $43.0097535 $23.00 99075 See 440.13 G0270 $22.00

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MedicineCPT Code MRAG0271 $22.00G0281 $13.00G0283 $10.00G0308 $10.00G0309 $678.00G0310 $557.00G0311 $436.00G0312 $476.00G0313 $393.00G0314 $309.00G0315 $417.00G0316 $344.00G0317 $268.00G0318 $262.00G0319 $215.00G0320 $168.00G0321 $532.00G0322 $380.00G0323 $329.00G0324 $206.00G0325 $19.00G0326 $11.00G0327 $13.00G0329 $7.00G0332 $7.00G0366 $66.00G0367 $21.00G9041 $13.00G9042 $22.00G9043 $9.00G9044 $9.00P3001 $8.00Q0035 $24.00Q0035-26 $19.00Q0035-TC $8.00Q0091 $11.00

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Evaluation & Management Evaluation & Management Evaluation & ManagementCPT Code MRA CPT Code MRA CPT Code MRA99201 $35.00 99315 $60.00 99456 BR99202 $58.00 99316 $77.00 99457 BR99203 $58.00 99318 $66.00 99499 BR99204 $84.00 99324 $59.00 99600 BR99205 $84.00 99325 $86.00 G0245 $58.0099211 $19.00 99326 $125.00 G0246 $34.0099212 $31.00 99327 $164.00 G0337 $62.0099213 $40.00 99328 $203.00 G0344 $86.0099214 $40.00 99334 $45.00 G0368 $8.0099215 $65.00 99335 $72.00 G0372 $13.0099217 $65.00 99336 $111.00 G0396 $29.0099218 $65.00 99337 $163.00 G0397 $56.0099219 $109.00 99339 $67.00 M0064 $34.0099220 $152.00 99340 $93.0099221 $66.00 99341 $59.0099222 $109.00 99342 $85.0099223 $152.00 99343 $109.0099231 $33.00 99344 $160.0099232 $54.00 99345 $193.0099233 $77.00 99347 $46.0099234 $129.00 99348 $71.0099235 $173.00 99349 $107.0099236 $213.00 99350 $156.0099238 $66.00 99354 $106.0099239 $88.00 99355 $104.0099241 $54.00 99356 $87.0099242 $88.00 99357 $88.0099243 $117.00 99358 $94.0099244 $163.00 99359 $45.0099245 $212.00 99360 $47.0099251 $54.00 99363 $108.0099252 $70.00 99364 $38.0099253 $96.00 99366 $37.0099254 $138.00 99367 $48.0099255 $190.00 99368 $31.0099281 $18.00 99374 $75.0099282 $28.00 99375 $75.0099283 $60.00 99377 $75.0099284 $94.00 99378 $104.0099285 $103.00 99379 $75.0099288 BR 99380 $104.0099291 $192.00 99406 $12.0099292 $95.00 99407 $24.0099304 $66.00 99408 $29.0099305 $88.00 99409 $58.0099306 $108.00 99441 $13.0099307 $34.00 99442 $23.0099308 $56.00 99443 $34.0099309 $80.00 99450 NC99310 $100.00 99455 $90.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.

Dental Dental DentalD-Code MRA D-Code MRA D-Code MRAD0120 $17.00 D2330 $40.00 D2932 $77.00D0140 $13.00 D2331 $61.00 D2933 $91.00D0150 $20.00 D2332 $66.00 D2940 $29.00D0160 $36.00 D2335 $81.00 D2950 $81.00D0170 $18.00 D2390 $57.00 D2951 $20.00D0180 $20.00 D2391 $43.00 D2952 $79.00D0210 $40.00 D2392 $55.00 D2953 $133.00D0220 $10.00 D2393 $63.00 D2954 $102.00D0230 $5.00 D2394 $69.00 D2955 $81.00D0240 $12.00 D2410 $163.00 D2957 $71.00D0250 $20.00 D2420 $203.00 D2960 $121.00D0260 $14.00 D2430 $293.00 D2961 $204.00D0270 $7.00 D2510 $155.00 D2962 $294.00D0272 $12.00 D2520 $259.00 D2980 $83.00D0274 $20.00 D2530 $244.00 D2999 BRD0277 $18.00 D2542 $302.00 D3110 $25.00D0290 $36.00 D2543 $318.00 D3120 $20.00D0310 $50.00 D2544 $348.00 D3220 $61.00D0320 $204.00 D2610 $206.00 D3221 $81.00D0321 $64.00 D2620 $266.00 D3230 $70.00D0322 $105.00 D2630 $348.00 D3240 $75.00D0330 $29.00 D2642 $287.00 D3310 $206.00D0340 $40.00 D2643 $328.00 D3320 $204.00D0350 $10.00 D2644 $378.00 D3330 $287.00D0415 $34.00 D2650 $206.00 D3331 $102.00D0425 $25.00 D2651 $266.00 D3332 $110.00D0460 $13.00 D2652 $348.00 D3333 $53.00D0470 $24.00 D2662 $266.00 D3346 $225.00D0472 $30.00 D2663 $328.00 D3347 $274.00D0473 BR D2664 $348.00 D3348 $337.00D0474 BR D2710 $194.00 D3351 $102.00D0480 BR D2720 $410.00 D3352 $81.00D0502 $54.00 D2721 $306.00 D3353 $163.00D0999 BR D2722 $348.00 D3410 $179.00D1110 $29.00 D2740 $410.00 D3421 $194.00D1204 $10.00 D2750 $451.00 D3425 $206.00D1205 $40.00 D2751 $328.00 D3426 $77.00D1310 $23.00 D2752 $368.00 D3430 $55.00D1320 $48.00 D2780 $368.00 D3450 $102.00D1330 $13.00 D2781 $266.00 D3460 $318.00D1351 $21.00 D2782 $306.00 D3470 $204.00D1510 $81.00 D2783 $389.00 D3910 $50.00D1515 $121.00 D2790 $389.00 D3920 $102.00D1520 $102.00 D2791 $287.00 D3950 $61.00D1525 $143.00 D2792 $328.00 D3999 BRD1550 $14.00 D2799 $204.00 D4210 $114.00D2140 $38.00 D2910 $29.00 D4211 $50.00D2150 $44.00 D2920 $29.00 D4240 $223.00D2160 $54.00 D2930 $81.00 D4241 $63.00D2161 $67.00 D2931 $121.00 D4245 $265.00

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Dental Dental DentalD-Code MRA D-Code MRA D-Code MRAD4249 $208.00 D5721 $163.00 D5982 $167.00D4260 $328.00 D5730 $121.00 D5983 BRD4261 $164.00 D5731 $121.00 D5984 BRD4263 $195.00 D5740 $102.00 D5985 $574.00D4264 $159.00 D5741 $102.00 D5986 $61.00D4265 $96.00 D5750 $132.00 D5987 BRD4266 $285.00 D5751 $163.00 D5988 $219.00D4267 $328.00 D5760 $100.00 D5999 BRD4268 $273.00 D5761 $163.00 D6010 $649.00D4270 $155.00 D5810 $244.00 D6040 $3,016.00D4271 $206.00 D5811 $244.00 D6050 $1,557.00D4273 $337.00 D5820 $194.00 D6053 $82.00D4274 $208.00 D5821 $204.00 D6054 $61.00D4275 $178.00 D5850 $46.00 D6055 $769.00D4276 $194.00 D5851 $50.00 D6056 $265.00D4320 $77.00 D5860 $543.00 D6057 $303.00D4321 $55.00 D5861 $553.00 D6058 $392.00D4341 $79.00 D5862 $181.00 D6059 $418.00D4342 $55.00 D5867 $36.00 D6060 $289.00D4355 $50.00 D5875 $100.00 D6061 $379.00D4381 $69.00 D5899 BR D6062 $365.00D4910 $40.00 D5911 $81.00 D6063 $359.00D4920 $27.00 D5912 $121.00 D6064 $377.00D4999 BR D5913 $2,052.00 D6065 $513.00D5110 $513.00 D5914 $2,052.00 D6066 $513.00D5120 $513.00 D5915 $2,770.00 D6067 $513.00D5130 $563.00 D5916 $2,874.00 D6068 $365.00D5140 $563.00 D5919 BR D6069 $359.00D5211 $256.00 D5922 $1,334.00 D6070 $322.00D5212 $259.00 D5923 $1,641.00 D6071 $326.00D5213 $614.00 D5924 BR D6072 $365.00D5214 $614.00 D5925 BR D6073 $346.00D5281 $279.00 D5926 $1,026.00 D6074 $350.00D5410 $27.00 D5927 $1,026.00 D6075 $414.00D5411 $27.00 D5928 $1,384.00 D6076 $402.00D5421 $27.00 D5929 BR D6077 $447.00D5422 $27.00 D5931 $656.00 D6078 $1,026.00D5510 $61.00 D5932 $1,539.00 D6079 $884.00D5520 $40.00 D5933 $306.00 D6080 $71.00D5610 $61.00 D5934 $1,539.00 D6090 $229.00D5620 $83.00 D5935 $1,539.00 D6095 $247.00D5630 $22.00 D5936 $563.00 D6100 $264.00D5640 $53.00 D5937 BR D6199 BRD5650 $61.00 D5951 $614.00 D6210 $410.00D5660 $102.00 D5953 $614.00 D6211 $287.00D5670 $305.00 D5954 BR D6212 $328.00D5671 $305.00 D5955 $1,334.00 D6240 $451.00D5710 $204.00 D5958 $780.00 D6241 $368.00D5711 $204.00 D5959 $244.00 D6242 $410.00D5720 $163.00 D5960 $163.00 D6245 $309.00

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Dental Dental DentalD-Code MRA D-Code MRA D-Code MRAD6250 $410.00 D7140 $45.00 D7650 $1,292.00D6251 $287.00 D7210 $70.00 D7660 $780.00D6252 $368.00 D7220 $111.00 D7670 $410.00D6253 $51.00 D7230 $139.00 D7671 $779.00D6545 $195.00 D7240 $147.00 D7680 $1,949.00D6548 $281.00 D7241 $204.00 D7710 $1,415.00D6600 $155.00 D7250 $81.00 D7720 $903.00D6601 $166.00 D7260 $244.00 D7730 $1,580.00D6602 $172.00 D7261 BR D7740 $922.00D6603 $203.00 D7270 $147.00 D7750 $1,334.00D6604 $110.00 D7272 $204.00 D7760 $1,046.00D6605 $141.00 D7280 $121.00 D7770 $533.00D6606 $139.00 D7282 $41.00 D7771 $73.00D6607 $151.00 D7285 $106.00 D7780 $2,504.00D6608 $170.00 D7286 $81.00 D7810 $1,292.00D6609 $178.00 D7287 BR D7820 $110.00D6610 $203.00 D7290 $133.00 D7830 $186.00D6611 $217.00 D7291 $77.00 D7840 $1,764.00D6612 $141.00 D7310 $85.00 D7850 $1,682.00D6613 $155.00 D7320 $108.00 D7852 $2,011.00D6614 $151.00 D7340 $195.00 D7854 $2,052.00D6615 $162.00 D7350 $410.00 D7856 BRD6720 $410.00 D7410 $102.00 D7858 $2,298.00D6721 $233.00 D7411 $100.00 D7860 $614.00D6722 $348.00 D7412 $139.00 D7865 $1,723.00D6740 $328.00 D7413 $205.00 D7870 $81.00D6750 $356.00 D7414 $180.00 D7871 BRD6751 $328.00 D7415 $291.00 D7872 $533.00D6752 $410.00 D7440 $161.00 D7873 $584.00D6780 $389.00 D7441 $247.00 D7874 $737.00D6781 $320.00 D7450 $139.00 D7875 $789.00D6782 $322.00 D7451 $179.00 D7876 $820.00D6783 $324.00 D7460 $137.00 D7877 $758.00D6790 $389.00 D7461 $195.00 D7880 $291.00D6791 $287.00 D7465 $71.00 D7899 BRD6792 $348.00 D7471 $174.00 D7910 $73.00D6793 $30.00 D7472 $143.00 D7911 $110.00D6920 $279.00 D7473 $147.00 D7912 $163.00D6930 $40.00 D7485 $162.00 D7920 $676.00D6940 $102.00 D7490 $2,545.00 D7940 $841.00D6950 $155.00 D7510 $54.00 D7941 $2,874.00D6970 $163.00 D7520 $121.00 D7943 $2,914.00D6971 $113.00 D7530 $85.00 D7944 $2,298.00D6972 $121.00 D7540 $121.00 D7945 $2,319.00D6973 $111.00 D7550 $143.00 D7946 $2,566.00D6975 $214.00 D7560 $266.00 D7947 $2,566.00D6976 $88.00 D7610 $1,189.00 D7948 $2,874.00D6977 $46.00 D7620 $984.00 D7949 $4,186.00D6980 $106.00 D7630 $1,354.00 D7950 $881.00D6999 BR D7640 $820.00 D7955 $922.00

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Dental DentalD-Code MRA D-Code MRAD7960 $121.00 D9630 $10.00D7970 $137.00 D9910 $21.00D7971 $67.00 D9911 $21.00D7972 BR D9920 $32.00D7980 $169.00 D9930 $34.00D7981 $820.00 D9940 $204.00D7982 $306.00 D9941 $58.00D7983 $244.00 D9950 $114.00D7990 $340.00 D9951 $46.00D7991 $820.00 D9952 $163.00D7995 BR D9970 $83.00D7996 BR D9971 $55.00D7997 BR D9972 $113.00D7999 BR D9973 $40.00D8010 $451.00 D9974 $50.00D8020 $533.00 D9999 BRD8030 $718.00D8040 $583.00D8050 $676.00D8060 $758.00D8070 $1,867.00D8080 $1,867.00D8090 $1,949.00D8210 $155.00D8220 $179.00D8660 $73.00D8670 $54.00D8680 $171.00D8690 $71.00D8691 $67.00D8692 $104.00D8999 BRD9110 $40.00D9210 $14.00D9211 $14.00D9212 $13.00D9215 $7.00D9220 $111.00D9221 $40.00D9230 $18.00D9241 $122.00D9242 $45.00D9248 $91.00D9310 $41.00D9410 $61.00D9420 $46.00D9430 $23.00D9440 $41.00D9450 BRD9610 $20.00

HCPCS © 2008 Part A, 131

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Injections Injections InjectionsJ-Code MRA J-Code MRA J-Code MRAJ0120 $12.00 J0636 BR J1205 $9.00J0130 BR J0637 BR J1212 $36.00J0150 $27.00 J0640 $22.00 J1230 $1.00J0152 BR J0670 BR J1240 $1.00J0170 $1.00 J0690 $3.00 J1245 $31.00J0190 $3.00 J0692 BR J1250 $49.00J0200 BR J0694 $10.00 J1260 BRJ0205 $38.00 J0696 $11.00 J1270 BRJ0207 BR J0697 $6.00 J1320 $1.00J0210 $7.00 J0698 $11.00 J1325 BRJ0215 BR J0702 $4.00 J1327 BRJ0256 $101.00 J0704 $2.00 J1330 $2.00J0280 $1.00 J0710 $3.00 J1335 BRJ0282 BR J0713 $8.00 J1364 $6.00J0285 BR J0715 $6.00 J1380 $1.00J0287 BR J0720 $6.00 J1390 $1.00J0288 BR J0725 $3.00 J1410 $33.00J0289 BR J0735 BR J1435 $1.00J0290 $2.00 J0740 BR J1436 $68.00J0295 $7.00 J0743 $14.00 J1438 BRJ0300 $2.00 J0744 BR J1440 $158.00J0330 $1.00 J0745 $1.00 J1441 $254.00J0350 $2,408.00 J0760 $3.00 J1450 BRJ0360 $6.00 J0770 $32.00 J1455 $12.00J0380 $1.00 J0780 $3.00 J1460 $2.00J0390 $3.00 J0800 $18.00 J1470 $4.00J0395 BR J0835 $12.00 J1480 $7.00J0456 BR J0850 $362.00 J1490 $9.00J0460 $1.00 J0895 $10.00 J1500 $11.00J0470 $11.00 J0900 $1.00 J1510 $13.00J0475 $201.00 J0945 $1.00 J1520 $15.00J0476 BR J0970 $1.00 J1530 $17.00J0500 $3.00 J1000 $3.00 J1540 $20.00J0515 $3.00 J1020 $1.00 J1550 $22.00J0520 $5.00 J1030 $2.00 J1560 BRJ0530 $4.00 J1040 $3.00 J1565 BRJ0540 $8.00 J1055 BR J1570 $36.00J0550 $21.00 J1060 $1.00 J1580 $3.00J0560 $6.00 J1070 $1.00 J1590 BRJ0570 $9.00 J1080 $2.00 J1595 BRJ0580 $26.00 J1094 BR J1600 $10.00J0583 BR J1100 $1.00 J1610 $27.00J0585 $393.00 J1110 $10.00 J1620 $69.00J0587 BR J1120 $35.00 J1626 BRJ0592 BR J1160 $2.00 J1630 $4.00J0595 BR J1165 $1.00 J1631 $28.00J0600 $6.00 J1170 $1.00 J1642 $1.00J0610 $1.00 J1180 $1.00 J1644 $1.00J0620 $3.00 J1190 BR J1645 BRJ0630 $21.00 J1200 $1.00 J1650 $16.00

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Injections Injections InjectionsJ-Code MRA J-Code MRA J-Code MRAJ1652 BR J2353 BR J2993 BRJ1655 BR J2354 BR J2995 BRJ1670 $23.00 J2355 BR J2997 BRJ1700 $1.00 J2360 $2.00 J3000 $2.00J1710 $5.00 J2370 $3.00 J3010 $2.00J1720 $4.00 J2400 BR J3030 $34.00J1730 $94.00 J2405 $6.00 J3070 $4.00J1742 BR J2410 $3.00 J3100 BRJ1745 BR J2430 $189.00 J3105 $2.00J1756 BR J2440 $2.00 J3120 $1.00J1785 $4.00 J2460 $1.00 J3130 $1.00J1790 $4.00 J2501 BR J3140 $1.00J1800 $10.00 J2505 BR J3150 $1.00J1810 $6.00 J2510 $1.00 J3230 $2.00J1815 BR J2515 $1.00 J3240 $214.00J1817 BR J2540 $1.00 J3250 $1.00J1825 BR J2543 BR J3260 $7.00J1830 $76.00 J2545 $105.00 J3265 $2.00J1835 BR J2550 $1.00 J3280 $5.00J1840 $7.00 J2560 $5.00 J3301 $1.00J1850 $4.00 J2590 $1.00 J3302 $1.00J1885 $7.00 J2597 $20.00 J3303 $1.00J1890 $11.00 J2650 $1.00 J3305 $55.00J1940 $1.00 J2670 BR J3310 $5.00J1950 $411.00 J2680 $16.00 J3320 $16.00J1955 $37.00 J2690 $7.00 J3350 $72.00J1956 BR J2700 $2.00 J3360 $1.00J1960 $2.00 J2710 $1.00 J3364 $52.00J1980 $3.00 J2720 $1.00 J3365 $433.00J1990 $8.00 J2725 $11.00 J3370 $9.00J2001 BR J2730 $29.00 J3400 $12.00J2010 $2.00 J2760 $29.00 J3410 $1.00J2020 BR J2765 $2.00 J3411 BRJ2060 $12.00 J2770 BR J3415 BRJ2150 $3.00 J2780 BR J3420 $1.00J2175 $1.00 J2783 BR J3430 $2.00J2180 $3.00 J2790 $36.00 J3465 BRJ2185 BR J2792 BR J3470 $7.00J2210 $3.00 J2795 BR J3475 $1.00J2250 $2.00 J2800 $3.00 J3480 $1.00J2260 $32.00 J2810 $3.00 J3485 BRJ2270 $1.00 J2820 $115.00 J3486 BRJ2271 BR J2910 $11.00 J3490 BRJ2275 $13.00 J2912 $1.00 J3590 BRJ2280 BR J2916 BR J7030 $11.00J2300 $2.00 J2920 $5.00 J7040 $10.00J2310 $3.00 J2930 $13.00 J7042 $10.00J2320 $5.00 J2940 BR J7050 $10.00J2321 $6.00 J2941 BR J7060 $10.00J2322 $8.00 J2950 $1.00 J7070 $11.00

HCPCS © 2008 Part A, 133

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InjectionsJ-Code MRAJ7100 $137.00J7110 $93.00J7120 $12.00J7130 $6.00J7190 $241.00J7191 BRJ7192 $316.00J7193 BRJ7194 $120.00J7195 BRJ7197 $284.00J7198 BRJ7199 BRJ7317 BRJ7350 BRJ7501 $98.00J7504 $282.00J7505 $576.00J7513 BRJ7516 BRJ7599 BR

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RULE 69L-7.020, F.A.C. 135

PART B

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

10021 0 $90.00 $176.00 $186.00 $197.00 $91.00 $95.00 $100.0010022 0 $92.00 $183.00 $194.00 $204.00 $87.00 $90.00 $94.0010040 10 $54.00 $118.00 $124.00 $129.00 $104.00 $108.00 $113.0010060 10 $53.00 $133.00 $141.00 $150.00 $116.00 $123.00 $130.0010061 10 $133.00 $232.00 $245.00 $261.00 $209.00 $221.00 $236.0010080 10 $65.00 $209.00 $222.00 $235.00 $120.00 $127.00 $135.0010081 10 $203.00 $324.00 $344.00 $364.00 $209.00 $220.00 $234.0010120 10 $53.00 $170.00 $180.00 $191.00 $115.00 $122.00 $129.0010121 10 $169.00 $329.00 $350.00 $373.00 $240.00 $254.00 $272.0010140 10 $53.00 $189.00 $201.00 $214.00 $152.00 $161.00 $173.0010160 10 $45.00 $154.00 $164.00 $174.00 $122.00 $130.00 $138.0010180 10 $164.00 $290.00 $310.00 $333.00 $229.00 $244.00 $264.0011000 0 $45.00 $66.00 $70.00 $75.00 $43.00 $46.00 $49.0011001 ZZZ $27.00 $29.00 $30.00 $33.00 $22.00 $23.00 $25.0011004 0 ------- $738.00 $767.00 $804.00 $738.00 $767.00 $804.0011005 0 ------- $978.00 $1,019.00 $1,071.00 $978.00 $1,019.00 $1,071.0011006 0 ------- $937.00 $985.00 $1,048.00 $937.00 $985.00 $1,048.0011008 ZZZ ------- $366.00 $387.00 $416.00 $366.00 $387.00 $416.0011010 10 $348.00 $591.00 $632.00 $678.00 $373.00 $399.00 $432.0011011 0 $432.00 $670.00 $716.00 $768.00 $400.00 $426.00 $462.0011012 0 $597.00 $942.00 $1,009.00 $1,086.00 $588.00 $630.00 $686.0011040 0 $43.00 $58.00 $62.00 $66.00 $37.00 $39.00 $42.0011041 0 $45.00 $71.00 $76.00 $82.00 $49.00 $53.00 $57.0011042 0 $88.00 $96.00 $102.00 $110.00 $65.00 $69.00 $75.0011043 10 $210.00 $340.00 $361.00 $383.00 $298.00 $316.00 $336.0011044 10 $283.00 $459.00 $487.00 $518.00 $411.00 $435.00 $462.0011055 0 $26.00 $58.00 $62.00 $66.00 $31.00 $33.00 $35.0011056 0 $35.00 $72.00 $77.00 $82.00 $44.00 $46.00 $50.0011057 0 $39.00 $88.00 $94.00 $100.00 $58.00 $61.00 $66.0011100 0 $78.00 $118.00 $125.00 $130.00 $59.00 $61.00 $64.0011101 ZZZ $41.00 $39.00 $41.00 $43.00 $30.00 $31.00 $33.0011200 10 $66.00 $97.00 $102.00 $107.00 $82.00 $86.00 $90.0011201 ZZZ $26.00 $23.00 $25.00 $26.00 $21.00 $22.00 $24.0011300 0 $59.00 $81.00 $85.00 $90.00 $37.00 $38.00 $40.0011301 0 $80.00 $109.00 $114.00 $120.00 $62.00 $65.00 $67.0011302 0 $96.00 $129.00 $136.00 $143.00 $77.00 $79.00 $83.0011303 0 $119.00 $154.00 $162.00 $170.00 $91.00 $94.00 $99.0011305 0 $61.00 $85.00 $90.00 $96.00 $49.00 $52.00 $55.0011306 0 $86.00 $115.00 $121.00 $128.00 $72.00 $75.00 $79.0011307 0 $100.00 $133.00 $140.00 $148.00 $83.00 $86.00 $91.0011308 0 $125.00 $155.00 $164.00 $174.00 $103.00 $109.00 $115.0011310 0 $75.00 $100.00 $105.00 $110.00 $53.00 $55.00 $58.0011311 0 $95.00 $124.00 $131.00 $137.00 $77.00 $80.00 $83.0011312 0 $110.00 $145.00 $152.00 $159.00 $89.00 $92.00 $96.0011313 0 $144.00 $184.00 $194.00 $204.00 $120.00 $125.00 $131.0011400 10 $81.00 $143.00 $151.00 $159.00 $91.00 $96.00 $101.0011401 10 $114.00 $173.00 $183.00 $193.00 $121.00 $127.00 $135.0011402 10 $145.00 $192.00 $204.00 $216.00 $134.00 $141.00 $150.0011403 10 $178.00 $222.00 $235.00 $249.00 $170.00 $180.00 $191.0011404 10 $200.00 $253.00 $268.00 $285.00 $190.00 $200.00 $213.00

CPT only © 2008 American Medical Association. All rights reserved. Part B, 136

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

11406 10 $246.00 $353.00 $373.00 $396.00 $282.00 $297.00 $315.0011420 10 $98.00 $144.00 $153.00 $162.00 $101.00 $106.00 $112.0011421 10 $92.00 $185.00 $196.00 $207.00 $135.00 $142.00 $151.0011422 10 $157.00 $207.00 $220.00 $233.00 $161.00 $171.00 $181.0011423 10 $163.00 $243.00 $257.00 $273.00 $189.00 $199.00 $212.0011424 10 $221.00 $279.00 $296.00 $314.00 $219.00 $232.00 $247.0011426 10 $303.00 $402.00 $425.00 $453.00 $335.00 $354.00 $378.0011440 10 $105.00 $159.00 $169.00 $178.00 $120.00 $127.00 $133.0011441 10 $102.00 $199.00 $210.00 $222.00 $157.00 $165.00 $175.0011442 10 $174.00 $224.00 $237.00 $251.00 $175.00 $185.00 $196.0011443 10 $221.00 $271.00 $287.00 $304.00 $217.00 $229.00 $243.0011444 10 $276.00 $342.00 $362.00 $383.00 $279.00 $294.00 $312.0011446 10 $344.00 $460.00 $486.00 $515.00 $393.00 $414.00 $439.0011450 90 $282.00 $429.00 $455.00 $484.00 $286.00 $302.00 $322.0011451 90 $366.00 $571.00 $607.00 $647.00 $383.00 $406.00 $435.0011462 90 $264.00 $423.00 $450.00 $478.00 $274.00 $290.00 $310.0011463 90 $351.00 $581.00 $618.00 $659.00 $387.00 $411.00 $441.0011470 90 $320.00 $467.00 $496.00 $527.00 $326.00 $345.00 $368.0011471 90 $391.00 $602.00 $641.00 $683.00 $417.00 $442.00 $473.0011600 10 $148.00 $216.00 $229.00 $240.00 $135.00 $141.00 $148.0011601 10 $180.00 $258.00 $272.00 $286.00 $172.00 $180.00 $189.0011602 10 $199.00 $280.00 $295.00 $310.00 $187.00 $195.00 $204.0011603 10 $226.00 $321.00 $337.00 $354.00 $223.00 $233.00 $244.0011604 10 $249.00 $355.00 $374.00 $393.00 $245.00 $256.00 $269.0011606 10 $315.00 $501.00 $527.00 $555.00 $367.00 $384.00 $404.0011620 10 $150.00 $218.00 $230.00 $241.00 $135.00 $141.00 $148.0011621 10 $191.00 $260.00 $274.00 $288.00 $174.00 $182.00 $191.0011622 10 $223.00 $293.00 $309.00 $325.00 $200.00 $210.00 $220.0011623 10 $259.00 $346.00 $364.00 $383.00 $248.00 $259.00 $272.0011624 10 $305.00 $393.00 $415.00 $437.00 $285.00 $299.00 $315.0011626 10 $373.00 $490.00 $518.00 $550.00 $368.00 $388.00 $412.0011640 10 $168.00 $228.00 $241.00 $254.00 $145.00 $152.00 $160.0011641 10 $227.00 $279.00 $295.00 $311.00 $191.00 $201.00 $211.0011642 10 $260.00 $321.00 $340.00 $358.00 $225.00 $236.00 $248.0011643 10 $305.00 $381.00 $402.00 $424.00 $281.00 $295.00 $311.0011644 10 $380.00 $475.00 $502.00 $530.00 $354.00 $372.00 $394.0011646 10 $494.00 $631.00 $668.00 $709.00 $505.00 $532.00 $566.0011719 0 $22.00 $25.00 $27.00 $28.00 $13.00 $13.00 $14.0011720 0 $32.00 $38.00 $41.00 $43.00 $23.00 $24.00 $26.0011721 0 $50.00 $56.00 $59.00 $63.00 $40.00 $42.00 $45.0011730 0 $62.00 $122.00 $130.00 $139.00 $81.00 $86.00 $92.0011732 ZZZ $31.00 $57.00 $60.00 $64.00 $41.00 $44.00 $47.0011740 0 $41.00 $54.00 $58.00 $61.00 $40.00 $43.00 $45.0011750 10 $156.00 $258.00 $273.00 $289.00 $221.00 $233.00 $247.0011752 10 $234.00 $367.00 $389.00 $413.00 $335.00 $354.00 $376.0011755 0 $106.00 $162.00 $172.00 $183.00 $110.00 $117.00 $124.0011760 10 $131.00 $242.00 $258.00 $275.00 $172.00 $183.00 $196.0011762 10 $223.00 $329.00 $350.00 $374.00 $266.00 $282.00 $302.0011765 10 $65.00 $151.00 $161.00 $171.00 $84.00 $89.00 $95.0011770 10 $275.00 $323.00 $344.00 $367.00 $225.00 $239.00 $257.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

11771 90 $496.00 $647.00 $687.00 $734.00 $515.00 $546.00 $585.0011772 90 $585.00 $799.00 $849.00 $907.00 $676.00 $717.00 $768.0011900 0 $33.00 $65.00 $68.00 $71.00 $38.00 $39.00 $40.0011901 0 $37.00 $81.00 $85.00 $89.00 $58.00 $60.00 $63.0011920 0 $147.00 $246.00 $263.00 $281.00 $149.00 $159.00 $172.0011921 0 $172.00 $279.00 $298.00 $319.00 $177.00 $188.00 $204.0011922 ZZZ $40.00 $80.00 $85.00 $91.00 $40.00 $43.00 $47.0011950 0 $107.00 $95.00 $100.00 $105.00 $63.00 $66.00 $69.0011951 0 $114.00 $125.00 $132.00 $140.00 $86.00 $91.00 $96.0011952 0 $155.00 $179.00 $189.00 $201.00 $128.00 $135.00 $143.0011954 0 $165.00 $213.00 $227.00 $243.00 $148.00 $158.00 $170.0011960 90 $829.00 $1,145.00 $1,216.00 $1,298.00 $1,145.00 $1,216.00 $1,298.0011970 90 $632.00 $760.00 $808.00 $868.00 $760.00 $808.00 $868.0011971 90 $280.00 $589.00 $627.00 $663.00 $372.00 $394.00 $418.0011976 0 $123.00 $186.00 $198.00 $211.00 $129.00 $137.00 $147.0012001 10 $84.00 $185.00 $196.00 $207.00 $130.00 $136.00 $144.0012002 10 $98.00 $198.00 $209.00 $221.00 $145.00 $153.00 $162.0012004 10 $122.00 $233.00 $246.00 $261.00 $171.00 $180.00 $191.0012005 10 $165.00 $290.00 $307.00 $325.00 $213.00 $224.00 $238.0012006 10 $203.00 $362.00 $382.00 $406.00 $270.00 $284.00 $302.0012007 10 $339.00 $409.00 $433.00 $462.00 $312.00 $329.00 $352.0012011 10 $98.00 $197.00 $209.00 $221.00 $135.00 $142.00 $150.0012013 10 $141.00 $217.00 $229.00 $243.00 $154.00 $162.00 $172.0012014 10 $165.00 $256.00 $270.00 $287.00 $185.00 $195.00 $207.0012015 10 $207.00 $322.00 $340.00 $360.00 $233.00 $244.00 $259.0012016 10 $268.00 $382.00 $404.00 $428.00 $284.00 $299.00 $317.0012017 10 $316.00 $345.00 $363.00 $386.00 $345.00 $363.00 $386.0012018 10 $515.00 $415.00 $439.00 $470.00 $415.00 $439.00 $470.0012020 10 $211.00 $335.00 $356.00 $379.00 $239.00 $254.00 $271.0012021 10 $87.00 $198.00 $211.00 $226.00 $175.00 $186.00 $199.0012031 10 $93.00 $270.00 $285.00 $301.00 $184.00 $193.00 $204.0012032 10 $110.00 $356.00 $376.00 $396.00 $231.00 $243.00 $255.0012034 10 $148.00 $353.00 $373.00 $394.00 $244.00 $256.00 $271.0012035 10 $223.00 $455.00 $483.00 $514.00 $299.00 $316.00 $338.0012036 10 $356.00 $508.00 $542.00 $580.00 $354.00 $376.00 $405.0012037 10 $411.00 $574.00 $612.00 $656.00 $412.00 $439.00 $473.0012041 10 $116.00 $287.00 $304.00 $321.00 $200.00 $210.00 $221.0012042 10 $141.00 $337.00 $355.00 $373.00 $232.00 $243.00 $255.0012044 10 $176.00 $385.00 $407.00 $431.00 $258.00 $271.00 $287.0012045 10 $250.00 $461.00 $490.00 $521.00 $312.00 $330.00 $353.0012046 10 $341.00 $547.00 $582.00 $621.00 $369.00 $391.00 $420.0012047 10 $363.00 $585.00 $623.00 $665.00 $408.00 $433.00 $464.0012051 10 $126.00 $317.00 $335.00 $354.00 $217.00 $228.00 $241.0012052 10 $148.00 $347.00 $366.00 $384.00 $245.00 $257.00 $269.0012053 10 $223.00 $382.00 $403.00 $425.00 $257.00 $270.00 $284.0012054 10 $301.00 $412.00 $436.00 $461.00 $279.00 $293.00 $310.0012055 10 $380.00 $507.00 $537.00 $570.00 $350.00 $369.00 $392.0012056 10 $487.00 $626.00 $665.00 $707.00 $434.00 $459.00 $491.0012057 10 $539.00 $672.00 $711.00 $754.00 $492.00 $518.00 $550.0013100 10 $178.00 $380.00 $402.00 $425.00 $288.00 $303.00 $320.00

CPT only © 2008 American Medical Association. All rights reserved. Part B, 138

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

13101 10 $240.00 $470.00 $495.00 $521.00 $347.00 $363.00 $382.0013102 ZZZ $89.00 $131.00 $139.00 $148.00 $96.00 $101.00 $108.0013120 10 $223.00 $394.00 $416.00 $439.00 $299.00 $315.00 $332.0013121 10 $348.00 $513.00 $540.00 $567.00 $385.00 $403.00 $423.0013122 ZZZ $104.00 $152.00 $161.00 $171.00 $110.00 $116.00 $123.0013131 10 $252.00 $434.00 $457.00 $481.00 $338.00 $355.00 $373.0013132 10 $484.00 $675.00 $707.00 $740.00 $558.00 $582.00 $608.0013133 ZZZ $154.00 $206.00 $217.00 $229.00 $167.00 $175.00 $185.0013150 10 $260.00 $446.00 $472.00 $499.00 $343.00 $361.00 $383.0013151 10 $375.00 $492.00 $518.00 $546.00 $393.00 $412.00 $434.0013152 10 $542.00 $669.00 $703.00 $739.00 $528.00 $553.00 $580.0013153 ZZZ $169.00 $230.00 $244.00 $259.00 $185.00 $195.00 $208.0013160 90 $655.00 $1,033.00 $1,097.00 $1,178.00 $1,033.00 $1,097.00 $1,178.0014000 90 $512.00 $787.00 $832.00 $880.00 $655.00 $691.00 $731.0014001 90 $695.00 $1,026.00 $1,084.00 $1,146.00 $879.00 $926.00 $980.0014020 90 $590.00 $876.00 $926.00 $978.00 $746.00 $786.00 $831.0014021 90 $818.00 $1,151.00 $1,211.00 $1,276.00 $1,013.00 $1,064.00 $1,120.0014040 90 $701.00 $920.00 $970.00 $1,022.00 $800.00 $841.00 $886.0014041 90 $936.00 $1,257.00 $1,319.00 $1,383.00 $1,103.00 $1,154.00 $1,209.0014060 90 $766.00 $942.00 $992.00 $1,046.00 $845.00 $889.00 $937.0014061 90 $1,330.00 $1,363.00 $1,429.00 $1,498.00 $1,194.00 $1,248.00 $1,307.0014300 90 $1,040.00 $1,331.00 $1,404.00 $1,486.00 $1,180.00 $1,243.00 $1,316.0014350 90 $734.00 $965.00 $1,024.00 $1,098.00 $965.00 $1,024.00 $1,098.0015040 0 ------- $325.00 $347.00 $368.00 $167.00 $177.00 $190.0015050 90 $349.00 $661.00 $701.00 $745.00 $550.00 $583.00 $620.0015100 90 $679.00 $1,118.00 $1,190.00 $1,273.00 $921.00 $980.00 $1,051.0015101 ZZZ $146.00 $254.00 $272.00 $290.00 $150.00 $160.00 $172.0015110 90 ------- $1,100.00 $1,168.00 $1,248.00 $949.00 $1,006.00 $1,077.0015111 ZZZ ------- $162.00 $172.00 $185.00 $143.00 $152.00 $164.0015115 90 ------- $1,078.00 $1,140.00 $1,212.00 $969.00 $1,023.00 $1,089.0015116 ZZZ ------- $213.00 $226.00 $243.00 $193.00 $205.00 $221.0015120 90 $788.00 $1,158.00 $1,227.00 $1,305.00 $987.00 $1,044.00 $1,112.0015121 ZZZ $235.00 $352.00 $376.00 $401.00 $232.00 $247.00 $266.0015130 90 ------- $870.00 $927.00 $991.00 $723.00 $769.00 $825.0015131 ZZZ ------- $130.00 $138.00 $149.00 $115.00 $122.00 $132.0015135 90 ------- $1,094.00 $1,160.00 $1,236.00 $989.00 $1,048.00 $1,118.0015136 ZZZ ------- $125.00 $133.00 $143.00 $116.00 $123.00 $133.0015150 90 ------- $914.00 $971.00 $1,039.00 $832.00 $883.00 $945.0015151 ZZZ ------- $171.00 $182.00 $196.00 $154.00 $164.00 $177.0015152 ZZZ ------- $210.00 $224.00 $241.00 $193.00 $205.00 $221.0015155 90 ------- $942.00 $996.00 $1,060.00 $887.00 $937.00 $998.0015156 ZZZ ------- $225.00 $239.00 $257.00 $212.00 $225.00 $242.0015157 ZZZ ------- $250.00 $265.00 $285.00 $231.00 $245.00 $264.0015170 90 ------- $521.00 $548.00 $582.00 $449.00 $471.00 $500.0015171 ZZZ ------- $120.00 $127.00 $136.00 $115.00 $121.00 $130.0015175 90 ------- $688.00 $726.00 $773.00 $619.00 $652.00 $695.0015176 ZZZ ------- $192.00 $203.00 $217.00 $183.00 $193.00 $207.0015200 90 $644.00 $982.00 $1,041.00 $1,108.00 $813.00 $860.00 $917.0015201 ZZZ $126.00 $191.00 $204.00 $219.00 $104.00 $111.00 $120.0015220 90 $687.00 $931.00 $988.00 $1,049.00 $774.00 $819.00 $872.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

15221 ZZZ $114.00 $177.00 $188.00 $201.00 $95.00 $101.00 $109.0015240 90 $763.00 $1,105.00 $1,168.00 $1,237.00 $971.00 $1,024.00 $1,085.0015241 ZZZ $334.00 $230.00 $245.00 $261.00 $149.00 $158.00 $169.0015260 90 $841.00 $1,170.00 $1,229.00 $1,290.00 $1,037.00 $1,087.00 $1,140.0015261 ZZZ $207.00 $263.00 $279.00 $295.00 $185.00 $195.00 $207.0015300 90 ------- $423.00 $447.00 $476.00 $366.00 $387.00 $412.0015301 ZZZ ------- $81.00 $86.00 $93.00 $76.00 $81.00 $87.0015320 90 ------- $483.00 $511.00 $544.00 $420.00 $444.00 $474.0015321 ZZZ ------- $122.00 $129.00 $140.00 $115.00 $122.00 $132.0015330 90 ------- $393.00 $417.00 $446.00 $335.00 $355.00 $381.0015331 ZZZ ------- $82.00 $87.00 $94.00 $77.00 $82.00 $89.0015335 90 ------- $425.00 $451.00 $482.00 $366.00 $388.00 $416.0015336 ZZZ ------- $119.00 $126.00 $136.00 $110.00 $117.00 $127.0015340 10 ------- $401.00 $425.00 $452.00 $344.00 $364.00 $388.0015341 ZZZ ------- $59.00 $63.00 $67.00 $37.00 $39.00 $42.0015360 90 ------- $451.00 $479.00 $510.00 $384.00 $407.00 $433.0015361 ZZZ ------- $92.00 $97.00 $105.00 $84.00 $89.00 $96.0015365 90 ------- $453.00 $481.00 $511.00 $392.00 $415.00 $442.0015366 ZZZ ------- $116.00 $122.00 $131.00 $108.00 $114.00 $123.0015400 90 $223.00 $468.00 $496.00 $528.00 $437.00 $463.00 $493.0015401 ZZZ $66.00 $130.00 $139.00 $149.00 $78.00 $82.00 $89.0015420 90 ------- $526.00 $558.00 $593.00 $470.00 $497.00 $530.0015421 ZZZ ------- $149.00 $159.00 $171.00 $115.00 $122.00 $132.0015430 90 ------- $668.00 $709.00 $755.00 $648.00 $687.00 $731.0015570 90 $748.00 $1,111.00 $1,183.00 $1,267.00 $902.00 $959.00 $1,031.0015572 90 $721.00 $1,043.00 $1,108.00 $1,184.00 $890.00 $943.00 $1,010.0015574 90 $775.00 $1,120.00 $1,188.00 $1,266.00 $960.00 $1,017.00 $1,086.0015576 90 $457.00 $989.00 $1,046.00 $1,108.00 $838.00 $884.00 $938.0015600 90 $259.00 $436.00 $466.00 $495.00 $259.00 $276.00 $295.0015610 90 $320.00 $400.00 $427.00 $456.00 $305.00 $326.00 $349.0015620 90 $506.00 $554.00 $588.00 $623.00 $392.00 $415.00 $440.0015630 90 $362.00 $565.00 $599.00 $633.00 $424.00 $448.00 $473.0015650 90 $427.00 $612.00 $648.00 $686.00 $466.00 $492.00 $521.0015731 90 ------- $1,359.00 $1,434.00 $1,519.00 $1,231.00 $1,297.00 $1,375.0015732 90 $1,465.00 $1,901.00 $2,011.00 $2,137.00 $1,666.00 $1,759.00 $1,872.0015734 90 $1,557.00 $1,974.00 $2,101.00 $2,254.00 $1,735.00 $1,845.00 $1,983.0015736 90 $1,862.00 $1,780.00 $1,899.00 $2,042.00 $1,510.00 $1,610.00 $1,737.0015738 90 $1,415.00 $1,893.00 $2,017.00 $2,168.00 $1,647.00 $1,754.00 $1,891.0015740 90 $913.00 $1,186.00 $1,244.00 $1,304.00 $1,035.00 $1,083.00 $1,133.0015750 90 $1,064.00 $1,158.00 $1,226.00 $1,308.00 $1,158.00 $1,226.00 $1,308.0015756 90 $2,892.00 $3,070.00 $3,257.00 $3,496.00 $3,070.00 $3,257.00 $3,496.0015757 90 $2,892.00 $3,031.00 $3,201.00 $3,412.00 $3,031.00 $3,201.00 $3,412.0015758 90 $2,884.00 $3,038.00 $3,216.00 $3,440.00 $3,038.00 $3,216.00 $3,440.0015760 90 $810.00 $1,033.00 $1,091.00 $1,154.00 $880.00 $927.00 $981.0015770 90 $674.00 $826.00 $877.00 $937.00 $826.00 $877.00 $937.0015775 0 $327.00 $405.00 $431.00 $462.00 $290.00 $307.00 $332.0015776 0 $475.00 $572.00 $609.00 $652.00 $440.00 $467.00 $503.0015780 90 $532.00 $1,021.00 $1,079.00 $1,139.00 $822.00 $865.00 $913.0015781 90 $420.00 $647.00 $684.00 $720.00 $533.00 $561.00 $590.0015782 90 $314.00 $696.00 $738.00 $778.00 $520.00 $549.00 $579.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

15783 90 $340.00 $595.00 $629.00 $661.00 $454.00 $478.00 $502.0015786 10 $146.00 $287.00 $302.00 $317.00 $169.00 $177.00 $185.0015787 ZZZ $27.00 $67.00 $71.00 $75.00 $25.00 $26.00 $28.0015788 90 $194.00 $511.00 $543.00 $571.00 $287.00 $302.00 $317.0015789 90 $360.00 $684.00 $720.00 $754.00 $512.00 $536.00 $560.0015792 90 $130.00 $499.00 $531.00 $560.00 $324.00 $343.00 $361.0015793 90 $232.00 $554.00 $585.00 $613.00 $426.00 $447.00 $469.0015819 90 $780.00 $914.00 $963.00 $1,022.00 $914.00 $963.00 $1,022.0015820 90 $556.00 $651.00 $685.00 $721.00 $586.00 $616.00 $647.0015821 90 $607.00 $696.00 $732.00 $770.00 $623.00 $654.00 $688.0015822 90 $499.00 $517.00 $547.00 $577.00 $455.00 $480.00 $507.0015823 90 $718.00 $802.00 $842.00 $884.00 $734.00 $769.00 $807.0015824 0 NC BR BR BR BR BR BR15825 0 NC BR BR BR BR BR BR15826 0 NC BR BR BR BR BR BR15828 0 NC BR BR BR BR BR BR15829 0 NC BR BR BR BR BR BR15830 90 ------- $1,517.00 $1,626.00 $1,770.00 $1,517.00 $1,626.00 $1,770.0015832 90 $926.00 $1,141.00 $1,213.00 $1,303.00 $1,141.00 $1,213.00 $1,303.0015833 90 $833.00 $1,060.00 $1,126.00 $1,208.00 $1,060.00 $1,126.00 $1,208.0015834 90 $837.00 $1,086.00 $1,155.00 $1,242.00 $1,086.00 $1,155.00 $1,242.0015835 90 $865.00 $1,112.00 $1,180.00 $1,266.00 $1,112.00 $1,180.00 $1,266.0015836 90 $721.00 $936.00 $994.00 $1,067.00 $936.00 $994.00 $1,067.0015837 90 $696.00 $964.00 $1,025.00 $1,097.00 $862.00 $916.00 $982.0015838 90 $600.00 $713.00 $748.00 $788.00 $713.00 $748.00 $788.0015839 90 $643.00 $1,046.00 $1,110.00 $1,186.00 $903.00 $957.00 $1,024.0015840 90 $1,187.00 $1,270.00 $1,337.00 $1,417.00 $1,270.00 $1,337.00 $1,417.0015841 90 $1,859.00 $2,122.00 $2,237.00 $2,379.00 $2,122.00 $2,237.00 $2,379.0015842 90 $3,099.00 $3,397.00 $3,601.00 $3,859.00 $3,397.00 $3,601.00 $3,859.0015845 90 $1,116.00 $1,165.00 $1,217.00 $1,275.00 $1,165.00 $1,217.00 $1,275.0015850 0 $63.00 $110.00 $116.00 $122.00 $53.00 $55.00 $58.0015851 0 $40.00 $121.00 $128.00 $134.00 $59.00 $61.00 $64.0015852 0 $35.00 $62.00 $65.00 $70.00 $62.00 $65.00 $70.0015860 0 $151.00 $149.00 $158.00 $171.00 $149.00 $158.00 $171.0015876 0 NC BR BR BR BR BR BR15877 0 NC BR BR BR BR BR BR15878 0 NC BR BR BR BR BR BR15879 0 NC BR BR BR BR BR BR15920 90 $571.00 $738.00 $784.00 $840.00 $738.00 $784.00 $840.0015922 90 $771.00 $952.00 $1,014.00 $1,091.00 $952.00 $1,014.00 $1,091.0015931 90 $638.00 $848.00 $900.00 $966.00 $848.00 $900.00 $966.0015933 90 $860.00 $1,044.00 $1,109.00 $1,192.00 $1,044.00 $1,109.00 $1,192.0015934 90 $1,064.00 $1,171.00 $1,245.00 $1,339.00 $1,171.00 $1,245.00 $1,339.0015935 90 $1,184.00 $1,385.00 $1,474.00 $1,585.00 $1,385.00 $1,474.00 $1,585.0015936 90 $1,032.00 $1,143.00 $1,216.00 $1,309.00 $1,143.00 $1,216.00 $1,309.0015937 90 $1,223.00 $1,337.00 $1,423.00 $1,532.00 $1,337.00 $1,423.00 $1,532.0015940 90 $318.00 $878.00 $932.00 $1,002.00 $878.00 $932.00 $1,002.0015941 90 $919.00 $1,153.00 $1,227.00 $1,319.00 $1,153.00 $1,227.00 $1,319.0015944 90 $954.00 $1,125.00 $1,197.00 $1,286.00 $1,125.00 $1,197.00 $1,286.0015945 90 $1,078.00 $1,245.00 $1,325.00 $1,425.00 $1,245.00 $1,325.00 $1,425.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

15946 90 $1,737.00 $2,071.00 $2,201.00 $2,367.00 $2,071.00 $2,201.00 $2,367.0015950 90 $549.00 $725.00 $770.00 $827.00 $725.00 $770.00 $827.0015951 90 $872.00 $1,034.00 $1,099.00 $1,180.00 $1,034.00 $1,099.00 $1,180.0015952 90 $876.00 $1,077.00 $1,145.00 $1,230.00 $1,077.00 $1,145.00 $1,230.0015953 90 $1,013.00 $1,202.00 $1,279.00 $1,375.00 $1,202.00 $1,279.00 $1,375.0015956 90 $1,382.00 $1,463.00 $1,556.00 $1,673.00 $1,463.00 $1,556.00 $1,673.0015958 90 $1,379.00 $1,493.00 $1,589.00 $1,709.00 $1,493.00 $1,589.00 $1,709.0015999 YYY BR ------- ------- ------- ------- ------- -------16000 0 $53.00 $87.00 $92.00 $98.00 $60.00 $63.00 $67.0016020 0 $49.00 $104.00 $110.00 $117.00 $72.00 $76.00 $81.0016025 0 $67.00 $185.00 $196.00 $209.00 $147.00 $156.00 $166.0016030 0 $153.00 $223.00 $237.00 $252.00 $170.00 $180.00 $193.0016035 0 $341.00 $282.00 $299.00 $321.00 $282.00 $299.00 $321.0016036 ZZZ $81.00 $113.00 $120.00 $129.00 $113.00 $120.00 $129.0017000 10 $60.00 $91.00 $96.00 $101.00 $64.00 $67.00 $70.0017003 ZZZ $16.00 $9.00 $10.00 $11.00 $6.00 $7.00 $7.0017004 10 $233.00 $212.00 $224.00 $235.00 $168.00 $176.00 $185.0017106 90 $341.00 $477.00 $503.00 $530.00 $410.00 $431.00 $454.0017107 90 $648.00 $836.00 $877.00 $923.00 $741.00 $776.00 $816.0017108 90 $1,015.00 $1,117.00 $1,163.00 $1,211.00 $1,015.00 $1,054.00 $1,095.0017110 10 $55.00 $120.00 $128.00 $135.00 $75.00 $79.00 $83.0017111 10 $83.00 $146.00 $154.00 $162.00 $96.00 $101.00 $106.0017250 0 $27.00 $92.00 $98.00 $104.00 $46.00 $49.00 $52.0017260 10 $96.00 $114.00 $120.00 $125.00 $81.00 $85.00 $88.0017261 10 $117.00 $162.00 $171.00 $179.00 $107.00 $112.00 $117.0017262 10 $150.00 $198.00 $208.00 $217.00 $137.00 $143.00 $149.0017263 10 $172.00 $218.00 $229.00 $239.00 $152.00 $158.00 $164.0017264 10 $189.00 $236.00 $248.00 $259.00 $163.00 $169.00 $176.0017266 10 $225.00 $268.00 $281.00 $293.00 $188.00 $195.00 $203.0017270 10 $125.00 $170.00 $179.00 $187.00 $116.00 $121.00 $125.0017271 10 $143.00 $187.00 $196.00 $205.00 $131.00 $136.00 $142.0017272 10 $170.00 $214.00 $225.00 $235.00 $152.00 $158.00 $164.0017273 10 $195.00 $239.00 $251.00 $262.00 $171.00 $178.00 $185.0017274 10 $240.00 $285.00 $299.00 $312.00 $210.00 $218.00 $227.0017276 10 $281.00 $335.00 $351.00 $368.00 $255.00 $266.00 $277.0017280 10 $123.00 $159.00 $168.00 $176.00 $106.00 $110.00 $115.0017281 10 $165.00 $203.00 $213.00 $223.00 $148.00 $154.00 $160.0017282 10 $194.00 $235.00 $247.00 $258.00 $171.00 $178.00 $185.0017283 10 $239.00 $286.00 $300.00 $313.00 $215.00 $224.00 $233.0017284 10 $282.00 $334.00 $350.00 $365.00 $256.00 $266.00 $277.0017286 10 $373.00 $430.00 $450.00 $471.00 $351.00 $365.00 $382.0017311 0 ------- $845.00 $890.00 $930.00 $463.00 $480.00 $498.0017312 ZZZ ------- $510.00 $538.00 $563.00 $246.00 $256.00 $265.0017313 0 ------- $772.00 $813.00 $851.00 $416.00 $431.00 $448.0017314 ZZZ ------- $471.00 $497.00 $520.00 $228.00 $236.00 $245.0017315 ZZZ ------- $100.00 $105.00 $110.00 $65.00 $67.00 $70.0017340 10 $37.00 $58.00 $60.00 $63.00 $58.00 $61.00 $64.0017360 10 $96.00 $155.00 $162.00 $170.00 $119.00 $124.00 $129.0017380 0 NC BR BR BR BR BR BR17999 YYY BR ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

19000 0 $74.00 $143.00 $152.00 $161.00 $60.00 $63.00 $67.0019001 ZZZ $40.00 $35.00 $37.00 $40.00 $30.00 $31.00 $33.0019020 90 $288.00 $535.00 $569.00 $606.00 $354.00 $376.00 $402.0019030 0 $98.00 $218.00 $230.00 $241.00 $105.00 $109.00 $114.0019100 0 $117.00 $176.00 $188.00 $200.00 $91.00 $96.00 $104.0019101 10 $338.00 $403.00 $429.00 $457.00 $274.00 $290.00 $311.0019102 0 $263.00 $287.00 $304.00 $320.00 $138.00 $144.00 $152.0019103 0 $601.00 $737.00 $783.00 $826.00 $258.00 $270.00 $285.0019105 0 ------- $2,521.00 $2,695.00 $2,843.00 $247.00 $258.00 $273.0019110 90 $406.00 $546.00 $581.00 $621.00 $398.00 $423.00 $455.0019112 90 $354.00 $520.00 $554.00 $591.00 $358.00 $381.00 $408.0019120 90 $429.00 $572.00 $608.00 $651.00 $492.00 $522.00 $561.0019125 90 $468.00 $631.00 $670.00 $717.00 $546.00 $579.00 $621.0019126 ZZZ $201.00 $211.00 $224.00 $241.00 $211.00 $224.00 $241.0019260 90 $1,101.00 $1,528.00 $1,621.00 $1,736.00 $1,528.00 $1,621.00 $1,736.0019271 90 $1,561.00 $2,080.00 $2,207.00 $2,360.00 $2,080.00 $2,207.00 $2,360.0019272 90 $1,674.00 $2,301.00 $2,441.00 $2,612.00 $2,301.00 $2,441.00 $2,612.0019290 0 $101.00 $209.00 $221.00 $232.00 $87.00 $90.00 $94.0019291 ZZZ $52.00 $91.00 $96.00 $101.00 $43.00 $45.00 $47.0019295 ZZZ $103.00 $125.00 $134.00 $142.00 $125.00 $134.00 $142.0019296 0 ------- $5,483.00 $5,870.00 $6,194.00 $267.00 $281.00 $299.0019297 ZZZ ------- $121.00 $127.00 $136.00 $121.00 $127.00 $136.0019298 0 ------- $1,919.00 $2,045.00 $2,156.00 $429.00 $448.00 $471.0019300 90 ------- $679.00 $723.00 $773.00 $480.00 $511.00 $549.0019301 90 ------- $733.00 $768.00 $811.00 $733.00 $768.00 $811.0019302 90 ------- $1,106.00 $1,174.00 $1,263.00 $1,106.00 $1,174.00 $1,263.0019303 90 ------- $1,130.00 $1,181.00 $1,245.00 $1,130.00 $1,181.00 $1,245.0019304 90 ------- $692.00 $735.00 $791.00 $692.00 $735.00 $791.0019305 90 ------- $1,364.00 $1,442.00 $1,541.00 $1,364.00 $1,442.00 $1,541.0019306 90 ------- $1,427.00 $1,510.00 $1,617.00 $1,427.00 $1,510.00 $1,617.0019307 90 ------- $1,436.00 $1,521.00 $1,629.00 $1,436.00 $1,521.00 $1,629.0019316 90 $954.00 $1,007.00 $1,075.00 $1,160.00 $1,007.00 $1,075.00 $1,160.0019318 90 $1,313.00 $1,506.00 $1,618.00 $1,765.00 $1,506.00 $1,618.00 $1,765.0019324 90 $440.00 $613.00 $651.00 $698.00 $613.00 $651.00 $698.0019325 90 $656.00 $829.00 $886.00 $957.00 $829.00 $886.00 $957.0019328 90 $457.00 $621.00 $662.00 $712.00 $621.00 $662.00 $712.0019330 90 $569.00 $794.00 $847.00 $914.00 $794.00 $847.00 $914.0019340 ZZZ $545.00 $529.00 $567.00 $617.00 $529.00 $567.00 $617.0019342 90 $963.00 $1,175.00 $1,253.00 $1,352.00 $1,175.00 $1,253.00 $1,352.0019350 90 $853.00 $1,127.00 $1,206.00 $1,296.00 $878.00 $938.00 $1,014.0019355 90 $755.00 $907.00 $962.00 $1,024.00 $700.00 $740.00 $790.0019357 90 $1,449.00 $1,974.00 $2,104.00 $2,265.00 $1,974.00 $2,104.00 $2,265.0019361 90 $1,667.00 $2,051.00 $2,177.00 $2,336.00 $2,051.00 $2,177.00 $2,336.0019364 90 $2,737.00 $3,629.00 $3,869.00 $4,182.00 $3,629.00 $3,869.00 $4,182.0019366 90 $1,676.00 $1,814.00 $1,935.00 $2,094.00 $1,814.00 $1,935.00 $2,094.0019367 90 $2,056.00 $2,366.00 $2,526.00 $2,732.00 $2,366.00 $2,526.00 $2,732.0019368 90 $2,444.00 $2,941.00 $3,148.00 $3,420.00 $2,941.00 $3,148.00 $3,420.0019369 90 $2,317.00 $2,683.00 $2,859.00 $3,088.00 $2,683.00 $2,859.00 $3,088.0019370 90 $662.00 $867.00 $924.00 $995.00 $867.00 $924.00 $995.0019371 90 $788.00 $1,006.00 $1,075.00 $1,161.00 $1,006.00 $1,075.00 $1,161.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

19380 90 $780.00 $976.00 $1,040.00 $1,119.00 $976.00 $1,040.00 $1,119.0019396 0 $231.00 $266.00 $284.00 $304.00 $183.00 $194.00 $209.0019499 YYY BR ------- ------- ------- ------- ------- -------20000 10 $45.00 $257.00 $273.00 $291.00 $202.00 $214.00 $228.0020005 10 $267.00 $382.00 $407.00 $435.00 $310.00 $329.00 $353.0020100 10 $727.00 $782.00 $827.00 $887.00 $782.00 $827.00 $887.0020101 10 $261.00 $499.00 $533.00 $568.00 $265.00 $282.00 $304.0020102 10 $314.00 $585.00 $623.00 $663.00 $318.00 $337.00 $362.0020103 10 $405.00 $719.00 $767.00 $821.00 $463.00 $494.00 $532.0020150 90 $1,141.00 $1,214.00 $1,292.00 $1,394.00 $1,214.00 $1,292.00 $1,394.0020200 0 $134.00 $240.00 $257.00 $275.00 $123.00 $131.00 $143.0020205 0 $243.00 $329.00 $352.00 $376.00 $194.00 $206.00 $222.0020206 0 $119.00 $345.00 $367.00 $387.00 $82.00 $86.00 $90.0020220 0 $128.00 $247.00 $262.00 $276.00 $103.00 $107.00 $112.0020225 0 $215.00 $1,016.00 $1,087.00 $1,149.00 $159.00 $169.00 $181.0020240 10 $279.00 $302.00 $321.00 $345.00 $302.00 $321.00 $345.0020245 10 $364.00 $823.00 $879.00 $948.00 $823.00 $879.00 $948.0020250 10 $447.00 $501.00 $540.00 $591.00 $501.00 $540.00 $591.0020251 10 $511.00 $558.00 $602.00 $659.00 $558.00 $602.00 $659.0020500 10 $59.00 $158.00 $168.00 $178.00 $128.00 $135.00 $144.0020501 0 $60.00 $171.00 $181.00 $191.00 $52.00 $54.00 $56.0020520 10 $75.00 $243.00 $258.00 $274.00 $185.00 $196.00 $209.0020525 10 $331.00 $611.00 $653.00 $697.00 $326.00 $348.00 $375.0020526 0 $64.00 $99.00 $106.00 $113.00 $78.00 $83.00 $89.0020550 0 $40.00 $76.00 $80.00 $86.00 $55.00 $59.00 $63.0020551 0 $62.00 $75.00 $79.00 $84.00 $57.00 $60.00 $64.0020552 0 $62.00 $67.00 $71.00 $75.00 $46.00 $48.00 $51.0020553 0 $62.00 $75.00 $78.00 $82.00 $50.00 $52.00 $55.0020555 0 ------- $425.00 $443.00 $467.00 $425.00 $443.00 $467.0020600 0 $41.00 $70.00 $75.00 $80.00 $54.00 $57.00 $61.0020605 0 $48.00 $76.00 $81.00 $86.00 $55.00 $59.00 $63.0020610 0 $49.00 $97.00 $103.00 $110.00 $67.00 $71.00 $76.0020612 0 $56.00 $76.00 $81.00 $87.00 $58.00 $62.00 $67.0020615 10 $94.00 $280.00 $296.00 $313.00 $206.00 $216.00 $229.0020650 10 $170.00 $251.00 $267.00 $286.00 $205.00 $218.00 $235.0020660 0 $320.00 $348.00 $372.00 $401.00 $312.00 $332.00 $360.0020661 90 $476.00 $606.00 $654.00 $715.00 $606.00 $654.00 $715.0020662 90 $559.00 $597.00 $629.00 $666.00 $597.00 $629.00 $666.0020663 90 $465.00 $580.00 $622.00 $673.00 $580.00 $622.00 $673.0020665 10 $105.00 $165.00 $177.00 $189.00 $135.00 $144.00 $155.0020670 10 $80.00 $559.00 $598.00 $636.00 $199.00 $213.00 $230.0020680 90 $332.00 $745.00 $789.00 $836.00 $516.00 $544.00 $578.0020690 90 $298.00 $639.00 $667.00 $701.00 $639.00 $667.00 $701.0020692 90 $516.00 $1,174.00 $1,225.00 $1,286.00 $1,174.00 $1,225.00 $1,286.0020693 90 $477.00 $607.00 $649.00 $702.00 $607.00 $649.00 $702.0020694 90 $421.00 $565.00 $605.00 $651.00 $443.00 $474.00 $513.0020802 90 $3,363.00 $3,144.00 $3,302.00 $3,502.00 $3,144.00 $3,302.00 $3,502.0020805 90 $4,317.00 $4,093.00 $4,310.00 $4,577.00 $4,093.00 $4,310.00 $4,577.0020808 90 $5,324.00 $5,307.00 $5,611.00 $5,988.00 $5,307.00 $5,611.00 $5,988.0020816 90 $3,060.00 $3,203.00 $3,415.00 $3,673.00 $3,203.00 $3,415.00 $3,673.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

20822 90 $2,511.00 $2,815.00 $3,010.00 $3,247.00 $2,815.00 $3,010.00 $3,247.0020824 90 $3,027.00 $3,176.00 $3,387.00 $3,646.00 $3,176.00 $3,387.00 $3,646.0020827 90 $3,920.00 $2,851.00 $3,035.00 $3,255.00 $2,851.00 $3,035.00 $3,255.0020838 90 $3,484.00 $2,995.00 $3,088.00 $3,185.00 $2,995.00 $3,088.00 $3,185.0020900 90 $454.00 $787.00 $842.00 $905.00 $610.00 $653.00 $705.0020902 90 $658.00 $799.00 $855.00 $925.00 $799.00 $855.00 $925.0020910 90 $338.00 $554.00 $589.00 $632.00 $554.00 $589.00 $632.0020912 90 $549.00 $624.00 $661.00 $704.00 $624.00 $661.00 $704.0020920 90 $460.00 $521.00 $553.00 $591.00 $521.00 $553.00 $591.0020922 90 $634.00 $754.00 $799.00 $848.00 $623.00 $658.00 $700.0020924 90 $583.00 $663.00 $709.00 $766.00 $663.00 $709.00 $766.0020926 90 $444.00 $568.00 $606.00 $654.00 $568.00 $606.00 $654.0020930 0 BR ------- ------- ------- ------- ------- -------20931 ZZZ $156.00 $159.00 $173.00 $192.00 $159.00 $173.00 $192.0020936 0 BR ------- ------- ------- ------- ------- -------20937 ZZZ $234.00 $237.00 $255.00 $280.00 $237.00 $255.00 $280.0020938 ZZZ $257.00 $260.00 $281.00 $310.00 $260.00 $281.00 $310.0020950 0 $123.00 $352.00 $377.00 $401.00 $122.00 $130.00 $141.0020955 90 $3,332.00 $3,338.00 $3,539.00 $3,795.00 $3,338.00 $3,539.00 $3,795.0020956 90 $3,167.00 $3,607.00 $3,866.00 $4,208.00 $3,607.00 $3,866.00 $4,208.0020957 90 $3,074.00 $3,420.00 $3,661.00 $3,990.00 $3,420.00 $3,661.00 $3,990.0020962 90 $3,122.00 $3,558.00 $3,811.00 $4,139.00 $3,558.00 $3,811.00 $4,139.0020969 90 $3,716.00 $3,692.00 $3,899.00 $4,158.00 $3,692.00 $3,899.00 $4,158.0020970 90 $3,650.00 $3,761.00 $4,012.00 $4,340.00 $3,761.00 $4,012.00 $4,340.0020972 90 $3,420.00 $3,384.00 $3,583.00 $3,844.00 $3,384.00 $3,583.00 $3,844.0020973 90 $3,821.00 $3,629.00 $3,840.00 $4,116.00 $3,629.00 $3,840.00 $4,116.0020974 0 $266.00 $80.00 $85.00 $92.00 $64.00 $68.00 $74.0020975 0 $334.00 $242.00 $260.00 $285.00 $242.00 $260.00 $285.0020979 0 $19.00 $72.00 $77.00 $82.00 $50.00 $53.00 $58.0020982 0 ------- $5,135.00 $5,491.00 $5,797.00 $537.00 $565.00 $601.0020985 ZZZ ------- $205.00 $221.00 $242.00 $205.00 $221.00 $242.0020999 YYY BR ------- ------- ------- ------- ------- -------21010 90 $854.00 $934.00 $986.00 $1,050.00 $934.00 $986.00 $1,050.0021015 90 $520.00 $551.00 $585.00 $626.00 $551.00 $585.00 $626.0021025 90 $546.00 $1,244.00 $1,322.00 $1,410.00 $1,077.00 $1,143.00 $1,221.0021026 90 $413.00 $725.00 $770.00 $818.00 $614.00 $651.00 $693.0021029 90 $700.00 $935.00 $993.00 $1,058.00 $801.00 $849.00 $905.0021030 90 $496.00 $606.00 $644.00 $685.00 $511.00 $542.00 $578.0021031 90 $310.00 $468.00 $500.00 $535.00 $369.00 $393.00 $423.0021032 90 $315.00 $476.00 $508.00 $544.00 $363.00 $388.00 $416.0021034 90 $1,140.00 $1,689.00 $1,786.00 $1,898.00 $1,512.00 $1,597.00 $1,698.0021040 90 $227.00 $608.00 $646.00 $687.00 $502.00 $533.00 $568.0021044 90 $957.00 $1,117.00 $1,177.00 $1,247.00 $1,117.00 $1,177.00 $1,247.0021045 90 $1,313.00 $1,551.00 $1,631.00 $1,725.00 $1,551.00 $1,631.00 $1,725.0021046 90 $899.00 $1,388.00 $1,477.00 $1,585.00 $1,388.00 $1,477.00 $1,585.0021047 90 $1,109.00 $1,691.00 $1,787.00 $1,906.00 $1,691.00 $1,787.00 $1,906.0021048 90 $925.00 $1,408.00 $1,495.00 $1,599.00 $1,408.00 $1,495.00 $1,599.0021049 90 $1,051.00 $1,605.00 $1,687.00 $1,783.00 $1,605.00 $1,687.00 $1,783.0021050 90 $1,026.00 $1,100.00 $1,168.00 $1,252.00 $1,100.00 $1,168.00 $1,252.0021060 90 $972.00 $1,017.00 $1,080.00 $1,157.00 $1,017.00 $1,080.00 $1,157.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

21070 90 $679.00 $834.00 $891.00 $960.00 $834.00 $891.00 $960.0021073 90 ------- $465.00 $496.00 $529.00 $306.00 $325.00 $349.0021076 10 $1,192.00 $1,297.00 $1,384.00 $1,493.00 $1,155.00 $1,232.00 $1,332.0021077 90 $3,002.00 $3,188.00 $3,393.00 $3,645.00 $2,890.00 $3,074.00 $3,309.0021079 90 $2,086.00 $2,185.00 $2,329.00 $2,505.00 $1,930.00 $2,055.00 $2,216.0021080 90 $2,346.00 $2,490.00 $2,658.00 $2,865.00 $2,184.00 $2,330.00 $2,519.0021081 90 $2,138.00 $2,260.00 $2,409.00 $2,590.00 $1,975.00 $2,102.00 $2,267.0021082 90 $1,855.00 $2,082.00 $2,222.00 $2,395.00 $1,826.00 $1,948.00 $2,106.0021083 90 $1,802.00 $1,977.00 $2,110.00 $2,273.00 $1,689.00 $1,802.00 $1,949.0021084 90 $2,105.00 $2,211.00 $2,337.00 $2,481.00 $1,896.00 $1,999.00 $2,124.0021085 10 $801.00 $903.00 $963.00 $1,035.00 $780.00 $831.00 $896.0021086 90 $2,333.00 $2,380.00 $2,540.00 $2,740.00 $2,161.00 $2,305.00 $2,492.0021087 90 $2,217.00 $2,350.00 $2,503.00 $2,692.00 $2,136.00 $2,273.00 $2,449.0021088 90 BR ------- ------- ------- ------- ------- -------21089 90 BR ------- ------- ------- ------- ------- -------21100 90 $297.00 $901.00 $957.00 $1,009.00 $498.00 $525.00 $554.0021110 90 $371.00 $895.00 $953.00 $1,015.00 $782.00 $832.00 $887.0021116 0 $207.00 $214.00 $227.00 $240.00 $57.00 $59.00 $62.0021120 90 $500.00 $787.00 $839.00 $892.00 $635.00 $675.00 $720.0021121 90 $651.00 $942.00 $1,001.00 $1,067.00 $818.00 $869.00 $927.0021122 90 $700.00 $915.00 $972.00 $1,040.00 $915.00 $972.00 $1,040.0021123 90 $903.00 $1,084.00 $1,151.00 $1,232.00 $1,084.00 $1,151.00 $1,232.0021125 90 $656.00 $3,543.00 $3,776.00 $3,982.00 $933.00 $979.00 $1,032.0021127 90 $909.00 $3,890.00 $4,157.00 $4,404.00 $1,119.00 $1,188.00 $1,273.0021137 90 $797.00 $959.00 $1,020.00 $1,094.00 $959.00 $1,020.00 $1,094.0021138 90 $960.00 $1,169.00 $1,245.00 $1,339.00 $1,169.00 $1,245.00 $1,339.0021139 90 $1,168.00 $1,244.00 $1,307.00 $1,380.00 $1,244.00 $1,307.00 $1,380.0021141 90 $1,438.00 $1,730.00 $1,835.00 $1,966.00 $1,730.00 $1,835.00 $1,966.0021142 90 $1,527.00 $1,700.00 $1,802.00 $1,930.00 $1,700.00 $1,802.00 $1,930.0021143 90 $1,511.00 $1,758.00 $1,847.00 $1,951.00 $1,758.00 $1,847.00 $1,951.0021145 90 $1,513.00 $2,008.00 $2,128.00 $2,280.00 $2,008.00 $2,128.00 $2,280.0021146 90 $1,570.00 $2,011.00 $2,133.00 $2,291.00 $2,011.00 $2,133.00 $2,291.0021147 90 $1,639.00 $2,108.00 $2,207.00 $2,323.00 $2,108.00 $2,207.00 $2,323.0021150 90 $1,914.00 $2,256.00 $2,381.00 $2,531.00 $2,256.00 $2,381.00 $2,531.0021151 90 $2,264.00 $2,402.00 $2,522.00 $2,664.00 $2,402.00 $2,522.00 $2,664.0021154 90 $2,364.00 $2,681.00 $2,817.00 $2,975.00 $2,681.00 $2,817.00 $2,975.0021155 90 $2,640.00 $3,222.00 $3,467.00 $3,790.00 $3,222.00 $3,467.00 $3,790.0021159 90 $3,302.00 $3,771.00 $4,058.00 $4,445.00 $3,771.00 $4,058.00 $4,445.0021160 90 $3,500.00 $3,801.00 $3,996.00 $4,234.00 $3,801.00 $3,996.00 $4,234.0021172 90 $2,111.00 $2,288.00 $2,427.00 $2,608.00 $2,288.00 $2,427.00 $2,608.0021175 90 $2,604.00 $2,737.00 $2,916.00 $3,152.00 $2,737.00 $2,916.00 $3,152.0021179 90 $1,826.00 $1,915.00 $2,031.00 $2,179.00 $1,915.00 $2,031.00 $2,179.0021180 90 $2,035.00 $2,182.00 $2,321.00 $2,500.00 $2,182.00 $2,321.00 $2,500.0021181 90 $813.00 $940.00 $999.00 $1,072.00 $940.00 $999.00 $1,072.0021182 90 $2,570.00 $2,606.00 $2,739.00 $2,900.00 $2,606.00 $2,739.00 $2,900.0021183 90 $2,770.00 $3,026.00 $3,212.00 $3,447.00 $3,026.00 $3,212.00 $3,447.0021184 90 $3,150.00 $3,200.00 $3,412.00 $3,693.00 $3,200.00 $3,412.00 $3,693.0021188 90 $1,786.00 $2,077.00 $2,181.00 $2,299.00 $2,077.00 $2,181.00 $2,299.0021193 90 $1,331.00 $1,615.00 $1,712.00 $1,833.00 $1,615.00 $1,712.00 $1,833.0021194 90 $1,540.00 $1,820.00 $1,917.00 $2,035.00 $1,820.00 $1,917.00 $2,035.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

21195 90 $1,360.00 $1,714.00 $1,805.00 $1,911.00 $1,714.00 $1,805.00 $1,911.0021196 90 $1,764.00 $1,871.00 $1,977.00 $2,102.00 $1,871.00 $1,977.00 $2,102.0021198 90 $1,268.00 $1,456.00 $1,536.00 $1,629.00 $1,456.00 $1,536.00 $1,629.0021199 90 $1,018.00 $1,308.00 $1,373.00 $1,452.00 $1,308.00 $1,373.00 $1,452.0021206 90 $1,112.00 $1,415.00 $1,491.00 $1,578.00 $1,415.00 $1,491.00 $1,578.0021208 90 $946.00 $1,997.00 $2,124.00 $2,248.00 $1,050.00 $1,109.00 $1,178.0021209 90 $576.00 $1,002.00 $1,066.00 $1,135.00 $813.00 $864.00 $922.0021210 90 $930.00 $2,347.00 $2,502.00 $2,653.00 $1,063.00 $1,127.00 $1,203.0021215 90 $970.00 $3,880.00 $4,148.00 $4,396.00 $1,115.00 $1,185.00 $1,271.0021230 90 $956.00 $998.00 $1,058.00 $1,130.00 $998.00 $1,058.00 $1,130.0021235 90 $707.00 $890.00 $942.00 $995.00 $707.00 $745.00 $787.0021240 90 $1,281.00 $1,456.00 $1,552.00 $1,672.00 $1,456.00 $1,552.00 $1,672.0021242 90 $1,207.00 $1,328.00 $1,410.00 $1,510.00 $1,328.00 $1,410.00 $1,510.0021243 90 $1,501.00 $2,177.00 $2,316.00 $2,490.00 $2,177.00 $2,316.00 $2,490.0021244 90 $1,062.00 $1,316.00 $1,390.00 $1,474.00 $1,316.00 $1,390.00 $1,474.0021245 90 $1,038.00 $1,414.00 $1,495.00 $1,584.00 $1,161.00 $1,224.00 $1,298.0021246 90 $1,010.00 $1,119.00 $1,182.00 $1,260.00 $1,119.00 $1,182.00 $1,260.0021247 90 $2,003.00 $2,106.00 $2,232.00 $2,387.00 $2,106.00 $2,232.00 $2,387.0021248 90 $1,023.00 $1,330.00 $1,414.00 $1,511.00 $1,134.00 $1,204.00 $1,290.0021249 90 $1,525.00 $1,881.00 $2,002.00 $2,148.00 $1,627.00 $1,730.00 $1,861.0021255 90 $1,459.00 $1,796.00 $1,910.00 $2,049.00 $1,796.00 $1,910.00 $2,049.0021256 90 $1,470.00 $1,472.00 $1,548.00 $1,638.00 $1,472.00 $1,548.00 $1,638.0021260 90 $1,372.00 $1,553.00 $1,624.00 $1,699.00 $1,553.00 $1,624.00 $1,699.0021261 90 $2,347.00 $2,833.00 $2,990.00 $3,182.00 $2,833.00 $2,990.00 $3,182.0021263 90 $2,361.00 $2,479.00 $2,605.00 $2,757.00 $2,479.00 $2,605.00 $2,757.0021267 90 $1,539.00 $1,991.00 $2,099.00 $2,219.00 $1,991.00 $2,099.00 $2,219.0021268 90 $1,946.00 $2,381.00 $2,534.00 $2,727.00 $2,381.00 $2,534.00 $2,727.0021270 90 $890.00 $1,121.00 $1,180.00 $1,242.00 $880.00 $921.00 $969.0021275 90 $963.00 $1,032.00 $1,092.00 $1,166.00 $1,032.00 $1,092.00 $1,166.0021280 90 $571.00 $647.00 $679.00 $712.00 $647.00 $679.00 $712.0021282 90 $360.00 $430.00 $452.00 $474.00 $430.00 $452.00 $474.0021295 90 $144.00 $217.00 $229.00 $243.00 $217.00 $229.00 $243.0021296 90 $384.00 $504.00 $532.00 $560.00 $504.00 $532.00 $560.0021299 YYY BR ------- ------- ------- ------- ------- -------21310 0 $81.00 $138.00 $147.00 $155.00 $38.00 $39.00 $42.0021315 10 $180.00 $319.00 $338.00 $357.00 $186.00 $196.00 $207.0021320 10 $235.00 $307.00 $326.00 $345.00 $176.00 $186.00 $198.0021325 90 $348.00 $605.00 $641.00 $676.00 $605.00 $641.00 $676.0021330 90 $639.00 $744.00 $789.00 $837.00 $744.00 $789.00 $837.0021335 90 $852.00 $929.00 $981.00 $1,036.00 $929.00 $981.00 $1,036.0021336 90 $478.00 $809.00 $855.00 $904.00 $809.00 $855.00 $904.0021337 90 $300.00 $482.00 $511.00 $540.00 $354.00 $373.00 $395.0021338 90 $550.00 $981.00 $1,045.00 $1,112.00 $981.00 $1,045.00 $1,112.0021339 90 $689.00 $1,063.00 $1,130.00 $1,203.00 $1,063.00 $1,130.00 $1,203.0021340 90 $907.00 $1,015.00 $1,072.00 $1,140.00 $1,015.00 $1,072.00 $1,140.0021343 90 $1,043.00 $1,486.00 $1,574.00 $1,673.00 $1,486.00 $1,574.00 $1,673.0021344 90 $1,450.00 $1,936.00 $2,050.00 $2,190.00 $1,936.00 $2,050.00 $2,190.0021345 90 $738.00 $998.00 $1,057.00 $1,123.00 $833.00 $881.00 $937.0021346 90 $917.00 $1,202.00 $1,274.00 $1,355.00 $1,202.00 $1,274.00 $1,355.0021347 90 $1,048.00 $1,442.00 $1,530.00 $1,628.00 $1,442.00 $1,530.00 $1,628.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

21348 90 $1,286.00 $1,566.00 $1,668.00 $1,799.00 $1,566.00 $1,668.00 $1,799.0021355 10 $295.00 $533.00 $563.00 $594.00 $398.00 $419.00 $442.0021356 10 $372.00 $610.00 $646.00 $685.00 $472.00 $499.00 $530.0021360 90 $590.00 $672.00 $711.00 $757.00 $672.00 $711.00 $757.0021365 90 $1,239.00 $1,409.00 $1,488.00 $1,584.00 $1,409.00 $1,488.00 $1,584.0021366 90 $1,386.00 $1,610.00 $1,712.00 $1,843.00 $1,610.00 $1,712.00 $1,843.0021385 90 $810.00 $906.00 $959.00 $1,019.00 $906.00 $959.00 $1,019.0021386 90 $812.00 $848.00 $896.00 $953.00 $848.00 $896.00 $953.0021387 90 $958.00 $966.00 $1,022.00 $1,089.00 $966.00 $1,022.00 $1,089.0021390 90 $920.00 $962.00 $1,011.00 $1,068.00 $962.00 $1,011.00 $1,068.0021395 90 $1,384.00 $1,235.00 $1,302.00 $1,385.00 $1,235.00 $1,302.00 $1,385.0021400 90 $143.00 $213.00 $226.00 $240.00 $176.00 $186.00 $198.0021401 90 $313.00 $573.00 $610.00 $647.00 $361.00 $382.00 $407.0021406 90 $852.00 $686.00 $725.00 $770.00 $686.00 $725.00 $770.0021407 90 $736.00 $812.00 $859.00 $915.00 $812.00 $859.00 $915.0021408 90 $1,007.00 $1,118.00 $1,183.00 $1,264.00 $1,118.00 $1,183.00 $1,264.0021421 90 $528.00 $875.00 $932.00 $993.00 $768.00 $818.00 $872.0021422 90 $761.00 $861.00 $913.00 $974.00 $861.00 $913.00 $974.0021423 90 $890.00 $1,022.00 $1,084.00 $1,159.00 $1,022.00 $1,084.00 $1,159.0021431 90 $598.00 $928.00 $983.00 $1,040.00 $928.00 $983.00 $1,040.0021432 90 $744.00 $847.00 $894.00 $948.00 $847.00 $894.00 $948.0021433 90 $1,981.00 $2,162.00 $2,284.00 $2,435.00 $2,162.00 $2,284.00 $2,435.0021435 90 $1,404.00 $1,693.00 $1,786.00 $1,899.00 $1,693.00 $1,786.00 $1,899.0021436 90 $2,045.00 $2,439.00 $2,574.00 $2,742.00 $2,439.00 $2,574.00 $2,742.0021440 90 $308.00 $613.00 $654.00 $694.00 $525.00 $558.00 $593.0021445 90 $533.00 $896.00 $955.00 $1,018.00 $766.00 $816.00 $872.0021450 90 $325.00 $640.00 $681.00 $720.00 $558.00 $592.00 $627.0021451 90 $498.00 $865.00 $920.00 $978.00 $758.00 $806.00 $858.0021452 90 $195.00 $756.00 $807.00 $855.00 $396.00 $422.00 $448.0021453 90 $902.00 $998.00 $1,062.00 $1,129.00 $919.00 $978.00 $1,040.0021454 90 $905.00 $701.00 $744.00 $793.00 $701.00 $744.00 $793.0021461 90 $769.00 $2,158.00 $2,301.00 $2,436.00 $1,140.00 $1,211.00 $1,287.0021462 90 $1,012.00 $2,371.00 $2,529.00 $2,683.00 $1,259.00 $1,338.00 $1,427.0021465 90 $923.00 $1,172.00 $1,242.00 $1,327.00 $1,172.00 $1,242.00 $1,327.0021470 90 $1,331.00 $1,520.00 $1,610.00 $1,720.00 $1,520.00 $1,610.00 $1,720.0021480 0 $82.00 $116.00 $123.00 $131.00 $43.00 $45.00 $48.0021485 90 $318.00 $763.00 $812.00 $862.00 $675.00 $717.00 $762.0021490 90 $865.00 $1,198.00 $1,280.00 $1,384.00 $1,198.00 $1,280.00 $1,384.0021495 90 $500.00 $816.00 $862.00 $908.00 $816.00 $862.00 $908.0021497 90 $372.00 $765.00 $815.00 $865.00 $673.00 $716.00 $761.0021499 YYY BR ------- ------- ------- ------- ------- -------21501 90 $315.00 $540.00 $574.00 $610.00 $399.00 $423.00 $451.0021502 90 $612.00 $681.00 $723.00 $777.00 $681.00 $723.00 $777.0021510 90 $534.00 $610.00 $649.00 $696.00 $610.00 $649.00 $696.0021550 10 $165.00 $309.00 $327.00 $345.00 $198.00 $208.00 $219.0021555 90 $337.00 $533.00 $568.00 $606.00 $416.00 $442.00 $474.0021556 90 $431.00 $522.00 $553.00 $591.00 $522.00 $553.00 $591.0021557 90 $794.00 $751.00 $796.00 $853.00 $751.00 $796.00 $853.0021600 90 $631.00 $706.00 $752.00 $808.00 $706.00 $752.00 $808.0021610 90 $828.00 $1,429.00 $1,539.00 $1,686.00 $1,429.00 $1,539.00 $1,686.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

21615 90 $938.00 $896.00 $954.00 $1,028.00 $896.00 $954.00 $1,028.0021616 90 $1,042.00 $1,100.00 $1,174.00 $1,269.00 $1,100.00 $1,174.00 $1,269.0021620 90 $689.00 $683.00 $727.00 $781.00 $683.00 $727.00 $781.0021627 90 $686.00 $714.00 $761.00 $819.00 $714.00 $761.00 $819.0021630 90 $1,455.00 $1,653.00 $1,758.00 $1,893.00 $1,653.00 $1,758.00 $1,893.0021632 90 $1,514.00 $1,640.00 $1,745.00 $1,879.00 $1,640.00 $1,745.00 $1,879.0021685 90 ------- $1,251.00 $1,312.00 $1,381.00 $1,251.00 $1,312.00 $1,381.0021700 90 $576.00 $539.00 $563.00 $588.00 $539.00 $563.00 $588.0021705 90 $746.00 $824.00 $878.00 $949.00 $824.00 $878.00 $949.0021720 90 $523.00 $505.00 $540.00 $586.00 $505.00 $540.00 $586.0021725 90 $588.00 $694.00 $744.00 $807.00 $694.00 $744.00 $807.0021740 90 $1,387.00 $1,426.00 $1,516.00 $1,634.00 $1,426.00 $1,516.00 $1,634.0021742 90 BR ------- ------- ------- ------- ------- -------21743 90 BR ------- ------- ------- ------- ------- -------21750 90 $1,009.00 $948.00 $1,010.00 $1,091.00 $948.00 $1,010.00 $1,091.0021800 90 $84.00 $120.00 $128.00 $135.00 $122.00 $129.00 $137.0021805 90 $236.00 $324.00 $345.00 $369.00 $324.00 $345.00 $369.0021810 90 $540.00 $658.00 $700.00 $752.00 $658.00 $700.00 $752.0021820 90 $143.00 $165.00 $176.00 $188.00 $165.00 $176.00 $188.0021825 90 $810.00 $742.00 $791.00 $852.00 $742.00 $791.00 $852.0021899 YYY BR ------- ------- ------- ------- ------- -------21920 10 $165.00 $302.00 $319.00 $336.00 $193.00 $202.00 $213.0021925 90 $371.00 $524.00 $558.00 $597.00 $426.00 $453.00 $486.0021930 90 $403.00 $584.00 $622.00 $665.00 $470.00 $499.00 $536.0021935 90 $1,280.00 $1,512.00 $1,607.00 $1,731.00 $1,512.00 $1,607.00 $1,731.0022010 90 ------- $1,159.00 $1,234.00 $1,328.00 $1,159.00 $1,234.00 $1,328.0022015 90 ------- $1,151.00 $1,225.00 $1,318.00 $1,151.00 $1,225.00 $1,318.0022100 90 $850.00 $1,070.00 $1,153.00 $1,260.00 $1,070.00 $1,153.00 $1,260.0022101 90 $862.00 $1,059.00 $1,136.00 $1,234.00 $1,059.00 $1,136.00 $1,234.0022102 90 $781.00 $1,061.00 $1,137.00 $1,235.00 $1,061.00 $1,137.00 $1,235.0022103 ZZZ $198.00 $197.00 $212.00 $233.00 $197.00 $212.00 $233.0022110 90 $889.00 $1,325.00 $1,428.00 $1,564.00 $1,325.00 $1,428.00 $1,564.0022112 90 $1,090.00 $1,310.00 $1,407.00 $1,533.00 $1,310.00 $1,407.00 $1,533.0022114 90 $1,062.00 $1,317.00 $1,417.00 $1,548.00 $1,317.00 $1,417.00 $1,548.0022116 ZZZ $195.00 $200.00 $216.00 $239.00 $200.00 $216.00 $239.0022206 90 ------- $3,118.00 $3,339.00 $3,636.00 $3,118.00 $3,339.00 $3,636.0022207 90 ------- $3,076.00 $3,293.00 $3,583.00 $3,076.00 $3,293.00 $3,583.0022208 ZZZ ------- $804.00 $870.00 $963.00 $804.00 $870.00 $963.0022210 90 $1,892.00 $2,362.00 $2,555.00 $2,813.00 $2,362.00 $2,555.00 $2,813.0022212 90 $1,668.00 $1,927.00 $2,072.00 $2,264.00 $1,927.00 $2,072.00 $2,264.0022214 90 $819.00 $1,945.00 $2,092.00 $2,284.00 $1,945.00 $2,092.00 $2,284.0022216 ZZZ $492.00 $522.00 $564.00 $623.00 $522.00 $564.00 $623.0022220 90 $1,801.00 $2,143.00 $2,320.00 $2,560.00 $2,143.00 $2,320.00 $2,560.0022222 90 $1,604.00 $1,940.00 $2,083.00 $2,277.00 $1,940.00 $2,083.00 $2,277.0022224 90 $1,731.00 $2,083.00 $2,238.00 $2,442.00 $2,083.00 $2,238.00 $2,442.0022226 ZZZ $488.00 $520.00 $562.00 $621.00 $520.00 $562.00 $621.0022305 90 $213.00 $240.00 $258.00 $280.00 $221.00 $238.00 $259.0022310 90 $272.00 $358.00 $381.00 $409.00 $334.00 $356.00 $383.0022315 90 $711.00 $1,102.00 $1,184.00 $1,286.00 $982.00 $1,056.00 $1,151.0022318 90 $1,755.00 $2,145.00 $2,327.00 $2,575.00 $2,145.00 $2,327.00 $2,575.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

22319 90 $1,983.00 $2,365.00 $2,569.00 $2,849.00 $2,365.00 $2,569.00 $2,849.0022325 90 $1,407.00 $1,835.00 $1,977.00 $2,165.00 $1,835.00 $1,977.00 $2,165.0022326 90 $1,710.00 $1,939.00 $2,096.00 $2,306.00 $1,939.00 $2,096.00 $2,306.0022327 90 $1,660.00 $1,898.00 $2,043.00 $2,237.00 $1,898.00 $2,043.00 $2,237.0022328 ZZZ $391.00 $391.00 $422.00 $465.00 $391.00 $422.00 $465.0022505 10 $174.00 $168.00 $180.00 $197.00 $168.00 $180.00 $197.0022520 10 $509.00 $3,204.00 $3,436.00 $3,659.00 $809.00 $870.00 $952.0022521 10 $477.00 $3,054.00 $3,275.00 $3,486.00 $763.00 $820.00 $897.0022522 ZZZ $231.00 $347.00 $373.00 $410.00 $347.00 $373.00 $410.0022523 10 ------- $833.00 $896.00 $979.00 $833.00 $896.00 $979.0022524 10 ------- $796.00 $855.00 $933.00 $796.00 $855.00 $933.0022525 ZZZ ------- $374.00 $402.00 $440.00 $374.00 $402.00 $440.0022526 10 ------- $2,712.00 $2,909.00 $3,091.00 $480.00 $517.00 $568.0022527 ZZZ ------- $2,207.00 $2,366.00 $2,507.00 $223.00 $241.00 $265.0022532 90 ------- $2,272.00 $2,434.00 $2,647.00 $2,272.00 $2,434.00 $2,647.0022533 90 ------- $2,085.00 $2,214.00 $2,378.00 $2,085.00 $2,214.00 $2,378.0022534 ZZZ ------- $513.00 $554.00 $611.00 $513.00 $554.00 $611.0022548 90 $2,271.00 $2,475.00 $2,672.00 $2,938.00 $2,475.00 $2,672.00 $2,938.0022554 90 $1,727.00 $1,752.00 $1,907.00 $2,116.00 $1,752.00 $1,907.00 $2,116.0022556 90 $2,054.00 $2,188.00 $2,347.00 $2,559.00 $2,188.00 $2,347.00 $2,559.0022558 90 $1,907.00 $1,964.00 $2,089.00 $2,249.00 $1,964.00 $2,089.00 $2,249.0022585 ZZZ $473.00 $480.00 $520.00 $577.00 $480.00 $520.00 $577.0022590 90 $1,895.00 $2,053.00 $2,222.00 $2,449.00 $2,053.00 $2,222.00 $2,449.0022595 90 $1,960.00 $1,947.00 $2,104.00 $2,315.00 $1,947.00 $2,104.00 $2,315.0022600 90 $1,567.00 $1,664.00 $1,798.00 $1,978.00 $1,664.00 $1,798.00 $1,978.0022610 90 $1,494.00 $1,638.00 $1,767.00 $1,939.00 $1,638.00 $1,767.00 $1,939.0022612 90 $1,861.00 $2,120.00 $2,281.00 $2,497.00 $2,120.00 $2,281.00 $2,497.0022614 ZZZ $530.00 $556.00 $602.00 $664.00 $556.00 $602.00 $664.0022630 90 $1,201.00 $2,057.00 $2,224.00 $2,448.00 $2,057.00 $2,224.00 $2,448.0022632 ZZZ $442.00 $454.00 $492.00 $544.00 $454.00 $492.00 $544.0022800 90 $1,960.00 $1,803.00 $1,941.00 $2,124.00 $1,803.00 $1,941.00 $2,124.0022802 90 $2,633.00 $2,878.00 $3,098.00 $3,393.00 $2,878.00 $3,098.00 $3,393.0022804 90 $2,951.00 $3,328.00 $3,578.00 $3,914.00 $3,328.00 $3,578.00 $3,914.0022808 90 $2,157.00 $2,433.00 $2,612.00 $2,851.00 $2,433.00 $2,612.00 $2,851.0022810 90 $2,356.00 $2,710.00 $2,900.00 $3,151.00 $2,710.00 $2,900.00 $3,151.0022812 90 $2,675.00 $2,953.00 $3,154.00 $3,418.00 $2,953.00 $3,154.00 $3,418.0022818 90 $2,701.00 $3,006.00 $3,233.00 $3,540.00 $3,006.00 $3,233.00 $3,540.0022819 90 $2,968.00 $3,421.00 $3,686.00 $4,045.00 $3,421.00 $3,686.00 $4,045.0022830 90 $1,176.00 $1,080.00 $1,166.00 $1,278.00 $1,080.00 $1,166.00 $1,278.0022840 ZZZ $943.00 $1,091.00 $1,182.00 $1,309.00 $1,091.00 $1,182.00 $1,309.0022841 0 BR ------- ------- ------- ------- ------- -------22842 ZZZ $2,352.00 $1,090.00 $1,180.00 $1,305.00 $1,090.00 $1,180.00 $1,305.0022843 ZZZ $1,028.00 $1,152.00 $1,246.00 $1,376.00 $1,152.00 $1,246.00 $1,376.0022844 ZZZ $1,277.00 $1,403.00 $1,511.00 $1,659.00 $1,403.00 $1,511.00 $1,659.0022845 ZZZ $1,853.00 $1,051.00 $1,143.00 $1,271.00 $1,051.00 $1,143.00 $1,271.0022846 ZZZ $999.00 $1,092.00 $1,187.00 $1,319.00 $1,092.00 $1,187.00 $1,319.0022847 ZZZ $1,077.00 $1,190.00 $1,288.00 $1,424.00 $1,190.00 $1,288.00 $1,424.0022848 ZZZ $529.00 $510.00 $549.00 $603.00 $510.00 $549.00 $603.0022849 90 $2,235.00 $1,753.00 $1,891.00 $2,076.00 $1,753.00 $1,891.00 $2,076.0022850 90 $872.00 $955.00 $1,031.00 $1,131.00 $955.00 $1,031.00 $1,131.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

22851 ZZZ $600.00 $580.00 $629.00 $696.00 $580.00 $629.00 $696.0022852 90 $854.00 $911.00 $983.00 $1,076.00 $911.00 $983.00 $1,076.0022855 90 $1,193.00 $1,491.00 $1,614.00 $1,780.00 $1,491.00 $1,614.00 $1,780.0022857 90 ------- $2,287.00 $2,431.00 $2,614.00 $2,287.00 $2,431.00 $2,614.0022862 90 ------- $2,752.00 $2,946.00 $3,204.00 $2,752.00 $2,946.00 $3,204.0022865 90 ------- $2,679.00 $2,867.00 $3,117.00 $2,679.00 $2,867.00 $3,117.0022899 YYY BR ------- ------- ------- ------- ------- -------22900 90 $446.00 $518.00 $549.00 $589.00 $518.00 $549.00 $589.0022999 YYY BR ------- ------- ------- ------- ------- -------23000 90 $447.00 $671.00 $717.00 $768.00 $464.00 $496.00 $535.0023020 90 $807.00 $907.00 $971.00 $1,052.00 $907.00 $971.00 $1,052.0023030 10 $323.00 $549.00 $587.00 $630.00 $339.00 $363.00 $393.0023031 10 $185.00 $525.00 $563.00 $602.00 $290.00 $310.00 $335.0023035 90 $861.00 $909.00 $972.00 $1,052.00 $909.00 $972.00 $1,052.0023040 90 $898.00 $944.00 $1,011.00 $1,096.00 $944.00 $1,011.00 $1,096.0023044 90 $708.00 $749.00 $801.00 $868.00 $749.00 $801.00 $868.0023065 10 $171.00 $259.00 $274.00 $290.00 $207.00 $218.00 $231.0023066 90 $302.00 $634.00 $677.00 $725.00 $438.00 $467.00 $503.0023075 10 $247.00 $324.00 $346.00 $370.00 $227.00 $242.00 $261.0023076 90 $613.00 $726.00 $774.00 $835.00 $726.00 $774.00 $835.0023077 90 $1,228.00 $1,530.00 $1,625.00 $1,746.00 $1,530.00 $1,625.00 $1,746.0023100 90 $616.00 $635.00 $680.00 $737.00 $635.00 $680.00 $737.0023101 90 $583.00 $588.00 $630.00 $682.00 $588.00 $630.00 $682.0023105 90 $814.00 $835.00 $895.00 $970.00 $835.00 $895.00 $970.0023106 90 $581.00 $624.00 $667.00 $722.00 $624.00 $667.00 $722.0023107 90 $851.00 $871.00 $933.00 $1,012.00 $871.00 $933.00 $1,012.0023120 90 $645.00 $736.00 $788.00 $854.00 $736.00 $788.00 $854.0023125 90 $865.00 $924.00 $990.00 $1,074.00 $924.00 $990.00 $1,074.0023130 90 $722.00 $792.00 $848.00 $919.00 $792.00 $848.00 $919.0023140 90 $597.00 $668.00 $714.00 $771.00 $668.00 $714.00 $771.0023145 90 $889.00 $902.00 $965.00 $1,044.00 $902.00 $965.00 $1,044.0023146 90 $704.00 $807.00 $864.00 $937.00 $807.00 $864.00 $937.0023150 90 $755.00 $847.00 $904.00 $975.00 $847.00 $904.00 $975.0023155 90 $945.00 $1,036.00 $1,110.00 $1,204.00 $1,036.00 $1,110.00 $1,204.0023156 90 $794.00 $883.00 $946.00 $1,025.00 $883.00 $946.00 $1,025.0023170 90 $645.00 $697.00 $746.00 $806.00 $697.00 $746.00 $806.0023172 90 $638.00 $713.00 $760.00 $817.00 $713.00 $760.00 $817.0023174 90 $882.00 $984.00 $1,054.00 $1,142.00 $984.00 $1,054.00 $1,142.0023180 90 $566.00 $917.00 $982.00 $1,063.00 $917.00 $982.00 $1,063.0023182 90 $865.00 $881.00 $942.00 $1,018.00 $881.00 $942.00 $1,018.0023184 90 $962.00 $993.00 $1,064.00 $1,151.00 $993.00 $1,064.00 $1,151.0023190 90 $656.00 $725.00 $775.00 $838.00 $725.00 $775.00 $838.0023195 90 $902.00 $983.00 $1,053.00 $1,141.00 $983.00 $1,053.00 $1,141.0023200 90 $1,095.00 $1,145.00 $1,223.00 $1,322.00 $1,145.00 $1,223.00 $1,322.0023210 90 $1,095.00 $1,199.00 $1,281.00 $1,385.00 $1,199.00 $1,281.00 $1,385.0023220 90 $1,307.00 $1,418.00 $1,517.00 $1,644.00 $1,418.00 $1,517.00 $1,644.0023221 90 $1,559.00 $1,665.00 $1,783.00 $1,936.00 $1,665.00 $1,783.00 $1,936.0023222 90 $1,921.00 $2,236.00 $2,388.00 $2,586.00 $2,236.00 $2,388.00 $2,586.0023330 10 $59.00 $283.00 $302.00 $321.00 $192.00 $204.00 $219.0023331 90 $520.00 $769.00 $824.00 $892.00 $769.00 $824.00 $892.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

23332 90 $1,029.00 $1,168.00 $1,250.00 $1,355.00 $1,168.00 $1,250.00 $1,355.0023350 0 $74.00 $207.00 $219.00 $231.00 $69.00 $71.00 $75.0023395 90 $1,366.00 $1,694.00 $1,812.00 $1,963.00 $1,694.00 $1,812.00 $1,963.0023397 90 $1,403.00 $1,521.00 $1,628.00 $1,767.00 $1,521.00 $1,628.00 $1,767.0023400 90 $1,196.00 $1,292.00 $1,384.00 $1,502.00 $1,292.00 $1,384.00 $1,502.0023405 90 $799.00 $832.00 $891.00 $967.00 $832.00 $891.00 $967.0023406 90 $977.00 $1,042.00 $1,117.00 $1,214.00 $1,042.00 $1,117.00 $1,214.0023410 90 $1,119.00 $1,195.00 $1,281.00 $1,391.00 $1,195.00 $1,281.00 $1,391.0023412 90 $1,229.00 $1,271.00 $1,363.00 $1,480.00 $1,271.00 $1,363.00 $1,480.0023415 90 $622.00 $976.00 $1,047.00 $1,136.00 $976.00 $1,047.00 $1,136.0023420 90 $1,276.00 $1,390.00 $1,486.00 $1,608.00 $1,390.00 $1,486.00 $1,608.0023430 90 $884.00 $982.00 $1,053.00 $1,143.00 $982.00 $1,053.00 $1,143.0023440 90 $906.00 $1,015.00 $1,089.00 $1,183.00 $1,015.00 $1,089.00 $1,183.0023450 90 $1,210.00 $1,273.00 $1,365.00 $1,483.00 $1,273.00 $1,365.00 $1,483.0023455 90 $1,340.00 $1,356.00 $1,454.00 $1,580.00 $1,356.00 $1,454.00 $1,580.0023460 90 $1,364.00 $1,466.00 $1,571.00 $1,707.00 $1,466.00 $1,571.00 $1,707.0023462 90 $1,383.00 $1,435.00 $1,536.00 $1,668.00 $1,435.00 $1,536.00 $1,668.0023465 90 $1,398.00 $1,495.00 $1,603.00 $1,742.00 $1,495.00 $1,603.00 $1,742.0023466 90 $1,332.00 $1,460.00 $1,561.00 $1,690.00 $1,460.00 $1,561.00 $1,690.0023470 90 $1,540.00 $1,630.00 $1,746.00 $1,896.00 $1,630.00 $1,746.00 $1,896.0023472 90 $1,570.00 $2,010.00 $2,151.00 $2,334.00 $2,010.00 $2,151.00 $2,334.0023480 90 $926.00 $1,093.00 $1,171.00 $1,271.00 $1,093.00 $1,171.00 $1,271.0023485 90 $1,181.00 $1,285.00 $1,377.00 $1,496.00 $1,285.00 $1,377.00 $1,496.0023490 90 $1,038.00 $1,068.00 $1,133.00 $1,214.00 $1,068.00 $1,133.00 $1,214.0023491 90 $1,251.00 $1,358.00 $1,455.00 $1,581.00 $1,358.00 $1,455.00 $1,581.0023500 90 $148.00 $262.00 $279.00 $299.00 $255.00 $272.00 $291.0023505 90 $293.00 $434.00 $465.00 $501.00 $410.00 $439.00 $474.0023515 90 $688.00 $888.00 $944.00 $1,015.00 $888.00 $944.00 $1,015.0023520 90 $205.00 $271.00 $290.00 $312.00 $270.00 $289.00 $311.0023525 90 $320.00 $426.00 $453.00 $484.00 $398.00 $423.00 $453.0023530 90 $659.00 $722.00 $773.00 $836.00 $722.00 $773.00 $836.0023532 90 $713.00 $814.00 $872.00 $946.00 $814.00 $872.00 $946.0023540 90 $148.00 $269.00 $286.00 $305.00 $258.00 $274.00 $293.0023545 90 $148.00 $382.00 $405.00 $430.00 $349.00 $370.00 $393.0023550 90 $701.00 $748.00 $801.00 $868.00 $748.00 $801.00 $868.0023552 90 $753.00 $864.00 $925.00 $1,002.00 $864.00 $925.00 $1,002.0023570 90 $88.00 $281.00 $300.00 $323.00 $281.00 $301.00 $323.0023575 90 $306.00 $477.00 $509.00 $546.00 $450.00 $480.00 $516.0023585 90 $809.00 $1,187.00 $1,255.00 $1,339.00 $1,187.00 $1,255.00 $1,339.0023600 90 $318.00 $394.00 $422.00 $453.00 $359.00 $384.00 $413.0023605 90 $511.00 $587.00 $629.00 $679.00 $541.00 $580.00 $627.0023615 90 $900.00 $1,120.00 $1,191.00 $1,280.00 $1,120.00 $1,191.00 $1,280.0023616 90 $1,895.00 $1,763.00 $1,900.00 $2,082.00 $1,763.00 $1,900.00 $2,082.0023620 90 $286.00 $323.00 $346.00 $372.00 $301.00 $322.00 $347.0023625 90 $422.00 $475.00 $508.00 $549.00 $445.00 $477.00 $515.0023630 90 $712.00 $938.00 $996.00 $1,066.00 $938.00 $996.00 $1,066.0023650 90 $296.00 $362.00 $382.00 $404.00 $325.00 $342.00 $362.0023655 90 $374.00 $481.00 $513.00 $552.00 $481.00 $513.00 $552.0023660 90 $712.00 $759.00 $813.00 $882.00 $759.00 $813.00 $882.0023665 90 $440.00 $524.00 $560.00 $603.00 $494.00 $528.00 $569.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

23670 90 $759.00 $1,046.00 $1,107.00 $1,182.00 $1,046.00 $1,107.00 $1,182.0023675 90 $550.00 $692.00 $741.00 $799.00 $642.00 $688.00 $744.0023680 90 $1,064.00 $1,158.00 $1,232.00 $1,325.00 $1,158.00 $1,232.00 $1,325.0023700 10 $237.00 $256.00 $275.00 $298.00 $256.00 $275.00 $298.0023800 90 $1,346.00 $1,354.00 $1,449.00 $1,570.00 $1,354.00 $1,449.00 $1,570.0023802 90 $1,368.00 $1,603.00 $1,710.00 $1,848.00 $1,603.00 $1,710.00 $1,848.0023900 90 $1,561.00 $1,772.00 $1,893.00 $2,051.00 $1,772.00 $1,893.00 $2,051.0023920 90 $1,300.00 $1,428.00 $1,525.00 $1,650.00 $1,428.00 $1,525.00 $1,650.0023921 90 $497.00 $574.00 $611.00 $656.00 $574.00 $611.00 $656.0023929 YYY BR ------- ------- ------- ------- ------- -------23930 10 $71.00 $456.00 $487.00 $520.00 $281.00 $299.00 $323.0023931 10 $62.00 $364.00 $389.00 $415.00 $205.00 $219.00 $236.0023935 90 $630.00 $653.00 $699.00 $757.00 $653.00 $699.00 $757.0024000 90 $550.00 $612.00 $655.00 $708.00 $612.00 $655.00 $708.0024006 90 $793.00 $929.00 $993.00 $1,073.00 $929.00 $993.00 $1,073.0024065 10 $166.00 $296.00 $313.00 $331.00 $204.00 $214.00 $226.0024066 90 $461.00 $741.00 $792.00 $848.00 $512.00 $546.00 $590.0024075 90 $349.00 $594.00 $634.00 $677.00 $397.00 $423.00 $455.0024076 90 $529.00 $610.00 $651.00 $702.00 $610.00 $651.00 $702.0024077 90 $1,058.00 $1,063.00 $1,133.00 $1,223.00 $1,063.00 $1,133.00 $1,223.0024100 90 $467.00 $517.00 $554.00 $600.00 $517.00 $554.00 $600.0024101 90 $591.00 $647.00 $692.00 $749.00 $647.00 $692.00 $749.0024102 90 $755.00 $805.00 $862.00 $933.00 $805.00 $862.00 $933.0024105 90 $360.00 $431.00 $462.00 $498.00 $431.00 $462.00 $498.0024110 90 $724.00 $760.00 $814.00 $883.00 $760.00 $814.00 $883.0024115 90 $898.00 $891.00 $955.00 $1,038.00 $891.00 $955.00 $1,038.0024116 90 $1,037.00 $1,151.00 $1,233.00 $1,339.00 $1,151.00 $1,233.00 $1,339.0024120 90 $595.00 $680.00 $728.00 $787.00 $680.00 $728.00 $787.0024125 90 $663.00 $764.00 $813.00 $873.00 $764.00 $813.00 $873.0024126 90 $731.00 $817.00 $870.00 $935.00 $817.00 $870.00 $935.0024130 90 $595.00 $658.00 $704.00 $761.00 $658.00 $704.00 $761.0024134 90 $966.00 $998.00 $1,068.00 $1,155.00 $998.00 $1,068.00 $1,155.0024136 90 $720.00 $824.00 $882.00 $955.00 $824.00 $882.00 $955.0024138 90 $697.00 $855.00 $914.00 $988.00 $855.00 $914.00 $988.0024140 90 $963.00 $954.00 $1,021.00 $1,103.00 $954.00 $1,021.00 $1,103.0024145 90 $592.00 $803.00 $859.00 $928.00 $803.00 $859.00 $928.0024147 90 $703.00 $836.00 $895.00 $968.00 $836.00 $895.00 $968.0024149 90 $1,224.00 $1,494.00 $1,593.00 $1,719.00 $1,494.00 $1,593.00 $1,719.0024150 90 $1,265.00 $1,290.00 $1,382.00 $1,501.00 $1,290.00 $1,382.00 $1,501.0024151 90 $1,383.00 $1,492.00 $1,595.00 $1,729.00 $1,492.00 $1,595.00 $1,729.0024152 90 $829.00 $946.00 $1,008.00 $1,087.00 $946.00 $1,008.00 $1,087.0024153 90 $936.00 $870.00 $908.00 $952.00 $870.00 $908.00 $952.0024155 90 $1,019.00 $1,110.00 $1,188.00 $1,287.00 $1,110.00 $1,188.00 $1,287.0024160 90 $533.00 $792.00 $847.00 $917.00 $792.00 $847.00 $917.0024164 90 $564.00 $646.00 $691.00 $748.00 $646.00 $691.00 $748.0024200 10 $58.00 $253.00 $270.00 $286.00 $174.00 $184.00 $197.0024201 90 $444.00 $714.00 $764.00 $818.00 $471.00 $503.00 $543.0024220 0 $89.00 $225.00 $238.00 $251.00 $90.00 $94.00 $98.0024300 90 $352.00 $505.00 $541.00 $582.00 $505.00 $541.00 $582.0024301 90 $869.00 $989.00 $1,057.00 $1,145.00 $989.00 $1,057.00 $1,145.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

24305 90 $579.00 $753.00 $804.00 $868.00 $753.00 $804.00 $868.0024310 90 $511.00 $617.00 $660.00 $713.00 $617.00 $660.00 $713.0024320 90 $944.00 $1,006.00 $1,076.00 $1,166.00 $1,006.00 $1,076.00 $1,166.0024330 90 $845.00 $944.00 $1,011.00 $1,095.00 $944.00 $1,011.00 $1,095.0024331 90 $927.00 $1,041.00 $1,114.00 $1,207.00 $1,041.00 $1,114.00 $1,207.0024332 90 $487.00 $780.00 $834.00 $901.00 $780.00 $834.00 $901.0024340 90 $697.00 $805.00 $863.00 $935.00 $805.00 $863.00 $935.0024341 90 $702.00 $928.00 $990.00 $1,066.00 $928.00 $990.00 $1,066.0024342 90 $950.00 $1,041.00 $1,116.00 $1,212.00 $1,041.00 $1,116.00 $1,212.0024343 90 $643.00 $914.00 $977.00 $1,056.00 $914.00 $977.00 $1,056.0024344 90 $971.00 $1,428.00 $1,526.00 $1,651.00 $1,428.00 $1,526.00 $1,651.0024345 90 $643.00 $910.00 $974.00 $1,052.00 $910.00 $974.00 $1,052.0024346 90 $971.00 $1,423.00 $1,520.00 $1,644.00 $1,423.00 $1,520.00 $1,644.0024357 90 ------- $576.00 $616.00 $666.00 $576.00 $616.00 $666.0024358 90 ------- $678.00 $726.00 $785.00 $678.00 $726.00 $785.0024359 90 ------- $838.00 $896.00 $969.00 $838.00 $896.00 $969.0024360 90 $1,125.00 $1,184.00 $1,268.00 $1,374.00 $1,184.00 $1,268.00 $1,374.0024361 90 $1,215.00 $1,327.00 $1,417.00 $1,532.00 $1,327.00 $1,417.00 $1,532.0024362 90 $1,269.00 $1,314.00 $1,409.00 $1,535.00 $1,314.00 $1,409.00 $1,535.0024363 90 $1,663.00 $1,942.00 $2,065.00 $2,222.00 $1,942.00 $2,065.00 $2,222.0024365 90 $747.00 $841.00 $900.00 $975.00 $841.00 $900.00 $975.0024366 90 $850.00 $902.00 $965.00 $1,045.00 $902.00 $965.00 $1,045.0024400 90 $991.00 $1,087.00 $1,165.00 $1,265.00 $1,087.00 $1,165.00 $1,265.0024410 90 $1,319.00 $1,396.00 $1,496.00 $1,626.00 $1,396.00 $1,496.00 $1,626.0024420 90 $1,265.00 $1,287.00 $1,376.00 $1,490.00 $1,287.00 $1,376.00 $1,490.0024430 90 $1,209.00 $1,358.00 $1,448.00 $1,563.00 $1,358.00 $1,448.00 $1,563.0024435 90 $1,260.00 $1,390.00 $1,485.00 $1,605.00 $1,390.00 $1,485.00 $1,605.0024470 90 $774.00 $866.00 $927.00 $1,005.00 $866.00 $927.00 $1,005.0024495 90 $742.00 $862.00 $919.00 $988.00 $862.00 $919.00 $988.0024498 90 $1,076.00 $1,159.00 $1,241.00 $1,348.00 $1,159.00 $1,241.00 $1,348.0024500 90 $288.00 $427.00 $456.00 $489.00 $382.00 $408.00 $438.0024505 90 $574.00 $628.00 $673.00 $726.00 $574.00 $615.00 $665.0024515 90 $1,018.00 $1,159.00 $1,242.00 $1,347.00 $1,159.00 $1,242.00 $1,347.0024516 90 $1,029.00 $1,147.00 $1,228.00 $1,333.00 $1,147.00 $1,228.00 $1,333.0024530 90 $88.00 $461.00 $493.00 $530.00 $414.00 $442.00 $477.0024535 90 $671.00 $787.00 $843.00 $911.00 $732.00 $785.00 $849.0024538 90 $850.00 $980.00 $1,050.00 $1,137.00 $980.00 $1,050.00 $1,137.0024545 90 $946.00 $1,173.00 $1,250.00 $1,346.00 $1,173.00 $1,250.00 $1,346.0024546 90 $1,273.00 $1,420.00 $1,526.00 $1,664.00 $1,420.00 $1,526.00 $1,664.0024560 90 $266.00 $385.00 $411.00 $441.00 $335.00 $358.00 $385.0024565 90 $526.00 $653.00 $699.00 $754.00 $603.00 $646.00 $698.0024566 90 $705.00 $893.00 $953.00 $1,026.00 $893.00 $953.00 $1,026.0024575 90 $872.00 $980.00 $1,055.00 $1,151.00 $980.00 $1,055.00 $1,151.0024576 90 $295.00 $404.00 $432.00 $464.00 $360.00 $385.00 $414.0024577 90 $575.00 $675.00 $723.00 $779.00 $624.00 $668.00 $721.0024579 90 $964.00 $1,104.00 $1,185.00 $1,290.00 $1,104.00 $1,185.00 $1,290.0024582 90 $773.00 $1,014.00 $1,083.00 $1,166.00 $1,014.00 $1,083.00 $1,166.0024586 90 $1,314.00 $1,458.00 $1,562.00 $1,697.00 $1,458.00 $1,562.00 $1,697.0024587 90 $1,278.00 $1,444.00 $1,544.00 $1,674.00 $1,444.00 $1,544.00 $1,674.0024600 90 $360.00 $459.00 $487.00 $519.00 $410.00 $435.00 $465.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

24605 90 $371.00 $586.00 $627.00 $677.00 $586.00 $627.00 $677.0024615 90 $836.00 $943.00 $1,009.00 $1,093.00 $943.00 $1,009.00 $1,093.0024620 90 $560.00 $710.00 $759.00 $818.00 $710.00 $759.00 $818.0024635 90 $1,329.00 $1,103.00 $1,198.00 $1,318.00 $1,103.00 $1,198.00 $1,318.0024650 90 $262.00 $312.00 $333.00 $358.00 $275.00 $294.00 $316.0024655 90 $436.00 $544.00 $582.00 $626.00 $496.00 $530.00 $571.0024665 90 $749.00 $848.00 $909.00 $985.00 $848.00 $909.00 $985.0024666 90 $905.00 $961.00 $1,029.00 $1,115.00 $961.00 $1,029.00 $1,115.0024670 90 $263.00 $351.00 $375.00 $403.00 $310.00 $332.00 $357.0024675 90 $490.00 $574.00 $615.00 $663.00 $528.00 $565.00 $611.0024685 90 $819.00 $857.00 $921.00 $1,001.00 $857.00 $921.00 $1,001.0024800 90 $984.00 $1,049.00 $1,118.00 $1,205.00 $1,049.00 $1,118.00 $1,205.0024802 90 $1,181.00 $1,315.00 $1,408.00 $1,529.00 $1,315.00 $1,408.00 $1,529.0024900 90 $858.00 $930.00 $993.00 $1,072.00 $930.00 $993.00 $1,072.0024920 90 $851.00 $922.00 $986.00 $1,069.00 $922.00 $986.00 $1,069.0024925 90 $661.00 $704.00 $752.00 $814.00 $704.00 $752.00 $814.0024930 90 $928.00 $972.00 $1,039.00 $1,125.00 $972.00 $1,039.00 $1,125.0024931 90 $1,063.00 $1,046.00 $1,114.00 $1,204.00 $1,046.00 $1,114.00 $1,204.0024935 90 $1,327.00 $1,397.00 $1,485.00 $1,596.00 $1,397.00 $1,485.00 $1,596.0024940 90 BR ------- ------- ------- ------- ------- -------24999 YYY BR ------- ------- ------- ------- ------- -------25000 90 $381.00 $477.00 $510.00 $547.00 $477.00 $510.00 $547.0025001 90 $294.00 $421.00 $449.00 $483.00 $421.00 $449.00 $483.0025020 90 $594.00 $767.00 $820.00 $881.00 $767.00 $820.00 $881.0025023 90 $1,040.00 $1,462.00 $1,560.00 $1,679.00 $1,462.00 $1,560.00 $1,679.0025024 90 $683.00 $970.00 $1,031.00 $1,106.00 $970.00 $1,031.00 $1,106.0025025 90 $1,104.00 $1,471.00 $1,553.00 $1,654.00 $1,471.00 $1,553.00 $1,654.0025028 90 $417.00 $672.00 $718.00 $771.00 $672.00 $718.00 $771.0025031 90 $266.00 $532.00 $568.00 $609.00 $532.00 $568.00 $609.0025035 90 $794.00 $933.00 $998.00 $1,075.00 $933.00 $998.00 $1,075.0025040 90 $654.00 $757.00 $809.00 $873.00 $757.00 $809.00 $873.0025065 10 $164.00 $295.00 $312.00 $329.00 $203.00 $214.00 $226.0025066 90 $322.00 $519.00 $555.00 $596.00 $519.00 $555.00 $596.0025075 90 $352.00 $451.00 $481.00 $517.00 $451.00 $481.00 $517.0025076 90 $544.00 $634.00 $677.00 $726.00 $634.00 $677.00 $726.0025077 90 $957.00 $1,034.00 $1,103.00 $1,186.00 $1,034.00 $1,103.00 $1,186.0025085 90 $562.00 $622.00 $664.00 $715.00 $622.00 $664.00 $715.0025100 90 $420.00 $458.00 $489.00 $526.00 $458.00 $489.00 $526.0025101 90 $492.00 $538.00 $575.00 $620.00 $538.00 $575.00 $620.0025105 90 $635.00 $657.00 $702.00 $757.00 $657.00 $702.00 $757.0025107 90 $600.00 $795.00 $846.00 $906.00 $795.00 $846.00 $906.0025109 90 ------- $658.00 $701.00 $754.00 $658.00 $701.00 $754.0025110 90 $403.00 $502.00 $537.00 $577.00 $502.00 $537.00 $577.0025111 90 $356.00 $411.00 $440.00 $473.00 $411.00 $440.00 $473.0025112 90 $441.00 $504.00 $538.00 $579.00 $504.00 $538.00 $579.0025115 90 $837.00 $1,103.00 $1,174.00 $1,257.00 $1,103.00 $1,174.00 $1,257.0025116 90 $807.00 $918.00 $981.00 $1,053.00 $918.00 $981.00 $1,053.0025118 90 $466.00 $509.00 $544.00 $585.00 $509.00 $544.00 $585.0025119 90 $653.00 $679.00 $726.00 $782.00 $679.00 $726.00 $782.0025120 90 $712.00 $798.00 $854.00 $919.00 $798.00 $854.00 $919.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

25125 90 $803.00 $902.00 $962.00 $1,031.00 $902.00 $962.00 $1,031.0025126 90 $781.00 $930.00 $996.00 $1,074.00 $930.00 $996.00 $1,074.0025130 90 $502.00 $592.00 $632.00 $680.00 $592.00 $632.00 $680.0025135 90 $631.00 $736.00 $785.00 $845.00 $736.00 $785.00 $845.0025136 90 $546.00 $657.00 $704.00 $762.00 $657.00 $704.00 $762.0025145 90 $713.00 $814.00 $870.00 $935.00 $814.00 $870.00 $935.0025150 90 $720.00 $775.00 $828.00 $893.00 $775.00 $828.00 $893.0025151 90 $771.00 $909.00 $971.00 $1,045.00 $909.00 $971.00 $1,045.0025170 90 $1,085.00 $1,237.00 $1,322.00 $1,425.00 $1,237.00 $1,322.00 $1,425.0025210 90 $561.00 $648.00 $691.00 $743.00 $648.00 $691.00 $743.0025215 90 $817.00 $841.00 $897.00 $966.00 $841.00 $897.00 $966.0025230 90 $531.00 $576.00 $616.00 $662.00 $576.00 $616.00 $662.0025240 90 $567.00 $595.00 $636.00 $684.00 $595.00 $636.00 $684.0025246 0 $72.00 $230.00 $243.00 $256.00 $100.00 $104.00 $109.0025248 90 $236.00 $616.00 $656.00 $703.00 $616.00 $656.00 $703.0025250 90 $616.00 $677.00 $723.00 $779.00 $677.00 $723.00 $779.0025251 90 $933.00 $922.00 $980.00 $1,051.00 $922.00 $980.00 $1,051.0025259 90 $348.00 $502.00 $537.00 $578.00 $502.00 $537.00 $578.0025260 90 $728.00 $957.00 $1,023.00 $1,098.00 $957.00 $1,023.00 $1,098.0025263 90 $809.00 $948.00 $1,013.00 $1,088.00 $948.00 $1,013.00 $1,088.0025265 90 $998.00 $1,119.00 $1,195.00 $1,284.00 $1,119.00 $1,195.00 $1,284.0025270 90 $549.00 $785.00 $839.00 $902.00 $785.00 $839.00 $902.0025272 90 $613.00 $878.00 $939.00 $1,009.00 $878.00 $939.00 $1,009.0025274 90 $887.00 $1,022.00 $1,092.00 $1,175.00 $1,022.00 $1,092.00 $1,175.0025275 90 $620.00 $870.00 $928.00 $1,000.00 $870.00 $928.00 $1,000.0025280 90 $670.00 $882.00 $942.00 $1,011.00 $882.00 $942.00 $1,011.0025290 90 $436.00 $803.00 $858.00 $919.00 $803.00 $858.00 $919.0025295 90 $562.00 $826.00 $882.00 $947.00 $826.00 $882.00 $947.0025300 90 $592.00 $895.00 $954.00 $1,025.00 $895.00 $954.00 $1,025.0025301 90 $757.00 $856.00 $915.00 $986.00 $856.00 $915.00 $986.0025310 90 $865.00 $958.00 $1,022.00 $1,098.00 $958.00 $1,022.00 $1,098.0025312 90 $968.00 $1,083.00 $1,156.00 $1,242.00 $1,083.00 $1,156.00 $1,242.0025315 90 $1,004.00 $1,159.00 $1,237.00 $1,331.00 $1,159.00 $1,237.00 $1,331.0025316 90 $1,203.00 $1,339.00 $1,427.00 $1,531.00 $1,339.00 $1,427.00 $1,531.0025320 90 $834.00 $1,240.00 $1,319.00 $1,414.00 $1,240.00 $1,319.00 $1,414.0025332 90 $1,022.00 $1,110.00 $1,187.00 $1,284.00 $1,110.00 $1,187.00 $1,284.0025335 90 $1,166.00 $1,273.00 $1,357.00 $1,462.00 $1,273.00 $1,357.00 $1,462.0025337 90 $946.00 $1,157.00 $1,233.00 $1,326.00 $1,157.00 $1,233.00 $1,326.0025350 90 $913.00 $1,045.00 $1,119.00 $1,206.00 $1,045.00 $1,119.00 $1,206.0025355 90 $1,014.00 $1,161.00 $1,243.00 $1,343.00 $1,161.00 $1,243.00 $1,343.0025360 90 $468.00 $1,019.00 $1,091.00 $1,176.00 $1,019.00 $1,091.00 $1,176.0025365 90 $1,216.00 $1,367.00 $1,464.00 $1,584.00 $1,367.00 $1,464.00 $1,584.0025370 90 $1,214.00 $1,463.00 $1,566.00 $1,693.00 $1,463.00 $1,566.00 $1,693.0025375 90 $1,280.00 $1,429.00 $1,531.00 $1,657.00 $1,429.00 $1,531.00 $1,657.0025390 90 $1,043.00 $1,169.00 $1,250.00 $1,346.00 $1,169.00 $1,250.00 $1,346.0025391 90 $1,349.00 $1,471.00 $1,572.00 $1,696.00 $1,471.00 $1,572.00 $1,696.0025392 90 $1,294.00 $1,467.00 $1,565.00 $1,685.00 $1,467.00 $1,565.00 $1,685.0025393 90 $1,473.00 $1,669.00 $1,788.00 $1,937.00 $1,669.00 $1,788.00 $1,937.0025394 90 $723.00 $1,004.00 $1,071.00 $1,156.00 $1,004.00 $1,071.00 $1,156.0025400 90 $1,112.00 $1,231.00 $1,317.00 $1,422.00 $1,231.00 $1,317.00 $1,422.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

25405 90 $1,388.00 $1,538.00 $1,644.00 $1,774.00 $1,538.00 $1,644.00 $1,774.0025415 90 $1,343.00 $1,447.00 $1,548.00 $1,671.00 $1,447.00 $1,548.00 $1,671.0025420 90 $1,554.00 $1,706.00 $1,823.00 $1,967.00 $1,706.00 $1,823.00 $1,967.0025425 90 $1,403.00 $1,550.00 $1,657.00 $1,783.00 $1,550.00 $1,657.00 $1,783.0025426 90 $1,401.00 $1,612.00 $1,722.00 $1,861.00 $1,612.00 $1,722.00 $1,861.0025430 90 $638.00 $910.00 $967.00 $1,039.00 $910.00 $967.00 $1,039.0025431 90 $631.00 $1,045.00 $1,122.00 $1,220.00 $1,045.00 $1,122.00 $1,220.0025440 90 $931.00 $1,033.00 $1,103.00 $1,191.00 $1,033.00 $1,103.00 $1,191.0025441 90 $1,147.00 $1,235.00 $1,320.00 $1,429.00 $1,235.00 $1,320.00 $1,429.0025442 90 $936.00 $1,047.00 $1,115.00 $1,199.00 $1,047.00 $1,115.00 $1,199.0025443 90 $970.00 $1,002.00 $1,066.00 $1,143.00 $1,002.00 $1,066.00 $1,143.0025444 90 $1,031.00 $1,078.00 $1,151.00 $1,243.00 $1,078.00 $1,151.00 $1,243.0025445 90 $959.00 $948.00 $1,014.00 $1,096.00 $948.00 $1,014.00 $1,096.0025446 90 $1,542.00 $1,550.00 $1,652.00 $1,782.00 $1,550.00 $1,652.00 $1,782.0025447 90 $952.00 $1,055.00 $1,125.00 $1,213.00 $1,055.00 $1,125.00 $1,213.0025449 90 $395.00 $1,362.00 $1,453.00 $1,569.00 $1,362.00 $1,453.00 $1,569.0025450 90 $805.00 $831.00 $891.00 $965.00 $831.00 $891.00 $965.0025455 90 $899.00 $968.00 $1,024.00 $1,088.00 $968.00 $1,024.00 $1,088.0025490 90 $955.00 $1,072.00 $1,145.00 $1,231.00 $1,072.00 $1,145.00 $1,231.0025491 90 $1,006.00 $1,129.00 $1,208.00 $1,302.00 $1,129.00 $1,208.00 $1,302.0025492 90 $1,170.00 $1,349.00 $1,446.00 $1,565.00 $1,349.00 $1,446.00 $1,565.0025500 90 $200.00 $318.00 $339.00 $363.00 $285.00 $304.00 $326.0025505 90 $517.00 $630.00 $675.00 $728.00 $580.00 $622.00 $672.0025515 90 $800.00 $880.00 $946.00 $1,029.00 $880.00 $946.00 $1,029.0025520 90 $644.00 $698.00 $747.00 $808.00 $664.00 $711.00 $770.0025525 90 $1,097.00 $1,091.00 $1,176.00 $1,286.00 $1,091.00 $1,176.00 $1,286.0025526 90 $1,293.00 $1,338.00 $1,433.00 $1,552.00 $1,338.00 $1,433.00 $1,552.0025530 90 $270.00 $309.00 $330.00 $354.00 $274.00 $293.00 $315.0025535 90 $516.00 $605.00 $648.00 $701.00 $569.00 $610.00 $660.0025545 90 $803.00 $834.00 $898.00 $978.00 $834.00 $898.00 $978.0025560 90 $276.00 $321.00 $343.00 $367.00 $281.00 $300.00 $322.0025565 90 $590.00 $657.00 $703.00 $759.00 $601.00 $643.00 $695.0025574 90 $804.00 $846.00 $901.00 $969.00 $846.00 $901.00 $969.0025575 90 $974.00 $1,160.00 $1,238.00 $1,336.00 $1,160.00 $1,238.00 $1,336.0025600 90 $312.00 $354.00 $379.00 $407.00 $313.00 $335.00 $360.0025605 90 $540.00 $761.00 $812.00 $872.00 $718.00 $765.00 $823.0025606 90 ------- $871.00 $931.00 $1,004.00 $871.00 $931.00 $1,004.0025607 90 ------- $907.00 $967.00 $1,041.00 $907.00 $967.00 $1,041.0025608 90 ------- $1,046.00 $1,120.00 $1,215.00 $1,046.00 $1,120.00 $1,215.0025609 90 ------- $1,334.00 $1,429.00 $1,551.00 $1,334.00 $1,429.00 $1,551.0025622 90 $148.00 $363.00 $388.00 $416.00 $320.00 $342.00 $367.0025624 90 $482.00 $576.00 $616.00 $664.00 $523.00 $560.00 $604.0025628 90 $716.00 $922.00 $983.00 $1,058.00 $922.00 $983.00 $1,058.0025630 90 $148.00 $372.00 $398.00 $427.00 $329.00 $351.00 $378.0025635 90 $458.00 $545.00 $584.00 $629.00 $475.00 $508.00 $549.0025645 90 $668.00 $743.00 $796.00 $861.00 $743.00 $796.00 $861.0025650 90 $185.00 $386.00 $412.00 $442.00 $348.00 $371.00 $398.0025651 90 $379.00 $601.00 $642.00 $691.00 $601.00 $642.00 $691.0025652 90 $560.00 $796.00 $851.00 $918.00 $796.00 $851.00 $918.0025660 90 $378.00 $499.00 $530.00 $566.00 $499.00 $530.00 $566.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

25670 90 $731.00 $797.00 $852.00 $921.00 $797.00 $852.00 $921.0025671 90 $462.00 $669.00 $715.00 $771.00 $669.00 $715.00 $771.0025675 90 $404.00 $531.00 $566.00 $605.00 $488.00 $519.00 $556.0025676 90 $741.00 $826.00 $884.00 $956.00 $826.00 $884.00 $956.0025680 90 $471.00 $575.00 $611.00 $655.00 $575.00 $611.00 $655.0025685 90 $887.00 $955.00 $1,022.00 $1,106.00 $955.00 $1,022.00 $1,106.0025690 90 $518.00 $590.00 $631.00 $681.00 $590.00 $631.00 $681.0025695 90 $520.00 $827.00 $884.00 $955.00 $827.00 $884.00 $955.0025800 90 $703.00 $989.00 $1,057.00 $1,142.00 $989.00 $1,057.00 $1,142.0025805 90 $1,078.00 $1,136.00 $1,214.00 $1,312.00 $1,136.00 $1,214.00 $1,312.0025810 90 $1,008.00 $1,134.00 $1,209.00 $1,301.00 $1,134.00 $1,209.00 $1,301.0025820 90 $2,276.00 $806.00 $863.00 $931.00 $806.00 $863.00 $931.0025825 90 $895.00 $982.00 $1,048.00 $1,128.00 $982.00 $1,048.00 $1,128.0025830 90 $991.00 $1,249.00 $1,333.00 $1,431.00 $1,249.00 $1,333.00 $1,431.0025900 90 $871.00 $1,030.00 $1,098.00 $1,177.00 $1,030.00 $1,098.00 $1,177.0025905 90 $900.00 $1,016.00 $1,084.00 $1,166.00 $1,016.00 $1,084.00 $1,166.0025907 90 $799.00 $900.00 $960.00 $1,029.00 $900.00 $960.00 $1,029.0025909 90 $849.00 $1,011.00 $1,081.00 $1,165.00 $1,011.00 $1,081.00 $1,165.0025915 90 $1,523.00 $1,670.00 $1,789.00 $1,941.00 $1,670.00 $1,789.00 $1,941.0025920 90 $771.00 $886.00 $947.00 $1,021.00 $886.00 $947.00 $1,021.0025922 90 $670.00 $776.00 $828.00 $892.00 $776.00 $828.00 $892.0025924 90 $768.00 $868.00 $927.00 $1,000.00 $868.00 $927.00 $1,000.0025927 90 $830.00 $1,031.00 $1,099.00 $1,179.00 $1,031.00 $1,099.00 $1,179.0025929 90 $645.00 $741.00 $790.00 $852.00 $741.00 $790.00 $852.0025931 90 $731.00 $958.00 $1,023.00 $1,097.00 $958.00 $1,023.00 $1,097.0025999 YYY BR ------- ------- ------- ------- ------- -------26010 10 $59.00 $328.00 $349.00 $371.00 $166.00 $176.00 $188.0026011 10 $223.00 $507.00 $542.00 $577.00 $237.00 $253.00 $272.0026020 90 $484.00 $544.00 $580.00 $624.00 $544.00 $580.00 $624.0026025 90 $548.00 $534.00 $570.00 $614.00 $534.00 $570.00 $614.0026030 90 $655.00 $630.00 $672.00 $724.00 $630.00 $672.00 $724.0026034 90 $601.00 $683.00 $730.00 $788.00 $683.00 $730.00 $788.0026035 90 $741.00 $1,040.00 $1,105.00 $1,187.00 $1,040.00 $1,105.00 $1,187.0026037 90 $730.00 $736.00 $786.00 $848.00 $736.00 $786.00 $848.0026040 90 $367.00 $392.00 $419.00 $452.00 $392.00 $419.00 $452.0026045 90 $621.00 $601.00 $644.00 $696.00 $601.00 $644.00 $696.0026055 90 $343.00 $759.00 $812.00 $863.00 $369.00 $394.00 $422.0026060 90 $293.00 $333.00 $357.00 $384.00 $333.00 $357.00 $384.0026070 90 $440.00 $373.00 $397.00 $425.00 $373.00 $397.00 $425.0026075 90 $400.00 $401.00 $427.00 $458.00 $401.00 $427.00 $458.0026080 90 $382.00 $486.00 $520.00 $559.00 $486.00 $520.00 $559.0026100 90 $398.00 $412.00 $440.00 $472.00 $412.00 $440.00 $472.0026105 90 $481.00 $421.00 $450.00 $485.00 $421.00 $450.00 $485.0026110 90 $282.00 $401.00 $428.00 $460.00 $401.00 $428.00 $460.0026115 90 $344.00 $804.00 $860.00 $917.00 $456.00 $487.00 $523.0026116 90 $544.00 $613.00 $654.00 $704.00 $613.00 $654.00 $704.0026117 90 $806.00 $836.00 $892.00 $961.00 $836.00 $892.00 $961.0026121 90 $833.00 $772.00 $825.00 $890.00 $772.00 $825.00 $890.0026123 90 $959.00 $1,039.00 $1,106.00 $1,187.00 $1,039.00 $1,106.00 $1,187.0026125 ZZZ $342.00 $379.00 $405.00 $439.00 $379.00 $405.00 $439.00

CPT only © 2008 American Medical Association. All rights reserved. Part B, 158

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

26130 90 $629.00 $588.00 $630.00 $682.00 $588.00 $630.00 $682.0026135 90 $668.00 $713.00 $761.00 $821.00 $713.00 $761.00 $821.0026140 90 $678.00 $646.00 $689.00 $742.00 $646.00 $689.00 $742.0026145 90 $660.00 $657.00 $702.00 $757.00 $657.00 $702.00 $757.0026160 90 $319.00 $737.00 $787.00 $838.00 $403.00 $430.00 $461.0026170 90 $452.00 $514.00 $548.00 $589.00 $514.00 $548.00 $589.0026180 90 $444.00 $561.00 $598.00 $644.00 $561.00 $598.00 $644.0026185 90 $511.00 $656.00 $697.00 $746.00 $656.00 $697.00 $746.0026200 90 $598.00 $579.00 $619.00 $668.00 $579.00 $619.00 $668.0026205 90 $788.00 $781.00 $834.00 $900.00 $781.00 $834.00 $900.0026210 90 $543.00 $561.00 $599.00 $645.00 $561.00 $599.00 $645.0026215 90 $731.00 $711.00 $757.00 $813.00 $711.00 $757.00 $813.0026230 90 $624.00 $651.00 $696.00 $752.00 $651.00 $696.00 $752.0026235 90 $612.00 $637.00 $680.00 $733.00 $637.00 $680.00 $733.0026236 90 $444.00 $564.00 $602.00 $648.00 $564.00 $602.00 $648.0026250 90 $814.00 $746.00 $795.00 $855.00 $746.00 $795.00 $855.0026255 90 $1,184.00 $1,176.00 $1,251.00 $1,343.00 $1,176.00 $1,251.00 $1,343.0026260 90 $758.00 $704.00 $751.00 $808.00 $704.00 $751.00 $808.0026261 90 $949.00 $848.00 $900.00 $964.00 $848.00 $900.00 $964.0026262 90 $624.00 $590.00 $631.00 $680.00 $590.00 $631.00 $680.0026320 90 $414.00 $438.00 $467.00 $502.00 $438.00 $467.00 $502.0026340 90 $266.00 $391.00 $418.00 $447.00 $391.00 $418.00 $447.0026350 90 $715.00 $963.00 $1,029.00 $1,101.00 $963.00 $1,029.00 $1,101.0026352 90 $855.00 $1,089.00 $1,163.00 $1,245.00 $1,089.00 $1,163.00 $1,245.0026356 90 $886.00 $1,378.00 $1,466.00 $1,561.00 $1,378.00 $1,466.00 $1,561.0026357 90 $932.00 $1,161.00 $1,242.00 $1,332.00 $1,161.00 $1,242.00 $1,332.0026358 90 $979.00 $1,233.00 $1,317.00 $1,412.00 $1,233.00 $1,317.00 $1,412.0026370 90 $832.00 $1,040.00 $1,113.00 $1,193.00 $1,040.00 $1,113.00 $1,193.0026372 90 $945.00 $1,205.00 $1,289.00 $1,384.00 $1,205.00 $1,289.00 $1,384.0026373 90 $904.00 $1,142.00 $1,220.00 $1,307.00 $1,142.00 $1,220.00 $1,307.0026390 90 $889.00 $1,110.00 $1,186.00 $1,274.00 $1,110.00 $1,186.00 $1,274.0026392 90 $1,123.00 $1,309.00 $1,399.00 $1,501.00 $1,309.00 $1,399.00 $1,501.0026410 90 $371.00 $767.00 $820.00 $878.00 $767.00 $820.00 $878.0026412 90 $737.00 $923.00 $987.00 $1,057.00 $923.00 $987.00 $1,057.0026415 90 $846.00 $954.00 $1,013.00 $1,080.00 $954.00 $1,013.00 $1,080.0026416 90 $1,093.00 $1,097.00 $1,159.00 $1,225.00 $1,097.00 $1,159.00 $1,225.0026418 90 $444.00 $768.00 $822.00 $878.00 $768.00 $822.00 $878.0026420 90 $741.00 $966.00 $1,033.00 $1,108.00 $966.00 $1,033.00 $1,108.0026426 90 $733.00 $824.00 $881.00 $945.00 $824.00 $881.00 $945.0026428 90 $790.00 $1,006.00 $1,075.00 $1,152.00 $1,006.00 $1,075.00 $1,152.0026432 90 $430.00 $668.00 $715.00 $765.00 $668.00 $715.00 $765.0026433 90 $371.00 $719.00 $769.00 $823.00 $719.00 $769.00 $823.0026434 90 $656.00 $849.00 $908.00 $973.00 $849.00 $908.00 $973.0026437 90 $491.00 $831.00 $888.00 $952.00 $831.00 $888.00 $952.0026440 90 $458.00 $845.00 $904.00 $965.00 $845.00 $904.00 $965.0026442 90 $548.00 $1,236.00 $1,316.00 $1,404.00 $1,236.00 $1,316.00 $1,404.0026445 90 $455.00 $790.00 $845.00 $902.00 $790.00 $845.00 $902.0026449 90 $738.00 $1,052.00 $1,120.00 $1,195.00 $1,052.00 $1,120.00 $1,195.0026450 90 $353.00 $534.00 $571.00 $613.00 $534.00 $571.00 $613.0026455 90 $364.00 $530.00 $567.00 $608.00 $530.00 $567.00 $608.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

26460 90 $346.00 $514.00 $550.00 $590.00 $514.00 $550.00 $590.0026471 90 $592.00 $817.00 $874.00 $936.00 $817.00 $874.00 $936.0026474 90 $586.00 $788.00 $841.00 $899.00 $788.00 $841.00 $899.0026476 90 $543.00 $766.00 $818.00 $876.00 $766.00 $818.00 $876.0026477 90 $553.00 $775.00 $829.00 $888.00 $775.00 $829.00 $888.0026478 90 $608.00 $837.00 $895.00 $959.00 $837.00 $895.00 $959.0026479 90 $653.00 $828.00 $885.00 $950.00 $828.00 $885.00 $950.0026480 90 $808.00 $1,016.00 $1,086.00 $1,162.00 $1,016.00 $1,086.00 $1,162.0026483 90 $986.00 $1,136.00 $1,213.00 $1,301.00 $1,136.00 $1,213.00 $1,301.0026485 90 $891.00 $1,092.00 $1,167.00 $1,249.00 $1,092.00 $1,167.00 $1,249.0026489 90 $738.00 $1,130.00 $1,203.00 $1,286.00 $1,130.00 $1,203.00 $1,286.0026490 90 $496.00 $1,037.00 $1,106.00 $1,186.00 $1,037.00 $1,106.00 $1,186.0026492 90 $971.00 $1,152.00 $1,229.00 $1,319.00 $1,152.00 $1,229.00 $1,319.0026494 90 $946.00 $1,058.00 $1,130.00 $1,213.00 $1,058.00 $1,130.00 $1,213.0026496 90 $949.00 $1,139.00 $1,217.00 $1,307.00 $1,139.00 $1,217.00 $1,307.0026497 90 $946.00 $1,142.00 $1,219.00 $1,309.00 $1,142.00 $1,219.00 $1,309.0026498 90 $1,317.00 $1,524.00 $1,627.00 $1,751.00 $1,524.00 $1,627.00 $1,751.0026499 90 $934.00 $1,079.00 $1,153.00 $1,238.00 $1,079.00 $1,153.00 $1,238.0026500 90 $557.00 $834.00 $891.00 $954.00 $834.00 $891.00 $954.0026502 90 $715.00 $936.00 $1,001.00 $1,076.00 $936.00 $1,001.00 $1,076.0026508 90 $334.00 $850.00 $909.00 $977.00 $850.00 $909.00 $977.0026510 90 $564.00 $794.00 $848.00 $907.00 $794.00 $848.00 $907.0026516 90 $630.00 $940.00 $1,004.00 $1,078.00 $940.00 $1,004.00 $1,078.0026517 90 $890.00 $1,095.00 $1,171.00 $1,260.00 $1,095.00 $1,171.00 $1,260.0026518 90 $877.00 $1,096.00 $1,170.00 $1,256.00 $1,096.00 $1,170.00 $1,256.0026520 90 $583.00 $884.00 $945.00 $1,010.00 $884.00 $945.00 $1,010.0026525 90 $531.00 $889.00 $951.00 $1,016.00 $889.00 $951.00 $1,016.0026530 90 $708.00 $689.00 $736.00 $794.00 $689.00 $736.00 $794.0026531 90 $877.00 $801.00 $854.00 $920.00 $801.00 $854.00 $920.0026535 90 $546.00 $501.00 $533.00 $573.00 $501.00 $533.00 $573.0026536 90 $770.00 $851.00 $909.00 $974.00 $851.00 $909.00 $974.0026540 90 $726.00 $882.00 $942.00 $1,011.00 $882.00 $942.00 $1,011.0026541 90 $926.00 $1,072.00 $1,145.00 $1,228.00 $1,072.00 $1,145.00 $1,228.0026542 90 $716.00 $908.00 $970.00 $1,039.00 $908.00 $970.00 $1,039.0026545 90 $722.00 $926.00 $990.00 $1,061.00 $926.00 $990.00 $1,061.0026546 90 $918.00 $1,270.00 $1,354.00 $1,449.00 $1,270.00 $1,354.00 $1,449.0026548 90 $665.00 $1,017.00 $1,086.00 $1,165.00 $1,017.00 $1,086.00 $1,165.0026550 90 $1,861.00 $2,010.00 $2,130.00 $2,274.00 $2,010.00 $2,130.00 $2,274.0026551 90 $3,901.00 $4,138.00 $4,429.00 $4,816.00 $4,138.00 $4,429.00 $4,816.0026553 90 $3,868.00 $3,693.00 $3,844.00 $4,013.00 $3,693.00 $3,844.00 $4,013.0026554 90 $4,551.00 $5,247.00 $5,617.00 $6,096.00 $5,247.00 $5,617.00 $6,096.0026555 90 $1,567.00 $1,798.00 $1,918.00 $2,064.00 $1,798.00 $1,918.00 $2,064.0026556 90 $4,005.00 $3,810.00 $3,967.00 $4,144.00 $3,810.00 $3,967.00 $4,144.0026560 90 $576.00 $734.00 $785.00 $842.00 $734.00 $785.00 $842.0026561 90 $1,067.00 $1,177.00 $1,253.00 $1,342.00 $1,177.00 $1,253.00 $1,342.0026562 90 $1,017.00 $1,595.00 $1,698.00 $1,825.00 $1,595.00 $1,698.00 $1,825.0026565 90 $730.00 $902.00 $964.00 $1,033.00 $902.00 $964.00 $1,033.0026567 90 $622.00 $907.00 $970.00 $1,040.00 $907.00 $970.00 $1,040.0026568 90 $1,003.00 $1,201.00 $1,286.00 $1,383.00 $1,201.00 $1,286.00 $1,383.0026580 90 $1,585.00 $1,682.00 $1,782.00 $1,906.00 $1,682.00 $1,782.00 $1,906.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

26587 90 $792.00 $1,227.00 $1,296.00 $1,382.00 $1,227.00 $1,296.00 $1,382.0026590 90 $1,609.00 $1,749.00 $1,867.00 $2,015.00 $1,749.00 $1,867.00 $2,015.0026591 90 $431.00 $589.00 $629.00 $672.00 $589.00 $629.00 $672.0026593 90 $587.00 $788.00 $841.00 $900.00 $788.00 $841.00 $900.0026596 90 $809.00 $945.00 $1,010.00 $1,090.00 $945.00 $1,010.00 $1,090.0026600 90 $133.00 $326.00 $347.00 $370.00 $293.00 $312.00 $333.0026605 90 $296.00 $392.00 $420.00 $452.00 $355.00 $380.00 $410.0026607 90 $334.00 $602.00 $644.00 $694.00 $602.00 $644.00 $694.0026608 90 $497.00 $612.00 $654.00 $706.00 $612.00 $654.00 $706.0026615 90 $521.00 $675.00 $717.00 $768.00 $675.00 $717.00 $768.0026641 90 $71.00 $434.00 $459.00 $487.00 $393.00 $415.00 $440.0026645 90 $371.00 $508.00 $542.00 $583.00 $466.00 $498.00 $536.0026650 90 $533.00 $608.00 $652.00 $706.00 $608.00 $652.00 $706.0026665 90 $693.00 $760.00 $806.00 $860.00 $760.00 $806.00 $860.0026670 90 $148.00 $403.00 $427.00 $454.00 $356.00 $376.00 $400.0026675 90 $501.00 $551.00 $589.00 $636.00 $507.00 $542.00 $586.0026676 90 $527.00 $641.00 $686.00 $740.00 $641.00 $686.00 $740.0026685 90 $592.00 $714.00 $763.00 $823.00 $714.00 $763.00 $823.0026686 90 $710.00 $801.00 $856.00 $924.00 $801.00 $856.00 $924.0026700 90 $88.00 $380.00 $401.00 $425.00 $348.00 $367.00 $390.0026705 90 $296.00 $504.00 $539.00 $580.00 $461.00 $492.00 $531.0026706 90 $469.00 $553.00 $591.00 $637.00 $553.00 $591.00 $637.0026715 90 $526.00 $683.00 $726.00 $779.00 $683.00 $726.00 $779.0026720 90 $96.00 $233.00 $249.00 $266.00 $208.00 $222.00 $238.0026725 90 $187.00 $423.00 $452.00 $486.00 $374.00 $400.00 $431.0026727 90 $187.00 $601.00 $643.00 $693.00 $601.00 $643.00 $693.0026735 90 $532.00 $708.00 $753.00 $807.00 $708.00 $753.00 $807.0026740 90 $148.00 $271.00 $290.00 $311.00 $253.00 $271.00 $291.0026742 90 $148.00 $460.00 $492.00 $528.00 $415.00 $443.00 $477.0026746 90 $548.00 $841.00 $887.00 $941.00 $841.00 $887.00 $941.0026750 90 $96.00 $217.00 $232.00 $247.00 $206.00 $219.00 $234.0026755 90 $133.00 $385.00 $410.00 $439.00 $329.00 $351.00 $376.0026756 90 $366.00 $530.00 $567.00 $611.00 $530.00 $567.00 $611.0026765 90 $398.00 $566.00 $601.00 $641.00 $566.00 $601.00 $641.0026770 90 $79.00 $324.00 $342.00 $362.00 $289.00 $305.00 $323.0026775 90 $275.00 $466.00 $497.00 $533.00 $413.00 $440.00 $473.0026776 90 $401.00 $565.00 $604.00 $650.00 $565.00 $604.00 $650.0026785 90 $408.00 $614.00 $649.00 $691.00 $614.00 $649.00 $691.0026820 90 $854.00 $1,050.00 $1,122.00 $1,206.00 $1,050.00 $1,122.00 $1,206.0026841 90 $756.00 $982.00 $1,051.00 $1,130.00 $982.00 $1,051.00 $1,130.0026842 90 $901.00 $1,057.00 $1,131.00 $1,216.00 $1,057.00 $1,131.00 $1,216.0026843 90 $800.00 $974.00 $1,040.00 $1,116.00 $974.00 $1,040.00 $1,116.0026844 90 $875.00 $1,085.00 $1,159.00 $1,244.00 $1,085.00 $1,159.00 $1,244.0026850 90 $704.00 $926.00 $989.00 $1,061.00 $926.00 $989.00 $1,061.0026852 90 $829.00 $1,051.00 $1,121.00 $1,201.00 $1,051.00 $1,121.00 $1,201.0026860 90 $542.00 $750.00 $802.00 $858.00 $750.00 $802.00 $858.0026861 ZZZ $151.00 $144.00 $154.00 $167.00 $144.00 $154.00 $167.0026862 90 $747.00 $962.00 $1,027.00 $1,101.00 $962.00 $1,027.00 $1,101.0026863 ZZZ $317.00 $320.00 $341.00 $368.00 $320.00 $341.00 $368.0026910 90 $747.00 $939.00 $1,003.00 $1,078.00 $939.00 $1,003.00 $1,078.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

26951 90 $444.00 $795.00 $846.00 $901.00 $795.00 $846.00 $901.0026952 90 $608.00 $864.00 $923.00 $989.00 $864.00 $923.00 $989.0026989 YYY BR ------- ------- ------- ------- ------- -------26990 90 $592.00 $800.00 $855.00 $923.00 $800.00 $855.00 $923.0026991 90 $466.00 $910.00 $973.00 $1,046.00 $673.00 $720.00 $779.0026992 90 $1,146.00 $1,270.00 $1,358.00 $1,471.00 $1,270.00 $1,358.00 $1,471.0027000 90 $421.00 $588.00 $631.00 $683.00 $588.00 $631.00 $683.0027001 90 $550.00 $712.00 $764.00 $829.00 $712.00 $764.00 $829.0027003 90 $698.00 $756.00 $806.00 $868.00 $756.00 $806.00 $868.0027005 90 $738.00 $962.00 $1,032.00 $1,121.00 $962.00 $1,032.00 $1,121.0027006 90 $788.00 $972.00 $1,042.00 $1,130.00 $972.00 $1,042.00 $1,130.0027025 90 $896.00 $1,160.00 $1,237.00 $1,334.00 $1,160.00 $1,237.00 $1,334.0027030 90 $1,148.00 $1,257.00 $1,347.00 $1,462.00 $1,257.00 $1,347.00 $1,462.0027033 90 $1,173.00 $1,300.00 $1,391.00 $1,510.00 $1,300.00 $1,391.00 $1,510.0027035 90 $1,413.00 $1,474.00 $1,564.00 $1,678.00 $1,474.00 $1,564.00 $1,678.0027036 90 $1,176.00 $1,319.00 $1,411.00 $1,528.00 $1,319.00 $1,411.00 $1,528.0027040 10 $196.00 $418.00 $443.00 $469.00 $254.00 $268.00 $284.0027041 90 $699.00 $889.00 $946.00 $1,017.00 $889.00 $946.00 $1,017.0027047 90 $535.00 $787.00 $839.00 $900.00 $666.00 $708.00 $762.0027048 90 $588.00 $610.00 $650.00 $700.00 $610.00 $650.00 $700.0027049 90 $1,162.00 $1,293.00 $1,375.00 $1,480.00 $1,293.00 $1,375.00 $1,480.0027050 90 $449.00 $452.00 $480.00 $515.00 $452.00 $480.00 $515.0027052 90 $624.00 $715.00 $763.00 $823.00 $715.00 $763.00 $823.0027054 90 $843.00 $889.00 $951.00 $1,029.00 $889.00 $951.00 $1,029.0027060 90 $491.00 $553.00 $589.00 $633.00 $553.00 $589.00 $633.0027062 90 $499.00 $584.00 $625.00 $676.00 $584.00 $625.00 $676.0027065 90 $583.00 $643.00 $688.00 $743.00 $643.00 $688.00 $743.0027066 90 $931.00 $1,059.00 $1,133.00 $1,227.00 $1,059.00 $1,133.00 $1,227.0027067 90 $1,234.00 $1,319.00 $1,400.00 $1,502.00 $1,319.00 $1,400.00 $1,502.0027070 90 $1,040.00 $1,105.00 $1,180.00 $1,274.00 $1,105.00 $1,180.00 $1,274.0027071 90 $1,112.00 $1,194.00 $1,276.00 $1,379.00 $1,194.00 $1,276.00 $1,379.0027075 90 $1,485.00 $3,059.00 $3,266.00 $3,541.00 $3,059.00 $3,266.00 $3,541.0027076 90 $1,859.00 $2,116.00 $2,260.00 $2,446.00 $2,116.00 $2,260.00 $2,446.0027077 90 $1,976.00 $3,550.00 $3,782.00 $4,086.00 $3,550.00 $3,782.00 $4,086.0027078 90 $1,164.00 $1,328.00 $1,418.00 $1,534.00 $1,328.00 $1,418.00 $1,534.0027079 90 $1,170.00 $1,294.00 $1,374.00 $1,477.00 $1,294.00 $1,374.00 $1,477.0027080 90 $568.00 $629.00 $669.00 $719.00 $629.00 $669.00 $719.0027086 10 $57.00 $314.00 $335.00 $357.00 $191.00 $203.00 $218.0027087 90 $555.00 $824.00 $881.00 $952.00 $824.00 $881.00 $952.0027090 90 $981.00 $1,103.00 $1,181.00 $1,282.00 $1,103.00 $1,181.00 $1,282.0027091 90 $1,482.00 $2,112.00 $2,258.00 $2,449.00 $2,112.00 $2,258.00 $2,449.0027093 0 $62.00 $261.00 $278.00 $295.00 $95.00 $100.00 $107.0027095 0 $121.00 $317.00 $338.00 $357.00 $107.00 $112.00 $119.0027096 0 $491.00 $244.00 $258.00 $271.00 $88.00 $92.00 $96.0027097 90 $795.00 $874.00 $936.00 $1,017.00 $874.00 $936.00 $1,017.0027098 90 $799.00 $806.00 $851.00 $906.00 $806.00 $851.00 $906.0027100 90 $987.00 $1,076.00 $1,152.00 $1,248.00 $1,076.00 $1,152.00 $1,248.0027105 90 $946.00 $1,109.00 $1,182.00 $1,275.00 $1,109.00 $1,182.00 $1,275.0027110 90 $1,174.00 $1,248.00 $1,335.00 $1,447.00 $1,248.00 $1,335.00 $1,447.0027111 90 $1,099.00 $1,170.00 $1,250.00 $1,352.00 $1,170.00 $1,250.00 $1,352.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

27120 90 $1,603.00 $1,708.00 $1,827.00 $1,982.00 $1,708.00 $1,827.00 $1,982.0027122 90 $1,406.00 $1,469.00 $1,572.00 $1,705.00 $1,469.00 $1,572.00 $1,705.0027125 90 $1,371.00 $1,480.00 $1,581.00 $1,711.00 $1,480.00 $1,581.00 $1,711.0027130 90 $1,853.00 $1,920.00 $2,054.00 $2,229.00 $1,920.00 $2,054.00 $2,229.0027132 90 $2,128.00 $2,245.00 $2,400.00 $2,602.00 $2,245.00 $2,400.00 $2,602.0027134 90 $2,576.00 $2,620.00 $2,803.00 $3,046.00 $2,620.00 $2,803.00 $3,046.0027137 90 $2,190.00 $1,993.00 $2,132.00 $2,314.00 $1,993.00 $2,132.00 $2,314.0027138 90 $2,025.00 $2,074.00 $2,219.00 $2,410.00 $2,074.00 $2,219.00 $2,410.0027140 90 $1,092.00 $1,195.00 $1,280.00 $1,389.00 $1,195.00 $1,280.00 $1,389.0027146 90 $1,432.00 $1,685.00 $1,801.00 $1,952.00 $1,685.00 $1,801.00 $1,952.0027147 90 $1,744.00 $1,943.00 $2,079.00 $2,257.00 $1,943.00 $2,079.00 $2,257.0027151 90 $1,732.00 $1,955.00 $2,092.00 $2,276.00 $1,955.00 $2,092.00 $2,276.0027156 90 $2,017.00 $2,302.00 $2,462.00 $2,672.00 $2,302.00 $2,462.00 $2,672.0027158 90 $1,588.00 $1,795.00 $1,916.00 $2,073.00 $1,795.00 $1,916.00 $2,073.0027161 90 $1,443.00 $1,629.00 $1,744.00 $1,893.00 $1,629.00 $1,744.00 $1,893.0027165 90 $1,572.00 $1,801.00 $1,923.00 $2,082.00 $1,801.00 $1,923.00 $2,082.0027170 90 $1,453.00 $1,570.00 $1,679.00 $1,821.00 $1,570.00 $1,679.00 $1,821.0027175 90 $491.00 $848.00 $906.00 $981.00 $848.00 $906.00 $981.0027176 90 $1,024.00 $1,207.00 $1,294.00 $1,407.00 $1,207.00 $1,294.00 $1,407.0027177 90 $1,257.00 $1,470.00 $1,573.00 $1,706.00 $1,470.00 $1,573.00 $1,706.0027178 90 $1,020.00 $1,175.00 $1,258.00 $1,364.00 $1,175.00 $1,258.00 $1,364.0027179 90 $1,107.00 $1,293.00 $1,384.00 $1,500.00 $1,293.00 $1,384.00 $1,500.0027181 90 $1,206.00 $1,374.00 $1,449.00 $1,540.00 $1,374.00 $1,449.00 $1,540.0027185 90 $676.00 $999.00 $1,085.00 $1,200.00 $999.00 $1,085.00 $1,200.0027187 90 $1,280.00 $1,326.00 $1,420.00 $1,542.00 $1,326.00 $1,420.00 $1,542.0027193 90 $425.00 $600.00 $642.00 $694.00 $603.00 $645.00 $697.0027194 90 $740.00 $961.00 $1,028.00 $1,114.00 $961.00 $1,028.00 $1,114.0027200 90 $180.00 $218.00 $232.00 $250.00 $220.00 $235.00 $252.0027202 90 $776.00 $968.00 $1,034.00 $1,108.00 $968.00 $1,034.00 $1,108.0027215 90 $954.00 $989.00 $1,063.00 $1,161.00 $989.00 $1,063.00 $1,161.0027216 90 $1,085.00 $1,416.00 $1,517.00 $1,648.00 $1,416.00 $1,517.00 $1,648.0027217 90 $1,285.00 $1,349.00 $1,444.00 $1,567.00 $1,349.00 $1,444.00 $1,567.0027218 90 $1,570.00 $1,828.00 $1,957.00 $2,128.00 $1,828.00 $1,957.00 $2,128.0027220 90 $444.00 $675.00 $722.00 $780.00 $670.00 $716.00 $774.0027222 90 $973.00 $1,293.00 $1,382.00 $1,495.00 $1,293.00 $1,382.00 $1,495.0027226 90 $1,350.00 $1,342.00 $1,435.00 $1,557.00 $1,342.00 $1,435.00 $1,557.0027227 90 $1,967.00 $2,225.00 $2,380.00 $2,581.00 $2,225.00 $2,380.00 $2,581.0027228 90 $2,195.00 $2,550.00 $2,726.00 $2,958.00 $2,550.00 $2,726.00 $2,958.0027230 90 $491.00 $604.00 $647.00 $699.00 $591.00 $633.00 $685.0027232 90 $916.00 $1,027.00 $1,098.00 $1,191.00 $1,027.00 $1,098.00 $1,191.0027235 90 $1,128.00 $1,209.00 $1,294.00 $1,403.00 $1,209.00 $1,294.00 $1,403.0027236 90 $1,421.00 $1,564.00 $1,671.00 $1,809.00 $1,564.00 $1,671.00 $1,809.0027238 90 $504.00 $580.00 $621.00 $670.00 $580.00 $621.00 $670.0027240 90 $1,043.00 $1,255.00 $1,342.00 $1,453.00 $1,255.00 $1,342.00 $1,453.0027244 90 $1,426.00 $1,545.00 $1,653.00 $1,793.00 $1,545.00 $1,653.00 $1,793.0027245 90 $1,691.00 $1,897.00 $2,032.00 $2,208.00 $1,897.00 $2,032.00 $2,208.0027246 90 $459.00 $496.00 $532.00 $576.00 $496.00 $532.00 $576.0027248 90 $980.00 $1,009.00 $1,081.00 $1,174.00 $1,009.00 $1,081.00 $1,174.0027250 90 $535.00 $611.00 $642.00 $680.00 $611.00 $642.00 $680.0027252 90 $520.00 $992.00 $1,059.00 $1,145.00 $992.00 $1,059.00 $1,145.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

27253 90 $1,162.00 $1,259.00 $1,348.00 $1,463.00 $1,259.00 $1,348.00 $1,463.0027254 90 $1,478.00 $1,699.00 $1,820.00 $1,978.00 $1,699.00 $1,820.00 $1,978.0027256 10 $338.00 $387.00 $409.00 $436.00 $323.00 $341.00 $365.0027257 10 $455.00 $440.00 $467.00 $502.00 $440.00 $467.00 $502.0027258 90 $1,355.00 $1,472.00 $1,576.00 $1,710.00 $1,472.00 $1,576.00 $1,710.0027259 90 $1,803.00 $2,051.00 $2,194.00 $2,381.00 $2,051.00 $2,194.00 $2,381.0027265 90 $442.00 $509.00 $540.00 $578.00 $509.00 $540.00 $578.0027266 90 $614.00 $759.00 $813.00 $881.00 $759.00 $813.00 $881.0027267 90 ------- $543.00 $582.00 $629.00 $543.00 $582.00 $629.0027268 90 ------- $671.00 $719.00 $779.00 $671.00 $719.00 $779.0027269 90 ------- $1,607.00 $1,717.00 $1,861.00 $1,607.00 $1,717.00 $1,861.0027275 10 $220.00 $238.00 $255.00 $276.00 $238.00 $255.00 $276.0027280 90 $1,179.00 $1,361.00 $1,459.00 $1,587.00 $1,361.00 $1,459.00 $1,587.0027282 90 $990.00 $1,092.00 $1,168.00 $1,265.00 $1,092.00 $1,168.00 $1,265.0027284 90 $1,435.00 $2,151.00 $2,298.00 $2,492.00 $2,151.00 $2,298.00 $2,492.0027286 90 $1,503.00 $2,131.00 $2,261.00 $2,426.00 $2,131.00 $2,261.00 $2,426.0027290 90 $2,073.00 $2,072.00 $2,206.00 $2,380.00 $2,072.00 $2,206.00 $2,380.0027295 90 $1,594.00 $1,675.00 $1,787.00 $1,934.00 $1,675.00 $1,787.00 $1,934.0027299 YYY BR ------- ------- ------- ------- ------- -------27301 90 $193.00 $852.00 $911.00 $979.00 $640.00 $684.00 $739.0027303 90 $520.00 $838.00 $897.00 $972.00 $838.00 $897.00 $972.0027305 90 $555.00 $612.00 $656.00 $710.00 $612.00 $656.00 $710.0027306 90 $377.00 $506.00 $543.00 $590.00 $506.00 $543.00 $590.0027307 90 $503.00 $616.00 $660.00 $716.00 $616.00 $660.00 $716.0027310 90 $877.00 $950.00 $1,017.00 $1,101.00 $950.00 $1,017.00 $1,101.0027323 10 $211.00 $320.00 $340.00 $361.00 $223.00 $236.00 $251.0027324 90 $433.00 $492.00 $525.00 $566.00 $492.00 $525.00 $566.0027325 90 ------- $668.00 $713.00 $770.00 $668.00 $713.00 $770.0027326 90 ------- $642.00 $687.00 $744.00 $642.00 $687.00 $744.0027327 90 $400.00 $564.00 $602.00 $644.00 $445.00 $475.00 $511.0027328 90 $503.00 $541.00 $578.00 $623.00 $541.00 $578.00 $623.0027329 90 $1,249.00 $1,344.00 $1,430.00 $1,540.00 $1,344.00 $1,430.00 $1,540.0027330 90 $492.00 $525.00 $562.00 $609.00 $525.00 $562.00 $609.0027331 90 $585.00 $617.00 $661.00 $717.00 $617.00 $661.00 $717.0027332 90 $786.00 $836.00 $896.00 $971.00 $836.00 $896.00 $971.0027333 90 $719.00 $758.00 $812.00 $879.00 $758.00 $812.00 $879.0027334 90 $840.00 $892.00 $955.00 $1,034.00 $892.00 $955.00 $1,034.0027335 90 $959.00 $1,009.00 $1,081.00 $1,172.00 $1,009.00 $1,081.00 $1,172.0027340 90 $405.00 $470.00 $504.00 $545.00 $470.00 $504.00 $545.0027345 90 $565.00 $623.00 $667.00 $722.00 $623.00 $667.00 $722.0027347 90 $394.00 $653.00 $697.00 $752.00 $653.00 $697.00 $752.0027350 90 $786.00 $850.00 $910.00 $985.00 $850.00 $910.00 $985.0027355 90 $763.00 $790.00 $846.00 $916.00 $790.00 $846.00 $916.0027356 90 $882.00 $966.00 $1,034.00 $1,120.00 $966.00 $1,034.00 $1,120.0027357 90 $950.00 $1,077.00 $1,156.00 $1,257.00 $1,077.00 $1,156.00 $1,257.0027358 ZZZ $394.00 $396.00 $424.00 $463.00 $396.00 $424.00 $463.0027360 90 $977.00 $1,119.00 $1,197.00 $1,295.00 $1,119.00 $1,197.00 $1,295.0027365 90 $1,421.00 $1,616.00 $1,727.00 $1,869.00 $1,616.00 $1,727.00 $1,869.0027370 0 $75.00 $220.00 $234.00 $247.00 $69.00 $72.00 $76.0027372 90 $371.00 $766.00 $820.00 $880.00 $525.00 $562.00 $608.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

27380 90 $698.00 $776.00 $831.00 $900.00 $776.00 $831.00 $900.0027381 90 $1,118.00 $1,059.00 $1,134.00 $1,229.00 $1,059.00 $1,134.00 $1,229.0027385 90 $753.00 $832.00 $891.00 $965.00 $832.00 $891.00 $965.0027386 90 $1,064.00 $1,100.00 $1,178.00 $1,277.00 $1,100.00 $1,178.00 $1,277.0027390 90 $506.00 $568.00 $608.00 $658.00 $568.00 $608.00 $658.0027391 90 $647.00 $747.00 $800.00 $866.00 $747.00 $800.00 $866.0027392 90 $834.00 $927.00 $993.00 $1,075.00 $927.00 $993.00 $1,075.0027393 90 $608.00 $662.00 $709.00 $768.00 $662.00 $709.00 $768.0027394 90 $748.00 $858.00 $920.00 $997.00 $858.00 $920.00 $997.0027395 90 $1,093.00 $1,162.00 $1,245.00 $1,351.00 $1,162.00 $1,245.00 $1,351.0027396 90 $742.00 $805.00 $862.00 $933.00 $805.00 $862.00 $933.0027397 90 $989.00 $1,165.00 $1,242.00 $1,340.00 $1,165.00 $1,242.00 $1,340.0027400 90 $832.00 $880.00 $938.00 $1,010.00 $880.00 $938.00 $1,010.0027403 90 $792.00 $844.00 $904.00 $980.00 $844.00 $904.00 $980.0027405 90 $842.00 $887.00 $950.00 $1,030.00 $887.00 $950.00 $1,030.0027407 90 $918.00 $1,024.00 $1,096.00 $1,189.00 $1,024.00 $1,096.00 $1,189.0027409 90 $1,212.00 $1,271.00 $1,361.00 $1,476.00 $1,271.00 $1,361.00 $1,476.0027412 90 ------- $2,209.00 $2,370.00 $2,584.00 $2,209.00 $2,370.00 $2,584.0027415 90 ------- $1,884.00 $2,038.00 $2,245.00 $1,884.00 $2,038.00 $2,245.0027416 90 ------- $1,261.00 $1,350.00 $1,466.00 $1,261.00 $1,350.00 $1,466.0027418 90 $1,596.00 $1,100.00 $1,177.00 $1,276.00 $1,100.00 $1,177.00 $1,276.0027420 90 $927.00 $988.00 $1,058.00 $1,148.00 $988.00 $1,058.00 $1,148.0027422 90 $930.00 $985.00 $1,055.00 $1,144.00 $985.00 $1,055.00 $1,144.0027424 90 $927.00 $986.00 $1,056.00 $1,145.00 $986.00 $1,056.00 $1,145.0027425 90 $639.00 $575.00 $616.00 $667.00 $575.00 $616.00 $667.0027427 90 $1,118.00 $946.00 $1,013.00 $1,099.00 $946.00 $1,013.00 $1,099.0027428 90 $1,266.00 $1,445.00 $1,545.00 $1,671.00 $1,445.00 $1,545.00 $1,671.0027429 90 $2,333.00 $1,616.00 $1,727.00 $1,869.00 $1,616.00 $1,727.00 $1,869.0027430 90 $884.00 $977.00 $1,047.00 $1,135.00 $977.00 $1,047.00 $1,135.0027435 90 $501.00 $1,038.00 $1,110.00 $1,200.00 $1,038.00 $1,110.00 $1,200.0027437 90 $819.00 $868.00 $930.00 $1,009.00 $868.00 $930.00 $1,009.0027438 90 $1,065.00 $1,109.00 $1,187.00 $1,288.00 $1,109.00 $1,187.00 $1,288.0027440 90 $1,064.00 $984.00 $1,054.00 $1,144.00 $984.00 $1,054.00 $1,144.0027441 90 $1,006.00 $1,038.00 $1,111.00 $1,206.00 $1,038.00 $1,111.00 $1,206.0027442 90 $1,117.00 $1,156.00 $1,239.00 $1,346.00 $1,156.00 $1,239.00 $1,346.0027443 90 $1,037.00 $1,083.00 $1,161.00 $1,259.00 $1,083.00 $1,161.00 $1,259.0027445 90 $1,618.00 $1,684.00 $1,803.00 $1,958.00 $1,684.00 $1,803.00 $1,958.0027446 90 $1,764.00 $1,500.00 $1,608.00 $1,749.00 $1,500.00 $1,608.00 $1,749.0027447 90 $1,960.00 $2,063.00 $2,208.00 $2,397.00 $2,063.00 $2,208.00 $2,397.0027448 90 $1,060.00 $1,092.00 $1,170.00 $1,270.00 $1,092.00 $1,170.00 $1,270.0027450 90 $1,311.00 $1,357.00 $1,454.00 $1,578.00 $1,357.00 $1,454.00 $1,578.0027454 90 $1,524.00 $1,720.00 $1,841.00 $1,998.00 $1,720.00 $1,841.00 $1,998.0027455 90 $1,157.00 $1,255.00 $1,345.00 $1,460.00 $1,255.00 $1,345.00 $1,460.0027457 90 $1,209.00 $1,294.00 $1,386.00 $1,505.00 $1,294.00 $1,386.00 $1,505.0027465 90 $1,253.00 $1,575.00 $1,675.00 $1,803.00 $1,575.00 $1,675.00 $1,803.0027466 90 $1,441.00 $1,572.00 $1,682.00 $1,823.00 $1,572.00 $1,682.00 $1,823.0027468 90 $1,613.00 $1,781.00 $1,907.00 $2,072.00 $1,781.00 $1,907.00 $2,072.0027470 90 $1,501.00 $1,568.00 $1,678.00 $1,820.00 $1,568.00 $1,678.00 $1,820.0027472 90 $1,665.00 $1,699.00 $1,819.00 $1,975.00 $1,699.00 $1,819.00 $1,975.0027475 90 $782.00 $858.00 $916.00 $989.00 $858.00 $916.00 $989.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

27477 90 $938.00 $967.00 $1,037.00 $1,126.00 $967.00 $1,037.00 $1,126.0027479 90 $1,123.00 $1,296.00 $1,400.00 $1,537.00 $1,296.00 $1,400.00 $1,537.0027485 90 $797.00 $885.00 $948.00 $1,028.00 $885.00 $948.00 $1,028.0027486 90 $1,771.00 $1,878.00 $2,008.00 $2,178.00 $1,878.00 $2,008.00 $2,178.0027487 90 $2,352.00 $2,376.00 $2,542.00 $2,760.00 $2,376.00 $2,542.00 $2,760.0027488 90 $1,438.00 $1,584.00 $1,693.00 $1,833.00 $1,584.00 $1,693.00 $1,833.0027495 90 $1,477.00 $1,511.00 $1,618.00 $1,755.00 $1,511.00 $1,618.00 $1,755.0027496 90 $563.00 $655.00 $699.00 $754.00 $655.00 $699.00 $754.0027497 90 $652.00 $713.00 $761.00 $821.00 $713.00 $761.00 $821.0027498 90 $701.00 $778.00 $829.00 $894.00 $778.00 $829.00 $894.0027499 90 $782.00 $874.00 $934.00 $1,011.00 $874.00 $934.00 $1,011.0027500 90 $520.00 $660.00 $706.00 $763.00 $612.00 $655.00 $709.0027501 90 $659.00 $649.00 $695.00 $751.00 $637.00 $681.00 $737.0027502 90 $909.00 $1,044.00 $1,116.00 $1,209.00 $1,044.00 $1,116.00 $1,209.0027503 90 $911.00 $1,057.00 $1,131.00 $1,227.00 $1,057.00 $1,131.00 $1,227.0027506 90 $1,522.00 $1,757.00 $1,877.00 $2,032.00 $1,757.00 $1,877.00 $2,032.0027507 90 $1,297.00 $1,318.00 $1,411.00 $1,533.00 $1,318.00 $1,411.00 $1,533.0027508 90 $400.00 $666.00 $712.00 $768.00 $626.00 $669.00 $723.0027509 90 $649.00 $845.00 $905.00 $979.00 $845.00 $905.00 $979.0027510 90 $755.00 $916.00 $979.00 $1,059.00 $916.00 $979.00 $1,059.0027511 90 $1,281.00 $1,374.00 $1,469.00 $1,591.00 $1,374.00 $1,469.00 $1,591.0027513 90 $1,562.00 $1,736.00 $1,858.00 $2,016.00 $1,736.00 $1,858.00 $2,016.0027514 90 $1,508.00 $1,448.00 $1,563.00 $1,712.00 $1,448.00 $1,563.00 $1,712.0027516 90 $579.00 $622.00 $664.00 $714.00 $585.00 $625.00 $672.0027517 90 $820.00 $865.00 $921.00 $990.00 $865.00 $921.00 $990.0027519 90 $1,311.00 $1,293.00 $1,392.00 $1,520.00 $1,293.00 $1,392.00 $1,520.0027520 90 $266.00 $391.00 $418.00 $449.00 $349.00 $373.00 $402.0027524 90 $910.00 $1,000.00 $1,071.00 $1,162.00 $1,000.00 $1,071.00 $1,162.0027530 90 $408.00 $492.00 $526.00 $567.00 $455.00 $487.00 $525.0027532 90 $641.00 $793.00 $849.00 $919.00 $751.00 $804.00 $871.0027535 90 $1,075.00 $1,222.00 $1,304.00 $1,409.00 $1,222.00 $1,304.00 $1,409.0027536 90 $1,282.00 $1,570.00 $1,678.00 $1,818.00 $1,570.00 $1,678.00 $1,818.0027538 90 $487.00 $590.00 $633.00 $683.00 $551.00 $591.00 $639.0027540 90 $1,106.00 $1,127.00 $1,215.00 $1,330.00 $1,127.00 $1,215.00 $1,330.0027550 90 $296.00 $615.00 $655.00 $701.00 $570.00 $606.00 $650.0027552 90 $619.00 $811.00 $869.00 $942.00 $811.00 $869.00 $942.0027556 90 $832.00 $1,276.00 $1,373.00 $1,500.00 $1,276.00 $1,373.00 $1,500.0027557 90 $1,479.00 $1,516.00 $1,630.00 $1,779.00 $1,516.00 $1,630.00 $1,779.0027558 90 $1,529.00 $1,660.00 $1,779.00 $1,933.00 $1,660.00 $1,779.00 $1,933.0027560 90 $88.00 $441.00 $467.00 $496.00 $386.00 $409.00 $435.0027562 90 $514.00 $584.00 $625.00 $675.00 $584.00 $625.00 $675.0027566 90 $1,047.00 $1,191.00 $1,275.00 $1,385.00 $1,191.00 $1,275.00 $1,385.0027570 10 $184.00 $191.00 $205.00 $222.00 $191.00 $205.00 $222.0027580 90 $1,644.00 $1,924.00 $2,058.00 $2,231.00 $1,924.00 $2,058.00 $2,231.0027590 90 $1,059.00 $1,083.00 $1,150.00 $1,238.00 $1,083.00 $1,150.00 $1,238.0027591 90 $1,182.00 $1,210.00 $1,290.00 $1,393.00 $1,210.00 $1,290.00 $1,393.0027592 90 $911.00 $915.00 $973.00 $1,047.00 $915.00 $973.00 $1,047.0027594 90 $600.00 $665.00 $708.00 $763.00 $665.00 $708.00 $763.0027596 90 $931.00 $968.00 $1,031.00 $1,111.00 $968.00 $1,031.00 $1,111.0027598 90 $976.00 $982.00 $1,047.00 $1,131.00 $982.00 $1,047.00 $1,131.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

27599 YYY BR ------- ------- ------- ------- ------- -------27600 90 $517.00 $555.00 $592.00 $638.00 $555.00 $592.00 $638.0027601 90 $516.00 $568.00 $604.00 $649.00 $568.00 $604.00 $649.0027602 90 $621.00 $685.00 $729.00 $787.00 $685.00 $729.00 $787.0027603 90 $412.00 $662.00 $707.00 $758.00 $501.00 $534.00 $575.0027604 90 $308.00 $581.00 $621.00 $666.00 $451.00 $482.00 $519.0027605 10 $236.00 $489.00 $522.00 $557.00 $269.00 $287.00 $309.0027606 10 $362.00 $399.00 $427.00 $463.00 $399.00 $427.00 $463.0027607 90 $608.00 $800.00 $855.00 $924.00 $800.00 $855.00 $924.0027610 90 $777.00 $862.00 $921.00 $995.00 $862.00 $921.00 $995.0027612 90 $701.00 $747.00 $796.00 $857.00 $747.00 $796.00 $857.0027613 10 $165.00 $297.00 $315.00 $333.00 $208.00 $220.00 $233.0027614 90 $327.00 $702.00 $749.00 $801.00 $539.00 $574.00 $617.0027615 90 $1,106.00 $1,170.00 $1,247.00 $1,343.00 $1,170.00 $1,247.00 $1,343.0027618 90 $421.00 $610.00 $651.00 $697.00 $494.00 $526.00 $566.0027619 90 $730.00 $985.00 $1,051.00 $1,129.00 $778.00 $830.00 $895.0027620 90 $587.00 $611.00 $654.00 $707.00 $611.00 $654.00 $707.0027625 90 $796.00 $793.00 $847.00 $915.00 $793.00 $847.00 $915.0027626 90 $863.00 $857.00 $917.00 $994.00 $857.00 $917.00 $994.0027630 90 $430.00 $675.00 $721.00 $773.00 $491.00 $524.00 $565.0027635 90 $781.00 $785.00 $840.00 $910.00 $785.00 $840.00 $910.0027637 90 $921.00 $989.00 $1,059.00 $1,146.00 $989.00 $1,059.00 $1,146.0027638 90 $978.00 $1,040.00 $1,115.00 $1,210.00 $1,040.00 $1,115.00 $1,210.0027640 90 $1,122.00 $1,163.00 $1,242.00 $1,343.00 $1,163.00 $1,242.00 $1,343.0027641 90 $922.00 $934.00 $996.00 $1,075.00 $934.00 $996.00 $1,075.0027645 90 $1,302.00 $1,406.00 $1,505.00 $1,630.00 $1,406.00 $1,505.00 $1,630.0027646 90 $1,212.00 $1,250.00 $1,336.00 $1,444.00 $1,250.00 $1,336.00 $1,444.0027647 90 $1,044.00 $1,097.00 $1,167.00 $1,257.00 $1,097.00 $1,167.00 $1,257.0027648 0 $72.00 $212.00 $225.00 $238.00 $69.00 $72.00 $76.0027650 90 $869.00 $935.00 $999.00 $1,082.00 $935.00 $999.00 $1,082.0027652 90 $935.00 $998.00 $1,067.00 $1,156.00 $998.00 $1,067.00 $1,156.0027654 90 $937.00 $938.00 $1,002.00 $1,083.00 $938.00 $1,002.00 $1,083.0027656 90 $458.00 $684.00 $731.00 $782.00 $456.00 $486.00 $524.0027658 90 $527.00 $510.00 $545.00 $588.00 $510.00 $545.00 $588.0027659 90 $725.00 $673.00 $719.00 $777.00 $673.00 $719.00 $777.0027664 90 $504.00 $489.00 $524.00 $566.00 $489.00 $524.00 $566.0027665 90 $618.00 $559.00 $599.00 $647.00 $559.00 $599.00 $647.0027675 90 $656.00 $689.00 $735.00 $794.00 $689.00 $735.00 $794.0027676 90 $762.00 $825.00 $882.00 $954.00 $825.00 $882.00 $954.0027680 90 $523.00 $578.00 $618.00 $668.00 $578.00 $618.00 $668.0027681 90 $634.00 $692.00 $741.00 $803.00 $692.00 $741.00 $803.0027685 90 $565.00 $787.00 $841.00 $903.00 $637.00 $679.00 $732.0027686 90 $706.00 $752.00 $804.00 $870.00 $752.00 $804.00 $870.0027687 90 $589.00 $620.00 $663.00 $717.00 $620.00 $663.00 $717.0027690 90 $757.00 $819.00 $874.00 $943.00 $819.00 $874.00 $943.0027691 90 $889.00 $973.00 $1,040.00 $1,126.00 $973.00 $1,040.00 $1,126.0027692 ZZZ $159.00 $154.00 $165.00 $180.00 $154.00 $165.00 $180.0027695 90 $658.00 $661.00 $707.00 $764.00 $661.00 $707.00 $764.0027696 90 $758.00 $791.00 $845.00 $912.00 $791.00 $845.00 $912.0027698 90 $881.00 $883.00 $943.00 $1,020.00 $883.00 $943.00 $1,020.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

27700 90 $835.00 $823.00 $876.00 $943.00 $823.00 $876.00 $943.0027702 90 $1,278.00 $1,337.00 $1,431.00 $1,553.00 $1,337.00 $1,431.00 $1,553.0027703 90 $1,337.00 $1,534.00 $1,642.00 $1,781.00 $1,534.00 $1,642.00 $1,781.0027704 90 $683.00 $742.00 $794.00 $861.00 $742.00 $794.00 $861.0027705 90 $985.00 $1,026.00 $1,099.00 $1,193.00 $1,026.00 $1,099.00 $1,193.0027707 90 $484.00 $515.00 $551.00 $595.00 $515.00 $551.00 $595.0027709 90 $1,118.00 $1,403.00 $1,480.00 $1,575.00 $1,403.00 $1,480.00 $1,575.0027712 90 $1,227.00 $1,437.00 $1,536.00 $1,664.00 $1,437.00 $1,536.00 $1,664.0027715 90 $1,285.00 $1,415.00 $1,514.00 $1,641.00 $1,415.00 $1,514.00 $1,641.0027720 90 $1,147.00 $1,170.00 $1,253.00 $1,359.00 $1,170.00 $1,253.00 $1,359.0027722 90 $1,076.00 $1,167.00 $1,249.00 $1,355.00 $1,167.00 $1,249.00 $1,355.0027724 90 $1,402.00 $1,718.00 $1,839.00 $1,997.00 $1,718.00 $1,839.00 $1,997.0027725 90 $1,312.00 $1,583.00 $1,692.00 $1,832.00 $1,583.00 $1,692.00 $1,832.0027726 90 ------- $1,164.00 $1,228.00 $1,306.00 $1,164.00 $1,228.00 $1,306.0027727 90 $1,175.00 $1,369.00 $1,465.00 $1,590.00 $1,369.00 $1,465.00 $1,590.0027730 90 $647.00 $787.00 $852.00 $937.00 $787.00 $852.00 $937.0027732 90 $611.00 $541.00 $576.00 $620.00 $541.00 $576.00 $620.0027734 90 $766.00 $828.00 $884.00 $956.00 $828.00 $884.00 $956.0027740 90 $1,044.00 $939.00 $1,006.00 $1,091.00 $939.00 $1,006.00 $1,091.0027742 90 $1,045.00 $889.00 $953.00 $1,039.00 $889.00 $953.00 $1,039.0027745 90 $940.00 $1,005.00 $1,077.00 $1,169.00 $1,005.00 $1,077.00 $1,169.0027750 90 $319.00 $424.00 $454.00 $489.00 $386.00 $414.00 $446.0027752 90 $614.00 $684.00 $732.00 $790.00 $638.00 $683.00 $739.0027756 90 $708.00 $742.00 $794.00 $858.00 $742.00 $794.00 $858.0027758 90 $1,115.00 $1,174.00 $1,257.00 $1,362.00 $1,174.00 $1,257.00 $1,362.0027759 90 $1,262.00 $1,336.00 $1,431.00 $1,553.00 $1,336.00 $1,431.00 $1,553.0027760 90 $223.00 $407.00 $435.00 $467.00 $365.00 $390.00 $419.0027762 90 $495.00 $613.00 $656.00 $706.00 $566.00 $605.00 $653.0027766 90 $759.00 $811.00 $872.00 $948.00 $811.00 $872.00 $948.0027767 90 ------- $322.00 $343.00 $365.00 $323.00 $344.00 $367.0027768 90 ------- $512.00 $548.00 $591.00 $512.00 $548.00 $591.0027769 90 ------- $889.00 $947.00 $1,022.00 $889.00 $947.00 $1,022.0027780 90 $244.00 $361.00 $386.00 $414.00 $323.00 $345.00 $371.0027781 90 $296.00 $527.00 $564.00 $608.00 $490.00 $525.00 $567.0027784 90 $643.00 $877.00 $932.00 $1,000.00 $877.00 $932.00 $1,000.0027786 90 $223.00 $386.00 $413.00 $443.00 $342.00 $366.00 $394.0027788 90 $422.00 $536.00 $574.00 $619.00 $493.00 $527.00 $570.0027792 90 $706.00 $897.00 $956.00 $1,028.00 $897.00 $956.00 $1,028.0027808 90 $332.00 $403.00 $431.00 $463.00 $358.00 $383.00 $412.0027810 90 $567.00 $601.00 $642.00 $692.00 $552.00 $590.00 $636.0027814 90 $972.00 $1,033.00 $1,109.00 $1,205.00 $1,033.00 $1,109.00 $1,205.0027816 90 $386.00 $383.00 $409.00 $438.00 $342.00 $365.00 $391.0027818 90 $613.00 $621.00 $663.00 $712.00 $567.00 $605.00 $651.0027822 90 $1,201.00 $1,141.00 $1,224.00 $1,327.00 $1,141.00 $1,224.00 $1,327.0027823 90 $1,472.00 $1,299.00 $1,393.00 $1,512.00 $1,299.00 $1,393.00 $1,512.0027824 90 $384.00 $379.00 $404.00 $433.00 $362.00 $386.00 $414.0027825 90 $670.00 $700.00 $748.00 $806.00 $644.00 $688.00 $743.0027826 90 $1,080.00 $1,055.00 $1,123.00 $1,206.00 $1,055.00 $1,123.00 $1,206.0027827 90 $1,310.00 $1,451.00 $1,554.00 $1,684.00 $1,451.00 $1,554.00 $1,684.0027828 90 $1,823.00 $1,716.00 $1,833.00 $1,982.00 $1,716.00 $1,833.00 $1,982.00

CPT only © 2008 American Medical Association. All rights reserved. Part B, 168

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

27829 90 $742.00 $825.00 $874.00 $931.00 $825.00 $874.00 $931.0027830 90 $412.00 $435.00 $464.00 $498.00 $409.00 $436.00 $468.0027831 90 $415.00 $488.00 $522.00 $563.00 $488.00 $522.00 $563.0027832 90 $617.00 $876.00 $926.00 $985.00 $876.00 $926.00 $985.0027840 90 $334.00 $440.00 $465.00 $494.00 $440.00 $465.00 $494.0027842 90 $373.00 $626.00 $669.00 $723.00 $626.00 $669.00 $723.0027846 90 $877.00 $980.00 $1,050.00 $1,139.00 $980.00 $1,050.00 $1,139.0027848 90 $1,224.00 $1,123.00 $1,203.00 $1,305.00 $1,123.00 $1,203.00 $1,305.0027860 10 $211.00 $234.00 $250.00 $271.00 $234.00 $250.00 $271.0027870 90 $1,269.00 $1,392.00 $1,487.00 $1,610.00 $1,392.00 $1,487.00 $1,610.0027871 90 $843.00 $922.00 $987.00 $1,070.00 $922.00 $987.00 $1,070.0027880 90 $1,015.00 $1,200.00 $1,269.00 $1,358.00 $1,200.00 $1,269.00 $1,358.0027881 90 $1,120.00 $1,189.00 $1,269.00 $1,371.00 $1,189.00 $1,269.00 $1,371.0027882 90 $854.00 $842.00 $895.00 $962.00 $842.00 $895.00 $962.0027884 90 $579.00 $774.00 $824.00 $888.00 $774.00 $824.00 $888.0027886 90 $835.00 $879.00 $936.00 $1,009.00 $879.00 $936.00 $1,009.0027888 90 $911.00 $938.00 $1,001.00 $1,080.00 $938.00 $1,001.00 $1,080.0027889 90 $879.00 $917.00 $975.00 $1,050.00 $917.00 $975.00 $1,050.0027892 90 $575.00 $722.00 $769.00 $828.00 $722.00 $769.00 $828.0027893 90 $574.00 $717.00 $764.00 $823.00 $717.00 $764.00 $823.0027894 90 $712.00 $1,092.00 $1,161.00 $1,248.00 $1,092.00 $1,161.00 $1,248.0027899 YYY BR ------- ------- ------- ------- ------- -------28001 10 $185.00 $330.00 $350.00 $374.00 $244.00 $259.00 $277.0028002 10 $362.00 $611.00 $647.00 $689.00 $503.00 $532.00 $567.0028003 90 $520.00 $859.00 $913.00 $977.00 $753.00 $799.00 $858.0028005 90 $520.00 $818.00 $868.00 $931.00 $818.00 $868.00 $931.0028008 90 $296.00 $524.00 $558.00 $596.00 $411.00 $437.00 $468.0028010 90 $235.00 $295.00 $313.00 $335.00 $282.00 $300.00 $321.0028011 90 $340.00 $421.00 $449.00 $482.00 $402.00 $428.00 $461.0028020 90 $509.00 $629.00 $671.00 $719.00 $488.00 $520.00 $560.0028022 90 $422.00 $574.00 $611.00 $653.00 $450.00 $479.00 $514.0028024 90 $371.00 $548.00 $584.00 $624.00 $430.00 $457.00 $490.0028035 90 $532.00 $625.00 $667.00 $713.00 $488.00 $519.00 $558.0028043 90 $305.00 $419.00 $446.00 $477.00 $352.00 $374.00 $401.0028045 90 $456.00 $584.00 $622.00 $665.00 $445.00 $473.00 $508.0028046 90 $814.00 $1,081.00 $1,150.00 $1,232.00 $909.00 $965.00 $1,037.0028050 90 $414.00 $546.00 $582.00 $623.00 $422.00 $449.00 $483.0028052 90 $402.00 $509.00 $542.00 $580.00 $386.00 $411.00 $441.0028054 90 $236.00 $475.00 $506.00 $540.00 $351.00 $373.00 $400.0028055 90 ------- $527.00 $559.00 $598.00 $527.00 $559.00 $598.0028060 90 $495.00 $618.00 $658.00 $704.00 $489.00 $520.00 $559.0028062 90 $657.00 $733.00 $780.00 $833.00 $570.00 $606.00 $650.0028070 90 $476.00 $614.00 $655.00 $702.00 $484.00 $516.00 $555.0028072 90 $445.00 $599.00 $639.00 $685.00 $469.00 $500.00 $539.0028080 90 $392.00 $575.00 $609.00 $647.00 $452.00 $478.00 $508.0028086 90 $462.00 $683.00 $731.00 $784.00 $499.00 $534.00 $576.0028088 90 $414.00 $550.00 $588.00 $631.00 $408.00 $436.00 $471.0028090 90 $414.00 $554.00 $590.00 $631.00 $422.00 $449.00 $482.0028092 90 $330.00 $504.00 $537.00 $574.00 $375.00 $399.00 $428.0028100 90 $571.00 $735.00 $785.00 $840.00 $551.00 $587.00 $632.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

28102 90 $700.00 $727.00 $775.00 $836.00 $727.00 $775.00 $836.0028103 90 $709.00 $596.00 $635.00 $683.00 $596.00 $635.00 $683.0028104 90 $491.00 $616.00 $656.00 $703.00 $483.00 $514.00 $552.0028106 90 $632.00 $633.00 $673.00 $724.00 $633.00 $673.00 $724.0028107 90 $517.00 $678.00 $722.00 $772.00 $519.00 $552.00 $593.0028108 90 $418.00 $513.00 $546.00 $583.00 $396.00 $420.00 $450.0028110 90 $421.00 $540.00 $576.00 $615.00 $394.00 $419.00 $449.0028111 90 $537.00 $625.00 $666.00 $712.00 $462.00 $492.00 $528.0028112 90 $457.00 $586.00 $625.00 $668.00 $432.00 $460.00 $494.0028113 90 $481.00 $686.00 $728.00 $774.00 $549.00 $581.00 $619.0028114 90 $890.00 $1,283.00 $1,363.00 $1,456.00 $1,074.00 $1,140.00 $1,221.0028116 90 $648.00 $907.00 $962.00 $1,027.00 $764.00 $809.00 $865.0028118 90 $568.00 $704.00 $750.00 $804.00 $558.00 $594.00 $640.0028119 90 $524.00 $627.00 $668.00 $714.00 $494.00 $525.00 $563.0028120 90 $601.00 $710.00 $757.00 $810.00 $535.00 $570.00 $613.0028122 90 $622.00 $815.00 $867.00 $928.00 $684.00 $727.00 $780.0028124 90 $480.00 $571.00 $607.00 $648.00 $455.00 $483.00 $517.0028126 90 $393.00 $457.00 $487.00 $519.00 $344.00 $366.00 $392.0028130 90 $727.00 $859.00 $913.00 $982.00 $859.00 $913.00 $982.0028140 90 $533.00 $779.00 $829.00 $887.00 $625.00 $664.00 $713.0028150 90 $416.00 $516.00 $550.00 $587.00 $393.00 $418.00 $448.0028153 90 $400.00 $474.00 $505.00 $539.00 $351.00 $373.00 $400.0028160 90 $412.00 $489.00 $521.00 $556.00 $373.00 $397.00 $425.0028171 90 $789.00 $835.00 $888.00 $956.00 $835.00 $888.00 $956.0028173 90 $747.00 $922.00 $979.00 $1,047.00 $759.00 $805.00 $864.0028175 90 $571.00 $669.00 $710.00 $758.00 $531.00 $562.00 $602.0028190 10 $75.00 $295.00 $314.00 $333.00 $181.00 $191.00 $204.0028192 90 $326.00 $573.00 $611.00 $653.00 $440.00 $467.00 $501.0028193 90 $341.00 $653.00 $695.00 $743.00 $519.00 $551.00 $591.0028200 90 $478.00 $566.00 $603.00 $644.00 $436.00 $463.00 $497.0028202 90 $613.00 $773.00 $823.00 $881.00 $609.00 $648.00 $696.0028208 90 $406.00 $541.00 $576.00 $616.00 $415.00 $442.00 $474.0028210 90 $609.00 $711.00 $756.00 $808.00 $564.00 $599.00 $642.0028220 90 $435.00 $537.00 $571.00 $610.00 $423.00 $449.00 $481.0028222 90 $555.00 $625.00 $664.00 $709.00 $507.00 $538.00 $576.0028225 90 $345.00 $468.00 $498.00 $531.00 $351.00 $372.00 $399.0028226 90 $334.00 $553.00 $588.00 $628.00 $436.00 $463.00 $496.0028230 90 $380.00 $518.00 $551.00 $589.00 $408.00 $434.00 $465.0028232 90 $286.00 $457.00 $487.00 $520.00 $345.00 $367.00 $393.0028234 90 $178.00 $470.00 $501.00 $534.00 $356.00 $379.00 $406.0028238 90 $695.00 $843.00 $898.00 $963.00 $685.00 $728.00 $784.0028240 90 $370.00 $527.00 $561.00 $600.00 $413.00 $440.00 $472.0028250 90 $535.00 $675.00 $719.00 $771.00 $544.00 $579.00 $623.0028260 90 $641.00 $839.00 $895.00 $961.00 $710.00 $756.00 $815.0028261 90 $881.00 $1,213.00 $1,287.00 $1,377.00 $1,072.00 $1,136.00 $1,218.0028262 90 $1,363.00 $1,732.00 $1,850.00 $1,995.00 $1,521.00 $1,624.00 $1,757.0028264 90 $912.00 $1,068.00 $1,139.00 $1,226.00 $947.00 $1,010.00 $1,090.0028270 90 $266.00 $570.00 $607.00 $649.00 $455.00 $483.00 $518.0028272 90 $336.00 $467.00 $497.00 $529.00 $354.00 $376.00 $402.0028280 90 $426.00 $642.00 $685.00 $733.00 $504.00 $537.00 $577.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

28285 90 $463.00 $554.00 $590.00 $630.00 $434.00 $461.00 $495.0028286 90 $441.00 $545.00 $579.00 $618.00 $420.00 $445.00 $477.0028288 90 $452.00 $688.00 $730.00 $777.00 $564.00 $598.00 $637.0028289 90 $458.00 $897.00 $954.00 $1,020.00 $739.00 $785.00 $841.0028290 90 $557.00 $695.00 $741.00 $795.00 $551.00 $587.00 $632.0028292 90 $666.00 $927.00 $982.00 $1,044.00 $774.00 $818.00 $871.0028293 90 $845.00 $1,241.00 $1,314.00 $1,396.00 $936.00 $988.00 $1,051.0028294 90 $797.00 $914.00 $972.00 $1,040.00 $729.00 $773.00 $830.0028296 90 $832.00 $975.00 $1,037.00 $1,110.00 $787.00 $835.00 $897.0028297 90 $838.00 $1,027.00 $1,095.00 $1,176.00 $832.00 $886.00 $955.0028298 90 $755.00 $872.00 $928.00 $994.00 $699.00 $742.00 $798.0028299 90 $829.00 $1,126.00 $1,196.00 $1,278.00 $938.00 $994.00 $1,065.0028300 90 $845.00 $900.00 $963.00 $1,042.00 $900.00 $963.00 $1,042.0028302 90 $930.00 $892.00 $951.00 $1,026.00 $892.00 $951.00 $1,026.0028304 90 $776.00 $974.00 $1,038.00 $1,113.00 $807.00 $859.00 $925.0028305 90 $1,030.00 $913.00 $967.00 $1,036.00 $913.00 $967.00 $1,036.0028306 90 $530.00 $725.00 $774.00 $829.00 $545.00 $581.00 $626.0028307 90 $614.00 $879.00 $938.00 $1,003.00 $612.00 $652.00 $702.0028308 90 $516.00 $648.00 $691.00 $738.00 $495.00 $526.00 $564.0028309 90 $955.00 $1,209.00 $1,289.00 $1,392.00 $1,209.00 $1,289.00 $1,392.0028310 90 $505.00 $645.00 $687.00 $734.00 $487.00 $518.00 $556.0028312 90 $469.00 $586.00 $625.00 $669.00 $437.00 $466.00 $500.0028313 90 $436.00 $610.00 $651.00 $698.00 $507.00 $540.00 $581.0028315 90 $462.00 $570.00 $606.00 $648.00 $444.00 $472.00 $506.0028320 90 $833.00 $858.00 $916.00 $991.00 $858.00 $916.00 $991.0028322 90 $667.00 $969.00 $1,035.00 $1,112.00 $787.00 $840.00 $907.0028340 90 $649.00 $761.00 $808.00 $862.00 $605.00 $641.00 $687.0028341 90 $753.00 $872.00 $925.00 $988.00 $715.00 $757.00 $810.0028344 90 $414.00 $547.00 $582.00 $619.00 $407.00 $432.00 $461.0028345 90 $557.00 $690.00 $735.00 $787.00 $556.00 $591.00 $635.0028360 90 $1,197.00 $1,291.00 $1,380.00 $1,494.00 $1,291.00 $1,380.00 $1,494.0028400 90 $266.00 $307.00 $328.00 $352.00 $281.00 $301.00 $323.0028405 90 $473.00 $507.00 $542.00 $584.00 $483.00 $516.00 $557.0028406 90 $616.00 $699.00 $749.00 $811.00 $699.00 $749.00 $811.0028415 90 $1,354.00 $1,549.00 $1,659.00 $1,799.00 $1,549.00 $1,659.00 $1,799.0028420 90 $1,619.00 $1,615.00 $1,728.00 $1,872.00 $1,615.00 $1,728.00 $1,872.0028430 90 $110.00 $288.00 $307.00 $329.00 $253.00 $270.00 $290.0028435 90 $371.00 $402.00 $430.00 $463.00 $381.00 $407.00 $439.0028436 90 $463.00 $555.00 $595.00 $642.00 $555.00 $595.00 $642.0028445 90 $874.00 $1,448.00 $1,550.00 $1,682.00 $1,448.00 $1,550.00 $1,682.0028446 90 ------- $1,534.00 $1,633.00 $1,760.00 $1,534.00 $1,633.00 $1,760.0028450 90 $148.00 $265.00 $283.00 $303.00 $236.00 $252.00 $270.0028455 90 $321.00 $362.00 $385.00 $413.00 $346.00 $368.00 $395.0028456 90 $288.00 $361.00 $386.00 $415.00 $361.00 $386.00 $415.0028465 90 $533.00 $802.00 $852.00 $914.00 $802.00 $852.00 $914.0028470 90 $178.00 $265.00 $283.00 $304.00 $237.00 $253.00 $272.0028475 90 $296.00 $336.00 $359.00 $386.00 $318.00 $339.00 $365.0028476 90 $364.00 $438.00 $468.00 $503.00 $438.00 $468.00 $503.0028485 90 $521.00 $683.00 $724.00 $773.00 $683.00 $724.00 $773.0028490 90 $80.00 $166.00 $177.00 $189.00 $146.00 $156.00 $166.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

28495 90 $133.00 $208.00 $221.00 $236.00 $191.00 $203.00 $216.0028496 90 $261.00 $532.00 $569.00 $606.00 $295.00 $315.00 $338.0028505 90 $399.00 $800.00 $844.00 $890.00 $604.00 $634.00 $669.0028510 90 $75.00 $144.00 $154.00 $164.00 $142.00 $152.00 $162.0028515 90 $115.00 $188.00 $200.00 $213.00 $178.00 $189.00 $201.0028525 90 $345.00 $686.00 $726.00 $769.00 $489.00 $516.00 $546.0028530 90 $120.00 $138.00 $147.00 $157.00 $131.00 $140.00 $149.0028531 90 $243.00 $490.00 $523.00 $557.00 $257.00 $274.00 $294.0028540 90 $145.00 $248.00 $264.00 $282.00 $237.00 $252.00 $269.0028545 90 $208.00 $292.00 $311.00 $334.00 $276.00 $295.00 $317.0028546 90 $325.00 $570.00 $610.00 $652.00 $396.00 $423.00 $455.0028555 90 $592.00 $1,046.00 $1,109.00 $1,181.00 $828.00 $875.00 $934.0028570 90 $189.00 $221.00 $236.00 $252.00 $204.00 $218.00 $233.0028575 90 $308.00 $407.00 $435.00 $469.00 $389.00 $417.00 $450.0028576 90 $382.00 $471.00 $503.00 $543.00 $471.00 $503.00 $543.0028585 90 $742.00 $1,084.00 $1,150.00 $1,227.00 $932.00 $987.00 $1,055.0028600 90 $144.00 $259.00 $276.00 $295.00 $239.00 $255.00 $273.0028605 90 $287.00 $338.00 $360.00 $386.00 $322.00 $344.00 $369.0028606 90 $487.00 $518.00 $555.00 $600.00 $518.00 $555.00 $600.0028615 90 $621.00 $999.00 $1,060.00 $1,135.00 $999.00 $1,060.00 $1,135.0028630 10 $145.00 $182.00 $193.00 $206.00 $144.00 $152.00 $163.0028635 10 $189.00 $219.00 $233.00 $250.00 $183.00 $194.00 $209.0028636 10 $318.00 $371.00 $396.00 $425.00 $281.00 $300.00 $324.0028645 90 $434.00 $719.00 $758.00 $799.00 $584.00 $613.00 $647.0028660 10 $106.00 $133.00 $141.00 $150.00 $108.00 $115.00 $122.0028665 10 $172.00 $193.00 $206.00 $221.00 $181.00 $192.00 $207.0028666 10 $309.00 $269.00 $288.00 $312.00 $269.00 $288.00 $312.0028675 90 $348.00 $676.00 $715.00 $756.00 $487.00 $512.00 $542.0028705 90 $1,353.00 $1,767.00 $1,887.00 $2,042.00 $1,767.00 $1,887.00 $2,042.0028715 90 $1,179.00 $1,304.00 $1,392.00 $1,504.00 $1,304.00 $1,392.00 $1,504.0028725 90 $1,015.00 $1,087.00 $1,161.00 $1,257.00 $1,087.00 $1,161.00 $1,257.0028730 90 $945.00 $1,115.00 $1,187.00 $1,278.00 $1,115.00 $1,187.00 $1,278.0028735 90 $961.00 $1,069.00 $1,138.00 $1,226.00 $1,069.00 $1,138.00 $1,226.0028737 90 $873.00 $947.00 $1,007.00 $1,084.00 $947.00 $1,007.00 $1,084.0028740 90 $690.00 $1,067.00 $1,136.00 $1,216.00 $835.00 $888.00 $954.0028750 90 $690.00 $1,049.00 $1,118.00 $1,196.00 $796.00 $847.00 $910.0028755 90 $466.00 $610.00 $651.00 $696.00 $454.00 $483.00 $519.0028760 90 $654.00 $949.00 $1,007.00 $1,075.00 $772.00 $818.00 $875.0028800 90 $731.00 $767.00 $816.00 $877.00 $767.00 $816.00 $877.0028805 90 $731.00 $971.00 $1,022.00 $1,085.00 $971.00 $1,022.00 $1,085.0028810 90 $543.00 $588.00 $625.00 $671.00 $588.00 $625.00 $671.0028820 90 $377.00 $658.00 $701.00 $747.00 $462.00 $490.00 $525.0028825 90 $339.00 $567.00 $605.00 $645.00 $379.00 $403.00 $433.0028890 90 ------- $447.00 $476.00 $507.00 $297.00 $315.00 $338.0028899 YYY BR ------- ------- ------- ------- ------- -------29000 0 $247.00 $312.00 $335.00 $362.00 $223.00 $239.00 $260.0029010 0 $271.00 $324.00 $349.00 $378.00 $217.00 $235.00 $257.0029015 0 $289.00 $300.00 $319.00 $339.00 $214.00 $227.00 $243.0029020 0 $237.00 $296.00 $316.00 $337.00 $192.00 $204.00 $219.0029025 0 $188.00 $327.00 $351.00 $379.00 $238.00 $256.00 $278.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

29035 0 $213.00 $288.00 $308.00 $330.00 $182.00 $194.00 $210.0029040 0 $260.00 $276.00 $295.00 $318.00 $204.00 $218.00 $236.0029044 0 $260.00 $316.00 $338.00 $363.00 $212.00 $227.00 $246.0029046 0 $286.00 $339.00 $364.00 $392.00 $246.00 $264.00 $287.0029049 0 $45.00 $112.00 $120.00 $129.00 $80.00 $85.00 $92.0029055 0 $180.00 $252.00 $270.00 $291.00 $175.00 $187.00 $203.0029058 0 $110.00 $145.00 $155.00 $165.00 $110.00 $117.00 $125.0029065 0 $88.00 $118.00 $126.00 $136.00 $89.00 $96.00 $104.0029075 0 $72.00 $109.00 $117.00 $126.00 $80.00 $86.00 $93.0029085 0 $59.00 $116.00 $124.00 $133.00 $85.00 $91.00 $99.0029086 0 $54.00 $86.00 $91.00 $97.00 $61.00 $64.00 $69.0029105 0 $59.00 $109.00 $116.00 $124.00 $77.00 $81.00 $88.0029125 0 $45.00 $83.00 $88.00 $94.00 $54.00 $57.00 $61.0029126 0 $53.00 $97.00 $103.00 $109.00 $65.00 $69.00 $73.0029130 0 $26.00 $51.00 $54.00 $58.00 $37.00 $39.00 $42.0029131 0 $53.00 $61.00 $64.00 $67.00 $40.00 $42.00 $43.0029200 0 $29.00 $67.00 $70.00 $73.00 $51.00 $53.00 $55.0029220 0 $37.00 $68.00 $71.00 $75.00 $52.00 $54.00 $57.0029240 0 $45.00 $76.00 $81.00 $85.00 $57.00 $60.00 $64.0029260 0 $26.00 $65.00 $69.00 $73.00 $47.00 $50.00 $53.0029280 0 $29.00 $63.00 $66.00 $70.00 $44.00 $46.00 $48.0029305 0 $223.00 $289.00 $309.00 $333.00 $206.00 $221.00 $240.0029325 0 $260.00 $312.00 $334.00 $360.00 $229.00 $245.00 $266.0029345 0 $126.00 $171.00 $183.00 $197.00 $135.00 $144.00 $157.0029355 0 $133.00 $176.00 $188.00 $203.00 $144.00 $154.00 $168.0029358 0 $241.00 $189.00 $203.00 $218.00 $137.00 $147.00 $160.0029365 0 $101.00 $152.00 $163.00 $176.00 $116.00 $125.00 $135.0029405 0 $96.00 $112.00 $120.00 $129.00 $86.00 $92.00 $99.0029425 0 $101.00 $121.00 $129.00 $139.00 $94.00 $101.00 $109.0029435 0 $133.00 $148.00 $159.00 $171.00 $115.00 $123.00 $133.0029440 0 $22.00 $66.00 $71.00 $76.00 $46.00 $49.00 $53.0029445 0 $214.00 $189.00 $202.00 $217.00 $151.00 $161.00 $175.0029450 0 $84.00 $195.00 $208.00 $223.00 $168.00 $179.00 $192.0029505 0 $75.00 $95.00 $101.00 $108.00 $61.00 $65.00 $69.0029515 0 $59.00 $87.00 $92.00 $98.00 $64.00 $68.00 $73.0029520 0 $22.00 $65.00 $69.00 $72.00 $49.00 $51.00 $54.0029530 0 $55.00 $67.00 $70.00 $75.00 $48.00 $51.00 $54.0029540 0 $41.00 $53.00 $56.00 $60.00 $44.00 $47.00 $50.0029550 0 $37.00 $51.00 $54.00 $58.00 $41.00 $44.00 $47.0029580 0 $39.00 $65.00 $69.00 $74.00 $48.00 $51.00 $55.0029590 0 $32.00 $70.00 $75.00 $80.00 $56.00 $60.00 $64.0029700 0 $29.00 $79.00 $84.00 $90.00 $46.00 $49.00 $53.0029705 0 $26.00 $86.00 $92.00 $99.00 $65.00 $69.00 $75.0029710 0 $29.00 $150.00 $160.00 $172.00 $110.00 $118.00 $127.0029715 0 $109.00 $111.00 $117.00 $124.00 $72.00 $76.00 $81.0029720 0 $29.00 $99.00 $107.00 $115.00 $60.00 $64.00 $70.0029730 0 $29.00 $83.00 $89.00 $96.00 $62.00 $66.00 $72.0029740 0 $37.00 $122.00 $130.00 $140.00 $91.00 $97.00 $106.0029750 0 $105.00 $129.00 $138.00 $149.00 $103.00 $111.00 $121.0029799 YYY BR ------- ------- ------- ------- ------- -------

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

29800 90 $557.00 $685.00 $730.00 $786.00 $685.00 $730.00 $786.0029804 90 $902.00 $851.00 $910.00 $984.00 $851.00 $910.00 $984.0029805 90 $360.00 $619.00 $664.00 $719.00 $619.00 $664.00 $719.0029806 90 $1,003.00 $1,413.00 $1,513.00 $1,641.00 $1,413.00 $1,513.00 $1,641.0029807 90 $976.00 $1,377.00 $1,474.00 $1,599.00 $1,377.00 $1,474.00 $1,599.0029819 90 $756.00 $776.00 $831.00 $901.00 $776.00 $831.00 $901.0029820 90 $718.00 $716.00 $767.00 $832.00 $716.00 $767.00 $832.0029821 90 $863.00 $782.00 $838.00 $909.00 $782.00 $838.00 $909.0029822 90 $749.00 $760.00 $815.00 $883.00 $760.00 $815.00 $883.0029823 90 $1,330.00 $831.00 $890.00 $965.00 $831.00 $890.00 $965.0029824 90 $611.00 $878.00 $939.00 $1,016.00 $878.00 $939.00 $1,016.0029825 90 $941.00 $775.00 $831.00 $901.00 $775.00 $831.00 $901.0029826 90 $980.00 $891.00 $955.00 $1,036.00 $891.00 $955.00 $1,036.0029827 90 $1,058.00 $1,458.00 $1,563.00 $1,699.00 $1,458.00 $1,563.00 $1,699.0029828 90 ------- $1,192.00 $1,276.00 $1,385.00 $1,192.00 $1,276.00 $1,385.0029830 90 $524.00 $597.00 $640.00 $693.00 $597.00 $640.00 $693.0029834 90 $635.00 $650.00 $697.00 $755.00 $650.00 $697.00 $755.0029835 90 $612.00 $668.00 $716.00 $776.00 $668.00 $716.00 $776.0029836 90 $680.00 $762.00 $815.00 $881.00 $762.00 $815.00 $881.0029837 90 $830.00 $699.00 $749.00 $812.00 $699.00 $749.00 $812.0029838 90 $931.00 $782.00 $837.00 $907.00 $782.00 $837.00 $907.0029840 90 $501.00 $578.00 $617.00 $665.00 $578.00 $617.00 $665.0029843 90 $580.00 $619.00 $661.00 $712.00 $619.00 $661.00 $712.0029844 90 $612.00 $651.00 $697.00 $753.00 $651.00 $697.00 $753.0029845 90 $931.00 $736.00 $783.00 $839.00 $736.00 $783.00 $839.0029846 90 $976.00 $684.00 $731.00 $789.00 $684.00 $731.00 $789.0029847 90 $1,277.00 $707.00 $755.00 $815.00 $707.00 $755.00 $815.0029848 90 $608.00 $633.00 $674.00 $724.00 $633.00 $674.00 $724.0029850 90 $752.00 $727.00 $776.00 $840.00 $727.00 $776.00 $840.0029851 90 $1,137.00 $1,251.00 $1,343.00 $1,462.00 $1,251.00 $1,343.00 $1,462.0029855 90 $1,007.00 $1,046.00 $1,121.00 $1,218.00 $1,046.00 $1,121.00 $1,218.0029856 90 $1,231.00 $1,337.00 $1,433.00 $1,556.00 $1,337.00 $1,433.00 $1,556.0029860 90 $658.00 $853.00 $911.00 $984.00 $853.00 $911.00 $984.0029861 90 $845.00 $937.00 $1,001.00 $1,084.00 $937.00 $1,001.00 $1,084.0029862 90 $907.00 $1,047.00 $1,117.00 $1,204.00 $1,047.00 $1,117.00 $1,204.0029863 90 $880.00 $1,028.00 $1,092.00 $1,171.00 $1,028.00 $1,092.00 $1,171.0029866 90 ------- $1,391.00 $1,489.00 $1,614.00 $1,391.00 $1,489.00 $1,614.0029867 90 ------- $1,681.00 $1,795.00 $1,941.00 $1,681.00 $1,795.00 $1,941.0029868 90 ------- $2,279.00 $2,445.00 $2,661.00 $2,279.00 $2,445.00 $2,661.0029870 90 $460.00 $534.00 $572.00 $618.00 $534.00 $572.00 $618.0029871 90 $631.00 $674.00 $722.00 $783.00 $674.00 $722.00 $783.0029873 90 $489.00 $673.00 $721.00 $780.00 $673.00 $721.00 $780.0029874 90 $676.00 $700.00 $748.00 $808.00 $700.00 $748.00 $808.0029875 90 $639.00 $653.00 $700.00 $759.00 $653.00 $700.00 $759.0029876 90 $809.00 $849.00 $907.00 $980.00 $849.00 $907.00 $980.0029877 90 $852.00 $802.00 $857.00 $926.00 $802.00 $857.00 $926.0029879 90 $1,064.00 $859.00 $918.00 $992.00 $859.00 $918.00 $992.0029880 90 $1,169.00 $898.00 $960.00 $1,038.00 $898.00 $960.00 $1,038.0029881 90 $745.00 $836.00 $893.00 $965.00 $836.00 $893.00 $965.0029882 90 $819.00 $905.00 $968.00 $1,047.00 $905.00 $968.00 $1,047.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

29883 90 $1,235.00 $1,114.00 $1,193.00 $1,293.00 $1,114.00 $1,193.00 $1,293.0029884 90 $721.00 $799.00 $854.00 $922.00 $799.00 $854.00 $922.0029885 90 $832.00 $971.00 $1,038.00 $1,122.00 $971.00 $1,038.00 $1,122.0029886 90 $697.00 $817.00 $873.00 $943.00 $817.00 $873.00 $943.0029887 90 $949.00 $966.00 $1,032.00 $1,116.00 $966.00 $1,032.00 $1,116.0029888 90 $1,296.00 $1,318.00 $1,412.00 $1,534.00 $1,318.00 $1,412.00 $1,534.0029889 90 $1,255.00 $1,603.00 $1,715.00 $1,858.00 $1,603.00 $1,715.00 $1,858.0029891 90 $796.00 $909.00 $969.00 $1,045.00 $909.00 $969.00 $1,045.0029892 90 $835.00 $938.00 $999.00 $1,075.00 $938.00 $999.00 $1,075.0029893 90 $472.00 $713.00 $756.00 $803.00 $552.00 $583.00 $621.0029894 90 $690.00 $687.00 $734.00 $794.00 $687.00 $734.00 $794.0029895 90 $679.00 $669.00 $715.00 $773.00 $669.00 $715.00 $773.0029897 90 $704.00 $700.00 $749.00 $810.00 $700.00 $749.00 $810.0029898 90 $863.00 $781.00 $834.00 $901.00 $781.00 $834.00 $901.0029899 90 $973.00 $1,399.00 $1,495.00 $1,619.00 $1,399.00 $1,495.00 $1,619.0029900 90 $434.00 $607.00 $650.00 $702.00 $607.00 $650.00 $702.0029901 90 $479.00 $671.00 $718.00 $776.00 $671.00 $718.00 $776.0029902 90 $514.00 $700.00 $748.00 $809.00 $700.00 $748.00 $809.0029904 90 ------- $793.00 $846.00 $912.00 $793.00 $846.00 $912.0029905 90 ------- $853.00 $910.00 $981.00 $853.00 $910.00 $981.0029906 90 ------- $899.00 $959.00 $1,034.00 $899.00 $959.00 $1,034.0029907 90 ------- $1,108.00 $1,184.00 $1,282.00 $1,108.00 $1,184.00 $1,282.0029999 YYY BR ------- ------- ------- ------- ------- -------30000 10 $96.00 $280.00 $297.00 $314.00 $146.00 $154.00 $163.0030020 10 $117.00 $264.00 $280.00 $296.00 $149.00 $157.00 $166.0030100 0 $86.00 $164.00 $174.00 $183.00 $89.00 $93.00 $98.0030110 10 $157.00 $267.00 $283.00 $299.00 $164.00 $173.00 $183.0030115 90 $360.00 $532.00 $564.00 $597.00 $532.00 $564.00 $597.0030117 90 $301.00 $953.00 $1,016.00 $1,072.00 $409.00 $433.00 $457.0030118 90 $819.00 $966.00 $1,018.00 $1,075.00 $966.00 $1,018.00 $1,075.0030120 90 $500.00 $630.00 $668.00 $708.00 $568.00 $601.00 $638.0030124 90 $243.00 $350.00 $369.00 $390.00 $350.00 $369.00 $390.0030125 90 $599.00 $782.00 $826.00 $874.00 $782.00 $826.00 $874.0030130 90 $275.00 $465.00 $493.00 $522.00 $465.00 $493.00 $522.0030140 90 $320.00 $523.00 $556.00 $589.00 $523.00 $556.00 $589.0030150 90 $790.00 $1,018.00 $1,078.00 $1,144.00 $1,018.00 $1,078.00 $1,144.0030160 90 $875.00 $1,011.00 $1,067.00 $1,130.00 $1,011.00 $1,067.00 $1,130.0030200 0 $68.00 $132.00 $141.00 $148.00 $77.00 $81.00 $86.0030210 10 $75.00 $174.00 $185.00 $195.00 $123.00 $130.00 $138.0030220 10 $154.00 $334.00 $355.00 $374.00 $157.00 $165.00 $174.0030300 10 $45.00 $279.00 $297.00 $313.00 $150.00 $159.00 $168.0030310 10 $170.00 $256.00 $271.00 $286.00 $256.00 $271.00 $286.0030320 90 $419.00 $580.00 $614.00 $649.00 $580.00 $614.00 $649.0030400 90 $741.00 $1,314.00 $1,393.00 $1,477.00 $1,314.00 $1,393.00 $1,477.0030410 90 $1,173.00 $1,599.00 $1,696.00 $1,801.00 $1,599.00 $1,696.00 $1,801.0030420 90 $1,424.00 $1,740.00 $1,837.00 $1,944.00 $1,740.00 $1,837.00 $1,944.0030430 90 $626.00 $1,166.00 $1,238.00 $1,311.00 $1,166.00 $1,238.00 $1,311.0030435 90 $1,005.00 $1,551.00 $1,644.00 $1,743.00 $1,551.00 $1,644.00 $1,743.0030450 90 $1,445.00 $2,036.00 $2,155.00 $2,290.00 $2,036.00 $2,155.00 $2,290.0030460 90 $857.00 $998.00 $1,056.00 $1,122.00 $998.00 $1,056.00 $1,122.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

30462 90 $1,633.00 $2,019.00 $2,146.00 $2,297.00 $2,019.00 $2,146.00 $2,297.0030465 90 $803.00 $1,233.00 $1,301.00 $1,377.00 $1,233.00 $1,301.00 $1,377.0030520 90 $533.00 $726.00 $764.00 $803.00 $726.00 $764.00 $803.0030540 90 $643.00 $866.00 $915.00 $967.00 $866.00 $915.00 $967.0030545 90 $981.00 $1,250.00 $1,335.00 $1,436.00 $1,250.00 $1,335.00 $1,436.0030560 10 $104.00 $320.00 $340.00 $359.00 $172.00 $182.00 $192.0030580 90 $566.00 $786.00 $837.00 $895.00 $650.00 $691.00 $741.0030600 90 $466.00 $721.00 $765.00 $815.00 $571.00 $605.00 $646.0030620 90 $564.00 $767.00 $812.00 $860.00 $767.00 $812.00 $860.0030630 90 $624.00 $777.00 $821.00 $868.00 $777.00 $821.00 $868.0030801 10 $88.00 $270.00 $288.00 $304.00 $160.00 $170.00 $179.0030802 10 $172.00 $349.00 $370.00 $390.00 $231.00 $244.00 $257.0030901 0 $75.00 $132.00 $139.00 $147.00 $81.00 $85.00 $90.0030903 0 $110.00 $233.00 $247.00 $261.00 $106.00 $111.00 $117.0030905 0 $224.00 $292.00 $310.00 $327.00 $137.00 $144.00 $152.0030906 0 $208.00 $335.00 $355.00 $375.00 $180.00 $189.00 $199.0030915 90 $596.00 $720.00 $759.00 $801.00 $720.00 $759.00 $801.0030920 90 $862.00 $1,029.00 $1,082.00 $1,140.00 $1,029.00 $1,082.00 $1,140.0030930 10 $213.00 $151.00 $160.00 $170.00 $151.00 $160.00 $170.0030999 YYY BR ------- ------- ------- ------- ------- -------31000 10 $81.00 $213.00 $227.00 $239.00 $131.00 $138.00 $145.0031002 10 $135.00 $251.00 $265.00 $280.00 $251.00 $265.00 $280.0031020 90 $281.00 $591.00 $629.00 $666.00 $432.00 $458.00 $485.0031030 90 $531.00 $875.00 $929.00 $985.00 $655.00 $693.00 $736.0031032 90 $604.00 $713.00 $753.00 $797.00 $713.00 $753.00 $797.0031040 90 $772.00 $953.00 $1,005.00 $1,065.00 $953.00 $1,005.00 $1,065.0031050 90 $489.00 $610.00 $645.00 $683.00 $610.00 $645.00 $683.0031051 90 $654.00 $801.00 $846.00 $895.00 $801.00 $846.00 $895.0031070 90 $410.00 $536.00 $567.00 $600.00 $536.00 $567.00 $600.0031075 90 $839.00 $977.00 $1,030.00 $1,088.00 $977.00 $1,030.00 $1,088.0031080 90 $942.00 $1,290.00 $1,364.00 $1,448.00 $1,290.00 $1,364.00 $1,448.0031081 90 $1,089.00 $1,587.00 $1,702.00 $1,842.00 $1,587.00 $1,702.00 $1,842.0031084 90 $1,210.00 $1,447.00 $1,524.00 $1,610.00 $1,447.00 $1,524.00 $1,610.0031085 90 $1,281.00 $1,572.00 $1,667.00 $1,776.00 $1,572.00 $1,667.00 $1,776.0031086 90 $1,081.00 $1,401.00 $1,475.00 $1,555.00 $1,401.00 $1,475.00 $1,555.0031087 90 $1,075.00 $1,394.00 $1,474.00 $1,566.00 $1,394.00 $1,474.00 $1,566.0031090 90 $877.00 $1,234.00 $1,305.00 $1,380.00 $1,234.00 $1,305.00 $1,380.0031200 90 $463.00 $675.00 $713.00 $748.00 $675.00 $713.00 $748.0031201 90 $716.00 $918.00 $971.00 $1,030.00 $918.00 $971.00 $1,030.0031205 90 $851.00 $1,079.00 $1,135.00 $1,192.00 $1,079.00 $1,135.00 $1,192.0031225 90 $1,683.00 $2,260.00 $2,365.00 $2,480.00 $2,260.00 $2,365.00 $2,480.0031230 90 $1,908.00 $2,547.00 $2,662.00 $2,789.00 $2,547.00 $2,662.00 $2,789.0031231 0 $122.00 $233.00 $248.00 $262.00 $100.00 $105.00 $111.0031233 0 $221.00 $332.00 $352.00 $373.00 $183.00 $193.00 $205.0031235 0 $217.00 $383.00 $407.00 $431.00 $219.00 $231.00 $245.0031237 0 $266.00 $414.00 $439.00 $465.00 $244.00 $257.00 $273.0031238 0 $311.00 $426.00 $451.00 $476.00 $264.00 $277.00 $293.0031239 10 $775.00 $843.00 $884.00 $930.00 $843.00 $884.00 $930.0031240 0 $224.00 $217.00 $228.00 $242.00 $217.00 $228.00 $242.0031254 0 $588.00 $373.00 $393.00 $418.00 $373.00 $393.00 $418.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

31255 0 $601.00 $554.00 $585.00 $624.00 $554.00 $585.00 $624.0031256 0 $292.00 $271.00 $286.00 $304.00 $271.00 $286.00 $304.0031267 0 $453.00 $437.00 $461.00 $491.00 $437.00 $461.00 $491.0031276 0 $690.00 $698.00 $737.00 $785.00 $698.00 $737.00 $785.0031287 0 $339.00 $318.00 $335.00 $357.00 $318.00 $335.00 $357.0031288 0 $396.00 $369.00 $389.00 $414.00 $369.00 $389.00 $414.0031290 10 $1,462.00 $1,507.00 $1,580.00 $1,666.00 $1,507.00 $1,580.00 $1,666.0031291 10 $1,551.00 $1,598.00 $1,680.00 $1,779.00 $1,598.00 $1,680.00 $1,779.0031292 10 $1,235.00 $1,304.00 $1,368.00 $1,443.00 $1,304.00 $1,368.00 $1,443.0031293 10 $1,346.00 $1,419.00 $1,487.00 $1,567.00 $1,419.00 $1,487.00 $1,567.0031294 10 $1,587.00 $1,634.00 $1,713.00 $1,806.00 $1,634.00 $1,713.00 $1,806.0031299 YYY BR ------- ------- ------- ------- ------- -------31300 90 $1,295.00 $1,569.00 $1,652.00 $1,741.00 $1,569.00 $1,652.00 $1,741.0031320 90 $508.00 $812.00 $860.00 $908.00 $812.00 $860.00 $908.0031360 90 $1,630.00 $2,418.00 $2,519.00 $2,627.00 $2,418.00 $2,519.00 $2,627.0031365 90 $2,238.00 $3,047.00 $3,175.00 $3,317.00 $3,047.00 $3,175.00 $3,317.0031367 90 $1,913.00 $2,671.00 $2,796.00 $2,932.00 $2,671.00 $2,796.00 $2,932.0031368 90 $2,478.00 $3,017.00 $3,163.00 $3,323.00 $3,017.00 $3,163.00 $3,323.0031370 90 $1,891.00 $2,528.00 $2,652.00 $2,786.00 $2,528.00 $2,652.00 $2,786.0031375 90 $1,720.00 $2,376.00 $2,492.00 $2,617.00 $2,376.00 $2,492.00 $2,617.0031380 90 $1,782.00 $2,355.00 $2,473.00 $2,601.00 $2,355.00 $2,473.00 $2,601.0031382 90 $1,822.00 $2,567.00 $2,688.00 $2,820.00 $2,567.00 $2,688.00 $2,820.0031390 90 $2,513.00 $3,416.00 $3,563.00 $3,725.00 $3,416.00 $3,563.00 $3,725.0031395 90 $2,937.00 $3,658.00 $3,823.00 $4,004.00 $3,658.00 $3,823.00 $4,004.0031400 90 $969.00 $1,261.00 $1,329.00 $1,401.00 $1,261.00 $1,329.00 $1,401.0031420 90 $969.00 $1,051.00 $1,104.00 $1,163.00 $1,051.00 $1,104.00 $1,163.0031500 0 $116.00 $147.00 $153.00 $161.00 $147.00 $153.00 $161.0031502 0 $74.00 $47.00 $49.00 $52.00 $47.00 $49.00 $52.0031505 0 $62.00 $105.00 $111.00 $117.00 $63.00 $66.00 $70.0031510 0 $145.00 $266.00 $281.00 $297.00 $159.00 $167.00 $177.0031511 0 $88.00 $268.00 $283.00 $300.00 $168.00 $177.00 $187.0031512 0 $197.00 $266.00 $281.00 $297.00 $172.00 $181.00 $191.0031513 0 $182.00 $176.00 $184.00 $195.00 $176.00 $184.00 $195.0031515 0 $160.00 $264.00 $280.00 $295.00 $144.00 $151.00 $160.0031525 0 $234.00 $318.00 $336.00 $354.00 $212.00 $223.00 $235.0031526 0 $222.00 $211.00 $222.00 $234.00 $211.00 $222.00 $234.0031527 0 $262.00 $256.00 $269.00 $284.00 $256.00 $269.00 $284.0031528 0 $202.00 $190.00 $199.00 $211.00 $190.00 $199.00 $211.0031529 0 $217.00 $217.00 $228.00 $241.00 $217.00 $228.00 $241.0031530 0 $284.00 $267.00 $280.00 $297.00 $267.00 $280.00 $297.0031531 0 $311.00 $287.00 $302.00 $319.00 $287.00 $302.00 $319.0031535 0 $272.00 $255.00 $268.00 $283.00 $255.00 $268.00 $283.0031536 0 $308.00 $285.00 $300.00 $317.00 $285.00 $300.00 $317.0031540 0 $357.00 $327.00 $343.00 $363.00 $327.00 $343.00 $363.0031541 0 $453.00 $359.00 $376.00 $398.00 $359.00 $376.00 $398.0031545 0 ------- $475.00 $495.00 $518.00 $475.00 $495.00 $518.0031546 0 ------- $729.00 $764.00 $807.00 $729.00 $764.00 $807.0031560 0 $446.00 $422.00 $443.00 $468.00 $422.00 $443.00 $468.0031561 0 $509.00 $462.00 $485.00 $513.00 $462.00 $485.00 $513.0031570 0 $369.00 $454.00 $480.00 $507.00 $307.00 $322.00 $340.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

31571 0 $363.00 $338.00 $355.00 $375.00 $338.00 $355.00 $375.0031575 0 $128.00 $149.00 $158.00 $166.00 $100.00 $106.00 $112.0031576 0 $186.00 $283.00 $299.00 $315.00 $162.00 $170.00 $178.0031577 0 $230.00 $311.00 $329.00 $348.00 $200.00 $211.00 $223.0031578 0 $264.00 $358.00 $379.00 $400.00 $223.00 $234.00 $247.0031579 0 $219.00 $286.00 $303.00 $320.00 $186.00 $195.00 $206.0031580 90 $1,213.00 $1,502.00 $1,580.00 $1,663.00 $1,502.00 $1,580.00 $1,663.0031582 90 $1,881.00 $2,422.00 $2,553.00 $2,694.00 $2,422.00 $2,553.00 $2,694.0031584 90 $1,616.00 $1,927.00 $2,031.00 $2,148.00 $1,927.00 $2,031.00 $2,148.0031587 90 $913.00 $1,234.00 $1,291.00 $1,355.00 $1,234.00 $1,291.00 $1,355.0031588 90 $1,206.00 $1,423.00 $1,497.00 $1,577.00 $1,423.00 $1,497.00 $1,577.0031590 90 $691.00 $1,133.00 $1,205.00 $1,280.00 $1,133.00 $1,205.00 $1,280.0031595 90 $773.00 $970.00 $1,023.00 $1,079.00 $970.00 $1,023.00 $1,079.0031599 YYY BR ------- ------- ------- ------- ------- -------31600 0 $306.00 $537.00 $567.00 $606.00 $537.00 $567.00 $606.0031603 0 $343.00 $302.00 $318.00 $340.00 $302.00 $318.00 $340.0031605 0 $297.00 $249.00 $263.00 $282.00 $249.00 $263.00 $282.0031610 90 $794.00 $899.00 $947.00 $1,002.00 $899.00 $947.00 $1,002.0031611 90 $614.00 $668.00 $704.00 $743.00 $668.00 $704.00 $743.0031612 0 $99.00 $103.00 $109.00 $116.00 $64.00 $67.00 $71.0031613 90 $384.00 $554.00 $587.00 $621.00 $554.00 $587.00 $621.0031614 90 $736.00 $901.00 $948.00 $998.00 $901.00 $948.00 $998.0031615 0 $213.00 $235.00 $248.00 $262.00 $167.00 $175.00 $184.0031620 ZZZ ------- $366.00 $389.00 $411.00 $96.00 $101.00 $106.0031622 0 $230.00 $417.00 $441.00 $464.00 $194.00 $202.00 $212.0031623 0 $225.00 $456.00 $481.00 $504.00 $194.00 $201.00 $209.0031624 0 $217.00 $424.00 $447.00 $468.00 $194.00 $201.00 $209.0031625 0 $235.00 $454.00 $479.00 $503.00 $228.00 $236.00 $246.0031628 0 $269.00 $542.00 $572.00 $599.00 $253.00 $262.00 $272.0031629 0 $198.00 $861.00 $912.00 $957.00 $269.00 $277.00 $287.0031630 0 $308.00 $279.00 $292.00 $309.00 $279.00 $292.00 $309.0031631 0 $252.00 $311.00 $326.00 $344.00 $311.00 $326.00 $344.0031632 ZZZ ------- $104.00 $112.00 $121.00 $76.00 $82.00 $90.0031633 ZZZ ------- $122.00 $129.00 $139.00 $92.00 $97.00 $105.0031635 0 $298.00 $474.00 $500.00 $526.00 $255.00 $266.00 $279.0031636 0 ------- $304.00 $318.00 $334.00 $304.00 $318.00 $334.0031637 ZZZ ------- $108.00 $113.00 $120.00 $108.00 $113.00 $120.0031638 0 ------- $335.00 $347.00 $360.00 $335.00 $347.00 $360.0031640 0 $399.00 $358.00 $376.00 $399.00 $358.00 $376.00 $399.0031641 0 $304.00 $348.00 $363.00 $382.00 $348.00 $363.00 $382.0031643 0 $208.00 $236.00 $245.00 $256.00 $236.00 $245.00 $256.0031645 0 $208.00 $407.00 $429.00 $450.00 $213.00 $221.00 $230.0031646 0 $161.00 $371.00 $391.00 $410.00 $185.00 $192.00 $200.0031656 0 $127.00 $438.00 $465.00 $490.00 $152.00 $158.00 $166.0031715 0 $57.00 $73.00 $76.00 $79.00 $73.00 $76.00 $79.0031717 0 $138.00 $463.00 $492.00 $518.00 $148.00 $155.00 $162.0031720 0 $89.00 $70.00 $73.00 $77.00 $70.00 $73.00 $77.0031725 0 $103.00 $128.00 $133.00 $140.00 $128.00 $133.00 $140.0031730 0 $199.00 $848.00 $904.00 $953.00 $194.00 $202.00 $213.0031750 90 $1,088.00 $1,672.00 $1,761.00 $1,854.00 $1,672.00 $1,761.00 $1,854.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

31755 90 $1,448.00 $2,122.00 $2,242.00 $2,364.00 $2,122.00 $2,242.00 $2,364.0031760 90 $1,648.00 $1,843.00 $1,955.00 $2,101.00 $1,843.00 $1,955.00 $2,101.0031766 90 $2,315.00 $2,476.00 $2,636.00 $2,852.00 $2,476.00 $2,636.00 $2,852.0031770 90 $1,815.00 $1,797.00 $1,903.00 $2,042.00 $1,797.00 $1,903.00 $2,042.0031775 90 $1,973.00 $1,923.00 $2,038.00 $2,188.00 $1,923.00 $2,038.00 $2,188.0031780 90 $1,577.00 $1,552.00 $1,630.00 $1,724.00 $1,552.00 $1,630.00 $1,724.0031781 90 $1,936.00 $1,886.00 $1,982.00 $2,103.00 $1,886.00 $1,982.00 $2,103.0031785 90 $1,320.00 $1,431.00 $1,504.00 $1,592.00 $1,431.00 $1,504.00 $1,592.0031786 90 $1,866.00 $2,019.00 $2,144.00 $2,307.00 $2,019.00 $2,144.00 $2,307.0031800 90 $628.00 $891.00 $943.00 $1,001.00 $891.00 $943.00 $1,001.0031805 90 $1,175.00 $1,108.00 $1,178.00 $1,270.00 $1,108.00 $1,178.00 $1,270.0031820 90 $458.00 $533.00 $563.00 $595.00 $418.00 $440.00 $465.0031825 90 $659.00 $748.00 $788.00 $831.00 $616.00 $647.00 $683.0031830 90 $460.00 $540.00 $573.00 $607.00 $437.00 $461.00 $490.0031899 YYY BR ------- ------- ------- ------- ------- -------32035 90 $821.00 $924.00 $977.00 $1,044.00 $924.00 $977.00 $1,044.0032036 90 $908.00 $1,005.00 $1,064.00 $1,139.00 $1,005.00 $1,064.00 $1,139.0032095 90 $848.00 $831.00 $881.00 $944.00 $831.00 $881.00 $944.0032100 90 $1,120.00 $1,304.00 $1,387.00 $1,497.00 $1,304.00 $1,387.00 $1,497.0032110 90 $1,223.00 $1,952.00 $2,070.00 $2,227.00 $1,952.00 $2,070.00 $2,227.0032120 90 $1,077.00 $1,146.00 $1,212.00 $1,297.00 $1,146.00 $1,212.00 $1,297.0032124 90 $1,144.00 $1,225.00 $1,298.00 $1,394.00 $1,225.00 $1,298.00 $1,394.0032140 90 $1,284.00 $1,310.00 $1,387.00 $1,487.00 $1,310.00 $1,387.00 $1,487.0032141 90 $1,267.00 $1,875.00 $1,958.00 $2,063.00 $1,875.00 $1,958.00 $2,063.0032150 90 $1,226.00 $1,322.00 $1,400.00 $1,501.00 $1,322.00 $1,400.00 $1,501.0032151 90 $1,231.00 $1,349.00 $1,430.00 $1,533.00 $1,349.00 $1,430.00 $1,533.0032160 90 $842.00 $993.00 $1,047.00 $1,114.00 $993.00 $1,047.00 $1,114.0032200 90 $1,132.00 $1,472.00 $1,557.00 $1,667.00 $1,472.00 $1,557.00 $1,667.0032201 0 $387.00 $1,220.00 $1,299.00 $1,367.00 $274.00 $285.00 $299.0032215 90 $1,024.00 $1,070.00 $1,136.00 $1,222.00 $1,070.00 $1,136.00 $1,222.0032220 90 $1,680.00 $2,145.00 $2,280.00 $2,457.00 $2,145.00 $2,280.00 $2,457.0032225 90 $1,268.00 $1,323.00 $1,402.00 $1,506.00 $1,323.00 $1,402.00 $1,506.0032310 90 $1,221.00 $1,228.00 $1,305.00 $1,404.00 $1,228.00 $1,305.00 $1,404.0032320 90 $1,787.00 $2,139.00 $2,271.00 $2,444.00 $2,139.00 $2,271.00 $2,444.0032400 0 $129.00 $198.00 $208.00 $218.00 $119.00 $123.00 $129.0032402 90 $798.00 $747.00 $792.00 $848.00 $747.00 $792.00 $848.0032405 0 $159.00 $133.00 $139.00 $145.00 $132.00 $138.00 $144.0032420 0 $116.00 $147.00 $152.00 $159.00 $147.00 $152.00 $159.0032421 0 ------- $215.00 $227.00 $238.00 $102.00 $106.00 $111.0032422 0 ------- $265.00 $279.00 $292.00 $165.00 $172.00 $179.0032440 90 $1,837.00 $2,164.00 $2,300.00 $2,480.00 $2,164.00 $2,300.00 $2,480.0032442 90 $2,093.00 $3,789.00 $3,947.00 $4,148.00 $3,789.00 $3,947.00 $4,148.0032445 90 $2,093.00 $4,203.00 $4,363.00 $4,563.00 $4,203.00 $4,363.00 $4,563.0032480 90 $1,622.00 $2,041.00 $2,170.00 $2,340.00 $2,041.00 $2,170.00 $2,340.0032482 90 $1,714.00 $2,172.00 $2,308.00 $2,488.00 $2,172.00 $2,308.00 $2,488.0032484 90 $1,771.00 $1,953.00 $2,068.00 $2,218.00 $1,953.00 $2,068.00 $2,218.0032486 90 $1,974.00 $2,986.00 $3,125.00 $3,304.00 $2,986.00 $3,125.00 $3,304.0032488 90 $2,094.00 $3,047.00 $3,196.00 $3,389.00 $3,047.00 $3,196.00 $3,389.0032491 90 $1,784.00 $1,991.00 $2,108.00 $2,260.00 $1,991.00 $2,108.00 $2,260.0032500 90 $1,331.00 $1,974.00 $2,097.00 $2,259.00 $1,974.00 $2,097.00 $2,259.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

32501 ZZZ $374.00 $343.00 $365.00 $395.00 $343.00 $365.00 $395.0032503 90 ------- $2,511.00 $2,670.00 $2,883.00 $2,511.00 $2,670.00 $2,883.0032504 90 ------- $2,867.00 $3,050.00 $3,295.00 $2,867.00 $3,050.00 $3,295.0032540 90 $1,308.00 $2,112.00 $2,202.00 $2,315.00 $2,112.00 $2,202.00 $2,315.0032550 0 ------- $1,102.00 $1,175.00 $1,243.00 $308.00 $324.00 $345.0032551 0 ------- $247.00 $262.00 $282.00 $247.00 $262.00 $282.0032560 0 ------- $409.00 $435.00 $461.00 $153.00 $161.00 $172.0032601 0 $456.00 $430.00 $458.00 $496.00 $430.00 $458.00 $496.0032602 0 $494.00 $467.00 $497.00 $539.00 $467.00 $497.00 $539.0032603 0 $585.00 $601.00 $640.00 $694.00 $601.00 $640.00 $694.0032604 0 $663.00 $673.00 $717.00 $775.00 $673.00 $717.00 $775.0032605 0 $550.00 $541.00 $576.00 $624.00 $541.00 $576.00 $624.0032606 0 $637.00 $648.00 $691.00 $748.00 $648.00 $691.00 $748.0032650 90 $957.00 $931.00 $992.00 $1,072.00 $931.00 $992.00 $1,072.0032651 90 $1,166.00 $1,400.00 $1,474.00 $1,570.00 $1,400.00 $1,474.00 $1,570.0032652 90 $1,615.00 $2,110.00 $2,217.00 $2,356.00 $2,110.00 $2,217.00 $2,356.0032653 90 $1,144.00 $1,360.00 $1,434.00 $1,530.00 $1,360.00 $1,434.00 $1,530.0032654 90 $1,096.00 $1,476.00 $1,545.00 $1,632.00 $1,476.00 $1,545.00 $1,632.0032655 90 $1,213.00 $1,259.00 $1,333.00 $1,428.00 $1,259.00 $1,333.00 $1,428.0032656 90 $1,222.00 $1,117.00 $1,190.00 $1,285.00 $1,117.00 $1,190.00 $1,285.0032657 90 $1,261.00 $1,104.00 $1,179.00 $1,278.00 $1,104.00 $1,179.00 $1,278.0032658 90 $1,142.00 $1,003.00 $1,069.00 $1,155.00 $1,003.00 $1,069.00 $1,155.0032659 90 $1,141.00 $1,017.00 $1,081.00 $1,165.00 $1,017.00 $1,081.00 $1,165.0032660 90 $1,691.00 $1,423.00 $1,507.00 $1,614.00 $1,423.00 $1,507.00 $1,614.0032661 90 $1,165.00 $1,122.00 $1,196.00 $1,292.00 $1,122.00 $1,196.00 $1,292.0032662 90 $1,459.00 $1,260.00 $1,343.00 $1,451.00 $1,260.00 $1,343.00 $1,451.0032663 90 $1,636.00 $1,874.00 $1,979.00 $2,116.00 $1,874.00 $1,979.00 $2,116.0032664 90 $1,197.00 $1,183.00 $1,266.00 $1,377.00 $1,183.00 $1,266.00 $1,377.0032665 90 $1,360.00 $1,596.00 $1,681.00 $1,790.00 $1,596.00 $1,681.00 $1,790.0032800 90 $1,166.00 $1,248.00 $1,324.00 $1,424.00 $1,248.00 $1,324.00 $1,424.0032810 90 $1,085.00 $1,213.00 $1,288.00 $1,385.00 $1,213.00 $1,288.00 $1,385.0032815 90 $1,917.00 $3,338.00 $3,474.00 $3,646.00 $3,338.00 $3,474.00 $3,646.0032820 90 $1,848.00 $1,817.00 $1,922.00 $2,055.00 $1,817.00 $1,922.00 $2,055.0032851 90 $3,100.00 $3,561.00 $3,789.00 $4,078.00 $3,561.00 $3,789.00 $4,078.0032852 90 $3,339.00 $3,968.00 $4,220.00 $4,539.00 $3,968.00 $4,220.00 $4,539.0032853 90 $3,787.00 $4,278.00 $4,555.00 $4,913.00 $4,278.00 $4,555.00 $4,913.0032854 90 $4,038.00 $4,616.00 $4,907.00 $5,280.00 $4,616.00 $4,907.00 $5,280.0032900 90 $1,532.00 $1,832.00 $1,941.00 $2,085.00 $1,832.00 $1,941.00 $2,085.0032905 90 $1,661.00 $1,830.00 $1,946.00 $2,099.00 $1,830.00 $1,946.00 $2,099.0032906 90 $2,100.00 $2,263.00 $2,406.00 $2,596.00 $2,263.00 $2,406.00 $2,596.0032940 90 $1,555.00 $1,675.00 $1,781.00 $1,921.00 $1,675.00 $1,781.00 $1,921.0032960 0 $126.00 $183.00 $193.00 $204.00 $130.00 $136.00 $144.0032997 0 $312.00 $481.00 $502.00 $529.00 $481.00 $502.00 $529.0032998 0 ------- $3,806.00 $4,066.00 $4,286.00 $395.00 $411.00 $431.0032999 YYY BR ------- ------- ------- ------- ------- -------33010 0 $124.00 $162.00 $168.00 $177.00 $162.00 $168.00 $177.0033011 0 $125.00 $165.00 $173.00 $181.00 $165.00 $173.00 $181.0033015 90 $555.00 $700.00 $735.00 $775.00 $700.00 $735.00 $775.0033020 90 $1,178.00 $1,170.00 $1,239.00 $1,329.00 $1,170.00 $1,239.00 $1,329.0033025 90 $1,165.00 $1,089.00 $1,157.00 $1,246.00 $1,089.00 $1,157.00 $1,246.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

33030 90 $1,786.00 $1,737.00 $1,843.00 $1,982.00 $1,737.00 $1,843.00 $1,982.0033031 90 $1,816.00 $1,927.00 $2,042.00 $2,195.00 $1,927.00 $2,042.00 $2,195.0033050 90 $1,224.00 $1,342.00 $1,424.00 $1,531.00 $1,342.00 $1,424.00 $1,531.0033120 90 $2,358.00 $2,131.00 $2,264.00 $2,442.00 $2,131.00 $2,264.00 $2,442.0033130 90 $1,734.00 $1,855.00 $1,967.00 $2,114.00 $1,855.00 $1,967.00 $2,114.0033140 90 $1,571.00 $2,084.00 $2,194.00 $2,338.00 $2,084.00 $2,194.00 $2,338.0033141 ZZZ $254.00 $233.00 $255.00 $286.00 $233.00 $255.00 $286.0033202 90 ------- $1,057.00 $1,122.00 $1,207.00 $1,057.00 $1,122.00 $1,207.0033203 90 ------- $1,070.00 $1,128.00 $1,200.00 $1,070.00 $1,128.00 $1,200.0033206 90 $642.00 $624.00 $654.00 $689.00 $624.00 $654.00 $689.0033207 90 $753.00 $669.00 $702.00 $739.00 $669.00 $702.00 $739.0033208 90 $573.00 $714.00 $747.00 $784.00 $714.00 $747.00 $784.0033210 0 $204.00 $242.00 $252.00 $264.00 $242.00 $252.00 $264.0033211 0 $210.00 $249.00 $259.00 $272.00 $249.00 $259.00 $272.0033212 90 $511.00 $469.00 $493.00 $520.00 $469.00 $493.00 $520.0033213 90 $437.00 $533.00 $558.00 $588.00 $533.00 $558.00 $588.0033214 90 $532.00 $668.00 $701.00 $739.00 $668.00 $701.00 $739.0033215 90 $304.00 $426.00 $447.00 $471.00 $426.00 $447.00 $471.0033216 90 $402.00 $520.00 $545.00 $572.00 $520.00 $545.00 $572.0033217 90 $428.00 $519.00 $544.00 $572.00 $519.00 $544.00 $572.0033218 90 $488.00 $538.00 $563.00 $591.00 $538.00 $563.00 $591.0033220 90 $390.00 $540.00 $565.00 $593.00 $540.00 $565.00 $593.0033222 90 $471.00 $483.00 $509.00 $538.00 $483.00 $509.00 $538.0033223 90 $585.00 $578.00 $606.00 $638.00 $578.00 $606.00 $638.0033224 0 $490.00 $690.00 $719.00 $754.00 $690.00 $719.00 $754.0033225 ZZZ $434.00 $617.00 $642.00 $671.00 $617.00 $642.00 $671.0033226 0 $472.00 $668.00 $698.00 $734.00 $668.00 $698.00 $734.0033233 90 $270.00 $337.00 $354.00 $373.00 $337.00 $354.00 $373.0033234 90 $598.00 $673.00 $706.00 $743.00 $673.00 $706.00 $743.0033235 90 $587.00 $875.00 $919.00 $968.00 $875.00 $919.00 $968.0033236 90 $933.00 $1,073.00 $1,140.00 $1,227.00 $1,073.00 $1,140.00 $1,227.0033237 90 $1,184.00 $1,167.00 $1,235.00 $1,321.00 $1,167.00 $1,235.00 $1,321.0033238 90 $1,235.00 $1,285.00 $1,366.00 $1,469.00 $1,285.00 $1,366.00 $1,469.0033240 90 $648.00 $636.00 $664.00 $694.00 $636.00 $664.00 $694.0033241 90 $301.00 $316.00 $331.00 $347.00 $316.00 $331.00 $347.0033243 90 $1,650.00 $1,826.00 $1,919.00 $2,035.00 $1,826.00 $1,919.00 $2,035.0033244 90 $1,081.00 $1,187.00 $1,245.00 $1,310.00 $1,187.00 $1,245.00 $1,310.0033249 90 $1,271.00 $1,229.00 $1,282.00 $1,339.00 $1,229.00 $1,282.00 $1,339.0033250 90 $1,687.00 $2,011.00 $2,131.00 $2,289.00 $2,011.00 $2,131.00 $2,289.0033251 90 $2,071.00 $2,204.00 $2,335.00 $2,510.00 $2,204.00 $2,335.00 $2,510.0033254 90 ------- $1,861.00 $1,981.00 $2,141.00 $1,861.00 $1,981.00 $2,141.0033255 90 ------- $2,238.00 $2,379.00 $2,567.00 $2,238.00 $2,379.00 $2,567.0033256 90 ------- $2,681.00 $2,854.00 $3,087.00 $2,681.00 $2,854.00 $3,087.0033257 ZZZ ------- $796.00 $838.00 $889.00 $796.00 $838.00 $889.0033258 ZZZ ------- $903.00 $952.00 $1,012.00 $903.00 $952.00 $1,012.0033259 ZZZ ------- $1,195.00 $1,268.00 $1,361.00 $1,195.00 $1,268.00 $1,361.0033261 90 $1,993.00 $2,213.00 $2,343.00 $2,513.00 $2,213.00 $2,343.00 $2,513.0033265 90 ------- $1,861.00 $1,981.00 $2,141.00 $1,861.00 $1,981.00 $2,141.0033266 90 ------- $2,554.00 $2,721.00 $2,947.00 $2,554.00 $2,721.00 $2,947.0033282 90 $470.00 $445.00 $466.00 $487.00 $445.00 $466.00 $487.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

33284 90 $365.00 $326.00 $342.00 $358.00 $326.00 $342.00 $358.0033300 90 $1,576.00 $2,926.00 $3,037.00 $3,177.00 $2,926.00 $3,037.00 $3,177.0033305 90 $1,889.00 $4,750.00 $4,893.00 $5,069.00 $4,750.00 $4,893.00 $5,069.0033310 90 $1,577.00 $1,603.00 $1,701.00 $1,829.00 $1,603.00 $1,701.00 $1,829.0033315 90 $1,875.00 $2,014.00 $2,135.00 $2,296.00 $2,014.00 $2,135.00 $2,296.0033320 90 $1,485.00 $1,437.00 $1,519.00 $1,625.00 $1,437.00 $1,519.00 $1,625.0033321 90 $1,890.00 $1,657.00 $1,764.00 $1,905.00 $1,657.00 $1,764.00 $1,905.0033322 90 $1,935.00 $1,866.00 $1,974.00 $2,116.00 $1,866.00 $1,974.00 $2,116.0033330 90 $1,726.00 $1,900.00 $2,007.00 $2,147.00 $1,900.00 $2,007.00 $2,147.0033332 90 $1,915.00 $1,888.00 $2,001.00 $2,149.00 $1,888.00 $2,001.00 $2,149.0033335 90 $2,336.00 $2,572.00 $2,727.00 $2,933.00 $2,572.00 $2,727.00 $2,933.0033400 90 $2,401.00 $3,025.00 $3,183.00 $3,389.00 $3,025.00 $3,183.00 $3,389.0033401 90 $2,228.00 $2,024.00 $2,157.00 $2,332.00 $2,024.00 $2,157.00 $2,332.0033403 90 $2,369.00 $2,145.00 $2,283.00 $2,462.00 $2,145.00 $2,283.00 $2,462.0033404 90 $2,698.00 $2,475.00 $2,632.00 $2,841.00 $2,475.00 $2,632.00 $2,841.0033405 90 $2,745.00 $3,192.00 $3,387.00 $3,646.00 $3,192.00 $3,387.00 $3,646.0033406 90 $2,962.00 $3,838.00 $4,043.00 $4,313.00 $3,838.00 $4,043.00 $4,313.0033410 90 $2,637.00 $3,373.00 $3,551.00 $3,784.00 $3,373.00 $3,551.00 $3,784.0033411 90 $2,981.00 $4,339.00 $4,549.00 $4,823.00 $4,339.00 $4,549.00 $4,823.0033412 90 $3,213.00 $3,478.00 $3,705.00 $4,010.00 $3,478.00 $3,705.00 $4,010.0033413 90 $3,282.00 $4,432.00 $4,677.00 $4,999.00 $4,432.00 $4,677.00 $4,999.0033414 90 $2,904.00 $2,918.00 $3,084.00 $3,306.00 $2,918.00 $3,084.00 $3,306.0033415 90 $2,563.00 $2,704.00 $2,854.00 $3,054.00 $2,704.00 $2,854.00 $3,054.0033416 90 $2,684.00 $2,742.00 $2,906.00 $3,125.00 $2,742.00 $2,906.00 $3,125.0033417 90 $2,756.00 $2,328.00 $2,477.00 $2,676.00 $2,328.00 $2,477.00 $2,676.0033420 90 $1,796.00 $1,826.00 $1,906.00 $2,006.00 $1,826.00 $1,906.00 $2,006.0033422 90 $2,431.00 $2,328.00 $2,473.00 $2,664.00 $2,328.00 $2,473.00 $2,664.0033425 90 $2,509.00 $3,429.00 $3,587.00 $3,793.00 $3,429.00 $3,587.00 $3,793.0033426 90 $2,806.00 $3,247.00 $3,434.00 $3,680.00 $3,247.00 $3,434.00 $3,680.0033427 90 $3,026.00 $3,459.00 $3,676.00 $3,967.00 $3,459.00 $3,676.00 $3,967.0033430 90 $2,891.00 $3,684.00 $3,877.00 $4,130.00 $3,684.00 $3,877.00 $4,130.0033460 90 $2,215.00 $3,019.00 $3,153.00 $3,327.00 $3,019.00 $3,153.00 $3,327.0033463 90 $2,396.00 $3,797.00 $3,954.00 $4,154.00 $3,797.00 $3,954.00 $4,154.0033464 90 $2,547.00 $3,153.00 $3,310.00 $3,517.00 $3,153.00 $3,310.00 $3,517.0033465 90 $2,665.00 $3,489.00 $3,655.00 $3,873.00 $3,489.00 $3,655.00 $3,873.0033468 90 $2,952.00 $2,586.00 $2,741.00 $2,944.00 $2,586.00 $2,741.00 $2,944.0033470 90 $1,749.00 $1,548.00 $1,607.00 $1,675.00 $1,548.00 $1,607.00 $1,675.0033471 90 $1,929.00 $1,875.00 $1,999.00 $2,163.00 $1,875.00 $1,999.00 $2,163.0033472 90 $2,001.00 $1,873.00 $2,000.00 $2,170.00 $1,873.00 $2,000.00 $2,170.0033474 90 $2,173.00 $2,695.00 $2,819.00 $2,981.00 $2,695.00 $2,819.00 $2,981.0033475 90 $2,666.00 $3,136.00 $3,316.00 $3,555.00 $3,136.00 $3,316.00 $3,555.0033476 90 $2,270.00 $1,990.00 $2,092.00 $2,220.00 $1,990.00 $2,092.00 $2,220.0033478 90 $2,544.00 $2,196.00 $2,338.00 $2,526.00 $2,196.00 $2,338.00 $2,526.0033496 90 $2,595.00 $2,319.00 $2,466.00 $2,664.00 $2,319.00 $2,466.00 $2,664.0033500 90 $2,370.00 $2,176.00 $2,314.00 $2,499.00 $2,176.00 $2,314.00 $2,499.0033501 90 $1,546.00 $1,471.00 $1,548.00 $1,647.00 $1,471.00 $1,548.00 $1,647.0033502 90 $1,938.00 $1,767.00 $1,879.00 $2,027.00 $1,767.00 $1,879.00 $2,027.0033503 90 $1,983.00 $1,739.00 $1,824.00 $1,926.00 $1,739.00 $1,824.00 $1,926.0033504 90 $2,416.00 $2,014.00 $2,140.00 $2,305.00 $2,014.00 $2,140.00 $2,305.0033505 90 $2,423.00 $2,676.00 $2,781.00 $2,909.00 $2,676.00 $2,781.00 $2,909.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

33506 90 $2,448.00 $2,827.00 $2,994.00 $3,217.00 $2,827.00 $2,994.00 $3,217.0033507 90 ------- $2,413.00 $2,560.00 $2,756.00 $2,413.00 $2,560.00 $2,756.0033508 ZZZ $17.00 $23.00 $24.00 $26.00 $23.00 $24.00 $26.0033510 90 $2,354.00 $2,719.00 $2,883.00 $3,099.00 $2,719.00 $2,883.00 $3,099.0033511 90 $2,546.00 $2,943.00 $3,114.00 $3,339.00 $2,943.00 $3,114.00 $3,339.0033512 90 $2,732.00 $3,269.00 $3,447.00 $3,680.00 $3,269.00 $3,447.00 $3,680.0033513 90 $2,933.00 $3,367.00 $3,552.00 $3,794.00 $3,367.00 $3,552.00 $3,794.0033514 90 $3,197.00 $3,516.00 $3,700.00 $3,940.00 $3,516.00 $3,700.00 $3,940.0033516 90 $3,404.00 $3,657.00 $3,853.00 $4,109.00 $3,657.00 $3,853.00 $4,109.0033517 ZZZ $219.00 $248.00 $262.00 $280.00 $248.00 $262.00 $280.0033518 ZZZ $414.00 $529.00 $554.00 $589.00 $529.00 $554.00 $589.0033519 ZZZ $607.00 $712.00 $748.00 $797.00 $712.00 $748.00 $797.0033521 ZZZ $801.00 $871.00 $918.00 $982.00 $871.00 $918.00 $982.0033522 ZZZ $994.00 $1,006.00 $1,066.00 $1,147.00 $1,006.00 $1,066.00 $1,147.0033523 ZZZ $1,189.00 $1,157.00 $1,228.00 $1,325.00 $1,157.00 $1,228.00 $1,325.0033530 ZZZ $521.00 $667.00 $698.00 $740.00 $667.00 $698.00 $740.0033533 90 $2,415.00 $2,667.00 $2,835.00 $3,057.00 $2,667.00 $2,835.00 $3,057.0033534 90 $2,654.00 $3,052.00 $3,229.00 $3,462.00 $3,052.00 $3,229.00 $3,462.0033535 90 $2,899.00 $3,356.00 $3,545.00 $3,793.00 $3,356.00 $3,545.00 $3,793.0033536 90 $3,143.00 $3,591.00 $3,793.00 $4,059.00 $3,591.00 $3,793.00 $4,059.0033542 90 $2,693.00 $3,352.00 $3,517.00 $3,733.00 $3,352.00 $3,517.00 $3,733.0033545 90 $3,250.00 $3,981.00 $4,177.00 $4,435.00 $3,981.00 $4,177.00 $4,435.0033548 90 ------- $3,939.00 $4,148.00 $4,422.00 $3,939.00 $4,148.00 $4,422.0033572 ZZZ $340.00 $329.00 $350.00 $380.00 $329.00 $350.00 $380.0033600 90 $2,644.00 $2,383.00 $2,539.00 $2,750.00 $2,383.00 $2,539.00 $2,750.0033602 90 $2,556.00 $2,264.00 $2,403.00 $2,588.00 $2,264.00 $2,403.00 $2,588.0033606 90 $2,831.00 $2,462.00 $2,620.00 $2,831.00 $2,462.00 $2,620.00 $2,831.0033608 90 $2,940.00 $2,540.00 $2,708.00 $2,934.00 $2,540.00 $2,708.00 $2,934.0033610 90 $2,871.00 $2,507.00 $2,672.00 $2,891.00 $2,507.00 $2,672.00 $2,891.0033611 90 $2,985.00 $2,676.00 $2,834.00 $3,045.00 $2,676.00 $2,834.00 $3,045.0033612 90 $3,152.00 $2,870.00 $3,058.00 $3,309.00 $2,870.00 $3,058.00 $3,309.0033615 90 $3,051.00 $2,696.00 $2,853.00 $3,063.00 $2,696.00 $2,853.00 $3,063.0033617 90 $3,272.00 $3,027.00 $3,224.00 $3,491.00 $3,027.00 $3,224.00 $3,491.0033619 90 $3,678.00 $3,764.00 $3,998.00 $4,309.00 $3,764.00 $3,998.00 $4,309.0033641 90 $1,981.00 $2,153.00 $2,272.00 $2,429.00 $2,153.00 $2,272.00 $2,429.0033645 90 $2,352.00 $2,176.00 $2,312.00 $2,494.00 $2,176.00 $2,312.00 $2,494.0033647 90 $2,732.00 $2,304.00 $2,436.00 $2,606.00 $2,304.00 $2,436.00 $2,606.0033660 90 $2,444.00 $2,480.00 $2,639.00 $2,853.00 $2,480.00 $2,639.00 $2,853.0033665 90 $2,700.00 $2,600.00 $2,748.00 $2,944.00 $2,600.00 $2,748.00 $2,944.0033670 90 $2,820.00 $2,807.00 $2,976.00 $3,201.00 $2,807.00 $2,976.00 $3,201.0033675 90 ------- $2,865.00 $3,047.00 $3,288.00 $2,865.00 $3,047.00 $3,288.0033676 90 ------- $2,966.00 $3,161.00 $3,422.00 $2,966.00 $3,161.00 $3,422.0033677 90 ------- $3,084.00 $3,287.00 $3,559.00 $3,084.00 $3,287.00 $3,559.0033681 90 $2,657.00 $2,552.00 $2,715.00 $2,930.00 $2,552.00 $2,715.00 $2,930.0033684 90 $2,740.00 $2,552.00 $2,686.00 $2,859.00 $2,552.00 $2,686.00 $2,859.0033688 90 $2,602.00 $2,556.00 $2,715.00 $2,934.00 $2,556.00 $2,715.00 $2,934.0033690 90 $1,884.00 $1,575.00 $1,658.00 $1,763.00 $1,575.00 $1,658.00 $1,763.0033692 90 $2,816.00 $2,674.00 $2,850.00 $3,080.00 $2,674.00 $2,850.00 $3,080.0033694 90 $2,856.00 $2,692.00 $2,869.00 $3,113.00 $2,692.00 $2,869.00 $3,113.0033697 90 $3,064.00 $2,880.00 $3,040.00 $3,248.00 $2,880.00 $3,040.00 $3,248.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

33702 90 $2,549.00 $2,142.00 $2,277.00 $2,455.00 $2,142.00 $2,277.00 $2,455.0033710 90 $2,731.00 $2,404.00 $2,561.00 $2,773.00 $2,404.00 $2,561.00 $2,773.0033720 90 $2,508.00 $2,153.00 $2,291.00 $2,476.00 $2,153.00 $2,291.00 $2,476.0033722 90 $2,704.00 $2,079.00 $2,155.00 $2,243.00 $2,079.00 $2,155.00 $2,243.0033724 90 ------- $2,130.00 $2,268.00 $2,456.00 $2,130.00 $2,268.00 $2,456.0033726 90 ------- $2,800.00 $2,975.00 $3,211.00 $2,800.00 $2,975.00 $3,211.0033730 90 $2,785.00 $2,765.00 $2,941.00 $3,178.00 $2,765.00 $2,941.00 $3,178.0033732 90 $2,622.00 $2,295.00 $2,435.00 $2,618.00 $2,295.00 $2,435.00 $2,618.0033735 90 $2,036.00 $1,687.00 $1,772.00 $1,876.00 $1,687.00 $1,772.00 $1,876.0033736 90 $2,288.00 $1,978.00 $2,099.00 $2,255.00 $1,978.00 $2,099.00 $2,255.0033737 90 $1,977.00 $1,808.00 $1,926.00 $2,084.00 $1,808.00 $1,926.00 $2,084.0033750 90 $1,877.00 $1,619.00 $1,683.00 $1,758.00 $1,619.00 $1,683.00 $1,758.0033755 90 $1,831.00 $1,727.00 $1,840.00 $1,992.00 $1,727.00 $1,840.00 $1,992.0033762 90 $1,900.00 $1,774.00 $1,887.00 $2,039.00 $1,774.00 $1,887.00 $2,039.0033764 90 $1,895.00 $1,772.00 $1,882.00 $2,029.00 $1,772.00 $1,882.00 $2,029.0033766 90 $2,119.00 $1,896.00 $2,026.00 $2,201.00 $1,896.00 $2,026.00 $2,201.0033767 90 $2,173.00 $1,989.00 $2,123.00 $2,303.00 $1,989.00 $2,123.00 $2,303.0033768 ZZZ ------- $582.00 $621.00 $674.00 $582.00 $621.00 $674.0033770 90 $2,954.00 $2,952.00 $3,146.00 $3,410.00 $2,952.00 $3,146.00 $3,410.0033771 90 $2,924.00 $2,993.00 $3,182.00 $3,443.00 $2,993.00 $3,182.00 $3,443.0033774 90 $2,681.00 $2,534.00 $2,704.00 $2,933.00 $2,534.00 $2,704.00 $2,933.0033775 90 $2,654.00 $2,565.00 $2,736.00 $2,969.00 $2,565.00 $2,736.00 $2,969.0033776 90 $2,844.00 $2,677.00 $2,852.00 $3,091.00 $2,677.00 $2,852.00 $3,091.0033777 90 $2,724.00 $2,669.00 $2,854.00 $3,107.00 $2,669.00 $2,854.00 $3,107.0033778 90 $3,199.00 $3,289.00 $3,503.00 $3,794.00 $3,289.00 $3,503.00 $3,794.0033779 90 $3,121.00 $2,954.00 $3,077.00 $3,233.00 $2,954.00 $3,077.00 $3,233.0033780 90 $3,232.00 $3,156.00 $3,307.00 $3,499.00 $3,156.00 $3,307.00 $3,499.0033781 90 $3,057.00 $3,112.00 $3,307.00 $3,578.00 $3,112.00 $3,307.00 $3,578.0033786 90 $2,970.00 $3,183.00 $3,383.00 $3,653.00 $3,183.00 $3,383.00 $3,653.0033788 90 $2,288.00 $2,105.00 $2,243.00 $2,431.00 $2,105.00 $2,243.00 $2,431.0033800 90 $1,546.00 $1,377.00 $1,467.00 $1,585.00 $1,377.00 $1,467.00 $1,585.0033802 90 $1,752.00 $1,466.00 $1,554.00 $1,669.00 $1,466.00 $1,554.00 $1,669.0033803 90 $1,746.00 $1,605.00 $1,715.00 $1,865.00 $1,605.00 $1,715.00 $1,865.0033813 90 $1,935.00 $1,739.00 $1,853.00 $2,006.00 $1,739.00 $1,853.00 $2,006.0033814 90 $2,464.00 $2,122.00 $2,261.00 $2,446.00 $2,122.00 $2,261.00 $2,446.0033820 90 $1,619.00 $1,349.00 $1,436.00 $1,551.00 $1,349.00 $1,436.00 $1,551.0033822 90 $1,559.00 $1,413.00 $1,507.00 $1,635.00 $1,413.00 $1,507.00 $1,635.0033824 90 $1,884.00 $1,634.00 $1,740.00 $1,881.00 $1,634.00 $1,740.00 $1,881.0033840 90 $2,029.00 $1,658.00 $1,748.00 $1,862.00 $1,658.00 $1,748.00 $1,862.0033845 90 $2,129.00 $1,843.00 $1,962.00 $2,119.00 $1,843.00 $1,962.00 $2,119.0033851 90 $2,129.00 $1,767.00 $1,883.00 $2,036.00 $1,767.00 $1,883.00 $2,036.0033852 90 $2,311.00 $1,965.00 $2,066.00 $2,189.00 $1,965.00 $2,066.00 $2,189.0033853 90 $3,057.00 $2,551.00 $2,713.00 $2,929.00 $2,551.00 $2,713.00 $2,929.0033860 90 $3,044.00 $4,160.00 $4,371.00 $4,652.00 $4,160.00 $4,371.00 $4,652.0033861 90 $3,069.00 $3,404.00 $3,625.00 $3,925.00 $3,404.00 $3,625.00 $3,925.0033863 90 $3,183.00 $4,237.00 $4,472.00 $4,788.00 $4,237.00 $4,472.00 $4,788.0033864 90 ------- $4,357.00 $4,599.00 $4,923.00 $4,357.00 $4,599.00 $4,923.0033870 90 $3,638.00 $3,549.00 $3,779.00 $4,090.00 $3,549.00 $3,779.00 $4,090.0033875 90 $2,876.00 $2,739.00 $2,911.00 $3,143.00 $2,739.00 $2,911.00 $3,143.0033877 90 $3,767.00 $4,638.00 $4,855.00 $5,144.00 $4,638.00 $4,855.00 $5,144.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

33880 90 ------- $2,447.00 $2,560.00 $2,704.00 $2,447.00 $2,560.00 $2,704.0033881 90 ------- $2,110.00 $2,208.00 $2,331.00 $2,110.00 $2,208.00 $2,331.0033883 90 ------- $1,563.00 $1,646.00 $1,753.00 $1,563.00 $1,646.00 $1,753.0033884 ZZZ ------- $570.00 $600.00 $641.00 $570.00 $600.00 $641.0033886 90 ------- $1,352.00 $1,423.00 $1,516.00 $1,352.00 $1,423.00 $1,516.0033889 0 ------- $1,149.00 $1,221.00 $1,320.00 $1,149.00 $1,221.00 $1,320.0033891 0 ------- $1,475.00 $1,567.00 $1,693.00 $1,475.00 $1,567.00 $1,693.0033910 90 $1,987.00 $2,252.00 $2,387.00 $2,566.00 $2,252.00 $2,387.00 $2,566.0033915 90 $1,588.00 $1,749.00 $1,819.00 $1,903.00 $1,749.00 $1,819.00 $1,903.0033916 90 $2,096.00 $2,174.00 $2,307.00 $2,484.00 $2,174.00 $2,307.00 $2,484.0033917 90 $2,345.00 $2,030.00 $2,164.00 $2,342.00 $2,030.00 $2,164.00 $2,342.0033920 90 $2,981.00 $2,460.00 $2,612.00 $2,819.00 $2,460.00 $2,612.00 $2,819.0033922 90 $2,227.00 $1,906.00 $2,022.00 $2,175.00 $1,906.00 $2,022.00 $2,175.0033924 ZZZ $421.00 $409.00 $436.00 $473.00 $409.00 $436.00 $473.0033925 90 ------- $2,611.00 $2,783.00 $3,010.00 $2,611.00 $2,783.00 $3,010.0033926 90 ------- $3,404.00 $3,620.00 $3,912.00 $3,404.00 $3,620.00 $3,912.0033935 90 $5,415.00 $4,908.00 $5,231.00 $5,663.00 $4,908.00 $5,231.00 $5,663.0033945 90 $3,813.00 $5,974.00 $6,225.00 $6,547.00 $5,974.00 $6,225.00 $6,547.0033960 0 $1,221.00 $1,373.00 $1,459.00 $1,579.00 $1,373.00 $1,459.00 $1,579.0033961 ZZZ $800.00 $747.00 $781.00 $826.00 $747.00 $781.00 $826.0033967 0 $258.00 $361.00 $378.00 $398.00 $361.00 $378.00 $398.0033968 0 $51.00 $47.00 $50.00 $54.00 $47.00 $50.00 $54.0033970 0 $576.00 $502.00 $532.00 $571.00 $502.00 $532.00 $571.0033971 90 $578.00 $959.00 $1,012.00 $1,079.00 $959.00 $1,012.00 $1,079.0033973 0 $756.00 $739.00 $784.00 $845.00 $739.00 $784.00 $845.0033974 90 $1,095.00 $1,230.00 $1,302.00 $1,393.00 $1,230.00 $1,302.00 $1,393.0033975 0 $1,758.00 $1,543.00 $1,643.00 $1,783.00 $1,543.00 $1,643.00 $1,783.0033976 0 $2,056.00 $1,718.00 $1,828.00 $1,978.00 $1,718.00 $1,828.00 $1,978.0033977 90 $1,561.00 $1,677.00 $1,785.00 $1,926.00 $1,677.00 $1,785.00 $1,926.0033978 90 $1,754.00 $1,874.00 $1,997.00 $2,160.00 $1,874.00 $1,997.00 $2,160.0033979 0 $2,496.00 $3,415.00 $3,643.00 $3,958.00 $3,415.00 $3,643.00 $3,958.0033980 90 $3,212.00 $4,935.00 $5,240.00 $5,649.00 $4,935.00 $5,240.00 $5,649.0033999 YYY BR ------- ------- ------- ------- ------- -------34001 90 $1,012.00 $1,309.00 $1,379.00 $1,471.00 $1,309.00 $1,379.00 $1,471.0034051 90 $1,134.00 $1,350.00 $1,433.00 $1,542.00 $1,350.00 $1,433.00 $1,542.0034101 90 $800.00 $862.00 $916.00 $985.00 $862.00 $916.00 $985.0034111 90 $669.00 $861.00 $914.00 $983.00 $861.00 $914.00 $983.0034151 90 $1,288.00 $1,999.00 $2,123.00 $2,292.00 $1,999.00 $2,123.00 $2,292.0034201 90 $777.00 $1,324.00 $1,382.00 $1,457.00 $1,324.00 $1,382.00 $1,457.0034203 90 $949.00 $1,380.00 $1,466.00 $1,580.00 $1,380.00 $1,466.00 $1,580.0034401 90 $953.00 $1,985.00 $2,099.00 $2,250.00 $1,985.00 $2,099.00 $2,250.0034421 90 $779.00 $1,034.00 $1,094.00 $1,172.00 $1,034.00 $1,094.00 $1,172.0034451 90 $1,117.00 $2,160.00 $2,294.00 $2,476.00 $2,160.00 $2,294.00 $2,476.0034471 90 $685.00 $1,409.00 $1,462.00 $1,528.00 $1,409.00 $1,462.00 $1,528.0034490 90 $660.00 $865.00 $918.00 $988.00 $865.00 $918.00 $988.0034501 90 $910.00 $1,345.00 $1,432.00 $1,546.00 $1,345.00 $1,432.00 $1,546.0034502 90 $2,044.00 $2,165.00 $2,298.00 $2,474.00 $2,165.00 $2,298.00 $2,474.0034510 90 $1,108.00 $1,538.00 $1,628.00 $1,744.00 $1,538.00 $1,628.00 $1,744.0034520 90 $1,077.00 $1,463.00 $1,549.00 $1,662.00 $1,463.00 $1,549.00 $1,662.0034530 90 $1,368.00 $1,357.00 $1,428.00 $1,520.00 $1,357.00 $1,428.00 $1,520.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

34800 90 $1,159.00 $1,613.00 $1,705.00 $1,826.00 $1,613.00 $1,705.00 $1,826.0034802 90 $1,279.00 $1,748.00 $1,839.00 $1,957.00 $1,748.00 $1,839.00 $1,957.0034803 90 ------- $1,777.00 $1,861.00 $1,967.00 $1,777.00 $1,861.00 $1,967.0034804 90 $1,279.00 $1,743.00 $1,833.00 $1,950.00 $1,743.00 $1,833.00 $1,950.0034805 90 ------- $1,643.00 $1,724.00 $1,828.00 $1,643.00 $1,724.00 $1,828.0034806 ZZZ ------- $146.00 $155.00 $169.00 $146.00 $155.00 $169.0034808 ZZZ $220.00 $301.00 $320.00 $347.00 $301.00 $320.00 $347.0034812 0 $359.00 $508.00 $545.00 $597.00 $508.00 $545.00 $597.0034813 ZZZ $256.00 $346.00 $368.00 $398.00 $346.00 $368.00 $398.0034820 0 $519.00 $718.00 $767.00 $834.00 $718.00 $767.00 $834.0034825 90 $694.00 $981.00 $1,034.00 $1,101.00 $981.00 $1,034.00 $1,101.0034826 ZZZ $220.00 $291.00 $307.00 $328.00 $291.00 $307.00 $328.0034830 90 $1,803.00 $2,610.00 $2,768.00 $2,983.00 $2,610.00 $2,768.00 $2,983.0034831 90 $1,950.00 $2,741.00 $2,906.00 $3,132.00 $2,741.00 $2,906.00 $3,132.0034832 90 $1,950.00 $2,823.00 $2,993.00 $3,223.00 $2,823.00 $2,993.00 $3,223.0034833 0 $650.00 $890.00 $947.00 $1,026.00 $890.00 $947.00 $1,026.0034834 0 $306.00 $405.00 $431.00 $466.00 $405.00 $431.00 $466.0034900 90 $960.00 $1,287.00 $1,362.00 $1,461.00 $1,287.00 $1,362.00 $1,461.0035001 90 $1,564.00 $1,626.00 $1,728.00 $1,864.00 $1,626.00 $1,728.00 $1,864.0035002 90 $1,547.00 $1,707.00 $1,814.00 $1,957.00 $1,707.00 $1,814.00 $1,957.0035005 90 $1,268.00 $1,475.00 $1,551.00 $1,646.00 $1,475.00 $1,551.00 $1,646.0035011 90 $1,007.00 $1,428.00 $1,518.00 $1,639.00 $1,428.00 $1,518.00 $1,639.0035013 90 $1,376.00 $1,766.00 $1,876.00 $2,024.00 $1,766.00 $1,876.00 $2,024.0035021 90 $1,635.00 $1,712.00 $1,816.00 $1,956.00 $1,712.00 $1,816.00 $1,956.0035022 90 $1,686.00 $1,965.00 $2,082.00 $2,237.00 $1,965.00 $2,082.00 $2,237.0035045 90 $995.00 $1,381.00 $1,468.00 $1,585.00 $1,381.00 $1,468.00 $1,585.0035081 90 $2,175.00 $2,440.00 $2,581.00 $2,771.00 $2,440.00 $2,581.00 $2,771.0035082 90 $2,661.00 $3,102.00 $3,290.00 $3,546.00 $3,102.00 $3,290.00 $3,546.0035091 90 $2,634.00 $2,657.00 $2,830.00 $3,066.00 $2,657.00 $2,830.00 $3,066.0035092 90 $2,872.00 $3,697.00 $3,917.00 $4,216.00 $3,697.00 $3,917.00 $4,216.0035102 90 $2,346.00 $2,655.00 $2,811.00 $3,022.00 $2,655.00 $2,811.00 $3,022.0035103 90 $2,587.00 $3,212.00 $3,409.00 $3,677.00 $3,212.00 $3,409.00 $3,677.0035111 90 $1,398.00 $1,979.00 $2,101.00 $2,265.00 $1,979.00 $2,101.00 $2,265.0035112 90 $1,351.00 $2,398.00 $2,541.00 $2,734.00 $2,398.00 $2,541.00 $2,734.0035121 90 $2,000.00 $2,374.00 $2,523.00 $2,725.00 $2,374.00 $2,523.00 $2,725.0035122 90 $2,382.00 $2,783.00 $2,948.00 $3,172.00 $2,783.00 $2,948.00 $3,172.0035131 90 $1,495.00 $2,020.00 $2,151.00 $2,329.00 $2,020.00 $2,151.00 $2,329.0035132 90 $1,742.00 $2,431.00 $2,581.00 $2,784.00 $2,431.00 $2,581.00 $2,784.0035141 90 $1,231.00 $1,604.00 $1,706.00 $1,844.00 $1,604.00 $1,706.00 $1,844.0035142 90 $1,339.00 $1,907.00 $2,026.00 $2,185.00 $1,907.00 $2,026.00 $2,185.0035151 90 $1,390.00 $1,806.00 $1,920.00 $2,074.00 $1,806.00 $1,920.00 $2,074.0035152 90 $1,229.00 $2,091.00 $2,220.00 $2,392.00 $2,091.00 $2,220.00 $2,392.0035180 90 $997.00 $1,114.00 $1,163.00 $1,222.00 $1,114.00 $1,163.00 $1,222.0035182 90 $1,345.00 $2,420.00 $2,573.00 $2,779.00 $2,420.00 $2,573.00 $2,779.0035184 90 $976.00 $1,449.00 $1,540.00 $1,661.00 $1,449.00 $1,540.00 $1,661.0035188 90 $1,048.00 $1,226.00 $1,305.00 $1,411.00 $1,226.00 $1,305.00 $1,411.0035189 90 $1,380.00 $2,286.00 $2,428.00 $2,619.00 $2,286.00 $2,428.00 $2,619.0035190 90 $1,018.00 $1,062.00 $1,128.00 $1,216.00 $1,062.00 $1,128.00 $1,216.0035201 90 $852.00 $1,334.00 $1,419.00 $1,532.00 $1,334.00 $1,419.00 $1,532.0035206 90 $835.00 $1,091.00 $1,160.00 $1,251.00 $1,091.00 $1,160.00 $1,251.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

35207 90 $935.00 $976.00 $1,039.00 $1,118.00 $976.00 $1,039.00 $1,118.0035211 90 $1,833.00 $1,912.00 $2,030.00 $2,186.00 $1,912.00 $2,030.00 $2,186.0035216 90 $1,494.00 $2,487.00 $2,594.00 $2,732.00 $2,487.00 $2,594.00 $2,732.0035221 90 $1,243.00 $1,970.00 $2,089.00 $2,248.00 $1,970.00 $2,089.00 $2,248.0035226 90 $841.00 $1,206.00 $1,281.00 $1,379.00 $1,206.00 $1,281.00 $1,379.0035231 90 $1,053.00 $1,656.00 $1,761.00 $1,900.00 $1,656.00 $1,761.00 $1,900.0035236 90 $947.00 $1,390.00 $1,477.00 $1,593.00 $1,390.00 $1,477.00 $1,593.0035241 90 $1,926.00 $2,006.00 $2,134.00 $2,304.00 $2,006.00 $2,134.00 $2,304.0035246 90 $1,701.00 $2,166.00 $2,303.00 $2,486.00 $2,166.00 $2,303.00 $2,486.0035251 90 $1,260.00 $2,354.00 $2,496.00 $2,690.00 $2,354.00 $2,496.00 $2,690.0035256 90 $1,568.00 $1,468.00 $1,561.00 $1,686.00 $1,468.00 $1,561.00 $1,686.0035261 90 $1,008.00 $1,469.00 $1,562.00 $1,686.00 $1,469.00 $1,562.00 $1,686.0035266 90 $921.00 $1,218.00 $1,294.00 $1,395.00 $1,218.00 $1,294.00 $1,395.0035271 90 $1,814.00 $1,906.00 $2,022.00 $2,176.00 $1,906.00 $2,022.00 $2,176.0035276 90 $1,541.00 $2,009.00 $2,136.00 $2,304.00 $2,009.00 $2,136.00 $2,304.0035281 90 $1,396.00 $2,245.00 $2,384.00 $2,571.00 $2,245.00 $2,384.00 $2,571.0035286 90 $1,036.00 $1,346.00 $1,432.00 $1,545.00 $1,346.00 $1,432.00 $1,545.0035301 90 $1,486.00 $1,508.00 $1,603.00 $1,730.00 $1,508.00 $1,603.00 $1,730.0035302 90 ------- $1,581.00 $1,681.00 $1,818.00 $1,581.00 $1,681.00 $1,818.0035303 90 ------- $1,736.00 $1,845.00 $1,995.00 $1,736.00 $1,845.00 $1,995.0035304 90 ------- $1,807.00 $1,921.00 $2,078.00 $1,807.00 $1,921.00 $2,078.0035305 90 ------- $1,736.00 $1,845.00 $1,995.00 $1,736.00 $1,845.00 $1,995.0035306 ZZZ ------- $655.00 $697.00 $756.00 $655.00 $697.00 $756.0035311 90 $1,999.00 $2,145.00 $2,270.00 $2,435.00 $2,145.00 $2,270.00 $2,435.0035321 90 $1,031.00 $1,283.00 $1,363.00 $1,471.00 $1,283.00 $1,363.00 $1,471.0035331 90 $1,724.00 $2,101.00 $2,235.00 $2,415.00 $2,101.00 $2,235.00 $2,415.0035341 90 $1,908.00 $2,003.00 $2,133.00 $2,310.00 $2,003.00 $2,133.00 $2,310.0035351 90 $1,555.00 $1,848.00 $1,964.00 $2,121.00 $1,848.00 $1,964.00 $2,121.0035355 90 $1,336.00 $1,502.00 $1,595.00 $1,721.00 $1,502.00 $1,595.00 $1,721.0035361 90 $1,859.00 $2,275.00 $2,419.00 $2,613.00 $2,275.00 $2,419.00 $2,613.0035363 90 $2,006.00 $2,432.00 $2,583.00 $2,787.00 $2,432.00 $2,583.00 $2,787.0035371 90 $1,006.00 $1,192.00 $1,268.00 $1,370.00 $1,192.00 $1,268.00 $1,370.0035372 90 $1,085.00 $1,432.00 $1,524.00 $1,648.00 $1,432.00 $1,524.00 $1,648.0035390 ZZZ $225.00 $233.00 $248.00 $269.00 $233.00 $248.00 $269.0035400 ZZZ $224.00 $220.00 $235.00 $254.00 $220.00 $235.00 $254.0035450 0 $643.00 $735.00 $778.00 $837.00 $735.00 $778.00 $837.0035452 0 $518.00 $515.00 $547.00 $591.00 $515.00 $547.00 $591.0035454 0 $520.00 $454.00 $484.00 $524.00 $454.00 $484.00 $524.0035456 0 $631.00 $549.00 $584.00 $632.00 $549.00 $584.00 $632.0035458 0 $804.00 $702.00 $745.00 $804.00 $702.00 $745.00 $804.0035459 0 $736.00 $646.00 $687.00 $743.00 $646.00 $687.00 $743.0035460 0 $430.00 $449.00 $478.00 $516.00 $449.00 $478.00 $516.0035470 0 $537.00 $4,210.00 $4,495.00 $4,743.00 $629.00 $659.00 $696.0035471 0 $626.00 $4,681.00 $4,996.00 $5,266.00 $741.00 $773.00 $812.0035472 0 $388.00 $3,167.00 $3,381.00 $3,568.00 $509.00 $534.00 $565.0035473 0 $375.00 $2,983.00 $3,186.00 $3,362.00 $447.00 $468.00 $496.0035474 0 $456.00 $4,093.00 $4,372.00 $4,612.00 $537.00 $562.00 $593.0035475 0 $569.00 $3,113.00 $3,316.00 $3,494.00 $668.00 $696.00 $731.0035476 0 $338.00 $2,357.00 $2,512.00 $2,645.00 $425.00 $441.00 $461.0035480 0 $935.00 $823.00 $870.00 $932.00 $823.00 $870.00 $932.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

35481 0 $565.00 $582.00 $621.00 $673.00 $582.00 $621.00 $673.0035482 0 $577.00 $497.00 $528.00 $570.00 $497.00 $528.00 $570.0035483 0 $696.00 $610.00 $650.00 $703.00 $610.00 $650.00 $703.0035484 0 $853.00 $757.00 $801.00 $861.00 $757.00 $801.00 $861.0035485 0 $670.00 $712.00 $758.00 $821.00 $712.00 $758.00 $821.0035490 0 $691.00 $823.00 $858.00 $901.00 $823.00 $858.00 $901.0035491 0 $423.00 $594.00 $625.00 $665.00 $594.00 $625.00 $665.0035492 0 $423.00 $513.00 $536.00 $563.00 $513.00 $536.00 $563.0035493 0 $523.00 $618.00 $646.00 $679.00 $618.00 $646.00 $679.0035494 0 $605.00 $777.00 $809.00 $846.00 $777.00 $809.00 $846.0035495 0 $532.00 $721.00 $754.00 $794.00 $721.00 $754.00 $794.0035500 ZZZ $423.00 $467.00 $497.00 $539.00 $467.00 $497.00 $539.0035501 90 $1,569.00 $2,175.00 $2,314.00 $2,504.00 $2,175.00 $2,314.00 $2,504.0035506 90 $1,641.00 $1,857.00 $1,961.00 $2,100.00 $1,857.00 $1,961.00 $2,100.0035508 90 $1,564.00 $1,896.00 $2,000.00 $2,136.00 $1,896.00 $2,000.00 $2,136.0035509 90 $1,529.00 $2,114.00 $2,249.00 $2,432.00 $2,114.00 $2,249.00 $2,432.0035510 90 ------- $1,756.00 $1,841.00 $1,951.00 $1,756.00 $1,841.00 $1,951.0035511 90 $1,256.00 $1,695.00 $1,799.00 $1,939.00 $1,695.00 $1,799.00 $1,939.0035512 90 ------- $1,722.00 $1,807.00 $1,916.00 $1,722.00 $1,807.00 $1,916.0035515 90 $1,387.00 $1,900.00 $2,004.00 $2,140.00 $1,900.00 $2,004.00 $2,140.0035516 90 $1,391.00 $1,674.00 $1,759.00 $1,872.00 $1,674.00 $1,759.00 $1,872.0035518 90 $1,313.00 $1,708.00 $1,814.00 $1,957.00 $1,708.00 $1,814.00 $1,957.0035521 90 $1,393.00 $1,819.00 $1,931.00 $2,080.00 $1,819.00 $1,931.00 $2,080.0035522 90 ------- $1,679.00 $1,764.00 $1,872.00 $1,679.00 $1,764.00 $1,872.0035523 90 ------- $1,757.00 $1,845.00 $1,956.00 $1,757.00 $1,845.00 $1,956.0035525 90 ------- $1,592.00 $1,675.00 $1,783.00 $1,592.00 $1,675.00 $1,783.0035526 90 $1,527.00 $2,429.00 $2,569.00 $2,751.00 $2,429.00 $2,569.00 $2,751.0035531 90 $2,000.00 $2,890.00 $3,068.00 $3,310.00 $2,890.00 $3,068.00 $3,310.0035533 90 $1,716.00 $2,234.00 $2,370.00 $2,553.00 $2,234.00 $2,370.00 $2,553.0035536 90 $1,888.00 $2,506.00 $2,663.00 $2,878.00 $2,506.00 $2,663.00 $2,878.0035537 90 ------- $3,069.00 $3,261.00 $3,525.00 $3,069.00 $3,261.00 $3,525.0035538 90 ------- $3,428.00 $3,642.00 $3,935.00 $3,428.00 $3,642.00 $3,935.0035539 90 ------- $3,216.00 $3,417.00 $3,693.00 $3,216.00 $3,417.00 $3,693.0035540 90 ------- $3,588.00 $3,812.00 $4,122.00 $3,588.00 $3,812.00 $4,122.0035548 90 $1,751.00 $1,725.00 $1,832.00 $1,974.00 $1,725.00 $1,832.00 $1,974.0035549 90 $1,902.00 $1,882.00 $2,000.00 $2,158.00 $1,882.00 $2,000.00 $2,158.0035551 90 $2,036.00 $2,121.00 $2,253.00 $2,432.00 $2,121.00 $2,253.00 $2,432.0035556 90 $1,745.00 $1,955.00 $2,066.00 $2,215.00 $1,955.00 $2,066.00 $2,215.0035558 90 $1,219.00 $1,753.00 $1,860.00 $2,004.00 $1,753.00 $1,860.00 $2,004.0035560 90 $1,899.00 $2,567.00 $2,730.00 $2,952.00 $2,567.00 $2,730.00 $2,952.0035563 90 $1,115.00 $1,985.00 $2,109.00 $2,276.00 $1,985.00 $2,109.00 $2,276.0035565 90 $1,312.00 $1,893.00 $2,010.00 $2,166.00 $1,893.00 $2,010.00 $2,166.0035566 90 $2,161.00 $2,347.00 $2,483.00 $2,664.00 $2,347.00 $2,483.00 $2,664.0035571 90 $1,612.00 $1,938.00 $2,059.00 $2,221.00 $1,938.00 $2,059.00 $2,221.0035572 ZZZ $369.00 $502.00 $535.00 $580.00 $502.00 $535.00 $580.0035583 90 $1,843.00 $2,018.00 $2,132.00 $2,284.00 $2,018.00 $2,132.00 $2,284.0035585 90 $2,277.00 $2,390.00 $2,532.00 $2,723.00 $2,390.00 $2,532.00 $2,723.0035587 90 $1,698.00 $2,003.00 $2,128.00 $2,296.00 $2,003.00 $2,128.00 $2,296.0035600 ZZZ $273.00 $368.00 $392.00 $426.00 $368.00 $392.00 $426.0035601 90 $1,495.00 $2,039.00 $2,167.00 $2,342.00 $2,039.00 $2,167.00 $2,342.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

35606 90 $1,539.00 $1,672.00 $1,770.00 $1,900.00 $1,672.00 $1,770.00 $1,900.0035612 90 $1,349.00 $1,305.00 $1,383.00 $1,487.00 $1,305.00 $1,383.00 $1,487.0035616 90 $1,346.00 $1,576.00 $1,659.00 $1,768.00 $1,576.00 $1,659.00 $1,768.0035621 90 $1,265.00 $1,602.00 $1,704.00 $1,841.00 $1,602.00 $1,704.00 $1,841.0035623 90 $1,193.00 $1,959.00 $2,080.00 $2,244.00 $1,959.00 $2,080.00 $2,244.0035626 90 $1,921.00 $2,245.00 $2,388.00 $2,581.00 $2,245.00 $2,388.00 $2,581.0035631 90 $1,891.00 $2,689.00 $2,858.00 $3,089.00 $2,689.00 $2,858.00 $3,089.0035636 90 $1,656.00 $2,360.00 $2,503.00 $2,697.00 $2,360.00 $2,503.00 $2,697.0035637 90 ------- $2,430.00 $2,581.00 $2,787.00 $2,430.00 $2,581.00 $2,787.0035638 90 ------- $2,469.00 $2,623.00 $2,832.00 $2,469.00 $2,623.00 $2,832.0035642 90 $1,298.00 $1,438.00 $1,523.00 $1,634.00 $1,438.00 $1,523.00 $1,634.0035645 90 $1,304.00 $1,466.00 $1,558.00 $1,681.00 $1,466.00 $1,558.00 $1,681.0035646 90 $2,105.00 $2,483.00 $2,638.00 $2,847.00 $2,483.00 $2,638.00 $2,847.0035647 90 $1,555.00 $2,243.00 $2,383.00 $2,571.00 $2,243.00 $2,383.00 $2,571.0035650 90 $1,236.00 $1,541.00 $1,637.00 $1,767.00 $1,541.00 $1,637.00 $1,767.0035651 90 $2,055.00 $1,972.00 $2,092.00 $2,253.00 $1,972.00 $2,092.00 $2,253.0035654 90 $1,603.00 $1,984.00 $2,108.00 $2,275.00 $1,984.00 $2,108.00 $2,275.0035656 90 $1,589.00 $1,566.00 $1,664.00 $1,797.00 $1,566.00 $1,664.00 $1,797.0035661 90 $1,145.00 $1,565.00 $1,662.00 $1,793.00 $1,565.00 $1,662.00 $1,793.0035663 90 $1,237.00 $1,811.00 $1,922.00 $2,071.00 $1,811.00 $1,922.00 $2,071.0035665 90 $1,333.00 $1,703.00 $1,809.00 $1,952.00 $1,703.00 $1,809.00 $1,952.0035666 90 $1,686.00 $1,834.00 $1,949.00 $2,101.00 $1,834.00 $1,949.00 $2,101.0035671 90 $1,315.00 $1,615.00 $1,716.00 $1,850.00 $1,615.00 $1,716.00 $1,850.0035681 ZZZ $751.00 $117.00 $124.00 $135.00 $117.00 $124.00 $135.0035682 ZZZ $627.00 $521.00 $555.00 $601.00 $521.00 $555.00 $601.0035683 ZZZ $702.00 $614.00 $653.00 $707.00 $614.00 $653.00 $707.0035685 ZZZ $216.00 $293.00 $312.00 $338.00 $293.00 $312.00 $338.0035686 ZZZ $178.00 $244.00 $259.00 $280.00 $244.00 $259.00 $280.0035691 90 $1,546.00 $1,424.00 $1,516.00 $1,639.00 $1,424.00 $1,516.00 $1,639.0035693 90 $1,140.00 $1,256.00 $1,337.00 $1,445.00 $1,256.00 $1,337.00 $1,445.0035694 90 $1,353.00 $1,488.00 $1,583.00 $1,712.00 $1,488.00 $1,583.00 $1,712.0035695 90 $1,351.00 $1,537.00 $1,633.00 $1,764.00 $1,537.00 $1,633.00 $1,764.0035697 ZZZ ------- $217.00 $231.00 $250.00 $217.00 $231.00 $250.0035700 ZZZ $264.00 $224.00 $238.00 $258.00 $224.00 $238.00 $258.0035701 90 $494.00 $753.00 $798.00 $856.00 $753.00 $798.00 $856.0035721 90 $500.00 $648.00 $689.00 $742.00 $648.00 $689.00 $742.0035741 90 $499.00 $706.00 $750.00 $806.00 $706.00 $750.00 $806.0035761 90 $532.00 $519.00 $552.00 $592.00 $519.00 $552.00 $592.0035800 90 $567.00 $666.00 $705.00 $755.00 $666.00 $705.00 $755.0035820 90 $951.00 $2,386.00 $2,471.00 $2,577.00 $2,386.00 $2,471.00 $2,577.0035840 90 $771.00 $869.00 $921.00 $989.00 $869.00 $921.00 $989.0035860 90 $496.00 $563.00 $596.00 $638.00 $563.00 $596.00 $638.0035870 90 $1,583.00 $1,827.00 $1,935.00 $2,079.00 $1,827.00 $1,935.00 $2,079.0035875 90 $827.00 $848.00 $901.00 $971.00 $848.00 $901.00 $971.0035876 90 $1,232.00 $1,360.00 $1,445.00 $1,559.00 $1,360.00 $1,445.00 $1,559.0035879 90 $1,163.00 $1,334.00 $1,416.00 $1,526.00 $1,334.00 $1,416.00 $1,526.0035881 90 $1,275.00 $1,484.00 $1,576.00 $1,699.00 $1,484.00 $1,576.00 $1,699.0035883 90 ------- $1,761.00 $1,873.00 $2,023.00 $1,761.00 $1,873.00 $2,023.0035884 90 ------- $1,871.00 $1,990.00 $2,150.00 $1,871.00 $1,990.00 $2,150.0035901 90 $709.00 $717.00 $764.00 $823.00 $717.00 $764.00 $823.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

35903 90 $818.00 $815.00 $867.00 $934.00 $815.00 $867.00 $934.0035905 90 $1,343.00 $2,516.00 $2,671.00 $2,881.00 $2,516.00 $2,671.00 $2,881.0035907 90 $1,335.00 $2,761.00 $2,930.00 $3,161.00 $2,761.00 $2,930.00 $3,161.0036000 0 $46.00 $35.00 $37.00 $39.00 $12.00 $13.00 $13.0036002 0 $181.00 $233.00 $247.00 $261.00 $151.00 $159.00 $168.0036005 0 $68.00 $451.00 $482.00 $507.00 $66.00 $69.00 $72.0036010 0 $136.00 $890.00 $949.00 $1,002.00 $169.00 $177.00 $188.0036011 0 $194.00 $1,355.00 $1,446.00 $1,527.00 $221.00 $231.00 $245.0036012 0 $186.00 $1,163.00 $1,239.00 $1,305.00 $244.00 $255.00 $267.0036013 0 $141.00 $1,141.00 $1,220.00 $1,288.00 $179.00 $188.00 $200.0036014 0 $159.00 $1,134.00 $1,208.00 $1,273.00 $210.00 $219.00 $230.0036015 0 $186.00 $1,237.00 $1,317.00 $1,388.00 $237.00 $247.00 $258.0036100 0 $176.00 $745.00 $793.00 $838.00 $220.00 $231.00 $245.0036120 0 $120.00 $603.00 $642.00 $677.00 $136.00 $142.00 $150.0036140 0 $106.00 $688.00 $734.00 $774.00 $141.00 $147.00 $155.0036145 0 $10.00 $674.00 $718.00 $756.00 $136.00 $141.00 $148.0036160 0 $196.00 $765.00 $816.00 $863.00 $186.00 $196.00 $209.0036200 0 $240.00 $915.00 $975.00 $1,029.00 $211.00 $221.00 $233.0036215 0 $240.00 $1,565.00 $1,667.00 $1,755.00 $328.00 $341.00 $357.0036216 0 $270.00 $1,700.00 $1,810.00 $1,906.00 $369.00 $384.00 $402.0036217 0 $325.00 $2,863.00 $3,055.00 $3,221.00 $445.00 $465.00 $489.0036218 ZZZ $79.00 $274.00 $292.00 $308.00 $71.00 $74.00 $78.0036245 0 $249.00 $1,766.00 $1,882.00 $1,984.00 $339.00 $353.00 $371.0036246 0 $272.00 $1,713.00 $1,825.00 $1,924.00 $373.00 $389.00 $410.0036247 0 $323.00 $2,699.00 $2,881.00 $3,038.00 $445.00 $465.00 $490.0036248 ZZZ $53.00 $233.00 $248.00 $261.00 $71.00 $74.00 $78.0036260 90 $749.00 $801.00 $851.00 $916.00 $801.00 $851.00 $916.0036261 90 $388.00 $484.00 $514.00 $551.00 $484.00 $514.00 $551.0036262 90 $297.00 $370.00 $393.00 $422.00 $370.00 $393.00 $422.0036299 YYY BR ------- ------- ------- ------- ------- -------36410 0 $18.00 $24.00 $26.00 $27.00 $12.00 $12.00 $13.0036415 0 BR ------- ------- ------- ------- ------- -------36416 0 BR ------- ------- ------- ------- ------- -------36425 0 $86.00 $51.00 $53.00 $56.00 $51.00 $53.00 $56.0036430 0 $37.00 $53.00 $58.00 $63.00 $53.00 $58.00 $63.0036455 0 $141.00 $168.00 $175.00 $183.00 $168.00 $175.00 $183.0036468 0 NC BR BR BR BR BR BR36469 0 NC BR BR BR BR BR BR36470 10 $76.00 $188.00 $200.00 $212.00 $95.00 $101.00 $107.0036471 10 $96.00 $231.00 $246.00 $262.00 $134.00 $142.00 $152.0036475 0 ------- $2,523.00 $2,689.00 $2,831.00 $455.00 $473.00 $494.0036476 ZZZ ------- $523.00 $553.00 $581.00 $222.00 $230.00 $240.0036478 0 ------- $2,189.00 $2,330.00 $2,453.00 $459.00 $477.00 $498.0036479 ZZZ ------- $532.00 $562.00 $590.00 $225.00 $233.00 $244.0036481 0 $499.00 $496.00 $518.00 $547.00 $496.00 $518.00 $547.0036500 0 $159.00 $246.00 $256.00 $268.00 $246.00 $256.00 $268.0036511 0 $92.00 $120.00 $125.00 $130.00 $120.00 $125.00 $130.0036512 0 $92.00 $121.00 $126.00 $131.00 $121.00 $126.00 $131.0036513 0 $92.00 $127.00 $134.00 $142.00 $127.00 $134.00 $142.0036514 0 $92.00 $774.00 $826.00 $869.00 $119.00 $123.00 $128.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

36515 0 $92.00 $2,882.00 $3,084.00 $3,251.00 $116.00 $120.00 $125.0036516 0 $92.00 $3,403.00 $3,644.00 $3,843.00 $85.00 $88.00 $93.0036522 0 $305.00 $1,833.00 $1,961.00 $2,069.00 $136.00 $143.00 $151.0036556 0 ------- $344.00 $364.00 $384.00 $165.00 $172.00 $181.0036558 10 ------- $1,168.00 $1,247.00 $1,322.00 $394.00 $418.00 $447.0036561 10 ------- $1,623.00 $1,730.00 $1,829.00 $467.00 $492.00 $522.0036563 10 ------- $1,604.00 $1,715.00 $1,821.00 $498.00 $529.00 $570.0036565 10 ------- $1,383.00 $1,472.00 $1,557.00 $463.00 $487.00 $517.0036566 10 ------- $3,785.00 $4,045.00 $4,269.00 $494.00 $518.00 $549.0036569 0 ------- $396.00 $422.00 $446.00 $131.00 $138.00 $148.0036571 10 ------- $1,739.00 $1,856.00 $1,964.00 $424.00 $447.00 $477.0036575 0 ------- $231.00 $249.00 $268.00 $60.00 $66.00 $74.0036576 10 ------- $487.00 $515.00 $541.00 $251.00 $262.00 $275.0036578 10 ------- $687.00 $729.00 $766.00 $287.00 $300.00 $314.0036580 0 ------- $349.00 $373.00 $396.00 $97.00 $104.00 $112.0036581 10 ------- $1,052.00 $1,119.00 $1,178.00 $269.00 $280.00 $293.0036582 10 ------- $1,448.00 $1,538.00 $1,616.00 $393.00 $407.00 $422.0036583 10 ------- $1,452.00 $1,542.00 $1,619.00 $396.00 $410.00 $426.0036584 0 ------- $345.00 $369.00 $393.00 $101.00 $107.00 $117.0036585 10 ------- $1,500.00 $1,595.00 $1,676.00 $370.00 $384.00 $399.0036589 10 ------- $228.00 $242.00 $257.00 $191.00 $202.00 $215.0036590 10 ------- $365.00 $389.00 $417.00 $274.00 $291.00 $313.0036591 0 ------- $28.00 $30.00 $32.00 $28.00 $30.00 $32.0036592 0 ------- $34.00 $37.00 $39.00 $34.00 $37.00 $39.0036593 0 ------- $59.00 $71.00 $87.00 $59.00 $71.00 $87.0036595 0 ------- $887.00 $943.00 $992.00 $256.00 $266.00 $278.0036596 0 ------- $196.00 $208.00 $219.00 $63.00 $66.00 $69.0036597 0 ------- $174.00 $183.00 $193.00 $85.00 $88.00 $93.0036598 0 ------- $160.00 $170.00 $179.00 $112.00 $118.00 $124.0036600 0 $24.00 $41.00 $43.00 $45.00 $21.00 $21.00 $22.0036620 0 $64.00 $69.00 $71.00 $75.00 $69.00 $71.00 $75.0036625 0 $133.00 $146.00 $154.00 $166.00 $146.00 $154.00 $166.0036640 0 $130.00 $164.00 $173.00 $184.00 $164.00 $173.00 $184.0036680 0 $72.00 $85.00 $89.00 $94.00 $85.00 $89.00 $94.0036800 0 $159.00 $217.00 $230.00 $244.00 $217.00 $230.00 $244.0036810 0 $345.00 $297.00 $314.00 $336.00 $297.00 $314.00 $336.0036815 0 $236.00 $206.00 $219.00 $236.00 $206.00 $219.00 $236.0036818 90 ------- $968.00 $1,035.00 $1,125.00 $968.00 $1,035.00 $1,125.0036819 90 $977.00 $1,118.00 $1,189.00 $1,283.00 $1,118.00 $1,189.00 $1,283.0036820 90 $800.00 $1,121.00 $1,191.00 $1,285.00 $1,121.00 $1,191.00 $1,285.0036821 90 $721.00 $742.00 $789.00 $850.00 $742.00 $789.00 $850.0036822 90 $630.00 $524.00 $559.00 $602.00 $524.00 $559.00 $602.0036823 90 $1,461.00 $1,751.00 $1,857.00 $1,997.00 $1,751.00 $1,857.00 $1,997.0036825 90 $867.00 $809.00 $860.00 $926.00 $809.00 $860.00 $926.0036830 90 $967.00 $929.00 $988.00 $1,067.00 $929.00 $988.00 $1,067.0036831 90 $488.00 $641.00 $681.00 $735.00 $641.00 $681.00 $735.0036832 90 $810.00 $819.00 $871.00 $940.00 $819.00 $871.00 $940.0036833 90 $780.00 $925.00 $983.00 $1,062.00 $925.00 $983.00 $1,062.0036834 90 $761.00 $855.00 $906.00 $973.00 $855.00 $906.00 $973.0036835 90 $542.00 $628.00 $667.00 $718.00 $628.00 $667.00 $718.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

36838 90 ------- $1,664.00 $1,770.00 $1,913.00 $1,664.00 $1,770.00 $1,913.0036860 0 $166.00 $232.00 $243.00 $255.00 $136.00 $141.00 $147.0036861 0 $224.00 $207.00 $219.00 $234.00 $207.00 $219.00 $234.0036870 90 $1,755.00 $2,611.00 $2,786.00 $2,935.00 $414.00 $431.00 $452.0037140 90 $1,666.00 $1,825.00 $1,911.00 $2,019.00 $1,825.00 $1,911.00 $2,019.0037145 90 $1,741.00 $2,018.00 $2,139.00 $2,299.00 $2,018.00 $2,139.00 $2,299.0037160 90 $1,681.00 $1,740.00 $1,842.00 $1,978.00 $1,740.00 $1,842.00 $1,978.0037180 90 $1,769.00 $1,982.00 $2,102.00 $2,263.00 $1,982.00 $2,102.00 $2,263.0037181 90 $1,923.00 $2,094.00 $2,216.00 $2,379.00 $2,094.00 $2,216.00 $2,379.0037182 0 $914.00 $1,186.00 $1,233.00 $1,291.00 $1,186.00 $1,233.00 $1,291.0037183 0 $425.00 $565.00 $588.00 $615.00 $565.00 $588.00 $615.0037184 0 ------- $3,491.00 $3,723.00 $3,923.00 $615.00 $641.00 $672.0037185 ZZZ ------- $1,153.00 $1,228.00 $1,294.00 $227.00 $236.00 $248.0037186 ZZZ ------- $2,364.00 $2,523.00 $2,659.00 $342.00 $356.00 $374.0037187 0 ------- $3,378.00 $3,602.00 $3,796.00 $571.00 $595.00 $624.0037188 0 ------- $2,903.00 $3,098.00 $3,266.00 $411.00 $428.00 $450.0037195 0 $302.00 ------- ------- ------- ------- ------- -------37200 0 $232.00 $314.00 $327.00 $342.00 $314.00 $327.00 $342.0037201 0 $408.00 $382.00 $399.00 $419.00 $382.00 $399.00 $419.0037202 0 $340.00 $460.00 $482.00 $508.00 $460.00 $482.00 $508.0037203 0 $287.00 $1,834.00 $1,953.00 $2,057.00 $362.00 $376.00 $394.0037204 0 $957.00 $1,271.00 $1,331.00 $1,407.00 $1,271.00 $1,331.00 $1,407.0037205 0 $589.00 $3,247.00 $3,463.00 $3,652.00 $611.00 $638.00 $672.0037206 ZZZ $288.00 $1,916.00 $2,045.00 $2,157.00 $293.00 $306.00 $323.0037207 0 $613.00 $619.00 $659.00 $713.00 $619.00 $659.00 $713.0037208 ZZZ $299.00 $300.00 $319.00 $346.00 $300.00 $319.00 $346.0037209 0 $116.00 $156.00 $163.00 $171.00 $156.00 $163.00 $171.0037210 0 ------- $4,708.00 $5,020.00 $5,288.00 $729.00 $757.00 $792.0037215 90 ------- $1,481.00 $1,543.00 $1,614.00 $1,481.00 $1,543.00 $1,614.0037216 90 ------- $1,332.00 $1,384.00 $1,447.00 $1,332.00 $1,384.00 $1,447.0037250 ZZZ $112.00 $153.00 $161.00 $172.00 $153.00 $161.00 $172.0037251 ZZZ $85.00 $116.00 $123.00 $132.00 $116.00 $123.00 $132.0037500 90 $739.00 $969.00 $1,030.00 $1,108.00 $969.00 $1,030.00 $1,108.0037501 YYY BR ------- ------- ------- ------- ------- -------37565 90 $364.00 $936.00 $989.00 $1,058.00 $936.00 $989.00 $1,058.0037600 90 $414.00 $980.00 $1,037.00 $1,109.00 $980.00 $1,037.00 $1,109.0037605 90 $521.00 $1,133.00 $1,206.00 $1,302.00 $1,133.00 $1,206.00 $1,302.0037606 90 $563.00 $742.00 $791.00 $853.00 $742.00 $791.00 $853.0037607 90 $456.00 $522.00 $556.00 $599.00 $522.00 $556.00 $599.0037609 10 $278.00 $388.00 $412.00 $439.00 $265.00 $281.00 $300.0037615 90 $495.00 $621.00 $653.00 $692.00 $621.00 $653.00 $692.0037616 90 $1,128.00 $1,472.00 $1,560.00 $1,675.00 $1,472.00 $1,560.00 $1,675.0037617 90 $1,132.00 $1,776.00 $1,882.00 $2,025.00 $1,776.00 $1,882.00 $2,025.0037618 90 $514.00 $507.00 $536.00 $573.00 $507.00 $536.00 $573.0037620 90 $818.00 $891.00 $934.00 $986.00 $891.00 $934.00 $986.0037650 90 $430.00 $698.00 $740.00 $793.00 $698.00 $740.00 $793.0037660 90 $789.00 $1,656.00 $1,749.00 $1,872.00 $1,656.00 $1,749.00 $1,872.0037700 90 $336.00 $348.00 $371.00 $399.00 $348.00 $371.00 $399.0037718 90 ------- $531.00 $548.00 $564.00 $531.00 $548.00 $564.0037722 90 ------- $650.00 $687.00 $732.00 $650.00 $687.00 $732.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

37735 90 $847.00 $880.00 $936.00 $1,009.00 $880.00 $936.00 $1,009.0037760 90 $813.00 $861.00 $915.00 $987.00 $861.00 $915.00 $987.0037765 90 ------- $601.00 $628.00 $658.00 $601.00 $628.00 $658.0037766 90 ------- $724.00 $754.00 $786.00 $724.00 $754.00 $786.0037780 90 $301.00 $355.00 $378.00 $406.00 $355.00 $378.00 $406.0037785 90 $270.00 $478.00 $509.00 $545.00 $357.00 $380.00 $409.0037788 90 $1,654.00 $1,797.00 $1,893.00 $2,013.00 $1,797.00 $1,893.00 $2,013.0037790 90 $690.00 $678.00 $710.00 $747.00 $678.00 $710.00 $747.0037799 YYY BR ------- ------- ------- ------- ------- -------38100 90 $974.00 $1,392.00 $1,464.00 $1,559.00 $1,392.00 $1,464.00 $1,559.0038101 90 $982.00 $1,413.00 $1,489.00 $1,589.00 $1,413.00 $1,489.00 $1,589.0038102 ZZZ $332.00 $346.00 $368.00 $397.00 $346.00 $368.00 $397.0038115 90 $1,020.00 $1,541.00 $1,620.00 $1,723.00 $1,541.00 $1,620.00 $1,723.0038120 90 $1,138.00 $1,333.00 $1,416.00 $1,525.00 $1,333.00 $1,416.00 $1,525.0038129 YYY BR ------- ------- ------- ------- ------- -------38200 0 $180.00 $184.00 $191.00 $200.00 $184.00 $191.00 $200.0038205 0 $79.00 $106.00 $110.00 $114.00 $106.00 $110.00 $114.0038206 0 $79.00 $106.00 $110.00 $115.00 $106.00 $110.00 $115.0038220 0 $212.00 $215.00 $227.00 $239.00 $79.00 $82.00 $85.0038221 0 $228.00 $238.00 $252.00 $264.00 $101.00 $105.00 $109.0038230 10 $265.00 $423.00 $446.00 $474.00 $423.00 $446.00 $474.0038240 0 $128.00 $163.00 $169.00 $176.00 $163.00 $169.00 $176.0038241 0 $128.00 $163.00 $170.00 $177.00 $163.00 $170.00 $177.0038242 0 $90.00 $123.00 $128.00 $133.00 $123.00 $128.00 $133.0038300 10 $104.00 $340.00 $361.00 $384.00 $229.00 $243.00 $259.0038305 90 $375.00 $593.00 $631.00 $678.00 $593.00 $631.00 $678.0038308 90 $425.00 $566.00 $600.00 $644.00 $566.00 $600.00 $644.0038380 90 $628.00 $718.00 $756.00 $801.00 $718.00 $756.00 $801.0038381 90 $1,087.00 $1,096.00 $1,166.00 $1,258.00 $1,096.00 $1,166.00 $1,258.0038382 90 $798.00 $882.00 $937.00 $1,007.00 $882.00 $937.00 $1,007.0038500 10 $234.00 $401.00 $427.00 $457.00 $318.00 $338.00 $363.0038505 0 $139.00 $164.00 $174.00 $184.00 $98.00 $103.00 $109.0038510 10 $349.00 $645.00 $682.00 $727.00 $536.00 $566.00 $604.0038520 90 $431.00 $588.00 $623.00 $668.00 $588.00 $623.00 $668.0038525 90 $369.00 $530.00 $563.00 $604.00 $530.00 $563.00 $604.0038530 90 $517.00 $689.00 $733.00 $790.00 $689.00 $733.00 $790.0038542 90 $507.00 $544.00 $574.00 $610.00 $544.00 $574.00 $610.0038550 90 $519.00 $603.00 $640.00 $687.00 $603.00 $640.00 $687.0038555 90 $1,115.00 $1,263.00 $1,336.00 $1,429.00 $1,263.00 $1,336.00 $1,429.0038562 90 $799.00 $897.00 $948.00 $1,012.00 $897.00 $948.00 $1,012.0038564 90 $831.00 $896.00 $948.00 $1,016.00 $896.00 $948.00 $1,016.0038570 10 $695.00 $725.00 $768.00 $824.00 $725.00 $768.00 $824.0038571 10 $902.00 $1,092.00 $1,143.00 $1,207.00 $1,092.00 $1,143.00 $1,207.0038572 10 $1,049.00 $1,269.00 $1,340.00 $1,435.00 $1,269.00 $1,340.00 $1,435.0038589 YYY BR ------- ------- ------- ------- ------- -------38700 90 $863.00 $972.00 $1,013.00 $1,060.00 $972.00 $1,013.00 $1,060.0038720 90 $1,328.00 $1,603.00 $1,669.00 $1,745.00 $1,603.00 $1,669.00 $1,745.0038724 90 $1,366.00 $1,734.00 $1,804.00 $1,885.00 $1,734.00 $1,804.00 $1,885.0038740 90 $539.00 $850.00 $901.00 $967.00 $850.00 $901.00 $967.0038745 90 $770.00 $1,085.00 $1,150.00 $1,237.00 $1,085.00 $1,150.00 $1,237.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

38746 ZZZ $312.00 $362.00 $386.00 $418.00 $362.00 $386.00 $418.0038747 ZZZ $337.00 $354.00 $375.00 $405.00 $354.00 $375.00 $405.0038760 90 $699.00 $1,071.00 $1,136.00 $1,221.00 $1,071.00 $1,136.00 $1,221.0038765 90 $1,283.00 $1,648.00 $1,742.00 $1,865.00 $1,648.00 $1,742.00 $1,865.0038770 90 $1,111.00 $1,079.00 $1,137.00 $1,210.00 $1,079.00 $1,137.00 $1,210.0038780 90 $1,357.00 $1,379.00 $1,455.00 $1,554.00 $1,379.00 $1,455.00 $1,554.0038790 0 $158.00 $109.00 $115.00 $122.00 $109.00 $115.00 $122.0038792 0 $26.00 $52.00 $55.00 $59.00 $52.00 $55.00 $59.0038794 90 $298.00 $402.00 $422.00 $445.00 $402.00 $422.00 $445.0038999 YYY BR ------- ------- ------- ------- ------- -------39000 90 $664.00 $645.00 $684.00 $732.00 $645.00 $684.00 $732.0039010 90 $1,148.00 $1,102.00 $1,171.00 $1,261.00 $1,102.00 $1,171.00 $1,261.0039200 90 $1,249.00 $1,210.00 $1,286.00 $1,386.00 $1,210.00 $1,286.00 $1,386.0039220 90 $1,542.00 $1,543.00 $1,637.00 $1,759.00 $1,543.00 $1,637.00 $1,759.0039400 10 $614.00 $665.00 $702.00 $748.00 $665.00 $702.00 $748.0039499 YYY BR ------- ------- ------- ------- ------- -------39501 90 $1,083.00 $1,100.00 $1,167.00 $1,255.00 $1,100.00 $1,167.00 $1,255.0039502 90 $1,268.00 $1,318.00 $1,398.00 $1,503.00 $1,318.00 $1,398.00 $1,503.0039503 90 $2,726.00 $7,493.00 $7,880.00 $8,402.00 $7,493.00 $7,880.00 $8,402.0039520 90 $1,345.00 $1,329.00 $1,413.00 $1,522.00 $1,329.00 $1,413.00 $1,522.0039530 90 $1,295.00 $1,263.00 $1,340.00 $1,443.00 $1,263.00 $1,340.00 $1,443.0039531 90 $1,243.00 $1,334.00 $1,415.00 $1,523.00 $1,334.00 $1,415.00 $1,523.0039540 90 $1,133.00 $1,122.00 $1,189.00 $1,277.00 $1,122.00 $1,189.00 $1,277.0039541 90 $1,179.00 $1,205.00 $1,277.00 $1,371.00 $1,205.00 $1,277.00 $1,371.0039545 90 $1,102.00 $1,192.00 $1,265.00 $1,359.00 $1,192.00 $1,265.00 $1,359.0039560 90 $968.00 $1,030.00 $1,091.00 $1,171.00 $1,030.00 $1,091.00 $1,171.0039561 90 $1,328.00 $1,588.00 $1,683.00 $1,807.00 $1,588.00 $1,683.00 $1,807.0039599 YYY BR ------- ------- ------- ------- ------- -------40490 0 $108.00 $153.00 $161.00 $169.00 $90.00 $94.00 $98.0040500 90 $422.00 $604.00 $640.00 $677.00 $452.00 $477.00 $505.0040510 90 $469.00 $595.00 $631.00 $670.00 $452.00 $478.00 $509.0040520 90 $467.00 $626.00 $665.00 $707.00 $461.00 $488.00 $520.0040525 90 $714.00 $716.00 $758.00 $808.00 $716.00 $758.00 $808.0040527 90 $851.00 $846.00 $895.00 $953.00 $846.00 $895.00 $953.0040530 90 $501.00 $684.00 $726.00 $770.00 $520.00 $550.00 $585.0040650 90 $368.00 $523.00 $555.00 $589.00 $365.00 $386.00 $410.0040652 90 $436.00 $619.00 $659.00 $701.00 $453.00 $481.00 $514.0040654 90 $529.00 $717.00 $762.00 $810.00 $540.00 $573.00 $610.0040700 90 $1,009.00 $1,174.00 $1,230.00 $1,294.00 $1,174.00 $1,230.00 $1,294.0040701 90 $1,452.00 $1,409.00 $1,486.00 $1,579.00 $1,409.00 $1,486.00 $1,579.0040702 90 $1,030.00 $1,111.00 $1,167.00 $1,236.00 $1,111.00 $1,167.00 $1,236.0040720 90 $1,107.00 $1,311.00 $1,391.00 $1,490.00 $1,311.00 $1,391.00 $1,490.0040761 90 $1,202.00 $1,380.00 $1,464.00 $1,569.00 $1,380.00 $1,464.00 $1,569.0040799 YYY BR ------- ------- ------- ------- ------- -------40800 10 $110.00 $236.00 $252.00 $267.00 $158.00 $168.00 $178.0040801 10 $208.00 $367.00 $391.00 $416.00 $278.00 $295.00 $315.0040804 10 $105.00 $247.00 $263.00 $278.00 $160.00 $170.00 $180.0040805 10 $245.00 $394.00 $419.00 $446.00 $290.00 $308.00 $329.0040806 0 $38.00 $124.00 $133.00 $140.00 $43.00 $45.00 $48.0040808 10 $100.00 $210.00 $224.00 $237.00 $131.00 $139.00 $148.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

40810 10 $141.00 $237.00 $252.00 $267.00 $157.00 $166.00 $177.0040812 10 $202.00 $338.00 $360.00 $383.00 $248.00 $264.00 $282.0040814 90 $319.00 $460.00 $490.00 $522.00 $384.00 $408.00 $435.0040816 90 $336.00 $482.00 $512.00 $544.00 $400.00 $424.00 $451.0040818 90 $249.00 $419.00 $444.00 $469.00 $337.00 $357.00 $376.0040819 90 $208.00 $364.00 $387.00 $412.00 $293.00 $312.00 $332.0040820 10 $104.00 $300.00 $320.00 $338.00 $204.00 $216.00 $229.0040830 10 $140.00 $293.00 $311.00 $330.00 $201.00 $213.00 $227.0040831 10 $213.00 $388.00 $414.00 $440.00 $285.00 $303.00 $323.0040840 90 $687.00 $1,005.00 $1,068.00 $1,139.00 $823.00 $873.00 $934.0040842 90 $684.00 $1,016.00 $1,080.00 $1,152.00 $822.00 $872.00 $932.0040843 90 $947.00 $1,285.00 $1,362.00 $1,451.00 $1,042.00 $1,101.00 $1,176.0040844 90 $1,232.00 $1,711.00 $1,817.00 $1,941.00 $1,453.00 $1,541.00 $1,650.0040845 90 $1,593.00 $1,885.00 $1,995.00 $2,123.00 $1,644.00 $1,737.00 $1,850.0040899 YYY BR ------- ------- ------- ------- ------- -------41000 10 $119.00 $193.00 $205.00 $217.00 $140.00 $148.00 $157.0041005 10 $109.00 $261.00 $278.00 $294.00 $157.00 $167.00 $176.0041006 90 $237.00 $437.00 $464.00 $493.00 $332.00 $351.00 $374.0041007 90 $283.00 $434.00 $461.00 $488.00 $316.00 $334.00 $354.0041008 90 $248.00 $448.00 $476.00 $508.00 $344.00 $365.00 $391.0041009 90 $319.00 $478.00 $509.00 $543.00 $376.00 $400.00 $428.0041010 10 $91.00 $239.00 $254.00 $267.00 $135.00 $143.00 $150.0041015 90 $267.00 $517.00 $549.00 $584.00 $427.00 $453.00 $483.0041016 90 $357.00 $531.00 $565.00 $604.00 $442.00 $471.00 $504.0041017 90 $300.00 $535.00 $570.00 $609.00 $445.00 $474.00 $507.0041018 90 $424.00 $618.00 $658.00 $704.00 $522.00 $555.00 $595.0041019 0 ------- $626.00 $652.00 $685.00 $626.00 $652.00 $685.0041100 10 $140.00 $204.00 $217.00 $231.00 $141.00 $150.00 $160.0041105 10 $136.00 $202.00 $215.00 $227.00 $141.00 $149.00 $158.0041108 10 $110.00 $173.00 $184.00 $194.00 $114.00 $120.00 $127.0041110 10 $159.00 $248.00 $263.00 $278.00 $164.00 $173.00 $183.0041112 90 $255.00 $396.00 $420.00 $445.00 $314.00 $332.00 $353.0041113 90 $301.00 $435.00 $462.00 $490.00 $350.00 $371.00 $394.0041114 90 $682.00 $812.00 $857.00 $910.00 $812.00 $857.00 $910.0041115 10 $176.00 $284.00 $302.00 $320.00 $186.00 $197.00 $210.0041116 90 $242.00 $382.00 $406.00 $429.00 $274.00 $290.00 $307.0041120 90 $813.00 $1,316.00 $1,389.00 $1,464.00 $1,316.00 $1,389.00 $1,464.0041130 90 $937.00 $1,604.00 $1,685.00 $1,769.00 $1,604.00 $1,685.00 $1,769.0041135 90 $1,869.00 $2,677.00 $2,806.00 $2,947.00 $2,677.00 $2,806.00 $2,947.0041140 90 $2,005.00 $2,789.00 $2,936.00 $3,100.00 $2,789.00 $2,936.00 $3,100.0041145 90 $2,406.00 $3,451.00 $3,622.00 $3,810.00 $3,451.00 $3,622.00 $3,810.0041150 90 $1,897.00 $2,735.00 $2,870.00 $3,016.00 $2,735.00 $2,870.00 $3,016.0041153 90 $2,091.00 $2,946.00 $3,085.00 $3,235.00 $2,946.00 $3,085.00 $3,235.0041155 90 $2,448.00 $3,610.00 $3,766.00 $3,938.00 $3,610.00 $3,766.00 $3,938.0041250 10 $168.00 $270.00 $286.00 $303.00 $174.00 $184.00 $195.0041251 10 $203.00 $294.00 $312.00 $330.00 $208.00 $220.00 $233.0041252 10 $294.00 $375.00 $398.00 $421.00 $273.00 $288.00 $306.0041500 90 $334.00 $573.00 $608.00 $642.00 $573.00 $608.00 $642.0041510 90 $313.00 $538.00 $569.00 $598.00 $538.00 $569.00 $598.0041520 90 $255.00 $412.00 $438.00 $464.00 $323.00 $343.00 $363.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

41599 YYY BR ------- ------- ------- ------- ------- -------41800 10 $107.00 $251.00 $268.00 $283.00 $152.00 $161.00 $170.0041805 10 $115.00 $253.00 $270.00 $286.00 $193.00 $206.00 $218.0041806 10 $217.00 $393.00 $419.00 $447.00 $317.00 $338.00 $361.0041820 0 NC BR BR BR BR BR BR41821 0 NC BR BR BR BR BR BR41822 10 $237.00 $352.00 $376.00 $401.00 $228.00 $242.00 $260.0041823 90 $312.00 $508.00 $542.00 $578.00 $401.00 $427.00 $457.0041825 10 $144.00 $244.00 $260.00 $276.00 $168.00 $179.00 $190.0041826 10 $211.00 $322.00 $343.00 $366.00 $251.00 $267.00 $286.0041827 90 $322.00 $506.00 $537.00 $569.00 $379.00 $400.00 $424.0041828 10 $176.00 $378.00 $404.00 $433.00 $296.00 $315.00 $339.0041830 10 $156.00 $467.00 $498.00 $531.00 $362.00 $385.00 $413.0041850 0 NC BR BR BR BR BR BR41870 0 NC BR BR BR BR BR BR41872 90 $249.00 $436.00 $463.00 $491.00 $329.00 $348.00 $370.0041874 90 $193.00 $445.00 $475.00 $508.00 $330.00 $352.00 $379.0041899 YYY BR ------- ------- ------- ------- ------- -------42000 10 $106.00 $194.00 $206.00 $218.00 $130.00 $137.00 $145.0042100 10 $122.00 $182.00 $193.00 $204.00 $138.00 $146.00 $155.0042104 10 $161.00 $243.00 $258.00 $274.00 $171.00 $181.00 $192.0042106 10 $204.00 $311.00 $331.00 $353.00 $232.00 $247.00 $263.0042107 90 $409.00 $552.00 $585.00 $620.00 $436.00 $461.00 $490.0042120 90 $573.00 $1,192.00 $1,248.00 $1,303.00 $1,192.00 $1,248.00 $1,303.0042140 90 $174.00 $295.00 $313.00 $330.00 $193.00 $204.00 $215.0042145 90 $741.00 $878.00 $921.00 $969.00 $878.00 $921.00 $969.0042160 10 $176.00 $299.00 $318.00 $336.00 $198.00 $210.00 $222.0042180 10 $222.00 $296.00 $313.00 $330.00 $234.00 $246.00 $260.0042182 10 $324.00 $408.00 $433.00 $460.00 $347.00 $367.00 $391.0042200 90 $946.00 $1,154.00 $1,220.00 $1,298.00 $1,154.00 $1,220.00 $1,298.0042205 90 $863.00 $1,198.00 $1,270.00 $1,357.00 $1,198.00 $1,270.00 $1,357.0042210 90 $1,174.00 $1,415.00 $1,509.00 $1,626.00 $1,415.00 $1,509.00 $1,626.0042215 90 $766.00 $933.00 $996.00 $1,072.00 $933.00 $996.00 $1,072.0042220 90 $586.00 $740.00 $783.00 $833.00 $740.00 $783.00 $833.0042225 90 $803.00 $1,254.00 $1,329.00 $1,406.00 $1,254.00 $1,329.00 $1,406.0042226 90 $848.00 $1,226.00 $1,299.00 $1,378.00 $1,226.00 $1,299.00 $1,378.0042227 90 $762.00 $1,208.00 $1,280.00 $1,358.00 $1,208.00 $1,280.00 $1,358.0042235 90 $631.00 $984.00 $1,042.00 $1,103.00 $984.00 $1,042.00 $1,103.0042260 90 $491.00 $1,072.00 $1,140.00 $1,219.00 $901.00 $957.00 $1,026.0042280 10 $148.00 $193.00 $205.00 $219.00 $138.00 $146.00 $156.0042281 10 $160.00 $247.00 $261.00 $276.00 $194.00 $205.00 $217.0042299 YYY BR ------- ------- ------- ------- ------- -------42300 10 $165.00 $253.00 $268.00 $283.00 $193.00 $204.00 $215.0042305 90 $448.00 $551.00 $580.00 $612.00 $551.00 $580.00 $612.0042310 10 $145.00 $198.00 $210.00 $222.00 $157.00 $166.00 $175.0042320 10 $208.00 $303.00 $321.00 $340.00 $228.00 $240.00 $254.0042330 10 $184.00 $283.00 $300.00 $317.00 $209.00 $220.00 $233.0042335 90 $287.00 $447.00 $474.00 $501.00 $330.00 $348.00 $368.0042340 90 $411.00 $570.00 $604.00 $639.00 $437.00 $461.00 $488.0042400 0 $94.00 $132.00 $141.00 $148.00 $76.00 $79.00 $84.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

42405 10 $258.00 $376.00 $398.00 $420.00 $292.00 $308.00 $325.0042408 90 $377.00 $559.00 $592.00 $628.00 $422.00 $446.00 $474.0042409 90 $266.00 $401.00 $426.00 $451.00 $288.00 $304.00 $322.0042410 90 $746.00 $806.00 $850.00 $903.00 $806.00 $850.00 $903.0042415 90 $1,364.00 $1,445.00 $1,516.00 $1,601.00 $1,445.00 $1,516.00 $1,601.0042420 90 $1,577.00 $1,660.00 $1,741.00 $1,838.00 $1,660.00 $1,741.00 $1,838.0042425 90 $1,097.00 $1,094.00 $1,148.00 $1,212.00 $1,094.00 $1,148.00 $1,212.0042426 90 $1,882.00 $1,778.00 $1,865.00 $1,970.00 $1,778.00 $1,865.00 $1,970.0042440 90 $634.00 $594.00 $625.00 $661.00 $594.00 $625.00 $661.0042450 90 $395.00 $559.00 $591.00 $626.00 $459.00 $484.00 $513.0042500 90 $407.00 $531.00 $563.00 $596.00 $437.00 $462.00 $490.0042505 90 $559.00 $696.00 $736.00 $779.00 $588.00 $620.00 $657.0042507 90 $522.00 $650.00 $685.00 $723.00 $650.00 $685.00 $723.0042508 90 $767.00 $926.00 $981.00 $1,046.00 $926.00 $981.00 $1,046.0042509 90 $915.00 $1,099.00 $1,156.00 $1,221.00 $1,099.00 $1,156.00 $1,221.0042510 90 $711.00 $807.00 $850.00 $898.00 $807.00 $850.00 $898.0042550 0 $82.00 $202.00 $213.00 $224.00 $86.00 $89.00 $93.0042600 90 $445.00 $591.00 $626.00 $662.00 $451.00 $475.00 $503.0042650 0 $67.00 $101.00 $107.00 $114.00 $76.00 $80.00 $85.0042660 0 $89.00 $130.00 $138.00 $145.00 $100.00 $106.00 $111.0042665 90 $238.00 $368.00 $390.00 $413.00 $264.00 $278.00 $295.0042699 YYY BR ------- ------- ------- ------- ------- -------42700 10 $144.00 $228.00 $241.00 $254.00 $171.00 $180.00 $190.0042720 10 $270.00 $569.00 $597.00 $629.00 $505.00 $529.00 $556.0042725 90 $720.00 $1,031.00 $1,081.00 $1,140.00 $1,031.00 $1,081.00 $1,140.0042800 10 $123.00 $191.00 $202.00 $214.00 $142.00 $150.00 $158.0042802 10 $150.00 $305.00 $324.00 $342.00 $176.00 $186.00 $196.0042804 10 $136.00 $250.00 $266.00 $280.00 $148.00 $156.00 $165.0042806 10 $167.00 $283.00 $300.00 $317.00 $174.00 $184.00 $194.0042808 10 $250.00 $282.00 $298.00 $315.00 $212.00 $223.00 $236.0042809 10 $152.00 $212.00 $225.00 $238.00 $165.00 $173.00 $183.0042810 90 $335.00 $476.00 $505.00 $534.00 $360.00 $380.00 $403.0042815 90 $659.00 $705.00 $743.00 $786.00 $705.00 $743.00 $786.0042821 90 $378.00 $393.00 $413.00 $437.00 $393.00 $413.00 $437.0042826 90 $320.00 $324.00 $341.00 $360.00 $324.00 $341.00 $360.0042831 90 $235.00 $284.00 $299.00 $316.00 $284.00 $299.00 $316.0042836 90 $286.00 $312.00 $329.00 $347.00 $312.00 $329.00 $347.0042842 90 $729.00 $1,196.00 $1,255.00 $1,317.00 $1,196.00 $1,255.00 $1,317.0042844 90 $1,173.00 $1,709.00 $1,796.00 $1,888.00 $1,709.00 $1,796.00 $1,888.0042845 90 $1,958.00 $2,785.00 $2,915.00 $3,058.00 $2,785.00 $2,915.00 $3,058.0042860 90 $207.00 $237.00 $250.00 $264.00 $237.00 $250.00 $264.0042870 90 $427.00 $722.00 $764.00 $807.00 $722.00 $764.00 $807.0042890 90 $1,047.00 $1,707.00 $1,786.00 $1,870.00 $1,707.00 $1,786.00 $1,870.0042892 90 $1,262.00 $2,221.00 $2,318.00 $2,422.00 $2,221.00 $2,318.00 $2,422.0042894 90 $1,825.00 $2,865.00 $2,994.00 $3,135.00 $2,865.00 $2,994.00 $3,135.0042900 10 $429.00 $452.00 $476.00 $506.00 $452.00 $476.00 $506.0042950 90 $745.00 $1,014.00 $1,073.00 $1,135.00 $1,014.00 $1,073.00 $1,135.0042953 90 $752.00 $1,286.00 $1,364.00 $1,444.00 $1,286.00 $1,364.00 $1,444.0042955 90 $561.00 $954.00 $1,012.00 $1,074.00 $954.00 $1,012.00 $1,074.0042960 10 $178.00 $217.00 $229.00 $242.00 $217.00 $229.00 $242.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

42961 90 $406.00 $539.00 $567.00 $599.00 $539.00 $567.00 $599.0042962 90 $602.00 $667.00 $701.00 $740.00 $667.00 $701.00 $740.0042970 90 $284.00 $495.00 $519.00 $546.00 $495.00 $519.00 $546.0042971 90 $472.00 $588.00 $618.00 $652.00 $588.00 $618.00 $652.0042972 90 $562.00 $670.00 $705.00 $745.00 $670.00 $705.00 $745.0042999 YYY BR ------- ------- ------- ------- ------- -------43020 90 $696.00 $701.00 $741.00 $790.00 $701.00 $741.00 $790.0043030 90 $712.00 $678.00 $713.00 $755.00 $678.00 $713.00 $755.0043045 90 $1,574.00 $1,725.00 $1,826.00 $1,958.00 $1,725.00 $1,826.00 $1,958.0043100 90 $744.00 $808.00 $852.00 $905.00 $808.00 $852.00 $905.0043101 90 $1,248.00 $1,358.00 $1,444.00 $1,557.00 $1,358.00 $1,444.00 $1,557.0043107 90 $2,325.00 $3,344.00 $3,538.00 $3,795.00 $3,344.00 $3,538.00 $3,795.0043108 90 $2,664.00 $5,172.00 $5,345.00 $5,562.00 $5,172.00 $5,345.00 $5,562.0043112 90 $2,471.00 $3,590.00 $3,803.00 $4,085.00 $3,590.00 $3,803.00 $4,085.0043113 90 $2,755.00 $5,113.00 $5,297.00 $5,531.00 $5,113.00 $5,297.00 $5,531.0043116 90 $2,509.00 $5,774.00 $5,936.00 $6,126.00 $5,774.00 $5,936.00 $6,126.0043117 90 $2,469.00 $3,266.00 $3,455.00 $3,707.00 $3,266.00 $3,455.00 $3,707.0043118 90 $2,607.00 $4,348.00 $4,516.00 $4,729.00 $4,348.00 $4,516.00 $4,729.0043121 90 $2,350.00 $3,514.00 $3,670.00 $3,871.00 $3,514.00 $3,670.00 $3,871.0043122 90 $2,287.00 $3,320.00 $3,516.00 $3,778.00 $3,320.00 $3,516.00 $3,778.0043123 90 $2,661.00 $5,220.00 $5,397.00 $5,619.00 $5,220.00 $5,397.00 $5,619.0043124 90 $2,242.00 $4,465.00 $4,626.00 $4,829.00 $4,465.00 $4,626.00 $4,829.0043130 90 $1,020.00 $1,023.00 $1,077.00 $1,144.00 $1,023.00 $1,077.00 $1,144.0043135 90 $1,332.00 $1,861.00 $1,952.00 $2,071.00 $1,861.00 $1,952.00 $2,071.0043200 0 $266.00 $281.00 $299.00 $315.00 $136.00 $143.00 $151.0043201 0 $245.00 $366.00 $388.00 $409.00 $167.00 $175.00 $185.0043202 0 $205.00 $368.00 $391.00 $413.00 $148.00 $156.00 $164.0043204 0 $228.00 $288.00 $302.00 $319.00 $288.00 $302.00 $319.0043205 0 $207.00 $289.00 $303.00 $319.00 $289.00 $303.00 $319.0043215 0 $160.00 $202.00 $212.00 $224.00 $202.00 $212.00 $224.0043216 0 $149.00 $232.00 $244.00 $258.00 $186.00 $196.00 $207.0043217 0 $176.00 $495.00 $526.00 $556.00 $221.00 $232.00 $246.0043219 0 $171.00 $223.00 $234.00 $248.00 $223.00 $234.00 $248.0043220 0 $128.00 $165.00 $173.00 $182.00 $165.00 $173.00 $182.0043226 0 $142.00 $183.00 $192.00 $203.00 $183.00 $192.00 $203.0043227 0 $218.00 $271.00 $284.00 $300.00 $271.00 $284.00 $300.0043228 0 $230.00 $289.00 $304.00 $323.00 $289.00 $304.00 $323.0043231 0 $182.00 $245.00 $256.00 $269.00 $245.00 $256.00 $269.0043232 0 $252.00 $342.00 $358.00 $378.00 $342.00 $358.00 $378.0043234 0 $193.00 $366.00 $388.00 $410.00 $155.00 $163.00 $172.0043235 0 $239.00 $388.00 $412.00 $435.00 $186.00 $195.00 $206.0043236 0 $285.00 $481.00 $510.00 $538.00 $225.00 $236.00 $248.0043237 0 ------- $315.00 $332.00 $355.00 $315.00 $332.00 $355.0043238 0 ------- $383.00 $402.00 $426.00 $383.00 $402.00 $426.0043239 0 $246.00 $447.00 $473.00 $499.00 $221.00 $231.00 $244.0043240 0 $369.00 $513.00 $538.00 $569.00 $513.00 $538.00 $569.0043241 0 $157.00 $201.00 $210.00 $222.00 $201.00 $210.00 $222.0043242 0 $384.00 $545.00 $570.00 $601.00 $545.00 $570.00 $601.0043243 0 $276.00 $344.00 $360.00 $379.00 $344.00 $360.00 $379.0043244 0 $268.00 $382.00 $399.00 $421.00 $382.00 $399.00 $421.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

43245 0 $214.00 $243.00 $255.00 $269.00 $243.00 $255.00 $269.0043246 0 $485.00 $325.00 $340.00 $359.00 $325.00 $340.00 $359.0043247 0 $229.00 $259.00 $272.00 $287.00 $259.00 $272.00 $287.0043248 0 $191.00 $243.00 $254.00 $268.00 $243.00 $254.00 $268.0043249 0 $175.00 $224.00 $235.00 $247.00 $224.00 $235.00 $247.0043250 0 $194.00 $244.00 $256.00 $270.00 $244.00 $256.00 $270.0043251 0 $224.00 $281.00 $295.00 $311.00 $281.00 $295.00 $311.0043255 0 $343.00 $364.00 $381.00 $401.00 $364.00 $381.00 $401.0043256 0 $235.00 $328.00 $343.00 $362.00 $328.00 $343.00 $362.0043257 0 ------- $395.00 $412.00 $433.00 $395.00 $412.00 $433.0043258 0 $276.00 $343.00 $359.00 $378.00 $343.00 $359.00 $378.0043259 0 $271.00 $388.00 $406.00 $426.00 $388.00 $406.00 $426.0043260 0 $349.00 $447.00 $467.00 $492.00 $447.00 $467.00 $492.0043261 0 $362.00 $470.00 $492.00 $518.00 $470.00 $492.00 $518.0043262 0 $447.00 $552.00 $578.00 $609.00 $552.00 $578.00 $609.0043263 0 $386.00 $545.00 $570.00 $600.00 $545.00 $570.00 $600.0043264 0 $522.00 $663.00 $693.00 $730.00 $663.00 $693.00 $730.0043265 0 $527.00 $745.00 $779.00 $820.00 $745.00 $779.00 $820.0043267 0 $434.00 $544.00 $569.00 $599.00 $544.00 $569.00 $599.0043268 0 $446.00 $559.00 $585.00 $616.00 $559.00 $585.00 $616.0043269 0 $410.00 $612.00 $640.00 $674.00 $612.00 $640.00 $674.0043271 0 $437.00 $552.00 $577.00 $608.00 $552.00 $577.00 $608.0043272 0 $401.00 $553.00 $579.00 $610.00 $553.00 $579.00 $610.0043280 90 $1,314.00 $1,374.00 $1,457.00 $1,567.00 $1,374.00 $1,457.00 $1,567.0043289 YYY BR ------- ------- ------- ------- ------- -------43300 90 $837.00 $816.00 $866.00 $927.00 $816.00 $866.00 $927.0043305 90 $1,428.00 $1,442.00 $1,515.00 $1,604.00 $1,442.00 $1,515.00 $1,604.0043310 90 $2,138.00 $2,037.00 $2,166.00 $2,339.00 $2,037.00 $2,166.00 $2,339.0043312 90 $2,331.00 $2,245.00 $2,386.00 $2,577.00 $2,245.00 $2,386.00 $2,577.0043313 90 $2,632.00 $3,603.00 $3,807.00 $4,075.00 $3,603.00 $3,807.00 $4,075.0043314 90 $2,891.00 $3,880.00 $4,110.00 $4,422.00 $3,880.00 $4,110.00 $4,422.0043320 90 $1,299.00 $1,751.00 $1,852.00 $1,986.00 $1,751.00 $1,852.00 $1,986.0043324 90 $1,280.00 $1,720.00 $1,821.00 $1,955.00 $1,720.00 $1,821.00 $1,955.0043325 90 $1,261.00 $1,691.00 $1,788.00 $1,915.00 $1,691.00 $1,788.00 $1,915.0043326 90 $1,198.00 $1,729.00 $1,834.00 $1,973.00 $1,729.00 $1,834.00 $1,973.0043330 90 $1,236.00 $1,661.00 $1,757.00 $1,885.00 $1,661.00 $1,757.00 $1,885.0043331 90 $1,378.00 $1,800.00 $1,910.00 $2,054.00 $1,800.00 $1,910.00 $2,054.0043340 90 $1,292.00 $1,725.00 $1,820.00 $1,943.00 $1,725.00 $1,820.00 $1,943.0043341 90 $1,351.00 $1,855.00 $1,964.00 $2,108.00 $1,855.00 $1,964.00 $2,108.0043350 90 $986.00 $1,449.00 $1,516.00 $1,597.00 $1,449.00 $1,516.00 $1,597.0043351 90 $1,180.00 $1,739.00 $1,839.00 $1,966.00 $1,739.00 $1,839.00 $1,966.0043352 90 $1,028.00 $1,402.00 $1,483.00 $1,588.00 $1,402.00 $1,483.00 $1,588.0043360 90 $2,277.00 $3,017.00 $3,197.00 $3,436.00 $3,017.00 $3,197.00 $3,436.0043361 90 $2,596.00 $3,369.00 $3,546.00 $3,774.00 $3,369.00 $3,546.00 $3,774.0043400 90 $1,261.00 $1,927.00 $2,018.00 $2,129.00 $1,927.00 $2,018.00 $2,129.0043401 90 $1,299.00 $1,955.00 $2,067.00 $2,215.00 $1,955.00 $2,067.00 $2,215.0043405 90 $1,330.00 $1,884.00 $1,993.00 $2,134.00 $1,884.00 $1,993.00 $2,134.0043410 90 $946.00 $1,283.00 $1,354.00 $1,445.00 $1,283.00 $1,354.00 $1,445.0043415 90 $1,382.00 $2,217.00 $2,348.00 $2,522.00 $2,217.00 $2,348.00 $2,522.0043420 90 $854.00 $1,267.00 $1,330.00 $1,408.00 $1,267.00 $1,330.00 $1,408.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

43425 90 $1,338.00 $1,921.00 $2,034.00 $2,184.00 $1,921.00 $2,034.00 $2,184.0043450 0 $91.00 $207.00 $219.00 $231.00 $114.00 $120.00 $127.0043453 0 $102.00 $389.00 $414.00 $436.00 $123.00 $129.00 $136.0043456 0 $149.00 $805.00 $858.00 $905.00 $200.00 $209.00 $221.0043458 0 $164.00 $502.00 $532.00 $561.00 $234.00 $246.00 $259.0043460 0 $203.00 $284.00 $297.00 $314.00 $284.00 $297.00 $314.0043496 90 BR ------- ------- ------- ------- ------- -------43499 YYY BR ------- ------- ------- ------- ------- -------43500 90 $649.00 $968.00 $1,023.00 $1,095.00 $968.00 $1,023.00 $1,095.0043501 90 $1,105.00 $1,675.00 $1,772.00 $1,900.00 $1,675.00 $1,772.00 $1,900.0043502 90 $1,247.00 $1,907.00 $2,019.00 $2,168.00 $1,907.00 $2,019.00 $2,168.0043510 90 $680.00 $1,215.00 $1,281.00 $1,362.00 $1,215.00 $1,281.00 $1,362.0043520 90 $599.00 $886.00 $939.00 $1,007.00 $886.00 $939.00 $1,007.0043600 0 $96.00 $136.00 $142.00 $150.00 $136.00 $142.00 $150.0043605 90 $686.00 $1,032.00 $1,091.00 $1,169.00 $1,032.00 $1,091.00 $1,169.0043610 90 $861.00 $1,222.00 $1,293.00 $1,387.00 $1,222.00 $1,293.00 $1,387.0043611 90 $1,001.00 $1,514.00 $1,601.00 $1,716.00 $1,514.00 $1,601.00 $1,716.0043620 90 $1,691.00 $2,479.00 $2,620.00 $2,809.00 $2,479.00 $2,620.00 $2,809.0043621 90 $1,718.00 $2,780.00 $2,926.00 $3,121.00 $2,780.00 $2,926.00 $3,121.0043622 90 $1,798.00 $2,842.00 $2,996.00 $3,202.00 $2,842.00 $2,996.00 $3,202.0043631 90 $1,445.00 $1,826.00 $1,933.00 $2,077.00 $1,826.00 $1,933.00 $2,077.0043632 90 $1,443.00 $2,392.00 $2,504.00 $2,652.00 $2,392.00 $2,504.00 $2,652.0043633 90 $1,467.00 $2,295.00 $2,408.00 $2,558.00 $2,295.00 $2,408.00 $2,558.0043634 90 $1,786.00 $2,525.00 $2,649.00 $2,812.00 $2,525.00 $2,649.00 $2,812.0043635 ZZZ $143.00 $148.00 $157.00 $170.00 $148.00 $157.00 $170.0043640 90 $1,119.00 $1,457.00 $1,540.00 $1,650.00 $1,457.00 $1,540.00 $1,650.0043641 90 $1,138.00 $1,477.00 $1,561.00 $1,672.00 $1,477.00 $1,561.00 $1,672.0043644 90 ------- $2,157.00 $2,275.00 $2,430.00 $2,157.00 $2,275.00 $2,430.0043645 90 ------- $2,316.00 $2,446.00 $2,618.00 $2,316.00 $2,446.00 $2,618.0043651 90 $716.00 $816.00 $866.00 $932.00 $816.00 $866.00 $932.0043652 90 $856.00 $967.00 $1,026.00 $1,103.00 $967.00 $1,026.00 $1,103.0043653 90 $617.00 $690.00 $731.00 $783.00 $690.00 $731.00 $783.0043659 YYY BR ------- ------- ------- ------- ------- -------43752 0 BR $52.00 $54.00 $55.00 $52.00 $54.00 $55.0043760 0 $81.00 $251.00 $268.00 $283.00 $69.00 $72.00 $77.0043761 0 $107.00 $160.00 $167.00 $175.00 $139.00 $144.00 $152.0043770 90 ------- $1,390.00 $1,472.00 $1,581.00 $1,390.00 $1,472.00 $1,581.0043771 90 ------- $1,590.00 $1,684.00 $1,809.00 $1,590.00 $1,684.00 $1,809.0043772 90 ------- $1,197.00 $1,268.00 $1,362.00 $1,197.00 $1,268.00 $1,362.0043773 90 ------- $1,590.00 $1,685.00 $1,810.00 $1,590.00 $1,685.00 $1,810.0043774 90 ------- $1,200.00 $1,270.00 $1,362.00 $1,200.00 $1,270.00 $1,362.0043800 90 $793.00 $1,158.00 $1,225.00 $1,314.00 $1,158.00 $1,225.00 $1,314.0043810 90 $846.00 $1,250.00 $1,322.00 $1,416.00 $1,250.00 $1,322.00 $1,416.0043820 90 $896.00 $1,576.00 $1,653.00 $1,755.00 $1,576.00 $1,653.00 $1,755.0043825 90 $1,128.00 $1,615.00 $1,708.00 $1,831.00 $1,615.00 $1,708.00 $1,831.0043830 90 $592.00 $855.00 $904.00 $968.00 $855.00 $904.00 $968.0043831 90 $593.00 $711.00 $754.00 $809.00 $711.00 $754.00 $809.0043832 90 $904.00 $1,315.00 $1,391.00 $1,489.00 $1,315.00 $1,391.00 $1,489.0043840 90 $893.00 $1,602.00 $1,681.00 $1,784.00 $1,602.00 $1,681.00 $1,784.0043842 90 $1,260.00 $1,539.00 $1,627.00 $1,745.00 $1,539.00 $1,627.00 $1,745.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

43843 90 $1,249.00 $1,575.00 $1,665.00 $1,785.00 $1,575.00 $1,665.00 $1,785.0043845 90 ------- $2,469.00 $2,614.00 $2,809.00 $2,469.00 $2,614.00 $2,809.0043846 90 $1,528.00 $2,032.00 $2,149.00 $2,304.00 $2,032.00 $2,149.00 $2,304.0043847 90 $1,678.00 $2,231.00 $2,360.00 $2,531.00 $2,231.00 $2,360.00 $2,531.0043848 90 $1,795.00 $2,415.00 $2,555.00 $2,741.00 $2,415.00 $2,555.00 $2,741.0043850 90 $1,425.00 $2,032.00 $2,150.00 $2,307.00 $2,032.00 $2,150.00 $2,307.0043855 90 $1,454.00 $2,117.00 $2,241.00 $2,407.00 $2,117.00 $2,241.00 $2,407.0043860 90 $1,435.00 $2,053.00 $2,171.00 $2,330.00 $2,053.00 $2,171.00 $2,330.0043865 90 $1,549.00 $2,142.00 $2,268.00 $2,435.00 $2,142.00 $2,268.00 $2,435.0043870 90 $590.00 $870.00 $920.00 $983.00 $870.00 $920.00 $983.0043880 90 $1,352.00 $2,009.00 $2,126.00 $2,283.00 $2,009.00 $2,126.00 $2,283.0043886 90 ------- $398.00 $416.00 $435.00 $398.00 $416.00 $435.0043887 90 ------- $385.00 $408.00 $437.00 $385.00 $408.00 $437.0043888 90 ------- $547.00 $579.00 $618.00 $547.00 $579.00 $618.0043999 YYY BR ------- ------- ------- ------- ------- -------44005 90 $1,171.00 $1,366.00 $1,445.00 $1,549.00 $1,366.00 $1,445.00 $1,549.0044010 90 $809.00 $1,070.00 $1,132.00 $1,212.00 $1,070.00 $1,132.00 $1,212.0044015 ZZZ $1,171.00 $190.00 $202.00 $218.00 $190.00 $202.00 $218.0044020 90 $891.00 $1,204.00 $1,272.00 $1,363.00 $1,204.00 $1,272.00 $1,363.0044021 90 $888.00 $1,213.00 $1,282.00 $1,374.00 $1,213.00 $1,282.00 $1,374.0044025 90 $905.00 $1,224.00 $1,294.00 $1,386.00 $1,224.00 $1,294.00 $1,386.0044050 90 $862.00 $1,167.00 $1,235.00 $1,326.00 $1,167.00 $1,235.00 $1,326.0044055 90 $957.00 $1,860.00 $1,965.00 $2,104.00 $1,860.00 $1,965.00 $2,104.0044100 0 $117.00 $148.00 $156.00 $165.00 $148.00 $156.00 $165.0044110 90 $784.00 $1,047.00 $1,105.00 $1,182.00 $1,047.00 $1,105.00 $1,182.0044111 90 $963.00 $1,225.00 $1,295.00 $1,386.00 $1,225.00 $1,295.00 $1,386.0044120 90 $1,078.00 $1,508.00 $1,590.00 $1,699.00 $1,508.00 $1,590.00 $1,699.0044121 ZZZ $308.00 $320.00 $340.00 $367.00 $320.00 $340.00 $367.0044125 90 $1,135.00 $1,473.00 $1,556.00 $1,666.00 $1,473.00 $1,556.00 $1,666.0044126 90 $1,951.00 $3,038.00 $3,206.00 $3,432.00 $3,038.00 $3,206.00 $3,432.0044127 90 $2,243.00 $3,547.00 $3,750.00 $4,023.00 $3,547.00 $3,750.00 $4,023.0044128 ZZZ $242.00 $325.00 $346.00 $374.00 $325.00 $346.00 $374.0044130 90 $938.00 $1,536.00 $1,609.00 $1,704.00 $1,536.00 $1,609.00 $1,704.0044133 0 BR ------- ------- ------- ------- ------- -------44136 0 BR ------- ------- ------- ------- ------- -------44139 ZZZ $154.00 $160.00 $169.00 $182.00 $160.00 $169.00 $182.0044140 90 $1,350.00 $1,688.00 $1,786.00 $1,917.00 $1,688.00 $1,786.00 $1,917.0044141 90 $1,488.00 $2,145.00 $2,248.00 $2,380.00 $2,145.00 $2,248.00 $2,380.0044143 90 $1,536.00 $2,064.00 $2,178.00 $2,329.00 $2,064.00 $2,178.00 $2,329.0044144 90 $1,442.00 $2,130.00 $2,238.00 $2,381.00 $2,130.00 $2,238.00 $2,381.0044145 90 $1,678.00 $2,104.00 $2,224.00 $2,383.00 $2,104.00 $2,224.00 $2,383.0044146 90 $1,840.00 $2,576.00 $2,709.00 $2,882.00 $2,576.00 $2,709.00 $2,882.0044147 90 $1,452.00 $2,266.00 $2,365.00 $2,495.00 $2,266.00 $2,365.00 $2,495.0044150 90 $1,661.00 $2,265.00 $2,386.00 $2,542.00 $2,265.00 $2,386.00 $2,542.0044151 90 $1,499.00 $2,591.00 $2,728.00 $2,906.00 $2,591.00 $2,728.00 $2,906.0044155 90 $1,892.00 $2,536.00 $2,667.00 $2,835.00 $2,536.00 $2,667.00 $2,835.0044156 90 $1,709.00 $2,799.00 $2,952.00 $3,151.00 $2,799.00 $2,952.00 $3,151.0044157 90 ------- $2,833.00 $2,994.00 $3,198.00 $2,833.00 $2,994.00 $3,198.0044158 90 ------- $2,907.00 $3,072.00 $3,283.00 $2,907.00 $3,072.00 $3,283.0044160 90 $1,236.00 $1,545.00 $1,633.00 $1,748.00 $1,545.00 $1,633.00 $1,748.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

44180 90 ------- $1,162.00 $1,231.00 $1,321.00 $1,162.00 $1,231.00 $1,321.0044186 90 ------- $819.00 $868.00 $932.00 $819.00 $868.00 $932.0044187 90 ------- $1,376.00 $1,455.00 $1,557.00 $1,376.00 $1,455.00 $1,557.0044188 90 ------- $1,517.00 $1,605.00 $1,719.00 $1,517.00 $1,605.00 $1,719.0044202 90 $1,603.00 $1,749.00 $1,852.00 $1,990.00 $1,749.00 $1,852.00 $1,990.0044203 ZZZ $235.00 $319.00 $338.00 $365.00 $319.00 $338.00 $365.0044204 90 $1,353.00 $1,952.00 $2,065.00 $2,215.00 $1,952.00 $2,065.00 $2,215.0044205 90 $1,198.00 $1,708.00 $1,807.00 $1,940.00 $1,708.00 $1,807.00 $1,940.0044206 90 $1,480.00 $2,209.00 $2,336.00 $2,504.00 $2,209.00 $2,336.00 $2,504.0044207 90 $1,620.00 $2,323.00 $2,455.00 $2,631.00 $2,323.00 $2,455.00 $2,631.0044208 90 $1,752.00 $2,527.00 $2,670.00 $2,860.00 $2,527.00 $2,670.00 $2,860.0044210 90 $1,551.00 $2,251.00 $2,378.00 $2,547.00 $2,251.00 $2,378.00 $2,547.0044211 90 $1,926.00 $2,769.00 $2,925.00 $3,131.00 $2,769.00 $2,925.00 $3,131.0044212 90 $1,800.00 $2,582.00 $2,726.00 $2,914.00 $2,582.00 $2,726.00 $2,914.0044213 ZZZ ------- $251.00 $266.00 $286.00 $251.00 $266.00 $286.0044227 90 ------- $2,109.00 $2,231.00 $2,393.00 $2,109.00 $2,231.00 $2,393.0044238 YYY BR ------- ------- ------- ------- ------- -------44300 90 $697.00 $1,044.00 $1,104.00 $1,183.00 $1,044.00 $1,104.00 $1,183.0044310 90 $950.00 $1,306.00 $1,380.00 $1,478.00 $1,306.00 $1,380.00 $1,478.0044312 90 $453.00 $727.00 $766.00 $815.00 $727.00 $766.00 $815.0044314 90 $892.00 $1,252.00 $1,321.00 $1,409.00 $1,252.00 $1,321.00 $1,409.0044316 90 $1,229.00 $1,726.00 $1,817.00 $1,936.00 $1,726.00 $1,817.00 $1,936.0044320 90 $1,029.00 $1,488.00 $1,573.00 $1,684.00 $1,488.00 $1,573.00 $1,684.0044322 90 $1,015.00 $1,181.00 $1,252.00 $1,339.00 $1,181.00 $1,252.00 $1,339.0044340 90 $397.00 $737.00 $778.00 $831.00 $737.00 $778.00 $831.0044345 90 $816.00 $1,302.00 $1,377.00 $1,474.00 $1,302.00 $1,377.00 $1,474.0044346 90 $923.00 $1,456.00 $1,537.00 $1,643.00 $1,456.00 $1,537.00 $1,643.0044360 0 $177.00 $202.00 $211.00 $222.00 $202.00 $211.00 $222.0044361 0 $195.00 $222.00 $232.00 $245.00 $222.00 $232.00 $245.0044363 0 $213.00 $266.00 $278.00 $294.00 $266.00 $278.00 $294.0044364 0 $255.00 $283.00 $296.00 $312.00 $283.00 $296.00 $312.0044365 0 $226.00 $252.00 $263.00 $277.00 $252.00 $263.00 $277.0044366 0 $300.00 $334.00 $350.00 $368.00 $334.00 $350.00 $368.0044369 0 $308.00 $340.00 $356.00 $375.00 $340.00 $356.00 $375.0044370 0 $253.00 $368.00 $385.00 $407.00 $368.00 $385.00 $407.0044372 0 $301.00 $331.00 $346.00 $366.00 $331.00 $346.00 $366.0044373 0 $238.00 $265.00 $277.00 $292.00 $265.00 $277.00 $292.0044376 0 $305.00 $392.00 $411.00 $434.00 $392.00 $411.00 $434.0044377 0 $320.00 $413.00 $432.00 $455.00 $413.00 $432.00 $455.0044378 0 $410.00 $532.00 $557.00 $587.00 $532.00 $557.00 $587.0044379 0 $396.00 $570.00 $598.00 $633.00 $570.00 $598.00 $633.0044380 0 $91.00 $88.00 $92.00 $97.00 $88.00 $92.00 $97.0044382 0 $110.00 $106.00 $111.00 $118.00 $106.00 $111.00 $118.0044383 0 $165.00 $227.00 $237.00 $250.00 $227.00 $237.00 $250.0044385 0 $219.00 $304.00 $322.00 $340.00 $138.00 $145.00 $153.0044386 0 $183.00 $448.00 $477.00 $504.00 $163.00 $172.00 $182.0044388 0 $326.00 $433.00 $459.00 $486.00 $215.00 $226.00 $240.0044389 0 $301.00 $512.00 $543.00 $574.00 $240.00 $251.00 $266.0044390 0 $319.00 $591.00 $627.00 $662.00 $290.00 $304.00 $321.0044391 0 $376.00 $671.00 $711.00 $751.00 $327.00 $343.00 $362.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

44392 0 $359.00 $555.00 $588.00 $622.00 $286.00 $300.00 $319.0044393 0 $413.00 $633.00 $671.00 $709.00 $360.00 $378.00 $400.0044394 0 $395.00 $645.00 $684.00 $723.00 $332.00 $348.00 $369.0044397 0 $259.00 $351.00 $368.00 $389.00 $351.00 $368.00 $389.0044500 0 $28.00 $34.00 $35.00 $37.00 $34.00 $35.00 $37.0044602 90 $815.00 $1,676.00 $1,754.00 $1,858.00 $1,676.00 $1,754.00 $1,858.0044603 90 $1,041.00 $1,914.00 $2,004.00 $2,123.00 $1,914.00 $2,004.00 $2,123.0044604 90 $1,027.00 $1,329.00 $1,405.00 $1,507.00 $1,329.00 $1,405.00 $1,507.0044605 90 $1,132.00 $1,638.00 $1,731.00 $1,854.00 $1,638.00 $1,731.00 $1,854.0044615 90 $994.00 $1,343.00 $1,420.00 $1,520.00 $1,343.00 $1,420.00 $1,520.0044620 90 $741.00 $1,065.00 $1,122.00 $1,198.00 $1,065.00 $1,122.00 $1,198.0044625 90 $1,277.00 $1,267.00 $1,336.00 $1,428.00 $1,267.00 $1,336.00 $1,428.0044626 90 $1,581.00 $2,033.00 $2,150.00 $2,306.00 $2,033.00 $2,150.00 $2,306.0044640 90 $1,036.00 $1,768.00 $1,868.00 $2,002.00 $1,768.00 $1,868.00 $2,002.0044650 90 $1,076.00 $1,838.00 $1,943.00 $2,084.00 $1,838.00 $1,943.00 $2,084.0044660 90 $1,050.00 $1,741.00 $1,827.00 $1,938.00 $1,741.00 $1,827.00 $1,938.0044661 90 $1,326.00 $1,977.00 $2,082.00 $2,221.00 $1,977.00 $2,082.00 $2,221.0044680 90 $1,049.00 $1,327.00 $1,401.00 $1,499.00 $1,327.00 $1,401.00 $1,499.0044700 90 $1,115.00 $1,283.00 $1,353.00 $1,444.00 $1,283.00 $1,353.00 $1,444.0044701 ZZZ $161.00 $220.00 $233.00 $250.00 $220.00 $233.00 $250.0044720 0 ------- $338.00 $353.00 $372.00 $338.00 $353.00 $372.0044721 0 ------- $510.00 $542.00 $586.00 $510.00 $542.00 $586.0044799 YYY BR ------- ------- ------- ------- ------- -------44800 90 $791.00 $949.00 $1,006.00 $1,079.00 $949.00 $1,006.00 $1,079.0044820 90 $755.00 $1,042.00 $1,103.00 $1,181.00 $1,042.00 $1,103.00 $1,181.0044850 90 $708.00 $925.00 $979.00 $1,048.00 $925.00 $979.00 $1,048.0044899 YYY BR ------- ------- ------- ------- ------- -------44900 90 $644.00 $932.00 $983.00 $1,050.00 $932.00 $983.00 $1,050.0044901 0 $310.00 $1,368.00 $1,459.00 $1,537.00 $233.00 $243.00 $255.0044950 90 $643.00 $807.00 $855.00 $919.00 $807.00 $855.00 $919.0044955 ZZZ $136.00 $111.00 $118.00 $127.00 $111.00 $118.00 $127.0044960 90 $790.00 $1,073.00 $1,134.00 $1,214.00 $1,073.00 $1,134.00 $1,214.0044970 90 $631.00 $736.00 $780.00 $837.00 $736.00 $780.00 $837.0044979 YYY BR ------- ------- ------- ------- ------- -------45000 90 $329.00 $496.00 $521.00 $551.00 $496.00 $521.00 $551.0045005 10 $197.00 $315.00 $335.00 $357.00 $193.00 $205.00 $219.0045020 90 $364.00 $635.00 $663.00 $696.00 $635.00 $663.00 $696.0045100 90 $321.00 $350.00 $371.00 $396.00 $350.00 $371.00 $396.0045108 90 $419.00 $430.00 $456.00 $488.00 $430.00 $456.00 $488.0045110 90 $1,801.00 $2,308.00 $2,437.00 $2,605.00 $2,308.00 $2,437.00 $2,605.0045111 90 $1,270.00 $1,358.00 $1,436.00 $1,538.00 $1,358.00 $1,436.00 $1,538.0045112 90 $1,904.00 $2,376.00 $2,502.00 $2,669.00 $2,376.00 $2,502.00 $2,669.0045113 90 $1,885.00 $2,435.00 $2,567.00 $2,740.00 $2,435.00 $2,567.00 $2,740.0045114 90 $1,732.00 $2,234.00 $2,357.00 $2,520.00 $2,234.00 $2,357.00 $2,520.0045116 90 $1,485.00 $2,014.00 $2,123.00 $2,265.00 $2,014.00 $2,123.00 $2,265.0045119 90 $1,911.00 $2,432.00 $2,561.00 $2,728.00 $2,432.00 $2,561.00 $2,728.0045120 90 $1,845.00 $1,948.00 $2,056.00 $2,199.00 $1,948.00 $2,056.00 $2,199.0045121 90 $1,870.00 $2,145.00 $2,265.00 $2,424.00 $2,145.00 $2,265.00 $2,424.0045123 90 $1,126.00 $1,371.00 $1,442.00 $1,536.00 $1,371.00 $1,442.00 $1,536.0045126 90 $2,444.00 $3,566.00 $3,742.00 $3,967.00 $3,566.00 $3,742.00 $3,967.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

45130 90 $1,041.00 $1,341.00 $1,411.00 $1,502.00 $1,341.00 $1,411.00 $1,502.0045135 90 $1,354.00 $1,653.00 $1,743.00 $1,861.00 $1,653.00 $1,743.00 $1,861.0045136 90 $1,526.00 $2,274.00 $2,389.00 $2,536.00 $2,274.00 $2,389.00 $2,536.0045150 90 $475.00 $477.00 $503.00 $537.00 $477.00 $503.00 $537.0045160 90 $949.00 $1,219.00 $1,285.00 $1,371.00 $1,219.00 $1,285.00 $1,371.0045170 90 $697.00 $958.00 $1,011.00 $1,080.00 $958.00 $1,011.00 $1,080.0045190 90 $623.00 $826.00 $873.00 $932.00 $826.00 $873.00 $932.0045300 0 $75.00 $127.00 $135.00 $141.00 $59.00 $61.00 $64.0045303 0 $72.00 $1,039.00 $1,109.00 $1,168.00 $99.00 $102.00 $105.0045305 0 $102.00 $213.00 $226.00 $239.00 $95.00 $100.00 $106.0045307 0 $172.00 $246.00 $260.00 $273.00 $118.00 $123.00 $129.0045308 0 $137.00 $208.00 $220.00 $231.00 $99.00 $103.00 $108.0045309 0 $174.00 $246.00 $263.00 $281.00 $125.00 $134.00 $144.0045315 0 $211.00 $264.00 $279.00 $295.00 $134.00 $141.00 $149.0045317 0 $209.00 $251.00 $265.00 $279.00 $141.00 $148.00 $156.0045320 0 $230.00 $254.00 $270.00 $285.00 $134.00 $141.00 $149.0045321 0 $154.00 $128.00 $134.00 $141.00 $128.00 $134.00 $141.0045327 0 $96.00 $147.00 $153.00 $162.00 $147.00 $153.00 $162.0045330 0 $87.00 $172.00 $182.00 $192.00 $80.00 $84.00 $88.0045331 0 $120.00 $220.00 $234.00 $246.00 $95.00 $100.00 $106.0045332 0 $174.00 $360.00 $383.00 $405.00 $142.00 $149.00 $158.0045333 0 $176.00 $359.00 $382.00 $403.00 $141.00 $148.00 $156.0045334 0 $171.00 $211.00 $221.00 $232.00 $211.00 $221.00 $232.0045335 0 $144.00 $291.00 $309.00 $326.00 $117.00 $123.00 $129.0045337 0 $144.00 $184.00 $193.00 $204.00 $184.00 $193.00 $204.0045338 0 $212.00 $403.00 $428.00 $452.00 $182.00 $191.00 $202.0045339 0 $237.00 $398.00 $421.00 $445.00 $242.00 $254.00 $268.0045340 0 $328.00 $511.00 $544.00 $574.00 $147.00 $154.00 $163.0045341 0 $153.00 $201.00 $210.00 $221.00 $201.00 $210.00 $221.0045342 0 $224.00 $307.00 $321.00 $338.00 $307.00 $321.00 $338.0045345 0 $164.00 $222.00 $232.00 $245.00 $222.00 $232.00 $245.0045355 0 $185.00 $267.00 $282.00 $300.00 $267.00 $282.00 $300.0045378 0 $341.00 $510.00 $540.00 $571.00 $280.00 $293.00 $310.0045379 0 $415.00 $644.00 $682.00 $720.00 $350.00 $367.00 $388.0045380 0 $369.00 $609.00 $645.00 $681.00 $335.00 $351.00 $371.0045381 0 $388.00 $591.00 $625.00 $659.00 $316.00 $330.00 $347.0045382 0 $481.00 $806.00 $853.00 $899.00 $426.00 $446.00 $469.0045383 0 $482.00 $725.00 $767.00 $810.00 $435.00 $456.00 $482.0045384 0 $415.00 $600.00 $635.00 $670.00 $351.00 $368.00 $388.0045385 0 $479.00 $687.00 $726.00 $766.00 $398.00 $417.00 $440.0045386 0 $739.00 $864.00 $919.00 $970.00 $344.00 $361.00 $382.0045387 0 $322.00 $444.00 $465.00 $492.00 $444.00 $465.00 $492.0045391 0 ------- $387.00 $405.00 $429.00 $387.00 $405.00 $429.0045392 0 ------- $483.00 $504.00 $529.00 $483.00 $504.00 $529.0045395 90 ------- $2,493.00 $2,633.00 $2,815.00 $2,493.00 $2,633.00 $2,815.0045397 90 ------- $2,687.00 $2,829.00 $3,014.00 $2,687.00 $2,829.00 $3,014.0045400 90 ------- $1,440.00 $1,519.00 $1,620.00 $1,440.00 $1,519.00 $1,620.0045402 90 ------- $1,931.00 $2,036.00 $2,174.00 $1,931.00 $2,036.00 $2,174.0045500 90 $584.00 $618.00 $652.00 $693.00 $618.00 $652.00 $693.0045505 90 $510.00 $676.00 $713.00 $760.00 $676.00 $713.00 $760.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

45520 0 $46.00 $142.00 $151.00 $160.00 $49.00 $51.00 $54.0045540 90 $1,009.00 $1,309.00 $1,378.00 $1,470.00 $1,309.00 $1,378.00 $1,470.0045541 90 $888.00 $1,127.00 $1,189.00 $1,268.00 $1,127.00 $1,189.00 $1,268.0045550 90 $1,350.00 $1,820.00 $1,919.00 $2,049.00 $1,820.00 $1,919.00 $2,049.0045560 90 $618.00 $890.00 $938.00 $998.00 $890.00 $938.00 $998.0045562 90 $915.00 $1,360.00 $1,434.00 $1,528.00 $1,360.00 $1,434.00 $1,528.0045563 90 $1,412.00 $2,010.00 $2,127.00 $2,280.00 $2,010.00 $2,127.00 $2,280.0045800 90 $1,050.00 $1,509.00 $1,586.00 $1,684.00 $1,509.00 $1,586.00 $1,684.0045805 90 $1,273.00 $1,736.00 $1,822.00 $1,930.00 $1,736.00 $1,822.00 $1,930.0045820 90 $1,066.00 $1,493.00 $1,563.00 $1,650.00 $1,493.00 $1,563.00 $1,650.0045825 90 $1,241.00 $1,793.00 $1,886.00 $2,006.00 $1,793.00 $1,886.00 $2,006.0045900 10 $120.00 $242.00 $255.00 $272.00 $242.00 $255.00 $272.0045905 10 $133.00 $206.00 $218.00 $233.00 $206.00 $218.00 $233.0045910 10 $163.00 $243.00 $257.00 $274.00 $243.00 $257.00 $274.0045915 10 $142.00 $385.00 $408.00 $432.00 $275.00 $290.00 $308.0045990 0 ------- $136.00 $143.00 $152.00 $136.00 $143.00 $152.0045999 YYY BR ------- ------- ------- ------- ------- -------46020 10 $230.00 $303.00 $320.00 $341.00 $268.00 $283.00 $301.0046030 10 $94.00 $150.00 $160.00 $170.00 $107.00 $113.00 $121.0046040 90 $393.00 $597.00 $634.00 $676.00 $485.00 $514.00 $550.0046045 90 $312.00 $486.00 $512.00 $543.00 $486.00 $512.00 $543.0046050 10 $105.00 $212.00 $225.00 $239.00 $114.00 $120.00 $129.0046060 90 $482.00 $537.00 $568.00 $606.00 $537.00 $568.00 $606.0046080 10 $246.00 $277.00 $294.00 $314.00 $198.00 $209.00 $224.0046083 10 $98.00 $200.00 $213.00 $226.00 $126.00 $133.00 $141.0046200 90 $323.00 $447.00 $475.00 $506.00 $359.00 $381.00 $406.0046210 90 $196.00 $426.00 $453.00 $482.00 $300.00 $319.00 $340.0046211 90 $353.00 $572.00 $608.00 $646.00 $445.00 $472.00 $503.0046220 10 $118.00 $221.00 $234.00 $249.00 $139.00 $147.00 $156.0046221 10 $124.00 $286.00 $303.00 $322.00 $220.00 $232.00 $247.0046230 10 $198.00 $310.00 $329.00 $351.00 $211.00 $223.00 $239.0046250 90 $400.00 $515.00 $547.00 $583.00 $370.00 $392.00 $418.0046255 90 $501.00 $580.00 $616.00 $657.00 $423.00 $448.00 $479.0046257 90 $504.00 $485.00 $514.00 $549.00 $485.00 $514.00 $549.0046258 90 $539.00 $529.00 $559.00 $597.00 $529.00 $559.00 $597.0046260 90 $598.00 $554.00 $586.00 $627.00 $554.00 $586.00 $627.0046261 90 $655.00 $618.00 $653.00 $695.00 $618.00 $653.00 $695.0046262 90 $686.00 $642.00 $678.00 $723.00 $642.00 $678.00 $723.0046270 90 $328.00 $547.00 $579.00 $614.00 $431.00 $455.00 $483.0046275 90 $442.00 $572.00 $605.00 $642.00 $464.00 $490.00 $520.0046280 90 $514.00 $535.00 $565.00 $602.00 $535.00 $565.00 $602.0046285 90 $335.00 $542.00 $571.00 $604.00 $452.00 $475.00 $502.0046288 90 $521.00 $632.00 $666.00 $710.00 $632.00 $666.00 $710.0046320 10 $126.00 $204.00 $217.00 $230.00 $134.00 $141.00 $151.0046500 10 $109.00 $232.00 $247.00 $261.00 $149.00 $158.00 $168.0046505 10 ------- $316.00 $331.00 $346.00 $264.00 $275.00 $287.0046600 0 $38.00 $103.00 $110.00 $116.00 $48.00 $50.00 $53.0046604 0 $92.00 $599.00 $641.00 $677.00 $86.00 $91.00 $97.0046606 0 $66.00 $255.00 $271.00 $286.00 $89.00 $93.00 $98.0046608 0 $115.00 $277.00 $296.00 $314.00 $104.00 $110.00 $118.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

46610 0 $114.00 $268.00 $285.00 $303.00 $102.00 $108.00 $116.0046611 0 $149.00 $222.00 $238.00 $254.00 $109.00 $117.00 $126.0046612 0 $196.00 $339.00 $364.00 $390.00 $135.00 $145.00 $159.0046614 0 $169.00 $169.00 $182.00 $196.00 $97.00 $104.00 $114.0046615 0 $202.00 $202.00 $218.00 $237.00 $139.00 $150.00 $166.0046700 90 $585.00 $763.00 $803.00 $854.00 $763.00 $803.00 $854.0046706 10 $140.00 $204.00 $216.00 $231.00 $204.00 $216.00 $231.0046710 90 ------- $1,291.00 $1,353.00 $1,430.00 $1,291.00 $1,353.00 $1,430.0046712 90 ------- $2,723.00 $2,868.00 $3,055.00 $2,723.00 $2,868.00 $3,055.0046715 90 $545.00 $610.00 $646.00 $693.00 $610.00 $646.00 $693.0046716 90 $906.00 $1,369.00 $1,441.00 $1,529.00 $1,369.00 $1,441.00 $1,529.0046730 90 $1,584.00 $2,225.00 $2,332.00 $2,465.00 $2,225.00 $2,332.00 $2,465.0046735 90 $1,881.00 $2,643.00 $2,775.00 $2,943.00 $2,643.00 $2,775.00 $2,943.0046740 90 $1,671.00 $2,474.00 $2,586.00 $2,723.00 $2,474.00 $2,586.00 $2,723.0046742 90 $2,236.00 $2,894.00 $3,031.00 $3,203.00 $2,894.00 $3,031.00 $3,203.0046744 90 $2,412.00 $4,234.00 $4,467.00 $4,776.00 $4,234.00 $4,467.00 $4,776.0046746 90 $2,725.00 $4,780.00 $5,056.00 $5,425.00 $4,780.00 $5,056.00 $5,425.0046748 90 $2,933.00 $4,714.00 $4,879.00 $5,077.00 $4,714.00 $4,879.00 $5,077.0046750 90 $636.00 $922.00 $969.00 $1,028.00 $922.00 $969.00 $1,028.0046753 90 $511.00 $699.00 $738.00 $788.00 $699.00 $738.00 $788.0046754 10 $188.00 $331.00 $349.00 $367.00 $247.00 $259.00 $272.0046760 90 $846.00 $1,313.00 $1,380.00 $1,465.00 $1,313.00 $1,380.00 $1,465.0046761 90 $813.00 $1,137.00 $1,196.00 $1,270.00 $1,137.00 $1,196.00 $1,270.0046762 90 $731.00 $1,102.00 $1,156.00 $1,223.00 $1,102.00 $1,156.00 $1,223.0046900 10 $128.00 $259.00 $274.00 $290.00 $168.00 $176.00 $187.0046910 10 $144.00 $273.00 $290.00 $307.00 $160.00 $169.00 $180.0046916 10 $145.00 $270.00 $285.00 $300.00 $171.00 $179.00 $188.0046917 10 $228.00 $553.00 $590.00 $625.00 $164.00 $173.00 $185.0046922 10 $189.00 $291.00 $310.00 $330.00 $162.00 $172.00 $184.0046924 10 $297.00 $608.00 $647.00 $684.00 $223.00 $234.00 $249.0046937 10 $268.00 $292.00 $307.00 $322.00 $204.00 $212.00 $222.0046938 90 $405.00 $507.00 $539.00 $576.00 $432.00 $458.00 $491.0046940 10 $165.00 $248.00 $263.00 $279.00 $181.00 $191.00 $203.0046942 10 $145.00 $228.00 $241.00 $255.00 $161.00 $169.00 $180.0046945 90 $199.00 $317.00 $336.00 $355.00 $252.00 $266.00 $282.0046946 90 $270.00 $352.00 $374.00 $397.00 $269.00 $285.00 $303.0046947 90 ------- $462.00 $492.00 $530.00 $462.00 $492.00 $530.0046999 YYY BR ------- ------- ------- ------- ------- -------47000 0 $218.00 $367.00 $389.00 $410.00 $132.00 $137.00 $144.0047001 ZZZ $141.00 $137.00 $146.00 $157.00 $137.00 $146.00 $157.0047010 90 $788.00 $1,466.00 $1,542.00 $1,638.00 $1,466.00 $1,542.00 $1,638.0047011 0 $347.00 $254.00 $264.00 $276.00 $254.00 $264.00 $276.0047015 90 $755.00 $1,400.00 $1,475.00 $1,570.00 $1,400.00 $1,475.00 $1,570.0047100 90 $550.00 $1,030.00 $1,091.00 $1,169.00 $1,030.00 $1,091.00 $1,169.0047120 90 $1,663.00 $2,922.00 $3,093.00 $3,319.00 $2,922.00 $3,093.00 $3,319.0047122 90 $2,512.00 $4,364.00 $4,619.00 $4,961.00 $4,364.00 $4,619.00 $4,961.0047125 90 $2,293.00 $3,915.00 $4,145.00 $4,453.00 $3,915.00 $4,145.00 $4,453.0047130 90 $2,482.00 $4,209.00 $4,455.00 $4,787.00 $4,209.00 $4,455.00 $4,787.0047135 90 $6,164.00 $6,183.00 $6,542.00 $7,020.00 $6,183.00 $6,542.00 $7,020.0047136 90 $4,985.00 $5,265.00 $5,571.00 $5,979.00 $5,265.00 $5,571.00 $5,979.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

47146 0 ------- $437.00 $464.00 $502.00 $437.00 $464.00 $502.0047147 0 ------- $509.00 $541.00 $586.00 $509.00 $541.00 $586.0047300 90 $778.00 $1,378.00 $1,455.00 $1,555.00 $1,378.00 $1,455.00 $1,555.0047350 90 $942.00 $1,696.00 $1,793.00 $1,921.00 $1,696.00 $1,793.00 $1,921.0047360 90 $1,305.00 $2,303.00 $2,429.00 $2,596.00 $2,303.00 $2,429.00 $2,596.0047361 90 $2,129.00 $3,827.00 $4,041.00 $4,324.00 $3,827.00 $4,041.00 $4,324.0047362 90 $849.00 $1,748.00 $1,844.00 $1,970.00 $1,748.00 $1,844.00 $1,970.0047370 90 $943.00 $1,569.00 $1,662.00 $1,786.00 $1,569.00 $1,662.00 $1,786.0047371 90 $889.00 $1,578.00 $1,673.00 $1,800.00 $1,578.00 $1,673.00 $1,800.0047379 YYY BR ------- ------- ------- ------- ------- -------47380 90 $1,107.00 $1,823.00 $1,928.00 $2,068.00 $1,823.00 $1,928.00 $2,068.0047381 90 $1,094.00 $1,860.00 $1,966.00 $2,106.00 $1,860.00 $1,966.00 $2,106.0047382 10 $660.00 $1,096.00 $1,143.00 $1,199.00 $1,096.00 $1,143.00 $1,199.0047399 YYY BR ------- ------- ------- ------- ------- -------47400 90 $1,435.00 $2,607.00 $2,732.00 $2,892.00 $2,607.00 $2,732.00 $2,892.0047420 90 $1,222.00 $1,671.00 $1,768.00 $1,897.00 $1,671.00 $1,768.00 $1,897.0047425 90 $1,275.00 $1,687.00 $1,784.00 $1,913.00 $1,687.00 $1,784.00 $1,913.0047460 90 $1,039.00 $1,571.00 $1,658.00 $1,771.00 $1,571.00 $1,658.00 $1,771.0047480 90 $755.00 $1,042.00 $1,101.00 $1,175.00 $1,042.00 $1,101.00 $1,175.0047490 90 $467.00 $683.00 $714.00 $747.00 $683.00 $714.00 $747.0047500 0 $103.00 $135.00 $141.00 $147.00 $135.00 $141.00 $147.0047505 0 $96.00 $52.00 $54.00 $56.00 $52.00 $54.00 $56.0047510 90 $487.00 $650.00 $679.00 $711.00 $650.00 $679.00 $711.0047511 90 $627.00 $806.00 $840.00 $880.00 $806.00 $840.00 $880.0047525 10 $295.00 $1,035.00 $1,097.00 $1,154.00 $424.00 $443.00 $464.0047530 90 $35.00 $1,918.00 $2,043.00 $2,152.00 $488.00 $510.00 $535.0047550 ZZZ $209.00 $219.00 $232.00 $250.00 $219.00 $232.00 $250.0047552 0 $364.00 $438.00 $457.00 $481.00 $438.00 $457.00 $481.0047553 0 $342.00 $435.00 $452.00 $473.00 $435.00 $452.00 $473.0047554 0 $594.00 $667.00 $703.00 $751.00 $667.00 $703.00 $751.0047555 0 $383.00 $521.00 $541.00 $567.00 $521.00 $541.00 $567.0047556 0 $425.00 $588.00 $611.00 $640.00 $588.00 $611.00 $640.0047560 0 $345.00 $353.00 $375.00 $405.00 $353.00 $375.00 $405.0047561 0 $388.00 $382.00 $405.00 $437.00 $382.00 $405.00 $437.0047562 90 $837.00 $918.00 $974.00 $1,046.00 $918.00 $974.00 $1,046.0047563 90 $900.00 $949.00 $1,008.00 $1,085.00 $949.00 $1,008.00 $1,085.0047564 90 $1,069.00 $1,101.00 $1,169.00 $1,260.00 $1,101.00 $1,169.00 $1,260.0047570 90 $961.00 $979.00 $1,039.00 $1,119.00 $979.00 $1,039.00 $1,119.0047579 YYY BR ------- ------- ------- ------- ------- -------47600 90 $868.00 $1,291.00 $1,361.00 $1,451.00 $1,291.00 $1,361.00 $1,451.0047605 90 $935.00 $1,223.00 $1,296.00 $1,391.00 $1,223.00 $1,296.00 $1,391.0047610 90 $1,164.00 $1,565.00 $1,656.00 $1,777.00 $1,565.00 $1,656.00 $1,777.0047612 90 $1,276.00 $1,578.00 $1,669.00 $1,789.00 $1,578.00 $1,669.00 $1,789.0047620 90 $1,295.00 $1,713.00 $1,813.00 $1,945.00 $1,713.00 $1,813.00 $1,945.0047630 90 $465.00 $741.00 $775.00 $815.00 $741.00 $775.00 $815.0047700 90 $1,111.00 $1,302.00 $1,380.00 $1,483.00 $1,302.00 $1,380.00 $1,483.0047701 90 $1,913.00 $2,188.00 $2,321.00 $2,499.00 $2,188.00 $2,321.00 $2,499.0047711 90 $1,442.00 $1,941.00 $2,053.00 $2,202.00 $1,941.00 $2,053.00 $2,202.0047712 90 $1,793.00 $2,491.00 $2,634.00 $2,824.00 $2,491.00 $2,634.00 $2,824.0047715 90 $1,157.00 $1,629.00 $1,723.00 $1,846.00 $1,629.00 $1,723.00 $1,846.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

47720 90 $1,040.00 $1,402.00 $1,483.00 $1,588.00 $1,402.00 $1,483.00 $1,588.0047721 90 $1,248.00 $1,654.00 $1,749.00 $1,874.00 $1,654.00 $1,749.00 $1,874.0047740 90 $1,188.00 $1,600.00 $1,691.00 $1,811.00 $1,600.00 $1,691.00 $1,811.0047741 90 $1,425.00 $1,818.00 $1,923.00 $2,062.00 $1,818.00 $1,923.00 $2,062.0047760 90 $1,568.00 $2,659.00 $2,789.00 $2,958.00 $2,659.00 $2,789.00 $2,958.0047765 90 $1,624.00 $3,397.00 $3,530.00 $3,701.00 $3,397.00 $3,530.00 $3,701.0047780 90 $1,635.00 $2,889.00 $3,023.00 $3,198.00 $2,889.00 $3,023.00 $3,198.0047785 90 $1,871.00 $3,724.00 $3,883.00 $4,089.00 $3,724.00 $3,883.00 $4,089.0047800 90 $1,485.00 $1,962.00 $2,076.00 $2,226.00 $1,962.00 $2,076.00 $2,226.0047801 90 $906.00 $1,326.00 $1,385.00 $1,455.00 $1,326.00 $1,385.00 $1,455.0047802 90 $1,352.00 $1,875.00 $1,982.00 $2,123.00 $1,875.00 $1,982.00 $2,123.0047900 90 $1,331.00 $1,701.00 $1,800.00 $1,930.00 $1,701.00 $1,800.00 $1,930.0047999 YYY BR ------- ------- ------- ------- ------- -------48000 90 $1,053.00 $2,329.00 $2,457.00 $2,627.00 $2,329.00 $2,457.00 $2,627.0048001 90 $1,305.00 $2,896.00 $3,062.00 $3,286.00 $2,896.00 $3,062.00 $3,286.0048020 90 $983.00 $1,432.00 $1,512.00 $1,618.00 $1,432.00 $1,512.00 $1,618.0048100 90 $779.00 $1,092.00 $1,154.00 $1,234.00 $1,092.00 $1,154.00 $1,234.0048102 10 $341.00 $681.00 $719.00 $756.00 $338.00 $352.00 $369.0048105 90 ------- $3,552.00 $3,751.00 $4,017.00 $3,552.00 $3,751.00 $4,017.0048120 90 $1,083.00 $1,370.00 $1,447.00 $1,550.00 $1,370.00 $1,447.00 $1,550.0048140 90 $1,546.00 $1,943.00 $2,054.00 $2,200.00 $1,943.00 $2,054.00 $2,200.0048145 90 $1,661.00 $2,017.00 $2,132.00 $2,286.00 $2,017.00 $2,132.00 $2,286.0048146 90 $1,830.00 $2,304.00 $2,435.00 $2,608.00 $2,304.00 $2,435.00 $2,608.0048148 90 $1,149.00 $1,529.00 $1,615.00 $1,729.00 $1,529.00 $1,615.00 $1,729.0048150 90 $3,101.00 $3,911.00 $4,139.00 $4,442.00 $3,911.00 $4,139.00 $4,442.0048152 90 $2,888.00 $3,612.00 $3,821.00 $4,101.00 $3,612.00 $3,821.00 $4,101.0048153 90 $3,099.00 $3,907.00 $4,134.00 $4,437.00 $3,907.00 $4,134.00 $4,437.0048154 90 $2,893.00 $3,632.00 $3,843.00 $4,125.00 $3,632.00 $3,843.00 $4,125.0048155 90 $1,855.00 $2,224.00 $2,350.00 $2,513.00 $2,224.00 $2,350.00 $2,513.0048160 0 BR ------- ------- ------- ------- ------- -------48400 ZZZ $100.00 $136.00 $142.00 $150.00 $136.00 $142.00 $150.0048500 90 $1,012.00 $1,383.00 $1,461.00 $1,563.00 $1,383.00 $1,461.00 $1,563.0048510 90 $938.00 $1,322.00 $1,395.00 $1,489.00 $1,322.00 $1,395.00 $1,489.0048511 0 $286.00 $1,233.00 $1,312.00 $1,382.00 $275.00 $286.00 $299.0048520 90 $1,103.00 $1,350.00 $1,426.00 $1,527.00 $1,350.00 $1,426.00 $1,527.0048540 90 $1,350.00 $1,631.00 $1,726.00 $1,852.00 $1,631.00 $1,726.00 $1,852.0048545 90 $1,170.00 $1,636.00 $1,726.00 $1,844.00 $1,636.00 $1,726.00 $1,844.0048547 90 $1,630.00 $2,211.00 $2,335.00 $2,500.00 $2,211.00 $2,335.00 $2,500.0048548 90 ------- $2,074.00 $2,193.00 $2,351.00 $2,074.00 $2,193.00 $2,351.0048552 0 ------- $292.00 $304.00 $320.00 $292.00 $304.00 $320.0048554 90 $2,365.00 $3,041.00 $3,216.00 $3,438.00 $3,041.00 $3,216.00 $3,438.0048556 90 $1,117.00 $1,501.00 $1,584.00 $1,692.00 $1,501.00 $1,584.00 $1,692.0048999 YYY BR ------- ------- ------- ------- ------- -------49000 90 $862.00 $969.00 $1,026.00 $1,102.00 $969.00 $1,026.00 $1,102.0049002 90 $784.00 $1,217.00 $1,273.00 $1,343.00 $1,217.00 $1,273.00 $1,343.0049010 90 $915.00 $1,172.00 $1,232.00 $1,310.00 $1,172.00 $1,232.00 $1,310.0049020 90 $910.00 $1,970.00 $2,079.00 $2,220.00 $1,970.00 $2,079.00 $2,220.0049021 0 $290.00 $1,191.00 $1,269.00 $1,337.00 $232.00 $241.00 $253.0049040 90 $763.00 $1,229.00 $1,295.00 $1,381.00 $1,229.00 $1,295.00 $1,381.0049041 0 $305.00 $1,192.00 $1,269.00 $1,336.00 $275.00 $286.00 $299.00

CPT only © 2008 American Medical Association. All rights reserved. Part B, 208

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

49060 90 $827.00 $1,371.00 $1,441.00 $1,532.00 $1,371.00 $1,441.00 $1,532.0049061 0 $288.00 $1,175.00 $1,251.00 $1,317.00 $254.00 $264.00 $277.0049062 90 $892.00 $943.00 $997.00 $1,067.00 $943.00 $997.00 $1,067.0049080 0 $123.00 $238.00 $252.00 $265.00 $93.00 $97.00 $102.0049081 0 $98.00 $204.00 $216.00 $228.00 $89.00 $93.00 $98.0049180 0 $212.00 $228.00 $241.00 $253.00 $118.00 $123.00 $129.0049203 90 ------- $1,502.00 $1,587.00 $1,699.00 $1,502.00 $1,587.00 $1,699.0049204 90 ------- $1,918.00 $2,025.00 $2,168.00 $1,918.00 $2,025.00 $2,168.0049205 90 ------- $2,196.00 $2,319.00 $2,483.00 $2,196.00 $2,319.00 $2,483.0049215 90 $1,551.00 $2,784.00 $2,943.00 $3,154.00 $2,784.00 $2,943.00 $3,154.0049220 90 $1,182.00 $1,214.00 $1,286.00 $1,379.00 $1,214.00 $1,286.00 $1,379.0049250 90 $622.00 $720.00 $762.00 $818.00 $720.00 $762.00 $818.0049255 90 $591.00 $977.00 $1,034.00 $1,106.00 $977.00 $1,034.00 $1,106.0049320 10 $415.00 $417.00 $443.00 $476.00 $417.00 $443.00 $476.0049321 10 $443.00 $439.00 $466.00 $501.00 $439.00 $466.00 $501.0049322 10 $460.00 $477.00 $505.00 $541.00 $477.00 $505.00 $541.0049323 90 $712.00 $800.00 $847.00 $908.00 $800.00 $847.00 $908.0049324 10 ------- $492.00 $520.00 $557.00 $492.00 $520.00 $557.0049325 10 ------- $531.00 $564.00 $606.00 $531.00 $564.00 $606.0049326 ZZZ ------- $245.00 $260.00 $280.00 $245.00 $260.00 $280.0049329 YYY BR ------- ------- ------- ------- ------- -------49400 0 $127.00 $239.00 $253.00 $267.00 $131.00 $137.00 $145.0049402 90 ------- $1,062.00 $1,123.00 $1,203.00 $1,062.00 $1,123.00 $1,203.0049419 90 $405.00 $569.00 $602.00 $644.00 $569.00 $602.00 $644.0049420 0 $162.00 $177.00 $186.00 $198.00 $177.00 $186.00 $198.0049421 90 $452.00 $491.00 $521.00 $560.00 $491.00 $521.00 $560.0049422 10 $468.00 $497.00 $528.00 $569.00 $497.00 $528.00 $569.0049423 0 $106.00 $755.00 $806.00 $849.00 $103.00 $107.00 $112.0049424 0 $54.00 $209.00 $222.00 $233.00 $54.00 $56.00 $58.0049425 90 $914.00 $964.00 $1,022.00 $1,099.00 $964.00 $1,022.00 $1,099.0049426 90 $725.00 $820.00 $869.00 $933.00 $820.00 $869.00 $933.0049427 0 $48.00 $63.00 $66.00 $69.00 $63.00 $66.00 $69.0049428 10 $184.00 $555.00 $588.00 $630.00 $555.00 $588.00 $630.0049429 10 $522.00 $590.00 $627.00 $676.00 $590.00 $627.00 $676.0049435 ZZZ ------- $159.00 $168.00 $181.00 $159.00 $168.00 $181.0049436 10 ------- $232.00 $245.00 $260.00 $232.00 $245.00 $260.0049440 10 ------- $1,487.00 $1,589.00 $1,682.00 $326.00 $344.00 $369.0049441 10 ------- $1,752.00 $1,867.00 $1,967.00 $347.00 $362.00 $379.0049442 10 ------- $1,429.00 $1,522.00 $1,603.00 $288.00 $300.00 $314.0049446 0 ------- $1,457.00 $1,554.00 $1,637.00 $227.00 $236.00 $246.0049450 0 ------- $1,018.00 $1,088.00 $1,147.00 $92.00 $96.00 $100.0049451 0 ------- $1,080.00 $1,153.00 $1,215.00 $127.00 $132.00 $138.0049452 0 ------- $1,323.00 $1,412.00 $1,488.00 $199.00 $207.00 $217.0049460 0 ------- $1,078.00 $1,153.00 $1,215.00 $65.00 $67.00 $70.0049465 0 ------- $226.00 $241.00 $253.00 $43.00 $44.00 $46.0049505 90 $510.00 $642.00 $682.00 $734.00 $642.00 $682.00 $734.0049507 90 $636.00 $791.00 $839.00 $902.00 $791.00 $839.00 $902.0049520 90 $631.00 $787.00 $835.00 $898.00 $787.00 $835.00 $898.0049521 90 $730.00 $962.00 $1,020.00 $1,098.00 $962.00 $1,020.00 $1,098.0049525 90 $584.00 $710.00 $753.00 $810.00 $710.00 $753.00 $810.00

CPT only © 2008 American Medical Association. All rights reserved. Part B, 209

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

49540 90 $668.00 $842.00 $894.00 $961.00 $842.00 $894.00 $961.0049550 90 $557.00 $715.00 $759.00 $816.00 $715.00 $759.00 $816.0049553 90 $598.00 $781.00 $828.00 $890.00 $781.00 $828.00 $890.0049555 90 $621.00 $744.00 $789.00 $849.00 $744.00 $789.00 $849.0049557 90 $715.00 $904.00 $959.00 $1,031.00 $904.00 $959.00 $1,031.0049560 90 $734.00 $927.00 $984.00 $1,058.00 $927.00 $984.00 $1,058.0049561 90 $856.00 $1,165.00 $1,234.00 $1,326.00 $1,165.00 $1,234.00 $1,326.0049565 90 $754.00 $955.00 $1,012.00 $1,087.00 $955.00 $1,012.00 $1,087.0049566 90 $881.00 $1,177.00 $1,247.00 $1,339.00 $1,177.00 $1,247.00 $1,339.0049568 ZZZ $339.00 $353.00 $374.00 $403.00 $353.00 $374.00 $403.0049570 90 $411.00 $503.00 $534.00 $573.00 $503.00 $534.00 $573.0049572 90 $491.00 $618.00 $653.00 $698.00 $618.00 $653.00 $698.0049585 90 $444.00 $541.00 $573.00 $616.00 $541.00 $573.00 $616.0049587 90 $501.00 $642.00 $681.00 $731.00 $642.00 $681.00 $731.0049590 90 $585.00 $708.00 $751.00 $808.00 $708.00 $751.00 $808.0049600 90 $774.00 $911.00 $963.00 $1,031.00 $911.00 $963.00 $1,031.0049605 90 $1,648.00 $6,225.00 $6,564.00 $7,015.00 $6,225.00 $6,564.00 $7,015.0049606 90 $1,416.00 $1,445.00 $1,533.00 $1,651.00 $1,445.00 $1,533.00 $1,651.0049610 90 $784.00 $855.00 $901.00 $959.00 $855.00 $901.00 $959.0049611 90 $770.00 $776.00 $816.00 $863.00 $776.00 $816.00 $863.0049650 90 $484.00 $533.00 $568.00 $615.00 $533.00 $568.00 $615.0049651 90 $621.00 $686.00 $730.00 $787.00 $686.00 $730.00 $787.0049659 YYY BR ------- ------- ------- ------- ------- -------49900 90 $512.00 $1,017.00 $1,081.00 $1,163.00 $1,017.00 $1,081.00 $1,163.0049904 90 $1,394.00 $1,932.00 $2,049.00 $2,195.00 $1,932.00 $2,049.00 $2,195.0049905 ZZZ $454.00 $466.00 $492.00 $528.00 $466.00 $492.00 $528.0049906 90 BR ------- ------- ------- ------- ------- -------49999 YYY BR ------- ------- ------- ------- ------- -------50010 90 $886.00 $942.00 $987.00 $1,041.00 $942.00 $987.00 $1,041.0050020 90 $1,084.00 $1,352.00 $1,415.00 $1,491.00 $1,352.00 $1,415.00 $1,491.0050021 0 $335.00 $1,243.00 $1,324.00 $1,395.00 $232.00 $241.00 $253.0050040 90 $910.00 $1,246.00 $1,300.00 $1,364.00 $1,246.00 $1,300.00 $1,364.0050045 90 $1,137.00 $1,249.00 $1,307.00 $1,378.00 $1,249.00 $1,307.00 $1,378.0050060 90 $1,394.00 $1,551.00 $1,619.00 $1,700.00 $1,551.00 $1,619.00 $1,700.0050065 90 $1,514.00 $1,607.00 $1,679.00 $1,767.00 $1,607.00 $1,679.00 $1,767.0050070 90 $1,476.00 $1,621.00 $1,693.00 $1,778.00 $1,621.00 $1,693.00 $1,778.0050075 90 $1,839.00 $1,992.00 $2,080.00 $2,185.00 $1,992.00 $2,080.00 $2,185.0050080 90 $1,186.00 $1,186.00 $1,239.00 $1,302.00 $1,186.00 $1,239.00 $1,302.0050081 90 $1,635.00 $1,741.00 $1,817.00 $1,908.00 $1,741.00 $1,817.00 $1,908.0050100 90 $1,250.00 $1,334.00 $1,412.00 $1,514.00 $1,334.00 $1,412.00 $1,514.0050120 90 $1,180.00 $1,294.00 $1,353.00 $1,424.00 $1,294.00 $1,353.00 $1,424.0050125 90 $1,228.00 $1,360.00 $1,426.00 $1,507.00 $1,360.00 $1,426.00 $1,507.0050130 90 $1,301.00 $1,404.00 $1,465.00 $1,539.00 $1,404.00 $1,465.00 $1,539.0050135 90 $1,506.00 $1,527.00 $1,594.00 $1,673.00 $1,527.00 $1,594.00 $1,673.0050200 0 $151.00 $198.00 $207.00 $217.00 $198.00 $207.00 $217.0050205 90 $807.00 $938.00 $990.00 $1,057.00 $938.00 $990.00 $1,057.0050220 90 $1,316.00 $1,396.00 $1,460.00 $1,538.00 $1,396.00 $1,460.00 $1,538.0050225 90 $1,554.00 $1,618.00 $1,691.00 $1,778.00 $1,618.00 $1,691.00 $1,778.0050230 90 $1,695.00 $1,740.00 $1,815.00 $1,906.00 $1,740.00 $1,815.00 $1,906.0050234 90 $1,671.00 $1,770.00 $1,848.00 $1,941.00 $1,770.00 $1,848.00 $1,941.00

CPT only © 2008 American Medical Association. All rights reserved. Part B, 210

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

50236 90 $1,873.00 $2,000.00 $2,088.00 $2,193.00 $2,000.00 $2,088.00 $2,193.0050240 90 $1,679.00 $1,790.00 $1,868.00 $1,961.00 $1,790.00 $1,868.00 $1,961.0050250 90 ------- $1,663.00 $1,735.00 $1,820.00 $1,663.00 $1,735.00 $1,820.0050280 90 $1,170.00 $1,284.00 $1,342.00 $1,412.00 $1,284.00 $1,342.00 $1,412.0050290 90 $1,080.00 $1,218.00 $1,279.00 $1,355.00 $1,218.00 $1,279.00 $1,355.0050320 90 $1,680.00 $1,807.00 $1,908.00 $2,035.00 $1,807.00 $1,908.00 $2,035.0050327 0 ------- $272.00 $283.00 $298.00 $272.00 $283.00 $298.0050328 0 ------- $239.00 $249.00 $263.00 $239.00 $249.00 $263.0050329 0 ------- $231.00 $241.00 $254.00 $231.00 $241.00 $254.0050340 90 $1,083.00 $1,139.00 $1,207.00 $1,293.00 $1,139.00 $1,207.00 $1,293.0050360 90 $2,475.00 $3,056.00 $3,214.00 $3,414.00 $3,056.00 $3,214.00 $3,414.0050365 90 $2,941.00 $3,437.00 $3,616.00 $3,846.00 $3,437.00 $3,616.00 $3,846.0050370 90 $1,128.00 $1,419.00 $1,491.00 $1,581.00 $1,419.00 $1,491.00 $1,581.0050380 90 $1,507.00 $2,298.00 $2,412.00 $2,552.00 $2,298.00 $2,412.00 $2,552.0050382 0 ------- $1,847.00 $1,967.00 $2,072.00 $383.00 $399.00 $418.0050384 0 ------- $1,656.00 $1,764.00 $1,858.00 $348.00 $362.00 $380.0050385 0 ------- $1,761.00 $1,877.00 $1,978.00 $332.00 $347.00 $363.0050386 0 ------- $1,139.00 $1,214.00 $1,278.00 $251.00 $262.00 $275.0050387 0 ------- $874.00 $932.00 $982.00 $138.00 $144.00 $151.0050389 0 ------- $543.00 $579.00 $611.00 $77.00 $80.00 $84.0050390 0 $118.00 $135.00 $141.00 $147.00 $135.00 $141.00 $147.0050391 0 ------- $177.00 $186.00 $196.00 $137.00 $143.00 $150.0050392 0 $189.00 $250.00 $261.00 $273.00 $250.00 $261.00 $273.0050393 0 $235.00 $304.00 $317.00 $332.00 $304.00 $317.00 $332.0050394 0 $64.00 $154.00 $163.00 $172.00 $71.00 $74.00 $78.0050395 0 $203.00 $251.00 $262.00 $275.00 $251.00 $262.00 $275.0050396 0 $101.00 $162.00 $170.00 $178.00 $162.00 $170.00 $178.0050398 0 $99.00 $779.00 $832.00 $877.00 $103.00 $107.00 $112.0050400 90 $1,441.00 $1,572.00 $1,640.00 $1,722.00 $1,572.00 $1,640.00 $1,722.0050405 90 $1,802.00 $1,896.00 $1,980.00 $2,083.00 $1,896.00 $1,980.00 $2,083.0050500 90 $1,471.00 $1,576.00 $1,658.00 $1,762.00 $1,576.00 $1,658.00 $1,762.0050520 90 $1,281.00 $1,414.00 $1,482.00 $1,565.00 $1,414.00 $1,482.00 $1,565.0050525 90 $1,644.00 $1,803.00 $1,886.00 $1,989.00 $1,803.00 $1,886.00 $1,989.0050526 90 $1,639.00 $1,834.00 $1,916.00 $2,020.00 $1,834.00 $1,916.00 $2,020.0050540 90 $1,468.00 $1,565.00 $1,633.00 $1,715.00 $1,565.00 $1,633.00 $1,715.0050541 90 $1,037.00 $1,256.00 $1,312.00 $1,378.00 $1,256.00 $1,312.00 $1,378.0050542 90 $1,093.00 $1,587.00 $1,657.00 $1,740.00 $1,587.00 $1,657.00 $1,740.0050543 90 $1,374.00 $2,027.00 $2,116.00 $2,223.00 $2,027.00 $2,116.00 $2,223.0050544 90 $1,428.00 $1,717.00 $1,792.00 $1,884.00 $1,717.00 $1,792.00 $1,884.0050545 90 $1,273.00 $1,839.00 $1,921.00 $2,019.00 $1,839.00 $1,921.00 $2,019.0050546 90 $1,325.00 $1,634.00 $1,709.00 $1,800.00 $1,634.00 $1,709.00 $1,800.0050547 90 $1,702.00 $2,041.00 $2,154.00 $2,297.00 $2,041.00 $2,154.00 $2,297.0050548 90 $1,555.00 $1,855.00 $1,937.00 $2,037.00 $1,855.00 $1,937.00 $2,037.0050549 YYY BR ------- ------- ------- ------- ------- -------50551 0 $411.00 $512.00 $538.00 $567.00 $410.00 $428.00 $450.0050553 0 $447.00 $533.00 $559.00 $587.00 $432.00 $450.00 $473.0050555 0 $668.00 $589.00 $618.00 $650.00 $476.00 $497.00 $522.0050557 0 $676.00 $593.00 $623.00 $656.00 $482.00 $503.00 $529.0050561 0 $755.00 $671.00 $704.00 $741.00 $550.00 $574.00 $605.0050562 90 $580.00 $812.00 $847.00 $890.00 $812.00 $847.00 $890.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

50570 0 $549.00 $685.00 $716.00 $753.00 $685.00 $716.00 $753.0050572 0 $728.00 $748.00 $784.00 $829.00 $748.00 $784.00 $829.0050574 0 $762.00 $791.00 $826.00 $869.00 $791.00 $826.00 $869.0050575 0 $991.00 $998.00 $1,042.00 $1,097.00 $998.00 $1,042.00 $1,097.0050576 0 $801.00 $788.00 $823.00 $866.00 $788.00 $823.00 $866.0050580 0 $726.00 $848.00 $886.00 $932.00 $848.00 $886.00 $932.0050590 90 $980.00 $1,241.00 $1,310.00 $1,379.00 $760.00 $795.00 $836.0050592 10 ------- $5,963.00 $6,375.00 $6,722.00 $501.00 $523.00 $549.0050593 10 ------- $6,199.00 $6,624.00 $6,983.00 $645.00 $672.00 $705.0050600 90 $1,150.00 $1,269.00 $1,325.00 $1,392.00 $1,269.00 $1,325.00 $1,392.0050605 90 $1,054.00 $1,263.00 $1,326.00 $1,404.00 $1,263.00 $1,326.00 $1,404.0050610 90 $1,209.00 $1,316.00 $1,381.00 $1,460.00 $1,316.00 $1,381.00 $1,460.0050620 90 $1,152.00 $1,230.00 $1,285.00 $1,349.00 $1,230.00 $1,285.00 $1,349.0050630 90 $1,170.00 $1,203.00 $1,257.00 $1,321.00 $1,203.00 $1,257.00 $1,321.0050650 90 $1,297.00 $1,403.00 $1,465.00 $1,539.00 $1,403.00 $1,465.00 $1,539.0050660 90 $1,426.00 $1,556.00 $1,625.00 $1,706.00 $1,556.00 $1,625.00 $1,706.0050684 0 $74.00 $263.00 $280.00 $295.00 $67.00 $70.00 $74.0050686 0 $109.00 $223.00 $236.00 $249.00 $121.00 $126.00 $133.0050688 10 $89.00 $111.00 $117.00 $123.00 $111.00 $117.00 $123.0050690 0 $85.00 $142.00 $150.00 $157.00 $96.00 $101.00 $106.0050700 90 $1,192.00 $1,274.00 $1,335.00 $1,408.00 $1,274.00 $1,335.00 $1,408.0050715 90 $1,397.00 $1,564.00 $1,649.00 $1,758.00 $1,564.00 $1,649.00 $1,758.0050722 90 $1,211.00 $1,364.00 $1,439.00 $1,537.00 $1,364.00 $1,439.00 $1,537.0050725 90 $1,371.00 $1,484.00 $1,552.00 $1,637.00 $1,484.00 $1,552.00 $1,637.0050727 90 $640.00 $682.00 $715.00 $754.00 $682.00 $715.00 $754.0050728 90 $924.00 $950.00 $998.00 $1,055.00 $950.00 $998.00 $1,055.0050740 90 $1,386.00 $1,509.00 $1,589.00 $1,691.00 $1,509.00 $1,589.00 $1,691.0050750 90 $1,457.00 $1,575.00 $1,644.00 $1,726.00 $1,575.00 $1,644.00 $1,726.0050760 90 $1,389.00 $1,497.00 $1,568.00 $1,654.00 $1,497.00 $1,568.00 $1,654.0050770 90 $1,485.00 $1,575.00 $1,646.00 $1,731.00 $1,575.00 $1,646.00 $1,731.0050780 90 $1,391.00 $1,492.00 $1,562.00 $1,647.00 $1,492.00 $1,562.00 $1,647.0050782 90 $1,465.00 $1,510.00 $1,584.00 $1,675.00 $1,510.00 $1,584.00 $1,675.0050783 90 $1,515.00 $1,580.00 $1,663.00 $1,768.00 $1,580.00 $1,663.00 $1,768.0050785 90 $1,548.00 $1,638.00 $1,710.00 $1,796.00 $1,638.00 $1,710.00 $1,796.0050800 90 $1,226.00 $1,247.00 $1,305.00 $1,375.00 $1,247.00 $1,305.00 $1,375.0050810 90 $1,527.00 $1,726.00 $1,820.00 $1,940.00 $1,726.00 $1,820.00 $1,940.0050815 90 $1,643.00 $1,655.00 $1,730.00 $1,820.00 $1,655.00 $1,730.00 $1,820.0050820 90 $1,729.00 $1,785.00 $1,870.00 $1,975.00 $1,785.00 $1,870.00 $1,975.0050825 90 $2,351.00 $2,247.00 $2,346.00 $2,466.00 $2,247.00 $2,346.00 $2,466.0050830 90 $2,292.00 $2,460.00 $2,570.00 $2,704.00 $2,460.00 $2,570.00 $2,704.0050840 90 $1,493.00 $1,667.00 $1,741.00 $1,829.00 $1,667.00 $1,741.00 $1,829.0050845 90 $1,513.00 $1,691.00 $1,769.00 $1,861.00 $1,691.00 $1,769.00 $1,861.0050860 90 $1,163.00 $1,293.00 $1,354.00 $1,428.00 $1,293.00 $1,354.00 $1,428.0050900 90 $1,043.00 $1,142.00 $1,196.00 $1,262.00 $1,142.00 $1,196.00 $1,262.0050920 90 $1,075.00 $1,192.00 $1,245.00 $1,307.00 $1,192.00 $1,245.00 $1,307.0050930 90 $1,380.00 $1,479.00 $1,543.00 $1,619.00 $1,479.00 $1,543.00 $1,619.0050940 90 $1,107.00 $1,195.00 $1,253.00 $1,323.00 $1,195.00 $1,253.00 $1,323.0050945 90 $1,096.00 $1,355.00 $1,419.00 $1,496.00 $1,355.00 $1,419.00 $1,496.0050947 90 $1,384.00 $1,925.00 $2,019.00 $2,137.00 $1,925.00 $2,019.00 $2,137.0050948 90 $1,265.00 $1,745.00 $1,824.00 $1,920.00 $1,745.00 $1,824.00 $1,920.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

50949 YYY BR ------- ------- ------- ------- ------- -------50951 0 $414.00 $534.00 $561.00 $590.00 $426.00 $446.00 $469.0050953 0 $461.00 $560.00 $588.00 $618.00 $466.00 $487.00 $512.0050955 0 $546.00 $644.00 $676.00 $712.00 $508.00 $531.00 $559.0050957 0 $546.00 $605.00 $635.00 $668.00 $494.00 $516.00 $543.0050961 0 $510.00 $544.00 $570.00 $600.00 $441.00 $460.00 $483.0050970 0 $510.00 $519.00 $542.00 $571.00 $519.00 $542.00 $571.0050972 0 $408.00 $500.00 $522.00 $550.00 $500.00 $522.00 $550.0050974 0 $661.00 $653.00 $682.00 $717.00 $653.00 $682.00 $717.0050976 0 $641.00 $649.00 $678.00 $714.00 $649.00 $678.00 $714.0050980 0 $443.00 $497.00 $519.00 $545.00 $497.00 $519.00 $545.0051020 90 $587.00 $623.00 $652.00 $684.00 $623.00 $652.00 $684.0051030 90 $538.00 $628.00 $658.00 $694.00 $628.00 $658.00 $694.0051040 90 $439.00 $394.00 $413.00 $435.00 $394.00 $413.00 $435.0051045 90 $548.00 $629.00 $658.00 $692.00 $629.00 $658.00 $692.0051050 90 $596.00 $632.00 $661.00 $693.00 $632.00 $661.00 $693.0051060 90 $768.00 $783.00 $818.00 $859.00 $783.00 $818.00 $859.0051065 90 $704.00 $776.00 $811.00 $851.00 $776.00 $811.00 $851.0051080 90 $510.00 $548.00 $573.00 $602.00 $548.00 $573.00 $602.0051100 0 ------- $87.00 $91.00 $96.00 $54.00 $56.00 $59.0051101 0 ------- $176.00 $187.00 $198.00 $73.00 $77.00 $82.0051102 10 ------- $460.00 $484.00 $509.00 $341.00 $357.00 $375.0051500 90 $775.00 $864.00 $909.00 $965.00 $864.00 $909.00 $965.0051520 90 $764.00 $803.00 $840.00 $883.00 $803.00 $840.00 $883.0051525 90 $1,069.00 $1,161.00 $1,212.00 $1,273.00 $1,161.00 $1,212.00 $1,273.0051530 90 $957.00 $1,049.00 $1,099.00 $1,160.00 $1,049.00 $1,099.00 $1,160.0051535 90 $932.00 $1,081.00 $1,136.00 $1,205.00 $1,081.00 $1,136.00 $1,205.0051550 90 $1,171.00 $1,293.00 $1,354.00 $1,428.00 $1,293.00 $1,354.00 $1,428.0051555 90 $1,514.00 $1,716.00 $1,795.00 $1,892.00 $1,716.00 $1,795.00 $1,892.0051565 90 $1,624.00 $1,759.00 $1,838.00 $1,933.00 $1,759.00 $1,838.00 $1,933.0051570 90 $1,762.00 $2,000.00 $2,085.00 $2,186.00 $2,000.00 $2,085.00 $2,186.0051575 90 $2,284.00 $2,480.00 $2,586.00 $2,713.00 $2,480.00 $2,586.00 $2,713.0051580 90 $2,252.00 $2,580.00 $2,691.00 $2,823.00 $2,580.00 $2,691.00 $2,823.0051585 90 $2,601.00 $2,871.00 $2,993.00 $3,140.00 $2,871.00 $2,993.00 $3,140.0051590 90 $2,441.00 $2,624.00 $2,735.00 $2,869.00 $2,624.00 $2,735.00 $2,869.0051595 90 $2,900.00 $2,979.00 $3,105.00 $3,257.00 $2,979.00 $3,105.00 $3,257.0051596 90 $3,063.00 $3,197.00 $3,333.00 $3,496.00 $3,197.00 $3,333.00 $3,496.0051597 90 $2,914.00 $3,099.00 $3,234.00 $3,396.00 $3,099.00 $3,234.00 $3,396.0051600 0 $54.00 $278.00 $296.00 $312.00 $61.00 $64.00 $67.0051605 0 $83.00 $53.00 $55.00 $58.00 $53.00 $55.00 $58.0051610 0 $45.00 $160.00 $169.00 $178.00 $87.00 $91.00 $96.0051700 0 $29.00 $123.00 $130.00 $137.00 $61.00 $64.00 $67.0051701 0 $58.00 $92.00 $98.00 $103.00 $38.00 $39.00 $42.0051702 0 $92.00 $117.00 $125.00 $131.00 $41.00 $43.00 $46.0051703 0 $128.00 $202.00 $213.00 $224.00 $111.00 $116.00 $122.0051705 10 $37.00 $162.00 $171.00 $180.00 $91.00 $95.00 $100.0051710 10 $119.00 $231.00 $244.00 $257.00 $128.00 $134.00 $141.0051715 0 $322.00 $406.00 $428.00 $452.00 $275.00 $288.00 $304.0051720 0 $140.00 $165.00 $175.00 $185.00 $117.00 $123.00 $131.0051725 0 $116.00 $329.00 $351.00 $371.00 $329.00 $351.00 $371.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

51725-26 0 ------- $106.00 $111.00 $118.00 $106.00 $111.00 $118.0051725-TC 0 ------- $223.00 $239.00 $254.00 $223.00 $239.00 $254.0051726 0 $136.00 $460.00 $491.00 $519.00 $460.00 $491.00 $519.0051726-26 0 ------- $121.00 $126.00 $133.00 $121.00 $126.00 $133.0051726-TC 0 ------- $339.00 $364.00 $386.00 $339.00 $364.00 $386.0051736 0 $47.00 $72.00 $76.00 $80.00 $72.00 $76.00 $80.0051736-26 0 ------- $44.00 $46.00 $48.00 $44.00 $46.00 $48.0051736-TC 0 ------- $28.00 $30.00 $32.00 $28.00 $30.00 $32.0051741 0 $81.00 $114.00 $120.00 $127.00 $114.00 $120.00 $127.0051741-26 0 ------- $81.00 $85.00 $89.00 $81.00 $85.00 $89.0051741-TC 0 ------- $33.00 $35.00 $38.00 $33.00 $35.00 $38.0051772 0 $96.00 $357.00 $381.00 $405.00 $357.00 $381.00 $405.0051772-26 0 ------- $115.00 $121.00 $128.00 $115.00 $121.00 $128.0051772-TC 0 ------- $242.00 $261.00 $277.00 $242.00 $261.00 $277.0051784 0 $119.00 $287.00 $306.00 $324.00 $287.00 $306.00 $324.0051784-26 0 ------- $108.00 $113.00 $119.00 $108.00 $113.00 $119.0051784-TC 0 ------- $179.00 $193.00 $205.00 $179.00 $193.00 $205.0051785 0 $52.00 $309.00 $329.00 $348.00 $309.00 $329.00 $348.0051785-26 0 ------- $107.00 $112.00 $118.00 $107.00 $112.00 $118.0051785-TC 0 ------- $202.00 $217.00 $230.00 $202.00 $217.00 $230.0051792 0 $143.00 $343.00 $368.00 $392.00 $343.00 $368.00 $392.0051792-26 0 ------- $77.00 $80.00 $84.00 $77.00 $80.00 $84.0051792-TC 0 ------- $266.00 $288.00 $308.00 $266.00 $288.00 $308.0051795 0 $132.00 $439.00 $470.00 $499.00 $439.00 $470.00 $499.0051795-26 0 ------- $108.00 $113.00 $119.00 $108.00 $113.00 $119.0051795-TC 0 ------- $331.00 $357.00 $380.00 $331.00 $357.00 $380.0051797 ZZZ $109.00 $256.00 $275.00 $294.00 $256.00 $275.00 $294.0051797-26 ZZZ ------- $67.00 $72.00 $78.00 $67.00 $72.00 $78.0051797-TC ZZZ ------- $189.00 $203.00 $216.00 $189.00 $203.00 $216.0051798 0 $20.00 $30.00 $34.00 $38.00 $30.00 $34.00 $38.0051800 90 $1,294.00 $1,416.00 $1,481.00 $1,558.00 $1,416.00 $1,481.00 $1,558.0051820 90 $1,236.00 $1,501.00 $1,578.00 $1,673.00 $1,501.00 $1,578.00 $1,673.0051840 90 $858.00 $896.00 $944.00 $1,002.00 $896.00 $944.00 $1,002.0051841 90 $1,040.00 $1,068.00 $1,123.00 $1,191.00 $1,068.00 $1,123.00 $1,191.0051845 90 $843.00 $801.00 $840.00 $887.00 $801.00 $840.00 $887.0051860 90 $912.00 $991.00 $1,043.00 $1,107.00 $991.00 $1,043.00 $1,107.0051865 90 $1,150.00 $1,209.00 $1,267.00 $1,338.00 $1,209.00 $1,267.00 $1,338.0051880 90 $590.00 $641.00 $675.00 $716.00 $641.00 $675.00 $716.0051900 90 $1,050.00 $1,127.00 $1,182.00 $1,251.00 $1,127.00 $1,182.00 $1,251.0051920 90 $881.00 $1,058.00 $1,113.00 $1,179.00 $1,058.00 $1,113.00 $1,179.0051925 90 $1,167.00 $1,502.00 $1,591.00 $1,702.00 $1,502.00 $1,591.00 $1,702.0051940 90 $2,082.00 $2,197.00 $2,294.00 $2,414.00 $2,197.00 $2,294.00 $2,414.0051960 90 $1,848.00 $1,876.00 $1,957.00 $2,055.00 $1,876.00 $1,957.00 $2,055.0051980 90 $858.00 $963.00 $1,007.00 $1,059.00 $963.00 $1,007.00 $1,059.0051990 90 $850.00 $1,035.00 $1,092.00 $1,164.00 $1,035.00 $1,092.00 $1,164.0051992 90 $925.00 $1,123.00 $1,182.00 $1,256.00 $1,123.00 $1,182.00 $1,256.0052000 0 $190.00 $289.00 $305.00 $321.00 $167.00 $174.00 $183.0052001 0 $133.00 $539.00 $567.00 $597.00 $397.00 $415.00 $437.0052005 0 $265.00 $407.00 $432.00 $455.00 $181.00 $190.00 $200.0052007 0 $230.00 $838.00 $892.00 $940.00 $228.00 $239.00 $251.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

52010 0 $292.00 $629.00 $668.00 $704.00 $227.00 $238.00 $250.0052204 0 $286.00 $705.00 $750.00 $790.00 $192.00 $200.00 $210.0052214 0 $367.00 $1,644.00 $1,754.00 $1,849.00 $273.00 $286.00 $301.0052224 0 $339.00 $1,553.00 $1,657.00 $1,748.00 $234.00 $245.00 $257.0052234 0 $471.00 $341.00 $357.00 $375.00 $341.00 $357.00 $375.0052235 0 $546.00 $401.00 $419.00 $441.00 $401.00 $419.00 $441.0052240 0 $887.00 $702.00 $733.00 $771.00 $702.00 $733.00 $771.0052250 0 $311.00 $334.00 $350.00 $368.00 $334.00 $350.00 $368.0052260 0 $262.00 $289.00 $302.00 $318.00 $289.00 $302.00 $318.0052265 0 $243.00 $676.00 $719.00 $758.00 $220.00 $230.00 $243.0052270 0 $374.00 $628.00 $666.00 $702.00 $251.00 $263.00 $277.0052275 0 $446.00 $867.00 $920.00 $970.00 $344.00 $360.00 $378.0052276 0 $490.00 $367.00 $384.00 $404.00 $367.00 $384.00 $404.0052277 0 $448.00 $452.00 $472.00 $497.00 $452.00 $472.00 $497.0052281 0 $259.00 $457.00 $484.00 $510.00 $213.00 $223.00 $235.0052282 0 $560.00 $466.00 $487.00 $512.00 $466.00 $487.00 $512.0052283 0 $309.00 $395.00 $416.00 $438.00 $276.00 $289.00 $304.0052285 0 $375.00 $398.00 $420.00 $442.00 $269.00 $281.00 $296.0052290 0 $304.00 $338.00 $353.00 $371.00 $338.00 $353.00 $371.0052300 0 $370.00 $391.00 $408.00 $430.00 $391.00 $408.00 $430.0052301 0 $382.00 $411.00 $431.00 $456.00 $411.00 $431.00 $456.0052305 0 $370.00 $388.00 $405.00 $426.00 $388.00 $405.00 $426.0052310 0 $348.00 $365.00 $386.00 $406.00 $209.00 $219.00 $230.0052315 0 $553.00 $656.00 $693.00 $730.00 $381.00 $398.00 $419.0052317 0 $772.00 $1,503.00 $1,597.00 $1,684.00 $485.00 $507.00 $533.0052318 0 $684.00 $661.00 $690.00 $726.00 $661.00 $690.00 $726.0052320 0 $369.00 $342.00 $358.00 $376.00 $342.00 $358.00 $376.0052325 0 $494.00 $446.00 $466.00 $491.00 $446.00 $466.00 $491.0052327 0 $369.00 $1,119.00 $1,189.00 $1,253.00 $369.00 $385.00 $405.0052330 0 $507.00 $1,745.00 $1,860.00 $1,961.00 $367.00 $384.00 $404.0052332 0 $451.00 $603.00 $641.00 $676.00 $214.00 $224.00 $236.0052334 0 $340.00 $355.00 $371.00 $391.00 $355.00 $371.00 $391.0052341 0 $317.00 $452.00 $473.00 $497.00 $452.00 $473.00 $497.0052342 0 $344.00 $487.00 $508.00 $535.00 $487.00 $508.00 $535.0052343 0 $380.00 $536.00 $560.00 $589.00 $536.00 $560.00 $589.0052344 0 $407.00 $578.00 $604.00 $635.00 $578.00 $604.00 $635.0052345 0 $433.00 $613.00 $640.00 $673.00 $613.00 $640.00 $673.0052346 0 $488.00 $685.00 $715.00 $752.00 $685.00 $715.00 $752.0052351 0 $297.00 $435.00 $454.00 $478.00 $435.00 $454.00 $478.0052352 0 $349.00 $510.00 $533.00 $561.00 $510.00 $533.00 $561.0052353 0 $404.00 $588.00 $614.00 $647.00 $588.00 $614.00 $647.0052354 0 $372.00 $543.00 $568.00 $597.00 $543.00 $568.00 $597.0052355 0 $447.00 $648.00 $677.00 $713.00 $648.00 $677.00 $713.0052400 90 $580.00 $754.00 $788.00 $828.00 $754.00 $788.00 $828.0052402 0 ------- $375.00 $392.00 $413.00 $375.00 $392.00 $413.0052450 90 $602.00 $630.00 $660.00 $695.00 $630.00 $660.00 $695.0052500 90 $705.00 $741.00 $774.00 $813.00 $741.00 $774.00 $813.0052601 90 $1,021.00 $1,117.00 $1,163.00 $1,217.00 $1,117.00 $1,163.00 $1,217.0052630 90 $653.00 $599.00 $626.00 $658.00 $599.00 $626.00 $658.0052640 90 $573.00 $545.00 $570.00 $600.00 $545.00 $570.00 $600.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

52647 90 $858.00 $3,478.00 $3,704.00 $3,902.00 $867.00 $906.00 $951.0052648 90 $957.00 $3,536.00 $3,764.00 $3,966.00 $926.00 $968.00 $1,016.0052649 90 ------- $1,359.00 $1,421.00 $1,492.00 $1,359.00 $1,421.00 $1,492.0052700 90 $517.00 $587.00 $614.00 $644.00 $587.00 $614.00 $644.0053000 10 $224.00 $204.00 $214.00 $225.00 $204.00 $214.00 $225.0053010 90 $336.00 $392.00 $410.00 $429.00 $392.00 $410.00 $429.0053020 0 $153.00 $134.00 $140.00 $148.00 $134.00 $140.00 $148.0053040 90 $460.00 $537.00 $562.00 $591.00 $537.00 $562.00 $591.0053060 10 $180.00 $251.00 $265.00 $283.00 $219.00 $231.00 $246.0053080 90 $567.00 $635.00 $667.00 $704.00 $635.00 $667.00 $704.0053085 90 $836.00 $887.00 $932.00 $985.00 $887.00 $932.00 $985.0053200 0 $218.00 $213.00 $223.00 $236.00 $194.00 $204.00 $215.0053210 90 $904.00 $1,049.00 $1,096.00 $1,151.00 $1,049.00 $1,096.00 $1,151.0053215 90 $1,142.00 $1,266.00 $1,322.00 $1,388.00 $1,266.00 $1,322.00 $1,388.0053220 90 $546.00 $610.00 $638.00 $670.00 $610.00 $638.00 $670.0053230 90 $760.00 $819.00 $857.00 $902.00 $819.00 $857.00 $902.0053235 90 $607.00 $862.00 $902.00 $947.00 $862.00 $902.00 $947.0053240 90 $506.00 $579.00 $607.00 $640.00 $579.00 $607.00 $640.0053250 90 $464.00 $532.00 $558.00 $589.00 $532.00 $558.00 $589.0053260 10 $240.00 $278.00 $293.00 $309.00 $242.00 $254.00 $269.0053265 10 $295.00 $308.00 $324.00 $342.00 $252.00 $264.00 $278.0053270 10 $226.00 $286.00 $302.00 $321.00 $254.00 $268.00 $285.0053275 10 $332.00 $364.00 $381.00 $401.00 $364.00 $381.00 $401.0053400 90 $929.00 $1,089.00 $1,139.00 $1,199.00 $1,089.00 $1,139.00 $1,199.0053405 90 $1,088.00 $1,190.00 $1,245.00 $1,310.00 $1,190.00 $1,245.00 $1,310.0053410 90 $1,151.00 $1,333.00 $1,392.00 $1,463.00 $1,333.00 $1,392.00 $1,463.0053415 90 $1,381.00 $1,524.00 $1,591.00 $1,671.00 $1,524.00 $1,591.00 $1,671.0053420 90 $1,088.00 $1,117.00 $1,165.00 $1,223.00 $1,117.00 $1,165.00 $1,223.0053425 90 $1,150.00 $1,282.00 $1,339.00 $1,407.00 $1,282.00 $1,339.00 $1,407.0053430 90 $1,116.00 $1,298.00 $1,356.00 $1,424.00 $1,298.00 $1,356.00 $1,424.0053431 90 $1,053.00 $1,575.00 $1,645.00 $1,728.00 $1,575.00 $1,645.00 $1,728.0053440 90 $1,057.00 $1,175.00 $1,227.00 $1,287.00 $1,175.00 $1,227.00 $1,287.0053442 90 $639.00 $1,034.00 $1,079.00 $1,132.00 $1,034.00 $1,079.00 $1,132.0053444 90 $755.00 $1,082.00 $1,131.00 $1,188.00 $1,082.00 $1,131.00 $1,188.0053445 90 $1,197.00 $1,188.00 $1,242.00 $1,304.00 $1,188.00 $1,242.00 $1,304.0053446 90 $699.00 $874.00 $914.00 $960.00 $874.00 $914.00 $960.0053447 90 $991.00 $1,110.00 $1,160.00 $1,219.00 $1,110.00 $1,160.00 $1,219.0053448 90 $1,259.00 $1,745.00 $1,821.00 $1,912.00 $1,745.00 $1,821.00 $1,912.0053449 90 $784.00 $826.00 $864.00 $907.00 $826.00 $864.00 $907.0053450 90 $447.00 $548.00 $573.00 $602.00 $548.00 $573.00 $602.0053460 90 $494.00 $617.00 $646.00 $678.00 $617.00 $646.00 $678.0053500 90 ------- $1,016.00 $1,063.00 $1,118.00 $1,016.00 $1,063.00 $1,118.0053502 90 $590.00 $659.00 $691.00 $729.00 $659.00 $691.00 $729.0053505 90 $586.00 $657.00 $687.00 $722.00 $657.00 $687.00 $722.0053510 90 $777.00 $867.00 $907.00 $954.00 $867.00 $907.00 $954.0053515 90 $987.00 $1,092.00 $1,144.00 $1,206.00 $1,092.00 $1,144.00 $1,206.0053520 90 $661.00 $754.00 $789.00 $828.00 $754.00 $789.00 $828.0053600 0 $37.00 $121.00 $128.00 $134.00 $89.00 $93.00 $98.0053601 0 $37.00 $117.00 $124.00 $130.00 $73.00 $77.00 $81.0053605 0 $81.00 $90.00 $94.00 $99.00 $90.00 $94.00 $99.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

53620 0 $59.00 $177.00 $187.00 $197.00 $120.00 $126.00 $132.0053621 0 $45.00 $168.00 $178.00 $187.00 $100.00 $105.00 $111.0053660 0 $49.00 $103.00 $109.00 $115.00 $57.00 $59.00 $62.0053661 0 $50.00 $103.00 $108.00 $114.00 $55.00 $58.00 $61.0053665 0 $50.00 $53.00 $56.00 $59.00 $53.00 $56.00 $59.0053850 90 $741.00 $4,103.00 $4,376.00 $4,613.00 $767.00 $801.00 $842.0053852 90 $728.00 $3,934.00 $4,194.00 $4,419.00 $832.00 $870.00 $913.0053899 YYY BR ------- ------- ------- ------- ------- -------54015 10 $348.00 $424.00 $444.00 $467.00 $424.00 $444.00 $467.0054050 10 $91.00 $159.00 $168.00 $177.00 $126.00 $132.00 $139.0054055 10 $106.00 $152.00 $161.00 $169.00 $115.00 $121.00 $127.0054056 10 $100.00 $165.00 $174.00 $182.00 $130.00 $137.00 $143.0054057 10 $149.00 $187.00 $198.00 $209.00 $121.00 $128.00 $134.0054060 10 $180.00 $257.00 $271.00 $286.00 $169.00 $178.00 $187.0054065 10 $281.00 $273.00 $287.00 $301.00 $205.00 $214.00 $224.0054100 0 $149.00 $251.00 $264.00 $277.00 $151.00 $158.00 $165.0054105 10 $261.00 $391.00 $412.00 $434.00 $294.00 $308.00 $324.0054110 90 $775.00 $851.00 $889.00 $934.00 $851.00 $889.00 $934.0054111 90 $1,035.00 $1,092.00 $1,141.00 $1,199.00 $1,092.00 $1,141.00 $1,199.0054112 90 $1,210.00 $1,281.00 $1,337.00 $1,405.00 $1,281.00 $1,337.00 $1,405.0054115 90 $588.00 $608.00 $637.00 $669.00 $564.00 $590.00 $620.0054120 90 $777.00 $850.00 $887.00 $931.00 $850.00 $887.00 $931.0054125 90 $1,092.00 $1,100.00 $1,149.00 $1,207.00 $1,100.00 $1,149.00 $1,207.0054130 90 $1,532.00 $1,631.00 $1,705.00 $1,793.00 $1,631.00 $1,705.00 $1,793.0054135 90 $1,945.00 $2,070.00 $2,161.00 $2,271.00 $2,070.00 $2,161.00 $2,271.0054162 10 $220.00 $387.00 $407.00 $428.00 $263.00 $275.00 $288.0054163 10 $207.00 $292.00 $306.00 $321.00 $292.00 $306.00 $321.0054164 10 $182.00 $257.00 $269.00 $283.00 $257.00 $269.00 $283.0054200 10 $78.00 $152.00 $161.00 $170.00 $114.00 $120.00 $127.0054205 90 $633.00 $728.00 $761.00 $799.00 $728.00 $761.00 $799.0054220 0 $189.00 $306.00 $323.00 $340.00 $185.00 $193.00 $203.0054230 0 $104.00 $132.00 $139.00 $146.00 $109.00 $114.00 $119.0054231 0 $172.00 $192.00 $202.00 $213.00 $162.00 $169.00 $179.0054235 0 $81.00 $121.00 $127.00 $134.00 $99.00 $103.00 $109.0054240 0 $109.00 $138.00 $147.00 $157.00 $138.00 $147.00 $157.0054240-26 0 ------- $93.00 $97.00 $103.00 $93.00 $97.00 $103.0054240-TC 0 ------- $45.00 $50.00 $54.00 $45.00 $50.00 $54.0054250 0 $104.00 $171.00 $180.00 $190.00 $171.00 $180.00 $190.0054250-26 0 ------- $156.00 $162.00 $171.00 $156.00 $162.00 $171.0054250-TC 0 ------- $16.00 $17.00 $19.00 $16.00 $17.00 $19.0054300 90 $830.00 $887.00 $928.00 $976.00 $887.00 $928.00 $976.0054304 90 $988.00 $1,040.00 $1,088.00 $1,143.00 $1,040.00 $1,088.00 $1,143.0054308 90 $881.00 $921.00 $962.00 $1,010.00 $921.00 $962.00 $1,010.0054312 90 $1,067.00 $1,169.00 $1,229.00 $1,301.00 $1,169.00 $1,229.00 $1,301.0054316 90 $1,316.00 $1,383.00 $1,446.00 $1,520.00 $1,383.00 $1,446.00 $1,520.0054318 90 $900.00 $952.00 $1,006.00 $1,077.00 $952.00 $1,006.00 $1,077.0054322 90 $974.00 $1,083.00 $1,132.00 $1,190.00 $1,083.00 $1,132.00 $1,190.0054324 90 $1,260.00 $1,350.00 $1,410.00 $1,481.00 $1,350.00 $1,410.00 $1,481.0054326 90 $1,212.00 $1,304.00 $1,362.00 $1,431.00 $1,304.00 $1,362.00 $1,431.0054328 90 $1,201.00 $1,281.00 $1,336.00 $1,399.00 $1,281.00 $1,336.00 $1,399.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

54332 90 $1,327.00 $1,396.00 $1,459.00 $1,532.00 $1,396.00 $1,459.00 $1,532.0054336 90 $1,672.00 $1,622.00 $1,709.00 $1,822.00 $1,622.00 $1,709.00 $1,822.0054340 90 $727.00 $785.00 $821.00 $863.00 $785.00 $821.00 $863.0054344 90 $1,360.00 $1,348.00 $1,418.00 $1,504.00 $1,348.00 $1,418.00 $1,504.0054348 90 $1,318.00 $1,412.00 $1,476.00 $1,552.00 $1,412.00 $1,476.00 $1,552.0054352 90 $1,820.00 $2,026.00 $2,128.00 $2,254.00 $2,026.00 $2,128.00 $2,254.0054360 90 $898.00 $997.00 $1,043.00 $1,096.00 $997.00 $1,043.00 $1,096.0054380 90 $1,054.00 $1,098.00 $1,148.00 $1,206.00 $1,098.00 $1,148.00 $1,206.0054385 90 $1,217.00 $1,326.00 $1,383.00 $1,445.00 $1,326.00 $1,383.00 $1,445.0054390 90 $1,635.00 $1,604.00 $1,673.00 $1,758.00 $1,604.00 $1,673.00 $1,758.0054400 90 $784.00 $730.00 $764.00 $804.00 $730.00 $764.00 $804.0054401 90 $892.00 $886.00 $930.00 $979.00 $886.00 $930.00 $979.0054405 90 $1,294.00 $1,102.00 $1,151.00 $1,209.00 $1,102.00 $1,151.00 $1,209.0054406 90 $687.00 $993.00 $1,038.00 $1,091.00 $993.00 $1,038.00 $1,091.0054408 90 $724.00 $1,065.00 $1,113.00 $1,169.00 $1,065.00 $1,113.00 $1,169.0054410 90 $856.00 $1,260.00 $1,316.00 $1,383.00 $1,260.00 $1,316.00 $1,383.0054411 90 $933.00 $1,377.00 $1,437.00 $1,507.00 $1,377.00 $1,437.00 $1,507.0054415 90 $510.00 $712.00 $745.00 $783.00 $712.00 $745.00 $783.0054416 90 $665.00 $950.00 $993.00 $1,043.00 $950.00 $993.00 $1,043.0054417 90 $819.00 $1,209.00 $1,262.00 $1,324.00 $1,209.00 $1,262.00 $1,324.0054420 90 $899.00 $964.00 $1,008.00 $1,059.00 $964.00 $1,008.00 $1,059.0054430 90 $799.00 $871.00 $911.00 $957.00 $871.00 $911.00 $957.0054435 90 $503.00 $564.00 $590.00 $620.00 $564.00 $590.00 $620.0054440 90 BR ------- ------- ------- ------- ------- -------54450 0 $88.00 $104.00 $109.00 $115.00 $82.00 $86.00 $90.0054500 0 $102.00 $102.00 $107.00 $113.00 $102.00 $107.00 $113.0054505 10 $259.00 $294.00 $308.00 $325.00 $294.00 $308.00 $325.0054512 90 $519.00 $732.00 $766.00 $807.00 $732.00 $766.00 $807.0054520 90 $445.00 $448.00 $473.00 $502.00 $448.00 $473.00 $502.0054522 90 $589.00 $808.00 $849.00 $900.00 $808.00 $849.00 $900.0054530 90 $683.00 $747.00 $782.00 $823.00 $747.00 $782.00 $823.0054535 90 $922.00 $999.00 $1,046.00 $1,101.00 $999.00 $1,046.00 $1,101.0054550 90 $588.00 $662.00 $694.00 $730.00 $662.00 $694.00 $730.0054560 90 $842.00 $934.00 $978.00 $1,031.00 $934.00 $978.00 $1,031.0054600 90 $524.00 $611.00 $639.00 $672.00 $611.00 $639.00 $672.0054620 10 $373.00 $413.00 $432.00 $455.00 $413.00 $432.00 $455.0054640 90 $594.00 $632.00 $664.00 $701.00 $632.00 $664.00 $701.0054650 90 $861.00 $943.00 $992.00 $1,054.00 $943.00 $992.00 $1,054.0054660 90 $401.00 $483.00 $508.00 $536.00 $483.00 $508.00 $536.0054670 90 $485.00 $554.00 $581.00 $611.00 $554.00 $581.00 $611.0054680 90 $948.00 $1,091.00 $1,145.00 $1,211.00 $1,091.00 $1,145.00 $1,211.0054690 90 $825.00 $888.00 $933.00 $988.00 $888.00 $933.00 $988.0054692 90 $850.00 $1,068.00 $1,124.00 $1,194.00 $1,068.00 $1,124.00 $1,194.0054699 YYY BR ------- ------- ------- ------- ------- -------54700 10 $133.00 $292.00 $307.00 $324.00 $292.00 $307.00 $324.0054800 0 $257.00 $181.00 $190.00 $202.00 $181.00 $190.00 $202.0054830 90 $411.00 $496.00 $519.00 $546.00 $496.00 $519.00 $546.0054840 90 $432.00 $439.00 $460.00 $484.00 $439.00 $460.00 $484.0054860 90 $503.00 $562.00 $588.00 $617.00 $562.00 $588.00 $617.0054861 90 $696.00 $763.00 $798.00 $838.00 $763.00 $798.00 $838.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

54865 90 ------- $478.00 $501.00 $527.00 $478.00 $501.00 $527.0054900 90 $969.00 $1,009.00 $1,053.00 $1,105.00 $1,009.00 $1,053.00 $1,105.0054901 90 $1,340.00 $1,484.00 $1,562.00 $1,661.00 $1,484.00 $1,562.00 $1,661.0055000 0 $109.00 $174.00 $184.00 $194.00 $115.00 $120.00 $127.0055040 90 $439.00 $458.00 $481.00 $508.00 $458.00 $481.00 $508.0055041 90 $634.00 $684.00 $716.00 $754.00 $684.00 $716.00 $754.0055060 90 $430.00 $509.00 $534.00 $563.00 $509.00 $534.00 $563.0055100 10 $156.00 $305.00 $322.00 $339.00 $217.00 $228.00 $240.0055110 90 $223.00 $517.00 $541.00 $569.00 $517.00 $541.00 $569.0055120 90 $350.00 $474.00 $496.00 $522.00 $474.00 $496.00 $522.0055150 90 $562.00 $652.00 $683.00 $719.00 $652.00 $683.00 $719.0055175 90 $426.00 $484.00 $506.00 $531.00 $484.00 $506.00 $531.0055180 90 $796.00 $933.00 $979.00 $1,033.00 $933.00 $979.00 $1,033.0055200 90 $310.00 $745.00 $790.00 $833.00 $379.00 $398.00 $419.0055250 90 $349.00 $658.00 $699.00 $737.00 $307.00 $323.00 $341.0055300 0 $167.00 $261.00 $272.00 $287.00 $261.00 $272.00 $287.0055400 90 $660.00 $688.00 $721.00 $760.00 $688.00 $721.00 $760.0055450 10 $391.00 $540.00 $570.00 $599.00 $340.00 $355.00 $373.0055500 90 $445.00 $513.00 $540.00 $572.00 $513.00 $540.00 $572.0055520 90 $446.00 $544.00 $576.00 $616.00 $544.00 $576.00 $616.0055530 90 $467.00 $480.00 $504.00 $532.00 $480.00 $504.00 $532.0055535 90 $496.00 $575.00 $602.00 $633.00 $575.00 $602.00 $633.0055540 90 $572.00 $660.00 $699.00 $747.00 $660.00 $699.00 $747.0055550 90 $486.00 $574.00 $603.00 $637.00 $574.00 $603.00 $637.0055559 YYY BR ------- ------- ------- ------- ------- -------55600 90 $486.00 $579.00 $609.00 $646.00 $579.00 $609.00 $646.0055605 90 $609.00 $678.00 $711.00 $749.00 $678.00 $711.00 $749.0055650 90 $853.00 $977.00 $1,023.00 $1,078.00 $977.00 $1,023.00 $1,078.0055680 90 $426.00 $472.00 $496.00 $525.00 $472.00 $496.00 $525.0055700 0 $183.00 $327.00 $344.00 $360.00 $179.00 $185.00 $192.0055705 10 $368.00 $369.00 $386.00 $406.00 $369.00 $386.00 $406.0055720 90 $555.00 $653.00 $692.00 $742.00 $653.00 $692.00 $742.0055725 90 $670.00 $789.00 $826.00 $870.00 $789.00 $826.00 $870.0055801 90 $1,331.00 $1,476.00 $1,542.00 $1,621.00 $1,476.00 $1,542.00 $1,621.0055810 90 $1,711.00 $1,792.00 $1,871.00 $1,965.00 $1,792.00 $1,871.00 $1,965.0055812 90 $1,989.00 $2,186.00 $2,283.00 $2,401.00 $2,186.00 $2,283.00 $2,401.0055815 90 $2,328.00 $2,411.00 $2,516.00 $2,643.00 $2,411.00 $2,516.00 $2,643.0055821 90 $1,153.00 $1,185.00 $1,237.00 $1,299.00 $1,185.00 $1,237.00 $1,299.0055831 90 $1,252.00 $1,285.00 $1,341.00 $1,408.00 $1,285.00 $1,341.00 $1,408.0055840 90 $1,705.00 $1,824.00 $1,905.00 $2,000.00 $1,824.00 $1,905.00 $2,000.0055842 90 $1,859.00 $1,955.00 $2,040.00 $2,143.00 $1,955.00 $2,040.00 $2,143.0055845 90 $2,222.00 $2,238.00 $2,336.00 $2,454.00 $2,238.00 $2,336.00 $2,454.0055860 90 $1,012.00 $1,192.00 $1,244.00 $1,306.00 $1,192.00 $1,244.00 $1,306.0055862 90 $1,351.00 $1,516.00 $1,587.00 $1,672.00 $1,516.00 $1,587.00 $1,672.0055865 90 $1,890.00 $1,816.00 $1,896.00 $1,992.00 $1,816.00 $1,896.00 $1,992.0055866 90 $1,615.00 $2,378.00 $2,482.00 $2,608.00 $2,378.00 $2,482.00 $2,608.0055870 0 $166.00 $234.00 $245.00 $258.00 $197.00 $206.00 $216.0055873 90 $1,127.00 $1,565.00 $1,637.00 $1,721.00 $1,565.00 $1,637.00 $1,721.0055875 90 ------- $1,037.00 $1,084.00 $1,139.00 $1,037.00 $1,084.00 $1,139.0055876 0 ------- $207.00 $221.00 $238.00 $156.00 $167.00 $181.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

55899 YYY BR ------- ------- ------- ------- ------- -------55920 0 ------- $593.00 $619.00 $651.00 $593.00 $619.00 $651.0056405 10 $131.00 $145.00 $154.00 $164.00 $140.00 $148.00 $158.0056420 10 $130.00 $174.00 $185.00 $196.00 $124.00 $132.00 $141.0056440 10 $271.00 $243.00 $257.00 $275.00 $243.00 $257.00 $275.0056441 10 $183.00 $197.00 $208.00 $222.00 $183.00 $193.00 $206.0056442 0 ------- $64.00 $68.00 $72.00 $64.00 $68.00 $72.0056501 10 $122.00 $172.00 $183.00 $195.00 $148.00 $157.00 $168.0056515 10 $200.00 $292.00 $309.00 $329.00 $258.00 $272.00 $290.0056605 0 $96.00 $112.00 $119.00 $127.00 $82.00 $87.00 $93.0056606 ZZZ $49.00 $53.00 $56.00 $60.00 $41.00 $43.00 $46.0056620 90 $607.00 $697.00 $736.00 $785.00 $697.00 $736.00 $785.0056625 90 $735.00 $782.00 $826.00 $881.00 $782.00 $826.00 $881.0056630 90 $1,061.00 $1,135.00 $1,196.00 $1,274.00 $1,135.00 $1,196.00 $1,274.0056631 90 $1,400.00 $1,453.00 $1,533.00 $1,634.00 $1,453.00 $1,533.00 $1,634.0056632 90 $1,636.00 $1,675.00 $1,769.00 $1,891.00 $1,675.00 $1,769.00 $1,891.0056633 90 $1,350.00 $1,481.00 $1,561.00 $1,663.00 $1,481.00 $1,561.00 $1,663.0056634 90 $1,537.00 $1,574.00 $1,660.00 $1,772.00 $1,574.00 $1,660.00 $1,772.0056637 90 $1,806.00 $1,870.00 $1,973.00 $2,105.00 $1,870.00 $1,973.00 $2,105.0056640 90 $1,777.00 $1,873.00 $1,981.00 $2,124.00 $1,873.00 $1,981.00 $2,124.0056700 10 $227.00 $245.00 $259.00 $276.00 $245.00 $259.00 $276.0056740 10 $321.00 $393.00 $416.00 $446.00 $393.00 $416.00 $446.0056800 10 $310.00 $322.00 $340.00 $364.00 $322.00 $340.00 $364.0056805 90 $1,349.00 $1,525.00 $1,610.00 $1,720.00 $1,525.00 $1,610.00 $1,720.0056810 10 $316.00 $347.00 $367.00 $393.00 $347.00 $367.00 $393.0056820 0 $119.00 $147.00 $156.00 $167.00 $114.00 $121.00 $130.0056821 0 $154.00 $199.00 $211.00 $226.00 $156.00 $166.00 $178.0057000 10 $237.00 $251.00 $265.00 $283.00 $251.00 $265.00 $283.0057010 90 $429.00 $563.00 $595.00 $634.00 $563.00 $595.00 $634.0057020 0 $118.00 $128.00 $135.00 $145.00 $111.00 $117.00 $126.0057022 10 $179.00 $221.00 $232.00 $247.00 $221.00 $232.00 $247.0057023 10 $290.00 $410.00 $434.00 $464.00 $410.00 $434.00 $464.0057061 10 $124.00 $151.00 $161.00 $171.00 $128.00 $135.00 $145.0057065 10 $251.00 $256.00 $272.00 $290.00 $227.00 $241.00 $258.0057100 0 $90.00 $119.00 $126.00 $134.00 $89.00 $94.00 $100.0057105 10 $132.00 $181.00 $192.00 $205.00 $165.00 $175.00 $187.0057106 90 $409.00 $614.00 $648.00 $689.00 $614.00 $648.00 $689.0057107 90 $1,467.00 $1,851.00 $1,954.00 $2,090.00 $1,851.00 $1,954.00 $2,090.0057109 90 $1,787.00 $2,119.00 $2,240.00 $2,398.00 $2,119.00 $2,240.00 $2,398.0057110 90 $1,015.00 $1,196.00 $1,265.00 $1,353.00 $1,196.00 $1,265.00 $1,353.0057111 90 $1,793.00 $2,155.00 $2,277.00 $2,436.00 $2,155.00 $2,277.00 $2,436.0057112 90 $1,907.00 $2,238.00 $2,357.00 $2,511.00 $2,238.00 $2,357.00 $2,511.0057120 90 $612.00 $674.00 $713.00 $761.00 $674.00 $713.00 $761.0057130 10 $220.00 $241.00 $255.00 $273.00 $213.00 $225.00 $241.0057135 10 $231.00 $258.00 $273.00 $292.00 $230.00 $243.00 $260.0057150 0 $50.00 $73.00 $78.00 $83.00 $40.00 $43.00 $46.0057155 90 $383.00 $554.00 $580.00 $608.00 $554.00 $580.00 $608.0057160 0 $67.00 $101.00 $107.00 $114.00 $65.00 $68.00 $73.0057170 0 $74.00 $102.00 $109.00 $116.00 $66.00 $70.00 $75.0057180 10 $124.00 $191.00 $203.00 $216.00 $145.00 $153.00 $164.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

57200 90 $313.00 $387.00 $409.00 $436.00 $387.00 $409.00 $436.0057210 90 $395.00 $481.00 $509.00 $543.00 $481.00 $509.00 $543.0057220 90 $378.00 $417.00 $441.00 $470.00 $417.00 $441.00 $470.0057230 90 $442.00 $511.00 $537.00 $569.00 $511.00 $537.00 $569.0057240 90 $536.00 $818.00 $850.00 $888.00 $818.00 $850.00 $888.0057250 90 $485.00 $803.00 $835.00 $873.00 $803.00 $835.00 $873.0057260 90 $700.00 $1,018.00 $1,062.00 $1,116.00 $1,018.00 $1,062.00 $1,116.0057265 90 $902.00 $1,158.00 $1,214.00 $1,284.00 $1,158.00 $1,214.00 $1,284.0057267 ZZZ ------- $367.00 $389.00 $420.00 $367.00 $389.00 $420.0057268 90 $577.00 $626.00 $662.00 $705.00 $626.00 $662.00 $705.0057270 90 $867.00 $1,052.00 $1,109.00 $1,183.00 $1,052.00 $1,109.00 $1,183.0057280 90 $1,071.00 $1,272.00 $1,341.00 $1,428.00 $1,272.00 $1,341.00 $1,428.0057282 90 $734.00 $674.00 $716.00 $769.00 $674.00 $716.00 $769.0057283 90 ------- $901.00 $946.00 $1,003.00 $901.00 $946.00 $1,003.0057284 90 $950.00 $1,109.00 $1,169.00 $1,243.00 $1,109.00 $1,169.00 $1,243.0057285 90 ------- $849.00 $883.00 $923.00 $849.00 $883.00 $923.0057287 90 $685.00 $907.00 $951.00 $1,004.00 $907.00 $951.00 $1,004.0057288 90 $1,009.00 $1,070.00 $1,121.00 $1,184.00 $1,070.00 $1,121.00 $1,184.0057289 90 $879.00 $1,010.00 $1,063.00 $1,130.00 $1,010.00 $1,063.00 $1,130.0057291 90 $622.00 $720.00 $761.00 $812.00 $720.00 $761.00 $812.0057292 90 $925.00 $1,099.00 $1,162.00 $1,243.00 $1,099.00 $1,162.00 $1,243.0057295 90 ------- $649.00 $687.00 $735.00 $649.00 $687.00 $735.0057296 90 ------- $1,239.00 $1,306.00 $1,391.00 $1,239.00 $1,306.00 $1,391.0057300 90 $653.00 $690.00 $728.00 $775.00 $690.00 $728.00 $775.0057305 90 $995.00 $1,164.00 $1,230.00 $1,317.00 $1,164.00 $1,230.00 $1,317.0057307 90 $997.00 $1,307.00 $1,383.00 $1,483.00 $1,307.00 $1,383.00 $1,483.0057308 90 $769.00 $834.00 $881.00 $941.00 $834.00 $881.00 $941.0057310 90 $517.00 $619.00 $648.00 $683.00 $619.00 $648.00 $683.0057311 90 $612.00 $706.00 $739.00 $779.00 $706.00 $739.00 $779.0057320 90 $693.00 $708.00 $743.00 $784.00 $708.00 $743.00 $784.0057330 90 $916.00 $1,022.00 $1,072.00 $1,133.00 $1,022.00 $1,072.00 $1,133.0057335 90 $963.00 $1,507.00 $1,586.00 $1,686.00 $1,507.00 $1,586.00 $1,686.0057400 0 $70.00 $180.00 $190.00 $203.00 $180.00 $190.00 $203.0057410 0 $57.00 $141.00 $149.00 $159.00 $141.00 $149.00 $159.0057415 10 $75.00 $207.00 $218.00 $232.00 $207.00 $218.00 $232.0057420 0 $124.00 $155.00 $164.00 $175.00 $121.00 $128.00 $137.0057421 0 $162.00 $211.00 $224.00 $239.00 $167.00 $177.00 $190.0057423 90 ------- $1,208.00 $1,273.00 $1,357.00 $1,208.00 $1,273.00 $1,357.0057425 90 ------- $1,273.00 $1,342.00 $1,431.00 $1,273.00 $1,342.00 $1,431.0057452 0 $96.00 $146.00 $155.00 $166.00 $122.00 $129.00 $139.0057454 0 $125.00 $207.00 $220.00 $235.00 $184.00 $195.00 $209.0057455 0 $149.00 $193.00 $205.00 $219.00 $150.00 $159.00 $171.0057456 0 $141.00 $182.00 $193.00 $206.00 $140.00 $149.00 $159.0057460 0 $223.00 $413.00 $439.00 $468.00 $221.00 $234.00 $251.0057461 0 $333.00 $460.00 $490.00 $522.00 $257.00 $271.00 $291.0057500 0 $89.00 $180.00 $191.00 $203.00 $98.00 $103.00 $110.0057505 10 $105.00 $135.00 $143.00 $153.00 $119.00 $127.00 $136.0057510 10 $140.00 $179.00 $190.00 $203.00 $156.00 $165.00 $177.0057511 10 $159.00 $194.00 $206.00 $220.00 $174.00 $185.00 $198.0057513 10 $191.00 $190.00 $202.00 $216.00 $175.00 $186.00 $199.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

57520 90 $359.00 $413.00 $438.00 $468.00 $364.00 $386.00 $413.0057522 90 $319.00 $351.00 $372.00 $396.00 $320.00 $339.00 $362.0057530 90 $386.00 $452.00 $478.00 $510.00 $452.00 $478.00 $510.0057531 90 $2,036.00 $2,265.00 $2,393.00 $2,560.00 $2,265.00 $2,393.00 $2,560.0057540 90 $815.00 $1,030.00 $1,088.00 $1,164.00 $1,030.00 $1,088.00 $1,164.0057545 90 $700.00 $1,088.00 $1,149.00 $1,227.00 $1,088.00 $1,149.00 $1,227.0057550 90 $486.00 $532.00 $562.00 $599.00 $532.00 $562.00 $599.0057555 90 $774.00 $795.00 $840.00 $897.00 $795.00 $840.00 $897.0057556 90 $718.00 $744.00 $784.00 $834.00 $744.00 $784.00 $834.0057558 10 ------- $166.00 $176.00 $188.00 $150.00 $159.00 $170.0057700 90 $279.00 $390.00 $412.00 $438.00 $390.00 $412.00 $438.0057720 90 $328.00 $403.00 $426.00 $454.00 $403.00 $426.00 $454.0057800 0 $71.00 $80.00 $85.00 $91.00 $65.00 $69.00 $74.0058100 0 $74.00 $148.00 $157.00 $167.00 $119.00 $126.00 $135.0058110 ZZZ ------- $67.00 $71.00 $76.00 $56.00 $60.00 $64.0058120 10 $297.00 $322.00 $341.00 $364.00 $286.00 $302.00 $323.0058140 90 $1,010.00 $1,213.00 $1,283.00 $1,374.00 $1,213.00 $1,283.00 $1,374.0058145 90 $677.00 $716.00 $757.00 $808.00 $716.00 $757.00 $808.0058146 90 $1,089.00 $1,544.00 $1,632.00 $1,748.00 $1,544.00 $1,632.00 $1,748.0058150 90 $1,110.00 $1,306.00 $1,378.00 $1,471.00 $1,306.00 $1,378.00 $1,471.0058152 90 $1,159.00 $1,665.00 $1,760.00 $1,883.00 $1,665.00 $1,760.00 $1,883.0058180 90 $1,118.00 $1,249.00 $1,315.00 $1,400.00 $1,249.00 $1,315.00 $1,400.0058200 90 $1,562.00 $1,735.00 $1,833.00 $1,959.00 $1,735.00 $1,833.00 $1,959.0058210 90 $2,080.00 $2,310.00 $2,439.00 $2,607.00 $2,310.00 $2,439.00 $2,607.0058240 90 $2,898.00 $3,519.00 $3,689.00 $3,907.00 $3,519.00 $3,689.00 $3,907.0058260 90 $926.00 $1,095.00 $1,157.00 $1,237.00 $1,095.00 $1,157.00 $1,237.0058262 90 $1,026.00 $1,225.00 $1,295.00 $1,386.00 $1,225.00 $1,295.00 $1,386.0058263 90 $1,120.00 $1,321.00 $1,396.00 $1,494.00 $1,321.00 $1,396.00 $1,494.0058267 90 $1,133.00 $1,403.00 $1,483.00 $1,587.00 $1,403.00 $1,483.00 $1,587.0058270 90 $1,019.00 $1,177.00 $1,244.00 $1,332.00 $1,177.00 $1,244.00 $1,332.0058275 90 $1,121.00 $1,305.00 $1,380.00 $1,476.00 $1,305.00 $1,380.00 $1,476.0058280 90 $1,132.00 $1,399.00 $1,478.00 $1,582.00 $1,399.00 $1,478.00 $1,582.0058285 90 $1,360.00 $1,756.00 $1,857.00 $1,990.00 $1,756.00 $1,857.00 $1,990.0058290 90 $1,089.00 $1,541.00 $1,629.00 $1,744.00 $1,541.00 $1,629.00 $1,744.0058291 90 $1,197.00 $1,674.00 $1,770.00 $1,896.00 $1,674.00 $1,770.00 $1,896.0058292 90 $1,268.00 $1,768.00 $1,870.00 $2,002.00 $1,768.00 $1,870.00 $2,002.0058293 90 $1,318.00 $1,839.00 $1,944.00 $2,082.00 $1,839.00 $1,944.00 $2,082.0058294 90 $1,168.00 $1,624.00 $1,715.00 $1,835.00 $1,624.00 $1,715.00 $1,835.0058300 0 $96.00 $108.00 $115.00 $123.00 $72.00 $77.00 $82.0058301 0 $71.00 $131.00 $139.00 $148.00 $92.00 $97.00 $104.0058321 0 $81.00 $103.00 $109.00 $116.00 $66.00 $70.00 $75.0058322 0 $90.00 $118.00 $125.00 $134.00 $80.00 $85.00 $91.0058323 0 $24.00 $30.00 $32.00 $34.00 $17.00 $18.00 $20.0058340 0 $87.00 $181.00 $193.00 $204.00 $79.00 $83.00 $88.0058345 10 $335.00 $365.00 $384.00 $406.00 $365.00 $384.00 $406.0058346 90 $408.00 $587.00 $615.00 $648.00 $587.00 $615.00 $648.0058350 10 $103.00 $129.00 $137.00 $146.00 $103.00 $109.00 $117.0058353 10 $225.00 $1,663.00 $1,779.00 $1,882.00 $295.00 $313.00 $336.0058356 10 ------- $2,983.00 $3,191.00 $3,377.00 $477.00 $506.00 $545.0058400 90 $519.00 $586.00 $619.00 $660.00 $586.00 $619.00 $660.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

58410 90 $752.00 $1,057.00 $1,116.00 $1,190.00 $1,057.00 $1,116.00 $1,190.0058520 90 $663.00 $1,033.00 $1,091.00 $1,165.00 $1,033.00 $1,091.00 $1,165.0058540 90 $923.00 $1,203.00 $1,271.00 $1,361.00 $1,203.00 $1,271.00 $1,361.0058541 90 ------- $1,124.00 $1,188.00 $1,272.00 $1,124.00 $1,188.00 $1,272.0058542 90 ------- $1,238.00 $1,304.00 $1,390.00 $1,238.00 $1,304.00 $1,390.0058543 90 ------- $1,259.00 $1,326.00 $1,414.00 $1,259.00 $1,326.00 $1,414.0058544 90 ------- $1,362.00 $1,435.00 $1,530.00 $1,362.00 $1,435.00 $1,530.0058545 90 $876.00 $1,193.00 $1,261.00 $1,350.00 $1,193.00 $1,261.00 $1,350.0058546 90 $1,104.00 $1,514.00 $1,601.00 $1,716.00 $1,514.00 $1,601.00 $1,716.0058548 90 ------- $2,379.00 $2,513.00 $2,688.00 $2,379.00 $2,513.00 $2,688.0058550 90 $1,038.00 $1,175.00 $1,243.00 $1,331.00 $1,175.00 $1,243.00 $1,331.0058552 90 $853.00 $1,290.00 $1,360.00 $1,449.00 $1,290.00 $1,360.00 $1,449.0058553 90 $1,096.00 $1,520.00 $1,608.00 $1,722.00 $1,520.00 $1,608.00 $1,722.0058554 90 $1,085.00 $1,726.00 $1,817.00 $1,934.00 $1,726.00 $1,817.00 $1,934.0058555 0 $261.00 $312.00 $331.00 $354.00 $257.00 $273.00 $292.0058558 0 $340.00 $412.00 $437.00 $468.00 $363.00 $384.00 $412.0058559 0 $436.00 $467.00 $494.00 $531.00 $467.00 $494.00 $531.0058560 0 $482.00 $530.00 $561.00 $602.00 $530.00 $561.00 $602.0058561 0 $677.00 $750.00 $794.00 $853.00 $750.00 $794.00 $853.0058562 0 $339.00 $441.00 $468.00 $501.00 $397.00 $420.00 $451.0058563 0 $450.00 $2,683.00 $2,869.00 $3,035.00 $468.00 $495.00 $531.0058565 90 ------- $2,714.00 $2,908.00 $3,089.00 $608.00 $651.00 $709.0058570 90 ------- $1,207.00 $1,276.00 $1,367.00 $1,207.00 $1,276.00 $1,367.0058571 90 ------- $1,315.00 $1,386.00 $1,478.00 $1,315.00 $1,386.00 $1,478.0058572 90 ------- $1,501.00 $1,586.00 $1,699.00 $1,501.00 $1,586.00 $1,699.0058573 90 ------- $1,681.00 $1,769.00 $1,883.00 $1,681.00 $1,769.00 $1,883.0058578 YYY BR ------- ------- ------- ------- ------- -------58579 YYY BR ------- ------- ------- ------- ------- -------58600 90 $337.00 $484.00 $512.00 $547.00 $484.00 $512.00 $547.0058605 90 $298.00 $439.00 $464.00 $496.00 $439.00 $464.00 $496.0058611 ZZZ $47.00 $107.00 $113.00 $121.00 $107.00 $113.00 $121.0058615 10 $319.00 $339.00 $360.00 $385.00 $339.00 $360.00 $385.0058660 90 $793.00 $897.00 $950.00 $1,019.00 $897.00 $950.00 $1,019.0058661 10 $804.00 $864.00 $915.00 $981.00 $864.00 $915.00 $981.0058662 90 $807.00 $944.00 $999.00 $1,071.00 $944.00 $999.00 $1,071.0058670 90 $450.00 $484.00 $512.00 $547.00 $484.00 $512.00 $547.0058671 90 $463.00 $485.00 $513.00 $549.00 $485.00 $513.00 $549.0058672 90 $872.00 $1,005.00 $1,066.00 $1,145.00 $1,005.00 $1,066.00 $1,145.0058673 90 $928.00 $1,084.00 $1,148.00 $1,232.00 $1,084.00 $1,148.00 $1,232.0058679 YYY BR ------- ------- ------- ------- ------- -------58700 90 $544.00 $1,010.00 $1,069.00 $1,145.00 $1,010.00 $1,069.00 $1,145.0058720 90 $844.00 $949.00 $1,004.00 $1,074.00 $949.00 $1,004.00 $1,074.0058740 90 $508.00 $1,160.00 $1,227.00 $1,314.00 $1,160.00 $1,227.00 $1,314.0058750 90 $949.00 $1,213.00 $1,284.00 $1,376.00 $1,213.00 $1,284.00 $1,376.0058752 90 $893.00 $1,197.00 $1,267.00 $1,357.00 $1,197.00 $1,267.00 $1,357.0058760 90 $769.00 $1,101.00 $1,168.00 $1,257.00 $1,101.00 $1,168.00 $1,257.0058770 90 $763.00 $1,144.00 $1,211.00 $1,298.00 $1,144.00 $1,211.00 $1,298.0058800 90 $343.00 $419.00 $442.00 $469.00 $387.00 $408.00 $433.0058805 90 $509.00 $527.00 $557.00 $595.00 $527.00 $557.00 $595.0058820 90 $326.00 $413.00 $437.00 $467.00 $413.00 $437.00 $467.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

58822 90 $603.00 $901.00 $949.00 $1,010.00 $901.00 $949.00 $1,010.0058823 0 $216.00 $1,210.00 $1,290.00 $1,360.00 $234.00 $245.00 $257.0058825 90 $469.00 $920.00 $972.00 $1,040.00 $920.00 $972.00 $1,040.0058900 90 $489.00 $538.00 $568.00 $606.00 $538.00 $568.00 $606.0058920 90 $571.00 $936.00 $991.00 $1,063.00 $936.00 $991.00 $1,063.0058925 90 $820.00 $964.00 $1,020.00 $1,091.00 $964.00 $1,020.00 $1,091.0058940 90 $592.00 $657.00 $694.00 $742.00 $657.00 $694.00 $742.0058943 90 $1,368.00 $1,484.00 $1,569.00 $1,680.00 $1,484.00 $1,569.00 $1,680.0058950 90 $1,170.00 $1,410.00 $1,490.00 $1,593.00 $1,410.00 $1,490.00 $1,593.0058951 90 $1,703.00 $1,819.00 $1,920.00 $2,052.00 $1,819.00 $1,920.00 $2,052.0058952 90 $1,876.00 $2,055.00 $2,170.00 $2,321.00 $2,055.00 $2,170.00 $2,321.0058953 90 $1,839.00 $2,554.00 $2,698.00 $2,887.00 $2,554.00 $2,698.00 $2,887.0058954 90 $1,999.00 $2,773.00 $2,930.00 $3,136.00 $2,773.00 $2,930.00 $3,136.0058956 90 ------- $1,854.00 $1,990.00 $2,175.00 $1,854.00 $1,990.00 $2,175.0058957 90 ------- $1,936.00 $2,045.00 $2,189.00 $1,936.00 $2,045.00 $2,189.0058958 90 ------- $2,143.00 $2,264.00 $2,424.00 $2,143.00 $2,264.00 $2,424.0058960 90 $1,174.00 $1,219.00 $1,289.00 $1,380.00 $1,219.00 $1,289.00 $1,380.0058999 YYY BR ------- ------- ------- ------- ------- -------59000 0 $123.00 $181.00 $196.00 $213.00 $116.00 $126.00 $140.0059001 0 $167.00 $259.00 $282.00 $313.00 $259.00 $282.00 $313.0059012 0 $267.00 $294.00 $319.00 $355.00 $294.00 $319.00 $355.0059015 0 $168.00 $219.00 $237.00 $262.00 $191.00 $207.00 $230.0059020 0 $85.00 $98.00 $107.00 $120.00 $98.00 $107.00 $120.0059020-26 0 ------- $55.00 $59.00 $66.00 $55.00 $59.00 $66.0059020-TC 0 ------- $43.00 $48.00 $54.00 $43.00 $48.00 $54.0059025 0 $54.00 $64.00 $70.00 $77.00 $64.00 $70.00 $77.0059025-26 0 ------- $44.00 $48.00 $54.00 $44.00 $48.00 $54.0059025-TC 0 ------- $20.00 $21.00 $23.00 $20.00 $21.00 $23.0059030 0 $155.00 $161.00 $175.00 $195.00 $161.00 $175.00 $195.0059050 0 $71.00 $74.00 $80.00 $89.00 $74.00 $80.00 $89.0059051 0 $47.00 $61.00 $66.00 $73.00 $61.00 $66.00 $73.0059100 90 $633.00 $1,157.00 $1,253.00 $1,387.00 $1,157.00 $1,253.00 $1,387.0059120 90 $893.00 $1,097.00 $1,187.00 $1,312.00 $1,097.00 $1,187.00 $1,312.0059121 90 $768.00 $1,107.00 $1,198.00 $1,325.00 $1,107.00 $1,198.00 $1,325.0059130 90 $832.00 $1,260.00 $1,367.00 $1,517.00 $1,260.00 $1,367.00 $1,517.0059135 90 $1,083.00 $1,266.00 $1,372.00 $1,521.00 $1,266.00 $1,372.00 $1,521.0059136 90 $934.00 $1,202.00 $1,302.00 $1,443.00 $1,202.00 $1,302.00 $1,443.0059140 90 $461.00 $515.00 $558.00 $617.00 $515.00 $558.00 $617.0059150 90 $543.00 $1,074.00 $1,165.00 $1,291.00 $1,074.00 $1,165.00 $1,291.0059151 90 $690.00 $1,054.00 $1,144.00 $1,267.00 $1,054.00 $1,144.00 $1,267.0059160 10 $279.00 $311.00 $336.00 $369.00 $261.00 $283.00 $313.0059200 0 $79.00 $105.00 $114.00 $125.00 $65.00 $71.00 $79.0059300 0 $179.00 $267.00 $289.00 $318.00 $207.00 $225.00 $251.0059320 0 $196.00 $219.00 $238.00 $265.00 $219.00 $238.00 $265.0059325 0 $316.00 $344.00 $372.00 $412.00 $344.00 $372.00 $412.0059350 0 $375.00 $402.00 $437.00 $488.00 $402.00 $437.00 $488.0059400 0 $1,816.00 $2,430.00 $2,622.00 $2,882.00 $2,430.00 $2,622.00 $2,882.0059409 0 $1,019.00 $1,114.00 $1,212.00 $1,352.00 $1,114.00 $1,212.00 $1,352.0059410 0 $1,123.00 $1,277.00 $1,387.00 $1,542.00 $1,277.00 $1,387.00 $1,542.0059412 0 $141.00 $148.00 $161.00 $179.00 $148.00 $161.00 $179.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

59414 0 $134.00 $133.00 $144.00 $161.00 $133.00 $144.00 $161.0059425 0 $414.00 $594.00 $638.00 $695.00 $471.00 $506.00 $556.0059426 0 $708.00 $1,059.00 $1,136.00 $1,237.00 $831.00 $892.00 $979.0059430 0 $140.00 $197.00 $214.00 $237.00 $181.00 $197.00 $219.0059510 0 $2,064.00 $2,752.00 $2,970.00 $3,265.00 $2,752.00 $2,970.00 $3,265.0059514 0 $1,199.00 $1,317.00 $1,432.00 $1,597.00 $1,317.00 $1,432.00 $1,597.0059515 0 $1,324.00 $1,534.00 $1,664.00 $1,847.00 $1,534.00 $1,664.00 $1,847.0059525 ZZZ $591.00 $694.00 $754.00 $838.00 $694.00 $754.00 $838.0059610 0 $1,805.00 $2,560.00 $2,765.00 $3,041.00 $2,560.00 $2,765.00 $3,041.0059612 0 $1,113.00 $1,247.00 $1,357.00 $1,513.00 $1,247.00 $1,357.00 $1,513.0059614 0 $1,208.00 $1,389.00 $1,509.00 $1,680.00 $1,389.00 $1,509.00 $1,680.0059618 0 $2,035.00 $2,882.00 $3,111.00 $3,422.00 $2,882.00 $3,111.00 $3,422.0059620 0 $1,293.00 $1,438.00 $1,564.00 $1,745.00 $1,438.00 $1,564.00 $1,745.0059622 0 $1,397.00 $1,666.00 $1,807.00 $2,007.00 $1,666.00 $1,807.00 $2,007.0059812 90 $343.00 $423.00 $457.00 $503.00 $404.00 $437.00 $482.0059820 90 $389.00 $507.00 $547.00 $597.00 $470.00 $507.00 $555.0059821 90 $398.00 $522.00 $564.00 $617.00 $484.00 $522.00 $574.0059830 90 $496.00 $605.00 $655.00 $723.00 $605.00 $655.00 $723.0059840 10 $331.00 $301.00 $326.00 $360.00 $295.00 $320.00 $354.0059841 10 $443.00 $525.00 $568.00 $626.00 $498.00 $539.00 $596.0059850 90 $449.00 $522.00 $564.00 $623.00 $522.00 $564.00 $623.0059851 90 $464.00 $555.00 $600.00 $660.00 $555.00 $600.00 $660.0059852 90 $642.00 $752.00 $813.00 $898.00 $752.00 $813.00 $898.0059855 90 $477.00 $580.00 $629.00 $696.00 $580.00 $629.00 $696.0059856 90 $577.00 $690.00 $749.00 $830.00 $690.00 $749.00 $830.0059857 90 $711.00 $806.00 $872.00 $964.00 $806.00 $872.00 $964.0059866 0 $304.00 $338.00 $366.00 $405.00 $338.00 $366.00 $405.0059870 90 $348.00 $635.00 $687.00 $756.00 $635.00 $687.00 $756.0059871 0 $192.00 $191.00 $207.00 $230.00 $191.00 $207.00 $230.0059898 YYY BR ------- ------- ------- ------- ------- -------59899 YYY BR ------- ------- ------- ------- ------- -------60000 10 $114.00 $196.00 $207.00 $219.00 $181.00 $190.00 $201.0060100 0 $96.00 $149.00 $156.00 $164.00 $107.00 $111.00 $117.0060200 90 $744.00 $832.00 $879.00 $935.00 $832.00 $879.00 $935.0060210 90 $872.00 $893.00 $943.00 $1,008.00 $893.00 $943.00 $1,008.0060212 90 $1,170.00 $1,286.00 $1,362.00 $1,460.00 $1,286.00 $1,362.00 $1,460.0060220 90 $851.00 $977.00 $1,032.00 $1,101.00 $977.00 $1,032.00 $1,101.0060225 90 $1,107.00 $1,177.00 $1,244.00 $1,330.00 $1,177.00 $1,244.00 $1,330.0060240 90 $1,228.00 $1,257.00 $1,329.00 $1,423.00 $1,257.00 $1,329.00 $1,423.0060252 90 $1,427.00 $1,683.00 $1,775.00 $1,893.00 $1,683.00 $1,775.00 $1,893.0060254 90 $1,911.00 $2,169.00 $2,281.00 $2,421.00 $2,169.00 $2,281.00 $2,421.0060260 90 $1,022.00 $1,409.00 $1,487.00 $1,587.00 $1,409.00 $1,487.00 $1,587.0060270 90 $1,468.00 $1,763.00 $1,857.00 $1,978.00 $1,763.00 $1,857.00 $1,978.0060271 90 $1,210.00 $1,356.00 $1,429.00 $1,520.00 $1,356.00 $1,429.00 $1,520.0060280 90 $546.00 $555.00 $585.00 $620.00 $555.00 $585.00 $620.0060281 90 $670.00 $746.00 $784.00 $829.00 $746.00 $784.00 $829.0060300 0 ------- $134.00 $142.00 $150.00 $67.00 $70.00 $73.0060500 90 $1,232.00 $1,300.00 $1,376.00 $1,476.00 $1,300.00 $1,376.00 $1,476.0060502 90 $1,475.00 $1,637.00 $1,734.00 $1,860.00 $1,637.00 $1,734.00 $1,860.0060505 90 $1,631.00 $1,794.00 $1,897.00 $2,031.00 $1,794.00 $1,897.00 $2,031.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

60512 ZZZ $310.00 $321.00 $340.00 $364.00 $321.00 $340.00 $364.0060520 90 $1,405.00 $1,358.00 $1,441.00 $1,550.00 $1,358.00 $1,441.00 $1,550.0060521 90 $1,591.00 $1,563.00 $1,666.00 $1,803.00 $1,563.00 $1,666.00 $1,803.0060522 90 $1,820.00 $1,879.00 $1,999.00 $2,158.00 $1,879.00 $1,999.00 $2,158.0060540 90 $1,272.00 $1,376.00 $1,448.00 $1,540.00 $1,376.00 $1,448.00 $1,540.0060545 90 $1,505.00 $1,579.00 $1,663.00 $1,771.00 $1,579.00 $1,663.00 $1,771.0060600 90 $1,477.00 $1,843.00 $1,934.00 $2,050.00 $1,843.00 $1,934.00 $2,050.0060605 90 $1,624.00 $2,304.00 $2,411.00 $2,545.00 $2,304.00 $2,411.00 $2,545.0060650 90 $1,340.00 $1,552.00 $1,639.00 $1,753.00 $1,552.00 $1,639.00 $1,753.0060659 YYY BR ------- ------- ------- ------- ------- -------60699 YYY BR ------- ------- ------- ------- ------- -------61020 0 $150.00 $172.00 $186.00 $203.00 $172.00 $186.00 $203.0061026 0 $138.00 $173.00 $186.00 $203.00 $173.00 $186.00 $203.0061050 0 $106.00 $140.00 $147.00 $155.00 $140.00 $147.00 $155.0061055 0 $143.00 $181.00 $190.00 $201.00 $181.00 $190.00 $201.0061070 0 $67.00 $109.00 $117.00 $127.00 $109.00 $117.00 $127.0061105 90 $503.00 $579.00 $629.00 $694.00 $579.00 $629.00 $694.0061107 0 $863.00 $445.00 $486.00 $543.00 $445.00 $486.00 $543.0061108 90 $959.00 $1,138.00 $1,232.00 $1,359.00 $1,138.00 $1,232.00 $1,359.0061120 90 $733.00 $933.00 $1,009.00 $1,110.00 $933.00 $1,009.00 $1,110.0061140 90 $1,389.00 $1,637.00 $1,778.00 $1,970.00 $1,637.00 $1,778.00 $1,970.0061150 90 $1,503.00 $1,752.00 $1,899.00 $2,100.00 $1,752.00 $1,899.00 $2,100.0061151 90 $795.00 $1,275.00 $1,380.00 $1,523.00 $1,275.00 $1,380.00 $1,523.0061154 90 $1,393.00 $1,636.00 $1,780.00 $1,975.00 $1,636.00 $1,780.00 $1,975.0061156 90 $1,473.00 $1,640.00 $1,783.00 $1,978.00 $1,640.00 $1,783.00 $1,978.0061210 0 $527.00 $519.00 $566.00 $633.00 $519.00 $566.00 $633.0061215 90 $637.00 $607.00 $656.00 $719.00 $607.00 $656.00 $719.0061250 90 $888.00 $1,112.00 $1,207.00 $1,337.00 $1,112.00 $1,207.00 $1,337.0061253 90 $1,042.00 $1,218.00 $1,312.00 $1,437.00 $1,218.00 $1,312.00 $1,437.0061304 90 $2,005.00 $2,176.00 $2,364.00 $2,623.00 $2,176.00 $2,364.00 $2,623.0061305 90 $2,419.00 $2,579.00 $2,788.00 $3,072.00 $2,579.00 $2,788.00 $3,072.0061312 90 $2,187.00 $2,673.00 $2,889.00 $3,184.00 $2,673.00 $2,889.00 $3,184.0061313 90 $2,207.00 $2,578.00 $2,795.00 $3,093.00 $2,578.00 $2,795.00 $3,093.0061314 90 $2,200.00 $2,388.00 $2,596.00 $2,883.00 $2,388.00 $2,596.00 $2,883.0061315 90 $2,393.00 $2,743.00 $2,981.00 $3,309.00 $2,743.00 $2,981.00 $3,309.0061316 ZZZ $88.00 $121.00 $132.00 $147.00 $121.00 $132.00 $147.0061320 90 $2,118.00 $2,533.00 $2,753.00 $3,056.00 $2,533.00 $2,753.00 $3,056.0061321 90 $2,310.00 $2,799.00 $3,037.00 $3,366.00 $2,799.00 $3,037.00 $3,366.0061322 90 $1,779.00 $3,034.00 $3,287.00 $3,636.00 $3,034.00 $3,287.00 $3,636.0061323 90 $1,842.00 $3,112.00 $3,376.00 $3,741.00 $3,112.00 $3,376.00 $3,741.0061330 90 $1,706.00 $1,997.00 $2,101.00 $2,229.00 $1,997.00 $2,101.00 $2,229.0061332 90 $2,307.00 $2,435.00 $2,609.00 $2,841.00 $2,435.00 $2,609.00 $2,841.0061333 90 $2,231.00 $2,393.00 $2,543.00 $2,739.00 $2,393.00 $2,543.00 $2,739.0061334 90 $1,525.00 $1,546.00 $1,625.00 $1,723.00 $1,546.00 $1,625.00 $1,723.0061340 90 $1,584.00 $1,893.00 $2,057.00 $2,281.00 $1,893.00 $2,057.00 $2,281.0061343 90 $2,673.00 $2,914.00 $3,167.00 $3,515.00 $2,914.00 $3,167.00 $3,515.0061345 90 $2,259.00 $2,682.00 $2,914.00 $3,236.00 $2,682.00 $2,914.00 $3,236.0061440 90 $2,110.00 $2,623.00 $2,850.00 $3,165.00 $2,623.00 $2,850.00 $3,165.0061450 90 $2,173.00 $2,464.00 $2,662.00 $2,931.00 $2,464.00 $2,662.00 $2,931.0061458 90 $2,433.00 $2,666.00 $2,898.00 $3,220.00 $2,666.00 $2,898.00 $3,220.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

61460 90 $2,426.00 $2,668.00 $2,876.00 $3,159.00 $2,668.00 $2,876.00 $3,159.0061470 90 $1,982.00 $2,458.00 $2,658.00 $2,931.00 $2,458.00 $2,658.00 $2,931.0061480 90 $1,922.00 $2,432.00 $2,644.00 $2,943.00 $2,432.00 $2,644.00 $2,943.0061490 90 $1,687.00 $2,536.00 $2,763.00 $3,077.00 $2,536.00 $2,763.00 $3,077.0061500 90 $1,637.00 $1,758.00 $1,901.00 $2,094.00 $1,758.00 $1,901.00 $2,094.0061501 90 $1,353.00 $1,483.00 $1,598.00 $1,752.00 $1,483.00 $1,598.00 $1,752.0061510 90 $2,506.00 $2,863.00 $3,109.00 $3,448.00 $2,863.00 $3,109.00 $3,448.0061512 90 $2,981.00 $3,411.00 $3,710.00 $4,123.00 $3,411.00 $3,710.00 $4,123.0061514 90 $2,262.00 $2,512.00 $2,730.00 $3,030.00 $2,512.00 $2,730.00 $3,030.0061516 90 $2,253.00 $2,454.00 $2,665.00 $2,957.00 $2,454.00 $2,665.00 $2,957.0061517 ZZZ $74.00 $122.00 $133.00 $148.00 $122.00 $133.00 $148.0061518 90 $3,163.00 $3,665.00 $3,983.00 $4,424.00 $3,665.00 $3,983.00 $4,424.0061519 90 $3,450.00 $3,958.00 $4,305.00 $4,787.00 $3,958.00 $4,305.00 $4,787.0061520 90 $4,349.00 $4,968.00 $5,353.00 $5,877.00 $4,968.00 $5,353.00 $5,877.0061521 90 $3,667.00 $4,262.00 $4,634.00 $5,151.00 $4,262.00 $4,634.00 $5,151.0061522 90 $2,415.00 $2,884.00 $3,135.00 $3,482.00 $2,884.00 $3,135.00 $3,482.0061524 90 $2,484.00 $2,750.00 $2,988.00 $3,316.00 $2,750.00 $2,988.00 $3,316.0061526 90 $3,918.00 $4,392.00 $4,664.00 $5,019.00 $4,392.00 $4,664.00 $5,019.0061530 90 $3,611.00 $3,735.00 $3,971.00 $4,278.00 $3,735.00 $3,971.00 $4,278.0061531 90 $1,344.00 $1,555.00 $1,686.00 $1,864.00 $1,555.00 $1,686.00 $1,864.0061533 90 $1,712.00 $1,992.00 $2,164.00 $2,399.00 $1,992.00 $2,164.00 $2,399.0061534 90 $1,535.00 $2,136.00 $2,320.00 $2,571.00 $2,136.00 $2,320.00 $2,571.0061535 90 $958.00 $1,259.00 $1,364.00 $1,507.00 $1,259.00 $1,364.00 $1,507.0061536 90 $2,862.00 $3,454.00 $3,756.00 $4,175.00 $3,454.00 $3,756.00 $4,175.0061537 90 ------- $3,052.00 $3,285.00 $3,604.00 $3,052.00 $3,285.00 $3,604.0061538 90 $2,466.00 $3,240.00 $3,476.00 $3,799.00 $3,240.00 $3,476.00 $3,799.0061539 90 $2,660.00 $3,128.00 $3,401.00 $3,779.00 $3,128.00 $3,401.00 $3,779.0061540 90 ------- $2,968.00 $3,240.00 $3,616.00 $2,968.00 $3,240.00 $3,616.0061541 90 $2,363.00 $2,778.00 $3,003.00 $3,310.00 $2,778.00 $3,003.00 $3,310.0061542 90 $2,533.00 $3,054.00 $3,319.00 $3,686.00 $3,054.00 $3,319.00 $3,686.0061543 90 $2,307.00 $2,820.00 $3,066.00 $3,408.00 $2,820.00 $3,066.00 $3,408.0061544 90 $2,271.00 $2,457.00 $2,658.00 $2,935.00 $2,457.00 $2,658.00 $2,935.0061545 90 $3,474.00 $4,190.00 $4,544.00 $5,032.00 $4,190.00 $4,544.00 $5,032.0061546 90 $2,695.00 $3,028.00 $3,284.00 $3,636.00 $3,028.00 $3,284.00 $3,636.0061548 90 $1,964.00 $1,974.00 $2,105.00 $2,276.00 $1,974.00 $2,105.00 $2,276.0061550 90 $1,141.00 $1,117.00 $1,165.00 $1,222.00 $1,117.00 $1,165.00 $1,222.0061552 90 $1,463.00 $1,568.00 $1,632.00 $1,705.00 $1,568.00 $1,632.00 $1,705.0061556 90 $1,760.00 $2,112.00 $2,274.00 $2,493.00 $2,112.00 $2,274.00 $2,493.0061557 90 $1,807.00 $2,229.00 $2,425.00 $2,693.00 $2,229.00 $2,425.00 $2,693.0061558 90 $2,085.00 $2,067.00 $2,153.00 $2,249.00 $2,067.00 $2,153.00 $2,249.0061559 90 $2,700.00 $3,205.00 $3,489.00 $3,879.00 $3,205.00 $3,489.00 $3,879.0061563 90 $2,175.00 $2,450.00 $2,632.00 $2,877.00 $2,450.00 $2,632.00 $2,877.0061564 90 $2,597.00 $3,226.00 $3,513.00 $3,912.00 $3,226.00 $3,513.00 $3,912.0061566 90 ------- $2,928.00 $3,166.00 $3,490.00 $2,928.00 $3,166.00 $3,490.0061567 90 ------- $3,242.00 $3,479.00 $3,795.00 $3,242.00 $3,479.00 $3,795.0061570 90 $1,975.00 $2,403.00 $2,603.00 $2,875.00 $2,403.00 $2,603.00 $2,875.0061571 90 $2,140.00 $2,611.00 $2,837.00 $3,148.00 $2,611.00 $2,837.00 $3,148.0061575 90 $2,992.00 $3,027.00 $3,227.00 $3,489.00 $3,027.00 $3,227.00 $3,489.0061576 90 $3,772.00 $4,601.00 $4,854.00 $5,166.00 $4,601.00 $4,854.00 $5,166.0061580 90 $2,383.00 $3,090.00 $3,262.00 $3,466.00 $3,090.00 $3,262.00 $3,466.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

61581 90 $2,674.00 $3,419.00 $3,610.00 $3,839.00 $3,419.00 $3,610.00 $3,839.0061582 90 $2,557.00 $3,657.00 $3,943.00 $4,311.00 $3,657.00 $3,943.00 $4,311.0061583 90 $2,972.00 $3,809.00 $4,134.00 $4,571.00 $3,809.00 $4,134.00 $4,571.0061584 90 $2,830.00 $3,679.00 $3,977.00 $4,373.00 $3,679.00 $3,977.00 $4,373.0061585 90 $3,142.00 $3,842.00 $4,113.00 $4,465.00 $3,842.00 $4,113.00 $4,465.0061586 90 $2,097.00 $2,758.00 $2,950.00 $3,188.00 $2,758.00 $2,950.00 $3,188.0061590 90 $3,299.00 $3,958.00 $4,188.00 $4,475.00 $3,958.00 $4,188.00 $4,475.0061591 90 $3,491.00 $4,002.00 $4,243.00 $4,545.00 $4,002.00 $4,243.00 $4,545.0061592 90 $3,245.00 $4,150.00 $4,501.00 $4,975.00 $4,150.00 $4,501.00 $4,975.0061595 90 $2,350.00 $2,979.00 $3,158.00 $3,378.00 $2,979.00 $3,158.00 $3,378.0061596 90 $2,827.00 $3,250.00 $3,417.00 $3,618.00 $3,250.00 $3,417.00 $3,618.0061597 90 $3,046.00 $3,771.00 $4,078.00 $4,493.00 $3,771.00 $4,078.00 $4,493.0061598 90 $2,693.00 $3,296.00 $3,522.00 $3,813.00 $3,296.00 $3,522.00 $3,813.0061600 90 $2,039.00 $2,690.00 $2,857.00 $3,064.00 $2,690.00 $2,857.00 $3,064.0061601 90 $2,279.00 $3,055.00 $3,300.00 $3,624.00 $3,055.00 $3,300.00 $3,624.0061605 90 $2,299.00 $2,784.00 $2,930.00 $3,103.00 $2,784.00 $2,930.00 $3,103.0061606 90 $3,178.00 $3,904.00 $4,219.00 $4,644.00 $3,904.00 $4,219.00 $4,644.0061607 90 $2,961.00 $3,584.00 $3,839.00 $4,176.00 $3,584.00 $3,839.00 $4,176.0061608 90 $3,458.00 $4,309.00 $4,677.00 $5,177.00 $4,309.00 $4,677.00 $5,177.0061609 ZZZ $798.00 $869.00 $949.00 $1,062.00 $869.00 $949.00 $1,062.0061610 ZZZ $2,354.00 $2,606.00 $2,844.00 $3,182.00 $2,606.00 $2,844.00 $3,182.0061611 ZZZ $584.00 $636.00 $694.00 $776.00 $636.00 $694.00 $776.0061612 ZZZ $2,219.00 $2,142.00 $2,287.00 $2,485.00 $2,142.00 $2,287.00 $2,485.0061613 90 $3,375.00 $4,121.00 $4,431.00 $4,842.00 $4,121.00 $4,431.00 $4,842.0061615 90 $2,576.00 $3,149.00 $3,348.00 $3,598.00 $3,149.00 $3,348.00 $3,598.0061616 90 $3,535.00 $4,241.00 $4,551.00 $4,958.00 $4,241.00 $4,551.00 $4,958.0061618 90 $1,389.00 $1,689.00 $1,821.00 $1,998.00 $1,689.00 $1,821.00 $1,998.0061619 90 $1,682.00 $1,945.00 $2,088.00 $2,278.00 $1,945.00 $2,088.00 $2,278.0061623 0 $540.00 $745.00 $786.00 $839.00 $745.00 $786.00 $839.0061624 0 $1,073.00 $1,455.00 $1,530.00 $1,628.00 $1,455.00 $1,530.00 $1,628.0061626 0 $877.00 $1,165.00 $1,217.00 $1,283.00 $1,165.00 $1,217.00 $1,283.0061630 90 ------- $1,670.00 $1,755.00 $1,862.00 $1,670.00 $1,755.00 $1,862.0061635 90 ------- $1,828.00 $1,920.00 $2,037.00 $1,828.00 $1,920.00 $2,037.0061640 0 ------- $776.00 $804.00 $841.00 $776.00 $804.00 $841.0061641 ZZZ ------- $273.00 $283.00 $296.00 $273.00 $283.00 $296.0061642 ZZZ ------- $546.00 $566.00 $591.00 $546.00 $566.00 $591.0061680 90 $2,758.00 $3,006.00 $3,269.00 $3,632.00 $3,006.00 $3,269.00 $3,632.0061682 90 $4,798.00 $5,728.00 $6,239.00 $6,952.00 $5,728.00 $6,239.00 $6,952.0061684 90 $3,341.00 $3,826.00 $4,163.00 $4,631.00 $3,826.00 $4,163.00 $4,631.0061686 90 $5,012.00 $6,117.00 $6,658.00 $7,411.00 $6,117.00 $6,658.00 $7,411.0061690 90 $2,556.00 $2,846.00 $3,082.00 $3,404.00 $2,846.00 $3,082.00 $3,404.0061692 90 $4,007.00 $4,917.00 $5,351.00 $5,955.00 $4,917.00 $5,351.00 $5,955.0061697 90 $3,231.00 $5,404.00 $5,831.00 $6,420.00 $5,404.00 $5,831.00 $6,420.0061698 90 $3,103.00 $5,688.00 $6,109.00 $6,686.00 $5,688.00 $6,109.00 $6,686.0061700 90 $4,037.00 $4,697.00 $5,120.00 $5,709.00 $4,697.00 $5,120.00 $5,709.0061702 90 $4,019.00 $5,005.00 $5,375.00 $5,878.00 $5,005.00 $5,375.00 $5,878.0061703 90 $1,444.00 $1,714.00 $1,853.00 $2,043.00 $1,714.00 $1,853.00 $2,043.0061705 90 $3,043.00 $3,426.00 $3,718.00 $4,123.00 $3,426.00 $3,718.00 $4,123.0061708 90 $2,546.00 $2,690.00 $2,808.00 $2,950.00 $2,690.00 $2,808.00 $2,950.0061710 90 $2,129.00 $2,509.00 $2,673.00 $2,891.00 $2,509.00 $2,673.00 $2,891.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

61711 90 $3,150.00 $3,497.00 $3,804.00 $4,231.00 $3,497.00 $3,804.00 $4,231.0061720 90 $1,558.00 $1,490.00 $1,593.00 $1,729.00 $1,490.00 $1,593.00 $1,729.0061735 90 $1,664.00 $1,793.00 $1,901.00 $2,039.00 $1,793.00 $1,901.00 $2,039.0061750 90 $1,521.00 $1,840.00 $1,998.00 $2,216.00 $1,840.00 $1,998.00 $2,216.0061751 90 $1,628.00 $1,792.00 $1,947.00 $2,159.00 $1,792.00 $1,947.00 $2,159.0061760 90 $1,670.00 $1,993.00 $2,168.00 $2,412.00 $1,993.00 $2,168.00 $2,412.0061770 90 $1,867.00 $1,919.00 $2,049.00 $2,221.00 $1,919.00 $2,049.00 $2,221.0061790 90 $952.00 $1,104.00 $1,200.00 $1,331.00 $1,104.00 $1,200.00 $1,331.0061791 90 $1,205.00 $1,417.00 $1,534.00 $1,693.00 $1,417.00 $1,534.00 $1,693.0061795 ZZZ $371.00 $338.00 $365.00 $401.00 $338.00 $365.00 $401.0061850 90 $1,090.00 $1,267.00 $1,377.00 $1,526.00 $1,267.00 $1,377.00 $1,526.0061860 90 $1,197.00 $2,024.00 $2,192.00 $2,422.00 $2,024.00 $2,192.00 $2,422.0061863 90 ------- $2,001.00 $2,182.00 $2,432.00 $2,001.00 $2,182.00 $2,432.0061864 ZZZ ------- $741.00 $886.00 $1,105.00 $741.00 $886.00 $1,105.0061867 90 ------- $2,834.00 $3,033.00 $3,298.00 $2,834.00 $3,033.00 $3,298.0061868 ZZZ ------- $977.00 $1,127.00 $1,351.00 $977.00 $1,127.00 $1,351.0061870 90 $616.00 $1,554.00 $1,687.00 $1,868.00 $1,554.00 $1,687.00 $1,868.0061875 90 $984.00 $1,350.00 $1,450.00 $1,586.00 $1,350.00 $1,450.00 $1,586.0061880 90 $559.00 $698.00 $757.00 $837.00 $698.00 $757.00 $837.0061885 90 $262.00 $782.00 $844.00 $925.00 $782.00 $844.00 $925.0061886 90 $678.00 $985.00 $1,062.00 $1,161.00 $985.00 $1,062.00 $1,161.0061888 10 $331.00 $528.00 $575.00 $637.00 $528.00 $575.00 $637.0062000 90 $848.00 $1,062.00 $1,112.00 $1,173.00 $1,062.00 $1,112.00 $1,173.0062005 90 $1,282.00 $1,590.00 $1,721.00 $1,901.00 $1,590.00 $1,721.00 $1,901.0062010 90 $1,754.00 $1,996.00 $2,168.00 $2,405.00 $1,996.00 $2,168.00 $2,405.0062100 90 $1,962.00 $2,105.00 $2,272.00 $2,499.00 $2,105.00 $2,272.00 $2,499.0062115 90 $1,686.00 $2,142.00 $2,327.00 $2,582.00 $2,142.00 $2,327.00 $2,582.0062116 90 $1,928.00 $2,322.00 $2,525.00 $2,804.00 $2,322.00 $2,525.00 $2,804.0062117 90 $2,211.00 $2,389.00 $2,555.00 $2,774.00 $2,389.00 $2,555.00 $2,774.0062120 90 $1,898.00 $2,278.00 $2,419.00 $2,589.00 $2,278.00 $2,419.00 $2,589.0062121 90 $1,822.00 $2,150.00 $2,308.00 $2,516.00 $2,150.00 $2,308.00 $2,516.0062140 90 $1,221.00 $1,377.00 $1,496.00 $1,657.00 $1,377.00 $1,496.00 $1,657.0062141 90 $1,955.00 $1,507.00 $1,636.00 $1,811.00 $1,507.00 $1,636.00 $1,811.0062142 90 $1,011.00 $1,137.00 $1,232.00 $1,362.00 $1,137.00 $1,232.00 $1,362.0062143 90 $1,096.00 $1,346.00 $1,462.00 $1,619.00 $1,346.00 $1,462.00 $1,619.0062145 90 $1,566.00 $1,824.00 $1,976.00 $2,184.00 $1,824.00 $1,976.00 $2,184.0062146 90 $1,327.00 $1,573.00 $1,699.00 $1,869.00 $1,573.00 $1,699.00 $1,869.0062147 90 $1,566.00 $1,866.00 $2,015.00 $2,218.00 $1,866.00 $2,015.00 $2,218.0062148 ZZZ $120.00 $172.00 $187.00 $208.00 $172.00 $187.00 $208.0062160 ZZZ $172.00 $268.00 $292.00 $326.00 $268.00 $292.00 $326.0062161 90 $1,229.00 $2,009.00 $2,184.00 $2,424.00 $2,009.00 $2,184.00 $2,424.0062162 90 $1,578.00 $2,459.00 $2,661.00 $2,937.00 $2,459.00 $2,661.00 $2,937.0062163 90 $999.00 $1,567.00 $1,704.00 $1,889.00 $1,567.00 $1,704.00 $1,889.0062164 90 $1,706.00 $2,573.00 $2,765.00 $3,022.00 $2,573.00 $2,765.00 $3,022.0062165 90 $1,336.00 $1,952.00 $2,073.00 $2,229.00 $1,952.00 $2,073.00 $2,229.0062180 90 $1,695.00 $2,066.00 $2,236.00 $2,468.00 $2,066.00 $2,236.00 $2,468.0062190 90 $1,034.00 $1,150.00 $1,247.00 $1,379.00 $1,150.00 $1,247.00 $1,379.0062192 90 $1,146.00 $1,253.00 $1,357.00 $1,499.00 $1,253.00 $1,357.00 $1,499.0062194 10 $239.00 $479.00 $512.00 $557.00 $479.00 $512.00 $557.0062200 90 $1,625.00 $1,808.00 $1,965.00 $2,179.00 $1,808.00 $1,965.00 $2,179.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

62201 90 $1,200.00 $1,533.00 $1,662.00 $1,835.00 $1,533.00 $1,662.00 $1,835.0062220 90 $1,215.00 $1,338.00 $1,453.00 $1,609.00 $1,338.00 $1,453.00 $1,609.0062223 90 $1,199.00 $1,342.00 $1,453.00 $1,602.00 $1,342.00 $1,453.00 $1,602.0062225 90 $488.00 $637.00 $689.00 $758.00 $637.00 $689.00 $758.0062230 90 $935.00 $1,090.00 $1,183.00 $1,310.00 $1,090.00 $1,183.00 $1,310.0062252 0 $85.00 $132.00 $143.00 $156.00 $132.00 $143.00 $156.0062252-26 0 ------- $66.00 $72.00 $80.00 $66.00 $72.00 $80.0062252-TC 0 ------- $67.00 $72.00 $76.00 $67.00 $72.00 $76.0062256 90 $616.00 $744.00 $807.00 $890.00 $744.00 $807.00 $890.0062258 90 $1,308.00 $1,477.00 $1,604.00 $1,777.00 $1,477.00 $1,604.00 $1,777.0062263 10 $426.00 $887.00 $937.00 $985.00 $488.00 $509.00 $534.0062264 10 $593.00 $563.00 $593.00 $624.00 $295.00 $307.00 $321.0062268 0 $285.00 $712.00 $756.00 $799.00 $355.00 $373.00 $396.0062269 0 $271.00 $788.00 $834.00 $880.00 $351.00 $367.00 $386.0062270 0 $109.00 $205.00 $217.00 $228.00 $99.00 $103.00 $108.0062272 0 $137.00 $246.00 $263.00 $280.00 $111.00 $118.00 $127.0062273 0 $130.00 $221.00 $232.00 $243.00 $143.00 $149.00 $156.0062280 10 $199.00 $436.00 $465.00 $493.00 $201.00 $213.00 $228.0062281 10 $186.00 $383.00 $405.00 $427.00 $188.00 $196.00 $206.0062282 10 $211.00 $434.00 $460.00 $485.00 $174.00 $182.00 $191.0062284 0 $196.00 $302.00 $321.00 $339.00 $118.00 $124.00 $131.0062287 90 $784.00 $709.00 $742.00 $779.00 $709.00 $742.00 $779.0062290 0 $235.00 $450.00 $476.00 $503.00 $222.00 $232.00 $245.0062291 0 $232.00 $411.00 $436.00 $461.00 $215.00 $225.00 $239.0062292 90 $1,064.00 $678.00 $712.00 $755.00 $678.00 $712.00 $755.0062294 90 $821.00 $1,000.00 $1,053.00 $1,120.00 $1,000.00 $1,053.00 $1,120.0062310 0 $200.00 $294.00 $311.00 $327.00 $129.00 $134.00 $141.0062311 0 $201.00 $269.00 $285.00 $300.00 $108.00 $112.00 $117.0062318 0 $208.00 $326.00 $345.00 $362.00 $132.00 $137.00 $144.0062319 0 $203.00 $291.00 $308.00 $323.00 $123.00 $127.00 $133.0062350 90 $488.00 $656.00 $696.00 $748.00 $656.00 $696.00 $748.0062351 90 $782.00 $1,090.00 $1,173.00 $1,283.00 $1,090.00 $1,173.00 $1,283.0062355 90 $402.00 $533.00 $563.00 $601.00 $533.00 $563.00 $601.0062360 90 $195.00 $346.00 $365.00 $387.00 $346.00 $365.00 $387.0062361 90 $390.00 $572.00 $607.00 $650.00 $572.00 $607.00 $650.0062362 90 $517.00 $722.00 $768.00 $828.00 $722.00 $768.00 $828.0062365 90 $418.00 $559.00 $594.00 $639.00 $559.00 $594.00 $639.0062367 0 BR $51.00 $53.00 $56.00 $30.00 $31.00 $33.0062368 0 BR $71.00 $75.00 $79.00 $48.00 $51.00 $53.0063001 90 $1,882.00 $1,603.00 $1,733.00 $1,910.00 $1,603.00 $1,733.00 $1,910.0063003 90 $1,591.00 $1,614.00 $1,744.00 $1,919.00 $1,614.00 $1,744.00 $1,919.0063005 90 $1,390.00 $1,523.00 $1,643.00 $1,804.00 $1,523.00 $1,643.00 $1,804.0063011 90 $1,151.00 $1,441.00 $1,558.00 $1,716.00 $1,441.00 $1,558.00 $1,716.0063012 90 $1,568.00 $1,559.00 $1,683.00 $1,850.00 $1,559.00 $1,683.00 $1,850.0063015 90 $1,862.00 $1,943.00 $2,106.00 $2,328.00 $1,943.00 $2,106.00 $2,328.0063016 90 $1,788.00 $1,979.00 $2,137.00 $2,352.00 $1,979.00 $2,137.00 $2,352.0063017 90 $1,489.00 $1,614.00 $1,743.00 $1,917.00 $1,614.00 $1,743.00 $1,917.0063020 90 $1,395.00 $1,537.00 $1,667.00 $1,842.00 $1,537.00 $1,667.00 $1,842.0063030 90 $1,145.00 $1,276.00 $1,383.00 $1,526.00 $1,276.00 $1,383.00 $1,526.0063035 ZZZ $280.00 $280.00 $305.00 $340.00 $280.00 $305.00 $340.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

63040 90 $1,764.00 $1,882.00 $2,041.00 $2,258.00 $1,882.00 $2,041.00 $2,258.0063042 90 $1,620.00 $1,760.00 $1,908.00 $2,107.00 $1,760.00 $1,908.00 $2,107.0063043 ZZZ BR ------- ------- ------- ------- ------- -------63044 ZZZ BR ------- ------- ------- ------- ------- -------63045 90 $1,647.00 $1,671.00 $1,809.00 $1,996.00 $1,671.00 $1,809.00 $1,996.0063046 90 $2,117.00 $1,586.00 $1,712.00 $1,881.00 $1,586.00 $1,712.00 $1,881.0063047 90 $1,907.00 $1,452.00 $1,569.00 $1,725.00 $1,452.00 $1,569.00 $1,725.0063048 ZZZ $367.00 $295.00 $318.00 $351.00 $295.00 $318.00 $351.0063050 90 ------- $1,989.00 $2,150.00 $2,369.00 $1,989.00 $2,150.00 $2,369.0063051 90 ------- $2,226.00 $2,392.00 $2,615.00 $2,226.00 $2,392.00 $2,615.0063055 90 $2,029.00 $2,159.00 $2,339.00 $2,585.00 $2,159.00 $2,339.00 $2,585.0063056 90 $1,960.00 $1,997.00 $2,161.00 $2,383.00 $1,997.00 $2,161.00 $2,383.0063057 ZZZ $421.00 $459.00 $498.00 $553.00 $459.00 $498.00 $553.0063064 90 $2,200.00 $2,369.00 $2,563.00 $2,828.00 $2,369.00 $2,563.00 $2,828.0063066 ZZZ $263.00 $279.00 $302.00 $333.00 $279.00 $302.00 $333.0063075 90 $1,720.00 $1,859.00 $2,018.00 $2,234.00 $1,859.00 $2,018.00 $2,234.0063076 ZZZ $383.00 $355.00 $386.00 $429.00 $355.00 $386.00 $429.0063077 90 $1,828.00 $1,981.00 $2,125.00 $2,317.00 $1,981.00 $2,125.00 $2,317.0063078 ZZZ $261.00 $278.00 $300.00 $330.00 $278.00 $300.00 $330.0063081 90 $2,203.00 $2,356.00 $2,547.00 $2,806.00 $2,356.00 $2,547.00 $2,806.0063082 ZZZ $391.00 $383.00 $415.00 $461.00 $383.00 $415.00 $461.0063085 90 $2,416.00 $2,459.00 $2,625.00 $2,844.00 $2,459.00 $2,625.00 $2,844.0063086 ZZZ $282.00 $266.00 $286.00 $313.00 $266.00 $286.00 $313.0063087 90 $2,930.00 $3,152.00 $3,374.00 $3,672.00 $3,152.00 $3,374.00 $3,672.0063088 ZZZ $381.00 $362.00 $389.00 $427.00 $362.00 $389.00 $427.0063090 90 $2,490.00 $2,540.00 $2,702.00 $2,913.00 $2,540.00 $2,702.00 $2,913.0063091 ZZZ $249.00 $245.00 $262.00 $285.00 $245.00 $262.00 $285.0063101 90 ------- $2,953.00 $3,163.00 $3,441.00 $2,953.00 $3,163.00 $3,441.0063102 90 ------- $2,948.00 $3,158.00 $3,436.00 $2,948.00 $3,158.00 $3,436.0063103 ZZZ ------- $387.00 $412.00 $445.00 $387.00 $412.00 $445.0063170 90 $1,788.00 $1,980.00 $2,144.00 $2,368.00 $1,980.00 $2,144.00 $2,368.0063172 90 $1,672.00 $1,822.00 $1,975.00 $2,183.00 $1,822.00 $1,975.00 $2,183.0063173 90 $1,851.00 $2,247.00 $2,439.00 $2,702.00 $2,247.00 $2,439.00 $2,702.0063180 90 $1,486.00 $1,820.00 $1,960.00 $2,148.00 $1,820.00 $1,960.00 $2,148.0063182 90 $1,711.00 $1,941.00 $2,108.00 $2,344.00 $1,941.00 $2,108.00 $2,344.0063185 90 $1,347.00 $1,438.00 $1,541.00 $1,677.00 $1,438.00 $1,541.00 $1,677.0063190 90 $1,610.00 $1,632.00 $1,750.00 $1,907.00 $1,632.00 $1,750.00 $1,907.0063191 90 $1,444.00 $1,752.00 $1,939.00 $2,211.00 $1,752.00 $1,939.00 $2,211.0063194 90 $1,593.00 $1,864.00 $1,988.00 $2,150.00 $1,864.00 $1,988.00 $2,150.0063195 90 $1,603.00 $1,977.00 $2,142.00 $2,368.00 $1,977.00 $2,142.00 $2,368.0063196 90 $1,810.00 $2,318.00 $2,514.00 $2,781.00 $2,318.00 $2,514.00 $2,781.0063197 90 $1,725.00 $2,043.00 $2,215.00 $2,456.00 $2,043.00 $2,215.00 $2,456.0063198 90 $1,956.00 $2,343.00 $2,538.00 $2,817.00 $2,343.00 $2,538.00 $2,817.0063199 90 $2,258.00 $2,189.00 $2,268.00 $2,359.00 $2,189.00 $2,268.00 $2,359.0063200 90 $1,569.00 $1,980.00 $2,148.00 $2,378.00 $1,980.00 $2,148.00 $2,378.0063250 90 $3,182.00 $3,791.00 $4,094.00 $4,509.00 $3,791.00 $4,094.00 $4,509.0063251 90 $3,207.00 $4,021.00 $4,365.00 $4,840.00 $4,021.00 $4,365.00 $4,840.0063252 90 $3,319.00 $4,013.00 $4,361.00 $4,844.00 $4,013.00 $4,361.00 $4,844.0063265 90 $1,940.00 $2,189.00 $2,373.00 $2,625.00 $2,189.00 $2,373.00 $2,625.0063266 90 $2,053.00 $2,253.00 $2,441.00 $2,698.00 $2,253.00 $2,441.00 $2,698.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

63267 90 $1,651.00 $1,809.00 $1,960.00 $2,165.00 $1,809.00 $1,960.00 $2,165.0063268 90 $1,469.00 $1,768.00 $1,901.00 $2,078.00 $1,768.00 $1,901.00 $2,078.0063270 90 $2,197.00 $2,706.00 $2,935.00 $3,249.00 $2,706.00 $2,935.00 $3,249.0063271 90 $2,401.00 $2,720.00 $2,951.00 $3,268.00 $2,720.00 $2,951.00 $3,268.0063272 90 $2,206.00 $2,501.00 $2,710.00 $2,997.00 $2,501.00 $2,710.00 $2,997.0063273 90 $2,012.00 $2,404.00 $2,601.00 $2,870.00 $2,404.00 $2,601.00 $2,870.0063275 90 $2,166.00 $2,358.00 $2,555.00 $2,824.00 $2,358.00 $2,555.00 $2,824.0063276 90 $2,135.00 $2,344.00 $2,541.00 $2,811.00 $2,344.00 $2,541.00 $2,811.0063277 90 $1,905.00 $2,060.00 $2,232.00 $2,466.00 $2,060.00 $2,232.00 $2,466.0063278 90 $1,877.00 $2,002.00 $2,161.00 $2,376.00 $2,002.00 $2,161.00 $2,376.0063280 90 $2,529.00 $2,798.00 $3,041.00 $3,375.00 $2,798.00 $3,041.00 $3,375.0063281 90 $2,496.00 $2,773.00 $3,012.00 $3,342.00 $2,773.00 $3,012.00 $3,342.0063282 90 $2,305.00 $2,611.00 $2,837.00 $3,149.00 $2,611.00 $2,837.00 $3,149.0063283 90 $2,041.00 $2,481.00 $2,693.00 $2,983.00 $2,481.00 $2,693.00 $2,983.0063285 90 $2,934.00 $3,461.00 $3,763.00 $4,181.00 $3,461.00 $3,763.00 $4,181.0063286 90 $3,003.00 $3,458.00 $3,762.00 $4,182.00 $3,458.00 $3,762.00 $4,182.0063287 90 $3,012.00 $3,623.00 $3,934.00 $4,363.00 $3,623.00 $3,934.00 $4,363.0063290 90 $3,073.00 $3,624.00 $3,925.00 $4,340.00 $3,624.00 $3,925.00 $4,340.0063295 ZZZ ------- $431.00 $464.00 $511.00 $431.00 $464.00 $511.0063300 90 $2,006.00 $2,430.00 $2,632.00 $2,909.00 $2,430.00 $2,632.00 $2,909.0063301 90 $2,209.00 $2,648.00 $2,839.00 $3,095.00 $2,648.00 $2,839.00 $3,095.0063302 90 $2,290.00 $2,637.00 $2,831.00 $3,092.00 $2,637.00 $2,831.00 $3,092.0063303 90 $2,357.00 $2,739.00 $2,915.00 $3,146.00 $2,739.00 $2,915.00 $3,146.0063304 90 $2,513.00 $2,964.00 $3,189.00 $3,494.00 $2,964.00 $3,189.00 $3,494.0063305 90 $2,574.00 $3,025.00 $3,233.00 $3,510.00 $3,025.00 $3,233.00 $3,510.0063306 90 $2,596.00 $3,185.00 $3,459.00 $3,838.00 $3,185.00 $3,459.00 $3,838.0063307 90 $2,522.00 $2,780.00 $2,950.00 $3,172.00 $2,780.00 $2,950.00 $3,172.0063308 ZZZ $425.00 $462.00 $503.00 $560.00 $462.00 $503.00 $560.0063600 90 $797.00 $1,062.00 $1,117.00 $1,191.00 $1,062.00 $1,117.00 $1,191.0063610 0 $476.00 $2,318.00 $2,471.00 $2,613.00 $571.00 $600.00 $639.0063615 90 $1,348.00 $1,479.00 $1,583.00 $1,722.00 $1,479.00 $1,583.00 $1,722.0063650 90 $819.00 $550.00 $574.00 $604.00 $550.00 $574.00 $604.0063655 90 $1,064.00 $1,093.00 $1,181.00 $1,299.00 $1,093.00 $1,181.00 $1,299.0063660 90 $707.00 $560.00 $593.00 $634.00 $560.00 $593.00 $634.0063685 90 $615.00 $648.00 $688.00 $741.00 $648.00 $688.00 $741.0063688 90 $707.00 $534.00 $569.00 $615.00 $534.00 $569.00 $615.0063700 90 $1,340.00 $1,600.00 $1,725.00 $1,894.00 $1,600.00 $1,725.00 $1,894.0063702 90 $1,512.00 $1,757.00 $1,900.00 $2,093.00 $1,757.00 $1,900.00 $2,093.0063704 90 $1,708.00 $2,022.00 $2,182.00 $2,398.00 $2,022.00 $2,182.00 $2,398.0063706 90 $1,873.00 $2,374.00 $2,582.00 $2,869.00 $2,374.00 $2,582.00 $2,869.0063707 90 $1,041.00 $1,176.00 $1,268.00 $1,390.00 $1,176.00 $1,268.00 $1,390.0063709 90 $1,310.00 $1,434.00 $1,546.00 $1,695.00 $1,434.00 $1,546.00 $1,695.0063710 90 $1,165.00 $1,444.00 $1,563.00 $1,724.00 $1,444.00 $1,563.00 $1,724.0063740 90 $1,062.00 $1,211.00 $1,313.00 $1,452.00 $1,211.00 $1,313.00 $1,452.0063741 90 $741.00 $797.00 $856.00 $936.00 $797.00 $856.00 $936.0063744 90 $738.00 $842.00 $910.00 $1,001.00 $842.00 $910.00 $1,001.0063746 90 $529.00 $698.00 $754.00 $828.00 $698.00 $754.00 $828.0064400 0 $78.00 $141.00 $148.00 $156.00 $80.00 $83.00 $87.0064402 0 $75.00 $141.00 $149.00 $157.00 $93.00 $98.00 $103.0064405 0 $103.00 $134.00 $140.00 $147.00 $92.00 $96.00 $100.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

64408 0 $120.00 $150.00 $157.00 $166.00 $113.00 $118.00 $125.0064410 0 $109.00 $185.00 $195.00 $205.00 $100.00 $104.00 $109.0064412 0 $89.00 $181.00 $192.00 $202.00 $87.00 $91.00 $96.0064413 0 $128.00 $151.00 $159.00 $166.00 $96.00 $100.00 $105.0064415 0 $109.00 $182.00 $192.00 $201.00 $95.00 $99.00 $104.0064416 10 $159.00 $237.00 $247.00 $261.00 $237.00 $247.00 $261.0064417 0 $105.00 $188.00 $199.00 $209.00 $96.00 $101.00 $106.0064418 0 $108.00 $180.00 $190.00 $200.00 $91.00 $95.00 $99.0064420 0 $89.00 $219.00 $232.00 $244.00 $83.00 $87.00 $91.0064421 0 $128.00 $328.00 $348.00 $367.00 $114.00 $118.00 $124.0064425 0 $116.00 $166.00 $174.00 $184.00 $119.00 $124.00 $131.0064430 0 $130.00 $199.00 $210.00 $222.00 $110.00 $115.00 $120.0064435 0 $114.00 $194.00 $206.00 $219.00 $112.00 $118.00 $126.0064445 0 $68.00 $185.00 $195.00 $205.00 $102.00 $107.00 $112.0064446 10 $165.00 $222.00 $230.00 $240.00 $222.00 $230.00 $240.0064447 0 $77.00 $93.00 $96.00 $100.00 $93.00 $96.00 $100.0064448 10 $152.00 $202.00 $209.00 $218.00 $202.00 $209.00 $218.0064449 10 ------- $198.00 $205.00 $213.00 $198.00 $205.00 $213.0064450 0 $53.00 $133.00 $141.00 $150.00 $94.00 $99.00 $106.0064470 0 $206.00 $372.00 $394.00 $415.00 $131.00 $136.00 $142.0064472 ZZZ $166.00 $156.00 $164.00 $173.00 $84.00 $87.00 $91.0064475 0 $183.00 $337.00 $358.00 $378.00 $104.00 $109.00 $114.0064476 ZZZ $166.00 $132.00 $139.00 $147.00 $63.00 $66.00 $69.0064479 0 $224.00 $394.00 $417.00 $438.00 $155.00 $162.00 $169.0064480 ZZZ $194.00 $190.00 $201.00 $211.00 $102.00 $106.00 $111.0064483 0 $206.00 $391.00 $414.00 $436.00 $137.00 $143.00 $150.0064484 ZZZ $183.00 $191.00 $202.00 $212.00 $86.00 $90.00 $94.0064505 0 $104.00 $131.00 $138.00 $145.00 $107.00 $112.00 $118.0064508 0 $99.00 $192.00 $204.00 $214.00 $91.00 $95.00 $100.0064510 0 $103.00 $197.00 $208.00 $218.00 $86.00 $90.00 $94.0064517 0 ------- $223.00 $234.00 $245.00 $151.00 $157.00 $163.0064520 0 $131.00 $263.00 $278.00 $293.00 $96.00 $100.00 $105.0064530 0 $135.00 $263.00 $278.00 $293.00 $115.00 $119.00 $125.0064550 0 $23.00 $21.00 $22.00 $24.00 $12.00 $12.00 $13.0064553 10 $137.00 $260.00 $275.00 $290.00 $206.00 $216.00 $228.0064555 10 $131.00 $270.00 $285.00 $301.00 $190.00 $199.00 $211.0064560 10 $197.00 $255.00 $270.00 $286.00 $193.00 $203.00 $215.0064561 10 $801.00 $1,614.00 $1,715.00 $1,808.00 $536.00 $561.00 $590.0064565 10 $121.00 $238.00 $252.00 $265.00 $158.00 $166.00 $175.0064573 90 $464.00 $770.00 $829.00 $908.00 $770.00 $829.00 $908.0064575 90 $367.00 $372.00 $396.00 $427.00 $372.00 $396.00 $427.0064577 90 $381.00 $502.00 $543.00 $596.00 $502.00 $543.00 $596.0064580 90 $343.00 $380.00 $400.00 $423.00 $380.00 $400.00 $423.0064581 90 $745.00 $1,047.00 $1,095.00 $1,154.00 $1,047.00 $1,095.00 $1,154.0064585 10 $37.00 $543.00 $579.00 $612.00 $224.00 $237.00 $251.0064590 10 $217.00 $467.00 $496.00 $523.00 $247.00 $260.00 $275.0064595 10 $153.00 $518.00 $553.00 $585.00 $200.00 $212.00 $225.0064600 10 $228.00 $559.00 $594.00 $629.00 $272.00 $286.00 $304.0064605 10 $319.00 $746.00 $796.00 $852.00 $438.00 $466.00 $504.0064610 10 $307.00 $913.00 $985.00 $1,074.00 $640.00 $693.00 $766.00

CPT only © 2008 American Medical Association. All rights reserved. Part B, 233

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

64612 10 $188.00 $203.00 $213.00 $223.00 $168.00 $176.00 $184.0064613 10 $168.00 $209.00 $219.00 $230.00 $160.00 $167.00 $175.0064614 10 $200.00 $232.00 $243.00 $255.00 $177.00 $184.00 $192.0064620 10 $185.00 $359.00 $379.00 $399.00 $211.00 $221.00 $232.0064622 10 $333.00 $451.00 $477.00 $502.00 $222.00 $231.00 $242.0064623 ZZZ $113.00 $167.00 $177.00 $186.00 $62.00 $64.00 $67.0064626 10 $262.00 $508.00 $535.00 $561.00 $291.00 $303.00 $316.0064627 ZZZ $151.00 $232.00 $246.00 $259.00 $73.00 $76.00 $79.0064630 10 $202.00 $297.00 $312.00 $329.00 $240.00 $252.00 $265.0064640 10 $208.00 $319.00 $338.00 $359.00 $235.00 $248.00 $264.0064650 0 ------- $77.00 $82.00 $86.00 $49.00 $52.00 $55.0064653 0 ------- $89.00 $94.00 $99.00 $62.00 $65.00 $69.0064680 10 $180.00 $412.00 $436.00 $459.00 $203.00 $213.00 $224.0064681 10 ------- $553.00 $585.00 $617.00 $283.00 $296.00 $312.0064702 90 $383.00 $561.00 $593.00 $630.00 $561.00 $593.00 $630.0064704 90 $402.00 $430.00 $457.00 $491.00 $430.00 $457.00 $491.0064708 90 $562.00 $595.00 $635.00 $686.00 $595.00 $635.00 $686.0064712 90 $678.00 $684.00 $724.00 $775.00 $684.00 $724.00 $775.0064713 90 $867.00 $973.00 $1,041.00 $1,130.00 $973.00 $1,041.00 $1,130.0064714 90 $715.00 $799.00 $844.00 $904.00 $799.00 $844.00 $904.0064716 90 $523.00 $658.00 $694.00 $736.00 $658.00 $694.00 $736.0064718 90 $558.00 $720.00 $768.00 $827.00 $720.00 $768.00 $827.0064719 90 $446.00 $507.00 $542.00 $585.00 $507.00 $542.00 $585.0064721 90 $439.00 $537.00 $573.00 $617.00 $535.00 $572.00 $615.0064722 90 $411.00 $411.00 $434.00 $462.00 $411.00 $434.00 $462.0064726 90 $271.00 $381.00 $404.00 $434.00 $381.00 $404.00 $434.0064727 ZZZ $261.00 $251.00 $268.00 $290.00 $251.00 $268.00 $290.0064732 90 $405.00 $483.00 $520.00 $569.00 $483.00 $520.00 $569.0064734 90 $432.00 $538.00 $576.00 $624.00 $538.00 $576.00 $624.0064736 90 $388.00 $476.00 $503.00 $534.00 $476.00 $503.00 $534.0064738 90 $475.00 $611.00 $655.00 $711.00 $611.00 $655.00 $711.0064740 90 $461.00 $594.00 $630.00 $672.00 $594.00 $630.00 $672.0064742 90 $517.00 $599.00 $634.00 $675.00 $599.00 $634.00 $675.0064744 90 $798.00 $552.00 $596.00 $653.00 $552.00 $596.00 $653.0064746 90 $494.00 $577.00 $613.00 $658.00 $577.00 $613.00 $658.0064752 90 $560.00 $632.00 $670.00 $718.00 $632.00 $670.00 $718.0064755 90 $1,042.00 $1,127.00 $1,194.00 $1,282.00 $1,127.00 $1,194.00 $1,282.0064760 90 $578.00 $597.00 $631.00 $673.00 $597.00 $631.00 $673.0064761 90 $495.00 $564.00 $591.00 $624.00 $564.00 $591.00 $624.0064763 90 $561.00 $652.00 $692.00 $743.00 $652.00 $692.00 $743.0064766 90 $713.00 $772.00 $817.00 $873.00 $772.00 $817.00 $873.0064771 90 $632.00 $754.00 $805.00 $870.00 $754.00 $805.00 $870.0064772 90 $636.00 $726.00 $779.00 $849.00 $726.00 $779.00 $849.0064774 90 $392.00 $523.00 $556.00 $596.00 $523.00 $556.00 $596.0064776 90 $390.00 $504.00 $537.00 $578.00 $504.00 $537.00 $578.0064778 ZZZ $249.00 $250.00 $267.00 $289.00 $250.00 $267.00 $289.0064782 90 $482.00 $585.00 $622.00 $667.00 $585.00 $622.00 $667.0064783 ZZZ $298.00 $295.00 $313.00 $338.00 $295.00 $313.00 $338.0064784 90 $751.00 $927.00 $985.00 $1,059.00 $927.00 $985.00 $1,059.0064786 90 $1,281.00 $1,421.00 $1,520.00 $1,649.00 $1,421.00 $1,520.00 $1,649.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

64787 ZZZ $458.00 $342.00 $363.00 $391.00 $342.00 $363.00 $391.0064788 90 $381.00 $487.00 $519.00 $559.00 $487.00 $519.00 $559.0064790 90 $884.00 $1,084.00 $1,163.00 $1,266.00 $1,084.00 $1,163.00 $1,266.0064792 90 $1,148.00 $1,363.00 $1,457.00 $1,580.00 $1,363.00 $1,457.00 $1,580.0064795 0 $247.00 $257.00 $276.00 $300.00 $257.00 $276.00 $300.0064802 90 $711.00 $799.00 $847.00 $911.00 $799.00 $847.00 $911.0064804 90 $1,202.00 $1,240.00 $1,318.00 $1,422.00 $1,240.00 $1,318.00 $1,422.0064809 90 $1,080.00 $1,125.00 $1,186.00 $1,264.00 $1,125.00 $1,186.00 $1,264.0064818 90 $845.00 $873.00 $924.00 $991.00 $873.00 $924.00 $991.0064820 90 $838.00 $969.00 $1,032.00 $1,111.00 $969.00 $1,032.00 $1,111.0064821 90 $609.00 $877.00 $933.00 $1,002.00 $877.00 $933.00 $1,002.0064822 90 $609.00 $876.00 $933.00 $1,004.00 $876.00 $933.00 $1,004.0064823 90 $703.00 $996.00 $1,062.00 $1,146.00 $996.00 $1,062.00 $1,146.0064831 90 $592.00 $935.00 $995.00 $1,070.00 $935.00 $995.00 $1,070.0064832 ZZZ $171.00 $464.00 $495.00 $536.00 $464.00 $495.00 $536.0064834 90 $711.00 $963.00 $1,027.00 $1,107.00 $963.00 $1,027.00 $1,107.0064835 90 $834.00 $1,047.00 $1,118.00 $1,207.00 $1,047.00 $1,118.00 $1,207.0064836 90 $856.00 $1,046.00 $1,115.00 $1,203.00 $1,046.00 $1,115.00 $1,203.0064837 ZZZ $480.00 $515.00 $550.00 $597.00 $515.00 $550.00 $597.0064840 90 $1,058.00 $1,154.00 $1,217.00 $1,294.00 $1,154.00 $1,217.00 $1,294.0064856 90 $1,063.00 $1,313.00 $1,398.00 $1,508.00 $1,313.00 $1,398.00 $1,508.0064857 90 $1,137.00 $1,373.00 $1,462.00 $1,576.00 $1,373.00 $1,462.00 $1,576.0064858 90 $1,313.00 $1,604.00 $1,725.00 $1,886.00 $1,604.00 $1,725.00 $1,886.0064859 ZZZ $341.00 $351.00 $375.00 $407.00 $351.00 $375.00 $407.0064861 90 $1,524.00 $1,842.00 $1,985.00 $2,178.00 $1,842.00 $1,985.00 $2,178.0064862 90 $1,798.00 $1,877.00 $2,026.00 $2,229.00 $1,877.00 $2,026.00 $2,229.0064864 90 $970.00 $1,131.00 $1,192.00 $1,265.00 $1,131.00 $1,192.00 $1,265.0064865 90 $1,250.00 $1,494.00 $1,577.00 $1,673.00 $1,494.00 $1,577.00 $1,673.0064866 90 $1,238.00 $1,554.00 $1,649.00 $1,765.00 $1,554.00 $1,649.00 $1,765.0064868 90 $1,162.00 $1,338.00 $1,413.00 $1,500.00 $1,338.00 $1,413.00 $1,500.0064870 90 $1,313.00 $1,319.00 $1,382.00 $1,458.00 $1,319.00 $1,382.00 $1,458.0064872 ZZZ $155.00 $163.00 $173.00 $188.00 $163.00 $173.00 $188.0064874 ZZZ $230.00 $242.00 $258.00 $279.00 $242.00 $258.00 $279.0064876 ZZZ $189.00 $275.00 $293.00 $316.00 $275.00 $293.00 $316.0064885 90 $1,382.00 $1,465.00 $1,543.00 $1,637.00 $1,465.00 $1,543.00 $1,637.0064886 90 $1,636.00 $1,737.00 $1,832.00 $1,950.00 $1,737.00 $1,832.00 $1,950.0064890 90 $1,112.00 $1,413.00 $1,506.00 $1,624.00 $1,413.00 $1,506.00 $1,624.0064891 90 $1,243.00 $1,368.00 $1,441.00 $1,530.00 $1,368.00 $1,441.00 $1,530.0064892 90 $1,177.00 $1,380.00 $1,475.00 $1,599.00 $1,380.00 $1,475.00 $1,599.0064893 90 $1,321.00 $1,481.00 $1,582.00 $1,714.00 $1,481.00 $1,582.00 $1,714.0064895 90 $1,500.00 $1,673.00 $1,776.00 $1,908.00 $1,673.00 $1,776.00 $1,908.0064896 90 $1,185.00 $1,842.00 $1,963.00 $2,121.00 $1,842.00 $1,963.00 $2,121.0064897 90 $1,419.00 $1,636.00 $1,738.00 $1,870.00 $1,636.00 $1,738.00 $1,870.0064898 90 $1,549.00 $1,779.00 $1,891.00 $2,035.00 $1,779.00 $1,891.00 $2,035.0064901 ZZZ $865.00 $810.00 $861.00 $928.00 $810.00 $861.00 $928.0064902 ZZZ $982.00 $943.00 $1,001.00 $1,078.00 $943.00 $1,001.00 $1,078.0064905 90 $1,059.00 $1,250.00 $1,329.00 $1,431.00 $1,250.00 $1,329.00 $1,431.0064907 90 $1,472.00 $1,658.00 $1,772.00 $1,924.00 $1,658.00 $1,772.00 $1,924.0064910 90 ------- $897.00 $958.00 $1,040.00 $897.00 $958.00 $1,040.0064911 90 ------- $1,085.00 $1,152.00 $1,243.00 $1,085.00 $1,152.00 $1,243.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

64999 YYY BR ------- ------- ------- ------- ------- -------65091 90 $678.00 $737.00 $772.00 $807.00 $737.00 $772.00 $807.0065093 90 $712.00 $740.00 $776.00 $812.00 $740.00 $776.00 $812.0065101 90 $726.00 $845.00 $885.00 $925.00 $845.00 $885.00 $925.0065103 90 $769.00 $881.00 $923.00 $963.00 $881.00 $923.00 $963.0065105 90 $846.00 $969.00 $1,014.00 $1,059.00 $969.00 $1,014.00 $1,059.0065110 90 $1,305.00 $1,415.00 $1,481.00 $1,550.00 $1,415.00 $1,481.00 $1,550.0065112 90 $1,386.00 $1,692.00 $1,778.00 $1,872.00 $1,692.00 $1,778.00 $1,872.0065114 90 $1,456.00 $1,735.00 $1,815.00 $1,899.00 $1,735.00 $1,815.00 $1,899.0065125 90 $312.00 $552.00 $585.00 $615.00 $333.00 $350.00 $368.0065130 90 $730.00 $835.00 $873.00 $912.00 $835.00 $873.00 $912.0065135 90 $678.00 $849.00 $889.00 $928.00 $849.00 $889.00 $928.0065140 90 $738.00 $921.00 $964.00 $1,007.00 $921.00 $964.00 $1,007.0065150 90 $652.00 $678.00 $711.00 $744.00 $678.00 $711.00 $744.0065155 90 $862.00 $984.00 $1,031.00 $1,079.00 $984.00 $1,031.00 $1,079.0065175 90 $654.00 $751.00 $787.00 $822.00 $751.00 $787.00 $822.0065205 0 $45.00 $66.00 $69.00 $72.00 $51.00 $53.00 $55.0065210 0 $53.00 $81.00 $84.00 $88.00 $62.00 $64.00 $67.0065220 0 $58.00 $69.00 $72.00 $76.00 $52.00 $54.00 $57.0065222 0 $62.00 $88.00 $92.00 $96.00 $67.00 $69.00 $72.0065235 90 $627.00 $779.00 $813.00 $847.00 $779.00 $813.00 $847.0065260 90 $956.00 $1,082.00 $1,129.00 $1,179.00 $1,082.00 $1,129.00 $1,179.0065265 90 $1,104.00 $1,214.00 $1,266.00 $1,320.00 $1,214.00 $1,266.00 $1,320.0065270 10 $88.00 $323.00 $342.00 $358.00 $162.00 $169.00 $176.0065272 90 $223.00 $575.00 $605.00 $633.00 $387.00 $403.00 $420.0065273 90 $376.00 $427.00 $445.00 $464.00 $427.00 $445.00 $464.0065275 90 $75.00 $624.00 $654.00 $682.00 $505.00 $526.00 $547.0065280 90 $711.00 $748.00 $779.00 $812.00 $748.00 $779.00 $812.0065285 90 $1,177.00 $1,168.00 $1,216.00 $1,267.00 $1,168.00 $1,216.00 $1,267.0065286 90 $692.00 $820.00 $862.00 $902.00 $549.00 $572.00 $596.0065290 90 $519.00 $552.00 $576.00 $602.00 $552.00 $576.00 $602.0065400 90 $603.00 $759.00 $795.00 $829.00 $664.00 $693.00 $722.0065410 0 $142.00 $169.00 $177.00 $186.00 $120.00 $125.00 $130.0065420 90 $448.00 $608.00 $642.00 $673.00 $425.00 $446.00 $466.0065426 90 $534.00 $754.00 $793.00 $830.00 $534.00 $557.00 $580.0065430 0 $81.00 $134.00 $140.00 $146.00 $120.00 $125.00 $131.0065435 0 $88.00 $93.00 $97.00 $101.00 $80.00 $84.00 $87.0065436 90 $319.00 $434.00 $454.00 $473.00 $416.00 $434.00 $453.0065450 90 $52.00 $363.00 $381.00 $399.00 $358.00 $376.00 $393.0065600 90 $325.00 $440.00 $461.00 $482.00 $373.00 $389.00 $406.0065710 90 $1,124.00 $1,243.00 $1,297.00 $1,352.00 $1,243.00 $1,297.00 $1,352.0065730 90 $1,314.00 $1,380.00 $1,439.00 $1,500.00 $1,380.00 $1,439.00 $1,500.0065750 90 $1,381.00 $1,402.00 $1,462.00 $1,524.00 $1,402.00 $1,462.00 $1,524.0065755 90 $1,373.00 $1,394.00 $1,452.00 $1,514.00 $1,394.00 $1,452.00 $1,514.0065770 90 $1,461.00 $1,601.00 $1,668.00 $1,739.00 $1,601.00 $1,668.00 $1,739.0065772 90 $449.00 $509.00 $533.00 $556.00 $451.00 $470.00 $490.0065775 90 $595.00 $620.00 $647.00 $674.00 $620.00 $647.00 $674.0065780 90 ------- $1,005.00 $1,050.00 $1,096.00 $1,005.00 $1,050.00 $1,096.0065781 90 ------- $1,504.00 $1,560.00 $1,614.00 $1,504.00 $1,560.00 $1,614.0065782 90 ------- $1,301.00 $1,352.00 $1,401.00 $1,301.00 $1,352.00 $1,401.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

65800 0 $88.00 $177.00 $185.00 $193.00 $152.00 $158.00 $165.0065805 0 $178.00 $194.00 $203.00 $212.00 $152.00 $158.00 $165.0065810 90 $516.00 $519.00 $542.00 $565.00 $519.00 $542.00 $565.0065815 90 $327.00 $742.00 $780.00 $817.00 $529.00 $552.00 $575.0065820 90 $813.00 $855.00 $895.00 $935.00 $855.00 $895.00 $935.0065850 90 $968.00 $963.00 $1,004.00 $1,048.00 $963.00 $1,004.00 $1,048.0065855 10 $441.00 $393.00 $412.00 $431.00 $341.00 $356.00 $372.0065860 90 $339.00 $364.00 $381.00 $399.00 $296.00 $308.00 $322.0065865 90 $540.00 $546.00 $571.00 $597.00 $546.00 $571.00 $597.0065870 90 $572.00 $666.00 $695.00 $725.00 $666.00 $695.00 $725.0065875 90 $597.00 $705.00 $737.00 $768.00 $705.00 $737.00 $768.0065880 90 $641.00 $744.00 $777.00 $810.00 $744.00 $777.00 $810.0065900 90 $945.00 $1,097.00 $1,145.00 $1,195.00 $1,097.00 $1,145.00 $1,195.0065920 90 $752.00 $881.00 $919.00 $958.00 $881.00 $919.00 $958.0065930 90 $700.00 $731.00 $763.00 $796.00 $731.00 $763.00 $796.0066020 10 $164.00 $220.00 $232.00 $244.00 $150.00 $157.00 $164.0066030 10 $160.00 $196.00 $207.00 $217.00 $125.00 $131.00 $137.0066130 90 $631.00 $822.00 $862.00 $902.00 $656.00 $684.00 $714.0066150 90 $798.00 $969.00 $1,014.00 $1,058.00 $969.00 $1,014.00 $1,058.0066155 90 $795.00 $964.00 $1,007.00 $1,050.00 $964.00 $1,007.00 $1,050.0066160 90 $942.00 $1,096.00 $1,144.00 $1,192.00 $1,096.00 $1,144.00 $1,192.0066165 90 $769.00 $946.00 $989.00 $1,031.00 $946.00 $989.00 $1,031.0066170 90 $1,089.00 $1,326.00 $1,384.00 $1,442.00 $1,326.00 $1,384.00 $1,442.0066172 90 $1,264.00 $1,662.00 $1,734.00 $1,807.00 $1,662.00 $1,734.00 $1,807.0066180 90 $1,313.00 $1,320.00 $1,374.00 $1,432.00 $1,320.00 $1,374.00 $1,432.0066185 90 $769.00 $831.00 $867.00 $904.00 $831.00 $867.00 $904.0066220 90 $711.00 $810.00 $845.00 $882.00 $810.00 $845.00 $882.0066225 90 $1,006.00 $1,046.00 $1,090.00 $1,137.00 $1,046.00 $1,090.00 $1,137.0066250 90 $602.00 $872.00 $917.00 $959.00 $617.00 $644.00 $671.0066500 90 $359.00 $405.00 $424.00 $444.00 $405.00 $424.00 $444.0066505 90 $359.00 $442.00 $464.00 $485.00 $442.00 $464.00 $485.0066600 90 $825.00 $910.00 $951.00 $992.00 $910.00 $951.00 $992.0066605 90 $1,136.00 $1,205.00 $1,259.00 $1,318.00 $1,205.00 $1,259.00 $1,318.0066625 90 $543.00 $488.00 $510.00 $534.00 $488.00 $510.00 $534.0066630 90 $623.00 $634.00 $662.00 $690.00 $634.00 $662.00 $690.0066635 90 $595.00 $640.00 $668.00 $696.00 $640.00 $668.00 $696.0066680 90 $526.00 $572.00 $598.00 $624.00 $572.00 $598.00 $624.0066682 90 $627.00 $693.00 $725.00 $757.00 $693.00 $725.00 $757.0066700 90 $506.00 $507.00 $531.00 $555.00 $445.00 $464.00 $485.0066710 90 $513.00 $500.00 $523.00 $547.00 $442.00 $461.00 $481.0066711 90 ------- $704.00 $735.00 $765.00 $704.00 $735.00 $765.0066720 90 $506.00 $528.00 $554.00 $581.00 $475.00 $497.00 $521.0066740 90 $473.00 $496.00 $519.00 $543.00 $445.00 $465.00 $485.0066761 90 $506.00 $510.00 $534.00 $557.00 $457.00 $477.00 $498.0066762 90 $433.00 $533.00 $558.00 $583.00 $473.00 $494.00 $516.0066770 90 $483.00 $592.00 $619.00 $647.00 $536.00 $559.00 $583.0066820 90 $433.00 $460.00 $484.00 $507.00 $460.00 $484.00 $507.0066821 90 $275.00 $362.00 $379.00 $395.00 $340.00 $356.00 $370.0066825 90 $753.00 $867.00 $907.00 $947.00 $867.00 $907.00 $947.0066830 90 $651.00 $796.00 $829.00 $863.00 $796.00 $829.00 $863.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

66840 90 $707.00 $781.00 $815.00 $850.00 $781.00 $815.00 $850.0066850 90 $805.00 $888.00 $925.00 $965.00 $888.00 $925.00 $965.0066852 90 $878.00 $951.00 $991.00 $1,033.00 $951.00 $991.00 $1,033.0066920 90 $785.00 $849.00 $885.00 $923.00 $849.00 $885.00 $923.0066930 90 $906.00 $963.00 $1,003.00 $1,045.00 $963.00 $1,003.00 $1,045.0066940 90 $819.00 $875.00 $912.00 $950.00 $875.00 $912.00 $950.0066982 90 $846.00 $1,217.00 $1,266.00 $1,319.00 $1,217.00 $1,266.00 $1,319.0066983 90 $763.00 $805.00 $831.00 $855.00 $805.00 $831.00 $855.0066984 90 $898.00 $864.00 $898.00 $934.00 $864.00 $898.00 $934.0066985 90 $744.00 $850.00 $885.00 $921.00 $850.00 $885.00 $921.0066986 90 $1,038.00 $1,054.00 $1,100.00 $1,149.00 $1,054.00 $1,100.00 $1,149.0066990 ZZZ $84.00 $107.00 $111.00 $115.00 $107.00 $111.00 $115.0066999 YYY BR ------- ------- ------- ------- ------- -------67005 90 $639.00 $529.00 $553.00 $578.00 $529.00 $553.00 $578.0067010 90 $647.00 $613.00 $640.00 $669.00 $613.00 $640.00 $669.0067015 90 $637.00 $659.00 $690.00 $721.00 $659.00 $690.00 $721.0067025 90 $774.00 $825.00 $864.00 $903.00 $702.00 $732.00 $763.0067027 90 $1,089.00 $964.00 $1,005.00 $1,048.00 $964.00 $1,005.00 $1,048.0067028 0 $338.00 $249.00 $261.00 $273.00 $195.00 $203.00 $212.0067030 90 $485.00 $583.00 $609.00 $635.00 $583.00 $609.00 $635.0067031 90 $402.00 $435.00 $455.00 $475.00 $394.00 $412.00 $429.0067036 90 $1,384.00 $1,090.00 $1,135.00 $1,183.00 $1,090.00 $1,135.00 $1,183.0067039 90 $1,490.00 $1,397.00 $1,456.00 $1,518.00 $1,397.00 $1,456.00 $1,518.0067040 90 $1,960.00 $1,612.00 $1,679.00 $1,750.00 $1,612.00 $1,679.00 $1,750.0067041 90 ------- $1,478.00 $1,537.00 $1,602.00 $1,478.00 $1,537.00 $1,602.0067042 90 ------- $1,693.00 $1,759.00 $1,832.00 $1,693.00 $1,759.00 $1,832.0067043 90 ------- $1,777.00 $1,847.00 $1,924.00 $1,777.00 $1,847.00 $1,924.0067101 90 $767.00 $873.00 $914.00 $954.00 $750.00 $782.00 $816.0067105 90 $941.00 $809.00 $846.00 $883.00 $720.00 $750.00 $782.0067107 90 $1,350.00 $1,367.00 $1,424.00 $1,485.00 $1,367.00 $1,424.00 $1,485.0067108 90 $1,878.00 $1,820.00 $1,895.00 $1,975.00 $1,820.00 $1,895.00 $1,975.0067110 90 $1,040.00 $984.00 $1,029.00 $1,075.00 $864.00 $901.00 $939.0067112 90 $1,500.00 $1,498.00 $1,560.00 $1,626.00 $1,498.00 $1,560.00 $1,626.0067113 90 ------- $1,951.00 $2,029.00 $2,113.00 $1,951.00 $2,029.00 $2,113.0067115 90 $496.00 $548.00 $572.00 $597.00 $548.00 $572.00 $597.0067120 90 $751.00 $746.00 $782.00 $817.00 $618.00 $645.00 $672.0067121 90 $962.00 $1,017.00 $1,060.00 $1,105.00 $1,017.00 $1,060.00 $1,105.0067141 90 $536.00 $583.00 $610.00 $637.00 $540.00 $564.00 $588.0067145 90 $514.00 $587.00 $614.00 $641.00 $552.00 $576.00 $601.0067208 90 $655.00 $672.00 $702.00 $732.00 $646.00 $673.00 $702.0067210 90 $779.00 $786.00 $819.00 $855.00 $757.00 $788.00 $822.0067218 90 $1,217.00 $1,592.00 $1,656.00 $1,725.00 $1,592.00 $1,656.00 $1,725.0067220 90 $894.00 $1,209.00 $1,260.00 $1,315.00 $1,147.00 $1,194.00 $1,245.0067221 0 $325.00 $359.00 $377.00 $395.00 $257.00 $268.00 $281.0067225 ZZZ $44.00 $35.00 $37.00 $38.00 $33.00 $34.00 $35.0067227 90 $652.00 $687.00 $718.00 $749.00 $640.00 $667.00 $696.0067228 90 $1,025.00 $1,319.00 $1,379.00 $1,441.00 $1,160.00 $1,210.00 $1,262.0067229 90 ------- $1,283.00 $1,335.00 $1,391.00 $1,283.00 $1,335.00 $1,391.0067250 90 $793.00 $902.00 $944.00 $987.00 $902.00 $944.00 $987.0067255 90 $872.00 $961.00 $1,005.00 $1,049.00 $961.00 $1,005.00 $1,049.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

67299 YYY BR ------- ------- ------- ------- ------- -------67311 90 $616.00 $673.00 $703.00 $735.00 $673.00 $703.00 $735.0067312 90 $773.00 $803.00 $837.00 $873.00 $803.00 $837.00 $873.0067314 90 $688.00 $751.00 $784.00 $818.00 $751.00 $784.00 $818.0067316 90 $857.00 $903.00 $941.00 $982.00 $903.00 $941.00 $982.0067318 90 $663.00 $787.00 $821.00 $857.00 $787.00 $821.00 $857.0067320 ZZZ $602.00 $368.00 $381.00 $395.00 $368.00 $381.00 $395.0067331 ZZZ $560.00 $349.00 $360.00 $374.00 $349.00 $360.00 $374.0067332 ZZZ $621.00 $379.00 $392.00 $407.00 $379.00 $392.00 $407.0067334 ZZZ $447.00 $343.00 $355.00 $368.00 $343.00 $355.00 $368.0067335 ZZZ $253.00 $177.00 $184.00 $192.00 $177.00 $184.00 $192.0067340 ZZZ $559.00 $410.00 $424.00 $440.00 $410.00 $424.00 $440.0067343 90 $628.00 $733.00 $765.00 $798.00 $733.00 $765.00 $798.0067345 10 $275.00 $272.00 $285.00 $299.00 $246.00 $257.00 $269.0067346 0 ------- $234.00 $244.00 $255.00 $234.00 $244.00 $255.0067399 YYY BR ------- ------- ------- ------- ------- -------67400 90 $960.00 $1,076.00 $1,127.00 $1,180.00 $1,076.00 $1,127.00 $1,180.0067405 90 $799.00 $910.00 $954.00 $998.00 $910.00 $954.00 $998.0067412 90 $976.00 $1,002.00 $1,049.00 $1,096.00 $1,002.00 $1,049.00 $1,096.0067413 90 $909.00 $1,000.00 $1,048.00 $1,096.00 $1,000.00 $1,048.00 $1,096.0067414 90 $1,023.00 $1,478.00 $1,537.00 $1,597.00 $1,478.00 $1,537.00 $1,597.0067415 0 $146.00 $124.00 $129.00 $135.00 $124.00 $129.00 $135.0067420 90 $1,729.00 $1,897.00 $1,983.00 $2,074.00 $1,897.00 $1,983.00 $2,074.0067430 90 $1,203.00 $1,441.00 $1,510.00 $1,583.00 $1,441.00 $1,510.00 $1,583.0067440 90 $1,257.00 $1,392.00 $1,457.00 $1,523.00 $1,392.00 $1,457.00 $1,523.0067445 90 $1,269.00 $1,613.00 $1,682.00 $1,756.00 $1,613.00 $1,682.00 $1,756.0067450 90 $1,300.00 $1,438.00 $1,504.00 $1,570.00 $1,438.00 $1,504.00 $1,570.0067500 0 $75.00 $103.00 $106.00 $110.00 $90.00 $93.00 $96.0067505 0 $109.00 $97.00 $101.00 $105.00 $84.00 $87.00 $90.0067515 0 $53.00 $102.00 $105.00 $108.00 $93.00 $95.00 $98.0067550 90 $946.00 $1,126.00 $1,182.00 $1,241.00 $1,126.00 $1,182.00 $1,241.0067560 90 $936.00 $1,137.00 $1,190.00 $1,244.00 $1,137.00 $1,190.00 $1,244.0067570 90 $1,148.00 $1,336.00 $1,397.00 $1,460.00 $1,336.00 $1,397.00 $1,460.0067599 YYY BR ------- ------- ------- ------- ------- -------67700 10 $87.00 $328.00 $349.00 $367.00 $131.00 $137.00 $144.0067710 10 $117.00 $280.00 $297.00 $313.00 $110.00 $115.00 $121.0067715 10 $102.00 $293.00 $311.00 $327.00 $124.00 $130.00 $136.0067800 10 $119.00 $146.00 $153.00 $160.00 $119.00 $124.00 $130.0067801 10 $189.00 $187.00 $195.00 $204.00 $154.00 $161.00 $168.0067805 10 $208.00 $231.00 $242.00 $254.00 $190.00 $198.00 $207.0067808 90 $308.00 $410.00 $428.00 $446.00 $410.00 $428.00 $446.0067810 0 $133.00 $256.00 $270.00 $284.00 $108.00 $112.00 $116.0067820 0 $36.00 $63.00 $66.00 $69.00 $63.00 $66.00 $69.0067825 10 $130.00 $150.00 $157.00 $164.00 $138.00 $144.00 $151.0067830 10 $239.00 $325.00 $344.00 $361.00 $157.00 $164.00 $172.0067835 90 $500.00 $504.00 $527.00 $551.00 $504.00 $527.00 $551.0067840 10 $187.00 $339.00 $358.00 $376.00 $182.00 $190.00 $198.0067850 10 $143.00 $252.00 $266.00 $279.00 $159.00 $166.00 $173.0067875 0 $163.00 $211.00 $223.00 $234.00 $113.00 $118.00 $124.0067880 90 $442.00 $526.00 $553.00 $578.00 $410.00 $428.00 $446.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

67882 90 $643.00 $645.00 $676.00 $706.00 $527.00 $550.00 $573.0067900 90 $487.00 $755.00 $794.00 $833.00 $591.00 $618.00 $647.0067901 90 $646.00 $753.00 $793.00 $835.00 $661.00 $694.00 $731.0067902 90 $650.00 $797.00 $833.00 $874.00 $797.00 $833.00 $874.0067903 90 $657.00 $743.00 $784.00 $826.00 $585.00 $614.00 $647.0067904 90 $720.00 $845.00 $887.00 $930.00 $665.00 $695.00 $726.0067906 90 $633.00 $595.00 $623.00 $656.00 $595.00 $623.00 $656.0067908 90 $550.00 $570.00 $599.00 $628.00 $503.00 $527.00 $552.0067909 90 $577.00 $636.00 $670.00 $703.00 $509.00 $533.00 $559.0067911 90 $517.00 $617.00 $642.00 $669.00 $617.00 $642.00 $669.0067912 90 ------- $1,116.00 $1,181.00 $1,239.00 $572.00 $597.00 $623.0067914 90 $487.00 $466.00 $491.00 $515.00 $332.00 $347.00 $363.0067915 90 $252.00 $421.00 $443.00 $465.00 $295.00 $308.00 $322.0067916 90 $675.00 $635.00 $668.00 $700.00 $497.00 $520.00 $544.0067917 90 $631.00 $693.00 $729.00 $766.00 $551.00 $577.00 $605.0067921 90 $419.00 $444.00 $468.00 $490.00 $310.00 $324.00 $339.0067922 90 $243.00 $409.00 $431.00 $451.00 $284.00 $297.00 $310.0067923 90 $718.00 $666.00 $700.00 $733.00 $535.00 $559.00 $585.0067924 90 $605.00 $694.00 $730.00 $765.00 $516.00 $539.00 $564.0067930 10 $280.00 $437.00 $460.00 $482.00 $284.00 $296.00 $309.0067935 90 $520.00 $707.00 $744.00 $782.00 $525.00 $549.00 $576.0067938 10 $67.00 $299.00 $317.00 $332.00 $130.00 $136.00 $142.0067950 90 $584.00 $687.00 $723.00 $760.00 $545.00 $571.00 $599.0067961 90 $571.00 $683.00 $719.00 $755.00 $529.00 $554.00 $581.0067966 90 $645.00 $873.00 $913.00 $953.00 $727.00 $757.00 $788.0067971 90 $875.00 $842.00 $879.00 $920.00 $842.00 $879.00 $920.0067973 90 $1,126.00 $1,094.00 $1,143.00 $1,198.00 $1,094.00 $1,143.00 $1,198.0067974 90 $1,140.00 $1,090.00 $1,139.00 $1,193.00 $1,090.00 $1,139.00 $1,193.0067975 90 $681.00 $794.00 $830.00 $869.00 $794.00 $830.00 $869.0067999 YYY BR ------- ------- ------- ------- ------- -------68020 10 $106.00 $136.00 $142.00 $148.00 $126.00 $132.00 $138.0068040 0 $75.00 $76.00 $80.00 $83.00 $63.00 $65.00 $68.0068100 0 $137.00 $209.00 $221.00 $232.00 $114.00 $119.00 $124.0068110 10 $172.00 $271.00 $286.00 $300.00 $169.00 $177.00 $185.0068115 10 $248.00 $379.00 $400.00 $420.00 $211.00 $221.00 $231.0068130 90 $378.00 $637.00 $670.00 $702.00 $468.00 $490.00 $512.0068135 10 $146.00 $180.00 $188.00 $196.00 $173.00 $180.00 $189.0068200 0 $59.00 $49.00 $51.00 $53.00 $40.00 $42.00 $43.0068320 90 $502.00 $834.00 $878.00 $918.00 $595.00 $621.00 $647.0068325 90 $672.00 $746.00 $780.00 $816.00 $746.00 $780.00 $816.0068326 90 $654.00 $722.00 $753.00 $785.00 $722.00 $753.00 $785.0068328 90 $741.00 $819.00 $857.00 $899.00 $819.00 $857.00 $899.0068330 90 $488.00 $704.00 $740.00 $775.00 $512.00 $535.00 $558.0068335 90 $636.00 $724.00 $755.00 $787.00 $724.00 $755.00 $787.0068340 90 $413.00 $638.00 $671.00 $702.00 $443.00 $462.00 $482.0068360 90 $449.00 $616.00 $647.00 $677.00 $458.00 $478.00 $498.0068362 90 $691.00 $733.00 $764.00 $797.00 $733.00 $764.00 $797.0068371 10 ------- $488.00 $515.00 $545.00 $488.00 $515.00 $545.0068399 YYY BR ------- ------- ------- ------- ------- -------68400 10 $154.00 $345.00 $365.00 $383.00 $163.00 $170.00 $178.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

68420 10 $191.00 $387.00 $409.00 $429.00 $205.00 $215.00 $224.0068440 10 $96.00 $133.00 $140.00 $147.00 $111.00 $116.00 $122.0068500 90 $882.00 $1,111.00 $1,160.00 $1,210.00 $1,111.00 $1,160.00 $1,210.0068505 90 $921.00 $1,116.00 $1,165.00 $1,215.00 $1,116.00 $1,165.00 $1,215.0068510 0 $491.00 $547.00 $576.00 $603.00 $337.00 $350.00 $365.0068520 90 $687.00 $780.00 $814.00 $849.00 $780.00 $814.00 $849.0068525 0 $340.00 $315.00 $327.00 $341.00 $315.00 $327.00 $341.0068530 10 $379.00 $531.00 $560.00 $587.00 $304.00 $317.00 $331.0068540 90 $875.00 $1,048.00 $1,093.00 $1,140.00 $1,048.00 $1,093.00 $1,140.0068550 90 $1,107.00 $1,287.00 $1,345.00 $1,407.00 $1,287.00 $1,345.00 $1,407.0068700 90 $628.00 $674.00 $702.00 $732.00 $674.00 $702.00 $732.0068705 10 $176.00 $285.00 $301.00 $315.00 $190.00 $199.00 $207.0068720 90 $807.00 $862.00 $900.00 $939.00 $862.00 $900.00 $939.0068745 90 $704.00 $867.00 $907.00 $949.00 $867.00 $907.00 $949.0068750 90 $792.00 $890.00 $929.00 $969.00 $890.00 $929.00 $969.0068760 10 $109.00 $242.00 $255.00 $268.00 $166.00 $174.00 $182.0068761 10 $130.00 $172.00 $181.00 $189.00 $134.00 $140.00 $146.0068770 90 $634.00 $631.00 $656.00 $683.00 $631.00 $656.00 $683.0068801 10 $202.00 $142.00 $150.00 $158.00 $122.00 $128.00 $134.0068810 10 $290.00 $308.00 $323.00 $337.00 $266.00 $278.00 $289.0068811 10 $191.00 $236.00 $247.00 $259.00 $236.00 $247.00 $259.0068815 10 $399.00 $532.00 $562.00 $590.00 $296.00 $310.00 $324.0068816 10 ------- $790.00 $840.00 $884.00 $279.00 $292.00 $306.0068840 10 $100.00 $142.00 $149.00 $156.00 $124.00 $130.00 $136.0068850 0 $76.00 $80.00 $84.00 $88.00 $72.00 $76.00 $79.0068899 YYY BR ------- ------- ------- ------- ------- -------69000 10 $52.00 $222.00 $236.00 $249.00 $146.00 $154.00 $162.0069005 10 $175.00 $262.00 $277.00 $292.00 $200.00 $211.00 $222.0069020 10 $109.00 $282.00 $299.00 $316.00 $179.00 $189.00 $199.0069100 0 $85.00 $129.00 $136.00 $143.00 $60.00 $62.00 $64.0069105 0 $87.00 $170.00 $181.00 $191.00 $83.00 $87.00 $92.0069110 90 $294.00 $551.00 $585.00 $618.00 $410.00 $433.00 $458.0069120 90 $274.00 $510.00 $540.00 $572.00 $510.00 $540.00 $572.0069140 90 $722.00 $1,091.00 $1,155.00 $1,219.00 $1,091.00 $1,155.00 $1,219.0069145 90 $248.00 $461.00 $489.00 $516.00 $308.00 $325.00 $343.0069150 90 $1,111.00 $1,352.00 $1,427.00 $1,512.00 $1,352.00 $1,427.00 $1,512.0069155 90 $1,680.00 $2,150.00 $2,264.00 $2,393.00 $2,150.00 $2,264.00 $2,393.0069200 0 $53.00 $154.00 $164.00 $173.00 $70.00 $74.00 $78.0069205 10 $110.00 $129.00 $137.00 $144.00 $129.00 $137.00 $144.0069210 0 $39.00 $63.00 $66.00 $70.00 $43.00 $45.00 $47.0069220 0 $78.00 $167.00 $178.00 $188.00 $79.00 $84.00 $89.0069222 10 $123.00 $272.00 $289.00 $305.00 $175.00 $185.00 $196.0069300 YYY $522.00 $744.00 $789.00 $840.00 $606.00 $641.00 $683.0069310 90 $937.00 $1,371.00 $1,449.00 $1,530.00 $1,371.00 $1,449.00 $1,530.0069320 90 $1,434.00 $1,956.00 $2,065.00 $2,181.00 $1,956.00 $2,065.00 $2,181.0069399 YYY BR ------- ------- ------- ------- ------- -------69400 0 $76.00 $169.00 $180.00 $190.00 $78.00 $82.00 $87.0069401 0 $52.00 $102.00 $108.00 $114.00 $64.00 $68.00 $72.0069405 10 $176.00 $320.00 $338.00 $357.00 $248.00 $261.00 $275.0069420 10 $117.00 $234.00 $248.00 $262.00 $151.00 $159.00 $168.00

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CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

69421 10 $155.00 $194.00 $205.00 $217.00 $194.00 $205.00 $217.0069424 0 $84.00 $158.00 $168.00 $178.00 $80.00 $84.00 $88.0069433 10 $145.00 $243.00 $258.00 $273.00 $164.00 $173.00 $183.0069436 10 $182.00 $213.00 $225.00 $239.00 $213.00 $225.00 $239.0069440 90 $699.00 $853.00 $901.00 $951.00 $853.00 $901.00 $951.0069450 90 $525.00 $665.00 $703.00 $742.00 $665.00 $703.00 $742.0069501 90 $829.00 $928.00 $978.00 $1,033.00 $928.00 $978.00 $1,033.0069502 90 $1,118.00 $1,229.00 $1,295.00 $1,367.00 $1,229.00 $1,295.00 $1,367.0069505 90 $1,176.00 $1,529.00 $1,616.00 $1,706.00 $1,529.00 $1,616.00 $1,706.0069511 90 $1,221.00 $1,569.00 $1,657.00 $1,750.00 $1,569.00 $1,657.00 $1,750.0069530 90 $1,616.00 $2,105.00 $2,218.00 $2,339.00 $2,105.00 $2,218.00 $2,339.0069535 90 $2,824.00 $3,451.00 $3,630.00 $3,831.00 $3,451.00 $3,630.00 $3,831.0069540 10 $126.00 $256.00 $272.00 $287.00 $161.00 $170.00 $180.0069550 90 $998.00 $1,317.00 $1,392.00 $1,470.00 $1,317.00 $1,392.00 $1,470.0069552 90 $1,621.00 $2,022.00 $2,132.00 $2,251.00 $2,022.00 $2,132.00 $2,251.0069554 90 $2,600.00 $3,267.00 $3,438.00 $3,633.00 $3,267.00 $3,438.00 $3,633.0069601 90 $1,195.00 $1,325.00 $1,396.00 $1,474.00 $1,325.00 $1,396.00 $1,474.0069602 90 $1,225.00 $1,379.00 $1,453.00 $1,535.00 $1,379.00 $1,453.00 $1,535.0069603 90 $1,264.00 $1,622.00 $1,713.00 $1,809.00 $1,622.00 $1,713.00 $1,809.0069604 90 $1,263.00 $1,413.00 $1,489.00 $1,573.00 $1,413.00 $1,489.00 $1,573.0069605 90 $1,526.00 $1,996.00 $2,106.00 $2,224.00 $1,996.00 $2,106.00 $2,224.0069610 10 $41.00 $499.00 $527.00 $556.00 $383.00 $403.00 $426.0069620 90 $651.00 $868.00 $919.00 $970.00 $620.00 $654.00 $691.0069631 90 $985.00 $1,098.00 $1,159.00 $1,223.00 $1,098.00 $1,159.00 $1,223.0069632 90 $1,166.00 $1,353.00 $1,427.00 $1,507.00 $1,353.00 $1,427.00 $1,507.0069633 90 $1,110.00 $1,303.00 $1,375.00 $1,451.00 $1,303.00 $1,375.00 $1,451.0069635 90 $1,207.00 $1,540.00 $1,627.00 $1,718.00 $1,540.00 $1,627.00 $1,718.0069636 90 $1,381.00 $1,753.00 $1,851.00 $1,954.00 $1,753.00 $1,851.00 $1,954.0069637 90 $1,370.00 $1,743.00 $1,841.00 $1,944.00 $1,743.00 $1,841.00 $1,944.0069641 90 $1,154.00 $1,313.00 $1,384.00 $1,462.00 $1,313.00 $1,384.00 $1,462.0069642 90 $1,519.00 $1,697.00 $1,789.00 $1,889.00 $1,697.00 $1,789.00 $1,889.0069643 90 $1,389.00 $1,549.00 $1,632.00 $1,723.00 $1,549.00 $1,632.00 $1,723.0069644 90 $1,529.00 $1,890.00 $1,994.00 $2,106.00 $1,890.00 $1,994.00 $2,106.0069645 90 $1,479.00 $1,849.00 $1,952.00 $2,061.00 $1,849.00 $1,952.00 $2,061.0069646 90 $1,620.00 $1,968.00 $2,077.00 $2,193.00 $1,968.00 $2,077.00 $2,193.0069650 90 $879.00 $1,004.00 $1,059.00 $1,118.00 $1,004.00 $1,059.00 $1,118.0069660 90 $1,072.00 $1,179.00 $1,242.00 $1,311.00 $1,179.00 $1,242.00 $1,311.0069661 90 $1,412.00 $1,547.00 $1,629.00 $1,720.00 $1,547.00 $1,629.00 $1,720.0069662 90 $1,386.00 $1,483.00 $1,561.00 $1,649.00 $1,483.00 $1,561.00 $1,649.0069666 90 $887.00 $1,017.00 $1,072.00 $1,133.00 $1,017.00 $1,072.00 $1,133.0069667 90 $887.00 $1,019.00 $1,075.00 $1,135.00 $1,019.00 $1,075.00 $1,135.0069670 90 $988.00 $1,193.00 $1,258.00 $1,328.00 $1,193.00 $1,258.00 $1,328.0069676 90 $828.00 $1,048.00 $1,107.00 $1,170.00 $1,048.00 $1,107.00 $1,170.0069700 90 $702.00 $890.00 $939.00 $992.00 $890.00 $939.00 $992.0069710 0 BR ------- ------- ------- ------- ------- -------69711 90 $878.00 $1,089.00 $1,148.00 $1,212.00 $1,089.00 $1,148.00 $1,212.0069714 90 $961.00 $1,373.00 $1,445.00 $1,525.00 $1,373.00 $1,445.00 $1,525.0069715 90 $1,217.00 $1,709.00 $1,798.00 $1,898.00 $1,709.00 $1,798.00 $1,898.0069717 90 $996.00 $1,450.00 $1,520.00 $1,594.00 $1,450.00 $1,520.00 $1,594.0069718 90 $1,232.00 $1,868.00 $2,001.00 $2,170.00 $1,868.00 $2,001.00 $2,170.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

69720 90 $1,307.00 $1,490.00 $1,570.00 $1,658.00 $1,490.00 $1,570.00 $1,658.0069725 90 $1,922.00 $2,437.00 $2,567.00 $2,719.00 $2,437.00 $2,567.00 $2,719.0069740 90 $1,274.00 $1,486.00 $1,563.00 $1,649.00 $1,486.00 $1,563.00 $1,649.0069745 90 $1,447.00 $1,507.00 $1,580.00 $1,662.00 $1,507.00 $1,580.00 $1,662.0069799 YYY BR ------- ------- ------- ------- ------- -------69801 90 $785.00 $936.00 $988.00 $1,043.00 $936.00 $988.00 $1,043.0069802 90 $1,115.00 $1,317.00 $1,387.00 $1,465.00 $1,317.00 $1,387.00 $1,465.0069805 90 $1,187.00 $1,341.00 $1,410.00 $1,488.00 $1,341.00 $1,410.00 $1,488.0069806 90 $1,123.00 $1,203.00 $1,267.00 $1,338.00 $1,203.00 $1,267.00 $1,338.0069820 90 $876.00 $1,096.00 $1,158.00 $1,225.00 $1,096.00 $1,158.00 $1,225.0069840 90 $869.00 $1,161.00 $1,225.00 $1,292.00 $1,161.00 $1,225.00 $1,292.0069905 90 $1,013.00 $1,155.00 $1,218.00 $1,286.00 $1,155.00 $1,218.00 $1,286.0069910 90 $1,228.00 $1,303.00 $1,371.00 $1,446.00 $1,303.00 $1,371.00 $1,446.0069915 90 $1,754.00 $1,981.00 $2,080.00 $2,193.00 $1,981.00 $2,080.00 $2,193.0069930 90 $1,498.00 $1,631.00 $1,715.00 $1,810.00 $1,631.00 $1,715.00 $1,810.0069949 YYY BR ------- ------- ------- ------- ------- -------69950 90 $2,017.00 $2,364.00 $2,486.00 $2,629.00 $2,364.00 $2,486.00 $2,629.0069955 90 $2,185.00 $2,589.00 $2,725.00 $2,883.00 $2,589.00 $2,725.00 $2,883.0069960 90 $2,116.00 $2,494.00 $2,617.00 $2,758.00 $2,494.00 $2,617.00 $2,758.0069970 90 $2,306.00 $2,774.00 $2,912.00 $3,070.00 $2,774.00 $2,912.00 $3,070.0069979 YYY BR ------- ------- ------- ------- ------- -------69990 ZZZ $262.00 $310.00 $338.00 $377.00 $310.00 $338.00 $377.00G0127 0 ------- $25.00 $26.00 $28.00 $12.00 $12.00 $13.00G0168 0 ------- $112.00 $119.00 $125.00 $34.00 $36.00 $38.00G0247 ZZZ ------- $55.00 $58.00 $60.00 $34.00 $35.00 $37.00G0289 ZZZ ------- $124.00 $134.00 $146.00 $124.00 $134.00 $146.00G0341 0 ------- $490.00 $511.00 $537.00 $490.00 $511.00 $537.00G0342 90 ------- $935.00 $990.00 $1,063.00 $935.00 $990.00 $1,063.00G0343 90 ------- $1,529.00 $1,613.00 $1,719.00 $1,529.00 $1,613.00 $1,719.00G0364 ZZZ ------- $18.00 $20.00 $22.00 $14.00 $15.00 $17.00G0392 0 ------- $3,113.00 $3,316.00 $3,494.00 $668.00 $696.00 $731.00G0393 0 ------- $2,357.00 $2,512.00 $2,645.00 $425.00 $441.00 $461.00

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RULE 69L-7.020, F.A.C. 244

PART C

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

70010 $70.00 $209.00 $225.00 $242.00 $209.00 $225.00 $242.0070010-26 NC $63.00 $65.00 $67.00 $63.00 $65.00 $67.0070010-TC NC $146.00 $160.00 $174.00 $146.00 $160.00 $174.0070015 $58.00 $145.00 $155.00 $165.00 $145.00 $155.00 $165.0070015-26 NC $65.00 $68.00 $71.00 $65.00 $68.00 $71.0070015-TC NC $80.00 $87.00 $94.00 $80.00 $87.00 $94.0070030 $24.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0070030-26 $10.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0070030-TC $15.00 $20.00 $22.00 $24.00 $20.00 $22.00 $24.0070100 $29.00 $33.00 $35.00 $37.00 $33.00 $35.00 $37.0070100-26 $9.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.0070100-TC $19.00 $23.00 $25.00 $27.00 $23.00 $25.00 $27.0070110 $36.00 $42.00 $45.00 $48.00 $42.00 $45.00 $48.0070110-26 $12.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0070110-TC $22.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0070120 $32.00 $37.00 $40.00 $43.00 $37.00 $40.00 $43.0070120-26 $9.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.0070120-TC $22.00 $27.00 $30.00 $32.00 $27.00 $30.00 $32.0070130 $46.00 $57.00 $61.00 $66.00 $57.00 $61.00 $66.0070130-26 $17.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0070130-TC $29.00 $39.00 $42.00 $46.00 $39.00 $42.00 $46.0070134 $45.00 $51.00 $55.00 $59.00 $51.00 $55.00 $59.0070134-26 $17.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0070134-TC $28.00 $33.00 $36.00 $39.00 $33.00 $36.00 $39.0070140 $33.00 $35.00 $37.00 $40.00 $35.00 $37.00 $40.0070140-26 $9.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0070140-TC $22.00 $24.00 $27.00 $29.00 $24.00 $27.00 $29.0070150 $42.00 $47.00 $50.00 $54.00 $47.00 $50.00 $54.0070150-26 $12.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.0070150-TC $29.00 $33.00 $37.00 $40.00 $33.00 $37.00 $40.0070160 $29.00 $33.00 $36.00 $38.00 $33.00 $36.00 $38.0070160-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0070160-TC $19.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0070170 $52.00 $371.00 $406.00 $445.00 $371.00 $406.00 $445.0070170-26 NC $15.00 $16.00 $16.00 $15.00 $16.00 $16.0070170-TC NC $366.00 $401.00 $439.00 $366.00 $401.00 $439.0070190 $34.00 $39.00 $42.00 $45.00 $39.00 $42.00 $45.0070190-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0070190-TC $22.00 $28.00 $30.00 $33.00 $28.00 $30.00 $33.0070200 $43.00 $48.00 $52.00 $56.00 $48.00 $52.00 $56.0070200-26 $14.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.0070200-TC $29.00 $34.00 $37.00 $40.00 $34.00 $37.00 $40.0070210 $32.00 $34.00 $36.00 $39.00 $34.00 $36.00 $39.0070210-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0070210-TC $22.00 $25.00 $27.00 $30.00 $25.00 $27.00 $30.0070220 $42.00 $44.00 $48.00 $52.00 $44.00 $48.00 $52.0070220-26 $12.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0070220-TC $29.00 $31.00 $34.00 $38.00 $31.00 $34.00 $38.0070240 $26.00 $30.00 $32.00 $34.00 $30.00 $32.00 $34.0070240-26 $9.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

70240-TC $15.00 $20.00 $22.00 $24.00 $20.00 $22.00 $24.0070250 $35.00 $39.00 $42.00 $45.00 $39.00 $42.00 $45.0070250-26 $12.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0070250-TC $22.00 $27.00 $29.00 $32.00 $27.00 $29.00 $32.0070260 $50.00 $54.00 $59.00 $63.00 $54.00 $59.00 $63.0070260-26 $17.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0070260-TC $33.00 $36.00 $40.00 $44.00 $36.00 $40.00 $44.0070300 $15.00 $16.00 $18.00 $19.00 $16.00 $18.00 $19.0070300-26 $5.00 $6.00 $6.00 $7.00 $6.00 $6.00 $7.0070300-TC $10.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.0070310 $24.00 $33.00 $36.00 $38.00 $33.00 $36.00 $38.0070310-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0070310-TC $15.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0070320 $40.00 $50.00 $54.00 $58.00 $50.00 $54.00 $58.0070320-26 $11.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.0070320-TC $29.00 $38.00 $42.00 $45.00 $38.00 $42.00 $45.0070328 $28.00 $32.00 $34.00 $36.00 $32.00 $34.00 $36.0070328-26 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.0070328-TC $18.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.0070330 $43.00 $50.00 $54.00 $58.00 $50.00 $54.00 $58.0070330-26 $12.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0070330-TC $31.00 $38.00 $41.00 $45.00 $38.00 $41.00 $45.0070332 $107.00 $103.00 $111.00 $119.00 $103.00 $111.00 $119.0070332-26 NC $28.00 $29.00 $30.00 $28.00 $29.00 $30.0070332-TC NC $74.00 $81.00 $89.00 $74.00 $81.00 $89.0070336 $497.00 $408.00 $441.00 $475.00 $408.00 $441.00 $475.0070336-26 $72.00 $78.00 $81.00 $85.00 $78.00 $81.00 $85.0070336-TC $419.00 $330.00 $360.00 $390.00 $330.00 $360.00 $390.0070350 $24.00 $23.00 $25.00 $27.00 $23.00 $25.00 $27.0070350-26 $10.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0070350-TC $14.00 $14.00 $16.00 $17.00 $14.00 $16.00 $17.0070355 $32.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0070355-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0070355-TC $21.00 $18.00 $20.00 $22.00 $18.00 $20.00 $22.0070360 $24.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0070360-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0070360-TC $15.00 $19.00 $21.00 $23.00 $19.00 $21.00 $23.0070370 $65.00 $77.00 $83.00 $89.00 $77.00 $83.00 $89.0070370-26 $16.00 $16.00 $17.00 $17.00 $16.00 $17.00 $17.0070370-TC $48.00 $61.00 $66.00 $71.00 $61.00 $66.00 $71.0070371 $122.00 $117.00 $125.00 $135.00 $117.00 $125.00 $135.0070371-26 $43.00 $44.00 $46.00 $48.00 $44.00 $46.00 $48.0070371-TC $79.00 $73.00 $80.00 $87.00 $73.00 $80.00 $87.0070373 $90.00 $94.00 $101.00 $109.00 $94.00 $101.00 $109.0070373-26 NC $23.00 $23.00 $24.00 $23.00 $23.00 $24.0070373-TC NC $71.00 $78.00 $85.00 $71.00 $78.00 $85.0070380 $34.00 $40.00 $43.00 $47.00 $40.00 $43.00 $47.0070380-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0070380-TC $24.00 $31.00 $34.00 $36.00 $31.00 $34.00 $36.0070390 $87.00 $106.00 $114.00 $123.00 $106.00 $114.00 $123.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

70390-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.0070390-TC NC $85.00 $93.00 $101.00 $85.00 $93.00 $101.0070450 $221.00 $244.00 $264.00 $284.00 $244.00 $264.00 $284.0070450-26 $43.00 $45.00 $47.00 $49.00 $45.00 $47.00 $49.0070450-TC $176.00 $199.00 $217.00 $236.00 $199.00 $217.00 $236.0070460 $271.00 $310.00 $335.00 $360.00 $310.00 $335.00 $360.0070460-26 $58.00 $60.00 $62.00 $65.00 $60.00 $62.00 $65.0070460-TC $211.00 $250.00 $272.00 $295.00 $250.00 $272.00 $295.0070470 $332.00 $376.00 $407.00 $438.00 $376.00 $407.00 $438.0070470-26 $65.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.0070470-TC $264.00 $309.00 $337.00 $365.00 $309.00 $337.00 $365.0070480 $244.00 $270.00 $290.00 $310.00 $270.00 $290.00 $310.0070480-26 $65.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.0070480-TC $176.00 $202.00 $220.00 $237.00 $202.00 $220.00 $237.0070481 $284.00 $366.00 $394.00 $421.00 $366.00 $394.00 $421.0070481-26 $70.00 $73.00 $76.00 $79.00 $73.00 $76.00 $79.0070481-TC $211.00 $293.00 $318.00 $343.00 $293.00 $318.00 $343.0070482 $340.00 $420.00 $453.00 $485.00 $420.00 $453.00 $485.0070482-26 $74.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.0070482-TC $264.00 $344.00 $373.00 $403.00 $344.00 $373.00 $403.0070486 $236.00 $263.00 $283.00 $303.00 $263.00 $283.00 $303.0070486-26 $58.00 $60.00 $62.00 $64.00 $60.00 $62.00 $64.0070486-TC $176.00 $203.00 $221.00 $239.00 $203.00 $221.00 $239.0070487 $279.00 $354.00 $382.00 $409.00 $354.00 $382.00 $409.0070487-26 $66.00 $69.00 $72.00 $75.00 $69.00 $72.00 $75.0070487-TC $211.00 $285.00 $310.00 $335.00 $285.00 $310.00 $335.0070488 $339.00 $419.00 $452.00 $485.00 $419.00 $452.00 $485.0070488-26 $72.00 $75.00 $77.00 $80.00 $75.00 $77.00 $80.0070488-TC $264.00 $344.00 $374.00 $404.00 $344.00 $374.00 $404.0070490 $244.00 $271.00 $291.00 $312.00 $271.00 $291.00 $312.0070490-26 $65.00 $68.00 $71.00 $74.00 $68.00 $71.00 $74.0070490-TC $176.00 $203.00 $220.00 $238.00 $203.00 $220.00 $238.0070491 $284.00 $352.00 $379.00 $406.00 $352.00 $379.00 $406.0070491-26 $70.00 $73.00 $76.00 $79.00 $73.00 $76.00 $79.0070491-TC $211.00 $278.00 $303.00 $327.00 $278.00 $303.00 $327.0070492 $340.00 $421.00 $453.00 $486.00 $421.00 $453.00 $486.0070492-26 $74.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.0070492-TC $264.00 $344.00 $374.00 $404.00 $344.00 $374.00 $404.0070496 $366.00 $440.00 $473.00 $507.00 $440.00 $473.00 $507.0070496-26 $92.00 $93.00 $96.00 $100.00 $93.00 $96.00 $100.0070496-TC $270.00 $347.00 $377.00 $407.00 $347.00 $377.00 $407.0070498 $366.00 $440.00 $474.00 $508.00 $440.00 $474.00 $508.0070498-26 $92.00 $93.00 $97.00 $101.00 $93.00 $97.00 $101.0070498-TC $270.00 $347.00 $377.00 $407.00 $347.00 $377.00 $407.0070540 $482.00 $432.00 $464.00 $495.00 $432.00 $464.00 $495.0070540-26 $70.00 $71.00 $74.00 $77.00 $71.00 $74.00 $77.0070540-TC $413.00 $360.00 $390.00 $419.00 $360.00 $390.00 $419.0070542 $579.00 $503.00 $541.00 $578.00 $503.00 $541.00 $578.0070542-26 $82.00 $86.00 $89.00 $92.00 $86.00 $89.00 $92.0070542-TC $495.00 $417.00 $452.00 $486.00 $417.00 $452.00 $486.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 247

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

70543 $1,029.00 $667.00 $719.00 $770.00 $667.00 $719.00 $770.0070543-26 $109.00 $114.00 $118.00 $122.00 $114.00 $118.00 $122.0070543-TC $916.00 $553.00 $601.00 $648.00 $553.00 $601.00 $648.0070544 $481.00 $427.00 $460.00 $495.00 $427.00 $460.00 $495.0070544-26 $61.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.0070544-TC $419.00 $363.00 $395.00 $426.00 $363.00 $395.00 $426.0070545 $481.00 $483.00 $522.00 $561.00 $483.00 $522.00 $561.0070545-26 $61.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.0070545-TC $419.00 $419.00 $456.00 $493.00 $419.00 $456.00 $493.0070546 $914.00 $645.00 $693.00 $739.00 $645.00 $693.00 $739.0070546-26 $92.00 $96.00 $99.00 $103.00 $96.00 $99.00 $103.0070546-TC $820.00 $549.00 $594.00 $636.00 $549.00 $594.00 $636.0070547 $481.00 $426.00 $460.00 $494.00 $426.00 $460.00 $494.0070547-26 $61.00 $63.00 $65.00 $68.00 $63.00 $65.00 $68.0070547-TC $419.00 $363.00 $395.00 $426.00 $363.00 $395.00 $426.0070548 $481.00 $483.00 $522.00 $561.00 $483.00 $522.00 $561.0070548-26 $61.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.0070548-TC $419.00 $419.00 $456.00 $492.00 $419.00 $456.00 $492.0070549 $914.00 $645.00 $693.00 $739.00 $645.00 $693.00 $739.0070549-26 $92.00 $96.00 $99.00 $103.00 $96.00 $99.00 $103.0070549-TC $820.00 $549.00 $594.00 $636.00 $549.00 $594.00 $636.0070551 $497.00 $441.00 $476.00 $512.00 $441.00 $476.00 $512.0070551-26 $76.00 $78.00 $81.00 $85.00 $78.00 $81.00 $85.0070551-TC $419.00 $363.00 $395.00 $427.00 $363.00 $395.00 $427.0070552 $596.00 $515.00 $556.00 $598.00 $515.00 $556.00 $598.0070552-26 $91.00 $95.00 $98.00 $102.00 $95.00 $98.00 $102.0070552-TC $502.00 $421.00 $458.00 $497.00 $421.00 $458.00 $497.0070553 $1,055.00 $685.00 $742.00 $802.00 $685.00 $742.00 $802.0070553-26 $120.00 $125.00 $129.00 $134.00 $125.00 $129.00 $134.0070553-TC $931.00 $560.00 $613.00 $668.00 $560.00 $613.00 $668.0070554 ------- $741.00 $802.00 $866.00 $741.00 $802.00 $866.0070554-26 ------- $111.00 $115.00 $120.00 $111.00 $115.00 $120.0070554-TC ------- $629.00 $687.00 $746.00 $629.00 $687.00 $746.0070555 ------- BR BR BR BR BR BR70555-26 ------- $136.00 $141.00 $146.00 $136.00 $141.00 $146.0070555-TC ------- BR BR BR BR BR BR70557 ------- $418.00 $460.00 $507.00 $418.00 $460.00 $507.0070557-26 ------- $154.00 $159.00 $164.00 $154.00 $159.00 $164.0070557-TC ------- $371.00 $408.00 $450.00 $371.00 $408.00 $450.0070558 ------- $480.00 $529.00 $583.00 $480.00 $529.00 $583.0070558-26 ------- $170.00 $176.00 $181.00 $170.00 $176.00 $181.0070558-TC ------- $428.00 $472.00 $519.00 $428.00 $472.00 $519.0070559 ------- $621.00 $684.00 $754.00 $621.00 $684.00 $754.0070559-26 ------- $172.00 $178.00 $185.00 $172.00 $178.00 $185.0070559-TC ------- $567.00 $624.00 $688.00 $567.00 $624.00 $688.0071010 $27.00 $27.00 $29.00 $31.00 $27.00 $29.00 $31.0071010-26 $9.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.0071010-TC $17.00 $18.00 $19.00 $21.00 $18.00 $19.00 $21.0071015 $30.00 $32.00 $34.00 $37.00 $32.00 $34.00 $37.0071015-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

71015-TC $19.00 $21.00 $23.00 $25.00 $21.00 $23.00 $25.0071020 $35.00 $36.00 $39.00 $42.00 $36.00 $39.00 $42.0071020-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0071020-TC $22.00 $24.00 $27.00 $29.00 $24.00 $27.00 $29.0071021 $41.00 $44.00 $47.00 $51.00 $44.00 $47.00 $51.0071021-26 $13.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0071021-TC $28.00 $30.00 $33.00 $36.00 $30.00 $33.00 $36.0071022 $44.00 $49.00 $52.00 $56.00 $49.00 $52.00 $56.0071022-26 $16.00 $16.00 $16.00 $17.00 $16.00 $16.00 $17.0071022-TC $28.00 $33.00 $36.00 $39.00 $33.00 $36.00 $39.0071023 $49.00 $66.00 $70.00 $75.00 $66.00 $70.00 $75.0071023-26 $19.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0071023-TC $29.00 $46.00 $50.00 $54.00 $46.00 $50.00 $54.0071030 $45.00 $50.00 $54.00 $58.00 $50.00 $54.00 $58.0071030-26 $16.00 $16.00 $16.00 $17.00 $16.00 $16.00 $17.0071030-TC $29.00 $35.00 $38.00 $41.00 $35.00 $38.00 $41.0071034 $79.00 $96.00 $103.00 $111.00 $96.00 $103.00 $111.0071034-26 $23.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0071034-TC $54.00 $71.00 $77.00 $83.00 $71.00 $77.00 $83.0071035 $56.00 $35.00 $38.00 $40.00 $35.00 $38.00 $40.0071035-26 $19.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.0071035-TC $38.00 $26.00 $28.00 $30.00 $26.00 $28.00 $30.0071040 $34.00 $101.00 $108.00 $116.00 $101.00 $108.00 $116.0071040-26 NC $30.00 $31.00 $33.00 $30.00 $31.00 $33.0071040-TC NC $71.00 $77.00 $83.00 $71.00 $77.00 $83.0071060 $108.00 $146.00 $157.00 $169.00 $146.00 $157.00 $169.0071060-26 NC $39.00 $40.00 $42.00 $39.00 $40.00 $42.0071060-TC NC $107.00 $117.00 $127.00 $107.00 $117.00 $127.0071090 $92.00 ------- ------- ------- ------- ------- -------71090-26 NC $31.00 $32.00 $33.00 $31.00 $32.00 $33.0071090-TC NC BR BR BR BR BR BR71100 $33.00 $36.00 $39.00 $42.00 $36.00 $39.00 $42.0071100-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0071100-TC $21.00 $24.00 $27.00 $29.00 $24.00 $27.00 $29.0071101 $38.00 $43.00 $46.00 $49.00 $43.00 $46.00 $49.0071101-26 $13.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0071101-TC $24.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0071110 $43.00 $46.00 $49.00 $53.00 $46.00 $49.00 $53.0071110-26 $13.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0071110-TC $29.00 $32.00 $35.00 $38.00 $32.00 $35.00 $38.0071111 $49.00 $57.00 $61.00 $65.00 $57.00 $61.00 $65.0071111-26 $16.00 $16.00 $17.00 $17.00 $16.00 $17.00 $17.0071111-TC $33.00 $40.00 $44.00 $48.00 $40.00 $44.00 $48.0071120 $35.00 $37.00 $40.00 $43.00 $37.00 $40.00 $43.0071120-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0071120-TC $24.00 $26.00 $29.00 $32.00 $26.00 $29.00 $32.0071130 $38.00 $41.00 $44.00 $47.00 $41.00 $44.00 $47.0071130-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0071130-TC $26.00 $30.00 $32.00 $35.00 $30.00 $32.00 $35.0071250 $282.00 $265.00 $285.00 $307.00 $265.00 $285.00 $307.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 249

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

71250-26 $59.00 $61.00 $63.00 $66.00 $61.00 $63.00 $66.0071250-TC $220.00 $204.00 $222.00 $241.00 $204.00 $222.00 $241.0071260 $328.00 $359.00 $388.00 $417.00 $359.00 $388.00 $417.0071260-26 $63.00 $65.00 $67.00 $70.00 $65.00 $67.00 $70.0071260-TC $264.00 $294.00 $320.00 $347.00 $294.00 $320.00 $347.0071270 $402.00 $418.00 $452.00 $486.00 $418.00 $452.00 $486.0071270-26 $70.00 $73.00 $76.00 $79.00 $73.00 $76.00 $79.0071270-TC $330.00 $345.00 $376.00 $408.00 $345.00 $376.00 $408.0071275 $431.00 $448.00 $481.00 $513.00 $448.00 $481.00 $513.0071275-26 $100.00 $102.00 $106.00 $110.00 $102.00 $106.00 $110.0071275-TC $328.00 $346.00 $375.00 $403.00 $346.00 $375.00 $403.0071550 $490.00 $438.00 $471.00 $503.00 $438.00 $471.00 $503.0071550-26 $75.00 $77.00 $80.00 $83.00 $77.00 $80.00 $83.0071550-TC $415.00 $361.00 $391.00 $420.00 $361.00 $391.00 $420.0071551 $587.00 $509.00 $547.00 $585.00 $509.00 $547.00 $585.0071551-26 $88.00 $91.00 $95.00 $98.00 $91.00 $95.00 $98.0071551-TC $496.00 $417.00 $452.00 $486.00 $417.00 $452.00 $486.0071552 $1,029.00 $670.00 $720.00 $768.00 $670.00 $720.00 $768.0071552-26 $114.00 $120.00 $124.00 $129.00 $120.00 $124.00 $129.0071552-TC $911.00 $550.00 $596.00 $639.00 $550.00 $596.00 $639.0071555 $514.00 $516.00 $557.00 $598.00 $516.00 $557.00 $598.0071555-26 $92.00 $96.00 $100.00 $104.00 $96.00 $100.00 $104.0071555-TC $419.00 $420.00 $457.00 $494.00 $420.00 $457.00 $494.0072010 $62.00 $71.00 $76.00 $81.00 $71.00 $76.00 $81.0072010-26 $22.00 $24.00 $24.00 $25.00 $24.00 $24.00 $25.0072010-TC $38.00 $47.00 $52.00 $56.00 $47.00 $52.00 $56.0072020 $22.00 $26.00 $28.00 $30.00 $26.00 $28.00 $30.0072020-26 $7.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0072020-TC $15.00 $18.00 $19.00 $21.00 $18.00 $19.00 $21.0072040 $34.00 $39.00 $42.00 $46.00 $39.00 $42.00 $46.0072040-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0072040-TC $22.00 $28.00 $31.00 $33.00 $28.00 $31.00 $33.0072050 $49.00 $56.00 $60.00 $65.00 $56.00 $60.00 $65.0072050-26 $16.00 $16.00 $16.00 $17.00 $16.00 $16.00 $17.0072050-TC $33.00 $40.00 $44.00 $48.00 $40.00 $44.00 $48.0072052 $61.00 $70.00 $76.00 $81.00 $70.00 $76.00 $81.0072052-26 $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0072052-TC $42.00 $51.00 $55.00 $60.00 $51.00 $55.00 $60.0072069 $40.00 $36.00 $38.00 $41.00 $36.00 $38.00 $41.0072069-26 $17.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.0072069-TC $24.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0072070 $36.00 $38.00 $41.00 $44.00 $38.00 $41.00 $44.0072070-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0072070-TC $24.00 $26.00 $29.00 $32.00 $26.00 $29.00 $32.0072072 $39.00 $42.00 $46.00 $49.00 $42.00 $46.00 $49.0072072-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0072072-TC $28.00 $31.00 $34.00 $37.00 $31.00 $34.00 $37.0072074 $45.00 $50.00 $54.00 $58.00 $50.00 $54.00 $58.0072074-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0072074-TC $34.00 $39.00 $42.00 $46.00 $39.00 $42.00 $46.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

72080 $36.00 $39.00 $42.00 $45.00 $39.00 $42.00 $45.0072080-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0072080-TC $24.00 $28.00 $30.00 $33.00 $28.00 $30.00 $33.0072090 $39.00 $49.00 $52.00 $56.00 $49.00 $52.00 $56.0072090-26 $14.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.0072090-TC $24.00 $34.00 $37.00 $40.00 $34.00 $37.00 $40.0072100 $36.00 $41.00 $44.00 $48.00 $41.00 $44.00 $48.0072100-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0072100-TC $24.00 $30.00 $33.00 $36.00 $30.00 $33.00 $36.0072110 $50.00 $58.00 $62.00 $67.00 $58.00 $62.00 $67.0072110-26 $16.00 $16.00 $16.00 $17.00 $16.00 $16.00 $17.0072110-TC $34.00 $42.00 $46.00 $50.00 $42.00 $46.00 $50.0072114 $64.00 $75.00 $80.00 $86.00 $75.00 $80.00 $86.0072114-26 $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0072114-TC $44.00 $55.00 $60.00 $65.00 $55.00 $60.00 $65.0072120 $45.00 $52.00 $56.00 $61.00 $52.00 $56.00 $61.0072120-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0072120-TC $33.00 $41.00 $44.00 $48.00 $41.00 $44.00 $48.0072125 $282.00 $265.00 $285.00 $307.00 $265.00 $285.00 $307.0072125-26 $59.00 $61.00 $63.00 $66.00 $61.00 $63.00 $66.0072125-TC $220.00 $204.00 $222.00 $241.00 $204.00 $222.00 $241.0072126 $328.00 $358.00 $387.00 $416.00 $358.00 $387.00 $416.0072126-26 $62.00 $64.00 $66.00 $69.00 $64.00 $66.00 $69.0072126-TC $264.00 $294.00 $320.00 $347.00 $294.00 $320.00 $347.0072127 $397.00 $413.00 $446.00 $480.00 $413.00 $446.00 $480.0072127-26 $65.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.0072127-TC $330.00 $345.00 $376.00 $408.00 $345.00 $376.00 $408.0072128 $282.00 $265.00 $285.00 $307.00 $265.00 $285.00 $307.0072128-26 $59.00 $61.00 $63.00 $66.00 $61.00 $63.00 $66.0072128-TC $220.00 $204.00 $222.00 $241.00 $204.00 $222.00 $241.0072129 $328.00 $358.00 $387.00 $416.00 $358.00 $387.00 $416.0072129-26 $62.00 $64.00 $67.00 $69.00 $64.00 $67.00 $69.0072129-TC $264.00 $294.00 $320.00 $347.00 $294.00 $320.00 $347.0072130 $397.00 $413.00 $446.00 $480.00 $413.00 $446.00 $480.0072130-26 $65.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.0072130-TC $330.00 $345.00 $376.00 $408.00 $345.00 $376.00 $408.0072131 $282.00 $265.00 $285.00 $307.00 $265.00 $285.00 $307.0072131-26 $59.00 $61.00 $63.00 $66.00 $61.00 $63.00 $66.0072131-TC $220.00 $204.00 $222.00 $241.00 $204.00 $222.00 $241.0072132 $328.00 $358.00 $387.00 $416.00 $358.00 $387.00 $416.0072132-26 $62.00 $64.00 $66.00 $69.00 $64.00 $66.00 $69.0072132-TC $264.00 $294.00 $320.00 $347.00 $294.00 $320.00 $347.0072133 $391.00 $413.00 $446.00 $480.00 $413.00 $446.00 $480.0072133-26 $65.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.0072133-TC $323.00 $345.00 $376.00 $408.00 $345.00 $376.00 $408.0072141 $503.00 $449.00 $485.00 $521.00 $449.00 $485.00 $521.0072141-26 $82.00 $85.00 $88.00 $91.00 $85.00 $88.00 $91.0072141-TC $419.00 $364.00 $397.00 $430.00 $364.00 $397.00 $430.0072142 $604.00 $523.00 $564.00 $606.00 $523.00 $564.00 $606.0072142-26 $99.00 $102.00 $106.00 $110.00 $102.00 $106.00 $110.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 251

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

72142-TC $502.00 $421.00 $458.00 $497.00 $421.00 $458.00 $497.0072146 $549.00 $449.00 $485.00 $522.00 $449.00 $485.00 $522.0072146-26 $82.00 $85.00 $88.00 $91.00 $85.00 $88.00 $91.0072146-TC $465.00 $364.00 $398.00 $431.00 $364.00 $398.00 $431.0072147 $603.00 $524.00 $566.00 $609.00 $524.00 $566.00 $609.0072147-26 $98.00 $102.00 $106.00 $110.00 $102.00 $106.00 $110.0072147-TC $502.00 $422.00 $460.00 $499.00 $422.00 $460.00 $499.0072148 $543.00 $443.00 $479.00 $516.00 $443.00 $479.00 $516.0072148-26 $76.00 $78.00 $81.00 $85.00 $78.00 $81.00 $85.0072148-TC $465.00 $364.00 $398.00 $431.00 $364.00 $398.00 $431.0072149 $597.00 $515.00 $556.00 $598.00 $515.00 $556.00 $598.0072149-26 $92.00 $95.00 $98.00 $102.00 $95.00 $98.00 $102.0072149-TC $502.00 $421.00 $458.00 $497.00 $421.00 $458.00 $497.0072156 $1,066.00 $696.00 $753.00 $813.00 $696.00 $753.00 $813.0072156-26 $131.00 $136.00 $140.00 $146.00 $136.00 $140.00 $146.0072156-TC $931.00 $560.00 $613.00 $668.00 $560.00 $613.00 $668.0072157 $1,066.00 $696.00 $754.00 $815.00 $696.00 $754.00 $815.0072157-26 $131.00 $136.00 $140.00 $146.00 $136.00 $140.00 $146.0072157-TC $931.00 $561.00 $614.00 $670.00 $561.00 $614.00 $670.0072158 $1,056.00 $685.00 $742.00 $802.00 $685.00 $742.00 $802.0072158-26 $121.00 $125.00 $129.00 $134.00 $125.00 $129.00 $134.0072158-TC $931.00 $560.00 $613.00 $668.00 $560.00 $613.00 $668.0072159 $563.00 $655.00 $708.00 $763.00 $655.00 $708.00 $763.0072159-26 $94.00 $94.00 $98.00 $102.00 $94.00 $98.00 $102.0072159-TC $465.00 $560.00 $610.00 $660.00 $560.00 $610.00 $660.0072170 $29.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0072170-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0072170-TC $19.00 $20.00 $22.00 $24.00 $20.00 $22.00 $24.0072190 $35.00 $42.00 $45.00 $48.00 $42.00 $45.00 $48.0072190-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0072190-TC $24.00 $31.00 $34.00 $36.00 $31.00 $34.00 $36.0072191 $413.00 $442.00 $475.00 $507.00 $442.00 $475.00 $507.0072191-26 $94.00 $96.00 $100.00 $104.00 $96.00 $100.00 $104.0072191-TC $315.00 $346.00 $375.00 $403.00 $346.00 $375.00 $403.0072192 $278.00 $262.00 $282.00 $304.00 $262.00 $282.00 $304.0072192-26 $56.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.0072192-TC $220.00 $204.00 $222.00 $242.00 $204.00 $222.00 $242.0072193 $317.00 $356.00 $385.00 $414.00 $356.00 $385.00 $414.0072193-26 $59.00 $62.00 $64.00 $66.00 $62.00 $64.00 $66.0072193-TC $256.00 $295.00 $321.00 $348.00 $295.00 $321.00 $348.0072194 $380.00 $409.00 $442.00 $475.00 $409.00 $442.00 $475.0072194-26 $62.00 $64.00 $66.00 $69.00 $64.00 $66.00 $69.0072194-TC $317.00 $345.00 $375.00 $406.00 $345.00 $375.00 $406.0072195 $491.00 $438.00 $471.00 $504.00 $438.00 $471.00 $504.0072195-26 $74.00 $77.00 $80.00 $83.00 $77.00 $80.00 $83.0072195-TC $415.00 $361.00 $392.00 $422.00 $361.00 $392.00 $422.0072196 $526.00 $510.00 $549.00 $587.00 $510.00 $549.00 $587.0072196-26 $84.00 $92.00 $95.00 $99.00 $92.00 $95.00 $99.0072196-TC $442.00 $418.00 $454.00 $488.00 $418.00 $454.00 $488.0072197 $1,037.00 $674.00 $726.00 $779.00 $674.00 $726.00 $779.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 252

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

72197-26 $114.00 $119.00 $124.00 $128.00 $119.00 $124.00 $128.0072197-TC $919.00 $554.00 $603.00 $650.00 $554.00 $603.00 $650.0072198 $517.00 $516.00 $556.00 $597.00 $516.00 $556.00 $597.0072198-26 $95.00 $96.00 $99.00 $103.00 $96.00 $99.00 $103.0072198-TC $419.00 $420.00 $457.00 $494.00 $420.00 $457.00 $494.0072200 $29.00 $31.00 $34.00 $36.00 $31.00 $34.00 $36.0072200-26 $9.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0072200-TC $19.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.0072202 $33.00 $38.00 $41.00 $44.00 $38.00 $41.00 $44.0072202-26 $9.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0072202-TC $22.00 $28.00 $31.00 $33.00 $28.00 $31.00 $33.0072220 $30.00 $33.00 $36.00 $39.00 $33.00 $36.00 $39.0072220-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0072220-TC $21.00 $24.00 $26.00 $29.00 $24.00 $26.00 $29.0072240 $132.00 $201.00 $217.00 $235.00 $201.00 $217.00 $235.0072240-26 NC $48.00 $49.00 $51.00 $48.00 $49.00 $51.0072240-TC NC $153.00 $168.00 $184.00 $153.00 $168.00 $184.0072255 $129.00 $184.00 $199.00 $215.00 $184.00 $199.00 $215.0072255-26 NC $47.00 $49.00 $50.00 $47.00 $49.00 $50.0072255-TC NC $137.00 $151.00 $165.00 $137.00 $151.00 $165.0072265 $132.00 $181.00 $196.00 $212.00 $181.00 $196.00 $212.0072265-26 NC $44.00 $45.00 $47.00 $44.00 $45.00 $47.0072265-TC NC $138.00 $151.00 $165.00 $138.00 $151.00 $165.0072270 $176.00 $280.00 $303.00 $327.00 $280.00 $303.00 $327.0072270-26 NC $70.00 $73.00 $76.00 $70.00 $73.00 $76.0072270-TC NC $210.00 $230.00 $251.00 $210.00 $230.00 $251.0072275 $112.00 $124.00 $134.00 $147.00 $124.00 $134.00 $147.0072275-26 NC $38.00 $40.00 $41.00 $38.00 $40.00 $41.0072275-TC NC $85.00 $95.00 $106.00 $85.00 $95.00 $106.0072285 $101.00 $274.00 $298.00 $325.00 $274.00 $298.00 $325.0072285-26 NC $60.00 $62.00 $65.00 $60.00 $62.00 $65.0072285-TC NC $214.00 $236.00 $260.00 $214.00 $236.00 $260.0072291 ------- BR BR BR BR BR BR72291-26 ------- $73.00 $76.00 $80.00 $73.00 $76.00 $80.0072291-TC ------- BR BR BR BR BR BR72292 ------- BR BR BR BR BR BR72292-26 ------- $75.00 $77.00 $81.00 $75.00 $77.00 $81.0072292-TC ------- BR BR BR BR BR BR72295 $107.00 $248.00 $270.00 $296.00 $248.00 $270.00 $296.0072295-26 NC $45.00 $46.00 $49.00 $45.00 $46.00 $49.0072295-TC NC $203.00 $224.00 $247.00 $203.00 $224.00 $247.0073000 $28.00 $30.00 $32.00 $34.00 $30.00 $32.00 $34.0073000-26 $8.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0073000-TC $19.00 $21.00 $23.00 $25.00 $21.00 $23.00 $25.0073010 $29.00 $31.00 $33.00 $35.00 $31.00 $33.00 $35.0073010-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073010-TC $19.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.0073020 $26.00 $26.00 $28.00 $30.00 $26.00 $28.00 $30.0073020-26 $7.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0073020-TC $17.00 $18.00 $20.00 $21.00 $18.00 $20.00 $21.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

73030 $31.00 $33.00 $36.00 $39.00 $33.00 $36.00 $39.0073030-26 $9.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.0073030-TC $21.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0073040 $68.00 $118.00 $127.00 $137.00 $118.00 $127.00 $137.0073040-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0073040-TC NC $89.00 $97.00 $106.00 $89.00 $97.00 $106.0073050 $35.00 $39.00 $42.00 $46.00 $39.00 $42.00 $46.0073050-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0073050-TC $24.00 $28.00 $31.00 $34.00 $28.00 $31.00 $34.0073060 $30.00 $33.00 $36.00 $39.00 $33.00 $36.00 $39.0073060-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073060-TC $21.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0073070 $27.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0073070-26 $7.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0073070-TC $19.00 $21.00 $23.00 $25.00 $21.00 $23.00 $25.0073080 $30.00 $36.00 $39.00 $43.00 $36.00 $39.00 $43.0073080-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073080-TC $21.00 $27.00 $30.00 $32.00 $27.00 $30.00 $32.0073085 $74.00 $110.00 $119.00 $128.00 $110.00 $119.00 $128.0073085-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0073085-TC NC $81.00 $89.00 $97.00 $81.00 $89.00 $97.0073090 $28.00 $30.00 $32.00 $34.00 $30.00 $32.00 $34.0073090-26 $8.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0073090-TC $19.00 $21.00 $23.00 $25.00 $21.00 $23.00 $25.0073100 $27.00 $30.00 $32.00 $35.00 $30.00 $32.00 $35.0073100-26 $8.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0073100-TC $18.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.0073110 $29.00 $35.00 $37.00 $40.00 $35.00 $37.00 $40.0073110-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073110-TC $19.00 $26.00 $28.00 $30.00 $26.00 $28.00 $30.0073115 $54.00 $108.00 $116.00 $124.00 $108.00 $116.00 $124.0073115-26 NC $28.00 $29.00 $30.00 $28.00 $29.00 $30.0073115-TC NC $79.00 $86.00 $94.00 $79.00 $86.00 $94.0073120 $27.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0073120-26 $8.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0073120-TC $18.00 $21.00 $23.00 $24.00 $21.00 $23.00 $24.0073130 $29.00 $33.00 $35.00 $38.00 $33.00 $35.00 $38.0073130-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073130-TC $19.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0073140 $22.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0073140-26 $7.00 $7.00 $7.00 $8.00 $7.00 $7.00 $8.0073140-TC $15.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.0073200 $242.00 $261.00 $281.00 $301.00 $261.00 $281.00 $301.0073200-26 $56.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.0073200-TC $185.00 $203.00 $221.00 $239.00 $203.00 $221.00 $239.0073201 $282.00 $344.00 $371.00 $399.00 $344.00 $371.00 $399.0073201-26 $59.00 $61.00 $63.00 $66.00 $61.00 $63.00 $66.0073201-TC $220.00 $283.00 $308.00 $333.00 $283.00 $308.00 $333.0073202 $342.00 $408.00 $440.00 $473.00 $408.00 $440.00 $473.0073202-26 $63.00 $64.00 $66.00 $69.00 $64.00 $66.00 $69.00

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

73202-TC $277.00 $344.00 $374.00 $404.00 $344.00 $374.00 $404.0073206 $375.00 $443.00 $476.00 $508.00 $443.00 $476.00 $508.0073206-26 $94.00 $96.00 $100.00 $104.00 $96.00 $100.00 $104.0073206-TC $277.00 $346.00 $376.00 $405.00 $346.00 $376.00 $405.0073218 $482.00 $432.00 $464.00 $495.00 $432.00 $464.00 $495.0073218-26 $68.00 $71.00 $74.00 $77.00 $71.00 $74.00 $77.0073218-TC $413.00 $360.00 $390.00 $419.00 $360.00 $390.00 $419.0073219 $579.00 $503.00 $541.00 $578.00 $503.00 $541.00 $578.0073219-26 $82.00 $86.00 $89.00 $92.00 $86.00 $89.00 $92.0073219-TC $495.00 $417.00 $452.00 $486.00 $417.00 $452.00 $486.0073220 $520.00 $667.00 $719.00 $771.00 $667.00 $719.00 $771.0073220-26 $78.00 $114.00 $118.00 $123.00 $114.00 $118.00 $123.0073220-TC $442.00 $553.00 $601.00 $648.00 $553.00 $601.00 $648.0073221 $482.00 $432.00 $464.00 $496.00 $432.00 $464.00 $496.0073221-26 $68.00 $71.00 $74.00 $77.00 $71.00 $74.00 $77.0073221-TC $413.00 $361.00 $391.00 $419.00 $361.00 $391.00 $419.0073222 $579.00 $503.00 $542.00 $579.00 $503.00 $542.00 $579.0073222-26 $82.00 $86.00 $89.00 $92.00 $86.00 $89.00 $92.0073222-TC $495.00 $418.00 $453.00 $487.00 $418.00 $453.00 $487.0073223 $1,029.00 $667.00 $719.00 $771.00 $667.00 $719.00 $771.0073223-26 $109.00 $114.00 $118.00 $122.00 $114.00 $118.00 $122.0073223-TC $916.00 $554.00 $601.00 $648.00 $554.00 $601.00 $648.0073225 $513.00 $623.00 $674.00 $726.00 $623.00 $674.00 $726.0073225-26 $92.00 $91.00 $94.00 $99.00 $91.00 $94.00 $99.0073225-TC $419.00 $533.00 $580.00 $627.00 $533.00 $580.00 $627.0073500 $27.00 $28.00 $30.00 $32.00 $28.00 $30.00 $32.0073500-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073500-TC $17.00 $19.00 $21.00 $22.00 $19.00 $21.00 $22.0073510 $32.00 $39.00 $42.00 $45.00 $39.00 $42.00 $45.0073510-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0073510-TC $21.00 $28.00 $30.00 $33.00 $28.00 $30.00 $33.0073520 $38.00 $43.00 $46.00 $49.00 $43.00 $46.00 $49.0073520-26 $12.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.0073520-TC $24.00 $29.00 $32.00 $35.00 $29.00 $32.00 $35.0073525 $84.00 $110.00 $119.00 $128.00 $110.00 $119.00 $128.0073525-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0073525-TC NC $81.00 $89.00 $97.00 $81.00 $89.00 $97.0073530 $34.00 ------- ------- ------- ------- ------- -------73530-26 $14.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.0073530-TC $19.00 ------- ------- ------- ------- ------- -------73542 $108.00 $98.00 $106.00 $114.00 $98.00 $106.00 $114.0073542-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.0073542-TC NC $68.00 $75.00 $82.00 $68.00 $75.00 $82.0073550 $30.00 $33.00 $35.00 $38.00 $33.00 $35.00 $38.0073550-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073550-TC $21.00 $23.00 $26.00 $28.00 $23.00 $26.00 $28.0073560 $29.00 $31.00 $33.00 $35.00 $31.00 $33.00 $35.0073560-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073560-TC $19.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.0073562 $31.00 $37.00 $39.00 $43.00 $37.00 $39.00 $43.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

73562-26 $9.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.0073562-TC $21.00 $27.00 $29.00 $32.00 $27.00 $29.00 $32.0073564 $35.00 $41.00 $44.00 $48.00 $41.00 $44.00 $48.0073564-26 $11.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0073564-TC $22.00 $30.00 $33.00 $36.00 $30.00 $33.00 $36.0073565 $28.00 $32.00 $34.00 $36.00 $32.00 $34.00 $36.0073565-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073565-TC $18.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.0073580 $84.00 $136.00 $147.00 $158.00 $136.00 $147.00 $158.0073580-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0073580-TC NC $107.00 $117.00 $127.00 $107.00 $117.00 $127.0073590 $29.00 $30.00 $32.00 $35.00 $30.00 $32.00 $35.0073590-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073590-TC $19.00 $21.00 $23.00 $24.00 $21.00 $23.00 $24.0073600 $27.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0073600-26 $8.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0073600-TC $18.00 $21.00 $23.00 $24.00 $21.00 $23.00 $24.0073610 $29.00 $33.00 $35.00 $38.00 $33.00 $35.00 $38.0073610-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073610-TC $19.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0073615 $72.00 $113.00 $122.00 $132.00 $113.00 $122.00 $132.0073615-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0073615-TC NC $84.00 $92.00 $101.00 $84.00 $92.00 $101.0073620 $27.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0073620-26 $8.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0073620-TC $18.00 $20.00 $22.00 $24.00 $20.00 $22.00 $24.0073630 $29.00 $33.00 $35.00 $38.00 $33.00 $35.00 $38.0073630-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073630-TC $19.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0073650 $26.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0073650-26 $8.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0073650-TC $17.00 $20.00 $22.00 $24.00 $20.00 $22.00 $24.0073660 $22.00 $28.00 $30.00 $32.00 $28.00 $30.00 $32.0073660-26 $7.00 $7.00 $7.00 $8.00 $7.00 $7.00 $8.0073660-TC $15.00 $21.00 $23.00 $25.00 $21.00 $23.00 $25.0073700 $242.00 $261.00 $281.00 $301.00 $261.00 $281.00 $301.0073700-26 $56.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.0073700-TC $185.00 $203.00 $221.00 $239.00 $203.00 $221.00 $239.0073701 $282.00 $345.00 $373.00 $400.00 $345.00 $373.00 $400.0073701-26 $61.00 $62.00 $64.00 $66.00 $62.00 $64.00 $66.0073701-TC $220.00 $284.00 $309.00 $334.00 $284.00 $309.00 $334.0073702 $341.00 $408.00 $441.00 $473.00 $408.00 $441.00 $473.0073702-26 $62.00 $64.00 $67.00 $69.00 $64.00 $67.00 $69.0073702-TC $277.00 $344.00 $374.00 $404.00 $344.00 $374.00 $404.0073706 $379.00 $447.00 $480.00 $512.00 $447.00 $480.00 $512.0073706-26 $98.00 $101.00 $105.00 $109.00 $101.00 $105.00 $109.0073706-TC $277.00 $346.00 $375.00 $403.00 $346.00 $375.00 $403.0073718 $482.00 $432.00 $464.00 $495.00 $432.00 $464.00 $495.0073718-26 $68.00 $71.00 $74.00 $77.00 $71.00 $74.00 $77.0073718-TC $413.00 $360.00 $390.00 $419.00 $360.00 $390.00 $419.00

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

73719 $579.00 $503.00 $541.00 $578.00 $503.00 $541.00 $578.0073719-26 $82.00 $86.00 $89.00 $92.00 $86.00 $89.00 $92.0073719-TC $495.00 $417.00 $452.00 $486.00 $417.00 $452.00 $486.0073720 $520.00 $667.00 $719.00 $770.00 $667.00 $719.00 $770.0073720-26 $78.00 $114.00 $118.00 $122.00 $114.00 $118.00 $122.0073720-TC $442.00 $553.00 $601.00 $648.00 $553.00 $601.00 $648.0073721 $482.00 $432.00 $464.00 $496.00 $432.00 $464.00 $496.0073721-26 $68.00 $71.00 $74.00 $77.00 $71.00 $74.00 $77.0073721-TC $413.00 $361.00 $391.00 $419.00 $361.00 $391.00 $419.0073722 $579.00 $503.00 $542.00 $579.00 $503.00 $542.00 $579.0073722-26 $82.00 $86.00 $89.00 $92.00 $86.00 $89.00 $92.0073722-TC $495.00 $418.00 $453.00 $487.00 $418.00 $453.00 $487.0073723 $1,029.00 $668.00 $720.00 $771.00 $668.00 $720.00 $771.0073723-26 $109.00 $114.00 $118.00 $123.00 $114.00 $118.00 $123.0073723-TC $916.00 $554.00 $601.00 $648.00 $554.00 $601.00 $648.0073725 $515.00 $516.00 $557.00 $598.00 $516.00 $557.00 $598.0073725-26 $92.00 $96.00 $100.00 $104.00 $96.00 $100.00 $104.0073725-TC $419.00 $420.00 $457.00 $494.00 $420.00 $457.00 $494.0074000 $29.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0074000-26 $9.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.0074000-TC $19.00 $19.00 $21.00 $23.00 $19.00 $21.00 $23.0074010 $33.00 $40.00 $43.00 $46.00 $40.00 $43.00 $46.0074010-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0074010-TC $21.00 $28.00 $30.00 $33.00 $28.00 $30.00 $33.0074020 $37.00 $43.00 $46.00 $49.00 $43.00 $46.00 $49.0074020-26 $13.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0074020-TC $22.00 $29.00 $31.00 $34.00 $29.00 $31.00 $34.0074022 $44.00 $51.00 $55.00 $59.00 $51.00 $55.00 $59.0074022-26 $16.00 $17.00 $17.00 $18.00 $17.00 $17.00 $18.0074022-TC $28.00 $35.00 $38.00 $41.00 $35.00 $38.00 $41.0074150 $274.00 $266.00 $287.00 $308.00 $266.00 $287.00 $308.0074150-26 $60.00 $63.00 $65.00 $68.00 $63.00 $65.00 $68.0074150-TC $211.00 $203.00 $222.00 $240.00 $203.00 $222.00 $240.0074160 $322.00 $362.00 $390.00 $419.00 $362.00 $390.00 $419.0074160-26 $65.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.0074160-TC $256.00 $294.00 $320.00 $346.00 $294.00 $320.00 $346.0074170 $390.00 $418.00 $450.00 $483.00 $418.00 $450.00 $483.0074170-26 $71.00 $74.00 $77.00 $80.00 $74.00 $77.00 $80.0074170-TC $317.00 $344.00 $374.00 $403.00 $344.00 $374.00 $403.0074175 $418.00 $446.00 $479.00 $510.00 $446.00 $479.00 $510.0074175-26 $98.00 $100.00 $104.00 $108.00 $100.00 $104.00 $108.0074175-TC $315.00 $346.00 $375.00 $403.00 $346.00 $375.00 $403.0074181 $498.00 $439.00 $473.00 $507.00 $439.00 $473.00 $507.0074181-26 $85.00 $77.00 $80.00 $83.00 $77.00 $80.00 $83.0074181-TC $415.00 $362.00 $393.00 $424.00 $362.00 $393.00 $424.0074182 $587.00 $509.00 $548.00 $586.00 $509.00 $548.00 $586.0074182-26 $88.00 $92.00 $95.00 $99.00 $92.00 $95.00 $99.0074182-TC $496.00 $418.00 $453.00 $487.00 $418.00 $453.00 $487.0074183 $1,037.00 $674.00 $726.00 $779.00 $674.00 $726.00 $779.0074183-26 $114.00 $119.00 $124.00 $128.00 $119.00 $124.00 $128.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

74183-TC $919.00 $554.00 $603.00 $650.00 $554.00 $603.00 $650.0074185 $514.00 $516.00 $556.00 $597.00 $516.00 $556.00 $597.0074185-26 $92.00 $96.00 $99.00 $103.00 $96.00 $99.00 $103.0074185-TC $419.00 $420.00 $457.00 $494.00 $420.00 $457.00 $494.0074190 $73.00 $371.00 $405.00 $441.00 $371.00 $405.00 $441.0074190-26 NC $25.00 $26.00 $27.00 $25.00 $26.00 $27.0074190-TC NC $363.00 $397.00 $431.00 $363.00 $397.00 $431.0074210 $63.00 $79.00 $85.00 $91.00 $79.00 $85.00 $91.0074210-26 $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0074210-TC $44.00 $59.00 $65.00 $70.00 $59.00 $65.00 $70.0074220 $68.00 $88.00 $94.00 $101.00 $88.00 $94.00 $101.0074220-26 $23.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0074220-TC $44.00 $63.00 $69.00 $74.00 $63.00 $69.00 $74.0074230 $77.00 $93.00 $99.00 $106.00 $93.00 $99.00 $106.0074230-26 $27.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0074230-TC $48.00 $65.00 $71.00 $76.00 $65.00 $71.00 $76.0074235 $160.00 ------- ------- ------- ------- ------- -------74235-26 NC $64.00 $66.00 $69.00 $64.00 $66.00 $69.0074235-TC NC BR BR BR BR BR BR74240 $91.00 $111.00 $119.00 $127.00 $111.00 $119.00 $127.0074240-26 $35.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.0074240-TC $55.00 $74.00 $81.00 $87.00 $74.00 $81.00 $87.0074241 $91.00 $116.00 $125.00 $133.00 $116.00 $125.00 $133.0074241-26 $35.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.0074241-TC $56.00 $80.00 $87.00 $94.00 $80.00 $87.00 $94.0074245 $137.00 $174.00 $187.00 $200.00 $174.00 $187.00 $200.0074245-26 $46.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.0074245-TC $89.00 $126.00 $137.00 $148.00 $126.00 $137.00 $148.0074246 $97.00 $126.00 $135.00 $144.00 $126.00 $135.00 $144.0074246-26 $35.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.0074246-TC $61.00 $89.00 $97.00 $105.00 $89.00 $97.00 $105.0074247 $99.00 $130.00 $139.00 $149.00 $130.00 $139.00 $149.0074247-26 $35.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.0074247-TC $63.00 $93.00 $101.00 $109.00 $93.00 $101.00 $109.0074249 $144.00 $186.00 $200.00 $214.00 $186.00 $200.00 $214.0074249-26 $46.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.0074249-TC $96.00 $138.00 $150.00 $162.00 $138.00 $150.00 $162.0074250 $73.00 $100.00 $107.00 $115.00 $100.00 $107.00 $115.0074250-26 $23.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0074250-TC $48.00 $75.00 $82.00 $88.00 $75.00 $82.00 $88.0074251 $85.00 $184.00 $197.00 $208.00 $184.00 $197.00 $208.0074251-26 $34.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.0074251-TC $48.00 $147.00 $158.00 $168.00 $147.00 $158.00 $168.0074260 $82.00 $118.00 $126.00 $134.00 $118.00 $126.00 $134.0074260-26 $25.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0074260-TC $56.00 $92.00 $99.00 $106.00 $92.00 $99.00 $106.0074270 $100.00 $130.00 $140.00 $149.00 $130.00 $140.00 $149.0074270-26 $35.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.0074270-TC $64.00 $93.00 $102.00 $110.00 $93.00 $102.00 $110.0074280 $136.00 $194.00 $208.00 $222.00 $194.00 $208.00 $222.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

74280-26 $50.00 $52.00 $54.00 $56.00 $52.00 $54.00 $56.0074280-TC $84.00 $142.00 $155.00 $166.00 $142.00 $155.00 $166.0074283 $201.00 $200.00 $212.00 $225.00 $200.00 $212.00 $225.0074283-26 $103.00 $106.00 $110.00 $114.00 $106.00 $110.00 $114.0074283-TC $95.00 $93.00 $102.00 $110.00 $93.00 $102.00 $110.0074290 $44.00 $63.00 $68.00 $72.00 $63.00 $68.00 $72.0074290-26 $16.00 $17.00 $17.00 $18.00 $17.00 $17.00 $18.0074290-TC $28.00 $46.00 $50.00 $54.00 $46.00 $50.00 $54.0074291 $26.00 $49.00 $53.00 $56.00 $49.00 $53.00 $56.0074291-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0074291-TC $15.00 $39.00 $42.00 $44.00 $39.00 $42.00 $44.0074300 $31.00 ------- ------- ------- ------- ------- -------74300-26 NC $19.00 $20.00 $21.00 $19.00 $20.00 $21.0074300-TC NC BR BR BR BR BR BR74301 BR ------- ------- ------- ------- ------- -------74301-26 NC $11.00 $11.00 $12.00 $11.00 $11.00 $12.0074301-TC NC BR BR BR BR BR BR74305 $51.00 ------- ------- ------- ------- ------- -------74305-26 NC $23.00 $23.00 $24.00 $23.00 $23.00 $24.0074305-TC NC BR BR BR BR BR BR74320 $145.00 $139.00 $151.00 $163.00 $139.00 $151.00 $163.0074320-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0074320-TC NC $110.00 $121.00 $132.00 $110.00 $121.00 $132.0074327 $103.00 $132.00 $142.00 $152.00 $132.00 $142.00 $152.0074327-26 NC $37.00 $39.00 $40.00 $37.00 $39.00 $40.0074327-TC NC $95.00 $103.00 $112.00 $95.00 $103.00 $112.0074328 $155.00 ------- ------- ------- ------- ------- -------74328-26 NC $38.00 $39.00 $40.00 $38.00 $39.00 $40.0074328-TC NC BR BR BR BR BR BR74329 $155.00 ------- ------- ------- ------- ------- -------74329-26 NC $38.00 $39.00 $40.00 $38.00 $39.00 $40.0074329-TC NC BR BR BR BR BR BR74330 $165.00 ------- ------- ------- ------- ------- -------74330-26 NC $48.00 $49.00 $51.00 $48.00 $49.00 $51.0074330-TC NC BR BR BR BR BR BR74340 $121.00 ------- ------- ------- ------- ------- -------74340-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0074340-TC NC BR BR BR BR BR BR74355 $137.00 ------- ------- ------- ------- ------- -------74355-26 NC $40.00 $41.00 $43.00 $40.00 $41.00 $43.0074355-TC NC BR BR BR BR BR BR74360 $145.00 ------- ------- ------- ------- ------- -------74360-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.0074360-TC NC BR BR BR BR BR BR74363 $274.00 ------- ------- ------- ------- ------- -------74363-26 NC $47.00 $48.00 $50.00 $47.00 $48.00 $50.0074363-TC NC BR BR BR BR BR BR74400 $89.00 $113.00 $122.00 $131.00 $113.00 $122.00 $131.0074400-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0074400-TC $63.00 $87.00 $95.00 $103.00 $87.00 $95.00 $103.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

74410 $98.00 $120.00 $130.00 $139.00 $120.00 $130.00 $139.0074410-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0074410-TC $72.00 $94.00 $103.00 $111.00 $94.00 $103.00 $111.0074415 $105.00 $136.00 $146.00 $157.00 $136.00 $146.00 $157.0074415-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0074415-TC $79.00 $110.00 $120.00 $129.00 $110.00 $120.00 $129.0074420 $117.00 $184.00 $201.00 $219.00 $184.00 $201.00 $219.0074420-26 $18.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0074420-TC $97.00 $177.00 $194.00 $211.00 $177.00 $194.00 $211.0074425 $68.00 $183.00 $201.00 $218.00 $183.00 $201.00 $218.0074425-26 NC $20.00 $21.00 $21.00 $20.00 $21.00 $21.0074425-TC NC $177.00 $193.00 $210.00 $177.00 $193.00 $210.0074430 $48.00 $78.00 $84.00 $90.00 $78.00 $84.00 $90.0074430-26 NC $17.00 $18.00 $19.00 $17.00 $18.00 $19.0074430-TC NC $61.00 $66.00 $71.00 $61.00 $66.00 $71.0074440 $62.00 $85.00 $91.00 $97.00 $85.00 $91.00 $97.0074440-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.0074440-TC NC $65.00 $70.00 $76.00 $65.00 $70.00 $76.0074445 $101.00 $198.00 $217.00 $237.00 $198.00 $217.00 $237.0074445-26 NC $62.00 $65.00 $68.00 $62.00 $65.00 $68.0074445-TC NC $177.00 $194.00 $211.00 $177.00 $194.00 $211.0074450 $60.00 $184.00 $201.00 $219.00 $184.00 $201.00 $219.0074450-26 NC $18.00 $19.00 $20.00 $18.00 $19.00 $20.0074450-TC NC $178.00 $194.00 $212.00 $178.00 $194.00 $212.0074455 $75.00 $96.00 $104.00 $112.00 $96.00 $104.00 $112.0074455-26 NC $18.00 $19.00 $20.00 $18.00 $19.00 $20.0074455-TC NC $78.00 $85.00 $92.00 $78.00 $85.00 $92.0074470 $74.00 $190.00 $209.00 $228.00 $190.00 $209.00 $228.0074470-26 NC $28.00 $29.00 $30.00 $28.00 $29.00 $30.0074470-TC NC $182.00 $199.00 $217.00 $182.00 $199.00 $217.0074475 $181.00 $160.00 $174.00 $189.00 $160.00 $174.00 $189.0074475-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0074475-TC NC $131.00 $144.00 $158.00 $131.00 $144.00 $158.0074480 $181.00 $160.00 $174.00 $189.00 $160.00 $174.00 $189.0074480-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0074480-TC NC $131.00 $144.00 $158.00 $131.00 $144.00 $158.0074485 $146.00 $143.00 $154.00 $167.00 $143.00 $154.00 $167.0074485-26 NC $29.00 $31.00 $32.00 $29.00 $31.00 $32.0074485-TC NC $113.00 $124.00 $135.00 $113.00 $124.00 $135.0074710 $57.00 $53.00 $57.00 $62.00 $53.00 $57.00 $62.0074710-26 $17.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0074710-TC $39.00 $35.00 $38.00 $42.00 $35.00 $38.00 $42.0074740 $68.00 $82.00 $89.00 $95.00 $82.00 $89.00 $95.0074740-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.0074740-TC NC $62.00 $68.00 $73.00 $62.00 $68.00 $73.0074742 $150.00 ------- ------- ------- ------- ------- -------74742-26 NC $32.00 $34.00 $35.00 $32.00 $34.00 $35.0074742-TC NC BR BR BR BR BR BR74775 $88.00 $190.00 $209.00 $231.00 $190.00 $209.00 $231.0074775-26 $32.00 $33.00 $34.00 $36.00 $33.00 $34.00 $36.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

74775-TC $55.00 $180.00 $198.00 $218.00 $180.00 $198.00 $218.0075557 ------- $500.00 $542.00 $588.00 $500.00 $542.00 $588.0075557-26 ------- $130.00 $134.00 $140.00 $130.00 $134.00 $140.0075557-TC ------- $370.00 $408.00 $448.00 $370.00 $408.00 $448.0075558 ------- $649.00 $705.00 $767.00 $649.00 $705.00 $767.0075558-26 ------- $126.00 $130.00 $135.00 $126.00 $130.00 $135.0075558-TC ------- $523.00 $575.00 $632.00 $523.00 $575.00 $632.0075559 ------- $530.00 $569.00 $609.00 $530.00 $569.00 $609.0075559-26 ------- $165.00 $171.00 $177.00 $165.00 $171.00 $177.0075559-TC ------- $365.00 $398.00 $433.00 $365.00 $398.00 $433.0075560 ------- $834.00 $901.00 $971.00 $834.00 $901.00 $971.0075560-26 ------- $145.00 $149.00 $154.00 $145.00 $149.00 $154.0075560-TC ------- $690.00 $753.00 $817.00 $690.00 $753.00 $817.0075561 ------- $704.00 $762.00 $824.00 $704.00 $762.00 $824.0075561-26 ------- $144.00 $149.00 $155.00 $144.00 $149.00 $155.0075561-TC ------- $561.00 $613.00 $669.00 $561.00 $613.00 $669.0075562 ------- $828.00 $896.00 $966.00 $828.00 $896.00 $966.0075562-26 ------- $138.00 $142.00 $147.00 $138.00 $142.00 $147.0075562-TC ------- $690.00 $753.00 $819.00 $690.00 $753.00 $819.0075563 ------- $729.00 $786.00 $843.00 $729.00 $786.00 $843.0075563-26 ------- $172.00 $178.00 $184.00 $172.00 $178.00 $184.0075563-TC ------- $557.00 $608.00 $659.00 $557.00 $608.00 $659.0075564 ------- $974.00 $1,053.00 $1,136.00 $974.00 $1,053.00 $1,136.0075564-26 ------- $162.00 $167.00 $172.00 $162.00 $167.00 $172.0075564-TC ------- $812.00 $886.00 $964.00 $812.00 $886.00 $964.0075600 $497.00 $437.00 $478.00 $521.00 $437.00 $478.00 $521.0075600-26 NC $28.00 $29.00 $30.00 $28.00 $29.00 $30.0075600-TC NC $410.00 $449.00 $491.00 $410.00 $449.00 $491.0075605 $183.00 $411.00 $448.00 $489.00 $411.00 $448.00 $489.0075605-26 NC $62.00 $65.00 $67.00 $62.00 $65.00 $67.0075605-TC NC $348.00 $383.00 $421.00 $348.00 $383.00 $421.0075625 $143.00 $407.00 $444.00 $485.00 $407.00 $444.00 $485.0075625-26 NC $61.00 $64.00 $66.00 $61.00 $64.00 $66.0075625-TC NC $346.00 $380.00 $418.00 $346.00 $380.00 $418.0075630 $239.00 $460.00 $501.00 $545.00 $460.00 $501.00 $545.0075630-26 NC $99.00 $103.00 $108.00 $99.00 $103.00 $108.0075630-TC NC $361.00 $398.00 $438.00 $361.00 $398.00 $438.0075635 $445.00 $473.00 $505.00 $537.00 $473.00 $505.00 $537.0075635-26 NC $129.00 $133.00 $139.00 $129.00 $133.00 $139.0075635-TC NC $344.00 $372.00 $399.00 $344.00 $372.00 $399.0075650 $218.00 $426.00 $464.00 $505.00 $426.00 $464.00 $505.0075650-26 NC $80.00 $83.00 $86.00 $80.00 $83.00 $86.0075650-TC NC $346.00 $381.00 $419.00 $346.00 $381.00 $419.0075658 $540.00 $423.00 $461.00 $503.00 $423.00 $461.00 $503.0075658-26 NC $71.00 $73.00 $77.00 $71.00 $73.00 $77.0075658-TC NC $353.00 $388.00 $426.00 $353.00 $388.00 $426.0075660 $540.00 $425.00 $463.00 $504.00 $425.00 $463.00 $504.0075660-26 NC $70.00 $73.00 $76.00 $70.00 $73.00 $76.0075660-TC NC $355.00 $390.00 $429.00 $355.00 $390.00 $429.0075662 $560.00 $463.00 $503.00 $546.00 $463.00 $503.00 $546.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

75662-26 NC $90.00 $93.00 $97.00 $90.00 $93.00 $97.0075662-TC NC $373.00 $409.00 $449.00 $373.00 $409.00 $449.0075665 $540.00 $431.00 $470.00 $513.00 $431.00 $470.00 $513.0075665-26 NC $72.00 $75.00 $79.00 $72.00 $75.00 $79.0075665-TC NC $359.00 $395.00 $434.00 $359.00 $395.00 $434.0075671 $219.00 $464.00 $504.00 $548.00 $464.00 $504.00 $548.0075671-26 NC $89.00 $92.00 $95.00 $89.00 $92.00 $95.0075671-TC NC $376.00 $413.00 $453.00 $376.00 $413.00 $453.0075676 $540.00 $425.00 $463.00 $505.00 $425.00 $463.00 $505.0075676-26 NC $71.00 $73.00 $77.00 $71.00 $73.00 $77.0075676-TC NC $355.00 $390.00 $429.00 $355.00 $390.00 $429.0075680 $207.00 $455.00 $494.00 $537.00 $455.00 $494.00 $537.0075680-26 NC $89.00 $92.00 $96.00 $89.00 $92.00 $96.0075680-TC NC $366.00 $402.00 $441.00 $366.00 $402.00 $441.0075685 $160.00 $425.00 $463.00 $504.00 $425.00 $463.00 $504.0075685-26 NC $70.00 $73.00 $76.00 $70.00 $73.00 $76.0075685-TC NC $355.00 $390.00 $429.00 $355.00 $390.00 $429.0075705 $587.00 $473.00 $513.00 $557.00 $473.00 $513.00 $557.0075705-26 NC $118.00 $123.00 $129.00 $118.00 $123.00 $129.0075705-TC NC $354.00 $390.00 $428.00 $354.00 $390.00 $428.0075710 $194.00 $420.00 $458.00 $500.00 $420.00 $458.00 $500.0075710-26 NC $62.00 $65.00 $68.00 $62.00 $65.00 $68.0075710-TC NC $357.00 $393.00 $432.00 $357.00 $393.00 $432.0075716 $293.00 $446.00 $485.00 $528.00 $446.00 $485.00 $528.0075716-26 NC $71.00 $73.00 $77.00 $71.00 $73.00 $77.0075716-TC NC $375.00 $412.00 $452.00 $375.00 $412.00 $452.0075722 $206.00 $416.00 $454.00 $495.00 $416.00 $454.00 $495.0075722-26 NC $62.00 $65.00 $67.00 $62.00 $65.00 $67.0075722-TC NC $354.00 $390.00 $428.00 $354.00 $390.00 $428.0075724 $214.00 $458.00 $497.00 $540.00 $458.00 $497.00 $540.0075724-26 NC $84.00 $86.00 $89.00 $84.00 $86.00 $89.0075724-TC NC $374.00 $411.00 $451.00 $374.00 $411.00 $451.0075726 $530.00 $414.00 $452.00 $493.00 $414.00 $452.00 $493.0075726-26 NC $60.00 $62.00 $65.00 $60.00 $62.00 $65.0075726-TC NC $354.00 $389.00 $428.00 $354.00 $389.00 $428.0075731 $530.00 $421.00 $460.00 $501.00 $421.00 $460.00 $501.0075731-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.0075731-TC NC $359.00 $394.00 $433.00 $359.00 $394.00 $433.0075733 $540.00 $456.00 $496.00 $539.00 $456.00 $496.00 $539.0075733-26 NC $74.00 $76.00 $79.00 $74.00 $76.00 $79.0075733-TC NC $382.00 $420.00 $460.00 $382.00 $420.00 $460.0075736 $530.00 $418.00 $455.00 $497.00 $418.00 $455.00 $497.0075736-26 NC $62.00 $64.00 $67.00 $62.00 $64.00 $67.0075736-TC NC $356.00 $391.00 $430.00 $356.00 $391.00 $430.0075741 $540.00 $411.00 $448.00 $488.00 $411.00 $448.00 $488.0075741-26 NC $70.00 $72.00 $75.00 $70.00 $72.00 $75.0075741-TC NC $341.00 $375.00 $413.00 $341.00 $375.00 $413.0075743 $253.00 $434.00 $472.00 $514.00 $434.00 $472.00 $514.0075743-26 NC $88.00 $91.00 $95.00 $88.00 $91.00 $95.0075743-TC NC $346.00 $381.00 $419.00 $346.00 $381.00 $419.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

75746 $530.00 $410.00 $447.00 $488.00 $410.00 $447.00 $488.0075746-26 NC $60.00 $62.00 $65.00 $60.00 $62.00 $65.0075746-TC NC $349.00 $385.00 $423.00 $349.00 $385.00 $423.0075756 $183.00 $426.00 $465.00 $506.00 $426.00 $465.00 $506.0075756-26 NC $64.00 $67.00 $69.00 $64.00 $67.00 $69.0075756-TC NC $362.00 $398.00 $437.00 $362.00 $398.00 $437.0075774 $80.00 $354.00 $389.00 $427.00 $354.00 $389.00 $427.0075774-26 NC $20.00 $21.00 $21.00 $20.00 $21.00 $21.0075774-TC NC $335.00 $369.00 $406.00 $335.00 $369.00 $406.0075790 $146.00 $178.00 $189.00 $200.00 $178.00 $189.00 $200.0075790-26 NC $97.00 $101.00 $105.00 $97.00 $101.00 $105.0075790-TC NC $81.00 $88.00 $95.00 $81.00 $88.00 $95.0075801 $245.00 $384.00 $423.00 $468.00 $384.00 $423.00 $468.0075801-26 NC $45.00 $47.00 $50.00 $45.00 $47.00 $50.0075801-TC NC $369.00 $406.00 $448.00 $369.00 $406.00 $448.0075803 $264.00 $387.00 $427.00 $471.00 $387.00 $427.00 $471.0075803-26 NC $62.00 $64.00 $66.00 $62.00 $64.00 $66.0075803-TC NC $369.00 $406.00 $448.00 $369.00 $406.00 $448.0075805 $271.00 $383.00 $422.00 $465.00 $383.00 $422.00 $465.0075805-26 NC $43.00 $45.00 $47.00 $43.00 $45.00 $47.0075805-TC NC $369.00 $406.00 $448.00 $369.00 $406.00 $448.0075807 $289.00 $387.00 $427.00 $471.00 $387.00 $427.00 $471.0075807-26 NC $62.00 $64.00 $66.00 $62.00 $64.00 $66.0075807-TC NC $369.00 $406.00 $448.00 $369.00 $406.00 $448.0075809 $54.00 $82.00 $88.00 $93.00 $82.00 $88.00 $93.0075809-26 NC $24.00 $25.00 $26.00 $24.00 $25.00 $26.0075809-TC NC $58.00 $63.00 $67.00 $58.00 $63.00 $67.0075810 $530.00 $2,003.00 $2,207.00 $2,431.00 $2,003.00 $2,207.00 $2,431.0075810-26 NC $60.00 $62.00 $64.00 $60.00 $62.00 $64.0075810-TC NC $1,985.00 $2,187.00 $2,408.00 $1,985.00 $2,187.00 $2,408.0075820 $72.00 $114.00 $121.00 $129.00 $114.00 $121.00 $129.0075820-26 NC $38.00 $39.00 $41.00 $38.00 $39.00 $41.0075820-TC NC $76.00 $82.00 $88.00 $76.00 $82.00 $88.0075822 $111.00 $145.00 $155.00 $165.00 $145.00 $155.00 $165.0075822-26 NC $56.00 $58.00 $61.00 $56.00 $58.00 $61.0075822-TC NC $89.00 $97.00 $104.00 $89.00 $97.00 $104.0075825 $194.00 $399.00 $436.00 $477.00 $399.00 $436.00 $477.0075825-26 NC $61.00 $64.00 $67.00 $61.00 $64.00 $67.0075825-TC NC $338.00 $372.00 $410.00 $338.00 $372.00 $410.0075827 $530.00 $398.00 $435.00 $475.00 $398.00 $435.00 $475.0075827-26 NC $60.00 $62.00 $64.00 $60.00 $62.00 $64.0075827-TC NC $339.00 $373.00 $411.00 $339.00 $373.00 $411.0075831 $54.00 $401.00 $437.00 $478.00 $401.00 $437.00 $478.0075831-26 NC $60.00 $62.00 $65.00 $60.00 $62.00 $65.0075831-TC NC $340.00 $375.00 $413.00 $340.00 $375.00 $413.0075833 $549.00 $430.00 $469.00 $511.00 $430.00 $469.00 $511.0075833-26 NC $80.00 $83.00 $87.00 $80.00 $83.00 $87.0075833-TC NC $350.00 $385.00 $424.00 $350.00 $385.00 $424.0075840 $531.00 $400.00 $437.00 $477.00 $400.00 $437.00 $477.0075840-26 NC $61.00 $63.00 $66.00 $61.00 $63.00 $66.00

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

75840-TC NC $339.00 $374.00 $411.00 $339.00 $374.00 $411.0075842 $549.00 $430.00 $468.00 $510.00 $430.00 $468.00 $510.0075842-26 NC $79.00 $82.00 $85.00 $79.00 $82.00 $85.0075842-TC NC $351.00 $386.00 $425.00 $351.00 $386.00 $425.0075860 $531.00 $407.00 $444.00 $484.00 $407.00 $444.00 $484.0075860-26 NC $62.00 $64.00 $66.00 $62.00 $64.00 $66.0075860-TC NC $345.00 $380.00 $418.00 $345.00 $380.00 $418.0075870 $531.00 $406.00 $442.00 $483.00 $406.00 $442.00 $483.0075870-26 NC $61.00 $63.00 $65.00 $61.00 $63.00 $65.0075870-TC NC $345.00 $380.00 $417.00 $345.00 $380.00 $417.0075872 $530.00 $426.00 $465.00 $509.00 $426.00 $465.00 $509.0075872-26 NC $67.00 $71.00 $76.00 $67.00 $71.00 $76.0075872-TC NC $359.00 $395.00 $433.00 $359.00 $395.00 $433.0075880 $72.00 $118.00 $126.00 $134.00 $118.00 $126.00 $134.0075880-26 NC $38.00 $39.00 $40.00 $38.00 $39.00 $40.0075880-TC NC $80.00 $87.00 $93.00 $80.00 $87.00 $93.0075885 $546.00 $417.00 $454.00 $494.00 $417.00 $454.00 $494.0075885-26 NC $76.00 $79.00 $82.00 $76.00 $79.00 $82.0075885-TC NC $340.00 $375.00 $413.00 $340.00 $375.00 $413.0075887 $546.00 $421.00 $459.00 $500.00 $421.00 $459.00 $500.0075887-26 NC $77.00 $80.00 $83.00 $77.00 $80.00 $83.0075887-TC NC $344.00 $379.00 $417.00 $344.00 $379.00 $417.0075889 $530.00 $401.00 $437.00 $477.00 $401.00 $437.00 $477.0075889-26 NC $60.00 $62.00 $65.00 $60.00 $62.00 $65.0075889-TC NC $340.00 $375.00 $413.00 $340.00 $375.00 $413.0075891 $530.00 $400.00 $437.00 $477.00 $400.00 $437.00 $477.0075891-26 NC $60.00 $62.00 $65.00 $60.00 $62.00 $65.0075891-TC NC $340.00 $374.00 $412.00 $340.00 $374.00 $412.0075893 $499.00 $369.00 $405.00 $443.00 $369.00 $405.00 $443.0075893-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0075893-TC NC $340.00 $375.00 $413.00 $340.00 $375.00 $413.0075894 $972.00 ------- ------- ------- ------- ------- -------75894-26 NC $70.00 $73.00 $77.00 $70.00 $73.00 $77.0075894-TC NC BR BR BR BR BR BR75896 $241.00 ------- ------- ------- ------- ------- -------75896-26 NC $70.00 $72.00 $75.00 $70.00 $72.00 $75.0075896-TC NC BR BR BR BR BR BR75898 $124.00 $209.00 $229.00 $250.00 $209.00 $229.00 $250.0075898-26 $84.00 $88.00 $91.00 $95.00 $88.00 $91.00 $95.0075898-TC $39.00 $182.00 $199.00 $216.00 $182.00 $199.00 $216.0075900 $810.00 ------- ------- ------- ------- ------- -------75900-26 NC $26.00 $27.00 $29.00 $26.00 $27.00 $29.0075900-TC NC BR BR BR BR BR BR75901 $98.00 $181.00 $206.00 $239.00 $181.00 $206.00 $239.0075901-26 NC $26.00 $27.00 $28.00 $26.00 $27.00 $28.0075901-TC NC $155.00 $179.00 $211.00 $155.00 $179.00 $211.0075902 $93.00 $127.00 $149.00 $178.00 $127.00 $149.00 $178.0075902-26 NC $21.00 $21.00 $22.00 $21.00 $21.00 $22.0075902-TC NC $107.00 $127.00 $156.00 $107.00 $127.00 $156.0075940 $151.00 ------- ------- ------- ------- ------- -------

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

75940-26 NC $30.00 $31.00 $33.00 $30.00 $31.00 $33.0075940-TC NC BR BR BR BR BR BR75945 $192.00 $169.00 $185.00 $202.00 $169.00 $185.00 $202.0075945-26 NC $23.00 $24.00 $25.00 $23.00 $24.00 $25.0075945-TC NC $161.00 $176.00 $191.00 $161.00 $176.00 $191.0075946 $108.00 ------- ------- ------- ------- ------- -------75946-26 NC $23.00 $24.00 $26.00 $23.00 $24.00 $26.0075946-TC NC BR BR BR BR BR BR75952 BR ------- ------- ------- ------- ------- -------75952-26 NC $247.00 $259.00 $276.00 $247.00 $259.00 $276.0075952-TC NC BR BR BR BR BR BR75953 BR ------- ------- ------- ------- ------- -------75953-26 NC $75.00 $79.00 $84.00 $75.00 $79.00 $84.0075953-TC NC BR BR BR BR BR BR75954 BR ------- ------- ------- ------- ------- -------75954-26 NC $120.00 $125.00 $131.00 $120.00 $125.00 $131.0075954-TC NC BR BR BR BR BR BR75956 ------- BR BR BR BR BR BR75956-26 ------- $391.00 $411.00 $438.00 $391.00 $411.00 $438.0075956-TC ------- BR BR BR BR BR BR75957 ------- BR BR BR BR BR BR75957-26 ------- $335.00 $353.00 $375.00 $335.00 $353.00 $375.0075957-TC ------- BR BR BR BR BR BR75958 ------- BR BR BR BR BR BR75958-26 ------- $223.00 $234.00 $249.00 $223.00 $234.00 $249.0075958-TC ------- BR BR BR BR BR BR75959 ------- BR BR BR BR BR BR75959-26 ------- $195.00 $205.00 $218.00 $195.00 $205.00 $218.0075959-TC ------- BR BR BR BR BR BR75960 $600.00 $433.00 $474.00 $520.00 $433.00 $474.00 $520.0075960-26 NC $45.00 $47.00 $49.00 $45.00 $47.00 $49.0075960-TC NC $388.00 $427.00 $471.00 $388.00 $427.00 $471.0075961 $616.00 $527.00 $565.00 $607.00 $527.00 $565.00 $607.0075961-26 NC $224.00 $232.00 $241.00 $224.00 $232.00 $241.0075961-TC NC $303.00 $333.00 $366.00 $303.00 $333.00 $366.0075962 $618.00 $455.00 $500.00 $549.00 $455.00 $500.00 $549.0075962-26 NC $29.00 $31.00 $32.00 $29.00 $31.00 $32.0075962-TC NC $426.00 $469.00 $517.00 $426.00 $469.00 $517.0075964 $333.00 $255.00 $280.00 $306.00 $255.00 $280.00 $306.0075964-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.0075964-TC NC $235.00 $259.00 $284.00 $235.00 $259.00 $284.0075966 $659.00 $504.00 $550.00 $601.00 $504.00 $550.00 $601.0075966-26 NC $72.00 $75.00 $78.00 $72.00 $75.00 $78.0075966-TC NC $432.00 $475.00 $523.00 $432.00 $475.00 $523.0075968 $333.00 $256.00 $280.00 $307.00 $256.00 $280.00 $307.0075968-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.0075968-TC NC $236.00 $259.00 $285.00 $236.00 $259.00 $285.0075970 $475.00 ------- ------- ------- ------- ------- -------75970-26 NC $44.00 $46.00 $48.00 $44.00 $46.00 $48.0075970-TC NC BR BR BR BR BR BR

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

75978 $617.00 $450.00 $494.00 $542.00 $450.00 $494.00 $542.0075978-26 NC $28.00 $29.00 $30.00 $28.00 $29.00 $30.0075978-TC NC $422.00 $465.00 $512.00 $422.00 $465.00 $512.0075980 $277.00 ------- ------- ------- ------- ------- -------75980-26 NC $77.00 $79.00 $82.00 $77.00 $79.00 $82.0075980-TC NC BR BR BR BR BR BR75982 $303.00 ------- ------- ------- ------- ------- -------75982-26 NC $77.00 $79.00 $82.00 $77.00 $79.00 $82.0075982-TC NC BR BR BR BR BR BR75984 $110.00 $123.00 $132.00 $142.00 $123.00 $132.00 $142.0075984-26 NC $38.00 $39.00 $40.00 $38.00 $39.00 $40.0075984-TC NC $85.00 $93.00 $101.00 $85.00 $93.00 $101.0075989 $180.00 $172.00 $184.00 $198.00 $172.00 $184.00 $198.0075989-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.0075989-TC NC $108.00 $119.00 $130.00 $108.00 $119.00 $130.0075992 $618.00 ------- ------- ------- ------- ------- -------75992-26 NC $30.00 $31.00 $33.00 $30.00 $31.00 $33.0075992-TC NC BR BR BR BR BR BR75993 $333.00 ------- ------- ------- ------- ------- -------75993-26 NC $20.00 $21.00 $21.00 $20.00 $21.00 $21.0075993-TC NC BR BR BR BR BR BR75994 $659.00 ------- ------- ------- ------- ------- -------75994-26 NC $72.00 $75.00 $78.00 $72.00 $75.00 $78.0075994-TC NC BR BR BR BR BR BR75995 $658.00 ------- ------- ------- ------- ------- -------75995-26 NC $70.00 $72.00 $75.00 $70.00 $72.00 $75.0075995-TC NC BR BR BR BR BR BR75996 $332.00 ------- ------- ------- ------- ------- -------75996-26 NC $19.00 $20.00 $21.00 $19.00 $20.00 $21.0075996-TC NC BR BR BR BR BR BR76000 $58.00 $92.00 $100.00 $107.00 $92.00 $100.00 $107.0076000-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0076000-TC $48.00 $83.00 $90.00 $97.00 $83.00 $90.00 $97.0076001 $134.00 ------- ------- ------- ------- ------- -------76001-26 $34.00 $37.00 $39.00 $41.00 $37.00 $39.00 $41.0076001-TC $97.00 ------- ------- ------- ------- ------- -------76080 $67.00 $71.00 $75.00 $81.00 $71.00 $75.00 $81.0076080-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0076080-TC NC $42.00 $46.00 $50.00 $42.00 $46.00 $50.0076098 $23.00 $23.00 $25.00 $27.00 $23.00 $25.00 $27.0076098-26 $8.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0076098-TC $15.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0076100 $77.00 $109.00 $116.00 $124.00 $109.00 $116.00 $124.0076100-26 $30.00 $31.00 $32.00 $34.00 $31.00 $32.00 $34.0076100-TC $46.00 $78.00 $84.00 $90.00 $78.00 $84.00 $90.0076101 $94.00 $167.00 $179.00 $191.00 $167.00 $179.00 $191.0076101-26 $36.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0076101-TC $59.00 $136.00 $147.00 $158.00 $136.00 $147.00 $158.0076102 $95.00 $208.00 $224.00 $238.00 $208.00 $224.00 $238.0076102-26 $30.00 $30.00 $31.00 $33.00 $30.00 $31.00 $33.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

76102-TC $65.00 $178.00 $192.00 $206.00 $178.00 $192.00 $206.0076120 $157.00 $79.00 $85.00 $91.00 $79.00 $85.00 $91.0076120-26 $56.00 $20.00 $21.00 $22.00 $20.00 $21.00 $22.0076120-TC $102.00 $59.00 $64.00 $69.00 $59.00 $64.00 $69.0076125 $49.00 ------- ------- ------- ------- ------- -------76125-26 $17.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.0076125-TC $33.00 ------- ------- ------- ------- ------- -------76140 $31.00 ------- ------- ------- ------- ------- -------76150 $15.00 $23.00 $25.00 $27.00 $23.00 $25.00 $27.0076350 BR ------- ------- ------- ------- ------- -------76376 ------- $110.00 $119.00 $128.00 $110.00 $119.00 $128.0076376-26 ------- $12.00 $12.00 $13.00 $12.00 $12.00 $13.0076376-TC ------- $98.00 $107.00 $115.00 $98.00 $107.00 $115.0076377 ------- $153.00 $168.00 $186.00 $153.00 $168.00 $186.0076377-26 ------- $45.00 $47.00 $50.00 $45.00 $47.00 $50.0076377-TC ------- $108.00 $121.00 $136.00 $108.00 $121.00 $136.0076380 $182.00 $158.00 $169.00 $181.00 $158.00 $169.00 $181.0076380-26 $50.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.0076380-TC $131.00 $107.00 $116.00 $126.00 $107.00 $116.00 $126.0076390 $493.00 $503.00 $546.00 $590.00 $503.00 $546.00 $590.0076390-26 $71.00 $72.00 $74.00 $77.00 $72.00 $74.00 $77.0076390-TC $419.00 $432.00 $472.00 $513.00 $432.00 $472.00 $513.0076496 BR ------- ------- ------- ------- ------- -------76496-26 BR ------- ------- ------- ------- ------- -------76496-TC BR $91.00 $101.00 $111.00 $91.00 $101.00 $111.0076497 BR ------- ------- ------- ------- ------- -------76497-26 BR ------- ------- ------- ------- ------- -------76497-TC BR $109.00 $120.00 $132.00 $109.00 $120.00 $132.0076498 BR ------- ------- ------- ------- ------- -------76498-26 BR ------- ------- ------- ------- ------- -------76498-TC BR $335.00 $369.00 $407.00 $335.00 $369.00 $407.0076499 BR ------- ------- ------- ------- ------- -------76499-26 BR ------- ------- ------- ------- ------- -------76499-TC BR ------- ------- ------- ------- ------- -------76506 $88.00 $100.00 $107.00 $115.00 $100.00 $107.00 $115.0076506-26 $33.00 $35.00 $37.00 $40.00 $35.00 $37.00 $40.0076506-TC $53.00 $64.00 $70.00 $75.00 $64.00 $70.00 $75.0076510 ------- $163.00 $172.00 $181.00 $163.00 $172.00 $181.0076510-26 ------- $83.00 $85.00 $87.00 $83.00 $85.00 $87.0076510-TC ------- $81.00 $87.00 $94.00 $81.00 $87.00 $94.0076511 $96.00 $115.00 $123.00 $130.00 $115.00 $123.00 $130.0076511-26 $48.00 $51.00 $52.00 $54.00 $51.00 $52.00 $54.0076511-TC $48.00 $64.00 $70.00 $76.00 $64.00 $70.00 $76.0076512 $96.00 $109.00 $116.00 $123.00 $109.00 $116.00 $123.0076512-26 $36.00 $51.00 $52.00 $53.00 $51.00 $52.00 $53.0076512-TC $60.00 $58.00 $64.00 $70.00 $58.00 $64.00 $70.0076513 $96.00 $97.00 $104.00 $112.00 $97.00 $104.00 $112.0076513-26 $36.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.0076513-TC $60.00 $62.00 $68.00 $74.00 $62.00 $68.00 $74.0076514 ------- $13.00 $14.00 $15.00 $13.00 $14.00 $15.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

76514-26 ------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.0076514-TC ------- $4.00 $4.00 $5.00 $4.00 $4.00 $5.0076516 $99.00 $77.00 $82.00 $87.00 $77.00 $82.00 $87.0076516-26 $37.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0076516-TC $63.00 $48.00 $52.00 $57.00 $48.00 $52.00 $57.0076519 $88.00 $81.00 $86.00 $92.00 $81.00 $86.00 $92.0076519-26 $31.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0076519-TC $53.00 $51.00 $56.00 $61.00 $51.00 $56.00 $61.0076529 $86.00 $77.00 $82.00 $88.00 $77.00 $82.00 $88.0076529-26 $31.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0076529-TC $53.00 $46.00 $50.00 $55.00 $46.00 $50.00 $55.0076536 $83.00 $111.00 $119.00 $127.00 $111.00 $119.00 $127.0076536-26 $31.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0076536-TC $54.00 $82.00 $89.00 $96.00 $82.00 $89.00 $96.0076604 $78.00 $91.00 $97.00 $104.00 $91.00 $97.00 $104.0076604-26 $28.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0076604-TC $48.00 $62.00 $68.00 $73.00 $62.00 $68.00 $73.0076645 $69.00 $91.00 $97.00 $103.00 $91.00 $97.00 $103.0076645-26 $31.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0076645-TC $40.00 $62.00 $68.00 $73.00 $62.00 $68.00 $73.0076700 $116.00 $142.00 $153.00 $163.00 $142.00 $153.00 $163.0076700-26 $42.00 $43.00 $44.00 $46.00 $43.00 $44.00 $46.0076700-TC $73.00 $100.00 $108.00 $117.00 $100.00 $108.00 $117.0076705 $84.00 $106.00 $114.00 $122.00 $106.00 $114.00 $122.0076705-26 $30.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0076705-TC $53.00 $75.00 $81.00 $88.00 $75.00 $81.00 $88.0076770 $112.00 $137.00 $147.00 $157.00 $137.00 $147.00 $157.0076770-26 $38.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0076770-TC $73.00 $98.00 $107.00 $115.00 $98.00 $107.00 $115.0076775 $84.00 $107.00 $115.00 $123.00 $107.00 $115.00 $123.0076775-26 $30.00 $31.00 $32.00 $34.00 $31.00 $32.00 $34.0076775-TC $53.00 $76.00 $83.00 $89.00 $76.00 $83.00 $89.0076776 ------- $148.00 $159.00 $169.00 $148.00 $159.00 $169.0076776-26 ------- $40.00 $41.00 $43.00 $40.00 $41.00 $43.0076776-TC ------- $108.00 $117.00 $126.00 $108.00 $117.00 $126.0076800 $112.00 $130.00 $138.00 $147.00 $130.00 $138.00 $147.0076800-26 $61.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.0076800-TC $54.00 $73.00 $79.00 $85.00 $73.00 $79.00 $85.0076801 $93.00 $143.00 $153.00 $163.00 $143.00 $153.00 $163.0076801-26 $51.00 $52.00 $53.00 $55.00 $52.00 $53.00 $55.0076801-TC $42.00 $91.00 $99.00 $108.00 $91.00 $99.00 $108.0076802 $73.00 $86.00 $93.00 $100.00 $86.00 $93.00 $100.0076802-26 $43.00 $44.00 $46.00 $48.00 $44.00 $46.00 $48.0076802-TC $30.00 $42.00 $47.00 $53.00 $42.00 $47.00 $53.0076805 $131.00 $153.00 $164.00 $175.00 $153.00 $164.00 $175.0076805-26 $51.00 $52.00 $53.00 $55.00 $52.00 $53.00 $55.0076805-TC $79.00 $102.00 $111.00 $120.00 $102.00 $111.00 $120.0076810 $252.00 $112.00 $121.00 $133.00 $112.00 $121.00 $133.0076810-26 $100.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.0076810-TC $151.00 $61.00 $69.00 $78.00 $61.00 $69.00 $78.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

76811 $243.00 $245.00 $266.00 $290.00 $245.00 $266.00 $290.0076811-26 $100.00 $100.00 $103.00 $108.00 $100.00 $103.00 $108.0076811-TC $142.00 $145.00 $162.00 $183.00 $145.00 $162.00 $183.0076812 $145.00 $162.00 $174.00 $189.00 $162.00 $174.00 $189.0076812-26 $94.00 $94.00 $97.00 $101.00 $94.00 $97.00 $101.0076812-TC $51.00 $69.00 $77.00 $88.00 $69.00 $77.00 $88.0076813 ------- $142.00 $152.00 $163.00 $142.00 $152.00 $163.0076813-26 ------- $62.00 $65.00 $67.00 $62.00 $65.00 $67.0076813-TC ------- $80.00 $88.00 $96.00 $80.00 $88.00 $96.0076814 ------- $93.00 $100.00 $109.00 $93.00 $100.00 $109.0076814-26 ------- $51.00 $53.00 $55.00 $51.00 $53.00 $55.0076814-TC ------- $42.00 $48.00 $54.00 $42.00 $48.00 $54.0076815 $88.00 $98.00 $105.00 $113.00 $98.00 $105.00 $113.0076815-26 $33.00 $34.00 $35.00 $37.00 $34.00 $35.00 $37.0076815-TC $53.00 $64.00 $70.00 $76.00 $64.00 $70.00 $76.0076816 $72.00 $109.00 $116.00 $123.00 $109.00 $116.00 $123.0076816-26 $30.00 $45.00 $46.00 $48.00 $45.00 $46.00 $48.0076816-TC $41.00 $64.00 $70.00 $75.00 $64.00 $70.00 $75.0076817 $96.00 $103.00 $110.00 $117.00 $103.00 $110.00 $117.0076817-26 $39.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0076817-TC $57.00 $64.00 $70.00 $75.00 $64.00 $70.00 $75.0076818 $105.00 $131.00 $140.00 $149.00 $131.00 $140.00 $149.0076818-26 $40.00 $55.00 $57.00 $60.00 $55.00 $57.00 $60.0076818-TC $60.00 $75.00 $82.00 $89.00 $75.00 $82.00 $89.0076819 $101.00 $106.00 $113.00 $121.00 $106.00 $113.00 $121.0076819-26 $40.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.0076819-TC $60.00 $65.00 $71.00 $78.00 $65.00 $71.00 $78.0076820 ------- $74.00 $80.00 $88.00 $74.00 $80.00 $88.0076820-26 ------- $27.00 $28.00 $29.00 $27.00 $28.00 $29.0076820-TC ------- $47.00 $52.00 $58.00 $47.00 $52.00 $58.0076821 ------- $109.00 $117.00 $126.00 $109.00 $117.00 $126.0076821-26 ------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.0076821-TC ------- $72.00 $79.00 $86.00 $72.00 $79.00 $86.0076825 $160.00 $189.00 $200.00 $212.00 $189.00 $200.00 $212.0076825-26 $65.00 $88.00 $90.00 $94.00 $88.00 $90.00 $94.0076825-TC $73.00 $101.00 $110.00 $118.00 $101.00 $110.00 $118.0076826 $71.00 $107.00 $114.00 $120.00 $107.00 $114.00 $120.0076826-26 $46.00 $43.00 $44.00 $46.00 $43.00 $44.00 $46.0076826-TC $27.00 $64.00 $69.00 $74.00 $64.00 $69.00 $74.0076827 $97.00 $89.00 $96.00 $104.00 $89.00 $96.00 $104.0076827-26 $35.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0076827-TC $65.00 $59.00 $65.00 $72.00 $59.00 $65.00 $72.0076828 $72.00 $66.00 $71.00 $76.00 $66.00 $71.00 $76.0076828-26 $29.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0076828-TC $42.00 $36.00 $40.00 $44.00 $36.00 $40.00 $44.0076830 $93.00 $122.00 $131.00 $141.00 $122.00 $131.00 $141.0076830-26 $35.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.0076830-TC $57.00 $86.00 $94.00 $101.00 $86.00 $94.00 $101.0076831 $95.00 $123.00 $132.00 $141.00 $123.00 $132.00 $141.0076831-26 $37.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 269

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

76831-TC $57.00 $86.00 $93.00 $101.00 $86.00 $93.00 $101.0076856 $93.00 $123.00 $132.00 $141.00 $123.00 $132.00 $141.0076856-26 $35.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.0076856-TC $57.00 $86.00 $94.00 $102.00 $86.00 $94.00 $102.0076857 $59.00 $84.00 $90.00 $96.00 $84.00 $90.00 $96.0076857-26 $19.00 $20.00 $21.00 $22.00 $20.00 $21.00 $22.0076857-TC $39.00 $64.00 $69.00 $74.00 $64.00 $69.00 $74.0076870 $90.00 $121.00 $130.00 $139.00 $121.00 $130.00 $139.0076870-26 $33.00 $34.00 $35.00 $37.00 $34.00 $35.00 $37.0076870-TC $57.00 $87.00 $95.00 $103.00 $87.00 $95.00 $103.0076872 $93.00 $138.00 $149.00 $159.00 $138.00 $149.00 $159.0076872-26 $36.00 $37.00 $39.00 $41.00 $37.00 $39.00 $41.0076872-TC $57.00 $101.00 $110.00 $118.00 $101.00 $110.00 $118.0076873 $151.00 $185.00 $198.00 $212.00 $185.00 $198.00 $212.0076873-26 $68.00 $83.00 $86.00 $90.00 $83.00 $86.00 $90.0076873-TC $80.00 $102.00 $112.00 $122.00 $102.00 $112.00 $122.0076880 $85.00 $123.00 $132.00 $141.00 $123.00 $132.00 $141.0076880-26 $32.00 $31.00 $32.00 $34.00 $31.00 $32.00 $34.0076880-TC $54.00 $92.00 $100.00 $107.00 $92.00 $100.00 $107.0076930 $93.00 $108.00 $115.00 $123.00 $108.00 $115.00 $123.0076930-26 NC $37.00 $39.00 $40.00 $37.00 $39.00 $40.0076930-TC NC $70.00 $77.00 $84.00 $70.00 $77.00 $84.0076932 $93.00 ------- ------- ------- ------- ------- -------76932-26 NC $38.00 $39.00 $40.00 $38.00 $39.00 $40.0076932-TC NC BR BR BR BR BR BR76936 $341.00 $360.00 $388.00 $417.00 $360.00 $388.00 $417.0076936-26 $102.00 $109.00 $113.00 $119.00 $109.00 $113.00 $119.0076936-TC $236.00 $251.00 $274.00 $298.00 $251.00 $274.00 $298.0076937 ------- $41.00 $45.00 $50.00 $41.00 $45.00 $50.0076937-26 ------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.0076937-TC ------- $24.00 $27.00 $31.00 $24.00 $27.00 $31.0076940 ------- BR BR BR BR BR BR76940-26 ------- $119.00 $127.00 $138.00 $119.00 $127.00 $138.0076940-TC ------- BR BR BR BR BR BR76941 $128.00 ------- ------- ------- ------- ------- -------76941-26 NC $71.00 $73.00 $76.00 $71.00 $73.00 $76.0076941-TC NC BR BR BR BR BR BR76942 $92.00 $186.00 $200.00 $213.00 $186.00 $200.00 $213.0076942-26 NC $36.00 $37.00 $38.00 $36.00 $37.00 $38.0076942-TC NC $151.00 $163.00 $175.00 $151.00 $163.00 $175.0076945 $93.00 ------- ------- ------- ------- ------- -------76945-26 NC $35.00 $36.00 $37.00 $35.00 $36.00 $37.0076945-TC NC BR BR BR BR BR BR76946 $78.00 $63.00 $68.00 $74.00 $63.00 $68.00 $74.0076946-26 NC $20.00 $21.00 $21.00 $20.00 $21.00 $21.0076946-TC NC $43.00 $47.00 $53.00 $43.00 $47.00 $53.0076948 $77.00 $62.00 $67.00 $74.00 $62.00 $67.00 $74.0076948-26 NC $19.00 $20.00 $21.00 $19.00 $20.00 $21.0076948-TC NC $43.00 $47.00 $53.00 $43.00 $47.00 $53.0076950 $80.00 $81.00 $86.00 $93.00 $81.00 $86.00 $93.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 270

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

76950-26 $30.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0076950-TC $48.00 $50.00 $55.00 $59.00 $50.00 $55.00 $59.0076965 $281.00 $214.00 $231.00 $251.00 $214.00 $231.00 $251.0076965-26 $84.00 $72.00 $75.00 $79.00 $72.00 $75.00 $79.0076965-TC $208.00 $141.00 $156.00 $172.00 $141.00 $156.00 $172.0076970 $60.00 $82.00 $88.00 $94.00 $82.00 $88.00 $94.0076970-26 $20.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.0076970-TC $39.00 $61.00 $66.00 $72.00 $61.00 $66.00 $72.0076975 $99.00 $177.00 $195.00 $214.00 $177.00 $195.00 $214.0076975-26 NC $44.00 $45.00 $47.00 $44.00 $45.00 $47.0076975-TC NC $163.00 $179.00 $197.00 $163.00 $179.00 $197.0076977 $34.00 $24.00 $27.00 $30.00 $24.00 $27.00 $30.0076977-26 $3.00 $3.00 $3.00 $4.00 $3.00 $3.00 $4.0076977-TC $31.00 $21.00 $23.00 $26.00 $21.00 $23.00 $26.0076998 ------- BR BR BR BR BR BR76998-26 ------- $67.00 $71.00 $76.00 $67.00 $71.00 $76.0076998-TC ------- BR BR BR BR BR BR76999 BR ------- ------- ------- ------- ------- -------76999-26 BR ------- ------- ------- ------- ------- -------76999-TC BR ------- ------- ------- ------- ------- -------77001 ------- $102.00 $110.00 $119.00 $102.00 $110.00 $119.0077001-26 ------- $20.00 $20.00 $21.00 $20.00 $20.00 $21.0077001-TC ------- $83.00 $90.00 $98.00 $83.00 $90.00 $98.0077002 ------- $79.00 $84.00 $90.00 $79.00 $84.00 $90.0077002-26 ------- $28.00 $28.00 $29.00 $28.00 $28.00 $29.0077002-TC ------- $51.00 $56.00 $61.00 $51.00 $56.00 $61.0077003 ------- $72.00 $77.00 $83.00 $72.00 $77.00 $83.0077003-26 ------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.0077003-TC ------- $42.00 $46.00 $51.00 $42.00 $46.00 $51.0077011 ------- $642.00 $692.00 $740.00 $642.00 $692.00 $740.0077011-26 ------- $64.00 $66.00 $68.00 $64.00 $66.00 $68.0077011-TC ------- $579.00 $626.00 $672.00 $579.00 $626.00 $672.0077012 ------- $288.00 $312.00 $340.00 $288.00 $312.00 $340.0077012-26 ------- $62.00 $64.00 $66.00 $62.00 $64.00 $66.0077012-TC ------- $226.00 $249.00 $273.00 $226.00 $249.00 $273.0077013-26 ------- $212.00 $219.00 $228.00 $212.00 $219.00 $228.0077013-TC ------- BR BR BR BR BR BR77014 ------- $195.00 $210.00 $225.00 $195.00 $210.00 $225.0077014-26 ------- $45.00 $46.00 $48.00 $45.00 $46.00 $48.0077014-TC ------- $151.00 $164.00 $177.00 $151.00 $164.00 $177.0077021 ------- $516.00 $558.00 $603.00 $516.00 $558.00 $603.0077021-26 ------- $81.00 $84.00 $88.00 $81.00 $84.00 $88.0077021-TC ------- $435.00 $474.00 $515.00 $435.00 $474.00 $515.0077022 ------- BR BR BR BR BR BR77022-26 ------- $228.00 $237.00 $248.00 $228.00 $237.00 $248.0077022-TC ------- BR BR BR BR BR BR77031 ------- $275.00 $298.00 $323.00 $275.00 $298.00 $323.0077031-26 ------- $85.00 $88.00 $92.00 $85.00 $88.00 $92.0077031-TC ------- $190.00 $209.00 $230.00 $190.00 $209.00 $230.0077032 ------- $72.00 $77.00 $83.00 $72.00 $77.00 $83.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

77032-26 ------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.0077032-TC ------- $43.00 $47.00 $51.00 $43.00 $47.00 $51.0077051 ------- $16.00 $17.00 $19.00 $16.00 $17.00 $19.0077051-26 ------- $4.00 $4.00 $4.00 $4.00 $4.00 $4.0077051-TC ------- $12.00 $13.00 $14.00 $12.00 $13.00 $14.0077052 ------- $16.00 $17.00 $19.00 $16.00 $17.00 $19.0077052-26 ------- $4.00 $4.00 $4.00 $4.00 $4.00 $4.0077052-TC ------- $12.00 $13.00 $14.00 $12.00 $13.00 $14.0077053 ------- $102.00 $110.00 $120.00 $102.00 $110.00 $120.0077053-26 ------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.0077053-TC ------- $82.00 $90.00 $99.00 $82.00 $90.00 $99.0077054 ------- $137.00 $149.00 $162.00 $137.00 $149.00 $162.0077054-26 ------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.0077054-TC ------- $114.00 $125.00 $136.00 $114.00 $125.00 $136.0077055 ------- $89.00 $95.00 $101.00 $89.00 $95.00 $101.0077055-26 ------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.0077055-TC ------- $52.00 $56.00 $61.00 $52.00 $56.00 $61.0077056 ------- $112.00 $120.00 $127.00 $112.00 $120.00 $127.0077056-26 ------- $46.00 $48.00 $50.00 $46.00 $48.00 $50.0077056-TC ------- $66.00 $72.00 $78.00 $66.00 $72.00 $78.0077057 ------- $90.00 $96.00 $102.00 $90.00 $96.00 $102.0077057-26 ------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.0077057-TC ------- $52.00 $57.00 $62.00 $52.00 $57.00 $62.0077058 ------- $904.00 $979.00 $1,056.00 $904.00 $979.00 $1,056.0077058-26 ------- $86.00 $89.00 $93.00 $86.00 $89.00 $93.0077058-TC ------- $817.00 $890.00 $963.00 $817.00 $890.00 $963.0077059 ------- $1,046.00 $1,136.00 $1,230.00 $1,046.00 $1,136.00 $1,230.0077059-26 ------- $86.00 $89.00 $93.00 $86.00 $89.00 $93.0077059-TC ------- $959.00 $1,047.00 $1,137.00 $959.00 $1,047.00 $1,137.0077071 ------- $38.00 $40.00 $43.00 $38.00 $40.00 $43.0077072 ------- $25.00 $27.00 $29.00 $25.00 $27.00 $29.0077072-26 ------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.0077072-TC ------- $15.00 $17.00 $18.00 $15.00 $17.00 $18.0077073 ------- $44.00 $48.00 $51.00 $44.00 $48.00 $51.0077073-26 ------- $15.00 $15.00 $16.00 $15.00 $15.00 $16.0077073-TC ------- $30.00 $33.00 $36.00 $30.00 $33.00 $36.0077074 ------- $73.00 $78.00 $84.00 $73.00 $78.00 $84.0077074-26 ------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.0077074-TC ------- $48.00 $53.00 $57.00 $48.00 $53.00 $57.0077075 ------- $103.00 $111.00 $118.00 $103.00 $111.00 $118.0077075-26 ------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.0077075-TC ------- $74.00 $81.00 $88.00 $74.00 $81.00 $88.0077077 ------- $53.00 $57.00 $62.00 $53.00 $57.00 $62.0077077-26 ------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.0077077-TC ------- $36.00 $40.00 $44.00 $36.00 $40.00 $44.0077078 ------- $90.00 $97.00 $104.00 $90.00 $97.00 $104.0077078-26 ------- $13.00 $13.00 $14.00 $13.00 $13.00 $14.0077078-TC ------- $77.00 $84.00 $90.00 $77.00 $84.00 $90.0077079 ------- $87.00 $94.00 $100.00 $87.00 $94.00 $100.0077079-26 ------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

77079-TC ------- $76.00 $82.00 $88.00 $76.00 $82.00 $88.0077080 ------- $89.00 $97.00 $106.00 $89.00 $97.00 $106.0077080-26 ------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.0077080-TC ------- $78.00 $86.00 $94.00 $78.00 $86.00 $94.0077081 ------- $37.00 $40.00 $44.00 $37.00 $40.00 $44.0077081-26 ------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.0077081-TC ------- $26.00 $29.00 $31.00 $26.00 $29.00 $31.0077082 ------- $36.00 $39.00 $42.00 $36.00 $39.00 $42.0077082-26 ------- $9.00 $9.00 $10.00 $9.00 $9.00 $10.0077082-TC ------- $27.00 $30.00 $33.00 $27.00 $30.00 $33.0077083 ------- $34.00 $37.00 $41.00 $34.00 $37.00 $41.0077083-26 ------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.0077083-TC ------- $24.00 $26.00 $29.00 $24.00 $26.00 $29.0077084 ------- $413.00 $446.00 $479.00 $413.00 $446.00 $479.0077084-26 ------- $84.00 $87.00 $90.00 $84.00 $87.00 $90.0077084-TC ------- $330.00 $359.00 $389.00 $330.00 $359.00 $389.0077261 $73.00 $75.00 $77.00 $81.00 $75.00 $77.00 $81.0077262 $110.00 $113.00 $117.00 $122.00 $113.00 $117.00 $122.0077263 $163.00 $168.00 $174.00 $182.00 $168.00 $174.00 $182.0077280 $166.00 $199.00 $215.00 $231.00 $199.00 $215.00 $231.0077280-26 $36.00 $37.00 $39.00 $41.00 $37.00 $39.00 $41.0077280-TC $130.00 $162.00 $176.00 $191.00 $162.00 $176.00 $191.0077285 $264.00 $334.00 $361.00 $387.00 $334.00 $361.00 $387.0077285-26 $53.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.0077285-TC $209.00 $279.00 $304.00 $328.00 $279.00 $304.00 $328.0077290 $325.00 $485.00 $523.00 $560.00 $485.00 $523.00 $560.0077290-26 $79.00 $82.00 $85.00 $89.00 $82.00 $85.00 $89.0077290-TC $243.00 $403.00 $438.00 $471.00 $403.00 $438.00 $471.0077295 $1,287.00 $999.00 $1,084.00 $1,180.00 $999.00 $1,084.00 $1,180.0077295-26 $232.00 $241.00 $250.00 $260.00 $241.00 $250.00 $260.0077295-TC $1,046.00 $758.00 $835.00 $920.00 $758.00 $835.00 $920.0077299 BR ------- ------- ------- ------- ------- -------77299-26 BR ------- ------- ------- ------- ------- -------77299-TC BR ------- ------- ------- ------- ------- -------77300 $87.00 $83.00 $88.00 $95.00 $83.00 $88.00 $95.0077300-26 $36.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0077300-TC $52.00 $50.00 $55.00 $59.00 $50.00 $55.00 $59.0077301 $1,473.00 $2,139.00 $2,300.00 $2,460.00 $2,139.00 $2,300.00 $2,460.0077301-26 $415.00 $422.00 $437.00 $455.00 $422.00 $437.00 $455.0077301-TC $1,046.00 $1,718.00 $1,863.00 $2,004.00 $1,718.00 $1,863.00 $2,004.0077305 $106.00 $94.00 $101.00 $110.00 $94.00 $101.00 $110.0077305-26 $36.00 $37.00 $39.00 $41.00 $37.00 $39.00 $41.0077305-TC $69.00 $57.00 $62.00 $69.00 $57.00 $62.00 $69.0077310 $142.00 $127.00 $136.00 $146.00 $127.00 $136.00 $146.0077310-26 $53.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.0077310-TC $87.00 $72.00 $79.00 $87.00 $72.00 $79.00 $87.0077315 $181.00 $174.00 $186.00 $199.00 $174.00 $186.00 $199.0077315-26 $79.00 $82.00 $85.00 $89.00 $82.00 $85.00 $89.0077315-TC $99.00 $92.00 $101.00 $110.00 $92.00 $101.00 $110.0077321 $200.00 $166.00 $180.00 $195.00 $166.00 $180.00 $195.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

77321-26 $48.00 $50.00 $52.00 $55.00 $50.00 $52.00 $55.0077321-TC $150.00 $116.00 $127.00 $140.00 $116.00 $127.00 $140.0077326 $137.00 $156.00 $168.00 $180.00 $156.00 $168.00 $180.0077326-26 $47.00 $49.00 $51.00 $53.00 $49.00 $51.00 $53.0077326-TC $88.00 $107.00 $117.00 $127.00 $107.00 $117.00 $127.0077327 $202.00 $224.00 $240.00 $257.00 $224.00 $240.00 $257.0077327-26 $71.00 $73.00 $76.00 $79.00 $73.00 $76.00 $79.0077327-TC $130.00 $151.00 $165.00 $178.00 $151.00 $165.00 $178.0077328 $295.00 $313.00 $336.00 $359.00 $313.00 $336.00 $359.0077328-26 $106.00 $111.00 $115.00 $120.00 $111.00 $115.00 $120.0077328-TC $185.00 $202.00 $221.00 $240.00 $202.00 $221.00 $240.0077331 $64.00 $67.00 $70.00 $74.00 $67.00 $70.00 $74.0077331-26 $45.00 $46.00 $47.00 $49.00 $46.00 $47.00 $49.0077331-TC $18.00 $21.00 $23.00 $25.00 $21.00 $23.00 $25.0077332 $78.00 $86.00 $93.00 $99.00 $86.00 $93.00 $99.0077332-26 $27.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0077332-TC $50.00 $58.00 $63.00 $68.00 $58.00 $63.00 $68.0077333 $115.00 $93.00 $100.00 $107.00 $93.00 $100.00 $107.0077333-26 $43.00 $44.00 $46.00 $48.00 $44.00 $46.00 $48.0077333-TC $70.00 $49.00 $54.00 $60.00 $49.00 $54.00 $60.0077334 $187.00 $185.00 $198.00 $213.00 $185.00 $198.00 $213.0077334-26 $63.00 $65.00 $67.00 $70.00 $65.00 $67.00 $70.0077334-TC $121.00 $120.00 $131.00 $143.00 $120.00 $131.00 $143.0077336 $111.00 $91.00 $100.00 $110.00 $91.00 $100.00 $110.0077370 $130.00 $140.00 $152.00 $165.00 $140.00 $152.00 $165.0077371 ------- $1,190.00 $1,277.00 $1,351.00 $1,190.00 $1,277.00 $1,351.0077372 ------- $904.00 $971.00 $1,028.00 $904.00 $971.00 $1,028.0077373 ------- $1,683.00 $1,806.00 $1,908.00 $1,683.00 $1,806.00 $1,908.0077399 BR ------- ------- ------- ------- ------- -------77399-26 BR ------- ------- ------- ------- ------- -------77399-TC BR ------- ------- ------- ------- ------- -------77401 $66.00 $51.00 $56.00 $62.00 $51.00 $56.00 $62.0077402 $66.00 $127.00 $138.00 $148.00 $127.00 $138.00 $148.0077403 $66.00 $116.00 $126.00 $135.00 $116.00 $126.00 $135.0077404 $66.00 $124.00 $135.00 $145.00 $124.00 $135.00 $145.0077406 $66.00 $125.00 $136.00 $146.00 $125.00 $136.00 $146.0077407 $78.00 $162.00 $176.00 $188.00 $162.00 $176.00 $188.0077408 $78.00 $150.00 $163.00 $175.00 $150.00 $163.00 $175.0077409 $78.00 $162.00 $175.00 $188.00 $162.00 $175.00 $188.0077411 $78.00 $161.00 $175.00 $188.00 $161.00 $175.00 $188.0077412 $87.00 $187.00 $203.00 $217.00 $187.00 $203.00 $217.0077413 $87.00 $189.00 $204.00 $219.00 $189.00 $204.00 $219.0077414 $87.00 $206.00 $222.00 $238.00 $206.00 $222.00 $238.0077416 $87.00 $206.00 $222.00 $238.00 $206.00 $222.00 $238.0077417 $21.00 $21.00 $23.00 $26.00 $21.00 $23.00 $26.0077418 $609.00 $621.00 $667.00 $707.00 $621.00 $667.00 $707.0077421 ------- $137.00 $147.00 $158.00 $137.00 $147.00 $158.0077421-26 ------- $21.00 $21.00 $22.00 $21.00 $21.00 $22.0077421-TC ------- $116.00 $126.00 $136.00 $116.00 $126.00 $136.0077422 ------- $147.00 $159.00 $171.00 $147.00 $159.00 $171.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

77423 ------- $199.00 $215.00 $230.00 $199.00 $215.00 $230.0077427 $166.00 $195.00 $202.00 $210.00 $195.00 $202.00 $210.0077431 $95.00 $101.00 $105.00 $109.00 $101.00 $105.00 $109.0077432 $417.00 $426.00 $441.00 $460.00 $426.00 $441.00 $460.0077435 ------- $708.00 $735.00 $767.00 $708.00 $735.00 $767.0077470 $527.00 $391.00 $424.00 $462.00 $391.00 $424.00 $462.0077470-26 $106.00 $111.00 $115.00 $120.00 $111.00 $115.00 $120.0077470-TC $417.00 $280.00 $309.00 $342.00 $280.00 $309.00 $342.0077499 BR ------- ------- ------- ------- ------- -------77499-26 BR ------- ------- ------- ------- ------- -------77499-TC BR ------- ------- ------- ------- ------- -------77520 BR ------- ------- ------- ------- ------- -------77522 BR ------- ------- ------- ------- ------- -------77523 BR ------- ------- ------- ------- ------- -------77525 BR ------- ------- ------- ------- ------- -------77600 $196.00 $343.00 $367.00 $391.00 $343.00 $367.00 $391.0077600-26 $80.00 $82.00 $85.00 $89.00 $82.00 $85.00 $89.0077600-TC $113.00 $261.00 $282.00 $302.00 $261.00 $282.00 $302.0077605 $263.00 $556.00 $596.00 $635.00 $556.00 $596.00 $635.0077605-26 $108.00 $111.00 $116.00 $122.00 $111.00 $116.00 $122.0077605-TC $151.00 $446.00 $481.00 $513.00 $446.00 $481.00 $513.0077610 $195.00 $494.00 $529.00 $562.00 $494.00 $529.00 $562.0077610-26 $79.00 $79.00 $82.00 $86.00 $79.00 $82.00 $86.0077610-TC $113.00 $415.00 $447.00 $476.00 $415.00 $447.00 $476.0077615 $262.00 $699.00 $749.00 $794.00 $699.00 $749.00 $794.0077615-26 $106.00 $109.00 $113.00 $118.00 $109.00 $113.00 $118.0077615-TC $151.00 $590.00 $635.00 $676.00 $590.00 $635.00 $676.0077620 $196.00 $356.00 $383.00 $411.00 $356.00 $383.00 $411.0077620-26 $80.00 $88.00 $93.00 $100.00 $88.00 $93.00 $100.0077620-TC $113.00 $268.00 $290.00 $310.00 $268.00 $290.00 $310.0077750 $299.00 $349.00 $365.00 $384.00 $349.00 $365.00 $384.0077750-26 $248.00 $261.00 $270.00 $282.00 $261.00 $270.00 $282.0077750-TC $49.00 $88.00 $95.00 $102.00 $88.00 $95.00 $102.0077761 $284.00 $356.00 $377.00 $399.00 $356.00 $377.00 $399.0077761-26 $188.00 $199.00 $206.00 $214.00 $199.00 $206.00 $214.0077761-TC $93.00 $158.00 $171.00 $184.00 $158.00 $171.00 $184.0077762 $427.00 $498.00 $526.00 $556.00 $498.00 $526.00 $556.0077762-26 $289.00 $303.00 $314.00 $327.00 $303.00 $314.00 $327.0077762-TC $135.00 $196.00 $212.00 $229.00 $196.00 $212.00 $229.0077763 $605.00 $703.00 $741.00 $782.00 $703.00 $741.00 $782.0077763-26 $435.00 $453.00 $469.00 $489.00 $453.00 $469.00 $489.0077763-TC $167.00 $250.00 $272.00 $293.00 $250.00 $272.00 $293.0077776 $316.00 $416.00 $442.00 $472.00 $416.00 $442.00 $472.0077776-26 $233.00 $251.00 $264.00 $280.00 $251.00 $264.00 $280.0077776-TC $82.00 $165.00 $179.00 $192.00 $165.00 $179.00 $192.0077777 $540.00 $600.00 $632.00 $668.00 $600.00 $632.00 $668.0077777-26 $378.00 $395.00 $410.00 $428.00 $395.00 $410.00 $428.0077777-TC $158.00 $204.00 $222.00 $240.00 $204.00 $222.00 $240.0077778 $764.00 $860.00 $905.00 $954.00 $860.00 $905.00 $954.0077778-26 $568.00 $592.00 $614.00 $640.00 $592.00 $614.00 $640.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

77778-TC $192.00 $267.00 $291.00 $314.00 $267.00 $291.00 $314.0077789 $74.00 $103.00 $108.00 $114.00 $103.00 $108.00 $114.0077789-26 $57.00 $61.00 $63.00 $66.00 $61.00 $63.00 $66.0077789-TC $16.00 $42.00 $45.00 $48.00 $42.00 $45.00 $48.0077790 $72.00 $88.00 $93.00 $97.00 $88.00 $93.00 $97.0077790-26 $53.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.0077790-TC $18.00 $33.00 $36.00 $38.00 $33.00 $36.00 $38.0077799 BR ------- ------- ------- ------- ------- -------77799-26 BR ------- ------- ------- ------- ------- -------77799-TC BR ------- ------- ------- ------- ------- -------78000 $46.00 $68.00 $73.00 $79.00 $68.00 $73.00 $79.0078000-26 $9.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0078000-TC $36.00 $58.00 $63.00 $68.00 $58.00 $63.00 $68.0078001 $62.00 $87.00 $94.00 $101.00 $87.00 $94.00 $101.0078001-26 $12.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.0078001-TC $48.00 $73.00 $80.00 $86.00 $73.00 $80.00 $86.0078003 $54.00 $75.00 $81.00 $87.00 $75.00 $81.00 $87.0078003-26 $17.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.0078003-TC $36.00 $58.00 $63.00 $68.00 $58.00 $63.00 $68.0078006 $115.00 $199.00 $215.00 $229.00 $199.00 $215.00 $229.0078006-26 $24.00 $26.00 $26.00 $27.00 $26.00 $26.00 $27.0078006-TC $89.00 $174.00 $188.00 $202.00 $174.00 $188.00 $202.0078007 $122.00 $142.00 $154.00 $165.00 $142.00 $154.00 $165.0078007-26 $25.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0078007-TC $96.00 $116.00 $126.00 $137.00 $116.00 $126.00 $137.0078010 $89.00 $143.00 $154.00 $165.00 $143.00 $154.00 $165.0078010-26 $19.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.0078010-TC $68.00 $122.00 $133.00 $143.00 $122.00 $133.00 $143.0078011 $114.00 $162.00 $174.00 $187.00 $162.00 $174.00 $187.0078011-26 $22.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0078011-TC $90.00 $138.00 $150.00 $161.00 $138.00 $150.00 $161.0078015 $132.00 $195.00 $210.00 $225.00 $195.00 $210.00 $225.0078015-26 $34.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.0078015-TC $96.00 $160.00 $173.00 $187.00 $160.00 $173.00 $187.0078016 $173.00 $285.00 $306.00 $327.00 $285.00 $306.00 $327.0078016-26 $42.00 $43.00 $44.00 $46.00 $43.00 $44.00 $46.0078016-TC $130.00 $242.00 $262.00 $281.00 $242.00 $262.00 $281.0078018 $248.00 $321.00 $346.00 $372.00 $321.00 $346.00 $372.0078018-26 $44.00 $46.00 $48.00 $50.00 $46.00 $48.00 $50.0078018-TC $202.00 $274.00 $299.00 $323.00 $274.00 $299.00 $323.0078020 $35.00 $97.00 $105.00 $114.00 $97.00 $105.00 $114.0078020-26 $30.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0078020-TC $5.00 $66.00 $73.00 $80.00 $66.00 $73.00 $80.0078070 $112.00 $197.00 $212.00 $226.00 $197.00 $212.00 $226.0078070-26 $36.00 $44.00 $45.00 $47.00 $44.00 $45.00 $47.0078070-TC $68.00 $154.00 $166.00 $178.00 $154.00 $166.00 $178.0078075 $242.00 $387.00 $417.00 $447.00 $387.00 $417.00 $447.0078075-26 $38.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0078075-TC $202.00 $348.00 $377.00 $406.00 $348.00 $377.00 $406.0078099 BR ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

78099-26 BR ------- ------- ------- ------- ------- -------78099-TC BR ------- ------- ------- ------- ------- -------78102 $106.00 $155.00 $167.00 $178.00 $155.00 $167.00 $178.0078102-26 $28.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0078102-TC $77.00 $126.00 $137.00 $148.00 $126.00 $137.00 $148.0078103 $158.00 $214.00 $231.00 $247.00 $214.00 $231.00 $247.0078103-26 $39.00 $40.00 $41.00 $43.00 $40.00 $41.00 $43.0078103-TC $118.00 $175.00 $190.00 $205.00 $175.00 $190.00 $205.0078104 $194.00 $253.00 $272.00 $292.00 $253.00 $272.00 $292.0078104-26 $41.00 $42.00 $44.00 $45.00 $42.00 $44.00 $45.0078104-TC $152.00 $210.00 $229.00 $247.00 $210.00 $229.00 $247.0078110 $45.00 $74.00 $79.00 $85.00 $74.00 $79.00 $85.0078110-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0078110-TC $35.00 $63.00 $68.00 $74.00 $63.00 $68.00 $74.0078111 $108.00 $112.00 $121.00 $131.00 $112.00 $121.00 $131.0078111-26 $11.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.0078111-TC $96.00 $100.00 $109.00 $119.00 $100.00 $109.00 $119.0078120 $78.00 $93.00 $101.00 $109.00 $93.00 $101.00 $109.0078120-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0078120-TC $65.00 $81.00 $88.00 $96.00 $81.00 $88.00 $96.0078121 $125.00 $124.00 $134.00 $145.00 $124.00 $134.00 $145.0078121-26 $16.00 $17.00 $17.00 $18.00 $17.00 $17.00 $18.0078121-TC $108.00 $107.00 $117.00 $127.00 $107.00 $117.00 $127.0078122 $196.00 $171.00 $186.00 $202.00 $171.00 $186.00 $202.0078122-26 $22.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0078122-TC $171.00 $146.00 $161.00 $176.00 $146.00 $161.00 $176.0078130 $139.00 $162.00 $175.00 $187.00 $162.00 $175.00 $187.0078130-26 $32.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0078130-TC $106.00 $129.00 $141.00 $152.00 $129.00 $141.00 $152.0078135 $216.00 $311.00 $336.00 $361.00 $311.00 $336.00 $361.0078135-26 $33.00 $34.00 $35.00 $37.00 $34.00 $35.00 $37.0078135-TC $182.00 $277.00 $301.00 $324.00 $277.00 $301.00 $324.0078140 $179.00 $177.00 $191.00 $207.00 $177.00 $191.00 $207.0078140-26 $31.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0078140-TC $147.00 $144.00 $157.00 $172.00 $144.00 $157.00 $172.0078185 $110.00 $175.00 $189.00 $202.00 $175.00 $189.00 $202.0078185-26 $20.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0078185-TC $88.00 $154.00 $167.00 $179.00 $154.00 $167.00 $179.0078190 $272.00 $253.00 $272.00 $292.00 $253.00 $272.00 $292.0078190-26 $57.00 $58.00 $60.00 $63.00 $58.00 $60.00 $63.0078190-TC $214.00 $195.00 $212.00 $229.00 $195.00 $212.00 $229.0078191 $307.00 $265.00 $288.00 $313.00 $265.00 $288.00 $313.0078191-26 $31.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0078191-TC $274.00 $232.00 $254.00 $278.00 $232.00 $254.00 $278.0078195 $216.00 $320.00 $344.00 $368.00 $320.00 $344.00 $368.0078195-26 $49.00 $64.00 $67.00 $69.00 $64.00 $67.00 $69.0078195-TC $152.00 $256.00 $278.00 $299.00 $256.00 $278.00 $299.0078199 BR ------- ------- ------- ------- ------- -------78199-26 BR ------- ------- ------- ------- ------- -------78199-TC BR ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

78201 $112.00 $165.00 $178.00 $191.00 $165.00 $178.00 $191.0078201-26 $22.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.0078201-TC $88.00 $142.00 $155.00 $166.00 $142.00 $155.00 $166.0078202 $135.00 $194.00 $209.00 $223.00 $194.00 $209.00 $223.0078202-26 $26.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0078202-TC $108.00 $167.00 $181.00 $195.00 $167.00 $181.00 $195.0078205 $259.00 $272.00 $295.00 $318.00 $272.00 $295.00 $318.0078205-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.0078205-TC $220.00 $234.00 $256.00 $278.00 $234.00 $256.00 $278.0078206 $265.00 $336.00 $360.00 $382.00 $336.00 $360.00 $382.0078206-26 $46.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.0078206-TC $214.00 $285.00 $307.00 $327.00 $285.00 $307.00 $327.0078215 $135.00 $184.00 $198.00 $212.00 $184.00 $198.00 $212.0078215-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0078215-TC $109.00 $158.00 $171.00 $184.00 $158.00 $171.00 $184.0078216 $160.00 $161.00 $175.00 $188.00 $161.00 $175.00 $188.0078216-26 $29.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0078216-TC $130.00 $132.00 $144.00 $157.00 $132.00 $144.00 $157.0078220 $165.00 $168.00 $182.00 $196.00 $168.00 $182.00 $196.0078220-26 $24.00 $26.00 $26.00 $27.00 $26.00 $26.00 $27.0078220-TC $139.00 $142.00 $155.00 $169.00 $142.00 $155.00 $169.0078223 $181.00 $290.00 $312.00 $333.00 $290.00 $312.00 $333.0078223-26 $43.00 $45.00 $46.00 $48.00 $45.00 $46.00 $48.0078223-TC $137.00 $245.00 $265.00 $285.00 $245.00 $265.00 $285.0078230 $106.00 $154.00 $166.00 $178.00 $154.00 $166.00 $178.0078230-26 $23.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0078230-TC $82.00 $130.00 $141.00 $152.00 $130.00 $141.00 $152.0078231 $146.00 $152.00 $164.00 $177.00 $152.00 $164.00 $177.0078231-26 $27.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0078231-TC $118.00 $124.00 $136.00 $148.00 $124.00 $136.00 $148.0078232 $157.00 $157.00 $170.00 $184.00 $157.00 $170.00 $184.0078232-26 $23.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0078232-TC $132.00 $132.00 $144.00 $157.00 $132.00 $144.00 $157.0078258 $146.00 $208.00 $223.00 $239.00 $208.00 $223.00 $239.0078258-26 $38.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.0078258-TC $108.00 $169.00 $183.00 $196.00 $169.00 $183.00 $196.0078261 $190.00 $244.00 $264.00 $283.00 $244.00 $264.00 $283.0078261-26 $36.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.0078261-TC $152.00 $207.00 $225.00 $244.00 $207.00 $225.00 $244.0078262 $195.00 $246.00 $265.00 $285.00 $246.00 $265.00 $285.0078262-26 $35.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.0078262-TC $159.00 $210.00 $228.00 $247.00 $210.00 $228.00 $247.0078264 $195.00 $271.00 $293.00 $314.00 $271.00 $293.00 $314.0078264-26 $40.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.0078264-TC $154.00 $230.00 $250.00 $269.00 $230.00 $250.00 $269.0078267 BR ------- ------- ------- ------- ------- -------78268 BR ------- ------- ------- ------- ------- -------78270 $68.00 $84.00 $91.00 $99.00 $84.00 $91.00 $99.0078270-26 $10.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0078270-TC $58.00 $73.00 $80.00 $87.00 $73.00 $80.00 $87.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

78271 $72.00 $85.00 $92.00 $100.00 $85.00 $92.00 $100.0078271-26 $10.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.0078271-TC $61.00 $75.00 $81.00 $89.00 $75.00 $81.00 $89.0078272 $100.00 $107.00 $116.00 $125.00 $107.00 $116.00 $125.0078272-26 $14.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.0078272-TC $87.00 $93.00 $102.00 $111.00 $93.00 $102.00 $111.0078278 $234.00 $306.00 $330.00 $353.00 $306.00 $330.00 $353.0078278-26 $50.00 $52.00 $54.00 $56.00 $52.00 $54.00 $56.0078278-TC $182.00 $254.00 $276.00 $297.00 $254.00 $276.00 $297.0078282 BR $267.00 $294.00 $324.00 $267.00 $294.00 $324.0078282-26 $19.00 $20.00 $21.00 $22.00 $20.00 $21.00 $22.0078282-TC BR $261.00 $287.00 $316.00 $261.00 $287.00 $316.0078290 $149.00 $269.00 $289.00 $309.00 $269.00 $289.00 $309.0078290-26 $35.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.0078290-TC $113.00 $233.00 $252.00 $270.00 $233.00 $252.00 $270.0078291 $161.00 $232.00 $249.00 $266.00 $232.00 $249.00 $266.0078291-26 $45.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.0078291-TC $114.00 $185.00 $201.00 $216.00 $185.00 $201.00 $216.0078299 BR ------- ------- ------- ------- ------- -------78299-26 BR ------- ------- ------- ------- ------- -------78299-TC BR ------- ------- ------- ------- ------- -------78300 $125.00 $169.00 $183.00 $196.00 $169.00 $183.00 $196.0078300-26 $32.00 $33.00 $34.00 $36.00 $33.00 $34.00 $36.0078300-TC $93.00 $136.00 $148.00 $160.00 $136.00 $148.00 $160.0078305 $181.00 $230.00 $248.00 $266.00 $230.00 $248.00 $266.0078305-26 $42.00 $44.00 $46.00 $48.00 $44.00 $46.00 $48.0078305-TC $137.00 $186.00 $202.00 $218.00 $186.00 $202.00 $218.0078306 $205.00 $257.00 $277.00 $297.00 $257.00 $277.00 $297.0078306-26 $44.00 $46.00 $48.00 $50.00 $46.00 $48.00 $50.0078306-TC $159.00 $211.00 $229.00 $248.00 $211.00 $229.00 $248.0078315 $233.00 $310.00 $333.00 $357.00 $310.00 $333.00 $357.0078315-26 $52.00 $54.00 $56.00 $58.00 $54.00 $56.00 $58.0078315-TC $179.00 $256.00 $278.00 $299.00 $256.00 $278.00 $299.0078320 $276.00 $289.00 $312.00 $336.00 $289.00 $312.00 $336.0078320-26 $53.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.0078320-TC $220.00 $234.00 $255.00 $277.00 $234.00 $255.00 $277.0078350 $40.00 $38.00 $41.00 $44.00 $38.00 $41.00 $44.0078350-26 $11.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0078350-TC $29.00 $27.00 $30.00 $33.00 $27.00 $30.00 $33.0078351 $23.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.0078399 BR ------- ------- ------- ------- ------- -------78399-26 BR ------- ------- ------- ------- ------- -------78399-TC BR ------- ------- ------- ------- ------- -------78414 BR ------- ------- ------- ------- ------- -------78414-26 $23.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0078414-TC BR ------- ------- ------- ------- ------- -------78428 $126.00 $192.00 $206.00 $220.00 $192.00 $206.00 $220.0078428-26 $41.00 $43.00 $45.00 $47.00 $43.00 $45.00 $47.0078428-TC $84.00 $149.00 $161.00 $174.00 $149.00 $161.00 $174.0078445 $97.00 $154.00 $166.00 $177.00 $154.00 $166.00 $177.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 279

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

78445-26 $28.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0078445-TC $69.00 $128.00 $139.00 $150.00 $128.00 $139.00 $150.0078456 $205.00 $265.00 $285.00 $306.00 $265.00 $285.00 $306.0078456-26 $49.00 $53.00 $55.00 $57.00 $53.00 $55.00 $57.0078456-TC $151.00 $211.00 $230.00 $249.00 $211.00 $230.00 $249.0078457 $140.00 $188.00 $202.00 $216.00 $188.00 $202.00 $216.0078457-26 $39.00 $40.00 $41.00 $43.00 $40.00 $41.00 $43.0078457-TC $99.00 $148.00 $160.00 $173.00 $148.00 $160.00 $173.0078458 $198.00 $223.00 $240.00 $258.00 $223.00 $240.00 $258.0078458-26 $46.00 $48.00 $49.00 $51.00 $48.00 $49.00 $51.0078458-TC $149.00 $175.00 $191.00 $207.00 $175.00 $191.00 $207.0078459 BR $1,538.00 $1,694.00 $1,866.00 $1,538.00 $1,694.00 $1,866.0078459-26 $100.00 $82.00 $84.00 $87.00 $82.00 $84.00 $87.0078459-TC BR $1,512.00 $1,665.00 $1,834.00 $1,512.00 $1,665.00 $1,834.0078460 $134.00 $186.00 $199.00 $213.00 $186.00 $199.00 $213.0078460-26 $44.00 $46.00 $48.00 $50.00 $46.00 $48.00 $50.0078460-TC $88.00 $140.00 $152.00 $163.00 $140.00 $152.00 $163.0078461 $294.00 $245.00 $264.00 $284.00 $245.00 $264.00 $284.0078461-26 $82.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0078461-TC $213.00 $179.00 $196.00 $213.00 $179.00 $196.00 $213.0078464 $322.00 $327.00 $354.00 $382.00 $327.00 $354.00 $382.0078464-26 $56.00 $60.00 $62.00 $64.00 $60.00 $62.00 $64.0078464-TC $264.00 $267.00 $292.00 $318.00 $267.00 $292.00 $318.0078465 $519.00 $562.00 $609.00 $657.00 $562.00 $609.00 $657.0078465-26 $75.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.0078465-TC $441.00 $481.00 $525.00 $570.00 $481.00 $525.00 $570.0078466 $135.00 $182.00 $196.00 $210.00 $182.00 $196.00 $210.0078466-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.0078466-TC $97.00 $145.00 $157.00 $169.00 $145.00 $157.00 $169.0078468 $180.00 $235.00 $254.00 $272.00 $235.00 $254.00 $272.0078468-26 $41.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.0078468-TC $137.00 $191.00 $208.00 $224.00 $191.00 $208.00 $224.0078469 $244.00 $286.00 $308.00 $332.00 $286.00 $308.00 $332.0078469-26 $47.00 $51.00 $52.00 $54.00 $51.00 $52.00 $54.0078469-TC $195.00 $235.00 $256.00 $278.00 $235.00 $256.00 $278.0078472 $259.00 $290.00 $314.00 $338.00 $290.00 $314.00 $338.0078472-26 $50.00 $53.00 $55.00 $57.00 $53.00 $55.00 $57.0078472-TC $206.00 $237.00 $259.00 $281.00 $237.00 $259.00 $281.0078473 $387.00 $409.00 $441.00 $475.00 $409.00 $441.00 $475.0078473-26 $75.00 $81.00 $83.00 $87.00 $81.00 $83.00 $87.0078473-TC $308.00 $328.00 $358.00 $389.00 $328.00 $358.00 $389.0078478 $91.00 $77.00 $83.00 $90.00 $77.00 $83.00 $90.0078478-26 $32.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0078478-TC $58.00 $48.00 $53.00 $58.00 $48.00 $53.00 $58.0078480 $91.00 $67.00 $73.00 $79.00 $67.00 $73.00 $79.0078480-26 $32.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0078480-TC $58.00 $48.00 $53.00 $58.00 $48.00 $53.00 $58.0078481 $248.00 $265.00 $286.00 $308.00 $265.00 $286.00 $308.0078481-26 $51.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.0078481-TC $195.00 $210.00 $229.00 $249.00 $210.00 $229.00 $249.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

78483 $373.00 $383.00 $413.00 $445.00 $383.00 $413.00 $445.0078483-26 $77.00 $83.00 $86.00 $89.00 $83.00 $86.00 $89.0078483-TC $294.00 $300.00 $327.00 $356.00 $300.00 $327.00 $356.0078491 BR $1,540.00 $1,696.00 $1,868.00 $1,540.00 $1,696.00 $1,868.0078491-26 $85.00 $83.00 $86.00 $89.00 $83.00 $86.00 $89.0078491-TC BR $1,512.00 $1,665.00 $1,834.00 $1,512.00 $1,665.00 $1,834.0078492 BR $1,548.00 $1,706.00 $1,879.00 $1,548.00 $1,706.00 $1,879.0078492-26 $100.00 $106.00 $109.00 $113.00 $106.00 $109.00 $113.0078492-TC BR $1,512.00 $1,665.00 $1,834.00 $1,512.00 $1,665.00 $1,834.0078494 $324.00 $335.00 $361.00 $388.00 $335.00 $361.00 $388.0078494-26 $59.00 $66.00 $68.00 $71.00 $66.00 $68.00 $71.0078494-TC $262.00 $269.00 $293.00 $317.00 $269.00 $293.00 $317.0078496 $92.00 $198.00 $216.00 $235.00 $198.00 $216.00 $235.0078496-26 $24.00 $28.00 $28.00 $30.00 $28.00 $28.00 $30.0078496-TC $66.00 $170.00 $187.00 $205.00 $170.00 $187.00 $205.0078499 BR ------- ------- ------- ------- ------- -------78499-26 BR ------- ------- ------- ------- ------- -------78499-TC BR ------- ------- ------- ------- ------- -------78580 $167.00 $213.00 $230.00 $247.00 $213.00 $230.00 $247.0078580-26 $38.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.0078580-TC $128.00 $174.00 $189.00 $205.00 $174.00 $189.00 $205.0078584 $171.00 $178.00 $192.00 $206.00 $178.00 $192.00 $206.0078584-26 $50.00 $52.00 $54.00 $56.00 $52.00 $54.00 $56.0078584-TC $119.00 $126.00 $138.00 $150.00 $126.00 $138.00 $150.0078585 $171.00 $349.00 $377.00 $405.00 $349.00 $377.00 $405.0078585-26 $36.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.0078585-TC $133.00 $292.00 $317.00 $342.00 $292.00 $317.00 $342.0078586 $118.00 $160.00 $173.00 $185.00 $160.00 $173.00 $185.0078586-26 $20.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0078586-TC $96.00 $139.00 $151.00 $163.00 $139.00 $151.00 $163.0078587 $131.00 $193.00 $208.00 $223.00 $193.00 $208.00 $223.0078587-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0078587-TC $105.00 $167.00 $181.00 $195.00 $167.00 $181.00 $195.0078588 $239.00 $294.00 $316.00 $337.00 $294.00 $316.00 $337.0078588-26 $53.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.0078588-TC $192.00 $237.00 $256.00 $275.00 $237.00 $256.00 $275.0078591 $128.00 $165.00 $178.00 $192.00 $165.00 $178.00 $192.0078591-26 $20.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0078591-TC $106.00 $144.00 $156.00 $168.00 $144.00 $156.00 $168.0078593 $151.00 $196.00 $212.00 $227.00 $196.00 $212.00 $227.0078593-26 $24.00 $26.00 $26.00 $27.00 $26.00 $26.00 $27.0078593-TC $126.00 $170.00 $185.00 $200.00 $170.00 $185.00 $200.0078594 $214.00 $242.00 $262.00 $282.00 $242.00 $262.00 $282.0078594-26 $27.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0078594-TC $186.00 $214.00 $233.00 $252.00 $214.00 $233.00 $252.0078596 $332.00 $391.00 $422.00 $453.00 $391.00 $422.00 $453.0078596-26 $65.00 $66.00 $68.00 $71.00 $66.00 $68.00 $71.0078596-TC $264.00 $325.00 $354.00 $383.00 $325.00 $354.00 $383.0078599 BR ------- ------- ------- ------- ------- -------78599-26 BR ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 281

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

78599-TC BR ------- ------- ------- ------- ------- -------78600 $131.00 $172.00 $186.00 $199.00 $172.00 $186.00 $199.0078600-26 $22.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.0078600-TC $108.00 $148.00 $161.00 $174.00 $148.00 $161.00 $174.0078601 $154.00 $207.00 $223.00 $240.00 $207.00 $223.00 $240.0078601-26 $26.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0078601-TC $126.00 $180.00 $196.00 $211.00 $180.00 $196.00 $211.0078605 $155.00 $198.00 $214.00 $230.00 $198.00 $214.00 $230.0078605-26 $27.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0078605-TC $126.00 $169.00 $184.00 $199.00 $169.00 $184.00 $199.0078606 $221.00 $286.00 $309.00 $331.00 $286.00 $309.00 $331.0078606-26 $45.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0078606-TC $177.00 $253.00 $274.00 $294.00 $253.00 $274.00 $294.0078607 $311.00 $377.00 $407.00 $437.00 $377.00 $407.00 $437.0078607-26 $64.00 $65.00 $67.00 $70.00 $65.00 $67.00 $70.0078607-TC $245.00 $312.00 $340.00 $368.00 $312.00 $340.00 $368.0078608 BR $1,164.00 $1,283.00 $1,414.00 $1,164.00 $1,283.00 $1,414.0078608-26 ------- $79.00 $81.00 $84.00 $79.00 $81.00 $84.0078608-TC ------- $1,141.00 $1,257.00 $1,385.00 $1,141.00 $1,257.00 $1,385.0078609 BR $78.00 $81.00 $84.00 $78.00 $81.00 $84.0078609-26 ------- $78.00 $81.00 $84.00 $78.00 $81.00 $84.0078609-TC ------- BR BR BR BR BR BR78610 $74.00 $184.00 $198.00 $211.00 $184.00 $198.00 $211.0078610-26 $15.00 $17.00 $17.00 $18.00 $17.00 $17.00 $18.0078610-TC $59.00 $168.00 $181.00 $194.00 $168.00 $181.00 $194.0078630 $223.00 $317.00 $343.00 $368.00 $317.00 $343.00 $368.0078630-26 $35.00 $36.00 $37.00 $39.00 $36.00 $37.00 $39.0078630-TC $188.00 $281.00 $305.00 $329.00 $281.00 $305.00 $329.0078635 $129.00 $260.00 $279.00 $298.00 $260.00 $279.00 $298.0078635-26 $32.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0078635-TC $95.00 $227.00 $246.00 $263.00 $227.00 $246.00 $263.0078645 $158.00 $245.00 $264.00 $282.00 $245.00 $264.00 $282.0078645-26 $29.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0078645-TC $128.00 $216.00 $234.00 $251.00 $216.00 $234.00 $251.0078647 $268.00 $345.00 $372.00 $400.00 $345.00 $372.00 $400.0078647-26 $46.00 $47.00 $49.00 $51.00 $47.00 $49.00 $51.0078647-TC $220.00 $297.00 $323.00 $349.00 $297.00 $323.00 $349.0078650 $206.00 $303.00 $327.00 $351.00 $303.00 $327.00 $351.0078650-26 $31.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0078650-TC $173.00 $270.00 $293.00 $316.00 $270.00 $293.00 $316.0078660 $107.00 $157.00 $169.00 $181.00 $157.00 $169.00 $181.0078660-26 $27.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0078660-TC $79.00 $129.00 $140.00 $151.00 $129.00 $140.00 $151.0078699 BR ------- ------- ------- ------- ------- -------78699-26 BR ------- ------- ------- ------- ------- -------78699-TC BR ------- ------- ------- ------- ------- -------78700 $137.00 $177.00 $191.00 $206.00 $177.00 $191.00 $206.0078700-26 $22.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0078700-TC $113.00 $153.00 $166.00 $180.00 $153.00 $166.00 $180.0078701 $158.00 $209.00 $226.00 $243.00 $209.00 $226.00 $243.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

78701-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0078701-TC $133.00 $184.00 $199.00 $215.00 $184.00 $199.00 $215.0078707 $217.00 $254.00 $274.00 $294.00 $254.00 $274.00 $294.0078707-26 $49.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.0078707-TC $166.00 $203.00 $221.00 $239.00 $203.00 $221.00 $239.0078708 $231.00 $226.00 $244.00 $262.00 $226.00 $244.00 $262.0078708-26 $61.00 $64.00 $67.00 $69.00 $64.00 $67.00 $69.0078708-TC $166.00 $162.00 $177.00 $193.00 $162.00 $177.00 $193.0078709 $241.00 $341.00 $366.00 $391.00 $341.00 $366.00 $391.0078709-26 $68.00 $75.00 $77.00 $80.00 $75.00 $77.00 $80.0078709-TC $166.00 $267.00 $289.00 $311.00 $267.00 $289.00 $311.0078710 $256.00 $270.00 $292.00 $316.00 $270.00 $292.00 $316.0078710-26 $34.00 $35.00 $36.00 $37.00 $35.00 $36.00 $37.0078710-TC $220.00 $235.00 $256.00 $279.00 $235.00 $256.00 $279.0078725 $87.00 $106.00 $115.00 $123.00 $106.00 $115.00 $123.0078725-26 $19.00 $20.00 $21.00 $22.00 $20.00 $21.00 $22.0078725-TC $66.00 $86.00 $94.00 $102.00 $86.00 $94.00 $102.0078730 $73.00 $82.00 $89.00 $96.00 $82.00 $89.00 $96.0078730-26 $18.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.0078730-TC $55.00 $71.00 $78.00 $84.00 $71.00 $78.00 $84.0078740 $109.00 $187.00 $201.00 $215.00 $187.00 $201.00 $215.0078740-26 $29.00 $30.00 $31.00 $33.00 $30.00 $31.00 $33.0078740-TC $79.00 $156.00 $169.00 $182.00 $156.00 $169.00 $182.0078761 $157.00 $205.00 $221.00 $237.00 $205.00 $221.00 $237.0078761-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.0078761-TC $119.00 $168.00 $182.00 $197.00 $168.00 $182.00 $197.0078799 BR ------- ------- ------- ------- ------- -------78799-26 BR ------- ------- ------- ------- ------- -------78799-TC BR ------- ------- ------- ------- ------- -------78800 $162.00 $195.00 $210.00 $226.00 $195.00 $210.00 $226.0078800-26 $34.00 $35.00 $37.00 $39.00 $35.00 $37.00 $39.0078800-TC $126.00 $159.00 $173.00 $188.00 $159.00 $173.00 $188.0078801 $199.00 $253.00 $273.00 $294.00 $253.00 $273.00 $294.0078801-26 $40.00 $43.00 $45.00 $47.00 $43.00 $45.00 $47.0078801-TC $158.00 $210.00 $228.00 $247.00 $210.00 $228.00 $247.0078802 $252.00 $327.00 $353.00 $380.00 $327.00 $353.00 $380.0078802-26 $44.00 $46.00 $47.00 $49.00 $46.00 $47.00 $49.0078802-TC $207.00 $281.00 $306.00 $331.00 $281.00 $306.00 $331.0078803 $303.00 $369.00 $399.00 $429.00 $369.00 $399.00 $429.0078803-26 $56.00 $58.00 $60.00 $63.00 $58.00 $60.00 $63.0078803-TC $245.00 $311.00 $338.00 $366.00 $311.00 $338.00 $366.0078804 ------- $576.00 $620.00 $661.00 $576.00 $620.00 $661.0078804-26 ------- $56.00 $58.00 $60.00 $56.00 $58.00 $60.0078804-TC ------- $520.00 $562.00 $601.00 $520.00 $562.00 $601.0078805 $166.00 $195.00 $210.00 $225.00 $195.00 $210.00 $225.0078805-26 $38.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.0078805-TC $126.00 $156.00 $170.00 $184.00 $156.00 $170.00 $184.0078806 $286.00 $352.00 $381.00 $411.00 $352.00 $381.00 $411.0078806-26 $44.00 $46.00 $47.00 $49.00 $46.00 $47.00 $49.0078806-TC $241.00 $306.00 $334.00 $361.00 $306.00 $334.00 $361.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

78807 $303.00 $368.00 $397.00 $427.00 $368.00 $397.00 $427.0078807-26 $57.00 $58.00 $59.00 $62.00 $58.00 $59.00 $62.0078807-TC $245.00 $310.00 $338.00 $366.00 $310.00 $338.00 $366.0078811 ------- $1,169.00 $1,288.00 $1,421.00 $1,169.00 $1,288.00 $1,421.0078811-26 ------- $85.00 $88.00 $93.00 $85.00 $88.00 $93.0078811-TC ------- $1,141.00 $1,257.00 $1,385.00 $1,141.00 $1,257.00 $1,385.0078812 ------- $1,174.00 $1,294.00 $1,426.00 $1,174.00 $1,294.00 $1,426.0078812-26 ------- $104.00 $108.00 $113.00 $104.00 $108.00 $113.0078812-TC ------- $1,141.00 $1,257.00 $1,385.00 $1,141.00 $1,257.00 $1,385.0078813 ------- $1,175.00 $1,295.00 $1,428.00 $1,175.00 $1,295.00 $1,428.0078813-26 ------- $108.00 $112.00 $117.00 $108.00 $112.00 $117.0078813-TC ------- $1,141.00 $1,257.00 $1,385.00 $1,141.00 $1,257.00 $1,385.0078814 ------- $1,177.00 $1,298.00 $1,430.00 $1,177.00 $1,298.00 $1,430.0078814-26 ------- $118.00 $122.00 $127.00 $118.00 $122.00 $127.0078814-TC ------- $1,141.00 $1,257.00 $1,385.00 $1,141.00 $1,257.00 $1,385.0078815 ------- $1,181.00 $1,301.00 $1,434.00 $1,181.00 $1,301.00 $1,434.0078815-26 ------- $130.00 $134.00 $140.00 $130.00 $134.00 $140.0078815-TC ------- $1,141.00 $1,257.00 $1,385.00 $1,141.00 $1,257.00 $1,385.0078816 ------- $1,182.00 $1,302.00 $1,435.00 $1,182.00 $1,302.00 $1,435.0078816-26 ------- $133.00 $137.00 $143.00 $133.00 $137.00 $143.0078816-TC ------- $1,141.00 $1,257.00 $1,385.00 $1,141.00 $1,257.00 $1,385.0078999 BR ------- ------- ------- ------- ------- -------78999-26 BR ------- ------- ------- ------- ------- -------78999-TC BR ------- ------- ------- ------- ------- -------79005 ------- $180.00 $192.00 $204.00 $180.00 $192.00 $204.0079005-26 ------- $95.00 $98.00 $102.00 $95.00 $98.00 $102.0079005-TC ------- $85.00 $94.00 $102.00 $85.00 $94.00 $102.0079101 ------- $193.00 $205.00 $219.00 $193.00 $205.00 $219.0079101-26 ------- $105.00 $109.00 $113.00 $105.00 $109.00 $113.0079101-TC ------- $88.00 $97.00 $106.00 $88.00 $97.00 $106.0079200 $203.00 $196.00 $209.00 $222.00 $196.00 $209.00 $222.0079200-26 $102.00 $105.00 $109.00 $113.00 $105.00 $109.00 $113.0079200-TC $97.00 $91.00 $100.00 $109.00 $91.00 $100.00 $109.0079300 BR ------- ------- ------- ------- ------- -------79300-26 $83.00 $89.00 $93.00 $98.00 $89.00 $93.00 $98.0079300-TC BR ------- ------- ------- ------- ------- -------79403 ------- $257.00 $273.00 $289.00 $257.00 $273.00 $289.0079403-26 ------- $121.00 $126.00 $131.00 $121.00 $126.00 $131.0079403-TC ------- $135.00 $147.00 $159.00 $135.00 $147.00 $159.0079440 $204.00 $189.00 $200.00 $213.00 $189.00 $200.00 $213.0079440-26 $104.00 $106.00 $109.00 $113.00 $106.00 $109.00 $113.0079440-TC $97.00 $83.00 $91.00 $100.00 $83.00 $91.00 $100.0079445 ------- BR BR BR BR BR BR79445-26 ------- $128.00 $133.00 $139.00 $128.00 $133.00 $139.0079445-TC ------- BR BR BR BR BR BR79999 BR ------- ------- ------- ------- ------- -------79999-26 BR ------- ------- ------- ------- ------- -------79999-TC BR ------- ------- ------- ------- ------- -------G0130 ------- $40.00 $43.00 $47.00 $40.00 $43.00 $47.00G0130-26 ------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

G0130-TC ------- $29.00 $31.00 $34.00 $29.00 $31.00 $34.00G0202 ------- $142.00 $152.00 $161.00 $142.00 $152.00 $161.00G0202-26 ------- $37.00 $38.00 $40.00 $37.00 $38.00 $40.00G0202-TC ------- $105.00 $113.00 $122.00 $105.00 $113.00 $122.00G0204 ------- $160.00 $171.00 $182.00 $160.00 $171.00 $182.00G0204-26 ------- $46.00 $48.00 $50.00 $46.00 $48.00 $50.00G0204-TC ------- $114.00 $124.00 $132.00 $114.00 $124.00 $132.00G0206 ------- $128.00 $137.00 $145.00 $128.00 $137.00 $145.00G0206-26 ------- $37.00 $38.00 $40.00 $37.00 $38.00 $40.00G0206-TC ------- $91.00 $99.00 $106.00 $91.00 $99.00 $106.00G0275 ------- $15.00 $15.00 $16.00 $15.00 $15.00 $16.00G0278 ------- $15.00 $15.00 $16.00 $15.00 $15.00 $16.00G0288 ------- $240.00 $260.00 $279.00 $240.00 $260.00 $279.00G0365 ------- $174.00 $189.00 $205.00 $174.00 $189.00 $205.00G0365-26 ------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00G0365-TC ------- $161.00 $175.00 $190.00 $161.00 $175.00 $190.00G0389 ------- $123.00 $132.00 $141.00 $123.00 $132.00 $141.00G0389-26 ------- $31.00 $32.00 $34.00 $31.00 $32.00 $34.00G0389-TC ------- $92.00 $100.00 $107.00 $92.00 $100.00 $107.00Q0092 ------- $16.00 $18.00 $19.00 $16.00 $18.00 $19.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $22.00 $23.00 $24.00 $20.00 $21.00 $21.0080500-26 $34.00 ------- ------- ------- ------- ------- -------80500-TC BR ------- ------- ------- ------- ------- -------80502 $72.00 $68.00 $70.00 $73.00 $67.00 $69.00 $71.0080502-26 $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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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. Part C, 299

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 301

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $20.00 $20.00 $21.00 $20.00 $20.00 $21.0083020-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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 303

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 304

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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. Part C, 305

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 306

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $19.00 $20.00 $20.00 $19.00 $20.00 $20.0083912-TC $28.00 ------- ------- ------- ------- ------- -------83915 $31.00 ------- ------- ------- ------- ------- -------83915-26 $10.00 ------- ------- ------- ------- ------- -------83915-TC $20.00 ------- ------- ------- ------- ------- -------83916 $54.00 ------- ------- ------- ------- ------- -------83916-26 $18.00 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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. Part C, 308

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 309

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $20.00 $20.00 $21.00 $20.00 $20.00 $21.0084165-TC $16.00 ------- ------- ------- ------- ------- -------84166 ------- BR BR BR BR BR BR84166-26 ------- $20.00 $20.00 $21.00 $20.00 $20.00 $21.0084166-TC ------- BR BR BR BR BR BR84181 $29.00 ------- ------- ------- ------- ------- -------84181-26 $10.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

84181-TC $19.00 ------- ------- ------- ------- ------- -------84182 $33.00 ------- ------- ------- ------- ------- -------84182-26 $11.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.0084182-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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 312

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 313

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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. Part C, 314

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 315

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 316

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

85049-TC BR ------- ------- ------- ------- ------- -------85060 $25.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0085060-26 $7.00 ------- ------- ------- ------- ------- -------85060-TC $18.00 ------- ------- ------- ------- ------- -------85097 $59.00 $99.00 $105.00 $109.00 $51.00 $52.00 $54.0085097-26 $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. Part C, 317

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 318

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $20.00 $20.00 $21.00 $20.00 $20.00 $21.0085390-TC $7.00 ------- ------- ------- ------- ------- -------85396 ------- $21.00 $23.00 $24.00 $21.00 $23.00 $24.0085400 $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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 319

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0085576-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. Part C, 320

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 321

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $52.00 $54.00 $55.00 $50.00 $52.00 $53.0086077-26 $26.00 ------- ------- ------- ------- ------- -------86077-TC $64.00 ------- ------- ------- ------- ------- -------86078 $91.00 $53.00 $55.00 $57.00 $50.00 $52.00 $54.0086078-26 $26.00 ------- ------- ------- ------- ------- -------86078-TC $64.00 ------- ------- ------- ------- ------- -------86079 $79.00 $53.00 $55.00 $57.00 $51.00 $52.00 $54.0086079-26 $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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 322

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $20.00 $20.00 $21.00 $20.00 $20.00 $21.0086255-TC $17.00 ------- ------- ------- ------- ------- -------86256 $25.00 ------- ------- ------- ------- ------- -------86256-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0086256-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. Part C, 323

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0086320-TC $29.00 ------- ------- ------- ------- ------- -------86325 $49.00 ------- ------- ------- ------- ------- -------86325-26 $16.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.0086325-TC $33.00 ------- ------- ------- ------- ------- -------86327 $62.00 ------- ------- ------- ------- ------- -------86327-26 $19.00 $23.00 $23.00 $24.00 $23.00 $23.00 $24.0086327-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 $20.00 $20.00 $21.00 $20.00 $20.00 $21.0086334-TC $45.00 ------- ------- ------- ------- ------- -------86335 ------- BR BR BR BR BR BR86335-26 ------- $20.00 $20.00 $21.00 $20.00 $20.00 $21.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 324

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

86335-TC ------- BR BR BR BR BR BR86336 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 325

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $7.00 $8.00 $6.00 $7.00 $8.0086490 $17.00 $9.00 $10.00 $12.00 $9.00 $10.00 $12.0086490-26 $5.00 ------- ------- ------- ------- ------- -------86490-TC $12.00 ------- ------- ------- ------- ------- -------86510 $13.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.0086510-26 $4.00 ------- ------- ------- ------- ------- -------86510-TC $8.00 ------- ------- ------- ------- ------- -------86580 $13.00 $9.00 $10.00 $11.00 $9.00 $10.00 $11.0086580-26 $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. Part C, 326

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 327

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 328

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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. Part C, 329

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 330

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 331

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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. Part C, 332

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 333

Page 334: FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER REIMBURSEMENT MANUAL 2008 Edition · 2009-03-27 · Florida Workers’ Compensation Health Care Provider Reimbursement Manual,

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $19.00 $20.00 $20.00 $19.00 $20.00 $20.0087164-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 ------- ------- ------- ------- ------- -------

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0087207-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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility 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 $63.00 $67.00 $70.00 $63.00 $67.00 $70.0088104-26 $37.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0088104-TC $10.00 $33.00 $36.00 $39.00 $33.00 $36.00 $39.0088106 $54.00 $80.00 $84.00 $89.00 $80.00 $84.00 $89.0088106-26 $16.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0088106-TC $38.00 $50.00 $54.00 $57.00 $50.00 $54.00 $57.0088107 $74.00 $101.00 $107.00 $112.00 $101.00 $107.00 $112.0088107-26 $57.00 $41.00 $42.00 $44.00 $41.00 $42.00 $44.0088107-TC $15.00 $60.00 $64.00 $68.00 $60.00 $64.00 $68.0088108 $59.00 $76.00 $80.00 $85.00 $76.00 $80.00 $85.0088108-26 $47.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0088108-TC $11.00 $46.00 $50.00 $53.00 $46.00 $50.00 $53.0088112 ------- $114.00 $119.00 $124.00 $114.00 $119.00 $124.0088112-26 ------- $61.00 $62.00 $64.00 $61.00 $62.00 $64.0088112-TC ------- $53.00 $57.00 $61.00 $53.00 $57.00 $61.0088125 $70.00 $20.00 $21.00 $23.00 $20.00 $21.00 $23.0088125-26 $20.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.0088125-TC $48.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.0088130 $25.00 ------- ------- ------- ------- ------- -------88130-26 $7.00 ------- ------- ------- ------- ------- -------88130-TC $18.00 ------- ------- ------- ------- ------- -------88140 $18.00 ------- ------- ------- ------- ------- -------88140-26 $5.00 ------- ------- ------- ------- ------- -------88140-TC $13.00 ------- ------- ------- ------- ------- -------88141 $33.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0088141-26 NC BR BR BR BR BR BR88141-TC NC BR BR BR BR BR BR88142 $82.00 ------- ------- ------- ------- ------- -------88142-26 $21.00 ------- ------- ------- ------- ------- -------88142-TC $59.00 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

88143 $94.00 ------- ------- ------- ------- ------- -------88143-26 $33.00 ------- ------- ------- ------- ------- -------88143-TC $59.00 ------- ------- ------- ------- ------- -------88147 $82.00 ------- ------- ------- ------- ------- -------88147-26 NC BR BR BR BR BR BR88147-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 $55.00 $58.00 $62.00 $55.00 $58.00 $62.0088160-26 $14.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0088160-TC $24.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0088161 $64.00 $60.00 $64.00 $67.00 $60.00 $64.00 $67.0088161-26 $19.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0088161-TC $37.00 $33.00 $36.00 $39.00 $33.00 $36.00 $39.0088162 $77.00 $82.00 $87.00 $91.00 $82.00 $87.00 $91.0088162-26 $22.00 $41.00 $42.00 $44.00 $41.00 $42.00 $44.0088162-TC $53.00 $41.00 $45.00 $48.00 $41.00 $45.00 $48.0088164 $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 $55.00 $58.00 $61.00 $55.00 $58.00 $61.0088172-26 $54.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0088172-TC $14.00 $23.00 $25.00 $27.00 $23.00 $25.00 $27.0088173 $95.00 $140.00 $148.00 $155.00 $140.00 $148.00 $155.0088173-26 $95.00 $73.00 $75.00 $78.00 $73.00 $75.00 $78.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

88173-TC $26.00 $67.00 $72.00 $77.00 $67.00 $72.00 $77.0088174 BR ------- ------- ------- ------- ------- -------88174-26 BR ------- ------- ------- ------- ------- -------88174-TC BR ------- ------- ------- ------- ------- -------88175 BR ------- ------- ------- ------- ------- -------88175-26 BR ------- ------- ------- ------- ------- -------88175-TC BR ------- ------- ------- ------- ------- -------88182 $88.00 $111.00 $118.00 $125.00 $111.00 $118.00 $125.0088182-26 $33.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.0088182-TC $54.00 $72.00 $77.00 $83.00 $72.00 $77.00 $83.0088184 ------- $75.00 $81.00 $86.00 $75.00 $81.00 $86.0088185 ------- $43.00 $47.00 $50.00 $43.00 $47.00 $50.0088187 ------- $67.00 $69.00 $70.00 $67.00 $69.00 $70.0088188 ------- $83.00 $85.00 $86.00 $83.00 $85.00 $86.0088189 ------- $107.00 $109.00 $110.00 $107.00 $109.00 $110.0088199 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 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0088300-26 $19.00 $5.00 $5.00 $5.00 $5.00 $5.00 $5.0088300-TC $5.00 $19.00 $21.00 $22.00 $19.00 $21.00 $22.0088302 $53.00 $52.00 $56.00 $59.00 $52.00 $56.00 $59.0088302-26 $42.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.0088302-TC $11.00 $45.00 $48.00 $52.00 $45.00 $48.00 $52.0088304 $70.00 $64.00 $69.00 $73.00 $64.00 $69.00 $73.0088304-26 $54.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0088304-TC $14.00 $53.00 $57.00 $61.00 $53.00 $57.00 $61.0088305 $108.00 $109.00 $116.00 $123.00 $109.00 $116.00 $123.0088305-26 $86.00 $40.00 $41.00 $43.00 $40.00 $41.00 $43.0088305-TC $21.00 $70.00 $75.00 $80.00 $70.00 $75.00 $80.0088307 $210.00 $215.00 $228.00 $240.00 $215.00 $228.00 $240.0088307-26 $168.00 $85.00 $88.00 $91.00 $85.00 $88.00 $91.0088307-TC $41.00 $130.00 $140.00 $149.00 $130.00 $140.00 $149.0088309 $322.00 $319.00 $337.00 $354.00 $319.00 $337.00 $354.0088309-26 $258.00 $144.00 $148.00 $152.00 $144.00 $148.00 $152.0088309-TC $64.00 $176.00 $189.00 $201.00 $176.00 $189.00 $201.0088311 $23.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0088311-26 $19.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

88311-TC $4.00 $7.00 $7.00 $8.00 $7.00 $7.00 $8.0088312 $23.00 $97.00 $102.00 $108.00 $97.00 $102.00 $108.0088312-26 $7.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0088312-TC $16.00 $68.00 $73.00 $77.00 $68.00 $73.00 $77.0088313 $23.00 $73.00 $78.00 $82.00 $73.00 $78.00 $82.0088313-26 $7.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0088313-TC $16.00 $60.00 $65.00 $69.00 $60.00 $65.00 $69.0088314 $21.00 $98.00 $105.00 $110.00 $98.00 $105.00 $110.0088314-26 $6.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0088314-TC $15.00 $74.00 $79.00 $84.00 $74.00 $79.00 $84.0088318 $33.00 $108.00 $115.00 $121.00 $108.00 $115.00 $121.0088318-26 $14.00 $23.00 $23.00 $24.00 $23.00 $23.00 $24.0088318-TC $18.00 $85.00 $91.00 $97.00 $85.00 $91.00 $97.0088319 $26.00 $153.00 $163.00 $172.00 $153.00 $163.00 $172.0088319-26 $13.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0088319-TC $14.00 $124.00 $133.00 $141.00 $124.00 $133.00 $141.0088321 $43.00 $93.00 $96.00 $99.00 $83.00 $86.00 $89.0088321-26 $43.00 ------- ------- ------- ------- ------- -------88321-TC NC BR BR BR BR BR BR88323 $61.00 $150.00 $157.00 $164.00 $150.00 $157.00 $164.0088323-26 $61.00 $91.00 $93.00 $96.00 $91.00 $93.00 $96.0088323-TC NC $59.00 $64.00 $68.00 $59.00 $64.00 $68.0088325 $54.00 $201.00 $210.00 $219.00 $129.00 $132.00 $136.0088325-26 $54.00 ------- ------- ------- ------- ------- -------88325-TC NC BR BR BR BR BR BR88329 $51.00 $52.00 $54.00 $56.00 $35.00 $36.00 $38.0088329-26 $51.00 ------- ------- ------- ------- ------- -------88329-TC NC BR BR BR BR BR BR88331 $102.00 $95.00 $99.00 $105.00 $95.00 $99.00 $105.0088331-26 $70.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.0088331-TC $33.00 $31.00 $34.00 $36.00 $31.00 $34.00 $36.0088332 $53.00 $43.00 $45.00 $47.00 $43.00 $45.00 $47.0088332-26 $36.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0088332-TC $17.00 $11.00 $12.00 $13.00 $11.00 $12.00 $13.0088333 ------- $97.00 $101.00 $107.00 $97.00 $101.00 $107.0088333-26 ------- $65.00 $67.00 $69.00 $65.00 $67.00 $69.0088333-TC ------- $32.00 $35.00 $38.00 $32.00 $35.00 $38.0088334 ------- $56.00 $59.00 $62.00 $56.00 $59.00 $62.0088334-26 ------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.0088334-TC ------- $19.00 $21.00 $22.00 $19.00 $21.00 $22.0088342 $53.00 $102.00 $108.00 $113.00 $102.00 $108.00 $113.0088342-26 $36.00 $45.00 $46.00 $48.00 $45.00 $46.00 $48.0088342-TC $17.00 $57.00 $62.00 $66.00 $57.00 $62.00 $66.0088346 $96.00 $103.00 $109.00 $115.00 $103.00 $109.00 $115.0088346-26 $66.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.0088346-TC $28.00 $58.00 $63.00 $67.00 $58.00 $63.00 $67.0088347 $133.00 $86.00 $90.00 $95.00 $86.00 $90.00 $95.0088347-26 $99.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.0088347-TC $33.00 $41.00 $45.00 $48.00 $41.00 $45.00 $48.0088348 $191.00 $606.00 $647.00 $683.00 $606.00 $647.00 $683.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

88348-26 $145.00 $80.00 $83.00 $86.00 $80.00 $83.00 $86.0088348-TC $44.00 $526.00 $564.00 $597.00 $526.00 $564.00 $597.0088349 $191.00 $288.00 $308.00 $326.00 $288.00 $308.00 $326.0088349-26 $145.00 $41.00 $42.00 $44.00 $41.00 $42.00 $44.0088349-TC $44.00 $247.00 $266.00 $282.00 $247.00 $266.00 $282.0088355 $108.00 $312.00 $331.00 $349.00 $312.00 $331.00 $349.0088355-26 $80.00 $95.00 $98.00 $102.00 $95.00 $98.00 $102.0088355-TC $26.00 $217.00 $233.00 $247.00 $217.00 $233.00 $247.0088356 $108.00 $311.00 $328.00 $345.00 $311.00 $328.00 $345.0088356-26 $80.00 $155.00 $160.00 $166.00 $155.00 $160.00 $166.0088356-TC $26.00 $156.00 $168.00 $179.00 $156.00 $168.00 $179.0088358 $108.00 $84.00 $90.00 $97.00 $84.00 $90.00 $97.0088358-26 $80.00 $52.00 $55.00 $59.00 $52.00 $55.00 $59.0088358-TC $26.00 $31.00 $35.00 $39.00 $31.00 $35.00 $39.0088360 ------- $123.00 $131.00 $138.00 $123.00 $131.00 $138.0088360-26 ------- $59.00 $61.00 $64.00 $59.00 $61.00 $64.0088360-TC ------- $64.00 $69.00 $74.00 $64.00 $69.00 $74.0088361 ------- $168.00 $180.00 $192.00 $168.00 $180.00 $192.0088361-26 ------- $65.00 $68.00 $72.00 $65.00 $68.00 $72.0088361-TC ------- $104.00 $112.00 $120.00 $104.00 $112.00 $120.0088362 BR $280.00 $296.00 $312.00 $280.00 $296.00 $312.0088362-26 BR $115.00 $119.00 $123.00 $115.00 $119.00 $123.0088362-TC BR $165.00 $177.00 $189.00 $165.00 $177.00 $189.0088365 $24.00 $155.00 $163.00 $171.00 $155.00 $163.00 $171.0088365-26 $24.00 $62.00 $64.00 $66.00 $62.00 $64.00 $66.0088365-TC BR $93.00 $100.00 $106.00 $93.00 $100.00 $106.0088367 ------- $236.00 $251.00 $265.00 $236.00 $251.00 $265.0088367-26 ------- $66.00 $69.00 $71.00 $66.00 $69.00 $71.0088367-TC ------- $169.00 $182.00 $194.00 $169.00 $182.00 $194.0088368 ------- $204.00 $217.00 $229.00 $204.00 $217.00 $229.0088368-26 ------- $72.00 $75.00 $77.00 $72.00 $75.00 $77.0088368-TC ------- $132.00 $142.00 $151.00 $132.00 $142.00 $151.0088371 $34.00 ------- ------- ------- ------- ------- -------88371-26 $10.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.0088371-TC $23.00 ------- ------- ------- ------- ------- -------88372 $38.00 ------- ------- ------- ------- ------- -------88372-26 $11.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0088372-TC $26.00 ------- ------- ------- ------- ------- -------88380 BR $171.00 $181.00 $191.00 $171.00 $181.00 $191.0088380-26 BR $79.00 $81.00 $84.00 $79.00 $81.00 $84.0088380-TC BR $92.00 $100.00 $107.00 $92.00 $100.00 $107.0088381 ------- $224.00 $238.00 $251.00 $224.00 $238.00 $251.0088381-26 ------- $60.00 $62.00 $65.00 $60.00 $62.00 $65.0088381-TC ------- $164.00 $176.00 $186.00 $164.00 $176.00 $186.0088385 ------- $507.00 $541.00 $571.00 $507.00 $541.00 $571.0088385-26 ------- $77.00 $80.00 $83.00 $77.00 $80.00 $83.0088385-TC ------- $430.00 $462.00 $489.00 $430.00 $462.00 $489.0088386 ------- $521.00 $556.00 $587.00 $521.00 $556.00 $587.0088386-26 ------- $97.00 $101.00 $104.00 $97.00 $101.00 $104.0088386-TC ------- $424.00 $455.00 $482.00 $424.00 $455.00 $482.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

88399 BR ------- ------- ------- ------- ------- -------88399-26 BR ------- ------- ------- ------- ------- -------88399-TC BR ------- ------- ------- ------- ------- -------89049 ------- $195.00 $206.00 $216.00 $64.00 $66.00 $69.0089050 $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 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0089060-TC $8.00 ------- ------- ------- ------- ------- -------89100 $51.00 $215.00 $230.00 $242.00 $39.00 $40.00 $42.0089100-26 $15.00 ------- ------- ------- ------- ------- -------89100-TC $36.00 ------- ------- ------- ------- ------- -------89105 $65.00 $218.00 $232.00 $244.00 $32.00 $34.00 $35.0089105-26 $19.00 ------- ------- ------- ------- ------- -------89105-TC $44.00 ------- ------- ------- ------- ------- -------89125 $14.00 ------- ------- ------- ------- ------- -------89125-26 $4.00 ------- ------- ------- ------- ------- -------89125-TC $10.00 ------- ------- ------- ------- ------- -------89130 $44.00 $181.00 $193.00 $203.00 $28.00 $29.00 $30.0089130-26 $13.00 ------- ------- ------- ------- ------- -------89130-TC $32.00 ------- ------- ------- ------- ------- -------89132 $20.00 $203.00 $217.00 $229.00 $16.00 $17.00 $18.0089132-26 $6.00 ------- ------- ------- ------- ------- -------89132-TC $14.00 ------- ------- ------- ------- ------- -------89135 $37.00 $242.00 $258.00 $272.00 $50.00 $52.00 $54.0089135-26 $11.00 ------- ------- ------- ------- ------- -------89135-TC $25.00 ------- ------- ------- ------- ------- -------89136 $43.00 $159.00 $170.00 $179.00 $15.00 $16.00 $17.0089136-26 $14.00 ------- ------- ------- ------- ------- -------89136-TC $29.00 ------- ------- ------- ------- ------- -------89140 $50.00 $200.00 $213.00 $223.00 $51.00 $53.00 $55.0089140-26 $16.00 ------- ------- ------- ------- ------- -------89140-TC $34.00 ------- ------- ------- ------- ------- -------89141 $56.00 $213.00 $227.00 $238.00 $49.00 $51.00 $53.0089141-26 $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 $18.00 $20.00 $17.00 $18.00 $20.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Pathology & Laboratory

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

89230 ------- $5.00 $5.00 $6.00 $5.00 $5.00 $6.00G0124 ------- $27.00 $28.00 $29.00 $27.00 $28.00 $29.00G0141 ------- $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

90471 $4.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0090472 $4.00 $11.00 $12.00 $12.00 $9.00 $10.00 $10.0090473 BR $14.00 $15.00 $15.00 $9.00 $10.00 $10.0090474 BR $10.00 $10.00 $11.00 $8.00 $8.00 $9.0090632 BR ------- ------- ------- ------- ------- -------90636 BR ------- ------- ------- ------- ------- -------90675 BR ------- ------- ------- ------- ------- -------90703 BR ------- ------- ------- ------- ------- -------90718 BR ------- ------- ------- ------- ------- -------90746 BR ------- ------- ------- ------- ------- -------90749 BR ------- ------- ------- ------- ------- -------90801 $140.00 $159.00 $164.00 $169.00 $137.00 $140.00 $144.0090802 $143.00 $169.00 $174.00 $180.00 $148.00 $152.00 $156.0090804 $62.00 $67.00 $69.00 $71.00 $58.00 $60.00 $62.0090805 $68.00 $74.00 $76.00 $78.00 $66.00 $67.00 $69.0090806 $94.00 $95.00 $98.00 $100.00 $89.00 $91.00 $94.0090807 $101.00 $105.00 $108.00 $111.00 $97.00 $99.00 $102.0090808 $144.00 $141.00 $144.00 $148.00 $134.00 $137.00 $141.0090809 $149.00 $150.00 $154.00 $158.00 $142.00 $145.00 $149.0090810 $69.00 $72.00 $74.00 $76.00 $64.00 $66.00 $68.0090811 $77.00 $82.00 $85.00 $87.00 $71.00 $73.00 $75.0090812 $101.00 $103.00 $106.00 $109.00 $94.00 $96.00 $99.0090813 $107.00 $113.00 $117.00 $120.00 $102.00 $105.00 $107.0090814 $143.00 $148.00 $152.00 $156.00 $140.00 $143.00 $147.0090815 $149.00 $157.00 $161.00 $166.00 $146.00 $150.00 $153.0090816 $64.00 $63.00 $65.00 $67.00 $63.00 $65.00 $67.0090817 $70.00 $70.00 $71.00 $73.00 $70.00 $71.00 $73.0090818 $96.00 $94.00 $96.00 $99.00 $94.00 $96.00 $99.0090819 $102.00 $101.00 $103.00 $106.00 $101.00 $103.00 $106.0090821 $144.00 $139.00 $143.00 $147.00 $139.00 $143.00 $147.0090822 $149.00 $146.00 $150.00 $154.00 $146.00 $150.00 $154.0090823 $73.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.0090824 $78.00 $76.00 $78.00 $80.00 $76.00 $78.00 $80.0090826 $103.00 $100.00 $103.00 $106.00 $100.00 $103.00 $106.0090827 $107.00 $105.00 $108.00 $111.00 $105.00 $108.00 $111.0090828 $146.00 $145.00 $149.00 $153.00 $145.00 $149.00 $153.0090829 $150.00 $151.00 $154.00 $158.00 $151.00 $154.00 $158.0090845 $85.00 $88.00 $90.00 $92.00 $86.00 $88.00 $90.0090846 $93.00 $93.00 $95.00 $98.00 $91.00 $93.00 $96.0090847 $110.00 $115.00 $119.00 $122.00 $110.00 $112.00 $115.0090849 $32.00 $35.00 $36.00 $37.00 $32.00 $33.00 $34.0090853 $32.00 $33.00 $34.00 $34.00 $31.00 $31.00 $32.0090857 $31.00 $37.00 $38.00 $39.00 $33.00 $34.00 $34.0090862 $50.00 $56.00 $58.00 $60.00 $48.00 $49.00 $50.0090865 $143.00 $162.00 $168.00 $174.00 $142.00 $147.00 $152.0090870 $94.00 $148.00 $154.00 $160.00 $91.00 $93.00 $96.0090875 $74.00 $75.00 $78.00 $80.00 $61.00 $63.00 $65.0090876 $112.00 $109.00 $113.00 $116.00 $96.00 $98.00 $101.0090880 $112.00 $116.00 $119.00 $122.00 $105.00 $108.00 $110.0090882 $104.00 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

90885 $49.00 $49.00 $50.00 $51.00 $49.00 $50.00 $51.0090887 $77.00 $85.00 $88.00 $90.00 $75.00 $77.00 $79.0090889 BR ------- ------- ------- ------- ------- -------90899 BR ------- ------- ------- ------- ------- -------90901 $46.00 $38.00 $40.00 $42.00 $21.00 $22.00 $23.0090911 $82.00 $94.00 $99.00 $105.00 $48.00 $50.00 $53.0090935 $76.00 $71.00 $73.00 $76.00 $71.00 $73.00 $76.0090937 $226.00 $116.00 $120.00 $124.00 $116.00 $120.00 $124.0090940 BR ------- ------- ------- ------- ------- -------90945 $80.00 $74.00 $77.00 $79.00 $74.00 $77.00 $79.0090947 $125.00 $119.00 $123.00 $127.00 $119.00 $123.00 $127.0090997 $115.00 $94.00 $97.00 $100.00 $94.00 $97.00 $100.0090999 BR ------- ------- ------- ------- ------- -------91000 $43.00 $78.00 $82.00 $86.00 $78.00 $82.00 $86.0091000-26 $40.00 $38.00 $39.00 $41.00 $38.00 $39.00 $41.0091000-TC $2.00 $39.00 $42.00 $45.00 $39.00 $42.00 $45.0091010 $116.00 $212.00 $226.00 $239.00 $212.00 $226.00 $239.0091010-26 $76.00 $69.00 $72.00 $75.00 $69.00 $72.00 $75.0091010-TC $32.00 $143.00 $154.00 $164.00 $143.00 $154.00 $164.0091011 $141.00 $271.00 $289.00 $305.00 $271.00 $289.00 $305.0091011-26 $89.00 $84.00 $87.00 $91.00 $84.00 $87.00 $91.0091011-TC $39.00 $187.00 $202.00 $214.00 $187.00 $202.00 $214.0091012 $143.00 $282.00 $300.00 $317.00 $282.00 $300.00 $317.0091012-26 $95.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.0091012-TC $45.00 $201.00 $216.00 $230.00 $201.00 $216.00 $230.0091020 $60.00 $245.00 $260.00 $275.00 $245.00 $260.00 $275.0091020-26 $49.00 $79.00 $82.00 $86.00 $79.00 $82.00 $86.0091020-TC $9.00 $165.00 $178.00 $190.00 $165.00 $178.00 $190.0091022 ------- $209.00 $222.00 $235.00 $209.00 $222.00 $235.0091022-26 ------- $80.00 $83.00 $86.00 $80.00 $83.00 $86.0091022-TC ------- $129.00 $140.00 $149.00 $129.00 $140.00 $149.0091030 $57.00 $142.00 $151.00 $159.00 $142.00 $151.00 $159.0091030-26 $47.00 $51.00 $52.00 $54.00 $51.00 $52.00 $54.0091030-TC $8.00 $92.00 $98.00 $104.00 $92.00 $98.00 $104.0091034 ------- $227.00 $243.00 $257.00 $227.00 $243.00 $257.0091034-26 ------- $54.00 $57.00 $59.00 $54.00 $57.00 $59.0091034-TC ------- $173.00 $186.00 $198.00 $173.00 $186.00 $198.0091035 ------- $502.00 $535.00 $565.00 $502.00 $535.00 $565.0091035-26 ------- $87.00 $90.00 $93.00 $87.00 $90.00 $93.0091035-TC ------- $415.00 $445.00 $471.00 $415.00 $445.00 $471.0091037 ------- $169.00 $180.00 $191.00 $169.00 $180.00 $191.0091037-26 ------- $55.00 $57.00 $60.00 $55.00 $57.00 $60.0091037-TC ------- $114.00 $123.00 $131.00 $114.00 $123.00 $131.0091038 ------- $147.00 $157.00 $166.00 $147.00 $157.00 $166.0091038-26 ------- $62.00 $65.00 $67.00 $62.00 $65.00 $67.0091038-TC ------- $85.00 $92.00 $99.00 $85.00 $92.00 $99.0091040 ------- $413.00 $442.00 $468.00 $413.00 $442.00 $468.0091040-26 ------- $52.00 $54.00 $56.00 $52.00 $54.00 $56.0091040-TC ------- $362.00 $389.00 $411.00 $362.00 $389.00 $411.0091052 $67.00 $138.00 $146.00 $154.00 $138.00 $146.00 $154.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

91052-26 $52.00 $44.00 $45.00 $47.00 $44.00 $45.00 $47.0091052-TC $12.00 $94.00 $101.00 $107.00 $94.00 $101.00 $107.0091055 $63.00 $147.00 $157.00 $165.00 $147.00 $157.00 $165.0091055-26 $46.00 $49.00 $51.00 $53.00 $49.00 $51.00 $53.0091055-TC $11.00 $99.00 $106.00 $112.00 $99.00 $106.00 $112.0091065 $34.00 $64.00 $69.00 $73.00 $64.00 $69.00 $73.0091065-26 $23.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0091065-TC $14.00 $53.00 $58.00 $61.00 $53.00 $58.00 $61.0091105 $35.00 $90.00 $96.00 $101.00 $19.00 $20.00 $21.0091110 ------- $985.00 $1,049.00 $1,103.00 $985.00 $1,049.00 $1,103.0091110-26 ------- $198.00 $204.00 $210.00 $198.00 $204.00 $210.0091110-TC ------- $788.00 $845.00 $893.00 $788.00 $845.00 $893.0091111 ------- $780.00 $833.00 $878.00 $780.00 $833.00 $878.0091111-26 ------- $56.00 $58.00 $60.00 $56.00 $58.00 $60.0091111-TC ------- $723.00 $775.00 $818.00 $723.00 $775.00 $818.0091120 ------- $433.00 $463.00 $489.00 $433.00 $463.00 $489.0091120-26 ------- $52.00 $54.00 $57.00 $52.00 $54.00 $57.0091120-TC ------- $381.00 $408.00 $432.00 $381.00 $408.00 $432.0091122 $169.00 $263.00 $280.00 $298.00 $263.00 $280.00 $298.0091122-26 $122.00 $97.00 $102.00 $107.00 $97.00 $102.00 $107.0091122-TC $37.00 $166.00 $179.00 $191.00 $166.00 $179.00 $191.0091123 BR ------- ------- ------- ------- ------- -------91132 BR ------- ------- ------- ------- ------- -------91132-26 $28.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0091132-TC BR ------- ------- ------- ------- ------- -------91133 BR ------- ------- ------- ------- ------- -------91133-26 $34.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.0091133-TC BR ------- ------- ------- ------- ------- -------91299 BR ------- ------- ------- ------- ------- -------91299-26 BR ------- ------- ------- ------- ------- -------91299-TC BR ------- ------- ------- ------- ------- -------92002 $63.00 $71.00 $74.00 $77.00 $45.00 $47.00 $48.0092004 $98.00 $134.00 $139.00 $144.00 $94.00 $96.00 $99.0092012 $53.00 $75.00 $78.00 $81.00 $47.00 $48.00 $50.0092014 $75.00 $109.00 $113.00 $117.00 $72.00 $74.00 $76.0092015 $34.00 $45.00 $48.00 $50.00 $19.00 $20.00 $20.0092018 $80.00 $134.00 $138.00 $143.00 $134.00 $138.00 $143.0092019 $70.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.0092020 $31.00 $26.00 $27.00 $28.00 $20.00 $21.00 $21.0092025 ------- $33.00 $35.00 $37.00 $33.00 $35.00 $37.0092025-26 ------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.0092025-TC ------- $15.00 $16.00 $18.00 $15.00 $16.00 $18.0092060 $40.00 $57.00 $60.00 $62.00 $57.00 $60.00 $62.0092060-26 $32.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.0092060-TC $7.00 $20.00 $21.00 $23.00 $20.00 $21.00 $23.0092065 $34.00 $42.00 $44.00 $47.00 $42.00 $44.00 $47.0092065-26 $19.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.0092065-TC $6.00 $23.00 $25.00 $26.00 $23.00 $25.00 $26.0092070 $66.00 $66.00 $69.00 $72.00 $38.00 $39.00 $40.0092081 $32.00 $52.00 $55.00 $58.00 $52.00 $55.00 $58.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

92081-26 $19.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.0092081-TC $6.00 $33.00 $35.00 $38.00 $33.00 $35.00 $38.0092082 $48.00 $67.00 $71.00 $75.00 $67.00 $71.00 $75.0092082-26 $24.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.0092082-TC $9.00 $44.00 $48.00 $50.00 $44.00 $48.00 $50.0092083 $59.00 $77.00 $82.00 $86.00 $77.00 $82.00 $86.0092083-26 $31.00 $27.00 $27.00 $28.00 $27.00 $27.00 $28.0092083-TC $14.00 $51.00 $55.00 $58.00 $51.00 $55.00 $58.0092100 $40.00 $86.00 $90.00 $93.00 $48.00 $49.00 $50.0092120 $32.00 $71.00 $74.00 $77.00 $42.00 $43.00 $44.0092130 $56.00 $79.00 $83.00 $87.00 $44.00 $45.00 $46.0092135 $69.00 $45.00 $48.00 $50.00 $45.00 $48.00 $50.0092135-26 $18.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.0092135-TC $49.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.0092136 $93.00 $86.00 $91.00 $97.00 $86.00 $91.00 $97.0092136-26 $29.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0092136-TC $63.00 $56.00 $61.00 $66.00 $56.00 $61.00 $66.0092140 $38.00 $56.00 $59.00 $61.00 $26.00 $27.00 $28.0092225 $45.00 $23.00 $24.00 $25.00 $20.00 $21.00 $21.0092226 $39.00 $21.00 $22.00 $23.00 $18.00 $18.00 $19.0092230 $58.00 $67.00 $70.00 $73.00 $31.00 $32.00 $33.0092235 $104.00 $131.00 $139.00 $147.00 $131.00 $139.00 $147.0092235-26 $46.00 $44.00 $45.00 $47.00 $44.00 $45.00 $47.0092235-TC $53.00 $87.00 $94.00 $100.00 $87.00 $94.00 $100.0092240 $132.00 $204.00 $217.00 $228.00 $204.00 $217.00 $228.0092240-26 $60.00 $60.00 $62.00 $64.00 $60.00 $62.00 $64.0092240-TC $67.00 $144.00 $155.00 $164.00 $144.00 $155.00 $164.0092250 $40.00 $73.00 $77.00 $81.00 $73.00 $77.00 $81.0092250-26 $24.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.0092250-TC $7.00 $50.00 $53.00 $57.00 $50.00 $53.00 $57.0092260 $20.00 $18.00 $18.00 $19.00 $11.00 $12.00 $12.0092265 $53.00 $82.00 $87.00 $92.00 $82.00 $87.00 $92.0092265-26 $37.00 $42.00 $44.00 $46.00 $42.00 $44.00 $46.0092265-TC $10.00 $40.00 $43.00 $46.00 $40.00 $43.00 $46.0092270 $64.00 $89.00 $94.00 $98.00 $89.00 $94.00 $98.0092270-26 $45.00 $43.00 $44.00 $46.00 $43.00 $44.00 $46.0092270-TC $19.00 $46.00 $50.00 $53.00 $46.00 $50.00 $53.0092275 $80.00 $126.00 $133.00 $140.00 $126.00 $133.00 $140.0092275-26 $56.00 $54.00 $56.00 $58.00 $54.00 $56.00 $58.0092275-TC $17.00 $72.00 $77.00 $82.00 $72.00 $77.00 $82.0092283 $24.00 $43.00 $46.00 $49.00 $43.00 $46.00 $49.0092283-26 $10.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0092283-TC $5.00 $34.00 $37.00 $39.00 $34.00 $37.00 $39.0092284 $192.00 $69.00 $74.00 $78.00 $69.00 $74.00 $78.0092284-26 $151.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0092284-TC $46.00 $57.00 $61.00 $65.00 $57.00 $61.00 $65.0092285 $26.00 $44.00 $47.00 $49.00 $44.00 $47.00 $49.0092285-26 $12.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0092285-TC $6.00 $32.00 $35.00 $37.00 $32.00 $35.00 $37.0092286 $91.00 $127.00 $135.00 $142.00 $127.00 $135.00 $142.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

92286-26 $53.00 $35.00 $36.00 $38.00 $35.00 $36.00 $38.0092286-TC $29.00 $92.00 $99.00 $105.00 $92.00 $99.00 $105.0092287 $99.00 $115.00 $121.00 $127.00 $42.00 $44.00 $45.0092310 $86.00 $88.00 $92.00 $96.00 $60.00 $62.00 $64.0092311 $78.00 $88.00 $92.00 $96.00 $55.00 $56.00 $58.0092312 $89.00 $98.00 $102.00 $106.00 $65.00 $67.00 $69.0092313 $70.00 $84.00 $88.00 $91.00 $47.00 $48.00 $50.0092314 $54.00 $67.00 $70.00 $73.00 $34.00 $35.00 $36.0092315 $44.00 $60.00 $63.00 $66.00 $23.00 $23.00 $24.0092316 $59.00 $76.00 $80.00 $84.00 $37.00 $38.00 $39.0092317 $39.00 $61.00 $65.00 $68.00 $22.00 $23.00 $24.0092325 $14.00 $25.00 $27.00 $29.00 $25.00 $27.00 $29.0092326 $44.00 $50.00 $55.00 $59.00 $50.00 $55.00 $59.0092340 $32.00 $37.00 $39.00 $40.00 $19.00 $19.00 $20.0092341 $43.00 $41.00 $43.00 $45.00 $23.00 $24.00 $25.0092342 $43.00 $45.00 $47.00 $48.00 $27.00 $28.00 $28.0092352 $31.00 $39.00 $41.00 $42.00 $19.00 $19.00 $20.0092353 $38.00 $46.00 $48.00 $50.00 $26.00 $26.00 $27.0092354 $221.00 $186.00 $201.00 $215.00 $186.00 $201.00 $215.0092355 $107.00 $94.00 $101.00 $107.00 $94.00 $101.00 $107.0092358 $24.00 $27.00 $29.00 $32.00 $27.00 $29.00 $32.0092370 $35.00 $31.00 $33.00 $35.00 $17.00 $18.00 $18.0092371 $18.00 $18.00 $20.00 $21.00 $18.00 $20.00 $21.0092499 BR ------- ------- ------- ------- ------- -------92499-26 BR ------- ------- ------- ------- ------- -------92499-TC BR ------- ------- ------- ------- ------- -------92502 $101.00 $98.00 $102.00 $106.00 $98.00 $102.00 $106.0092504 $24.00 $29.00 $31.00 $32.00 $10.00 $10.00 $11.0092506 $63.00 $153.00 $163.00 $171.00 $47.00 $49.00 $50.0092507 $40.00 $66.00 $70.00 $73.00 $28.00 $29.00 $30.0092508 $42.00 $31.00 $33.00 $34.00 $15.00 $15.00 $16.0092511 $81.00 $159.00 $169.00 $177.00 $61.00 $64.00 $66.0092512 $46.00 $63.00 $67.00 $70.00 $28.00 $29.00 $30.0092516 $36.00 $64.00 $68.00 $71.00 $24.00 $24.00 $25.0092520 $47.00 $58.00 $60.00 $63.00 $42.00 $43.00 $45.0092526 $48.00 $87.00 $92.00 $96.00 $28.00 $29.00 $30.0092531 $10.00 ------- ------- ------- ------- ------- -------92532 $14.00 ------- ------- ------- ------- ------- -------92533 $41.00 ------- ------- ------- ------- ------- -------92534 BR ------- ------- ------- ------- ------- -------92541 $37.00 $60.00 $64.00 $68.00 $60.00 $64.00 $68.0092541-26 $25.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0092541-TC $9.00 $38.00 $41.00 $44.00 $38.00 $41.00 $44.0092542 $33.00 $62.00 $66.00 $70.00 $62.00 $66.00 $70.0092542-26 $20.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.0092542-TC $10.00 $44.00 $47.00 $51.00 $44.00 $47.00 $51.0092543 $28.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0092543-26 $19.00 $6.00 $6.00 $7.00 $6.00 $6.00 $7.0092543-TC $10.00 $23.00 $25.00 $26.00 $23.00 $25.00 $26.0092544 $26.00 $50.00 $53.00 $56.00 $50.00 $53.00 $56.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 357

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

92544-26 $16.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0092544-TC $8.00 $35.00 $38.00 $41.00 $35.00 $38.00 $41.0092545 $22.00 $46.00 $49.00 $52.00 $46.00 $49.00 $52.0092545-26 $14.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0092545-TC $8.00 $33.00 $36.00 $38.00 $33.00 $36.00 $38.0092546 $29.00 $87.00 $93.00 $99.00 $87.00 $93.00 $99.0092546-26 $17.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.0092546-TC $9.00 $72.00 $77.00 $82.00 $72.00 $77.00 $82.0092547 $21.00 $7.00 $9.00 $11.00 $7.00 $9.00 $11.0092548 $92.00 $106.00 $114.00 $123.00 $106.00 $114.00 $123.0092548-26 $30.00 $28.00 $28.00 $30.00 $28.00 $28.00 $30.0092548-TC $59.00 $78.00 $86.00 $94.00 $78.00 $86.00 $94.0092551 $17.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.0092552 $16.00 $23.00 $25.00 $28.00 $23.00 $25.00 $28.0092553 $24.00 $32.00 $35.00 $38.00 $32.00 $35.00 $38.0092555 $14.00 $18.00 $20.00 $22.00 $18.00 $20.00 $22.0092556 $21.00 $25.00 $28.00 $31.00 $25.00 $28.00 $31.0092557 $46.00 $59.00 $63.00 $69.00 $57.00 $61.00 $66.0092560 $23.00 ------- ------- ------- ------- ------- -------92561 $27.00 $32.00 $35.00 $38.00 $32.00 $35.00 $38.0092562 $15.00 $23.00 $25.00 $27.00 $23.00 $25.00 $27.0092563 $14.00 $21.00 $23.00 $25.00 $21.00 $23.00 $25.0092564 $17.00 $22.00 $24.00 $27.00 $22.00 $24.00 $27.0092565 $15.00 $15.00 $17.00 $19.00 $15.00 $17.00 $19.0092567 $20.00 $24.00 $26.00 $29.00 $23.00 $25.00 $27.0092568 $14.00 $23.00 $24.00 $26.00 $23.00 $24.00 $26.0092569 $15.00 $19.00 $21.00 $23.00 $19.00 $21.00 $23.0092571 $14.00 $19.00 $21.00 $23.00 $19.00 $21.00 $23.0092572 $3.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.0092575 $11.00 $30.00 $32.00 $35.00 $30.00 $32.00 $35.0092576 $17.00 $23.00 $26.00 $28.00 $23.00 $26.00 $28.0092577 $28.00 $24.00 $26.00 $30.00 $24.00 $26.00 $30.0092579 $28.00 $51.00 $54.00 $57.00 $49.00 $51.00 $54.0092582 $28.00 $41.00 $45.00 $49.00 $41.00 $45.00 $49.0092583 $34.00 $37.00 $41.00 $45.00 $37.00 $41.00 $45.0092584 $94.00 $88.00 $98.00 $109.00 $88.00 $98.00 $109.0092585 $114.00 $111.00 $120.00 $130.00 $111.00 $120.00 $130.0092585-26 $52.00 $27.00 $28.00 $30.00 $27.00 $28.00 $30.0092585-TC $70.00 $83.00 $91.00 $100.00 $83.00 $91.00 $100.0092586 $70.00 $73.00 $81.00 $89.00 $73.00 $81.00 $89.0092587 $58.00 $52.00 $57.00 $63.00 $52.00 $57.00 $63.0092587-26 $8.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.0092587-TC $49.00 $45.00 $49.00 $55.00 $45.00 $49.00 $55.0092588 $78.00 $76.00 $83.00 $90.00 $76.00 $83.00 $90.0092588-26 $20.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.0092588-TC $57.00 $57.00 $63.00 $70.00 $57.00 $63.00 $70.0092590 $41.00 ------- ------- ------- ------- ------- -------92591 BR ------- ------- ------- ------- ------- -------92592 BR ------- ------- ------- ------- ------- -------92593 BR ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

92594 BR ------- ------- ------- ------- ------- -------92595 BR ------- ------- ------- ------- ------- -------92596 $22.00 $35.00 $39.00 $42.00 $35.00 $39.00 $42.0092597 $96.00 $106.00 $112.00 $117.00 $48.00 $50.00 $52.0092603 $88.00 $153.00 $159.00 $165.00 $144.00 $149.00 $155.0092604 $60.00 $92.00 $96.00 $101.00 $85.00 $89.00 $93.0092605 BR ------- ------- ------- ------- ------- -------92606 BR ------- ------- ------- ------- ------- -------92607 $109.00 $155.00 $166.00 $177.00 $155.00 $166.00 $177.0092608 $22.00 $31.00 $34.00 $38.00 $31.00 $34.00 $38.0092609 $59.00 $82.00 $88.00 $94.00 $82.00 $88.00 $94.0092610 $42.00 $106.00 $115.00 $123.00 $106.00 $115.00 $123.0092611 $46.00 $111.00 $120.00 $128.00 $111.00 $120.00 $128.0092612 $173.00 $162.00 $171.00 $178.00 $71.00 $73.00 $75.0092613 BR $42.00 $44.00 $46.00 $42.00 $44.00 $46.0092614 $134.00 $146.00 $154.00 $161.00 $71.00 $73.00 $75.0092615 BR $37.00 $39.00 $41.00 $37.00 $39.00 $41.0092616 $183.00 $202.00 $212.00 $222.00 $105.00 $108.00 $112.0092617 BR $46.00 $48.00 $51.00 $46.00 $48.00 $51.0092620 ------- $64.00 $70.00 $75.00 $64.00 $70.00 $75.0092621 ------- $17.00 $19.00 $22.00 $17.00 $19.00 $22.0092625 ------- $64.00 $69.00 $75.00 $64.00 $69.00 $75.0092626 ------- $86.00 $93.00 $100.00 $86.00 $93.00 $100.0092627 ------- $21.00 $23.00 $24.00 $21.00 $23.00 $24.0092640 ------- $53.00 $57.00 $61.00 $53.00 $57.00 $61.0092700 BR ------- ------- ------- ------- ------- -------92950 $203.00 $303.00 $319.00 $337.00 $192.00 $200.00 $210.0092953 $35.00 $12.00 $13.00 $14.00 $12.00 $13.00 $14.0092960 $162.00 $297.00 $313.00 $328.00 $139.00 $144.00 $149.0092961 $239.00 $276.00 $288.00 $302.00 $276.00 $288.00 $302.0092970 $201.00 $189.00 $196.00 $203.00 $189.00 $196.00 $203.0092971 $100.00 $107.00 $111.00 $115.00 $107.00 $111.00 $115.0092973 $174.00 $195.00 $204.00 $215.00 $195.00 $204.00 $215.0092974 $197.00 $179.00 $187.00 $197.00 $179.00 $187.00 $197.0092975 $400.00 $429.00 $449.00 $472.00 $429.00 $449.00 $472.0092977 $302.00 $221.00 $244.00 $269.00 $221.00 $244.00 $269.0092978 $269.00 ------- ------- ------- ------- ------- -------92978-26 $95.00 $103.00 $107.00 $111.00 $103.00 $107.00 $111.0092978-TC $170.00 ------- ------- ------- ------- ------- -------92979 $163.00 ------- ------- ------- ------- ------- -------92979-26 $76.00 $83.00 $86.00 $90.00 $83.00 $86.00 $90.0092979-TC $86.00 ------- ------- ------- ------- ------- -------92980 $952.00 $889.00 $930.00 $978.00 $889.00 $930.00 $978.0092981 $268.00 $247.00 $258.00 $272.00 $247.00 $258.00 $272.0092982 $705.00 $659.00 $689.00 $725.00 $659.00 $689.00 $725.0092984 $191.00 $177.00 $185.00 $194.00 $177.00 $185.00 $194.0092986 $1,222.00 $1,465.00 $1,533.00 $1,611.00 $1,465.00 $1,533.00 $1,611.0092987 $1,271.00 $1,519.00 $1,590.00 $1,672.00 $1,519.00 $1,590.00 $1,672.0092990 $974.00 $1,158.00 $1,212.00 $1,274.00 $1,158.00 $1,212.00 $1,274.0092992 BR ------- ------- ------- ------- ------- -------

CPT only © 2008 American Medical Association. All rights reserved. Part C, 359

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

92993 BR ------- ------- ------- ------- ------- -------92995 $776.00 $725.00 $758.00 $798.00 $725.00 $758.00 $798.0092996 $210.00 $186.00 $192.00 $199.00 $186.00 $192.00 $199.0092997 $765.00 $672.00 $694.00 $719.00 $672.00 $694.00 $719.0092998 $331.00 $340.00 $353.00 $368.00 $340.00 $353.00 $368.0093000 $26.00 $25.00 $26.00 $28.00 $25.00 $26.00 $28.0093005 $16.00 $15.00 $17.00 $18.00 $15.00 $17.00 $18.0093010 $12.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0093012 $90.00 $211.00 $229.00 $246.00 $211.00 $229.00 $246.0093014 $28.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0093015 $104.00 $113.00 $121.00 $130.00 $113.00 $121.00 $130.0093016 $25.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0093017 $63.00 $70.00 $77.00 $84.00 $70.00 $77.00 $84.0093018 $54.00 $17.00 $17.00 $18.00 $17.00 $17.00 $18.0093024 $111.00 $128.00 $136.00 $145.00 $128.00 $136.00 $145.0093024-26 $71.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0093024-TC $42.00 $63.00 $68.00 $74.00 $63.00 $68.00 $74.0093025 $277.00 $263.00 $282.00 $300.00 $263.00 $282.00 $300.0093025-26 ------- $43.00 $44.00 $46.00 $43.00 $44.00 $46.0093025-TC ------- $220.00 $237.00 $253.00 $220.00 $237.00 $253.0093040 $14.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0093041 $31.00 $7.00 $7.00 $8.00 $7.00 $7.00 $8.0093042 $9.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0093224 $159.00 $151.00 $164.00 $178.00 $151.00 $164.00 $178.0093225 $46.00 $46.00 $51.00 $56.00 $46.00 $51.00 $56.0093226 $83.00 $75.00 $83.00 $91.00 $75.00 $83.00 $91.0093227 $50.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0093230 $168.00 $157.00 $171.00 $186.00 $157.00 $171.00 $186.0093231 $57.00 $51.00 $56.00 $62.00 $51.00 $56.00 $62.0093232 $82.00 $78.00 $85.00 $93.00 $78.00 $85.00 $93.0093233 $55.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0093235 $123.00 ------- ------- ------- ------- ------- -------93236 $97.00 ------- ------- ------- ------- ------- -------93237 $28.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0093268 $109.00 $296.00 $320.00 $344.00 $296.00 $320.00 $344.0093270 $46.00 $35.00 $39.00 $43.00 $35.00 $39.00 $43.0093271 $90.00 $233.00 $252.00 $271.00 $233.00 $252.00 $271.0093272 $28.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0093278 $58.00 $53.00 $58.00 $64.00 $53.00 $58.00 $64.0093278-26 $24.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.0093278-TC $44.00 $39.00 $44.00 $49.00 $39.00 $44.00 $49.0093303 $215.00 $238.00 $255.00 $274.00 $238.00 $255.00 $274.0093303-26 $70.00 $70.00 $72.00 $74.00 $70.00 $72.00 $74.0093303-TC $144.00 $168.00 $183.00 $200.00 $168.00 $183.00 $200.0093304 $114.00 $142.00 $152.00 $163.00 $142.00 $152.00 $163.0093304-26 $43.00 $40.00 $41.00 $43.00 $40.00 $41.00 $43.0093304-TC $73.00 $102.00 $111.00 $120.00 $102.00 $111.00 $120.0093307 $196.00 $206.00 $222.00 $240.00 $206.00 $222.00 $240.0093307-26 $56.00 $52.00 $53.00 $55.00 $52.00 $53.00 $55.0093307-TC $144.00 $154.00 $169.00 $184.00 $154.00 $169.00 $184.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 360

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

93308 $118.00 $122.00 $132.00 $142.00 $122.00 $132.00 $142.0093308-26 $46.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0093308-TC $75.00 $93.00 $101.00 $110.00 $93.00 $101.00 $110.0093312 $322.00 $339.00 $363.00 $388.00 $339.00 $363.00 $388.0093312-26 $140.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.0093312-TC $182.00 $218.00 $238.00 $259.00 $218.00 $238.00 $259.0093313 $76.00 $46.00 $47.00 $50.00 $46.00 $47.00 $50.0093314 $212.00 $292.00 $314.00 $338.00 $292.00 $314.00 $338.0093314-26 $65.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.0093314-TC $144.00 $223.00 $243.00 $264.00 $223.00 $243.00 $264.0093315 $287.00 $616.00 $678.00 $747.00 $616.00 $678.00 $747.0093315-26 $144.00 $154.00 $159.00 $164.00 $154.00 $159.00 $164.0093315-TC $141.00 $565.00 $622.00 $685.00 $565.00 $622.00 $685.0093316 $78.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.0093317 $236.00 ------- ------- ------- ------- ------- -------93317-26 $95.00 $96.00 $100.00 $104.00 $96.00 $100.00 $104.0093317-TC $141.00 ------- ------- ------- ------- ------- -------93318 BR $600.00 $662.00 $731.00 $600.00 $662.00 $731.0093318-26 $114.00 $116.00 $121.00 $127.00 $116.00 $121.00 $127.0093318-TC BR $565.00 $622.00 $685.00 $565.00 $622.00 $685.0093320 $86.00 $91.00 $99.00 $107.00 $91.00 $99.00 $107.0093320-26 $30.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0093320-TC $65.00 $70.00 $77.00 $85.00 $70.00 $77.00 $85.0093321 $50.00 $46.00 $50.00 $55.00 $46.00 $50.00 $55.0093321-26 $10.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0093321-TC $42.00 $37.00 $41.00 $45.00 $37.00 $41.00 $45.0093325 $114.00 $87.00 $96.00 $107.00 $87.00 $96.00 $107.0093325-26 $4.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.0093325-TC $110.00 $83.00 $92.00 $102.00 $83.00 $92.00 $102.0093350 $216.00 $211.00 $225.00 $239.00 $211.00 $225.00 $239.0093350-26 $77.00 $83.00 $86.00 $89.00 $83.00 $86.00 $89.0093350-TC $66.00 $128.00 $139.00 $150.00 $128.00 $139.00 $150.0093501 $674.00 $913.00 $990.00 $1,071.00 $913.00 $990.00 $1,071.0093501-26 $160.00 $178.00 $186.00 $196.00 $178.00 $186.00 $196.0093501-TC $634.00 $735.00 $804.00 $876.00 $735.00 $804.00 $876.0093503 $187.00 $120.00 $124.00 $130.00 $120.00 $124.00 $130.0093505 $318.00 $672.00 $716.00 $759.00 $672.00 $716.00 $759.0093505-26 $248.00 $258.00 $269.00 $283.00 $258.00 $269.00 $283.0093505-TC $74.00 $415.00 $447.00 $476.00 $415.00 $447.00 $476.0093508 $698.00 $1,064.00 $1,144.00 $1,222.00 $1,064.00 $1,144.00 $1,222.0093508-26 $232.00 $252.00 $263.00 $277.00 $252.00 $263.00 $277.0093508-TC $469.00 $812.00 $880.00 $945.00 $812.00 $880.00 $945.0093510 $1,628.00 $1,643.00 $1,790.00 $1,948.00 $1,643.00 $1,790.00 $1,948.0093510-26 $247.00 $265.00 $278.00 $292.00 $265.00 $278.00 $292.0093510-TC $1,388.00 $1,378.00 $1,512.00 $1,656.00 $1,378.00 $1,512.00 $1,656.0093511 $1,629.00 ------- ------- ------- ------- ------- -------93511-26 $270.00 $307.00 $321.00 $338.00 $307.00 $321.00 $338.0093511-TC $1,350.00 ------- ------- ------- ------- ------- -------93514 $2,208.00 ------- ------- ------- ------- ------- -------93514-26 $525.00 $410.00 $428.00 $450.00 $410.00 $428.00 $450.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

93514-TC $1,683.00 ------- ------- ------- ------- ------- -------93524 $2,150.00 ------- ------- ------- ------- ------- -------93524-26 $392.00 $422.00 $441.00 $464.00 $422.00 $441.00 $464.0093524-TC $1,766.00 ------- ------- ------- ------- ------- -------93526 $2,147.00 $2,126.00 $2,316.00 $2,522.00 $2,126.00 $2,316.00 $2,522.0093526-26 $363.00 $364.00 $381.00 $401.00 $364.00 $381.00 $401.0093526-TC $1,815.00 $1,762.00 $1,935.00 $2,121.00 $1,762.00 $1,935.00 $2,121.0093527 $2,186.00 ------- ------- ------- ------- ------- -------93527-26 $451.00 $441.00 $461.00 $485.00 $441.00 $461.00 $485.0093527-TC $1,766.00 ------- ------- ------- ------- ------- -------93528 $2,266.00 ------- ------- ------- ------- ------- -------93528-26 $482.00 $537.00 $561.00 $590.00 $537.00 $561.00 $590.0093528-TC $1,766.00 ------- ------- ------- ------- ------- -------93529 $2,032.00 ------- ------- ------- ------- ------- -------93529-26 $262.00 $293.00 $306.00 $322.00 $293.00 $306.00 $322.0093529-TC $1,766.00 ------- ------- ------- ------- ------- -------93530 $872.00 ------- ------- ------- ------- ------- -------93530-26 $250.00 $248.00 $259.00 $273.00 $248.00 $259.00 $273.0093530-TC $634.00 ------- ------- ------- ------- ------- -------93531 $2,268.00 ------- ------- ------- ------- ------- -------93531-26 $467.00 $484.00 $506.00 $532.00 $484.00 $506.00 $532.0093531-TC $1,815.00 ------- ------- ------- ------- ------- -------93532 $2,317.00 ------- ------- ------- ------- ------- -------93532-26 $569.00 $567.00 $592.00 $622.00 $567.00 $592.00 $622.0093532-TC $1,766.00 ------- ------- ------- ------- ------- -------93533 $2,131.00 ------- ------- ------- ------- ------- -------93533-26 $352.00 $393.00 $411.00 $432.00 $393.00 $411.00 $432.0093533-TC $1,766.00 ------- ------- ------- ------- ------- -------93539 $45.00 $67.00 $71.00 $74.00 $23.00 $23.00 $24.0093540 $49.00 $189.00 $201.00 $212.00 $24.00 $25.00 $26.0093541 $38.00 $17.00 $17.00 $18.00 $17.00 $17.00 $18.0093542 $38.00 $116.00 $123.00 $130.00 $17.00 $17.00 $18.0093543 $213.00 $65.00 $69.00 $73.00 $17.00 $17.00 $18.0093544 $30.00 $48.00 $51.00 $53.00 $15.00 $15.00 $16.0093545 $240.00 $133.00 $142.00 $149.00 $23.00 $23.00 $24.0093555 $278.00 $194.00 $211.00 $231.00 $194.00 $211.00 $231.0093555-26 $42.00 $46.00 $48.00 $50.00 $46.00 $48.00 $50.0093555-TC $234.00 $148.00 $163.00 $181.00 $148.00 $163.00 $181.0093556 $414.00 $282.00 $308.00 $338.00 $282.00 $308.00 $338.0093556-26 $44.00 $47.00 $49.00 $51.00 $47.00 $49.00 $51.0093556-TC $368.00 $235.00 $259.00 $287.00 $235.00 $259.00 $287.0093561 $59.00 ------- ------- ------- ------- ------- -------93561-26 $47.00 $26.00 $26.00 $27.00 $26.00 $26.00 $27.0093561-TC $20.00 ------- ------- ------- ------- ------- -------93562 $46.00 ------- ------- ------- ------- ------- -------93562-26 $33.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0093562-TC $13.00 ------- ------- ------- ------- ------- -------93571 $270.00 ------- ------- ------- ------- ------- -------93571-26 $93.00 $103.00 $106.00 $110.00 $103.00 $106.00 $110.0093571-TC $170.00 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

93572 $222.00 ------- ------- ------- ------- ------- -------93572-26 $74.00 $80.00 $83.00 $85.00 $80.00 $83.00 $85.0093572-TC $155.00 ------- ------- ------- ------- ------- -------93580 $974.00 $1,071.00 $1,119.00 $1,177.00 $1,071.00 $1,119.00 $1,177.0093581 $1,303.00 $1,419.00 $1,482.00 $1,560.00 $1,419.00 $1,482.00 $1,560.0093600 $198.00 ------- ------- ------- ------- ------- -------93600-26 $129.00 $126.00 $132.00 $139.00 $126.00 $132.00 $139.0093600-TC $73.00 ------- ------- ------- ------- ------- -------93602 $159.00 ------- ------- ------- ------- ------- -------93602-26 $119.00 $125.00 $131.00 $139.00 $125.00 $131.00 $139.0093602-TC $42.00 ------- ------- ------- ------- ------- -------93603 $187.00 ------- ------- ------- ------- ------- -------93603-26 $127.00 $126.00 $132.00 $140.00 $126.00 $132.00 $140.0093603-TC $63.00 ------- ------- ------- ------- ------- -------93609 $578.00 ------- ------- ------- ------- ------- -------93609-26 $481.00 $296.00 $309.00 $325.00 $296.00 $309.00 $325.0093609-TC $101.00 ------- ------- ------- ------- ------- -------93610 $214.00 ------- ------- ------- ------- ------- -------93610-26 $166.00 $178.00 $186.00 $197.00 $178.00 $186.00 $197.0093610-TC $52.00 ------- ------- ------- ------- ------- -------93612 $224.00 ------- ------- ------- ------- ------- -------93612-26 $167.00 $178.00 $186.00 $197.00 $178.00 $186.00 $197.0093612-TC $61.00 ------- ------- ------- ------- ------- -------93613 $377.00 $415.00 $434.00 $457.00 $415.00 $434.00 $457.0093615 $62.00 ------- ------- ------- ------- ------- -------93615-26 $49.00 $54.00 $56.00 $58.00 $54.00 $56.00 $58.0093615-TC $12.00 ------- ------- ------- ------- ------- -------93616 $94.00 ------- ------- ------- ------- ------- -------93616-26 $82.00 $74.00 $77.00 $81.00 $74.00 $77.00 $81.0093616-TC $12.00 ------- ------- ------- ------- ------- -------93618 $399.00 ------- ------- ------- ------- ------- -------93618-26 $258.00 $253.00 $264.00 $278.00 $253.00 $264.00 $278.0093618-TC $148.00 ------- ------- ------- ------- ------- -------93619 $717.00 ------- ------- ------- ------- ------- -------93619-26 $444.00 $440.00 $460.00 $484.00 $440.00 $460.00 $484.0093619-TC $290.00 ------- ------- ------- ------- ------- -------93620 $358.00 ------- ------- ------- ------- ------- -------93620-26 $272.00 $691.00 $722.00 $760.00 $691.00 $722.00 $760.0093620-TC $91.00 ------- ------- ------- ------- ------- -------93621 BR ------- ------- ------- ------- ------- -------93621-26 $769.00 $125.00 $130.00 $137.00 $125.00 $130.00 $137.0093621-TC BR ------- ------- ------- ------- ------- -------93622 BR ------- ------- ------- ------- ------- -------93622-26 $771.00 $183.00 $191.00 $201.00 $183.00 $191.00 $201.0093622-TC BR ------- ------- ------- ------- ------- -------93623 BR ------- ------- ------- ------- ------- -------93623-26 $167.00 $169.00 $176.00 $185.00 $169.00 $176.00 $185.0093623-TC BR ------- ------- ------- ------- ------- -------93624 $333.00 ------- ------- ------- ------- ------- -------93624-26 $256.00 $292.00 $305.00 $321.00 $292.00 $305.00 $321.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

93624-TC $74.00 ------- ------- ------- ------- ------- -------93631 $651.00 ------- ------- ------- ------- ------- -------93631-26 $420.00 $449.00 $476.00 $512.00 $449.00 $476.00 $512.0093631-TC $239.00 ------- ------- ------- ------- ------- -------93640 $467.00 ------- ------- ------- ------- ------- -------93640-26 $230.00 $207.00 $216.00 $227.00 $207.00 $216.00 $227.0093640-TC $269.00 ------- ------- ------- ------- ------- -------93641 $613.00 ------- ------- ------- ------- ------- -------93641-26 $360.00 $350.00 $366.00 $385.00 $350.00 $366.00 $385.0093641-TC $269.00 ------- ------- ------- ------- ------- -------93642 $549.00 ------- ------- ------- ------- ------- -------93642-26 $295.00 $284.00 $294.00 $304.00 $284.00 $294.00 $304.0093642-TC $269.00 $261.00 $286.00 $312.00 $261.00 $286.00 $312.0093650 $639.00 $634.00 $663.00 $697.00 $634.00 $663.00 $697.0093651 $985.00 $961.00 $1,004.00 $1,056.00 $961.00 $1,004.00 $1,056.0093652 $1,044.00 $1,047.00 $1,094.00 $1,151.00 $1,047.00 $1,094.00 $1,151.0093660 $162.00 $181.00 $190.00 $199.00 $181.00 $190.00 $199.0093660-26 $103.00 $107.00 $110.00 $114.00 $107.00 $110.00 $114.0093660-TC $61.00 $74.00 $80.00 $85.00 $74.00 $80.00 $85.0093662 BR ------- ------- ------- ------- ------- -------93662-26 $158.00 $160.00 $165.00 $171.00 $160.00 $165.00 $171.0093662-TC BR ------- ------- ------- ------- ------- -------93668 BR $17.00 $18.00 $19.00 $17.00 $18.00 $19.0093701 $36.00 $41.00 $43.00 $46.00 $41.00 $43.00 $46.0093701-26 $9.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0093701-TC $27.00 $31.00 $33.00 $35.00 $31.00 $33.00 $35.0093720 $43.00 $49.00 $53.00 $57.00 $49.00 $53.00 $57.0093721 $27.00 $40.00 $44.00 $48.00 $40.00 $44.00 $48.0093722 $24.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0093724 $411.00 $383.00 $404.00 $426.00 $383.00 $404.00 $426.0093724-26 $259.00 $273.00 $282.00 $292.00 $273.00 $282.00 $292.0093724-TC $148.00 $110.00 $122.00 $135.00 $110.00 $122.00 $135.0093740 $17.00 $11.00 $12.00 $13.00 $11.00 $12.00 $13.0093740-26 $12.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0093740-TC $5.00 $3.00 $4.00 $4.00 $3.00 $4.00 $4.0093770 NC NC NC NC NC NC NC93770-26 NC NC NC NC NC NC NC93770-TC NC NC NC NC NC NC NC93784 NC NC NC NC NC NC NC93786 NC NC NC NC NC NC NC93788 NC NC NC NC NC NC NC93790 NC NC NC NC NC NC NC93797 $17.00 $19.00 $21.00 $22.00 $10.00 $11.00 $11.0093798 $38.00 $29.00 $30.00 $32.00 $16.00 $16.00 $17.0093799 BR ------- ------- ------- ------- ------- -------93799-26 BR ------- ------- ------- ------- ------- -------93799-TC BR ------- ------- ------- ------- ------- -------93875 $55.00 $111.00 $120.00 $130.00 $111.00 $120.00 $130.0093875-26 $17.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0093875-TC $42.00 $100.00 $109.00 $118.00 $100.00 $109.00 $118.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

93880 $176.00 $194.00 $211.00 $228.00 $194.00 $211.00 $228.0093880-26 $31.00 $33.00 $34.00 $36.00 $33.00 $34.00 $36.0093880-TC $144.00 $162.00 $177.00 $192.00 $162.00 $177.00 $192.0093882 $117.00 $181.00 $197.00 $214.00 $181.00 $197.00 $214.0093882-26 $21.00 $22.00 $23.00 $25.00 $22.00 $23.00 $25.0093882-TC $95.00 $159.00 $173.00 $189.00 $159.00 $173.00 $189.0093886 $215.00 $212.00 $229.00 $248.00 $212.00 $229.00 $248.0093886-26 $50.00 $51.00 $53.00 $56.00 $51.00 $53.00 $56.0093886-TC $162.00 $161.00 $176.00 $192.00 $161.00 $176.00 $192.0093888 $142.00 $99.00 $107.00 $115.00 $99.00 $107.00 $115.0093888-26 $33.00 $34.00 $36.00 $38.00 $34.00 $36.00 $38.0093888-TC $109.00 $65.00 $71.00 $77.00 $65.00 $71.00 $77.0093890 ------- $158.00 $170.00 $183.00 $158.00 $170.00 $183.0093890-26 ------- $55.00 $57.00 $60.00 $55.00 $57.00 $60.0093890-TC ------- $103.00 $113.00 $124.00 $103.00 $113.00 $124.0093892 ------- $164.00 $176.00 $189.00 $164.00 $176.00 $189.0093892-26 ------- $61.00 $64.00 $66.00 $61.00 $64.00 $66.0093892-TC ------- $103.00 $112.00 $123.00 $103.00 $112.00 $123.0093893 ------- $164.00 $176.00 $189.00 $164.00 $176.00 $189.0093893-26 ------- $61.00 $64.00 $66.00 $61.00 $64.00 $66.0093893-TC ------- $103.00 $112.00 $123.00 $103.00 $112.00 $123.0093922 $60.00 $132.00 $144.00 $155.00 $132.00 $144.00 $155.0093922-26 $16.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.0093922-TC $44.00 $119.00 $129.00 $140.00 $119.00 $129.00 $140.0093923 $112.00 $204.00 $221.00 $239.00 $204.00 $221.00 $239.0093923-26 $28.00 $25.00 $26.00 $28.00 $25.00 $26.00 $28.0093923-TC $85.00 $179.00 $195.00 $212.00 $179.00 $195.00 $212.0093924 $122.00 $248.00 $269.00 $290.00 $248.00 $269.00 $290.0093924-26 $31.00 $28.00 $30.00 $32.00 $28.00 $30.00 $32.0093924-TC $92.00 $219.00 $239.00 $259.00 $219.00 $239.00 $259.0093925 $175.00 $191.00 $207.00 $223.00 $191.00 $207.00 $223.0093925-26 $31.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.0093925-TC $144.00 $160.00 $174.00 $189.00 $160.00 $174.00 $189.0093926 $117.00 $123.00 $133.00 $144.00 $123.00 $133.00 $144.0093926-26 $21.00 $21.00 $23.00 $24.00 $21.00 $23.00 $24.0093926-TC $96.00 $102.00 $111.00 $120.00 $102.00 $111.00 $120.0093930 $174.00 $187.00 $203.00 $221.00 $187.00 $203.00 $221.0093930-26 $26.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0093930-TC $150.00 $161.00 $177.00 $193.00 $161.00 $177.00 $193.0093931 $118.00 $120.00 $130.00 $141.00 $120.00 $130.00 $141.0093931-26 $17.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.0093931-TC $101.00 $102.00 $112.00 $122.00 $102.00 $112.00 $122.0093965 $63.00 $136.00 $146.00 $158.00 $136.00 $146.00 $158.0093965-26 $26.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.0093965-TC $42.00 $117.00 $127.00 $137.00 $117.00 $127.00 $137.0093970 $189.00 $200.00 $218.00 $237.00 $200.00 $218.00 $237.0093970-26 $36.00 $38.00 $39.00 $42.00 $38.00 $39.00 $42.0093970-TC $154.00 $162.00 $178.00 $195.00 $162.00 $178.00 $195.0093971 $121.00 $127.00 $138.00 $150.00 $127.00 $138.00 $150.0093971-26 $23.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

93971-TC $96.00 $103.00 $113.00 $124.00 $103.00 $113.00 $124.0093975 $277.00 $260.00 $279.00 $300.00 $260.00 $279.00 $300.0093975-26 $89.00 $99.00 $103.00 $108.00 $99.00 $103.00 $108.0093975-TC $181.00 $161.00 $176.00 $192.00 $161.00 $176.00 $192.0093976 $184.00 $227.00 $245.00 $265.00 $227.00 $245.00 $265.0093976-26 $59.00 $64.00 $66.00 $69.00 $64.00 $66.00 $69.0093976-TC $121.00 $163.00 $179.00 $196.00 $163.00 $179.00 $196.0093978 $177.00 $199.00 $216.00 $236.00 $199.00 $216.00 $236.0093978-26 $34.00 $36.00 $38.00 $40.00 $36.00 $38.00 $40.0093978-TC $143.00 $162.00 $178.00 $195.00 $162.00 $178.00 $195.0093979 $122.00 $127.00 $138.00 $149.00 $127.00 $138.00 $149.0093979-26 $23.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0093979-TC $98.00 $103.00 $112.00 $123.00 $103.00 $112.00 $123.0093980 $183.00 $196.00 $214.00 $234.00 $196.00 $214.00 $234.0093980-26 $65.00 $68.00 $71.00 $74.00 $68.00 $71.00 $74.0093980-TC $105.00 $128.00 $143.00 $160.00 $128.00 $143.00 $160.0093981 $148.00 $149.00 $164.00 $181.00 $149.00 $164.00 $181.0093981-26 $25.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.0093981-TC $124.00 $126.00 $140.00 $155.00 $126.00 $140.00 $155.0093982 ------- $43.00 $45.00 $48.00 $43.00 $45.00 $48.0093990 $110.00 $116.00 $126.00 $136.00 $116.00 $126.00 $136.0093990-26 $14.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.0093990-TC $96.00 $102.00 $111.00 $120.00 $102.00 $111.00 $120.0094002 ------- $92.00 $95.00 $99.00 $92.00 $95.00 $99.0094003 ------- $67.00 $69.00 $72.00 $67.00 $69.00 $72.0094004 ------- $48.00 $50.00 $52.00 $48.00 $50.00 $52.0094005 ------- $87.00 $90.00 $93.00 $87.00 $90.00 $93.0094010 $30.00 $36.00 $39.00 $41.00 $36.00 $39.00 $41.0094010-26 $12.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0094010-TC $16.00 $27.00 $29.00 $32.00 $27.00 $29.00 $32.0094014 $39.00 $52.00 $55.00 $57.00 $52.00 $55.00 $57.0094015 $14.00 $25.00 $27.00 $29.00 $25.00 $27.00 $29.0094016 $26.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0094060 $57.00 $62.00 $67.00 $72.00 $62.00 $67.00 $72.0094060-26 $18.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.0094060-TC $36.00 $47.00 $52.00 $56.00 $47.00 $52.00 $56.0094070 $32.00 $66.00 $71.00 $77.00 $66.00 $71.00 $77.0094070-26 $11.00 $30.00 $31.00 $33.00 $30.00 $31.00 $33.0094070-TC $19.00 $35.00 $39.00 $44.00 $35.00 $39.00 $44.0094150 $8.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.0094150-26 $6.00 $4.00 $4.00 $5.00 $4.00 $4.00 $5.0094150-TC $3.00 $18.00 $20.00 $21.00 $18.00 $20.00 $21.0094200 $17.00 $25.00 $26.00 $28.00 $25.00 $26.00 $28.0094200-26 $7.00 $6.00 $6.00 $7.00 $6.00 $6.00 $7.0094200-TC $9.00 $19.00 $20.00 $22.00 $19.00 $20.00 $22.0094240 $43.00 $42.00 $46.00 $49.00 $42.00 $46.00 $49.0094240-26 $15.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0094240-TC $26.00 $29.00 $32.00 $35.00 $29.00 $32.00 $35.0094250 $12.00 $28.00 $30.00 $32.00 $28.00 $30.00 $32.0094250-26 $8.00 $6.00 $6.00 $7.00 $6.00 $6.00 $7.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

94250-TC $5.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.0094260 $27.00 $34.00 $36.00 $40.00 $34.00 $36.00 $40.0094260-26 $8.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.0094260-TC $18.00 $27.00 $30.00 $32.00 $27.00 $30.00 $32.0094350 $36.00 $40.00 $43.00 $46.00 $40.00 $43.00 $46.0094350-26 $14.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0094350-TC $20.00 $27.00 $29.00 $32.00 $27.00 $29.00 $32.0094360 $37.00 $46.00 $50.00 $54.00 $46.00 $50.00 $54.0094360-26 $11.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0094360-TC $26.00 $33.00 $36.00 $40.00 $33.00 $36.00 $40.0094370 $33.00 $37.00 $40.00 $42.00 $37.00 $40.00 $42.0094370-26 $18.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0094370-TC $12.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0094375 $34.00 $39.00 $42.00 $44.00 $39.00 $42.00 $44.0094375-26 $16.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.0094375-TC $17.00 $24.00 $26.00 $28.00 $24.00 $26.00 $28.0094400 $40.00 $57.00 $62.00 $67.00 $57.00 $62.00 $67.0094400-26 $24.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0094400-TC $14.00 $36.00 $40.00 $44.00 $36.00 $40.00 $44.0094450 $37.00 $53.00 $57.00 $60.00 $53.00 $57.00 $60.0094450-26 $20.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0094450-TC $15.00 $33.00 $36.00 $39.00 $33.00 $36.00 $39.0094452 ------- $59.00 $63.00 $66.00 $59.00 $63.00 $66.0094452-26 ------- $16.00 $16.00 $17.00 $16.00 $16.00 $17.0094452-TC ------- $43.00 $46.00 $49.00 $43.00 $46.00 $49.0094453 ------- $80.00 $85.00 $90.00 $80.00 $85.00 $90.0094453-26 ------- $20.00 $21.00 $22.00 $20.00 $21.00 $22.0094453-TC ------- $60.00 $64.00 $68.00 $60.00 $64.00 $68.0094610 ------- $72.00 $78.00 $87.00 $72.00 $78.00 $87.0094620 $91.00 $96.00 $103.00 $111.00 $96.00 $103.00 $111.0094620-26 $38.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.0094620-TC $54.00 $64.00 $70.00 $76.00 $64.00 $70.00 $76.0094621 $122.00 $168.00 $179.00 $190.00 $168.00 $179.00 $190.0094621-26 $71.00 $73.00 $76.00 $79.00 $73.00 $76.00 $79.0094621-TC $52.00 $95.00 $103.00 $111.00 $95.00 $103.00 $111.0094640 $19.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0094642 BR ------- ------- ------- ------- ------- -------94644 ------- $39.00 $42.00 $45.00 $39.00 $42.00 $45.0094645 ------- $15.00 $16.00 $18.00 $15.00 $16.00 $18.0094660 $54.00 $59.00 $62.00 $65.00 $39.00 $40.00 $42.0094662 $38.00 $38.00 $39.00 $41.00 $38.00 $39.00 $41.0094664 $18.00 $17.00 $18.00 $21.00 $17.00 $18.00 $21.0094667 $23.00 $24.00 $26.00 $29.00 $24.00 $26.00 $29.0094668 $16.00 $20.00 $22.00 $24.00 $20.00 $22.00 $24.0094680 $47.00 $71.00 $77.00 $82.00 $71.00 $77.00 $82.0094680-26 $23.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0094680-TC $22.00 $58.00 $63.00 $68.00 $58.00 $63.00 $68.0094681 $60.00 $86.00 $94.00 $102.00 $86.00 $94.00 $102.0094681-26 $12.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0094681-TC $43.00 $76.00 $83.00 $91.00 $76.00 $83.00 $91.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 367

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

94690 $24.00 $65.00 $71.00 $76.00 $65.00 $71.00 $76.0094690-26 $4.00 $4.00 $4.00 $5.00 $4.00 $4.00 $5.0094690-TC $20.00 $61.00 $66.00 $71.00 $61.00 $66.00 $71.0094720 $49.00 $56.00 $61.00 $65.00 $56.00 $61.00 $65.0094720-26 $15.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0094720-TC $31.00 $43.00 $47.00 $52.00 $43.00 $47.00 $52.0094725 $79.00 $94.00 $102.00 $110.00 $94.00 $102.00 $110.0094725-26 $14.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0094725-TC $64.00 $81.00 $89.00 $97.00 $81.00 $89.00 $97.0094750 $37.00 $72.00 $78.00 $83.00 $72.00 $78.00 $83.0094750-26 $14.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0094750-TC $21.00 $61.00 $66.00 $71.00 $61.00 $66.00 $71.0094760 $9.00 $3.00 $4.00 $4.00 $3.00 $4.00 $4.0094761 $20.00 $7.00 $9.00 $11.00 $7.00 $9.00 $11.0094762 $30.00 $32.00 $36.00 $41.00 $32.00 $36.00 $41.0094770 $21.00 $41.00 $45.00 $49.00 $41.00 $45.00 $49.0094770-26 $9.00 $8.00 $8.00 $8.00 $8.00 $8.00 $8.0094770-TC $12.00 $33.00 $37.00 $41.00 $33.00 $37.00 $41.0094799 BR ------- ------- ------- ------- ------- -------94799-26 BR ------- ------- ------- ------- ------- -------94799-TC BR ------- ------- ------- ------- ------- -------95004 $3.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.0095010 $11.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0095012 ------- $20.00 $21.00 $23.00 $20.00 $21.00 $23.0095015 $11.00 $13.00 $14.00 $15.00 $13.00 $14.00 $15.0095024 $3.00 $7.00 $8.00 $9.00 $7.00 $8.00 $9.0095027 $5.00 $6.00 $6.00 $7.00 $6.00 $6.00 $7.0095028 $8.00 $11.00 $12.00 $13.00 $11.00 $12.00 $13.0095044 $7.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0095052 $9.00 $8.00 $9.00 $10.00 $8.00 $9.00 $10.0095056 $6.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0095060 $13.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.0095065 $7.00 $18.00 $20.00 $21.00 $18.00 $20.00 $21.0095070 $82.00 $62.00 $67.00 $71.00 $62.00 $67.00 $71.0095071 $105.00 $78.00 $84.00 $89.00 $78.00 $84.00 $89.0095075 $82.00 $67.00 $69.00 $72.00 $50.00 $51.00 $53.0095115 $10.00 $13.00 $15.00 $16.00 $13.00 $15.00 $16.0095117 $9.00 $17.00 $18.00 $20.00 $17.00 $18.00 $20.0095120 BR ------- ------- ------- ------- ------- -------95125 BR ------- ------- ------- ------- ------- -------95130 BR ------- ------- ------- ------- ------- -------95131 BR ------- ------- ------- ------- ------- -------95132 BR ------- ------- ------- ------- ------- -------95133 BR ------- ------- ------- ------- ------- -------95134 BR ------- ------- ------- ------- ------- -------95144 $9.00 $12.00 $13.00 $13.00 $4.00 $4.00 $4.0095145 $17.00 $16.00 $17.00 $18.00 $4.00 $4.00 $4.0095146 $24.00 $25.00 $26.00 $28.00 $4.00 $4.00 $4.0095147 $33.00 $24.00 $26.00 $27.00 $4.00 $4.00 $4.0095148 $32.00 $33.00 $36.00 $38.00 $4.00 $4.00 $4.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

95149 $36.00 $44.00 $47.00 $50.00 $4.00 $4.00 $4.0095165 $7.00 $12.00 $13.00 $13.00 $4.00 $4.00 $4.0095170 $13.00 $9.00 $10.00 $11.00 $4.00 $4.00 $4.0095180 $103.00 $149.00 $155.00 $161.00 $110.00 $113.00 $116.0095199 BR ------- ------- ------- ------- ------- -------95250 $114.00 $150.00 $161.00 $170.00 $150.00 $161.00 $170.0095251 ------- $41.00 $42.00 $43.00 $41.00 $42.00 $43.0095805 $334.00 $573.00 $616.00 $657.00 $573.00 $616.00 $657.0095805-26 $94.00 $98.00 $101.00 $105.00 $98.00 $101.00 $105.0095805-TC $237.00 $475.00 $514.00 $551.00 $475.00 $514.00 $551.0095806 $232.00 $228.00 $246.00 $267.00 $228.00 $246.00 $267.0095806-26 $109.00 $86.00 $89.00 $93.00 $86.00 $89.00 $93.0095806-TC $137.00 $142.00 $157.00 $174.00 $142.00 $157.00 $174.0095807 $367.00 $567.00 $610.00 $654.00 $567.00 $610.00 $654.0095807-26 $98.00 $85.00 $88.00 $91.00 $85.00 $88.00 $91.0095807-TC $256.00 $482.00 $523.00 $563.00 $482.00 $523.00 $563.0095808 $456.00 $700.00 $752.00 $802.00 $700.00 $752.00 $802.0095808-26 $149.00 $138.00 $142.00 $148.00 $138.00 $142.00 $148.0095808-TC $256.00 $563.00 $610.00 $654.00 $563.00 $610.00 $654.0095810 $521.00 $858.00 $919.00 $978.00 $858.00 $919.00 $978.0095810-26 $183.00 $181.00 $188.00 $195.00 $181.00 $188.00 $195.0095810-TC $256.00 $676.00 $731.00 $782.00 $676.00 $731.00 $782.0095811 $644.00 $942.00 $1,008.00 $1,072.00 $942.00 $1,008.00 $1,072.0095811-26 $196.00 $195.00 $201.00 $210.00 $195.00 $201.00 $210.0095811-TC $423.00 $747.00 $807.00 $862.00 $747.00 $807.00 $862.0095812 $137.00 $246.00 $263.00 $280.00 $246.00 $263.00 $280.0095812-26 $58.00 $58.00 $61.00 $63.00 $58.00 $61.00 $63.0095812-TC $68.00 $187.00 $202.00 $216.00 $187.00 $202.00 $216.0095813 $177.00 $303.00 $323.00 $342.00 $303.00 $323.00 $342.0095813-26 $89.00 $92.00 $96.00 $100.00 $92.00 $96.00 $100.0095813-TC $68.00 $210.00 $227.00 $242.00 $210.00 $227.00 $242.0095816 $133.00 $226.00 $242.00 $257.00 $226.00 $242.00 $257.0095816-26 $54.00 $58.00 $61.00 $63.00 $58.00 $61.00 $63.0095816-TC $78.00 $168.00 $181.00 $194.00 $168.00 $181.00 $194.0095819 $115.00 $229.00 $245.00 $260.00 $229.00 $245.00 $260.0095819-26 $58.00 $58.00 $61.00 $63.00 $58.00 $61.00 $63.0095819-TC $56.00 $170.00 $184.00 $197.00 $170.00 $184.00 $197.0095822 $120.00 $250.00 $268.00 $286.00 $250.00 $268.00 $286.0095822-26 $58.00 $58.00 $61.00 $63.00 $58.00 $61.00 $63.0095822-TC $63.00 $192.00 $208.00 $222.00 $192.00 $208.00 $222.0095824 $51.00 ------- ------- ------- ------- ------- -------95824-26 $41.00 $40.00 $41.00 $43.00 $40.00 $41.00 $43.0095824-TC $10.00 ------- ------- ------- ------- ------- -------95827 $145.00 $331.00 $355.00 $377.00 $331.00 $355.00 $377.0095827-26 $59.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.0095827-TC $86.00 $274.00 $296.00 $316.00 $274.00 $296.00 $316.0095829 $328.00 $1,355.00 $1,443.00 $1,523.00 $1,355.00 $1,443.00 $1,523.0095829-26 $291.00 $339.00 $354.00 $374.00 $339.00 $354.00 $374.0095829-TC $6.00 $1,016.00 $1,089.00 $1,150.00 $1,016.00 $1,089.00 $1,150.0095830 $133.00 $193.00 $204.00 $214.00 $92.00 $96.00 $101.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 369

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

95831 $26.00 $28.00 $29.00 $31.00 $15.00 $16.00 $16.0095832 $21.00 $26.00 $27.00 $29.00 $16.00 $17.00 $18.0095833 $34.00 $40.00 $42.00 $43.00 $25.00 $26.00 $27.0095834 $44.00 $47.00 $49.00 $51.00 $33.00 $34.00 $36.0095851 $18.00 $19.00 $20.00 $21.00 $9.00 $9.00 $10.0095852 $14.00 $15.00 $16.00 $16.00 $6.00 $7.00 $7.0095857 $40.00 $44.00 $46.00 $48.00 $28.00 $29.00 $30.0095860 $73.00 $91.00 $96.00 $101.00 $91.00 $96.00 $101.0095860-26 $53.00 $53.00 $55.00 $58.00 $53.00 $55.00 $58.0095860-TC $15.00 $37.00 $40.00 $43.00 $37.00 $40.00 $43.0095861 $113.00 $125.00 $132.00 $140.00 $125.00 $132.00 $140.0095861-26 $86.00 $85.00 $88.00 $91.00 $85.00 $88.00 $91.0095861-TC $28.00 $41.00 $44.00 $48.00 $41.00 $44.00 $48.0095863 $138.00 $150.00 $158.00 $167.00 $150.00 $158.00 $167.0095863-26 $102.00 $101.00 $105.00 $109.00 $101.00 $105.00 $109.0095863-TC $35.00 $48.00 $53.00 $57.00 $48.00 $53.00 $57.0095864 $177.00 $181.00 $192.00 $204.00 $181.00 $192.00 $204.0095864-26 $114.00 $108.00 $112.00 $116.00 $108.00 $112.00 $116.0095864-TC $67.00 $73.00 $80.00 $87.00 $73.00 $80.00 $87.0095865 ------- $120.00 $127.00 $133.00 $120.00 $127.00 $133.0095865-26 ------- $88.00 $91.00 $95.00 $88.00 $91.00 $95.0095865-TC ------- $33.00 $36.00 $38.00 $33.00 $36.00 $38.0095866 ------- $93.00 $98.00 $103.00 $93.00 $98.00 $103.0095866-26 ------- $69.00 $72.00 $75.00 $69.00 $72.00 $75.0095866-TC ------- $24.00 $26.00 $28.00 $24.00 $26.00 $28.0095867 $66.00 $75.00 $79.00 $83.00 $75.00 $79.00 $83.0095867-26 $43.00 $43.00 $44.00 $46.00 $43.00 $44.00 $46.0095867-TC $21.00 $32.00 $35.00 $38.00 $32.00 $35.00 $38.0095868 $96.00 $103.00 $109.00 $115.00 $103.00 $109.00 $115.0095868-26 $71.00 $64.00 $66.00 $69.00 $64.00 $66.00 $69.0095868-TC $26.00 $39.00 $42.00 $46.00 $39.00 $42.00 $46.0095869 $29.00 $44.00 $47.00 $49.00 $44.00 $47.00 $49.0095869-26 $21.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.0095869-TC $8.00 $23.00 $25.00 $27.00 $23.00 $25.00 $27.0095870 $29.00 $43.00 $46.00 $49.00 $43.00 $46.00 $49.0095870-26 $21.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.0095870-TC $8.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.0095872 $104.00 $171.00 $177.00 $185.00 $171.00 $177.00 $185.0095872-26 $81.00 $141.00 $145.00 $149.00 $141.00 $145.00 $149.0095872-TC $22.00 $30.00 $33.00 $36.00 $30.00 $33.00 $36.0095873 ------- $43.00 $46.00 $49.00 $43.00 $46.00 $49.0095873-26 ------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.0095873-TC ------- $22.00 $24.00 $26.00 $22.00 $24.00 $26.0095874 ------- $43.00 $45.00 $48.00 $43.00 $45.00 $48.0095874-26 ------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.0095874-TC ------- $22.00 $24.00 $25.00 $22.00 $24.00 $25.0095875 $43.00 $105.00 $111.00 $118.00 $105.00 $111.00 $118.0095875-26 $34.00 $61.00 $63.00 $65.00 $61.00 $63.00 $65.0095875-TC $7.00 $44.00 $48.00 $52.00 $44.00 $48.00 $52.0095900 $37.00 $61.00 $65.00 $68.00 $61.00 $65.00 $68.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 370

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

95900-26 $24.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.0095900-TC $10.00 $38.00 $41.00 $44.00 $38.00 $41.00 $44.0095903 $43.00 $69.00 $73.00 $77.00 $69.00 $73.00 $77.0095903-26 $33.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0095903-TC $9.00 $36.00 $39.00 $41.00 $36.00 $39.00 $41.0095904 $31.00 $53.00 $57.00 $60.00 $53.00 $57.00 $60.0095904-26 $20.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0095904-TC $8.00 $34.00 $37.00 $40.00 $34.00 $37.00 $40.0095920 $168.00 $170.00 $181.00 $192.00 $170.00 $181.00 $192.0095920-26 $118.00 $119.00 $124.00 $131.00 $119.00 $124.00 $131.0095920-TC $48.00 $52.00 $57.00 $62.00 $52.00 $57.00 $62.0095921 $61.00 $74.00 $78.00 $82.00 $74.00 $78.00 $82.0095921-26 $46.00 $47.00 $49.00 $50.00 $47.00 $49.00 $50.0095921-TC $14.00 $27.00 $29.00 $31.00 $27.00 $29.00 $31.0095922 $65.00 $87.00 $91.00 $96.00 $87.00 $91.00 $96.0095922-26 $50.00 $52.00 $54.00 $56.00 $52.00 $54.00 $56.0095922-TC $14.00 $35.00 $38.00 $40.00 $35.00 $38.00 $40.0095923 $105.00 $121.00 $129.00 $136.00 $121.00 $129.00 $136.0095923-26 $47.00 $49.00 $51.00 $53.00 $49.00 $51.00 $53.0095923-TC $57.00 $73.00 $78.00 $83.00 $73.00 $78.00 $83.0095925 $94.00 $109.00 $117.00 $125.00 $109.00 $117.00 $125.0095925-26 $53.00 $30.00 $31.00 $33.00 $30.00 $31.00 $33.0095925-TC $41.00 $79.00 $85.00 $92.00 $79.00 $85.00 $92.0095926 $66.00 $107.00 $115.00 $122.00 $107.00 $115.00 $122.0095926-26 $34.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.0095926-TC $34.00 $78.00 $84.00 $90.00 $78.00 $84.00 $90.0095927 $67.00 $111.00 $119.00 $127.00 $111.00 $119.00 $127.0095927-26 $34.00 $31.00 $32.00 $34.00 $31.00 $32.00 $34.0095927-TC $34.00 $80.00 $87.00 $93.00 $80.00 $87.00 $93.0095928 ------- $198.00 $209.00 $220.00 $198.00 $209.00 $220.0095928-26 ------- $80.00 $83.00 $86.00 $80.00 $83.00 $86.0095928-TC ------- $117.00 $126.00 $134.00 $117.00 $126.00 $134.0095929 ------- $208.00 $220.00 $231.00 $208.00 $220.00 $231.0095929-26 ------- $81.00 $83.00 $87.00 $81.00 $83.00 $87.0095929-TC ------- $127.00 $137.00 $145.00 $127.00 $137.00 $145.0095930 $44.00 $111.00 $119.00 $125.00 $111.00 $119.00 $125.0095930-26 $25.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0095930-TC $11.00 $92.00 $98.00 $104.00 $92.00 $98.00 $104.0095933 $62.00 $70.00 $75.00 $81.00 $70.00 $75.00 $81.0095933-26 $33.00 $33.00 $34.00 $36.00 $33.00 $34.00 $36.0095933-TC $30.00 $37.00 $41.00 $45.00 $37.00 $41.00 $45.0095934 $36.00 $46.00 $49.00 $52.00 $46.00 $49.00 $52.0095934-26 $28.00 $28.00 $28.00 $30.00 $28.00 $28.00 $30.0095934-TC $8.00 $19.00 $21.00 $22.00 $19.00 $21.00 $22.0095936 $39.00 $44.00 $46.00 $49.00 $44.00 $46.00 $49.0095936-26 $30.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0095936-TC $8.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.0095937 $40.00 $60.00 $64.00 $69.00 $60.00 $64.00 $69.0095937-26 $31.00 $38.00 $40.00 $43.00 $38.00 $40.00 $43.0095937-TC $9.00 $22.00 $24.00 $26.00 $22.00 $24.00 $26.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 371

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

95950 $265.00 $261.00 $284.00 $310.00 $261.00 $284.00 $310.0095950-26 $84.00 $82.00 $85.00 $88.00 $82.00 $85.00 $88.0095950-TC $177.00 $180.00 $199.00 $222.00 $180.00 $199.00 $222.0095951 $34.00 ------- ------- ------- ------- ------- -------95951-26 $14.00 $324.00 $336.00 $351.00 $324.00 $336.00 $351.0095951-TC $20.00 ------- ------- ------- ------- ------- -------95953 $411.00 $451.00 $484.00 $520.00 $451.00 $484.00 $520.0095953-26 $165.00 $176.00 $183.00 $190.00 $176.00 $183.00 $190.0095953-TC $240.00 $275.00 $301.00 $329.00 $275.00 $301.00 $329.0095954 $208.00 $271.00 $287.00 $303.00 $271.00 $287.00 $303.0095954-26 $134.00 $127.00 $132.00 $138.00 $127.00 $132.00 $138.0095954-TC $23.00 $144.00 $155.00 $165.00 $144.00 $155.00 $165.0095955 $130.00 $151.00 $162.00 $175.00 $151.00 $162.00 $175.0095955-26 $59.00 $53.00 $55.00 $57.00 $53.00 $55.00 $57.0095955-TC $74.00 $98.00 $107.00 $118.00 $98.00 $107.00 $118.0095956 $541.00 $773.00 $829.00 $884.00 $773.00 $829.00 $884.0095956-26 $166.00 $166.00 $172.00 $180.00 $166.00 $172.00 $180.0095956-TC $314.00 $607.00 $657.00 $704.00 $607.00 $657.00 $704.0095957 $171.00 $252.00 $268.00 $285.00 $252.00 $268.00 $285.0095957-26 $104.00 $107.00 $111.00 $116.00 $107.00 $111.00 $116.0095957-TC $64.00 $145.00 $157.00 $169.00 $145.00 $157.00 $169.0095958 $296.00 $378.00 $399.00 $421.00 $378.00 $399.00 $421.0095958-26 $230.00 $228.00 $236.00 $246.00 $228.00 $236.00 $246.0095958-TC $66.00 $150.00 $163.00 $175.00 $150.00 $163.00 $175.0095961 $216.00 $256.00 $275.00 $298.00 $256.00 $275.00 $298.0095961-26 $166.00 $183.00 $196.00 $213.00 $183.00 $196.00 $213.0095961-TC $48.00 $73.00 $79.00 $85.00 $73.00 $79.00 $85.0095962 $227.00 $239.00 $254.00 $271.00 $239.00 $254.00 $271.0095962-26 $176.00 $184.00 $193.00 $206.00 $184.00 $193.00 $206.0095962-TC $48.00 $55.00 $60.00 $66.00 $55.00 $60.00 $66.0095965 BR ------- ------- ------- ------- ------- -------95965-26 $420.00 $438.00 $455.00 $476.00 $438.00 $455.00 $476.0095965-TC BR ------- ------- ------- ------- ------- -------95966 BR ------- ------- ------- ------- ------- -------95966-26 $210.00 $216.00 $224.00 $233.00 $216.00 $224.00 $233.0095966-TC BR ------- ------- ------- ------- ------- -------95967 BR ------- ------- ------- ------- ------- -------95967-26 $184.00 $181.00 $188.00 $195.00 $181.00 $188.00 $195.0095967-TC BR ------- ------- ------- ------- ------- -------95970 $22.00 $53.00 $56.00 $59.00 $24.00 $25.00 $26.0095971 $39.00 $58.00 $61.00 $65.00 $41.00 $43.00 $46.0095972 $78.00 $110.00 $116.00 $124.00 $82.00 $86.00 $92.0095973 $47.00 $60.00 $63.00 $66.00 $49.00 $51.00 $54.0095974 $155.00 $182.00 $190.00 $198.00 $161.00 $168.00 $175.0095975 $88.00 $102.00 $107.00 $112.00 $94.00 $98.00 $103.0095978 ------- $215.00 $224.00 $234.00 $186.00 $193.00 $201.0095979 ------- $97.00 $101.00 $105.00 $88.00 $91.00 $95.0095980 ------- $44.00 $46.00 $48.00 $44.00 $46.00 $48.0095981 ------- $29.00 $31.00 $33.00 $17.00 $18.00 $18.0095982 ------- $45.00 $48.00 $50.00 $34.00 $36.00 $38.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 372

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

95990 $57.00 $65.00 $71.00 $76.00 $65.00 $71.00 $76.0095991 ------- $93.00 $99.00 $104.00 $39.00 $41.00 $43.0095999 BR ------- ------- ------- ------- ------- -------96000 $93.00 $92.00 $96.00 $100.00 $92.00 $96.00 $100.0096001 $111.00 $109.00 $113.00 $118.00 $109.00 $113.00 $118.0096002 $21.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0096003 $20.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0096004 $97.00 $117.00 $121.00 $126.00 $117.00 $121.00 $126.0096020 ------- BR BR BR BR BR BR96020-26 ------- $179.00 $186.00 $193.00 $179.00 $186.00 $193.0096020-TC ------- BR BR BR BR BR BR96040 ------- $39.00 $42.00 $45.00 $39.00 $42.00 $45.0096101 ------- $91.00 $94.00 $97.00 $91.00 $93.00 $96.0096102 ------- $54.00 $56.00 $59.00 $24.00 $25.00 $25.0096103 ------- $42.00 $44.00 $46.00 $26.00 $26.00 $27.0096105 $68.00 $78.00 $87.00 $96.00 $78.00 $87.00 $96.0096110 $88.00 $18.00 $22.00 $28.00 $18.00 $22.00 $28.0096111 $68.00 $141.00 $147.00 $155.00 $139.00 $145.00 $152.0096116 ------- $107.00 $112.00 $119.00 $100.00 $105.00 $112.0096118 ------- $124.00 $130.00 $138.00 $99.00 $104.00 $110.0096119 ------- $81.00 $88.00 $97.00 $37.00 $41.00 $47.0096120 ------- $68.00 $71.00 $75.00 $25.00 $26.00 $27.0096125 ------- $103.00 $108.00 $115.00 $87.00 $92.00 $97.0096150 ------- $25.00 $25.00 $26.00 $24.00 $25.00 $25.0096151 ------- $24.00 $24.00 $25.00 $23.00 $24.00 $24.0096152 ------- $23.00 $23.00 $24.00 $23.00 $23.00 $24.0096153 ------- $6.00 $6.00 $6.00 $5.00 $5.00 $6.0096154 ------- $22.00 $23.00 $24.00 $22.00 $23.00 $23.0096155 ------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00DSPNS see formula See Appx D See Appx D See Appx D See Appx D See Appx D See Appx D96401 ------- $67.00 $72.00 $76.00 $67.00 $72.00 $76.0096402 ------- $43.00 $45.00 $48.00 $43.00 $45.00 $48.0096405 $57.00 $141.00 $150.00 $158.00 $31.00 $32.00 $33.0096406 $86.00 $161.00 $171.00 $180.00 $43.00 $45.00 $46.0096409 ------- $125.00 $134.00 $142.00 $125.00 $134.00 $142.0096411 ------- $72.00 $78.00 $83.00 $72.00 $78.00 $83.0096413 ------- $169.00 $182.00 $193.00 $169.00 $182.00 $193.0096415 ------- $39.00 $43.00 $47.00 $39.00 $43.00 $47.0096416 ------- $183.00 $197.00 $209.00 $183.00 $197.00 $209.0096417 ------- $84.00 $91.00 $97.00 $84.00 $91.00 $97.0096420 $46.00 $118.00 $127.00 $136.00 $118.00 $127.00 $136.0096422 $46.00 $194.00 $209.00 $222.00 $194.00 $209.00 $222.0096423 $17.00 $84.00 $90.00 $95.00 $84.00 $90.00 $95.0096425 $54.00 $191.00 $205.00 $218.00 $191.00 $205.00 $218.0096440 $156.00 $367.00 $389.00 $410.00 $141.00 $148.00 $156.0096445 $157.00 $354.00 $376.00 $396.00 $132.00 $138.00 $145.0096450 $134.00 $297.00 $315.00 $332.00 $104.00 $109.00 $114.0096521 ------- $147.00 $158.00 $168.00 $147.00 $158.00 $168.0096522 ------- $118.00 $126.00 $135.00 $118.00 $126.00 $135.0096523 ------- $29.00 $31.00 $33.00 $29.00 $31.00 $33.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 373

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

96542 $126.00 $185.00 $197.00 $209.00 $51.00 $54.00 $57.0096549 BR ------- ------- ------- ------- ------- -------96567 $62.00 $114.00 $123.00 $131.00 $114.00 $123.00 $131.0096570 $69.00 $62.00 $66.00 $70.00 $62.00 $66.00 $70.0096571 $38.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.0096900 $17.00 $21.00 $23.00 $24.00 $21.00 $23.00 $24.0096902 $24.00 $22.00 $22.00 $23.00 $21.00 $21.00 $22.0096904 ------- $75.00 $81.00 $85.00 $75.00 $81.00 $85.0096910 $21.00 $61.00 $66.00 $71.00 $61.00 $66.00 $71.0096912 $24.00 $78.00 $85.00 $91.00 $78.00 $85.00 $91.0096913 $53.00 $107.00 $116.00 $125.00 $107.00 $116.00 $125.0096920 $152.00 $164.00 $173.00 $180.00 $66.00 $68.00 $69.0096921 $155.00 $162.00 $171.00 $178.00 $66.00 $68.00 $71.0096922 $214.00 $239.00 $252.00 $262.00 $113.00 $116.00 $119.0096999 BR ------- ------- ------- ------- ------- -------97001 $62.00 $75.00 $78.00 $81.00 $75.00 $78.00 $81.0097002 $29.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.0097003 $62.00 $80.00 $84.00 $88.00 $80.00 $84.00 $88.0097004 $29.00 $47.00 $50.00 $52.00 $47.00 $50.00 $52.0097005 NC BR BR BR BR BR BR97006 NC BR BR BR BR BR BR97010 $10.00 $5.00 $5.00 $6.00 $5.00 $5.00 $6.0097012 $16.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0097014 $14.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.0097016 $15.00 $16.00 $16.00 $17.00 $16.00 $16.00 $17.0097018 $10.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0097022 $15.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.0097024 $10.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.0097026 $9.00 $5.00 $5.00 $6.00 $5.00 $5.00 $6.0097028 $10.00 $7.00 $7.00 $8.00 $7.00 $7.00 $8.0097032 $16.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.0097033 $16.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.0097034 $13.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.0097035 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0097036 $19.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0097039 $15.00 ------- ------- ------- ------- ------- -------97110 $22.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.0097112 $23.00 $30.00 $31.00 $33.00 $30.00 $31.00 $33.0097113 $24.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.0097116 $21.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0097124 $19.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.0097139 $15.00 ------- ------- ------- ------- ------- -------97140 $26.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0097150 $18.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.0097260 $23.00 ------- ------- ------- ------- ------- -------97261 $17.00 ------- ------- ------- ------- ------- -------97530 $22.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0097532 $22.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0097533 $24.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0097535 $23.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

CPT only © 2008 American Medical Association. All rights reserved. Part C, 374

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

97537 $23.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0097542 $17.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0097545 $83.00 ------- ------- ------- ------- ------- -------97546 $41.00 ------- ------- ------- ------- ------- -------97597 ------- $59.00 $63.00 $66.00 $40.00 $42.00 $44.0097598 ------- $73.00 $77.00 $81.00 $51.00 $54.00 $56.0097602 BR ------- ------- ------- ------- ------- -------97605 ------- $36.00 $37.00 $39.00 $28.00 $29.00 $30.0097606 ------- $39.00 $41.00 $42.00 $31.00 $32.00 $34.0097750 BR BR BR BR BR BR BR97752 $48.00 ------- ------- ------- ------- ------- -------97755 ------- $35.00 $36.00 $38.00 $35.00 $36.00 $38.0097760 ------- $34.00 $35.00 $37.00 $34.00 $35.00 $37.0097761 ------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.0097762 ------- $33.00 $35.00 $37.00 $33.00 $35.00 $37.0097799 BR ------- ------- ------- ------- ------- -------97802 $26.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0097803 $17.00 $26.00 $27.00 $28.00 $25.00 $26.00 $27.0097804 $7.00 $15.00 $16.00 $16.00 $15.00 $15.00 $16.0097810 ------- $37.00 $38.00 $40.00 $31.00 $32.00 $34.0097811 ------- $28.00 $29.00 $31.00 $26.00 $27.00 $28.0097813 ------- $39.00 $40.00 $42.00 $34.00 $35.00 $36.0097814 ------- $31.00 $33.00 $34.00 $29.00 $30.00 $31.0097850 $54.00 ------- ------- ------- ------- ------- -------97851 $26.00 ------- ------- ------- ------- ------- -------97852 $54.00 ------- ------- ------- ------- ------- -------97853 $26.00 ------- ------- ------- ------- ------- -------98925 NC NC NC NC NC NC NC98926 $32.00 $41.00 $43.00 $45.00 $34.00 $35.00 $37.0098927 NC NC NC NC NC NC NC98928 $23.00 $62.00 $65.00 $67.00 $52.00 $54.00 $56.0098929 NC NC NC NC NC NC NC98940 NC NC NC NC NC NC NC98941 $32.00 $36.00 $37.00 $38.00 $31.00 $32.00 $33.0098942 NC NC NC NC NC NC NC98943 $23.00 $24.00 $24.00 $25.00 $20.00 $21.00 $22.0098960 ------- $23.00 $25.00 $27.00 $23.00 $25.00 $27.0098961 ------- $12.00 $13.00 $14.00 $12.00 $13.00 $14.0098962 ------- $8.00 $9.00 $10.00 $8.00 $9.00 $10.0098966 ------- $13.00 $14.00 $14.00 $12.00 $13.00 $13.0098967 ------- $25.00 $26.00 $27.00 $24.00 $25.00 $26.0098968 ------- $37.00 $39.00 $40.00 $36.00 $37.00 $39.0099000 $6.00 ------- ------- ------- ------- ------- -------99001 $4.00 ------- ------- ------- ------- ------- -------99002 $35.00 ------- ------- ------- ------- ------- -------99026 BR ------- ------- ------- ------- ------- -------99027 BR ------- ------- ------- ------- ------- -------99070 BR ------- ------- ------- ------- ------- -------99071 NC NC NC NC NC NC NC99075 See 440.13 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

99078 NC NC NC NC NC NC NC99080 BR ------- ------- ------- ------- ------- -------99082 BR ------- ------- ------- ------- ------- -------99090 BR ------- ------- ------- ------- ------- -------99091 BR $53.00 $54.00 $56.00 $53.00 $54.00 $56.0099172 BR ------- ------- ------- ------- ------- -------99173 BR $3.00 $3.00 $4.00 $3.00 $3.00 $4.0099175 $53.00 $40.00 $45.00 $50.00 $40.00 $45.00 $50.0099183 $123.00 $211.00 $222.00 $234.00 $122.00 $127.00 $133.0099185 $23.00 $48.00 $52.00 $56.00 $48.00 $52.00 $56.0099186 $78.00 $95.00 $109.00 $127.00 $95.00 $109.00 $127.0099190 BR ------- ------- ------- ------- ------- -------99191 BR ------- ------- ------- ------- ------- -------99192 BR ------- ------- ------- ------- ------- -------99195 $16.00 $60.00 $65.00 $69.00 $60.00 $65.00 $69.0099199 NC NC NC NC NC NC NCG0101 ------- $38.00 $39.00 $41.00 $38.00 $39.00 $41.00G0102 ------- $21.00 $22.00 $23.00 $9.00 $10.00 $10.00G0104 ------- $135.00 $143.00 $151.00 $63.00 $66.00 $70.00G0105 ------- $401.00 $425.00 $448.00 $220.00 $230.00 $243.00G0105-53 ------- $135.00 $143.00 $151.00 $63.00 $66.00 $70.00G0106 ------- $194.00 $208.00 $222.00 $194.00 $208.00 $222.00G0106-26 ------- $52.00 $54.00 $56.00 $52.00 $54.00 $56.00G0106-TC ------- $142.00 $155.00 $166.00 $142.00 $155.00 $166.00G0108 ------- $29.00 $31.00 $33.00 $29.00 $31.00 $33.00G0109 ------- $16.00 $18.00 $19.00 $16.00 $18.00 $19.00G0117 ------- $46.00 $49.00 $51.00 $46.00 $49.00 $51.00G0118 ------- $31.00 $33.00 $35.00 $31.00 $33.00 $35.00G0120 ------- $191.00 $204.00 $218.00 $191.00 $204.00 $218.00G0120-26 ------- $52.00 $54.00 $56.00 $52.00 $54.00 $56.00G0120-TC ------- $139.00 $151.00 $162.00 $139.00 $151.00 $162.00G0121 ------- $401.00 $425.00 $448.00 $220.00 $230.00 $243.00G0121-53 ------- $135.00 $143.00 $151.00 $63.00 $66.00 $70.00G0122 ------- $209.00 $224.00 $239.00 $209.00 $224.00 $239.00G0122-26 ------- $51.00 $53.00 $55.00 $51.00 $53.00 $55.00G0122-TC ------- $158.00 $171.00 $184.00 $158.00 $171.00 $184.00G0128 ------- $4.00 $5.00 $5.00 $4.00 $5.00 $5.00G0166 ------- $162.00 $173.00 $183.00 $162.00 $173.00 $183.00G0179 ------- $47.00 $50.00 $52.00 $47.00 $50.00 $52.00G0180 ------- $62.00 $65.00 $68.00 $62.00 $65.00 $68.00G0181 ------- $113.00 $117.00 $122.00 $113.00 $117.00 $122.00G0182 ------- $117.00 $122.00 $127.00 $117.00 $122.00 $127.00G0237 ------- $15.00 $16.00 $17.00 $15.00 $16.00 $17.00G0238 ------- $15.00 $17.00 $18.00 $15.00 $17.00 $18.00G0239 ------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.00G0248 ------- $197.00 $212.00 $223.00 $197.00 $212.00 $223.00G0249 ------- $145.00 $156.00 $164.00 $145.00 $156.00 $164.00G0250 ------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00G0268 ------- $49.00 $52.00 $54.00 $33.00 $34.00 $35.00G0270 ------- $26.00 $27.00 $28.00 $25.00 $26.00 $27.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 Edition RULE 69L-7.020, F.A.C.Medicine

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

G0271 ------- $15.00 $16.00 $16.00 $15.00 $15.00 $16.00G0281 ------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00G0283 ------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00G0308 ------- $773.00 $802.00 $831.00 $773.00 $802.00 $831.00G0309 ------- $635.00 $658.00 $682.00 $635.00 $658.00 $682.00G0310 ------- $497.00 $515.00 $533.00 $497.00 $515.00 $533.00G0311 ------- $542.00 $561.00 $581.00 $542.00 $561.00 $581.00G0312 ------- $447.00 $462.00 $479.00 $447.00 $462.00 $479.00G0313 ------- $351.00 $362.00 $375.00 $351.00 $362.00 $375.00G0314 ------- $475.00 $492.00 $509.00 $475.00 $492.00 $509.00G0315 ------- $392.00 $405.00 $419.00 $392.00 $405.00 $419.00G0316 ------- $305.00 $314.00 $325.00 $305.00 $314.00 $325.00G0317 ------- $299.00 $309.00 $321.00 $299.00 $309.00 $321.00G0318 ------- $245.00 $254.00 $263.00 $245.00 $254.00 $263.00G0319 ------- $192.00 $198.00 $205.00 $192.00 $198.00 $205.00G0320 ------- $606.00 $627.00 $649.00 $606.00 $627.00 $649.00G0321 ------- $433.00 $447.00 $463.00 $433.00 $447.00 $463.00G0322 ------- $375.00 $387.00 $400.00 $375.00 $387.00 $400.00G0323 ------- $234.00 $242.00 $250.00 $234.00 $242.00 $250.00G0324 ------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00G0325 ------- $13.00 $13.00 $14.00 $13.00 $13.00 $14.00G0326 ------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00G0327 ------- $8.00 $9.00 $9.00 $8.00 $9.00 $9.00G0329 ------- $9.00 $9.00 $10.00 $9.00 $9.00 $10.00G0332 ------- $77.00 $83.00 $87.00 $77.00 $83.00 $87.00G0366 ------- $25.00 $26.00 $28.00 $25.00 $26.00 $28.00G0367 ------- $15.00 $17.00 $18.00 $15.00 $17.00 $18.00G9041 ------- $25.00 $26.00 $26.00 $25.00 $26.00 $26.00G9042 ------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.00G9043 ------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.00G9044 ------- $9.00 $10.00 $11.00 $9.00 $10.00 $11.00P3001 ------- $27.00 $28.00 $29.00 $27.00 $28.00 $29.00Q0035 ------- $23.00 $24.00 $26.00 $23.00 $24.00 $26.00Q0035-26 ------- $9.00 $9.00 $10.00 $9.00 $9.00 $10.00Q0035-TC ------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.00Q0091 ------- $43.00 $45.00 $48.00 $20.00 $21.00 $21.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.Evaluation and Management

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

99201 $35.00 $39.00 $41.00 $43.00 $25.00 $26.00 $27.0099202 $58.00 $67.00 $70.00 $74.00 $47.00 $49.00 $51.0099203 $58.00 $99.00 $104.00 $109.00 $73.00 $76.00 $80.0099204 $84.00 $151.00 $158.00 $165.00 $120.00 $125.00 $130.0099205 $84.00 $190.00 $198.00 $207.00 $156.00 $162.00 $169.0099211 $19.00 $21.00 $22.00 $23.00 $9.00 $10.00 $10.0099212 $31.00 $40.00 $42.00 $45.00 $25.00 $26.00 $27.0099213 $40.00 $64.00 $67.00 $70.00 $46.00 $47.00 $49.0099214 $40.00 $97.00 $101.00 $105.00 $72.00 $74.00 $77.0099215 $65.00 $132.00 $137.00 $143.00 $103.00 $107.00 $111.0099217 $65.00 $71.00 $74.00 $77.00 $71.00 $74.00 $77.0099218 $65.00 $67.00 $70.00 $72.00 $67.00 $70.00 $72.0099219 $109.00 $111.00 $114.00 $119.00 $111.00 $114.00 $119.0099220 $152.00 $155.00 $161.00 $167.00 $155.00 $161.00 $167.0099221 $66.00 $94.00 $96.00 $100.00 $94.00 $96.00 $100.0099222 $109.00 $129.00 $133.00 $138.00 $129.00 $133.00 $138.0099223 $152.00 $189.00 $194.00 $201.00 $189.00 $194.00 $201.0099231 $33.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0099232 $54.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.0099233 $77.00 $99.00 $102.00 $105.00 $99.00 $102.00 $105.0099234 $129.00 $135.00 $140.00 $146.00 $135.00 $140.00 $146.0099235 $173.00 $178.00 $184.00 $191.00 $178.00 $184.00 $191.0099236 $213.00 $221.00 $228.00 $237.00 $221.00 $228.00 $237.0099238 $66.00 $71.00 $73.00 $76.00 $71.00 $73.00 $76.0099239 $88.00 $102.00 $105.00 $109.00 $102.00 $105.00 $109.0099241 $54.00 $52.00 $55.00 $58.00 $35.00 $37.00 $39.0099242 $88.00 $97.00 $102.00 $108.00 $74.00 $77.00 $82.0099243 $117.00 $133.00 $140.00 $147.00 $103.00 $108.00 $113.0099244 $163.00 $195.00 $204.00 $213.00 $161.00 $167.00 $174.0099245 $212.00 $241.00 $252.00 $264.00 $202.00 $210.00 $219.0099251 $54.00 $51.00 $52.00 $55.00 $51.00 $52.00 $55.0099252 $70.00 $81.00 $84.00 $88.00 $81.00 $84.00 $88.0099253 $96.00 $120.00 $124.00 $129.00 $120.00 $124.00 $129.0099254 $138.00 $172.00 $178.00 $184.00 $172.00 $178.00 $184.0099255 $190.00 $212.00 $220.00 $229.00 $212.00 $220.00 $229.0099281 $18.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.0099282 $28.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.0099283 $60.00 $66.00 $69.00 $72.00 $66.00 $69.00 $72.0099284 $94.00 $121.00 $126.00 $131.00 $121.00 $126.00 $131.0099285 $103.00 $182.00 $188.00 $197.00 $182.00 $188.00 $197.0099288 BR ------- ------- ------- ------- ------- -------99291 $192.00 $274.00 $285.00 $297.00 $226.00 $233.00 $242.0099292 $95.00 $123.00 $128.00 $133.00 $113.00 $117.00 $122.0099304 ------- $83.00 $86.00 $89.00 $83.00 $86.00 $89.0099305 ------- $116.00 $119.00 $123.00 $116.00 $119.00 $123.0099306 ------- $149.00 $153.00 $158.00 $149.00 $153.00 $158.0099307 ------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.0099308 ------- $63.00 $65.00 $68.00 $63.00 $65.00 $68.0099309 ------- $85.00 $88.00 $91.00 $85.00 $88.00 $91.0099310 ------- $124.00 $128.00 $132.00 $124.00 $128.00 $132.00

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.Evaluation and Management

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

99315 $60.00 $62.00 $64.00 $67.00 $62.00 $64.00 $67.0099316 $77.00 $81.00 $83.00 $87.00 $81.00 $83.00 $87.0099318 ------- $87.00 $90.00 $92.00 $87.00 $90.00 $92.0099324 ------- $58.00 $61.00 $63.00 $58.00 $61.00 $63.0099325 ------- $85.00 $88.00 $92.00 $85.00 $88.00 $92.0099326 ------- $138.00 $142.00 $147.00 $138.00 $142.00 $147.0099327 ------- $179.00 $184.00 $191.00 $179.00 $184.00 $191.0099328 ------- $211.00 $218.00 $226.00 $211.00 $218.00 $226.0099334 ------- $58.00 $60.00 $63.00 $58.00 $60.00 $63.0099335 ------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.0099336 ------- $128.00 $132.00 $136.00 $128.00 $132.00 $136.0099337 ------- $183.00 $189.00 $195.00 $183.00 $189.00 $195.0099339 ------- $73.00 $75.00 $79.00 $73.00 $75.00 $79.0099340 ------- $101.00 $105.00 $109.00 $101.00 $105.00 $109.0099341 $59.00 $58.00 $60.00 $63.00 $58.00 $60.00 $63.0099342 $85.00 $85.00 $88.00 $92.00 $85.00 $88.00 $92.0099343 $109.00 $134.00 $139.00 $144.00 $134.00 $139.00 $144.0099344 $160.00 $176.00 $181.00 $188.00 $176.00 $181.00 $188.0099345 $193.00 $211.00 $218.00 $226.00 $211.00 $218.00 $226.0099347 $46.00 $55.00 $57.00 $60.00 $55.00 $57.00 $60.0099348 $71.00 $84.00 $86.00 $89.00 $84.00 $86.00 $89.0099349 $107.00 $122.00 $126.00 $131.00 $122.00 $126.00 $131.0099350 $156.00 $171.00 $177.00 $183.00 $171.00 $177.00 $183.0099354 $106.00 $98.00 $102.00 $106.00 $93.00 $96.00 $100.0099355 $104.00 $96.00 $100.00 $103.00 $91.00 $94.00 $97.0099356 $87.00 $90.00 $93.00 $96.00 $90.00 $93.00 $96.0099357 $88.00 $90.00 $93.00 $97.00 $90.00 $93.00 $97.0099358 BR $103.00 $106.00 $110.00 $103.00 $106.00 $110.0099359 BR $50.00 $51.00 $53.00 $50.00 $51.00 $53.0099360 BR $59.00 $60.00 $62.00 $59.00 $60.00 $62.0099363 ------- $116.00 $121.00 $126.00 $80.00 $83.00 $86.0099364 ------- $40.00 $42.00 $44.00 $31.00 $32.00 $34.0099366 ------- $42.00 $44.00 $46.00 $41.00 $43.00 $45.0099367 ------- $54.00 $55.00 $57.00 $54.00 $55.00 $57.0099368 ------- $35.00 $36.00 $37.00 $35.00 $36.00 $37.0099374 $75.00 $68.00 $71.00 $74.00 $57.00 $59.00 $61.0099375 $75.00 $113.00 $118.00 $123.00 $106.00 $110.00 $115.0099377 $75.00 $68.00 $71.00 $74.00 $57.00 $59.00 $61.0099378 $104.00 $121.00 $126.00 $132.00 $114.00 $119.00 $124.0099379 $75.00 $67.00 $70.00 $73.00 $56.00 $58.00 $60.0099380 $104.00 $102.00 $105.00 $109.00 $88.00 $91.00 $94.0099406 ------- $13.00 $14.00 $14.00 $13.00 $13.00 $13.0099407 ------- $26.00 $27.00 $28.00 $25.00 $26.00 $26.0099408 ------- $32.00 $33.00 $33.00 $30.00 $31.00 $32.0099409 ------- $63.00 $65.00 $66.00 $61.00 $63.00 $64.0099441 ------- $14.00 $15.00 $15.00 $13.00 $13.00 $14.0099442 ------- $25.00 $26.00 $27.00 $24.00 $25.00 $26.0099443 ------- $37.00 $39.00 $40.00 $36.00 $37.00 $39.0099450 NC NC NC NC NC NC NC99455 $90.00 ------- ------- ------- ------- ------- -------

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Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2008 EditionRULE 69L-7.020, F.A.C.Evaluation and Management

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)

Locality 04 (Non-Facility MRA)

Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)

Locality 04 (Facility MRA)

99456 BR ------- ------- ------- ------- ------- -------99457 BR ------- ------- ------- ------- ------- -------99499 BR ------- ------- ------- ------- ------- -------99600 BR ------- ------- ------- ------- ------- -------G0245 ------- $67.00 $70.00 $73.00 $47.00 $48.00 $50.00G0246 ------- $40.00 $42.00 $43.00 $24.00 $25.00 $26.00G0337 ------- $71.00 $74.00 $78.00 $71.00 $74.00 $78.00G0344 ------- $100.00 $105.00 $110.00 $73.00 $77.00 $81.00G0368 ------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00G0372 ------- $16.00 $16.00 $17.00 $9.00 $9.00 $10.00G0396 ------- $32.00 $33.00 $33.00 $30.00 $31.00 $32.00G0397 ------- $63.00 $65.00 $66.00 $61.00 $62.00 $64.00M0064 ------- $39.00 $41.00 $42.00 $18.00 $18.00 $19.00

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition

RULE 69L-7.020, F.A.C. 381

APPENDIX A

DEFINITIONS

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition

RULE 69L-7.020, F.A.C. 382

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 self-

insured 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.

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(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, CDT-2009/2010, 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.

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APPENDIX B

OFFICIAL SOURCE OF REFERENCES DIRECTORY OFFICIAL S

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OURC

E OF REFERENC

ES

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.

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♦ 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

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APPENDIX C

MODIFIERS

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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.

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APPENDIX D

WORKERS’ COMPENSATION UNIQUE CODES

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APPENDIX D. WORKERS’ COMPENSATION UNIQUE CODES DSPNS Legend, prescription, and over-the-counter drugs dispensed by Page 16 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.) COMPD Compounded drugs dispensed. Page 17 97260 Manipulation of spine by a physician other than an Page 28 osteopathic or chiropractic physician. 97261 Manipulation of the temporomandibular joint; upper Page 28 extremities including the hand and wrist; the lower extremities; and other regions by a physician other than an osteopathic or chiropractic physician. 97750 Functional capacity evaluation (FCE) with written report. Page 32 97752 Muscle testing manually or by automated equipment with Page 29 written report. 97850 Physical reconditioning assessment; per hour. Page 23 97851 Physical reconditioning assessment; additional thirty (30) Page 23 minutes. 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

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COMPENSATION UN

APPENDIX E

MEDICARE LOCALITY MAP

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Medicare Payment Localities (Counties)

Locality 01 / Locality 02:

Alachua Franklin Lake Putnam Baker Gadsden Leon Santa Rosa Bay Gilchrist Levy Sarasota Bradford Glades Liberty Seminole Brevard Gulf Madison St. Johns Calhoun Hamilton Manatee Sumter Charlotte Hardee Marion Suwannee Citrus Hendry Nassau Taylor Clay Hernando Okaloosa Union Columbia Highlands Okeechobee Volusia De Soto Hillsborough Orange Wakulla Dixie Holmes Osceola Walton Duval Jackson Pasco Washington Escambia Jefferson Pinellas Flagler Lafayette Polk

Locality 03: Broward Collier Martin Indian River Lee Palm Beach St. Lucie

Locality 04: Dade Monroe

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INDEX

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INDEX A 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 B Biofeedback, 18 By Report (BR), 12 C Chiropractic manipulative treatment (CMT), 28 Commission on Accreditation of Rehabilitation Facilities (CARF), 382 Compounding drugs, 16 Consensus Independent Medical Examination (CIME), 20 Consultations, 19 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

E Electrodiagnostic medicine, 18 Electromyography, 18 Eligibility, 8 Evaluation and management services, 19 F Failed appointments, 13 Federal facilities, 11 Follow-up days (FUD), 33 Functional capacity evaluation (FCE), 32 G Global reimbursement, 33 H Health care provider(s), 382 Home health agency, 20 Home health services, 20 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 J J codes, 20 L Level I: Classification (defined), 15

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Level II: Classification (defined), 15 Level III: Classification (defined), 15 M 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 N National Correct Coding Initiative (NCCI), 13, 383, 386 National Drug Code (NDC), 16, 17 Nerve conduction studies (NCS), 19 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

Psychological services, 22 Psychotherapy, 22 Q Qualifying circumstances, 37 R Radiology, 23 Professional component modifier, 23 Technical component modifier, 23 Reference materials, 385 Reimbursement information, 11 S 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 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

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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