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Florida Workers’ Compensation
Health Care Provider Reimbursement Manual
Rule 69L-7.020, F.A.C.
2017 Edition
Effective _______
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2017 Edition Page 2 Effective Date: _______
TABLE OF CONTENTS
CHAPTER 1 0BINTRODUCTION AND OVERVIEW ................................................................ 5
4BOverview ----------------------------------------------------------------------------------------------------- 5
5BE-Alert System ---------------------------------------------------------------------------------------------- 5
6BHow to Obtain or Purchase Manuals ------------------------------------------------------------------- 6
9BHealth Care Provider Use of Codes, Descriptions, and Modifiers ------------------------------- 10
Billing New Procedure Codes Not Listed in the Fee Schedule ------------------------------------ 10
10BCarrier Use of Codes, Descriptions, and References ------------------------------------------------ 11
11BGeneral Reimbursement Information ----------------------------------------------------------------- 14
Co-Payments ----------------------------------------------------------------------------------------------- 14
14BExceptions to Service Limitations ---------------------------------------------------------------------- 18
15BDisputing Reimbursement ------------------------------------------------------------------------------- 18
CHAPTER 2 MEDICAL SERVICES ........................................................................................ 21
17BAnesthesia Services ---------------------------------------------------------------------------------------- 21
Post-Operative Pain Management --------------------------------------------------------------------- 27
18BBiofeedback Services -------------------------------------------------------------------------------------- 27
19BDental Services --------------------------------------------------------------------------------------------- 28
20BElectrodiagnostic Medicine ------------------------------------------------------------------------------ 29
21BEvaluation and Management Services ----------------------------------------------------------------- 31
22BFunctional Capacity Evaluations (FCE) -------------------------------------------------------------- 32
23BHome Health Agency Services -------------------------------------------------------------------------- 33
24BIndependent Medical Examinations ------------------------------------------------------------------- 35
25BFailure to Appear for IME ------------------------------------------------------------------------------ 35
26BConsensus Independent Medical Examination ------------------------------------------------------ 35
26B27BMedications ------------------------------------------------------------------------------------------------- 36
Home Medical Equipment and 28BMedical Suppliers -------------------------------------------------- 42
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29BOphthalmologic Services --------------------------------------------------------------------------------- 43
30BPermanent Impairment Ratings (PIR) ---------------------------------------------------------------- 44
31BPsychiatric and Psychological Services ---------------------------------------------------------------- 45
32BRadiology---------------------------------------------------------------------------------------------------- 47
33BThermography --------------------------------------------------------------------------------------------- 48
34BPhysical Medicine and Rehabilitation Services ------------------------------------------------------ 49
35BAcupuncture ------------------------------------------------------------------------------------------------ 57
36BOrthotics and Prosthetics -------------------------------------------------------------------------------- 58
37BTests and Measurements --------------------------------------------------------------------------------- 59
38B41BSurgical Services ------------------------------------------------------------------------------------------- 65
2BCHAPTER 3 MAXIMUM REIMBURSEMENT ALLOWANCES ........................................ 73
3BCHAPTER 4 BILLING INSTRUCTIONS AND FORMS ..................................................... 415
Bill Submission/Filing and Reporting Requirements --------------------------------------------- 415
Form DFS-F5-DWC-9/CMS-1500 -------------------------------------------------------------------- 417
Form DFS-F5-DWC-10--------------------------------------------------------------------------------- 419
APPENDIX A WORKERS’ COMPENSATION UNIQUE PROCEDURE CODES .......... 421
APPENDIX B OFFICIAL SOURCE FOR REFERENCES .................................................. 422
APPENDIX C MEDICARE PAYMENT LOCALITIES (COUNTIES) ............................... 425
APPENDIX D FORMS .............................................................................................................. 426
APPENDIX E DEFINITIONS .................................................................................................. 427
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Chapter 1 0B0BIntroduction and Overview
5B4BOverview
Changes to the Manual
It is important that health care providers (HCPs) and carriers read the
updated material in the Florida Workers’ Compensation Health Care
Provider Reimbursement Manual (Manual). Both parties have a
responsibility for performing specific duties when billing, reporting, or
reimbursing medical services rendered to injured workers.
Reimbursement Manuals will be available under the “Reimbursement
Manuals” section on the DWC website.
6B5BE-Alert System The Division of Workers’ Compensation has an electronic alert (E-Alert)
system to notify subscribers of news impacting the Workers’ Compensation
industry and dates of upcoming public meetings and workshops.
To subscribe to the “E-Alerts,” please go to the DWC website. Look for the
box entitled “Register.” Once registered, you will receive E-Alerts whenever
they are provided by the Division.
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Chapter 1 1B0BIntroduction and Overview
7B4BOverview, continued
Background There are three different Workers’ Compensation Reimbursement
Manuals:
Florida Workers’ Compensation Reimbursement Manual for
Ambulatory Surgical Centers, Rule 69L-7.100, Florida
Administrative Code (F.A.C.);
Florida Workers’ Compensation Health Care Provider
Reimbursement Manual, Rule 69L-7.020, F.A.C.; and
Florida Workers’ Compensation Reimbursement Manual for
Hospitals, Rule 69L-7.501, F.A.C.
Other Applicable
Rules
In addition to this Manual, Rule 69L-7.020, F.A.C., also recognizes
Rule Chapter 69L-7, F.A.C.
8B6BHow to Obtain or
Purchase Manuals
This Manual can be obtained free of charge on the DWC website, under
“Reimbursement Manuals,” or may be purchased in hard copy from the
Department of Financial Services, Document Processing Section, at 200
East Gaines Street, Tallahassee, Florida 32399-0311.
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Chapter 1 Introduction and Overview, continued
Purpose The purpose of the Manual is to furnish health care providers with the
policies and procedures needed to report services rendered to injured
workers and to file medical bills to carriers or self-insured employers for
reimbursement of services rendered. The Manual also provides carriers
or self-insured employers the schedule of Maximum Reimbursement
Allowances (MRAs) approved by the Three-Member Panel for
reimbursing health care providers for medically necessary care and
treatment.
The Manual provides descriptions and instructions on how and when to
complete forms and other documentation that will assist in the medical
bill filing process, as well as how to apply the reimbursement
methodology for the schedule of MRAs to assist in the proper
reimbursement of billed services.
The administrative purpose of the Manual is to furnish HCPs with
general information, billing and reimbursement policies, and MRAs for
covered services and procedures.
Prior Authorization of
Services
Pursuant to section 440.13(3), F.S., all HCPs and out-of-state
providers must have authorization by the Workers’ Compensation
carrier or a self-insured employer prior to:
Rendering initial care, remedial medical services, and
pharmacy services; or
Making a referral for the injured worker to facilities or
other HCPs.
Note: Exceptions to prior authorization are:
Federal facilities;
Emergency services and care, defined in section 395.002,
F.S.; or
An HCP referral for emergency treatment resulting from
emergency services.
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Chapter 1 Introduction and Overview, continued
Notification of
Emergency Treatment
A HCP who renders emergency care must notify the carrier, in writing
by U.S.P.S. mail, by electronic mail, or by facsimile, by the close of the
third state of Florida business day after care has been rendered.
If the emergency care results in admission to a health care facility, the
HCP must notify the carrier by telephone within 24 hours after initial
treatment.
Carrier Responsibilities
at Authorization
A carrier is responsible for meeting its obligations under this Manual
regardless of any business arrangements with any service company/third
party administrator (TPA), submitter, or any entity acting on behalf of a
carrier through which medical bills are paid, adjusted and paid, disallowed,
denied, or otherwise processed or submitted to the Division.
At the time of authorization for medical service(s), a carrier must notify
each HCP, in writing, of additional form completion requirements or
supporting documents that are necessary for reimbursement and provide the
specific address for submitting a reimbursement request.
At the time of authorization for medical service(s), a carrier must inform
out-of-state HCPs of the specific reporting, billing, and submission
requirements of this Manual and provide the specific address for submitting
a reimbursement request.
Fraud Statement An HCP involved in the process of making a claim under the Workers’
Compensation program must provide his or her personal signature once per
calendar year attesting that he or she has reviewed, understands, and
acknowledges the following statement:
“Any person who, knowingly and with intent to injure, defraud, or deceive
any employer or employee, insurance company, or self-insured program,
files a statement of claim containing any false or misleading information
commits insurance fraud, punishable as provided in section 817.234, F.S.”
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Chapter 1 Introduction and Overview, continued
9B9BHealth Care Provider Use
of Codes, Descriptions, and
Modifiers
All HCPs must use the codes and descriptions, modifiers, policies,
definitions, and instructions of the referenced CPT®, CDT®, HCPCS
Level II®, ICD-10®, Florida Workers’ Compensation Unique
Procedure Codes, or other materials referenced in Rule 69L-7.020
F.A.C., and:
The Minnesota Department of Labor and Industry Disability
Schedule, as adopted in Rule 69L-7.604, F.A.C.;
The Florida Impairment Rating Guide, as adopted in
Rule 69L-7.604, F.A.C.;
The 1996 Florida Uniform Permanent Impairment Rating
Schedule, as adopted in Rule 69L-7.604, F.A.C.; and
The American Medical Association’s Guide to the Evaluation
of Permanent Impairment, as adopted in Rule 69L-7.604,
F.A.C.
The use of HCPCS Level II® codes is allowed only when there is not
a more specific CPT® code available for use.
All diagnosis codes must be reported at the highest level of
specificity according to the ICD-10-CM® valid number of digits, i.e.,
seven (7) digits where noted in the ICD-10-CM® manual.
10BBilling New
Procedure Codes
11BNot Listed in the
Fee Schedule
In the event that a new CPT® or HCPCS Level II® code is created in
the CPT® or HCPCS Level II® manuals released subsequent to the
applicable manual incorporated by reference in rule, the HCP may
bill the newly created CPT® code or HCPCS Level II® code and the
carrier must reimburse, subject to any other provision of this manual.
Note: See Codes with No MRAs in this Chapter.
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Chapter 1 Introduction and Overview, continued 12B10B
13BCarrier Use of Codes,
14BDescriptions,
15Band References
Carriers must use the codes and descriptions, modifiers, policies,
definitions, and instructions of the referenced CPT®, CDT®, HCPCS
Level II®, ICD-10®, or Florida Workers’ Compensation Unique
Procedure Codes on the medical bill prior to making reimbursement
decisions.
Notice of Privacy Practices
All HCPs will, except in emergency treatment situations, 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. If not
obtained, the HCP must document its good faith efforts to obtain
such acknowledgement and the reason why the acknowledgement
was not obtained.
In the event a patient, guardian, 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 HCP must notify the carrier
immediately, if possible, or by close of business on the next regular
state of Florida business day.
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Chapter 1 Introduction and Overview, continued
Disclosure to Carriers Unless instructed otherwise, it is the responsibility of all HCPs to
furnish, without charge, the following documentation to the carrier:
A complete report of the patient’s symptoms, findings, and
plan of treatment pursuant to reporting requirements of
Form DFS-F5-DWC-25(DWC-25);
An operative report when a surgical procedure is
performed;
A narrative report when a consultation or an independent
medical examination is rendered;
Copies of medical records, when requested at the time of
authorization by the employer/carrier or designated entity,
in order to determine the medical necessity of services that
must be substantiated in more detail than previously
disclosed;
A copy of the DWC-25, signed by the physician, associated
with the recommended or rendered care or treatment.
Failure of the HCP to forward information when requested by the
carrier may result in the billed service being disallowed payment
until sufficient documentation is provided to render a
determination.
Moreover, an HCP’s failure to release medical records or
information upon a reasonable request, or to release full and truthful
medical reports of all of his or her findings, will constitute a
violation of Chapter 440, F.S., subject to penalties imposed by the
Division.
Disclosure to Injured
Workers, Employers,
and Carriers
An HCP, upon request, must furnish the injured worker, injured
worker’s attorney, employer, carrier, carrier’s designee, or carrier’s
attorney, relevant portions of his or her office chart, records, and
reports. The relevant portions sought must be related to the
particular injury or illness for which compensation is sought.
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Chapter 1 Introduction and Overview, continued
Injured Worker’s
Requests
An HCP may charge an injured worker or his or her
representatives no more than $0.50 per page for copies of written
medical records. The relevant portions of the medical record
sought must be related to the particular injury or illness for which
compensation is sought.
Payment must be made to an HCP by the requesting party at the
HCP’s actual cost for x-rays, microfilm, or other non-written
records.
Carrier’s Requests An HCP, upon request, must furnish a copy of the injured
worker’s medical records, medical charts and reports to a carrier
or a carrier’s designee or attorney.
An HCP, upon request, must furnish the carrier, carrier’s designee,
or carrier’s attorney, all non-written medical records.
Division or Judge of
Compensation Claims
Requests
An HCP, upon request, must provide medical records and reports
to the Division or Judge of Compensation Claims without charge.
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Chapter 1 Introduction and Overview, continued
16B11BGeneral Reimbursement Information
Billing the Injured
Worker
HCPs must not bill the injured worker for services rendered for a
compensable work-related injury except when it is to collect a co-
payment fee or when apportioning out the percentage of need for the
care attributable to a pre-existing condition.
17BCo-Payments An HCP is entitled to collect a co-payment of $10.00 per visit when
providing medical services and care to an injured worker who has
reached overall maximum medical improvement (MMI).
The co-payment(s):
May only be collected for evaluation and management visits
after the injured worker has received an assignment of MMI;
Will not apply to emergency care or services provided to the
injured worker;
Will not apply to laboratory, radiology, or diagnostic services;
and
Is not in addition to the MRA or fee agreement. The
reimbursement amount otherwise payable by the carrier will be
reduced by the amount of the co-payment.
Federal Facilities Federal facilities are exempt from the reimbursement provisions and
allowances in this Manual.
A carrier must reimburse a federal facility its usual charge.
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Chapter 1 Introduction and Overview, continued
General Reimbursement Information, continued
Florida Health Care
Providers
Reimbursement will be made to a Florida HCP after applying the
appropriate reimbursement policies contained in this Manual.
A carrier will reimburse an HCP either the MRA in the appropriate
reimbursement schedule or an agreed upon contract price.
Note: See Chapter 3 for MRAs and instructions on how to determine
the correct MRA.
Out-of-State Providers Prior to the delivery of medical services, a carrier and HCP must
agree upon the amounts of reimbursement for the services at the time
of authorization or, if no agreement is made prior to the service being
rendered, the carrier will reimburse the greater of:
The MRA according to the out-of-state fee schedule for the
services provided; or
The MRA according to Chapter 3, Part A, of this Manual.
Codes Paid by MRAs Reimbursement for procedure codes listed in this Manual with an
MRA will be at the maximum reimbursement allowance after the
application of any reimbursement policies contained in this Manual.
When the billed charge is less than the MRA, the reimbursement will
be the MRA amount in the fee schedule.
Note: The only exception is when there is a defined
reimbursement amount between the HCP and carrier provided in a
contractual agreement.
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Chapter 1 Introduction and Overview, continued
18B13BGeneral Reimbursement Information, continued
Codes Paid
By Report
Reimbursement will be determined by the carrier for procedure codes
listed in the fee schedule as By Report.
Payment will be based on an HCP’s documentation submitted to the
carrier containing information on the complete description of the
service or procedures actually performed, medical necessity, and cost
of any additional supplies.
At a minimum, reimbursement will be:
The Florida Workers’ Compensation MRA for clinically
similar procedure codes in the current fee schedule.
The HCP must submit the required documentation to the carrier when
the following situations occur:
The procedure code’s MRA is listed in the fee schedule as By
Report in Chapter 3 of this Manual;
There is a valid procedure code in the CPT® or the HCPCS
Level II® Manual which corresponds to the date of service; or
The billed procedure code is not listed in this Manual.
Note: See Codes with No MRAs in this Chapter.
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Chapter 1 Introduction and Overview, continued
General Reimbursement Information, continued
Codes with No MRAs Carriers must have an established methodology for determining
reimbursement for procedure codes that have no established MRAs,
unlisted procedure codes, and codes that are paid By Report.
Carriers will:
Determine reimbursement by comparing the billed procedure
code(s) with clinically similar procedure code(s) found in the
appropriate CPT® or HCPCS Level II® Manual;
Make reimbursement decisions based on either peer
physician recommendations or the HCP’s documentation,
medical bills, relative value data, services, and supplies; and
Reimburse all work-related and medically necessary services
provided in a documented medical or dental emergency.
The carrier’s reimbursement methodology must also be available in
response to any Petition for Resolution of Reimbursement Dispute or
upon request by the Division.
Reimbursement for
Failed Appointments
Reimbursement is not made for an injured worker’s failed
appointment.
Note: This exclusion does not apply to Independent Medical
Examinations pursuant to section 440.13(5)(d), F.S.
See Independent Medical Examinations in Chapter 2.
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Chapter 1 Introduction and Overview, continued
General Reimbursement Information, continued
19B14BExceptions to Service
Limitations
When an HCP deems it medically necessary in the treatment of an
injured worker’s injury or illness to furnish medical services that
exceed the number of services in the reimbursement policies in this
Manual, an HCP must:
Submit documentation to the carrier substantiating the
medical necessity for the request, and
Receive specific written authorization from the carrier to
render the requested additional services before they are
provided.
Services Unrelated to
the Compensable
Injury
Carriers will not reimburse the HCP for services unrelated to the
treatment or care of a compensable injury except when the treatment is
required to stabilize or maintain the injured worker’s medical status in
order to treat the patient’s compensable injury or condition.
20B15BDisputing
Reimbursement
The HCP may elect to contest the disallowance or adjustment of
payment under section 440.13(7), F.S. The election to contest the
disallowance or adjustment of payment under section 440.13(7), F.S.,
must be made by the HCP within forty-five (45) calendar days of receipt
of the Explanation of Bill Review (EOBR) or notice of disallowance or
adjustment of payment.
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Chapter 1 Introduction and Overview, continued
Classification of an Injured Worker’s Treatment/Status, continued
General Policies
HCPs are to utilize the Workers’ Compensation specific patient
classification levels when submitting the required treatment status
on the DWC-25 to the carrier.
Classification System
The following best describes the patient classification levels:
Criteria based;
Comprised of descriptive categories to provide a means to
promote decision-making, accountability, and responsible
medical bill handling practices; or
Neither hierarchical nor severity indicators.
Purpose of Proper
Patient Classification
Proper classification of the patient is intended to:
Convey to carriers the complexity of services that may be
required for optimal clinical management;
Distinguish the overall critical differences among cases
that influence the intensity, scope, and cost of services
provided;
Facilitate recognition of three varying clinical
configurations that affect the medical treatment plan and
treatment progress or other available benefits for an injured
worker;
Assist the carrier in decisions related to authorization of
recommended treatment plans or treatment plan revisions;
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 an HCP; and
Enhance communication between the HCP and the carrier
to facilitate the authorization process for the provision of
medically necessary care.
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Chapter 1 Introduction and Overview, continued
16BClassification of an Injured Worker’s Treatment/Status, continued
Patient Classification
Levels
Level I: Key issue – specific, well defined medical condition, with
clear correlation between objective relevant findings and patient’s
subjective complaints. Treatment correlates to specific findings.
Level II: Key issue – regional or generalized de-conditioning (i.e.,
deficits in strength, flexibility, endurance, and motor control).
Treatment includes physical reconditioning or functional
restoration.
Level III: Key issue – poor correlation between patient’s
complaints and objective, relevant physical findings, both somatic
and non-somatic clinical factors. Treatment includes
interdisciplinary management and rehabilitation.
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2BChapter 2 Medical Services
21B17BAnesthesia Services
Reimbursable
Providers
Anesthesia services are reimbursed to anesthesiologists, certified
registered nurse anesthetists (CRNAs), and anesthesia assistants (AAs)
practicing within the scope of state licensure. A surgeon may also be
reimbursed for anesthesia services performed during surgery.
Anesthesia
Minutes
Anesthesia time begins when the provider starts to prepare the injured
worker for anesthesia care in the operating room or in an equivalent area
and stops when the provider is no longer in personal attendance, which is
when the injured worker may be safely placed under postoperative
supervision.
Note: Anesthesia time must 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.
Anesthesia Time
Units
The minutes of anesthesia must be converted by the carrier into time units
as follows:
For anesthesiologists, each ten (10) minutes of anesthesia time
equals one (1) time unit and each minute over a time unit has a
value of one-tenth (1/10) time unit.
For CRNAs or AAs, each fifteen (15) minutes of anesthesia time
equals one (1) time unit and each minute over has a value of one-
fifteenth (1/15) time unit.
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Chapter 2 Medical Services, continued
Anesthesia Services, continued
Physical Status
Modifiers
Anesthesia services will warrant additional reimbursement for units based
upon the injured worker’s condition and the complexity of the anesthesia
service provided.
A physical status modifier will be determined by the provider (CRNA or
anesthesiologist only) to rank the injured worker’s condition. Additional
reimbursement will be based on the unit value for the specific physical
status modifier, as assigned by the CPT® Manual.
A physical status modifier is required for billing and reimbursement of
anesthesia bills.
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
CPT® only copyright 2016 American Medical Association. All rights reserved.
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Chapter 2 Medical Services, continued
Anesthesia Services, continued
Difficult or
Qualifying
Circumstances
Anesthesia services that are provided under particularly difficult circumstances
may warrant additional reimbursement for unit values based on unusual events.
Listed below are the specific qualifying circumstances, as assigned by the
CPT® Manual, that impact the anesthesia services provided.
These procedure codes are not to be reported alone, but are reported as
additional procedure codes. The listed unit value must be added to the base
value units to calculate the reimbursement. List each of the following codes
below the primary anesthesia procedure code on the billing form.
Code Unit Value
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 hypothermia 5
99140 Anesthesia complicated by
emergency conditions (specify) 2
All others 0
CPT® only copyright 2016 American Medical Association. All rights reserved.
Calculation of
Anesthesia
Reimbursement
Select the applicable anesthesia procedure code and note the base value from
the fee schedule in Chapter 3, Part A, of this Manual.
Determine the time units based on provider type. Determine any additional
units that are justified by the physical status modifier and qualifying
circumstances. Add the base value, time units, physical status modifier, and
any applicable qualifying circumstances to determine total anesthesia value.
Multiply the total anesthesia value by the conversion factor (CF) of $29.49 to
obtain the total anesthesia reimbursement.
Base Value (BV)
Time Units (TM)
Physical Status modifier units
+ Qualifying Circumstances Units = Total Anesthesia Units
Total Anesthesia Units x $29.49 = $ Reimbursement
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Chapter 2 Medical Services, continued
Anesthesia Services, continued
Procedures Listed
as BV with No TM
Units
Certain anesthesia services do not have a listed time value component.
The reimbursement method for an anesthesia service that does not have time
units associated with the anesthesia base value is as follows:
Select the applicable anesthesia procedure code and base value from the
schedule in Chapter 3, Part A, of this Manual;
Determine any additional units that are justified by the physical status
modifiers or qualifying circumstances;
Add the base value, physical status modifier, and any applicable
qualifying circumstances to determine total anesthesia value; and
Multiply the total anesthesia value by the CF of $29.49 to obtain the
total anesthesia reimbursement.
Base Value
Physical Status Modifier units
+ Qualifying Status units = Total Anesthesia Units
Total Anesthesia Units x $29.49 (CF) = $ Reimbursement
Note: CRNAs and AAs reimbursement will be limited to 85% of the total
anesthesia reimbursement allowance for an anesthesiologist for any
procedure that has no TM units.
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Chapter 2 Medical Services, continued
Anesthesia Services, continued
Medical Direction
of CRNA/AA by
Anesthesiologist
Reimbursement will only be made to the anesthesiologist for the direct
supervision of anesthesia services which are provided by the anesthesiologist
and billed under the name and license number of the physician.
Reimbursement will be made to an anesthesiologist for providing medical
direction, including pre-operative and post-operative evaluations or
consultations to a CRNA/AA as previously identified by the specific protocol.
Reimbursement for a CRNA/AA requiring medical direction by an
anesthesiologist will be fifty percent (50%) of the anesthesia reimbursement
allowance listed in Chapter 3, Part A, or the agreed upon contract price.
Reimbursement for medical direction by an anesthesiologist will be fifty
percent (50%) of the anesthesia reimbursement allowance listed in Chapter 3,
Part A, of this Manual, or the agreed upon contract price.
Reimbursement will not be made to either the anesthesiologist or the
CRNA/AA until the carrier has received and reviewed the medical bills and
anesthesia reports from both providers.
No additional reimbursement will be made for general supervisory services
rendered by the anesthesiologist.
Special Billing
Requirement
All anesthesia services must be billed on Form DFS-F5-DWC-9 (DWC-9).
Anesthesia services, must include the CPT® code and the “P” code (physical
status modifier) which corresponds with the procedure performed in Field 24D.
On the next line of Field 24D, anesthesia providers must enter the date of
service and the 5-digit qualifying circumstances code, which corresponds with
the procedure performed, if applicable.
Medical direction must be billed by the anesthesiologist by adding the HCPCS
Level II® modifier QY to the anesthesia procedure code.
The HCPCS Level II® modifier QK must be appended to the anesthesia code
when the medical direction requires more than one concurrent anesthesia
procedure.
When medical direction is required, the CRNA or AA must bill by appending
the HCPCS Level II® modifier QX to the anesthesia procedure code. The
CRNA or AA must provide his or her Florida Department of Health (DOH)
license number in Field 33b.
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Chapter 2 Medical Services, continued
Anesthesia Services, continued
Special Billing
Requirements,
continued
When a CRNA provides anesthesia services, the CRNA must enter his/her DOH
license number in Field 33b.
Note: See subsection 69L-7.730(2), F.A.C.
Anesthesia
Performed by the
Operating
Surgeon
When an operating surgeon provides regional or general anesthesia for a
surgical procedure that he or she actually performs, modifier 47 is appended to
the anesthesia procedure code to indicate that the operating surgeon performed
the anesthesia.
No additional reimbursement is calculated when the operating surgeon bills
with the “P” code (physical status modifier).
An operating surgeon cannot report time units in the calculation of anesthesia
reimbursement request on the medical bill. Reimbursement will be for the base
value (BV) multiplied by the anesthesia conversion factor only for the
anesthesia service rendered.
Base Value x $29.49 (anesthesia CF) = $ Reimbursement
Note: See Chapter 3, Part A, of this Manual for anesthesia Base Values.
Conscious
Sedation
CPT® procedure codes denoted with a bullseye symbol (ʘ), in the adopted
CPT® manual, indicate that conscious sedation is not separately reimbursable in
addition to the procedure.
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22BAnesthesia Services, continued
23BPost-Operative Pain
Management
Nerve blocks for post-operative pain management will be reimbursed if ordered
by the surgeon and provided in addition to general anesthesia or conscious
sedation. Nerve blocks may be performed pre-operatively, intra-operatively, or
post-operatively. The HCP performing the nerve block must provide a separate
procedure report and submit the documentation to the carrier for
reimbursement.
Reimbursement for a nerve block will be made in accordance with the MRAs
listed in this Manual when performed by an HCP who is not the operating
surgeon.
The professional component for a nerve block must be billed by the HCP on the
DWC-9 claim form.
24BNote: If the nerve block is performed by the operating surgeon, the Billing and
Reimbursement of Multiple Surgical Procedures, under the Surgical
Services section in this manual, will apply.
25B18BBiofeedback Services
Requirements for
Reimbursement
Reimbursement for the collection and interpretation of biofeedback data
digitally stored and downloaded will be included in the reimbursement to the
HCP for the basic biofeedback service.
The written interpretation of the digitally stored biofeedback results must be
signed and dated by the HCP and maintained in the medical record.
Limitations to
Biofeedback
Services
Reimbursement for biofeedback training will be limited to twelve (12) visits per
date of injury.
Note: This biofeedback training limitation does not include individual psycho-
physiological therapy incorporating biofeedback training by any modality with
psychotherapy.
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26B19BDental Services
Reimbursable
Providers
A carrier will only reimburse a dentist or an oral surgeon for authorized
services.
Note: Emergency oral surgery does not require prior authorization. The carrier
must be notified by the HCP no later than the close of the third state of Florida
business day after emergency treatment.
Dental Codes and
Descriptions
Dentists must use the dental guidelines, codes and descriptors from the CDT®
or the D codes in the HCPCS Level II® for dental procedures.
Dental services are billed on Form DFS-F5-DWC-11.
Oral Surgery
Services
Oral Surgeons must use the CPT® guidelines, codes, descriptors, and modifiers
for oral and maxillofacial surgical services.
Oral surgery services are billed on the DWC-9 form.
Note: Oral Surgeons will refer to the label block Billing and Reimbursement
of Multiple Surgical Procedures under Surgical Services in this Manual for
information regarding reimbursement for multiple surgical procedures, as well
as other surgical reimbursement guidelines.
Temporo-
mandibular
Joint (TMJ)
Services
Dentists must bill using a combination of the dental guidelines, codes and
descriptors from the CDT® manual and the D codes from the HCPCS Level II®
manual.
To receive reimbursement:
Dentists who provide TMJ services may use a combination of CPT®
codes and dental codes from the CDT® or HCPCS Level II®, or
Dentists will refer to the physical medicine section of this Manual for
information on physical medicine reimbursement policies.
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Chapter 2 Medical Services, continued
Dental Services, continued
Reimbursement to
Dentists and Oral
Surgeons
Reimbursement to a dentist or oral surgeon for dental procedures or services
will be the MRA or the agreed upon contract price.
Note: See Chapter 3 for the MRAs for Dentists and Oral and Maxillofacial
Surgeons in this Manual.
27B20BElectrodiagnostic Medicine
Determining
Medical Necessity
The referring physician must determine the medical necessity of an
Electromyography (EMG) or a Nerve Conduction Study (NCS). Only a
physician will determine the frequency of testing or the necessity of repeat
testing.
Reimbursement
Policy for EMG
Only HCPs specifically qualified by state regulations to perform EMG will be
reimbursed.
Reimbursement must include the testing, interpretation of the studies, and a
written report of the findings.
When the initial evaluation and management service and needle EMG testing
are performed during the same visit, reimbursement will be made for both
services.
When the follow-up evaluation and management service and needle EMG
testing are performed on the same day, reimbursement will be made for both
services only if the documentation validates the medical necessity for the
follow-up evaluation and management service.
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Electrodiagnostic Medicine, continued
Reimbursement
Policy for EMG,
continued
When needle EMG testing is performed in a hospital or other facility,
reimbursement will be made for an interpretation and report of the testing.
Modifier 26 must be appended to the appropriate procedure code for
reimbursement.
Nerve Conduction
Studies
An HCP, specifically qualified by regulations in his or her state, will determine
the nerves to be tested based on specific clinical findings during the
examination performed at the time of the study
Reimbursement
Policies for NCS
When the initial evaluation and management service and the NCS are
performed during the same visit, reimbursement will be made for both services.
When a follow-up evaluation and management service and the NCS are
performed on the same day, reimbursement will be made for both services only
if the documentation validates the medical necessity of the follow-up evaluation
and management service.
A technologist under the direct supervision of the physician may perform a
NCS. However, the services must be billed under the supervising physician’s
name and DOH, or out-of-state, license number.
Reimbursement will include the testing, interpretation of the studies, and a
written report of the findings.
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28B21BEvaluation and Management Services
Office Visits
A carrier will reimburse an HCP for evaluation and management services (new
or established patient visits).
A new patient means an injured worker who:
Is new to the HCP,
Is an established patient who has not received service for more than 3
years from the same HCP, or
Is an established patient with a new compensable injury or illness and a
new date of accident.
Note: Reimbursement is limited to one (1) evaluation and management visit
per day at the level of care documented by the HCP.
Home Visit
Services
An HCP will not be reimbursed for home visits unless prior authorization from
the carrier has been received.
An HCP must bill for a home visit using the appropriate evaluation and
management procedure code.
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Consultations
A consultation is a type of service provided by a physician whose opinion or
advice regarding evaluation or management of a specific problem is requested
by another physician or other appropriate resource. A physician will be
reimbursed for consultations, confirmatory consultations, and follow-up
consultation services.
Reimbursement for consultations must include a review of all submitted
medical records, paper and non-paper; a physical examination of the injured
worker; and a written report.
The consultant’s opinion and any services that were ordered or performed must
be communicated by written report to the requesting physician or other
appropriate source.
29B22BFunctional Capacity Evaluations (FCE)
Reimbursement
Criteria
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).
Reimbursement for an authorized FCE will be made at any time in the clinical
continuum (see Patient Classification System in Chapter 1 of this Manual), as
long as the evaluation protocol matches the scope and specificity of the clinical
situation and referral question(s).
Reimbursement will be made for the CPT® code 97750, specifically designated
for use solely in reporting a FCE. The reimbursement for an FCE includes a
written program plan and a written report. The provider must provide the results
of the evaluation and recommendations to the injured worker, the carrier, and
the authorized physician without additional charge.
Reimbursement for an FCE will be made only when a physical therapist or
occupational therapist is directly and actively involved with the testing
protocol, although additional professional personnel may be involved as well.
Note: Bill an FCE using CPT® procedure code 97750.
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30B23BHome Health Agency Services
Authorization A Home Health Agency must obtain authorization from the carrier prior to
assigning any licensed health care employees to render services in an injured
worker’s residence.
The carrier’s authorization to provide home health services does not authorize
home medical equipment and supplies unless such authorization is expressly
stated.
Definition Home Health Services are medically necessary services which can be
effectively and efficiently provided in the place of residence of an injured
worker. Services may include home health visits (nurses and home health
aides), therapy services (speech therapy, physical therapy, occupational
therapy), and the coordination of authorized home medical equipment.
Home Health Visit
Definition
A Home Health Visit is a face-to-face encounter between a registered nurse,
licensed practical nurse, home health aide, or licensed therapist employed by a
Home Health Agency and an injured worker at his or her place of residence.
A Home Health Visit is not limited to a specific length of time, but is defined as
an entry into the injured worker’s place of residence for the length of time
needed, as prescribed by the HCP, to provide medically necessary nursing,
home health aide, or therapy service(s). An injured worker’s residence cannot
be a facility such as a hospital, a nursing facility, or a rehabilitation facility of
any type.
General Policies A Home Health Agency must have a signed order outlining the Home Health
Plan of Care from the authorized physician in order to obtain carrier
authorization of home health services. The Home Health Plan of Care must be
renewed every thirty (30) calendar days and submitted to the carrier for
authorization.
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Home Health Agency Services, continued
Staff Skill Level A Home Health Agency must provide staff with the skill level designated and
appropriate for each service prescribed in the HCP’s order and approved plan
of care, as authorized by the carrier.
Staff Substitutions If a staff absence occurs, the Home Health Agency is responsible for providing
and assuring that appropriate staff substitutions are made.
Licensure or discipline of the staff substitutions must be equivalent to, or
above, the discipline level specified in the plan of care.
Reimbursement The carrier will reimburse the Home Health Agency at the reimbursement
amounts agreed upon between the Home Health Agency and the carrier prior to
the services being provided in the home.
Billing for Home
Health Agency
Services
The Home Health Agency must bill on the Form DFS-F5-DWC-90 (DWC-90)
and include a copy of its contractual agreement when submitting the billing
form to the carrier for proper reimbursement.
When a Home Health Agency is billing for authorized Home Medical
Equipment (HME), on the DWC-90, a copy of the HCP’s original order for the
HME item(s) must accompany the bill submitted to the carrier.
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31B24BIndependent Medical Examinations
Requirements for
Reimbursement
Components of a physician’s Independent Medical Examination (IME) must
include:
The review of applicable paper medical records,
The review of applicable non-paper medical records, and
The examination of the injured worker with production of a written
report.
Reimbursement
for IME
A physician will be reimbursed by the party requesting the IME.
IME services are reimbursed at an agreed upon contract amount.
Note: The only procedure code for billing an IME is the Workers’
Compensation Unique Procedure Code 99456.
32B25BFailure to Appear
for IME
If an injured worker fails to appear for an IME scheduled by the employer or
carrier, without good cause, and fails to advise the physician at least 24 hours
before the scheduled date for the examination that he or she will not appear, the
physician may bill his or her cancellation or no-show fee to the carrier.
Note: The physician must bill using the Workers’ Compensation Unique
Procedure Code 99456 CN to indicate the injured worker failed to appear or the
appointment was canceled without proper notice.
33B26BConsensus Independent Medical Examination
Requirements for
Reimbursement
Components of a physician’s Consensus Independent Medical Examination
(CIME) must include:
The review of applicable paper and non-paper medical records;
An examination of the injured worker including determination of
MMI;
Assignment of a permanent impairment rating, as appropriate; and
A written report.
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34B26BConsensus Independent Medical Examination, continued
Reimbursement
for CIME
Reimbursement for a CIME will be negotiated between the physician and the
carrier prior to rendering the service. A physician will be reimbursed by the
carrier for a CIME.
Note: CIME service must be billed with the Workers’ Compensation Unique
Procedure Code 99457 for reimbursement.
35B27BMedications
General Policies Medicinal drugs, commonly known as legend or prescription drugs, dispensed
to treat an injured worker must be ordered by an HCP.
Medicinal drugs are dispensed, stored, and sold only by a pharmacist licensed
under Chapter 465, F.S., or a licensed dispensing practitioner according to the
provisions in section 465.0276, F.S.
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Medications, continued
Codes and
Descriptions for
Medications
All HCPs must refer to the HCPCS Level II® Manual in effect for the date
of service when reporting injection procedures, as well as immune
globulin or vaccine products.
All HCPs must use the J codes in the HCPCS Level II® Manual, as
adopted in Rule 69L-7.020, F.A.C., for reporting other injectable
medications.
If the specific medication is not listed in either of these references, the
HCP must bill the medication using the National Drug Code (NDC)
number for reimbursement.
Reimbursement for
Administration of
Injectable
Medication
Reimbursement for injectable medication will be made to an HCP as
follows:
Reimbursement will be made to an HCP using CPT® or HCPCS
Level II® J codes for specific injectable medications and CPT®
codes for the administration of injectable medications.
Reimbursement for the administration of injectable medication(s)
will be made at either the listed MRA in the appropriate schedule
or an agreed upon contract price.
Reimbursement for an injection will include a local anesthetic, if
necessary.
Reimbursement for administration of multiple medications
contained in the same syringe is limited to one administration fee.
Reimbursement will be:
1. At either the agreed upon contract price or the listed MRA,
in Chapter 3, Part A, of this Manual for the first reported
drug; and
2. At either fifty percent (50%) of the listed MRA in the
appropriate schedule for each additional drug or an amount
specified in an agreed upon contract.
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Medications, continued
Reimbursement for
Injectable
Medications
Reimbursement to HCPs for injectable medications provided in the office
will be twenty percent (20%) above the acquisition invoice cost of the
injectable medication based on submission of:
The name, strength, and dosage of the medication, vaccine, or
toxoid; and
Submission of the acquisition invoice.
Medications via
Infusion Pumps
A special reimbursement provision is allowed for identification of the
loading dose of medication(s) administered via infusion pump.
HCPs must utilize an appropriate HCPCS Level II® code when billing.
Reimbursement will be twenty percent (20%) above the documented
acquisition invoice cost of the drug or an agreed upon contract amount
between the HCP and the carrier.
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Medications, continued
Dispensing
Medications
For reimbursement purposes, the dispensing of medicinal drugs will be
limited to a pharmacist or a licensed dispensing practitioner. The
medication must be billed using the NDC number, along with the
Workers’ Compensation Unique Procedure Code DSPNS. The
reimbursement for prescription medications will be:
Average Wholesale Price (AWP) + $4.18 (dispensing fee) = $
Reimbursement
Note: See section 440.13(12)(c), F.S., for the definition of Average
Wholesale Price.
For repackaged or relabeled prescription medications dispensed by an
HCP on or after date of service July 1, 2013, see section 440.13(12)(c),
F.S., to obtain the reimbursement of repackaged prescription medications.
Note: See Rule Chapter 69L-7, F.A.C., for proper billing of repackaged
or relabeled medications.
Compounded
Drugs
Medicinal drugs may be compounded by an authorized pharmacist or an
authorized physician when the drug formulation prescribed is not
commercially available. Dispensing compounded drugs is identified as a
specialty service under section 440.13(3)(i), F.S. Compounded drugs may
not have an NDC number.
Reimbursement
for Compounded
Drugs
The provision and reimbursement of compounded drugs are limited to a
pharmacist or a physician. Compounded drugs must be billed using the
Workers’ Compensation Unique Procedure Code COMPD, along with
submission of a list which contains the NDC number and quantity used for
each component of the compounded product.
Reimbursement is the lesser of:
1. [AWP (of each component)] + $4.18 = Reimbursement; or
2. The amount the carrier has contracted for pursuant to
section 440.13(12)(c), F.S.
Note: Please refer to section 440.13(12)(c), F.S., for the definition
of AWP.
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Medications, continued
Unlisted
Medications
Reimbursement for unlisted medications with no MRA in Chapter 3 of this
Manual, will be twenty percent (20%) above the actual cost of the
medication based on the submission of documentation, which includes:
The name, strength, and dosage of the medication dispensed to the
injured worker; and
The invoice verifying the cost of the medication.
Over the Counter
Drugs
A dispensing practitioner must use the NDC number and submit an invoice
to the carrier that provides the name, dosage, package size, and cost of the
drug(s), including applicable manufacturer’s shipping and handling.
Reimbursement will be made to a pharmacist for dispensing over-the-
counter drugs at the pharmacist’s usual charge for the drug.
Non-
Reimbursable
Drugs and
Supplies
Reimbursement will be made at the HCP’s charge or at an amount not to
exceed twenty percent (20%) above the actual cost of each drug
furnished.
Reimbursement will not be made for oral vitamins, nutrient preparations,
or dietary supplements. Reimbursement will not be made for medical food
pursuant to section 440.13(3)(k), F.S., as defined in 21 U.S.C. s. 360ee (b)
(3), unless the self-insured employer or the carrier in its sole discretion
authorizes the provision of such food. Authorization may be limited by
frequency, type, dosage, and reimbursement amount of such food as part
of a proposed written course of medical treatment.
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HCP Supplies
Reimbursable
Materials and
Supplies
Reimbursement for materials and supplies not incidental to a service or a
procedure will be reimbursed using the specific HCPCS Level II® supply
codes.
Reimbursement is limited to twenty percent (20%) above the acquisition
invoice cost of the material(s) and supply(ies) based on submission of the
documentation that substantiates the HCP’s cost.
Unlisted Supply
Code
When a more specific code is not available for reimbursable materials and
supplies, the HCP must bill using the HCPCS Level II® miscellaneous
supply code A9999 and submit the following documentation:
A detailed description of the supply or material and the unique
medical need for the injured worker; and
A copy of the acquisition invoice to document the cost of the item
billed, including unit(s) of supply and unit pricing information. If
needed, please circle the items on any invoice that are specific to
the injured worker when submitting the medical bill.
Materials and
Supplies Not
Separately
Reimbursed
Material and supplies that are necessary to perform a procedure or service
will be included in the reimbursement for the procedure or service and will
not be reimbursed separately.
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36BHome Medical Equipment and 28BMedical Suppliers
Guidelines and
Requirements
All guidelines and requirements in this Manual are the same for Home
Medical Equipment (HME) providers and medical suppliers.
General
Requirements
Medical supplies and HME must be prescribed by an HCP and may be
provided to an injured worker by an HME provider through rental or
purchase.
Authorization An HME provider or medical supplier must obtain a written or electronic
authorization and a written payment agreement from the carrier prior to
furnishing an injured worker with medical supplies or equipment.
Billing
HME providers or medical suppliers must provide the carrier with a copy
of the HCP’s original order with the medical bill when requesting
reimbursement.
An HME provider or medical supplier is required to bill on the Form
DFS-F5-DWC-10 (DWC-10) using HCPCS Level II® codes. The HME
provider or medical supplier is not required to provide invoices with the
bill to document the acquisition costs of supplies and equipment.
Note: When a specific code is not available to describe the item provided,
bill HCPCS Level II® code A9999. The carrier may provide additional,
specific billing instructions at the time of authorization.
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37BHome Medical Equipment and 28BMedical Suppliers, continued
Reimbursement
Reimbursement is made by the carrier to an HME provider or medical
supplier for rental or purchase of HME and supplies ordered or prescribed by
an HCP according to the written payment agreement obtained at the time of
authorization.
The carrier:
May rent the item from the HME provider or medical supplier for the
injured worker;
May write a provision in the payment agreement that when the amount
received by the HME provider or medical supplier from the rental
payments equals the purchase price, the item will become the property
of the carrier or injured worker; or
May purchase the item from the HME provider or medical supplier.
Limitations for
HME and
Supplies
All additional HME and medical supplies require explicit prior
authorization by the carrier as a requirement for reimbursement.
No reimbursement will be made for HME or medical supplies that are
automatically supplied or refilled by the supplier.
38B29BOphthalmologic Services
General
Reimbursement
Requirements
Reimbursement for ophthalmologic services will be made for all medically
necessary services. Prior authorization from the carrier is required unless
the condition is an emergency situation.
Glasses, Contacts
or Frames
Reimbursement will only be made for glasses, 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 or surgery to correct an injury.
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39B30BPermanent Impairment Ratings (PIR)
Providers Eligible to
Determine
Permanent
Impairment Rating
Only a physician licensed by the Chapters listed in section 440.15(3)(b),
F.S., will be reimbursed by the carrier for addressing Maximum Medical
Improvement (MMI) and the assignment of a Permanent Impairment
Rating (PIR).
Reimbursement
Components and
PIR
The components of a PIR must include an examination that provides:
The evaluation of an injured worker’s condition to establish the
MMI date and PIR of zero (0) percent or greater; and
The systematic completion of the required reporting form, DWC-
25, and submission to the appropriate parties in accordance with
section 440.15(3), F.S.
The DWC-25 does not replace physician notes or other medical records.
The DWC-25 must be fully completed and must document the method(s)
and guide used to assign a PIR.
Reimbursement will not be made for an evaluation and management code
on the same date of service as a PIR.
Note: The procedure code for billing a PIR is the CPT® code 99455.
The Interactive DWC-25 is available at the following link: DWC website
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40B31BPsychiatric and Psychological Services
Providers Eligible
for
Reimbursement
Reimbursement for psychiatric and psychological services will be made by
the carrier to the following HCPs who provide individual psychotherapy
services within the scope of state licensure:
Medical physicians;
Osteopathic physicians;
Psychologists;
Mental health practitioners; or
Other health care practitioners.
Required
Documentation
All psychiatric and psychotherapy procedure codes that are reimbursed
based on face-to-face time with the injured worker must have a beginning
and an ending time documented in the medical record.
Individual
Psychotherapy
Combined with
Evaluation and
Management
Codes
Only an HCP may be reimbursed for individual psychotherapy in
combination with evaluation and management services provided at a
therapy session. Documentation must support the services billed.
An HCP will not be reimbursed for an evaluation and management
procedure code (99201-99499) on the same day that reimbursement is made
for psychotherapy combined with evaluation and management services.
Note: Refer to the CPT® to identify the combined procedure codes.
Multiple
Psychotherapy
Sessions on the
Same Day
When more than one individual psychotherapy session is performed on the
same day, only the session lasting the longest period of time will be
reimbursed.
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Psychiatric and Psychological Service, continued
Family
Psychotherapy
Reimbursement for family psychotherapy, with or without the injured
worker present, will be made if the documentation supports that the purpose
is related to the treatment of the injured worker’s compensable injury.
Reimbursement will not be made for psychiatric or psychological services
provided directly to members of the injured worker’s family for support and
assistance in adjusting to the injured worker’s condition.
Central Nervous
System Testing
Central Nervous System (CNS) Assessment and Testing must be authorized
by the carrier prior to the service being rendered.
Reimbursement of
CNS Testing
Reimbursement will be made for CNS Assessment and Testing when the
documentation includes:
An assessment and administration of a test with
interpretation and a written report;
The number of hours (units of service), supported by the
HCP’s documentation, required to perform the
assessment and testing; and
The procedure code used for billing indicating if the
service is per hour or is all inclusive.
Reimbursement will be the MRA, in Chapter 3 of this Manual, or the
agreed upon contract price.
Behavioral
Assessment
Interventions
Reimbursement will be made for Health and Behavior Assessment and
Intervention Services when authorized by the carrier.
Billing All HCPs must refer to the most specific Health and Behavior Assessment
and Intervention procedure codes when billing for health and behavioral
interventions.
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41B32BRadiology
Reimbursable
Services
Reimbursement will be made for radiology services including diagnostic
radiology (diagnostic imaging), diagnostic ultrasound, and nuclear
medicine.
Components of
Radiology
Reimbursement
Radiology services consist of two components: the technical component
and the professional component.
Technical Component: modifier TC
When the technical component [the actual performance of the radiological
test and the production of the hard copy film(s)] is reported separately, the
service is billed by adding the HCPCS Level II® modifier TC to the
procedure code when requesting payment.
Professional Component: modifier 26
When the professional component (physician interpretation of radiological
test results) is reported separately, the service is billed by adding the
HCPCS Level II® modifier 26 to the procedure code when requesting
payment.
Global Services Global services may be reported when one physician provides both the
technical and the professional components of a radiological procedure or
service. The unmodified 5-digit procedure code is used to identify a global
service inclusive of the professional service and the technical component of
providing that service.
Reimbursement
Policies
Reimbursement will not be made for a professional component (modifier
26) billed in the following situations:
A professional component billed by a physician for x-rays taken and
interpreted by another physician and reviewed during an IME,
CIME, medical visit, or consultation;
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;
A professional component billed by a physician who is not the HCP
that reviewed, interpreted, and signed the radiology report.
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Radiology, continued
Independent
Radiology
Facilities
Reimbursement will be made to an independent radiology facility for the
technical component of the service by appending the HCPCS Level II®
modifier TC to the 5-digit procedure code.
No reimbursement will be made for the professional component of a service
to an independent radiology facility. Only a technical component may be
reimbursed to an independent radiology facility.
The professional component will be billed separately by the HCP that
interprets the radiology exam.
42B33BThermography
Requirements for
Authorization
The carrier will not authorize a physician to perform thermography any
earlier than forty-five (45) calendar days after the date of accident unless
the documentation of medical necessity is submitted to the carrier along
with the request for authorization prior to rendering the service.
Thermography
Limitations
Reimbursement for thermography is limited to one (1) body area; either
major or limited.
Major body areas. (The following areas include all views.)
1. Head,
2. Cervical spine and upper extremities, and
3. Lumbosacral spine and lower extremities.
Limited body areas. (The following areas include all views.)
1. Thoracic spine, and
2. Any portion of a major area.
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Transcutaneous Electrical Neurostimulators (TENS)
Reimbursement
Requirements
An authorization and a written reimbursement agreement must be
obtained from the carrier for rental or purchase of a TENS unit prior to an
HCP furnishing a TENS unit to the injured worker.
Reimbursement will be twenty percent (20%) above the HCP’s
documented cost when the TENS unit is purchased.
A copy of the HCP’s acquisition invoice must be submitted with the bill
to substantiate the HCP cost.
Training Sessions
for TENS
Reimbursement will be made to an HCP for furnishing training to an
injured worker on the application and use of a TENS unit.
Note: Reimbursement is limited to four (4) training sessions per approved
TENS unit. The carrier must designate the number of training sessions
authorized.
43B34BPhysical Medicine and Rehabilitation Services
General
Information
Physical medicine and rehabilitation services will 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
supported in the HCP’s evaluation and in the physical medicine plan of
care.
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34BPhysical Medicine and Rehabilitation Services, continued
Physical
Medicine
Plan of Care
(DWC-25)
The requirement of medically necessary physical medicine services
(i.e., modalities and therapeutic services, physical reconditioning, or
interdisciplinary rehabilitation programs) must be documented on the
DWC-25, submitted to the carrier by the physician, and supported in
the evaluation with a physical medicine plan of care, regardless of
the location where the services are rendered or whether rendered by a
physician or other practitioner.
If the carrier questions the appropriateness of the therapy listed in the
plan of care, the carrier must contact the physician to obtain the
rationale for the ordered therapy prior to authorization.
The physician is responsible for providing the carrier the
documentation of medical necessity for the therapy in order to avoid
unnecessary delays in obtaining authorization for treatment or in
initiating therapy.
Covered Services Carriers will reimburse HCPs, as specified in this Manual, for the
following physical medicine and rehabilitation services provided to
injured workers for a compensable injury/illness:
Modalities and therapeutic procedures applied to acute
injuries to reduce symptoms, restore function, and return the
injured worker to work.
Physical reconditioning focused on injuries requiring
intensive physical reconditioning services to restore the
injured worker to pre-injury level of physical health and
function. The goal will be for the worker to return to a job
and/or become physically reconditioned.
Interdisciplinary rehabilitation programs covering a variety of
services that are coordinated, outcome focused, and directed
at the injured worker’s needs to increase functioning or return
to work.
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34BPhysical Medicine and Rehabilitation Services, continued
Authorization of
Services
Reimbursement will only be made for physical medicine, therapeutic
procedures, modalities, and rehabilitation services up to six (6) months
after the date of accident, based on a signed order or referral from an
HCP.
Exceptions to
Limitations
Exceptions may be made to the above limitation when the HCP provides
documented, objective, relevant medical findings that demonstrate the
following:
The injured worker has a specifically defined, relevant clinical
dysfunction, consistent with the patient classifications outlined in
Chapter 1 of this Manual, that is reasonably expected to respond
to the requested physical medicine modalities or procedures; and
The injured worker does not conform to either the Level II or
Level III patient classifications based on specific documentation
of the following:
1. No systemic musculoskeletal deficit (strength, flexibility,
endurance, coordination) or substantive functional loss
requiring an intensive physical reconditioning program;
2. No behavioral or psychological issues that present a
substantive factor in the rehabilitation effort or outcome;
3. No significant vocational or return to work issues; and
4. No significant disparity between the injured worker’s
subjective complaints, response to intervention, and other
relevant clinical indicators when compared with
documented, objective, relevant medical findings.
Note: See Classification of an Injured Worker’s Treatment/Status in
Chapter 1 of this Manual.
Service
Limitations
Reimbursement for physical medicine services is limited to one visit per
day, unless additional visits are authorized by the carrier.
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34BPhysical Medicine and Rehabilitation Services, continued
Physical
Medicine Initial
Evaluation
Reimbursement for an initial evaluation by an HCP will be billed as
an evaluation and management service.
Reimbursement for an initial evaluation by a therapist will be billed
using procedure codes 97161 – 97163, based on the complexity of
the evaluation. Documentation must support the time spent with the
injured worker.
Separate reimbursement will not be made to an HCP and to a
therapist for an evaluation by each on the same date of service.
Reimbursement for an initial evaluation will include the evaluation
and a plan of care or treatment.
Note: Documentation of the evaluation and preparation of a plan of
care, approved by the HCP, must be submitted to the carrier with
the medical bill. At a minimum, the documentation must include:
The evaluation findings, including any functional
limitations;
The proposed therapy, specifying the frequency and
duration of services; and
The anticipated degree of restoration of function with
measurable goals.
Physical Medicine
Re-Evaluation by a
Therapist
Reimbursement will be made for a re-evaluation by a therapist, no
more than once every four (4) weeks, when ordered by an HCP and
documented on the DWC-25.
Re-evaluations must be billed using procedure code 97164.
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Physical Medicine and Rehabilitation Services, continued
Evaluation by an
Athletic Trainer
Reimbursement for an initial evaluation by an athletic trainer will be
made only after a referral from an HCP and must be billed using
procedure code(s) 97169 – 97171, according to the level of complexity.
Documentation must support the time spent with the injured worker.
Separate reimbursement will not be made to an HCP and to an athletic
trainer for an evaluation by each on the same date of service.
Reimbursement for an initial evaluation by an athletic trainer must
include the evaluation and a plan of care or treatment.
Re-Evaluation by
an Athletic
Trainer
Reimbursement will be made for a re-evaluation by an athletic trainer,
no more than once every four (4) weeks, when ordered by an HCP and
documented on the DWC-25.
Re-evaluations must be billed using procedure code 97172.
Evaluation by an
Occupational
Therapist
Reimbursement for an initial evaluation by an occupational therapist
will be made only after a referral from an HCP. The therapist must bill
using procedure code(s) 97165 – 97167, according to the level of
complexity, and documentation must support the time spent with the
injured worker.
Separate reimbursement will not be made to an HCP and to an
occupational therapist for an evaluation by each on the same date of
service.
Reimbursement for an initial evaluation by an occupational therapist
must include the evaluation and a plan of care or treatment.
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Physical Medicine and Rehabilitation Services, continued
Re-Evaluation by
an Occupational
Therapist
Reimbursement will be made for a re-evaluation by an occupational
therapist, no more than once every four (4) weeks, when ordered by an
HCP and documented on the DWC-25. Re-evaluations must be billed
using procedure code 97168.
Revised Plan of
Care
The physician must prepare and submit to the carrier a revised
DWC-25 to document the change in care or treatment.
Modalities and
Therapeutic
Procedures
Reimbursement to an HCP will 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.
Codes 97010-97028 will 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.
Codes 97032-97542 will each equal one (1) reimbursable unit of
service for each fifteen (15) minute increment of service performed.
Code 97150 will be restricted to one (1) reimbursable unit of service
per visit.
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Physical Medicine and Rehabilitation Services, continued
Manipulative
Treatment
Reimbursement to a physician for a manipulative treatment will be
limited to:
One (1) visit per day, and
Two (2) body regions per visit.
Each of the following is one body region:
The entire spine.
Head.
Two (2) upper extremities.
Two (2) lower extremities.
One (1) upper and one (1) lower extremity.
Rib cage.
Abdomen.
Spinal Manipulation
by a Physician
The entire spine will be reimbursed as one (1) region for Workers’
Compensation even though there are five (5) spinal regions:
Cervical,
Thoracic,
Lumbar,
Sacral, and
Pelvic.
Reimbursement will be made to a physician for spinal manipulation
when billed using procedure code 97260.
Manipulation of
Extra-Spinal
Regions
Procedure code 97261 will be reimbursed when a physician performs a
manipulation treatment on the following:
Head region,
Lower extremities,
Upper extremities,
One upper and one lower extremity,
Rib cage and abdomen, and
Viscera region.
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Physical Medicine and Rehabilitation Services, continued
Osteopathic
Manipulative
Treatment
Reimbursement for osteopathic manipulative treatment to the
two (2) body regions, spinal and extra-spinal, listed in this Chapter
will be made for procedure codes 98926 and 98928, respectively.
Reimbursement will be made for code 98926 when used to bill for a
spinal manipulation. The spine will be reimbursed as one (1) region
for Workers’ Compensation, although there are five (5) spinal regions
(cervical, thoracic, lumbar, sacral, and pelvic).
Reimbursement will be made for procedure code 98928 when used for
manipulation to the head region; lower extremities; upper extremities;
one upper and one lower extremity; rib cage and abdomen; and viscera
region.
Chiropractic
Manipulative
Treatment
Reimbursement for chiropractic manipulative treatment to two (2)
regions, spinal and extra-spinal, listed in this section will be made
when billed with procedure codes 98941 and 98943, respectively.
Chiropractic Spinal
Manipulations
Reimbursement will be made for procedure code 98941 when used to
bill for a spinal manipulation. The spine will be reimbursed as one (1)
region for Workers’ Compensation, although there are five (5) spinal
regions: cervical region (includes atlanto-occipital joint), thoracic
region (includes costo-vertebral and costo-transverse joints), lumbar
region, sacral region, and pelvic (sacroiliac joint) region.
Chiropractic Extra-
Spinal
Manipulations
Reimbursement will be made for procedure code 98943, when used to
bill for a manipulation to an extra-spinal region: head (including
temporomandibular joint, excluding atlanto-occipital), lower
extremities, upper extremities, rib cage (excluding costotransverse and
costovertebral joints), and abdomen.
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Physical Medicine and Rehabilitation Services, continued
44B35BAcupuncture
Providers Eligible for
Reimbursement
Reimbursement for acupuncture will be made to an HCP
specifically licensed by the DOH to diagnose and treat with
acupuncture.
Reimbursement
Requirements
Reimbursement for acupuncture or electro-acupuncture service is
based on fifteen (15) minute increments of face-to-face contact
with the injured worker during a session.
Each treatment session consists of only one (1) initial fifteen
minute (15 minute) increment.
If additional time is required to be reported, use the appropriate
add-on codes.
Reinsertion of the acupuncture needle(s) is required for the use of
acupuncture add-on codes.
Acupuncture Limitations Reimbursement is limited to one visit per day.
Only one (1) initial acupuncture treatment procedure code may be
billed per injured worker per visit.
Note: An HCP may not bill the initial acupuncture treatment both
with electrical stimulation and without electrical stimulation for the
same visit.
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45BPhysical Medicine and Rehabilitation Services, continued
46B36BOrthotics and Prosthetics
Reimbursement
Policies
All prosthetic or orthotic devices must be prescribed by the authorized
physician.
Reimbursement will only be made to a licensed orthotics or prosthetics
providers, occupational therapists or physical therapist providers for
custom fabricated orthotic or prosthetic device(s) when they bill on the
DWC-9 and directly provide the service. If the licensed provider is
employed by an HME provider, medical supplier, Home Health Agency,
or any other employer, the bill is submitted by the employing party.
Orthotics and prosthetics must be billed using HCPCS Level II® codes
that specifically describe the device(s).
Reimbursement Prior written authorization by the carrier is a requirement for
reimbursement of fabricated orthotics and prosthetics.
Reimbursement for orthotics and prosthetics will be By Report (BR).
Orthotic Fitter
and Orthotic
Fitter Assistant
Orthotic Fitters and Orthotic Fitter Assistants may be reimbursed for
services provided within the scope of their licensure that are prescribed by
a licensed HCP.
These services must be billed on the DWC-9 claim form using HCPCS
Level II® codes that specifically describe the service or supply provided.
The DOH license number of the Orthotic Fitter or Orthotic Fitter
Assistant must be on the claim form in Field 33b.
If the licensed HCP is employed by an HME supplier, Home Health
Agency, or any other employer, the bill must be submitted by the
employing party.
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47BPhysical Medicine and Rehabilitation Services, continued
48B37BTests and Measurements
General Policies &
Limitations
Reimbursement to an HCP will be limited to one (1) visit by an injured
worker per thirty (30) calendar 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 authorized physician and
approved by the carrier.
Billing HCPs must bill using the Workers’ Compensation Unique Procedure Code
97752, specifically designated for both manual and automated testing.
Reimbursement Reimbursement for tests and measurements must include a written report
of the testing results.
Manual muscle testing procedure codes and range of motion procedure
codes will not be reimbursed when reported separately with procedure
code 97752.
Reimbursement will be made for range of motion measurements.
38B
Physical Reconditioning Services
Providers Eligible
for
Reimbursement
Reimbursement for physical reconditioning services will only be made to
an authorized occupational therapist, physical therapist, or athletic trainer.
Authorization
Reimbursement will only be made for carrier authorized physical
reconditioning based on a signed order from the HCP.
Physical reconditioning services must be authorized by the carrier prior to
initiation and must not begin any earlier than thirty (30) calendar days after
the injured worker’s date of accident.
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49B38BPhysical Reconditioning Services, continued
Physical
Reconditioning
Assessment
Reimbursement for a physical reconditioning assessment and written report
will be determined from the number of hours reported by the HCP to
perform the assessment and the listed MRA.
Note: Reimbursement is limited to eight (8) hours for the assessment and
report.
Billing and
Reimbursement
for Physical
Reconditioning
Reimbursement will be made for Workers’ Compensation Unique
Procedure Codes 97850 and 97851, specifically designated for use in
reporting a physical reconditioning assessment.
Reimbursement will be made for procedure code 97850 when it is used to
bill for the initial hour of a physical reconditioning assessment.
Reimbursement will be made for procedure code 97851 for each additional
thirty (30) minutes of a physical reconditioning assessment subsequent to
procedure code 97850.
Reimbursement for a physical reconditioning program will be paid based on
the number of hours documented by the HCP and the listed MRA.
Note: Reimbursement will be limited to a program lasting no longer than
sixty (60) hours during a six (6) week period, which includes a physical
reconditioning assessment.
Reimbursement will be made for Workers’ Compensation Unique
Procedure Codes 97852 and 97853, specifically designated for use in
reporting a physical reconditioning program.
Reimbursement will be made for procedure code 97852 when used to bill
the initial per hour session of physical reconditioning each day.
Reimbursement will be made for procedure code 97853 when used to bill
each additional thirty (30) minutes per session of physical reconditioning
each day.
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50B38BPhysical Reconditioning Services, continued
Multiple
Therapies by the
Same Provider
Reimbursement will be made for a physical reconditioning program when
the services are provided alone, along with, or subsequent to modalities and
procedures by the same authorized occupational therapist or physical
therapist.
Limitations Reimbursement will be made to a therapist or athletic trainer for only one
(1) physical reconditioning program for an injured worker per date of
accident, unless authorized by the carrier for an exacerbation of the injury
or surgical intervention, as documented by the authorized physician.
Note: Reimbursement for an extension of a physical reconditioning
program will be limited to reimbursement of an additional twenty (20)
hours during a two (2) week period.
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51B40BChapter 2 Medical Services, continued
Interdisciplinary Rehabilitation Programs
Authorization
Reimbursement will only be made to an interdisciplinary rehabilitation
facility for carrier authorized interdisciplinary services based on a signed
order from the HCP.
Exceptions to
Policies
Approval beyond the policies provided in this section must be obtained
from the carrier, in writing, prior to an HCP furnishing the service. Any
unusual circumstances must be documented and forwarded by the HCP to
the carrier for review before an exception to the policies can be considered
and a determination made by the carrier to authorize additional services.
CARF
Accreditation
Requirements
Reimbursement for Interdisciplinary Rehabilitation Programs will 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.
Work
Hardening
Programs
Reimbursement for a work hardening program will be made to a facility for
the duration of the recommended individualized program. Procedure codes
97545 and 97546 are specifically designated to use exclusively in reporting
the services of a work hardening program as follows:
Bill the initial two (2) hours of a work hardening program each day
using procedure code 97545, and
Bill each additional hour of a work hardening program each day
using procedure code 97546.
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Interdisciplinary Rehabilitation Programs, continued
Pain Programs Reimbursement for an interdisciplinary pain management program will be
made to a facility for the recommended time indicated in the injured
worker’s program plan.
Pain Program
Components
The services provided must relate to the physical, psychological, social,
functional, and vocational goals of the injured worker’s program plan.
Services billed must address all of these components in the documentation
submitted to the carrier for reimbursement.
Reimbursement
for Pain Programs
Reimbursement will 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.
Discharge from an
Interdisciplinary
Program
The facility’s program director must determine if the injured worker will
be discharged from the work hardening or pain program before
completion. If the injured worker has not completed the program and the
program director recommends discontinuance of the program, the program
director will provide discharge information to the injured worker, the
carrier, and the authorized physician without charge.
Discharge Report Upon program completion, a report shall be sent by the facility’s program
director, without charge, to the authorized physician and to the carrier with
the final bill. The report will include:
The injured worker’s current clinical status and plan for transition
from the program, and
Return to work recommendations and functional limitations.
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Interdisciplinary Rehabilitation Programs, continued
Functional
Capacity
Evaluation
Reimbursement for a carrier authorized Functional Capacity Evaluation
(FCE) will be made at any time in the clinical continuum, as long as the
evaluation protocol matches the scope and specificity of the clinical
situation and referral question(s).
Note: See Patient Classification System in Chapter 1 of this Manual.
Requirements for
FCE
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).
Note: Reimbursement will only be made when a physical therapist or
occupational therapist is directly or actively involved with the testing
protocol, although additional professional personnel may be involved as
well.
Billing and
Reimbursement
for FCE
The provider must provide written results of the evaluation and
recommendations to the injured worker, the carrier and the authorized
physician without additional charge. The reimbursement for FCE includes
a written program plan and a written report.
Note: The Workers’ Compensation Unique Procedure Code 97750 is
designated for billing a FCE using the DWC-9 form.
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52B41BSurgical Services
General
Reimbursement
Information
General reimbursement information from an authoritative resource is used
to determine any limitations or reductions from the MRAs in Chapter 3.
All procedure codes having indicators for multiple surgery pricing rules,
bilateral surgery pricing rules, assistant at surgery, co-surgeon, team
surgery, and information are found in an authoritative resource, such as the
National Physician Fee Schedule Relative Value File, copyrighted by the
American Medical Association. The Relative Value File is available from
the American Medical Association, 515 N. State Street, Chicago, IL 60610,
or by calling 1-800-621-8335. These indicators will be used to determine
reimbursement by the Division.
Global Surgical
Package
Reimbursement for a surgical package (global reimbursement) will include
the provision of certain services before and after surgery. Examples of
these services include:
The immediate preoperative visit;
Local infiltration, metacarpal/metatarsal/digital block or topical
anesthesia;
The surgical procedure;
Immediate postoperative care, including dictating operative notes,
talking with the family and other physicians;
Writing orders;
Evaluating the patient in the post-anesthesia recovery area;
Postoperative follow-up care; and
The time period for routine follow-up care related to the surgical
procedure is listed in the Follow-Up Days (FUD) column in
Chapter 3, Part B, of this Manual.
1. Reimbursement for a procedure code with a ZZZ designation
for the global period will be the same as the other procedure
code that is billed in conjunction with this “add-on”
procedure code.
2. Reimbursement for a procedure code with a YYY
designation in the global period will be set by the carrier.
Note: The MRA to a physician for surgical procedures can be found in
Chapter 3, Part B, of this Manual.
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Surgical Services, continued
Services
Reimbursed in
Addition to Global
Package
Reimbursement will be made for other services in addition to the surgical
package only in the following situations:
The preoperative visit is the initial visit made by the surgeon, when
an evaluation is necessary to prepare an injured worker for an
unscheduled surgery and when there is a need to establish the
reason for a particular type of surgery;
The preoperative visit by the surgeon is a consultation for
unscheduled surgery;
The preoperative services are not part of the usual preparation for
the particular surgical procedure; or
The services are to treat complications, exacerbations, recurrences,
or other diseases and injuries. Documentation substantiating the
medical necessity of the additional services rendered must be
submitted with the medical bill.
Surgery
Performed During
Post-Op Period
Reimbursement for surgical services will be made when an additional
surgery is performed during the postoperative period of another surgical
procedure.
Reimbursement for normal postoperative care must run concurrently and
must be made according to the separate FUD periods listed in Chapter 3,
Part B, of this Manual, unless it is a procedure code with the YYY
designation. For these codes, the FUD period will be set by the carrier.
Assistant Surgeon Reimbursement for an assistant surgeon will be twenty-five percent (25%)
of the physician reimbursement listed in the MRAs in Chapter 3, Part B, of
this Manual. The services provided must be identified by appending the
modifier 80 to the specific procedure code.
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Surgical Services, continued
Non-Physician
Surgical Assistants
Reimbursement will be made to a non-physician surgical assistant for surgical
services. Non-physician surgical assistants include: physician assistants,
advanced registered nurse practitioners, and registered nurse first assistants.
Billing
Requirements for
Non-Physician
Surgical Assistants
The surgical procedure code(s) must be appended with the HCPCS Level II®
modifier AS to identify services rendered by a non-physician surgical
assistant at surgery.
Non-physician surgical assistants must follow the billing requirements in
Rule 69L-7.730, F.A.C.
The non-physician surgical assistant must provide his or her DOH license
number in Field 33b on the DWC-9 medical bill form.
Note: No reimbursement is made to non-physician surgical assistants
employed by hospitals.
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Surgical Services, continued
Reimbursement
for Non-Physician
Surgical Assistants
Reimbursement will be made for non-physician surgical assistants
performing surgical services. Reimbursement will be seventy-five percent
(75%) of twenty-five percent (25%) of the physician MRA listed in
Chapter 3, Part B, of this Manual, when the carrier has determined:
The non-physician meets state licensure requirements, and either
Written authorization to the non-physician surgical assistant was
provided by the carrier prior to the surgery, or
During a medical emergency, a physician was not available to
assist at surgery.
Procedure codes having indicators for multiple surgery pricing rules,
bilateral surgery pricing rules, assistant at surgery, co-surgeon, team
surgery, and other reimbursement information shall be utilized for
determining reimbursement for all procedure codes. These indicators will
come from an authoritative resource, such as the National Physician Fee
Schedule Relative Value File, copyrighted by the American Medical
Association. The Relative Value File is available from the American
Medical Association, 515 N. State Street, Chicago, IL 60610, or by calling
1-800-621-8335. These indicators will be used to determine
reimbursement by the Division.
Two Surgeons
Distinct Parts
Reimbursements will be made to two (2) surgeons during the same
operative session for performing distinct parts of a surgical procedure.
The services provided must be identified by the same procedure code with
modifier 62 appended.
Two Surgeons
Separate
Procedures
Reimbursement will be made to two (2) surgeons for rendering separate
surgical procedures during the same operative session. The services must
be identified by billing different, unmodified procedure codes.
Reimbursement to each surgeon will be:
The listed MRA in Chapter 3, Part B, of this Manual; or
The agreed upon contract price.
Note: Reimbursement will not be made to either surgeon until the carrier
has received and reviewed each surgeon’s bill and individual operative
reports.
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Chapter 2 Medical Services, continued
Surgical Services, continued
Surgical Team Reimbursement for a surgical team will be made By Report (BR) to each
team member for each surgeon’s surgical service.
Each team member must identify the specific procedure they provided by
appending modifier 66 to the procedure code(s) billed.
Note: Reimbursement will not be made until all surgical bills and
individual operative reports are received and reviewed by the carrier.
Billing and
Reimbursement
for Multiple
Surgical
Procedures
Reimbursement will be made for all medically necessary surgical
procedures when more than one (1) procedure is performed at a single
operative session.
Each procedure performed must be identified by use of the appropriate
five-digit CPT® code and listed separately.
The primary, or most significant, procedure must be reported first.
Each additional procedure code must be listed separately and reported with
a modifier 51.
Reimbursement for the primary surgical procedure will be the MRA listed
in Chapter 3, Part B, of this Manual or the agreed upon contract price.
Reimbursement for additional surgical procedure(s) will be fifty percent
(50%) of the listed MRA in Chapter 3, Part B, of this Manual or the agreed
upon contract price.
Note: Designated add-on procedure codes, listed in the CPT® Manual, are
exempt from modifier 51 billing and the multiple surgery pricing reduction
rules. Add-on procedure codes must not be billed with a modifier 51.
Designated add-on procedure codes must be billed immediately following
their primary procedure codes for proper identification and reimbursement.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 70 Effective Date: _______
Chapter 2 Medical Services, continued
Surgical Services, continued
Billing and
Reimbursement
for Procedures
Listed as Bilateral
Bilateral procedures that are listed as “bilateral” in the CPT® description are
exempt from modifier 50.
Bill using the five-digit procedure code only.
Reimbursement will be:
The MRA listed in Chapter 3, Part B, in this Manual; or
The agreed upon contract price.
Billing and
Reimbursement
for Bilateral
Procedures Not
Listed as Bilateral
Procedures performed bilaterally that do not contain the word “bilateral” in
CPT® require a modifier to identify they were performed bilaterally for
proper reimbursement. Bill the five-digit procedure code on one line only
using modifier 50.
Reimbursement for a bilateral procedure code that does not include the word
“bilateral” in the description will only be made when the payment policy
indicators from an authoritative resource, such as the National Physician Fee
Schedule Relative Value File, allows bilateral reimbursement.
If the payment policy indicator allows bilateral reimbursement, the
maximum reimbursement amount will be:
One hundred and fifty percent (150%) of the MRA, unless otherwise
stated in this Manual; or
The agreed upon contract price.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 71 Effective Date: _______
Chapter 2 Medical Services, continued
Surgical Services, continued
Billing and
Reimbursement
for Bilateral
Procedures as
Multiple Surgery
All bills must contain:
The primary procedure code on the first line without modifier 51;
Bill additional procedure code(s) using modifier 51 to indicate
multiple procedures performed during the same operative session;
and
Bill bilateral procedure code(s), using modifier 50 in the first
modifier position, followed by modifier 51 in the second modifier
position, where appropriate.
Reimbursement for these bilateral, multiple surgery codes will be according
to the multiple surgery discount rules.
Note: Add-on procedure codes, listed in the CPT® Manual, are exempt from
modifier 51 billing and from the multiple surgery pricing reduction rules.
Add-on procedure codes must not be billed with a modifier 51.
Billing and
Reimbursement
for Bilateral
Procedures
Performed
Unilaterally
When a procedure is listed in the CPT® as a bilateral-procedure, but is
performed unilaterally, the procedure must be identified with a modifier 52.
Reimbursement will be either:
Fifty percent (50%) of the MRA listed in Chapter 3, Part B, of this
Manual; or
The agreed upon contract amount for a bilateral procedure.
Terminated
Procedures
A bill submitted for reimbursement of a terminated surgery must include
documentation that specifies the following:
Reason for termination of surgery;
Services, reported by CPT® code, that were actually performed;
Supplies actually provided;
Supplies not provided that would have been provided if the surgery
had not been terminated;
Time actually spent by the HCP in each stage, e.g. pre-operative,
operative, and post-operative;
Time that would have been spent in each of these stages if the
surgery had not been terminated; and
Modifier 53 must be added to the procedure code(s) to identify the
circumstances under which the services were terminated.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 72 Effective Date: _______
Chapter 2 Medical Services, continued
Surgical Services, continued
Reimbursement for
Terminated Procedures
Terminated Procedures will be reimbursed as follows:
No reimbursement will be made for a procedure that is
terminated either for medical or non-medical reasons before
the pre-operative procedures are initiated by staff.
Reimbursement will be fifty percent (50%) of the amount
allowed for the procedure(s), according to the policies in this
Manual, if a procedure is terminated due to the onset of
medical complications after the patient has been taken to the
operating suite, but before anesthesia has been induced.
Payment will be fifty percent (50%) of the amount allowed for
the procedure(s), according to policies in this Manual, if a
medical complication arises which causes the procedure to be
terminated after induction of anesthesia.
Modifier 51 Exempt A procedure code that is “Modifier 51 Exempt” is an HCPCS Level
II® or CPT® code typically performed in addition to a primary
procedure code of the same or similar description. These additional
procedure codes are summarized, but not completely identified, in the
CPT codebook incorporated by reference in Rule 69L-7.020, F.A.C.
“Modifier 51 Exempt” procedure codes do not require modifier 51 in
Field 24D on the DWC-9 claim form and are reimbursed 100% of the
MRA.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 73 Effective Date: __________
3B2BChapter 3 Maximum Reimbursement Allowances
General
Instructions
This chapter establishes the MRAs for services and procedures performed by
Florida workers’ compensation HCPs and for out-of-state providers who
have not contracted with the carrier for alternate reimbursement.
Part A Part A establishes the MRAs for services and procedures performed by
workers’ compensation HCPs not specifically addressed in this Manual and
for out-of-state providers who have not contracted with the carrier for
alternate reimbursement.
Part A includes the basic value (or base unit) on which reimbursement will
be calculated for all anesthesia services according to this Manual.
Part A also includes the MRAs for dental codes and injectable medications.
Part B Part B establishes the MRAs for Florida physicians who provide surgical
procedures and services. Physician assistants and advanced registered nurse
practitioners will be paid eighty-five percent (85%) of the physician’s MRA
when these non-physician providers directly perform the surgical procedure
or service.
Part C
Part C establishes the MRAs for Florida physicians, physical and
occupational therapists, athletic trainers, audiologists, speech pathologists,
and psychologists who provide non-surgical procedures and services.
Physician assistants and advanced registered nurse practitioners will 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 includes the reimbursement for other health services. Independent
clinical laboratories and freestanding imaging/x-ray centers are reimbursed at
the technical component (TC), non-facility MRA. Dietitians, nutritionists,
and nutrition counselors are reimbursed eighty-five percent (85%) of the
physician’s MRA and clinical social workers are reimbursed seventy-five
percent (75%) of the physician’s MRA.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 74 Effective Date: _______
Chapter 3 Maximum Reimbursement Allowances, continued
Determining the MRA
To determine the MRA that an HCP is entitled under Part B or Part C:
A. Determine the county location of the HCP according to the
Medicare locality map in Appendix C.
B. Determine whether the procedure should be paid according to
the non-facility MRA (services rendered in an HCP’s office,
urgent care center, diagnostic facility, nursing home, home
health agency, or home) or the facility MRA (services rendered
in a hospital setting, ambulatory surgical center, skilled nursing
facility, inpatient psychiatric facility, or 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 column.
F. Reimbursement will be the greater of the amount in the 2003
MRA column or the amount in the column at the point of
intersection.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
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THIS PAGE INTENTIONALLY LEFT BLANK
2017 Edition Page 76 Effective Date: ________
Chapter 3 Maximum Reimbursement Allowances, continued
PART A
SCHEDULE OF MAXIMUM REIMBURSEMENT
ALLOWANCES
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 77
Anesthesia Anesthesia Anesthesia
CPT Code BV + TM CPT Code BV + TM CPT Code BV + TM
00100 5 + TM 00528 8 + TM 00842 4 + TM
00102 6 + TM 00529 11 + TM 00844 7 + TM
00103 5 + TM 00530 4 + TM 00846 8 + TM
00104 4 + TM 00532 4 + TM 00848 8 + TM
00120 5 + TM 00534 7 + TM 00851 6 + TM
00124 4 + TM 00537 10 + TM 00860 6 + TM
00126 4 + TM 00539 18 + TM 00862 7 + TM
00140 5 + TM 00540 12 + TM 00864 8 + TM
00142 4 + TM 00541 15 + TM 00865 7 + TM
00144 6 + TM 00542 15 + TM 00866 10 + TM
00145 6 + TM 00546 15 + TM 00868 10 + TM
00147 6 + TM 00548 17 + TM 00870 5 + TM
00148 4 + TM 00550 10 + TM 00872 7 + TM
00160 5 + TM 00560 15 + TM 00873 5 + TM
00162 7 + TM 00562 20 + TM 00880 15 + TM
00164 4 + TM 00563 25 + TM 00882 10 + TM
00170 5 + TM 00566 25 + TM 00902 5 + TM
00172 6 + TM 00567 18 + TM 00904 7 + TM
00174 6 + TM 00580 20 + TM 00906 4 + TM
00176 7 + TM 00600 10 + TM 00908 6 + TM
00190 5 + TM 00604 13 + TM 00910 3 + TM
00192 7 + TM 00620 10 + TM 00912 5 + TM
00210 11 + TM 00625 13 + TM 00914 5 + TM
00211 10 + TM 00626 15 + TM 00916 5 + TM
00212 5 + TM 00630 8 + TM 00918 5 + TM
00214 9 + TM 00632 7 + TM 00920 3 + TM
00215 9 + TM 00635 4 + TM 00921 3 + TM
00216 15 + TM 00640 3 + TM 00922 6 + TM
00218 13 + TM 00670 13 + TM 00924 4 + TM
00220 10 + TM 00700 4 + TM 00926 4 + TM
00222 6 + TM 00702 4 + TM 00928 6 + TM
00300 5 + TM 00730 5 + TM 00930 4 + TM
00320 6 + TM 00740 5 + TM 00932 4 + TM
00322 3 + TM 00750 4 + TM 00934 6 + TM
00350 10 + TM 00752 6 + TM 00936 8 + TM
00352 5 + TM 00754 7 + TM 00938 4 + TM
00400 3 + TM 00756 7 + TM 00940 3 + TM
00402 5 + TM 00770 15 + TM 00942 4 + TM
00404 5 + TM 00790 7 + TM 00944 6 + TM
00406 13 + TM 00792 13 + TM 00948 4 + TM
00410 4 + TM 00794 8 + TM 00950 5 + TM
00450 5 + TM 00796 30 + TM 00952 4 + TM
00454 3 + TM 00797 11 + TM 01112 5 + TM
00470 6 + TM 00800 4 + TM 01120 6 + TM
00472 10 + TM 00802 5 + TM 01130 3 + TM
00474 13 + TM 00810 5 + TM 01140 15 + TM
00500 15 + TM 00820 5 + TM 01150 10 + TM
00520 6 + TM 00830 4 + TM 01160 4 + TM
00522 4 + TM 00832 6 + TM 01170 8 + TM
00524 4 + TM 00840 6 + TM 01173 12 + TM
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CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 78
Anesthesia Anesthesia Anesthesia
CPT Code BV + TM CPT Code BV + TM CPT Code BV + TM
01180 3 + TM 01630 5 + TM 01951 3 + TM
01190 4 + TM 01634 9 + TM 01952 5 + TM
01200 4 + TM 01636 15 + TM 01953 1 + TM
01202 4 + TM 01638 10 + TM 01960 5 + TM
01210 6 + TM 01650 6 + TM 01961 7 + TM
01212 10 + TM 01652 10 + TM 01962 8 + TM
01214 8 + TM 01654 8 + TM 01963 10 + TM
01215 10 + TM 01656 10 + TM 01967 5 + TM
01220 4 + TM 01670 4 + TM 01968 3 + TM
01230 6 + TM 01680 3 + TM 01969 5 + TM
01232 5 + TM 01682 4 + TM 01990 0
01234 8 + TM 01710 3 + TM 01991 3 + TM
01250 4 + TM 01712 5 + TM 01992 5 + TM
01260 3 + TM 01714 5 + TM 01996 3
01270 8 + TM 01716 5 + TM 01999 BR
01272 4 + TM 01730 3 + TM
01274 6 + TM 01732 3 + TM
01320 4 + TM 01740 4 + TM
01340 4 + TM 01742 5 + TM
01360 5 + TM 01744 5 + TM
01380 3 + TM 01756 6 + TM
01382 3 + TM 01758 5 + TM
01390 3 + TM 01760 7 + TM
01392 4 + TM 01770 6 + TM
01400 4 + TM 01772 6 + TM
01402 7 + TM 01780 3 + TM
01404 5 + TM 01782 4 + TM
01420 3 + TM 01810 3 + TM
01430 3 + TM 01820 3 + TM
01432 6 + TM 01829 3 + TM
01440 8 + TM 01830 3 + TM
01442 8 + TM 01832 6 + TM
01444 8 + TM 01840 6 + TM
01462 3 + TM 01842 6 + TM
01464 3 + TM 01844 6 + TM
01470 3 + TM 01850 3 + TM
01472 5 + TM 01852 4 + TM
01474 5 + TM 01860 3 + TM
01480 3 + TM 01916 5 + TM
01482 4 + TM 01920 7 + TM
01484 4 + TM 01922 7 + TM
01486 7 + TM 01924 6 + TM
01490 3 + TM 01925 8 + TM
01500 8 + TM 01926 10 + TM
01502 6 + TM 01930 5 + TM
01520 3 + TM 01931 7 + TM
01522 5 + TM 01932 7 + TM
01610 5 + TM 01933 8 + TM
01620 4 + TM 01935 5 + TM
01622 4 + TM 01936 5 + TM
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CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 79
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
10021 $90.00 0 11401 $114.00 10 11762 $223.00 10
10022 $92.00 0 11402 $145.00 10 11765 $65.00 10
10030 $791.00 0 11403 $178.00 10 11770 $275.00 10
10035 $544.00 0 11404 $200.00 10 11771 $496.00 90
10036 $473.00 ZZZ 11406 $246.00 10 11772 $585.00 90
10040 $54.00 10 11420 $98.00 10 11900 $33.00 0
10060 $53.00 10 11421 $92.00 10 11901 $37.00 0
10061 $133.00 10 11422 $157.00 10 11920 $147.00 0
10080 $65.00 10 11423 $163.00 10 11921 $172.00 0
10081 $203.00 10 11424 $221.00 10 11922 $40.00 ZZZ
10120 $53.00 10 11426 $303.00 10 11950 $107.00 0
10121 $169.00 10 11440 $105.00 10 11951 $114.00 0
10140 $53.00 10 11441 $102.00 10 11952 $155.00 0
10160 $45.00 10 11442 $174.00 10 11954 $165.00 0
10180 $164.00 10 11443 $221.00 10 11960 $829.00 90
11000 $45.00 0 11444 $276.00 10 11970 $632.00 90
11001 $27.00 ZZZ 11446 $344.00 10 11971 $280.00 90
11004 $564.00 0 11450 $282.00 90 11976 $123.00 0
11005 $768.00 0 11451 $366.00 90 12001 $84.00 0
11006 $710.00 0 11462 $264.00 90 12002 $98.00 0
11008 $289.00 ZZZ 11463 $351.00 90 12004 $122.00 0
11010 $348.00 10 11470 $320.00 90 12005 $165.00 0
11011 $432.00 0 11471 $391.00 90 12006 $203.00 0
11012 $597.00 0 11600 $148.00 10 12007 $339.00 0
11042 $88.00 0 11601 $180.00 10 12011 $98.00 0
11043 $210.00 0 11602 $199.00 10 12013 $141.00 0
11044 $283.00 0 11603 $226.00 10 12014 $165.00 0
11045 $43.00 ZZZ 11604 $249.00 10 12015 $207.00 0
11046 $75.00 ZZZ 11606 $315.00 10 12016 $268.00 0
11047 $127.00 ZZZ 11620 $150.00 10 12017 $316.00 0
11055 $26.00 0 11621 $191.00 10 12018 $515.00 0
11056 $35.00 0 11622 $223.00 10 12020 $211.00 10
11057 $39.00 0 11623 $259.00 10 12021 $87.00 10
11100 $78.00 0 11624 $305.00 10 12031 $93.00 10
11101 $41.00 ZZZ 11626 $373.00 10 12032 $110.00 10
11200 $66.00 10 11640 $168.00 10 12034 $148.00 10
11201 $26.00 ZZZ 11641 $227.00 10 12035 $223.00 10
11300 $59.00 0 11642 $260.00 10 12036 $356.00 10
11301 $80.00 0 11643 $305.00 10 12037 $411.00 10
11302 $96.00 0 11644 $380.00 10 12041 $116.00 10
11303 $119.00 0 11646 $494.00 10 12042 $141.00 10
11305 $61.00 0 11719 $22.00 0 12044 $176.00 10
11306 $86.00 0 11720 $32.00 0 12045 $250.00 10
11307 $100.00 0 11721 $50.00 0 12046 $341.00 10
11308 $125.00 0 11730 $62.00 0 12047 $363.00 10
11310 $75.00 0 11732 $31.00 ZZZ 12051 $126.00 10
11311 $95.00 0 11740 $41.00 0 12052 $148.00 10
11312 $110.00 0 11750 $156.00 10 12053 $223.00 10
11313 $144.00 0 11755 $106.00 0 12054 $301.00 10
11400 $81.00 10 11760 $131.00 10 12055 $380.00 10
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Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
12056 $487.00 10 15200 $644.00 90 15819 $780.00 90
12057 $539.00 10 15201 $126.00 ZZZ 15820 $556.00 90
13100 $178.00 10 15220 $687.00 90 15821 $607.00 90
13101 $240.00 10 15221 $114.00 ZZZ 15822 $499.00 90
13102 $89.00 ZZZ 15240 $763.00 90 15823 $718.00 90
13120 $223.00 10 15241 $334.00 ZZZ 15824 BR 0
13121 $348.00 10 15260 $841.00 90 15825 BR 0
13122 $104.00 ZZZ 15261 $207.00 ZZZ 15826 BR 0
13131 $252.00 10 15271 $143.00 0 15828 BR 0
13132 $484.00 10 15272 $27.00 ZZZ 15829 BR 0
13133 $154.00 ZZZ 15273 $299.00 0 15830 $1,072.00 90
13151 $375.00 10 15274 $70.00 ZZZ 15832 $926.00 90
13152 $542.00 10 15275 $155.00 0 15833 $833.00 90
13153 $169.00 ZZZ 15276 $35.00 ZZZ 15834 $837.00 90
13160 $655.00 90 15277 $320.00 0 15835 $865.00 90
14000 $512.00 90 15278 $83.00 ZZZ 15836 $721.00 90
14001 $695.00 90 15570 $748.00 90 15837 $696.00 90
14020 $590.00 90 15572 $721.00 90 15838 $600.00 90
14021 $818.00 90 15574 $775.00 90 15839 $643.00 90
14040 $701.00 90 15576 $457.00 90 15840 $1,187.00 90
14041 $936.00 90 15600 $259.00 90 15841 $1,859.00 90
14060 $766.00 90 15610 $320.00 90 15842 $3,099.00 90
14061 $1,330.00 90 15620 $506.00 90 15845 $1,116.00 90
14301 $1,088.00 90 15630 $362.00 90 15850 $63.00 0
14302 $228.00 ZZZ 15650 $427.00 90 15851 $40.00 0
14350 $734.00 90 15731 $990.00 90 15852 $35.00 0
15002 $351.00 0 15732 $1,465.00 90 15860 $151.00 0
15003 $77.00 ZZZ 15734 $1,557.00 90 15876 BR 0
15004 $407.00 0 15736 $1,862.00 90 15877 BR 0
15005 $127.00 ZZZ 15738 $1,415.00 90 15878 BR 0
15040 $258.00 0 15740 $913.00 90 15879 BR 0
15050 $349.00 90 15750 $1,064.00 90 15920 $571.00 90
15100 $679.00 90 15756 $2,892.00 90 15922 $771.00 90
15101 $146.00 ZZZ 15757 $2,892.00 90 15931 $638.00 90
15110 $815.00 90 15758 $2,884.00 90 15933 $860.00 90
15111 $129.00 ZZZ 15760 $810.00 90 15934 $1,064.00 90
15115 $766.00 90 15770 $674.00 90 15935 $1,184.00 90
15116 $167.00 ZZZ 15775 $327.00 0 15936 $1,032.00 90
15120 $788.00 90 15776 $475.00 0 15937 $1,223.00 90
15121 $235.00 ZZZ 15777 $219.00 ZZZ 15940 $318.00 90
15130 $677.00 90 15780 $532.00 90 15941 $919.00 90
15131 $105.00 ZZZ 15781 $420.00 90 15944 $954.00 90
15135 $820.00 90 15782 $314.00 90 15945 $1,078.00 90
15136 $98.00 ZZZ 15783 $340.00 90 15946 $1,737.00 90
15150 $677.00 90 15786 $146.00 10 15950 $549.00 90
15151 $136.00 ZZZ 15787 $27.00 ZZZ 15951 $872.00 90
15152 $167.00 ZZZ 15788 $194.00 90 15952 $876.00 90
15155 $678.00 90 15789 $360.00 90 15953 $1,013.00 90
15156 $177.00 ZZZ 15792 $130.00 90 15956 $1,382.00 90
15157 $196.00 ZZZ 15793 $232.00 90 15958 $1,379.00 90
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CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 81
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
15999 BR YYY 19084 $543.00 ZZZ 19370 $662.00 90
16000 $53.00 0 19085 $1,025.00 0 19371 $788.00 90
16020 $49.00 0 19086 $817.00 ZZZ 19380 $780.00 90
16025 $67.00 0 19100 $117.00 0 19396 $231.00 0
16030 $153.00 0 19101 $338.00 10 19499 BR YYY
16035 $341.00 0 19105 $1,878.00 0 20005 $267.00 10
16036 $81.00 ZZZ 19110 $406.00 90 20100 $727.00 10
17000 $60.00 10 19112 $354.00 90 20101 $261.00 10
17003 $16.00 ZZZ 19120 $429.00 90 20102 $314.00 10
17004 $233.00 10 19125 $468.00 90 20103 $405.00 10
17106 $341.00 90 19126 $201.00 ZZZ 20150 $1,141.00 90
17107 $648.00 90 19260 $1,101.00 90 20200 $134.00 0
17108 $1,015.00 90 19271 $1,561.00 90 20205 $243.00 0
17110 $55.00 10 19272 $1,674.00 90 20206 $119.00 0
17111 $83.00 10 19281 $246.00 0 20220 $128.00 0
17250 $27.00 0 19282 $171.00 ZZZ 20225 $215.00 0
17260 $96.00 10 19283 $279.00 0 20240 $279.00 0
17261 $117.00 10 19284 $205.00 ZZZ 20245 $364.00 10
17262 $150.00 10 19285 $472.00 0 20250 $447.00 10
17263 $172.00 10 19286 $396.00 ZZZ 20251 $511.00 10
17264 $189.00 10 19287 $875.00 0 20500 $59.00 10
17266 $225.00 10 19288 $696.00 ZZZ 20501 $60.00 0
17270 $125.00 10 19296 $4,903.00 0 20520 $75.00 10
17271 $143.00 10 19297 $96.00 ZZZ 20525 $331.00 10
17272 $170.00 10 19298 $1,841.00 0 20526 $64.00 0
17273 $195.00 10 19300 $482.00 90 20527 $84.00 0
17274 $240.00 10 19301 $367.00 90 20550 $40.00 0
17276 $281.00 10 19302 $780.00 90 20551 $62.00 0
17280 $123.00 10 19303 $788.00 90 20552 $62.00 0
17281 $165.00 10 19304 $487.00 90 20553 $62.00 0
17282 $194.00 10 19305 $964.00 90 20555 $301.00 0
17283 $239.00 10 19306 $1,003.00 90 20600 $41.00 0
17284 $282.00 10 19307 $1,008.00 90 20604 $73.00 0
17286 $373.00 10 19316 $954.00 90 20605 $48.00 0
17311 $629.00 0 19318 $1,313.00 90 20606 $81.00 0
17312 $380.00 ZZZ 19324 $440.00 90 20610 $49.00 0
17313 $575.00 0 19325 $656.00 90 20611 $93.00 0
17314 $352.00 ZZZ 19328 $457.00 90 20612 $56.00 0
17315 $74.00 ZZZ 19330 $569.00 90 20615 $94.00 10
17340 $37.00 10 19340 $545.00 90 20650 $170.00 10
17360 $96.00 10 19342 $963.00 90 20660 $320.00 0
17380 BR 0 19350 $853.00 90 20661 $476.00 90
17999 BR YYY 19355 $755.00 90 20662 $559.00 90
19000 $74.00 0 19357 $1,449.00 90 20663 $465.00 90
19001 $40.00 ZZZ 19361 $1,667.00 90 20665 $105.00 10
19020 $288.00 90 19364 $2,737.00 90 20670 $80.00 10
19030 $98.00 0 19366 $1,676.00 90 20680 $332.00 90
19081 $682.00 0 19367 $2,056.00 90 20690 $298.00 90
19082 $551.00 ZZZ 19368 $2,444.00 90 20692 $516.00 90
19083 $677.00 0 19369 $2,317.00 90 20693 $477.00 90
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CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 82
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
20694 $421.00 90 21030 $496.00 90 21159 $3,302.00 90
20696 $1,156.00 90 21031 $310.00 90 21160 $3,500.00 90
20697 $1,860.00 0 21032 $315.00 90 21172 $2,111.00 90
20802 $3,363.00 90 21034 $1,140.00 90 21175 $2,604.00 90
20805 $4,317.00 90 21040 $227.00 90 21179 $1,826.00 90
20808 $5,324.00 90 21044 $957.00 90 21180 $2,035.00 90
20816 $3,060.00 90 21045 $1,313.00 90 21181 $813.00 90
20822 $2,511.00 90 21046 $899.00 90 21182 $2,570.00 90
20824 $3,027.00 90 21047 $1,109.00 90 21183 $2,770.00 90
20827 $3,920.00 90 21048 $925.00 90 21184 $3,150.00 90
20838 $3,484.00 90 21049 $1,051.00 90 21188 $1,786.00 90
20900 $454.00 0 21050 $1,026.00 90 21193 $1,331.00 90
20902 $658.00 0 21060 $972.00 90 21194 $1,540.00 90
20910 $338.00 90 21070 $679.00 90 21195 $1,360.00 90
20912 $549.00 90 21073 $337.00 90 21196 $1,764.00 90
20920 $460.00 90 21076 $1,192.00 10 21198 $1,268.00 90
20922 $634.00 90 21077 $3,002.00 90 21199 $1,018.00 90
20924 $583.00 90 21079 $2,086.00 90 21206 $1,112.00 90
20926 $444.00 90 21080 $2,346.00 90 21208 $946.00 90
20930 BR 0 21081 $2,138.00 90 21209 $576.00 90
20931 $156.00 ZZZ 21082 $1,855.00 90 21210 $930.00 90
20936 BR 0 21083 $1,802.00 90 21215 $970.00 90
20937 $234.00 ZZZ 21084 $2,105.00 90 21230 $956.00 90
20938 $257.00 ZZZ 21085 $801.00 10 21235 $707.00 90
20950 $123.00 0 21086 $2,333.00 90 21240 $1,281.00 90
20955 $3,332.00 90 21087 $2,217.00 90 21242 $1,207.00 90
20956 $3,167.00 90 21088 BR 90 21243 $1,501.00 90
20957 $3,074.00 90 21089 BR YYY 21244 $1,062.00 90
20962 $3,122.00 90 21100 $297.00 90 21245 $1,038.00 90
20969 $3,716.00 90 21110 $371.00 90 21246 $1,010.00 90
20970 $3,650.00 90 21116 $207.00 0 21247 $2,003.00 90
20972 $3,420.00 90 21120 $500.00 90 21248 $1,023.00 90
20973 $3,821.00 90 21121 $651.00 90 21249 $1,525.00 90
20974 $266.00 0 21122 $700.00 90 21255 $1,459.00 90
20975 $334.00 0 21123 $903.00 90 21256 $1,470.00 90
20979 $19.00 0 21125 $656.00 90 21260 $1,372.00 90
20982 $4,231.00 0 21127 $909.00 90 21261 $2,347.00 90
20983 $7,394.00 0 21137 $797.00 90 21263 $2,361.00 90
20985 $140.00 ZZZ 21138 $960.00 90 21267 $1,539.00 90
20999 BR YYY 21139 $1,168.00 90 21268 $1,946.00 90
21010 $854.00 90 21141 $1,438.00 90 21270 $890.00 90
21011 $349.00 90 21142 $1,527.00 90 21275 $963.00 90
21012 $341.00 90 21143 $1,511.00 90 21280 $571.00 90
21013 $521.00 90 21145 $1,513.00 90 21282 $360.00 90
21014 $528.00 90 21146 $1,570.00 90 21295 $144.00 90
21015 $520.00 90 21147 $1,639.00 90 21296 $384.00 90
21016 $1,063.00 90 21150 $1,914.00 90 21299 BR YYY
21025 $546.00 90 21151 $2,264.00 90 21310 $81.00 0
21026 $413.00 90 21154 $2,364.00 90 21315 $180.00 10
21029 $700.00 90 21155 $2,640.00 90 21320 $235.00 10
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 83
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
21325 $348.00 90 21490 $865.00 90 22110 $889.00 90
21330 $639.00 90 21497 $372.00 90 22112 $1,090.00 90
21335 $852.00 90 21499 BR YYY 22114 $1,062.00 90
21336 $478.00 90 21501 $315.00 90 22116 $195.00 ZZZ
21337 $300.00 90 21502 $612.00 90 22206 $2,153.00 90
21338 $550.00 90 21510 $534.00 90 22207 $2,126.00 90
21339 $689.00 90 21550 $165.00 10 22208 $545.00 ZZZ
21340 $907.00 90 21552 $453.00 90 22210 $1,892.00 90
21343 $1,043.00 90 21554 $744.00 90 22212 $1,668.00 90
21344 $1,450.00 90 21555 $337.00 90 22214 $819.00 90
21345 $738.00 90 21556 $431.00 90 22216 $492.00 ZZZ
21346 $917.00 90 21557 $794.00 90 22220 $1,801.00 90
21347 $1,048.00 90 21558 $1,380.00 90 22222 $1,604.00 90
21348 $1,286.00 90 21600 $631.00 90 22224 $1,731.00 90
21355 $295.00 10 21610 $828.00 90 22226 $488.00 ZZZ
21356 $372.00 10 21615 $938.00 90 22310 $272.00 90
21360 $590.00 90 21616 $1,042.00 90 22315 $711.00 90
21365 $1,239.00 90 21620 $689.00 90 22318 $1,755.00 90
21366 $1,386.00 90 21627 $686.00 90 22319 $1,983.00 90
21385 $810.00 90 21630 $1,455.00 90 22325 $1,407.00 90
21386 $812.00 90 21632 $1,514.00 90 22326 $1,710.00 90
21387 $958.00 90 21685 $918.00 90 22327 $1,660.00 90
21390 $920.00 90 21700 $576.00 90 22328 $391.00 ZZZ
21395 $1,384.00 90 21705 $746.00 90 22505 $174.00 10
21400 $143.00 90 21720 $523.00 90 22510 $1,804.00 10
21401 $313.00 90 21725 $588.00 90 22511 $1,786.00 10
21406 $852.00 90 21740 $1,387.00 90 22512 $1,001.00 ZZZ
21407 $736.00 90 21742 BR 90 22513 $7,471.00 10
21408 $1,007.00 90 21743 BR 90 22514 $7,462.00 10
21421 $528.00 90 21750 $1,009.00 90 22515 $4,518.00 ZZZ
21422 $761.00 90 21811 $634.00 0 22526 $2,013.00 10
21423 $890.00 90 21812 $761.00 0 22527 $1,637.00 ZZZ
21431 $598.00 90 21813 $992.00 0 22532 $1,618.00 90
21432 $744.00 90 21820 $143.00 90 22533 $1,509.00 90
21433 $1,981.00 90 21825 $810.00 90 22534 $381.00 ZZZ
21435 $1,404.00 90 21899 BR YYY 22548 $2,271.00 90
21436 $2,045.00 90 21920 $165.00 10 22551 $1,759.00 90
21440 $308.00 90 21925 $371.00 90 22552 $406.00 ZZZ
21445 $533.00 90 21930 $403.00 90 22554 $1,727.00 90
21450 $325.00 90 21931 $478.00 90 22556 $2,054.00 90
21451 $498.00 90 21932 $672.00 90 22558 $1,907.00 90
21452 $195.00 90 21933 $749.00 90 22585 $473.00 ZZZ
21453 $902.00 90 21935 $1,280.00 90 22586 $1,926.00 90
21454 $905.00 90 21936 $1,442.00 90 22590 $1,895.00 90
21461 $769.00 90 22010 $822.00 90 22595 $1,960.00 90
21462 $1,012.00 90 22015 $815.00 90 22600 $1,567.00 90
21465 $923.00 90 22100 $850.00 90 22610 $1,494.00 90
21470 $1,331.00 90 22101 $862.00 90 22612 $1,861.00 90
21480 $82.00 0 22102 $781.00 90 22614 $530.00 ZZZ
21485 $318.00 90 22103 $198.00 ZZZ 22630 $1,201.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 84
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
22632 $442.00 ZZZ 23031 $185.00 10 23420 $1,276.00 90
22633 $1,894.00 90 23035 $861.00 90 23430 $884.00 90
22634 $511.00 ZZZ 23040 $898.00 90 23440 $906.00 90
22800 $1,960.00 90 23044 $708.00 90 23450 $1,210.00 90
22802 $2,633.00 90 23065 $171.00 10 23455 $1,340.00 90
22804 $2,951.00 90 23066 $302.00 90 23460 $1,364.00 90
22808 $2,157.00 90 23071 $426.00 90 23462 $1,383.00 90
22810 $2,356.00 90 23073 $705.00 90 23465 $1,398.00 90
22812 $2,675.00 90 23075 $247.00 90 23466 $1,332.00 90
22818 $2,701.00 90 23076 $613.00 90 23470 $1,540.00 90
22819 $2,968.00 90 23077 $1,228.00 90 23472 $1,570.00 90
22830 $1,176.00 90 23078 $1,476.00 90 23473 $1,672.00 90
22840 $943.00 ZZZ 23100 $616.00 90 23474 $1,807.00 90
22841 BR 0 23101 $583.00 90 23480 $926.00 90
22842 $2,352.00 ZZZ 23105 $814.00 90 23485 $1,181.00 90
22843 $1,028.00 ZZZ 23106 $581.00 90 23490 $1,038.00 90
22844 $1,277.00 ZZZ 23107 $851.00 90 23491 $1,251.00 90
22845 $1,853.00 ZZZ 23120 $645.00 90 23500 $148.00 90
22846 $999.00 ZZZ 23125 $865.00 90 23505 $293.00 90
22847 $1,077.00 ZZZ 23130 $722.00 90 23515 $688.00 90
22848 $529.00 ZZZ 23140 $597.00 90 23520 $205.00 90
22849 $2,235.00 90 23145 $889.00 90 23525 $320.00 90
22850 $872.00 90 23146 $704.00 90 23530 $659.00 90
22852 $854.00 90 23150 $755.00 90 23532 $713.00 90
22853 $274.00 ZZZ 23155 $945.00 90 23540 $148.00 90
22854 $355.00 ZZZ 23156 $794.00 90 23545 $148.00 90
22855 $1,193.00 90 23170 $645.00 90 23550 $701.00 90
22856 $1,701.00 90 23172 $638.00 90 23552 $753.00 90
22857 $1,386.00 90 23174 $882.00 90 23570 $88.00 90
22858 $527.00 ZZZ 23180 $566.00 90 23575 $306.00 90
22859 $355.00 ZZZ 23182 $865.00 90 23585 $809.00 90
22861 $2,262.00 90 23184 $962.00 90 23600 $318.00 90
22862 $1,690.00 90 23190 $656.00 90 23605 $511.00 90
22864 $2,035.00 90 23195 $902.00 90 23615 $900.00 90
22865 $1,646.00 90 23200 $1,095.00 90 23616 $1,895.00 90
22867 $1,025.00 90 23210 $1,095.00 90 23620 $286.00 90
22868 $256.00 ZZZ 23220 $1,307.00 90 23625 $422.00 90
22869 $563.00 90 23330 $59.00 10 23630 $712.00 90
22870 $149.00 ZZZ 23333 $466.00 90 23650 $296.00 90
22899 BR YYY 23334 $1,100.00 90 23655 $374.00 90
22900 $446.00 90 23335 $1,312.00 90 23660 $712.00 90
22901 $673.00 90 23350 $74.00 0 23665 $440.00 90
22902 $436.00 90 23395 $1,366.00 90 23670 $759.00 90
22903 $440.00 90 23397 $1,403.00 90 23675 $550.00 90
22904 $1,069.00 90 23400 $1,196.00 90 23680 $1,064.00 90
22905 $1,362.00 90 23405 $799.00 90 23700 $237.00 10
22999 BR YYY 23406 $977.00 90 23800 $1,346.00 90
23000 $447.00 90 23410 $1,119.00 90 23802 $1,368.00 90
23020 $807.00 90 23412 $1,229.00 90 23900 $1,561.00 90
23030 $323.00 10 23415 $622.00 90 23920 $1,300.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 85
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
23921 $497.00 90 24341 $702.00 90 24655 $436.00 90
23929 BR YYY 24342 $950.00 90 24665 $749.00 90
23930 $71.00 10 24343 $643.00 90 24666 $905.00 90
23931 $62.00 10 24344 $971.00 90 24670 $263.00 90
23935 $630.00 90 24345 $643.00 90 24675 $490.00 90
24000 $550.00 90 24346 $971.00 90 24685 $819.00 90
24006 $793.00 90 24357 $408.00 90 24800 $984.00 90
24065 $166.00 10 24358 $478.00 90 24802 $1,181.00 90
24066 $461.00 90 24359 $587.00 90 24900 $858.00 90
24071 $413.00 90 24360 $1,125.00 90 24920 $851.00 90
24073 $704.00 90 24361 $1,215.00 90 24925 $661.00 90
24075 $349.00 90 24362 $1,269.00 90 24930 $928.00 90
24076 $529.00 90 24363 $1,663.00 90 24931 $1,063.00 90
24077 $1,058.00 90 24365 $747.00 90 24935 $1,327.00 90
24079 $1,357.00 90 24366 $850.00 90 24940 BR 90
24100 $467.00 90 24370 $1,581.00 90 24999 BR YYY
24101 $591.00 90 24371 $1,826.00 90 25000 $381.00 90
24102 $755.00 90 24400 $991.00 90 25001 $294.00 90
24105 $360.00 90 24410 $1,319.00 90 25020 $594.00 90
24110 $724.00 90 24420 $1,265.00 90 25023 $1,040.00 90
24115 $898.00 90 24430 $1,209.00 90 25024 $683.00 90
24116 $1,037.00 90 24435 $1,260.00 90 25025 $1,104.00 90
24120 $595.00 90 24470 $774.00 90 25028 $417.00 90
24125 $663.00 90 24495 $742.00 90 25031 $266.00 90
24126 $731.00 90 24498 $1,076.00 90 25035 $794.00 90
24130 $595.00 90 24500 $288.00 90 25040 $654.00 90
24134 $966.00 90 24505 $574.00 90 25065 $164.00 10
24136 $720.00 90 24515 $1,018.00 90 25066 $322.00 90
24138 $697.00 90 24516 $1,029.00 90 25071 $432.00 90
24140 $963.00 90 24530 $88.00 90 25073 $540.00 90
24145 $592.00 90 24535 $671.00 90 25075 $352.00 90
24147 $703.00 90 24538 $850.00 90 25076 $544.00 90
24149 $1,224.00 90 24545 $946.00 90 25077 $957.00 90
24150 $1,265.00 90 24546 $1,273.00 90 25078 $1,195.00 90
24152 $829.00 90 24560 $266.00 90 25085 $562.00 90
24155 $1,019.00 90 24565 $526.00 90 25100 $420.00 90
24160 $533.00 90 24566 $705.00 90 25101 $492.00 90
24164 $564.00 90 24575 $872.00 90 25105 $635.00 90
24200 $58.00 10 24576 $295.00 90 25107 $600.00 90
24201 $444.00 90 24577 $575.00 90 25109 $470.00 90
24220 $89.00 0 24579 $964.00 90 25110 $403.00 90
24300 $352.00 90 24582 $773.00 90 25111 $356.00 90
24301 $869.00 90 24586 $1,314.00 90 25112 $441.00 90
24305 $579.00 90 24587 $1,278.00 90 25115 $837.00 90
24310 $511.00 90 24600 $360.00 90 25116 $807.00 90
24320 $944.00 90 24605 $371.00 90 25118 $466.00 90
24330 $845.00 90 24615 $836.00 90 25119 $653.00 90
24331 $927.00 90 24620 $560.00 90 25120 $712.00 90
24332 $487.00 90 24635 $1,329.00 90 25125 $803.00 90
24340 $697.00 90 24650 $262.00 90 25126 $781.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 86
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
25130 $502.00 90 25420 $1,554.00 90 25675 $404.00 90
25135 $631.00 90 25425 $1,403.00 90 25676 $741.00 90
25136 $546.00 90 25426 $1,401.00 90 25680 $471.00 90
25145 $713.00 90 25430 $638.00 90 25685 $887.00 90
25150 $720.00 90 25431 $631.00 90 25690 $518.00 90
25151 $771.00 90 25440 $931.00 90 25695 $520.00 90
25170 $1,085.00 90 25441 $1,147.00 90 25800 $703.00 90
25210 $561.00 90 25442 $936.00 90 25805 $1,078.00 90
25215 $817.00 90 25443 $970.00 90 25810 $1,008.00 90
25230 $531.00 90 25444 $1,031.00 90 25820 $2,276.00 90
25240 $567.00 90 25445 $959.00 90 25825 $895.00 90
25246 $72.00 0 25446 $1,542.00 90 25830 $991.00 90
25248 $236.00 90 25447 $952.00 90 25900 $871.00 90
25250 $616.00 90 25449 $395.00 90 25905 $900.00 90
25251 $933.00 90 25450 $805.00 90 25907 $799.00 90
25259 $348.00 90 25455 $899.00 90 25909 $849.00 90
25260 $728.00 90 25490 $955.00 90 25915 $1,523.00 90
25263 $809.00 90 25491 $1,006.00 90 25920 $771.00 90
25265 $998.00 90 25492 $1,170.00 90 25922 $670.00 90
25270 $549.00 90 25500 $200.00 90 25924 $768.00 90
25272 $613.00 90 25505 $517.00 90 25927 $830.00 90
25274 $887.00 90 25515 $800.00 90 25929 $645.00 90
25275 $620.00 90 25520 $644.00 90 25931 $731.00 90
25280 $670.00 90 25525 $1,097.00 90 25999 BR YYY
25290 $436.00 90 25526 $1,293.00 90 26010 $59.00 10
25295 $562.00 90 25530 $270.00 90 26011 $223.00 10
25300 $592.00 90 25535 $516.00 90 26020 $484.00 90
25301 $757.00 90 25545 $803.00 90 26025 $548.00 90
25310 $865.00 90 25560 $276.00 90 26030 $655.00 90
25312 $968.00 90 25565 $590.00 90 26034 $601.00 90
25315 $1,004.00 90 25574 $804.00 90 26035 $741.00 90
25316 $1,203.00 90 25575 $974.00 90 26037 $730.00 90
25320 $834.00 90 25600 $312.00 90 26040 $367.00 90
25332 $1,022.00 90 25605 $540.00 90 26045 $621.00 90
25335 $1,166.00 90 25606 $643.00 90 26055 $343.00 90
25337 $946.00 90 25607 $645.00 90 26060 $293.00 90
25350 $913.00 90 25608 $739.00 90 26070 $440.00 90
25355 $1,014.00 90 25609 $942.00 90 26075 $400.00 90
25360 $468.00 90 25622 $148.00 90 26080 $382.00 90
25365 $1,216.00 90 25624 $482.00 90 26100 $398.00 90
25370 $1,214.00 90 25628 $716.00 90 26105 $481.00 90
25375 $1,280.00 90 25630 $148.00 90 26110 $282.00 90
25390 $1,043.00 90 25635 $458.00 90 26111 $423.00 90
25391 $1,349.00 90 25645 $668.00 90 26113 $557.00 90
25392 $1,294.00 90 25650 $185.00 90 26115 $344.00 90
25393 $1,473.00 90 25651 $379.00 90 26116 $544.00 90
25394 $723.00 90 25652 $560.00 90 26117 $806.00 90
25400 $1,112.00 90 25660 $378.00 90 26118 $1,076.00 90
25405 $1,388.00 90 25670 $731.00 90 26121 $833.00 90
25415 $1,343.00 90 25671 $462.00 90 26123 $959.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 87
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
26125 $342.00 ZZZ 26460 $346.00 90 26587 $792.00 90
26130 $629.00 90 26471 $592.00 90 26590 $1,609.00 90
26135 $668.00 90 26474 $586.00 90 26591 $431.00 90
26140 $678.00 90 26476 $543.00 90 26593 $587.00 90
26145 $660.00 90 26477 $553.00 90 26596 $809.00 90
26160 $319.00 90 26478 $608.00 90 26600 $133.00 90
26170 $452.00 90 26479 $653.00 90 26605 $296.00 90
26180 $444.00 90 26480 $808.00 90 26607 $334.00 90
26185 $511.00 90 26483 $986.00 90 26608 $497.00 90
26200 $598.00 90 26485 $891.00 90 26615 $521.00 90
26205 $788.00 90 26489 $738.00 90 26641 $71.00 90
26210 $543.00 90 26490 $496.00 90 26645 $371.00 90
26215 $731.00 90 26492 $971.00 90 26650 $533.00 90
26230 $624.00 90 26494 $946.00 90 26665 $693.00 90
26235 $612.00 90 26496 $949.00 90 26670 $148.00 90
26236 $444.00 90 26497 $946.00 90 26675 $501.00 90
26250 $814.00 90 26498 $1,317.00 90 26676 $527.00 90
26260 $758.00 90 26499 $934.00 90 26685 $592.00 90
26262 $624.00 90 26500 $557.00 90 26686 $710.00 90
26320 $414.00 90 26502 $715.00 90 26700 $88.00 90
26340 $266.00 90 26508 $334.00 90 26705 $296.00 90
26341 $99.00 10 26510 $564.00 90 26706 $469.00 90
26350 $715.00 90 26516 $630.00 90 26715 $526.00 90
26352 $855.00 90 26517 $890.00 90 26720 $96.00 90
26356 $886.00 90 26518 $877.00 90 26725 $187.00 90
26357 $932.00 90 26520 $583.00 90 26727 $187.00 90
26358 $979.00 90 26525 $531.00 90 26735 $532.00 90
26370 $832.00 90 26530 $708.00 90 26740 $148.00 90
26372 $945.00 90 26531 $877.00 90 26742 $148.00 90
26373 $904.00 90 26535 $546.00 90 26746 $548.00 90
26390 $889.00 90 26536 $770.00 90 26750 $96.00 90
26392 $1,123.00 90 26540 $726.00 90 26755 $133.00 90
26410 $371.00 90 26541 $926.00 90 26756 $366.00 90
26412 $737.00 90 26542 $716.00 90 26765 $398.00 90
26415 $846.00 90 26545 $722.00 90 26770 $79.00 90
26416 $1,093.00 90 26546 $918.00 90 26775 $275.00 90
26418 $444.00 90 26548 $665.00 90 26776 $401.00 90
26420 $741.00 90 26550 $1,861.00 90 26785 $408.00 90
26426 $733.00 90 26551 $3,901.00 90 26820 $854.00 90
26428 $790.00 90 26553 $3,868.00 90 26841 $756.00 90
26432 $430.00 90 26554 $4,551.00 90 26842 $901.00 90
26433 $371.00 90 26555 $1,567.00 90 26843 $800.00 90
26434 $656.00 90 26556 $4,005.00 90 26844 $875.00 90
26437 $491.00 90 26560 $576.00 90 26850 $704.00 90
26440 $458.00 90 26561 $1,067.00 90 26852 $829.00 90
26442 $548.00 90 26562 $1,017.00 90 26860 $542.00 90
26445 $455.00 90 26565 $730.00 90 26861 $151.00 ZZZ
26449 $738.00 90 26567 $622.00 90 26862 $747.00 90
26450 $353.00 90 26568 $1,003.00 90 26863 $317.00 ZZZ
26455 $364.00 90 26580 $1,585.00 90 26910 $747.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 88
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
26951 $444.00 90 27100 $987.00 90 27246 $459.00 90
26952 $608.00 90 27105 $946.00 90 27248 $980.00 90
26989 BR YYY 27110 $1,174.00 90 27250 $535.00 0
26990 $592.00 90 27111 $1,099.00 90 27252 $520.00 90
26991 $466.00 90 27120 $1,603.00 90 27253 $1,162.00 90
26992 $1,146.00 90 27122 $1,406.00 90 27254 $1,478.00 90
27000 $421.00 90 27125 $1,371.00 90 27256 $338.00 10
27001 $550.00 90 27130 $1,853.00 90 27257 $455.00 10
27003 $698.00 90 27132 $2,128.00 90 27258 $1,355.00 90
27005 $738.00 90 27134 $2,576.00 90 27259 $1,803.00 90
27006 $788.00 90 27137 $2,190.00 90 27265 $442.00 90
27025 $896.00 90 27138 $2,025.00 90 27266 $614.00 90
27027 $866.00 90 27140 $1,092.00 90 27267 $382.00 90
27030 $1,148.00 90 27146 $1,432.00 90 27268 $470.00 90
27033 $1,173.00 90 27147 $1,744.00 90 27269 $1,117.00 90
27035 $1,413.00 90 27151 $1,732.00 90 27275 $220.00 10
27036 $1,176.00 90 27156 $2,017.00 90 27279 $718.00 90
27040 $196.00 10 27158 $1,588.00 90 27280 $1,179.00 90
27041 $699.00 90 27161 $1,443.00 90 27282 $990.00 90
27043 $476.00 90 27165 $1,572.00 90 27284 $1,435.00 90
27045 $764.00 90 27170 $1,453.00 90 27286 $1,503.00 90
27047 $535.00 90 27175 $491.00 90 27290 $2,073.00 90
27048 $588.00 90 27176 $1,024.00 90 27295 $1,594.00 90
27049 $1,162.00 90 27177 $1,257.00 90 27299 BR YYY
27050 $449.00 90 27178 $1,020.00 90 27301 $193.00 90
27052 $624.00 90 27179 $1,107.00 90 27303 $520.00 90
27054 $843.00 90 27181 $1,206.00 90 27305 $555.00 90
27057 $972.00 90 27185 $676.00 90 27306 $377.00 90
27059 $1,849.00 90 27187 $1,280.00 90 27307 $503.00 90
27060 $491.00 90 27197 $120.00 0 27310 $877.00 90
27062 $499.00 90 27198 $306.00 0 27323 $211.00 10
27065 $583.00 90 27200 $180.00 90 27324 $433.00 90
27066 $931.00 90 27202 $776.00 90 27325 $476.00 90
27067 $1,234.00 90 27215 $954.00 90 27326 $451.00 90
27070 $1,040.00 90 27216 $1,085.00 90 27327 $400.00 90
27071 $1,112.00 90 27217 $1,285.00 90 27328 $503.00 90
27075 $1,485.00 90 27218 $1,570.00 90 27329 $1,249.00 90
27076 $1,859.00 90 27220 $444.00 90 27330 $492.00 90
27077 $1,976.00 90 27222 $973.00 90 27331 $585.00 90
27078 $1,164.00 90 27226 $1,350.00 90 27332 $786.00 90
27080 $568.00 90 27227 $1,967.00 90 27333 $719.00 90
27086 $57.00 10 27228 $2,195.00 90 27334 $840.00 90
27087 $555.00 90 27230 $491.00 90 27335 $959.00 90
27090 $981.00 90 27232 $916.00 90 27337 $425.00 90
27091 $1,482.00 90 27235 $1,128.00 90 27339 $765.00 90
27093 $62.00 0 27236 $1,421.00 90 27340 $405.00 90
27095 $121.00 0 27238 $504.00 90 27345 $565.00 90
27096 $491.00 0 27240 $1,043.00 90 27347 $394.00 90
27097 $795.00 90 27244 $1,426.00 90 27350 $786.00 90
27098 $799.00 90 27245 $1,691.00 90 27355 $763.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 89
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
27356 $882.00 90 27455 $1,157.00 90 27570 $184.00 10
27357 $950.00 90 27457 $1,209.00 90 27580 $1,644.00 90
27358 $394.00 ZZZ 27465 $1,253.00 90 27590 $1,059.00 90
27360 $977.00 90 27466 $1,441.00 90 27591 $1,182.00 90
27364 $1,601.00 90 27468 $1,613.00 90 27592 $911.00 90
27365 $1,421.00 90 27470 $1,501.00 90 27594 $600.00 90
27370 $75.00 0 27472 $1,665.00 90 27596 $931.00 90
27372 $371.00 90 27475 $782.00 90 27598 $976.00 90
27380 $698.00 90 27477 $938.00 90 27599 BR YYY
27381 $1,118.00 90 27479 $1,123.00 90 27600 $517.00 90
27385 $753.00 90 27485 $797.00 90 27601 $516.00 90
27386 $1,064.00 90 27486 $1,771.00 90 27602 $621.00 90
27390 $506.00 90 27487 $2,352.00 90 27603 $412.00 90
27391 $647.00 90 27488 $1,438.00 90 27604 $308.00 90
27392 $834.00 90 27495 $1,477.00 90 27605 $236.00 10
27393 $608.00 90 27496 $563.00 90 27606 $362.00 10
27394 $748.00 90 27497 $652.00 90 27607 $608.00 90
27395 $1,093.00 90 27498 $701.00 90 27610 $777.00 90
27396 $742.00 90 27499 $782.00 90 27612 $701.00 90
27397 $989.00 90 27500 $520.00 90 27613 $165.00 10
27400 $832.00 90 27501 $659.00 90 27614 $327.00 90
27403 $792.00 90 27502 $909.00 90 27615 $1,106.00 90
27405 $842.00 90 27503 $911.00 90 27616 $1,297.00 90
27407 $918.00 90 27506 $1,522.00 90 27618 $421.00 90
27409 $1,212.00 90 27507 $1,297.00 90 27619 $730.00 90
27412 $1,605.00 90 27508 $400.00 90 27620 $587.00 90
27415 $1,340.00 90 27509 $649.00 90 27625 $796.00 90
27416 $878.00 90 27510 $755.00 90 27626 $863.00 90
27418 $1,596.00 90 27511 $1,281.00 90 27630 $430.00 90
27420 $927.00 90 27513 $1,562.00 90 27632 $422.00 90
27422 $930.00 90 27514 $1,508.00 90 27634 $697.00 90
27424 $927.00 90 27516 $579.00 90 27635 $781.00 90
27425 $639.00 90 27517 $820.00 90 27637 $921.00 90
27427 $1,118.00 90 27519 $1,311.00 90 27638 $978.00 90
27428 $1,266.00 90 27520 $266.00 90 27640 $1,122.00 90
27429 $2,333.00 90 27524 $910.00 90 27641 $922.00 90
27430 $884.00 90 27530 $408.00 90 27645 $1,302.00 90
27435 $501.00 90 27532 $641.00 90 27646 $1,212.00 90
27437 $819.00 90 27535 $1,075.00 90 27647 $1,044.00 90
27438 $1,065.00 90 27536 $1,282.00 90 27648 $72.00 0
27440 $1,064.00 90 27538 $487.00 90 27650 $869.00 90
27441 $1,006.00 90 27540 $1,106.00 90 27652 $935.00 90
27442 $1,117.00 90 27550 $296.00 90 27654 $937.00 90
27443 $1,037.00 90 27552 $619.00 90 27656 $458.00 90
27445 $1,618.00 90 27556 $832.00 90 27658 $527.00 90
27446 $1,764.00 90 27557 $1,479.00 90 27659 $725.00 90
27447 $1,960.00 90 27558 $1,529.00 90 27664 $504.00 90
27448 $1,060.00 90 27560 $88.00 90 27665 $618.00 90
27450 $1,311.00 90 27562 $514.00 90 27675 $656.00 90
27454 $1,524.00 90 27566 $1,047.00 90 27676 $762.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 90
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
27680 $523.00 90 27810 $567.00 90 28050 $414.00 90
27681 $634.00 90 27814 $972.00 90 28052 $402.00 90
27685 $565.00 90 27816 $386.00 90 28054 $236.00 90
27686 $706.00 90 27818 $613.00 90 28055 $377.00 90
27687 $589.00 90 27822 $1,201.00 90 28060 $495.00 90
27690 $757.00 90 27823 $1,472.00 90 28062 $657.00 90
27691 $889.00 90 27824 $384.00 90 28070 $476.00 90
27692 $159.00 ZZZ 27825 $670.00 90 28072 $445.00 90
27695 $658.00 90 27826 $1,080.00 90 28080 $392.00 90
27696 $758.00 90 27827 $1,310.00 90 28086 $462.00 90
27698 $881.00 90 27828 $1,823.00 90 28088 $414.00 90
27700 $835.00 90 27829 $742.00 90 28090 $414.00 90
27702 $1,278.00 90 27830 $412.00 90 28092 $330.00 90
27703 $1,337.00 90 27831 $415.00 90 28100 $571.00 90
27704 $683.00 90 27832 $617.00 90 28102 $700.00 90
27705 $985.00 90 27840 $334.00 90 28103 $709.00 90
27707 $484.00 90 27842 $373.00 90 28104 $491.00 90
27709 $1,118.00 90 27846 $877.00 90 28106 $632.00 90
27712 $1,227.00 90 27848 $1,224.00 90 28107 $517.00 90
27715 $1,285.00 90 27860 $211.00 10 28108 $418.00 90
27720 $1,147.00 90 27870 $1,269.00 90 28110 $421.00 90
27722 $1,076.00 90 27871 $843.00 90 28111 $537.00 90
27724 $1,402.00 90 27880 $1,015.00 90 28112 $457.00 90
27725 $1,312.00 90 27881 $1,120.00 90 28113 $481.00 90
27726 $823.00 90 27882 $854.00 90 28114 $890.00 90
27727 $1,175.00 90 27884 $579.00 90 28116 $648.00 90
27730 $647.00 90 27886 $835.00 90 28118 $568.00 90
27732 $611.00 90 27888 $911.00 90 28119 $524.00 90
27734 $766.00 90 27889 $879.00 90 28120 $601.00 90
27740 $1,044.00 90 27892 $575.00 90 28122 $622.00 90
27742 $1,045.00 90 27893 $574.00 90 28124 $480.00 90
27745 $940.00 90 27894 $712.00 90 28126 $393.00 90
27750 $319.00 90 27899 BR YYY 28130 $727.00 90
27752 $614.00 90 28001 $185.00 10 28140 $533.00 90
27756 $708.00 90 28002 $362.00 10 28150 $416.00 90
27758 $1,115.00 90 28003 $520.00 90 28153 $400.00 90
27759 $1,262.00 90 28005 $520.00 90 28160 $412.00 90
27760 $223.00 90 28008 $296.00 90 28171 $789.00 90
27762 $495.00 90 28010 $235.00 90 28173 $747.00 90
27766 $759.00 90 28011 $340.00 90 28175 $571.00 90
27767 $233.00 90 28020 $509.00 90 28190 $75.00 10
27768 $361.00 90 28022 $422.00 90 28192 $326.00 90
27769 $622.00 90 28024 $371.00 90 28193 $341.00 90
27780 $244.00 90 28035 $532.00 90 28200 $478.00 90
27781 $296.00 90 28039 $525.00 90 28202 $613.00 90
27784 $643.00 90 28041 $473.00 90 28208 $406.00 90
27786 $223.00 90 28043 $305.00 90 28210 $609.00 90
27788 $422.00 90 28045 $456.00 90 28220 $435.00 90
27792 $706.00 90 28046 $814.00 90 28222 $555.00 90
27808 $332.00 90 28047 $1,056.00 90 28225 $345.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 91
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
28226 $334.00 90 28435 $371.00 90 28760 $654.00 90
28230 $380.00 90 28436 $463.00 90 28800 $731.00 90
28232 $286.00 90 28445 $874.00 90 28805 $731.00 90
28234 $178.00 90 28446 $1,075.00 90 28810 $543.00 90
28238 $695.00 90 28450 $148.00 90 28820 $377.00 90
28240 $370.00 90 28455 $321.00 90 28825 $339.00 90
28250 $535.00 90 28456 $288.00 90 28890 $358.00 90
28260 $641.00 90 28465 $533.00 90 28899 BR YYY
28261 $881.00 90 28470 $178.00 90 29000 $247.00 0
28262 $1,363.00 90 28475 $296.00 90 29010 $271.00 0
28264 $912.00 90 28476 $364.00 90 29015 $289.00 0
28270 $266.00 90 28485 $521.00 90 29035 $213.00 0
28272 $336.00 90 28490 $80.00 90 29040 $260.00 0
28280 $426.00 90 28495 $133.00 90 29044 $260.00 0
28285 $463.00 90 28496 $261.00 90 29046 $286.00 0
28286 $441.00 90 28505 $399.00 90 29049 $45.00 0
28288 $452.00 90 28510 $75.00 90 29055 $180.00 0
28289 $458.00 90 28515 $115.00 90 29058 $110.00 0
28291 $759.00 90 28525 $345.00 90 29065 $88.00 0
28292 $666.00 90 28530 $120.00 90 29075 $72.00 0
28295 $973.00 90 28531 $243.00 90 29085 $59.00 0
28296 $832.00 90 28540 $145.00 90 29086 $54.00 0
28297 $838.00 90 28545 $208.00 90 29105 $59.00 0
28298 $755.00 90 28546 $325.00 90 29125 $45.00 0
28299 $829.00 90 28555 $592.00 90 29126 $53.00 0
28300 $845.00 90 28570 $189.00 90 29130 $26.00 0
28302 $930.00 90 28575 $308.00 90 29131 $53.00 0
28304 $776.00 90 28576 $382.00 90 29200 $29.00 0
28305 $1,030.00 90 28585 $742.00 90 29240 $45.00 0
28306 $530.00 90 28600 $144.00 90 29260 $26.00 0
28307 $614.00 90 28605 $287.00 90 29280 $29.00 0
28308 $516.00 90 28606 $487.00 90 29305 $223.00 0
28309 $955.00 90 28615 $621.00 90 29325 $260.00 0
28310 $505.00 90 28630 $145.00 10 29345 $126.00 0
28312 $469.00 90 28635 $189.00 10 29355 $133.00 0
28313 $436.00 90 28636 $318.00 10 29358 $241.00 0
28315 $462.00 90 28645 $434.00 90 29365 $101.00 0
28320 $833.00 90 28660 $106.00 10 29405 $96.00 0
28322 $667.00 90 28665 $172.00 10 29425 $101.00 0
28340 $649.00 90 28666 $309.00 10 29435 $133.00 0
28341 $753.00 90 28675 $348.00 90 29440 $22.00 0
28344 $414.00 90 28705 $1,353.00 90 29445 $214.00 0
28345 $557.00 90 28715 $1,179.00 90 29450 $84.00 0
28360 $1,197.00 90 28725 $1,015.00 90 29505 $75.00 0
28400 $266.00 90 28730 $945.00 90 29515 $59.00 0
28405 $473.00 90 28735 $961.00 90 29520 $22.00 0
28406 $616.00 90 28737 $873.00 90 29530 $55.00 0
28415 $1,354.00 90 28740 $690.00 90 29540 $41.00 0
28420 $1,619.00 90 28750 $690.00 90 29550 $37.00 0
28430 $110.00 90 28755 $466.00 90 29580 $39.00 0
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 92
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
29581 $62.00 0 29868 $1,694.00 90 30150 $790.00 90
29582 $71.00 0 29870 $460.00 90 30160 $875.00 90
29583 $44.00 0 29871 $631.00 90 30200 $68.00 0
29584 $71.00 0 29873 $489.00 90 30210 $75.00 10
29700 $29.00 0 29874 $676.00 90 30220 $154.00 10
29705 $26.00 0 29875 $639.00 90 30300 $45.00 10
29710 $29.00 0 29876 $809.00 90 30310 $170.00 10
29720 $29.00 0 29877 $852.00 90 30320 $419.00 90
29730 $29.00 0 29879 $1,064.00 90 30400 $741.00 90
29740 $37.00 0 29880 $1,169.00 90 30410 $1,173.00 90
29750 $105.00 0 29881 $745.00 90 30420 $1,424.00 90
29799 BR YYY 29882 $819.00 90 30430 $626.00 90
29800 $557.00 90 29883 $1,235.00 90 30435 $1,005.00 90
29804 $902.00 90 29884 $721.00 90 30450 $1,445.00 90
29805 $360.00 90 29885 $832.00 90 30460 $857.00 90
29806 $1,003.00 90 29886 $697.00 90 30462 $1,633.00 90
29807 $976.00 90 29887 $949.00 90 30465 $803.00 90
29819 $756.00 90 29888 $1,296.00 90 30520 $533.00 90
29820 $718.00 90 29889 $1,255.00 90 30540 $643.00 90
29821 $863.00 90 29891 $796.00 90 30545 $981.00 90
29822 $749.00 90 29892 $835.00 90 30560 $104.00 10
29823 $1,330.00 90 29893 $472.00 90 30580 $566.00 90
29824 $611.00 90 29894 $690.00 90 30600 $466.00 90
29825 $941.00 90 29895 $679.00 90 30620 $564.00 90
29826 $980.00 ZZZ 29897 $704.00 90 30630 $624.00 90
29827 $1,058.00 90 29898 $863.00 90 30801 $88.00 10
29828 $830.00 90 29899 $973.00 90 30802 $172.00 10
29830 $524.00 90 29900 $434.00 90 30901 $75.00 0
29834 $635.00 90 29901 $479.00 90 30903 $110.00 0
29835 $612.00 90 29902 $514.00 90 30905 $224.00 0
29836 $680.00 90 29904 $557.00 90 30906 $208.00 0
29837 $830.00 90 29905 $601.00 90 30915 $596.00 90
29838 $931.00 90 29906 $633.00 90 30920 $862.00 90
29840 $501.00 90 29907 $775.00 90 30930 $213.00 10
29843 $580.00 90 29914 $1,036.00 90 30999 BR YYY
29844 $612.00 90 29915 $1,057.00 90 31000 $81.00 10
29845 $931.00 90 29916 $1,057.00 90 31002 $135.00 10
29846 $976.00 90 29999 BR YYY 31020 $281.00 90
29847 $1,277.00 90 30000 $96.00 10 31030 $531.00 90
29848 $608.00 90 30020 $117.00 10 31032 $604.00 90
29850 $752.00 90 30100 $86.00 0 31040 $772.00 90
29851 $1,137.00 90 30110 $157.00 10 31050 $489.00 90
29855 $1,007.00 90 30115 $360.00 90 31051 $654.00 90
29856 $1,231.00 90 30117 $301.00 90 31070 $410.00 90
29860 $658.00 90 30118 $819.00 90 31075 $839.00 90
29861 $845.00 90 30120 $500.00 90 31080 $942.00 90
29862 $907.00 90 30124 $243.00 90 31081 $1,089.00 90
29863 $880.00 90 30125 $599.00 90 31084 $1,210.00 90
29866 $1,046.00 90 30130 $275.00 90 31085 $1,281.00 90
29867 $1,250.00 90 30140 $320.00 90 31086 $1,081.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 93
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
31087 $1,075.00 90 31513 $182.00 0 31624 $217.00 0
31090 $877.00 90 31515 $160.00 0 31625 $235.00 0
31200 $463.00 90 31525 $234.00 0 31626 $450.00 0
31201 $716.00 90 31526 $222.00 0 31627 $1,310.00 ZZZ
31205 $851.00 90 31527 $262.00 0 31628 $269.00 0
31225 $1,683.00 90 31528 $202.00 0 31629 $198.00 0
31230 $1,908.00 90 31529 $217.00 0 31630 $308.00 0
31231 $122.00 0 31530 $284.00 0 31631 $252.00 0
31233 $221.00 0 31531 $311.00 0 31632 $73.00 ZZZ
31235 $217.00 0 31535 $272.00 0 31633 $90.00 ZZZ
31237 $266.00 0 31536 $308.00 0 31634 $1,886.00 0
31238 $311.00 0 31540 $357.00 0 31635 $298.00 0
31239 $775.00 10 31541 $453.00 0 31636 $241.00 0
31240 $224.00 0 31545 $384.00 0 31637 $86.00 ZZZ
31254 $588.00 0 31546 $587.00 0 31638 $268.00 0
31255 $601.00 0 31551 $1,462.00 90 31640 $399.00 0
31256 $292.00 0 31552 $1,478.00 90 31641 $304.00 0
31267 $453.00 0 31553 $1,612.00 90 31643 $208.00 0
31276 $690.00 0 31554 $1,697.00 90 31645 $208.00 0
31287 $339.00 0 31560 $446.00 0 31646 $161.00 0
31288 $396.00 0 31561 $509.00 0 31647 $228.00 0
31290 $1,462.00 10 31570 $369.00 0 31648 $218.00 0
31291 $1,551.00 10 31571 $363.00 0 31649 $71.00 ZZZ
31292 $1,235.00 10 31572 $508.00 0 31651 $82.00 ZZZ
31293 $1,346.00 10 31573 $270.00 0 31652 $921.00 0
31294 $1,587.00 10 31574 $1,047.00 0 31653 $979.00 0
31295 $2,104.00 0 31575 $128.00 0 31654 $147.00 ZZZ
31296 $2,136.00 0 31576 $186.00 0 31660 $218.00 0
31297 $2,101.00 0 31577 $230.00 0 31661 $230.00 0
31299 BR YYY 31578 $264.00 0 31717 $138.00 0
31300 $1,295.00 90 31579 $219.00 0 31720 $89.00 0
31320 $508.00 90 31580 $1,213.00 90 31725 $103.00 0
31360 $1,630.00 90 31584 $1,616.00 90 31730 $199.00 0
31365 $2,238.00 90 31587 $913.00 90 31750 $1,088.00 90
31367 $1,913.00 90 31590 $691.00 90 31755 $1,448.00 90
31368 $2,478.00 90 31591 $1,071.00 90 31760 $1,648.00 90
31370 $1,891.00 90 31592 $1,733.00 90 31766 $2,315.00 90
31375 $1,720.00 90 31595 $773.00 90 31770 $1,815.00 90
31380 $1,782.00 90 31599 BR YYY 31775 $1,973.00 90
31382 $1,822.00 90 31600 $306.00 0 31780 $1,577.00 90
31390 $2,513.00 90 31603 $343.00 0 31781 $1,936.00 90
31395 $2,937.00 90 31605 $297.00 0 31785 $1,320.00 90
31400 $969.00 90 31610 $794.00 90 31786 $1,866.00 90
31420 $969.00 90 31611 $614.00 90 31800 $628.00 90
31500 $116.00 0 31612 $99.00 0 31805 $1,175.00 90
31502 $74.00 0 31613 $384.00 90 31820 $458.00 90
31505 $62.00 0 31614 $736.00 90 31825 $659.00 90
31510 $145.00 0 31615 $213.00 0 31830 $460.00 90
31511 $88.00 0 31622 $230.00 0 31899 BR YYY
31512 $197.00 0 31623 $225.00 0 32035 $821.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 94
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
32036 $908.00 90 32606 $637.00 0 33031 $1,816.00 90
32096 $835.00 90 32607 $321.00 0 33050 $1,224.00 90
32097 $836.00 90 32608 $394.00 0 33120 $2,358.00 90
32098 $789.00 90 32609 $272.00 0 33130 $1,734.00 90
32100 $1,120.00 90 32650 $957.00 90 33140 $1,571.00 90
32110 $1,223.00 90 32651 $1,166.00 90 33141 $254.00 ZZZ
32120 $1,077.00 90 32652 $1,615.00 90 33202 $749.00 90
32124 $1,144.00 90 32653 $1,144.00 90 33203 $766.00 90
32140 $1,284.00 90 32654 $1,096.00 90 33206 $642.00 90
32141 $1,267.00 90 32655 $1,213.00 90 33207 $753.00 90
32150 $1,226.00 90 32656 $1,222.00 90 33208 $573.00 90
32151 $1,231.00 90 32658 $1,142.00 90 33210 $204.00 0
32160 $842.00 90 32659 $1,141.00 90 33211 $210.00 0
32200 $1,132.00 90 32661 $1,165.00 90 33212 $511.00 90
32215 $1,024.00 90 32662 $1,459.00 90 33213 $437.00 90
32220 $1,680.00 90 32663 $1,636.00 90 33214 $532.00 90
32225 $1,268.00 90 32664 $1,197.00 90 33215 $304.00 90
32310 $1,221.00 90 32665 $1,360.00 90 33216 $402.00 90
32320 $1,787.00 90 32666 $902.00 90 33217 $428.00 90
32400 $129.00 0 32667 $164.00 ZZZ 33218 $488.00 90
32405 $159.00 0 32668 $164.00 ZZZ 33220 $390.00 90
32440 $1,837.00 90 32669 $1,395.00 90 33221 $379.00 90
32442 $2,093.00 90 32670 $1,658.00 90 33222 $471.00 90
32445 $2,093.00 90 32671 $1,847.00 90 33223 $585.00 90
32480 $1,622.00 90 32672 $1,584.00 90 33224 $490.00 0
32482 $1,714.00 90 32673 $1,251.00 90 33225 $434.00 ZZZ
32484 $1,771.00 90 32674 $224.00 ZZZ 33226 $472.00 0
32486 $1,974.00 90 32701 $229.00 0 33227 $359.00 90
32488 $2,094.00 90 32800 $1,166.00 90 33228 $374.00 90
32491 $1,784.00 90 32810 $1,085.00 90 33229 $393.00 90
32501 $374.00 ZZZ 32815 $1,917.00 90 33230 $408.00 90
32503 $1,875.00 90 32820 $1,848.00 90 33231 $421.00 90
32504 $2,145.00 90 32851 $3,100.00 90 33233 $270.00 90
32505 $964.00 90 32852 $3,339.00 90 33234 $598.00 90
32506 $164.00 ZZZ 32853 $3,787.00 90 33235 $587.00 90
32507 $164.00 ZZZ 32854 $4,038.00 90 33236 $933.00 90
32540 $1,308.00 90 32900 $1,532.00 90 33237 $1,184.00 90
32550 $821.00 0 32905 $1,661.00 90 33238 $1,235.00 90
32551 $171.00 0 32906 $2,100.00 90 33240 $648.00 90
32552 $196.00 10 32940 $1,555.00 90 33241 $301.00 90
32553 $597.00 0 32960 $126.00 0 33243 $1,650.00 90
32554 $201.00 0 32997 $312.00 0 33244 $1,081.00 90
32555 $300.00 0 32998 $2,809.00 0 33249 $1,271.00 90
32556 $542.00 0 32999 BR YYY 33250 $1,687.00 90
32557 $578.00 0 33010 $124.00 0 33251 $2,071.00 90
32560 $302.00 0 33011 $125.00 0 33254 $1,307.00 90
32561 $97.00 0 33015 $555.00 90 33255 $1,573.00 90
32562 $87.00 0 33020 $1,178.00 90 33256 $1,879.00 90
32601 $456.00 0 33025 $1,165.00 90 33257 $565.00 ZZZ
32604 $663.00 0 33030 $1,786.00 90 33258 $639.00 ZZZ
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 95
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
33259 $839.00 ZZZ 33460 $2,215.00 90 33615 $3,051.00 90
33261 $1,993.00 90 33463 $2,396.00 90 33617 $3,272.00 90
33262 $394.00 90 33464 $2,547.00 90 33619 $3,678.00 90
33263 $409.00 90 33465 $2,665.00 90 33620 $1,527.00 90
33264 $427.00 90 33468 $2,952.00 90 33621 $914.00 90
33265 $1,307.00 90 33470 $1,749.00 90 33622 $3,597.00 90
33266 $1,789.00 90 33471 $1,929.00 90 33641 $1,981.00 90
33270 $614.00 90 33474 $2,173.00 90 33645 $2,352.00 90
33271 $517.00 90 33475 $2,666.00 90 33647 $2,732.00 90
33272 $364.00 90 33476 $2,270.00 90 33660 $2,444.00 90
33273 $418.00 90 33477 $1,345.00 0 33665 $2,700.00 90
33282 $470.00 90 33478 $2,544.00 90 33670 $2,820.00 90
33284 $365.00 90 33496 $2,595.00 90 33675 $2,085.00 90
33300 $1,576.00 90 33500 $2,370.00 90 33676 $2,151.00 90
33305 $1,889.00 90 33501 $1,546.00 90 33677 $2,236.00 90
33310 $1,577.00 90 33502 $1,938.00 90 33681 $2,657.00 90
33315 $1,875.00 90 33503 $1,983.00 90 33684 $2,740.00 90
33320 $1,485.00 90 33504 $2,416.00 90 33688 $2,602.00 90
33321 $1,890.00 90 33505 $2,423.00 90 33690 $1,884.00 90
33322 $1,935.00 90 33506 $2,448.00 90 33692 $2,816.00 90
33330 $1,726.00 90 33507 $1,809.00 90 33694 $2,856.00 90
33335 $2,336.00 90 33508 $17.00 ZZZ 33697 $3,064.00 90
33361 $1,404.00 0 33510 $2,354.00 90 33702 $2,549.00 90
33362 $1,535.00 0 33511 $2,546.00 90 33710 $2,731.00 90
33363 $1,589.00 0 33512 $2,732.00 90 33720 $2,508.00 90
33364 $1,671.00 0 33513 $2,933.00 90 33722 $2,704.00 90
33365 $1,843.00 0 33514 $3,197.00 90 33724 $1,491.00 90
33366 $1,995.00 0 33516 $3,404.00 90 33726 $1,963.00 90
33367 $644.00 ZZZ 33517 $219.00 ZZZ 33730 $2,785.00 90
33368 $780.00 ZZZ 33518 $414.00 ZZZ 33732 $2,622.00 90
33369 $1,030.00 ZZZ 33519 $607.00 ZZZ 33735 $2,036.00 90
33404 $2,698.00 90 33521 $801.00 ZZZ 33736 $2,288.00 90
33405 $2,745.00 90 33522 $994.00 ZZZ 33737 $1,977.00 90
33406 $2,962.00 90 33523 $1,189.00 ZZZ 33750 $1,877.00 90
33410 $2,637.00 90 33530 $521.00 ZZZ 33755 $1,831.00 90
33411 $2,981.00 90 33533 $2,415.00 90 33762 $1,900.00 90
33412 $3,213.00 90 33534 $2,654.00 90 33764 $1,895.00 90
33413 $3,282.00 90 33535 $2,899.00 90 33766 $2,119.00 90
33414 $2,904.00 90 33536 $3,143.00 90 33767 $2,173.00 90
33415 $2,563.00 90 33542 $2,693.00 90 33768 $449.00 ZZZ
33416 $2,684.00 90 33545 $3,250.00 90 33770 $2,954.00 90
33417 $2,756.00 90 33548 $2,381.00 90 33771 $2,924.00 90
33418 $1,871.00 90 33572 $340.00 ZZZ 33774 $2,681.00 90
33419 $440.00 ZZZ 33600 $2,644.00 90 33775 $2,654.00 90
33420 $1,796.00 90 33602 $2,556.00 90 33776 $2,844.00 90
33422 $2,431.00 90 33606 $2,831.00 90 33777 $2,724.00 90
33425 $2,509.00 90 33608 $2,940.00 90 33778 $3,199.00 90
33426 $2,806.00 90 33610 $2,871.00 90 33779 $3,121.00 90
33427 $3,026.00 90 33611 $2,985.00 90 33780 $3,232.00 90
33430 $2,891.00 90 33612 $3,152.00 90 33781 $3,057.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 96
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
33782 $3,439.00 90 33956 $875.00 0 34510 $1,108.00 90
33783 $3,834.00 90 33957 $194.00 0 34520 $1,077.00 90
33786 $2,970.00 90 33958 $191.00 0 34530 $1,368.00 90
33788 $2,288.00 90 33959 $246.00 0 34800 $1,159.00 90
33800 $1,546.00 90 33962 $249.00 0 34802 $1,279.00 90
33802 $1,752.00 90 33963 $493.00 0 34803 $1,372.00 90
33803 $1,746.00 90 33964 $513.00 0 34804 $1,279.00 90
33813 $1,935.00 90 33965 $194.00 0 34805 $1,243.00 90
33814 $2,464.00 90 33966 $246.00 0 34806 $100.00 ZZZ
33820 $1,619.00 90 33967 $258.00 0 34808 $220.00 ZZZ
33822 $1,559.00 90 33968 $51.00 0 34812 $359.00 0
33824 $1,884.00 90 33969 $287.00 0 34813 $256.00 ZZZ
33840 $2,029.00 90 33970 $576.00 0 34820 $519.00 0
33845 $2,129.00 90 33971 $578.00 90 34825 $694.00 90
33851 $2,129.00 90 33973 $756.00 0 34826 $220.00 ZZZ
33852 $2,311.00 90 33974 $1,095.00 90 34830 $1,803.00 90
33853 $3,057.00 90 33975 $1,758.00 0 34831 $1,950.00 90
33860 $3,044.00 90 33976 $2,056.00 0 34832 $1,950.00 90
33863 $3,183.00 90 33977 $1,561.00 0 34833 $650.00 0
33864 $3,035.00 90 33978 $1,754.00 0 34834 $306.00 0
33870 $3,638.00 90 33979 $2,496.00 0 34900 $960.00 90
33875 $2,876.00 90 33980 $3,212.00 0 35001 $1,564.00 90
33877 $3,767.00 90 33981 $879.00 0 35002 $1,547.00 90
33880 $1,866.00 90 33982 $2,052.00 0 35005 $1,268.00 90
33881 $1,603.00 90 33983 $2,418.00 0 35011 $1,007.00 90
33883 $1,187.00 90 33984 $298.00 0 35013 $1,376.00 90
33884 $441.00 ZZZ 33985 $541.00 0 35021 $1,635.00 90
33886 $1,025.00 90 33986 $554.00 0 35022 $1,686.00 90
33889 $882.00 0 33987 $218.00 ZZZ 35045 $995.00 90
33891 $1,126.00 0 33988 $812.00 0 35081 $2,175.00 90
33910 $1,987.00 90 33989 $525.00 0 35082 $2,661.00 90
33915 $1,588.00 90 33990 $454.00 0 35091 $2,634.00 90
33916 $2,096.00 90 33991 $662.00 0 35092 $2,872.00 90
33917 $2,345.00 90 33992 $215.00 0 35102 $2,346.00 90
33920 $2,981.00 90 33993 $188.00 0 35103 $2,587.00 90
33922 $2,227.00 90 33999 BR YYY 35111 $1,398.00 90
33924 $421.00 ZZZ 34001 $1,012.00 90 35112 $1,351.00 90
33925 $1,849.00 90 34051 $1,134.00 90 35121 $2,000.00 90
33926 $2,499.00 90 34101 $800.00 90 35122 $2,382.00 90
33935 $5,415.00 90 34111 $669.00 90 35131 $1,495.00 90
33945 $3,813.00 90 34151 $1,288.00 90 35132 $1,742.00 90
33946 $319.00 0 34201 $777.00 90 35141 $1,231.00 90
33947 $353.00 0 34203 $949.00 90 35142 $1,339.00 90
33948 $252.00 0 34401 $953.00 90 35151 $1,390.00 90
33949 $245.00 0 34421 $779.00 90 35152 $1,229.00 90
33951 $435.00 0 34451 $1,117.00 90 35180 $997.00 90
33952 $449.00 0 34471 $685.00 90 35182 $1,345.00 90
33953 $486.00 0 34490 $660.00 90 35184 $976.00 90
33954 $502.00 0 34501 $910.00 90 35188 $1,048.00 90
33955 $873.00 0 34502 $2,044.00 90 35189 $1,380.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 97
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
35190 $1,018.00 90 35522 $1,253.00 90 35671 $1,315.00 90
35201 $852.00 90 35523 $1,237.00 90 35681 $751.00 ZZZ
35206 $835.00 90 35525 $1,197.00 90 35682 $627.00 ZZZ
35207 $935.00 90 35526 $1,527.00 90 35683 $702.00 ZZZ
35211 $1,833.00 90 35531 $2,000.00 90 35685 $216.00 ZZZ
35216 $1,494.00 90 35533 $1,716.00 90 35686 $178.00 ZZZ
35221 $1,243.00 90 35535 $1,816.00 90 35691 $1,546.00 90
35226 $841.00 90 35536 $1,888.00 90 35693 $1,140.00 90
35231 $1,053.00 90 35537 $2,141.00 90 35694 $1,353.00 90
35236 $947.00 90 35538 $2,391.00 90 35695 $1,351.00 90
35241 $1,926.00 90 35539 $2,248.00 90 35697 $166.00 ZZZ
35246 $1,701.00 90 35540 $2,505.00 90 35700 $264.00 ZZZ
35251 $1,260.00 90 35556 $1,745.00 90 35701 $494.00 90
35256 $1,568.00 90 35558 $1,219.00 90 35721 $500.00 90
35261 $1,008.00 90 35560 $1,899.00 90 35741 $499.00 90
35266 $921.00 90 35563 $1,115.00 90 35761 $532.00 90
35271 $1,814.00 90 35565 $1,312.00 90 35800 $567.00 90
35276 $1,541.00 90 35566 $2,161.00 90 35820 $951.00 90
35281 $1,396.00 90 35570 $1,455.00 90 35840 $771.00 90
35286 $1,036.00 90 35571 $1,612.00 90 35860 $496.00 90
35301 $1,486.00 90 35572 $369.00 ZZZ 35870 $1,583.00 90
35302 $1,109.00 90 35583 $1,843.00 90 35875 $827.00 90
35303 $1,218.00 90 35585 $2,277.00 90 35876 $1,232.00 90
35304 $1,267.00 90 35587 $1,698.00 90 35879 $1,163.00 90
35305 $1,218.00 90 35600 $273.00 ZZZ 35881 $1,275.00 90
35306 $456.00 ZZZ 35601 $1,495.00 90 35883 $1,247.00 90
35311 $1,999.00 90 35606 $1,539.00 90 35884 $1,324.00 90
35321 $1,031.00 90 35612 $1,349.00 90 35901 $709.00 90
35331 $1,724.00 90 35616 $1,346.00 90 35903 $818.00 90
35341 $1,908.00 90 35621 $1,265.00 90 35905 $1,343.00 90
35351 $1,555.00 90 35623 $1,193.00 90 35907 $1,335.00 90
35355 $1,336.00 90 35626 $1,921.00 90 36000 $46.00 0
35361 $1,859.00 90 35631 $1,891.00 90 36002 $181.00 0
35363 $2,006.00 90 35632 $1,725.00 90 36005 $68.00 0
35371 $1,006.00 90 35633 $1,926.00 90 36010 $136.00 0
35372 $1,085.00 90 35634 $1,688.00 90 36011 $194.00 0
35390 $225.00 ZZZ 35636 $1,656.00 90 36012 $186.00 0
35400 $224.00 ZZZ 35637 $1,704.00 90 36013 $141.00 0
35500 $423.00 ZZZ 35638 $1,731.00 90 36014 $159.00 0
35501 $1,569.00 90 35642 $1,298.00 90 36015 $186.00 0
35506 $1,641.00 90 35645 $1,304.00 90 36100 $176.00 0
35508 $1,564.00 90 35646 $2,105.00 90 36120 $120.00 0
35509 $1,529.00 90 35647 $1,555.00 90 36140 $106.00 0
35510 $1,316.00 90 35650 $1,236.00 90 36160 $196.00 0
35511 $1,256.00 90 35654 $1,603.00 90 36200 $240.00 0
35512 $1,291.00 90 35656 $1,589.00 90 36215 $240.00 0
35515 $1,387.00 90 35661 $1,145.00 90 36216 $270.00 0
35516 $1,391.00 90 35663 $1,237.00 90 36217 $325.00 0
35518 $1,313.00 90 35665 $1,333.00 90 36218 $79.00 ZZZ
35521 $1,393.00 90 35666 $1,686.00 90 36221 $1,132.00 0
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 98
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
36222 $1,433.00 0 36576 $429.00 10 37160 $1,681.00 90
36223 $1,560.00 0 36578 $546.00 10 37180 $1,769.00 90
36224 $1,715.00 0 36580 $307.00 0 37181 $1,923.00 90
36225 $1,545.00 0 36581 $646.00 10 37182 $914.00 0
36226 $1,749.00 0 36582 $1,210.00 10 37183 $425.00 0
36227 $253.00 ZZZ 36583 $708.00 10 37184 $3,074.00 0
36228 $1,190.00 ZZZ 36584 $321.00 0 37185 $1,002.00 ZZZ
36245 $249.00 0 36585 $1,525.00 10 37186 $2,076.00 ZZZ
36246 $272.00 0 36589 $176.00 10 37187 $2,991.00 0
36247 $323.00 0 36590 $378.00 10 37188 $2,586.00 0
36248 $53.00 ZZZ 36591 $21.00 0 37191 $2,683.00 0
36251 $1,436.00 0 36592 $26.00 0 37192 $1,555.00 0
36252 $1,561.00 0 36593 $37.00 0 37193 $1,638.00 0
36253 $2,307.00 0 36595 $880.00 0 37195 $302.00 0
36254 $2,211.00 0 36596 $194.00 0 37197 $1,541.00 0
36260 $749.00 90 36597 $167.00 0 37200 $232.00 0
36261 $388.00 90 36598 $130.00 0 37211 $419.00 0
36262 $297.00 90 36600 $24.00 0 37212 $370.00 0
36299 BR YYY 36620 $64.00 0 37213 $258.00 0
36410 $18.00 0 36625 $133.00 0 37214 $152.00 0
36415 BR 0 36640 $130.00 0 37215 $1,095.00 90
36416 BR 0 36680 $72.00 0 37216 $1,055.00 90
36425 $86.00 0 36800 $159.00 0 37217 $1,164.00 90
36430 $37.00 0 36810 $345.00 0 37218 $861.00 90
36455 $141.00 0 36815 $236.00 0 37220 $3,236.00 0
36468 BR 0 36818 $736.00 90 37221 $4,750.00 0
36470 $76.00 10 36819 $977.00 90 37222 $911.00 ZZZ
36471 $96.00 10 36820 $800.00 90 37223 $2,638.00 ZZZ
36475 $2,216.00 0 36821 $721.00 90 37224 $3,919.00 0
36476 $434.00 ZZZ 36823 $1,461.00 90 37225 $11,190.00 0
36478 $2,041.00 0 36825 $867.00 90 37226 $9,188.00 0
36479 $438.00 ZZZ 36830 $967.00 90 37227 $15,065.00 0
36481 $499.00 0 36831 $488.00 90 37228 $5,569.00 0
36500 $159.00 0 36832 $810.00 90 37229 $11,021.00 0
36511 $92.00 0 36833 $780.00 90 37230 $8,434.00 0
36512 $92.00 0 36835 $542.00 90 37231 $13,463.00 0
36513 $92.00 0 36838 $1,230.00 90 37232 $1,238.00 ZZZ
36514 $92.00 0 36860 $166.00 0 37233 $1,486.00 ZZZ
36515 $92.00 0 36861 $224.00 0 37234 $3,935.00 ZZZ
36516 $92.00 0 36901 $581.00 0 37235 $4,017.00 ZZZ
36522 $305.00 0 36902 $1,235.00 0 37236 $2,863.00 0
36556 $316.00 0 36903 $5,663.00 0 37237 $1,243.00 ZZZ
36558 $703.00 10 36904 $1,801.00 0 37238 $4,186.00 0
36561 $1,333.00 10 36905 $2,304.00 0 37239 $2,081.00 ZZZ
36563 $1,679.00 10 36906 $6,867.00 0 37241 $4,634.00 0
36565 $1,073.00 10 36907 $739.00 ZZZ 37242 $7,805.00 0
36566 $1,121.00 10 36908 $2,722.00 ZZZ 37243 $9,853.00 0
36569 $350.00 0 36909 $1,985.00 ZZZ 37244 $6,899.00 0
36571 $1,550.00 10 37140 $1,666.00 90 37246 $2,175.00 0
36575 $172.00 0 37145 $1,741.00 90 37247 $880.00 ZZZ
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 99
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
37248 $1,507.00 0 38305 $375.00 90 39599 BR YYY
37249 $646.00 ZZZ 38308 $425.00 90 40490 $108.00 0
37252 $1,426.00 ZZZ 38380 $628.00 90 40500 $422.00 90
37253 $222.00 ZZZ 38381 $1,087.00 90 40510 $469.00 90
37500 $739.00 90 38382 $798.00 90 40520 $467.00 90
37501 BR YYY 38500 $234.00 10 40525 $714.00 90
37565 $364.00 90 38505 $139.00 0 40527 $851.00 90
37600 $414.00 90 38510 $349.00 10 40530 $501.00 90
37605 $521.00 90 38520 $431.00 90 40650 $368.00 90
37606 $563.00 90 38525 $369.00 90 40652 $436.00 90
37607 $456.00 90 38530 $517.00 90 40654 $529.00 90
37609 $278.00 10 38542 $507.00 90 40700 $1,009.00 90
37615 $495.00 90 38550 $519.00 90 40701 $1,452.00 90
37616 $1,128.00 90 38555 $1,115.00 90 40702 $1,030.00 90
37617 $1,132.00 90 38562 $799.00 90 40720 $1,107.00 90
37618 $514.00 90 38564 $831.00 90 40761 $1,202.00 90
37619 $1,712.00 90 38570 $695.00 10 40799 BR YYY
37650 $430.00 90 38571 $902.00 10 40800 $110.00 10
37660 $789.00 90 38572 $1,049.00 10 40801 $208.00 10
37700 $336.00 90 38589 BR YYY 40804 $105.00 10
37718 $416.00 90 38700 $863.00 90 40805 $245.00 10
37722 $495.00 90 38720 $1,328.00 90 40806 $38.00 0
37735 $847.00 90 38724 $1,366.00 90 40808 $100.00 10
37760 $813.00 90 38740 $539.00 90 40810 $141.00 10
37761 $577.00 90 38745 $770.00 90 40812 $202.00 10
37765 $462.00 90 38746 $312.00 ZZZ 40814 $319.00 90
37766 $561.00 90 38747 $337.00 ZZZ 40816 $336.00 90
37780 $301.00 90 38760 $699.00 90 40818 $249.00 90
37785 $270.00 90 38765 $1,283.00 90 40819 $208.00 90
37788 $1,654.00 90 38770 $1,111.00 90 40820 $104.00 10
37790 $690.00 90 38780 $1,357.00 90 40830 $140.00 10
37799 BR YYY 38790 $158.00 0 40831 $213.00 10
38100 $974.00 90 38792 $26.00 0 40840 $687.00 90
38101 $982.00 90 38794 $298.00 90 40842 $684.00 90
38102 $332.00 ZZZ 38900 $141.00 ZZZ 40843 $947.00 90
38115 $1,020.00 90 38999 BR YYY 40844 $1,232.00 90
38120 $1,138.00 90 39000 $664.00 90 40845 $1,593.00 90
38129 BR YYY 39010 $1,148.00 90 40899 BR YYY
38200 $180.00 0 39200 $1,249.00 90 41000 $119.00 10
38205 $79.00 0 39220 $1,542.00 90 41005 $109.00 10
38206 $79.00 0 39401 $324.00 0 41006 $237.00 90
38220 $212.00 0 39402 $423.00 0 41007 $283.00 90
38221 $228.00 0 39499 BR YYY 41008 $248.00 90
38230 $265.00 0 39501 $1,083.00 90 41009 $319.00 90
38232 $214.00 0 39503 $2,726.00 90 41010 $91.00 10
38240 $128.00 0 39540 $1,133.00 90 41015 $267.00 90
38241 $128.00 0 39541 $1,179.00 90 41016 $357.00 90
38242 $90.00 0 39545 $1,102.00 90 41017 $300.00 90
38243 $121.00 0 39560 $968.00 90 41018 $424.00 90
38300 $104.00 10 39561 $1,328.00 90 41019 $444.00 0
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 100
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
41100 $140.00 10 42145 $741.00 90 42804 $136.00 10
41105 $136.00 10 42160 $176.00 10 42806 $167.00 10
41108 $110.00 10 42180 $222.00 10 42808 $250.00 10
41110 $159.00 10 42182 $324.00 10 42809 $152.00 10
41112 $255.00 90 42200 $946.00 90 42810 $335.00 90
41113 $301.00 90 42205 $863.00 90 42815 $659.00 90
41114 $682.00 90 42210 $1,174.00 90 42821 $378.00 90
41115 $176.00 10 42215 $766.00 90 42826 $320.00 90
41116 $242.00 90 42220 $586.00 90 42831 $235.00 90
41120 $813.00 90 42225 $803.00 90 42836 $286.00 90
41130 $937.00 90 42226 $848.00 90 42842 $729.00 90
41135 $1,869.00 90 42227 $762.00 90 42844 $1,173.00 90
41140 $2,005.00 90 42235 $631.00 90 42845 $1,958.00 90
41145 $2,406.00 90 42260 $491.00 90 42860 $207.00 90
41150 $1,897.00 90 42280 $148.00 10 42870 $427.00 90
41153 $2,091.00 90 42281 $160.00 10 42890 $1,047.00 90
41155 $2,448.00 90 42299 BR YYY 42892 $1,262.00 90
41250 $168.00 10 42300 $165.00 10 42894 $1,825.00 90
41251 $203.00 10 42305 $448.00 90 42900 $429.00 10
41252 $294.00 10 42310 $145.00 10 42950 $745.00 90
41500 $334.00 90 42320 $208.00 10 42953 $752.00 90
41510 $313.00 90 42330 $184.00 10 42955 $561.00 90
41512 $644.00 90 42335 $287.00 90 42960 $178.00 10
41520 $255.00 90 42340 $411.00 90 42961 $406.00 90
41530 $3,327.00 0 42400 $94.00 0 42962 $602.00 90
41599 BR YYY 42405 $258.00 10 42970 $284.00 90
41800 $107.00 10 42408 $377.00 90 42971 $472.00 90
41805 $115.00 10 42409 $266.00 90 42972 $562.00 90
41806 $217.00 10 42410 $746.00 90 42999 BR YYY
41820 BR 0 42415 $1,364.00 90 43020 $696.00 90
41821 BR 0 42420 $1,577.00 90 43030 $712.00 90
41822 $237.00 10 42425 $1,097.00 90 43045 $1,574.00 90
41823 $312.00 90 42426 $1,882.00 90 43100 $744.00 90
41825 $144.00 10 42440 $634.00 90 43101 $1,248.00 90
41826 $211.00 10 42450 $395.00 90 43107 $2,325.00 90
41827 $322.00 90 42500 $407.00 90 43108 $2,664.00 90
41828 $176.00 10 42505 $559.00 90 43112 $2,471.00 90
41830 $156.00 10 42507 $522.00 90 43113 $2,755.00 90
41850 BR 0 42509 $915.00 90 43116 $2,509.00 90
41870 BR 0 42510 $711.00 90 43117 $2,469.00 90
41872 $249.00 90 42550 $82.00 0 43118 $2,607.00 90
41874 $193.00 90 42600 $445.00 90 43121 $2,350.00 90
41899 BR YYY 42650 $67.00 0 43122 $2,287.00 90
42000 $106.00 10 42660 $89.00 0 43123 $2,661.00 90
42100 $122.00 10 42665 $238.00 90 43124 $2,242.00 90
42104 $161.00 10 42699 BR YYY 43130 $1,020.00 90
42106 $204.00 10 42700 $144.00 10 43135 $1,332.00 90
42107 $409.00 90 42720 $270.00 10 43180 $573.00 90
42120 $573.00 90 42725 $720.00 90 43191 $130.00 0
42140 $174.00 90 42800 $123.00 10 43192 $155.00 0
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 101
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
43193 $185.00 0 43260 $349.00 0 43420 $854.00 90
43194 $168.00 0 43261 $362.00 0 43425 $1,338.00 90
43195 $186.00 0 43262 $447.00 0 43450 $91.00 0
43196 $203.00 0 43263 $386.00 0 43453 $102.00 0
43197 $188.00 0 43264 $522.00 0 43460 $203.00 0
43198 $210.00 0 43265 $527.00 0 43496 BR 90
43200 $266.00 0 43266 $241.00 0 43499 BR YYY
43201 $245.00 0 43270 $737.00 0 43500 $649.00 90
43202 $205.00 0 43273 $129.00 ZZZ 43501 $1,105.00 90
43204 $228.00 0 43274 $498.00 0 43502 $1,247.00 90
43205 $207.00 0 43275 $411.00 0 43510 $680.00 90
43206 $337.00 0 43276 $518.00 0 43520 $599.00 90
43210 $444.00 0 43277 $413.00 0 43605 $686.00 90
43211 $253.00 0 43278 $470.00 0 43610 $861.00 90
43212 $200.00 0 43279 $1,319.00 90 43611 $1,001.00 90
43213 $1,253.00 0 43280 $1,314.00 90 43620 $1,691.00 90
43214 $203.00 0 43281 $1,577.00 90 43621 $1,718.00 90
43215 $160.00 0 43282 $1,774.00 90 43622 $1,798.00 90
43216 $149.00 0 43283 $161.00 ZZZ 43631 $1,445.00 90
43217 $176.00 0 43289 BR YYY 43632 $1,443.00 90
43220 $128.00 0 43300 $837.00 90 43633 $1,467.00 90
43226 $142.00 0 43305 $1,428.00 90 43634 $1,786.00 90
43227 $218.00 0 43310 $2,138.00 90 43635 $143.00 ZZZ
43229 $739.00 0 43312 $2,331.00 90 43640 $1,119.00 90
43231 $182.00 0 43313 $2,632.00 90 43641 $1,138.00 90
43232 $252.00 0 43314 $2,891.00 90 43644 $1,598.00 90
43233 $241.00 0 43320 $1,299.00 90 43645 $1,724.00 90
43235 $239.00 0 43325 $1,261.00 90 43651 $716.00 90
43236 $285.00 0 43327 $838.00 90 43652 $856.00 90
43237 $219.00 0 43328 $1,193.00 90 43653 $617.00 90
43238 $271.00 0 43330 $1,236.00 90 43659 BR YYY
43239 $246.00 0 43331 $1,378.00 90 43752 $36.00 0
43240 $369.00 0 43332 $1,188.00 90 43753 $21.00 0
43241 $157.00 0 43333 $1,292.00 90 43754 $92.00 0
43242 $384.00 0 43334 $1,282.00 90 43755 $140.00 0
43243 $276.00 0 43335 $1,374.00 90 43756 $214.00 0
43244 $268.00 0 43336 $1,557.00 90 43757 $301.00 0
43245 $214.00 0 43337 $1,681.00 90 43760 $81.00 0
43246 $485.00 0 43338 $120.00 ZZZ 43761 $107.00 0
43247 $229.00 0 43340 $1,292.00 90 43770 $1,009.00 90
43248 $191.00 0 43341 $1,351.00 90 43771 $1,162.00 90
43249 $175.00 0 43351 $1,180.00 90 43772 $885.00 90
43250 $194.00 0 43352 $1,028.00 90 43773 $1,162.00 90
43251 $224.00 0 43360 $2,277.00 90 43774 $888.00 90
43252 $376.00 0 43361 $2,596.00 90 43775 $1,146.00 90
43253 $280.00 0 43400 $1,261.00 90 43800 $793.00 90
43254 $291.00 0 43401 $1,299.00 90 43810 $846.00 90
43255 $343.00 0 43405 $1,330.00 90 43820 $896.00 90
43257 $305.00 0 43410 $946.00 90 43825 $1,128.00 90
43259 $271.00 0 43415 $1,382.00 90 43830 $592.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 102
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
43831 $593.00 90 44157 $1,952.00 90 44388 $326.00 0
43832 $904.00 90 44158 $2,003.00 90 44388-53 $178.00 0
43840 $893.00 90 44160 $1,236.00 90 44389 $301.00 0
43843 $1,249.00 90 44180 $853.00 90 44390 $319.00 0
43845 $1,738.00 90 44186 $600.00 90 44391 $376.00 0
43846 $1,528.00 90 44187 $992.00 90 44392 $359.00 0
43847 $1,678.00 90 44188 $1,088.00 90 44394 $395.00 0
43848 $1,795.00 90 44202 $1,603.00 90 44401 $3,308.00 0
43850 $1,425.00 90 44203 $235.00 ZZZ 44402 $282.00 0
43855 $1,454.00 90 44204 $1,353.00 90 44403 $324.00 0
43860 $1,435.00 90 44205 $1,198.00 90 44404 $434.00 0
43865 $1,549.00 90 44206 $1,480.00 90 44405 $622.00 0
43870 $590.00 90 44207 $1,620.00 90 44406 $247.00 0
43880 $1,352.00 90 44208 $1,752.00 90 44407 $296.00 0
43886 $280.00 90 44210 $1,551.00 90 44408 $250.00 0
43887 $274.00 90 44211 $1,926.00 90 44500 $28.00 0
43888 $389.00 90 44212 $1,800.00 90 44602 $815.00 90
43999 BR YYY 44213 $196.00 ZZZ 44603 $1,041.00 90
44005 $1,171.00 90 44227 $1,536.00 90 44604 $1,027.00 90
44010 $809.00 90 44238 BR YYY 44605 $1,132.00 90
44015 $1,171.00 ZZZ 44300 $697.00 90 44615 $994.00 90
44020 $891.00 90 44310 $950.00 90 44620 $741.00 90
44021 $888.00 90 44312 $453.00 90 44625 $1,277.00 90
44025 $905.00 90 44314 $892.00 90 44626 $1,581.00 90
44050 $862.00 90 44316 $1,229.00 90 44640 $1,036.00 90
44055 $957.00 90 44320 $1,029.00 90 44650 $1,076.00 90
44100 $117.00 0 44322 $1,015.00 90 44660 $1,050.00 90
44110 $784.00 90 44340 $397.00 90 44661 $1,326.00 90
44111 $963.00 90 44345 $816.00 90 44680 $1,049.00 90
44120 $1,078.00 90 44346 $923.00 90 44700 $1,115.00 90
44121 $308.00 ZZZ 44360 $177.00 0 44701 $161.00 ZZZ
44125 $1,135.00 90 44361 $195.00 0 44720 $268.00 0
44126 $1,951.00 90 44363 $213.00 0 44721 $393.00 0
44127 $2,243.00 90 44364 $255.00 0 44799 BR YYY
44128 $242.00 ZZZ 44365 $226.00 0 44800 $791.00 90
44130 $938.00 90 44366 $300.00 0 44820 $755.00 90
44133 BR 0 44369 $308.00 0 44850 $708.00 90
44136 BR 0 44370 $253.00 0 44899 BR YYY
44139 $154.00 ZZZ 44372 $301.00 0 44900 $644.00 90
44140 $1,350.00 90 44373 $238.00 0 44950 $643.00 90
44141 $1,488.00 90 44376 $305.00 0 44955 $136.00 ZZZ
44143 $1,536.00 90 44377 $320.00 0 44960 $790.00 90
44144 $1,442.00 90 44378 $410.00 0 44970 $631.00 90
44145 $1,678.00 90 44379 $396.00 0 44979 BR YYY
44146 $1,840.00 90 44380 $91.00 0 45000 $329.00 90
44147 $1,452.00 90 44381 $1,016.00 0 45005 $197.00 10
44150 $1,661.00 90 44382 $110.00 0 45020 $364.00 90
44151 $1,499.00 90 44384 $164.00 0 45100 $321.00 90
44155 $1,892.00 90 44385 $219.00 0 45108 $419.00 90
44156 $1,709.00 90 44386 $183.00 0 45110 $1,801.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 103
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
45111 $1,270.00 90 45386 $739.00 0 46270 $328.00 90
45112 $1,904.00 90 45388 $3,327.00 0 46275 $442.00 90
45113 $1,885.00 90 45389 $311.00 0 46280 $514.00 90
45114 $1,732.00 90 45390 $355.00 0 46285 $335.00 90
45116 $1,485.00 90 45391 $283.00 0 46288 $521.00 90
45119 $1,911.00 90 45392 $358.00 0 46320 $126.00 10
45120 $1,845.00 90 45393 $271.00 0 46500 $109.00 10
45121 $1,870.00 90 45395 $1,813.00 90 46505 $229.00 10
45123 $1,126.00 90 45397 $1,969.00 90 46600 $38.00 0
45126 $2,444.00 90 45398 $744.00 0 46601 $140.00 0
45130 $1,041.00 90 45400 $1,058.00 90 46604 $92.00 0
45135 $1,354.00 90 45402 $1,435.00 90 46606 $66.00 0
45136 $1,526.00 90 45500 $584.00 90 46607 $195.00 0
45150 $475.00 90 45505 $510.00 90 46608 $115.00 0
45160 $949.00 90 45520 $46.00 0 46610 $114.00 0
45171 $615.00 90 45540 $1,009.00 90 46611 $149.00 0
45172 $835.00 90 45541 $888.00 90 46612 $196.00 0
45190 $623.00 90 45550 $1,350.00 90 46614 $169.00 0
45300 $75.00 0 45560 $618.00 90 46615 $202.00 0
45303 $72.00 0 45562 $915.00 90 46700 $585.00 90
45305 $102.00 0 45563 $1,412.00 90 46706 $140.00 10
45307 $172.00 0 45800 $1,050.00 90 46707 $473.00 90
45308 $137.00 0 45805 $1,273.00 90 46710 $953.00 90
45309 $174.00 0 45820 $1,066.00 90 46712 $1,999.00 90
45315 $211.00 0 45825 $1,241.00 90 46715 $545.00 90
45317 $209.00 0 45900 $120.00 10 46716 $906.00 90
45320 $230.00 0 45905 $133.00 10 46730 $1,584.00 90
45321 $154.00 0 45910 $163.00 10 46735 $1,881.00 90
45327 $96.00 0 45915 $142.00 10 46740 $1,671.00 90
45330 $87.00 0 45990 $105.00 0 46742 $2,236.00 90
45331 $120.00 0 45999 BR YYY 46744 $2,412.00 90
45332 $174.00 0 46020 $230.00 10 46746 $2,725.00 90
45333 $176.00 0 46030 $94.00 10 46748 $2,933.00 90
45334 $171.00 0 46040 $393.00 90 46750 $636.00 90
45335 $144.00 0 46045 $312.00 90 46753 $511.00 90
45337 $144.00 0 46050 $105.00 10 46754 $188.00 10
45338 $212.00 0 46060 $482.00 90 46760 $846.00 90
45340 $328.00 0 46080 $246.00 10 46761 $813.00 90
45341 $153.00 0 46083 $98.00 10 46762 $731.00 90
45342 $224.00 0 46200 $323.00 90 46900 $128.00 10
45346 $3,167.00 0 46220 $118.00 10 46910 $144.00 10
45347 $168.00 0 46221 $124.00 10 46916 $145.00 10
45349 $214.00 0 46230 $198.00 10 46917 $228.00 10
45350 $593.00 0 46250 $400.00 90 46922 $189.00 10
45379 $415.00 0 46255 $501.00 90 46924 $297.00 10
45380 $369.00 0 46257 $504.00 90 46930 $207.00 90
45381 $388.00 0 46258 $539.00 90 46940 $165.00 10
45382 $481.00 0 46260 $598.00 90 46942 $145.00 10
45384 $415.00 0 46261 $655.00 90 46945 $199.00 90
45385 $479.00 0 46262 $686.00 90 46946 $270.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 104
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
46947 $328.00 90 47554 $594.00 0 48510 $938.00 90
46999 BR YYY 47555 $383.00 0 48520 $1,103.00 90
47000 $218.00 0 47556 $425.00 0 48540 $1,350.00 90
47001 $141.00 ZZZ 47562 $837.00 90 48545 $1,170.00 90
47010 $788.00 90 47563 $900.00 90 48547 $1,630.00 90
47015 $755.00 90 47564 $1,069.00 90 48548 $1,460.00 90
47100 $550.00 90 47570 $961.00 90 48552 $230.00 0
47120 $1,663.00 90 47579 BR YYY 48554 $2,365.00 90
47122 $2,512.00 90 47600 $868.00 90 48556 $1,117.00 90
47125 $2,293.00 90 47605 $935.00 90 48999 BR YYY
47130 $2,482.00 90 47610 $1,164.00 90 49000 $862.00 90
47135 $6,164.00 90 47612 $1,276.00 90 49002 $784.00 90
47146 $337.00 0 47620 $1,295.00 90 49010 $915.00 90
47147 $393.00 0 47700 $1,111.00 90 49020 $910.00 90
47300 $778.00 90 47701 $1,913.00 90 49040 $763.00 90
47350 $942.00 90 47711 $1,442.00 90 49060 $827.00 90
47360 $1,305.00 90 47712 $1,793.00 90 49062 $892.00 90
47361 $2,129.00 90 47715 $1,157.00 90 49082 $193.00 0
47362 $849.00 90 47720 $1,040.00 90 49083 $300.00 0
47370 $943.00 90 47721 $1,248.00 90 49084 $104.00 0
47371 $889.00 90 47740 $1,188.00 90 49180 $212.00 0
47379 BR YYY 47741 $1,425.00 90 49185 $1,012.00 0
47380 $1,107.00 90 47760 $1,568.00 90 49203 $1,049.00 90
47381 $1,094.00 90 47765 $1,624.00 90 49204 $1,337.00 90
47382 $660.00 10 47780 $1,635.00 90 49205 $1,530.00 90
47383 $7,678.00 10 47785 $1,871.00 90 49215 $1,551.00 90
47399 BR YYY 47800 $1,485.00 90 49220 $1,182.00 90
47400 $1,435.00 90 47801 $906.00 90 49250 $622.00 90
47420 $1,222.00 90 47802 $1,352.00 90 49255 $591.00 90
47425 $1,275.00 90 47900 $1,331.00 90 49320 $415.00 10
47460 $1,039.00 90 47999 BR YYY 49321 $443.00 10
47480 $755.00 90 48000 $1,053.00 90 49322 $460.00 10
47490 $467.00 10 48001 $1,305.00 90 49323 $712.00 90
47531 $379.00 0 48020 $983.00 90 49324 $348.00 10
47532 $835.00 0 48100 $779.00 90 49325 $374.00 10
47533 $1,362.00 0 48102 $341.00 10 49326 $171.00 ZZZ
47534 $1,678.00 0 48105 $2,505.00 90 49327 $133.00 ZZZ
47535 $1,126.00 0 48120 $1,083.00 90 49329 BR YYY
47536 $831.00 0 48140 $1,546.00 90 49400 $127.00 0
47537 $411.00 0 48145 $1,661.00 90 49402 $748.00 90
47538 $4,584.00 0 48146 $1,830.00 90 49405 $886.00 0
47539 $5,009.00 0 48148 $1,149.00 90 49406 $886.00 0
47540 $5,208.00 0 48150 $3,101.00 90 49407 $749.00 0
47541 $1,202.00 0 48152 $2,888.00 90 49411 $537.00 0
47542 $526.00 ZZZ 48153 $3,099.00 90 49412 $83.00 ZZZ
47543 $1,350.00 ZZZ 48154 $2,893.00 90 49418 $1,453.00 0
47544 $831.00 ZZZ 48155 $1,855.00 90 49419 $405.00 90
47550 $209.00 ZZZ 48160 BR 0 49421 $452.00 0
47552 $364.00 0 48400 $100.00 ZZZ 49422 $468.00 10
47553 $342.00 0 48500 $1,012.00 90 49423 $106.00 0
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 105
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
49424 $54.00 0 49659 BR YYY 50396 $101.00 0
49425 $914.00 90 49900 $512.00 90 50400 $1,441.00 90
49426 $725.00 90 49904 $1,394.00 90 50405 $1,802.00 90
49427 $48.00 0 49905 $454.00 ZZZ 50430 $531.00 0
49428 $184.00 10 49906 BR 90 50431 $165.00 0
49429 $522.00 10 49999 BR YYY 50432 $860.00 0
49435 $110.00 ZZZ 50010 $886.00 90 50433 $1,158.00 0
49436 $164.00 10 50020 $1,084.00 90 50434 $916.00 0
49440 $1,113.00 10 50040 $910.00 90 50435 $481.00 0
49441 $1,319.00 10 50045 $1,137.00 90 50500 $1,471.00 90
49442 $1,075.00 10 50060 $1,394.00 90 50520 $1,281.00 90
49446 $1,100.00 0 50065 $1,514.00 90 50525 $1,644.00 90
49450 $771.00 0 50070 $1,476.00 90 50526 $1,639.00 90
49451 $817.00 0 50075 $1,839.00 90 50540 $1,468.00 90
49452 $998.00 0 50080 $1,186.00 90 50541 $1,037.00 90
49460 $818.00 0 50081 $1,635.00 90 50542 $1,093.00 90
49465 $170.00 0 50100 $1,250.00 90 50543 $1,374.00 90
49505 $510.00 90 50120 $1,180.00 90 50544 $1,428.00 90
49507 $636.00 90 50125 $1,228.00 90 50545 $1,273.00 90
49520 $631.00 90 50130 $1,301.00 90 50546 $1,325.00 90
49521 $730.00 90 50135 $1,506.00 90 50547 $1,702.00 90
49525 $584.00 90 50200 $151.00 0 50548 $1,555.00 90
49540 $668.00 90 50205 $807.00 90 50549 BR YYY
49550 $557.00 90 50220 $1,316.00 90 50551 $411.00 0
49553 $598.00 90 50225 $1,554.00 90 50553 $447.00 0
49555 $621.00 90 50230 $1,695.00 90 50555 $668.00 0
49557 $715.00 90 50234 $1,671.00 90 50557 $676.00 0
49560 $734.00 90 50236 $1,873.00 90 50561 $755.00 0
49561 $856.00 90 50240 $1,679.00 90 50562 $580.00 90
49565 $754.00 90 50250 $1,157.00 90 50570 $549.00 0
49566 $881.00 90 50280 $1,170.00 90 50572 $728.00 0
49568 $339.00 ZZZ 50290 $1,080.00 90 50574 $762.00 0
49570 $411.00 90 50320 $1,680.00 90 50575 $991.00 0
49572 $491.00 90 50327 $214.00 0 50576 $801.00 0
49585 $444.00 90 50328 $187.00 0 50580 $726.00 0
49587 $501.00 90 50329 $179.00 0 50590 $980.00 90
49590 $585.00 90 50340 $1,083.00 90 50592 $5,936.00 10
49600 $774.00 90 50360 $2,475.00 90 50593 $4,692.00 10
49605 $1,648.00 90 50365 $2,941.00 90 50600 $1,150.00 90
49606 $1,416.00 90 50370 $1,128.00 90 50605 $1,054.00 90
49610 $784.00 90 50380 $1,507.00 90 50606 $538.00 ZZZ
49611 $770.00 90 50382 $1,594.00 0 50610 $1,209.00 90
49650 $484.00 90 50384 $1,540.00 0 50620 $1,152.00 90
49651 $621.00 90 50385 $1,326.00 0 50630 $1,170.00 90
49652 $700.00 90 50386 $857.00 0 50650 $1,297.00 90
49653 $874.00 90 50387 $772.00 0 50660 $1,426.00 90
49654 $795.00 90 50389 $529.00 0 50684 $74.00 0
49655 $971.00 90 50390 $118.00 0 50686 $109.00 0
49656 $864.00 90 50391 $139.00 0 50688 $89.00 10
49657 $1,240.00 90 50395 $203.00 0 50690 $85.00 0
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 106
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
50693 $1,078.00 0 51050 $596.00 90 51736-26 $32.00 0
50694 $1,187.00 0 51060 $768.00 90 51736-TC $15.00 0
50695 $1,447.00 0 51065 $704.00 90 51741 $81.00 0
50700 $1,192.00 90 51080 $510.00 90 51741-26 $59.00 0
50705 $1,735.00 ZZZ 51100 $63.00 0 51741-TC $17.00 0
50706 $778.00 ZZZ 51101 $130.00 0 51784 $119.00 0
50715 $1,397.00 90 51102 $335.00 0 51784-26 $80.00 0
50722 $1,211.00 90 51500 $775.00 90 51784-TC $136.00 0
50725 $1,371.00 90 51520 $764.00 90 51785 $52.00 0
50727 $640.00 90 51525 $1,069.00 90 51785-26 $80.00 0
50728 $924.00 90 51530 $957.00 90 51785-TC $155.00 0
50740 $1,386.00 90 51535 $932.00 90 51792 $143.00 0
50750 $1,457.00 90 51550 $1,171.00 90 51792-26 $60.00 0
50760 $1,389.00 90 51555 $1,514.00 90 51792-TC $213.00 0
50770 $1,485.00 90 51565 $1,624.00 90 51797 $109.00 ZZZ
50780 $1,391.00 90 51570 $1,762.00 90 51797-26 $84.00 ZZZ
50782 $1,465.00 90 51575 $2,284.00 90 51797-TC $205.00 ZZZ
50783 $1,515.00 90 51580 $2,252.00 90 51798 $20.00 0
50785 $1,548.00 90 51585 $2,601.00 90 51800 $1,294.00 90
50800 $1,226.00 90 51590 $2,441.00 90 51820 $1,236.00 90
50810 $1,527.00 90 51595 $2,900.00 90 51840 $858.00 90
50815 $1,643.00 90 51596 $3,063.00 90 51841 $1,040.00 90
50820 $1,729.00 90 51597 $2,914.00 90 51845 $843.00 90
50825 $2,351.00 90 51600 $54.00 0 51860 $912.00 90
50830 $2,292.00 90 51605 $83.00 0 51865 $1,150.00 90
50840 $1,493.00 90 51610 $45.00 0 51880 $590.00 90
50845 $1,513.00 90 51700 $29.00 0 51900 $1,050.00 90
50860 $1,163.00 90 51701 $58.00 0 51920 $881.00 90
50900 $1,043.00 90 51702 $92.00 0 51925 $1,167.00 90
50920 $1,075.00 90 51703 $128.00 0 51940 $2,082.00 90
50930 $1,380.00 90 51705 $37.00 0 51960 $1,848.00 90
50940 $1,107.00 90 51710 $119.00 0 51980 $858.00 90
50945 $1,096.00 90 51715 $322.00 0 51990 $850.00 90
50947 $1,384.00 90 51720 $140.00 0 51992 $925.00 90
50948 $1,265.00 90 51725 $116.00 0 52000 $190.00 0
50949 BR YYY 51725-26 $79.00 0 52001 $133.00 0
50951 $414.00 0 51725-TC $199.00 0 52005 $265.00 0
50953 $461.00 0 51726 $136.00 0 52007 $230.00 0
50955 $546.00 0 51726-26 $90.00 0 52010 $292.00 0
50957 $546.00 0 51726-TC $274.00 0 52204 $286.00 0
50961 $510.00 0 51727 $314.00 0 52214 $367.00 0
50970 $510.00 0 51727-26 $111.00 0 52224 $339.00 0
50972 $408.00 0 51727-TC $203.00 0 52234 $471.00 0
50974 $661.00 0 51728 $315.00 0 52235 $546.00 0
50976 $641.00 0 51728-26 $108.00 0 52240 $887.00 0
50980 $443.00 0 51728-TC $207.00 0 52250 $311.00 0
51020 $587.00 90 51729 $341.00 0 52260 $262.00 0
51030 $538.00 90 51729-26 $131.00 0 52265 $243.00 0
51040 $439.00 90 51729-TC $211.00 0 52270 $374.00 0
51045 $548.00 90 51736 $47.00 0 52275 $446.00 0
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 107
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
52276 $490.00 0 53060 $180.00 10 53860 $1,546.00 90
52277 $448.00 0 53080 $567.00 90 53899 BR YYY
52281 $259.00 0 53085 $836.00 90 54015 $348.00 10
52282 $560.00 0 53200 $218.00 0 54050 $91.00 10
52283 $309.00 0 53210 $904.00 90 54055 $106.00 10
52285 $375.00 0 53215 $1,142.00 90 54056 $100.00 10
52287 $311.00 0 53220 $546.00 90 54057 $149.00 10
52290 $304.00 0 53230 $760.00 90 54060 $180.00 10
52300 $370.00 0 53235 $607.00 90 54065 $281.00 10
52301 $382.00 0 53240 $506.00 90 54100 $149.00 0
52305 $370.00 0 53250 $464.00 90 54105 $261.00 10
52310 $348.00 0 53260 $240.00 10 54110 $775.00 90
52315 $553.00 0 53265 $295.00 10 54111 $1,035.00 90
52317 $772.00 0 53270 $226.00 10 54112 $1,210.00 90
52318 $684.00 0 53275 $332.00 10 54115 $588.00 90
52320 $369.00 0 53400 $929.00 90 54120 $777.00 90
52325 $494.00 0 53405 $1,088.00 90 54125 $1,092.00 90
52327 $369.00 0 53410 $1,151.00 90 54130 $1,532.00 90
52330 $507.00 0 53415 $1,381.00 90 54135 $1,945.00 90
52332 $451.00 0 53420 $1,088.00 90 54162 $220.00 10
52334 $340.00 0 53425 $1,150.00 90 54163 $207.00 10
52341 $317.00 0 53430 $1,116.00 90 54164 $182.00 10
52342 $344.00 0 53431 $1,053.00 90 54200 $78.00 10
52343 $380.00 0 53440 $1,057.00 90 54205 $633.00 90
52344 $407.00 0 53442 $639.00 90 54220 $189.00 0
52345 $433.00 0 53444 $755.00 90 54230 $104.00 0
52346 $488.00 0 53445 $1,197.00 90 54231 $172.00 0
52351 $297.00 0 53446 $699.00 90 54235 $81.00 0
52352 $349.00 0 53447 $991.00 90 54240 $109.00 0
52353 $404.00 0 53448 $1,259.00 90 54240-26 $68.00 0
52354 $372.00 0 53449 $784.00 90 54240-TC $24.00 0
52355 $447.00 0 53450 $447.00 90 54250 $104.00 0
52356 $424.00 0 53460 $494.00 90 54250-26 $116.00 0
52400 $580.00 90 53500 $719.00 90 54250-TC $9.00 0
52402 $279.00 0 53502 $590.00 90 54300 $830.00 90
52441 $1,258.00 0 53505 $586.00 90 54304 $988.00 90
52442 $962.00 ZZZ 53510 $777.00 90 54308 $881.00 90
52450 $602.00 90 53515 $987.00 90 54312 $1,067.00 90
52500 $705.00 90 53520 $661.00 90 54316 $1,316.00 90
52601 $1,021.00 90 53600 $37.00 0 54318 $900.00 90
52630 $653.00 90 53601 $37.00 0 54322 $974.00 90
52640 $573.00 90 53605 $81.00 0 54324 $1,260.00 90
52647 $858.00 90 53620 $59.00 0 54326 $1,212.00 90
52648 $957.00 90 53621 $45.00 0 54328 $1,201.00 90
52649 $973.00 90 53660 $49.00 0 54332 $1,327.00 90
52700 $517.00 90 53661 $50.00 0 54336 $1,672.00 90
53000 $224.00 10 53665 $50.00 0 54340 $727.00 90
53010 $336.00 90 53850 $741.00 90 54344 $1,360.00 90
53020 $153.00 0 53852 $728.00 90 54348 $1,318.00 90
53040 $460.00 90 53855 $770.00 0 54352 $1,820.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 108
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
54360 $898.00 90 55040 $439.00 90 56420 $130.00 10
54380 $1,054.00 90 55041 $634.00 90 56440 $271.00 10
54385 $1,217.00 90 55060 $430.00 90 56441 $183.00 10
54390 $1,635.00 90 55100 $156.00 10 56442 $45.00 0
54400 $784.00 90 55110 $223.00 90 56501 $122.00 10
54401 $892.00 90 55120 $350.00 90 56515 $200.00 10
54405 $1,294.00 90 55150 $562.00 90 56605 $96.00 0
54406 $687.00 90 55175 $426.00 90 56606 $49.00 ZZZ
54408 $724.00 90 55180 $796.00 90 56620 $607.00 90
54410 $856.00 90 55200 $310.00 90 56625 $735.00 90
54411 $933.00 90 55250 $349.00 90 56630 $1,061.00 90
54415 $510.00 90 55300 $167.00 0 56631 $1,400.00 90
54416 $665.00 90 55400 $660.00 90 56632 $1,636.00 90
54417 $819.00 90 55450 $391.00 10 56633 $1,350.00 90
54420 $899.00 90 55500 $445.00 90 56634 $1,537.00 90
54430 $799.00 90 55520 $446.00 90 56637 $1,806.00 90
54435 $503.00 90 55530 $467.00 90 56640 $1,777.00 90
54437 $701.00 90 55535 $496.00 90 56700 $227.00 10
54438 $1,413.00 90 55540 $572.00 90 56740 $321.00 10
54440 BR 90 55550 $486.00 90 56800 $310.00 10
54450 $88.00 0 55559 BR YYY 56805 $1,349.00 90
54500 $102.00 0 55600 $486.00 90 56810 $316.00 10
54505 $259.00 10 55605 $609.00 90 56820 $119.00 0
54512 $519.00 90 55650 $853.00 90 56821 $154.00 0
54520 $445.00 90 55680 $426.00 90 57000 $237.00 10
54522 $589.00 90 55700 $183.00 0 57010 $429.00 90
54530 $683.00 90 55705 $368.00 10 57020 $118.00 0
54535 $922.00 90 55706 $373.00 10 57022 $179.00 10
54550 $588.00 90 55720 $555.00 90 57023 $290.00 10
54560 $842.00 90 55725 $670.00 90 57061 $124.00 10
54600 $524.00 90 55801 $1,331.00 90 57065 $251.00 10
54620 $373.00 10 55810 $1,711.00 90 57100 $90.00 0
54640 $594.00 90 55812 $1,989.00 90 57105 $132.00 10
54650 $861.00 90 55815 $2,328.00 90 57106 $409.00 90
54660 $401.00 90 55821 $1,153.00 90 57107 $1,467.00 90
54670 $485.00 90 55831 $1,252.00 90 57109 $1,787.00 90
54680 $948.00 90 55840 $1,705.00 90 57110 $1,015.00 90
54690 $825.00 90 55842 $1,859.00 90 57111 $1,793.00 90
54692 $850.00 90 55845 $2,222.00 90 57112 $1,907.00 90
54699 BR YYY 55860 $1,012.00 90 57120 $612.00 90
54700 $133.00 10 55862 $1,351.00 90 57130 $220.00 10
54800 $257.00 0 55865 $1,890.00 90 57135 $231.00 10
54830 $411.00 90 55866 $1,615.00 90 57150 $50.00 0
54840 $432.00 90 55870 $166.00 0 57155 $383.00 0
54860 $503.00 90 55873 $1,127.00 90 57156 $198.00 0
54861 $696.00 90 55875 $729.00 90 57160 $67.00 0
54865 $333.00 90 55876 $147.00 0 57170 $74.00 0
54900 $969.00 90 55899 BR YYY 57180 $124.00 10
54901 $1,340.00 90 55920 $420.00 0 57200 $313.00 90
55000 $109.00 0 56405 $131.00 10 57210 $395.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 109
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
57220 $378.00 90 57522 $319.00 90 58540 $923.00 90
57230 $442.00 90 57530 $386.00 90 58541 $793.00 90
57240 $536.00 90 57531 $2,036.00 90 58542 $877.00 90
57250 $485.00 90 57540 $815.00 90 58543 $891.00 90
57260 $700.00 90 57545 $700.00 90 58544 $965.00 90
57265 $902.00 90 57550 $486.00 90 58545 $876.00 90
57267 $284.00 ZZZ 57555 $774.00 90 58546 $1,104.00 90
57268 $577.00 90 57556 $718.00 90 58548 $1,688.00 90
57270 $867.00 90 57558 $120.00 10 58550 $1,038.00 90
57280 $1,071.00 90 57700 $279.00 90 58552 $853.00 90
57282 $734.00 90 57720 $328.00 90 58553 $1,096.00 90
57283 $673.00 90 57800 $71.00 0 58554 $1,085.00 90
57284 $950.00 90 58100 $74.00 0 58555 $261.00 0
57285 $607.00 90 58110 $53.00 ZZZ 58558 $340.00 0
57287 $685.00 90 58120 $297.00 10 58559 $436.00 0
57288 $1,009.00 90 58140 $1,010.00 90 58560 $482.00 0
57289 $879.00 90 58145 $677.00 90 58561 $677.00 0
57291 $622.00 90 58146 $1,089.00 90 58562 $339.00 0
57292 $925.00 90 58150 $1,110.00 90 58563 $450.00 0
57295 $485.00 90 58152 $1,159.00 90 58565 $2,189.00 90
57296 $880.00 90 58180 $1,118.00 90 58570 $844.00 90
57300 $653.00 90 58200 $1,562.00 90 58571 $922.00 90
57305 $995.00 90 58210 $2,080.00 90 58572 $1,047.00 90
57307 $997.00 90 58240 $2,898.00 90 58573 $1,178.00 90
57308 $769.00 90 58260 $926.00 90 58578 BR YYY
57310 $517.00 90 58262 $1,026.00 90 58579 BR YYY
57311 $612.00 90 58263 $1,120.00 90 58600 $337.00 90
57320 $693.00 90 58267 $1,133.00 90 58605 $298.00 90
57330 $916.00 90 58270 $1,019.00 90 58611 $47.00 ZZZ
57335 $963.00 90 58275 $1,121.00 90 58615 $319.00 10
57400 $70.00 0 58280 $1,132.00 90 58660 $793.00 90
57410 $57.00 0 58285 $1,360.00 90 58661 $804.00 10
57415 $75.00 10 58290 $1,089.00 90 58662 $807.00 90
57420 $124.00 0 58291 $1,197.00 90 58670 $450.00 90
57421 $162.00 0 58292 $1,268.00 90 58671 $463.00 90
57423 $848.00 90 58293 $1,318.00 90 58672 $872.00 90
57425 $902.00 90 58294 $1,168.00 90 58673 $928.00 90
57426 $879.00 90 58301 $71.00 0 58679 BR YYY
57452 $96.00 0 58321 $81.00 0 58700 $544.00 90
57454 $125.00 0 58322 $90.00 0 58720 $844.00 90
57455 $149.00 0 58323 $24.00 0 58740 $508.00 90
57456 $141.00 0 58340 $87.00 0 58750 $949.00 90
57460 $223.00 0 58345 $335.00 10 58752 $893.00 90
57461 $333.00 0 58346 $408.00 90 58760 $769.00 90
57500 $89.00 0 58350 $103.00 10 58770 $763.00 90
57505 $105.00 10 58353 $225.00 10 58800 $343.00 90
57510 $140.00 10 58356 $531.00 10 58805 $509.00 90
57511 $159.00 10 58400 $519.00 90 58820 $326.00 90
57513 $191.00 10 58410 $752.00 90 58822 $603.00 90
57520 $359.00 90 58520 $663.00 90 58825 $469.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 110
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
58900 $489.00 90 59430 $140.00 0 60522 $1,820.00 90
58920 $571.00 90 59510 $2,064.00 0 60540 $1,272.00 90
58925 $820.00 90 59514 $1,199.00 0 60545 $1,505.00 90
58940 $592.00 90 59515 $1,324.00 0 60600 $1,477.00 90
58943 $1,368.00 90 59525 $591.00 ZZZ 60605 $1,624.00 90
58950 $1,170.00 90 59610 $1,805.00 0 60650 $1,340.00 90
58951 $1,703.00 90 59612 $1,113.00 0 60659 BR YYY
58952 $1,876.00 90 59614 $1,208.00 0 60699 BR YYY
58953 $1,839.00 90 59618 $2,035.00 0 61020 $150.00 0
58954 $1,999.00 90 59620 $1,293.00 0 61026 $138.00 0
58956 $1,329.00 90 59622 $1,397.00 0 61050 $106.00 0
58957 $1,365.00 90 59812 $343.00 90 61055 $143.00 0
58958 $1,511.00 90 59820 $389.00 90 61070 $67.00 0
58960 $1,174.00 90 59821 $398.00 90 61105 $503.00 90
58999 BR YYY 59830 $496.00 90 61107 $863.00 0
59000 $123.00 0 59840 $331.00 10 61108 $959.00 90
59001 $167.00 0 59841 $443.00 10 61120 $733.00 90
59012 $267.00 0 59850 $449.00 90 61140 $1,389.00 90
59015 $168.00 0 59851 $464.00 90 61150 $1,503.00 90
59020 $85.00 0 59852 $642.00 90 61151 $795.00 90
59020-26 $40.00 0 59855 $477.00 90 61154 $1,393.00 90
59020-TC $23.00 0 59856 $577.00 90 61156 $1,473.00 90
59025 $54.00 0 59857 $711.00 90 61210 $527.00 0
59025-26 $32.00 0 59866 $304.00 0 61215 $637.00 90
59025-TC $10.00 0 59870 $348.00 90 61250 $888.00 90
59030 $155.00 0 59871 $192.00 0 61253 $1,042.00 90
59050 $71.00 0 59898 BR YYY 61304 $2,005.00 90
59051 $47.00 0 59899 BR YYY 61305 $2,419.00 90
59100 $633.00 90 60000 $114.00 10 61312 $2,187.00 90
59120 $893.00 90 60100 $96.00 0 61313 $2,207.00 90
59121 $768.00 90 60200 $744.00 90 61314 $2,200.00 90
59130 $832.00 90 60210 $872.00 90 61315 $2,393.00 90
59135 $1,083.00 90 60212 $1,170.00 90 61316 $88.00 ZZZ
59136 $934.00 90 60220 $851.00 90 61320 $2,118.00 90
59140 $461.00 90 60225 $1,107.00 90 61321 $2,310.00 90
59150 $543.00 90 60240 $1,228.00 90 61322 $1,779.00 90
59151 $690.00 90 60252 $1,427.00 90 61323 $1,842.00 90
59160 $279.00 10 60254 $1,911.00 90 61330 $1,706.00 90
59200 $79.00 0 60260 $1,022.00 90 61332 $2,307.00 90
59300 $179.00 0 60270 $1,468.00 90 61333 $2,231.00 90
59320 $196.00 0 60271 $1,210.00 90 61340 $1,584.00 90
59325 $316.00 0 60280 $546.00 90 61343 $2,673.00 90
59350 $375.00 0 60281 $670.00 90 61345 $2,259.00 90
59400 $1,816.00 0 60300 $99.00 0 61450 $2,173.00 90
59409 $1,019.00 0 60500 $1,232.00 90 61458 $2,433.00 90
59410 $1,123.00 0 60502 $1,475.00 90 61460 $2,426.00 90
59412 $141.00 0 60505 $1,631.00 90 61480 $1,922.00 90
59414 $134.00 0 60512 $310.00 ZZZ 61500 $1,637.00 90
59425 $414.00 0 60520 $1,405.00 90 61501 $1,353.00 90
59426 $708.00 0 60521 $1,591.00 90 61510 $2,506.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 111
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
61512 $2,981.00 90 61592 $3,245.00 90 61770 $1,867.00 90
61514 $2,262.00 90 61595 $2,350.00 90 61781 $240.00 ZZZ
61516 $2,253.00 90 61596 $2,827.00 90 61782 $197.00 ZZZ
61517 $74.00 ZZZ 61597 $3,046.00 90 61783 $241.00 ZZZ
61518 $3,163.00 90 61598 $2,693.00 90 61790 $952.00 90
61519 $3,450.00 90 61600 $2,039.00 90 61791 $1,205.00 90
61520 $4,349.00 90 61601 $2,279.00 90 61796 $1,027.00 90
61521 $3,667.00 90 61605 $2,299.00 90 61797 $224.00 ZZZ
61522 $2,415.00 90 61606 $3,178.00 90 61798 $1,404.00 90
61524 $2,484.00 90 61607 $2,961.00 90 61799 $308.00 ZZZ
61526 $3,918.00 90 61608 $3,458.00 90 61800 $156.00 ZZZ
61530 $3,611.00 90 61610 $2,354.00 ZZZ 61850 $1,090.00 90
61531 $1,344.00 90 61611 $584.00 ZZZ 61860 $1,197.00 90
61533 $1,712.00 90 61612 $2,219.00 ZZZ 61863 $1,231.00 90
61534 $1,535.00 90 61613 $3,375.00 90 61864 $295.00 ZZZ
61535 $958.00 90 61615 $2,576.00 90 61867 $1,863.00 90
61536 $2,862.00 90 61616 $3,535.00 90 61868 $491.00 ZZZ
61537 $1,714.00 90 61618 $1,389.00 90 61870 $616.00 90
61538 $2,466.00 90 61619 $1,682.00 90 61880 $559.00 90
61539 $2,660.00 90 61623 $540.00 0 61885 $262.00 90
61540 $2,069.00 90 61624 $1,073.00 0 61886 $678.00 90
61541 $2,363.00 90 61626 $877.00 0 61888 $331.00 10
61543 $2,307.00 90 61630 $1,245.00 0 62000 $848.00 90
61544 $2,271.00 90 61635 $1,362.00 0 62005 $1,282.00 90
61545 $3,474.00 90 61640 $555.00 0 62010 $1,754.00 90
61546 $2,695.00 90 61641 $195.00 ZZZ 62100 $1,962.00 90
61548 $1,964.00 90 61642 $390.00 ZZZ 62115 $1,686.00 90
61550 $1,141.00 90 61645 $809.00 0 62117 $2,211.00 90
61552 $1,463.00 90 61650 $540.00 0 62120 $1,898.00 90
61556 $1,760.00 90 61651 $229.00 ZZZ 62121 $1,822.00 90
61557 $1,807.00 90 61680 $2,758.00 90 62140 $1,221.00 90
61558 $2,085.00 90 61682 $4,798.00 90 62141 $1,955.00 90
61559 $2,700.00 90 61684 $3,341.00 90 62142 $1,011.00 90
61563 $2,175.00 90 61686 $5,012.00 90 62143 $1,096.00 90
61564 $2,597.00 90 61690 $2,556.00 90 62145 $1,566.00 90
61566 $2,048.00 90 61692 $4,007.00 90 62146 $1,327.00 90
61567 $2,340.00 90 61697 $3,231.00 90 62147 $1,566.00 90
61570 $1,975.00 90 61698 $3,103.00 90 62148 $120.00 ZZZ
61571 $2,140.00 90 61700 $4,037.00 90 62160 $172.00 ZZZ
61575 $2,992.00 90 61702 $4,019.00 90 62161 $1,229.00 90
61576 $3,772.00 90 61703 $1,444.00 90 62162 $1,578.00 90
61580 $2,383.00 90 61705 $3,043.00 90 62163 $999.00 90
61581 $2,674.00 90 61708 $2,546.00 90 62164 $1,706.00 90
61582 $2,557.00 90 61710 $2,129.00 90 62165 $1,336.00 90
61583 $2,972.00 90 61711 $3,150.00 90 62180 $1,695.00 90
61584 $2,830.00 90 61720 $1,558.00 90 62190 $1,034.00 90
61585 $3,142.00 90 61735 $1,664.00 90 62192 $1,146.00 90
61586 $2,097.00 90 61750 $1,521.00 90 62194 $239.00 10
61590 $3,299.00 90 61751 $1,628.00 90 62200 $1,625.00 90
61591 $3,491.00 90 61760 $1,670.00 90 62201 $1,200.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 112
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
62220 $1,215.00 90 63003 $1,591.00 90 63196 $1,810.00 90
62223 $1,199.00 90 63005 $1,390.00 90 63197 $1,725.00 90
62225 $488.00 90 63011 $1,151.00 90 63198 $1,956.00 90
62230 $935.00 90 63012 $1,568.00 90 63199 $2,258.00 90
62252 $85.00 0 63015 $1,862.00 90 63200 $1,569.00 90
62252-26 $49.00 0 63016 $1,788.00 90 63250 $3,182.00 90
62252-TC $42.00 0 63017 $1,489.00 90 63251 $3,207.00 90
62256 $616.00 90 63020 $1,395.00 90 63252 $3,319.00 90
62258 $1,308.00 90 63030 $1,145.00 90 63265 $1,940.00 90
62263 $426.00 10 63035 $280.00 ZZZ 63266 $2,053.00 90
62264 $593.00 10 63040 $1,764.00 90 63267 $1,651.00 90
62267 $253.00 0 63042 $1,620.00 90 63268 $1,469.00 90
62268 $285.00 0 63043 BR ZZZ 63270 $2,197.00 90
62269 $271.00 0 63044 BR ZZZ 63271 $2,401.00 90
62270 $109.00 0 63045 $1,647.00 90 63272 $2,206.00 90
62272 $137.00 0 63046 $2,117.00 90 63273 $2,012.00 90
62273 $130.00 0 63047 $1,907.00 90 63275 $2,166.00 90
62280 $199.00 10 63048 $367.00 ZZZ 63276 $2,135.00 90
62281 $186.00 10 63050 $1,411.00 90 63277 $1,905.00 90
62282 $211.00 10 63051 $1,605.00 90 63278 $1,877.00 90
62284 $196.00 0 63055 $2,029.00 90 63280 $2,529.00 90
62287 $784.00 90 63056 $1,960.00 90 63281 $2,496.00 90
62290 $235.00 0 63057 $421.00 ZZZ 63282 $2,305.00 90
62291 $232.00 0 63064 $2,200.00 90 63283 $2,041.00 90
62292 $1,064.00 90 63066 $263.00 ZZZ 63285 $2,934.00 90
62294 $821.00 90 63075 $1,720.00 90 63286 $3,003.00 90
62302 $246.00 0 63076 $383.00 ZZZ 63287 $3,012.00 90
62303 $256.00 0 63077 $1,828.00 90 63290 $3,073.00 90
62304 $244.00 0 63078 $261.00 ZZZ 63295 $319.00 ZZZ
62305 $266.00 0 63081 $2,203.00 90 63300 $2,006.00 90
62320 $170.00 0 63082 $391.00 ZZZ 63301 $2,209.00 90
62321 $253.00 0 63085 $2,416.00 90 63302 $2,290.00 90
62322 $159.00 0 63086 $282.00 ZZZ 63303 $2,357.00 90
62323 $249.00 0 63087 $2,930.00 90 63304 $2,513.00 90
62324 $149.00 0 63088 $381.00 ZZZ 63305 $2,574.00 90
62325 $225.00 0 63090 $2,490.00 90 63306 $2,596.00 90
62326 $156.00 0 63091 $249.00 ZZZ 63307 $2,522.00 90
62327 $229.00 0 63101 $2,127.00 90 63308 $425.00 ZZZ
62350 $488.00 10 63102 $2,127.00 90 63600 $797.00 90
62351 $782.00 90 63103 $249.00 ZZZ 63610 $476.00 0
62355 $402.00 10 63170 $1,788.00 90 63615 $1,348.00 90
62360 $195.00 10 63172 $1,672.00 90 63620 $1,133.00 90
62361 $390.00 10 63173 $1,851.00 90 63621 $256.00 ZZZ
62362 $517.00 10 63180 $1,486.00 90 63650 $819.00 10
62365 $418.00 10 63182 $1,711.00 90 63655 $1,064.00 90
62367 $39.00 0 63185 $1,347.00 90 63661 $584.00 10
62368 $53.00 0 63190 $1,610.00 90 63662 $792.00 90
62369 $121.00 0 63191 $1,444.00 90 63663 $811.00 10
62370 $128.00 0 63194 $1,593.00 90 63664 $820.00 90
63001 $1,882.00 90 63195 $1,603.00 90 63685 $615.00 10
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 113
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
63688 $707.00 10 64495 $89.00 ZZZ 64708 $562.00 90
63700 $1,340.00 90 64505 $104.00 0 64712 $678.00 90
63702 $1,512.00 90 64508 $99.00 0 64713 $867.00 90
63704 $1,708.00 90 64510 $103.00 0 64714 $715.00 90
63706 $1,873.00 90 64517 $188.00 0 64716 $523.00 90
63707 $1,041.00 90 64520 $131.00 0 64718 $558.00 90
63709 $1,310.00 90 64530 $135.00 0 64719 $446.00 90
63710 $1,165.00 90 64550 $23.00 0 64721 $439.00 90
63740 $1,062.00 90 64553 $137.00 10 64722 $411.00 90
63741 $741.00 90 64555 $131.00 10 64726 $271.00 90
63744 $738.00 90 64561 $801.00 10 64727 $261.00 ZZZ
63746 $529.00 90 64565 $121.00 10 64732 $405.00 90
64400 $78.00 0 64566 $121.00 0 64734 $432.00 90
64402 $75.00 0 64568 $628.00 90 64736 $388.00 90
64405 $103.00 0 64569 $799.00 90 64738 $475.00 90
64408 $120.00 0 64570 $709.00 90 64740 $461.00 90
64410 $109.00 0 64575 $367.00 90 64742 $517.00 90
64413 $128.00 0 64580 $343.00 90 64744 $798.00 90
64415 $109.00 0 64581 $745.00 90 64746 $494.00 90
64416 $159.00 0 64585 $37.00 10 64755 $1,042.00 90
64417 $105.00 0 64590 $217.00 10 64760 $578.00 90
64418 $108.00 0 64595 $153.00 10 64763 $561.00 90
64420 $89.00 0 64600 $228.00 10 64766 $713.00 90
64421 $128.00 0 64605 $319.00 10 64771 $632.00 90
64425 $116.00 0 64610 $307.00 10 64772 $636.00 90
64430 $130.00 0 64611 $114.00 10 64774 $392.00 90
64435 $114.00 0 64612 $188.00 10 64776 $390.00 90
64445 $68.00 0 64615 $146.00 10 64778 $249.00 ZZZ
64446 $165.00 0 64616 $125.00 10 64782 $482.00 90
64447 $77.00 0 64617 $193.00 10 64783 $298.00 ZZZ
64448 $152.00 0 64620 $185.00 10 64784 $751.00 90
64449 $152.00 0 64630 $202.00 10 64786 $1,281.00 90
64450 $53.00 0 64632 $87.00 10 64787 $458.00 ZZZ
64455 $49.00 0 64633 $441.00 10 64788 $381.00 90
64461 $151.00 0 64634 $200.00 ZZZ 64790 $884.00 90
64462 $86.00 ZZZ 64635 $435.00 10 64792 $1,148.00 90
64463 $164.00 0 64636 $181.00 ZZZ 64795 $247.00 0
64479 $224.00 0 64640 $208.00 10 64802 $711.00 90
64480 $194.00 ZZZ 64642 $142.00 0 64804 $1,202.00 90
64483 $206.00 0 64643 $93.00 ZZZ 64809 $1,080.00 90
64484 $183.00 ZZZ 64644 $162.00 0 64818 $845.00 90
64486 $127.00 0 64645 $114.00 ZZZ 64820 $838.00 90
64487 $156.00 0 64646 $152.00 0 64821 $609.00 90
64488 $156.00 0 64647 $176.00 0 64822 $609.00 90
64489 $218.00 0 64650 $62.00 0 64823 $703.00 90
64490 $196.00 0 64653 $71.00 0 64831 $592.00 90
64491 $96.00 ZZZ 64680 $180.00 10 64832 $171.00 ZZZ
64492 $97.00 ZZZ 64681 $464.00 10 64834 $711.00 90
64493 $177.00 0 64702 $383.00 90 64835 $834.00 90
64494 $88.00 ZZZ 64704 $402.00 90 64836 $856.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 114
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
64837 $480.00 ZZZ 65222 $62.00 0 66030 $160.00 10
64840 $1,058.00 90 65235 $627.00 90 66130 $631.00 90
64856 $1,063.00 90 65260 $956.00 90 66150 $798.00 90
64857 $1,137.00 90 65265 $1,104.00 90 66155 $795.00 90
64858 $1,313.00 90 65270 $88.00 10 66160 $942.00 90
64859 $341.00 ZZZ 65272 $223.00 90 66170 $1,089.00 90
64861 $1,524.00 90 65273 $376.00 90 66172 $1,264.00 90
64862 $1,798.00 90 65275 $75.00 90 66174 $1,006.00 90
64864 $970.00 90 65280 $711.00 90 66175 $1,140.00 90
64865 $1,250.00 90 65285 $1,177.00 90 66179 $1,092.00 90
64866 $1,238.00 90 65286 $692.00 90 66180 $1,313.00 90
64868 $1,162.00 90 65290 $519.00 90 66183 $1,090.00 90
64872 $155.00 ZZZ 65400 $603.00 90 66184 $796.00 90
64874 $230.00 ZZZ 65410 $142.00 0 66185 $769.00 90
64876 $189.00 ZZZ 65420 $448.00 90 66220 $711.00 90
64885 $1,382.00 90 65426 $534.00 90 66225 $1,006.00 90
64886 $1,636.00 90 65430 $81.00 0 66250 $602.00 90
64890 $1,112.00 90 65435 $88.00 0 66500 $359.00 90
64891 $1,243.00 90 65436 $319.00 90 66505 $359.00 90
64892 $1,177.00 90 65450 $52.00 90 66600 $825.00 90
64893 $1,321.00 90 65600 $325.00 90 66605 $1,136.00 90
64895 $1,500.00 90 65710 $1,124.00 90 66625 $543.00 90
64896 $1,185.00 90 65730 $1,314.00 90 66630 $623.00 90
64897 $1,419.00 90 65750 $1,381.00 90 66635 $595.00 90
64898 $1,549.00 90 65755 $1,373.00 90 66680 $526.00 90
64901 $865.00 ZZZ 65756 $1,201.00 90 66682 $627.00 90
64902 $982.00 ZZZ 65770 $1,461.00 90 66700 $506.00 90
64905 $1,059.00 90 65772 $449.00 90 66710 $513.00 90
64907 $1,472.00 90 65775 $595.00 90 66711 $507.00 90
64910 $645.00 90 65778 $1,389.00 0 66720 $506.00 90
64911 $783.00 90 65779 $1,238.00 0 66740 $473.00 90
64999 BR YYY 65780 $766.00 90 66761 $506.00 10
65091 $678.00 90 65781 $1,169.00 90 66762 $433.00 90
65093 $712.00 90 65782 $1,008.00 90 66770 $483.00 90
65101 $726.00 90 65785 $2,144.00 90 66820 $433.00 90
65103 $769.00 90 65800 $88.00 0 66821 $275.00 90
65105 $846.00 90 65810 $516.00 90 66825 $753.00 90
65110 $1,305.00 90 65815 $327.00 90 66830 $651.00 90
65112 $1,386.00 90 65820 $813.00 90 66840 $707.00 90
65114 $1,456.00 90 65850 $968.00 90 66850 $805.00 90
65125 $312.00 90 65855 $441.00 10 66852 $878.00 90
65130 $730.00 90 65860 $339.00 90 66920 $785.00 90
65135 $678.00 90 65865 $540.00 90 66930 $906.00 90
65140 $738.00 90 65870 $572.00 90 66940 $819.00 90
65150 $652.00 90 65875 $597.00 90 66982 $846.00 90
65155 $862.00 90 65880 $641.00 90 66983 $763.00 90
65175 $654.00 90 65900 $945.00 90 66984 $898.00 90
65205 $45.00 0 65920 $752.00 90 66985 $744.00 90
65210 $53.00 0 65930 $700.00 90 66986 $1,038.00 90
65220 $58.00 0 66020 $164.00 10 66990 $84.00 ZZZ
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 115
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
66999 BR YYY 67345 $275.00 10 67916 $675.00 90
67005 $639.00 90 67346 $173.00 0 67917 $631.00 90
67010 $647.00 90 67399 BR YYY 67921 $419.00 90
67015 $637.00 90 67400 $960.00 90 67922 $243.00 90
67025 $774.00 90 67405 $799.00 90 67923 $718.00 90
67027 $1,089.00 90 67412 $976.00 90 67924 $605.00 90
67028 $338.00 0 67413 $909.00 90 67930 $280.00 10
67030 $485.00 90 67414 $1,023.00 90 67935 $520.00 90
67031 $402.00 90 67415 $146.00 0 67938 $67.00 10
67036 $1,384.00 90 67420 $1,729.00 90 67950 $584.00 90
67039 $1,490.00 90 67430 $1,203.00 90 67961 $571.00 90
67040 $1,960.00 90 67440 $1,257.00 90 67966 $645.00 90
67041 $1,065.00 90 67445 $1,269.00 90 67971 $875.00 90
67042 $1,218.00 90 67450 $1,300.00 90 67973 $1,126.00 90
67043 $1,279.00 90 67500 $75.00 0 67974 $1,140.00 90
67101 $767.00 10 67505 $109.00 0 67975 $681.00 90
67105 $941.00 10 67515 $53.00 0 67999 BR YYY
67107 $1,350.00 90 67550 $946.00 90 68020 $106.00 10
67108 $1,878.00 90 67560 $936.00 90 68040 $75.00 0
67110 $1,040.00 90 67570 $1,148.00 90 68100 $137.00 0
67113 $1,405.00 90 67599 BR YYY 68110 $172.00 10
67115 $496.00 90 67700 $87.00 10 68115 $248.00 10
67120 $751.00 90 67710 $117.00 10 68130 $378.00 90
67121 $962.00 90 67715 $102.00 10 68135 $146.00 10
67141 $536.00 90 67800 $119.00 10 68200 $59.00 0
67145 $514.00 90 67801 $189.00 10 68320 $502.00 90
67208 $655.00 90 67805 $208.00 10 68325 $672.00 90
67210 $779.00 90 67808 $308.00 90 68326 $654.00 90
67218 $1,217.00 90 67810 $133.00 0 68328 $741.00 90
67220 $894.00 90 67820 $36.00 0 68330 $488.00 90
67221 $325.00 0 67825 $130.00 10 68335 $636.00 90
67225 $44.00 ZZZ 67830 $239.00 10 68340 $413.00 90
67227 $652.00 10 67835 $500.00 90 68360 $449.00 90
67228 $1,025.00 10 67840 $187.00 10 68362 $691.00 90
67229 $926.00 90 67850 $143.00 10 68371 $363.00 10
67250 $793.00 90 67875 $163.00 0 68399 BR YYY
67255 $872.00 90 67880 $442.00 90 68400 $154.00 10
67299 BR YYY 67882 $643.00 90 68420 $191.00 10
67311 $616.00 90 67900 $487.00 90 68440 $96.00 10
67312 $773.00 90 67901 $646.00 90 68500 $882.00 90
67314 $688.00 90 67902 $650.00 90 68505 $921.00 90
67316 $857.00 90 67903 $657.00 90 68510 $491.00 0
67318 $663.00 90 67904 $720.00 90 68520 $687.00 90
67320 $602.00 ZZZ 67906 $633.00 90 68525 $340.00 0
67331 $560.00 ZZZ 67908 $550.00 90 68530 $379.00 10
67332 $621.00 ZZZ 67909 $577.00 90 68540 $875.00 90
67334 $447.00 ZZZ 67911 $517.00 90 68550 $1,107.00 90
67335 $253.00 ZZZ 67912 $983.00 90 68700 $628.00 90
67340 $559.00 ZZZ 67914 $487.00 90 68705 $176.00 10
67343 $628.00 90 67915 $252.00 90 68720 $807.00 90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 116
Surgery Surgery Surgery
CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD
68745 $704.00 90 69554 $2,600.00 90 69950 $2,017.00 90
68750 $792.00 90 69601 $1,195.00 90 69955 $2,185.00 90
68760 $109.00 10 69602 $1,225.00 90 69960 $2,116.00 90
68761 $130.00 10 69603 $1,264.00 90 69970 $2,306.00 90
68770 $634.00 90 69604 $1,263.00 90 69979 BR YYY
68801 $202.00 10 69605 $1,526.00 90 69990 $262.00 ZZZ
68810 $290.00 10 69610 $41.00 10 G0127 $17.00 0
68811 $191.00 10 69620 $651.00 90 G0168 $75.00 0
68815 $399.00 10 69631 $985.00 90 G0247 $38.00 ZZZ
68816 $592.00 10 69632 $1,166.00 90 G0276 $409.00 0
68840 $100.00 10 69633 $1,110.00 90 G0289 $82.00 ZZZ
68850 $76.00 0 69635 $1,207.00 90 G0341 $333.00 0
68899 BR YYY 69636 $1,381.00 90 G0342 $622.00 90
69000 $52.00 10 69637 $1,370.00 90 G0343 $1,026.00 90
69005 $175.00 10 69641 $1,154.00 90 G0364 $12.00 ZZZ
69020 $109.00 10 69642 $1,519.00 90 G0412 $742.00 90
69100 $85.00 0 69643 $1,389.00 90 G0413 $1,092.00 90
69105 $87.00 0 69644 $1,529.00 90 G0414 $1,017.00 90
69110 $294.00 90 69645 $1,479.00 90 G0415 $1,407.00 90
69120 $274.00 90 69646 $1,620.00 90 G0429 $102.00 0
69140 $722.00 90 69650 $879.00 90
69145 $248.00 90 69660 $1,072.00 90
69150 $1,111.00 90 69661 $1,412.00 90
69155 $1,680.00 90 69662 $1,386.00 90
69200 $53.00 0 69666 $887.00 90
69205 $110.00 10 69667 $887.00 90
69209 $13.00 0 69670 $988.00 90
69210 $39.00 0 69676 $828.00 90
69220 $78.00 0 69700 $702.00 90
69222 $123.00 10 69710 BR 0
69300 $522.00 YYY 69711 $878.00 90
69310 $937.00 90 69714 $961.00 90
69320 $1,434.00 90 69715 $1,217.00 90
69399 BR YYY 69717 $996.00 90
69420 $117.00 10 69718 $1,232.00 90
69421 $155.00 10 69720 $1,307.00 90
69424 $84.00 0 69725 $1,922.00 90
69433 $145.00 10 69740 $1,274.00 90
69436 $182.00 10 69745 $1,447.00 90
69440 $699.00 90 69799 BR YYY
69450 $525.00 90 69801 $785.00 0
69501 $829.00 90 69805 $1,187.00 90
69502 $1,118.00 90 69806 $1,123.00 90
69505 $1,176.00 90 69820 $876.00 90
69511 $1,221.00 90 69840 $869.00 90
69530 $1,616.00 90 69905 $1,013.00 90
69535 $2,824.00 90 69910 $1,228.00 90
69540 $126.00 10 69915 $1,754.00 90
69550 $998.00 90 69930 $1,498.00 90
69552 $1,621.00 90 69949 BR YYY
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 117
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
70010 $70.00 70240-TC $15.00 70450-26 $43.00
70010-26 $19.00 70250 $35.00 70450-TC $176.00
70010-TC $51.00 70250-26 $12.00 70460 $271.00
70015 $58.00 70250-TC $22.00 70460-26 $58.00
70015-26 $31.00 70260 $50.00 70460-TC $211.00
70015-TC $27.00 70260-26 $17.00 70470 $332.00
70030 $24.00 70260-TC $33.00 70470-26 $65.00
70030-26 $10.00 70300 $15.00 70470-TC $264.00
70030-TC $15.00 70300-26 $5.00 70480 $244.00
70100 $29.00 70300-TC $10.00 70480-26 $65.00
70100-26 $9.00 70310 $24.00 70480-TC $176.00
70100-TC $19.00 70310-26 $8.00 70481 $284.00
70110 $36.00 70310-TC $15.00 70481-26 $70.00
70110-26 $12.00 70320 $40.00 70481-TC $211.00
70110-TC $22.00 70320-26 $11.00 70482 $340.00
70120 $32.00 70320-TC $29.00 70482-26 $74.00
70120-26 $9.00 70328 $28.00 70482-TC $264.00
70120-TC $22.00 70328-26 $10.00 70486 $236.00
70130 $46.00 70328-TC $18.00 70486-26 $58.00
70130-26 $17.00 70330 $43.00 70486-TC $176.00
70130-TC $29.00 70330-26 $12.00 70487 $279.00
70134 $45.00 70330-TC $31.00 70487-26 $66.00
70134-26 $17.00 70332 $107.00 70487-TC $211.00
70134-TC $28.00 70332-26 $27.00 70488 $339.00
70140 $33.00 70332-TC $80.00 70488-26 $72.00
70140-26 $9.00 70336 $497.00 70488-TC $264.00
70140-TC $22.00 70336-26 $72.00 70490 $244.00
70150 $42.00 70336-TC $419.00 70490-26 $65.00
70150-26 $12.00 70350 $24.00 70490-TC $176.00
70150-TC $29.00 70350-26 $10.00 70491 $284.00
70160 $29.00 70350-TC $14.00 70491-26 $70.00
70160-26 $8.00 70355 $32.00 70491-TC $211.00
70160-TC $19.00 70355-26 $10.00 70492 $340.00
70170 $52.00 70355-TC $21.00 70492-26 $74.00
70170-26 $15.00 70360 $24.00 70492-TC $264.00
70170-TC $37.00 70360-26 $8.00 70496 $366.00
70190 $34.00 70360-TC $15.00 70496-26 $92.00
70190-26 $10.00 70370 $65.00 70496-TC $270.00
70190-TC $22.00 70370-26 $16.00 70498 $366.00
70200 $43.00 70370-TC $48.00 70498-26 $92.00
70200-26 $14.00 70371 $122.00 70498-TC $270.00
70200-TC $29.00 70371-26 $43.00 70540 $482.00
70210 $32.00 70371-TC $79.00 70540-26 $70.00
70210-26 $8.00 70380 $34.00 70540-TC $413.00
70210-TC $22.00 70380-26 $8.00 70542 $579.00
70220 $42.00 70380-TC $24.00 70542-26 $82.00
70220-26 $12.00 70390 $87.00 70542-TC $495.00
70220-TC $29.00 70390-26 $19.00 70543 $1,029.00
70240 $26.00 70390-TC $68.00 70543-26 $109.00
70240-26 $9.00 70450 $221.00 70543-TC $916.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 118
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
70544 $481.00 71020-TC $22.00 71550-26 $75.00
70544-26 $61.00 71021 $41.00 71550-TC $415.00
70544-TC $419.00 71021-26 $13.00 71551 $587.00
70545 $481.00 71021-TC $28.00 71551-26 $88.00
70545-26 $61.00 71022 $44.00 71551-TC $496.00
70545-TC $419.00 71022-26 $16.00 71552 $1,029.00
70546 $914.00 71022-TC $28.00 71552-26 $114.00
70546-26 $92.00 71023 $49.00 71552-TC $911.00
70546-TC $820.00 71023-26 $19.00 71555 $514.00
70547 $481.00 71023-TC $29.00 71555-26 $92.00
70547-26 $61.00 71030 $45.00 71555-TC $419.00
70547-TC $419.00 71030-26 $16.00 72020 $22.00
70548 $481.00 71030-TC $29.00 72020-26 $7.00
70548-26 $61.00 71034 $79.00 72020-TC $15.00
70548-TC $419.00 71034-26 $23.00 72040 $34.00
70549 $914.00 71034-TC $54.00 72040-26 $11.00
70549-26 $92.00 71035 $56.00 72040-TC $22.00
70549-TC $820.00 71035-26 $19.00 72050 $49.00
70551 $497.00 71035-TC $38.00 72050-26 $16.00
70551-26 $76.00 71100 $33.00 72050-TC $33.00
70551-TC $419.00 71100-26 $11.00 72052 $61.00
70552 $596.00 71100-TC $21.00 72052-26 $18.00
70552-26 $91.00 71101 $38.00 72052-TC $42.00
70552-TC $502.00 71101-26 $13.00 72070 $36.00
70553 $1,055.00 71101-TC $24.00 72070-26 $11.00
70553-26 $120.00 71110 $43.00 72070-TC $24.00
70553-TC $931.00 71110-26 $13.00 72072 $39.00
70554 $618.00 71110-TC $29.00 72072-26 $11.00
70554-26 $99.00 71111 $49.00 72072-TC $28.00
70554-TC $520.00 71111-26 $16.00 72074 $45.00
70555 BR 71111-TC $33.00 72074-26 $11.00
70555-26 $118.00 71120 $35.00 72074-TC $34.00
70555-TC BR 71120-26 $10.00 72080 $36.00
70557 $392.00 71120-TC $24.00 72080-26 $11.00
70557-26 $148.00 71130 $38.00 72080-TC $24.00
70557-TC $349.00 71130-26 $11.00 72081 $39.00
70558 $425.00 71130-TC $26.00 72081-26 $14.00
70558-26 $164.00 71250 $282.00 72081-TC $25.00
70558-TC $376.00 71250-26 $59.00 72082 $63.00
70559 $548.00 71250-TC $220.00 72082-26 $16.00
70559-26 $164.00 71260 $328.00 72082-TC $46.00
70559-TC $499.00 71260-26 $63.00 72083 $68.00
71010 $27.00 71260-TC $264.00 72083-26 $18.00
71010-26 $9.00 71270 $402.00 72083-TC $50.00
71010-TC $17.00 71270-26 $70.00 72084 $81.00
71015 $30.00 71270-TC $330.00 72084-26 $21.00
71015-26 $10.00 71275 $431.00 72084-TC $61.00
71015-TC $19.00 71275-26 $100.00 72100 $36.00
71020 $35.00 71275-TC $328.00 72100-26 $11.00
71020-26 $11.00 71550 $490.00 72100-TC $24.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 119
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
72110 $50.00 72148-TC $465.00 72202-26 $9.00
72110-26 $16.00 72149 $597.00 72202-TC $22.00
72110-TC $34.00 72149-26 $92.00 72220 $30.00
72114 $64.00 72149-TC $502.00 72220-26 $8.00
72114-26 $18.00 72156 $1,066.00 72220-TC $21.00
72114-TC $44.00 72156-26 $131.00 72240 $132.00
72120 $45.00 72156-TC $931.00 72240-26 $26.00
72120-26 $11.00 72157 $1,066.00 72240-TC $106.00
72120-TC $33.00 72157-26 $131.00 72255 $129.00
72125 $282.00 72157-TC $931.00 72255-26 $28.00
72125-26 $59.00 72158 $1,056.00 72255-TC $101.00
72125-TC $220.00 72158-26 $121.00 72265 $132.00
72126 $328.00 72158-TC $931.00 72265-26 $28.00
72126-26 $62.00 72159 $563.00 72265-TC $104.00
72126-TC $264.00 72159-26 $94.00 72270 $176.00
72127 $397.00 72159-TC $465.00 72270-26 $39.00
72127-26 $65.00 72170 $29.00 72270-TC $137.00
72127-TC $330.00 72170-26 $8.00 72275 $112.00
72128 $282.00 72170-TC $19.00 72275-26 $34.00
72128-26 $59.00 72190 $35.00 72275-TC $78.00
72128-TC $220.00 72190-26 $10.00 72285 $101.00
72129 $328.00 72190-TC $24.00 72285-26 $15.00
72129-26 $62.00 72191 $413.00 72285-TC $86.00
72129-TC $264.00 72191-26 $94.00 72295 $107.00
72130 $397.00 72191-TC $315.00 72295-26 $13.00
72130-26 $65.00 72192 $278.00 72295-TC $94.00
72130-TC $330.00 72192-26 $56.00 73000 $28.00
72131 $282.00 72192-TC $220.00 73000-26 $8.00
72131-26 $59.00 72193 $317.00 73000-TC $19.00
72131-TC $220.00 72193-26 $59.00 73010 $29.00
72132 $328.00 72193-TC $256.00 73010-26 $8.00
72132-26 $62.00 72194 $380.00 73010-TC $19.00
72132-TC $264.00 72194-26 $62.00 73020 $26.00
72133 $391.00 72194-TC $317.00 73020-26 $7.00
72133-26 $65.00 72195 $491.00 73020-TC $17.00
72133-TC $323.00 72195-26 $74.00 73030 $31.00
72141 $503.00 72195-TC $415.00 73030-26 $9.00
72141-26 $82.00 72196 $526.00 73030-TC $21.00
72141-TC $419.00 72196-26 $84.00 73040 $68.00
72142 $604.00 72196-TC $442.00 73040-26 $17.00
72142-26 $99.00 72197 $1,037.00 73040-TC $51.00
72142-TC $502.00 72197-26 $114.00 73050 $35.00
72146 $549.00 72197-TC $919.00 73050-26 $10.00
72146-26 $82.00 72198 $517.00 73050-TC $24.00
72146-TC $465.00 72198-26 $95.00 73060 $30.00
72147 $603.00 72198-TC $419.00 73060-26 $8.00
72147-26 $98.00 72200 $29.00 73060-TC $21.00
72147-TC $502.00 72200-26 $9.00 73070 $27.00
72148 $543.00 72200-TC $19.00 73070-26 $7.00
72148-26 $76.00 72202 $33.00 73070-TC $19.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 120
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
73080 $30.00 73221-TC $413.00 73580-26 $18.00
73080-26 $8.00 73222 $579.00 73580-TC $66.00
73080-TC $21.00 73222-26 $82.00 73590 $29.00
73085 $74.00 73222-TC $495.00 73590-26 $8.00
73085-26 $19.00 73223 $1,029.00 73590-TC $19.00
73085-TC $55.00 73223-26 $109.00 73600 $27.00
73090 $28.00 73223-TC $916.00 73600-26 $8.00
73090-26 $8.00 73225 $513.00 73600-TC $18.00
73090-TC $19.00 73225-26 $92.00 73610 $29.00
73100 $27.00 73225-TC $419.00 73610-26 $8.00
73100-26 $8.00 73501 $30.00 73610-TC $19.00
73100-TC $18.00 73501-26 $10.00 73615 $72.00
73110 $29.00 73501-TC $20.00 73615-26 $19.00
73110-26 $8.00 73502 $42.00 73615-TC $53.00
73110-TC $19.00 73502-26 $11.00 73620 $27.00
73115 $54.00 73502-TC $30.00 73620-26 $8.00
73115-26 $17.00 73503 $52.00 73620-TC $18.00
73115-TC $37.00 73503-26 $15.00 73630 $29.00
73120 $27.00 73503-TC $37.00 73630-26 $8.00
73120-26 $8.00 73521 $40.00 73630-TC $19.00
73120-TC $18.00 73521-26 $12.00 73650 $26.00
73130 $29.00 73521-TC $28.00 73650-26 $8.00
73130-26 $8.00 73522 $49.00 73650-TC $17.00
73130-TC $19.00 73522-26 $15.00 73660 $22.00
73140 $22.00 73522-TC $34.00 73660-26 $7.00
73140-26 $7.00 73523 $57.00 73660-TC $15.00
73140-TC $15.00 73523-26 $16.00 73700 $242.00
73200 $242.00 73523-TC $40.00 73700-26 $56.00
73200-26 $56.00 73525 $84.00 73700-TC $185.00
73200-TC $185.00 73525-26 $21.00 73701 $282.00
73201 $282.00 73525-TC $63.00 73701-26 $61.00
73201-26 $59.00 73551 $28.00 73701-TC $220.00
73201-TC $220.00 73551-26 $9.00 73702 $341.00
73202 $342.00 73551-TC $19.00 73702-26 $62.00
73202-26 $63.00 73552 $33.00 73702-TC $277.00
73202-TC $277.00 73552-26 $10.00 73706 $379.00
73206 $375.00 73552-TC $23.00 73706-26 $98.00
73206-26 $94.00 73560 $29.00 73706-TC $277.00
73206-TC $277.00 73560-26 $8.00 73718 $482.00
73218 $482.00 73560-TC $19.00 73718-26 $68.00
73218-26 $68.00 73562 $31.00 73718-TC $413.00
73218-TC $413.00 73562-26 $9.00 73719 $579.00
73219 $579.00 73562-TC $21.00 73719-26 $82.00
73219-26 $82.00 73564 $35.00 73719-TC $495.00
73219-TC $495.00 73564-26 $11.00 73720 $520.00
73220 $520.00 73564-TC $22.00 73720-26 $78.00
73220-26 $78.00 73565 $28.00 73720-TC $442.00
73220-TC $442.00 73565-26 $8.00 73721 $482.00
73221 $482.00 73565-TC $18.00 73721-26 $68.00
73221-26 $68.00 73580 $84.00 73721-TC $413.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 121
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
73722 $579.00 74182-TC $496.00 74261-26 $122.00
73722-26 $82.00 74183 $1,037.00 74261-TC $126.00
73722-TC $495.00 74183-26 $114.00 74262 $376.00
73723 $1,029.00 74183-TC $919.00 74262-26 $127.00
73723-26 $109.00 74185 $514.00 74262-TC $249.00
73723-TC $916.00 74185-26 $92.00 74263 $757.00
73725 $515.00 74185-TC $419.00 74263-26 $117.00
73725-26 $92.00 74190 $73.00 74263-TC $639.00
73725-TC $419.00 74190-26 $24.00 74270 $100.00
74000 $29.00 74190-TC $49.00 74270-26 $35.00
74000-26 $9.00 74210 $63.00 74270-TC $64.00
74000-TC $19.00 74210-26 $18.00 74280 $136.00
74010 $33.00 74210-TC $44.00 74280-26 $50.00
74010-26 $11.00 74220 $68.00 74280-TC $84.00
74010-TC $21.00 74220-26 $23.00 74283 $201.00
74020 $37.00 74220-TC $44.00 74283-26 $103.00
74020-26 $13.00 74230 $77.00 74283-TC $95.00
74020-TC $22.00 74230-26 $27.00 74290 $44.00
74022 $44.00 74230-TC $48.00 74290-26 $16.00
74022-26 $16.00 74235 $160.00 74290-TC $28.00
74022-TC $28.00 74235-26 $60.00 74300 $31.00
74150 $274.00 74235-TC $100.00 74300-26 $19.00
74150-26 $60.00 74240 $91.00 74300-TC $104.00
74150-TC $211.00 74240-26 $35.00 74301 $107.00
74160 $322.00 74240-TC $55.00 74301-26 $11.00
74160-26 $65.00 74241 $91.00 74301-TC $104.00
74160-TC $256.00 74241-26 $35.00 74328 $155.00
74170 $390.00 74241-TC $56.00 74328-26 $35.00
74170-26 $71.00 74245 $137.00 74328-TC $120.00
74170-TC $317.00 74245-26 $46.00 74329 $155.00
74174 $502.00 74245-TC $89.00 74329-26 $35.00
74174-26 $112.00 74246 $97.00 74329-TC $120.00
74174-TC $390.00 74246-26 $35.00 74330 $165.00
74175 $418.00 74246-TC $61.00 74330-26 $45.00
74175-26 $98.00 74247 $99.00 74330-TC $120.00
74175-TC $315.00 74247-26 $35.00 74340 $121.00
74176 $219.00 74247-TC $63.00 74340-26 $26.00
74176-26 $89.00 74249 $144.00 74340-TC $95.00
74176-TC $130.00 74249-26 $46.00 74355 $137.00
74177 $327.00 74249-TC $96.00 74355-26 $38.00
74177-26 $93.00 74250 $73.00 74355-TC $99.00
74177-TC $235.00 74250-26 $23.00 74360 $145.00
74178 $381.00 74250-TC $48.00 74360-26 $27.00
74178-26 $102.00 74251 $85.00 74360-TC $118.00
74178-TC $279.00 74251-26 $34.00 74363 $274.00
74181 $498.00 74251-TC $48.00 74363-26 $44.00
74181-26 $85.00 74260 $82.00 74363-TC $230.00
74181-TC $415.00 74260-26 $25.00 74400 $89.00
74182 $587.00 74260-TC $56.00 74400-26 $24.00
74182-26 $88.00 74261 $248.00 74400-TC $63.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 122
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
74410 $98.00 74775-TC $55.00 75710-26 $21.00
74410-26 $24.00 75557 $462.00 75710-TC $173.00
74410-TC $72.00 75557-26 $79.00 75716 $293.00
74415 $105.00 75557-TC $344.00 75716-26 $35.00
74415-26 $24.00 75559 $495.00 75716-TC $258.00
74415-TC $79.00 75559-26 $99.00 75726 $530.00
74420 $117.00 75559-TC $344.00 75726-26 $56.00
74420-26 $18.00 75561 $656.00 75726-TC $474.00
74420-TC $97.00 75561-26 $87.00 75731 $530.00
74425 $68.00 75561-TC $525.00 75731-26 $56.00
74425-26 $18.00 75563 $683.00 75731-TC $474.00
74425-TC $50.00 75563-26 $101.00 75733 $540.00
74430 $48.00 75563-TC $526.00 75733-26 $65.00
74430-26 $14.00 75565 $56.00 75733-TC $475.00
74430-TC $34.00 75565-26 $13.00 75736 $530.00
74440 $62.00 75565-TC $44.00 75736-26 $56.00
74440-26 $19.00 75571 $50.00 75736-TC $474.00
74440-TC $43.00 75571-26 $28.00 75741 $540.00
74445 $101.00 75571-TC $22.00 75741-26 $65.00
74445-26 $57.00 75572 $291.00 75741-TC $475.00
74445-TC $44.00 75572-26 $87.00 75743 $253.00
74450 $60.00 75572-TC $204.00 75743-26 $37.00
74450-26 $14.00 75573 $349.00 75743-TC $216.00
74450-TC $46.00 75573-26 $126.00 75746 $530.00
74455 $75.00 75573-TC $222.00 75746-26 $56.00
74455-26 $16.00 75574 $341.00 75746-TC $474.00
74455-TC $59.00 75574-26 $119.00 75756 $183.00
74470 $74.00 75574-TC $222.00 75756-26 $20.00
74470-26 $27.00 75600 $497.00 75756-TC $163.00
74470-TC $47.00 75600-26 $25.00 75774 $80.00
74485 $146.00 75600-TC $472.00 75774-26 $3.00
74485-26 $27.00 75605 $183.00 75774-TC $77.00
74485-TC $119.00 75605-26 $20.00 75801 $245.00
74710 $57.00 75605-TC $163.00 75801-26 $41.00
74710-26 $17.00 75625 $143.00 75801-TC $204.00
74710-TC $39.00 75625-26 $15.00 75803 $264.00
74712 $426.00 75625-TC $128.00 75803-26 $58.00
74712-26 $154.00 75630 $239.00 75803-TC $206.00
74712-TC $273.00 75630-26 $37.00 75805 $271.00
74713 $233.00 75630-TC $202.00 75805-26 $40.00
74713-26 $91.00 75635 $445.00 75805-TC $231.00
74713-TC $142.00 75635-26 $75.00 75807 $289.00
74740 $68.00 75635-TC $370.00 75807-26 $58.00
74740-26 $19.00 75658 $540.00 75807-TC $231.00
74740-TC $49.00 75658-26 $66.00 75809 $54.00
74742 $150.00 75658-TC $474.00 75809-26 $24.00
74742-26 $30.00 75705 $587.00 75809-TC $30.00
74742-TC $120.00 75705-26 $109.00 75810 $530.00
74775 $88.00 75705-TC $478.00 75810-26 $56.00
74775-26 $32.00 75710 $194.00 75810-TC $474.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 123
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
75820 $72.00 75893-TC $473.00 76080-26 $27.00
75820-26 $35.00 75894 $972.00 76080-TC $40.00
75820-TC $37.00 75894-26 $65.00 76098 $23.00
75822 $111.00 75894-TC $907.00 76098-26 $8.00
75822-26 $54.00 75898 $124.00 76098-TC $15.00
75822-TC $57.00 75898-26 $84.00 76100 $77.00
75825 $194.00 75898-TC $39.00 76100-26 $30.00
75825-26 $21.00 75901 $98.00 76100-TC $46.00
75825-TC $173.00 75901-26 $23.00 76101 $94.00
75827 $530.00 75901-TC $75.00 76101-26 $36.00
75827-26 $56.00 75902 $93.00 76101-TC $59.00
75827-TC $474.00 75902-26 $19.00 76102 $95.00
75831 $54.00 75902-TC $74.00 76102-26 $30.00
75831-26 $6.00 75952 BR 76102-TC $65.00
75831-TC $48.00 75952-26 $254.00 76120 $157.00
75833 $549.00 75952-TC BR 76120-26 $56.00
75833-26 $74.00 75953 BR 76120-TC $102.00
75833-TC $475.00 75953-26 $98.00 76125 $49.00
75840 $531.00 75953-TC BR 76125-26 $17.00
75840-26 $57.00 75954 BR 76125-TC $33.00
75840-TC $474.00 75954-26 $132.00 76140 $31.00
75842 $549.00 75954-TC BR 76376 $144.00
75842-26 $73.00 75956 BR 76376-26 $11.00
75842-TC $476.00 75956-26 $394.00 76376-TC $133.00
75860 $531.00 75956-TC BR 76377 $185.00
75860-26 $57.00 75957 BR 76377-26 $43.00
75860-TC $474.00 75957-26 $338.00 76377-TC $142.00
75870 $531.00 75957-TC BR 76380 $182.00
75870-26 $57.00 75958 BR 76380-26 $50.00
75870-TC $474.00 75958-26 $225.00 76380-TC $131.00
75872 $530.00 75958-TC BR 76390 $493.00
75872-26 $56.00 75959 BR 76390-26 $71.00
75872-TC $474.00 75959-26 $197.00 76390-TC $419.00
75880 $72.00 75959-TC BR 76496 BR
75880-26 $35.00 75970 $475.00 76496-26 BR
75880-TC $37.00 75970-26 $42.00 76496-TC $79.00
75885 $546.00 75970-TC $433.00 76497 BR
75885-26 $71.00 75984 $110.00 76497-26 BR
75885-TC $475.00 75984-26 $36.00 76497-TC $94.00
75887 $546.00 75984-TC $74.00 76498 BR
75887-26 $71.00 75989 $180.00 76498-26 BR
75887-TC $475.00 75989-26 $59.00 76498-TC $280.00
75889 $530.00 75989-TC $121.00 76499 BR
75889-26 $56.00 76000 $58.00 76499-26 BR
75889-TC $474.00 76000-26 $8.00 76499-TC BR
75891 $530.00 76000-TC $48.00 76506 $88.00
75891-26 $56.00 76001 $134.00 76506-26 $33.00
75891-TC $474.00 76001-26 $34.00 76506-TC $53.00
75893 $499.00 76001-TC $97.00 76510 $171.00
75893-26 $26.00 76080 $67.00 76510-26 $86.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 124
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
76510-TC $85.00 76776-26 $36.00 76825 $160.00
76511 $96.00 76776-TC $88.00 76825-26 $65.00
76511-26 $48.00 76800 $112.00 76825-TC $73.00
76511-TC $48.00 76800-26 $61.00 76826 $71.00
76512 $96.00 76800-TC $54.00 76826-26 $46.00
76512-26 $36.00 76801 $93.00 76826-TC $27.00
76512-TC $60.00 76801-26 $51.00 76827 $97.00
76513 $96.00 76801-TC $42.00 76827-26 $35.00
76513-26 $36.00 76802 $73.00 76827-TC $65.00
76513-TC $60.00 76802-26 $43.00 76828 $72.00
76514 $12.00 76802-TC $30.00 76828-26 $29.00
76514-26 $10.00 76805 $131.00 76828-TC $42.00
76514-TC $3.00 76805-26 $51.00 76830 $93.00
76516 $99.00 76805-TC $79.00 76830-26 $35.00
76516-26 $37.00 76810 $252.00 76830-TC $57.00
76516-TC $63.00 76810-26 $100.00 76831 $95.00
76519 $88.00 76810-TC $151.00 76831-26 $37.00
76519-26 $31.00 76811 $243.00 76831-TC $57.00
76519-TC $53.00 76811-26 $100.00 76856 $93.00
76529 $86.00 76811-TC $142.00 76856-26 $35.00
76529-26 $31.00 76812 $145.00 76856-TC $57.00
76529-TC $53.00 76812-26 $94.00 76857 $59.00
76536 $83.00 76812-TC $51.00 76857-26 $19.00
76536-26 $31.00 76813 $125.00 76857-TC $39.00
76536-TC $54.00 76813-26 $55.00 76870 $90.00
76604 $78.00 76813-TC $71.00 76870-26 $33.00
76604-26 $28.00 76814 $83.00 76870-TC $57.00
76604-TC $48.00 76814-26 $46.00 76872 $93.00
76641 $109.00 76814-TC $37.00 76872-26 $36.00
76641-26 $37.00 76815 $88.00 76872-TC $57.00
76641-TC $72.00 76815-26 $33.00 76873 $151.00
76642 $90.00 76815-TC $53.00 76873-26 $68.00
76642-26 $35.00 76816 $72.00 76873-TC $80.00
76642-TC $55.00 76816-26 $30.00 76881 $120.00
76700 $116.00 76816-TC $41.00 76881-26 $32.00
76700-26 $42.00 76817 $96.00 76881-TC $88.00
76700-TC $73.00 76817-26 $39.00 76882 $36.00
76705 $84.00 76817-TC $57.00 76882-26 $25.00
76705-26 $30.00 76818 $105.00 76882-TC $11.00
76705-TC $53.00 76818-26 $40.00 76930 $93.00
76706 $95.00 76818-TC $60.00 76930-26 $34.00
76706-26 $28.00 76819 $101.00 76930-TC $59.00
76706-TC $67.00 76819-26 $40.00 76932 $93.00
76770 $112.00 76819-TC $60.00 76932-26 $34.00
76770-26 $38.00 76820 $93.00 76932-TC $59.00
76770-TC $73.00 76820-26 $27.00 76936 $341.00
76775 $84.00 76820-TC $66.00 76936-26 $102.00
76775-26 $30.00 76821 $103.00 76936-TC $236.00
76775-TC $53.00 76821-26 $38.00 76937 $34.00
76776 $124.00 76821-TC $66.00 76937-26 $17.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 125
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
76937-TC $18.00 77012-26 $55.00 77081 $40.00
76940 $171.00 77012-TC $251.00 77081-26 $11.00
76940-26 $104.00 77013-26 $191.00 77081-TC $29.00
76940-TC $68.00 77013-TC $297.00 77084 $356.00
76941 $128.00 77014 $135.00 77084-26 $77.00
76941-26 $69.00 77014-26 $41.00 77084-TC $280.00
76941-TC $59.00 77014-TC $94.00 77085 $57.00
76942 $92.00 77021 $353.00 77085-26 $16.00
76942-26 $24.00 77021-26 $73.00 77085-TC $41.00
76942-TC $68.00 77021-TC $280.00 77086 $36.00
76945 $93.00 77022 BR 77086-26 $9.00
76945-26 $34.00 77022-26 $204.00 77086-TC $27.00
76945-TC $59.00 77022-TC $280.00 77261 $73.00
76946 $78.00 77053 $102.00 77262 $110.00
76946-26 $19.00 77053-26 $17.00 77263 $163.00
76946-TC $59.00 77053-TC $85.00 77280 $166.00
76948 $77.00 77054 $126.00 77280-26 $36.00
76948-26 $19.00 77054-26 $22.00 77280-TC $130.00
76948-TC $58.00 77054-TC $104.00 77285 $264.00
76965 $281.00 77058 $804.00 77285-26 $53.00
76965-26 $84.00 77058-26 $78.00 77285-TC $209.00
76965-TC $208.00 77058-TC $726.00 77290 $325.00
76970 $60.00 77059 $994.00 77290-26 $79.00
76970-26 $20.00 77059-26 $78.00 77290-TC $243.00
76970-TC $39.00 77059-TC $917.00 77293 $432.00
76975 $99.00 77063 $56.00 77293-26 $104.00
76975-26 $41.00 77063-26 $30.00 77293-TC $328.00
76975-TC $58.00 77063-TC $25.00 77295 $1,287.00
76977 $34.00 77071 $29.00 77295-26 $232.00
76977-26 $3.00 77072 $22.00 77295-TC $1,046.00
76977-TC $31.00 77072-26 $9.00 77299 BR
76998 BR 77072-TC $14.00 77299-26 BR
76998-26 $61.00 77073 $42.00 77299-TC BR
76998-TC $96.00 77073-26 $13.00 77300 $87.00
76999 BR 77073-TC $29.00 77300-26 $36.00
76999-26 BR 77074 $64.00 77300-TC $52.00
76999-TC BR 77074-26 $22.00 77301 $1,473.00
77001 $83.00 77074-TC $42.00 77301-26 $415.00
77001-26 $18.00 77075 $89.00 77301-TC $1,046.00
77001-TC $64.00 77075-26 $26.00 77306 $151.00
77002 $75.00 77075-TC $63.00 77306-26 $73.00
77002-26 $25.00 77077 $54.00 77306-TC $78.00
77002-TC $50.00 77077-26 $15.00 77307 $292.00
77003 $73.00 77077-TC $39.00 77307-26 $151.00
77003-26 $27.00 77078 $84.00 77307-TC $140.00
77003-TC $45.00 77078-26 $12.00 77316 $191.00
77011 $309.00 77078-TC $72.00 77316-26 $73.00
77011-26 $58.00 77080 $83.00 77316-TC $117.00
77011-TC $251.00 77080-26 $11.00 77317 $248.00
77012 $306.00 77080-TC $72.00 77317-26 $96.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 126
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
77317-TC $153.00 77523 BR 77790 $72.00
77318 $358.00 77525 BR 77790-26 $53.00
77318-26 $151.00 77600 $196.00 77790-TC $18.00
77318-TC $207.00 77600-26 $80.00 77799 BR
77321 $200.00 77600-TC $113.00 77799-26 BR
77321-26 $48.00 77605 $263.00 77799-TC BR
77321-TC $150.00 77605-26 $108.00 78012 $78.00
77331 $64.00 77605-TC $151.00 78012-26 $9.00
77331-26 $45.00 77610 $195.00 78012-TC $69.00
77331-TC $18.00 77610-26 $79.00 78013 $198.00
77332 $78.00 77610-TC $113.00 78013-26 $18.00
77332-26 $27.00 77615 $262.00 78013-TC $179.00
77332-TC $50.00 77615-26 $106.00 78014 $240.00
77333 $115.00 77615-TC $151.00 78014-26 $25.00
77333-26 $43.00 77620 $196.00 78014-TC $215.00
77333-TC $70.00 77620-26 $80.00 78015 $132.00
77334 $187.00 77620-TC $113.00 78015-26 $34.00
77334-26 $63.00 77750 $299.00 78015-TC $96.00
77334-TC $121.00 77750-26 $248.00 78016 $173.00
77336 $111.00 77750-TC $49.00 78016-26 $42.00
77338 $502.00 77761 $284.00 78016-TC $130.00
77338-26 $223.00 77761-26 $188.00 78018 $248.00
77338-TC $279.00 77761-TC $93.00 78018-26 $44.00
77370 $130.00 77762 $427.00 78018-TC $202.00
77371 $1,151.00 77762-26 $289.00 78020 $35.00
77372 $874.00 77762-TC $135.00 78020-26 $30.00
77373 $1,630.00 77763 $605.00 78020-TC $5.00
77399 BR 77763-26 $435.00 78070 $112.00
77399-26 BR 77763-TC $167.00 78070-26 $36.00
77399-TC BR 77767 $227.00 78070-TC $68.00
77401 $66.00 77767-26 $55.00 78071 $357.00
77402 $66.00 77767-TC $172.00 78071-26 $59.00
77407 $78.00 77768 $356.00 78071-TC $298.00
77412 $87.00 77768-26 $73.00 78072 $446.00
77417 $21.00 77768-TC $283.00 78072-26 $80.00
77422 $70.00 77770 $324.00 78072-TC $366.00
77423 $91.00 77770-26 $102.00 78075 $242.00
77427 $166.00 77770-TC $222.00 78075-26 $38.00
77431 $95.00 77771 $604.00 78075-TC $202.00
77432 $417.00 77771-26 $199.00 78099 BR
77435 $644.00 77771-TC $405.00 78099-26 BR
77469 $313.00 77772 $922.00 78099-TC BR
77470 $527.00 77772-26 $282.00 78102 $106.00
77470-26 $106.00 77772-TC $640.00 78102-26 $28.00
77470-TC $417.00 77778 $764.00 78102-TC $77.00
77499 BR 77778-26 $568.00 78103 $158.00
77499-26 BR 77778-TC $192.00 78103-26 $39.00
77499-TC BR 77789 $74.00 78103-TC $118.00
77520 BR 77789-26 $57.00 78104 $194.00
77522 BR 77789-TC $16.00 78104-26 $41.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 127
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
78104-TC $152.00 78206-26 $46.00 78272-26 $14.00
78110 $45.00 78206-TC $214.00 78272-TC $87.00
78110-26 $9.00 78215 $135.00 78278 $234.00
78110-TC $35.00 78215-26 $24.00 78278-26 $50.00
78111 $108.00 78215-TC $109.00 78278-TC $182.00
78111-26 $11.00 78216 $160.00 78282 $230.00
78111-TC $96.00 78216-26 $29.00 78282-26 $19.00
78120 $78.00 78216-TC $130.00 78282-TC $224.00
78120-26 $11.00 78226 $339.00 78290 $149.00
78120-TC $65.00 78226-26 $37.00 78290-26 $35.00
78121 $125.00 78226-TC $301.00 78290-TC $113.00
78121-26 $16.00 78227 $418.00 78291 $161.00
78121-TC $108.00 78227-26 $45.00 78291-26 $45.00
78122 $196.00 78227-TC $373.00 78291-TC $114.00
78122-26 $22.00 78230 $106.00 78299 BR
78122-TC $171.00 78230-26 $23.00 78299-26 BR
78130 $139.00 78230-TC $82.00 78299-TC BR
78130-26 $32.00 78231 $146.00 78300 $125.00
78130-TC $106.00 78231-26 $27.00 78300-26 $32.00
78135 $216.00 78231-TC $118.00 78300-TC $93.00
78135-26 $33.00 78232 $157.00 78305 $181.00
78135-TC $182.00 78232-26 $23.00 78305-26 $42.00
78140 $179.00 78232-TC $132.00 78305-TC $137.00
78140-26 $31.00 78258 $146.00 78306 $205.00
78140-TC $147.00 78258-26 $38.00 78306-26 $44.00
78185 $110.00 78258-TC $108.00 78306-TC $159.00
78185-26 $20.00 78261 $190.00 78315 $233.00
78185-TC $88.00 78261-26 $36.00 78315-26 $52.00
78190 $272.00 78261-TC $152.00 78315-TC $179.00
78190-26 $57.00 78262 $195.00 78320 $276.00
78190-TC $214.00 78262-26 $35.00 78320-26 $53.00
78191 $307.00 78262-TC $159.00 78320-TC $220.00
78191-26 $31.00 78264 $195.00 78350 $40.00
78191-TC $274.00 78264-26 $40.00 78350-26 $11.00
78195 $216.00 78264-TC $154.00 78350-TC $29.00
78195-26 $49.00 78265 $381.00 78351 $23.00
78195-TC $152.00 78265-26 $49.00 78399 BR
78199 BR 78265-TC $332.00 78399-26 BR
78199-26 BR 78266 $494.00 78399-TC BR
78199-TC BR 78266-26 $54.00 78414 BR
78201 $112.00 78266-TC $440.00 78414-26 $23.00
78201-26 $22.00 78267 BR 78414-TC BR
78201-TC $88.00 78268 BR 78428 $126.00
78202 $135.00 78270 $68.00 78428-26 $41.00
78202-26 $26.00 78270-26 $10.00 78428-TC $84.00
78202-TC $108.00 78270-TC $58.00 78445 $97.00
78205 $259.00 78271 $72.00 78445-26 $28.00
78205-26 $36.00 78271-26 $10.00 78445-TC $69.00
78205-TC $220.00 78271-TC $61.00 78451 $351.00
78206 $265.00 78272 $100.00 78451-26 $68.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 128
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
78451-TC $283.00 78494-26 $59.00 78630 $223.00
78452 $486.00 78494-TC $262.00 78630-26 $35.00
78452-26 $80.00 78496 $92.00 78630-TC $188.00
78452-TC $407.00 78496-26 $24.00 78635 $129.00
78453 $313.00 78496-TC $66.00 78635-26 $32.00
78453-26 $51.00 78499 BR 78635-TC $95.00
78453-TC $263.00 78499-26 BR 78645 $158.00
78454 $446.00 78499-TC BR 78645-26 $29.00
78454-26 $67.00 78579 $191.00 78645-TC $128.00
78454-TC $379.00 78579-26 $24.00 78647 $268.00
78456 $205.00 78579-TC $166.00 78647-26 $46.00
78456-26 $49.00 78580 $167.00 78647-TC $220.00
78456-TC $151.00 78580-26 $38.00 78650 $206.00
78457 $140.00 78580-TC $128.00 78650-26 $31.00
78457-26 $39.00 78582 $343.00 78650-TC $173.00
78457-TC $99.00 78582-26 $53.00 78660 $107.00
78458 $198.00 78582-TC $289.00 78660-26 $27.00
78458-26 $46.00 78597 $206.00 78660-TC $79.00
78458-TC $149.00 78597-26 $36.00 78699 BR
78459 $755.00 78597-TC $171.00 78699-26 BR
78459-26 $100.00 78598 $314.00 78699-TC BR
78459-TC $731.00 78598-26 $42.00 78700 $137.00
78466 $135.00 78598-TC $272.00 78700-26 $22.00
78466-26 $36.00 78599 BR 78700-TC $113.00
78466-TC $97.00 78599-26 BR 78701 $158.00
78468 $180.00 78599-TC BR 78701-26 $24.00
78468-26 $41.00 78600 $131.00 78701-TC $133.00
78468-TC $137.00 78600-26 $22.00 78707 $217.00
78469 $244.00 78600-TC $108.00 78707-26 $49.00
78469-26 $47.00 78601 $154.00 78707-TC $166.00
78469-TC $195.00 78601-26 $26.00 78708 $231.00
78472 $259.00 78601-TC $126.00 78708-26 $61.00
78472-26 $50.00 78605 $155.00 78708-TC $166.00
78472-TC $206.00 78605-26 $27.00 78709 $241.00
78473 $387.00 78605-TC $126.00 78709-26 $68.00
78473-26 $75.00 78606 $221.00 78709-TC $166.00
78473-TC $308.00 78606-26 $45.00 78710 $256.00
78481 $248.00 78606-TC $177.00 78710-26 $34.00
78481-26 $51.00 78607 $311.00 78710-TC $220.00
78481-TC $195.00 78607-26 $64.00 78725 $87.00
78483 $373.00 78607-TC $245.00 78725-26 $19.00
78483-26 $77.00 78608 $876.00 78725-TC $66.00
78483-TC $294.00 78608-26 $78.00 78730 $73.00
78491 $756.00 78608-TC $855.00 78730-26 $18.00
78491-26 $85.00 78609 $51.00 78730-TC $55.00
78491-TC $731.00 78609-26 $78.00 78740 $109.00
78492 $764.00 78609-TC BR 78740-26 $29.00
78492-26 $100.00 78610 $74.00 78740-TC $79.00
78492-TC $731.00 78610-26 $15.00 78761 $157.00
78494 $324.00 78610-TC $59.00 78761-26 $36.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 129
Radiology Radiology Radiology
CPT Code MRA CPT Code MRA CPT Code MRA
78761-TC $119.00 79005 $199.00 G6001-TC $22.00
78799 BR 79005-26 $94.00 G6002 $76.00
78799-26 BR 79005-TC $105.00 G6002-26 $20.00
78799-TC BR 79101 $207.00 G6002-TC $55.00
78800 $162.00 79101-26 $103.00 G6003 $188.00
78800-26 $34.00 79101-TC $105.00 G6004 $146.00
78800-TC $126.00 79200 $203.00 G6005 $145.00
78801 $199.00 79200-26 $102.00 G6006 $145.00
78801-26 $40.00 79200-TC $97.00 G6007 $303.00
78801-TC $158.00 79300 BR G6008 $202.00
78802 $252.00 79300-26 $83.00 G6009 $199.00
78802-26 $44.00 79300-TC BR G6010 $199.00
78802-TC $207.00 79403 $287.00 G6011 $324.00
78803 $303.00 79403-26 $121.00 G6012 $266.00
78803-26 $56.00 79403-TC $165.00 G6013 $266.00
78803-TC $245.00 79440 $204.00 G6014 $266.00
78804 $227.00 79440-26 $104.00 G6015 $347.00
78804-26 $55.00 79440-TC $97.00 G6016 $346.00
78804-TC $171.00 79445 $232.00 Q0092 $14.00
78805 $166.00 79445-26 $127.00
78805-26 $38.00 79445-TC $105.00
78805-TC $126.00 79999 BR
78806 $286.00 79999-26 BR
78806-26 $44.00 79999-TC BR
78806-TC $241.00 G0130 $34.00
78807 $303.00 G0130-26 $10.00
78807-26 $57.00 G0130-TC $24.00
78807-TC $245.00 G0202 $120.00
78808 $47.00 G0202-26 $32.00
78811 $879.00 G0202-TC $88.00
78811-26 $83.00 G0204 $136.00
78811-TC $855.00 G0204-26 $40.00
78812 $884.00 G0204-TC $96.00
78812-26 $102.00 G0206 $109.00
78812-TC $855.00 G0206-26 $32.00
78813 $885.00 G0206-TC $77.00
78813-26 $106.00 G0252-26 $78.00
78813-TC $855.00 G0278 $13.00
78814 $982.00 G0279 $56.00
78814-26 $116.00 G0279-26 $30.00
78814-TC $950.00 G0279-TC $25.00
78815 $985.00 G0288 $201.00
78815-26 $128.00 G0297 $255.00
78815-TC $950.00 G0297-26 $52.00
78816 $986.00 G0297-TC $203.00
78816-26 $132.00 G0365 $164.00
78816-TC $950.00 G0365-26 $12.00
78999 BR G0365-TC $152.00
78999-26 BR G6001 $52.00
78999-TC BR G6001-26 $30.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 130
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
80048 $23.00 80170-TC $11.00 80400-26 $18.00
80048-26 $4.00 80173 $33.00 80400-TC $36.00
80048-TC $19.00 80173-26 $11.00 80402 $138.00
80050 $45.00 80173-TC $22.00 80402-26 $42.00
80050-26 $18.00 80176 $35.00 80402-TC $95.00
80050-TC $26.00 80176-26 $11.00 80406 $138.00
80051 $16.00 80176-TC $23.00 80406-26 $42.00
80051-26 $6.00 80178 $17.00 80406-TC $95.00
80051-TC $10.00 80178-26 $6.00 80408 $213.00
80053 $29.00 80178-TC $11.00 80408-26 $77.00
80053-26 $8.00 80184 $34.00 80408-TC $136.00
80053-TC $21.00 80184-26 $10.00 80410 $166.00
80055 $67.00 80184-TC $23.00 80410-26 $54.00
80055-26 $21.00 80185 $36.00 80410-TC $110.00
80055-TC $43.00 80185-26 $10.00 80412 $533.00
80061 $31.00 80185-TC $25.00 80412-26 $176.00
80061-26 $11.00 80186 $38.00 80412-TC $355.00
80061-TC $19.00 80186-26 $11.00 80414 $88.00
80069 $26.00 80186-TC $26.00 80414-26 $26.00
80069-26 $6.00 80188 $35.00 80414-TC $59.00
80069-TC $20.00 80188-26 $11.00 80415 $93.00
80074 $107.00 80188-TC $23.00 80415-26 $28.00
80074-26 $43.00 80190 $41.00 80415-TC $64.00
80074-TC $64.00 80190-26 $13.00 80416 $256.00
80076 $18.00 80190-TC $28.00 80416-26 $88.00
80076-26 $7.00 80192 $44.00 80416-TC $166.00
80076-TC $11.00 80192-26 $17.00 80417 $256.00
80150 $40.00 80192-TC $26.00 80417-26 $88.00
80150-26 $13.00 80194 $33.00 80417-TC $166.00
80150-TC $26.00 80194-26 $10.00 80418 $934.00
80156 $35.00 80194-TC $22.00 80418-26 $266.00
80156-26 $11.00 80197 $34.00 80418-TC $666.00
80156-TC $23.00 80197-26 $11.00 80420 $107.00
80157 $22.00 80197-TC $22.00 80420-26 $33.00
80157-26 $8.00 80198 $20.00 80420-TC $74.00
80157-TC $14.00 80198-26 $5.00 80422 $62.00
80158 $35.00 80198-TC $15.00 80422-26 $18.00
80158-26 $12.00 80200 $24.00 80422-TC $43.00
80158-TC $22.00 80200-26 $7.00 80424 $94.00
80162 $13.00 80200-TC $16.00 80424-26 $26.00
80162-26 $3.00 80201 $33.00 80424-TC $67.00
80162-TC $9.00 80201-26 $11.00 80426 $232.00
80164 $43.00 80201-TC $21.00 80426-26 $54.00
80164-26 $14.00 80202 $42.00 80426-TC $176.00
80164-TC $29.00 80202-26 $14.00 80428 $93.00
80168 $43.00 80202-TC $28.00 80428-26 $19.00
80168-26 $17.00 80299 BR 80428-TC $73.00
80168-TC $25.00 80299-26 BR 80430 $99.00
80170 $18.00 80299-TC BR 80430-26 $24.00
80170-26 $6.00 80400 $54.00 80430-TC $74.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 131
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
80432 $243.00 81025-TC $4.00 82105-26 $8.00
80432-26 $56.00 81050 $33.00 82105-TC $18.00
80432-TC $186.00 81050-26 $11.00 82106 $26.00
80434 $161.00 81050-TC $21.00 82106-26 $8.00
80434-26 $49.00 81099 BR 82106-TC $18.00
80434-TC $110.00 81099-26 BR 82108 $45.00
80435 $166.00 81099-TC BR 82108-26 $14.00
80435-26 $49.00 82009 $10.00 82108-TC $32.00
80435-TC $115.00 82009-26 $3.00 82120 $9.00
80436 $119.00 82009-TC $6.00 82120-26 $3.00
80436-26 $35.00 82010 $22.00 82120-TC $5.00
80436-TC $85.00 82010-26 $7.00 82127 $33.00
80438 $82.00 82010-TC $15.00 82127-26 $11.00
80438-26 $24.00 82013 $24.00 82127-TC $22.00
80438-TC $56.00 82013-26 $7.00 82128 $26.00
80439 $176.00 82013-TC $17.00 82128-26 $6.00
80439-26 $33.00 82024 $26.00 82128-TC $19.00
80439-TC $144.00 82024-26 $7.00 82131 $57.00
80500 $34.00 82024-TC $18.00 82131-26 $13.00
80500-26 $34.00 82030 $43.00 82131-TC $44.00
80500-TC BR 82030-26 $17.00 82135 $41.00
80502 $72.00 82030-TC $25.00 82135-26 $13.00
80502-26 $72.00 82040 $11.00 82135-TC $28.00
80502-TC BR 82040-26 $3.00 82136 $38.00
81000 $7.00 82040-TC $7.00 82136-26 $14.00
81000-26 $3.00 82042 $12.00 82136-TC $23.00
81000-TC $4.00 82042-26 $3.00 82139 $38.00
81001 $7.00 82042-TC $8.00 82139-26 $14.00
81001-26 $3.00 82043 $14.00 82139-TC $23.00
81001-TC $4.00 82043-26 $4.00 82140 $40.00
81002 $5.00 82043-TC $10.00 82140-26 $12.00
81002-26 $3.00 82044 $12.00 82140-TC $28.00
81002-TC $3.00 82044-26 $4.00 82143 $28.00
81003 $5.00 82044-TC $9.00 82143-26 $8.00
81003-26 $2.00 82075 $32.00 82143-TC $19.00
81003-TC $3.00 82075-26 $10.00 82150 $16.00
81005 $3.00 82075-TC $21.00 82150-26 $5.00
81005-26 $1.00 82085 $24.00 82150-TC $11.00
81005-TC $3.00 82085-26 $7.00 82154 $34.00
81007 $5.00 82085-TC $17.00 82154-26 $13.00
81007-26 $2.00 82088 $91.00 82154-TC $20.00
81007-TC $4.00 82088-26 $28.00 82157 $57.00
81015 $5.00 82088-TC $62.00 82157-26 $17.00
81015-26 $3.00 82103 $21.00 82157-TC $40.00
81015-TC $3.00 82103-26 $7.00 82160 $67.00
81020 $8.00 82103-TC $14.00 82160-26 $21.00
81020-26 $3.00 82104 $22.00 82160-TC $43.00
81020-TC $5.00 82104-26 $7.00 82163 $42.00
81025 $7.00 82104-TC $15.00 82163-26 $12.00
81025-26 $4.00 82105 $26.00 82163-TC $31.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 132
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
82164 $32.00 82306-TC $52.00 82382-26 $12.00
82164-26 $10.00 82308 $62.00 82382-TC $25.00
82164-TC $21.00 82308-26 $18.00 82383 $62.00
82172 $33.00 82308-TC $43.00 82383-26 $18.00
82172-26 $10.00 82310 $11.00 82383-TC $43.00
82172-TC $22.00 82310-26 $3.00 82384 $62.00
82175 $48.00 82310-TC $7.00 82384-26 $18.00
82175-26 $15.00 82330 $37.00 82384-TC $43.00
82175-TC $33.00 82330-26 $11.00 82387 $34.00
82180 $25.00 82330-TC $25.00 82387-26 $10.00
82180-26 $8.00 82331 $14.00 82387-TC $23.00
82180-TC $17.00 82331-26 $4.00 82390 $24.00
82190 $24.00 82331-TC $10.00 82390-26 $7.00
82190-26 $8.00 82340 $13.00 82390-TC $17.00
82190-TC $16.00 82340-26 $4.00 82397 $22.00
82232 $43.00 82340-TC $8.00 82397-26 $7.00
82232-26 $14.00 82355 $31.00 82397-TC $15.00
82232-TC $29.00 82355-26 $10.00 82415 $28.00
82239 $23.00 82355-TC $20.00 82415-26 $8.00
82239-26 $8.00 82360 $31.00 82415-TC $19.00
82239-TC $15.00 82360-26 $10.00 82435 $8.00
82240 $49.00 82360-TC $20.00 82435-26 $2.00
82240-26 $15.00 82365 $31.00 82435-TC $6.00
82240-TC $34.00 82365-26 $8.00 82436 $14.00
82247 $10.00 82365-TC $21.00 82436-26 $4.00
82247-26 $3.00 82370 $22.00 82436-TC $10.00
82247-TC $7.00 82370-26 $7.00 82438 $13.00
82248 $10.00 82370-TC $15.00 82438-26 $4.00
82248-26 $3.00 82373 $16.00 82438-TC $8.00
82248-TC $7.00 82373-26 $5.00 82441 $16.00
82252 $11.00 82373-TC $11.00 82441-26 $5.00
82252-26 $3.00 82374 $10.00 82441-TC $11.00
82252-TC $7.00 82374-26 $3.00 82465 $8.00
82261 $38.00 82374-TC $6.00 82465-26 $2.00
82261-26 $13.00 82375 $26.00 82465-TC $6.00
82261-TC $24.00 82375-26 $7.00 82480 $23.00
82270 $5.00 82375-TC $18.00 82480-26 $6.00
82270-26 $2.00 82376 $11.00 82480-TC $17.00
82270-TC $3.00 82376-26 $3.00 82482 $23.00
82274 BR 82376-TC $7.00 82482-26 $7.00
82274-26 BR 82378 $31.00 82482-TC $15.00
82274-TC BR 82378-26 $8.00 82485 $37.00
82286 $12.00 82378-TC $21.00 82485-26 $8.00
82286-26 $3.00 82379 $38.00 82485-TC $28.00
82286-TC $8.00 82379-26 $13.00 82495 $48.00
82300 $48.00 82379-TC $24.00 82495-26 $16.00
82300-26 $15.00 82380 $21.00 82495-TC $32.00
82300-TC $33.00 82380-26 $6.00 82507 $55.00
82306 $79.00 82380-TC $15.00 82507-26 $16.00
82306-26 $25.00 82382 $38.00 82507-TC $39.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 133
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
82523 $43.00 82600-TC $28.00 82677-26 $17.00
82523-26 $17.00 82607 $38.00 82677-TC $35.00
82523-TC $25.00 82607-26 $10.00 82679 $70.00
82525 $34.00 82607-TC $27.00 82679-26 $20.00
82525-26 $10.00 82608 $40.00 82679-TC $48.00
82525-TC $23.00 82608-26 $13.00 82693 $23.00
82528 $40.00 82608-TC $26.00 82693-26 $7.00
82528-26 $13.00 82615 $17.00 82693-TC $16.00
82528-TC $26.00 82615-26 $5.00 82696 $57.00
82530 $38.00 82615-TC $12.00 82696-26 $19.00
82530-26 $12.00 82626 $59.00 82696-TC $38.00
82530-TC $25.00 82626-26 $19.00 82705 $14.00
82533 $35.00 82626-TC $40.00 82705-26 $6.00
82533-26 $10.00 82627 $37.00 82705-TC $9.00
82533-TC $24.00 82627-26 $12.00 82710 $42.00
82540 $10.00 82627-TC $24.00 82710-26 $13.00
82540-26 $3.00 82633 $81.00 82710-TC $29.00
82540-TC $6.00 82633-26 $23.00 82715 $33.00
82542 $42.00 82633-TC $56.00 82715-26 $11.00
82542-26 $13.00 82634 $81.00 82715-TC $21.00
82542-TC $28.00 82634-26 $23.00 82725 $28.00
82550 $16.00 82634-TC $56.00 82725-26 $8.00
82550-26 $4.00 82638 $23.00 82725-TC $19.00
82550-TC $12.00 82638-26 $7.00 82726 $42.00
82552 $33.00 82638-TC $16.00 82726-26 $13.00
82552-26 $10.00 82652 $89.00 82726-TC $28.00
82552-TC $22.00 82652-26 $25.00 82728 $24.00
82553 $16.00 82652-TC $62.00 82728-26 $7.00
82553-26 $5.00 82657 $42.00 82728-TC $17.00
82553-TC $11.00 82657-26 $13.00 82735 $36.00
82554 $19.00 82657-TC $28.00 82735-26 $12.00
82554-26 $6.00 82658 $42.00 82735-TC $23.00
82554-TC $13.00 82658-26 $13.00 82746 $39.00
82565 $13.00 82658-TC $28.00 82746-26 $13.00
82565-26 $2.00 82664 $40.00 82746-TC $25.00
82565-TC $11.00 82664-26 $13.00 82747 $29.00
82570 $10.00 82664-TC $26.00 82747-26 $10.00
82570-26 $2.00 82668 $45.00 82747-TC $19.00
82570-TC $7.00 82668-26 $14.00 82757 $36.00
82575 $25.00 82668-TC $32.00 82757-26 $11.00
82575-26 $8.00 82670 $61.00 82757-TC $24.00
82575-TC $17.00 82670-26 $18.00 82759 $38.00
82585 $15.00 82670-TC $42.00 82759-26 $12.00
82585-26 $3.00 82671 $61.00 82759-TC $25.00
82585-TC $12.00 82671-26 $17.00 82760 $26.00
82595 $31.00 82671-TC $43.00 82760-26 $8.00
82595-26 $10.00 82672 $57.00 82760-TC $18.00
82595-TC $21.00 82672-26 $16.00 82775 $47.00
82600 $40.00 82672-TC $41.00 82775-26 $14.00
82600-26 $12.00 82677 $52.00 82775-TC $33.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 134
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
82776 $14.00 82950-TC $7.00 83013-26 $38.00
82776-26 $3.00 82951 $22.00 83013-TC $94.00
82776-TC $11.00 82951-26 $7.00 83014 $19.00
82784 $15.00 82951-TC $15.00 83014-26 $6.00
82784-26 $5.00 82952 $11.00 83014-TC $13.00
82784-TC $11.00 82952-26 $3.00 83015 $51.00
82785 $33.00 82952-TC $7.00 83015-26 $15.00
82785-26 $11.00 82955 $25.00 83015-TC $36.00
82785-TC $21.00 82955-26 $7.00 83018 $56.00
82787 $54.00 82955-TC $18.00 83018-26 $16.00
82787-26 $17.00 82960 $14.00 83018-TC $40.00
82787-TC $37.00 82960-26 $4.00 83020 $24.00
82800 $22.00 82960-TC $10.00 83020-26 $6.00
82800-26 $6.00 82962 $5.00 83020-TC $18.00
82800-TC $16.00 82962-26 $1.00 83021 $39.00
82803 $53.00 82962-TC $4.00 83021-26 $13.00
82803-26 $16.00 82963 $54.00 83021-TC $25.00
82803-TC $37.00 82963-26 $17.00 83026 $8.00
82805 $36.00 82963-TC $37.00 83026-26 $5.00
82805-26 $10.00 82965 $16.00 83026-TC $3.00
82805-TC $24.00 82965-26 $5.00 83030 $18.00
82810 $28.00 82965-TC $11.00 83030-26 $6.00
82810-26 $8.00 82977 $16.00 83030-TC $12.00
82810-TC $19.00 82977-26 $4.00 83033 $15.00
82820 $16.00 82977-TC $12.00 83033-26 $4.00
82820-26 $5.00 82978 $25.00 83033-TC $11.00
82820-TC $11.00 82978-26 $7.00 83036 $15.00
82938 $48.00 82978-TC $18.00 83036-26 $5.00
82938-26 $16.00 82979 $18.00 83036-TC $10.00
82938-TC $32.00 82979-26 $5.00 83045 $13.00
82941 $47.00 82979-TC $13.00 83045-26 $4.00
82941-26 $15.00 82985 $41.00 83045-TC $8.00
82941-TC $32.00 82985-26 $12.00 83050 $16.00
82943 $38.00 82985-TC $29.00 83050-26 $5.00
82943-26 $12.00 83001 $40.00 83050-TC $11.00
82943-TC $25.00 83001-26 $12.00 83051 $16.00
82945 $9.00 83001-TC $28.00 83051-26 $5.00
82945-26 $3.00 83002 $42.00 83051-TC $11.00
82945-TC $5.00 83002-26 $13.00 83060 $22.00
82946 $29.00 83002-TC $29.00 83060-26 $6.00
82946-26 $7.00 83003 $36.00 83060-TC $16.00
82946-TC $21.00 83003-26 $10.00 83065 $18.00
82947 $11.00 83003-TC $25.00 83065-26 $6.00
82947-26 $3.00 83010 $26.00 83065-TC $12.00
82947-TC $7.00 83010-26 $8.00 83068 $20.00
82948 $5.00 83010-TC $18.00 83068-26 $5.00
82948-26 $3.00 83012 $36.00 83068-TC $15.00
82948-TC $3.00 83012-26 $14.00 83069 $11.00
82950 $12.00 83012-TC $21.00 83069-26 $3.00
82950-26 $4.00 83013 $133.00 83069-TC $7.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 135
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
83070 $13.00 83527-TC $23.00 83721-26 $5.00
83070-26 $4.00 83528 $43.00 83721-TC $11.00
83070-TC $8.00 83528-26 $14.00 83727 $43.00
83080 $38.00 83528-TC $29.00 83727-26 $14.00
83080-26 $11.00 83540 $16.00 83727-TC $29.00
83080-TC $26.00 83540-26 $3.00 83735 $15.00
83088 $59.00 83540-TC $13.00 83735-26 $5.00
83088-26 $18.00 83550 $20.00 83735-TC $10.00
83088-TC $41.00 83550-26 $5.00 83775 $17.00
83090 $38.00 83550-TC $15.00 83775-26 $5.00
83090-26 $13.00 83570 $23.00 83775-TC $12.00
83090-TC $25.00 83570-26 $7.00 83785 $58.00
83150 $49.00 83570-TC $16.00 83785-26 $17.00
83150-26 $16.00 83582 $34.00 83785-TC $41.00
83150-TC $33.00 83582-26 $8.00 83789 $39.00
83491 $37.00 83582-TC $24.00 83789-26 $13.00
83491-26 $11.00 83586 $38.00 83789-TC $25.00
83491-TC $25.00 83586-26 $13.00 83825 $34.00
83497 $35.00 83586-TC $24.00 83825-26 $11.00
83497-26 $11.00 83593 $59.00 83825-TC $22.00
83497-TC $23.00 83593-26 $18.00 83835 $41.00
83498 $62.00 83593-TC $41.00 83835-26 $12.00
83498-26 $20.00 83605 $19.00 83835-TC $29.00
83498-TC $41.00 83605-26 $6.00 83857 $26.00
83499 $51.00 83605-TC $13.00 83857-26 $8.00
83499-26 $15.00 83615 $16.00 83857-TC $18.00
83499-TC $36.00 83615-26 $5.00 83864 $32.00
83500 $69.00 83615-TC $11.00 83864-26 $8.00
83500-26 $21.00 83625 $23.00 83864-TC $22.00
83500-TC $45.00 83625-26 $6.00 83872 $13.00
83505 $77.00 83625-TC $17.00 83872-26 $4.00
83505-26 $21.00 83632 $42.00 83872-TC $8.00
83505-TC $54.00 83632-26 $14.00 83873 $54.00
83516 $26.00 83632-TC $28.00 83873-26 $18.00
83516-26 $8.00 83655 $31.00 83873-TC $36.00
83516-TC $18.00 83655-26 $8.00 83874 $25.00
83518 $21.00 83655-TC $21.00 83874-26 $8.00
83518-26 $7.00 83670 $18.00 83874-TC $17.00
83518-TC $14.00 83670-26 $5.00 83880 BR
83519 $21.00 83670-TC $13.00 83880-26 BR
83519-26 $7.00 83690 $18.00 83880-TC BR
83519-TC $14.00 83690-26 $6.00 83883 $11.00
83520 $20.00 83690-TC $12.00 83883-26 $3.00
83520-26 $6.00 83718 $16.00 83883-TC $7.00
83520-TC $14.00 83718-26 $5.00 83885 $45.00
83525 $31.00 83718-TC $11.00 83885-26 $14.00
83525-26 $8.00 83719 $42.00 83885-TC $32.00
83525-TC $21.00 83719-26 $14.00 83915 $31.00
83527 $35.00 83719-TC $28.00 83915-26 $10.00
83527-26 $11.00 83721 $16.00 83915-TC $20.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 136
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
83916 $54.00 84066-TC $12.00 84135-26 $19.00
83916-26 $18.00 84075 $12.00 84135-TC $38.00
83916-TC $36.00 84075-26 $3.00 84138 $56.00
83918 $41.00 84075-TC $8.00 84138-26 $18.00
83918-26 $12.00 84078 $19.00 84138-TC $38.00
83918-TC $29.00 84078-26 $5.00 84140 $41.00
83919 $42.00 84078-TC $14.00 84140-26 $8.00
83919-26 $12.00 84080 $36.00 84140-TC $33.00
83919-TC $29.00 84080-26 $11.00 84143 $62.00
83921 $37.00 84080-TC $24.00 84143-26 $20.00
83921-26 $12.00 84081 $45.00 84143-TC $41.00
83921-TC $25.00 84081-26 $15.00 84144 $38.00
83930 $11.00 84081-TC $31.00 84144-26 $7.00
83930-26 $3.00 84085 $15.00 84144-TC $31.00
83930-TC $7.00 84085-26 $5.00 84146 $53.00
83935 $17.00 84085-TC $10.00 84146-26 $17.00
83935-26 $5.00 84087 $25.00 84146-TC $36.00
83935-TC $12.00 84087-26 $7.00 84150 $69.00
83937 $29.00 84087-TC $18.00 84150-26 $20.00
83937-26 $10.00 84100 $11.00 84150-TC $47.00
83937-TC $19.00 84100-26 $3.00 84152 $42.00
83945 $32.00 84100-TC $7.00 84152-26 $14.00
83945-26 $11.00 84105 $11.00 84152-TC $27.00
83945-TC $20.00 84105-26 $3.00 84153 $33.00
83950 BR 84105-TC $7.00 84153-26 $11.00
83950-26 BR 84106 $10.00 84153-TC $21.00
83950-TC BR 84106-26 $2.00 84154 $33.00
83970 $94.00 84106-TC $7.00 84154-26 $11.00
83970-26 $31.00 84110 $21.00 84154-TC $21.00
83970-TC $62.00 84110-26 $6.00 84155 $12.00
83986 $8.00 84110-TC $15.00 84155-26 $4.00
83986-26 $3.00 84119 $21.00 84155-TC $7.00
83986-TC $5.00 84119-26 $6.00 84160 $5.00
83992 $40.00 84119-TC $15.00 84160-26 $2.00
83992-26 $12.00 84120 $38.00 84160-TC $2.00
83992-TC $28.00 84120-26 $11.00 84165 $24.00
84030 $11.00 84120-TC $26.00 84165-26 $8.00
84030-26 $3.00 84126 $71.00 84165-TC $16.00
84030-TC $7.00 84126-26 $20.00 84166 BR
84035 $12.00 84126-TC $49.00 84166-26 $20.00
84035-26 $3.00 84132 $11.00 84166-TC BR
84035-TC $8.00 84132-26 $3.00 84181 $29.00
84060 $20.00 84132-TC $7.00 84181-26 $10.00
84060-26 $6.00 84133 $11.00 84181-TC $19.00
84060-TC $14.00 84133-26 $3.00 84182 $33.00
84061 $14.00 84133-TC $7.00 84182-26 $11.00
84061-26 $4.00 84134 $24.00 84182-TC $21.00
84061-TC $10.00 84134-26 $7.00 84202 $39.00
84066 $18.00 84134-TC $17.00 84202-26 $13.00
84066-26 $6.00 84135 $57.00 84202-TC $25.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 137
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
84203 $16.00 84285-TC $42.00 84430-26 $10.00
84203-26 $5.00 84295 $10.00 84430-TC $20.00
84203-TC $11.00 84295-26 $3.00 84432 $28.00
84206 $32.00 84295-TC $6.00 84432-26 $8.00
84206-26 $10.00 84300 $10.00 84432-TC $19.00
84206-TC $21.00 84300-26 $3.00 84436 $14.00
84207 $54.00 84300-TC $6.00 84436-26 $3.00
84207-26 $16.00 84302 BR 84436-TC $11.00
84207-TC $38.00 84302-26 BR 84437 $13.00
84210 $24.00 84302-TC BR 84437-26 $4.00
84210-26 $10.00 84305 $34.00 84437-TC $8.00
84210-TC $15.00 84305-26 $11.00 84439 $16.00
84220 $25.00 84305-TC $22.00 84439-26 $4.00
84220-26 $8.00 84307 $26.00 84439-TC $12.00
84220-TC $17.00 84307-26 $8.00 84442 $25.00
84228 $32.00 84307-TC $18.00 84442-26 $6.00
84228-26 $10.00 84311 $11.00 84442-TC $19.00
84228-TC $21.00 84311-26 $3.00 84443 $32.00
84233 $116.00 84311-TC $7.00 84443-26 $7.00
84233-26 $35.00 84315 $5.00 84443-TC $23.00
84233-TC $81.00 84315-26 $2.00 84445 $98.00
84234 $116.00 84315-TC $3.00 84445-26 $29.00
84234-26 $35.00 84375 $37.00 84445-TC $69.00
84234-TC $81.00 84375-26 $11.00 84446 $35.00
84235 $114.00 84375-TC $25.00 84446-26 $11.00
84235-26 $34.00 84376 $10.00 84446-TC $23.00
84235-TC $80.00 84376-26 $3.00 84449 $38.00
84238 $97.00 84376-TC $7.00 84449-26 $13.00
84238-26 $32.00 84377 $10.00 84449-TC $24.00
84238-TC $65.00 84377-26 $3.00 84450 $11.00
84244 $47.00 84377-TC $7.00 84450-26 $3.00
84244-26 $15.00 84378 $25.00 84450-TC $7.00
84244-TC $32.00 84378-26 $8.00 84460 $13.00
84252 $47.00 84378-TC $17.00 84460-26 $4.00
84252-26 $14.00 84379 $25.00 84460-TC $8.00
84252-TC $33.00 84379-26 $8.00 84466 $22.00
84255 $58.00 84379-TC $17.00 84466-26 $7.00
84255-26 $17.00 84392 $8.00 84466-TC $15.00
84255-TC $41.00 84392-26 $2.00 84478 $12.00
84260 $54.00 84392-TC $6.00 84478-26 $3.00
84260-26 $16.00 84402 $72.00 84478-TC $8.00
84260-TC $38.00 84402-26 $21.00 84479 $15.00
84270 $36.00 84402-TC $49.00 84479-26 $5.00
84270-26 $11.00 84403 $67.00 84479-TC $10.00
84270-TC $24.00 84403-26 $19.00 84480 $20.00
84275 $37.00 84403-TC $45.00 84480-26 $6.00
84275-26 $11.00 84425 $54.00 84480-TC $14.00
84275-TC $25.00 84425-26 $17.00 84481 $33.00
84285 $59.00 84425-TC $37.00 84481-26 $10.00
84285-26 $17.00 84430 $31.00 84481-TC $22.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 138
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
84482 $45.00 84583-TC $7.00 85007-26 $3.00
84482-26 $15.00 84585 $36.00 85007-TC $4.00
84482-TC $31.00 84585-26 $11.00 85008 $5.00
84484 $21.00 84585-TC $24.00 85008-26 $2.00
84484-26 $6.00 84586 $42.00 85008-TC $3.00
84484-TC $15.00 84586-26 $14.00 85009 $8.00
84485 $15.00 84586-TC $27.00 85009-26 $3.00
84485-26 $4.00 84588 $73.00 85009-TC $5.00
84485-TC $11.00 84588-26 $23.00 85013 $3.00
84488 $15.00 84588-TC $47.00 85013-26 $1.00
84488-26 $4.00 84590 $33.00 85013-TC $2.00
84488-TC $11.00 84590-26 $11.00 85014 $4.00
84490 $15.00 84590-TC $21.00 85014-26 $1.00
84490-26 $4.00 84591 $26.00 85014-TC $3.00
84490-TC $11.00 84591-26 $9.00 85018 $5.00
84510 $26.00 84591-TC $18.00 85018-26 $2.00
84510-26 $8.00 84597 $37.00 85018-TC $3.00
84510-TC $18.00 84597-26 $11.00 85025 $20.00
84512 $17.00 84597-TC $25.00 85025-26 $6.00
84512-26 $5.00 84600 $43.00 85025-TC $14.00
84512-TC $12.00 84600-26 $13.00 85027 $15.00
84520 $12.00 84600-TC $31.00 85027-26 $5.00
84520-26 $3.00 84620 $29.00 85027-TC $10.00
84520-TC $8.00 84620-26 $8.00 85032 BR
84525 $7.00 84620-TC $20.00 85032-26 BR
84525-26 $2.00 84630 $26.00 85032-TC BR
84525-TC $5.00 84630-26 $8.00 85041 $7.00
84540 $13.00 84630-TC $18.00 85041-26 $3.00
84540-26 $4.00 84681 $52.00 85041-TC $4.00
84540-TC $8.00 84681-26 $17.00 85044 $10.00
84545 $18.00 84681-TC $35.00 85044-26 $3.00
84545-26 $5.00 84702 $38.00 85044-TC $6.00
84545-TC $13.00 84702-26 $11.00 85045 $6.00
84550 $12.00 84702-TC $26.00 85045-26 $2.00
84550-26 $4.00 84703 $22.00 85045-TC $4.00
84550-TC $7.00 84703-26 $6.00 85046 $13.00
84560 $12.00 84703-TC $15.00 85046-26 $4.00
84560-26 $3.00 84830 $17.00 85046-TC $9.00
84560-TC $8.00 84830-26 $5.00 85048 $7.00
84577 $34.00 84830-TC $12.00 85048-26 $3.00
84577-26 $11.00 84999 BR 85048-TC $4.00
84577-TC $22.00 84999-26 BR 85049 BR
84578 $7.00 84999-TC BR 85049-26 BR
84578-26 $2.00 85002 $10.00 85049-TC BR
84578-TC $5.00 85002-26 $3.00 85060 $25.00
84580 $17.00 85002-TC $6.00 85060-26 $7.00
84580-26 $5.00 85004 BR 85060-TC $18.00
84580-TC $12.00 85004-26 BR 85097 $59.00
84583 $11.00 85004-TC BR 85097-26 $59.00
84583-26 $3.00 85007 $6.00 85097-TC BR
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 139
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
85130 $19.00 85291-TC $14.00 85366-26 $3.00
85130-26 $6.00 85292 $51.00 85366-TC $10.00
85130-TC $13.00 85292-26 $17.00 85370 $20.00
85170 $7.00 85292-TC $34.00 85370-26 $5.00
85170-26 $2.00 85293 $51.00 85370-TC $15.00
85170-TC $5.00 85293-26 $17.00 85378 $13.00
85175 $10.00 85293-TC $34.00 85378-26 $4.00
85175-26 $3.00 85300 $35.00 85378-TC $8.00
85175-TC $6.00 85300-26 $12.00 85379 $18.00
85210 $31.00 85300-TC $23.00 85379-26 $6.00
85210-26 $8.00 85301 $29.00 85379-TC $12.00
85210-TC $21.00 85301-26 $10.00 85380 BR
85220 $47.00 85301-TC $19.00 85380-26 BR
85220-26 $15.00 85302 $33.00 85380-TC BR
85220-TC $32.00 85302-26 $11.00 85384 $11.00
85230 $47.00 85302-TC $21.00 85384-26 $3.00
85230-26 $14.00 85303 $26.00 85384-TC $7.00
85230-TC $33.00 85303-26 $8.00 85385 $16.00
85240 $48.00 85303-TC $18.00 85385-26 $5.00
85240-26 $15.00 85305 $21.00 85385-TC $11.00
85240-TC $33.00 85305-26 $7.00 85390 $10.00
85244 $49.00 85305-TC $14.00 85390-26 $2.00
85244-26 $15.00 85306 $29.00 85390-TC $7.00
85244-TC $34.00 85306-26 $10.00 85396 $22.00
85245 $54.00 85306-TC $19.00 85400 $12.00
85245-26 $18.00 85307 $35.00 85400-26 $3.00
85245-TC $36.00 85307-26 $12.00 85400-TC $8.00
85246 $54.00 85307-TC $23.00 85410 $12.00
85246-26 $18.00 85335 $21.00 85410-26 $3.00
85246-TC $36.00 85335-26 $7.00 85410-TC $8.00
85247 $54.00 85335-TC $14.00 85415 $28.00
85247-26 $18.00 85337 $19.00 85415-26 $10.00
85247-TC $36.00 85337-26 $6.00 85415-TC $18.00
85250 $49.00 85337-TC $13.00 85420 $16.00
85250-26 $14.00 85345 $10.00 85420-26 $3.00
85250-TC $35.00 85345-26 $2.00 85420-TC $13.00
85260 $49.00 85345-TC $7.00 85421 $39.00
85260-26 $14.00 85347 $8.00 85421-26 $12.00
85260-TC $35.00 85347-26 $2.00 85421-TC $26.00
85270 $49.00 85347-TC $6.00 85441 $7.00
85270-26 $14.00 85348 $10.00 85441-26 $2.00
85270-TC $35.00 85348-26 $3.00 85441-TC $5.00
85280 $49.00 85348-TC $6.00 85445 $16.00
85280-26 $14.00 85360 $16.00 85445-26 $5.00
85280-TC $35.00 85360-26 $4.00 85445-TC $11.00
85290 $44.00 85360-TC $12.00 85460 $15.00
85290-26 $13.00 85362 $18.00 85460-26 $4.00
85290-TC $32.00 85362-26 $7.00 85460-TC $11.00
85291 $20.00 85362-TC $11.00 85461 $12.00
85291-26 $6.00 85366 $13.00 85461-26 $3.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 140
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
85461-TC $8.00 85635-26 $8.00 86023 $28.00
85475 $15.00 85635-TC $18.00 86023-26 $10.00
85475-26 $4.00 85651 $8.00 86023-TC $18.00
85475-TC $11.00 85651-26 $2.00 86038 $22.00
85520 $22.00 85651-TC $6.00 86038-26 $7.00
85520-26 $6.00 85652 $8.00 86038-TC $15.00
85520-TC $16.00 85652-26 $2.00 86039 $19.00
85525 $20.00 85652-TC $6.00 86039-26 $6.00
85525-26 $6.00 85660 $10.00 86039-TC $13.00
85525-TC $14.00 85660-26 $3.00 86060 $13.00
85530 $39.00 85660-TC $6.00 86060-26 $3.00
85530-26 $12.00 85670 $13.00 86060-TC $10.00
85530-TC $26.00 85670-26 $3.00 86063 $21.00
85536 $14.00 85670-TC $10.00 86063-26 $6.00
85536-26 $4.00 85675 $13.00 86063-TC $15.00
85536-TC $10.00 85675-26 $4.00 86077 $91.00
85540 $24.00 85675-TC $8.00 86077-26 $26.00
85540-26 $7.00 85705 $13.00 86077-TC $64.00
85540-TC $17.00 85705-26 $4.00 86078 $91.00
85547 $23.00 85705-TC $8.00 86078-26 $26.00
85547-26 $6.00 85730 $11.00 86078-TC $64.00
85547-TC $17.00 85730-26 $3.00 86079 $79.00
85549 $45.00 85730-TC $7.00 86079-26 $25.00
85549-26 $15.00 85732 $17.00 86079-TC $52.00
85549-TC $31.00 85732-26 $5.00 86140 $14.00
85555 $17.00 85732-TC $12.00 86140-26 $4.00
85555-26 $5.00 85810 $19.00 86140-TC $10.00
85555-TC $12.00 85810-26 $4.00 86141 BR
85557 $34.00 85810-TC $15.00 86141-26 BR
85557-26 $10.00 85999 BR 86141-TC BR
85557-TC $23.00 85999-26 BR 86146 $58.00
85576 $21.00 85999-TC BR 86146-26 $19.00
85576-26 $5.00 86000 $16.00 86146-TC $39.00
85576-TC $16.00 86000-26 $5.00 86147 $53.00
85597 $32.00 86000-TC $11.00 86147-26 $16.00
85597-26 $10.00 86001 $12.00 86147-TC $36.00
85597-TC $21.00 86001-26 $4.00 86148 $59.00
85610 $6.00 86001-TC $8.00 86148-26 $21.00
85610-26 $3.00 86003 $6.00 86148-TC $38.00
85610-TC $4.00 86003-26 $2.00 86153-26 $35.00
85611 $6.00 86003-TC $3.00 86155 $26.00
85611-26 $2.00 86005 $11.00 86155-26 $8.00
85611-TC $4.00 86005-26 $4.00 86155-TC $18.00
85612 $22.00 86005-TC $6.00 86156 $11.00
85612-26 $6.00 86021 $41.00 86156-26 $3.00
85612-TC $16.00 86021-26 $12.00 86156-TC $7.00
85613 $15.00 86021-TC $29.00 86157 $13.00
85613-26 $4.00 86022 $57.00 86157-26 $4.00
85613-TC $11.00 86022-26 $18.00 86157-TC $8.00
85635 $26.00 86022-TC $39.00 86160 $21.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 141
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
86160-26 $5.00 86304 $47.00 86337-TC $36.00
86160-TC $16.00 86304-26 $15.00 86340 $39.00
86161 $21.00 86304-TC $32.00 86340-26 $13.00
86161-26 $5.00 86308 $8.00 86340-TC $25.00
86161-TC $16.00 86308-26 $3.00 86341 $38.00
86162 $54.00 86308-TC $5.00 86341-26 $13.00
86162-26 $18.00 86309 $12.00 86341-TC $24.00
86162-TC $36.00 86309-26 $3.00 86343 $33.00
86171 $25.00 86309-TC $8.00 86343-26 $11.00
86171-26 $7.00 86310 $19.00 86343-TC $21.00
86171-TC $18.00 86310-26 $6.00 86344 $21.00
86185 $19.00 86310-TC $13.00 86344-26 $7.00
86185-26 $6.00 86316 $37.00 86344-TC $14.00
86185-TC $13.00 86316-26 $11.00 86353 $102.00
86215 $36.00 86316-TC $25.00 86353-26 $31.00
86215-26 $12.00 86317 $31.00 86353-TC $72.00
86215-TC $23.00 86317-26 $10.00 86359 $61.00
86225 $36.00 86317-TC $20.00 86359-26 $19.00
86225-26 $11.00 86318 $23.00 86359-TC $41.00
86225-TC $24.00 86318-26 $10.00 86360 $99.00
86226 $24.00 86318-TC $14.00 86360-26 $33.00
86226-26 $8.00 86320 $49.00 86360-TC $67.00
86226-TC $16.00 86320-26 $19.00 86361 $66.00
86235 $33.00 86320-TC $29.00 86361-26 $21.00
86235-26 $10.00 86325 $49.00 86361-TC $43.00
86235-TC $22.00 86325-26 $16.00 86376 $35.00
86243 $50.00 86325-TC $33.00 86376-26 $11.00
86243-26 $15.00 86327 $62.00 86376-TC $23.00
86243-TC $35.00 86327-26 $19.00 86378 $45.00
86255 $25.00 86327-TC $42.00 86378-26 $15.00
86255-26 $8.00 86329 $37.00 86378-TC $31.00
86255-TC $17.00 86329-26 $12.00 86382 $45.00
86256 $25.00 86329-TC $24.00 86382-26 $14.00
86256-26 $8.00 86331 $22.00 86382-TC $32.00
86256-TC $17.00 86331-26 $6.00 86384 $24.00
86277 $41.00 86331-TC $15.00 86384-26 $8.00
86277-26 $14.00 86332 $54.00 86384-TC $16.00
86277-TC $26.00 86332-26 $18.00 86403 $18.00
86280 $15.00 86332-TC $36.00 86403-26 $3.00
86280-26 $3.00 86334 $65.00 86403-TC $14.00
86280-TC $12.00 86334-26 $18.00 86406 $21.00
86294 BR 86334-TC $45.00 86406-26 $5.00
86294-26 BR 86335 BR 86406-TC $16.00
86294-TC BR 86335-26 $20.00 86430 $13.00
86300 $47.00 86335-TC BR 86430-26 $4.00
86300-26 $15.00 86336 BR 86430-TC $8.00
86300-TC $32.00 86336-26 BR 86431 $17.00
86301 $47.00 86336-TC BR 86431-26 $6.00
86301-26 $15.00 86337 $54.00 86431-TC $11.00
86301-TC $32.00 86337-26 $18.00 86485 $13.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 142
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
86485-26 $4.00 86619-TC $15.00 86663-26 $7.00
86485-TC $8.00 86622 $16.00 86663-TC $14.00
86486 $6.00 86622-26 $5.00 86664 $53.00
86490 $17.00 86622-TC $11.00 86664-26 $17.00
86490-26 $5.00 86625 $21.00 86664-TC $36.00
86490-TC $12.00 86625-26 $6.00 86665 $29.00
86510 $13.00 86625-TC $15.00 86665-26 $10.00
86510-26 $4.00 86628 $20.00 86665-TC $19.00
86510-TC $8.00 86628-26 $6.00 86666 $23.00
86580 $13.00 86628-TC $14.00 86666-26 $8.00
86580-26 $4.00 86631 $20.00 86666-TC $15.00
86580-TC $8.00 86631-26 $6.00 86668 $17.00
86590 $18.00 86631-TC $14.00 86668-26 $5.00
86590-26 $6.00 86632 $20.00 86668-TC $12.00
86590-TC $12.00 86632-26 $6.00 86671 $20.00
86592 $8.00 86632-TC $14.00 86671-26 $6.00
86592-26 $2.00 86635 $18.00 86671-TC $14.00
86592-TC $6.00 86635-26 $5.00 86674 $23.00
86593 $11.00 86635-TC $13.00 86674-26 $7.00
86593-26 $3.00 86638 $20.00 86674-TC $16.00
86593-TC $7.00 86638-26 $6.00 86677 $24.00
86602 $17.00 86638-TC $14.00 86677-26 $8.00
86602-26 $5.00 86641 $21.00 86677-TC $16.00
86602-TC $12.00 86641-26 $7.00 86682 $21.00
86603 $20.00 86641-TC $14.00 86682-26 $7.00
86603-26 $6.00 86644 $22.00 86682-TC $14.00
86603-TC $14.00 86644-26 $7.00 86684 $24.00
86606 $24.00 86644-TC $15.00 86684-26 $8.00
86606-26 $8.00 86645 $28.00 86684-TC $16.00
86606-TC $16.00 86645-26 $10.00 86687 $22.00
86609 $20.00 86645-TC $18.00 86687-26 $7.00
86609-26 $6.00 86648 $24.00 86687-TC $16.00
86609-TC $14.00 86648-26 $8.00 86688 $20.00
86611 $23.00 86648-TC $16.00 86688-26 $7.00
86611-26 $8.00 86651 $21.00 86688-TC $14.00
86611-TC $15.00 86651-26 $7.00 86689 $25.00
86612 $21.00 86651-TC $14.00 86689-26 $8.00
86612-26 $6.00 86652 $21.00 86689-TC $17.00
86612-TC $15.00 86652-26 $7.00 86692 $22.00
86615 $21.00 86652-TC $14.00 86692-26 $7.00
86615-26 $6.00 86653 $21.00 86692-TC $15.00
86615-TC $15.00 86653-26 $7.00 86694 $22.00
86617 $29.00 86653-TC $14.00 86694-26 $7.00
86617-26 $10.00 86654 $21.00 86694-TC $15.00
86617-TC $19.00 86654-26 $7.00 86695 $21.00
86618 $26.00 86654-TC $14.00 86695-26 $7.00
86618-26 $8.00 86658 $21.00 86695-TC $14.00
86618-TC $18.00 86658-26 $7.00 86696 $44.00
86619 $21.00 86658-TC $14.00 86696-26 $14.00
86619-26 $6.00 86663 $21.00 86696-TC $30.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 143
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
86698 $20.00 86729-TC $13.00 86777-26 $7.00
86698-26 $6.00 86732 $21.00 86777-TC $15.00
86698-TC $14.00 86732-26 $7.00 86778 $23.00
86701 $21.00 86732-TC $14.00 86778-26 $7.00
86701-26 $7.00 86735 $21.00 86778-TC $16.00
86701-TC $15.00 86735-26 $7.00 86784 $21.00
86702 $21.00 86735-TC $14.00 86784-26 $7.00
86702-26 $7.00 86738 $21.00 86784-TC $14.00
86702-TC $14.00 86738-26 $7.00 86787 $20.00
86703 $22.00 86738-TC $14.00 86787-26 $6.00
86703-26 $7.00 86741 $21.00 86787-TC $14.00
86703-TC $15.00 86741-26 $7.00 86790 $21.00
86704 $33.00 86741-TC $14.00 86790-26 $7.00
86704-26 $11.00 86744 $21.00 86790-TC $14.00
86704-TC $21.00 86744-26 $7.00 86793 $21.00
86705 $35.00 86744-TC $14.00 86793-26 $7.00
86705-26 $11.00 86747 $23.00 86793-TC $14.00
86705-TC $23.00 86747-26 $7.00 86800 $26.00
86706 $24.00 86747-TC $16.00 86800-26 $8.00
86706-26 $8.00 86750 $21.00 86800-TC $18.00
86706-TC $16.00 86750-26 $7.00 86803 $24.00
86707 $26.00 86750-TC $14.00 86803-26 $8.00
86707-26 $8.00 86753 $20.00 86803-TC $16.00
86707-TC $18.00 86753-26 $6.00 86804 $26.00
86708 $32.00 86753-TC $14.00 86804-26 $8.00
86708-26 $10.00 86756 $20.00 86804-TC $18.00
86708-TC $21.00 86756-26 $6.00 86805 $97.00
86709 $29.00 86756-TC $14.00 86805-26 $33.00
86709-26 $10.00 86757 $44.00 86805-TC $64.00
86709-TC $19.00 86757-26 $14.00 86806 $87.00
86710 $22.00 86757-TC $30.00 86806-26 $28.00
86710-26 $7.00 86759 $21.00 86806-TC $57.00
86710-TC $15.00 86759-26 $7.00 86807 $74.00
86713 $23.00 86759-TC $14.00 86807-26 $21.00
86713-26 $7.00 86762 $22.00 86807-TC $51.00
86713-TC $16.00 86762-26 $7.00 86808 $52.00
86717 $20.00 86762-TC $15.00 86808-26 $15.00
86717-26 $6.00 86765 $20.00 86808-TC $37.00
86717-TC $14.00 86765-26 $6.00 86812 $108.00
86720 $21.00 86765-TC $14.00 86812-26 $32.00
86720-26 $7.00 86768 $21.00 86812-TC $75.00
86720-TC $14.00 86768-26 $7.00 86813 $101.00
86723 $21.00 86768-TC $14.00 86813-26 $29.00
86723-26 $7.00 86771 $21.00 86813-TC $71.00
86723-TC $14.00 86771-26 $7.00 86816 $64.00
86727 $20.00 86771-TC $14.00 86816-26 $18.00
86727-26 $6.00 86774 $23.00 86816-TC $44.00
86727-TC $14.00 86774-26 $7.00 86817 $134.00
86729 $19.00 86774-TC $16.00 86817-26 $39.00
86729-26 $6.00 86777 $22.00 86817-TC $94.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 144
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
86821 $123.00 86910-TC $57.00 86975-26 $16.00
86821-26 $36.00 86911 $19.00 86975-TC $37.00
86821-TC $86.00 86911-26 $6.00 86976 $53.00
86822 $96.00 86911-TC $13.00 86976-26 $16.00
86822-26 $32.00 86920 $19.00 86976-TC $37.00
86822-TC $64.00 86920-26 $3.00 86977 $53.00
86849 BR 86920-TC $15.00 86977-26 $16.00
86849-26 BR 86921 $23.00 86977-TC $37.00
86849-TC BR 86921-26 $7.00 86978 $65.00
86850 $10.00 86921-TC $16.00 86978-26 $19.00
86850-26 $3.00 86922 $20.00 86978-TC $44.00
86850-TC $6.00 86922-26 $6.00 86985 $35.00
86860 $44.00 86922-TC $14.00 86985-26 $12.00
86860-26 $15.00 86927 $21.00 86985-TC $23.00
86860-TC $29.00 86927-26 $5.00 86999 BR
86870 $17.00 86927-TC $16.00 86999-26 BR
86870-26 $6.00 86930 $155.00 86999-TC BR
86870-TC $11.00 86930-26 $45.00 87003 $40.00
86880 $13.00 86930-TC $108.00 87003-26 $13.00
86880-26 $4.00 86931 $155.00 87003-TC $26.00
86880-TC $8.00 86931-26 $45.00 87015 $14.00
86885 $15.00 86931-TC $108.00 87015-26 $5.00
86885-26 $4.00 86932 $161.00 87015-TC $9.00
86885-TC $11.00 86932-26 $48.00 87040 $18.00
86886 $14.00 86932-TC $111.00 87040-26 $6.00
86886-26 $4.00 86940 $18.00 87040-TC $12.00
86886-TC $10.00 86940-26 $5.00 87045 $18.00
86890 $67.00 86940-TC $13.00 87045-26 $6.00
86890-26 $11.00 86941 $31.00 87045-TC $11.00
86890-TC $54.00 86941-26 $8.00 87046 $5.00
86891 $91.00 86941-TC $21.00 87046-26 $2.00
86891-26 $26.00 86945 $35.00 87046-TC $3.00
86891-TC $64.00 86945-26 $11.00 87070 $14.00
86900 $10.00 86945-TC $23.00 87070-26 $4.00
86900-26 $3.00 86950 $99.00 87070-TC $10.00
86900-TC $6.00 86950-26 $29.00 87071 $11.00
86901 $10.00 86950-TC $70.00 87071-26 $3.00
86901-26 $3.00 86965 $25.00 87071-TC $8.00
86901-TC $6.00 86965-26 $7.00 87073 $11.00
86904 $19.00 86965-TC $18.00 87073-26 $3.00
86904-26 $6.00 86970 $41.00 87073-TC $8.00
86904-TC $13.00 86970-26 $12.00 87075 $18.00
86905 $7.00 86970-TC $29.00 87075-26 $6.00
86905-26 $1.00 86971 $20.00 87075-TC $12.00
86905-TC $6.00 86971-26 $5.00 87076 $24.00
86906 $11.00 86971-TC $15.00 87076-26 $8.00
86906-26 $3.00 86972 $20.00 87076-TC $16.00
86906-TC $7.00 86972-26 $6.00 87077 $16.00
86910 $83.00 86972-TC $14.00 87077-26 $5.00
86910-26 $24.00 86975 $53.00 87077-TC $11.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 145
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
87081 $12.00 87149-TC $31.00 87197-26 $10.00
87081-26 $3.00 87152 $12.00 87197-TC $19.00
87081-TC $8.00 87152-26 $4.00 87205 $11.00
87084 $23.00 87152-TC $8.00 87205-26 $3.00
87084-26 $7.00 87158 $5.00 87205-TC $7.00
87084-TC $16.00 87158-26 $1.00 87206 $15.00
87086 $14.00 87158-TC $3.00 87206-26 $3.00
87086-26 $3.00 87164 $24.00 87206-TC $12.00
87086-TC $11.00 87164-26 $8.00 87207 $10.00
87088 $18.00 87164-TC $16.00 87207-26 $3.00
87088-26 $6.00 87166 $24.00 87207-TC $6.00
87088-TC $12.00 87166-26 $7.00 87210 $8.00
87101 $20.00 87166-TC $17.00 87210-26 $2.00
87101-26 $6.00 87168 $10.00 87210-TC $6.00
87101-TC $14.00 87168-26 $3.00 87220 $12.00
87102 $20.00 87168-TC $7.00 87220-26 $4.00
87102-26 $6.00 87169 $10.00 87220-TC $7.00
87102-TC $14.00 87169-26 $3.00 87230 $35.00
87103 $32.00 87169-TC $7.00 87230-26 $11.00
87103-26 $11.00 87172 $10.00 87230-TC $23.00
87103-TC $20.00 87172-26 $3.00 87250 $33.00
87106 $25.00 87172-TC $7.00 87250-26 $13.00
87106-26 $7.00 87176 $16.00 87250-TC $19.00
87106-TC $18.00 87176-26 $5.00 87252 $44.00
87107 $23.00 87176-TC $11.00 87252-26 $14.00
87107-26 $8.00 87177 $18.00 87252-TC $31.00
87107-TC $15.00 87177-26 $6.00 87253 $33.00
87109 $26.00 87177-TC $12.00 87253-26 $10.00
87109-26 $8.00 87181 $13.00 87253-TC $22.00
87109-TC $18.00 87181-26 $3.00 87254 $11.00
87110 $23.00 87181-TC $8.00 87254-26 $3.00
87110-26 $7.00 87184 $13.00 87254-TC $8.00
87110-TC $15.00 87184-26 $3.00 87255 BR
87116 $15.00 87184-TC $10.00 87255-26 BR
87116-26 $3.00 87185 $11.00 87255-TC BR
87116-TC $11.00 87185-26 $3.00 87260 $26.00
87118 $28.00 87185-TC $8.00 87260-26 $8.00
87118-26 $9.00 87186 $16.00 87260-TC $18.00
87118-TC $20.00 87186-26 $4.00 87265 $26.00
87140 $24.00 87186-TC $12.00 87265-26 $8.00
87140-26 $7.00 87187 $20.00 87265-TC $18.00
87140-TC $17.00 87187-26 $3.00 87267 BR
87143 $34.00 87187-TC $17.00 87267-26 BR
87143-26 $11.00 87188 $18.00 87267-TC BR
87143-TC $22.00 87188-26 $5.00 87270 $26.00
87147 $26.00 87188-TC $13.00 87270-26 $8.00
87147-26 $8.00 87190 $7.00 87270-TC $18.00
87147-TC $18.00 87190-26 $2.00 87271 BR
87149 $46.00 87190-TC $5.00 87271-26 BR
87149-26 $15.00 87197 $29.00 87271-TC BR
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 146
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
87272 $26.00 87320-TC $18.00 87400-26 $4.00
87272-26 $8.00 87324 $26.00 87400-TC $9.00
87272-TC $18.00 87324-26 $8.00 87420 $26.00
87273 $27.00 87324-TC $18.00 87420-26 $8.00
87273-26 $9.00 87327 $27.00 87420-TC $18.00
87273-TC $19.00 87327-26 $9.00 87425 $26.00
87274 $26.00 87327-TC $19.00 87425-26 $8.00
87274-26 $8.00 87328 $26.00 87425-TC $18.00
87274-TC $18.00 87328-26 $8.00 87427 $27.00
87275 $27.00 87328-TC $18.00 87427-26 $9.00
87275-26 $9.00 87332 $26.00 87427-TC $19.00
87275-TC $19.00 87332-26 $8.00 87430 $26.00
87276 $26.00 87332-TC $18.00 87430-26 $8.00
87276-26 $8.00 87335 $26.00 87430-TC $18.00
87276-TC $18.00 87335-26 $8.00 87449 $26.00
87277 $27.00 87335-TC $18.00 87449-26 $8.00
87277-26 $9.00 87336 $27.00 87449-TC $18.00
87277-TC $19.00 87336-26 $9.00 87450 $21.00
87278 $26.00 87336-TC $19.00 87450-26 $6.00
87278-26 $8.00 87337 $27.00 87450-TC $15.00
87278-TC $18.00 87337-26 $9.00 87451 $19.00
87279 $27.00 87337-TC $19.00 87451-26 $7.00
87279-26 $9.00 87338 $27.00 87451-TC $12.00
87279-TC $19.00 87338-26 $7.00 87470 $42.00
87280 $26.00 87338-TC $20.00 87470-26 $13.00
87280-26 $8.00 87339 $27.00 87470-TC $28.00
87280-TC $18.00 87339-26 $9.00 87471 $73.00
87281 $27.00 87339-TC $19.00 87471-26 $23.00
87281-26 $9.00 87340 $20.00 87471-TC $48.00
87281-TC $19.00 87340-26 $6.00 87472 $88.00
87283 $27.00 87340-TC $14.00 87472-26 $28.00
87283-26 $9.00 87341 $23.00 87472-TC $58.00
87283-TC $19.00 87341-26 $8.00 87475 $40.00
87285 $26.00 87341-TC $15.00 87475-26 $13.00
87285-26 $8.00 87350 $20.00 87475-TC $26.00
87285-TC $18.00 87350-26 $6.00 87476 $73.00
87290 $26.00 87350-TC $14.00 87476-26 $23.00
87290-26 $8.00 87380 $35.00 87476-TC $48.00
87290-TC $18.00 87380-26 $11.00 87477 $88.00
87299 $26.00 87380-TC $23.00 87477-26 $28.00
87299-26 $8.00 87385 $26.00 87477-TC $58.00
87299-TC $18.00 87385-26 $8.00 87480 $42.00
87300 $13.00 87385-TC $18.00 87480-26 $13.00
87300-26 $4.00 87390 $38.00 87480-TC $28.00
87300-TC $9.00 87390-26 $13.00 87481 $73.00
87301 $26.00 87390-TC $24.00 87481-26 $23.00
87301-26 $8.00 87391 $38.00 87481-TC $48.00
87301-TC $18.00 87391-26 $13.00 87482 $86.00
87320 $26.00 87391-TC $24.00 87482-26 $28.00
87320-26 $8.00 87400 $13.00 87482-TC $56.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 147
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
87485 $42.00 87521-TC $48.00 87540-26 $13.00
87485-26 $13.00 87522 $88.00 87540-TC $28.00
87485-TC $28.00 87522-26 $28.00 87541 $73.00
87486 $73.00 87522-TC $58.00 87541-26 $23.00
87486-26 $23.00 87525 $42.00 87541-TC $48.00
87486-TC $48.00 87525-26 $13.00 87542 $86.00
87487 $88.00 87525-TC $28.00 87542-26 $28.00
87487-26 $28.00 87526 $73.00 87542-TC $56.00
87487-TC $58.00 87526-26 $23.00 87550 $42.00
87490 $42.00 87526-TC $48.00 87550-26 $13.00
87490-26 $13.00 87527 $86.00 87550-TC $28.00
87490-TC $28.00 87527-26 $28.00 87551 $73.00
87491 $73.00 87527-TC $56.00 87551-26 $23.00
87491-26 $23.00 87528 $42.00 87551-TC $48.00
87491-TC $48.00 87528-26 $13.00 87552 $88.00
87492 $73.00 87528-TC $28.00 87552-26 $28.00
87492-26 $23.00 87529 $73.00 87552-TC $58.00
87492-TC $48.00 87529-26 $23.00 87555 $42.00
87495 $42.00 87529-TC $48.00 87555-26 $13.00
87495-26 $13.00 87530 $88.00 87555-TC $28.00
87495-TC $28.00 87530-26 $28.00 87556 $73.00
87496 $73.00 87530-TC $58.00 87556-26 $23.00
87496-26 $23.00 87531 $42.00 87556-TC $48.00
87496-TC $48.00 87531-26 $13.00 87557 $88.00
87497 $88.00 87531-TC $28.00 87557-26 $28.00
87497-26 $28.00 87532 $73.00 87557-TC $58.00
87497-TC $58.00 87532-26 $23.00 87560 $42.00
87510 $42.00 87532-TC $48.00 87560-26 $13.00
87510-26 $13.00 87533 $86.00 87560-TC $28.00
87510-TC $28.00 87533-26 $28.00 87561 $73.00
87511 $73.00 87533-TC $56.00 87561-26 $23.00
87511-26 $23.00 87534 $42.00 87561-TC $48.00
87511-TC $48.00 87534-26 $13.00 87562 $88.00
87512 $86.00 87534-TC $28.00 87562-26 $28.00
87512-26 $28.00 87535 $73.00 87562-TC $58.00
87512-TC $56.00 87535-26 $23.00 87580 $42.00
87515 $42.00 87535-TC $48.00 87580-26 $13.00
87515-26 $13.00 87536 $86.00 87580-TC $28.00
87515-TC $28.00 87536-26 $28.00 87581 $73.00
87516 $73.00 87536-TC $56.00 87581-26 $23.00
87516-26 $23.00 87537 $42.00 87581-TC $48.00
87516-TC $48.00 87537-26 $13.00 87582 $86.00
87517 $88.00 87537-TC $28.00 87582-26 $28.00
87517-26 $28.00 87538 $73.00 87582-TC $56.00
87517-TC $58.00 87538-26 $23.00 87590 $42.00
87520 $42.00 87538-TC $48.00 87590-26 $13.00
87520-26 $13.00 87539 $88.00 87590-TC $28.00
87520-TC $28.00 87539-26 $28.00 87591 $73.00
87521 $73.00 87539-TC $58.00 87591-26 $23.00
87521-26 $23.00 87540 $42.00 87591-TC $48.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 148
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
87592 $88.00 87901-TC $398.00 88106-26 $16.00
87592-26 $28.00 87902 BR 88106-TC $38.00
87592-TC $58.00 87902-26 BR 88108 $59.00
87650 $42.00 87902-TC BR 88108-26 $47.00
87650-26 $13.00 87903 $1,126.00 88108-TC $11.00
87650-TC $28.00 87903-26 $371.00 88112 $121.00
87651 $73.00 87903-TC $755.00 88112-26 $65.00
87651-26 $23.00 87904 $59.00 88112-TC $56.00
87651-TC $48.00 87904-26 $20.00 88120 $619.00
87652 $86.00 87904-TC $39.00 88120-26 $59.00
87652-26 $28.00 87999 BR 88120-TC $560.00
87652-TC $56.00 87999-26 BR 88121 $535.00
87797 $42.00 87999-TC BR 88121-26 $51.00
87797-26 $13.00 88000 $445.00 88121-TC $484.00
87797-TC $28.00 88000-26 $445.00 88125 $70.00
87798 $73.00 88000-TC BR 88125-26 $20.00
87798-26 $23.00 88005 $500.00 88125-TC $48.00
87798-TC $48.00 88005-26 $500.00 88130 $25.00
87799 $88.00 88005-TC BR 88130-26 $7.00
87799-26 $28.00 88007 $556.00 88130-TC $18.00
87799-TC $58.00 88007-26 $556.00 88140 $18.00
87800 $46.00 88007-TC BR 88140-26 $5.00
87800-26 $15.00 88020 $556.00 88140-TC $13.00
87800-TC $31.00 88020-26 $556.00 88141 $33.00
87801 $81.00 88020-TC BR 88141-26 BR
87801-26 $26.00 88025 $610.00 88141-TC BR
87801-TC $54.00 88025-26 $610.00 88142 $82.00
87802 BR 88025-TC BR 88142-26 $21.00
87802-26 BR 88027 $666.00 88142-TC $59.00
87802-TC BR 88027-26 $666.00 88143 $94.00
87803 BR 88027-TC BR 88143-26 $33.00
87803-26 BR 88036 $477.00 88143-TC $59.00
87803-TC BR 88036-26 $477.00 88147 $82.00
87804 BR 88036-TC BR 88147-26 BR
87804-26 BR 88037 $389.00 88147-TC $82.00
87804-TC BR 88037-26 $389.00 88148 $104.00
87810 $26.00 88037-TC BR 88148-26 $21.00
87810-26 $8.00 88040 $1,445.00 88148-TC $82.00
87810-TC $18.00 88040-26 $1,445.00 88150 $13.00
87850 $26.00 88040-TC BR 88150-26 $3.00
87850-26 $8.00 88045 BR 88150-TC $9.00
87850-TC $18.00 88045-26 BR 88152 $46.00
87880 $26.00 88045-TC BR 88152-26 $8.00
87880-26 $8.00 88099 BR 88152-TC $38.00
87880-TC $18.00 88099-26 BR 88153 $82.00
87899 $26.00 88099-TC BR 88153-26 $21.00
87899-26 $8.00 88104 $49.00 88153-TC $59.00
87899-TC $18.00 88104-26 $37.00 88154 $104.00
87901 $594.00 88104-TC $10.00 88154-26 $21.00
87901-26 $196.00 88106 $54.00 88154-TC $82.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 149
Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA CPT Code MRA
88155 $14.00 88233 $243.00 88323-TC $32.00
88155-26 $3.00 88233-26 $73.00 88325 $54.00
88155-TC $10.00 88233-TC $170.00 88325-26 $54.00
88160 $45.00 88235 $256.00 88325-TC BR
88160-26 $14.00 88235-26 $76.00 88329 $51.00
88160-TC $24.00 88235-TC $177.00 88329-26 $51.00
88161 $64.00 88240 $21.00 88329-TC BR
88161-26 $19.00 88240-26 $6.00 88331 $102.00
88161-TC $37.00 88240-TC $15.00 88331-26 $70.00
88162 $77.00 88241 $21.00 88331-TC $33.00
88162-26 $22.00 88241-26 $6.00 88332 $53.00
88162-TC $53.00 88241-TC $15.00 88332-26 $36.00
88164 $54.00 88300 $24.00 88332-TC $17.00
88164-26 $21.00 88300-26 $19.00 88333 $89.00
88164-TC $33.00 88300-TC $5.00 88333-26 $67.00
88165 $72.00 88302 $53.00 88333-TC $22.00
88165-26 $33.00 88302-26 $42.00 88334 $47.00
88165-TC $38.00 88302-TC $11.00 88334-26 $33.00
88166 $82.00 88304 $70.00 88334-TC $14.00
88166-26 $21.00 88304-26 $54.00 88341 $90.00
88166-TC $59.00 88304-TC $14.00 88341-26 $28.00
88167 $87.00 88305 $108.00 88341-TC $62.00
88167-26 $26.00 88305-26 $86.00 88342 $53.00
88167-TC $59.00 88305-TC $21.00 88342-26 $36.00
88172 $70.00 88307 $210.00 88342-TC $17.00
88172-26 $54.00 88307-26 $168.00 88344 $174.00
88172-TC $14.00 88307-TC $41.00 88344-26 $41.00
88173 $95.00 88309 $322.00 88344-TC $133.00
88173-26 $95.00 88309-26 $258.00 88346 $96.00
88173-TC $26.00 88309-TC $64.00 88346-26 $66.00
88174 BR 88311 $23.00 88346-TC $28.00
88174-26 BR 88311-26 $19.00 88348 $191.00
88174-TC BR 88311-TC $4.00 88348-26 $145.00
88175 BR 88312 $23.00 88348-TC $44.00
88175-26 BR 88312-26 $7.00 88350 $72.00
88175-TC BR 88312-TC $16.00 88350-26 $29.00
88177 $30.00 88313 $23.00 88350-TC $44.00
88177-26 $22.00 88313-26 $7.00 88355 $108.00
88177-TC $8.00 88313-TC $16.00 88355-26 $80.00
88182 $88.00 88314 $21.00 88355-TC $26.00
88182-26 $33.00 88314-26 $6.00 88356 $108.00
88182-TC $54.00 88314-TC $15.00 88356-26 $80.00
88184 $51.00 88319 $26.00 88356-TC $26.00
88185 $25.00 88319-26 $13.00 88358 $108.00
88187 $69.00 88319-TC $14.00 88358-26 $80.00
88188 $86.00 88321 $43.00 88358-TC $26.00
88189 $113.00 88321-26 $43.00 88360 $110.00
88199 BR 88321-TC BR 88360-26 $62.00
88199-26 BR 88323 $61.00 88360-TC $49.00
88199-TC BR 88323-26 $61.00 88361 $139.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 150
Pathology & Laboratory Pathology & Laboratory
CPT Code MRA CPT Code MRA
88361-26 $55.00 88388-26 $24.00
88361-TC $84.00 88388-TC $9.00
88362 $251.00 88399 BR
88362-26 $119.00 88399-26 BR
88362-TC $132.00 88399-TC BR
88363 $22.00 89049 $190.00
88364 $135.00 89050 $10.00
88364-26 $35.00 89050-26 $3.00
88364-TC $100.00 89050-TC $6.00
88365 $24.00 89051 $13.00
88365-26 $24.00 89051-26 $4.00
88365-TC $68.00 89051-TC $8.00
88366 $263.00 89055 BR
88366-26 $65.00 89055-26 BR
88366-TC $198.00 89055-TC BR
88367 $210.00 89060 $13.00
88367-26 $72.00 89060-26 $5.00
88367-TC $138.00 89060-TC $8.00
88368 $190.00 89125 $14.00
88368-26 $78.00 89125-26 $4.00
88368-TC $112.00 89125-TC $10.00
88369 $108.00 89160 $6.00
88369-26 $32.00 89160-26 $2.00
88369-TC $77.00 89160-TC $4.00
88371 $34.00 89190 $10.00
88371-26 $10.00 89190-26 $3.00
88371-TC $23.00 89190-TC $6.00
88372 $38.00 89220 $17.00
88372-26 $11.00 89230 $5.00
88372-TC $26.00 G0124 $24.00
88373 $75.00 G0141 $24.00
88373-26 $21.00 G0416 $651.00
88373-TC $54.00 G0416-26 $184.00
88374 $346.00 G0416-TC $467.00
88374-26 $46.00 G0452-26 $19.00
88374-TC $300.00 G0455 $126.00
88375 $20.00
88377 $412.00
88377-26 $67.00
88377-TC $346.00
88380 $159.00
88380-26 $71.00
88380-TC $88.00
88381 $213.00
88381-26 $54.00
88381-TC $159.00
88387 $36.00
88387-26 $29.00
88387-TC $6.00
88388 $33.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 151
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
90460 $25.00 90959 $298.00 91111 $743.00
90461 $13.00 90960 $287.00 91111-26 $53.00
90471 $4.00 90961 $241.00 91111-TC $690.00
90472 $4.00 90962 $186.00 91112 $1,083.00
90473 $13.00 90963 $552.00 91112-26 $113.00
90474 $9.00 90964 $481.00 91112-TC $969.00
90632 BR 90965 $456.00 91117 $152.00
90636 BR 90966 $241.00 91120 $457.00
90675 BR 90967 $18.00 91120-26 $52.00
90746 BR 90968 $15.00 91120-TC $405.00
90749 BR 90969 $15.00 91122 $169.00
90785 $14.00 90970 $8.00 91122-26 $122.00
90791 $134.00 90997 $115.00 91122-TC $37.00
90792 $144.00 90999 BR 91132 $149.00
90832 $65.00 91010 $116.00 91132-26 $28.00
90833 $66.00 91010-26 $76.00 91132-TC $122.00
90834 $86.00 91010-TC $32.00 91133 $174.00
90836 $84.00 91013 $24.00 91133-26 $34.00
90837 $129.00 91013-26 $10.00 91133-TC $139.00
90838 $111.00 91013-TC $14.00 91200 $32.00
90839 $134.00 91020 $60.00 91200-26 $13.00
90840 $64.00 91020-26 $49.00 91200-TC $19.00
90845 $85.00 91020-TC $9.00 91299 BR
90846 $93.00 91022 $227.00 91299-26 BR
90847 $110.00 91022-26 $77.00 91299-TC BR
90849 $32.00 91022-TC $150.00 92002 $63.00
90853 $32.00 91030 $57.00 92004 $98.00
90865 $143.00 91030-26 $47.00 92012 $53.00
90870 $94.00 91030-TC $8.00 92014 $75.00
90875 $74.00 91034 $240.00 92015 $34.00
90876 $112.00 91034-26 $52.00 92018 $80.00
90880 $112.00 91034-TC $188.00 92019 $70.00
90882 $104.00 91035 $474.00 92020 $31.00
90885 $49.00 91035-26 $84.00 92025 $29.00
90887 $77.00 91035-TC $390.00 92025-26 $17.00
90889 BR 91037 $152.00 92025-TC $13.00
90899 BR 91037-26 $52.00 92060 $40.00
90901 $46.00 91037-TC $100.00 92060-26 $32.00
90911 $82.00 91038 $130.00 92060-TC $7.00
90935 $76.00 91038-26 $59.00 92065 $34.00
90937 $226.00 91038-TC $72.00 92065-26 $19.00
90940 BR 91040 $463.00 92065-TC $6.00
90945 $80.00 91040-26 $52.00 92071 $39.00
90947 $125.00 91040-TC $411.00 92072 $140.00
90951 $943.00 91065 $34.00 92081 $32.00
90954 $818.00 91065-26 $23.00 92081-26 $19.00
90955 $461.00 91065-TC $14.00 92081-TC $6.00
90956 $321.00 91110 $928.00 92082 $48.00
90957 $651.00 91110-26 $185.00 92082-26 $24.00
90958 $440.00 91110-TC $743.00 92082-TC $9.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 152
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
92083 $59.00 92283-TC $5.00 92537-26 $32.00
92083-26 $31.00 92284 $192.00 92537-TC $9.00
92083-TC $14.00 92284-26 $151.00 92538 $21.00
92100 $40.00 92284-TC $46.00 92538-26 $16.00
92132 $36.00 92285 $26.00 92538-TC $5.00
92132-26 $20.00 92285-26 $12.00 92540 $102.00
92132-TC $16.00 92285-TC $6.00 92540-26 $81.00
92133 $45.00 92286 $91.00 92540-TC $22.00
92133-26 $29.00 92286-26 $53.00 92541 $37.00
92133-TC $16.00 92286-TC $29.00 92541-26 $25.00
92134 $46.00 92287 $99.00 92541-TC $9.00
92134-26 $30.00 92287-26 $48.00 92542 $33.00
92134-TC $16.00 92287-TC $77.00 92542-26 $20.00
92136 $93.00 92310 $86.00 92542-TC $10.00
92136-26 $29.00 92311 $78.00 92544 $26.00
92136-TC $63.00 92312 $89.00 92544-26 $16.00
92145 $15.00 92313 $70.00 92544-TC $8.00
92145-26 $9.00 92314 $54.00 92545 $22.00
92145-TC $7.00 92315 $44.00 92545-26 $14.00
92225 $45.00 92316 $59.00 92545-TC $8.00
92226 $39.00 92317 $39.00 92546 $29.00
92227 $14.00 92325 $14.00 92546-26 $17.00
92228 $35.00 92326 $44.00 92546-TC $9.00
92228-26 $22.00 92340 $32.00 92547 $21.00
92228-TC $14.00 92341 $43.00 92548 $92.00
92230 $58.00 92342 $43.00 92548-26 $30.00
92235 $104.00 92358 $24.00 92548-TC $59.00
92235-26 $46.00 92370 $35.00 92550 $21.00
92235-TC $53.00 92371 $18.00 92551 $17.00
92240 $132.00 92499 BR 92552 $16.00
92240-26 $60.00 92499-26 BR 92553 $24.00
92240-TC $67.00 92499-TC BR 92555 $14.00
92242 $230.00 92502 $101.00 92556 $21.00
92242-26 $56.00 92504 $24.00 92557 $46.00
92242-TC $173.00 92507 $40.00 92560 $23.00
92250 $40.00 92508 $42.00 92561 $27.00
92250-26 $24.00 92511 $81.00 92562 $15.00
92250-TC $7.00 92512 $46.00 92563 $14.00
92260 $20.00 92516 $36.00 92564 $17.00
92265 $53.00 92520 $47.00 92565 $15.00
92265-26 $37.00 92521 $114.00 92567 $20.00
92265-TC $10.00 92522 $93.00 92568 $14.00
92270 $64.00 92523 $193.00 92570 $33.00
92270-26 $45.00 92524 $97.00 92571 $14.00
92270-TC $19.00 92526 $48.00 92572 $3.00
92275 $80.00 92531 $10.00 92575 $11.00
92275-26 $56.00 92532 $14.00 92576 $17.00
92275-TC $17.00 92533 $41.00 92577 $28.00
92283 $24.00 92534 BR 92579 $28.00
92283-26 $10.00 92537 $41.00 92582 $28.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 153
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
92583 $34.00 92950 $203.00 93260-TC $22.00
92584 $94.00 92953 $35.00 93261 $61.00
92585 $114.00 92960 $162.00 93261-26 $39.00
92585-26 $52.00 92961 $239.00 93261-TC $22.00
92585-TC $70.00 92970 $201.00 93268 $109.00
92586 $70.00 92971 $100.00 93270 $46.00
92587 $58.00 92973 $174.00 93271 $90.00
92587-26 $8.00 92974 $197.00 93272 $28.00
92587-TC $49.00 92975 $400.00 93278 $58.00
92588 $78.00 92977 $302.00 93278-26 $24.00
92588-26 $20.00 92978 $269.00 93278-TC $44.00
92588-TC $57.00 92978-26 $95.00 93279 $50.00
92590 $41.00 92978-TC $170.00 93279-26 $33.00
92591 BR 92979 $163.00 93279-TC $17.00
92592 BR 92979-26 $76.00 93280 $59.00
92593 BR 92979-TC $86.00 93280-26 $39.00
92594 BR 92986 $1,222.00 93280-TC $20.00
92595 BR 92987 $1,271.00 93281 $68.00
92596 $22.00 92990 $974.00 93281-26 $45.00
92597 $96.00 92992 BR 93281-TC $23.00
92603 $88.00 92993 BR 93282 $63.00
92604 $60.00 92997 $765.00 93282-26 $43.00
92605 $95.00 92998 $331.00 93282-TC $20.00
92606 $84.00 93000 $26.00 93283 $82.00
92607 $109.00 93005 $16.00 93283-26 $58.00
92608 $22.00 93010 $12.00 93283-TC $24.00
92609 $59.00 93015 $104.00 93284 $90.00
92610 $42.00 93016 $25.00 93284-26 $63.00
92611 $46.00 93017 $63.00 93284-TC $27.00
92612 $173.00 93018 $54.00 93285 $42.00
92613 $43.00 93024 $111.00 93285-26 $26.00
92614 $134.00 93024-26 $71.00 93285-TC $16.00
92615 $39.00 93024-TC $42.00 93286 $27.00
92616 $183.00 93025 $277.00 93286-26 $15.00
92617 $48.00 93025-26 $40.00 93286-TC $12.00
92618 $34.00 93025-TC $299.00 93287 $36.00
92620 $45.00 93040 $14.00 93287-26 $23.00
92621 $12.00 93041 $31.00 93287-TC $13.00
92625 $45.00 93042 $9.00 93288 $37.00
92626 $86.00 93050 $18.00 93288-26 $21.00
92627 $22.00 93050-26 $9.00 93288-TC $16.00
92640 $53.00 93050-TC $9.00 93289 $66.00
92700 BR 93224 $159.00 93289-26 $46.00
92920 $561.00 93225 $46.00 93289-TC $19.00
92924 $668.00 93226 $83.00 93290 $31.00
92928 $623.00 93227 $50.00 93290-26 $21.00
92933 $697.00 93228 $27.00 93290-TC $9.00
92937 $623.00 93229 $669.00 93291 $36.00
92941 $699.00 93260 $68.00 93291-26 $21.00
92943 $699.00 93260-26 $45.00 93291-TC $15.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 154
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
93292 $32.00 93325-26 $4.00 93505-26 $248.00
93292-26 $21.00 93325-TC $110.00 93505-TC $74.00
93292-TC $11.00 93350 $216.00 93530 $872.00
93293 $54.00 93350-26 $77.00 93530-26 $250.00
93293-26 $16.00 93350-TC $66.00 93530-TC $634.00
93293-TC $38.00 93351 $282.00 93531 $2,268.00
93294 $34.00 93351-26 $86.00 93531-26 $467.00
93295 $68.00 93351-TC $195.00 93531-TC $1,815.00
93296 $26.00 93352 $34.00 93532 $2,317.00
93297 $27.00 93355 $230.00 93532-26 $569.00
93298 $27.00 93451 $790.00 93532-TC $1,766.00
93303 $215.00 93451-26 $151.00 93533 $2,131.00
93303-26 $70.00 93451-TC $638.00 93533-26 $352.00
93303-TC $144.00 93452 $887.00 93533-TC $1,766.00
93304 $114.00 93452-26 $265.00 93561 $59.00
93304-26 $43.00 93452-TC $622.00 93561-26 $47.00
93304-TC $73.00 93453 $1,149.00 93561-TC $20.00
93306 $229.00 93453-26 $347.00 93562 $46.00
93306-26 $64.00 93453-TC $801.00 93562-26 $33.00
93306-TC $165.00 93454 $903.00 93562-TC $13.00
93307 $196.00 93454-26 $267.00 93563 $57.00
93307-26 $56.00 93454-TC $637.00 93564 $58.00
93307-TC $144.00 93455 $1,052.00 93565 $44.00
93308 $118.00 93455-26 $308.00 93566 $173.00
93308-26 $46.00 93455-TC $744.00 93567 $142.00
93308-TC $75.00 93456 $1,132.00 93568 $154.00
93312 $322.00 93456-26 $341.00 93571 $270.00
93312-26 $140.00 93456-TC $791.00 93571-26 $93.00
93312-TC $182.00 93457 $1,280.00 93571-TC $170.00
93313 $76.00 93457-26 $383.00 93572 $222.00
93314 $212.00 93457-TC $897.00 93572-26 $74.00
93314-26 $65.00 93458 $1,084.00 93572-TC $155.00
93314-TC $144.00 93458-26 $326.00 93580 $974.00
93315 $287.00 93458-TC $758.00 93581 $1,303.00
93315-26 $144.00 93459 $1,197.00 93582 $697.00
93315-TC $141.00 93459-26 $367.00 93583 $776.00
93316 $78.00 93459-TC $830.00 93600 $198.00
93317 $236.00 93460 $1,284.00 93600-26 $129.00
93317-26 $95.00 93460-26 $408.00 93600-TC $73.00
93317-TC $141.00 93460-TC $875.00 93602 $159.00
93318 $412.00 93461 $1,468.00 93602-26 $119.00
93318-26 $114.00 93461-26 $451.00 93602-TC $42.00
93318-TC $384.00 93461-TC $1,018.00 93603 $187.00
93320 $86.00 93462 $215.00 93603-26 $127.00
93320-26 $30.00 93463 $109.00 93603-TC $63.00
93320-TC $65.00 93464 $284.00 93609 $578.00
93321 $50.00 93464-26 $99.00 93609-26 $481.00
93321-26 $10.00 93464-TC $186.00 93609-TC $101.00
93321-TC $42.00 93503 $187.00 93610 $214.00
93325 $114.00 93505 $318.00 93610-26 $166.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 155
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
93610-TC $52.00 93655 $432.00 93893 $251.00
93612 $224.00 93656 $1,153.00 93893-26 $63.00
93612-26 $167.00 93657 $433.00 93893-TC $188.00
93612-TC $61.00 93660 $162.00 93922 $60.00
93613 $377.00 93660-26 $103.00 93922-26 $16.00
93615 $62.00 93660-TC $61.00 93922-TC $44.00
93615-26 $49.00 93662 BR 93923 $112.00
93615-TC $12.00 93662-26 $158.00 93923-26 $28.00
93616 $94.00 93662-TC BR 93923-TC $85.00
93616-26 $82.00 93701 $36.00 93924 $122.00
93616-TC $12.00 93701-26 $9.00 93924-26 $31.00
93618 $399.00 93701-TC $27.00 93924-TC $92.00
93618-26 $258.00 93702 $109.00 93925 $175.00
93618-TC $148.00 93724 $411.00 93925-26 $31.00
93619 $717.00 93724-26 $259.00 93925-TC $144.00
93619-26 $444.00 93724-TC $148.00 93926 $117.00
93619-TC $290.00 93740 $17.00 93926-26 $21.00
93620 $358.00 93740-26 $12.00 93926-TC $96.00
93620-26 $272.00 93740-TC $5.00 93930 $174.00
93620-TC $91.00 93750 $55.00 93930-26 $26.00
93621 BR 93770 NC 93930-TC $150.00
93621-26 $769.00 93770-26 NC 93931 $118.00
93621-TC BR 93770-TC NC 93931-26 $17.00
93622 BR 93784 NC 93931-TC $101.00
93622-26 $771.00 93786 NC 93970 $189.00
93622-TC BR 93788 NC 93970-26 $36.00
93623 BR 93790 NC 93970-TC $154.00
93623-26 $167.00 93797 $17.00 93971 $121.00
93623-TC BR 93798 $38.00 93971-26 $23.00
93624 $333.00 93799 BR 93971-TC $96.00
93624-26 $256.00 93799-26 BR 93975 $277.00
93624-TC $74.00 93799-TC BR 93975-26 $89.00
93631 $651.00 93880 $176.00 93975-TC $181.00
93631-26 $420.00 93880-26 $31.00 93976 $184.00
93631-TC $239.00 93880-TC $144.00 93976-26 $59.00
93640 $467.00 93882 $117.00 93976-TC $121.00
93640-26 $230.00 93882-26 $21.00 93978 $177.00
93640-TC $269.00 93882-TC $95.00 93978-26 $34.00
93641 $613.00 93886 $215.00 93978-TC $143.00
93641-26 $360.00 93886-26 $50.00 93979 $122.00
93641-TC $269.00 93886-TC $162.00 93979-26 $23.00
93642 $549.00 93888 $142.00 93979-TC $98.00
93642-26 $295.00 93888-26 $33.00 93980 $183.00
93642-TC $269.00 93888-TC $109.00 93980-26 $65.00
93644 $282.00 93890 $241.00 93980-TC $105.00
93644-26 $176.00 93890-26 $55.00 93981 $148.00
93644-TC $106.00 93890-TC $185.00 93981-26 $25.00
93650 $639.00 93892 $256.00 93981-TC $124.00
93653 $865.00 93892-26 $63.00 93982 $10.00
93654 $1,152.00 93892-TC $193.00 93990 $110.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 156
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
93990-26 $14.00 94644 $36.00 95056 $6.00
93990-TC $96.00 94645 $14.00 95060 $13.00
94002 $84.00 94660 $54.00 95065 $7.00
94003 $61.00 94662 $38.00 95070 $82.00
94004 $45.00 94664 $18.00 95071 $105.00
94010 $30.00 94667 $23.00 95076 $117.00
94010-26 $12.00 94668 $16.00 95079 $84.00
94010-TC $16.00 94669 $35.00 95115 $10.00
94014 $39.00 94680 $47.00 95117 $9.00
94015 $14.00 94680-26 $23.00 95120 BR
94016 $26.00 94680-TC $22.00 95125 BR
94060 $57.00 94681 $60.00 95130 BR
94060-26 $18.00 94681-26 $12.00 95131 BR
94060-TC $36.00 94681-TC $43.00 95132 BR
94070 $32.00 94690 $24.00 95133 BR
94070-26 $11.00 94690-26 $4.00 95134 BR
94070-TC $19.00 94690-TC $20.00 95144 $9.00
94150 $8.00 94726 $53.00 95145 $17.00
94150-26 $6.00 94726-26 $13.00 95146 $24.00
94150-TC $3.00 94726-TC $41.00 95147 $33.00
94200 $17.00 94727 $42.00 95148 $32.00
94200-26 $7.00 94727-26 $13.00 95149 $36.00
94200-TC $9.00 94727-TC $30.00 95165 $7.00
94250 $12.00 94728 $40.00 95170 $13.00
94250-26 $8.00 94728-26 $13.00 95180 $103.00
94250-TC $5.00 94728-TC $28.00 95199 BR
94375 $34.00 94729 $54.00 95250 $114.00
94375-26 $16.00 94729-26 $9.00 95251 $28.00
94375-TC $17.00 94729-TC $45.00 95803 $151.00
94400 $40.00 94750 $37.00 95803-26 $44.00
94400-26 $24.00 94750-26 $14.00 95803-TC $107.00
94400-TC $14.00 94750-TC $21.00 95805 $334.00
94450 $37.00 94760 $9.00 95805-26 $94.00
94450-26 $20.00 94761 $20.00 95805-TC $237.00
94450-TC $15.00 94762 $30.00 95806 $232.00
94452 $52.00 94770 $21.00 95806-26 $109.00
94452-26 $16.00 94770-26 $9.00 95806-TC $137.00
94452-TC $36.00 94770-TC $12.00 95807 $367.00
94453 $74.00 94799 BR 95807-26 $98.00
94453-26 $20.00 94799-26 BR 95807-TC $256.00
94453-TC $53.00 94799-TC BR 95808 $456.00
94610 $63.00 95004 $3.00 95808-26 $149.00
94620 $91.00 95012 $19.00 95808-TC $256.00
94620-26 $38.00 95017 $8.00 95810 $521.00
94620-TC $54.00 95018 $20.00 95810-26 $183.00
94621 $122.00 95024 $3.00 95810-TC $256.00
94621-26 $71.00 95027 $5.00 95811 $644.00
94621-TC $52.00 95028 $8.00 95811-26 $196.00
94640 $19.00 95044 $7.00 95811-TC $423.00
94642 BR 95052 $9.00 95812 $137.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 157
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
95812-26 $58.00 95867-26 $43.00 95912 $266.00
95812-TC $68.00 95867-TC $21.00 95912-26 $161.00
95813 $177.00 95868 $96.00 95912-TC $105.00
95813-26 $89.00 95868-26 $71.00 95913 $308.00
95813-TC $68.00 95868-TC $26.00 95913-26 $191.00
95816 $133.00 95869 $29.00 95913-TC $117.00
95816-26 $54.00 95869-26 $21.00 95921 $61.00
95816-TC $78.00 95869-TC $8.00 95921-26 $46.00
95819 $115.00 95870 $29.00 95921-TC $14.00
95819-26 $58.00 95870-26 $21.00 95922 $65.00
95819-TC $56.00 95870-TC $8.00 95922-26 $50.00
95822 $120.00 95872 $104.00 95922-TC $14.00
95822-26 $58.00 95872-26 $81.00 95923 $105.00
95822-TC $63.00 95872-TC $22.00 95923-26 $47.00
95824 $51.00 95873 $29.00 95923-TC $57.00
95824-26 $41.00 95873-26 $21.00 95924 $147.00
95824-TC $10.00 95873-TC $8.00 95924-26 $90.00
95827 $145.00 95874 $30.00 95924-TC $57.00
95827-26 $59.00 95874-26 $21.00 95925 $94.00
95827-TC $86.00 95874-TC $8.00 95925-26 $53.00
95829 $328.00 95875 $43.00 95925-TC $41.00
95829-26 $291.00 95875-26 $34.00 95926 $66.00
95829-TC $6.00 95875-TC $7.00 95926-26 $34.00
95830 $133.00 95885 $59.00 95926-TC $34.00
95831 $26.00 95885-26 $19.00 95927 $67.00
95832 $21.00 95885-TC $40.00 95927-26 $34.00
95833 $34.00 95886 $92.00 95927-TC $34.00
95834 $44.00 95886-26 $47.00 95928 $175.00
95851 $18.00 95886-TC $45.00 95928-26 $84.00
95852 $14.00 95887 $87.00 95928-TC $91.00
95857 $40.00 95887-26 $38.00 95929 $182.00
95860 $73.00 95887-TC $48.00 95929-26 $84.00
95860-26 $53.00 95905 $68.00 95929-TC $98.00
95860-TC $15.00 95905-26 $3.00 95930 $44.00
95861 $113.00 95905-TC $66.00 95930-26 $25.00
95861-26 $86.00 95907 $95.00 95930-TC $11.00
95861-TC $28.00 95907-26 $54.00 95933 $62.00
95863 $138.00 95907-TC $42.00 95933-26 $33.00
95863-26 $102.00 95908 $117.00 95933-TC $30.00
95863-TC $35.00 95908-26 $67.00 95937 $40.00
95864 $177.00 95908-TC $51.00 95937-26 $31.00
95864-26 $114.00 95909 $142.00 95937-TC $9.00
95864-TC $67.00 95909-26 $80.00 95938 $339.00
95865 $119.00 95909-TC $61.00 95938-26 $47.00
95865-26 $92.00 95910 $186.00 95938-TC $292.00
95865-TC $27.00 95910-26 $107.00 95939 $495.00
95866 $80.00 95910-TC $79.00 95939-26 $122.00
95866-26 $71.00 95911 $226.00 95939-TC $373.00
95866-TC $9.00 95911-26 $134.00 95940 $33.00
95867 $66.00 95911-TC $92.00 95950 $265.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 158
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
95950-26 $84.00 95992 $44.00 96416 $186.00
95950-TC $177.00 95999 BR 96417 $85.00
95951 $34.00 96000 $93.00 96420 $46.00
95951-26 $14.00 96001 $111.00 96422 $46.00
95951-TC $20.00 96002 $21.00 96423 $17.00
95953 $411.00 96003 $20.00 96425 $54.00
95953-26 $165.00 96004 $97.00 96440 $156.00
95953-TC $240.00 96020 BR 96446 $193.00
95954 $208.00 96020-26 $156.00 96450 $134.00
95954-26 $134.00 96020-TC BR 96521 $153.00
95954-TC $23.00 96101 $97.00 96522 $111.00
95955 $130.00 96102 $44.00 96523 $28.00
95955-26 $59.00 96103 $28.00 96542 $126.00
95955-TC $74.00 96105 $68.00 96549 BR
95956 $541.00 96110 $88.00 96567 $62.00
95956-26 $166.00 96111 $68.00 96570 $69.00
95956-TC $314.00 96116 $109.00 96571 $38.00
95957 $171.00 96118 $130.00 96900 $17.00
95957-26 $104.00 96119 $66.00 96904 $70.00
95957-TC $64.00 96120 $48.00 96910 $21.00
95958 $296.00 96125 $57.00 96912 $24.00
95958-26 $230.00 96127 $5.00 96913 $53.00
95958-TC $66.00 96150 $26.00 96920 $152.00
95961 $216.00 96151 $25.00 96921 $155.00
95961-26 $166.00 96152 $24.00 96922 $214.00
95961-TC $48.00 96153 $6.00 96931 $162.00
95962 $227.00 96154 $24.00 96932 $29.00
95962-26 $176.00 96155 $22.00 96933 $46.00
95962-TC $48.00 96360 $57.00 96934 $83.00
95965 BR 96361 $15.00 96935 $35.00
95965-26 $420.00 96365 $69.00 96936 $44.00
95965-TC BR 96366 $19.00 96999 BR
95966 BR 96367 $30.00 97010 $10.00
95966-26 $210.00 96368 $20.00 97012 $16.00
95966-TC BR 96369 $195.00 97014 $14.00
95967 BR 96370 $15.00 97016 $15.00
95967-26 $184.00 96371 $91.00 97018 $10.00
95967-TC BR 96372 $25.00 97022 $15.00
95970 $22.00 96373 $19.00 97024 $10.00
95971 $39.00 96374 $56.00 97026 $9.00
95972 $78.00 96375 $22.00 97028 $10.00
95974 $155.00 96377 BR 97032 $16.00
95975 $88.00 96401 $53.00 97033 $16.00
95978 $213.00 96402 $46.00 97034 $13.00
95979 $98.00 96405 $57.00 97035 $11.00
95980 $27.00 96406 $86.00 97036 $19.00
95981 $10.00 96409 $122.00 97039 $15.00
95982 $22.00 96411 $71.00 97110 $22.00
95990 $57.00 96413 $173.00 97112 $23.00
95991 $84.00 96415 $39.00 97113 $24.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 159
Medicine Medicine Medicine
CPT Code MRA CPT Code MRA CPT Code MRA
97116 $21.00 97853 $26.00 G0118 $27.00
97124 $19.00 98925 NC G0120 $179.00
97139 $15.00 98926 $32.00 G0120-26 $46.00
97140 $26.00 98927 NC G0120-TC $132.00
97150 $18.00 98928 $23.00 G0121 $344.00
97161 $82.00 98929 NC G0121-53 $115.00
97162 $82.00 98940 NC G0122 $177.00
97163 $82.00 98941 $32.00 G0122-26 $45.00
97164 $56.00 98942 NC G0122-TC $132.00
97165 $79.00 98943 $23.00 G0128 $4.00
97166 $79.00 98960 $19.00 G0166 $138.00
97167 $79.00 98961 $9.00 G0179 $41.00
97168 $52.00 98962 $7.00 G0180 $54.00
97169 BR 99000 $6.00 G0181 $99.00
97170 BR 99001 $4.00 G0182 $102.00
97171 BR 99002 $35.00 G0237 $12.00
97172 BR 99026 BR G0238 $13.00
97260 $23.00 99027 BR G0239 $11.00
97261 $17.00 99070 BR G0248 $168.00
97530 $22.00 99071 NC G0249 $124.00
97532 $22.00 99075 See 440.13 G0250 $9.00
97533 $24.00 99078 NC G0268 $43.00
97535 $23.00 99082 BR G0270 $22.00
97537 $23.00 99090 BR G0271 $13.00
97542 $17.00 99152 $52.00 G0277 $45.00
97545 $83.00 99153 $11.00 G0281 $10.00
97546 $41.00 99156 $77.00 G0283 $10.00
97597 $49.00 99157 $58.00 G0329 $7.00
97598 $62.00 99172 BR G0403 $17.00
97602 BR 99173 $3.00 G0404 $8.00
97605 $34.00 99174 $8.00 G0405 $9.00
97606 $37.00 99175 $53.00 G0422 $103.00
97610 $121.00 99183 $123.00 G0423 $103.00
97750 BR 99184 $232.00 G0424 $30.00
97752 $48.00 99190 BR G0453 $33.00
97755 $35.00 99191 BR G0454 $9.00
97760 $31.00 99192 BR G0459 $49.00
97761 $28.00 99195 $16.00 G0473 $13.00
97762 $26.00 99199 NC G0500 $59.00
97799 BR G0101 $32.00 G0502 $143.00
97802 $26.00 G0102 $18.00 G0503 $126.00
97803 $17.00 G0104 $115.00 G0504 $66.00
97804 $7.00 G0105 $344.00 G0505 $238.00
97810 $35.00 G0105-53 $115.00 G0506 $64.00
97811 $27.00 G0106 $165.00 G9157 $112.00
97813 $37.00 G0106-26 $46.00 G9187 $48.00
97814 $30.00 G0106-TC $119.00 P3001 $24.00
97850 $54.00 G0108 $24.00 Q0035 $19.00
97851 $26.00 G0109 $14.00 Q0035-26 $8.00
97852 $54.00 G0117 $40.00 Q0035-TC $11.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 160
Medicine
CPT Code MRA
Q0091 $37.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 161
Evaluation & Management Evaluation & Management Evaluation & Managemen
CPT Code MRA CPT Code MRA CPT Code MRA
99201 $35.00 99309 $80.00 99457 BR
99202 $58.00 99310 $100.00 99487 $52.00
99203 $58.00 99315 $60.00 99489 $41.00
99204 $84.00 99316 $77.00 99490 $41.00
99205 $84.00 99318 $66.00 99495 $164.00
99211 $19.00 99324 $59.00 99496 $232.00
99212 $31.00 99325 $86.00 99497 $86.00
99213 $40.00 99326 $125.00 99498 $75.00
99214 $40.00 99327 $164.00 99499 BR
99215 $65.00 99328 $203.00 99600 BR
99217 $65.00 99334 $45.00 G0245 $58.00
99218 $65.00 99335 $72.00 G0246 $34.00
99219 $109.00 99336 $111.00 G0296 $29.00
99220 $152.00 99337 $163.00 G0337 $62.00
99221 $66.00 99339 $67.00 G0372 $13.00
99222 $109.00 99340 $93.00 G0396 $29.00
99223 $152.00 99341 $59.00 G0397 $56.00
99224 $40.00 99342 $85.00 G0402 $165.00
99225 $73.00 99343 $109.00 G0406 $39.00
99226 $105.00 99344 $160.00 G0407 $72.00
99231 $33.00 99345 $193.00 G0408 $104.00
99232 $54.00 99347 $46.00 G0409 $16.00
99233 $77.00 99348 $71.00 G0507 $48.00
99234 $129.00 99349 $107.00 G0508 $201.00
99235 $173.00 99350 $156.00 G0509 $194.00
99236 $213.00 99354 $106.00 G9685 $206.00
99238 $66.00 99355 $104.00 G9686 $80.00
99239 $88.00 99356 $87.00
99241 $54.00 99357 $88.00
99242 $88.00 99360 $47.00
99243 $117.00 99363 $108.00
99244 $163.00 99364 $38.00
99245 $212.00 99366 $37.00
99251 $54.00 99367 $48.00
99252 $70.00 99368 $31.00
99253 $96.00 99374 $75.00
99254 $138.00 99375 $75.00
99255 $190.00 99377 $75.00
99281 $18.00 99378 $104.00
99282 $28.00 99379 $75.00
99283 $60.00 99380 $104.00
99284 $94.00 99406 $12.00
99285 $103.00 99407 $24.00
99291 $192.00 99408 $29.00
99292 $95.00 99409 $58.00
99304 $66.00 99415 $9.00
99305 $88.00 99416 $5.00
99306 $108.00 99450 NC
99307 $34.00 99455 $90.00
99308 $56.00 99456 BR
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 162
Dental Dental Dental
D-Code MRA D-Code MRA D-Code MRA
D0120 $17.00 D2390 $57.00 D2951 $20.00
D0140 $13.00 D2391 $43.00 D2952 $79.00
D0150 $20.00 D2392 $55.00 D2953 $133.00
D0160 $36.00 D2393 $63.00 D2954 $102.00
D0170 $18.00 D2394 $69.00 D2955 $81.00
D0180 $20.00 D2410 $163.00 D2957 $71.00
D0210 $40.00 D2420 $203.00 D2960 $121.00
D0220 $10.00 D2430 $293.00 D2961 $204.00
D0230 $5.00 D2510 $155.00 D2962 $294.00
D0240 $12.00 D2520 $259.00 D2980 $83.00
D0250 $20.00 D2530 $244.00 D2999 BR
D0270 $7.00 D2542 $302.00 D3110 $25.00
D0272 $12.00 D2543 $318.00 D3120 $20.00
D0274 $20.00 D2544 $348.00 D3220 $61.00
D0277 $18.00 D2610 $206.00 D3221 $81.00
D0310 $50.00 D2620 $266.00 D3230 $70.00
D0320 $204.00 D2630 $348.00 D3240 $75.00
D0321 $64.00 D2642 $287.00 D3310 $206.00
D0322 $105.00 D2643 $328.00 D3320 $204.00
D0330 $29.00 D2644 $378.00 D3330 $287.00
D0340 $40.00 D2650 $206.00 D3331 $102.00
D0350 $10.00 D2651 $266.00 D3332 $110.00
D0415 $34.00 D2652 $348.00 D3333 $53.00
D0425 $25.00 D2662 $266.00 D3346 $225.00
D0460 $13.00 D2663 $328.00 D3347 $274.00
D0470 $24.00 D2664 $348.00 D3348 $337.00
D0472 $30.00 D2710 $194.00 D3351 $102.00
D0473 BR D2720 $410.00 D3352 $81.00
D0474 BR D2721 $306.00 D3353 $163.00
D0480 BR D2722 $348.00 D3410 $179.00
D0502 $54.00 D2740 $410.00 D3421 $194.00
D0999 BR D2750 $451.00 D3425 $206.00
D1110 $29.00 D2751 $328.00 D3426 $77.00
D1310 $23.00 D2752 $368.00 D3430 $55.00
D1320 $48.00 D2780 $368.00 D3450 $102.00
D1330 $13.00 D2781 $266.00 D3460 $318.00
D1351 $21.00 D2782 $306.00 D3470 $204.00
D1510 $81.00 D2783 $389.00 D3910 $50.00
D1515 $121.00 D2790 $389.00 D3920 $102.00
D1520 $102.00 D2791 $287.00 D3950 $61.00
D1525 $143.00 D2792 $328.00 D3999 BR
D1550 $14.00 D2799 $204.00 D4210 $114.00
D2140 $38.00 D2910 $29.00 D4211 $50.00
D2150 $44.00 D2920 $29.00 D4240 $223.00
D2160 $54.00 D2930 $81.00 D4241 $63.00
D2161 $67.00 D2931 $121.00 D4245 $265.00
D2330 $40.00 D2932 $77.00 D4249 $208.00
D2331 $61.00 D2933 $91.00 D4260 $328.00
D2332 $66.00 D2940 $29.00 D4261 $164.00
D2335 $81.00 D2950 $81.00 D4263 $195.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 163
Dental Dental Dental
D-Code MRA D-Code MRA D-Code MRA
D4264 $159.00 D5750 $132.00 D5999 BR
D4265 $96.00 D5751 $163.00 D6010 $649.00
D4266 $285.00 D5760 $100.00 D6040 $3,016.00
D4267 $328.00 D5761 $163.00 D6050 $1,557.00
D4268 $273.00 D5810 $244.00 D6055 $769.00
D4270 $155.00 D5811 $244.00 D6056 $265.00
D4273 $337.00 D5820 $194.00 D6057 $303.00
D4274 $208.00 D5821 $204.00 D6058 $392.00
D4275 $178.00 D5850 $46.00 D6059 $418.00
D4276 $194.00 D5851 $50.00 D6060 $289.00
D4320 $77.00 D5862 $181.00 D6061 $379.00
D4321 $55.00 D5867 $36.00 D6062 $365.00
D4341 $79.00 D5875 $100.00 D6063 $359.00
D4342 $55.00 D5899 BR D6064 $377.00
D4355 $50.00 D5911 $81.00 D6065 $513.00
D4381 $69.00 D5912 $121.00 D6066 $513.00
D4910 $40.00 D5913 $2,052.00 D6067 $513.00
D4920 $27.00 D5914 $2,052.00 D6068 $365.00
D4999 BR D5915 $2,770.00 D6069 $359.00
D5110 $513.00 D5916 $2,874.00 D6070 $322.00
D5120 $513.00 D5919 BR D6071 $326.00
D5130 $563.00 D5922 $1,334.00 D6072 $365.00
D5140 $563.00 D5923 $1,641.00 D6073 $346.00
D5211 $256.00 D5924 BR D6074 $350.00
D5212 $259.00 D5925 BR D6075 $414.00
D5213 $614.00 D5926 $1,026.00 D6076 $402.00
D5214 $614.00 D5927 $1,026.00 D6077 $447.00
D5281 $279.00 D5928 $1,384.00 D6080 $71.00
D5410 $27.00 D5929 BR D6090 $229.00
D5411 $27.00 D5931 $656.00 D6095 $247.00
D5421 $27.00 D5932 $1,539.00 D6100 $264.00
D5422 $27.00 D5933 $306.00 D6199 BR
D5510 $61.00 D5934 $1,539.00 D6210 $410.00
D5520 $40.00 D5935 $1,539.00 D6211 $287.00
D5610 $61.00 D5936 $563.00 D6212 $328.00
D5620 $83.00 D5937 BR D6240 $451.00
D5630 $22.00 D5951 $614.00 D6241 $368.00
D5640 $53.00 D5953 $614.00 D6242 $410.00
D5650 $61.00 D5954 BR D6245 $309.00
D5660 $102.00 D5955 $1,334.00 D6250 $410.00
D5670 $305.00 D5958 $780.00 D6251 $287.00
D5671 $305.00 D5959 $244.00 D6252 $368.00
D5710 $204.00 D5960 $163.00 D6253 $51.00
D5711 $204.00 D5982 $167.00 D6545 $195.00
D5720 $163.00 D5983 BR D6548 $281.00
D5721 $163.00 D5984 BR D6600 $155.00
D5730 $121.00 D5985 $574.00 D6601 $166.00
D5731 $121.00 D5986 $61.00 D6602 $172.00
D5740 $102.00 D5987 BR D6603 $203.00
D5741 $102.00 D5988 $219.00 D6604 $110.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 164
Dental Dental Dental
D-Code MRA D-Code MRA D-Code MRA
D6605 $141.00 D7320 $108.00 D7852 $2,011.00
D6606 $139.00 D7340 $195.00 D7854 $2,052.00
D6607 $151.00 D7350 $410.00 D7856 BR
D6608 $170.00 D7410 $102.00 D7858 $2,298.00
D6609 $178.00 D7411 $100.00 D7860 $614.00
D6610 $203.00 D7412 $139.00 D7865 $1,723.00
D6611 $217.00 D7413 $205.00 D7870 $81.00
D6612 $141.00 D7414 $180.00 D7871 BR
D6613 $155.00 D7415 $291.00 D7872 $533.00
D6614 $151.00 D7440 $161.00 D7873 $584.00
D6615 $162.00 D7441 $247.00 D7874 $737.00
D6720 $410.00 D7450 $139.00 D7875 $789.00
D6721 $233.00 D7451 $179.00 D7876 $820.00
D6722 $348.00 D7460 $137.00 D7877 $758.00
D6740 $328.00 D7461 $195.00 D7880 $291.00
D6750 $356.00 D7465 $71.00 D7899 BR
D6751 $328.00 D7471 $174.00 D7910 $73.00
D6752 $410.00 D7472 $143.00 D7911 $110.00
D6780 $389.00 D7473 $147.00 D7912 $163.00
D6781 $320.00 D7485 $162.00 D7920 $676.00
D6782 $322.00 D7490 $2,545.00 D7940 $841.00
D6783 $324.00 D7510 $54.00 D7941 $2,874.00
D6790 $389.00 D7520 $121.00 D7943 $2,914.00
D6791 $287.00 D7530 $85.00 D7944 $2,298.00
D6792 $348.00 D7540 $121.00 D7945 $2,319.00
D6793 $30.00 D7550 $143.00 D7946 $2,566.00
D6920 $279.00 D7560 $266.00 D7947 $2,566.00
D6930 $40.00 D7610 $1,189.00 D7948 $2,874.00
D6940 $102.00 D7620 $984.00 D7949 $4,186.00
D6950 $155.00 D7630 $1,354.00 D7950 $881.00
D6980 $106.00 D7640 $820.00 D7955 $922.00
D6999 BR D7650 $1,292.00 D7960 $121.00
D7140 $45.00 D7660 $780.00 D7970 $137.00
D7210 $70.00 D7670 $410.00 D7971 $67.00
D7220 $111.00 D7671 $779.00 D7972 BR
D7230 $139.00 D7680 $1,949.00 D7980 $169.00
D7240 $147.00 D7710 $1,415.00 D7981 $820.00
D7241 $204.00 D7720 $903.00 D7982 $306.00
D7250 $81.00 D7730 $1,580.00 D7983 $244.00
D7260 $244.00 D7740 $922.00 D7990 $340.00
D7270 $147.00 D7750 $1,334.00 D7991 $820.00
D7272 $204.00 D7760 $1,046.00 D7995 BR
D7280 $121.00 D7770 $533.00 D7996 BR
D7282 $41.00 D7771 $73.00 D7997 BR
D7285 $106.00 D7780 $2,504.00 D7999 BR
D7286 $81.00 D7810 $1,292.00 D8010 $451.00
D7287 BR D7820 $110.00 D8020 $533.00
D7290 $133.00 D7830 $186.00 D8030 $718.00
D7291 $77.00 D7840 $1,764.00 D8040 $583.00
D7310 $85.00 D7850 $1,682.00 D8050 $676.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 165
Dental
D-Code MRA
D8060 $758.00
D8070 $1,867.00
D8080 $1,867.00
D8090 $1,949.00
D8210 $155.00
D8220 $179.00
D8660 $73.00
D8670 $54.00
D8680 $171.00
D8690 $71.00
D8691 $67.00
D8692 $104.00
D8999 BR
D9110 $40.00
D9210 $14.00
D9211 $14.00
D9212 $13.00
D9215 $7.00
D9230 $18.00
D9248 $91.00
D9310 $41.00
D9410 $61.00
D9420 $46.00
D9430 $23.00
D9440 $41.00
D9450 BR
D9610 $20.00
D9630 $10.00
D9910 $21.00
D9911 $21.00
D9920 $32.00
D9930 $34.00
D9940 $204.00
D9941 $58.00
D9950 $114.00
D9951 $46.00
D9952 $163.00
D9970 $83.00
D9971 $55.00
D9972 $113.00
D9973 $40.00
D9974 $50.00
D9999 BR
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 166
Injections Injections Injections
J-Code MRA J-Code MRA J-Code MRA
J0120 $12.00 J0702 $4.00 J1450 BR
J0130 BR J0710 $3.00 J1455 $12.00
J0190 $3.00 J0713 $8.00 J1460 $2.00
J0200 BR J0715 $6.00 J1560 BR
J0205 $38.00 J0720 $6.00 J1570 $36.00
J0207 BR J0725 $3.00 J1580 $3.00
J0210 $7.00 J0735 BR J1595 BR
J0215 BR J0740 BR J1600 $10.00
J0256 $101.00 J0743 $14.00 J1610 $27.00
J0280 $1.00 J0744 BR J1620 $69.00
J0282 BR J0745 $1.00 J1626 BR
J0285 BR J0770 $32.00 J1630 $4.00
J0287 BR J0780 $3.00 J1631 $28.00
J0288 BR J0800 $18.00 J1642 $1.00
J0289 BR J0850 $362.00 J1644 $1.00
J0290 $2.00 J0895 $10.00 J1645 BR
J0295 $7.00 J0945 $1.00 J1650 $16.00
J0300 $2.00 J1000 $3.00 J1652 BR
J0330 $1.00 J1020 $1.00 J1655 BR
J0350 $2,408.00 J1030 $2.00 J1670 $23.00
J0360 $6.00 J1040 $3.00 J1700 $1.00
J0380 $1.00 J1094 BR J1710 $5.00
J0390 $3.00 J1100 $1.00 J1720 $4.00
J0395 BR J1110 $10.00 J1730 $94.00
J0456 BR J1120 $35.00 J1742 BR
J0470 $11.00 J1160 $2.00 J1745 BR
J0475 $201.00 J1165 $1.00 J1750 BR
J0476 BR J1170 $1.00 J1756 BR
J0500 $3.00 J1180 $1.00 J1790 $4.00
J0515 $3.00 J1190 BR J1800 $10.00
J0520 $5.00 J1200 $1.00 J1810 $6.00
J0583 BR J1205 $9.00 J1815 BR
J0585 $393.00 J1212 $36.00 J1817 BR
J0587 BR J1230 $1.00 J1830 $76.00
J0592 BR J1240 $1.00 J1835 BR
J0595 BR J1245 $31.00 J1840 $7.00
J0600 $6.00 J1250 $49.00 J1850 $4.00
J0610 $1.00 J1260 BR J1885 $7.00
J0620 $3.00 J1270 BR J1890 $11.00
J0630 $21.00 J1320 $1.00 J1940 $1.00
J0636 BR J1325 BR J1950 $411.00
J0637 BR J1327 BR J1955 $37.00
J0640 $22.00 J1330 $2.00 J1956 BR
J0670 BR J1335 BR J1960 $2.00
J0690 $3.00 J1364 $6.00 J1980 $3.00
J0692 BR J1380 $1.00 J1990 $8.00
J0694 $10.00 J1410 $33.00 J2001 BR
J0696 $11.00 J1435 $1.00 J2010 $2.00
J0697 $6.00 J1436 $68.00 J2020 BR
J0698 $11.00 J1438 BR J2060 $12.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________
CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 167
Injections Injections Injections
J-Code MRA J-Code MRA J-Code MRA
J2150 $3.00 J2795 BR J7030 $11.00
J2175 $1.00 J2800 $3.00 J7040 $10.00
J2180 $3.00 J2810 $3.00 J7042 $10.00
J2185 BR J2820 $115.00 J7050 $10.00
J2210 $3.00 J2910 $11.00 J7060 $10.00
J2250 $2.00 J2916 BR J7070 $11.00
J2260 $32.00 J2920 $5.00 J7100 $137.00
J2270 $1.00 J2930 $13.00 J7110 $93.00
J2280 BR J2940 BR J7120 $12.00
J2300 $2.00 J2941 BR J7190 $241.00
J2310 $3.00 J2950 $1.00 J7191 BR
J2320 $5.00 J2993 BR J7192 $316.00
J2353 BR J2995 BR J7193 BR
J2354 BR J2997 BR J7194 $120.00
J2355 BR J3000 $2.00 J7195 BR
J2360 $2.00 J3010 $2.00 J7197 $284.00
J2370 $3.00 J3030 $34.00 J7198 BR
J2400 BR J3070 $4.00 J7199 BR
J2405 $6.00 J3105 $2.00 J7320 $0.00
J2410 $3.00 J3230 $2.00 J7501 $98.00
J2430 $189.00 J3240 $214.00 J7504 $282.00
J2440 $2.00 J3250 $1.00 J7505 $576.00
J2460 $1.00 J3260 $7.00 J7513 BR
J2501 BR J3265 $2.00 J7516 BR
J2505 BR J3280 $5.00 J7599 BR
J2510 $1.00 J3301 $1.00
J2515 $1.00 J3302 $1.00
J2540 $1.00 J3303 $1.00
J2543 BR J3305 $55.00
J2545 $105.00 J3310 $5.00
J2550 $1.00 J3320 $16.00
J2560 $5.00 J3350 $72.00
J2590 $1.00 J3360 $1.00
J2597 $20.00 J3364 $52.00
J2650 $1.00 J3365 $433.00
J2670 BR J3370 $9.00
J2680 $16.00 J3400 $12.00
J2690 $7.00 J3410 $1.00
J2700 $2.00 J3411 BR
J2710 $1.00 J3415 BR
J2720 $1.00 J3420 $1.00
J2725 $11.00 J3430 $2.00
J2730 $29.00 J3465 BR
J2760 $29.00 J3470 $7.00
J2765 $2.00 J3475 $1.00
J2770 BR J3480 $1.00
J2780 BR J3485 BR
J2783 BR J3486 BR
J2790 $36.00 J3490 BR
J2792 BR J3590 BR
2017 Edition Page 168 Effective Date: _________
Chapter 3 Maximum Reimbursement Allowances, continued
PART B
SCHEDULE OF MAXIMUM REIMBURSEMENT
ALLOWANCES
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 169
Surgery
CPT Code FUD 2003 MRALocality 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 $173.00 $183.00 $191.00 $102.00 $108.00 $114.00
10022 0 $92.00 $197.00 $209.00 $215.00 $96.00 $100.00 $105.00
10030 0 ---------- $969.00 $1,036.00 $1,070.00 $233.00 $250.00 $275.00
10035 0 ---------- $741.00 $789.00 $805.00 $132.00 $139.00 $148.00
10036 ZZZ ---------- $638.00 $680.00 $690.00 $65.00 $69.00 $73.00
10040 10 $54.00 $145.00 $153.00 $161.00 $127.00 $135.00 $142.00
10060 10 $53.00 $165.00 $174.00 $180.00 $139.00 $146.00 $152.00
10061 10 $133.00 $293.00 $309.00 $322.00 $258.00 $272.00 $284.00
10080 10 $65.00 $250.00 $266.00 $275.00 $147.00 $156.00 $164.00
10081 10 $203.00 $379.00 $402.00 $418.00 $245.00 $259.00 $274.00
10120 10 $53.00 $213.00 $225.00 $232.00 $147.00 $155.00 $161.00
10121 10 $169.00 $387.00 $410.00 $428.00 $269.00 $284.00 $301.00
10140 10 $53.00 $230.00 $243.00 $252.00 $170.00 $179.00 $188.00
10160 10 $45.00 $183.00 $193.00 $201.00 $137.00 $145.00 $152.00
10180 10 $164.00 $351.00 $375.00 $397.00 $261.00 $279.00 $299.00
11000 0 $45.00 $76.00 $80.00 $83.00 $42.00 $43.00 $45.00
11001 ZZZ $27.00 $31.00 $32.00 $33.00 $21.00 $22.00 $23.00
11004 0 ---------- $867.00 $923.00 $1,003.00 $867.00 $923.00 $1,003.00
11005 0 ---------- $1,182.00 $1,266.00 $1,393.00 $1,182.00 $1,266.00 $1,393.00
11006 0 ---------- $1,058.00 $1,127.00 $1,228.00 $1,058.00 $1,127.00 $1,228.00
11008 ZZZ ---------- $416.00 $446.00 $491.00 $416.00 $446.00 $491.00
11010 10 $348.00 $716.00 $764.00 $801.00 $419.00 $447.00 $481.00
11011 0 $432.00 $763.00 $815.00 $858.00 $445.00 $475.00 $515.00
11012 0 $597.00 $1,013.00 $1,081.00 $1,141.00 $632.00 $675.00 $730.00
11042 0 $88.00 $163.00 $173.00 $178.00 $90.00 $94.00 $99.00
11043 0 $210.00 $325.00 $344.00 $361.00 $229.00 $241.00 $257.00
11044 0 $283.00 $451.00 $479.00 $506.00 $341.00 $361.00 $388.00
11045 ZZZ ---------- $58.00 $62.00 $65.00 $38.00 $41.00 $43.00
11046 ZZZ ---------- $106.00 $113.00 $120.00 $84.00 $89.00 $96.00
11047 ZZZ ---------- $181.00 $193.00 $207.00 $149.00 $158.00 $172.00
11055 0 $26.00 $66.00 $70.00 $71.00 $23.00 $24.00 $25.00
11056 0 $35.00 $81.00 $85.00 $87.00 $33.00 $34.00 $35.00
11057 0 $39.00 $91.00 $96.00 $98.00 $43.00 $44.00 $46.00
11100 0 $78.00 $145.00 $154.00 $159.00 $72.00 $76.00 $80.00
11101 ZZZ $41.00 $47.00 $49.00 $52.00 $37.00 $39.00 $41.00
11200 10 $66.00 $124.00 $132.00 $137.00 $105.00 $111.00 $116.00
11201 ZZZ $26.00 $27.00 $29.00 $31.00 $24.00 $26.00 $27.00
11300 0 $59.00 $136.00 $145.00 $149.00 $52.00 $55.00 $58.00
11301 0 $80.00 $169.00 $179.00 $185.00 $79.00 $83.00 $88.00
11302 0 $96.00 $199.00 $211.00 $218.00 $93.00 $98.00 $104.00
11303 0 $119.00 $220.00 $234.00 $242.00 $109.00 $116.00 $123.00
11305 0 $61.00 $138.00 $146.00 $150.00 $57.00 $60.00 $63.00
11306 0 $86.00 $171.00 $182.00 $187.00 $76.00 $80.00 $84.00
11307 0 $100.00 $202.00 $214.00 $221.00 $98.00 $103.00 $109.00
11308 0 $125.00 $212.00 $224.00 $230.00 $108.00 $112.00 $118.00
11310 0 $75.00 $160.00 $169.00 $175.00 $70.00 $73.00 $78.00
11311 0 $95.00 $157.00 $166.00 $173.00 $96.00 $101.00 $107.00
11312 0 $110.00 $226.00 $240.00 $249.00 $115.00 $122.00 $129.00
11313 0 $144.00 $263.00 $279.00 $291.00 $148.00 $156.00 $166.00
11400 10 $81.00 $174.00 $184.00 $191.00 $115.00 $122.00 $128.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 170
Surgery
CPT Code FUD 2003 MRALocality 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)
11401 10 $114.00 $210.00 $223.00 $231.00 $150.00 $159.00 $167.00
11402 10 $145.00 $234.00 $249.00 $259.00 $165.00 $175.00 $184.00
11403 10 $178.00 $272.00 $289.00 $304.00 $213.00 $227.00 $240.00
11404 10 $200.00 $309.00 $330.00 $347.00 $236.00 $251.00 $267.00
11406 10 $246.00 $450.00 $480.00 $509.00 $362.00 $386.00 $414.00
11420 10 $98.00 $171.00 $181.00 $187.00 $117.00 $123.00 $129.00
11421 10 $92.00 $220.00 $234.00 $243.00 $159.00 $168.00 $176.00
11422 10 $157.00 $248.00 $263.00 $274.00 $195.00 $207.00 $218.00
11423 10 $163.00 $286.00 $303.00 $318.00 $227.00 $241.00 $255.00
11424 10 $221.00 $332.00 $354.00 $372.00 $262.00 $278.00 $296.00
11426 10 $303.00 $479.00 $510.00 $541.00 $403.00 $428.00 $459.00
11440 10 $105.00 $188.00 $199.00 $206.00 $146.00 $155.00 $160.00
11441 10 $102.00 $236.00 $251.00 $261.00 $188.00 $199.00 $208.00
11442 10 $174.00 $265.00 $282.00 $294.00 $209.00 $222.00 $233.00
11443 10 $221.00 $318.00 $337.00 $354.00 $258.00 $273.00 $289.00
11444 10 $276.00 $401.00 $426.00 $448.00 $330.00 $350.00 $371.00
11446 10 $344.00 $559.00 $593.00 $626.00 $475.00 $504.00 $535.00
11450 90 $282.00 $541.00 $579.00 $609.00 $369.00 $394.00 $423.00
11451 90 $366.00 $691.00 $738.00 $778.00 $476.00 $509.00 $547.00
11462 90 $264.00 $527.00 $563.00 $591.00 $352.00 $376.00 $402.00
11463 90 $351.00 $698.00 $745.00 $782.00 $477.00 $509.00 $544.00
11470 90 $320.00 $584.00 $624.00 $656.00 $409.00 $436.00 $467.00
11471 90 $391.00 $725.00 $773.00 $812.00 $510.00 $543.00 $581.00
11600 10 $148.00 $270.00 $287.00 $298.00 $173.00 $183.00 $192.00
11601 10 $180.00 $323.00 $343.00 $357.00 $217.00 $229.00 $242.00
11602 10 $199.00 $350.00 $372.00 $387.00 $238.00 $252.00 $266.00
11603 10 $226.00 $402.00 $427.00 $446.00 $286.00 $303.00 $321.00
11604 10 $249.00 $447.00 $476.00 $498.00 $316.00 $335.00 $356.00
11606 10 $315.00 $644.00 $686.00 $724.00 $472.00 $502.00 $539.00
11620 10 $150.00 $273.00 $290.00 $302.00 $175.00 $186.00 $196.00
11621 10 $191.00 $325.00 $345.00 $360.00 $218.00 $231.00 $245.00
11622 10 $223.00 $363.00 $385.00 $402.00 $250.00 $265.00 $280.00
11623 10 $259.00 $427.00 $453.00 $475.00 $310.00 $329.00 $349.00
11624 10 $305.00 $483.00 $513.00 $539.00 $353.00 $374.00 $399.00
11626 10 $373.00 $583.00 $621.00 $655.00 $434.00 $461.00 $494.00
11640 10 $168.00 $282.00 $299.00 $311.00 $181.00 $192.00 $202.00
11641 10 $227.00 $336.00 $357.00 $372.00 $227.00 $241.00 $255.00
11642 10 $260.00 $384.00 $408.00 $427.00 $269.00 $285.00 $302.00
11643 10 $305.00 $455.00 $483.00 $507.00 $337.00 $357.00 $380.00
11644 10 $380.00 $561.00 $596.00 $626.00 $418.00 $443.00 $471.00
11646 10 $494.00 $738.00 $784.00 $828.00 $582.00 $618.00 $660.00
11719 0 $22.00 $20.00 $21.00 $21.00 $11.00 $11.00 $12.00
11720 0 $32.00 $45.00 $47.00 $48.00 $21.00 $22.00 $23.00
11721 0 $50.00 $63.00 $66.00 $68.00 $36.00 $37.00 $39.00
11730 0 $62.00 $147.00 $154.00 $158.00 $80.00 $83.00 $87.00
11732 ZZZ $31.00 $45.00 $47.00 $48.00 $26.00 $27.00 $28.00
11740 0 $41.00 $69.00 $73.00 $74.00 $46.00 $48.00 $50.00
11750 10 $156.00 $214.00 $225.00 $231.00 $161.00 $169.00 $174.00
11755 0 $106.00 $186.00 $196.00 $201.00 $111.00 $116.00 $120.00
11760 10 $131.00 $264.00 $280.00 $289.00 $165.00 $174.00 $182.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 171
Surgery
CPT Code FUD 2003 MRALocality 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)
11762 10 $223.00 $391.00 $412.00 $424.00 $263.00 $275.00 $286.00
11765 10 $65.00 $232.00 $245.00 $250.00 $134.00 $140.00 $144.00
11770 10 $275.00 $395.00 $422.00 $446.00 $272.00 $291.00 $314.00
11771 90 $496.00 $822.00 $880.00 $936.00 $638.00 $683.00 $738.00
11772 90 $585.00 $996.00 $1,066.00 $1,134.00 $840.00 $899.00 $966.00
11900 0 $33.00 $78.00 $83.00 $86.00 $46.00 $48.00 $51.00
11901 0 $37.00 $99.00 $105.00 $110.00 $71.00 $75.00 $80.00
11920 0 $147.00 $241.00 $256.00 $267.00 $166.00 $176.00 $186.00
11921 0 $172.00 $280.00 $297.00 $311.00 $195.00 $207.00 $220.00
11922 ZZZ $40.00 $86.00 $92.00 $95.00 $44.00 $47.00 $50.00
11950 0 $107.00 $111.00 $118.00 $124.00 $78.00 $83.00 $88.00
11951 0 $114.00 $143.00 $152.00 $160.00 $107.00 $113.00 $121.00
11952 0 $155.00 $179.00 $189.00 $200.00 $138.00 $145.00 $156.00
11954 0 $165.00 $226.00 $240.00 $253.00 $169.00 $179.00 $192.00
11960 90 $829.00 $1,373.00 $1,459.00 $1,543.00 $1,373.00 $1,459.00 $1,543.00
11970 90 $632.00 $884.00 $940.00 $996.00 $884.00 $940.00 $996.00
11971 90 $280.00 $659.00 $701.00 $728.00 $456.00 $485.00 $509.00
11976 0 $123.00 $202.00 $214.00 $223.00 $138.00 $144.00 $153.00
12001 0 $84.00 $126.00 $133.00 $139.00 $65.00 $68.00 $73.00
12002 0 $98.00 $153.00 $162.00 $169.00 $86.00 $91.00 $97.00
12004 0 $122.00 $181.00 $192.00 $200.00 $108.00 $114.00 $122.00
12005 0 $165.00 $229.00 $243.00 $255.00 $141.00 $148.00 $159.00
12006 0 $203.00 $271.00 $287.00 $302.00 $173.00 $183.00 $197.00
12007 0 $339.00 $313.00 $332.00 $350.00 $217.00 $229.00 $247.00
12011 0 $98.00 $154.00 $163.00 $170.00 $81.00 $85.00 $91.00
12013 0 $141.00 $161.00 $171.00 $178.00 $86.00 $90.00 $97.00
12014 0 $165.00 $189.00 $200.00 $210.00 $110.00 $116.00 $125.00
12015 0 $207.00 $230.00 $243.00 $255.00 $139.00 $147.00 $158.00
12016 0 $268.00 $291.00 $308.00 $324.00 $190.00 $200.00 $215.00
12017 0 $316.00 $232.00 $245.00 $265.00 $232.00 $245.00 $265.00
12018 0 $515.00 $262.00 $277.00 $298.00 $262.00 $277.00 $298.00
12020 10 $211.00 $396.00 $421.00 $439.00 $274.00 $290.00 $307.00
12021 10 $87.00 $231.00 $246.00 $258.00 $199.00 $211.00 $224.00
12031 10 $93.00 $334.00 $355.00 $369.00 $222.00 $236.00 $249.00
12032 10 $110.00 $426.00 $453.00 $471.00 $283.00 $300.00 $316.00
12034 10 $148.00 $441.00 $469.00 $490.00 $303.00 $321.00 $341.00
12035 10 $223.00 $538.00 $573.00 $600.00 $351.00 $373.00 $398.00
12036 10 $356.00 $599.00 $638.00 $671.00 $410.00 $436.00 $467.00
12037 10 $411.00 $687.00 $732.00 $773.00 $484.00 $516.00 $555.00
12041 10 $116.00 $334.00 $354.00 $369.00 $219.00 $232.00 $245.00
12042 10 $141.00 $409.00 $434.00 $453.00 $292.00 $310.00 $327.00
12044 10 $176.00 $506.00 $537.00 $559.00 $314.00 $332.00 $352.00
12045 10 $250.00 $566.00 $601.00 $628.00 $393.00 $416.00 $441.00
12046 10 $341.00 $677.00 $724.00 $766.00 $456.00 $488.00 $527.00
12047 10 $363.00 $774.00 $822.00 $857.00 $537.00 $569.00 $601.00
12051 10 $126.00 $363.00 $386.00 $402.00 $249.00 $264.00 $279.00
12052 10 $148.00 $416.00 $441.00 $460.00 $297.00 $315.00 $333.00
12053 10 $223.00 $487.00 $517.00 $539.00 $318.00 $337.00 $356.00
12054 10 $301.00 $509.00 $540.00 $564.00 $326.00 $345.00 $366.00
12055 10 $380.00 $659.00 $700.00 $731.00 $445.00 $472.00 $500.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 172
Surgery
CPT Code FUD 2003 MRALocality 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)
12056 10 $487.00 $694.00 $734.00 $765.00 $498.00 $525.00 $554.00
12057 10 $539.00 $778.00 $831.00 $882.00 $579.00 $618.00 $667.00
13100 10 $178.00 $472.00 $501.00 $522.00 $301.00 $319.00 $338.00
13101 10 $240.00 $558.00 $592.00 $617.00 $369.00 $391.00 $414.00
13102 ZZZ $89.00 $172.00 $183.00 $193.00 $110.00 $117.00 $125.00
13120 10 $223.00 $494.00 $525.00 $547.00 $344.00 $365.00 $385.00
13121 10 $348.00 $603.00 $640.00 $667.00 $392.00 $414.00 $439.00
13122 ZZZ $104.00 $190.00 $202.00 $212.00 $127.00 $135.00 $144.00
13131 10 $252.00 $545.00 $578.00 $604.00 $366.00 $388.00 $411.00
13132 10 $484.00 $674.00 $715.00 $747.00 $462.00 $489.00 $518.00
13133 ZZZ $154.00 $256.00 $271.00 $286.00 $194.00 $206.00 $220.00
13151 10 $375.00 $599.00 $635.00 $665.00 $421.00 $446.00 $473.00
13152 10 $542.00 $719.00 $763.00 $798.00 $511.00 $541.00 $574.00
13153 ZZZ $169.00 $278.00 $295.00 $311.00 $209.00 $222.00 $237.00
13160 90 $655.00 $1,177.00 $1,251.00 $1,339.00 $1,177.00 $1,251.00 $1,339.00
14000 90 $512.00 $885.00 $942.00 $990.00 $729.00 $775.00 $821.00
14001 90 $695.00 $1,146.00 $1,220.00 $1,286.00 $957.00 $1,017.00 $1,081.00
14020 90 $590.00 $990.00 $1,052.00 $1,103.00 $824.00 $874.00 $923.00
14021 90 $818.00 $1,242.00 $1,319.00 $1,385.00 $1,046.00 $1,109.00 $1,173.00
14040 90 $701.00 $1,086.00 $1,151.00 $1,207.00 $918.00 $973.00 $1,027.00
14041 90 $936.00 $1,347.00 $1,429.00 $1,499.00 $1,134.00 $1,201.00 $1,270.00
14060 90 $766.00 $1,110.00 $1,176.00 $1,235.00 $978.00 $1,036.00 $1,094.00
14061 90 $1,330.00 $1,448.00 $1,536.00 $1,612.00 $1,213.00 $1,285.00 $1,358.00
14301 90 ---------- $1,543.00 $1,638.00 $1,727.00 $1,290.00 $1,368.00 $1,454.00
14302 ZZZ ---------- $328.00 $349.00 $375.00 $328.00 $349.00 $375.00
14350 90 $734.00 $994.00 $1,043.00 $1,092.00 $994.00 $1,043.00 $1,092.00
15002 0 ---------- $495.00 $527.00 $554.00 $335.00 $356.00 $382.00
15003 ZZZ ---------- $108.00 $115.00 $121.00 $68.00 $72.00 $78.00
15004 0 ---------- $569.00 $603.00 $630.00 $396.00 $418.00 $443.00
15005 ZZZ ---------- $180.00 $192.00 $204.00 $136.00 $144.00 $156.00
15040 0 ---------- $359.00 $383.00 $400.00 $189.00 $201.00 $217.00
15050 90 $349.00 $795.00 $844.00 $883.00 $641.00 $680.00 $717.00
15100 90 $679.00 $1,232.00 $1,314.00 $1,393.00 $1,047.00 $1,115.00 $1,193.00
15101 ZZZ $146.00 $265.00 $283.00 $298.00 $165.00 $176.00 $191.00
15110 90 ---------- $1,147.00 $1,217.00 $1,289.00 $1,011.00 $1,071.00 $1,142.00
15111 ZZZ ---------- $171.00 $183.00 $199.00 $156.00 $167.00 $183.00
15115 90 ---------- $1,153.00 $1,218.00 $1,282.00 $1,016.00 $1,072.00 $1,135.00
15116 ZZZ ---------- $238.00 $253.00 $269.00 $219.00 $232.00 $249.00
15120 90 $788.00 $1,219.00 $1,295.00 $1,368.00 $1,019.00 $1,082.00 $1,152.00
15121 ZZZ $235.00 $297.00 $317.00 $334.00 $197.00 $210.00 $226.00
15130 90 ---------- $958.00 $1,021.00 $1,082.00 $817.00 $870.00 $930.00
15131 ZZZ ---------- $133.00 $141.00 $153.00 $123.00 $131.00 $142.00
15135 90 ---------- $1,203.00 $1,272.00 $1,337.00 $1,065.00 $1,125.00 $1,188.00
15136 ZZZ ---------- $126.00 $133.00 $140.00 $119.00 $125.00 $133.00
15150 90 ---------- $1,000.00 $1,071.00 $1,158.00 $924.00 $990.00 $1,075.00
15151 ZZZ ---------- $179.00 $191.00 $208.00 $166.00 $178.00 $195.00
15152 ZZZ ---------- $220.00 $237.00 $260.00 $208.00 $224.00 $247.00
15155 90 ---------- $1,034.00 $1,094.00 $1,155.00 $963.00 $1,018.00 $1,078.00
15156 ZZZ ---------- $241.00 $257.00 $278.00 $229.00 $244.00 $266.00
15157 ZZZ ---------- $269.00 $284.00 $303.00 $252.00 $267.00 $285.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 173
Surgery
CPT Code FUD 2003 MRALocality 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)
15200 90 $644.00 $1,188.00 $1,264.00 $1,333.00 $981.00 $1,043.00 $1,109.00
15201 ZZZ $126.00 $207.00 $221.00 $231.00 $117.00 $124.00 $134.00
15220 90 $687.00 $1,098.00 $1,167.00 $1,224.00 $894.00 $949.00 $1,005.00
15221 ZZZ $114.00 $193.00 $206.00 $215.00 $106.00 $113.00 $121.00
15240 90 $763.00 $1,332.00 $1,415.00 $1,486.00 $1,164.00 $1,234.00 $1,304.00
15241 ZZZ $334.00 $262.00 $279.00 $292.00 $165.00 $175.00 $187.00
15260 90 $841.00 $1,445.00 $1,532.00 $1,605.00 $1,249.00 $1,322.00 $1,393.00
15261 ZZZ $207.00 $305.00 $324.00 $339.00 $206.00 $218.00 $232.00
15271 0 ---------- $199.00 $210.00 $220.00 $125.00 $131.00 $140.00
15272 ZZZ ---------- $39.00 $41.00 $43.00 $26.00 $27.00 $29.00
15273 0 ---------- $430.00 $458.00 $486.00 $302.00 $321.00 $348.00
15274 ZZZ ---------- $103.00 $110.00 $117.00 $69.00 $74.00 $80.00
15275 0 ---------- $211.00 $222.00 $230.00 $140.00 $146.00 $154.00
15276 ZZZ ---------- $50.00 $52.00 $55.00 $37.00 $39.00 $42.00
15277 0 ---------- $469.00 $498.00 $527.00 $338.00 $358.00 $386.00
15278 ZZZ ---------- $123.00 $132.00 $140.00 $86.00 $92.00 $100.00
15570 90 $748.00 $1,309.00 $1,393.00 $1,471.00 $1,075.00 $1,143.00 $1,219.00
15572 90 $721.00 $1,274.00 $1,355.00 $1,429.00 $1,089.00 $1,157.00 $1,229.00
15574 90 $775.00 $1,305.00 $1,385.00 $1,459.00 $1,115.00 $1,183.00 $1,254.00
15576 90 $457.00 $1,150.00 $1,219.00 $1,278.00 $974.00 $1,031.00 $1,088.00
15600 90 $259.00 $450.00 $480.00 $497.00 $296.00 $314.00 $330.00
15610 90 $320.00 $500.00 $532.00 $552.00 $347.00 $369.00 $388.00
15620 90 $506.00 $616.00 $655.00 $683.00 $467.00 $496.00 $522.00
15630 90 $362.00 $648.00 $689.00 $718.00 $499.00 $530.00 $557.00
15650 90 $427.00 $716.00 $761.00 $796.00 $554.00 $589.00 $622.00
15731 90 ---------- $1,616.00 $1,714.00 $1,808.00 $1,465.00 $1,552.00 $1,645.00
15732 90 $1,465.00 $1,836.00 $1,941.00 $2,036.00 $1,617.00 $1,707.00 $1,800.00
15734 90 $1,557.00 $2,182.00 $2,328.00 $2,490.00 $1,942.00 $2,071.00 $2,231.00
15736 90 $1,862.00 $1,908.00 $2,030.00 $2,160.00 $1,671.00 $1,778.00 $1,905.00
15738 90 $1,415.00 $2,030.00 $2,160.00 $2,303.00 $1,808.00 $1,923.00 $2,064.00
15740 90 $913.00 $1,456.00 $1,544.00 $1,623.00 $1,241.00 $1,316.00 $1,392.00
15750 90 $1,064.00 $1,338.00 $1,421.00 $1,512.00 $1,338.00 $1,421.00 $1,512.00
15756 90 $2,892.00 $3,407.00 $3,612.00 $3,858.00 $3,407.00 $3,612.00 $3,858.00
15757 90 $2,892.00 $3,358.00 $3,555.00 $3,792.00 $3,358.00 $3,555.00 $3,792.00
15758 90 $2,884.00 $3,367.00 $3,566.00 $3,804.00 $3,367.00 $3,566.00 $3,804.00
15760 90 $810.00 $1,217.00 $1,291.00 $1,354.00 $1,030.00 $1,090.00 $1,151.00
15770 90 $674.00 $970.00 $1,029.00 $1,090.00 $970.00 $1,029.00 $1,090.00
15775 0 $327.00 $430.00 $455.00 $478.00 $327.00 $345.00 $367.00
15776 0 $475.00 $691.00 $730.00 $760.00 $511.00 $538.00 $565.00
15777 ZZZ ---------- $320.00 $340.00 $367.00 $320.00 $340.00 $367.00
15780 90 $532.00 $1,220.00 $1,293.00 $1,347.00 $936.00 $989.00 $1,040.00
15781 90 $420.00 $785.00 $835.00 $873.00 $624.00 $663.00 $699.00
15782 90 $314.00 $896.00 $955.00 $993.00 $640.00 $682.00 $717.00
15783 90 $340.00 $675.00 $716.00 $746.00 $532.00 $565.00 $593.00
15786 10 $146.00 $344.00 $364.00 $375.00 $197.00 $207.00 $217.00
15787 ZZZ $27.00 $68.00 $72.00 $74.00 $25.00 $26.00 $26.00
15788 90 $194.00 $636.00 $677.00 $694.00 $348.00 $370.00 $383.00
15789 90 $360.00 $785.00 $833.00 $865.00 $610.00 $646.00 $676.00
15792 90 $130.00 $605.00 $645.00 $662.00 $364.00 $387.00 $402.00
15793 90 $232.00 $696.00 $739.00 $767.00 $528.00 $560.00 $587.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 174
Surgery
CPT Code FUD 2003 MRALocality 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)
15819 90 $780.00 $1,151.00 $1,223.00 $1,298.00 $1,151.00 $1,223.00 $1,298.00
15820 90 $556.00 $832.00 $884.00 $930.00 $753.00 $800.00 $844.00
15821 90 $607.00 $855.00 $900.00 $931.00 $771.00 $811.00 $841.00
15822 90 $499.00 $627.00 $662.00 $684.00 $553.00 $583.00 $605.00
15823 90 $718.00 $852.00 $896.00 $923.00 $768.00 $806.00 $832.00
15824 0 NC BR BR BR BR BR BR
15825 0 NC BR BR BR BR BR BR
15826 0 NC BR BR BR BR BR BR
15828 0 NC BR BR BR BR BR BR
15829 0 NC BR BR BR BR BR BR
15830 90 ---------- $1,720.00 $1,830.00 $1,959.00 $1,720.00 $1,830.00 $1,959.00
15832 90 $926.00 $1,333.00 $1,415.00 $1,506.00 $1,333.00 $1,415.00 $1,506.00
15833 90 $833.00 $1,242.00 $1,318.00 $1,399.00 $1,242.00 $1,318.00 $1,399.00
15834 90 $837.00 $1,291.00 $1,372.00 $1,459.00 $1,291.00 $1,372.00 $1,459.00
15835 90 $865.00 $1,333.00 $1,417.00 $1,511.00 $1,333.00 $1,417.00 $1,511.00
15836 90 $721.00 $1,145.00 $1,216.00 $1,291.00 $1,145.00 $1,216.00 $1,291.00
15837 90 $696.00 $1,223.00 $1,300.00 $1,369.00 $1,034.00 $1,099.00 $1,166.00
15838 90 $600.00 $824.00 $871.00 $920.00 $824.00 $871.00 $920.00
15839 90 $643.00 $1,266.00 $1,346.00 $1,422.00 $1,075.00 $1,141.00 $1,216.00
15840 90 $1,187.00 $1,461.00 $1,546.00 $1,638.00 $1,461.00 $1,546.00 $1,638.00
15841 90 $1,859.00 $2,325.00 $2,455.00 $2,608.00 $2,325.00 $2,455.00 $2,608.00
15842 90 $3,099.00 $3,573.00 $3,774.00 $4,017.00 $3,573.00 $3,774.00 $4,017.00
15845 90 $1,116.00 $1,432.00 $1,505.00 $1,567.00 $1,432.00 $1,505.00 $1,567.00
15850 0 $63.00 $124.00 $132.00 $137.00 $61.00 $64.00 $69.00
15851 0 $40.00 $138.00 $146.00 $150.00 $67.00 $70.00 $73.00
15852 0 $35.00 $69.00 $74.00 $79.00 $69.00 $74.00 $79.00
15860 0 $151.00 $163.00 $173.00 $187.00 $163.00 $173.00 $187.00
15876 0 NC BR BR BR BR BR BR
15877 0 NC BR BR BR BR BR BR
15878 0 NC BR BR BR BR BR BR
15879 0 NC BR BR BR BR BR BR
15920 90 $571.00 $907.00 $970.00 $1,042.00 $907.00 $970.00 $1,042.00
15922 90 $771.00 $1,135.00 $1,205.00 $1,279.00 $1,135.00 $1,205.00 $1,279.00
15931 90 $638.00 $1,014.00 $1,085.00 $1,176.00 $1,014.00 $1,085.00 $1,176.00
15933 90 $860.00 $1,238.00 $1,321.00 $1,420.00 $1,238.00 $1,321.00 $1,420.00
15934 90 $1,064.00 $1,371.00 $1,464.00 $1,578.00 $1,371.00 $1,464.00 $1,578.00
15935 90 $1,184.00 $1,615.00 $1,722.00 $1,846.00 $1,615.00 $1,722.00 $1,846.00
15936 90 $1,032.00 $1,308.00 $1,395.00 $1,502.00 $1,308.00 $1,395.00 $1,502.00
15937 90 $1,223.00 $1,513.00 $1,612.00 $1,731.00 $1,513.00 $1,612.00 $1,731.00
15940 90 $318.00 $1,028.00 $1,098.00 $1,184.00 $1,028.00 $1,098.00 $1,184.00
15941 90 $919.00 $1,310.00 $1,396.00 $1,492.00 $1,310.00 $1,396.00 $1,492.00
15944 90 $954.00 $1,298.00 $1,382.00 $1,478.00 $1,298.00 $1,382.00 $1,478.00
15945 90 $1,078.00 $1,434.00 $1,526.00 $1,630.00 $1,434.00 $1,526.00 $1,630.00
15946 90 $1,737.00 $2,396.00 $2,550.00 $2,731.00 $2,396.00 $2,550.00 $2,731.00
15950 90 $549.00 $866.00 $926.00 $996.00 $866.00 $926.00 $996.00
15951 90 $872.00 $1,259.00 $1,336.00 $1,415.00 $1,259.00 $1,336.00 $1,415.00
15952 90 $876.00 $1,305.00 $1,386.00 $1,471.00 $1,305.00 $1,386.00 $1,471.00
15953 90 $1,013.00 $1,447.00 $1,537.00 $1,633.00 $1,447.00 $1,537.00 $1,633.00
15956 90 $1,382.00 $1,683.00 $1,793.00 $1,924.00 $1,683.00 $1,793.00 $1,924.00
15958 90 $1,379.00 $1,715.00 $1,826.00 $1,955.00 $1,715.00 $1,826.00 $1,955.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 175
Surgery
CPT Code FUD 2003 MRALocality 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)
15999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
16000 0 $53.00 $98.00 $104.00 $108.00 $67.00 $71.00 $75.00
16020 0 $49.00 $115.00 $122.00 $126.00 $78.00 $82.00 $86.00
16025 0 $67.00 $210.00 $222.00 $233.00 $162.00 $172.00 $182.00
16030 0 $153.00 $265.00 $282.00 $297.00 $196.00 $208.00 $223.00
16035 0 $341.00 $287.00 $301.00 $321.00 $287.00 $301.00 $321.00
16036 ZZZ $81.00 $121.00 $129.00 $140.00 $121.00 $129.00 $140.00
17000 10 $60.00 $94.00 $99.00 $103.00 $76.00 $80.00 $84.00
17003 ZZZ $16.00 $8.00 $9.00 $9.00 $4.00 $4.00 $4.00
17004 10 $233.00 $211.00 $224.00 $233.00 $144.00 $152.00 $160.00
17106 90 $341.00 $486.00 $515.00 $538.00 $400.00 $424.00 $446.00
17107 90 $648.00 $615.00 $652.00 $681.00 $501.00 $530.00 $559.00
17108 90 $1,015.00 $918.00 $974.00 $1,022.00 $769.00 $814.00 $861.00
17110 10 $55.00 $154.00 $164.00 $168.00 $99.00 $105.00 $109.00
17111 10 $83.00 $184.00 $195.00 $201.00 $123.00 $130.00 $136.00
17250 0 $27.00 $110.00 $117.00 $121.00 $53.00 $56.00 $59.00
17260 10 $96.00 $134.00 $142.00 $148.00 $102.00 $108.00 $114.00
17261 10 $117.00 $201.00 $213.00 $221.00 $132.00 $140.00 $147.00
17262 10 $150.00 $246.00 $261.00 $272.00 $169.00 $179.00 $188.00
17263 10 $172.00 $269.00 $286.00 $297.00 $187.00 $198.00 $209.00
17264 10 $189.00 $288.00 $305.00 $318.00 $199.00 $211.00 $223.00
17266 10 $225.00 $329.00 $349.00 $364.00 $235.00 $249.00 $263.00
17270 10 $125.00 $212.00 $225.00 $234.00 $145.00 $154.00 $162.00
17271 10 $143.00 $230.00 $244.00 $254.00 $161.00 $170.00 $179.00
17272 10 $170.00 $263.00 $279.00 $290.00 $185.00 $196.00 $207.00
17273 10 $195.00 $294.00 $312.00 $325.00 $210.00 $222.00 $235.00
17274 10 $240.00 $348.00 $369.00 $386.00 $258.00 $272.00 $288.00
17276 10 $281.00 $403.00 $427.00 $446.00 $308.00 $325.00 $344.00
17280 10 $123.00 $198.00 $211.00 $219.00 $132.00 $140.00 $147.00
17281 10 $165.00 $251.00 $267.00 $278.00 $182.00 $192.00 $203.00
17282 10 $194.00 $289.00 $306.00 $320.00 $209.00 $221.00 $234.00
17283 10 $239.00 $347.00 $368.00 $385.00 $262.00 $277.00 $293.00
17284 10 $282.00 $397.00 $421.00 $441.00 $306.00 $324.00 $343.00
17286 10 $373.00 $512.00 $542.00 $571.00 $412.00 $436.00 $464.00
17311 0 ---------- $934.00 $992.00 $1,034.00 $557.00 $589.00 $627.00
17312 ZZZ ---------- $547.00 $581.00 $604.00 $296.00 $314.00 $334.00
17313 0 ---------- $872.00 $926.00 $963.00 $499.00 $528.00 $562.00
17314 ZZZ ---------- $524.00 $557.00 $578.00 $275.00 $291.00 $310.00
17315 ZZZ ---------- $114.00 $121.00 $127.00 $78.00 $83.00 $88.00
17340 10 $37.00 $74.00 $78.00 $82.00 $71.00 $74.00 $78.00
17360 10 $96.00 $183.00 $193.00 $203.00 $143.00 $151.00 $160.00
17380 0 NC BR BR BR BR BR BR
17999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
19000 0 $74.00 $158.00 $167.00 $173.00 $64.00 $68.00 $72.00
19001 ZZZ $40.00 $39.00 $41.00 $43.00 $32.00 $34.00 $36.00
19020 90 $288.00 $670.00 $717.00 $754.00 $446.00 $478.00 $513.00
19030 0 $98.00 $231.00 $244.00 $251.00 $114.00 $119.00 $125.00
19081 0 ---------- $958.00 $1,018.00 $1,040.00 $249.00 $261.00 $276.00
19082 ZZZ ---------- $786.00 $837.00 $851.00 $125.00 $131.00 $139.00
19083 0 ---------- $928.00 $987.00 $1,008.00 $234.00 $245.00 $259.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 176
Surgery
CPT Code FUD 2003 MRALocality 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)
19084 ZZZ ---------- $755.00 $804.00 $817.00 $116.00 $122.00 $128.00
19085 0 ---------- $1,405.00 $1,494.00 $1,521.00 $273.00 $285.00 $300.00
19086 ZZZ ---------- $1,119.00 $1,192.00 $1,209.00 $136.00 $141.00 $148.00
19100 0 $117.00 $214.00 $229.00 $242.00 $105.00 $113.00 $124.00
19101 10 $338.00 $487.00 $521.00 $552.00 $327.00 $350.00 $379.00
19105 0 ---------- $3,213.00 $3,426.00 $3,474.00 $294.00 $309.00 $327.00
19110 90 $406.00 $693.00 $742.00 $787.00 $502.00 $538.00 $581.00
19112 90 $354.00 $654.00 $700.00 $739.00 $457.00 $489.00 $526.00
19120 90 $429.00 $716.00 $768.00 $825.00 $610.00 $655.00 $711.00
19125 90 $468.00 $796.00 $853.00 $919.00 $679.00 $729.00 $793.00
19126 ZZZ $201.00 $244.00 $262.00 $290.00 $244.00 $262.00 $290.00
19260 90 $1,101.00 $1,781.00 $1,909.00 $2,076.00 $1,781.00 $1,909.00 $2,076.00
19271 90 $1,561.00 $2,394.00 $2,566.00 $2,775.00 $2,394.00 $2,566.00 $2,775.00
19272 90 $1,674.00 $2,625.00 $2,813.00 $3,046.00 $2,625.00 $2,813.00 $3,046.00
19281 0 ---------- $335.00 $354.00 $364.00 $149.00 $155.00 $162.00
19282 ZZZ ---------- $231.00 $245.00 $250.00 $75.00 $78.00 $81.00
19283 0 ---------- $378.00 $401.00 $412.00 $151.00 $157.00 $166.00
19284 ZZZ ---------- $283.00 $300.00 $307.00 $76.00 $80.00 $85.00
19285 0 ---------- $712.00 $757.00 $770.00 $128.00 $133.00 $140.00
19286 ZZZ ---------- $618.00 $659.00 $668.00 $64.00 $67.00 $71.00
19287 0 ---------- $1,189.00 $1,266.00 $1,286.00 $190.00 $199.00 $208.00
19288 ZZZ ---------- $954.00 $1,016.00 $1,029.00 $95.00 $99.00 $103.00
19296 0 ---------- $5,401.00 $5,770.00 $5,857.00 $317.00 $340.00 $373.00
19297 ZZZ ---------- $144.00 $154.00 $171.00 $144.00 $154.00 $171.00
19298 0 ---------- $1,364.00 $1,451.00 $1,492.00 $464.00 $489.00 $521.00
19300 90 ---------- $751.00 $804.00 $855.00 $604.00 $647.00 $696.00
19301 90 ---------- $970.00 $1,040.00 $1,136.00 $970.00 $1,040.00 $1,136.00
19302 90 ---------- $1,339.00 $1,437.00 $1,570.00 $1,339.00 $1,437.00 $1,570.00
19303 90 ---------- $1,504.00 $1,614.00 $1,764.00 $1,504.00 $1,614.00 $1,764.00
19304 90 ---------- $849.00 $910.00 $985.00 $849.00 $910.00 $985.00
19305 90 ---------- $1,678.00 $1,800.00 $1,963.00 $1,678.00 $1,800.00 $1,963.00
19306 90 ---------- $1,762.00 $1,891.00 $2,064.00 $1,762.00 $1,891.00 $2,064.00
19307 90 ---------- $1,777.00 $1,907.00 $2,081.00 $1,777.00 $1,907.00 $2,081.00
19316 90 $954.00 $1,127.00 $1,199.00 $1,282.00 $1,127.00 $1,199.00 $1,282.00
19318 90 $1,313.00 $1,612.00 $1,711.00 $1,823.00 $1,612.00 $1,711.00 $1,823.00
19324 90 $440.00 $726.00 $777.00 $839.00 $726.00 $777.00 $839.00
19325 90 $656.00 $933.00 $990.00 $1,049.00 $933.00 $990.00 $1,049.00
19328 90 $457.00 $719.00 $765.00 $812.00 $719.00 $765.00 $812.00
19330 90 $569.00 $922.00 $981.00 $1,043.00 $922.00 $981.00 $1,043.00
19340 90 $545.00 $1,463.00 $1,554.00 $1,653.00 $1,463.00 $1,554.00 $1,653.00
19342 90 $963.00 $1,342.00 $1,425.00 $1,513.00 $1,342.00 $1,425.00 $1,513.00
19350 90 $853.00 $1,180.00 $1,255.00 $1,322.00 $980.00 $1,041.00 $1,106.00
19355 90 $755.00 $1,015.00 $1,088.00 $1,170.00 $845.00 $906.00 $987.00
19357 90 $1,449.00 $2,180.00 $2,317.00 $2,450.00 $2,180.00 $2,317.00 $2,450.00
19361 90 $1,667.00 $2,308.00 $2,450.00 $2,613.00 $2,308.00 $2,450.00 $2,613.00
19364 90 $2,737.00 $4,050.00 $4,299.00 $4,595.00 $4,050.00 $4,299.00 $4,595.00
19366 90 $1,676.00 $2,078.00 $2,210.00 $2,373.00 $2,078.00 $2,210.00 $2,373.00
19367 90 $2,056.00 $2,621.00 $2,782.00 $2,969.00 $2,621.00 $2,782.00 $2,969.00
19368 90 $2,444.00 $3,235.00 $3,434.00 $3,669.00 $3,235.00 $3,434.00 $3,669.00
19369 90 $2,317.00 $2,967.00 $3,141.00 $3,339.00 $2,967.00 $3,141.00 $3,339.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 177
Surgery
CPT Code FUD 2003 MRALocality 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)
19370 90 $662.00 $998.00 $1,060.00 $1,126.00 $998.00 $1,060.00 $1,126.00
19371 90 $788.00 $1,141.00 $1,213.00 $1,289.00 $1,141.00 $1,213.00 $1,289.00
19380 90 $780.00 $1,125.00 $1,196.00 $1,270.00 $1,125.00 $1,196.00 $1,270.00
19396 0 $231.00 $412.00 $438.00 $455.00 $214.00 $227.00 $243.00
19499 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
20005 10 $267.00 $445.00 $473.00 $497.00 $343.00 $363.00 $386.00
20100 10 $727.00 $905.00 $966.00 $1,051.00 $905.00 $966.00 $1,051.00
20101 10 $261.00 $632.00 $677.00 $711.00 $311.00 $333.00 $364.00
20102 10 $314.00 $691.00 $739.00 $778.00 $378.00 $405.00 $441.00
20103 10 $405.00 $827.00 $880.00 $922.00 $511.00 $543.00 $581.00
20150 90 $1,141.00 $1,398.00 $1,494.00 $1,619.00 $1,398.00 $1,494.00 $1,619.00
20200 0 $134.00 $294.00 $315.00 $331.00 $143.00 $154.00 $169.00
20205 0 $243.00 $413.00 $444.00 $471.00 $234.00 $253.00 $278.00
20206 0 $119.00 $325.00 $345.00 $352.00 $86.00 $90.00 $95.00
20220 0 $128.00 $234.00 $247.00 $253.00 $105.00 $109.00 $114.00
20225 0 $215.00 $719.00 $765.00 $779.00 $158.00 $166.00 $174.00
20240 0 $279.00 $225.00 $237.00 $252.00 $225.00 $237.00 $252.00
20245 10 $364.00 $523.00 $554.00 $595.00 $523.00 $554.00 $595.00
20250 10 $447.00 $576.00 $620.00 $676.00 $576.00 $620.00 $676.00
20251 10 $511.00 $631.00 $680.00 $742.00 $631.00 $680.00 $742.00
20500 10 $59.00 $146.00 $153.00 $159.00 $120.00 $126.00 $131.00
20501 0 $60.00 $164.00 $174.00 $178.00 $56.00 $58.00 $61.00
20520 10 $75.00 $288.00 $306.00 $318.00 $211.00 $223.00 $235.00
20525 10 $331.00 $674.00 $718.00 $748.00 $362.00 $385.00 $411.00
20526 0 $64.00 $111.00 $118.00 $125.00 $85.00 $90.00 $97.00
20527 0 ---------- $121.00 $129.00 $136.00 $98.00 $104.00 $111.00
20550 0 $40.00 $75.00 $79.00 $83.00 $58.00 $61.00 $64.00
20551 0 $62.00 $86.00 $90.00 $94.00 $62.00 $65.00 $68.00
20552 0 $62.00 $78.00 $82.00 $86.00 $55.00 $58.00 $61.00
20553 0 $62.00 $90.00 $95.00 $99.00 $63.00 $66.00 $69.00
20555 0 ---------- $478.00 $502.00 $531.00 $478.00 $502.00 $531.00
20600 0 $41.00 $68.00 $72.00 $75.00 $52.00 $54.00 $57.00
20604 0 ---------- $103.00 $108.00 $113.00 $68.00 $71.00 $76.00
20605 0 $48.00 $72.00 $76.00 $79.00 $54.00 $57.00 $60.00
20606 0 ---------- $114.00 $120.00 $126.00 $78.00 $81.00 $86.00
20610 0 $49.00 $87.00 $92.00 $97.00 $68.00 $72.00 $77.00
20611 0 ---------- $130.00 $138.00 $144.00 $91.00 $96.00 $102.00
20612 0 $56.00 $86.00 $91.00 $95.00 $61.00 $64.00 $68.00
20615 10 $94.00 $341.00 $361.00 $376.00 $234.00 $248.00 $261.00
20650 10 $170.00 $297.00 $315.00 $329.00 $229.00 $242.00 $255.00
20660 0 $320.00 $376.00 $409.00 $460.00 $376.00 $409.00 $460.00
20661 90 $476.00 $746.00 $810.00 $885.00 $746.00 $810.00 $885.00
20662 90 $559.00 $621.00 $648.00 $667.00 $621.00 $648.00 $667.00
20663 90 $465.00 $658.00 $700.00 $743.00 $658.00 $700.00 $743.00
20665 10 $105.00 $150.00 $157.00 $162.00 $130.00 $136.00 $140.00
20670 10 $80.00 $527.00 $561.00 $577.00 $212.00 $225.00 $237.00
20680 90 $332.00 $879.00 $935.00 $979.00 $616.00 $654.00 $696.00
20690 90 $298.00 $874.00 $932.00 $1,001.00 $874.00 $932.00 $1,001.00
20692 90 $516.00 $1,636.00 $1,739.00 $1,855.00 $1,636.00 $1,739.00 $1,855.00
20693 90 $477.00 $645.00 $684.00 $725.00 $645.00 $684.00 $725.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 178
Surgery
CPT Code FUD 2003 MRALocality 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)
20694 90 $421.00 $606.00 $646.00 $679.00 $490.00 $522.00 $554.00
20696 90 ---------- $1,773.00 $1,889.00 $2,027.00 $1,773.00 $1,889.00 $2,027.00
20697 0 ---------- $2,870.00 $3,065.00 $3,096.00 $2,870.00 $3,065.00 $3,096.00
20802 90 $3,363.00 $4,072.00 $4,331.00 $4,646.00 $4,072.00 $4,331.00 $4,646.00
20805 90 $4,317.00 $4,622.00 $4,915.00 $5,293.00 $4,622.00 $4,915.00 $5,293.00
20808 90 $5,324.00 $5,871.00 $6,219.00 $6,628.00 $5,871.00 $6,219.00 $6,628.00
20816 90 $3,060.00 $3,093.00 $3,284.00 $3,506.00 $3,093.00 $3,284.00 $3,506.00
20822 90 $2,511.00 $2,629.00 $2,794.00 $2,985.00 $2,629.00 $2,794.00 $2,985.00
20824 90 $3,027.00 $2,869.00 $3,036.00 $3,236.00 $2,869.00 $3,036.00 $3,236.00
20827 90 $3,920.00 $2,687.00 $2,848.00 $3,026.00 $2,687.00 $2,848.00 $3,026.00
20838 90 $3,484.00 $3,941.00 $4,160.00 $4,405.00 $3,941.00 $4,160.00 $4,405.00
20900 0 $454.00 $587.00 $625.00 $650.00 $279.00 $297.00 $319.00
20902 0 $658.00 $423.00 $450.00 $485.00 $423.00 $450.00 $485.00
20910 90 $338.00 $654.00 $695.00 $734.00 $654.00 $695.00 $734.00
20912 90 $549.00 $690.00 $731.00 $772.00 $690.00 $731.00 $772.00
20920 90 $460.00 $572.00 $606.00 $640.00 $572.00 $606.00 $640.00
20922 90 $634.00 $854.00 $913.00 $974.00 $719.00 $768.00 $828.00
20924 90 $583.00 $738.00 $786.00 $837.00 $738.00 $786.00 $837.00
20926 90 $444.00 $615.00 $653.00 $694.00 $615.00 $653.00 $694.00
20930 0 BR ---------- ---------- ---------- ---------- ---------- ----------
20931 ZZZ $156.00 $174.00 $189.00 $213.00 $174.00 $189.00 $213.00
20936 0 BR ---------- ---------- ---------- ---------- ---------- ----------
20937 ZZZ $234.00 $256.00 $275.00 $304.00 $256.00 $275.00 $304.00
20938 ZZZ $257.00 $285.00 $310.00 $347.00 $285.00 $310.00 $347.00
20950 0 $123.00 $350.00 $374.00 $385.00 $133.00 $141.00 $150.00
20955 90 $3,332.00 $3,682.00 $3,900.00 $4,162.00 $3,682.00 $3,900.00 $4,162.00
20956 90 $3,167.00 $3,939.00 $4,206.00 $4,550.00 $3,939.00 $4,206.00 $4,550.00
20957 90 $3,074.00 $3,322.00 $3,472.00 $3,646.00 $3,322.00 $3,472.00 $3,646.00
20962 90 $3,122.00 $3,139.00 $3,281.00 $3,438.00 $3,139.00 $3,281.00 $3,438.00
20969 90 $3,716.00 $4,059.00 $4,294.00 $4,578.00 $4,059.00 $4,294.00 $4,578.00
20970 90 $3,650.00 $4,257.00 $4,540.00 $4,898.00 $4,257.00 $4,540.00 $4,898.00
20972 90 $3,420.00 $3,538.00 $3,709.00 $3,915.00 $3,538.00 $3,709.00 $3,915.00
20973 90 $3,821.00 $3,624.00 $3,788.00 $3,985.00 $3,624.00 $3,788.00 $3,985.00
20974 0 $266.00 $110.00 $117.00 $124.00 $74.00 $79.00 $85.00
20975 0 $334.00 $266.00 $286.00 $313.00 $266.00 $286.00 $313.00
20979 0 $19.00 $74.00 $78.00 $82.00 $48.00 $50.00 $53.00
20982 0 ---------- $2,354.00 $2,503.00 $2,553.00 $542.00 $568.00 $599.00
20983 0 ---------- $8,602.00 $9,177.00 $9,294.00 $544.00 $571.00 $605.00
20985 ZZZ ---------- $220.00 $234.00 $254.00 $220.00 $234.00 $254.00
20999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
21010 90 $854.00 $1,104.00 $1,170.00 $1,243.00 $1,104.00 $1,170.00 $1,243.00
21011 90 ---------- $494.00 $527.00 $551.00 $375.00 $399.00 $423.00
21012 90 ---------- $495.00 $528.00 $565.00 $495.00 $528.00 $565.00
21013 90 ---------- $742.00 $790.00 $831.00 $584.00 $621.00 $661.00
21014 90 ---------- $762.00 $811.00 $865.00 $762.00 $811.00 $865.00
21015 90 $520.00 $1,033.00 $1,099.00 $1,172.00 $1,033.00 $1,099.00 $1,172.00
21016 90 ---------- $1,497.00 $1,592.00 $1,704.00 $1,497.00 $1,592.00 $1,704.00
21025 90 $546.00 $1,287.00 $1,368.00 $1,439.00 $1,099.00 $1,167.00 $1,236.00
21026 90 $413.00 $885.00 $941.00 $983.00 $724.00 $770.00 $810.00
21029 90 $700.00 $1,105.00 $1,172.00 $1,228.00 $929.00 $984.00 $1,038.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 179
Surgery
CPT Code FUD 2003 MRALocality 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)
21030 90 $496.00 $745.00 $793.00 $829.00 $608.00 $646.00 $681.00
21031 90 $310.00 $566.00 $602.00 $628.00 $430.00 $457.00 $481.00
21032 90 $315.00 $572.00 $609.00 $634.00 $424.00 $451.00 $475.00
21034 90 $1,140.00 $1,910.00 $2,025.00 $2,140.00 $1,698.00 $1,799.00 $1,911.00
21040 90 $227.00 $750.00 $798.00 $834.00 $608.00 $646.00 $681.00
21044 90 $957.00 $1,278.00 $1,353.00 $1,434.00 $1,278.00 $1,353.00 $1,434.00
21045 90 $1,313.00 $1,792.00 $1,897.00 $2,013.00 $1,792.00 $1,897.00 $2,013.00
21046 90 $899.00 $1,631.00 $1,732.00 $1,832.00 $1,631.00 $1,732.00 $1,832.00
21047 90 $1,109.00 $1,932.00 $2,047.00 $2,178.00 $1,932.00 $2,047.00 $2,178.00
21048 90 $925.00 $1,674.00 $1,778.00 $1,882.00 $1,674.00 $1,778.00 $1,882.00
21049 90 $1,051.00 $1,766.00 $1,866.00 $1,980.00 $1,766.00 $1,866.00 $1,980.00
21050 90 $1,026.00 $1,213.00 $1,283.00 $1,355.00 $1,213.00 $1,283.00 $1,355.00
21060 90 $972.00 $1,168.00 $1,237.00 $1,308.00 $1,168.00 $1,237.00 $1,308.00
21070 90 $679.00 $883.00 $933.00 $984.00 $883.00 $933.00 $984.00
21073 90 ---------- $569.00 $606.00 $632.00 $375.00 $398.00 $423.00
21076 10 $1,192.00 $1,449.00 $1,538.00 $1,630.00 $1,228.00 $1,302.00 $1,391.00
21077 90 $3,002.00 $3,659.00 $3,884.00 $4,115.00 $3,111.00 $3,298.00 $3,523.00
21079 90 $2,086.00 $2,465.00 $2,619.00 $2,776.00 $2,074.00 $2,201.00 $2,354.00
21080 90 $2,346.00 $2,768.00 $2,939.00 $3,114.00 $2,310.00 $2,450.00 $2,620.00
21081 90 $2,138.00 $2,552.00 $2,711.00 $2,873.00 $2,124.00 $2,254.00 $2,411.00
21082 90 $1,855.00 $2,403.00 $2,553.00 $2,700.00 $1,978.00 $2,099.00 $2,242.00
21083 90 $1,802.00 $2,289.00 $2,433.00 $2,570.00 $1,841.00 $1,954.00 $2,087.00
21084 90 $2,105.00 $2,627.00 $2,791.00 $2,952.00 $2,134.00 $2,265.00 $2,420.00
21085 10 $801.00 $1,099.00 $1,168.00 $1,232.00 $838.00 $890.00 $951.00
21086 90 $2,333.00 $2,721.00 $2,891.00 $3,067.00 $2,305.00 $2,447.00 $2,619.00
21087 90 $2,217.00 $2,707.00 $2,874.00 $3,048.00 $2,289.00 $2,428.00 $2,598.00
21088 90 BR ---------- ---------- ---------- ---------- ---------- ----------
21089 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
21100 90 $297.00 $1,171.00 $1,245.00 $1,280.00 $584.00 $619.00 $647.00
21110 90 $371.00 $1,145.00 $1,219.00 $1,266.00 $966.00 $1,028.00 $1,074.00
21116 0 $207.00 $205.00 $218.00 $224.00 $65.00 $69.00 $73.00
21120 90 $500.00 $854.00 $908.00 $945.00 $687.00 $730.00 $765.00
21121 90 $651.00 $1,156.00 $1,229.00 $1,287.00 $976.00 $1,037.00 $1,093.00
21122 90 $700.00 $954.00 $1,009.00 $1,059.00 $954.00 $1,009.00 $1,059.00
21123 90 $903.00 $1,314.00 $1,397.00 $1,478.00 $1,314.00 $1,397.00 $1,478.00
21125 90 $656.00 $4,450.00 $4,742.00 $4,843.00 $1,074.00 $1,136.00 $1,203.00
21127 90 $909.00 $6,082.00 $6,487.00 $6,623.00 $1,303.00 $1,383.00 $1,469.00
21137 90 $797.00 $1,013.00 $1,073.00 $1,137.00 $1,013.00 $1,073.00 $1,137.00
21138 90 $960.00 $1,343.00 $1,426.00 $1,516.00 $1,343.00 $1,426.00 $1,516.00
21139 90 $1,168.00 $1,577.00 $1,672.00 $1,770.00 $1,577.00 $1,672.00 $1,770.00
21141 90 $1,438.00 $1,992.00 $2,115.00 $2,252.00 $1,992.00 $2,115.00 $2,252.00
21142 90 $1,527.00 $2,108.00 $2,239.00 $2,381.00 $2,108.00 $2,239.00 $2,381.00
21143 90 $1,511.00 $2,147.00 $2,280.00 $2,427.00 $2,147.00 $2,280.00 $2,427.00
21145 90 $1,513.00 $2,350.00 $2,494.00 $2,657.00 $2,350.00 $2,494.00 $2,657.00
21146 90 $1,570.00 $2,450.00 $2,601.00 $2,774.00 $2,450.00 $2,601.00 $2,774.00
21147 90 $1,639.00 $2,469.00 $2,615.00 $2,784.00 $2,469.00 $2,615.00 $2,784.00
21150 90 $1,914.00 $2,549.00 $2,705.00 $2,883.00 $2,549.00 $2,705.00 $2,883.00
21151 90 $2,264.00 $2,945.00 $3,123.00 $3,317.00 $2,945.00 $3,123.00 $3,317.00
21154 90 $2,364.00 $2,761.00 $2,912.00 $3,086.00 $2,761.00 $2,912.00 $3,086.00
21155 90 $2,640.00 $3,066.00 $3,233.00 $3,428.00 $3,066.00 $3,233.00 $3,428.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 180
Surgery
CPT Code FUD 2003 MRALocality 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)
21159 90 $3,302.00 $3,851.00 $4,068.00 $4,321.00 $3,851.00 $4,068.00 $4,321.00
21160 90 $3,500.00 $3,997.00 $4,213.00 $4,474.00 $3,997.00 $4,213.00 $4,474.00
21172 90 $2,111.00 $3,128.00 $3,423.00 $3,853.00 $3,128.00 $3,423.00 $3,853.00
21175 90 $2,604.00 $3,072.00 $3,230.00 $3,391.00 $3,072.00 $3,230.00 $3,391.00
21179 90 $1,826.00 $2,006.00 $2,122.00 $2,264.00 $2,006.00 $2,122.00 $2,264.00
21180 90 $2,035.00 $2,366.00 $2,531.00 $2,753.00 $2,366.00 $2,531.00 $2,753.00
21181 90 $813.00 $1,080.00 $1,147.00 $1,219.00 $1,080.00 $1,147.00 $1,219.00
21182 90 $2,570.00 $2,921.00 $3,101.00 $3,329.00 $2,921.00 $3,101.00 $3,329.00
21183 90 $2,770.00 $3,217.00 $3,357.00 $3,470.00 $3,217.00 $3,357.00 $3,470.00
21184 90 $3,150.00 $4,172.00 $4,587.00 $5,217.00 $4,172.00 $4,587.00 $5,217.00
21188 90 $1,786.00 $2,382.00 $2,526.00 $2,678.00 $2,382.00 $2,526.00 $2,678.00
21193 90 $1,331.00 $1,727.00 $1,824.00 $1,933.00 $1,727.00 $1,824.00 $1,933.00
21194 90 $1,540.00 $2,172.00 $2,306.00 $2,458.00 $2,172.00 $2,306.00 $2,458.00
21195 90 $1,360.00 $1,922.00 $2,033.00 $2,147.00 $1,922.00 $2,033.00 $2,147.00
21196 90 $1,764.00 $2,171.00 $2,302.00 $2,440.00 $2,171.00 $2,302.00 $2,440.00
21198 90 $1,268.00 $1,704.00 $1,807.00 $1,910.00 $1,704.00 $1,807.00 $1,910.00
21199 90 $1,018.00 $1,485.00 $1,569.00 $1,669.00 $1,485.00 $1,569.00 $1,669.00
21206 90 $1,112.00 $1,772.00 $1,881.00 $1,987.00 $1,772.00 $1,881.00 $1,987.00
21208 90 $946.00 $2,601.00 $2,768.00 $2,859.00 $1,227.00 $1,302.00 $1,378.00
21209 90 $576.00 $1,161.00 $1,231.00 $1,282.00 $896.00 $948.00 $996.00
21210 90 $930.00 $3,196.00 $3,406.00 $3,508.00 $1,269.00 $1,348.00 $1,431.00
21215 90 $970.00 $5,586.00 $5,957.00 $6,088.00 $1,321.00 $1,403.00 $1,489.00
21230 90 $956.00 $1,088.00 $1,153.00 $1,224.00 $1,088.00 $1,153.00 $1,224.00
21235 90 $707.00 $1,034.00 $1,097.00 $1,146.00 $820.00 $869.00 $916.00
21240 90 $1,281.00 $1,645.00 $1,746.00 $1,858.00 $1,645.00 $1,746.00 $1,858.00
21242 90 $1,207.00 $1,512.00 $1,606.00 $1,707.00 $1,512.00 $1,606.00 $1,707.00
21243 90 $1,501.00 $2,512.00 $2,668.00 $2,839.00 $2,512.00 $2,668.00 $2,839.00
21244 90 $1,062.00 $1,546.00 $1,640.00 $1,730.00 $1,546.00 $1,640.00 $1,730.00
21245 90 $1,038.00 $1,584.00 $1,679.00 $1,760.00 $1,286.00 $1,359.00 $1,438.00
21246 90 $1,010.00 $1,302.00 $1,387.00 $1,487.00 $1,302.00 $1,387.00 $1,487.00
21247 90 $2,003.00 $2,247.00 $2,376.00 $2,523.00 $2,247.00 $2,376.00 $2,523.00
21248 90 $1,023.00 $1,608.00 $1,709.00 $1,801.00 $1,331.00 $1,414.00 $1,502.00
21249 90 $1,525.00 $2,200.00 $2,338.00 $2,471.00 $1,887.00 $2,003.00 $2,134.00
21255 90 $1,459.00 $2,017.00 $2,139.00 $2,262.00 $2,017.00 $2,139.00 $2,262.00
21256 90 $1,470.00 $1,734.00 $1,818.00 $1,888.00 $1,734.00 $1,818.00 $1,888.00
21260 90 $1,372.00 $1,817.00 $1,921.00 $2,028.00 $1,817.00 $1,921.00 $2,028.00
21261 90 $2,347.00 $3,085.00 $3,255.00 $3,446.00 $3,085.00 $3,255.00 $3,446.00
21263 90 $2,361.00 $2,847.00 $3,004.00 $3,178.00 $2,847.00 $3,004.00 $3,178.00
21267 90 $1,539.00 $2,278.00 $2,398.00 $2,493.00 $2,278.00 $2,398.00 $2,493.00
21268 90 $1,946.00 $2,541.00 $2,682.00 $2,834.00 $2,541.00 $2,682.00 $2,834.00
21270 90 $890.00 $1,373.00 $1,444.00 $1,485.00 $1,043.00 $1,092.00 $1,130.00
21275 90 $963.00 $1,224.00 $1,300.00 $1,383.00 $1,224.00 $1,300.00 $1,383.00
21280 90 $571.00 $810.00 $852.00 $882.00 $810.00 $852.00 $882.00
21282 90 $360.00 $541.00 $572.00 $594.00 $541.00 $572.00 $594.00
21295 90 $144.00 $265.00 $280.00 $290.00 $265.00 $280.00 $290.00
21296 90 $384.00 $637.00 $675.00 $706.00 $637.00 $675.00 $706.00
21299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
21310 0 $81.00 $184.00 $196.00 $200.00 $40.00 $42.00 $46.00
21315 10 $180.00 $387.00 $411.00 $425.00 $218.00 $231.00 $242.00
21320 10 $235.00 $360.00 $382.00 $396.00 $195.00 $207.00 $219.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 181
Surgery
CPT Code FUD 2003 MRALocality 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)
21325 90 $348.00 $674.00 $716.00 $746.00 $674.00 $716.00 $746.00
21330 90 $639.00 $818.00 $869.00 $909.00 $818.00 $869.00 $909.00
21335 90 $852.00 $1,041.00 $1,103.00 $1,160.00 $1,041.00 $1,103.00 $1,160.00
21336 90 $478.00 $922.00 $978.00 $1,022.00 $922.00 $978.00 $1,022.00
21337 90 $300.00 $572.00 $608.00 $632.00 $424.00 $451.00 $473.00
21338 90 $550.00 $1,074.00 $1,142.00 $1,192.00 $1,074.00 $1,142.00 $1,192.00
21339 90 $689.00 $1,215.00 $1,292.00 $1,355.00 $1,215.00 $1,292.00 $1,355.00
21340 90 $907.00 $1,147.00 $1,199.00 $1,237.00 $1,147.00 $1,199.00 $1,237.00
21343 90 $1,043.00 $1,759.00 $1,871.00 $1,976.00 $1,759.00 $1,871.00 $1,976.00
21344 90 $1,450.00 $2,032.00 $2,149.00 $2,281.00 $2,032.00 $2,149.00 $2,281.00
21345 90 $738.00 $1,155.00 $1,225.00 $1,285.00 $940.00 $995.00 $1,052.00
21346 90 $917.00 $1,307.00 $1,385.00 $1,456.00 $1,307.00 $1,385.00 $1,456.00
21347 90 $1,048.00 $1,646.00 $1,749.00 $1,845.00 $1,646.00 $1,749.00 $1,845.00
21348 90 $1,286.00 $1,754.00 $1,858.00 $1,971.00 $1,754.00 $1,858.00 $1,971.00
21355 10 $295.00 $642.00 $681.00 $711.00 $484.00 $513.00 $542.00
21356 10 $372.00 $716.00 $761.00 $795.00 $548.00 $581.00 $613.00
21360 90 $590.00 $783.00 $830.00 $876.00 $783.00 $830.00 $876.00
21365 90 $1,239.00 $1,628.00 $1,724.00 $1,833.00 $1,628.00 $1,724.00 $1,833.00
21366 90 $1,386.00 $1,661.00 $1,756.00 $1,870.00 $1,661.00 $1,756.00 $1,870.00
21385 90 $810.00 $982.00 $1,038.00 $1,095.00 $982.00 $1,038.00 $1,095.00
21386 90 $812.00 $1,012.00 $1,075.00 $1,142.00 $1,012.00 $1,075.00 $1,142.00
21387 90 $958.00 $1,027.00 $1,086.00 $1,147.00 $1,027.00 $1,086.00 $1,147.00
21390 90 $920.00 $1,151.00 $1,215.00 $1,277.00 $1,151.00 $1,215.00 $1,277.00
21395 90 $1,384.00 $1,482.00 $1,577.00 $1,685.00 $1,482.00 $1,577.00 $1,685.00
21400 90 $143.00 $272.00 $289.00 $301.00 $223.00 $237.00 $248.00
21401 90 $313.00 $688.00 $732.00 $760.00 $440.00 $467.00 $493.00
21406 90 $852.00 $830.00 $882.00 $934.00 $830.00 $882.00 $934.00
21407 90 $736.00 $935.00 $989.00 $1,040.00 $935.00 $989.00 $1,040.00
21408 90 $1,007.00 $1,300.00 $1,376.00 $1,457.00 $1,300.00 $1,376.00 $1,457.00
21421 90 $528.00 $1,200.00 $1,277.00 $1,326.00 $999.00 $1,063.00 $1,110.00
21422 90 $761.00 $983.00 $1,043.00 $1,103.00 $983.00 $1,043.00 $1,103.00
21423 90 $890.00 $1,150.00 $1,219.00 $1,292.00 $1,150.00 $1,219.00 $1,292.00
21431 90 $598.00 $1,053.00 $1,115.00 $1,163.00 $1,053.00 $1,115.00 $1,163.00
21432 90 $744.00 $989.00 $1,050.00 $1,112.00 $989.00 $1,050.00 $1,112.00
21433 90 $1,981.00 $2,551.00 $2,708.00 $2,890.00 $2,551.00 $2,708.00 $2,890.00
21435 90 $1,404.00 $1,866.00 $1,979.00 $2,114.00 $1,866.00 $1,979.00 $2,114.00
21436 90 $2,045.00 $2,787.00 $2,951.00 $3,145.00 $2,787.00 $2,951.00 $3,145.00
21440 90 $308.00 $818.00 $871.00 $900.00 $669.00 $712.00 $739.00
21445 90 $533.00 $1,095.00 $1,165.00 $1,214.00 $900.00 $957.00 $1,003.00
21450 90 $325.00 $873.00 $929.00 $959.00 $704.00 $749.00 $778.00
21451 90 $498.00 $1,165.00 $1,240.00 $1,284.00 $966.00 $1,028.00 $1,070.00
21452 90 $195.00 $799.00 $851.00 $873.00 $478.00 $508.00 $526.00
21453 90 $902.00 $1,296.00 $1,379.00 $1,430.00 $1,117.00 $1,188.00 $1,237.00
21454 90 $905.00 $840.00 $892.00 $945.00 $840.00 $892.00 $945.00
21461 90 $769.00 $2,995.00 $3,192.00 $3,275.00 $1,351.00 $1,436.00 $1,502.00
21462 90 $1,012.00 $3,191.00 $3,400.00 $3,496.00 $1,511.00 $1,606.00 $1,684.00
21465 90 $923.00 $1,374.00 $1,460.00 $1,551.00 $1,374.00 $1,460.00 $1,551.00
21470 90 $1,331.00 $1,767.00 $1,875.00 $1,993.00 $1,767.00 $1,875.00 $1,993.00
21480 0 $82.00 $138.00 $147.00 $151.00 $47.00 $50.00 $53.00
21485 90 $318.00 $990.00 $1,055.00 $1,093.00 $834.00 $888.00 $925.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 182
Surgery
CPT Code FUD 2003 MRALocality 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)
21490 90 $865.00 $1,342.00 $1,425.00 $1,515.00 $1,342.00 $1,425.00 $1,515.00
21497 90 $372.00 $1,047.00 $1,114.00 $1,152.00 $875.00 $931.00 $967.00
21499 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
21501 90 $315.00 $644.00 $687.00 $720.00 $466.00 $497.00 $529.00
21502 90 $612.00 $751.00 $804.00 $871.00 $751.00 $804.00 $871.00
21510 90 $534.00 $659.00 $706.00 $764.00 $659.00 $706.00 $764.00
21550 10 $165.00 $371.00 $394.00 $409.00 $229.00 $242.00 $256.00
21552 90 ---------- $659.00 $706.00 $764.00 $659.00 $706.00 $764.00
21554 90 ---------- $1,081.00 $1,155.00 $1,249.00 $1,081.00 $1,155.00 $1,249.00
21555 90 $337.00 $593.00 $633.00 $668.00 $447.00 $477.00 $510.00
21556 90 $431.00 $776.00 $826.00 $886.00 $776.00 $826.00 $886.00
21557 90 $794.00 $1,415.00 $1,509.00 $1,626.00 $1,415.00 $1,509.00 $1,626.00
21558 90 ---------- $1,996.00 $2,131.00 $2,308.00 $1,996.00 $2,131.00 $2,308.00
21600 90 $631.00 $814.00 $870.00 $934.00 $814.00 $870.00 $934.00
21610 90 $828.00 $1,790.00 $1,954.00 $2,190.00 $1,790.00 $1,954.00 $2,190.00
21615 90 $938.00 $933.00 $1,000.00 $1,095.00 $933.00 $1,000.00 $1,095.00
21616 90 $1,042.00 $1,130.00 $1,212.00 $1,330.00 $1,130.00 $1,212.00 $1,330.00
21620 90 $689.00 $744.00 $796.00 $860.00 $744.00 $796.00 $860.00
21627 90 $686.00 $793.00 $848.00 $913.00 $793.00 $848.00 $913.00
21630 90 $1,455.00 $1,798.00 $1,918.00 $2,073.00 $1,798.00 $1,918.00 $2,073.00
21632 90 $1,514.00 $1,779.00 $1,901.00 $2,066.00 $1,779.00 $1,901.00 $2,066.00
21685 90 ---------- $1,449.00 $1,532.00 $1,623.00 $1,449.00 $1,532.00 $1,623.00
21700 90 $576.00 $552.00 $591.00 $645.00 $552.00 $591.00 $645.00
21705 90 $746.00 $832.00 $892.00 $984.00 $832.00 $892.00 $984.00
21720 90 $523.00 $738.00 $802.00 $884.00 $738.00 $802.00 $884.00
21725 90 $588.00 $790.00 $843.00 $904.00 $790.00 $843.00 $904.00
21740 90 $1,387.00 $1,544.00 $1,657.00 $1,821.00 $1,544.00 $1,657.00 $1,821.00
21742 90 BR ---------- ---------- ---------- ---------- ---------- ----------
21743 90 BR ---------- ---------- ---------- ---------- ---------- ----------
21750 90 $1,009.00 $1,023.00 $1,096.00 $1,200.00 $1,023.00 $1,096.00 $1,200.00
21811 0 ---------- $913.00 $977.00 $1,070.00 $913.00 $977.00 $1,070.00
21812 0 ---------- $1,097.00 $1,175.00 $1,290.00 $1,097.00 $1,175.00 $1,290.00
21813 0 ---------- $1,441.00 $1,537.00 $1,679.00 $1,441.00 $1,537.00 $1,679.00
21820 90 $143.00 $200.00 $213.00 $223.00 $205.00 $218.00 $228.00
21825 90 $810.00 $797.00 $854.00 $925.00 $797.00 $854.00 $925.00
21899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
21920 10 $165.00 $363.00 $386.00 $401.00 $232.00 $246.00 $260.00
21925 90 $371.00 $646.00 $691.00 $733.00 $522.00 $559.00 $599.00
21930 90 $403.00 $680.00 $726.00 $770.00 $535.00 $572.00 $614.00
21931 90 ---------- $696.00 $746.00 $809.00 $696.00 $746.00 $809.00
21932 90 ---------- $981.00 $1,051.00 $1,141.00 $981.00 $1,051.00 $1,141.00
21933 90 ---------- $1,095.00 $1,173.00 $1,274.00 $1,095.00 $1,173.00 $1,274.00
21935 90 $1,280.00 $1,527.00 $1,633.00 $1,770.00 $1,527.00 $1,633.00 $1,770.00
21936 90 ---------- $2,104.00 $2,252.00 $2,450.00 $2,104.00 $2,252.00 $2,450.00
22010 90 ---------- $1,421.00 $1,533.00 $1,679.00 $1,421.00 $1,533.00 $1,679.00
22015 90 ---------- $1,398.00 $1,507.00 $1,648.00 $1,398.00 $1,507.00 $1,648.00
22100 90 $850.00 $1,387.00 $1,515.00 $1,690.00 $1,387.00 $1,515.00 $1,690.00
22101 90 $862.00 $1,264.00 $1,362.00 $1,486.00 $1,264.00 $1,362.00 $1,486.00
22102 90 $781.00 $1,150.00 $1,227.00 $1,319.00 $1,150.00 $1,227.00 $1,319.00
22103 ZZZ $198.00 $213.00 $229.00 $253.00 $213.00 $229.00 $253.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 183
Surgery
CPT Code FUD 2003 MRALocality 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)
22110 90 $889.00 $1,566.00 $1,695.00 $1,868.00 $1,566.00 $1,695.00 $1,868.00
22112 90 $1,090.00 $1,668.00 $1,823.00 $2,038.00 $1,668.00 $1,823.00 $2,038.00
22114 90 $1,062.00 $1,462.00 $1,563.00 $1,687.00 $1,462.00 $1,563.00 $1,687.00
22116 ZZZ $195.00 $216.00 $234.00 $261.00 $216.00 $234.00 $261.00
22206 90 ---------- $3,705.00 $4,005.00 $4,431.00 $3,705.00 $4,005.00 $4,431.00
22207 90 ---------- $3,625.00 $3,911.00 $4,311.00 $3,625.00 $3,911.00 $4,311.00
22208 ZZZ ---------- $889.00 $960.00 $1,065.00 $889.00 $960.00 $1,065.00
22210 90 $1,892.00 $2,697.00 $2,920.00 $3,228.00 $2,697.00 $2,920.00 $3,228.00
22212 90 $1,668.00 $2,222.00 $2,393.00 $2,618.00 $2,222.00 $2,393.00 $2,618.00
22214 90 $819.00 $2,227.00 $2,400.00 $2,626.00 $2,227.00 $2,400.00 $2,626.00
22216 ZZZ $492.00 $555.00 $599.00 $663.00 $555.00 $599.00 $663.00
22220 90 $1,801.00 $2,400.00 $2,589.00 $2,844.00 $2,400.00 $2,589.00 $2,844.00
22222 90 $1,604.00 $2,222.00 $2,366.00 $2,544.00 $2,222.00 $2,366.00 $2,544.00
22224 90 $1,731.00 $2,361.00 $2,535.00 $2,762.00 $2,361.00 $2,535.00 $2,762.00
22226 ZZZ $488.00 $552.00 $595.00 $659.00 $552.00 $595.00 $659.00
22310 90 $272.00 $448.00 $478.00 $512.00 $415.00 $443.00 $476.00
22315 90 $711.00 $1,291.00 $1,386.00 $1,491.00 $1,140.00 $1,225.00 $1,328.00
22318 90 $1,755.00 $2,510.00 $2,744.00 $3,085.00 $2,510.00 $2,744.00 $3,085.00
22319 90 $1,983.00 $2,810.00 $3,082.00 $3,484.00 $2,810.00 $3,082.00 $3,484.00
22325 90 $1,407.00 $2,164.00 $2,342.00 $2,582.00 $2,164.00 $2,342.00 $2,582.00
22326 90 $1,710.00 $2,260.00 $2,456.00 $2,732.00 $2,260.00 $2,456.00 $2,732.00
22327 90 $1,660.00 $2,264.00 $2,455.00 $2,715.00 $2,264.00 $2,455.00 $2,715.00
22328 ZZZ $391.00 $435.00 $473.00 $531.00 $435.00 $473.00 $531.00
22505 10 $174.00 $195.00 $208.00 $224.00 $195.00 $208.00 $224.00
22510 10 ---------- $2,330.00 $2,477.00 $2,532.00 $642.00 $674.00 $712.00
22511 10 ---------- $2,307.00 $2,453.00 $2,507.00 $602.00 $633.00 $669.00
22512 ZZZ ---------- $1,325.00 $1,412.00 $1,445.00 $312.00 $329.00 $352.00
22513 10 ---------- $9,834.00 $10,500.00 $10,661.00 $776.00 $827.00 $893.00
22514 10 ---------- $9,773.00 $10,435.00 $10,590.00 $722.00 $768.00 $829.00
22515 ZZZ ---------- $5,960.00 $6,365.00 $6,457.00 $339.00 $362.00 $394.00
22526 10 ---------- $3,179.00 $3,388.00 $3,449.00 $495.00 $522.00 $554.00
22527 ZZZ ---------- $2,675.00 $2,853.00 $2,895.00 $236.00 $248.00 $264.00
22532 90 ---------- $2,682.00 $2,902.00 $3,206.00 $2,682.00 $2,902.00 $3,206.00
22533 90 ---------- $2,482.00 $2,665.00 $2,907.00 $2,482.00 $2,665.00 $2,907.00
22534 ZZZ ---------- $551.00 $595.00 $660.00 $551.00 $595.00 $660.00
22548 90 $2,271.00 $2,997.00 $3,285.00 $3,710.00 $2,997.00 $3,285.00 $3,710.00
22551 90 ---------- $2,605.00 $2,830.00 $3,152.00 $2,605.00 $2,830.00 $3,152.00
22552 ZZZ ---------- $615.00 $669.00 $751.00 $615.00 $669.00 $751.00
22554 90 $1,727.00 $1,895.00 $2,053.00 $2,271.00 $1,895.00 $2,053.00 $2,271.00
22556 90 $2,054.00 $2,523.00 $2,729.00 $3,017.00 $2,523.00 $2,729.00 $3,017.00
22558 90 $1,907.00 $2,312.00 $2,488.00 $2,729.00 $2,312.00 $2,488.00 $2,729.00
22585 ZZZ $473.00 $503.00 $544.00 $604.00 $503.00 $544.00 $604.00
22586 90 ---------- $2,888.00 $3,127.00 $3,465.00 $2,888.00 $3,127.00 $3,465.00
22590 90 $1,895.00 $2,407.00 $2,623.00 $2,930.00 $2,407.00 $2,623.00 $2,930.00
22595 90 $1,960.00 $2,294.00 $2,499.00 $2,789.00 $2,294.00 $2,499.00 $2,789.00
22600 90 $1,567.00 $1,951.00 $2,119.00 $2,350.00 $1,951.00 $2,119.00 $2,350.00
22610 90 $1,494.00 $1,902.00 $2,060.00 $2,272.00 $1,902.00 $2,060.00 $2,272.00
22612 90 $1,861.00 $2,391.00 $2,579.00 $2,836.00 $2,391.00 $2,579.00 $2,836.00
22614 ZZZ $530.00 $602.00 $653.00 $729.00 $602.00 $653.00 $729.00
22630 90 $1,201.00 $2,388.00 $2,597.00 $2,892.00 $2,388.00 $2,597.00 $2,892.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 184
Surgery
CPT Code FUD 2003 MRALocality 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)
22632 ZZZ $442.00 $497.00 $541.00 $609.00 $497.00 $541.00 $609.00
22633 90 ---------- $2,809.00 $3,039.00 $3,364.00 $2,809.00 $3,039.00 $3,364.00
22634 ZZZ ---------- $764.00 $828.00 $925.00 $764.00 $828.00 $925.00
22800 90 $1,960.00 $2,022.00 $2,176.00 $2,378.00 $2,022.00 $2,176.00 $2,378.00
22802 90 $2,633.00 $3,155.00 $3,393.00 $3,715.00 $3,155.00 $3,393.00 $3,715.00
22804 90 $2,951.00 $3,654.00 $3,932.00 $4,314.00 $3,654.00 $3,932.00 $4,314.00
22808 90 $2,157.00 $2,795.00 $3,022.00 $3,341.00 $2,795.00 $3,022.00 $3,341.00
22810 90 $2,356.00 $3,097.00 $3,343.00 $3,690.00 $3,097.00 $3,343.00 $3,690.00
22812 90 $2,675.00 $3,258.00 $3,471.00 $3,738.00 $3,258.00 $3,471.00 $3,738.00
22818 90 $2,701.00 $3,279.00 $3,512.00 $3,823.00 $3,279.00 $3,512.00 $3,823.00
22819 90 $2,968.00 $4,187.00 $4,582.00 $5,171.00 $4,187.00 $4,582.00 $5,171.00
22830 90 $1,176.00 $1,217.00 $1,313.00 $1,438.00 $1,217.00 $1,313.00 $1,438.00
22840 ZZZ $943.00 $1,167.00 $1,265.00 $1,410.00 $1,167.00 $1,265.00 $1,410.00
22841 0 BR ---------- ---------- ---------- ---------- ---------- ----------
22842 ZZZ $2,352.00 $1,172.00 $1,270.00 $1,417.00 $1,172.00 $1,270.00 $1,417.00
22843 ZZZ $1,028.00 $1,254.00 $1,358.00 $1,514.00 $1,254.00 $1,358.00 $1,514.00
22844 ZZZ $1,277.00 $1,506.00 $1,624.00 $1,798.00 $1,506.00 $1,624.00 $1,798.00
22845 ZZZ $1,853.00 $1,127.00 $1,225.00 $1,374.00 $1,127.00 $1,225.00 $1,374.00
22846 ZZZ $999.00 $1,170.00 $1,271.00 $1,425.00 $1,170.00 $1,271.00 $1,425.00
22847 ZZZ $1,077.00 $1,272.00 $1,374.00 $1,525.00 $1,272.00 $1,374.00 $1,525.00
22848 ZZZ $529.00 $549.00 $592.00 $654.00 $549.00 $592.00 $654.00
22849 90 $2,235.00 $1,959.00 $2,115.00 $2,330.00 $1,959.00 $2,115.00 $2,330.00
22850 90 $872.00 $1,083.00 $1,169.00 $1,281.00 $1,083.00 $1,169.00 $1,281.00
22852 90 $854.00 $1,035.00 $1,116.00 $1,221.00 $1,035.00 $1,116.00 $1,221.00
22853 ZZZ ---------- $402.00 $438.00 $491.00 $402.00 $438.00 $491.00
22854 ZZZ ---------- $521.00 $567.00 $636.00 $521.00 $567.00 $636.00
22855 90 $1,193.00 $1,673.00 $1,811.00 $2,002.00 $1,673.00 $1,811.00 $2,002.00
22856 90 ---------- $2,482.00 $2,690.00 $2,984.00 $2,482.00 $2,690.00 $2,984.00
22857 90 ---------- $2,637.00 $2,815.00 $3,039.00 $2,637.00 $2,815.00 $3,039.00
22858 ZZZ ---------- $766.00 $829.00 $922.00 $766.00 $829.00 $922.00
22859 ZZZ ---------- $521.00 $567.00 $636.00 $521.00 $567.00 $636.00
22861 90 ---------- $2,966.00 $3,187.00 $3,507.00 $2,966.00 $3,187.00 $3,507.00
22862 90 ---------- $3,182.00 $3,411.00 $3,713.00 $3,182.00 $3,411.00 $3,713.00
22864 90 ---------- $3,184.00 $3,488.00 $3,941.00 $3,184.00 $3,488.00 $3,941.00
22865 90 ---------- $3,065.00 $3,303.00 $3,636.00 $3,065.00 $3,303.00 $3,636.00
22867 90 ---------- $1,483.00 $1,608.00 $1,779.00 $1,483.00 $1,608.00 $1,779.00
22868 ZZZ ---------- $375.00 $407.00 $455.00 $375.00 $407.00 $455.00
22869 90 ---------- $807.00 $870.00 $950.00 $807.00 $870.00 $950.00
22870 ZZZ ---------- $218.00 $236.00 $264.00 $218.00 $236.00 $264.00
22899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
22900 90 $446.00 $836.00 $895.00 $971.00 $836.00 $895.00 $971.00
22901 90 ---------- $990.00 $1,061.00 $1,153.00 $990.00 $1,061.00 $1,153.00
22902 90 ---------- $631.00 $675.00 $717.00 $486.00 $520.00 $561.00
22903 90 ---------- $650.00 $697.00 $757.00 $650.00 $697.00 $757.00
22904 90 ---------- $1,564.00 $1,674.00 $1,821.00 $1,564.00 $1,674.00 $1,821.00
22905 90 ---------- $1,987.00 $2,126.00 $2,317.00 $1,987.00 $2,126.00 $2,317.00
22999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
23000 90 $447.00 $822.00 $877.00 $916.00 $535.00 $571.00 $607.00
23020 90 $807.00 $1,007.00 $1,073.00 $1,149.00 $1,007.00 $1,073.00 $1,149.00
23030 10 $323.00 $628.00 $670.00 $702.00 $375.00 $400.00 $429.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 185
Surgery
CPT Code FUD 2003 MRALocality 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)
23031 10 $185.00 $600.00 $640.00 $666.00 $319.00 $341.00 $364.00
23035 90 $861.00 $992.00 $1,058.00 $1,132.00 $992.00 $1,058.00 $1,132.00
23040 90 $898.00 $1,048.00 $1,117.00 $1,196.00 $1,048.00 $1,117.00 $1,196.00
23044 90 $708.00 $829.00 $885.00 $949.00 $829.00 $885.00 $949.00
23065 10 $171.00 $310.00 $329.00 $345.00 $244.00 $259.00 $274.00
23066 90 $302.00 $791.00 $845.00 $885.00 $519.00 $555.00 $592.00
23071 90 ---------- $619.00 $663.00 $717.00 $619.00 $663.00 $717.00
23073 90 ---------- $1,025.00 $1,097.00 $1,185.00 $1,025.00 $1,097.00 $1,185.00
23075 90 $247.00 $670.00 $716.00 $755.00 $478.00 $510.00 $548.00
23076 90 $613.00 $793.00 $848.00 $914.00 $793.00 $848.00 $914.00
23077 90 $1,228.00 $1,697.00 $1,815.00 $1,970.00 $1,697.00 $1,815.00 $1,970.00
23078 90 ---------- $2,131.00 $2,277.00 $2,470.00 $2,131.00 $2,277.00 $2,470.00
23100 90 $616.00 $726.00 $775.00 $828.00 $726.00 $775.00 $828.00
23101 90 $583.00 $651.00 $695.00 $743.00 $651.00 $695.00 $743.00
23105 90 $814.00 $928.00 $988.00 $1,056.00 $928.00 $988.00 $1,056.00
23106 90 $581.00 $700.00 $748.00 $799.00 $700.00 $748.00 $799.00
23107 90 $851.00 $965.00 $1,029.00 $1,100.00 $965.00 $1,029.00 $1,100.00
23120 90 $645.00 $849.00 $906.00 $966.00 $849.00 $906.00 $966.00
23125 90 $865.00 $1,017.00 $1,086.00 $1,167.00 $1,017.00 $1,086.00 $1,167.00
23130 90 $722.00 $888.00 $947.00 $1,013.00 $888.00 $947.00 $1,013.00
23140 90 $597.00 $787.00 $841.00 $902.00 $787.00 $841.00 $902.00
23145 90 $889.00 $1,004.00 $1,072.00 $1,152.00 $1,004.00 $1,072.00 $1,152.00
23146 90 $704.00 $895.00 $953.00 $1,016.00 $895.00 $953.00 $1,016.00
23150 90 $755.00 $960.00 $1,023.00 $1,093.00 $960.00 $1,023.00 $1,093.00
23155 90 $945.00 $1,154.00 $1,230.00 $1,317.00 $1,154.00 $1,230.00 $1,317.00
23156 90 $794.00 $978.00 $1,043.00 $1,118.00 $978.00 $1,043.00 $1,118.00
23170 90 $645.00 $817.00 $872.00 $934.00 $817.00 $872.00 $934.00
23172 90 $638.00 $808.00 $862.00 $922.00 $808.00 $862.00 $922.00
23174 90 $882.00 $1,108.00 $1,183.00 $1,267.00 $1,108.00 $1,183.00 $1,267.00
23180 90 $566.00 $968.00 $1,034.00 $1,111.00 $968.00 $1,034.00 $1,111.00
23182 90 $865.00 $959.00 $1,023.00 $1,093.00 $959.00 $1,023.00 $1,093.00
23184 90 $962.00 $1,069.00 $1,140.00 $1,220.00 $1,069.00 $1,140.00 $1,220.00
23190 90 $656.00 $834.00 $890.00 $954.00 $834.00 $890.00 $954.00
23195 90 $902.00 $1,106.00 $1,181.00 $1,267.00 $1,106.00 $1,181.00 $1,267.00
23200 90 $1,095.00 $2,228.00 $2,376.00 $2,559.00 $2,228.00 $2,376.00 $2,559.00
23210 90 $1,095.00 $2,614.00 $2,790.00 $3,014.00 $2,614.00 $2,790.00 $3,014.00
23220 90 $1,307.00 $2,878.00 $3,069.00 $3,310.00 $2,878.00 $3,069.00 $3,310.00
23330 10 $59.00 $349.00 $372.00 $388.00 $223.00 $238.00 $252.00
23333 90 ---------- $656.00 $697.00 $741.00 $656.00 $697.00 $741.00
23334 90 ---------- $1,583.00 $1,689.00 $1,816.00 $1,583.00 $1,689.00 $1,816.00
23335 90 ---------- $1,887.00 $2,012.00 $2,166.00 $1,887.00 $2,012.00 $2,166.00
23350 0 $74.00 $182.00 $192.00 $197.00 $75.00 $78.00 $81.00
23395 90 $1,366.00 $1,881.00 $2,004.00 $2,150.00 $1,881.00 $2,004.00 $2,150.00
23397 90 $1,403.00 $1,681.00 $1,794.00 $1,932.00 $1,681.00 $1,794.00 $1,932.00
23400 90 $1,196.00 $1,385.00 $1,475.00 $1,583.00 $1,385.00 $1,475.00 $1,583.00
23405 90 $799.00 $909.00 $968.00 $1,036.00 $909.00 $968.00 $1,036.00
23406 90 $977.00 $1,125.00 $1,198.00 $1,282.00 $1,125.00 $1,198.00 $1,282.00
23410 90 $1,119.00 $1,203.00 $1,282.00 $1,374.00 $1,203.00 $1,282.00 $1,374.00
23412 90 $1,229.00 $1,247.00 $1,329.00 $1,424.00 $1,247.00 $1,329.00 $1,424.00
23415 90 $622.00 $1,019.00 $1,087.00 $1,165.00 $1,019.00 $1,087.00 $1,165.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 186
Surgery
CPT Code FUD 2003 MRALocality 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)
23420 90 $1,276.00 $1,419.00 $1,514.00 $1,623.00 $1,419.00 $1,514.00 $1,623.00
23430 90 $884.00 $1,088.00 $1,160.00 $1,241.00 $1,088.00 $1,160.00 $1,241.00
23440 90 $906.00 $1,104.00 $1,177.00 $1,261.00 $1,104.00 $1,177.00 $1,261.00
23450 90 $1,210.00 $1,396.00 $1,490.00 $1,604.00 $1,396.00 $1,490.00 $1,604.00
23455 90 $1,340.00 $1,462.00 $1,557.00 $1,672.00 $1,462.00 $1,557.00 $1,672.00
23460 90 $1,364.00 $1,598.00 $1,704.00 $1,832.00 $1,598.00 $1,704.00 $1,832.00
23462 90 $1,383.00 $1,552.00 $1,654.00 $1,778.00 $1,552.00 $1,654.00 $1,778.00
23465 90 $1,398.00 $1,632.00 $1,739.00 $1,866.00 $1,632.00 $1,739.00 $1,866.00
23466 90 $1,332.00 $1,640.00 $1,748.00 $1,874.00 $1,640.00 $1,748.00 $1,874.00
23470 90 $1,540.00 $1,768.00 $1,884.00 $2,025.00 $1,768.00 $1,884.00 $2,025.00
23472 90 $1,570.00 $2,147.00 $2,287.00 $2,459.00 $2,147.00 $2,287.00 $2,459.00
23473 90 ---------- $2,399.00 $2,556.00 $2,751.00 $2,399.00 $2,556.00 $2,751.00
23474 90 ---------- $2,593.00 $2,762.00 $2,974.00 $2,593.00 $2,762.00 $2,974.00
23480 90 $926.00 $1,203.00 $1,284.00 $1,380.00 $1,203.00 $1,284.00 $1,380.00
23485 90 $1,181.00 $1,398.00 $1,490.00 $1,599.00 $1,398.00 $1,490.00 $1,599.00
23490 90 $1,038.00 $1,235.00 $1,319.00 $1,423.00 $1,235.00 $1,319.00 $1,423.00
23491 90 $1,251.00 $1,485.00 $1,584.00 $1,702.00 $1,485.00 $1,584.00 $1,702.00
23500 90 $148.00 $310.00 $330.00 $347.00 $315.00 $335.00 $352.00
23505 90 $293.00 $501.00 $534.00 $564.00 $475.00 $506.00 $536.00
23515 90 $688.00 $1,052.00 $1,121.00 $1,200.00 $1,052.00 $1,121.00 $1,200.00
23520 90 $205.00 $326.00 $348.00 $368.00 $331.00 $353.00 $373.00
23525 90 $320.00 $531.00 $566.00 $596.00 $494.00 $526.00 $555.00
23530 90 $659.00 $833.00 $889.00 $953.00 $833.00 $889.00 $953.00
23532 90 $713.00 $902.00 $961.00 $1,025.00 $902.00 $961.00 $1,025.00
23540 90 $148.00 $319.00 $339.00 $356.00 $323.00 $344.00 $361.00
23545 90 $148.00 $478.00 $507.00 $531.00 $437.00 $464.00 $487.00
23550 90 $701.00 $815.00 $868.00 $925.00 $815.00 $868.00 $925.00
23552 90 $753.00 $955.00 $1,018.00 $1,089.00 $955.00 $1,018.00 $1,089.00
23570 90 $88.00 $331.00 $352.00 $371.00 $341.00 $363.00 $382.00
23575 90 $306.00 $571.00 $609.00 $645.00 $537.00 $573.00 $609.00
23585 90 $809.00 $1,438.00 $1,533.00 $1,646.00 $1,438.00 $1,533.00 $1,646.00
23600 90 $318.00 $463.00 $494.00 $518.00 $438.00 $466.00 $491.00
23605 90 $511.00 $663.00 $706.00 $747.00 $610.00 $650.00 $690.00
23615 90 $900.00 $1,294.00 $1,380.00 $1,478.00 $1,294.00 $1,380.00 $1,478.00
23616 90 $1,895.00 $1,827.00 $1,948.00 $2,094.00 $1,827.00 $1,948.00 $2,094.00
23620 90 $286.00 $382.00 $407.00 $428.00 $365.00 $389.00 $409.00
23625 90 $422.00 $540.00 $575.00 $608.00 $504.00 $537.00 $569.00
23630 90 $712.00 $1,138.00 $1,213.00 $1,297.00 $1,138.00 $1,213.00 $1,297.00
23650 90 $296.00 $447.00 $474.00 $497.00 $412.00 $437.00 $460.00
23655 90 $374.00 $579.00 $617.00 $655.00 $579.00 $617.00 $655.00
23660 90 $712.00 $847.00 $903.00 $964.00 $847.00 $903.00 $964.00
23665 90 $440.00 $609.00 $649.00 $687.00 $569.00 $607.00 $644.00
23670 90 $759.00 $1,281.00 $1,365.00 $1,462.00 $1,281.00 $1,365.00 $1,462.00
23675 90 $550.00 $788.00 $840.00 $890.00 $723.00 $770.00 $819.00
23680 90 $1,064.00 $1,357.00 $1,447.00 $1,552.00 $1,357.00 $1,447.00 $1,552.00
23700 10 $237.00 $286.00 $305.00 $326.00 $286.00 $305.00 $326.00
23800 90 $1,346.00 $1,493.00 $1,591.00 $1,709.00 $1,493.00 $1,591.00 $1,709.00
23802 90 $1,368.00 $1,877.00 $2,001.00 $2,147.00 $1,877.00 $2,001.00 $2,147.00
23900 90 $1,561.00 $2,049.00 $2,186.00 $2,357.00 $2,049.00 $2,186.00 $2,357.00
23920 90 $1,300.00 $1,623.00 $1,731.00 $1,863.00 $1,623.00 $1,731.00 $1,863.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 187
Surgery
CPT Code FUD 2003 MRALocality 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)
23921 90 $497.00 $674.00 $718.00 $762.00 $674.00 $718.00 $762.00
23929 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
23930 10 $71.00 $505.00 $539.00 $567.00 $317.00 $339.00 $365.00
23931 10 $62.00 $403.00 $429.00 $445.00 $230.00 $245.00 $259.00
23935 90 $630.00 $734.00 $783.00 $833.00 $734.00 $783.00 $833.00
24000 90 $550.00 $694.00 $740.00 $788.00 $694.00 $740.00 $788.00
24006 90 $793.00 $1,038.00 $1,106.00 $1,182.00 $1,038.00 $1,106.00 $1,182.00
24065 10 $166.00 $362.00 $385.00 $401.00 $243.00 $258.00 $272.00
24066 90 $461.00 $890.00 $952.00 $1,003.00 $608.00 $650.00 $698.00
24071 90 ---------- $598.00 $640.00 $691.00 $598.00 $640.00 $691.00
24073 90 ---------- $1,022.00 $1,093.00 $1,181.00 $1,022.00 $1,093.00 $1,181.00
24075 90 $349.00 $699.00 $747.00 $786.00 $482.00 $515.00 $552.00
24076 90 $529.00 $796.00 $850.00 $913.00 $796.00 $850.00 $913.00
24077 90 $1,058.00 $1,534.00 $1,641.00 $1,777.00 $1,534.00 $1,641.00 $1,777.00
24079 90 ---------- $1,970.00 $2,106.00 $2,281.00 $1,970.00 $2,106.00 $2,281.00
24100 90 $467.00 $600.00 $639.00 $678.00 $600.00 $639.00 $678.00
24101 90 $591.00 $723.00 $770.00 $821.00 $723.00 $770.00 $821.00
24102 90 $755.00 $898.00 $956.00 $1,021.00 $898.00 $956.00 $1,021.00
24105 90 $360.00 $504.00 $538.00 $570.00 $504.00 $538.00 $570.00
24110 90 $724.00 $848.00 $905.00 $968.00 $848.00 $905.00 $968.00
24115 90 $898.00 $1,055.00 $1,121.00 $1,191.00 $1,055.00 $1,121.00 $1,191.00
24116 90 $1,037.00 $1,267.00 $1,352.00 $1,454.00 $1,267.00 $1,352.00 $1,454.00
24120 90 $595.00 $768.00 $818.00 $872.00 $768.00 $818.00 $872.00
24125 90 $663.00 $891.00 $947.00 $1,005.00 $891.00 $947.00 $1,005.00
24126 90 $731.00 $936.00 $997.00 $1,062.00 $936.00 $997.00 $1,062.00
24130 90 $595.00 $737.00 $786.00 $838.00 $737.00 $786.00 $838.00
24134 90 $966.00 $1,094.00 $1,168.00 $1,253.00 $1,094.00 $1,168.00 $1,253.00
24136 90 $720.00 $866.00 $921.00 $983.00 $866.00 $921.00 $983.00
24138 90 $697.00 $980.00 $1,045.00 $1,116.00 $980.00 $1,045.00 $1,116.00
24140 90 $963.00 $1,027.00 $1,095.00 $1,172.00 $1,027.00 $1,095.00 $1,172.00
24145 90 $592.00 $853.00 $910.00 $974.00 $853.00 $910.00 $974.00
24147 90 $703.00 $905.00 $966.00 $1,030.00 $905.00 $966.00 $1,030.00
24149 90 $1,224.00 $1,716.00 $1,828.00 $1,953.00 $1,716.00 $1,828.00 $1,953.00
24150 90 $1,265.00 $2,302.00 $2,457.00 $2,651.00 $2,302.00 $2,457.00 $2,651.00
24152 90 $829.00 $1,960.00 $2,081.00 $2,221.00 $1,960.00 $2,081.00 $2,221.00
24155 90 $1,019.00 $1,254.00 $1,338.00 $1,439.00 $1,254.00 $1,338.00 $1,439.00
24160 90 $533.00 $1,862.00 $1,984.00 $2,131.00 $1,862.00 $1,984.00 $2,131.00
24164 90 $564.00 $1,069.00 $1,142.00 $1,225.00 $1,069.00 $1,142.00 $1,225.00
24200 10 $58.00 $292.00 $311.00 $324.00 $202.00 $214.00 $226.00
24201 90 $444.00 $780.00 $833.00 $876.00 $529.00 $565.00 $605.00
24220 0 $89.00 $222.00 $235.00 $241.00 $100.00 $105.00 $110.00
24300 90 $352.00 $595.00 $634.00 $668.00 $595.00 $634.00 $668.00
24301 90 $869.00 $1,095.00 $1,166.00 $1,247.00 $1,095.00 $1,166.00 $1,247.00
24305 90 $579.00 $836.00 $889.00 $945.00 $836.00 $889.00 $945.00
24310 90 $511.00 $679.00 $721.00 $766.00 $679.00 $721.00 $766.00
24320 90 $944.00 $1,118.00 $1,191.00 $1,277.00 $1,118.00 $1,191.00 $1,277.00
24330 90 $845.00 $1,047.00 $1,117.00 $1,196.00 $1,047.00 $1,117.00 $1,196.00
24331 90 $927.00 $1,128.00 $1,196.00 $1,267.00 $1,128.00 $1,196.00 $1,267.00
24332 90 $487.00 $893.00 $953.00 $1,020.00 $893.00 $953.00 $1,020.00
24340 90 $697.00 $892.00 $951.00 $1,015.00 $892.00 $951.00 $1,015.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 188
Surgery
CPT Code FUD 2003 MRALocality 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)
24341 90 $702.00 $1,085.00 $1,156.00 $1,233.00 $1,085.00 $1,156.00 $1,233.00
24342 90 $950.00 $1,133.00 $1,207.00 $1,292.00 $1,133.00 $1,207.00 $1,292.00
24343 90 $643.00 $1,028.00 $1,095.00 $1,168.00 $1,028.00 $1,095.00 $1,168.00
24344 90 $971.00 $1,598.00 $1,705.00 $1,828.00 $1,598.00 $1,705.00 $1,828.00
24345 90 $643.00 $1,023.00 $1,090.00 $1,162.00 $1,023.00 $1,090.00 $1,162.00
24346 90 $971.00 $1,609.00 $1,718.00 $1,844.00 $1,609.00 $1,718.00 $1,844.00
24357 90 ---------- $608.00 $645.00 $680.00 $608.00 $645.00 $680.00
24358 90 ---------- $758.00 $807.00 $858.00 $758.00 $807.00 $858.00
24359 90 ---------- $961.00 $1,023.00 $1,092.00 $961.00 $1,023.00 $1,092.00
24360 90 $1,125.00 $1,320.00 $1,409.00 $1,514.00 $1,320.00 $1,409.00 $1,514.00
24361 90 $1,215.00 $1,471.00 $1,568.00 $1,684.00 $1,471.00 $1,568.00 $1,684.00
24362 90 $1,269.00 $1,556.00 $1,659.00 $1,780.00 $1,556.00 $1,659.00 $1,780.00
24363 90 $1,663.00 $2,143.00 $2,282.00 $2,451.00 $2,143.00 $2,282.00 $2,451.00
24365 90 $747.00 $933.00 $995.00 $1,066.00 $933.00 $995.00 $1,066.00
24366 90 $850.00 $993.00 $1,058.00 $1,132.00 $993.00 $1,058.00 $1,132.00
24370 90 ---------- $2,285.00 $2,433.00 $2,614.00 $2,285.00 $2,433.00 $2,614.00
24371 90 ---------- $2,631.00 $2,801.00 $3,012.00 $2,631.00 $2,801.00 $3,012.00
24400 90 $991.00 $1,197.00 $1,276.00 $1,366.00 $1,197.00 $1,276.00 $1,366.00
24410 90 $1,319.00 $1,555.00 $1,660.00 $1,786.00 $1,555.00 $1,660.00 $1,786.00
24420 90 $1,265.00 $1,441.00 $1,534.00 $1,641.00 $1,441.00 $1,534.00 $1,641.00
24430 90 $1,209.00 $1,552.00 $1,654.00 $1,775.00 $1,552.00 $1,654.00 $1,775.00
24435 90 $1,260.00 $1,575.00 $1,679.00 $1,799.00 $1,575.00 $1,679.00 $1,799.00
24470 90 $774.00 $980.00 $1,047.00 $1,122.00 $980.00 $1,047.00 $1,122.00
24495 90 $742.00 $790.00 $847.00 $924.00 $790.00 $847.00 $924.00
24498 90 $1,076.00 $1,266.00 $1,350.00 $1,448.00 $1,266.00 $1,350.00 $1,448.00
24500 90 $288.00 $509.00 $542.00 $570.00 $466.00 $496.00 $523.00
24505 90 $574.00 $714.00 $761.00 $804.00 $649.00 $692.00 $734.00
24515 90 $1,018.00 $1,282.00 $1,367.00 $1,464.00 $1,282.00 $1,367.00 $1,464.00
24516 90 $1,029.00 $1,260.00 $1,343.00 $1,442.00 $1,260.00 $1,343.00 $1,442.00
24530 90 $88.00 $541.00 $577.00 $607.00 $493.00 $525.00 $554.00
24535 90 $671.00 $883.00 $941.00 $998.00 $820.00 $874.00 $930.00
24538 90 $850.00 $1,087.00 $1,161.00 $1,243.00 $1,087.00 $1,161.00 $1,243.00
24545 90 $946.00 $1,362.00 $1,451.00 $1,556.00 $1,362.00 $1,451.00 $1,556.00
24546 90 $1,273.00 $1,525.00 $1,625.00 $1,744.00 $1,525.00 $1,625.00 $1,744.00
24560 90 $266.00 $454.00 $483.00 $506.00 $409.00 $435.00 $457.00
24565 90 $526.00 $762.00 $812.00 $860.00 $703.00 $750.00 $797.00
24566 90 $705.00 $1,045.00 $1,116.00 $1,193.00 $1,045.00 $1,116.00 $1,193.00
24575 90 $872.00 $1,070.00 $1,141.00 $1,219.00 $1,070.00 $1,141.00 $1,219.00
24576 90 $295.00 $481.00 $513.00 $537.00 $435.00 $463.00 $487.00
24577 90 $575.00 $782.00 $834.00 $885.00 $721.00 $770.00 $820.00
24579 90 $964.00 $1,221.00 $1,301.00 $1,392.00 $1,221.00 $1,301.00 $1,392.00
24582 90 $773.00 $1,177.00 $1,256.00 $1,342.00 $1,177.00 $1,256.00 $1,342.00
24586 90 $1,314.00 $1,588.00 $1,692.00 $1,815.00 $1,588.00 $1,692.00 $1,815.00
24587 90 $1,278.00 $1,594.00 $1,701.00 $1,831.00 $1,594.00 $1,701.00 $1,831.00
24600 90 $360.00 $520.00 $551.00 $580.00 $479.00 $507.00 $536.00
24605 90 $371.00 $678.00 $723.00 $770.00 $678.00 $723.00 $770.00
24615 90 $836.00 $1,040.00 $1,108.00 $1,186.00 $1,040.00 $1,108.00 $1,186.00
24620 90 $560.00 $795.00 $845.00 $898.00 $795.00 $845.00 $898.00
24635 90 $1,329.00 $980.00 $1,045.00 $1,116.00 $980.00 $1,045.00 $1,116.00
24650 90 $262.00 $370.00 $394.00 $412.00 $341.00 $363.00 $381.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 189
Surgery
CPT Code FUD 2003 MRALocality 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)
24655 90 $436.00 $621.00 $661.00 $696.00 $568.00 $605.00 $639.00
24665 90 $749.00 $948.00 $1,011.00 $1,077.00 $948.00 $1,011.00 $1,077.00
24666 90 $905.00 $1,069.00 $1,140.00 $1,218.00 $1,069.00 $1,140.00 $1,218.00
24670 90 $263.00 $412.00 $439.00 $460.00 $374.00 $398.00 $419.00
24675 90 $490.00 $646.00 $688.00 $727.00 $593.00 $631.00 $669.00
24685 90 $819.00 $950.00 $1,013.00 $1,081.00 $950.00 $1,013.00 $1,081.00
24800 90 $984.00 $1,215.00 $1,297.00 $1,393.00 $1,215.00 $1,297.00 $1,393.00
24802 90 $1,181.00 $1,438.00 $1,526.00 $1,623.00 $1,438.00 $1,526.00 $1,623.00
24900 90 $858.00 $1,070.00 $1,142.00 $1,225.00 $1,070.00 $1,142.00 $1,225.00
24920 90 $851.00 $1,054.00 $1,124.00 $1,205.00 $1,054.00 $1,124.00 $1,205.00
24925 90 $661.00 $766.00 $823.00 $894.00 $766.00 $823.00 $894.00
24930 90 $928.00 $1,113.00 $1,187.00 $1,273.00 $1,113.00 $1,187.00 $1,273.00
24931 90 $1,063.00 $1,171.00 $1,235.00 $1,310.00 $1,171.00 $1,235.00 $1,310.00
24935 90 $1,327.00 $1,453.00 $1,559.00 $1,714.00 $1,453.00 $1,559.00 $1,714.00
24940 90 BR ---------- ---------- ---------- ---------- ---------- ----------
24999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
25000 90 $381.00 $482.00 $514.00 $543.00 $482.00 $514.00 $543.00
25001 90 $294.00 $493.00 $525.00 $555.00 $493.00 $525.00 $555.00
25020 90 $594.00 $824.00 $878.00 $927.00 $824.00 $878.00 $927.00
25023 90 $1,040.00 $1,593.00 $1,697.00 $1,805.00 $1,593.00 $1,697.00 $1,805.00
25024 90 $683.00 $1,133.00 $1,207.00 $1,293.00 $1,133.00 $1,207.00 $1,293.00
25025 90 $1,104.00 $1,801.00 $1,923.00 $2,072.00 $1,801.00 $1,923.00 $2,072.00
25028 90 $417.00 $751.00 $802.00 $848.00 $751.00 $802.00 $848.00
25031 90 $266.00 $525.00 $560.00 $596.00 $525.00 $560.00 $596.00
25035 90 $794.00 $847.00 $903.00 $963.00 $847.00 $903.00 $963.00
25040 90 $654.00 $817.00 $870.00 $926.00 $817.00 $870.00 $926.00
25065 10 $164.00 $357.00 $380.00 $394.00 $236.00 $250.00 $263.00
25066 90 $322.00 $520.00 $555.00 $590.00 $520.00 $555.00 $590.00
25071 90 ---------- $625.00 $668.00 $720.00 $625.00 $668.00 $720.00
25073 90 ---------- $779.00 $831.00 $890.00 $779.00 $831.00 $890.00
25075 90 $352.00 $678.00 $724.00 $759.00 $460.00 $491.00 $524.00
25076 90 $544.00 $753.00 $802.00 $856.00 $753.00 $802.00 $856.00
25077 90 $957.00 $1,310.00 $1,400.00 $1,510.00 $1,310.00 $1,400.00 $1,510.00
25078 90 ---------- $1,723.00 $1,840.00 $1,989.00 $1,723.00 $1,840.00 $1,989.00
25085 90 $562.00 $649.00 $691.00 $734.00 $649.00 $691.00 $734.00
25100 90 $420.00 $487.00 $518.00 $550.00 $487.00 $518.00 $550.00
25101 90 $492.00 $583.00 $620.00 $658.00 $583.00 $620.00 $658.00
25105 90 $635.00 $697.00 $741.00 $787.00 $697.00 $741.00 $787.00
25107 90 $600.00 $891.00 $949.00 $1,007.00 $891.00 $949.00 $1,007.00
25109 90 ---------- $780.00 $829.00 $880.00 $780.00 $829.00 $880.00
25110 90 $403.00 $493.00 $525.00 $558.00 $493.00 $525.00 $558.00
25111 90 $356.00 $461.00 $491.00 $520.00 $461.00 $491.00 $520.00
25112 90 $441.00 $559.00 $595.00 $632.00 $559.00 $595.00 $632.00
25115 90 $837.00 $1,103.00 $1,174.00 $1,250.00 $1,103.00 $1,174.00 $1,250.00
25116 90 $807.00 $868.00 $923.00 $979.00 $868.00 $923.00 $979.00
25118 90 $466.00 $550.00 $586.00 $621.00 $550.00 $586.00 $621.00
25119 90 $653.00 $714.00 $760.00 $807.00 $714.00 $760.00 $807.00
25120 90 $712.00 $720.00 $766.00 $814.00 $720.00 $766.00 $814.00
25125 90 $803.00 $851.00 $903.00 $953.00 $851.00 $903.00 $953.00
25126 90 $781.00 $859.00 $918.00 $985.00 $859.00 $918.00 $985.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 190
Surgery
CPT Code FUD 2003 MRALocality 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)
25130 90 $502.00 $643.00 $683.00 $723.00 $643.00 $683.00 $723.00
25135 90 $631.00 $812.00 $867.00 $927.00 $812.00 $867.00 $927.00
25136 90 $546.00 $700.00 $744.00 $787.00 $700.00 $744.00 $787.00
25145 90 $713.00 $752.00 $803.00 $859.00 $752.00 $803.00 $859.00
25150 90 $720.00 $821.00 $875.00 $934.00 $821.00 $875.00 $934.00
25151 90 $771.00 $846.00 $901.00 $959.00 $846.00 $901.00 $959.00
25170 90 $1,085.00 $2,185.00 $2,335.00 $2,523.00 $2,185.00 $2,335.00 $2,523.00
25210 90 $561.00 $704.00 $748.00 $793.00 $704.00 $748.00 $793.00
25215 90 $817.00 $897.00 $954.00 $1,015.00 $897.00 $954.00 $1,015.00
25230 90 $531.00 $625.00 $666.00 $707.00 $625.00 $666.00 $707.00
25240 90 $567.00 $618.00 $657.00 $695.00 $618.00 $657.00 $695.00
25246 0 $72.00 $226.00 $239.00 $246.00 $110.00 $115.00 $121.00
25248 90 $236.00 $598.00 $638.00 $682.00 $598.00 $638.00 $682.00
25250 90 $616.00 $771.00 $824.00 $881.00 $771.00 $824.00 $881.00
25251 90 $933.00 $1,052.00 $1,123.00 $1,207.00 $1,052.00 $1,123.00 $1,207.00
25259 90 $348.00 $593.00 $633.00 $666.00 $593.00 $633.00 $666.00
25260 90 $728.00 $912.00 $971.00 $1,032.00 $912.00 $971.00 $1,032.00
25263 90 $809.00 $907.00 $968.00 $1,035.00 $907.00 $968.00 $1,035.00
25265 90 $998.00 $1,092.00 $1,166.00 $1,249.00 $1,092.00 $1,166.00 $1,249.00
25270 90 $549.00 $708.00 $753.00 $799.00 $708.00 $753.00 $799.00
25272 90 $613.00 $801.00 $853.00 $906.00 $801.00 $853.00 $906.00
25274 90 $887.00 $960.00 $1,021.00 $1,085.00 $960.00 $1,021.00 $1,085.00
25275 90 $620.00 $973.00 $1,035.00 $1,102.00 $973.00 $1,035.00 $1,102.00
25280 90 $670.00 $816.00 $868.00 $922.00 $816.00 $868.00 $922.00
25290 90 $436.00 $631.00 $671.00 $712.00 $631.00 $671.00 $712.00
25295 90 $562.00 $760.00 $809.00 $861.00 $760.00 $809.00 $861.00
25300 90 $592.00 $989.00 $1,054.00 $1,125.00 $989.00 $1,054.00 $1,125.00
25301 90 $757.00 $935.00 $995.00 $1,061.00 $935.00 $995.00 $1,061.00
25310 90 $865.00 $898.00 $956.00 $1,016.00 $898.00 $956.00 $1,016.00
25312 90 $968.00 $1,045.00 $1,112.00 $1,186.00 $1,045.00 $1,112.00 $1,186.00
25315 90 $1,004.00 $1,129.00 $1,206.00 $1,295.00 $1,129.00 $1,206.00 $1,295.00
25316 90 $1,203.00 $1,334.00 $1,422.00 $1,525.00 $1,334.00 $1,422.00 $1,525.00
25320 90 $834.00 $1,432.00 $1,524.00 $1,620.00 $1,432.00 $1,524.00 $1,620.00
25332 90 $1,022.00 $1,227.00 $1,306.00 $1,393.00 $1,227.00 $1,306.00 $1,393.00
25335 90 $1,166.00 $1,379.00 $1,467.00 $1,567.00 $1,379.00 $1,467.00 $1,567.00
25337 90 $946.00 $1,295.00 $1,379.00 $1,468.00 $1,295.00 $1,379.00 $1,468.00
25350 90 $913.00 $979.00 $1,041.00 $1,109.00 $979.00 $1,041.00 $1,109.00
25355 90 $1,014.00 $1,112.00 $1,184.00 $1,266.00 $1,112.00 $1,184.00 $1,266.00
25360 90 $468.00 $950.00 $1,012.00 $1,079.00 $950.00 $1,012.00 $1,079.00
25365 90 $1,216.00 $1,342.00 $1,432.00 $1,538.00 $1,342.00 $1,432.00 $1,538.00
25370 90 $1,214.00 $1,476.00 $1,576.00 $1,694.00 $1,476.00 $1,576.00 $1,694.00
25375 90 $1,280.00 $1,400.00 $1,494.00 $1,607.00 $1,400.00 $1,494.00 $1,607.00
25390 90 $1,043.00 $1,123.00 $1,195.00 $1,275.00 $1,123.00 $1,195.00 $1,275.00
25391 90 $1,349.00 $1,463.00 $1,561.00 $1,679.00 $1,463.00 $1,561.00 $1,679.00
25392 90 $1,294.00 $1,491.00 $1,585.00 $1,691.00 $1,491.00 $1,585.00 $1,691.00
25393 90 $1,473.00 $1,630.00 $1,723.00 $1,819.00 $1,630.00 $1,723.00 $1,819.00
25394 90 $723.00 $1,138.00 $1,208.00 $1,281.00 $1,138.00 $1,208.00 $1,281.00
25400 90 $1,112.00 $1,172.00 $1,248.00 $1,333.00 $1,172.00 $1,248.00 $1,333.00
25405 90 $1,388.00 $1,518.00 $1,616.00 $1,731.00 $1,518.00 $1,616.00 $1,731.00
25415 90 $1,343.00 $1,420.00 $1,516.00 $1,629.00 $1,420.00 $1,516.00 $1,629.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 191
Surgery
CPT Code FUD 2003 MRALocality 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)
25420 90 $1,554.00 $1,707.00 $1,820.00 $1,955.00 $1,707.00 $1,820.00 $1,955.00
25425 90 $1,403.00 $1,413.00 $1,508.00 $1,621.00 $1,413.00 $1,508.00 $1,621.00
25426 90 $1,401.00 $1,596.00 $1,691.00 $1,797.00 $1,596.00 $1,691.00 $1,797.00
25430 90 $638.00 $1,069.00 $1,141.00 $1,223.00 $1,069.00 $1,141.00 $1,223.00
25431 90 $631.00 $1,143.00 $1,212.00 $1,284.00 $1,143.00 $1,212.00 $1,284.00
25440 90 $931.00 $1,121.00 $1,193.00 $1,272.00 $1,121.00 $1,193.00 $1,272.00
25441 90 $1,147.00 $1,359.00 $1,441.00 $1,527.00 $1,359.00 $1,441.00 $1,527.00
25442 90 $936.00 $1,173.00 $1,248.00 $1,329.00 $1,173.00 $1,248.00 $1,329.00
25443 90 $970.00 $1,135.00 $1,213.00 $1,305.00 $1,135.00 $1,213.00 $1,305.00
25444 90 $1,031.00 $1,192.00 $1,267.00 $1,349.00 $1,192.00 $1,267.00 $1,349.00
25445 90 $959.00 $1,054.00 $1,122.00 $1,200.00 $1,054.00 $1,122.00 $1,200.00
25446 90 $1,542.00 $1,718.00 $1,827.00 $1,954.00 $1,718.00 $1,827.00 $1,954.00
25447 90 $952.00 $1,205.00 $1,282.00 $1,366.00 $1,205.00 $1,282.00 $1,366.00
25449 90 $395.00 $1,510.00 $1,605.00 $1,714.00 $1,510.00 $1,605.00 $1,714.00
25450 90 $805.00 $752.00 $794.00 $839.00 $752.00 $794.00 $839.00
25455 90 $899.00 $1,060.00 $1,132.00 $1,214.00 $1,060.00 $1,132.00 $1,214.00
25490 90 $955.00 $1,051.00 $1,123.00 $1,204.00 $1,051.00 $1,123.00 $1,204.00
25491 90 $1,006.00 $1,083.00 $1,156.00 $1,241.00 $1,083.00 $1,156.00 $1,241.00
25492 90 $1,170.00 $1,326.00 $1,416.00 $1,522.00 $1,326.00 $1,416.00 $1,522.00
25500 90 $200.00 $387.00 $412.00 $432.00 $357.00 $380.00 $399.00
25505 90 $517.00 $714.00 $759.00 $800.00 $657.00 $699.00 $739.00
25515 90 $800.00 $973.00 $1,037.00 $1,108.00 $973.00 $1,037.00 $1,108.00
25520 90 $644.00 $813.00 $868.00 $924.00 $775.00 $827.00 $882.00
25525 90 $1,097.00 $1,145.00 $1,220.00 $1,304.00 $1,145.00 $1,220.00 $1,304.00
25526 90 $1,293.00 $1,390.00 $1,482.00 $1,586.00 $1,390.00 $1,482.00 $1,586.00
25530 90 $270.00 $370.00 $394.00 $413.00 $337.00 $359.00 $377.00
25535 90 $516.00 $699.00 $744.00 $787.00 $650.00 $693.00 $735.00
25545 90 $803.00 $905.00 $965.00 $1,028.00 $905.00 $965.00 $1,028.00
25560 90 $276.00 $393.00 $418.00 $438.00 $358.00 $380.00 $399.00
25565 90 $590.00 $740.00 $788.00 $832.00 $673.00 $716.00 $760.00
25574 90 $804.00 $982.00 $1,047.00 $1,118.00 $982.00 $1,047.00 $1,118.00
25575 90 $974.00 $1,316.00 $1,404.00 $1,503.00 $1,316.00 $1,404.00 $1,503.00
25600 90 $312.00 $463.00 $494.00 $516.00 $439.00 $468.00 $490.00
25605 90 $540.00 $779.00 $829.00 $876.00 $736.00 $783.00 $830.00
25606 90 ---------- $963.00 $1,028.00 $1,097.00 $963.00 $1,028.00 $1,097.00
25607 90 ---------- $1,069.00 $1,139.00 $1,215.00 $1,069.00 $1,139.00 $1,215.00
25608 90 ---------- $1,201.00 $1,280.00 $1,367.00 $1,201.00 $1,280.00 $1,367.00
25609 90 ---------- $1,529.00 $1,628.00 $1,740.00 $1,529.00 $1,628.00 $1,740.00
25622 90 $148.00 $431.00 $459.00 $480.00 $395.00 $420.00 $441.00
25624 90 $482.00 $681.00 $727.00 $768.00 $624.00 $666.00 $707.00
25628 90 $716.00 $1,049.00 $1,117.00 $1,191.00 $1,049.00 $1,117.00 $1,191.00
25630 90 $148.00 $434.00 $462.00 $485.00 $401.00 $426.00 $449.00
25635 90 $458.00 $598.00 $635.00 $665.00 $539.00 $571.00 $601.00
25645 90 $668.00 $819.00 $872.00 $928.00 $819.00 $872.00 $928.00
25650 90 $185.00 $453.00 $482.00 $505.00 $427.00 $454.00 $477.00
25651 90 $379.00 $696.00 $740.00 $784.00 $696.00 $740.00 $784.00
25652 90 $560.00 $907.00 $967.00 $1,032.00 $907.00 $967.00 $1,032.00
25660 90 $378.00 $590.00 $626.00 $661.00 $590.00 $626.00 $661.00
25670 90 $731.00 $881.00 $939.00 $1,002.00 $881.00 $939.00 $1,002.00
25671 90 $462.00 $768.00 $820.00 $873.00 $768.00 $820.00 $873.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 192
Surgery
CPT Code FUD 2003 MRALocality 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)
25675 90 $404.00 $615.00 $653.00 $685.00 $564.00 $598.00 $629.00
25676 90 $741.00 $913.00 $973.00 $1,038.00 $913.00 $973.00 $1,038.00
25680 90 $471.00 $691.00 $734.00 $777.00 $691.00 $734.00 $777.00
25685 90 $887.00 $1,072.00 $1,144.00 $1,227.00 $1,072.00 $1,144.00 $1,227.00
25690 90 $518.00 $681.00 $725.00 $769.00 $681.00 $725.00 $769.00
25695 90 $520.00 $924.00 $986.00 $1,056.00 $924.00 $986.00 $1,056.00
25800 90 $703.00 $1,066.00 $1,135.00 $1,210.00 $1,066.00 $1,135.00 $1,210.00
25805 90 $1,078.00 $1,238.00 $1,321.00 $1,418.00 $1,238.00 $1,321.00 $1,418.00
25810 90 $1,008.00 $1,265.00 $1,345.00 $1,434.00 $1,265.00 $1,345.00 $1,434.00
25820 90 $2,276.00 $889.00 $946.00 $1,003.00 $889.00 $946.00 $1,003.00
25825 90 $895.00 $1,098.00 $1,168.00 $1,239.00 $1,098.00 $1,168.00 $1,239.00
25830 90 $991.00 $1,359.00 $1,447.00 $1,530.00 $1,359.00 $1,447.00 $1,530.00
25900 90 $871.00 $1,033.00 $1,101.00 $1,177.00 $1,033.00 $1,101.00 $1,177.00
25905 90 $900.00 $1,027.00 $1,097.00 $1,178.00 $1,027.00 $1,097.00 $1,178.00
25907 90 $799.00 $886.00 $944.00 $1,007.00 $886.00 $944.00 $1,007.00
25909 90 $849.00 $998.00 $1,066.00 $1,144.00 $998.00 $1,066.00 $1,144.00
25915 90 $1,523.00 $1,485.00 $1,565.00 $1,662.00 $1,485.00 $1,565.00 $1,662.00
25920 90 $771.00 $1,015.00 $1,083.00 $1,160.00 $1,015.00 $1,083.00 $1,160.00
25922 90 $670.00 $738.00 $779.00 $823.00 $738.00 $779.00 $823.00
25924 90 $768.00 $962.00 $1,020.00 $1,078.00 $962.00 $1,020.00 $1,078.00
25927 90 $830.00 $1,163.00 $1,242.00 $1,319.00 $1,163.00 $1,242.00 $1,319.00
25929 90 $645.00 $836.00 $894.00 $963.00 $836.00 $894.00 $963.00
25931 90 $731.00 $1,047.00 $1,118.00 $1,189.00 $1,047.00 $1,118.00 $1,189.00
25999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
26010 10 $59.00 $369.00 $392.00 $404.00 $196.00 $208.00 $218.00
26011 10 $223.00 $544.00 $580.00 $599.00 $267.00 $283.00 $300.00
26020 90 $484.00 $624.00 $665.00 $705.00 $624.00 $665.00 $705.00
26025 90 $548.00 $609.00 $649.00 $688.00 $609.00 $649.00 $688.00
26030 90 $655.00 $713.00 $759.00 $806.00 $713.00 $759.00 $806.00
26034 90 $601.00 $780.00 $832.00 $884.00 $780.00 $832.00 $884.00
26035 90 $741.00 $1,250.00 $1,334.00 $1,429.00 $1,250.00 $1,334.00 $1,429.00
26037 90 $730.00 $822.00 $875.00 $932.00 $822.00 $875.00 $932.00
26040 90 $367.00 $447.00 $476.00 $503.00 $447.00 $476.00 $503.00
26045 90 $621.00 $678.00 $722.00 $769.00 $678.00 $722.00 $769.00
26055 90 $343.00 $779.00 $832.00 $861.00 $444.00 $473.00 $498.00
26060 90 $293.00 $373.00 $397.00 $418.00 $373.00 $397.00 $418.00
26070 90 $440.00 $454.00 $483.00 $510.00 $454.00 $483.00 $510.00
26075 90 $400.00 $479.00 $510.00 $540.00 $479.00 $510.00 $540.00
26080 90 $382.00 $561.00 $598.00 $632.00 $561.00 $598.00 $632.00
26100 90 $398.00 $467.00 $497.00 $527.00 $467.00 $497.00 $527.00
26105 90 $481.00 $481.00 $513.00 $545.00 $481.00 $513.00 $545.00
26110 90 $282.00 $463.00 $493.00 $521.00 $463.00 $493.00 $521.00
26111 90 ---------- $607.00 $646.00 $687.00 $607.00 $646.00 $687.00
26113 90 ---------- $797.00 $848.00 $902.00 $797.00 $848.00 $902.00
26115 90 $344.00 $712.00 $758.00 $792.00 $480.00 $511.00 $542.00
26116 90 $544.00 $764.00 $813.00 $864.00 $764.00 $813.00 $864.00
26117 90 $806.00 $1,088.00 $1,159.00 $1,237.00 $1,088.00 $1,159.00 $1,237.00
26118 90 ---------- $1,543.00 $1,643.00 $1,758.00 $1,543.00 $1,643.00 $1,758.00
26121 90 $833.00 $866.00 $922.00 $982.00 $866.00 $922.00 $982.00
26123 90 $959.00 $1,212.00 $1,290.00 $1,373.00 $1,212.00 $1,290.00 $1,373.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 193
Surgery
CPT Code FUD 2003 MRALocality 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)
26125 ZZZ $342.00 $407.00 $432.00 $466.00 $407.00 $432.00 $466.00
26130 90 $629.00 $669.00 $715.00 $762.00 $669.00 $715.00 $762.00
26135 90 $668.00 $796.00 $846.00 $899.00 $796.00 $846.00 $899.00
26140 90 $678.00 $729.00 $776.00 $824.00 $729.00 $776.00 $824.00
26145 90 $660.00 $743.00 $791.00 $841.00 $743.00 $791.00 $841.00
26160 90 $319.00 $803.00 $857.00 $888.00 $479.00 $510.00 $538.00
26170 90 $452.00 $585.00 $622.00 $658.00 $585.00 $622.00 $658.00
26180 90 $444.00 $638.00 $678.00 $717.00 $638.00 $678.00 $717.00
26185 90 $511.00 $781.00 $828.00 $871.00 $781.00 $828.00 $871.00
26200 90 $598.00 $649.00 $691.00 $734.00 $649.00 $691.00 $734.00
26205 90 $788.00 $869.00 $927.00 $992.00 $869.00 $927.00 $992.00
26210 90 $543.00 $638.00 $679.00 $720.00 $638.00 $679.00 $720.00
26215 90 $731.00 $812.00 $866.00 $926.00 $812.00 $866.00 $926.00
26230 90 $624.00 $723.00 $769.00 $816.00 $723.00 $769.00 $816.00
26235 90 $612.00 $712.00 $757.00 $804.00 $712.00 $757.00 $804.00
26236 90 $444.00 $637.00 $678.00 $720.00 $637.00 $678.00 $720.00
26250 90 $814.00 $1,573.00 $1,671.00 $1,780.00 $1,573.00 $1,671.00 $1,780.00
26260 90 $758.00 $1,178.00 $1,257.00 $1,349.00 $1,178.00 $1,257.00 $1,349.00
26262 90 $624.00 $917.00 $977.00 $1,045.00 $917.00 $977.00 $1,045.00
26320 90 $414.00 $499.00 $531.00 $562.00 $499.00 $531.00 $562.00
26340 90 $266.00 $473.00 $504.00 $527.00 $473.00 $504.00 $527.00
26341 10 ---------- $140.00 $149.00 $157.00 $109.00 $116.00 $123.00
26350 90 $715.00 $1,000.00 $1,065.00 $1,116.00 $1,000.00 $1,065.00 $1,116.00
26352 90 $855.00 $1,126.00 $1,196.00 $1,250.00 $1,126.00 $1,196.00 $1,250.00
26356 90 $886.00 $1,145.00 $1,219.00 $1,291.00 $1,145.00 $1,219.00 $1,291.00
26357 90 $932.00 $1,288.00 $1,374.00 $1,467.00 $1,288.00 $1,374.00 $1,467.00
26358 90 $979.00 $1,410.00 $1,496.00 $1,581.00 $1,410.00 $1,496.00 $1,581.00
26370 90 $832.00 $1,069.00 $1,138.00 $1,196.00 $1,069.00 $1,138.00 $1,196.00
26372 90 $945.00 $1,219.00 $1,299.00 $1,369.00 $1,219.00 $1,299.00 $1,369.00
26373 90 $904.00 $1,175.00 $1,248.00 $1,306.00 $1,175.00 $1,248.00 $1,306.00
26390 90 $889.00 $1,195.00 $1,276.00 $1,357.00 $1,195.00 $1,276.00 $1,357.00
26392 90 $1,123.00 $1,381.00 $1,473.00 $1,560.00 $1,381.00 $1,473.00 $1,560.00
26410 90 $371.00 $792.00 $844.00 $883.00 $792.00 $844.00 $883.00
26412 90 $737.00 $977.00 $1,043.00 $1,100.00 $977.00 $1,043.00 $1,100.00
26415 90 $846.00 $952.00 $998.00 $1,025.00 $952.00 $998.00 $1,025.00
26416 90 $1,093.00 $1,229.00 $1,309.00 $1,383.00 $1,229.00 $1,309.00 $1,383.00
26418 90 $444.00 $807.00 $860.00 $897.00 $807.00 $860.00 $897.00
26420 90 $741.00 $995.00 $1,059.00 $1,112.00 $995.00 $1,059.00 $1,112.00
26426 90 $733.00 $725.00 $771.00 $819.00 $725.00 $771.00 $819.00
26428 90 $790.00 $1,041.00 $1,105.00 $1,156.00 $1,041.00 $1,105.00 $1,156.00
26432 90 $430.00 $698.00 $744.00 $778.00 $698.00 $744.00 $778.00
26433 90 $371.00 $743.00 $792.00 $830.00 $743.00 $792.00 $830.00
26434 90 $656.00 $913.00 $974.00 $1,027.00 $913.00 $974.00 $1,027.00
26437 90 $491.00 $877.00 $934.00 $982.00 $877.00 $934.00 $982.00
26440 90 $458.00 $866.00 $923.00 $964.00 $866.00 $923.00 $964.00
26442 90 $548.00 $1,366.00 $1,455.00 $1,531.00 $1,366.00 $1,455.00 $1,531.00
26445 90 $455.00 $804.00 $857.00 $893.00 $804.00 $857.00 $893.00
26449 90 $738.00 $1,004.00 $1,068.00 $1,133.00 $1,004.00 $1,068.00 $1,133.00
26450 90 $353.00 $570.00 $607.00 $637.00 $570.00 $607.00 $637.00
26455 90 $364.00 $567.00 $603.00 $632.00 $567.00 $603.00 $632.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 194
Surgery
CPT Code FUD 2003 MRALocality 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 $553.00 $589.00 $618.00 $553.00 $589.00 $618.00
26471 90 $592.00 $865.00 $920.00 $965.00 $865.00 $920.00 $965.00
26474 90 $586.00 $846.00 $903.00 $951.00 $846.00 $903.00 $951.00
26476 90 $543.00 $810.00 $861.00 $900.00 $810.00 $861.00 $900.00
26477 90 $553.00 $819.00 $872.00 $915.00 $819.00 $872.00 $915.00
26478 90 $608.00 $872.00 $929.00 $976.00 $872.00 $929.00 $976.00
26479 90 $653.00 $863.00 $917.00 $959.00 $863.00 $917.00 $959.00
26480 90 $808.00 $1,055.00 $1,122.00 $1,174.00 $1,055.00 $1,122.00 $1,174.00
26483 90 $986.00 $1,187.00 $1,264.00 $1,330.00 $1,187.00 $1,264.00 $1,330.00
26485 90 $891.00 $1,137.00 $1,210.00 $1,271.00 $1,137.00 $1,210.00 $1,271.00
26489 90 $738.00 $1,324.00 $1,413.00 $1,495.00 $1,324.00 $1,413.00 $1,495.00
26490 90 $496.00 $1,135.00 $1,212.00 $1,286.00 $1,135.00 $1,212.00 $1,286.00
26492 90 $971.00 $1,261.00 $1,347.00 $1,432.00 $1,261.00 $1,347.00 $1,432.00
26494 90 $946.00 $1,107.00 $1,177.00 $1,240.00 $1,107.00 $1,177.00 $1,240.00
26496 90 $949.00 $1,216.00 $1,290.00 $1,357.00 $1,216.00 $1,290.00 $1,357.00
26497 90 $946.00 $1,238.00 $1,321.00 $1,405.00 $1,238.00 $1,321.00 $1,405.00
26498 90 $1,317.00 $1,620.00 $1,718.00 $1,814.00 $1,620.00 $1,718.00 $1,814.00
26499 90 $934.00 $1,162.00 $1,234.00 $1,297.00 $1,162.00 $1,234.00 $1,297.00
26500 90 $557.00 $880.00 $937.00 $985.00 $880.00 $937.00 $985.00
26502 90 $715.00 $1,006.00 $1,074.00 $1,136.00 $1,006.00 $1,074.00 $1,136.00
26508 90 $334.00 $888.00 $945.00 $992.00 $888.00 $945.00 $992.00
26510 90 $564.00 $836.00 $889.00 $932.00 $836.00 $889.00 $932.00
26516 90 $630.00 $989.00 $1,052.00 $1,106.00 $989.00 $1,052.00 $1,106.00
26517 90 $890.00 $1,114.00 $1,186.00 $1,258.00 $1,114.00 $1,186.00 $1,258.00
26518 90 $877.00 $1,167.00 $1,239.00 $1,301.00 $1,167.00 $1,239.00 $1,301.00
26520 90 $583.00 $911.00 $971.00 $1,016.00 $911.00 $971.00 $1,016.00
26525 90 $531.00 $912.00 $971.00 $1,015.00 $912.00 $971.00 $1,015.00
26530 90 $708.00 $779.00 $829.00 $880.00 $779.00 $829.00 $880.00
26531 90 $877.00 $904.00 $962.00 $1,022.00 $904.00 $962.00 $1,022.00
26535 90 $546.00 $610.00 $647.00 $684.00 $610.00 $647.00 $684.00
26536 90 $770.00 $994.00 $1,057.00 $1,106.00 $994.00 $1,057.00 $1,106.00
26540 90 $726.00 $927.00 $987.00 $1,038.00 $927.00 $987.00 $1,038.00
26541 90 $926.00 $1,137.00 $1,210.00 $1,278.00 $1,137.00 $1,210.00 $1,278.00
26542 90 $716.00 $958.00 $1,019.00 $1,072.00 $958.00 $1,019.00 $1,072.00
26545 90 $722.00 $998.00 $1,065.00 $1,125.00 $998.00 $1,065.00 $1,125.00
26546 90 $918.00 $1,413.00 $1,504.00 $1,588.00 $1,413.00 $1,504.00 $1,588.00
26548 90 $665.00 $1,073.00 $1,141.00 $1,203.00 $1,073.00 $1,141.00 $1,203.00
26550 90 $1,861.00 $2,352.00 $2,494.00 $2,638.00 $2,352.00 $2,494.00 $2,638.00
26551 90 $3,901.00 $4,864.00 $5,165.00 $5,503.00 $4,864.00 $5,165.00 $5,503.00
26553 90 $3,868.00 $4,120.00 $4,344.00 $4,610.00 $4,120.00 $4,344.00 $4,610.00
26554 90 $4,551.00 $4,827.00 $5,088.00 $5,403.00 $4,827.00 $5,088.00 $5,403.00
26555 90 $1,567.00 $1,846.00 $1,962.00 $2,086.00 $1,846.00 $1,962.00 $2,086.00
26556 90 $4,005.00 $4,995.00 $5,333.00 $5,747.00 $4,995.00 $5,333.00 $5,747.00
26560 90 $576.00 $820.00 $875.00 $922.00 $820.00 $875.00 $922.00
26561 90 $1,067.00 $1,327.00 $1,412.00 $1,494.00 $1,327.00 $1,412.00 $1,494.00
26562 90 $1,017.00 $1,905.00 $2,021.00 $2,133.00 $1,905.00 $2,021.00 $2,133.00
26565 90 $730.00 $956.00 $1,018.00 $1,072.00 $956.00 $1,018.00 $1,072.00
26567 90 $622.00 $959.00 $1,021.00 $1,075.00 $959.00 $1,021.00 $1,075.00
26568 90 $1,003.00 $1,276.00 $1,361.00 $1,439.00 $1,276.00 $1,361.00 $1,439.00
26580 90 $1,585.00 $2,150.00 $2,284.00 $2,423.00 $2,150.00 $2,284.00 $2,423.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 195
Surgery
CPT Code FUD 2003 MRALocality 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 $1,463.00 $1,554.00 $1,657.00 $1,463.00 $1,554.00 $1,657.00
26590 90 $1,609.00 $1,911.00 $2,042.00 $2,201.00 $1,911.00 $2,042.00 $2,201.00
26591 90 $431.00 $607.00 $646.00 $673.00 $607.00 $646.00 $673.00
26593 90 $587.00 $844.00 $898.00 $942.00 $844.00 $898.00 $942.00
26596 90 $809.00 $1,077.00 $1,143.00 $1,205.00 $1,077.00 $1,143.00 $1,205.00
26600 90 $133.00 $415.00 $442.00 $462.00 $392.00 $417.00 $437.00
26605 90 $296.00 $455.00 $485.00 $509.00 $417.00 $444.00 $468.00
26607 90 $334.00 $656.00 $699.00 $742.00 $656.00 $699.00 $742.00
26608 90 $497.00 $685.00 $729.00 $773.00 $685.00 $729.00 $773.00
26615 90 $521.00 $833.00 $887.00 $942.00 $833.00 $887.00 $942.00
26641 90 $71.00 $534.00 $567.00 $595.00 $489.00 $519.00 $547.00
26645 90 $371.00 $611.00 $652.00 $690.00 $564.00 $601.00 $639.00
26650 90 $533.00 $686.00 $730.00 $773.00 $686.00 $730.00 $773.00
26665 90 $693.00 $909.00 $968.00 $1,030.00 $909.00 $968.00 $1,030.00
26670 90 $148.00 $483.00 $512.00 $538.00 $441.00 $467.00 $492.00
26675 90 $501.00 $645.00 $687.00 $725.00 $596.00 $634.00 $672.00
26676 90 $527.00 $718.00 $765.00 $810.00 $718.00 $765.00 $810.00
26685 90 $592.00 $833.00 $887.00 $943.00 $833.00 $887.00 $943.00
26686 90 $710.00 $909.00 $970.00 $1,039.00 $909.00 $970.00 $1,039.00
26700 90 $88.00 $461.00 $488.00 $513.00 $434.00 $460.00 $485.00
26705 90 $296.00 $589.00 $626.00 $659.00 $542.00 $576.00 $609.00
26706 90 $469.00 $634.00 $675.00 $717.00 $634.00 $675.00 $717.00
26715 90 $526.00 $827.00 $881.00 $935.00 $827.00 $881.00 $935.00
26720 90 $96.00 $279.00 $297.00 $309.00 $260.00 $277.00 $289.00
26725 90 $187.00 $478.00 $508.00 $534.00 $434.00 $461.00 $487.00
26727 90 $187.00 $675.00 $720.00 $762.00 $675.00 $720.00 $762.00
26735 90 $532.00 $863.00 $919.00 $977.00 $863.00 $919.00 $977.00
26740 90 $148.00 $326.00 $347.00 $363.00 $307.00 $327.00 $343.00
26742 90 $148.00 $527.00 $560.00 $590.00 $480.00 $511.00 $540.00
26746 90 $548.00 $1,078.00 $1,147.00 $1,222.00 $1,078.00 $1,147.00 $1,222.00
26750 90 $96.00 $259.00 $275.00 $287.00 $260.00 $276.00 $288.00
26755 90 $133.00 $445.00 $473.00 $496.00 $390.00 $414.00 $437.00
26756 90 $366.00 $598.00 $636.00 $672.00 $598.00 $636.00 $672.00
26765 90 $398.00 $721.00 $768.00 $813.00 $721.00 $768.00 $813.00
26770 90 $79.00 $390.00 $413.00 $432.00 $363.00 $384.00 $403.00
26775 90 $275.00 $544.00 $578.00 $607.00 $495.00 $526.00 $555.00
26776 90 $401.00 $636.00 $678.00 $717.00 $636.00 $678.00 $717.00
26785 90 $408.00 $791.00 $842.00 $893.00 $791.00 $842.00 $893.00
26820 90 $854.00 $1,092.00 $1,164.00 $1,234.00 $1,092.00 $1,164.00 $1,234.00
26841 90 $756.00 $1,025.00 $1,091.00 $1,149.00 $1,025.00 $1,091.00 $1,149.00
26842 90 $901.00 $1,111.00 $1,183.00 $1,248.00 $1,111.00 $1,183.00 $1,248.00
26843 90 $800.00 $1,045.00 $1,114.00 $1,178.00 $1,045.00 $1,114.00 $1,178.00
26844 90 $875.00 $1,169.00 $1,248.00 $1,326.00 $1,169.00 $1,248.00 $1,326.00
26850 90 $704.00 $976.00 $1,039.00 $1,093.00 $976.00 $1,039.00 $1,093.00
26852 90 $829.00 $1,128.00 $1,200.00 $1,266.00 $1,128.00 $1,200.00 $1,266.00
26860 90 $542.00 $792.00 $843.00 $883.00 $792.00 $843.00 $883.00
26861 ZZZ $151.00 $154.00 $163.00 $176.00 $154.00 $163.00 $176.00
26862 90 $747.00 $1,026.00 $1,092.00 $1,149.00 $1,026.00 $1,092.00 $1,149.00
26863 ZZZ $317.00 $342.00 $363.00 $390.00 $342.00 $363.00 $390.00
26910 90 $747.00 $1,024.00 $1,091.00 $1,154.00 $1,024.00 $1,091.00 $1,154.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 196
Surgery
CPT Code FUD 2003 MRALocality 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 $919.00 $980.00 $1,030.00 $919.00 $980.00 $1,030.00
26952 90 $608.00 $909.00 $968.00 $1,019.00 $909.00 $968.00 $1,019.00
26989 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
26990 90 $592.00 $913.00 $975.00 $1,043.00 $913.00 $975.00 $1,043.00
26991 90 $466.00 $1,011.00 $1,078.00 $1,137.00 $763.00 $813.00 $869.00
26992 90 $1,146.00 $1,402.00 $1,493.00 $1,598.00 $1,402.00 $1,493.00 $1,598.00
27000 90 $421.00 $590.00 $625.00 $661.00 $590.00 $625.00 $661.00
27001 90 $550.00 $790.00 $842.00 $900.00 $790.00 $842.00 $900.00
27003 90 $698.00 $850.00 $904.00 $964.00 $850.00 $904.00 $964.00
27005 90 $738.00 $1,058.00 $1,128.00 $1,207.00 $1,058.00 $1,128.00 $1,207.00
27006 90 $788.00 $1,072.00 $1,141.00 $1,219.00 $1,072.00 $1,141.00 $1,219.00
27025 90 $896.00 $1,335.00 $1,422.00 $1,522.00 $1,335.00 $1,422.00 $1,522.00
27027 90 ---------- $1,300.00 $1,384.00 $1,483.00 $1,300.00 $1,384.00 $1,483.00
27030 90 $1,148.00 $1,375.00 $1,466.00 $1,575.00 $1,375.00 $1,466.00 $1,575.00
27033 90 $1,173.00 $1,429.00 $1,524.00 $1,637.00 $1,429.00 $1,524.00 $1,637.00
27035 90 $1,413.00 $1,536.00 $1,607.00 $1,675.00 $1,536.00 $1,607.00 $1,675.00
27036 90 $1,176.00 $1,483.00 $1,582.00 $1,698.00 $1,483.00 $1,582.00 $1,698.00
27040 10 $196.00 $487.00 $518.00 $539.00 $291.00 $309.00 $328.00
27041 90 $699.00 $1,016.00 $1,082.00 $1,161.00 $1,016.00 $1,082.00 $1,161.00
27043 90 ---------- $697.00 $746.00 $810.00 $697.00 $746.00 $810.00
27045 90 ---------- $1,105.00 $1,181.00 $1,276.00 $1,105.00 $1,181.00 $1,276.00
27047 90 $535.00 $673.00 $720.00 $765.00 $532.00 $569.00 $613.00
27048 90 $588.00 $902.00 $965.00 $1,043.00 $902.00 $965.00 $1,043.00
27049 90 $1,162.00 $1,975.00 $2,108.00 $2,285.00 $1,975.00 $2,108.00 $2,285.00
27050 90 $449.00 $560.00 $597.00 $635.00 $560.00 $597.00 $635.00
27052 90 $624.00 $845.00 $902.00 $964.00 $845.00 $902.00 $964.00
27054 90 $843.00 $999.00 $1,065.00 $1,140.00 $999.00 $1,065.00 $1,140.00
27057 90 ---------- $1,490.00 $1,591.00 $1,716.00 $1,490.00 $1,591.00 $1,716.00
27059 90 ---------- $2,696.00 $2,881.00 $3,129.00 $2,696.00 $2,881.00 $3,129.00
27060 90 $491.00 $674.00 $719.00 $768.00 $674.00 $719.00 $768.00
27062 90 $499.00 $663.00 $707.00 $755.00 $663.00 $707.00 $755.00
27065 90 $583.00 $752.00 $802.00 $858.00 $752.00 $802.00 $858.00
27066 90 $931.00 $1,189.00 $1,268.00 $1,359.00 $1,189.00 $1,268.00 $1,359.00
27067 90 $1,234.00 $1,501.00 $1,599.00 $1,714.00 $1,501.00 $1,599.00 $1,714.00
27070 90 $1,040.00 $1,245.00 $1,327.00 $1,419.00 $1,245.00 $1,327.00 $1,419.00
27071 90 $1,112.00 $1,338.00 $1,428.00 $1,529.00 $1,338.00 $1,428.00 $1,529.00
27075 90 $1,485.00 $3,093.00 $3,301.00 $3,569.00 $3,093.00 $3,301.00 $3,569.00
27076 90 $1,859.00 $3,745.00 $3,994.00 $4,317.00 $3,745.00 $3,994.00 $4,317.00
27077 90 $1,976.00 $4,171.00 $4,440.00 $4,784.00 $4,171.00 $4,440.00 $4,784.00
27078 90 $1,164.00 $3,049.00 $3,251.00 $3,508.00 $3,049.00 $3,251.00 $3,508.00
27080 90 $568.00 $750.00 $803.00 $865.00 $750.00 $803.00 $865.00
27086 10 $57.00 $391.00 $417.00 $435.00 $233.00 $248.00 $264.00
27087 90 $555.00 $905.00 $964.00 $1,034.00 $905.00 $964.00 $1,034.00
27090 90 $981.00 $1,215.00 $1,295.00 $1,389.00 $1,215.00 $1,295.00 $1,389.00
27091 90 $1,482.00 $2,356.00 $2,512.00 $2,705.00 $2,356.00 $2,512.00 $2,705.00
27093 0 $62.00 $261.00 $277.00 $284.00 $103.00 $107.00 $113.00
27095 0 $121.00 $339.00 $360.00 $371.00 $122.00 $129.00 $137.00
27096 0 $491.00 $223.00 $235.00 $241.00 $121.00 $126.00 $131.00
27097 90 $795.00 $990.00 $1,057.00 $1,133.00 $990.00 $1,057.00 $1,133.00
27098 90 $799.00 $926.00 $978.00 $1,032.00 $926.00 $978.00 $1,032.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 197
Surgery
CPT Code FUD 2003 MRALocality 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)
27100 90 $987.00 $1,195.00 $1,273.00 $1,362.00 $1,195.00 $1,273.00 $1,362.00
27105 90 $946.00 $1,271.00 $1,357.00 $1,458.00 $1,271.00 $1,357.00 $1,458.00
27110 90 $1,174.00 $1,424.00 $1,520.00 $1,635.00 $1,424.00 $1,520.00 $1,635.00
27111 90 $1,099.00 $1,326.00 $1,418.00 $1,528.00 $1,326.00 $1,418.00 $1,528.00
27120 90 $1,603.00 $1,906.00 $2,031.00 $2,184.00 $1,906.00 $2,031.00 $2,184.00
27122 90 $1,406.00 $1,619.00 $1,727.00 $1,857.00 $1,619.00 $1,727.00 $1,857.00
27125 90 $1,371.00 $1,669.00 $1,781.00 $1,915.00 $1,669.00 $1,781.00 $1,915.00
27130 90 $1,853.00 $2,002.00 $2,133.00 $2,297.00 $2,002.00 $2,133.00 $2,297.00
27132 90 $2,128.00 $2,473.00 $2,636.00 $2,839.00 $2,473.00 $2,636.00 $2,839.00
27134 90 $2,576.00 $2,837.00 $3,024.00 $3,261.00 $2,837.00 $3,024.00 $3,261.00
27137 90 $2,190.00 $2,177.00 $2,320.00 $2,500.00 $2,177.00 $2,320.00 $2,500.00
27138 90 $2,025.00 $2,262.00 $2,411.00 $2,597.00 $2,262.00 $2,411.00 $2,597.00
27140 90 $1,092.00 $1,308.00 $1,394.00 $1,494.00 $1,308.00 $1,394.00 $1,494.00
27146 90 $1,432.00 $1,874.00 $1,997.00 $2,145.00 $1,874.00 $1,997.00 $2,145.00
27147 90 $1,744.00 $2,152.00 $2,293.00 $2,464.00 $2,152.00 $2,293.00 $2,464.00
27151 90 $1,732.00 $2,354.00 $2,512.00 $2,710.00 $2,354.00 $2,512.00 $2,710.00
27156 90 $2,017.00 $2,495.00 $2,652.00 $2,842.00 $2,495.00 $2,652.00 $2,842.00
27158 90 $1,588.00 $2,072.00 $2,212.00 $2,387.00 $2,072.00 $2,212.00 $2,387.00
27161 90 $1,443.00 $1,786.00 $1,903.00 $2,044.00 $1,786.00 $1,903.00 $2,044.00
27165 90 $1,572.00 $2,021.00 $2,154.00 $2,315.00 $2,021.00 $2,154.00 $2,315.00
27170 90 $1,453.00 $1,733.00 $1,848.00 $1,989.00 $1,733.00 $1,848.00 $1,989.00
27175 90 $491.00 $957.00 $1,016.00 $1,081.00 $957.00 $1,016.00 $1,081.00
27176 90 $1,024.00 $1,349.00 $1,440.00 $1,548.00 $1,349.00 $1,440.00 $1,548.00
27177 90 $1,257.00 $1,641.00 $1,752.00 $1,886.00 $1,641.00 $1,752.00 $1,886.00
27178 90 $1,020.00 $1,162.00 $1,218.00 $1,272.00 $1,162.00 $1,218.00 $1,272.00
27179 90 $1,107.00 $1,400.00 $1,490.00 $1,595.00 $1,400.00 $1,490.00 $1,595.00
27181 90 $1,206.00 $1,933.00 $2,119.00 $2,386.00 $1,933.00 $2,119.00 $2,386.00
27185 90 $676.00 $1,052.00 $1,123.00 $1,205.00 $1,052.00 $1,123.00 $1,205.00
27187 90 $1,280.00 $1,456.00 $1,553.00 $1,668.00 $1,456.00 $1,553.00 $1,668.00
27197 0 ---------- $168.00 $178.00 $187.00 $168.00 $178.00 $187.00
27198 0 ---------- $435.00 $460.00 $491.00 $435.00 $460.00 $491.00
27200 90 $180.00 $259.00 $276.00 $291.00 $269.00 $287.00 $302.00
27202 90 $776.00 $819.00 $881.00 $960.00 $819.00 $881.00 $960.00
27215 90 $954.00 $912.00 $962.00 $1,020.00 $912.00 $962.00 $1,020.00
27216 90 $1,085.00 $1,353.00 $1,427.00 $1,514.00 $1,353.00 $1,427.00 $1,514.00
27217 90 $1,285.00 $1,269.00 $1,338.00 $1,420.00 $1,269.00 $1,338.00 $1,420.00
27218 90 $1,570.00 $1,758.00 $1,853.00 $1,968.00 $1,758.00 $1,853.00 $1,968.00
27220 90 $444.00 $770.00 $822.00 $877.00 $765.00 $815.00 $871.00
27222 90 $973.00 $1,431.00 $1,526.00 $1,639.00 $1,431.00 $1,526.00 $1,639.00
27226 90 $1,350.00 $1,556.00 $1,659.00 $1,785.00 $1,556.00 $1,659.00 $1,785.00
27227 90 $1,967.00 $2,455.00 $2,618.00 $2,823.00 $2,455.00 $2,618.00 $2,823.00
27228 90 $2,195.00 $2,793.00 $2,978.00 $3,214.00 $2,793.00 $2,978.00 $3,214.00
27230 90 $491.00 $688.00 $733.00 $780.00 $683.00 $728.00 $775.00
27232 90 $916.00 $1,101.00 $1,171.00 $1,258.00 $1,101.00 $1,171.00 $1,258.00
27235 90 $1,128.00 $1,337.00 $1,427.00 $1,535.00 $1,337.00 $1,427.00 $1,535.00
27236 90 $1,421.00 $1,762.00 $1,879.00 $2,020.00 $1,762.00 $1,879.00 $2,020.00
27238 90 $504.00 $668.00 $712.00 $759.00 $668.00 $712.00 $759.00
27240 90 $1,043.00 $1,407.00 $1,500.00 $1,612.00 $1,407.00 $1,500.00 $1,612.00
27244 90 $1,426.00 $1,814.00 $1,935.00 $2,082.00 $1,814.00 $1,935.00 $2,082.00
27245 90 $1,691.00 $1,814.00 $1,935.00 $2,082.00 $1,814.00 $1,935.00 $2,082.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 198
Surgery
CPT Code FUD 2003 MRALocality 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)
27246 90 $459.00 $558.00 $594.00 $634.00 $560.00 $598.00 $637.00
27248 90 $980.00 $1,091.00 $1,163.00 $1,249.00 $1,091.00 $1,163.00 $1,249.00
27250 0 $535.00 $269.00 $284.00 $307.00 $269.00 $284.00 $307.00
27252 90 $520.00 $1,112.00 $1,185.00 $1,273.00 $1,112.00 $1,185.00 $1,273.00
27253 90 $1,162.00 $1,384.00 $1,477.00 $1,587.00 $1,384.00 $1,477.00 $1,587.00
27254 90 $1,478.00 $1,868.00 $1,992.00 $2,144.00 $1,868.00 $1,992.00 $2,144.00
27256 10 $338.00 $432.00 $458.00 $486.00 $346.00 $366.00 $393.00
27257 10 $455.00 $502.00 $534.00 $574.00 $502.00 $534.00 $574.00
27258 90 $1,355.00 $1,634.00 $1,745.00 $1,880.00 $1,634.00 $1,745.00 $1,880.00
27259 90 $1,803.00 $2,296.00 $2,451.00 $2,643.00 $2,296.00 $2,451.00 $2,643.00
27265 90 $442.00 $574.00 $609.00 $644.00 $574.00 $609.00 $644.00
27266 90 $614.00 $848.00 $905.00 $969.00 $848.00 $905.00 $969.00
27267 90 ---------- $627.00 $668.00 $711.00 $627.00 $668.00 $711.00
27268 90 ---------- $772.00 $821.00 $875.00 $772.00 $821.00 $875.00
27269 90 ---------- $1,836.00 $1,958.00 $2,110.00 $1,836.00 $1,958.00 $2,110.00
27275 10 $220.00 $264.00 $281.00 $299.00 $264.00 $281.00 $299.00
27279 90 ---------- $1,025.00 $1,104.00 $1,205.00 $1,025.00 $1,104.00 $1,205.00
27280 90 $1,179.00 $2,041.00 $2,201.00 $2,419.00 $2,041.00 $2,201.00 $2,419.00
27282 90 $990.00 $1,192.00 $1,269.00 $1,358.00 $1,192.00 $1,269.00 $1,358.00
27284 90 $1,435.00 $2,162.00 $2,272.00 $2,393.00 $2,162.00 $2,272.00 $2,393.00
27286 90 $1,503.00 $2,384.00 $2,530.00 $2,702.00 $2,384.00 $2,530.00 $2,702.00
27290 90 $2,073.00 $2,379.00 $2,540.00 $2,743.00 $2,379.00 $2,540.00 $2,743.00
27295 90 $1,594.00 $1,874.00 $2,000.00 $2,163.00 $1,874.00 $2,000.00 $2,163.00
27299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
27301 90 $193.00 $964.00 $1,030.00 $1,090.00 $734.00 $785.00 $843.00
27303 90 $520.00 $935.00 $997.00 $1,068.00 $935.00 $997.00 $1,068.00
27305 90 $555.00 $697.00 $742.00 $790.00 $697.00 $742.00 $790.00
27306 90 $377.00 $507.00 $536.00 $564.00 $507.00 $536.00 $564.00
27307 90 $503.00 $619.00 $656.00 $697.00 $619.00 $656.00 $697.00
27310 90 $877.00 $1,068.00 $1,139.00 $1,221.00 $1,068.00 $1,139.00 $1,221.00
27323 10 $211.00 $384.00 $409.00 $428.00 $259.00 $276.00 $293.00
27324 90 $433.00 $581.00 $622.00 $668.00 $581.00 $622.00 $668.00
27325 90 ---------- $754.00 $810.00 $880.00 $754.00 $810.00 $880.00
27326 90 ---------- $729.00 $781.00 $840.00 $729.00 $781.00 $840.00
27327 90 $400.00 $654.00 $699.00 $736.00 $458.00 $490.00 $524.00
27328 90 $503.00 $915.00 $978.00 $1,055.00 $915.00 $978.00 $1,055.00
27329 90 $1,249.00 $1,539.00 $1,646.00 $1,784.00 $1,539.00 $1,646.00 $1,784.00
27330 90 $492.00 $597.00 $637.00 $679.00 $597.00 $637.00 $679.00
27331 90 $585.00 $690.00 $736.00 $785.00 $690.00 $736.00 $785.00
27332 90 $786.00 $936.00 $999.00 $1,069.00 $936.00 $999.00 $1,069.00
27333 90 $719.00 $854.00 $912.00 $976.00 $854.00 $912.00 $976.00
27334 90 $840.00 $997.00 $1,063.00 $1,137.00 $997.00 $1,063.00 $1,137.00
27335 90 $959.00 $1,114.00 $1,187.00 $1,271.00 $1,114.00 $1,187.00 $1,271.00
27337 90 ---------- $616.00 $660.00 $714.00 $616.00 $660.00 $714.00
27339 90 ---------- $1,113.00 $1,190.00 $1,287.00 $1,113.00 $1,190.00 $1,287.00
27340 90 $405.00 $537.00 $573.00 $610.00 $537.00 $573.00 $610.00
27345 90 $565.00 $697.00 $743.00 $793.00 $697.00 $743.00 $793.00
27347 90 $394.00 $769.00 $820.00 $876.00 $769.00 $820.00 $876.00
27350 90 $786.00 $949.00 $1,012.00 $1,082.00 $949.00 $1,012.00 $1,082.00
27355 90 $763.00 $879.00 $937.00 $1,002.00 $879.00 $937.00 $1,002.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 199
Surgery
CPT Code FUD 2003 MRALocality 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)
27356 90 $882.00 $1,073.00 $1,143.00 $1,223.00 $1,073.00 $1,143.00 $1,223.00
27357 90 $950.00 $1,190.00 $1,270.00 $1,361.00 $1,190.00 $1,270.00 $1,361.00
27358 ZZZ $394.00 $417.00 $445.00 $483.00 $417.00 $445.00 $483.00
27360 90 $977.00 $1,240.00 $1,322.00 $1,415.00 $1,240.00 $1,322.00 $1,415.00
27364 90 ---------- $2,314.00 $2,471.00 $2,675.00 $2,314.00 $2,471.00 $2,675.00
27365 90 $1,421.00 $3,054.00 $3,257.00 $3,515.00 $3,054.00 $3,257.00 $3,515.00
27370 0 $75.00 $214.00 $227.00 $233.00 $74.00 $78.00 $82.00
27372 90 $371.00 $857.00 $914.00 $959.00 $585.00 $623.00 $665.00
27380 90 $698.00 $861.00 $918.00 $979.00 $861.00 $918.00 $979.00
27381 90 $1,118.00 $1,165.00 $1,242.00 $1,329.00 $1,165.00 $1,242.00 $1,329.00
27385 90 $753.00 $832.00 $887.00 $944.00 $832.00 $887.00 $944.00
27386 90 $1,064.00 $1,207.00 $1,287.00 $1,375.00 $1,207.00 $1,287.00 $1,375.00
27390 90 $506.00 $641.00 $685.00 $732.00 $641.00 $685.00 $732.00
27391 90 $647.00 $832.00 $886.00 $944.00 $832.00 $886.00 $944.00
27392 90 $834.00 $1,023.00 $1,090.00 $1,168.00 $1,023.00 $1,090.00 $1,168.00
27393 90 $608.00 $742.00 $791.00 $845.00 $742.00 $791.00 $845.00
27394 90 $748.00 $921.00 $974.00 $1,028.00 $921.00 $974.00 $1,028.00
27395 90 $1,093.00 $1,289.00 $1,376.00 $1,478.00 $1,289.00 $1,376.00 $1,478.00
27396 90 $742.00 $894.00 $955.00 $1,024.00 $894.00 $955.00 $1,024.00
27397 90 $989.00 $1,325.00 $1,413.00 $1,516.00 $1,325.00 $1,413.00 $1,516.00
27400 90 $832.00 $1,001.00 $1,069.00 $1,148.00 $1,001.00 $1,069.00 $1,148.00
27403 90 $792.00 $933.00 $996.00 $1,066.00 $933.00 $996.00 $1,066.00
27405 90 $842.00 $983.00 $1,048.00 $1,121.00 $983.00 $1,048.00 $1,121.00
27407 90 $918.00 $1,132.00 $1,206.00 $1,291.00 $1,132.00 $1,206.00 $1,291.00
27409 90 $1,212.00 $1,418.00 $1,514.00 $1,628.00 $1,418.00 $1,514.00 $1,628.00
27412 90 ---------- $2,441.00 $2,605.00 $2,807.00 $2,441.00 $2,605.00 $2,807.00
27415 90 ---------- $2,025.00 $2,161.00 $2,327.00 $2,025.00 $2,161.00 $2,327.00
27416 90 ---------- $1,444.00 $1,541.00 $1,659.00 $1,444.00 $1,541.00 $1,659.00
27418 90 $1,596.00 $1,206.00 $1,285.00 $1,376.00 $1,206.00 $1,285.00 $1,376.00
27420 90 $927.00 $1,086.00 $1,157.00 $1,239.00 $1,086.00 $1,157.00 $1,239.00
27422 90 $930.00 $1,085.00 $1,157.00 $1,239.00 $1,085.00 $1,157.00 $1,239.00
27424 90 $927.00 $1,096.00 $1,170.00 $1,256.00 $1,096.00 $1,170.00 $1,256.00
27425 90 $639.00 $649.00 $693.00 $738.00 $649.00 $693.00 $738.00
27427 90 $1,118.00 $1,039.00 $1,107.00 $1,185.00 $1,039.00 $1,107.00 $1,185.00
27428 90 $1,266.00 $1,627.00 $1,734.00 $1,857.00 $1,627.00 $1,734.00 $1,857.00
27429 90 $2,333.00 $1,818.00 $1,936.00 $2,072.00 $1,818.00 $1,936.00 $2,072.00
27430 90 $884.00 $1,079.00 $1,151.00 $1,232.00 $1,079.00 $1,151.00 $1,232.00
27435 90 $501.00 $1,177.00 $1,255.00 $1,341.00 $1,177.00 $1,255.00 $1,341.00
27437 90 $819.00 $968.00 $1,033.00 $1,108.00 $968.00 $1,033.00 $1,108.00
27438 90 $1,065.00 $1,230.00 $1,311.00 $1,405.00 $1,230.00 $1,311.00 $1,405.00
27440 90 $1,064.00 $1,165.00 $1,242.00 $1,331.00 $1,165.00 $1,242.00 $1,331.00
27441 90 $1,006.00 $1,211.00 $1,292.00 $1,389.00 $1,211.00 $1,292.00 $1,389.00
27442 90 $1,117.00 $1,275.00 $1,359.00 $1,458.00 $1,275.00 $1,359.00 $1,458.00
27443 90 $1,037.00 $1,193.00 $1,273.00 $1,367.00 $1,193.00 $1,273.00 $1,367.00
27445 90 $1,618.00 $1,846.00 $1,969.00 $2,119.00 $1,846.00 $1,969.00 $2,119.00
27446 90 $1,764.00 $1,709.00 $1,822.00 $1,960.00 $1,709.00 $1,822.00 $1,960.00
27447 90 $1,960.00 $2,000.00 $2,132.00 $2,295.00 $2,000.00 $2,132.00 $2,295.00
27448 90 $1,060.00 $1,125.00 $1,193.00 $1,270.00 $1,125.00 $1,193.00 $1,270.00
27450 90 $1,311.00 $1,488.00 $1,587.00 $1,704.00 $1,488.00 $1,587.00 $1,704.00
27454 90 $1,524.00 $1,913.00 $2,041.00 $2,197.00 $1,913.00 $2,041.00 $2,197.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 200
Surgery
CPT Code FUD 2003 MRALocality 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)
27455 90 $1,157.00 $1,381.00 $1,473.00 $1,582.00 $1,381.00 $1,473.00 $1,582.00
27457 90 $1,209.00 $1,388.00 $1,477.00 $1,584.00 $1,388.00 $1,477.00 $1,584.00
27465 90 $1,253.00 $1,817.00 $1,936.00 $2,083.00 $1,817.00 $1,936.00 $2,083.00
27466 90 $1,441.00 $1,726.00 $1,839.00 $1,975.00 $1,726.00 $1,839.00 $1,975.00
27468 90 $1,613.00 $1,983.00 $2,117.00 $2,283.00 $1,983.00 $2,117.00 $2,283.00
27470 90 $1,501.00 $1,728.00 $1,843.00 $1,980.00 $1,728.00 $1,843.00 $1,980.00
27472 90 $1,665.00 $1,859.00 $1,982.00 $2,132.00 $1,859.00 $1,982.00 $2,132.00
27475 90 $782.00 $968.00 $1,033.00 $1,108.00 $968.00 $1,033.00 $1,108.00
27477 90 $938.00 $1,075.00 $1,147.00 $1,232.00 $1,075.00 $1,147.00 $1,232.00
27479 90 $1,123.00 $1,354.00 $1,445.00 $1,555.00 $1,354.00 $1,445.00 $1,555.00
27485 90 $797.00 $975.00 $1,041.00 $1,116.00 $975.00 $1,041.00 $1,116.00
27486 90 $1,771.00 $2,074.00 $2,210.00 $2,377.00 $2,074.00 $2,210.00 $2,377.00
27487 90 $2,352.00 $2,598.00 $2,768.00 $2,982.00 $2,598.00 $2,768.00 $2,982.00
27488 90 $1,438.00 $1,766.00 $1,882.00 $2,023.00 $1,766.00 $1,882.00 $2,023.00
27495 90 $1,477.00 $1,656.00 $1,766.00 $1,900.00 $1,656.00 $1,766.00 $1,900.00
27496 90 $563.00 $782.00 $835.00 $892.00 $782.00 $835.00 $892.00
27497 90 $652.00 $845.00 $902.00 $968.00 $845.00 $902.00 $968.00
27498 90 $701.00 $950.00 $1,014.00 $1,086.00 $950.00 $1,014.00 $1,086.00
27499 90 $782.00 $1,006.00 $1,069.00 $1,138.00 $1,006.00 $1,069.00 $1,138.00
27500 90 $520.00 $750.00 $799.00 $850.00 $698.00 $743.00 $793.00
27501 90 $659.00 $732.00 $781.00 $834.00 $726.00 $775.00 $828.00
27502 90 $909.00 $1,114.00 $1,186.00 $1,271.00 $1,114.00 $1,186.00 $1,271.00
27503 90 $911.00 $1,171.00 $1,249.00 $1,340.00 $1,171.00 $1,249.00 $1,340.00
27506 90 $1,522.00 $1,970.00 $2,101.00 $2,259.00 $1,970.00 $2,101.00 $2,259.00
27507 90 $1,297.00 $1,432.00 $1,527.00 $1,643.00 $1,432.00 $1,527.00 $1,643.00
27508 90 $400.00 $756.00 $806.00 $855.00 $714.00 $761.00 $809.00
27509 90 $649.00 $932.00 $993.00 $1,058.00 $932.00 $993.00 $1,058.00
27510 90 $755.00 $998.00 $1,063.00 $1,139.00 $998.00 $1,063.00 $1,139.00
27511 90 $1,281.00 $1,471.00 $1,569.00 $1,690.00 $1,471.00 $1,569.00 $1,690.00
27513 90 $1,562.00 $1,834.00 $1,955.00 $2,110.00 $1,834.00 $1,955.00 $2,110.00
27514 90 $1,508.00 $1,426.00 $1,520.00 $1,637.00 $1,426.00 $1,520.00 $1,637.00
27516 90 $579.00 $730.00 $779.00 $826.00 $687.00 $734.00 $781.00
27517 90 $820.00 $933.00 $990.00 $1,053.00 $933.00 $990.00 $1,053.00
27519 90 $1,311.00 $1,316.00 $1,405.00 $1,515.00 $1,316.00 $1,405.00 $1,515.00
27520 90 $266.00 $459.00 $489.00 $513.00 $421.00 $448.00 $473.00
27524 90 $910.00 $1,100.00 $1,173.00 $1,257.00 $1,100.00 $1,173.00 $1,257.00
27530 90 $408.00 $428.00 $456.00 $478.00 $399.00 $425.00 $447.00
27532 90 $641.00 $891.00 $950.00 $1,013.00 $840.00 $896.00 $958.00
27535 90 $1,075.00 $1,322.00 $1,410.00 $1,518.00 $1,322.00 $1,410.00 $1,518.00
27536 90 $1,282.00 $1,750.00 $1,866.00 $2,006.00 $1,750.00 $1,866.00 $2,006.00
27538 90 $487.00 $683.00 $729.00 $771.00 $642.00 $685.00 $727.00
27540 90 $1,106.00 $1,188.00 $1,267.00 $1,357.00 $1,188.00 $1,267.00 $1,357.00
27550 90 $296.00 $729.00 $776.00 $821.00 $679.00 $723.00 $767.00
27552 90 $619.00 $913.00 $973.00 $1,040.00 $913.00 $973.00 $1,040.00
27556 90 $832.00 $1,270.00 $1,352.00 $1,452.00 $1,270.00 $1,352.00 $1,452.00
27557 90 $1,479.00 $1,506.00 $1,603.00 $1,723.00 $1,506.00 $1,603.00 $1,723.00
27558 90 $1,529.00 $1,769.00 $1,887.00 $2,037.00 $1,769.00 $1,887.00 $2,037.00
27560 90 $88.00 $513.00 $545.00 $574.00 $476.00 $505.00 $533.00
27562 90 $514.00 $688.00 $732.00 $779.00 $688.00 $732.00 $779.00
27566 90 $1,047.00 $1,304.00 $1,391.00 $1,493.00 $1,304.00 $1,391.00 $1,493.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 201
Surgery
CPT Code FUD 2003 MRALocality 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)
27570 10 $184.00 $219.00 $234.00 $249.00 $219.00 $234.00 $249.00
27580 90 $1,644.00 $2,114.00 $2,254.00 $2,423.00 $2,114.00 $2,254.00 $2,423.00
27590 90 $1,059.00 $1,203.00 $1,289.00 $1,410.00 $1,203.00 $1,289.00 $1,410.00
27591 90 $1,182.00 $1,421.00 $1,517.00 $1,632.00 $1,421.00 $1,517.00 $1,632.00
27592 90 $911.00 $1,021.00 $1,092.00 $1,190.00 $1,021.00 $1,092.00 $1,190.00
27594 90 $600.00 $747.00 $800.00 $866.00 $747.00 $800.00 $866.00
27596 90 $931.00 $1,077.00 $1,153.00 $1,254.00 $1,077.00 $1,153.00 $1,254.00
27598 90 $976.00 $1,067.00 $1,142.00 $1,240.00 $1,067.00 $1,142.00 $1,240.00
27599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
27600 90 $517.00 $600.00 $641.00 $690.00 $600.00 $641.00 $690.00
27601 90 $516.00 $653.00 $697.00 $747.00 $653.00 $697.00 $747.00
27602 90 $621.00 $728.00 $780.00 $850.00 $728.00 $780.00 $850.00
27603 90 $412.00 $756.00 $807.00 $851.00 $566.00 $603.00 $645.00
27604 90 $308.00 $697.00 $742.00 $775.00 $498.00 $529.00 $560.00
27605 10 $236.00 $482.00 $510.00 $525.00 $268.00 $281.00 $294.00
27606 10 $362.00 $411.00 $436.00 $464.00 $411.00 $436.00 $464.00
27607 90 $608.00 $888.00 $945.00 $1,010.00 $888.00 $945.00 $1,010.00
27610 90 $777.00 $947.00 $1,007.00 $1,074.00 $947.00 $1,007.00 $1,074.00
27612 90 $701.00 $817.00 $864.00 $912.00 $817.00 $864.00 $912.00
27613 10 $165.00 $357.00 $379.00 $393.00 $235.00 $249.00 $262.00
27614 90 $327.00 $827.00 $879.00 $921.00 $591.00 $627.00 $666.00
27615 90 $1,106.00 $1,511.00 $1,612.00 $1,740.00 $1,511.00 $1,612.00 $1,740.00
27616 90 ---------- $1,878.00 $2,004.00 $2,164.00 $1,878.00 $2,004.00 $2,164.00
27618 90 $421.00 $642.00 $685.00 $719.00 $450.00 $479.00 $511.00
27619 90 $730.00 $682.00 $722.00 $767.00 $682.00 $722.00 $767.00
27620 90 $587.00 $659.00 $700.00 $741.00 $659.00 $700.00 $741.00
27625 90 $796.00 $843.00 $892.00 $945.00 $843.00 $892.00 $945.00
27626 90 $863.00 $880.00 $930.00 $984.00 $880.00 $930.00 $984.00
27630 90 $430.00 $793.00 $842.00 $876.00 $528.00 $559.00 $590.00
27632 90 ---------- $607.00 $648.00 $698.00 $607.00 $648.00 $698.00
27634 90 ---------- $1,009.00 $1,076.00 $1,158.00 $1,009.00 $1,076.00 $1,158.00
27635 90 $781.00 $853.00 $907.00 $967.00 $853.00 $907.00 $967.00
27637 90 $921.00 $1,115.00 $1,189.00 $1,275.00 $1,115.00 $1,189.00 $1,275.00
27638 90 $978.00 $1,115.00 $1,185.00 $1,267.00 $1,115.00 $1,185.00 $1,267.00
27640 90 $1,122.00 $1,221.00 $1,299.00 $1,389.00 $1,221.00 $1,299.00 $1,389.00
27641 90 $922.00 $975.00 $1,034.00 $1,101.00 $975.00 $1,034.00 $1,101.00
27645 90 $1,302.00 $2,623.00 $2,797.00 $3,016.00 $2,623.00 $2,797.00 $3,016.00
27646 90 $1,212.00 $2,190.00 $2,331.00 $2,506.00 $2,190.00 $2,331.00 $2,506.00
27647 90 $1,044.00 $1,489.00 $1,545.00 $1,603.00 $1,489.00 $1,545.00 $1,603.00
27648 0 $72.00 $231.00 $245.00 $252.00 $78.00 $82.00 $87.00
27650 90 $869.00 $955.00 $1,012.00 $1,071.00 $955.00 $1,012.00 $1,071.00
27652 90 $935.00 $996.00 $1,050.00 $1,108.00 $996.00 $1,050.00 $1,108.00
27654 90 $937.00 $1,028.00 $1,086.00 $1,147.00 $1,028.00 $1,086.00 $1,147.00
27656 90 $458.00 $881.00 $940.00 $982.00 $566.00 $604.00 $644.00
27658 90 $527.00 $539.00 $570.00 $600.00 $539.00 $570.00 $600.00
27659 90 $725.00 $693.00 $731.00 $770.00 $693.00 $731.00 $770.00
27664 90 $504.00 $524.00 $555.00 $586.00 $524.00 $555.00 $586.00
27665 90 $618.00 $594.00 $628.00 $662.00 $594.00 $628.00 $662.00
27675 90 $656.00 $710.00 $749.00 $790.00 $710.00 $749.00 $790.00
27676 90 $762.00 $883.00 $936.00 $994.00 $883.00 $936.00 $994.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 202
Surgery
CPT Code FUD 2003 MRALocality 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)
27680 90 $523.00 $623.00 $661.00 $701.00 $623.00 $661.00 $701.00
27681 90 $634.00 $797.00 $851.00 $911.00 $797.00 $851.00 $911.00
27685 90 $565.00 $945.00 $1,001.00 $1,040.00 $671.00 $708.00 $745.00
27686 90 $706.00 $814.00 $865.00 $921.00 $814.00 $865.00 $921.00
27687 90 $589.00 $658.00 $696.00 $734.00 $658.00 $696.00 $734.00
27690 90 $757.00 $918.00 $969.00 $1,021.00 $918.00 $969.00 $1,021.00
27691 90 $889.00 $1,089.00 $1,156.00 $1,228.00 $1,089.00 $1,156.00 $1,228.00
27692 ZZZ $159.00 $156.00 $165.00 $178.00 $156.00 $165.00 $178.00
27695 90 $658.00 $691.00 $732.00 $772.00 $691.00 $732.00 $772.00
27696 90 $758.00 $802.00 $845.00 $889.00 $802.00 $845.00 $889.00
27698 90 $881.00 $933.00 $987.00 $1,047.00 $933.00 $987.00 $1,047.00
27700 90 $835.00 $885.00 $932.00 $982.00 $885.00 $932.00 $982.00
27702 90 $1,278.00 $1,413.00 $1,501.00 $1,606.00 $1,413.00 $1,501.00 $1,606.00
27703 90 $1,337.00 $1,627.00 $1,729.00 $1,849.00 $1,627.00 $1,729.00 $1,849.00
27704 90 $683.00 $837.00 $891.00 $949.00 $837.00 $891.00 $949.00
27705 90 $985.00 $1,109.00 $1,180.00 $1,262.00 $1,109.00 $1,180.00 $1,262.00
27707 90 $484.00 $578.00 $616.00 $653.00 $578.00 $616.00 $653.00
27709 90 $1,118.00 $1,724.00 $1,837.00 $1,975.00 $1,724.00 $1,837.00 $1,975.00
27712 90 $1,227.00 $1,628.00 $1,738.00 $1,871.00 $1,628.00 $1,738.00 $1,871.00
27715 90 $1,285.00 $1,547.00 $1,650.00 $1,776.00 $1,547.00 $1,650.00 $1,776.00
27720 90 $1,147.00 $1,281.00 $1,366.00 $1,464.00 $1,281.00 $1,366.00 $1,464.00
27722 90 $1,076.00 $1,307.00 $1,394.00 $1,497.00 $1,307.00 $1,394.00 $1,497.00
27724 90 $1,402.00 $1,865.00 $1,988.00 $2,141.00 $1,865.00 $1,988.00 $2,141.00
27725 90 $1,312.00 $1,754.00 $1,871.00 $2,012.00 $1,754.00 $1,871.00 $2,012.00
27726 90 ---------- $1,416.00 $1,508.00 $1,620.00 $1,416.00 $1,508.00 $1,620.00
27727 90 $1,175.00 $1,309.00 $1,383.00 $1,473.00 $1,309.00 $1,383.00 $1,473.00
27730 90 $647.00 $807.00 $858.00 $914.00 $807.00 $858.00 $914.00
27732 90 $611.00 $537.00 $567.00 $598.00 $537.00 $567.00 $598.00
27734 90 $766.00 $960.00 $1,025.00 $1,099.00 $960.00 $1,025.00 $1,099.00
27740 90 $1,044.00 $1,008.00 $1,069.00 $1,133.00 $1,008.00 $1,069.00 $1,133.00
27742 90 $1,045.00 $1,093.00 $1,156.00 $1,218.00 $1,093.00 $1,156.00 $1,218.00
27745 90 $940.00 $1,106.00 $1,179.00 $1,262.00 $1,106.00 $1,179.00 $1,262.00
27750 90 $319.00 $494.00 $526.00 $553.00 $455.00 $484.00 $511.00
27752 90 $614.00 $773.00 $824.00 $875.00 $717.00 $764.00 $815.00
27756 90 $708.00 $839.00 $895.00 $955.00 $839.00 $895.00 $955.00
27758 90 $1,115.00 $1,306.00 $1,393.00 $1,494.00 $1,306.00 $1,393.00 $1,494.00
27759 90 $1,262.00 $1,468.00 $1,565.00 $1,682.00 $1,468.00 $1,565.00 $1,682.00
27760 90 $223.00 $472.00 $502.00 $525.00 $433.00 $460.00 $483.00
27762 90 $495.00 $674.00 $716.00 $755.00 $617.00 $655.00 $693.00
27766 90 $759.00 $886.00 $945.00 $1,008.00 $886.00 $945.00 $1,008.00
27767 90 ---------- $398.00 $424.00 $445.00 $401.00 $427.00 $447.00
27768 90 ---------- $633.00 $676.00 $719.00 $633.00 $676.00 $719.00
27769 90 ---------- $1,058.00 $1,128.00 $1,209.00 $1,058.00 $1,128.00 $1,209.00
27780 90 $244.00 $434.00 $462.00 $484.00 $397.00 $423.00 $445.00
27781 90 $296.00 $611.00 $651.00 $687.00 $569.00 $606.00 $642.00
27784 90 $643.00 $1,044.00 $1,113.00 $1,191.00 $1,044.00 $1,113.00 $1,191.00
27786 90 $223.00 $448.00 $477.00 $500.00 $408.00 $434.00 $457.00
27788 90 $422.00 $602.00 $640.00 $675.00 $552.00 $587.00 $621.00
27792 90 $706.00 $951.00 $1,014.00 $1,083.00 $951.00 $1,014.00 $1,083.00
27808 90 $332.00 $474.00 $505.00 $529.00 $428.00 $455.00 $479.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 203
Surgery
CPT Code FUD 2003 MRALocality 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)
27810 90 $567.00 $667.00 $710.00 $749.00 $609.00 $647.00 $686.00
27814 90 $972.00 $1,127.00 $1,201.00 $1,285.00 $1,127.00 $1,201.00 $1,285.00
27816 90 $386.00 $457.00 $486.00 $510.00 $412.00 $439.00 $461.00
27818 90 $613.00 $693.00 $736.00 $777.00 $625.00 $664.00 $704.00
27822 90 $1,201.00 $1,251.00 $1,333.00 $1,421.00 $1,251.00 $1,333.00 $1,421.00
27823 90 $1,472.00 $1,422.00 $1,515.00 $1,619.00 $1,422.00 $1,515.00 $1,619.00
27824 90 $384.00 $448.00 $477.00 $502.00 $436.00 $464.00 $489.00
27825 90 $670.00 $785.00 $836.00 $888.00 $717.00 $763.00 $814.00
27826 90 $1,080.00 $1,238.00 $1,319.00 $1,406.00 $1,238.00 $1,319.00 $1,406.00
27827 90 $1,310.00 $1,606.00 $1,712.00 $1,830.00 $1,606.00 $1,712.00 $1,830.00
27828 90 $1,823.00 $1,926.00 $2,053.00 $2,200.00 $1,926.00 $2,053.00 $2,200.00
27829 90 $742.00 $1,011.00 $1,077.00 $1,145.00 $1,011.00 $1,077.00 $1,145.00
27830 90 $412.00 $540.00 $576.00 $609.00 $505.00 $539.00 $572.00
27831 90 $415.00 $545.00 $579.00 $611.00 $545.00 $579.00 $611.00
27832 90 $617.00 $1,107.00 $1,181.00 $1,267.00 $1,107.00 $1,181.00 $1,267.00
27840 90 $334.00 $528.00 $560.00 $591.00 $528.00 $560.00 $591.00
27842 90 $373.00 $716.00 $763.00 $813.00 $716.00 $763.00 $813.00
27846 90 $877.00 $1,064.00 $1,132.00 $1,209.00 $1,064.00 $1,132.00 $1,209.00
27848 90 $1,224.00 $1,180.00 $1,255.00 $1,342.00 $1,180.00 $1,255.00 $1,342.00
27860 10 $211.00 $251.00 $266.00 $282.00 $251.00 $266.00 $282.00
27870 90 $1,269.00 $1,509.00 $1,604.00 $1,714.00 $1,509.00 $1,604.00 $1,714.00
27871 90 $843.00 $999.00 $1,063.00 $1,135.00 $999.00 $1,063.00 $1,135.00
27880 90 $1,015.00 $1,377.00 $1,474.00 $1,610.00 $1,377.00 $1,474.00 $1,610.00
27881 90 $1,120.00 $1,290.00 $1,379.00 $1,495.00 $1,290.00 $1,379.00 $1,495.00
27882 90 $854.00 $899.00 $963.00 $1,050.00 $899.00 $963.00 $1,050.00
27884 90 $579.00 $857.00 $917.00 $996.00 $857.00 $917.00 $996.00
27886 90 $835.00 $979.00 $1,048.00 $1,137.00 $979.00 $1,048.00 $1,137.00
27888 90 $911.00 $1,016.00 $1,083.00 $1,164.00 $1,016.00 $1,083.00 $1,164.00
27889 90 $879.00 $972.00 $1,041.00 $1,136.00 $972.00 $1,041.00 $1,136.00
27892 90 $575.00 $814.00 $867.00 $929.00 $814.00 $867.00 $929.00
27893 90 $574.00 $884.00 $944.00 $1,010.00 $884.00 $944.00 $1,010.00
27894 90 $712.00 $1,264.00 $1,350.00 $1,456.00 $1,264.00 $1,350.00 $1,456.00
27899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
28001 10 $185.00 $393.00 $414.00 $425.00 $244.00 $255.00 $264.00
28002 10 $362.00 $631.00 $664.00 $686.00 $460.00 $481.00 $502.00
28003 90 $520.00 $1,007.00 $1,059.00 $1,099.00 $812.00 $851.00 $888.00
28005 90 $520.00 $835.00 $874.00 $912.00 $835.00 $874.00 $912.00
28008 90 $296.00 $618.00 $650.00 $669.00 $423.00 $443.00 $460.00
28010 90 $235.00 $331.00 $347.00 $358.00 $299.00 $314.00 $324.00
28011 90 $340.00 $460.00 $483.00 $501.00 $413.00 $433.00 $450.00
28020 90 $509.00 $773.00 $819.00 $850.00 $525.00 $554.00 $583.00
28022 90 $422.00 $693.00 $732.00 $755.00 $467.00 $491.00 $512.00
28024 90 $371.00 $655.00 $691.00 $712.00 $438.00 $459.00 $478.00
28035 90 $532.00 $754.00 $797.00 $825.00 $514.00 $541.00 $566.00
28039 90 ---------- $727.00 $769.00 $798.00 $508.00 $535.00 $561.00
28041 90 ---------- $663.00 $697.00 $731.00 $663.00 $697.00 $731.00
28043 90 $305.00 $572.00 $603.00 $621.00 $380.00 $398.00 $414.00
28045 90 $456.00 $710.00 $748.00 $770.00 $503.00 $527.00 $547.00
28046 90 $814.00 $1,062.00 $1,115.00 $1,172.00 $1,062.00 $1,115.00 $1,172.00
28047 90 ---------- $1,564.00 $1,655.00 $1,766.00 $1,564.00 $1,655.00 $1,766.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 204
Surgery
CPT Code FUD 2003 MRALocality 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)
28050 90 $414.00 $678.00 $717.00 $741.00 $447.00 $471.00 $492.00
28052 90 $402.00 $632.00 $669.00 $691.00 $410.00 $431.00 $450.00
28054 90 $236.00 $547.00 $576.00 $590.00 $345.00 $361.00 $373.00
28055 90 ---------- $545.00 $568.00 $590.00 $545.00 $568.00 $590.00
28060 90 $495.00 $739.00 $780.00 $805.00 $515.00 $540.00 $563.00
28062 90 $657.00 $840.00 $884.00 $910.00 $590.00 $616.00 $641.00
28070 90 $476.00 $768.00 $813.00 $842.00 $519.00 $547.00 $573.00
28072 90 $445.00 $728.00 $771.00 $798.00 $482.00 $509.00 $533.00
28080 90 $392.00 $749.00 $791.00 $814.00 $528.00 $555.00 $576.00
28086 90 $462.00 $780.00 $828.00 $859.00 $522.00 $551.00 $580.00
28088 90 $414.00 $636.00 $673.00 $695.00 $407.00 $429.00 $448.00
28090 90 $414.00 $671.00 $708.00 $730.00 $445.00 $467.00 $486.00
28092 90 $330.00 $604.00 $638.00 $656.00 $388.00 $407.00 $423.00
28100 90 $571.00 $869.00 $920.00 $955.00 $598.00 $631.00 $663.00
28102 90 $700.00 $884.00 $943.00 $1,008.00 $884.00 $943.00 $1,008.00
28103 90 $709.00 $573.00 $597.00 $619.00 $573.00 $597.00 $619.00
28104 90 $491.00 $755.00 $798.00 $825.00 $512.00 $538.00 $563.00
28106 90 $632.00 $619.00 $644.00 $666.00 $619.00 $644.00 $666.00
28107 90 $517.00 $738.00 $776.00 $797.00 $504.00 $526.00 $544.00
28108 90 $418.00 $627.00 $661.00 $680.00 $415.00 $435.00 $451.00
28110 90 $421.00 $660.00 $697.00 $717.00 $418.00 $438.00 $456.00
28111 90 $537.00 $706.00 $746.00 $772.00 $473.00 $497.00 $521.00
28112 90 $457.00 $699.00 $739.00 $762.00 $453.00 $476.00 $497.00
28113 90 $481.00 $845.00 $891.00 $918.00 $612.00 $643.00 $667.00
28114 90 $890.00 $1,547.00 $1,637.00 $1,708.00 $1,216.00 $1,284.00 $1,351.00
28116 90 $648.00 $1,091.00 $1,150.00 $1,192.00 $830.00 $871.00 $910.00
28118 90 $568.00 $848.00 $896.00 $929.00 $596.00 $628.00 $658.00
28119 90 $524.00 $751.00 $791.00 $816.00 $521.00 $546.00 $568.00
28120 90 $601.00 $970.00 $1,027.00 $1,068.00 $721.00 $760.00 $799.00
28122 90 $622.00 $859.00 $905.00 $937.00 $637.00 $668.00 $697.00
28124 90 $480.00 $681.00 $717.00 $737.00 $476.00 $497.00 $515.00
28126 90 $393.00 $564.00 $595.00 $611.00 $358.00 $375.00 $389.00
28130 90 $727.00 $935.00 $988.00 $1,044.00 $935.00 $988.00 $1,044.00
28140 90 $533.00 $858.00 $907.00 $945.00 $640.00 $673.00 $709.00
28150 90 $416.00 $609.00 $642.00 $661.00 $404.00 $424.00 $441.00
28153 90 $400.00 $585.00 $617.00 $634.00 $379.00 $397.00 $412.00
28160 90 $412.00 $598.00 $631.00 $649.00 $387.00 $406.00 $421.00
28171 90 $789.00 $1,230.00 $1,276.00 $1,323.00 $1,230.00 $1,276.00 $1,323.00
28173 90 $747.00 $1,104.00 $1,150.00 $1,198.00 $1,104.00 $1,150.00 $1,198.00
28175 90 $571.00 $709.00 $740.00 $769.00 $709.00 $740.00 $769.00
28190 10 $75.00 $364.00 $385.00 $395.00 $193.00 $202.00 $210.00
28192 90 $326.00 $670.00 $706.00 $728.00 $452.00 $474.00 $494.00
28193 90 $341.00 $760.00 $800.00 $824.00 $533.00 $558.00 $580.00
28200 90 $478.00 $701.00 $741.00 $765.00 $465.00 $489.00 $510.00
28202 90 $613.00 $850.00 $894.00 $921.00 $613.00 $641.00 $666.00
28208 90 $406.00 $681.00 $720.00 $743.00 $453.00 $476.00 $497.00
28210 90 $609.00 $836.00 $882.00 $912.00 $601.00 $630.00 $658.00
28220 90 $435.00 $645.00 $679.00 $699.00 $437.00 $457.00 $474.00
28222 90 $555.00 $726.00 $763.00 $784.00 $505.00 $527.00 $546.00
28225 90 $345.00 $589.00 $622.00 $640.00 $376.00 $395.00 $411.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 205
Surgery
CPT Code FUD 2003 MRALocality 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)
28226 90 $334.00 $697.00 $734.00 $751.00 $455.00 $475.00 $490.00
28230 90 $380.00 $622.00 $655.00 $674.00 $409.00 $429.00 $445.00
28232 90 $286.00 $551.00 $582.00 $597.00 $350.00 $366.00 $380.00
28234 90 $178.00 $581.00 $613.00 $630.00 $379.00 $397.00 $412.00
28238 90 $695.00 $962.00 $1,014.00 $1,050.00 $705.00 $739.00 $773.00
28240 90 $370.00 $645.00 $681.00 $702.00 $428.00 $449.00 $467.00
28250 90 $535.00 $829.00 $877.00 $910.00 $585.00 $616.00 $646.00
28260 90 $641.00 $997.00 $1,053.00 $1,094.00 $748.00 $786.00 $826.00
28261 90 $881.00 $1,446.00 $1,525.00 $1,590.00 $1,152.00 $1,211.00 $1,273.00
28262 90 $1,363.00 $2,139.00 $2,282.00 $2,427.00 $1,742.00 $1,858.00 $1,998.00
28264 90 $912.00 $1,264.00 $1,337.00 $1,398.00 $981.00 $1,035.00 $1,094.00
28270 90 $266.00 $704.00 $743.00 $766.00 $483.00 $507.00 $527.00
28272 90 $336.00 $562.00 $591.00 $606.00 $366.00 $382.00 $395.00
28280 90 $426.00 $739.00 $780.00 $805.00 $505.00 $530.00 $553.00
28285 90 $463.00 $765.00 $806.00 $831.00 $545.00 $571.00 $594.00
28286 90 $441.00 $642.00 $676.00 $693.00 $430.00 $449.00 $464.00
28288 90 $452.00 $863.00 $911.00 $941.00 $618.00 $650.00 $677.00
28289 90 $458.00 $1,067.00 $1,128.00 $1,165.00 $673.00 $708.00 $740.00
28291 90 ---------- $1,048.00 $1,104.00 $1,141.00 $697.00 $730.00 $762.00
28292 90 $666.00 $1,066.00 $1,124.00 $1,157.00 $698.00 $731.00 $761.00
28295 90 ---------- $1,335.00 $1,408.00 $1,445.00 $774.00 $809.00 $840.00
28296 90 $832.00 $1,296.00 $1,368.00 $1,404.00 $744.00 $778.00 $808.00
28297 90 $838.00 $1,494.00 $1,581.00 $1,632.00 $874.00 $919.00 $963.00
28298 90 $755.00 $1,211.00 $1,280.00 $1,319.00 $718.00 $753.00 $787.00
28299 90 $829.00 $1,427.00 $1,507.00 $1,551.00 $839.00 $879.00 $917.00
28300 90 $845.00 $950.00 $1,005.00 $1,066.00 $950.00 $1,005.00 $1,066.00
28302 90 $930.00 $1,049.00 $1,120.00 $1,202.00 $1,049.00 $1,120.00 $1,202.00
28304 90 $776.00 $1,193.00 $1,262.00 $1,317.00 $885.00 $934.00 $986.00
28305 90 $1,030.00 $969.00 $1,019.00 $1,072.00 $969.00 $1,019.00 $1,072.00
28306 90 $530.00 $881.00 $932.00 $967.00 $586.00 $618.00 $650.00
28307 90 $614.00 $955.00 $1,011.00 $1,049.00 $640.00 $674.00 $709.00
28308 90 $516.00 $810.00 $856.00 $884.00 $545.00 $573.00 $598.00
28309 90 $955.00 $1,316.00 $1,390.00 $1,475.00 $1,316.00 $1,390.00 $1,475.00
28310 90 $505.00 $784.00 $827.00 $853.00 $519.00 $544.00 $568.00
28312 90 $469.00 $726.00 $767.00 $790.00 $461.00 $484.00 $504.00
28313 90 $436.00 $755.00 $799.00 $828.00 $518.00 $546.00 $572.00
28315 90 $462.00 $690.00 $728.00 $750.00 $471.00 $494.00 $514.00
28320 90 $833.00 $891.00 $942.00 $995.00 $891.00 $942.00 $995.00
28322 90 $667.00 $1,133.00 $1,201.00 $1,256.00 $840.00 $888.00 $940.00
28340 90 $649.00 $828.00 $868.00 $892.00 $597.00 $621.00 $642.00
28341 90 $753.00 $963.00 $1,008.00 $1,037.00 $711.00 $739.00 $765.00
28344 90 $414.00 $798.00 $850.00 $886.00 $517.00 $550.00 $583.00
28345 90 $557.00 $760.00 $799.00 $822.00 $535.00 $559.00 $580.00
28360 90 $1,197.00 $1,346.00 $1,420.00 $1,503.00 $1,346.00 $1,420.00 $1,503.00
28400 90 $266.00 $353.00 $375.00 $391.00 $324.00 $343.00 $359.00
28405 90 $473.00 $563.00 $597.00 $626.00 $514.00 $544.00 $573.00
28406 90 $616.00 $753.00 $801.00 $848.00 $753.00 $801.00 $848.00
28415 90 $1,354.00 $1,640.00 $1,741.00 $1,853.00 $1,640.00 $1,741.00 $1,853.00
28420 90 $1,619.00 $1,864.00 $1,989.00 $2,133.00 $1,864.00 $1,989.00 $2,133.00
28430 90 $110.00 $336.00 $356.00 $372.00 $300.00 $318.00 $333.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 206
Surgery
CPT Code FUD 2003 MRALocality 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)
28435 90 $371.00 $460.00 $488.00 $511.00 $413.00 $438.00 $461.00
28436 90 $463.00 $643.00 $685.00 $726.00 $643.00 $685.00 $726.00
28445 90 $874.00 $1,557.00 $1,653.00 $1,764.00 $1,557.00 $1,653.00 $1,764.00
28446 90 ---------- $1,774.00 $1,891.00 $2,032.00 $1,774.00 $1,891.00 $2,032.00
28450 90 $148.00 $306.00 $325.00 $338.00 $274.00 $290.00 $303.00
28455 90 $321.00 $410.00 $432.00 $449.00 $370.00 $390.00 $406.00
28456 90 $288.00 $450.00 $480.00 $505.00 $450.00 $480.00 $505.00
28465 90 $533.00 $911.00 $964.00 $1,017.00 $911.00 $964.00 $1,017.00
28470 90 $178.00 $310.00 $329.00 $342.00 $291.00 $308.00 $321.00
28475 90 $296.00 $365.00 $385.00 $401.00 $326.00 $344.00 $359.00
28476 90 $364.00 $504.00 $536.00 $562.00 $504.00 $536.00 $562.00
28485 90 $521.00 $781.00 $824.00 $863.00 $781.00 $824.00 $863.00
28490 90 $80.00 $205.00 $218.00 $225.00 $177.00 $188.00 $195.00
28495 90 $133.00 $252.00 $267.00 $275.00 $214.00 $225.00 $234.00
28496 90 $261.00 $631.00 $672.00 $692.00 $341.00 $362.00 $379.00
28505 90 $399.00 $961.00 $1,016.00 $1,057.00 $726.00 $765.00 $803.00
28510 90 $75.00 $175.00 $185.00 $191.00 $170.00 $180.00 $186.00
28515 90 $115.00 $229.00 $242.00 $249.00 $203.00 $214.00 $221.00
28525 90 $345.00 $806.00 $852.00 $881.00 $573.00 $603.00 $630.00
28530 90 $120.00 $163.00 $172.00 $177.00 $145.00 $153.00 $158.00
28531 90 $243.00 $485.00 $512.00 $522.00 $261.00 $273.00 $281.00
28540 90 $145.00 $273.00 $286.00 $294.00 $247.00 $259.00 $266.00
28545 90 $208.00 $423.00 $451.00 $475.00 $377.00 $403.00 $425.00
28546 90 $325.00 $796.00 $849.00 $879.00 $477.00 $508.00 $534.00
28555 90 $592.00 $1,267.00 $1,345.00 $1,412.00 $973.00 $1,031.00 $1,095.00
28570 90 $189.00 $254.00 $268.00 $274.00 $216.00 $227.00 $233.00
28575 90 $308.00 $508.00 $541.00 $570.00 $462.00 $492.00 $520.00
28576 90 $382.00 $572.00 $610.00 $647.00 $572.00 $610.00 $647.00
28585 90 $742.00 $1,242.00 $1,307.00 $1,356.00 $981.00 $1,028.00 $1,075.00
28600 90 $144.00 $314.00 $333.00 $346.00 $271.00 $287.00 $300.00
28605 90 $287.00 $468.00 $499.00 $525.00 $422.00 $451.00 $476.00
28606 90 $487.00 $574.00 $610.00 $646.00 $574.00 $610.00 $646.00
28615 90 $621.00 $1,168.00 $1,240.00 $1,313.00 $1,168.00 $1,240.00 $1,313.00
28630 10 $145.00 $227.00 $241.00 $251.00 $161.00 $170.00 $180.00
28635 10 $189.00 $251.00 $265.00 $274.00 $191.00 $201.00 $210.00
28636 10 $318.00 $500.00 $534.00 $560.00 $327.00 $349.00 $373.00
28645 90 $434.00 $942.00 $993.00 $1,030.00 $702.00 $737.00 $771.00
28660 10 $106.00 $167.00 $177.00 $184.00 $129.00 $136.00 $143.00
28665 10 $172.00 $223.00 $234.00 $244.00 $190.00 $200.00 $209.00
28666 10 $309.00 $269.00 $284.00 $300.00 $269.00 $284.00 $300.00
28675 90 $348.00 $836.00 $885.00 $918.00 $595.00 $628.00 $659.00
28705 90 $1,353.00 $1,828.00 $1,933.00 $2,056.00 $1,828.00 $1,933.00 $2,056.00
28715 90 $1,179.00 $1,371.00 $1,455.00 $1,549.00 $1,371.00 $1,455.00 $1,549.00
28725 90 $1,015.00 $1,135.00 $1,203.00 $1,278.00 $1,135.00 $1,203.00 $1,278.00
28730 90 $945.00 $1,067.00 $1,129.00 $1,196.00 $1,067.00 $1,129.00 $1,196.00
28735 90 $961.00 $1,143.00 $1,206.00 $1,276.00 $1,143.00 $1,206.00 $1,276.00
28737 90 $873.00 $1,013.00 $1,067.00 $1,123.00 $1,013.00 $1,067.00 $1,123.00
28740 90 $690.00 $1,217.00 $1,288.00 $1,343.00 $905.00 $955.00 $1,007.00
28750 90 $690.00 $1,164.00 $1,233.00 $1,285.00 $856.00 $903.00 $952.00
28755 90 $466.00 $726.00 $767.00 $791.00 $477.00 $502.00 $523.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 207
Surgery
CPT Code FUD 2003 MRALocality 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)
28760 90 $654.00 $1,141.00 $1,203.00 $1,248.00 $842.00 $884.00 $926.00
28800 90 $731.00 $789.00 $831.00 $878.00 $789.00 $831.00 $878.00
28805 90 $731.00 $1,077.00 $1,137.00 $1,210.00 $1,077.00 $1,137.00 $1,210.00
28810 90 $543.00 $634.00 $672.00 $717.00 $634.00 $672.00 $717.00
28820 90 $377.00 $809.00 $857.00 $891.00 $575.00 $606.00 $638.00
28825 90 $339.00 $772.00 $818.00 $849.00 $538.00 $568.00 $597.00
28890 90 ---------- $462.00 $487.00 $502.00 $325.00 $341.00 $354.00
28899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
29000 0 $247.00 $432.00 $467.00 $499.00 $270.00 $294.00 $325.00
29010 0 $271.00 $310.00 $328.00 $341.00 $201.00 $212.00 $223.00
29015 0 $289.00 $378.00 $401.00 $417.00 $246.00 $260.00 $274.00
29035 0 $213.00 $362.00 $386.00 $403.00 $210.00 $224.00 $239.00
29040 0 $260.00 $320.00 $340.00 $353.00 $212.00 $224.00 $236.00
29044 0 $260.00 $355.00 $377.00 $394.00 $223.00 $237.00 $252.00
29046 0 $286.00 $370.00 $393.00 $408.00 $240.00 $254.00 $268.00
29049 0 $45.00 $105.00 $112.00 $117.00 $82.00 $87.00 $92.00
29055 0 $180.00 $312.00 $334.00 $350.00 $201.00 $215.00 $229.00
29058 0 $110.00 $177.00 $189.00 $200.00 $138.00 $147.00 $158.00
29065 0 $88.00 $136.00 $145.00 $152.00 $99.00 $105.00 $111.00
29075 0 $72.00 $123.00 $131.00 $137.00 $90.00 $96.00 $101.00
29085 0 $59.00 $136.00 $145.00 $151.00 $98.00 $105.00 $111.00
29086 0 $54.00 $107.00 $114.00 $117.00 $72.00 $76.00 $79.00
29105 0 $59.00 $125.00 $133.00 $138.00 $87.00 $92.00 $97.00
29125 0 $45.00 $91.00 $96.00 $100.00 $57.00 $60.00 $63.00
29126 0 $53.00 $107.00 $113.00 $118.00 $70.00 $73.00 $77.00
29130 0 $26.00 $59.00 $62.00 $65.00 $42.00 $44.00 $47.00
29131 0 $53.00 $72.00 $76.00 $80.00 $48.00 $51.00 $54.00
29200 0 $29.00 $42.00 $44.00 $45.00 $26.00 $27.00 $28.00
29240 0 $45.00 $40.00 $42.00 $43.00 $26.00 $27.00 $28.00
29260 0 $26.00 $41.00 $43.00 $45.00 $29.00 $30.00 $31.00
29280 0 $29.00 $41.00 $43.00 $44.00 $28.00 $29.00 $31.00
29305 0 $223.00 $349.00 $373.00 $391.00 $231.00 $247.00 $264.00
29325 0 $260.00 $388.00 $414.00 $434.00 $259.00 $276.00 $295.00
29345 0 $126.00 $195.00 $208.00 $219.00 $148.00 $157.00 $168.00
29355 0 $133.00 $202.00 $215.00 $227.00 $156.00 $166.00 $178.00
29358 0 $241.00 $229.00 $245.00 $257.00 $152.00 $163.00 $174.00
29365 0 $101.00 $175.00 $187.00 $197.00 $128.00 $136.00 $145.00
29405 0 $96.00 $116.00 $124.00 $129.00 $87.00 $92.00 $97.00
29425 0 $101.00 $111.00 $118.00 $122.00 $82.00 $86.00 $91.00
29435 0 $133.00 $168.00 $179.00 $187.00 $122.00 $129.00 $138.00
29440 0 $22.00 $62.00 $65.00 $67.00 $42.00 $43.00 $45.00
29445 0 $214.00 $192.00 $202.00 $211.00 $151.00 $159.00 $167.00
29450 0 $84.00 $207.00 $217.00 $226.00 $165.00 $172.00 $180.00
29505 0 $75.00 $118.00 $125.00 $130.00 $72.00 $76.00 $80.00
29515 0 $59.00 $102.00 $108.00 $112.00 $72.00 $76.00 $80.00
29520 0 $22.00 $44.00 $46.00 $47.00 $27.00 $28.00 $28.00
29530 0 $55.00 $40.00 $42.00 $43.00 $26.00 $27.00 $28.00
29540 0 $41.00 $37.00 $39.00 $40.00 $26.00 $27.00 $29.00
29550 0 $37.00 $27.00 $28.00 $29.00 $17.00 $17.00 $18.00
29580 0 $39.00 $74.00 $78.00 $82.00 $52.00 $54.00 $57.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 208
Surgery
CPT Code FUD 2003 MRALocality 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)
29581 0 ---------- $86.00 $91.00 $92.00 $19.00 $19.00 $20.00
29582 0 ---------- $97.00 $103.00 $104.00 $23.00 $23.00 $24.00
29583 0 ---------- $61.00 $64.00 $65.00 $16.00 $17.00 $17.00
29584 0 ---------- $97.00 $103.00 $104.00 $23.00 $23.00 $24.00
29700 0 $29.00 $89.00 $95.00 $99.00 $50.00 $52.00 $56.00
29705 0 $26.00 $96.00 $102.00 $108.00 $69.00 $74.00 $79.00
29710 0 $29.00 $175.00 $187.00 $198.00 $123.00 $132.00 $143.00
29720 0 $29.00 $121.00 $129.00 $135.00 $66.00 $70.00 $76.00
29730 0 $29.00 $92.00 $98.00 $103.00 $66.00 $70.00 $75.00
29740 0 $37.00 $144.00 $154.00 $163.00 $104.00 $111.00 $121.00
29750 0 $105.00 $129.00 $135.00 $140.00 $100.00 $104.00 $108.00
29799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
29800 90 $557.00 $771.00 $823.00 $880.00 $771.00 $823.00 $880.00
29804 90 $902.00 $940.00 $998.00 $1,060.00 $940.00 $998.00 $1,060.00
29805 90 $360.00 $688.00 $734.00 $785.00 $688.00 $734.00 $785.00
29806 90 $1,003.00 $1,561.00 $1,665.00 $1,790.00 $1,561.00 $1,665.00 $1,790.00
29807 90 $976.00 $1,521.00 $1,624.00 $1,745.00 $1,521.00 $1,624.00 $1,745.00
29819 90 $756.00 $856.00 $914.00 $978.00 $856.00 $914.00 $978.00
29820 90 $718.00 $777.00 $826.00 $878.00 $777.00 $826.00 $878.00
29821 90 $863.00 $849.00 $902.00 $958.00 $849.00 $902.00 $958.00
29822 90 $749.00 $824.00 $875.00 $928.00 $824.00 $875.00 $928.00
29823 90 $1,330.00 $899.00 $954.00 $1,012.00 $899.00 $954.00 $1,012.00
29824 90 $611.00 $968.00 $1,028.00 $1,090.00 $968.00 $1,028.00 $1,090.00
29825 90 $941.00 $839.00 $891.00 $945.00 $839.00 $891.00 $945.00
29826 ZZZ $980.00 $263.00 $280.00 $304.00 $263.00 $280.00 $304.00
29827 90 $1,058.00 $1,542.00 $1,635.00 $1,740.00 $1,542.00 $1,635.00 $1,740.00
29828 90 ---------- $1,330.00 $1,413.00 $1,504.00 $1,330.00 $1,413.00 $1,504.00
29830 90 $524.00 $665.00 $709.00 $755.00 $665.00 $709.00 $755.00
29834 90 $635.00 $707.00 $751.00 $797.00 $707.00 $751.00 $797.00
29835 90 $612.00 $728.00 $774.00 $823.00 $728.00 $774.00 $823.00
29836 90 $680.00 $830.00 $880.00 $933.00 $830.00 $880.00 $933.00
29837 90 $830.00 $759.00 $807.00 $857.00 $759.00 $807.00 $857.00
29838 90 $931.00 $856.00 $911.00 $971.00 $856.00 $911.00 $971.00
29840 90 $501.00 $654.00 $696.00 $739.00 $654.00 $696.00 $739.00
29843 90 $580.00 $706.00 $754.00 $806.00 $706.00 $754.00 $806.00
29844 90 $612.00 $719.00 $763.00 $808.00 $719.00 $763.00 $808.00
29845 90 $931.00 $835.00 $887.00 $940.00 $835.00 $887.00 $940.00
29846 90 $976.00 $755.00 $803.00 $852.00 $755.00 $803.00 $852.00
29847 90 $1,277.00 $791.00 $843.00 $901.00 $791.00 $843.00 $901.00
29848 90 $608.00 $742.00 $791.00 $841.00 $742.00 $791.00 $841.00
29850 90 $752.00 $888.00 $947.00 $1,015.00 $888.00 $947.00 $1,015.00
29851 90 $1,137.00 $1,326.00 $1,412.00 $1,516.00 $1,326.00 $1,412.00 $1,516.00
29855 90 $1,007.00 $1,145.00 $1,220.00 $1,307.00 $1,145.00 $1,220.00 $1,307.00
29856 90 $1,231.00 $1,459.00 $1,557.00 $1,674.00 $1,459.00 $1,557.00 $1,674.00
29860 90 $658.00 $966.00 $1,030.00 $1,104.00 $966.00 $1,030.00 $1,104.00
29861 90 $845.00 $1,052.00 $1,119.00 $1,192.00 $1,052.00 $1,119.00 $1,192.00
29862 90 $907.00 $1,174.00 $1,247.00 $1,325.00 $1,174.00 $1,247.00 $1,325.00
29863 90 $880.00 $1,174.00 $1,248.00 $1,327.00 $1,174.00 $1,248.00 $1,327.00
29866 90 ---------- $1,519.00 $1,618.00 $1,733.00 $1,519.00 $1,618.00 $1,733.00
29867 90 ---------- $1,885.00 $2,012.00 $2,166.00 $1,885.00 $2,012.00 $2,166.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 209
Surgery
CPT Code FUD 2003 MRALocality 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)
29868 90 ---------- $2,432.00 $2,593.00 $2,794.00 $2,432.00 $2,593.00 $2,794.00
29870 90 $460.00 $832.00 $888.00 $934.00 $599.00 $639.00 $682.00
29871 90 $631.00 $752.00 $802.00 $859.00 $752.00 $802.00 $859.00
29873 90 $489.00 $760.00 $811.00 $864.00 $760.00 $811.00 $864.00
29874 90 $676.00 $785.00 $837.00 $894.00 $785.00 $837.00 $894.00
29875 90 $639.00 $722.00 $770.00 $823.00 $722.00 $770.00 $823.00
29876 90 $809.00 $963.00 $1,028.00 $1,102.00 $963.00 $1,028.00 $1,102.00
29877 90 $852.00 $908.00 $968.00 $1,035.00 $908.00 $968.00 $1,035.00
29879 90 $1,064.00 $969.00 $1,033.00 $1,105.00 $969.00 $1,033.00 $1,105.00
29880 90 $1,169.00 $821.00 $875.00 $934.00 $821.00 $875.00 $934.00
29881 90 $745.00 $789.00 $841.00 $898.00 $789.00 $841.00 $898.00
29882 90 $819.00 $1,029.00 $1,098.00 $1,178.00 $1,029.00 $1,098.00 $1,178.00
29883 90 $1,235.00 $1,239.00 $1,322.00 $1,419.00 $1,239.00 $1,322.00 $1,419.00
29884 90 $721.00 $894.00 $950.00 $1,010.00 $894.00 $950.00 $1,010.00
29885 90 $832.00 $1,093.00 $1,165.00 $1,247.00 $1,093.00 $1,165.00 $1,247.00
29886 90 $697.00 $929.00 $992.00 $1,063.00 $929.00 $992.00 $1,063.00
29887 90 $949.00 $1,081.00 $1,151.00 $1,230.00 $1,081.00 $1,151.00 $1,230.00
29888 90 $1,296.00 $1,448.00 $1,543.00 $1,657.00 $1,448.00 $1,543.00 $1,657.00
29889 90 $1,255.00 $1,796.00 $1,916.00 $2,059.00 $1,796.00 $1,916.00 $2,059.00
29891 90 $796.00 $978.00 $1,036.00 $1,099.00 $978.00 $1,036.00 $1,099.00
29892 90 $835.00 $940.00 $988.00 $1,037.00 $940.00 $988.00 $1,037.00
29893 90 $472.00 $869.00 $914.00 $938.00 $613.00 $641.00 $661.00
29894 90 $690.00 $723.00 $765.00 $810.00 $723.00 $765.00 $810.00
29895 90 $679.00 $694.00 $733.00 $774.00 $694.00 $733.00 $774.00
29897 90 $704.00 $733.00 $777.00 $825.00 $733.00 $777.00 $825.00
29898 90 $863.00 $821.00 $868.00 $919.00 $821.00 $868.00 $919.00
29899 90 $973.00 $1,524.00 $1,621.00 $1,736.00 $1,524.00 $1,621.00 $1,736.00
29900 90 $434.00 $600.00 $628.00 $646.00 $600.00 $628.00 $646.00
29901 90 $479.00 $760.00 $806.00 $848.00 $760.00 $806.00 $848.00
29902 90 $514.00 $705.00 $744.00 $784.00 $705.00 $744.00 $784.00
29904 90 ---------- $920.00 $981.00 $1,051.00 $920.00 $981.00 $1,051.00
29905 90 ---------- $993.00 $1,059.00 $1,132.00 $993.00 $1,059.00 $1,132.00
29906 90 ---------- $1,009.00 $1,073.00 $1,142.00 $1,009.00 $1,073.00 $1,142.00
29907 90 ---------- $1,284.00 $1,370.00 $1,470.00 $1,284.00 $1,370.00 $1,470.00
29914 90 ---------- $1,453.00 $1,543.00 $1,645.00 $1,453.00 $1,543.00 $1,645.00
29915 90 ---------- $1,479.00 $1,570.00 $1,672.00 $1,479.00 $1,570.00 $1,672.00
29916 90 ---------- $1,481.00 $1,571.00 $1,673.00 $1,481.00 $1,571.00 $1,673.00
29999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
30000 10 $96.00 $319.00 $339.00 $349.00 $168.00 $178.00 $187.00
30020 10 $117.00 $323.00 $343.00 $354.00 $170.00 $180.00 $189.00
30100 0 $86.00 $196.00 $208.00 $214.00 $99.00 $104.00 $110.00
30110 10 $157.00 $321.00 $341.00 $353.00 $186.00 $197.00 $207.00
30115 90 $360.00 $610.00 $646.00 $675.00 $610.00 $646.00 $675.00
30117 90 $301.00 $1,204.00 $1,283.00 $1,311.00 $480.00 $509.00 $530.00
30118 90 $819.00 $1,099.00 $1,165.00 $1,227.00 $1,099.00 $1,165.00 $1,227.00
30120 90 $500.00 $741.00 $787.00 $824.00 $631.00 $669.00 $705.00
30124 90 $243.00 $405.00 $429.00 $449.00 $405.00 $429.00 $449.00
30125 90 $599.00 $862.00 $913.00 $957.00 $862.00 $913.00 $957.00
30130 90 $275.00 $535.00 $568.00 $590.00 $535.00 $568.00 $590.00
30140 90 $320.00 $616.00 $655.00 $679.00 $616.00 $655.00 $679.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 210
Surgery
CPT Code FUD 2003 MRALocality 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)
30150 90 $790.00 $1,097.00 $1,164.00 $1,226.00 $1,097.00 $1,164.00 $1,226.00
30160 90 $875.00 $1,103.00 $1,168.00 $1,230.00 $1,103.00 $1,168.00 $1,230.00
30200 0 $68.00 $157.00 $167.00 $172.00 $85.00 $90.00 $95.00
30210 10 $75.00 $209.00 $222.00 $229.00 $141.00 $150.00 $157.00
30220 10 $154.00 $419.00 $445.00 $458.00 $178.00 $189.00 $199.00
30300 10 $45.00 $247.00 $263.00 $270.00 $150.00 $158.00 $165.00
30310 10 $170.00 $291.00 $308.00 $321.00 $291.00 $308.00 $321.00
30320 90 $419.00 $638.00 $676.00 $706.00 $638.00 $676.00 $706.00
30400 90 $741.00 $1,429.00 $1,515.00 $1,584.00 $1,429.00 $1,515.00 $1,584.00
30410 90 $1,173.00 $1,671.00 $1,770.00 $1,855.00 $1,671.00 $1,770.00 $1,855.00
30420 90 $1,424.00 $1,952.00 $2,068.00 $2,174.00 $1,952.00 $2,068.00 $2,174.00
30430 90 $626.00 $1,206.00 $1,279.00 $1,333.00 $1,206.00 $1,279.00 $1,333.00
30435 90 $1,005.00 $1,784.00 $1,897.00 $1,991.00 $1,784.00 $1,897.00 $1,991.00
30450 90 $1,445.00 $2,129.00 $2,252.00 $2,367.00 $2,129.00 $2,252.00 $2,367.00
30460 90 $857.00 $1,170.00 $1,243.00 $1,317.00 $1,170.00 $1,243.00 $1,317.00
30462 90 $1,633.00 $2,025.00 $2,142.00 $2,266.00 $2,025.00 $2,142.00 $2,266.00
30465 90 $803.00 $1,398.00 $1,481.00 $1,558.00 $1,398.00 $1,481.00 $1,558.00
30520 90 $533.00 $882.00 $935.00 $979.00 $882.00 $935.00 $979.00
30540 90 $643.00 $982.00 $1,040.00 $1,090.00 $982.00 $1,040.00 $1,090.00
30545 90 $981.00 $1,265.00 $1,338.00 $1,405.00 $1,265.00 $1,338.00 $1,405.00
30560 10 $104.00 $370.00 $394.00 $404.00 $193.00 $205.00 $214.00
30580 90 $566.00 $933.00 $991.00 $1,040.00 $742.00 $788.00 $835.00
30600 90 $466.00 $807.00 $856.00 $894.00 $616.00 $651.00 $688.00
30620 90 $564.00 $882.00 $936.00 $977.00 $882.00 $936.00 $977.00
30630 90 $624.00 $883.00 $935.00 $980.00 $883.00 $935.00 $980.00
30801 10 $88.00 $316.00 $336.00 $345.00 $191.00 $203.00 $210.00
30802 10 $172.00 $405.00 $430.00 $445.00 $269.00 $285.00 $299.00
30901 0 $75.00 $135.00 $143.00 $150.00 $84.00 $88.00 $95.00
30903 0 $110.00 $308.00 $328.00 $338.00 $119.00 $125.00 $134.00
30905 0 $224.00 $379.00 $403.00 $416.00 $156.00 $165.00 $176.00
30906 0 $208.00 $485.00 $515.00 $532.00 $201.00 $212.00 $226.00
30915 90 $596.00 $820.00 $868.00 $912.00 $820.00 $868.00 $912.00
30920 90 $862.00 $1,196.00 $1,266.00 $1,334.00 $1,196.00 $1,266.00 $1,334.00
30930 10 $213.00 $174.00 $184.00 $192.00 $174.00 $184.00 $192.00
30999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
31000 10 $81.00 $256.00 $272.00 $281.00 $150.00 $159.00 $167.00
31002 10 $135.00 $268.00 $283.00 $294.00 $268.00 $283.00 $294.00
31020 90 $281.00 $676.00 $719.00 $741.00 $506.00 $538.00 $558.00
31030 90 $531.00 $971.00 $1,031.00 $1,073.00 $752.00 $798.00 $837.00
31032 90 $604.00 $816.00 $865.00 $908.00 $816.00 $865.00 $908.00
31040 90 $772.00 $1,090.00 $1,155.00 $1,217.00 $1,090.00 $1,155.00 $1,217.00
31050 90 $489.00 $685.00 $726.00 $759.00 $685.00 $726.00 $759.00
31051 90 $654.00 $914.00 $969.00 $1,014.00 $914.00 $969.00 $1,014.00
31070 90 $410.00 $618.00 $656.00 $684.00 $618.00 $656.00 $684.00
31075 90 $839.00 $1,117.00 $1,183.00 $1,241.00 $1,117.00 $1,183.00 $1,241.00
31080 90 $942.00 $1,494.00 $1,589.00 $1,682.00 $1,494.00 $1,589.00 $1,682.00
31081 90 $1,089.00 $2,182.00 $2,375.00 $2,605.00 $2,182.00 $2,375.00 $2,605.00
31084 90 $1,210.00 $1,701.00 $1,807.00 $1,912.00 $1,701.00 $1,807.00 $1,912.00
31085 90 $1,281.00 $2,334.00 $2,543.00 $2,797.00 $2,334.00 $2,543.00 $2,797.00
31086 90 $1,081.00 $1,617.00 $1,713.00 $1,802.00 $1,617.00 $1,713.00 $1,802.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 211
Surgery
CPT Code FUD 2003 MRALocality 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)
31087 90 $1,075.00 $1,564.00 $1,659.00 $1,757.00 $1,564.00 $1,659.00 $1,757.00
31090 90 $877.00 $1,450.00 $1,537.00 $1,607.00 $1,450.00 $1,537.00 $1,607.00
31200 90 $463.00 $800.00 $844.00 $867.00 $800.00 $844.00 $867.00
31201 90 $716.00 $1,050.00 $1,113.00 $1,167.00 $1,050.00 $1,113.00 $1,167.00
31205 90 $851.00 $1,268.00 $1,334.00 $1,376.00 $1,268.00 $1,334.00 $1,376.00
31225 90 $1,683.00 $2,700.00 $2,858.00 $3,021.00 $2,700.00 $2,858.00 $3,021.00
31230 90 $1,908.00 $2,976.00 $3,145.00 $3,326.00 $2,976.00 $3,145.00 $3,326.00
31231 0 $122.00 $290.00 $308.00 $316.00 $95.00 $100.00 $106.00
31233 0 $221.00 $367.00 $390.00 $404.00 $199.00 $210.00 $222.00
31235 0 $217.00 $420.00 $445.00 $462.00 $235.00 $248.00 $262.00
31237 0 $266.00 $364.00 $386.00 $403.00 $234.00 $247.00 $263.00
31238 0 $311.00 $365.00 $387.00 $404.00 $246.00 $259.00 $275.00
31239 10 $775.00 $882.00 $927.00 $967.00 $882.00 $927.00 $967.00
31240 0 $224.00 $234.00 $247.00 $263.00 $234.00 $247.00 $263.00
31254 0 $588.00 $399.00 $421.00 $448.00 $399.00 $421.00 $448.00
31255 0 $601.00 $584.00 $617.00 $657.00 $584.00 $617.00 $657.00
31256 0 $292.00 $288.00 $304.00 $323.00 $288.00 $304.00 $323.00
31267 0 $453.00 $463.00 $489.00 $521.00 $463.00 $489.00 $521.00
31276 0 $690.00 $737.00 $778.00 $829.00 $737.00 $778.00 $829.00
31287 0 $339.00 $338.00 $357.00 $380.00 $338.00 $357.00 $380.00
31288 0 $396.00 $393.00 $415.00 $441.00 $393.00 $415.00 $441.00
31290 10 $1,462.00 $1,683.00 $1,781.00 $1,898.00 $1,683.00 $1,781.00 $1,898.00
31291 10 $1,551.00 $1,803.00 $1,915.00 $2,055.00 $1,803.00 $1,915.00 $2,055.00
31292 10 $1,235.00 $1,451.00 $1,533.00 $1,627.00 $1,451.00 $1,533.00 $1,627.00
31293 10 $1,346.00 $1,578.00 $1,668.00 $1,773.00 $1,578.00 $1,668.00 $1,773.00
31294 10 $1,587.00 $1,828.00 $1,934.00 $2,060.00 $1,828.00 $1,934.00 $2,060.00
31295 0 ---------- $2,766.00 $2,952.00 $2,994.00 $239.00 $252.00 $268.00
31296 0 ---------- $2,824.00 $3,013.00 $3,059.00 $286.00 $302.00 $321.00
31297 0 ---------- $2,770.00 $2,956.00 $2,998.00 $234.00 $247.00 $263.00
31299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
31300 90 $1,295.00 $1,872.00 $1,983.00 $2,082.00 $1,872.00 $1,983.00 $2,082.00
31320 90 $508.00 $800.00 $849.00 $885.00 $800.00 $849.00 $885.00
31360 90 $1,630.00 $3,052.00 $3,229.00 $3,411.00 $3,052.00 $3,229.00 $3,411.00
31365 90 $2,238.00 $3,773.00 $3,990.00 $4,223.00 $3,773.00 $3,990.00 $4,223.00
31367 90 $1,913.00 $3,217.00 $3,402.00 $3,582.00 $3,217.00 $3,402.00 $3,582.00
31368 90 $2,478.00 $3,583.00 $3,791.00 $3,997.00 $3,583.00 $3,791.00 $3,997.00
31370 90 $1,891.00 $3,027.00 $3,205.00 $3,376.00 $3,027.00 $3,205.00 $3,376.00
31375 90 $1,720.00 $2,869.00 $3,037.00 $3,198.00 $2,869.00 $3,037.00 $3,198.00
31380 90 $1,782.00 $2,828.00 $2,993.00 $3,149.00 $2,828.00 $2,993.00 $3,149.00
31382 90 $1,822.00 $3,116.00 $3,299.00 $3,477.00 $3,116.00 $3,299.00 $3,477.00
31390 90 $2,513.00 $4,201.00 $4,441.00 $4,693.00 $4,201.00 $4,441.00 $4,693.00
31395 90 $2,937.00 $4,439.00 $4,696.00 $4,962.00 $4,439.00 $4,696.00 $4,962.00
31400 90 $969.00 $1,409.00 $1,492.00 $1,564.00 $1,409.00 $1,492.00 $1,564.00
31420 90 $969.00 $1,197.00 $1,267.00 $1,337.00 $1,197.00 $1,267.00 $1,337.00
31500 0 $116.00 $209.00 $219.00 $233.00 $209.00 $219.00 $233.00
31502 0 $74.00 $51.00 $54.00 $57.00 $51.00 $54.00 $57.00
31505 0 $62.00 $115.00 $122.00 $126.00 $71.00 $75.00 $78.00
31510 0 $145.00 $299.00 $318.00 $330.00 $178.00 $188.00 $199.00
31511 0 $88.00 $300.00 $318.00 $332.00 $190.00 $201.00 $213.00
31512 0 $197.00 $292.00 $310.00 $323.00 $190.00 $200.00 $212.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 212
Surgery
CPT Code FUD 2003 MRALocality 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)
31513 0 $182.00 $193.00 $204.00 $217.00 $193.00 $204.00 $217.00
31515 0 $160.00 $256.00 $270.00 $279.00 $151.00 $158.00 $166.00
31525 0 $234.00 $359.00 $381.00 $397.00 $235.00 $248.00 $263.00
31526 0 $222.00 $230.00 $243.00 $258.00 $230.00 $243.00 $258.00
31527 0 $262.00 $286.00 $302.00 $322.00 $286.00 $302.00 $322.00
31528 0 $202.00 $212.00 $224.00 $238.00 $212.00 $224.00 $238.00
31529 0 $217.00 $237.00 $251.00 $267.00 $237.00 $251.00 $267.00
31530 0 $284.00 $291.00 $307.00 $327.00 $291.00 $307.00 $327.00
31531 0 $311.00 $311.00 $328.00 $349.00 $311.00 $328.00 $349.00
31535 0 $272.00 $278.00 $294.00 $313.00 $278.00 $294.00 $313.00
31536 0 $308.00 $310.00 $327.00 $348.00 $310.00 $327.00 $348.00
31540 0 $357.00 $356.00 $376.00 $400.00 $356.00 $376.00 $400.00
31541 0 $453.00 $388.00 $410.00 $436.00 $388.00 $410.00 $436.00
31545 0 ---------- $533.00 $562.00 $598.00 $533.00 $562.00 $598.00
31546 0 ---------- $811.00 $856.00 $912.00 $811.00 $856.00 $912.00
31551 90 ---------- $2,060.00 $2,174.00 $2,294.00 $2,060.00 $2,174.00 $2,294.00
31552 90 ---------- $2,076.00 $2,193.00 $2,309.00 $2,076.00 $2,193.00 $2,309.00
31553 90 ---------- $2,262.00 $2,390.00 $2,515.00 $2,262.00 $2,390.00 $2,515.00
31554 90 ---------- $2,377.00 $2,512.00 $2,638.00 $2,377.00 $2,512.00 $2,638.00
31560 0 $446.00 $460.00 $485.00 $516.00 $460.00 $485.00 $516.00
31561 0 $509.00 $505.00 $533.00 $568.00 $505.00 $533.00 $568.00
31570 0 $369.00 $483.00 $513.00 $538.00 $338.00 $358.00 $382.00
31571 0 $363.00 $368.00 $388.00 $413.00 $368.00 $388.00 $413.00
31572 0 ---------- $695.00 $739.00 $761.00 $265.00 $280.00 $298.00
31573 0 ---------- $374.00 $397.00 $413.00 $219.00 $231.00 $245.00
31574 0 ---------- $1,413.00 $1,506.00 $1,533.00 $219.00 $231.00 $245.00
31575 0 $128.00 $160.00 $170.00 $176.00 $98.00 $103.00 $109.00
31576 0 $186.00 $371.00 $394.00 $407.00 $174.00 $184.00 $194.00
31577 0 $230.00 $385.00 $409.00 $424.00 $197.00 $208.00 $220.00
31578 0 $264.00 $424.00 $450.00 $466.00 $219.00 $231.00 $245.00
31579 0 $219.00 $251.00 $266.00 $278.00 $174.00 $184.00 $195.00
31580 90 $1,213.00 $1,789.00 $1,896.00 $1,988.00 $1,789.00 $1,896.00 $1,988.00
31584 90 $1,616.00 $1,992.00 $2,109.00 $2,216.00 $1,992.00 $2,109.00 $2,216.00
31587 90 $913.00 $1,678.00 $1,779.00 $1,879.00 $1,678.00 $1,779.00 $1,879.00
31590 90 $691.00 $1,241.00 $1,320.00 $1,379.00 $1,241.00 $1,320.00 $1,379.00
31591 90 ---------- $1,499.00 $1,585.00 $1,664.00 $1,499.00 $1,585.00 $1,664.00
31592 90 ---------- $2,440.00 $2,575.00 $2,716.00 $2,440.00 $2,575.00 $2,716.00
31595 90 $773.00 $1,084.00 $1,149.00 $1,204.00 $1,084.00 $1,149.00 $1,204.00
31599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
31600 0 $306.00 $592.00 $630.00 $684.00 $592.00 $630.00 $684.00
31603 0 $343.00 $332.00 $352.00 $381.00 $332.00 $352.00 $381.00
31605 0 $297.00 $276.00 $293.00 $318.00 $276.00 $293.00 $318.00
31610 90 $794.00 $1,028.00 $1,089.00 $1,150.00 $1,028.00 $1,089.00 $1,150.00
31611 90 $614.00 $766.00 $811.00 $849.00 $766.00 $811.00 $849.00
31612 0 $99.00 $119.00 $126.00 $133.00 $72.00 $76.00 $82.00
31613 90 $384.00 $648.00 $689.00 $723.00 $648.00 $689.00 $723.00
31614 90 $736.00 $1,078.00 $1,143.00 $1,200.00 $1,078.00 $1,143.00 $1,200.00
31615 0 $213.00 $239.00 $253.00 $264.00 $168.00 $177.00 $187.00
31622 0 $230.00 $340.00 $360.00 $372.00 $194.00 $203.00 $214.00
31623 0 $225.00 $380.00 $400.00 $411.00 $196.00 $204.00 $213.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 213
Surgery
CPT Code FUD 2003 MRALocality 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)
31624 0 $217.00 $356.00 $375.00 $386.00 $199.00 $207.00 $216.00
31625 0 $235.00 $465.00 $491.00 $505.00 $230.00 $239.00 $251.00
31626 0 ---------- $1,166.00 $1,239.00 $1,266.00 $294.00 $308.00 $325.00
31627 ZZZ ---------- $1,913.00 $2,040.00 $2,067.00 $144.00 $150.00 $159.00
31628 0 $269.00 $494.00 $520.00 $534.00 $258.00 $268.00 $279.00
31629 0 $198.00 $608.00 $643.00 $660.00 $275.00 $287.00 $300.00
31630 0 $308.00 $295.00 $310.00 $329.00 $295.00 $310.00 $329.00
31631 0 $252.00 $340.00 $358.00 $383.00 $340.00 $358.00 $383.00
31632 ZZZ ---------- $92.00 $96.00 $100.00 $72.00 $75.00 $78.00
31633 ZZZ ---------- $115.00 $120.00 $125.00 $93.00 $97.00 $101.00
31634 0 ---------- $2,461.00 $2,622.00 $2,663.00 $286.00 $300.00 $318.00
31635 0 $298.00 $397.00 $418.00 $433.00 $258.00 $269.00 $284.00
31636 0 ---------- $325.00 $341.00 $361.00 $325.00 $341.00 $361.00
31637 ZZZ ---------- $109.00 $113.00 $117.00 $109.00 $113.00 $117.00
31638 0 ---------- $371.00 $389.00 $414.00 $371.00 $389.00 $414.00
31640 0 $399.00 $373.00 $391.00 $414.00 $373.00 $391.00 $414.00
31641 0 $304.00 $380.00 $398.00 $420.00 $380.00 $398.00 $420.00
31643 0 $208.00 $259.00 $270.00 $282.00 $259.00 $270.00 $282.00
31645 0 $208.00 $360.00 $378.00 $391.00 $218.00 $228.00 $238.00
31646 0 $161.00 $323.00 $341.00 $351.00 $186.00 $194.00 $203.00
31647 0 ---------- $311.00 $326.00 $345.00 $311.00 $326.00 $345.00
31648 0 ---------- $283.00 $294.00 $307.00 $283.00 $294.00 $307.00
31649 ZZZ ---------- $102.00 $107.00 $112.00 $102.00 $107.00 $112.00
31651 ZZZ ---------- $109.00 $113.00 $119.00 $109.00 $113.00 $119.00
31652 0 ---------- $1,146.00 $1,215.00 $1,240.00 $326.00 $340.00 $356.00
31653 0 ---------- $1,213.00 $1,287.00 $1,314.00 $361.00 $376.00 $395.00
31654 ZZZ ---------- $178.00 $187.00 $194.00 $100.00 $104.00 $109.00
31660 0 ---------- $287.00 $298.00 $310.00 $287.00 $298.00 $310.00
31661 0 ---------- $302.00 $314.00 $327.00 $302.00 $314.00 $327.00
31717 0 $138.00 $363.00 $383.00 $392.00 $158.00 $164.00 $170.00
31720 0 $89.00 $76.00 $80.00 $84.00 $76.00 $80.00 $84.00
31725 0 $103.00 $115.00 $120.00 $126.00 $115.00 $120.00 $126.00
31730 0 $199.00 $1,701.00 $1,816.00 $1,852.00 $224.00 $238.00 $259.00
31750 90 $1,088.00 $2,011.00 $2,136.00 $2,245.00 $2,011.00 $2,136.00 $2,245.00
31755 90 $1,448.00 $2,528.00 $2,681.00 $2,794.00 $2,528.00 $2,681.00 $2,794.00
31760 90 $1,648.00 $2,092.00 $2,247.00 $2,471.00 $2,092.00 $2,247.00 $2,471.00
31766 90 $2,315.00 $2,692.00 $2,890.00 $3,187.00 $2,692.00 $2,890.00 $3,187.00
31770 90 $1,815.00 $2,014.00 $2,163.00 $2,383.00 $2,014.00 $2,163.00 $2,383.00
31775 90 $1,973.00 $1,870.00 $1,948.00 $2,037.00 $1,870.00 $1,948.00 $2,037.00
31780 90 $1,577.00 $1,739.00 $1,848.00 $1,989.00 $1,739.00 $1,848.00 $1,989.00
31781 90 $1,936.00 $2,098.00 $2,253.00 $2,486.00 $2,098.00 $2,253.00 $2,486.00
31785 90 $1,320.00 $1,589.00 $1,682.00 $1,800.00 $1,589.00 $1,682.00 $1,800.00
31786 90 $1,866.00 $2,203.00 $2,329.00 $2,485.00 $2,203.00 $2,329.00 $2,485.00
31800 90 $628.00 $1,050.00 $1,113.00 $1,165.00 $1,050.00 $1,113.00 $1,165.00
31805 90 $1,175.00 $1,225.00 $1,314.00 $1,438.00 $1,225.00 $1,314.00 $1,438.00
31820 90 $458.00 $616.00 $653.00 $683.00 $473.00 $501.00 $530.00
31825 90 $659.00 $856.00 $906.00 $950.00 $693.00 $733.00 $775.00
31830 90 $460.00 $628.00 $667.00 $699.00 $496.00 $526.00 $556.00
31899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
32035 90 $821.00 $1,077.00 $1,152.00 $1,251.00 $1,077.00 $1,152.00 $1,251.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 214
Surgery
CPT Code FUD 2003 MRALocality 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)
32036 90 $908.00 $1,153.00 $1,235.00 $1,346.00 $1,153.00 $1,235.00 $1,346.00
32096 90 ---------- $1,212.00 $1,299.00 $1,425.00 $1,212.00 $1,299.00 $1,425.00
32097 90 ---------- $1,208.00 $1,294.00 $1,419.00 $1,208.00 $1,294.00 $1,419.00
32098 90 ---------- $1,145.00 $1,227.00 $1,345.00 $1,145.00 $1,227.00 $1,345.00
32100 90 $1,120.00 $1,218.00 $1,307.00 $1,433.00 $1,218.00 $1,307.00 $1,433.00
32110 90 $1,223.00 $2,200.00 $2,358.00 $2,587.00 $2,200.00 $2,358.00 $2,587.00
32120 90 $1,077.00 $1,306.00 $1,400.00 $1,532.00 $1,306.00 $1,400.00 $1,532.00
32124 90 $1,144.00 $1,391.00 $1,491.00 $1,634.00 $1,391.00 $1,491.00 $1,634.00
32140 90 $1,284.00 $1,482.00 $1,590.00 $1,745.00 $1,482.00 $1,590.00 $1,745.00
32141 90 $1,267.00 $2,298.00 $2,463.00 $2,709.00 $2,298.00 $2,463.00 $2,709.00
32150 90 $1,226.00 $1,508.00 $1,617.00 $1,771.00 $1,508.00 $1,617.00 $1,771.00
32151 90 $1,231.00 $1,503.00 $1,611.00 $1,762.00 $1,503.00 $1,611.00 $1,762.00
32160 90 $842.00 $1,183.00 $1,267.00 $1,383.00 $1,183.00 $1,267.00 $1,383.00
32200 90 $1,132.00 $1,686.00 $1,803.00 $1,964.00 $1,686.00 $1,803.00 $1,964.00
32215 90 $1,024.00 $1,192.00 $1,277.00 $1,393.00 $1,192.00 $1,277.00 $1,393.00
32220 90 $1,680.00 $2,375.00 $2,546.00 $2,788.00 $2,375.00 $2,546.00 $2,788.00
32225 90 $1,268.00 $1,490.00 $1,596.00 $1,748.00 $1,490.00 $1,596.00 $1,748.00
32310 90 $1,221.00 $1,370.00 $1,468.00 $1,605.00 $1,370.00 $1,468.00 $1,605.00
32320 90 $1,787.00 $2,400.00 $2,573.00 $2,822.00 $2,400.00 $2,573.00 $2,822.00
32400 0 $129.00 $213.00 $225.00 $232.00 $128.00 $133.00 $140.00
32405 0 $159.00 $536.00 $570.00 $580.00 $133.00 $139.00 $145.00
32440 90 $1,837.00 $2,355.00 $2,524.00 $2,772.00 $2,355.00 $2,524.00 $2,772.00
32442 90 $2,093.00 $4,661.00 $5,005.00 $5,532.00 $4,661.00 $5,005.00 $5,532.00
32445 90 $2,093.00 $5,366.00 $5,761.00 $6,359.00 $5,366.00 $5,761.00 $6,359.00
32480 90 $1,622.00 $2,226.00 $2,386.00 $2,621.00 $2,226.00 $2,386.00 $2,621.00
32482 90 $1,714.00 $2,379.00 $2,551.00 $2,800.00 $2,379.00 $2,551.00 $2,800.00
32484 90 $1,771.00 $2,164.00 $2,321.00 $2,552.00 $2,164.00 $2,321.00 $2,552.00
32486 90 $1,974.00 $3,557.00 $3,816.00 $4,209.00 $3,557.00 $3,816.00 $4,209.00
32488 90 $2,094.00 $3,626.00 $3,889.00 $4,281.00 $3,626.00 $3,889.00 $4,281.00
32491 90 $1,784.00 $2,215.00 $2,375.00 $2,608.00 $2,215.00 $2,375.00 $2,608.00
32501 ZZZ $374.00 $372.00 $399.00 $441.00 $372.00 $399.00 $441.00
32503 90 ---------- $2,724.00 $2,922.00 $3,214.00 $2,724.00 $2,922.00 $3,214.00
32504 90 ---------- $3,134.00 $3,365.00 $3,709.00 $3,134.00 $3,365.00 $3,709.00
32505 90 ---------- $1,398.00 $1,499.00 $1,643.00 $1,398.00 $1,499.00 $1,643.00
32506 ZZZ ---------- $238.00 $255.00 $282.00 $238.00 $255.00 $282.00
32507 ZZZ ---------- $238.00 $255.00 $282.00 $238.00 $255.00 $282.00
32540 90 $1,308.00 $2,614.00 $2,804.00 $3,082.00 $2,614.00 $2,804.00 $3,082.00
32550 0 ---------- $991.00 $1,055.00 $1,085.00 $310.00 $328.00 $351.00
32551 0 ---------- $236.00 $250.00 $270.00 $236.00 $250.00 $270.00
32552 10 ---------- $266.00 $282.00 $298.00 $233.00 $246.00 $262.00
32553 0 ---------- $727.00 $769.00 $787.00 $266.00 $277.00 $290.00
32554 0 ---------- $283.00 $300.00 $309.00 $132.00 $138.00 $146.00
32555 0 ---------- $404.00 $427.00 $438.00 $165.00 $171.00 $179.00
32556 0 ---------- $765.00 $814.00 $831.00 $182.00 $190.00 $202.00
32557 0 ---------- $710.00 $752.00 $768.00 $225.00 $234.00 $245.00
32560 0 ---------- $341.00 $363.00 $375.00 $117.00 $124.00 $133.00
32561 0 ---------- $133.00 $140.00 $147.00 $101.00 $106.00 $112.00
32562 0 ---------- $120.00 $126.00 $133.00 $91.00 $96.00 $102.00
32601 0 $456.00 $465.00 $498.00 $546.00 $465.00 $498.00 $546.00
32604 0 $663.00 $732.00 $786.00 $868.00 $732.00 $786.00 $868.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 215
Surgery
CPT Code FUD 2003 MRALocality 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)
32606 0 $637.00 $699.00 $750.00 $826.00 $699.00 $750.00 $826.00
32607 0 ---------- $465.00 $498.00 $547.00 $465.00 $498.00 $547.00
32608 0 ---------- $572.00 $612.00 $673.00 $572.00 $612.00 $673.00
32609 0 ---------- $389.00 $416.00 $456.00 $389.00 $416.00 $456.00
32650 90 $957.00 $995.00 $1,066.00 $1,163.00 $995.00 $1,066.00 $1,163.00
32651 90 $1,166.00 $1,647.00 $1,766.00 $1,938.00 $1,647.00 $1,766.00 $1,938.00
32652 90 $1,615.00 $2,503.00 $2,684.00 $2,950.00 $2,503.00 $2,684.00 $2,950.00
32653 90 $1,144.00 $1,591.00 $1,705.00 $1,870.00 $1,591.00 $1,705.00 $1,870.00
32654 90 $1,096.00 $1,784.00 $1,915.00 $2,108.00 $1,784.00 $1,915.00 $2,108.00
32655 90 $1,213.00 $1,435.00 $1,538.00 $1,685.00 $1,435.00 $1,538.00 $1,685.00
32656 90 $1,222.00 $1,200.00 $1,287.00 $1,407.00 $1,200.00 $1,287.00 $1,407.00
32658 90 $1,142.00 $1,069.00 $1,147.00 $1,256.00 $1,069.00 $1,147.00 $1,256.00
32659 90 $1,141.00 $1,095.00 $1,174.00 $1,284.00 $1,095.00 $1,174.00 $1,284.00
32661 90 $1,165.00 $1,201.00 $1,289.00 $1,415.00 $1,201.00 $1,289.00 $1,415.00
32662 90 $1,459.00 $1,339.00 $1,435.00 $1,572.00 $1,339.00 $1,435.00 $1,572.00
32663 90 $1,636.00 $2,111.00 $2,264.00 $2,488.00 $2,111.00 $2,264.00 $2,488.00
32664 90 $1,197.00 $1,266.00 $1,355.00 $1,481.00 $1,266.00 $1,355.00 $1,481.00
32665 90 $1,360.00 $1,857.00 $1,989.00 $2,181.00 $1,857.00 $1,989.00 $2,181.00
32666 90 ---------- $1,307.00 $1,401.00 $1,535.00 $1,307.00 $1,401.00 $1,535.00
32667 ZZZ ---------- $239.00 $256.00 $283.00 $239.00 $256.00 $283.00
32668 ZZZ ---------- $239.00 $256.00 $283.00 $239.00 $256.00 $283.00
32669 90 ---------- $2,028.00 $2,175.00 $2,391.00 $2,028.00 $2,175.00 $2,391.00
32670 90 ---------- $2,417.00 $2,590.00 $2,847.00 $2,417.00 $2,590.00 $2,847.00
32671 90 ---------- $2,682.00 $2,876.00 $3,164.00 $2,682.00 $2,876.00 $3,164.00
32672 90 ---------- $2,299.00 $2,466.00 $2,713.00 $2,299.00 $2,466.00 $2,713.00
32673 90 ---------- $1,831.00 $1,964.00 $2,157.00 $1,831.00 $1,964.00 $2,157.00
32674 ZZZ ---------- $328.00 $352.00 $390.00 $328.00 $352.00 $390.00
32701 0 ---------- $323.00 $344.00 $376.00 $323.00 $344.00 $376.00
32800 90 $1,166.00 $1,416.00 $1,516.00 $1,655.00 $1,416.00 $1,516.00 $1,655.00
32810 90 $1,085.00 $1,338.00 $1,433.00 $1,567.00 $1,338.00 $1,433.00 $1,567.00
32815 90 $1,917.00 $4,211.00 $4,515.00 $4,968.00 $4,211.00 $4,515.00 $4,968.00
32820 90 $1,848.00 $2,107.00 $2,262.00 $2,475.00 $2,107.00 $2,262.00 $2,475.00
32851 90 $3,100.00 $4,992.00 $5,357.00 $5,907.00 $4,992.00 $5,357.00 $5,907.00
32852 90 $3,339.00 $5,459.00 $5,862.00 $6,475.00 $5,459.00 $5,862.00 $6,475.00
32853 90 $3,787.00 $6,972.00 $7,484.00 $8,267.00 $6,972.00 $7,484.00 $8,267.00
32854 90 $4,038.00 $7,403.00 $7,946.00 $8,778.00 $7,403.00 $7,946.00 $8,778.00
32900 90 $1,532.00 $2,110.00 $2,260.00 $2,471.00 $2,110.00 $2,260.00 $2,471.00
32905 90 $1,661.00 $2,023.00 $2,169.00 $2,381.00 $2,023.00 $2,169.00 $2,381.00
32906 90 $2,100.00 $2,497.00 $2,678.00 $2,944.00 $2,497.00 $2,678.00 $2,944.00
32940 90 $1,555.00 $1,865.00 $2,002.00 $2,202.00 $1,865.00 $2,002.00 $2,202.00
32960 0 $126.00 $183.00 $191.00 $198.00 $136.00 $141.00 $147.00
32997 0 $312.00 $501.00 $519.00 $542.00 $501.00 $519.00 $542.00
32998 0 ---------- $2,662.00 $2,832.00 $2,877.00 $416.00 $433.00 $455.00
32999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
33010 0 $124.00 $162.00 $173.00 $190.00 $162.00 $173.00 $190.00
33011 0 $125.00 $164.00 $176.00 $193.00 $164.00 $176.00 $193.00
33015 90 $555.00 $764.00 $816.00 $887.00 $764.00 $816.00 $887.00
33020 90 $1,178.00 $1,322.00 $1,416.00 $1,551.00 $1,322.00 $1,416.00 $1,551.00
33025 90 $1,165.00 $1,201.00 $1,287.00 $1,412.00 $1,201.00 $1,287.00 $1,412.00
33030 90 $1,786.00 $3,029.00 $3,248.00 $3,576.00 $3,029.00 $3,248.00 $3,576.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 216
Surgery
CPT Code FUD 2003 MRALocality 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)
33031 90 $1,816.00 $3,736.00 $4,004.00 $4,406.00 $3,736.00 $4,004.00 $4,406.00
33050 90 $1,224.00 $1,499.00 $1,605.00 $1,755.00 $1,499.00 $1,605.00 $1,755.00
33120 90 $2,358.00 $3,177.00 $3,406.00 $3,751.00 $3,177.00 $3,406.00 $3,751.00
33130 90 $1,734.00 $2,086.00 $2,240.00 $2,466.00 $2,086.00 $2,240.00 $2,466.00
33140 90 $1,571.00 $2,388.00 $2,562.00 $2,823.00 $2,388.00 $2,562.00 $2,823.00
33141 ZZZ $254.00 $200.00 $215.00 $237.00 $200.00 $215.00 $237.00
33202 90 ---------- $1,169.00 $1,254.00 $1,378.00 $1,169.00 $1,254.00 $1,378.00
33203 90 ---------- $1,215.00 $1,304.00 $1,434.00 $1,215.00 $1,304.00 $1,434.00
33206 90 $642.00 $675.00 $724.00 $789.00 $675.00 $724.00 $789.00
33207 90 $753.00 $722.00 $774.00 $846.00 $722.00 $774.00 $846.00
33208 90 $573.00 $784.00 $840.00 $919.00 $784.00 $840.00 $919.00
33210 0 $204.00 $251.00 $268.00 $295.00 $251.00 $268.00 $295.00
33211 0 $210.00 $256.00 $275.00 $302.00 $256.00 $275.00 $302.00
33212 90 $511.00 $479.00 $513.00 $559.00 $479.00 $513.00 $559.00
33213 90 $437.00 $501.00 $537.00 $586.00 $501.00 $537.00 $586.00
33214 90 $532.00 $715.00 $766.00 $834.00 $715.00 $766.00 $834.00
33215 90 $304.00 $465.00 $499.00 $544.00 $465.00 $499.00 $544.00
33216 90 $402.00 $553.00 $592.00 $644.00 $553.00 $592.00 $644.00
33217 90 $428.00 $542.00 $581.00 $632.00 $542.00 $581.00 $632.00
33218 90 $488.00 $581.00 $622.00 $677.00 $581.00 $622.00 $677.00
33220 90 $390.00 $581.00 $623.00 $677.00 $581.00 $623.00 $677.00
33221 90 ---------- $539.00 $578.00 $629.00 $539.00 $578.00 $629.00
33222 90 $471.00 $500.00 $536.00 $580.00 $500.00 $536.00 $580.00
33223 90 $585.00 $609.00 $653.00 $712.00 $609.00 $653.00 $712.00
33224 0 $490.00 $781.00 $838.00 $920.00 $781.00 $838.00 $920.00
33225 ZZZ $434.00 $713.00 $765.00 $841.00 $713.00 $765.00 $841.00
33226 0 $472.00 $751.00 $806.00 $885.00 $751.00 $806.00 $885.00
33227 90 ---------- $505.00 $541.00 $590.00 $505.00 $541.00 $590.00
33228 90 ---------- $528.00 $566.00 $617.00 $528.00 $566.00 $617.00
33229 90 ---------- $560.00 $600.00 $654.00 $560.00 $600.00 $654.00
33230 90 ---------- $573.00 $615.00 $671.00 $573.00 $615.00 $671.00
33231 90 ---------- $603.00 $646.00 $704.00 $603.00 $646.00 $704.00
33233 90 $270.00 $340.00 $364.00 $394.00 $340.00 $364.00 $394.00
33234 90 $598.00 $726.00 $779.00 $849.00 $726.00 $779.00 $849.00
33235 90 $587.00 $954.00 $1,023.00 $1,115.00 $954.00 $1,023.00 $1,115.00
33236 90 $933.00 $1,176.00 $1,262.00 $1,381.00 $1,176.00 $1,262.00 $1,381.00
33237 90 $1,184.00 $1,257.00 $1,348.00 $1,476.00 $1,257.00 $1,348.00 $1,476.00
33238 90 $1,235.00 $1,398.00 $1,496.00 $1,632.00 $1,398.00 $1,496.00 $1,632.00
33240 90 $648.00 $547.00 $586.00 $640.00 $547.00 $586.00 $640.00
33241 90 $301.00 $319.00 $342.00 $371.00 $319.00 $342.00 $371.00
33243 90 $1,650.00 $2,062.00 $2,210.00 $2,423.00 $2,062.00 $2,210.00 $2,423.00
33244 90 $1,081.00 $1,290.00 $1,384.00 $1,512.00 $1,290.00 $1,384.00 $1,512.00
33249 90 $1,271.00 $1,377.00 $1,476.00 $1,613.00 $1,377.00 $1,476.00 $1,613.00
33250 90 $1,687.00 $2,187.00 $2,338.00 $2,558.00 $2,187.00 $2,338.00 $2,558.00
33251 90 $2,071.00 $2,457.00 $2,637.00 $2,906.00 $2,457.00 $2,637.00 $2,906.00
33254 90 ---------- $2,061.00 $2,212.00 $2,433.00 $2,061.00 $2,212.00 $2,433.00
33255 90 ---------- $2,485.00 $2,668.00 $2,938.00 $2,485.00 $2,668.00 $2,938.00
33256 90 ---------- $2,938.00 $3,149.00 $3,463.00 $2,938.00 $3,149.00 $3,463.00
33257 ZZZ ---------- $873.00 $935.00 $1,022.00 $873.00 $935.00 $1,022.00
33258 ZZZ ---------- $982.00 $1,052.00 $1,149.00 $982.00 $1,052.00 $1,149.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 217
Surgery
CPT Code FUD 2003 MRALocality 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)
33259 ZZZ ---------- $1,268.00 $1,359.00 $1,486.00 $1,268.00 $1,359.00 $1,486.00
33261 90 $1,993.00 $2,456.00 $2,636.00 $2,906.00 $2,456.00 $2,636.00 $2,906.00
33262 90 ---------- $558.00 $598.00 $652.00 $558.00 $598.00 $652.00
33263 90 ---------- $581.00 $623.00 $680.00 $581.00 $623.00 $680.00
33264 90 ---------- $606.00 $650.00 $709.00 $606.00 $650.00 $709.00
33265 90 ---------- $2,046.00 $2,192.00 $2,403.00 $2,046.00 $2,192.00 $2,403.00
33266 90 ---------- $2,790.00 $2,991.00 $3,290.00 $2,790.00 $2,991.00 $3,290.00
33270 90 ---------- $884.00 $948.00 $1,033.00 $884.00 $948.00 $1,033.00
33271 90 ---------- $736.00 $788.00 $855.00 $736.00 $788.00 $855.00
33272 90 ---------- $521.00 $558.00 $608.00 $521.00 $558.00 $608.00
33273 90 ---------- $609.00 $651.00 $707.00 $609.00 $651.00 $707.00
33282 90 $470.00 $335.00 $359.00 $389.00 $335.00 $359.00 $389.00
33284 90 $365.00 $294.00 $315.00 $341.00 $294.00 $315.00 $341.00
33300 90 $1,576.00 $3,711.00 $3,978.00 $4,383.00 $3,711.00 $3,978.00 $4,383.00
33305 90 $1,889.00 $6,225.00 $6,675.00 $7,368.00 $6,225.00 $6,675.00 $7,368.00
33310 90 $1,577.00 $1,769.00 $1,889.00 $2,058.00 $1,769.00 $1,889.00 $2,058.00
33315 90 $1,875.00 $2,894.00 $3,100.00 $3,411.00 $2,894.00 $3,100.00 $3,411.00
33320 90 $1,485.00 $1,601.00 $1,715.00 $1,882.00 $1,601.00 $1,715.00 $1,882.00
33321 90 $1,890.00 $1,792.00 $1,918.00 $2,100.00 $1,792.00 $1,918.00 $2,100.00
33322 90 $1,935.00 $2,093.00 $2,242.00 $2,460.00 $2,093.00 $2,242.00 $2,460.00
33330 90 $1,726.00 $2,157.00 $2,313.00 $2,541.00 $2,157.00 $2,313.00 $2,541.00
33335 90 $2,336.00 $2,834.00 $3,036.00 $3,336.00 $2,834.00 $3,036.00 $3,336.00
33361 0 ---------- $2,068.00 $2,219.00 $2,448.00 $2,068.00 $2,219.00 $2,448.00
33362 0 ---------- $2,258.00 $2,422.00 $2,673.00 $2,258.00 $2,422.00 $2,673.00
33363 0 ---------- $2,373.00 $2,546.00 $2,806.00 $2,373.00 $2,546.00 $2,806.00
33364 0 ---------- $2,464.00 $2,644.00 $2,917.00 $2,464.00 $2,644.00 $2,917.00
33365 0 ---------- $2,711.00 $2,908.00 $3,210.00 $2,711.00 $2,908.00 $3,210.00
33366 0 ---------- $2,934.00 $3,148.00 $3,477.00 $2,934.00 $3,148.00 $3,477.00
33367 ZZZ ---------- $953.00 $1,022.00 $1,130.00 $953.00 $1,022.00 $1,130.00
33368 ZZZ ---------- $1,140.00 $1,223.00 $1,354.00 $1,140.00 $1,223.00 $1,354.00
33369 ZZZ ---------- $1,508.00 $1,619.00 $1,795.00 $1,508.00 $1,619.00 $1,795.00
33404 90 $2,698.00 $2,648.00 $2,835.00 $3,109.00 $2,648.00 $2,835.00 $3,109.00
33405 90 $2,745.00 $3,432.00 $3,678.00 $4,046.00 $3,432.00 $3,678.00 $4,046.00
33406 90 $2,962.00 $4,358.00 $4,671.00 $5,144.00 $4,358.00 $4,671.00 $5,144.00
33410 90 $2,637.00 $3,848.00 $4,123.00 $4,536.00 $3,848.00 $4,123.00 $4,536.00
33411 90 $2,981.00 $5,084.00 $5,447.00 $5,998.00 $5,084.00 $5,447.00 $5,998.00
33412 90 $3,213.00 $4,814.00 $5,163.00 $5,698.00 $4,814.00 $5,163.00 $5,698.00
33413 90 $3,282.00 $4,816.00 $5,073.00 $5,401.00 $4,816.00 $5,073.00 $5,401.00
33414 90 $2,904.00 $3,277.00 $3,519.00 $3,887.00 $3,277.00 $3,519.00 $3,887.00
33415 90 $2,563.00 $3,072.00 $3,287.00 $3,608.00 $3,072.00 $3,287.00 $3,608.00
33416 90 $2,684.00 $3,069.00 $3,289.00 $3,616.00 $3,069.00 $3,289.00 $3,616.00
33417 90 $2,756.00 $2,531.00 $2,717.00 $2,993.00 $2,531.00 $2,717.00 $2,993.00
33418 90 ---------- $2,724.00 $2,916.00 $3,196.00 $2,724.00 $2,916.00 $3,196.00
33419 ZZZ ---------- $646.00 $692.00 $761.00 $646.00 $692.00 $761.00
33420 90 $1,796.00 $2,210.00 $2,372.00 $2,612.00 $2,210.00 $2,372.00 $2,612.00
33422 90 $2,431.00 $2,526.00 $2,709.00 $2,981.00 $2,526.00 $2,709.00 $2,981.00
33425 90 $2,509.00 $4,132.00 $4,426.00 $4,868.00 $4,132.00 $4,426.00 $4,868.00
33426 90 $2,806.00 $3,602.00 $3,860.00 $4,245.00 $3,602.00 $3,860.00 $4,245.00
33427 90 $3,026.00 $3,702.00 $3,966.00 $4,364.00 $3,702.00 $3,966.00 $4,364.00
33430 90 $2,891.00 $4,232.00 $4,535.00 $4,990.00 $4,232.00 $4,535.00 $4,990.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 218
Surgery
CPT Code FUD 2003 MRALocality 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)
33460 90 $2,215.00 $3,681.00 $3,948.00 $4,355.00 $3,681.00 $3,948.00 $4,355.00
33463 90 $2,396.00 $4,680.00 $5,013.00 $5,518.00 $4,680.00 $5,013.00 $5,518.00
33464 90 $2,547.00 $3,693.00 $3,956.00 $4,349.00 $3,693.00 $3,956.00 $4,349.00
33465 90 $2,665.00 $4,178.00 $4,477.00 $4,931.00 $4,178.00 $4,477.00 $4,931.00
33468 90 $2,952.00 $3,738.00 $4,014.00 $4,436.00 $3,738.00 $4,014.00 $4,436.00
33470 90 $1,749.00 $1,956.00 $2,100.00 $2,303.00 $1,956.00 $2,100.00 $2,303.00
33471 90 $1,929.00 $2,090.00 $2,244.00 $2,460.00 $2,090.00 $2,244.00 $2,460.00
33474 90 $2,173.00 $3,315.00 $3,560.00 $3,929.00 $3,315.00 $3,560.00 $3,929.00
33475 90 $2,666.00 $3,529.00 $3,783.00 $4,164.00 $3,529.00 $3,783.00 $4,164.00
33476 90 $2,270.00 $2,308.00 $2,477.00 $2,727.00 $2,308.00 $2,477.00 $2,727.00
33477 0 ---------- $1,960.00 $2,076.00 $2,240.00 $1,960.00 $2,076.00 $2,240.00
33478 90 $2,544.00 $2,385.00 $2,561.00 $2,819.00 $2,385.00 $2,561.00 $2,819.00
33496 90 $2,595.00 $2,530.00 $2,712.00 $2,983.00 $2,530.00 $2,712.00 $2,983.00
33500 90 $2,370.00 $2,362.00 $2,531.00 $2,781.00 $2,362.00 $2,531.00 $2,781.00
33501 90 $1,546.00 $1,683.00 $1,806.00 $1,989.00 $1,683.00 $1,806.00 $1,989.00
33502 90 $1,938.00 $1,932.00 $2,074.00 $2,280.00 $1,932.00 $2,074.00 $2,280.00
33503 90 $1,983.00 $2,006.00 $2,153.00 $2,365.00 $2,006.00 $2,153.00 $2,365.00
33504 90 $2,416.00 $2,222.00 $2,386.00 $2,625.00 $2,222.00 $2,386.00 $2,625.00
33505 90 $2,423.00 $3,150.00 $3,383.00 $3,741.00 $3,150.00 $3,383.00 $3,741.00
33506 90 $2,448.00 $3,133.00 $3,364.00 $3,718.00 $3,133.00 $3,364.00 $3,718.00
33507 90 ---------- $2,626.00 $2,820.00 $3,114.00 $2,626.00 $2,820.00 $3,114.00
33508 ZZZ $17.00 $25.00 $26.00 $29.00 $25.00 $26.00 $29.00
33510 90 $2,354.00 $2,921.00 $3,129.00 $3,440.00 $2,921.00 $3,129.00 $3,440.00
33511 90 $2,546.00 $3,211.00 $3,440.00 $3,783.00 $3,211.00 $3,440.00 $3,783.00
33512 90 $2,732.00 $3,651.00 $3,912.00 $4,304.00 $3,651.00 $3,912.00 $4,304.00
33513 90 $2,933.00 $3,760.00 $4,029.00 $4,433.00 $3,760.00 $4,029.00 $4,433.00
33514 90 $3,197.00 $3,972.00 $4,256.00 $4,685.00 $3,972.00 $4,256.00 $4,685.00
33516 90 $3,404.00 $4,165.00 $4,472.00 $4,938.00 $4,165.00 $4,472.00 $4,938.00
33517 ZZZ $219.00 $285.00 $306.00 $338.00 $285.00 $306.00 $338.00
33518 ZZZ $414.00 $627.00 $672.00 $742.00 $627.00 $672.00 $742.00
33519 ZZZ $607.00 $829.00 $888.00 $981.00 $829.00 $888.00 $981.00
33521 ZZZ $801.00 $994.00 $1,066.00 $1,178.00 $994.00 $1,066.00 $1,178.00
33522 ZZZ $994.00 $1,116.00 $1,195.00 $1,320.00 $1,116.00 $1,195.00 $1,320.00
33523 ZZZ $1,189.00 $1,264.00 $1,354.00 $1,494.00 $1,264.00 $1,354.00 $1,494.00
33530 ZZZ $521.00 $801.00 $858.00 $949.00 $801.00 $858.00 $949.00
33533 90 $2,415.00 $2,824.00 $3,026.00 $3,326.00 $2,824.00 $3,026.00 $3,326.00
33534 90 $2,654.00 $3,325.00 $3,563.00 $3,919.00 $3,325.00 $3,563.00 $3,919.00
33535 90 $2,899.00 $3,713.00 $3,979.00 $4,379.00 $3,713.00 $3,979.00 $4,379.00
33536 90 $3,143.00 $4,002.00 $4,288.00 $4,717.00 $4,002.00 $4,288.00 $4,717.00
33542 90 $2,693.00 $3,973.00 $4,256.00 $4,684.00 $3,973.00 $4,256.00 $4,684.00
33545 90 $3,250.00 $4,696.00 $5,035.00 $5,552.00 $4,696.00 $5,035.00 $5,552.00
33548 90 ---------- $4,489.00 $4,811.00 $5,295.00 $4,489.00 $4,811.00 $5,295.00
33572 ZZZ $340.00 $350.00 $375.00 $414.00 $350.00 $375.00 $414.00
33600 90 $2,644.00 $2,609.00 $2,801.00 $3,085.00 $2,609.00 $2,801.00 $3,085.00
33602 90 $2,556.00 $2,532.00 $2,718.00 $2,993.00 $2,532.00 $2,718.00 $2,993.00
33606 90 $2,831.00 $2,701.00 $2,900.00 $3,195.00 $2,701.00 $2,900.00 $3,195.00
33608 90 $2,940.00 $2,733.00 $2,935.00 $3,233.00 $2,733.00 $2,935.00 $3,233.00
33610 90 $2,871.00 $2,696.00 $2,895.00 $3,190.00 $2,696.00 $2,895.00 $3,190.00
33611 90 $2,985.00 $2,974.00 $3,194.00 $3,526.00 $2,974.00 $3,194.00 $3,526.00
33612 90 $3,152.00 $3,054.00 $3,279.00 $3,621.00 $3,054.00 $3,279.00 $3,621.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 219
Surgery
CPT Code FUD 2003 MRALocality 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)
33615 90 $3,051.00 $3,037.00 $3,261.00 $3,598.00 $3,037.00 $3,261.00 $3,598.00
33617 90 $3,272.00 $3,292.00 $3,535.00 $3,901.00 $3,292.00 $3,535.00 $3,901.00
33619 90 $3,678.00 $4,145.00 $4,451.00 $4,908.00 $4,145.00 $4,451.00 $4,908.00
33620 90 ---------- $2,515.00 $2,701.00 $2,982.00 $2,515.00 $2,701.00 $2,982.00
33621 90 ---------- $1,412.00 $1,515.00 $1,667.00 $1,412.00 $1,515.00 $1,667.00
33622 90 ---------- $5,530.00 $5,936.00 $6,537.00 $5,530.00 $5,936.00 $6,537.00
33641 90 $1,981.00 $2,496.00 $2,680.00 $2,958.00 $2,496.00 $2,680.00 $2,958.00
33645 90 $2,352.00 $2,635.00 $2,830.00 $3,123.00 $2,635.00 $2,830.00 $3,123.00
33647 90 $2,732.00 $2,769.00 $2,973.00 $3,282.00 $2,769.00 $2,973.00 $3,282.00
33660 90 $2,444.00 $2,675.00 $2,872.00 $3,170.00 $2,675.00 $2,872.00 $3,170.00
33665 90 $2,700.00 $2,989.00 $3,209.00 $3,535.00 $2,989.00 $3,209.00 $3,535.00
33670 90 $2,820.00 $3,013.00 $3,236.00 $3,578.00 $3,013.00 $3,236.00 $3,578.00
33675 90 ---------- $3,006.00 $3,228.00 $3,564.00 $3,006.00 $3,228.00 $3,564.00
33676 90 ---------- $3,242.00 $3,481.00 $3,828.00 $3,242.00 $3,481.00 $3,828.00
33677 90 ---------- $3,369.00 $3,617.00 $3,978.00 $3,369.00 $3,617.00 $3,978.00
33681 90 $2,657.00 $2,791.00 $2,997.00 $3,300.00 $2,791.00 $2,997.00 $3,300.00
33684 90 $2,740.00 $2,879.00 $3,091.00 $3,413.00 $2,879.00 $3,091.00 $3,413.00
33688 90 $2,602.00 $3,026.00 $3,248.00 $3,575.00 $3,026.00 $3,248.00 $3,575.00
33690 90 $1,884.00 $1,815.00 $1,948.00 $2,140.00 $1,815.00 $1,948.00 $2,140.00
33692 90 $2,816.00 $3,144.00 $3,376.00 $3,715.00 $3,144.00 $3,376.00 $3,715.00
33694 90 $2,856.00 $2,974.00 $3,194.00 $3,526.00 $2,974.00 $3,194.00 $3,526.00
33697 90 $3,064.00 $3,134.00 $3,365.00 $3,716.00 $3,134.00 $3,365.00 $3,716.00
33702 90 $2,549.00 $2,347.00 $2,520.00 $2,775.00 $2,347.00 $2,520.00 $2,775.00
33710 90 $2,731.00 $3,128.00 $3,358.00 $3,709.00 $3,128.00 $3,358.00 $3,709.00
33720 90 $2,508.00 $2,348.00 $2,521.00 $2,777.00 $2,348.00 $2,521.00 $2,777.00
33722 90 $2,704.00 $2,473.00 $2,655.00 $2,929.00 $2,473.00 $2,655.00 $2,929.00
33724 90 ---------- $2,342.00 $2,515.00 $2,774.00 $2,342.00 $2,515.00 $2,774.00
33726 90 ---------- $3,100.00 $3,329.00 $3,676.00 $3,100.00 $3,329.00 $3,676.00
33730 90 $2,785.00 $3,052.00 $3,277.00 $3,615.00 $3,052.00 $3,277.00 $3,615.00
33732 90 $2,622.00 $2,501.00 $2,685.00 $2,957.00 $2,501.00 $2,685.00 $2,957.00
33735 90 $2,036.00 $1,962.00 $2,106.00 $2,315.00 $1,962.00 $2,106.00 $2,315.00
33736 90 $2,288.00 $2,131.00 $2,288.00 $2,516.00 $2,131.00 $2,288.00 $2,516.00
33737 90 $1,977.00 $1,967.00 $2,111.00 $2,322.00 $1,967.00 $2,111.00 $2,322.00
33750 90 $1,877.00 $2,001.00 $2,148.00 $2,357.00 $2,001.00 $2,148.00 $2,357.00
33755 90 $1,831.00 $2,074.00 $2,226.00 $2,440.00 $2,074.00 $2,226.00 $2,440.00
33762 90 $1,900.00 $2,033.00 $2,182.00 $2,395.00 $2,033.00 $2,182.00 $2,395.00
33764 90 $1,895.00 $1,994.00 $2,140.00 $2,353.00 $1,994.00 $2,140.00 $2,353.00
33766 90 $2,119.00 $2,116.00 $2,271.00 $2,493.00 $2,116.00 $2,271.00 $2,493.00
33767 90 $2,173.00 $2,162.00 $2,321.00 $2,559.00 $2,162.00 $2,321.00 $2,559.00
33768 ZZZ ---------- $677.00 $727.00 $802.00 $677.00 $727.00 $802.00
33770 90 $2,954.00 $3,401.00 $3,651.00 $4,018.00 $3,401.00 $3,651.00 $4,018.00
33771 90 $2,924.00 $3,509.00 $3,768.00 $4,149.00 $3,509.00 $3,768.00 $4,149.00
33774 90 $2,681.00 $2,732.00 $2,933.00 $3,231.00 $2,732.00 $2,933.00 $3,231.00
33775 90 $2,654.00 $2,948.00 $3,164.00 $3,475.00 $2,948.00 $3,164.00 $3,475.00
33776 90 $2,844.00 $3,114.00 $3,342.00 $3,670.00 $3,114.00 $3,342.00 $3,670.00
33777 90 $2,724.00 $2,879.00 $3,091.00 $3,411.00 $2,879.00 $3,091.00 $3,411.00
33778 90 $3,199.00 $3,579.00 $3,843.00 $4,243.00 $3,579.00 $3,843.00 $4,243.00
33779 90 $3,121.00 $3,742.00 $4,018.00 $4,423.00 $3,742.00 $4,018.00 $4,423.00
33780 90 $3,232.00 $3,808.00 $4,089.00 $4,501.00 $3,808.00 $4,089.00 $4,501.00
33781 90 $3,057.00 $3,726.00 $4,000.00 $4,406.00 $3,726.00 $4,000.00 $4,406.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 220
Surgery
CPT Code FUD 2003 MRALocality 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)
33782 90 ---------- $4,932.00 $5,296.00 $5,857.00 $4,932.00 $5,296.00 $5,857.00
33783 90 ---------- $5,330.00 $5,723.00 $6,331.00 $5,330.00 $5,723.00 $6,331.00
33786 90 $2,970.00 $3,652.00 $3,920.00 $4,313.00 $3,652.00 $3,920.00 $4,313.00
33788 90 $2,288.00 $2,441.00 $2,620.00 $2,878.00 $2,441.00 $2,620.00 $2,878.00
33800 90 $1,546.00 $1,499.00 $1,609.00 $1,772.00 $1,499.00 $1,609.00 $1,772.00
33802 90 $1,752.00 $1,640.00 $1,760.00 $1,933.00 $1,640.00 $1,760.00 $1,933.00
33803 90 $1,746.00 $1,746.00 $1,875.00 $2,065.00 $1,746.00 $1,875.00 $2,065.00
33813 90 $1,935.00 $1,955.00 $2,098.00 $2,300.00 $1,955.00 $2,098.00 $2,300.00
33814 90 $2,464.00 $2,310.00 $2,480.00 $2,729.00 $2,310.00 $2,480.00 $2,729.00
33820 90 $1,619.00 $1,468.00 $1,576.00 $1,733.00 $1,468.00 $1,576.00 $1,733.00
33822 90 $1,559.00 $1,615.00 $1,733.00 $1,900.00 $1,615.00 $1,733.00 $1,900.00
33824 90 $1,884.00 $1,786.00 $1,917.00 $2,107.00 $1,786.00 $1,917.00 $2,107.00
33840 90 $2,029.00 $1,953.00 $2,096.00 $2,297.00 $1,953.00 $2,096.00 $2,297.00
33845 90 $2,129.00 $2,020.00 $2,168.00 $2,384.00 $2,020.00 $2,168.00 $2,384.00
33851 90 $2,129.00 $2,008.00 $2,155.00 $2,363.00 $2,008.00 $2,155.00 $2,363.00
33852 90 $2,311.00 $2,122.00 $2,278.00 $2,508.00 $2,122.00 $2,278.00 $2,508.00
33853 90 $3,057.00 $2,785.00 $2,990.00 $3,295.00 $2,785.00 $2,990.00 $3,295.00
33860 90 $3,044.00 $4,870.00 $5,219.00 $5,750.00 $4,870.00 $5,219.00 $5,750.00
33863 90 $3,183.00 $4,781.00 $5,124.00 $5,649.00 $4,781.00 $5,124.00 $5,649.00
33864 90 ---------- $4,898.00 $5,250.00 $5,787.00 $4,898.00 $5,250.00 $5,787.00
33870 90 $3,638.00 $3,828.00 $4,104.00 $4,521.00 $3,828.00 $4,104.00 $4,521.00
33875 90 $2,876.00 $4,159.00 $4,459.00 $4,918.00 $4,159.00 $4,459.00 $4,918.00
33877 90 $3,767.00 $5,538.00 $5,942.00 $6,571.00 $5,538.00 $5,942.00 $6,571.00
33880 90 ---------- $2,746.00 $2,941.00 $3,245.00 $2,746.00 $2,941.00 $3,245.00
33881 90 ---------- $2,358.00 $2,526.00 $2,787.00 $2,358.00 $2,526.00 $2,787.00
33883 90 ---------- $1,708.00 $1,829.00 $2,014.00 $1,708.00 $1,829.00 $2,014.00
33884 ZZZ ---------- $632.00 $677.00 $748.00 $632.00 $677.00 $748.00
33886 90 ---------- $1,471.00 $1,576.00 $1,737.00 $1,471.00 $1,576.00 $1,737.00
33889 0 ---------- $1,208.00 $1,294.00 $1,433.00 $1,208.00 $1,294.00 $1,433.00
33891 0 ---------- $1,507.00 $1,618.00 $1,799.00 $1,507.00 $1,618.00 $1,799.00
33910 90 $1,987.00 $3,993.00 $4,280.00 $4,712.00 $3,993.00 $4,280.00 $4,712.00
33915 90 $1,588.00 $1,937.00 $2,076.00 $2,298.00 $1,937.00 $2,076.00 $2,298.00
33916 90 $2,096.00 $6,383.00 $6,852.00 $7,573.00 $6,383.00 $6,852.00 $7,573.00
33917 90 $2,345.00 $2,210.00 $2,372.00 $2,610.00 $2,210.00 $2,372.00 $2,610.00
33920 90 $2,981.00 $2,890.00 $3,103.00 $3,410.00 $2,890.00 $3,103.00 $3,410.00
33922 90 $2,227.00 $2,107.00 $2,262.00 $2,489.00 $2,107.00 $2,262.00 $2,489.00
33924 ZZZ $421.00 $438.00 $471.00 $522.00 $438.00 $471.00 $522.00
33925 90 ---------- $2,618.00 $2,812.00 $3,105.00 $2,618.00 $2,812.00 $3,105.00
33926 90 ---------- $3,885.00 $4,171.00 $4,591.00 $3,885.00 $4,171.00 $4,591.00
33935 90 $5,415.00 $7,553.00 $8,108.00 $8,959.00 $7,553.00 $8,108.00 $8,959.00
33945 90 $3,813.00 $7,374.00 $7,909.00 $8,723.00 $7,374.00 $7,909.00 $8,723.00
33946 0 ---------- $467.00 $497.00 $544.00 $467.00 $497.00 $544.00
33947 0 ---------- $519.00 $554.00 $608.00 $519.00 $554.00 $608.00
33948 0 ---------- $358.00 $379.00 $409.00 $358.00 $379.00 $409.00
33949 0 ---------- $352.00 $374.00 $406.00 $352.00 $374.00 $406.00
33951 0 ---------- $638.00 $671.00 $715.00 $638.00 $671.00 $715.00
33952 0 ---------- $651.00 $698.00 $770.00 $651.00 $698.00 $770.00
33953 0 ---------- $712.00 $750.00 $799.00 $712.00 $750.00 $799.00
33954 0 ---------- $728.00 $781.00 $863.00 $728.00 $781.00 $863.00
33955 0 ---------- $1,248.00 $1,314.00 $1,401.00 $1,248.00 $1,314.00 $1,401.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 221
Surgery
CPT Code FUD 2003 MRALocality 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)
33956 0 ---------- $1,269.00 $1,359.00 $1,498.00 $1,269.00 $1,359.00 $1,498.00
33957 0 ---------- $278.00 $293.00 $312.00 $278.00 $293.00 $312.00
33958 0 ---------- $272.00 $288.00 $309.00 $272.00 $288.00 $309.00
33959 0 ---------- $352.00 $371.00 $395.00 $352.00 $371.00 $395.00
33962 0 ---------- $359.00 $385.00 $425.00 $359.00 $385.00 $425.00
33963 0 ---------- $704.00 $741.00 $791.00 $704.00 $741.00 $791.00
33964 0 ---------- $722.00 $759.00 $811.00 $722.00 $759.00 $811.00
33965 0 ---------- $278.00 $293.00 $312.00 $278.00 $293.00 $312.00
33966 0 ---------- $362.00 $389.00 $430.00 $362.00 $389.00 $430.00
33967 0 $258.00 $395.00 $423.00 $467.00 $395.00 $423.00 $467.00
33968 0 $51.00 $51.00 $54.00 $60.00 $51.00 $54.00 $60.00
33969 0 ---------- $421.00 $452.00 $501.00 $421.00 $452.00 $501.00
33970 0 $576.00 $541.00 $580.00 $640.00 $541.00 $580.00 $640.00
33971 90 $578.00 $1,068.00 $1,144.00 $1,251.00 $1,068.00 $1,144.00 $1,251.00
33973 0 $756.00 $784.00 $841.00 $928.00 $784.00 $841.00 $928.00
33974 90 $1,095.00 $1,344.00 $1,439.00 $1,573.00 $1,344.00 $1,439.00 $1,573.00
33975 0 $1,758.00 $1,998.00 $2,144.00 $2,372.00 $1,998.00 $2,144.00 $2,372.00
33976 0 $2,056.00 $2,439.00 $2,619.00 $2,903.00 $2,439.00 $2,619.00 $2,903.00
33977 0 $1,561.00 $1,713.00 $1,837.00 $2,024.00 $1,713.00 $1,837.00 $2,024.00
33978 0 $1,754.00 $2,034.00 $2,184.00 $2,416.00 $2,034.00 $2,184.00 $2,416.00
33979 0 $2,496.00 $2,980.00 $3,196.00 $3,536.00 $2,980.00 $3,196.00 $3,536.00
33980 0 $3,212.00 $2,717.00 $2,914.00 $3,218.00 $2,717.00 $2,914.00 $3,218.00
33981 0 ---------- $1,264.00 $1,353.00 $1,493.00 $1,264.00 $1,353.00 $1,493.00
33982 0 ---------- $2,988.00 $3,202.00 $3,536.00 $2,988.00 $3,202.00 $3,536.00
33983 0 ---------- $3,536.00 $3,792.00 $4,194.00 $3,536.00 $3,792.00 $4,194.00
33984 0 ---------- $437.00 $469.00 $519.00 $437.00 $469.00 $519.00
33985 0 ---------- $790.00 $848.00 $939.00 $790.00 $848.00 $939.00
33986 0 ---------- $798.00 $857.00 $949.00 $798.00 $857.00 $949.00
33987 ZZZ ---------- $321.00 $345.00 $382.00 $321.00 $345.00 $382.00
33988 0 ---------- $1,197.00 $1,285.00 $1,422.00 $1,197.00 $1,285.00 $1,422.00
33989 0 ---------- $759.00 $815.00 $903.00 $759.00 $815.00 $903.00
33990 0 ---------- $648.00 $695.00 $767.00 $648.00 $695.00 $767.00
33991 0 ---------- $949.00 $1,017.00 $1,121.00 $949.00 $1,017.00 $1,121.00
33992 0 ---------- $305.00 $327.00 $361.00 $305.00 $327.00 $361.00
33993 0 ---------- $266.00 $285.00 $314.00 $266.00 $285.00 $314.00
33999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
34001 90 $1,012.00 $1,478.00 $1,583.00 $1,742.00 $1,478.00 $1,583.00 $1,742.00
34051 90 $1,134.00 $1,360.00 $1,459.00 $1,613.00 $1,360.00 $1,459.00 $1,613.00
34101 90 $800.00 $915.00 $981.00 $1,081.00 $915.00 $981.00 $1,081.00
34111 90 $669.00 $914.00 $980.00 $1,079.00 $914.00 $980.00 $1,079.00
34151 90 $1,288.00 $2,147.00 $2,302.00 $2,540.00 $2,147.00 $2,302.00 $2,540.00
34201 90 $777.00 $1,579.00 $1,694.00 $1,871.00 $1,579.00 $1,694.00 $1,871.00
34203 90 $949.00 $1,461.00 $1,567.00 $1,729.00 $1,461.00 $1,567.00 $1,729.00
34401 90 $953.00 $2,217.00 $2,371.00 $2,598.00 $2,217.00 $2,371.00 $2,598.00
34421 90 $779.00 $1,107.00 $1,186.00 $1,305.00 $1,107.00 $1,186.00 $1,305.00
34451 90 $1,117.00 $2,483.00 $2,665.00 $2,931.00 $2,483.00 $2,665.00 $2,931.00
34471 90 $685.00 $1,666.00 $1,783.00 $1,964.00 $1,666.00 $1,783.00 $1,964.00
34490 90 $660.00 $928.00 $995.00 $1,096.00 $928.00 $995.00 $1,096.00
34501 90 $910.00 $1,363.00 $1,455.00 $1,590.00 $1,363.00 $1,455.00 $1,590.00
34502 90 $2,044.00 $2,333.00 $2,494.00 $2,731.00 $2,333.00 $2,494.00 $2,731.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 222
Surgery
CPT Code FUD 2003 MRALocality 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)
34510 90 $1,108.00 $1,811.00 $1,945.00 $2,137.00 $1,811.00 $1,945.00 $2,137.00
34520 90 $1,077.00 $1,602.00 $1,714.00 $1,880.00 $1,602.00 $1,714.00 $1,880.00
34530 90 $1,368.00 $1,456.00 $1,562.00 $1,726.00 $1,456.00 $1,562.00 $1,726.00
34800 90 $1,159.00 $1,728.00 $1,851.00 $2,040.00 $1,728.00 $1,851.00 $2,040.00
34802 90 $1,279.00 $1,907.00 $2,042.00 $2,249.00 $1,907.00 $2,042.00 $2,249.00
34803 90 ---------- $1,979.00 $2,120.00 $2,338.00 $1,979.00 $2,120.00 $2,338.00
34804 90 $1,279.00 $1,911.00 $2,048.00 $2,258.00 $1,911.00 $2,048.00 $2,258.00
34805 90 ---------- $1,828.00 $1,960.00 $2,166.00 $1,828.00 $1,960.00 $2,166.00
34806 ZZZ ---------- $154.00 $165.00 $184.00 $154.00 $165.00 $184.00
34808 ZZZ $220.00 $320.00 $343.00 $381.00 $320.00 $343.00 $381.00
34812 0 $359.00 $519.00 $557.00 $618.00 $519.00 $557.00 $618.00
34813 ZZZ $256.00 $364.00 $390.00 $433.00 $364.00 $390.00 $433.00
34820 0 $519.00 $753.00 $807.00 $895.00 $753.00 $807.00 $895.00
34825 90 $694.00 $1,060.00 $1,134.00 $1,244.00 $1,060.00 $1,134.00 $1,244.00
34826 ZZZ $220.00 $316.00 $338.00 $374.00 $316.00 $338.00 $374.00
34830 90 $1,803.00 $2,769.00 $2,973.00 $3,299.00 $2,769.00 $2,973.00 $3,299.00
34831 90 $1,950.00 $2,932.00 $3,146.00 $3,491.00 $2,932.00 $3,146.00 $3,491.00
34832 90 $1,950.00 $2,907.00 $3,114.00 $3,447.00 $2,907.00 $3,114.00 $3,447.00
34833 0 $650.00 $934.00 $1,002.00 $1,109.00 $934.00 $1,002.00 $1,109.00
34834 0 $306.00 $418.00 $448.00 $496.00 $418.00 $448.00 $496.00
34900 90 $960.00 $1,364.00 $1,461.00 $1,607.00 $1,364.00 $1,461.00 $1,607.00
35001 90 $1,564.00 $1,706.00 $1,828.00 $2,015.00 $1,706.00 $1,828.00 $2,015.00
35002 90 $1,547.00 $1,751.00 $1,873.00 $2,062.00 $1,751.00 $1,873.00 $2,062.00
35005 90 $1,268.00 $1,714.00 $1,843.00 $2,031.00 $1,714.00 $1,843.00 $2,031.00
35011 90 $1,007.00 $1,539.00 $1,651.00 $1,822.00 $1,539.00 $1,651.00 $1,822.00
35013 90 $1,376.00 $1,917.00 $2,056.00 $2,266.00 $1,917.00 $2,056.00 $2,266.00
35021 90 $1,635.00 $1,882.00 $2,018.00 $2,219.00 $1,882.00 $2,018.00 $2,219.00
35022 90 $1,686.00 $2,167.00 $2,318.00 $2,540.00 $2,167.00 $2,318.00 $2,540.00
35045 90 $995.00 $1,506.00 $1,614.00 $1,773.00 $1,506.00 $1,614.00 $1,773.00
35081 90 $2,175.00 $2,676.00 $2,871.00 $3,174.00 $2,676.00 $2,871.00 $3,174.00
35082 90 $2,661.00 $3,369.00 $3,614.00 $3,997.00 $3,369.00 $3,614.00 $3,997.00
35091 90 $2,634.00 $2,757.00 $2,957.00 $3,277.00 $2,757.00 $2,957.00 $3,277.00
35092 90 $2,872.00 $4,003.00 $4,294.00 $4,753.00 $4,003.00 $4,294.00 $4,753.00
35102 90 $2,346.00 $2,894.00 $3,103.00 $3,431.00 $2,894.00 $3,103.00 $3,431.00
35103 90 $2,587.00 $3,457.00 $3,708.00 $4,104.00 $3,457.00 $3,708.00 $4,104.00
35111 90 $1,398.00 $2,040.00 $2,189.00 $2,427.00 $2,040.00 $2,189.00 $2,427.00
35112 90 $1,351.00 $2,876.00 $3,090.00 $3,403.00 $2,876.00 $3,090.00 $3,403.00
35121 90 $2,000.00 $2,533.00 $2,716.00 $3,001.00 $2,533.00 $2,716.00 $3,001.00
35122 90 $2,382.00 $3,294.00 $3,539.00 $3,900.00 $3,294.00 $3,539.00 $3,900.00
35131 90 $1,495.00 $2,131.00 $2,285.00 $2,524.00 $2,131.00 $2,285.00 $2,524.00
35132 90 $1,742.00 $2,512.00 $2,691.00 $2,977.00 $2,512.00 $2,691.00 $2,977.00
35141 90 $1,231.00 $1,695.00 $1,818.00 $2,007.00 $1,695.00 $1,818.00 $2,007.00
35142 90 $1,339.00 $2,029.00 $2,176.00 $2,403.00 $2,029.00 $2,176.00 $2,403.00
35151 90 $1,390.00 $1,904.00 $2,042.00 $2,256.00 $1,904.00 $2,042.00 $2,256.00
35152 90 $1,229.00 $2,138.00 $2,292.00 $2,537.00 $2,138.00 $2,292.00 $2,537.00
35180 90 $997.00 $1,424.00 $1,516.00 $1,630.00 $1,424.00 $1,516.00 $1,630.00
35182 90 $1,345.00 $2,713.00 $2,913.00 $3,210.00 $2,713.00 $2,913.00 $3,210.00
35184 90 $976.00 $1,703.00 $1,829.00 $2,009.00 $1,703.00 $1,829.00 $2,009.00
35188 90 $1,048.00 $1,611.00 $1,724.00 $1,882.00 $1,611.00 $1,724.00 $1,882.00
35189 90 $1,380.00 $2,430.00 $2,602.00 $2,865.00 $2,430.00 $2,602.00 $2,865.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 223
Surgery
CPT Code FUD 2003 MRALocality 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)
35190 90 $1,018.00 $1,158.00 $1,242.00 $1,365.00 $1,158.00 $1,242.00 $1,365.00
35201 90 $852.00 $1,436.00 $1,538.00 $1,688.00 $1,436.00 $1,538.00 $1,688.00
35206 90 $835.00 $1,183.00 $1,267.00 $1,391.00 $1,183.00 $1,267.00 $1,391.00
35207 90 $935.00 $1,109.00 $1,179.00 $1,259.00 $1,109.00 $1,179.00 $1,259.00
35211 90 $1,833.00 $2,081.00 $2,227.00 $2,441.00 $2,081.00 $2,227.00 $2,441.00
35216 90 $1,494.00 $3,101.00 $3,323.00 $3,651.00 $3,101.00 $3,323.00 $3,651.00
35221 90 $1,243.00 $2,224.00 $2,385.00 $2,627.00 $2,224.00 $2,385.00 $2,627.00
35226 90 $841.00 $1,273.00 $1,364.00 $1,503.00 $1,273.00 $1,364.00 $1,503.00
35231 90 $1,053.00 $1,850.00 $1,968.00 $2,123.00 $1,850.00 $1,968.00 $2,123.00
35236 90 $947.00 $1,500.00 $1,607.00 $1,767.00 $1,500.00 $1,607.00 $1,767.00
35241 90 $1,926.00 $2,063.00 $2,185.00 $2,354.00 $2,063.00 $2,185.00 $2,354.00
35246 90 $1,701.00 $2,388.00 $2,562.00 $2,822.00 $2,388.00 $2,562.00 $2,822.00
35251 90 $1,260.00 $2,618.00 $2,809.00 $3,103.00 $2,618.00 $2,809.00 $3,103.00
35256 90 $1,568.00 $1,558.00 $1,671.00 $1,842.00 $1,558.00 $1,671.00 $1,842.00
35261 90 $1,008.00 $1,621.00 $1,739.00 $1,914.00 $1,621.00 $1,739.00 $1,914.00
35266 90 $921.00 $1,324.00 $1,420.00 $1,564.00 $1,324.00 $1,420.00 $1,564.00
35271 90 $1,814.00 $2,097.00 $2,249.00 $2,471.00 $2,097.00 $2,249.00 $2,471.00
35276 90 $1,541.00 $2,217.00 $2,377.00 $2,614.00 $2,217.00 $2,377.00 $2,614.00
35281 90 $1,396.00 $2,467.00 $2,645.00 $2,915.00 $2,467.00 $2,645.00 $2,915.00
35286 90 $1,036.00 $1,426.00 $1,529.00 $1,685.00 $1,426.00 $1,529.00 $1,685.00
35301 90 $1,486.00 $1,735.00 $1,861.00 $2,055.00 $1,735.00 $1,861.00 $2,055.00
35302 90 ---------- $1,724.00 $1,849.00 $2,042.00 $1,724.00 $1,849.00 $2,042.00
35303 90 ---------- $1,903.00 $2,041.00 $2,254.00 $1,903.00 $2,041.00 $2,254.00
35304 90 ---------- $1,975.00 $2,118.00 $2,340.00 $1,975.00 $2,118.00 $2,340.00
35305 90 ---------- $1,889.00 $2,025.00 $2,237.00 $1,889.00 $2,025.00 $2,237.00
35306 ZZZ ---------- $687.00 $736.00 $818.00 $687.00 $736.00 $818.00
35311 90 $1,999.00 $2,371.00 $2,541.00 $2,795.00 $2,371.00 $2,541.00 $2,795.00
35321 90 $1,031.00 $1,363.00 $1,462.00 $1,614.00 $1,363.00 $1,462.00 $1,614.00
35331 90 $1,724.00 $2,225.00 $2,385.00 $2,633.00 $2,225.00 $2,385.00 $2,633.00
35341 90 $1,908.00 $2,103.00 $2,255.00 $2,493.00 $2,103.00 $2,255.00 $2,493.00
35351 90 $1,555.00 $1,963.00 $2,105.00 $2,327.00 $1,963.00 $2,105.00 $2,327.00
35355 90 $1,336.00 $1,587.00 $1,702.00 $1,881.00 $1,587.00 $1,702.00 $1,881.00
35361 90 $1,859.00 $2,344.00 $2,514.00 $2,785.00 $2,344.00 $2,514.00 $2,785.00
35363 90 $2,006.00 $2,701.00 $2,899.00 $3,199.00 $2,701.00 $2,899.00 $3,199.00
35371 90 $1,006.00 $1,254.00 $1,345.00 $1,483.00 $1,254.00 $1,345.00 $1,483.00
35372 90 $1,085.00 $1,504.00 $1,613.00 $1,780.00 $1,504.00 $1,613.00 $1,780.00
35390 ZZZ $225.00 $246.00 $263.00 $292.00 $246.00 $263.00 $292.00
35400 ZZZ $224.00 $230.00 $246.00 $274.00 $230.00 $246.00 $274.00
35500 ZZZ $423.00 $492.00 $528.00 $585.00 $492.00 $528.00 $585.00
35501 90 $1,569.00 $2,301.00 $2,467.00 $2,726.00 $2,301.00 $2,467.00 $2,726.00
35506 90 $1,641.00 $1,963.00 $2,106.00 $2,333.00 $1,963.00 $2,106.00 $2,333.00
35508 90 $1,564.00 $2,056.00 $2,206.00 $2,443.00 $2,056.00 $2,206.00 $2,443.00
35509 90 $1,529.00 $2,174.00 $2,332.00 $2,586.00 $2,174.00 $2,332.00 $2,586.00
35510 90 ---------- $1,888.00 $2,024.00 $2,242.00 $1,888.00 $2,024.00 $2,242.00
35511 90 $1,256.00 $1,864.00 $2,002.00 $2,210.00 $1,864.00 $2,002.00 $2,210.00
35512 90 ---------- $2,092.00 $2,243.00 $2,462.00 $2,092.00 $2,243.00 $2,462.00
35515 90 $1,387.00 $2,162.00 $2,278.00 $2,422.00 $2,162.00 $2,278.00 $2,422.00
35516 90 $1,391.00 $1,876.00 $2,012.00 $2,232.00 $1,876.00 $2,012.00 $2,232.00
35518 90 $1,313.00 $1,784.00 $1,914.00 $2,120.00 $1,784.00 $1,914.00 $2,120.00
35521 90 $1,393.00 $1,884.00 $2,022.00 $2,240.00 $1,884.00 $2,022.00 $2,240.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 224
Surgery
CPT Code FUD 2003 MRALocality 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)
35522 90 ---------- $1,856.00 $1,991.00 $2,199.00 $1,856.00 $1,991.00 $2,199.00
35523 90 ---------- $1,960.00 $2,101.00 $2,316.00 $1,960.00 $2,101.00 $2,316.00
35525 90 ---------- $1,760.00 $1,887.00 $2,082.00 $1,760.00 $1,887.00 $2,082.00
35526 90 $1,527.00 $2,585.00 $2,776.00 $3,068.00 $2,585.00 $2,776.00 $3,068.00
35531 90 $2,000.00 $3,114.00 $3,339.00 $3,692.00 $3,114.00 $3,339.00 $3,692.00
35533 90 $1,716.00 $2,304.00 $2,469.00 $2,734.00 $2,304.00 $2,469.00 $2,734.00
35535 90 ---------- $2,951.00 $3,167.00 $3,514.00 $2,951.00 $3,167.00 $3,514.00
35536 90 $1,888.00 $2,616.00 $2,781.00 $3,026.00 $2,616.00 $2,781.00 $3,026.00
35537 90 ---------- $3,621.00 $3,881.00 $4,260.00 $3,621.00 $3,881.00 $4,260.00
35538 90 ---------- $3,623.00 $3,888.00 $4,315.00 $3,623.00 $3,888.00 $4,315.00
35539 90 ---------- $3,436.00 $3,693.00 $4,107.00 $3,436.00 $3,693.00 $4,107.00
35540 90 ---------- $3,930.00 $4,212.00 $4,650.00 $3,930.00 $4,212.00 $4,650.00
35556 90 $1,745.00 $2,150.00 $2,305.00 $2,546.00 $2,150.00 $2,305.00 $2,546.00
35558 90 $1,219.00 $1,887.00 $2,021.00 $2,226.00 $1,887.00 $2,021.00 $2,226.00
35560 90 $1,899.00 $2,631.00 $2,823.00 $3,131.00 $2,631.00 $2,823.00 $3,131.00
35563 90 $1,115.00 $2,279.00 $2,441.00 $2,673.00 $2,279.00 $2,441.00 $2,673.00
35565 90 $1,312.00 $2,042.00 $2,190.00 $2,417.00 $2,042.00 $2,190.00 $2,417.00
35566 90 $2,161.00 $2,568.00 $2,754.00 $3,045.00 $2,568.00 $2,754.00 $3,045.00
35570 90 ---------- $2,319.00 $2,485.00 $2,744.00 $2,319.00 $2,485.00 $2,744.00
35571 90 $1,612.00 $2,039.00 $2,187.00 $2,417.00 $2,039.00 $2,187.00 $2,417.00
35572 ZZZ $369.00 $532.00 $571.00 $633.00 $532.00 $571.00 $633.00
35583 90 $1,843.00 $2,224.00 $2,385.00 $2,635.00 $2,224.00 $2,385.00 $2,635.00
35585 90 $2,277.00 $2,579.00 $2,767.00 $3,059.00 $2,579.00 $2,767.00 $3,059.00
35587 90 $1,698.00 $2,103.00 $2,256.00 $2,492.00 $2,103.00 $2,256.00 $2,492.00
35600 ZZZ $273.00 $389.00 $416.00 $459.00 $389.00 $416.00 $459.00
35601 90 $1,495.00 $2,152.00 $2,307.00 $2,549.00 $2,152.00 $2,307.00 $2,549.00
35606 90 $1,539.00 $1,803.00 $1,933.00 $2,135.00 $1,803.00 $1,933.00 $2,135.00
35612 90 $1,349.00 $1,634.00 $1,754.00 $1,940.00 $1,634.00 $1,754.00 $1,940.00
35616 90 $1,346.00 $1,702.00 $1,826.00 $2,024.00 $1,702.00 $1,826.00 $2,024.00
35621 90 $1,265.00 $1,688.00 $1,811.00 $2,001.00 $1,688.00 $1,811.00 $2,001.00
35623 90 $1,193.00 $2,032.00 $2,179.00 $2,410.00 $2,032.00 $2,179.00 $2,410.00
35626 90 $1,921.00 $2,406.00 $2,580.00 $2,845.00 $2,406.00 $2,580.00 $2,845.00
35631 90 $1,891.00 $2,850.00 $3,058.00 $3,385.00 $2,850.00 $3,058.00 $3,385.00
35632 90 ---------- $2,781.00 $2,985.00 $3,312.00 $2,781.00 $2,985.00 $3,312.00
35633 90 ---------- $3,084.00 $3,308.00 $3,662.00 $3,084.00 $3,308.00 $3,662.00
35634 90 ---------- $2,767.00 $2,965.00 $3,276.00 $2,767.00 $2,965.00 $3,276.00
35636 90 $1,656.00 $2,498.00 $2,681.00 $2,971.00 $2,498.00 $2,681.00 $2,971.00
35637 90 ---------- $2,664.00 $2,857.00 $3,156.00 $2,664.00 $2,857.00 $3,156.00
35638 90 ---------- $2,708.00 $2,905.00 $3,210.00 $2,708.00 $2,905.00 $3,210.00
35642 90 $1,298.00 $1,671.00 $1,794.00 $1,972.00 $1,671.00 $1,794.00 $1,972.00
35645 90 $1,304.00 $1,592.00 $1,709.00 $1,882.00 $1,592.00 $1,709.00 $1,882.00
35646 90 $2,105.00 $2,637.00 $2,828.00 $3,125.00 $2,637.00 $2,828.00 $3,125.00
35647 90 $1,555.00 $2,387.00 $2,560.00 $2,827.00 $2,387.00 $2,560.00 $2,827.00
35650 90 $1,236.00 $1,667.00 $1,787.00 $1,970.00 $1,667.00 $1,787.00 $1,970.00
35654 90 $1,603.00 $2,106.00 $2,259.00 $2,496.00 $2,106.00 $2,259.00 $2,496.00
35656 90 $1,589.00 $1,663.00 $1,784.00 $1,968.00 $1,663.00 $1,784.00 $1,968.00
35661 90 $1,145.00 $1,666.00 $1,786.00 $1,970.00 $1,666.00 $1,786.00 $1,970.00
35663 90 $1,237.00 $1,918.00 $2,055.00 $2,267.00 $1,918.00 $2,055.00 $2,267.00
35665 90 $1,333.00 $1,799.00 $1,929.00 $2,128.00 $1,799.00 $1,929.00 $2,128.00
35666 90 $1,686.00 $1,939.00 $2,079.00 $2,293.00 $1,939.00 $2,079.00 $2,293.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 225
Surgery
CPT Code FUD 2003 MRALocality 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)
35671 90 $1,315.00 $1,709.00 $1,832.00 $2,019.00 $1,709.00 $1,832.00 $2,019.00
35681 ZZZ $751.00 $124.00 $133.00 $148.00 $124.00 $133.00 $148.00
35682 ZZZ $627.00 $545.00 $585.00 $649.00 $545.00 $585.00 $649.00
35683 ZZZ $702.00 $631.00 $676.00 $750.00 $631.00 $676.00 $750.00
35685 ZZZ $216.00 $307.00 $329.00 $365.00 $307.00 $329.00 $365.00
35686 ZZZ $178.00 $247.00 $265.00 $295.00 $247.00 $265.00 $295.00
35691 90 $1,546.00 $1,440.00 $1,542.00 $1,700.00 $1,440.00 $1,542.00 $1,700.00
35693 90 $1,140.00 $1,273.00 $1,360.00 $1,490.00 $1,273.00 $1,360.00 $1,490.00
35694 90 $1,353.00 $1,519.00 $1,630.00 $1,805.00 $1,519.00 $1,630.00 $1,805.00
35695 90 $1,351.00 $1,601.00 $1,718.00 $1,902.00 $1,601.00 $1,718.00 $1,902.00
35697 ZZZ ---------- $228.00 $244.00 $271.00 $228.00 $244.00 $271.00
35700 ZZZ $264.00 $235.00 $252.00 $280.00 $235.00 $252.00 $280.00
35701 90 $494.00 $844.00 $898.00 $967.00 $844.00 $898.00 $967.00
35721 90 $500.00 $694.00 $744.00 $814.00 $694.00 $744.00 $814.00
35741 90 $499.00 $776.00 $830.00 $907.00 $776.00 $830.00 $907.00
35761 90 $532.00 $585.00 $625.00 $676.00 $585.00 $625.00 $676.00
35800 90 $567.00 $1,074.00 $1,146.00 $1,243.00 $1,074.00 $1,146.00 $1,243.00
35820 90 $951.00 $3,050.00 $3,269.00 $3,598.00 $3,050.00 $3,269.00 $3,598.00
35840 90 $771.00 $1,801.00 $1,931.00 $2,118.00 $1,801.00 $1,931.00 $2,118.00
35860 90 $496.00 $1,281.00 $1,373.00 $1,511.00 $1,281.00 $1,373.00 $1,511.00
35870 90 $1,583.00 $1,913.00 $2,051.00 $2,271.00 $1,913.00 $2,051.00 $2,271.00
35875 90 $827.00 $910.00 $976.00 $1,075.00 $910.00 $976.00 $1,075.00
35876 90 $1,232.00 $1,451.00 $1,555.00 $1,715.00 $1,451.00 $1,555.00 $1,715.00
35879 90 $1,163.00 $1,413.00 $1,515.00 $1,670.00 $1,413.00 $1,515.00 $1,670.00
35881 90 $1,275.00 $1,564.00 $1,676.00 $1,849.00 $1,564.00 $1,676.00 $1,849.00
35883 90 ---------- $1,855.00 $1,990.00 $2,199.00 $1,855.00 $1,990.00 $2,199.00
35884 90 ---------- $1,907.00 $2,046.00 $2,270.00 $1,907.00 $2,046.00 $2,270.00
35901 90 $709.00 $751.00 $805.00 $880.00 $751.00 $805.00 $880.00
35903 90 $818.00 $855.00 $917.00 $1,004.00 $855.00 $917.00 $1,004.00
35905 90 $1,343.00 $2,712.00 $2,908.00 $3,209.00 $2,712.00 $2,908.00 $3,209.00
35907 90 $1,335.00 $2,941.00 $3,155.00 $3,494.00 $2,941.00 $3,155.00 $3,494.00
36000 0 $46.00 $36.00 $38.00 $39.00 $14.00 $14.00 $15.00
36002 0 $181.00 $231.00 $244.00 $256.00 $158.00 $167.00 $178.00
36005 0 $68.00 $444.00 $474.00 $484.00 $72.00 $76.00 $82.00
36010 0 $136.00 $670.00 $714.00 $734.00 $165.00 $175.00 $189.00
36011 0 $194.00 $1,143.00 $1,218.00 $1,246.00 $235.00 $248.00 $267.00
36012 0 $186.00 $1,179.00 $1,256.00 $1,285.00 $260.00 $274.00 $294.00
36013 0 $141.00 $1,060.00 $1,129.00 $1,150.00 $184.00 $193.00 $206.00
36014 0 $159.00 $1,101.00 $1,172.00 $1,198.00 $225.00 $237.00 $254.00
36015 0 $186.00 $1,188.00 $1,263.00 $1,289.00 $254.00 $266.00 $282.00
36100 0 $176.00 $671.00 $717.00 $747.00 $234.00 $250.00 $276.00
36120 0 $120.00 $584.00 $623.00 $642.00 $153.00 $163.00 $178.00
36140 0 $106.00 $587.00 $626.00 $645.00 $137.00 $146.00 $160.00
36160 0 $196.00 $680.00 $723.00 $739.00 $184.00 $193.00 $204.00
36200 0 $240.00 $783.00 $836.00 $865.00 $214.00 $229.00 $252.00
36215 0 $240.00 $1,553.00 $1,654.00 $1,693.00 $350.00 $370.00 $397.00
36216 0 $270.00 $1,612.00 $1,719.00 $1,771.00 $410.00 $436.00 $475.00
36217 0 $325.00 $2,625.00 $2,801.00 $2,870.00 $488.00 $519.00 $566.00
36218 ZZZ $79.00 $259.00 $276.00 $285.00 $78.00 $83.00 $90.00
36221 0 ---------- $1,427.00 $1,523.00 $1,566.00 $306.00 $327.00 $358.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 226
Surgery
CPT Code FUD 2003 MRALocality 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)
36222 0 ---------- $1,674.00 $1,790.00 $1,849.00 $429.00 $459.00 $506.00
36223 0 ---------- $2,050.00 $2,190.00 $2,257.00 $473.00 $507.00 $557.00
36224 0 ---------- $2,607.00 $2,788.00 $2,871.00 $539.00 $580.00 $641.00
36225 0 ---------- $1,974.00 $2,111.00 $2,178.00 $472.00 $506.00 $559.00
36226 0 ---------- $2,473.00 $2,644.00 $2,723.00 $531.00 $570.00 $629.00
36227 ZZZ ---------- $360.00 $386.00 $407.00 $177.00 $190.00 $209.00
36228 ZZZ ---------- $1,770.00 $1,893.00 $1,949.00 $362.00 $389.00 $430.00
36245 0 $249.00 $1,798.00 $1,917.00 $1,964.00 $361.00 $382.00 $414.00
36246 0 $272.00 $1,151.00 $1,228.00 $1,274.00 $388.00 $413.00 $452.00
36247 0 $323.00 $2,072.00 $2,210.00 $2,269.00 $460.00 $487.00 $529.00
36248 ZZZ $53.00 $212.00 $225.00 $231.00 $73.00 $76.00 $81.00
36251 0 ---------- $1,899.00 $2,027.00 $2,080.00 $401.00 $427.00 $465.00
36252 0 ---------- $2,068.00 $2,210.00 $2,285.00 $550.00 $589.00 $647.00
36253 0 ---------- $3,032.00 $3,227.00 $3,288.00 $539.00 $565.00 $599.00
36254 0 ---------- $2,964.00 $3,168.00 $3,261.00 $643.00 $688.00 $757.00
36260 90 $749.00 $956.00 $1,026.00 $1,122.00 $956.00 $1,026.00 $1,122.00
36261 90 $388.00 $490.00 $526.00 $580.00 $490.00 $526.00 $580.00
36262 90 $297.00 $442.00 $474.00 $511.00 $442.00 $474.00 $511.00
36299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
36410 0 $18.00 $24.00 $25.00 $26.00 $14.00 $14.00 $15.00
36415 0 BR ---------- ---------- ---------- ---------- ---------- ----------
36416 0 BR ---------- ---------- ---------- ---------- ---------- ----------
36425 0 $86.00 $59.00 $62.00 $66.00 $59.00 $62.00 $66.00
36430 0 $37.00 $48.00 $52.00 $53.00 $48.00 $52.00 $53.00
36455 0 $141.00 $193.00 $205.00 $225.00 $193.00 $205.00 $225.00
36468 0 NC BR BR BR BR BR BR
36470 10 $76.00 $208.00 $221.00 $230.00 $122.00 $129.00 $138.00
36471 10 $96.00 $248.00 $264.00 $277.00 $149.00 $158.00 $170.00
36475 0 ---------- $2,101.00 $2,244.00 $2,304.00 $424.00 $453.00 $496.00
36476 ZZZ ---------- $420.00 $448.00 $473.00 $207.00 $222.00 $244.00
36478 0 ---------- $1,669.00 $1,781.00 $1,835.00 $421.00 $448.00 $489.00
36479 ZZZ ---------- $439.00 $468.00 $491.00 $207.00 $221.00 $242.00
36481 0 $499.00 $2,699.00 $2,872.00 $2,923.00 $498.00 $520.00 $549.00
36500 0 $159.00 $274.00 $290.00 $313.00 $274.00 $290.00 $313.00
36511 0 $92.00 $136.00 $141.00 $146.00 $136.00 $141.00 $146.00
36512 0 $92.00 $137.00 $142.00 $147.00 $137.00 $142.00 $147.00
36513 0 $92.00 $143.00 $151.00 $161.00 $143.00 $151.00 $161.00
36514 0 $92.00 $744.00 $791.00 $805.00 $136.00 $142.00 $149.00
36515 0 $92.00 $2,843.00 $3,033.00 $3,070.00 $131.00 $137.00 $145.00
36516 0 $92.00 $2,870.00 $3,066.00 $3,106.00 $105.00 $113.00 $125.00
36522 0 $305.00 $1,940.00 $2,068.00 $2,092.00 $148.00 $154.00 $159.00
36556 0 ---------- $330.00 $349.00 $362.00 $178.00 $187.00 $198.00
36558 10 ---------- $999.00 $1,062.00 $1,094.00 $389.00 $409.00 $435.00
36561 10 ---------- $1,517.00 $1,617.00 $1,668.00 $505.00 $536.00 $576.00
36563 10 ---------- $1,718.00 $1,837.00 $1,904.00 $553.00 $593.00 $647.00
36565 10 ---------- $1,247.00 $1,333.00 $1,391.00 $503.00 $538.00 $588.00
36566 10 ---------- $7,410.00 $7,913.00 $8,036.00 $558.00 $596.00 $647.00
36569 0 ---------- $348.00 $368.00 $377.00 $134.00 $140.00 $146.00
36571 10 ---------- $1,686.00 $1,800.00 $1,852.00 $461.00 $491.00 $530.00
36575 0 ---------- $229.00 $244.00 $250.00 $52.00 $54.00 $58.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 227
Surgery
CPT Code FUD 2003 MRALocality 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)
36576 10 ---------- $448.00 $477.00 $502.00 $274.00 $291.00 $314.00
36578 10 ---------- $630.00 $670.00 $694.00 $300.00 $317.00 $339.00
36580 0 ---------- $297.00 $316.00 $324.00 $98.00 $103.00 $109.00
36581 10 ---------- $975.00 $1,036.00 $1,060.00 $270.00 $283.00 $299.00
36582 10 ---------- $1,403.00 $1,495.00 $1,539.00 $433.00 $459.00 $493.00
36583 10 ---------- $1,737.00 $1,857.00 $1,918.00 $484.00 $520.00 $568.00
36584 0 ---------- $284.00 $301.00 $307.00 $97.00 $101.00 $106.00
36585 10 ---------- $1,493.00 $1,591.00 $1,634.00 $406.00 $430.00 $462.00
36589 10 ---------- $236.00 $250.00 $263.00 $202.00 $213.00 $226.00
36590 10 ---------- $323.00 $343.00 $366.00 $283.00 $301.00 $324.00
36591 0 ---------- $32.00 $35.00 $35.00 $32.00 $35.00 $35.00
36592 0 ---------- $36.00 $39.00 $40.00 $36.00 $39.00 $40.00
36593 0 ---------- $43.00 $46.00 $48.00 $43.00 $46.00 $48.00
36595 0 ---------- $814.00 $863.00 $884.00 $271.00 $283.00 $299.00
36596 0 ---------- $183.00 $194.00 $199.00 $65.00 $69.00 $72.00
36597 0 ---------- $178.00 $188.00 $194.00 $90.00 $94.00 $99.00
36598 0 ---------- $154.00 $163.00 $167.00 $54.00 $57.00 $60.00
36600 0 $24.00 $44.00 $46.00 $47.00 $22.00 $23.00 $24.00
36620 0 $64.00 $75.00 $78.00 $82.00 $75.00 $78.00 $82.00
36625 0 $133.00 $156.00 $165.00 $179.00 $156.00 $165.00 $179.00
36640 0 $130.00 $167.00 $173.00 $180.00 $167.00 $173.00 $180.00
36680 0 $72.00 $87.00 $92.00 $99.00 $87.00 $92.00 $99.00
36800 0 $159.00 $184.00 $193.00 $207.00 $184.00 $193.00 $207.00
36810 0 $345.00 $323.00 $343.00 $371.00 $323.00 $343.00 $371.00
36815 0 $236.00 $209.00 $224.00 $248.00 $209.00 $224.00 $248.00
36818 90 ---------- $1,058.00 $1,135.00 $1,248.00 $1,058.00 $1,135.00 $1,248.00
36819 90 $977.00 $1,119.00 $1,200.00 $1,322.00 $1,119.00 $1,200.00 $1,322.00
36820 90 $800.00 $1,117.00 $1,198.00 $1,317.00 $1,117.00 $1,198.00 $1,317.00
36821 90 $721.00 $1,013.00 $1,086.00 $1,195.00 $1,013.00 $1,086.00 $1,195.00
36823 90 $1,461.00 $2,088.00 $2,241.00 $2,457.00 $2,088.00 $2,241.00 $2,457.00
36825 90 $867.00 $1,218.00 $1,307.00 $1,438.00 $1,218.00 $1,307.00 $1,438.00
36830 90 $967.00 $1,019.00 $1,093.00 $1,203.00 $1,019.00 $1,093.00 $1,203.00
36831 90 $488.00 $941.00 $1,009.00 $1,110.00 $941.00 $1,009.00 $1,110.00
36832 90 $810.00 $1,154.00 $1,238.00 $1,361.00 $1,154.00 $1,238.00 $1,361.00
36833 90 $780.00 $1,239.00 $1,329.00 $1,462.00 $1,239.00 $1,329.00 $1,462.00
36835 90 $542.00 $738.00 $792.00 $864.00 $738.00 $792.00 $864.00
36838 90 ---------- $1,755.00 $1,883.00 $2,079.00 $1,755.00 $1,883.00 $2,079.00
36860 0 $166.00 $294.00 $310.00 $319.00 $162.00 $169.00 $176.00
36861 0 $224.00 $204.00 $219.00 $241.00 $204.00 $219.00 $241.00
36901 0 ---------- $792.00 $844.00 $869.00 $217.00 $230.00 $249.00
36902 0 ---------- $1,676.00 $1,787.00 $1,829.00 $324.00 $343.00 $371.00
36903 0 ---------- $7,611.00 $8,124.00 $8,237.00 $443.00 $469.00 $508.00
36904 0 ---------- $2,446.00 $2,608.00 $2,672.00 $511.00 $541.00 $585.00
36905 0 ---------- $3,129.00 $3,336.00 $3,418.00 $641.00 $679.00 $734.00
36906 0 ---------- $9,244.00 $9,866.00 $10,020.00 $748.00 $792.00 $858.00
36907 ZZZ ---------- $1,002.00 $1,069.00 $1,094.00 $187.00 $198.00 $214.00
36908 ZZZ ---------- $3,663.00 $3,910.00 $3,969.00 $280.00 $296.00 $321.00
36909 ZZZ ---------- $2,676.00 $2,856.00 $2,904.00 $266.00 $281.00 $304.00
37140 90 $1,666.00 $3,494.00 $3,750.00 $4,123.00 $3,494.00 $3,750.00 $4,123.00
37145 90 $1,741.00 $3,250.00 $3,492.00 $3,847.00 $3,250.00 $3,492.00 $3,847.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 228
Surgery
CPT Code FUD 2003 MRALocality 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)
37160 90 $1,681.00 $3,339.00 $3,587.00 $3,952.00 $3,339.00 $3,587.00 $3,952.00
37180 90 $1,769.00 $3,212.00 $3,452.00 $3,802.00 $3,212.00 $3,452.00 $3,802.00
37181 90 $1,923.00 $3,202.00 $3,383.00 $3,625.00 $3,202.00 $3,383.00 $3,625.00
37182 0 $914.00 $1,223.00 $1,272.00 $1,332.00 $1,223.00 $1,272.00 $1,332.00
37183 0 $425.00 $7,938.00 $8,462.00 $8,567.00 $559.00 $582.00 $609.00
37184 0 ---------- $3,077.00 $3,286.00 $3,380.00 $684.00 $730.00 $799.00
37185 ZZZ ---------- $981.00 $1,048.00 $1,083.00 $257.00 $274.00 $302.00
37186 ZZZ ---------- $1,848.00 $1,973.00 $2,027.00 $376.00 $401.00 $439.00
37187 0 ---------- $2,723.00 $2,902.00 $2,974.00 $592.00 $626.00 $675.00
37188 0 ---------- $2,316.00 $2,468.00 $2,519.00 $418.00 $441.00 $472.00
37191 0 ---------- $3,514.00 $3,748.00 $3,807.00 $338.00 $356.00 $382.00
37192 0 ---------- $2,208.00 $2,346.00 $2,393.00 $537.00 $561.00 $591.00
37193 0 ---------- $2,116.00 $2,252.00 $2,308.00 $527.00 $555.00 $595.00
37195 0 $302.00 ---------- ---------- ---------- ---------- ---------- ----------
37197 0 ---------- $1,994.00 $2,125.00 $2,179.00 $455.00 $482.00 $520.00
37200 0 $232.00 $324.00 $337.00 $353.00 $324.00 $337.00 $353.00
37211 0 ---------- $583.00 $619.00 $671.00 $583.00 $619.00 $671.00
37212 0 ---------- $507.00 $536.00 $579.00 $507.00 $536.00 $579.00
37213 0 ---------- $351.00 $370.00 $397.00 $351.00 $370.00 $397.00
37214 0 ---------- $185.00 $195.00 $210.00 $185.00 $195.00 $210.00
37215 90 ---------- $1,515.00 $1,625.00 $1,788.00 $1,515.00 $1,625.00 $1,788.00
37216 90 ---------- BR BR BR BR BR BR
37217 90 ---------- $1,674.00 $1,792.00 $1,970.00 $1,674.00 $1,792.00 $1,970.00
37218 90 ---------- $1,238.00 $1,326.00 $1,456.00 $1,238.00 $1,326.00 $1,456.00
37220 0 ---------- $4,217.00 $4,504.00 $4,608.00 $615.00 $658.00 $724.00
37221 0 ---------- $6,240.00 $6,665.00 $6,803.00 $760.00 $812.00 $893.00
37222 ZZZ ---------- $1,193.00 $1,275.00 $1,316.00 $287.00 $307.00 $338.00
37223 ZZZ ---------- $3,494.00 $3,732.00 $3,800.00 $328.00 $351.00 $386.00
37224 0 ---------- $5,108.00 $5,455.00 $5,573.00 $679.00 $725.00 $796.00
37225 0 ---------- $14,881.00 $15,895.00 $16,141.00 $929.00 $994.00 $1,094.00
37226 0 ---------- $12,197.00 $13,027.00 $13,233.00 $802.00 $857.00 $943.00
37227 0 ---------- $20,148.00 $21,520.00 $21,840.00 $1,119.00 $1,197.00 $1,318.00
37228 0 ---------- $7,306.00 $7,803.00 $7,959.00 $833.00 $890.00 $978.00
37229 0 ---------- $14,683.00 $15,683.00 $15,941.00 $1,085.00 $1,161.00 $1,277.00
37230 0 ---------- $11,238.00 $12,004.00 $12,226.00 $1,072.00 $1,147.00 $1,262.00
37231 0 ---------- $18,151.00 $19,386.00 $19,686.00 $1,162.00 $1,242.00 $1,365.00
37232 ZZZ ---------- $1,640.00 $1,752.00 $1,798.00 $310.00 $331.00 $364.00
37233 ZZZ ---------- $1,993.00 $2,129.00 $2,198.00 $504.00 $538.00 $592.00
37234 ZZZ ---------- $5,319.00 $5,682.00 $5,779.00 $436.00 $467.00 $513.00
37235 ZZZ ---------- $5,725.00 $6,114.00 $6,230.00 $604.00 $645.00 $708.00
37236 0 ---------- $5,426.00 $5,792.00 $5,904.00 $670.00 $712.00 $774.00
37237 ZZZ ---------- $3,311.00 $3,536.00 $3,601.00 $326.00 $348.00 $382.00
37238 0 ---------- $5,639.00 $6,016.00 $6,107.00 $452.00 $477.00 $513.00
37239 ZZZ ---------- $2,742.00 $2,928.00 $2,978.00 $230.00 $246.00 $269.00
37241 0 ---------- $6,495.00 $6,930.00 $7,049.00 $668.00 $707.00 $764.00
37242 0 ---------- $10,157.00 $10,836.00 $10,987.00 $722.00 $759.00 $811.00
37243 0 ---------- $13,186.00 $14,062.00 $14,237.00 $844.00 $880.00 $926.00
37244 0 ---------- $9,220.00 $9,822.00 $9,963.00 $994.00 $1,037.00 $1,092.00
37246 0 ---------- $2,949.00 $3,146.00 $3,219.00 $533.00 $565.00 $612.00
37247 ZZZ ---------- $1,197.00 $1,276.00 $1,310.00 $264.00 $280.00 $304.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 229
Surgery
CPT Code FUD 2003 MRALocality 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)
37248 0 ---------- $2,049.00 $2,185.00 $2,243.00 $458.00 $486.00 $527.00
37249 ZZZ ---------- $880.00 $939.00 $966.00 $225.00 $238.00 $259.00
37252 ZZZ ---------- $1,887.00 $2,016.00 $2,050.00 $141.00 $151.00 $167.00
37253 ZZZ ---------- $292.00 $312.00 $327.00 $114.00 $122.00 $135.00
37500 90 $739.00 $984.00 $1,055.00 $1,162.00 $984.00 $1,055.00 $1,162.00
37501 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
37565 90 $364.00 $1,087.00 $1,150.00 $1,226.00 $1,087.00 $1,150.00 $1,226.00
37600 90 $414.00 $1,064.00 $1,132.00 $1,224.00 $1,064.00 $1,132.00 $1,224.00
37605 90 $521.00 $1,199.00 $1,285.00 $1,414.00 $1,199.00 $1,285.00 $1,414.00
37606 90 $563.00 $783.00 $841.00 $923.00 $783.00 $841.00 $923.00
37607 90 $456.00 $568.00 $608.00 $666.00 $568.00 $608.00 $666.00
37609 10 $278.00 $443.00 $473.00 $500.00 $306.00 $327.00 $352.00
37615 90 $495.00 $747.00 $792.00 $841.00 $747.00 $792.00 $841.00
37616 90 $1,128.00 $1,660.00 $1,778.00 $1,947.00 $1,660.00 $1,778.00 $1,947.00
37617 90 $1,132.00 $2,025.00 $2,168.00 $2,377.00 $2,025.00 $2,168.00 $2,377.00
37618 90 $514.00 $574.00 $615.00 $669.00 $574.00 $615.00 $669.00
37619 90 ---------- $2,504.00 $2,686.00 $2,961.00 $2,504.00 $2,686.00 $2,961.00
37650 90 $430.00 $703.00 $753.00 $828.00 $703.00 $753.00 $828.00
37660 90 $789.00 $1,962.00 $2,105.00 $2,311.00 $1,962.00 $2,105.00 $2,311.00
37700 90 $336.00 $372.00 $399.00 $434.00 $372.00 $399.00 $434.00
37718 90 ---------- $654.00 $701.00 $767.00 $654.00 $701.00 $767.00
37722 90 ---------- $722.00 $775.00 $850.00 $722.00 $775.00 $850.00
37735 90 $847.00 $891.00 $955.00 $1,055.00 $891.00 $955.00 $1,055.00
37760 90 $813.00 $931.00 $997.00 $1,095.00 $931.00 $997.00 $1,095.00
37761 90 ---------- $828.00 $887.00 $969.00 $828.00 $887.00 $969.00
37765 90 ---------- $945.00 $1,008.00 $1,074.00 $676.00 $722.00 $785.00
37766 90 ---------- $1,124.00 $1,200.00 $1,282.00 $827.00 $882.00 $961.00
37780 90 $301.00 $377.00 $404.00 $441.00 $377.00 $404.00 $441.00
37785 90 $270.00 $516.00 $552.00 $589.00 $392.00 $420.00 $456.00
37788 90 $1,654.00 $1,854.00 $1,943.00 $2,048.00 $1,854.00 $1,943.00 $2,048.00
37790 90 $690.00 $713.00 $748.00 $786.00 $713.00 $748.00 $786.00
37799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
38100 90 $974.00 $1,735.00 $1,861.00 $2,041.00 $1,735.00 $1,861.00 $2,041.00
38101 90 $982.00 $1,736.00 $1,861.00 $2,038.00 $1,736.00 $1,861.00 $2,038.00
38102 ZZZ $332.00 $397.00 $426.00 $469.00 $397.00 $426.00 $469.00
38115 90 $1,020.00 $1,907.00 $2,042.00 $2,234.00 $1,907.00 $2,042.00 $2,234.00
38120 90 $1,138.00 $1,578.00 $1,693.00 $1,853.00 $1,578.00 $1,693.00 $1,853.00
38129 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
38200 0 $180.00 $198.00 $206.00 $215.00 $198.00 $206.00 $215.00
38205 0 $79.00 $121.00 $125.00 $130.00 $121.00 $125.00 $130.00
38206 0 $79.00 $121.00 $125.00 $130.00 $121.00 $125.00 $130.00
38220 0 $212.00 $234.00 $249.00 $257.00 $91.00 $96.00 $102.00
38221 0 $228.00 $234.00 $247.00 $252.00 $108.00 $112.00 $116.00
38230 0 $265.00 $291.00 $305.00 $321.00 $291.00 $305.00 $321.00
38232 0 ---------- $288.00 $303.00 $321.00 $288.00 $303.00 $321.00
38240 0 $128.00 $324.00 $337.00 $348.00 $324.00 $337.00 $348.00
38241 0 $128.00 $242.00 $252.00 $260.00 $242.00 $252.00 $260.00
38242 0 $90.00 $171.00 $178.00 $184.00 $171.00 $178.00 $184.00
38243 0 ---------- $171.00 $178.00 $184.00 $171.00 $178.00 $184.00
38300 10 $104.00 $386.00 $412.00 $432.00 $265.00 $283.00 $302.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 230
Surgery
CPT Code FUD 2003 MRALocality 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)
38305 90 $375.00 $676.00 $721.00 $776.00 $676.00 $721.00 $776.00
38308 90 $425.00 $664.00 $711.00 $773.00 $664.00 $711.00 $773.00
38380 90 $628.00 $821.00 $871.00 $929.00 $821.00 $871.00 $929.00
38381 90 $1,087.00 $1,207.00 $1,294.00 $1,417.00 $1,207.00 $1,294.00 $1,417.00
38382 90 $798.00 $1,003.00 $1,075.00 $1,173.00 $1,003.00 $1,075.00 $1,173.00
38500 10 $234.00 $481.00 $515.00 $551.00 $378.00 $405.00 $440.00
38505 0 $139.00 $177.00 $187.00 $192.00 $104.00 $109.00 $113.00
38510 10 $349.00 $754.00 $804.00 $858.00 $622.00 $663.00 $715.00
38520 90 $431.00 $687.00 $734.00 $794.00 $687.00 $734.00 $794.00
38525 90 $369.00 $650.00 $697.00 $760.00 $650.00 $697.00 $760.00
38530 90 $517.00 $821.00 $878.00 $951.00 $821.00 $878.00 $951.00
38542 90 $507.00 $761.00 $809.00 $865.00 $761.00 $809.00 $865.00
38550 90 $519.00 $747.00 $801.00 $869.00 $747.00 $801.00 $869.00
38555 90 $1,115.00 $1,516.00 $1,628.00 $1,779.00 $1,516.00 $1,628.00 $1,779.00
38562 90 $799.00 $1,044.00 $1,113.00 $1,201.00 $1,044.00 $1,113.00 $1,201.00
38564 90 $831.00 $1,044.00 $1,117.00 $1,214.00 $1,044.00 $1,117.00 $1,214.00
38570 10 $695.00 $746.00 $791.00 $849.00 $746.00 $791.00 $849.00
38571 10 $902.00 $985.00 $1,037.00 $1,100.00 $985.00 $1,037.00 $1,100.00
38572 10 $1,049.00 $1,400.00 $1,494.00 $1,622.00 $1,400.00 $1,494.00 $1,622.00
38589 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
38700 90 $863.00 $1,180.00 $1,248.00 $1,329.00 $1,180.00 $1,248.00 $1,329.00
38720 90 $1,328.00 $1,979.00 $2,099.00 $2,249.00 $1,979.00 $2,099.00 $2,249.00
38724 90 $1,366.00 $2,132.00 $2,255.00 $2,404.00 $2,132.00 $2,255.00 $2,404.00
38740 90 $539.00 $1,036.00 $1,112.00 $1,214.00 $1,036.00 $1,112.00 $1,214.00
38745 90 $770.00 $1,311.00 $1,407.00 $1,538.00 $1,311.00 $1,407.00 $1,538.00
38746 ZZZ $312.00 $327.00 $351.00 $388.00 $327.00 $351.00 $388.00
38747 ZZZ $337.00 $404.00 $434.00 $478.00 $404.00 $434.00 $478.00
38760 90 $699.00 $1,258.00 $1,346.00 $1,465.00 $1,258.00 $1,346.00 $1,465.00
38765 90 $1,283.00 $1,937.00 $2,071.00 $2,257.00 $1,937.00 $2,071.00 $2,257.00
38770 90 $1,111.00 $1,194.00 $1,262.00 $1,348.00 $1,194.00 $1,262.00 $1,348.00
38780 90 $1,357.00 $1,519.00 $1,608.00 $1,721.00 $1,519.00 $1,608.00 $1,721.00
38790 0 $158.00 $122.00 $130.00 $139.00 $122.00 $130.00 $139.00
38792 0 $26.00 $58.00 $61.00 $64.00 $58.00 $61.00 $64.00
38794 90 $298.00 $434.00 $454.00 $471.00 $434.00 $454.00 $471.00
38900 ZZZ ---------- $210.00 $225.00 $249.00 $210.00 $225.00 $249.00
38999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
39000 90 $664.00 $738.00 $789.00 $856.00 $738.00 $789.00 $856.00
39010 90 $1,148.00 $1,182.00 $1,267.00 $1,387.00 $1,182.00 $1,267.00 $1,387.00
39200 90 $1,249.00 $1,312.00 $1,406.00 $1,542.00 $1,312.00 $1,406.00 $1,542.00
39220 90 $1,542.00 $1,704.00 $1,825.00 $1,997.00 $1,704.00 $1,825.00 $1,997.00
39401 0 ---------- $470.00 $504.00 $555.00 $470.00 $504.00 $555.00
39402 0 ---------- $615.00 $660.00 $728.00 $615.00 $660.00 $728.00
39499 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
39501 90 $1,083.00 $1,270.00 $1,360.00 $1,485.00 $1,270.00 $1,360.00 $1,485.00
39503 90 $2,726.00 $8,949.00 $9,567.00 $10,486.00 $8,949.00 $9,567.00 $10,486.00
39540 90 $1,133.00 $1,305.00 $1,399.00 $1,533.00 $1,305.00 $1,399.00 $1,533.00
39541 90 $1,179.00 $1,418.00 $1,521.00 $1,668.00 $1,418.00 $1,521.00 $1,668.00
39545 90 $1,102.00 $1,329.00 $1,424.00 $1,557.00 $1,329.00 $1,424.00 $1,557.00
39560 90 $968.00 $1,196.00 $1,281.00 $1,399.00 $1,196.00 $1,281.00 $1,399.00
39561 90 $1,328.00 $1,861.00 $1,996.00 $2,181.00 $1,861.00 $1,996.00 $2,181.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 231
Surgery
CPT Code FUD 2003 MRALocality 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)
39599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
40490 0 $108.00 $183.00 $194.00 $202.00 $108.00 $114.00 $121.00
40500 90 $422.00 $721.00 $766.00 $797.00 $528.00 $560.00 $590.00
40510 90 $469.00 $693.00 $736.00 $770.00 $520.00 $552.00 $584.00
40520 90 $467.00 $700.00 $744.00 $778.00 $523.00 $554.00 $586.00
40525 90 $714.00 $806.00 $854.00 $905.00 $806.00 $854.00 $905.00
40527 90 $851.00 $912.00 $964.00 $1,021.00 $912.00 $964.00 $1,021.00
40530 90 $501.00 $769.00 $817.00 $856.00 $587.00 $622.00 $659.00
40650 90 $368.00 $624.00 $662.00 $689.00 $434.00 $460.00 $484.00
40652 90 $436.00 $701.00 $745.00 $776.00 $514.00 $546.00 $575.00
40654 90 $529.00 $818.00 $870.00 $910.00 $622.00 $660.00 $698.00
40700 90 $1,009.00 $1,480.00 $1,572.00 $1,671.00 $1,480.00 $1,572.00 $1,671.00
40701 90 $1,452.00 $1,756.00 $1,865.00 $1,985.00 $1,756.00 $1,865.00 $1,985.00
40702 90 $1,030.00 $1,321.00 $1,394.00 $1,475.00 $1,321.00 $1,394.00 $1,475.00
40720 90 $1,107.00 $1,463.00 $1,552.00 $1,650.00 $1,463.00 $1,552.00 $1,650.00
40761 90 $1,202.00 $1,426.00 $1,506.00 $1,599.00 $1,426.00 $1,506.00 $1,599.00
40799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
40800 10 $110.00 $302.00 $322.00 $332.00 $191.00 $204.00 $213.00
40801 10 $208.00 $453.00 $482.00 $502.00 $327.00 $347.00 $366.00
40804 10 $105.00 $261.00 $278.00 $287.00 $165.00 $175.00 $183.00
40805 10 $245.00 $463.00 $493.00 $514.00 $342.00 $364.00 $384.00
40806 0 $38.00 $147.00 $157.00 $160.00 $48.00 $51.00 $54.00
40808 10 $100.00 $264.00 $281.00 $290.00 $157.00 $167.00 $174.00
40810 10 $141.00 $294.00 $313.00 $323.00 $186.00 $197.00 $206.00
40812 10 $202.00 $415.00 $442.00 $460.00 $290.00 $308.00 $325.00
40814 90 $319.00 $557.00 $593.00 $619.00 $448.00 $476.00 $501.00
40816 90 $336.00 $581.00 $617.00 $644.00 $464.00 $493.00 $518.00
40818 90 $249.00 $515.00 $546.00 $563.00 $396.00 $420.00 $436.00
40819 90 $208.00 $454.00 $483.00 $502.00 $351.00 $373.00 $391.00
40820 10 $104.00 $376.00 $401.00 $412.00 $249.00 $265.00 $275.00
40830 10 $140.00 $382.00 $406.00 $419.00 $242.00 $256.00 $268.00
40831 10 $213.00 $483.00 $514.00 $533.00 $329.00 $350.00 $367.00
40840 90 $687.00 $1,170.00 $1,242.00 $1,305.00 $922.00 $977.00 $1,037.00
40842 90 $684.00 $1,185.00 $1,260.00 $1,327.00 $957.00 $1,017.00 $1,081.00
40843 90 $947.00 $1,577.00 $1,676.00 $1,767.00 $1,264.00 $1,341.00 $1,430.00
40844 90 $1,232.00 $1,873.00 $1,983.00 $2,086.00 $1,544.00 $1,632.00 $1,732.00
40845 90 $1,593.00 $2,123.00 $2,249.00 $2,372.00 $1,804.00 $1,909.00 $2,028.00
40899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
41000 10 $119.00 $232.00 $247.00 $257.00 $164.00 $174.00 $183.00
41005 10 $109.00 $321.00 $342.00 $352.00 $181.00 $192.00 $200.00
41006 90 $237.00 $557.00 $593.00 $618.00 $397.00 $422.00 $446.00
41007 90 $283.00 $548.00 $584.00 $608.00 $385.00 $409.00 $431.00
41008 90 $248.00 $549.00 $584.00 $610.00 $399.00 $424.00 $448.00
41009 90 $319.00 $583.00 $620.00 $648.00 $433.00 $460.00 $486.00
41010 10 $91.00 $283.00 $301.00 $309.00 $155.00 $164.00 $171.00
41015 90 $267.00 $657.00 $698.00 $729.00 $515.00 $548.00 $577.00
41016 90 $357.00 $638.00 $678.00 $709.00 $517.00 $549.00 $578.00
41017 90 $300.00 $646.00 $687.00 $717.00 $520.00 $553.00 $582.00
41018 90 $424.00 $735.00 $781.00 $818.00 $609.00 $646.00 $682.00
41019 0 ---------- $688.00 $716.00 $744.00 $688.00 $716.00 $744.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 232
Surgery
CPT Code FUD 2003 MRALocality 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)
41100 10 $140.00 $240.00 $255.00 $265.00 $158.00 $167.00 $176.00
41105 10 $136.00 $245.00 $260.00 $271.00 $164.00 $174.00 $184.00
41108 10 $110.00 $211.00 $225.00 $233.00 $132.00 $141.00 $148.00
41110 10 $159.00 $302.00 $321.00 $332.00 $191.00 $203.00 $213.00
41112 90 $255.00 $481.00 $512.00 $532.00 $370.00 $393.00 $413.00
41113 90 $301.00 $528.00 $561.00 $585.00 $411.00 $436.00 $458.00
41114 90 $682.00 $934.00 $990.00 $1,047.00 $934.00 $990.00 $1,047.00
41115 10 $176.00 $350.00 $372.00 $385.00 $211.00 $224.00 $235.00
41116 90 $242.00 $474.00 $504.00 $522.00 $321.00 $341.00 $358.00
41120 90 $813.00 $1,562.00 $1,657.00 $1,730.00 $1,562.00 $1,657.00 $1,730.00
41130 90 $937.00 $1,932.00 $2,047.00 $2,147.00 $1,932.00 $2,047.00 $2,147.00
41135 90 $1,869.00 $3,201.00 $3,390.00 $3,579.00 $3,201.00 $3,390.00 $3,579.00
41140 90 $2,005.00 $3,218.00 $3,408.00 $3,590.00 $3,218.00 $3,408.00 $3,590.00
41145 90 $2,406.00 $4,070.00 $4,307.00 $4,536.00 $4,070.00 $4,307.00 $4,536.00
41150 90 $1,897.00 $3,235.00 $3,425.00 $3,608.00 $3,235.00 $3,425.00 $3,608.00
41153 90 $2,091.00 $3,523.00 $3,728.00 $3,932.00 $3,523.00 $3,728.00 $3,932.00
41155 90 $2,448.00 $4,452.00 $4,713.00 $4,990.00 $4,452.00 $4,713.00 $4,990.00
41250 10 $168.00 $380.00 $403.00 $417.00 $224.00 $237.00 $248.00
41251 10 $203.00 $410.00 $436.00 $453.00 $265.00 $282.00 $297.00
41252 10 $294.00 $456.00 $484.00 $505.00 $311.00 $330.00 $349.00
41500 90 $334.00 $648.00 $689.00 $718.00 $648.00 $689.00 $718.00
41510 90 $313.00 $609.00 $647.00 $669.00 $609.00 $647.00 $669.00
41512 90 ---------- $955.00 $1,012.00 $1,056.00 $955.00 $1,012.00 $1,056.00
41520 90 $255.00 $506.00 $539.00 $561.00 $377.00 $401.00 $421.00
41530 0 ---------- $1,368.00 $1,457.00 $1,488.00 $540.00 $573.00 $596.00
41599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
41800 10 $107.00 $389.00 $414.00 $424.00 $213.00 $226.00 $234.00
41805 10 $115.00 $351.00 $374.00 $386.00 $247.00 $263.00 $273.00
41806 10 $217.00 $508.00 $541.00 $563.00 $380.00 $404.00 $424.00
41820 0 NC BR BR BR BR BR BR
41821 0 NC BR BR BR BR BR BR
41822 10 $237.00 $451.00 $480.00 $500.00 $274.00 $291.00 $308.00
41823 90 $312.00 $660.00 $703.00 $732.00 $490.00 $521.00 $549.00
41825 10 $144.00 $303.00 $322.00 $334.00 $179.00 $190.00 $200.00
41826 10 $211.00 $454.00 $483.00 $502.00 $313.00 $333.00 $350.00
41827 90 $322.00 $638.00 $678.00 $706.00 $455.00 $483.00 $509.00
41828 10 $176.00 $447.00 $476.00 $499.00 $319.00 $339.00 $361.00
41830 10 $156.00 $568.00 $604.00 $630.00 $418.00 $444.00 $468.00
41850 0 NC BR BR BR BR BR BR
41870 0 NC BR BR BR BR BR BR
41872 90 $249.00 $541.00 $575.00 $597.00 $386.00 $409.00 $430.00
41874 90 $193.00 $548.00 $583.00 $608.00 $380.00 $404.00 $427.00
41899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
42000 10 $106.00 $228.00 $242.00 $251.00 $152.00 $161.00 $169.00
42100 10 $122.00 $215.00 $229.00 $238.00 $160.00 $169.00 $178.00
42104 10 $161.00 $308.00 $327.00 $340.00 $203.00 $216.00 $227.00
42106 10 $204.00 $393.00 $418.00 $435.00 $263.00 $279.00 $294.00
42107 90 $409.00 $665.00 $706.00 $738.00 $508.00 $538.00 $568.00
42120 90 $573.00 $1,476.00 $1,564.00 $1,639.00 $1,476.00 $1,564.00 $1,639.00
42140 90 $174.00 $357.00 $380.00 $392.00 $223.00 $237.00 $248.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 233
Surgery
CPT Code FUD 2003 MRALocality 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)
42145 90 $741.00 $1,025.00 $1,084.00 $1,143.00 $1,025.00 $1,084.00 $1,143.00
42160 10 $176.00 $331.00 $352.00 $365.00 $215.00 $227.00 $239.00
42180 10 $222.00 $349.00 $370.00 $386.00 $267.00 $282.00 $298.00
42182 10 $324.00 $462.00 $489.00 $513.00 $375.00 $396.00 $419.00
42200 90 $946.00 $1,244.00 $1,314.00 $1,385.00 $1,244.00 $1,314.00 $1,385.00
42205 90 $863.00 $1,335.00 $1,413.00 $1,498.00 $1,335.00 $1,413.00 $1,498.00
42210 90 $1,174.00 $1,522.00 $1,613.00 $1,710.00 $1,522.00 $1,613.00 $1,710.00
42215 90 $766.00 $1,056.00 $1,122.00 $1,187.00 $1,056.00 $1,122.00 $1,187.00
42220 90 $586.00 $769.00 $814.00 $857.00 $769.00 $814.00 $857.00
42225 90 $803.00 $1,260.00 $1,335.00 $1,397.00 $1,260.00 $1,335.00 $1,397.00
42226 90 $848.00 $1,315.00 $1,399.00 $1,476.00 $1,315.00 $1,399.00 $1,476.00
42227 90 $762.00 $1,236.00 $1,311.00 $1,377.00 $1,236.00 $1,311.00 $1,377.00
42235 90 $631.00 $1,052.00 $1,115.00 $1,166.00 $1,052.00 $1,115.00 $1,166.00
42260 90 $491.00 $1,217.00 $1,291.00 $1,358.00 $1,022.00 $1,083.00 $1,148.00
42280 10 $148.00 $236.00 $251.00 $263.00 $164.00 $174.00 $185.00
42281 10 $160.00 $293.00 $311.00 $324.00 $219.00 $232.00 $245.00
42299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
42300 10 $165.00 $299.00 $317.00 $330.00 $222.00 $235.00 $247.00
42305 90 $448.00 $632.00 $669.00 $709.00 $632.00 $669.00 $709.00
42310 10 $145.00 $230.00 $244.00 $255.00 $180.00 $190.00 $200.00
42320 10 $208.00 $354.00 $376.00 $391.00 $254.00 $269.00 $283.00
42330 10 $184.00 $332.00 $352.00 $367.00 $240.00 $254.00 $268.00
42335 90 $287.00 $534.00 $567.00 $590.00 $375.00 $397.00 $418.00
42340 90 $411.00 $667.00 $708.00 $738.00 $492.00 $520.00 $549.00
42400 0 $94.00 $149.00 $157.00 $162.00 $80.00 $84.00 $88.00
42405 10 $258.00 $429.00 $455.00 $477.00 $331.00 $350.00 $370.00
42408 90 $377.00 $650.00 $690.00 $720.00 $477.00 $505.00 $533.00
42409 90 $266.00 $475.00 $504.00 $523.00 $323.00 $342.00 $360.00
42410 90 $746.00 $911.00 $965.00 $1,027.00 $911.00 $965.00 $1,027.00
42415 90 $1,364.00 $1,549.00 $1,637.00 $1,740.00 $1,549.00 $1,637.00 $1,740.00
42420 90 $1,577.00 $1,739.00 $1,838.00 $1,955.00 $1,739.00 $1,838.00 $1,955.00
42425 90 $1,097.00 $1,225.00 $1,295.00 $1,376.00 $1,225.00 $1,295.00 $1,376.00
42426 90 $1,882.00 $1,985.00 $2,098.00 $2,235.00 $1,985.00 $2,098.00 $2,235.00
42440 90 $634.00 $601.00 $636.00 $674.00 $601.00 $636.00 $674.00
42450 90 $395.00 $649.00 $689.00 $719.00 $521.00 $552.00 $580.00
42500 90 $407.00 $622.00 $660.00 $689.00 $497.00 $527.00 $554.00
42505 90 $559.00 $798.00 $846.00 $886.00 $659.00 $697.00 $736.00
42507 90 $522.00 $727.00 $770.00 $809.00 $727.00 $770.00 $809.00
42509 90 $915.00 $1,228.00 $1,299.00 $1,370.00 $1,228.00 $1,299.00 $1,370.00
42510 90 $711.00 $937.00 $993.00 $1,047.00 $937.00 $993.00 $1,047.00
42550 0 $82.00 $191.00 $201.00 $207.00 $93.00 $97.00 $101.00
42600 90 $445.00 $674.00 $714.00 $744.00 $500.00 $528.00 $555.00
42650 0 $67.00 $119.00 $126.00 $131.00 $85.00 $90.00 $95.00
42660 0 $89.00 $187.00 $201.00 $215.00 $134.00 $145.00 $158.00
42665 90 $238.00 $449.00 $477.00 $496.00 $302.00 $320.00 $337.00
42699 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
42700 10 $144.00 $270.00 $286.00 $297.00 $196.00 $208.00 $218.00
42720 10 $270.00 $658.00 $696.00 $735.00 $575.00 $607.00 $644.00
42725 90 $720.00 $1,204.00 $1,276.00 $1,358.00 $1,204.00 $1,276.00 $1,358.00
42800 10 $123.00 $226.00 $240.00 $249.00 $162.00 $172.00 $181.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 234
Surgery
CPT Code FUD 2003 MRALocality 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)
42804 10 $136.00 $275.00 $293.00 $302.00 $163.00 $173.00 $181.00
42806 10 $167.00 $310.00 $330.00 $341.00 $191.00 $202.00 $212.00
42808 10 $250.00 $325.00 $345.00 $360.00 $237.00 $250.00 $264.00
42809 10 $152.00 $286.00 $303.00 $316.00 $179.00 $189.00 $200.00
42810 90 $335.00 $551.00 $584.00 $607.00 $417.00 $442.00 $463.00
42815 90 $659.00 $811.00 $859.00 $905.00 $811.00 $859.00 $905.00
42821 90 $378.00 $439.00 $464.00 $490.00 $439.00 $464.00 $490.00
42826 90 $320.00 $365.00 $387.00 $408.00 $365.00 $387.00 $408.00
42831 90 $235.00 $324.00 $343.00 $360.00 $324.00 $343.00 $360.00
42836 90 $286.00 $350.00 $370.00 $390.00 $350.00 $370.00 $390.00
42842 90 $729.00 $1,476.00 $1,564.00 $1,640.00 $1,476.00 $1,564.00 $1,640.00
42844 90 $1,173.00 $2,035.00 $2,155.00 $2,264.00 $2,035.00 $2,155.00 $2,264.00
42845 90 $1,958.00 $3,286.00 $3,474.00 $3,666.00 $3,286.00 $3,474.00 $3,666.00
42860 90 $207.00 $272.00 $288.00 $302.00 $272.00 $288.00 $302.00
42870 90 $427.00 $859.00 $911.00 $947.00 $859.00 $911.00 $947.00
42890 90 $1,047.00 $2,102.00 $2,225.00 $2,341.00 $2,102.00 $2,225.00 $2,341.00
42892 90 $1,262.00 $2,780.00 $2,942.00 $3,103.00 $2,780.00 $2,942.00 $3,103.00
42894 90 $1,825.00 $3,496.00 $3,698.00 $3,902.00 $3,496.00 $3,698.00 $3,902.00
42900 10 $429.00 $495.00 $523.00 $554.00 $495.00 $523.00 $554.00
42950 90 $745.00 $1,183.00 $1,255.00 $1,309.00 $1,183.00 $1,255.00 $1,309.00
42953 90 $752.00 $1,420.00 $1,508.00 $1,573.00 $1,420.00 $1,508.00 $1,573.00
42955 90 $561.00 $1,104.00 $1,171.00 $1,224.00 $1,104.00 $1,171.00 $1,224.00
42960 10 $178.00 $248.00 $262.00 $277.00 $248.00 $262.00 $277.00
42961 90 $406.00 $614.00 $649.00 $684.00 $614.00 $649.00 $684.00
42962 90 $602.00 $758.00 $802.00 $847.00 $758.00 $802.00 $847.00
42970 90 $284.00 $595.00 $629.00 $662.00 $595.00 $629.00 $662.00
42971 90 $472.00 $672.00 $711.00 $753.00 $672.00 $711.00 $753.00
42972 90 $562.00 $746.00 $789.00 $834.00 $746.00 $789.00 $834.00
42999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
43020 90 $696.00 $783.00 $826.00 $873.00 $783.00 $826.00 $873.00
43030 90 $712.00 $759.00 $803.00 $854.00 $759.00 $803.00 $854.00
43045 90 $1,574.00 $1,958.00 $2,101.00 $2,307.00 $1,958.00 $2,101.00 $2,307.00
43100 90 $744.00 $908.00 $959.00 $1,015.00 $908.00 $959.00 $1,015.00
43101 90 $1,248.00 $1,601.00 $1,719.00 $1,884.00 $1,601.00 $1,719.00 $1,884.00
43107 90 $2,325.00 $3,859.00 $4,142.00 $4,556.00 $3,859.00 $4,142.00 $4,556.00
43108 90 $2,664.00 $7,058.00 $7,576.00 $8,348.00 $7,058.00 $7,576.00 $8,348.00
43112 90 $2,471.00 $4,083.00 $4,384.00 $4,828.00 $4,083.00 $4,384.00 $4,828.00
43113 90 $2,755.00 $6,621.00 $7,110.00 $7,857.00 $6,621.00 $7,110.00 $7,857.00
43116 90 $2,509.00 $7,778.00 $8,214.00 $8,764.00 $7,778.00 $8,214.00 $8,764.00
43117 90 $2,469.00 $3,732.00 $4,005.00 $4,410.00 $3,732.00 $4,005.00 $4,410.00
43118 90 $2,607.00 $5,725.00 $6,141.00 $6,756.00 $5,725.00 $6,141.00 $6,756.00
43121 90 $2,350.00 $4,319.00 $4,632.00 $5,099.00 $4,319.00 $4,632.00 $5,099.00
43122 90 $2,287.00 $3,865.00 $4,147.00 $4,556.00 $3,865.00 $4,147.00 $4,556.00
43123 90 $2,661.00 $7,112.00 $7,628.00 $8,391.00 $7,112.00 $7,628.00 $8,391.00
43124 90 $2,242.00 $5,802.00 $6,212.00 $6,818.00 $5,802.00 $6,212.00 $6,818.00
43130 90 $1,020.00 $1,158.00 $1,229.00 $1,318.00 $1,158.00 $1,229.00 $1,318.00
43135 90 $1,332.00 $2,237.00 $2,396.00 $2,629.00 $2,237.00 $2,396.00 $2,629.00
43180 90 ---------- $806.00 $851.00 $904.00 $806.00 $851.00 $904.00
43191 0 ---------- $227.00 $240.00 $256.00 $227.00 $240.00 $256.00
43192 0 ---------- $250.00 $264.00 $280.00 $250.00 $264.00 $280.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 235
Surgery
CPT Code FUD 2003 MRALocality 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)
43193 0 ---------- $250.00 $264.00 $281.00 $250.00 $264.00 $281.00
43194 0 ---------- $288.00 $306.00 $329.00 $288.00 $306.00 $329.00
43195 0 ---------- $273.00 $288.00 $307.00 $273.00 $288.00 $307.00
43196 0 ---------- $292.00 $308.00 $329.00 $292.00 $308.00 $329.00
43197 0 ---------- $266.00 $283.00 $294.00 $124.00 $131.00 $141.00
43198 0 ---------- $295.00 $314.00 $326.00 $148.00 $156.00 $167.00
43200 0 $266.00 $303.00 $322.00 $333.00 $130.00 $138.00 $147.00
43201 0 $245.00 $310.00 $330.00 $341.00 $154.00 $162.00 $173.00
43202 0 $205.00 $428.00 $455.00 $469.00 $154.00 $163.00 $174.00
43204 0 $228.00 $203.00 $213.00 $226.00 $203.00 $213.00 $226.00
43205 0 $207.00 $211.00 $222.00 $234.00 $211.00 $222.00 $234.00
43206 0 ---------- $374.00 $396.00 $411.00 $199.00 $210.00 $222.00
43210 0 ---------- $649.00 $688.00 $741.00 $649.00 $688.00 $741.00
43211 0 ---------- $353.00 $371.00 $394.00 $353.00 $371.00 $394.00
43212 0 ---------- $287.00 $305.00 $329.00 $287.00 $305.00 $329.00
43213 0 ---------- $1,591.00 $1,695.00 $1,734.00 $387.00 $408.00 $435.00
43214 0 ---------- $288.00 $304.00 $323.00 $288.00 $304.00 $323.00
43215 0 $160.00 $504.00 $537.00 $555.00 $213.00 $225.00 $241.00
43216 0 $149.00 $497.00 $528.00 $543.00 $201.00 $211.00 $224.00
43217 0 $176.00 $533.00 $566.00 $586.00 $241.00 $255.00 $272.00
43220 0 $128.00 $1,470.00 $1,568.00 $1,593.00 $176.00 $186.00 $198.00
43226 0 $142.00 $445.00 $473.00 $489.00 $195.00 $207.00 $220.00
43227 0 $218.00 $870.00 $926.00 $948.00 $247.00 $260.00 $276.00
43229 0 ---------- $897.00 $954.00 $980.00 $295.00 $312.00 $331.00
43231 0 $182.00 $470.00 $498.00 $515.00 $239.00 $251.00 $265.00
43232 0 $252.00 $565.00 $598.00 $618.00 $295.00 $310.00 $327.00
43233 0 ---------- $341.00 $360.00 $384.00 $341.00 $360.00 $384.00
43235 0 $239.00 $360.00 $382.00 $396.00 $184.00 $194.00 $206.00
43236 0 $285.00 $460.00 $488.00 $503.00 $207.00 $218.00 $230.00
43237 0 ---------- $292.00 $308.00 $326.00 $292.00 $308.00 $326.00
43238 0 ---------- $349.00 $367.00 $389.00 $349.00 $367.00 $389.00
43239 0 $246.00 $479.00 $508.00 $524.00 $207.00 $219.00 $232.00
43240 0 $369.00 $588.00 $619.00 $657.00 $588.00 $619.00 $657.00
43241 0 $157.00 $213.00 $225.00 $239.00 $213.00 $225.00 $239.00
43242 0 $384.00 $393.00 $413.00 $437.00 $393.00 $413.00 $437.00
43243 0 $276.00 $355.00 $374.00 $397.00 $355.00 $374.00 $397.00
43244 0 $268.00 $367.00 $386.00 $409.00 $367.00 $386.00 $409.00
43245 0 $214.00 $768.00 $818.00 $842.00 $263.00 $278.00 $297.00
43246 0 $485.00 $301.00 $318.00 $340.00 $301.00 $318.00 $340.00
43247 0 $229.00 $493.00 $523.00 $542.00 $265.00 $279.00 $297.00
43248 0 $191.00 $492.00 $521.00 $539.00 $248.00 $261.00 $277.00
43249 0 $175.00 $1,397.00 $1,489.00 $1,516.00 $230.00 $242.00 $257.00
43250 0 $194.00 $557.00 $593.00 $614.00 $256.00 $270.00 $289.00
43251 0 $224.00 $617.00 $655.00 $677.00 $293.00 $309.00 $328.00
43252 0 ---------- $427.00 $452.00 $471.00 $252.00 $266.00 $283.00
43253 0 ---------- $393.00 $413.00 $437.00 $393.00 $413.00 $437.00
43254 0 ---------- $405.00 $426.00 $452.00 $405.00 $426.00 $452.00
43255 0 $343.00 $923.00 $981.00 $1,006.00 $301.00 $316.00 $335.00
43257 0 ---------- $349.00 $368.00 $392.00 $349.00 $368.00 $392.00
43259 0 $271.00 $338.00 $356.00 $377.00 $338.00 $356.00 $377.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 236
Surgery
CPT Code FUD 2003 MRALocality 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)
43260 0 $349.00 $482.00 $507.00 $537.00 $482.00 $507.00 $537.00
43261 0 $362.00 $507.00 $533.00 $564.00 $507.00 $533.00 $564.00
43262 0 $447.00 $535.00 $563.00 $596.00 $535.00 $563.00 $596.00
43263 0 $386.00 $536.00 $564.00 $599.00 $536.00 $564.00 $599.00
43264 0 $522.00 $545.00 $573.00 $607.00 $545.00 $573.00 $607.00
43265 0 $527.00 $649.00 $683.00 $723.00 $649.00 $683.00 $723.00
43266 0 ---------- $328.00 $346.00 $369.00 $328.00 $346.00 $369.00
43270 0 ---------- $928.00 $986.00 $1,013.00 $336.00 $354.00 $375.00
43273 ZZZ ---------- $180.00 $189.00 $201.00 $180.00 $189.00 $201.00
43274 0 ---------- $693.00 $729.00 $773.00 $693.00 $729.00 $773.00
43275 0 ---------- $564.00 $593.00 $629.00 $564.00 $593.00 $629.00
43276 0 ---------- $722.00 $759.00 $804.00 $722.00 $759.00 $804.00
43277 0 ---------- $567.00 $596.00 $632.00 $567.00 $596.00 $632.00
43278 0 ---------- $649.00 $682.00 $723.00 $649.00 $682.00 $723.00
43279 90 ---------- $1,946.00 $2,087.00 $2,293.00 $1,946.00 $2,087.00 $2,293.00
43280 90 $1,314.00 $1,626.00 $1,745.00 $1,914.00 $1,626.00 $1,745.00 $1,914.00
43281 90 ---------- $2,329.00 $2,498.00 $2,745.00 $2,329.00 $2,498.00 $2,745.00
43282 90 ---------- $2,621.00 $2,812.00 $3,092.00 $2,621.00 $2,812.00 $3,092.00
43283 ZZZ ---------- $241.00 $259.00 $286.00 $241.00 $259.00 $286.00
43289 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
43300 90 $837.00 $906.00 $960.00 $1,020.00 $906.00 $960.00 $1,020.00
43305 90 $1,428.00 $1,604.00 $1,695.00 $1,805.00 $1,604.00 $1,695.00 $1,805.00
43310 90 $2,138.00 $2,229.00 $2,390.00 $2,629.00 $2,229.00 $2,390.00 $2,629.00
43312 90 $2,331.00 $2,427.00 $2,594.00 $2,840.00 $2,427.00 $2,594.00 $2,840.00
43313 90 $2,632.00 $4,008.00 $4,223.00 $4,490.00 $4,008.00 $4,223.00 $4,490.00
43314 90 $2,891.00 $4,480.00 $4,782.00 $5,217.00 $4,480.00 $4,782.00 $5,217.00
43320 90 $1,299.00 $2,082.00 $2,229.00 $2,437.00 $2,082.00 $2,229.00 $2,437.00
43325 90 $1,261.00 $2,009.00 $2,153.00 $2,358.00 $2,009.00 $2,153.00 $2,358.00
43327 90 ---------- $1,231.00 $1,320.00 $1,445.00 $1,231.00 $1,320.00 $1,445.00
43328 90 ---------- $1,703.00 $1,827.00 $2,009.00 $1,703.00 $1,827.00 $2,009.00
43330 90 $1,236.00 $2,011.00 $2,160.00 $2,374.00 $2,011.00 $2,160.00 $2,374.00
43331 90 $1,378.00 $2,015.00 $2,160.00 $2,367.00 $2,015.00 $2,160.00 $2,367.00
43332 90 ---------- $1,748.00 $1,876.00 $2,059.00 $1,748.00 $1,876.00 $2,059.00
43333 90 ---------- $1,910.00 $2,050.00 $2,253.00 $1,910.00 $2,050.00 $2,253.00
43334 90 ---------- $1,892.00 $2,030.00 $2,234.00 $1,892.00 $2,030.00 $2,234.00
43335 90 ---------- $2,031.00 $2,180.00 $2,402.00 $2,031.00 $2,180.00 $2,402.00
43336 90 ---------- $2,273.00 $2,438.00 $2,675.00 $2,273.00 $2,438.00 $2,675.00
43337 90 ---------- $2,451.00 $2,631.00 $2,890.00 $2,451.00 $2,631.00 $2,890.00
43338 ZZZ ---------- $177.00 $190.00 $211.00 $177.00 $190.00 $211.00
43340 90 $1,292.00 $2,060.00 $2,212.00 $2,428.00 $2,060.00 $2,212.00 $2,428.00
43341 90 $1,351.00 $2,120.00 $2,276.00 $2,504.00 $2,120.00 $2,276.00 $2,504.00
43351 90 $1,180.00 $2,064.00 $2,212.00 $2,411.00 $2,064.00 $2,212.00 $2,411.00
43352 90 $1,028.00 $1,611.00 $1,728.00 $1,895.00 $1,611.00 $1,728.00 $1,895.00
43360 90 $2,277.00 $3,557.00 $3,814.00 $4,182.00 $3,557.00 $3,814.00 $4,182.00
43361 90 $2,596.00 $3,891.00 $4,167.00 $4,571.00 $3,891.00 $4,167.00 $4,571.00
43400 90 $1,261.00 $2,193.00 $2,309.00 $2,444.00 $2,193.00 $2,309.00 $2,444.00
43401 90 $1,299.00 $2,181.00 $2,298.00 $2,443.00 $2,181.00 $2,298.00 $2,443.00
43405 90 $1,330.00 $2,291.00 $2,453.00 $2,675.00 $2,291.00 $2,453.00 $2,675.00
43410 90 $946.00 $1,573.00 $1,686.00 $1,839.00 $1,573.00 $1,686.00 $1,839.00
43415 90 $1,382.00 $3,878.00 $4,157.00 $4,565.00 $3,878.00 $4,157.00 $4,565.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 237
Surgery
CPT Code FUD 2003 MRALocality 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)
43420 90 $854.00 $1,497.00 $1,583.00 $1,687.00 $1,497.00 $1,583.00 $1,687.00
43425 90 $1,338.00 $2,196.00 $2,354.00 $2,583.00 $2,196.00 $2,354.00 $2,583.00
43450 0 $91.00 $220.00 $234.00 $242.00 $118.00 $124.00 $131.00
43453 0 $102.00 $1,244.00 $1,327.00 $1,346.00 $128.00 $134.00 $142.00
43460 0 $203.00 $318.00 $335.00 $355.00 $318.00 $335.00 $355.00
43496 90 BR ---------- ---------- ---------- ---------- ---------- ----------
43499 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
43500 90 $649.00 $1,177.00 $1,260.00 $1,376.00 $1,177.00 $1,260.00 $1,376.00
43501 90 $1,105.00 $2,026.00 $2,174.00 $2,386.00 $2,026.00 $2,174.00 $2,386.00
43502 90 $1,247.00 $2,270.00 $2,438.00 $2,684.00 $2,270.00 $2,438.00 $2,684.00
43510 90 $680.00 $1,390.00 $1,493.00 $1,638.00 $1,390.00 $1,493.00 $1,638.00
43520 90 $599.00 $1,030.00 $1,105.00 $1,210.00 $1,030.00 $1,105.00 $1,210.00
43605 90 $686.00 $1,262.00 $1,355.00 $1,486.00 $1,262.00 $1,355.00 $1,486.00
43610 90 $861.00 $1,472.00 $1,579.00 $1,730.00 $1,472.00 $1,579.00 $1,730.00
43611 90 $1,001.00 $1,838.00 $1,972.00 $2,163.00 $1,838.00 $1,972.00 $2,163.00
43620 90 $1,691.00 $2,965.00 $3,179.00 $3,490.00 $2,965.00 $3,179.00 $3,490.00
43621 90 $1,718.00 $3,425.00 $3,675.00 $4,041.00 $3,425.00 $3,675.00 $4,041.00
43622 90 $1,798.00 $3,459.00 $3,709.00 $4,074.00 $3,459.00 $3,709.00 $4,074.00
43631 90 $1,445.00 $2,183.00 $2,342.00 $2,571.00 $2,183.00 $2,342.00 $2,571.00
43632 90 $1,443.00 $3,065.00 $3,289.00 $3,616.00 $3,065.00 $3,289.00 $3,616.00
43633 90 $1,467.00 $2,898.00 $3,110.00 $3,419.00 $2,898.00 $3,110.00 $3,419.00
43634 90 $1,786.00 $3,198.00 $3,431.00 $3,773.00 $3,198.00 $3,431.00 $3,773.00
43635 ZZZ $143.00 $171.00 $184.00 $204.00 $171.00 $184.00 $204.00
43640 90 $1,119.00 $1,771.00 $1,900.00 $2,083.00 $1,771.00 $1,900.00 $2,083.00
43641 90 $1,138.00 $1,789.00 $1,915.00 $2,091.00 $1,789.00 $1,915.00 $2,091.00
43644 90 ---------- $2,609.00 $2,799.00 $3,073.00 $2,609.00 $2,799.00 $3,073.00
43645 90 ---------- $2,781.00 $2,983.00 $3,275.00 $2,781.00 $2,983.00 $3,275.00
43651 90 $716.00 $976.00 $1,048.00 $1,146.00 $976.00 $1,048.00 $1,146.00
43652 90 $856.00 $1,147.00 $1,232.00 $1,349.00 $1,147.00 $1,232.00 $1,349.00
43653 90 $617.00 $853.00 $915.00 $996.00 $853.00 $915.00 $996.00
43659 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
43752 0 BR $60.00 $63.00 $66.00 $60.00 $63.00 $66.00
43753 0 ---------- $32.00 $34.00 $36.00 $32.00 $34.00 $36.00
43754 0 ---------- $169.00 $181.00 $185.00 $51.00 $54.00 $57.00
43755 0 ---------- $193.00 $206.00 $213.00 $89.00 $94.00 $100.00
43756 0 ---------- $279.00 $297.00 $304.00 $74.00 $78.00 $82.00
43757 0 ---------- $403.00 $428.00 $438.00 $114.00 $120.00 $127.00
43760 0 $81.00 $672.00 $717.00 $728.00 $70.00 $74.00 $79.00
43761 0 $107.00 $170.00 $178.00 $187.00 $152.00 $159.00 $168.00
43770 90 ---------- $1,679.00 $1,802.00 $1,972.00 $1,679.00 $1,802.00 $1,972.00
43771 90 ---------- $1,907.00 $2,045.00 $2,238.00 $1,907.00 $2,045.00 $2,238.00
43772 90 ---------- $1,421.00 $1,522.00 $1,665.00 $1,421.00 $1,522.00 $1,665.00
43773 90 ---------- $1,913.00 $2,053.00 $2,249.00 $1,913.00 $2,053.00 $2,249.00
43774 90 ---------- $1,439.00 $1,544.00 $1,691.00 $1,439.00 $1,544.00 $1,691.00
43775 90 ---------- $1,664.00 $1,779.00 $1,952.00 $1,664.00 $1,779.00 $1,952.00
43800 90 $793.00 $1,397.00 $1,499.00 $1,642.00 $1,397.00 $1,499.00 $1,642.00
43810 90 $846.00 $1,524.00 $1,634.00 $1,790.00 $1,524.00 $1,634.00 $1,790.00
43820 90 $896.00 $2,018.00 $2,165.00 $2,375.00 $2,018.00 $2,165.00 $2,375.00
43825 90 $1,128.00 $1,942.00 $2,081.00 $2,278.00 $1,942.00 $2,081.00 $2,278.00
43830 90 $592.00 $1,043.00 $1,118.00 $1,218.00 $1,043.00 $1,118.00 $1,218.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 238
Surgery
CPT Code FUD 2003 MRALocality 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)
43831 90 $593.00 $833.00 $888.00 $957.00 $833.00 $888.00 $957.00
43832 90 $904.00 $1,556.00 $1,668.00 $1,826.00 $1,556.00 $1,668.00 $1,826.00
43840 90 $893.00 $2,044.00 $2,192.00 $2,405.00 $2,044.00 $2,192.00 $2,405.00
43843 90 $1,249.00 $1,908.00 $2,046.00 $2,241.00 $1,908.00 $2,046.00 $2,241.00
43845 90 ---------- $2,953.00 $3,168.00 $3,477.00 $2,953.00 $3,168.00 $3,477.00
43846 90 $1,528.00 $2,437.00 $2,615.00 $2,871.00 $2,437.00 $2,615.00 $2,871.00
43847 90 $1,678.00 $2,666.00 $2,854.00 $3,121.00 $2,666.00 $2,854.00 $3,121.00
43848 90 $1,795.00 $2,896.00 $3,106.00 $3,410.00 $2,896.00 $3,106.00 $3,410.00
43850 90 $1,425.00 $2,428.00 $2,601.00 $2,850.00 $2,428.00 $2,601.00 $2,850.00
43855 90 $1,454.00 $2,486.00 $2,641.00 $2,847.00 $2,486.00 $2,641.00 $2,847.00
43860 90 $1,435.00 $2,462.00 $2,640.00 $2,897.00 $2,462.00 $2,640.00 $2,897.00
43865 90 $1,549.00 $2,547.00 $2,729.00 $2,989.00 $2,547.00 $2,729.00 $2,989.00
43870 90 $590.00 $1,064.00 $1,140.00 $1,245.00 $1,064.00 $1,140.00 $1,245.00
43880 90 $1,352.00 $2,408.00 $2,584.00 $2,836.00 $2,408.00 $2,584.00 $2,836.00
43886 90 ---------- $534.00 $573.00 $618.00 $534.00 $573.00 $618.00
43887 90 ---------- $482.00 $518.00 $560.00 $482.00 $518.00 $560.00
43888 90 ---------- $679.00 $727.00 $788.00 $679.00 $727.00 $788.00
43999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
44005 90 $1,171.00 $1,646.00 $1,766.00 $1,935.00 $1,646.00 $1,766.00 $1,935.00
44010 90 $809.00 $1,289.00 $1,376.00 $1,494.00 $1,289.00 $1,376.00 $1,494.00
44015 ZZZ $1,171.00 $217.00 $233.00 $257.00 $217.00 $233.00 $257.00
44020 90 $891.00 $1,462.00 $1,567.00 $1,717.00 $1,462.00 $1,567.00 $1,717.00
44021 90 $888.00 $1,461.00 $1,565.00 $1,712.00 $1,461.00 $1,565.00 $1,712.00
44025 90 $905.00 $1,474.00 $1,578.00 $1,723.00 $1,474.00 $1,578.00 $1,723.00
44050 90 $862.00 $1,403.00 $1,505.00 $1,648.00 $1,403.00 $1,505.00 $1,648.00
44055 90 $957.00 $2,244.00 $2,405.00 $2,638.00 $2,244.00 $2,405.00 $2,638.00
44100 0 $117.00 $162.00 $171.00 $182.00 $162.00 $171.00 $182.00
44110 90 $784.00 $1,277.00 $1,368.00 $1,494.00 $1,277.00 $1,368.00 $1,494.00
44111 90 $963.00 $1,469.00 $1,570.00 $1,709.00 $1,469.00 $1,570.00 $1,709.00
44120 90 $1,078.00 $1,841.00 $1,973.00 $2,163.00 $1,841.00 $1,973.00 $2,163.00
44121 ZZZ $308.00 $367.00 $394.00 $434.00 $367.00 $394.00 $434.00
44125 90 $1,135.00 $1,773.00 $1,899.00 $2,076.00 $1,773.00 $1,899.00 $2,076.00
44126 90 $1,951.00 $3,666.00 $3,927.00 $4,304.00 $3,666.00 $3,927.00 $4,304.00
44127 90 $2,243.00 $4,166.00 $4,457.00 $4,880.00 $4,166.00 $4,457.00 $4,880.00
44128 ZZZ $242.00 $371.00 $397.00 $437.00 $371.00 $397.00 $437.00
44130 90 $938.00 $1,973.00 $2,113.00 $2,312.00 $1,973.00 $2,113.00 $2,312.00
44133 0 BR ---------- ---------- ---------- ---------- ---------- ----------
44136 0 BR ---------- ---------- ---------- ---------- ---------- ----------
44139 ZZZ $154.00 $184.00 $197.00 $217.00 $184.00 $197.00 $217.00
44140 90 $1,350.00 $2,015.00 $2,160.00 $2,364.00 $2,015.00 $2,160.00 $2,364.00
44141 90 $1,488.00 $2,739.00 $2,935.00 $3,206.00 $2,739.00 $2,935.00 $3,206.00
44143 90 $1,536.00 $2,501.00 $2,680.00 $2,931.00 $2,501.00 $2,680.00 $2,931.00
44144 90 $1,442.00 $2,659.00 $2,849.00 $3,119.00 $2,659.00 $2,849.00 $3,119.00
44145 90 $1,678.00 $2,490.00 $2,662.00 $2,906.00 $2,490.00 $2,662.00 $2,906.00
44146 90 $1,840.00 $3,177.00 $3,397.00 $3,697.00 $3,177.00 $3,397.00 $3,697.00
44147 90 $1,452.00 $2,923.00 $3,130.00 $3,426.00 $2,923.00 $3,130.00 $3,426.00
44150 90 $1,661.00 $2,796.00 $2,991.00 $3,256.00 $2,796.00 $2,991.00 $3,256.00
44151 90 $1,499.00 $3,198.00 $3,425.00 $3,737.00 $3,198.00 $3,425.00 $3,737.00
44155 90 $1,892.00 $3,113.00 $3,322.00 $3,602.00 $3,113.00 $3,322.00 $3,602.00
44156 90 $1,709.00 $3,408.00 $3,655.00 $4,004.00 $3,408.00 $3,655.00 $4,004.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 239
Surgery
CPT Code FUD 2003 MRALocality 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)
44157 90 ---------- $3,229.00 $3,450.00 $3,752.00 $3,229.00 $3,450.00 $3,752.00
44158 90 ---------- $3,359.00 $3,605.00 $3,952.00 $3,359.00 $3,605.00 $3,952.00
44160 90 $1,236.00 $1,864.00 $1,997.00 $2,183.00 $1,864.00 $1,997.00 $2,183.00
44180 90 ---------- $1,379.00 $1,478.00 $1,616.00 $1,379.00 $1,478.00 $1,616.00
44186 90 ---------- $976.00 $1,047.00 $1,145.00 $976.00 $1,047.00 $1,145.00
44187 90 ---------- $1,643.00 $1,752.00 $1,893.00 $1,643.00 $1,752.00 $1,893.00
44188 90 ---------- $1,827.00 $1,954.00 $2,120.00 $1,827.00 $1,954.00 $2,120.00
44202 90 $1,603.00 $2,082.00 $2,231.00 $2,442.00 $2,082.00 $2,231.00 $2,442.00
44203 ZZZ $235.00 $365.00 $390.00 $428.00 $365.00 $390.00 $428.00
44204 90 $1,353.00 $2,309.00 $2,469.00 $2,693.00 $2,309.00 $2,469.00 $2,693.00
44205 90 $1,198.00 $2,007.00 $2,144.00 $2,336.00 $2,007.00 $2,144.00 $2,336.00
44206 90 $1,480.00 $2,628.00 $2,811.00 $3,067.00 $2,628.00 $2,811.00 $3,067.00
44207 90 $1,620.00 $2,730.00 $2,912.00 $3,167.00 $2,730.00 $2,912.00 $3,167.00
44208 90 $1,752.00 $2,974.00 $3,173.00 $3,445.00 $2,974.00 $3,173.00 $3,445.00
44210 90 $1,551.00 $2,658.00 $2,830.00 $3,060.00 $2,658.00 $2,830.00 $3,060.00
44211 90 $1,926.00 $3,258.00 $3,466.00 $3,740.00 $3,258.00 $3,466.00 $3,740.00
44212 90 $1,800.00 $3,048.00 $3,239.00 $3,488.00 $3,048.00 $3,239.00 $3,488.00
44213 ZZZ ---------- $285.00 $304.00 $332.00 $285.00 $304.00 $332.00
44227 90 ---------- $2,506.00 $2,682.00 $2,932.00 $2,506.00 $2,682.00 $2,932.00
44238 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
44300 90 $697.00 $1,262.00 $1,354.00 $1,482.00 $1,262.00 $1,354.00 $1,482.00
44310 90 $950.00 $1,564.00 $1,672.00 $1,821.00 $1,564.00 $1,672.00 $1,821.00
44312 90 $453.00 $876.00 $934.00 $1,007.00 $876.00 $934.00 $1,007.00
44314 90 $892.00 $1,496.00 $1,595.00 $1,727.00 $1,496.00 $1,595.00 $1,727.00
44316 90 $1,229.00 $2,133.00 $2,289.00 $2,511.00 $2,133.00 $2,289.00 $2,511.00
44320 90 $1,029.00 $1,801.00 $1,928.00 $2,104.00 $1,801.00 $1,928.00 $2,104.00
44322 90 $1,015.00 $1,473.00 $1,579.00 $1,706.00 $1,473.00 $1,579.00 $1,706.00
44340 90 $397.00 $926.00 $991.00 $1,073.00 $926.00 $991.00 $1,073.00
44345 90 $816.00 $1,573.00 $1,682.00 $1,830.00 $1,573.00 $1,682.00 $1,830.00
44346 90 $923.00 $1,771.00 $1,893.00 $2,061.00 $1,771.00 $1,893.00 $2,061.00
44360 0 $177.00 $215.00 $226.00 $239.00 $215.00 $226.00 $239.00
44361 0 $195.00 $237.00 $250.00 $264.00 $237.00 $250.00 $264.00
44363 0 $213.00 $287.00 $303.00 $321.00 $287.00 $303.00 $321.00
44364 0 $255.00 $306.00 $321.00 $340.00 $306.00 $321.00 $340.00
44365 0 $226.00 $269.00 $282.00 $297.00 $269.00 $282.00 $297.00
44366 0 $300.00 $359.00 $378.00 $400.00 $359.00 $378.00 $400.00
44369 0 $308.00 $368.00 $387.00 $410.00 $368.00 $387.00 $410.00
44370 0 $253.00 $399.00 $421.00 $447.00 $399.00 $421.00 $447.00
44372 0 $301.00 $361.00 $381.00 $405.00 $361.00 $381.00 $405.00
44373 0 $238.00 $288.00 $304.00 $324.00 $288.00 $304.00 $324.00
44376 0 $305.00 $426.00 $449.00 $476.00 $426.00 $449.00 $476.00
44377 0 $320.00 $449.00 $472.00 $501.00 $449.00 $472.00 $501.00
44378 0 $410.00 $576.00 $606.00 $642.00 $576.00 $606.00 $642.00
44379 0 $396.00 $614.00 $646.00 $685.00 $614.00 $646.00 $685.00
44380 0 $91.00 $233.00 $248.00 $254.00 $83.00 $88.00 $92.00
44381 0 ---------- $1,281.00 $1,367.00 $1,386.00 $126.00 $133.00 $141.00
44382 0 $110.00 $362.00 $385.00 $394.00 $109.00 $115.00 $121.00
44384 0 ---------- $228.00 $239.00 $252.00 $228.00 $239.00 $252.00
44385 0 $219.00 $266.00 $283.00 $292.00 $107.00 $113.00 $120.00
44386 0 $183.00 $396.00 $422.00 $433.00 $133.00 $140.00 $149.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 240
Surgery
CPT Code FUD 2003 MRALocality 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)
44388 0 $326.00 $409.00 $434.00 $453.00 $235.00 $248.00 $266.00
44388-53 0 ---------- $203.00 $215.00 $224.00 $116.00 $122.00 $130.00
44389 0 $301.00 $532.00 $565.00 $586.00 $258.00 $272.00 $290.00
44390 0 $319.00 $529.00 $560.00 $582.00 $315.00 $332.00 $351.00
44391 0 $376.00 $964.00 $1,025.00 $1,053.00 $345.00 $363.00 $386.00
44392 0 $359.00 $496.00 $527.00 $550.00 $298.00 $314.00 $336.00
44394 0 $395.00 $572.00 $607.00 $633.00 $338.00 $357.00 $381.00
44401 0 ---------- $4,349.00 $4,640.00 $4,707.00 $364.00 $384.00 $409.00
44402 0 ---------- $390.00 $411.00 $436.00 $390.00 $411.00 $436.00
44403 0 ---------- $455.00 $479.00 $508.00 $455.00 $479.00 $508.00
44404 0 ---------- $506.00 $537.00 $556.00 $257.00 $271.00 $288.00
44405 0 ---------- $750.00 $798.00 $821.00 $274.00 $289.00 $307.00
44406 0 ---------- $344.00 $363.00 $385.00 $344.00 $363.00 $385.00
44407 0 ---------- $412.00 $435.00 $462.00 $412.00 $435.00 $462.00
44408 0 ---------- $347.00 $366.00 $388.00 $347.00 $366.00 $388.00
44500 0 $28.00 $28.00 $29.00 $31.00 $28.00 $29.00 $31.00
44602 90 $815.00 $2,129.00 $2,282.00 $2,506.00 $2,129.00 $2,282.00 $2,506.00
44603 90 $1,041.00 $2,442.00 $2,617.00 $2,869.00 $2,442.00 $2,617.00 $2,869.00
44604 90 $1,027.00 $1,592.00 $1,706.00 $1,869.00 $1,592.00 $1,706.00 $1,869.00
44605 90 $1,132.00 $1,957.00 $2,095.00 $2,290.00 $1,957.00 $2,095.00 $2,290.00
44615 90 $994.00 $1,612.00 $1,726.00 $1,886.00 $1,612.00 $1,726.00 $1,886.00
44620 90 $741.00 $1,299.00 $1,389.00 $1,512.00 $1,299.00 $1,389.00 $1,512.00
44625 90 $1,277.00 $1,521.00 $1,623.00 $1,763.00 $1,521.00 $1,623.00 $1,763.00
44626 90 $1,581.00 $2,413.00 $2,583.00 $2,828.00 $2,413.00 $2,583.00 $2,828.00
44640 90 $1,036.00 $2,108.00 $2,256.00 $2,467.00 $2,108.00 $2,256.00 $2,467.00
44650 90 $1,076.00 $2,174.00 $2,325.00 $2,541.00 $2,174.00 $2,325.00 $2,541.00
44660 90 $1,050.00 $1,995.00 $2,118.00 $2,285.00 $1,995.00 $2,118.00 $2,285.00
44661 90 $1,326.00 $2,326.00 $2,481.00 $2,701.00 $2,326.00 $2,481.00 $2,701.00
44680 90 $1,049.00 $1,604.00 $1,720.00 $1,883.00 $1,604.00 $1,720.00 $1,883.00
44700 90 $1,115.00 $1,517.00 $1,614.00 $1,743.00 $1,517.00 $1,614.00 $1,743.00
44701 ZZZ $161.00 $255.00 $272.00 $299.00 $255.00 $272.00 $299.00
44720 0 ---------- $451.00 $478.00 $512.00 $451.00 $478.00 $512.00
44721 0 ---------- $585.00 $629.00 $695.00 $585.00 $629.00 $695.00
44799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
44800 90 $791.00 $1,143.00 $1,224.00 $1,333.00 $1,143.00 $1,224.00 $1,333.00
44820 90 $755.00 $1,252.00 $1,341.00 $1,463.00 $1,252.00 $1,341.00 $1,463.00
44850 90 $708.00 $1,122.00 $1,202.00 $1,312.00 $1,122.00 $1,202.00 $1,312.00
44899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
44900 90 $644.00 $1,147.00 $1,227.00 $1,337.00 $1,147.00 $1,227.00 $1,337.00
44950 90 $643.00 $964.00 $1,034.00 $1,132.00 $964.00 $1,034.00 $1,132.00
44955 ZZZ $136.00 $127.00 $136.00 $150.00 $127.00 $136.00 $150.00
44960 90 $790.00 $1,314.00 $1,410.00 $1,546.00 $1,314.00 $1,410.00 $1,546.00
44970 90 $631.00 $898.00 $963.00 $1,052.00 $898.00 $963.00 $1,052.00
44979 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
45000 90 $329.00 $623.00 $663.00 $710.00 $623.00 $663.00 $710.00
45005 10 $197.00 $390.00 $417.00 $437.00 $237.00 $253.00 $271.00
45020 90 $364.00 $849.00 $907.00 $981.00 $849.00 $907.00 $981.00
45100 90 $321.00 $439.00 $467.00 $499.00 $439.00 $467.00 $499.00
45108 90 $419.00 $540.00 $578.00 $626.00 $540.00 $578.00 $626.00
45110 90 $1,801.00 $2,754.00 $2,936.00 $3,178.00 $2,754.00 $2,936.00 $3,178.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 241
Surgery
CPT Code FUD 2003 MRALocality 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)
45111 90 $1,270.00 $1,623.00 $1,734.00 $1,883.00 $1,623.00 $1,734.00 $1,883.00
45112 90 $1,904.00 $2,803.00 $2,980.00 $3,222.00 $2,803.00 $2,980.00 $3,222.00
45113 90 $1,885.00 $2,877.00 $3,057.00 $3,294.00 $2,877.00 $3,057.00 $3,294.00
45114 90 $1,732.00 $2,717.00 $2,912.00 $3,191.00 $2,717.00 $2,912.00 $3,191.00
45116 90 $1,485.00 $2,428.00 $2,597.00 $2,836.00 $2,428.00 $2,597.00 $2,836.00
45119 90 $1,911.00 $2,898.00 $3,078.00 $3,317.00 $2,898.00 $3,078.00 $3,317.00
45120 90 $1,845.00 $2,386.00 $2,561.00 $2,808.00 $2,386.00 $2,561.00 $2,808.00
45121 90 $1,870.00 $2,464.00 $2,608.00 $2,794.00 $2,464.00 $2,608.00 $2,794.00
45123 90 $1,126.00 $1,665.00 $1,769.00 $1,905.00 $1,665.00 $1,769.00 $1,905.00
45126 90 $2,444.00 $4,158.00 $4,414.00 $4,757.00 $4,158.00 $4,414.00 $4,757.00
45130 90 $1,041.00 $1,617.00 $1,717.00 $1,845.00 $1,617.00 $1,717.00 $1,845.00
45135 90 $1,354.00 $2,050.00 $2,198.00 $2,403.00 $2,050.00 $2,198.00 $2,403.00
45136 90 $1,526.00 $2,868.00 $3,079.00 $3,373.00 $2,868.00 $3,079.00 $3,373.00
45150 90 $475.00 $526.00 $552.00 $580.00 $526.00 $552.00 $580.00
45160 90 $949.00 $1,531.00 $1,643.00 $1,799.00 $1,531.00 $1,643.00 $1,799.00
45171 90 ---------- $882.00 $941.00 $1,007.00 $882.00 $941.00 $1,007.00
45172 90 ---------- $1,193.00 $1,269.00 $1,359.00 $1,193.00 $1,269.00 $1,359.00
45190 90 $623.00 $1,023.00 $1,087.00 $1,160.00 $1,023.00 $1,087.00 $1,160.00
45300 0 $75.00 $173.00 $184.00 $190.00 $80.00 $84.00 $90.00
45303 0 $72.00 $1,238.00 $1,322.00 $1,344.00 $129.00 $137.00 $148.00
45305 0 $102.00 $202.00 $215.00 $224.00 $109.00 $116.00 $124.00
45307 0 $172.00 $237.00 $252.00 $265.00 $145.00 $154.00 $166.00
45308 0 $137.00 $227.00 $243.00 $257.00 $126.00 $135.00 $148.00
45309 0 $174.00 $237.00 $254.00 $269.00 $134.00 $144.00 $158.00
45315 0 $211.00 $258.00 $276.00 $293.00 $158.00 $169.00 $184.00
45317 0 $209.00 $260.00 $276.00 $290.00 $167.00 $177.00 $189.00
45320 0 $230.00 $254.00 $272.00 $288.00 $157.00 $168.00 $184.00
45321 0 $154.00 $152.00 $162.00 $175.00 $152.00 $162.00 $175.00
45327 0 $96.00 $168.00 $177.00 $188.00 $168.00 $177.00 $188.00
45330 0 $87.00 $232.00 $247.00 $253.00 $83.00 $88.00 $93.00
45331 0 $120.00 $355.00 $377.00 $386.00 $107.00 $113.00 $119.00
45332 0 $174.00 $351.00 $374.00 $386.00 $157.00 $166.00 $177.00
45333 0 $176.00 $408.00 $435.00 $447.00 $141.00 $149.00 $159.00
45334 0 $171.00 $760.00 $809.00 $826.00 $176.00 $185.00 $196.00
45335 0 $144.00 $324.00 $345.00 $353.00 $99.00 $104.00 $111.00
45337 0 $144.00 $173.00 $183.00 $196.00 $173.00 $183.00 $196.00
45338 0 $212.00 $377.00 $400.00 $414.00 $180.00 $190.00 $202.00
45340 0 $328.00 $594.00 $633.00 $645.00 $116.00 $122.00 $130.00
45341 0 $153.00 $185.00 $194.00 $206.00 $185.00 $194.00 $206.00
45342 0 $224.00 $254.00 $267.00 $282.00 $254.00 $267.00 $282.00
45346 0 ---------- $4,170.00 $4,451.00 $4,507.00 $240.00 $253.00 $269.00
45347 0 ---------- $231.00 $243.00 $258.00 $231.00 $243.00 $258.00
45349 0 ---------- $297.00 $313.00 $332.00 $297.00 $313.00 $332.00
45350 0 ---------- $722.00 $770.00 $785.00 $150.00 $159.00 $168.00
45379 0 $415.00 $578.00 $613.00 $639.00 $359.00 $378.00 $403.00
45380 0 $369.00 $569.00 $604.00 $626.00 $300.00 $317.00 $336.00
45381 0 $388.00 $545.00 $577.00 $599.00 $300.00 $316.00 $335.00
45382 0 $481.00 $1,004.00 $1,066.00 $1,097.00 $388.00 $408.00 $433.00
45384 0 $415.00 $634.00 $673.00 $701.00 $343.00 $363.00 $388.00
45385 0 $479.00 $603.00 $638.00 $665.00 $381.00 $401.00 $426.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 242
Surgery
CPT Code FUD 2003 MRALocality 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)
45386 0 $739.00 $816.00 $867.00 $894.00 $318.00 $335.00 $357.00
45388 0 ---------- $4,393.00 $4,687.00 $4,756.00 $406.00 $429.00 $457.00
45389 0 ---------- $435.00 $458.00 $487.00 $435.00 $458.00 $487.00
45390 0 ---------- $498.00 $524.00 $557.00 $498.00 $524.00 $557.00
45391 0 ---------- $386.00 $406.00 $430.00 $386.00 $406.00 $430.00
45392 0 ---------- $455.00 $479.00 $508.00 $455.00 $479.00 $508.00
45393 0 ---------- $380.00 $401.00 $428.00 $380.00 $401.00 $428.00
45395 90 ---------- $2,943.00 $3,130.00 $3,373.00 $2,943.00 $3,130.00 $3,373.00
45397 90 ---------- $3,199.00 $3,396.00 $3,649.00 $3,199.00 $3,396.00 $3,649.00
45398 0 ---------- $937.00 $996.00 $1,025.00 $352.00 $371.00 $394.00
45400 90 ---------- $1,694.00 $1,799.00 $1,934.00 $1,694.00 $1,799.00 $1,934.00
45402 90 ---------- $2,266.00 $2,407.00 $2,597.00 $2,266.00 $2,407.00 $2,597.00
45500 90 $584.00 $762.00 $806.00 $852.00 $762.00 $806.00 $852.00
45505 90 $510.00 $870.00 $927.00 $992.00 $870.00 $927.00 $992.00
45520 0 $46.00 $215.00 $229.00 $233.00 $59.00 $62.00 $65.00
45540 90 $1,009.00 $1,573.00 $1,671.00 $1,800.00 $1,573.00 $1,671.00 $1,800.00
45541 90 $888.00 $1,402.00 $1,497.00 $1,619.00 $1,402.00 $1,497.00 $1,619.00
45550 90 $1,350.00 $2,177.00 $2,314.00 $2,496.00 $2,177.00 $2,314.00 $2,496.00
45560 90 $618.00 $1,008.00 $1,061.00 $1,122.00 $1,008.00 $1,061.00 $1,122.00
45562 90 $915.00 $1,674.00 $1,789.00 $1,941.00 $1,674.00 $1,789.00 $1,941.00
45563 90 $1,412.00 $2,458.00 $2,636.00 $2,880.00 $2,458.00 $2,636.00 $2,880.00
45800 90 $1,050.00 $1,791.00 $1,904.00 $2,054.00 $1,791.00 $1,904.00 $2,054.00
45805 90 $1,273.00 $2,136.00 $2,280.00 $2,471.00 $2,136.00 $2,280.00 $2,471.00
45820 90 $1,066.00 $1,658.00 $1,739.00 $1,834.00 $1,658.00 $1,739.00 $1,834.00
45825 90 $1,241.00 $2,108.00 $2,223.00 $2,359.00 $2,108.00 $2,223.00 $2,359.00
45900 10 $120.00 $299.00 $319.00 $343.00 $299.00 $319.00 $343.00
45905 10 $133.00 $248.00 $264.00 $282.00 $248.00 $264.00 $282.00
45910 10 $163.00 $284.00 $302.00 $322.00 $284.00 $302.00 $322.00
45915 10 $142.00 $472.00 $501.00 $523.00 $331.00 $350.00 $371.00
45990 0 ---------- $160.00 $171.00 $184.00 $160.00 $171.00 $184.00
45999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
46020 10 $230.00 $398.00 $424.00 $448.00 $342.00 $364.00 $388.00
46030 10 $94.00 $198.00 $211.00 $222.00 $133.00 $141.00 $151.00
46040 90 $393.00 $770.00 $822.00 $870.00 $607.00 $648.00 $694.00
46045 90 $312.00 $638.00 $682.00 $731.00 $638.00 $682.00 $731.00
46050 10 $105.00 $283.00 $302.00 $313.00 $142.00 $151.00 $161.00
46060 90 $482.00 $697.00 $743.00 $793.00 $697.00 $743.00 $793.00
46080 10 $246.00 $357.00 $381.00 $403.00 $237.00 $253.00 $274.00
46083 10 $98.00 $250.00 $266.00 $277.00 $155.00 $165.00 $175.00
46200 90 $323.00 $634.00 $676.00 $706.00 $471.00 $502.00 $531.00
46220 10 $118.00 $292.00 $311.00 $325.00 $174.00 $185.00 $197.00
46221 10 $124.00 $380.00 $404.00 $421.00 $276.00 $292.00 $308.00
46230 10 $198.00 $390.00 $416.00 $437.00 $254.00 $270.00 $290.00
46250 90 $400.00 $662.00 $706.00 $743.00 $462.00 $493.00 $528.00
46255 90 $501.00 $726.00 $775.00 $817.00 $520.00 $555.00 $595.00
46257 90 $504.00 $617.00 $658.00 $705.00 $617.00 $658.00 $705.00
46258 90 $539.00 $686.00 $736.00 $798.00 $686.00 $736.00 $798.00
46260 90 $598.00 $699.00 $746.00 $801.00 $699.00 $746.00 $801.00
46261 90 $655.00 $768.00 $817.00 $875.00 $768.00 $817.00 $875.00
46262 90 $686.00 $812.00 $864.00 $923.00 $812.00 $864.00 $923.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 243
Surgery
CPT Code FUD 2003 MRALocality 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)
46270 90 $328.00 $729.00 $778.00 $822.00 $572.00 $611.00 $653.00
46275 90 $442.00 $771.00 $821.00 $864.00 $603.00 $642.00 $683.00
46280 90 $514.00 $685.00 $729.00 $776.00 $685.00 $729.00 $776.00
46285 90 $335.00 $766.00 $816.00 $857.00 $602.00 $641.00 $681.00
46288 90 $521.00 $807.00 $858.00 $917.00 $807.00 $858.00 $917.00
46320 10 $126.00 $262.00 $279.00 $292.00 $163.00 $174.00 $186.00
46500 10 $109.00 $265.00 $282.00 $293.00 $178.00 $189.00 $199.00
46505 10 ---------- $410.00 $436.00 $461.00 $348.00 $370.00 $394.00
46600 0 $38.00 $124.00 $132.00 $136.00 $60.00 $63.00 $67.00
46601 0 ---------- $193.00 $203.00 $210.00 $137.00 $143.00 $149.00
46604 0 $92.00 $854.00 $911.00 $926.00 $98.00 $104.00 $111.00
46606 0 $66.00 $316.00 $336.00 $347.00 $112.00 $119.00 $127.00
46607 0 ---------- $273.00 $289.00 $300.00 $186.00 $196.00 $206.00
46608 0 $115.00 $329.00 $352.00 $367.00 $125.00 $134.00 $146.00
46610 0 $114.00 $320.00 $341.00 $354.00 $121.00 $129.00 $140.00
46611 0 $149.00 $249.00 $265.00 $275.00 $120.00 $128.00 $137.00
46612 0 $196.00 $350.00 $374.00 $388.00 $137.00 $146.00 $158.00
46614 0 $169.00 $181.00 $193.00 $200.00 $95.00 $101.00 $107.00
46615 0 $202.00 $205.00 $219.00 $231.00 $137.00 $146.00 $158.00
46700 90 $585.00 $961.00 $1,021.00 $1,090.00 $961.00 $1,021.00 $1,090.00
46706 10 $140.00 $259.00 $277.00 $301.00 $259.00 $277.00 $301.00
46707 90 ---------- $691.00 $737.00 $790.00 $691.00 $737.00 $790.00
46710 90 ---------- $1,534.00 $1,623.00 $1,729.00 $1,534.00 $1,623.00 $1,729.00
46712 90 ---------- $3,119.00 $3,293.00 $3,505.00 $3,119.00 $3,293.00 $3,505.00
46715 90 $545.00 $803.00 $862.00 $937.00 $803.00 $862.00 $937.00
46716 90 $906.00 $1,620.00 $1,710.00 $1,808.00 $1,620.00 $1,710.00 $1,808.00
46730 90 $1,584.00 $2,675.00 $2,821.00 $2,991.00 $2,675.00 $2,821.00 $2,991.00
46735 90 $1,881.00 $3,101.00 $3,270.00 $3,470.00 $3,101.00 $3,270.00 $3,470.00
46740 90 $1,671.00 $2,989.00 $3,157.00 $3,355.00 $2,989.00 $3,157.00 $3,355.00
46742 90 $2,236.00 $3,999.00 $4,246.00 $4,525.00 $3,999.00 $4,246.00 $4,525.00
46744 90 $2,412.00 $5,308.00 $5,703.00 $6,270.00 $5,308.00 $5,703.00 $6,270.00
46746 90 $2,725.00 $5,285.00 $5,561.00 $5,906.00 $5,285.00 $5,561.00 $5,906.00
46748 90 $2,933.00 $5,851.00 $6,165.00 $6,558.00 $5,851.00 $6,165.00 $6,558.00
46750 90 $636.00 $1,107.00 $1,170.00 $1,243.00 $1,107.00 $1,170.00 $1,243.00
46753 90 $511.00 $845.00 $894.00 $946.00 $845.00 $894.00 $946.00
46754 10 $188.00 $416.00 $437.00 $448.00 $325.00 $340.00 $350.00
46760 90 $846.00 $1,622.00 $1,715.00 $1,819.00 $1,622.00 $1,715.00 $1,819.00
46761 90 $813.00 $1,357.00 $1,434.00 $1,526.00 $1,357.00 $1,434.00 $1,526.00
46762 90 $731.00 $1,338.00 $1,411.00 $1,494.00 $1,338.00 $1,411.00 $1,494.00
46900 10 $128.00 $341.00 $363.00 $376.00 $199.00 $211.00 $223.00
46910 10 $144.00 $362.00 $385.00 $400.00 $195.00 $207.00 $221.00
46916 10 $145.00 $325.00 $345.00 $357.00 $208.00 $219.00 $231.00
46917 10 $228.00 $632.00 $672.00 $688.00 $193.00 $204.00 $214.00
46922 10 $189.00 $377.00 $403.00 $420.00 $199.00 $212.00 $227.00
46924 10 $297.00 $745.00 $793.00 $817.00 $269.00 $285.00 $304.00
46930 90 ---------- $290.00 $308.00 $318.00 $210.00 $223.00 $233.00
46940 10 $165.00 $326.00 $346.00 $362.00 $215.00 $228.00 $243.00
46942 10 $145.00 $307.00 $326.00 $340.00 $193.00 $204.00 $217.00
46945 90 $199.00 $437.00 $466.00 $485.00 $325.00 $346.00 $364.00
46946 90 $270.00 $445.00 $474.00 $495.00 $326.00 $347.00 $367.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 244
Surgery
CPT Code FUD 2003 MRALocality 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)
46947 90 ---------- $564.00 $603.00 $651.00 $564.00 $603.00 $651.00
46999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
47000 0 $218.00 $424.00 $450.00 $459.00 $132.00 $138.00 $144.00
47001 ZZZ $141.00 $158.00 $170.00 $188.00 $158.00 $170.00 $188.00
47010 90 $788.00 $1,806.00 $1,936.00 $2,116.00 $1,806.00 $1,936.00 $2,116.00
47015 90 $755.00 $1,740.00 $1,867.00 $2,042.00 $1,740.00 $1,867.00 $2,042.00
47100 90 $550.00 $1,259.00 $1,350.00 $1,471.00 $1,259.00 $1,350.00 $1,471.00
47120 90 $1,663.00 $3,506.00 $3,764.00 $4,131.00 $3,506.00 $3,764.00 $4,131.00
47122 90 $2,512.00 $5,174.00 $5,553.00 $6,108.00 $5,174.00 $5,553.00 $6,108.00
47125 90 $2,293.00 $4,637.00 $4,977.00 $5,474.00 $4,637.00 $4,977.00 $5,474.00
47130 90 $2,482.00 $4,984.00 $5,349.00 $5,885.00 $4,984.00 $5,349.00 $5,885.00
47135 90 $6,164.00 $8,076.00 $8,666.00 $9,510.00 $8,076.00 $8,666.00 $9,510.00
47146 0 ---------- $502.00 $539.00 $596.00 $502.00 $539.00 $596.00
47147 0 ---------- $581.00 $624.00 $689.00 $581.00 $624.00 $689.00
47300 90 $778.00 $1,695.00 $1,818.00 $1,985.00 $1,695.00 $1,818.00 $1,985.00
47350 90 $942.00 $2,051.00 $2,199.00 $2,404.00 $2,051.00 $2,199.00 $2,404.00
47360 90 $1,305.00 $2,780.00 $2,977.00 $3,256.00 $2,780.00 $2,977.00 $3,256.00
47361 90 $2,129.00 $4,573.00 $4,903.00 $5,384.00 $4,573.00 $4,903.00 $5,384.00
47362 90 $849.00 $2,179.00 $2,339.00 $2,564.00 $2,179.00 $2,339.00 $2,564.00
47370 90 $943.00 $1,876.00 $2,013.00 $2,208.00 $1,876.00 $2,013.00 $2,208.00
47371 90 $889.00 $1,857.00 $1,983.00 $2,158.00 $1,857.00 $1,983.00 $2,158.00
47379 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
47380 90 $1,107.00 $2,163.00 $2,316.00 $2,534.00 $2,163.00 $2,316.00 $2,534.00
47381 90 $1,094.00 $2,043.00 $2,153.00 $2,292.00 $2,043.00 $2,153.00 $2,292.00
47382 10 $660.00 $6,646.00 $7,068.00 $7,180.00 $1,106.00 $1,152.00 $1,205.00
47383 10 ---------- $9,294.00 $9,909.00 $10,031.00 $667.00 $695.00 $727.00
47399 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
47400 90 $1,435.00 $3,209.00 $3,440.00 $3,770.00 $3,209.00 $3,440.00 $3,770.00
47420 90 $1,222.00 $2,012.00 $2,159.00 $2,365.00 $2,012.00 $2,159.00 $2,365.00
47425 90 $1,275.00 $1,959.00 $2,096.00 $2,289.00 $1,959.00 $2,096.00 $2,289.00
47460 90 $1,039.00 $1,888.00 $2,026.00 $2,218.00 $1,888.00 $2,026.00 $2,218.00
47480 90 $755.00 $1,306.00 $1,401.00 $1,525.00 $1,306.00 $1,401.00 $1,525.00
47490 10 $467.00 $478.00 $501.00 $520.00 $478.00 $501.00 $520.00
47531 0 ---------- $432.00 $459.00 $467.00 $104.00 $109.00 $114.00
47532 0 ---------- $1,111.00 $1,179.00 $1,204.00 $317.00 $331.00 $348.00
47533 0 ---------- $1,709.00 $1,815.00 $1,849.00 $397.00 $414.00 $435.00
47534 0 ---------- $2,038.00 $2,162.00 $2,205.00 $553.00 $575.00 $603.00
47535 0 ---------- $1,401.00 $1,489.00 $1,515.00 $294.00 $306.00 $321.00
47536 0 ---------- $951.00 $1,010.00 $1,028.00 $197.00 $205.00 $214.00
47537 0 ---------- $507.00 $537.00 $548.00 $143.00 $149.00 $155.00
47538 0 ---------- $5,896.00 $6,288.00 $6,363.00 $350.00 $364.00 $382.00
47539 0 ---------- $6,539.00 $6,967.00 $7,060.00 $635.00 $661.00 $692.00
47540 0 ---------- $6,703.00 $7,142.00 $7,238.00 $658.00 $686.00 $719.00
47541 0 ---------- $1,627.00 $1,725.00 $1,763.00 $496.00 $517.00 $543.00
47542 ZZZ ---------- $640.00 $678.00 $693.00 $202.00 $210.00 $220.00
47543 ZZZ ---------- $804.00 $858.00 $887.00 $241.00 $257.00 $280.00
47544 ZZZ ---------- $1,497.00 $1,593.00 $1,621.00 $241.00 $252.00 $267.00
47550 ZZZ $209.00 $251.00 $270.00 $298.00 $251.00 $270.00 $298.00
47552 0 $364.00 $456.00 $475.00 $498.00 $456.00 $475.00 $498.00
47553 0 $342.00 $454.00 $472.00 $496.00 $454.00 $472.00 $496.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 245
Surgery
CPT Code FUD 2003 MRALocality 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)
47554 0 $594.00 $704.00 $741.00 $789.00 $704.00 $741.00 $789.00
47555 0 $383.00 $538.00 $560.00 $587.00 $538.00 $560.00 $587.00
47556 0 $425.00 $614.00 $639.00 $669.00 $614.00 $639.00 $669.00
47562 90 $837.00 $984.00 $1,056.00 $1,155.00 $984.00 $1,056.00 $1,155.00
47563 90 $900.00 $1,070.00 $1,148.00 $1,257.00 $1,070.00 $1,148.00 $1,257.00
47564 90 $1,069.00 $1,669.00 $1,791.00 $1,961.00 $1,669.00 $1,791.00 $1,961.00
47570 90 $961.00 $1,166.00 $1,252.00 $1,374.00 $1,166.00 $1,252.00 $1,374.00
47579 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
47600 90 $868.00 $1,601.00 $1,717.00 $1,880.00 $1,601.00 $1,717.00 $1,880.00
47605 90 $935.00 $1,687.00 $1,810.00 $1,984.00 $1,687.00 $1,810.00 $1,984.00
47610 90 $1,164.00 $1,886.00 $2,024.00 $2,221.00 $1,886.00 $2,024.00 $2,221.00
47612 90 $1,276.00 $1,904.00 $2,042.00 $2,238.00 $1,904.00 $2,042.00 $2,238.00
47620 90 $1,295.00 $2,059.00 $2,209.00 $2,421.00 $2,059.00 $2,209.00 $2,421.00
47700 90 $1,111.00 $1,554.00 $1,666.00 $1,818.00 $1,554.00 $1,666.00 $1,818.00
47701 90 $1,913.00 $2,557.00 $2,733.00 $2,977.00 $2,557.00 $2,733.00 $2,977.00
47711 90 $1,442.00 $2,339.00 $2,510.00 $2,753.00 $2,339.00 $2,510.00 $2,753.00
47712 90 $1,793.00 $3,003.00 $3,223.00 $3,540.00 $3,003.00 $3,223.00 $3,540.00
47715 90 $1,157.00 $1,989.00 $2,134.00 $2,337.00 $1,989.00 $2,134.00 $2,337.00
47720 90 $1,040.00 $1,707.00 $1,829.00 $1,994.00 $1,707.00 $1,829.00 $1,994.00
47721 90 $1,248.00 $2,030.00 $2,180.00 $2,392.00 $2,030.00 $2,180.00 $2,392.00
47740 90 $1,188.00 $1,960.00 $2,102.00 $2,300.00 $1,960.00 $2,102.00 $2,300.00
47741 90 $1,425.00 $2,178.00 $2,335.00 $2,555.00 $2,178.00 $2,335.00 $2,555.00
47760 90 $1,568.00 $3,394.00 $3,643.00 $4,001.00 $3,394.00 $3,643.00 $4,001.00
47765 90 $1,624.00 $4,588.00 $4,928.00 $5,424.00 $4,588.00 $4,928.00 $5,424.00
47780 90 $1,635.00 $3,730.00 $4,004.00 $4,403.00 $3,730.00 $4,004.00 $4,403.00
47785 90 $1,871.00 $4,892.00 $5,249.00 $5,772.00 $4,892.00 $5,249.00 $5,772.00
47800 90 $1,485.00 $2,367.00 $2,538.00 $2,779.00 $2,367.00 $2,538.00 $2,779.00
47801 90 $906.00 $1,479.00 $1,560.00 $1,659.00 $1,479.00 $1,560.00 $1,659.00
47802 90 $1,352.00 $2,291.00 $2,461.00 $2,701.00 $2,291.00 $2,461.00 $2,701.00
47900 90 $1,331.00 $2,060.00 $2,211.00 $2,422.00 $2,060.00 $2,211.00 $2,422.00
47999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
48000 90 $1,053.00 $2,806.00 $3,007.00 $3,296.00 $2,806.00 $3,007.00 $3,296.00
48001 90 $1,305.00 $3,492.00 $3,752.00 $4,134.00 $3,492.00 $3,752.00 $4,134.00
48020 90 $983.00 $1,741.00 $1,866.00 $2,040.00 $1,741.00 $1,866.00 $2,040.00
48100 90 $779.00 $1,334.00 $1,431.00 $1,566.00 $1,334.00 $1,431.00 $1,566.00
48102 10 $341.00 $747.00 $789.00 $810.00 $355.00 $370.00 $387.00
48105 90 ---------- $4,293.00 $4,604.00 $5,056.00 $4,293.00 $4,604.00 $5,056.00
48120 90 $1,083.00 $1,663.00 $1,784.00 $1,955.00 $1,663.00 $1,784.00 $1,955.00
48140 90 $1,546.00 $2,353.00 $2,526.00 $2,772.00 $2,353.00 $2,526.00 $2,772.00
48145 90 $1,661.00 $2,442.00 $2,620.00 $2,874.00 $2,442.00 $2,620.00 $2,874.00
48146 90 $1,830.00 $2,812.00 $3,017.00 $3,305.00 $2,812.00 $3,017.00 $3,305.00
48148 90 $1,149.00 $1,869.00 $2,007.00 $2,204.00 $1,869.00 $2,007.00 $2,204.00
48150 90 $3,101.00 $4,696.00 $5,042.00 $5,545.00 $4,696.00 $5,042.00 $5,545.00
48152 90 $2,888.00 $4,350.00 $4,672.00 $5,136.00 $4,350.00 $4,672.00 $5,136.00
48153 90 $3,099.00 $4,668.00 $5,011.00 $5,507.00 $4,668.00 $5,011.00 $5,507.00
48154 90 $2,893.00 $4,347.00 $4,667.00 $5,130.00 $4,347.00 $4,667.00 $5,130.00
48155 90 $1,855.00 $2,729.00 $2,929.00 $3,210.00 $2,729.00 $2,929.00 $3,210.00
48160 0 BR ---------- ---------- ---------- ---------- ---------- ----------
48400 ZZZ $100.00 $161.00 $171.00 $187.00 $161.00 $171.00 $187.00
48500 90 $1,012.00 $1,683.00 $1,796.00 $1,944.00 $1,683.00 $1,796.00 $1,944.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 246
Surgery
CPT Code FUD 2003 MRALocality 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)
48510 90 $938.00 $1,629.00 $1,746.00 $1,904.00 $1,629.00 $1,746.00 $1,904.00
48520 90 $1,103.00 $1,639.00 $1,756.00 $1,922.00 $1,639.00 $1,756.00 $1,922.00
48540 90 $1,350.00 $1,974.00 $2,120.00 $2,329.00 $1,974.00 $2,120.00 $2,329.00
48545 90 $1,170.00 $2,023.00 $2,173.00 $2,387.00 $2,023.00 $2,173.00 $2,387.00
48547 90 $1,630.00 $2,683.00 $2,876.00 $3,152.00 $2,683.00 $2,876.00 $3,152.00
48548 90 ---------- $2,493.00 $2,673.00 $2,931.00 $2,493.00 $2,673.00 $2,931.00
48552 0 ---------- $356.00 $381.00 $421.00 $356.00 $381.00 $421.00
48554 90 $2,365.00 $3,799.00 $4,072.00 $4,425.00 $3,799.00 $4,072.00 $4,425.00
48556 90 $1,117.00 $1,893.00 $2,032.00 $2,216.00 $1,893.00 $2,032.00 $2,216.00
48999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
49000 90 $862.00 $1,152.00 $1,234.00 $1,346.00 $1,152.00 $1,234.00 $1,346.00
49002 90 $784.00 $1,570.00 $1,682.00 $1,841.00 $1,570.00 $1,682.00 $1,841.00
49010 90 $915.00 $1,402.00 $1,500.00 $1,638.00 $1,402.00 $1,500.00 $1,638.00
49020 90 $910.00 $2,388.00 $2,559.00 $2,799.00 $2,388.00 $2,559.00 $2,799.00
49040 90 $763.00 $1,497.00 $1,603.00 $1,751.00 $1,497.00 $1,603.00 $1,751.00
49060 90 $827.00 $1,646.00 $1,761.00 $1,922.00 $1,646.00 $1,761.00 $1,922.00
49062 90 $892.00 $1,106.00 $1,184.00 $1,290.00 $1,106.00 $1,184.00 $1,290.00
49082 0 ---------- $269.00 $286.00 $294.00 $109.00 $115.00 $121.00
49083 0 ---------- $409.00 $433.00 $443.00 $159.00 $166.00 $174.00
49084 0 ---------- $164.00 $175.00 $192.00 $164.00 $175.00 $192.00
49180 0 $212.00 $230.00 $242.00 $249.00 $126.00 $131.00 $137.00
49185 0 ---------- $1,344.00 $1,431.00 $1,452.00 $179.00 $187.00 $196.00
49203 90 ---------- $1,793.00 $1,917.00 $2,090.00 $1,793.00 $1,917.00 $2,090.00
49204 90 ---------- $2,300.00 $2,460.00 $2,685.00 $2,300.00 $2,460.00 $2,685.00
49205 90 ---------- $2,644.00 $2,831.00 $3,096.00 $2,644.00 $2,831.00 $3,096.00
49215 90 $1,551.00 $3,323.00 $3,549.00 $3,862.00 $3,323.00 $3,549.00 $3,862.00
49220 90 $1,182.00 $1,460.00 $1,568.00 $1,720.00 $1,460.00 $1,568.00 $1,720.00
49250 90 $622.00 $877.00 $939.00 $1,022.00 $877.00 $939.00 $1,022.00
49255 90 $591.00 $1,180.00 $1,262.00 $1,372.00 $1,180.00 $1,262.00 $1,372.00
49320 10 $415.00 $483.00 $516.00 $558.00 $483.00 $516.00 $558.00
49321 10 $443.00 $513.00 $548.00 $594.00 $513.00 $548.00 $594.00
49322 10 $460.00 $548.00 $584.00 $631.00 $548.00 $584.00 $631.00
49323 90 $712.00 $946.00 $1,009.00 $1,090.00 $946.00 $1,009.00 $1,090.00
49324 10 ---------- $582.00 $623.00 $680.00 $582.00 $623.00 $680.00
49325 10 ---------- $621.00 $666.00 $727.00 $621.00 $666.00 $727.00
49326 ZZZ ---------- $287.00 $308.00 $341.00 $287.00 $308.00 $341.00
49327 ZZZ ---------- $199.00 $213.00 $236.00 $199.00 $213.00 $236.00
49329 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
49400 0 $127.00 $193.00 $204.00 $213.00 $138.00 $145.00 $153.00
49402 90 ---------- $1,283.00 $1,375.00 $1,503.00 $1,283.00 $1,375.00 $1,503.00
49405 0 ---------- $1,116.00 $1,184.00 $1,207.00 $293.00 $305.00 $319.00
49406 0 ---------- $1,116.00 $1,184.00 $1,207.00 $293.00 $305.00 $319.00
49407 0 ---------- $911.00 $965.00 $987.00 $312.00 $325.00 $342.00
49411 0 ---------- $672.00 $710.00 $727.00 $271.00 $282.00 $295.00
49412 ZZZ ---------- $124.00 $133.00 $146.00 $124.00 $133.00 $146.00
49418 0 ---------- $1,875.00 $1,996.00 $2,029.00 $302.00 $316.00 $333.00
49419 90 $405.00 $661.00 $705.00 $762.00 $661.00 $705.00 $762.00
49421 0 $452.00 $348.00 $372.00 $410.00 $348.00 $372.00 $410.00
49422 10 $468.00 $569.00 $610.00 $666.00 $569.00 $610.00 $666.00
49423 0 $106.00 $751.00 $799.00 $811.00 $106.00 $110.00 $115.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 247
Surgery
CPT Code FUD 2003 MRALocality 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)
49424 0 $54.00 $202.00 $214.00 $219.00 $56.00 $59.00 $62.00
49425 90 $914.00 $1,072.00 $1,141.00 $1,233.00 $1,072.00 $1,141.00 $1,233.00
49426 90 $725.00 $914.00 $978.00 $1,067.00 $914.00 $978.00 $1,067.00
49427 0 $48.00 $68.00 $72.00 $77.00 $68.00 $72.00 $77.00
49428 10 $184.00 $693.00 $751.00 $833.00 $693.00 $751.00 $833.00
49429 10 $522.00 $690.00 $741.00 $813.00 $690.00 $741.00 $813.00
49435 ZZZ ---------- $182.00 $195.00 $216.00 $182.00 $195.00 $216.00
49436 10 ---------- $277.00 $298.00 $324.00 $277.00 $298.00 $324.00
49440 10 ---------- $1,338.00 $1,421.00 $1,447.00 $305.00 $319.00 $334.00
49441 10 ---------- $1,512.00 $1,609.00 $1,643.00 $359.00 $377.00 $399.00
49442 10 ---------- $1,256.00 $1,334.00 $1,358.00 $306.00 $320.00 $333.00
49446 0 ---------- $1,282.00 $1,363.00 $1,386.00 $221.00 $230.00 $242.00
49450 0 ---------- $913.00 $972.00 $986.00 $99.00 $103.00 $108.00
49451 0 ---------- $999.00 $1,064.00 $1,080.00 $134.00 $140.00 $147.00
49452 0 ---------- $1,237.00 $1,315.00 $1,336.00 $206.00 $214.00 $224.00
49460 0 ---------- $1,007.00 $1,074.00 $1,088.00 $71.00 $74.00 $78.00
49465 0 ---------- $226.00 $240.00 $244.00 $46.00 $47.00 $49.00
49505 90 $510.00 $776.00 $832.00 $907.00 $776.00 $832.00 $907.00
49507 90 $636.00 $873.00 $937.00 $1,022.00 $873.00 $937.00 $1,022.00
49520 90 $631.00 $945.00 $1,013.00 $1,108.00 $945.00 $1,013.00 $1,108.00
49521 90 $730.00 $1,072.00 $1,151.00 $1,259.00 $1,072.00 $1,151.00 $1,259.00
49525 90 $584.00 $855.00 $917.00 $1,001.00 $855.00 $917.00 $1,001.00
49540 90 $668.00 $1,007.00 $1,081.00 $1,181.00 $1,007.00 $1,081.00 $1,181.00
49550 90 $557.00 $859.00 $922.00 $1,006.00 $859.00 $922.00 $1,006.00
49553 90 $598.00 $942.00 $1,011.00 $1,104.00 $942.00 $1,011.00 $1,104.00
49555 90 $621.00 $893.00 $958.00 $1,046.00 $893.00 $958.00 $1,046.00
49557 90 $715.00 $1,084.00 $1,164.00 $1,273.00 $1,084.00 $1,164.00 $1,273.00
49560 90 $734.00 $1,104.00 $1,184.00 $1,294.00 $1,104.00 $1,184.00 $1,294.00
49561 90 $856.00 $1,395.00 $1,497.00 $1,640.00 $1,395.00 $1,497.00 $1,640.00
49565 90 $754.00 $1,149.00 $1,232.00 $1,346.00 $1,149.00 $1,232.00 $1,346.00
49566 90 $881.00 $1,408.00 $1,510.00 $1,654.00 $1,408.00 $1,510.00 $1,654.00
49568 ZZZ $339.00 $405.00 $435.00 $479.00 $405.00 $435.00 $479.00
49570 90 $411.00 $618.00 $663.00 $720.00 $618.00 $663.00 $720.00
49572 90 $491.00 $769.00 $825.00 $900.00 $769.00 $825.00 $900.00
49585 90 $444.00 $661.00 $709.00 $771.00 $661.00 $709.00 $771.00
49587 90 $501.00 $706.00 $758.00 $825.00 $706.00 $758.00 $825.00
49590 90 $585.00 $855.00 $917.00 $1,001.00 $855.00 $917.00 $1,001.00
49600 90 $774.00 $963.00 $1,009.00 $1,060.00 $963.00 $1,009.00 $1,060.00
49605 90 $1,648.00 $7,483.00 $8,042.00 $8,876.00 $7,483.00 $8,042.00 $8,876.00
49606 90 $1,416.00 $1,707.00 $1,834.00 $2,018.00 $1,707.00 $1,834.00 $2,018.00
49610 90 $784.00 $959.00 $1,012.00 $1,077.00 $959.00 $1,012.00 $1,077.00
49611 90 $770.00 $823.00 $868.00 $920.00 $823.00 $868.00 $920.00
49650 90 $484.00 $637.00 $683.00 $743.00 $637.00 $683.00 $743.00
49651 90 $621.00 $829.00 $889.00 $968.00 $829.00 $889.00 $968.00
49652 90 ---------- $1,113.00 $1,194.00 $1,305.00 $1,113.00 $1,194.00 $1,305.00
49653 90 ---------- $1,389.00 $1,490.00 $1,630.00 $1,389.00 $1,490.00 $1,630.00
49654 90 ---------- $1,267.00 $1,360.00 $1,488.00 $1,267.00 $1,360.00 $1,488.00
49655 90 ---------- $1,547.00 $1,660.00 $1,817.00 $1,547.00 $1,660.00 $1,817.00
49656 90 ---------- $1,376.00 $1,476.00 $1,616.00 $1,376.00 $1,476.00 $1,616.00
49657 90 ---------- $1,985.00 $2,129.00 $2,335.00 $1,985.00 $2,129.00 $2,335.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 248
Surgery
CPT Code FUD 2003 MRALocality 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)
49659 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
49900 90 $512.00 $1,212.00 $1,298.00 $1,410.00 $1,212.00 $1,298.00 $1,410.00
49904 90 $1,394.00 $2,112.00 $2,256.00 $2,444.00 $2,112.00 $2,256.00 $2,444.00
49905 ZZZ $454.00 $534.00 $571.00 $626.00 $534.00 $571.00 $626.00
49906 90 BR ---------- ---------- ---------- ---------- ---------- ----------
49999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
50010 90 $886.00 $1,092.00 $1,158.00 $1,240.00 $1,092.00 $1,158.00 $1,240.00
50020 90 $1,084.00 $1,488.00 $1,561.00 $1,645.00 $1,488.00 $1,561.00 $1,645.00
50040 90 $910.00 $1,358.00 $1,424.00 $1,500.00 $1,358.00 $1,424.00 $1,500.00
50045 90 $1,137.00 $1,381.00 $1,451.00 $1,535.00 $1,381.00 $1,451.00 $1,535.00
50060 90 $1,394.00 $1,674.00 $1,754.00 $1,848.00 $1,674.00 $1,754.00 $1,848.00
50065 90 $1,514.00 $1,775.00 $1,860.00 $1,960.00 $1,775.00 $1,860.00 $1,960.00
50070 90 $1,476.00 $1,825.00 $1,923.00 $2,044.00 $1,825.00 $1,923.00 $2,044.00
50075 90 $1,839.00 $2,144.00 $2,247.00 $2,371.00 $2,144.00 $2,247.00 $2,371.00
50080 90 $1,186.00 $1,275.00 $1,336.00 $1,408.00 $1,275.00 $1,336.00 $1,408.00
50081 90 $1,635.00 $1,873.00 $1,963.00 $2,069.00 $1,873.00 $1,963.00 $2,069.00
50100 90 $1,250.00 $1,626.00 $1,730.00 $1,860.00 $1,626.00 $1,730.00 $1,860.00
50120 90 $1,180.00 $1,419.00 $1,493.00 $1,584.00 $1,419.00 $1,493.00 $1,584.00
50125 90 $1,228.00 $1,511.00 $1,593.00 $1,691.00 $1,511.00 $1,593.00 $1,691.00
50130 90 $1,301.00 $1,513.00 $1,586.00 $1,670.00 $1,513.00 $1,586.00 $1,670.00
50135 90 $1,506.00 $1,646.00 $1,725.00 $1,818.00 $1,646.00 $1,725.00 $1,818.00
50200 0 $151.00 $740.00 $787.00 $802.00 $190.00 $199.00 $209.00
50205 90 $807.00 $1,126.00 $1,205.00 $1,313.00 $1,126.00 $1,205.00 $1,313.00
50220 90 $1,316.00 $1,542.00 $1,625.00 $1,728.00 $1,542.00 $1,625.00 $1,728.00
50225 90 $1,554.00 $1,768.00 $1,859.00 $1,971.00 $1,768.00 $1,859.00 $1,971.00
50230 90 $1,695.00 $1,887.00 $1,980.00 $2,095.00 $1,887.00 $1,980.00 $2,095.00
50234 90 $1,671.00 $1,913.00 $2,007.00 $2,120.00 $1,913.00 $2,007.00 $2,120.00
50236 90 $1,873.00 $2,155.00 $2,259.00 $2,384.00 $2,155.00 $2,259.00 $2,384.00
50240 90 $1,679.00 $1,943.00 $2,037.00 $2,149.00 $1,943.00 $2,037.00 $2,149.00
50250 90 ---------- $1,774.00 $1,858.00 $1,957.00 $1,774.00 $1,858.00 $1,957.00
50280 90 $1,170.00 $1,409.00 $1,482.00 $1,570.00 $1,409.00 $1,482.00 $1,570.00
50290 90 $1,080.00 $1,316.00 $1,380.00 $1,454.00 $1,316.00 $1,380.00 $1,454.00
50320 90 $1,680.00 $2,241.00 $2,406.00 $2,624.00 $2,241.00 $2,406.00 $2,624.00
50327 0 ---------- $328.00 $352.00 $387.00 $328.00 $352.00 $387.00
50328 0 ---------- $288.00 $308.00 $339.00 $288.00 $308.00 $339.00
50329 0 ---------- $271.00 $289.00 $316.00 $271.00 $289.00 $316.00
50340 90 $1,083.00 $1,408.00 $1,511.00 $1,646.00 $1,408.00 $1,511.00 $1,646.00
50360 90 $2,475.00 $3,624.00 $3,884.00 $4,247.00 $3,624.00 $3,884.00 $4,247.00
50365 90 $2,941.00 $4,269.00 $4,571.00 $4,983.00 $4,269.00 $4,571.00 $4,983.00
50370 90 $1,128.00 $1,792.00 $1,919.00 $2,089.00 $1,792.00 $1,919.00 $2,089.00
50380 90 $1,507.00 $2,863.00 $3,065.00 $3,333.00 $2,863.00 $3,065.00 $3,333.00
50382 0 ---------- $1,534.00 $1,629.00 $1,660.00 $380.00 $396.00 $415.00
50384 0 ---------- $1,207.00 $1,279.00 $1,306.00 $343.00 $357.00 $375.00
50385 0 ---------- $1,491.00 $1,585.00 $1,614.00 $323.00 $337.00 $355.00
50386 0 ---------- $953.00 $1,013.00 $1,034.00 $241.00 $253.00 $267.00
50387 0 ---------- $675.00 $718.00 $730.00 $125.00 $130.00 $136.00
50389 0 ---------- $410.00 $435.00 $443.00 $80.00 $83.00 $87.00
50390 0 $118.00 $142.00 $147.00 $154.00 $142.00 $147.00 $154.00
50391 0 ---------- $176.00 $184.00 $192.00 $144.00 $150.00 $158.00
50395 0 $203.00 $261.00 $273.00 $286.00 $261.00 $273.00 $286.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 249
Surgery
CPT Code FUD 2003 MRALocality 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)
50396 0 $101.00 $171.00 $178.00 $186.00 $171.00 $178.00 $186.00
50400 90 $1,441.00 $1,701.00 $1,784.00 $1,882.00 $1,701.00 $1,784.00 $1,882.00
50405 90 $1,802.00 $2,054.00 $2,153.00 $2,271.00 $2,054.00 $2,153.00 $2,271.00
50430 0 ---------- $634.00 $672.00 $686.00 $225.00 $235.00 $245.00
50431 0 ---------- $227.00 $240.00 $246.00 $97.00 $101.00 $105.00
50432 0 ---------- $1,069.00 $1,134.00 $1,156.00 $305.00 $318.00 $332.00
50433 0 ---------- $1,461.00 $1,550.00 $1,580.00 $381.00 $397.00 $415.00
50434 0 ---------- $1,146.00 $1,217.00 $1,240.00 $288.00 $300.00 $314.00
50435 0 ---------- $650.00 $691.00 $703.00 $148.00 $154.00 $161.00
50500 90 $1,471.00 $1,702.00 $1,785.00 $1,884.00 $1,702.00 $1,785.00 $1,884.00
50520 90 $1,281.00 $1,511.00 $1,583.00 $1,666.00 $1,511.00 $1,583.00 $1,666.00
50525 90 $1,644.00 $2,390.00 $2,584.00 $2,860.00 $2,390.00 $2,584.00 $2,860.00
50526 90 $1,639.00 $2,202.00 $2,338.00 $2,524.00 $2,202.00 $2,338.00 $2,524.00
50540 90 $1,468.00 $1,669.00 $1,745.00 $1,831.00 $1,669.00 $1,745.00 $1,831.00
50541 90 $1,037.00 $1,349.00 $1,414.00 $1,490.00 $1,349.00 $1,414.00 $1,490.00
50542 90 $1,093.00 $1,711.00 $1,793.00 $1,890.00 $1,711.00 $1,793.00 $1,890.00
50543 90 $1,374.00 $2,184.00 $2,289.00 $2,413.00 $2,184.00 $2,289.00 $2,413.00
50544 90 $1,428.00 $1,832.00 $1,920.00 $2,026.00 $1,832.00 $1,920.00 $2,026.00
50545 90 $1,273.00 $1,970.00 $2,065.00 $2,180.00 $1,970.00 $2,065.00 $2,180.00
50546 90 $1,325.00 $1,769.00 $1,858.00 $1,965.00 $1,769.00 $1,858.00 $1,965.00
50547 90 $1,702.00 $2,399.00 $2,563.00 $2,783.00 $2,399.00 $2,563.00 $2,783.00
50548 90 $1,555.00 $1,982.00 $2,077.00 $2,193.00 $1,982.00 $2,077.00 $2,193.00
50549 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
50551 0 $411.00 $522.00 $548.00 $575.00 $434.00 $455.00 $480.00
50553 0 $447.00 $556.00 $584.00 $611.00 $461.00 $482.00 $508.00
50555 0 $668.00 $598.00 $628.00 $658.00 $503.00 $526.00 $555.00
50557 0 $676.00 $609.00 $640.00 $670.00 $510.00 $535.00 $564.00
50561 0 $755.00 $689.00 $724.00 $759.00 $581.00 $608.00 $642.00
50562 90 $580.00 $854.00 $895.00 $943.00 $854.00 $895.00 $943.00
50570 0 $549.00 $728.00 $763.00 $807.00 $728.00 $763.00 $807.00
50572 0 $728.00 $785.00 $822.00 $868.00 $785.00 $822.00 $868.00
50574 0 $762.00 $834.00 $873.00 $922.00 $834.00 $873.00 $922.00
50575 0 $991.00 $1,055.00 $1,105.00 $1,168.00 $1,055.00 $1,105.00 $1,168.00
50576 0 $801.00 $832.00 $871.00 $920.00 $832.00 $871.00 $920.00
50580 0 $726.00 $897.00 $939.00 $992.00 $897.00 $939.00 $992.00
50590 90 $980.00 $1,034.00 $1,089.00 $1,136.00 $830.00 $870.00 $915.00
50592 10 ---------- $1,707.00 $1,810.00 $1,846.00 $508.00 $530.00 $554.00
50593 10 ---------- $6,200.00 $6,604.00 $6,694.00 $682.00 $710.00 $743.00
50600 90 $1,150.00 $1,383.00 $1,451.00 $1,531.00 $1,383.00 $1,451.00 $1,531.00
50605 90 $1,054.00 $1,467.00 $1,562.00 $1,690.00 $1,467.00 $1,562.00 $1,690.00
50606 ZZZ ---------- $973.00 $1,033.00 $1,054.00 $231.00 $241.00 $254.00
50610 90 $1,209.00 $1,420.00 $1,490.00 $1,572.00 $1,420.00 $1,490.00 $1,572.00
50620 90 $1,152.00 $1,322.00 $1,385.00 $1,457.00 $1,322.00 $1,385.00 $1,457.00
50630 90 $1,170.00 $1,316.00 $1,380.00 $1,454.00 $1,316.00 $1,380.00 $1,454.00
50650 90 $1,297.00 $1,520.00 $1,594.00 $1,682.00 $1,520.00 $1,594.00 $1,682.00
50660 90 $1,426.00 $1,703.00 $1,789.00 $1,893.00 $1,703.00 $1,789.00 $1,893.00
50684 0 $74.00 $149.00 $158.00 $162.00 $73.00 $77.00 $80.00
50686 0 $109.00 $208.00 $220.00 $227.00 $131.00 $138.00 $145.00
50688 10 $89.00 $115.00 $120.00 $125.00 $115.00 $120.00 $125.00
50690 0 $85.00 $140.00 $148.00 $153.00 $103.00 $107.00 $112.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 250
Surgery
CPT Code FUD 2003 MRALocality 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)
50693 0 ---------- $1,362.00 $1,447.00 $1,472.00 $302.00 $314.00 $329.00
50694 0 ---------- $1,499.00 $1,590.00 $1,621.00 $395.00 $412.00 $431.00
50695 0 ---------- $1,841.00 $1,953.00 $1,992.00 $507.00 $528.00 $553.00
50700 90 $1,192.00 $1,353.00 $1,419.00 $1,494.00 $1,353.00 $1,419.00 $1,494.00
50705 ZZZ ---------- $2,656.00 $2,829.00 $2,871.00 $295.00 $308.00 $324.00
50706 ZZZ ---------- $1,377.00 $1,464.00 $1,491.00 $278.00 $290.00 $306.00
50715 90 $1,397.00 $1,816.00 $1,933.00 $2,089.00 $1,816.00 $1,933.00 $2,089.00
50722 90 $1,211.00 $1,548.00 $1,636.00 $1,746.00 $1,548.00 $1,636.00 $1,746.00
50725 90 $1,371.00 $1,659.00 $1,745.00 $1,852.00 $1,659.00 $1,745.00 $1,852.00
50727 90 $640.00 $744.00 $783.00 $826.00 $744.00 $783.00 $826.00
50728 90 $924.00 $1,021.00 $1,070.00 $1,125.00 $1,021.00 $1,070.00 $1,125.00
50740 90 $1,386.00 $1,819.00 $1,951.00 $2,137.00 $1,819.00 $1,951.00 $2,137.00
50750 90 $1,457.00 $1,681.00 $1,758.00 $1,847.00 $1,681.00 $1,758.00 $1,847.00
50760 90 $1,389.00 $1,661.00 $1,752.00 $1,867.00 $1,661.00 $1,752.00 $1,867.00
50770 90 $1,485.00 $1,731.00 $1,822.00 $1,936.00 $1,731.00 $1,822.00 $1,936.00
50780 90 $1,391.00 $1,631.00 $1,717.00 $1,823.00 $1,631.00 $1,717.00 $1,823.00
50782 90 $1,465.00 $1,786.00 $1,914.00 $2,092.00 $1,786.00 $1,914.00 $2,092.00
50783 90 $1,515.00 $1,664.00 $1,746.00 $1,844.00 $1,664.00 $1,746.00 $1,844.00
50785 90 $1,548.00 $1,783.00 $1,871.00 $1,977.00 $1,783.00 $1,871.00 $1,977.00
50800 90 $1,226.00 $1,354.00 $1,421.00 $1,499.00 $1,354.00 $1,421.00 $1,499.00
50810 90 $1,527.00 $2,037.00 $2,175.00 $2,362.00 $2,037.00 $2,175.00 $2,362.00
50815 90 $1,643.00 $1,799.00 $1,887.00 $1,990.00 $1,799.00 $1,887.00 $1,990.00
50820 90 $1,729.00 $1,933.00 $2,029.00 $2,145.00 $1,933.00 $2,029.00 $2,145.00
50825 90 $2,351.00 $2,440.00 $2,561.00 $2,709.00 $2,440.00 $2,561.00 $2,709.00
50830 90 $2,292.00 $2,678.00 $2,813.00 $2,980.00 $2,678.00 $2,813.00 $2,980.00
50840 90 $1,493.00 $1,806.00 $1,894.00 $1,997.00 $1,806.00 $1,894.00 $1,997.00
50845 90 $1,513.00 $1,833.00 $1,922.00 $2,025.00 $1,833.00 $1,922.00 $2,025.00
50860 90 $1,163.00 $1,398.00 $1,468.00 $1,551.00 $1,398.00 $1,468.00 $1,551.00
50900 90 $1,043.00 $1,264.00 $1,333.00 $1,416.00 $1,264.00 $1,333.00 $1,416.00
50920 90 $1,075.00 $1,344.00 $1,414.00 $1,496.00 $1,344.00 $1,414.00 $1,496.00
50930 90 $1,380.00 $1,616.00 $1,692.00 $1,781.00 $1,616.00 $1,692.00 $1,781.00
50940 90 $1,107.00 $1,291.00 $1,352.00 $1,419.00 $1,291.00 $1,352.00 $1,419.00
50945 90 $1,096.00 $1,435.00 $1,506.00 $1,590.00 $1,435.00 $1,506.00 $1,590.00
50947 90 $1,384.00 $2,040.00 $2,139.00 $2,259.00 $2,040.00 $2,139.00 $2,259.00
50948 90 $1,265.00 $1,876.00 $1,966.00 $2,075.00 $1,876.00 $1,966.00 $2,075.00
50949 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
50951 0 $414.00 $545.00 $573.00 $600.00 $452.00 $473.00 $500.00
50953 0 $461.00 $576.00 $605.00 $634.00 $480.00 $502.00 $530.00
50955 0 $546.00 $617.00 $648.00 $679.00 $519.00 $544.00 $574.00
50957 0 $546.00 $623.00 $655.00 $686.00 $523.00 $548.00 $578.00
50961 0 $510.00 $561.00 $590.00 $619.00 $468.00 $490.00 $518.00
50970 0 $510.00 $546.00 $572.00 $603.00 $546.00 $572.00 $603.00
50972 0 $408.00 $528.00 $552.00 $583.00 $528.00 $552.00 $583.00
50974 0 $661.00 $698.00 $730.00 $771.00 $698.00 $730.00 $771.00
50976 0 $641.00 $688.00 $720.00 $760.00 $688.00 $720.00 $760.00
50980 0 $443.00 $525.00 $549.00 $580.00 $525.00 $549.00 $580.00
51020 90 $587.00 $684.00 $718.00 $754.00 $684.00 $718.00 $754.00
51030 90 $538.00 $686.00 $720.00 $755.00 $686.00 $720.00 $755.00
51040 90 $439.00 $421.00 $442.00 $464.00 $421.00 $442.00 $464.00
51045 90 $548.00 $716.00 $757.00 $803.00 $716.00 $757.00 $803.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 251
Surgery
CPT Code FUD 2003 MRALocality 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)
51050 90 $596.00 $689.00 $723.00 $759.00 $689.00 $723.00 $759.00
51060 90 $768.00 $845.00 $885.00 $928.00 $845.00 $885.00 $928.00
51065 90 $704.00 $846.00 $888.00 $934.00 $846.00 $888.00 $934.00
51080 90 $510.00 $598.00 $628.00 $660.00 $598.00 $628.00 $660.00
51100 0 ---------- $88.00 $93.00 $97.00 $58.00 $60.00 $64.00
51101 0 ---------- $173.00 $184.00 $189.00 $76.00 $80.00 $84.00
51102 0 ---------- $323.00 $340.00 $353.00 $212.00 $222.00 $234.00
51500 90 $775.00 $934.00 $980.00 $1,032.00 $934.00 $980.00 $1,032.00
51520 90 $764.00 $871.00 $914.00 $962.00 $871.00 $914.00 $962.00
51525 90 $1,069.00 $1,260.00 $1,322.00 $1,393.00 $1,260.00 $1,322.00 $1,393.00
51530 90 $957.00 $1,174.00 $1,240.00 $1,320.00 $1,174.00 $1,240.00 $1,320.00
51535 90 $932.00 $1,144.00 $1,200.00 $1,264.00 $1,144.00 $1,200.00 $1,264.00
51550 90 $1,171.00 $1,421.00 $1,496.00 $1,587.00 $1,421.00 $1,496.00 $1,587.00
51555 90 $1,514.00 $1,865.00 $1,960.00 $2,075.00 $1,865.00 $1,960.00 $2,075.00
51565 90 $1,624.00 $1,912.00 $2,008.00 $2,124.00 $1,912.00 $2,008.00 $2,124.00
51570 90 $1,762.00 $2,175.00 $2,281.00 $2,411.00 $2,175.00 $2,281.00 $2,411.00
51575 90 $2,284.00 $2,678.00 $2,806.00 $2,962.00 $2,678.00 $2,806.00 $2,962.00
51580 90 $2,252.00 $2,832.00 $2,977.00 $3,155.00 $2,832.00 $2,977.00 $3,155.00
51585 90 $2,601.00 $3,112.00 $3,264.00 $3,450.00 $3,112.00 $3,264.00 $3,450.00
51590 90 $2,441.00 $2,845.00 $2,983.00 $3,152.00 $2,845.00 $2,983.00 $3,152.00
51595 90 $2,900.00 $3,218.00 $3,371.00 $3,559.00 $3,218.00 $3,371.00 $3,559.00
51596 90 $3,063.00 $3,461.00 $3,627.00 $3,829.00 $3,461.00 $3,627.00 $3,829.00
51597 90 $2,914.00 $3,372.00 $3,537.00 $3,738.00 $3,372.00 $3,537.00 $3,738.00
51600 0 $54.00 $254.00 $270.00 $275.00 $65.00 $68.00 $71.00
51605 0 $83.00 $56.00 $59.00 $62.00 $56.00 $59.00 $62.00
51610 0 $45.00 $150.00 $159.00 $163.00 $94.00 $98.00 $102.00
51700 0 $29.00 $102.00 $108.00 $111.00 $52.00 $55.00 $57.00
51701 0 $58.00 $67.00 $71.00 $74.00 $38.00 $40.00 $42.00
51702 0 $92.00 $88.00 $94.00 $96.00 $38.00 $40.00 $42.00
51703 0 $128.00 $177.00 $187.00 $194.00 $113.00 $118.00 $125.00
51705 0 $37.00 $128.00 $136.00 $140.00 $76.00 $80.00 $84.00
51710 0 $119.00 $182.00 $192.00 $199.00 $117.00 $123.00 $129.00
51715 0 $322.00 $415.00 $438.00 $456.00 $293.00 $308.00 $325.00
51720 0 $140.00 $124.00 $131.00 $135.00 $93.00 $98.00 $102.00
51725 0 $116.00 $262.00 $276.00 $284.00 $262.00 $276.00 $284.00
51725-26 0 ---------- $112.00 $116.00 $121.00 $112.00 $116.00 $121.00
51725-TC 0 ---------- $150.00 $160.00 $162.00 $150.00 $160.00 $162.00
51726 0 $136.00 $367.00 $388.00 $397.00 $367.00 $388.00 $397.00
51726-26 0 ---------- $125.00 $130.00 $135.00 $125.00 $130.00 $135.00
51726-TC 0 ---------- $242.00 $259.00 $262.00 $242.00 $259.00 $262.00
51727 0 ---------- $434.00 $459.00 $470.00 $434.00 $459.00 $470.00
51727-26 0 ---------- $157.00 $163.00 $170.00 $157.00 $163.00 $170.00
51727-TC 0 ---------- $277.00 $296.00 $300.00 $277.00 $296.00 $300.00
51728 0 ---------- $438.00 $464.00 $475.00 $438.00 $464.00 $475.00
51728-26 0 ---------- $153.00 $159.00 $166.00 $153.00 $159.00 $166.00
51728-TC 0 ---------- $285.00 $305.00 $309.00 $285.00 $305.00 $309.00
51729 0 ---------- $474.00 $502.00 $514.00 $474.00 $502.00 $514.00
51729-26 0 ---------- $185.00 $192.00 $201.00 $185.00 $192.00 $201.00
51729-TC 0 ---------- $290.00 $310.00 $313.00 $290.00 $310.00 $313.00
51736 0 $47.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 252
Surgery
CPT Code FUD 2003 MRALocality 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)
51736-26 0 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
51736-TC 0 ---------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
51741 0 $81.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00
51741-26 0 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
51741-TC 0 ---------- $10.00 $11.00 $12.00 $10.00 $11.00 $12.00
51784 0 $119.00 $98.00 $103.00 $106.00 $98.00 $103.00 $106.00
51784-26 0 ---------- $55.00 $57.00 $59.00 $55.00 $57.00 $59.00
51784-TC 0 ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00
51785 0 $52.00 $373.00 $400.00 $419.00 $373.00 $400.00 $419.00
51785-26 0 ---------- $134.00 $145.00 $161.00 $134.00 $145.00 $161.00
51785-TC 0 ---------- $238.00 $255.00 $258.00 $238.00 $255.00 $258.00
51792 0 $143.00 $293.00 $311.00 $318.00 $293.00 $311.00 $318.00
51792-26 0 ---------- $81.00 $84.00 $87.00 $81.00 $84.00 $87.00
51792-TC 0 ---------- $213.00 $227.00 $230.00 $213.00 $227.00 $230.00
51797 ZZZ $109.00 $156.00 $165.00 $169.00 $156.00 $165.00 $169.00
51797-26 ZZZ ---------- $59.00 $61.00 $64.00 $59.00 $61.00 $64.00
51797-TC ZZZ ---------- $97.00 $104.00 $105.00 $97.00 $104.00 $105.00
51798 0 $20.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.00
51800 90 $1,294.00 $1,535.00 $1,610.00 $1,699.00 $1,535.00 $1,610.00 $1,699.00
51820 90 $1,236.00 $1,743.00 $1,855.00 $2,002.00 $1,743.00 $1,855.00 $2,002.00
51840 90 $858.00 $960.00 $1,008.00 $1,062.00 $960.00 $1,008.00 $1,062.00
51841 90 $1,040.00 $1,148.00 $1,208.00 $1,278.00 $1,148.00 $1,208.00 $1,278.00
51845 90 $843.00 $853.00 $895.00 $942.00 $853.00 $895.00 $942.00
51860 90 $912.00 $1,099.00 $1,161.00 $1,238.00 $1,099.00 $1,161.00 $1,238.00
51865 90 $1,150.00 $1,317.00 $1,387.00 $1,471.00 $1,317.00 $1,387.00 $1,471.00
51880 90 $590.00 $685.00 $722.00 $763.00 $685.00 $722.00 $763.00
51900 90 $1,050.00 $1,231.00 $1,295.00 $1,370.00 $1,231.00 $1,295.00 $1,370.00
51920 90 $881.00 $1,153.00 $1,218.00 $1,297.00 $1,153.00 $1,218.00 $1,297.00
51925 90 $1,167.00 $1,515.00 $1,597.00 $1,694.00 $1,515.00 $1,597.00 $1,694.00
51940 90 $2,082.00 $2,431.00 $2,548.00 $2,688.00 $2,431.00 $2,548.00 $2,688.00
51960 90 $1,848.00 $2,034.00 $2,132.00 $2,248.00 $2,034.00 $2,132.00 $2,248.00
51980 90 $858.00 $1,043.00 $1,093.00 $1,149.00 $1,043.00 $1,093.00 $1,149.00
51990 90 $850.00 $1,101.00 $1,156.00 $1,220.00 $1,101.00 $1,156.00 $1,220.00
51992 90 $925.00 $1,231.00 $1,293.00 $1,367.00 $1,231.00 $1,293.00 $1,367.00
52000 0 $190.00 $231.00 $245.00 $253.00 $148.00 $155.00 $163.00
52001 0 $133.00 $536.00 $564.00 $590.00 $423.00 $444.00 $468.00
52005 0 $265.00 $375.00 $396.00 $409.00 $196.00 $205.00 $217.00
52007 0 $230.00 $620.00 $657.00 $675.00 $244.00 $256.00 $270.00
52010 0 $292.00 $516.00 $546.00 $563.00 $244.00 $256.00 $270.00
52204 0 $286.00 $516.00 $547.00 $562.00 $208.00 $218.00 $230.00
52214 0 $367.00 $917.00 $974.00 $996.00 $261.00 $273.00 $289.00
52224 0 $339.00 $962.00 $1,021.00 $1,046.00 $301.00 $316.00 $334.00
52234 0 $471.00 $363.00 $380.00 $401.00 $363.00 $380.00 $401.00
52235 0 $546.00 $425.00 $446.00 $470.00 $425.00 $446.00 $470.00
52240 0 $887.00 $578.00 $605.00 $639.00 $578.00 $605.00 $639.00
52250 0 $311.00 $352.00 $369.00 $390.00 $352.00 $369.00 $390.00
52260 0 $262.00 $310.00 $325.00 $342.00 $310.00 $325.00 $342.00
52265 0 $243.00 $512.00 $543.00 $559.00 $239.00 $250.00 $264.00
52270 0 $374.00 $502.00 $530.00 $548.00 $268.00 $280.00 $296.00
52275 0 $446.00 $677.00 $716.00 $740.00 $366.00 $384.00 $405.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 253
Surgery
CPT Code FUD 2003 MRALocality 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)
52276 0 $490.00 $390.00 $409.00 $432.00 $390.00 $409.00 $432.00
52277 0 $448.00 $476.00 $499.00 $526.00 $476.00 $499.00 $526.00
52281 0 $259.00 $386.00 $408.00 $422.00 $224.00 $235.00 $247.00
52282 0 $560.00 $496.00 $520.00 $550.00 $496.00 $520.00 $550.00
52283 0 $309.00 $397.00 $418.00 $437.00 $296.00 $311.00 $328.00
52285 0 $375.00 $400.00 $422.00 $440.00 $288.00 $302.00 $319.00
52287 0 ---------- $441.00 $465.00 $482.00 $249.00 $261.00 $276.00
52290 0 $304.00 $359.00 $376.00 $397.00 $359.00 $376.00 $397.00
52300 0 $370.00 $413.00 $433.00 $457.00 $413.00 $433.00 $457.00
52301 0 $382.00 $427.00 $448.00 $472.00 $427.00 $448.00 $472.00
52305 0 $370.00 $411.00 $431.00 $455.00 $411.00 $431.00 $455.00
52310 0 $348.00 $346.00 $365.00 $380.00 $223.00 $234.00 $247.00
52315 0 $553.00 $589.00 $621.00 $647.00 $404.00 $424.00 $447.00
52317 0 $772.00 $1,129.00 $1,195.00 $1,231.00 $512.00 $536.00 $566.00
52318 0 $684.00 $698.00 $731.00 $772.00 $698.00 $731.00 $772.00
52320 0 $369.00 $364.00 $381.00 $403.00 $364.00 $381.00 $403.00
52325 0 $494.00 $474.00 $496.00 $524.00 $474.00 $496.00 $524.00
52327 0 $369.00 $387.00 $405.00 $429.00 $387.00 $405.00 $429.00
52330 0 $507.00 $699.00 $738.00 $764.00 $389.00 $407.00 $430.00
52332 0 $451.00 $681.00 $723.00 $741.00 $229.00 $240.00 $253.00
52334 0 $340.00 $376.00 $394.00 $416.00 $376.00 $394.00 $416.00
52341 0 $317.00 $419.00 $439.00 $463.00 $419.00 $439.00 $463.00
52342 0 $344.00 $456.00 $478.00 $505.00 $456.00 $478.00 $505.00
52343 0 $380.00 $507.00 $531.00 $560.00 $507.00 $531.00 $560.00
52344 0 $407.00 $544.00 $570.00 $602.00 $544.00 $570.00 $602.00
52345 0 $433.00 $581.00 $609.00 $642.00 $581.00 $609.00 $642.00
52346 0 $488.00 $658.00 $688.00 $727.00 $658.00 $688.00 $727.00
52351 0 $297.00 $446.00 $467.00 $493.00 $446.00 $467.00 $493.00
52352 0 $349.00 $521.00 $546.00 $576.00 $521.00 $546.00 $576.00
52353 0 $404.00 $578.00 $605.00 $639.00 $578.00 $605.00 $639.00
52354 0 $372.00 $615.00 $644.00 $679.00 $615.00 $644.00 $679.00
52355 0 $447.00 $689.00 $722.00 $763.00 $689.00 $722.00 $763.00
52356 0 ---------- $613.00 $642.00 $677.00 $613.00 $642.00 $677.00
52400 90 $580.00 $701.00 $735.00 $775.00 $701.00 $735.00 $775.00
52402 0 ---------- $394.00 $413.00 $437.00 $394.00 $413.00 $437.00
52441 0 ---------- $1,711.00 $1,820.00 $1,855.00 $335.00 $350.00 $370.00
52442 ZZZ ---------- $1,300.00 $1,386.00 $1,404.00 $89.00 $93.00 $99.00
52450 90 $602.00 $685.00 $719.00 $755.00 $685.00 $719.00 $755.00
52500 90 $705.00 $712.00 $747.00 $784.00 $712.00 $747.00 $784.00
52601 90 $1,021.00 $1,240.00 $1,300.00 $1,369.00 $1,240.00 $1,300.00 $1,369.00
52630 90 $653.00 $583.00 $612.00 $642.00 $583.00 $612.00 $642.00
52640 90 $573.00 $457.00 $481.00 $503.00 $457.00 $481.00 $503.00
52647 90 $858.00 $2,484.00 $2,635.00 $2,702.00 $947.00 $993.00 $1,045.00
52648 90 $957.00 $2,558.00 $2,712.00 $2,784.00 $1,009.00 $1,059.00 $1,114.00
52649 90 ---------- $1,205.00 $1,263.00 $1,330.00 $1,205.00 $1,263.00 $1,330.00
52700 90 $517.00 $645.00 $677.00 $711.00 $645.00 $677.00 $711.00
53000 10 $224.00 $215.00 $226.00 $237.00 $215.00 $226.00 $237.00
53010 90 $336.00 $428.00 $450.00 $471.00 $428.00 $450.00 $471.00
53020 0 $153.00 $143.00 $150.00 $158.00 $143.00 $150.00 $158.00
53040 90 $460.00 $572.00 $601.00 $631.00 $572.00 $601.00 $631.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 254
Surgery
CPT Code FUD 2003 MRALocality 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)
53060 10 $180.00 $265.00 $279.00 $293.00 $240.00 $252.00 $265.00
53080 90 $567.00 $612.00 $643.00 $674.00 $612.00 $643.00 $674.00
53085 90 $836.00 $966.00 $1,018.00 $1,078.00 $966.00 $1,018.00 $1,078.00
53200 0 $218.00 $227.00 $239.00 $252.00 $210.00 $220.00 $233.00
53210 90 $904.00 $1,142.00 $1,200.00 $1,268.00 $1,142.00 $1,200.00 $1,268.00
53215 90 $1,142.00 $1,362.00 $1,428.00 $1,506.00 $1,362.00 $1,428.00 $1,506.00
53220 90 $546.00 $669.00 $704.00 $742.00 $669.00 $704.00 $742.00
53230 90 $760.00 $886.00 $929.00 $978.00 $886.00 $929.00 $978.00
53235 90 $607.00 $928.00 $974.00 $1,026.00 $928.00 $974.00 $1,026.00
53240 90 $506.00 $619.00 $650.00 $683.00 $619.00 $650.00 $683.00
53250 90 $464.00 $596.00 $627.00 $658.00 $596.00 $627.00 $658.00
53260 10 $240.00 $291.00 $306.00 $321.00 $262.00 $275.00 $290.00
53265 10 $295.00 $314.00 $331.00 $346.00 $271.00 $285.00 $300.00
53270 10 $226.00 $298.00 $314.00 $329.00 $269.00 $282.00 $297.00
53275 10 $332.00 $385.00 $404.00 $426.00 $385.00 $404.00 $426.00
53400 90 $929.00 $1,171.00 $1,228.00 $1,292.00 $1,171.00 $1,228.00 $1,292.00
53405 90 $1,088.00 $1,288.00 $1,352.00 $1,426.00 $1,288.00 $1,352.00 $1,426.00
53410 90 $1,151.00 $1,433.00 $1,502.00 $1,583.00 $1,433.00 $1,502.00 $1,583.00
53415 90 $1,381.00 $1,658.00 $1,738.00 $1,831.00 $1,658.00 $1,738.00 $1,831.00
53420 90 $1,088.00 $1,233.00 $1,293.00 $1,362.00 $1,233.00 $1,293.00 $1,362.00
53425 90 $1,150.00 $1,374.00 $1,440.00 $1,517.00 $1,374.00 $1,440.00 $1,517.00
53430 90 $1,116.00 $1,418.00 $1,487.00 $1,569.00 $1,418.00 $1,487.00 $1,569.00
53431 90 $1,053.00 $1,693.00 $1,774.00 $1,869.00 $1,693.00 $1,774.00 $1,869.00
53440 90 $1,057.00 $1,102.00 $1,155.00 $1,216.00 $1,102.00 $1,155.00 $1,216.00
53442 90 $639.00 $1,143.00 $1,200.00 $1,261.00 $1,143.00 $1,200.00 $1,261.00
53444 90 $755.00 $1,161.00 $1,217.00 $1,281.00 $1,161.00 $1,217.00 $1,281.00
53445 90 $1,197.00 $1,101.00 $1,155.00 $1,214.00 $1,101.00 $1,155.00 $1,214.00
53446 90 $699.00 $938.00 $984.00 $1,034.00 $938.00 $984.00 $1,034.00
53447 90 $991.00 $1,183.00 $1,241.00 $1,306.00 $1,183.00 $1,241.00 $1,306.00
53448 90 $1,259.00 $1,882.00 $1,974.00 $2,083.00 $1,882.00 $1,974.00 $2,083.00
53449 90 $784.00 $894.00 $937.00 $986.00 $894.00 $937.00 $986.00
53450 90 $447.00 $595.00 $625.00 $656.00 $595.00 $625.00 $656.00
53460 90 $494.00 $668.00 $701.00 $737.00 $668.00 $701.00 $737.00
53500 90 ---------- $1,095.00 $1,149.00 $1,211.00 $1,095.00 $1,149.00 $1,211.00
53502 90 $590.00 $710.00 $745.00 $783.00 $710.00 $745.00 $783.00
53505 90 $586.00 $709.00 $744.00 $782.00 $709.00 $744.00 $782.00
53510 90 $777.00 $923.00 $968.00 $1,018.00 $923.00 $968.00 $1,018.00
53515 90 $987.00 $1,156.00 $1,211.00 $1,274.00 $1,156.00 $1,211.00 $1,274.00
53520 90 $661.00 $812.00 $852.00 $895.00 $812.00 $852.00 $895.00
53600 0 $37.00 $119.00 $126.00 $131.00 $94.00 $98.00 $103.00
53601 0 $37.00 $116.00 $122.00 $127.00 $79.00 $83.00 $87.00
53605 0 $81.00 $95.00 $100.00 $105.00 $95.00 $100.00 $105.00
53620 0 $59.00 $167.00 $176.00 $184.00 $129.00 $135.00 $142.00
53621 0 $45.00 $156.00 $164.00 $171.00 $106.00 $111.00 $117.00
53660 0 $49.00 $100.00 $105.00 $109.00 $61.00 $64.00 $68.00
53661 0 $50.00 $98.00 $104.00 $107.00 $59.00 $62.00 $66.00
53665 0 $50.00 $57.00 $60.00 $64.00 $57.00 $60.00 $64.00
53850 90 $741.00 $2,875.00 $3,054.00 $3,122.00 $885.00 $929.00 $975.00
53852 90 $728.00 $2,659.00 $2,823.00 $2,891.00 $910.00 $955.00 $1,004.00
53855 0 ---------- $1,068.00 $1,138.00 $1,155.00 $122.00 $128.00 $135.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 255
Surgery
CPT Code FUD 2003 MRALocality 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)
53860 90 ---------- $2,156.00 $2,296.00 $2,334.00 $330.00 $346.00 $364.00
53899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
54015 10 $348.00 $451.00 $473.00 $498.00 $451.00 $473.00 $498.00
54050 10 $91.00 $188.00 $199.00 $207.00 $153.00 $161.00 $169.00
54055 10 $106.00 $169.00 $178.00 $186.00 $134.00 $142.00 $148.00
54056 10 $100.00 $201.00 $213.00 $221.00 $160.00 $169.00 $177.00
54057 10 $149.00 $193.00 $204.00 $211.00 $137.00 $145.00 $151.00
54060 10 $180.00 $255.00 $270.00 $280.00 $189.00 $199.00 $209.00
54065 10 $281.00 $312.00 $330.00 $345.00 $251.00 $265.00 $279.00
54100 0 $149.00 $281.00 $298.00 $309.00 $184.00 $194.00 $204.00
54105 10 $261.00 $379.00 $399.00 $417.00 $311.00 $327.00 $343.00
54110 90 $775.00 $916.00 $961.00 $1,012.00 $916.00 $961.00 $1,012.00
54111 90 $1,035.00 $1,183.00 $1,240.00 $1,307.00 $1,183.00 $1,240.00 $1,307.00
54112 90 $1,210.00 $1,375.00 $1,441.00 $1,518.00 $1,375.00 $1,441.00 $1,518.00
54115 90 $588.00 $659.00 $693.00 $726.00 $623.00 $654.00 $687.00
54120 90 $777.00 $924.00 $970.00 $1,020.00 $924.00 $970.00 $1,020.00
54125 90 $1,092.00 $1,194.00 $1,252.00 $1,321.00 $1,194.00 $1,252.00 $1,321.00
54130 90 $1,532.00 $1,751.00 $1,835.00 $1,933.00 $1,751.00 $1,835.00 $1,933.00
54135 90 $1,945.00 $2,221.00 $2,327.00 $2,454.00 $2,221.00 $2,327.00 $2,454.00
54162 10 $220.00 $367.00 $387.00 $403.00 $290.00 $304.00 $319.00
54163 10 $207.00 $318.00 $334.00 $350.00 $318.00 $334.00 $350.00
54164 10 $182.00 $281.00 $296.00 $310.00 $281.00 $296.00 $310.00
54200 10 $78.00 $152.00 $160.00 $166.00 $121.00 $127.00 $132.00
54205 90 $633.00 $777.00 $815.00 $856.00 $777.00 $815.00 $856.00
54220 0 $189.00 $292.00 $309.00 $322.00 $197.00 $208.00 $220.00
54230 0 $104.00 $139.00 $146.00 $153.00 $116.00 $122.00 $128.00
54231 0 $172.00 $202.00 $213.00 $222.00 $171.00 $179.00 $189.00
54235 0 $81.00 $130.00 $136.00 $142.00 $107.00 $112.00 $118.00
54240 0 $109.00 $151.00 $160.00 $170.00 $151.00 $160.00 $170.00
54240-26 0 ---------- $103.00 $109.00 $118.00 $103.00 $109.00 $118.00
54240-TC 0 ---------- $48.00 $51.00 $52.00 $48.00 $51.00 $52.00
54250 0 $104.00 $176.00 $183.00 $191.00 $176.00 $183.00 $191.00
54250-26 0 ---------- $161.00 $167.00 $174.00 $161.00 $167.00 $174.00
54250-TC 0 ---------- $15.00 $16.00 $17.00 $15.00 $16.00 $17.00
54300 90 $830.00 $940.00 $986.00 $1,038.00 $940.00 $986.00 $1,038.00
54304 90 $988.00 $1,095.00 $1,147.00 $1,206.00 $1,095.00 $1,147.00 $1,206.00
54308 90 $881.00 $1,046.00 $1,097.00 $1,155.00 $1,046.00 $1,097.00 $1,155.00
54312 90 $1,067.00 $1,257.00 $1,326.00 $1,406.00 $1,257.00 $1,326.00 $1,406.00
54316 90 $1,316.00 $1,535.00 $1,618.00 $1,717.00 $1,535.00 $1,618.00 $1,717.00
54318 90 $900.00 $1,040.00 $1,091.00 $1,147.00 $1,040.00 $1,091.00 $1,147.00
54322 90 $974.00 $1,134.00 $1,190.00 $1,256.00 $1,134.00 $1,190.00 $1,256.00
54324 90 $1,260.00 $1,417.00 $1,485.00 $1,562.00 $1,417.00 $1,485.00 $1,562.00
54326 90 $1,212.00 $1,386.00 $1,453.00 $1,530.00 $1,386.00 $1,453.00 $1,530.00
54328 90 $1,201.00 $1,395.00 $1,459.00 $1,525.00 $1,395.00 $1,459.00 $1,525.00
54332 90 $1,327.00 $1,550.00 $1,627.00 $1,713.00 $1,550.00 $1,627.00 $1,713.00
54336 90 $1,672.00 $1,744.00 $1,828.00 $1,925.00 $1,744.00 $1,828.00 $1,925.00
54340 90 $727.00 $825.00 $863.00 $904.00 $825.00 $863.00 $904.00
54344 90 $1,360.00 $1,390.00 $1,457.00 $1,534.00 $1,390.00 $1,457.00 $1,534.00
54348 90 $1,318.00 $1,487.00 $1,559.00 $1,642.00 $1,487.00 $1,559.00 $1,642.00
54352 90 $1,820.00 $2,080.00 $2,179.00 $2,297.00 $2,080.00 $2,179.00 $2,297.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 256
Surgery
CPT Code FUD 2003 MRALocality 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)
54360 90 $898.00 $1,055.00 $1,107.00 $1,165.00 $1,055.00 $1,107.00 $1,165.00
54380 90 $1,054.00 $1,170.00 $1,228.00 $1,292.00 $1,170.00 $1,228.00 $1,292.00
54385 90 $1,217.00 $1,422.00 $1,495.00 $1,577.00 $1,422.00 $1,495.00 $1,577.00
54390 90 $1,635.00 $1,820.00 $1,908.00 $2,010.00 $1,820.00 $1,908.00 $2,010.00
54400 90 $784.00 $774.00 $811.00 $853.00 $774.00 $811.00 $853.00
54401 90 $892.00 $953.00 $1,001.00 $1,049.00 $953.00 $1,001.00 $1,049.00
54405 90 $1,294.00 $1,184.00 $1,242.00 $1,307.00 $1,184.00 $1,242.00 $1,307.00
54406 90 $687.00 $1,069.00 $1,122.00 $1,180.00 $1,069.00 $1,122.00 $1,180.00
54408 90 $724.00 $1,157.00 $1,214.00 $1,278.00 $1,157.00 $1,214.00 $1,278.00
54410 90 $856.00 $1,258.00 $1,319.00 $1,388.00 $1,258.00 $1,319.00 $1,388.00
54411 90 $933.00 $1,503.00 $1,576.00 $1,660.00 $1,503.00 $1,576.00 $1,660.00
54415 90 $510.00 $772.00 $810.00 $852.00 $772.00 $810.00 $852.00
54416 90 $665.00 $1,037.00 $1,089.00 $1,144.00 $1,037.00 $1,089.00 $1,144.00
54417 90 $819.00 $1,317.00 $1,380.00 $1,454.00 $1,317.00 $1,380.00 $1,454.00
54420 90 $899.00 $1,029.00 $1,080.00 $1,136.00 $1,029.00 $1,080.00 $1,136.00
54430 90 $799.00 $935.00 $981.00 $1,032.00 $935.00 $981.00 $1,032.00
54435 90 $503.00 $608.00 $638.00 $669.00 $608.00 $638.00 $669.00
54437 90 ---------- $992.00 $1,042.00 $1,097.00 $992.00 $1,042.00 $1,097.00
54438 90 ---------- $1,985.00 $2,089.00 $2,218.00 $1,985.00 $2,089.00 $2,218.00
54440 90 BR ---------- ---------- ---------- ---------- ---------- ----------
54450 0 $88.00 $102.00 $107.00 $112.00 $85.00 $89.00 $95.00
54500 0 $102.00 $109.00 $115.00 $120.00 $109.00 $115.00 $120.00
54505 10 $259.00 $306.00 $322.00 $338.00 $306.00 $322.00 $338.00
54512 90 $519.00 $791.00 $831.00 $877.00 $791.00 $831.00 $877.00
54520 90 $445.00 $477.00 $502.00 $529.00 $477.00 $502.00 $529.00
54522 90 $589.00 $865.00 $908.00 $954.00 $865.00 $908.00 $954.00
54530 90 $683.00 $737.00 $774.00 $814.00 $737.00 $774.00 $814.00
54535 90 $922.00 $1,102.00 $1,158.00 $1,222.00 $1,102.00 $1,158.00 $1,222.00
54550 90 $588.00 $725.00 $762.00 $802.00 $725.00 $762.00 $802.00
54560 90 $842.00 $1,055.00 $1,112.00 $1,179.00 $1,055.00 $1,112.00 $1,179.00
54600 90 $524.00 $665.00 $699.00 $735.00 $665.00 $699.00 $735.00
54620 10 $373.00 $439.00 $460.00 $484.00 $439.00 $460.00 $484.00
54640 90 $594.00 $698.00 $734.00 $773.00 $698.00 $734.00 $773.00
54650 90 $861.00 $1,069.00 $1,128.00 $1,199.00 $1,069.00 $1,128.00 $1,199.00
54660 90 $401.00 $530.00 $557.00 $585.00 $530.00 $557.00 $585.00
54670 90 $485.00 $597.00 $628.00 $660.00 $597.00 $628.00 $660.00
54680 90 $948.00 $1,176.00 $1,235.00 $1,302.00 $1,176.00 $1,235.00 $1,302.00
54690 90 $825.00 $969.00 $1,017.00 $1,073.00 $969.00 $1,017.00 $1,073.00
54692 90 $850.00 $1,182.00 $1,252.00 $1,342.00 $1,182.00 $1,252.00 $1,342.00
54699 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
54700 10 $133.00 $312.00 $329.00 $347.00 $312.00 $329.00 $347.00
54800 0 $257.00 $196.00 $207.00 $220.00 $196.00 $207.00 $220.00
54830 90 $411.00 $543.00 $571.00 $600.00 $543.00 $571.00 $600.00
54840 90 $432.00 $468.00 $492.00 $516.00 $468.00 $492.00 $516.00
54860 90 $503.00 $611.00 $641.00 $673.00 $611.00 $641.00 $673.00
54861 90 $696.00 $826.00 $867.00 $911.00 $826.00 $867.00 $911.00
54865 90 ---------- $523.00 $549.00 $576.00 $523.00 $549.00 $576.00
54900 90 $969.00 $1,230.00 $1,297.00 $1,376.00 $1,230.00 $1,297.00 $1,376.00
54901 90 $1,340.00 $1,547.00 $1,622.00 $1,708.00 $1,547.00 $1,622.00 $1,708.00
55000 0 $109.00 $167.00 $177.00 $184.00 $125.00 $131.00 $138.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 257
Surgery
CPT Code FUD 2003 MRALocality 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)
55040 90 $439.00 $493.00 $519.00 $546.00 $493.00 $519.00 $546.00
55041 90 $634.00 $745.00 $783.00 $824.00 $745.00 $783.00 $824.00
55060 90 $430.00 $555.00 $584.00 $614.00 $555.00 $584.00 $614.00
55100 10 $156.00 $307.00 $325.00 $339.00 $241.00 $254.00 $267.00
55110 90 $223.00 $566.00 $596.00 $627.00 $566.00 $596.00 $627.00
55120 90 $350.00 $525.00 $553.00 $582.00 $525.00 $553.00 $582.00
55150 90 $562.00 $719.00 $756.00 $796.00 $719.00 $756.00 $796.00
55175 90 $426.00 $531.00 $558.00 $586.00 $531.00 $558.00 $586.00
55180 90 $796.00 $1,006.00 $1,057.00 $1,113.00 $1,006.00 $1,057.00 $1,113.00
55200 90 $310.00 $614.00 $649.00 $672.00 $399.00 $419.00 $440.00
55250 90 $349.00 $544.00 $576.00 $595.00 $331.00 $348.00 $365.00
55300 0 $167.00 $276.00 $289.00 $305.00 $276.00 $289.00 $305.00
55400 90 $660.00 $728.00 $764.00 $803.00 $728.00 $764.00 $803.00
55450 10 $391.00 $525.00 $555.00 $579.00 $383.00 $404.00 $427.00
55500 90 $445.00 $580.00 $613.00 $651.00 $580.00 $613.00 $651.00
55520 90 $446.00 $672.00 $719.00 $780.00 $672.00 $719.00 $780.00
55530 90 $467.00 $513.00 $539.00 $566.00 $513.00 $539.00 $566.00
55535 90 $496.00 $627.00 $658.00 $691.00 $627.00 $658.00 $691.00
55540 90 $572.00 $822.00 $882.00 $962.00 $822.00 $882.00 $962.00
55550 90 $486.00 $625.00 $656.00 $689.00 $625.00 $656.00 $689.00
55559 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
55600 90 $486.00 $615.00 $645.00 $677.00 $615.00 $645.00 $677.00
55605 90 $609.00 $799.00 $843.00 $892.00 $799.00 $843.00 $892.00
55650 90 $853.00 $1,053.00 $1,105.00 $1,164.00 $1,053.00 $1,105.00 $1,164.00
55680 90 $426.00 $535.00 $567.00 $605.00 $535.00 $567.00 $605.00
55700 0 $183.00 $350.00 $370.00 $383.00 $193.00 $202.00 $213.00
55705 10 $368.00 $390.00 $409.00 $430.00 $390.00 $409.00 $430.00
55706 10 ---------- $543.00 $570.00 $598.00 $543.00 $570.00 $598.00
55720 90 $555.00 $660.00 $693.00 $728.00 $660.00 $693.00 $728.00
55725 90 $670.00 $969.00 $1,034.00 $1,116.00 $969.00 $1,034.00 $1,116.00
55801 90 $1,331.00 $1,609.00 $1,689.00 $1,781.00 $1,609.00 $1,689.00 $1,781.00
55810 90 $1,711.00 $1,924.00 $2,016.00 $2,125.00 $1,924.00 $2,016.00 $2,125.00
55812 90 $1,989.00 $2,447.00 $2,584.00 $2,763.00 $2,447.00 $2,584.00 $2,763.00
55815 90 $2,328.00 $2,598.00 $2,721.00 $2,867.00 $2,598.00 $2,721.00 $2,867.00
55821 90 $1,153.00 $1,281.00 $1,343.00 $1,415.00 $1,281.00 $1,343.00 $1,415.00
55831 90 $1,252.00 $1,386.00 $1,452.00 $1,530.00 $1,386.00 $1,452.00 $1,530.00
55840 90 $1,705.00 $1,720.00 $1,803.00 $1,900.00 $1,720.00 $1,803.00 $1,900.00
55842 90 $1,859.00 $1,719.00 $1,802.00 $1,900.00 $1,719.00 $1,802.00 $1,900.00
55845 90 $2,222.00 $2,002.00 $2,098.00 $2,212.00 $2,002.00 $2,098.00 $2,212.00
55860 90 $1,012.00 $1,282.00 $1,342.00 $1,410.00 $1,282.00 $1,342.00 $1,410.00
55862 90 $1,351.00 $1,648.00 $1,732.00 $1,832.00 $1,648.00 $1,732.00 $1,832.00
55865 90 $1,890.00 $1,958.00 $2,052.00 $2,163.00 $1,958.00 $2,052.00 $2,163.00
55866 90 $1,615.00 $2,121.00 $2,222.00 $2,342.00 $2,121.00 $2,222.00 $2,342.00
55870 0 $166.00 $253.00 $267.00 $279.00 $209.00 $219.00 $231.00
55873 90 $1,127.00 $9,691.00 $10,328.00 $10,480.00 $1,119.00 $1,174.00 $1,236.00
55875 90 ---------- $1,115.00 $1,168.00 $1,226.00 $1,115.00 $1,168.00 $1,226.00
55876 0 ---------- $194.00 $204.00 $212.00 $147.00 $154.00 $162.00
55899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
55920 0 ---------- $654.00 $682.00 $713.00 $654.00 $682.00 $713.00
56405 10 $131.00 $156.00 $165.00 $173.00 $155.00 $164.00 $172.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 258
Surgery
CPT Code FUD 2003 MRALocality 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)
56420 10 $130.00 $172.00 $182.00 $189.00 $132.00 $139.00 $146.00
56440 10 $271.00 $263.00 $276.00 $291.00 $263.00 $276.00 $291.00
56441 10 $183.00 $206.00 $217.00 $227.00 $199.00 $209.00 $220.00
56442 0 ---------- $68.00 $72.00 $75.00 $68.00 $72.00 $75.00
56501 10 $122.00 $186.00 $197.00 $205.00 $165.00 $174.00 $182.00
56515 10 $200.00 $325.00 $344.00 $362.00 $291.00 $308.00 $326.00
56605 0 $96.00 $118.00 $124.00 $130.00 $88.00 $93.00 $98.00
56606 ZZZ $49.00 $55.00 $58.00 $61.00 $44.00 $46.00 $50.00
56620 90 $607.00 $760.00 $808.00 $864.00 $760.00 $808.00 $864.00
56625 90 $735.00 $930.00 $993.00 $1,071.00 $930.00 $993.00 $1,071.00
56630 90 $1,061.00 $1,377.00 $1,470.00 $1,593.00 $1,377.00 $1,470.00 $1,593.00
56631 90 $1,400.00 $1,756.00 $1,876.00 $2,036.00 $1,756.00 $1,876.00 $2,036.00
56632 90 $1,636.00 $2,047.00 $2,187.00 $2,373.00 $2,047.00 $2,187.00 $2,373.00
56633 90 $1,350.00 $1,800.00 $1,923.00 $2,087.00 $1,800.00 $1,923.00 $2,087.00
56634 90 $1,537.00 $1,935.00 $2,074.00 $2,265.00 $1,935.00 $2,074.00 $2,265.00
56637 90 $1,806.00 $2,254.00 $2,411.00 $2,626.00 $2,254.00 $2,411.00 $2,626.00
56640 90 $1,777.00 $2,276.00 $2,441.00 $2,671.00 $2,276.00 $2,441.00 $2,671.00
56700 10 $227.00 $270.00 $284.00 $299.00 $270.00 $284.00 $299.00
56740 10 $321.00 $436.00 $461.00 $490.00 $436.00 $461.00 $490.00
56800 10 $310.00 $348.00 $366.00 $387.00 $348.00 $366.00 $387.00
56805 90 $1,349.00 $1,838.00 $1,944.00 $2,066.00 $1,838.00 $1,944.00 $2,066.00
56810 10 $316.00 $376.00 $396.00 $418.00 $376.00 $396.00 $418.00
56820 0 $119.00 $162.00 $171.00 $181.00 $128.00 $135.00 $145.00
56821 0 $154.00 $212.00 $225.00 $237.00 $170.00 $179.00 $191.00
57000 10 $237.00 $265.00 $279.00 $293.00 $265.00 $279.00 $293.00
57010 90 $429.00 $624.00 $657.00 $691.00 $624.00 $657.00 $691.00
57020 0 $118.00 $133.00 $140.00 $147.00 $117.00 $123.00 $130.00
57022 10 $179.00 $249.00 $263.00 $281.00 $249.00 $263.00 $281.00
57023 10 $290.00 $446.00 $468.00 $494.00 $446.00 $468.00 $494.00
57061 10 $124.00 $161.00 $170.00 $178.00 $141.00 $149.00 $156.00
57065 10 $251.00 $281.00 $298.00 $315.00 $253.00 $268.00 $285.00
57100 0 $90.00 $129.00 $137.00 $145.00 $99.00 $105.00 $112.00
57105 10 $132.00 $195.00 $207.00 $218.00 $182.00 $193.00 $204.00
57106 90 $409.00 $719.00 $763.00 $814.00 $719.00 $763.00 $814.00
57107 90 $1,467.00 $2,144.00 $2,280.00 $2,461.00 $2,144.00 $2,280.00 $2,461.00
57109 90 $1,787.00 $2,625.00 $2,819.00 $3,094.00 $2,625.00 $2,819.00 $3,094.00
57110 90 $1,015.00 $1,289.00 $1,355.00 $1,430.00 $1,289.00 $1,355.00 $1,430.00
57111 90 $1,793.00 $2,357.00 $2,484.00 $2,641.00 $2,357.00 $2,484.00 $2,641.00
57112 90 $1,907.00 $2,667.00 $2,840.00 $3,074.00 $2,667.00 $2,840.00 $3,074.00
57120 90 $612.00 $731.00 $769.00 $809.00 $731.00 $769.00 $809.00
57130 10 $220.00 $252.00 $266.00 $278.00 $228.00 $239.00 $252.00
57135 10 $231.00 $275.00 $291.00 $306.00 $250.00 $264.00 $279.00
57150 0 $50.00 $64.00 $67.00 $70.00 $42.00 $44.00 $47.00
57155 0 $383.00 $519.00 $544.00 $564.00 $403.00 $421.00 $440.00
57156 0 ---------- $281.00 $294.00 $304.00 $212.00 $221.00 $229.00
57160 0 $67.00 $108.00 $114.00 $119.00 $68.00 $71.00 $76.00
57170 0 $74.00 $87.00 $92.00 $96.00 $71.00 $74.00 $79.00
57180 10 $124.00 $199.00 $210.00 $219.00 $152.00 $160.00 $168.00
57200 90 $313.00 $436.00 $461.00 $488.00 $436.00 $461.00 $488.00
57210 90 $395.00 $527.00 $555.00 $585.00 $527.00 $555.00 $585.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 259
Surgery
CPT Code FUD 2003 MRALocality 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)
57220 90 $378.00 $459.00 $483.00 $508.00 $459.00 $483.00 $508.00
57230 90 $442.00 $567.00 $597.00 $628.00 $567.00 $597.00 $628.00
57240 90 $536.00 $969.00 $1,018.00 $1,073.00 $969.00 $1,018.00 $1,073.00
57250 90 $485.00 $975.00 $1,024.00 $1,080.00 $975.00 $1,024.00 $1,080.00
57260 90 $700.00 $1,201.00 $1,262.00 $1,332.00 $1,201.00 $1,262.00 $1,332.00
57265 90 $902.00 $1,317.00 $1,384.00 $1,461.00 $1,317.00 $1,384.00 $1,461.00
57267 ZZZ ---------- $373.00 $391.00 $414.00 $373.00 $391.00 $414.00
57268 90 $577.00 $696.00 $733.00 $773.00 $696.00 $733.00 $773.00
57270 90 $867.00 $1,162.00 $1,224.00 $1,299.00 $1,162.00 $1,224.00 $1,299.00
57280 90 $1,071.00 $1,381.00 $1,451.00 $1,534.00 $1,381.00 $1,451.00 $1,534.00
57282 90 $734.00 $719.00 $756.00 $795.00 $719.00 $756.00 $795.00
57283 90 ---------- $994.00 $1,044.00 $1,102.00 $994.00 $1,044.00 $1,102.00
57284 90 $950.00 $1,179.00 $1,238.00 $1,308.00 $1,179.00 $1,238.00 $1,308.00
57285 90 ---------- $971.00 $1,020.00 $1,075.00 $971.00 $1,020.00 $1,075.00
57287 90 $685.00 $983.00 $1,032.00 $1,085.00 $983.00 $1,032.00 $1,085.00
57288 90 $1,009.00 $1,035.00 $1,087.00 $1,144.00 $1,035.00 $1,087.00 $1,144.00
57289 90 $879.00 $1,066.00 $1,118.00 $1,176.00 $1,066.00 $1,118.00 $1,176.00
57291 90 $622.00 $759.00 $798.00 $839.00 $759.00 $798.00 $839.00
57292 90 $925.00 $1,182.00 $1,243.00 $1,315.00 $1,182.00 $1,243.00 $1,315.00
57295 90 ---------- $687.00 $723.00 $760.00 $687.00 $723.00 $760.00
57296 90 ---------- $1,355.00 $1,423.00 $1,504.00 $1,355.00 $1,423.00 $1,504.00
57300 90 $653.00 $819.00 $869.00 $927.00 $819.00 $869.00 $927.00
57305 90 $995.00 $1,381.00 $1,471.00 $1,591.00 $1,381.00 $1,471.00 $1,591.00
57307 90 $997.00 $1,564.00 $1,676.00 $1,832.00 $1,564.00 $1,676.00 $1,832.00
57308 90 $769.00 $919.00 $966.00 $1,018.00 $919.00 $966.00 $1,018.00
57310 90 $517.00 $672.00 $706.00 $742.00 $672.00 $706.00 $742.00
57311 90 $612.00 $763.00 $800.00 $840.00 $763.00 $800.00 $840.00
57320 90 $693.00 $772.00 $811.00 $854.00 $772.00 $811.00 $854.00
57330 90 $916.00 $1,097.00 $1,152.00 $1,217.00 $1,097.00 $1,152.00 $1,217.00
57335 90 $963.00 $1,810.00 $1,911.00 $2,026.00 $1,810.00 $1,911.00 $2,026.00
57400 0 $70.00 $196.00 $207.00 $220.00 $196.00 $207.00 $220.00
57410 0 $57.00 $156.00 $165.00 $175.00 $156.00 $165.00 $175.00
57415 10 $75.00 $230.00 $242.00 $255.00 $230.00 $242.00 $255.00
57420 0 $124.00 $170.00 $180.00 $190.00 $135.00 $143.00 $153.00
57421 0 $162.00 $226.00 $240.00 $253.00 $182.00 $192.00 $206.00
57423 90 ---------- $1,318.00 $1,384.00 $1,462.00 $1,318.00 $1,384.00 $1,462.00
57425 90 ---------- $1,404.00 $1,475.00 $1,558.00 $1,404.00 $1,475.00 $1,558.00
57426 90 ---------- $1,215.00 $1,277.00 $1,346.00 $1,215.00 $1,277.00 $1,346.00
57452 0 $96.00 $156.00 $165.00 $173.00 $134.00 $141.00 $149.00
57454 0 $125.00 $219.00 $231.00 $242.00 $197.00 $207.00 $218.00
57455 0 $149.00 $204.00 $215.00 $226.00 $161.00 $170.00 $180.00
57456 0 $141.00 $192.00 $203.00 $212.00 $150.00 $158.00 $167.00
57460 0 $223.00 $397.00 $420.00 $436.00 $236.00 $248.00 $262.00
57461 0 $333.00 $451.00 $477.00 $496.00 $273.00 $287.00 $305.00
57500 0 $89.00 $179.00 $190.00 $197.00 $110.00 $116.00 $122.00
57505 10 $105.00 $145.00 $153.00 $160.00 $132.00 $140.00 $146.00
57510 10 $140.00 $187.00 $197.00 $207.00 $167.00 $175.00 $185.00
57511 10 $159.00 $206.00 $217.00 $227.00 $189.00 $199.00 $209.00
57513 10 $191.00 $208.00 $220.00 $231.00 $193.00 $204.00 $216.00
57520 90 $359.00 $441.00 $467.00 $492.00 $399.00 $422.00 $446.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 260
Surgery
CPT Code FUD 2003 MRALocality 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)
57522 90 $319.00 $376.00 $397.00 $417.00 $350.00 $369.00 $389.00
57530 90 $386.00 $501.00 $529.00 $560.00 $501.00 $529.00 $560.00
57531 90 $2,036.00 $2,744.00 $2,943.00 $3,223.00 $2,744.00 $2,943.00 $3,223.00
57540 90 $815.00 $1,240.00 $1,328.00 $1,445.00 $1,240.00 $1,328.00 $1,445.00
57545 90 $700.00 $1,214.00 $1,284.00 $1,370.00 $1,214.00 $1,284.00 $1,370.00
57550 90 $486.00 $581.00 $611.00 $641.00 $581.00 $611.00 $641.00
57555 90 $774.00 $869.00 $915.00 $968.00 $869.00 $915.00 $968.00
57556 90 $718.00 $812.00 $853.00 $897.00 $812.00 $853.00 $897.00
57558 10 ---------- $177.00 $186.00 $195.00 $162.00 $171.00 $179.00
57700 90 $279.00 $449.00 $474.00 $498.00 $449.00 $474.00 $498.00
57720 90 $328.00 $441.00 $464.00 $488.00 $441.00 $464.00 $488.00
57800 0 $71.00 $86.00 $91.00 $95.00 $70.00 $74.00 $78.00
58100 0 $74.00 $156.00 $164.00 $172.00 $127.00 $134.00 $141.00
58110 ZZZ ---------- $69.00 $72.00 $76.00 $60.00 $63.00 $66.00
58120 10 $297.00 $370.00 $390.00 $411.00 $317.00 $334.00 $354.00
58140 90 $1,010.00 $1,332.00 $1,404.00 $1,491.00 $1,332.00 $1,404.00 $1,491.00
58145 90 $677.00 $792.00 $835.00 $884.00 $792.00 $835.00 $884.00
58146 90 $1,089.00 $1,667.00 $1,751.00 $1,850.00 $1,667.00 $1,751.00 $1,850.00
58150 90 $1,110.00 $1,483.00 $1,568.00 $1,676.00 $1,483.00 $1,568.00 $1,676.00
58152 90 $1,159.00 $1,809.00 $1,903.00 $2,016.00 $1,809.00 $1,903.00 $2,016.00
58180 90 $1,118.00 $1,397.00 $1,472.00 $1,564.00 $1,397.00 $1,472.00 $1,564.00
58200 90 $1,562.00 $2,032.00 $2,165.00 $2,345.00 $2,032.00 $2,165.00 $2,345.00
58210 90 $2,080.00 $2,746.00 $2,932.00 $3,188.00 $2,746.00 $2,932.00 $3,188.00
58240 90 $2,898.00 $4,315.00 $4,597.00 $4,980.00 $4,315.00 $4,597.00 $4,980.00
58260 90 $926.00 $1,190.00 $1,251.00 $1,320.00 $1,190.00 $1,251.00 $1,320.00
58262 90 $1,026.00 $1,330.00 $1,397.00 $1,477.00 $1,330.00 $1,397.00 $1,477.00
58263 90 $1,120.00 $1,427.00 $1,499.00 $1,582.00 $1,427.00 $1,499.00 $1,582.00
58267 90 $1,133.00 $1,512.00 $1,587.00 $1,673.00 $1,512.00 $1,587.00 $1,673.00
58270 90 $1,019.00 $1,273.00 $1,338.00 $1,414.00 $1,273.00 $1,338.00 $1,414.00
58275 90 $1,121.00 $1,420.00 $1,493.00 $1,578.00 $1,420.00 $1,493.00 $1,578.00
58280 90 $1,132.00 $1,513.00 $1,589.00 $1,677.00 $1,513.00 $1,589.00 $1,677.00
58285 90 $1,360.00 $2,126.00 $2,279.00 $2,493.00 $2,126.00 $2,279.00 $2,493.00
58290 90 $1,089.00 $1,662.00 $1,746.00 $1,846.00 $1,662.00 $1,746.00 $1,846.00
58291 90 $1,197.00 $1,791.00 $1,880.00 $1,984.00 $1,791.00 $1,880.00 $1,984.00
58292 90 $1,268.00 $1,889.00 $1,981.00 $2,091.00 $1,889.00 $1,981.00 $2,091.00
58293 90 $1,318.00 $1,966.00 $2,064.00 $2,179.00 $1,966.00 $2,064.00 $2,179.00
58294 90 $1,168.00 $1,752.00 $1,839.00 $1,942.00 $1,752.00 $1,839.00 $1,942.00
58301 0 $71.00 $135.00 $142.00 $149.00 $98.00 $103.00 $109.00
58321 0 $81.00 $109.00 $115.00 $120.00 $71.00 $74.00 $79.00
58322 0 $90.00 $122.00 $128.00 $134.00 $85.00 $89.00 $95.00
58323 0 $24.00 $22.00 $23.00 $23.00 $17.00 $18.00 $19.00
58340 0 $87.00 $166.00 $176.00 $181.00 $84.00 $88.00 $92.00
58345 10 $335.00 $400.00 $420.00 $442.00 $400.00 $420.00 $442.00
58346 90 $408.00 $655.00 $685.00 $714.00 $655.00 $685.00 $714.00
58350 10 $103.00 $136.00 $144.00 $150.00 $112.00 $119.00 $124.00
58353 10 $225.00 $1,381.00 $1,469.00 $1,498.00 $315.00 $331.00 $349.00
58356 10 ---------- $2,584.00 $2,750.00 $2,803.00 $500.00 $525.00 $556.00
58400 90 $519.00 $634.00 $666.00 $702.00 $634.00 $666.00 $702.00
58410 90 $752.00 $1,166.00 $1,228.00 $1,301.00 $1,166.00 $1,228.00 $1,301.00
58520 90 $663.00 $1,234.00 $1,321.00 $1,441.00 $1,234.00 $1,321.00 $1,441.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 261
Surgery
CPT Code FUD 2003 MRALocality 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)
58540 90 $923.00 $1,298.00 $1,363.00 $1,437.00 $1,298.00 $1,363.00 $1,437.00
58541 90 ---------- $1,033.00 $1,086.00 $1,145.00 $1,033.00 $1,086.00 $1,145.00
58542 90 ---------- $1,182.00 $1,242.00 $1,313.00 $1,182.00 $1,242.00 $1,313.00
58543 90 ---------- $1,192.00 $1,251.00 $1,319.00 $1,192.00 $1,251.00 $1,319.00
58544 90 ---------- $1,304.00 $1,373.00 $1,455.00 $1,304.00 $1,373.00 $1,455.00
58545 90 $876.00 $1,312.00 $1,384.00 $1,472.00 $1,312.00 $1,384.00 $1,472.00
58546 90 $1,104.00 $1,619.00 $1,699.00 $1,794.00 $1,619.00 $1,699.00 $1,794.00
58548 90 ---------- $2,829.00 $3,022.00 $3,286.00 $2,829.00 $3,022.00 $3,286.00
58550 90 $1,038.00 $1,272.00 $1,337.00 $1,412.00 $1,272.00 $1,337.00 $1,412.00
58552 90 $853.00 $1,432.00 $1,509.00 $1,604.00 $1,432.00 $1,509.00 $1,604.00
58553 90 $1,096.00 $1,646.00 $1,731.00 $1,835.00 $1,646.00 $1,731.00 $1,835.00
58554 90 $1,085.00 $1,928.00 $2,033.00 $2,164.00 $1,928.00 $2,033.00 $2,164.00
58555 0 $261.00 $377.00 $399.00 $414.00 $223.00 $235.00 $248.00
58558 0 $340.00 $1,869.00 $1,990.00 $2,028.00 $342.00 $360.00 $381.00
58559 0 $436.00 $421.00 $443.00 $469.00 $421.00 $443.00 $469.00
58560 0 $482.00 $461.00 $484.00 $511.00 $461.00 $484.00 $511.00
58561 0 $677.00 $631.00 $664.00 $697.00 $631.00 $664.00 $697.00
58562 0 $339.00 $481.00 $508.00 $530.00 $337.00 $355.00 $375.00
58563 0 $450.00 $2,180.00 $2,322.00 $2,362.00 $396.00 $416.00 $438.00
58565 90 ---------- $2,585.00 $2,751.00 $2,806.00 $624.00 $656.00 $690.00
58570 90 ---------- $1,127.00 $1,187.00 $1,256.00 $1,127.00 $1,187.00 $1,256.00
58571 90 ---------- $1,314.00 $1,394.00 $1,497.00 $1,314.00 $1,394.00 $1,497.00
58572 90 ---------- $1,482.00 $1,562.00 $1,660.00 $1,482.00 $1,562.00 $1,660.00
58573 90 ---------- $1,782.00 $1,889.00 $2,029.00 $1,782.00 $1,889.00 $2,029.00
58578 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
58579 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
58600 90 $337.00 $520.00 $545.00 $572.00 $520.00 $545.00 $572.00
58605 90 $298.00 $472.00 $496.00 $522.00 $472.00 $496.00 $522.00
58611 ZZZ $47.00 $112.00 $117.00 $124.00 $112.00 $117.00 $124.00
58615 10 $319.00 $359.00 $378.00 $401.00 $359.00 $378.00 $401.00
58660 90 $793.00 $977.00 $1,030.00 $1,095.00 $977.00 $1,030.00 $1,095.00
58661 10 $804.00 $946.00 $998.00 $1,064.00 $946.00 $998.00 $1,064.00
58662 90 $807.00 $1,031.00 $1,087.00 $1,155.00 $1,031.00 $1,087.00 $1,155.00
58670 90 $450.00 $524.00 $551.00 $580.00 $524.00 $551.00 $580.00
58671 90 $463.00 $522.00 $548.00 $577.00 $522.00 $548.00 $577.00
58672 90 $872.00 $1,057.00 $1,110.00 $1,171.00 $1,057.00 $1,110.00 $1,171.00
58673 90 $928.00 $1,151.00 $1,209.00 $1,277.00 $1,151.00 $1,209.00 $1,277.00
58679 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
58700 90 $544.00 $1,135.00 $1,201.00 $1,284.00 $1,135.00 $1,201.00 $1,284.00
58720 90 $844.00 $1,078.00 $1,144.00 $1,226.00 $1,078.00 $1,144.00 $1,226.00
58740 90 $508.00 $1,286.00 $1,360.00 $1,451.00 $1,286.00 $1,360.00 $1,451.00
58750 90 $949.00 $1,411.00 $1,504.00 $1,626.00 $1,411.00 $1,504.00 $1,626.00
58752 90 $893.00 $1,314.00 $1,385.00 $1,472.00 $1,314.00 $1,385.00 $1,472.00
58760 90 $769.00 $1,163.00 $1,221.00 $1,288.00 $1,163.00 $1,221.00 $1,288.00
58770 90 $763.00 $1,274.00 $1,353.00 $1,457.00 $1,274.00 $1,353.00 $1,457.00
58800 90 $343.00 $452.00 $476.00 $500.00 $426.00 $448.00 $472.00
58805 90 $509.00 $582.00 $612.00 $643.00 $582.00 $612.00 $643.00
58820 90 $326.00 $473.00 $503.00 $537.00 $473.00 $503.00 $537.00
58822 90 $603.00 $1,004.00 $1,055.00 $1,111.00 $1,004.00 $1,055.00 $1,111.00
58825 90 $469.00 $1,112.00 $1,189.00 $1,292.00 $1,112.00 $1,189.00 $1,292.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 262
Surgery
CPT Code FUD 2003 MRALocality 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)
58900 90 $489.00 $594.00 $625.00 $658.00 $594.00 $625.00 $658.00
58920 90 $571.00 $1,114.00 $1,195.00 $1,305.00 $1,114.00 $1,195.00 $1,305.00
58925 90 $820.00 $1,087.00 $1,150.00 $1,228.00 $1,087.00 $1,150.00 $1,228.00
58940 90 $592.00 $768.00 $816.00 $875.00 $768.00 $816.00 $875.00
58943 90 $1,368.00 $1,737.00 $1,851.00 $2,006.00 $1,737.00 $1,851.00 $2,006.00
58950 90 $1,170.00 $1,674.00 $1,786.00 $1,937.00 $1,674.00 $1,786.00 $1,937.00
58951 90 $1,703.00 $2,162.00 $2,308.00 $2,508.00 $2,162.00 $2,308.00 $2,508.00
58952 90 $1,876.00 $2,447.00 $2,615.00 $2,843.00 $2,447.00 $2,615.00 $2,843.00
58953 90 $1,839.00 $3,030.00 $3,236.00 $3,521.00 $3,030.00 $3,236.00 $3,521.00
58954 90 $1,999.00 $3,294.00 $3,520.00 $3,834.00 $3,294.00 $3,520.00 $3,834.00
58956 90 ---------- $2,052.00 $2,190.00 $2,376.00 $2,052.00 $2,190.00 $2,376.00
58957 90 ---------- $2,365.00 $2,528.00 $2,751.00 $2,365.00 $2,528.00 $2,751.00
58958 90 ---------- $2,607.00 $2,784.00 $3,026.00 $2,607.00 $2,784.00 $3,026.00
58960 90 $1,174.00 $1,435.00 $1,532.00 $1,661.00 $1,435.00 $1,532.00 $1,661.00
58999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
59000 0 $123.00 $182.00 $195.00 $209.00 $122.00 $131.00 $145.00
59001 0 $167.00 $271.00 $292.00 $322.00 $271.00 $292.00 $322.00
59012 0 $267.00 $307.00 $331.00 $366.00 $307.00 $331.00 $366.00
59015 0 $168.00 $231.00 $249.00 $272.00 $201.00 $216.00 $239.00
59020 0 $85.00 $102.00 $109.00 $116.00 $102.00 $109.00 $116.00
59020-26 0 ---------- $56.00 $60.00 $66.00 $56.00 $60.00 $66.00
59020-TC 0 ---------- $46.00 $50.00 $50.00 $46.00 $50.00 $50.00
59025 0 $54.00 $70.00 $75.00 $80.00 $70.00 $75.00 $80.00
59025-26 0 ---------- $45.00 $48.00 $53.00 $45.00 $48.00 $53.00
59025-TC 0 ---------- $25.00 $27.00 $28.00 $25.00 $27.00 $28.00
59030 0 $155.00 $146.00 $151.00 $157.00 $146.00 $151.00 $157.00
59050 0 $71.00 $72.00 $76.00 $82.00 $72.00 $76.00 $82.00
59051 0 $47.00 $64.00 $69.00 $77.00 $64.00 $69.00 $77.00
59100 90 $633.00 $1,155.00 $1,220.00 $1,301.00 $1,155.00 $1,220.00 $1,301.00
59120 90 $893.00 $1,186.00 $1,275.00 $1,400.00 $1,186.00 $1,275.00 $1,400.00
59121 90 $768.00 $1,188.00 $1,276.00 $1,398.00 $1,188.00 $1,276.00 $1,398.00
59130 90 $832.00 $1,398.00 $1,506.00 $1,659.00 $1,398.00 $1,506.00 $1,659.00
59135 90 $1,083.00 $1,202.00 $1,250.00 $1,296.00 $1,202.00 $1,250.00 $1,296.00
59136 90 $934.00 $1,324.00 $1,425.00 $1,571.00 $1,324.00 $1,425.00 $1,571.00
59140 90 $461.00 $535.00 $558.00 $577.00 $535.00 $558.00 $577.00
59150 90 $543.00 $1,150.00 $1,235.00 $1,355.00 $1,150.00 $1,235.00 $1,355.00
59151 90 $690.00 $1,124.00 $1,210.00 $1,332.00 $1,124.00 $1,210.00 $1,332.00
59160 10 $279.00 $300.00 $323.00 $351.00 $260.00 $280.00 $307.00
59200 0 $79.00 $104.00 $112.00 $120.00 $68.00 $73.00 $80.00
59300 0 $179.00 $282.00 $303.00 $326.00 $222.00 $238.00 $262.00
59320 0 $196.00 $230.00 $248.00 $273.00 $230.00 $248.00 $273.00
59325 0 $316.00 $367.00 $395.00 $437.00 $367.00 $395.00 $437.00
59350 0 $375.00 $413.00 $440.00 $478.00 $413.00 $440.00 $478.00
59400 0 $1,816.00 $3,114.00 $3,342.00 $3,651.00 $3,114.00 $3,342.00 $3,651.00
59409 0 $1,019.00 $1,229.00 $1,320.00 $1,455.00 $1,229.00 $1,320.00 $1,455.00
59410 0 $1,123.00 $1,568.00 $1,684.00 $1,855.00 $1,568.00 $1,684.00 $1,855.00
59412 0 $141.00 $155.00 $167.00 $184.00 $155.00 $167.00 $184.00
59414 0 $134.00 $140.00 $151.00 $167.00 $140.00 $151.00 $167.00
59425 0 $414.00 $671.00 $719.00 $779.00 $538.00 $577.00 $636.00
59426 0 $708.00 $1,198.00 $1,283.00 $1,387.00 $948.00 $1,016.00 $1,116.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 263
Surgery
CPT Code FUD 2003 MRALocality 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)
59430 0 $140.00 $271.00 $291.00 $314.00 $210.00 $225.00 $248.00
59510 0 $2,064.00 $3,466.00 $3,729.00 $4,090.00 $3,466.00 $3,729.00 $4,090.00
59514 0 $1,199.00 $1,388.00 $1,493.00 $1,650.00 $1,388.00 $1,493.00 $1,650.00
59515 0 $1,324.00 $1,909.00 $2,055.00 $2,270.00 $1,909.00 $2,055.00 $2,270.00
59525 ZZZ $591.00 $738.00 $795.00 $881.00 $738.00 $795.00 $881.00
59610 0 $1,805.00 $3,289.00 $3,540.00 $3,888.00 $3,289.00 $3,540.00 $3,888.00
59612 0 $1,113.00 $1,393.00 $1,501.00 $1,664.00 $1,393.00 $1,501.00 $1,664.00
59614 0 $1,208.00 $1,730.00 $1,864.00 $2,064.00 $1,730.00 $1,864.00 $2,064.00
59618 0 $2,035.00 $3,515.00 $3,783.00 $4,154.00 $3,515.00 $3,783.00 $4,154.00
59620 0 $1,293.00 $1,416.00 $1,520.00 $1,676.00 $1,416.00 $1,520.00 $1,676.00
59622 0 $1,397.00 $1,941.00 $2,086.00 $2,297.00 $1,941.00 $2,086.00 $2,297.00
59812 90 $343.00 $472.00 $507.00 $553.00 $442.00 $475.00 $520.00
59820 90 $389.00 $558.00 $600.00 $650.00 $528.00 $568.00 $617.00
59821 90 $398.00 $564.00 $606.00 $657.00 $530.00 $570.00 $621.00
59830 90 $496.00 $653.00 $703.00 $771.00 $653.00 $703.00 $771.00
59840 10 $331.00 $321.00 $345.00 $375.00 $309.00 $332.00 $362.00
59841 10 $443.00 $571.00 $614.00 $672.00 $542.00 $583.00 $641.00
59850 90 $449.00 $570.00 $613.00 $674.00 $570.00 $613.00 $674.00
59851 90 $464.00 $596.00 $641.00 $702.00 $596.00 $641.00 $702.00
59852 90 $642.00 $725.00 $756.00 $782.00 $725.00 $756.00 $782.00
59855 90 $477.00 $623.00 $670.00 $736.00 $623.00 $670.00 $736.00
59856 90 $577.00 $734.00 $790.00 $870.00 $734.00 $790.00 $870.00
59857 90 $711.00 $748.00 $779.00 $807.00 $748.00 $779.00 $807.00
59866 0 $304.00 $313.00 $326.00 $338.00 $313.00 $326.00 $338.00
59870 90 $348.00 $701.00 $754.00 $822.00 $701.00 $754.00 $822.00
59871 0 $192.00 $202.00 $218.00 $240.00 $202.00 $218.00 $240.00
59898 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
59899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
60000 10 $114.00 $226.00 $239.00 $249.00 $205.00 $216.00 $226.00
60100 0 $96.00 $161.00 $169.00 $176.00 $116.00 $121.00 $127.00
60200 90 $744.00 $971.00 $1,034.00 $1,110.00 $971.00 $1,034.00 $1,110.00
60210 90 $872.00 $1,045.00 $1,114.00 $1,202.00 $1,045.00 $1,114.00 $1,202.00
60212 90 $1,170.00 $1,494.00 $1,593.00 $1,722.00 $1,494.00 $1,593.00 $1,722.00
60220 90 $851.00 $1,040.00 $1,106.00 $1,189.00 $1,040.00 $1,106.00 $1,189.00
60225 90 $1,107.00 $1,374.00 $1,464.00 $1,578.00 $1,374.00 $1,464.00 $1,578.00
60240 90 $1,228.00 $1,361.00 $1,451.00 $1,569.00 $1,361.00 $1,451.00 $1,569.00
60252 90 $1,427.00 $1,960.00 $2,088.00 $2,259.00 $1,960.00 $2,088.00 $2,259.00
60254 90 $1,911.00 $2,468.00 $2,622.00 $2,826.00 $2,468.00 $2,622.00 $2,826.00
60260 90 $1,022.00 $1,618.00 $1,721.00 $1,857.00 $1,618.00 $1,721.00 $1,857.00
60270 90 $1,468.00 $2,035.00 $2,168.00 $2,349.00 $2,035.00 $2,168.00 $2,349.00
60271 90 $1,210.00 $1,566.00 $1,666.00 $1,798.00 $1,566.00 $1,666.00 $1,798.00
60280 90 $546.00 $641.00 $680.00 $719.00 $641.00 $680.00 $719.00
60281 90 $670.00 $864.00 $918.00 $981.00 $864.00 $918.00 $981.00
60300 0 ---------- $166.00 $175.00 $181.00 $73.00 $77.00 $81.00
60500 90 $1,232.00 $1,433.00 $1,530.00 $1,659.00 $1,433.00 $1,530.00 $1,659.00
60502 90 $1,475.00 $1,916.00 $2,047.00 $2,224.00 $1,916.00 $2,047.00 $2,224.00
60505 90 $1,631.00 $2,050.00 $2,180.00 $2,350.00 $2,050.00 $2,180.00 $2,350.00
60512 ZZZ $310.00 $365.00 $389.00 $425.00 $365.00 $389.00 $425.00
60520 90 $1,405.00 $1,561.00 $1,672.00 $1,829.00 $1,561.00 $1,672.00 $1,829.00
60521 90 $1,591.00 $1,684.00 $1,805.00 $1,978.00 $1,684.00 $1,805.00 $1,978.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 264
Surgery
CPT Code FUD 2003 MRALocality 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)
60522 90 $1,820.00 $2,048.00 $2,196.00 $2,409.00 $2,048.00 $2,196.00 $2,409.00
60540 90 $1,272.00 $1,585.00 $1,688.00 $1,827.00 $1,585.00 $1,688.00 $1,827.00
60545 90 $1,505.00 $1,816.00 $1,936.00 $2,100.00 $1,816.00 $1,936.00 $2,100.00
60600 90 $1,477.00 $2,088.00 $2,231.00 $2,442.00 $2,088.00 $2,231.00 $2,442.00
60605 90 $1,624.00 $2,858.00 $3,030.00 $3,244.00 $2,858.00 $3,030.00 $3,244.00
60650 90 $1,340.00 $1,782.00 $1,900.00 $2,064.00 $1,782.00 $1,900.00 $2,064.00
60659 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
60699 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
61020 0 $150.00 $152.00 $164.00 $181.00 $152.00 $164.00 $181.00
61026 0 $138.00 $154.00 $163.00 $175.00 $154.00 $163.00 $175.00
61050 0 $106.00 $126.00 $132.00 $138.00 $126.00 $132.00 $138.00
61055 0 $143.00 $181.00 $192.00 $207.00 $181.00 $192.00 $207.00
61070 0 $67.00 $85.00 $90.00 $97.00 $85.00 $90.00 $97.00
61105 90 $503.00 $671.00 $731.00 $812.00 $671.00 $731.00 $812.00
61107 0 $863.00 $494.00 $543.00 $621.00 $494.00 $543.00 $621.00
61108 90 $959.00 $1,384.00 $1,514.00 $1,695.00 $1,384.00 $1,514.00 $1,695.00
61120 90 $733.00 $1,144.00 $1,253.00 $1,407.00 $1,144.00 $1,253.00 $1,407.00
61140 90 $1,389.00 $1,944.00 $2,130.00 $2,401.00 $1,944.00 $2,130.00 $2,401.00
61150 90 $1,503.00 $2,099.00 $2,304.00 $2,609.00 $2,099.00 $2,304.00 $2,609.00
61151 90 $795.00 $1,542.00 $1,692.00 $1,914.00 $1,542.00 $1,692.00 $1,914.00
61154 90 $1,393.00 $1,955.00 $2,142.00 $2,412.00 $1,955.00 $2,142.00 $2,412.00
61156 90 $1,473.00 $1,931.00 $2,120.00 $2,400.00 $1,931.00 $2,120.00 $2,400.00
61210 0 $527.00 $582.00 $641.00 $734.00 $582.00 $641.00 $734.00
61215 90 $637.00 $773.00 $845.00 $942.00 $773.00 $845.00 $942.00
61250 90 $888.00 $1,260.00 $1,368.00 $1,518.00 $1,260.00 $1,368.00 $1,518.00
61253 90 $1,042.00 $1,194.00 $1,261.00 $1,340.00 $1,194.00 $1,261.00 $1,340.00
61304 90 $2,005.00 $2,530.00 $2,771.00 $3,131.00 $2,530.00 $2,771.00 $3,131.00
61305 90 $2,419.00 $3,136.00 $3,446.00 $3,914.00 $3,136.00 $3,446.00 $3,914.00
61312 90 $2,187.00 $3,229.00 $3,544.00 $4,019.00 $3,229.00 $3,544.00 $4,019.00
61313 90 $2,207.00 $3,070.00 $3,367.00 $3,809.00 $3,070.00 $3,367.00 $3,809.00
61314 90 $2,200.00 $2,830.00 $3,103.00 $3,510.00 $2,830.00 $3,103.00 $3,510.00
61315 90 $2,393.00 $3,213.00 $3,526.00 $3,998.00 $3,213.00 $3,526.00 $3,998.00
61316 ZZZ $88.00 $140.00 $154.00 $177.00 $140.00 $154.00 $177.00
61320 90 $2,118.00 $2,945.00 $3,229.00 $3,655.00 $2,945.00 $3,229.00 $3,655.00
61321 90 $2,310.00 $3,280.00 $3,598.00 $4,077.00 $3,280.00 $3,598.00 $4,077.00
61322 90 $1,779.00 $3,695.00 $4,056.00 $4,602.00 $3,695.00 $4,056.00 $4,602.00
61323 90 $1,842.00 $3,753.00 $4,127.00 $4,699.00 $3,753.00 $4,127.00 $4,699.00
61330 90 $1,706.00 $2,711.00 $2,963.00 $3,335.00 $2,711.00 $2,963.00 $3,335.00
61332 90 $2,307.00 $2,491.00 $2,611.00 $2,733.00 $2,491.00 $2,611.00 $2,733.00
61333 90 $2,231.00 $2,620.00 $2,738.00 $2,840.00 $2,620.00 $2,738.00 $2,840.00
61340 90 $1,584.00 $2,250.00 $2,471.00 $2,800.00 $2,250.00 $2,471.00 $2,800.00
61343 90 $2,673.00 $3,403.00 $3,731.00 $4,224.00 $3,403.00 $3,731.00 $4,224.00
61345 90 $2,259.00 $3,158.00 $3,467.00 $3,933.00 $3,158.00 $3,467.00 $3,933.00
61450 90 $2,173.00 $3,005.00 $3,303.00 $3,756.00 $3,005.00 $3,303.00 $3,756.00
61458 90 $2,433.00 $3,118.00 $3,422.00 $3,879.00 $3,118.00 $3,422.00 $3,879.00
61460 90 $2,426.00 $3,192.00 $3,497.00 $3,954.00 $3,192.00 $3,497.00 $3,954.00
61480 90 $1,922.00 $3,033.00 $3,334.00 $3,792.00 $3,033.00 $3,334.00 $3,792.00
61500 90 $1,637.00 $2,004.00 $2,174.00 $2,414.00 $2,004.00 $2,174.00 $2,414.00
61501 90 $1,353.00 $1,735.00 $1,878.00 $2,076.00 $1,735.00 $1,878.00 $2,076.00
61510 90 $2,506.00 $3,379.00 $3,705.00 $4,191.00 $3,379.00 $3,705.00 $4,191.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 265
Surgery
CPT Code FUD 2003 MRALocality 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)
61512 90 $2,981.00 $3,956.00 $4,341.00 $4,924.00 $3,956.00 $4,341.00 $4,924.00
61514 90 $2,262.00 $2,945.00 $3,229.00 $3,653.00 $2,945.00 $3,229.00 $3,653.00
61516 90 $2,253.00 $2,873.00 $3,148.00 $3,558.00 $2,873.00 $3,148.00 $3,558.00
61517 ZZZ $74.00 $138.00 $152.00 $174.00 $138.00 $152.00 $174.00
61518 90 $3,163.00 $4,276.00 $4,690.00 $5,316.00 $4,276.00 $4,690.00 $5,316.00
61519 90 $3,450.00 $4,570.00 $5,014.00 $5,690.00 $4,570.00 $5,014.00 $5,690.00
61520 90 $4,349.00 $5,831.00 $6,379.00 $7,210.00 $5,831.00 $6,379.00 $7,210.00
61521 90 $3,667.00 $4,945.00 $5,429.00 $6,169.00 $4,945.00 $5,429.00 $6,169.00
61522 90 $2,415.00 $3,417.00 $3,756.00 $4,271.00 $3,417.00 $3,756.00 $4,271.00
61524 90 $2,484.00 $3,237.00 $3,556.00 $4,037.00 $3,237.00 $3,556.00 $4,037.00
61526 90 $3,918.00 $5,725.00 $6,297.00 $7,180.00 $5,725.00 $6,297.00 $7,180.00
61530 90 $3,611.00 $4,771.00 $5,240.00 $5,962.00 $4,771.00 $5,240.00 $5,962.00
61531 90 $1,344.00 $1,855.00 $2,033.00 $2,293.00 $1,855.00 $2,033.00 $2,293.00
61533 90 $1,712.00 $2,342.00 $2,567.00 $2,901.00 $2,342.00 $2,567.00 $2,901.00
61534 90 $1,535.00 $2,561.00 $2,813.00 $3,190.00 $2,561.00 $2,813.00 $3,190.00
61535 90 $958.00 $1,515.00 $1,659.00 $1,868.00 $1,515.00 $1,659.00 $1,868.00
61536 90 $2,862.00 $3,975.00 $4,358.00 $4,938.00 $3,975.00 $4,358.00 $4,938.00
61537 90 ---------- $3,859.00 $4,241.00 $4,826.00 $3,859.00 $4,241.00 $4,826.00
61538 90 $2,466.00 $4,161.00 $4,573.00 $5,205.00 $4,161.00 $4,573.00 $5,205.00
61539 90 $2,660.00 $3,692.00 $4,060.00 $4,620.00 $3,692.00 $4,060.00 $4,620.00
61540 90 ---------- $3,356.00 $3,682.00 $4,174.00 $3,356.00 $3,682.00 $4,174.00
61541 90 $2,363.00 $3,357.00 $3,691.00 $4,196.00 $3,357.00 $3,691.00 $4,196.00
61543 90 $2,307.00 $3,216.00 $3,500.00 $3,914.00 $3,216.00 $3,500.00 $3,914.00
61544 90 $2,271.00 $2,971.00 $3,266.00 $3,713.00 $2,971.00 $3,266.00 $3,713.00
61545 90 $3,474.00 $4,984.00 $5,480.00 $6,239.00 $4,984.00 $5,480.00 $6,239.00
61546 90 $2,695.00 $3,586.00 $3,940.00 $4,478.00 $3,586.00 $3,940.00 $4,478.00
61548 90 $1,964.00 $2,418.00 $2,636.00 $2,957.00 $2,418.00 $2,636.00 $2,957.00
61550 90 $1,141.00 $1,831.00 $2,009.00 $2,265.00 $1,831.00 $2,009.00 $2,265.00
61552 90 $1,463.00 $1,710.00 $1,802.00 $1,915.00 $1,710.00 $1,802.00 $1,915.00
61556 90 $1,760.00 $2,361.00 $2,551.00 $2,821.00 $2,361.00 $2,551.00 $2,821.00
61557 90 $1,807.00 $2,614.00 $2,871.00 $3,253.00 $2,614.00 $2,871.00 $3,253.00
61558 90 $2,085.00 $2,926.00 $3,214.00 $3,648.00 $2,926.00 $3,214.00 $3,648.00
61559 90 $2,700.00 $3,482.00 $3,766.00 $4,162.00 $3,482.00 $3,766.00 $4,162.00
61563 90 $2,175.00 $3,060.00 $3,357.00 $3,803.00 $3,060.00 $3,357.00 $3,803.00
61564 90 $2,597.00 $3,508.00 $3,813.00 $4,258.00 $3,508.00 $3,813.00 $4,258.00
61566 90 ---------- $3,513.00 $3,862.00 $4,392.00 $3,513.00 $3,862.00 $4,392.00
61567 90 ---------- $3,709.00 $4,087.00 $4,688.00 $3,709.00 $4,087.00 $4,688.00
61570 90 $1,975.00 $2,846.00 $3,117.00 $3,520.00 $2,846.00 $3,117.00 $3,520.00
61571 90 $2,140.00 $3,104.00 $3,411.00 $3,875.00 $3,104.00 $3,411.00 $3,875.00
61575 90 $2,992.00 $3,859.00 $4,231.00 $4,794.00 $3,859.00 $4,231.00 $4,794.00
61576 90 $3,772.00 $5,034.00 $5,337.00 $5,705.00 $5,034.00 $5,337.00 $5,705.00
61580 90 $2,383.00 $3,657.00 $3,917.00 $4,235.00 $3,657.00 $3,917.00 $4,235.00
61581 90 $2,674.00 $3,869.00 $4,095.00 $4,339.00 $3,869.00 $4,095.00 $4,339.00
61582 90 $2,557.00 $4,560.00 $4,983.00 $5,553.00 $4,560.00 $4,983.00 $5,553.00
61583 90 $2,972.00 $4,422.00 $4,835.00 $5,423.00 $4,422.00 $4,835.00 $5,423.00
61584 90 $2,830.00 $4,340.00 $4,744.00 $5,318.00 $4,340.00 $4,744.00 $5,318.00
61585 90 $3,142.00 $4,857.00 $5,316.00 $5,980.00 $4,857.00 $5,316.00 $5,980.00
61586 90 $2,097.00 $3,587.00 $3,913.00 $4,342.00 $3,587.00 $3,913.00 $4,342.00
61590 90 $3,299.00 $4,506.00 $4,805.00 $5,180.00 $4,506.00 $4,805.00 $5,180.00
61591 90 $3,491.00 $4,584.00 $4,906.00 $5,325.00 $4,584.00 $4,906.00 $5,325.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 266
Surgery
CPT Code FUD 2003 MRALocality 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)
61592 90 $3,245.00 $4,857.00 $5,308.00 $5,954.00 $4,857.00 $5,308.00 $5,954.00
61595 90 $2,350.00 $3,488.00 $3,740.00 $4,060.00 $3,488.00 $3,740.00 $4,060.00
61596 90 $2,827.00 $3,581.00 $3,786.00 $4,026.00 $3,581.00 $3,786.00 $4,026.00
61597 90 $3,046.00 $4,365.00 $4,759.00 $5,332.00 $4,365.00 $4,759.00 $5,332.00
61598 90 $2,693.00 $4,274.00 $4,673.00 $5,236.00 $4,274.00 $4,673.00 $5,236.00
61600 90 $2,039.00 $3,144.00 $3,366.00 $3,637.00 $3,144.00 $3,366.00 $3,637.00
61601 90 $2,279.00 $3,641.00 $3,971.00 $4,430.00 $3,641.00 $3,971.00 $4,430.00
61605 90 $2,299.00 $3,174.00 $3,367.00 $3,588.00 $3,174.00 $3,367.00 $3,588.00
61606 90 $3,178.00 $4,513.00 $4,916.00 $5,495.00 $4,513.00 $4,916.00 $5,495.00
61607 90 $2,961.00 $4,051.00 $4,361.00 $4,785.00 $4,051.00 $4,361.00 $4,785.00
61608 90 $3,458.00 $4,993.00 $5,462.00 $6,148.00 $4,993.00 $5,462.00 $6,148.00
61610 ZZZ $2,354.00 $2,476.00 $2,631.00 $2,843.00 $2,476.00 $2,631.00 $2,843.00
61611 ZZZ $584.00 $576.00 $606.00 $646.00 $576.00 $606.00 $646.00
61612 ZZZ $2,219.00 $1,768.00 $1,828.00 $1,915.00 $1,768.00 $1,828.00 $1,915.00
61613 90 $3,375.00 $4,927.00 $5,372.00 $6,011.00 $4,927.00 $5,372.00 $6,011.00
61615 90 $2,576.00 $3,701.00 $3,986.00 $4,365.00 $3,701.00 $3,986.00 $4,365.00
61616 90 $3,535.00 $5,075.00 $5,529.00 $6,179.00 $5,075.00 $5,529.00 $6,179.00
61618 90 $1,389.00 $1,973.00 $2,146.00 $2,393.00 $1,973.00 $2,146.00 $2,393.00
61619 90 $1,682.00 $2,165.00 $2,335.00 $2,572.00 $2,165.00 $2,335.00 $2,572.00
61623 0 $540.00 $870.00 $938.00 $1,040.00 $870.00 $938.00 $1,040.00
61624 0 $1,073.00 $1,752.00 $1,890.00 $2,101.00 $1,752.00 $1,890.00 $2,101.00
61626 0 $877.00 $1,289.00 $1,363.00 $1,467.00 $1,289.00 $1,363.00 $1,467.00
61630 0 ---------- $2,045.00 $2,208.00 $2,446.00 $2,045.00 $2,208.00 $2,446.00
61635 0 ---------- $2,173.00 $2,334.00 $2,567.00 $2,173.00 $2,334.00 $2,567.00
61640 0 ---------- $733.00 $768.00 $834.00 $733.00 $768.00 $834.00
61641 ZZZ ---------- $257.00 $270.00 $292.00 $257.00 $270.00 $292.00
61642 ZZZ ---------- $514.00 $539.00 $585.00 $514.00 $539.00 $585.00
61645 0 ---------- $1,187.00 $1,268.00 $1,392.00 $1,187.00 $1,268.00 $1,392.00
61650 0 ---------- $813.00 $872.00 $962.00 $813.00 $872.00 $962.00
61651 ZZZ ---------- $346.00 $371.00 $409.00 $346.00 $371.00 $409.00
61680 90 $2,758.00 $3,505.00 $3,845.00 $4,356.00 $3,505.00 $3,845.00 $4,356.00
61682 90 $4,798.00 $6,494.00 $7,128.00 $8,107.00 $6,494.00 $7,128.00 $8,107.00
61684 90 $3,341.00 $4,454.00 $4,897.00 $5,577.00 $4,454.00 $4,897.00 $5,577.00
61686 90 $5,012.00 $7,056.00 $7,761.00 $8,854.00 $7,056.00 $7,761.00 $8,854.00
61690 90 $2,556.00 $3,378.00 $3,706.00 $4,198.00 $3,378.00 $3,706.00 $4,198.00
61692 90 $4,007.00 $5,715.00 $6,282.00 $7,155.00 $5,715.00 $6,282.00 $7,155.00
61697 90 $3,231.00 $6,575.00 $7,221.00 $8,217.00 $6,575.00 $7,221.00 $8,217.00
61698 90 $3,103.00 $7,256.00 $7,979.00 $9,097.00 $7,256.00 $7,979.00 $9,097.00
61700 90 $4,037.00 $5,304.00 $5,821.00 $6,612.00 $5,304.00 $5,821.00 $6,612.00
61702 90 $4,019.00 $6,252.00 $6,863.00 $7,801.00 $6,252.00 $6,863.00 $7,801.00
61703 90 $1,444.00 $1,884.00 $2,045.00 $2,278.00 $1,884.00 $2,045.00 $2,278.00
61705 90 $3,043.00 $4,076.00 $4,482.00 $5,104.00 $4,076.00 $4,482.00 $5,104.00
61708 90 $2,546.00 $3,569.00 $3,879.00 $4,344.00 $3,569.00 $3,879.00 $4,344.00
61710 90 $2,129.00 $3,314.00 $3,637.00 $4,130.00 $3,314.00 $3,637.00 $4,130.00
61711 90 $3,150.00 $4,058.00 $4,457.00 $5,063.00 $4,058.00 $4,457.00 $5,063.00
61720 90 $1,558.00 $1,975.00 $2,169.00 $2,458.00 $1,975.00 $2,169.00 $2,458.00
61735 90 $1,664.00 $2,476.00 $2,720.00 $3,086.00 $2,476.00 $2,720.00 $3,086.00
61750 90 $1,521.00 $2,183.00 $2,397.00 $2,717.00 $2,183.00 $2,397.00 $2,717.00
61751 90 $1,628.00 $2,135.00 $2,343.00 $2,649.00 $2,135.00 $2,343.00 $2,649.00
61760 90 $1,670.00 $2,453.00 $2,694.00 $3,057.00 $2,453.00 $2,694.00 $3,057.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 267
Surgery
CPT Code FUD 2003 MRALocality 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)
61770 90 $1,867.00 $2,534.00 $2,785.00 $3,164.00 $2,534.00 $2,785.00 $3,164.00
61781 ZZZ ---------- $371.00 $407.00 $465.00 $371.00 $407.00 $465.00
61782 ZZZ ---------- $260.00 $275.00 $295.00 $260.00 $275.00 $295.00
61783 ZZZ ---------- $361.00 $395.00 $446.00 $361.00 $395.00 $446.00
61790 90 $952.00 $1,354.00 $1,484.00 $1,672.00 $1,354.00 $1,484.00 $1,672.00
61791 90 $1,205.00 $1,687.00 $1,847.00 $2,081.00 $1,687.00 $1,847.00 $2,081.00
61796 90 ---------- $1,572.00 $1,725.00 $1,950.00 $1,572.00 $1,725.00 $1,950.00
61797 ZZZ ---------- $348.00 $384.00 $440.00 $348.00 $384.00 $440.00
61798 90 ---------- $2,146.00 $2,354.00 $2,667.00 $2,146.00 $2,354.00 $2,667.00
61799 ZZZ ---------- $482.00 $530.00 $608.00 $482.00 $530.00 $608.00
61800 ZZZ ---------- $241.00 $265.00 $301.00 $241.00 $265.00 $301.00
61850 90 $1,090.00 $1,523.00 $1,671.00 $1,890.00 $1,523.00 $1,671.00 $1,890.00
61860 90 $1,197.00 $2,400.00 $2,628.00 $2,969.00 $2,400.00 $2,628.00 $2,969.00
61863 90 ---------- $2,325.00 $2,550.00 $2,883.00 $2,325.00 $2,550.00 $2,883.00
61864 ZZZ ---------- $449.00 $494.00 $566.00 $449.00 $494.00 $566.00
61867 90 ---------- $3,546.00 $3,893.00 $4,419.00 $3,546.00 $3,893.00 $4,419.00
61868 ZZZ ---------- $788.00 $867.00 $992.00 $788.00 $867.00 $992.00
61870 90 $616.00 $1,564.00 $1,686.00 $1,858.00 $1,564.00 $1,686.00 $1,858.00
61880 90 $559.00 $864.00 $944.00 $1,053.00 $864.00 $944.00 $1,053.00
61885 90 $262.00 $776.00 $846.00 $936.00 $776.00 $846.00 $936.00
61886 90 $678.00 $1,280.00 $1,397.00 $1,554.00 $1,280.00 $1,397.00 $1,554.00
61888 10 $331.00 $607.00 $664.00 $745.00 $607.00 $664.00 $745.00
62000 90 $848.00 $1,466.00 $1,595.00 $1,781.00 $1,466.00 $1,595.00 $1,781.00
62005 90 $1,282.00 $1,943.00 $2,126.00 $2,397.00 $1,943.00 $2,126.00 $2,397.00
62010 90 $1,754.00 $2,369.00 $2,600.00 $2,944.00 $2,369.00 $2,600.00 $2,944.00
62100 90 $1,962.00 $2,430.00 $2,647.00 $2,965.00 $2,430.00 $2,647.00 $2,965.00
62115 90 $1,686.00 $1,927.00 $2,031.00 $2,158.00 $1,927.00 $2,031.00 $2,158.00
62117 90 $2,211.00 $3,066.00 $3,371.00 $3,834.00 $3,066.00 $3,371.00 $3,834.00
62120 90 $1,898.00 $2,425.00 $2,565.00 $2,715.00 $2,425.00 $2,565.00 $2,715.00
62121 90 $1,822.00 $2,381.00 $2,561.00 $2,795.00 $2,381.00 $2,561.00 $2,795.00
62140 90 $1,221.00 $1,583.00 $1,726.00 $1,932.00 $1,583.00 $1,726.00 $1,932.00
62141 90 $1,955.00 $1,750.00 $1,910.00 $2,141.00 $1,750.00 $1,910.00 $2,141.00
62142 90 $1,011.00 $1,359.00 $1,486.00 $1,666.00 $1,359.00 $1,486.00 $1,666.00
62143 90 $1,096.00 $1,603.00 $1,755.00 $1,976.00 $1,603.00 $1,755.00 $1,976.00
62145 90 $1,566.00 $2,186.00 $2,394.00 $2,704.00 $2,186.00 $2,394.00 $2,704.00
62146 90 $1,327.00 $1,838.00 $2,004.00 $2,243.00 $1,838.00 $2,004.00 $2,243.00
62147 90 $1,566.00 $2,185.00 $2,383.00 $2,671.00 $2,185.00 $2,383.00 $2,671.00
62148 ZZZ $120.00 $200.00 $220.00 $252.00 $200.00 $220.00 $252.00
62160 ZZZ $172.00 $301.00 $331.00 $379.00 $301.00 $331.00 $379.00
62161 90 $1,229.00 $2,344.00 $2,571.00 $2,907.00 $2,344.00 $2,571.00 $2,907.00
62162 90 $1,578.00 $2,929.00 $3,215.00 $3,642.00 $2,929.00 $3,215.00 $3,642.00
62163 90 $999.00 $1,897.00 $2,083.00 $2,354.00 $1,897.00 $2,083.00 $2,354.00
62164 90 $1,706.00 $3,219.00 $3,531.00 $3,997.00 $3,219.00 $3,531.00 $3,997.00
62165 90 $1,336.00 $2,342.00 $2,537.00 $2,817.00 $2,342.00 $2,537.00 $2,817.00
62180 90 $1,695.00 $2,494.00 $2,740.00 $3,109.00 $2,494.00 $2,740.00 $3,109.00
62190 90 $1,034.00 $1,073.00 $1,139.00 $1,225.00 $1,073.00 $1,139.00 $1,225.00
62192 90 $1,146.00 $1,502.00 $1,643.00 $1,845.00 $1,502.00 $1,643.00 $1,845.00
62194 10 $239.00 $671.00 $729.00 $809.00 $671.00 $729.00 $809.00
62200 90 $1,625.00 $2,091.00 $2,291.00 $2,587.00 $2,091.00 $2,291.00 $2,587.00
62201 90 $1,200.00 $1,856.00 $2,035.00 $2,296.00 $1,856.00 $2,035.00 $2,296.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 268
Surgery
CPT Code FUD 2003 MRALocality 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)
62220 90 $1,215.00 $1,590.00 $1,741.00 $1,962.00 $1,590.00 $1,741.00 $1,962.00
62223 90 $1,199.00 $1,599.00 $1,747.00 $1,957.00 $1,599.00 $1,747.00 $1,957.00
62225 90 $488.00 $768.00 $838.00 $931.00 $768.00 $838.00 $931.00
62230 90 $935.00 $1,291.00 $1,412.00 $1,587.00 $1,291.00 $1,412.00 $1,587.00
62252 0 $85.00 $125.00 $136.00 $148.00 $125.00 $136.00 $148.00
62252-26 0 ---------- $73.00 $80.00 $91.00 $73.00 $80.00 $91.00
62252-TC 0 ---------- $53.00 $56.00 $57.00 $53.00 $56.00 $57.00
62256 90 $616.00 $914.00 $999.00 $1,117.00 $914.00 $999.00 $1,117.00
62258 90 $1,308.00 $1,722.00 $1,885.00 $2,123.00 $1,722.00 $1,885.00 $2,123.00
62263 10 $426.00 $844.00 $891.00 $912.00 $465.00 $487.00 $504.00
62264 10 $593.00 $589.00 $620.00 $638.00 $345.00 $359.00 $375.00
62267 0 ---------- $352.00 $371.00 $383.00 $233.00 $243.00 $254.00
62268 0 $285.00 $379.00 $397.00 $417.00 $379.00 $397.00 $417.00
62269 0 $271.00 $393.00 $412.00 $435.00 $393.00 $412.00 $435.00
62270 0 $109.00 $223.00 $237.00 $246.00 $115.00 $121.00 $129.00
62272 0 $137.00 $284.00 $304.00 $318.00 $125.00 $134.00 $146.00
62273 0 $130.00 $244.00 $256.00 $265.00 $165.00 $172.00 $180.00
62280 10 $199.00 $424.00 $449.00 $465.00 $234.00 $246.00 $260.00
62281 10 $186.00 $342.00 $362.00 $377.00 $229.00 $241.00 $254.00
62282 10 $211.00 $415.00 $440.00 $454.00 $213.00 $224.00 $236.00
62284 0 $196.00 $263.00 $278.00 $287.00 $129.00 $135.00 $143.00
62287 90 $784.00 $834.00 $879.00 $926.00 $834.00 $879.00 $926.00
62290 0 $235.00 $461.00 $487.00 $500.00 $248.00 $259.00 $270.00
62291 0 $232.00 $463.00 $488.00 $500.00 $245.00 $256.00 $266.00
62292 90 $1,064.00 $833.00 $872.00 $907.00 $833.00 $872.00 $907.00
62294 90 $821.00 $1,468.00 $1,611.00 $1,822.00 $1,468.00 $1,611.00 $1,822.00
62302 0 ---------- $341.00 $359.00 $370.00 $180.00 $187.00 $196.00
62303 0 ---------- $351.00 $370.00 $381.00 $181.00 $189.00 $198.00
62304 0 ---------- $336.00 $354.00 $364.00 $176.00 $184.00 $192.00
62305 0 ---------- $365.00 $385.00 $396.00 $184.00 $192.00 $201.00
62320 0 ---------- $236.00 $250.00 $260.00 $149.00 $157.00 $166.00
62321 0 ---------- $348.00 $369.00 $381.00 $161.00 $169.00 $179.00
62322 0 ---------- $220.00 $232.00 $241.00 $128.00 $135.00 $142.00
62323 0 ---------- $341.00 $361.00 $371.00 $147.00 $154.00 $162.00
62324 0 ---------- $208.00 $220.00 $230.00 $138.00 $144.00 $154.00
62325 0 ---------- $311.00 $329.00 $342.00 $158.00 $166.00 $177.00
62326 0 ---------- $217.00 $230.00 $239.00 $134.00 $141.00 $149.00
62327 0 ---------- $315.00 $334.00 $345.00 $143.00 $150.00 $159.00
62350 10 $488.00 $588.00 $626.00 $672.00 $588.00 $626.00 $672.00
62351 90 $782.00 $1,289.00 $1,393.00 $1,530.00 $1,289.00 $1,393.00 $1,530.00
62355 10 $402.00 $393.00 $420.00 $450.00 $393.00 $420.00 $450.00
62360 10 $195.00 $456.00 $487.00 $525.00 $456.00 $487.00 $525.00
62361 10 $390.00 $638.00 $696.00 $775.00 $638.00 $696.00 $775.00
62362 10 $517.00 $569.00 $608.00 $657.00 $569.00 $608.00 $657.00
62365 10 $418.00 $440.00 $472.00 $510.00 $440.00 $472.00 $510.00
62367 0 BR $58.00 $61.00 $64.00 $37.00 $39.00 $41.00
62368 0 BR $80.00 $84.00 $87.00 $51.00 $54.00 $57.00
62369 0 ---------- $164.00 $174.00 $178.00 $52.00 $54.00 $57.00
62370 0 ---------- $174.00 $184.00 $189.00 $67.00 $70.00 $74.00
63001 90 $1,882.00 $1,900.00 $2,073.00 $2,323.00 $1,900.00 $2,073.00 $2,323.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 269
Surgery
CPT Code FUD 2003 MRALocality 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)
63003 90 $1,591.00 $1,894.00 $2,063.00 $2,305.00 $1,894.00 $2,063.00 $2,305.00
63005 90 $1,390.00 $1,798.00 $1,956.00 $2,178.00 $1,798.00 $1,956.00 $2,178.00
63011 90 $1,151.00 $1,640.00 $1,767.00 $1,938.00 $1,640.00 $1,767.00 $1,938.00
63012 90 $1,568.00 $1,808.00 $1,964.00 $2,182.00 $1,808.00 $1,964.00 $2,182.00
63015 90 $1,862.00 $2,271.00 $2,480.00 $2,781.00 $2,271.00 $2,480.00 $2,781.00
63016 90 $1,788.00 $2,333.00 $2,541.00 $2,844.00 $2,333.00 $2,541.00 $2,844.00
63017 90 $1,489.00 $1,919.00 $2,092.00 $2,340.00 $1,919.00 $2,092.00 $2,340.00
63020 90 $1,395.00 $1,759.00 $1,909.00 $2,116.00 $1,759.00 $1,909.00 $2,116.00
63030 90 $1,145.00 $1,462.00 $1,583.00 $1,746.00 $1,462.00 $1,583.00 $1,746.00
63035 ZZZ $280.00 $294.00 $319.00 $356.00 $294.00 $319.00 $356.00
63040 90 $1,764.00 $2,115.00 $2,293.00 $2,544.00 $2,115.00 $2,293.00 $2,544.00
63042 90 $1,620.00 $1,953.00 $2,110.00 $2,325.00 $1,953.00 $2,110.00 $2,325.00
63043 ZZZ BR ---------- ---------- ---------- ---------- ---------- ----------
63044 ZZZ BR ---------- ---------- ---------- ---------- ---------- ----------
63045 90 $1,647.00 $1,964.00 $2,139.00 $2,387.00 $1,964.00 $2,139.00 $2,387.00
63046 90 $2,117.00 $1,851.00 $2,006.00 $2,222.00 $1,851.00 $2,006.00 $2,222.00
63047 90 $1,907.00 $1,664.00 $1,802.00 $1,990.00 $1,664.00 $1,802.00 $1,990.00
63048 ZZZ $367.00 $325.00 $353.00 $394.00 $325.00 $353.00 $394.00
63050 90 ---------- $2,280.00 $2,470.00 $2,737.00 $2,280.00 $2,470.00 $2,737.00
63051 90 ---------- $2,593.00 $2,807.00 $3,109.00 $2,593.00 $2,807.00 $3,109.00
63055 90 $2,029.00 $2,498.00 $2,726.00 $3,059.00 $2,498.00 $2,726.00 $3,059.00
63056 90 $1,960.00 $2,252.00 $2,442.00 $2,710.00 $2,252.00 $2,442.00 $2,710.00
63057 ZZZ $421.00 $492.00 $534.00 $597.00 $492.00 $534.00 $597.00
63064 90 $2,200.00 $2,713.00 $2,953.00 $3,304.00 $2,713.00 $2,953.00 $3,304.00
63066 ZZZ $263.00 $324.00 $356.00 $407.00 $324.00 $356.00 $407.00
63075 90 $1,720.00 $2,055.00 $2,229.00 $2,473.00 $2,055.00 $2,229.00 $2,473.00
63076 ZZZ $383.00 $382.00 $415.00 $466.00 $382.00 $415.00 $466.00
63077 90 $1,828.00 $2,259.00 $2,441.00 $2,698.00 $2,259.00 $2,441.00 $2,698.00
63078 ZZZ $261.00 $295.00 $318.00 $351.00 $295.00 $318.00 $351.00
63081 90 $2,203.00 $2,671.00 $2,896.00 $3,217.00 $2,671.00 $2,896.00 $3,217.00
63082 ZZZ $391.00 $410.00 $445.00 $499.00 $410.00 $445.00 $499.00
63085 90 $2,416.00 $2,915.00 $3,159.00 $3,511.00 $2,915.00 $3,159.00 $3,511.00
63086 ZZZ $282.00 $293.00 $317.00 $353.00 $293.00 $317.00 $353.00
63087 90 $2,930.00 $3,669.00 $3,973.00 $4,412.00 $3,669.00 $3,973.00 $4,412.00
63088 ZZZ $381.00 $399.00 $432.00 $482.00 $399.00 $432.00 $482.00
63090 90 $2,490.00 $2,941.00 $3,157.00 $3,455.00 $2,941.00 $3,157.00 $3,455.00
63091 ZZZ $249.00 $269.00 $289.00 $317.00 $269.00 $289.00 $317.00
63101 90 ---------- $3,537.00 $3,848.00 $4,298.00 $3,537.00 $3,848.00 $4,298.00
63102 90 ---------- $3,448.00 $3,733.00 $4,135.00 $3,448.00 $3,733.00 $4,135.00
63103 ZZZ ---------- $450.00 $488.00 $545.00 $450.00 $488.00 $545.00
63170 90 $1,788.00 $2,478.00 $2,722.00 $3,085.00 $2,478.00 $2,722.00 $3,085.00
63172 90 $1,672.00 $2,177.00 $2,387.00 $2,697.00 $2,177.00 $2,387.00 $2,697.00
63173 90 $1,851.00 $2,639.00 $2,891.00 $3,265.00 $2,639.00 $2,891.00 $3,265.00
63180 90 $1,486.00 $2,026.00 $2,185.00 $2,405.00 $2,026.00 $2,185.00 $2,405.00
63182 90 $1,711.00 $2,539.00 $2,789.00 $3,163.00 $2,539.00 $2,789.00 $3,163.00
63185 90 $1,347.00 $1,720.00 $1,857.00 $2,043.00 $1,720.00 $1,857.00 $2,043.00
63190 90 $1,610.00 $1,926.00 $2,076.00 $2,279.00 $1,926.00 $2,076.00 $2,279.00
63191 90 $1,444.00 $1,901.00 $2,043.00 $2,230.00 $1,901.00 $2,043.00 $2,230.00
63194 90 $1,593.00 $2,099.00 $2,251.00 $2,458.00 $2,099.00 $2,251.00 $2,458.00
63195 90 $1,603.00 $1,869.00 $1,970.00 $2,091.00 $1,869.00 $1,970.00 $2,091.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 270
Surgery
CPT Code FUD 2003 MRALocality 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)
63196 90 $1,810.00 $2,083.00 $2,195.00 $2,333.00 $2,083.00 $2,195.00 $2,333.00
63197 90 $1,725.00 $2,081.00 $2,194.00 $2,328.00 $2,081.00 $2,194.00 $2,328.00
63198 90 $1,956.00 $2,455.00 $2,587.00 $2,752.00 $2,455.00 $2,587.00 $2,752.00
63199 90 $2,258.00 $2,577.00 $2,715.00 $2,888.00 $2,577.00 $2,715.00 $2,888.00
63200 90 $1,569.00 $2,372.00 $2,600.00 $2,938.00 $2,372.00 $2,600.00 $2,938.00
63250 90 $3,182.00 $4,655.00 $5,120.00 $5,836.00 $4,655.00 $5,120.00 $5,836.00
63251 90 $3,207.00 $4,703.00 $5,164.00 $5,870.00 $4,703.00 $5,164.00 $5,870.00
63252 90 $3,319.00 $4,719.00 $5,183.00 $5,891.00 $4,719.00 $5,183.00 $5,891.00
63265 90 $1,940.00 $2,564.00 $2,802.00 $3,151.00 $2,564.00 $2,802.00 $3,151.00
63266 90 $2,053.00 $2,643.00 $2,888.00 $3,248.00 $2,643.00 $2,888.00 $3,248.00
63267 90 $1,651.00 $2,085.00 $2,268.00 $2,528.00 $2,085.00 $2,268.00 $2,528.00
63268 90 $1,469.00 $2,128.00 $2,313.00 $2,574.00 $2,128.00 $2,313.00 $2,574.00
63270 90 $2,197.00 $3,225.00 $3,541.00 $4,018.00 $3,225.00 $3,541.00 $4,018.00
63271 90 $2,401.00 $3,187.00 $3,490.00 $3,944.00 $3,187.00 $3,490.00 $3,944.00
63272 90 $2,206.00 $2,902.00 $3,169.00 $3,563.00 $2,902.00 $3,169.00 $3,563.00
63273 90 $2,012.00 $2,821.00 $3,083.00 $3,468.00 $2,821.00 $3,083.00 $3,468.00
63275 90 $2,166.00 $2,768.00 $3,027.00 $3,410.00 $2,768.00 $3,027.00 $3,410.00
63276 90 $2,135.00 $2,753.00 $3,010.00 $3,390.00 $2,753.00 $3,010.00 $3,390.00
63277 90 $1,905.00 $2,367.00 $2,575.00 $2,873.00 $2,367.00 $2,575.00 $2,873.00
63278 90 $1,877.00 $2,441.00 $2,678.00 $3,029.00 $2,441.00 $2,678.00 $3,029.00
63280 90 $2,529.00 $3,261.00 $3,574.00 $4,041.00 $3,261.00 $3,574.00 $4,041.00
63281 90 $2,496.00 $3,237.00 $3,549.00 $4,014.00 $3,237.00 $3,549.00 $4,014.00
63282 90 $2,305.00 $3,040.00 $3,328.00 $3,756.00 $3,040.00 $3,328.00 $3,756.00
63283 90 $2,041.00 $2,918.00 $3,198.00 $3,614.00 $2,918.00 $3,198.00 $3,614.00
63285 90 $2,934.00 $4,094.00 $4,501.00 $5,122.00 $4,094.00 $4,501.00 $5,122.00
63286 90 $3,003.00 $3,972.00 $4,351.00 $4,921.00 $3,972.00 $4,351.00 $4,921.00
63287 90 $3,012.00 $4,297.00 $4,725.00 $5,379.00 $4,297.00 $4,725.00 $5,379.00
63290 90 $3,073.00 $4,344.00 $4,771.00 $5,423.00 $4,344.00 $4,771.00 $5,423.00
63295 ZZZ ---------- $524.00 $577.00 $661.00 $524.00 $577.00 $661.00
63300 90 $2,006.00 $2,813.00 $3,067.00 $3,438.00 $2,813.00 $3,067.00 $3,438.00
63301 90 $2,209.00 $3,179.00 $3,455.00 $3,859.00 $3,179.00 $3,455.00 $3,859.00
63302 90 $2,290.00 $3,337.00 $3,661.00 $4,150.00 $3,337.00 $3,661.00 $4,150.00
63303 90 $2,357.00 $3,492.00 $3,828.00 $4,339.00 $3,492.00 $3,828.00 $4,339.00
63304 90 $2,513.00 $3,584.00 $3,921.00 $4,425.00 $3,584.00 $3,921.00 $4,425.00
63305 90 $2,574.00 $3,717.00 $4,064.00 $4,587.00 $3,717.00 $4,064.00 $4,587.00
63306 90 $2,596.00 $3,152.00 $3,392.00 $3,746.00 $3,152.00 $3,392.00 $3,746.00
63307 90 $2,522.00 $3,287.00 $3,534.00 $3,881.00 $3,287.00 $3,534.00 $3,881.00
63308 ZZZ $425.00 $501.00 $547.00 $618.00 $501.00 $547.00 $618.00
63600 90 $797.00 $1,299.00 $1,359.00 $1,418.00 $1,299.00 $1,359.00 $1,418.00
63610 0 $476.00 $656.00 $682.00 $710.00 $656.00 $682.00 $710.00
63615 90 $1,348.00 $1,926.00 $2,116.00 $2,400.00 $1,926.00 $2,116.00 $2,400.00
63620 90 ---------- $1,734.00 $1,902.00 $2,151.00 $1,734.00 $1,902.00 $2,151.00
63621 ZZZ ---------- $394.00 $432.00 $493.00 $394.00 $432.00 $493.00
63650 10 $819.00 $1,818.00 $1,928.00 $1,969.00 $597.00 $624.00 $652.00
63655 90 $1,064.00 $1,251.00 $1,358.00 $1,504.00 $1,251.00 $1,358.00 $1,504.00
63661 10 ---------- $820.00 $872.00 $907.00 $471.00 $499.00 $530.00
63662 90 ---------- $1,263.00 $1,372.00 $1,519.00 $1,263.00 $1,372.00 $1,519.00
63663 10 ---------- $1,107.00 $1,171.00 $1,215.00 $656.00 $690.00 $729.00
63664 90 ---------- $1,305.00 $1,417.00 $1,570.00 $1,305.00 $1,417.00 $1,570.00
63685 10 $615.00 $539.00 $577.00 $622.00 $539.00 $577.00 $622.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 271
Surgery
CPT Code FUD 2003 MRALocality 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)
63688 10 $707.00 $548.00 $586.00 $633.00 $548.00 $586.00 $633.00
63700 90 $1,340.00 $1,707.00 $1,819.00 $1,956.00 $1,707.00 $1,819.00 $1,956.00
63702 90 $1,512.00 $1,902.00 $2,030.00 $2,191.00 $1,902.00 $2,030.00 $2,191.00
63704 90 $1,708.00 $2,154.00 $2,287.00 $2,444.00 $2,154.00 $2,287.00 $2,444.00
63706 90 $1,873.00 $2,633.00 $2,845.00 $3,134.00 $2,633.00 $2,845.00 $3,134.00
63707 90 $1,041.00 $1,389.00 $1,505.00 $1,663.00 $1,389.00 $1,505.00 $1,663.00
63709 90 $1,310.00 $1,664.00 $1,802.00 $1,992.00 $1,664.00 $1,802.00 $1,992.00
63710 90 $1,165.00 $1,633.00 $1,767.00 $1,949.00 $1,633.00 $1,767.00 $1,949.00
63740 90 $1,062.00 $1,425.00 $1,554.00 $1,736.00 $1,425.00 $1,554.00 $1,736.00
63741 90 $741.00 $1,025.00 $1,115.00 $1,240.00 $1,025.00 $1,115.00 $1,240.00
63744 90 $738.00 $1,005.00 $1,093.00 $1,217.00 $1,005.00 $1,093.00 $1,217.00
63746 90 $529.00 $920.00 $1,007.00 $1,128.00 $920.00 $1,007.00 $1,128.00
64400 0 $78.00 $181.00 $194.00 $204.00 $105.00 $112.00 $122.00
64402 0 $75.00 $191.00 $205.00 $217.00 $120.00 $128.00 $140.00
64405 0 $103.00 $143.00 $153.00 $161.00 $93.00 $99.00 $107.00
64408 0 $120.00 $169.00 $179.00 $187.00 $126.00 $133.00 $141.00
64410 0 $109.00 $191.00 $202.00 $209.00 $110.00 $116.00 $122.00
64413 0 $128.00 $181.00 $192.00 $200.00 $119.00 $125.00 $134.00
64415 0 $109.00 $165.00 $173.00 $179.00 $95.00 $98.00 $103.00
64416 0 $159.00 $115.00 $119.00 $125.00 $115.00 $119.00 $125.00
64417 0 $105.00 $180.00 $189.00 $195.00 $102.00 $106.00 $111.00
64418 0 $108.00 $203.00 $215.00 $222.00 $111.00 $116.00 $122.00
64420 0 $89.00 $156.00 $164.00 $170.00 $98.00 $102.00 $107.00
64421 0 $128.00 $211.00 $221.00 $228.00 $133.00 $138.00 $144.00
64425 0 $116.00 $187.00 $196.00 $204.00 $136.00 $142.00 $149.00
64430 0 $130.00 $193.00 $204.00 $210.00 $118.00 $123.00 $129.00
64435 0 $114.00 $191.00 $202.00 $209.00 $121.00 $127.00 $134.00
64445 0 $68.00 $191.00 $201.00 $208.00 $106.00 $110.00 $116.00
64446 0 $165.00 $115.00 $119.00 $125.00 $115.00 $119.00 $125.00
64447 0 $77.00 $168.00 $176.00 $182.00 $97.00 $100.00 $105.00
64448 0 $152.00 $104.00 $108.00 $113.00 $104.00 $108.00 $113.00
64449 0 ---------- $123.00 $127.00 $134.00 $123.00 $127.00 $134.00
64450 0 $53.00 $112.00 $118.00 $122.00 $65.00 $68.00 $71.00
64455 0 ---------- $68.00 $71.00 $74.00 $51.00 $53.00 $55.00
64461 0 ---------- $209.00 $220.00 $228.00 $127.00 $133.00 $140.00
64462 ZZZ ---------- $119.00 $126.00 $130.00 $80.00 $83.00 $88.00
64463 0 ---------- $235.00 $247.00 $256.00 $131.00 $137.00 $144.00
64479 0 $224.00 $328.00 $346.00 $356.00 $191.00 $199.00 $208.00
64480 ZZZ $194.00 $158.00 $167.00 $172.00 $92.00 $97.00 $101.00
64483 0 $206.00 $303.00 $320.00 $328.00 $161.00 $168.00 $175.00
64484 ZZZ $183.00 $123.00 $129.00 $133.00 $75.00 $78.00 $82.00
64486 0 ---------- $171.00 $181.00 $187.00 $91.00 $96.00 $101.00
64487 0 ---------- $189.00 $199.00 $205.00 $99.00 $102.00 $107.00
64488 0 ---------- $197.00 $207.00 $214.00 $108.00 $113.00 $119.00
64489 0 ---------- $250.00 $263.00 $270.00 $115.00 $119.00 $125.00
64490 0 ---------- $264.00 $278.00 $286.00 $154.00 $160.00 $167.00
64491 ZZZ ---------- $132.00 $138.00 $143.00 $88.00 $91.00 $95.00
64492 ZZZ ---------- $132.00 $139.00 $144.00 $89.00 $92.00 $96.00
64493 0 ---------- $239.00 $252.00 $259.00 $131.00 $137.00 $142.00
64494 ZZZ ---------- $121.00 $127.00 $132.00 $76.00 $79.00 $82.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 272
Surgery
CPT Code FUD 2003 MRALocality 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)
64495 ZZZ ---------- $122.00 $128.00 $132.00 $76.00 $80.00 $83.00
64505 0 $104.00 $151.00 $159.00 $167.00 $127.00 $134.00 $141.00
64508 0 $99.00 $87.00 $92.00 $98.00 $104.00 $110.00 $116.00
64510 0 $103.00 $177.00 $187.00 $192.00 $105.00 $110.00 $114.00
64517 0 ---------- $261.00 $274.00 $282.00 $179.00 $187.00 $194.00
64520 0 $131.00 $257.00 $272.00 $279.00 $117.00 $122.00 $127.00
64530 0 $135.00 $263.00 $278.00 $284.00 $132.00 $138.00 $143.00
64550 0 $23.00 $22.00 $23.00 $24.00 $13.00 $13.00 $13.00
64553 10 $137.00 $286.00 $301.00 $311.00 $218.00 $228.00 $237.00
64555 10 $131.00 $297.00 $314.00 $325.00 $220.00 $231.00 $241.00
64561 10 $801.00 $1,149.00 $1,219.00 $1,251.00 $444.00 $466.00 $491.00
64565 10 $121.00 $273.00 $289.00 $300.00 $194.00 $204.00 $215.00
64566 0 ---------- $176.00 $187.00 $191.00 $44.00 $46.00 $49.00
64568 90 ---------- $980.00 $1,062.00 $1,175.00 $980.00 $1,062.00 $1,175.00
64569 90 ---------- $1,184.00 $1,285.00 $1,428.00 $1,184.00 $1,285.00 $1,428.00
64570 90 ---------- $988.00 $1,070.00 $1,183.00 $988.00 $1,070.00 $1,183.00
64575 90 $367.00 $470.00 $502.00 $539.00 $470.00 $502.00 $539.00
64580 90 $343.00 $446.00 $478.00 $518.00 $446.00 $478.00 $518.00
64581 90 $745.00 $974.00 $1,022.00 $1,080.00 $974.00 $1,022.00 $1,080.00
64585 10 $37.00 $345.00 $365.00 $378.00 $208.00 $219.00 $230.00
64590 10 $217.00 $374.00 $397.00 $411.00 $234.00 $246.00 $259.00
64595 10 $153.00 $345.00 $366.00 $377.00 $183.00 $193.00 $203.00
64600 10 $228.00 $557.00 $594.00 $623.00 $325.00 $346.00 $372.00
64605 10 $319.00 $863.00 $918.00 $960.00 $509.00 $540.00 $579.00
64610 10 $307.00 $1,087.00 $1,176.00 $1,276.00 $747.00 $812.00 $908.00
64611 10 ---------- $172.00 $187.00 $203.00 $153.00 $166.00 $182.00
64612 10 $188.00 $188.00 $201.00 $213.00 $170.00 $181.00 $193.00
64615 10 ---------- $216.00 $235.00 $261.00 $190.00 $207.00 $233.00
64616 10 ---------- $189.00 $205.00 $226.00 $166.00 $181.00 $201.00
64617 10 ---------- $259.00 $278.00 $297.00 $177.00 $190.00 $208.00
64620 10 $185.00 $290.00 $303.00 $314.00 $247.00 $258.00 $268.00
64630 10 $202.00 $331.00 $351.00 $370.00 $280.00 $296.00 $314.00
64632 10 ---------- $121.00 $126.00 $130.00 $99.00 $103.00 $106.00
64633 10 ---------- $585.00 $616.00 $632.00 $325.00 $339.00 $352.00
64634 ZZZ ---------- $261.00 $276.00 $282.00 $99.00 $103.00 $108.00
64635 10 ---------- $578.00 $609.00 $625.00 $321.00 $334.00 $347.00
64636 ZZZ ---------- $237.00 $250.00 $256.00 $86.00 $90.00 $94.00
64640 10 $208.00 $185.00 $195.00 $200.00 $132.00 $139.00 $143.00
64642 0 ---------- $206.00 $221.00 $237.00 $162.00 $174.00 $190.00
64643 ZZZ ---------- $135.00 $144.00 $154.00 $108.00 $115.00 $125.00
64644 0 ---------- $236.00 $253.00 $271.00 $177.00 $190.00 $207.00
64645 ZZZ ---------- $167.00 $179.00 $193.00 $126.00 $135.00 $148.00
64646 0 ---------- $217.00 $233.00 $251.00 $174.00 $187.00 $205.00
64647 0 ---------- $260.00 $280.00 $303.00 $207.00 $224.00 $247.00
64650 0 ---------- $110.00 $117.00 $123.00 $63.00 $67.00 $72.00
64653 0 ---------- $136.00 $146.00 $155.00 $81.00 $88.00 $97.00
64680 10 $180.00 $428.00 $453.00 $466.00 $238.00 $249.00 $260.00
64681 10 ---------- $746.00 $803.00 $851.00 $406.00 $439.00 $484.00
64702 90 $383.00 $723.00 $769.00 $814.00 $723.00 $769.00 $814.00
64704 90 $402.00 $460.00 $483.00 $505.00 $460.00 $483.00 $505.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 273
Surgery
CPT Code FUD 2003 MRALocality 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)
64708 90 $562.00 $724.00 $772.00 $822.00 $724.00 $772.00 $822.00
64712 90 $678.00 $850.00 $907.00 $972.00 $850.00 $907.00 $972.00
64713 90 $867.00 $1,134.00 $1,212.00 $1,311.00 $1,134.00 $1,212.00 $1,311.00
64714 90 $715.00 $1,038.00 $1,103.00 $1,177.00 $1,038.00 $1,103.00 $1,177.00
64716 90 $523.00 $773.00 $820.00 $868.00 $773.00 $820.00 $868.00
64718 90 $558.00 $859.00 $917.00 $977.00 $859.00 $917.00 $977.00
64719 90 $446.00 $581.00 $619.00 $659.00 $581.00 $619.00 $659.00
64721 90 $439.00 $621.00 $663.00 $705.00 $618.00 $659.00 $701.00
64722 90 $411.00 $528.00 $562.00 $599.00 $528.00 $562.00 $599.00
64726 90 $271.00 $393.00 $411.00 $427.00 $393.00 $411.00 $427.00
64727 ZZZ $261.00 $276.00 $296.00 $322.00 $276.00 $296.00 $322.00
64732 90 $405.00 $545.00 $579.00 $614.00 $545.00 $579.00 $614.00
64734 90 $432.00 $755.00 $826.00 $918.00 $755.00 $826.00 $918.00
64736 90 $388.00 $564.00 $599.00 $634.00 $564.00 $599.00 $634.00
64738 90 $475.00 $670.00 $711.00 $755.00 $670.00 $711.00 $755.00
64740 90 $461.00 $653.00 $691.00 $727.00 $653.00 $691.00 $727.00
64742 90 $517.00 $661.00 $699.00 $739.00 $661.00 $699.00 $739.00
64744 90 $798.00 $737.00 $804.00 $893.00 $737.00 $804.00 $893.00
64746 90 $494.00 $628.00 $671.00 $726.00 $628.00 $671.00 $726.00
64755 90 $1,042.00 $1,316.00 $1,413.00 $1,555.00 $1,316.00 $1,413.00 $1,555.00
64760 90 $578.00 $734.00 $784.00 $848.00 $734.00 $784.00 $848.00
64763 90 $561.00 $705.00 $749.00 $802.00 $705.00 $749.00 $802.00
64766 90 $713.00 $819.00 $858.00 $899.00 $819.00 $858.00 $899.00
64771 90 $632.00 $876.00 $932.00 $993.00 $876.00 $932.00 $993.00
64772 90 $636.00 $827.00 $883.00 $948.00 $827.00 $883.00 $948.00
64774 90 $392.00 $605.00 $644.00 $687.00 $605.00 $644.00 $687.00
64776 90 $390.00 $563.00 $595.00 $628.00 $563.00 $595.00 $628.00
64778 ZZZ $249.00 $207.00 $214.00 $223.00 $207.00 $214.00 $223.00
64782 90 $482.00 $660.00 $697.00 $735.00 $660.00 $697.00 $735.00
64783 ZZZ $298.00 $327.00 $347.00 $371.00 $327.00 $347.00 $371.00
64784 90 $751.00 $1,067.00 $1,135.00 $1,212.00 $1,067.00 $1,135.00 $1,212.00
64786 90 $1,281.00 $1,600.00 $1,709.00 $1,844.00 $1,600.00 $1,709.00 $1,844.00
64787 ZZZ $458.00 $360.00 $381.00 $409.00 $360.00 $381.00 $409.00
64788 90 $381.00 $583.00 $622.00 $666.00 $583.00 $622.00 $666.00
64790 90 $884.00 $1,260.00 $1,355.00 $1,480.00 $1,260.00 $1,355.00 $1,480.00
64792 90 $1,148.00 $1,589.00 $1,689.00 $1,803.00 $1,589.00 $1,689.00 $1,803.00
64795 0 $247.00 $291.00 $314.00 $346.00 $291.00 $314.00 $346.00
64802 90 $711.00 $944.00 $1,000.00 $1,065.00 $944.00 $1,000.00 $1,065.00
64804 90 $1,202.00 $1,338.00 $1,427.00 $1,554.00 $1,338.00 $1,427.00 $1,554.00
64809 90 $1,080.00 $1,357.00 $1,459.00 $1,603.00 $1,357.00 $1,459.00 $1,603.00
64818 90 $845.00 $834.00 $868.00 $909.00 $834.00 $868.00 $909.00
64820 90 $838.00 $1,033.00 $1,092.00 $1,158.00 $1,033.00 $1,092.00 $1,158.00
64821 90 $609.00 $1,002.00 $1,063.00 $1,125.00 $1,002.00 $1,063.00 $1,125.00
64822 90 $609.00 $1,001.00 $1,062.00 $1,124.00 $1,001.00 $1,062.00 $1,124.00
64823 90 $703.00 $1,156.00 $1,233.00 $1,323.00 $1,156.00 $1,233.00 $1,323.00
64831 90 $592.00 $999.00 $1,063.00 $1,131.00 $999.00 $1,063.00 $1,131.00
64832 ZZZ $171.00 $501.00 $532.00 $572.00 $501.00 $532.00 $572.00
64834 90 $711.00 $1,092.00 $1,161.00 $1,240.00 $1,092.00 $1,161.00 $1,240.00
64835 90 $834.00 $1,182.00 $1,259.00 $1,348.00 $1,182.00 $1,259.00 $1,348.00
64836 90 $856.00 $1,204.00 $1,279.00 $1,363.00 $1,204.00 $1,279.00 $1,363.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 274
Surgery
CPT Code FUD 2003 MRALocality 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)
64837 ZZZ $480.00 $564.00 $599.00 $642.00 $564.00 $599.00 $642.00
64840 90 $1,058.00 $1,436.00 $1,535.00 $1,656.00 $1,436.00 $1,535.00 $1,656.00
64856 90 $1,063.00 $1,491.00 $1,588.00 $1,706.00 $1,491.00 $1,588.00 $1,706.00
64857 90 $1,137.00 $1,551.00 $1,651.00 $1,769.00 $1,551.00 $1,651.00 $1,769.00
64858 90 $1,313.00 $1,728.00 $1,841.00 $1,980.00 $1,728.00 $1,841.00 $1,980.00
64859 ZZZ $341.00 $371.00 $393.00 $420.00 $371.00 $393.00 $420.00
64861 90 $1,524.00 $1,845.00 $1,956.00 $2,096.00 $1,845.00 $1,956.00 $2,096.00
64862 90 $1,798.00 $2,082.00 $2,242.00 $2,462.00 $2,082.00 $2,242.00 $2,462.00
64864 90 $970.00 $1,287.00 $1,362.00 $1,447.00 $1,287.00 $1,362.00 $1,447.00
64865 90 $1,250.00 $1,624.00 $1,718.00 $1,816.00 $1,624.00 $1,718.00 $1,816.00
64866 90 $1,238.00 $1,666.00 $1,761.00 $1,861.00 $1,666.00 $1,761.00 $1,861.00
64868 90 $1,162.00 $1,512.00 $1,607.00 $1,713.00 $1,512.00 $1,607.00 $1,713.00
64872 ZZZ $155.00 $175.00 $186.00 $202.00 $175.00 $186.00 $202.00
64874 ZZZ $230.00 $244.00 $257.00 $275.00 $244.00 $257.00 $275.00
64876 ZZZ $189.00 $262.00 $276.00 $295.00 $262.00 $276.00 $295.00
64885 90 $1,382.00 $1,667.00 $1,767.00 $1,884.00 $1,667.00 $1,767.00 $1,884.00
64886 90 $1,636.00 $1,906.00 $2,016.00 $2,145.00 $1,906.00 $2,016.00 $2,145.00
64890 90 $1,112.00 $1,598.00 $1,696.00 $1,806.00 $1,598.00 $1,696.00 $1,806.00
64891 90 $1,243.00 $1,690.00 $1,790.00 $1,904.00 $1,690.00 $1,790.00 $1,904.00
64892 90 $1,177.00 $1,540.00 $1,642.00 $1,768.00 $1,540.00 $1,642.00 $1,768.00
64893 90 $1,321.00 $1,669.00 $1,772.00 $1,889.00 $1,669.00 $1,772.00 $1,889.00
64895 90 $1,500.00 $1,983.00 $2,113.00 $2,274.00 $1,983.00 $2,113.00 $2,274.00
64896 90 $1,185.00 $2,116.00 $2,247.00 $2,403.00 $2,116.00 $2,247.00 $2,403.00
64897 90 $1,419.00 $1,892.00 $2,013.00 $2,158.00 $1,892.00 $2,013.00 $2,158.00
64898 90 $1,549.00 $2,237.00 $2,431.00 $2,706.00 $2,237.00 $2,431.00 $2,706.00
64901 ZZZ $865.00 $823.00 $868.00 $926.00 $823.00 $868.00 $926.00
64902 ZZZ $982.00 $966.00 $1,022.00 $1,096.00 $966.00 $1,022.00 $1,096.00
64905 90 $1,059.00 $1,518.00 $1,615.00 $1,728.00 $1,518.00 $1,615.00 $1,728.00
64907 90 $1,472.00 $1,951.00 $2,071.00 $2,211.00 $1,951.00 $2,071.00 $2,211.00
64910 90 ---------- $1,199.00 $1,275.00 $1,358.00 $1,199.00 $1,275.00 $1,358.00
64911 90 ---------- $1,484.00 $1,575.00 $1,673.00 $1,484.00 $1,575.00 $1,673.00
64999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
65091 90 $678.00 $891.00 $936.00 $962.00 $891.00 $936.00 $962.00
65093 90 $712.00 $880.00 $924.00 $950.00 $880.00 $924.00 $950.00
65101 90 $726.00 $1,034.00 $1,087.00 $1,117.00 $1,034.00 $1,087.00 $1,117.00
65103 90 $769.00 $1,079.00 $1,133.00 $1,164.00 $1,079.00 $1,133.00 $1,164.00
65105 90 $846.00 $1,189.00 $1,248.00 $1,283.00 $1,189.00 $1,248.00 $1,283.00
65110 90 $1,305.00 $1,725.00 $1,810.00 $1,867.00 $1,725.00 $1,810.00 $1,867.00
65112 90 $1,386.00 $2,005.00 $2,104.00 $2,174.00 $2,005.00 $2,104.00 $2,174.00
65114 90 $1,456.00 $2,088.00 $2,188.00 $2,258.00 $2,088.00 $2,188.00 $2,258.00
65125 90 $312.00 $626.00 $663.00 $679.00 $406.00 $428.00 $442.00
65130 90 $730.00 $1,024.00 $1,075.00 $1,105.00 $1,024.00 $1,075.00 $1,105.00
65135 90 $678.00 $1,040.00 $1,092.00 $1,122.00 $1,040.00 $1,092.00 $1,122.00
65140 90 $738.00 $1,131.00 $1,186.00 $1,219.00 $1,131.00 $1,186.00 $1,219.00
65150 90 $652.00 $810.00 $851.00 $875.00 $810.00 $851.00 $875.00
65155 90 $862.00 $1,185.00 $1,244.00 $1,279.00 $1,185.00 $1,244.00 $1,279.00
65175 90 $654.00 $921.00 $967.00 $994.00 $921.00 $967.00 $994.00
65205 0 $45.00 $79.00 $82.00 $84.00 $62.00 $65.00 $67.00
65210 0 $53.00 $96.00 $100.00 $103.00 $75.00 $78.00 $81.00
65220 0 $58.00 $82.00 $87.00 $90.00 $61.00 $64.00 $68.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 275
Surgery
CPT Code FUD 2003 MRALocality 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)
65222 0 $62.00 $94.00 $98.00 $100.00 $74.00 $77.00 $79.00
65235 90 $627.00 $999.00 $1,047.00 $1,078.00 $999.00 $1,047.00 $1,078.00
65260 90 $956.00 $1,352.00 $1,416.00 $1,458.00 $1,352.00 $1,416.00 $1,458.00
65265 90 $1,104.00 $1,523.00 $1,595.00 $1,642.00 $1,523.00 $1,595.00 $1,642.00
65270 10 $88.00 $367.00 $388.00 $396.00 $198.00 $207.00 $214.00
65272 90 $223.00 $699.00 $736.00 $754.00 $495.00 $518.00 $534.00
65273 90 $376.00 $538.00 $564.00 $583.00 $538.00 $564.00 $583.00
65275 90 $75.00 $807.00 $848.00 $870.00 $651.00 $681.00 $702.00
65280 90 $711.00 $947.00 $992.00 $1,022.00 $947.00 $992.00 $1,022.00
65285 90 $1,177.00 $1,565.00 $1,637.00 $1,688.00 $1,565.00 $1,637.00 $1,688.00
65286 90 $692.00 $980.00 $1,032.00 $1,057.00 $699.00 $731.00 $754.00
65290 90 $519.00 $694.00 $728.00 $752.00 $694.00 $728.00 $752.00
65400 90 $603.00 $951.00 $999.00 $1,026.00 $848.00 $890.00 $915.00
65410 0 $142.00 $199.00 $210.00 $215.00 $148.00 $155.00 $160.00
65420 90 $448.00 $717.00 $756.00 $773.00 $530.00 $556.00 $572.00
65426 90 $534.00 $907.00 $955.00 $978.00 $674.00 $706.00 $727.00
65430 0 $81.00 $160.00 $168.00 $173.00 $146.00 $153.00 $158.00
65435 0 $88.00 $112.00 $117.00 $120.00 $98.00 $103.00 $106.00
65436 90 $319.00 $544.00 $571.00 $587.00 $524.00 $549.00 $565.00
65450 90 $52.00 $454.00 $478.00 $490.00 $450.00 $473.00 $485.00
65600 90 $325.00 $551.00 $579.00 $594.00 $484.00 $507.00 $522.00
65710 90 $1,124.00 $1,557.00 $1,630.00 $1,679.00 $1,557.00 $1,630.00 $1,679.00
65730 90 $1,314.00 $1,729.00 $1,811.00 $1,865.00 $1,729.00 $1,811.00 $1,865.00
65750 90 $1,381.00 $1,740.00 $1,821.00 $1,877.00 $1,740.00 $1,821.00 $1,877.00
65755 90 $1,373.00 $1,731.00 $1,812.00 $1,867.00 $1,731.00 $1,812.00 $1,867.00
65756 90 ---------- $1,674.00 $1,750.00 $1,806.00 $1,674.00 $1,750.00 $1,806.00
65770 90 $1,461.00 $1,979.00 $2,070.00 $2,134.00 $1,979.00 $2,070.00 $2,134.00
65772 90 $449.00 $632.00 $663.00 $681.00 $572.00 $599.00 $617.00
65775 90 $595.00 $775.00 $812.00 $836.00 $775.00 $812.00 $836.00
65778 0 ---------- $1,931.00 $2,060.00 $2,082.00 $82.00 $85.00 $87.00
65779 0 ---------- $1,641.00 $1,747.00 $1,769.00 $216.00 $226.00 $233.00
65780 90 ---------- $936.00 $982.00 $1,009.00 $936.00 $982.00 $1,009.00
65781 90 ---------- $1,881.00 $1,968.00 $2,028.00 $1,881.00 $1,968.00 $2,028.00
65782 90 ---------- $1,622.00 $1,698.00 $1,749.00 $1,622.00 $1,698.00 $1,749.00
65785 90 ---------- $2,898.00 $3,088.00 $3,144.00 $555.00 $587.00 $617.00
65800 0 $88.00 $167.00 $175.00 $180.00 $130.00 $136.00 $141.00
65810 90 $516.00 $654.00 $686.00 $706.00 $654.00 $686.00 $706.00
65815 90 $327.00 $887.00 $934.00 $957.00 $672.00 $705.00 $725.00
65820 90 $813.00 $1,050.00 $1,102.00 $1,133.00 $1,050.00 $1,102.00 $1,133.00
65850 90 $968.00 $1,184.00 $1,239.00 $1,276.00 $1,184.00 $1,239.00 $1,276.00
65855 10 $441.00 $343.00 $360.00 $370.00 $294.00 $308.00 $318.00
65860 90 $339.00 $432.00 $454.00 $466.00 $358.00 $375.00 $386.00
65865 90 $540.00 $664.00 $697.00 $717.00 $664.00 $697.00 $717.00
65870 90 $572.00 $831.00 $871.00 $897.00 $831.00 $871.00 $897.00
65875 90 $597.00 $886.00 $929.00 $956.00 $886.00 $929.00 $956.00
65880 90 $641.00 $933.00 $978.00 $1,007.00 $933.00 $978.00 $1,007.00
65900 90 $945.00 $1,356.00 $1,421.00 $1,462.00 $1,356.00 $1,421.00 $1,462.00
65920 90 $752.00 $1,108.00 $1,162.00 $1,195.00 $1,108.00 $1,162.00 $1,195.00
65930 90 $700.00 $898.00 $940.00 $968.00 $898.00 $940.00 $968.00
66020 10 $164.00 $259.00 $273.00 $279.00 $185.00 $194.00 $199.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 276
Surgery
CPT Code FUD 2003 MRALocality 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)
66030 10 $160.00 $230.00 $243.00 $248.00 $155.00 $163.00 $167.00
66130 90 $631.00 $974.00 $1,023.00 $1,051.00 $804.00 $841.00 $867.00
66150 90 $798.00 $1,230.00 $1,291.00 $1,327.00 $1,230.00 $1,291.00 $1,327.00
66155 90 $795.00 $1,230.00 $1,290.00 $1,326.00 $1,230.00 $1,290.00 $1,326.00
66160 90 $942.00 $1,388.00 $1,455.00 $1,497.00 $1,388.00 $1,455.00 $1,497.00
66170 90 $1,089.00 $1,540.00 $1,613.00 $1,661.00 $1,540.00 $1,613.00 $1,661.00
66172 90 $1,264.00 $1,674.00 $1,755.00 $1,805.00 $1,674.00 $1,755.00 $1,805.00
66174 90 ---------- $1,337.00 $1,399.00 $1,442.00 $1,337.00 $1,399.00 $1,442.00
66175 90 ---------- $1,400.00 $1,465.00 $1,510.00 $1,400.00 $1,465.00 $1,510.00
66179 90 ---------- $1,517.00 $1,589.00 $1,636.00 $1,517.00 $1,589.00 $1,636.00
66180 90 $1,313.00 $1,602.00 $1,677.00 $1,727.00 $1,602.00 $1,677.00 $1,727.00
66183 90 ---------- $1,449.00 $1,518.00 $1,562.00 $1,449.00 $1,518.00 $1,562.00
66184 90 ---------- $1,103.00 $1,156.00 $1,189.00 $1,103.00 $1,156.00 $1,189.00
66185 90 $769.00 $1,187.00 $1,244.00 $1,280.00 $1,187.00 $1,244.00 $1,280.00
66220 90 $711.00 $1,002.00 $1,053.00 $1,090.00 $1,002.00 $1,053.00 $1,090.00
66225 90 $1,006.00 $1,314.00 $1,376.00 $1,417.00 $1,314.00 $1,376.00 $1,417.00
66250 90 $602.00 $1,043.00 $1,098.00 $1,125.00 $785.00 $822.00 $847.00
66500 90 $359.00 $496.00 $521.00 $535.00 $496.00 $521.00 $535.00
66505 90 $359.00 $547.00 $576.00 $593.00 $547.00 $576.00 $593.00
66600 90 $825.00 $1,169.00 $1,226.00 $1,261.00 $1,169.00 $1,226.00 $1,261.00
66605 90 $1,136.00 $1,489.00 $1,559.00 $1,606.00 $1,489.00 $1,559.00 $1,606.00
66625 90 $543.00 $603.00 $633.00 $651.00 $603.00 $633.00 $651.00
66630 90 $623.00 $801.00 $840.00 $865.00 $801.00 $840.00 $865.00
66635 90 $595.00 $809.00 $847.00 $872.00 $809.00 $847.00 $872.00
66680 90 $526.00 $728.00 $764.00 $786.00 $728.00 $764.00 $786.00
66682 90 $627.00 $894.00 $938.00 $964.00 $894.00 $938.00 $964.00
66700 90 $506.00 $630.00 $662.00 $680.00 $554.00 $580.00 $597.00
66710 90 $513.00 $616.00 $646.00 $664.00 $554.00 $580.00 $597.00
66711 90 ---------- $904.00 $947.00 $974.00 $904.00 $947.00 $974.00
66720 90 $506.00 $643.00 $676.00 $693.00 $574.00 $603.00 $620.00
66740 90 $473.00 $612.00 $642.00 $660.00 $554.00 $580.00 $597.00
66761 10 $506.00 $413.00 $434.00 $445.00 $332.00 $348.00 $358.00
66762 90 $433.00 $665.00 $698.00 $717.00 $600.00 $629.00 $647.00
66770 90 $483.00 $740.00 $777.00 $798.00 $681.00 $714.00 $735.00
66820 90 $433.00 $550.00 $579.00 $594.00 $550.00 $579.00 $594.00
66821 90 $275.00 $460.00 $484.00 $497.00 $436.00 $458.00 $470.00
66825 90 $753.00 $1,066.00 $1,119.00 $1,150.00 $1,066.00 $1,119.00 $1,150.00
66830 90 $651.00 $1,005.00 $1,052.00 $1,084.00 $1,005.00 $1,052.00 $1,084.00
66840 90 $707.00 $981.00 $1,028.00 $1,059.00 $981.00 $1,028.00 $1,059.00
66850 90 $805.00 $1,117.00 $1,170.00 $1,205.00 $1,117.00 $1,170.00 $1,205.00
66852 90 $878.00 $1,190.00 $1,246.00 $1,284.00 $1,190.00 $1,246.00 $1,284.00
66920 90 $785.00 $1,063.00 $1,113.00 $1,147.00 $1,063.00 $1,113.00 $1,147.00
66930 90 $906.00 $1,206.00 $1,262.00 $1,300.00 $1,206.00 $1,262.00 $1,300.00
66940 90 $819.00 $1,102.00 $1,154.00 $1,188.00 $1,102.00 $1,154.00 $1,188.00
66982 90 $846.00 $1,122.00 $1,174.00 $1,210.00 $1,122.00 $1,174.00 $1,210.00
66983 90 $763.00 $1,045.00 $1,090.00 $1,119.00 $1,045.00 $1,090.00 $1,119.00
66984 90 $898.00 $902.00 $944.00 $972.00 $902.00 $944.00 $972.00
66985 90 $744.00 $1,084.00 $1,135.00 $1,168.00 $1,084.00 $1,135.00 $1,168.00
66986 90 $1,038.00 $1,281.00 $1,341.00 $1,382.00 $1,281.00 $1,341.00 $1,382.00
66990 ZZZ $84.00 $129.00 $134.00 $139.00 $129.00 $134.00 $139.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 277
Surgery
CPT Code FUD 2003 MRALocality 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)
66999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
67005 90 $639.00 $664.00 $697.00 $717.00 $664.00 $697.00 $717.00
67010 90 $647.00 $764.00 $800.00 $824.00 $764.00 $800.00 $824.00
67015 90 $637.00 $815.00 $855.00 $880.00 $815.00 $855.00 $880.00
67025 90 $774.00 $1,016.00 $1,067.00 $1,096.00 $890.00 $933.00 $961.00
67027 90 $1,089.00 $1,202.00 $1,258.00 $1,297.00 $1,202.00 $1,258.00 $1,297.00
67028 0 $338.00 $144.00 $151.00 $156.00 $142.00 $149.00 $154.00
67030 90 $485.00 $746.00 $784.00 $806.00 $746.00 $784.00 $806.00
67031 90 $402.00 $545.00 $572.00 $588.00 $502.00 $526.00 $542.00
67036 90 $1,384.00 $1,270.00 $1,330.00 $1,370.00 $1,270.00 $1,330.00 $1,370.00
67039 90 $1,490.00 $1,362.00 $1,426.00 $1,469.00 $1,362.00 $1,426.00 $1,469.00
67040 90 $1,960.00 $1,473.00 $1,541.00 $1,589.00 $1,473.00 $1,541.00 $1,589.00
67041 90 ---------- $1,627.00 $1,702.00 $1,755.00 $1,627.00 $1,702.00 $1,755.00
67042 90 ---------- $1,629.00 $1,703.00 $1,757.00 $1,629.00 $1,703.00 $1,757.00
67043 90 ---------- $1,721.00 $1,799.00 $1,856.00 $1,721.00 $1,799.00 $1,856.00
67101 10 $767.00 $458.00 $482.00 $494.00 $400.00 $420.00 $431.00
67105 10 $941.00 $416.00 $437.00 $449.00 $387.00 $406.00 $418.00
67107 90 $1,350.00 $1,600.00 $1,674.00 $1,726.00 $1,600.00 $1,674.00 $1,726.00
67108 90 $1,878.00 $1,698.00 $1,775.00 $1,831.00 $1,698.00 $1,775.00 $1,831.00
67110 90 $1,040.00 $1,229.00 $1,290.00 $1,325.00 $1,144.00 $1,198.00 $1,233.00
67113 90 ---------- $1,894.00 $1,981.00 $2,043.00 $1,894.00 $1,981.00 $2,043.00
67115 90 $496.00 $703.00 $737.00 $759.00 $703.00 $737.00 $759.00
67120 90 $751.00 $919.00 $966.00 $992.00 $786.00 $823.00 $848.00
67121 90 $962.00 $1,281.00 $1,341.00 $1,381.00 $1,281.00 $1,341.00 $1,381.00
67141 90 $536.00 $734.00 $770.00 $792.00 $687.00 $720.00 $741.00
67145 90 $514.00 $739.00 $775.00 $797.00 $701.00 $735.00 $756.00
67208 90 $655.00 $843.00 $884.00 $910.00 $815.00 $854.00 $880.00
67210 90 $779.00 $728.00 $763.00 $785.00 $704.00 $738.00 $760.00
67218 90 $1,217.00 $1,958.00 $2,046.00 $2,112.00 $1,958.00 $2,046.00 $2,112.00
67220 90 $894.00 $749.00 $786.00 $808.00 $704.00 $738.00 $760.00
67221 0 $325.00 $402.00 $422.00 $434.00 $304.00 $317.00 $328.00
67225 ZZZ $44.00 $42.00 $44.00 $45.00 $40.00 $42.00 $43.00
67227 10 $652.00 $407.00 $427.00 $439.00 $363.00 $380.00 $391.00
67228 10 $1,025.00 $479.00 $502.00 $517.00 $435.00 $455.00 $469.00
67229 90 ---------- $1,647.00 $1,722.00 $1,776.00 $1,647.00 $1,722.00 $1,776.00
67250 90 $793.00 $1,096.00 $1,150.00 $1,182.00 $1,096.00 $1,150.00 $1,182.00
67255 90 $872.00 $961.00 $1,007.00 $1,036.00 $961.00 $1,007.00 $1,036.00
67299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
67311 90 $616.00 $842.00 $882.00 $908.00 $842.00 $882.00 $908.00
67312 90 $773.00 $1,003.00 $1,050.00 $1,082.00 $1,003.00 $1,050.00 $1,082.00
67314 90 $688.00 $947.00 $992.00 $1,022.00 $947.00 $992.00 $1,022.00
67316 90 $857.00 $1,131.00 $1,183.00 $1,219.00 $1,131.00 $1,183.00 $1,219.00
67318 90 $663.00 $993.00 $1,041.00 $1,071.00 $993.00 $1,041.00 $1,071.00
67320 ZZZ $602.00 $460.00 $479.00 $497.00 $460.00 $479.00 $497.00
67331 ZZZ $560.00 $437.00 $455.00 $472.00 $437.00 $455.00 $472.00
67332 ZZZ $621.00 $474.00 $494.00 $512.00 $474.00 $494.00 $512.00
67334 ZZZ $447.00 $430.00 $448.00 $464.00 $430.00 $448.00 $464.00
67335 ZZZ $253.00 $212.00 $221.00 $229.00 $212.00 $221.00 $229.00
67340 ZZZ $559.00 $512.00 $533.00 $552.00 $512.00 $533.00 $552.00
67343 90 $628.00 $922.00 $966.00 $995.00 $922.00 $966.00 $995.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 278
Surgery
CPT Code FUD 2003 MRALocality 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)
67345 10 $275.00 $344.00 $364.00 $381.00 $312.00 $329.00 $346.00
67346 0 ---------- $275.00 $287.00 $297.00 $275.00 $287.00 $297.00
67399 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
67400 90 $960.00 $1,306.00 $1,370.00 $1,410.00 $1,306.00 $1,370.00 $1,410.00
67405 90 $799.00 $1,113.00 $1,170.00 $1,207.00 $1,113.00 $1,170.00 $1,207.00
67412 90 $976.00 $1,195.00 $1,254.00 $1,291.00 $1,195.00 $1,254.00 $1,291.00
67413 90 $909.00 $1,199.00 $1,259.00 $1,296.00 $1,199.00 $1,259.00 $1,296.00
67414 90 $1,023.00 $1,873.00 $1,962.00 $2,025.00 $1,873.00 $1,962.00 $2,025.00
67415 0 $146.00 $150.00 $156.00 $162.00 $150.00 $156.00 $162.00
67420 90 $1,729.00 $2,288.00 $2,400.00 $2,483.00 $2,288.00 $2,400.00 $2,483.00
67430 90 $1,203.00 $1,739.00 $1,826.00 $1,883.00 $1,739.00 $1,826.00 $1,883.00
67440 90 $1,257.00 $1,693.00 $1,775.00 $1,826.00 $1,693.00 $1,775.00 $1,826.00
67445 90 $1,269.00 $1,980.00 $2,074.00 $2,142.00 $1,980.00 $2,074.00 $2,142.00
67450 90 $1,300.00 $1,758.00 $1,846.00 $1,903.00 $1,758.00 $1,846.00 $1,903.00
67500 0 $75.00 $112.00 $116.00 $121.00 $103.00 $107.00 $112.00
67505 0 $109.00 $125.00 $131.00 $135.00 $115.00 $120.00 $124.00
67515 0 $53.00 $137.00 $143.00 $148.00 $127.00 $133.00 $137.00
67550 90 $946.00 $1,355.00 $1,422.00 $1,465.00 $1,355.00 $1,422.00 $1,465.00
67560 90 $936.00 $1,389.00 $1,457.00 $1,500.00 $1,389.00 $1,457.00 $1,500.00
67570 90 $1,148.00 $1,656.00 $1,751.00 $1,832.00 $1,656.00 $1,751.00 $1,832.00
67599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
67700 10 $87.00 $368.00 $390.00 $398.00 $164.00 $172.00 $177.00
67710 10 $117.00 $306.00 $324.00 $330.00 $136.00 $143.00 $147.00
67715 10 $102.00 $330.00 $350.00 $357.00 $153.00 $161.00 $167.00
67800 10 $119.00 $177.00 $186.00 $191.00 $146.00 $153.00 $158.00
67801 10 $189.00 $227.00 $238.00 $245.00 $188.00 $197.00 $203.00
67805 10 $208.00 $282.00 $296.00 $304.00 $233.00 $243.00 $251.00
67808 90 $308.00 $519.00 $544.00 $561.00 $519.00 $544.00 $561.00
67810 0 $133.00 $239.00 $254.00 $262.00 $104.00 $110.00 $116.00
67820 0 $36.00 $71.00 $74.00 $75.00 $75.00 $78.00 $80.00
67825 10 $130.00 $179.00 $188.00 $193.00 $170.00 $179.00 $183.00
67830 10 $239.00 $366.00 $387.00 $395.00 $194.00 $204.00 $210.00
67835 90 $500.00 $619.00 $648.00 $668.00 $619.00 $648.00 $668.00
67840 10 $187.00 $380.00 $402.00 $411.00 $223.00 $234.00 $241.00
67850 10 $143.00 $300.00 $317.00 $327.00 $193.00 $204.00 $212.00
67875 0 $163.00 $238.00 $251.00 $257.00 $138.00 $145.00 $150.00
67880 90 $442.00 $639.00 $672.00 $690.00 $519.00 $544.00 $560.00
67882 90 $643.00 $788.00 $828.00 $850.00 $665.00 $697.00 $718.00
67900 90 $487.00 $896.00 $944.00 $973.00 $722.00 $757.00 $784.00
67901 90 $646.00 $1,056.00 $1,112.00 $1,142.00 $815.00 $854.00 $882.00
67902 90 $650.00 $1,022.00 $1,072.00 $1,108.00 $1,022.00 $1,072.00 $1,108.00
67903 90 $657.00 $830.00 $873.00 $897.00 $684.00 $716.00 $739.00
67904 90 $720.00 $1,024.00 $1,077.00 $1,108.00 $844.00 $885.00 $914.00
67906 90 $633.00 $718.00 $751.00 $774.00 $718.00 $751.00 $774.00
67908 90 $550.00 $689.00 $724.00 $743.00 $597.00 $626.00 $644.00
67909 90 $577.00 $749.00 $789.00 $811.00 $619.00 $650.00 $671.00
67911 90 $517.00 $794.00 $832.00 $859.00 $794.00 $832.00 $859.00
67912 90 ---------- $1,220.00 $1,292.00 $1,326.00 $694.00 $730.00 $759.00
67914 90 $487.00 $651.00 $687.00 $704.00 $460.00 $484.00 $498.00
67915 90 $252.00 $403.00 $426.00 $435.00 $276.00 $291.00 $298.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 279
Surgery
CPT Code FUD 2003 MRALocality 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)
67916 90 $675.00 $824.00 $869.00 $891.00 $608.00 $638.00 $659.00
67917 90 $631.00 $840.00 $884.00 $908.00 $646.00 $678.00 $699.00
67921 90 $419.00 $636.00 $672.00 $687.00 $435.00 $457.00 $470.00
67922 90 $243.00 $400.00 $423.00 $431.00 $276.00 $291.00 $298.00
67923 90 $718.00 $822.00 $866.00 $887.00 $607.00 $636.00 $655.00
67924 90 $605.00 $877.00 $923.00 $947.00 $646.00 $677.00 $698.00
67930 10 $280.00 $508.00 $535.00 $550.00 $342.00 $357.00 $370.00
67935 90 $520.00 $832.00 $877.00 $904.00 $629.00 $659.00 $684.00
67938 10 $67.00 $335.00 $354.00 $360.00 $163.00 $171.00 $176.00
67950 90 $584.00 $800.00 $843.00 $867.00 $655.00 $687.00 $710.00
67961 90 $571.00 $802.00 $844.00 $866.00 $642.00 $673.00 $693.00
67966 90 $645.00 $1,077.00 $1,131.00 $1,164.00 $930.00 $974.00 $1,005.00
67971 90 $875.00 $1,023.00 $1,071.00 $1,105.00 $1,023.00 $1,071.00 $1,105.00
67973 90 $1,126.00 $1,317.00 $1,378.00 $1,423.00 $1,317.00 $1,378.00 $1,423.00
67974 90 $1,140.00 $1,313.00 $1,374.00 $1,418.00 $1,313.00 $1,374.00 $1,418.00
67975 90 $681.00 $967.00 $1,013.00 $1,046.00 $967.00 $1,013.00 $1,046.00
67999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
68020 10 $106.00 $167.00 $176.00 $180.00 $155.00 $163.00 $167.00
68040 0 $75.00 $87.00 $91.00 $93.00 $72.00 $74.00 $77.00
68100 0 $137.00 $235.00 $248.00 $254.00 $138.00 $144.00 $149.00
68110 10 $172.00 $312.00 $329.00 $336.00 $209.00 $219.00 $225.00
68115 10 $248.00 $431.00 $455.00 $465.00 $260.00 $272.00 $280.00
68130 90 $378.00 $749.00 $789.00 $808.00 $579.00 $607.00 $625.00
68135 10 $146.00 $220.00 $230.00 $237.00 $212.00 $223.00 $229.00
68200 0 $59.00 $58.00 $61.00 $63.00 $49.00 $52.00 $54.00
68320 90 $502.00 $1,007.00 $1,061.00 $1,087.00 $759.00 $796.00 $819.00
68325 90 $672.00 $929.00 $974.00 $1,004.00 $929.00 $974.00 $1,004.00
68326 90 $654.00 $911.00 $954.00 $983.00 $911.00 $954.00 $983.00
68328 90 $741.00 $1,001.00 $1,049.00 $1,083.00 $1,001.00 $1,049.00 $1,083.00
68330 90 $488.00 $841.00 $885.00 $908.00 $649.00 $681.00 $701.00
68335 90 $636.00 $914.00 $958.00 $987.00 $914.00 $958.00 $987.00
68340 90 $413.00 $757.00 $797.00 $816.00 $562.00 $589.00 $606.00
68360 90 $449.00 $741.00 $780.00 $801.00 $581.00 $609.00 $628.00
68362 90 $691.00 $925.00 $969.00 $999.00 $925.00 $969.00 $999.00
68371 10 ---------- $581.00 $609.00 $627.00 $581.00 $609.00 $627.00
68399 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
68400 10 $154.00 $391.00 $413.00 $421.00 $186.00 $195.00 $201.00
68420 10 $191.00 $444.00 $469.00 $479.00 $238.00 $250.00 $258.00
68440 10 $96.00 $142.00 $149.00 $153.00 $138.00 $145.00 $149.00
68500 90 $882.00 $1,380.00 $1,447.00 $1,493.00 $1,380.00 $1,447.00 $1,493.00
68505 90 $921.00 $1,367.00 $1,432.00 $1,477.00 $1,367.00 $1,432.00 $1,477.00
68510 0 $491.00 $620.00 $652.00 $670.00 $415.00 $433.00 $449.00
68520 90 $687.00 $968.00 $1,015.00 $1,046.00 $968.00 $1,015.00 $1,046.00
68525 0 $340.00 $377.00 $394.00 $408.00 $377.00 $394.00 $408.00
68530 10 $379.00 $593.00 $625.00 $640.00 $365.00 $382.00 $394.00
68540 90 $875.00 $1,309.00 $1,371.00 $1,412.00 $1,309.00 $1,371.00 $1,412.00
68550 90 $1,107.00 $1,577.00 $1,657.00 $1,721.00 $1,577.00 $1,657.00 $1,721.00
68700 90 $628.00 $852.00 $892.00 $919.00 $852.00 $892.00 $919.00
68705 10 $176.00 $329.00 $346.00 $355.00 $234.00 $246.00 $253.00
68720 90 $807.00 $1,067.00 $1,118.00 $1,153.00 $1,067.00 $1,118.00 $1,153.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 280
Surgery
CPT Code FUD 2003 MRALocality 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)
68745 90 $704.00 $1,070.00 $1,121.00 $1,154.00 $1,070.00 $1,121.00 $1,154.00
68750 90 $792.00 $1,108.00 $1,162.00 $1,197.00 $1,108.00 $1,162.00 $1,197.00
68760 10 $109.00 $279.00 $294.00 $301.00 $205.00 $215.00 $221.00
68761 10 $130.00 $205.00 $216.00 $221.00 $167.00 $175.00 $179.00
68770 90 $634.00 $888.00 $931.00 $960.00 $888.00 $931.00 $960.00
68801 10 $202.00 $123.00 $129.00 $132.00 $110.00 $116.00 $119.00
68810 10 $290.00 $219.00 $231.00 $236.00 $179.00 $188.00 $193.00
68811 10 $191.00 $192.00 $202.00 $208.00 $192.00 $202.00 $208.00
68815 10 $399.00 $548.00 $580.00 $592.00 $312.00 $328.00 $337.00
68816 10 ---------- $882.00 $937.00 $952.00 $230.00 $241.00 $249.00
68840 10 $100.00 $178.00 $187.00 $192.00 $163.00 $171.00 $176.00
68850 0 $76.00 $87.00 $92.00 $95.00 $80.00 $84.00 $87.00
68899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
69000 10 $52.00 $262.00 $278.00 $288.00 $170.00 $180.00 $188.00
69005 10 $175.00 $304.00 $322.00 $336.00 $226.00 $239.00 $252.00
69020 10 $109.00 $324.00 $344.00 $355.00 $203.00 $215.00 $224.00
69100 0 $85.00 $141.00 $150.00 $155.00 $72.00 $76.00 $80.00
69105 0 $87.00 $195.00 $207.00 $213.00 $92.00 $97.00 $102.00
69110 90 $294.00 $645.00 $686.00 $712.00 $464.00 $493.00 $517.00
69120 90 $274.00 $577.00 $611.00 $637.00 $577.00 $611.00 $637.00
69140 90 $722.00 $1,241.00 $1,317.00 $1,370.00 $1,241.00 $1,317.00 $1,370.00
69145 90 $248.00 $553.00 $588.00 $607.00 $355.00 $377.00 $394.00
69150 90 $1,111.00 $1,509.00 $1,599.00 $1,686.00 $1,509.00 $1,599.00 $1,686.00
69155 90 $1,680.00 $2,407.00 $2,546.00 $2,685.00 $2,407.00 $2,546.00 $2,685.00
69200 0 $53.00 $116.00 $123.00 $128.00 $69.00 $73.00 $77.00
69205 10 $110.00 $145.00 $154.00 $161.00 $145.00 $154.00 $161.00
69209 0 ---------- $17.00 $19.00 $19.00 $17.00 $19.00 $19.00
69210 0 $39.00 $69.00 $73.00 $76.00 $48.00 $50.00 $53.00
69220 0 $78.00 $127.00 $135.00 $140.00 $75.00 $79.00 $84.00
69222 10 $123.00 $306.00 $325.00 $336.00 $195.00 $206.00 $216.00
69300 YYY $522.00 $843.00 $894.00 $935.00 $665.00 $704.00 $743.00
69310 90 $937.00 $1,552.00 $1,647.00 $1,720.00 $1,552.00 $1,647.00 $1,720.00
69320 90 $1,434.00 $2,176.00 $2,305.00 $2,411.00 $2,176.00 $2,305.00 $2,411.00
69399 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
69420 10 $117.00 $267.00 $284.00 $294.00 $172.00 $182.00 $191.00
69421 10 $155.00 $213.00 $226.00 $237.00 $213.00 $226.00 $237.00
69424 0 $84.00 $178.00 $189.00 $195.00 $90.00 $95.00 $100.00
69433 10 $145.00 $284.00 $301.00 $312.00 $189.00 $201.00 $211.00
69436 10 $182.00 $230.00 $244.00 $256.00 $230.00 $244.00 $256.00
69440 90 $699.00 $983.00 $1,042.00 $1,090.00 $983.00 $1,042.00 $1,090.00
69450 90 $525.00 $776.00 $822.00 $859.00 $776.00 $822.00 $859.00
69501 90 $829.00 $1,053.00 $1,115.00 $1,171.00 $1,053.00 $1,115.00 $1,171.00
69502 90 $1,118.00 $1,405.00 $1,489.00 $1,569.00 $1,405.00 $1,489.00 $1,569.00
69505 90 $1,176.00 $1,717.00 $1,820.00 $1,903.00 $1,717.00 $1,820.00 $1,903.00
69511 90 $1,221.00 $1,762.00 $1,868.00 $1,956.00 $1,762.00 $1,868.00 $1,956.00
69530 90 $1,616.00 $2,400.00 $2,545.00 $2,680.00 $2,400.00 $2,545.00 $2,680.00
69535 90 $2,824.00 $3,901.00 $4,135.00 $4,380.00 $3,901.00 $4,135.00 $4,380.00
69540 10 $126.00 $291.00 $309.00 $318.00 $180.00 $191.00 $199.00
69550 90 $998.00 $1,483.00 $1,572.00 $1,642.00 $1,483.00 $1,572.00 $1,642.00
69552 90 $1,621.00 $2,238.00 $2,367.00 $2,485.00 $2,238.00 $2,367.00 $2,485.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 281
Surgery
CPT Code FUD 2003 MRALocality 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)
69554 90 $2,600.00 $3,644.00 $3,854.00 $4,069.00 $3,644.00 $3,854.00 $4,069.00
69601 90 $1,195.00 $1,503.00 $1,591.00 $1,674.00 $1,503.00 $1,591.00 $1,674.00
69602 90 $1,225.00 $1,570.00 $1,663.00 $1,750.00 $1,570.00 $1,663.00 $1,750.00
69603 90 $1,264.00 $1,812.00 $1,921.00 $2,013.00 $1,812.00 $1,921.00 $2,013.00
69604 90 $1,263.00 $1,598.00 $1,692.00 $1,779.00 $1,598.00 $1,692.00 $1,779.00
69605 90 $1,526.00 $2,421.00 $2,587.00 $2,752.00 $2,421.00 $2,587.00 $2,752.00
69610 10 $41.00 $547.00 $580.00 $608.00 $423.00 $447.00 $474.00
69620 90 $651.00 $976.00 $1,036.00 $1,076.00 $700.00 $742.00 $778.00
69631 90 $985.00 $1,263.00 $1,339.00 $1,402.00 $1,263.00 $1,339.00 $1,402.00
69632 90 $1,166.00 $1,544.00 $1,636.00 $1,716.00 $1,544.00 $1,636.00 $1,716.00
69633 90 $1,110.00 $1,496.00 $1,586.00 $1,664.00 $1,496.00 $1,586.00 $1,664.00
69635 90 $1,207.00 $1,767.00 $1,875.00 $1,966.00 $1,767.00 $1,875.00 $1,966.00
69636 90 $1,381.00 $1,970.00 $2,088.00 $2,185.00 $1,970.00 $2,088.00 $2,185.00
69637 90 $1,370.00 $2,005.00 $2,130.00 $2,238.00 $2,005.00 $2,130.00 $2,238.00
69641 90 $1,154.00 $1,494.00 $1,582.00 $1,662.00 $1,494.00 $1,582.00 $1,662.00
69642 90 $1,519.00 $1,919.00 $2,031.00 $2,135.00 $1,919.00 $2,031.00 $2,135.00
69643 90 $1,389.00 $1,758.00 $1,862.00 $1,958.00 $1,758.00 $1,862.00 $1,958.00
69644 90 $1,529.00 $2,115.00 $2,241.00 $2,348.00 $2,115.00 $2,241.00 $2,348.00
69645 90 $1,479.00 $2,078.00 $2,202.00 $2,307.00 $2,078.00 $2,202.00 $2,307.00
69646 90 $1,620.00 $2,210.00 $2,341.00 $2,454.00 $2,210.00 $2,341.00 $2,454.00
69650 90 $879.00 $1,158.00 $1,228.00 $1,290.00 $1,158.00 $1,228.00 $1,290.00
69660 90 $1,072.00 $1,333.00 $1,411.00 $1,485.00 $1,333.00 $1,411.00 $1,485.00
69661 90 $1,412.00 $1,735.00 $1,836.00 $1,932.00 $1,735.00 $1,836.00 $1,932.00
69662 90 $1,386.00 $1,675.00 $1,773.00 $1,870.00 $1,675.00 $1,773.00 $1,870.00
69666 90 $887.00 $1,166.00 $1,235.00 $1,298.00 $1,166.00 $1,235.00 $1,298.00
69667 90 $887.00 $1,166.00 $1,236.00 $1,299.00 $1,166.00 $1,236.00 $1,299.00
69670 90 $988.00 $1,363.00 $1,444.00 $1,517.00 $1,363.00 $1,444.00 $1,517.00
69676 90 $828.00 $1,188.00 $1,259.00 $1,319.00 $1,188.00 $1,259.00 $1,319.00
69700 90 $702.00 $995.00 $1,054.00 $1,106.00 $995.00 $1,054.00 $1,106.00
69710 0 BR ---------- ---------- ---------- ---------- ---------- ----------
69711 90 $878.00 $1,236.00 $1,309.00 $1,374.00 $1,236.00 $1,309.00 $1,374.00
69714 90 $961.00 $1,554.00 $1,645.00 $1,734.00 $1,554.00 $1,645.00 $1,734.00
69715 90 $1,217.00 $2,009.00 $2,139.00 $2,285.00 $2,009.00 $2,139.00 $2,285.00
69717 90 $996.00 $1,636.00 $1,732.00 $1,828.00 $1,636.00 $1,732.00 $1,828.00
69718 90 $1,232.00 $1,941.00 $2,053.00 $2,168.00 $1,941.00 $2,053.00 $2,168.00
69720 90 $1,307.00 $1,758.00 $1,871.00 $1,983.00 $1,758.00 $1,871.00 $1,983.00
69725 90 $1,922.00 $2,724.00 $2,880.00 $3,044.00 $2,724.00 $2,880.00 $3,044.00
69740 90 $1,274.00 $1,736.00 $1,847.00 $1,969.00 $1,736.00 $1,847.00 $1,969.00
69745 90 $1,447.00 $1,683.00 $1,769.00 $1,844.00 $1,683.00 $1,769.00 $1,844.00
69799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
69801 0 $785.00 $277.00 $294.00 $307.00 $184.00 $195.00 $207.00
69805 90 $1,187.00 $1,522.00 $1,610.00 $1,698.00 $1,522.00 $1,610.00 $1,698.00
69806 90 $1,123.00 $1,362.00 $1,441.00 $1,518.00 $1,362.00 $1,441.00 $1,518.00
69820 90 $876.00 $1,199.00 $1,267.00 $1,327.00 $1,199.00 $1,267.00 $1,327.00
69840 90 $869.00 $1,294.00 $1,371.00 $1,436.00 $1,294.00 $1,371.00 $1,436.00
69905 90 $1,013.00 $1,315.00 $1,393.00 $1,462.00 $1,315.00 $1,393.00 $1,462.00
69910 90 $1,228.00 $1,477.00 $1,564.00 $1,650.00 $1,477.00 $1,564.00 $1,650.00
69915 90 $1,754.00 $2,316.00 $2,465.00 $2,638.00 $2,316.00 $2,465.00 $2,638.00
69930 90 $1,498.00 $1,771.00 $1,873.00 $1,979.00 $1,771.00 $1,873.00 $1,979.00
69949 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part B, 282
Surgery
CPT Code FUD 2003 MRALocality 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)
69950 90 $2,017.00 $2,655.00 $2,821.00 $3,019.00 $2,655.00 $2,821.00 $3,019.00
69955 90 $2,185.00 $2,856.00 $3,016.00 $3,184.00 $2,856.00 $3,016.00 $3,184.00
69960 90 $2,116.00 $2,796.00 $2,955.00 $3,129.00 $2,796.00 $2,955.00 $3,129.00
69970 90 $2,306.00 $3,110.00 $3,287.00 $3,480.00 $3,110.00 $3,287.00 $3,480.00
69979 YYY BR ---------- ---------- ---------- ---------- ---------- ----------
69990 ZZZ $262.00 $343.00 $376.00 $430.00 $343.00 $376.00 $430.00
G0127 0 ---------- $32.00 $34.00 $34.00 $11.00 $11.00 $12.00
G0168 0 ---------- $141.00 $151.00 $154.00 $41.00 $43.00 $45.00
G0247 ZZZ ---------- $100.00 $106.00 $108.00 $33.00 $34.00 $36.00
G0276 0 ---------- $587.00 $622.00 $671.00 $587.00 $622.00 $671.00
G0289 ZZZ ---------- $131.00 $139.00 $151.00 $131.00 $139.00 $151.00
G0341 0 ---------- $2,846.00 $3,031.00 $3,093.00 $550.00 $579.00 $617.00
G0342 90 ---------- $1,026.00 $1,082.00 $1,148.00 $1,026.00 $1,082.00 $1,148.00
G0343 90 ---------- $1,893.00 $2,024.00 $2,196.00 $1,893.00 $2,024.00 $2,196.00
G0364 ZZZ ---------- $17.00 $18.00 $19.00 $13.00 $13.00 $13.00
G0412 90 ---------- $1,058.00 $1,128.00 $1,212.00 $1,058.00 $1,128.00 $1,212.00
G0413 90 ---------- $1,573.00 $1,678.00 $1,807.00 $1,573.00 $1,678.00 $1,807.00
G0414 90 ---------- $1,431.00 $1,517.00 $1,614.00 $1,431.00 $1,517.00 $1,614.00
G0415 90 ---------- $2,020.00 $2,154.00 $2,322.00 $2,020.00 $2,154.00 $2,322.00
G0429 0 ---------- $141.00 $149.00 $156.00 $104.00 $110.00 $116.00
2017 Edition Page 283 Effective Date: _________
Chapter 3 Maximum Reimbursement Allowances, continued
PART C
SCHEDULE OF MAXIMUM REIMBURSEMENT
ALLOWANCES
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 284
Radiology
CPT Code 2003 MRALocality 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 $76.00 $81.00 $86.00 $76.00 $81.00 $86.00
70010-26 NC BR BR BR BR BR BR
70010-TC NC BR BR BR BR BR BR
70015 $58.00 $170.00 $181.00 $186.00 $170.00 $181.00 $186.00
70015-26 NC $72.00 $75.00 $80.00 $72.00 $75.00 $80.00
70015-TC NC $99.00 $105.00 $107.00 $99.00 $105.00 $107.00
70030 $24.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
70030-26 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00
70030-TC $15.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
70100 $29.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00
70100-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
70100-TC $19.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00
70110 $36.00 $41.00 $44.00 $44.00 $41.00 $44.00 $44.00
70110-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
70110-TC $22.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
70120 $32.00 $36.00 $39.00 $40.00 $36.00 $39.00 $40.00
70120-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
70120-TC $22.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00
70130 $46.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.00
70130-26 $17.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
70130-TC $29.00 $40.00 $43.00 $43.00 $40.00 $43.00 $43.00
70134 $45.00 $56.00 $59.00 $60.00 $56.00 $59.00 $60.00
70134-26 $17.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.00
70134-TC $28.00 $36.00 $39.00 $40.00 $36.00 $39.00 $40.00
70140 $33.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
70140-26 $9.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.00
70140-TC $22.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
70150 $42.00 $45.00 $48.00 $48.00 $45.00 $48.00 $48.00
70150-26 $12.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.00
70150-TC $29.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
70160 $29.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.00
70160-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
70160-TC $19.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00
70170 $52.00 $255.00 $271.00 $275.00 $255.00 $271.00 $275.00
70170-26 NC $17.00 $18.00 $18.00 $17.00 $18.00 $18.00
70170-TC NC $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
70190 $34.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.00
70190-26 $10.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
70190-TC $22.00 $26.00 $28.00 $28.00 $26.00 $28.00 $28.00
70200 $43.00 $46.00 $48.00 $49.00 $46.00 $48.00 $49.00
70200-26 $14.00 $16.00 $16.00 $17.00 $16.00 $16.00 $17.00
70200-TC $29.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
70210 $32.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
70210-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
70210-TC $22.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00
70220 $42.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
70220-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
70220-TC $29.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
70240 $26.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00
70240-26 $9.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 285
Radiology
CPT Code 2003 MRALocality 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 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
70250 $35.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
70250-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
70250-TC $22.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
70260 $50.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.00
70260-26 $17.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.00
70260-TC $33.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
70300 $15.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
70300-26 $5.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.00
70300-TC $10.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
70310 $24.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.00
70310-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00
70310-TC $15.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
70320 $40.00 $57.00 $61.00 $63.00 $57.00 $61.00 $63.00
70320-26 $11.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
70320-TC $29.00 $44.00 $47.00 $47.00 $44.00 $47.00 $47.00
70328 $28.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00
70328-26 $10.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
70328-TC $18.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
70330 $43.00 $52.00 $55.00 $56.00 $52.00 $55.00 $56.00
70330-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
70330-TC $31.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.00
70332 $107.00 $87.00 $92.00 $94.00 $87.00 $92.00 $94.00
70332-26 NC $35.00 $36.00 $37.00 $35.00 $36.00 $37.00
70332-TC NC $52.00 $56.00 $57.00 $52.00 $56.00 $57.00
70336 $497.00 $321.00 $340.00 $346.00 $321.00 $340.00 $346.00
70336-26 $72.00 $83.00 $86.00 $88.00 $83.00 $86.00 $88.00
70336-TC $419.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
70350 $24.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
70350-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.00
70350-TC $14.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.00
70355 $32.00 $23.00 $24.00 $26.00 $23.00 $24.00 $26.00
70355-26 $10.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.00
70355-TC $21.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.00
70360 $24.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
70360-26 $8.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00
70360-TC $15.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
70370 $65.00 $83.00 $88.00 $90.00 $83.00 $88.00 $90.00
70370-26 $16.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
70370-TC $48.00 $65.00 $69.00 $70.00 $65.00 $69.00 $70.00
70371 $122.00 $98.00 $103.00 $105.00 $98.00 $103.00 $105.00
70371-26 $43.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00
70371-TC $79.00 $51.00 $55.00 $56.00 $51.00 $55.00 $56.00
70380 $34.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
70380-26 $8.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
70380-TC $24.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00
70390 $87.00 $101.00 $107.00 $109.00 $101.00 $107.00 $109.00
70390-26 NC $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
70390-TC NC $79.00 $85.00 $86.00 $79.00 $85.00 $86.00
70450 $221.00 $126.00 $133.00 $136.00 $126.00 $133.00 $136.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 286
Radiology
CPT Code 2003 MRALocality 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)
70450-26 $43.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.00
70450-TC $176.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00
70460 $271.00 $176.00 $186.00 $189.00 $176.00 $186.00 $189.00
70460-26 $58.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.00
70460-TC $211.00 $112.00 $120.00 $121.00 $112.00 $120.00 $121.00
70470 $332.00 $208.00 $220.00 $224.00 $208.00 $220.00 $224.00
70470-26 $65.00 $72.00 $74.00 $77.00 $72.00 $74.00 $77.00
70470-TC $264.00 $136.00 $145.00 $147.00 $136.00 $145.00 $147.00
70480 $244.00 $191.00 $202.00 $205.00 $191.00 $202.00 $205.00
70480-26 $65.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.00
70480-TC $176.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
70481 $284.00 $297.00 $315.00 $320.00 $297.00 $315.00 $320.00
70481-26 $70.00 $78.00 $81.00 $83.00 $78.00 $81.00 $83.00
70481-TC $211.00 $219.00 $234.00 $237.00 $219.00 $234.00 $237.00
70482 $340.00 $324.00 $344.00 $350.00 $324.00 $344.00 $350.00
70482-26 $74.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.00
70482-TC $264.00 $243.00 $260.00 $263.00 $243.00 $260.00 $263.00
70486 $236.00 $151.00 $159.00 $162.00 $151.00 $159.00 $162.00
70486-26 $58.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.00
70486-TC $176.00 $102.00 $110.00 $111.00 $102.00 $110.00 $111.00
70487 $279.00 $182.00 $192.00 $195.00 $182.00 $192.00 $195.00
70487-26 $66.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.00
70487-TC $211.00 $118.00 $126.00 $128.00 $118.00 $126.00 $128.00
70488 $339.00 $221.00 $234.00 $238.00 $221.00 $234.00 $238.00
70488-26 $72.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.00
70488-TC $264.00 $150.00 $160.00 $162.00 $150.00 $160.00 $162.00
70490 $244.00 $191.00 $202.00 $205.00 $191.00 $202.00 $205.00
70490-26 $65.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.00
70490-TC $176.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
70491 $284.00 $255.00 $270.00 $274.00 $255.00 $270.00 $274.00
70491-26 $70.00 $78.00 $81.00 $84.00 $78.00 $81.00 $84.00
70491-TC $211.00 $176.00 $189.00 $191.00 $176.00 $189.00 $191.00
70492 $340.00 $300.00 $317.00 $323.00 $300.00 $317.00 $323.00
70492-26 $74.00 $82.00 $85.00 $87.00 $82.00 $85.00 $87.00
70492-TC $264.00 $218.00 $233.00 $235.00 $218.00 $233.00 $235.00
70496 $366.00 $317.00 $336.00 $342.00 $317.00 $336.00 $342.00
70496-26 $92.00 $99.00 $102.00 $106.00 $99.00 $102.00 $106.00
70496-TC $270.00 $218.00 $234.00 $236.00 $218.00 $234.00 $236.00
70498 $366.00 $317.00 $335.00 $341.00 $317.00 $335.00 $341.00
70498-26 $92.00 $99.00 $102.00 $106.00 $99.00 $102.00 $106.00
70498-TC $270.00 $218.00 $233.00 $236.00 $218.00 $233.00 $236.00
70540 $482.00 $314.00 $332.00 $338.00 $314.00 $332.00 $338.00
70540-26 $70.00 $76.00 $79.00 $81.00 $76.00 $79.00 $81.00
70540-TC $413.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
70542 $579.00 $366.00 $388.00 $394.00 $366.00 $388.00 $394.00
70542-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00
70542-TC $495.00 $274.00 $293.00 $297.00 $274.00 $293.00 $297.00
70543 $1,029.00 $450.00 $476.00 $484.00 $450.00 $476.00 $484.00
70543-26 $109.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00
70543-TC $916.00 $329.00 $351.00 $355.00 $329.00 $351.00 $355.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 287
Radiology
CPT Code 2003 MRALocality 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)
70544 $481.00 $306.00 $324.00 $329.00 $306.00 $324.00 $329.00
70544-26 $61.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.00
70544-TC $419.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
70545 $481.00 $347.00 $368.00 $374.00 $347.00 $368.00 $374.00
70545-26 $61.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.00
70545-TC $419.00 $279.00 $298.00 $302.00 $279.00 $298.00 $302.00
70546 $914.00 $550.00 $584.00 $593.00 $550.00 $584.00 $593.00
70546-26 $92.00 $102.00 $105.00 $108.00 $102.00 $105.00 $108.00
70546-TC $820.00 $449.00 $479.00 $485.00 $449.00 $479.00 $485.00
70547 $481.00 $306.00 $324.00 $329.00 $306.00 $324.00 $329.00
70547-26 $61.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.00
70547-TC $419.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
70548 $481.00 $347.00 $368.00 $374.00 $347.00 $368.00 $374.00
70548-26 $61.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.00
70548-TC $419.00 $279.00 $298.00 $301.00 $279.00 $298.00 $301.00
70549 $914.00 $550.00 $584.00 $593.00 $550.00 $584.00 $593.00
70549-26 $92.00 $102.00 $105.00 $108.00 $102.00 $105.00 $108.00
70549-TC $820.00 $449.00 $479.00 $485.00 $449.00 $479.00 $485.00
70551 $497.00 $250.00 $264.00 $269.00 $250.00 $264.00 $269.00
70551-26 $76.00 $83.00 $86.00 $89.00 $83.00 $86.00 $89.00
70551-TC $419.00 $167.00 $178.00 $180.00 $167.00 $178.00 $180.00
70552 $596.00 $346.00 $366.00 $373.00 $346.00 $366.00 $373.00
70552-26 $91.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.00
70552-TC $502.00 $245.00 $262.00 $265.00 $245.00 $262.00 $265.00
70553 $1,055.00 $409.00 $432.00 $440.00 $409.00 $432.00 $440.00
70553-26 $120.00 $129.00 $134.00 $138.00 $129.00 $134.00 $138.00
70553-TC $931.00 $279.00 $298.00 $302.00 $279.00 $298.00 $302.00
70554 ---------- $485.00 $514.00 $522.00 $485.00 $514.00 $522.00
70554-26 ---------- $120.00 $124.00 $128.00 $120.00 $124.00 $128.00
70554-TC ---------- $365.00 $390.00 $394.00 $365.00 $390.00 $394.00
70555 ---------- BR BR BR BR BR BR
70555-26 ---------- $141.00 $146.00 $150.00 $141.00 $146.00 $150.00
70555-TC ---------- BR BR BR BR BR BR
70557 ---------- $403.00 $426.00 $434.00 $403.00 $426.00 $434.00
70557-26 ---------- $166.00 $172.00 $178.00 $166.00 $172.00 $178.00
70557-TC ---------- $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
70558 ---------- $629.00 $666.00 $677.00 $629.00 $666.00 $677.00
70558-26 ---------- $181.00 $187.00 $193.00 $181.00 $187.00 $193.00
70558-TC ---------- $449.00 $479.00 $484.00 $449.00 $479.00 $484.00
70559 ---------- $462.00 $488.00 $498.00 $462.00 $488.00 $498.00
70559-26 ---------- $183.00 $190.00 $197.00 $183.00 $190.00 $197.00
70559-TC ---------- $279.00 $298.00 $301.00 $279.00 $298.00 $301.00
71010 $27.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
71010-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
71010-TC $17.00 $14.00 $16.00 $16.00 $14.00 $16.00 $16.00
71015 $30.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
71015-26 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
71015-TC $19.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
71020 $35.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
71020-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 288
Radiology
CPT Code 2003 MRALocality 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)
71020-TC $22.00 $18.00 $20.00 $20.00 $18.00 $20.00 $20.00
71021 $41.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
71021-26 $13.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.00
71021-TC $28.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
71022 $44.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.00
71022-26 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.00
71022-TC $28.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
71023 $49.00 $69.00 $73.00 $74.00 $69.00 $73.00 $74.00
71023-26 $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
71023-TC $29.00 $47.00 $51.00 $51.00 $47.00 $51.00 $51.00
71030 $45.00 $46.00 $48.00 $49.00 $46.00 $48.00 $49.00
71030-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.00
71030-TC $29.00 $28.00 $30.00 $30.00 $28.00 $30.00 $30.00
71034 $79.00 $89.00 $95.00 $97.00 $89.00 $95.00 $97.00
71034-26 $23.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
71034-TC $54.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
71035 $56.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.00
71035-26 $19.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
71035-TC $38.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
71100 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00
71100-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
71100-TC $21.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.00
71101 $38.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.00
71101-26 $13.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.00
71101-TC $24.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.00
71110 $43.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
71110-26 $13.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.00
71110-TC $29.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00
71111 $49.00 $52.00 $55.00 $57.00 $52.00 $55.00 $57.00
71111-26 $16.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.00
71111-TC $33.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00
71120 $35.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
71120-26 $10.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
71120-TC $24.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
71130 $38.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
71130-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
71130-TC $26.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00
71250 $282.00 $176.00 $187.00 $190.00 $176.00 $187.00 $190.00
71250-26 $59.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.00
71250-TC $220.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
71260 $328.00 $248.00 $262.00 $267.00 $248.00 $262.00 $267.00
71260-26 $63.00 $70.00 $73.00 $75.00 $70.00 $73.00 $75.00
71260-TC $264.00 $178.00 $190.00 $192.00 $178.00 $190.00 $192.00
71270 $402.00 $297.00 $314.00 $319.00 $297.00 $314.00 $319.00
71270-26 $70.00 $78.00 $81.00 $83.00 $78.00 $81.00 $83.00
71270-TC $330.00 $219.00 $234.00 $236.00 $219.00 $234.00 $236.00
71275 $431.00 $325.00 $344.00 $350.00 $325.00 $344.00 $350.00
71275-26 $100.00 $103.00 $106.00 $110.00 $103.00 $106.00 $110.00
71275-TC $328.00 $222.00 $238.00 $241.00 $222.00 $238.00 $241.00
71550 $490.00 $320.00 $339.00 $344.00 $320.00 $339.00 $344.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 289
Radiology
CPT Code 2003 MRALocality 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)
71550-26 $75.00 $82.00 $85.00 $88.00 $82.00 $85.00 $88.00
71550-TC $415.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
71551 $587.00 $497.00 $527.00 $535.00 $497.00 $527.00 $535.00
71551-26 $88.00 $98.00 $101.00 $104.00 $98.00 $101.00 $104.00
71551-TC $496.00 $399.00 $426.00 $431.00 $399.00 $426.00 $431.00
71552 $1,029.00 $577.00 $612.00 $622.00 $577.00 $612.00 $622.00
71552-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.00
71552-TC $911.00 $449.00 $480.00 $485.00 $449.00 $480.00 $485.00
71555 $514.00 $429.00 $455.00 $462.00 $429.00 $455.00 $462.00
71555-26 $92.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.00
71555-TC $419.00 $328.00 $351.00 $355.00 $328.00 $351.00 $355.00
72020 $22.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
72020-26 $7.00 $9.00 $9.00 $9.00 $9.00 $9.00 $9.00
72020-TC $15.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.00
72040 $34.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00
72040-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
72040-TC $22.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.00
72050 $49.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.00
72050-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.00
72050-TC $33.00 $31.00 $34.00 $34.00 $31.00 $34.00 $34.00
72052 $61.00 $61.00 $64.00 $66.00 $61.00 $64.00 $66.00
72052-26 $18.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.00
72052-TC $42.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.00
72070 $36.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
72070-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
72070-TC $24.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.00
72072 $39.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
72072-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
72072-TC $28.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
72074 $45.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
72074-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
72074-TC $34.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
72080 $36.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00
72080-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
72080-TC $24.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
72081 ---------- $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
72081-26 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00
72081-TC ---------- $27.00 $29.00 $30.00 $27.00 $29.00 $30.00
72082 ---------- $67.00 $72.00 $73.00 $67.00 $72.00 $73.00
72082-26 ---------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
72082-TC ---------- $49.00 $53.00 $54.00 $49.00 $53.00 $54.00
72083 ---------- $73.00 $78.00 $79.00 $73.00 $78.00 $79.00
72083-26 ---------- $20.00 $20.00 $21.00 $20.00 $20.00 $21.00
72083-TC ---------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.00
72084 ---------- $87.00 $92.00 $94.00 $87.00 $92.00 $94.00
72084-26 ---------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.00
72084-TC ---------- $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
72100 $36.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.00
72100-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
72100-TC $24.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 290
Radiology
CPT Code 2003 MRALocality 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)
72110 $50.00 $53.00 $56.00 $58.00 $53.00 $56.00 $58.00
72110-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.00
72110-TC $34.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.00
72114 $64.00 $67.00 $71.00 $73.00 $67.00 $71.00 $73.00
72114-26 $18.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.00
72114-TC $44.00 $48.00 $52.00 $53.00 $48.00 $52.00 $53.00
72120 $45.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.00
72120-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
72120-TC $33.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.00
72125 $282.00 $179.00 $189.00 $193.00 $179.00 $189.00 $193.00
72125-26 $59.00 $61.00 $63.00 $65.00 $61.00 $63.00 $65.00
72125-TC $220.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
72126 $328.00 $247.00 $261.00 $266.00 $247.00 $261.00 $266.00
72126-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00
72126-TC $264.00 $178.00 $190.00 $192.00 $178.00 $190.00 $192.00
72127 $397.00 $291.00 $308.00 $313.00 $291.00 $308.00 $313.00
72127-26 $65.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.00
72127-TC $330.00 $219.00 $234.00 $237.00 $219.00 $234.00 $237.00
72128 $282.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00
72128-26 $59.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00
72128-TC $220.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
72129 $328.00 $248.00 $262.00 $267.00 $248.00 $262.00 $267.00
72129-26 $62.00 $69.00 $72.00 $74.00 $69.00 $72.00 $74.00
72129-TC $264.00 $179.00 $191.00 $193.00 $179.00 $191.00 $193.00
72130 $397.00 $292.00 $310.00 $315.00 $292.00 $310.00 $315.00
72130-26 $65.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.00
72130-TC $330.00 $221.00 $236.00 $238.00 $221.00 $236.00 $238.00
72131 $282.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00
72131-26 $59.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00
72131-TC $220.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
72132 $328.00 $246.00 $261.00 $265.00 $246.00 $261.00 $265.00
72132-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00
72132-TC $264.00 $178.00 $190.00 $192.00 $178.00 $190.00 $192.00
72133 $391.00 $291.00 $308.00 $313.00 $291.00 $308.00 $313.00
72133-26 $65.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.00
72133-TC $323.00 $219.00 $234.00 $237.00 $219.00 $234.00 $237.00
72141 $503.00 $243.00 $257.00 $262.00 $243.00 $257.00 $262.00
72141-26 $82.00 $84.00 $87.00 $90.00 $84.00 $87.00 $90.00
72141-TC $419.00 $159.00 $170.00 $172.00 $159.00 $170.00 $172.00
72142 $604.00 $351.00 $372.00 $379.00 $351.00 $372.00 $379.00
72142-26 $99.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.00
72142-TC $502.00 $251.00 $268.00 $271.00 $251.00 $268.00 $271.00
72146 $549.00 $244.00 $258.00 $263.00 $244.00 $258.00 $263.00
72146-26 $82.00 $84.00 $87.00 $90.00 $84.00 $87.00 $90.00
72146-TC $465.00 $160.00 $171.00 $173.00 $160.00 $171.00 $173.00
72147 $603.00 $349.00 $370.00 $376.00 $349.00 $370.00 $376.00
72147-26 $98.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.00
72147-TC $502.00 $248.00 $265.00 $269.00 $248.00 $265.00 $269.00
72148 $543.00 $243.00 $256.00 $261.00 $243.00 $256.00 $261.00
72148-26 $76.00 $84.00 $87.00 $90.00 $84.00 $87.00 $90.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 291
Radiology
CPT Code 2003 MRALocality 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)
72148-TC $465.00 $158.00 $169.00 $171.00 $158.00 $169.00 $171.00
72149 $597.00 $348.00 $368.00 $375.00 $348.00 $368.00 $375.00
72149-26 $92.00 $101.00 $105.00 $109.00 $101.00 $105.00 $109.00
72149-TC $502.00 $246.00 $263.00 $267.00 $246.00 $263.00 $267.00
72156 $1,066.00 $411.00 $435.00 $443.00 $411.00 $435.00 $443.00
72156-26 $131.00 $129.00 $134.00 $138.00 $129.00 $134.00 $138.00
72156-TC $931.00 $282.00 $301.00 $305.00 $282.00 $301.00 $305.00
72157 $1,066.00 $412.00 $436.00 $444.00 $412.00 $436.00 $444.00
72157-26 $131.00 $129.00 $134.00 $138.00 $129.00 $134.00 $138.00
72157-TC $931.00 $283.00 $302.00 $306.00 $283.00 $302.00 $306.00
72158 $1,056.00 $410.00 $433.00 $441.00 $410.00 $433.00 $441.00
72158-26 $121.00 $130.00 $134.00 $138.00 $130.00 $134.00 $138.00
72158-TC $931.00 $280.00 $299.00 $303.00 $280.00 $299.00 $303.00
72159 $563.00 $448.00 $476.00 $483.00 $448.00 $476.00 $483.00
72159-26 $94.00 $102.00 $105.00 $109.00 $102.00 $105.00 $109.00
72159-TC $465.00 $346.00 $370.00 $374.00 $346.00 $370.00 $374.00
72170 $29.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00
72170-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
72170-TC $19.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
72190 $35.00 $41.00 $44.00 $44.00 $41.00 $44.00 $44.00
72190-26 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
72190-TC $24.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
72191 $413.00 $331.00 $351.00 $357.00 $331.00 $351.00 $357.00
72191-26 $94.00 $102.00 $106.00 $109.00 $102.00 $106.00 $109.00
72191-TC $315.00 $229.00 $245.00 $248.00 $229.00 $245.00 $248.00
72192 $278.00 $159.00 $168.00 $171.00 $159.00 $168.00 $171.00
72192-26 $56.00 $62.00 $64.00 $66.00 $62.00 $64.00 $66.00
72192-TC $220.00 $97.00 $104.00 $105.00 $97.00 $104.00 $105.00
72193 $317.00 $244.00 $259.00 $263.00 $244.00 $259.00 $263.00
72193-26 $59.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00
72193-TC $256.00 $178.00 $191.00 $193.00 $178.00 $191.00 $193.00
72194 $380.00 $280.00 $297.00 $302.00 $280.00 $297.00 $302.00
72194-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00
72194-TC $317.00 $211.00 $226.00 $229.00 $211.00 $226.00 $229.00
72195 $491.00 $320.00 $339.00 $345.00 $320.00 $339.00 $345.00
72195-26 $74.00 $83.00 $85.00 $88.00 $83.00 $85.00 $88.00
72195-TC $415.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
72196 $526.00 $442.00 $469.00 $477.00 $442.00 $469.00 $477.00
72196-26 $84.00 $98.00 $101.00 $105.00 $98.00 $101.00 $105.00
72196-TC $442.00 $344.00 $368.00 $372.00 $344.00 $368.00 $372.00
72197 $1,037.00 $545.00 $578.00 $587.00 $545.00 $578.00 $587.00
72197-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.00
72197-TC $919.00 $417.00 $446.00 $451.00 $417.00 $446.00 $451.00
72198 $517.00 $433.00 $459.00 $466.00 $433.00 $459.00 $466.00
72198-26 $95.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.00
72198-TC $419.00 $332.00 $354.00 $359.00 $332.00 $354.00 $359.00
72200 $29.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.00
72200-26 $9.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
72200-TC $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
72202 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 292
Radiology
CPT Code 2003 MRALocality 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)
72202-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
72202-TC $22.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
72220 $30.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
72220-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
72220-TC $21.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
72240 $132.00 $107.00 $113.00 $116.00 $107.00 $113.00 $116.00
72240-26 NC $51.00 $53.00 $54.00 $51.00 $53.00 $54.00
72240-TC NC $56.00 $60.00 $61.00 $56.00 $60.00 $61.00
72255 $129.00 $108.00 $114.00 $117.00 $108.00 $114.00 $117.00
72255-26 NC $53.00 $55.00 $57.00 $53.00 $55.00 $57.00
72255-TC NC $55.00 $59.00 $60.00 $55.00 $59.00 $60.00
72265 $132.00 $101.00 $106.00 $109.00 $101.00 $106.00 $109.00
72265-26 NC $47.00 $48.00 $50.00 $47.00 $48.00 $50.00
72265-TC NC $54.00 $58.00 $59.00 $54.00 $58.00 $59.00
72270 $176.00 $140.00 $147.00 $150.00 $140.00 $147.00 $150.00
72270-26 NC $76.00 $78.00 $81.00 $76.00 $78.00 $81.00
72270-TC NC $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
72275 $112.00 $125.00 $132.00 $135.00 $125.00 $132.00 $135.00
72275-26 NC $44.00 $45.00 $47.00 $44.00 $45.00 $47.00
72275-TC NC $81.00 $87.00 $88.00 $81.00 $87.00 $88.00
72285 $101.00 $124.00 $130.00 $133.00 $124.00 $130.00 $133.00
72285-26 NC $68.00 $70.00 $73.00 $68.00 $70.00 $73.00
72285-TC NC $56.00 $60.00 $60.00 $56.00 $60.00 $60.00
72295 $107.00 $107.00 $113.00 $115.00 $107.00 $113.00 $115.00
72295-26 NC $49.00 $51.00 $53.00 $49.00 $51.00 $53.00
72295-TC NC $58.00 $62.00 $63.00 $58.00 $62.00 $63.00
73000 $28.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
73000-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73000-TC $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
73010 $29.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00
73010-26 $8.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
73010-TC $19.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00
73020 $26.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
73020-26 $7.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00
73020-TC $17.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
73030 $31.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
73030-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
73030-TC $21.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
73040 $68.00 $108.00 $114.00 $116.00 $108.00 $114.00 $116.00
73040-26 NC $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
73040-TC NC $77.00 $83.00 $84.00 $77.00 $83.00 $84.00
73050 $35.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.00
73050-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.00
73050-TC $24.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
73060 $30.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
73060-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73060-TC $21.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00
73070 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
73070-26 $7.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00
73070-TC $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 293
Radiology
CPT Code 2003 MRALocality 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)
73080 $30.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00
73080-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
73080-TC $21.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.00
73085 $74.00 $104.00 $110.00 $112.00 $104.00 $110.00 $112.00
73085-26 NC $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
73085-TC NC $71.00 $76.00 $77.00 $71.00 $76.00 $77.00
73090 $28.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00
73090-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73090-TC $19.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
73100 $27.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
73100-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73100-TC $18.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00
73110 $29.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.00
73110-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
73110-TC $19.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00
73115 $54.00 $115.00 $122.00 $124.00 $115.00 $122.00 $124.00
73115-26 NC $32.00 $33.00 $35.00 $32.00 $33.00 $35.00
73115-TC NC $83.00 $89.00 $90.00 $83.00 $89.00 $90.00
73120 $27.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.00
73120-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73120-TC $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
73130 $29.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00
73130-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
73130-TC $19.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
73140 $22.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00
73140-26 $7.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.00
73140-TC $15.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00
73200 $242.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00
73200-26 $56.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00
73200-TC $185.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
73201 $282.00 $240.00 $254.00 $259.00 $240.00 $254.00 $259.00
73201-26 $59.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00
73201-TC $220.00 $175.00 $187.00 $189.00 $175.00 $187.00 $189.00
73202 $342.00 $298.00 $317.00 $322.00 $298.00 $317.00 $322.00
73202-26 $63.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00
73202-TC $277.00 $230.00 $245.00 $248.00 $230.00 $245.00 $248.00
73206 $375.00 $355.00 $376.00 $382.00 $355.00 $376.00 $382.00
73206-26 $94.00 $101.00 $105.00 $108.00 $101.00 $105.00 $108.00
73206-TC $277.00 $254.00 $271.00 $274.00 $254.00 $271.00 $274.00
73218 $482.00 $315.00 $334.00 $340.00 $315.00 $334.00 $340.00
73218-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.00
73218-TC $413.00 $238.00 $255.00 $258.00 $238.00 $255.00 $258.00
73219 $579.00 $432.00 $459.00 $466.00 $432.00 $459.00 $466.00
73219-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00
73219-TC $495.00 $341.00 $364.00 $368.00 $341.00 $364.00 $368.00
73220 $520.00 $538.00 $571.00 $580.00 $538.00 $571.00 $580.00
73220-26 $78.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00
73220-TC $442.00 $417.00 $446.00 $451.00 $417.00 $446.00 $451.00
73221 $482.00 $257.00 $272.00 $277.00 $257.00 $272.00 $277.00
73221-26 $68.00 $77.00 $80.00 $82.00 $77.00 $80.00 $82.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 294
Radiology
CPT Code 2003 MRALocality 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)
73221-TC $413.00 $180.00 $192.00 $195.00 $180.00 $192.00 $195.00
73222 $579.00 $407.00 $432.00 $439.00 $407.00 $432.00 $439.00
73222-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00
73222-TC $495.00 $315.00 $337.00 $341.00 $315.00 $337.00 $341.00
73223 $1,029.00 $507.00 $537.00 $546.00 $507.00 $537.00 $546.00
73223-26 $109.00 $122.00 $126.00 $130.00 $122.00 $126.00 $130.00
73223-TC $916.00 $385.00 $411.00 $416.00 $385.00 $411.00 $416.00
73225 $513.00 $440.00 $467.00 $475.00 $440.00 $467.00 $475.00
73225-26 $92.00 $97.00 $100.00 $104.00 $97.00 $100.00 $104.00
73225-TC $419.00 $343.00 $367.00 $371.00 $343.00 $367.00 $371.00
73501 ---------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
73501-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
73501-TC ---------- $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
73502 ---------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.00
73502-26 ---------- $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
73502-TC ---------- $32.00 $35.00 $35.00 $32.00 $35.00 $35.00
73503 ---------- $56.00 $59.00 $61.00 $56.00 $59.00 $61.00
73503-26 ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
73503-TC ---------- $40.00 $43.00 $43.00 $40.00 $43.00 $43.00
73521 ---------- $43.00 $46.00 $46.00 $43.00 $46.00 $46.00
73521-26 ---------- $13.00 $13.00 $14.00 $13.00 $13.00 $14.00
73521-TC ---------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
73522 ---------- $53.00 $56.00 $58.00 $53.00 $56.00 $58.00
73522-26 ---------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.00
73522-TC ---------- $36.00 $39.00 $39.00 $36.00 $39.00 $39.00
73523 ---------- $61.00 $65.00 $67.00 $61.00 $65.00 $67.00
73523-26 ---------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
73523-TC ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00
73525 $84.00 $110.00 $117.00 $119.00 $110.00 $117.00 $119.00
73525-26 NC $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
73525-TC NC $78.00 $83.00 $84.00 $78.00 $83.00 $84.00
73551 ---------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
73551-26 ---------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73551-TC ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
73552 ---------- $35.00 $38.00 $38.00 $35.00 $38.00 $38.00
73552-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
73552-TC ---------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
73560 $29.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00
73560-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73560-TC $19.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.00
73562 $31.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
73562-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
73562-TC $21.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00
73564 $35.00 $43.00 $46.00 $46.00 $43.00 $46.00 $46.00
73564-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
73564-TC $22.00 $30.00 $33.00 $33.00 $30.00 $33.00 $33.00
73565 $28.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
73565-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
73565-TC $18.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
73580 $84.00 $123.00 $130.00 $133.00 $123.00 $130.00 $133.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 295
Radiology
CPT Code 2003 MRALocality 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)
73580-26 NC $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
73580-TC NC $91.00 $97.00 $99.00 $91.00 $97.00 $99.00
73590 $29.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.00
73590-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73590-TC $19.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
73600 $27.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
73600-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
73600-TC $18.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
73610 $29.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00
73610-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
73610-TC $19.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.00
73615 $72.00 $114.00 $120.00 $123.00 $114.00 $120.00 $123.00
73615-26 NC $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
73615-TC NC $82.00 $87.00 $89.00 $82.00 $87.00 $89.00
73620 $27.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00
73620-26 $8.00 $9.00 $9.00 $9.00 $9.00 $9.00 $9.00
73620-TC $18.00 $19.00 $21.00 $21.00 $19.00 $21.00 $21.00
73630 $29.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
73630-26 $8.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00
73630-TC $19.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00
73650 $26.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
73650-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00
73650-TC $17.00 $20.00 $22.00 $22.00 $20.00 $22.00 $22.00
73660 $22.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
73660-26 $7.00 $8.00 $8.00 $8.00 $8.00 $8.00 $8.00
73660-TC $15.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
73700 $242.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00
73700-26 $56.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00
73700-TC $185.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
73701 $282.00 $244.00 $259.00 $263.00 $244.00 $259.00 $263.00
73701-26 $61.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00
73701-TC $220.00 $178.00 $191.00 $193.00 $178.00 $191.00 $193.00
73702 $341.00 $295.00 $313.00 $318.00 $295.00 $313.00 $318.00
73702-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00
73702-TC $277.00 $226.00 $242.00 $244.00 $226.00 $242.00 $244.00
73706 $379.00 $384.00 $407.00 $415.00 $384.00 $407.00 $415.00
73706-26 $98.00 $107.00 $110.00 $114.00 $107.00 $110.00 $114.00
73706-TC $277.00 $277.00 $297.00 $301.00 $277.00 $297.00 $301.00
73718 $482.00 $314.00 $334.00 $339.00 $314.00 $334.00 $339.00
73718-26 $68.00 $76.00 $79.00 $82.00 $76.00 $79.00 $82.00
73718-TC $413.00 $238.00 $255.00 $258.00 $238.00 $255.00 $258.00
73719 $579.00 $371.00 $393.00 $399.00 $371.00 $393.00 $399.00
73719-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00
73719-TC $495.00 $279.00 $298.00 $302.00 $279.00 $298.00 $302.00
73720 $520.00 $541.00 $574.00 $583.00 $541.00 $574.00 $583.00
73720-26 $78.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00
73720-TC $442.00 $420.00 $448.00 $453.00 $420.00 $448.00 $453.00
73721 $482.00 $256.00 $271.00 $277.00 $256.00 $271.00 $277.00
73721-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.00
73721-TC $413.00 $180.00 $192.00 $195.00 $180.00 $192.00 $195.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 296
Radiology
CPT Code 2003 MRALocality 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)
73722 $579.00 $411.00 $436.00 $442.00 $411.00 $436.00 $442.00
73722-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00
73722-TC $495.00 $319.00 $341.00 $345.00 $319.00 $341.00 $345.00
73723 $1,029.00 $507.00 $538.00 $546.00 $507.00 $538.00 $546.00
73723-26 $109.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00
73723-TC $916.00 $386.00 $412.00 $417.00 $386.00 $412.00 $417.00
73725 $515.00 $433.00 $459.00 $466.00 $433.00 $459.00 $466.00
73725-26 $92.00 $102.00 $105.00 $108.00 $102.00 $105.00 $108.00
73725-TC $419.00 $331.00 $354.00 $358.00 $331.00 $354.00 $358.00
74000 $29.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
74000-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
74000-TC $19.00 $16.00 $17.00 $17.00 $16.00 $17.00 $17.00
74010 $33.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.00
74010-26 $11.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.00
74010-TC $21.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
74020 $37.00 $41.00 $43.00 $45.00 $41.00 $43.00 $45.00
74020-26 $13.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.00
74020-TC $22.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00
74022 $44.00 $49.00 $51.00 $53.00 $49.00 $51.00 $53.00
74022-26 $16.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
74022-TC $28.00 $30.00 $33.00 $33.00 $30.00 $33.00 $33.00
74150 $274.00 $163.00 $172.00 $175.00 $163.00 $172.00 $175.00
74150-26 $60.00 $67.00 $70.00 $72.00 $67.00 $70.00 $72.00
74150-TC $211.00 $96.00 $102.00 $104.00 $96.00 $102.00 $104.00
74160 $322.00 $249.00 $264.00 $269.00 $249.00 $264.00 $269.00
74160-26 $65.00 $72.00 $74.00 $77.00 $72.00 $74.00 $77.00
74160-TC $256.00 $178.00 $190.00 $192.00 $178.00 $190.00 $192.00
74170 $390.00 $283.00 $300.00 $305.00 $283.00 $300.00 $305.00
74170-26 $71.00 $79.00 $82.00 $84.00 $79.00 $82.00 $84.00
74170-TC $317.00 $204.00 $218.00 $221.00 $204.00 $218.00 $221.00
74174 ---------- $403.00 $426.00 $434.00 $403.00 $426.00 $434.00
74174-26 ---------- $124.00 $128.00 $132.00 $124.00 $128.00 $132.00
74174-TC ---------- $279.00 $298.00 $302.00 $279.00 $298.00 $302.00
74175 $418.00 $332.00 $351.00 $358.00 $332.00 $351.00 $358.00
74175-26 $98.00 $102.00 $105.00 $109.00 $102.00 $105.00 $109.00
74175-TC $315.00 $230.00 $246.00 $249.00 $230.00 $246.00 $249.00
74176 ---------- $219.00 $231.00 $236.00 $219.00 $231.00 $236.00
74176-26 ---------- $99.00 $102.00 $105.00 $99.00 $102.00 $105.00
74176-TC ---------- $121.00 $129.00 $130.00 $121.00 $129.00 $130.00
74177 ---------- $337.00 $356.00 $362.00 $337.00 $356.00 $362.00
74177-26 ---------- $103.00 $106.00 $110.00 $103.00 $106.00 $110.00
74177-TC ---------- $234.00 $250.00 $253.00 $234.00 $250.00 $253.00
74178 ---------- $382.00 $404.00 $411.00 $382.00 $404.00 $411.00
74178-26 ---------- $113.00 $117.00 $121.00 $113.00 $117.00 $121.00
74178-TC ---------- $269.00 $287.00 $291.00 $269.00 $287.00 $291.00
74181 $498.00 $320.00 $339.00 $345.00 $320.00 $339.00 $345.00
74181-26 $85.00 $82.00 $85.00 $88.00 $82.00 $85.00 $88.00
74181-TC $415.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
74182 $587.00 $489.00 $519.00 $527.00 $489.00 $519.00 $527.00
74182-26 $88.00 $98.00 $101.00 $105.00 $98.00 $101.00 $105.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 297
Radiology
CPT Code 2003 MRALocality 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)
74182-TC $496.00 $391.00 $418.00 $422.00 $391.00 $418.00 $422.00
74183 $1,037.00 $546.00 $579.00 $588.00 $546.00 $579.00 $588.00
74183-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.00
74183-TC $919.00 $418.00 $447.00 $452.00 $418.00 $447.00 $452.00
74185 $514.00 $434.00 $461.00 $468.00 $434.00 $461.00 $468.00
74185-26 $92.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.00
74185-TC $419.00 $334.00 $356.00 $361.00 $334.00 $356.00 $361.00
74190 $73.00 $499.00 $532.00 $539.00 $499.00 $532.00 $539.00
74190-26 NC $27.00 $27.00 $28.00 $27.00 $27.00 $28.00
74190-TC NC $473.00 $505.00 $510.00 $473.00 $505.00 $510.00
74210 $63.00 $84.00 $89.00 $90.00 $84.00 $89.00 $90.00
74210-26 $18.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.00
74210-TC $44.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
74220 $68.00 $95.00 $101.00 $103.00 $95.00 $101.00 $103.00
74220-26 $23.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
74220-TC $44.00 $69.00 $74.00 $75.00 $69.00 $74.00 $75.00
74230 $77.00 $138.00 $146.00 $149.00 $138.00 $146.00 $149.00
74230-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
74230-TC $48.00 $108.00 $115.00 $117.00 $108.00 $115.00 $117.00
74235 $160.00 ---------- ---------- ---------- ---------- ---------- ----------
74235-26 NC $69.00 $72.00 $74.00 $69.00 $72.00 $74.00
74235-TC NC BR BR BR BR BR BR
74240 $91.00 $122.00 $129.00 $132.00 $122.00 $129.00 $132.00
74240-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
74240-TC $55.00 $83.00 $89.00 $90.00 $83.00 $89.00 $90.00
74241 $91.00 $127.00 $135.00 $137.00 $127.00 $135.00 $137.00
74241-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
74241-TC $56.00 $88.00 $94.00 $95.00 $88.00 $94.00 $95.00
74245 $137.00 $185.00 $196.00 $199.00 $185.00 $196.00 $199.00
74245-26 $46.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.00
74245-TC $89.00 $133.00 $143.00 $144.00 $133.00 $143.00 $144.00
74246 $97.00 $137.00 $145.00 $148.00 $137.00 $145.00 $148.00
74246-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
74246-TC $61.00 $98.00 $105.00 $106.00 $98.00 $105.00 $106.00
74247 $99.00 $153.00 $162.00 $165.00 $153.00 $162.00 $165.00
74247-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
74247-TC $63.00 $113.00 $121.00 $123.00 $113.00 $121.00 $123.00
74249 $144.00 $198.00 $210.00 $213.00 $198.00 $210.00 $213.00
74249-26 $46.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.00
74249-TC $96.00 $147.00 $157.00 $159.00 $147.00 $157.00 $159.00
74250 $73.00 $112.00 $119.00 $121.00 $112.00 $119.00 $121.00
74250-26 $23.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00
74250-TC $48.00 $85.00 $91.00 $92.00 $85.00 $91.00 $92.00
74251 $85.00 $158.00 $168.00 $171.00 $158.00 $168.00 $171.00
74251-26 $34.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
74251-TC $48.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00
74260 $82.00 $148.00 $157.00 $159.00 $148.00 $157.00 $159.00
74260-26 $25.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
74260-TC $56.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00
74261 ---------- $255.00 $268.00 $274.00 $255.00 $268.00 $274.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 298
Radiology
CPT Code 2003 MRALocality 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)
74261-26 ---------- $136.00 $141.00 $145.00 $136.00 $141.00 $145.00
74261-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
74262 ---------- $420.00 $444.00 $452.00 $420.00 $444.00 $452.00
74262-26 ---------- $142.00 $146.00 $151.00 $142.00 $146.00 $151.00
74262-TC ---------- $279.00 $298.00 $301.00 $279.00 $298.00 $301.00
74263 ---------- $808.00 $858.00 $868.00 $808.00 $858.00 $868.00
74263-26 ---------- $127.00 $130.00 $133.00 $127.00 $130.00 $133.00
74263-TC ---------- $681.00 $728.00 $735.00 $681.00 $728.00 $735.00
74270 $100.00 $158.00 $167.00 $170.00 $158.00 $167.00 $170.00
74270-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
74270-TC $64.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
74280 $136.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00
74280-26 $50.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.00
74280-TC $84.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
74283 $201.00 $228.00 $240.00 $245.00 $228.00 $240.00 $245.00
74283-26 $103.00 $116.00 $120.00 $124.00 $116.00 $120.00 $124.00
74283-TC $95.00 $112.00 $120.00 $121.00 $112.00 $120.00 $121.00
74290 $44.00 $76.00 $80.00 $82.00 $76.00 $80.00 $82.00
74290-26 $16.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
74290-TC $28.00 $58.00 $62.00 $62.00 $58.00 $62.00 $62.00
74300 $31.00 ---------- ---------- ---------- ---------- ---------- ----------
74300-26 NC $21.00 $22.00 $22.00 $21.00 $22.00 $22.00
74300-TC NC BR BR BR BR BR BR
74301 BR ---------- ---------- ---------- ---------- ---------- ----------
74301-26 NC $12.00 $12.00 $13.00 $12.00 $12.00 $13.00
74301-TC NC BR BR BR BR BR BR
74328 $155.00 ---------- ---------- ---------- ---------- ---------- ----------
74328-26 NC $40.00 $42.00 $43.00 $40.00 $42.00 $43.00
74328-TC NC BR BR BR BR BR BR
74329 $155.00 ---------- ---------- ---------- ---------- ---------- ----------
74329-26 NC $40.00 $42.00 $43.00 $40.00 $42.00 $43.00
74329-TC NC BR BR BR BR BR BR
74330 $165.00 ---------- ---------- ---------- ---------- ---------- ----------
74330-26 NC $51.00 $53.00 $55.00 $51.00 $53.00 $55.00
74330-TC NC BR BR BR BR BR BR
74340 $121.00 ---------- ---------- ---------- ---------- ---------- ----------
74340-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
74340-TC NC BR BR BR BR BR BR
74355 $137.00 ---------- ---------- ---------- ---------- ---------- ----------
74355-26 NC $43.00 $44.00 $46.00 $43.00 $44.00 $46.00
74355-TC NC BR BR BR BR BR BR
74360 $145.00 ---------- ---------- ---------- ---------- ---------- ----------
74360-26 NC $32.00 $33.00 $35.00 $32.00 $33.00 $35.00
74360-TC NC BR BR BR BR BR BR
74363 $274.00 ---------- ---------- ---------- ---------- ---------- ----------
74363-26 NC $48.00 $50.00 $52.00 $48.00 $50.00 $52.00
74363-TC NC BR BR BR BR BR BR
74400 $89.00 $119.00 $126.00 $128.00 $119.00 $126.00 $128.00
74400-26 $24.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
74400-TC $63.00 $91.00 $97.00 $99.00 $91.00 $97.00 $99.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 299
Radiology
CPT Code 2003 MRALocality 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 $117.00 $124.00 $127.00 $117.00 $124.00 $127.00
74410-26 $24.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
74410-TC $72.00 $90.00 $96.00 $97.00 $90.00 $96.00 $97.00
74415 $105.00 $147.00 $156.00 $158.00 $147.00 $156.00 $158.00
74415-26 $24.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
74415-TC $79.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00
74420 $117.00 $492.00 $525.00 $531.00 $492.00 $525.00 $531.00
74420-26 $18.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.00
74420-TC $97.00 $473.00 $505.00 $510.00 $473.00 $505.00 $510.00
74425 $68.00 $492.00 $525.00 $531.00 $492.00 $525.00 $531.00
74425-26 NC $20.00 $20.00 $21.00 $20.00 $20.00 $21.00
74425-TC NC $473.00 $505.00 $510.00 $473.00 $505.00 $510.00
74430 $48.00 $41.00 $44.00 $45.00 $41.00 $44.00 $45.00
74430-26 NC $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
74430-TC NC $23.00 $25.00 $25.00 $23.00 $25.00 $25.00
74440 $62.00 $88.00 $93.00 $95.00 $88.00 $93.00 $95.00
74440-26 NC $21.00 $22.00 $22.00 $21.00 $22.00 $22.00
74440-TC NC $67.00 $71.00 $72.00 $67.00 $71.00 $72.00
74445 $101.00 $179.00 $189.00 $192.00 $179.00 $189.00 $192.00
74445-26 NC $61.00 $62.00 $64.00 $61.00 $62.00 $64.00
74445-TC NC $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
74450 $60.00 $256.00 $273.00 $277.00 $256.00 $273.00 $277.00
74450-26 NC $19.00 $19.00 $20.00 $19.00 $19.00 $20.00
74450-TC NC $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
74455 $75.00 $88.00 $94.00 $95.00 $88.00 $94.00 $95.00
74455-26 NC $19.00 $19.00 $20.00 $19.00 $19.00 $20.00
74455-TC NC $70.00 $74.00 $75.00 $70.00 $74.00 $75.00
74470 $74.00 $267.00 $284.00 $288.00 $267.00 $284.00 $288.00
74470-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
74470-TC NC $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
74485 $146.00 $99.00 $105.00 $107.00 $99.00 $105.00 $107.00
74485-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.00
74485-TC NC $70.00 $75.00 $76.00 $70.00 $75.00 $76.00
74710 $57.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.00
74710-26 $17.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
74710-TC $39.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
74712 ---------- $289.00 $302.00 $309.00 $289.00 $302.00 $309.00
74712-26 ---------- $170.00 $175.00 $181.00 $170.00 $175.00 $181.00
74712-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
74713 ---------- $253.00 $267.00 $272.00 $253.00 $267.00 $272.00
74713-26 ---------- $105.00 $108.00 $112.00 $105.00 $108.00 $112.00
74713-TC ---------- $148.00 $159.00 $161.00 $148.00 $159.00 $161.00
74740 $68.00 $81.00 $86.00 $87.00 $81.00 $86.00 $87.00
74740-26 NC $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
74740-TC NC $59.00 $64.00 $64.00 $59.00 $64.00 $64.00
74742 $150.00 ---------- ---------- ---------- ---------- ---------- ----------
74742-26 NC $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
74742-TC NC BR BR BR BR BR BR
74775 $88.00 $273.00 $290.00 $294.00 $273.00 $290.00 $294.00
74775-26 $32.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 300
Radiology
CPT Code 2003 MRALocality 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 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
75557 ---------- $347.00 $366.00 $372.00 $347.00 $366.00 $372.00
75557-26 ---------- $130.00 $134.00 $138.00 $130.00 $134.00 $138.00
75557-TC ---------- $217.00 $232.00 $234.00 $217.00 $232.00 $234.00
75559 ---------- $398.00 $419.00 $425.00 $398.00 $419.00 $425.00
75559-26 ---------- $160.00 $165.00 $169.00 $160.00 $165.00 $169.00
75559-TC ---------- $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
75561 ---------- $460.00 $486.00 $494.00 $460.00 $486.00 $494.00
75561-26 ---------- $144.00 $148.00 $152.00 $144.00 $148.00 $152.00
75561-TC ---------- $315.00 $337.00 $341.00 $315.00 $337.00 $341.00
75563 ---------- $547.00 $578.00 $587.00 $547.00 $578.00 $587.00
75563-26 ---------- $165.00 $169.00 $174.00 $165.00 $169.00 $174.00
75563-TC ---------- $382.00 $408.00 $413.00 $382.00 $408.00 $413.00
75565 ---------- $59.00 $63.00 $63.00 $59.00 $63.00 $63.00
75565-26 ---------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00
75565-TC ---------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.00
75571 ---------- $96.00 $101.00 $103.00 $96.00 $101.00 $103.00
75571-26 ---------- $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
75571-TC ---------- $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
75572 ---------- $307.00 $325.00 $330.00 $307.00 $325.00 $330.00
75572-26 ---------- $98.00 $101.00 $104.00 $98.00 $101.00 $104.00
75572-TC ---------- $209.00 $224.00 $227.00 $209.00 $224.00 $227.00
75573 ---------- $421.00 $445.00 $453.00 $421.00 $445.00 $453.00
75573-26 ---------- $142.00 $147.00 $151.00 $142.00 $147.00 $151.00
75573-TC ---------- $279.00 $298.00 $302.00 $279.00 $298.00 $302.00
75574 ---------- $413.00 $436.00 $444.00 $413.00 $436.00 $444.00
75574-26 ---------- $134.00 $138.00 $142.00 $134.00 $138.00 $142.00
75574-TC ---------- $279.00 $299.00 $303.00 $279.00 $299.00 $303.00
75600 $497.00 $212.00 $226.00 $230.00 $212.00 $226.00 $230.00
75600-26 NC $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
75600-TC NC $185.00 $197.00 $200.00 $185.00 $197.00 $200.00
75605 $183.00 $151.00 $159.00 $164.00 $151.00 $159.00 $164.00
75605-26 NC $63.00 $66.00 $69.00 $63.00 $66.00 $69.00
75605-TC NC $87.00 $93.00 $95.00 $87.00 $93.00 $95.00
75625 $143.00 $151.00 $160.00 $165.00 $151.00 $160.00 $165.00
75625-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.00
75625-TC NC $87.00 $93.00 $94.00 $87.00 $93.00 $94.00
75630 $239.00 $187.00 $198.00 $204.00 $187.00 $198.00 $204.00
75630-26 NC $100.00 $104.00 $110.00 $100.00 $104.00 $110.00
75630-TC NC $87.00 $93.00 $95.00 $87.00 $93.00 $95.00
75635 $445.00 $414.00 $437.00 $446.00 $414.00 $437.00 $446.00
75635-26 NC $135.00 $139.00 $144.00 $135.00 $139.00 $144.00
75635-TC NC $279.00 $298.00 $302.00 $279.00 $298.00 $302.00
75658 $540.00 $184.00 $196.00 $202.00 $184.00 $196.00 $202.00
75658-26 NC $74.00 $77.00 $82.00 $74.00 $77.00 $82.00
75658-TC NC $111.00 $119.00 $120.00 $111.00 $119.00 $120.00
75705 $587.00 $273.00 $290.00 $301.00 $273.00 $290.00 $301.00
75705-26 NC $132.00 $139.00 $149.00 $132.00 $139.00 $149.00
75705-TC NC $141.00 $151.00 $153.00 $141.00 $151.00 $153.00
75710 $194.00 $177.00 $188.00 $194.00 $177.00 $188.00 $194.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 301
Radiology
CPT Code 2003 MRALocality 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)
75710-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.00
75710-TC NC $113.00 $121.00 $122.00 $113.00 $121.00 $122.00
75716 $293.00 $204.00 $216.00 $222.00 $204.00 $216.00 $222.00
75716-26 NC $73.00 $76.00 $80.00 $73.00 $76.00 $80.00
75716-TC NC $131.00 $140.00 $142.00 $131.00 $140.00 $142.00
75726 $530.00 $163.00 $172.00 $176.00 $163.00 $172.00 $176.00
75726-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.00
75726-TC NC $100.00 $107.00 $108.00 $100.00 $107.00 $108.00
75731 $530.00 $186.00 $197.00 $201.00 $186.00 $197.00 $201.00
75731-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
75731-TC NC $122.00 $130.00 $132.00 $122.00 $130.00 $132.00
75733 $540.00 $202.00 $213.00 $217.00 $202.00 $213.00 $217.00
75733-26 NC $71.00 $74.00 $76.00 $71.00 $74.00 $76.00
75733-TC NC $130.00 $140.00 $142.00 $130.00 $140.00 $142.00
75736 $530.00 $174.00 $185.00 $190.00 $174.00 $185.00 $190.00
75736-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.00
75736-TC NC $112.00 $119.00 $121.00 $112.00 $119.00 $121.00
75741 $540.00 $164.00 $173.00 $177.00 $164.00 $173.00 $177.00
75741-26 NC $72.00 $74.00 $77.00 $72.00 $74.00 $77.00
75741-TC NC $93.00 $99.00 $100.00 $93.00 $99.00 $100.00
75743 $253.00 $185.00 $194.00 $199.00 $185.00 $194.00 $199.00
75743-26 NC $91.00 $94.00 $98.00 $91.00 $94.00 $98.00
75743-TC NC $94.00 $100.00 $102.00 $94.00 $100.00 $102.00
75746 $530.00 $167.00 $176.00 $180.00 $167.00 $176.00 $180.00
75746-26 NC $63.00 $66.00 $68.00 $63.00 $66.00 $68.00
75746-TC NC $103.00 $110.00 $112.00 $103.00 $110.00 $112.00
75756 $183.00 $186.00 $197.00 $204.00 $186.00 $197.00 $204.00
75756-26 NC $65.00 $69.00 $73.00 $65.00 $69.00 $73.00
75756-TC NC $120.00 $129.00 $131.00 $120.00 $129.00 $131.00
75774 $80.00 $93.00 $99.00 $101.00 $93.00 $99.00 $101.00
75774-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.00
75774-TC NC $73.00 $78.00 $80.00 $73.00 $78.00 $80.00
75801 $245.00 $771.00 $824.00 $837.00 $771.00 $824.00 $837.00
75801-26 NC $52.00 $55.00 $61.00 $52.00 $55.00 $61.00
75801-TC NC $719.00 $768.00 $776.00 $719.00 $768.00 $776.00
75803 $264.00 $788.00 $839.00 $850.00 $788.00 $839.00 $850.00
75803-26 NC $69.00 $71.00 $74.00 $69.00 $71.00 $74.00
75803-TC NC $719.00 $768.00 $776.00 $719.00 $768.00 $776.00
75805 $271.00 $765.00 $816.00 $825.00 $765.00 $816.00 $825.00
75805-26 NC $46.00 $48.00 $49.00 $46.00 $48.00 $49.00
75805-TC NC $719.00 $768.00 $776.00 $719.00 $768.00 $776.00
75807 $289.00 $2,548.00 $2,719.00 $2,748.00 $2,548.00 $2,719.00 $2,748.00
75807-26 NC $66.00 $69.00 $71.00 $66.00 $69.00 $71.00
75807-TC NC $2,482.00 $2,650.00 $2,677.00 $2,482.00 $2,650.00 $2,677.00
75809 $54.00 $107.00 $113.00 $115.00 $107.00 $113.00 $115.00
75809-26 NC $27.00 $28.00 $29.00 $27.00 $28.00 $29.00
75809-TC NC $80.00 $85.00 $86.00 $80.00 $85.00 $86.00
75810 $530.00 $784.00 $835.00 $845.00 $784.00 $835.00 $845.00
75810-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
75810-TC NC $719.00 $768.00 $776.00 $719.00 $768.00 $776.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 302
Radiology
CPT Code 2003 MRALocality 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)
75820 $72.00 $125.00 $133.00 $136.00 $125.00 $133.00 $136.00
75820-26 NC $39.00 $41.00 $43.00 $39.00 $41.00 $43.00
75820-TC NC $86.00 $92.00 $93.00 $86.00 $92.00 $93.00
75822 $111.00 $149.00 $158.00 $162.00 $149.00 $158.00 $162.00
75822-26 NC $59.00 $62.00 $65.00 $59.00 $62.00 $65.00
75822-TC NC $90.00 $96.00 $97.00 $90.00 $96.00 $97.00
75825 $194.00 $149.00 $157.00 $163.00 $149.00 $157.00 $163.00
75825-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.00
75825-TC NC $84.00 $90.00 $91.00 $84.00 $90.00 $91.00
75827 $530.00 $152.00 $161.00 $167.00 $152.00 $161.00 $167.00
75827-26 NC $64.00 $68.00 $72.00 $64.00 $68.00 $72.00
75827-TC NC $87.00 $93.00 $95.00 $87.00 $93.00 $95.00
75831 $54.00 $153.00 $162.00 $166.00 $153.00 $162.00 $166.00
75831-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.00
75831-TC NC $90.00 $97.00 $98.00 $90.00 $97.00 $98.00
75833 $549.00 $181.00 $192.00 $200.00 $181.00 $192.00 $200.00
75833-26 NC $83.00 $87.00 $93.00 $83.00 $87.00 $93.00
75833-TC NC $98.00 $105.00 $107.00 $98.00 $105.00 $107.00
75840 $531.00 $162.00 $171.00 $175.00 $162.00 $171.00 $175.00
75840-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
75840-TC NC $98.00 $104.00 $106.00 $98.00 $104.00 $106.00
75842 $549.00 $196.00 $207.00 $212.00 $196.00 $207.00 $212.00
75842-26 NC $83.00 $86.00 $89.00 $83.00 $86.00 $89.00
75842-TC NC $113.00 $121.00 $123.00 $113.00 $121.00 $123.00
75860 $531.00 $157.00 $166.00 $170.00 $157.00 $166.00 $170.00
75860-26 NC $63.00 $66.00 $69.00 $63.00 $66.00 $69.00
75860-TC NC $93.00 $100.00 $101.00 $93.00 $100.00 $101.00
75870 $531.00 $162.00 $171.00 $175.00 $162.00 $171.00 $175.00
75870-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
75870-TC NC $98.00 $104.00 $106.00 $98.00 $104.00 $106.00
75872 $530.00 $169.00 $179.00 $183.00 $169.00 $179.00 $183.00
75872-26 NC $64.00 $67.00 $69.00 $64.00 $67.00 $69.00
75872-TC NC $105.00 $112.00 $113.00 $105.00 $112.00 $113.00
75880 $72.00 $158.00 $168.00 $170.00 $158.00 $168.00 $170.00
75880-26 NC $40.00 $41.00 $42.00 $40.00 $41.00 $42.00
75880-TC NC $118.00 $126.00 $128.00 $118.00 $126.00 $128.00
75885 $546.00 $171.00 $180.00 $183.00 $171.00 $180.00 $183.00
75885-26 NC $77.00 $79.00 $82.00 $77.00 $79.00 $82.00
75885-TC NC $94.00 $100.00 $102.00 $94.00 $100.00 $102.00
75887 $546.00 $173.00 $182.00 $185.00 $173.00 $182.00 $185.00
75887-26 NC $78.00 $80.00 $83.00 $78.00 $80.00 $83.00
75887-TC NC $95.00 $101.00 $103.00 $95.00 $101.00 $103.00
75889 $530.00 $156.00 $165.00 $169.00 $156.00 $165.00 $169.00
75889-26 NC $62.00 $64.00 $66.00 $62.00 $64.00 $66.00
75889-TC NC $95.00 $101.00 $102.00 $95.00 $101.00 $102.00
75891 $530.00 $158.00 $167.00 $171.00 $158.00 $167.00 $171.00
75891-26 NC $63.00 $65.00 $67.00 $63.00 $65.00 $67.00
75891-TC NC $95.00 $102.00 $103.00 $95.00 $102.00 $103.00
75893 $499.00 $128.00 $136.00 $138.00 $128.00 $136.00 $138.00
75893-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 303
Radiology
CPT Code 2003 MRALocality 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)
75893-TC NC $98.00 $105.00 $106.00 $98.00 $105.00 $106.00
75894 $972.00 ---------- ---------- ---------- ---------- ---------- ----------
75894-26 NC $78.00 $82.00 $87.00 $78.00 $82.00 $87.00
75894-TC NC BR BR BR BR BR BR
75898 $124.00 $818.00 $872.00 $887.00 $818.00 $872.00 $887.00
75898-26 $84.00 $99.00 $104.00 $111.00 $99.00 $104.00 $111.00
75898-TC $39.00 $719.00 $768.00 $776.00 $719.00 $768.00 $776.00
75901 $98.00 $190.00 $202.00 $205.00 $190.00 $202.00 $205.00
75901-26 NC $27.00 $27.00 $28.00 $27.00 $27.00 $28.00
75901-TC NC $164.00 $175.00 $177.00 $164.00 $175.00 $177.00
75902 $93.00 $78.00 $83.00 $85.00 $78.00 $83.00 $85.00
75902-26 NC $22.00 $22.00 $23.00 $22.00 $22.00 $23.00
75902-TC NC $57.00 $61.00 $62.00 $57.00 $61.00 $62.00
75952 BR ---------- ---------- ---------- ---------- ---------- ----------
75952-26 NC $259.00 $275.00 $299.00 $259.00 $275.00 $299.00
75952-TC NC BR BR BR BR BR BR
75953 BR ---------- ---------- ---------- ---------- ---------- ----------
75953-26 NC $79.00 $84.00 $91.00 $79.00 $84.00 $91.00
75953-TC NC BR BR BR BR BR BR
75954 BR ---------- ---------- ---------- ---------- ---------- ----------
75954-26 NC $132.00 $141.00 $154.00 $132.00 $141.00 $154.00
75954-TC NC BR BR BR BR BR BR
75956 ---------- BR BR BR BR BR BR
75956-26 ---------- $405.00 $430.00 $469.00 $405.00 $430.00 $469.00
75956-TC ---------- BR BR BR BR BR BR
75957 ---------- BR BR BR BR BR BR
75957-26 ---------- $348.00 $369.00 $403.00 $348.00 $369.00 $403.00
75957-TC ---------- BR BR BR BR BR BR
75958 ---------- BR BR BR BR BR BR
75958-26 ---------- $232.00 $246.00 $268.00 $232.00 $246.00 $268.00
75958-TC ---------- BR BR BR BR BR BR
75959 ---------- BR BR BR BR BR BR
75959-26 ---------- $199.00 $212.00 $233.00 $199.00 $212.00 $233.00
75959-TC ---------- BR BR BR BR BR BR
75970 $475.00 ---------- ---------- ---------- ---------- ---------- ----------
75970-26 NC $45.00 $47.00 $48.00 $45.00 $47.00 $48.00
75970-TC NC BR BR BR BR BR BR
75984 $110.00 $115.00 $121.00 $124.00 $115.00 $121.00 $124.00
75984-26 NC $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
75984-TC NC $76.00 $81.00 $82.00 $76.00 $81.00 $82.00
75989 $180.00 $132.00 $139.00 $142.00 $132.00 $139.00 $142.00
75989-26 NC $66.00 $68.00 $70.00 $66.00 $68.00 $70.00
75989-TC NC $67.00 $71.00 $72.00 $67.00 $71.00 $72.00
76000 $58.00 $51.00 $55.00 $56.00 $51.00 $55.00 $56.00
76000-26 $8.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
76000-TC $48.00 $41.00 $44.00 $45.00 $41.00 $44.00 $45.00
76001 $134.00 ---------- ---------- ---------- ---------- ---------- ----------
76001-26 $34.00 $42.00 $44.00 $47.00 $42.00 $44.00 $47.00
76001-TC $97.00 ---------- ---------- ---------- ---------- ---------- ----------
76080 $67.00 $60.00 $64.00 $65.00 $60.00 $64.00 $65.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 304
Radiology
CPT Code 2003 MRALocality 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)
76080-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
76080-TC NC $31.00 $33.00 $34.00 $31.00 $33.00 $34.00
76098 $23.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
76098-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00
76098-TC $15.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
76100 $77.00 $100.00 $106.00 $108.00 $100.00 $106.00 $108.00
76100-26 $30.00 $36.00 $37.00 $39.00 $36.00 $37.00 $39.00
76100-TC $46.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
76101 $94.00 $143.00 $152.00 $156.00 $143.00 $152.00 $156.00
76101-26 $36.00 $40.00 $42.00 $45.00 $40.00 $42.00 $45.00
76101-TC $59.00 $103.00 $110.00 $111.00 $103.00 $110.00 $111.00
76102 $95.00 $156.00 $166.00 $168.00 $156.00 $166.00 $168.00
76102-26 $30.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.00
76102-TC $65.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00
76120 $157.00 $85.00 $90.00 $92.00 $85.00 $90.00 $92.00
76120-26 $56.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.00
76120-TC $102.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
76125 $49.00 ---------- ---------- ---------- ---------- ---------- ----------
76125-26 $17.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
76125-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------
76140 $31.00 ---------- ---------- ---------- ---------- ---------- ----------
76376 ---------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
76376-26 ---------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.00
76376-TC ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00
76377 ---------- $79.00 $83.00 $85.00 $79.00 $83.00 $85.00
76377-26 ---------- $45.00 $47.00 $48.00 $45.00 $47.00 $48.00
76377-TC ---------- $33.00 $36.00 $36.00 $33.00 $36.00 $36.00
76380 $182.00 $119.00 $125.00 $128.00 $119.00 $125.00 $128.00
76380-26 $50.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.00
76380-TC $131.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
76390 $493.00 $476.00 $506.00 $512.00 $476.00 $506.00 $512.00
76390-26 $71.00 $78.00 $80.00 $81.00 $78.00 $80.00 $81.00
76390-TC $419.00 $399.00 $426.00 $430.00 $399.00 $426.00 $430.00
76496 BR ---------- ---------- ---------- ---------- ---------- ----------
76496-26 BR ---------- ---------- ---------- ---------- ---------- ----------
76496-TC BR $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
76497 BR ---------- ---------- ---------- ---------- ---------- ----------
76497-26 BR ---------- ---------- ---------- ---------- ---------- ----------
76497-TC BR $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
76498 BR ---------- ---------- ---------- ---------- ---------- ----------
76498-26 BR ---------- ---------- ---------- ---------- ---------- ----------
76498-TC BR $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
76499 BR ---------- ---------- ---------- ---------- ---------- ----------
76499-26 BR ---------- ---------- ---------- ---------- ---------- ----------
76499-TC BR ---------- ---------- ---------- ---------- ---------- ----------
76506 $88.00 $129.00 $137.00 $140.00 $129.00 $137.00 $140.00
76506-26 $33.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.00
76506-TC $53.00 $92.00 $99.00 $100.00 $92.00 $99.00 $100.00
76510 ---------- $184.00 $193.00 $195.00 $184.00 $193.00 $195.00
76510-26 ---------- $98.00 $101.00 $102.00 $98.00 $101.00 $102.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 305
Radiology
CPT Code 2003 MRALocality 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)
76510-TC ---------- $86.00 $92.00 $93.00 $86.00 $92.00 $93.00
76511 $96.00 $111.00 $116.00 $117.00 $111.00 $116.00 $117.00
76511-26 $48.00 $59.00 $60.00 $61.00 $59.00 $60.00 $61.00
76511-TC $48.00 $52.00 $56.00 $56.00 $52.00 $56.00 $56.00
76512 $96.00 $101.00 $105.00 $107.00 $101.00 $105.00 $107.00
76512-26 $36.00 $58.00 $60.00 $60.00 $58.00 $60.00 $60.00
76512-TC $60.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
76513 $96.00 $103.00 $108.00 $110.00 $103.00 $108.00 $110.00
76513-26 $36.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.00
76513-TC $60.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
76514 ---------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.00
76514-26 ---------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.00
76514-TC ---------- $6.00 $6.00 $7.00 $6.00 $6.00 $7.00
76516 $99.00 $85.00 $90.00 $91.00 $85.00 $90.00 $91.00
76516-26 $37.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
76516-TC $63.00 $51.00 $54.00 $55.00 $51.00 $54.00 $55.00
76519 $88.00 $91.00 $96.00 $98.00 $91.00 $96.00 $98.00
76519-26 $31.00 $35.00 $36.00 $36.00 $35.00 $36.00 $36.00
76519-TC $53.00 $57.00 $61.00 $62.00 $57.00 $61.00 $62.00
76529 $86.00 $85.00 $90.00 $91.00 $85.00 $90.00 $91.00
76529-26 $31.00 $35.00 $36.00 $37.00 $35.00 $36.00 $37.00
76529-TC $53.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.00
76536 $83.00 $126.00 $134.00 $136.00 $126.00 $134.00 $136.00
76536-26 $31.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
76536-TC $54.00 $95.00 $101.00 $103.00 $95.00 $101.00 $103.00
76604 $78.00 $96.00 $102.00 $104.00 $96.00 $102.00 $104.00
76604-26 $28.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
76604-TC $48.00 $66.00 $70.00 $71.00 $66.00 $70.00 $71.00
76641 ---------- $117.00 $124.00 $126.00 $117.00 $124.00 $126.00
76641-26 ---------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.00
76641-TC ---------- $76.00 $81.00 $82.00 $76.00 $81.00 $82.00
76642 ---------- $97.00 $102.00 $104.00 $97.00 $102.00 $104.00
76642-26 ---------- $38.00 $40.00 $41.00 $38.00 $40.00 $41.00
76642-TC ---------- $58.00 $62.00 $63.00 $58.00 $62.00 $63.00
76700 $116.00 $133.00 $141.00 $144.00 $133.00 $141.00 $144.00
76700-26 $42.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.00
76700-TC $73.00 $88.00 $94.00 $95.00 $88.00 $94.00 $95.00
76705 $84.00 $100.00 $105.00 $107.00 $100.00 $105.00 $107.00
76705-26 $30.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.00
76705-TC $53.00 $67.00 $71.00 $72.00 $67.00 $71.00 $72.00
76706 ---------- $102.00 $108.00 $110.00 $102.00 $108.00 $110.00
76706-26 ---------- $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
76706-TC ---------- $71.00 $76.00 $77.00 $71.00 $76.00 $77.00
76770 $112.00 $124.00 $131.00 $133.00 $124.00 $131.00 $133.00
76770-26 $38.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00
76770-TC $73.00 $82.00 $88.00 $89.00 $82.00 $88.00 $89.00
76775 $84.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
76775-26 $30.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
76775-TC $53.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
76776 ---------- $170.00 $181.00 $184.00 $170.00 $181.00 $184.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 306
Radiology
CPT Code 2003 MRALocality 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)
76776-26 ---------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.00
76776-TC ---------- $128.00 $137.00 $138.00 $128.00 $137.00 $138.00
76800 $112.00 $132.00 $140.00 $146.00 $132.00 $140.00 $146.00
76800-26 $61.00 $69.00 $73.00 $78.00 $69.00 $73.00 $78.00
76800-TC $54.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
76801 $93.00 $136.00 $143.00 $146.00 $136.00 $143.00 $146.00
76801-26 $51.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00
76801-TC $42.00 $79.00 $85.00 $86.00 $79.00 $85.00 $86.00
76802 $73.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.00
76802-26 $43.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.00
76802-TC $30.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
76805 $131.00 $156.00 $165.00 $169.00 $156.00 $165.00 $169.00
76805-26 $51.00 $57.00 $59.00 $62.00 $57.00 $59.00 $62.00
76805-TC $79.00 $99.00 $106.00 $107.00 $99.00 $106.00 $107.00
76810 $252.00 $103.00 $108.00 $111.00 $103.00 $108.00 $111.00
76810-26 $100.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00
76810-TC $151.00 $46.00 $50.00 $50.00 $46.00 $50.00 $50.00
76811 $243.00 $204.00 $215.00 $222.00 $204.00 $215.00 $222.00
76811-26 $100.00 $112.00 $116.00 $122.00 $112.00 $116.00 $122.00
76811-TC $142.00 $92.00 $99.00 $100.00 $92.00 $99.00 $100.00
76812 $145.00 $227.00 $240.00 $247.00 $227.00 $240.00 $247.00
76812-26 $94.00 $106.00 $110.00 $115.00 $106.00 $110.00 $115.00
76812-TC $51.00 $122.00 $130.00 $132.00 $122.00 $130.00 $132.00
76813 ---------- $135.00 $143.00 $147.00 $135.00 $143.00 $147.00
76813-26 ---------- $70.00 $72.00 $76.00 $70.00 $72.00 $76.00
76813-TC ---------- $66.00 $70.00 $71.00 $66.00 $70.00 $71.00
76814 ---------- $91.00 $96.00 $99.00 $91.00 $96.00 $99.00
76814-26 ---------- $59.00 $61.00 $64.00 $59.00 $61.00 $64.00
76814-TC ---------- $32.00 $35.00 $35.00 $32.00 $35.00 $35.00
76815 $88.00 $93.00 $98.00 $101.00 $93.00 $98.00 $101.00
76815-26 $33.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
76815-TC $53.00 $56.00 $60.00 $61.00 $56.00 $60.00 $61.00
76816 $72.00 $128.00 $135.00 $138.00 $128.00 $135.00 $138.00
76816-26 $30.00 $50.00 $52.00 $54.00 $50.00 $52.00 $54.00
76816-TC $41.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00
76817 $96.00 $107.00 $113.00 $116.00 $107.00 $113.00 $116.00
76817-26 $39.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.00
76817-TC $57.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
76818 $105.00 $137.00 $145.00 $149.00 $137.00 $145.00 $149.00
76818-26 $40.00 $62.00 $65.00 $68.00 $62.00 $65.00 $68.00
76818-TC $60.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.00
76819 $101.00 $100.00 $105.00 $108.00 $100.00 $105.00 $108.00
76819-26 $40.00 $45.00 $47.00 $49.00 $45.00 $47.00 $49.00
76819-TC $60.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.00
76820 ---------- $54.00 $57.00 $59.00 $54.00 $57.00 $59.00
76820-26 ---------- $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
76820-TC ---------- $24.00 $26.00 $27.00 $24.00 $26.00 $27.00
76821 ---------- $103.00 $109.00 $112.00 $103.00 $109.00 $112.00
76821-26 ---------- $41.00 $43.00 $45.00 $41.00 $43.00 $45.00
76821-TC ---------- $61.00 $66.00 $67.00 $61.00 $66.00 $67.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 307
Radiology
CPT Code 2003 MRALocality 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)
76825 $160.00 $304.00 $322.00 $328.00 $304.00 $322.00 $328.00
76825-26 $65.00 $95.00 $98.00 $102.00 $95.00 $98.00 $102.00
76825-TC $73.00 $209.00 $223.00 $226.00 $209.00 $223.00 $226.00
76826 $71.00 $178.00 $189.00 $192.00 $178.00 $189.00 $192.00
76826-26 $46.00 $47.00 $48.00 $49.00 $47.00 $48.00 $49.00
76826-TC $27.00 $131.00 $141.00 $142.00 $131.00 $141.00 $142.00
76827 $97.00 $83.00 $88.00 $90.00 $83.00 $88.00 $90.00
76827-26 $35.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.00
76827-TC $65.00 $50.00 $54.00 $55.00 $50.00 $54.00 $55.00
76828 $72.00 $60.00 $63.00 $65.00 $60.00 $63.00 $65.00
76828-26 $29.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.00
76828-TC $42.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.00
76830 $93.00 $133.00 $141.00 $144.00 $133.00 $141.00 $144.00
76830-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
76830-TC $57.00 $94.00 $101.00 $102.00 $94.00 $101.00 $102.00
76831 $95.00 $131.00 $139.00 $141.00 $131.00 $139.00 $141.00
76831-26 $37.00 $42.00 $43.00 $45.00 $42.00 $43.00 $45.00
76831-TC $57.00 $89.00 $95.00 $97.00 $89.00 $95.00 $97.00
76856 $93.00 $120.00 $127.00 $130.00 $120.00 $127.00 $130.00
76856-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00
76856-TC $57.00 $81.00 $87.00 $88.00 $81.00 $87.00 $88.00
76857 $59.00 $53.00 $56.00 $58.00 $53.00 $56.00 $58.00
76857-26 $19.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
76857-TC $39.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
76870 $90.00 $75.00 $79.00 $81.00 $75.00 $79.00 $81.00
76870-26 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00
76870-TC $57.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
76872 $93.00 $104.00 $109.00 $111.00 $104.00 $109.00 $111.00
76872-26 $36.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.00
76872-TC $57.00 $66.00 $71.00 $72.00 $66.00 $71.00 $72.00
76873 $151.00 $187.00 $197.00 $200.00 $187.00 $197.00 $200.00
76873-26 $68.00 $87.00 $90.00 $92.00 $87.00 $90.00 $92.00
76873-TC $80.00 $100.00 $107.00 $108.00 $100.00 $107.00 $108.00
76881 ---------- $129.00 $136.00 $138.00 $129.00 $136.00 $138.00
76881-26 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
76881-TC ---------- $93.00 $99.00 $101.00 $93.00 $99.00 $101.00
76882 ---------- $40.00 $42.00 $43.00 $40.00 $42.00 $43.00
76882-26 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
76882-TC ---------- $12.00 $13.00 $14.00 $12.00 $13.00 $14.00
76930 $93.00 ---------- ---------- ---------- ---------- ---------- ----------
76930-26 NC $37.00 $38.00 $39.00 $37.00 $38.00 $39.00
76930-TC NC BR BR BR BR BR BR
76932 $93.00 ---------- ---------- ---------- ---------- ---------- ----------
76932-26 NC $37.00 $38.00 $39.00 $37.00 $38.00 $39.00
76932-TC NC BR BR BR BR BR BR
76936 $341.00 $299.00 $318.00 $328.00 $299.00 $318.00 $328.00
76936-26 $102.00 $112.00 $118.00 $125.00 $112.00 $118.00 $125.00
76936-TC $236.00 $187.00 $200.00 $203.00 $187.00 $200.00 $203.00
76937 ---------- $34.00 $36.00 $37.00 $34.00 $36.00 $37.00
76937-26 ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 308
Radiology
CPT Code 2003 MRALocality 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)
76937-TC ---------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
76940 ---------- BR BR BR BR BR BR
76940-26 ---------- $119.00 $125.00 $132.00 $119.00 $125.00 $132.00
76940-TC ---------- BR BR BR BR BR BR
76941 $128.00 ---------- ---------- ---------- ---------- ---------- ----------
76941-26 NC $72.00 $74.00 $76.00 $72.00 $74.00 $76.00
76941-TC NC BR BR BR BR BR BR
76942 $92.00 $66.00 $70.00 $71.00 $66.00 $70.00 $71.00
76942-26 NC $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
76942-TC NC $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
76945 $93.00 ---------- ---------- ---------- ---------- ---------- ----------
76945-26 NC $40.00 $41.00 $43.00 $40.00 $41.00 $43.00
76945-TC NC BR BR BR BR BR BR
76946 $78.00 $36.00 $38.00 $40.00 $36.00 $38.00 $40.00
76946-26 NC $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
76946-TC NC $14.00 $15.00 $16.00 $14.00 $15.00 $16.00
76948 $77.00 $79.00 $83.00 $85.00 $79.00 $83.00 $85.00
76948-26 NC $38.00 $39.00 $41.00 $38.00 $39.00 $41.00
76948-TC NC $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
76965 $281.00 $101.00 $105.00 $107.00 $101.00 $105.00 $107.00
76965-26 $84.00 $75.00 $77.00 $79.00 $75.00 $77.00 $79.00
76965-TC $208.00 $26.00 $28.00 $28.00 $26.00 $28.00 $28.00
76970 $60.00 $85.00 $90.00 $92.00 $85.00 $90.00 $92.00
76970-26 $20.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.00
76970-TC $39.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
76975 $99.00 $285.00 $303.00 $308.00 $285.00 $303.00 $308.00
76975-26 NC $48.00 $49.00 $51.00 $48.00 $49.00 $51.00
76975-TC NC $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
76977 $34.00 $8.00 $9.00 $10.00 $8.00 $9.00 $10.00
76977-26 $3.00 $3.00 $3.00 $4.00 $3.00 $3.00 $4.00
76977-TC $31.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.00
76998 ---------- BR BR BR BR BR BR
76998-26 ---------- $74.00 $78.00 $85.00 $74.00 $78.00 $85.00
76998-TC ---------- BR BR BR BR BR BR
76999 BR ---------- ---------- ---------- ---------- ---------- ----------
76999-26 BR ---------- ---------- ---------- ---------- ---------- ----------
76999-TC BR ---------- ---------- ---------- ---------- ---------- ----------
77001 ---------- $91.00 $97.00 $99.00 $91.00 $97.00 $99.00
77001-26 ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
77001-TC ---------- $70.00 $74.00 $75.00 $70.00 $74.00 $75.00
77002 ---------- $101.00 $107.00 $109.00 $101.00 $107.00 $109.00
77002-26 ---------- $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
77002-TC ---------- $69.00 $74.00 $75.00 $69.00 $74.00 $75.00
77003 ---------- $102.00 $108.00 $110.00 $102.00 $108.00 $110.00
77003-26 ---------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
77003-TC ---------- $68.00 $73.00 $74.00 $68.00 $73.00 $74.00
77011 ---------- $242.00 $257.00 $261.00 $242.00 $257.00 $261.00
77011-26 ---------- $71.00 $73.00 $76.00 $71.00 $73.00 $76.00
77011-TC ---------- $171.00 $183.00 $185.00 $171.00 $183.00 $185.00
77012 ---------- $136.00 $143.00 $146.00 $136.00 $143.00 $146.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 309
Radiology
CPT Code 2003 MRALocality 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)
77012-26 ---------- $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
77012-TC ---------- $71.00 $76.00 $77.00 $71.00 $76.00 $77.00
77013-26 ---------- $219.00 $227.00 $234.00 $219.00 $227.00 $234.00
77013-TC ---------- BR BR BR BR BR BR
77014 ---------- $129.00 $136.00 $138.00 $129.00 $136.00 $138.00
77014-26 ---------- $49.00 $51.00 $52.00 $49.00 $51.00 $52.00
77014-TC ---------- $79.00 $85.00 $86.00 $79.00 $85.00 $86.00
77021 ---------- $431.00 $457.00 $464.00 $431.00 $457.00 $464.00
77021-26 ---------- $84.00 $87.00 $90.00 $84.00 $87.00 $90.00
77021-TC ---------- $347.00 $370.00 $374.00 $347.00 $370.00 $374.00
77022 ---------- BR BR BR BR BR BR
77022-26 ---------- $240.00 $248.00 $256.00 $240.00 $248.00 $256.00
77022-TC ---------- BR BR BR BR BR BR
77053 ---------- $64.00 $67.00 $69.00 $64.00 $67.00 $69.00
77053-26 ---------- $21.00 $21.00 $22.00 $21.00 $21.00 $22.00
77053-TC ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00
77054 ---------- $84.00 $89.00 $91.00 $84.00 $89.00 $91.00
77054-26 ---------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
77054-TC ---------- $58.00 $62.00 $63.00 $58.00 $62.00 $63.00
77058 ---------- $541.00 $575.00 $583.00 $541.00 $575.00 $583.00
77058-26 ---------- $92.00 $95.00 $98.00 $92.00 $95.00 $98.00
77058-TC ---------- $449.00 $480.00 $485.00 $449.00 $480.00 $485.00
77059 ---------- $541.00 $575.00 $583.00 $541.00 $575.00 $583.00
77059-26 ---------- $92.00 $95.00 $98.00 $92.00 $95.00 $98.00
77059-TC ---------- $449.00 $480.00 $485.00 $449.00 $480.00 $485.00
77063 ---------- $61.00 $64.00 $65.00 $61.00 $64.00 $65.00
77063-26 ---------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
77063-TC ---------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
77071 ---------- $53.00 $57.00 $59.00 $53.00 $57.00 $59.00
77072 ---------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
77072-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
77072-TC ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00
77073 ---------- $39.00 $41.00 $43.00 $39.00 $41.00 $43.00
77073-26 ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
77073-TC ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
77074 ---------- $70.00 $74.00 $76.00 $70.00 $74.00 $76.00
77074-26 ---------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
77074-TC ---------- $44.00 $47.00 $48.00 $44.00 $47.00 $48.00
77075 ---------- $94.00 $100.00 $102.00 $94.00 $100.00 $102.00
77075-26 ---------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
77075-TC ---------- $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
77077 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
77077-26 ---------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
77077-TC ---------- $22.00 $24.00 $25.00 $22.00 $24.00 $25.00
77078 ---------- $77.00 $82.00 $83.00 $77.00 $82.00 $83.00
77078-26 ---------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00
77078-TC ---------- $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
77080 ---------- $44.00 $47.00 $48.00 $44.00 $47.00 $48.00
77080-26 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
77080-TC ---------- $33.00 $35.00 $36.00 $33.00 $35.00 $36.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 310
Radiology
CPT Code 2003 MRALocality 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)
77081 ---------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
77081-26 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
77081-TC ---------- $18.00 $20.00 $20.00 $18.00 $20.00 $20.00
77084 ---------- $420.00 $446.00 $453.00 $420.00 $446.00 $453.00
77084-26 ---------- $91.00 $94.00 $97.00 $91.00 $94.00 $97.00
77084-TC ---------- $329.00 $352.00 $356.00 $329.00 $352.00 $356.00
77085 ---------- $61.00 $64.00 $66.00 $61.00 $64.00 $66.00
77085-26 ---------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.00
77085-TC ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00
77086 ---------- $38.00 $41.00 $42.00 $38.00 $41.00 $42.00
77086-26 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
77086-TC ---------- $28.00 $31.00 $31.00 $28.00 $31.00 $31.00
77261 $73.00 $85.00 $89.00 $92.00 $85.00 $89.00 $92.00
77262 $110.00 $127.00 $132.00 $136.00 $127.00 $132.00 $136.00
77263 $163.00 $187.00 $194.00 $201.00 $187.00 $194.00 $201.00
77280 $166.00 $295.00 $314.00 $318.00 $295.00 $314.00 $318.00
77280-26 $36.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.00
77280-TC $130.00 $255.00 $272.00 $275.00 $255.00 $272.00 $275.00
77285 $264.00 $470.00 $500.00 $506.00 $470.00 $500.00 $506.00
77285-26 $53.00 $61.00 $63.00 $64.00 $61.00 $63.00 $64.00
77285-TC $209.00 $409.00 $437.00 $441.00 $409.00 $437.00 $441.00
77290 $325.00 $556.00 $591.00 $599.00 $556.00 $591.00 $599.00
77290-26 $79.00 $91.00 $93.00 $96.00 $91.00 $93.00 $96.00
77290-TC $243.00 $466.00 $498.00 $503.00 $466.00 $498.00 $503.00
77293 ---------- $504.00 $535.00 $543.00 $504.00 $535.00 $543.00
77293-26 ---------- $116.00 $120.00 $123.00 $116.00 $120.00 $123.00
77293-TC ---------- $388.00 $415.00 $420.00 $388.00 $415.00 $420.00
77295 $1,287.00 $536.00 $564.00 $575.00 $536.00 $564.00 $575.00
77295-26 $232.00 $248.00 $255.00 $261.00 $248.00 $255.00 $261.00
77295-TC $1,046.00 $289.00 $309.00 $314.00 $289.00 $309.00 $314.00
77299 BR ---------- ---------- ---------- ---------- ---------- ----------
77299-26 BR ---------- ---------- ---------- ---------- ---------- ----------
77299-TC BR ---------- ---------- ---------- ---------- ---------- ----------
77300 $87.00 $73.00 $77.00 $79.00 $73.00 $77.00 $79.00
77300-26 $36.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
77300-TC $52.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
77301 $1,473.00 $2,115.00 $2,245.00 $2,281.00 $2,115.00 $2,245.00 $2,281.00
77301-26 $415.00 $462.00 $476.00 $488.00 $462.00 $476.00 $488.00
77301-TC $1,046.00 $1,653.00 $1,769.00 $1,793.00 $1,653.00 $1,769.00 $1,793.00
77306 ---------- $164.00 $172.00 $176.00 $164.00 $172.00 $176.00
77306-26 ---------- $81.00 $84.00 $86.00 $81.00 $84.00 $86.00
77306-TC ---------- $83.00 $88.00 $90.00 $83.00 $88.00 $90.00
77307 ---------- $317.00 $332.00 $339.00 $317.00 $332.00 $339.00
77307-26 ---------- $168.00 $173.00 $177.00 $168.00 $173.00 $177.00
77307-TC ---------- $149.00 $160.00 $162.00 $149.00 $160.00 $162.00
77316 ---------- $206.00 $217.00 $221.00 $206.00 $217.00 $221.00
77316-26 ---------- $81.00 $84.00 $86.00 $81.00 $84.00 $86.00
77316-TC ---------- $125.00 $133.00 $136.00 $125.00 $133.00 $136.00
77317 ---------- $268.00 $283.00 $289.00 $268.00 $283.00 $289.00
77317-26 ---------- $106.00 $109.00 $112.00 $106.00 $109.00 $112.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 311
Radiology
CPT Code 2003 MRALocality 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)
77317-TC ---------- $162.00 $174.00 $177.00 $162.00 $174.00 $177.00
77318 ---------- $388.00 $409.00 $417.00 $388.00 $409.00 $417.00
77318-26 ---------- $168.00 $173.00 $177.00 $168.00 $173.00 $177.00
77318-TC ---------- $220.00 $236.00 $240.00 $220.00 $236.00 $240.00
77321 $200.00 $102.00 $107.00 $109.00 $102.00 $107.00 $109.00
77321-26 $48.00 $55.00 $57.00 $58.00 $55.00 $57.00 $58.00
77321-TC $150.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00
77331 $64.00 $71.00 $74.00 $76.00 $71.00 $74.00 $76.00
77331-26 $45.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.00
77331-TC $18.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
77332 $78.00 $73.00 $77.00 $79.00 $73.00 $77.00 $79.00
77332-26 $27.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
77332-TC $50.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00
77333 $115.00 $105.00 $111.00 $113.00 $105.00 $111.00 $113.00
77333-26 $43.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.00
77333-TC $70.00 $62.00 $66.00 $67.00 $62.00 $66.00 $67.00
77334 $187.00 $143.00 $150.00 $153.00 $143.00 $150.00 $153.00
77334-26 $63.00 $67.00 $69.00 $70.00 $67.00 $69.00 $70.00
77334-TC $121.00 $76.00 $82.00 $83.00 $76.00 $82.00 $83.00
77336 $111.00 $86.00 $93.00 $96.00 $86.00 $93.00 $96.00
77338 ---------- $555.00 $584.00 $595.00 $555.00 $584.00 $595.00
77338-26 ---------- $248.00 $255.00 $261.00 $248.00 $255.00 $261.00
77338-TC ---------- $307.00 $329.00 $334.00 $307.00 $329.00 $334.00
77370 $130.00 $132.00 $143.00 $148.00 $132.00 $143.00 $148.00
77371 ---------- BR BR BR BR BR BR
77372 ---------- $1,152.00 $1,232.00 $1,249.00 $1,152.00 $1,232.00 $1,249.00
77373 ---------- $1,462.00 $1,564.00 $1,585.00 $1,462.00 $1,564.00 $1,585.00
77399 BR ---------- ---------- ---------- ---------- ---------- ----------
77399-26 BR ---------- ---------- ---------- ---------- ---------- ----------
77399-TC BR ---------- ---------- ---------- ---------- ---------- ----------
77401 $66.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
77402 $66.00 ---------- ---------- ---------- ---------- ---------- ----------
77407 $78.00 ---------- ---------- ---------- ---------- ---------- ----------
77412 $87.00 ---------- ---------- ---------- ---------- ---------- ----------
77417 $21.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
77422 ---------- BR BR BR BR BR BR
77423 ---------- BR BR BR BR BR BR
77427 $166.00 $208.00 $217.00 $225.00 $208.00 $217.00 $225.00
77431 $95.00 $115.00 $119.00 $124.00 $115.00 $119.00 $124.00
77432 $417.00 $470.00 $489.00 $508.00 $470.00 $489.00 $508.00
77435 ---------- $709.00 $736.00 $764.00 $709.00 $736.00 $764.00
77469 ---------- $360.00 $374.00 $387.00 $360.00 $374.00 $387.00
77470 $527.00 $159.00 $166.00 $170.00 $159.00 $166.00 $170.00
77470-26 $106.00 $118.00 $121.00 $125.00 $118.00 $121.00 $125.00
77470-TC $417.00 $42.00 $45.00 $45.00 $42.00 $45.00 $45.00
77499 BR ---------- ---------- ---------- ---------- ---------- ----------
77499-26 BR ---------- ---------- ---------- ---------- ---------- ----------
77499-TC BR ---------- ---------- ---------- ---------- ---------- ----------
77520 BR ---------- ---------- ---------- ---------- ---------- ----------
77522 BR ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 312
Radiology
CPT Code 2003 MRALocality 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)
77523 BR ---------- ---------- ---------- ---------- ---------- ----------
77525 BR ---------- ---------- ---------- ---------- ---------- ----------
77600 $196.00 $447.00 $476.00 $483.00 $447.00 $476.00 $483.00
77600-26 $80.00 $78.00 $81.00 $83.00 $78.00 $81.00 $83.00
77600-TC $113.00 $369.00 $395.00 $400.00 $369.00 $395.00 $400.00
77605 $263.00 $842.00 $899.00 $918.00 $842.00 $899.00 $918.00
77605-26 $108.00 $117.00 $124.00 $134.00 $117.00 $124.00 $134.00
77605-TC $151.00 $725.00 $775.00 $784.00 $725.00 $775.00 $784.00
77610 $195.00 $925.00 $987.00 $1,003.00 $925.00 $987.00 $1,003.00
77610-26 $79.00 $79.00 $83.00 $88.00 $79.00 $83.00 $88.00
77610-TC $113.00 $847.00 $905.00 $915.00 $847.00 $905.00 $915.00
77615 $262.00 $1,102.00 $1,174.00 $1,190.00 $1,102.00 $1,174.00 $1,190.00
77615-26 $106.00 $106.00 $110.00 $112.00 $106.00 $110.00 $112.00
77615-TC $151.00 $996.00 $1,065.00 $1,078.00 $996.00 $1,065.00 $1,078.00
77620 $196.00 $503.00 $537.00 $552.00 $503.00 $537.00 $552.00
77620-26 $80.00 $100.00 $107.00 $117.00 $100.00 $107.00 $117.00
77620-TC $113.00 $403.00 $430.00 $436.00 $403.00 $430.00 $436.00
77750 $299.00 $411.00 $429.00 $438.00 $411.00 $429.00 $438.00
77750-26 $248.00 $289.00 $298.00 $305.00 $289.00 $298.00 $305.00
77750-TC $49.00 $122.00 $131.00 $133.00 $122.00 $131.00 $133.00
77761 $284.00 $429.00 $451.00 $461.00 $429.00 $451.00 $461.00
77761-26 $188.00 $221.00 $228.00 $235.00 $221.00 $228.00 $235.00
77761-TC $93.00 $208.00 $223.00 $226.00 $208.00 $223.00 $226.00
77762 $427.00 $575.00 $603.00 $618.00 $575.00 $603.00 $618.00
77762-26 $289.00 $334.00 $346.00 $356.00 $334.00 $346.00 $356.00
77762-TC $135.00 $241.00 $258.00 $262.00 $241.00 $258.00 $262.00
77763 $605.00 $810.00 $847.00 $866.00 $810.00 $847.00 $866.00
77763-26 $435.00 $501.00 $516.00 $529.00 $501.00 $516.00 $529.00
77763-TC $167.00 $309.00 $331.00 $337.00 $309.00 $331.00 $337.00
77767 ---------- $244.00 $259.00 $263.00 $244.00 $259.00 $263.00
77767-26 ---------- $61.00 $63.00 $65.00 $61.00 $63.00 $65.00
77767-TC ---------- $183.00 $196.00 $198.00 $183.00 $196.00 $198.00
77768 ---------- $382.00 $406.00 $412.00 $382.00 $406.00 $412.00
77768-26 ---------- $81.00 $84.00 $86.00 $81.00 $84.00 $86.00
77768-TC ---------- $301.00 $322.00 $327.00 $301.00 $322.00 $327.00
77770 ---------- $349.00 $369.00 $375.00 $349.00 $369.00 $375.00
77770-26 ---------- $113.00 $116.00 $119.00 $113.00 $116.00 $119.00
77770-TC ---------- $236.00 $253.00 $256.00 $236.00 $253.00 $256.00
77771 ---------- $650.00 $687.00 $699.00 $650.00 $687.00 $699.00
77771-26 ---------- $220.00 $226.00 $232.00 $220.00 $226.00 $232.00
77771-TC ---------- $430.00 $460.00 $467.00 $430.00 $460.00 $467.00
77772 ---------- $992.00 $1,050.00 $1,068.00 $992.00 $1,050.00 $1,068.00
77772-26 ---------- $311.00 $321.00 $329.00 $311.00 $321.00 $329.00
77772-TC ---------- $681.00 $729.00 $739.00 $681.00 $729.00 $739.00
77778 $764.00 $902.00 $946.00 $967.00 $902.00 $946.00 $967.00
77778-26 $568.00 $506.00 $522.00 $535.00 $506.00 $522.00 $535.00
77778-TC $192.00 $396.00 $424.00 $432.00 $396.00 $424.00 $432.00
77789 $74.00 $130.00 $137.00 $139.00 $130.00 $137.00 $139.00
77789-26 $57.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00
77789-TC $16.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 313
Radiology
CPT Code 2003 MRALocality 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)
77790 $72.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
77790-26 $53.00 ---------- ---------- ---------- ---------- ---------- ----------
77790-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
77799 BR ---------- ---------- ---------- ---------- ---------- ----------
77799-26 BR ---------- ---------- ---------- ---------- ---------- ----------
77799-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78012 ---------- $89.00 $95.00 $97.00 $89.00 $95.00 $97.00
78012-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
78012-TC ---------- $79.00 $84.00 $86.00 $79.00 $84.00 $86.00
78013 ---------- $212.00 $226.00 $230.00 $212.00 $226.00 $230.00
78013-26 ---------- $21.00 $21.00 $22.00 $21.00 $21.00 $22.00
78013-TC ---------- $192.00 $205.00 $208.00 $192.00 $205.00 $208.00
78014 ---------- $269.00 $286.00 $291.00 $269.00 $286.00 $291.00
78014-26 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
78014-TC ---------- $240.00 $257.00 $261.00 $240.00 $257.00 $261.00
78015 $132.00 $247.00 $263.00 $267.00 $247.00 $263.00 $267.00
78015-26 $34.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.00
78015-TC $96.00 $210.00 $225.00 $228.00 $210.00 $225.00 $228.00
78016 $173.00 $316.00 $336.00 $340.00 $316.00 $336.00 $340.00
78016-26 $42.00 $39.00 $39.00 $39.00 $39.00 $39.00 $39.00
78016-TC $130.00 $277.00 $297.00 $301.00 $277.00 $297.00 $301.00
78018 $248.00 $348.00 $371.00 $376.00 $348.00 $371.00 $376.00
78018-26 $44.00 $47.00 $48.00 $49.00 $47.00 $48.00 $49.00
78018-TC $202.00 $302.00 $323.00 $327.00 $302.00 $323.00 $327.00
78020 $35.00 $93.00 $99.00 $101.00 $93.00 $99.00 $101.00
78020-26 $30.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
78020-TC $5.00 $62.00 $67.00 $68.00 $62.00 $67.00 $68.00
78070 $112.00 $334.00 $355.00 $361.00 $334.00 $355.00 $361.00
78070-26 $36.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.00
78070-TC $68.00 $290.00 $310.00 $314.00 $290.00 $310.00 $314.00
78071 ---------- $398.00 $423.00 $430.00 $398.00 $423.00 $430.00
78071-26 ---------- $66.00 $68.00 $70.00 $66.00 $68.00 $70.00
78071-TC ---------- $332.00 $355.00 $360.00 $332.00 $355.00 $360.00
78072 ---------- $459.00 $488.00 $495.00 $459.00 $488.00 $495.00
78072-26 ---------- $86.00 $89.00 $91.00 $86.00 $89.00 $91.00
78072-TC ---------- $373.00 $399.00 $404.00 $373.00 $399.00 $404.00
78075 $242.00 $493.00 $526.00 $533.00 $493.00 $526.00 $533.00
78075-26 $38.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00
78075-TC $202.00 $451.00 $483.00 $489.00 $451.00 $483.00 $489.00
78099 BR ---------- ---------- ---------- ---------- ---------- ----------
78099-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78099-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78102 $106.00 $190.00 $202.00 $206.00 $190.00 $202.00 $206.00
78102-26 $28.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
78102-TC $77.00 $160.00 $171.00 $174.00 $160.00 $171.00 $174.00
78103 $158.00 $244.00 $260.00 $264.00 $244.00 $260.00 $264.00
78103-26 $39.00 $40.00 $41.00 $42.00 $40.00 $41.00 $42.00
78103-TC $118.00 $205.00 $219.00 $222.00 $205.00 $219.00 $222.00
78104 $194.00 $273.00 $290.00 $295.00 $273.00 $290.00 $295.00
78104-26 $41.00 $43.00 $44.00 $46.00 $43.00 $44.00 $46.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 314
Radiology
CPT Code 2003 MRALocality 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)
78104-TC $152.00 $230.00 $246.00 $249.00 $230.00 $246.00 $249.00
78110 $45.00 $111.00 $119.00 $121.00 $111.00 $119.00 $121.00
78110-26 $9.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.00
78110-TC $35.00 $100.00 $107.00 $109.00 $100.00 $107.00 $109.00
78111 $108.00 $106.00 $113.00 $115.00 $106.00 $113.00 $115.00
78111-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
78111-TC $96.00 $94.00 $100.00 $102.00 $94.00 $100.00 $102.00
78120 $78.00 $104.00 $111.00 $114.00 $104.00 $111.00 $114.00
78120-26 $11.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.00
78120-TC $65.00 $91.00 $98.00 $100.00 $91.00 $98.00 $100.00
78121 $125.00 $116.00 $123.00 $126.00 $116.00 $123.00 $126.00
78121-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.00
78121-TC $108.00 $98.00 $105.00 $107.00 $98.00 $105.00 $107.00
78122 $196.00 $108.00 $114.00 $117.00 $108.00 $114.00 $117.00
78122-26 $22.00 $24.00 $24.00 $25.00 $24.00 $24.00 $25.00
78122-TC $171.00 $84.00 $90.00 $92.00 $84.00 $90.00 $92.00
78130 $139.00 $187.00 $198.00 $202.00 $187.00 $198.00 $202.00
78130-26 $32.00 $34.00 $35.00 $35.00 $34.00 $35.00 $35.00
78130-TC $106.00 $153.00 $164.00 $166.00 $153.00 $164.00 $166.00
78135 $216.00 $387.00 $413.00 $419.00 $387.00 $413.00 $419.00
78135-26 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00
78135-TC $182.00 $351.00 $375.00 $380.00 $351.00 $375.00 $380.00
78140 $179.00 $154.00 $164.00 $167.00 $154.00 $164.00 $167.00
78140-26 $31.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
78140-TC $147.00 $120.00 $129.00 $131.00 $120.00 $129.00 $131.00
78185 $110.00 $235.00 $250.00 $254.00 $235.00 $250.00 $254.00
78185-26 $20.00 $23.00 $23.00 $24.00 $23.00 $23.00 $24.00
78185-TC $88.00 $212.00 $227.00 $230.00 $212.00 $227.00 $230.00
78190 $272.00 $437.00 $465.00 $471.00 $437.00 $465.00 $471.00
78190-26 $57.00 $60.00 $62.00 $63.00 $60.00 $62.00 $63.00
78190-TC $214.00 $376.00 $403.00 $408.00 $376.00 $403.00 $408.00
78191 $307.00 $187.00 $198.00 $202.00 $187.00 $198.00 $202.00
78191-26 $31.00 $34.00 $35.00 $35.00 $34.00 $35.00 $35.00
78191-TC $274.00 $153.00 $164.00 $166.00 $153.00 $164.00 $166.00
78195 $216.00 $397.00 $422.00 $429.00 $397.00 $422.00 $429.00
78195-26 $49.00 $67.00 $69.00 $71.00 $67.00 $69.00 $71.00
78195-TC $152.00 $330.00 $353.00 $358.00 $330.00 $353.00 $358.00
78199 BR ---------- ---------- ---------- ---------- ---------- ----------
78199-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78199-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78201 $112.00 $210.00 $224.00 $227.00 $210.00 $224.00 $227.00
78201-26 $22.00 $24.00 $24.00 $25.00 $24.00 $24.00 $25.00
78201-TC $88.00 $186.00 $199.00 $202.00 $186.00 $199.00 $202.00
78202 $135.00 $222.00 $237.00 $240.00 $222.00 $237.00 $240.00
78202-26 $26.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
78202-TC $108.00 $196.00 $210.00 $213.00 $196.00 $210.00 $213.00
78205 $259.00 $235.00 $250.00 $254.00 $235.00 $250.00 $254.00
78205-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.00
78205-TC $220.00 $197.00 $211.00 $214.00 $197.00 $211.00 $214.00
78206 $265.00 $381.00 $405.00 $412.00 $381.00 $405.00 $412.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 315
Radiology
CPT Code 2003 MRALocality 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)
78206-26 $46.00 $53.00 $54.00 $56.00 $53.00 $54.00 $56.00
78206-TC $214.00 $328.00 $351.00 $356.00 $328.00 $351.00 $356.00
78215 $135.00 $216.00 $230.00 $234.00 $216.00 $230.00 $234.00
78215-26 $24.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00
78215-TC $109.00 $189.00 $202.00 $205.00 $189.00 $202.00 $205.00
78216 $160.00 $142.00 $150.00 $153.00 $142.00 $150.00 $153.00
78216-26 $29.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
78216-TC $130.00 $111.00 $119.00 $121.00 $111.00 $119.00 $121.00
78226 ---------- $368.00 $392.00 $398.00 $368.00 $392.00 $398.00
78226-26 ---------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.00
78226-TC ---------- $327.00 $349.00 $354.00 $327.00 $349.00 $354.00
78227 ---------- $499.00 $531.00 $539.00 $499.00 $531.00 $539.00
78227-26 ---------- $50.00 $52.00 $54.00 $50.00 $52.00 $54.00
78227-TC ---------- $448.00 $479.00 $486.00 $448.00 $479.00 $486.00
78230 $106.00 $195.00 $207.00 $211.00 $195.00 $207.00 $211.00
78230-26 $23.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
78230-TC $82.00 $169.00 $181.00 $183.00 $169.00 $181.00 $183.00
78231 $146.00 $144.00 $153.00 $156.00 $144.00 $153.00 $156.00
78231-26 $27.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.00
78231-TC $118.00 $114.00 $123.00 $125.00 $114.00 $123.00 $125.00
78232 $157.00 $112.00 $118.00 $121.00 $112.00 $118.00 $121.00
78232-26 $23.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.00
78232-TC $132.00 $90.00 $96.00 $98.00 $90.00 $96.00 $98.00
78258 $146.00 $251.00 $267.00 $271.00 $251.00 $267.00 $271.00
78258-26 $38.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00
78258-TC $108.00 $209.00 $224.00 $227.00 $209.00 $224.00 $227.00
78261 $190.00 $273.00 $291.00 $295.00 $273.00 $291.00 $295.00
78261-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.00
78261-TC $152.00 $235.00 $252.00 $255.00 $235.00 $252.00 $255.00
78262 $195.00 $270.00 $287.00 $291.00 $270.00 $287.00 $291.00
78262-26 $35.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.00
78262-TC $159.00 $233.00 $249.00 $252.00 $233.00 $249.00 $252.00
78264 $195.00 $374.00 $398.00 $404.00 $374.00 $398.00 $404.00
78264-26 $40.00 $44.00 $45.00 $47.00 $44.00 $45.00 $47.00
78264-TC $154.00 $330.00 $353.00 $358.00 $330.00 $353.00 $358.00
78265 ---------- $406.00 $432.00 $439.00 $406.00 $432.00 $439.00
78265-26 ---------- $55.00 $56.00 $58.00 $55.00 $56.00 $58.00
78265-TC ---------- $351.00 $375.00 $381.00 $351.00 $375.00 $381.00
78266 ---------- $512.00 $545.00 $553.00 $512.00 $545.00 $553.00
78266-26 ---------- $60.00 $62.00 $64.00 $60.00 $62.00 $64.00
78266-TC ---------- $452.00 $483.00 $489.00 $452.00 $483.00 $489.00
78267 BR ---------- ---------- ---------- ---------- ---------- ----------
78268 BR ---------- ---------- ---------- ---------- ---------- ----------
78270 $68.00 $113.00 $120.00 $123.00 $113.00 $120.00 $123.00
78270-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.00
78270-TC $58.00 $101.00 $108.00 $110.00 $101.00 $108.00 $110.00
78271 $72.00 $100.00 $107.00 $109.00 $100.00 $107.00 $109.00
78271-26 $10.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
78271-TC $61.00 $88.00 $95.00 $97.00 $88.00 $95.00 $97.00
78272 $100.00 $109.00 $116.00 $118.00 $109.00 $116.00 $118.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 316
Radiology
CPT Code 2003 MRALocality 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)
78272-26 $14.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.00
78272-TC $87.00 $94.00 $101.00 $103.00 $94.00 $101.00 $103.00
78278 $234.00 $388.00 $413.00 $419.00 $388.00 $413.00 $419.00
78278-26 $50.00 $55.00 $57.00 $58.00 $55.00 $57.00 $58.00
78278-TC $182.00 $333.00 $356.00 $361.00 $333.00 $356.00 $361.00
78282 BR $372.00 $396.00 $401.00 $372.00 $396.00 $401.00
78282-26 $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
78282-TC BR $350.00 $374.00 $378.00 $350.00 $374.00 $378.00
78290 $149.00 $369.00 $393.00 $399.00 $369.00 $393.00 $399.00
78290-26 $35.00 $38.00 $39.00 $41.00 $38.00 $39.00 $41.00
78290-TC $113.00 $331.00 $354.00 $359.00 $331.00 $354.00 $359.00
78291 $161.00 $285.00 $303.00 $308.00 $285.00 $303.00 $308.00
78291-26 $45.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.00
78291-TC $114.00 $237.00 $253.00 $257.00 $237.00 $253.00 $257.00
78299 BR ---------- ---------- ---------- ---------- ---------- ----------
78299-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78299-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78300 $125.00 $202.00 $215.00 $219.00 $202.00 $215.00 $219.00
78300-26 $32.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00
78300-TC $93.00 $167.00 $179.00 $181.00 $167.00 $179.00 $181.00
78305 $181.00 $259.00 $275.00 $280.00 $259.00 $275.00 $280.00
78305-26 $42.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00
78305-TC $137.00 $212.00 $227.00 $230.00 $212.00 $227.00 $230.00
78306 $205.00 $280.00 $298.00 $302.00 $280.00 $298.00 $302.00
78306-26 $44.00 $47.00 $49.00 $50.00 $47.00 $49.00 $50.00
78306-TC $159.00 $233.00 $249.00 $252.00 $233.00 $249.00 $252.00
78315 $233.00 $385.00 $410.00 $416.00 $385.00 $410.00 $416.00
78315-26 $52.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.00
78315-TC $179.00 $329.00 $351.00 $356.00 $329.00 $351.00 $356.00
78320 $276.00 $255.00 $270.00 $275.00 $255.00 $270.00 $275.00
78320-26 $53.00 $57.00 $59.00 $60.00 $57.00 $59.00 $60.00
78320-TC $220.00 $198.00 $212.00 $215.00 $198.00 $212.00 $215.00
78350 $40.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00
78350-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
78350-TC $29.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
78351 $23.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.00
78399 BR ---------- ---------- ---------- ---------- ---------- ----------
78399-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78399-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78414 BR ---------- ---------- ---------- ---------- ---------- ----------
78414-26 $23.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.00
78414-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78428 $126.00 $202.00 $214.00 $218.00 $202.00 $214.00 $218.00
78428-26 $41.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00
78428-TC $84.00 $160.00 $171.00 $174.00 $160.00 $171.00 $174.00
78445 $97.00 $202.00 $215.00 $219.00 $202.00 $215.00 $219.00
78445-26 $28.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00
78445-TC $69.00 $175.00 $187.00 $190.00 $175.00 $187.00 $190.00
78451 ---------- $378.00 $402.00 $408.00 $378.00 $402.00 $408.00
78451-26 ---------- $75.00 $78.00 $80.00 $75.00 $78.00 $80.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 317
Radiology
CPT Code 2003 MRALocality 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)
78451-TC ---------- $303.00 $324.00 $328.00 $303.00 $324.00 $328.00
78452 ---------- $525.00 $558.00 $566.00 $525.00 $558.00 $566.00
78452-26 ---------- $88.00 $91.00 $93.00 $88.00 $91.00 $93.00
78452-TC ---------- $436.00 $467.00 $473.00 $436.00 $467.00 $473.00
78453 ---------- $338.00 $359.00 $365.00 $338.00 $359.00 $365.00
78453-26 ---------- $56.00 $57.00 $59.00 $56.00 $57.00 $59.00
78453-TC ---------- $282.00 $302.00 $306.00 $282.00 $302.00 $306.00
78454 ---------- $486.00 $517.00 $525.00 $486.00 $517.00 $525.00
78454-26 ---------- $75.00 $78.00 $80.00 $75.00 $78.00 $80.00
78454-TC ---------- $411.00 $439.00 $445.00 $411.00 $439.00 $445.00
78456 $205.00 $355.00 $378.00 $384.00 $355.00 $378.00 $384.00
78456-26 $49.00 $55.00 $56.00 $58.00 $55.00 $56.00 $58.00
78456-TC $151.00 $301.00 $322.00 $326.00 $301.00 $322.00 $326.00
78457 $140.00 $196.00 $208.00 $211.00 $196.00 $208.00 $211.00
78457-26 $39.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00
78457-TC $99.00 $154.00 $165.00 $167.00 $154.00 $165.00 $167.00
78458 $198.00 $228.00 $243.00 $247.00 $228.00 $243.00 $247.00
78458-26 $46.00 $51.00 $53.00 $54.00 $51.00 $53.00 $54.00
78458-TC $149.00 $177.00 $190.00 $193.00 $177.00 $190.00 $193.00
78459 BR $1,277.00 $1,360.00 $1,375.00 $1,277.00 $1,360.00 $1,375.00
78459-26 $100.00 $79.00 $82.00 $84.00 $79.00 $82.00 $84.00
78459-TC BR $1,197.00 $1,279.00 $1,292.00 $1,197.00 $1,279.00 $1,292.00
78466 $135.00 $218.00 $231.00 $235.00 $218.00 $231.00 $235.00
78466-26 $36.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
78466-TC $97.00 $178.00 $191.00 $193.00 $178.00 $191.00 $193.00
78468 $180.00 $216.00 $230.00 $233.00 $216.00 $230.00 $233.00
78468-26 $41.00 $44.00 $45.00 $46.00 $44.00 $45.00 $46.00
78468-TC $137.00 $173.00 $185.00 $187.00 $173.00 $185.00 $187.00
78469 $244.00 $253.00 $268.00 $272.00 $253.00 $268.00 $272.00
78469-26 $47.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.00
78469-TC $195.00 $202.00 $217.00 $220.00 $202.00 $217.00 $220.00
78472 $259.00 $255.00 $271.00 $275.00 $255.00 $271.00 $275.00
78472-26 $50.00 $54.00 $56.00 $58.00 $54.00 $56.00 $58.00
78472-TC $206.00 $201.00 $215.00 $218.00 $201.00 $215.00 $218.00
78473 $387.00 $322.00 $341.00 $347.00 $322.00 $341.00 $347.00
78473-26 $75.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.00
78473-TC $308.00 $242.00 $259.00 $263.00 $242.00 $259.00 $263.00
78481 $248.00 $195.00 $206.00 $210.00 $195.00 $206.00 $210.00
78481-26 $51.00 $54.00 $55.00 $57.00 $54.00 $55.00 $57.00
78481-TC $195.00 $141.00 $151.00 $153.00 $141.00 $151.00 $153.00
78483 $373.00 $270.00 $286.00 $291.00 $270.00 $286.00 $291.00
78483-26 $77.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.00
78483-TC $294.00 $190.00 $204.00 $207.00 $190.00 $204.00 $207.00
78491 BR $1,470.00 $1,566.00 $1,583.00 $1,470.00 $1,566.00 $1,583.00
78491-26 $85.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.00
78491-TC BR $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00
78492 BR $1,490.00 $1,587.00 $1,604.00 $1,490.00 $1,587.00 $1,604.00
78492-26 $100.00 $101.00 $103.00 $106.00 $101.00 $103.00 $106.00
78492-TC BR $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00
78494 $324.00 $250.00 $265.00 $269.00 $250.00 $265.00 $269.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 318
Radiology
CPT Code 2003 MRALocality 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)
78494-26 $59.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
78494-TC $262.00 $185.00 $198.00 $201.00 $185.00 $198.00 $201.00
78496 $92.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.00
78496-26 $24.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00
78496-TC $66.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00
78499 BR ---------- ---------- ---------- ---------- ---------- ----------
78499-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78499-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78579 ---------- $207.00 $220.00 $223.00 $207.00 $220.00 $223.00
78579-26 ---------- $27.00 $28.00 $28.00 $27.00 $28.00 $28.00
78579-TC ---------- $180.00 $192.00 $195.00 $180.00 $192.00 $195.00
78580 $167.00 $266.00 $283.00 $288.00 $266.00 $283.00 $288.00
78580-26 $38.00 $41.00 $42.00 $44.00 $41.00 $42.00 $44.00
78580-TC $128.00 $225.00 $241.00 $244.00 $225.00 $241.00 $244.00
78582 ---------- $373.00 $397.00 $403.00 $373.00 $397.00 $403.00
78582-26 ---------- $60.00 $62.00 $64.00 $60.00 $62.00 $64.00
78582-TC ---------- $313.00 $335.00 $339.00 $313.00 $335.00 $339.00
78597 ---------- $225.00 $239.00 $242.00 $225.00 $239.00 $242.00
78597-26 ---------- $40.00 $41.00 $42.00 $40.00 $41.00 $42.00
78597-TC ---------- $185.00 $198.00 $200.00 $185.00 $198.00 $200.00
78598 ---------- $340.00 $362.00 $368.00 $340.00 $362.00 $368.00
78598-26 ---------- $47.00 $48.00 $49.00 $47.00 $48.00 $49.00
78598-TC ---------- $294.00 $314.00 $319.00 $294.00 $314.00 $319.00
78599 BR ---------- ---------- ---------- ---------- ---------- ----------
78599-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78599-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78600 $131.00 $206.00 $220.00 $224.00 $206.00 $220.00 $224.00
78600-26 $22.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
78600-TC $108.00 $181.00 $194.00 $196.00 $181.00 $194.00 $196.00
78601 $154.00 $239.00 $254.00 $259.00 $239.00 $254.00 $259.00
78601-26 $26.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
78601-TC $126.00 $211.00 $225.00 $228.00 $211.00 $225.00 $228.00
78605 $155.00 $223.00 $237.00 $241.00 $223.00 $237.00 $241.00
78605-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
78605-TC $126.00 $193.00 $206.00 $209.00 $193.00 $206.00 $209.00
78606 $221.00 $366.00 $390.00 $396.00 $366.00 $390.00 $396.00
78606-26 $45.00 $35.00 $36.00 $37.00 $35.00 $36.00 $37.00
78606-TC $177.00 $331.00 $354.00 $359.00 $331.00 $354.00 $359.00
78607 $311.00 $392.00 $416.00 $423.00 $392.00 $416.00 $423.00
78607-26 $64.00 $67.00 $69.00 $71.00 $67.00 $69.00 $71.00
78607-TC $245.00 $325.00 $347.00 $352.00 $325.00 $347.00 $352.00
78608 BR $1,470.00 $1,567.00 $1,584.00 $1,470.00 $1,567.00 $1,584.00
78608-26 ---------- $81.00 $83.00 $85.00 $81.00 $83.00 $85.00
78608-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00
78609 BR $83.00 $85.00 $87.00 $83.00 $85.00 $87.00
78609-26 ---------- $83.00 $85.00 $87.00 $83.00 $85.00 $87.00
78609-TC ---------- BR BR BR BR BR BR
78610 $74.00 $195.00 $208.00 $211.00 $195.00 $208.00 $211.00
78610-26 $15.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.00
78610-TC $59.00 $177.00 $190.00 $193.00 $177.00 $190.00 $193.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 319
Radiology
CPT Code 2003 MRALocality 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)
78630 $223.00 $376.00 $401.00 $407.00 $376.00 $401.00 $407.00
78630-26 $35.00 $38.00 $39.00 $41.00 $38.00 $39.00 $41.00
78630-TC $188.00 $338.00 $362.00 $367.00 $338.00 $362.00 $367.00
78635 $129.00 $380.00 $405.00 $411.00 $380.00 $405.00 $411.00
78635-26 $32.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00
78635-TC $95.00 $345.00 $369.00 $374.00 $345.00 $369.00 $374.00
78645 $158.00 $360.00 $384.00 $390.00 $360.00 $384.00 $390.00
78645-26 $29.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
78645-TC $128.00 $329.00 $352.00 $356.00 $329.00 $352.00 $356.00
78647 $268.00 $394.00 $420.00 $426.00 $394.00 $420.00 $426.00
78647-26 $46.00 $52.00 $53.00 $55.00 $52.00 $53.00 $55.00
78647-TC $220.00 $343.00 $366.00 $371.00 $343.00 $366.00 $371.00
78650 $206.00 $368.00 $392.00 $398.00 $368.00 $392.00 $398.00
78650-26 $31.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
78650-TC $173.00 $334.00 $357.00 $362.00 $334.00 $357.00 $362.00
78660 $107.00 $200.00 $213.00 $217.00 $200.00 $213.00 $217.00
78660-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
78660-TC $79.00 $170.00 $182.00 $185.00 $170.00 $182.00 $185.00
78699 BR ---------- ---------- ---------- ---------- ---------- ----------
78699-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78699-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78700 $137.00 $191.00 $203.00 $206.00 $191.00 $203.00 $206.00
78700-26 $22.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.00
78700-TC $113.00 $166.00 $177.00 $180.00 $166.00 $177.00 $180.00
78701 $158.00 $235.00 $250.00 $254.00 $235.00 $250.00 $254.00
78701-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
78701-TC $133.00 $208.00 $223.00 $226.00 $208.00 $223.00 $226.00
78707 $217.00 $260.00 $276.00 $280.00 $260.00 $276.00 $280.00
78707-26 $49.00 $53.00 $54.00 $56.00 $53.00 $54.00 $56.00
78707-TC $166.00 $207.00 $221.00 $224.00 $207.00 $221.00 $224.00
78708 $231.00 $197.00 $209.00 $213.00 $197.00 $209.00 $213.00
78708-26 $61.00 $67.00 $69.00 $71.00 $67.00 $69.00 $71.00
78708-TC $166.00 $130.00 $140.00 $142.00 $130.00 $140.00 $142.00
78709 $241.00 $406.00 $432.00 $439.00 $406.00 $432.00 $439.00
78709-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.00
78709-TC $166.00 $329.00 $352.00 $357.00 $329.00 $352.00 $357.00
78710 $256.00 $224.00 $238.00 $242.00 $224.00 $238.00 $242.00
78710-26 $34.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
78710-TC $220.00 $189.00 $202.00 $205.00 $189.00 $202.00 $205.00
78725 $87.00 $119.00 $126.00 $129.00 $119.00 $126.00 $129.00
78725-26 $19.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.00
78725-TC $66.00 $98.00 $105.00 $107.00 $98.00 $105.00 $107.00
78730 $73.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00
78730-26 $18.00 $8.00 $8.00 $8.00 $8.00 $8.00 $8.00
78730-TC $55.00 $70.00 $75.00 $76.00 $70.00 $75.00 $76.00
78740 $109.00 $243.00 $259.00 $263.00 $243.00 $259.00 $263.00
78740-26 $29.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.00
78740-TC $79.00 $213.00 $227.00 $231.00 $213.00 $227.00 $231.00
78761 $157.00 $238.00 $253.00 $257.00 $238.00 $253.00 $257.00
78761-26 $36.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 320
Radiology
CPT Code 2003 MRALocality 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)
78761-TC $119.00 $197.00 $211.00 $214.00 $197.00 $211.00 $214.00
78799 BR ---------- ---------- ---------- ---------- ---------- ----------
78799-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78799-TC BR ---------- ---------- ---------- ---------- ---------- ----------
78800 $162.00 $215.00 $229.00 $234.00 $215.00 $229.00 $234.00
78800-26 $34.00 $38.00 $40.00 $42.00 $38.00 $40.00 $42.00
78800-TC $126.00 $177.00 $189.00 $192.00 $177.00 $189.00 $192.00
78801 $199.00 $293.00 $312.00 $318.00 $293.00 $312.00 $318.00
78801-26 $40.00 $45.00 $47.00 $50.00 $45.00 $47.00 $50.00
78801-TC $158.00 $247.00 $264.00 $268.00 $247.00 $264.00 $268.00
78802 $252.00 $360.00 $383.00 $389.00 $360.00 $383.00 $389.00
78802-26 $44.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00
78802-TC $207.00 $313.00 $335.00 $339.00 $313.00 $335.00 $339.00
78803 $303.00 $380.00 $404.00 $411.00 $380.00 $404.00 $411.00
78803-26 $56.00 $59.00 $60.00 $62.00 $59.00 $60.00 $62.00
78803-TC $245.00 $322.00 $344.00 $349.00 $322.00 $344.00 $349.00
78804 ---------- $629.00 $670.00 $680.00 $629.00 $670.00 $680.00
78804-26 ---------- $58.00 $60.00 $62.00 $58.00 $60.00 $62.00
78804-TC ---------- $570.00 $610.00 $618.00 $570.00 $610.00 $618.00
78805 $166.00 $204.00 $217.00 $221.00 $204.00 $217.00 $221.00
78805-26 $38.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.00
78805-TC $126.00 $164.00 $175.00 $178.00 $164.00 $175.00 $178.00
78806 $286.00 $371.00 $395.00 $401.00 $371.00 $395.00 $401.00
78806-26 $44.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00
78806-TC $241.00 $324.00 $346.00 $351.00 $324.00 $346.00 $351.00
78807 $303.00 $381.00 $405.00 $411.00 $381.00 $405.00 $411.00
78807-26 $57.00 $59.00 $60.00 $62.00 $59.00 $60.00 $62.00
78807-TC $245.00 $323.00 $345.00 $350.00 $323.00 $345.00 $350.00
78808 ---------- $49.00 $52.00 $54.00 $49.00 $52.00 $54.00
78811 ---------- $1,284.00 $1,368.00 $1,384.00 $1,284.00 $1,368.00 $1,384.00
78811-26 ---------- $87.00 $89.00 $92.00 $87.00 $89.00 $92.00
78811-TC ---------- $1,197.00 $1,279.00 $1,292.00 $1,197.00 $1,279.00 $1,292.00
78812 ---------- $1,495.00 $1,593.00 $1,610.00 $1,495.00 $1,593.00 $1,610.00
78812-26 ---------- $105.00 $109.00 $112.00 $105.00 $109.00 $112.00
78812-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00
78813 ---------- $1,499.00 $1,597.00 $1,615.00 $1,499.00 $1,597.00 $1,615.00
78813-26 ---------- $110.00 $113.00 $117.00 $110.00 $113.00 $117.00
78813-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00
78814 ---------- $1,512.00 $1,610.00 $1,629.00 $1,512.00 $1,610.00 $1,629.00
78814-26 ---------- $122.00 $126.00 $130.00 $122.00 $126.00 $130.00
78814-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00
78815 ---------- $1,524.00 $1,622.00 $1,641.00 $1,524.00 $1,622.00 $1,641.00
78815-26 ---------- $134.00 $139.00 $142.00 $134.00 $139.00 $142.00
78815-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00
78816 ---------- $1,525.00 $1,624.00 $1,643.00 $1,525.00 $1,624.00 $1,643.00
78816-26 ---------- $136.00 $140.00 $144.00 $136.00 $140.00 $144.00
78816-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00
78999 BR ---------- ---------- ---------- ---------- ---------- ----------
78999-26 BR ---------- ---------- ---------- ---------- ---------- ----------
78999-TC BR ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 321
Radiology
CPT Code 2003 MRALocality 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)
79005 ---------- $152.00 $159.00 $162.00 $152.00 $159.00 $162.00
79005-26 ---------- $99.00 $102.00 $104.00 $99.00 $102.00 $104.00
79005-TC ---------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.00
79101 ---------- $159.00 $166.00 $169.00 $159.00 $166.00 $169.00
79101-26 ---------- $108.00 $111.00 $113.00 $108.00 $111.00 $113.00
79101-TC ---------- $51.00 $55.00 $56.00 $51.00 $55.00 $56.00
79200 $203.00 $155.00 $161.00 $164.00 $155.00 $161.00 $164.00
79200-26 $102.00 $96.00 $98.00 $99.00 $96.00 $98.00 $99.00
79200-TC $97.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.00
79300 BR ---------- ---------- ---------- ---------- ---------- ----------
79300-26 $83.00 $90.00 $93.00 $96.00 $90.00 $93.00 $96.00
79300-TC BR ---------- ---------- ---------- ---------- ---------- ----------
79403 ---------- $212.00 $222.00 $228.00 $212.00 $222.00 $228.00
79403-26 ---------- $124.00 $127.00 $131.00 $124.00 $127.00 $131.00
79403-TC ---------- $89.00 $95.00 $97.00 $89.00 $95.00 $97.00
79440 $204.00 $164.00 $171.00 $175.00 $164.00 $171.00 $175.00
79440-26 $104.00 $109.00 $113.00 $116.00 $109.00 $113.00 $116.00
79440-TC $97.00 $54.00 $58.00 $59.00 $54.00 $58.00 $59.00
79445 ---------- BR BR BR BR BR BR
79445-26 ---------- $130.00 $134.00 $138.00 $130.00 $134.00 $138.00
79445-TC ---------- BR BR BR BR BR BR
79999 BR ---------- ---------- ---------- ---------- ---------- ----------
79999-26 BR ---------- ---------- ---------- ---------- ---------- ----------
79999-TC BR ---------- ---------- ---------- ---------- ---------- ----------
G0130 ---------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
G0130-26 ---------- $13.00 $13.00 $13.00 $13.00 $13.00 $13.00
G0130-TC ---------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
G0202 ---------- $147.00 $156.00 $159.00 $147.00 $156.00 $159.00
G0202-26 ---------- $42.00 $43.00 $44.00 $42.00 $43.00 $44.00
G0202-TC ---------- $106.00 $113.00 $115.00 $106.00 $113.00 $115.00
G0204 ---------- $183.00 $193.00 $197.00 $183.00 $193.00 $197.00
G0204-26 ---------- $55.00 $57.00 $58.00 $55.00 $57.00 $58.00
G0204-TC ---------- $128.00 $137.00 $139.00 $128.00 $137.00 $139.00
G0206 ---------- $144.00 $153.00 $156.00 $144.00 $153.00 $156.00
G0206-26 ---------- $44.00 $46.00 $47.00 $44.00 $46.00 $47.00
G0206-TC ---------- $100.00 $107.00 $108.00 $100.00 $107.00 $108.00
G0252-26 ---------- $83.00 $85.00 $87.00 $83.00 $85.00 $87.00
G0278 ---------- $16.00 $18.00 $20.00 $16.00 $18.00 $20.00
G0279 ---------- $61.00 $64.00 $65.00 $61.00 $64.00 $65.00
G0279-26 ---------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
G0279-TC ---------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
G0288 ---------- $40.00 $44.00 $47.00 $40.00 $44.00 $47.00
G0297 ---------- $272.00 $288.00 $292.00 $272.00 $288.00 $292.00
G0297-26 ---------- $57.00 $58.00 $59.00 $57.00 $58.00 $59.00
G0297-TC ---------- $215.00 $230.00 $233.00 $215.00 $230.00 $233.00
G0365 ---------- $133.00 $142.00 $144.00 $133.00 $142.00 $144.00
G0365-26 ---------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.00
G0365-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
G6001 ---------- $57.00 $60.00 $61.00 $57.00 $60.00 $61.00
G6001-26 ---------- $33.00 $34.00 $35.00 $33.00 $34.00 $35.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 322
Radiology
CPT Code 2003 MRALocality 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)
G6001-TC ---------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
G6002 ---------- $82.00 $87.00 $89.00 $82.00 $87.00 $89.00
G6002-26 ---------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.00
G6002-TC ---------- $59.00 $64.00 $64.00 $59.00 $64.00 $64.00
G6003 ---------- $204.00 $218.00 $220.00 $204.00 $218.00 $220.00
G6004 ---------- $155.00 $165.00 $167.00 $155.00 $165.00 $167.00
G6005 ---------- $154.00 $165.00 $167.00 $154.00 $165.00 $167.00
G6006 ---------- $154.00 $165.00 $167.00 $154.00 $165.00 $167.00
G6007 ---------- $318.00 $340.00 $343.00 $318.00 $340.00 $343.00
G6008 ---------- $213.00 $227.00 $230.00 $213.00 $227.00 $230.00
G6009 ---------- $212.00 $226.00 $229.00 $212.00 $226.00 $229.00
G6010 ---------- $211.00 $226.00 $228.00 $211.00 $226.00 $228.00
G6011 ---------- $308.00 $329.00 $333.00 $308.00 $329.00 $333.00
G6012 ---------- $281.00 $301.00 $304.00 $281.00 $301.00 $304.00
G6013 ---------- $282.00 $301.00 $304.00 $282.00 $301.00 $304.00
G6014 ---------- $282.00 $301.00 $305.00 $282.00 $301.00 $305.00
G6015 ---------- $369.00 $394.00 $399.00 $369.00 $394.00 $399.00
G6016 ---------- $367.00 $392.00 $396.00 $367.00 $392.00 $396.00
Q0092 ---------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 323
Pathology & Laboratory
CPT Code 2003 MRALocality 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 ---------- ---------- ---------- ---------- ---------- ----------
80150 $40.00 ---------- ---------- ---------- ---------- ---------- ----------
80150-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
80150-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------
80156 $35.00 ---------- ---------- ---------- ---------- ---------- ----------
80156-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
80162 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
80162-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
80162-TC $9.00 ---------- ---------- ---------- ---------- ---------- ----------
80164 $43.00 ---------- ---------- ---------- ---------- ---------- ----------
80164-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------
80164-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------
80168 $43.00 ---------- ---------- ---------- ---------- ---------- ----------
80168-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------
80168-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------
80170 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
80170-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 324
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
80170-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------
80173 $33.00 ---------- ---------- ---------- ---------- ---------- ----------
80173-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
80173-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------
80176 $35.00 ---------- ---------- ---------- ---------- ---------- ----------
80176-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
80176-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------
80178 $17.00 ---------- ---------- ---------- ---------- ---------- ----------
80178-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
80178-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 325
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 326
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
80438-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------
80439 $176.00 ---------- ---------- ---------- ---------- ---------- ----------
80439-26 $33.00 ---------- ---------- ---------- ---------- ---------- ----------
80439-TC $144.00 ---------- ---------- ---------- ---------- ---------- ----------
80500 $34.00 $26.00 $27.00 $28.00 $22.00 $23.00 $24.00
80500-26 $34.00 ---------- ---------- ---------- ---------- ---------- ----------
80500-TC BR ---------- ---------- ---------- ---------- ---------- ----------
80502 $72.00 $82.00 $85.00 $88.00 $79.00 $82.00 $84.00
80502-26 $72.00 ---------- ---------- ---------- ---------- ---------- ----------
80502-TC BR ---------- ---------- ---------- ---------- ---------- ----------
81000 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
81000-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81000-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------
81001 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
81001-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81001-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------
81002 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
81002-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81002-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81003 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
81003-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------
81003-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81005 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81005-26 $1.00 ---------- ---------- ---------- ---------- ---------- ----------
81005-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81007 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
81007-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------
81007-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------
81015 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
81015-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81015-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81020 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
81020-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
81020-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------
81025 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
81025-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 327
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
81025-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------
81050 $33.00 ---------- ---------- ---------- ---------- ---------- ----------
81050-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
81050-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------
81099 BR ---------- ---------- ---------- ---------- ---------- ----------
81099-26 BR ---------- ---------- ---------- ---------- ---------- ----------
81099-TC BR ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
82103 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
82103-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
82103-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
82104 $22.00 ---------- ---------- ---------- ---------- ---------- ----------
82104-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
82104-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------
82105 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 328
Pathology & Laboratory
CPT Code 2003 MRALocality 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 $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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
82160-TC $43.00 ---------- ---------- ---------- ---------- ---------- ----------
82163 $42.00 ---------- ---------- ---------- ---------- ---------- ----------
82163-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------
82163-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 329
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 330
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
82306-TC $52.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 331
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
82482-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------
82485 $37.00 ---------- ---------- ---------- ---------- ---------- ----------
82485-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
82485-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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 332
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
82542 $42.00 ---------- ---------- ---------- ---------- ---------- ----------
82542-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
82542-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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 333
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
82652 $89.00 ---------- ---------- ---------- ---------- ---------- ----------
82652-26 $25.00 ---------- ---------- ---------- ---------- ---------- ----------
82652-TC $62.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
82671-TC $43.00 ---------- ---------- ---------- ---------- ---------- ----------
82672 $57.00 ---------- ---------- ---------- ---------- ---------- ----------
82672-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------
82672-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------
82677 $52.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 334
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
82677-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------
82677-TC $35.00 ---------- ---------- ---------- ---------- ---------- ----------
82679 $70.00 ---------- ---------- ---------- ---------- ---------- ----------
82679-26 $20.00 ---------- ---------- ---------- ---------- ---------- ----------
82679-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 335
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
82938 $48.00 ---------- ---------- ---------- ---------- ---------- ----------
82938-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------
82938-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------
82941 $47.00 ---------- ---------- ---------- ---------- ---------- ----------
82941-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------
82941-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 336
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
82977 $16.00 ---------- ---------- ---------- ---------- ---------- ----------
82977-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
82977-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
82978 $25.00 ---------- ---------- ---------- ---------- ---------- ----------
82978-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
82978-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
82979 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
82979-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
82979-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 337
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $21.00 $21.00 $20.00 $21.00 $21.00
83020-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
83021 $39.00 ---------- ---------- ---------- ---------- ---------- ----------
83021-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
83021-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------
83026 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
83026-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
83026-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------
83030 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 338
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
83070 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
83070-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
83070-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 339
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 340
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
83789 $39.00 ---------- ---------- ---------- ---------- ---------- ----------
83789-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
83789-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------
83825 $34.00 ---------- ---------- ---------- ---------- ---------- ----------
83825-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
83825-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------
83835 $41.00 ---------- ---------- ---------- ---------- ---------- ----------
83835-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------
83835-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------
83857 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
83857-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
83857-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
83864 $32.00 ---------- ---------- ---------- ---------- ---------- ----------
83864-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
83864-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
83915 $31.00 ---------- ---------- ---------- ---------- ---------- ----------
83915-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
83915-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 341
Pathology & Laboratory
CPT Code 2003 MRALocality 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 $54.00 ---------- ---------- ---------- ---------- ---------- ----------
83916-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
84061-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
84061-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------
84066 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
84066-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 342
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
84132 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
84132-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
84132-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 343
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $21.00 $21.00 $20.00 $21.00 $21.00
84165-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------
84166 ---------- BR BR BR BR BR BR
84166-26 ---------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
84166-TC ---------- BR BR BR BR BR BR
84181 $29.00 ---------- ---------- ---------- ---------- ---------- ----------
84181-26 $10.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
84181-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------
84182 $33.00 ---------- ---------- ---------- ---------- ---------- ----------
84182-26 $11.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
84182-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------
84202 $39.00 ---------- ---------- ---------- ---------- ---------- ----------
84202-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
84202-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 344
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 345
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 346
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 347
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 348
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
85002 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
85002-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
85002-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------
85004 BR ---------- ---------- ---------- ---------- ---------- ----------
85004-26 BR ---------- ---------- ---------- ---------- ---------- ----------
85004-TC BR ---------- ---------- ---------- ---------- ---------- ----------
85007 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 349
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
85049-TC BR ---------- ---------- ---------- ---------- ---------- ----------
85060 $25.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
85060-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
85060-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
85097 $59.00 $99.00 $104.00 $106.00 $56.00 $58.00 $60.00
85097-26 $59.00 ---------- ---------- ---------- ---------- ---------- ----------
85097-TC BR ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 350
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 351
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 352
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $21.00 $21.00 $20.00 $21.00 $21.00
85390-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------
85396 ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
85400 $12.00 ---------- ---------- ---------- ---------- ---------- ----------
85400-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
85400-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
85410 $12.00 ---------- ---------- ---------- ---------- ---------- ----------
85410-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
85410-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
85415 $28.00 ---------- ---------- ---------- ---------- ---------- ----------
85415-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
85415-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
85420 $16.00 ---------- ---------- ---------- ---------- ---------- ----------
85420-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
85420-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------
85421 $39.00 ---------- ---------- ---------- ---------- ---------- ----------
85421-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------
85421-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------
85441 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
85441-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------
85441-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------
85445 $16.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 353
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $21.00
85576-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------
85597 $32.00 ---------- ---------- ---------- ---------- ---------- ----------
85597-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
85597-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------
85610 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
85610-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
85610-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------
85611 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
85611-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------
85611-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 354
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 355
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $63.00 $65.00 $67.00 $59.00 $61.00 $62.00
86077-26 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
86077-TC $64.00 ---------- ---------- ---------- ---------- ---------- ----------
86078 $91.00 $63.00 $65.00 $67.00 $58.00 $60.00 $62.00
86078-26 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
86078-TC $64.00 ---------- ---------- ---------- ---------- ---------- ----------
86079 $79.00 $62.00 $65.00 $67.00 $58.00 $60.00 $62.00
86079-26 $25.00 ---------- ---------- ---------- ---------- ---------- ----------
86079-TC $52.00 ---------- ---------- ---------- ---------- ---------- ----------
86140 $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86140-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
86140-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------
86141 BR ---------- ---------- ---------- ---------- ---------- ----------
86141-26 BR ---------- ---------- ---------- ---------- ---------- ----------
86141-TC BR ---------- ---------- ---------- ---------- ---------- ----------
86146 $58.00 ---------- ---------- ---------- ---------- ---------- ----------
86146-26 $19.00 ---------- ---------- ---------- ---------- ---------- ----------
86146-TC $39.00 ---------- ---------- ---------- ---------- ---------- ----------
86147 $53.00 ---------- ---------- ---------- ---------- ---------- ----------
86147-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------
86147-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------
86148 $59.00 ---------- ---------- ---------- ---------- ---------- ----------
86148-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
86148-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------
86153-26 ---------- $38.00 $40.00 $40.00 $38.00 $40.00 $40.00
86155 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
86155-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86155-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
86156 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
86156-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
86156-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86157 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
86157-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
86157-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86160 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 356
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $21.00 $21.00 $20.00 $21.00 $21.00
86255-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------
86256 $25.00 ---------- ---------- ---------- ---------- ---------- ----------
86256-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
86256-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------
86277 $41.00 ---------- ---------- ---------- ---------- ---------- ----------
86277-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86277-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------
86280 $15.00 ---------- ---------- ---------- ---------- ---------- ----------
86280-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
86280-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
86294 BR ---------- ---------- ---------- ---------- ---------- ----------
86294-26 BR ---------- ---------- ---------- ---------- ---------- ----------
86294-TC BR ---------- ---------- ---------- ---------- ---------- ----------
86300 $47.00 ---------- ---------- ---------- ---------- ---------- ----------
86300-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------
86300-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------
86301 $47.00 ---------- ---------- ---------- ---------- ---------- ----------
86301-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------
86301-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 357
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $21.00
86320-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------
86325 $49.00 ---------- ---------- ---------- ---------- ---------- ----------
86325-26 $16.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
86325-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------
86327 $62.00 ---------- ---------- ---------- ---------- ---------- ----------
86327-26 $19.00 $23.00 $24.00 $24.00 $23.00 $24.00 $24.00
86327-TC $42.00 ---------- ---------- ---------- ---------- ---------- ----------
86329 $37.00 ---------- ---------- ---------- ---------- ---------- ----------
86329-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------
86329-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------
86331 $22.00 ---------- ---------- ---------- ---------- ---------- ----------
86331-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86331-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------
86332 $54.00 ---------- ---------- ---------- ---------- ---------- ----------
86332-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
86332-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------
86334 $65.00 ---------- ---------- ---------- ---------- ---------- ----------
86334-26 $18.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
86334-TC $45.00 ---------- ---------- ---------- ---------- ---------- ----------
86335 ---------- BR BR BR BR BR BR
86335-26 ---------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
86335-TC ---------- BR BR BR BR BR BR
86336 BR ---------- ---------- ---------- ---------- ---------- ----------
86336-26 BR ---------- ---------- ---------- ---------- ---------- ----------
86336-TC BR ---------- ---------- ---------- ---------- ---------- ----------
86337 $54.00 ---------- ---------- ---------- ---------- ---------- ----------
86337-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 358
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
86430-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
86430-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86431 $17.00 ---------- ---------- ---------- ---------- ---------- ----------
86431-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86431-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------
86485 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 359
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
86485-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
86485-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86486 ---------- $5.00 $6.00 $6.00 $5.00 $6.00 $6.00
86490 $17.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00
86490-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
86490-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
86510 $13.00 $7.00 $7.00 $8.00 $7.00 $7.00 $8.00
86510-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
86510-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86580 $13.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
86580-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
86580-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86590 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
86590-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86590-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
86592 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86592-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------
86592-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86593 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
86593-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
86593-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86602 $17.00 ---------- ---------- ---------- ---------- ---------- ----------
86602-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
86602-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
86603 $20.00 ---------- ---------- ---------- ---------- ---------- ----------
86603-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86603-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86606 $24.00 ---------- ---------- ---------- ---------- ---------- ----------
86606-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86606-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------
86609 $20.00 ---------- ---------- ---------- ---------- ---------- ----------
86609-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86609-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86611 $23.00 ---------- ---------- ---------- ---------- ---------- ----------
86611-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86611-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------
86612 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
86612-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86612-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------
86615 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
86615-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86615-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------
86617 $29.00 ---------- ---------- ---------- ---------- ---------- ----------
86617-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
86617-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------
86618 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
86618-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
86618-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
86619 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
86619-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 360
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
86654-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86654-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86658 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
86658-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86658-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86663 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 361
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
86695 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
86695-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86695-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86696 $44.00 ---------- ---------- ---------- ---------- ---------- ----------
86696-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86696-TC $30.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 362
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
86723-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86727 $20.00 ---------- ---------- ---------- ---------- ---------- ----------
86727-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
86727-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86729 $19.00 ---------- ---------- ---------- ---------- ---------- ----------
86729-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 363
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
86771-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86771-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------
86774 $23.00 ---------- ---------- ---------- ---------- ---------- ----------
86774-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86774-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------
86777 $22.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 364
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
86777-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86777-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------
86778 $23.00 ---------- ---------- ---------- ---------- ---------- ----------
86778-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
86778-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 365
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 366
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 367
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 368
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 369
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
87164-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------
87166 $24.00 ---------- ---------- ---------- ---------- ---------- ----------
87166-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
87166-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------
87168 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
87168-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
87168-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------
87169 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
87169-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
87169-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------
87172 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
87172-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
87172-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------
87176 $16.00 ---------- ---------- ---------- ---------- ---------- ----------
87176-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
87176-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------
87177 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
87177-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
87177-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
87181 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
87181-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
87181-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
87184 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
87184-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
87184-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------
87185 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 370
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $21.00
87207-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------
87210 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
87210-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------
87210-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------
87220 $12.00 ---------- ---------- ---------- ---------- ---------- ----------
87220-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
87220-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------
87230 $35.00 ---------- ---------- ---------- ---------- ---------- ----------
87230-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
87230-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------
87250 $33.00 ---------- ---------- ---------- ---------- ---------- ----------
87250-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
87250-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------
87252 $44.00 ---------- ---------- ---------- ---------- ---------- ----------
87252-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------
87252-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------
87253 $33.00 ---------- ---------- ---------- ---------- ---------- ----------
87253-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
87253-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------
87254 $11.00 ---------- ---------- ---------- ---------- ---------- ----------
87254-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
87254-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
87255 BR ---------- ---------- ---------- ---------- ---------- ----------
87255-26 BR ---------- ---------- ---------- ---------- ---------- ----------
87255-TC BR ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 371
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 372
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 373
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 374
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 375
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 376
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 377
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
87592 $88.00 ---------- ---------- ---------- ---------- ---------- ----------
87592-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------
87592-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
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 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 378
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 ---------- ---------- ---------- ---------- ---------- ----------
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 $81.00 $85.00 $86.00 $81.00 $85.00 $86.00
88104-26 $37.00 $33.00 $34.00 $34.00 $33.00 $34.00 $34.00
88104-TC $10.00 $48.00 $51.00 $52.00 $48.00 $51.00 $52.00
88106 $54.00 $69.00 $73.00 $74.00 $69.00 $73.00 $74.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 379
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
88106-26 $16.00 $22.00 $23.00 $23.00 $22.00 $23.00 $23.00
88106-TC $38.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00
88108 $59.00 $68.00 $72.00 $73.00 $68.00 $72.00 $73.00
88108-26 $47.00 $26.00 $27.00 $27.00 $26.00 $27.00 $27.00
88108-TC $11.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
88112 ---------- $74.00 $78.00 $79.00 $74.00 $78.00 $79.00
88112-26 ---------- $32.00 $32.00 $33.00 $32.00 $32.00 $33.00
88112-TC ---------- $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
88120 ---------- $677.00 $720.00 $728.00 $677.00 $720.00 $728.00
88120-26 ---------- $66.00 $68.00 $69.00 $66.00 $68.00 $69.00
88120-TC ---------- $611.00 $652.00 $659.00 $611.00 $652.00 $659.00
88121 ---------- $585.00 $622.00 $629.00 $585.00 $622.00 $629.00
88121-26 ---------- $57.00 $58.00 $59.00 $57.00 $58.00 $59.00
88121-TC ---------- $528.00 $564.00 $570.00 $528.00 $564.00 $570.00
88125 $70.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
88125-26 $20.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00
88125-TC $48.00 $8.00 $9.00 $10.00 $8.00 $9.00 $10.00
88130 $25.00 ---------- ---------- ---------- ---------- ---------- ----------
88130-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------
88130-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------
88140 $18.00 ---------- ---------- ---------- ---------- ---------- ----------
88140-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------
88140-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------
88141 $33.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
88141-26 NC BR BR BR BR BR BR
88141-TC NC BR BR BR BR BR BR
88142 $82.00 ---------- ---------- ---------- ---------- ---------- ----------
88142-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
88142-TC $59.00 ---------- ---------- ---------- ---------- ---------- ----------
88143 $94.00 ---------- ---------- ---------- ---------- ---------- ----------
88143-26 $33.00 ---------- ---------- ---------- ---------- ---------- ----------
88143-TC $59.00 ---------- ---------- ---------- ---------- ---------- ----------
88147 $82.00 ---------- ---------- ---------- ---------- ---------- ----------
88147-26 NC BR BR BR BR BR BR
88147-TC $82.00 ---------- ---------- ---------- ---------- ---------- ----------
88148 $104.00 ---------- ---------- ---------- ---------- ---------- ----------
88148-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
88148-TC $82.00 ---------- ---------- ---------- ---------- ---------- ----------
88150 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
88150-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
88150-TC $9.00 ---------- ---------- ---------- ---------- ---------- ----------
88152 $46.00 ---------- ---------- ---------- ---------- ---------- ----------
88152-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------
88152-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------
88153 $82.00 ---------- ---------- ---------- ---------- ---------- ----------
88153-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
88153-TC $59.00 ---------- ---------- ---------- ---------- ---------- ----------
88154 $104.00 ---------- ---------- ---------- ---------- ---------- ----------
88154-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
88154-TC $82.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 380
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
88155 $14.00 ---------- ---------- ---------- ---------- ---------- ----------
88155-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
88155-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------
88160 $45.00 $79.00 $83.00 $84.00 $79.00 $83.00 $84.00
88160-26 $14.00 $30.00 $31.00 $31.00 $30.00 $31.00 $31.00
88160-TC $24.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.00
88161 $64.00 $71.00 $75.00 $76.00 $71.00 $75.00 $76.00
88161-26 $19.00 $29.00 $29.00 $30.00 $29.00 $29.00 $30.00
88161-TC $37.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
88162 $77.00 $108.00 $114.00 $116.00 $108.00 $114.00 $116.00
88162-26 $22.00 $45.00 $46.00 $47.00 $45.00 $46.00 $47.00
88162-TC $53.00 $64.00 $68.00 $70.00 $64.00 $68.00 $70.00
88164 $54.00 ---------- ---------- ---------- ---------- ---------- ----------
88164-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
88164-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------
88165 $72.00 ---------- ---------- ---------- ---------- ---------- ----------
88165-26 $33.00 ---------- ---------- ---------- ---------- ---------- ----------
88165-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------
88166 $82.00 ---------- ---------- ---------- ---------- ---------- ----------
88166-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------
88166-TC $59.00 ---------- ---------- ---------- ---------- ---------- ----------
88167 $87.00 ---------- ---------- ---------- ---------- ---------- ----------
88167-26 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
88167-TC $59.00 ---------- ---------- ---------- ---------- ---------- ----------
88172 $70.00 $63.00 $66.00 $67.00 $63.00 $66.00 $67.00
88172-26 $54.00 $42.00 $43.00 $43.00 $42.00 $43.00 $43.00
88172-TC $14.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.00
88173 $95.00 $167.00 $175.00 $178.00 $167.00 $175.00 $178.00
88173-26 $95.00 $81.00 $83.00 $84.00 $81.00 $83.00 $84.00
88173-TC $26.00 $86.00 $92.00 $94.00 $86.00 $92.00 $94.00
88174 BR ---------- ---------- ---------- ---------- ---------- ----------
88174-26 BR ---------- ---------- ---------- ---------- ---------- ----------
88174-TC BR ---------- ---------- ---------- ---------- ---------- ----------
88175 BR ---------- ---------- ---------- ---------- ---------- ----------
88175-26 BR ---------- ---------- ---------- ---------- ---------- ----------
88175-TC BR ---------- ---------- ---------- ---------- ---------- ----------
88177 ---------- $33.00 $35.00 $35.00 $33.00 $35.00 $35.00
88177-26 ---------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
88177-TC ---------- $8.00 $8.00 $9.00 $8.00 $8.00 $9.00
88182 $88.00 $130.00 $137.00 $139.00 $130.00 $137.00 $139.00
88182-26 $33.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00
88182-TC $54.00 $87.00 $94.00 $95.00 $87.00 $94.00 $95.00
88184 ---------- $65.00 $70.00 $71.00 $65.00 $70.00 $71.00
88185 ---------- $40.00 $42.00 $43.00 $40.00 $42.00 $43.00
88187 ---------- $64.00 $67.00 $69.00 $64.00 $67.00 $69.00
88188 ---------- $82.00 $85.00 $88.00 $82.00 $85.00 $88.00
88189 ---------- $102.00 $105.00 $108.00 $102.00 $105.00 $108.00
88199 BR ---------- ---------- ---------- ---------- ---------- ----------
88199-26 BR ---------- ---------- ---------- ---------- ---------- ----------
88199-TC BR ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 381
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
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 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00
88300-26 $19.00 $5.00 $5.00 $6.00 $5.00 $5.00 $6.00
88300-TC $5.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00
88302 $53.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00
88302-26 $42.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.00
88302-TC $11.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
88304 $70.00 $44.00 $47.00 $48.00 $44.00 $47.00 $48.00
88304-26 $54.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00
88304-TC $14.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.00
88305 $108.00 $75.00 $78.00 $80.00 $75.00 $78.00 $80.00
88305-26 $86.00 $43.00 $45.00 $45.00 $43.00 $45.00 $45.00
88305-TC $21.00 $31.00 $34.00 $34.00 $31.00 $34.00 $34.00
88307 $210.00 $287.00 $304.00 $308.00 $287.00 $304.00 $308.00
88307-26 $168.00 $96.00 $99.00 $100.00 $96.00 $99.00 $100.00
88307-TC $41.00 $192.00 $205.00 $208.00 $192.00 $205.00 $208.00
88309 $322.00 $442.00 $465.00 $472.00 $442.00 $465.00 $472.00
88309-26 $258.00 $169.00 $174.00 $177.00 $169.00 $174.00 $177.00
88309-TC $64.00 $272.00 $291.00 $295.00 $272.00 $291.00 $295.00
88311 $23.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.00
88311-26 $19.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00
88311-TC $4.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
88312 $23.00 $106.00 $112.00 $114.00 $106.00 $112.00 $114.00
88312-26 $7.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.00
88312-TC $16.00 $75.00 $81.00 $82.00 $75.00 $81.00 $82.00
88313 $23.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.00
88313-26 $7.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.00
88313-TC $16.00 $61.00 $66.00 $67.00 $61.00 $66.00 $67.00
88314 $21.00 $84.00 $89.00 $91.00 $84.00 $89.00 $91.00
88314-26 $6.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.00
88314-TC $15.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.00
88319 $26.00 $96.00 $101.00 $103.00 $96.00 $101.00 $103.00
88319-26 $13.00 $31.00 $31.00 $32.00 $31.00 $31.00 $32.00
88319-TC $14.00 $65.00 $70.00 $71.00 $65.00 $70.00 $71.00
88321 $43.00 $114.00 $119.00 $122.00 $97.00 $100.00 $103.00
88321-26 $43.00 ---------- ---------- ---------- ---------- ---------- ----------
88321-TC NC BR BR BR BR BR BR
88323 $61.00 $142.00 $147.00 $149.00 $142.00 $147.00 $149.00
88323-26 $61.00 $99.00 $101.00 $102.00 $99.00 $101.00 $102.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 382
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
88323-TC NC $44.00 $47.00 $47.00 $44.00 $47.00 $47.00
88325 $54.00 $208.00 $217.00 $222.00 $173.00 $179.00 $184.00
88325-26 $54.00 ---------- ---------- ---------- ---------- ---------- ----------
88325-TC NC BR BR BR BR BR BR
88329 $51.00 $58.00 $60.00 $62.00 $42.00 $43.00 $45.00
88329-26 $51.00 ---------- ---------- ---------- ---------- ---------- ----------
88329-TC NC BR BR BR BR BR BR
88331 $102.00 $106.00 $111.00 $113.00 $106.00 $111.00 $113.00
88331-26 $70.00 $72.00 $74.00 $75.00 $72.00 $74.00 $75.00
88331-TC $33.00 $34.00 $37.00 $38.00 $34.00 $37.00 $38.00
88332 $53.00 $58.00 $60.00 $61.00 $58.00 $60.00 $61.00
88332-26 $36.00 $36.00 $36.00 $37.00 $36.00 $36.00 $37.00
88332-TC $17.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00
88333 ---------- $103.00 $107.00 $109.00 $103.00 $107.00 $109.00
88333-26 ---------- $72.00 $74.00 $76.00 $72.00 $74.00 $76.00
88333-TC ---------- $31.00 $33.00 $34.00 $31.00 $33.00 $34.00
88334 ---------- $65.00 $68.00 $69.00 $65.00 $68.00 $69.00
88334-26 ---------- $44.00 $46.00 $46.00 $44.00 $46.00 $46.00
88334-TC ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
88341 ---------- $98.00 $103.00 $105.00 $98.00 $103.00 $105.00
88341-26 ---------- $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
88341-TC ---------- $66.00 $70.00 $71.00 $66.00 $70.00 $71.00
88342 $53.00 $116.00 $122.00 $124.00 $116.00 $122.00 $124.00
88342-26 $36.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.00
88342-TC $17.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.00
88344 ---------- $186.00 $197.00 $199.00 $186.00 $197.00 $199.00
88344-26 ---------- $45.00 $46.00 $47.00 $45.00 $46.00 $47.00
88344-TC ---------- $141.00 $151.00 $152.00 $141.00 $151.00 $152.00
88346 $96.00 $102.00 $108.00 $109.00 $102.00 $108.00 $109.00
88346-26 $66.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.00
88346-TC $28.00 $61.00 $65.00 $66.00 $61.00 $65.00 $66.00
88348 $191.00 $373.00 $396.00 $401.00 $373.00 $396.00 $401.00
88348-26 $145.00 $87.00 $89.00 $90.00 $87.00 $89.00 $90.00
88348-TC $44.00 $286.00 $307.00 $311.00 $286.00 $307.00 $311.00
88350 ---------- $79.00 $83.00 $84.00 $79.00 $83.00 $84.00
88350-26 ---------- $33.00 $34.00 $34.00 $33.00 $34.00 $34.00
88350-TC ---------- $46.00 $50.00 $50.00 $46.00 $50.00 $50.00
88355 $108.00 $156.00 $161.00 $163.00 $156.00 $161.00 $163.00
88355-26 $80.00 $92.00 $94.00 $94.00 $92.00 $94.00 $94.00
88355-TC $26.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00
88356 $108.00 $229.00 $238.00 $241.00 $229.00 $238.00 $241.00
88356-26 $80.00 $137.00 $139.00 $141.00 $137.00 $139.00 $141.00
88356-TC $26.00 $92.00 $99.00 $101.00 $92.00 $99.00 $101.00
88358 $108.00 $98.00 $102.00 $104.00 $98.00 $102.00 $104.00
88358-26 $80.00 $52.00 $53.00 $54.00 $52.00 $53.00 $54.00
88358-TC $26.00 $45.00 $49.00 $49.00 $45.00 $49.00 $49.00
88360 ---------- $152.00 $160.00 $162.00 $152.00 $160.00 $162.00
88360-26 ---------- $63.00 $64.00 $65.00 $63.00 $64.00 $65.00
88360-TC ---------- $89.00 $95.00 $97.00 $89.00 $95.00 $97.00
88361 ---------- $168.00 $176.00 $179.00 $168.00 $176.00 $179.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 383
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
88361-26 ---------- $67.00 $68.00 $70.00 $67.00 $68.00 $70.00
88361-TC ---------- $101.00 $108.00 $109.00 $101.00 $108.00 $109.00
88362 BR $252.00 $264.00 $268.00 $252.00 $264.00 $268.00
88362-26 BR $125.00 $129.00 $131.00 $125.00 $129.00 $131.00
88362-TC BR $127.00 $136.00 $138.00 $127.00 $136.00 $138.00
88363 ---------- $26.00 $27.00 $28.00 $22.00 $23.00 $24.00
88364 ---------- $142.00 $150.00 $152.00 $142.00 $150.00 $152.00
88364-26 ---------- $40.00 $41.00 $42.00 $40.00 $41.00 $42.00
88364-TC ---------- $102.00 $109.00 $110.00 $102.00 $109.00 $110.00
88365 $24.00 $191.00 $202.00 $205.00 $191.00 $202.00 $205.00
88365-26 $24.00 $51.00 $52.00 $53.00 $51.00 $52.00 $53.00
88365-TC BR $141.00 $150.00 $152.00 $141.00 $150.00 $152.00
88366 ---------- $276.00 $292.00 $296.00 $276.00 $292.00 $296.00
88366-26 ---------- $71.00 $73.00 $74.00 $71.00 $73.00 $74.00
88366-TC ---------- $205.00 $220.00 $222.00 $205.00 $220.00 $222.00
88367 ---------- $114.00 $120.00 $122.00 $114.00 $120.00 $122.00
88367-26 ---------- $40.00 $40.00 $41.00 $40.00 $40.00 $41.00
88367-TC ---------- $75.00 $80.00 $81.00 $75.00 $80.00 $81.00
88368 ---------- $126.00 $133.00 $134.00 $126.00 $133.00 $134.00
88368-26 ---------- $46.00 $47.00 $48.00 $46.00 $47.00 $48.00
88368-TC ---------- $80.00 $86.00 $87.00 $80.00 $86.00 $87.00
88369 ---------- $115.00 $122.00 $123.00 $115.00 $122.00 $123.00
88369-26 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
88369-TC ---------- $79.00 $85.00 $86.00 $79.00 $85.00 $86.00
88371 $34.00 ---------- ---------- ---------- ---------- ---------- ----------
88371-26 $10.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
88371-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------
88372 $38.00 ---------- ---------- ---------- ---------- ---------- ----------
88372-26 $11.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
88372-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------
88373 ---------- $85.00 $90.00 $91.00 $85.00 $90.00 $91.00
88373-26 ---------- $31.00 $32.00 $32.00 $31.00 $32.00 $32.00
88373-TC ---------- $54.00 $58.00 $58.00 $54.00 $58.00 $58.00
88374 ---------- $363.00 $386.00 $390.00 $363.00 $386.00 $390.00
88374-26 ---------- $51.00 $52.00 $53.00 $51.00 $52.00 $53.00
88374-TC ---------- $313.00 $334.00 $338.00 $313.00 $334.00 $338.00
88375 ---------- $52.00 $53.00 $55.00 $52.00 $53.00 $55.00
88377 ---------- $434.00 $461.00 $466.00 $434.00 $461.00 $466.00
88377-26 ---------- $73.00 $74.00 $75.00 $73.00 $74.00 $75.00
88377-TC ---------- $361.00 $386.00 $391.00 $361.00 $386.00 $391.00
88380 BR $148.00 $156.00 $158.00 $148.00 $156.00 $158.00
88380-26 BR $63.00 $64.00 $65.00 $63.00 $64.00 $65.00
88380-TC BR $86.00 $92.00 $93.00 $86.00 $92.00 $93.00
88381 ---------- $131.00 $139.00 $141.00 $131.00 $139.00 $141.00
88381-26 ---------- $29.00 $29.00 $30.00 $29.00 $29.00 $30.00
88381-TC ---------- $102.00 $109.00 $111.00 $102.00 $109.00 $111.00
88387 ---------- $42.00 $44.00 $45.00 $42.00 $44.00 $45.00
88387-26 ---------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
88387-TC ---------- $8.00 $9.00 $9.00 $8.00 $9.00 $9.00
88388 ---------- $38.00 $40.00 $41.00 $38.00 $40.00 $41.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 384
Pathology & Laboratory
CPT Code 2003 MRALocality 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)
88388-26 ---------- $27.00 $28.00 $29.00 $27.00 $28.00 $29.00
88388-TC ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
88399 BR ---------- ---------- ---------- ---------- ---------- ----------
88399-26 BR ---------- ---------- ---------- ---------- ---------- ----------
88399-TC BR ---------- ---------- ---------- ---------- ---------- ----------
89049 ---------- $289.00 $306.00 $312.00 $75.00 $77.00 $81.00
89050 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
89050-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
89050-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------
89051 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
89051-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
89051-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
89055 BR ---------- ---------- ---------- ---------- ---------- ----------
89055-26 BR ---------- ---------- ---------- ---------- ---------- ----------
89055-TC BR ---------- ---------- ---------- ---------- ---------- ----------
89060 $13.00 ---------- ---------- ---------- ---------- ---------- ----------
89060-26 $5.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
89060-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------
89125 $14.00 ---------- ---------- ---------- ---------- ---------- ----------
89125-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
89125-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------
89160 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
89160-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------
89160-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------
89190 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
89190-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------
89190-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------
89220 ---------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.00
89230 ---------- $5.00 $5.00 $5.00 $5.00 $5.00 $5.00
G0124 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
G0141 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
G0416 ---------- $524.00 $552.00 $559.00 $524.00 $552.00 $559.00
G0416-26 ---------- $203.00 $209.00 $212.00 $203.00 $209.00 $212.00
G0416-TC ---------- $321.00 $343.00 $347.00 $321.00 $343.00 $347.00
G0452-26 ---------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
G0455 ---------- $142.00 $150.00 $156.00 $84.00 $89.00 $94.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 385
Medicine
CPT Code 2003 MRALocality 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)
90460 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
90461 ---------- $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
90471 $4.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
90472 $4.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
90473 BR $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
90474 BR $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
90632 BR ---------- ---------- ---------- ---------- ---------- ----------
90636 BR ---------- ---------- ---------- ---------- ---------- ----------
90675 BR ---------- ---------- ---------- ---------- ---------- ----------
90746 BR ---------- ---------- ---------- ---------- ---------- ----------
90749 BR ---------- ---------- ---------- ---------- ---------- ----------
90785 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00
90791 ---------- $146.00 $149.00 $153.00 $141.00 $144.00 $148.00
90792 ---------- $164.00 $168.00 $173.00 $159.00 $163.00 $168.00
90832 ---------- $71.00 $72.00 $74.00 $70.00 $72.00 $73.00
90833 ---------- $74.00 $76.00 $78.00 $73.00 $75.00 $77.00
90834 ---------- $94.00 $96.00 $99.00 $94.00 $95.00 $98.00
90836 ---------- $93.00 $95.00 $98.00 $92.00 $95.00 $97.00
90837 ---------- $142.00 $145.00 $148.00 $141.00 $144.00 $147.00
90838 ---------- $123.00 $126.00 $130.00 $122.00 $125.00 $129.00
90839 ---------- $148.00 $151.00 $154.00 $147.00 $150.00 $153.00
90840 ---------- $71.00 $72.00 $74.00 $70.00 $72.00 $73.00
90845 $85.00 $101.00 $104.00 $106.00 $101.00 $103.00 $106.00
90846 $93.00 $114.00 $117.00 $120.00 $113.00 $116.00 $119.00
90847 $110.00 $119.00 $121.00 $124.00 $118.00 $120.00 $123.00
90849 $32.00 $38.00 $40.00 $41.00 $35.00 $36.00 $37.00
90853 $32.00 $28.00 $29.00 $30.00 $28.00 $29.00 $29.00
90865 $143.00 $184.00 $191.00 $195.00 $143.00 $147.00 $150.00
90870 $94.00 $194.00 $202.00 $206.00 $124.00 $127.00 $130.00
90875 $74.00 $69.00 $71.00 $73.00 $68.00 $71.00 $73.00
90876 $112.00 $120.00 $125.00 $128.00 $108.00 $112.00 $116.00
90880 $112.00 $113.00 $115.00 $118.00 $104.00 $106.00 $109.00
90882 $104.00 ---------- ---------- ---------- ---------- ---------- ----------
90885 $49.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.00
90887 $77.00 $98.00 $102.00 $105.00 $85.00 $88.00 $91.00
90889 BR ---------- ---------- ---------- ---------- ---------- ----------
90899 BR ---------- ---------- ---------- ---------- ---------- ----------
90901 $46.00 $40.00 $42.00 $43.00 $22.00 $22.00 $23.00
90911 $82.00 $93.00 $97.00 $100.00 $50.00 $52.00 $54.00
90935 $76.00 $81.00 $83.00 $86.00 $81.00 $83.00 $86.00
90937 $226.00 $116.00 $120.00 $124.00 $116.00 $120.00 $124.00
90940 BR ---------- ---------- ---------- ---------- ---------- ----------
90945 $80.00 $95.00 $99.00 $102.00 $95.00 $99.00 $102.00
90947 $125.00 $139.00 $143.00 $148.00 $139.00 $143.00 $148.00
90951 ---------- $1,055.00 $1,092.00 $1,130.00 $1,055.00 $1,092.00 $1,130.00
90954 ---------- $911.00 $943.00 $975.00 $911.00 $943.00 $975.00
90955 ---------- $512.00 $530.00 $548.00 $512.00 $530.00 $548.00
90956 ---------- $355.00 $368.00 $380.00 $355.00 $368.00 $380.00
90957 ---------- $719.00 $744.00 $769.00 $719.00 $744.00 $769.00
90958 ---------- $486.00 $503.00 $519.00 $486.00 $503.00 $519.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 386
Medicine
CPT Code 2003 MRALocality 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)
90959 ---------- $330.00 $342.00 $352.00 $330.00 $342.00 $352.00
90960 ---------- $315.00 $327.00 $337.00 $315.00 $327.00 $337.00
90961 ---------- $265.00 $275.00 $283.00 $265.00 $275.00 $283.00
90962 ---------- $204.00 $211.00 $218.00 $204.00 $211.00 $218.00
90963 ---------- $608.00 $629.00 $650.00 $608.00 $629.00 $650.00
90964 ---------- $532.00 $551.00 $569.00 $532.00 $551.00 $569.00
90965 ---------- $506.00 $524.00 $541.00 $506.00 $524.00 $541.00
90966 ---------- $264.00 $273.00 $282.00 $264.00 $273.00 $282.00
90967 ---------- $20.00 $21.00 $22.00 $20.00 $21.00 $22.00
90968 ---------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.00
90969 ---------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.00
90970 ---------- $9.00 $9.00 $9.00 $9.00 $9.00 $9.00
90997 $115.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.00
90999 BR ---------- ---------- ---------- ---------- ---------- ----------
91010 $116.00 $191.00 $202.00 $206.00 $191.00 $202.00 $206.00
91010-26 $76.00 $76.00 $78.00 $81.00 $76.00 $78.00 $81.00
91010-TC $32.00 $116.00 $124.00 $125.00 $116.00 $124.00 $125.00
91013 ---------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
91013-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
91013-TC ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00
91020 $60.00 $252.00 $266.00 $271.00 $252.00 $266.00 $271.00
91020-26 $49.00 $84.00 $86.00 $88.00 $84.00 $86.00 $88.00
91020-TC $9.00 $168.00 $180.00 $182.00 $168.00 $180.00 $182.00
91022 ---------- $182.00 $192.00 $195.00 $182.00 $192.00 $195.00
91022-26 ---------- $84.00 $87.00 $89.00 $84.00 $87.00 $89.00
91022-TC ---------- $98.00 $105.00 $106.00 $98.00 $105.00 $106.00
91030 $57.00 $145.00 $153.00 $156.00 $145.00 $153.00 $156.00
91030-26 $47.00 $52.00 $54.00 $55.00 $52.00 $54.00 $55.00
91030-TC $8.00 $93.00 $99.00 $101.00 $93.00 $99.00 $101.00
91034 ---------- $203.00 $216.00 $220.00 $203.00 $216.00 $220.00
91034-26 ---------- $57.00 $60.00 $62.00 $57.00 $60.00 $62.00
91034-TC ---------- $146.00 $156.00 $158.00 $146.00 $156.00 $158.00
91035 ---------- $516.00 $549.00 $557.00 $516.00 $549.00 $557.00
91035-26 ---------- $95.00 $98.00 $102.00 $95.00 $98.00 $102.00
91035-TC ---------- $421.00 $450.00 $455.00 $421.00 $450.00 $455.00
91037 ---------- $173.00 $183.00 $186.00 $173.00 $183.00 $186.00
91037-26 ---------- $57.00 $59.00 $60.00 $57.00 $59.00 $60.00
91037-TC ---------- $116.00 $124.00 $126.00 $116.00 $124.00 $126.00
91038 ---------- $480.00 $511.00 $518.00 $480.00 $511.00 $518.00
91038-26 ---------- $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
91038-TC ---------- $416.00 $444.00 $449.00 $416.00 $444.00 $449.00
91040 ---------- $457.00 $486.00 $492.00 $457.00 $486.00 $492.00
91040-26 ---------- $56.00 $58.00 $59.00 $56.00 $58.00 $59.00
91040-TC ---------- $401.00 $428.00 $432.00 $401.00 $428.00 $432.00
91065 $34.00 $80.00 $85.00 $87.00 $80.00 $85.00 $87.00
91065-26 $23.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
91065-TC $14.00 $69.00 $74.00 $75.00 $69.00 $74.00 $75.00
91110 ---------- $907.00 $963.00 $975.00 $907.00 $963.00 $975.00
91110-26 ---------- $171.00 $177.00 $181.00 $171.00 $177.00 $181.00
91110-TC ---------- $736.00 $786.00 $794.00 $736.00 $786.00 $794.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 387
Medicine
CPT Code 2003 MRALocality 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)
91111 ---------- $794.00 $847.00 $856.00 $794.00 $847.00 $856.00
91111-26 ---------- $59.00 $61.00 $62.00 $59.00 $61.00 $62.00
91111-TC ---------- $736.00 $786.00 $794.00 $736.00 $786.00 $794.00
91112 ---------- $1,151.00 $1,225.00 $1,239.00 $1,151.00 $1,225.00 $1,239.00
91112-26 ---------- $123.00 $127.00 $130.00 $123.00 $127.00 $130.00
91112-TC ---------- $1,028.00 $1,098.00 $1,109.00 $1,028.00 $1,098.00 $1,109.00
91117 ---------- $157.00 $164.00 $169.00 $157.00 $164.00 $169.00
91120 ---------- $456.00 $486.00 $492.00 $456.00 $486.00 $492.00
91120-26 ---------- $57.00 $59.00 $61.00 $57.00 $59.00 $61.00
91120-TC ---------- $399.00 $427.00 $431.00 $399.00 $427.00 $431.00
91122 $169.00 $250.00 $264.00 $270.00 $250.00 $264.00 $270.00
91122-26 $122.00 $103.00 $107.00 $111.00 $103.00 $107.00 $111.00
91122-TC $37.00 $147.00 $157.00 $159.00 $147.00 $157.00 $159.00
91132 BR $158.00 $168.00 $170.00 $158.00 $168.00 $170.00
91132-26 $28.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
91132-TC BR $128.00 $137.00 $139.00 $128.00 $137.00 $139.00
91133 BR $185.00 $196.00 $199.00 $185.00 $196.00 $199.00
91133-26 $34.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.00
91133-TC BR $146.00 $156.00 $158.00 $146.00 $156.00 $158.00
91200 ---------- $42.00 $44.00 $45.00 $42.00 $44.00 $45.00
91200-26 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00
91200-TC ---------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
91299 BR ---------- ---------- ---------- ---------- ---------- ----------
91299-26 BR ---------- ---------- ---------- ---------- ---------- ----------
91299-TC BR ---------- ---------- ---------- ---------- ---------- ----------
92002 $63.00 $88.00 $92.00 $94.00 $53.00 $55.00 $56.00
92004 $98.00 $163.00 $170.00 $173.00 $111.00 $115.00 $117.00
92012 $53.00 $93.00 $98.00 $99.00 $59.00 $61.00 $62.00
92014 $75.00 $135.00 $141.00 $144.00 $89.00 $92.00 $94.00
92015 $34.00 $22.00 $23.00 $24.00 $22.00 $22.00 $23.00
92018 $80.00 $161.00 $167.00 $171.00 $161.00 $167.00 $171.00
92019 $70.00 $81.00 $83.00 $85.00 $81.00 $83.00 $85.00
92020 $31.00 $29.00 $31.00 $31.00 $23.00 $24.00 $25.00
92025 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
92025-26 ---------- $22.00 $23.00 $23.00 $22.00 $23.00 $23.00
92025-TC ---------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
92060 $40.00 $71.00 $74.00 $75.00 $71.00 $74.00 $75.00
92060-26 $32.00 $42.00 $44.00 $44.00 $42.00 $44.00 $44.00
92060-TC $7.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00
92065 $34.00 $59.00 $62.00 $63.00 $59.00 $62.00 $63.00
92065-26 $19.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
92065-TC $6.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
92071 ---------- $42.00 $43.00 $44.00 $37.00 $38.00 $39.00
92072 ---------- $148.00 $153.00 $156.00 $114.00 $118.00 $120.00
92081 $32.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
92081-26 $19.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.00
92081-TC $6.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
92082 $48.00 $53.00 $55.00 $56.00 $53.00 $55.00 $56.00
92082-26 $24.00 $24.00 $25.00 $25.00 $24.00 $25.00 $25.00
92082-TC $9.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 388
Medicine
CPT Code 2003 MRALocality 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)
92083 $59.00 $70.00 $74.00 $75.00 $70.00 $74.00 $75.00
92083-26 $31.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.00
92083-TC $14.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.00
92100 $40.00 $87.00 $91.00 $92.00 $38.00 $39.00 $40.00
92132 ---------- $34.00 $36.00 $37.00 $34.00 $36.00 $37.00
92132-26 ---------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.00
92132-TC ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00
92133 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
92133-26 ---------- $25.00 $26.00 $26.00 $25.00 $26.00 $26.00
92133-TC ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
92134 ---------- $45.00 $47.00 $48.00 $45.00 $47.00 $48.00
92134-26 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
92134-TC ---------- $16.00 $18.00 $18.00 $16.00 $18.00 $18.00
92136 $93.00 $97.00 $103.00 $104.00 $97.00 $103.00 $104.00
92136-26 $29.00 $35.00 $36.00 $36.00 $35.00 $36.00 $36.00
92136-TC $63.00 $62.00 $67.00 $68.00 $62.00 $67.00 $68.00
92145 ---------- $20.00 $21.00 $22.00 $20.00 $21.00 $22.00
92145-26 ---------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.00
92145-TC ---------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
92225 $45.00 $29.00 $31.00 $31.00 $24.00 $25.00 $25.00
92226 $39.00 $27.00 $28.00 $29.00 $21.00 $22.00 $22.00
92227 ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00
92228 ---------- $38.00 $40.00 $41.00 $38.00 $40.00 $41.00
92228-26 ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
92228-TC ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00
92230 $58.00 $63.00 $66.00 $67.00 $37.00 $38.00 $39.00
92235 $104.00 $93.00 $98.00 $99.00 $93.00 $98.00 $99.00
92235-26 $46.00 $48.00 $49.00 $50.00 $48.00 $49.00 $50.00
92235-TC $53.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.00
92240 $132.00 $223.00 $237.00 $240.00 $223.00 $237.00 $240.00
92240-26 $60.00 $52.00 $53.00 $54.00 $52.00 $53.00 $54.00
92240-TC $67.00 $172.00 $184.00 $186.00 $172.00 $184.00 $186.00
92242 ---------- $244.00 $258.00 $261.00 $244.00 $258.00 $261.00
92242-26 ---------- $61.00 $63.00 $64.00 $61.00 $63.00 $64.00
92242-TC ---------- $182.00 $195.00 $197.00 $182.00 $195.00 $197.00
92250 $40.00 $71.00 $75.00 $76.00 $71.00 $75.00 $76.00
92250-26 $24.00 $24.00 $25.00 $25.00 $24.00 $25.00 $25.00
92250-TC $7.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00
92260 $20.00 $20.00 $21.00 $22.00 $12.00 $13.00 $13.00
92265 $53.00 $93.00 $97.00 $98.00 $93.00 $97.00 $98.00
92265-26 $37.00 $51.00 $53.00 $53.00 $51.00 $53.00 $53.00
92265-TC $10.00 $41.00 $44.00 $45.00 $41.00 $44.00 $45.00
92270 $64.00 $100.00 $105.00 $106.00 $100.00 $105.00 $106.00
92270-26 $45.00 $45.00 $47.00 $47.00 $45.00 $47.00 $47.00
92270-TC $19.00 $54.00 $58.00 $59.00 $54.00 $58.00 $59.00
92275 $80.00 $161.00 $169.00 $171.00 $161.00 $169.00 $171.00
92275-26 $56.00 $60.00 $62.00 $62.00 $60.00 $62.00 $62.00
92275-TC $17.00 $101.00 $108.00 $109.00 $101.00 $108.00 $109.00
92283 $24.00 $60.00 $64.00 $65.00 $60.00 $64.00 $65.00
92283-26 $10.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 389
Medicine
CPT Code 2003 MRALocality 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)
92283-TC $5.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.00
92284 $192.00 $68.00 $72.00 $73.00 $68.00 $72.00 $73.00
92284-26 $151.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
92284-TC $46.00 $53.00 $57.00 $58.00 $53.00 $57.00 $58.00
92285 $26.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
92285-26 $12.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00
92285-TC $6.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
92286 $91.00 $42.00 $44.00 $45.00 $42.00 $44.00 $45.00
92286-26 $53.00 $25.00 $25.00 $26.00 $25.00 $25.00 $26.00
92286-TC $29.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.00
92287 $99.00 $149.00 $157.00 $159.00 $149.00 $157.00 $159.00
92287-26 ---------- $52.00 $53.00 $54.00 $52.00 $53.00 $54.00
92287-TC ---------- $97.00 $104.00 $105.00 $97.00 $104.00 $105.00
92310 $86.00 $105.00 $110.00 $113.00 $67.00 $69.00 $71.00
92311 $78.00 $110.00 $115.00 $117.00 $62.00 $64.00 $65.00
92312 $89.00 $128.00 $134.00 $136.00 $72.00 $74.00 $75.00
92313 $70.00 $105.00 $110.00 $111.00 $53.00 $54.00 $55.00
92314 $54.00 $87.00 $91.00 $93.00 $40.00 $41.00 $42.00
92315 $44.00 $80.00 $84.00 $86.00 $25.00 $26.00 $26.00
92316 $59.00 $100.00 $106.00 $107.00 $37.00 $38.00 $39.00
92317 $39.00 $82.00 $87.00 $88.00 $26.00 $27.00 $28.00
92325 $14.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.00
92326 $44.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.00
92340 $32.00 $39.00 $41.00 $41.00 $21.00 $22.00 $22.00
92341 $43.00 $44.00 $46.00 $48.00 $27.00 $28.00 $29.00
92342 $43.00 $48.00 $50.00 $51.00 $30.00 $31.00 $32.00
92358 $24.00 $12.00 $13.00 $14.00 $12.00 $13.00 $14.00
92370 $35.00 $34.00 $35.00 $36.00 $18.00 $19.00 $20.00
92371 $18.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00
92499 BR ---------- ---------- ---------- ---------- ---------- ----------
92499-26 BR ---------- ---------- ---------- ---------- ---------- ----------
92499-TC BR ---------- ---------- ---------- ---------- ---------- ----------
92502 $101.00 $108.00 $112.00 $116.00 $108.00 $112.00 $116.00
92504 $24.00 $32.00 $34.00 $35.00 $11.00 $11.00 $11.00
92507 $40.00 $87.00 $90.00 $92.00 $87.00 $90.00 $92.00
92508 $42.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
92511 $81.00 $119.00 $126.00 $129.00 $42.00 $44.00 $46.00
92512 $46.00 $66.00 $70.00 $71.00 $32.00 $33.00 $35.00
92516 $36.00 $76.00 $80.00 $81.00 $26.00 $27.00 $28.00
92520 $47.00 $83.00 $87.00 $90.00 $46.00 $48.00 $50.00
92521 ---------- $123.00 $127.00 $130.00 $123.00 $127.00 $130.00
92522 ---------- $102.00 $106.00 $108.00 $102.00 $106.00 $108.00
92523 ---------- $216.00 $225.00 $229.00 $216.00 $225.00 $229.00
92524 ---------- $98.00 $102.00 $104.00 $98.00 $102.00 $104.00
92526 $48.00 $95.00 $98.00 $100.00 $95.00 $98.00 $100.00
92531 $10.00 ---------- ---------- ---------- ---------- ---------- ----------
92532 $14.00 ---------- ---------- ---------- ---------- ---------- ----------
92533 $41.00 ---------- ---------- ---------- ---------- ---------- ----------
92534 BR ---------- ---------- ---------- ---------- ---------- ----------
92537 ---------- $45.00 $46.00 $47.00 $45.00 $46.00 $47.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 390
Medicine
CPT Code 2003 MRALocality 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)
92537-26 ---------- $35.00 $36.00 $37.00 $35.00 $36.00 $37.00
92537-TC ---------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
92538 ---------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.00
92538-26 ---------- $18.00 $18.00 $19.00 $18.00 $18.00 $19.00
92538-TC ---------- $5.00 $6.00 $6.00 $5.00 $6.00 $6.00
92540 ---------- $113.00 $117.00 $119.00 $113.00 $117.00 $119.00
92540-26 ---------- $89.00 $91.00 $93.00 $89.00 $91.00 $93.00
92540-TC ---------- $24.00 $26.00 $26.00 $24.00 $26.00 $26.00
92541 $37.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00
92541-26 $25.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
92541-TC $9.00 $4.00 $4.00 $5.00 $4.00 $4.00 $5.00
92542 $33.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
92542-26 $20.00 $28.00 $29.00 $29.00 $28.00 $29.00 $29.00
92542-TC $10.00 $3.00 $4.00 $4.00 $3.00 $4.00 $4.00
92544 $26.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.00
92544-26 $16.00 $16.00 $17.00 $17.00 $16.00 $17.00 $17.00
92544-TC $8.00 $3.00 $3.00 $3.00 $3.00 $3.00 $3.00
92545 $22.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.00
92545-26 $14.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00
92545-TC $8.00 $2.00 $3.00 $3.00 $2.00 $3.00 $3.00
92546 $29.00 $110.00 $118.00 $119.00 $110.00 $118.00 $119.00
92546-26 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00
92546-TC $9.00 $94.00 $101.00 $102.00 $94.00 $101.00 $102.00
92547 $21.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00
92548 $92.00 $107.00 $114.00 $116.00 $107.00 $114.00 $116.00
92548-26 $30.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.00
92548-TC $59.00 $78.00 $84.00 $85.00 $78.00 $84.00 $85.00
92550 ---------- $24.00 $24.00 $25.00 $24.00 $24.00 $25.00
92551 $17.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00
92552 $16.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00
92553 $24.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.00
92555 $14.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
92556 $21.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
92557 $46.00 $42.00 $44.00 $45.00 $37.00 $38.00 $39.00
92560 $23.00 ---------- ---------- ---------- ---------- ---------- ----------
92561 $27.00 $41.00 $45.00 $46.00 $41.00 $45.00 $46.00
92562 $15.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.00
92563 $14.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00
92564 $17.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
92565 $15.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.00
92567 $20.00 $16.00 $17.00 $17.00 $12.00 $13.00 $13.00
92568 $14.00 $18.00 $18.00 $19.00 $17.00 $18.00 $19.00
92570 ---------- $36.00 $37.00 $38.00 $33.00 $35.00 $36.00
92571 $14.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
92572 $3.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00
92575 $11.00 $63.00 $67.00 $68.00 $63.00 $67.00 $68.00
92576 $17.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.00
92577 $28.00 $16.00 $18.00 $18.00 $16.00 $18.00 $18.00
92579 $28.00 $50.00 $52.00 $53.00 $43.00 $44.00 $45.00
92582 $28.00 $72.00 $77.00 $78.00 $72.00 $77.00 $78.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 391
Medicine
CPT Code 2003 MRALocality 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)
92583 $34.00 $54.00 $58.00 $58.00 $54.00 $58.00 $58.00
92584 $94.00 $79.00 $84.00 $86.00 $79.00 $84.00 $86.00
92585 $114.00 $146.00 $155.00 $158.00 $146.00 $155.00 $158.00
92585-26 $52.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
92585-TC $70.00 $116.00 $124.00 $126.00 $116.00 $124.00 $126.00
92586 $70.00 $92.00 $99.00 $100.00 $92.00 $99.00 $100.00
92587 $58.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
92587-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
92587-TC $49.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00
92588 $78.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.00
92588-26 $20.00 $33.00 $34.00 $34.00 $33.00 $34.00 $34.00
92588-TC $57.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.00
92590 $41.00 ---------- ---------- ---------- ---------- ---------- ----------
92591 BR ---------- ---------- ---------- ---------- ---------- ----------
92592 BR ---------- ---------- ---------- ---------- ---------- ----------
92593 BR ---------- ---------- ---------- ---------- ---------- ----------
92594 BR ---------- ---------- ---------- ---------- ---------- ----------
92595 BR ---------- ---------- ---------- ---------- ---------- ----------
92596 $22.00 $44.00 $48.00 $49.00 $44.00 $48.00 $49.00
92597 $96.00 $81.00 $84.00 $86.00 $81.00 $84.00 $86.00
92603 $88.00 $168.00 $174.00 $178.00 $136.00 $141.00 $144.00
92604 $60.00 $99.00 $103.00 $105.00 $76.00 $78.00 $80.00
92605 BR $104.00 $108.00 $111.00 $100.00 $103.00 $106.00
92606 BR $92.00 $96.00 $99.00 $80.00 $83.00 $85.00
92607 $109.00 $141.00 $146.00 $149.00 $141.00 $146.00 $149.00
92608 $22.00 $58.00 $61.00 $62.00 $58.00 $61.00 $62.00
92609 $59.00 $121.00 $126.00 $128.00 $121.00 $126.00 $128.00
92610 $42.00 $95.00 $99.00 $101.00 $81.00 $84.00 $86.00
92611 $46.00 $96.00 $100.00 $103.00 $96.00 $100.00 $103.00
92612 $173.00 $204.00 $215.00 $219.00 $77.00 $80.00 $83.00
92613 BR $43.00 $45.00 $47.00 $43.00 $45.00 $47.00
92614 $134.00 $158.00 $166.00 $170.00 $75.00 $78.00 $81.00
92615 BR $38.00 $39.00 $40.00 $38.00 $39.00 $40.00
92616 $183.00 $226.00 $238.00 $243.00 $113.00 $118.00 $122.00
92617 BR $47.00 $49.00 $50.00 $47.00 $49.00 $50.00
92618 ---------- $38.00 $39.00 $41.00 $37.00 $39.00 $40.00
92620 ---------- $105.00 $109.00 $111.00 $92.00 $95.00 $97.00
92621 ---------- $25.00 $25.00 $26.00 $21.00 $22.00 $22.00
92625 ---------- $78.00 $81.00 $83.00 $70.00 $72.00 $74.00
92626 ---------- $99.00 $103.00 $105.00 $85.00 $88.00 $90.00
92627 ---------- $25.00 $25.00 $26.00 $20.00 $21.00 $21.00
92640 ---------- $123.00 $128.00 $131.00 $107.00 $110.00 $113.00
92700 BR ---------- ---------- ---------- ---------- ---------- ----------
92920 ---------- $635.00 $681.00 $751.00 $635.00 $681.00 $751.00
92924 ---------- $759.00 $814.00 $898.00 $759.00 $814.00 $898.00
92928 ---------- $707.00 $759.00 $837.00 $707.00 $759.00 $837.00
92933 ---------- $794.00 $851.00 $939.00 $794.00 $851.00 $939.00
92937 ---------- $707.00 $758.00 $836.00 $707.00 $758.00 $836.00
92941 ---------- $795.00 $853.00 $941.00 $795.00 $853.00 $941.00
92943 ---------- $794.00 $852.00 $939.00 $794.00 $852.00 $939.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 392
Medicine
CPT Code 2003 MRALocality 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)
92950 $203.00 $337.00 $354.00 $367.00 $214.00 $223.00 $234.00
92953 $35.00 $1.00 $1.00 $2.00 $1.00 $1.00 $2.00
92960 $162.00 $175.00 $183.00 $189.00 $124.00 $129.00 $134.00
92961 $239.00 $295.00 $315.00 $345.00 $295.00 $315.00 $345.00
92970 $201.00 $215.00 $226.00 $240.00 $215.00 $226.00 $240.00
92971 $100.00 $120.00 $129.00 $141.00 $120.00 $129.00 $141.00
92973 $174.00 $211.00 $226.00 $249.00 $211.00 $226.00 $249.00
92974 $197.00 $194.00 $208.00 $230.00 $194.00 $208.00 $230.00
92975 $400.00 $450.00 $483.00 $532.00 $450.00 $483.00 $532.00
92977 $302.00 $75.00 $82.00 $85.00 $75.00 $82.00 $85.00
92978 $269.00 ---------- ---------- ---------- ---------- ---------- ----------
92978-26 $95.00 $113.00 $121.00 $132.00 $113.00 $121.00 $132.00
92978-TC $170.00 ---------- ---------- ---------- ---------- ---------- ----------
92979 $163.00 ---------- ---------- ---------- ---------- ---------- ----------
92979-26 $76.00 $91.00 $97.00 $106.00 $91.00 $97.00 $106.00
92979-TC $86.00 ---------- ---------- ---------- ---------- ---------- ----------
92986 $1,222.00 $1,566.00 $1,679.00 $1,841.00 $1,566.00 $1,679.00 $1,841.00
92987 $1,271.00 $1,616.00 $1,732.00 $1,898.00 $1,616.00 $1,732.00 $1,898.00
92990 $974.00 $1,288.00 $1,381.00 $1,515.00 $1,288.00 $1,381.00 $1,515.00
92992 BR ---------- ---------- ---------- ---------- ---------- ----------
92993 BR ---------- ---------- ---------- ---------- ---------- ----------
92997 $765.00 $768.00 $819.00 $893.00 $768.00 $819.00 $893.00
92998 $331.00 $379.00 $403.00 $438.00 $379.00 $403.00 $438.00
93000 $26.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
93005 $16.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
93010 $12.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00
93015 $104.00 $83.00 $88.00 $89.00 $83.00 $88.00 $89.00
93016 $25.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.00
93017 $63.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
93018 $54.00 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00
93024 $111.00 $122.00 $128.00 $131.00 $122.00 $128.00 $131.00
93024-26 $71.00 $64.00 $65.00 $67.00 $64.00 $65.00 $67.00
93024-TC $42.00 $58.00 $63.00 $64.00 $58.00 $63.00 $64.00
93025 $277.00 $176.00 $186.00 $189.00 $176.00 $186.00 $189.00
93025-26 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
93025-TC ---------- $134.00 $143.00 $145.00 $134.00 $143.00 $145.00
93040 $14.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.00
93041 $31.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00
93042 $9.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.00
93050 ---------- $19.00 $21.00 $21.00 $19.00 $21.00 $21.00
93050-26 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
93050-TC ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
93224 $159.00 $99.00 $105.00 $107.00 $99.00 $105.00 $107.00
93225 $46.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00
93226 $83.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
93227 $50.00 $30.00 $31.00 $31.00 $30.00 $31.00 $31.00
93228 ---------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.00
93229 ---------- $767.00 $820.00 $830.00 $767.00 $820.00 $830.00
93260 ---------- $72.00 $75.00 $76.00 $72.00 $75.00 $76.00
93260-26 ---------- $49.00 $50.00 $51.00 $49.00 $50.00 $51.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 393
Medicine
CPT Code 2003 MRALocality 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)
93260-TC ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
93261 ---------- $66.00 $69.00 $70.00 $66.00 $69.00 $70.00
93261-26 ---------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.00
93261-TC ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
93268 $109.00 $219.00 $233.00 $236.00 $219.00 $233.00 $236.00
93270 $46.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
93271 $90.00 $181.00 $193.00 $195.00 $181.00 $193.00 $195.00
93272 $28.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
93278 $58.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00
93278-26 $24.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.00
93278-TC $44.00 $19.00 $21.00 $21.00 $19.00 $21.00 $21.00
93279 ---------- $55.00 $58.00 $59.00 $55.00 $58.00 $59.00
93279-26 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
93279-TC ---------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
93280 ---------- $64.00 $67.00 $69.00 $64.00 $67.00 $69.00
93280-26 ---------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.00
93280-TC ---------- $21.00 $23.00 $23.00 $21.00 $23.00 $23.00
93281 ---------- $75.00 $79.00 $80.00 $75.00 $79.00 $80.00
93281-26 ---------- $50.00 $52.00 $53.00 $50.00 $52.00 $53.00
93281-TC ---------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.00
93282 ---------- $70.00 $73.00 $74.00 $70.00 $73.00 $74.00
93282-26 ---------- $48.00 $49.00 $50.00 $48.00 $49.00 $50.00
93282-TC ---------- $22.00 $24.00 $24.00 $22.00 $24.00 $24.00
93283 ---------- $90.00 $94.00 $96.00 $90.00 $94.00 $96.00
93283-26 ---------- $64.00 $66.00 $68.00 $64.00 $66.00 $68.00
93283-TC ---------- $25.00 $27.00 $28.00 $25.00 $27.00 $28.00
93284 ---------- $100.00 $104.00 $106.00 $100.00 $104.00 $106.00
93284-26 ---------- $70.00 $73.00 $74.00 $70.00 $73.00 $74.00
93284-TC ---------- $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
93285 ---------- $46.00 $48.00 $50.00 $46.00 $48.00 $50.00
93285-26 ---------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.00
93285-TC ---------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.00
93286 ---------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
93286-26 ---------- $17.00 $17.00 $18.00 $17.00 $17.00 $18.00
93286-TC ---------- $13.00 $14.00 $14.00 $13.00 $14.00 $14.00
93287 ---------- $40.00 $42.00 $44.00 $40.00 $42.00 $44.00
93287-26 ---------- $26.00 $27.00 $27.00 $26.00 $27.00 $27.00
93287-TC ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00
93288 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
93288-26 ---------- $24.00 $25.00 $25.00 $24.00 $25.00 $25.00
93288-TC ---------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.00
93289 ---------- $72.00 $75.00 $77.00 $72.00 $75.00 $77.00
93289-26 ---------- $51.00 $53.00 $54.00 $51.00 $53.00 $54.00
93289-TC ---------- $21.00 $23.00 $23.00 $21.00 $23.00 $23.00
93290 ---------- $35.00 $36.00 $37.00 $35.00 $36.00 $37.00
93290-26 ---------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
93290-TC ---------- $10.00 $11.00 $12.00 $10.00 $11.00 $12.00
93291 ---------- $40.00 $42.00 $44.00 $40.00 $42.00 $44.00
93291-26 ---------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
93291-TC ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 394
Medicine
CPT Code 2003 MRALocality 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)
93292 ---------- $36.00 $38.00 $39.00 $36.00 $38.00 $39.00
93292-26 ---------- $24.00 $25.00 $25.00 $24.00 $25.00 $25.00
93292-TC ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
93293 ---------- $58.00 $62.00 $63.00 $58.00 $62.00 $63.00
93293-26 ---------- $18.00 $18.00 $19.00 $18.00 $18.00 $19.00
93293-TC ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00
93294 ---------- $38.00 $39.00 $41.00 $38.00 $39.00 $41.00
93295 ---------- $76.00 $79.00 $82.00 $76.00 $79.00 $82.00
93296 ---------- $28.00 $30.00 $31.00 $28.00 $30.00 $31.00
93297 ---------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
93298 ---------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
93303 $215.00 $256.00 $271.00 $275.00 $256.00 $271.00 $275.00
93303-26 $70.00 $71.00 $73.00 $75.00 $71.00 $73.00 $75.00
93303-TC $144.00 $184.00 $197.00 $200.00 $184.00 $197.00 $200.00
93304 $114.00 $168.00 $177.00 $180.00 $168.00 $177.00 $180.00
93304-26 $43.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.00
93304-TC $73.00 $127.00 $135.00 $137.00 $127.00 $135.00 $137.00
93306 ---------- $247.00 $261.00 $265.00 $247.00 $261.00 $265.00
93306-26 ---------- $71.00 $73.00 $75.00 $71.00 $73.00 $75.00
93306-TC ---------- $175.00 $188.00 $190.00 $175.00 $188.00 $190.00
93307 $196.00 $141.00 $148.00 $151.00 $141.00 $148.00 $151.00
93307-26 $56.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.00
93307-TC $144.00 $90.00 $97.00 $98.00 $90.00 $97.00 $98.00
93308 $118.00 $135.00 $143.00 $145.00 $135.00 $143.00 $145.00
93308-26 $46.00 $29.00 $30.00 $30.00 $29.00 $30.00 $30.00
93308-TC $75.00 $106.00 $113.00 $115.00 $106.00 $113.00 $115.00
93312 $322.00 $268.00 $282.00 $287.00 $268.00 $282.00 $287.00
93312-26 $140.00 $123.00 $126.00 $129.00 $123.00 $126.00 $129.00
93312-TC $182.00 $146.00 $156.00 $158.00 $146.00 $156.00 $158.00
93313 $76.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00
93314 $212.00 $258.00 $273.00 $281.00 $258.00 $273.00 $281.00
93314-26 $65.00 $104.00 $108.00 $113.00 $104.00 $108.00 $113.00
93314-TC $144.00 $155.00 $165.00 $168.00 $155.00 $165.00 $168.00
93315 $287.00 $617.00 $654.00 $662.00 $617.00 $654.00 $662.00
93315-26 $144.00 $145.00 $149.00 $152.00 $145.00 $149.00 $152.00
93315-TC $141.00 $473.00 $505.00 $510.00 $473.00 $505.00 $510.00
93316 $78.00 $31.00 $32.00 $34.00 $31.00 $32.00 $34.00
93317 $236.00 ---------- ---------- ---------- ---------- ---------- ----------
93317-26 $95.00 $106.00 $111.00 $117.00 $106.00 $111.00 $117.00
93317-TC $141.00 ---------- ---------- ---------- ---------- ---------- ----------
93318 BR $592.00 $628.00 $639.00 $592.00 $628.00 $639.00
93318-26 $114.00 $119.00 $123.00 $129.00 $119.00 $123.00 $129.00
93318-TC BR $473.00 $505.00 $510.00 $473.00 $505.00 $510.00
93320 $86.00 $59.00 $62.00 $62.00 $59.00 $62.00 $62.00
93320-26 $30.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
93320-TC $65.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.00
93321 $50.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
93321-26 $10.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.00
93321-TC $42.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.00
93325 $114.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 395
Medicine
CPT Code 2003 MRALocality 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)
93325-26 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00
93325-TC $110.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
93350 $216.00 $260.00 $275.00 $279.00 $260.00 $275.00 $279.00
93350-26 $77.00 $80.00 $82.00 $83.00 $80.00 $82.00 $83.00
93350-TC $66.00 $181.00 $193.00 $196.00 $181.00 $193.00 $196.00
93351 ---------- $293.00 $310.00 $315.00 $293.00 $310.00 $315.00
93351-26 ---------- $95.00 $98.00 $100.00 $95.00 $98.00 $100.00
93351-TC ---------- $198.00 $212.00 $215.00 $198.00 $212.00 $215.00
93352 ---------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
93355 ---------- $257.00 $266.00 $277.00 $257.00 $266.00 $277.00
93451 ---------- $787.00 $840.00 $862.00 $787.00 $840.00 $862.00
93451-26 ---------- $155.00 $165.00 $180.00 $155.00 $165.00 $180.00
93451-TC ---------- $632.00 $675.00 $682.00 $632.00 $675.00 $682.00
93452 ---------- $903.00 $963.00 $997.00 $903.00 $963.00 $997.00
93452-26 ---------- $282.00 $300.00 $326.00 $282.00 $300.00 $326.00
93452-TC ---------- $621.00 $664.00 $671.00 $621.00 $664.00 $671.00
93453 ---------- $1,174.00 $1,254.00 $1,300.00 $1,174.00 $1,254.00 $1,300.00
93453-26 ---------- $378.00 $403.00 $440.00 $378.00 $403.00 $440.00
93453-TC ---------- $796.00 $851.00 $860.00 $796.00 $851.00 $860.00
93454 ---------- $917.00 $979.00 $1,015.00 $917.00 $979.00 $1,015.00
93454-26 ---------- $286.00 $305.00 $333.00 $286.00 $305.00 $333.00
93454-TC ---------- $631.00 $674.00 $682.00 $631.00 $674.00 $682.00
93455 ---------- $1,072.00 $1,145.00 $1,186.00 $1,072.00 $1,145.00 $1,186.00
93455-26 ---------- $333.00 $355.00 $388.00 $333.00 $355.00 $388.00
93455-TC ---------- $739.00 $790.00 $798.00 $739.00 $790.00 $798.00
93456 ---------- $1,160.00 $1,239.00 $1,284.00 $1,160.00 $1,239.00 $1,284.00
93456-26 ---------- $372.00 $396.00 $433.00 $372.00 $396.00 $433.00
93456-TC ---------- $788.00 $842.00 $852.00 $788.00 $842.00 $852.00
93457 ---------- $1,315.00 $1,404.00 $1,456.00 $1,315.00 $1,404.00 $1,456.00
93457-26 ---------- $419.00 $447.00 $488.00 $419.00 $447.00 $488.00
93457-TC ---------- $896.00 $957.00 $968.00 $896.00 $957.00 $968.00
93458 ---------- $1,105.00 $1,181.00 $1,225.00 $1,105.00 $1,181.00 $1,225.00
93458-26 ---------- $353.00 $377.00 $411.00 $353.00 $377.00 $411.00
93458-TC ---------- $752.00 $804.00 $813.00 $752.00 $804.00 $813.00
93459 ---------- $1,226.00 $1,309.00 $1,359.00 $1,226.00 $1,309.00 $1,359.00
93459-26 ---------- $400.00 $427.00 $466.00 $400.00 $427.00 $466.00
93459-TC ---------- $826.00 $883.00 $893.00 $826.00 $883.00 $893.00
93460 ---------- $1,322.00 $1,412.00 $1,467.00 $1,322.00 $1,412.00 $1,467.00
93460-26 ---------- $448.00 $477.00 $522.00 $448.00 $477.00 $522.00
93460-TC ---------- $875.00 $935.00 $945.00 $875.00 $935.00 $945.00
93461 ---------- $1,512.00 $1,615.00 $1,675.00 $1,512.00 $1,615.00 $1,675.00
93461-26 ---------- $495.00 $528.00 $577.00 $495.00 $528.00 $577.00
93461-TC ---------- $1,017.00 $1,087.00 $1,098.00 $1,017.00 $1,087.00 $1,098.00
93462 ---------- $249.00 $267.00 $294.00 $249.00 $267.00 $294.00
93463 ---------- $112.00 $116.00 $120.00 $112.00 $116.00 $120.00
93464 ---------- $277.00 $292.00 $296.00 $277.00 $292.00 $296.00
93464-26 ---------- $98.00 $101.00 $103.00 $98.00 $101.00 $103.00
93464-TC ---------- $179.00 $191.00 $193.00 $179.00 $191.00 $193.00
93503 $187.00 $148.00 $154.00 $161.00 $148.00 $154.00 $161.00
93505 $318.00 $768.00 $820.00 $852.00 $768.00 $820.00 $852.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 396
Medicine
CPT Code 2003 MRALocality 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)
93505-26 $248.00 $259.00 $276.00 $302.00 $259.00 $276.00 $302.00
93505-TC $74.00 $509.00 $544.00 $550.00 $509.00 $544.00 $550.00
93530 $872.00 ---------- ---------- ---------- ---------- ---------- ----------
93530-26 $250.00 $243.00 $258.00 $278.00 $243.00 $258.00 $278.00
93530-TC $634.00 ---------- ---------- ---------- ---------- ---------- ----------
93531 $2,268.00 ---------- ---------- ---------- ---------- ---------- ----------
93531-26 $467.00 $502.00 $529.00 $567.00 $502.00 $529.00 $567.00
93531-TC $1,815.00 ---------- ---------- ---------- ---------- ---------- ----------
93532 $2,317.00 ---------- ---------- ---------- ---------- ---------- ----------
93532-26 $569.00 $632.00 $675.00 $738.00 $632.00 $675.00 $738.00
93532-TC $1,766.00 ---------- ---------- ---------- ---------- ---------- ----------
93533 $2,131.00 ---------- ---------- ---------- ---------- ---------- ----------
93533-26 $352.00 $422.00 $451.00 $493.00 $422.00 $451.00 $493.00
93533-TC $1,766.00 ---------- ---------- ---------- ---------- ---------- ----------
93561 $59.00 ---------- ---------- ---------- ---------- ---------- ----------
93561-26 $47.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.00
93561-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------
93562 $46.00 ---------- ---------- ---------- ---------- ---------- ----------
93562-26 $33.00 $1.00 $1.00 $2.00 $1.00 $1.00 $2.00
93562-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------
93563 ---------- $69.00 $74.00 $80.00 $69.00 $74.00 $80.00
93564 ---------- $73.00 $79.00 $87.00 $73.00 $79.00 $87.00
93565 ---------- $54.00 $57.00 $62.00 $54.00 $57.00 $62.00
93566 ---------- $177.00 $189.00 $197.00 $55.00 $59.00 $65.00
93567 ---------- $151.00 $162.00 $169.00 $63.00 $67.00 $74.00
93568 ---------- $159.00 $170.00 $177.00 $56.00 $60.00 $66.00
93571 $270.00 ---------- ---------- ---------- ---------- ---------- ----------
93571-26 $93.00 $113.00 $121.00 $132.00 $113.00 $121.00 $132.00
93571-TC $170.00 ---------- ---------- ---------- ---------- ---------- ----------
93572 $222.00 ---------- ---------- ---------- ---------- ---------- ----------
93572-26 $74.00 $91.00 $97.00 $106.00 $91.00 $97.00 $106.00
93572-TC $155.00 ---------- ---------- ---------- ---------- ---------- ----------
93580 $974.00 $1,165.00 $1,247.00 $1,370.00 $1,165.00 $1,247.00 $1,370.00
93581 $1,303.00 $1,603.00 $1,720.00 $1,897.00 $1,603.00 $1,720.00 $1,897.00
93582 ---------- $778.00 $831.00 $908.00 $778.00 $831.00 $908.00
93583 ---------- $885.00 $948.00 $1,044.00 $885.00 $948.00 $1,044.00
93600 $198.00 ---------- ---------- ---------- ---------- ---------- ----------
93600-26 $129.00 $140.00 $150.00 $163.00 $140.00 $150.00 $163.00
93600-TC $73.00 ---------- ---------- ---------- ---------- ---------- ----------
93602 $159.00 ---------- ---------- ---------- ---------- ---------- ----------
93602-26 $119.00 $137.00 $146.00 $159.00 $137.00 $146.00 $159.00
93602-TC $42.00 ---------- ---------- ---------- ---------- ---------- ----------
93603 $187.00 ---------- ---------- ---------- ---------- ---------- ----------
93603-26 $127.00 $137.00 $146.00 $159.00 $137.00 $146.00 $159.00
93603-TC $63.00 ---------- ---------- ---------- ---------- ---------- ----------
93609 $578.00 ---------- ---------- ---------- ---------- ---------- ----------
93609-26 $481.00 $329.00 $351.00 $382.00 $329.00 $351.00 $382.00
93609-TC $101.00 ---------- ---------- ---------- ---------- ---------- ----------
93610 $214.00 ---------- ---------- ---------- ---------- ---------- ----------
93610-26 $166.00 $194.00 $207.00 $226.00 $194.00 $207.00 $226.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 397
Medicine
CPT Code 2003 MRALocality 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)
93610-TC $52.00 ---------- ---------- ---------- ---------- ---------- ----------
93612 $224.00 ---------- ---------- ---------- ---------- ---------- ----------
93612-26 $167.00 $192.00 $205.00 $223.00 $192.00 $205.00 $223.00
93612-TC $61.00 ---------- ---------- ---------- ---------- ---------- ----------
93613 $377.00 $473.00 $508.00 $558.00 $473.00 $508.00 $558.00
93615 $62.00 ---------- ---------- ---------- ---------- ---------- ----------
93615-26 $49.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.00
93615-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
93616 $94.00 ---------- ---------- ---------- ---------- ---------- ----------
93616-26 $82.00 $60.00 $62.00 $64.00 $60.00 $62.00 $64.00
93616-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
93618 $399.00 ---------- ---------- ---------- ---------- ---------- ----------
93618-26 $258.00 $262.00 $280.00 $305.00 $262.00 $280.00 $305.00
93618-TC $148.00 ---------- ---------- ---------- ---------- ---------- ----------
93619 $717.00 ---------- ---------- ---------- ---------- ---------- ----------
93619-26 $444.00 $462.00 $493.00 $538.00 $462.00 $493.00 $538.00
93619-TC $290.00 ---------- ---------- ---------- ---------- ---------- ----------
93620 $358.00 ---------- ---------- ---------- ---------- ---------- ----------
93620-26 $272.00 $743.00 $793.00 $864.00 $743.00 $793.00 $864.00
93620-TC $91.00 ---------- ---------- ---------- ---------- ---------- ----------
93621 BR ---------- ---------- ---------- ---------- ---------- ----------
93621-26 $769.00 $139.00 $149.00 $162.00 $139.00 $149.00 $162.00
93621-TC BR ---------- ---------- ---------- ---------- ---------- ----------
93622 BR ---------- ---------- ---------- ---------- ---------- ----------
93622-26 $771.00 $204.00 $218.00 $237.00 $204.00 $218.00 $237.00
93622-TC BR ---------- ---------- ---------- ---------- ---------- ----------
93623 BR ---------- ---------- ---------- ---------- ---------- ----------
93623-26 $167.00 $189.00 $201.00 $220.00 $189.00 $201.00 $220.00
93623-TC BR ---------- ---------- ---------- ---------- ---------- ----------
93624 $333.00 ---------- ---------- ---------- ---------- ---------- ----------
93624-26 $256.00 $287.00 $307.00 $336.00 $287.00 $307.00 $336.00
93624-TC $74.00 ---------- ---------- ---------- ---------- ---------- ----------
93631 $651.00 ---------- ---------- ---------- ---------- ---------- ----------
93631-26 $420.00 $472.00 $504.00 $552.00 $472.00 $504.00 $552.00
93631-TC $239.00 ---------- ---------- ---------- ---------- ---------- ----------
93640 $467.00 ---------- ---------- ---------- ---------- ---------- ----------
93640-26 $230.00 $212.00 $226.00 $247.00 $212.00 $226.00 $247.00
93640-TC $269.00 ---------- ---------- ---------- ---------- ---------- ----------
93641 $613.00 ---------- ---------- ---------- ---------- ---------- ----------
93641-26 $360.00 $370.00 $395.00 $430.00 $370.00 $395.00 $430.00
93641-TC $269.00 ---------- ---------- ---------- ---------- ---------- ----------
93642 $549.00 $392.00 $419.00 $450.00 $392.00 $419.00 $450.00
93642-26 $295.00 $304.00 $325.00 $354.00 $304.00 $325.00 $354.00
93642-TC $269.00 $87.00 $94.00 $95.00 $87.00 $94.00 $95.00
93644 ---------- $240.00 $250.00 $255.00 $240.00 $250.00 $255.00
93644-26 ---------- $178.00 $184.00 $188.00 $178.00 $184.00 $188.00
93644-TC ---------- $62.00 $66.00 $67.00 $62.00 $66.00 $67.00
93650 $639.00 $703.00 $754.00 $827.00 $703.00 $754.00 $827.00
93653 ---------- $996.00 $1,068.00 $1,174.00 $996.00 $1,068.00 $1,174.00
93654 ---------- $1,334.00 $1,430.00 $1,573.00 $1,334.00 $1,430.00 $1,573.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 398
Medicine
CPT Code 2003 MRALocality 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)
93655 ---------- $508.00 $544.00 $599.00 $508.00 $544.00 $599.00
93656 ---------- $1,338.00 $1,435.00 $1,577.00 $1,338.00 $1,435.00 $1,577.00
93657 ---------- $506.00 $543.00 $598.00 $506.00 $543.00 $598.00
93660 $162.00 $174.00 $182.00 $185.00 $174.00 $182.00 $185.00
93660-26 $103.00 $105.00 $108.00 $111.00 $105.00 $108.00 $111.00
93660-TC $61.00 $68.00 $73.00 $74.00 $68.00 $73.00 $74.00
93662 BR ---------- ---------- ---------- ---------- ---------- ----------
93662-26 $158.00 $161.00 $165.00 $169.00 $161.00 $165.00 $169.00
93662-TC BR ---------- ---------- ---------- ---------- ---------- ----------
93701 $36.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00
93701-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------
93701-TC $27.00 ---------- ---------- ---------- ---------- ---------- ----------
93702 ---------- $132.00 $141.00 $143.00 $132.00 $141.00 $143.00
93724 $411.00 $302.00 $311.00 $318.00 $302.00 $311.00 $318.00
93724-26 $259.00 $272.00 $279.00 $286.00 $272.00 $279.00 $286.00
93724-TC $148.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
93740 $17.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00
93740-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------
93740-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------
93750 ---------- $63.00 $66.00 $69.00 $53.00 $55.00 $58.00
93770 NC NC NC NC NC NC NC
93770-26 NC NC NC NC NC NC NC
93770-TC NC NC NC NC NC NC NC
93784 NC NC NC NC NC NC NC
93786 NC NC NC NC NC NC NC
93788 NC NC NC NC NC NC NC
93790 NC NC NC NC NC NC NC
93797 $17.00 $18.00 $19.00 $19.00 $10.00 $10.00 $11.00
93798 $38.00 $28.00 $29.00 $30.00 $16.00 $16.00 $17.00
93799 BR ---------- ---------- ---------- ---------- ---------- ----------
93799-26 BR ---------- ---------- ---------- ---------- ---------- ----------
93799-TC BR ---------- ---------- ---------- ---------- ---------- ----------
93880 $176.00 $219.00 $233.00 $238.00 $219.00 $233.00 $238.00
93880-26 $31.00 $45.00 $47.00 $50.00 $45.00 $47.00 $50.00
93880-TC $144.00 $174.00 $186.00 $188.00 $174.00 $186.00 $188.00
93882 $117.00 $140.00 $149.00 $153.00 $140.00 $149.00 $153.00
93882-26 $21.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.00
93882-TC $95.00 $111.00 $118.00 $120.00 $111.00 $118.00 $120.00
93886 $215.00 $291.00 $309.00 $314.00 $291.00 $309.00 $314.00
93886-26 $50.00 $53.00 $55.00 $57.00 $53.00 $55.00 $57.00
93886-TC $162.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
93888 $142.00 $148.00 $158.00 $161.00 $148.00 $158.00 $161.00
93888-26 $33.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
93888-TC $109.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
93890 ---------- $295.00 $314.00 $319.00 $295.00 $314.00 $319.00
93890-26 ---------- $58.00 $60.00 $62.00 $58.00 $60.00 $62.00
93890-TC ---------- $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
93892 ---------- $187.00 $197.00 $202.00 $187.00 $197.00 $202.00
93892-26 ---------- $68.00 $71.00 $74.00 $68.00 $71.00 $74.00
93892-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 399
Medicine
CPT Code 2003 MRALocality 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)
93893 ---------- $186.00 $196.00 $200.00 $186.00 $196.00 $200.00
93893-26 ---------- $67.00 $70.00 $72.00 $67.00 $70.00 $72.00
93893-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
93922 $60.00 $96.00 $102.00 $104.00 $96.00 $102.00 $104.00
93922-26 $16.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.00
93922-TC $44.00 $81.00 $87.00 $88.00 $81.00 $87.00 $88.00
93923 $112.00 $149.00 $159.00 $162.00 $149.00 $159.00 $162.00
93923-26 $28.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
93923-TC $85.00 $123.00 $132.00 $134.00 $123.00 $132.00 $134.00
93924 $122.00 $185.00 $198.00 $201.00 $185.00 $198.00 $201.00
93924-26 $31.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00
93924-TC $92.00 $157.00 $168.00 $170.00 $157.00 $168.00 $170.00
93925 $175.00 $279.00 $297.00 $302.00 $279.00 $297.00 $302.00
93925-26 $31.00 $45.00 $46.00 $48.00 $45.00 $46.00 $48.00
93925-TC $144.00 $235.00 $251.00 $254.00 $235.00 $251.00 $254.00
93926 $117.00 $146.00 $156.00 $159.00 $146.00 $156.00 $159.00
93926-26 $21.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
93926-TC $96.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00
93930 $174.00 $225.00 $240.00 $245.00 $225.00 $240.00 $245.00
93930-26 $26.00 $46.00 $48.00 $50.00 $46.00 $48.00 $50.00
93930-TC $150.00 $180.00 $192.00 $195.00 $180.00 $192.00 $195.00
93931 $118.00 $139.00 $148.00 $151.00 $139.00 $148.00 $151.00
93931-26 $17.00 $28.00 $29.00 $31.00 $28.00 $29.00 $31.00
93931-TC $101.00 $111.00 $119.00 $120.00 $111.00 $119.00 $120.00
93970 $189.00 $213.00 $227.00 $231.00 $213.00 $227.00 $231.00
93970-26 $36.00 $39.00 $41.00 $43.00 $39.00 $41.00 $43.00
93970-TC $154.00 $174.00 $186.00 $188.00 $174.00 $186.00 $188.00
93971 $121.00 $130.00 $138.00 $140.00 $130.00 $138.00 $140.00
93971-26 $23.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
93971-TC $96.00 $105.00 $112.00 $113.00 $105.00 $112.00 $113.00
93975 $277.00 $303.00 $323.00 $329.00 $303.00 $323.00 $329.00
93975-26 $89.00 $66.00 $68.00 $72.00 $66.00 $68.00 $72.00
93975-TC $181.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00
93976 $184.00 $164.00 $174.00 $177.00 $164.00 $174.00 $177.00
93976-26 $59.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.00
93976-TC $121.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00
93978 $177.00 $207.00 $220.00 $225.00 $207.00 $220.00 $225.00
93978-26 $34.00 $45.00 $47.00 $50.00 $45.00 $47.00 $50.00
93978-TC $143.00 $161.00 $173.00 $175.00 $161.00 $173.00 $175.00
93979 $122.00 $130.00 $138.00 $142.00 $130.00 $138.00 $142.00
93979-26 $23.00 $29.00 $30.00 $32.00 $29.00 $30.00 $32.00
93979-TC $98.00 $101.00 $108.00 $110.00 $101.00 $108.00 $110.00
93980 $183.00 $133.00 $139.00 $142.00 $133.00 $139.00 $142.00
93980-26 $65.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00
93980-TC $105.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00
93981 $148.00 $80.00 $85.00 $87.00 $80.00 $85.00 $87.00
93981-26 $25.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
93981-TC $124.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.00
93982 ---------- $48.00 $51.00 $53.00 $48.00 $51.00 $53.00
93990 $110.00 $147.00 $157.00 $162.00 $147.00 $157.00 $162.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 400
Medicine
CPT Code 2003 MRALocality 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)
93990-26 $14.00 $28.00 $30.00 $33.00 $28.00 $30.00 $33.00
93990-TC $96.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00
94002 ---------- $105.00 $109.00 $114.00 $105.00 $109.00 $114.00
94003 ---------- $76.00 $79.00 $82.00 $76.00 $79.00 $82.00
94004 ---------- $56.00 $58.00 $60.00 $56.00 $58.00 $60.00
94010 $30.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
94010-26 $12.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00
94010-TC $16.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
94014 $39.00 $62.00 $65.00 $66.00 $62.00 $65.00 $66.00
94015 $14.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00
94016 $26.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
94060 $57.00 $66.00 $70.00 $71.00 $66.00 $70.00 $71.00
94060-26 $18.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00
94060-TC $36.00 $51.00 $55.00 $56.00 $51.00 $55.00 $56.00
94070 $32.00 $66.00 $69.00 $71.00 $66.00 $69.00 $71.00
94070-26 $11.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
94070-TC $19.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00
94150 $8.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.00
94150-26 $6.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.00
94150-TC $3.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00
94200 $17.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00
94200-26 $7.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00
94200-TC $9.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
94250 $12.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
94250-26 $8.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00
94250-TC $5.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00
94375 $34.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.00
94375-26 $16.00 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00
94375-TC $17.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
94400 $40.00 $62.00 $65.00 $67.00 $62.00 $65.00 $67.00
94400-26 $24.00 $22.00 $23.00 $23.00 $22.00 $23.00 $23.00
94400-TC $14.00 $40.00 $43.00 $43.00 $40.00 $43.00 $43.00
94450 $37.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.00
94450-26 $20.00 $23.00 $23.00 $24.00 $23.00 $23.00 $24.00
94450-TC $15.00 $53.00 $56.00 $57.00 $53.00 $56.00 $57.00
94452 ---------- $62.00 $66.00 $67.00 $62.00 $66.00 $67.00
94452-26 ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00
94452-TC ---------- $46.00 $49.00 $50.00 $46.00 $49.00 $50.00
94453 ---------- $86.00 $92.00 $93.00 $86.00 $92.00 $93.00
94453-26 ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
94453-TC ---------- $65.00 $70.00 $71.00 $65.00 $70.00 $71.00
94610 ---------- $63.00 $65.00 $68.00 $63.00 $65.00 $68.00
94620 $91.00 $62.00 $65.00 $66.00 $62.00 $65.00 $66.00
94620-26 $38.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
94620-TC $54.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.00
94621 $122.00 $177.00 $187.00 $190.00 $177.00 $187.00 $190.00
94621-26 $71.00 $77.00 $80.00 $82.00 $77.00 $80.00 $82.00
94621-TC $52.00 $100.00 $107.00 $109.00 $100.00 $107.00 $109.00
94640 $19.00 $20.00 $21.00 $22.00 $20.00 $21.00 $22.00
94642 BR ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 401
Medicine
CPT Code 2003 MRALocality 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)
94644 ---------- $47.00 $51.00 $51.00 $47.00 $51.00 $51.00
94645 ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00
94660 $54.00 $70.00 $74.00 $76.00 $43.00 $45.00 $47.00
94662 $38.00 $40.00 $42.00 $44.00 $40.00 $42.00 $44.00
94664 $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
94667 $23.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
94668 $16.00 $31.00 $34.00 $34.00 $31.00 $34.00 $34.00
94669 ---------- $35.00 $38.00 $39.00 $35.00 $38.00 $39.00
94680 $47.00 $62.00 $65.00 $66.00 $62.00 $65.00 $66.00
94680-26 $23.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
94680-TC $22.00 $47.00 $51.00 $51.00 $47.00 $51.00 $51.00
94681 $60.00 $58.00 $62.00 $63.00 $58.00 $62.00 $63.00
94681-26 $12.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
94681-TC $43.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00
94690 $24.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.00
94690-26 $4.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.00
94690-TC $20.00 $51.00 $54.00 $55.00 $51.00 $54.00 $55.00
94726 ---------- $57.00 $60.00 $62.00 $57.00 $60.00 $62.00
94726-26 ---------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00
94726-TC ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00
94727 ---------- $46.00 $48.00 $49.00 $46.00 $48.00 $49.00
94727-26 ---------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00
94727-TC ---------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.00
94728 ---------- $43.00 $46.00 $46.00 $43.00 $46.00 $46.00
94728-26 ---------- $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
94728-TC ---------- $29.00 $31.00 $32.00 $29.00 $31.00 $32.00
94729 ---------- $59.00 $62.00 $64.00 $59.00 $62.00 $64.00
94729-26 ---------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
94729-TC ---------- $48.00 $52.00 $53.00 $48.00 $52.00 $53.00
94750 $37.00 $85.00 $90.00 $92.00 $85.00 $90.00 $92.00
94750-26 $14.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
94750-TC $21.00 $73.00 $78.00 $79.00 $73.00 $78.00 $79.00
94760 $9.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00
94761 $20.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.00
94762 $30.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00
94770 $21.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.00
94770-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------
94770-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------
94799 BR ---------- ---------- ---------- ---------- ---------- ----------
94799-26 BR ---------- ---------- ---------- ---------- ---------- ----------
94799-TC BR ---------- ---------- ---------- ---------- ---------- ----------
95004 $3.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.00
95012 ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
95017 ---------- $9.00 $9.00 $9.00 $4.00 $4.00 $5.00
95018 ---------- $22.00 $24.00 $24.00 $8.00 $8.00 $9.00
95024 $3.00 $8.00 $9.00 $10.00 $1.00 $1.00 $2.00
95027 $5.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.00
95028 $8.00 $14.00 $16.00 $16.00 $14.00 $16.00 $16.00
95044 $7.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00
95052 $9.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 402
Medicine
CPT Code 2003 MRALocality 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)
95056 $6.00 $47.00 $51.00 $51.00 $47.00 $51.00 $51.00
95060 $13.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.00
95065 $7.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00
95070 $82.00 $33.00 $36.00 $37.00 $33.00 $36.00 $37.00
95071 $105.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.00
95076 ---------- $127.00 $133.00 $135.00 $82.00 $84.00 $86.00
95079 ---------- $91.00 $95.00 $97.00 $75.00 $77.00 $79.00
95115 $10.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
95117 $9.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
95120 BR ---------- ---------- ---------- ---------- ---------- ----------
95125 BR ---------- ---------- ---------- ---------- ---------- ----------
95130 BR ---------- ---------- ---------- ---------- ---------- ----------
95131 BR ---------- ---------- ---------- ---------- ---------- ----------
95132 BR ---------- ---------- ---------- ---------- ---------- ----------
95133 BR ---------- ---------- ---------- ---------- ---------- ----------
95134 BR ---------- ---------- ---------- ---------- ---------- ----------
95144 $9.00 $14.00 $15.00 $16.00 $4.00 $4.00 $4.00
95145 $17.00 $27.00 $29.00 $29.00 $4.00 $4.00 $4.00
95146 $24.00 $49.00 $53.00 $53.00 $4.00 $4.00 $4.00
95147 $33.00 $52.00 $56.00 $57.00 $4.00 $4.00 $4.00
95148 $32.00 $74.00 $79.00 $80.00 $4.00 $4.00 $4.00
95149 $36.00 $98.00 $104.00 $106.00 $4.00 $4.00 $4.00
95165 $7.00 $14.00 $15.00 $16.00 $4.00 $4.00 $4.00
95170 $13.00 $10.00 $11.00 $12.00 $4.00 $4.00 $4.00
95180 $103.00 $147.00 $153.00 $156.00 $113.00 $116.00 $119.00
95199 BR ---------- ---------- ---------- ---------- ---------- ----------
95250 $114.00 $169.00 $181.00 $183.00 $169.00 $181.00 $183.00
95251 ---------- $49.00 $51.00 $52.00 $49.00 $51.00 $52.00
95803 ---------- $153.00 $161.00 $164.00 $153.00 $161.00 $164.00
95803-26 ---------- $49.00 $50.00 $52.00 $49.00 $50.00 $52.00
95803-TC ---------- $104.00 $111.00 $112.00 $104.00 $111.00 $112.00
95805 $334.00 $460.00 $490.00 $498.00 $460.00 $490.00 $498.00
95805-26 $94.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00
95805-TC $237.00 $394.00 $422.00 $428.00 $394.00 $422.00 $428.00
95806 $232.00 $184.00 $194.00 $197.00 $184.00 $194.00 $197.00
95806-26 $109.00 $69.00 $71.00 $72.00 $69.00 $71.00 $72.00
95806-TC $137.00 $115.00 $123.00 $125.00 $115.00 $123.00 $125.00
95807 $367.00 $500.00 $532.00 $541.00 $500.00 $532.00 $541.00
95807-26 $98.00 $70.00 $72.00 $74.00 $70.00 $72.00 $74.00
95807-TC $256.00 $430.00 $460.00 $467.00 $430.00 $460.00 $467.00
95808 $456.00 $688.00 $732.00 $743.00 $688.00 $732.00 $743.00
95808-26 $149.00 $99.00 $102.00 $105.00 $99.00 $102.00 $105.00
95808-TC $256.00 $589.00 $630.00 $638.00 $589.00 $630.00 $638.00
95810 $521.00 $671.00 $713.00 $725.00 $671.00 $713.00 $725.00
95810-26 $183.00 $137.00 $141.00 $144.00 $137.00 $141.00 $144.00
95810-TC $256.00 $535.00 $572.00 $580.00 $535.00 $572.00 $580.00
95811 $644.00 $705.00 $749.00 $762.00 $705.00 $749.00 $762.00
95811-26 $196.00 $142.00 $146.00 $150.00 $142.00 $146.00 $150.00
95811-TC $423.00 $563.00 $603.00 $612.00 $563.00 $603.00 $612.00
95812 $137.00 $348.00 $370.00 $376.00 $348.00 $370.00 $376.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 403
Medicine
CPT Code 2003 MRALocality 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)
95812-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
95812-TC $68.00 $284.00 $303.00 $307.00 $284.00 $303.00 $307.00
95813 $177.00 $440.00 $467.00 $474.00 $440.00 $467.00 $474.00
95813-26 $89.00 $98.00 $101.00 $104.00 $98.00 $101.00 $104.00
95813-TC $68.00 $342.00 $366.00 $370.00 $342.00 $366.00 $370.00
95816 $133.00 $389.00 $413.00 $420.00 $389.00 $413.00 $420.00
95816-26 $54.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
95816-TC $78.00 $324.00 $346.00 $351.00 $324.00 $346.00 $351.00
95819 $115.00 $446.00 $475.00 $482.00 $446.00 $475.00 $482.00
95819-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
95819-TC $56.00 $381.00 $408.00 $413.00 $381.00 $408.00 $413.00
95822 $120.00 $403.00 $429.00 $435.00 $403.00 $429.00 $435.00
95822-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00
95822-TC $63.00 $338.00 $362.00 $366.00 $338.00 $362.00 $366.00
95824 $51.00 ---------- ---------- ---------- ---------- ---------- ----------
95824-26 $41.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.00
95824-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------
95827 $145.00 $713.00 $761.00 $773.00 $713.00 $761.00 $773.00
95827-26 $59.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.00
95827-TC $86.00 $649.00 $694.00 $705.00 $649.00 $694.00 $705.00
95829 $328.00 $2,062.00 $2,193.00 $2,229.00 $2,062.00 $2,193.00 $2,229.00
95829-26 $291.00 $381.00 $397.00 $413.00 $381.00 $397.00 $413.00
95829-TC $6.00 $1,681.00 $1,797.00 $1,816.00 $1,681.00 $1,797.00 $1,816.00
95830 $133.00 $239.00 $252.00 $258.00 $103.00 $108.00 $112.00
95831 $26.00 $35.00 $37.00 $38.00 $18.00 $19.00 $20.00
95832 $21.00 $34.00 $37.00 $38.00 $19.00 $21.00 $22.00
95833 $34.00 $41.00 $43.00 $43.00 $24.00 $25.00 $25.00
95834 $44.00 $57.00 $60.00 $62.00 $35.00 $37.00 $38.00
95851 $18.00 $20.00 $21.00 $21.00 $9.00 $9.00 $9.00
95852 $14.00 $17.00 $18.00 $18.00 $6.00 $7.00 $7.00
95857 $40.00 $59.00 $62.00 $64.00 $34.00 $35.00 $36.00
95860 $73.00 $133.00 $140.00 $143.00 $133.00 $140.00 $143.00
95860-26 $53.00 $58.00 $60.00 $61.00 $58.00 $60.00 $61.00
95860-TC $15.00 $75.00 $81.00 $82.00 $75.00 $81.00 $82.00
95861 $113.00 $190.00 $200.00 $204.00 $190.00 $200.00 $204.00
95861-26 $86.00 $93.00 $96.00 $99.00 $93.00 $96.00 $99.00
95861-TC $28.00 $97.00 $103.00 $105.00 $97.00 $103.00 $105.00
95863 $138.00 $238.00 $250.00 $255.00 $238.00 $250.00 $255.00
95863-26 $102.00 $112.00 $116.00 $119.00 $112.00 $116.00 $119.00
95863-TC $35.00 $126.00 $135.00 $136.00 $126.00 $135.00 $136.00
95864 $177.00 $268.00 $282.00 $288.00 $268.00 $282.00 $288.00
95864-26 $114.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00
95864-TC $67.00 $147.00 $157.00 $159.00 $147.00 $157.00 $159.00
95865 ---------- $161.00 $169.00 $173.00 $161.00 $169.00 $173.00
95865-26 ---------- $95.00 $99.00 $102.00 $95.00 $99.00 $102.00
95865-TC ---------- $66.00 $70.00 $71.00 $66.00 $70.00 $71.00
95866 ---------- $148.00 $156.00 $159.00 $148.00 $156.00 $159.00
95866-26 ---------- $76.00 $78.00 $81.00 $76.00 $78.00 $81.00
95866-TC ---------- $72.00 $77.00 $78.00 $72.00 $77.00 $78.00
95867 $66.00 $106.00 $111.00 $114.00 $106.00 $111.00 $114.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 404
Medicine
CPT Code 2003 MRALocality 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)
95867-26 $43.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00
95867-TC $21.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.00
95868 $96.00 $147.00 $155.00 $158.00 $147.00 $155.00 $158.00
95868-26 $71.00 $71.00 $74.00 $76.00 $71.00 $74.00 $76.00
95868-TC $26.00 $76.00 $81.00 $82.00 $76.00 $81.00 $82.00
95869 $29.00 $99.00 $105.00 $107.00 $99.00 $105.00 $107.00
95869-26 $21.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
95869-TC $8.00 $76.00 $82.00 $83.00 $76.00 $82.00 $83.00
95870 $29.00 $100.00 $106.00 $108.00 $100.00 $106.00 $108.00
95870-26 $21.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
95870-TC $8.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00
95872 $104.00 $218.00 $228.00 $234.00 $218.00 $228.00 $234.00
95872-26 $81.00 $173.00 $179.00 $185.00 $173.00 $179.00 $185.00
95872-TC $22.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.00
95873 ---------- $79.00 $83.00 $84.00 $79.00 $83.00 $84.00
95873-26 ---------- $22.00 $23.00 $23.00 $22.00 $23.00 $23.00
95873-TC ---------- $57.00 $60.00 $61.00 $57.00 $60.00 $61.00
95874 ---------- $80.00 $85.00 $86.00 $80.00 $85.00 $86.00
95874-26 ---------- $22.00 $23.00 $24.00 $22.00 $23.00 $24.00
95874-TC ---------- $57.00 $61.00 $62.00 $57.00 $61.00 $62.00
95875 $43.00 $128.00 $135.00 $138.00 $128.00 $135.00 $138.00
95875-26 $34.00 $66.00 $69.00 $71.00 $66.00 $69.00 $71.00
95875-TC $7.00 $62.00 $66.00 $67.00 $62.00 $66.00 $67.00
95885 ---------- $64.00 $67.00 $68.00 $64.00 $67.00 $68.00
95885-26 ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
95885-TC ---------- $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
95886 ---------- $99.00 $104.00 $106.00 $99.00 $104.00 $106.00
95886-26 ---------- $52.00 $54.00 $55.00 $52.00 $54.00 $55.00
95886-TC ---------- $48.00 $51.00 $51.00 $48.00 $51.00 $51.00
95887 ---------- $88.00 $92.00 $94.00 $88.00 $92.00 $94.00
95887-26 ---------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.00
95887-TC ---------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.00
95905 ---------- $77.00 $82.00 $83.00 $77.00 $82.00 $83.00
95905-26 ---------- $3.00 $3.00 $4.00 $3.00 $3.00 $4.00
95905-TC ---------- $73.00 $78.00 $80.00 $73.00 $78.00 $80.00
95907 ---------- $107.00 $112.00 $115.00 $107.00 $112.00 $115.00
95907-26 ---------- $60.00 $62.00 $64.00 $60.00 $62.00 $64.00
95907-TC ---------- $47.00 $50.00 $51.00 $47.00 $50.00 $51.00
95908 ---------- $137.00 $144.00 $147.00 $137.00 $144.00 $147.00
95908-26 ---------- $76.00 $78.00 $80.00 $76.00 $78.00 $80.00
95908-TC ---------- $62.00 $66.00 $67.00 $62.00 $66.00 $67.00
95909 ---------- $163.00 $172.00 $175.00 $163.00 $172.00 $175.00
95909-26 ---------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.00
95909-TC ---------- $73.00 $78.00 $79.00 $73.00 $78.00 $79.00
95910 ---------- $216.00 $227.00 $232.00 $216.00 $227.00 $232.00
95910-26 ---------- $121.00 $125.00 $128.00 $121.00 $125.00 $128.00
95910-TC ---------- $95.00 $102.00 $103.00 $95.00 $102.00 $103.00
95911 ---------- $258.00 $270.00 $276.00 $258.00 $270.00 $276.00
95911-26 ---------- $151.00 $156.00 $160.00 $151.00 $156.00 $160.00
95911-TC ---------- $107.00 $114.00 $116.00 $107.00 $114.00 $116.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 405
Medicine
CPT Code 2003 MRALocality 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)
95912 ---------- $285.00 $298.00 $305.00 $285.00 $298.00 $305.00
95912-26 ---------- $178.00 $184.00 $190.00 $178.00 $184.00 $190.00
95912-TC ---------- $107.00 $114.00 $115.00 $107.00 $114.00 $115.00
95913 ---------- $328.00 $343.00 $350.00 $328.00 $343.00 $350.00
95913-26 ---------- $211.00 $218.00 $224.00 $211.00 $218.00 $224.00
95913-TC ---------- $116.00 $124.00 $126.00 $116.00 $124.00 $126.00
95921 $61.00 $93.00 $98.00 $100.00 $93.00 $98.00 $100.00
95921-26 $46.00 $51.00 $52.00 $54.00 $51.00 $52.00 $54.00
95921-TC $14.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00
95922 $65.00 $109.00 $115.00 $117.00 $109.00 $115.00 $117.00
95922-26 $50.00 $54.00 $56.00 $57.00 $54.00 $56.00 $57.00
95922-TC $14.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.00
95923 $105.00 $153.00 $162.00 $165.00 $153.00 $162.00 $165.00
95923-26 $47.00 $52.00 $54.00 $55.00 $52.00 $54.00 $55.00
95923-TC $57.00 $101.00 $108.00 $110.00 $101.00 $108.00 $110.00
95924 ---------- $168.00 $176.00 $181.00 $168.00 $176.00 $181.00
95924-26 ---------- $101.00 $105.00 $109.00 $101.00 $105.00 $109.00
95924-TC ---------- $67.00 $71.00 $72.00 $67.00 $71.00 $72.00
95925 $94.00 $150.00 $159.00 $162.00 $150.00 $159.00 $162.00
95925-26 $53.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
95925-TC $41.00 $118.00 $127.00 $129.00 $118.00 $127.00 $129.00
95926 $66.00 $145.00 $154.00 $157.00 $145.00 $154.00 $157.00
95926-26 $34.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
95926-TC $34.00 $114.00 $122.00 $124.00 $114.00 $122.00 $124.00
95927 $67.00 $149.00 $158.00 $161.00 $149.00 $158.00 $161.00
95927-26 $34.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
95927-TC $34.00 $118.00 $126.00 $128.00 $118.00 $126.00 $128.00
95928 ---------- $232.00 $245.00 $249.00 $232.00 $245.00 $249.00
95928-26 ---------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.00
95928-TC ---------- $142.00 $151.00 $153.00 $142.00 $151.00 $153.00
95929 ---------- $239.00 $252.00 $256.00 $239.00 $252.00 $256.00
95929-26 ---------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.00
95929-TC ---------- $148.00 $158.00 $160.00 $148.00 $158.00 $160.00
95930 $44.00 $139.00 $148.00 $150.00 $139.00 $148.00 $150.00
95930-26 $25.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.00
95930-TC $11.00 $118.00 $127.00 $129.00 $118.00 $127.00 $129.00
95933 $62.00 $84.00 $88.00 $90.00 $84.00 $88.00 $90.00
95933-26 $33.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00
95933-TC $30.00 $48.00 $51.00 $52.00 $48.00 $51.00 $52.00
95937 $40.00 $89.00 $94.00 $96.00 $89.00 $94.00 $96.00
95937-26 $31.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.00
95937-TC $9.00 $51.00 $54.00 $55.00 $51.00 $54.00 $55.00
95938 ---------- $368.00 $392.00 $398.00 $368.00 $392.00 $398.00
95938-26 ---------- $52.00 $54.00 $56.00 $52.00 $54.00 $56.00
95938-TC ---------- $316.00 $338.00 $342.00 $316.00 $338.00 $342.00
95939 ---------- $545.00 $578.00 $588.00 $545.00 $578.00 $588.00
95939-26 ---------- $135.00 $139.00 $144.00 $135.00 $139.00 $144.00
95939-TC ---------- $410.00 $439.00 $444.00 $410.00 $439.00 $444.00
95940 ---------- $37.00 $38.00 $40.00 $37.00 $38.00 $40.00
95950 $265.00 $360.00 $382.00 $388.00 $360.00 $382.00 $388.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 406
Medicine
CPT Code 2003 MRALocality 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)
95950-26 $84.00 $90.00 $93.00 $96.00 $90.00 $93.00 $96.00
95950-TC $177.00 $270.00 $289.00 $293.00 $270.00 $289.00 $293.00
95951 $34.00 ---------- ---------- ---------- ---------- ---------- ----------
95951-26 $14.00 $360.00 $372.00 $383.00 $360.00 $372.00 $383.00
95951-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------
95953 $411.00 $461.00 $487.00 $497.00 $461.00 $487.00 $497.00
95953-26 $165.00 $185.00 $191.00 $197.00 $185.00 $191.00 $197.00
95953-TC $240.00 $277.00 $296.00 $300.00 $277.00 $296.00 $300.00
95954 $208.00 $491.00 $520.00 $530.00 $491.00 $520.00 $530.00
95954-26 $134.00 $142.00 $147.00 $152.00 $142.00 $147.00 $152.00
95954-TC $23.00 $349.00 $373.00 $379.00 $349.00 $373.00 $379.00
95955 $130.00 $231.00 $245.00 $249.00 $231.00 $245.00 $249.00
95955-26 $59.00 $60.00 $62.00 $64.00 $60.00 $62.00 $64.00
95955-TC $74.00 $171.00 $182.00 $185.00 $171.00 $182.00 $185.00
95956 $541.00 $1,751.00 $1,866.00 $1,894.00 $1,751.00 $1,866.00 $1,894.00
95956-26 $166.00 $215.00 $223.00 $230.00 $215.00 $223.00 $230.00
95956-TC $314.00 $1,536.00 $1,643.00 $1,665.00 $1,536.00 $1,643.00 $1,665.00
95957 $171.00 $332.00 $351.00 $358.00 $332.00 $351.00 $358.00
95957-26 $104.00 $118.00 $122.00 $126.00 $118.00 $122.00 $126.00
95957-TC $64.00 $214.00 $229.00 $232.00 $214.00 $229.00 $232.00
95958 $296.00 $633.00 $669.00 $684.00 $633.00 $669.00 $684.00
95958-26 $230.00 $255.00 $265.00 $274.00 $255.00 $265.00 $274.00
95958-TC $66.00 $377.00 $404.00 $409.00 $377.00 $404.00 $409.00
95961 $216.00 $337.00 $356.00 $367.00 $337.00 $356.00 $367.00
95961-26 $166.00 $184.00 $193.00 $202.00 $184.00 $193.00 $202.00
95961-TC $48.00 $153.00 $163.00 $165.00 $153.00 $163.00 $165.00
95962 $227.00 $290.00 $304.00 $313.00 $290.00 $304.00 $313.00
95962-26 $176.00 $196.00 $204.00 $212.00 $196.00 $204.00 $212.00
95962-TC $48.00 $94.00 $100.00 $102.00 $94.00 $100.00 $102.00
95965 BR ---------- ---------- ---------- ---------- ---------- ----------
95965-26 $420.00 $474.00 $490.00 $504.00 $474.00 $490.00 $504.00
95965-TC BR ---------- ---------- ---------- ---------- ---------- ----------
95966 BR ---------- ---------- ---------- ---------- ---------- ----------
95966-26 $210.00 $237.00 $245.00 $253.00 $237.00 $245.00 $253.00
95966-TC BR ---------- ---------- ---------- ---------- ---------- ----------
95967 BR ---------- ---------- ---------- ---------- ---------- ----------
95967-26 $184.00 $208.00 $215.00 $222.00 $208.00 $215.00 $222.00
95967-TC BR ---------- ---------- ---------- ---------- ---------- ----------
95970 $22.00 $74.00 $79.00 $80.00 $27.00 $29.00 $30.00
95971 $39.00 $56.00 $59.00 $61.00 $46.00 $48.00 $50.00
95972 $78.00 $65.00 $68.00 $71.00 $48.00 $50.00 $52.00
95974 $155.00 $232.00 $244.00 $254.00 $187.00 $195.00 $205.00
95975 $88.00 $125.00 $131.00 $136.00 $105.00 $110.00 $115.00
95978 ---------- $279.00 $293.00 $305.00 $219.00 $229.00 $240.00
95979 ---------- $121.00 $127.00 $132.00 $102.00 $106.00 $111.00
95980 ---------- $54.00 $57.00 $63.00 $54.00 $57.00 $63.00
95981 ---------- $35.00 $38.00 $39.00 $20.00 $21.00 $23.00
95982 ---------- $59.00 $63.00 $66.00 $42.00 $44.00 $47.00
95990 $57.00 $97.00 $104.00 $106.00 $97.00 $104.00 $106.00
95991 ---------- $129.00 $137.00 $140.00 $45.00 $47.00 $49.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 407
Medicine
CPT Code 2003 MRALocality 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)
95992 ---------- $48.00 $50.00 $51.00 $42.00 $43.00 $45.00
95999 BR ---------- ---------- ---------- ---------- ---------- ----------
96000 $93.00 $107.00 $111.00 $115.00 $107.00 $111.00 $115.00
96001 $111.00 $140.00 $149.00 $160.00 $140.00 $149.00 $160.00
96002 $21.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
96003 $20.00 $19.00 $19.00 $19.00 $19.00 $19.00 $19.00
96004 $97.00 $132.00 $137.00 $143.00 $132.00 $137.00 $143.00
96020 ---------- BR BR BR BR BR BR
96020-26 ---------- $181.00 $186.00 $190.00 $181.00 $186.00 $190.00
96020-TC ---------- BR BR BR BR BR BR
96101 ---------- $89.00 $91.00 $93.00 $88.00 $90.00 $93.00
96102 ---------- $67.00 $71.00 $72.00 $27.00 $27.00 $28.00
96103 ---------- $31.00 $32.00 $33.00 $30.00 $31.00 $32.00
96105 $68.00 $119.00 $123.00 $126.00 $119.00 $123.00 $126.00
96110 $88.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.00
96111 $68.00 $147.00 $151.00 $156.00 $140.00 $145.00 $149.00
96116 ---------- $103.00 $106.00 $109.00 $97.00 $99.00 $102.00
96118 ---------- $108.00 $111.00 $114.00 $88.00 $90.00 $92.00
96119 ---------- $86.00 $90.00 $92.00 $27.00 $27.00 $28.00
96120 ---------- $53.00 $56.00 $57.00 $29.00 $31.00 $32.00
96125 ---------- $128.00 $133.00 $136.00 $128.00 $133.00 $136.00
96127 ---------- $6.00 $7.00 $7.00 $6.00 $7.00 $7.00
96150 ---------- $24.00 $25.00 $25.00 $24.00 $24.00 $25.00
96151 ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $24.00
96152 ---------- $22.00 $23.00 $23.00 $22.00 $22.00 $23.00
96153 ---------- $5.00 $5.00 $6.00 $5.00 $5.00 $5.00
96154 ---------- $22.00 $22.00 $23.00 $21.00 $22.00 $23.00
96155 ---------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.00
96360 ---------- $62.00 $66.00 $68.00 $62.00 $66.00 $68.00
96361 ---------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.00
96365 ---------- $75.00 $80.00 $81.00 $75.00 $80.00 $81.00
96366 ---------- $20.00 $22.00 $22.00 $20.00 $22.00 $22.00
96367 ---------- $33.00 $35.00 $36.00 $33.00 $35.00 $36.00
96368 ---------- $22.00 $24.00 $24.00 $22.00 $24.00 $24.00
96369 ---------- $191.00 $203.00 $206.00 $191.00 $203.00 $206.00
96370 See formula $17.00 $17.00 $18.00 $17.00 $17.00 $18.00
96371 ---------- $73.00 $78.00 $79.00 $73.00 $78.00 $79.00
96372 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00
96373 ---------- $21.00 $22.00 $22.00 $21.00 $22.00 $22.00
96374 ---------- $62.00 $66.00 $68.00 $62.00 $66.00 $68.00
96375 ---------- $24.00 $26.00 $26.00 $24.00 $26.00 $26.00
96377 ---------- BR BR BR BR BR BR
96401 ---------- $80.00 $86.00 $88.00 $80.00 $86.00 $88.00
96402 ---------- $35.00 $38.00 $38.00 $35.00 $38.00 $38.00
96405 $57.00 $89.00 $94.00 $95.00 $34.00 $35.00 $36.00
96406 $86.00 $130.00 $137.00 $140.00 $52.00 $54.00 $56.00
96409 ---------- $120.00 $128.00 $131.00 $120.00 $128.00 $131.00
96411 ---------- $67.00 $72.00 $74.00 $67.00 $72.00 $74.00
96413 ---------- $149.00 $159.00 $163.00 $149.00 $159.00 $163.00
96415 ---------- $31.00 $33.00 $34.00 $31.00 $33.00 $34.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 408
Medicine
CPT Code 2003 MRALocality 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)
96416 ---------- $150.00 $160.00 $164.00 $150.00 $160.00 $164.00
96417 ---------- $70.00 $75.00 $77.00 $70.00 $75.00 $77.00
96420 $46.00 $115.00 $123.00 $126.00 $115.00 $123.00 $126.00
96422 $46.00 $199.00 $213.00 $218.00 $199.00 $213.00 $218.00
96423 $17.00 $81.00 $87.00 $89.00 $81.00 $87.00 $89.00
96425 $54.00 $197.00 $212.00 $217.00 $197.00 $212.00 $217.00
96440 $156.00 $842.00 $899.00 $922.00 $146.00 $157.00 $172.00
96446 ---------- $221.00 $238.00 $249.00 $36.00 $41.00 $49.00
96450 $134.00 $198.00 $209.00 $214.00 $91.00 $95.00 $99.00
96521 ---------- $150.00 $161.00 $165.00 $150.00 $161.00 $165.00
96522 ---------- $123.00 $132.00 $136.00 $123.00 $132.00 $136.00
96523 ---------- $27.00 $28.00 $29.00 $27.00 $28.00 $29.00
96542 $126.00 $135.00 $143.00 $145.00 $47.00 $49.00 $51.00
96549 BR ---------- ---------- ---------- ---------- ---------- ----------
96567 $62.00 $144.00 $155.00 $157.00 $144.00 $155.00 $157.00
96570 $69.00 $66.00 $70.00 $76.00 $66.00 $70.00 $76.00
96571 $38.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00
96900 $17.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00
96904 ---------- $67.00 $72.00 $73.00 $67.00 $72.00 $73.00
96910 $21.00 $76.00 $81.00 $82.00 $76.00 $81.00 $82.00
96912 $24.00 $98.00 $104.00 $106.00 $98.00 $104.00 $106.00
96913 $53.00 $139.00 $148.00 $151.00 $139.00 $148.00 $151.00
96920 $152.00 $169.00 $179.00 $182.00 $75.00 $78.00 $80.00
96921 $155.00 $187.00 $197.00 $200.00 $85.00 $88.00 $91.00
96922 $214.00 $259.00 $272.00 $277.00 $137.00 $142.00 $146.00
96931 ---------- $173.00 $185.00 $190.00 $173.00 $185.00 $190.00
96932 ---------- $30.00 $33.00 $33.00 $30.00 $33.00 $33.00
96933 ---------- $52.00 $54.00 $58.00 $52.00 $54.00 $58.00
96934 ---------- $91.00 $96.00 $101.00 $91.00 $96.00 $101.00
96935 ---------- $37.00 $40.00 $40.00 $37.00 $40.00 $40.00
96936 ---------- $49.00 $52.00 $56.00 $49.00 $52.00 $56.00
96999 BR ---------- ---------- ---------- ---------- ---------- ----------
97010 $10.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.00
97012 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.00
97014 $14.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.00
97016 $15.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00
97018 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
97022 $15.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00
97024 $10.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.00
97026 $9.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.00
97028 $10.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.00
97032 $16.00 $21.00 $22.00 $22.00 $21.00 $22.00 $22.00
97033 $16.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
97034 $13.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00
97035 $11.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00
97036 $19.00 $36.00 $38.00 $38.00 $36.00 $38.00 $38.00
97039 $15.00 ---------- ---------- ---------- ---------- ---------- ----------
97110 $22.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
97112 $23.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00
97113 $24.00 $47.00 $49.00 $50.00 $47.00 $49.00 $50.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 409
Medicine
CPT Code 2003 MRALocality 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)
97116 $21.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00
97124 $19.00 $29.00 $30.00 $30.00 $29.00 $30.00 $30.00
97139 $15.00 ---------- ---------- ---------- ---------- ---------- ----------
97140 $26.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.00
97150 $18.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.00
97161 ---------- $90.00 $94.00 $97.00 $90.00 $94.00 $97.00
97162 ---------- $90.00 $94.00 $97.00 $90.00 $94.00 $97.00
97163 ---------- $90.00 $94.00 $97.00 $90.00 $94.00 $97.00
97164 ---------- $61.00 $64.00 $66.00 $61.00 $64.00 $66.00
97165 ---------- $87.00 $91.00 $94.00 $87.00 $91.00 $94.00
97166 ---------- $87.00 $91.00 $94.00 $87.00 $91.00 $94.00
97167 ---------- $87.00 $91.00 $94.00 $87.00 $91.00 $94.00
97168 ---------- $57.00 $60.00 $62.00 $57.00 $60.00 $62.00
97169 ---------- BR BR BR BR BR BR
97170 ---------- BR BR BR BR BR BR
97171 ---------- BR BR BR BR BR BR
97172 ---------- BR BR BR BR BR BR
97260 $23.00 ---------- ---------- ---------- ---------- ---------- ----------
97261 $17.00 ---------- ---------- ---------- ---------- ---------- ----------
97530 $22.00 $38.00 $40.00 $40.00 $38.00 $40.00 $40.00
97532 $22.00 $29.00 $30.00 $31.00 $24.00 $25.00 $25.00
97533 $24.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00
97535 $23.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.00
97537 $23.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
97542 $17.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00
97545 $83.00 ---------- ---------- ---------- ---------- ---------- ----------
97546 $41.00 ---------- ---------- ---------- ---------- ---------- ----------
97597 ---------- $82.00 $86.00 $87.00 $26.00 $27.00 $27.00
97598 ---------- $27.00 $28.00 $29.00 $12.00 $13.00 $13.00
97602 BR ---------- ---------- ---------- ---------- ---------- ----------
97605 ---------- $45.00 $47.00 $48.00 $28.00 $29.00 $29.00
97606 ---------- $53.00 $56.00 $57.00 $30.00 $31.00 $32.00
97610 ---------- $129.00 $137.00 $138.00 $18.00 $18.00 $18.00
97750 BR BR BR BR BR BR BR
97752 $48.00 ---------- ---------- ---------- ---------- ---------- ----------
97755 ---------- $39.00 $41.00 $42.00 $39.00 $41.00 $42.00
97760 ---------- $42.00 $44.00 $45.00 $42.00 $44.00 $45.00
97761 ---------- $37.00 $38.00 $39.00 $37.00 $38.00 $39.00
97762 ---------- $52.00 $55.00 $56.00 $52.00 $55.00 $56.00
97799 BR ---------- ---------- ---------- ---------- ---------- ----------
97802 $26.00 $38.00 $40.00 $40.00 $36.00 $37.00 $38.00
97803 $17.00 $33.00 $34.00 $35.00 $31.00 $32.00 $32.00
97804 $7.00 $18.00 $18.00 $19.00 $17.00 $17.00 $18.00
97810 ---------- $41.00 $42.00 $44.00 $34.00 $36.00 $37.00
97811 ---------- $30.00 $31.00 $33.00 $28.00 $29.00 $30.00
97813 ---------- $43.00 $45.00 $46.00 $37.00 $39.00 $40.00
97814 ---------- $34.00 $35.00 $37.00 $31.00 $32.00 $33.00
97850 $54.00 ---------- ---------- ---------- ---------- ---------- ----------
97851 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
97852 $54.00 ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 410
Medicine
CPT Code 2003 MRALocality 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)
97853 $26.00 ---------- ---------- ---------- ---------- ---------- ----------
98925 NC NC NC NC NC NC NC
98926 $32.00 $51.00 $53.00 $54.00 $40.00 $42.00 $43.00
98927 NC NC NC NC NC NC NC
98928 $23.00 $81.00 $84.00 $86.00 $67.00 $69.00 $71.00
98929 NC NC NC NC NC NC NC
98940 NC NC NC NC NC NC NC
98941 $32.00 $45.00 $46.00 $47.00 $39.00 $39.00 $40.00
98942 NC NC NC NC NC NC NC
98943 $23.00 $30.00 $32.00 $33.00 $27.00 $27.00 $28.00
98960 ---------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.00
98961 ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00
98962 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
99000 $6.00 ---------- ---------- ---------- ---------- ---------- ----------
99001 $4.00 ---------- ---------- ---------- ---------- ---------- ----------
99002 $35.00 ---------- ---------- ---------- ---------- ---------- ----------
99026 BR ---------- ---------- ---------- ---------- ---------- ----------
99027 BR ---------- ---------- ---------- ---------- ---------- ----------
99070 BR ---------- ---------- ---------- ---------- ---------- ----------
99071 NC NC NC NC NC NC NC
99075 See 440.13 ---------- ---------- ---------- ---------- ---------- ----------
99078 NC NC NC NC NC NC NC
99082 BR ---------- ---------- ---------- ---------- ---------- ----------
99090 BR ---------- ---------- ---------- ---------- ---------- ----------
99152 ---------- $55.00 $59.00 $60.00 $14.00 $14.00 $15.00
99153 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
99156 ---------- $86.00 $90.00 $94.00 $86.00 $90.00 $94.00
99157 ---------- $65.00 $68.00 $71.00 $65.00 $68.00 $71.00
99172 BR ---------- ---------- ---------- ---------- ---------- ----------
99173 BR $4.00 $4.00 $4.00 $4.00 $4.00 $4.00
99174 ---------- BR BR BR BR BR BR
99175 $53.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.00
99183 $123.00 $126.00 $132.00 $140.00 $126.00 $132.00 $140.00
99184 ---------- $241.00 $250.00 $262.00 $241.00 $250.00 $262.00
99190 BR ---------- ---------- ---------- ---------- ---------- ----------
99191 BR ---------- ---------- ---------- ---------- ---------- ----------
99192 BR ---------- ---------- ---------- ---------- ---------- ----------
99195 $16.00 $108.00 $116.00 $119.00 $108.00 $116.00 $119.00
99199 NC NC NC NC NC NC NC
G0101 ---------- $43.00 $45.00 $47.00 $32.00 $33.00 $35.00
G0102 ---------- $22.00 $23.00 $23.00 $10.00 $10.00 $11.00
G0104 ---------- $182.00 $194.00 $199.00 $65.00 $69.00 $73.00
G0105 ---------- $351.00 $372.00 $388.00 $217.00 $229.00 $243.00
G0105-53 ---------- $175.00 $186.00 $193.00 $109.00 $115.00 $122.00
G0106 ---------- $228.00 $242.00 $245.00 $228.00 $242.00 $245.00
G0106-26 ---------- $55.00 $56.00 $57.00 $55.00 $56.00 $57.00
G0106-TC ---------- $174.00 $186.00 $188.00 $174.00 $186.00 $188.00
G0108 ---------- $59.00 $62.00 $63.00 $59.00 $62.00 $63.00
G0109 ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00
G0117 ---------- $59.00 $62.00 $63.00 $59.00 $62.00 $63.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 411
Medicine
CPT Code 2003 MRALocality 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)
G0118 ---------- $46.00 $49.00 $50.00 $46.00 $49.00 $50.00
G0120 ---------- $234.00 $249.00 $256.00 $234.00 $249.00 $256.00
G0120-26 ---------- $60.00 $64.00 $68.00 $60.00 $64.00 $68.00
G0120-TC ---------- $174.00 $186.00 $188.00 $174.00 $186.00 $188.00
G0121 ---------- $352.00 $373.00 $390.00 $218.00 $230.00 $245.00
G0121-53 ---------- $176.00 $186.00 $194.00 $109.00 $115.00 $123.00
G0122 ---------- $287.00 $304.00 $308.00 $287.00 $304.00 $308.00
G0122-26 ---------- $55.00 $56.00 $58.00 $55.00 $56.00 $58.00
G0122-TC ---------- $232.00 $247.00 $250.00 $232.00 $247.00 $250.00
G0128 ---------- $8.00 $9.00 $10.00 $8.00 $9.00 $10.00
G0166 ---------- $148.00 $159.00 $161.00 $148.00 $159.00 $161.00
G0179 ---------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.00
G0180 ---------- $59.00 $62.00 $64.00 $59.00 $62.00 $64.00
G0181 ---------- $120.00 $125.00 $129.00 $120.00 $125.00 $129.00
G0182 ---------- $121.00 $125.00 $129.00 $121.00 $125.00 $129.00
G0237 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
G0238 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
G0239 ---------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.00
G0248 ---------- $117.00 $125.00 $127.00 $117.00 $125.00 $127.00
G0249 ---------- $117.00 $125.00 $127.00 $117.00 $125.00 $127.00
G0250 ---------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
G0268 ---------- $59.00 $63.00 $66.00 $39.00 $41.00 $44.00
G0270 ---------- $33.00 $34.00 $35.00 $31.00 $32.00 $32.00
G0271 ---------- $18.00 $18.00 $19.00 $17.00 $17.00 $18.00
G0277 ---------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.00
G0281 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00
G0283 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00
G0329 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00
G0403 ---------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.00
G0404 ---------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00
G0405 ---------- $10.00 $10.00 $10.00 $10.00 $10.00 $10.00
G0422 ---------- $120.00 $125.00 $128.00 $120.00 $125.00 $128.00
G0423 ---------- $120.00 $125.00 $128.00 $120.00 $125.00 $128.00
G0424 ---------- $32.00 $34.00 $35.00 $16.00 $16.00 $17.00
G0453 ---------- $37.00 $38.00 $40.00 $37.00 $38.00 $40.00
G0454 ---------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00
G0459 ---------- $46.00 $47.00 $48.00 $46.00 $47.00 $48.00
G0473 ---------- $14.00 $15.00 $15.00 $13.00 $13.00 $14.00
G0500 ---------- $63.00 $67.00 $68.00 $7.00 $7.00 $8.00
G0502 ---------- $155.00 $162.00 $166.00 $99.00 $103.00 $107.00
G0503 ---------- $137.00 $144.00 $147.00 $89.00 $93.00 $96.00
G0504 ---------- $72.00 $75.00 $77.00 $48.00 $50.00 $51.00
G0505 ---------- $260.00 $271.00 $278.00 $196.00 $203.00 $209.00
G0506 ---------- $70.00 $73.00 $75.00 $51.00 $53.00 $55.00
G9157 ---------- $110.00 $114.00 $119.00 $110.00 $114.00 $119.00
G9187 ---------- $48.00 $52.00 $53.00 $48.00 $52.00 $53.00
P3001 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00
Q0035 ---------- $22.00 $24.00 $25.00 $22.00 $24.00 $25.00
Q0035-26 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
Q0035-TC ---------- $13.00 $14.00 $14.00 $13.00 $14.00 $14.00
Q0091 ---------- $49.00 $52.00 $54.00 $22.00 $23.00 $25.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 412
Evaluation and Management
CPT Code 2003 MRALocality 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 $48.00 $51.00 $53.00 $30.00 $32.00 $33.00
99202 $58.00 $82.00 $87.00 $89.00 $57.00 $59.00 $62.00
99203 $58.00 $120.00 $126.00 $131.00 $87.00 $91.00 $95.00
99204 $84.00 $182.00 $191.00 $198.00 $146.00 $152.00 $159.00
99205 $84.00 $230.00 $241.00 $251.00 $190.00 $198.00 $208.00
99211 $19.00 $22.00 $23.00 $24.00 $10.00 $11.00 $11.00
99212 $31.00 $48.00 $50.00 $52.00 $29.00 $30.00 $31.00
99213 $40.00 $80.00 $84.00 $87.00 $57.00 $59.00 $62.00
99214 $40.00 $118.00 $124.00 $127.00 $88.00 $91.00 $94.00
99215 $65.00 $160.00 $167.00 $172.00 $124.00 $129.00 $134.00
99217 $65.00 $81.00 $85.00 $88.00 $81.00 $85.00 $88.00
99218 $65.00 $112.00 $116.00 $121.00 $112.00 $116.00 $121.00
99219 $109.00 $152.00 $158.00 $164.00 $152.00 $158.00 $164.00
99220 $152.00 $208.00 $216.00 $224.00 $208.00 $216.00 $224.00
99221 $66.00 $115.00 $120.00 $126.00 $115.00 $120.00 $126.00
99222 $109.00 $154.00 $160.00 $167.00 $154.00 $160.00 $167.00
99223 $152.00 $227.00 $236.00 $246.00 $227.00 $236.00 $246.00
99224 ---------- $45.00 $47.00 $49.00 $45.00 $47.00 $49.00
99225 ---------- $82.00 $84.00 $87.00 $82.00 $84.00 $87.00
99226 ---------- $118.00 $122.00 $126.00 $118.00 $122.00 $126.00
99231 $33.00 $44.00 $46.00 $48.00 $44.00 $46.00 $48.00
99232 $54.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.00
99233 $77.00 $117.00 $121.00 $126.00 $117.00 $121.00 $126.00
99234 $129.00 $150.00 $156.00 $162.00 $150.00 $156.00 $162.00
99235 $173.00 $189.00 $197.00 $204.00 $189.00 $197.00 $204.00
99236 $213.00 $244.00 $253.00 $263.00 $244.00 $253.00 $263.00
99238 $66.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.00
99239 $88.00 $120.00 $124.00 $128.00 $120.00 $124.00 $128.00
99241 $54.00 $52.00 $55.00 $56.00 $36.00 $38.00 $39.00
99242 $88.00 $99.00 $103.00 $106.00 $76.00 $79.00 $82.00
99243 $117.00 $135.00 $141.00 $145.00 $107.00 $110.00 $114.00
99244 $163.00 $203.00 $211.00 $217.00 $172.00 $178.00 $184.00
99245 $212.00 $247.00 $257.00 $264.00 $213.00 $220.00 $227.00
99251 $54.00 $55.00 $57.00 $58.00 $55.00 $57.00 $58.00
99252 $70.00 $84.00 $86.00 $89.00 $84.00 $86.00 $89.00
99253 $96.00 $128.00 $132.00 $137.00 $128.00 $132.00 $137.00
99254 $138.00 $186.00 $193.00 $199.00 $186.00 $193.00 $199.00
99255 $190.00 $225.00 $233.00 $240.00 $225.00 $233.00 $240.00
99281 $18.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00
99282 $28.00 $47.00 $49.00 $51.00 $47.00 $49.00 $51.00
99283 $60.00 $70.00 $73.00 $77.00 $70.00 $73.00 $77.00
99284 $94.00 $133.00 $138.00 $146.00 $133.00 $138.00 $146.00
99285 $103.00 $197.00 $205.00 $215.00 $197.00 $205.00 $215.00
99291 $192.00 $306.00 $320.00 $333.00 $252.00 $262.00 $275.00
99292 $95.00 $138.00 $144.00 $150.00 $127.00 $132.00 $138.00
99304 ---------- $102.00 $106.00 $110.00 $102.00 $106.00 $110.00
99305 ---------- $145.00 $151.00 $156.00 $145.00 $151.00 $156.00
99306 ---------- $186.00 $193.00 $199.00 $186.00 $193.00 $199.00
99307 ---------- $50.00 $52.00 $53.00 $50.00 $52.00 $53.00
99308 ---------- $77.00 $80.00 $83.00 $77.00 $80.00 $83.00
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 413
Evaluation and Management
CPT Code 2003 MRALocality 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)
99309 ---------- $102.00 $106.00 $109.00 $102.00 $106.00 $109.00
99310 ---------- $151.00 $157.00 $163.00 $151.00 $157.00 $163.00
99315 $60.00 $82.00 $85.00 $87.00 $82.00 $85.00 $87.00
99316 $77.00 $118.00 $123.00 $127.00 $118.00 $123.00 $127.00
99318 ---------- $107.00 $111.00 $115.00 $107.00 $111.00 $115.00
99324 ---------- $62.00 $64.00 $66.00 $62.00 $64.00 $66.00
99325 ---------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.00
99326 ---------- $156.00 $162.00 $167.00 $156.00 $162.00 $167.00
99327 ---------- $207.00 $215.00 $222.00 $207.00 $215.00 $222.00
99328 ---------- $243.00 $252.00 $261.00 $243.00 $252.00 $261.00
99334 ---------- $67.00 $70.00 $72.00 $67.00 $70.00 $72.00
99335 ---------- $106.00 $110.00 $113.00 $106.00 $110.00 $113.00
99336 ---------- $150.00 $156.00 $162.00 $150.00 $156.00 $162.00
99337 ---------- $216.00 $224.00 $232.00 $216.00 $224.00 $232.00
99339 ---------- $85.00 $89.00 $91.00 $85.00 $89.00 $91.00
99340 ---------- $120.00 $125.00 $129.00 $120.00 $125.00 $129.00
99341 $59.00 $61.00 $64.00 $66.00 $61.00 $64.00 $66.00
99342 $85.00 $89.00 $92.00 $95.00 $89.00 $92.00 $95.00
99343 $109.00 $146.00 $151.00 $157.00 $146.00 $151.00 $157.00
99344 $160.00 $204.00 $212.00 $219.00 $204.00 $212.00 $219.00
99345 $193.00 $247.00 $257.00 $267.00 $247.00 $257.00 $267.00
99347 $46.00 $62.00 $64.00 $66.00 $62.00 $64.00 $66.00
99348 $71.00 $94.00 $98.00 $101.00 $94.00 $98.00 $101.00
99349 $107.00 $143.00 $149.00 $154.00 $143.00 $149.00 $154.00
99350 $156.00 $199.00 $207.00 $214.00 $199.00 $207.00 $214.00
99354 $106.00 $145.00 $150.00 $156.00 $137.00 $142.00 $147.00
99355 $104.00 $109.00 $113.00 $117.00 $101.00 $105.00 $109.00
99356 $87.00 $103.00 $107.00 $110.00 $103.00 $107.00 $110.00
99357 $88.00 $103.00 $107.00 $110.00 $103.00 $107.00 $110.00
99360 BR $68.00 $71.00 $73.00 $68.00 $71.00 $73.00
99363 ---------- $139.00 $146.00 $150.00 $94.00 $97.00 $101.00
99364 ---------- $48.00 $50.00 $51.00 $36.00 $37.00 $39.00
99366 ---------- $48.00 $50.00 $51.00 $47.00 $49.00 $50.00
99367 ---------- $63.00 $65.00 $68.00 $63.00 $65.00 $68.00
99368 ---------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.00
99374 $75.00 $78.00 $81.00 $83.00 $63.00 $65.00 $68.00
99375 $75.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.00
99377 $75.00 $78.00 $81.00 $83.00 $63.00 $65.00 $68.00
99378 $104.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.00
99379 $75.00 $78.00 $81.00 $83.00 $63.00 $65.00 $68.00
99380 $104.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.00
99406 ---------- $16.00 $17.00 $18.00 $14.00 $14.00 $15.00
99407 ---------- $31.00 $33.00 $34.00 $29.00 $30.00 $31.00
99408 ---------- $39.00 $41.00 $42.00 $37.00 $39.00 $40.00
99409 ---------- $76.00 $79.00 $82.00 $74.00 $77.00 $80.00
99415 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
99416 ---------- $5.00 $5.00 $5.00 $5.00 $5.00 $5.00
99450 NC NC NC NC NC NC NC
99455 $90.00 ---------- ---------- ---------- ---------- ---------- ----------
99456 BR ---------- ---------- ---------- ---------- ---------- ----------
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________
CPT only © 2016 American Medical Association. All rights reserved. Part C, 414
Evaluation and Management
CPT Code 2003 MRALocality 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)
99457 BR ---------- ---------- ---------- ---------- ---------- ----------
99487 ---------- $101.00 $106.00 $109.00 $58.00 $60.00 $62.00
99489 ---------- $51.00 $53.00 $54.00 $29.00 $30.00 $31.00
99490 ---------- $47.00 $49.00 $50.00 $36.00 $37.00 $39.00
99495 ---------- $180.00 $188.00 $193.00 $123.00 $128.00 $132.00
99496 ---------- $254.00 $266.00 $273.00 $179.00 $185.00 $191.00
99497 ---------- $91.00 $94.00 $98.00 $86.00 $89.00 $92.00
99498 ---------- $80.00 $83.00 $85.00 $80.00 $83.00 $85.00
99499 BR ---------- ---------- ---------- ---------- ---------- ----------
99600 BR ---------- ---------- ---------- ---------- ---------- ----------
G0245 ---------- $73.00 $76.00 $78.00 $48.00 $50.00 $52.00
G0246 ---------- $42.00 $44.00 $45.00 $24.00 $25.00 $26.00
G0296 ---------- $32.00 $33.00 $34.00 $30.00 $31.00 $32.00
G0337 ---------- $81.00 $84.00 $86.00 $81.00 $84.00 $86.00
G0372 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00
G0396 ---------- $40.00 $42.00 $43.00 $38.00 $39.00 $41.00
G0397 ---------- $79.00 $81.00 $84.00 $76.00 $79.00 $82.00
G0402 ---------- $184.00 $192.00 $197.00 $142.00 $147.00 $152.00
G0406 ---------- $43.00 $44.00 $46.00 $43.00 $44.00 $46.00
G0407 ---------- $80.00 $83.00 $86.00 $80.00 $83.00 $86.00
G0408 ---------- $115.00 $119.00 $123.00 $115.00 $119.00 $123.00
G0409 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00
G0507 ---------- $52.00 $54.00 $56.00 $36.00 $37.00 $38.00
G0508 ---------- $223.00 $231.00 $239.00 $223.00 $231.00 $239.00
G0509 ---------- $215.00 $222.00 $231.00 $215.00 $222.00 $231.00
G9685 ---------- $227.00 $236.00 $246.00 $227.00 $236.00 $246.00
G9686 ---------- $88.00 $91.00 $94.00 $88.00 $91.00 $94.00
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 415 Effective Date: _______
4B3BChapter 4 Billing Instructions and Forms
53BBill Submission/Filing and Reporting Requirements
Carrier
Responsibilities
A carrier is responsible for meeting its obligations under this Manual
regardless of any business arrangements with any service company/TPA,
submitter, or any entity acting on behalf of the carrier under which medical
bills are paid, adjusted and paid, disallowed, denied, or otherwise processed
or submitted to the Division.
At the time of authorization for medical service(s) or upon receipt of
notification of emergency care, a carrier must notify each HCP, in writing,
of additional form completion requirements or supporting documentation
that are necessary for reimbursement determinations that are in addition to
the requirements of this Manual and Rule 69L-7.740, F.A.C.
At the time of authorization for medical service(s), or upon receipt of
notification of emergency care, a carrier must inform out-of-state health care
providers of the specific reporting, billing, and submission requirements of
this Manual and Rule 69L-7.740, F.A.C., and provide in-state and out-of-
state HCPs the specific address for submitting a reimbursement request.
Provider
Responsibilities
All HCPs are required to meet their obligations under this Manual,
regardless of any business arrangement with any entity under which medical
bills are prepared, processed, or submitted to the carrier.
Billing for Services
Under Payment
Plan(s)
HCPs receiving reimbursement under any payment plan(s) (pre-payment,
prospective payment, or capitation, etc.) are required to accurately complete
the DWC-9 and submit the form to the carrier for all services rendered to
injured workers.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 416 Effective Date: _______
Chapter 4 Billing Instructions and Forms, continued
Bill Submission/Filing and Reporting Requirements, continued
Additional
Information
Requested by
Carrier
All HCPs are required to submit any additional form completion information
and supporting documentation requested, in writing, by the carrier at the
time of authorization.
Bill Completion Bills must be legibly and accurately completed by all HCPs.
A carrier can require an HCP to complete additional data elements that are
not required by the Division on the DWC-9, DWC-10, DWC-11, or DWC-
90, if requested by the carrier, in writing, at the time of authorization.
Form
DFS-F5-DWC-25
Physicians must utilize only the DWC-25 to request authorization for
treatment, to report the injured worker’s medical treatment/status and:
No other reporting forms may be used in lieu of the DWC-25;
Failure to accurately complete and submit the DWC-25 in
accordance with the instructions provided in this Manual may result
in the Division imposing sanctions or penalties pursuant to section
440.13(8), F.S., or section 440.13(11) F.S.;
The DWC-25 does not replace physician notes, medical records or
Division-required medical reports;
All information submitted on physician notes, medical records, or
Division-required medical reports must be consistent with
information documented on the DWC-25; and
Carriers must utilize the information submitted on the DWC-25 to
monitor the medical necessity of services provided and services
requested based on the medical condition being treated during the
authorization process.
Note: The Interactive Form DWC-25 is available under the “Forms” section
on the DWC website.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 417 Effective Date: _______
Chapter 4 Billing Instructions and Forms, continued
Bill Submission/Filing and Reporting Requirements, continued
Billing for a
Compensable
Injury
All medical bills and forms related to services rendered for a compensable
injury must be submitted by an HCP to the carrier, service company/TPA, or
any entity acting on behalf of the carrier, as a requirement for billing.
Methods for
Billing
Medical claim forms or medical bills may be electronically filed or
submitted via facsimile by an HCP to the carrier, service company/TPA, or
any entity acting on behalf of the carrier, provided the carrier agrees.
Bill Corrections HCPs are responsible for correcting and resubmitting any billing forms
returned by the carrier, service company/TPA, or any entity acting on behalf
of the carrier.
54BForm DFS-F5-DWC-9/CMS-1500
Health Care
Providers Who
Bill on the
DWC-9
HCPs, except physician assistants, advanced registered nurse practitioners,
certified registered nurse anesthetists, and anesthesia assistants, who are
salaried workers of an authorized physician and who render direct billable
services for which reimbursement is sought from a carrier, service
company/TPA, or any entity acting on behalf of the carrier or service
company/TPA, must report and bill for such services on a DWC-9 by
entering the employing physician’s DOH license number in Field 33b on the
DWC-9.
Home Medical
Equipment
Physicians, physician assistants, and ARNPs billing for Home Medical
Equipment must enter the applicable HCPCS Level II® code in Field 24D on
the DWC-9 and attach the acquisition invoice documenting the cost of the
supply.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 418 Effective Date: _______
Chapter 4 Billing Instructions and Forms, continued
Form DFS-F5-DWC-9/CMS-1500, continued
Dispensing
Prescription
Medications
Physicians, Physician Assistants, and ARNPs must enter the NDC number in
the universal 5 4 2 format, with no dashes, in Form Field 24D when billing
for dispensed medication.
The Workers’ Compensation Unique Procedure Code DSPNS must be billed
in addition to the NDC number in Field 24D if the drug is dispensed from
the practitioner’s office for the injured worker’s use at home.
Compounded Drugs Pursuant to paragraph 69L-7.730(2)(l), F.A.C., when a physician or
pharmacist compounds a drug that is not commercially available for
prescription use by the injured worker at home, the physician or pharmacist
must bill the Workers’ Compensation Unique Procedure Code COMPD in
Field 24D.
Submission of an itemized list which contains the NDC number and quantity
used for each component is a reimbursement requirement for compounded
drugs.
Reimbursement is the lesser of:
1. [AWP (of each component)] + $4.18 = Reimbursement; or
2. The amount the carrier has contracted for pursuant to
section 440.13(12)(c), F.S.
Note: Please refer to section 440.13(12)(c), F.S., for the
definition of AWP.
Administration of
Injectable
Medications
HCPs must use the appropriate HCPCS Level II® code in Fields 24D when
available. If no HCPCS Level II® code is available, use the NDC number in
the universal NDC 5 4 2 format, with no dashes, in Field 24D.
Over-the-Counter
Medications
HCPs must use the appropriate HCPCS Level II® code in Field 24D when
available. If no HCPCS Level II® code is available, use the NDC number in
the universal 5 4 2 format, with no dashes, in Field 24D.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 419 Effective Date: _______
Chapter 4 Billing Instructions and Forms, continued
Form DFS-F5-DWC-9/CMS-1500, continued
Medication
Management
Therapy Services
Pharmacists who provide Medication Management Therapy Services that are
ordered by an HCP must bill by entering the appropriate CPT® code in Field
24D.
Note: A copy of the written prescription order for Medication Management
Therapy Services must be submitted with the bill for reimbursement.
Non-Physician
Surgical
Assistant
A certified physician assistant or registered nurse first assistant who
provides services as a surgical assistant, in lieu of a second physician, must
enter the CPT® code(s) which represents the service(s) provided with
modifier AS in Field 24D.
55BForm DFS-F5-DWC-10
Health Care
Providers Who
Bill on the
DWC-10
Pharmacists must bill using the DWC-10 for pharmaceuticals and medical
supplies prescribed by an HCP.
Medical Suppliers must bill using the DWC-10 and are required to bill using
HCPCS Level II® codes for medical supplies and equipment prescribed by
an HCP.
Note: Pharmacists and medical suppliers may only bill on an alternate to
DWC-10 when a carrier has pre-approved the use of an alternate form. The
DWC-9, DWC-11, or DWC-90 must not be approved for use as an alternate
form.
Billing Policy Pharmacists must enter the NDC number, in the universal 5 4 2 format, with
no dashes, in form Field 9.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 420 Effective Date: _______
Chapter 4 Billing Instructions and Forms, continued
Form DFS-F5-DWC-10, continued
Compounded
Drugs
When a pharmacist compounds a drug that is not commercially available, the
pharmacist must enter the Workers’ Compensation Unique Procedure Code
COMPD in Field 9a of the DWC-10.
Submission of an itemized list which contains the NDC number and quantity
used for each component is a requirement for compounded drugs.
The individual drug components used in compounding must be identified by
the NDC numbers in the universal 5 4 2 format, with no dashes.
Over the
Counter
Medications
Pharmacists must enter the NDC number, in the universal 5 4 2 format, with
no dashes, in form Field 9a.
Home Medical
Equipment
Pharmacists must enter the applicable HCPCS Level II® code(s) in Field 21
of the DWC-10. Enter the quantity or units dispensed in Field 22.
HME providers or medical suppliers must enter the applicable HCPCS Level
II® code(s) in Field 21, and the quantity or units dispensed in Field 22.
The license number of the pharmacist, HME provider or medical supplier
must be entered in Field 29.
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 421 Effective Date: _______
Appendix A Workers’ Compensation Unique Procedure Codes
DSPNS Legend or prescription drugs dispensed by a licensed dispensing
practitioner. (See subsection 69L-7.720(1), F.A.C., for the
specific use of this code).
COMPD Compounded drugs dispensed by a pharmacist or physician.
(See subsection 69L-7.720(1), F.A.C., for the specific use
of this code).
97260 Manipulation of spine by a physician other than an osteopathic or
chiropractic physician.
97261 Manipulation of the temporomandibular joint; upper extremities, including
the hand and wrist; the lower extremities; and other regions by a
physician other than an osteopathic or chiropractic physician.
97752 Muscle testing manually or by automated equipment with written report.
97850 Physical reconditioning assessment, per hour.
97851 Physical reconditioning assessment, additional thirty minutes.
97852 Physical reconditioning program, per hour.
97853 Physical reconditioning program, additional thirty minutes.
99456 Independent Medical Examination.
99456-CN Independent Medical Examination; cancelled less than 24 hours before
appointment without good cause or failed to appear.
99457 Consensus Independent Medical Examination (CIME).
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 422 Effective Date: _______
Appendix B Official Source for References As medical information pertaining to coding systems and policies 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.
♦ Relative Value Guide: A Guide for Anesthesia Values
American Society of Anesthesiologists
520 N. Northwest Highway
Park Ridge, Il. 60068-2573
(847) 825-5586
Website: http://www.asahq.org
♦ Current Dental Terminology (CDT)
American Dental Association
211 East Chicago Avenue, 6th Floor
Chicago, Illinois 60611-2678
(312) 440-2653
(800) 621-8099
(312) 440-7494 Fax
Website: www.ada.org
ADA Order Department
American Dental Association
Post Office Box 776
St. Charles, Illinois 60174
(800) 947-4746
(888) 476-1880 Fax
Website link: ADA e Customer
♦ MediSpan
Wolters Kluwer Health, Inc.
8425 Woodfield Crossing Boulevard, Suite 490
Indianapolis, IN 46240
(855) 539-7686
(317) 735-5300
Website: www.wolterskluwer.com/Pages/Home.aspx
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
2017 Edition Page 423 Effective Date: _______
Appendix B Official Source for References, continued
Current Procedural Terminology, (CPT®
)
CPT® Assistant
Guide To The Evaluation of Permanent Impairment, 6th Edition
HCPCS Level II®
ICD-10-CM®
National Physician Fee Schedule Relative Value File
American Medical Association (AMA) – MAIN OFFICE
515 North State Street
Chicago, Illinois 60610
(312) 464-5000
(312) 464-4184 Fax
Website: 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.
American Academy of Orthopedic Surgeons (AAOS)
Complete Global Service Data for Orthopaedic Surgery, Vol. 1 & 2
9400 W. Higgins Road
Rosemont, Illinois 60018
(847) 823-7186
(847 ) 823-8125 Fax
Website: www.orthoguidelines.org/
Florida Workers’ Compensation Health Care Provider Reimbursement Manual
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Appendix C Medicare Payment Localities (Counties)
Locality 01 / Locality 02:
Alachua Gulf Okaloosa
Baker Hamilton Okeechobee
Bay Hardee Orange
Bradford Hendry Osceola
Brevard Hernando Pasco
Calhoun Highlands Pinellas
Charlotte Hillsborough Polk
Citrus Holmes Putnam
Clay Jackson Santa Rosa
Columbia Jefferson Sarasota
De Soto Lafayette St. Johns
Dixie Lake Sumter
Duval Leon Suwannee
Escambia Levy Taylor
Flagler Liberty Union
Franklin Madison Volusia
Gadsden Manatee Wakulla
Gilchrist Marion Walton
Glades Nassau Washington
Locality 01 / Locality 02:
Franklin Lake Putnam Alachua
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
Indian
River
Lee
Martin
Palm Beach
St. Lucie
Locality 04: Dade
Monroe
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Appendix D Forms
Note: The following Forms and Form Completion Instructions are incorporated by
reference in Rule 69L-7.720, F.A.C.
Forms Incorporated by Reference for Medical Billing, Filing and Reporting:
Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Claim Form, Rev 02/12).
Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Equipment
& Supplies Form).
Form DFS-F5-DWC-11 (American Dental Association Dental Claim Form,
Rev.2012).
Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical
Treatment/Status Reporting Form), Rev. 01/31/2008.
Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2006).
Form Completion Instructions are available at the following link:
DWC website, Click on “Chapter 69L-7.”
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Appendix E Definitions
1.“Add-on Code(s)” means a procedure performed in addition to a primary procedure
performed by the same physician. An ‘add-on’ code describes additional or supplemental
procedure(s) associated with the primary service and are designated with a ‘+’ sign in the
CPT® codebook.
2. “Ambulatory Surgical Center (ASC)” means a health care facility as defined in section
440.13(1)(f), F.S.
3. “Authorization” means the approval given to a health care provider by the carrier, self-
insured employer, or entity representing the carrier or self-insured employer for the provision
of medical services to an injured worker.
4. “Division” means the Division of Workers’ Compensation of the Department of Financial
Services as defined in section 440.02(14), F.S.
5. “Home Medical Equipment” is defined in section 400.925(6), F.S.
6. “Home Medical Equipment provider” is defined in section 400.925(7), F.S.
7. “Emergency Care and Services” means emergency services and care as defined in section
395.002, F.S.
8. “Health Care Provider (HCP)” means a provider as defined in section 440.13(1)(g), F.S.
9. “Home Health Agency” means an agency as defined in Chapter 400, Part III, F.S.
10. “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 worker by a health care
provider.
11. “Medically Necessary or Medical Necessity” means any medical service or medical
supply that satisfies the criteria for those terms as defined in section 440.13(1)(k), F.S.
12.“Medical Record” means patient records maintained in accordance with the form and
content required under Chapter 395, F.S.
13.“Medical Record Review” means a review of the medical record of the injured worker
in order to verify the medical necessity of the services and the care as they relate to the
itemized statement for a specific bill.
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Appendix E Definitions, continued
14.“Modifier 51 Exempt” means a HCPCS Level II® or CPT© procedure code that does
not require a modifier 51 or have multiple surgery pricing reduction applied for
reimbursement.
Note: See the CPT codebook for a list of “Modifier 51 Exempt” codes.
15.“NDC Number” means the National Drug Code number as defined in paragraph 69L-
7.710(1)(oo), F.A.C.
16.“Physician” means a physician as defined in section 440.13(1)(p), F.S.
17.“Repackaged NDC number” means the National Drug Code number as defined in
paragraph 69L-7.710(1)(oo), F.A.C.
18.“Unlisted Medication” means a medication that lacks assignment of a National Drug
Code (NDC number) or a HCPCS Level II® procedure code.