FLORIDA WORKERS’ COMPENSATION
HEALTH CARE PROVIDER
REIMBURSEMENT MANUAL
2004
Department of Financial Services
Division of Workers’ Compensation
200 East Gaines Street
Tallahassee, Florida 32399
Effective January 1, 2004
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
69L-7.020 Florida Workers’ Compensation Health Care Provider Reimbursement Manual.
(1) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004
Edition, is adopted by reference as part of this rule. The manual contains reimbursement policies,
guidelines, codes and maximum reimbursement allowances for medical services and supplies
provided by health care providers. The manual provides reimbursement policies and payment
methodologies for pharmacists and medical suppliers. The Florida Workers’ Compensation Health
Care Provider Reimbursement Manual, incorporated above, is available for inspection during normal
business hours at the Florida Department of Financial Services, Document Processing Section, 200
E. Gaines Street, Tallahassee, Florida 32399-0311, or via the Department’s web site at
http://www.fldfs.com .
(2) The Physicians’ Current Procedural Terminology (CPT®), 2003 Professional Edition,
Copyright 2002, American Medical Association; the Current Dental Terminology (CDT-4), Fourth
Edition, Copyright 2002, American Dental Association for D codes and for injectable J codes, and
the other medical services and supply codes, the American Medical Association “Healthcare
Common Procedure Coding System, Medicare’s National Level II Codes, HCPCS 2003”, Fifteenth
Edition, Copyright 2002, Ingenix Publishing Group, are adopted by reference as part of this rule.
When a health care provider performs a procedure or service, which is not listed in the Florida
Workers’ Compensation Health Care Provider Reimbursement Manual, incorporated in subsection
(1) above, the provider must use a code contained in the CPT®, CDT-4 or HCPCS section as
specified.
Specific Authority 440.591 F.S. Law Implemented: 440.13 (11), (12), and (14) F.S. History-New 10-1-82,
Amended 3-16-83, 11-6-83, 5-21-85, Formerly 38F-7.020, Amended 4-1-88, 7-20-88, 6-1-91, 4-29-92, 2-18-96, 91-97, 12-15-97, 9-17-98, 9-30-01, 7-7-02, Formerly 38F-7.020, Amended 00-00-03.
i
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
FLORIDA WORKERS’ COMPENSATION
HEALTH CARE PROVIDER
REIMBURSEMENT MANUAL
2004 EDITION
Rule 69L-7.020, Florida Administrative Code
In accordance with section 440.13, Florida Statutes (F.S.), this manual provides reimbursement
policies and a schedule of maximum reimbursement allowances, as applicable, for licensed
physicians, licensed health care providers, licensed pharmacists and medical suppliers rendering
medical services and supplies to Florida’s injured workers. The maximum reimbursement allowances
and procedure codes are listed in Section X.
NOTICES AND DISCLAIMERS
The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition,
provides five-digit codes and two-digit modifiers for reporting medical services and procedures that
were selected from the following references by the State of Florida for inclusion in this publication.
When a service or procedure is performed that does not have a code listed in the Florida Workers’
Compensation Health Care Provider Reimbursement Manual, 2004 Edition, the physician or health
care provider must use a code listed in the following materials:
Physicians’ Current Procedural Terminology (CPT®), 2003 Professional Edition,
Copyright 2002, American Medical Association.
Current Dental Terminology (CDT-4), Fourth Edition, Copyright 2002, American
Dental Association.
HCPCS 2003, Fifteenth Edition, Copyright 2002, Ingenix Publishing Group.
The CPT and CDT-4 contain listings of descriptive terms and identifying codes used by physicians
and dentists for reporting medical and dental services and procedures.
HCPCS is used in part for the listing of descriptive terms and codes for dental services and
procedures performed by dentists. HCPCS also contains a listing of injectable medications and codes
used to report injections administered by physicians as well as other codes used to report medical
services and supplies.
It is expressly understood and agreed that the American Medical Association’s rights include, but not
limited to, common law and statutory rights of literary property in the CPT and in any update thereto,
including all descriptive terms and identifying codes and modifiers for reporting procedures and
medical services and/or any other information or materials contained in the CPT and in any update
thereto are not assigned or released as a result of the agreement between the American Medical
Association and the State of Florida, but are at all times reserved and retained by the American
Medical Association.
ii
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
CPT codes, descriptions and material only are copyright 2002 American Medical Association. All
Rights Reserved. No fee schedules, basic units, relative values or related listings are included in
CPT. The American Medical Association assumes no liability for the data contained or not contained
herein.
This product includes CPT, which is commercial technical data and/or computer databases and/or
commercial computer software and/or commercial software documentation, as applicable which were
developed exclusively at private expense by the American Medical Association, 515 North State
Street, Chicago, Illinois 60610. U.S. Government rights to use, modify, reproduce, release, perform,
display, or disclose these technical data and/or computer data bases and/or computer software and/or
computer software documentation are subject to the limited rights restrictions of DFARS 252.2277015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and
DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and
the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights
provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any
applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
iii
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
CONTENTS
SECTION I:
ADMINISTRATIVE PURPOSE OF MANUAL ......................................................1
SECTION II:
BASIC PROGRAM REQUIREMENTS
Provider Eligibility.....................................................................................................1
Authorization..............................................................................................................1
Materials Adopted for Reference ...............................................................................1
Medical Records.........................................................................................................2
Reimbursement Information ......................................................................................3
SECTION III:
DENTAL SERVICES ................................................................................................6
SECTION IV:
DISPENSING OF MEDICATION
Medicinal Drugs.........................................................................................................6
Patent, Proprietary or Over-the-Counter Drugs .........................................................7
SECTION V:
MEDICAL SUPPLIER SERVICES
Appliances..................................................................................................................8
Devices.......................................................................................................................8
Durable Medical Equipment ......................................................................................8
Hearing Aids ..............................................................................................................8
Medical Supplies........................................................................................................8
Ocular Aids ................................................................................................................8
Orthotics.....................................................................................................................8
Prosthetics ..................................................................................................................8
Transcutaneous Neurostimulators ..............................................................................8
SECTION VI:
MEDICAL SERVICES
Biofeedback Services .................................................................................................8
Electrodiagnostic Medicine........................................................................................8
Evaluation and Management Services .......................................................................9
Home Health Services..............................................................................................10
Impairment Rating ...................................................................................................10
Independent Medical Examination ..........................................................................10
Independent Medical Examination, Consensus .......................................................10
Injectable Medications .............................................................................................10
Medical and Surgical Supplies.................................................................................11
Ophthalmological Services ......................................................................................11
Psychiatric and Psychological Services ...................................................................11
Radiology .................................................................................................................12
Thermography ..........................................................................................................13
Transcutaneous Neurostimulator..............................................................................13
SECTION VII: PHYSICAL MEDICINE AND REHABILITATION SERVICES
General Information .................................................................................................14
Level I:
Physical Medicine Services...................................................................15
Evaluation..............................................................................................15
Modalities and Therapeutic Procedures ................................................16
Manipulative Treatment ........................................................................16
Acupuncture ..........................................................................................17
iv
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Level II:
Physical Reconditioning Services .........................................................18
Physical Reconditioning Assessment ....................................................18
Physical Reconditioning Program .........................................................18
Level III: Rehabilitation Programs ........................................................................19
Functional Capacity Evaluation ............................................................20
Work Hardening Program .....................................................................20
Pain Program. ........................................................................................20
SECTION VIII. SURGICAL SERVICES
Surgical Package (Global Reimbursement) .............................................................21
Surgical Assistants ...................................................................................................22
Multiple Procedures .................................................................................................23
Bilateral Procedures .................................................................................................23
SECTION IX.
ANESTHESIA SERVICES
Base Value or Base Unit ..........................................................................................23
Time Units................................................................................................................24
Physical Status Modifiers.........................................................................................24
Qualifying Circumstances........................................................................................25
Reimbursement Methodology..................................................................................25
SECTION X.
SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES
General Instructions for Use of Schedule………………………………………….28
PART A:
Anesthesia ................................................................................................................30
Surgery .....................................................................................................................32
Radiology .................................................................................................................66
Pathology..................................................................................................................80
Medicine.................................................................................................................102
Evaluation and Management..................................................................................110
Dental .....................................................................................................................111
Injections ................................................................................................................115
PART B:
Surgery ...................................................................................................................119
PART C:
Radiology ...............................................................................................................219
Pathology................................................................................................................257
Medicine.................................................................................................................321
Evaluation and Management..................................................................................343
APPENDIX.
APPENDIX A. DEFINITIONS ................................................................................................345
APPENDIX B. DIRECTORY OF REFERENCES ..................................................................348
APPENDIX C. MODIFIERS....................................................................................................351
APPENDIX D. WORKERS’ COMPENSATION UNIQUE CODES .....................................353
APPENDIX E. MEDICARE LOCALITY MAP......................................................................355
INDEX ...............................................................................................................................................357
v
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
SECTION I: ADMINISTRATIVE PURPOSE OF MANUAL.
The administrative purpose of the Florida Workers’ Compensation Health Care Provider
Reimbursement Manual, 2004 Edition, is to provide reimbursement guidelines, codes and maximum
reimbursement allowances for licensed physicians and health care providers rendering medically
necessary services to Florida’s injured employees.
This manual also contains reimbursement policies and payment methodologies for pharmacists and
medical suppliers. The use of Physicians’ Current Procedural Terminology (CPT®) or Healthcare
Common Procedure Coding System (HCPCS) codes is not required to receive reimbursement for
services rendered by these providers.
Federal facilities are exempt from the reimbursement guidelines and maximum reimbursement
allowances provided in this manual for services rendered in federal facilities.
SECTION II: BASIC PROGRAM REQUIREMENTS.
A. Provider Eligibility.
1. Florida health care providers must comply with provider eligibility requirements in section
440.13, Florida Statutes (F.S.), in order to qualify for reimbursement for rendering medical
services to injured employees.
2. Provider eligibility information and the required application may be obtained from the
Agency for Health Care Administration.
B. Authorization.
1. Florida health care providers, out-of-state providers and federal facilities must be authorized
by the employer’s workers’ compensation carrier or a self-insured employer prior to
rendering initial and remedial medical services or referring the injured employee to facilities
or other certified health care providers.
2. Carriers must comply with the statutory requirements in section 440.13, F.S., in responding
to authorization requests.
3. Emergency care, defined in section 395.002, F.S., does not require authorization by a carrier
nor does a provider referral for emergency treatment resulting from emergency care. These
are the only exceptions to the requirements of prior authorization for medical care and
treatment.
C. Materials Adopted for Reference.
1. The following publications are adopted for reference to the listings of descriptive terms and
identifying codes for reporting medical services and procedures provided to injured
employees by physicians and other health care providers:
a. Physicians’ Current Procedural Terminology (CPT®), 2003 Professional Edition,
Copyright 2002, American Medical Association.
1
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
b. Current Dental Terminology (CDT-4), Fourth Edition, Copyright 2002, American Dental
Association.
c. HCPCS 2003, Fifteenth Edition, Copyright 2002, Ingenix Publishing Group, for D codes,
injectable J codes, and the other medical services and supply codes.
2. Physicians and providers shall use the codes and descriptions, modifiers, guidelines,
definitions and instructions of the referenced CPT, CDT-4 and HCPCS in part for dental
codes, injection codes, and the other medical services and supply codes. Physicians shall use
the Category III CPT codes for emerging technology, services and procedures when available
instead of a Category I CPT unlisted code. The code descriptors, guidelines, definitions, and
instructions of the aforementioned references are not provided in this manual. Any
modification to a code descriptor by the workers’ compensation program shall be specified
and shall take precedence over any descriptor contained in the referenced CPT, CDT-4 or
HCPCS.
3. Health care providers and medical suppliers shall use Category II HCPCS codes when a more
specific Category I CPT code is not available to report professional services, procedures and
supplies.
D. Medical Records.
1. Required documentation.
Unless instructed otherwise, it is the responsibility of all health care providers to furnish
without charge, the following documentation to the carrier:
a. A complete report of the patient’s symptoms, findings and plan of treatment pursuant to
reporting requirements in section 440.13, F.S.
b. An operative report when a surgical procedure is performed.
c. A narrative report when a consultation or an independent medical examination is
rendered.
d. A narrative report, computerized report or other explanatory report form when a report is
listed as part of a code’s descriptor, when a report is provided as an explanation of the
results of the testing procedures or when anesthesia, pathology, or radiology services are
performed.
2. Additional written documentation.
If requested, a health care provider must provide additional written documentation to a carrier,
without charge, when the medical necessity of medical care must be substantiated in more
detail than the information contained in the medical record. Failure to forward the following
information, when requested by the carrier, may result in the billed service being disallowed
and not reimbursed.
a. Objective findings that support the need for medical care, as well as continuing treatment.
b. The estimated period of time and number of services required for treatment.
2
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
c. The anticipated benefits of the treatment to the patient.
3.
Special carrier requests (Code 99080).
Carriers may request physicians to prepare special narrative reports or to complete
information on forms not required by the Division of Workers’ Compensation (Division) or
the Agency for Health Care Administration (Agency). Prior to a provider’s provision of a
special request, the carrier and provider shall agree upon reimbursement for completion of
the special report or form. Reimbursement for special requests shall be made by the carrier at
the agreed upon reimbursement amount.
4. Copies of medical records.
a. A health care provider, when requested, shall provide a copy of the injured
employee’s medical records to a carrier or carrier’s representative, attorney or
rehabilitation staff. Reimbursement shall be made to a health care provider for
medical records by the carrier as follows:
(1) Up to $1.00 per page for providing copies of requested medical records, or for
furnishing duplicates of required documentation, additional written
documentation or other records previously submitted to the carrier.
(2) An additional fee up to $1.00 per year for each year of records, when a year or
more of medical records are requested by a carrier.
b. A health care provider, when requested, shall furnish an injured employee or the
employee’s attorney a copy of the employee’s medical chart, records and reports.
Reimbursement for medical records shall be made to a health care provider by the
employee or employee’s representative at $.50 per page.
c. A health care provider, when requested, shall furnish the injured employee’s nonpaper medical records to an injured employee and a carrier or any of their
representatives. Reimbursement shall be made to a health care provider by the
requesting party at the provider’s actual cost for x-rays, microfilm, or other non-paper
records.
d. A health care provider, when requested, shall provide medical records to the Division
or Agency without charge. Failure to forward the requested information shall result
in administrative action pursuant to the provisions in section 440.13, F.S.
E. Reimbursement Information.
1. Provider payment.
a. Federal facilities.
Federal facilities are exempt from the reimbursement provisions and allowances in this
reimbursement manual. A carrier shall reimburse a federal facility its usual charges.
b. Florida health care providers.
3
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
(1) Reimbursement shall be made to a Florida health care provider for medical services.
After applying the appropriate reimbursement guidelines contained in this manual, a
carrier shall reimburse a provider either the agreed upon contract price or the
maximum reimbursement allowance in the appropriate schedule pursuant to
440.13(12)(a), Florida Statutes (F.S.).
(2) Services rendered by a physician assistant, advanced registered nurse practitioner or
any non-physician health care provider, regardless of the party submitting the bill,
shall be reimbursed according to Part A, Section X in this manual.
c. Out-of-state providers.
(1) Prior to the delivery of medical services, a carrier may mutually agree with an out-ofstate provider upon the amounts of reimbursement to be made by the carrier for the
services to be provided. The carrier shall make reimbursement at the reimbursement
amounts agreed upon by the provider and carrier.
(2) If a reimbursement agreement is not made, the carrier shall reimburse the provider
the greater of the maximum reimbursement allowances for the services in Part A,
Section X in this manual or the maximum reimbursement allowances under the
workers’ compensation program in the state where the services are provided.
2. Reimbursement guidelines.
a. Codes paid by maximum reimbursement allowances (MRAs).
Reimbursement for codes, listed in this manual with MRAs, shall be at the maximum
reimbursement allowances after the application of any reimbursement policies contained
in this manual by the carrier, except when there is an agreed upon contract.
b. Codes paid by report (BR).
(1) Reimbursement shall be determined by the carrier for codes paid by report (BR).
Payment shall be based on a provider’s documentation submitted to the carrier in a
special report containing information on the complete description of the services or
procedures, medical necessity, pertinent clinical data, prevailing charges, fees,
relative values and reimbursement for similar procedures or cost of the services or
supplies.
(2) The provider shall submit a special report in addition to the requirements in Section
II. D. to satisfy the following:
(a) Codes listed in this manual that do not have an established MRA but a BR in the
MRA column.
(b) Codes for non-referenced medical procedures with a generic code ending in “99” that
are listed in this manual with BR in the MRA column.
(c) Category III codes, which are temporary five character alphanumeric codes, that
are in the published CPT or provided electronically on the American Medical
Association’s web site but are not contained in this manual.
4
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
(d) Valid codes that are not listed in this manual, but are contained in the materials
adopted for reference in Section II. C.
(e) Codes with valid modifiers that do not have an established MRA.
c. Codes not covered (NC).
Reimbursement shall not be made for services or supplies that are not covered (NC)
under Florida’s workers’ compensation program. These codes are listed in this manual
with NC in the MRA column.
d. Exclusion.
Reimbursement shall not be made for failed appointments. This exclusion does not
apply to the statutory provisions for independent medical examinations contained in
section 440.13, F.S.
e. Exceptions.
All health care providers are subject to the reimbursement guidelines contained in this manual. If a provider deems it is medically necessary in the treatment of a particular
individual’s injury or illness to furnish medical services that exceed the number of services
in specific reimbursement policy guidelines, a provider must:
(1) Submit documentation to the carrier substantiating the medical necessity for the
request.
(2) Receive specific written authorization from the carrier to render the requested
services before services are provided.
3. Carrier reimbursement responsibilities.
a. Carriers shall use the codes and descriptions, guidelines, definitions and instructions in
the referenced CPT, CDT-4 and HCPCS, in part for dental services, injections, and other
medical services and supply codes, when reviewing bills prior to making reimbursement
decisions.
b. Carriers shall use a methodology, available upon request by the state agency, for
determining reimbursement for codes that have no established MRAs, including Category
III codes, unlisted codes and codes that are paid BR.
(1) Carriers shall utilize the expertise of peer review physicians for concurrent review,
including the appropriateness and cost of the medical services reported; billing and
coding issues; and reimbursement determinations.
(2) Carriers shall make reimbursement decisions based on all the provider
documentation; the carrier medical claims data; relative value studies; prevailing
charges and reimbursement for procedures, services and supplies; and peer review
physician recommendations.
5
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
c. Carriers shall reimburse all work-related medically necessary services provided in a
documented medical or dental emergency.
d. Carriers shall reimburse all authorized services including those prior authorized services
that exceed the reimbursement guidelines set forth in this manual.
SECTION III: DENTAL SERVICES.
A. All dental services shall be authorized by a carrier before the services are initiated. A carrier
shall only reimburse a dentist or oral surgeon for authorized services.
B. Dentists shall use the dental guidelines, codes and descriptors from the CDT-4 or the D codes in
the HCPCS for dental procedures.
C. Dentists shall use the appropriate guidelines, codes and descriptors from the CPT and CDT-4 or
D codes in the HCPCS for temporomandibular joint services.
1. Dentists who provide temporomandibular joint services may use a combination of CPT codes
and dental codes from the CDT-4 or HCPCS.
2. Dentists shall refer to the physical medicine section of this manual for information on physical
therapy reimbursement guidelines.
D. Oral surgeons shall use the CPT surgical guidelines, codes, descriptors and modifiers for oral and
maxillofacial surgical services.
1. Surgeons shall refer to surgical services section of this manual for information on reimbursement for multiple surgical procedures, as well as other surgical reimbursement guidelines.
2. Surgeons may refer to other sections in this manual and may use CPT codes.
E. Reimbursement to a provider shall be as follows:
1. Reimbursement to a dentist or oral surgeon for a dental procedure or service shall be either
the agreed upon contract price, or the listed MRA in the appropriate schedule.
2. Reimbursement to a surgeon for an oral and maxillofacial consultation shall be limited to one
(1) consultative visit per date of accident.
SECTION IV: DISPENSING OF MEDICATION.
A. Medicinal drugs.
1. Medicinal drugs, commonly known as legend or prescription drugs, shall be ordered for an
injured employee by a licensed physician, authorized by the carrier to treat the employee.
2. Medicinal drugs are dispensed, stored and sold only by a pharmacist licensed under Chapter
465, F.S., or a dispensing practitioner, according to the provisions in section 465.0276, F.S.
6
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
3. Medicinal drugs may be compounded by a pharmacist or physician when the drug
formulation prescribed is not commercially available.
4. Federal regulations.
a. The Food and Drug Administration requires drug manufacturers to register and list
manufactured drug products. The National Drug Code (NDC) is assigned by the
manufacturer and placed on all prescription stock packages.
b. The Food and Drug Administration considers the “compounding of drugs” to be the
practice of pharmacy/medicine. A compounded drug does not have a NDC.
5. Reimbursement limitations.
a. Reimbursement shall only be made to a licensed pharmacist or licensed, dispensing
physician for provision of medicinal drugs. A physician shall use the workers’
compensation unique code 96370 to bill for dispensing prescription drugs furnished to a
patient.
b. Reimbursement for prescription drugs shall be as follows:
(1) The pharmaceutical reimbursement formula:
Average Wholesale Price (AWP) + $4.18 dispensing fee = Reimbursement; or
(2) The contracted reimbursement amount determined in accordance with the contractual
arrangement between the provider and carrier.
c. A pharmacist or physician shall be reimbursed for a professional service related to
compounding drugs whose formulations are not commercially available. The amount of
reimbursement to be made by the carrier shall be mutually agreed upon by the provider
and carrier prior to the compounding.
B. Patent, proprietary or over-the-counter drugs.
1. Reimbursement shall be made to a pharmacist for dispensing over-the-counter drugs at the
pharmacist’s usual charge for the drugs.
2. Reimbursement to a physician shall be as follows:
a. Reimbursement shall be made to a physician for furnishing over-the-counter drugs. A
physician shall use code 99070 and submit an invoice to the carrier that provides the
name, dosage, package size and cost of drugs, including shipping and handling and taxes,
when applicable.
b. Reimbursement shall be made at the physician’s charge or no greater than twenty (20)
percent above the actual cost of each drug furnished.
c. Reimbursement shall not be made for oral vitamins, nutrient preparations and dietary
supplements.
7
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
SECTION V: MEDICAL SUPPLIER SERVICES.
A. Medical supplies, durable medical equipment (DME), appliances, devices, transcutaneous
neurostimulators (TNS), ocular and hearing aids, prosthetics or orthotics shall be prescribed by a
physician and may be provided to an injured employee by a medical supplier through rental or
purchase.
B. A medical supplier shall obtain and accept written authorization and payment agreement from the
carrier prior to furnishing an injured employee medical supplies or equipment.
C. A medical supplier shall provide the carrier with a copy of the physician’s original order with the
bill for reimbursement. A medical supplier is not required to submit codes or to provide invoices
with the bill to document the actual costs of supplies and equipment.
D. Reimbursement.
1. Reimbursement shall be made to a medical supplier by the carrier for rental or purchase of
medical equipment, appliances, transcutaneous neurostimulators, ocular and hearing aids,
prosthetics, esthetics and supplies.
a. The carrier may rent the item from the supplier for the injured employee. The carrier may
write a provision in the payment agreement that when the amount received by the
supplier from the rental payments equals the purchase price, the item will become the
property of the carrier or injured employee.
b. The carrier may purchase the item from the supplier.
2. A carrier shall reimburse a medical supplier at the price stated in the payment agreement,
upon receipt of a bill and copy of the physician’s original order.
SECTION VI: MEDICAL SERVICES.
A. Biofeedback Services.
1. Reimbursement to a health care provider for biofeedback training shall be limited to twelve
(12) visits per date of accident by the injured employee. This biofeedback training limitation
does not include individual psychophysiological therapy incorporating biofeedback training
by any modality with psychotherapy.
2. Reimbursement shall be made to a provider for the collection and interpretation of
biofeedback data digitally stored or transmitted by the injured employee to the provider.
3. Downloading of biofeedback data by a health care provider during an injured employee’s
visit for an evaluation and management service or physical medicine service shall not be
reimbursed.
B. Electrodiagnostic Medicine.
1. Needle electromyography (EMG).
8
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
a. Only a physician or a recognized practitioner specifically qualified by regulations in
Florida shall be reimbursed for needle electromyography (EMG) testing.
(1) The physician shall prescribe the appropriate number of studies to be performed,
including the frequency and necessity of repeat testing.
(2) Reimbursement for needle electromyography shall include the EMG testing of
selected muscles, the interpretation of the studies and a report of the findings.
b. When an initial evaluation and management service and needle EMG testing are
performed during a visit, reimbursement shall be made to a physician for both services.
c. When a follow-up evaluation and management service and needle EMG testing are
performed on the same day, reimbursement shall be made to a physician for both services
if the physician’s documentation validates the medical necessity of the follow-up
evaluation and management service.
d. When needle EMG testing is performed in a hospital or other facility, reimbursement
shall be made to a physician for an interpretation of the testing if modifier –26 is added to
the appropriate code.
2. Nerve conduction studies (NCSs).
a. Only a physician or a recognized practitioner specifically qualified by regulations in
Florida shall be reimbursed for nerve conduction studies (NCSs). Reimbursement shall
include the testing, interpretation and report.
(1) A physician shall perform an initial evaluation to determine the nerves to test and the
appropriate NCS to be performed.
(2) A physician, or a technologist under the direct supervision of the physician, may
perform a NCS.
(3) Only a physician shall interpret a NCS.
(4) A physician shall determine the frequency and necessity of repeat testing.
b. When an initial evaluation and management service and NCSs are performed during the
same visit, reimbursement shall be made to a physician for both services.
c. When a follow-up evaluation and management service and NCSs are performed on the
same day, reimbursement shall be made to a physician for both services if the physician’s
documentation validates the medical necessity of the follow-up evaluation and
management service.
C. Evaluation and Management Services.
1. Office visits.
A physician shall be reimbursed by a carrier for evaluation and management services (new
patient and established patient visits). Reimbursement is limited to one (1) visit a day at the
highest level of care provided by the physician.
9
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
2. Consultations, confirmatory consultations and follow-up consultation services.
A physician shall be reimbursed for consultations, confirmatory consultations and follow-up
consultation services. Reimbursement shall include a review of all submitted medical
records, paper and non-paper; an examination of the injured employee; and a written report.
D. Home Health Services.
1. A physician shall be reimbursed for home visits when authorized by the carrier. A physician
shall use the appropriate evaluation and management home visit code to report the service.
2. A home health agency shall be reimbursed for carrier authorized home health services
provided in a patient’s residence, based on a signed order from the authorized, treating
physician. The carrier shall reimburse a home health agency at the reimbursement amounts
agreed upon by the agency and the carrier.
E. Impairment Rating (Code 99455).
1. A physician shall be reimbursed by the carrier for an impairment rating.
2. Reimbursement shall include an examination to evaluate an injured em-ployee’s condition;
the establishment of the date of maximum medical improvement and the assignment of an
impairment rating of zero (0) percent or greater; and the completion and submission of the
required reporting form to the appropriate parties in accordance with section 440.15, F.S.
F. Independent Medical Examination (Code 99456).
1. A physician shall be reimbursed by the carrier for an independent medical examination (IME).
2. Reimbursement for an IME shall include the review of applicable paper and non-paper medical
records; an examination of the injured employee; and a written report.
G. Independent Medical Examination, Consensus (99457).
1. A physician shall be reimbursed by the carrier for a consensus independent medical
examination (CIME).
2. Reimbursement for a CIME shall include the review of applicable paper and non-paper
medical records, an examination of the injured employee, and a written report.
3. Reimbursement for a CIME shall be negotiated between the physician and the carrier prior to
rendering the service.
H. Injectable Medications.
Reimbursement for injectable medications is separate and is not included in the reimbursement
for the administration of an injection or reimbursement for a procedure in which an injectable
medication is administered in conjunction with the procedure. Payment for injectable
medications shall be made to physicians as follows:
1. Reimbursement shall be made to a physician, using HCPCS J codes for injectable drugs and
CPT codes for the administration of injectable drugs at either the agreed upon contract price
10
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
or the listed MRA in the appropriate schedule. Physicians licensed under Chapter 458 or
Chapter 459, F.S. shall be reimbursed for CPT codes based on the MRA listed in Part C,
Section X in this manual.
2. Reimbursement for an injection shall include a local anesthetic, if necessary.
3. Reimbursement for multiple medications, administered from the same syringe, shall be as
follows:
a. At either the agreed upon contract price or the listed MRA, in the appropriate schedule
for the first reported drug; and
b. At either the agreed upon contract price or fifty (50) percent of the listed MRA, in the
appropriate schedule for each additional drug. Each additional drug shall be reported by
adding modifier –51 to the HCPCS or CPT code.
4. Reimbursement to a physician for codes 99070, 90749 or J3490, shall be limited to no more
than twenty (20) percent above the actual cost of the injectable medication, based on
submission of:
a. The name, strength and dosage of the medication, vaccine or toxoid; and
b. An invoice, verifying the cost of the medication, vaccine or toxoid, including shipping
and handling and taxes, when applicable.
I. Medical and Surgical Supplies (99070 or Specific HCPCS Level II Codes).
1. Reimbursement for supplies that are necessary to perform a procedure or provide a service
shall be included in the reimbursement for the service and shall not be made separately.
2. Reimbursement for special supplies and materials shall be limited to an amount not to exceed
twenty (20) percent above the actual cost of the supplies and materials, when the provider
submits an invoice to the carrier that substantiates the provider’s cost of the item, including
shipping and handling, and taxes, when applicable.
J. Ophthalmological Services.
1. Reimbursement for ophthalmological services shall be made for all medically necessary services.
2. Reimbursement shall only be made for spectacles, contact lens or frames of comparable
quality to the original when they are damaged, lost or required for treatment as a result of an
injury.
K. Psychiatric and Psychological Services.
1. Reimbursement for psychiatric and psychological services shall be made by the carrier to an
authorized, licensed medical doctor, osteopathic physician, a psychologist, mental health
practitioner or health professional providing services in compliance with state licensure.
2. Reimbursement shall be made for individual psychotherapy services.
11
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
3. Reimbursement shall be made to a physician for individual psychotherapy with medical
evaluation and management services provided at the therapy session by a physician. An
evaluation and management service provided on the same day as individual psychotherapy
with medical evaluation and management services by the physician shall not be reimbursed.
4. Reimbursement shall only be made for an evaluation and management service when
individual psychotherapy is not provided. Reimbursement shall only be made to physicians
for evaluation and management services.
5. When multiple individual psychotherapy sessions are provided on the same day, only the
session lasting the longest period of time shall be reimbursed.
6. Reimbursement for family psychotherapy with or without the injured employee shall be made
if the documentation supports that the purpose is related to the treatment of the injured
employee’s compensable injury. Reimbursement shall not be made for psychological services
provided directly to members of the injured employee’s family for support and assistance in
adjusting to the injured employee’s condition.
7. Reimbursement shall be made for central nervous system assessments/testing.
a. Reimbursement includes an assessment and administration of a test with interpretation
and report.
b. The amount of reimbursement for these services shall be determined from the number of
hours (units of service) reported by the provider to perform the assessment/test and the
listed MRA. The procedure code’s descriptor shall indicate if the service is per hour or all
inclusive.
L. Radiology.
1. Reimbursement shall be made for radiology services, including nuclear medicine and
diagnostic ultrasound services.
2. Reimbursement for radiological services, provided in a hospital, ambulatory surgical center
or similar facility, shall be made only to radiologists for the professional component, when
modifier –26 is added to the radiology code.
3. Reimbursement shall not be made for a professional component (modifier –26) billed in the
following situations:
a. A professional component billed by a physician for x-rays taken and interpreted by
another physician and reviewed during an IME, medical visit or consultation.
b. 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.
4. Reimbursement shall be made to an independent radiology facility for a facility charge in
certain circumstances. Reimbursement for a facility charge shall be made BR when a
radiologist bills the following related services: an injection procedure; radiological
supervision and interpretation; and the use of a freestanding radiology facility.
12
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
a. In addition to the injection procedure, the code with the descriptor “radiological
supervision and interpretation” must be reported twice as follows:
(1) The five-digit code to identify the specific “supervision and interpretation”
radiological service provided.
(2) The five-digit code plus the workers’ compensation unique modifier – FC to indicate
the service was rendered in an independent or freestanding radiology facility, not a
hospital.
b. When both a technical component (modifier –TC) and a facility charge (modifier –FC)
are billed with the “supervision and interpretation” code on the same date of service,
reimbursement shall only be made for the facility charge (modifier –FC).
M. Thermography.
1. Authorization.
The carrier shall not authorize a physician to perform thermography any earlier than fortyfive (45) days after the date of accident unless documentation of medical necessity is
submitted to the carrier along with the request for authorization.
2. Reimbursement.
a. Reimbursement for thermography shall be limited to one (1) body area, either major or limited.
(1) Major body areas. (The following areas include all views.)
(a) Head.
(b) Cervical spine and upper extremities.
(c) Lumbosacral spine and lower extremities.
(2) Limited body areas. (The following areas include all views.)
(a) Thoracic spine.
(b) Any portion of a major area.
b. Reimbursement for thermography to a major body area shall be made at either the agreed
upon contract price or the listed MRA, in the appropriate schedule.
c. Reimbursement for thermography to a limited body area, reported by adding modifier –52
to the code shall be made at either the agreed upon contract price or fifty (50) percent of the
MRA in the appropriate schedule.
N. Transcutaneous Neurostimulator.
13
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
1. Reimbursement shall be made to an authorized physician or other health care provider for
furnishing an injured employee with a transcutaneous (surface) neurostimulator (TNS),
prescribed by a physician.
a. Authorization and a payment agreement shall be obtained from the carrier for rental or
purchase of a TNS prior to a physician or provider furnishing a TNS to the injured employee.
b. Reimbursement for a TNS shall be made at the price agreed upon between the provider
and the carrier when authorization is given by the carrier.
c. Reimbursement shall not exceed twenty (20) percent above the provider’s documented
cost when the TNS is purchased. A copy of the provider’s invoice shall be submitted
with the bill, substantiating the actual cost, including shipping and handling and taxes,
when applicable.
2. Reimbursement shall be made to an authorized physician or provider for furnishing training
to an injured employee on the application of a transcutaneous neurostimulator. Reimbursement is limited to no more than four (4) training sessions.
SECTION VII: PHYSICAL MEDICINE AND REHABILITATION SERVICES.
A. General Information.
1. Physical medicine and rehabilitation services shall be prescribed by a physician.
2. The Florida workers’ compensation program shall reimburse authorized providers, as specified
in this section, for three (3) levels of physical medicine and rehabilitation services:
a. Level I applies to acute injuries which are evaluated, tested and treated with modalities
and therapeutic procedures to reduce symptoms, restore function and return the injured
employee to work.
b. Level II focuses on injuries requiring intensive physical reconditioning services to restore
the injured employee to pre-injury level of physical health and function. The goal shall
be for the employee to return to a job or become physically reconditioned.
c. Level III covers a variety of services that are coordinated, outcomes-focused and directed
at the injured employee’s needs to increase the employee’s functioning or to return the
employee to work. Specifically, work hardening services and pain program services shall
only be performed in rehabilitation programs accredited by the Commission on
Accreditation of Rehabilitation Facilities (CARF). These services are provided through
the following CARF programs: Outpatient Medical Rehabilitation Program; Occupational
Rehabilitation Program; or Interdisciplinary Pain Rehabilitation Program.
3. Approval for the provision and payment of medically necessary services beyond the
guidelines provided in Section VII for any of the Levels must be obtained from the carrier, in
writing, prior to a provider furnishing the service. The unusual circumstances must be
documented and forwarded by the provider to the carrier for review before an exception to
the guidelines can be considered and a determination made by the carrier to authorize
additional services.
14
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
B. Level I: Physical Medicine Services.
1. Authorization.
a. Reimbursement shall only be made for carrier authorized Level I services, based on a
signed order from an authorized, treating physician. All services shall be authorized prior
to initiation of services.
b. Reimbursement for physical medicine services shall only be made to the following:
(1) A licensed physician, including physical medicine services provided by a physicianemployed therapist and billed by the physician.
(2) A licensed therapist or health care provider, not employed by a physician.
c. Reimbursement for physical medicine services shall not exceed one (1) visit per day,
unless specifically authorized by the carrier.
d. Reimbursement for Level I services shall only be made for six (6) months after the date
of injury, unless specifically ordered by the treating physician and authorized by the
carrier.
e. Reimbursement shall only be made to licensed occupational and physical therapists for a
carrier authorized custom fabricated orthotic or prosthetic device, whether reported using
CPT codes or appropriate Level II HCPCS codes that specifically describe the device,
when it is ordered by a physician.
2. Initial evaluation.
a. Reimbursement for an initial evaluation, provided by a physician or a physicianemployed therapist, shall be made when billed by a physician as an evaluation and
management service. Separate reimbursement shall not be made to a physician and to a
physician-employed therapist for an evaluation by each.
b. Reimbursement for an initial evaluation, performed in a freestanding facility by a
therapist not employed by a physician, shall be made when billed by the therapist under
code 97001 or 97003.
c. Reimbursement for an initial evaluation shall include the evaluation and a plan of care or
treatment.
(1) Documentation of the evaluation and plan of care shall be submitted to the carrier with
the claim form. At a minimum, the documentation shall contain:
(a) The evaluation findings, including any functional limitations.
(b) The proposed therapy, specifying the frequency and duration of the services.
(c) The anticipated degree of restoration of function with measurable goals.
15
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
(2) If the carrier questions the appropriateness of the therapy listed in the plan of care, the
carrier shall immediately contact the physician, who ordered the therapy, for the
treatment rationale. It shall be the responsibility of the physician to provide the
documentation of medical necessity for the therapy to the carrier timely in order to
avoid unnecessary delays in obtaining authorization for treatment or in initiating
therapy.
3. Re-evaluation.
Reimbursement shall be made for a re-evaluation ordered by a physician and performed by a
therapist, not employed by a physician, in a freestanding facility. A re-evaluation must be
billed using either code 97002 or 97004.
4. Revised plan.
a. The physician or therapist shall submit to the carrier a revised plan of care or treatment,
when appropriate and in accordance with section 440.13 (16), Florida Statutes, (F.S.).
b. An authorized treating physician has the responsibility of providing documentation of
medical necessity for therapy modifications if questioned by the carrier.
5. Modalities and therapeutic procedures.
a. Reimbursement to a provider for therapy shall be limited to one (1) visit a day.
b. Reimbursement to a provider shall be made for the modalities and therapeutic procedures
listed in the plan of care with the limitation that no more than four (4) units of service
shall be reimbursed per visit.
(1) Codes 97010-97028 shall each equal one (1) reimbursable unit of service. The
performance of the supervised modality codes is not time-oriented and each code may
only be reported once during the visit.
(2) Codes 97032-97542 shall each equal one (1) reimbursable unit of service for each
fifteen (15) minutes of service performed.
(3) Code 97150 shall be restricted to one (1) reimbursable unit of service per visit.
6. Manipulative treatment.
a. Reimbursement to a physician for a manipulative treatment shall be limited to one (1)
visit a day.
b. Reimbursement for manipulative treatment under workers’ compensation shall be limited
to two (2) body regions.
(1) The entire spine is one (1) region.
(2) Each of the following is one (1) region: head; two (2) upper extremities; two (2)
lower extremities; one (1) upper and one (1) lower extremity; rib cage; and abdomen.
16
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
c. Reimbursement for manipulative treatment to the two (2) regions, listed in Section
VII.B.6.b., shall be made for workers’ compensation unique codes 97260 and 97261,
specifically designated for physicians other than osteopaths and chiropractors.
(1) Reimbursement shall be made for code 97260, when used to bill for a spinal
manipulation. The spine shall be reimbursed as one (1) entity for workers’
compensation, although there are five (5) spinal regions (cervical; thoracic; lumbar;
sacral; and pelvic).
(2) Reimbursement shall be made for code 97261, when used to bill for a manipulation
of the temporomandibular joint; the upper extremities, including the hand and wrist;
the lower extremities; and other regions.
d. Reimbursement for osteopathic manipulative treatment (OMT) to the two (2) regions,
listed in Section VII.B.6.b., shall be made for codes 98926 and 98928.
(1) Reimbursement shall be made for code 98926, when used to bill for a spinal
manipulation. The spine shall be reimbursed as one (1) entity for workers’
compensation, although there are five (5) spinal regions (cervical region; thoracic
region; lumbar region; sacral region; pelvic region).
(2) Reimbursement shall be made for code 98928, when used to bill for a manipulation to
the head region; lower extremities; upper extremities; rib cage region; and abdomen
and viscera region.
e. Reimbursement for chiropractic manipulative treatment (CMT) to the two (2) regions,
listed in Section VII.B.6.b., shall be made for codes 98941 and 98943. These manipulation
codes are specifically designated for chiropractic physicians.
(1) Reimbursement shall be made for code 98941, when used to bill for a spinal
manipulation. The spine shall be reimbursed as one (1) entity for workers’
compensation, although there are five (5) spinal regions: cervical region (includes
atlanto-occipital joint); thoracic region (includes costovertebral and costo-transverse
joints); lumbar region; sacral region; and pelvic (sacroiliac joint) region.
(2) Reimbursement shall be made for code 98943, when used to bill for a manipulation to
an extraspinal region: head (including temporomandibular joint, excluding atlantooccipital); lower extremities; upper extremities; rib cage (excluding costotransverse
and costovertebral joints); and abdomen.
7. Acupuncture.
a. Reimbursement for acupuncture shall be limited to one (1) visit a day.
b. Reimbursement for acupuncture with one (1) or more needles shall be made to a
physician or licensed provider not employed by a physician.
8. Tests and measurements.
a. Reimbursement to a provider shall be limited to one (1) visit by an injured employee per
thirty (30) days for tests and measurements to a select body area or number of areas
unless a different interval is outlined in the patient’s plan of care. A variation to the
17
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
standard limitation for tests and measurements must be ordered by the treating physician
and authorized by the carrier.
b. Reimbursement shall be made for the workers’ compensation unique code 97752,
specifically designated for both manual and automated testing. Reimbursement shall
include a report of the testing results. Manual muscle testing (95831-95834) and range of
motion codes (95851-95852) shall not be reimbursed when reported separately with code
97752.
c. Reimbursement shall be made for range of motion measurements. Code 95851 may be
reported and paid for either manual or computerized range of motion measurements and
report.
9. Medical supplies (Code 99070 or Specific HCPCS Level II Codes).
a. Reimbursement shall be made to a provider when medical supplies are used in addition to
the normal supplies for a physical medicine service.
b. Reimbursement to a provider shall not exceed twenty (20) percent above the provider’s
actual cost of a supply. An invoice substantiating the provider’s cost of the item, shall be
submitted to the carrier with the claim form, including shipping and handling and taxes,
when applicable.
C. Level II: Physical Reconditioning Services.
1. Authorization.
a. Reimbursement shall only be made for carrier authorized Level II services, based on a
signed order from the authorized, treating physician. Physical reconditioning services
shall be authorized prior to initiation and shall not begin any earlier than thirty (30) days
following the employee’s date of accident.
b. Reimbursement for physical reconditioning services shall only be made to an authorized
occupational or physical therapist not employed by a physician.
2. Physical reconditioning assessment.
a. Reimbursement for a physical reconditioning assessment and written report shall be
determined from the number of hours reported by the provider to perform the assessment
and the listed MRA. Reimbursement shall be limited to eight (8) hours.
b. Reimbursement shall be made for workers’ compensation unique codes 97850 and
97851, specifically designated to use in reporting a physical reconditioning assessment.
(1) Reimbursement shall be made for code 97850, when used to bill per hour charges for
a physical reconditioning assessment.
(2) Reimbursement shall be made for code 97851, when used to bill each additional
thirty (30) minutes of a physical reconditioning assessment.
3. Physical reconditioning program.
18
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
a. Reimbursement for a physical reconditioning program shall be paid based on the number
of hours billed by the provider and the listed MRA. Reimbursement shall be limited to a
program lasting no longer than sixty (60) hours during a six (6) week period, including a
physical reconditioning assessment.
b. Reimbursement shall be made for workers’ compensation unique codes 97852 and
97853, specifically designated to use in reporting for physical reconditioning.
(1) Reimbursement shall be made for code 97852, when used to bill per hour charges for
physical reconditioning.
(2) Reimbursement shall be made for code 97853, when used to bill each additional
thirty (30) minutes for physical reconditioning.
c. Reimbursement shall be made for a physical reconditioning program when the services
are provided alone, concurrently with or subsequent to Level I services by the same
authorized occupational or physical therapist.
d. Reimbursement shall be made to a therapist for only one (1) physical reconditioning
program for an injured employee per date of accident, unless authorized by the carrier for
an exacerbation of the injury or surgical intervention, documented by the treating
physician.
e. Reimbursement for an extension of the program shall be limited to reimbursement for an
additional twenty (20) hours during a two (2) week period. An extension shall be ordered
by the physician and authorized by the carrier.
4. Discharge from the physical reconditioning program.
a. The treating physician shall determine if the injured employee shall be discharged from
the physical reconditioning program before completion. If the injured employee has not
completed the program and the treating physician recommends discontinuance of the
program, the physician shall provide discharge information to the injured employee, the
carrier and the therapist without charge.
b. Upon program completion, a report of the following shall be sent by the therapist without
charge to the treating physician and the carrier with the final bill:
(1) The injured employee’s current clinical status and degree of reconditioning/restoration; and
(2) Return to work recommendations.
D. Level III. Rehabilitation Programs.
1. Authorization.
a. Reimbursement shall only be made to a facility for carrier authorized Level III services,
based on a signed order from the authorized, treating physician. All services shall be
authorized prior to initiation of services.
19
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
b. Reimbursement for Level III services shall only be made to rehabilitation programs
accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF),
except for a facility operating pursuant to Chapter 395, F.S., as part of a hospital. Level
III services must be provided through a CARF accredited Outpatient Medical
Rehabilitation Program, Occupational Rehabilitation Program or Interdisciplinary Pain
Rehabilitation Program.
2. Functional Capacity Evaluation (FCE).
a. Reimbursement for a functional capacity evaluation shall be made only when the
evaluation is provided as a part of Level III services. Reimbursement shall be made for
workers’ compensation unique code 97750, specifically designated for use solely in
reporting a functional capacity evaluation.
b. The reimbursement for a functional capacity evaluation includes a written program plan
or a written report. The facility shall provide the results of the evaluation and
recommendations to the injured employee, the carrier and the treating physician without
additional charge.
3. Work hardening program.
a. Reimbursement for a work hardening program shall be made to a facility for the duration
of the recommended individualized program.
b. Reimbursement shall be made for 97545 and 97546, specifically designated to use
exclusively in reporting a work hardening program.
(1) Reimbursement shall be made for code 97545 when used to bill the initial two (2)
hours each day of a work hardening program.
(2) Reimbursement shall be made for code 97546 when used to bill each additional hour
each day of a work hardening program.
4. Pain program.
a. Reimbursement for an interdisciplinary pain management program shall be made to a
facility for the recommended time indicated in the injured employee’s individual program
plan.
b. Reimbursement shall be made for codes submitted with documentation of the services
rendered. The services provided must relate to the physical, psychological, social,
functional and vocational goals of the employee’s program plan.
c. Reimbursement shall be made for biofeedback; physical and rehabilitation medicine
services; pharmacy services; psychological and psychiatric services and testing;
musculoskeletal services tests and measurements; neuromuscular services tests and
studies and other medically necessary services during the course of the program.
5. Discharge from a CARF accredited program.
20
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
a. The facility’s program director shall determine if the injured employee shall be
discharged from the work hardening or pain program before completion. If the injured
employee has not completed the program and the program director recommends
discontinuance of the program, the director shall provide discharge information to the
injured employee, the carrier and the treating physician without charge.
b. Upon program completion, a report shall be sent by the facility’s program director
without charge to the treating physician and to the carrier with the final bill. The report
shall include:
(1) The injured employee’s current clinical status and plan for transition from the program; and
(2) Return to work recommendations.
SECTION VIII: SURGICAL SERVICES.
A. General reimbursement information.
1. Reimbursement for a surgical package (global reimbursement) shall be made to a
physician for the provision of certain services before and after surgery. The maximum
reimbursement allowance for surgical procedures shall be based on Part B, Section X in this
manual. (See Section X for complete instructions). Payment for these services includes:
a. The immediate preoperative visit.
b. Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia.
c. The surgical procedure and operative report.
d. The time period for follow-up care listed in the follow-up days column (FU days) in
Section X.
(1) Reimbursement for a procedure code with a YYY designation for the global period
shall be set by the carrier.
(2) Reimbursement for a procedure code with a ZZZ designation for the global period
shall be the same as the other procedure code that is billed in conjunction with this
“add-on” procedure code.
2. Reimbursement shall be made for other services in addition to the surgical package in the
following situations when:
a. A preoperative visit is the initial visit, when prolonged detention or evaluation is
necessary to prepare an injured employee and when there is a need to establish the reason
for a particular type of surgery.
b. The preoperative visit is a consultation.
c. The preoperative services are not part of the usual preparation for the particular surgical
procedure.
21
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
d. The services are to treat complications, exacerbations, recurrences, or other diseases and
injuries. Documentation substantiating the medical necessity of the additional services
rendered shall be submitted with the claim form.
3. Reimbursement shall be made for additional surgery performed during the follow-up period.
a. Reimbursement for surgical services shall be made when an additional surgery is
performed during the postoperative period of another surgical procedure.
b. Reimbursement for normal postoperative care shall run concurrently and shall be made
according to the separate follow-up day periods (FU days) listed in Section X. unless it is
a procedure code with a YYY designation. For these codes the follow-up day period
shall be set by the carrier.
B. Reimbursement for surgical assistants, two (2) surgeons and surgical team.
1. Surgical assistants.
a. Reimbursement for surgical assistant services shall be twenty-five (25) percent of the
listed MRA, in Part B, Section X in this manual.
b. Reimbursement shall be made to a non-physician assistant for surgical services.
Reimbursement by the carrier shall not exceed seventy-five (75) percent of the allowance
addressed in Section VIII.B1.a. when the carrier has:
(1) Determined the non-physician assistant meets state licensure requirements and holds
current certification, as applicable, and
(2) Provided written authorization to the non-physician assistant prior to the surgery; or
(3) Verified that during a medical emergency a physician was not available to assist at
surgery.
2. Two surgeons.
a. Reimbursement shall be made to two (2) surgeons at the same operative session for
performing distinct parts of a surgical procedure. The services provided shall be
identified by the same code with modifier –62 added. Reimbursement to each surgeon
shall be made at sixty-two and one-half (62.5) percent of the listed MRA in Part B,
Section X in this manual.
b. Reimbursement shall be made to two (2) surgeons at the same operative session for
rendering separate surgical procedures, identified by different, unmodified codes.
Reimbursement to each surgeon shall be made at the listed MRA, in Part B, Section X.
c. Reimbursement shall not be made to either surgeon until the carrier has received and
reviewed each surgeon’s bill and individual operative report.
3. Surgical team.
22
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Reimbursement for a surgical team shall be made BR to each team member for each
surgeon’s surgical service. Each team member shall identify the specific procedure with
modifier –66 added to the code.
C. Reimbursement for multiple procedures.
1. Reimbursement shall be made for all medically necessary procedures when more than one (1)
procedure is performed at a single operative session.
2. Reimbursement for the primary surgical procedure shall be, the MRA in Part B, Section X in
this manual.
3. Reimbursement for an additional procedure shall be made at fifty (50) percent of the listed
MRA in Part B, Section X. The additional procedure shall be identified when modifier –51 is
added to the code to indicate the performance of multiple procedures.
D. Reimbursement for bilateral procedures.
1. Reimbursement shall be made for bilateral procedures that are performed at the same
operative session.
2. Reimbursement for a bilateral procedure that contains the word “bilateral” in the descriptor
shall be made at the listed MRA in Part B, Section X.
3. Reimbursement for a bilateral procedure that does not indicate that it is bilateral shall be
made, as follows, when the procedure is billed twice:
a. Reimbursement for the first procedure shall be made at the listed MRA, in Part B,
Section X.
b. Reimbursement for the second procedure, identified by adding modifier –50 to the
procedure code, shall be made at fifty (50) percent of the listed MRA in Part B, Section
X.
SECTION IX: ANESTHESIA SERVICES.
A. Reimbursement for anesthesia services shall be made to a physician or certified registered nurse
anesthetist (CRNA).
1. Reimbursement shall be based on application of the following values, physical status modifiers
and certain qualifying circumstances.
a. Basic value (BV) or base unit.
(1) The usual preoperative and postoperative visits, the anesthesia care during the
procedure, the administration of fluids and/or blood and the usual monitoring services
(ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry) are
included in the basic value.
23
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
(2) When multiple surgical procedures are performed during an operative session, the
basic value for the anesthesia procedure with the highest value is billed and
reimbursed.
(3) The basic value units, listed in Section X. under Anesthesia, for each anesthesia
procedure code, are used in calculating reimbursement.
b. Time (TM) units.
(1) Anesthesia time begins when the provider starts to prepare the injured employee for
anesthesia care in the operating room or in an equivalent area and stops when the
provider is no longer in personal attendance.
(2) Anesthesia time shall be billed as the total number of minutes of anesthesia. For
example, one (1) hour and fifteen (15) minutes of anesthesia must be billed as
seventy-five (75) minutes of anesthesia.
(3) The minutes of anesthesia must be converted into time (TM) units as follows:
(a) For anesthesiologists, each ten (10) minutes of anesthesia time equals one (1) unit
of anesthesia and each minute over a unit has a value of one-tenth (1/10) unit.
(b) For CRNAs, each fifteen (15) minutes of anesthesia time equals one (1) minute over
a unit has a value of one-fifteenth (1/15) unit.
(c) For codes providing BV + TM, time units shall be calculated and added to the
listed BV to determine the reimbursement for the anesthesia services.
(d) Only the BV units apply for codes without a time unit (TM) after the base unit.
For some anesthesia services, time is not reported additionally. Therefore,
additional units of time are not calculated for these codes when determining
reimbursement.
c. Physical status modifiers.
(1) Anesthesia services shall warrant additional reimbursement for units based upon the
injured employee’s condition and the complexity of the anesthesia service provided.
(2) A physical status modifier shall be determined to rank the injured employee’s condition. Additional reimbursement shall be based on the unit value for the specific
physical status modifier (see Section IX. A.2.a. (5).
Physical Status
Modifiers
P1
P2
P3
P4
Unit
Values
A normal healthy patient
A patient with mild systemic disease
A patient with severe systemic disease
A patient with severe systemic disease
that is a constant threat to life
24
0
0
1
2
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
P5
P6
A moribund patient who is not expected
to survive without the operation
A declared brain-dead patient whose organs
are being removed for donor purposes
3
0
d. Qualifying circumstances.
Anesthesia services, which are provided under particularly difficult circumstances,
may warrant additional reimbursement for unit values based on unusual events. This
subsection includes a list of important qualifying circumstances that impact the
anesthesia service provided. These procedures are not reported alone but are reported
as additional procedure numbers qualifying an anesthesia procedure for additional
reimbursement. The listed unit value must be added to the basic unit values to obtain
the reimbursement (see Section IX. A. 2.a.(5)). List each of the following codes
separately in addition to the procedure code for the primary anesthesia procedure.
Unit
Values
Qualifying Circumstances
99100
99116
99135
99140
2.
Anesthesia for patient of extreme age,
under one year and over seventy
1
Anesthesia complicated by utilization
of total body hypothermia
5
Anesthesia complicated by utilization
of controlled hypotension
5
Anesthesia complicated by emergency
conditions (specify)
2
Reimbursement for anesthesia services shall be made at the provider’s usual charge or the
anesthesia reimbursement allowance (ARA) listed in Part A, Section X in this manual.
a. Methodology for calculating the anesthesia reimbursement allowance (ARA) for
procedures that are listed basic value (BV) + time (TM).
(1) Select the applicable anesthesia procedure code and basic value from the schedule in
Section X.
(2) Determine the time units according to Section IX.A.1.b.(3) (ten [10] minutes = one
[1] time unit for an anesthesiologist and fifteen [15] minutes = one [1] time unit for a
CRNA).
(3) Any minutes that exceed a whole unit are counted as partial units (fractions of units),
such as one (1) minute is one-tenth (1/10) unit for an anesthesiologist and onefifteenth (1/15) unit for a CRNA.
(4) Determine any additional units that are justified by the physical status modifiers or
qualifying circumstances addressed above in Section IX.A.1.c. and IX.A.1.d.
25
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
(5) Add the basic value, time units, physical status modifier and any applicable
qualifying circumstances to determine the total anesthesia value.
(6) Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the
anesthesia reimbursement allowance.
b. Methodology for calculating the anesthesia reimbursement allowance (ARA) for
procedures that are listed only basic value (BV) and no time.
Multiply the basic value by the conversion factor of $29.49 to obtain the anesthesia
reimbursement allowance.
c. Methodology for calculating the anesthesia reimbursement allowance (ARA) for
monitored anesthesia care.
(1) Follow the guidelines, as applicable, in Section IX.A.2.a. as though anesthesia was
administered (basic value + time).
(2) Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the
anesthesia reimbursement allowance.
B. Reimbursement for medical direction provided by anesthesiologist.
1. Medical direction for CRNA employed by anesthesiologist.
a. Reimbursement shall be made to the anesthesiologist only for anesthesia services which
are billed under the name and license number of the physician-employer.
b. No additional reimbursement shall be made for supervisory services rendered by the
physician.
2. Medical direction for a CRNA not employed by the anesthesiologist.
a. A CRNA shall bill on the number of units of time to perform the surgical procedure. The
reimbursement shall be calculated by dividing the total anesthesia time by fifteen (15)
minute intervals for CRNAs.
b. Reimbursement shall be made to an anesthesiologist for providing medical direction,
including preoperative and postoperative evaluations to a CRNA not employed by the
physician.
(1) Medical direction shall be billed by the anesthesiologist by adding a unique workers’
compensation modifier –QY to the anesthesia procedure code.
(2) Reimbursement for medical direction by anesthesiologists shall be the provider’s
usual charges, or fifty (50) percent of the anesthesia reimbursement allowance listed
in Part A, Section X in this manual.
26
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
SECTION X
SCHEDULE OF MAXIMUM REIMBURSEMENT
ALLOWANCES
27
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
MAXIMUM REIMBURSEMENT ALLOWANCES
General Instructions:
I. Part A of Section X establishes the Maximum Reimbursement Allowances (MRAs) for all
services and procedures performed by certified providers, including anesthesiology service
providers under state licensure but excluding physicians licensed under Chapters 458 and
459, Florida Statutes. Appropriate reimbursement for a procedure code is listed in the MRA
column to the right of each procedure.
II. Part B of Section X establishes the maximum reimbursement allowances for all surgical
procedures.
Part C of Section X establishes the maximum reimbursement allowances for physicians
licensed under Chapter 458 or Chapter 459.
1. Determine the county location of the provider according to the Medicare
locality map in Appendix E.
2. Determine whether the procedure should be paid according to the non-facility
MRA (services rendered in a physician’s office or laboratory) or the facility
MRA (services rendered in a hospital setting, ambulatory surgical center,
skilled nursing facility, inpatient psychiatric facility, and comprehensive
[Level III] outpatient rehabilitation facility).
3. 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.
4. Locate the point of intersection for the procedure code column and the
appropriate non-facility or facility locality row on the reimbursement matrix.
5. Compare the amount allowed at the point of intersection on the matrix to the
amount listed in the 2003 MRA column.
6. Reimburse the provider the greater of the amount in the 2003 MRA column or
the amount in the column at the point of intersection.
28
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
PART A
SCHEDULE OF MAXIMUM REIMBURSEMENT
ALLOWANCES
29
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Anesthesia
CPT Code
00100
00102
00103
00104
00120
00124
00126
00140
00142
00144
00145
00147
00148
00160
00162
00164
00170
00172
00174
00176
00190
00192
00210
00212
00214
00215
00216
00218
00220
00222
00300
00320
00322
00350
00352
00400
00402
00404
00406
00410
00450
00452
00454
00470
00472
00474
00500
00520
00522
00524
BV + TM
5 + TM
6 + TM
5 + TM
4 + TM
5 + TM
4 + TM
4 + TM
5 + TM
6 + TM
6 + TM
6 + TM
6 + TM
4 + TM
5 + TM
7 + TM
4 + TM
5 + TM
6 + TM
6 + TM
7 + TM
5 + TM
7 + TM
11 + TM
5 + TM
9 + TM
9 + TM
15 + TM
13 + TM
10 + TM
6 + TM
5 + TM
6 + TM
3 + TM
10 + TM
5 + TM
3 + TM
5 + TM
5 + TM
13 + TM
4 + TM
5 + TM
6 + TM
3 + TM
6 + TM
10 + TM
13 + TM
15 + TM
6 + TM
4 + TM
4 + TM
Anesthesia
CPT Code
00528
00530
00532
00534
00537
00539
00540
00541
00542
00544
00546
00548
00550
00560
00562
00563
00566
00580
00600
00604
00620
00622
00630
00632
00634
00635
00640
00670
00700
00702
00730
00740
00750
00752
00754
00756
00770
00790
00792
00794
00796
00797
00800
00802
00810
00820
00830
00832
00840
00842
BV + TM
8 + TM
4 + TM
4 + TM
7 + TM
8 + TM
17 + TM
13 + TM
15 + TM
15 + TM
15 + TM
15 + TM
15 + TM
10 + TM
15 + TM
20 + TM
25 + TM
25 + TM
20 + TM
10 + TM
13 + TM
10 + TM
13 + TM
8 + TM
7 + TM
10 + TM
4 + TM
3 + TM
13 + TM
3 + TM
4 + TM
5 + TM
5 + TM
4 + TM
6 + TM
7 + TM
7 + TM
15 + TM
7 + TM
13 + TM
8 + TM
30 + TM
10 + TM
3 + TM
5 + TM
5 + TM
5 + TM
4 + TM
6 + TM
6 + TM
4 + TM
CPT only © 2002 American Medical Association. All Rights Reserved.
Anesthesia
CPT Code
00844
00846
00848
00851
00860
00862
00864
00865
00866
00868
00870
00872
00873
00880
00882
00902
00904
00906
00908
00910
00912
00914
00916
00918
00920
00921
00922
00924
00926
00928
00930
00932
00934
00936
00938
00940
00942
00944
00948
00950
00952
01112
01120
01130
01140
01150
01160
01170
01180
01190
BV + TM
7 + TM
8 + TM
8 + TM
6 + TM
6 + TM
7 + TM
8 + TM
8 + TM
10 + TM
10 + TM
5 + TM
7 + TM
5 + TM
15 + TM
10 + TM
4 + TM
7 + TM
4 + TM
6 + TM
3 + TM
5 + TM
5 + TM
5 + TM
5 + TM
3 + TM
3 + TM
6 + TM
4 + TM
4 + TM
6 + TM
4 + TM
4 + TM
6 + TM
8 + TM
4 + TM
3 + TM
4 + TM
6 + TM
4 + TM
5 + TM
4 + TM
5 + TM
6 + TM
3 + TM
15 + TM
8 + TM
4 + TM
8 + TM
3 + TM
4 + TM
30
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Anesthesia
CPT Code
01200
01202
01210
01212
01214
01215
01220
01230
01232
01234
01250
01260
01270
01272
01274
01320
01340
01360
01380
01382
01390
01392
01400
01402
01404
01420
01430
01432
01440
01442
01444
01462
01464
01470
01472
01474
01480
01482
01484
01486
01490
01500
01502
01520
01522
01610
01620
01622
01630
01632
BV + TM
4 + TM
4 + TM
6 + TM
10 + TM
8 + TM
10 + TM
4 + TM
6 + TM
5 + TM
8 + TM
4 + TM
3 + TM
8 + TM
4 + TM
6 + TM
4 + TM
4 + TM
5 + TM
3 + TM
3 + TM
3 + TM
4 + TM
4 + TM
7 + TM
5 + TM
3 + TM
3 + TM
6 + TM
5 + TM
8 + TM
8 + TM
3 + TM
3 + TM
3 + TM
5 + TM
5 + TM
3 + TM
4 + TM
4 + TM
7 + TM
3 + TM
8 + TM
6 + TM
3 + TM
5 + TM
5 + TM
4 + TM
4 + TM
5 + TM
6 + TM
Anesthesia
CPT Code
01634
01636
01638
01650
01652
01654
01656
01670
01680
01682
01710
01712
01714
01716
01730
01732
01740
01742
01744
01756
01758
01760
01770
01772
01780
01782
01810
01820
01829
01830
01832
01840
01842
01844
01850
01852
01860
01905
01916
01920
01922
01924
01925
01926
01930
01931
01932
01933
01951
01952
BV + TM
9 + TM
15 + TM
10 + TM
6 + TM
10 + TM
8 + TM
10 + TM
4 + TM
3 + TM
4 + TM
3 + TM
5 + TM
5 + TM
5 + TM
3 + TM
3 + TM
4 + TM
5 + TM
5 + TM
6 + TM
5 + TM
7 + TM
6 + TM
6 + TM
3 + TM
4 + TM
3 + TM
3 + TM
3 + TM
3 + TM
6 + TM
6 + TM
6 + TM
6 + TM
3 + TM
4 + TM
3 + TM
5 + TM
5 + TM
7 + TM
7 + TM
6 + TM
8 + TM
10 + TM
5 + TM
7 + TM
7 + TM
8 + TM
3 + TM
5 + TM
CPT only © 2002 American Medical Association. All Rights Reserved.
Anesthesia
CPT Code
01953
01960
01961
01962
01963
01964
01967
01968
01969
01990
01991
01992
01995
01996
01999
BV + TM
1 + TM
5 + TM
7 + TM
8 + TM
10 + TM
4 + TM
5 + TM
3 + TM
5 + TM
0
3 + TM
5 + TM
5
3
BR
31
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
10021
10022
10040
10060
10061
10080
10081
10120
10121
10140
10160
10180
11000
11001
11010
11011
11012
11040
11041
11042
11043
11044
11055
11056
11057
11100
11101
11200
11201
11300
11301
11302
11303
11305
11306
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406
11420
11421
11422
MRA
$90.00
$92.00
$54.00
$53.00
$133.00
$65.00
$203.00
$53.00
$169.00
$53.00
$45.00
$164.00
$45.00
$27.00
$348.00
$432.00
$597.00
$43.00
$45.00
$88.00
$210.00
$283.00
$26.00
$35.00
$39.00
$78.00
$41.00
$66.00
$26.00
$59.00
$80.00
$96.00
$119.00
$61.00
$86.00
$100.00
$125.00
$75.00
$95.00
$110.00
$144.00
$81.00
$114.00
$145.00
$178.00
$200.00
$246.00
$98.00
$92.00
$157.00
FU Days
0
0
10
10
10
10
10
10
10
10
10
10
0
ZZZ
10
0
0
0
0
0
10
10
0
0
0
0
ZZZ
10
ZZZ
0
0
0
0
0
0
0
0
0
0
0
0
10
10
10
10
10
10
10
10
10
Surgery
CPT Code
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11451
11462
11463
11470
11471
11600
11601
11602
11603
11604
11606
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
11719
11720
11721
11730
11732
11740
11750
11752
11755
11760
11762
11765
11770
11771
11772
11900
11901
MRA
$163.00
$221.00
$303.00
$105.00
$102.00
$174.00
$221.00
$276.00
$344.00
$282.00
$366.00
$264.00
$351.00
$320.00
$391.00
$148.00
$180.00
$199.00
$226.00
$249.00
$315.00
$150.00
$191.00
$223.00
$259.00
$305.00
$373.00
$168.00
$227.00
$260.00
$305.00
$380.00
$494.00
$22.00
$32.00
$50.00
$62.00
$31.00
$41.00
$156.00
$234.00
$106.00
$131.00
$223.00
$65.00
$275.00
$496.00
$585.00
$33.00
$37.00
FU Days
10
10
10
10
10
10
10
10
10
90
90
90
90
90
90
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
0
0
0
0
ZZZ
0
10
10
0
10
10
10
10
90
90
0
0
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
11920
11921
11922
11950
11951
11952
11954
11960
11970
11971
11976
12001
12002
12004
12005
12006
12007
12011
12013
12014
12015
12016
12017
12018
12020
12021
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
13100
13101
13102
13120
13121
MRA
$147.00
$172.00
$40.00
$107.00
$114.00
$155.00
$165.00
$829.00
$632.00
$280.00
$123.00
$84.00
$98.00
$122.00
$165.00
$203.00
$339.00
$98.00
$141.00
$165.00
$207.00
$268.00
$316.00
$515.00
$211.00
$87.00
$93.00
$110.00
$148.00
$223.00
$356.00
$411.00
$116.00
$141.00
$176.00
$250.00
$341.00
$363.00
$126.00
$148.00
$223.00
$301.00
$380.00
$487.00
$539.00
$178.00
$240.00
$89.00
$223.00
$348.00
FU Days
0
0
ZZZ
0
0
0
0
90
90
90
0
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
ZZZ
10
10
32
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
13122
13131
13132
13133
13150
13151
13152
13153
13160
14000
14001
14020
14021
14040
14041
14060
14061
14300
14350
15000
15001
15050
15100
15101
15120
15121
15200
15201
15220
15221
15240
15241
15260
15261
15342
15343
15350
15351
15400
15401
15570
15572
15574
15576
15600
15610
15620
15630
15650
15732
MRA
$104.00
$252.00
$484.00
$154.00
$260.00
$375.00
$542.00
$169.00
$655.00
$512.00
$695.00
$590.00
$818.00
$701.00
$936.00
$766.00
$1,330.00
$1,040.00
$734.00
$287.00
$70.00
$349.00
$679.00
$146.00
$788.00
$235.00
$644.00
$126.00
$687.00
$114.00
$763.00
$334.00
$841.00
$207.00
$118.00
$25.00
$232.00
$66.00
$223.00
$66.00
$748.00
$721.00
$775.00
$457.00
$259.00
$320.00
$506.00
$362.00
$427.00
$1,465.00
FU Days
ZZZ
10
10
ZZZ
10
10
10
ZZZ
90
90
90
90
90
90
90
90
90
90
90
0
ZZZ
90
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
10
ZZZ
90
ZZZ
90
ZZZ
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
15734
15736
15738
15740
15750
15756
15757
15758
15760
15770
15775
15776
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15810
15811
15819
15820
15821
15822
15823
15824
15825
15826
15828
15829
15831
15832
15833
15834
15835
15836
15837
15838
15839
15840
15841
15842
15845
15850
15851
15852
MRA
$1,557.00
$1,862.00
$1,415.00
$913.00
$1,064.00
$2,892.00
$2,892.00
$2,884.00
$810.00
$674.00
$327.00
$475.00
$532.00
$420.00
$314.00
$340.00
$146.00
$27.00
$194.00
$360.00
$130.00
$232.00
$401.00
$440.00
$780.00
$556.00
$607.00
$499.00
$718.00
NC
NC
NC
NC
NC
$990.00
$926.00
$833.00
$837.00
$865.00
$721.00
$696.00
$600.00
$643.00
$1,187.00
$1,859.00
$3,099.00
$1,116.00
$63.00
$40.00
$35.00
FU Days
90
90
90
90
90
90
90
90
90
90
0
0
90
90
90
90
10
ZZZ
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
15860
15876
15877
15878
15879
15920
15922
15931
15933
15934
15935
15936
15937
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
15999
16000
16010
16015
16020
16025
16030
16035
16036
17000
17003
17004
17106
17107
17108
17110
17111
17250
17260
17261
17262
17263
17264
17266
17270
17271
MRA
$151.00
NC
NC
NC
NC
$571.00
$771.00
$638.00
$860.00
$1,064.00
$1,184.00
$1,032.00
$1,223.00
$318.00
$919.00
$954.00
$1,078.00
$1,737.00
$549.00
$872.00
$876.00
$1,013.00
$1,382.00
$1,379.00
BR
$53.00
$59.00
$213.00
$49.00
$67.00
$153.00
$341.00
$81.00
$60.00
$16.00
$233.00
$341.00
$648.00
$1,015.00
$55.00
$83.00
$27.00
$96.00
$117.00
$150.00
$172.00
$189.00
$225.00
$125.00
$143.00
FU Days
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
90
ZZZ
10
ZZZ
10
90
90
90
10
10
0
10
10
10
10
10
10
10
10
33
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
17272
17273
17274
17276
17280
17281
17282
17283
17284
17286
17304
17305
17306
17307
17310
17340
17360
17380
17999
19000
19001
19020
19030
19100
19101
19102
19103
19110
19112
19120
19125
19126
19140
19160
19162
19180
19182
19200
19220
19240
19260
19271
19272
19290
19291
19295
19316
19318
19324
19325
MRA
$170.00
$195.00
$240.00
$281.00
$123.00
$165.00
$194.00
$239.00
$282.00
$373.00
$590.00
$247.00
$227.00
$232.00
$62.00
$37.00
$96.00
NC
BR
$74.00
$40.00
$288.00
$98.00
$117.00
$338.00
$263.00
$601.00
$406.00
$354.00
$429.00
$468.00
$201.00
$541.00
$485.00
$1,054.00
$689.00
$628.00
$1,192.00
$1,211.00
$1,195.00
$1,101.00
$1,561.00
$1,674.00
$101.00
$52.00
$103.00
$954.00
$1,313.00
$440.00
$656.00
FU Days
10
10
10
10
10
10
10
10
10
10
0
0
0
0
0
10
10
0
YYY
0
ZZZ
90
0
0
10
0
0
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
0
ZZZ
ZZZ
90
90
90
90
Surgery
CPT Code
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
19499
20000
20005
20100
20101
20102
20103
20150
20200
20205
20206
20220
20225
20240
20245
20250
20251
20500
20501
20520
20525
20526
20550
20551
20552
20553
20600
20605
20610
20612
20615
20650
20660
MRA
$457.00
$569.00
$545.00
$963.00
$853.00
$755.00
$1,449.00
$1,667.00
$2,737.00
$1,676.00
$2,056.00
$2,444.00
$2,317.00
$662.00
$788.00
$780.00
$231.00
BR
$45.00
$267.00
$727.00
$261.00
$314.00
$405.00
$1,141.00
$134.00
$243.00
$119.00
$128.00
$215.00
$279.00
$364.00
$447.00
$511.00
$59.00
$60.00
$75.00
$331.00
$64.00
$40.00
$62.00
$62.00
$62.00
$41.00
$48.00
$49.00
$56.00
$94.00
$170.00
$320.00
FU Days
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
0
YYY
10
10
10
10
10
10
90
0
0
0
0
0
10
10
10
10
10
0
10
10
0
0
0
0
0
0
0
0
0
10
10
0
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
20661
20662
20663
20665
20670
20680
20690
20692
20693
20694
20802
20805
20808
20816
20822
20824
20827
20838
20900
20902
20910
20912
20920
20922
20924
20926
20930
20931
20936
20937
20938
20950
20955
20956
20957
20962
20969
20970
20972
20973
20974
20975
20979
20999
21010
21015
21025
21026
21029
21030
MRA
$476.00
$559.00
$465.00
$105.00
$80.00
$332.00
$298.00
$516.00
$477.00
$421.00
$3,363.00
$4,317.00
$5,324.00
$3,060.00
$2,511.00
$3,027.00
$3,920.00
$3,484.00
$454.00
$658.00
$338.00
$549.00
$460.00
$634.00
$583.00
$444.00
BR
$156.00
BR
$234.00
$257.00
$123.00
$3,332.00
$3,167.00
$3,074.00
$3,122.00
$3,716.00
$3,650.00
$3,420.00
$3,821.00
$266.00
$334.00
$19.00
BR
$854.00
$520.00
$546.00
$413.00
$700.00
$496.00
FU Days
90
90
90
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
ZZZ
0
ZZZ
ZZZ
0
90
90
90
90
90
90
90
90
0
0
0
YYY
90
90
90
90
90
90
34
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
21031
21032
21034
21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
21087
21088
21089
21100
21110
21116
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
MRA
$310.00
$315.00
$1,140.00
$227.00
$957.00
$1,313.00
$899.00
$1,109.00
$925.00
$1,051.00
$1,026.00
$972.00
$679.00
$1,192.00
$3,002.00
$2,086.00
$2,346.00
$2,138.00
$1,855.00
$1,802.00
$2,105.00
$801.00
$2,333.00
$2,217.00
BR
BR
$297.00
$371.00
$207.00
$500.00
$651.00
$700.00
$903.00
$656.00
$909.00
$797.00
$960.00
$1,168.00
$1,438.00
$1,527.00
$1,511.00
$1,513.00
$1,570.00
$1,639.00
$1,914.00
$2,264.00
$2,364.00
$2,640.00
$3,302.00
$3,500.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
10
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199
21206
21208
21209
21210
21215
21230
21235
21240
21242
21243
21244
21245
21246
21247
21248
21249
21255
21256
21260
21261
21263
21267
21268
21270
21275
21280
21282
21295
21296
21299
21300
21310
21315
21320
21325
MRA
$2,111.00
$2,604.00
$1,826.00
$2,035.00
$813.00
$2,570.00
$2,770.00
$3,150.00
$1,786.00
$1,331.00
$1,540.00
$1,360.00
$1,764.00
$1,268.00
$1,018.00
$1,112.00
$946.00
$576.00
$930.00
$970.00
$956.00
$707.00
$1,281.00
$1,207.00
$1,501.00
$1,062.00
$1,038.00
$1,010.00
$2,003.00
$1,023.00
$1,525.00
$1,459.00
$1,470.00
$1,372.00
$2,347.00
$2,361.00
$1,539.00
$1,946.00
$890.00
$963.00
$571.00
$360.00
$144.00
$384.00
BR
$107.00
$81.00
$180.00
$235.00
$348.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
10
10
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
21330
21335
21336
21337
21338
21339
21340
21343
21344
21345
21346
21347
21348
21355
21356
21360
21365
21366
21385
21386
21387
21390
21395
21400
21401
21406
21407
21408
21421
21422
21423
21431
21432
21433
21435
21436
21440
21445
21450
21451
21452
21453
21454
21461
21462
21465
21470
21480
21485
21490
MRA
$639.00
$852.00
$478.00
$300.00
$550.00
$689.00
$907.00
$1,043.00
$1,450.00
$738.00
$917.00
$1,048.00
$1,286.00
$295.00
$372.00
$590.00
$1,239.00
$1,386.00
$810.00
$812.00
$958.00
$920.00
$1,384.00
$143.00
$313.00
$852.00
$736.00
$1,007.00
$528.00
$761.00
$890.00
$598.00
$744.00
$1,981.00
$1,404.00
$2,045.00
$308.00
$533.00
$325.00
$498.00
$195.00
$902.00
$905.00
$769.00
$1,012.00
$923.00
$1,331.00
$82.00
$318.00
$865.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
35
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
21493
21494
21495
21497
21499
21501
21502
21510
21550
21555
21556
21557
21600
21610
21615
21616
21620
21627
21630
21632
21700
21705
21720
21725
21740
21742
21743
21750
21800
21805
21810
21820
21825
21899
21920
21925
21930
21935
22100
22101
22102
22103
22110
22112
22114
22116
22210
22212
22214
22216
MRA
$107.00
$529.00
$500.00
$372.00
BR
$315.00
$612.00
$534.00
$165.00
$337.00
$431.00
$794.00
$631.00
$828.00
$938.00
$1,042.00
$689.00
$686.00
$1,455.00
$1,514.00
$576.00
$746.00
$523.00
$588.00
$1,387.00
BR
BR
$1,009.00
$84.00
$236.00
$540.00
$143.00
$810.00
BR
$165.00
$371.00
$403.00
$1,280.00
$850.00
$862.00
$781.00
$198.00
$889.00
$1,090.00
$1,062.00
$195.00
$1,892.00
$1,668.00
$819.00
$492.00
FU Days
90
90
90
90
YYY
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
10
90
90
90
90
90
90
ZZZ
90
90
90
ZZZ
90
90
90
ZZZ
Surgery
CPT Code
22220
22222
22224
22226
22305
22310
22315
22318
22319
22325
22326
22327
22328
22505
22520
22521
22522
22548
22554
22556
22558
22585
22590
22595
22600
22610
22612
22614
22630
22632
22800
22802
22804
22808
22810
22812
22818
22819
22830
22840
22841
22842
22843
22844
22845
22846
22847
22848
22849
22850
MRA
$1,801.00
$1,604.00
$1,731.00
$488.00
$213.00
$272.00
$711.00
$1,755.00
$1,983.00
$1,407.00
$1,710.00
$1,660.00
$391.00
$174.00
$509.00
$477.00
$231.00
$2,271.00
$1,727.00
$2,054.00
$1,907.00
$473.00
$1,895.00
$1,960.00
$1,567.00
$1,494.00
$1,861.00
$530.00
$1,201.00
$442.00
$1,960.00
$2,633.00
$2,951.00
$2,157.00
$2,356.00
$2,675.00
$2,701.00
$2,968.00
$1,176.00
$943.00
BR
$2,352.00
$1,028.00
$1,277.00
$1,853.00
$999.00
$1,077.00
$529.00
$2,235.00
$872.00
FU Days
90
90
90
ZZZ
90
90
90
90
90
90
90
90
ZZZ
10
10
10
ZZZ
90
90
90
90
ZZZ
90
90
90
90
90
ZZZ
90
ZZZ
90
90
90
90
90
90
90
90
90
ZZZ
0
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
22851
22852
22855
22899
22900
22999
23000
23020
23030
23031
23035
23040
23044
23065
23066
23075
23076
23077
23100
23101
23105
23106
23107
23120
23125
23130
23140
23145
23146
23150
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23221
23222
23330
23331
23332
23350
23395
MRA
$600.00
$854.00
$1,193.00
BR
$446.00
BR
$447.00
$807.00
$323.00
$185.00
$861.00
$898.00
$708.00
$171.00
$302.00
$247.00
$613.00
$1,228.00
$616.00
$583.00
$814.00
$581.00
$851.00
$645.00
$865.00
$722.00
$597.00
$889.00
$704.00
$755.00
$945.00
$794.00
$645.00
$638.00
$882.00
$566.00
$865.00
$962.00
$656.00
$902.00
$1,095.00
$1,095.00
$1,307.00
$1,559.00
$1,921.00
$59.00
$520.00
$1,029.00
$74.00
$1,366.00
FU Days
ZZZ
90
90
YYY
90
YYY
90
90
10
10
90
90
90
10
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
0
90
36
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23455
23460
23462
23465
23466
23470
23472
23480
23485
23490
23491
23500
23505
23515
23520
23525
23530
23532
23540
23545
23550
23552
23570
23575
23585
23600
23605
23615
23616
23620
23625
23630
23650
23655
23660
23665
23670
23675
23680
MRA
$1,403.00
$1,196.00
$799.00
$977.00
$1,119.00
$1,229.00
$622.00
$1,276.00
$884.00
$906.00
$1,210.00
$1,340.00
$1,364.00
$1,383.00
$1,398.00
$1,332.00
$1,540.00
$1,570.00
$926.00
$1,181.00
$1,038.00
$1,251.00
$148.00
$293.00
$688.00
$205.00
$320.00
$659.00
$713.00
$148.00
$148.00
$701.00
$753.00
$88.00
$306.00
$809.00
$318.00
$511.00
$900.00
$1,895.00
$286.00
$422.00
$712.00
$296.00
$374.00
$712.00
$440.00
$759.00
$550.00
$1,064.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
23700
23800
23802
23900
23920
23921
23929
23930
23931
23935
24000
24006
24065
24066
24075
24076
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
24201
24220
24300
24301
24305
24310
24320
MRA
$237.00
$1,346.00
$1,368.00
$1,561.00
$1,300.00
$497.00
BR
$71.00
$62.00
$630.00
$550.00
$793.00
$166.00
$461.00
$349.00
$529.00
$1,058.00
$467.00
$591.00
$755.00
$360.00
$724.00
$898.00
$1,037.00
$595.00
$663.00
$731.00
$595.00
$966.00
$720.00
$697.00
$963.00
$592.00
$703.00
$1,224.00
$1,265.00
$1,383.00
$829.00
$936.00
$1,019.00
$533.00
$564.00
$58.00
$444.00
$89.00
$352.00
$869.00
$579.00
$511.00
$944.00
FU Days
10
90
90
90
90
90
YYY
10
10
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
0
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
24330
24331
24332
24340
24341
24342
24343
24344
24345
24346
24350
24351
24352
24354
24356
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
24435
24470
24495
24498
24500
24505
24515
24516
24530
24535
24538
24545
24546
24560
24565
24566
24575
24576
24577
24579
24582
24586
24587
24600
24605
MRA
$845.00
$927.00
$487.00
$697.00
$702.00
$950.00
$643.00
$971.00
$643.00
$971.00
$444.00
$522.00
$585.00
$578.00
$634.00
$1,125.00
$1,215.00
$1,269.00
$1,663.00
$747.00
$850.00
$991.00
$1,319.00
$1,265.00
$1,209.00
$1,260.00
$774.00
$742.00
$1,076.00
$288.00
$574.00
$1,018.00
$1,029.00
$88.00
$671.00
$850.00
$946.00
$1,273.00
$266.00
$526.00
$705.00
$872.00
$295.00
$575.00
$964.00
$773.00
$1,314.00
$1,278.00
$360.00
$371.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
37
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
24615
24620
24635
24650
24655
24665
24666
24670
24675
24685
24800
24802
24900
24920
24925
24930
24931
24935
24940
24999
25000
25001
25020
25023
25024
25025
25028
25031
25035
25040
25065
25066
25075
25076
25077
25085
25100
25101
25105
25107
25110
25111
25112
25115
25116
25118
25119
25120
25125
25126
MRA
$836.00
$560.00
$1,329.00
$262.00
$436.00
$749.00
$905.00
$263.00
$490.00
$819.00
$984.00
$1,181.00
$858.00
$851.00
$661.00
$928.00
$1,063.00
$1,327.00
BR
BR
$381.00
$294.00
$594.00
$1,040.00
$683.00
$1,104.00
$417.00
$266.00
$794.00
$654.00
$164.00
$322.00
$352.00
$544.00
$957.00
$562.00
$420.00
$492.00
$635.00
$600.00
$403.00
$356.00
$441.00
$837.00
$807.00
$466.00
$653.00
$712.00
$803.00
$781.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25246
25248
25250
25251
25259
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
25392
25393
25394
25400
25405
25415
MRA
$502.00
$631.00
$546.00
$713.00
$720.00
$771.00
$1,085.00
$561.00
$817.00
$531.00
$567.00
$72.00
$236.00
$616.00
$933.00
$348.00
$728.00
$809.00
$998.00
$549.00
$613.00
$887.00
$620.00
$670.00
$436.00
$562.00
$592.00
$757.00
$865.00
$968.00
$1,004.00
$1,203.00
$834.00
$1,022.00
$1,166.00
$946.00
$913.00
$1,014.00
$468.00
$1,216.00
$1,214.00
$1,280.00
$1,043.00
$1,349.00
$1,294.00
$1,473.00
$723.00
$1,112.00
$1,388.00
$1,343.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
25420
25425
25426
25430
25431
25440
25441
25442
25443
25444
25445
25446
25447
25449
25450
25455
25490
25491
25492
25500
25505
25515
25520
25525
25526
25530
25535
25545
25560
25565
25574
25575
25600
25605
25611
25620
25622
25624
25628
25630
25635
25645
25650
25651
25652
25660
25670
25671
25675
25676
MRA
$1,554.00
$1,403.00
$1,401.00
$638.00
$631.00
$931.00
$1,147.00
$936.00
$970.00
$1,031.00
$959.00
$1,542.00
$952.00
$395.00
$805.00
$899.00
$955.00
$1,006.00
$1,170.00
$200.00
$517.00
$800.00
$644.00
$1,097.00
$1,293.00
$270.00
$516.00
$803.00
$276.00
$590.00
$804.00
$974.00
$312.00
$540.00
$707.00
$769.00
$148.00
$482.00
$716.00
$148.00
$458.00
$668.00
$185.00
$379.00
$560.00
$378.00
$731.00
$462.00
$404.00
$741.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
38
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
25680
25685
25690
25695
25800
25805
25810
25820
25825
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
25999
26010
26011
26020
26025
26030
26034
26035
26037
26040
26045
26055
26060
26070
26075
26080
26100
26105
26110
26115
26116
26117
26121
26123
26125
26130
26135
26140
26145
MRA
$471.00
$887.00
$518.00
$520.00
$703.00
$1,078.00
$1,008.00
$2,276.00
$895.00
$991.00
$871.00
$900.00
$799.00
$849.00
$1,523.00
$771.00
$670.00
$768.00
$830.00
$645.00
$731.00
BR
$59.00
$223.00
$484.00
$548.00
$655.00
$601.00
$741.00
$730.00
$367.00
$621.00
$343.00
$293.00
$440.00
$400.00
$382.00
$398.00
$481.00
$282.00
$344.00
$544.00
$806.00
$833.00
$959.00
$342.00
$629.00
$668.00
$678.00
$660.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
Surgery
CPT Code
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26320
26340
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
MRA
$319.00
$452.00
$444.00
$511.00
$598.00
$788.00
$543.00
$731.00
$624.00
$612.00
$444.00
$814.00
$1,184.00
$758.00
$949.00
$624.00
$414.00
$266.00
$715.00
$855.00
$886.00
$932.00
$979.00
$832.00
$945.00
$904.00
$889.00
$1,123.00
$371.00
$737.00
$846.00
$1,093.00
$444.00
$741.00
$733.00
$790.00
$430.00
$371.00
$656.00
$491.00
$458.00
$548.00
$455.00
$738.00
$353.00
$364.00
$346.00
$592.00
$586.00
$543.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
26477
26478
26479
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26504
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540
26541
26542
26545
26546
26548
26550
26551
26553
26554
26555
26556
26560
26561
26562
26565
26567
26568
26580
26587
26590
26591
MRA
$553.00
$608.00
$653.00
$808.00
$986.00
$891.00
$738.00
$496.00
$971.00
$946.00
$949.00
$946.00
$1,317.00
$934.00
$557.00
$715.00
$761.00
$334.00
$564.00
$630.00
$890.00
$877.00
$583.00
$531.00
$708.00
$877.00
$546.00
$770.00
$726.00
$926.00
$716.00
$722.00
$918.00
$665.00
$1,861.00
$3,901.00
$3,868.00
$4,551.00
$1,567.00
$4,005.00
$576.00
$1,067.00
$1,017.00
$730.00
$622.00
$1,003.00
$1,585.00
$792.00
$1,609.00
$431.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
39
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
26593
26596
26600
26605
26607
26608
26615
26641
26645
26650
26665
26670
26675
26676
26685
26686
26700
26705
26706
26715
26720
26725
26727
26735
26740
26742
26746
26750
26755
26756
26765
26770
26775
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26989
MRA
$587.00
$809.00
$133.00
$296.00
$334.00
$497.00
$521.00
$71.00
$371.00
$533.00
$693.00
$148.00
$501.00
$527.00
$592.00
$710.00
$88.00
$296.00
$469.00
$526.00
$96.00
$187.00
$187.00
$532.00
$148.00
$148.00
$548.00
$96.00
$133.00
$366.00
$398.00
$79.00
$275.00
$401.00
$408.00
$854.00
$756.00
$901.00
$800.00
$875.00
$704.00
$829.00
$542.00
$151.00
$747.00
$317.00
$747.00
$444.00
$608.00
BR
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
ZZZ
90
90
90
YYY
Surgery
CPT Code
26990
26991
26992
27000
27001
27003
27005
27006
27025
27030
27033
27035
27036
27040
27041
27047
27048
27049
27050
27052
27054
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27079
27080
27086
27087
27090
27091
27093
27095
27096
27097
27098
27100
27105
27110
27111
27120
27122
27125
MRA
$592.00
$466.00
$1,146.00
$421.00
$550.00
$698.00
$738.00
$788.00
$896.00
$1,148.00
$1,173.00
$1,413.00
$1,176.00
$196.00
$699.00
$535.00
$588.00
$1,162.00
$449.00
$624.00
$843.00
$491.00
$499.00
$583.00
$931.00
$1,234.00
$1,040.00
$1,112.00
$1,485.00
$1,859.00
$1,976.00
$1,164.00
$1,170.00
$568.00
$57.00
$555.00
$981.00
$1,482.00
$62.00
$121.00
$491.00
$795.00
$799.00
$987.00
$946.00
$1,174.00
$1,099.00
$1,603.00
$1,406.00
$1,371.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
0
0
0
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
27130
27132
27134
27137
27138
27140
27146
27147
27151
27156
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27193
27194
27200
27202
27215
27216
27217
27218
27220
27222
27226
27227
27228
27230
27232
27235
27236
27238
27240
27244
27245
27246
27248
27250
27252
27253
27254
27256
MRA
$1,853.00
$2,128.00
$2,576.00
$2,190.00
$2,025.00
$1,092.00
$1,432.00
$1,744.00
$1,732.00
$2,017.00
$1,588.00
$1,443.00
$1,572.00
$1,453.00
$491.00
$1,024.00
$1,257.00
$1,020.00
$1,107.00
$1,206.00
$676.00
$1,280.00
$425.00
$740.00
$180.00
$776.00
$954.00
$1,085.00
$1,285.00
$1,570.00
$444.00
$973.00
$1,350.00
$1,967.00
$2,195.00
$491.00
$916.00
$1,128.00
$1,421.00
$504.00
$1,043.00
$1,426.00
$1,691.00
$459.00
$980.00
$535.00
$520.00
$1,162.00
$1,478.00
$338.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
40
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
27257
27258
27259
27265
27266
27275
27280
27282
27284
27286
27290
27295
27299
27301
27303
27305
27306
27307
27310
27315
27320
27323
27324
27327
27328
27329
27330
27331
27332
27333
27334
27335
27340
27345
27347
27350
27355
27356
27357
27358
27360
27365
27370
27372
27380
27381
27385
27386
27390
27391
MRA
$455.00
$1,355.00
$1,803.00
$442.00
$614.00
$220.00
$1,179.00
$990.00
$1,435.00
$1,503.00
$2,073.00
$1,594.00
BR
$193.00
$520.00
$555.00
$377.00
$503.00
$877.00
$570.00
$522.00
$211.00
$433.00
$400.00
$503.00
$1,249.00
$492.00
$585.00
$786.00
$719.00
$840.00
$959.00
$405.00
$565.00
$394.00
$786.00
$763.00
$882.00
$950.00
$394.00
$977.00
$1,421.00
$75.00
$371.00
$698.00
$1,118.00
$753.00
$1,064.00
$506.00
$647.00
FU Days
10
90
90
90
90
10
90
90
90
90
90
90
YYY
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
0
90
90
90
90
90
90
90
Surgery
CPT Code
27392
27393
27394
27395
27396
27397
27400
27403
27405
27407
27409
27418
27420
27422
27424
27425
27427
27428
27429
27430
27435
27437
27438
27440
27441
27442
27443
27445
27446
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27475
27477
27479
27485
27486
27487
27488
27495
27496
27497
MRA
$834.00
$608.00
$748.00
$1,093.00
$742.00
$989.00
$832.00
$792.00
$842.00
$918.00
$1,212.00
$1,596.00
$927.00
$930.00
$927.00
$639.00
$1,118.00
$1,266.00
$2,333.00
$884.00
$501.00
$819.00
$1,065.00
$1,064.00
$1,006.00
$1,117.00
$1,037.00
$1,618.00
$1,764.00
$1,960.00
$1,060.00
$1,311.00
$1,524.00
$1,157.00
$1,209.00
$1,253.00
$1,441.00
$1,613.00
$1,501.00
$1,665.00
$782.00
$938.00
$1,123.00
$797.00
$1,771.00
$2,352.00
$1,438.00
$1,477.00
$563.00
$652.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
27498
27499
27500
27501
27502
27503
27506
27507
27508
27509
27510
27511
27513
27514
27516
27517
27519
27520
27524
27530
27532
27535
27536
27538
27540
27550
27552
27556
27557
27558
27560
27562
27566
27570
27580
27590
27591
27592
27594
27596
27598
27599
27600
27601
27602
27603
27604
27605
27606
27607
MRA
$701.00
$782.00
$520.00
$659.00
$909.00
$911.00
$1,522.00
$1,297.00
$400.00
$649.00
$755.00
$1,281.00
$1,562.00
$1,508.00
$579.00
$820.00
$1,311.00
$266.00
$910.00
$408.00
$641.00
$1,075.00
$1,282.00
$487.00
$1,106.00
$296.00
$619.00
$832.00
$1,479.00
$1,529.00
$88.00
$514.00
$1,047.00
$184.00
$1,644.00
$1,059.00
$1,182.00
$911.00
$600.00
$931.00
$976.00
BR
$517.00
$516.00
$621.00
$412.00
$308.00
$236.00
$362.00
$608.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
YYY
90
90
90
90
90
10
10
90
41
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
27610
27612
27613
27614
27615
27618
27619
27620
27625
27626
27630
27635
27637
27638
27640
27641
27645
27646
27647
27648
27650
27652
27654
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27686
27687
27690
27691
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
MRA
$777.00
$701.00
$165.00
$327.00
$1,106.00
$421.00
$730.00
$587.00
$796.00
$863.00
$430.00
$781.00
$921.00
$978.00
$1,122.00
$922.00
$1,302.00
$1,212.00
$1,044.00
$72.00
$869.00
$935.00
$937.00
$458.00
$527.00
$725.00
$504.00
$618.00
$656.00
$762.00
$523.00
$634.00
$565.00
$706.00
$589.00
$757.00
$889.00
$159.00
$658.00
$758.00
$881.00
$835.00
$1,278.00
$1,337.00
$683.00
$985.00
$484.00
$1,118.00
$1,227.00
$1,285.00
FU Days
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
27720
27722
27724
27725
27727
27730
27732
27734
27740
27742
27745
27750
27752
27756
27758
27759
27760
27762
27766
27780
27781
27784
27786
27788
27792
27808
27810
27814
27816
27818
27822
27823
27824
27825
27826
27827
27828
27829
27830
27831
27832
27840
27842
27846
27848
27860
27870
27871
27880
27881
MRA
$1,147.00
$1,076.00
$1,402.00
$1,312.00
$1,175.00
$647.00
$611.00
$766.00
$1,044.00
$1,045.00
$940.00
$319.00
$614.00
$708.00
$1,115.00
$1,262.00
$223.00
$495.00
$759.00
$244.00
$296.00
$643.00
$223.00
$422.00
$706.00
$332.00
$567.00
$972.00
$386.00
$613.00
$1,201.00
$1,472.00
$384.00
$670.00
$1,080.00
$1,310.00
$1,823.00
$742.00
$412.00
$415.00
$617.00
$334.00
$373.00
$877.00
$1,224.00
$211.00
$1,269.00
$843.00
$1,015.00
$1,120.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
27882
27884
27886
27888
27889
27892
27893
27894
27899
28001
28002
28003
28005
28008
28010
28011
28020
28022
28024
28030
28035
28043
28045
28046
28050
28052
28054
28060
28062
28070
28072
28080
28086
28088
28090
28092
28100
28102
28103
28104
28106
28107
28108
28110
28111
28112
28113
28114
28116
28118
MRA
$854.00
$579.00
$835.00
$911.00
$879.00
$575.00
$574.00
$712.00
BR
$185.00
$362.00
$520.00
$520.00
$296.00
$235.00
$340.00
$509.00
$422.00
$371.00
$453.00
$532.00
$305.00
$456.00
$814.00
$414.00
$402.00
$236.00
$495.00
$657.00
$476.00
$445.00
$392.00
$462.00
$414.00
$414.00
$330.00
$571.00
$700.00
$709.00
$491.00
$632.00
$517.00
$418.00
$421.00
$537.00
$457.00
$481.00
$890.00
$648.00
$568.00
FU Days
90
90
90
90
90
90
90
90
YYY
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
42
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
28119
28120
28122
28124
28126
28130
28140
28150
28153
28160
28171
28173
28175
28190
28192
28193
28200
28202
28208
28210
28220
28222
28225
28226
28230
28232
28234
28238
28240
28250
28260
28261
28262
28264
28270
28272
28280
28285
28286
28288
28289
28290
28292
28293
28294
28296
28297
28298
28299
28300
MRA
$524.00
$601.00
$622.00
$480.00
$393.00
$727.00
$533.00
$416.00
$400.00
$412.00
$789.00
$747.00
$571.00
$75.00
$326.00
$341.00
$478.00
$613.00
$406.00
$609.00
$435.00
$555.00
$345.00
$334.00
$380.00
$286.00
$178.00
$695.00
$370.00
$535.00
$641.00
$881.00
$1,363.00
$912.00
$266.00
$336.00
$426.00
$463.00
$441.00
$452.00
$458.00
$557.00
$666.00
$845.00
$797.00
$832.00
$838.00
$755.00
$829.00
$845.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
28302
28304
28305
28306
28307
28308
28309
28310
28312
28313
28315
28320
28322
28340
28341
28344
28345
28360
28400
28405
28406
28415
28420
28430
28435
28436
28445
28450
28455
28456
28465
28470
28475
28476
28485
28490
28495
28496
28505
28510
28515
28525
28530
28531
28540
28545
28546
28555
28570
28575
MRA
$930.00
$776.00
$1,030.00
$530.00
$614.00
$516.00
$955.00
$505.00
$469.00
$436.00
$462.00
$833.00
$667.00
$649.00
$753.00
$414.00
$557.00
$1,197.00
$266.00
$473.00
$616.00
$1,354.00
$1,619.00
$110.00
$371.00
$463.00
$874.00
$148.00
$321.00
$288.00
$533.00
$178.00
$296.00
$364.00
$521.00
$80.00
$133.00
$261.00
$399.00
$75.00
$115.00
$345.00
$120.00
$243.00
$145.00
$208.00
$325.00
$592.00
$189.00
$308.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
28576
28585
28600
28605
28606
28615
28630
28635
28636
28645
28660
28665
28666
28675
28705
28715
28725
28730
28735
28737
28740
28750
28755
28760
28800
28805
28810
28820
28825
28899
29000
29010
29015
29020
29025
29035
29040
29044
29046
29049
29055
29058
29065
29075
29085
29086
29105
29125
29126
29130
MRA
$382.00
$742.00
$144.00
$287.00
$487.00
$621.00
$145.00
$189.00
$318.00
$434.00
$106.00
$172.00
$309.00
$348.00
$1,353.00
$1,179.00
$1,015.00
$945.00
$961.00
$873.00
$690.00
$690.00
$466.00
$654.00
$731.00
$731.00
$543.00
$377.00
$339.00
BR
$247.00
$271.00
$289.00
$237.00
$188.00
$213.00
$260.00
$260.00
$286.00
$45.00
$180.00
$110.00
$88.00
$72.00
$59.00
$54.00
$59.00
$45.00
$53.00
$26.00
FU Days
90
90
90
90
90
90
10
10
10
90
10
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
43
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
29131
29200
29220
29240
29260
29280
29305
29325
29345
29355
29358
29365
29405
29425
29435
29440
29445
29450
29505
29515
29520
29530
29540
29550
29580
29590
29700
29705
29710
29715
29720
29730
29740
29750
29799
29800
29804
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29830
MRA
$53.00
$29.00
$37.00
$45.00
$26.00
$29.00
$223.00
$260.00
$126.00
$133.00
$241.00
$101.00
$96.00
$101.00
$133.00
$22.00
$214.00
$84.00
$75.00
$59.00
$22.00
$55.00
$41.00
$37.00
$39.00
$32.00
$29.00
$26.00
$29.00
$109.00
$29.00
$29.00
$37.00
$105.00
BR
$557.00
$902.00
$360.00
$1,003.00
$976.00
$756.00
$718.00
$863.00
$749.00
$1,330.00
$611.00
$941.00
$980.00
$1,058.00
$524.00
FU Days
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
29834
29835
29836
29837
29838
29840
29843
29844
29845
29846
29847
29848
29850
29851
29855
29856
29860
29861
29862
29863
29870
29871
29873
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
29894
29895
29897
29898
29899
29900
29901
29902
29999
MRA
$635.00
$612.00
$680.00
$830.00
$931.00
$501.00
$580.00
$612.00
$931.00
$976.00
$1,277.00
$608.00
$752.00
$1,137.00
$1,007.00
$1,231.00
$658.00
$845.00
$907.00
$880.00
$460.00
$631.00
$489.00
$676.00
$639.00
$809.00
$852.00
$1,064.00
$1,169.00
$745.00
$819.00
$1,235.00
$721.00
$832.00
$697.00
$949.00
$1,296.00
$1,255.00
$796.00
$835.00
$472.00
$690.00
$679.00
$704.00
$863.00
$973.00
$434.00
$479.00
$514.00
BR
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
30000
30020
30100
30110
30115
30117
30118
30120
30124
30125
30130
30140
30150
30160
30200
30210
30220
30300
30310
30320
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
30540
30545
30560
30580
30600
30620
30630
30801
30802
30901
30903
30905
30906
30915
30920
30930
30999
31000
31002
31020
MRA
$96.00
$117.00
$86.00
$157.00
$360.00
$301.00
$819.00
$500.00
$243.00
$599.00
$275.00
$320.00
$790.00
$875.00
$68.00
$75.00
$154.00
$45.00
$170.00
$419.00
$741.00
$1,173.00
$1,424.00
$626.00
$1,005.00
$1,445.00
$857.00
$1,633.00
$803.00
$533.00
$643.00
$981.00
$104.00
$566.00
$466.00
$564.00
$624.00
$88.00
$172.00
$75.00
$110.00
$224.00
$208.00
$596.00
$862.00
$213.00
BR
$81.00
$135.00
$281.00
FU Days
10
10
0
10
90
90
90
90
90
90
90
90
90
90
0
10
10
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
10
10
0
0
0
0
90
90
10
YYY
10
10
90
44
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
31200
31201
31205
31225
31230
31231
31233
31235
31237
31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
31299
31300
31320
31360
31365
31367
31368
31370
31375
31380
31382
31390
MRA
$531.00
$604.00
$772.00
$489.00
$654.00
$410.00
$839.00
$942.00
$1,089.00
$1,210.00
$1,281.00
$1,081.00
$1,075.00
$877.00
$463.00
$716.00
$851.00
$1,683.00
$1,908.00
$122.00
$221.00
$217.00
$266.00
$311.00
$775.00
$224.00
$588.00
$601.00
$292.00
$453.00
$690.00
$339.00
$396.00
$1,462.00
$1,551.00
$1,235.00
$1,346.00
$1,587.00
BR
$1,295.00
$508.00
$1,630.00
$2,238.00
$1,913.00
$2,478.00
$1,891.00
$1,720.00
$1,782.00
$1,822.00
$2,513.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
10
0
0
0
0
0
0
0
0
10
10
10
10
10
YYY
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
31395
31400
31420
31500
31502
31505
31510
31511
31512
31513
31515
31525
31526
31527
31528
31529
31530
31531
31535
31536
31540
31541
31560
31561
31570
31571
31575
31576
31577
31578
31579
31580
31582
31584
31585
31586
31587
31588
31590
31595
31599
31600
31603
31605
31610
31611
31612
31613
31614
31615
MRA
$2,937.00
$969.00
$969.00
$116.00
$74.00
$62.00
$145.00
$88.00
$197.00
$182.00
$160.00
$234.00
$222.00
$262.00
$202.00
$217.00
$284.00
$311.00
$272.00
$308.00
$357.00
$453.00
$446.00
$509.00
$369.00
$363.00
$128.00
$186.00
$230.00
$264.00
$219.00
$1,213.00
$1,881.00
$1,616.00
$474.00
$778.00
$913.00
$1,206.00
$691.00
$773.00
BR
$306.00
$343.00
$297.00
$794.00
$614.00
$99.00
$384.00
$736.00
$213.00
FU Days
90
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
YYY
0
0
0
90
90
0
90
90
0
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
31622
31623
31624
31625
31628
31629
31630
31631
31635
31640
31641
31643
31645
31646
31656
31700
31708
31710
31715
31717
31720
31725
31730
31750
31755
31760
31766
31770
31775
31780
31781
31785
31786
31800
31805
31820
31825
31830
31899
32000
32002
32005
32020
32035
32036
32095
32100
32110
32120
32124
MRA
$230.00
$225.00
$217.00
$235.00
$269.00
$198.00
$308.00
$252.00
$298.00
$399.00
$304.00
$208.00
$208.00
$161.00
$127.00
$114.00
$76.00
$74.00
$57.00
$138.00
$89.00
$103.00
$199.00
$1,088.00
$1,448.00
$1,648.00
$2,315.00
$1,815.00
$1,973.00
$1,577.00
$1,936.00
$1,320.00
$1,866.00
$628.00
$1,175.00
$458.00
$659.00
$460.00
BR
$136.00
$116.00
$147.00
$286.00
$821.00
$908.00
$848.00
$1,120.00
$1,223.00
$1,077.00
$1,144.00
FU Days
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
90
90
90
90
90
90
90
45
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
32140
32141
32150
32151
32160
32200
32201
32215
32220
32225
32310
32320
32400
32402
32405
32420
32440
32442
32445
32480
32482
32484
32486
32488
32491
32500
32501
32520
32522
32525
32540
32601
32602
32603
32604
32605
32606
32650
32651
32652
32653
32654
32655
32656
32657
32658
32659
32660
32661
32662
MRA
$1,284.00
$1,267.00
$1,226.00
$1,231.00
$842.00
$1,132.00
$387.00
$1,024.00
$1,680.00
$1,268.00
$1,221.00
$1,787.00
$129.00
$798.00
$159.00
$116.00
$1,837.00
$2,093.00
$2,093.00
$1,622.00
$1,714.00
$1,771.00
$1,974.00
$2,094.00
$1,784.00
$1,331.00
$374.00
$1,935.00
$2,102.00
$2,264.00
$1,308.00
$456.00
$494.00
$585.00
$663.00
$550.00
$637.00
$957.00
$1,166.00
$1,615.00
$1,144.00
$1,096.00
$1,213.00
$1,222.00
$1,261.00
$1,142.00
$1,141.00
$1,691.00
$1,165.00
$1,459.00
FU Days
90
90
90
90
90
90
0
90
90
90
90
90
0
90
0
0
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
32663
32664
32665
32800
32810
32815
32820
32851
32852
32853
32854
32900
32905
32906
32940
32960
32997
32999
33010
33011
33015
33020
33025
33030
33031
33050
33120
33130
33140
33141
33200
33201
33206
33207
33208
33210
33211
33212
33213
33214
33215
33216
33217
33218
33220
33222
33223
33224
33225
33226
MRA
$1,636.00
$1,197.00
$1,360.00
$1,166.00
$1,085.00
$1,917.00
$1,848.00
$3,100.00
$3,339.00
$3,787.00
$4,038.00
$1,532.00
$1,661.00
$2,100.00
$1,555.00
$126.00
$312.00
BR
$124.00
$125.00
$555.00
$1,178.00
$1,165.00
$1,786.00
$1,816.00
$1,224.00
$2,358.00
$1,734.00
$1,571.00
$254.00
$1,170.00
$1,052.00
$642.00
$753.00
$573.00
$204.00
$210.00
$511.00
$437.00
$532.00
$304.00
$402.00
$428.00
$488.00
$390.00
$471.00
$585.00
$490.00
$434.00
$472.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
YYY
0
0
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
0
0
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
33233
33234
33235
33236
33237
33238
33240
33241
33243
33244
33245
33246
33249
33250
33251
33253
33261
33282
33284
33300
33305
33310
33315
33320
33321
33322
33330
33332
33335
33400
33401
33403
33404
33405
33406
33410
33411
33412
33413
33414
33415
33416
33417
33420
33422
33425
33426
33427
33430
33460
MRA
$270.00
$598.00
$587.00
$933.00
$1,184.00
$1,235.00
$648.00
$301.00
$1,650.00
$1,081.00
$1,400.00
$1,888.00
$1,271.00
$1,687.00
$2,071.00
$2,563.00
$1,993.00
$470.00
$365.00
$1,576.00
$1,889.00
$1,577.00
$1,875.00
$1,485.00
$1,890.00
$1,935.00
$1,726.00
$1,915.00
$2,336.00
$2,401.00
$2,228.00
$2,369.00
$2,698.00
$2,745.00
$2,962.00
$2,637.00
$2,981.00
$3,213.00
$3,282.00
$2,904.00
$2,563.00
$2,684.00
$2,756.00
$1,796.00
$2,431.00
$2,509.00
$2,806.00
$3,026.00
$2,891.00
$2,215.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
46
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
33463
33464
33465
33468
33470
33471
33472
33474
33475
33476
33478
33496
33500
33501
33502
33503
33504
33505
33506
33508
33510
33511
33512
33513
33514
33516
33517
33518
33519
33521
33522
33523
33530
33533
33534
33535
33536
33542
33545
33572
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
MRA
$2,396.00
$2,547.00
$2,665.00
$2,952.00
$1,749.00
$1,929.00
$2,001.00
$2,173.00
$2,666.00
$2,270.00
$2,544.00
$2,595.00
$2,370.00
$1,546.00
$1,938.00
$1,983.00
$2,416.00
$2,423.00
$2,448.00
$17.00
$2,354.00
$2,546.00
$2,732.00
$2,933.00
$3,197.00
$3,404.00
$219.00
$414.00
$607.00
$801.00
$994.00
$1,189.00
$521.00
$2,415.00
$2,654.00
$2,899.00
$3,143.00
$2,693.00
$3,250.00
$340.00
$2,644.00
$2,556.00
$2,831.00
$2,940.00
$2,871.00
$2,985.00
$3,152.00
$3,051.00
$3,272.00
$3,678.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
33641
33645
33647
33660
33665
33670
33681
33684
33688
33690
33692
33694
33697
33702
33710
33720
33722
33730
33732
33735
33736
33737
33750
33755
33762
33764
33766
33767
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33786
33788
33800
33802
33803
33813
33814
33820
33822
33824
33840
33845
MRA
$1,981.00
$2,352.00
$2,732.00
$2,444.00
$2,700.00
$2,820.00
$2,657.00
$2,740.00
$2,602.00
$1,884.00
$2,816.00
$2,856.00
$3,064.00
$2,549.00
$2,731.00
$2,508.00
$2,704.00
$2,785.00
$2,622.00
$2,036.00
$2,288.00
$1,977.00
$1,877.00
$1,831.00
$1,900.00
$1,895.00
$2,119.00
$2,173.00
$2,954.00
$2,924.00
$2,681.00
$2,654.00
$2,844.00
$2,724.00
$3,199.00
$3,121.00
$3,232.00
$3,057.00
$2,970.00
$2,288.00
$1,546.00
$1,752.00
$1,746.00
$1,935.00
$2,464.00
$1,619.00
$1,559.00
$1,884.00
$2,029.00
$2,129.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
33851
33852
33853
33860
33861
33863
33870
33875
33877
33910
33915
33916
33917
33918
33919
33920
33922
33924
33935
33945
33960
33961
33967
33968
33970
33971
33973
33974
33975
33976
33977
33978
33979
33980
33999
34001
34051
34101
34111
34151
34201
34203
34401
34421
34451
34471
34490
34501
34502
34510
MRA
$2,129.00
$2,311.00
$3,057.00
$3,044.00
$3,069.00
$3,183.00
$3,638.00
$2,876.00
$3,767.00
$1,987.00
$1,588.00
$2,096.00
$2,345.00
$2,349.00
$2,873.00
$2,981.00
$2,227.00
$421.00
$5,415.00
$3,813.00
$1,221.00
$800.00
$258.00
$51.00
$576.00
$578.00
$756.00
$1,095.00
$1,758.00
$2,056.00
$1,561.00
$1,754.00
$2,496.00
$3,212.00
BR
$1,012.00
$1,134.00
$800.00
$669.00
$1,288.00
$777.00
$949.00
$953.00
$779.00
$1,117.00
$685.00
$660.00
$910.00
$2,044.00
$1,108.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
0
ZZZ
0
0
0
90
0
90
0
0
90
90
0
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
47
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
34520
34530
34800
34802
34804
34808
34812
34813
34820
34825
34826
34830
34831
34832
34833
34834
34900
35001
35002
35005
35011
35013
35021
35022
35045
35081
35082
35091
35092
35102
35103
35111
35112
35121
35122
35131
35132
35141
35142
35151
35152
35161
35162
35180
35182
35184
35188
35189
35190
35201
MRA
$1,077.00
$1,368.00
$1,159.00
$1,279.00
$1,279.00
$220.00
$359.00
$256.00
$519.00
$694.00
$220.00
$1,803.00
$1,950.00
$1,950.00
$650.00
$306.00
$960.00
$1,564.00
$1,547.00
$1,268.00
$1,007.00
$1,376.00
$1,635.00
$1,686.00
$995.00
$2,175.00
$2,661.00
$2,634.00
$2,872.00
$2,346.00
$2,587.00
$1,398.00
$1,351.00
$2,000.00
$2,382.00
$1,495.00
$1,742.00
$1,231.00
$1,339.00
$1,390.00
$1,229.00
$1,516.00
$1,633.00
$997.00
$1,345.00
$976.00
$1,048.00
$1,380.00
$1,018.00
$852.00
FU Days
90
90
90
90
90
ZZZ
0
ZZZ
0
90
ZZZ
90
90
90
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
35206
35207
35211
35216
35221
35226
35231
35236
35241
35246
35251
35256
35261
35266
35271
35276
35281
35286
35301
35311
35321
35331
35341
35351
35355
35361
35363
35371
35372
35381
35390
35400
35450
35452
35454
35456
35458
35459
35460
35470
35471
35472
35473
35474
35475
35476
35480
35481
35482
35483
MRA
$835.00
$935.00
$1,833.00
$1,494.00
$1,243.00
$841.00
$1,053.00
$947.00
$1,926.00
$1,701.00
$1,260.00
$1,568.00
$1,008.00
$921.00
$1,814.00
$1,541.00
$1,396.00
$1,036.00
$1,486.00
$1,999.00
$1,031.00
$1,724.00
$1,908.00
$1,555.00
$1,336.00
$1,859.00
$2,006.00
$1,006.00
$1,085.00
$1,278.00
$225.00
$224.00
$643.00
$518.00
$520.00
$631.00
$804.00
$736.00
$430.00
$537.00
$626.00
$388.00
$375.00
$456.00
$569.00
$338.00
$935.00
$565.00
$577.00
$696.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
35484
35485
35490
35491
35492
35493
35494
35495
35500
35501
35506
35507
35508
35509
35511
35515
35516
35518
35521
35526
35531
35533
35536
35541
35546
35548
35549
35551
35556
35558
35560
35563
35565
35566
35571
35572
35582
35583
35585
35587
35600
35601
35606
35612
35616
35621
35623
35626
35631
35636
MRA
$853.00
$670.00
$691.00
$423.00
$423.00
$523.00
$605.00
$532.00
$423.00
$1,569.00
$1,641.00
$1,606.00
$1,564.00
$1,529.00
$1,256.00
$1,387.00
$1,391.00
$1,313.00
$1,393.00
$1,527.00
$2,000.00
$1,716.00
$1,888.00
$2,005.00
$2,022.00
$1,751.00
$1,902.00
$2,036.00
$1,745.00
$1,219.00
$1,899.00
$1,115.00
$1,312.00
$2,161.00
$1,612.00
$369.00
$2,166.00
$1,843.00
$2,277.00
$1,698.00
$273.00
$1,495.00
$1,539.00
$1,349.00
$1,346.00
$1,265.00
$1,193.00
$1,921.00
$1,891.00
$1,656.00
FU Days
0
0
0
0
0
0
0
0
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
48
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
35641
35642
35645
35646
35647
35650
35651
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35685
35686
35691
35693
35694
35695
35700
35701
35721
35741
35761
35800
35820
35840
35860
35870
35875
35876
35879
35881
35901
35903
35905
35907
36000
36002
36005
36010
36011
36012
36013
36014
36015
MRA
$1,966.00
$1,298.00
$1,304.00
$2,105.00
$1,555.00
$1,236.00
$2,055.00
$1,603.00
$1,589.00
$1,145.00
$1,237.00
$1,333.00
$1,686.00
$1,315.00
$751.00
$627.00
$702.00
$216.00
$178.00
$1,546.00
$1,140.00
$1,353.00
$1,351.00
$264.00
$494.00
$500.00
$499.00
$532.00
$567.00
$951.00
$771.00
$496.00
$1,583.00
$827.00
$1,232.00
$1,163.00
$1,275.00
$709.00
$818.00
$1,343.00
$1,335.00
$46.00
$181.00
$68.00
$136.00
$194.00
$186.00
$141.00
$159.00
$186.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
Surgery
CPT Code
36100
36120
36140
36145
36160
36200
36215
36216
36217
36218
36245
36246
36247
36248
36260
36261
36262
36299
36410
36415
36416
36425
36430
36455
36468
36469
36470
36471
36481
36489
36491
36493
36500
36511
36512
36513
36514
36515
36516
36522
36530
36531
36532
36533
36534
36535
36536
36537
36540
36550
MRA
$176.00
$120.00
$106.00
$10.00
$196.00
$240.00
$240.00
$270.00
$325.00
$79.00
$249.00
$272.00
$323.00
$53.00
$749.00
$388.00
$297.00
BR
$18.00
BR
BR
$86.00
$37.00
$141.00
NC
NC
$76.00
$96.00
$499.00
$134.00
$87.00
$65.00
$159.00
$92.00
$92.00
$92.00
$92.00
$92.00
$92.00
$305.00
$493.00
$412.00
$237.00
$448.00
$235.00
$213.00
$1,375.00
$312.00
BR
$37.00
FU Days
0
0
0
0
0
0
0
0
0
ZZZ
0
0
0
ZZZ
90
90
90
YYY
0
0
0
0
0
0
0
0
10
10
0
0
0
0
0
0
0
0
0
0
0
0
10
10
10
10
10
10
0
0
0
0
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
36600
36620
36625
36640
36680
36800
36810
36815
36819
36820
36821
36822
36823
36825
36830
36831
36832
36833
36834
36835
36860
36861
36870
37140
37145
37160
37180
37181
37182
37183
37195
37200
37201
37202
37203
37204
37205
37206
37207
37208
37209
37250
37251
37500
37501
37565
37600
37605
37606
37607
MRA
$24.00
$64.00
$133.00
$130.00
$72.00
$159.00
$345.00
$236.00
$977.00
$800.00
$721.00
$630.00
$1,461.00
$867.00
$967.00
$488.00
$810.00
$780.00
$761.00
$542.00
$166.00
$224.00
$1,755.00
$1,666.00
$1,741.00
$1,681.00
$1,769.00
$1,923.00
$914.00
$425.00
$302.00
$232.00
$408.00
$340.00
$287.00
$957.00
$589.00
$288.00
$613.00
$299.00
$116.00
$112.00
$85.00
$739.00
BR
$364.00
$414.00
$521.00
$563.00
$456.00
FU Days
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
0
0
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
ZZZ
0
ZZZ
0
ZZZ
ZZZ
0
0
90
90
90
90
90
49
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
37609
37615
37616
37617
37618
37620
37650
37660
37700
37720
37730
37735
37760
37780
37785
37788
37790
37799
38100
38101
38102
38115
38120
38129
38200
38205
38206
38220
38221
38230
38240
38241
38242
38300
38305
38308
38380
38381
38382
38500
38505
38510
38520
38525
38530
38542
38550
38555
38562
38564
MRA
$278.00
$495.00
$1,128.00
$1,132.00
$514.00
$818.00
$430.00
$789.00
$336.00
$480.00
$624.00
$847.00
$813.00
$301.00
$270.00
$1,654.00
$690.00
BR
$974.00
$982.00
$332.00
$1,020.00
$1,138.00
BR
$180.00
$79.00
$79.00
$212.00
$228.00
$265.00
$128.00
$128.00
$90.00
$104.00
$375.00
$425.00
$628.00
$1,087.00
$798.00
$234.00
$139.00
$349.00
$431.00
$369.00
$517.00
$507.00
$519.00
$1,115.00
$799.00
$831.00
FU Days
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
90
ZZZ
90
90
YYY
0
0
0
0
0
10
0
0
0
10
90
90
90
90
90
10
0
10
90
90
90
90
90
90
90
90
Surgery
CPT Code
38570
38571
38572
38589
38700
38720
38724
38740
38745
38746
38747
38760
38765
38770
38780
38790
38792
38794
38999
39000
39010
39200
39220
39400
39499
39501
39502
39503
39520
39530
39531
39540
39541
39545
39560
39561
39599
40490
40500
40510
40520
40525
40527
40530
40650
40652
40654
40700
40701
40702
MRA
$695.00
$902.00
$1,049.00
BR
$863.00
$1,328.00
$1,366.00
$539.00
$770.00
$312.00
$337.00
$699.00
$1,283.00
$1,111.00
$1,357.00
$158.00
$26.00
$298.00
BR
$664.00
$1,148.00
$1,249.00
$1,542.00
$614.00
BR
$1,083.00
$1,268.00
$2,726.00
$1,345.00
$1,295.00
$1,243.00
$1,133.00
$1,179.00
$1,102.00
$968.00
$1,328.00
BR
$108.00
$422.00
$469.00
$467.00
$714.00
$851.00
$501.00
$368.00
$436.00
$529.00
$1,009.00
$1,452.00
$1,030.00
FU Days
10
10
10
YYY
90
90
90
90
90
ZZZ
ZZZ
90
90
90
90
0
0
90
YYY
90
90
90
90
10
YYY
90
90
90
90
90
90
90
90
90
90
90
YYY
0
90
90
90
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
40720
40761
40799
40800
40801
40804
40805
40806
40808
40810
40812
40814
40816
40818
40819
40820
40830
40831
40840
40842
40843
40844
40845
40899
41000
41005
41006
41007
41008
41009
41010
41015
41016
41017
41018
41100
41105
41108
41110
41112
41113
41114
41115
41116
41120
41130
41135
41140
41145
41150
MRA
$1,107.00
$1,202.00
BR
$110.00
$208.00
$105.00
$245.00
$38.00
$100.00
$141.00
$202.00
$319.00
$336.00
$249.00
$208.00
$104.00
$140.00
$213.00
$687.00
$684.00
$947.00
$1,232.00
$1,593.00
BR
$119.00
$109.00
$237.00
$283.00
$248.00
$319.00
$91.00
$267.00
$357.00
$300.00
$424.00
$140.00
$136.00
$110.00
$159.00
$255.00
$301.00
$682.00
$176.00
$242.00
$813.00
$937.00
$1,869.00
$2,005.00
$2,406.00
$1,897.00
FU Days
90
90
YYY
10
10
10
10
0
10
10
10
90
90
90
90
10
10
10
90
90
90
90
90
YYY
10
10
90
90
90
90
10
90
90
90
90
10
10
10
10
90
90
90
10
90
90
90
90
90
90
90
50
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
41153
41155
41250
41251
41252
41500
41510
41520
41599
41800
41805
41806
41820
41821
41822
41823
41825
41826
41827
41828
41830
41850
41870
41872
41874
41899
42000
42100
42104
42106
42107
42120
42140
42145
42160
42180
42182
42200
42205
42210
42215
42220
42225
42226
42227
42235
42260
42280
42281
42299
MRA
$2,091.00
$2,448.00
$168.00
$203.00
$294.00
$334.00
$313.00
$255.00
BR
$107.00
$115.00
$217.00
NC
NC
$237.00
$312.00
$144.00
$211.00
$322.00
$176.00
$156.00
NC
NC
$249.00
$193.00
BR
$106.00
$122.00
$161.00
$204.00
$409.00
$573.00
$174.00
$741.00
$176.00
$222.00
$324.00
$946.00
$863.00
$1,174.00
$766.00
$586.00
$803.00
$848.00
$762.00
$631.00
$491.00
$148.00
$160.00
BR
FU Days
90
90
10
10
10
90
90
90
YYY
10
10
10
0
0
10
90
10
10
90
10
10
0
0
90
90
YYY
10
10
10
10
90
90
90
90
10
10
10
90
90
90
90
90
90
90
90
90
90
10
10
YYY
Surgery
CPT Code
42300
42305
42310
42320
42325
42326
42330
42335
42340
42400
42405
42408
42409
42410
42415
42420
42425
42426
42440
42450
42500
42505
42507
42508
42509
42510
42550
42600
42650
42660
42665
42699
42700
42720
42725
42800
42802
42804
42806
42808
42809
42810
42815
42821
42826
42831
42836
42842
42844
42845
MRA
$165.00
$448.00
$145.00
$208.00
$245.00
$369.00
$184.00
$287.00
$411.00
$94.00
$258.00
$377.00
$266.00
$746.00
$1,364.00
$1,577.00
$1,097.00
$1,882.00
$634.00
$395.00
$407.00
$559.00
$522.00
$767.00
$915.00
$711.00
$82.00
$445.00
$67.00
$89.00
$238.00
BR
$144.00
$270.00
$720.00
$123.00
$150.00
$136.00
$167.00
$250.00
$152.00
$335.00
$659.00
$378.00
$320.00
$235.00
$286.00
$729.00
$1,173.00
$1,958.00
FU Days
10
90
10
10
90
90
10
90
90
0
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
0
0
90
YYY
10
10
90
10
10
10
10
10
10
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
42860
42870
42890
42892
42894
42900
42950
42953
42955
42960
42961
42962
42970
42971
42972
42999
43020
43030
43045
43100
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
43123
43124
43130
43135
43200
43201
43202
43204
43205
43215
43216
43217
43219
43220
43226
43227
43228
43231
43232
43234
MRA
$207.00
$427.00
$1,047.00
$1,262.00
$1,825.00
$429.00
$745.00
$752.00
$561.00
$178.00
$406.00
$602.00
$284.00
$472.00
$562.00
BR
$696.00
$712.00
$1,574.00
$744.00
$1,248.00
$2,325.00
$2,664.00
$2,471.00
$2,755.00
$2,509.00
$2,469.00
$2,607.00
$2,350.00
$2,287.00
$2,661.00
$2,242.00
$1,020.00
$1,332.00
$266.00
$245.00
$205.00
$228.00
$207.00
$160.00
$149.00
$176.00
$171.00
$128.00
$142.00
$218.00
$230.00
$182.00
$252.00
$193.00
FU Days
90
90
90
90
90
10
90
90
90
10
90
90
90
90
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
51
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
43235
43236
43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249
43250
43251
43255
43256
43258
43259
43260
43261
43262
43263
43264
43265
43267
43268
43269
43271
43272
43280
43289
43300
43305
43310
43312
43313
43314
43320
43324
43325
43326
43330
43331
43340
43341
43350
43351
43352
43360
MRA
$239.00
$285.00
$246.00
$369.00
$157.00
$384.00
$276.00
$268.00
$214.00
$485.00
$229.00
$191.00
$175.00
$194.00
$224.00
$343.00
$235.00
$276.00
$271.00
$349.00
$362.00
$447.00
$386.00
$522.00
$527.00
$434.00
$446.00
$410.00
$437.00
$401.00
$1,314.00
BR
$837.00
$1,428.00
$2,138.00
$2,331.00
$2,632.00
$2,891.00
$1,299.00
$1,280.00
$1,261.00
$1,198.00
$1,236.00
$1,378.00
$1,292.00
$1,351.00
$986.00
$1,180.00
$1,028.00
$2,277.00
FU Days
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
43361
43400
43401
43405
43410
43415
43420
43425
43450
43453
43456
43458
43460
43496
43499
43500
43501
43502
43510
43520
43600
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
43635
43638
43639
43640
43641
43651
43652
43653
43659
43750
43752
43760
43761
43800
43810
43820
43825
43830
43831
MRA
$2,596.00
$1,261.00
$1,299.00
$1,330.00
$946.00
$1,382.00
$854.00
$1,338.00
$91.00
$102.00
$149.00
$164.00
$203.00
BR
BR
$649.00
$1,105.00
$1,247.00
$680.00
$599.00
$96.00
$686.00
$861.00
$1,001.00
$1,691.00
$1,718.00
$1,798.00
$1,445.00
$1,443.00
$1,467.00
$1,786.00
$143.00
$1,575.00
$1,605.00
$1,119.00
$1,138.00
$716.00
$856.00
$617.00
BR
$278.00
BR
$81.00
$107.00
$793.00
$846.00
$896.00
$1,128.00
$592.00
$593.00
FU Days
90
90
90
90
90
90
90
90
0
0
0
0
0
90
YYY
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
YYY
10
0
0
0
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
43832
43840
43842
43843
43846
43847
43848
43850
43855
43860
43865
43870
43880
43999
44005
44010
44015
44020
44021
44025
44050
44055
44100
44110
44111
44120
44121
44125
44126
44127
44128
44130
44133
44136
44139
44140
44141
44143
44144
44145
44146
44147
44150
44151
44152
44153
44155
44156
44160
44200
MRA
$904.00
$893.00
$1,260.00
$1,249.00
$1,528.00
$1,678.00
$1,795.00
$1,425.00
$1,454.00
$1,435.00
$1,549.00
$590.00
$1,352.00
BR
$1,171.00
$809.00
$1,171.00
$891.00
$888.00
$905.00
$862.00
$957.00
$117.00
$784.00
$963.00
$1,078.00
$308.00
$1,135.00
$1,951.00
$2,243.00
$242.00
$938.00
BR
BR
$154.00
$1,350.00
$1,488.00
$1,536.00
$1,442.00
$1,678.00
$1,840.00
$1,452.00
$1,661.00
$1,499.00
$1,890.00
$2,110.00
$1,892.00
$1,709.00
$1,236.00
$1,046.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
90
ZZZ
90
90
90
90
90
0
90
90
90
ZZZ
90
90
90
ZZZ
90
0
0
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
52
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
44201
44202
44203
44204
44205
44206
44207
44208
44210
44211
44212
44238
44239
44300
44310
44312
44314
44316
44320
44322
44340
44345
44346
44360
44361
44363
44364
44365
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44382
44383
44385
44386
44388
44389
44390
44391
44392
44393
44394
44397
MRA
$649.00
$1,603.00
$235.00
$1,353.00
$1,198.00
$1,480.00
$1,620.00
$1,752.00
$1,551.00
$1,926.00
$1,800.00
BR
BR
$697.00
$950.00
$453.00
$892.00
$1,229.00
$1,029.00
$1,015.00
$397.00
$816.00
$923.00
$177.00
$195.00
$213.00
$255.00
$226.00
$300.00
$308.00
$253.00
$301.00
$238.00
$305.00
$320.00
$410.00
$396.00
$91.00
$110.00
$165.00
$219.00
$183.00
$326.00
$301.00
$319.00
$376.00
$359.00
$413.00
$395.00
$259.00
FU Days
90
90
ZZZ
90
90
90
90
90
90
90
90
YYY
YYY
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Surgery
CPT Code
44500
44602
44603
44604
44605
44615
44620
44625
44626
44640
44650
44660
44661
44680
44700
44701
44799
44800
44820
44850
44899
44900
44901
44950
44955
44960
44970
44979
45000
45005
45020
45100
45108
45110
45111
45112
45113
45114
45116
45119
45120
45121
45123
45126
45130
45135
45136
45150
45160
45170
MRA
$28.00
$815.00
$1,041.00
$1,027.00
$1,132.00
$994.00
$741.00
$1,277.00
$1,581.00
$1,036.00
$1,076.00
$1,050.00
$1,326.00
$1,049.00
$1,115.00
$161.00
BR
$791.00
$755.00
$708.00
BR
$644.00
$310.00
$643.00
$136.00
$790.00
$631.00
BR
$329.00
$197.00
$364.00
$321.00
$419.00
$1,801.00
$1,270.00
$1,904.00
$1,885.00
$1,732.00
$1,485.00
$1,911.00
$1,845.00
$1,870.00
$1,126.00
$2,444.00
$1,041.00
$1,354.00
$1,526.00
$475.00
$949.00
$697.00
FU Days
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
YYY
90
90
90
YYY
90
0
90
ZZZ
90
90
YYY
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
45190
45300
45303
45305
45307
45308
45309
45315
45317
45320
45321
45327
45330
45331
45332
45333
45334
45335
45337
45338
45339
45340
45341
45342
45345
45355
45378
45379
45380
45381
45382
45383
45384
45385
45386
45387
45500
45505
45520
45540
45541
45550
45560
45562
45563
45800
45805
45820
45825
45900
MRA
$623.00
$75.00
$72.00
$102.00
$172.00
$137.00
$174.00
$211.00
$209.00
$230.00
$154.00
$96.00
$87.00
$120.00
$174.00
$176.00
$171.00
$144.00
$144.00
$212.00
$237.00
$328.00
$153.00
$224.00
$164.00
$185.00
$341.00
$415.00
$369.00
$388.00
$481.00
$482.00
$415.00
$479.00
$739.00
$322.00
$584.00
$510.00
$46.00
$1,009.00
$888.00
$1,350.00
$618.00
$915.00
$1,412.00
$1,050.00
$1,273.00
$1,066.00
$1,241.00
$120.00
FU Days
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
0
90
90
90
90
90
90
90
90
90
90
10
53
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
45905
45910
45915
45999
46020
46030
46040
46045
46050
46060
46080
46083
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
46270
46275
46280
46285
46288
46320
46500
46600
46604
46606
46608
46610
46611
46612
46614
46615
46700
46706
46715
46716
46730
46735
46740
46742
46744
MRA
$133.00
$163.00
$142.00
BR
$230.00
$94.00
$393.00
$312.00
$105.00
$482.00
$246.00
$98.00
$323.00
$196.00
$353.00
$118.00
$124.00
$198.00
$400.00
$501.00
$504.00
$539.00
$598.00
$655.00
$686.00
$328.00
$442.00
$514.00
$335.00
$521.00
$126.00
$109.00
$38.00
$92.00
$66.00
$115.00
$114.00
$149.00
$196.00
$169.00
$202.00
$585.00
$140.00
$545.00
$906.00
$1,584.00
$1,881.00
$1,671.00
$2,236.00
$2,412.00
FU Days
10
10
10
YYY
10
10
90
90
10
90
10
10
90
90
90
10
10
10
90
90
90
90
90
90
90
90
90
90
90
90
10
10
0
0
0
0
0
0
0
0
0
90
0
90
90
90
90
90
90
90
Surgery
CPT Code
46746
46748
46750
46753
46754
46760
46761
46762
46900
46910
46916
46917
46922
46924
46934
46935
46936
46937
46938
46940
46942
46945
46946
46999
47000
47001
47010
47011
47015
47100
47120
47122
47125
47130
47134
47135
47136
47300
47350
47360
47361
47362
47370
47371
47379
47380
47381
47382
47399
47400
MRA
$2,725.00
$2,933.00
$636.00
$511.00
$188.00
$846.00
$813.00
$731.00
$128.00
$144.00
$145.00
$228.00
$189.00
$297.00
$249.00
$202.00
$316.00
$268.00
$405.00
$165.00
$145.00
$199.00
$270.00
BR
$218.00
$141.00
$788.00
$347.00
$755.00
$550.00
$1,663.00
$2,512.00
$2,293.00
$2,482.00
$2,711.00
$6,164.00
$4,985.00
$778.00
$942.00
$1,305.00
$2,129.00
$849.00
$943.00
$889.00
BR
$1,107.00
$1,094.00
$660.00
BR
$1,435.00
FU Days
90
90
90
90
10
90
90
90
10
10
10
10
10
10
90
10
90
10
90
10
10
90
90
YYY
0
ZZZ
90
0
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
YYY
90
90
10
YYY
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
47420
47425
47460
47480
47490
47500
47505
47510
47511
47525
47530
47550
47552
47553
47554
47555
47556
47560
47561
47562
47563
47564
47570
47579
47600
47605
47610
47612
47620
47630
47700
47701
47711
47712
47715
47716
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900
47999
48000
MRA
$1,222.00
$1,275.00
$1,039.00
$755.00
$467.00
$103.00
$96.00
$487.00
$627.00
$295.00
$35.00
$209.00
$364.00
$342.00
$594.00
$383.00
$425.00
$345.00
$388.00
$837.00
$900.00
$1,069.00
$961.00
BR
$868.00
$935.00
$1,164.00
$1,276.00
$1,295.00
$465.00
$1,111.00
$1,913.00
$1,442.00
$1,793.00
$1,157.00
$989.00
$1,040.00
$1,248.00
$1,188.00
$1,425.00
$1,568.00
$1,624.00
$1,635.00
$1,871.00
$1,485.00
$906.00
$1,352.00
$1,331.00
BR
$1,053.00
FU Days
90
90
90
90
90
0
0
90
90
10
90
ZZZ
0
0
0
0
0
0
0
90
90
90
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
54
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
48001
48005
48020
48100
48102
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48160
48180
48400
48500
48510
48511
48520
48540
48545
48547
48554
48556
48999
49000
49002
49010
49020
49021
49040
49041
49060
49061
49062
49080
49081
49085
49180
49200
49201
49215
49220
49250
49255
49320
49321
MRA
$1,305.00
$1,533.00
$983.00
$779.00
$341.00
$1,083.00
$1,546.00
$1,661.00
$1,830.00
$1,149.00
$3,101.00
$2,888.00
$3,099.00
$2,893.00
$1,855.00
BR
$1,616.00
$100.00
$1,012.00
$938.00
$286.00
$1,103.00
$1,350.00
$1,170.00
$1,630.00
$2,365.00
$1,117.00
BR
$862.00
$784.00
$915.00
$910.00
$290.00
$763.00
$305.00
$827.00
$288.00
$892.00
$123.00
$98.00
$632.00
$212.00
$823.00
$1,180.00
$1,551.00
$1,182.00
$622.00
$591.00
$415.00
$443.00
FU Days
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
0
90
ZZZ
90
90
0
90
90
90
90
90
90
YYY
90
90
90
90
0
90
0
90
0
90
0
0
90
0
90
90
90
90
90
90
10
10
Surgery
CPT Code
49322
49323
49329
49400
49419
49420
49421
49422
49423
49424
49425
49426
49427
49428
49429
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560
49561
49565
49566
49568
49570
49572
49585
49587
49590
49600
49605
49606
49610
49611
49650
49651
49659
49900
49904
49905
49906
49999
50010
50020
MRA
$460.00
$712.00
BR
$127.00
$405.00
$162.00
$452.00
$468.00
$106.00
$54.00
$914.00
$725.00
$48.00
$184.00
$522.00
$510.00
$636.00
$631.00
$730.00
$584.00
$668.00
$557.00
$598.00
$621.00
$715.00
$734.00
$856.00
$754.00
$881.00
$339.00
$411.00
$491.00
$444.00
$501.00
$585.00
$774.00
$1,648.00
$1,416.00
$784.00
$770.00
$484.00
$621.00
BR
$512.00
$1,394.00
$454.00
BR
BR
$886.00
$1,084.00
FU Days
10
90
YYY
0
0
0
90
10
0
0
90
90
0
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
0
ZZZ
90
YYY
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
50021
50040
50045
50060
50065
50070
50075
50080
50081
50100
50120
50125
50130
50135
50200
50205
50220
50225
50230
50234
50236
50240
50280
50290
50320
50340
50360
50365
50370
50380
50390
50392
50393
50394
50395
50396
50398
50400
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
MRA
$335.00
$910.00
$1,137.00
$1,394.00
$1,514.00
$1,476.00
$1,839.00
$1,186.00
$1,635.00
$1,250.00
$1,180.00
$1,228.00
$1,301.00
$1,506.00
$151.00
$807.00
$1,316.00
$1,554.00
$1,695.00
$1,671.00
$1,873.00
$1,679.00
$1,170.00
$1,080.00
$1,680.00
$1,083.00
$2,475.00
$2,941.00
$1,128.00
$1,507.00
$118.00
$189.00
$235.00
$64.00
$203.00
$101.00
$99.00
$1,441.00
$1,802.00
$1,471.00
$1,281.00
$1,644.00
$1,639.00
$1,468.00
$1,037.00
$1,093.00
$1,374.00
$1,428.00
$1,273.00
$1,325.00
FU Days
0
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
55
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
50547
50548
50549
50551
50553
50555
50557
50559
50561
50562
50570
50572
50574
50575
50576
50578
50580
50590
50600
50605
50610
50620
50630
50650
50660
50684
50686
50688
50690
50700
50715
50722
50725
50727
50728
50740
50750
50760
50770
50780
50782
50783
50785
50800
50810
50815
50820
50825
50830
50840
MRA
$1,702.00
$1,555.00
BR
$411.00
$447.00
$668.00
$676.00
$396.00
$755.00
$580.00
$549.00
$728.00
$762.00
$991.00
$801.00
$711.00
$726.00
$980.00
$1,150.00
$1,054.00
$1,209.00
$1,152.00
$1,170.00
$1,297.00
$1,426.00
$74.00
$109.00
$89.00
$85.00
$1,192.00
$1,397.00
$1,211.00
$1,371.00
$640.00
$924.00
$1,386.00
$1,457.00
$1,389.00
$1,485.00
$1,391.00
$1,465.00
$1,515.00
$1,548.00
$1,226.00
$1,527.00
$1,643.00
$1,729.00
$2,351.00
$2,292.00
$1,493.00
FU Days
90
90
YYY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
0
0
10
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
50845
50860
50900
50920
50930
50940
50945
50947
50948
50949
50951
50953
50955
50957
50959
50961
50970
50972
50974
50976
50978
50980
51000
51005
51010
51020
51030
51040
51045
51050
51060
51065
51080
51500
51520
51525
51530
51535
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
MRA
$1,513.00
$1,163.00
$1,043.00
$1,075.00
$1,380.00
$1,107.00
$1,096.00
$1,384.00
$1,265.00
BR
$414.00
$461.00
$546.00
$546.00
$316.00
$510.00
$510.00
$408.00
$661.00
$641.00
$379.00
$443.00
$75.00
$87.00
$191.00
$587.00
$538.00
$439.00
$548.00
$596.00
$768.00
$704.00
$510.00
$775.00
$764.00
$1,069.00
$957.00
$932.00
$1,171.00
$1,514.00
$1,624.00
$1,762.00
$2,284.00
$2,252.00
$2,601.00
$2,441.00
$2,900.00
$3,063.00
$2,914.00
$54.00
FU Days
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
51605
51610
51700
51701
51702
51703
51705
51710
51715
51720
51725
51726
51736
51741
51772
51784
51785
51792
51795
51797
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940
51960
51980
51990
51992
52000
52001
52005
52007
52010
52204
52214
52224
52234
52235
52240
52250
52260
MRA
$83.00
$45.00
$29.00
$58.00
$92.00
$128.00
$37.00
$119.00
$322.00
$140.00
$116.00
$136.00
$47.00
$81.00
$96.00
$119.00
$52.00
$143.00
$132.00
$109.00
$20.00
$1,294.00
$1,236.00
$858.00
$1,040.00
$843.00
$912.00
$1,150.00
$590.00
$1,050.00
$881.00
$1,167.00
$2,082.00
$1,848.00
$858.00
$850.00
$925.00
$190.00
$133.00
$265.00
$230.00
$292.00
$286.00
$367.00
$339.00
$471.00
$546.00
$887.00
$311.00
$262.00
FU Days
0
0
0
0
0
0
10
10
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
56
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
52265
52270
52275
52276
52277
52281
52282
52283
52285
52290
52300
52301
52305
52310
52315
52317
52318
52320
52325
52327
52330
52332
52334
52341
52342
52343
52344
52345
52346
52347
52351
52352
52353
52354
52355
52400
52450
52500
52510
52601
52606
52612
52614
52620
52630
52640
52647
52648
52700
53000
MRA
$243.00
$374.00
$446.00
$490.00
$448.00
$259.00
$560.00
$309.00
$375.00
$304.00
$370.00
$382.00
$370.00
$348.00
$553.00
$772.00
$684.00
$369.00
$494.00
$369.00
$507.00
$451.00
$340.00
$317.00
$344.00
$380.00
$407.00
$433.00
$488.00
$281.00
$297.00
$349.00
$404.00
$372.00
$447.00
$580.00
$602.00
$705.00
$604.00
$1,021.00
$581.00
$711.00
$609.00
$554.00
$653.00
$573.00
$858.00
$957.00
$517.00
$224.00
FU Days
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
Surgery
CPT Code
53010
53020
53040
53060
53080
53085
53200
53210
53215
53220
53230
53235
53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
53425
53430
53431
53440
53442
53444
53445
53446
53447
53448
53449
53450
53460
53502
53505
53510
53515
53520
53600
53601
53605
53620
53621
53660
53661
53665
53850
MRA
$336.00
$153.00
$460.00
$180.00
$567.00
$836.00
$218.00
$904.00
$1,142.00
$546.00
$760.00
$607.00
$506.00
$464.00
$240.00
$295.00
$226.00
$332.00
$929.00
$1,088.00
$1,151.00
$1,381.00
$1,088.00
$1,150.00
$1,116.00
$1,053.00
$1,057.00
$639.00
$755.00
$1,197.00
$699.00
$991.00
$1,259.00
$784.00
$447.00
$494.00
$590.00
$586.00
$777.00
$987.00
$661.00
$37.00
$37.00
$81.00
$59.00
$45.00
$49.00
$50.00
$50.00
$741.00
FU Days
90
0
90
10
90
90
0
90
90
90
90
90
90
90
10
10
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
53852
53853
53899
54015
54050
54055
54056
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54125
54130
54135
54162
54163
54164
54200
54205
54220
54230
54231
54235
54240
54250
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
MRA
$728.00
$2,073.00
BR
$348.00
$91.00
$106.00
$100.00
$149.00
$180.00
$281.00
$149.00
$261.00
$775.00
$1,035.00
$1,210.00
$588.00
$777.00
$1,092.00
$1,532.00
$1,945.00
$220.00
$207.00
$182.00
$78.00
$633.00
$189.00
$104.00
$172.00
$81.00
$109.00
$104.00
$830.00
$988.00
$881.00
$1,067.00
$1,316.00
$900.00
$974.00
$1,260.00
$1,212.00
$1,201.00
$1,327.00
$1,672.00
$727.00
$1,360.00
$1,318.00
$1,820.00
$898.00
$1,054.00
$1,217.00
FU Days
90
90
YYY
10
10
10
10
10
10
10
0
10
90
90
90
90
90
90
90
90
10
10
10
10
90
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
57
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
54390
54400
54401
54405
54406
54408
54410
54411
54415
54416
54417
54420
54430
54435
54440
54450
54500
54505
54512
54520
54522
54530
54535
54550
54560
54600
54620
54640
54650
54660
54670
54680
54690
54692
54699
54700
54800
54820
54830
54840
54860
54861
54900
54901
55000
55040
55041
55060
55100
55110
MRA
$1,635.00
$784.00
$892.00
$1,294.00
$687.00
$724.00
$856.00
$933.00
$510.00
$665.00
$819.00
$899.00
$799.00
$503.00
BR
$88.00
$102.00
$259.00
$519.00
$445.00
$589.00
$683.00
$922.00
$588.00
$842.00
$524.00
$373.00
$594.00
$861.00
$401.00
$485.00
$948.00
$825.00
$850.00
BR
$133.00
$257.00
$379.00
$411.00
$432.00
$503.00
$696.00
$969.00
$1,340.00
$109.00
$439.00
$634.00
$430.00
$156.00
$223.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
10
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
YYY
10
0
90
90
90
90
90
90
90
0
90
90
90
10
90
Surgery
CPT Code
55120
55150
55175
55180
55200
55250
55300
55400
55450
55500
55520
55530
55535
55540
55550
55559
55600
55605
55650
55680
55700
55705
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55859
55860
55862
55865
55866
55870
55873
55899
56405
56420
56440
56441
56501
56515
56605
56606
56620
MRA
$350.00
$562.00
$426.00
$796.00
$310.00
$349.00
$167.00
$660.00
$391.00
$445.00
$446.00
$467.00
$496.00
$572.00
$486.00
BR
$486.00
$609.00
$853.00
$426.00
$183.00
$368.00
$555.00
$670.00
$1,331.00
$1,711.00
$1,989.00
$2,328.00
$1,153.00
$1,252.00
$1,705.00
$1,859.00
$2,222.00
$843.00
$1,012.00
$1,351.00
$1,890.00
$1,615.00
$166.00
$1,127.00
BR
$131.00
$130.00
$271.00
$183.00
$122.00
$200.00
$96.00
$49.00
$607.00
FU Days
90
90
90
90
90
90
0
90
10
90
90
90
90
90
90
YYY
90
90
90
90
0
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
YYY
10
10
10
10
10
10
0
ZZZ
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
56625
56630
56631
56632
56633
56634
56637
56640
56700
56720
56740
56800
56805
56810
56820
56821
57000
57010
57020
57022
57023
57061
57065
57100
57105
57106
57107
57109
57110
57111
57112
57120
57130
57135
57150
57155
57160
57170
57180
57200
57210
57220
57230
57240
57250
57260
57265
57268
57270
57280
MRA
$735.00
$1,061.00
$1,400.00
$1,636.00
$1,350.00
$1,537.00
$1,806.00
$1,777.00
$227.00
$72.00
$321.00
$310.00
$1,349.00
$316.00
$119.00
$154.00
$237.00
$429.00
$118.00
$179.00
$290.00
$124.00
$251.00
$90.00
$132.00
$409.00
$1,467.00
$1,787.00
$1,015.00
$1,793.00
$1,907.00
$612.00
$220.00
$231.00
$50.00
$383.00
$67.00
$74.00
$124.00
$313.00
$395.00
$378.00
$442.00
$536.00
$485.00
$700.00
$902.00
$577.00
$867.00
$1,071.00
FU Days
90
90
90
90
90
90
90
90
10
0
10
10
90
10
0
0
10
90
0
10
10
10
10
0
10
90
90
90
90
90
90
90
10
10
0
90
0
0
10
90
90
90
90
90
90
90
90
90
90
90
58
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
57282
57284
57287
57288
57289
57291
57292
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
57421
57452
57454
57455
57456
57460
57461
57500
57505
57510
57511
57513
57520
57522
57530
57531
57540
57545
57550
57555
57556
57700
57720
57800
57820
58100
58120
58140
58145
58146
MRA
$734.00
$950.00
$685.00
$1,009.00
$879.00
$622.00
$925.00
$653.00
$995.00
$997.00
$769.00
$517.00
$612.00
$693.00
$916.00
$963.00
$70.00
$57.00
$75.00
$124.00
$162.00
$96.00
$125.00
$149.00
$141.00
$223.00
$333.00
$89.00
$105.00
$140.00
$159.00
$191.00
$359.00
$319.00
$386.00
$2,036.00
$815.00
$700.00
$486.00
$774.00
$718.00
$279.00
$328.00
$71.00
$182.00
$74.00
$297.00
$1,010.00
$677.00
$1,089.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
10
0
0
0
0
0
0
0
0
0
10
10
10
10
90
90
90
90
90
90
90
90
90
90
90
0
10
0
10
90
90
90
Surgery
CPT Code
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58290
58291
58292
58293
58294
58300
58301
58321
58322
58323
58340
58345
58346
58350
58353
58400
58410
58520
58540
58545
58546
58550
58552
58553
58554
58555
58558
58559
58560
58561
58562
58563
58578
58579
58600
58605
MRA
$1,110.00
$1,159.00
$1,118.00
$1,562.00
$2,080.00
$2,898.00
$926.00
$1,026.00
$1,120.00
$1,133.00
$1,019.00
$1,121.00
$1,132.00
$1,360.00
$1,089.00
$1,197.00
$1,268.00
$1,318.00
$1,168.00
$96.00
$71.00
$81.00
$90.00
$24.00
$87.00
$335.00
$408.00
$103.00
$225.00
$519.00
$752.00
$663.00
$923.00
$876.00
$1,104.00
$1,038.00
$853.00
$1,096.00
$1,085.00
$261.00
$340.00
$436.00
$482.00
$677.00
$339.00
$450.00
BR
BR
$337.00
$298.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
10
90
10
10
90
90
90
90
10
10
10
10
10
10
0
0
0
0
0
0
0
YYY
YYY
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
58611
58615
58660
58661
58662
58670
58671
58672
58673
58679
58700
58720
58740
58750
58752
58760
58770
58800
58805
58820
58822
58823
58825
58900
58920
58925
58940
58943
58950
58951
58952
58953
58954
58960
58999
59000
59001
59012
59015
59020
59025
59030
59050
59051
59100
59120
59121
59130
59135
59136
MRA
$47.00
$319.00
$793.00
$804.00
$807.00
$450.00
$463.00
$872.00
$928.00
BR
$544.00
$844.00
$508.00
$949.00
$893.00
$769.00
$763.00
$343.00
$509.00
$326.00
$603.00
$216.00
$469.00
$489.00
$571.00
$820.00
$592.00
$1,368.00
$1,170.00
$1,703.00
$1,876.00
$1,839.00
$1,999.00
$1,174.00
BR
$123.00
$167.00
$267.00
$168.00
$85.00
$54.00
$155.00
$71.00
$47.00
$633.00
$893.00
$768.00
$832.00
$1,083.00
$934.00
FU Days
ZZZ
10
90
10
90
90
90
90
90
YYY
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
59
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
59140
59150
59151
59160
59200
59300
59320
59325
59350
59400
59409
59410
59412
59414
59425
59426
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622
59812
59820
59821
59830
59840
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
59898
59899
60000
60001
60100
60200
60210
60212
MRA
$461.00
$543.00
$690.00
$279.00
$79.00
$179.00
$196.00
$316.00
$375.00
$1,816.00
$1,019.00
$1,123.00
$141.00
$134.00
$414.00
$708.00
$140.00
$2,064.00
$1,199.00
$1,324.00
$591.00
$1,805.00
$1,113.00
$1,208.00
$2,035.00
$1,293.00
$1,397.00
$343.00
$389.00
$398.00
$496.00
$331.00
$443.00
$449.00
$464.00
$642.00
$477.00
$577.00
$711.00
$304.00
$348.00
$192.00
BR
BR
$114.00
$88.00
$96.00
$744.00
$872.00
$1,170.00
FU Days
90
90
90
10
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ZZZ
0
0
0
0
0
0
90
90
90
90
10
10
90
90
90
90
90
90
0
90
0
YYY
YYY
10
0
0
90
90
90
Surgery
CPT Code
60220
60225
60240
60252
60254
60260
60270
60271
60280
60281
60500
60502
60505
60512
60520
60521
60522
60540
60545
60600
60605
60650
60659
60699
61020
61026
61050
61055
61070
61105
61107
61108
61120
61140
61150
61151
61154
61156
61210
61215
61250
61253
61304
61305
61312
61313
61314
61315
61316
61320
MRA
$851.00
$1,107.00
$1,228.00
$1,427.00
$1,911.00
$1,022.00
$1,468.00
$1,210.00
$546.00
$670.00
$1,232.00
$1,475.00
$1,631.00
$310.00
$1,405.00
$1,591.00
$1,820.00
$1,272.00
$1,505.00
$1,477.00
$1,624.00
$1,340.00
BR
BR
$150.00
$138.00
$106.00
$143.00
$67.00
$503.00
$863.00
$959.00
$733.00
$1,389.00
$1,503.00
$795.00
$1,393.00
$1,473.00
$527.00
$637.00
$888.00
$1,042.00
$2,005.00
$2,419.00
$2,187.00
$2,207.00
$2,200.00
$2,393.00
$88.00
$2,118.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
YYY
YYY
0
0
0
0
0
90
0
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
ZZZ
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
61321
61322
61323
61330
61332
61333
61334
61340
61343
61345
61440
61450
61458
61460
61470
61480
61490
61500
61501
61510
61512
61514
61516
61517
61518
61519
61520
61521
61522
61524
61526
61530
61531
61533
61534
61535
61536
61538
61539
61541
61542
61543
61544
61545
61546
61548
61550
61552
61556
61557
MRA
$2,310.00
$1,779.00
$1,842.00
$1,706.00
$2,307.00
$2,231.00
$1,525.00
$1,584.00
$2,673.00
$2,259.00
$2,110.00
$2,173.00
$2,433.00
$2,426.00
$1,982.00
$1,922.00
$1,687.00
$1,637.00
$1,353.00
$2,506.00
$2,981.00
$2,262.00
$2,253.00
$74.00
$3,163.00
$3,450.00
$4,349.00
$3,667.00
$2,415.00
$2,484.00
$3,918.00
$3,611.00
$1,344.00
$1,712.00
$1,535.00
$958.00
$2,862.00
$2,466.00
$2,660.00
$2,363.00
$2,533.00
$2,307.00
$2,271.00
$3,474.00
$2,695.00
$1,964.00
$1,141.00
$1,463.00
$1,760.00
$1,807.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
60
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
61558
61559
61563
61564
61570
61571
61575
61576
61580
61581
61582
61583
61584
61585
61586
61590
61591
61592
61595
61596
61597
61598
61600
61601
61605
61606
61607
61608
61609
61610
61611
61612
61613
61615
61616
61618
61619
61623
61624
61626
61680
61682
61684
61686
61690
61692
61697
61698
61700
61702
MRA
$2,085.00
$2,700.00
$2,175.00
$2,597.00
$1,975.00
$2,140.00
$2,992.00
$3,772.00
$2,383.00
$2,674.00
$2,557.00
$2,972.00
$2,830.00
$3,142.00
$2,097.00
$3,299.00
$3,491.00
$3,245.00
$2,350.00
$2,827.00
$3,046.00
$2,693.00
$2,039.00
$2,279.00
$2,299.00
$3,178.00
$2,961.00
$3,458.00
$798.00
$2,354.00
$584.00
$2,219.00
$3,375.00
$2,576.00
$3,535.00
$1,389.00
$1,682.00
$540.00
$1,073.00
$877.00
$2,758.00
$4,798.00
$3,341.00
$5,012.00
$2,556.00
$4,007.00
$3,231.00
$3,103.00
$4,037.00
$4,019.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
ZZZ
ZZZ
90
90
90
90
90
0
0
0
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
61703
61705
61708
61710
61711
61720
61735
61750
61751
61760
61770
61790
61791
61793
61795
61850
61860
61862
61870
61875
61880
61885
61886
61888
62000
62005
62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
62148
62160
62161
62162
62163
62164
62165
62180
62190
62192
MRA
$1,444.00
$3,043.00
$2,546.00
$2,129.00
$3,150.00
$1,558.00
$1,664.00
$1,521.00
$1,628.00
$1,670.00
$1,867.00
$952.00
$1,205.00
$1,594.00
$371.00
$1,090.00
$1,197.00
$1,551.00
$616.00
$984.00
$559.00
$262.00
$678.00
$331.00
$848.00
$1,282.00
$1,754.00
$1,962.00
$1,686.00
$1,928.00
$2,211.00
$1,898.00
$1,822.00
$1,221.00
$1,955.00
$1,011.00
$1,096.00
$1,566.00
$1,327.00
$1,566.00
$120.00
$172.00
$1,229.00
$1,578.00
$999.00
$1,706.00
$1,336.00
$1,695.00
$1,034.00
$1,146.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
0
0
0
0
0
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
62194
62200
62201
62220
62223
62225
62230
62252
62256
62258
62263
62264
62268
62269
62270
62272
62273
62280
62281
62282
62284
62287
62290
62291
62292
62294
62310
62311
62318
62319
62350
62351
62355
62360
62361
62362
62365
62367
62368
63001
63003
63005
63011
63012
63015
63016
63017
63020
63030
63035
MRA
$239.00
$1,625.00
$1,200.00
$1,215.00
$1,199.00
$488.00
$935.00
$85.00
$616.00
$1,308.00
$426.00
$593.00
$285.00
$271.00
$109.00
$137.00
$130.00
$199.00
$186.00
$211.00
$196.00
$784.00
$235.00
$232.00
$1,064.00
$821.00
$200.00
$201.00
$208.00
$203.00
$488.00
$782.00
$402.00
$195.00
$390.00
$517.00
$418.00
BR
BR
$1,882.00
$1,591.00
$1,390.00
$1,151.00
$1,568.00
$1,862.00
$1,788.00
$1,489.00
$1,395.00
$1,145.00
$280.00
FU Days
10
90
90
90
90
90
90
0
90
90
10
0
0
0
0
0
0
10
10
10
0
90
0
0
90
90
0
0
0
0
90
90
90
90
90
90
90
0
0
90
90
90
90
90
90
90
90
90
90
ZZZ
61
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
63040
63042
63043
63044
63045
63046
63047
63048
63055
63056
63057
63064
63066
63075
63076
63077
63078
63081
63082
63085
63086
63087
63088
63090
63091
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
MRA
$1,764.00
$1,620.00
BR
BR
$1,647.00
$2,117.00
$1,907.00
$367.00
$2,029.00
$1,960.00
$421.00
$2,200.00
$263.00
$1,720.00
$383.00
$1,828.00
$261.00
$2,203.00
$391.00
$2,416.00
$282.00
$2,930.00
$381.00
$2,490.00
$249.00
$1,788.00
$1,672.00
$1,851.00
$1,486.00
$1,711.00
$1,347.00
$1,610.00
$1,444.00
$1,593.00
$1,603.00
$1,810.00
$1,725.00
$1,956.00
$2,258.00
$1,569.00
$3,182.00
$3,207.00
$3,319.00
$1,940.00
$2,053.00
$1,651.00
$1,469.00
$2,197.00
$2,401.00
$2,206.00
FU Days
90
90
ZZZ
ZZZ
90
90
90
ZZZ
90
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
Surgery
CPT Code
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63300
63301
63302
63303
63304
63305
63306
63307
63308
63600
63610
63615
63650
63655
63660
63685
63688
63700
63702
63704
63706
63707
63709
63710
63740
63741
63744
63746
64400
64402
64405
64408
64410
64412
64413
64415
64416
MRA
$2,012.00
$2,166.00
$2,135.00
$1,905.00
$1,877.00
$2,529.00
$2,496.00
$2,305.00
$2,041.00
$2,934.00
$3,003.00
$3,012.00
$3,073.00
$2,006.00
$2,209.00
$2,290.00
$2,357.00
$2,513.00
$2,574.00
$2,596.00
$2,522.00
$425.00
$797.00
$476.00
$1,348.00
$819.00
$1,064.00
$707.00
$615.00
$707.00
$1,340.00
$1,512.00
$1,708.00
$1,873.00
$1,041.00
$1,310.00
$1,165.00
$1,062.00
$741.00
$738.00
$529.00
$78.00
$75.00
$103.00
$120.00
$109.00
$89.00
$128.00
$109.00
$159.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
64417
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64450
64470
64472
64475
64476
64479
64480
64483
64484
64505
64508
64510
64520
64530
64550
64553
64555
64560
64561
64565
64573
64575
64577
64580
64581
64585
64590
64595
64600
64605
64610
64612
64613
64614
64620
64622
64623
64626
64627
MRA
$105.00
$108.00
$89.00
$128.00
$116.00
$130.00
$114.00
$68.00
$165.00
$77.00
$152.00
$53.00
$206.00
$166.00
$183.00
$166.00
$224.00
$194.00
$206.00
$183.00
$104.00
$99.00
$103.00
$131.00
$135.00
$23.00
$137.00
$131.00
$197.00
$801.00
$121.00
$464.00
$367.00
$381.00
$343.00
$745.00
$37.00
$217.00
$153.00
$228.00
$319.00
$307.00
$188.00
$168.00
$200.00
$185.00
$333.00
$113.00
$262.00
$151.00
FU Days
0
0
0
0
0
0
0
0
0
0
0
0
0
ZZZ
0
ZZZ
0
ZZZ
0
ZZZ
0
0
0
0
0
0
10
10
10
10
10
90
90
90
90
90
10
10
10
10
10
10
10
10
10
10
10
ZZZ
10
ZZZ
62
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
64630
64640
64680
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
64727
64732
64734
64736
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
64766
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64804
64809
64818
64820
64821
MRA
$202.00
$208.00
$180.00
$383.00
$402.00
$562.00
$678.00
$867.00
$715.00
$523.00
$558.00
$446.00
$439.00
$411.00
$271.00
$261.00
$405.00
$432.00
$388.00
$475.00
$461.00
$517.00
$798.00
$494.00
$560.00
$1,042.00
$578.00
$495.00
$561.00
$713.00
$632.00
$636.00
$392.00
$390.00
$249.00
$482.00
$298.00
$751.00
$1,281.00
$458.00
$381.00
$884.00
$1,148.00
$247.00
$711.00
$1,202.00
$1,080.00
$845.00
$838.00
$609.00
FU Days
10
10
10
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
ZZZ
90
90
ZZZ
90
90
90
0
90
90
90
90
90
90
Surgery
CPT Code
64822
64823
64831
64832
64834
64835
64836
64837
64840
64856
64857
64858
64859
64861
64862
64864
64865
64866
64868
64870
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
64999
65091
65093
65101
65103
65105
65110
65112
65114
65125
65130
65135
65140
MRA
$609.00
$703.00
$592.00
$171.00
$711.00
$834.00
$856.00
$480.00
$1,058.00
$1,063.00
$1,137.00
$1,313.00
$341.00
$1,524.00
$1,798.00
$970.00
$1,250.00
$1,238.00
$1,162.00
$1,313.00
$155.00
$230.00
$189.00
$1,382.00
$1,636.00
$1,112.00
$1,243.00
$1,177.00
$1,321.00
$1,500.00
$1,185.00
$1,419.00
$1,549.00
$865.00
$982.00
$1,059.00
$1,472.00
BR
$678.00
$712.00
$726.00
$769.00
$846.00
$1,305.00
$1,386.00
$1,456.00
$312.00
$730.00
$678.00
$738.00
FU Days
90
90
90
ZZZ
90
90
90
ZZZ
90
90
90
90
ZZZ
90
90
90
90
90
90
90
ZZZ
ZZZ
ZZZ
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
90
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
65150
65155
65175
65205
65210
65220
65222
65235
65260
65265
65270
65272
65273
65275
65280
65285
65286
65290
65400
65410
65420
65426
65430
65435
65436
65450
65600
65710
65730
65750
65755
65770
65772
65775
65800
65805
65810
65815
65820
65850
65855
65860
65865
65870
65875
65880
65900
65920
65930
66020
MRA
$652.00
$862.00
$654.00
$45.00
$53.00
$58.00
$62.00
$627.00
$956.00
$1,104.00
$88.00
$223.00
$376.00
$75.00
$711.00
$1,177.00
$692.00
$519.00
$603.00
$142.00
$448.00
$534.00
$81.00
$88.00
$319.00
$52.00
$325.00
$1,124.00
$1,314.00
$1,381.00
$1,373.00
$1,461.00
$449.00
$595.00
$88.00
$178.00
$516.00
$327.00
$813.00
$968.00
$441.00
$339.00
$540.00
$572.00
$597.00
$641.00
$945.00
$752.00
$700.00
$164.00
FU Days
90
90
90
0
0
0
0
90
90
90
10
90
90
90
90
90
90
90
90
0
90
90
0
0
90
90
90
90
90
90
90
90
90
90
0
0
90
90
90
90
10
90
90
90
90
90
90
90
90
10
63
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
66030
66130
66150
66155
66160
66165
66170
66172
66180
66185
66220
66225
66250
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
66710
66720
66740
66761
66762
66770
66820
66821
66825
66830
66840
66850
66852
66920
66930
66940
66982
66983
66984
66985
66986
66990
66999
67005
67010
67015
67025
MRA
$160.00
$631.00
$798.00
$795.00
$942.00
$769.00
$1,089.00
$1,264.00
$1,313.00
$769.00
$711.00
$1,006.00
$602.00
$359.00
$359.00
$825.00
$1,136.00
$543.00
$623.00
$595.00
$526.00
$627.00
$506.00
$513.00
$506.00
$473.00
$506.00
$433.00
$483.00
$433.00
$275.00
$753.00
$651.00
$707.00
$805.00
$878.00
$785.00
$906.00
$819.00
$846.00
$763.00
$898.00
$744.00
$1,038.00
$84.00
BR
$639.00
$647.00
$637.00
$774.00
FU Days
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
YYY
90
90
90
90
Surgery
CPT Code
67027
67028
67030
67031
67036
67038
67039
67040
67101
67105
67107
67108
67110
67112
67115
67120
67121
67141
67145
67208
67210
67218
67220
67221
67225
67227
67228
67250
67255
67299
67311
67312
67314
67316
67318
67320
67331
67332
67334
67335
67340
67343
67345
67350
67399
67400
67405
67412
67413
67414
MRA
$1,089.00
$338.00
$485.00
$402.00
$1,384.00
$1,860.00
$1,490.00
$1,960.00
$767.00
$941.00
$1,350.00
$1,878.00
$1,040.00
$1,500.00
$496.00
$751.00
$962.00
$536.00
$514.00
$655.00
$779.00
$1,217.00
$894.00
$325.00
$44.00
$652.00
$1,025.00
$793.00
$872.00
BR
$616.00
$773.00
$688.00
$857.00
$663.00
$602.00
$560.00
$621.00
$447.00
$253.00
$559.00
$628.00
$275.00
$240.00
BR
$960.00
$799.00
$976.00
$909.00
$1,023.00
FU Days
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
ZZZ
90
90
90
90
YYY
90
90
90
90
90
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
90
10
0
YYY
90
90
90
90
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
67415
67420
67430
67440
67445
67450
67500
67505
67515
67550
67560
67570
67599
67700
67710
67715
67800
67801
67805
67808
67810
67820
67825
67830
67835
67840
67850
67875
67880
67882
67900
67901
67902
67903
67904
67906
67908
67909
67911
67914
67915
67916
67917
67921
67922
67923
67924
67930
67935
67938
MRA
$146.00
$1,729.00
$1,203.00
$1,257.00
$1,269.00
$1,300.00
$75.00
$109.00
$53.00
$946.00
$936.00
$1,148.00
BR
$87.00
$117.00
$102.00
$119.00
$189.00
$208.00
$308.00
$133.00
$36.00
$130.00
$239.00
$500.00
$187.00
$143.00
$163.00
$442.00
$643.00
$487.00
$646.00
$650.00
$657.00
$720.00
$633.00
$550.00
$577.00
$517.00
$487.00
$252.00
$675.00
$631.00
$419.00
$243.00
$718.00
$605.00
$280.00
$520.00
$67.00
FU Days
0
90
90
90
90
90
0
0
0
90
90
90
YYY
10
10
10
10
10
10
90
0
0
10
10
90
10
10
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
10
64
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
67950
67961
67966
67971
67973
67974
67975
67999
68020
68040
68100
68110
68115
68130
68135
68200
68320
68325
68326
68328
68330
68335
68340
68360
68362
68399
68400
68420
68440
68500
68505
68510
68520
68525
68530
68540
68550
68700
68705
68720
68745
68750
68760
68761
68770
68801
68810
68811
68815
68840
MRA
$584.00
$571.00
$645.00
$875.00
$1,126.00
$1,140.00
$681.00
BR
$106.00
$75.00
$137.00
$172.00
$248.00
$378.00
$146.00
$59.00
$502.00
$672.00
$654.00
$741.00
$488.00
$636.00
$413.00
$449.00
$691.00
BR
$154.00
$191.00
$96.00
$882.00
$921.00
$491.00
$687.00
$340.00
$379.00
$875.00
$1,107.00
$628.00
$176.00
$807.00
$704.00
$792.00
$109.00
$130.00
$634.00
$202.00
$290.00
$191.00
$399.00
$100.00
FU Days
90
90
90
90
90
90
90
YYY
10
0
0
10
10
90
10
0
90
90
90
90
90
90
90
90
90
YYY
10
10
10
90
90
0
90
0
10
90
90
90
10
90
90
90
10
10
90
10
10
10
10
10
Surgery
CPT Code
68850
68899
69000
69005
69020
69100
69105
69110
69120
69140
69145
69150
69155
69200
69205
69210
69220
69222
69300
69310
69320
69399
69400
69401
69405
69410
69420
69421
69424
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69550
69552
69554
69601
69602
69603
69604
69605
69610
69620
MRA
$76.00
BR
$52.00
$175.00
$109.00
$85.00
$87.00
$294.00
$274.00
$722.00
$248.00
$1,111.00
$1,680.00
$53.00
$110.00
$39.00
$78.00
$123.00
$522.00
$937.00
$1,434.00
BR
$76.00
$52.00
$176.00
$53.00
$117.00
$155.00
$84.00
$145.00
$182.00
$699.00
$525.00
$829.00
$1,118.00
$1,176.00
$1,221.00
$1,616.00
$2,824.00
$126.00
$998.00
$1,621.00
$2,600.00
$1,195.00
$1,225.00
$1,264.00
$1,263.00
$1,526.00
$41.00
$651.00
FU Days
0
YYY
10
10
10
0
0
90
90
90
90
90
90
0
10
0
0
10
YYY
90
90
YYY
0
0
10
0
10
10
0
10
10
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
10
90
CPT only © 2002 American Medical Association. All Rights Reserved.
Surgery
CPT Code
69631
69632
69633
69635
69636
69637
69641
69642
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69700
69710
69711
69714
69715
69717
69718
69720
69725
69740
69745
69799
69801
69802
69805
69806
69820
69840
69905
69910
69915
69930
69949
69950
69955
69960
69970
69979
69990
MRA
$985.00
$1,166.00
$1,110.00
$1,207.00
$1,381.00
$1,370.00
$1,154.00
$1,519.00
$1,389.00
$1,529.00
$1,479.00
$1,620.00
$879.00
$1,072.00
$1,412.00
$1,386.00
$887.00
$887.00
$988.00
$828.00
$702.00
BR
$878.00
$961.00
$1,217.00
$996.00
$1,232.00
$1,307.00
$1,922.00
$1,274.00
$1,447.00
BR
$785.00
$1,115.00
$1,187.00
$1,123.00
$876.00
$869.00
$1,013.00
$1,228.00
$1,754.00
$1,498.00
BR
$2,017.00
$2,185.00
$2,116.00
$2,306.00
BR
$262.00
FU Days
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
YYY
90
90
90
90
90
90
90
90
90
90
YYY
90
90
90
90
YYY
ZZZ
65
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
70010
70010-26
70010-TC
70015
70015-26
70015-TC
70030
70030-26
70030-TC
70100
70100-26
70100-TC
70110
70110-26
70110-TC
70120
70120-26
70120-TC
70130
70130-26
70130-TC
70134
70134-26
70134-TC
70140
70140-26
70140-TC
70150
70150-26
70150-TC
70160
70160-26
70160-TC
70170
70170-26
70170-TC
70190
70190-26
70190-TC
70200
70200-26
70200-TC
70210
70210-26
70210-TC
70220
70220-26
70220-TC
70240
70240-26
MRA
$70.00
NC
NC
$58.00
NC
NC
$24.00
$10.00
$15.00
$29.00
$9.00
$19.00
$36.00
$12.00
$22.00
$32.00
$9.00
$22.00
$46.00
$17.00
$29.00
$45.00
$17.00
$28.00
$33.00
$9.00
$22.00
$42.00
$12.00
$29.00
$29.00
$8.00
$19.00
$52.00
NC
NC
$34.00
$10.00
$22.00
$43.00
$14.00
$29.00
$32.00
$8.00
$22.00
$42.00
$12.00
$29.00
$26.00
$9.00
Radiology
CPT Code
70240-TC
70250
70250-26
70250-TC
70260
70260-26
70260-TC
70300
70300-26
70300-TC
70310
70310-26
70310-TC
70320
70320-26
70320-TC
70328
70328-26
70328-TC
70330
70330-26
70330-TC
70332
70332-26
70332-TC
70336
70336-26
70336-TC
70350
70350-26
70350-TC
70355
70355-26
70355-TC
70360
70360-26
70360-TC
70370
70370-26
70370-TC
70371
70371-26
70371-TC
70373
70373-26
70373-TC
70380
70380-26
70380-TC
70390
MRA
$15.00
$35.00
$12.00
$22.00
$50.00
$17.00
$33.00
$15.00
$5.00
$10.00
$24.00
$8.00
$15.00
$40.00
$11.00
$29.00
$28.00
$10.00
$18.00
$43.00
$12.00
$31.00
$107.00
NC
NC
$497.00
$72.00
$419.00
$24.00
$10.00
$14.00
$32.00
$10.00
$21.00
$24.00
$8.00
$15.00
$65.00
$16.00
$48.00
$122.00
$43.00
$79.00
$90.00
NC
NC
$34.00
$8.00
$24.00
$87.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
70390-26
70390-TC
70450
70450-26
70450-TC
70460
70460-26
70460-TC
70470
70470-26
70470-TC
70480
70480-26
70480-TC
70481
70481-26
70481-TC
70482
70482-26
70482-TC
70486
70486-26
70486-TC
70487
70487-26
70487-TC
70488
70488-26
70488-TC
70490
70490-26
70490-TC
70491
70491-26
70491-TC
70492
70492-26
70492-TC
70496
70496-26
70496-TC
70498
70498-26
70498-TC
70540
70540-26
70540-TC
70542
70542-26
70542-TC
MRA
NC
NC
$221.00
$43.00
$176.00
$271.00
$58.00
$211.00
$332.00
$65.00
$264.00
$244.00
$65.00
$176.00
$284.00
$70.00
$211.00
$340.00
$74.00
$264.00
$236.00
$58.00
$176.00
$279.00
$66.00
$211.00
$339.00
$72.00
$264.00
$244.00
$65.00
$176.00
$284.00
$70.00
$211.00
$340.00
$74.00
$264.00
$366.00
$92.00
$270.00
$366.00
$92.00
$270.00
$482.00
$70.00
$413.00
$579.00
$82.00
$495.00
66
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
70543
70543-26
70543-TC
70544
70544-26
70544-TC
70545
70545-26
70545-TC
70546
70546-26
70546-TC
70547
70547-26
70547-TC
70548
70548-26
70548-TC
70549
70549-26
70549-TC
70551
70551-26
70551-TC
70552
70552-26
70552-TC
70553
70553-26
70553-TC
71010
71010-26
71010-TC
71015
71015-26
71015-TC
71020
71020-26
71020-TC
71021
71021-26
71021-TC
71022
71022-26
71022-TC
71023
71023-26
71023-TC
71030
71030-26
MRA
$1,029.00
$109.00
$916.00
$481.00
$61.00
$419.00
$481.00
$61.00
$419.00
$914.00
$92.00
$820.00
$481.00
$61.00
$419.00
$481.00
$61.00
$419.00
$914.00
$92.00
$820.00
$497.00
$76.00
$419.00
$596.00
$91.00
$502.00
$1,055.00
$120.00
$931.00
$27.00
$9.00
$17.00
$30.00
$10.00
$19.00
$35.00
$11.00
$22.00
$41.00
$13.00
$28.00
$44.00
$16.00
$28.00
$49.00
$19.00
$29.00
$45.00
$16.00
Radiology
CPT Code
71030-TC
71034
71034-26
71034-TC
71035
71035-26
71035-TC
71040
71040-26
71040-TC
71060
71060-26
71060-TC
71090
71090-26
71090-TC
71100
71100-26
71100-TC
71101
71101-26
71101-TC
71110
71110-26
71110-TC
71111
71111-26
71111-TC
71120
71120-26
71120-TC
71130
71130-26
71130-TC
71250
71250-26
71250-TC
71260
71260-26
71260-TC
71270
71270-26
71270-TC
71275
71275-26
71275-TC
71550
71550-26
71550-TC
71551
MRA
$29.00
$79.00
$23.00
$54.00
$56.00
$19.00
$38.00
$34.00
NC
NC
$108.00
NC
NC
$92.00
NC
NC
$33.00
$11.00
$21.00
$38.00
$13.00
$24.00
$43.00
$13.00
$29.00
$49.00
$16.00
$33.00
$35.00
$10.00
$24.00
$38.00
$11.00
$26.00
$282.00
$59.00
$220.00
$328.00
$63.00
$264.00
$402.00
$70.00
$330.00
$431.00
$100.00
$328.00
$490.00
$75.00
$415.00
$587.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
71551-26
71551-TC
71552
71552-26
71552-TC
71555
71555-26
71555-TC
72010
72010-26
72010-TC
72020
72020-26
72020-TC
72040
72040-26
72040-TC
72050
72050-26
72050-TC
72052
72052-26
72052-TC
72069
72069-26
72069-TC
72070
72070-26
72070-TC
72072
72072-26
72072-TC
72074
72074-26
72074-TC
72080
72080-26
72080-TC
72090
72090-26
72090-TC
72100
72100-26
72100-TC
72110
72110-26
72110-TC
72114
72114-26
72114-TC
MRA
$88.00
$496.00
$1,029.00
$114.00
$911.00
$514.00
$92.00
$419.00
$62.00
$22.00
$38.00
$22.00
$7.00
$15.00
$34.00
$11.00
$22.00
$49.00
$16.00
$33.00
$61.00
$18.00
$42.00
$40.00
$17.00
$24.00
$36.00
$11.00
$24.00
$39.00
$11.00
$28.00
$45.00
$11.00
$34.00
$36.00
$11.00
$24.00
$39.00
$14.00
$24.00
$36.00
$11.00
$24.00
$50.00
$16.00
$34.00
$64.00
$18.00
$44.00
67
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
72120
72120-26
72120-TC
72125
72125-26
72125-TC
72126
72126-26
72126-TC
72127
72127-26
72127-TC
72128
72128-26
72128-TC
72129
72129-26
72129-TC
72130
72130-26
72130-TC
72131
72131-26
72131-TC
72132
72132-26
72132-TC
72133
72133-26
72133-TC
72141
72141-26
72141-TC
72142
72142-26
72142-TC
72146
72146-26
72146-TC
72147
72147-26
72147-TC
72148
72148-26
72148-TC
72149
72149-26
72149-TC
72156
72156-26
MRA
$45.00
$11.00
$33.00
$282.00
$59.00
$220.00
$328.00
$62.00
$264.00
$397.00
$65.00
$330.00
$282.00
$59.00
$220.00
$328.00
$62.00
$264.00
$397.00
$65.00
$330.00
$282.00
$59.00
$220.00
$328.00
$62.00
$264.00
$391.00
$65.00
$323.00
$503.00
$82.00
$419.00
$604.00
$99.00
$502.00
$549.00
$82.00
$465.00
$603.00
$98.00
$502.00
$543.00
$76.00
$465.00
$597.00
$92.00
$502.00
$1,066.00
$131.00
Radiology
CPT Code
72156-TC
72157
72157-26
72157-TC
72158
72158-26
72158-TC
72159
72159-26
72159-TC
72170
72170-26
72170-TC
72190
72190-26
72190-TC
72191
72191-26
72191-TC
72192
72192-26
72192-TC
72193
72193-26
72193-TC
72194
72194-26
72194-TC
72195
72195-26
72195-TC
72196
72196-26
72196-TC
72197
72197-26
72197-TC
72198
72198-26
72198-TC
72200
72200-26
72200-TC
72202
72202-26
72202-TC
72220
72220-26
72220-TC
72240
MRA
$931.00
$1,066.00
$131.00
$931.00
$1,056.00
$121.00
$931.00
$563.00
$94.00
$465.00
$29.00
$8.00
$19.00
$35.00
$10.00
$24.00
$413.00
$94.00
$315.00
$278.00
$56.00
$220.00
$317.00
$59.00
$256.00
$380.00
$62.00
$317.00
$491.00
$74.00
$415.00
$526.00
$84.00
$442.00
$1,037.00
$114.00
$919.00
$517.00
$95.00
$419.00
$29.00
$9.00
$19.00
$33.00
$9.00
$22.00
$30.00
$8.00
$21.00
$132.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
72240-26
72240-TC
72255
72255-26
72255-TC
72265
72265-26
72265-TC
72270
72270-26
72270-TC
72275
72275-26
72275-TC
72285
72285-26
72285-TC
72295
72295-26
72295-TC
73000
73000-26
73000-TC
73010
73010-26
73010-TC
73020
73020-26
73020-TC
73030
73030-26
73030-TC
73040
73040-26
73040-TC
73050
73050-26
73050-TC
73060
73060-26
73060-TC
73070
73070-26
73070-TC
73080
73080-26
73080-TC
73085
73085-26
73085-TC
MRA
NC
NC
$129.00
NC
NC
$132.00
NC
NC
$176.00
NC
NC
$112.00
NC
NC
$101.00
NC
NC
$107.00
NC
NC
$28.00
$8.00
$19.00
$29.00
$8.00
$19.00
$26.00
$7.00
$17.00
$31.00
$9.00
$21.00
$68.00
NC
NC
$35.00
$10.00
$24.00
$30.00
$8.00
$21.00
$27.00
$7.00
$19.00
$30.00
$8.00
$21.00
$74.00
NC
NC
68
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
73090
73090-26
73090-TC
73100
73100-26
73100-TC
73110
73110-26
73110-TC
73115
73115-26
73115-TC
73120
73120-26
73120-TC
73130
73130-26
73130-TC
73140
73140-26
73140-TC
73200
73200-26
73200-TC
73201
73201-26
73201-TC
73202
73202-26
73202-TC
73206
73206-26
73206-TC
73218
73218-26
73218-TC
73219
73219-26
73219-TC
73220
73220-26
73220-TC
73221
73221-26
73221-TC
73222
73222-26
73222-TC
73223
73223-26
MRA
$28.00
$8.00
$19.00
$27.00
$8.00
$18.00
$29.00
$8.00
$19.00
$54.00
NC
NC
$27.00
$8.00
$18.00
$29.00
$8.00
$19.00
$22.00
$7.00
$15.00
$242.00
$56.00
$185.00
$282.00
$59.00
$220.00
$342.00
$63.00
$277.00
$375.00
$94.00
$277.00
$482.00
$68.00
$413.00
$579.00
$82.00
$495.00
$520.00
$78.00
$442.00
$482.00
$68.00
$413.00
$579.00
$82.00
$495.00
$1,029.00
$109.00
Radiology
CPT Code
73223-TC
73225
73225-26
73225-TC
73500
73500-26
73500-TC
73510
73510-26
73510-TC
73520
73520-26
73520-TC
73525
73525-26
73525-TC
73530
73530-26
73530-TC
73542
73542-26
73542-TC
73550
73550-26
73550-TC
73560
73560-26
73560-TC
73562
73562-26
73562-TC
73564
73564-26
73564-TC
73565
73565-26
73565-TC
73580
73580-26
73580-TC
73590
73590-26
73590-TC
73600
73600-26
73600-TC
73610
73610-26
73610-TC
73615
MRA
$916.00
$513.00
$92.00
$419.00
$27.00
$8.00
$17.00
$32.00
$10.00
$21.00
$38.00
$12.00
$24.00
$84.00
NC
NC
$34.00
$14.00
$19.00
$108.00
NC
NC
$30.00
$8.00
$21.00
$29.00
$8.00
$19.00
$31.00
$9.00
$21.00
$35.00
$11.00
$22.00
$28.00
$8.00
$18.00
$84.00
NC
NC
$29.00
$8.00
$19.00
$27.00
$8.00
$18.00
$29.00
$8.00
$19.00
$72.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
73615-26
73615-TC
73620
73620-26
73620-TC
73630
73630-26
73630-TC
73650
73650-26
73650-TC
73660
73660-26
73660-TC
73700
73700-26
73700-TC
73701
73701-26
73701-TC
73702
73702-26
73702-TC
73706
73706-26
73706-TC
73718
73718-26
73718-TC
73719
73719-26
73719-TC
73720
73720-26
73720-TC
73721
73721-26
73721-TC
73722
73722-26
73722-TC
73723
73723-26
73723-TC
73725
73725-26
73725-TC
74000
74000-26
74000-TC
MRA
NC
NC
$27.00
$8.00
$18.00
$29.00
$8.00
$19.00
$26.00
$8.00
$17.00
$22.00
$7.00
$15.00
$242.00
$56.00
$185.00
$282.00
$61.00
$220.00
$341.00
$62.00
$277.00
$379.00
$98.00
$277.00
$482.00
$68.00
$413.00
$579.00
$82.00
$495.00
$520.00
$78.00
$442.00
$482.00
$68.00
$413.00
$579.00
$82.00
$495.00
$1,029.00
$109.00
$916.00
$515.00
$92.00
$419.00
$29.00
$9.00
$19.00
69
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
74010
74010-26
74010-TC
74020
74020-26
74020-TC
74022
74022-26
74022-TC
74150
74150-26
74150-TC
74160
74160-26
74160-TC
74170
74170-26
74170-TC
74175
74175-26
74175-TC
74181
74181-26
74181-TC
74182
74182-26
74182-TC
74183
74183-26
74183-TC
74185
74185-26
74185-TC
74190
74190-26
74190-TC
74210
74210-26
74210-TC
74220
74220-26
74220-TC
74230
74230-26
74230-TC
74235
74235-26
74235-TC
74240
74240-26
MRA
$33.00
$11.00
$21.00
$37.00
$13.00
$22.00
$44.00
$16.00
$28.00
$274.00
$60.00
$211.00
$322.00
$65.00
$256.00
$390.00
$71.00
$317.00
$418.00
$98.00
$315.00
$498.00
$85.00
$415.00
$587.00
$88.00
$496.00
$1,037.00
$114.00
$919.00
$514.00
$92.00
$419.00
$73.00
NC
NC
$63.00
$18.00
$44.00
$68.00
$23.00
$44.00
$77.00
$27.00
$48.00
$160.00
NC
NC
$91.00
$35.00
Radiology
CPT Code
74240-TC
74241
74241-26
74241-TC
74245
74245-26
74245-TC
74246
74246-26
74246-TC
74247
74247-26
74247-TC
74249
74249-26
74249-TC
74250
74250-26
74250-TC
74251
74251-26
74251-TC
74260
74260-26
74260-TC
74270
74270-26
74270-TC
74280
74280-26
74280-TC
74283
74283-26
74283-TC
74290
74290-26
74290-TC
74291
74291-26
74291-TC
74300
74300-26
74300-TC
74301
74301-26
74301-TC
74305
74305-26
74305-TC
74320
MRA
$55.00
$91.00
$35.00
$56.00
$137.00
$46.00
$89.00
$97.00
$35.00
$61.00
$99.00
$35.00
$63.00
$144.00
$46.00
$96.00
$73.00
$23.00
$48.00
$85.00
$34.00
$48.00
$82.00
$25.00
$56.00
$100.00
$35.00
$64.00
$136.00
$50.00
$84.00
$201.00
$103.00
$95.00
$44.00
$16.00
$28.00
$26.00
$10.00
$15.00
$31.00
NC
NC
BR
NC
NC
$51.00
NC
NC
$145.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
74320-26
74320-TC
74327
74327-26
74327-TC
74328
74328-26
74328-TC
74329
74329-26
74329-TC
74330
74330-26
74330-TC
74340
74340-26
74340-TC
74350
74350-26
74350-TC
74355
74355-26
74355-TC
74360
74360-26
74360-TC
74363
74363-26
74363-TC
74400
74400-26
74400-TC
74410
74410-26
74410-TC
74415
74415-26
74415-TC
74420
74420-26
74420-TC
74425
74425-26
74425-TC
74430
74430-26
74430-TC
74440
74440-26
74440-TC
MRA
NC
NC
$103.00
NC
NC
$155.00
NC
NC
$155.00
NC
NC
$165.00
NC
NC
$121.00
NC
NC
$158.00
NC
NC
$137.00
NC
NC
$145.00
NC
NC
$274.00
NC
NC
$89.00
$24.00
$63.00
$98.00
$24.00
$72.00
$105.00
$24.00
$79.00
$117.00
$18.00
$97.00
$68.00
NC
NC
$48.00
NC
NC
$62.00
NC
NC
70
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
74445
74445-26
74445-TC
74450
74450-26
74450-TC
74455
74455-26
74455-TC
74470
74470-26
74470-TC
74475
74475-26
74475-TC
74480
74480-26
74480-TC
74485
74485-26
74485-TC
74710
74710-26
74710-TC
74740
74740-26
74740-TC
74742
74742-26
74742-TC
74775
74775-26
74775-TC
75552
75552-26
75552-TC
75553
75553-26
75553-TC
75554
75554-26
75554-TC
75555
75555-26
75555-TC
75600
75600-26
75600-TC
75605
75605-26
MRA
$101.00
NC
NC
$60.00
NC
NC
$75.00
NC
NC
$74.00
NC
NC
$181.00
NC
NC
$181.00
NC
NC
$146.00
NC
NC
$57.00
$17.00
$39.00
$68.00
NC
NC
$150.00
NC
NC
$88.00
$32.00
$55.00
$503.00
$82.00
$419.00
$524.00
$100.00
$419.00
$517.00
$94.00
$419.00
$513.00
$91.00
$419.00
$497.00
NC
NC
$183.00
NC
Radiology
CPT Code
75605-TC
75625
75625-26
75625-TC
75630
75630-26
75630-TC
75635
75635-26
75635-TC
75650
75650-26
75650-TC
75658
75658-26
75658-TC
75660
75660-26
75660-TC
75662
75662-26
75662-TC
75665
75665-26
75665-TC
75671
75671-26
75671-TC
75676
75676-26
75676-TC
75680
75680-26
75680-TC
75685
75685-26
75685-TC
75705
75705-26
75705-TC
75710
75710-26
75710-TC
75716
75716-26
75716-TC
75722
75722-26
75722-TC
75724
MRA
NC
$143.00
NC
NC
$239.00
NC
NC
$445.00
NC
NC
$218.00
NC
NC
$540.00
NC
NC
$540.00
NC
NC
$560.00
NC
NC
$540.00
NC
NC
$219.00
NC
NC
$540.00
NC
NC
$207.00
NC
NC
$160.00
NC
NC
$587.00
NC
NC
$194.00
NC
NC
$293.00
NC
NC
$206.00
NC
NC
$214.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
75724-26
75724-TC
75726
75726-26
75726-TC
75731
75731-26
75731-TC
75733
75733-26
75733-TC
75736
75736-26
75736-TC
75741
75741-26
75741-TC
75743
75743-26
75743-TC
75746
75746-26
75746-TC
75756
75756-26
75756-TC
75774
75774-26
75774-TC
75790
75790-26
75790-TC
75801
75801-26
75801-TC
75803
75803-26
75803-TC
75805
75805-26
75805-TC
75807
75807-26
75807-TC
75809
75809-26
75809-TC
75810
75810-26
75810-TC
MRA
NC
NC
$530.00
NC
NC
$530.00
NC
NC
$540.00
NC
NC
$530.00
NC
NC
$540.00
NC
NC
$253.00
NC
NC
$530.00
NC
NC
$183.00
NC
NC
$80.00
NC
NC
$146.00
NC
NC
$245.00
NC
NC
$264.00
NC
NC
$271.00
NC
NC
$289.00
NC
NC
$54.00
NC
NC
$530.00
NC
NC
71
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
75820
75820-26
75820-TC
75822
75822-26
75822-TC
75825
75825-26
75825-TC
75827
75827-26
75827-TC
75831
75831-26
75831-TC
75833
75833-26
75833-TC
75840
75840-26
75840-TC
75842
75842-26
75842-TC
75860
75860-26
75860-TC
75870
75870-26
75870-TC
75872
75872-26
75872-TC
75880
75880-26
75880-TC
75885
75885-26
75885-TC
75887
75887-26
75887-TC
75889
75889-26
75889-TC
75891
75891-26
75891-TC
75893
75893-26
MRA
$72.00
NC
NC
$111.00
NC
NC
$194.00
NC
NC
$530.00
NC
NC
$54.00
NC
NC
$549.00
NC
NC
$531.00
NC
NC
$549.00
NC
NC
$531.00
NC
NC
$531.00
NC
NC
$530.00
NC
NC
$72.00
NC
NC
$546.00
NC
NC
$546.00
NC
NC
$530.00
NC
NC
$530.00
NC
NC
$499.00
NC
Radiology
CPT Code
75893-TC
75894
75894-26
75894-TC
75896
75896-26
75896-TC
75898
75898-26
75898-TC
75900
75900-26
75900-TC
75901
75901-26
75901-TC
75902
75902-26
75902-TC
75940
75940-26
75940-TC
75945
75945-26
75945-TC
75946
75946-26
75946-TC
75952
75952-26
75952-TC
75953
75953-26
75953-TC
75954
75954-26
75954-TC
75960
75960-26
75960-TC
75961
75961-26
75961-TC
75962
75962-26
75962-TC
75964
75964-26
75964-TC
75966
MRA
NC
$972.00
NC
NC
$241.00
NC
NC
$124.00
$84.00
$39.00
$810.00
NC
NC
$98.00
NC
NC
$93.00
NC
NC
$151.00
NC
NC
$192.00
NC
NC
$108.00
NC
NC
BR
NC
NC
BR
NC
NC
BR
NC
NC
$600.00
NC
NC
$616.00
NC
NC
$618.00
NC
NC
$333.00
NC
NC
$659.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
75966-26
75966-TC
75968
75968-26
75968-TC
75970
75970-26
75970-TC
75978
75978-26
75978-TC
75980
75980-26
75980-TC
75982
75982-26
75982-TC
75984
75984-26
75984-TC
75989
75989-26
75989-TC
75992
75992-26
75992-TC
75993
75993-26
75993-TC
75994
75994-26
75994-TC
75995
75995-26
75995-TC
75996
75996-26
75996-TC
76000
76000-26
76000-TC
76001
76001-26
76001-TC
76003
76003-26
76003-TC
76005
76005-26
76005-TC
MRA
NC
NC
$333.00
NC
NC
$475.00
NC
NC
$617.00
NC
NC
$277.00
NC
NC
$303.00
NC
NC
$110.00
NC
NC
$180.00
NC
NC
$618.00
NC
NC
$333.00
NC
NC
$659.00
NC
NC
$658.00
NC
NC
$332.00
NC
NC
$58.00
$8.00
$48.00
$134.00
$34.00
$97.00
$78.00
$28.00
$48.00
$79.00
$29.00
$48.00
72
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
76006
76012
76012-26
76012-TC
76013
76013-26
76013-TC
76020
76020-26
76020-TC
76040
76040-26
76040-TC
76061
76061-26
76061-TC
76062
76062-26
76062-TC
76066
76066-26
76066-TC
76070
76070-26
76070-TC
76071
76071-26
76071-TC
76075
76075-26
76075-TC
76076
76076-26
76076-TC
76078
76078-26
76078-TC
76080
76080-26
76080-TC
76085
76085-26
76085-TC
76086
76086-26
76086-TC
76088
76088-26
76088-TC
76090
MRA
$19.00
BR
NC
NC
BR
NC
NC
$29.00
$9.00
$19.00
$44.00
$14.00
$29.00
$61.00
$22.00
$37.00
$82.00
$27.00
$54.00
$58.00
$16.00
$41.00
$123.00
$13.00
$110.00
$121.00
$11.00
$110.00
$132.00
$15.00
$115.00
$40.00
$11.00
$29.00
$39.00
$10.00
$29.00
$67.00
NC
NC
$18.00
$3.00
$14.00
$117.00
NC
NC
$161.00
NC
NC
$68.00
Radiology
CPT Code
76090-26
76090-TC
76091
76091-26
76091-TC
76093
76093-26
76093-TC
76094
76094-26
76094-TC
76095
76095-26
76095-TC
76096
76096-26
76096-TC
76098
76098-26
76098-TC
76100
76100-26
76100-TC
76101
76101-26
76101-TC
76102
76102-26
76102-TC
76120
76120-26
76120-TC
76125
76125-26
76125-TC
76140
76150
76350
76355
76355-26
76355-TC
76360
76360-26
76360-TC
76362
76362-26
76362-TC
76370
76370-26
76370-TC
MRA
$17.00
$39.00
$85.00
$30.00
$48.00
$745.00
$83.00
$658.00
$980.00
$83.00
$894.00
$351.00
NC
NC
$79.00
NC
NC
$23.00
$8.00
$15.00
$77.00
$30.00
$46.00
$94.00
$36.00
$59.00
$95.00
$30.00
$65.00
$157.00
$56.00
$102.00
$49.00
$17.00
$33.00
$31.00
$15.00
BR
$372.00
$62.00
$308.00
$168.00
NC
NC
$550.00
$203.00
$341.00
$155.00
$43.00
$110.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
76375
76375-26
76375-TC
76380
76380-26
76380-TC
76390
76390-26
76390-TC
76393
76393-26
76393-TC
76394
76394-26
76394-TC
76400
76400-26
76400-TC
76490
76490-26
76490-TC
76496
76496-26
76496-TC
76497
76497-26
76497-TC
76498
76498-26
76498-TC
76499
76499-26
76499-TC
76506
76506-26
76506-TC
76511
76511-26
76511-TC
76512
76512-26
76512-TC
76513
76513-26
76513-TC
76516
76516-26
76516-TC
76519
76519-26
MRA
$140.00
$8.00
$132.00
$182.00
$50.00
$131.00
$493.00
$71.00
$419.00
$496.00
NC
NC
$671.00
$216.00
$449.00
$503.00
$81.00
$419.00
$169.00
$106.00
$63.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$88.00
$33.00
$53.00
$96.00
$48.00
$48.00
$96.00
$36.00
$60.00
$96.00
$36.00
$60.00
$99.00
$37.00
$63.00
$88.00
$31.00
73
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
76519-TC
76529
76529-26
76529-TC
76536
76536-26
76536-TC
76604
76604-26
76604-TC
76645
76645-26
76645-TC
76700
76700-26
76700-TC
76705
76705-26
76705-TC
76770
76770-26
76770-TC
76775
76775-26
76775-TC
76778
76778-26
76778-TC
76800
76800-26
76800-TC
76801
76801-26
76801-TC
76802
76802-26
76802-TC
76805
76805-26
76805-TC
76810
76810-26
76810-TC
76811
76811-26
76811-TC
76812
76812-26
76812-TC
76815
MRA
$53.00
$86.00
$31.00
$53.00
$83.00
$31.00
$54.00
$78.00
$28.00
$48.00
$69.00
$31.00
$40.00
$116.00
$42.00
$73.00
$84.00
$30.00
$53.00
$112.00
$38.00
$73.00
$84.00
$30.00
$53.00
$112.00
$38.00
$73.00
$112.00
$61.00
$54.00
$93.00
$51.00
$42.00
$73.00
$43.00
$30.00
$131.00
$51.00
$79.00
$252.00
$100.00
$151.00
$243.00
$100.00
$142.00
$145.00
$94.00
$51.00
$88.00
Radiology
CPT Code
76815-26
76815-TC
76816
76816-26
76816-TC
76817
76817-26
76817-TC
76818
76818-26
76818-TC
76819
76819-26
76819-TC
76825
76825-26
76825-TC
76826
76826-26
76826-TC
76827
76827-26
76827-TC
76828
76828-26
76828-TC
76830
76830-26
76830-TC
76831
76831-26
76831-TC
76856
76856-26
76856-TC
76857
76857-26
76857-TC
76870
76870-26
76870-TC
76872
76872-26
76872-TC
76873
76873-26
76873-TC
76880
76880-26
76880-TC
MRA
$33.00
$53.00
$72.00
$30.00
$41.00
$96.00
$39.00
$57.00
$105.00
$40.00
$60.00
$101.00
$40.00
$60.00
$160.00
$65.00
$73.00
$71.00
$46.00
$27.00
$97.00
$35.00
$65.00
$72.00
$29.00
$42.00
$93.00
$35.00
$57.00
$95.00
$37.00
$57.00
$93.00
$35.00
$57.00
$59.00
$19.00
$39.00
$90.00
$33.00
$57.00
$93.00
$36.00
$57.00
$151.00
$68.00
$80.00
$85.00
$32.00
$54.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
76930
76930-26
76930-TC
76932
76932-26
76932-TC
76936
76936-26
76936-TC
76941
76941-26
76941-TC
76942
76942-26
76942-TC
76945
76945-26
76945-TC
76946
76946-26
76946-TC
76948
76948-26
76948-TC
76950
76950-26
76950-TC
76965
76965-26
76965-TC
76970
76970-26
76970-TC
76975
76975-26
76975-TC
76977
76977-26
76977-TC
76986
76986-26
76986-TC
76999
76999-26
76999-TC
77261
77262
77263
77280
77280-26
MRA
$93.00
NC
NC
$93.00
NC
NC
$341.00
$102.00
$236.00
$128.00
NC
NC
$92.00
NC
NC
$93.00
NC
NC
$78.00
NC
NC
$77.00
NC
NC
$80.00
$30.00
$48.00
$281.00
$84.00
$208.00
$60.00
$20.00
$39.00
$99.00
NC
NC
$34.00
$3.00
$31.00
$162.00
$62.00
$97.00
BR
BR
BR
$73.00
$110.00
$163.00
$166.00
$36.00
74
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
77280-TC
77285
77285-26
77285-TC
77290
77290-26
77290-TC
77295
77295-26
77295-TC
77299
77299-26
77299-TC
77300
77300-26
77300-TC
77301
77301-26
77301-TC
77305
77305-26
77305-TC
77310
77310-26
77310-TC
77315
77315-26
77315-TC
77321
77321-26
77321-TC
77326
77326-26
77326-TC
77327
77327-26
77327-TC
77328
77328-26
77328-TC
77331
77331-26
77331-TC
77332
77332-26
77332-TC
77333
77333-26
77333-TC
77334
MRA
$130.00
$264.00
$53.00
$209.00
$325.00
$79.00
$243.00
$1,287.00
$232.00
$1,046.00
BR
BR
BR
$87.00
$36.00
$52.00
$1,473.00
$415.00
$1,046.00
$106.00
$36.00
$69.00
$142.00
$53.00
$87.00
$181.00
$79.00
$99.00
$200.00
$48.00
$150.00
$137.00
$47.00
$88.00
$202.00
$71.00
$130.00
$295.00
$106.00
$185.00
$64.00
$45.00
$18.00
$78.00
$27.00
$50.00
$115.00
$43.00
$70.00
$187.00
Radiology
CPT Code
77334-26
77334-TC
77336
77370
77399
77399-26
77399-TC
77401
77402
77403
77404
77406
77407
77408
77409
77411
77412
77413
77414
77416
77417
77418
77427
77431
77432
77470
77470-26
77470-TC
77499
77499-26
77499-TC
77520
77522
77523
77525
77600
77600-26
77600-TC
77605
77605-26
77605-TC
77610
77610-26
77610-TC
77615
77615-26
77615-TC
77620
77620-26
77620-TC
MRA
$63.00
$121.00
$111.00
$130.00
BR
BR
BR
$66.00
$66.00
$66.00
$66.00
$66.00
$78.00
$78.00
$78.00
$78.00
$87.00
$87.00
$87.00
$87.00
$21.00
$609.00
$166.00
$95.00
$417.00
$527.00
$106.00
$417.00
BR
BR
BR
BR
BR
BR
BR
$196.00
$80.00
$113.00
$263.00
$108.00
$151.00
$195.00
$79.00
$113.00
$262.00
$106.00
$151.00
$196.00
$80.00
$113.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
77750
77750-26
77750-TC
77761
77761-26
77761-TC
77762
77762-26
77762-TC
77763
77763-26
77763-TC
77776
77776-26
77776-TC
77777
77777-26
77777-TC
77778
77778-26
77778-TC
77781
77781-26
77781-TC
77782
77782-26
77782-TC
77783
77783-26
77783-TC
77784
77784-26
77784-TC
77789
77789-26
77789-TC
77790
77790-26
77790-TC
77799
77799-26
77799-TC
78000
78000-26
78000-TC
78001
78001-26
78001-TC
78003
78003-26
MRA
$299.00
$248.00
$49.00
$284.00
$188.00
$93.00
$427.00
$289.00
$135.00
$605.00
$435.00
$167.00
$316.00
$233.00
$82.00
$540.00
$378.00
$158.00
$764.00
$568.00
$192.00
$847.00
$85.00
$759.00
$890.00
$127.00
$759.00
$956.00
$189.00
$759.00
$1,055.00
$284.00
$759.00
$74.00
$57.00
$16.00
$72.00
$53.00
$18.00
BR
BR
BR
$46.00
$9.00
$36.00
$62.00
$12.00
$48.00
$54.00
$17.00
75
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
78003-TC
78006
78006-26
78006-TC
78007
78007-26
78007-TC
78010
78010-26
78010-TC
78011
78011-26
78011-TC
78015
78015-26
78015-TC
78016
78016-26
78016-TC
78018
78018-26
78018-TC
78020
78020-26
78020-TC
78070
78070-26
78070-TC
78075
78075-26
78075-TC
78099
78099-26
78099-TC
78102
78102-26
78102-TC
78103
78103-26
78103-TC
78104
78104-26
78104-TC
78110
78110-26
78110-TC
78111
78111-26
78111-TC
78120
MRA
$36.00
$115.00
$24.00
$89.00
$122.00
$25.00
$96.00
$89.00
$19.00
$68.00
$114.00
$22.00
$90.00
$132.00
$34.00
$96.00
$173.00
$42.00
$130.00
$248.00
$44.00
$202.00
$35.00
$30.00
$5.00
$112.00
$36.00
$68.00
$242.00
$38.00
$202.00
BR
BR
BR
$106.00
$28.00
$77.00
$158.00
$39.00
$118.00
$194.00
$41.00
$152.00
$45.00
$9.00
$35.00
$108.00
$11.00
$96.00
$78.00
Radiology
CPT Code
78120-26
78120-TC
78121
78121-26
78121-TC
78122
78122-26
78122-TC
78130
78130-26
78130-TC
78135
78135-26
78135-TC
78140
78140-26
78140-TC
78160
78160-26
78160-TC
78162
78162-26
78162-TC
78170
78170-26
78170-TC
78172
78172-26
78172-TC
78185
78185-26
78185-TC
78190
78190-26
78190-TC
78191
78191-26
78191-TC
78195
78195-26
78195-TC
78199
78199-26
78199-TC
78201
78201-26
78201-TC
78202
78202-26
78202-TC
MRA
$11.00
$65.00
$125.00
$16.00
$108.00
$196.00
$22.00
$171.00
$139.00
$32.00
$106.00
$216.00
$33.00
$182.00
$179.00
$31.00
$147.00
$155.00
$17.00
$137.00
$143.00
$23.00
$119.00
$220.00
$20.00
$198.00
BR
$27.00
BR
$110.00
$20.00
$88.00
$272.00
$57.00
$214.00
$307.00
$31.00
$274.00
$216.00
$49.00
$152.00
BR
BR
BR
$112.00
$22.00
$88.00
$135.00
$26.00
$108.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
78205
78205-26
78205-TC
78206
78206-26
78206-TC
78215
78215-26
78215-TC
78216
78216-26
78216-TC
78220
78220-26
78220-TC
78223
78223-26
78223-TC
78230
78230-26
78230-TC
78231
78231-26
78231-TC
78232
78232-26
78232-TC
78258
78258-26
78258-TC
78261
78261-26
78261-TC
78262
78262-26
78262-TC
78264
78264-26
78264-TC
78267
78268
78270
78270-26
78270-TC
78271
78271-26
78271-TC
78272
78272-26
78272-TC
MRA
$259.00
$36.00
$220.00
$265.00
$46.00
$214.00
$135.00
$24.00
$109.00
$160.00
$29.00
$130.00
$165.00
$24.00
$139.00
$181.00
$43.00
$137.00
$106.00
$23.00
$82.00
$146.00
$27.00
$118.00
$157.00
$23.00
$132.00
$146.00
$38.00
$108.00
$190.00
$36.00
$152.00
$195.00
$35.00
$159.00
$195.00
$40.00
$154.00
BR
BR
$68.00
$10.00
$58.00
$72.00
$10.00
$61.00
$100.00
$14.00
$87.00
76
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
78278
78278-26
78278-TC
78282
78282-26
78282-TC
78290
78290-26
78290-TC
78291
78291-26
78291-TC
78299
78299-26
78299-TC
78300
78300-26
78300-TC
78305
78305-26
78305-TC
78306
78306-26
78306-TC
78315
78315-26
78315-TC
78320
78320-26
78320-TC
78350
78350-26
78350-TC
78351
78399
78399-26
78399-TC
78414
78414-26
78414-TC
78428
78428-26
78428-TC
78445
78445-26
78445-TC
78455
78455-26
78455-TC
78456
MRA
$234.00
$50.00
$182.00
BR
$19.00
BR
$149.00
$35.00
$113.00
$161.00
$45.00
$114.00
BR
BR
BR
$125.00
$32.00
$93.00
$181.00
$42.00
$137.00
$205.00
$44.00
$159.00
$233.00
$52.00
$179.00
$276.00
$53.00
$220.00
$40.00
$11.00
$29.00
$23.00
BR
BR
BR
BR
$23.00
BR
$126.00
$41.00
$84.00
$97.00
$28.00
$69.00
$187.00
$38.00
$148.00
$205.00
Radiology
CPT Code
78456-26
78456-TC
78457
78457-26
78457-TC
78458
78458-26
78458-TC
78459
78459-26
78459-TC
78460
78460-26
78460-TC
78461
78461-26
78461-TC
78464
78464-26
78464-TC
78465
78465-26
78465-TC
78466
78466-26
78466-TC
78468
78468-26
78468-TC
78469
78469-26
78469-TC
78472
78472-26
78472-TC
78473
78473-26
78473-TC
78478
78478-26
78478-TC
78480
78480-26
78480-TC
78481
78481-26
78481-TC
78483
78483-26
78483-TC
MRA
$49.00
$151.00
$140.00
$39.00
$99.00
$198.00
$46.00
$149.00
BR
$100.00
BR
$134.00
$44.00
$88.00
$294.00
$82.00
$213.00
$322.00
$56.00
$264.00
$519.00
$75.00
$441.00
$135.00
$36.00
$97.00
$180.00
$41.00
$137.00
$244.00
$47.00
$195.00
$259.00
$50.00
$206.00
$387.00
$75.00
$308.00
$91.00
$32.00
$58.00
$91.00
$32.00
$58.00
$248.00
$51.00
$195.00
$373.00
$77.00
$294.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
78491
78491-26
78491-TC
78492
78492-26
78492-TC
78494
78494-26
78494-TC
78496
78496-26
78496-TC
78499
78499-26
78499-TC
78580
78580-26
78580-TC
78584
78584-26
78584-TC
78585
78585-26
78585-TC
78586
78586-26
78586-TC
78587
78587-26
78587-TC
78588
78588-26
78588-TC
78591
78591-26
78591-TC
78593
78593-26
78593-TC
78594
78594-26
78594-TC
78596
78596-26
78596-TC
78599
78599-26
78599-TC
78600
78600-26
MRA
BR
$85.00
BR
BR
$100.00
BR
$324.00
$59.00
$262.00
$92.00
$24.00
$66.00
BR
BR
BR
$167.00
$38.00
$128.00
$171.00
$50.00
$119.00
$171.00
$36.00
$133.00
$118.00
$20.00
$96.00
$131.00
$24.00
$105.00
$239.00
$53.00
$192.00
$128.00
$20.00
$106.00
$151.00
$24.00
$126.00
$214.00
$27.00
$186.00
$332.00
$65.00
$264.00
BR
BR
BR
$131.00
$22.00
77
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
78600-TC
78601
78601-26
78601-TC
78605
78605-26
78605-TC
78606
78606-26
78606-TC
78607
78607-26
78607-TC
78608
78609
78610
78610-26
78610-TC
78615
78615-26
78615-TC
78630
78630-26
78630-TC
78635
78635-26
78635-TC
78645
78645-26
78645-TC
78647
78647-26
78647-TC
78650
78650-26
78650-TC
78660
78660-26
78660-TC
78699
78699-26
78699-TC
78700
78700-26
78700-TC
78701
78701-26
78701-TC
78704
78704-26
MRA
$108.00
$154.00
$26.00
$126.00
$155.00
$27.00
$126.00
$221.00
$45.00
$177.00
$311.00
$64.00
$245.00
BR
BR
$74.00
$15.00
$59.00
$166.00
$21.00
$143.00
$223.00
$35.00
$188.00
$129.00
$32.00
$95.00
$158.00
$29.00
$128.00
$268.00
$46.00
$220.00
$206.00
$31.00
$173.00
$107.00
$27.00
$79.00
BR
BR
BR
$137.00
$22.00
$113.00
$158.00
$24.00
$133.00
$187.00
$38.00
Radiology
CPT Code
78704-TC
78707
78707-26
78707-TC
78708
78708-26
78708-TC
78709
78709-26
78709-TC
78710
78710-26
78710-TC
78715
78715-26
78715-TC
78725
78725-26
78725-TC
78730
78730-26
78730-TC
78740
78740-26
78740-TC
78760
78760-26
78760-TC
78761
78761-26
78761-TC
78799
78799-26
78799-TC
78800
78800-26
78800-TC
78801
78801-26
78801-TC
78802
78802-26
78802-TC
78803
78803-26
78803-TC
78805
78805-26
78805-TC
78806
MRA
$147.00
$217.00
$49.00
$166.00
$231.00
$61.00
$166.00
$241.00
$68.00
$166.00
$256.00
$34.00
$220.00
$74.00
$15.00
$59.00
$87.00
$19.00
$66.00
$73.00
$18.00
$55.00
$109.00
$29.00
$79.00
$135.00
$34.00
$99.00
$157.00
$36.00
$119.00
BR
BR
BR
$162.00
$34.00
$126.00
$199.00
$40.00
$158.00
$252.00
$44.00
$207.00
$303.00
$56.00
$245.00
$166.00
$38.00
$126.00
$286.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Radiology
CPT Code
78806-26
78806-TC
78807
78807-26
78807-TC
78810
78810-26
78810-TC
78890
78890-26
78890-TC
78891
78891-26
78891-TC
78990
78999
78999-26
78999-TC
79000
79000-26
79000-TC
79001
79001-26
79001-TC
79020
79020-26
79020-TC
79030
79030-26
79030-TC
79035
79035-26
79035-TC
79100
79100-26
79100-TC
79200
79200-26
79200-TC
79300
79300-26
79300-TC
79400
79400-26
79400-TC
79420
79420-26
79420-TC
79440
79440-26
MRA
$44.00
$241.00
$303.00
$57.00
$245.00
BR
$103.00
BR
$52.00
$3.00
$48.00
$104.00
$5.00
$97.00
BR
BR
BR
BR
$192.00
$92.00
$97.00
$104.00
$54.00
$48.00
$192.00
$92.00
$97.00
$208.00
$107.00
$97.00
$230.00
$129.00
$97.00
$168.00
$68.00
$97.00
$203.00
$102.00
$97.00
BR
$83.00
BR
$201.00
$101.00
$97.00
BR
$77.00
BR
$204.00
$104.00
78
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
79440-TC
79900
79999
79999-26
79999-TC
MRA
$97.00
BR
BR
BR
BR
CPT only © 2002 American Medical Association. All Rights Reserved.
79
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
80048
$23.00
80048-26
$4.00
80048-TC
$19.00
80050
$45.00
80050-26
$18.00
80050-TC
$26.00
80051
$16.00
80051-26
$6.00
80051-TC
$10.00
80053
$29.00
80053-26
$8.00
80053-TC
$21.00
80055
$67.00
80055-26
$21.00
80055-TC
$43.00
80061
$31.00
80061-26
$11.00
80061-TC
$19.00
80069
$26.00
80069-26
$6.00
80069-TC
$20.00
80074
$107.00
80074-26
$43.00
80074-TC
$64.00
80076
$18.00
80076-26
$7.00
80076-TC
$11.00
80100
$38.00
80100-26
$11.00
80100-TC
$26.00
80101
$13.00
80101-26
$3.00
80101-TC
$9.00
80102
$23.00
80102-26
$6.00
80102-TC
$16.00
80103
$12.00
80103-26
$4.00
80103-TC
$7.00
80150
$40.00
80150-26
$13.00
80150-TC
$26.00
80152
$43.00
80152-26
$14.00
80152-TC
$29.00
80154
$49.00
80154-26
$15.00
80154-TC
$34.00
80156
$35.00
80156-26
$11.00
Pathology & Laboratory
CPT Code
MRA
80156-TC
$23.00
80157
$22.00
80157-26
$8.00
80157-TC
$14.00
80158
$35.00
80158-26
$12.00
80158-TC
$22.00
80160
$35.00
80160-26
$12.00
80160-TC
$22.00
80162
$13.00
80162-26
$3.00
80162-TC
$9.00
80164
$43.00
80164-26
$14.00
80164-TC
$29.00
80166
$35.00
80166-26
$10.00
80166-TC
$24.00
80168
$43.00
80168-26
$17.00
80168-TC
$25.00
80170
$18.00
80170-26
$6.00
80170-TC
$11.00
80172
$44.00
80172-26
$13.00
80172-TC
$32.00
80173
$33.00
80173-26
$11.00
80173-TC
$22.00
80174
$41.00
80174-26
$12.00
80174-TC
$29.00
80176
$35.00
80176-26
$11.00
80176-TC
$23.00
80178
$17.00
80178-26
$6.00
80178-TC
$11.00
80182
$43.00
80182-26
$14.00
80182-TC
$29.00
80184
$34.00
80184-26
$10.00
80184-TC
$23.00
80185
$36.00
80185-26
$10.00
80185-TC
$25.00
80186
$38.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
80186-26
$11.00
80186-TC
$26.00
80188
$35.00
80188-26
$11.00
80188-TC
$23.00
80190
$41.00
80190-26
$13.00
80190-TC
$28.00
80192
$44.00
80192-26
$17.00
80192-TC
$26.00
80194
$33.00
80194-26
$10.00
80194-TC
$22.00
80196
$13.00
80196-26
$3.00
80196-TC
$9.00
80197
$34.00
80197-26
$11.00
80197-TC
$22.00
80198
$20.00
80198-26
$5.00
80198-TC
$15.00
80200
$24.00
80200-26
$7.00
80200-TC
$16.00
80201
$33.00
80201-26
$11.00
80201-TC
$21.00
80202
$42.00
80202-26
$14.00
80202-TC
$28.00
80299
BR
80299-26
BR
80299-TC
BR
80400
$54.00
80400-26
$18.00
80400-TC
$36.00
80402
$138.00
80402-26
$42.00
80402-TC
$95.00
80406
$138.00
80406-26
$42.00
80406-TC
$95.00
80408
$213.00
80408-26
$77.00
80408-TC
$136.00
80410
$166.00
80410-26
$54.00
80410-TC
$110.00
80
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
80412
$533.00
80412-26
$176.00
80412-TC
$355.00
80414
$88.00
80414-26
$26.00
80414-TC
$59.00
80415
$93.00
80415-26
$28.00
80415-TC
$64.00
80416
$256.00
80416-26
$88.00
80416-TC
$166.00
80417
$256.00
80417-26
$88.00
80417-TC
$166.00
80418
$934.00
80418-26
$266.00
80418-TC
$666.00
80420
$107.00
80420-26
$33.00
80420-TC
$74.00
80422
$62.00
80422-26
$18.00
80422-TC
$43.00
80424
$94.00
80424-26
$26.00
80424-TC
$67.00
80426
$232.00
80426-26
$54.00
80426-TC
$176.00
80428
$93.00
80428-26
$19.00
80428-TC
$73.00
80430
$99.00
80430-26
$24.00
80430-TC
$74.00
80432
$243.00
80432-26
$56.00
80432-TC
$186.00
80434
$161.00
80434-26
$49.00
80434-TC
$110.00
80435
$166.00
80435-26
$49.00
80435-TC
$115.00
80436
$119.00
80436-26
$35.00
80436-TC
$85.00
80438
$82.00
80438-26
$24.00
Pathology & Laboratory
CPT Code
MRA
80438-TC
$56.00
80439
$176.00
80439-26
$33.00
80439-TC
$144.00
80440
$188.00
80440-26
$36.00
80440-TC
$151.00
80500
$34.00
80500-26
$34.00
80500-TC
BR
80502
$72.00
80502-26
$72.00
80502-TC
BR
81000
$7.00
81000-26
$3.00
81000-TC
$4.00
81001
$7.00
81001-26
$3.00
81001-TC
$4.00
81002
$5.00
81002-26
$3.00
81002-TC
$3.00
81003
$5.00
81003-26
$2.00
81003-TC
$3.00
81005
$3.00
81005-26
$1.00
81005-TC
$3.00
81007
$5.00
81007-26
$2.00
81007-TC
$4.00
81015
$5.00
81015-26
$3.00
81015-TC
$3.00
81020
$8.00
81020-26
$3.00
81020-TC
$5.00
81025
$7.00
81025-26
$4.00
81025-TC
$4.00
81050
$33.00
81050-26
$11.00
81050-TC
$21.00
81099
BR
81099-26
BR
81099-TC
BR
82000
$24.00
82000-26
$7.00
82000-TC
$17.00
82003
$36.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
82003-26
$10.00
82003-TC
$25.00
82009
$10.00
82009-26
$3.00
82009-TC
$6.00
82010
$22.00
82010-26
$7.00
82010-TC
$15.00
82013
$24.00
82013-26
$7.00
82013-TC
$17.00
82024
$26.00
82024-26
$7.00
82024-TC
$18.00
82030
$43.00
82030-26
$17.00
82030-TC
$25.00
82040
$11.00
82040-26
$3.00
82040-TC
$7.00
82042
$12.00
82042-26
$3.00
82042-TC
$8.00
82043
$14.00
82043-26
$4.00
82043-TC
$10.00
82044
$12.00
82044-26
$4.00
82044-TC
$9.00
82055
$33.00
82055-26
$10.00
82055-TC
$22.00
82075
$32.00
82075-26
$10.00
82075-TC
$21.00
82085
$24.00
82085-26
$7.00
82085-TC
$17.00
82088
$91.00
82088-26
$28.00
82088-TC
$62.00
82101
$59.00
82101-26
$18.00
82101-TC
$41.00
82103
$21.00
82103-26
$7.00
82103-TC
$14.00
82104
$22.00
82104-26
$7.00
82104-TC
$15.00
81
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
82105
$26.00
82105-26
$8.00
82105-TC
$18.00
82106
$26.00
82106-26
$8.00
82106-TC
$18.00
82108
$45.00
82108-26
$14.00
82108-TC
$32.00
82120
$9.00
82120-26
$3.00
82120-TC
$5.00
82127
$33.00
82127-26
$11.00
82127-TC
$22.00
82128
$26.00
82128-26
$6.00
82128-TC
$19.00
82131
$57.00
82131-26
$13.00
82131-TC
$44.00
82135
$41.00
82135-26
$13.00
82135-TC
$28.00
82136
$38.00
82136-26
$14.00
82136-TC
$23.00
82139
$38.00
82139-26
$14.00
82139-TC
$23.00
82140
$40.00
82140-26
$12.00
82140-TC
$28.00
82143
$28.00
82143-26
$8.00
82143-TC
$19.00
82145
$35.00
82145-26
$10.00
82145-TC
$24.00
82150
$16.00
82150-26
$5.00
82150-TC
$11.00
82154
$34.00
82154-26
$13.00
82154-TC
$20.00
82157
$57.00
82157-26
$17.00
82157-TC
$40.00
82160
$67.00
82160-26
$21.00
Pathology & Laboratory
CPT Code
MRA
82160-TC
$43.00
82163
$42.00
82163-26
$12.00
82163-TC
$31.00
82164
$32.00
82164-26
$10.00
82164-TC
$21.00
82172
$33.00
82172-26
$10.00
82172-TC
$22.00
82175
$48.00
82175-26
$15.00
82175-TC
$33.00
82180
$25.00
82180-26
$8.00
82180-TC
$17.00
82190
$24.00
82190-26
$8.00
82190-TC
$16.00
82205
$34.00
82205-26
$10.00
82205-TC
$23.00
82232
$43.00
82232-26
$14.00
82232-TC
$29.00
82239
$23.00
82239-26
$8.00
82239-TC
$15.00
82240
$49.00
82240-26
$15.00
82240-TC
$34.00
82247
$10.00
82247-26
$3.00
82247-TC
$7.00
82248
$10.00
82248-26
$3.00
82248-TC
$7.00
82252
$11.00
82252-26
$3.00
82252-TC
$7.00
82261
$38.00
82261-26
$13.00
82261-TC
$24.00
82270
$5.00
82270-26
$2.00
82270-TC
$3.00
82273
$8.00
82273-26
$2.00
82273-TC
$6.00
82274
BR
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
82306-TC
$52.00
82307
$57.00
82307-26
$19.00
82307-TC
$38.00
82308
$62.00
82308-26
$18.00
82308-TC
$43.00
82310
$11.00
82310-26
$3.00
82310-TC
$7.00
82330
$37.00
82330-26
$11.00
82330-TC
$25.00
82331
$14.00
82331-26
$4.00
82331-TC
$10.00
82340
$13.00
82340-26
$4.00
82340-TC
$8.00
82355
$31.00
82355-26
$10.00
82355-TC
$20.00
82360
$31.00
82360-26
$10.00
82360-TC
$20.00
82365
$31.00
82365-26
$8.00
82365-TC
$21.00
82370
$22.00
82370-26
$7.00
82370-TC
$15.00
82373
$16.00
82373-26
$5.00
82373-TC
$11.00
82374
$10.00
82374-26
$3.00
82374-TC
$6.00
82375
$26.00
82375-26
$7.00
82375-TC
$18.00
82
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
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
Pathology & Laboratory
CPT Code
MRA
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
82486
$42.00
82486-26
$14.00
82486-TC
$27.00
82487
$43.00
82487-26
$14.00
82487-TC
$29.00
82488
$57.00
82488-26
$19.00
82488-TC
$38.00
82489
$47.00
82489-26
$15.00
82489-TC
$32.00
82491
$58.00
82491-26
$17.00
82491-TC
$41.00
82492
$42.00
82492-26
$13.00
82492-TC
$28.00
82495
$48.00
82495-26
$16.00
82495-TC
$32.00
82507
$55.00
82507-26
$16.00
82507-TC
$39.00
82520
$26.00
82520-26
$8.00
82520-TC
$18.00
82523
$43.00
82523-26
$17.00
82523-TC
$25.00
82525
$34.00
82525-26
$10.00
82525-TC
$23.00
82528
$40.00
82528-26
$13.00
82528-TC
$26.00
82530
$38.00
82530-26
$12.00
82530-TC
$25.00
82533
$35.00
82533-26
$10.00
82533-TC
$24.00
82540
$10.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
82540-26
$3.00
82540-TC
$6.00
82541
$42.00
82541-26
$13.00
82541-TC
$28.00
82542
$42.00
82542-26
$13.00
82542-TC
$28.00
82543
$42.00
82543-26
$13.00
82543-TC
$28.00
82544
$42.00
82544-26
$13.00
82544-TC
$28.00
82550
$16.00
82550-26
$4.00
82550-TC
$12.00
82552
$33.00
82552-26
$10.00
82552-TC
$22.00
82553
$16.00
82553-26
$5.00
82553-TC
$11.00
82554
$19.00
82554-26
$6.00
82554-TC
$13.00
82565
$13.00
82565-26
$2.00
82565-TC
$11.00
82570
$10.00
82570-26
$2.00
82570-TC
$7.00
82575
$25.00
82575-26
$8.00
82575-TC
$17.00
82585
$15.00
82585-26
$3.00
82585-TC
$12.00
82595
$31.00
82595-26
$10.00
82595-TC
$21.00
82600
$40.00
82600-26
$12.00
82600-TC
$28.00
82607
$38.00
82607-26
$10.00
82607-TC
$27.00
82608
$40.00
82608-26
$13.00
82608-TC
$26.00
83
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
82646
$37.00
82646-26
$11.00
82646-TC
$25.00
82649
$43.00
82649-26
$17.00
82649-TC
$25.00
82651
$43.00
82651-26
$17.00
82651-TC
$25.00
82652
$89.00
82652-26
$25.00
82652-TC
$62.00
82654
$37.00
82654-26
$11.00
82654-TC
$25.00
82657
$42.00
82657-26
$13.00
82657-TC
$28.00
82658
$42.00
82658-26
$13.00
82658-TC
$28.00
82664
$40.00
82664-26
$13.00
82664-TC
$26.00
82666
$58.00
82666-26
$17.00
82666-TC
$41.00
82668
$45.00
82668-26
$14.00
82668-TC
$32.00
82670
$61.00
82670-26
$18.00
Pathology & Laboratory
CPT Code
MRA
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
82677-26
$17.00
82677-TC
$35.00
82679
$70.00
82679-26
$20.00
82679-TC
$48.00
82690
$53.00
82690-26
$21.00
82690-TC
$32.00
82693
$23.00
82693-26
$7.00
82693-TC
$16.00
82696
$57.00
82696-26
$19.00
82696-TC
$38.00
82705
$14.00
82705-26
$6.00
82705-TC
$9.00
82710
$42.00
82710-26
$13.00
82710-TC
$29.00
82715
$33.00
82715-26
$11.00
82715-TC
$21.00
82725
$28.00
82725-26
$8.00
82725-TC
$19.00
82726
$42.00
82726-26
$13.00
82726-TC
$28.00
82728
$24.00
82728-26
$7.00
82728-TC
$17.00
82735
$36.00
82735-26
$12.00
82735-TC
$23.00
82742
$42.00
82742-26
$13.00
82742-TC
$29.00
82746
$39.00
82746-26
$13.00
82746-TC
$25.00
82747
$29.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
82776
$14.00
82776-26
$3.00
82776-TC
$11.00
82784
$15.00
82784-26
$5.00
82784-TC
$11.00
82785
$33.00
82785-26
$11.00
82785-TC
$21.00
82787
$54.00
82787-26
$17.00
82787-TC
$37.00
82800
$22.00
82800-26
$6.00
82800-TC
$16.00
82803
$53.00
82803-26
$16.00
82803-TC
$37.00
82805
$36.00
82805-26
$10.00
82805-TC
$24.00
82810
$28.00
82810-26
$8.00
82810-TC
$19.00
82820
$16.00
82820-26
$5.00
82820-TC
$11.00
82926
$20.00
82926-26
$5.00
82926-TC
$15.00
82928
$12.00
82928-26
$4.00
82928-TC
$7.00
82938
$48.00
82938-26
$16.00
82938-TC
$32.00
84
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
82950-TC
$7.00
82951
$22.00
82951-26
$7.00
82951-TC
$15.00
82952
$11.00
82952-26
$3.00
82952-TC
$7.00
82953
$41.00
82953-26
$14.00
82953-TC
$26.00
82955
$25.00
82955-26
$7.00
82955-TC
$18.00
82960
$14.00
82960-26
$4.00
82960-TC
$10.00
82962
$5.00
82962-26
$1.00
82962-TC
$4.00
82963
$54.00
82963-26
$17.00
82963-TC
$37.00
82965
$16.00
82965-26
$5.00
82965-TC
$11.00
82975
$28.00
82975-26
$8.00
82975-TC
$19.00
82977
$16.00
82977-26
$4.00
Pathology & Laboratory
CPT Code
MRA
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
82980
$15.00
82980-26
$3.00
82980-TC
$11.00
82985
$41.00
82985-26
$12.00
82985-TC
$29.00
83001
$40.00
83001-26
$12.00
83001-TC
$28.00
83002
$42.00
83002-26
$13.00
83002-TC
$29.00
83003
$36.00
83003-26
$10.00
83003-TC
$25.00
83008
$34.00
83008-26
$10.00
83008-TC
$23.00
83010
$26.00
83010-26
$8.00
83010-TC
$18.00
83012
$36.00
83012-26
$14.00
83012-TC
$21.00
83013
$133.00
83013-26
$38.00
83013-TC
$94.00
83014
$19.00
83014-26
$6.00
83014-TC
$13.00
83015
$51.00
83015-26
$15.00
83015-TC
$36.00
83018
$56.00
83018-26
$16.00
83018-TC
$40.00
83020
$24.00
83020-26
$6.00
83020-TC
$18.00
83021
$39.00
83021-26
$13.00
83021-TC
$25.00
83026
$8.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
83055
$13.00
83055-26
$4.00
83055-TC
$8.00
83060
$22.00
83060-26
$6.00
83060-TC
$16.00
83065
$18.00
83065-26
$6.00
83065-TC
$12.00
83068
$20.00
83068-26
$5.00
83068-TC
$15.00
83069
$11.00
83069-26
$3.00
83069-TC
$7.00
83070
$13.00
83070-26
$4.00
83070-TC
$8.00
83071
$18.00
83071-26
$5.00
83071-TC
$13.00
83080
$38.00
83080-26
$11.00
83080-TC
$26.00
83088
$59.00
83088-26
$18.00
83088-TC
$41.00
83090
$38.00
83090-26
$13.00
83090-TC
$25.00
85
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
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
Pathology & Laboratory
CPT Code
MRA
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
83715
$21.00
83715-26
$5.00
83715-TC
$16.00
83716
$54.00
83716-26
$19.00
83716-TC
$35.00
83718
$16.00
83718-26
$5.00
83718-TC
$11.00
83719
$42.00
83719-26
$14.00
83719-TC
$28.00
83721
$16.00
83721-26
$5.00
83721-TC
$11.00
83727
$43.00
83727-26
$14.00
83727-TC
$29.00
83735
$15.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
83735-26
$5.00
83735-TC
$10.00
83775
$17.00
83775-26
$5.00
83775-TC
$12.00
83785
$58.00
83785-26
$17.00
83785-TC
$41.00
83788
$39.00
83788-26
$13.00
83788-TC
$25.00
83789
$39.00
83789-26
$13.00
83789-TC
$25.00
83805
$44.00
83805-26
$15.00
83805-TC
$29.00
83825
$34.00
83825-26
$11.00
83825-TC
$22.00
83835
$41.00
83835-26
$12.00
83835-TC
$29.00
83840
$42.00
83840-26
$14.00
83840-TC
$28.00
83857
$26.00
83857-26
$8.00
83857-TC
$18.00
83858
$37.00
83858-26
$12.00
83858-TC
$24.00
83864
$32.00
83864-26
$8.00
83864-TC
$22.00
83866
$26.00
83866-26
$7.00
83866-TC
$19.00
83872
$13.00
83872-26
$4.00
83872-TC
$8.00
83873
$54.00
83873-26
$18.00
83873-TC
$36.00
83874
$25.00
83874-26
$8.00
83874-TC
$17.00
83880
BR
83880-26
BR
83880-TC
BR
86
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
83883
$11.00
83883-26
$3.00
83883-TC
$7.00
83885
$45.00
83885-26
$14.00
83885-TC
$32.00
83887
$58.00
83887-26
$17.00
83887-TC
$41.00
83890
$7.00
83890-26
$2.00
83890-TC
$5.00
83891
$7.00
83891-26
$2.00
83891-TC
$5.00
83892
$7.00
83892-26
$2.00
83892-TC
$5.00
83893
$7.00
83893-26
$2.00
83893-TC
$5.00
83894
$7.00
83894-26
$2.00
83894-TC
$5.00
83896
$7.00
83896-26
$2.00
83896-TC
$5.00
83897
$9.00
83897-26
$3.00
83897-TC
$5.00
83898
$43.00
83898-26
$14.00
83898-TC
$29.00
83901
$44.00
83901-26
$14.00
83901-TC
$29.00
83902
$38.00
83902-26
$13.00
83902-TC
$24.00
83903
$44.00
83903-26
$14.00
83903-TC
$29.00
83904
$44.00
83904-26
$14.00
83904-TC
$29.00
83905
$44.00
83905-26
$14.00
83905-TC
$29.00
83906
$44.00
83906-26
$14.00
Pathology & Laboratory
CPT Code
MRA
83906-TC
$29.00
83912
$39.00
83912-26
$11.00
83912-TC
$28.00
83915
$31.00
83915-26
$10.00
83915-TC
$20.00
83916
$54.00
83916-26
$18.00
83916-TC
$36.00
83918
$41.00
83918-26
$12.00
83918-TC
$29.00
83919
$42.00
83919-26
$12.00
83919-TC
$29.00
83921
$37.00
83921-26
$12.00
83921-TC
$25.00
83925
$13.00
83925-26
$3.00
83925-TC
$9.00
83930
$11.00
83930-26
$3.00
83930-TC
$7.00
83935
$17.00
83935-26
$5.00
83935-TC
$12.00
83937
$29.00
83937-26
$10.00
83937-TC
$19.00
83945
$32.00
83945-26
$11.00
83945-TC
$20.00
83950
BR
83950-26
BR
83950-TC
BR
83970
$94.00
83970-26
$31.00
83970-TC
$62.00
83986
$8.00
83986-26
$3.00
83986-TC
$5.00
83992
$40.00
83992-26
$12.00
83992-TC
$28.00
84022
$41.00
84022-26
$13.00
84022-TC
$28.00
84030
$11.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
87
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
84126
$71.00
84126-26
$20.00
84126-TC
$49.00
84127
$18.00
84127-26
$6.00
84127-TC
$12.00
84132
$11.00
84132-26
$3.00
84132-TC
$7.00
84133
$11.00
84133-26
$3.00
84133-TC
$7.00
84134
$24.00
84134-26
$7.00
84134-TC
$17.00
84135
$57.00
84135-26
$19.00
84135-TC
$38.00
84138
$56.00
84138-26
$18.00
84138-TC
$38.00
84140
$41.00
84140-26
$8.00
84140-TC
$33.00
84143
$62.00
84143-26
$20.00
84143-TC
$41.00
84144
$38.00
84144-26
$7.00
84144-TC
$31.00
84146
$53.00
84146-26
$17.00
84146-TC
$36.00
84150
$69.00
84150-26
$20.00
84150-TC
$47.00
84152
$42.00
84152-26
$14.00
84152-TC
$27.00
84153
$33.00
84153-26
$11.00
84153-TC
$21.00
84154
$33.00
84154-26
$11.00
84154-TC
$21.00
84155
$12.00
84155-26
$4.00
84155-TC
$7.00
84160
$5.00
84160-26
$2.00
Pathology & Laboratory
CPT Code
MRA
84160-TC
$2.00
84165
$24.00
84165-26
$8.00
84165-TC
$16.00
84181
$29.00
84181-26
$10.00
84181-TC
$19.00
84182
$33.00
84182-26
$11.00
84182-TC
$21.00
84202
$39.00
84202-26
$13.00
84202-TC
$25.00
84203
$16.00
84203-26
$5.00
84203-TC
$11.00
84206
$32.00
84206-26
$10.00
84206-TC
$21.00
84207
$54.00
84207-26
$16.00
84207-TC
$38.00
84210
$24.00
84210-26
$10.00
84210-TC
$15.00
84220
$25.00
84220-26
$8.00
84220-TC
$17.00
84228
$32.00
84228-26
$10.00
84228-TC
$21.00
84233
$116.00
84233-26
$35.00
84233-TC
$81.00
84234
$116.00
84234-26
$35.00
84234-TC
$81.00
84235
$114.00
84235-26
$34.00
84235-TC
$80.00
84238
$97.00
84238-26
$32.00
84238-TC
$65.00
84244
$47.00
84244-26
$15.00
84244-TC
$32.00
84252
$47.00
84252-26
$14.00
84252-TC
$33.00
84255
$58.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
88
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
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
Pathology & Laboratory
CPT Code
MRA
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
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
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
89
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
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
Pathology & Laboratory
CPT Code
MRA
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
85060-26
$7.00
85060-TC
$18.00
85097
$59.00
85097-26
$59.00
85097-TC
BR
85130
$19.00
85130-26
$6.00
85130-TC
$13.00
85170
$7.00
85170-26
$2.00
85170-TC
$5.00
85175
$10.00
85175-26
$3.00
85175-TC
$6.00
85210
$31.00
85210-26
$8.00
85210-TC
$21.00
85220
$47.00
85220-26
$15.00
85220-TC
$32.00
85230
$47.00
85230-26
$14.00
85230-TC
$33.00
85240
$48.00
85240-26
$15.00
85240-TC
$33.00
85244
$49.00
85244-26
$15.00
85244-TC
$34.00
85245
$54.00
85245-26
$18.00
85245-TC
$36.00
85246
$54.00
85246-26
$18.00
85246-TC
$36.00
85247
$54.00
85247-26
$18.00
85247-TC
$36.00
85250
$49.00
85250-26
$14.00
85250-TC
$35.00
85260
$49.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
90
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
85366-26
$3.00
85366-TC
$10.00
85370
$20.00
85370-26
$5.00
85370-TC
$15.00
85378
$13.00
85378-26
$4.00
85378-TC
$8.00
85379
$18.00
85379-26
$6.00
85379-TC
$12.00
85380
BR
85380-26
BR
85380-TC
BR
85384
$11.00
85384-26
$3.00
85384-TC
$7.00
85385
$16.00
85385-26
$5.00
85385-TC
$11.00
85390
$10.00
85390-26
$2.00
85390-TC
$7.00
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
Pathology & Laboratory
CPT Code
MRA
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
85461-TC
$8.00
85475
$15.00
85475-26
$4.00
85475-TC
$11.00
85520
$22.00
85520-26
$6.00
85520-TC
$16.00
85525
$20.00
85525-26
$6.00
85525-TC
$14.00
85530
$39.00
85530-26
$12.00
85530-TC
$26.00
85536
$14.00
85536-26
$4.00
85536-TC
$10.00
85540
$24.00
85540-26
$7.00
85540-TC
$17.00
85547
$23.00
85547-26
$6.00
85547-TC
$17.00
85549
$45.00
85549-26
$15.00
85549-TC
$31.00
85555
$17.00
85555-26
$5.00
85555-TC
$12.00
85557
$34.00
85557-26
$10.00
85557-TC
$23.00
85576
$21.00
85576-26
$5.00
85576-TC
$16.00
85597
$32.00
85597-26
$10.00
85597-TC
$21.00
85610
$6.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
91
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
86023
$28.00
86023-26
$10.00
86023-TC
$18.00
86038
$22.00
86038-26
$7.00
86038-TC
$15.00
86039
$19.00
86039-26
$6.00
86039-TC
$13.00
86060
$13.00
86060-26
$3.00
86060-TC
$10.00
86063
$21.00
86063-26
$6.00
86063-TC
$15.00
86077
$91.00
86077-26
$26.00
86077-TC
$64.00
86078
$91.00
86078-26
$26.00
86078-TC
$64.00
86079
$79.00
86079-26
$25.00
86079-TC
$52.00
86140
$14.00
86140-26
$4.00
86140-TC
$10.00
86141
BR
86141-26
BR
86141-TC
BR
86146
$58.00
86146-26
$19.00
86146-TC
$39.00
86147
$53.00
86147-26
$16.00
86147-TC
$36.00
86148
$59.00
86148-26
$21.00
Pathology & Laboratory
CPT Code
MRA
86148-TC
$38.00
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
86160-26
$5.00
86160-TC
$16.00
86161
$21.00
86161-26
$5.00
86161-TC
$16.00
86162
$54.00
86162-26
$18.00
86162-TC
$36.00
86171
$25.00
86171-26
$7.00
86171-TC
$18.00
86185
$19.00
86185-26
$6.00
86185-TC
$13.00
86215
$36.00
86215-26
$12.00
86215-TC
$23.00
86225
$36.00
86225-26
$11.00
86225-TC
$24.00
86226
$24.00
86226-26
$8.00
86226-TC
$16.00
86235
$33.00
86235-26
$10.00
86235-TC
$22.00
86243
$50.00
86243-26
$15.00
86243-TC
$35.00
86255
$25.00
86255-26
$8.00
86255-TC
$17.00
86256
$25.00
86256-26
$8.00
86256-TC
$17.00
86277
$41.00
86277-26
$14.00
86277-TC
$26.00
86280
$15.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
86304
$47.00
86304-26
$15.00
86304-TC
$32.00
86308
$8.00
86308-26
$3.00
86308-TC
$5.00
86309
$12.00
86309-26
$3.00
86309-TC
$8.00
86310
$19.00
86310-26
$6.00
86310-TC
$13.00
86316
$37.00
86316-26
$11.00
86316-TC
$25.00
86317
$31.00
86317-26
$10.00
86317-TC
$20.00
86318
$23.00
86318-26
$10.00
86318-TC
$14.00
86320
$49.00
86320-26
$19.00
86320-TC
$29.00
86325
$49.00
86325-26
$16.00
86325-TC
$33.00
86327
$62.00
86327-26
$19.00
86327-TC
$42.00
86329
$37.00
86329-26
$12.00
86329-TC
$24.00
86331
$22.00
86331-26
$6.00
86331-TC
$15.00
86332
$54.00
86332-26
$18.00
86332-TC
$36.00
92
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
86334
$65.00
86334-26
$18.00
86334-TC
$45.00
86336
BR
86336-26
BR
86336-TC
BR
86337
$54.00
86337-26
$18.00
86337-TC
$36.00
86340
$39.00
86340-26
$13.00
86340-TC
$25.00
86341
$38.00
86341-26
$13.00
86341-TC
$24.00
86343
$33.00
86343-26
$11.00
86343-TC
$21.00
86344
$21.00
86344-26
$7.00
86344-TC
$14.00
86353
$102.00
86353-26
$31.00
86353-TC
$72.00
86359
$61.00
86359-26
$19.00
86359-TC
$41.00
86360
$99.00
86360-26
$33.00
86360-TC
$67.00
86361
$66.00
86361-26
$21.00
86361-TC
$43.00
86376
$35.00
86376-26
$11.00
86376-TC
$23.00
86378
$45.00
86378-26
$15.00
86378-TC
$31.00
86382
$45.00
86382-26
$14.00
86382-TC
$32.00
86384
$24.00
86384-26
$8.00
86384-TC
$16.00
86403
$18.00
86403-26
$3.00
86403-TC
$14.00
86406
$21.00
86406-26
$5.00
Pathology & Laboratory
CPT Code
MRA
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
86485-26
$4.00
86485-TC
$8.00
86490
$17.00
86490-26
$5.00
86490-TC
$12.00
86510
$13.00
86510-26
$4.00
86510-TC
$8.00
86580
$13.00
86580-26
$4.00
86580-TC
$8.00
86585
$10.00
86585-26
$3.00
86585-TC
$6.00
86586
BR
86586-26
BR
86586-TC
BR
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
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
93
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
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
Pathology & Laboratory
CPT Code
MRA
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
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
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
94
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
86777-26
$7.00
86777-TC
$15.00
86778
$23.00
86778-26
$7.00
86778-TC
$16.00
86781
$22.00
86781-26
$7.00
86781-TC
$15.00
86784
$21.00
86784-26
$7.00
86784-TC
$14.00
86787
$20.00
86787-26
$6.00
86787-TC
$14.00
86790
$21.00
86790-26
$7.00
86790-TC
$14.00
86793
$21.00
86793-26
$7.00
86793-TC
$14.00
86800
$26.00
86800-26
$8.00
86800-TC
$18.00
86803
$24.00
86803-26
$8.00
86803-TC
$16.00
86804
$26.00
86804-26
$8.00
86804-TC
$18.00
86805
$97.00
86805-26
$33.00
86805-TC
$64.00
86806
$87.00
86806-26
$28.00
86806-TC
$57.00
86807
$74.00
86807-26
$21.00
Pathology & Laboratory
CPT Code
MRA
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
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
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
86900-26
$3.00
86900-TC
$6.00
86901
$10.00
86901-26
$3.00
86901-TC
$6.00
86903
$15.00
86903-26
$5.00
86903-TC
$10.00
86904
$19.00
86904-26
$6.00
86904-TC
$13.00
86905
$7.00
86905-26
$1.00
86905-TC
$6.00
86906
$11.00
86906-26
$3.00
86906-TC
$7.00
86910
$83.00
86910-26
$24.00
86910-TC
$57.00
86911
$19.00
86911-26
$6.00
86911-TC
$13.00
86920
$19.00
86920-26
$3.00
86920-TC
$15.00
86921
$23.00
86921-26
$7.00
86921-TC
$16.00
86922
$20.00
86922-26
$6.00
86922-TC
$14.00
86927
$21.00
86927-26
$5.00
86927-TC
$16.00
86930
$155.00
86930-26
$45.00
86930-TC
$108.00
86931
$155.00
86931-26
$45.00
86931-TC
$108.00
86932
$161.00
86932-26
$48.00
86932-TC
$111.00
86940
$18.00
86940-26
$5.00
86940-TC
$13.00
86941
$31.00
86941-26
$8.00
86941-TC
$21.00
95
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
86975-26
$16.00
86975-TC
$37.00
86976
$53.00
86976-26
$16.00
86976-TC
$37.00
86977
$53.00
86977-26
$16.00
86977-TC
$37.00
86978
$65.00
86978-26
$19.00
86978-TC
$44.00
86985
$35.00
86985-26
$12.00
86985-TC
$23.00
86999
BR
86999-26
BR
86999-TC
BR
87001
$35.00
87001-26
$11.00
87001-TC
$23.00
87003
$40.00
87003-26
$13.00
87003-TC
$26.00
87015
$14.00
87015-26
$5.00
87015-TC
$9.00
87040
$18.00
87040-26
$6.00
87040-TC
$12.00
87045
$18.00
87045-26
$6.00
Pathology & Laboratory
CPT Code
MRA
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
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
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
87149-TC
$31.00
87152
$12.00
87152-26
$4.00
87152-TC
$8.00
87158
$5.00
87158-26
$1.00
87158-TC
$3.00
87164
$24.00
87164-26
$8.00
87164-TC
$16.00
87166
$24.00
87166-26
$7.00
87166-TC
$17.00
87168
$10.00
87168-26
$3.00
87168-TC
$7.00
87169
$10.00
87169-26
$3.00
87169-TC
$7.00
87172
$10.00
87172-26
$3.00
87172-TC
$7.00
87176
$16.00
87176-26
$5.00
87176-TC
$11.00
87177
$18.00
87177-26
$6.00
87177-TC
$12.00
96
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
87197-26
$10.00
87197-TC
$19.00
87205
$11.00
87205-26
$3.00
87205-TC
$7.00
87206
$15.00
87206-26
$3.00
87206-TC
$12.00
87207
$10.00
87207-26
$3.00
87207-TC
$6.00
87210
$8.00
87210-26
$2.00
87210-TC
$6.00
87220
$12.00
87220-26
$4.00
87220-TC
$7.00
87230
$35.00
87230-26
$11.00
87230-TC
$23.00
87250
$33.00
87250-26
$13.00
87250-TC
$19.00
87252
$44.00
87252-26
$14.00
87252-TC
$31.00
87253
$33.00
87253-26
$10.00
Pathology & Laboratory
CPT Code
MRA
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
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
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
97
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
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
Pathology & Laboratory
CPT Code
MRA
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
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
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
98
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
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
Pathology & Laboratory
CPT Code
MRA
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
87592
$88.00
87592-26
$28.00
87592-TC
$58.00
87620
$42.00
87620-26
$13.00
87620-TC
$28.00
87621
$73.00
87621-26
$23.00
87621-TC
$48.00
87622
$86.00
87622-26
$28.00
87622-TC
$56.00
87650
$42.00
87650-26
$13.00
87650-TC
$28.00
87651
$73.00
87651-26
$23.00
87651-TC
$48.00
87652
$86.00
87652-26
$28.00
87652-TC
$56.00
87797
$42.00
87797-26
$13.00
87797-TC
$28.00
87798
$73.00
87798-26
$23.00
87798-TC
$48.00
87799
$88.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
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
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
99
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
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
88104-26
$37.00
88104-TC
$10.00
88106
$54.00
88106-26
$16.00
88106-TC
$38.00
88107
$74.00
88107-26
$57.00
88107-TC
$15.00
88108
$59.00
88108-26
$47.00
88108-TC
$11.00
88125
$70.00
88125-26
$20.00
88125-TC
$48.00
88130
$25.00
88130-26
$7.00
88130-TC
$18.00
88140
$18.00
88140-26
$5.00
88140-TC
$13.00
88141
$33.00
88141-26
NC
Pathology & Laboratory
CPT Code
MRA
88141-TC
NC
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
88147-TC
$82.00
88148
$104.00
88148-26
$21.00
88148-TC
$82.00
88150
$13.00
88150-26
$3.00
88150-TC
$9.00
88152
$46.00
88152-26
$8.00
88152-TC
$38.00
88153
$82.00
88153-26
$21.00
88153-TC
$59.00
88154
$104.00
88154-26
$21.00
88154-TC
$82.00
88155
$14.00
88155-26
$3.00
88155-TC
$10.00
88160
$45.00
88160-26
$14.00
88160-TC
$24.00
88161
$64.00
88161-26
$19.00
88161-TC
$37.00
88162
$77.00
88162-26
$22.00
88162-TC
$53.00
88164
$54.00
88164-26
$21.00
88164-TC
$33.00
88165
$72.00
88165-26
$33.00
88165-TC
$38.00
88166
$82.00
88166-26
$21.00
88166-TC
$59.00
88167
$87.00
88167-26
$26.00
88167-TC
$59.00
88172
$70.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
88172-26
$54.00
88172-TC
$14.00
88173
$95.00
88173-26
$95.00
88173-TC
$26.00
88174
BR
88174-26
BR
88174-TC
BR
88175
BR
88175-26
BR
88175-TC
BR
88180
$88.00
88180-26
$33.00
88180-TC
$54.00
88182
$88.00
88182-26
$33.00
88182-TC
$54.00
88199
BR
88199-26
BR
88199-TC
BR
88233
$243.00
88233-26
$73.00
88233-TC
$170.00
88235
$256.00
88235-26
$76.00
88235-TC
$177.00
88240
$21.00
88240-26
$6.00
88240-TC
$15.00
88241
$21.00
88241-26
$6.00
88241-TC
$15.00
88300
$24.00
88300-26
$19.00
88300-TC
$5.00
88302
$53.00
88302-26
$42.00
88302-TC
$11.00
88304
$70.00
88304-26
$54.00
88304-TC
$14.00
88305
$108.00
88305-26
$86.00
88305-TC
$21.00
88307
$210.00
88307-26
$168.00
88307-TC
$41.00
88309
$322.00
88309-26
$258.00
88309-TC
$64.00
100
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology & Laboratory
CPT Code
MRA
88311
$23.00
88311-26
$19.00
88311-TC
$4.00
88312
$23.00
88312-26
$7.00
88312-TC
$16.00
88313
$23.00
88313-26
$7.00
88313-TC
$16.00
88314
$21.00
88314-26
$6.00
88314-TC
$15.00
88318
$33.00
88318-26
$14.00
88318-TC
$18.00
88319
$26.00
88319-26
$13.00
88319-TC
$14.00
88321
$43.00
88321-26
$43.00
88321-TC
NC
88323
$61.00
88323-26
$61.00
88323-TC
NC
88325
$54.00
88325-26
$54.00
88325-TC
NC
88329
$51.00
88329-26
$51.00
88329-TC
NC
88331
$102.00
88331-26
$70.00
88331-TC
$33.00
88332
$53.00
88332-26
$36.00
88332-TC
$17.00
88342
$53.00
88342-26
$36.00
88342-TC
$17.00
88346
$96.00
88346-26
$66.00
88346-TC
$28.00
88347
$133.00
88347-26
$99.00
88347-TC
$33.00
88348
$191.00
88348-26
$145.00
88348-TC
$44.00
88349
$191.00
88349-26
$145.00
Pathology & Laboratory
CPT Code
MRA
88349-TC
$44.00
88355
$108.00
88355-26
$80.00
88355-TC
$26.00
88356
$108.00
88356-26
$80.00
88356-TC
$26.00
88358
$108.00
88358-26
$80.00
88358-TC
$26.00
88362
BR
88362-26
BR
88362-TC
BR
88365
$24.00
88365-26
$24.00
88365-TC
BR
88371
$34.00
88371-26
$10.00
88371-TC
$23.00
88372
$38.00
88372-26
$11.00
88372-TC
$26.00
88380
BR
88380-26
BR
88380-TC
BR
88399
BR
88399-26
BR
88399-TC
BR
88400
$5.00
88400-26
$2.00
88400-TC
$3.00
89050
$10.00
89050-26
$3.00
89050-TC
$6.00
89051
$13.00
89051-26
$4.00
89051-TC
$8.00
89055
BR
89055-26
BR
89055-TC
BR
89060
$13.00
89060-26
$5.00
89060-TC
$8.00
89100
$51.00
89100-26
$15.00
89100-TC
$36.00
89105
$65.00
89105-26
$19.00
89105-TC
$44.00
89125
$14.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Pathology & Laboratory
CPT Code
MRA
89125-26
$4.00
89125-TC
$10.00
89130
$44.00
89130-26
$13.00
89130-TC
$32.00
89132
$20.00
89132-26
$6.00
89132-TC
$14.00
89135
$37.00
89135-26
$11.00
89135-TC
$25.00
89136
$43.00
89136-26
$14.00
89136-TC
$29.00
89140
$50.00
89140-26
$16.00
89140-TC
$34.00
89141
$56.00
89141-26
$19.00
89141-TC
$37.00
89160
$6.00
89160-26
$2.00
89160-TC
$4.00
89190
$10.00
89190-26
$3.00
89190-TC
$6.00
89350
$18.00
89350-26
$6.00
89350-TC
$12.00
89355
$10.00
89355-26
$3.00
89355-TC
$6.00
89360
$15.00
89360-26
$4.00
89360-TC
$11.00
89365
$24.00
89365-26
$7.00
89365-TC
$17.00
89399
BR
89399-26
BR
89399-TC
BR
101
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
90471
90472
90473
90474
90632
90636
90675
90703
90718
90746
90749
90780
90781
90782
90783
90784
90788
90799
90801
90802
90804
90805
90806
90807
90808
90809
90810
90811
90812
90813
90814
90815
90816
90817
90818
90819
90821
90822
90823
90824
90826
90827
90828
90829
90845
90846
90847
90849
90853
90857
MRA
$4.00
$4.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
$42.00
$20.00
$5.00
$15.00
$20.00
$6.00
BR
$140.00
$143.00
$62.00
$68.00
$94.00
$101.00
$144.00
$149.00
$69.00
$77.00
$101.00
$107.00
$143.00
$149.00
$64.00
$70.00
$96.00
$102.00
$144.00
$149.00
$73.00
$78.00
$103.00
$107.00
$146.00
$150.00
$85.00
$93.00
$110.00
$32.00
$32.00
$31.00
Medicine
CPT Code
90862
90865
90870
90871
90875
90876
90880
90882
90885
90887
90889
90899
90901
90911
90921
90925
90935
90937
90939
90940
90945
90947
90997
90999
91000
91000-26
91000-TC
91010
91010-26
91010-TC
91011
91011-26
91011-TC
91012
91012-26
91012-TC
91020
91020-26
91020-TC
91030
91030-26
91030-TC
91032
91032-26
91032-TC
91033
91033-26
91033-TC
91052
91052-26
MRA
$50.00
$143.00
$94.00
$135.00
$74.00
$112.00
$112.00
$104.00
$49.00
$77.00
BR
BR
$46.00
$82.00
$259.00
$8.00
$76.00
$226.00
BR
BR
$80.00
$125.00
$115.00
BR
$43.00
$40.00
$2.00
$116.00
$76.00
$32.00
$141.00
$89.00
$39.00
$143.00
$95.00
$45.00
$60.00
$49.00
$9.00
$57.00
$47.00
$8.00
$108.00
$71.00
$30.00
$141.00
$82.00
$53.00
$67.00
$52.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Medicine
CPT Code
91052-TC
91055
91055-26
91055-TC
91060
91060-26
91060-TC
91065
91065-26
91065-TC
91100
91105
91122
91122-26
91122-TC
91123
91132
91132-26
91132-TC
91133
91133-26
91133-TC
91299
91299-26
91299-TC
92002
92004
92012
92014
92015
92018
92019
92020
92060
92060-26
92060-TC
92065
92065-26
92065-TC
92070
92081
92081-26
92081-TC
92082
92082-26
92082-TC
92083
92083-26
92083-TC
92100
MRA
$12.00
$63.00
$46.00
$11.00
$35.00
$27.00
$8.00
$34.00
$23.00
$14.00
$57.00
$35.00
$169.00
$122.00
$37.00
BR
BR
$28.00
BR
BR
$34.00
BR
BR
BR
BR
$63.00
$98.00
$53.00
$75.00
$34.00
$80.00
$70.00
$31.00
$40.00
$32.00
$7.00
$34.00
$19.00
$6.00
$66.00
$32.00
$19.00
$6.00
$48.00
$24.00
$9.00
$59.00
$31.00
$14.00
$40.00
102
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
92120
92130
92135
92135-26
92135-TC
92136
92136-26
92136-TC
92140
92225
92226
92230
92235
92235-26
92235-TC
92240
92240-26
92240-TC
92250
92250-26
92250-TC
92260
92265
92265-26
92265-TC
92270
92270-26
92270-TC
92275
92275-26
92275-TC
92283
92283-26
92283-TC
92284
92284-26
92284-TC
92285
92285-26
92285-TC
92286
92286-26
92286-TC
92287
92310
92311
92312
92313
92314
92315
MRA
$32.00
$56.00
$69.00
$18.00
$49.00
$93.00
$29.00
$63.00
$38.00
$45.00
$39.00
$58.00
$104.00
$46.00
$53.00
$132.00
$60.00
$67.00
$40.00
$24.00
$7.00
$20.00
$53.00
$37.00
$10.00
$64.00
$45.00
$19.00
$80.00
$56.00
$17.00
$24.00
$10.00
$5.00
$192.00
$151.00
$46.00
$26.00
$12.00
$6.00
$91.00
$53.00
$29.00
$99.00
$86.00
$78.00
$89.00
$70.00
$54.00
$44.00
Medicine
CPT Code
92316
92317
92325
92326
92330
92335
92340
92341
92342
92352
92353
92354
92355
92358
92370
92371
92390
92391
92392
92393
92395
92396
92499
92499-26
92499-TC
92502
92504
92506
92507
92508
92510
92511
92512
92516
92520
92526
92531
92532
92533
92534
92541
92541-26
92541-TC
92542
92542-26
92542-TC
92543
92543-26
92543-TC
92544
MRA
$59.00
$39.00
$14.00
$44.00
$79.00
$65.00
$32.00
$43.00
$43.00
$31.00
$38.00
$221.00
$107.00
$24.00
$35.00
$18.00
$61.00
$83.00
$84.00
$264.00
$35.00
$52.00
BR
BR
BR
$101.00
$24.00
$63.00
$40.00
$42.00
$114.00
$81.00
$46.00
$36.00
$47.00
$48.00
$10.00
$14.00
$41.00
BR
$37.00
$25.00
$9.00
$33.00
$20.00
$10.00
$28.00
$19.00
$10.00
$26.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Medicine
CPT Code
92544-26
92544-TC
92545
92545-26
92545-TC
92546
92546-26
92546-TC
92547
92548
92548-26
92548-TC
92551
92552
92553
92555
92556
92557
92560
92561
92562
92563
92564
92565
92567
92568
92569
92571
92572
92573
92575
92576
92577
92579
92582
92583
92584
92585
92585-26
92585-TC
92586
92587
92587-26
92587-TC
92588
92588-26
92588-TC
92589
92590
92591
MRA
$16.00
$8.00
$22.00
$14.00
$8.00
$29.00
$17.00
$9.00
$21.00
$92.00
$30.00
$59.00
$17.00
$16.00
$24.00
$14.00
$21.00
$46.00
$23.00
$27.00
$15.00
$14.00
$17.00
$15.00
$20.00
$14.00
$15.00
$14.00
$3.00
$13.00
$11.00
$17.00
$28.00
$28.00
$28.00
$34.00
$94.00
$114.00
$52.00
$70.00
$70.00
$58.00
$8.00
$49.00
$78.00
$20.00
$57.00
$54.00
$41.00
BR
103
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
92592
92593
92594
92595
92596
92597
92603
92604
92605
92606
92607
92608
92609
92610
92611
92612
92613
92614
92615
92616
92617
92700
92950
92953
92960
92961
92970
92971
92973
92974
92975
92977
92978
92978-26
92978-TC
92979
92979-26
92979-TC
92980
92981
92982
92984
92986
92987
92990
92992
92993
92995
92996
92997
MRA
BR
BR
BR
BR
$22.00
$96.00
$88.00
$60.00
BR
BR
$109.00
$22.00
$59.00
$42.00
$46.00
$173.00
BR
$134.00
BR
$183.00
BR
BR
$203.00
$35.00
$162.00
$239.00
$201.00
$100.00
$174.00
$197.00
$400.00
$302.00
$269.00
$95.00
$170.00
$163.00
$76.00
$86.00
$952.00
$268.00
$705.00
$191.00
$1,222.00
$1,271.00
$974.00
BR
BR
$776.00
$210.00
$765.00
Medicine
CPT Code
92998
93000
93005
93010
93012
93014
93015
93016
93017
93018
93024
93024-26
93024-TC
93025
93040
93041
93042
93224
93225
93226
93227
93230
93231
93232
93233
93235
93236
93237
93268
93270
93271
93272
93278
93278-26
93278-TC
93303
93303-26
93303-TC
93304
93304-26
93304-TC
93307
93307-26
93307-TC
93308
93308-26
93308-TC
93312
93312-26
93312-TC
MRA
$331.00
$26.00
$16.00
$12.00
$90.00
$28.00
$104.00
$25.00
$63.00
$54.00
$111.00
$71.00
$42.00
$277.00
$14.00
$31.00
$9.00
$159.00
$46.00
$83.00
$50.00
$168.00
$57.00
$82.00
$55.00
$123.00
$97.00
$28.00
$109.00
$46.00
$90.00
$28.00
$58.00
$24.00
$44.00
$215.00
$70.00
$144.00
$114.00
$43.00
$73.00
$196.00
$56.00
$144.00
$118.00
$46.00
$75.00
$322.00
$140.00
$182.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Medicine
CPT Code
93313
93314
93314-26
93314-TC
93315
93315-26
93315-TC
93316
93317
93317-26
93317-TC
93318
93318-26
93318-TC
93320
93320-26
93320-TC
93321
93321-26
93321-TC
93325
93325-26
93325-TC
93350
93350-26
93350-TC
93501
93501-26
93501-TC
93503
93505
93505-26
93505-TC
93508
93508-26
93508-TC
93510
93510-26
93510-TC
93511
93511-26
93511-TC
93514
93514-26
93514-TC
93524
93524-26
93524-TC
93526
93526-26
MRA
$76.00
$212.00
$65.00
$144.00
$287.00
$144.00
$141.00
$78.00
$236.00
$95.00
$141.00
BR
$114.00
BR
$86.00
$30.00
$65.00
$50.00
$10.00
$42.00
$114.00
$4.00
$110.00
$216.00
$77.00
$66.00
$674.00
$160.00
$634.00
$187.00
$318.00
$248.00
$74.00
$698.00
$232.00
$469.00
$1,628.00
$247.00
$1,388.00
$1,629.00
$270.00
$1,350.00
$2,208.00
$525.00
$1,683.00
$2,150.00
$392.00
$1,766.00
$2,147.00
$363.00
104
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
93526-TC
93527
93527-26
93527-TC
93528
93528-26
93528-TC
93529
93529-26
93529-TC
93530
93530-26
93530-TC
93531
93531-26
93531-TC
93532
93532-26
93532-TC
93533
93533-26
93533-TC
93539
93540
93541
93542
93543
93544
93545
93555
93555-26
93555-TC
93556
93556-26
93556-TC
93561
93561-26
93561-TC
93562
93562-26
93562-TC
93571
93571-26
93571-TC
93572
93572-26
93572-TC
93580
93580-26
93580-TC
MRA
$1,815.00
$2,186.00
$451.00
$1,766.00
$2,266.00
$482.00
$1,766.00
$2,032.00
$262.00
$1,766.00
$872.00
$250.00
$634.00
$2,268.00
$467.00
$1,815.00
$2,317.00
$569.00
$1,766.00
$2,131.00
$352.00
$1,766.00
$45.00
$49.00
$38.00
$38.00
$213.00
$30.00
$240.00
$278.00
$42.00
$234.00
$414.00
$44.00
$368.00
$59.00
$47.00
$20.00
$46.00
$33.00
$13.00
$270.00
$93.00
$170.00
$222.00
$74.00
$155.00
$974.00
BR
BR
Medicine
CPT Code
93581
93581-26
93581-TC
93600
93600-26
93600-TC
93602
93602-26
93602-TC
93603
93603-26
93603-TC
93609
93609-26
93609-TC
93610
93610-26
93610-TC
93612
93612-26
93612-TC
93613
93613-26
93613-TC
93615
93615-26
93615-TC
93616
93616-26
93616-TC
93618
93618-26
93618-TC
93619
93619-26
93619-TC
93620
93620-26
93620-TC
93621
93621-26
93621-TC
93622
93622-26
93622-TC
93623
93623-26
93623-TC
93624
93624-26
MRA
$1,303.00
BR
BR
$198.00
$129.00
$73.00
$159.00
$119.00
$42.00
$187.00
$127.00
$63.00
$578.00
$481.00
$101.00
$214.00
$166.00
$52.00
$224.00
$167.00
$61.00
$377.00
$378.00
BR
$62.00
$49.00
$12.00
$94.00
$82.00
$12.00
$399.00
$258.00
$148.00
$717.00
$444.00
$290.00
$358.00
$272.00
$91.00
BR
$769.00
BR
BR
$771.00
BR
BR
$167.00
BR
$333.00
$256.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Medicine
CPT Code
93624-TC
93631
93631-26
93631-TC
93640
93640-26
93640-TC
93641
93641-26
93641-TC
93642
93642-26
93642-TC
93650
93651
93652
93660
93660-26
93660-TC
93662
93662-26
93662-TC
93668
93701
93701-26
93701-TC
93720
93721
93722
93724
93724-26
93724-TC
93727
93731
93731-26
93731-TC
93732
93732-26
93732-TC
93733
93733-26
93733-TC
93734
93734-26
93734-TC
93735
93735-26
93735-TC
93736
93736-26
MRA
$74.00
$651.00
$420.00
$239.00
$467.00
$230.00
$269.00
$613.00
$360.00
$269.00
$549.00
$295.00
$269.00
$639.00
$985.00
$1,044.00
$162.00
$103.00
$61.00
BR
$158.00
BR
BR
$36.00
$9.00
$27.00
$43.00
$27.00
$24.00
$411.00
$259.00
$148.00
$28.00
$43.00
$24.00
$18.00
$68.00
$48.00
$19.00
$38.00
$11.00
$28.00
$34.00
$21.00
$13.00
$30.00
$20.00
$7.00
$33.00
$10.00
105
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
93736-TC
93740
93740-26
93740-TC
93741
93741-26
93741-TC
93742
93742-26
93742-TC
93743
93743-26
93743-TC
93744
93744-26
93744-TC
93760
93762
93770
93770-26
93770-TC
93784
93786
93788
93790
93797
93798
93799
93799-26
93799-TC
93875
93875-26
93875-TC
93880
93880-26
93880-TC
93882
93882-26
93882-TC
93886
93886-26
93886-TC
93888
93888-26
93888-TC
93922
93922-26
93922-TC
93923
93923-26
MRA
$24.00
$17.00
$12.00
$5.00
$68.00
$33.00
$32.00
$77.00
$37.00
$43.00
$78.00
$43.00
$32.00
$88.00
$48.00
$43.00
$314.00
$378.00
NC
NC
NC
NC
NC
NC
NC
$17.00
$38.00
BR
BR
BR
$55.00
$17.00
$42.00
$176.00
$31.00
$144.00
$117.00
$21.00
$95.00
$215.00
$50.00
$162.00
$142.00
$33.00
$109.00
$60.00
$16.00
$44.00
$112.00
$28.00
Medicine
CPT Code
93923-TC
93924
93924-26
93924-TC
93925
93925-26
93925-TC
93926
93926-26
93926-TC
93930
93930-26
93930-TC
93931
93931-26
93931-TC
93965
93965-26
93965-TC
93970
93970-26
93970-TC
93971
93971-26
93971-TC
93975
93975-26
93975-TC
93976
93976-26
93976-TC
93978
93978-26
93978-TC
93979
93979-26
93979-TC
93980
93980-26
93980-TC
93981
93981-26
93981-TC
93990
93990-26
93990-TC
94010
94010-26
94010-TC
94014
MRA
$85.00
$122.00
$31.00
$92.00
$175.00
$31.00
$144.00
$117.00
$21.00
$96.00
$174.00
$26.00
$150.00
$118.00
$17.00
$101.00
$63.00
$26.00
$42.00
$189.00
$36.00
$154.00
$121.00
$23.00
$96.00
$277.00
$89.00
$181.00
$184.00
$59.00
$121.00
$177.00
$34.00
$143.00
$122.00
$23.00
$98.00
$183.00
$65.00
$105.00
$148.00
$25.00
$124.00
$110.00
$14.00
$96.00
$30.00
$12.00
$16.00
$39.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Medicine
CPT Code
94015
94016
94060
94060-26
94060-TC
94070
94070-26
94070-TC
94150
94150-26
94150-TC
94200
94200-26
94200-TC
94240
94240-26
94240-TC
94250
94250-26
94250-TC
94260
94260-26
94260-TC
94350
94350-26
94350-TC
94360
94360-26
94360-TC
94370
94370-26
94370-TC
94375
94375-26
94375-TC
94400
94400-26
94400-TC
94450
94450-26
94450-TC
94620
94620-26
94620-TC
94621
94621-26
94621-TC
94640
94642
94656
MRA
$14.00
$26.00
$57.00
$18.00
$36.00
$32.00
$11.00
$19.00
$8.00
$6.00
$3.00
$17.00
$7.00
$9.00
$43.00
$15.00
$26.00
$12.00
$8.00
$5.00
$27.00
$8.00
$18.00
$36.00
$14.00
$20.00
$37.00
$11.00
$26.00
$33.00
$18.00
$12.00
$34.00
$16.00
$17.00
$40.00
$24.00
$14.00
$37.00
$20.00
$15.00
$91.00
$38.00
$54.00
$122.00
$71.00
$52.00
$19.00
BR
$75.00
106
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
94657
94660
94662
94664
94667
94668
94680
94680-26
94680-TC
94681
94681-26
94681-TC
94690
94690-26
94690-TC
94720
94720-26
94720-TC
94725
94725-26
94725-TC
94750
94750-26
94750-TC
94760
94761
94762
94770
94770-26
94770-TC
94799
94799-26
94799-TC
95004
95010
95015
95024
95027
95028
95044
95052
95056
95060
95065
95070
95071
95075
95078
95115
95117
MRA
$44.00
$54.00
$38.00
$18.00
$23.00
$16.00
$47.00
$23.00
$22.00
$60.00
$12.00
$43.00
$24.00
$4.00
$20.00
$49.00
$15.00
$31.00
$79.00
$14.00
$64.00
$37.00
$14.00
$21.00
$9.00
$20.00
$30.00
$21.00
$9.00
$12.00
BR
BR
BR
$3.00
$11.00
$11.00
$3.00
$5.00
$8.00
$7.00
$9.00
$6.00
$13.00
$7.00
$82.00
$105.00
$82.00
$9.00
$10.00
$9.00
Medicine
CPT Code
95120
95125
95130
95131
95132
95133
95134
95144
95145
95146
95147
95148
95149
95165
95170
95180
95199
95250
95805
95805-26
95805-TC
95806
95806-26
95806-TC
95807
95807-26
95807-TC
95808
95808-26
95808-TC
95810
95810-26
95810-TC
95811
95811-26
95811-TC
95812
95812-26
95812-TC
95813
95813-26
95813-TC
95816
95816-26
95816-TC
95819
95819-26
95819-TC
95822
95822-26
MRA
BR
BR
BR
BR
BR
BR
BR
$9.00
$17.00
$24.00
$33.00
$32.00
$36.00
$7.00
$13.00
$103.00
BR
$114.00
$334.00
$94.00
$237.00
$232.00
$109.00
$137.00
$367.00
$98.00
$256.00
$456.00
$149.00
$256.00
$521.00
$183.00
$256.00
$644.00
$196.00
$423.00
$137.00
$58.00
$68.00
$177.00
$89.00
$68.00
$133.00
$54.00
$78.00
$115.00
$58.00
$56.00
$120.00
$58.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Medicine
CPT Code
95822-TC
95824
95824-26
95824-TC
95827
95827-26
95827-TC
95829
95829-26
95829-TC
95830
95831
95832
95833
95834
95851
95852
95857
95858
95858-26
95858-TC
95860
95860-26
95860-TC
95861
95861-26
95861-TC
95863
95863-26
95863-TC
95864
95864-26
95864-TC
95867
95867-26
95867-TC
95868
95868-26
95868-TC
95869
95869-26
95869-TC
95870
95870-26
95870-TC
95872
95872-26
95872-TC
95875
95875-26
MRA
$63.00
$51.00
$41.00
$10.00
$145.00
$59.00
$86.00
$328.00
$291.00
$6.00
$133.00
$26.00
$21.00
$34.00
$44.00
$18.00
$14.00
$40.00
$65.00
$56.00
$10.00
$73.00
$53.00
$15.00
$113.00
$86.00
$28.00
$138.00
$102.00
$35.00
$177.00
$114.00
$67.00
$66.00
$43.00
$21.00
$96.00
$71.00
$26.00
$29.00
$21.00
$8.00
$29.00
$21.00
$8.00
$104.00
$81.00
$22.00
$43.00
$34.00
107
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
95875-TC
95900
95900-26
95900-TC
95903
95903-26
95903-TC
95904
95904-26
95904-TC
95920
95920-26
95920-TC
95921
95921-26
95921-TC
95922
95922-26
95922-TC
95923
95923-26
95923-TC
95925
95925-26
95925-TC
95926
95926-26
95926-TC
95927
95927-26
95927-TC
95930
95930-26
95930-TC
95933
95933-26
95933-TC
95934
95934-26
95934-TC
95936
95936-26
95936-TC
95937
95937-26
95937-TC
95950
95950-26
95950-TC
95951
MRA
$7.00
$37.00
$24.00
$10.00
$43.00
$33.00
$9.00
$31.00
$20.00
$8.00
$168.00
$118.00
$48.00
$61.00
$46.00
$14.00
$65.00
$50.00
$14.00
$105.00
$47.00
$57.00
$94.00
$53.00
$41.00
$66.00
$34.00
$34.00
$67.00
$34.00
$34.00
$44.00
$25.00
$11.00
$62.00
$33.00
$30.00
$36.00
$28.00
$8.00
$39.00
$30.00
$8.00
$40.00
$31.00
$9.00
$265.00
$84.00
$177.00
$34.00
Medicine
CPT Code
95951-26
95951-TC
95953
95953-26
95953-TC
95954
95954-26
95954-TC
95955
95955-26
95955-TC
95956
95956-26
95956-TC
95957
95957-26
95957-TC
95958
95958-26
95958-TC
95961
95961-26
95961-TC
95962
95962-26
95962-TC
95965
95965-26
95965-TC
95966
95966-26
95966-TC
95967
95967-26
95967-TC
95970
95971
95972
95973
95974
95975
95990
95999
96000
96001
96002
96003
96004
96100
96105
MRA
$14.00
$20.00
$411.00
$165.00
$240.00
$208.00
$134.00
$23.00
$130.00
$59.00
$74.00
$541.00
$166.00
$314.00
$171.00
$104.00
$64.00
$296.00
$230.00
$66.00
$216.00
$166.00
$48.00
$227.00
$176.00
$48.00
BR
$420.00
BR
BR
$210.00
BR
BR
$184.00
BR
$22.00
$39.00
$78.00
$47.00
$155.00
$88.00
$57.00
BR
$93.00
$111.00
$21.00
$20.00
$97.00
$68.00
$68.00
CPT only © 2002 American Medical Association. All Rights Reserved.
Medicine
CPT Code
96110
96111
96115
96117
96370
96400
96405
96406
96408
96410
96412
96414
96420
96422
96423
96425
96440
96445
96450
96520
96530
96542
96545
96549
96567
96570
96571
96900
96902
96910
96912
96913
96920
96921
96922
96999
97001
97002
97003
97004
97005
97006
97010
97012
97014
97016
97018
97020
97022
97024
MRA
$88.00
$68.00
$68.00
$68.00
See formula
$20.00
$57.00
$86.00
$36.00
$5.00
$43.00
$50.00
$46.00
$46.00
$17.00
$54.00
$156.00
$157.00
$134.00
$33.00
$49.00
$126.00
BR
BR
$62.00
$69.00
$38.00
$17.00
$24.00
$21.00
$24.00
$53.00
$152.00
$155.00
$214.00
BR
$62.00
$29.00
$62.00
$29.00
NC
NC
$10.00
$16.00
$14.00
$15.00
$10.00
$10.00
$15.00
$10.00
108
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97260
97261
97504
97520
97530
97532
97533
97535
97537
97542
97545
97546
97601
97602
97703
97750
97752
97780
97781
97799
97802
97803
97804
97850
97851
97852
97853
98925
98926
98927
98928
98929
98940
98941
MRA
$9.00
$10.00
$16.00
$16.00
$13.00
$11.00
$19.00
$15.00
$22.00
$23.00
$24.00
$21.00
$19.00
$15.00
$26.00
$18.00
$23.00
$17.00
$23.00
$23.00
$22.00
$22.00
$24.00
$23.00
$23.00
$17.00
$83.00
$41.00
$42.00
BR
$15.00
BR
$48.00
$32.00
BR
BR
$26.00
$17.00
$7.00
$54.00
$26.00
$54.00
$26.00
NC
$32.00
NC
$23.00
NC
NC
$32.00
Medicine
CPT Code
98942
98943
99000
99001
99002
99025
99026
99027
99070
99071
99075
99078
99080
99082
99090
99091
99141
99142
99172
99173
99175
99183
99185
99186
99190
99191
99192
99195
99199
MRA
NC
$23.00
$6.00
$4.00
$35.00
$31.00
BR
BR
BR
NC
See 440.13(10)
NC
BR
BR
BR
BR
$80.00
$66.00
BR
BR
$53.00
$123.00
$23.00
$78.00
BR
BR
BR
$16.00
NC
CPT only © 2002 American Medical Association. All Rights Reserved.
109
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Evaluation & Management
CPT Code
MRA
99201
$35.00
99202
$58.00
99203
$58.00
99204
$84.00
99205
$84.00
99211
$19.00
99212
$31.00
99213
$40.00
99214
$40.00
99215
$65.00
99217
$65.00
99218
$65.00
99219
$109.00
99220
$152.00
99221
$66.00
99222
$109.00
99223
$152.00
99231
$33.00
99232
$54.00
99233
$77.00
99234
$129.00
99235
$173.00
99236
$213.00
99238
$66.00
99239
$88.00
99241
$54.00
99242
$88.00
99243
$117.00
99244
$163.00
99245
$212.00
99251
$54.00
99252
$70.00
99253
$96.00
99254
$138.00
99255
$190.00
99261
$24.00
99262
$44.00
99263
$65.00
99271
$49.00
99272
$61.00
99273
$86.00
99274
$116.00
99275
$149.00
99281
$18.00
99282
$28.00
99283
$60.00
99284
$94.00
99285
$103.00
99288
BR
99291
$192.00
Evaluation & Management
CPT Code
MRA
99292
$95.00
99295
$800.00
99296
$399.00
99301
$58.00
99302
$65.00
99303
$108.00
99311
$23.00
99312
$52.00
99313
$72.00
99315
$60.00
99316
$77.00
99321
$42.00
99322
$60.00
99323
$79.00
99331
$36.00
99332
$47.00
99333
$59.00
99341
$59.00
99342
$85.00
99343
$109.00
99344
$160.00
99345
$193.00
99347
$46.00
99348
$71.00
99349
$107.00
99350
$156.00
99354
$106.00
99355
$104.00
99356
$87.00
99357
$88.00
99358
BR
99359
BR
99360
BR
99361
BR
99362
BR
99371
NC
99372
$17.00
99373
$22.00
99374
$75.00
99375
$75.00
99377
$75.00
99378
$104.00
99379
$75.00
99380
$104.00
99450
NC
99455
$90.00
99456
BR
99457
BR
99499
BR
CPT only © 2002 American Medical Association. All Rights Reserved.
110
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Dental
CPT Code
D0120
D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0274
D0277
D0290
D0310
D0320
D0321
D0322
D0330
D0340
D0350
D0415
D0425
D0460
D0470
D0472
D0473
D0474
D0480
D0502
D0999
D1110
D1204
D1205
D1310
D1320
D1330
D1351
D1510
D1515
D1520
D1525
D1550
D2140
D2150
D2160
D2161
MRA
$17.00
$13.00
$20.00
$36.00
$18.00
$20.00
$40.00
$10.00
$5.00
$12.00
$20.00
$14.00
$7.00
$12.00
$20.00
$18.00
$36.00
$50.00
$204.00
$64.00
$105.00
$29.00
$40.00
$10.00
$34.00
$25.00
$13.00
$24.00
$30.00
BR
BR
BR
$54.00
BR
$29.00
$10.00
$40.00
$23.00
$48.00
$13.00
$21.00
$81.00
$121.00
$102.00
$143.00
$14.00
$38.00
$44.00
$54.00
$67.00
HCPCS © 2002
Dental
CPT Code
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2799
D2910
D2920
D2930
D2931
MRA
$40.00
$61.00
$66.00
$81.00
$57.00
$43.00
$55.00
$63.00
$69.00
$163.00
$203.00
$293.00
$155.00
$259.00
$244.00
$302.00
$318.00
$348.00
$206.00
$266.00
$348.00
$287.00
$328.00
$378.00
$206.00
$266.00
$348.00
$266.00
$328.00
$348.00
$194.00
$410.00
$306.00
$348.00
$410.00
$451.00
$328.00
$368.00
$368.00
$266.00
$306.00
$389.00
$389.00
$287.00
$328.00
$204.00
$29.00
$29.00
$81.00
$121.00
Dental
CPT Code
D2932
D2933
D2940
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
D2970
D2980
D2999
D3110
D3120
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3331
D3332
D3333
D3346
D3347
D3348
D3351
D3352
D3353
D3410
D3421
D3425
D3426
D3430
D3450
D3460
D3470
D3910
D3920
D3950
D3999
D4210
D4211
D4240
D4241
MRA
$77.00
$91.00
$29.00
$81.00
$20.00
$79.00
$133.00
$102.00
$81.00
$71.00
$121.00
$204.00
$294.00
$81.00
$83.00
BR
$25.00
$20.00
$61.00
$81.00
$70.00
$75.00
$206.00
$204.00
$287.00
$102.00
$110.00
$53.00
$225.00
$274.00
$337.00
$102.00
$81.00
$163.00
$179.00
$194.00
$206.00
$77.00
$55.00
$102.00
$318.00
$204.00
$50.00
$102.00
$61.00
BR
$114.00
$50.00
$223.00
$63.00
111
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Dental
CPT Code
D4245
D4249
D4260
D4261
D4263
D4264
D4265
D4266
D4267
D4268
D4270
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4381
D4910
D4920
D4999
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5670
D5671
D5710
D5711
MRA
$265.00
$208.00
$328.00
$164.00
$195.00
$159.00
$96.00
$285.00
$328.00
$273.00
$155.00
$206.00
$337.00
$208.00
$178.00
$194.00
$77.00
$55.00
$79.00
$55.00
$50.00
$69.00
$40.00
$27.00
BR
$513.00
$513.00
$563.00
$563.00
$256.00
$259.00
$614.00
$614.00
$279.00
$27.00
$27.00
$27.00
$27.00
$61.00
$40.00
$61.00
$83.00
$22.00
$53.00
$61.00
$102.00
$305.00
$305.00
$204.00
$204.00
HCPCS © 2002
Dental
CPT Code
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5810
D5811
D5820
D5821
D5850
D5851
D5860
D5861
D5862
D5867
D5875
D5899
D5911
D5912
D5913
D5914
D5915
D5916
D5919
D5922
D5923
D5924
D5925
D5926
D5927
D5928
D5929
D5931
D5932
D5933
D5934
D5935
D5936
D5937
D5951
D5953
D5954
D5955
D5958
D5959
MRA
$163.00
$163.00
$121.00
$121.00
$102.00
$102.00
$132.00
$163.00
$100.00
$163.00
$244.00
$244.00
$194.00
$204.00
$46.00
$50.00
$543.00
$553.00
$181.00
$36.00
$100.00
BR
$81.00
$121.00
$2,052.00
$2,052.00
$2,770.00
$2,874.00
BR
$1,334.00
$1,641.00
BR
BR
$1,026.00
$1,026.00
$1,384.00
BR
$656.00
$1,539.00
$306.00
$1,539.00
$1,539.00
$563.00
BR
$614.00
$614.00
BR
$1,334.00
$780.00
$244.00
Dental
CPT Code
D5960
D5982
D5983
D5984
D5985
D5986
D5987
D5988
D5999
D6010
D6020
D6040
D6050
D6053
D6054
D6055
D6056
D6057
D6058
D6059
D6060
D6061
D6062
D6063
D6064
D6065
D6066
D6067
D6068
D6069
D6070
D6071
D6072
D6073
D6074
D6075
D6076
D6077
D6078
D6079
D6080
D6090
D6095
D6100
D6199
D6210
D6211
D6212
D6240
D6241
MRA
$163.00
$167.00
BR
BR
$574.00
$61.00
BR
$219.00
BR
$649.00
$259.00
$3,016.00
$1,557.00
$82.00
$61.00
$769.00
$265.00
$303.00
$392.00
$418.00
$289.00
$379.00
$365.00
$359.00
$377.00
$513.00
$513.00
$513.00
$365.00
$359.00
$322.00
$326.00
$365.00
$346.00
$350.00
$414.00
$402.00
$447.00
$1,026.00
$884.00
$71.00
$229.00
$247.00
$264.00
BR
$410.00
$287.00
$328.00
$451.00
$368.00
112
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Dental
CPT Code
D6242
D6245
D6250
D6251
D6252
D6253
D6545
D6548
D6600
D6601
D6602
D6603
D6604
D6605
D6606
D6607
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6793
D6920
D6930
D6940
D6950
D6970
D6971
D6972
D6973
D6975
D6976
D6977
MRA
$410.00
$309.00
$410.00
$287.00
$368.00
$51.00
$195.00
$281.00
$155.00
$166.00
$172.00
$203.00
$110.00
$141.00
$139.00
$151.00
$170.00
$178.00
$203.00
$217.00
$141.00
$155.00
$151.00
$162.00
$410.00
$233.00
$348.00
$328.00
$356.00
$328.00
$410.00
$389.00
$320.00
$322.00
$324.00
$389.00
$287.00
$348.00
$30.00
$279.00
$40.00
$102.00
$155.00
$163.00
$113.00
$121.00
$111.00
$214.00
$88.00
$46.00
HCPCS © 2002
Dental
CPT Code
D6980
D6999
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
D7261
D7270
D7272
D7280
D7281
D7282
D7285
D7286
D7287
D7290
D7291
D7310
D7320
D7340
D7350
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7520
D7530
D7540
D7550
D7560
D7610
MRA
$106.00
BR
$45.00
$70.00
$111.00
$139.00
$147.00
$204.00
$81.00
$244.00
BR
$147.00
$204.00
$121.00
$81.00
$41.00
$106.00
$81.00
BR
$133.00
$77.00
$85.00
$108.00
$195.00
$410.00
$102.00
$100.00
$139.00
$205.00
$180.00
$291.00
$161.00
$247.00
$139.00
$179.00
$137.00
$195.00
$71.00
$174.00
$143.00
$147.00
$162.00
$2,545.00
$54.00
$121.00
$85.00
$121.00
$143.00
$266.00
$1,189.00
Dental
CPT Code
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850
D7852
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7920
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
MRA
$984.00
$1,354.00
$820.00
$1,292.00
$780.00
$410.00
$779.00
$1,949.00
$1,415.00
$903.00
$1,580.00
$922.00
$1,334.00
$1,046.00
$533.00
$73.00
$2,504.00
$1,292.00
$110.00
$186.00
$1,764.00
$1,682.00
$2,011.00
$2,052.00
BR
$2,298.00
$614.00
$1,723.00
$81.00
BR
$533.00
$584.00
$737.00
$789.00
$820.00
$758.00
$291.00
BR
$73.00
$110.00
$163.00
$676.00
$841.00
$2,874.00
$2,914.00
$2,298.00
$2,319.00
$2,566.00
$2,566.00
$2,874.00
113
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Dental
CPT Code
D7949
D7950
D7955
D7960
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D7995
D7996
D7997
D7999
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
D8210
D8220
D8660
D8670
D8680
D8690
D8691
D8692
D8999
D9110
D9210
D9211
D9212
D9215
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
MRA
$4,186.00
$881.00
$922.00
$121.00
$137.00
$67.00
BR
$169.00
$820.00
$306.00
$244.00
$340.00
$820.00
BR
BR
BR
BR
$451.00
$533.00
$718.00
$583.00
$676.00
$758.00
$1,867.00
$1,867.00
$1,949.00
$155.00
$179.00
$73.00
$54.00
$171.00
$71.00
$67.00
$104.00
BR
$40.00
$14.00
$14.00
$13.00
$7.00
$111.00
$40.00
$18.00
$122.00
$45.00
$91.00
$41.00
$61.00
$46.00
$23.00
HCPCS © 2002
Dental
CPT Code
D9440
D9450
D9610
D9630
D9910
D9911
D9920
D9930
D9940
D9941
D9950
D9951
D9952
D9970
D9971
D9972
D9973
D9974
D9999
MRA
$41.00
BR
$20.00
$10.00
$21.00
$21.00
$32.00
$34.00
$204.00
$58.00
$114.00
$46.00
$163.00
$83.00
$55.00
$113.00
$40.00
$50.00
BR
114
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Injections
CPT Code
J0120
J0130
J0150
J0151
J0170
J0190
J0200
J0205
J0207
J0210
J0256
J0280
J0282
J0285
J0287
J0288
J0289
J0290
J0295
J0300
J0330
J0350
J0360
J0380
J0390
J0395
J0456
J0460
J0470
J0475
J0476
J0500
J0515
J0520
J0530
J0540
J0550
J0560
J0570
J0580
J0585
J0587
J0592
J0600
J0610
J0620
J0630
J0636
J0637
J0640
MRA
$12.00
BR
$27.00
BR
$1.00
$3.00
BR
$38.00
BR
$7.00
$101.00
$1.00
BR
BR
BR
BR
BR
$2.00
$7.00
$2.00
$1.00
$2,408.00
$6.00
$1.00
$3.00
BR
BR
$1.00
$11.00
$201.00
BR
$3.00
$3.00
$5.00
$4.00
$8.00
$21.00
$6.00
$9.00
$26.00
$393.00
BR
BR
$6.00
$1.00
$3.00
$21.00
BR
BR
$22.00
HCPCS © 2002
Injections
CPT Code
J0670
J0690
J0692
J0694
J0696
J0697
J0698
J0702
J0704
J0710
J0713
J0715
J0720
J0725
J0735
J0740
J0743
J0744
J0745
J0760
J0770
J0780
J0800
J0835
J0850
J0880
J0895
J0900
J0945
J0970
J1000
J1020
J1030
J1040
J1055
J1060
J1070
J1080
J1094
J1100
J1110
J1120
J1160
J1165
J1170
J1180
J1190
J1200
J1205
J1212
MRA
NC
$3.00
BR
$10.00
$11.00
$6.00
$11.00
$4.00
$2.00
$3.00
$8.00
$6.00
$6.00
$3.00
BR
BR
$14.00
BR
$1.00
$3.00
$32.00
$3.00
$18.00
$12.00
$362.00
BR
$10.00
$1.00
$1.00
$1.00
$3.00
$1.00
$2.00
$3.00
BR
$1.00
$1.00
$2.00
BR
$1.00
$10.00
$35.00
$2.00
$1.00
$1.00
$1.00
BR
$1.00
$9.00
$36.00
Injections
CPT Code
J1230
J1240
J1245
J1250
J1260
J1270
J1320
J1325
J1327
J1330
J1364
J1380
J1390
J1410
J1435
J1436
J1438
J1440
J1441
J1450
J1455
J1460
J1470
J1480
J1490
J1500
J1510
J1520
J1530
J1540
J1550
J1560
J1563
J1564
J1565
J1570
J1580
J1590
J1600
J1610
J1620
J1626
J1630
J1631
J1642
J1644
J1645
J1650
J1652
J1655
MRA
$1.00
$1.00
$31.00
$49.00
BR
BR
$1.00
BR
BR
$2.00
$6.00
$1.00
$1.00
$33.00
$1.00
$68.00
BR
$158.00
$254.00
BR
$12.00
$2.00
$4.00
$7.00
$9.00
$11.00
$13.00
$15.00
$17.00
$20.00
$22.00
BR
BR
BR
BR
$36.00
$3.00
BR
$10.00
$27.00
$69.00
BR
$4.00
$28.00
$1.00
$1.00
BR
$16.00
BR
BR
115
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Injections
CPT Code
J1670
J1700
J1710
J1720
J1730
J1742
J1745
J1750
J1756
J1785
J1790
J1800
J1810
J1815
J1817
J1825
J1830
J1835
J1840
J1850
J1885
J1890
J1910
J1940
J1950
J1955
J1956
J1960
J1980
J1990
J2000
J2010
J2020
J2060
J2150
J2175
J2180
J2210
J2250
J2260
J2270
J2271
J2275
J2300
J2310
J2320
J2321
J2322
J2324
J2355
MRA
$23.00
$1.00
$5.00
$4.00
$94.00
BR
BR
BR
BR
$4.00
$4.00
$10.00
$6.00
BR
BR
BR
$76.00
BR
$7.00
$4.00
$7.00
$11.00
$9.00
$1.00
$411.00
$37.00
BR
$2.00
$3.00
$8.00
$7.00
$2.00
BR
$12.00
$3.00
$1.00
$3.00
$3.00
$2.00
$32.00
$1.00
BR
$13.00
$2.00
$3.00
$5.00
$6.00
$8.00
BR
BR
HCPCS © 2002
Injections
CPT Code
J2360
J2370
J2400
J2405
J2410
J2430
J2440
J2460
J2501
J2510
J2515
J2540
J2543
J2545
J2550
J2560
J2590
J2597
J2650
J2670
J2680
J2690
J2700
J2710
J2720
J2725
J2730
J2760
J2765
J2770
J2780
J2790
J2792
J2795
J2800
J2810
J2820
J2910
J2912
J2916
J2920
J2930
J2940
J2941
J2950
J2993
J2995
J2997
J3000
J3010
MRA
$2.00
$3.00
BR
$6.00
$3.00
$189.00
$2.00
$1.00
BR
$1.00
$1.00
$1.00
BR
$105.00
$1.00
$5.00
$1.00
$20.00
$1.00
BR
$16.00
$7.00
$2.00
$1.00
$1.00
$11.00
$29.00
$29.00
$2.00
BR
BR
$36.00
BR
BR
$3.00
$3.00
$115.00
$11.00
$1.00
BR
$5.00
$13.00
BR
BR
$1.00
BR
BR
BR
$2.00
$2.00
Injections
CPT Code
J3030
J3070
J3100
J3105
J3120
J3130
J3140
J3150
J3230
J3240
J3245
J3250
J3260
J3265
J3280
J3301
J3302
J3303
J3305
J3310
J3320
J3350
J3360
J3364
J3365
J3370
J3395
J3400
J3410
J3420
J3430
J3470
J3475
J3480
J3485
J3490
J3590
J7030
J7040
J7042
J7050
J7051
J7060
J7070
J7100
J7110
J7120
J7130
J7190
J7191
MRA
$34.00
$4.00
BR
$2.00
$1.00
$1.00
$1.00
$1.00
$2.00
$214.00
BR
$1.00
$7.00
$2.00
$5.00
$1.00
$1.00
$1.00
$55.00
$5.00
$16.00
$72.00
$1.00
$52.00
$433.00
$9.00
BR
$12.00
$1.00
$1.00
$2.00
$7.00
$1.00
$1.00
BR
BR
BR
$11.00
$10.00
$10.00
$10.00
$1.00
$10.00
$11.00
$137.00
$93.00
$12.00
$6.00
$241.00
BR
116
Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Injections
CPT Code
J7192
J7193
J7194
J7195
J7197
J7198
J7199
J7310
J7317
J7320
J7350
J7501
J7504
J7505
J7513
J7516
J7599
MRA
$316.00
BR
$120.00
BR
$284.00
BR
BR
BR
BR
BR
BR
$98.00
$282.00
$576.00
BR
BR
BR
HCPCS © 2002
117
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
PART B
SCHEDULE OF MAXIMUM REIMBURSEMENT
ALLOWANCES
118
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
10021
10022
10040
10060
10061
10080
10081
10120
10121
10140
10160
10180
11000
11001
11010
11011
11012
11040
11041
11042
11043
11044
11055
11056
11057
11100
11101
11200
11201
11300
11301
11302
11303
11305
11306
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406
11420
11421
11422
11423
11424
0
0
10
10
10
10
10
10
10
10
10
10
0
ZZZ
10
0
0
0
0
0
10
10
0
0
0
0
ZZZ
10
ZZZ
0
0
0
0
0
0
0
0
0
0
0
0
10
10
10
10
10
10
10
10
10
10
10
$90.00
$92.00
$54.00
$53.00
$133.00
$65.00
$203.00
$53.00
$169.00
$53.00
$45.00
$164.00
$45.00
$27.00
$348.00
$432.00
$597.00
$43.00
$45.00
$88.00
$210.00
$283.00
$26.00
$35.00
$39.00
$78.00
$41.00
$66.00
$26.00
$59.00
$80.00
$96.00
$119.00
$61.00
$86.00
$100.00
$125.00
$75.00
$95.00
$110.00
$144.00
$81.00
$114.00
$145.00
$178.00
$200.00
$246.00
$98.00
$92.00
$157.00
$163.00
$221.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$184.00
$197.00
$116.00
$137.00
$223.00
$168.00
$277.00
$143.00
$296.00
$159.00
$105.00
$201.00
$65.00
$35.00
$357.00
$470.00
$672.00
$54.00
$77.00
$109.00
$309.00
$406.00
$48.00
$61.00
$74.00
$104.00
$40.00
$101.00
$43.00
$76.00
$99.00
$119.00
$144.00
$77.00
$107.00
$123.00
$146.00
$93.00
$116.00
$134.00
$175.00
$148.00
$171.00
$195.00
$222.00
$254.00
$313.00
$143.00
$182.00
$203.00
$242.00
$278.00
$196.00
$209.00
$123.00
$146.00
$238.00
$180.00
$296.00
$153.00
$317.00
$171.00
$113.00
$217.00
$69.00
$37.00
$385.00
$506.00
$728.00
$58.00
$82.00
$117.00
$332.00
$438.00
$51.00
$65.00
$78.00
$110.00
$43.00
$108.00
$46.00
$81.00
$105.00
$127.00
$153.00
$82.00
$113.00
$131.00
$155.00
$99.00
$123.00
$142.00
$187.00
$158.00
$183.00
$209.00
$238.00
$272.00
$336.00
$153.00
$195.00
$218.00
$259.00
$299.00
$204.00
$217.00
$128.00
$152.00
$249.00
$188.00
$310.00
$160.00
$334.00
$180.00
$119.00
$230.00
$73.00
$39.00
$408.00
$535.00
$774.00
$61.00
$86.00
$123.00
$349.00
$460.00
$53.00
$67.00
$82.00
$115.00
$45.00
$112.00
$48.00
$84.00
$109.00
$132.00
$159.00
$86.00
$118.00
$136.00
$161.00
$104.00
$128.00
$148.00
$194.00
$165.00
$191.00
$218.00
$250.00
$285.00
$352.00
$160.00
$203.00
$228.00
$271.00
$313.00
$94.00
$88.00
$97.00
$97.00
$200.00
$100.00
$211.00
$85.00
$239.00
$129.00
$88.00
$191.00
$45.00
$22.00
$336.00
$410.00
$610.00
$39.00
$61.00
$85.00
$264.00
$366.00
$32.00
$45.00
$58.00
$62.00
$32.00
$56.00
$22.00
$38.00
$64.00
$79.00
$92.00
$49.00
$74.00
$85.00
$105.00
$55.00
$80.00
$92.00
$123.00
$93.00
$120.00
$139.00
$166.00
$184.00
$237.00
$103.00
$136.00
$158.00
$185.00
$216.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$100.00
$93.00
$103.00
$103.00
$213.00
$107.00
$225.00
$91.00
$256.00
$139.00
$94.00
$206.00
$48.00
$23.00
$362.00
$441.00
$661.00
$41.00
$65.00
$91.00
$284.00
$395.00
$33.00
$48.00
$62.00
$65.00
$33.00
$60.00
$23.00
$41.00
$68.00
$84.00
$98.00
$52.00
$78.00
$90.00
$111.00
$59.00
$85.00
$97.00
$131.00
$100.00
$128.00
$149.00
$178.00
$198.00
$254.00
$110.00
$145.00
$169.00
$198.00
$231.00
$104.00
$97.00
$107.00
$108.00
$224.00
$112.00
$237.00
$96.00
$270.00
$147.00
$100.00
$219.00
$51.00
$24.00
$384.00
$469.00
$705.00
$44.00
$69.00
$96.00
$299.00
$416.00
$35.00
$50.00
$64.00
$68.00
$35.00
$62.00
$24.00
$42.00
$71.00
$87.00
$102.00
$55.00
$82.00
$93.00
$116.00
$61.00
$88.00
$101.00
$136.00
$104.00
$135.00
$156.00
$188.00
$208.00
$268.00
$116.00
$152.00
$178.00
$208.00
$243.00
119
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
11426
11440
11441
11442
11443
11444
11446
11450
11451
11462
11463
11470
11471
11600
11601
11602
11603
11604
11606
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
11719
11720
11721
11730
11732
11740
11750
11752
11755
11760
11762
11765
11770
11771
11772
11900
11901
11920
11921
11922
11950
10
10
10
10
10
10
10
90
90
90
90
90
90
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
0
0
0
0
ZZZ
0
10
10
0
10
10
10
10
90
90
0
0
0
0
ZZZ
0
$303.00
$105.00
$102.00
$174.00
$221.00
$276.00
$344.00
$282.00
$366.00
$264.00
$351.00
$320.00
$391.00
$148.00
$180.00
$199.00
$226.00
$249.00
$315.00
$150.00
$191.00
$223.00
$259.00
$305.00
$373.00
$168.00
$227.00
$260.00
$305.00
$380.00
$494.00
$22.00
$32.00
$50.00
$62.00
$31.00
$41.00
$156.00
$234.00
$106.00
$131.00
$223.00
$65.00
$275.00
$496.00
$585.00
$33.00
$37.00
$147.00
$172.00
$40.00
$107.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$395.00
$169.00
$198.00
$225.00
$275.00
$351.00
$453.00
$355.00
$466.00
$341.00
$497.00
$404.00
$525.00
$195.00
$225.00
$239.00
$265.00
$292.00
$383.00
$187.00
$223.00
$255.00
$301.00
$346.00
$461.00
$198.00
$260.00
$303.00
$352.00
$449.00
$608.00
$21.00
$34.00
$51.00
$102.00
$46.00
$60.00
$188.00
$258.00
$124.00
$178.00
$275.00
$93.00
$292.00
$593.00
$707.00
$64.00
$77.00
$197.00
$233.00
$46.00
$106.00
$423.00
$181.00
$212.00
$241.00
$294.00
$376.00
$483.00
$381.00
$501.00
$366.00
$535.00
$434.00
$563.00
$209.00
$240.00
$256.00
$283.00
$312.00
$411.00
$200.00
$238.00
$272.00
$322.00
$370.00
$493.00
$212.00
$278.00
$323.00
$376.00
$481.00
$650.00
$23.00
$36.00
$55.00
$109.00
$50.00
$65.00
$201.00
$279.00
$131.00
$192.00
$297.00
$99.00
$313.00
$637.00
$760.00
$68.00
$82.00
$212.00
$251.00
$50.00
$113.00
$445.00
$189.00
$222.00
$252.00
$308.00
$394.00
$505.00
$400.00
$527.00
$383.00
$562.00
$455.00
$591.00
$217.00
$251.00
$267.00
$296.00
$326.00
$430.00
$209.00
$248.00
$284.00
$337.00
$388.00
$517.00
$221.00
$291.00
$338.00
$394.00
$504.00
$681.00
$24.00
$38.00
$57.00
$115.00
$53.00
$68.00
$211.00
$297.00
$136.00
$202.00
$314.00
$104.00
$329.00
$671.00
$801.00
$70.00
$85.00
$223.00
$265.00
$53.00
$118.00
$317.00
$127.00
$159.00
$176.00
$219.00
$285.00
$385.00
$202.00
$293.00
$187.00
$301.00
$243.00
$331.00
$120.00
$159.00
$169.00
$186.00
$201.00
$276.00
$113.00
$158.00
$184.00
$223.00
$258.00
$358.00
$130.00
$195.00
$228.00
$269.00
$349.00
$504.00
$13.00
$24.00
$40.00
$84.00
$43.00
$27.00
$141.00
$241.00
$97.00
$151.00
$258.00
$62.00
$207.00
$515.00
$607.00
$38.00
$60.00
$131.00
$159.00
$41.00
$67.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$339.00
$136.00
$170.00
$189.00
$234.00
$305.00
$410.00
$217.00
$315.00
$201.00
$324.00
$260.00
$355.00
$128.00
$169.00
$180.00
$199.00
$214.00
$295.00
$121.00
$168.00
$196.00
$238.00
$276.00
$382.00
$139.00
$208.00
$243.00
$288.00
$373.00
$538.00
$13.00
$25.00
$43.00
$90.00
$46.00
$29.00
$151.00
$261.00
$102.00
$163.00
$278.00
$66.00
$222.00
$554.00
$652.00
$40.00
$63.00
$141.00
$172.00
$44.00
$71.00
$358.00
$142.00
$178.00
$198.00
$246.00
$320.00
$430.00
$230.00
$335.00
$213.00
$344.00
$276.00
$376.00
$134.00
$177.00
$189.00
$208.00
$225.00
$311.00
$126.00
$176.00
$206.00
$250.00
$291.00
$403.00
$145.00
$217.00
$255.00
$302.00
$392.00
$566.00
$14.00
$26.00
$45.00
$95.00
$49.00
$31.00
$160.00
$278.00
$107.00
$172.00
$295.00
$69.00
$234.00
$585.00
$690.00
$42.00
$65.00
$150.00
$182.00
$46.00
$74.00
120
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
11951
11952
11954
11960
11970
11971
11976
12001
12002
12004
12005
12006
12007
12011
12013
12014
12015
12016
12017
12018
12020
12021
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
13100
13101
13102
13120
13121
13122
13131
13132
13133
13150
13151
0
0
0
90
90
90
0
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
ZZZ
10
10
ZZZ
10
10
ZZZ
10
10
$114.00
$155.00
$165.00
$829.00
$632.00
$280.00
$123.00
$84.00
$98.00
$122.00
$165.00
$203.00
$339.00
$98.00
$141.00
$165.00
$207.00
$268.00
$316.00
$515.00
$211.00
$87.00
$93.00
$110.00
$148.00
$223.00
$356.00
$411.00
$116.00
$141.00
$176.00
$250.00
$341.00
$363.00
$126.00
$148.00
$223.00
$301.00
$380.00
$487.00
$539.00
$178.00
$240.00
$89.00
$223.00
$348.00
$104.00
$252.00
$484.00
$154.00
$260.00
$375.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$145.00
$192.00
$231.00
$1,046.00
$647.00
$429.00
$179.00
$199.00
$212.00
$246.00
$308.00
$384.00
$434.00
$211.00
$232.00
$270.00
$340.00
$404.00
$354.00
$418.00
$271.00
$188.00
$229.00
$279.00
$317.00
$345.00
$486.00
$540.00
$251.00
$303.00
$332.00
$379.00
$509.00
$560.00
$288.00
$302.00
$329.00
$365.00
$469.00
$614.00
$631.00
$341.00
$394.00
$106.00
$356.00
$428.00
$123.00
$396.00
$550.00
$180.00
$468.00
$498.00
$155.00
$206.00
$249.00
$1,124.00
$698.00
$461.00
$193.00
$213.00
$227.00
$263.00
$330.00
$412.00
$465.00
$226.00
$248.00
$289.00
$364.00
$432.00
$379.00
$447.00
$291.00
$202.00
$245.00
$297.00
$338.00
$370.00
$523.00
$582.00
$268.00
$323.00
$355.00
$407.00
$547.00
$601.00
$308.00
$322.00
$350.00
$390.00
$502.00
$657.00
$676.00
$364.00
$419.00
$113.00
$380.00
$455.00
$132.00
$422.00
$584.00
$193.00
$501.00
$532.00
$162.00
$217.00
$262.00
$1,182.00
$739.00
$482.00
$203.00
$223.00
$238.00
$275.00
$346.00
$432.00
$489.00
$237.00
$260.00
$302.00
$381.00
$454.00
$400.00
$472.00
$306.00
$213.00
$256.00
$310.00
$354.00
$389.00
$550.00
$612.00
$280.00
$337.00
$372.00
$428.00
$574.00
$630.00
$321.00
$336.00
$366.00
$408.00
$526.00
$689.00
$709.00
$380.00
$437.00
$119.00
$397.00
$475.00
$139.00
$441.00
$608.00
$203.00
$524.00
$555.00
$92.00
$130.00
$151.00
$1,046.00
$647.00
$309.00
$135.00
$115.00
$148.00
$174.00
$218.00
$279.00
$320.00
$119.00
$157.00
$188.00
$238.00
$294.00
$354.00
$418.00
$216.00
$154.00
$155.00
$196.00
$230.00
$273.00
$350.00
$403.00
$171.00
$217.00
$251.00
$296.00
$364.00
$401.00
$203.00
$217.00
$245.00
$270.00
$352.00
$440.00
$514.00
$260.00
$323.00
$97.00
$272.00
$350.00
$112.00
$314.00
$478.00
$172.00
$339.00
$392.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$98.00
$140.00
$162.00
$1,124.00
$698.00
$332.00
$144.00
$123.00
$158.00
$185.00
$233.00
$298.00
$343.00
$127.00
$168.00
$200.00
$253.00
$314.00
$379.00
$447.00
$232.00
$166.00
$165.00
$208.00
$246.00
$292.00
$376.00
$434.00
$182.00
$231.00
$268.00
$318.00
$390.00
$430.00
$216.00
$231.00
$260.00
$288.00
$376.00
$470.00
$550.00
$277.00
$342.00
$104.00
$290.00
$372.00
$120.00
$334.00
$507.00
$184.00
$362.00
$417.00
$103.00
$148.00
$172.00
$1,182.00
$739.00
$348.00
$153.00
$130.00
$167.00
$195.00
$246.00
$315.00
$363.00
$134.00
$177.00
$211.00
$267.00
$331.00
$400.00
$472.00
$245.00
$176.00
$174.00
$218.00
$258.00
$309.00
$398.00
$460.00
$191.00
$242.00
$282.00
$336.00
$412.00
$453.00
$226.00
$242.00
$273.00
$302.00
$396.00
$495.00
$579.00
$290.00
$358.00
$109.00
$304.00
$388.00
$126.00
$350.00
$529.00
$193.00
$380.00
$436.00
121
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
13152
13153
13160
14000
14001
14020
14021
14040
14041
14060
14061
14300
14350
15000
15001
15050
15100
15101
15120
15121
15200
15201
15220
15221
15240
15241
15260
15261
15342
15343
15350
15351
15400
15401
15570
15572
15574
15576
15600
15610
15620
15630
15650
15732
15734
15736
15738
15740
15750
15756
15757
15758
10
ZZZ
90
90
90
90
90
90
90
90
90
90
90
0
ZZZ
90
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
10
ZZZ
90
ZZZ
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$542.00
$169.00
$655.00
$512.00
$695.00
$590.00
$818.00
$701.00
$936.00
$766.00
$1,330.00
$1,040.00
$734.00
$287.00
$70.00
$349.00
$679.00
$146.00
$788.00
$235.00
$644.00
$126.00
$687.00
$114.00
$763.00
$334.00
$841.00
$207.00
$118.00
$25.00
$232.00
$66.00
$223.00
$66.00
$748.00
$721.00
$775.00
$457.00
$259.00
$320.00
$506.00
$362.00
$427.00
$1,465.00
$1,557.00
$1,862.00
$1,415.00
$913.00
$1,064.00
$2,892.00
$2,892.00
$2,884.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$635.00
$198.00
$912.00
$696.00
$903.00
$758.00
$1,014.00
$858.00
$1,160.00
$927.00
$1,253.00
$1,205.00
$863.00
$403.00
$119.00
$495.00
$1,086.00
$257.00
$1,051.00
$356.00
$918.00
$127.00
$914.00
$113.00
$957.00
$176.00
$1,029.00
$265.00
$156.00
$27.00
$639.00
$104.00
$463.00
$118.00
$923.00
$904.00
$961.00
$917.00
$407.00
$303.00
$494.00
$484.00
$523.00
$1,612.00
$1,638.00
$1,508.00
$1,624.00
$994.00
$1,048.00
$2,987.00
$3,058.00
$3,064.00
$677.00
$211.00
$984.00
$745.00
$966.00
$811.00
$1,082.00
$917.00
$1,235.00
$990.00
$1,335.00
$1,288.00
$932.00
$433.00
$128.00
$533.00
$1,168.00
$277.00
$1,128.00
$383.00
$986.00
$136.00
$980.00
$121.00
$1,026.00
$189.00
$1,096.00
$283.00
$168.00
$28.00
$688.00
$112.00
$498.00
$127.00
$993.00
$972.00
$1,032.00
$982.00
$438.00
$326.00
$531.00
$519.00
$562.00
$1,726.00
$1,765.00
$1,626.00
$1,750.00
$1,058.00
$1,127.00
$3,201.00
$3,284.00
$3,294.00
$706.00
$222.00
$1,046.00
$780.00
$1,012.00
$848.00
$1,132.00
$958.00
$1,290.00
$1,035.00
$1,393.00
$1,349.00
$989.00
$456.00
$135.00
$562.00
$1,229.00
$291.00
$1,185.00
$402.00
$1,035.00
$144.00
$1,028.00
$128.00
$1,078.00
$199.00
$1,145.00
$296.00
$176.00
$30.00
$721.00
$118.00
$523.00
$134.00
$1,049.00
$1,026.00
$1,087.00
$1,031.00
$457.00
$343.00
$555.00
$543.00
$589.00
$1,816.00
$1,868.00
$1,722.00
$1,854.00
$1,104.00
$1,192.00
$3,376.00
$3,470.00
$3,485.00
$537.00
$188.00
$912.00
$552.00
$758.00
$624.00
$897.00
$774.00
$1,057.00
$847.00
$1,142.00
$1,104.00
$863.00
$333.00
$78.00
$440.00
$910.00
$170.00
$943.00
$242.00
$721.00
$107.00
$741.00
$96.00
$848.00
$150.00
$980.00
$201.00
$93.00
$19.00
$440.00
$77.00
$463.00
$80.00
$821.00
$809.00
$889.00
$790.00
$222.00
$265.00
$331.00
$361.00
$405.00
$1,612.00
$1,638.00
$1,508.00
$1,624.00
$899.00
$1,048.00
$2,987.00
$3,058.00
$3,064.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$570.00
$200.00
$984.00
$590.00
$810.00
$667.00
$956.00
$826.00
$1,125.00
$904.00
$1,215.00
$1,179.00
$932.00
$357.00
$84.00
$474.00
$979.00
$183.00
$1,012.00
$260.00
$773.00
$115.00
$793.00
$103.00
$909.00
$161.00
$1,044.00
$215.00
$99.00
$20.00
$473.00
$83.00
$498.00
$86.00
$883.00
$869.00
$954.00
$845.00
$239.00
$286.00
$356.00
$387.00
$434.00
$1,726.00
$1,765.00
$1,626.00
$1,750.00
$955.00
$1,127.00
$3,201.00
$3,284.00
$3,294.00
$596.00
$211.00
$1,046.00
$620.00
$850.00
$699.00
$1,001.00
$865.00
$1,176.00
$946.00
$1,269.00
$1,236.00
$989.00
$378.00
$89.00
$501.00
$1,034.00
$194.00
$1,066.00
$275.00
$815.00
$122.00
$835.00
$109.00
$956.00
$170.00
$1,090.00
$225.00
$105.00
$21.00
$499.00
$89.00
$523.00
$92.00
$935.00
$920.00
$1,007.00
$889.00
$251.00
$301.00
$374.00
$406.00
$456.00
$1,816.00
$1,868.00
$1,722.00
$1,854.00
$998.00
$1,192.00
$3,376.00
$3,470.00
$3,485.00
122
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
15760
15770
15775
15776
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15810
15811
15819
15820
15821
15822
15823
15824
15825
15826
15828
15829
15831
15832
15833
15834
15835
15836
15837
15838
15839
15840
15841
15842
15845
15850
15851
15852
15860
15876
15877
15878
15879
15920
15922
15931
15933
15934
90
90
0
0
90
90
90
90
10
ZZZ
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
90
90
90
90
90
$810.00
$674.00
$327.00
$475.00
$532.00
$420.00
$314.00
$340.00
$146.00
$27.00
$194.00
$360.00
$130.00
$232.00
$401.00
$440.00
$780.00
$556.00
$607.00
$499.00
$718.00
NC
NC
NC
NC
NC
$990.00
$926.00
$833.00
$837.00
$865.00
$721.00
$696.00
$600.00
$643.00
$1,187.00
$1,859.00
$3,099.00
$1,116.00
$63.00
$40.00
$35.00
$151.00
NC
NC
NC
NC
$571.00
$771.00
$638.00
$860.00
$1,064.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$929.00
$725.00
$367.00
$597.00
$715.00
$508.00
$440.00
$462.00
$195.00
$33.00
$265.00
$565.00
$244.00
$369.00
$447.00
$601.00
$846.00
$625.00
$671.00
$533.00
$768.00
--------------------$1,082.00
$1,035.00
$954.00
$960.00
$997.00
$832.00
$835.00
$673.00
$880.00
$1,216.00
$2,047.00
$3,276.00
$1,096.00
----$126.00
$133.00
$170.00
----------------$721.00
$922.00
$797.00
$1,008.00
$1,129.00
$995.00
$780.00
$395.00
$644.00
$760.00
$541.00
$467.00
$493.00
$208.00
$36.00
$282.00
$602.00
$260.00
$392.00
$479.00
$646.00
$905.00
$666.00
$715.00
$567.00
$815.00
--------------------$1,165.00
$1,114.00
$1,029.00
$1,035.00
$1,071.00
$895.00
$896.00
$720.00
$944.00
$1,302.00
$2,210.00
$3,527.00
$1,166.00
----$135.00
$143.00
$181.00
----------------$776.00
$994.00
$857.00
$1,085.00
$1,216.00
$1,044.00
$824.00
$418.00
$679.00
$793.00
$563.00
$486.00
$514.00
$216.00
$37.00
$294.00
$627.00
$271.00
$407.00
$505.00
$679.00
$952.00
$694.00
$744.00
$590.00
$847.00
--------------------$1,234.00
$1,179.00
$1,091.00
$1,097.00
$1,133.00
$947.00
$943.00
$756.00
$996.00
$1,371.00
$2,347.00
$3,738.00
$1,220.00
----$140.00
$149.00
$189.00
----------------$821.00
$1,052.00
$908.00
$1,148.00
$1,288.00
$808.00
$725.00
$293.00
$458.00
$713.00
$495.00
$433.00
$406.00
$172.00
$26.00
$162.00
$436.00
$206.00
$369.00
$447.00
$535.00
$846.00
$534.00
$571.00
$444.00
$673.00
--------------------$1,082.00
$1,035.00
$954.00
$960.00
$997.00
$832.00
$787.00
$673.00
$808.00
$1,216.00
$2,047.00
$3,276.00
$1,096.00
----$63.00
$65.00
$146.00
----------------$721.00
$922.00
$797.00
$1,008.00
$1,129.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$865.00
$780.00
$315.00
$494.00
$759.00
$527.00
$459.00
$432.00
$182.00
$27.00
$172.00
$462.00
$219.00
$392.00
$479.00
$575.00
$905.00
$568.00
$607.00
$471.00
$714.00
--------------------$1,165.00
$1,114.00
$1,029.00
$1,035.00
$1,071.00
$895.00
$844.00
$720.00
$868.00
$1,302.00
$2,210.00
$3,527.00
$1,166.00
----$67.00
$70.00
$155.00
----------------$776.00
$994.00
$857.00
$1,085.00
$1,216.00
$909.00
$824.00
$336.00
$524.00
$791.00
$549.00
$478.00
$452.00
$190.00
$29.00
$179.00
$482.00
$228.00
$407.00
$505.00
$606.00
$952.00
$593.00
$632.00
$490.00
$742.00
--------------------$1,234.00
$1,179.00
$1,091.00
$1,097.00
$1,133.00
$947.00
$890.00
$756.00
$916.00
$1,371.00
$2,347.00
$3,738.00
$1,220.00
----$70.00
$74.00
$163.00
----------------$821.00
$1,052.00
$908.00
$1,148.00
$1,288.00
123
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
15935
15936
15937
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
15999
16000
16010
16015
16020
16025
16030
16035
16036
17000
17003
17004
17106
17107
17108
17110
17111
17250
17260
17261
17262
17263
17264
17266
17270
17271
17272
17273
17274
17276
17280
17281
17282
17283
17284
17286
17304
17305
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
90
ZZZ
10
ZZZ
10
90
90
90
10
10
0
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
0
0
$1,184.00
$1,032.00
$1,223.00
$318.00
$919.00
$954.00
$1,078.00
$1,737.00
$549.00
$872.00
$876.00
$1,013.00
$1,382.00
$1,379.00
BR
$53.00
$59.00
$213.00
$49.00
$67.00
$153.00
$341.00
$81.00
$60.00
$16.00
$233.00
$341.00
$648.00
$1,015.00
$55.00
$83.00
$27.00
$96.00
$117.00
$150.00
$172.00
$189.00
$225.00
$125.00
$143.00
$170.00
$195.00
$240.00
$281.00
$123.00
$165.00
$194.00
$239.00
$282.00
$373.00
$590.00
$247.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,318.00
$1,136.00
$1,311.00
$821.00
$1,132.00
$1,073.00
$1,190.00
$1,914.00
$682.00
$1,002.00
$1,009.00
$1,152.00
$1,393.00
$1,408.00
----$101.00
$106.00
$224.00
$99.00
$195.00
$265.00
$285.00
$113.00
$83.00
$14.00
$267.00
$481.00
$850.00
$1,176.00
$119.00
$134.00
$88.00
$115.00
$141.00
$176.00
$196.00
$212.00
$250.00
$153.00
$166.00
$191.00
$217.00
$264.00
$318.00
$140.00
$184.00
$214.00
$265.00
$316.00
$421.00
$796.00
$337.00
$1,420.00
$1,223.00
$1,412.00
$884.00
$1,219.00
$1,155.00
$1,283.00
$2,062.00
$734.00
$1,079.00
$1,087.00
$1,242.00
$1,500.00
$1,517.00
----$108.00
$114.00
$241.00
$106.00
$209.00
$284.00
$306.00
$120.00
$88.00
$15.00
$283.00
$513.00
$904.00
$1,253.00
$127.00
$143.00
$94.00
$122.00
$150.00
$187.00
$208.00
$225.00
$265.00
$163.00
$176.00
$202.00
$231.00
$280.00
$337.00
$149.00
$196.00
$227.00
$281.00
$335.00
$447.00
$844.00
$358.00
$1,504.00
$1,295.00
$1,495.00
$937.00
$1,289.00
$1,222.00
$1,358.00
$2,185.00
$777.00
$1,142.00
$1,151.00
$1,316.00
$1,588.00
$1,606.00
----$112.00
$119.00
$254.00
$111.00
$219.00
$297.00
$324.00
$126.00
$92.00
$16.00
$294.00
$535.00
$943.00
$1,312.00
$132.00
$148.00
$98.00
$127.00
$155.00
$194.00
$216.00
$234.00
$276.00
$169.00
$183.00
$210.00
$240.00
$291.00
$351.00
$155.00
$203.00
$236.00
$292.00
$348.00
$466.00
$876.00
$371.00
$1,318.00
$1,136.00
$1,311.00
$821.00
$1,132.00
$1,073.00
$1,190.00
$1,914.00
$682.00
$1,002.00
$1,009.00
$1,152.00
$1,393.00
$1,408.00
----$62.00
$66.00
$178.00
$57.00
$136.00
$160.00
$285.00
$113.00
$45.00
$12.00
$210.00
$405.00
$756.00
$1,094.00
$57.00
$76.00
$44.00
$68.00
$89.00
$120.00
$135.00
$145.00
$171.00
$99.00
$113.00
$135.00
$156.00
$195.00
$240.00
$88.00
$131.00
$156.00
$200.00
$243.00
$343.00
$580.00
$218.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,420.00
$1,223.00
$1,412.00
$884.00
$1,219.00
$1,155.00
$1,283.00
$2,062.00
$734.00
$1,079.00
$1,087.00
$1,242.00
$1,500.00
$1,517.00
----$66.00
$70.00
$191.00
$60.00
$145.00
$172.00
$306.00
$120.00
$48.00
$12.00
$221.00
$431.00
$803.00
$1,165.00
$61.00
$80.00
$47.00
$72.00
$94.00
$127.00
$143.00
$152.00
$181.00
$105.00
$119.00
$142.00
$164.00
$205.00
$253.00
$93.00
$138.00
$165.00
$211.00
$256.00
$363.00
$612.00
$230.00
$1,504.00
$1,295.00
$1,495.00
$937.00
$1,289.00
$1,222.00
$1,358.00
$2,185.00
$777.00
$1,142.00
$1,151.00
$1,316.00
$1,588.00
$1,606.00
----$69.00
$74.00
$202.00
$64.00
$154.00
$181.00
$324.00
$126.00
$50.00
$13.00
$230.00
$450.00
$839.00
$1,221.00
$64.00
$84.00
$50.00
$75.00
$97.00
$132.00
$148.00
$158.00
$189.00
$109.00
$124.00
$148.00
$171.00
$214.00
$264.00
$96.00
$143.00
$171.00
$219.00
$267.00
$379.00
$636.00
$239.00
124
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
17306
17307
17310
17340
17360
17380
17999
19000
19001
19020
19030
19100
19101
19102
19103
19110
19112
19120
19125
19126
19140
19160
19162
19180
19182
19200
19220
19240
19260
19271
19272
19290
19291
19295
19316
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
0
0
0
10
10
0
YYY
0
ZZZ
90
0
0
10
0
0
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
0
ZZZ
ZZZ
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
$227.00
$232.00
$62.00
$37.00
$96.00
NC
BR
$74.00
$40.00
$288.00
$98.00
$117.00
$338.00
$263.00
$601.00
$406.00
$354.00
$429.00
$468.00
$201.00
$541.00
$485.00
$1,054.00
$689.00
$628.00
$1,192.00
$1,211.00
$1,195.00
$1,101.00
$1,561.00
$1,674.00
$101.00
$52.00
$103.00
$954.00
$1,313.00
$440.00
$656.00
$457.00
$569.00
$545.00
$963.00
$853.00
$755.00
$1,449.00
$1,667.00
$2,737.00
$1,676.00
$2,056.00
$2,444.00
$2,317.00
$662.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$337.00
$337.00
$106.00
$59.00
$153.00
--------$105.00
$63.00
$534.00
$255.00
$140.00
$417.00
$346.00
$796.00
$665.00
$655.00
$555.00
$590.00
$216.00
$747.00
$561.00
$1,153.00
$788.00
$682.00
$1,318.00
$1,335.00
$1,335.00
$1,327.00
$1,648.00
$1,844.00
$208.00
$116.00
$130.00
$980.00
$1,465.00
$542.00
$787.00
$546.00
$687.00
$518.00
$1,023.00
$1,165.00
$1,096.00
$1,518.00
$1,603.00
$3,542.00
$1,717.00
$2,324.00
$2,884.00
$2,714.00
$756.00
$358.00
$358.00
$114.00
$63.00
$163.00
--------$113.00
$67.00
$574.00
$272.00
$150.00
$446.00
$370.00
$851.00
$715.00
$705.00
$597.00
$635.00
$233.00
$804.00
$603.00
$1,241.00
$847.00
$734.00
$1,416.00
$1,435.00
$1,436.00
$1,429.00
$1,782.00
$1,993.00
$222.00
$124.00
$140.00
$1,056.00
$1,579.00
$584.00
$848.00
$588.00
$740.00
$558.00
$1,102.00
$1,255.00
$1,180.00
$1,636.00
$1,727.00
$3,803.00
$1,849.00
$2,504.00
$3,107.00
$2,925.00
$815.00
$371.00
$372.00
$119.00
$66.00
$169.00
--------$118.00
$70.00
$601.00
$282.00
$157.00
$464.00
$385.00
$881.00
$749.00
$737.00
$630.00
$670.00
$247.00
$843.00
$637.00
$1,314.00
$896.00
$777.00
$1,498.00
$1,519.00
$1,521.00
$1,515.00
$1,896.00
$2,120.00
$231.00
$128.00
$145.00
$1,119.00
$1,671.00
$618.00
$897.00
$622.00
$784.00
$592.00
$1,167.00
$1,319.00
$1,238.00
$1,736.00
$1,834.00
$4,019.00
$1,964.00
$2,653.00
$3,294.00
$3,099.00
$862.00
$218.00
$219.00
$49.00
$53.00
$111.00
--------$61.00
$30.00
$367.00
$107.00
$92.00
$265.00
$142.00
$258.00
$460.00
$359.00
$466.00
$503.00
$216.00
$470.00
$561.00
$1,153.00
$788.00
$682.00
$1,318.00
$1,335.00
$1,335.00
$1,327.00
$1,648.00
$1,844.00
$89.00
$44.00
$130.00
$980.00
$1,465.00
$542.00
$787.00
$546.00
$687.00
$518.00
$1,023.00
$841.00
$696.00
$1,518.00
$1,603.00
$3,542.00
$1,717.00
$2,324.00
$2,884.00
$2,714.00
$756.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$230.00
$231.00
$53.00
$56.00
$117.00
--------$65.00
$32.00
$395.00
$113.00
$98.00
$282.00
$151.00
$272.00
$495.00
$386.00
$501.00
$541.00
$233.00
$505.00
$603.00
$1,241.00
$847.00
$734.00
$1,416.00
$1,435.00
$1,436.00
$1,429.00
$1,782.00
$1,993.00
$93.00
$46.00
$140.00
$1,056.00
$1,579.00
$584.00
$848.00
$588.00
$740.00
$558.00
$1,102.00
$906.00
$749.00
$1,636.00
$1,727.00
$3,803.00
$1,849.00
$2,504.00
$3,107.00
$2,925.00
$815.00
$239.00
$240.00
$56.00
$59.00
$122.00
--------$69.00
$33.00
$416.00
$117.00
$103.00
$295.00
$158.00
$283.00
$522.00
$408.00
$531.00
$573.00
$247.00
$534.00
$637.00
$1,314.00
$896.00
$777.00
$1,498.00
$1,519.00
$1,521.00
$1,515.00
$1,896.00
$2,120.00
$97.00
$48.00
$145.00
$1,119.00
$1,671.00
$618.00
$897.00
$622.00
$784.00
$592.00
$1,167.00
$958.00
$793.00
$1,736.00
$1,834.00
$4,019.00
$1,964.00
$2,653.00
$3,294.00
$3,099.00
$862.00
125
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
19371
19380
19396
19499
20000
20005
20100
20101
20102
20103
20150
20200
20205
20206
20220
20225
20240
20245
20250
20251
20500
20501
20520
20525
20526
20550
20551
20552
20553
20600
20605
20610
20612
20615
20650
20660
20661
20662
20663
20665
20670
20680
20690
20692
20693
20694
20802
20805
20808
20816
20822
20824
90
90
0
YYY
10
10
10
10
10
10
90
0
0
0
0
0
10
10
10
10
10
0
10
10
0
0
0
0
0
0
0
0
0
10
10
0
90
90
90
10
10
90
90
90
90
90
90
90
90
90
90
90
$788.00
$780.00
$231.00
BR
$45.00
$267.00
$727.00
$261.00
$314.00
$405.00
$1,141.00
$134.00
$243.00
$119.00
$128.00
$215.00
$279.00
$364.00
$447.00
$511.00
$59.00
$60.00
$75.00
$331.00
$64.00
$40.00
$62.00
$62.00
$62.00
$41.00
$48.00
$49.00
$56.00
$94.00
$170.00
$320.00
$476.00
$559.00
$465.00
$105.00
$80.00
$332.00
$298.00
$516.00
$477.00
$421.00
$3,363.00
$4,317.00
$5,324.00
$3,060.00
$2,511.00
$3,027.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$884.00
$866.00
$428.00
----$223.00
$341.00
$854.00
$319.00
$386.00
$511.00
$1,186.00
$167.00
$322.00
$207.00
$305.00
$314.00
$389.00
$756.00
$498.00
$570.00
$355.00
$193.00
$377.00
$535.00
$89.00
$79.00
$76.00
$69.00
$78.00
$69.00
$76.00
$92.00
$77.00
$364.00
$378.00
$268.00
$642.00
$663.00
$595.00
$181.00
$399.00
$460.00
$296.00
$510.00
$993.00
$706.00
$3,788.00
$4,871.00
$5,935.00
$4,017.00
$3,557.00
$3,993.00
$952.00
$933.00
$461.00
----$238.00
$367.00
$918.00
$340.00
$414.00
$550.00
$1,265.00
$180.00
$346.00
$222.00
$326.00
$336.00
$419.00
$804.00
$535.00
$620.00
$382.00
$207.00
$405.00
$577.00
$94.00
$84.00
$81.00
$74.00
$84.00
$74.00
$82.00
$99.00
$82.00
$391.00
$408.00
$295.00
$702.00
$718.00
$645.00
$196.00
$431.00
$498.00
$321.00
$547.00
$1,075.00
$764.00
$4,118.00
$5,209.00
$6,390.00
$4,318.00
$3,840.00
$4,304.00
$1,008.00
$987.00
$482.00
----$250.00
$387.00
$971.00
$357.00
$435.00
$582.00
$1,326.00
$191.00
$362.00
$230.00
$338.00
$349.00
$440.00
$838.00
$565.00
$660.00
$396.00
$214.00
$422.00
$606.00
$99.00
$88.00
$85.00
$78.00
$88.00
$78.00
$86.00
$104.00
$86.00
$408.00
$428.00
$317.00
$750.00
$762.00
$686.00
$207.00
$451.00
$526.00
$344.00
$578.00
$1,132.00
$804.00
$4,401.00
$5,466.00
$6,755.00
$4,531.00
$4,042.00
$4,531.00
$884.00
$866.00
$174.00
----$175.00
$302.00
$784.00
$250.00
$306.00
$450.00
$1,186.00
$114.00
$180.00
$71.00
$210.00
$248.00
$389.00
$756.00
$498.00
$570.00
$254.00
$53.00
$279.00
$415.00
$71.00
$53.00
$58.00
$52.00
$58.00
$55.00
$56.00
$65.00
$53.00
$258.00
$291.00
$268.00
$642.00
$663.00
$595.00
$140.00
$275.00
$460.00
$296.00
$510.00
$993.00
$566.00
$3,788.00
$4,871.00
$5,935.00
$4,017.00
$3,557.00
$3,993.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$952.00
$933.00
$187.00
----$187.00
$324.00
$842.00
$267.00
$328.00
$485.00
$1,265.00
$123.00
$193.00
$75.00
$225.00
$265.00
$419.00
$804.00
$535.00
$620.00
$273.00
$56.00
$300.00
$448.00
$76.00
$57.00
$62.00
$55.00
$62.00
$59.00
$60.00
$70.00
$56.00
$276.00
$314.00
$295.00
$702.00
$718.00
$645.00
$152.00
$298.00
$498.00
$321.00
$547.00
$1,075.00
$612.00
$4,118.00
$5,209.00
$6,390.00
$4,318.00
$3,840.00
$4,304.00
$1,008.00
$987.00
$199.00
----$197.00
$343.00
$893.00
$281.00
$346.00
$515.00
$1,326.00
$132.00
$205.00
$79.00
$233.00
$276.00
$440.00
$838.00
$565.00
$660.00
$284.00
$58.00
$313.00
$472.00
$79.00
$60.00
$65.00
$59.00
$65.00
$62.00
$63.00
$74.00
$60.00
$290.00
$331.00
$317.00
$750.00
$762.00
$686.00
$161.00
$313.00
$526.00
$344.00
$578.00
$1,132.00
$647.00
$4,401.00
$5,466.00
$6,755.00
$4,531.00
$4,042.00
$4,531.00
126
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
20827
20838
20900
20902
20910
20912
20920
20922
20924
20926
20930
20931
20936
20937
20938
20950
20955
20956
20957
20962
20969
20970
20972
20973
20974
20975
20979
20999
21010
21015
21025
21026
21029
21030
21031
21032
21034
21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
21076
21077
21079
21080
21081
90
90
90
90
90
90
90
90
90
90
0
ZZZ
0
ZZZ
ZZZ
0
90
90
90
90
90
90
90
90
0
0
0
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
$3,920.00
$3,484.00
$454.00
$658.00
$338.00
$549.00
$460.00
$634.00
$583.00
$444.00
BR
$156.00
BR
$234.00
$257.00
$123.00
$3,332.00
$3,167.00
$3,074.00
$3,122.00
$3,716.00
$3,650.00
$3,420.00
$3,821.00
$266.00
$334.00
$19.00
BR
$854.00
$520.00
$546.00
$413.00
$700.00
$496.00
$310.00
$315.00
$1,140.00
$227.00
$957.00
$1,313.00
$899.00
$1,109.00
$925.00
$1,051.00
$1,026.00
$972.00
$679.00
$1,192.00
$3,002.00
$2,086.00
$2,346.00
$2,138.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$3,731.00
$3,853.00
$652.00
$895.00
$732.00
$720.00
$573.00
$826.00
$728.00
$638.00
----$160.00
----$241.00
$263.00
$183.00
$3,702.00
$3,750.00
$3,447.00
$3,688.00
$4,054.00
$3,928.00
$3,450.00
$3,976.00
$57.00
$225.00
$69.00
----$893.00
$645.00
$915.00
$532.00
$774.00
$447.00
$344.00
$342.00
$1,421.00
$391.00
$1,040.00
$1,391.00
$1,226.00
$1,522.00
$1,262.00
$1,435.00
$1,162.00
$1,081.00
$747.00
$1,225.00
$3,082.00
$2,048.00
$2,351.00
$2,113.00
$4,028.00
$4,188.00
$707.00
$970.00
$786.00
$772.00
$617.00
$894.00
$787.00
$691.00
----$176.00
----$263.00
$289.00
$198.00
$3,992.00
$4,081.00
$3,751.00
$3,999.00
$4,357.00
$4,233.00
$3,756.00
$4,277.00
$63.00
$246.00
$74.00
----$948.00
$693.00
$978.00
$570.00
$832.00
$486.00
$369.00
$366.00
$1,521.00
$415.00
$1,110.00
$1,485.00
$1,311.00
$1,627.00
$1,347.00
$1,522.00
$1,243.00
$1,166.00
$799.00
$1,317.00
$3,315.00
$2,185.00
$2,529.00
$2,260.00
$4,241.00
$4,475.00
$750.00
$1,029.00
$824.00
$809.00
$650.00
$946.00
$833.00
$732.00
----$191.00
----$283.00
$312.00
$208.00
$4,228.00
$4,364.00
$4,020.00
$4,261.00
$4,602.00
$4,483.00
$4,034.00
$4,527.00
$67.00
$265.00
$77.00
----$988.00
$728.00
$1,027.00
$598.00
$876.00
$518.00
$387.00
$384.00
$1,602.00
$432.00
$1,164.00
$1,559.00
$1,376.00
$1,714.00
$1,413.00
$1,590.00
$1,302.00
$1,232.00
$840.00
$1,393.00
$3,505.00
$2,289.00
$2,672.00
$2,376.00
$3,731.00
$3,853.00
$642.00
$895.00
$627.00
$720.00
$573.00
$701.00
$728.00
$638.00
----$160.00
----$241.00
$263.00
$183.00
$3,702.00
$3,750.00
$3,447.00
$3,688.00
$4,054.00
$3,928.00
$3,450.00
$3,976.00
$53.00
$225.00
$51.00
----$893.00
$645.00
$891.00
$517.00
$735.00
$412.00
$287.00
$292.00
$1,420.00
$333.00
$1,040.00
$1,391.00
$1,226.00
$1,522.00
$1,262.00
$1,435.00
$1,162.00
$1,081.00
$747.00
$1,110.00
$2,792.00
$1,830.00
$2,106.00
$1,890.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$4,028.00
$4,188.00
$696.00
$970.00
$673.00
$772.00
$617.00
$760.00
$787.00
$691.00
----$176.00
----$263.00
$289.00
$198.00
$3,992.00
$4,081.00
$3,751.00
$3,999.00
$4,357.00
$4,233.00
$3,756.00
$4,277.00
$58.00
$246.00
$54.00
----$948.00
$693.00
$953.00
$554.00
$789.00
$448.00
$307.00
$312.00
$1,520.00
$353.00
$1,110.00
$1,485.00
$1,311.00
$1,627.00
$1,347.00
$1,522.00
$1,243.00
$1,166.00
$799.00
$1,194.00
$3,003.00
$1,950.00
$2,265.00
$2,021.00
$4,241.00
$4,475.00
$738.00
$1,029.00
$707.00
$809.00
$650.00
$807.00
$833.00
$732.00
----$191.00
----$283.00
$312.00
$208.00
$4,228.00
$4,364.00
$4,020.00
$4,261.00
$4,602.00
$4,483.00
$4,034.00
$4,527.00
$62.00
$265.00
$57.00
----$988.00
$728.00
$1,001.00
$581.00
$833.00
$479.00
$323.00
$329.00
$1,600.00
$368.00
$1,164.00
$1,559.00
$1,376.00
$1,714.00
$1,413.00
$1,590.00
$1,302.00
$1,232.00
$840.00
$1,265.00
$3,183.00
$2,047.00
$2,399.00
$2,128.00
127
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
21082
21083
21084
21085
21086
21087
21088
21089
21100
21110
21116
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199
21206
21208
21209
21210
21215
FUD 2003 MRA
90
90
90
10
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$1,855.00
$1,802.00
$2,105.00
$801.00
$2,333.00
$2,217.00
BR
BR
$297.00
$371.00
$207.00
$500.00
$651.00
$700.00
$903.00
$656.00
$909.00
$797.00
$960.00
$1,168.00
$1,438.00
$1,527.00
$1,511.00
$1,513.00
$1,570.00
$1,639.00
$1,914.00
$2,264.00
$2,364.00
$2,640.00
$3,302.00
$3,500.00
$2,111.00
$2,604.00
$1,826.00
$2,035.00
$813.00
$2,570.00
$2,770.00
$3,150.00
$1,786.00
$1,331.00
$1,540.00
$1,360.00
$1,764.00
$1,268.00
$1,018.00
$1,112.00
$946.00
$576.00
$930.00
$970.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,863.00
$1,807.00
$2,061.00
$805.00
$2,290.00
$2,255.00
--------$513.00
$539.00
$420.00
$744.00
$807.00
$838.00
$1,030.00
$1,044.00
$1,085.00
$919.00
$1,166.00
$1,277.00
$1,541.00
$1,612.00
$1,583.00
$1,685.00
$1,759.00
$1,784.00
$2,134.00
$2,521.00
$2,816.00
$3,098.00
$3,813.00
$3,918.00
$2,291.00
$2,979.00
$2,148.00
$2,311.00
$967.00
$2,848.00
$3,115.00
$3,372.00
$2,009.00
$1,486.00
$1,706.00
$1,546.00
$1,684.00
$1,347.00
$1,338.00
$1,247.00
$1,046.00
$765.00
$1,009.00
$1,042.00
$1,986.00
$1,944.00
$2,198.00
$858.00
$2,445.00
$2,417.00
--------$545.00
$573.00
$451.00
$795.00
$862.00
$894.00
$1,108.00
$1,114.00
$1,158.00
$976.00
$1,260.00
$1,361.00
$1,652.00
$1,714.00
$1,673.00
$1,815.00
$1,893.00
$1,901.00
$2,256.00
$2,688.00
$3,075.00
$3,385.00
$4,166.00
$4,206.00
$2,440.00
$3,252.00
$2,316.00
$2,475.00
$1,039.00
$3,043.00
$3,328.00
$3,634.00
$2,150.00
$1,593.00
$1,819.00
$1,648.00
$1,803.00
$1,439.00
$1,430.00
$1,330.00
$1,122.00
$821.00
$1,081.00
$1,120.00
$2,081.00
$2,054.00
$2,303.00
$900.00
$2,565.00
$2,547.00
--------$565.00
$596.00
$467.00
$826.00
$902.00
$936.00
$1,172.00
$1,165.00
$1,211.00
$1,017.00
$1,338.00
$1,426.00
$1,743.00
$1,793.00
$1,742.00
$1,924.00
$2,006.00
$1,994.00
$2,346.00
$2,817.00
$3,303.00
$3,638.00
$4,479.00
$4,445.00
$2,559.00
$3,492.00
$2,452.00
$2,604.00
$1,096.00
$3,198.00
$3,497.00
$3,852.00
$2,261.00
$1,680.00
$1,907.00
$1,727.00
$1,899.00
$1,509.00
$1,504.00
$1,395.00
$1,180.00
$861.00
$1,136.00
$1,181.00
$1,684.00
$1,619.00
$1,842.00
$728.00
$2,047.00
$2,041.00
--------$421.00
$490.00
$58.00
$563.00
$723.00
$838.00
$1,030.00
$973.00
$973.00
$919.00
$1,166.00
$1,277.00
$1,541.00
$1,612.00
$1,583.00
$1,685.00
$1,759.00
$1,784.00
$2,134.00
$2,521.00
$2,816.00
$3,098.00
$3,813.00
$3,918.00
$2,291.00
$2,979.00
$2,148.00
$2,311.00
$967.00
$2,848.00
$3,115.00
$3,372.00
$2,009.00
$1,486.00
$1,706.00
$1,546.00
$1,684.00
$1,347.00
$1,338.00
$1,247.00
$981.00
$659.00
$968.00
$953.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,794.00
$1,741.00
$1,962.00
$776.00
$2,184.00
$2,187.00
--------$446.00
$521.00
$62.00
$600.00
$772.00
$894.00
$1,108.00
$1,037.00
$1,037.00
$976.00
$1,260.00
$1,361.00
$1,652.00
$1,714.00
$1,673.00
$1,815.00
$1,893.00
$1,901.00
$2,256.00
$2,688.00
$3,075.00
$3,385.00
$4,166.00
$4,206.00
$2,440.00
$3,252.00
$2,316.00
$2,475.00
$1,039.00
$3,043.00
$3,328.00
$3,634.00
$2,150.00
$1,593.00
$1,819.00
$1,648.00
$1,803.00
$1,439.00
$1,430.00
$1,330.00
$1,052.00
$706.00
$1,037.00
$1,024.00
$1,882.00
$1,845.00
$2,059.00
$815.00
$2,295.00
$2,309.00
--------$463.00
$543.00
$65.00
$625.00
$809.00
$936.00
$1,172.00
$1,086.00
$1,087.00
$1,017.00
$1,338.00
$1,426.00
$1,743.00
$1,793.00
$1,742.00
$1,924.00
$2,006.00
$1,994.00
$2,346.00
$2,817.00
$3,303.00
$3,638.00
$4,479.00
$4,445.00
$2,559.00
$3,492.00
$2,452.00
$2,604.00
$1,096.00
$3,198.00
$3,497.00
$3,852.00
$2,261.00
$1,680.00
$1,907.00
$1,727.00
$1,899.00
$1,509.00
$1,504.00
$1,395.00
$1,107.00
$743.00
$1,090.00
$1,082.00
128
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
21230
21235
21240
21242
21243
21244
21245
21246
21247
21248
21249
21255
21256
21260
21261
21263
21267
21268
21270
21275
21280
21282
21295
21296
21299
21300
21310
21315
21320
21325
21330
21335
21336
21337
21338
21339
21340
21343
21344
21345
21346
21347
21348
21355
21356
21360
21365
21366
21385
21386
21387
21390
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
10
90
90
90
90
90
90
90
$956.00
$707.00
$1,281.00
$1,207.00
$1,501.00
$1,062.00
$1,038.00
$1,010.00
$2,003.00
$1,023.00
$1,525.00
$1,459.00
$1,470.00
$1,372.00
$2,347.00
$2,361.00
$1,539.00
$1,946.00
$890.00
$963.00
$571.00
$360.00
$144.00
$384.00
BR
$107.00
$81.00
$180.00
$235.00
$348.00
$639.00
$852.00
$478.00
$300.00
$550.00
$689.00
$907.00
$1,043.00
$1,450.00
$738.00
$917.00
$1,048.00
$1,286.00
$295.00
$372.00
$590.00
$1,239.00
$1,386.00
$810.00
$812.00
$958.00
$920.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,093.00
$966.00
$1,331.00
$1,281.00
$1,835.00
$1,104.00
$1,246.00
$1,208.00
$2,079.00
$1,080.00
$1,531.00
$1,471.00
$1,527.00
$1,433.00
$2,728.00
$2,200.00
$1,742.00
$2,066.00
$1,026.00
$1,157.00
$616.00
$440.00
$297.00
$455.00
----$175.00
$163.00
$251.00
$338.00
$388.00
$570.00
$823.00
$587.00
$405.00
$649.00
$782.00
$1,039.00
$1,195.00
$1,757.00
$923.00
$1,078.00
$1,174.00
$1,468.00
$423.00
$389.00
$633.00
$1,386.00
$1,564.00
$868.00
$898.00
$938.00
$967.00
$1,173.00
$1,035.00
$1,424.00
$1,380.00
$1,967.00
$1,181.00
$1,332.00
$1,298.00
$2,234.00
$1,158.00
$1,636.00
$1,567.00
$1,627.00
$1,530.00
$2,907.00
$2,347.00
$1,859.00
$2,177.00
$1,095.00
$1,241.00
$654.00
$469.00
$319.00
$486.00
----$189.00
$175.00
$269.00
$363.00
$416.00
$611.00
$879.00
$628.00
$434.00
$695.00
$840.00
$1,111.00
$1,279.00
$1,882.00
$987.00
$1,153.00
$1,259.00
$1,574.00
$452.00
$417.00
$677.00
$1,485.00
$1,672.00
$926.00
$961.00
$1,004.00
$1,031.00
$1,233.00
$1,080.00
$1,496.00
$1,459.00
$2,073.00
$1,240.00
$1,394.00
$1,369.00
$2,359.00
$1,219.00
$1,720.00
$1,641.00
$1,701.00
$1,607.00
$3,048.00
$2,470.00
$1,948.00
$2,256.00
$1,147.00
$1,306.00
$679.00
$489.00
$333.00
$508.00
----$197.00
$182.00
$280.00
$378.00
$436.00
$642.00
$921.00
$658.00
$453.00
$730.00
$885.00
$1,166.00
$1,344.00
$1,983.00
$1,032.00
$1,210.00
$1,326.00
$1,660.00
$473.00
$439.00
$710.00
$1,563.00
$1,757.00
$970.00
$1,010.00
$1,054.00
$1,080.00
$1,093.00
$763.00
$1,331.00
$1,281.00
$1,835.00
$1,104.00
$1,149.00
$1,208.00
$2,079.00
$1,020.00
$1,467.00
$1,471.00
$1,527.00
$1,433.00
$2,728.00
$2,200.00
$1,742.00
$2,066.00
$1,026.00
$1,157.00
$616.00
$440.00
$297.00
$455.00
----$55.00
$40.00
$146.00
$202.00
$388.00
$570.00
$823.00
$587.00
$308.00
$649.00
$782.00
$1,039.00
$1,195.00
$1,757.00
$834.00
$1,078.00
$1,174.00
$1,468.00
$319.00
$389.00
$633.00
$1,386.00
$1,564.00
$868.00
$898.00
$938.00
$967.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,173.00
$816.00
$1,424.00
$1,380.00
$1,967.00
$1,181.00
$1,227.00
$1,298.00
$2,234.00
$1,093.00
$1,568.00
$1,567.00
$1,627.00
$1,530.00
$2,907.00
$2,347.00
$1,859.00
$2,177.00
$1,095.00
$1,241.00
$654.00
$469.00
$319.00
$486.00
----$59.00
$42.00
$156.00
$216.00
$416.00
$611.00
$879.00
$628.00
$330.00
$695.00
$840.00
$1,111.00
$1,279.00
$1,882.00
$891.00
$1,153.00
$1,259.00
$1,574.00
$341.00
$417.00
$677.00
$1,485.00
$1,672.00
$926.00
$961.00
$1,004.00
$1,031.00
$1,233.00
$854.00
$1,496.00
$1,459.00
$2,073.00
$1,240.00
$1,286.00
$1,369.00
$2,359.00
$1,152.00
$1,649.00
$1,641.00
$1,701.00
$1,607.00
$3,048.00
$2,470.00
$1,948.00
$2,256.00
$1,147.00
$1,306.00
$679.00
$489.00
$333.00
$508.00
----$63.00
$45.00
$163.00
$226.00
$436.00
$642.00
$921.00
$658.00
$346.00
$730.00
$885.00
$1,166.00
$1,344.00
$1,983.00
$933.00
$1,210.00
$1,326.00
$1,660.00
$358.00
$439.00
$710.00
$1,563.00
$1,757.00
$970.00
$1,010.00
$1,054.00
$1,080.00
129
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
21395
21400
21401
21406
21407
21408
21421
21422
21423
21431
21432
21433
21435
21436
21440
21445
21450
21451
21452
21453
21454
21461
21462
21465
21470
21480
21485
21490
21493
21494
21495
21497
21499
21501
21502
21510
21550
21555
21556
21557
21600
21610
21615
21616
21620
21627
21630
21632
21700
21705
21720
21725
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
YYY
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$1,384.00
$143.00
$313.00
$852.00
$736.00
$1,007.00
$528.00
$761.00
$890.00
$598.00
$744.00
$1,981.00
$1,404.00
$2,045.00
$308.00
$533.00
$325.00
$498.00
$195.00
$902.00
$905.00
$769.00
$1,012.00
$923.00
$1,331.00
$82.00
$318.00
$865.00
$107.00
$529.00
$500.00
$372.00
BR
$315.00
$612.00
$534.00
$165.00
$337.00
$431.00
$794.00
$631.00
$828.00
$938.00
$1,042.00
$689.00
$686.00
$1,455.00
$1,514.00
$576.00
$746.00
$523.00
$588.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,185.00
$230.00
$421.00
$719.00
$854.00
$1,190.00
$648.00
$828.00
$975.00
$717.00
$845.00
$2,266.00
$1,586.00
$2,395.00
$427.00
$649.00
$499.00
$593.00
$566.00
$676.00
$642.00
$905.00
$1,058.00
$1,036.00
$1,343.00
$111.00
$408.00
$1,050.00
$235.00
$591.00
$556.00
$445.00
----$429.00
$771.00
$681.00
$225.00
$453.00
$469.00
$875.00
$768.00
$1,402.00
$967.00
$1,142.00
$783.00
$1,008.00
$1,658.00
$1,644.00
$780.00
$913.00
$725.00
$773.00
$1,269.00
$247.00
$453.00
$770.00
$913.00
$1,280.00
$694.00
$886.00
$1,046.00
$768.00
$901.00
$2,435.00
$1,704.00
$2,562.00
$458.00
$698.00
$535.00
$635.00
$607.00
$726.00
$688.00
$971.00
$1,133.00
$1,105.00
$1,439.00
$119.00
$436.00
$1,132.00
$252.00
$630.00
$594.00
$477.00
----$460.00
$832.00
$735.00
$240.00
$486.00
$503.00
$940.00
$829.00
$1,518.00
$1,045.00
$1,230.00
$844.00
$1,088.00
$1,789.00
$1,777.00
$831.00
$981.00
$785.00
$836.00
$1,335.00
$258.00
$476.00
$809.00
$957.00
$1,351.00
$726.00
$931.00
$1,102.00
$806.00
$941.00
$2,572.00
$1,798.00
$2,697.00
$478.00
$734.00
$557.00
$665.00
$630.00
$761.00
$722.00
$1,020.00
$1,188.00
$1,158.00
$1,517.00
$124.00
$458.00
$1,201.00
$263.00
$660.00
$622.00
$499.00
----$484.00
$878.00
$775.00
$251.00
$512.00
$531.00
$991.00
$876.00
$1,614.00
$1,109.00
$1,302.00
$891.00
$1,144.00
$1,895.00
$1,889.00
$863.00
$1,034.00
$832.00
$886.00
$1,185.00
$129.00
$337.00
$719.00
$854.00
$1,190.00
$582.00
$828.00
$975.00
$717.00
$845.00
$2,266.00
$1,586.00
$2,395.00
$327.00
$558.00
$298.00
$545.00
$313.00
$622.00
$642.00
$841.00
$937.00
$1,036.00
$1,343.00
$43.00
$386.00
$1,050.00
$235.00
$591.00
$556.00
$407.00
----$390.00
$771.00
$681.00
$171.00
$364.00
$469.00
$875.00
$768.00
$1,402.00
$967.00
$1,142.00
$783.00
$1,008.00
$1,658.00
$1,644.00
$684.00
$913.00
$679.00
$773.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,269.00
$138.00
$363.00
$770.00
$913.00
$1,280.00
$624.00
$886.00
$1,046.00
$768.00
$901.00
$2,435.00
$1,704.00
$2,562.00
$351.00
$600.00
$318.00
$584.00
$335.00
$667.00
$688.00
$902.00
$1,003.00
$1,105.00
$1,439.00
$46.00
$412.00
$1,132.00
$252.00
$630.00
$594.00
$436.00
----$418.00
$832.00
$735.00
$182.00
$391.00
$503.00
$940.00
$829.00
$1,518.00
$1,045.00
$1,230.00
$844.00
$1,088.00
$1,789.00
$1,777.00
$728.00
$981.00
$736.00
$836.00
$1,335.00
$146.00
$383.00
$809.00
$957.00
$1,351.00
$653.00
$931.00
$1,102.00
$806.00
$941.00
$2,572.00
$1,798.00
$2,697.00
$367.00
$633.00
$334.00
$611.00
$349.00
$700.00
$722.00
$948.00
$1,054.00
$1,158.00
$1,517.00
$48.00
$433.00
$1,201.00
$263.00
$660.00
$622.00
$457.00
----$441.00
$878.00
$775.00
$191.00
$413.00
$531.00
$991.00
$876.00
$1,614.00
$1,109.00
$1,302.00
$891.00
$1,144.00
$1,895.00
$1,889.00
$757.00
$1,034.00
$781.00
$886.00
130
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
21740
21742
21743
21750
21800
21805
21810
21820
21825
21899
21920
21925
21930
21935
22100
22101
22102
22103
22110
22112
22114
22116
22210
22212
22214
22216
22220
22222
22224
22226
22305
22310
22315
22318
22319
22325
22326
22327
22328
22505
22520
22521
22522
22548
22554
22556
22558
22585
22590
22595
22600
22610
90
90
90
90
90
90
90
90
90
YYY
10
90
90
90
90
90
90
ZZZ
90
90
90
ZZZ
90
90
90
ZZZ
90
90
90
ZZZ
90
90
90
90
90
90
90
90
ZZZ
10
10
10
ZZZ
90
90
90
90
ZZZ
90
90
90
90
$1,387.00
BR
BR
$1,009.00
$84.00
$236.00
$540.00
$143.00
$810.00
BR
$165.00
$371.00
$403.00
$1,280.00
$850.00
$862.00
$781.00
$198.00
$889.00
$1,090.00
$1,062.00
$195.00
$1,892.00
$1,668.00
$819.00
$492.00
$1,801.00
$1,604.00
$1,731.00
$488.00
$213.00
$272.00
$711.00
$1,755.00
$1,983.00
$1,407.00
$1,710.00
$1,660.00
$391.00
$174.00
$509.00
$477.00
$231.00
$2,271.00
$1,727.00
$2,054.00
$1,907.00
$473.00
$1,895.00
$1,960.00
$1,567.00
$1,494.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,569.00
--------$1,109.00
$170.00
$386.00
$727.00
$216.00
$927.00
----$231.00
$835.00
$507.00
$1,657.00
$998.00
$1,008.00
$1,015.00
$202.00
$1,302.00
$1,284.00
$1,281.00
$201.00
$2,305.00
$1,868.00
$1,893.00
$524.00
$2,066.00
$1,918.00
$2,055.00
$524.00
$287.00
$401.00
$954.00
$2,070.00
$2,350.00
$1,765.00
$1,945.00
$1,837.00
$388.00
$345.00
$706.00
$665.00
$322.00
$2,411.00
$1,779.00
$2,150.00
$1,979.00
$481.00
$1,942.00
$1,849.00
$1,554.00
$1,541.00
$1,697.00
--------$1,199.00
$183.00
$416.00
$780.00
$233.00
$999.00
----$246.00
$898.00
$545.00
$1,784.00
$1,088.00
$1,098.00
$1,104.00
$221.00
$1,425.00
$1,399.00
$1,396.00
$220.00
$2,527.00
$2,031.00
$2,058.00
$573.00
$2,262.00
$2,087.00
$2,237.00
$574.00
$311.00
$434.00
$1,039.00
$2,282.00
$2,590.00
$1,919.00
$2,133.00
$1,997.00
$422.00
$374.00
$761.00
$717.00
$344.00
$2,656.00
$1,957.00
$2,349.00
$2,153.00
$529.00
$2,134.00
$2,032.00
$1,705.00
$1,685.00
$1,803.00
--------$1,272.00
$191.00
$437.00
$819.00
$245.00
$1,053.00
----$256.00
$938.00
$574.00
$1,887.00
$1,164.00
$1,174.00
$1,178.00
$238.00
$1,530.00
$1,496.00
$1,494.00
$238.00
$2,722.00
$2,169.00
$2,196.00
$617.00
$2,432.00
$2,235.00
$2,393.00
$619.00
$329.00
$458.00
$1,109.00
$2,471.00
$2,803.00
$2,048.00
$2,298.00
$2,133.00
$453.00
$393.00
$810.00
$763.00
$362.00
$2,877.00
$2,115.00
$2,525.00
$2,305.00
$572.00
$2,306.00
$2,196.00
$1,838.00
$1,810.00
$1,569.00
--------$1,109.00
$107.00
$386.00
$727.00
$150.00
$927.00
----$148.00
$482.00
$411.00
$1,657.00
$998.00
$1,008.00
$1,015.00
$202.00
$1,302.00
$1,284.00
$1,281.00
$201.00
$2,305.00
$1,868.00
$1,893.00
$524.00
$2,066.00
$1,918.00
$2,055.00
$524.00
$259.00
$371.00
$954.00
$2,070.00
$2,350.00
$1,765.00
$1,945.00
$1,837.00
$388.00
$267.00
$706.00
$665.00
$322.00
$2,411.00
$1,779.00
$2,150.00
$1,979.00
$481.00
$1,942.00
$1,849.00
$1,554.00
$1,541.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,697.00
--------$1,199.00
$115.00
$416.00
$780.00
$162.00
$999.00
----$157.00
$518.00
$441.00
$1,784.00
$1,088.00
$1,098.00
$1,104.00
$221.00
$1,425.00
$1,399.00
$1,396.00
$220.00
$2,527.00
$2,031.00
$2,058.00
$573.00
$2,262.00
$2,087.00
$2,237.00
$574.00
$281.00
$402.00
$1,039.00
$2,282.00
$2,590.00
$1,919.00
$2,133.00
$1,997.00
$422.00
$289.00
$761.00
$717.00
$344.00
$2,656.00
$1,957.00
$2,349.00
$2,153.00
$529.00
$2,134.00
$2,032.00
$1,705.00
$1,685.00
$1,803.00
--------$1,272.00
$120.00
$437.00
$819.00
$171.00
$1,053.00
----$164.00
$546.00
$467.00
$1,887.00
$1,164.00
$1,174.00
$1,178.00
$238.00
$1,530.00
$1,496.00
$1,494.00
$238.00
$2,722.00
$2,169.00
$2,196.00
$617.00
$2,432.00
$2,235.00
$2,393.00
$619.00
$298.00
$425.00
$1,109.00
$2,471.00
$2,803.00
$2,048.00
$2,298.00
$2,133.00
$453.00
$306.00
$810.00
$763.00
$362.00
$2,877.00
$2,115.00
$2,525.00
$2,305.00
$572.00
$2,306.00
$2,196.00
$1,838.00
$1,810.00
131
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
22612
22614
22630
22632
22800
22802
22804
22808
22810
22812
22818
22819
22830
22840
22841
22842
22843
22844
22845
22846
22847
22848
22849
22850
22851
22852
22855
22899
22900
22999
23000
23020
23030
23031
23035
23040
23044
23065
23066
23075
23076
23077
23100
23101
23105
23106
23107
23120
23125
23130
23140
23145
90
ZZZ
90
ZZZ
90
90
90
90
90
90
90
90
90
ZZZ
0
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
90
90
ZZZ
90
90
YYY
90
YYY
90
90
10
10
90
90
90
10
90
10
90
90
90
90
90
90
90
90
90
90
90
90
$1,861.00
$530.00
$1,201.00
$442.00
$1,960.00
$2,633.00
$2,951.00
$2,157.00
$2,356.00
$2,675.00
$2,701.00
$2,968.00
$1,176.00
$943.00
BR
$2,352.00
$1,028.00
$1,277.00
$1,853.00
$999.00
$1,077.00
$529.00
$2,235.00
$872.00
$600.00
$854.00
$1,193.00
BR
$446.00
BR
$447.00
$807.00
$323.00
$185.00
$861.00
$898.00
$708.00
$171.00
$302.00
$247.00
$613.00
$1,228.00
$616.00
$583.00
$814.00
$581.00
$851.00
$645.00
$865.00
$722.00
$597.00
$889.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,968.00
$559.00
$1,976.00
$455.00
$1,727.00
$2,812.00
$3,290.00
$2,418.00
$2,726.00
$2,934.00
$2,874.00
$3,171.00
$1,063.00
$1,087.00
----$1,091.00
$1,143.00
$1,421.00
$1,049.00
$1,088.00
$1,198.00
$518.00
$1,786.00
$991.00
$577.00
$946.00
$1,486.00
----$538.00
----$689.00
$1,062.00
$504.00
$451.00
$1,280.00
$1,137.00
$957.00
$255.00
$629.00
$397.00
$850.00
$1,621.00
$800.00
$776.00
$1,001.00
$803.00
$1,034.00
$907.00
$1,094.00
$945.00
$820.00
$1,124.00
$2,147.00
$611.00
$2,170.00
$499.00
$1,881.00
$3,059.00
$3,580.00
$2,646.00
$2,970.00
$3,191.00
$3,139.00
$3,451.00
$1,160.00
$1,189.00
----$1,193.00
$1,249.00
$1,549.00
$1,155.00
$1,197.00
$1,314.00
$564.00
$1,948.00
$1,080.00
$632.00
$1,031.00
$1,630.00
----$578.00
----$742.00
$1,151.00
$544.00
$487.00
$1,386.00
$1,233.00
$1,036.00
$272.00
$679.00
$428.00
$917.00
$1,748.00
$866.00
$840.00
$1,084.00
$870.00
$1,120.00
$983.00
$1,185.00
$1,024.00
$886.00
$1,218.00
$2,303.00
$658.00
$2,342.00
$539.00
$2,012.00
$3,273.00
$3,831.00
$2,847.00
$3,183.00
$3,415.00
$3,372.00
$3,697.00
$1,243.00
$1,281.00
----$1,286.00
$1,344.00
$1,661.00
$1,252.00
$1,296.00
$1,419.00
$605.00
$2,086.00
$1,155.00
$682.00
$1,101.00
$1,757.00
----$611.00
----$779.00
$1,220.00
$572.00
$511.00
$1,462.00
$1,306.00
$1,095.00
$284.00
$714.00
$448.00
$968.00
$1,849.00
$915.00
$887.00
$1,149.00
$919.00
$1,187.00
$1,041.00
$1,256.00
$1,085.00
$935.00
$1,289.00
$1,968.00
$559.00
$1,976.00
$455.00
$1,727.00
$2,812.00
$3,290.00
$2,418.00
$2,726.00
$2,934.00
$2,874.00
$3,171.00
$1,063.00
$1,087.00
----$1,091.00
$1,143.00
$1,421.00
$1,049.00
$1,088.00
$1,198.00
$518.00
$1,786.00
$991.00
$577.00
$946.00
$1,486.00
----$538.00
----$611.00
$1,062.00
$421.00
$371.00
$1,280.00
$1,137.00
$957.00
$188.00
$558.00
$293.00
$850.00
$1,621.00
$800.00
$776.00
$1,001.00
$803.00
$1,034.00
$907.00
$1,094.00
$945.00
$820.00
$1,124.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,147.00
$611.00
$2,170.00
$499.00
$1,881.00
$3,059.00
$3,580.00
$2,646.00
$2,970.00
$3,191.00
$3,139.00
$3,451.00
$1,160.00
$1,189.00
----$1,193.00
$1,249.00
$1,549.00
$1,155.00
$1,197.00
$1,314.00
$564.00
$1,948.00
$1,080.00
$632.00
$1,031.00
$1,630.00
----$578.00
----$659.00
$1,151.00
$455.00
$400.00
$1,386.00
$1,233.00
$1,036.00
$200.00
$602.00
$315.00
$917.00
$1,748.00
$866.00
$840.00
$1,084.00
$870.00
$1,120.00
$983.00
$1,185.00
$1,024.00
$886.00
$1,218.00
$2,303.00
$658.00
$2,342.00
$539.00
$2,012.00
$3,273.00
$3,831.00
$2,847.00
$3,183.00
$3,415.00
$3,372.00
$3,697.00
$1,243.00
$1,281.00
----$1,286.00
$1,344.00
$1,661.00
$1,252.00
$1,296.00
$1,419.00
$605.00
$2,086.00
$1,155.00
$682.00
$1,101.00
$1,757.00
----$611.00
----$693.00
$1,220.00
$480.00
$421.00
$1,462.00
$1,306.00
$1,095.00
$209.00
$634.00
$331.00
$968.00
$1,849.00
$915.00
$887.00
$1,149.00
$919.00
$1,187.00
$1,041.00
$1,256.00
$1,085.00
$935.00
$1,289.00
132
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
23146
23150
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23221
23222
23330
23331
23332
23350
23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23455
23460
23462
23465
23466
23470
23472
23480
23485
23490
23491
23500
23505
23515
23520
23525
23530
23532
23540
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$704.00
$755.00
$945.00
$794.00
$645.00
$638.00
$882.00
$566.00
$865.00
$962.00
$656.00
$902.00
$1,095.00
$1,095.00
$1,307.00
$1,559.00
$1,921.00
$59.00
$520.00
$1,029.00
$74.00
$1,366.00
$1,403.00
$1,196.00
$799.00
$977.00
$1,119.00
$1,229.00
$622.00
$1,276.00
$884.00
$906.00
$1,210.00
$1,340.00
$1,364.00
$1,383.00
$1,398.00
$1,332.00
$1,540.00
$1,570.00
$926.00
$1,181.00
$1,038.00
$1,251.00
$148.00
$293.00
$688.00
$205.00
$320.00
$659.00
$713.00
$148.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,019.00
$1,005.00
$1,213.00
$1,036.00
$943.00
$930.00
$1,156.00
$1,325.00
$1,303.00
$1,384.00
$852.00
$1,124.00
$1,410.00
$1,437.00
$1,630.00
$1,889.00
$2,445.00
$385.00
$927.00
$1,293.00
$409.00
$1,690.00
$1,668.00
$1,515.00
$965.00
$1,217.00
$1,361.00
$1,438.00
$1,100.00
$1,486.00
$1,153.00
$1,198.00
$1,442.00
$1,529.00
$1,618.00
$1,597.00
$1,598.00
$1,519.00
$1,623.00
$1,927.00
$1,255.00
$1,445.00
$1,264.00
$1,514.00
$320.00
$520.00
$850.00
$326.00
$502.00
$822.00
$895.00
$356.00
$1,105.00
$1,089.00
$1,309.00
$1,122.00
$1,019.00
$1,007.00
$1,253.00
$1,433.00
$1,408.00
$1,496.00
$922.00
$1,219.00
$1,524.00
$1,555.00
$1,768.00
$2,051.00
$2,655.00
$414.00
$1,005.00
$1,403.00
$439.00
$1,834.00
$1,810.00
$1,644.00
$1,046.00
$1,320.00
$1,476.00
$1,561.00
$1,194.00
$1,612.00
$1,250.00
$1,299.00
$1,564.00
$1,659.00
$1,756.00
$1,734.00
$1,719.00
$1,648.00
$1,763.00
$2,079.00
$1,362.00
$1,567.00
$1,357.00
$1,644.00
$346.00
$563.00
$922.00
$352.00
$542.00
$887.00
$971.00
$383.00
$1,170.00
$1,154.00
$1,381.00
$1,189.00
$1,073.00
$1,064.00
$1,327.00
$1,511.00
$1,482.00
$1,577.00
$977.00
$1,294.00
$1,611.00
$1,646.00
$1,878.00
$2,182.00
$2,828.00
$432.00
$1,064.00
$1,490.00
$454.00
$1,952.00
$1,926.00
$1,746.00
$1,108.00
$1,401.00
$1,569.00
$1,660.00
$1,268.00
$1,713.00
$1,327.00
$1,380.00
$1,663.00
$1,765.00
$1,869.00
$1,847.00
$1,813.00
$1,754.00
$1,882.00
$2,205.00
$1,446.00
$1,665.00
$1,428.00
$1,749.00
$364.00
$594.00
$978.00
$370.00
$571.00
$937.00
$1,032.00
$401.00
$1,019.00
$1,005.00
$1,213.00
$1,036.00
$943.00
$930.00
$1,156.00
$1,325.00
$1,303.00
$1,384.00
$852.00
$1,124.00
$1,410.00
$1,437.00
$1,630.00
$1,889.00
$2,445.00
$288.00
$927.00
$1,293.00
$70.00
$1,690.00
$1,668.00
$1,515.00
$965.00
$1,217.00
$1,361.00
$1,438.00
$1,100.00
$1,486.00
$1,153.00
$1,198.00
$1,442.00
$1,529.00
$1,618.00
$1,597.00
$1,598.00
$1,519.00
$1,623.00
$1,927.00
$1,255.00
$1,445.00
$1,264.00
$1,514.00
$248.00
$419.00
$850.00
$256.00
$403.00
$822.00
$895.00
$253.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,105.00
$1,089.00
$1,309.00
$1,122.00
$1,019.00
$1,007.00
$1,253.00
$1,433.00
$1,408.00
$1,496.00
$922.00
$1,219.00
$1,524.00
$1,555.00
$1,768.00
$2,051.00
$2,655.00
$310.00
$1,005.00
$1,403.00
$74.00
$1,834.00
$1,810.00
$1,644.00
$1,046.00
$1,320.00
$1,476.00
$1,561.00
$1,194.00
$1,612.00
$1,250.00
$1,299.00
$1,564.00
$1,659.00
$1,756.00
$1,734.00
$1,719.00
$1,648.00
$1,763.00
$2,079.00
$1,362.00
$1,567.00
$1,357.00
$1,644.00
$268.00
$454.00
$922.00
$276.00
$436.00
$887.00
$971.00
$272.00
$1,170.00
$1,154.00
$1,381.00
$1,189.00
$1,073.00
$1,064.00
$1,327.00
$1,511.00
$1,482.00
$1,577.00
$977.00
$1,294.00
$1,611.00
$1,646.00
$1,878.00
$2,182.00
$2,828.00
$324.00
$1,064.00
$1,490.00
$77.00
$1,952.00
$1,926.00
$1,746.00
$1,108.00
$1,401.00
$1,569.00
$1,660.00
$1,268.00
$1,713.00
$1,327.00
$1,380.00
$1,663.00
$1,765.00
$1,869.00
$1,847.00
$1,813.00
$1,754.00
$1,882.00
$2,205.00
$1,446.00
$1,665.00
$1,428.00
$1,749.00
$283.00
$481.00
$978.00
$292.00
$461.00
$937.00
$1,032.00
$287.00
133
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
23545
23550
23552
23570
23575
23585
23600
23605
23615
23616
23620
23625
23630
23650
23655
23660
23665
23670
23675
23680
23700
23800
23802
23900
23920
23921
23929
23930
23931
23935
24000
24006
24065
24066
24075
24076
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
YYY
10
10
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$148.00
$701.00
$753.00
$88.00
$306.00
$809.00
$318.00
$511.00
$900.00
$1,895.00
$286.00
$422.00
$712.00
$296.00
$374.00
$712.00
$440.00
$759.00
$550.00
$1,064.00
$237.00
$1,346.00
$1,368.00
$1,561.00
$1,300.00
$497.00
BR
$71.00
$62.00
$630.00
$550.00
$793.00
$166.00
$461.00
$349.00
$529.00
$1,058.00
$467.00
$591.00
$755.00
$360.00
$724.00
$898.00
$1,037.00
$595.00
$663.00
$731.00
$595.00
$966.00
$720.00
$697.00
$963.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$445.00
$833.00
$941.00
$329.00
$551.00
$998.00
$460.00
$716.00
$1,065.00
$2,053.00
$415.00
$609.00
$847.00
$470.00
$477.00
$843.00
$650.00
$903.00
$780.00
$1,086.00
$327.00
$1,554.00
$1,664.00
$1,915.00
$1,542.00
$663.00
----$470.00
$394.00
$1,024.00
$643.00
$974.00
$400.00
$737.00
$624.00
$720.00
$1,348.00
$570.00
$702.00
$862.00
$475.00
$929.00
$1,071.00
$1,314.00
$729.00
$808.00
$867.00
$714.00
$1,376.00
$776.00
$868.00
$1,397.00
$480.00
$901.00
$1,021.00
$355.00
$596.00
$1,083.00
$498.00
$775.00
$1,155.00
$2,230.00
$449.00
$659.00
$919.00
$505.00
$514.00
$914.00
$703.00
$980.00
$845.00
$1,178.00
$354.00
$1,685.00
$1,807.00
$2,073.00
$1,670.00
$719.00
----$506.00
$425.00
$1,107.00
$696.00
$1,056.00
$428.00
$795.00
$673.00
$776.00
$1,453.00
$616.00
$761.00
$934.00
$515.00
$1,006.00
$1,157.00
$1,425.00
$790.00
$871.00
$934.00
$774.00
$1,489.00
$835.00
$942.00
$1,510.00
$506.00
$954.00
$1,085.00
$374.00
$629.00
$1,150.00
$524.00
$818.00
$1,227.00
$2,380.00
$472.00
$694.00
$976.00
$529.00
$544.00
$969.00
$741.00
$1,040.00
$893.00
$1,252.00
$375.00
$1,791.00
$1,926.00
$2,202.00
$1,773.00
$762.00
----$531.00
$444.00
$1,165.00
$739.00
$1,123.00
$445.00
$836.00
$705.00
$818.00
$1,533.00
$652.00
$807.00
$992.00
$544.00
$1,064.00
$1,223.00
$1,514.00
$837.00
$921.00
$987.00
$822.00
$1,571.00
$883.00
$1,002.00
$1,591.00
$368.00
$833.00
$941.00
$266.00
$451.00
$998.00
$355.00
$621.00
$1,065.00
$2,053.00
$310.00
$512.00
$847.00
$365.00
$477.00
$843.00
$555.00
$903.00
$693.00
$1,086.00
$327.00
$1,554.00
$1,664.00
$1,915.00
$1,542.00
$663.00
----$366.00
$293.00
$1,024.00
$643.00
$974.00
$277.00
$634.00
$524.00
$720.00
$1,348.00
$570.00
$702.00
$862.00
$475.00
$929.00
$1,071.00
$1,314.00
$729.00
$808.00
$867.00
$714.00
$1,376.00
$776.00
$868.00
$1,397.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$398.00
$901.00
$1,021.00
$288.00
$489.00
$1,083.00
$384.00
$673.00
$1,155.00
$2,230.00
$336.00
$554.00
$919.00
$392.00
$514.00
$914.00
$601.00
$980.00
$751.00
$1,178.00
$354.00
$1,685.00
$1,807.00
$2,073.00
$1,670.00
$719.00
----$394.00
$316.00
$1,107.00
$696.00
$1,056.00
$296.00
$684.00
$565.00
$776.00
$1,453.00
$616.00
$761.00
$934.00
$515.00
$1,006.00
$1,157.00
$1,425.00
$790.00
$871.00
$934.00
$774.00
$1,489.00
$835.00
$942.00
$1,510.00
$421.00
$954.00
$1,085.00
$304.00
$518.00
$1,150.00
$407.00
$712.00
$1,227.00
$2,380.00
$355.00
$586.00
$976.00
$412.00
$544.00
$969.00
$636.00
$1,040.00
$797.00
$1,252.00
$375.00
$1,791.00
$1,926.00
$2,202.00
$1,773.00
$762.00
----$415.00
$331.00
$1,165.00
$739.00
$1,123.00
$308.00
$721.00
$594.00
$818.00
$1,533.00
$652.00
$807.00
$992.00
$544.00
$1,064.00
$1,223.00
$1,514.00
$837.00
$921.00
$987.00
$822.00
$1,571.00
$883.00
$1,002.00
$1,591.00
134
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
24201
24220
24300
24301
24305
24310
24320
24330
24331
24332
24340
24341
24342
24343
24344
24345
24346
24350
24351
24352
24354
24356
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
24435
24470
24495
24498
24500
24505
24515
24516
24530
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
10
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$592.00
$703.00
$1,224.00
$1,265.00
$1,383.00
$829.00
$936.00
$1,019.00
$533.00
$564.00
$58.00
$444.00
$89.00
$352.00
$869.00
$579.00
$511.00
$944.00
$845.00
$927.00
$487.00
$697.00
$702.00
$950.00
$643.00
$971.00
$643.00
$971.00
$444.00
$522.00
$585.00
$578.00
$634.00
$1,125.00
$1,215.00
$1,269.00
$1,663.00
$747.00
$850.00
$991.00
$1,319.00
$1,265.00
$1,209.00
$1,260.00
$774.00
$742.00
$1,076.00
$288.00
$574.00
$1,018.00
$1,029.00
$88.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,014.00
$1,013.00
$1,382.00
$1,526.00
$1,751.00
$1,062.00
$965.00
$1,140.00
$801.00
$657.00
$377.00
$700.00
$607.00
$490.00
$1,046.00
$817.00
$764.00
$1,134.00
$993.00
$1,088.00
$678.00
$849.00
$850.00
$1,090.00
$892.00
$1,367.00
$892.00
$1,367.00
$624.00
$688.00
$732.00
$731.00
$751.00
$1,200.00
$1,352.00
$1,482.00
$1,654.00
$850.00
$916.00
$1,288.00
$1,555.00
$1,635.00
$1,403.00
$1,481.00
$933.00
$968.00
$1,325.00
$447.00
$760.00
$1,255.00
$1,283.00
$524.00
$1,097.00
$1,098.00
$1,499.00
$1,654.00
$1,900.00
$1,146.00
$1,024.00
$1,233.00
$869.00
$713.00
$405.00
$755.00
$652.00
$530.00
$1,132.00
$885.00
$825.00
$1,218.00
$1,074.00
$1,180.00
$730.00
$921.00
$922.00
$1,183.00
$967.00
$1,481.00
$967.00
$1,481.00
$677.00
$746.00
$794.00
$792.00
$814.00
$1,302.00
$1,469.00
$1,605.00
$1,796.00
$921.00
$995.00
$1,396.00
$1,683.00
$1,771.00
$1,522.00
$1,607.00
$1,013.00
$1,044.00
$1,438.00
$483.00
$823.00
$1,362.00
$1,392.00
$567.00
$1,158.00
$1,160.00
$1,596.00
$1,754.00
$2,018.00
$1,213.00
$1,069.00
$1,308.00
$925.00
$757.00
$422.00
$794.00
$675.00
$559.00
$1,202.00
$939.00
$871.00
$1,281.00
$1,140.00
$1,254.00
$772.00
$979.00
$979.00
$1,259.00
$1,027.00
$1,576.00
$1,027.00
$1,576.00
$717.00
$791.00
$843.00
$841.00
$863.00
$1,388.00
$1,566.00
$1,706.00
$1,919.00
$979.00
$1,061.00
$1,481.00
$1,785.00
$1,875.00
$1,618.00
$1,707.00
$1,078.00
$1,101.00
$1,527.00
$509.00
$868.00
$1,449.00
$1,479.00
$597.00
$1,014.00
$1,013.00
$1,382.00
$1,526.00
$1,751.00
$1,062.00
$965.00
$1,140.00
$801.00
$657.00
$261.00
$609.00
$93.00
$490.00
$1,046.00
$817.00
$764.00
$1,134.00
$993.00
$1,088.00
$678.00
$849.00
$850.00
$1,090.00
$892.00
$1,367.00
$892.00
$1,367.00
$624.00
$688.00
$732.00
$731.00
$751.00
$1,200.00
$1,352.00
$1,482.00
$1,654.00
$850.00
$916.00
$1,288.00
$1,555.00
$1,635.00
$1,403.00
$1,481.00
$933.00
$968.00
$1,325.00
$353.00
$652.00
$1,255.00
$1,283.00
$448.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,097.00
$1,098.00
$1,499.00
$1,654.00
$1,900.00
$1,146.00
$1,024.00
$1,233.00
$869.00
$713.00
$280.00
$658.00
$98.00
$530.00
$1,132.00
$885.00
$825.00
$1,218.00
$1,074.00
$1,180.00
$730.00
$921.00
$922.00
$1,183.00
$967.00
$1,481.00
$967.00
$1,481.00
$677.00
$746.00
$794.00
$792.00
$814.00
$1,302.00
$1,469.00
$1,605.00
$1,796.00
$921.00
$995.00
$1,396.00
$1,683.00
$1,771.00
$1,522.00
$1,607.00
$1,013.00
$1,044.00
$1,438.00
$381.00
$707.00
$1,362.00
$1,392.00
$486.00
$1,158.00
$1,160.00
$1,596.00
$1,754.00
$2,018.00
$1,213.00
$1,069.00
$1,308.00
$925.00
$757.00
$293.00
$694.00
$103.00
$559.00
$1,202.00
$939.00
$871.00
$1,281.00
$1,140.00
$1,254.00
$772.00
$979.00
$979.00
$1,259.00
$1,027.00
$1,576.00
$1,027.00
$1,576.00
$717.00
$791.00
$843.00
$841.00
$863.00
$1,388.00
$1,566.00
$1,706.00
$1,919.00
$979.00
$1,061.00
$1,481.00
$1,785.00
$1,875.00
$1,618.00
$1,707.00
$1,078.00
$1,101.00
$1,527.00
$404.00
$749.00
$1,449.00
$1,479.00
$513.00
135
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
24535
24538
24545
24546
24560
24565
24566
24575
24576
24577
24579
24582
24586
24587
24600
24605
24615
24620
24635
24650
24655
24665
24666
24670
24675
24685
24800
24802
24900
24920
24925
24930
24931
24935
24940
24999
25000
25001
25020
25023
25024
25025
25028
25031
25035
25040
25065
25066
25075
25076
25077
25085
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
$671.00
$850.00
$946.00
$1,273.00
$266.00
$526.00
$705.00
$872.00
$295.00
$575.00
$964.00
$773.00
$1,314.00
$1,278.00
$360.00
$371.00
$836.00
$560.00
$1,329.00
$262.00
$436.00
$749.00
$905.00
$263.00
$490.00
$819.00
$984.00
$1,181.00
$858.00
$851.00
$661.00
$928.00
$1,063.00
$1,327.00
BR
BR
$381.00
$294.00
$594.00
$1,040.00
$683.00
$1,104.00
$417.00
$266.00
$794.00
$654.00
$164.00
$322.00
$352.00
$544.00
$957.00
$562.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$853.00
$1,084.00
$1,126.00
$1,604.00
$412.00
$729.00
$967.00
$1,040.00
$405.00
$756.00
$1,239.00
$1,032.00
$1,440.00
$1,431.00
$591.00
$567.00
$947.00
$736.00
$1,593.00
$361.00
$632.00
$956.00
$1,073.00
$379.00
$662.00
$1,013.00
$1,139.00
$1,374.00
$1,105.00
$1,183.00
$888.00
$1,169.00
$1,190.00
$1,500.00
--------$569.00
$412.00
$901.00
$1,596.00
$951.00
$1,545.00
$799.00
$734.00
$1,255.00
$885.00
$233.00
$650.00
$574.00
$913.00
$1,317.00
$872.00
$924.00
$1,173.00
$1,222.00
$1,741.00
$445.00
$789.00
$1,048.00
$1,128.00
$438.00
$819.00
$1,345.00
$1,119.00
$1,564.00
$1,555.00
$638.00
$614.00
$1,028.00
$797.00
$1,727.00
$390.00
$683.00
$1,036.00
$1,164.00
$409.00
$717.00
$1,099.00
$1,232.00
$1,491.00
$1,194.00
$1,279.00
$962.00
$1,262.00
$1,287.00
$1,613.00
--------$615.00
$446.00
$974.00
$1,722.00
$1,031.00
$1,675.00
$861.00
$792.00
$1,357.00
$958.00
$249.00
$701.00
$618.00
$985.00
$1,420.00
$943.00
$979.00
$1,243.00
$1,300.00
$1,853.00
$468.00
$833.00
$1,111.00
$1,201.00
$462.00
$867.00
$1,430.00
$1,187.00
$1,670.00
$1,661.00
$671.00
$653.00
$1,095.00
$846.00
$1,831.00
$410.00
$721.00
$1,099.00
$1,236.00
$431.00
$757.00
$1,166.00
$1,308.00
$1,588.00
$1,263.00
$1,352.00
$1,018.00
$1,334.00
$1,368.00
$1,703.00
--------$646.00
$472.00
$1,025.00
$1,816.00
$1,096.00
$1,785.00
$905.00
$831.00
$1,426.00
$1,014.00
$259.00
$736.00
$648.00
$1,032.00
$1,494.00
$992.00
$743.00
$1,084.00
$1,126.00
$1,604.00
$317.00
$622.00
$967.00
$1,040.00
$330.00
$651.00
$1,239.00
$1,032.00
$1,440.00
$1,431.00
$493.00
$567.00
$947.00
$736.00
$1,593.00
$269.00
$522.00
$956.00
$1,073.00
$302.00
$556.00
$1,013.00
$1,139.00
$1,374.00
$1,105.00
$1,183.00
$888.00
$1,169.00
$1,190.00
$1,500.00
--------$569.00
$412.00
$901.00
$1,596.00
$951.00
$1,545.00
$799.00
$734.00
$1,255.00
$885.00
$233.00
$650.00
$574.00
$913.00
$1,317.00
$872.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$806.00
$1,173.00
$1,222.00
$1,741.00
$343.00
$674.00
$1,048.00
$1,128.00
$357.00
$707.00
$1,345.00
$1,119.00
$1,564.00
$1,555.00
$532.00
$614.00
$1,028.00
$797.00
$1,727.00
$291.00
$565.00
$1,036.00
$1,164.00
$326.00
$603.00
$1,099.00
$1,232.00
$1,491.00
$1,194.00
$1,279.00
$962.00
$1,262.00
$1,287.00
$1,613.00
--------$615.00
$446.00
$974.00
$1,722.00
$1,031.00
$1,675.00
$861.00
$792.00
$1,357.00
$958.00
$249.00
$701.00
$618.00
$985.00
$1,420.00
$943.00
$857.00
$1,243.00
$1,300.00
$1,853.00
$363.00
$715.00
$1,111.00
$1,201.00
$378.00
$751.00
$1,430.00
$1,187.00
$1,670.00
$1,661.00
$562.00
$653.00
$1,095.00
$846.00
$1,831.00
$308.00
$599.00
$1,099.00
$1,236.00
$345.00
$639.00
$1,166.00
$1,308.00
$1,588.00
$1,263.00
$1,352.00
$1,018.00
$1,334.00
$1,368.00
$1,703.00
--------$646.00
$472.00
$1,025.00
$1,816.00
$1,096.00
$1,785.00
$905.00
$831.00
$1,426.00
$1,014.00
$259.00
$736.00
$648.00
$1,032.00
$1,494.00
$992.00
136
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
25100
25101
25105
25107
25110
25111
25112
25115
25116
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25246
25248
25250
25251
25259
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$420.00
$492.00
$635.00
$600.00
$403.00
$356.00
$441.00
$837.00
$807.00
$466.00
$653.00
$712.00
$803.00
$781.00
$502.00
$631.00
$546.00
$713.00
$720.00
$771.00
$1,085.00
$561.00
$817.00
$531.00
$567.00
$72.00
$236.00
$616.00
$933.00
$348.00
$728.00
$809.00
$998.00
$549.00
$613.00
$887.00
$620.00
$670.00
$436.00
$562.00
$592.00
$757.00
$865.00
$968.00
$1,004.00
$1,203.00
$834.00
$1,022.00
$1,166.00
$946.00
$913.00
$1,014.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$602.00
$665.00
$892.00
$942.00
$648.00
$523.00
$628.00
$1,361.00
$1,213.00
$649.00
$918.00
$1,105.00
$1,241.00
$1,220.00
$718.00
$856.00
$752.00
$1,140.00
$1,017.00
$1,225.00
$1,521.00
$777.00
$1,073.00
$712.00
$844.00
$578.00
$792.00
$688.00
$949.00
$487.00
$1,289.00
$1,282.00
$1,436.00
$1,139.00
$1,227.00
$1,350.00
$863.00
$1,215.00
$1,216.00
$1,161.00
$1,002.00
$978.00
$1,290.00
$1,412.00
$1,486.00
$1,693.00
$1,187.00
$1,123.00
$1,483.00
$1,271.00
$1,344.00
$1,462.00
$650.00
$719.00
$964.00
$1,018.00
$699.00
$564.00
$677.00
$1,470.00
$1,309.00
$701.00
$992.00
$1,194.00
$1,342.00
$1,319.00
$776.00
$925.00
$808.00
$1,231.00
$1,100.00
$1,322.00
$1,647.00
$839.00
$1,160.00
$770.00
$912.00
$620.00
$852.00
$744.00
$1,026.00
$527.00
$1,391.00
$1,383.00
$1,550.00
$1,229.00
$1,325.00
$1,459.00
$935.00
$1,312.00
$1,311.00
$1,254.00
$1,082.00
$1,058.00
$1,393.00
$1,526.00
$1,605.00
$1,834.00
$1,283.00
$1,216.00
$1,605.00
$1,374.00
$1,454.00
$1,584.00
$684.00
$758.00
$1,016.00
$1,072.00
$734.00
$593.00
$713.00
$1,546.00
$1,375.00
$738.00
$1,045.00
$1,254.00
$1,412.00
$1,388.00
$818.00
$978.00
$848.00
$1,292.00
$1,161.00
$1,389.00
$1,740.00
$885.00
$1,224.00
$812.00
$960.00
$641.00
$893.00
$790.00
$1,088.00
$557.00
$1,462.00
$1,452.00
$1,631.00
$1,289.00
$1,391.00
$1,536.00
$995.00
$1,378.00
$1,371.00
$1,317.00
$1,144.00
$1,120.00
$1,464.00
$1,607.00
$1,689.00
$1,939.00
$1,358.00
$1,293.00
$1,699.00
$1,453.00
$1,531.00
$1,673.00
$602.00
$665.00
$892.00
$942.00
$648.00
$523.00
$628.00
$1,361.00
$1,213.00
$649.00
$918.00
$1,105.00
$1,241.00
$1,220.00
$718.00
$856.00
$752.00
$1,140.00
$1,017.00
$1,225.00
$1,521.00
$777.00
$1,073.00
$712.00
$844.00
$102.00
$792.00
$688.00
$949.00
$487.00
$1,289.00
$1,282.00
$1,436.00
$1,139.00
$1,227.00
$1,350.00
$863.00
$1,215.00
$1,216.00
$1,161.00
$1,002.00
$978.00
$1,290.00
$1,412.00
$1,486.00
$1,693.00
$1,187.00
$1,123.00
$1,483.00
$1,271.00
$1,344.00
$1,462.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$650.00
$719.00
$964.00
$1,018.00
$699.00
$564.00
$677.00
$1,470.00
$1,309.00
$701.00
$992.00
$1,194.00
$1,342.00
$1,319.00
$776.00
$925.00
$808.00
$1,231.00
$1,100.00
$1,322.00
$1,647.00
$839.00
$1,160.00
$770.00
$912.00
$107.00
$852.00
$744.00
$1,026.00
$527.00
$1,391.00
$1,383.00
$1,550.00
$1,229.00
$1,325.00
$1,459.00
$935.00
$1,312.00
$1,311.00
$1,254.00
$1,082.00
$1,058.00
$1,393.00
$1,526.00
$1,605.00
$1,834.00
$1,283.00
$1,216.00
$1,605.00
$1,374.00
$1,454.00
$1,584.00
$684.00
$758.00
$1,016.00
$1,072.00
$734.00
$593.00
$713.00
$1,546.00
$1,375.00
$738.00
$1,045.00
$1,254.00
$1,412.00
$1,388.00
$818.00
$978.00
$848.00
$1,292.00
$1,161.00
$1,389.00
$1,740.00
$885.00
$1,224.00
$812.00
$960.00
$112.00
$893.00
$790.00
$1,088.00
$557.00
$1,462.00
$1,452.00
$1,631.00
$1,289.00
$1,391.00
$1,536.00
$995.00
$1,378.00
$1,371.00
$1,317.00
$1,144.00
$1,120.00
$1,464.00
$1,607.00
$1,689.00
$1,939.00
$1,358.00
$1,293.00
$1,699.00
$1,453.00
$1,531.00
$1,673.00
137
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
25360
25365
25370
25375
25390
25391
25392
25393
25394
25400
25405
25415
25420
25425
25426
25430
25431
25440
25441
25442
25443
25444
25445
25446
25447
25449
25450
25455
25490
25491
25492
25500
25505
25515
25520
25525
25526
25530
25535
25545
25560
25565
25574
25575
25600
25605
25611
25620
25622
25624
25628
25630
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$468.00
$1,216.00
$1,214.00
$1,280.00
$1,043.00
$1,349.00
$1,294.00
$1,473.00
$723.00
$1,112.00
$1,388.00
$1,343.00
$1,554.00
$1,403.00
$1,401.00
$638.00
$631.00
$931.00
$1,147.00
$936.00
$970.00
$1,031.00
$959.00
$1,542.00
$952.00
$395.00
$805.00
$899.00
$955.00
$1,006.00
$1,170.00
$200.00
$517.00
$800.00
$644.00
$1,097.00
$1,293.00
$270.00
$516.00
$803.00
$276.00
$590.00
$804.00
$974.00
$312.00
$540.00
$707.00
$769.00
$148.00
$482.00
$716.00
$148.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,322.00
$1,633.00
$1,691.00
$1,721.00
$1,474.00
$1,742.00
$1,708.00
$1,924.00
$1,017.00
$1,534.00
$1,847.00
$1,737.00
$2,003.00
$2,074.00
$1,920.00
$905.00
$872.00
$1,164.00
$1,261.00
$1,064.00
$1,040.00
$1,100.00
$967.00
$1,567.00
$1,035.00
$1,373.00
$1,090.00
$1,242.00
$1,371.00
$1,448.00
$1,605.00
$354.00
$698.00
$1,028.00
$771.00
$1,305.00
$1,519.00
$338.00
$683.00
$1,021.00
$355.00
$736.00
$855.00
$1,155.00
$386.00
$759.00
$966.00
$988.00
$382.00
$644.00
$982.00
$405.00
$1,431.00
$1,768.00
$1,833.00
$1,865.00
$1,594.00
$1,883.00
$1,846.00
$2,076.00
$1,103.00
$1,660.00
$2,000.00
$1,882.00
$2,169.00
$2,238.00
$2,082.00
$977.00
$924.00
$1,262.00
$1,370.00
$1,148.00
$1,125.00
$1,191.00
$1,048.00
$1,700.00
$1,121.00
$1,485.00
$1,175.00
$1,339.00
$1,480.00
$1,569.00
$1,736.00
$382.00
$755.00
$1,113.00
$835.00
$1,415.00
$1,647.00
$365.00
$739.00
$1,107.00
$382.00
$796.00
$927.00
$1,253.00
$417.00
$822.00
$1,047.00
$1,071.00
$412.00
$697.00
$1,064.00
$438.00
$1,508.00
$1,868.00
$1,941.00
$1,973.00
$1,682.00
$1,988.00
$1,950.00
$2,191.00
$1,175.00
$1,753.00
$2,115.00
$1,992.00
$2,296.00
$2,352.00
$2,207.00
$1,036.00
$964.00
$1,339.00
$1,462.00
$1,216.00
$1,194.00
$1,266.00
$1,114.00
$1,811.00
$1,191.00
$1,578.00
$1,235.00
$1,409.00
$1,559.00
$1,657.00
$1,834.00
$401.00
$798.00
$1,180.00
$884.00
$1,504.00
$1,747.00
$384.00
$780.00
$1,175.00
$402.00
$842.00
$982.00
$1,331.00
$439.00
$870.00
$1,109.00
$1,136.00
$434.00
$735.00
$1,128.00
$462.00
$1,322.00
$1,633.00
$1,691.00
$1,721.00
$1,474.00
$1,742.00
$1,708.00
$1,924.00
$1,017.00
$1,534.00
$1,847.00
$1,737.00
$2,003.00
$2,074.00
$1,920.00
$905.00
$872.00
$1,164.00
$1,261.00
$1,064.00
$1,040.00
$1,100.00
$967.00
$1,567.00
$1,035.00
$1,373.00
$1,090.00
$1,242.00
$1,371.00
$1,448.00
$1,605.00
$284.00
$590.00
$1,028.00
$683.00
$1,305.00
$1,519.00
$265.00
$588.00
$1,021.00
$281.00
$625.00
$855.00
$1,155.00
$306.00
$650.00
$966.00
$988.00
$303.00
$535.00
$982.00
$322.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,431.00
$1,768.00
$1,833.00
$1,865.00
$1,594.00
$1,883.00
$1,846.00
$2,076.00
$1,103.00
$1,660.00
$2,000.00
$1,882.00
$2,169.00
$2,238.00
$2,082.00
$977.00
$924.00
$1,262.00
$1,370.00
$1,148.00
$1,125.00
$1,191.00
$1,048.00
$1,700.00
$1,121.00
$1,485.00
$1,175.00
$1,339.00
$1,480.00
$1,569.00
$1,736.00
$306.00
$639.00
$1,113.00
$740.00
$1,415.00
$1,647.00
$286.00
$637.00
$1,107.00
$303.00
$678.00
$927.00
$1,253.00
$331.00
$705.00
$1,047.00
$1,071.00
$327.00
$579.00
$1,064.00
$348.00
$1,508.00
$1,868.00
$1,941.00
$1,973.00
$1,682.00
$1,988.00
$1,950.00
$2,191.00
$1,175.00
$1,753.00
$2,115.00
$1,992.00
$2,296.00
$2,352.00
$2,207.00
$1,036.00
$964.00
$1,339.00
$1,462.00
$1,216.00
$1,194.00
$1,266.00
$1,114.00
$1,811.00
$1,191.00
$1,578.00
$1,235.00
$1,409.00
$1,559.00
$1,657.00
$1,834.00
$323.00
$677.00
$1,180.00
$786.00
$1,504.00
$1,747.00
$303.00
$675.00
$1,175.00
$320.00
$719.00
$982.00
$1,331.00
$350.00
$749.00
$1,109.00
$1,136.00
$346.00
$614.00
$1,128.00
$369.00
138
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
25635
25645
25650
25651
25652
25660
25670
25671
25675
25676
25680
25685
25690
25695
25800
25805
25810
25820
25825
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
25999
26010
26011
26020
26025
26030
26034
26035
26037
26040
26045
26055
26060
26070
26075
26080
26100
26105
26110
26115
26116
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$458.00
$668.00
$185.00
$379.00
$560.00
$378.00
$731.00
$462.00
$404.00
$741.00
$471.00
$887.00
$518.00
$520.00
$703.00
$1,078.00
$1,008.00
$2,276.00
$895.00
$991.00
$871.00
$900.00
$799.00
$849.00
$1,523.00
$771.00
$670.00
$768.00
$830.00
$645.00
$731.00
BR
$59.00
$223.00
$484.00
$548.00
$655.00
$601.00
$741.00
$730.00
$367.00
$621.00
$343.00
$293.00
$440.00
$400.00
$382.00
$398.00
$481.00
$282.00
$344.00
$544.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$620.00
$886.00
$416.00
$593.00
$782.00
$545.00
$941.00
$647.00
$638.00
$952.00
$656.00
$1,081.00
$678.00
$969.00
$1,107.00
$1,240.00
$1,172.00
$908.00
$1,063.00
$1,422.00
$1,228.00
$1,294.00
$1,197.00
$1,281.00
$2,142.00
$988.00
$875.00
$994.00
$1,199.00
$821.00
$1,185.00
----$377.00
$734.00
$532.00
$533.00
$630.00
$659.00
$940.00
$736.00
$379.00
$586.00
$912.00
$324.00
$370.00
$395.00
$470.00
$404.00
$407.00
$391.00
$928.00
$598.00
$666.00
$958.00
$450.00
$643.00
$848.00
$589.00
$1,020.00
$702.00
$689.00
$1,031.00
$706.00
$1,170.00
$736.00
$1,048.00
$1,199.00
$1,344.00
$1,269.00
$982.00
$1,150.00
$1,536.00
$1,326.00
$1,396.00
$1,294.00
$1,382.00
$2,322.00
$1,067.00
$945.00
$1,075.00
$1,293.00
$886.00
$1,277.00
----$406.00
$791.00
$575.00
$577.00
$680.00
$713.00
$1,015.00
$796.00
$411.00
$635.00
$983.00
$350.00
$397.00
$425.00
$508.00
$436.00
$440.00
$423.00
$1,000.00
$647.00
$696.00
$1,013.00
$474.00
$682.00
$901.00
$623.00
$1,080.00
$745.00
$726.00
$1,093.00
$744.00
$1,240.00
$780.00
$1,109.00
$1,271.00
$1,426.00
$1,345.00
$1,039.00
$1,218.00
$1,619.00
$1,396.00
$1,468.00
$1,362.00
$1,454.00
$2,460.00
$1,129.00
$1,000.00
$1,137.00
$1,361.00
$937.00
$1,340.00
----$422.00
$823.00
$609.00
$611.00
$721.00
$756.00
$1,076.00
$843.00
$436.00
$674.00
$1,025.00
$370.00
$418.00
$449.00
$537.00
$462.00
$465.00
$448.00
$1,046.00
$686.00
$477.00
$886.00
$334.00
$593.00
$782.00
$545.00
$941.00
$647.00
$536.00
$952.00
$656.00
$1,081.00
$678.00
$969.00
$1,107.00
$1,240.00
$1,172.00
$908.00
$1,063.00
$1,422.00
$1,228.00
$1,294.00
$1,197.00
$1,281.00
$2,142.00
$988.00
$875.00
$994.00
$1,199.00
$821.00
$1,185.00
----$173.00
$247.00
$532.00
$533.00
$630.00
$659.00
$940.00
$736.00
$379.00
$586.00
$333.00
$324.00
$370.00
$395.00
$470.00
$404.00
$407.00
$391.00
$441.00
$598.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$512.00
$958.00
$361.00
$643.00
$848.00
$589.00
$1,020.00
$702.00
$579.00
$1,031.00
$706.00
$1,170.00
$736.00
$1,048.00
$1,199.00
$1,344.00
$1,269.00
$982.00
$1,150.00
$1,536.00
$1,326.00
$1,396.00
$1,294.00
$1,382.00
$2,322.00
$1,067.00
$945.00
$1,075.00
$1,293.00
$886.00
$1,277.00
----$186.00
$267.00
$575.00
$577.00
$680.00
$713.00
$1,015.00
$796.00
$411.00
$635.00
$361.00
$350.00
$397.00
$425.00
$508.00
$436.00
$440.00
$423.00
$477.00
$647.00
$538.00
$1,013.00
$382.00
$682.00
$901.00
$623.00
$1,080.00
$745.00
$613.00
$1,093.00
$744.00
$1,240.00
$780.00
$1,109.00
$1,271.00
$1,426.00
$1,345.00
$1,039.00
$1,218.00
$1,619.00
$1,396.00
$1,468.00
$1,362.00
$1,454.00
$2,460.00
$1,129.00
$1,000.00
$1,137.00
$1,361.00
$937.00
$1,340.00
----$195.00
$281.00
$609.00
$611.00
$721.00
$756.00
$1,076.00
$843.00
$436.00
$674.00
$382.00
$370.00
$418.00
$449.00
$537.00
$462.00
$465.00
$448.00
$504.00
$686.00
139
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
26117
26121
26123
26125
26130
26135
26140
26145
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26320
26340
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
90
$806.00
90
$833.00
90
$959.00
ZZZ $342.00
90
$629.00
90
$668.00
90
$678.00
90
$660.00
90
$319.00
90
$452.00
90
$444.00
90
$511.00
90
$598.00
90
$788.00
90
$543.00
90
$731.00
90
$624.00
90
$612.00
90
$444.00
90
$814.00
90 $1,184.00
90
$758.00
90
$949.00
90
$624.00
90
$414.00
90
$266.00
90
$715.00
90
$855.00
90
$886.00
90
$932.00
90
$979.00
90
$832.00
90
$945.00
90
$904.00
90
$889.00
90 $1,123.00
90
$371.00
90
$737.00
90
$846.00
90 $1,093.00
90
$444.00
90
$741.00
90
$733.00
90
$790.00
90
$430.00
90
$371.00
90
$656.00
90
$491.00
90
$458.00
90
$548.00
90
$455.00
90
$738.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$833.00
$767.00
$964.00
$391.00
$564.00
$708.00
$639.00
$649.00
$1,106.00
$509.00
$550.00
$581.00
$573.00
$774.00
$550.00
$702.00
$649.00
$635.00
$562.00
$743.00
$1,144.00
$698.00
$814.00
$583.00
$451.00
$371.00
$1,324.00
$1,445.00
$1,517.00
$1,530.00
$1,588.00
$1,423.00
$1,581.00
$1,524.00
$1,349.00
$1,696.00
$1,064.00
$1,216.00
$1,244.00
$1,453.00
$1,032.00
$1,256.00
$1,195.00
$1,305.00
$884.00
$961.00
$1,067.00
$1,042.00
$1,212.00
$1,460.00
$1,163.00
$1,382.00
$900.00
$830.00
$1,043.00
$423.00
$609.00
$766.00
$691.00
$702.00
$1,192.00
$550.00
$595.00
$629.00
$621.00
$838.00
$594.00
$757.00
$704.00
$688.00
$608.00
$803.00
$1,225.00
$754.00
$874.00
$630.00
$487.00
$400.00
$1,428.00
$1,559.00
$1,636.00
$1,650.00
$1,712.00
$1,535.00
$1,705.00
$1,644.00
$1,455.00
$1,830.00
$1,147.00
$1,313.00
$1,336.00
$1,570.00
$1,112.00
$1,355.00
$1,290.00
$1,407.00
$953.00
$1,036.00
$1,150.00
$1,125.00
$1,307.00
$1,574.00
$1,254.00
$1,490.00
$954.00
$881.00
$1,107.00
$451.00
$645.00
$813.00
$733.00
$744.00
$1,242.00
$583.00
$630.00
$666.00
$659.00
$889.00
$630.00
$800.00
$748.00
$730.00
$644.00
$852.00
$1,288.00
$800.00
$922.00
$668.00
$516.00
$421.00
$1,493.00
$1,633.00
$1,715.00
$1,729.00
$1,795.00
$1,609.00
$1,788.00
$1,722.00
$1,530.00
$1,922.00
$1,199.00
$1,376.00
$1,398.00
$1,652.00
$1,161.00
$1,420.00
$1,351.00
$1,474.00
$996.00
$1,084.00
$1,206.00
$1,181.00
$1,365.00
$1,649.00
$1,309.00
$1,560.00
$833.00
$767.00
$964.00
$391.00
$564.00
$708.00
$639.00
$649.00
$372.00
$509.00
$550.00
$581.00
$573.00
$774.00
$550.00
$702.00
$649.00
$635.00
$562.00
$743.00
$1,144.00
$698.00
$814.00
$583.00
$451.00
$371.00
$1,324.00
$1,445.00
$1,517.00
$1,530.00
$1,588.00
$1,423.00
$1,581.00
$1,524.00
$1,349.00
$1,696.00
$1,064.00
$1,216.00
$1,244.00
$1,453.00
$1,032.00
$1,256.00
$1,195.00
$1,305.00
$884.00
$961.00
$1,067.00
$1,042.00
$1,212.00
$1,460.00
$1,163.00
$1,382.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$900.00
$830.00
$1,043.00
$423.00
$609.00
$766.00
$691.00
$702.00
$402.00
$550.00
$595.00
$629.00
$621.00
$838.00
$594.00
$757.00
$704.00
$688.00
$608.00
$803.00
$1,225.00
$754.00
$874.00
$630.00
$487.00
$400.00
$1,428.00
$1,559.00
$1,636.00
$1,650.00
$1,712.00
$1,535.00
$1,705.00
$1,644.00
$1,455.00
$1,830.00
$1,147.00
$1,313.00
$1,336.00
$1,570.00
$1,112.00
$1,355.00
$1,290.00
$1,407.00
$953.00
$1,036.00
$1,150.00
$1,125.00
$1,307.00
$1,574.00
$1,254.00
$1,490.00
$954.00
$881.00
$1,107.00
$451.00
$645.00
$813.00
$733.00
$744.00
$425.00
$583.00
$630.00
$666.00
$659.00
$889.00
$630.00
$800.00
$748.00
$730.00
$644.00
$852.00
$1,288.00
$800.00
$922.00
$668.00
$516.00
$421.00
$1,493.00
$1,633.00
$1,715.00
$1,729.00
$1,795.00
$1,609.00
$1,788.00
$1,722.00
$1,530.00
$1,922.00
$1,199.00
$1,376.00
$1,398.00
$1,652.00
$1,161.00
$1,420.00
$1,351.00
$1,474.00
$996.00
$1,084.00
$1,206.00
$1,181.00
$1,365.00
$1,649.00
$1,309.00
$1,560.00
140
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
26450
26455
26460
26471
26474
26476
26477
26478
26479
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26504
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540
26541
26542
26545
26546
26548
26550
26551
26553
26554
26555
26556
26560
26561
26562
26565
26567
26568
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$353.00
$364.00
$346.00
$592.00
$586.00
$543.00
$553.00
$608.00
$653.00
$808.00
$986.00
$891.00
$738.00
$496.00
$971.00
$946.00
$949.00
$946.00
$1,317.00
$934.00
$557.00
$715.00
$761.00
$334.00
$564.00
$630.00
$890.00
$877.00
$583.00
$531.00
$708.00
$877.00
$546.00
$770.00
$726.00
$926.00
$716.00
$722.00
$918.00
$665.00
$1,861.00
$3,901.00
$3,868.00
$4,551.00
$1,567.00
$4,005.00
$576.00
$1,067.00
$1,017.00
$730.00
$622.00
$1,003.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$632.00
$625.00
$602.00
$1,020.00
$1,009.00
$973.00
$980.00
$1,055.00
$1,051.00
$1,362.00
$1,479.00
$1,439.00
$1,374.00
$1,248.00
$1,347.00
$1,285.00
$1,331.00
$1,352.00
$1,728.00
$1,341.00
$1,072.00
$1,159.00
$1,164.00
$1,062.00
$1,016.00
$1,152.00
$1,305.00
$1,312.00
$1,227.00
$1,237.00
$686.00
$802.00
$486.00
$875.00
$1,101.00
$1,297.00
$1,117.00
$1,155.00
$1,309.00
$1,248.00
$2,327.00
$4,565.00
$3,825.00
$5,155.00
$2,070.00
$4,477.00
$942.00
$1,379.00
$1,761.00
$1,121.00
$1,122.00
$1,522.00
$682.00
$675.00
$650.00
$1,102.00
$1,090.00
$1,049.00
$1,057.00
$1,140.00
$1,136.00
$1,470.00
$1,596.00
$1,552.00
$1,478.00
$1,348.00
$1,455.00
$1,390.00
$1,437.00
$1,460.00
$1,867.00
$1,444.00
$1,155.00
$1,251.00
$1,255.00
$1,147.00
$1,097.00
$1,244.00
$1,406.00
$1,417.00
$1,323.00
$1,334.00
$743.00
$868.00
$526.00
$945.00
$1,189.00
$1,402.00
$1,207.00
$1,245.00
$1,414.00
$1,347.00
$2,494.00
$4,959.00
$4,042.00
$5,602.00
$2,239.00
$4,866.00
$1,015.00
$1,472.00
$1,880.00
$1,211.00
$1,211.00
$1,642.00
$716.00
$709.00
$682.00
$1,156.00
$1,143.00
$1,099.00
$1,106.00
$1,197.00
$1,193.00
$1,539.00
$1,674.00
$1,627.00
$1,550.00
$1,418.00
$1,533.00
$1,464.00
$1,513.00
$1,537.00
$1,972.00
$1,514.00
$1,209.00
$1,314.00
$1,317.00
$1,204.00
$1,151.00
$1,307.00
$1,476.00
$1,492.00
$1,383.00
$1,395.00
$789.00
$922.00
$560.00
$996.00
$1,248.00
$1,477.00
$1,268.00
$1,305.00
$1,490.00
$1,415.00
$2,616.00
$5,289.00
$4,203.00
$5,984.00
$2,366.00
$5,195.00
$1,063.00
$1,534.00
$1,961.00
$1,272.00
$1,272.00
$1,724.00
$632.00
$625.00
$602.00
$1,020.00
$1,009.00
$973.00
$980.00
$1,055.00
$1,051.00
$1,362.00
$1,479.00
$1,439.00
$1,374.00
$1,248.00
$1,347.00
$1,285.00
$1,331.00
$1,352.00
$1,728.00
$1,341.00
$1,072.00
$1,159.00
$1,164.00
$1,062.00
$1,016.00
$1,152.00
$1,305.00
$1,312.00
$1,227.00
$1,237.00
$686.00
$802.00
$486.00
$875.00
$1,101.00
$1,297.00
$1,117.00
$1,155.00
$1,309.00
$1,248.00
$2,327.00
$4,565.00
$3,825.00
$5,155.00
$2,070.00
$4,477.00
$942.00
$1,379.00
$1,761.00
$1,121.00
$1,122.00
$1,522.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$682.00
$675.00
$650.00
$1,102.00
$1,090.00
$1,049.00
$1,057.00
$1,140.00
$1,136.00
$1,470.00
$1,596.00
$1,552.00
$1,478.00
$1,348.00
$1,455.00
$1,390.00
$1,437.00
$1,460.00
$1,867.00
$1,444.00
$1,155.00
$1,251.00
$1,255.00
$1,147.00
$1,097.00
$1,244.00
$1,406.00
$1,417.00
$1,323.00
$1,334.00
$743.00
$868.00
$526.00
$945.00
$1,189.00
$1,402.00
$1,207.00
$1,245.00
$1,414.00
$1,347.00
$2,494.00
$4,959.00
$4,042.00
$5,602.00
$2,239.00
$4,866.00
$1,015.00
$1,472.00
$1,880.00
$1,211.00
$1,211.00
$1,642.00
$716.00
$709.00
$682.00
$1,156.00
$1,143.00
$1,099.00
$1,106.00
$1,197.00
$1,193.00
$1,539.00
$1,674.00
$1,627.00
$1,550.00
$1,418.00
$1,533.00
$1,464.00
$1,513.00
$1,537.00
$1,972.00
$1,514.00
$1,209.00
$1,314.00
$1,317.00
$1,204.00
$1,151.00
$1,307.00
$1,476.00
$1,492.00
$1,383.00
$1,395.00
$789.00
$922.00
$560.00
$996.00
$1,248.00
$1,477.00
$1,268.00
$1,305.00
$1,490.00
$1,415.00
$2,616.00
$5,289.00
$4,203.00
$5,984.00
$2,366.00
$5,195.00
$1,063.00
$1,534.00
$1,961.00
$1,272.00
$1,272.00
$1,724.00
141
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
26580
26587
26590
26591
26593
26596
26600
26605
26607
26608
26615
26641
26645
26650
26665
26670
26675
26676
26685
26686
26700
26705
26706
26715
26720
26725
26727
26735
26740
26742
26746
26750
26755
26756
26765
26770
26775
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
90 $1,585.00
90
$792.00
90 $1,609.00
90
$431.00
90
$587.00
90
$809.00
90
$133.00
90
$296.00
90
$334.00
90
$497.00
90
$521.00
90
$71.00
90
$371.00
90
$533.00
90
$693.00
90
$148.00
90
$501.00
90
$527.00
90
$592.00
90
$710.00
90
$88.00
90
$296.00
90
$469.00
90
$526.00
90
$96.00
90
$187.00
90
$187.00
90
$532.00
90
$148.00
90
$148.00
90
$548.00
90
$96.00
90
$133.00
90
$366.00
90
$398.00
90
$79.00
90
$275.00
90
$401.00
90
$408.00
90
$854.00
90
$756.00
90
$901.00
90
$800.00
90
$875.00
90
$704.00
90
$829.00
90
$542.00
ZZZ $151.00
90
$747.00
ZZZ $317.00
90
$747.00
90
$444.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,781.00
$1,088.00
$1,838.00
$860.00
$980.00
$986.00
$327.00
$476.00
$727.00
$759.00
$727.00
$552.00
$622.00
$788.00
$909.00
$527.00
$594.00
$780.00
$858.00
$941.00
$458.00
$558.00
$590.00
$758.00
$253.00
$462.00
$755.00
$785.00
$308.00
$586.00
$777.00
$284.00
$436.00
$690.00
$631.00
$412.00
$519.00
$721.00
$633.00
$1,277.00
$1,174.00
$1,277.00
$1,174.00
$1,301.00
$1,133.00
$1,265.00
$944.00
$148.00
$1,179.00
$335.00
$1,126.00
$903.00
$1,906.00
$1,162.00
$1,964.00
$926.00
$1,057.00
$1,060.00
$353.00
$515.00
$786.00
$821.00
$786.00
$594.00
$672.00
$852.00
$983.00
$566.00
$641.00
$844.00
$929.00
$1,019.00
$492.00
$602.00
$638.00
$820.00
$273.00
$499.00
$816.00
$848.00
$333.00
$633.00
$840.00
$306.00
$470.00
$745.00
$681.00
$442.00
$560.00
$779.00
$684.00
$1,381.00
$1,270.00
$1,380.00
$1,269.00
$1,405.00
$1,224.00
$1,366.00
$1,019.00
$161.00
$1,273.00
$363.00
$1,214.00
$974.00
$2,000.00
$1,225.00
$2,057.00
$966.00
$1,107.00
$1,115.00
$371.00
$541.00
$830.00
$867.00
$830.00
$624.00
$708.00
$900.00
$1,039.00
$594.00
$676.00
$891.00
$984.00
$1,079.00
$516.00
$635.00
$675.00
$866.00
$287.00
$526.00
$861.00
$896.00
$350.00
$666.00
$887.00
$321.00
$495.00
$784.00
$716.00
$463.00
$589.00
$821.00
$721.00
$1,455.00
$1,337.00
$1,454.00
$1,336.00
$1,480.00
$1,287.00
$1,437.00
$1,068.00
$172.00
$1,338.00
$388.00
$1,277.00
$1,020.00
$1,781.00
$1,010.00
$1,838.00
$860.00
$980.00
$986.00
$253.00
$385.00
$727.00
$759.00
$727.00
$462.00
$517.00
$788.00
$909.00
$440.00
$492.00
$780.00
$858.00
$941.00
$352.00
$458.00
$590.00
$758.00
$179.00
$355.00
$755.00
$785.00
$243.00
$482.00
$777.00
$215.00
$331.00
$690.00
$631.00
$301.00
$412.00
$721.00
$633.00
$1,277.00
$1,174.00
$1,277.00
$1,174.00
$1,301.00
$1,133.00
$1,265.00
$944.00
$148.00
$1,179.00
$335.00
$1,126.00
$903.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,906.00
$1,078.00
$1,964.00
$926.00
$1,057.00
$1,060.00
$273.00
$416.00
$786.00
$821.00
$786.00
$497.00
$559.00
$852.00
$983.00
$473.00
$532.00
$844.00
$929.00
$1,019.00
$378.00
$494.00
$638.00
$820.00
$193.00
$384.00
$816.00
$848.00
$263.00
$522.00
$840.00
$232.00
$357.00
$745.00
$681.00
$323.00
$445.00
$779.00
$684.00
$1,381.00
$1,270.00
$1,380.00
$1,269.00
$1,405.00
$1,224.00
$1,366.00
$1,019.00
$161.00
$1,273.00
$363.00
$1,214.00
$974.00
$2,000.00
$1,138.00
$2,057.00
$966.00
$1,107.00
$1,115.00
$288.00
$440.00
$830.00
$867.00
$830.00
$524.00
$591.00
$900.00
$1,039.00
$497.00
$563.00
$891.00
$984.00
$1,079.00
$399.00
$523.00
$675.00
$866.00
$204.00
$408.00
$861.00
$896.00
$277.00
$551.00
$887.00
$244.00
$378.00
$784.00
$716.00
$340.00
$470.00
$821.00
$721.00
$1,455.00
$1,337.00
$1,454.00
$1,336.00
$1,480.00
$1,287.00
$1,437.00
$1,068.00
$172.00
$1,338.00
$388.00
$1,277.00
$1,020.00
142
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
26952
26989
26990
26991
26992
27000
27001
27003
27005
27006
27025
27030
27033
27035
27036
27040
27041
27047
27048
27049
27050
27052
27054
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27079
27080
27086
27087
27090
27091
27093
27095
27096
27097
27098
27100
27105
27110
27111
27120
27122
27125
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
0
0
0
90
90
90
90
90
90
90
90
90
$608.00
BR
$592.00
$466.00
$1,146.00
$421.00
$550.00
$698.00
$738.00
$788.00
$896.00
$1,148.00
$1,173.00
$1,413.00
$1,176.00
$196.00
$699.00
$535.00
$588.00
$1,162.00
$449.00
$624.00
$843.00
$491.00
$499.00
$583.00
$931.00
$1,234.00
$1,040.00
$1,112.00
$1,485.00
$1,859.00
$1,976.00
$1,164.00
$1,170.00
$568.00
$57.00
$555.00
$981.00
$1,482.00
$62.00
$121.00
$491.00
$795.00
$799.00
$987.00
$946.00
$1,174.00
$1,099.00
$1,603.00
$1,406.00
$1,371.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,059.00
----$1,232.00
$972.00
$1,754.00
$711.00
$825.00
$893.00
$1,102.00
$1,101.00
$1,172.00
$1,389.00
$1,418.00
$1,802.00
$1,458.00
$458.00
$981.00
$890.00
$754.00
$1,450.00
$615.00
$793.00
$1,043.00
$683.00
$688.00
$789.00
$1,239.00
$1,548.00
$1,521.00
$1,615.00
$3,160.00
$2,286.00
$3,635.00
$1,554.00
$1,559.00
$746.00
$355.00
$948.00
$1,097.00
$2,007.00
$680.00
$641.00
$576.00
$981.00
$1,005.00
$1,293.00
$1,319.00
$1,418.00
$1,312.00
$1,651.00
$1,433.00
$1,395.00
$1,142.00
----$1,330.00
$1,051.00
$1,899.00
$770.00
$894.00
$965.00
$1,195.00
$1,193.00
$1,267.00
$1,508.00
$1,539.00
$1,938.00
$1,582.00
$490.00
$1,056.00
$959.00
$814.00
$1,565.00
$664.00
$858.00
$1,130.00
$737.00
$745.00
$853.00
$1,342.00
$1,680.00
$1,644.00
$1,747.00
$3,364.00
$2,475.00
$3,887.00
$1,680.00
$1,689.00
$807.00
$381.00
$1,025.00
$1,191.00
$2,182.00
$731.00
$688.00
$618.00
$1,064.00
$1,091.00
$1,403.00
$1,431.00
$1,526.00
$1,418.00
$1,792.00
$1,556.00
$1,515.00
$1,198.00
----$1,397.00
$1,107.00
$2,006.00
$814.00
$948.00
$1,021.00
$1,269.00
$1,266.00
$1,343.00
$1,603.00
$1,637.00
$2,042.00
$1,680.00
$511.00
$1,114.00
$1,009.00
$858.00
$1,656.00
$699.00
$908.00
$1,197.00
$775.00
$788.00
$900.00
$1,423.00
$1,785.00
$1,732.00
$1,842.00
$3,517.00
$2,628.00
$4,084.00
$1,777.00
$1,792.00
$853.00
$398.00
$1,086.00
$1,270.00
$2,333.00
$757.00
$713.00
$641.00
$1,130.00
$1,158.00
$1,490.00
$1,521.00
$1,609.00
$1,501.00
$1,913.00
$1,660.00
$1,617.00
$1,059.00
----$1,232.00
$872.00
$1,754.00
$711.00
$825.00
$893.00
$1,102.00
$1,101.00
$1,172.00
$1,389.00
$1,418.00
$1,802.00
$1,458.00
$351.00
$981.00
$774.00
$754.00
$1,450.00
$615.00
$793.00
$1,043.00
$683.00
$688.00
$789.00
$1,239.00
$1,548.00
$1,521.00
$1,615.00
$3,160.00
$2,286.00
$3,635.00
$1,554.00
$1,559.00
$746.00
$298.00
$948.00
$1,097.00
$2,007.00
$95.00
$108.00
$92.00
$981.00
$1,005.00
$1,293.00
$1,319.00
$1,418.00
$1,312.00
$1,651.00
$1,433.00
$1,395.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,142.00
----$1,330.00
$942.00
$1,899.00
$770.00
$894.00
$965.00
$1,195.00
$1,193.00
$1,267.00
$1,508.00
$1,539.00
$1,938.00
$1,582.00
$376.00
$1,056.00
$833.00
$814.00
$1,565.00
$664.00
$858.00
$1,130.00
$737.00
$745.00
$853.00
$1,342.00
$1,680.00
$1,644.00
$1,747.00
$3,364.00
$2,475.00
$3,887.00
$1,680.00
$1,689.00
$807.00
$320.00
$1,025.00
$1,191.00
$2,182.00
$102.00
$115.00
$97.00
$1,064.00
$1,091.00
$1,403.00
$1,431.00
$1,526.00
$1,418.00
$1,792.00
$1,556.00
$1,515.00
$1,198.00
----$1,397.00
$995.00
$2,006.00
$814.00
$948.00
$1,021.00
$1,269.00
$1,266.00
$1,343.00
$1,603.00
$1,637.00
$2,042.00
$1,680.00
$392.00
$1,114.00
$880.00
$858.00
$1,656.00
$699.00
$908.00
$1,197.00
$775.00
$788.00
$900.00
$1,423.00
$1,785.00
$1,732.00
$1,842.00
$3,517.00
$2,628.00
$4,084.00
$1,777.00
$1,792.00
$853.00
$335.00
$1,086.00
$1,270.00
$2,333.00
$107.00
$121.00
$102.00
$1,130.00
$1,158.00
$1,490.00
$1,521.00
$1,609.00
$1,501.00
$1,913.00
$1,660.00
$1,617.00
143
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
27130
27132
27134
27137
27138
27140
27146
27147
27151
27156
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27193
27194
27200
27202
27215
27216
27217
27218
27220
27222
27226
27227
27228
27230
27232
27235
27236
27238
27240
27244
27245
27246
27248
27250
27252
27253
27254
27256
27257
27258
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
10
90
$1,853.00
$2,128.00
$2,576.00
$2,190.00
$2,025.00
$1,092.00
$1,432.00
$1,744.00
$1,732.00
$2,017.00
$1,588.00
$1,443.00
$1,572.00
$1,453.00
$491.00
$1,024.00
$1,257.00
$1,020.00
$1,107.00
$1,206.00
$676.00
$1,280.00
$425.00
$740.00
$180.00
$776.00
$954.00
$1,085.00
$1,285.00
$1,570.00
$444.00
$973.00
$1,350.00
$1,967.00
$2,195.00
$491.00
$916.00
$1,128.00
$1,421.00
$504.00
$1,043.00
$1,426.00
$1,691.00
$459.00
$980.00
$535.00
$520.00
$1,162.00
$1,478.00
$338.00
$455.00
$1,355.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,856.00
$2,155.00
$2,577.00
$1,950.00
$2,033.00
$1,321.00
$1,827.00
$2,066.00
$1,959.00
$2,456.00
$1,940.00
$1,700.00
$1,799.00
$1,647.00
$862.00
$1,211.00
$1,473.00
$1,181.00
$1,308.00
$1,395.00
$1,057.00
$1,476.00
$689.00
$1,028.00
$265.00
$1,480.00
$1,110.00
$1,625.00
$1,472.00
$1,899.00
$742.00
$1,262.00
$1,418.00
$2,236.00
$2,568.00
$714.00
$1,093.00
$1,274.00
$1,475.00
$646.00
$1,250.00
$1,591.00
$1,967.00
$656.00
$1,119.00
$709.00
$1,022.00
$1,309.00
$1,765.00
$456.00
$531.00
$1,604.00
$2,017.00
$2,342.00
$2,801.00
$2,120.00
$2,210.00
$1,433.00
$1,979.00
$2,236.00
$2,129.00
$2,668.00
$2,103.00
$1,845.00
$1,953.00
$1,787.00
$936.00
$1,315.00
$1,600.00
$1,282.00
$1,421.00
$1,507.00
$1,147.00
$1,601.00
$747.00
$1,115.00
$286.00
$1,592.00
$1,203.00
$1,764.00
$1,597.00
$2,065.00
$804.00
$1,370.00
$1,541.00
$2,428.00
$2,789.00
$773.00
$1,185.00
$1,384.00
$1,602.00
$700.00
$1,356.00
$1,727.00
$2,137.00
$711.00
$1,214.00
$762.00
$1,107.00
$1,422.00
$1,916.00
$492.00
$572.00
$1,738.00
$2,155.00
$2,502.00
$2,994.00
$2,265.00
$2,361.00
$1,522.00
$2,101.00
$2,375.00
$2,278.00
$2,844.00
$2,237.00
$1,965.00
$2,082.00
$1,901.00
$998.00
$1,401.00
$1,707.00
$1,367.00
$1,515.00
$1,599.00
$1,217.00
$1,702.00
$791.00
$1,186.00
$301.00
$1,661.00
$1,277.00
$1,877.00
$1,700.00
$2,205.00
$853.00
$1,460.00
$1,644.00
$2,590.00
$2,977.00
$817.00
$1,261.00
$1,473.00
$1,710.00
$742.00
$1,443.00
$1,841.00
$2,280.00
$751.00
$1,290.00
$803.00
$1,178.00
$1,515.00
$2,043.00
$520.00
$604.00
$1,847.00
$1,856.00
$2,155.00
$2,577.00
$1,950.00
$2,033.00
$1,321.00
$1,827.00
$2,066.00
$1,959.00
$2,456.00
$1,940.00
$1,700.00
$1,799.00
$1,647.00
$862.00
$1,211.00
$1,473.00
$1,181.00
$1,308.00
$1,395.00
$1,057.00
$1,476.00
$596.00
$946.00
$196.00
$1,480.00
$1,110.00
$1,625.00
$1,472.00
$1,899.00
$649.00
$1,262.00
$1,418.00
$2,236.00
$2,568.00
$637.00
$1,093.00
$1,274.00
$1,475.00
$646.00
$1,250.00
$1,591.00
$1,967.00
$581.00
$1,119.00
$709.00
$1,022.00
$1,309.00
$1,765.00
$456.00
$531.00
$1,604.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,017.00
$2,342.00
$2,801.00
$2,120.00
$2,210.00
$1,433.00
$1,979.00
$2,236.00
$2,129.00
$2,668.00
$2,103.00
$1,845.00
$1,953.00
$1,787.00
$936.00
$1,315.00
$1,600.00
$1,282.00
$1,421.00
$1,507.00
$1,147.00
$1,601.00
$646.00
$1,027.00
$212.00
$1,592.00
$1,203.00
$1,764.00
$1,597.00
$2,065.00
$704.00
$1,370.00
$1,541.00
$2,428.00
$2,789.00
$690.00
$1,185.00
$1,384.00
$1,602.00
$700.00
$1,356.00
$1,727.00
$2,137.00
$630.00
$1,214.00
$762.00
$1,107.00
$1,422.00
$1,916.00
$492.00
$572.00
$1,738.00
$2,155.00
$2,502.00
$2,994.00
$2,265.00
$2,361.00
$1,522.00
$2,101.00
$2,375.00
$2,278.00
$2,844.00
$2,237.00
$1,965.00
$2,082.00
$1,901.00
$998.00
$1,401.00
$1,707.00
$1,367.00
$1,515.00
$1,599.00
$1,217.00
$1,702.00
$687.00
$1,094.00
$224.00
$1,661.00
$1,277.00
$1,877.00
$1,700.00
$2,205.00
$749.00
$1,460.00
$1,644.00
$2,590.00
$2,977.00
$731.00
$1,261.00
$1,473.00
$1,710.00
$742.00
$1,443.00
$1,841.00
$2,280.00
$667.00
$1,290.00
$803.00
$1,178.00
$1,515.00
$2,043.00
$520.00
$604.00
$1,847.00
144
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
27259
27265
27266
27275
27280
27282
27284
27286
27290
27295
27299
27301
27303
27305
27306
27307
27310
27315
27320
27323
27324
27327
27328
27329
27330
27331
27332
27333
27334
27335
27340
27345
27347
27350
27355
27356
27357
27358
27360
27365
27370
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
90
90
90
10
90
90
90
90
90
90
YYY
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
0
90
90
90
90
90
90
90
90
90
90
90
$1,803.00
$442.00
$614.00
$220.00
$1,179.00
$990.00
$1,435.00
$1,503.00
$2,073.00
$1,594.00
BR
$193.00
$520.00
$555.00
$377.00
$503.00
$877.00
$570.00
$522.00
$211.00
$433.00
$400.00
$503.00
$1,249.00
$492.00
$585.00
$786.00
$719.00
$840.00
$959.00
$405.00
$565.00
$394.00
$786.00
$763.00
$882.00
$950.00
$394.00
$977.00
$1,421.00
$75.00
$371.00
$698.00
$1,118.00
$753.00
$1,064.00
$506.00
$647.00
$834.00
$608.00
$748.00
$1,093.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,130.00
$600.00
$818.00
$317.00
$1,513.00
$1,255.00
$2,247.00
$2,274.00
$2,190.00
$1,794.00
----$1,178.00
$1,249.00
$810.00
$659.00
$758.00
$1,056.00
$618.00
$595.00
$418.00
$632.00
$676.00
$677.00
$1,538.00
$615.00
$729.00
$932.00
$852.00
$1,001.00
$1,122.00
$553.00
$725.00
$703.00
$932.00
$977.00
$1,132.00
$1,221.00
$408.00
$1,544.00
$1,679.00
$636.00
$716.00
$847.00
$1,118.00
$900.00
$1,172.00
$712.00
$881.00
$1,099.00
$805.00
$1,045.00
$1,378.00
$2,312.00
$650.00
$888.00
$343.00
$1,644.00
$1,349.00
$2,417.00
$2,445.00
$2,371.00
$1,942.00
----$1,272.00
$1,351.00
$876.00
$713.00
$820.00
$1,145.00
$667.00
$644.00
$448.00
$683.00
$728.00
$731.00
$1,660.00
$665.00
$790.00
$1,010.00
$924.00
$1,086.00
$1,217.00
$599.00
$786.00
$761.00
$1,011.00
$1,059.00
$1,226.00
$1,325.00
$444.00
$1,670.00
$1,823.00
$683.00
$773.00
$918.00
$1,213.00
$976.00
$1,271.00
$770.00
$954.00
$1,190.00
$873.00
$1,133.00
$1,494.00
$2,464.00
$687.00
$944.00
$362.00
$1,749.00
$1,421.00
$2,552.00
$2,582.00
$2,522.00
$2,064.00
----$1,334.00
$1,425.00
$924.00
$752.00
$867.00
$1,216.00
$708.00
$684.00
$467.00
$720.00
$764.00
$771.00
$1,756.00
$704.00
$837.00
$1,073.00
$981.00
$1,152.00
$1,293.00
$633.00
$832.00
$805.00
$1,074.00
$1,121.00
$1,300.00
$1,406.00
$475.00
$1,761.00
$1,940.00
$707.00
$814.00
$974.00
$1,290.00
$1,036.00
$1,351.00
$813.00
$1,011.00
$1,260.00
$925.00
$1,200.00
$1,585.00
$2,130.00
$600.00
$818.00
$317.00
$1,513.00
$1,255.00
$2,247.00
$2,274.00
$2,190.00
$1,794.00
----$1,084.00
$1,249.00
$810.00
$659.00
$758.00
$1,056.00
$618.00
$595.00
$299.00
$632.00
$574.00
$677.00
$1,538.00
$615.00
$729.00
$932.00
$852.00
$1,001.00
$1,122.00
$553.00
$725.00
$703.00
$932.00
$977.00
$1,132.00
$1,221.00
$408.00
$1,544.00
$1,679.00
$68.00
$621.00
$847.00
$1,118.00
$900.00
$1,172.00
$712.00
$881.00
$1,099.00
$805.00
$1,045.00
$1,378.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,312.00
$650.00
$888.00
$343.00
$1,644.00
$1,349.00
$2,417.00
$2,445.00
$2,371.00
$1,942.00
----$1,170.00
$1,351.00
$876.00
$713.00
$820.00
$1,145.00
$667.00
$644.00
$321.00
$683.00
$619.00
$731.00
$1,660.00
$665.00
$790.00
$1,010.00
$924.00
$1,086.00
$1,217.00
$599.00
$786.00
$761.00
$1,011.00
$1,059.00
$1,226.00
$1,325.00
$444.00
$1,670.00
$1,823.00
$72.00
$671.00
$918.00
$1,213.00
$976.00
$1,271.00
$770.00
$954.00
$1,190.00
$873.00
$1,133.00
$1,494.00
$2,464.00
$687.00
$944.00
$362.00
$1,749.00
$1,421.00
$2,552.00
$2,582.00
$2,522.00
$2,064.00
----$1,228.00
$1,425.00
$924.00
$752.00
$867.00
$1,216.00
$708.00
$684.00
$335.00
$720.00
$651.00
$771.00
$1,756.00
$704.00
$837.00
$1,073.00
$981.00
$1,152.00
$1,293.00
$633.00
$832.00
$805.00
$1,074.00
$1,121.00
$1,300.00
$1,406.00
$475.00
$1,761.00
$1,940.00
$76.00
$708.00
$974.00
$1,290.00
$1,036.00
$1,351.00
$813.00
$1,011.00
$1,260.00
$925.00
$1,200.00
$1,585.00
145
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
27396
27397
27400
27403
27405
27407
27409
27418
27420
27422
27424
27425
27427
27428
27429
27430
27435
27437
27438
27440
27441
27442
27443
27445
27446
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27475
27477
27479
27485
27486
27487
27488
27495
27496
27497
27498
27499
27500
27501
27502
27503
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$742.00
$989.00
$832.00
$792.00
$842.00
$918.00
$1,212.00
$1,596.00
$927.00
$930.00
$927.00
$639.00
$1,118.00
$1,266.00
$2,333.00
$884.00
$501.00
$819.00
$1,065.00
$1,064.00
$1,006.00
$1,117.00
$1,037.00
$1,618.00
$1,764.00
$1,960.00
$1,060.00
$1,311.00
$1,524.00
$1,157.00
$1,209.00
$1,253.00
$1,441.00
$1,613.00
$1,501.00
$1,665.00
$782.00
$938.00
$1,123.00
$797.00
$1,771.00
$2,352.00
$1,438.00
$1,477.00
$563.00
$652.00
$701.00
$782.00
$520.00
$659.00
$909.00
$911.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,004.00
$1,277.00
$1,075.00
$942.00
$1,002.00
$1,129.00
$1,361.00
$1,193.00
$1,072.00
$1,069.00
$1,070.00
$679.00
$1,024.00
$1,457.00
$1,588.00
$1,065.00
$1,046.00
$858.00
$1,090.00
$920.00
$977.00
$1,149.00
$1,079.00
$1,660.00
$1,500.00
$1,996.00
$1,258.00
$1,521.00
$1,822.00
$1,378.00
$1,376.00
$1,503.00
$1,744.00
$1,934.00
$1,754.00
$1,896.00
$976.00
$1,071.00
$1,362.00
$1,002.00
$1,809.00
$2,319.00
$1,511.00
$1,712.00
$759.00
$818.00
$887.00
$981.00
$856.00
$919.00
$1,193.00
$1,195.00
$1,088.00
$1,386.00
$1,164.00
$1,021.00
$1,087.00
$1,224.00
$1,475.00
$1,294.00
$1,163.00
$1,160.00
$1,161.00
$736.00
$1,110.00
$1,581.00
$1,724.00
$1,155.00
$1,135.00
$931.00
$1,183.00
$999.00
$1,061.00
$1,249.00
$1,172.00
$1,804.00
$1,630.00
$2,169.00
$1,364.00
$1,651.00
$1,978.00
$1,495.00
$1,494.00
$1,628.00
$1,882.00
$2,100.00
$1,903.00
$2,058.00
$1,057.00
$1,160.00
$1,479.00
$1,087.00
$1,966.00
$2,521.00
$1,641.00
$1,857.00
$820.00
$883.00
$958.00
$1,062.00
$926.00
$995.00
$1,295.00
$1,297.00
$1,152.00
$1,471.00
$1,232.00
$1,084.00
$1,154.00
$1,299.00
$1,568.00
$1,375.00
$1,236.00
$1,234.00
$1,234.00
$779.00
$1,179.00
$1,682.00
$1,836.00
$1,227.00
$1,206.00
$992.00
$1,262.00
$1,068.00
$1,133.00
$1,333.00
$1,249.00
$1,927.00
$1,740.00
$2,316.00
$1,447.00
$1,755.00
$2,106.00
$1,590.00
$1,591.00
$1,729.00
$1,992.00
$2,238.00
$2,023.00
$2,189.00
$1,120.00
$1,232.00
$1,574.00
$1,154.00
$2,099.00
$2,694.00
$1,751.00
$1,974.00
$867.00
$933.00
$1,014.00
$1,127.00
$977.00
$1,049.00
$1,375.00
$1,378.00
$1,004.00
$1,277.00
$1,075.00
$942.00
$1,002.00
$1,129.00
$1,361.00
$1,193.00
$1,072.00
$1,069.00
$1,070.00
$679.00
$1,024.00
$1,457.00
$1,588.00
$1,065.00
$1,046.00
$858.00
$1,090.00
$920.00
$977.00
$1,149.00
$1,079.00
$1,660.00
$1,500.00
$1,996.00
$1,258.00
$1,521.00
$1,822.00
$1,378.00
$1,376.00
$1,503.00
$1,744.00
$1,934.00
$1,754.00
$1,896.00
$976.00
$1,071.00
$1,362.00
$1,002.00
$1,809.00
$2,319.00
$1,511.00
$1,712.00
$759.00
$818.00
$887.00
$981.00
$731.00
$794.00
$1,193.00
$1,195.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,088.00
$1,386.00
$1,164.00
$1,021.00
$1,087.00
$1,224.00
$1,475.00
$1,294.00
$1,163.00
$1,160.00
$1,161.00
$736.00
$1,110.00
$1,581.00
$1,724.00
$1,155.00
$1,135.00
$931.00
$1,183.00
$999.00
$1,061.00
$1,249.00
$1,172.00
$1,804.00
$1,630.00
$2,169.00
$1,364.00
$1,651.00
$1,978.00
$1,495.00
$1,494.00
$1,628.00
$1,882.00
$2,100.00
$1,903.00
$2,058.00
$1,057.00
$1,160.00
$1,479.00
$1,087.00
$1,966.00
$2,521.00
$1,641.00
$1,857.00
$820.00
$883.00
$958.00
$1,062.00
$792.00
$860.00
$1,295.00
$1,297.00
$1,152.00
$1,471.00
$1,232.00
$1,084.00
$1,154.00
$1,299.00
$1,568.00
$1,375.00
$1,236.00
$1,234.00
$1,234.00
$779.00
$1,179.00
$1,682.00
$1,836.00
$1,227.00
$1,206.00
$992.00
$1,262.00
$1,068.00
$1,133.00
$1,333.00
$1,249.00
$1,927.00
$1,740.00
$2,316.00
$1,447.00
$1,755.00
$2,106.00
$1,590.00
$1,591.00
$1,729.00
$1,992.00
$2,238.00
$2,023.00
$2,189.00
$1,120.00
$1,232.00
$1,574.00
$1,154.00
$2,099.00
$2,694.00
$1,751.00
$1,974.00
$867.00
$933.00
$1,014.00
$1,127.00
$838.00
$910.00
$1,375.00
$1,378.00
146
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
27506
27507
27508
27509
27510
27511
27513
27514
27516
27517
27519
27520
27524
27530
27532
27535
27536
27538
27540
27550
27552
27556
27557
27558
27560
27562
27566
27570
27580
27590
27591
27592
27594
27596
27598
27599
27600
27601
27602
27603
27604
27605
27606
27607
27610
27612
27613
27614
27615
27618
27619
27620
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
YYY
90
90
90
90
90
10
10
90
90
90
10
90
90
90
90
90
$1,522.00
$1,297.00
$400.00
$649.00
$755.00
$1,281.00
$1,562.00
$1,508.00
$579.00
$820.00
$1,311.00
$266.00
$910.00
$408.00
$641.00
$1,075.00
$1,282.00
$487.00
$1,106.00
$296.00
$619.00
$832.00
$1,479.00
$1,529.00
$88.00
$514.00
$1,047.00
$184.00
$1,644.00
$1,059.00
$1,182.00
$911.00
$600.00
$931.00
$976.00
BR
$517.00
$516.00
$621.00
$412.00
$308.00
$236.00
$362.00
$608.00
$777.00
$701.00
$165.00
$327.00
$1,106.00
$421.00
$730.00
$587.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,738.00
$1,450.00
$706.00
$920.00
$901.00
$1,459.00
$1,826.00
$1,746.00
$717.00
$1,001.00
$1,564.00
$450.00
$1,034.00
$530.00
$813.00
$1,278.00
$1,518.00
$676.00
$1,289.00
$702.00
$869.00
$1,570.00
$1,773.00
$1,839.00
$520.00
$621.00
$1,224.00
$271.00
$1,956.00
$1,305.00
$1,456.00
$1,173.00
$844.00
$1,229.00
$1,175.00
----$710.00
$708.00
$821.00
$1,065.00
$832.00
$699.00
$887.00
$1,194.00
$1,025.00
$853.00
$408.00
$887.00
$1,542.00
$869.00
$1,138.00
$767.00
$1,884.00
$1,574.00
$765.00
$998.00
$978.00
$1,584.00
$1,983.00
$1,895.00
$777.00
$1,085.00
$1,698.00
$487.00
$1,123.00
$574.00
$881.00
$1,387.00
$1,648.00
$732.00
$1,399.00
$758.00
$943.00
$1,704.00
$1,924.00
$1,997.00
$560.00
$670.00
$1,329.00
$293.00
$2,123.00
$1,408.00
$1,575.00
$1,266.00
$911.00
$1,327.00
$1,269.00
----$767.00
$764.00
$885.00
$1,148.00
$897.00
$754.00
$958.00
$1,292.00
$1,110.00
$925.00
$438.00
$956.00
$1,662.00
$935.00
$1,229.00
$832.00
$2,005.00
$1,675.00
$811.00
$1,058.00
$1,042.00
$1,684.00
$2,112.00
$2,019.00
$821.00
$1,152.00
$1,807.00
$513.00
$1,195.00
$606.00
$936.00
$1,473.00
$1,758.00
$774.00
$1,491.00
$800.00
$1,002.00
$1,811.00
$2,048.00
$2,127.00
$588.00
$709.00
$1,417.00
$309.00
$2,262.00
$1,487.00
$1,668.00
$1,336.00
$962.00
$1,401.00
$1,341.00
----$809.00
$807.00
$935.00
$1,200.00
$940.00
$789.00
$1,004.00
$1,362.00
$1,176.00
$981.00
$456.00
$1,002.00
$1,750.00
$979.00
$1,294.00
$880.00
$1,738.00
$1,450.00
$614.00
$920.00
$901.00
$1,459.00
$1,826.00
$1,746.00
$610.00
$909.00
$1,564.00
$358.00
$1,034.00
$440.00
$719.00
$1,278.00
$1,518.00
$567.00
$1,289.00
$618.00
$869.00
$1,570.00
$1,773.00
$1,839.00
$412.00
$621.00
$1,224.00
$271.00
$1,956.00
$1,305.00
$1,456.00
$1,173.00
$844.00
$1,229.00
$1,175.00
----$710.00
$708.00
$821.00
$806.00
$683.00
$364.00
$500.00
$1,194.00
$1,025.00
$853.00
$273.00
$685.00
$1,542.00
$625.00
$948.00
$767.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,884.00
$1,574.00
$666.00
$998.00
$978.00
$1,584.00
$1,983.00
$1,895.00
$662.00
$986.00
$1,698.00
$388.00
$1,123.00
$476.00
$781.00
$1,387.00
$1,648.00
$615.00
$1,399.00
$667.00
$943.00
$1,704.00
$1,924.00
$1,997.00
$444.00
$670.00
$1,329.00
$293.00
$2,123.00
$1,408.00
$1,575.00
$1,266.00
$911.00
$1,327.00
$1,269.00
----$767.00
$764.00
$885.00
$869.00
$737.00
$394.00
$542.00
$1,292.00
$1,110.00
$925.00
$292.00
$738.00
$1,662.00
$673.00
$1,024.00
$832.00
$2,005.00
$1,675.00
$708.00
$1,058.00
$1,042.00
$1,684.00
$2,112.00
$2,019.00
$702.00
$1,050.00
$1,807.00
$410.00
$1,195.00
$505.00
$832.00
$1,473.00
$1,758.00
$652.00
$1,491.00
$705.00
$1,002.00
$1,811.00
$2,048.00
$2,127.00
$468.00
$709.00
$1,417.00
$309.00
$2,262.00
$1,487.00
$1,668.00
$1,336.00
$962.00
$1,401.00
$1,341.00
----$809.00
$807.00
$935.00
$911.00
$775.00
$417.00
$575.00
$1,362.00
$1,176.00
$981.00
$305.00
$777.00
$1,750.00
$708.00
$1,083.00
$880.00
147
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
27625
27626
27630
27635
27637
27638
27640
27641
27645
27646
27647
27648
27650
27652
27654
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27686
27687
27690
27691
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
27720
27722
27724
27725
27727
27730
27732
27734
27740
27742
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$796.00
$863.00
$430.00
$781.00
$921.00
$978.00
$1,122.00
$922.00
$1,302.00
$1,212.00
$1,044.00
$72.00
$869.00
$935.00
$937.00
$458.00
$527.00
$725.00
$504.00
$618.00
$656.00
$762.00
$523.00
$634.00
$565.00
$706.00
$589.00
$757.00
$889.00
$159.00
$658.00
$758.00
$881.00
$835.00
$1,278.00
$1,337.00
$683.00
$985.00
$484.00
$1,118.00
$1,227.00
$1,285.00
$1,147.00
$1,076.00
$1,402.00
$1,312.00
$1,175.00
$647.00
$611.00
$766.00
$1,044.00
$1,045.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$984.00
$1,053.00
$841.00
$1,024.00
$1,213.00
$1,272.00
$1,594.00
$1,366.00
$1,752.00
$1,596.00
$1,283.00
$526.00
$1,051.00
$1,101.00
$1,107.00
$886.00
$937.00
$1,130.00
$1,002.00
$1,033.00
$847.00
$969.00
$753.00
$840.00
$897.00
$1,179.00
$804.00
$992.00
$1,145.00
$157.00
$855.00
$977.00
$1,029.00
$830.00
$1,326.00
$1,496.00
$702.00
$1,197.00
$689.00
$1,171.00
$1,533.00
$1,608.00
$1,388.00
$1,377.00
$1,909.00
$1,709.00
$1,552.00
$1,455.00
$1,000.00
$964.00
$1,717.00
$1,431.00
$1,067.00
$1,142.00
$908.00
$1,109.00
$1,315.00
$1,378.00
$1,725.00
$1,477.00
$1,899.00
$1,724.00
$1,390.00
$565.00
$1,141.00
$1,195.00
$1,201.00
$954.00
$1,013.00
$1,223.00
$1,083.00
$1,116.00
$918.00
$1,051.00
$816.00
$910.00
$972.00
$1,276.00
$872.00
$1,076.00
$1,242.00
$171.00
$926.00
$1,059.00
$1,116.00
$901.00
$1,441.00
$1,626.00
$751.00
$1,298.00
$745.00
$1,270.00
$1,663.00
$1,744.00
$1,505.00
$1,493.00
$2,060.00
$1,854.00
$1,681.00
$1,565.00
$1,079.00
$1,037.00
$1,857.00
$1,553.00
$1,132.00
$1,210.00
$953.00
$1,172.00
$1,394.00
$1,461.00
$1,821.00
$1,557.00
$2,012.00
$1,819.00
$1,477.00
$585.00
$1,213.00
$1,272.00
$1,277.00
$997.00
$1,064.00
$1,288.00
$1,135.00
$1,173.00
$974.00
$1,114.00
$864.00
$963.00
$1,027.00
$1,345.00
$923.00
$1,142.00
$1,319.00
$183.00
$979.00
$1,123.00
$1,186.00
$962.00
$1,537.00
$1,737.00
$789.00
$1,377.00
$785.00
$1,347.00
$1,769.00
$1,852.00
$1,597.00
$1,585.00
$2,179.00
$1,971.00
$1,782.00
$1,635.00
$1,130.00
$1,091.00
$1,952.00
$1,644.00
$984.00
$1,053.00
$633.00
$1,024.00
$1,213.00
$1,272.00
$1,594.00
$1,366.00
$1,752.00
$1,596.00
$1,283.00
$68.00
$1,051.00
$1,101.00
$1,107.00
$590.00
$758.00
$905.00
$742.00
$797.00
$847.00
$969.00
$753.00
$840.00
$811.00
$949.00
$804.00
$992.00
$1,145.00
$157.00
$855.00
$977.00
$1,029.00
$830.00
$1,326.00
$1,496.00
$702.00
$1,197.00
$689.00
$1,171.00
$1,533.00
$1,608.00
$1,388.00
$1,377.00
$1,909.00
$1,709.00
$1,552.00
$916.00
$733.00
$964.00
$1,125.00
$1,153.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,067.00
$1,142.00
$684.00
$1,109.00
$1,315.00
$1,378.00
$1,725.00
$1,477.00
$1,899.00
$1,724.00
$1,390.00
$72.00
$1,141.00
$1,195.00
$1,201.00
$635.00
$820.00
$981.00
$803.00
$863.00
$918.00
$1,051.00
$816.00
$910.00
$880.00
$1,029.00
$872.00
$1,076.00
$1,242.00
$171.00
$926.00
$1,059.00
$1,116.00
$901.00
$1,441.00
$1,626.00
$751.00
$1,298.00
$745.00
$1,270.00
$1,663.00
$1,744.00
$1,505.00
$1,493.00
$2,060.00
$1,854.00
$1,681.00
$986.00
$790.00
$1,037.00
$1,220.00
$1,253.00
$1,132.00
$1,210.00
$721.00
$1,172.00
$1,394.00
$1,461.00
$1,821.00
$1,557.00
$2,012.00
$1,819.00
$1,477.00
$75.00
$1,213.00
$1,272.00
$1,277.00
$668.00
$865.00
$1,037.00
$845.00
$910.00
$974.00
$1,114.00
$864.00
$963.00
$932.00
$1,090.00
$923.00
$1,142.00
$1,319.00
$183.00
$979.00
$1,123.00
$1,186.00
$962.00
$1,537.00
$1,737.00
$789.00
$1,377.00
$785.00
$1,347.00
$1,769.00
$1,852.00
$1,597.00
$1,585.00
$2,179.00
$1,971.00
$1,782.00
$1,036.00
$832.00
$1,091.00
$1,294.00
$1,335.00
148
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
27745
27750
27752
27756
27758
27759
27760
27762
27766
27780
27781
27784
27786
27788
27792
27808
27810
27814
27816
27818
27822
27823
27824
27825
27826
27827
27828
27829
27830
27831
27832
27840
27842
27846
27848
27860
27870
27871
27880
27881
27882
27884
27886
27888
27889
27892
27893
27894
27899
28001
28002
28003
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
YYY
10
10
90
$940.00
$319.00
$614.00
$708.00
$1,115.00
$1,262.00
$223.00
$495.00
$759.00
$244.00
$296.00
$643.00
$223.00
$422.00
$706.00
$332.00
$567.00
$972.00
$386.00
$613.00
$1,201.00
$1,472.00
$384.00
$670.00
$1,080.00
$1,310.00
$1,823.00
$742.00
$412.00
$415.00
$617.00
$334.00
$373.00
$877.00
$1,224.00
$211.00
$1,269.00
$843.00
$1,015.00
$1,120.00
$854.00
$579.00
$835.00
$911.00
$879.00
$575.00
$574.00
$712.00
BR
$185.00
$362.00
$520.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,183.00
$477.00
$762.00
$956.00
$1,290.00
$1,486.00
$454.00
$699.00
$919.00
$428.00
$591.00
$855.00
$442.00
$600.00
$864.00
$499.00
$697.00
$1,179.00
$475.00
$725.00
$1,294.00
$1,470.00
$498.00
$790.00
$1,099.00
$1,576.00
$1,739.00
$761.00
$500.00
$538.00
$805.00
$558.00
$617.00
$1,096.00
$1,244.00
$321.00
$1,511.00
$1,098.00
$1,264.00
$1,383.00
$1,148.00
$1,002.00
$1,096.00
$1,115.00
$1,094.00
$830.00
$823.00
$1,074.00
----$432.00
$606.00
$1,039.00
$1,282.00
$516.00
$826.00
$1,035.00
$1,397.00
$1,613.00
$490.00
$757.00
$997.00
$462.00
$639.00
$927.00
$478.00
$650.00
$937.00
$539.00
$755.00
$1,279.00
$513.00
$785.00
$1,397.00
$1,590.00
$539.00
$856.00
$1,191.00
$1,709.00
$1,887.00
$825.00
$539.00
$583.00
$872.00
$601.00
$667.00
$1,188.00
$1,349.00
$347.00
$1,640.00
$1,191.00
$1,364.00
$1,497.00
$1,238.00
$1,081.00
$1,183.00
$1,207.00
$1,182.00
$895.00
$889.00
$1,160.00
----$465.00
$654.00
$1,123.00
$1,359.00
$544.00
$874.00
$1,093.00
$1,481.00
$1,715.00
$516.00
$800.00
$1,060.00
$485.00
$675.00
$983.00
$503.00
$687.00
$995.00
$566.00
$798.00
$1,360.00
$539.00
$829.00
$1,474.00
$1,683.00
$566.00
$906.00
$1,261.00
$1,815.00
$2,007.00
$872.00
$568.00
$617.00
$924.00
$632.00
$708.00
$1,262.00
$1,433.00
$366.00
$1,744.00
$1,263.00
$1,443.00
$1,586.00
$1,304.00
$1,140.00
$1,250.00
$1,278.00
$1,250.00
$946.00
$941.00
$1,229.00
----$488.00
$690.00
$1,185.00
$1,183.00
$388.00
$656.00
$956.00
$1,290.00
$1,486.00
$367.00
$596.00
$919.00
$335.00
$487.00
$855.00
$353.00
$495.00
$864.00
$392.00
$590.00
$1,179.00
$395.00
$618.00
$1,294.00
$1,470.00
$396.00
$683.00
$1,099.00
$1,576.00
$1,739.00
$761.00
$429.00
$538.00
$805.00
$558.00
$617.00
$1,096.00
$1,244.00
$321.00
$1,511.00
$1,098.00
$1,264.00
$1,383.00
$1,148.00
$1,002.00
$1,096.00
$1,115.00
$1,094.00
$830.00
$823.00
$1,074.00
----$315.00
$479.00
$1,016.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,282.00
$420.00
$711.00
$1,035.00
$1,397.00
$1,613.00
$397.00
$646.00
$997.00
$362.00
$527.00
$927.00
$382.00
$536.00
$937.00
$424.00
$640.00
$1,279.00
$427.00
$669.00
$1,397.00
$1,590.00
$429.00
$740.00
$1,191.00
$1,709.00
$1,887.00
$825.00
$463.00
$583.00
$872.00
$601.00
$667.00
$1,188.00
$1,349.00
$347.00
$1,640.00
$1,191.00
$1,364.00
$1,497.00
$1,238.00
$1,081.00
$1,183.00
$1,207.00
$1,182.00
$895.00
$889.00
$1,160.00
----$339.00
$518.00
$1,098.00
$1,359.00
$445.00
$756.00
$1,093.00
$1,481.00
$1,715.00
$420.00
$685.00
$1,060.00
$382.00
$558.00
$983.00
$404.00
$569.00
$995.00
$448.00
$679.00
$1,360.00
$450.00
$710.00
$1,474.00
$1,683.00
$453.00
$786.00
$1,261.00
$1,815.00
$2,007.00
$872.00
$489.00
$617.00
$924.00
$632.00
$708.00
$1,262.00
$1,433.00
$366.00
$1,744.00
$1,263.00
$1,443.00
$1,586.00
$1,304.00
$1,140.00
$1,250.00
$1,278.00
$1,250.00
$946.00
$941.00
$1,229.00
----$358.00
$549.00
$1,159.00
149
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
28005
28008
28010
28011
28020
28022
28024
28030
28035
28043
28045
28046
28050
28052
28054
28060
28062
28070
28072
28080
28086
28088
28090
28092
28100
28102
28103
28104
28106
28107
28108
28110
28111
28112
28113
28114
28116
28118
28119
28120
28122
28124
28126
28130
28140
28150
28153
28160
28171
28173
28175
28190
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
$520.00
$296.00
$235.00
$340.00
$509.00
$422.00
$371.00
$453.00
$532.00
$305.00
$456.00
$814.00
$414.00
$402.00
$236.00
$495.00
$657.00
$476.00
$445.00
$392.00
$462.00
$414.00
$414.00
$330.00
$571.00
$700.00
$709.00
$491.00
$632.00
$517.00
$418.00
$421.00
$537.00
$457.00
$481.00
$890.00
$648.00
$568.00
$524.00
$601.00
$622.00
$480.00
$393.00
$727.00
$533.00
$416.00
$400.00
$412.00
$789.00
$747.00
$571.00
$75.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,030.00
$655.00
$536.00
$702.00
$747.00
$671.00
$657.00
$533.00
$756.00
$574.00
$674.00
$1,186.00
$628.00
$626.00
$593.00
$734.00
$851.00
$688.00
$686.00
$597.00
$839.00
$690.00
$651.00
$626.00
$913.00
$903.00
$875.00
$730.00
$759.00
$815.00
$604.00
$673.00
$811.00
$735.00
$732.00
$1,266.00
$889.00
$815.00
$735.00
$936.00
$978.00
$748.00
$612.00
$919.00
$928.00
$675.00
$619.00
$639.00
$969.00
$1,052.00
$819.00
$421.00
$1,115.00
$708.00
$580.00
$760.00
$807.00
$726.00
$708.00
$579.00
$818.00
$620.00
$729.00
$1,279.00
$679.00
$676.00
$640.00
$794.00
$921.00
$744.00
$742.00
$646.00
$908.00
$745.00
$703.00
$676.00
$988.00
$976.00
$947.00
$790.00
$823.00
$882.00
$653.00
$726.00
$876.00
$795.00
$791.00
$1,371.00
$963.00
$881.00
$796.00
$1,011.00
$1,058.00
$809.00
$661.00
$997.00
$1,002.00
$729.00
$669.00
$691.00
$1,046.00
$1,135.00
$885.00
$452.00
$1,181.00
$745.00
$609.00
$800.00
$850.00
$765.00
$744.00
$620.00
$863.00
$652.00
$768.00
$1,348.00
$715.00
$711.00
$673.00
$838.00
$973.00
$786.00
$783.00
$680.00
$955.00
$783.00
$741.00
$710.00
$1,040.00
$1,033.00
$1,001.00
$834.00
$876.00
$929.00
$687.00
$762.00
$921.00
$836.00
$833.00
$1,451.00
$1,020.00
$930.00
$841.00
$1,061.00
$1,117.00
$852.00
$696.00
$1,058.00
$1,056.00
$766.00
$703.00
$727.00
$1,108.00
$1,198.00
$933.00
$471.00
$1,030.00
$568.00
$426.00
$590.00
$622.00
$583.00
$572.00
$533.00
$570.00
$461.00
$565.00
$1,118.00
$543.00
$530.00
$493.00
$631.00
$700.00
$599.00
$616.00
$489.00
$655.00
$566.00
$538.00
$513.00
$719.00
$903.00
$748.00
$643.00
$759.00
$673.00
$508.00
$582.00
$676.00
$638.00
$638.00
$1,122.00
$789.00
$704.00
$622.00
$804.00
$900.00
$667.00
$555.00
$919.00
$791.00
$596.00
$506.00
$586.00
$969.00
$942.00
$689.00
$275.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,115.00
$614.00
$461.00
$639.00
$672.00
$631.00
$617.00
$579.00
$618.00
$498.00
$612.00
$1,205.00
$587.00
$573.00
$533.00
$683.00
$758.00
$648.00
$667.00
$530.00
$710.00
$613.00
$582.00
$555.00
$778.00
$976.00
$811.00
$696.00
$823.00
$728.00
$549.00
$628.00
$730.00
$690.00
$690.00
$1,217.00
$855.00
$763.00
$675.00
$869.00
$974.00
$722.00
$601.00
$997.00
$855.00
$644.00
$548.00
$634.00
$1,046.00
$1,017.00
$745.00
$295.00
$1,181.00
$648.00
$486.00
$675.00
$710.00
$668.00
$649.00
$620.00
$656.00
$526.00
$648.00
$1,273.00
$620.00
$605.00
$562.00
$722.00
$805.00
$687.00
$706.00
$560.00
$750.00
$646.00
$615.00
$584.00
$823.00
$1,033.00
$860.00
$736.00
$876.00
$771.00
$580.00
$661.00
$770.00
$728.00
$729.00
$1,291.00
$909.00
$808.00
$716.00
$915.00
$1,030.00
$762.00
$633.00
$1,058.00
$903.00
$679.00
$578.00
$668.00
$1,108.00
$1,076.00
$788.00
$309.00
150
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
28192
28193
28200
28202
28208
28210
28220
28222
28225
28226
28230
28232
28234
28238
28240
28250
28260
28261
28262
28264
28270
28272
28280
28285
28286
28288
28289
28290
28292
28293
28294
28296
28297
28298
28299
28300
28302
28304
28305
28306
28307
28308
28309
28310
28312
28313
28315
28320
28322
28340
28341
28344
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$326.00
$341.00
$478.00
$613.00
$406.00
$609.00
$435.00
$555.00
$345.00
$334.00
$380.00
$286.00
$178.00
$695.00
$370.00
$535.00
$641.00
$881.00
$1,363.00
$912.00
$266.00
$336.00
$426.00
$463.00
$441.00
$452.00
$458.00
$557.00
$666.00
$845.00
$797.00
$832.00
$838.00
$755.00
$829.00
$845.00
$930.00
$776.00
$1,030.00
$530.00
$614.00
$516.00
$955.00
$505.00
$469.00
$436.00
$462.00
$833.00
$667.00
$649.00
$753.00
$414.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$666.00
$756.00
$679.00
$962.00
$655.00
$837.00
$655.00
$739.00
$592.00
$657.00
$646.00
$598.00
$600.00
$961.00
$651.00
$788.00
$931.00
$1,234.00
$1,783.00
$1,164.00
$707.00
$594.00
$758.00
$699.00
$691.00
$726.00
$982.00
$818.00
$898.00
$946.00
$1,015.00
$1,077.00
$1,129.00
$962.00
$1,165.00
$1,297.00
$1,274.00
$1,027.00
$1,282.00
$796.00
$1,015.00
$698.00
$1,268.00
$767.00
$701.00
$752.00
$672.00
$989.00
$1,075.00
$872.00
$962.00
$683.00
$718.00
$815.00
$734.00
$1,040.00
$708.00
$903.00
$710.00
$800.00
$641.00
$711.00
$699.00
$647.00
$648.00
$1,041.00
$705.00
$854.00
$1,009.00
$1,340.00
$1,934.00
$1,263.00
$765.00
$643.00
$821.00
$757.00
$748.00
$785.00
$1,063.00
$885.00
$973.00
$1,027.00
$1,100.00
$1,168.00
$1,225.00
$1,043.00
$1,258.00
$1,404.00
$1,375.00
$1,107.00
$1,366.00
$862.00
$1,094.00
$756.00
$1,373.00
$831.00
$758.00
$813.00
$728.00
$1,073.00
$1,165.00
$946.00
$1,044.00
$739.00
$755.00
$857.00
$773.00
$1,095.00
$747.00
$952.00
$749.00
$846.00
$675.00
$750.00
$737.00
$681.00
$681.00
$1,103.00
$743.00
$903.00
$1,070.00
$1,426.00
$2,054.00
$1,342.00
$807.00
$678.00
$866.00
$798.00
$789.00
$828.00
$1,122.00
$935.00
$1,030.00
$1,094.00
$1,166.00
$1,239.00
$1,298.00
$1,106.00
$1,330.00
$1,484.00
$1,449.00
$1,168.00
$1,420.00
$911.00
$1,147.00
$800.00
$1,459.00
$878.00
$799.00
$858.00
$769.00
$1,140.00
$1,234.00
$1,002.00
$1,108.00
$779.00
$539.00
$655.00
$588.00
$746.00
$555.00
$689.00
$575.00
$679.00
$500.00
$599.00
$597.00
$532.00
$504.00
$829.00
$584.00
$695.00
$847.00
$1,168.00
$1,692.00
$1,164.00
$646.00
$499.00
$656.00
$606.00
$602.00
$694.00
$885.00
$786.00
$796.00
$835.00
$893.00
$970.00
$1,058.00
$881.00
$1,056.00
$1,032.00
$1,019.00
$909.00
$1,037.00
$663.00
$764.00
$579.00
$1,268.00
$663.00
$644.00
$752.00
$567.00
$989.00
$917.00
$749.00
$847.00
$545.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$581.00
$706.00
$635.00
$807.00
$601.00
$744.00
$623.00
$736.00
$542.00
$649.00
$646.00
$576.00
$545.00
$900.00
$632.00
$753.00
$918.00
$1,269.00
$1,836.00
$1,263.00
$700.00
$540.00
$711.00
$656.00
$652.00
$752.00
$959.00
$852.00
$863.00
$907.00
$969.00
$1,053.00
$1,149.00
$956.00
$1,140.00
$1,119.00
$1,101.00
$980.00
$1,102.00
$719.00
$823.00
$629.00
$1,373.00
$718.00
$697.00
$813.00
$615.00
$1,073.00
$995.00
$812.00
$920.00
$591.00
$613.00
$745.00
$671.00
$855.00
$636.00
$788.00
$660.00
$780.00
$572.00
$686.00
$683.00
$607.00
$575.00
$957.00
$669.00
$798.00
$975.00
$1,353.00
$1,953.00
$1,342.00
$740.00
$571.00
$753.00
$694.00
$690.00
$793.00
$1,015.00
$900.00
$917.00
$969.00
$1,030.00
$1,120.00
$1,220.00
$1,016.00
$1,208.00
$1,189.00
$1,165.00
$1,036.00
$1,148.00
$763.00
$868.00
$668.00
$1,459.00
$761.00
$736.00
$858.00
$651.00
$1,140.00
$1,058.00
$864.00
$980.00
$625.00
151
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
28345
28360
28400
28405
28406
28415
28420
28430
28435
28436
28445
28450
28455
28456
28465
28470
28475
28476
28485
28490
28495
28496
28505
28510
28515
28525
28530
28531
28540
28545
28546
28555
28570
28575
28576
28585
28600
28605
28606
28615
28630
28635
28636
28645
28660
28665
28666
28675
28705
28715
28725
28730
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
10
10
90
10
10
10
90
90
90
90
90
$557.00
$1,197.00
$266.00
$473.00
$616.00
$1,354.00
$1,619.00
$110.00
$371.00
$463.00
$874.00
$148.00
$321.00
$288.00
$533.00
$178.00
$296.00
$364.00
$521.00
$80.00
$133.00
$261.00
$399.00
$75.00
$115.00
$345.00
$120.00
$243.00
$145.00
$208.00
$325.00
$592.00
$189.00
$308.00
$382.00
$742.00
$144.00
$287.00
$487.00
$621.00
$145.00
$189.00
$318.00
$434.00
$106.00
$172.00
$309.00
$348.00
$1,353.00
$1,179.00
$1,015.00
$945.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$807.00
$1,472.00
$427.00
$614.00
$818.00
$1,712.00
$1,766.00
$394.00
$485.00
$678.00
$1,554.00
$381.00
$449.00
$475.00
$822.00
$349.00
$437.00
$541.00
$737.00
$203.00
$236.00
$671.00
$784.00
$187.00
$221.00
$738.00
$211.00
$684.00
$304.00
$345.00
$637.00
$1,026.00
$304.00
$489.00
$825.00
$947.00
$334.00
$414.00
$1,096.00
$934.00
$213.00
$238.00
$513.00
$577.00
$222.00
$240.00
$537.00
$643.00
$1,834.00
$1,404.00
$1,258.00
$1,176.00
$874.00
$1,598.00
$462.00
$665.00
$886.00
$1,858.00
$1,915.00
$426.00
$525.00
$734.00
$1,664.00
$412.00
$486.00
$513.00
$888.00
$377.00
$474.00
$585.00
$799.00
$218.00
$255.00
$724.00
$846.00
$202.00
$238.00
$797.00
$228.00
$738.00
$328.00
$373.00
$689.00
$1,110.00
$328.00
$529.00
$891.00
$1,028.00
$360.00
$448.00
$1,184.00
$1,013.00
$229.00
$257.00
$555.00
$625.00
$239.00
$260.00
$581.00
$695.00
$1,979.00
$1,523.00
$1,365.00
$1,276.00
$924.00
$1,698.00
$484.00
$703.00
$938.00
$1,976.00
$2,036.00
$447.00
$554.00
$775.00
$1,747.00
$431.00
$513.00
$539.00
$939.00
$396.00
$500.00
$616.00
$846.00
$229.00
$268.00
$756.00
$887.00
$212.00
$250.00
$834.00
$239.00
$771.00
$345.00
$394.00
$724.00
$1,169.00
$345.00
$558.00
$935.00
$1,090.00
$378.00
$471.00
$1,240.00
$1,074.00
$240.00
$272.00
$583.00
$660.00
$249.00
$274.00
$610.00
$728.00
$2,095.00
$1,621.00
$1,451.00
$1,357.00
$727.00
$1,472.00
$366.00
$567.00
$818.00
$1,712.00
$1,766.00
$331.00
$440.00
$678.00
$1,554.00
$314.00
$431.00
$475.00
$822.00
$284.00
$399.00
$541.00
$737.00
$169.00
$204.00
$394.00
$564.00
$169.00
$194.00
$518.00
$199.00
$344.00
$304.00
$345.00
$495.00
$796.00
$293.00
$473.00
$581.00
$887.00
$313.00
$412.00
$651.00
$934.00
$213.00
$238.00
$321.00
$465.00
$189.00
$240.00
$302.00
$423.00
$1,834.00
$1,404.00
$1,258.00
$1,176.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$789.00
$1,598.00
$396.00
$615.00
$886.00
$1,858.00
$1,915.00
$357.00
$476.00
$734.00
$1,664.00
$340.00
$466.00
$513.00
$888.00
$308.00
$433.00
$585.00
$799.00
$183.00
$221.00
$426.00
$610.00
$182.00
$210.00
$560.00
$214.00
$373.00
$328.00
$373.00
$536.00
$863.00
$316.00
$512.00
$629.00
$963.00
$338.00
$445.00
$706.00
$1,013.00
$229.00
$257.00
$348.00
$504.00
$203.00
$260.00
$327.00
$458.00
$1,979.00
$1,523.00
$1,365.00
$1,276.00
$836.00
$1,698.00
$416.00
$651.00
$938.00
$1,976.00
$2,036.00
$376.00
$504.00
$775.00
$1,747.00
$357.00
$493.00
$539.00
$939.00
$324.00
$457.00
$616.00
$846.00
$192.00
$232.00
$448.00
$643.00
$191.00
$221.00
$589.00
$225.00
$393.00
$345.00
$394.00
$566.00
$914.00
$332.00
$540.00
$664.00
$1,023.00
$355.00
$469.00
$746.00
$1,074.00
$240.00
$272.00
$369.00
$536.00
$212.00
$274.00
$348.00
$484.00
$2,095.00
$1,621.00
$1,451.00
$1,357.00
152
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
28735
28737
28740
28750
28755
28760
28800
28805
28810
28820
28825
28899
29000
29010
29015
29020
29025
29035
29040
29044
29046
29049
29055
29058
29065
29075
29085
29086
29105
29125
29126
29130
29131
29200
29220
29240
29260
29280
29305
29325
29345
29355
29358
29365
29405
29425
29435
29440
29445
29450
29505
29515
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
$961.00
$873.00
$690.00
$690.00
$466.00
$654.00
$731.00
$731.00
$543.00
$377.00
$339.00
BR
$247.00
$271.00
$289.00
$237.00
$188.00
$213.00
$260.00
$260.00
$286.00
$45.00
$180.00
$110.00
$88.00
$72.00
$59.00
$54.00
$59.00
$45.00
$53.00
$26.00
$53.00
$29.00
$37.00
$45.00
$26.00
$29.00
$223.00
$260.00
$126.00
$133.00
$241.00
$101.00
$96.00
$101.00
$133.00
$22.00
$214.00
$84.00
$75.00
$59.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,170.00
$1,033.00
$1,145.00
$1,164.00
$731.00
$954.00
$920.00
$925.00
$745.00
$800.00
$724.00
----$283.00
$271.00
$279.00
$276.00
$291.00
$256.00
$255.00
$292.00
$295.00
$106.00
$229.00
$141.00
$108.00
$99.00
$106.00
$70.00
$103.00
$78.00
$98.00
$50.00
$64.00
$74.00
$73.00
$82.00
$68.00
$68.00
$263.00
$287.00
$158.00
$164.00
$172.00
$140.00
$103.00
$112.00
$137.00
$64.00
$185.00
$181.00
$90.00
$80.00
$1,269.00
$1,121.00
$1,240.00
$1,260.00
$791.00
$1,034.00
$993.00
$999.00
$804.00
$862.00
$780.00
----$306.00
$293.00
$300.00
$295.00
$314.00
$277.00
$278.00
$316.00
$320.00
$115.00
$248.00
$152.00
$117.00
$107.00
$115.00
$75.00
$112.00
$84.00
$105.00
$54.00
$68.00
$79.00
$79.00
$87.00
$72.00
$72.00
$285.00
$311.00
$171.00
$178.00
$186.00
$152.00
$112.00
$122.00
$149.00
$69.00
$200.00
$192.00
$97.00
$86.00
$1,349.00
$1,193.00
$1,310.00
$1,328.00
$834.00
$1,095.00
$1,050.00
$1,055.00
$847.00
$903.00
$817.00
----$324.00
$309.00
$314.00
$308.00
$331.00
$292.00
$296.00
$334.00
$339.00
$122.00
$262.00
$160.00
$123.00
$114.00
$121.00
$79.00
$118.00
$88.00
$109.00
$56.00
$71.00
$83.00
$83.00
$91.00
$76.00
$76.00
$302.00
$329.00
$182.00
$189.00
$197.00
$162.00
$119.00
$130.00
$158.00
$73.00
$213.00
$201.00
$101.00
$91.00
$1,170.00
$1,033.00
$924.00
$901.00
$610.00
$843.00
$920.00
$925.00
$745.00
$608.00
$555.00
----$217.00
$205.00
$213.00
$187.00
$228.00
$179.00
$209.00
$214.00
$241.00
$80.00
$175.00
$112.00
$86.00
$77.00
$81.00
$62.00
$76.00
$53.00
$65.00
$37.00
$41.00
$53.00
$56.00
$58.00
$47.00
$45.00
$201.00
$226.00
$132.00
$142.00
$135.00
$114.00
$84.00
$94.00
$114.00
$46.00
$151.00
$166.00
$61.00
$64.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,269.00
$1,121.00
$1,002.00
$977.00
$661.00
$915.00
$993.00
$999.00
$804.00
$656.00
$598.00
----$236.00
$222.00
$228.00
$199.00
$246.00
$194.00
$228.00
$233.00
$262.00
$87.00
$190.00
$121.00
$93.00
$84.00
$88.00
$66.00
$82.00
$57.00
$70.00
$39.00
$44.00
$56.00
$61.00
$62.00
$50.00
$48.00
$219.00
$245.00
$144.00
$154.00
$146.00
$124.00
$91.00
$102.00
$124.00
$50.00
$164.00
$176.00
$66.00
$69.00
$1,349.00
$1,193.00
$1,064.00
$1,035.00
$700.00
$972.00
$1,050.00
$1,055.00
$847.00
$690.00
$629.00
----$251.00
$236.00
$240.00
$209.00
$260.00
$207.00
$245.00
$248.00
$279.00
$93.00
$202.00
$128.00
$99.00
$89.00
$93.00
$70.00
$87.00
$60.00
$74.00
$42.00
$46.00
$59.00
$64.00
$65.00
$52.00
$50.00
$233.00
$261.00
$153.00
$164.00
$156.00
$133.00
$97.00
$109.00
$132.00
$54.00
$176.00
$184.00
$69.00
$73.00
153
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
29520
29530
29540
29550
29580
29590
29700
29705
29710
29715
29720
29730
29740
29750
29799
29800
29804
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29830
29834
29835
29836
29837
29838
29840
29843
29844
29845
29846
29847
29848
29850
29851
29855
29856
29860
29861
29862
29863
29870
29871
0
0
0
0
0
0
0
0
0
0
0
0
0
0
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$22.00
$55.00
$41.00
$37.00
$39.00
$32.00
$29.00
$26.00
$29.00
$109.00
$29.00
$29.00
$37.00
$105.00
BR
$557.00
$902.00
$360.00
$1,003.00
$976.00
$756.00
$718.00
$863.00
$749.00
$1,330.00
$611.00
$941.00
$980.00
$1,058.00
$524.00
$635.00
$612.00
$680.00
$830.00
$931.00
$501.00
$580.00
$612.00
$931.00
$976.00
$1,277.00
$608.00
$752.00
$1,137.00
$1,007.00
$1,231.00
$658.00
$845.00
$907.00
$880.00
$460.00
$631.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$71.00
$71.00
$47.00
$46.00
$61.00
$66.00
$73.00
$81.00
$147.00
$105.00
$89.00
$80.00
$117.00
$122.00
----$819.00
$867.00
$733.00
$1,396.00
$1,357.00
$787.00
$731.00
$794.00
$771.00
$842.00
$853.00
$786.00
$905.00
$1,455.00
$607.00
$662.00
$676.00
$781.00
$713.00
$797.00
$591.00
$635.00
$666.00
$754.00
$698.00
$723.00
$597.00
$716.00
$1,260.00
$1,059.00
$1,364.00
$822.00
$908.00
$1,006.00
$1,004.00
$542.00
$678.00
$76.00
$76.00
$50.00
$50.00
$66.00
$70.00
$78.00
$87.00
$159.00
$113.00
$97.00
$86.00
$126.00
$133.00
----$886.00
$929.00
$795.00
$1,516.00
$1,474.00
$854.00
$793.00
$862.00
$837.00
$914.00
$925.00
$853.00
$983.00
$1,573.00
$659.00
$718.00
$733.00
$848.00
$774.00
$865.00
$639.00
$688.00
$722.00
$813.00
$757.00
$783.00
$647.00
$768.00
$1,368.00
$1,151.00
$1,482.00
$893.00
$986.00
$1,092.00
$1,090.00
$587.00
$735.00
$79.00
$79.00
$53.00
$53.00
$69.00
$74.00
$83.00
$93.00
$169.00
$118.00
$103.00
$92.00
$134.00
$141.00
----$936.00
$974.00
$843.00
$1,617.00
$1,571.00
$910.00
$845.00
$917.00
$891.00
$973.00
$985.00
$908.00
$1,047.00
$1,671.00
$700.00
$763.00
$779.00
$903.00
$824.00
$920.00
$677.00
$732.00
$768.00
$861.00
$804.00
$832.00
$686.00
$810.00
$1,459.00
$1,227.00
$1,581.00
$952.00
$1,051.00
$1,163.00
$1,162.00
$623.00
$781.00
$50.00
$48.00
$44.00
$40.00
$49.00
$57.00
$47.00
$64.00
$113.00
$72.00
$60.00
$61.00
$90.00
$102.00
----$819.00
$867.00
$733.00
$1,396.00
$1,357.00
$787.00
$731.00
$794.00
$771.00
$842.00
$853.00
$786.00
$905.00
$1,455.00
$607.00
$662.00
$676.00
$781.00
$713.00
$797.00
$591.00
$635.00
$666.00
$754.00
$698.00
$723.00
$597.00
$716.00
$1,260.00
$1,059.00
$1,364.00
$822.00
$908.00
$1,006.00
$1,004.00
$542.00
$678.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$53.00
$51.00
$47.00
$43.00
$52.00
$61.00
$51.00
$69.00
$122.00
$77.00
$65.00
$66.00
$98.00
$111.00
----$886.00
$929.00
$795.00
$1,516.00
$1,474.00
$854.00
$793.00
$862.00
$837.00
$914.00
$925.00
$853.00
$983.00
$1,573.00
$659.00
$718.00
$733.00
$848.00
$774.00
$865.00
$639.00
$688.00
$722.00
$813.00
$757.00
$783.00
$647.00
$768.00
$1,368.00
$1,151.00
$1,482.00
$893.00
$986.00
$1,092.00
$1,090.00
$587.00
$735.00
$55.00
$54.00
$49.00
$46.00
$55.00
$64.00
$55.00
$74.00
$131.00
$82.00
$70.00
$71.00
$105.00
$119.00
----$936.00
$974.00
$843.00
$1,617.00
$1,571.00
$910.00
$845.00
$917.00
$891.00
$973.00
$985.00
$908.00
$1,047.00
$1,671.00
$700.00
$763.00
$779.00
$903.00
$824.00
$920.00
$677.00
$732.00
$768.00
$861.00
$804.00
$832.00
$686.00
$810.00
$1,459.00
$1,227.00
$1,581.00
$952.00
$1,051.00
$1,163.00
$1,162.00
$623.00
$781.00
154
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
29873
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
29894
29895
29897
29898
29899
29900
29901
29902
29999
30000
30020
30100
30110
30115
30117
30118
30120
30124
30125
30130
30140
30150
30160
30200
30210
30220
30300
30310
30320
30400
30410
30420
30430
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
10
10
0
10
90
90
90
90
90
90
90
90
90
90
0
10
10
10
10
90
90
90
90
90
$489.00
$676.00
$639.00
$809.00
$852.00
$1,064.00
$1,169.00
$745.00
$819.00
$1,235.00
$721.00
$832.00
$697.00
$949.00
$1,296.00
$1,255.00
$796.00
$835.00
$472.00
$690.00
$679.00
$704.00
$863.00
$973.00
$434.00
$479.00
$514.00
BR
$96.00
$117.00
$86.00
$157.00
$360.00
$301.00
$819.00
$500.00
$243.00
$599.00
$275.00
$320.00
$790.00
$875.00
$68.00
$75.00
$154.00
$45.00
$170.00
$419.00
$741.00
$1,173.00
$1,424.00
$626.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$668.00
$716.00
$666.00
$817.00
$768.00
$829.00
$868.00
$804.00
$863.00
$1,088.00
$764.00
$928.00
$786.00
$924.00
$1,333.00
$1,549.00
$863.00
$913.00
$499.00
$701.00
$687.00
$721.00
$798.00
$1,341.00
$609.00
$670.00
$719.00
----$201.00
$209.00
$116.00
$226.00
$457.00
$415.00
$928.00
$582.00
$330.00
$707.00
$376.00
$411.00
$925.00
$944.00
$102.00
$164.00
$207.00
$183.00
$199.00
$506.00
$975.00
$1,234.00
$1,473.00
$750.00
$722.00
$774.00
$722.00
$887.00
$834.00
$900.00
$942.00
$872.00
$934.00
$1,176.00
$830.00
$1,007.00
$853.00
$1,003.00
$1,448.00
$1,679.00
$937.00
$991.00
$543.00
$762.00
$746.00
$783.00
$866.00
$1,457.00
$661.00
$727.00
$780.00
----$215.00
$223.00
$124.00
$242.00
$488.00
$444.00
$989.00
$623.00
$352.00
$756.00
$401.00
$439.00
$991.00
$1,011.00
$109.00
$176.00
$221.00
$196.00
$213.00
$541.00
$1,043.00
$1,321.00
$1,574.00
$804.00
$764.00
$821.00
$768.00
$944.00
$887.00
$958.00
$1,003.00
$929.00
$992.00
$1,247.00
$883.00
$1,073.00
$908.00
$1,069.00
$1,545.00
$1,787.00
$998.00
$1,055.00
$579.00
$812.00
$795.00
$834.00
$924.00
$1,554.00
$702.00
$772.00
$829.00
----$224.00
$232.00
$129.00
$253.00
$511.00
$463.00
$1,035.00
$652.00
$367.00
$792.00
$419.00
$459.00
$1,040.00
$1,061.00
$114.00
$183.00
$231.00
$204.00
$223.00
$567.00
$1,095.00
$1,388.00
$1,652.00
$844.00
$668.00
$716.00
$666.00
$817.00
$768.00
$829.00
$868.00
$804.00
$863.00
$1,088.00
$764.00
$928.00
$786.00
$924.00
$1,333.00
$1,549.00
$863.00
$913.00
$499.00
$701.00
$687.00
$721.00
$798.00
$1,341.00
$609.00
$670.00
$719.00
----$150.00
$153.00
$76.00
$132.00
$457.00
$326.00
$928.00
$582.00
$330.00
$707.00
$376.00
$411.00
$925.00
$944.00
$65.00
$88.00
$125.00
$75.00
$199.00
$506.00
$975.00
$1,234.00
$1,473.00
$750.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$722.00
$774.00
$722.00
$887.00
$834.00
$900.00
$942.00
$872.00
$934.00
$1,176.00
$830.00
$1,007.00
$853.00
$1,003.00
$1,448.00
$1,679.00
$937.00
$991.00
$543.00
$762.00
$746.00
$783.00
$866.00
$1,457.00
$661.00
$727.00
$780.00
----$160.00
$163.00
$81.00
$141.00
$488.00
$349.00
$989.00
$623.00
$352.00
$756.00
$401.00
$439.00
$991.00
$1,011.00
$69.00
$94.00
$134.00
$80.00
$213.00
$541.00
$1,043.00
$1,321.00
$1,574.00
$804.00
$764.00
$821.00
$768.00
$944.00
$887.00
$958.00
$1,003.00
$929.00
$992.00
$1,247.00
$883.00
$1,073.00
$908.00
$1,069.00
$1,545.00
$1,787.00
$998.00
$1,055.00
$579.00
$812.00
$795.00
$834.00
$924.00
$1,554.00
$702.00
$772.00
$829.00
----$167.00
$170.00
$85.00
$148.00
$511.00
$364.00
$1,035.00
$652.00
$367.00
$792.00
$419.00
$459.00
$1,040.00
$1,061.00
$72.00
$99.00
$140.00
$84.00
$223.00
$567.00
$1,095.00
$1,388.00
$1,652.00
$844.00
155
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
30435
30450
30460
30462
30465
30520
30540
30545
30560
30580
30600
30620
30630
30801
30802
30901
30903
30905
30906
30915
30920
30930
30999
31000
31002
31020
31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
31200
31201
31205
31225
31230
31231
31233
31235
31237
31238
31239
31240
90
90
90
90
90
90
90
90
10
90
90
90
90
10
10
0
0
0
0
90
90
10
YYY
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
10
0
$1,005.00
$1,445.00
$857.00
$1,633.00
$803.00
$533.00
$643.00
$981.00
$104.00
$566.00
$466.00
$564.00
$624.00
$88.00
$172.00
$75.00
$110.00
$224.00
$208.00
$596.00
$862.00
$213.00
BR
$81.00
$135.00
$281.00
$531.00
$604.00
$772.00
$489.00
$654.00
$410.00
$839.00
$942.00
$1,089.00
$1,210.00
$1,281.00
$1,081.00
$1,075.00
$877.00
$463.00
$716.00
$851.00
$1,683.00
$1,908.00
$122.00
$221.00
$217.00
$266.00
$311.00
$775.00
$224.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,158.00
$1,709.00
$1,000.00
$1,809.00
$1,069.00
$598.00
$737.00
$1,090.00
$183.00
$611.00
$588.00
$648.00
$736.00
$184.00
$263.00
$135.00
$238.00
$293.00
$338.00
$737.00
$952.00
$174.00
----$181.00
$204.00
$370.00
$557.00
$656.00
$859.00
$536.00
$710.00
$478.00
$899.00
$1,052.00
$1,234.00
$1,252.00
$1,313.00
$1,212.00
$1,241.00
$955.00
$544.00
$836.00
$961.00
$1,787.00
$2,016.00
$157.00
$248.00
$286.00
$318.00
$359.00
$784.00
$218.00
$1,243.00
$1,829.00
$1,071.00
$1,944.00
$1,144.00
$639.00
$786.00
$1,163.00
$195.00
$652.00
$635.00
$693.00
$786.00
$197.00
$281.00
$144.00
$255.00
$314.00
$362.00
$786.00
$1,016.00
$187.00
----$194.00
$218.00
$396.00
$594.00
$700.00
$917.00
$573.00
$759.00
$511.00
$960.00
$1,121.00
$1,342.00
$1,336.00
$1,405.00
$1,293.00
$1,330.00
$1,019.00
$578.00
$892.00
$1,021.00
$1,907.00
$2,151.00
$168.00
$265.00
$305.00
$339.00
$384.00
$832.00
$233.00
$1,309.00
$1,923.00
$1,125.00
$2,053.00
$1,203.00
$668.00
$822.00
$1,218.00
$204.00
$684.00
$673.00
$725.00
$822.00
$206.00
$294.00
$151.00
$266.00
$328.00
$377.00
$822.00
$1,063.00
$195.00
----$202.00
$228.00
$413.00
$623.00
$733.00
$962.00
$600.00
$796.00
$534.00
$1,004.00
$1,174.00
$1,433.00
$1,400.00
$1,477.00
$1,354.00
$1,400.00
$1,066.00
$601.00
$933.00
$1,065.00
$1,998.00
$2,254.00
$176.00
$277.00
$319.00
$355.00
$401.00
$867.00
$244.00
$1,158.00
$1,709.00
$1,000.00
$1,809.00
$1,069.00
$598.00
$737.00
$1,090.00
$142.00
$611.00
$588.00
$648.00
$736.00
$172.00
$250.00
$83.00
$110.00
$147.00
$194.00
$737.00
$952.00
$174.00
----$94.00
$204.00
$338.00
$549.00
$656.00
$859.00
$536.00
$710.00
$478.00
$899.00
$1,052.00
$1,234.00
$1,252.00
$1,313.00
$1,212.00
$1,241.00
$955.00
$544.00
$836.00
$961.00
$1,787.00
$2,016.00
$89.00
$178.00
$215.00
$242.00
$267.00
$784.00
$218.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,243.00
$1,829.00
$1,071.00
$1,944.00
$1,144.00
$639.00
$786.00
$1,163.00
$152.00
$652.00
$635.00
$693.00
$786.00
$184.00
$268.00
$88.00
$117.00
$156.00
$207.00
$786.00
$1,016.00
$187.00
----$100.00
$218.00
$361.00
$585.00
$700.00
$917.00
$573.00
$759.00
$511.00
$960.00
$1,121.00
$1,342.00
$1,336.00
$1,405.00
$1,293.00
$1,330.00
$1,019.00
$578.00
$892.00
$1,021.00
$1,907.00
$2,151.00
$95.00
$190.00
$229.00
$258.00
$285.00
$832.00
$233.00
$1,309.00
$1,923.00
$1,125.00
$2,053.00
$1,203.00
$668.00
$822.00
$1,218.00
$159.00
$684.00
$673.00
$725.00
$822.00
$192.00
$280.00
$93.00
$124.00
$165.00
$217.00
$822.00
$1,063.00
$195.00
----$105.00
$228.00
$377.00
$613.00
$733.00
$962.00
$600.00
$796.00
$534.00
$1,004.00
$1,174.00
$1,433.00
$1,400.00
$1,477.00
$1,354.00
$1,400.00
$1,066.00
$601.00
$933.00
$1,065.00
$1,998.00
$2,254.00
$100.00
$199.00
$240.00
$270.00
$299.00
$867.00
$244.00
156
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
31299
31300
31320
31360
31365
31367
31368
31370
31375
31380
31382
31390
31395
31400
31420
31500
31502
31505
31510
31511
31512
31513
31515
31525
31526
31527
31528
31529
31530
31531
31535
31536
31540
31541
31560
31561
31570
31571
31575
31576
0
0
0
0
0
0
0
10
10
10
10
10
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
$588.00
$601.00
$292.00
$453.00
$690.00
$339.00
$396.00
$1,462.00
$1,551.00
$1,235.00
$1,346.00
$1,587.00
BR
$1,295.00
$508.00
$1,630.00
$2,238.00
$1,913.00
$2,478.00
$1,891.00
$1,720.00
$1,782.00
$1,822.00
$2,513.00
$2,937.00
$969.00
$969.00
$116.00
$74.00
$62.00
$145.00
$88.00
$197.00
$182.00
$160.00
$234.00
$222.00
$262.00
$202.00
$217.00
$284.00
$311.00
$272.00
$308.00
$357.00
$453.00
$446.00
$509.00
$369.00
$363.00
$128.00
$186.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$386.00
$577.00
$275.00
$453.00
$731.00
$326.00
$381.00
$1,507.00
$1,604.00
$1,295.00
$1,401.00
$1,625.00
----$1,623.00
$923.00
$1,863.00
$2,434.00
$2,351.00
$2,860.00
$2,306.00
$2,124.00
$2,123.00
$2,238.00
$2,894.00
$3,379.00
$1,328.00
$1,307.00
$159.00
$132.00
$66.00
$244.00
$271.00
$264.00
$178.00
$215.00
$286.00
$216.00
$261.00
$191.00
$222.00
$271.00
$300.00
$262.00
$297.00
$343.00
$377.00
$448.00
$487.00
$413.00
$353.00
$161.00
$227.00
$412.00
$615.00
$293.00
$482.00
$779.00
$348.00
$406.00
$1,606.00
$1,723.00
$1,380.00
$1,489.00
$1,724.00
----$1,734.00
$989.00
$1,990.00
$2,599.00
$2,512.00
$3,054.00
$2,463.00
$2,269.00
$2,267.00
$2,390.00
$3,091.00
$3,611.00
$1,419.00
$1,398.00
$169.00
$141.00
$70.00
$261.00
$290.00
$283.00
$189.00
$229.00
$305.00
$230.00
$278.00
$203.00
$236.00
$289.00
$319.00
$279.00
$316.00
$366.00
$402.00
$477.00
$519.00
$440.00
$376.00
$173.00
$242.00
$432.00
$645.00
$308.00
$506.00
$817.00
$365.00
$426.00
$1,684.00
$1,819.00
$1,445.00
$1,557.00
$1,799.00
----$1,811.00
$1,030.00
$2,080.00
$2,720.00
$2,627.00
$3,194.00
$2,575.00
$2,373.00
$2,370.00
$2,499.00
$3,233.00
$3,777.00
$1,481.00
$1,458.00
$178.00
$146.00
$73.00
$273.00
$303.00
$295.00
$199.00
$239.00
$319.00
$241.00
$291.00
$213.00
$248.00
$303.00
$335.00
$292.00
$332.00
$384.00
$421.00
$500.00
$545.00
$459.00
$395.00
$180.00
$253.00
$386.00
$577.00
$275.00
$453.00
$731.00
$326.00
$381.00
$1,507.00
$1,604.00
$1,295.00
$1,401.00
$1,625.00
----$1,623.00
$923.00
$1,863.00
$2,434.00
$2,351.00
$2,860.00
$2,306.00
$2,124.00
$2,123.00
$2,238.00
$2,894.00
$3,379.00
$1,328.00
$1,307.00
$159.00
$48.00
$44.00
$154.00
$155.00
$166.00
$178.00
$140.00
$216.00
$216.00
$261.00
$191.00
$222.00
$271.00
$300.00
$262.00
$297.00
$343.00
$377.00
$448.00
$487.00
$319.00
$353.00
$88.00
$157.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$412.00
$615.00
$293.00
$482.00
$779.00
$348.00
$406.00
$1,606.00
$1,723.00
$1,380.00
$1,489.00
$1,724.00
----$1,734.00
$989.00
$1,990.00
$2,599.00
$2,512.00
$3,054.00
$2,463.00
$2,269.00
$2,267.00
$2,390.00
$3,091.00
$3,611.00
$1,419.00
$1,398.00
$169.00
$51.00
$47.00
$164.00
$166.00
$178.00
$189.00
$148.00
$230.00
$230.00
$278.00
$203.00
$236.00
$289.00
$319.00
$279.00
$316.00
$366.00
$402.00
$477.00
$519.00
$339.00
$376.00
$94.00
$167.00
$432.00
$645.00
$308.00
$506.00
$817.00
$365.00
$426.00
$1,684.00
$1,819.00
$1,445.00
$1,557.00
$1,799.00
----$1,811.00
$1,030.00
$2,080.00
$2,720.00
$2,627.00
$3,194.00
$2,575.00
$2,373.00
$2,370.00
$2,499.00
$3,233.00
$3,777.00
$1,481.00
$1,458.00
$178.00
$53.00
$50.00
$173.00
$174.00
$187.00
$199.00
$156.00
$241.00
$241.00
$291.00
$213.00
$248.00
$303.00
$335.00
$292.00
$332.00
$384.00
$421.00
$500.00
$545.00
$354.00
$395.00
$99.00
$175.00
157
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
31577
31578
31579
31580
31582
31584
31585
31586
31587
31588
31590
31595
31599
31600
31603
31605
31610
31611
31612
31613
31614
31615
31622
31623
31624
31625
31628
31629
31630
31631
31635
31640
31641
31643
31645
31646
31656
31700
31708
31710
31715
31717
31720
31725
31730
31750
31755
31760
31766
31770
31775
31780
0
0
0
90
90
90
90
90
90
90
90
90
YYY
0
0
0
90
90
0
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
$230.00
$264.00
$219.00
$1,213.00
$1,881.00
$1,616.00
$474.00
$778.00
$913.00
$1,206.00
$691.00
$773.00
BR
$306.00
$343.00
$297.00
$794.00
$614.00
$99.00
$384.00
$736.00
$213.00
$230.00
$225.00
$217.00
$235.00
$269.00
$198.00
$308.00
$252.00
$298.00
$399.00
$304.00
$208.00
$208.00
$161.00
$127.00
$114.00
$76.00
$74.00
$57.00
$138.00
$89.00
$103.00
$199.00
$1,088.00
$1,448.00
$1,648.00
$2,315.00
$1,815.00
$1,973.00
$1,577.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$278.00
$311.00
$267.00
$1,467.00
$2,241.00
$1,987.00
$688.00
$1,062.00
$1,353.00
$1,552.00
$993.00
$1,011.00
----$531.00
$316.00
$260.00
$1,010.00
$806.00
$122.00
$687.00
$987.00
$296.00
$316.00
$309.00
$294.00
$243.00
$364.00
$240.00
$307.00
$338.00
$280.00
$386.00
$376.00
$250.00
$227.00
$197.00
$161.00
$186.00
$104.00
$104.00
$89.00
$278.00
$148.00
$134.00
$271.00
$1,500.00
$1,806.00
$1,820.00
$2,519.00
$1,972.00
$2,119.00
$1,617.00
$297.00
$332.00
$286.00
$1,567.00
$2,393.00
$2,122.00
$736.00
$1,136.00
$1,446.00
$1,658.00
$1,062.00
$1,081.00
----$561.00
$338.00
$279.00
$1,082.00
$862.00
$131.00
$737.00
$1,056.00
$317.00
$336.00
$328.00
$312.00
$256.00
$385.00
$252.00
$328.00
$359.00
$297.00
$412.00
$399.00
$263.00
$239.00
$208.00
$170.00
$198.00
$110.00
$110.00
$95.00
$296.00
$158.00
$142.00
$288.00
$1,605.00
$1,930.00
$1,936.00
$2,711.00
$2,121.00
$2,294.00
$1,732.00
$310.00
$347.00
$298.00
$1,637.00
$2,503.00
$2,221.00
$766.00
$1,185.00
$1,512.00
$1,732.00
$1,108.00
$1,130.00
----$585.00
$357.00
$296.00
$1,132.00
$899.00
$136.00
$769.00
$1,102.00
$330.00
$350.00
$341.00
$324.00
$267.00
$399.00
$262.00
$345.00
$378.00
$310.00
$433.00
$417.00
$274.00
$248.00
$217.00
$177.00
$206.00
$114.00
$114.00
$99.00
$307.00
$164.00
$148.00
$300.00
$1,680.00
$2,018.00
$2,030.00
$2,875.00
$2,244.00
$2,441.00
$1,824.00
$196.00
$216.00
$182.00
$1,467.00
$2,241.00
$1,987.00
$688.00
$1,062.00
$1,353.00
$1,552.00
$993.00
$1,011.00
----$531.00
$316.00
$260.00
$1,010.00
$806.00
$70.00
$687.00
$987.00
$171.00
$205.00
$209.00
$209.00
$243.00
$269.00
$240.00
$307.00
$338.00
$280.00
$386.00
$376.00
$250.00
$227.00
$197.00
$161.00
$105.00
$104.00
$104.00
$89.00
$155.00
$73.00
$134.00
$206.00
$1,500.00
$1,806.00
$1,820.00
$2,519.00
$1,972.00
$2,119.00
$1,617.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$209.00
$230.00
$194.00
$1,567.00
$2,393.00
$2,122.00
$736.00
$1,136.00
$1,446.00
$1,658.00
$1,062.00
$1,081.00
----$561.00
$338.00
$279.00
$1,082.00
$862.00
$74.00
$737.00
$1,056.00
$182.00
$216.00
$221.00
$220.00
$256.00
$282.00
$252.00
$328.00
$359.00
$297.00
$412.00
$399.00
$263.00
$239.00
$208.00
$170.00
$112.00
$110.00
$110.00
$95.00
$164.00
$77.00
$142.00
$218.00
$1,605.00
$1,930.00
$1,936.00
$2,711.00
$2,121.00
$2,294.00
$1,732.00
$219.00
$242.00
$204.00
$1,637.00
$2,503.00
$2,221.00
$766.00
$1,185.00
$1,512.00
$1,732.00
$1,108.00
$1,130.00
----$585.00
$357.00
$296.00
$1,132.00
$899.00
$78.00
$769.00
$1,102.00
$191.00
$226.00
$231.00
$229.00
$267.00
$293.00
$262.00
$345.00
$378.00
$310.00
$433.00
$417.00
$274.00
$248.00
$217.00
$177.00
$117.00
$114.00
$114.00
$99.00
$170.00
$81.00
$148.00
$228.00
$1,680.00
$2,018.00
$2,030.00
$2,875.00
$2,244.00
$2,441.00
$1,824.00
158
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
31781
31785
31786
31800
31805
31820
31825
31830
31899
32000
32002
32005
32020
32035
32036
32095
32100
32110
32120
32124
32140
32141
32150
32151
32160
32200
32201
32215
32220
32225
32310
32320
32400
32402
32405
32420
32440
32442
32445
32480
32482
32484
32486
32488
32491
32500
32501
32520
32522
32525
32540
32601
90
90
90
90
90
90
90
90
YYY
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
0
90
0
0
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
0
$1,936.00
$1,320.00
$1,866.00
$628.00
$1,175.00
$458.00
$659.00
$460.00
BR
$136.00
$116.00
$147.00
$286.00
$821.00
$908.00
$848.00
$1,120.00
$1,223.00
$1,077.00
$1,144.00
$1,284.00
$1,267.00
$1,226.00
$1,231.00
$842.00
$1,132.00
$387.00
$1,024.00
$1,680.00
$1,268.00
$1,221.00
$1,787.00
$129.00
$798.00
$159.00
$116.00
$1,837.00
$2,093.00
$2,093.00
$1,622.00
$1,714.00
$1,771.00
$1,974.00
$2,094.00
$1,784.00
$1,331.00
$374.00
$1,935.00
$2,102.00
$2,264.00
$1,308.00
$456.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,033.00
$1,572.00
$2,108.00
$748.00
$1,276.00
$642.00
$918.00
$638.00
----$233.00
$159.00
$163.00
$293.00
$890.00
$988.00
$880.00
$1,366.00
$1,889.00
$1,134.00
$1,196.00
$1,295.00
$1,296.00
$1,294.00
$1,322.00
$840.00
$1,352.00
$482.00
$1,116.00
$2,016.00
$1,304.00
$1,257.00
$2,010.00
$184.00
$832.00
$219.00
$158.00
$2,028.00
$2,205.00
$2,119.00
$1,946.00
$2,017.00
$1,737.00
$2,012.00
$2,141.00
$1,823.00
$1,794.00
$347.00
$1,795.00
$1,971.00
$2,147.00
$1,299.00
$491.00
$2,177.00
$1,680.00
$2,262.00
$802.00
$1,375.00
$688.00
$983.00
$683.00
----$249.00
$168.00
$174.00
$314.00
$961.00
$1,068.00
$951.00
$1,467.00
$2,013.00
$1,227.00
$1,292.00
$1,400.00
$1,402.00
$1,396.00
$1,423.00
$905.00
$1,452.00
$513.00
$1,206.00
$2,167.00
$1,410.00
$1,360.00
$2,164.00
$195.00
$898.00
$232.00
$167.00
$2,181.00
$2,384.00
$2,294.00
$2,089.00
$2,165.00
$1,880.00
$2,179.00
$2,318.00
$1,975.00
$1,918.00
$375.00
$1,944.00
$2,130.00
$2,325.00
$1,407.00
$530.00
$2,294.00
$1,765.00
$2,386.00
$843.00
$1,455.00
$718.00
$1,026.00
$714.00
----$258.00
$175.00
$184.00
$333.00
$1,018.00
$1,133.00
$1,006.00
$1,548.00
$2,113.00
$1,302.00
$1,372.00
$1,487.00
$1,490.00
$1,481.00
$1,506.00
$959.00
$1,533.00
$533.00
$1,278.00
$2,294.00
$1,499.00
$1,446.00
$2,294.00
$202.00
$950.00
$242.00
$174.00
$2,314.00
$2,538.00
$2,447.00
$2,209.00
$2,290.00
$2,004.00
$2,325.00
$2,473.00
$2,106.00
$2,019.00
$401.00
$2,075.00
$2,269.00
$2,481.00
$1,499.00
$563.00
$2,033.00
$1,572.00
$2,108.00
$748.00
$1,276.00
$636.00
$918.00
$638.00
----$106.00
$159.00
$163.00
$293.00
$890.00
$988.00
$880.00
$1,366.00
$1,889.00
$1,134.00
$1,196.00
$1,295.00
$1,296.00
$1,294.00
$1,322.00
$840.00
$1,352.00
$482.00
$1,116.00
$2,016.00
$1,304.00
$1,257.00
$2,010.00
$121.00
$832.00
$134.00
$158.00
$2,028.00
$2,205.00
$2,119.00
$1,946.00
$2,017.00
$1,737.00
$2,012.00
$2,141.00
$1,823.00
$1,794.00
$347.00
$1,795.00
$1,971.00
$2,147.00
$1,299.00
$491.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,177.00
$1,680.00
$2,262.00
$802.00
$1,375.00
$681.00
$983.00
$683.00
----$112.00
$168.00
$174.00
$314.00
$961.00
$1,068.00
$951.00
$1,467.00
$2,013.00
$1,227.00
$1,292.00
$1,400.00
$1,402.00
$1,396.00
$1,423.00
$905.00
$1,452.00
$513.00
$1,206.00
$2,167.00
$1,410.00
$1,360.00
$2,164.00
$127.00
$898.00
$142.00
$167.00
$2,181.00
$2,384.00
$2,294.00
$2,089.00
$2,165.00
$1,880.00
$2,179.00
$2,318.00
$1,975.00
$1,918.00
$375.00
$1,944.00
$2,130.00
$2,325.00
$1,407.00
$530.00
$2,294.00
$1,765.00
$2,386.00
$843.00
$1,455.00
$712.00
$1,026.00
$714.00
----$117.00
$175.00
$184.00
$333.00
$1,018.00
$1,133.00
$1,006.00
$1,548.00
$2,113.00
$1,302.00
$1,372.00
$1,487.00
$1,490.00
$1,481.00
$1,506.00
$959.00
$1,533.00
$533.00
$1,278.00
$2,294.00
$1,499.00
$1,446.00
$2,294.00
$132.00
$950.00
$148.00
$174.00
$2,314.00
$2,538.00
$2,447.00
$2,209.00
$2,290.00
$2,004.00
$2,325.00
$2,473.00
$2,106.00
$2,019.00
$401.00
$2,075.00
$2,269.00
$2,481.00
$1,499.00
$563.00
159
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
32602
32603
32604
32605
32606
32650
32651
32652
32653
32654
32655
32656
32657
32658
32659
32660
32661
32662
32663
32664
32665
32800
32810
32815
32820
32851
32852
32853
32854
32900
32905
32906
32940
32960
32997
32999
33010
33011
33015
33020
33025
33030
33031
33050
33120
33130
33140
33141
33200
33201
33206
33207
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
YYY
0
0
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
$494.00
$585.00
$663.00
$550.00
$637.00
$957.00
$1,166.00
$1,615.00
$1,144.00
$1,096.00
$1,213.00
$1,222.00
$1,261.00
$1,142.00
$1,141.00
$1,691.00
$1,165.00
$1,459.00
$1,636.00
$1,197.00
$1,360.00
$1,166.00
$1,085.00
$1,917.00
$1,848.00
$3,100.00
$3,339.00
$3,787.00
$4,038.00
$1,532.00
$1,661.00
$2,100.00
$1,555.00
$126.00
$312.00
BR
$124.00
$125.00
$555.00
$1,178.00
$1,165.00
$1,786.00
$1,816.00
$1,224.00
$2,358.00
$1,734.00
$1,571.00
$254.00
$1,170.00
$1,052.00
$642.00
$753.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$528.00
$646.00
$735.00
$612.00
$709.00
$938.00
$1,089.00
$1,561.00
$1,078.00
$1,074.00
$1,102.00
$1,120.00
$1,154.00
$1,021.00
$1,019.00
$1,452.00
$1,137.00
$1,371.00
$1,574.00
$1,188.00
$1,288.00
$1,264.00
$1,247.00
$2,008.00
$1,910.00
$3,243.00
$3,493.00
$3,950.00
$4,159.00
$1,770.00
$1,820.00
$2,271.00
$1,714.00
$205.00
$431.00
----$169.00
$171.00
$603.00
$1,121.00
$1,089.00
$1,695.00
$1,936.00
$1,336.00
$2,215.00
$1,858.00
$1,672.00
$355.00
$1,176.00
$1,063.00
$645.00
$744.00
$571.00
$694.00
$793.00
$662.00
$766.00
$1,013.00
$1,177.00
$1,690.00
$1,165.00
$1,162.00
$1,191.00
$1,213.00
$1,248.00
$1,106.00
$1,102.00
$1,571.00
$1,232.00
$1,484.00
$1,704.00
$1,285.00
$1,391.00
$1,363.00
$1,348.00
$2,173.00
$2,058.00
$3,514.00
$3,781.00
$4,282.00
$4,506.00
$1,913.00
$1,969.00
$2,458.00
$1,857.00
$219.00
$462.00
----$179.00
$181.00
$648.00
$1,212.00
$1,178.00
$1,837.00
$2,098.00
$1,444.00
$2,397.00
$2,008.00
$1,805.00
$384.00
$1,263.00
$1,148.00
$689.00
$794.00
$606.00
$734.00
$842.00
$705.00
$816.00
$1,077.00
$1,252.00
$1,803.00
$1,242.00
$1,237.00
$1,267.00
$1,292.00
$1,329.00
$1,179.00
$1,173.00
$1,674.00
$1,313.00
$1,582.00
$1,816.00
$1,369.00
$1,480.00
$1,444.00
$1,430.00
$2,314.00
$2,181.00
$3,751.00
$4,034.00
$4,576.00
$4,813.00
$2,036.00
$2,096.00
$2,621.00
$1,979.00
$228.00
$490.00
----$187.00
$189.00
$684.00
$1,288.00
$1,254.00
$1,957.00
$2,236.00
$1,534.00
$2,552.00
$2,135.00
$1,919.00
$410.00
$1,331.00
$1,216.00
$722.00
$832.00
$528.00
$646.00
$735.00
$612.00
$709.00
$938.00
$1,089.00
$1,561.00
$1,078.00
$1,074.00
$1,102.00
$1,120.00
$1,154.00
$1,021.00
$1,019.00
$1,452.00
$1,137.00
$1,371.00
$1,574.00
$1,188.00
$1,288.00
$1,264.00
$1,247.00
$2,008.00
$1,910.00
$3,243.00
$3,493.00
$3,950.00
$4,159.00
$1,770.00
$1,820.00
$2,271.00
$1,714.00
$128.00
$431.00
----$169.00
$171.00
$603.00
$1,121.00
$1,089.00
$1,695.00
$1,936.00
$1,336.00
$2,215.00
$1,858.00
$1,672.00
$355.00
$1,176.00
$1,063.00
$645.00
$744.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$571.00
$694.00
$793.00
$662.00
$766.00
$1,013.00
$1,177.00
$1,690.00
$1,165.00
$1,162.00
$1,191.00
$1,213.00
$1,248.00
$1,106.00
$1,102.00
$1,571.00
$1,232.00
$1,484.00
$1,704.00
$1,285.00
$1,391.00
$1,363.00
$1,348.00
$2,173.00
$2,058.00
$3,514.00
$3,781.00
$4,282.00
$4,506.00
$1,913.00
$1,969.00
$2,458.00
$1,857.00
$136.00
$462.00
----$179.00
$181.00
$648.00
$1,212.00
$1,178.00
$1,837.00
$2,098.00
$1,444.00
$2,397.00
$2,008.00
$1,805.00
$384.00
$1,263.00
$1,148.00
$689.00
$794.00
$606.00
$734.00
$842.00
$705.00
$816.00
$1,077.00
$1,252.00
$1,803.00
$1,242.00
$1,237.00
$1,267.00
$1,292.00
$1,329.00
$1,179.00
$1,173.00
$1,674.00
$1,313.00
$1,582.00
$1,816.00
$1,369.00
$1,480.00
$1,444.00
$1,430.00
$2,314.00
$2,181.00
$3,751.00
$4,034.00
$4,576.00
$4,813.00
$2,036.00
$2,096.00
$2,621.00
$1,979.00
$143.00
$490.00
----$187.00
$189.00
$684.00
$1,288.00
$1,254.00
$1,957.00
$2,236.00
$1,534.00
$2,552.00
$2,135.00
$1,919.00
$410.00
$1,331.00
$1,216.00
$722.00
$832.00
160
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
33208
33210
33211
33212
33213
33214
33215
33216
33217
33218
33220
33222
33223
33224
33225
33226
33233
33234
33235
33236
33237
33238
33240
33241
33243
33244
33245
33246
33249
33250
33251
33253
33261
33282
33284
33300
33305
33310
33315
33320
33321
33322
33330
33332
33335
33400
33401
33403
33404
33405
33406
33410
90
0
0
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$573.00
$204.00
$210.00
$511.00
$437.00
$532.00
$304.00
$402.00
$428.00
$488.00
$390.00
$471.00
$585.00
$490.00
$434.00
$472.00
$270.00
$598.00
$587.00
$933.00
$1,184.00
$1,235.00
$648.00
$301.00
$1,650.00
$1,081.00
$1,400.00
$1,888.00
$1,271.00
$1,687.00
$2,071.00
$2,563.00
$1,993.00
$470.00
$365.00
$1,576.00
$1,889.00
$1,577.00
$1,875.00
$1,485.00
$1,890.00
$1,935.00
$1,726.00
$1,915.00
$2,336.00
$2,401.00
$2,228.00
$2,369.00
$2,698.00
$2,745.00
$2,962.00
$2,637.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$757.00
$239.00
$247.00
$531.00
$596.00
$725.00
$416.00
$573.00
$584.00
$527.00
$531.00
$473.00
$617.00
$669.00
$594.00
$644.00
$380.00
$705.00
$833.00
$1,187.00
$1,267.00
$1,317.00
$697.00
$357.00
$1,833.00
$1,170.00
$1,338.00
$1,884.00
$1,218.00
$1,865.00
$2,114.00
$2,617.00
$2,154.00
$474.00
$354.00
$1,613.00
$1,910.00
$1,682.00
$1,982.00
$1,509.00
$1,810.00
$1,848.00
$1,868.00
$2,005.00
$2,544.00
$2,363.00
$2,027.00
$2,079.00
$2,328.00
$2,862.00
$3,040.00
$2,677.00
$806.00
$253.00
$261.00
$568.00
$636.00
$772.00
$444.00
$610.00
$622.00
$563.00
$567.00
$506.00
$658.00
$705.00
$626.00
$679.00
$406.00
$752.00
$889.00
$1,282.00
$1,368.00
$1,417.00
$744.00
$381.00
$1,977.00
$1,249.00
$1,435.00
$2,030.00
$1,293.00
$1,974.00
$2,271.00
$2,829.00
$2,324.00
$509.00
$381.00
$1,737.00
$2,068.00
$1,820.00
$2,148.00
$1,621.00
$1,964.00
$1,999.00
$2,018.00
$2,157.00
$2,757.00
$2,547.00
$2,187.00
$2,235.00
$2,515.00
$3,087.00
$3,277.00
$2,901.00
$844.00
$264.00
$272.00
$596.00
$667.00
$808.00
$466.00
$637.00
$650.00
$590.00
$593.00
$531.00
$688.00
$732.00
$651.00
$706.00
$424.00
$788.00
$932.00
$1,361.00
$1,451.00
$1,501.00
$779.00
$398.00
$2,103.00
$1,313.00
$1,511.00
$2,150.00
$1,350.00
$2,055.00
$2,402.00
$3,012.00
$2,469.00
$535.00
$398.00
$1,840.00
$2,203.00
$1,935.00
$2,291.00
$1,714.00
$2,097.00
$2,126.00
$2,145.00
$2,285.00
$2,941.00
$2,705.00
$2,325.00
$2,367.00
$2,678.00
$3,281.00
$3,482.00
$3,099.00
$757.00
$239.00
$247.00
$531.00
$596.00
$725.00
$416.00
$573.00
$584.00
$527.00
$531.00
$473.00
$617.00
$669.00
$594.00
$644.00
$380.00
$705.00
$833.00
$1,187.00
$1,267.00
$1,317.00
$697.00
$357.00
$1,833.00
$1,170.00
$1,338.00
$1,884.00
$1,218.00
$1,865.00
$2,114.00
$2,617.00
$2,154.00
$474.00
$354.00
$1,613.00
$1,910.00
$1,682.00
$1,982.00
$1,509.00
$1,810.00
$1,848.00
$1,868.00
$2,005.00
$2,544.00
$2,363.00
$2,027.00
$2,079.00
$2,328.00
$2,862.00
$3,040.00
$2,677.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$806.00
$253.00
$261.00
$568.00
$636.00
$772.00
$444.00
$610.00
$622.00
$563.00
$567.00
$506.00
$658.00
$705.00
$626.00
$679.00
$406.00
$752.00
$889.00
$1,282.00
$1,368.00
$1,417.00
$744.00
$381.00
$1,977.00
$1,249.00
$1,435.00
$2,030.00
$1,293.00
$1,974.00
$2,271.00
$2,829.00
$2,324.00
$509.00
$381.00
$1,737.00
$2,068.00
$1,820.00
$2,148.00
$1,621.00
$1,964.00
$1,999.00
$2,018.00
$2,157.00
$2,757.00
$2,547.00
$2,187.00
$2,235.00
$2,515.00
$3,087.00
$3,277.00
$2,901.00
$844.00
$264.00
$272.00
$596.00
$667.00
$808.00
$466.00
$637.00
$650.00
$590.00
$593.00
$531.00
$688.00
$732.00
$651.00
$706.00
$424.00
$788.00
$932.00
$1,361.00
$1,451.00
$1,501.00
$779.00
$398.00
$2,103.00
$1,313.00
$1,511.00
$2,150.00
$1,350.00
$2,055.00
$2,402.00
$3,012.00
$2,469.00
$535.00
$398.00
$1,840.00
$2,203.00
$1,935.00
$2,291.00
$1,714.00
$2,097.00
$2,126.00
$2,145.00
$2,285.00
$2,941.00
$2,705.00
$2,325.00
$2,367.00
$2,678.00
$3,281.00
$3,482.00
$3,099.00
161
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
33411
33412
33413
33414
33415
33416
33417
33420
33422
33425
33426
33427
33430
33460
33463
33464
33465
33468
33470
33471
33472
33474
33475
33476
33478
33496
33500
33501
33502
33503
33504
33505
33506
33508
33510
33511
33512
33513
33514
33516
33517
33518
33519
33521
33522
33523
33530
33533
33534
33535
33536
33542
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
90
90
90
90
90
$2,981.00
$3,213.00
$3,282.00
$2,904.00
$2,563.00
$2,684.00
$2,756.00
$1,796.00
$2,431.00
$2,509.00
$2,806.00
$3,026.00
$2,891.00
$2,215.00
$2,396.00
$2,547.00
$2,665.00
$2,952.00
$1,749.00
$1,929.00
$2,001.00
$2,173.00
$2,666.00
$2,270.00
$2,544.00
$2,595.00
$2,370.00
$1,546.00
$1,938.00
$1,983.00
$2,416.00
$2,423.00
$2,448.00
$17.00
$2,354.00
$2,546.00
$2,732.00
$2,933.00
$3,197.00
$3,404.00
$219.00
$414.00
$607.00
$801.00
$994.00
$1,189.00
$521.00
$2,415.00
$2,654.00
$2,899.00
$3,143.00
$2,693.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,967.00
$3,376.00
$3,441.00
$2,647.00
$2,357.00
$2,574.00
$2,519.00
$1,729.00
$2,152.00
$2,164.00
$2,709.00
$3,194.00
$2,745.00
$2,070.00
$2,217.00
$2,352.00
$2,451.00
$2,752.00
$1,894.00
$1,932.00
$2,050.00
$1,996.00
$2,748.00
$2,136.00
$2,313.00
$2,429.00
$2,141.00
$1,540.00
$2,050.00
$1,871.00
$2,261.00
$2,341.00
$2,950.00
$23.00
$2,416.00
$2,514.00
$2,654.00
$2,691.00
$2,765.00
$2,931.00
$191.00
$360.00
$528.00
$697.00
$867.00
$1,036.00
$434.00
$2,481.00
$2,672.00
$2,834.00
$2,956.00
$2,533.00
$3,204.00
$3,641.00
$3,697.00
$2,866.00
$2,548.00
$2,789.00
$2,727.00
$1,838.00
$2,333.00
$2,334.00
$2,928.00
$3,442.00
$2,967.00
$2,243.00
$2,400.00
$2,548.00
$2,654.00
$2,985.00
$2,056.00
$2,098.00
$2,223.00
$2,160.00
$2,937.00
$2,291.00
$2,510.00
$2,631.00
$2,308.00
$1,663.00
$2,215.00
$1,991.00
$2,446.00
$2,486.00
$3,162.00
$25.00
$2,604.00
$2,712.00
$2,867.00
$2,914.00
$3,002.00
$3,181.00
$207.00
$391.00
$572.00
$756.00
$940.00
$1,124.00
$471.00
$2,674.00
$2,884.00
$3,060.00
$3,166.00
$2,743.00
$3,410.00
$3,873.00
$3,917.00
$3,054.00
$2,712.00
$2,977.00
$2,906.00
$1,928.00
$2,492.00
$2,483.00
$3,118.00
$3,658.00
$3,161.00
$2,392.00
$2,558.00
$2,718.00
$2,831.00
$3,184.00
$2,194.00
$2,243.00
$2,369.00
$2,301.00
$3,091.00
$2,422.00
$2,682.00
$2,803.00
$2,451.00
$1,768.00
$2,350.00
$2,085.00
$2,602.00
$2,596.00
$3,338.00
$26.00
$2,764.00
$2,881.00
$3,051.00
$3,108.00
$3,211.00
$3,401.00
$222.00
$419.00
$613.00
$810.00
$1,008.00
$1,205.00
$504.00
$2,839.00
$3,066.00
$3,258.00
$3,344.00
$2,922.00
$2,967.00
$3,376.00
$3,441.00
$2,647.00
$2,357.00
$2,574.00
$2,519.00
$1,729.00
$2,152.00
$2,164.00
$2,709.00
$3,194.00
$2,745.00
$2,070.00
$2,217.00
$2,352.00
$2,451.00
$2,752.00
$1,894.00
$1,932.00
$2,050.00
$1,996.00
$2,748.00
$2,136.00
$2,313.00
$2,429.00
$2,141.00
$1,540.00
$2,050.00
$1,871.00
$2,261.00
$2,341.00
$2,950.00
$23.00
$2,416.00
$2,514.00
$2,654.00
$2,691.00
$2,765.00
$2,931.00
$191.00
$360.00
$528.00
$697.00
$867.00
$1,036.00
$434.00
$2,481.00
$2,672.00
$2,834.00
$2,956.00
$2,533.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$3,204.00
$3,641.00
$3,697.00
$2,866.00
$2,548.00
$2,789.00
$2,727.00
$1,838.00
$2,333.00
$2,334.00
$2,928.00
$3,442.00
$2,967.00
$2,243.00
$2,400.00
$2,548.00
$2,654.00
$2,985.00
$2,056.00
$2,098.00
$2,223.00
$2,160.00
$2,937.00
$2,291.00
$2,510.00
$2,631.00
$2,308.00
$1,663.00
$2,215.00
$1,991.00
$2,446.00
$2,486.00
$3,162.00
$25.00
$2,604.00
$2,712.00
$2,867.00
$2,914.00
$3,002.00
$3,181.00
$207.00
$391.00
$572.00
$756.00
$940.00
$1,124.00
$471.00
$2,674.00
$2,884.00
$3,060.00
$3,166.00
$2,743.00
$3,410.00
$3,873.00
$3,917.00
$3,054.00
$2,712.00
$2,977.00
$2,906.00
$1,928.00
$2,492.00
$2,483.00
$3,118.00
$3,658.00
$3,161.00
$2,392.00
$2,558.00
$2,718.00
$2,831.00
$3,184.00
$2,194.00
$2,243.00
$2,369.00
$2,301.00
$3,091.00
$2,422.00
$2,682.00
$2,803.00
$2,451.00
$1,768.00
$2,350.00
$2,085.00
$2,602.00
$2,596.00
$3,338.00
$26.00
$2,764.00
$2,881.00
$3,051.00
$3,108.00
$3,211.00
$3,401.00
$222.00
$419.00
$613.00
$810.00
$1,008.00
$1,205.00
$504.00
$2,839.00
$3,066.00
$3,258.00
$3,344.00
$2,922.00
162
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
33545
33572
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33641
33645
33647
33660
33665
33670
33681
33684
33688
33690
33692
33694
33697
33702
33710
33720
33722
33730
33732
33735
33736
33737
33750
33755
33762
33764
33766
33767
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33786
33788
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$3,250.00
$340.00
$2,644.00
$2,556.00
$2,831.00
$2,940.00
$2,871.00
$2,985.00
$3,152.00
$3,051.00
$3,272.00
$3,678.00
$1,981.00
$2,352.00
$2,732.00
$2,444.00
$2,700.00
$2,820.00
$2,657.00
$2,740.00
$2,602.00
$1,884.00
$2,816.00
$2,856.00
$3,064.00
$2,549.00
$2,731.00
$2,508.00
$2,704.00
$2,785.00
$2,622.00
$2,036.00
$2,288.00
$1,977.00
$1,877.00
$1,831.00
$1,900.00
$1,895.00
$2,119.00
$2,173.00
$2,954.00
$2,924.00
$2,681.00
$2,654.00
$2,844.00
$2,724.00
$3,199.00
$3,121.00
$3,232.00
$3,057.00
$2,970.00
$2,288.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$3,108.00
$329.00
$2,454.00
$2,422.00
$2,666.00
$2,691.00
$2,708.00
$2,857.00
$3,020.00
$2,828.00
$3,192.00
$3,893.00
$1,830.00
$2,155.00
$2,522.00
$2,536.00
$2,545.00
$2,688.00
$2,647.00
$2,559.00
$2,492.00
$1,813.00
$2,641.00
$2,882.00
$3,059.00
$2,378.00
$2,631.00
$2,339.00
$2,547.00
$2,783.00
$2,433.00
$1,744.00
$2,115.00
$2,007.00
$1,840.00
$1,882.00
$1,851.00
$1,861.00
$2,088.00
$2,175.00
$3,026.00
$2,772.00
$2,636.00
$2,724.00
$2,905.00
$2,822.00
$3,333.00
$2,859.00
$3,527.00
$2,901.00
$3,246.00
$2,302.00
$3,361.00
$357.00
$2,622.00
$2,606.00
$2,880.00
$2,922.00
$2,937.00
$3,068.00
$3,271.00
$3,034.00
$3,442.00
$4,192.00
$1,982.00
$2,337.00
$2,725.00
$2,722.00
$2,762.00
$2,855.00
$2,859.00
$2,773.00
$2,702.00
$1,966.00
$2,858.00
$3,122.00
$3,314.00
$2,578.00
$2,852.00
$2,529.00
$2,764.00
$2,977.00
$2,615.00
$1,848.00
$2,283.00
$2,178.00
$1,968.00
$2,043.00
$1,974.00
$1,994.00
$2,265.00
$2,357.00
$3,274.00
$3,013.00
$2,862.00
$2,958.00
$3,154.00
$3,065.00
$3,605.00
$3,041.00
$3,820.00
$3,152.00
$3,511.00
$2,493.00
$3,580.00
$382.00
$2,757.00
$2,760.00
$3,062.00
$3,123.00
$3,134.00
$3,245.00
$3,490.00
$3,206.00
$3,654.00
$4,441.00
$2,113.00
$2,496.00
$2,897.00
$2,876.00
$2,948.00
$2,990.00
$3,039.00
$2,958.00
$2,887.00
$2,095.00
$3,045.00
$3,331.00
$3,535.00
$2,749.00
$3,042.00
$2,692.00
$2,950.00
$3,138.00
$2,766.00
$1,928.00
$2,424.00
$2,324.00
$2,071.00
$2,184.00
$2,072.00
$2,103.00
$2,416.00
$2,512.00
$3,492.00
$3,229.00
$3,062.00
$3,165.00
$3,373.00
$3,279.00
$3,842.00
$3,189.00
$4,074.00
$3,379.00
$3,742.00
$2,657.00
$3,108.00
$329.00
$2,454.00
$2,422.00
$2,666.00
$2,691.00
$2,708.00
$2,857.00
$3,020.00
$2,828.00
$3,192.00
$3,893.00
$1,830.00
$2,155.00
$2,522.00
$2,536.00
$2,545.00
$2,688.00
$2,647.00
$2,559.00
$2,492.00
$1,813.00
$2,641.00
$2,882.00
$3,059.00
$2,378.00
$2,631.00
$2,339.00
$2,547.00
$2,783.00
$2,433.00
$1,744.00
$2,115.00
$2,007.00
$1,840.00
$1,882.00
$1,851.00
$1,861.00
$2,088.00
$2,175.00
$3,026.00
$2,772.00
$2,636.00
$2,724.00
$2,905.00
$2,822.00
$3,333.00
$2,859.00
$3,527.00
$2,901.00
$3,246.00
$2,302.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$3,361.00
$357.00
$2,622.00
$2,606.00
$2,880.00
$2,922.00
$2,937.00
$3,068.00
$3,271.00
$3,034.00
$3,442.00
$4,192.00
$1,982.00
$2,337.00
$2,725.00
$2,722.00
$2,762.00
$2,855.00
$2,859.00
$2,773.00
$2,702.00
$1,966.00
$2,858.00
$3,122.00
$3,314.00
$2,578.00
$2,852.00
$2,529.00
$2,764.00
$2,977.00
$2,615.00
$1,848.00
$2,283.00
$2,178.00
$1,968.00
$2,043.00
$1,974.00
$1,994.00
$2,265.00
$2,357.00
$3,274.00
$3,013.00
$2,862.00
$2,958.00
$3,154.00
$3,065.00
$3,605.00
$3,041.00
$3,820.00
$3,152.00
$3,511.00
$2,493.00
$3,580.00
$382.00
$2,757.00
$2,760.00
$3,062.00
$3,123.00
$3,134.00
$3,245.00
$3,490.00
$3,206.00
$3,654.00
$4,441.00
$2,113.00
$2,496.00
$2,897.00
$2,876.00
$2,948.00
$2,990.00
$3,039.00
$2,958.00
$2,887.00
$2,095.00
$3,045.00
$3,331.00
$3,535.00
$2,749.00
$3,042.00
$2,692.00
$2,950.00
$3,138.00
$2,766.00
$1,928.00
$2,424.00
$2,324.00
$2,071.00
$2,184.00
$2,072.00
$2,103.00
$2,416.00
$2,512.00
$3,492.00
$3,229.00
$3,062.00
$3,165.00
$3,373.00
$3,279.00
$3,842.00
$3,189.00
$4,074.00
$3,379.00
$3,742.00
$2,657.00
163
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
33800
33802
33803
33813
33814
33820
33822
33824
33840
33845
33851
33852
33853
33860
33861
33863
33870
33875
33877
33910
33915
33916
33917
33918
33919
33920
33922
33924
33935
33945
33960
33961
33967
33968
33970
33971
33973
33974
33975
33976
33977
33978
33979
33980
33999
34001
34051
34101
34111
34151
34201
34203
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
0
ZZZ
0
0
0
90
0
90
0
0
90
90
0
90
YYY
90
90
90
90
90
90
90
$1,546.00
$1,752.00
$1,746.00
$1,935.00
$2,464.00
$1,619.00
$1,559.00
$1,884.00
$2,029.00
$2,129.00
$2,129.00
$2,311.00
$3,057.00
$3,044.00
$3,069.00
$3,183.00
$3,638.00
$2,876.00
$3,767.00
$1,987.00
$1,588.00
$2,096.00
$2,345.00
$2,349.00
$2,873.00
$2,981.00
$2,227.00
$421.00
$5,415.00
$3,813.00
$1,221.00
$800.00
$258.00
$51.00
$576.00
$578.00
$756.00
$1,095.00
$1,758.00
$2,056.00
$1,561.00
$1,754.00
$2,496.00
$3,212.00
BR
$1,012.00
$1,134.00
$800.00
$669.00
$1,288.00
$777.00
$949.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,494.00
$1,623.00
$1,814.00
$1,946.00
$2,261.00
$1,513.00
$1,696.00
$1,765.00
$1,869.00
$2,037.00
$1,975.00
$2,146.00
$2,789.00
$3,109.00
$3,368.00
$3,589.00
$3,556.00
$2,759.00
$3,529.00
$2,130.00
$1,736.00
$2,223.00
$2,213.00
$2,310.00
$3,291.00
$2,663.00
$2,031.00
$413.00
$4,951.00
$3,529.00
$1,353.00
$822.00
$354.00
$48.00
$496.00
$948.00
$717.00
$1,355.00
$1,472.00
$1,705.00
$1,639.00
$1,818.00
$3,440.00
$4,414.00
----$1,028.00
$1,224.00
$804.00
$790.00
$1,874.00
$815.00
$1,281.00
$1,593.00
$1,739.00
$1,968.00
$2,111.00
$2,429.00
$1,639.00
$1,839.00
$1,916.00
$2,018.00
$2,208.00
$2,143.00
$2,329.00
$3,027.00
$3,356.00
$3,622.00
$3,861.00
$3,841.00
$2,987.00
$3,815.00
$2,306.00
$1,843.00
$2,402.00
$2,399.00
$2,505.00
$3,525.00
$2,874.00
$2,183.00
$449.00
$5,377.00
$3,826.00
$1,460.00
$894.00
$375.00
$52.00
$534.00
$1,020.00
$772.00
$1,458.00
$1,573.00
$1,847.00
$1,776.00
$1,968.00
$3,682.00
$4,718.00
----$1,110.00
$1,326.00
$867.00
$845.00
$1,997.00
$877.00
$1,370.00
$1,668.00
$1,832.00
$2,099.00
$2,251.00
$2,567.00
$1,745.00
$1,959.00
$2,044.00
$2,141.00
$2,354.00
$2,286.00
$2,486.00
$3,233.00
$3,570.00
$3,841.00
$4,096.00
$4,091.00
$3,186.00
$4,065.00
$2,457.00
$1,925.00
$2,555.00
$2,557.00
$2,672.00
$3,719.00
$3,056.00
$2,308.00
$482.00
$5,759.00
$4,087.00
$1,559.00
$960.00
$393.00
$55.00
$568.00
$1,076.00
$821.00
$1,541.00
$1,662.00
$1,977.00
$1,895.00
$2,098.00
$3,891.00
$4,973.00
----$1,182.00
$1,417.00
$922.00
$892.00
$2,101.00
$930.00
$1,445.00
$1,494.00
$1,623.00
$1,814.00
$1,946.00
$2,261.00
$1,513.00
$1,696.00
$1,765.00
$1,869.00
$2,037.00
$1,975.00
$2,146.00
$2,789.00
$3,109.00
$3,368.00
$3,589.00
$3,556.00
$2,759.00
$3,529.00
$2,130.00
$1,736.00
$2,223.00
$2,213.00
$2,310.00
$3,291.00
$2,663.00
$2,031.00
$413.00
$4,951.00
$3,529.00
$1,353.00
$822.00
$353.00
$48.00
$496.00
$948.00
$717.00
$1,355.00
$1,472.00
$1,705.00
$1,639.00
$1,818.00
$3,440.00
$4,414.00
----$1,028.00
$1,224.00
$804.00
$790.00
$1,874.00
$815.00
$1,281.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,593.00
$1,739.00
$1,968.00
$2,111.00
$2,429.00
$1,639.00
$1,839.00
$1,916.00
$2,018.00
$2,208.00
$2,143.00
$2,329.00
$3,027.00
$3,356.00
$3,622.00
$3,861.00
$3,841.00
$2,987.00
$3,815.00
$2,306.00
$1,843.00
$2,402.00
$2,399.00
$2,505.00
$3,525.00
$2,874.00
$2,183.00
$449.00
$5,377.00
$3,826.00
$1,460.00
$894.00
$374.00
$52.00
$534.00
$1,020.00
$772.00
$1,458.00
$1,573.00
$1,847.00
$1,776.00
$1,968.00
$3,682.00
$4,718.00
----$1,110.00
$1,326.00
$867.00
$845.00
$1,997.00
$877.00
$1,370.00
$1,668.00
$1,832.00
$2,099.00
$2,251.00
$2,567.00
$1,745.00
$1,959.00
$2,044.00
$2,141.00
$2,354.00
$2,286.00
$2,486.00
$3,233.00
$3,570.00
$3,841.00
$4,096.00
$4,091.00
$3,186.00
$4,065.00
$2,457.00
$1,925.00
$2,555.00
$2,557.00
$2,672.00
$3,719.00
$3,056.00
$2,308.00
$482.00
$5,759.00
$4,087.00
$1,559.00
$960.00
$391.00
$55.00
$568.00
$1,076.00
$821.00
$1,541.00
$1,662.00
$1,977.00
$1,895.00
$2,098.00
$3,891.00
$4,973.00
----$1,182.00
$1,417.00
$922.00
$892.00
$2,101.00
$930.00
$1,445.00
164
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
34401
34421
34451
34471
34490
34501
34502
34510
34520
34530
34800
34802
34804
34808
34812
34813
34820
34825
34826
34830
34831
34832
34833
34834
34900
35001
35002
35005
35011
35013
35021
35022
35045
35081
35082
35091
35092
35102
35103
35111
35112
35121
35122
35131
35132
35141
35142
35151
35152
35161
35162
35180
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
0
ZZZ
0
90
ZZZ
90
90
90
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$953.00
$779.00
$1,117.00
$685.00
$660.00
$910.00
$2,044.00
$1,108.00
$1,077.00
$1,368.00
$1,159.00
$1,279.00
$1,279.00
$220.00
$359.00
$256.00
$519.00
$694.00
$220.00
$1,803.00
$1,950.00
$1,950.00
$650.00
$306.00
$960.00
$1,564.00
$1,547.00
$1,268.00
$1,007.00
$1,376.00
$1,635.00
$1,686.00
$995.00
$2,175.00
$2,661.00
$2,634.00
$2,872.00
$2,346.00
$2,587.00
$1,398.00
$1,351.00
$2,000.00
$2,382.00
$1,495.00
$1,742.00
$1,231.00
$1,339.00
$1,390.00
$1,229.00
$1,516.00
$1,633.00
$997.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,823.00
$951.00
$1,984.00
$810.00
$841.00
$1,343.00
$2,083.00
$1,556.00
$1,446.00
$1,396.00
$1,575.00
$1,734.00
$1,734.00
$294.00
$482.00
$341.00
$696.00
$948.00
$295.00
$2,437.00
$2,508.00
$2,640.00
$891.00
$421.00
$1,321.00
$1,554.00
$1,615.00
$1,377.00
$1,349.00
$1,655.00
$1,532.00
$1,753.00
$1,383.00
$2,182.00
$2,910.00
$2,722.00
$3,365.00
$2,369.00
$3,030.00
$1,869.00
$2,201.00
$2,285.00
$2,644.00
$1,898.00
$2,244.00
$1,526.00
$1,750.00
$1,727.00
$1,920.00
$1,510.00
$1,569.00
$1,087.00
$1,925.00
$1,016.00
$2,103.00
$868.00
$897.00
$1,438.00
$2,247.00
$1,665.00
$1,545.00
$1,511.00
$1,677.00
$1,847.00
$1,847.00
$313.00
$514.00
$363.00
$741.00
$1,011.00
$314.00
$2,596.00
$2,670.00
$2,811.00
$944.00
$452.00
$1,416.00
$1,683.00
$1,729.00
$1,468.00
$1,437.00
$1,771.00
$1,646.00
$1,876.00
$1,473.00
$2,357.00
$3,134.00
$2,940.00
$3,612.00
$2,557.00
$3,251.00
$1,991.00
$2,338.00
$2,455.00
$2,843.00
$2,031.00
$2,398.00
$1,631.00
$1,866.00
$1,848.00
$2,047.00
$1,632.00
$1,693.00
$1,171.00
$2,008.00
$1,070.00
$2,201.00
$916.00
$942.00
$1,516.00
$2,393.00
$1,755.00
$1,626.00
$1,612.00
$1,763.00
$1,942.00
$1,942.00
$329.00
$541.00
$382.00
$780.00
$1,062.00
$330.00
$2,729.00
$2,809.00
$2,956.00
$988.00
$478.00
$1,497.00
$1,799.00
$1,826.00
$1,545.00
$1,511.00
$1,872.00
$1,745.00
$1,982.00
$1,548.00
$2,512.00
$3,333.00
$3,137.00
$3,831.00
$2,724.00
$3,444.00
$2,094.00
$2,453.00
$2,604.00
$3,020.00
$2,144.00
$2,531.00
$1,721.00
$1,964.00
$1,952.00
$2,155.00
$1,740.00
$1,802.00
$1,243.00
$1,823.00
$951.00
$1,984.00
$810.00
$841.00
$1,343.00
$2,083.00
$1,556.00
$1,446.00
$1,396.00
$1,575.00
$1,734.00
$1,734.00
$294.00
$482.00
$341.00
$696.00
$948.00
$295.00
$2,437.00
$2,508.00
$2,640.00
$891.00
$421.00
$1,321.00
$1,554.00
$1,615.00
$1,377.00
$1,349.00
$1,655.00
$1,532.00
$1,753.00
$1,383.00
$2,182.00
$2,910.00
$2,722.00
$3,365.00
$2,369.00
$3,030.00
$1,869.00
$2,201.00
$2,285.00
$2,644.00
$1,898.00
$2,244.00
$1,526.00
$1,750.00
$1,727.00
$1,920.00
$1,510.00
$1,569.00
$1,087.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,925.00
$1,016.00
$2,103.00
$868.00
$897.00
$1,438.00
$2,247.00
$1,665.00
$1,545.00
$1,511.00
$1,677.00
$1,847.00
$1,847.00
$313.00
$514.00
$363.00
$741.00
$1,011.00
$314.00
$2,596.00
$2,670.00
$2,811.00
$944.00
$452.00
$1,416.00
$1,683.00
$1,729.00
$1,468.00
$1,437.00
$1,771.00
$1,646.00
$1,876.00
$1,473.00
$2,357.00
$3,134.00
$2,940.00
$3,612.00
$2,557.00
$3,251.00
$1,991.00
$2,338.00
$2,455.00
$2,843.00
$2,031.00
$2,398.00
$1,631.00
$1,866.00
$1,848.00
$2,047.00
$1,632.00
$1,693.00
$1,171.00
$2,008.00
$1,070.00
$2,201.00
$916.00
$942.00
$1,516.00
$2,393.00
$1,755.00
$1,626.00
$1,612.00
$1,763.00
$1,942.00
$1,942.00
$329.00
$541.00
$382.00
$780.00
$1,062.00
$330.00
$2,729.00
$2,809.00
$2,956.00
$988.00
$478.00
$1,497.00
$1,799.00
$1,826.00
$1,545.00
$1,511.00
$1,872.00
$1,745.00
$1,982.00
$1,548.00
$2,512.00
$3,333.00
$3,137.00
$3,831.00
$2,724.00
$3,444.00
$2,094.00
$2,453.00
$2,604.00
$3,020.00
$2,144.00
$2,531.00
$1,721.00
$1,964.00
$1,952.00
$2,155.00
$1,740.00
$1,802.00
$1,243.00
165
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
35182
35184
35188
35189
35190
35201
35206
35207
35211
35216
35221
35226
35231
35236
35241
35246
35251
35256
35261
35266
35271
35276
35281
35286
35301
35311
35321
35331
35341
35351
35355
35361
35363
35371
35372
35381
35390
35400
35450
35452
35454
35456
35458
35459
35460
35470
35471
35472
35473
35474
35475
35476
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
0
0
0
0
0
0
0
0
0
0
0
0
0
0
$1,345.00
$976.00
$1,048.00
$1,380.00
$1,018.00
$852.00
$835.00
$935.00
$1,833.00
$1,494.00
$1,243.00
$841.00
$1,053.00
$947.00
$1,926.00
$1,701.00
$1,260.00
$1,568.00
$1,008.00
$921.00
$1,814.00
$1,541.00
$1,396.00
$1,036.00
$1,486.00
$1,999.00
$1,031.00
$1,724.00
$1,908.00
$1,555.00
$1,336.00
$1,859.00
$2,006.00
$1,006.00
$1,085.00
$1,278.00
$225.00
$224.00
$643.00
$518.00
$520.00
$631.00
$804.00
$736.00
$430.00
$537.00
$626.00
$388.00
$375.00
$456.00
$569.00
$338.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,228.00
$1,371.00
$1,137.00
$2,102.00
$1,013.00
$1,229.00
$1,099.00
$1,060.00
$1,966.00
$1,651.00
$1,833.00
$1,219.00
$1,540.00
$1,370.00
$2,052.00
$2,166.00
$2,224.00
$1,467.00
$1,343.00
$1,213.00
$1,952.00
$2,046.00
$2,080.00
$1,325.00
$1,487.00
$2,067.00
$1,219.00
$2,019.00
$1,955.00
$1,773.00
$1,442.00
$2,143.00
$2,287.00
$1,146.00
$1,380.00
$1,262.00
$237.00
$224.00
$756.00
$547.00
$482.00
$579.00
$739.00
$671.00
$474.00
$655.00
$759.00
$531.00
$469.00
$539.00
$708.00
$461.00
$2,365.00
$1,461.00
$1,225.00
$2,242.00
$1,091.00
$1,309.00
$1,174.00
$1,143.00
$2,130.00
$1,783.00
$1,953.00
$1,294.00
$1,638.00
$1,459.00
$2,222.00
$2,317.00
$2,361.00
$1,564.00
$1,432.00
$1,295.00
$2,114.00
$2,199.00
$2,210.00
$1,418.00
$1,608.00
$2,223.00
$1,304.00
$2,173.00
$2,111.00
$1,906.00
$1,549.00
$2,300.00
$2,452.00
$1,228.00
$1,476.00
$1,363.00
$256.00
$242.00
$808.00
$590.00
$520.00
$625.00
$798.00
$724.00
$511.00
$695.00
$802.00
$563.00
$497.00
$570.00
$748.00
$487.00
$2,479.00
$1,537.00
$1,302.00
$2,361.00
$1,158.00
$1,376.00
$1,235.00
$1,209.00
$2,271.00
$1,895.00
$2,055.00
$1,352.00
$1,718.00
$1,531.00
$2,367.00
$2,443.00
$2,474.00
$1,642.00
$1,507.00
$1,363.00
$2,252.00
$2,326.00
$2,319.00
$1,495.00
$1,715.00
$2,361.00
$1,377.00
$2,309.00
$2,250.00
$2,022.00
$1,641.00
$2,436.00
$2,596.00
$1,298.00
$1,559.00
$1,451.00
$274.00
$258.00
$854.00
$628.00
$553.00
$665.00
$850.00
$771.00
$544.00
$727.00
$837.00
$589.00
$520.00
$596.00
$780.00
$507.00
$2,228.00
$1,371.00
$1,137.00
$2,102.00
$1,013.00
$1,229.00
$1,099.00
$1,060.00
$1,966.00
$1,651.00
$1,833.00
$1,219.00
$1,540.00
$1,370.00
$2,052.00
$2,166.00
$2,224.00
$1,467.00
$1,343.00
$1,213.00
$1,952.00
$2,046.00
$2,080.00
$1,325.00
$1,487.00
$2,067.00
$1,219.00
$2,019.00
$1,955.00
$1,773.00
$1,442.00
$2,143.00
$2,287.00
$1,146.00
$1,380.00
$1,262.00
$237.00
$224.00
$756.00
$547.00
$482.00
$579.00
$739.00
$671.00
$474.00
$655.00
$759.00
$531.00
$469.00
$539.00
$708.00
$461.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,365.00
$1,461.00
$1,225.00
$2,242.00
$1,091.00
$1,309.00
$1,174.00
$1,143.00
$2,130.00
$1,783.00
$1,953.00
$1,294.00
$1,638.00
$1,459.00
$2,222.00
$2,317.00
$2,361.00
$1,564.00
$1,432.00
$1,295.00
$2,114.00
$2,199.00
$2,210.00
$1,418.00
$1,608.00
$2,223.00
$1,304.00
$2,173.00
$2,111.00
$1,906.00
$1,549.00
$2,300.00
$2,452.00
$1,228.00
$1,476.00
$1,363.00
$256.00
$242.00
$808.00
$590.00
$520.00
$625.00
$798.00
$724.00
$511.00
$695.00
$802.00
$563.00
$497.00
$570.00
$748.00
$487.00
$2,479.00
$1,537.00
$1,302.00
$2,361.00
$1,158.00
$1,376.00
$1,235.00
$1,209.00
$2,271.00
$1,895.00
$2,055.00
$1,352.00
$1,718.00
$1,531.00
$2,367.00
$2,443.00
$2,474.00
$1,642.00
$1,507.00
$1,363.00
$2,252.00
$2,326.00
$2,319.00
$1,495.00
$1,715.00
$2,361.00
$1,377.00
$2,309.00
$2,250.00
$2,022.00
$1,641.00
$2,436.00
$2,596.00
$1,298.00
$1,559.00
$1,451.00
$274.00
$258.00
$854.00
$628.00
$553.00
$665.00
$850.00
$771.00
$544.00
$727.00
$837.00
$589.00
$520.00
$596.00
$780.00
$507.00
166
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
35480
35481
35482
35483
35484
35485
35490
35491
35492
35493
35494
35495
35500
35501
35506
35507
35508
35509
35511
35515
35516
35518
35521
35526
35531
35533
35536
35541
35546
35548
35549
35551
35556
35558
35560
35563
35565
35566
35571
35572
35582
35583
35585
35587
35600
35601
35606
35612
35616
35621
35623
35626
0
0
0
0
0
0
0
0
0
0
0
0
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
ZZZ
90
90
90
90
90
90
90
$935.00
$565.00
$577.00
$696.00
$853.00
$670.00
$691.00
$423.00
$423.00
$523.00
$605.00
$532.00
$423.00
$1,569.00
$1,641.00
$1,606.00
$1,564.00
$1,529.00
$1,256.00
$1,387.00
$1,391.00
$1,313.00
$1,393.00
$1,527.00
$2,000.00
$1,716.00
$1,888.00
$2,005.00
$2,022.00
$1,751.00
$1,902.00
$2,036.00
$1,745.00
$1,219.00
$1,899.00
$1,115.00
$1,312.00
$2,161.00
$1,612.00
$369.00
$2,166.00
$1,843.00
$2,277.00
$1,698.00
$273.00
$1,495.00
$1,539.00
$1,349.00
$1,346.00
$1,265.00
$1,193.00
$1,921.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$849.00
$602.00
$531.00
$629.00
$802.00
$741.00
$826.00
$576.00
$518.00
$625.00
$773.00
$727.00
$466.00
$1,477.00
$1,536.00
$1,530.00
$1,471.00
$1,413.00
$1,601.00
$1,470.00
$1,225.00
$1,594.00
$1,688.00
$2,231.00
$2,696.00
$2,112.00
$2,375.00
$1,996.00
$1,978.00
$1,684.00
$1,831.00
$2,078.00
$1,704.00
$1,605.00
$2,407.00
$1,816.00
$1,749.00
$2,117.00
$1,927.00
$509.00
$2,105.00
$1,794.00
$2,331.00
$1,997.00
$367.00
$1,371.00
$1,458.00
$1,231.00
$1,239.00
$1,536.00
$1,816.00
$2,114.00
$913.00
$649.00
$573.00
$676.00
$864.00
$800.00
$873.00
$612.00
$550.00
$663.00
$816.00
$770.00
$500.00
$1,599.00
$1,660.00
$1,653.00
$1,594.00
$1,527.00
$1,711.00
$1,591.00
$1,323.00
$1,705.00
$1,804.00
$2,376.00
$2,879.00
$2,259.00
$2,539.00
$2,150.00
$2,134.00
$1,818.00
$1,980.00
$2,247.00
$1,840.00
$1,711.00
$2,575.00
$1,933.00
$1,864.00
$2,285.00
$2,065.00
$545.00
$2,274.00
$1,937.00
$2,516.00
$2,139.00
$397.00
$1,483.00
$1,576.00
$1,327.00
$1,339.00
$1,643.00
$1,939.00
$2,276.00
$970.00
$690.00
$610.00
$717.00
$920.00
$852.00
$911.00
$641.00
$577.00
$694.00
$850.00
$804.00
$531.00
$1,709.00
$1,772.00
$1,762.00
$1,705.00
$1,629.00
$1,806.00
$1,699.00
$1,412.00
$1,800.00
$1,903.00
$2,500.00
$3,037.00
$2,385.00
$2,680.00
$2,286.00
$2,273.00
$1,937.00
$2,113.00
$2,399.00
$1,961.00
$1,801.00
$2,721.00
$2,030.00
$1,961.00
$2,433.00
$2,181.00
$578.00
$2,424.00
$2,062.00
$2,676.00
$2,258.00
$425.00
$1,583.00
$1,680.00
$1,412.00
$1,428.00
$1,734.00
$2,044.00
$2,419.00
$849.00
$602.00
$531.00
$629.00
$802.00
$741.00
$826.00
$576.00
$518.00
$625.00
$773.00
$727.00
$466.00
$1,477.00
$1,536.00
$1,530.00
$1,471.00
$1,413.00
$1,601.00
$1,470.00
$1,225.00
$1,594.00
$1,688.00
$2,231.00
$2,696.00
$2,112.00
$2,375.00
$1,996.00
$1,978.00
$1,684.00
$1,831.00
$2,078.00
$1,704.00
$1,605.00
$2,407.00
$1,816.00
$1,749.00
$2,117.00
$1,927.00
$509.00
$2,105.00
$1,794.00
$2,331.00
$1,997.00
$367.00
$1,371.00
$1,458.00
$1,231.00
$1,239.00
$1,536.00
$1,816.00
$2,114.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$913.00
$649.00
$573.00
$676.00
$864.00
$800.00
$873.00
$612.00
$550.00
$663.00
$816.00
$770.00
$500.00
$1,599.00
$1,660.00
$1,653.00
$1,594.00
$1,527.00
$1,711.00
$1,591.00
$1,323.00
$1,705.00
$1,804.00
$2,376.00
$2,879.00
$2,259.00
$2,539.00
$2,150.00
$2,134.00
$1,818.00
$1,980.00
$2,247.00
$1,840.00
$1,711.00
$2,575.00
$1,933.00
$1,864.00
$2,285.00
$2,065.00
$545.00
$2,274.00
$1,937.00
$2,516.00
$2,139.00
$397.00
$1,483.00
$1,576.00
$1,327.00
$1,339.00
$1,643.00
$1,939.00
$2,276.00
$970.00
$690.00
$610.00
$717.00
$920.00
$852.00
$911.00
$641.00
$577.00
$694.00
$850.00
$804.00
$531.00
$1,709.00
$1,772.00
$1,762.00
$1,705.00
$1,629.00
$1,806.00
$1,699.00
$1,412.00
$1,800.00
$1,903.00
$2,500.00
$3,037.00
$2,385.00
$2,680.00
$2,286.00
$2,273.00
$1,937.00
$2,113.00
$2,399.00
$1,961.00
$1,801.00
$2,721.00
$2,030.00
$1,961.00
$2,433.00
$2,181.00
$578.00
$2,424.00
$2,062.00
$2,676.00
$2,258.00
$425.00
$1,583.00
$1,680.00
$1,412.00
$1,428.00
$1,734.00
$2,044.00
$2,419.00
167
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
35631
35636
35641
35642
35645
35646
35647
35650
35651
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35685
35686
35691
35693
35694
35695
35700
35701
35721
35741
35761
35800
35820
35840
35860
35870
35875
35876
35879
35881
35901
35903
35905
35907
36000
36002
36005
36010
36011
36012
36013
36014
36015
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
$1,891.00
$1,656.00
$1,966.00
$1,298.00
$1,304.00
$2,105.00
$1,555.00
$1,236.00
$2,055.00
$1,603.00
$1,589.00
$1,145.00
$1,237.00
$1,333.00
$1,686.00
$1,315.00
$751.00
$627.00
$702.00
$216.00
$178.00
$1,546.00
$1,140.00
$1,353.00
$1,351.00
$264.00
$494.00
$500.00
$499.00
$532.00
$567.00
$951.00
$771.00
$496.00
$1,583.00
$827.00
$1,232.00
$1,163.00
$1,275.00
$709.00
$818.00
$1,343.00
$1,335.00
$46.00
$181.00
$68.00
$136.00
$194.00
$186.00
$141.00
$159.00
$186.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,545.00
$2,226.00
$1,918.00
$1,406.00
$1,376.00
$2,426.00
$2,193.00
$1,439.00
$1,934.00
$1,896.00
$1,525.00
$1,446.00
$1,666.00
$1,607.00
$1,828.00
$1,586.00
$119.00
$534.00
$631.00
$294.00
$243.00
$1,408.00
$1,210.00
$1,482.00
$1,484.00
$228.00
$692.00
$649.00
$701.00
$524.00
$594.00
$956.00
$808.00
$492.00
$1,759.00
$879.00
$1,405.00
$1,262.00
$1,410.00
$753.00
$932.00
$2,446.00
$2,609.00
$42.00
$224.00
$465.00
$172.00
$220.00
$245.00
$170.00
$210.00
$245.00
$2,721.00
$2,377.00
$2,072.00
$1,512.00
$1,484.00
$2,623.00
$2,370.00
$1,540.00
$2,079.00
$2,027.00
$1,646.00
$1,544.00
$1,773.00
$1,718.00
$1,964.00
$1,699.00
$128.00
$577.00
$682.00
$312.00
$258.00
$1,520.00
$1,307.00
$1,599.00
$1,602.00
$247.00
$739.00
$694.00
$748.00
$565.00
$641.00
$1,036.00
$871.00
$531.00
$1,898.00
$944.00
$1,515.00
$1,350.00
$1,506.00
$812.00
$1,005.00
$2,603.00
$2,769.00
$45.00
$239.00
$499.00
$183.00
$233.00
$259.00
$181.00
$222.00
$258.00
$2,872.00
$2,507.00
$2,209.00
$1,605.00
$1,578.00
$2,797.00
$2,528.00
$1,628.00
$2,207.00
$2,140.00
$1,754.00
$1,627.00
$1,863.00
$1,813.00
$2,080.00
$1,792.00
$137.00
$617.00
$728.00
$327.00
$271.00
$1,620.00
$1,394.00
$1,703.00
$1,708.00
$264.00
$776.00
$730.00
$786.00
$598.00
$681.00
$1,110.00
$925.00
$564.00
$2,020.00
$997.00
$1,610.00
$1,424.00
$1,587.00
$861.00
$1,063.00
$2,733.00
$2,901.00
$46.00
$248.00
$516.00
$192.00
$243.00
$270.00
$190.00
$231.00
$269.00
$2,545.00
$2,226.00
$1,918.00
$1,406.00
$1,376.00
$2,426.00
$2,193.00
$1,439.00
$1,934.00
$1,896.00
$1,525.00
$1,446.00
$1,666.00
$1,607.00
$1,828.00
$1,586.00
$119.00
$534.00
$631.00
$294.00
$243.00
$1,408.00
$1,210.00
$1,482.00
$1,484.00
$228.00
$692.00
$649.00
$701.00
$524.00
$594.00
$956.00
$808.00
$492.00
$1,759.00
$879.00
$1,405.00
$1,262.00
$1,410.00
$753.00
$932.00
$2,446.00
$2,609.00
$12.00
$154.00
$66.00
$172.00
$220.00
$245.00
$170.00
$210.00
$245.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,721.00
$2,377.00
$2,072.00
$1,512.00
$1,484.00
$2,623.00
$2,370.00
$1,540.00
$2,079.00
$2,027.00
$1,646.00
$1,544.00
$1,773.00
$1,718.00
$1,964.00
$1,699.00
$128.00
$577.00
$682.00
$312.00
$258.00
$1,520.00
$1,307.00
$1,599.00
$1,602.00
$247.00
$739.00
$694.00
$748.00
$565.00
$641.00
$1,036.00
$871.00
$531.00
$1,898.00
$944.00
$1,515.00
$1,350.00
$1,506.00
$812.00
$1,005.00
$2,603.00
$2,769.00
$13.00
$163.00
$69.00
$183.00
$233.00
$259.00
$181.00
$222.00
$258.00
$2,872.00
$2,507.00
$2,209.00
$1,605.00
$1,578.00
$2,797.00
$2,528.00
$1,628.00
$2,207.00
$2,140.00
$1,754.00
$1,627.00
$1,863.00
$1,813.00
$2,080.00
$1,792.00
$137.00
$617.00
$728.00
$327.00
$271.00
$1,620.00
$1,394.00
$1,703.00
$1,708.00
$264.00
$776.00
$730.00
$786.00
$598.00
$681.00
$1,110.00
$925.00
$564.00
$2,020.00
$997.00
$1,610.00
$1,424.00
$1,587.00
$861.00
$1,063.00
$2,733.00
$2,901.00
$13.00
$170.00
$72.00
$192.00
$243.00
$270.00
$190.00
$231.00
$269.00
168
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
36100
36120
36140
36145
36160
36200
36215
36216
36217
36218
36245
36246
36247
36248
36260
36261
36262
36299
36410
36415
36416
36425
36430
36455
36468
36469
36470
36471
36481
36489
36491
36493
36500
36511
36512
36513
36514
36515
36516
36522
36530
36531
36532
36533
36534
36535
36536
36537
36540
36550
36600
36620
0
$176.00
0
$120.00
0
$106.00
0
$10.00
0
$196.00
0
$240.00
0
$240.00
0
$270.00
0
$325.00
ZZZ
$79.00
0
$249.00
0
$272.00
0
$323.00
ZZZ
$53.00
90
$749.00
90
$388.00
90
$297.00
YYY
BR
0
$18.00
0
BR
0
BR
0
$86.00
0
$37.00
0
$141.00
0
NC
0
NC
10
$76.00
10
$96.00
0
$499.00
0
$134.00
0
$87.00
0
$65.00
0
$159.00
0
$92.00
0
$92.00
0
$92.00
0
$92.00
0
$92.00
0
$92.00
0
$305.00
10
$493.00
10
$412.00
10
$237.00
10
$448.00
10
$235.00
10
$213.00
0
$1,375.00
0
$312.00
0
BR
0
$37.00
0
$24.00
0
$64.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$218.00
$141.00
$141.00
$141.00
$181.00
$212.00
$328.00
$369.00
$445.00
$71.00
$332.00
$371.00
$443.00
$72.00
$821.00
$468.00
$351.00
----$29.00
--------$52.00
$52.00
$170.00
--------$175.00
$219.00
$513.00
$331.00
$117.00
$107.00
$247.00
$125.00
$125.00
$125.00
$125.00
$125.00
$125.00
$418.00
$528.00
$432.00
$262.00
$959.00
$224.00
$265.00
$1,830.00
$415.00
----$39.00
$37.00
$73.00
$231.00
$149.00
$149.00
$148.00
$194.00
$224.00
$346.00
$389.00
$470.00
$75.00
$351.00
$392.00
$468.00
$76.00
$883.00
$502.00
$378.00
----$31.00
--------$55.00
$58.00
$179.00
--------$188.00
$236.00
$544.00
$351.00
$126.00
$113.00
$260.00
$132.00
$132.00
$132.00
$132.00
$132.00
$132.00
$447.00
$566.00
$463.00
$282.00
$1,031.00
$239.00
$284.00
$1,965.00
$445.00
----$50.00
$40.00
$77.00
$242.00
$156.00
$156.00
$155.00
$204.00
$234.00
$361.00
$405.00
$491.00
$78.00
$366.00
$409.00
$489.00
$80.00
$936.00
$530.00
$400.00
----$32.00
--------$58.00
$61.00
$186.00
--------$196.00
$247.00
$569.00
$364.00
$133.00
$118.00
$270.00
$137.00
$137.00
$137.00
$137.00
$137.00
$137.00
$463.00
$597.00
$488.00
$299.00
$1,076.00
$250.00
$298.00
$2,035.00
$461.00
----$61.00
$42.00
$81.00
$218.00
$141.00
$141.00
$141.00
$181.00
$212.00
$328.00
$369.00
$445.00
$71.00
$332.00
$371.00
$443.00
$72.00
$821.00
$468.00
$351.00
----$12.00
--------$52.00
$52.00
$170.00
--------$80.00
$115.00
$513.00
$181.00
$117.00
$107.00
$247.00
$125.00
$125.00
$125.00
$125.00
$125.00
$125.00
$144.00
$528.00
$432.00
$262.00
$464.00
$224.00
$216.00
$267.00
$64.00
----$39.00
$22.00
$73.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$231.00
$149.00
$149.00
$148.00
$194.00
$224.00
$346.00
$389.00
$470.00
$75.00
$351.00
$392.00
$468.00
$76.00
$883.00
$502.00
$378.00
----$13.00
--------$55.00
$58.00
$179.00
--------$86.00
$124.00
$544.00
$190.00
$126.00
$113.00
$260.00
$132.00
$132.00
$132.00
$132.00
$132.00
$132.00
$153.00
$566.00
$463.00
$282.00
$497.00
$239.00
$232.00
$284.00
$68.00
----$50.00
$23.00
$77.00
$242.00
$156.00
$156.00
$155.00
$204.00
$234.00
$361.00
$405.00
$491.00
$78.00
$366.00
$409.00
$489.00
$80.00
$936.00
$530.00
$400.00
----$13.00
--------$58.00
$61.00
$186.00
--------$91.00
$131.00
$569.00
$197.00
$133.00
$118.00
$270.00
$137.00
$137.00
$137.00
$137.00
$137.00
$137.00
$159.00
$597.00
$488.00
$299.00
$525.00
$250.00
$245.00
$298.00
$71.00
----$61.00
$24.00
$81.00
169
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
36625
36640
36680
36800
36810
36815
36819
36820
36821
36822
36823
36825
36830
36831
36832
36833
36834
36835
36860
36861
36870
37140
37145
37160
37180
37181
37182
37183
37195
37200
37201
37202
37203
37204
37205
37206
37207
37208
37209
37250
37251
37500
37501
37565
37600
37605
37606
37607
37609
37615
37616
37617
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
0
0
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
ZZZ
0
ZZZ
0
ZZZ
ZZZ
0
0
90
90
90
90
90
10
90
90
90
$133.00
$130.00
$72.00
$159.00
$345.00
$236.00
$977.00
$800.00
$721.00
$630.00
$1,461.00
$867.00
$967.00
$488.00
$810.00
$780.00
$761.00
$542.00
$166.00
$224.00
$1,755.00
$1,666.00
$1,741.00
$1,681.00
$1,769.00
$1,923.00
$914.00
$425.00
$302.00
$232.00
$408.00
$340.00
$287.00
$957.00
$589.00
$288.00
$613.00
$299.00
$116.00
$112.00
$85.00
$739.00
BR
$364.00
$414.00
$521.00
$563.00
$456.00
$278.00
$495.00
$1,128.00
$1,132.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$142.00
$152.00
$96.00
$219.00
$335.00
$210.00
$1,117.00
$1,118.00
$752.00
$661.00
$1,702.00
$832.00
$983.00
$645.00
$870.00
$976.00
$752.00
$631.00
$235.00
$207.00
$2,336.00
$1,766.00
$1,930.00
$1,671.00
$1,907.00
$2,043.00
$1,261.00
$582.00
$415.00
$317.00
$390.00
$461.00
$392.00
$1,268.00
$628.00
$294.00
$646.00
$305.00
$159.00
$154.00
$117.00
$1,002.00
----$823.00
$898.00
$1,024.00
$561.00
$531.00
$506.00
$502.00
$1,469.00
$1,677.00
$151.00
$163.00
$102.00
$233.00
$360.00
$226.00
$1,205.00
$1,206.00
$811.00
$713.00
$1,832.00
$897.00
$1,060.00
$693.00
$938.00
$1,052.00
$811.00
$681.00
$250.00
$219.00
$2,506.00
$1,868.00
$2,075.00
$1,796.00
$2,055.00
$2,196.00
$1,350.00
$615.00
$457.00
$334.00
$412.00
$491.00
$414.00
$1,339.00
$665.00
$311.00
$696.00
$328.00
$167.00
$165.00
$125.00
$1,059.00
----$868.00
$946.00
$1,087.00
$607.00
$572.00
$542.00
$540.00
$1,587.00
$1,789.00
$160.00
$172.00
$107.00
$245.00
$381.00
$239.00
$1,282.00
$1,283.00
$861.00
$752.00
$1,944.00
$953.00
$1,126.00
$734.00
$996.00
$1,118.00
$862.00
$723.00
$260.00
$229.00
$2,592.00
$1,950.00
$2,201.00
$1,905.00
$2,185.00
$2,331.00
$1,428.00
$643.00
$484.00
$347.00
$430.00
$514.00
$431.00
$1,398.00
$694.00
$325.00
$740.00
$350.00
$175.00
$174.00
$133.00
$1,098.00
----$903.00
$981.00
$1,137.00
$647.00
$607.00
$564.00
$571.00
$1,686.00
$1,884.00
$142.00
$152.00
$96.00
$219.00
$335.00
$210.00
$1,117.00
$1,118.00
$752.00
$661.00
$1,702.00
$832.00
$983.00
$645.00
$870.00
$976.00
$752.00
$631.00
$173.00
$207.00
$391.00
$1,766.00
$1,930.00
$1,671.00
$1,907.00
$2,043.00
$1,261.00
$582.00
$415.00
$317.00
$390.00
$461.00
$392.00
$1,268.00
$628.00
$294.00
$646.00
$305.00
$159.00
$154.00
$117.00
$1,002.00
----$823.00
$898.00
$1,024.00
$561.00
$531.00
$287.00
$502.00
$1,469.00
$1,677.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$151.00
$163.00
$102.00
$233.00
$360.00
$226.00
$1,205.00
$1,206.00
$811.00
$713.00
$1,832.00
$897.00
$1,060.00
$693.00
$938.00
$1,052.00
$811.00
$681.00
$183.00
$219.00
$412.00
$1,868.00
$2,075.00
$1,796.00
$2,055.00
$2,196.00
$1,350.00
$615.00
$457.00
$334.00
$412.00
$491.00
$414.00
$1,339.00
$665.00
$311.00
$696.00
$328.00
$167.00
$165.00
$125.00
$1,059.00
----$868.00
$946.00
$1,087.00
$607.00
$572.00
$306.00
$540.00
$1,587.00
$1,789.00
$160.00
$172.00
$107.00
$245.00
$381.00
$239.00
$1,282.00
$1,283.00
$861.00
$752.00
$1,944.00
$953.00
$1,126.00
$734.00
$996.00
$1,118.00
$862.00
$723.00
$191.00
$229.00
$429.00
$1,950.00
$2,201.00
$1,905.00
$2,185.00
$2,331.00
$1,428.00
$643.00
$484.00
$347.00
$430.00
$514.00
$431.00
$1,398.00
$694.00
$325.00
$740.00
$350.00
$175.00
$174.00
$133.00
$1,098.00
----$903.00
$981.00
$1,137.00
$647.00
$607.00
$321.00
$571.00
$1,686.00
$1,884.00
170
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
37618
37620
37650
37660
37700
37720
37730
37735
37760
37780
37785
37788
37790
37799
38100
38101
38102
38115
38120
38129
38200
38205
38206
38220
38221
38230
38240
38241
38242
38300
38305
38308
38380
38381
38382
38500
38505
38510
38520
38525
38530
38542
38550
38555
38562
38564
38570
38571
38572
38589
38700
38720
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
90
ZZZ
90
90
YYY
0
0
0
0
0
10
0
0
0
10
90
90
90
90
90
10
0
10
90
90
90
90
90
90
90
90
10
10
10
YYY
90
90
$514.00
$818.00
$430.00
$789.00
$336.00
$480.00
$624.00
$847.00
$813.00
$301.00
$270.00
$1,654.00
$690.00
BR
$974.00
$982.00
$332.00
$1,020.00
$1,138.00
BR
$180.00
$79.00
$79.00
$212.00
$228.00
$265.00
$128.00
$128.00
$90.00
$104.00
$375.00
$425.00
$628.00
$1,087.00
$798.00
$234.00
$139.00
$349.00
$431.00
$369.00
$517.00
$507.00
$519.00
$1,115.00
$799.00
$831.00
$695.00
$902.00
$1,049.00
BR
$863.00
$1,328.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$448.00
$842.00
$655.00
$1,585.00
$366.00
$501.00
$638.00
$886.00
$872.00
$364.00
$560.00
$1,753.00
$757.00
----$1,132.00
$1,197.00
$355.00
$1,229.00
$1,325.00
----$185.00
$108.00
$108.00
$282.00
$305.00
$362.00
$159.00
$159.00
$123.00
$329.00
$750.00
$635.00
$787.00
$1,229.00
$1,024.00
$355.00
$216.00
$611.00
$639.00
$550.00
$726.00
$622.00
$631.00
$1,306.00
$908.00
$918.00
$740.00
$1,086.00
$1,280.00
----$1,107.00
$1,528.00
$483.00
$897.00
$698.00
$1,679.00
$395.00
$540.00
$687.00
$956.00
$940.00
$392.00
$603.00
$1,862.00
$809.00
----$1,213.00
$1,283.00
$382.00
$1,316.00
$1,426.00
----$195.00
$114.00
$114.00
$302.00
$325.00
$384.00
$167.00
$167.00
$129.00
$353.00
$800.00
$679.00
$844.00
$1,329.00
$1,103.00
$379.00
$231.00
$650.00
$683.00
$588.00
$776.00
$666.00
$679.00
$1,405.00
$974.00
$987.00
$795.00
$1,150.00
$1,367.00
----$1,185.00
$1,634.00
$512.00
$942.00
$733.00
$1,755.00
$417.00
$572.00
$728.00
$1,015.00
$997.00
$414.00
$632.00
$1,949.00
$849.00
----$1,283.00
$1,356.00
$406.00
$1,391.00
$1,513.00
----$203.00
$118.00
$118.00
$312.00
$336.00
$401.00
$173.00
$173.00
$134.00
$368.00
$833.00
$712.00
$888.00
$1,412.00
$1,165.00
$397.00
$241.00
$679.00
$717.00
$618.00
$816.00
$699.00
$717.00
$1,486.00
$1,028.00
$1,044.00
$842.00
$1,202.00
$1,440.00
----$1,236.00
$1,710.00
$448.00
$842.00
$655.00
$1,585.00
$366.00
$501.00
$638.00
$886.00
$872.00
$364.00
$358.00
$1,753.00
$757.00
----$1,132.00
$1,197.00
$355.00
$1,229.00
$1,325.00
----$185.00
$108.00
$108.00
$77.00
$98.00
$362.00
$159.00
$159.00
$123.00
$236.00
$631.00
$635.00
$787.00
$1,229.00
$1,024.00
$331.00
$116.00
$611.00
$639.00
$550.00
$726.00
$622.00
$631.00
$1,306.00
$908.00
$918.00
$740.00
$1,086.00
$1,280.00
----$1,107.00
$1,528.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$483.00
$897.00
$698.00
$1,679.00
$395.00
$540.00
$687.00
$956.00
$940.00
$392.00
$386.00
$1,862.00
$809.00
----$1,213.00
$1,283.00
$382.00
$1,316.00
$1,426.00
----$195.00
$114.00
$114.00
$81.00
$102.00
$384.00
$167.00
$167.00
$129.00
$252.00
$672.00
$679.00
$844.00
$1,329.00
$1,103.00
$354.00
$124.00
$650.00
$683.00
$588.00
$776.00
$666.00
$679.00
$1,405.00
$974.00
$987.00
$795.00
$1,150.00
$1,367.00
----$1,185.00
$1,634.00
$512.00
$942.00
$733.00
$1,755.00
$417.00
$572.00
$728.00
$1,015.00
$997.00
$414.00
$409.00
$1,949.00
$849.00
----$1,283.00
$1,356.00
$406.00
$1,391.00
$1,513.00
----$203.00
$118.00
$118.00
$84.00
$106.00
$401.00
$173.00
$173.00
$134.00
$264.00
$701.00
$712.00
$888.00
$1,412.00
$1,165.00
$371.00
$130.00
$679.00
$717.00
$618.00
$816.00
$699.00
$717.00
$1,486.00
$1,028.00
$1,044.00
$842.00
$1,202.00
$1,440.00
----$1,236.00
$1,710.00
171
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
38724
38740
38745
38746
38747
38760
38765
38770
38780
38790
38792
38794
38999
39000
39010
39200
39220
39400
39499
39501
39502
39503
39520
39530
39531
39540
39541
39545
39560
39561
39599
40490
40500
40510
40520
40525
40527
40530
40650
40652
40654
40700
40701
40702
40720
40761
40799
40800
40801
40804
40805
40806
90
90
90
ZZZ
ZZZ
90
90
90
90
0
0
90
YYY
90
90
90
90
10
YYY
90
90
90
90
90
90
90
90
90
90
90
YYY
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
10
10
10
10
0
$1,366.00
$539.00
$770.00
$312.00
$337.00
$699.00
$1,283.00
$1,111.00
$1,357.00
$158.00
$26.00
$298.00
BR
$664.00
$1,148.00
$1,249.00
$1,542.00
$614.00
BR
$1,083.00
$1,268.00
$2,726.00
$1,345.00
$1,295.00
$1,243.00
$1,133.00
$1,179.00
$1,102.00
$968.00
$1,328.00
BR
$108.00
$422.00
$469.00
$467.00
$714.00
$851.00
$501.00
$368.00
$436.00
$529.00
$1,009.00
$1,452.00
$1,030.00
$1,107.00
$1,202.00
BR
$110.00
$208.00
$105.00
$245.00
$38.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,606.00
$831.00
$1,118.00
$359.00
$361.00
$1,055.00
$1,648.00
$1,060.00
$1,389.00
$1,610.00
$37.00
$310.00
----$723.00
$1,037.00
$1,147.00
$1,452.00
$550.00
----$1,129.00
$1,330.00
$6,678.00
$1,399.00
$1,299.00
$1,370.00
$1,137.00
$1,206.00
$1,225.00
$1,057.00
$1,483.00
----$149.00
$522.00
$590.00
$640.00
$831.00
$962.00
$623.00
$468.00
$572.00
$674.00
$1,206.00
$1,503.00
$1,185.00
$1,347.00
$1,435.00
----$153.00
$257.00
$181.00
$280.00
$64.00
$1,718.00
$885.00
$1,191.00
$388.00
$388.00
$1,124.00
$1,758.00
$1,130.00
$1,492.00
$1,731.00
$40.00
$325.00
----$781.00
$1,123.00
$1,241.00
$1,571.00
$595.00
----$1,215.00
$1,431.00
$7,019.00
$1,510.00
$1,400.00
$1,478.00
$1,224.00
$1,298.00
$1,323.00
$1,141.00
$1,600.00
----$159.00
$558.00
$632.00
$687.00
$891.00
$1,032.00
$668.00
$502.00
$614.00
$723.00
$1,287.00
$1,610.00
$1,267.00
$1,447.00
$1,541.00
----$164.00
$274.00
$193.00
$299.00
$68.00
$1,798.00
$928.00
$1,249.00
$414.00
$413.00
$1,178.00
$1,848.00
$1,188.00
$1,578.00
$1,791.00
$42.00
$338.00
----$825.00
$1,196.00
$1,322.00
$1,674.00
$632.00
----$1,288.00
$1,518.00
$7,291.00
$1,604.00
$1,485.00
$1,571.00
$1,297.00
$1,377.00
$1,404.00
$1,211.00
$1,700.00
----$165.00
$583.00
$661.00
$720.00
$936.00
$1,085.00
$701.00
$525.00
$643.00
$758.00
$1,349.00
$1,694.00
$1,330.00
$1,525.00
$1,624.00
----$171.00
$287.00
$202.00
$312.00
$71.00
$1,606.00
$831.00
$1,118.00
$359.00
$361.00
$1,055.00
$1,648.00
$1,060.00
$1,389.00
$93.00
$37.00
$310.00
----$723.00
$1,037.00
$1,147.00
$1,452.00
$550.00
----$1,129.00
$1,330.00
$6,678.00
$1,399.00
$1,299.00
$1,370.00
$1,137.00
$1,206.00
$1,225.00
$1,057.00
$1,483.00
----$95.00
$512.00
$578.00
$597.00
$831.00
$962.00
$606.00
$437.00
$571.00
$663.00
$1,206.00
$1,503.00
$1,185.00
$1,347.00
$1,435.00
----$107.00
$214.00
$118.00
$231.00
$59.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,718.00
$885.00
$1,191.00
$388.00
$388.00
$1,124.00
$1,758.00
$1,130.00
$1,492.00
$98.00
$40.00
$325.00
----$781.00
$1,123.00
$1,241.00
$1,571.00
$595.00
----$1,215.00
$1,431.00
$7,019.00
$1,510.00
$1,400.00
$1,478.00
$1,224.00
$1,298.00
$1,323.00
$1,141.00
$1,600.00
----$101.00
$548.00
$619.00
$640.00
$891.00
$1,032.00
$650.00
$469.00
$613.00
$712.00
$1,287.00
$1,610.00
$1,267.00
$1,447.00
$1,541.00
----$114.00
$228.00
$126.00
$246.00
$63.00
$1,798.00
$928.00
$1,249.00
$414.00
$413.00
$1,178.00
$1,848.00
$1,188.00
$1,578.00
$104.00
$42.00
$338.00
----$825.00
$1,196.00
$1,322.00
$1,674.00
$632.00
----$1,288.00
$1,518.00
$7,291.00
$1,604.00
$1,485.00
$1,571.00
$1,297.00
$1,377.00
$1,404.00
$1,211.00
$1,700.00
----$105.00
$572.00
$648.00
$671.00
$936.00
$1,085.00
$682.00
$491.00
$642.00
$746.00
$1,349.00
$1,694.00
$1,330.00
$1,525.00
$1,624.00
----$120.00
$240.00
$132.00
$258.00
$65.00
172
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
40808
40810
40812
40814
40816
40818
40819
40820
40830
40831
40840
40842
40843
40844
40845
40899
41000
41005
41006
41007
41008
41009
41010
41015
41016
41017
41018
41100
41105
41108
41110
41112
41113
41114
41115
41116
41120
41130
41135
41140
41145
41150
41153
41155
41250
41251
41252
41500
41510
41520
41599
41800
10
10
10
90
90
90
90
10
10
10
90
90
90
90
90
YYY
10
10
90
90
90
90
10
90
90
90
90
10
10
10
10
90
90
90
10
90
90
90
90
90
90
90
90
90
10
10
10
90
90
90
YYY
10
$100.00
$141.00
$202.00
$319.00
$336.00
$249.00
$208.00
$104.00
$140.00
$213.00
$687.00
$684.00
$947.00
$1,232.00
$1,593.00
BR
$119.00
$109.00
$237.00
$283.00
$248.00
$319.00
$91.00
$267.00
$357.00
$300.00
$424.00
$140.00
$136.00
$110.00
$159.00
$255.00
$301.00
$682.00
$176.00
$242.00
$813.00
$937.00
$1,869.00
$2,005.00
$2,406.00
$1,897.00
$2,091.00
$2,448.00
$168.00
$203.00
$294.00
$334.00
$313.00
$255.00
BR
$107.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$147.00
$172.00
$245.00
$351.00
$370.00
$330.00
$306.00
$190.00
$221.00
$273.00
$789.00
$773.00
$1,018.00
$1,348.00
$1,562.00
----$187.00
$179.00
$362.00
$359.00
$360.00
$375.00
$216.00
$423.00
$425.00
$428.00
$501.00
$205.00
$184.00
$157.00
$202.00
$315.00
$341.00
$732.00
$223.00
$299.00
$969.00
$1,083.00
$2,047.00
$2,245.00
$2,685.00
$2,102.00
$2,171.00
$2,496.00
$246.00
$258.00
$335.00
$414.00
$421.00
$297.00
----$161.00
$158.00
$184.00
$262.00
$376.00
$396.00
$353.00
$327.00
$203.00
$236.00
$292.00
$846.00
$825.00
$1,085.00
$1,450.00
$1,669.00
----$200.00
$192.00
$387.00
$383.00
$385.00
$401.00
$231.00
$452.00
$453.00
$458.00
$534.00
$219.00
$197.00
$169.00
$216.00
$337.00
$364.00
$782.00
$239.00
$320.00
$1,034.00
$1,157.00
$2,183.00
$2,395.00
$2,863.00
$2,243.00
$2,316.00
$2,664.00
$263.00
$276.00
$358.00
$442.00
$450.00
$317.00
----$172.00
$164.00
$192.00
$275.00
$394.00
$414.00
$367.00
$342.00
$211.00
$247.00
$307.00
$892.00
$866.00
$1,138.00
$1,536.00
$1,755.00
----$209.00
$200.00
$405.00
$400.00
$402.00
$419.00
$240.00
$473.00
$474.00
$480.00
$559.00
$229.00
$205.00
$176.00
$225.00
$352.00
$381.00
$821.00
$249.00
$334.00
$1,083.00
$1,212.00
$2,289.00
$2,512.00
$3,000.00
$2,351.00
$2,428.00
$2,794.00
$275.00
$289.00
$375.00
$462.00
$470.00
$332.00
----$180.00
$102.00
$128.00
$211.00
$334.00
$356.00
$330.00
$305.00
$182.00
$219.00
$273.00
$789.00
$773.00
$1,018.00
$1,346.00
$1,562.00
----$144.00
$141.00
$345.00
$325.00
$345.00
$356.00
$216.00
$375.00
$387.00
$387.00
$464.00
$158.00
$142.00
$112.00
$147.00
$282.00
$318.00
$732.00
$220.00
$299.00
$969.00
$1,083.00
$2,047.00
$2,245.00
$2,685.00
$2,102.00
$2,171.00
$2,496.00
$189.00
$223.00
$278.00
$414.00
$421.00
$297.00
----$131.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$109.00
$137.00
$225.00
$357.00
$381.00
$353.00
$326.00
$194.00
$235.00
$292.00
$846.00
$825.00
$1,085.00
$1,448.00
$1,669.00
----$154.00
$150.00
$369.00
$348.00
$368.00
$380.00
$231.00
$400.00
$413.00
$414.00
$494.00
$169.00
$152.00
$119.00
$157.00
$301.00
$340.00
$782.00
$235.00
$320.00
$1,034.00
$1,157.00
$2,183.00
$2,395.00
$2,863.00
$2,243.00
$2,316.00
$2,664.00
$202.00
$239.00
$297.00
$442.00
$450.00
$317.00
----$141.00
$115.00
$143.00
$236.00
$374.00
$399.00
$367.00
$340.00
$202.00
$246.00
$307.00
$892.00
$866.00
$1,138.00
$1,534.00
$1,755.00
----$161.00
$157.00
$386.00
$364.00
$385.00
$397.00
$240.00
$420.00
$432.00
$434.00
$517.00
$177.00
$159.00
$125.00
$164.00
$316.00
$356.00
$821.00
$245.00
$334.00
$1,083.00
$1,212.00
$2,289.00
$2,512.00
$3,000.00
$2,351.00
$2,428.00
$2,794.00
$212.00
$250.00
$312.00
$462.00
$470.00
$332.00
----$147.00
173
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
41805
41806
41820
41821
41822
41823
41825
41826
41827
41828
41830
41850
41870
41872
41874
41899
42000
42100
42104
42106
42107
42120
42140
42145
42160
42180
42182
42200
42205
42210
42215
42220
42225
42226
42227
42235
42260
42280
42281
42299
42300
42305
42310
42320
42325
42326
42330
42335
42340
42400
42405
42408
10
$115.00
10
$217.00
0
NC
0
NC
10
$237.00
90
$312.00
10
$144.00
10
$211.00
90
$322.00
10
$176.00
10
$156.00
0
NC
0
NC
90
$249.00
90
$193.00
YYY
BR
10
$106.00
10
$122.00
10
$161.00
10
$204.00
90
$409.00
90
$573.00
90
$174.00
90
$741.00
10
$176.00
10
$222.00
10
$324.00
90
$946.00
90
$863.00
90 $1,174.00
90
$766.00
90
$586.00
90
$803.00
90
$848.00
90
$762.00
90
$631.00
90
$491.00
10
$148.00
10
$160.00
YYY
BR
10
$165.00
90
$448.00
10
$145.00
10
$208.00
90
$245.00
90
$369.00
10
$184.00
90
$287.00
90
$411.00
0
$94.00
10
$258.00
90
$377.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$163.00
$275.00
--------$270.00
$359.00
$189.00
$256.00
$362.00
$316.00
$344.00
--------$282.00
$310.00
----$192.00
$195.00
$215.00
$244.00
$444.00
$636.00
$280.00
$806.00
$259.00
$284.00
$379.00
$1,160.00
$1,170.00
$1,272.00
$929.00
$707.00
$974.00
$1,014.00
$918.00
$728.00
$888.00
$155.00
$194.00
----$236.00
$592.00
$199.00
$264.00
$313.00
$375.00
$257.00
$359.00
$487.00
$164.00
$346.00
$471.00
$175.00
$294.00
--------$290.00
$385.00
$203.00
$273.00
$387.00
$338.00
$367.00
--------$301.00
$332.00
----$205.00
$208.00
$230.00
$262.00
$474.00
$679.00
$300.00
$860.00
$277.00
$303.00
$404.00
$1,241.00
$1,245.00
$1,362.00
$1,001.00
$753.00
$1,042.00
$1,083.00
$980.00
$775.00
$951.00
$166.00
$207.00
----$252.00
$633.00
$212.00
$282.00
$334.00
$402.00
$275.00
$384.00
$520.00
$176.00
$370.00
$504.00
$182.00
$308.00
--------$305.00
$404.00
$212.00
$286.00
$405.00
$353.00
$384.00
--------$315.00
$347.00
----$214.00
$217.00
$241.00
$274.00
$496.00
$711.00
$312.00
$900.00
$289.00
$317.00
$423.00
$1,303.00
$1,302.00
$1,435.00
$1,057.00
$785.00
$1,092.00
$1,134.00
$1,027.00
$810.00
$1,002.00
$174.00
$217.00
----$264.00
$664.00
$222.00
$295.00
$348.00
$423.00
$287.00
$401.00
$545.00
$183.00
$387.00
$528.00
$163.00
$269.00
--------$178.00
$331.00
$187.00
$256.00
$362.00
$286.00
$326.00
--------$282.00
$287.00
----$143.00
$194.00
$215.00
$244.00
$444.00
$636.00
$253.00
$806.00
$230.00
$241.00
$359.00
$1,160.00
$1,170.00
$1,272.00
$929.00
$707.00
$974.00
$1,014.00
$918.00
$728.00
$888.00
$122.00
$153.00
----$199.00
$592.00
$166.00
$233.00
$205.00
$298.00
$173.00
$359.00
$487.00
$62.00
$344.00
$471.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$175.00
$288.00
--------$192.00
$355.00
$201.00
$273.00
$387.00
$306.00
$348.00
--------$301.00
$307.00
----$153.00
$208.00
$230.00
$262.00
$474.00
$679.00
$271.00
$860.00
$246.00
$257.00
$383.00
$1,241.00
$1,245.00
$1,362.00
$1,001.00
$753.00
$1,042.00
$1,083.00
$980.00
$775.00
$951.00
$130.00
$163.00
----$213.00
$633.00
$177.00
$249.00
$218.00
$319.00
$184.00
$384.00
$520.00
$66.00
$367.00
$504.00
$182.00
$302.00
--------$204.00
$373.00
$209.00
$286.00
$405.00
$320.00
$364.00
--------$315.00
$321.00
----$160.00
$217.00
$241.00
$274.00
$496.00
$711.00
$283.00
$900.00
$257.00
$270.00
$401.00
$1,303.00
$1,302.00
$1,435.00
$1,057.00
$785.00
$1,092.00
$1,134.00
$1,027.00
$810.00
$1,002.00
$137.00
$172.00
----$223.00
$664.00
$185.00
$260.00
$228.00
$337.00
$193.00
$401.00
$545.00
$70.00
$384.00
$528.00
174
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
42409
42410
42415
42420
42425
42426
42440
42450
42500
42505
42507
42508
42509
42510
42550
42600
42650
42660
42665
42699
42700
42720
42725
42800
42802
42804
42806
42808
42809
42810
42815
42821
42826
42831
42836
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
42953
42955
42960
42961
42962
42970
42971
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
0
0
90
YYY
10
10
90
10
10
10
10
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
10
90
90
90
90
$266.00
$746.00
$1,364.00
$1,577.00
$1,097.00
$1,882.00
$634.00
$395.00
$407.00
$559.00
$522.00
$767.00
$915.00
$711.00
$82.00
$445.00
$67.00
$89.00
$238.00
BR
$144.00
$270.00
$720.00
$123.00
$150.00
$136.00
$167.00
$250.00
$152.00
$335.00
$659.00
$378.00
$320.00
$235.00
$286.00
$729.00
$1,173.00
$1,958.00
$207.00
$427.00
$1,047.00
$1,262.00
$1,825.00
$429.00
$745.00
$752.00
$561.00
$178.00
$406.00
$602.00
$284.00
$472.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$319.00
$903.00
$1,538.00
$1,762.00
$1,227.00
$1,892.00
$675.00
$487.00
$471.00
$605.00
$641.00
$894.00
$1,130.00
$792.00
$687.00
$571.00
$96.00
$119.00
$309.00
----$248.00
$535.00
$1,005.00
$227.00
$239.00
$217.00
$259.00
$373.00
$270.00
$448.00
$710.00
$441.00
$367.00
$273.00
$353.00
$861.00
$1,340.00
$2,184.00
$272.00
$593.00
$1,236.00
$1,470.00
$2,082.00
$472.00
$811.00
$935.00
$730.00
$231.00
$564.00
$693.00
$480.00
$624.00
$341.00
$966.00
$1,642.00
$1,881.00
$1,311.00
$2,020.00
$720.00
$520.00
$503.00
$646.00
$691.00
$954.00
$1,218.00
$845.00
$738.00
$610.00
$102.00
$127.00
$330.00
----$266.00
$572.00
$1,074.00
$243.00
$256.00
$232.00
$277.00
$400.00
$289.00
$480.00
$759.00
$471.00
$392.00
$291.00
$377.00
$918.00
$1,430.00
$2,330.00
$291.00
$634.00
$1,319.00
$1,569.00
$2,222.00
$504.00
$866.00
$1,001.00
$782.00
$247.00
$602.00
$740.00
$512.00
$667.00
$357.00
$1,015.00
$1,723.00
$1,973.00
$1,375.00
$2,119.00
$755.00
$545.00
$526.00
$676.00
$729.00
$999.00
$1,287.00
$884.00
$763.00
$638.00
$107.00
$132.00
$345.00
----$277.00
$598.00
$1,126.00
$253.00
$267.00
$242.00
$289.00
$417.00
$301.00
$501.00
$795.00
$492.00
$410.00
$305.00
$394.00
$961.00
$1,499.00
$2,444.00
$304.00
$662.00
$1,381.00
$1,644.00
$2,329.00
$529.00
$906.00
$1,050.00
$822.00
$258.00
$630.00
$774.00
$536.00
$698.00
$319.00
$903.00
$1,538.00
$1,762.00
$1,227.00
$1,892.00
$675.00
$487.00
$471.00
$605.00
$641.00
$894.00
$1,130.00
$792.00
$88.00
$540.00
$62.00
$119.00
$309.00
----$181.00
$529.00
$1,005.00
$204.00
$216.00
$193.00
$222.00
$280.00
$184.00
$399.00
$710.00
$441.00
$367.00
$273.00
$353.00
$861.00
$1,340.00
$2,184.00
$272.00
$593.00
$1,236.00
$1,470.00
$2,082.00
$472.00
$811.00
$935.00
$730.00
$231.00
$564.00
$693.00
$480.00
$624.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$341.00
$966.00
$1,642.00
$1,881.00
$1,311.00
$2,020.00
$720.00
$520.00
$503.00
$646.00
$691.00
$954.00
$1,218.00
$845.00
$92.00
$577.00
$66.00
$127.00
$330.00
----$193.00
$565.00
$1,074.00
$218.00
$231.00
$207.00
$237.00
$300.00
$197.00
$427.00
$759.00
$471.00
$392.00
$291.00
$377.00
$918.00
$1,430.00
$2,330.00
$291.00
$634.00
$1,319.00
$1,569.00
$2,222.00
$504.00
$866.00
$1,001.00
$782.00
$247.00
$602.00
$740.00
$512.00
$667.00
$357.00
$1,015.00
$1,723.00
$1,973.00
$1,375.00
$2,119.00
$755.00
$545.00
$526.00
$676.00
$729.00
$999.00
$1,287.00
$884.00
$96.00
$603.00
$70.00
$132.00
$345.00
----$202.00
$592.00
$1,126.00
$228.00
$241.00
$216.00
$248.00
$313.00
$206.00
$446.00
$795.00
$492.00
$410.00
$305.00
$394.00
$961.00
$1,499.00
$2,444.00
$304.00
$662.00
$1,381.00
$1,644.00
$2,329.00
$529.00
$906.00
$1,050.00
$822.00
$258.00
$630.00
$774.00
$536.00
$698.00
175
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
42972
42999
43020
43030
43045
43100
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
43123
43124
43130
43135
43200
43201
43202
43204
43205
43215
43216
43217
43219
43220
43226
43227
43228
43231
43232
43234
43235
43236
43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249
43250
43251
43255
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
$562.00
BR
$696.00
$712.00
$1,574.00
$744.00
$1,248.00
$2,325.00
$2,664.00
$2,471.00
$2,755.00
$2,509.00
$2,469.00
$2,607.00
$2,350.00
$2,287.00
$2,661.00
$2,242.00
$1,020.00
$1,332.00
$266.00
$245.00
$205.00
$228.00
$207.00
$160.00
$149.00
$176.00
$171.00
$128.00
$142.00
$218.00
$230.00
$182.00
$252.00
$193.00
$239.00
$285.00
$246.00
$369.00
$157.00
$384.00
$276.00
$268.00
$214.00
$485.00
$229.00
$191.00
$175.00
$194.00
$224.00
$343.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$667.00
----$767.00
$763.00
$1,690.00
$864.00
$1,353.00
$3,101.00
$2,735.00
$3,373.00
$2,856.00
$2,655.00
$3,070.00
$2,649.00
$2,341.00
$3,064.00
$2,696.00
$2,292.00
$1,091.00
$1,412.00
$475.00
$329.00
$407.00
$282.00
$283.00
$202.00
$188.00
$221.00
$219.00
$167.00
$182.00
$270.00
$289.00
$250.00
$344.00
$318.00
$413.00
$385.00
$454.00
$499.00
$195.00
$524.00
$334.00
$366.00
$847.00
$318.00
$250.00
$234.00
$217.00
$238.00
$273.00
$350.00
$712.00
----$821.00
$816.00
$1,821.00
$925.00
$1,460.00
$3,315.00
$2,950.00
$3,608.00
$3,092.00
$2,841.00
$3,287.00
$2,854.00
$2,530.00
$3,274.00
$2,915.00
$2,470.00
$1,170.00
$1,524.00
$510.00
$352.00
$436.00
$298.00
$299.00
$214.00
$199.00
$235.00
$232.00
$177.00
$193.00
$286.00
$308.00
$265.00
$365.00
$340.00
$442.00
$410.00
$484.00
$528.00
$206.00
$551.00
$352.00
$386.00
$908.00
$337.00
$265.00
$247.00
$229.00
$251.00
$288.00
$369.00
$747.00
----$864.00
$856.00
$1,932.00
$973.00
$1,552.00
$3,496.00
$3,138.00
$3,808.00
$3,300.00
$2,993.00
$3,474.00
$3,033.00
$2,698.00
$3,453.00
$3,108.00
$2,622.00
$1,232.00
$1,619.00
$529.00
$365.00
$453.00
$311.00
$311.00
$225.00
$209.00
$246.00
$243.00
$185.00
$201.00
$298.00
$323.00
$278.00
$382.00
$354.00
$459.00
$426.00
$503.00
$552.00
$215.00
$573.00
$367.00
$401.00
$941.00
$352.00
$276.00
$257.00
$239.00
$263.00
$301.00
$384.00
$667.00
----$767.00
$763.00
$1,690.00
$864.00
$1,353.00
$3,101.00
$2,735.00
$3,373.00
$2,856.00
$2,655.00
$3,070.00
$2,649.00
$2,341.00
$3,064.00
$2,696.00
$2,292.00
$1,091.00
$1,412.00
$144.00
$175.00
$158.00
$282.00
$283.00
$202.00
$188.00
$221.00
$219.00
$167.00
$182.00
$270.00
$289.00
$250.00
$344.00
$160.00
$180.00
$217.00
$213.00
$499.00
$195.00
$524.00
$334.00
$366.00
$237.00
$318.00
$250.00
$234.00
$217.00
$238.00
$273.00
$350.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$712.00
----$821.00
$816.00
$1,821.00
$925.00
$1,460.00
$3,315.00
$2,950.00
$3,608.00
$3,092.00
$2,841.00
$3,287.00
$2,854.00
$2,530.00
$3,274.00
$2,915.00
$2,470.00
$1,170.00
$1,524.00
$154.00
$185.00
$168.00
$298.00
$299.00
$214.00
$199.00
$235.00
$232.00
$177.00
$193.00
$286.00
$308.00
$265.00
$365.00
$170.00
$191.00
$229.00
$225.00
$528.00
$206.00
$551.00
$352.00
$386.00
$251.00
$337.00
$265.00
$247.00
$229.00
$251.00
$288.00
$369.00
$747.00
----$864.00
$856.00
$1,932.00
$973.00
$1,552.00
$3,496.00
$3,138.00
$3,808.00
$3,300.00
$2,993.00
$3,474.00
$3,033.00
$2,698.00
$3,453.00
$3,108.00
$2,622.00
$1,232.00
$1,619.00
$161.00
$194.00
$176.00
$311.00
$311.00
$225.00
$209.00
$246.00
$243.00
$185.00
$201.00
$298.00
$323.00
$278.00
$382.00
$178.00
$199.00
$239.00
$235.00
$552.00
$215.00
$573.00
$367.00
$401.00
$262.00
$352.00
$276.00
$257.00
$239.00
$263.00
$301.00
$384.00
176
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
43256
43258
43259
43260
43261
43262
43263
43264
43265
43267
43268
43269
43271
43272
43280
43289
43300
43305
43310
43312
43313
43314
43320
43324
43325
43326
43330
43331
43340
43341
43350
43351
43352
43360
43361
43400
43401
43405
43410
43415
43420
43425
43450
43453
43456
43458
43460
43496
43499
43500
43501
43502
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
90
YYY
90
90
90
$235.00
$276.00
$271.00
$349.00
$362.00
$447.00
$386.00
$522.00
$527.00
$434.00
$446.00
$410.00
$437.00
$401.00
$1,314.00
BR
$837.00
$1,428.00
$2,138.00
$2,331.00
$2,632.00
$2,891.00
$1,299.00
$1,280.00
$1,261.00
$1,198.00
$1,236.00
$1,378.00
$1,292.00
$1,351.00
$986.00
$1,180.00
$1,028.00
$2,277.00
$2,596.00
$1,261.00
$1,299.00
$1,330.00
$946.00
$1,382.00
$854.00
$1,338.00
$91.00
$102.00
$149.00
$164.00
$203.00
BR
BR
$649.00
$1,105.00
$1,247.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$320.00
$333.00
$355.00
$436.00
$458.00
$537.00
$527.00
$644.00
$720.00
$537.00
$537.00
$588.00
$537.00
$537.00
$1,380.00
----$868.00
$1,581.00
$2,196.00
$2,534.00
$3,683.00
$4,038.00
$1,613.00
$1,607.00
$1,595.00
$1,622.00
$1,557.00
$1,679.00
$1,601.00
$1,775.00
$1,363.00
$1,537.00
$1,323.00
$2,794.00
$3,158.00
$1,633.00
$1,726.00
$1,574.00
$1,186.00
$1,978.00
$1,211.00
$1,735.00
$141.00
$114.00
$189.00
$225.00
$278.00
--------$857.00
$1,526.00
$1,757.00
$338.00
$352.00
$374.00
$460.00
$483.00
$567.00
$555.00
$679.00
$759.00
$567.00
$567.00
$618.00
$567.00
$567.00
$1,485.00
----$931.00
$1,689.00
$2,378.00
$2,739.00
$3,983.00
$4,355.00
$1,724.00
$1,718.00
$1,705.00
$1,740.00
$1,662.00
$1,803.00
$1,710.00
$1,910.00
$1,454.00
$1,643.00
$1,416.00
$2,988.00
$3,381.00
$1,725.00
$1,843.00
$1,683.00
$1,270.00
$2,111.00
$1,287.00
$1,863.00
$150.00
$120.00
$200.00
$238.00
$294.00
--------$914.00
$1,629.00
$1,876.00
$353.00
$367.00
$390.00
$479.00
$504.00
$591.00
$576.00
$708.00
$789.00
$591.00
$591.00
$641.00
$590.00
$591.00
$1,575.00
----$981.00
$1,774.00
$2,535.00
$2,912.00
$4,247.00
$4,631.00
$1,815.00
$1,813.00
$1,797.00
$1,840.00
$1,749.00
$1,907.00
$1,799.00
$2,023.00
$1,526.00
$1,731.00
$1,491.00
$3,153.00
$3,571.00
$1,797.00
$1,941.00
$1,773.00
$1,338.00
$2,221.00
$1,345.00
$1,971.00
$156.00
$126.00
$209.00
$249.00
$307.00
--------$962.00
$1,715.00
$1,977.00
$320.00
$333.00
$355.00
$436.00
$458.00
$537.00
$527.00
$644.00
$720.00
$537.00
$537.00
$588.00
$537.00
$537.00
$1,380.00
----$868.00
$1,581.00
$2,196.00
$2,534.00
$3,683.00
$4,038.00
$1,613.00
$1,607.00
$1,595.00
$1,622.00
$1,557.00
$1,679.00
$1,601.00
$1,775.00
$1,363.00
$1,537.00
$1,323.00
$2,794.00
$3,158.00
$1,633.00
$1,726.00
$1,574.00
$1,186.00
$1,978.00
$1,211.00
$1,735.00
$104.00
$114.00
$189.00
$225.00
$278.00
--------$857.00
$1,526.00
$1,757.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$338.00
$352.00
$374.00
$460.00
$483.00
$567.00
$555.00
$679.00
$759.00
$567.00
$567.00
$618.00
$567.00
$567.00
$1,485.00
----$931.00
$1,689.00
$2,378.00
$2,739.00
$3,983.00
$4,355.00
$1,724.00
$1,718.00
$1,705.00
$1,740.00
$1,662.00
$1,803.00
$1,710.00
$1,910.00
$1,454.00
$1,643.00
$1,416.00
$2,988.00
$3,381.00
$1,725.00
$1,843.00
$1,683.00
$1,270.00
$2,111.00
$1,287.00
$1,863.00
$110.00
$120.00
$200.00
$238.00
$294.00
--------$914.00
$1,629.00
$1,876.00
$353.00
$367.00
$390.00
$479.00
$504.00
$591.00
$576.00
$708.00
$789.00
$591.00
$591.00
$641.00
$590.00
$591.00
$1,575.00
----$981.00
$1,774.00
$2,535.00
$2,912.00
$4,247.00
$4,631.00
$1,815.00
$1,813.00
$1,797.00
$1,840.00
$1,749.00
$1,907.00
$1,799.00
$2,023.00
$1,526.00
$1,731.00
$1,491.00
$3,153.00
$3,571.00
$1,797.00
$1,941.00
$1,773.00
$1,338.00
$2,221.00
$1,345.00
$1,971.00
$115.00
$126.00
$209.00
$249.00
$307.00
--------$962.00
$1,715.00
$1,977.00
177
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
43510
43520
43600
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
43635
43638
43639
43640
43641
43651
43652
43653
43659
43750
43752
43760
43761
43800
43810
43820
43825
43830
43831
43832
43840
43842
43843
43846
43847
43848
43850
43855
43860
43865
43870
43880
43999
44005
44010
44015
44020
44021
44025
90
90
0
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
YYY
10
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
90
ZZZ
90
90
90
$680.00
$599.00
$96.00
$686.00
$861.00
$1,001.00
$1,691.00
$1,718.00
$1,798.00
$1,445.00
$1,443.00
$1,467.00
$1,786.00
$143.00
$1,575.00
$1,605.00
$1,119.00
$1,138.00
$716.00
$856.00
$617.00
BR
$278.00
BR
$81.00
$107.00
$793.00
$846.00
$896.00
$1,128.00
$592.00
$593.00
$904.00
$893.00
$1,260.00
$1,249.00
$1,528.00
$1,678.00
$1,795.00
$1,425.00
$1,454.00
$1,435.00
$1,549.00
$590.00
$1,352.00
BR
$1,171.00
$809.00
$1,171.00
$891.00
$888.00
$905.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,082.00
$839.00
$153.00
$925.00
$1,133.00
$1,372.00
$2,276.00
$2,324.00
$2,452.00
$1,724.00
$1,725.00
$1,763.00
$1,911.00
$152.00
$2,176.00
$2,224.00
$1,319.00
$1,339.00
$800.00
$953.00
$645.00
----$375.00
----$129.00
$146.00
$1,071.00
$1,136.00
$1,188.00
$1,467.00
$763.00
$655.00
$1,220.00
$1,201.00
$1,572.00
$1,563.00
$1,980.00
$2,215.00
$2,407.00
$1,864.00
$1,967.00
$1,889.00
$2,000.00
$779.00
$1,884.00
----$1,256.00
$1,005.00
$192.00
$1,092.00
$1,117.00
$1,112.00
$1,153.00
$898.00
$162.00
$987.00
$1,210.00
$1,464.00
$2,428.00
$2,480.00
$2,615.00
$1,847.00
$1,848.00
$1,888.00
$2,045.00
$164.00
$2,321.00
$2,374.00
$1,413.00
$1,434.00
$861.00
$1,026.00
$694.00
----$400.00
----$138.00
$155.00
$1,143.00
$1,211.00
$1,267.00
$1,566.00
$813.00
$705.00
$1,301.00
$1,282.00
$1,681.00
$1,671.00
$2,117.00
$2,367.00
$2,573.00
$1,990.00
$2,099.00
$2,019.00
$2,137.00
$830.00
$2,011.00
----$1,344.00
$1,075.00
$206.00
$1,169.00
$1,195.00
$1,190.00
$1,209.00
$946.00
$169.00
$1,039.00
$1,274.00
$1,542.00
$2,556.00
$2,611.00
$2,754.00
$1,952.00
$1,954.00
$1,997.00
$2,161.00
$174.00
$2,445.00
$2,501.00
$1,494.00
$1,515.00
$913.00
$1,089.00
$735.00
----$420.00
----$144.00
$161.00
$1,204.00
$1,274.00
$1,334.00
$1,650.00
$854.00
$747.00
$1,367.00
$1,350.00
$1,769.00
$1,760.00
$2,229.00
$2,491.00
$2,709.00
$2,098.00
$2,210.00
$2,129.00
$2,254.00
$873.00
$2,119.00
----$1,419.00
$1,134.00
$219.00
$1,234.00
$1,260.00
$1,256.00
$1,082.00
$839.00
$153.00
$925.00
$1,133.00
$1,372.00
$2,276.00
$2,324.00
$2,452.00
$1,724.00
$1,725.00
$1,763.00
$1,911.00
$152.00
$2,176.00
$2,224.00
$1,319.00
$1,339.00
$800.00
$953.00
$645.00
----$375.00
----$82.00
$146.00
$1,071.00
$1,136.00
$1,188.00
$1,467.00
$763.00
$655.00
$1,220.00
$1,201.00
$1,572.00
$1,563.00
$1,980.00
$2,215.00
$2,407.00
$1,864.00
$1,967.00
$1,889.00
$2,000.00
$779.00
$1,884.00
----$1,256.00
$1,005.00
$192.00
$1,092.00
$1,117.00
$1,112.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,153.00
$898.00
$162.00
$987.00
$1,210.00
$1,464.00
$2,428.00
$2,480.00
$2,615.00
$1,847.00
$1,848.00
$1,888.00
$2,045.00
$164.00
$2,321.00
$2,374.00
$1,413.00
$1,434.00
$861.00
$1,026.00
$694.00
----$400.00
----$87.00
$155.00
$1,143.00
$1,211.00
$1,267.00
$1,566.00
$813.00
$705.00
$1,301.00
$1,282.00
$1,681.00
$1,671.00
$2,117.00
$2,367.00
$2,573.00
$1,990.00
$2,099.00
$2,019.00
$2,137.00
$830.00
$2,011.00
----$1,344.00
$1,075.00
$206.00
$1,169.00
$1,195.00
$1,190.00
$1,209.00
$946.00
$169.00
$1,039.00
$1,274.00
$1,542.00
$2,556.00
$2,611.00
$2,754.00
$1,952.00
$1,954.00
$1,997.00
$2,161.00
$174.00
$2,445.00
$2,501.00
$1,494.00
$1,515.00
$913.00
$1,089.00
$735.00
----$420.00
----$92.00
$161.00
$1,204.00
$1,274.00
$1,334.00
$1,650.00
$854.00
$747.00
$1,367.00
$1,350.00
$1,769.00
$1,760.00
$2,229.00
$2,491.00
$2,709.00
$2,098.00
$2,210.00
$2,129.00
$2,254.00
$873.00
$2,119.00
----$1,419.00
$1,134.00
$219.00
$1,234.00
$1,260.00
$1,256.00
178
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
44050
44055
44100
44110
44111
44120
44121
44125
44126
44127
44128
44130
44133
44136
44139
44140
44141
44143
44144
44145
44146
44147
44150
44151
44152
44153
44155
44156
44160
44200
44201
44202
44203
44204
44205
44206
44207
44208
44210
44211
44212
44238
44239
44300
44310
44312
44314
44316
44320
44322
44340
44345
90
90
0
90
90
90
ZZZ
90
90
90
ZZZ
90
0
0
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
YYY
YYY
90
90
90
90
90
90
90
90
90
$862.00
$957.00
$117.00
$784.00
$963.00
$1,078.00
$308.00
$1,135.00
$1,951.00
$2,243.00
$242.00
$938.00
BR
BR
$154.00
$1,350.00
$1,488.00
$1,536.00
$1,442.00
$1,678.00
$1,840.00
$1,452.00
$1,661.00
$1,499.00
$1,890.00
$2,110.00
$1,892.00
$1,709.00
$1,236.00
$1,046.00
$649.00
$1,603.00
$235.00
$1,353.00
$1,198.00
$1,480.00
$1,620.00
$1,752.00
$1,551.00
$1,926.00
$1,800.00
BR
BR
$697.00
$950.00
$453.00
$892.00
$1,229.00
$1,029.00
$1,015.00
$397.00
$816.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,092.00
$1,639.00
$160.00
$935.00
$1,140.00
$1,312.00
$329.00
$1,350.00
$2,673.00
$3,073.00
$337.00
$1,128.00
--------$164.00
$1,626.00
$1,604.00
$1,817.00
$1,677.00
$2,009.00
$2,165.00
$1,584.00
$1,931.00
$2,138.00
$2,133.00
$2,406.00
$2,207.00
$2,429.00
$1,442.00
$1,131.00
$780.00
$1,693.00
$329.00
$1,923.00
$1,703.00
$2,034.00
$2,227.00
$2,404.00
$2,129.00
$2,641.00
$2,469.00
--------$940.00
$1,210.00
$637.00
$1,147.00
$1,575.00
$1,351.00
$1,105.00
$636.00
$1,190.00
$1,167.00
$1,738.00
$170.00
$1,001.00
$1,221.00
$1,404.00
$355.00
$1,444.00
$2,788.00
$3,206.00
$362.00
$1,207.00
--------$176.00
$1,749.00
$1,724.00
$1,945.00
$1,796.00
$2,149.00
$2,313.00
$1,694.00
$2,066.00
$2,280.00
$2,282.00
$2,567.00
$2,358.00
$2,587.00
$1,551.00
$1,216.00
$838.00
$1,818.00
$355.00
$2,068.00
$1,831.00
$2,168.00
$2,373.00
$2,558.00
$2,269.00
$2,808.00
$2,628.00
--------$1,001.00
$1,288.00
$678.00
$1,219.00
$1,675.00
$1,439.00
$1,187.00
$678.00
$1,267.00
$1,231.00
$1,820.00
$178.00
$1,056.00
$1,288.00
$1,482.00
$377.00
$1,525.00
$2,866.00
$3,295.00
$385.00
$1,274.00
--------$186.00
$1,856.00
$1,826.00
$2,055.00
$1,897.00
$2,268.00
$2,437.00
$1,789.00
$2,180.00
$2,396.00
$2,409.00
$2,701.00
$2,485.00
$2,718.00
$1,645.00
$1,291.00
$888.00
$1,928.00
$377.00
$2,196.00
$1,944.00
$2,282.00
$2,498.00
$2,686.00
$2,387.00
$2,947.00
$2,760.00
--------$1,053.00
$1,354.00
$711.00
$1,279.00
$1,758.00
$1,513.00
$1,254.00
$712.00
$1,332.00
$1,092.00
$1,639.00
$160.00
$935.00
$1,140.00
$1,312.00
$329.00
$1,350.00
$2,673.00
$3,073.00
$337.00
$1,128.00
--------$164.00
$1,626.00
$1,604.00
$1,817.00
$1,677.00
$2,009.00
$2,165.00
$1,584.00
$1,931.00
$2,138.00
$2,133.00
$2,406.00
$2,207.00
$2,429.00
$1,442.00
$1,131.00
$780.00
$1,693.00
$329.00
$1,923.00
$1,703.00
$2,034.00
$2,227.00
$2,404.00
$2,129.00
$2,641.00
$2,469.00
--------$940.00
$1,210.00
$637.00
$1,147.00
$1,575.00
$1,351.00
$1,105.00
$636.00
$1,190.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,167.00
$1,738.00
$170.00
$1,001.00
$1,221.00
$1,404.00
$355.00
$1,444.00
$2,788.00
$3,206.00
$362.00
$1,207.00
--------$176.00
$1,749.00
$1,724.00
$1,945.00
$1,796.00
$2,149.00
$2,313.00
$1,694.00
$2,066.00
$2,280.00
$2,282.00
$2,567.00
$2,358.00
$2,587.00
$1,551.00
$1,216.00
$838.00
$1,818.00
$355.00
$2,068.00
$1,831.00
$2,168.00
$2,373.00
$2,558.00
$2,269.00
$2,808.00
$2,628.00
--------$1,001.00
$1,288.00
$678.00
$1,219.00
$1,675.00
$1,439.00
$1,187.00
$678.00
$1,267.00
$1,231.00
$1,820.00
$178.00
$1,056.00
$1,288.00
$1,482.00
$377.00
$1,525.00
$2,866.00
$3,295.00
$385.00
$1,274.00
--------$186.00
$1,856.00
$1,826.00
$2,055.00
$1,897.00
$2,268.00
$2,437.00
$1,789.00
$2,180.00
$2,396.00
$2,409.00
$2,701.00
$2,485.00
$2,718.00
$1,645.00
$1,291.00
$888.00
$1,928.00
$377.00
$2,196.00
$1,944.00
$2,282.00
$2,498.00
$2,686.00
$2,387.00
$2,947.00
$2,760.00
--------$1,053.00
$1,354.00
$711.00
$1,279.00
$1,758.00
$1,513.00
$1,254.00
$712.00
$1,332.00
179
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
44346
44360
44361
44363
44364
44365
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44382
44383
44385
44386
44388
44389
44390
44391
44392
44393
44394
44397
44500
44602
44603
44604
44605
44615
44620
44625
44626
44640
44650
44660
44661
44680
44700
44701
44799
44800
44820
44850
44899
44900
44901
44950
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
YYY
90
90
90
YYY
90
0
90
$923.00
$177.00
$195.00
$213.00
$255.00
$226.00
$300.00
$308.00
$253.00
$301.00
$238.00
$305.00
$320.00
$410.00
$396.00
$91.00
$110.00
$165.00
$219.00
$183.00
$326.00
$301.00
$319.00
$376.00
$359.00
$413.00
$395.00
$259.00
$28.00
$815.00
$1,041.00
$1,027.00
$1,132.00
$994.00
$741.00
$1,277.00
$1,581.00
$1,036.00
$1,076.00
$1,050.00
$1,326.00
$1,049.00
$1,115.00
$161.00
BR
$791.00
$755.00
$708.00
BR
$644.00
$310.00
$643.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,299.00
$205.00
$225.00
$268.00
$287.00
$257.00
$334.00
$340.00
$359.00
$336.00
$272.00
$395.00
$414.00
$528.00
$551.00
$96.00
$112.00
$225.00
$320.00
$408.00
$470.00
$522.00
$546.00
$525.00
$569.00
$639.00
$627.00
$355.00
$43.00
$1,198.00
$1,394.00
$1,223.00
$1,503.00
$1,226.00
$948.00
$1,157.00
$1,930.00
$1,612.00
$1,675.00
$1,564.00
$1,823.00
$1,186.00
$1,223.00
$221.00
----$904.00
$948.00
$854.00
----$801.00
$401.00
$779.00
$1,383.00
$218.00
$238.00
$284.00
$304.00
$273.00
$353.00
$359.00
$379.00
$357.00
$288.00
$418.00
$438.00
$558.00
$583.00
$102.00
$119.00
$238.00
$342.00
$437.00
$502.00
$558.00
$583.00
$559.00
$608.00
$681.00
$670.00
$377.00
$46.00
$1,273.00
$1,486.00
$1,310.00
$1,605.00
$1,313.00
$1,015.00
$1,238.00
$2,074.00
$1,714.00
$1,780.00
$1,655.00
$1,934.00
$1,270.00
$1,304.00
$235.00
----$972.00
$1,015.00
$916.00
----$857.00
$426.00
$834.00
$1,453.00
$227.00
$248.00
$297.00
$318.00
$285.00
$368.00
$375.00
$395.00
$374.00
$301.00
$437.00
$457.00
$583.00
$608.00
$108.00
$125.00
$248.00
$356.00
$455.00
$522.00
$579.00
$606.00
$581.00
$633.00
$709.00
$697.00
$394.00
$48.00
$1,336.00
$1,564.00
$1,385.00
$1,691.00
$1,387.00
$1,071.00
$1,308.00
$2,202.00
$1,800.00
$1,868.00
$1,729.00
$2,027.00
$1,343.00
$1,372.00
$247.00
----$1,030.00
$1,071.00
$968.00
----$903.00
$443.00
$881.00
$1,299.00
$205.00
$225.00
$268.00
$287.00
$257.00
$334.00
$340.00
$359.00
$336.00
$272.00
$395.00
$414.00
$528.00
$551.00
$96.00
$112.00
$225.00
$146.00
$169.00
$221.00
$242.00
$291.00
$316.00
$292.00
$364.00
$336.00
$355.00
$43.00
$1,198.00
$1,394.00
$1,223.00
$1,503.00
$1,226.00
$948.00
$1,157.00
$1,930.00
$1,612.00
$1,675.00
$1,564.00
$1,823.00
$1,186.00
$1,223.00
$221.00
----$904.00
$948.00
$854.00
----$801.00
$401.00
$779.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,383.00
$218.00
$238.00
$284.00
$304.00
$273.00
$353.00
$359.00
$379.00
$357.00
$288.00
$418.00
$438.00
$558.00
$583.00
$102.00
$119.00
$238.00
$155.00
$180.00
$234.00
$257.00
$308.00
$335.00
$309.00
$386.00
$356.00
$377.00
$46.00
$1,273.00
$1,486.00
$1,310.00
$1,605.00
$1,313.00
$1,015.00
$1,238.00
$2,074.00
$1,714.00
$1,780.00
$1,655.00
$1,934.00
$1,270.00
$1,304.00
$235.00
----$972.00
$1,015.00
$916.00
----$857.00
$426.00
$834.00
$1,453.00
$227.00
$248.00
$297.00
$318.00
$285.00
$368.00
$375.00
$395.00
$374.00
$301.00
$437.00
$457.00
$583.00
$608.00
$108.00
$125.00
$248.00
$163.00
$189.00
$246.00
$269.00
$323.00
$349.00
$324.00
$403.00
$373.00
$394.00
$48.00
$1,336.00
$1,564.00
$1,385.00
$1,691.00
$1,387.00
$1,071.00
$1,308.00
$2,202.00
$1,800.00
$1,868.00
$1,729.00
$2,027.00
$1,343.00
$1,372.00
$247.00
----$1,030.00
$1,071.00
$968.00
----$903.00
$443.00
$881.00
180
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
44955
44960
44970
44979
45000
45005
45020
45100
45108
45110
45111
45112
45113
45114
45116
45119
45120
45121
45123
45126
45130
45135
45136
45150
45160
45170
45190
45300
45303
45305
45307
45308
45309
45315
45317
45320
45321
45327
45330
45331
45332
45333
45334
45335
45337
45338
45339
45340
45341
45342
45345
45355
ZZZ
90
90
YYY
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
$136.00
$790.00
$631.00
BR
$329.00
$197.00
$364.00
$321.00
$419.00
$1,801.00
$1,270.00
$1,904.00
$1,885.00
$1,732.00
$1,485.00
$1,911.00
$1,845.00
$1,870.00
$1,126.00
$2,444.00
$1,041.00
$1,354.00
$1,526.00
$475.00
$949.00
$697.00
$623.00
$75.00
$72.00
$102.00
$172.00
$137.00
$174.00
$211.00
$209.00
$230.00
$154.00
$96.00
$87.00
$120.00
$174.00
$176.00
$171.00
$144.00
$144.00
$212.00
$237.00
$328.00
$153.00
$224.00
$164.00
$185.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$114.00
$960.00
$700.00
----$401.00
$331.00
$428.00
$328.00
$416.00
$2,163.00
$1,290.00
$2,275.00
$2,307.00
$2,066.00
$1,862.00
$2,313.00
$1,886.00
$2,084.00
$1,249.00
$3,424.00
$1,236.00
$1,483.00
$2,148.00
$465.00
$1,169.00
$898.00
$788.00
$87.00
$103.00
$134.00
$180.00
$124.00
$228.00
$208.00
$178.00
$180.00
$95.00
$131.00
$140.00
$171.00
$290.00
$272.00
$200.00
$194.00
$175.00
$336.00
$328.00
$438.00
$210.00
$307.00
$225.00
$254.00
$123.00
$1,028.00
$753.00
----$429.00
$356.00
$459.00
$351.00
$447.00
$2,311.00
$1,385.00
$2,426.00
$2,455.00
$2,208.00
$1,990.00
$2,461.00
$2,023.00
$2,239.00
$1,326.00
$3,646.00
$1,315.00
$1,584.00
$2,309.00
$497.00
$1,245.00
$958.00
$841.00
$94.00
$111.00
$143.00
$195.00
$135.00
$245.00
$225.00
$193.00
$195.00
$103.00
$139.00
$149.00
$183.00
$310.00
$291.00
$212.00
$207.00
$185.00
$359.00
$348.00
$469.00
$225.00
$325.00
$238.00
$271.00
$131.00
$1,086.00
$798.00
----$451.00
$372.00
$483.00
$370.00
$472.00
$2,436.00
$1,468.00
$2,556.00
$2,579.00
$2,331.00
$2,099.00
$2,586.00
$2,141.00
$2,374.00
$1,389.00
$3,833.00
$1,381.00
$1,668.00
$2,448.00
$523.00
$1,307.00
$1,009.00
$885.00
$98.00
$116.00
$150.00
$205.00
$143.00
$257.00
$237.00
$204.00
$206.00
$111.00
$146.00
$155.00
$191.00
$322.00
$303.00
$222.00
$215.00
$194.00
$374.00
$363.00
$485.00
$236.00
$340.00
$248.00
$285.00
$114.00
$960.00
$700.00
----$401.00
$188.00
$428.00
$328.00
$416.00
$2,163.00
$1,290.00
$2,275.00
$2,307.00
$2,066.00
$1,862.00
$2,313.00
$1,886.00
$2,084.00
$1,249.00
$3,424.00
$1,236.00
$1,483.00
$2,148.00
$465.00
$1,169.00
$898.00
$788.00
$34.00
$39.00
$78.00
$77.00
$69.00
$150.00
$112.00
$119.00
$125.00
$95.00
$131.00
$77.00
$88.00
$134.00
$134.00
$200.00
$105.00
$175.00
$174.00
$229.00
$125.00
$210.00
$307.00
$225.00
$254.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$123.00
$1,028.00
$753.00
----$429.00
$202.00
$459.00
$351.00
$447.00
$2,311.00
$1,385.00
$2,426.00
$2,455.00
$2,208.00
$1,990.00
$2,461.00
$2,023.00
$2,239.00
$1,326.00
$3,646.00
$1,315.00
$1,584.00
$2,309.00
$497.00
$1,245.00
$958.00
$841.00
$36.00
$42.00
$84.00
$85.00
$76.00
$161.00
$122.00
$129.00
$135.00
$103.00
$139.00
$81.00
$94.00
$142.00
$143.00
$212.00
$111.00
$185.00
$184.00
$242.00
$132.00
$225.00
$325.00
$238.00
$271.00
$131.00
$1,086.00
$798.00
----$451.00
$213.00
$483.00
$370.00
$472.00
$2,436.00
$1,468.00
$2,556.00
$2,579.00
$2,331.00
$2,099.00
$2,586.00
$2,141.00
$2,374.00
$1,389.00
$3,833.00
$1,381.00
$1,668.00
$2,448.00
$523.00
$1,307.00
$1,009.00
$885.00
$39.00
$45.00
$89.00
$91.00
$81.00
$170.00
$131.00
$138.00
$144.00
$111.00
$146.00
$85.00
$98.00
$149.00
$150.00
$222.00
$115.00
$194.00
$193.00
$253.00
$137.00
$236.00
$340.00
$248.00
$285.00
181
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
45378
45379
45380
45381
45382
45383
45384
45385
45386
45387
45500
45505
45520
45540
45541
45550
45560
45562
45563
45800
45805
45820
45825
45900
45905
45910
45915
45999
46020
46030
46040
46045
46050
46060
46080
46083
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
46270
46275
46280
0
0
0
0
0
0
0
0
0
0
90
90
0
90
90
90
90
90
90
90
90
90
90
10
10
10
10
YYY
10
10
90
90
10
90
10
10
90
90
90
10
10
10
90
90
90
90
90
90
90
90
90
90
$341.00
$415.00
$369.00
$388.00
$481.00
$482.00
$415.00
$479.00
$739.00
$322.00
$584.00
$510.00
$46.00
$1,009.00
$888.00
$1,350.00
$618.00
$915.00
$1,412.00
$1,050.00
$1,273.00
$1,066.00
$1,241.00
$120.00
$133.00
$163.00
$142.00
BR
$230.00
$94.00
$393.00
$312.00
$105.00
$482.00
$246.00
$98.00
$323.00
$196.00
$353.00
$118.00
$124.00
$198.00
$400.00
$501.00
$504.00
$539.00
$598.00
$655.00
$686.00
$328.00
$442.00
$514.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$590.00
$658.00
$649.00
$524.00
$777.00
$771.00
$694.00
$735.00
$989.00
$441.00
$604.00
$593.00
$68.00
$1,278.00
$1,060.00
$1,752.00
$866.00
$1,203.00
$1,829.00
$1,352.00
$1,622.00
$1,401.00
$1,624.00
$192.00
$683.00
$923.00
$395.00
----$312.00
$215.00
$540.00
$378.00
$238.00
$500.00
$316.00
$305.00
$378.00
$398.00
$491.00
$149.00
$194.00
$351.00
$483.00
$557.00
$458.00
$485.00
$555.00
$598.00
$634.00
$454.00
$482.00
$513.00
$630.00
$702.00
$692.00
$558.00
$828.00
$822.00
$740.00
$784.00
$1,057.00
$467.00
$645.00
$631.00
$72.00
$1,362.00
$1,128.00
$1,865.00
$922.00
$1,283.00
$1,953.00
$1,436.00
$1,728.00
$1,488.00
$1,715.00
$204.00
$732.00
$989.00
$421.00
----$334.00
$231.00
$581.00
$405.00
$256.00
$537.00
$339.00
$328.00
$406.00
$428.00
$526.00
$160.00
$206.00
$376.00
$520.00
$600.00
$494.00
$523.00
$598.00
$643.00
$682.00
$488.00
$517.00
$549.00
$655.00
$730.00
$718.00
$580.00
$860.00
$855.00
$768.00
$815.00
$1,095.00
$488.00
$678.00
$662.00
$76.00
$1,431.00
$1,182.00
$1,958.00
$967.00
$1,349.00
$2,057.00
$1,506.00
$1,814.00
$1,560.00
$1,786.00
$214.00
$759.00
$1,024.00
$438.00
----$349.00
$241.00
$611.00
$428.00
$267.00
$566.00
$356.00
$341.00
$426.00
$449.00
$552.00
$168.00
$215.00
$394.00
$548.00
$632.00
$524.00
$556.00
$634.00
$680.00
$722.00
$513.00
$543.00
$578.00
$283.00
$353.00
$334.00
$307.00
$412.00
$437.00
$353.00
$397.00
$333.00
$441.00
$604.00
$593.00
$39.00
$1,278.00
$1,060.00
$1,752.00
$866.00
$1,203.00
$1,829.00
$1,352.00
$1,622.00
$1,401.00
$1,624.00
$192.00
$170.00
$204.00
$222.00
----$276.00
$127.00
$429.00
$378.00
$131.00
$500.00
$218.00
$153.00
$306.00
$257.00
$378.00
$114.00
$162.00
$224.00
$352.00
$404.00
$458.00
$485.00
$555.00
$598.00
$634.00
$335.00
$389.00
$513.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$299.00
$374.00
$353.00
$325.00
$435.00
$463.00
$374.00
$421.00
$352.00
$467.00
$645.00
$631.00
$42.00
$1,362.00
$1,128.00
$1,865.00
$922.00
$1,283.00
$1,953.00
$1,436.00
$1,728.00
$1,488.00
$1,715.00
$204.00
$181.00
$216.00
$235.00
----$295.00
$136.00
$461.00
$405.00
$141.00
$537.00
$234.00
$164.00
$328.00
$276.00
$405.00
$122.00
$172.00
$240.00
$380.00
$436.00
$494.00
$523.00
$598.00
$643.00
$682.00
$360.00
$417.00
$549.00
$313.00
$390.00
$368.00
$339.00
$453.00
$484.00
$390.00
$439.00
$366.00
$488.00
$678.00
$662.00
$44.00
$1,431.00
$1,182.00
$1,958.00
$967.00
$1,349.00
$2,057.00
$1,506.00
$1,814.00
$1,560.00
$1,786.00
$214.00
$189.00
$225.00
$246.00
----$309.00
$143.00
$487.00
$428.00
$148.00
$566.00
$247.00
$172.00
$345.00
$291.00
$426.00
$130.00
$180.00
$252.00
$403.00
$462.00
$524.00
$556.00
$634.00
$680.00
$722.00
$380.00
$440.00
$578.00
182
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
46285
46288
46320
46500
46600
46604
46606
46608
46610
46611
46612
46614
46615
46700
46706
46715
46716
46730
46735
46740
46742
46744
46746
46748
46750
46753
46754
46760
46761
46762
46900
46910
46916
46917
46922
46924
46934
46935
46936
46937
46938
46940
46942
46945
46946
46999
47000
47001
47010
47011
47015
47100
90
90
10
10
0
0
0
0
0
0
0
0
0
90
0
90
90
90
90
90
90
90
90
90
90
90
10
90
90
90
10
10
10
10
10
10
90
10
90
10
90
10
10
90
90
YYY
0
ZZZ
90
0
90
90
$335.00
$521.00
$126.00
$109.00
$38.00
$92.00
$66.00
$115.00
$114.00
$149.00
$196.00
$169.00
$202.00
$585.00
$140.00
$545.00
$906.00
$1,584.00
$1,881.00
$1,671.00
$2,236.00
$2,412.00
$2,725.00
$2,933.00
$636.00
$511.00
$188.00
$846.00
$813.00
$731.00
$128.00
$144.00
$145.00
$228.00
$189.00
$297.00
$249.00
$202.00
$316.00
$268.00
$405.00
$165.00
$145.00
$199.00
$270.00
BR
$218.00
$141.00
$788.00
$347.00
$755.00
$550.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$426.00
$601.00
$278.00
$221.00
$67.00
$118.00
$88.00
$173.00
$143.00
$198.00
$249.00
$197.00
$234.00
$721.00
$191.00
$617.00
$1,201.00
$2,071.00
$2,473.00
$2,247.00
$2,846.00
$3,835.00
$4,349.00
$4,659.00
$834.00
$649.00
$383.00
$1,125.00
$1,070.00
$963.00
$272.00
$285.00
$263.00
$334.00
$293.00
$400.00
$497.00
$339.00
$493.00
$358.00
$505.00
$281.00
$251.00
$295.00
$387.00
----$503.00
$140.00
$1,317.00
$410.00
$1,197.00
$942.00
$456.00
$643.00
$298.00
$236.00
$71.00
$126.00
$94.00
$186.00
$154.00
$212.00
$266.00
$210.00
$250.00
$766.00
$204.00
$665.00
$1,286.00
$2,210.00
$2,643.00
$2,389.00
$3,034.00
$4,043.00
$4,587.00
$4,911.00
$888.00
$692.00
$410.00
$1,194.00
$1,136.00
$1,020.00
$291.00
$305.00
$280.00
$358.00
$314.00
$428.00
$532.00
$363.00
$528.00
$381.00
$541.00
$300.00
$268.00
$317.00
$415.00
----$538.00
$150.00
$1,390.00
$436.00
$1,269.00
$1,001.00
$479.00
$678.00
$312.00
$247.00
$75.00
$132.00
$99.00
$195.00
$162.00
$223.00
$278.00
$220.00
$264.00
$802.00
$214.00
$704.00
$1,357.00
$2,325.00
$2,788.00
$2,507.00
$3,189.00
$4,208.00
$4,773.00
$5,112.00
$931.00
$726.00
$425.00
$1,249.00
$1,189.00
$1,067.00
$303.00
$318.00
$291.00
$374.00
$328.00
$446.00
$555.00
$378.00
$552.00
$395.00
$568.00
$314.00
$280.00
$331.00
$434.00
----$557.00
$159.00
$1,445.00
$453.00
$1,327.00
$1,049.00
$354.00
$601.00
$165.00
$116.00
$35.00
$94.00
$59.00
$107.00
$97.00
$132.00
$170.00
$144.00
$195.00
$721.00
$191.00
$617.00
$1,201.00
$2,071.00
$2,473.00
$2,247.00
$2,846.00
$3,835.00
$4,349.00
$4,659.00
$834.00
$649.00
$185.00
$1,125.00
$1,070.00
$963.00
$141.00
$174.00
$181.00
$178.00
$174.00
$234.00
$368.00
$175.00
$372.00
$229.00
$418.00
$167.00
$145.00
$208.00
$263.00
----$133.00
$140.00
$1,317.00
$410.00
$1,197.00
$942.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$379.00
$643.00
$177.00
$124.00
$37.00
$100.00
$63.00
$115.00
$104.00
$141.00
$181.00
$153.00
$209.00
$766.00
$204.00
$665.00
$1,286.00
$2,210.00
$2,643.00
$2,389.00
$3,034.00
$4,043.00
$4,587.00
$4,911.00
$888.00
$692.00
$196.00
$1,194.00
$1,136.00
$1,020.00
$150.00
$185.00
$192.00
$191.00
$187.00
$250.00
$393.00
$186.00
$398.00
$242.00
$448.00
$178.00
$154.00
$224.00
$282.00
----$140.00
$150.00
$1,390.00
$436.00
$1,269.00
$1,001.00
$399.00
$678.00
$186.00
$131.00
$39.00
$105.00
$67.00
$121.00
$110.00
$149.00
$191.00
$161.00
$221.00
$802.00
$214.00
$704.00
$1,357.00
$2,325.00
$2,788.00
$2,507.00
$3,189.00
$4,208.00
$4,773.00
$5,112.00
$931.00
$726.00
$204.00
$1,249.00
$1,189.00
$1,067.00
$157.00
$195.00
$199.00
$200.00
$197.00
$262.00
$411.00
$196.00
$418.00
$252.00
$472.00
$187.00
$162.00
$235.00
$296.00
----$146.00
$159.00
$1,445.00
$453.00
$1,327.00
$1,049.00
183
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
47120
47122
47125
47130
47134
47135
47136
47300
47350
47360
47361
47362
47370
47371
47379
47380
47381
47382
47399
47400
47420
47425
47460
47480
47490
47500
47505
47510
47511
47525
47530
47550
47552
47553
47554
47555
47556
47560
47561
47562
47563
47564
47570
47579
47600
47605
47610
47612
47620
47630
47700
47701
90
90
90
90
0
90
90
90
90
90
90
90
90
90
YYY
90
90
10
YYY
90
90
90
90
90
90
0
0
90
90
10
90
ZZZ
0
0
0
0
0
0
0
90
90
90
90
YYY
90
90
90
90
90
90
90
90
$1,663.00
$2,512.00
$2,293.00
$2,482.00
$2,711.00
$6,164.00
$4,985.00
$778.00
$942.00
$1,305.00
$2,129.00
$849.00
$943.00
$889.00
BR
$1,107.00
$1,094.00
$660.00
BR
$1,435.00
$1,222.00
$1,275.00
$1,039.00
$755.00
$467.00
$103.00
$96.00
$487.00
$627.00
$295.00
$35.00
$209.00
$364.00
$342.00
$594.00
$383.00
$425.00
$345.00
$388.00
$837.00
$900.00
$1,069.00
$961.00
BR
$868.00
$935.00
$1,164.00
$1,276.00
$1,295.00
$465.00
$1,111.00
$1,913.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,738.00
$4,144.00
$3,721.00
$4,020.00
$2,886.00
$6,694.00
$5,934.00
$1,187.00
$1,512.00
$2,073.00
$3,522.00
$1,474.00
$1,518.00
$1,518.00
----$1,747.00
$1,766.00
$1,141.00
----$2,453.00
$1,555.00
$1,549.00
$1,423.00
$919.00
$749.00
$136.00
$169.00
$645.00
$1,063.00
$453.00
$553.00
$222.00
$450.00
$467.00
$671.00
$551.00
$620.00
$367.00
$396.00
$875.00
$935.00
$1,105.00
$983.00
----$1,082.00
$1,162.00
$1,468.00
$1,459.00
$1,596.00
$637.00
$1,290.00
$2,228.00
$2,910.00
$4,404.00
$3,954.00
$4,271.00
$3,104.00
$7,197.00
$6,382.00
$1,262.00
$1,607.00
$2,202.00
$3,744.00
$1,568.00
$1,602.00
$1,602.00
----$1,839.00
$1,859.00
$1,217.00
----$2,600.00
$1,664.00
$1,655.00
$1,515.00
$982.00
$795.00
$144.00
$181.00
$682.00
$1,128.00
$478.00
$587.00
$238.00
$478.00
$493.00
$717.00
$582.00
$654.00
$395.00
$425.00
$941.00
$1,006.00
$1,188.00
$1,057.00
----$1,158.00
$1,243.00
$1,571.00
$1,561.00
$1,708.00
$673.00
$1,383.00
$2,401.00
$3,050.00
$4,620.00
$4,146.00
$4,480.00
$3,299.00
$7,623.00
$6,754.00
$1,323.00
$1,684.00
$2,308.00
$3,928.00
$1,643.00
$1,667.00
$1,667.00
----$1,909.00
$1,929.00
$1,281.00
----$2,718.00
$1,756.00
$1,744.00
$1,590.00
$1,033.00
$827.00
$150.00
$187.00
$710.00
$1,172.00
$497.00
$611.00
$253.00
$503.00
$514.00
$756.00
$606.00
$681.00
$419.00
$450.00
$998.00
$1,067.00
$1,261.00
$1,122.00
----$1,222.00
$1,311.00
$1,659.00
$1,648.00
$1,803.00
$703.00
$1,460.00
$2,552.00
$2,738.00
$4,144.00
$3,721.00
$4,020.00
$2,886.00
$6,694.00
$5,934.00
$1,187.00
$1,512.00
$2,073.00
$3,522.00
$1,474.00
$1,518.00
$1,518.00
----$1,747.00
$1,766.00
$1,141.00
----$2,453.00
$1,555.00
$1,549.00
$1,423.00
$919.00
$749.00
$136.00
$53.00
$645.00
$1,063.00
$453.00
$553.00
$222.00
$450.00
$467.00
$671.00
$551.00
$620.00
$367.00
$396.00
$875.00
$935.00
$1,105.00
$983.00
----$1,082.00
$1,162.00
$1,468.00
$1,459.00
$1,596.00
$637.00
$1,290.00
$2,228.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,910.00
$4,404.00
$3,954.00
$4,271.00
$3,104.00
$7,197.00
$6,382.00
$1,262.00
$1,607.00
$2,202.00
$3,744.00
$1,568.00
$1,602.00
$1,602.00
----$1,839.00
$1,859.00
$1,217.00
----$2,600.00
$1,664.00
$1,655.00
$1,515.00
$982.00
$795.00
$144.00
$56.00
$682.00
$1,128.00
$478.00
$587.00
$238.00
$478.00
$493.00
$717.00
$582.00
$654.00
$395.00
$425.00
$941.00
$1,006.00
$1,188.00
$1,057.00
----$1,158.00
$1,243.00
$1,571.00
$1,561.00
$1,708.00
$673.00
$1,383.00
$2,401.00
$3,050.00
$4,620.00
$4,146.00
$4,480.00
$3,299.00
$7,623.00
$6,754.00
$1,323.00
$1,684.00
$2,308.00
$3,928.00
$1,643.00
$1,667.00
$1,667.00
----$1,909.00
$1,929.00
$1,281.00
----$2,718.00
$1,756.00
$1,744.00
$1,590.00
$1,033.00
$827.00
$150.00
$58.00
$710.00
$1,172.00
$497.00
$611.00
$253.00
$503.00
$514.00
$756.00
$606.00
$681.00
$419.00
$450.00
$998.00
$1,067.00
$1,261.00
$1,122.00
----$1,222.00
$1,311.00
$1,659.00
$1,648.00
$1,803.00
$703.00
$1,460.00
$2,552.00
184
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
47711
47712
47715
47716
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900
47999
48000
48001
48005
48020
48100
48102
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48160
48180
48400
48500
48510
48511
48520
48540
48545
48547
48554
48556
48999
49000
49002
49010
49020
49021
49040
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
90
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
0
90
ZZZ
90
90
0
90
90
90
90
90
90
YYY
90
90
90
90
0
90
$1,442.00
$1,793.00
$1,157.00
$989.00
$1,040.00
$1,248.00
$1,188.00
$1,425.00
$1,568.00
$1,624.00
$1,635.00
$1,871.00
$1,485.00
$906.00
$1,352.00
$1,331.00
BR
$1,053.00
$1,305.00
$1,533.00
$983.00
$779.00
$341.00
$1,083.00
$1,546.00
$1,661.00
$1,830.00
$1,149.00
$3,101.00
$2,888.00
$3,099.00
$2,893.00
$1,855.00
BR
$1,616.00
$100.00
$1,012.00
$938.00
$286.00
$1,103.00
$1,350.00
$1,170.00
$1,630.00
$2,365.00
$1,117.00
BR
$862.00
$784.00
$915.00
$910.00
$290.00
$763.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,822.00
$2,356.00
$1,474.00
$1,317.00
$1,301.00
$1,534.00
$1,489.00
$1,693.00
$2,023.00
$1,994.00
$2,071.00
$2,447.00
$1,840.00
$1,295.00
$1,744.00
$1,590.00
----$2,100.00
$2,620.00
$3,092.00
$1,236.00
$1,017.00
$679.00
$1,242.00
$1,802.00
$1,897.00
$2,131.00
$1,413.00
$3,740.00
$3,448.00
$3,743.00
$3,462.00
$2,044.00
----$1,916.00
$137.00
$1,208.00
$1,153.00
$393.00
$1,226.00
$1,529.00
$1,441.00
$1,973.00
$2,512.00
$1,300.00
----$958.00
$886.00
$1,034.00
$1,788.00
$437.00
$1,133.00
$1,950.00
$2,524.00
$1,577.00
$1,409.00
$1,393.00
$1,642.00
$1,594.00
$1,812.00
$2,165.00
$2,135.00
$2,217.00
$2,619.00
$1,968.00
$1,371.00
$1,867.00
$1,700.00
----$2,218.00
$2,773.00
$3,272.00
$1,324.00
$1,090.00
$723.00
$1,329.00
$1,933.00
$2,036.00
$2,286.00
$1,516.00
$4,011.00
$3,699.00
$4,013.00
$3,714.00
$2,193.00
----$2,053.00
$145.00
$1,294.00
$1,230.00
$417.00
$1,314.00
$1,639.00
$1,543.00
$2,113.00
$2,698.00
$1,396.00
----$1,030.00
$953.00
$1,111.00
$1,896.00
$466.00
$1,204.00
$2,059.00
$2,667.00
$1,664.00
$1,487.00
$1,469.00
$1,732.00
$1,682.00
$1,912.00
$2,285.00
$2,255.00
$2,340.00
$2,765.00
$2,076.00
$1,426.00
$1,969.00
$1,792.00
----$2,311.00
$2,897.00
$3,419.00
$1,398.00
$1,150.00
$750.00
$1,403.00
$2,045.00
$2,154.00
$2,416.00
$1,603.00
$4,244.00
$3,914.00
$4,245.00
$3,930.00
$2,318.00
----$2,172.00
$151.00
$1,367.00
$1,293.00
$433.00
$1,389.00
$1,735.00
$1,630.00
$2,234.00
$2,863.00
$1,477.00
----$1,091.00
$1,009.00
$1,176.00
$1,983.00
$484.00
$1,260.00
$1,822.00
$2,356.00
$1,474.00
$1,317.00
$1,301.00
$1,534.00
$1,489.00
$1,693.00
$2,023.00
$1,994.00
$2,071.00
$2,447.00
$1,840.00
$1,295.00
$1,744.00
$1,590.00
----$2,100.00
$2,620.00
$3,092.00
$1,236.00
$1,017.00
$364.00
$1,242.00
$1,802.00
$1,897.00
$2,131.00
$1,413.00
$3,740.00
$3,448.00
$3,743.00
$3,462.00
$2,044.00
----$1,916.00
$137.00
$1,208.00
$1,153.00
$393.00
$1,226.00
$1,529.00
$1,441.00
$1,973.00
$2,512.00
$1,300.00
----$958.00
$886.00
$1,034.00
$1,788.00
$437.00
$1,133.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,950.00
$2,524.00
$1,577.00
$1,409.00
$1,393.00
$1,642.00
$1,594.00
$1,812.00
$2,165.00
$2,135.00
$2,217.00
$2,619.00
$1,968.00
$1,371.00
$1,867.00
$1,700.00
----$2,218.00
$2,773.00
$3,272.00
$1,324.00
$1,090.00
$384.00
$1,329.00
$1,933.00
$2,036.00
$2,286.00
$1,516.00
$4,011.00
$3,699.00
$4,013.00
$3,714.00
$2,193.00
----$2,053.00
$145.00
$1,294.00
$1,230.00
$417.00
$1,314.00
$1,639.00
$1,543.00
$2,113.00
$2,698.00
$1,396.00
----$1,030.00
$953.00
$1,111.00
$1,896.00
$466.00
$1,204.00
$2,059.00
$2,667.00
$1,664.00
$1,487.00
$1,469.00
$1,732.00
$1,682.00
$1,912.00
$2,285.00
$2,255.00
$2,340.00
$2,765.00
$2,076.00
$1,426.00
$1,969.00
$1,792.00
----$2,311.00
$2,897.00
$3,419.00
$1,398.00
$1,150.00
$400.00
$1,403.00
$2,045.00
$2,154.00
$2,416.00
$1,603.00
$4,244.00
$3,914.00
$4,245.00
$3,930.00
$2,318.00
----$2,172.00
$151.00
$1,367.00
$1,293.00
$433.00
$1,389.00
$1,735.00
$1,630.00
$2,234.00
$2,863.00
$1,477.00
----$1,091.00
$1,009.00
$1,176.00
$1,983.00
$484.00
$1,260.00
185
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
49041
49060
49061
49062
49080
49081
49085
49180
49200
49201
49215
49220
49250
49255
49320
49321
49322
49323
49329
49400
49419
49420
49421
49422
49423
49424
49425
49426
49427
49428
49429
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560
49561
49565
49566
49568
49570
49572
49585
49587
49590
49600
0
$305.00
90
$827.00
0
$288.00
90
$892.00
0
$123.00
0
$98.00
90
$632.00
0
$212.00
90
$823.00
90 $1,180.00
90 $1,551.00
90 $1,182.00
90
$622.00
90
$591.00
10
$415.00
10
$443.00
10
$460.00
90
$712.00
YYY
BR
0
$127.00
0
$405.00
0
$162.00
90
$452.00
10
$468.00
0
$106.00
0
$54.00
90
$914.00
90
$725.00
0
$48.00
10
$184.00
10
$522.00
90
$510.00
90
$636.00
90
$631.00
90
$730.00
90
$584.00
90
$668.00
90
$557.00
90
$598.00
90
$621.00
90
$715.00
90
$734.00
90
$856.00
90
$754.00
90
$881.00
ZZZ $339.00
90
$411.00
90
$491.00
90
$444.00
90
$501.00
90
$585.00
90
$774.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$486.00
$1,313.00
$471.00
$985.00
$286.00
$217.00
$987.00
$493.00
$880.00
$1,258.00
$2,562.00
$1,217.00
$721.00
$949.00
$435.00
$451.00
$490.00
$730.00
----$141.00
$555.00
$167.00
$512.00
$498.00
$111.00
$62.00
$976.00
$840.00
$71.00
$478.00
$592.00
$642.00
$827.00
$798.00
$946.00
$714.00
$849.00
$698.00
$764.00
$757.00
$887.00
$936.00
$1,114.00
$944.00
$1,125.00
$361.00
$485.00
$566.00
$544.00
$624.00
$713.00
$920.00
$517.00
$1,390.00
$501.00
$1,058.00
$306.00
$231.00
$1,052.00
$527.00
$943.00
$1,352.00
$2,731.00
$1,309.00
$776.00
$1,020.00
$468.00
$485.00
$527.00
$783.00
----$149.00
$594.00
$177.00
$550.00
$535.00
$117.00
$65.00
$1,051.00
$902.00
$76.00
$506.00
$638.00
$688.00
$886.00
$855.00
$1,012.00
$764.00
$909.00
$747.00
$818.00
$811.00
$950.00
$1,002.00
$1,192.00
$1,010.00
$1,205.00
$389.00
$520.00
$606.00
$583.00
$668.00
$764.00
$990.00
$536.00
$1,448.00
$520.00
$1,117.00
$318.00
$240.00
$1,105.00
$546.00
$995.00
$1,431.00
$2,873.00
$1,388.00
$821.00
$1,080.00
$495.00
$513.00
$557.00
$828.00
----$156.00
$626.00
$186.00
$581.00
$567.00
$122.00
$67.00
$1,114.00
$953.00
$79.00
$528.00
$679.00
$725.00
$934.00
$902.00
$1,069.00
$806.00
$959.00
$788.00
$864.00
$855.00
$1,003.00
$1,057.00
$1,259.00
$1,066.00
$1,272.00
$413.00
$548.00
$639.00
$614.00
$705.00
$806.00
$1,049.00
$486.00
$1,313.00
$471.00
$985.00
$95.00
$95.00
$987.00
$121.00
$880.00
$1,258.00
$2,562.00
$1,217.00
$721.00
$949.00
$435.00
$451.00
$490.00
$730.00
----$141.00
$555.00
$167.00
$512.00
$498.00
$111.00
$62.00
$976.00
$840.00
$71.00
$478.00
$592.00
$619.00
$827.00
$798.00
$946.00
$714.00
$849.00
$698.00
$764.00
$757.00
$887.00
$936.00
$1,114.00
$944.00
$1,125.00
$361.00
$485.00
$566.00
$544.00
$624.00
$713.00
$920.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$517.00
$1,390.00
$501.00
$1,058.00
$101.00
$101.00
$1,052.00
$127.00
$943.00
$1,352.00
$2,731.00
$1,309.00
$776.00
$1,020.00
$468.00
$485.00
$527.00
$783.00
----$149.00
$594.00
$177.00
$550.00
$535.00
$117.00
$65.00
$1,051.00
$902.00
$76.00
$506.00
$638.00
$663.00
$886.00
$855.00
$1,012.00
$764.00
$909.00
$747.00
$818.00
$811.00
$950.00
$1,002.00
$1,192.00
$1,010.00
$1,205.00
$389.00
$520.00
$606.00
$583.00
$668.00
$764.00
$990.00
$536.00
$1,448.00
$520.00
$1,117.00
$105.00
$105.00
$1,105.00
$133.00
$995.00
$1,431.00
$2,873.00
$1,388.00
$821.00
$1,080.00
$495.00
$513.00
$557.00
$828.00
----$156.00
$626.00
$186.00
$581.00
$567.00
$122.00
$67.00
$1,114.00
$953.00
$79.00
$528.00
$679.00
$699.00
$934.00
$902.00
$1,069.00
$806.00
$959.00
$788.00
$864.00
$855.00
$1,003.00
$1,057.00
$1,259.00
$1,066.00
$1,272.00
$413.00
$548.00
$639.00
$614.00
$705.00
$806.00
$1,049.00
186
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
49605
49606
49610
49611
49650
49651
49659
49900
49904
49905
49906
49999
50010
50020
50021
50040
50045
50060
50065
50070
50075
50080
50081
50100
50120
50125
50130
50135
50200
50205
50220
50225
50230
50234
50236
50240
50280
50290
50320
50340
50360
50365
50370
50380
50390
50392
50393
50394
50395
50396
50398
50400
90
90
90
90
90
90
YYY
90
0
ZZZ
90
YYY
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
90
$1,648.00
$1,416.00
$784.00
$770.00
$484.00
$621.00
BR
$512.00
$1,394.00
$454.00
BR
BR
$886.00
$1,084.00
$335.00
$910.00
$1,137.00
$1,394.00
$1,514.00
$1,476.00
$1,839.00
$1,186.00
$1,635.00
$1,250.00
$1,180.00
$1,228.00
$1,301.00
$1,506.00
$151.00
$807.00
$1,316.00
$1,554.00
$1,695.00
$1,671.00
$1,873.00
$1,679.00
$1,170.00
$1,080.00
$1,680.00
$1,083.00
$2,475.00
$2,941.00
$1,128.00
$1,507.00
$118.00
$189.00
$235.00
$64.00
$203.00
$101.00
$99.00
$1,441.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$5,440.00
$1,520.00
$907.00
$960.00
$514.00
$677.00
----$1,021.00
$1,907.00
$483.00
--------$918.00
$1,458.00
$666.00
$1,331.00
$1,229.00
$1,488.00
$1,508.00
$1,563.00
$1,936.00
$1,290.00
$1,775.00
$1,385.00
$1,260.00
$1,307.00
$1,346.00
$1,481.00
$185.00
$931.00
$1,354.00
$1,559.00
$1,685.00
$1,708.00
$1,990.00
$1,794.00
$1,239.00
$1,192.00
$1,730.00
$1,127.00
$2,626.00
$3,103.00
$1,232.00
$1,817.00
$136.00
$235.00
$288.00
$160.00
$235.00
$154.00
$136.00
$1,506.00
$5,714.00
$1,644.00
$968.00
$1,026.00
$553.00
$728.00
----$1,097.00
$2,048.00
$518.00
--------$979.00
$1,550.00
$711.00
$1,413.00
$1,309.00
$1,579.00
$1,596.00
$1,658.00
$2,054.00
$1,370.00
$1,885.00
$1,490.00
$1,340.00
$1,389.00
$1,428.00
$1,572.00
$195.00
$996.00
$1,441.00
$1,655.00
$1,789.00
$1,813.00
$2,113.00
$1,906.00
$1,316.00
$1,272.00
$1,848.00
$1,210.00
$2,818.00
$3,332.00
$1,322.00
$1,946.00
$144.00
$247.00
$304.00
$171.00
$248.00
$162.00
$144.00
$1,599.00
$5,927.00
$1,752.00
$1,016.00
$1,073.00
$586.00
$772.00
----$1,162.00
$2,160.00
$549.00
--------$1,028.00
$1,615.00
$737.00
$1,474.00
$1,373.00
$1,652.00
$1,668.00
$1,735.00
$2,150.00
$1,431.00
$1,971.00
$1,578.00
$1,405.00
$1,456.00
$1,495.00
$1,647.00
$203.00
$1,049.00
$1,512.00
$1,734.00
$1,873.00
$1,899.00
$2,210.00
$1,995.00
$1,379.00
$1,337.00
$1,947.00
$1,276.00
$2,979.00
$3,523.00
$1,394.00
$2,050.00
$150.00
$257.00
$316.00
$177.00
$259.00
$169.00
$150.00
$1,675.00
$5,440.00
$1,520.00
$907.00
$960.00
$514.00
$677.00
----$1,021.00
$1,907.00
$483.00
--------$918.00
$1,458.00
$666.00
$1,331.00
$1,229.00
$1,488.00
$1,508.00
$1,563.00
$1,936.00
$1,290.00
$1,775.00
$1,385.00
$1,260.00
$1,307.00
$1,346.00
$1,481.00
$185.00
$931.00
$1,354.00
$1,559.00
$1,685.00
$1,708.00
$1,990.00
$1,794.00
$1,239.00
$1,192.00
$1,730.00
$1,127.00
$2,626.00
$3,103.00
$1,232.00
$1,817.00
$136.00
$235.00
$288.00
$53.00
$235.00
$154.00
$102.00
$1,506.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$5,714.00
$1,644.00
$968.00
$1,026.00
$553.00
$728.00
----$1,097.00
$2,048.00
$518.00
--------$979.00
$1,550.00
$711.00
$1,413.00
$1,309.00
$1,579.00
$1,596.00
$1,658.00
$2,054.00
$1,370.00
$1,885.00
$1,490.00
$1,340.00
$1,389.00
$1,428.00
$1,572.00
$195.00
$996.00
$1,441.00
$1,655.00
$1,789.00
$1,813.00
$2,113.00
$1,906.00
$1,316.00
$1,272.00
$1,848.00
$1,210.00
$2,818.00
$3,332.00
$1,322.00
$1,946.00
$144.00
$247.00
$304.00
$56.00
$248.00
$162.00
$107.00
$1,599.00
$5,927.00
$1,752.00
$1,016.00
$1,073.00
$586.00
$772.00
----$1,162.00
$2,160.00
$549.00
--------$1,028.00
$1,615.00
$737.00
$1,474.00
$1,373.00
$1,652.00
$1,668.00
$1,735.00
$2,150.00
$1,431.00
$1,971.00
$1,578.00
$1,405.00
$1,456.00
$1,495.00
$1,647.00
$203.00
$1,049.00
$1,512.00
$1,734.00
$1,873.00
$1,899.00
$2,210.00
$1,995.00
$1,379.00
$1,337.00
$1,947.00
$1,276.00
$2,979.00
$3,523.00
$1,394.00
$2,050.00
$150.00
$257.00
$316.00
$59.00
$259.00
$169.00
$112.00
$1,675.00
187
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
50547
50548
50549
50551
50553
50555
50557
50559
50561
50562
50570
50572
50574
50575
50576
50578
50580
50590
50600
50605
50610
50620
50630
50650
50660
50684
50686
50688
50690
50700
50715
50722
50725
50727
50728
50740
50750
50760
50770
50780
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
0
0
10
0
90
90
90
90
90
90
90
90
90
90
90
$1,802.00
$1,471.00
$1,281.00
$1,644.00
$1,639.00
$1,468.00
$1,037.00
$1,093.00
$1,374.00
$1,428.00
$1,273.00
$1,325.00
$1,702.00
$1,555.00
BR
$411.00
$447.00
$668.00
$676.00
$396.00
$755.00
$580.00
$549.00
$728.00
$762.00
$991.00
$801.00
$711.00
$726.00
$980.00
$1,150.00
$1,054.00
$1,209.00
$1,152.00
$1,170.00
$1,297.00
$1,426.00
$74.00
$109.00
$89.00
$85.00
$1,192.00
$1,397.00
$1,211.00
$1,371.00
$640.00
$924.00
$1,386.00
$1,457.00
$1,389.00
$1,485.00
$1,391.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,853.00
$1,593.00
$1,436.00
$1,801.00
$1,966.00
$1,570.00
$1,178.00
$1,499.00
$1,880.00
$1,634.00
$1,750.00
$1,505.00
$1,939.00
$1,769.00
----$500.00
$1,007.00
$1,133.00
$1,079.00
$471.00
$1,096.00
$799.00
$668.00
$728.00
$773.00
$981.00
$770.00
$795.00
$831.00
$1,014.00
$1,255.00
$1,252.00
$1,281.00
$1,193.00
$1,179.00
$1,374.00
$1,525.00
$655.00
$201.00
$145.00
$684.00
$1,246.00
$1,629.00
$1,379.00
$1,503.00
$726.00
$1,029.00
$1,465.00
$1,530.00
$1,463.00
$1,526.00
$1,449.00
$1,967.00
$1,699.00
$1,532.00
$1,917.00
$2,093.00
$1,669.00
$1,250.00
$1,595.00
$1,989.00
$1,734.00
$1,858.00
$1,600.00
$2,071.00
$1,877.00
----$532.00
$1,076.00
$1,211.00
$1,153.00
$495.00
$1,171.00
$852.00
$708.00
$772.00
$819.00
$1,039.00
$816.00
$843.00
$880.00
$1,081.00
$1,333.00
$1,335.00
$1,363.00
$1,266.00
$1,252.00
$1,459.00
$1,620.00
$704.00
$215.00
$154.00
$735.00
$1,322.00
$1,746.00
$1,476.00
$1,605.00
$772.00
$1,097.00
$1,565.00
$1,625.00
$1,557.00
$1,622.00
$1,541.00
$2,059.00
$1,785.00
$1,609.00
$2,010.00
$2,194.00
$1,749.00
$1,310.00
$1,674.00
$2,078.00
$1,818.00
$1,949.00
$1,680.00
$2,183.00
$1,967.00
----$556.00
$1,118.00
$1,258.00
$1,199.00
$515.00
$1,217.00
$898.00
$741.00
$809.00
$858.00
$1,089.00
$855.00
$883.00
$922.00
$1,127.00
$1,396.00
$1,403.00
$1,430.00
$1,325.00
$1,310.00
$1,528.00
$1,695.00
$728.00
$223.00
$161.00
$760.00
$1,381.00
$1,841.00
$1,556.00
$1,688.00
$808.00
$1,152.00
$1,649.00
$1,703.00
$1,633.00
$1,700.00
$1,615.00
$1,853.00
$1,593.00
$1,436.00
$1,801.00
$1,966.00
$1,570.00
$1,178.00
$1,499.00
$1,880.00
$1,634.00
$1,750.00
$1,505.00
$1,939.00
$1,769.00
----$392.00
$421.00
$458.00
$464.00
$471.00
$532.00
$799.00
$668.00
$728.00
$773.00
$981.00
$770.00
$795.00
$831.00
$732.00
$1,255.00
$1,252.00
$1,281.00
$1,193.00
$1,179.00
$1,374.00
$1,525.00
$53.00
$114.00
$145.00
$81.00
$1,246.00
$1,629.00
$1,379.00
$1,503.00
$726.00
$1,029.00
$1,465.00
$1,530.00
$1,463.00
$1,526.00
$1,449.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,967.00
$1,699.00
$1,532.00
$1,917.00
$2,093.00
$1,669.00
$1,250.00
$1,595.00
$1,989.00
$1,734.00
$1,858.00
$1,600.00
$2,071.00
$1,877.00
----$416.00
$446.00
$485.00
$492.00
$495.00
$563.00
$852.00
$708.00
$772.00
$819.00
$1,039.00
$816.00
$843.00
$880.00
$777.00
$1,333.00
$1,335.00
$1,363.00
$1,266.00
$1,252.00
$1,459.00
$1,620.00
$56.00
$121.00
$154.00
$86.00
$1,322.00
$1,746.00
$1,476.00
$1,605.00
$772.00
$1,097.00
$1,565.00
$1,625.00
$1,557.00
$1,622.00
$1,541.00
$2,059.00
$1,785.00
$1,609.00
$2,010.00
$2,194.00
$1,749.00
$1,310.00
$1,674.00
$2,078.00
$1,818.00
$1,949.00
$1,680.00
$2,183.00
$1,967.00
----$435.00
$467.00
$508.00
$515.00
$515.00
$590.00
$898.00
$741.00
$809.00
$858.00
$1,089.00
$855.00
$883.00
$922.00
$813.00
$1,396.00
$1,403.00
$1,430.00
$1,325.00
$1,310.00
$1,528.00
$1,695.00
$58.00
$127.00
$161.00
$90.00
$1,381.00
$1,841.00
$1,556.00
$1,688.00
$808.00
$1,152.00
$1,649.00
$1,703.00
$1,633.00
$1,700.00
$1,615.00
188
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
50782
50783
50785
50800
50810
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
50949
50951
50953
50955
50957
50959
50961
50970
50972
50974
50976
50978
50980
51000
51005
51010
51020
51030
51040
51045
51050
51060
51065
51080
51500
51520
51525
51530
51535
51550
51555
51565
51570
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$1,465.00
$1,515.00
$1,548.00
$1,226.00
$1,527.00
$1,643.00
$1,729.00
$2,351.00
$2,292.00
$1,493.00
$1,513.00
$1,163.00
$1,043.00
$1,075.00
$1,380.00
$1,107.00
$1,096.00
$1,384.00
$1,265.00
BR
$414.00
$461.00
$546.00
$546.00
$316.00
$510.00
$510.00
$408.00
$661.00
$641.00
$379.00
$443.00
$75.00
$87.00
$191.00
$587.00
$538.00
$439.00
$548.00
$596.00
$768.00
$704.00
$510.00
$775.00
$764.00
$1,069.00
$957.00
$932.00
$1,171.00
$1,514.00
$1,624.00
$1,762.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,594.00
$1,616.00
$1,600.00
$1,227.00
$1,721.00
$1,621.00
$1,741.00
$2,221.00
$2,435.00
$1,618.00
$1,600.00
$1,238.00
$1,108.00
$1,162.00
$1,504.00
$1,169.00
$1,269.00
$1,842.00
$1,680.00
----$535.00
$1,017.00
$1,240.00
$1,039.00
$303.00
$1,185.00
$502.00
$484.00
$642.00
$634.00
$360.00
$481.00
$134.00
$205.00
$470.00
$612.00
$628.00
$424.00
$637.00
$596.00
$755.00
$747.00
$572.00
$851.00
$790.00
$1,112.00
$1,020.00
$1,062.00
$1,243.00
$1,652.00
$1,696.00
$1,891.00
$1,691.00
$1,718.00
$1,700.00
$1,305.00
$1,844.00
$1,725.00
$1,850.00
$2,361.00
$2,593.00
$1,720.00
$1,698.00
$1,317.00
$1,181.00
$1,233.00
$1,609.00
$1,246.00
$1,350.00
$1,968.00
$1,795.00
----$569.00
$1,087.00
$1,326.00
$1,110.00
$319.00
$1,267.00
$532.00
$513.00
$679.00
$672.00
$382.00
$509.00
$143.00
$220.00
$503.00
$651.00
$669.00
$451.00
$679.00
$633.00
$802.00
$794.00
$609.00
$912.00
$840.00
$1,180.00
$1,085.00
$1,132.00
$1,323.00
$1,756.00
$1,803.00
$2,011.00
$1,768.00
$1,801.00
$1,781.00
$1,366.00
$1,945.00
$1,807.00
$1,938.00
$2,474.00
$2,723.00
$1,801.00
$1,777.00
$1,380.00
$1,240.00
$1,289.00
$1,697.00
$1,308.00
$1,417.00
$2,076.00
$1,894.00
----$595.00
$1,130.00
$1,376.00
$1,154.00
$332.00
$1,316.00
$557.00
$537.00
$711.00
$704.00
$400.00
$534.00
$149.00
$229.00
$524.00
$681.00
$699.00
$471.00
$711.00
$662.00
$839.00
$830.00
$636.00
$962.00
$879.00
$1,235.00
$1,137.00
$1,188.00
$1,387.00
$1,840.00
$1,890.00
$2,109.00
$1,594.00
$1,616.00
$1,600.00
$1,227.00
$1,721.00
$1,621.00
$1,741.00
$2,221.00
$2,435.00
$1,618.00
$1,600.00
$1,238.00
$1,108.00
$1,162.00
$1,504.00
$1,169.00
$1,269.00
$1,842.00
$1,680.00
----$410.00
$438.00
$474.00
$476.00
$303.00
$424.00
$502.00
$484.00
$642.00
$634.00
$360.00
$481.00
$55.00
$73.00
$294.00
$612.00
$628.00
$424.00
$637.00
$596.00
$755.00
$747.00
$572.00
$851.00
$790.00
$1,112.00
$1,020.00
$1,062.00
$1,243.00
$1,652.00
$1,696.00
$1,891.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,691.00
$1,718.00
$1,700.00
$1,305.00
$1,844.00
$1,725.00
$1,850.00
$2,361.00
$2,593.00
$1,720.00
$1,698.00
$1,317.00
$1,181.00
$1,233.00
$1,609.00
$1,246.00
$1,350.00
$1,968.00
$1,795.00
----$434.00
$464.00
$501.00
$504.00
$319.00
$448.00
$532.00
$513.00
$679.00
$672.00
$382.00
$509.00
$58.00
$78.00
$312.00
$651.00
$669.00
$451.00
$679.00
$633.00
$802.00
$794.00
$609.00
$912.00
$840.00
$1,180.00
$1,085.00
$1,132.00
$1,323.00
$1,756.00
$1,803.00
$2,011.00
$1,768.00
$1,801.00
$1,781.00
$1,366.00
$1,945.00
$1,807.00
$1,938.00
$2,474.00
$2,723.00
$1,801.00
$1,777.00
$1,380.00
$1,240.00
$1,289.00
$1,697.00
$1,308.00
$1,417.00
$2,076.00
$1,894.00
----$455.00
$486.00
$525.00
$528.00
$332.00
$470.00
$557.00
$537.00
$711.00
$704.00
$400.00
$534.00
$61.00
$83.00
$327.00
$681.00
$699.00
$471.00
$711.00
$662.00
$839.00
$830.00
$636.00
$962.00
$879.00
$1,235.00
$1,137.00
$1,188.00
$1,387.00
$1,840.00
$1,890.00
$2,109.00
189
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
51575
51580
51585
51590
51595
51596
51597
51600
51605
51610
51700
51701
51702
51703
51705
51710
51715
51720
51725
51726
51736
51741
51772
51784
51785
51792
51795
51797
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940
51960
51980
51990
51992
52000
52001
52005
52007
52010
52204
52214
FUD 2003 MRA
90
90
90
90
90
90
90
0
0
0
0
0
0
0
10
10
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
$2,284.00
$2,252.00
$2,601.00
$2,441.00
$2,900.00
$3,063.00
$2,914.00
$54.00
$83.00
$45.00
$29.00
$58.00
$92.00
$128.00
$37.00
$119.00
$322.00
$140.00
$116.00
$136.00
$47.00
$81.00
$96.00
$119.00
$52.00
$143.00
$132.00
$109.00
$20.00
$1,294.00
$1,236.00
$858.00
$1,040.00
$843.00
$912.00
$1,150.00
$590.00
$1,050.00
$881.00
$1,167.00
$2,082.00
$1,848.00
$858.00
$850.00
$925.00
$190.00
$133.00
$265.00
$230.00
$292.00
$286.00
$367.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,350.00
$2,416.00
$2,694.00
$2,497.00
$2,806.00
$2,998.00
$2,930.00
$279.00
$699.00
$709.00
$104.00
$79.00
$123.00
$173.00
$123.00
$271.00
$381.00
$175.00
$439.00
$435.00
$61.00
$102.00
$399.00
$341.00
$341.00
$333.00
$415.00
$299.00
$33.00
$1,379.00
$1,507.00
$902.00
$1,111.00
$828.00
$1,019.00
$1,220.00
$678.00
$1,079.00
$981.00
$1,332.00
$2,308.00
$1,841.00
$938.00
$1,012.00
$1,078.00
$331.00
$679.00
$440.00
$220.00
$542.00
$394.00
$553.00
$2,495.00
$2,567.00
$2,860.00
$2,651.00
$2,977.00
$3,181.00
$3,114.00
$299.00
$751.00
$762.00
$111.00
$84.00
$132.00
$184.00
$132.00
$290.00
$406.00
$186.00
$472.00
$468.00
$65.00
$109.00
$429.00
$366.00
$366.00
$361.00
$447.00
$322.00
$37.00
$1,467.00
$1,611.00
$964.00
$1,187.00
$880.00
$1,087.00
$1,298.00
$723.00
$1,149.00
$1,046.00
$1,430.00
$2,458.00
$1,956.00
$998.00
$1,082.00
$1,146.00
$354.00
$724.00
$471.00
$234.00
$580.00
$421.00
$591.00
$2,613.00
$2,688.00
$2,996.00
$2,776.00
$3,116.00
$3,330.00
$3,265.00
$309.00
$777.00
$788.00
$115.00
$87.00
$137.00
$192.00
$137.00
$301.00
$424.00
$194.00
$491.00
$487.00
$68.00
$114.00
$447.00
$381.00
$381.00
$378.00
$466.00
$335.00
$41.00
$1,539.00
$1,696.00
$1,015.00
$1,249.00
$921.00
$1,142.00
$1,361.00
$758.00
$1,204.00
$1,099.00
$1,511.00
$2,579.00
$2,047.00
$1,046.00
$1,140.00
$1,202.00
$368.00
$754.00
$489.00
$245.00
$602.00
$438.00
$615.00
$2,350.00
$2,416.00
$2,694.00
$2,497.00
$2,806.00
$2,998.00
$2,930.00
$61.00
$45.00
$73.00
$62.00
$37.00
$40.00
$108.00
$81.00
$144.00
$264.00
$142.00
$439.00
$435.00
$61.00
$102.00
$399.00
$341.00
$341.00
$333.00
$415.00
$299.00
$33.00
$1,379.00
$1,507.00
$902.00
$1,111.00
$828.00
$1,019.00
$1,220.00
$678.00
$1,079.00
$981.00
$1,332.00
$2,308.00
$1,841.00
$938.00
$1,012.00
$1,078.00
$147.00
$408.00
$174.00
$220.00
$219.00
$174.00
$267.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,495.00
$2,567.00
$2,860.00
$2,651.00
$2,977.00
$3,181.00
$3,114.00
$65.00
$48.00
$77.00
$65.00
$39.00
$43.00
$115.00
$86.00
$153.00
$280.00
$150.00
$472.00
$468.00
$65.00
$109.00
$429.00
$366.00
$366.00
$361.00
$447.00
$322.00
$37.00
$1,467.00
$1,611.00
$964.00
$1,187.00
$880.00
$1,087.00
$1,298.00
$723.00
$1,149.00
$1,046.00
$1,430.00
$2,458.00
$1,956.00
$998.00
$1,082.00
$1,146.00
$156.00
$433.00
$184.00
$234.00
$233.00
$185.00
$283.00
$2,613.00
$2,688.00
$2,996.00
$2,776.00
$3,116.00
$3,330.00
$3,265.00
$67.00
$51.00
$80.00
$68.00
$41.00
$45.00
$121.00
$90.00
$160.00
$294.00
$158.00
$491.00
$487.00
$68.00
$114.00
$447.00
$381.00
$381.00
$378.00
$466.00
$335.00
$41.00
$1,539.00
$1,696.00
$1,015.00
$1,249.00
$921.00
$1,142.00
$1,361.00
$758.00
$1,204.00
$1,099.00
$1,511.00
$2,579.00
$2,047.00
$1,046.00
$1,140.00
$1,202.00
$163.00
$453.00
$193.00
$245.00
$244.00
$194.00
$296.00
190
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
52224
52234
52235
52240
52250
52260
52265
52270
52275
52276
52277
52281
52282
52283
52285
52290
52300
52301
52305
52310
52315
52317
52318
52320
52325
52327
52330
52332
52334
52341
52342
52343
52344
52345
52346
52347
52351
52352
52353
52354
52355
52400
52450
52500
52510
52601
52606
52612
52614
52620
52630
52640
FUD 2003 MRA
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
$339.00
$471.00
$546.00
$887.00
$311.00
$262.00
$243.00
$374.00
$446.00
$490.00
$448.00
$259.00
$560.00
$309.00
$375.00
$304.00
$370.00
$382.00
$370.00
$348.00
$553.00
$772.00
$684.00
$369.00
$494.00
$369.00
$507.00
$451.00
$340.00
$317.00
$344.00
$380.00
$407.00
$433.00
$488.00
$281.00
$297.00
$349.00
$404.00
$372.00
$447.00
$580.00
$602.00
$705.00
$604.00
$1,021.00
$581.00
$711.00
$609.00
$554.00
$653.00
$573.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$468.00
$331.00
$390.00
$690.00
$326.00
$283.00
$436.00
$495.00
$601.00
$661.00
$447.00
$544.00
$983.00
$488.00
$503.00
$330.00
$382.00
$401.00
$379.00
$383.00
$562.00
$744.00
$651.00
$336.00
$439.00
$373.00
$1,120.00
$952.00
$348.00
$435.00
$470.00
$521.00
$557.00
$592.00
$665.00
$388.00
$424.00
$498.00
$575.00
$531.00
$636.00
$735.00
$591.00
$648.00
$521.00
$924.00
$614.00
$619.00
$537.00
$507.00
$548.00
$509.00
$499.00
$351.00
$413.00
$731.00
$346.00
$300.00
$465.00
$528.00
$641.00
$705.00
$474.00
$582.00
$1,051.00
$520.00
$537.00
$350.00
$406.00
$427.00
$402.00
$409.00
$599.00
$793.00
$690.00
$356.00
$466.00
$395.00
$1,200.00
$1,021.00
$369.00
$462.00
$498.00
$553.00
$591.00
$628.00
$706.00
$412.00
$450.00
$528.00
$610.00
$564.00
$674.00
$780.00
$628.00
$688.00
$553.00
$980.00
$651.00
$657.00
$570.00
$538.00
$582.00
$540.00
$519.00
$368.00
$432.00
$766.00
$362.00
$314.00
$484.00
$549.00
$667.00
$734.00
$497.00
$605.00
$1,093.00
$542.00
$559.00
$367.00
$425.00
$449.00
$421.00
$425.00
$624.00
$827.00
$722.00
$373.00
$488.00
$414.00
$1,245.00
$1,059.00
$386.00
$484.00
$522.00
$579.00
$619.00
$658.00
$740.00
$432.00
$472.00
$554.00
$639.00
$591.00
$707.00
$818.00
$657.00
$720.00
$579.00
$1,026.00
$682.00
$687.00
$596.00
$563.00
$609.00
$565.00
$227.00
$331.00
$390.00
$690.00
$326.00
$283.00
$215.00
$248.00
$341.00
$363.00
$447.00
$205.00
$458.00
$271.00
$262.00
$330.00
$382.00
$401.00
$379.00
$203.00
$373.00
$477.00
$651.00
$336.00
$439.00
$373.00
$360.00
$205.00
$348.00
$435.00
$470.00
$521.00
$557.00
$592.00
$665.00
$388.00
$424.00
$498.00
$575.00
$531.00
$636.00
$735.00
$591.00
$648.00
$521.00
$924.00
$614.00
$619.00
$537.00
$507.00
$548.00
$509.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$240.00
$351.00
$413.00
$731.00
$346.00
$300.00
$228.00
$262.00
$361.00
$385.00
$474.00
$218.00
$485.00
$287.00
$278.00
$350.00
$406.00
$427.00
$402.00
$216.00
$396.00
$506.00
$690.00
$356.00
$466.00
$395.00
$382.00
$218.00
$369.00
$462.00
$498.00
$553.00
$591.00
$628.00
$706.00
$412.00
$450.00
$528.00
$610.00
$564.00
$674.00
$780.00
$628.00
$688.00
$553.00
$980.00
$651.00
$657.00
$570.00
$538.00
$582.00
$540.00
$251.00
$368.00
$432.00
$766.00
$362.00
$314.00
$239.00
$275.00
$379.00
$403.00
$497.00
$228.00
$508.00
$301.00
$292.00
$367.00
$425.00
$449.00
$421.00
$226.00
$415.00
$530.00
$722.00
$373.00
$488.00
$414.00
$400.00
$228.00
$386.00
$484.00
$522.00
$579.00
$619.00
$658.00
$740.00
$432.00
$472.00
$554.00
$639.00
$591.00
$707.00
$818.00
$657.00
$720.00
$579.00
$1,026.00
$682.00
$687.00
$596.00
$563.00
$609.00
$565.00
191
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
52647
52648
52700
53000
53010
53020
53040
53060
53080
53085
53200
53210
53215
53220
53230
53235
53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
53425
53430
53431
53440
53442
53444
53445
53446
53447
53448
53449
53450
53460
53502
53505
53510
53515
53520
53600
53601
53605
53620
53621
53660
53661
FUD 2003 MRA
90
90
90
10
90
0
90
10
90
90
0
90
90
90
90
90
90
90
10
10
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
$858.00
$957.00
$517.00
$224.00
$336.00
$153.00
$460.00
$180.00
$567.00
$836.00
$218.00
$904.00
$1,142.00
$546.00
$760.00
$607.00
$506.00
$464.00
$240.00
$295.00
$226.00
$332.00
$929.00
$1,088.00
$1,151.00
$1,381.00
$1,088.00
$1,150.00
$1,116.00
$1,053.00
$1,057.00
$639.00
$755.00
$1,197.00
$699.00
$991.00
$1,259.00
$784.00
$447.00
$494.00
$590.00
$586.00
$777.00
$987.00
$661.00
$37.00
$37.00
$81.00
$59.00
$45.00
$49.00
$50.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,649.00
$839.00
$526.00
$479.00
$395.00
$245.00
$926.00
$435.00
$695.00
$980.00
$373.00
$1,049.00
$1,237.00
$628.00
$803.00
$841.00
$588.00
$525.00
$423.00
$451.00
$441.00
$394.00
$1,058.00
$1,161.00
$1,301.00
$1,488.00
$1,181.00
$1,279.00
$1,306.00
$1,524.00
$1,040.00
$906.00
$1,029.00
$1,139.00
$841.00
$1,048.00
$1,632.00
$812.00
$553.00
$624.00
$675.00
$659.00
$860.00
$1,066.00
$738.00
$108.00
$99.00
$90.00
$151.00
$138.00
$87.00
$86.00
$2,838.00
$889.00
$558.00
$513.00
$420.00
$261.00
$990.00
$467.00
$742.00
$1,044.00
$399.00
$1,116.00
$1,313.00
$668.00
$853.00
$893.00
$626.00
$558.00
$453.00
$482.00
$471.00
$419.00
$1,126.00
$1,234.00
$1,381.00
$1,579.00
$1,256.00
$1,359.00
$1,388.00
$1,620.00
$1,101.00
$958.00
$1,094.00
$1,209.00
$895.00
$1,112.00
$1,736.00
$862.00
$588.00
$664.00
$719.00
$700.00
$914.00
$1,133.00
$785.00
$114.00
$106.00
$95.00
$161.00
$147.00
$93.00
$92.00
$2,944.00
$931.00
$584.00
$532.00
$437.00
$272.00
$1,030.00
$488.00
$775.00
$1,092.00
$415.00
$1,168.00
$1,373.00
$698.00
$893.00
$933.00
$655.00
$583.00
$473.00
$502.00
$491.00
$438.00
$1,180.00
$1,293.00
$1,445.00
$1,653.00
$1,315.00
$1,422.00
$1,453.00
$1,699.00
$1,150.00
$998.00
$1,148.00
$1,265.00
$937.00
$1,163.00
$1,820.00
$901.00
$615.00
$694.00
$752.00
$732.00
$955.00
$1,186.00
$821.00
$120.00
$111.00
$100.00
$168.00
$153.00
$97.00
$95.00
$783.00
$839.00
$526.00
$232.00
$395.00
$128.00
$697.00
$277.00
$695.00
$980.00
$187.00
$1,049.00
$1,237.00
$628.00
$803.00
$841.00
$588.00
$525.00
$274.00
$281.00
$292.00
$394.00
$1,058.00
$1,161.00
$1,301.00
$1,488.00
$1,181.00
$1,279.00
$1,306.00
$1,524.00
$1,040.00
$906.00
$1,029.00
$1,139.00
$841.00
$1,048.00
$1,632.00
$812.00
$553.00
$624.00
$675.00
$659.00
$860.00
$1,066.00
$738.00
$87.00
$72.00
$90.00
$118.00
$98.00
$54.00
$54.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$830.00
$889.00
$558.00
$246.00
$420.00
$136.00
$744.00
$297.00
$742.00
$1,044.00
$199.00
$1,116.00
$1,313.00
$668.00
$853.00
$893.00
$626.00
$558.00
$293.00
$299.00
$311.00
$419.00
$1,126.00
$1,234.00
$1,381.00
$1,579.00
$1,256.00
$1,359.00
$1,388.00
$1,620.00
$1,101.00
$958.00
$1,094.00
$1,209.00
$895.00
$1,112.00
$1,736.00
$862.00
$588.00
$664.00
$719.00
$700.00
$914.00
$1,133.00
$785.00
$92.00
$77.00
$95.00
$125.00
$104.00
$58.00
$57.00
$869.00
$931.00
$584.00
$257.00
$437.00
$143.00
$776.00
$312.00
$775.00
$1,092.00
$209.00
$1,168.00
$1,373.00
$698.00
$893.00
$933.00
$655.00
$583.00
$307.00
$313.00
$325.00
$438.00
$1,180.00
$1,293.00
$1,445.00
$1,653.00
$1,315.00
$1,422.00
$1,453.00
$1,699.00
$1,150.00
$998.00
$1,148.00
$1,265.00
$937.00
$1,163.00
$1,820.00
$901.00
$615.00
$694.00
$752.00
$732.00
$955.00
$1,186.00
$821.00
$97.00
$80.00
$100.00
$131.00
$109.00
$60.00
$60.00
192
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
53665
53850
53852
53853
53899
54015
54050
54055
54056
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54125
54130
54135
54162
54163
54164
54200
54205
54220
54230
54231
54235
54240
54250
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
0
90
90
90
YYY
10
10
10
10
10
10
10
0
10
90
90
90
90
90
90
90
90
10
10
10
10
90
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$50.00
$741.00
$728.00
$2,073.00
BR
$348.00
$91.00
$106.00
$100.00
$149.00
$180.00
$281.00
$149.00
$261.00
$775.00
$1,035.00
$1,210.00
$588.00
$777.00
$1,092.00
$1,532.00
$1,945.00
$220.00
$207.00
$182.00
$78.00
$633.00
$189.00
$104.00
$172.00
$81.00
$109.00
$104.00
$830.00
$988.00
$881.00
$1,067.00
$1,316.00
$900.00
$974.00
$1,260.00
$1,212.00
$1,201.00
$1,327.00
$1,672.00
$727.00
$1,360.00
$1,318.00
$1,820.00
$898.00
$1,054.00
$1,217.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$54.00
$3,595.00
$3,088.00
$2,179.00
----$606.00
$202.00
$338.00
$218.00
$218.00
$343.00
$385.00
$264.00
$460.00
$882.00
$1,141.00
$1,289.00
$799.00
$892.00
$1,143.00
$1,622.00
$2,060.00
$276.00
$265.00
$229.00
$174.00
$744.00
$223.00
$94.00
$216.00
$119.00
$164.00
$261.00
$956.00
$1,126.00
$1,069.00
$1,215.00
$1,437.00
$1,061.00
$1,120.00
$1,425.00
$1,344.00
$1,337.00
$1,438.00
$1,818.00
$852.00
$1,376.00
$1,476.00
$2,056.00
$1,028.00
$1,200.00
$1,413.00
$57.00
$3,857.00
$3,311.00
$2,337.00
----$646.00
$216.00
$362.00
$233.00
$233.00
$367.00
$411.00
$281.00
$491.00
$937.00
$1,212.00
$1,369.00
$853.00
$948.00
$1,214.00
$1,722.00
$2,186.00
$294.00
$282.00
$243.00
$186.00
$791.00
$238.00
$100.00
$230.00
$127.00
$177.00
$279.00
$1,017.00
$1,197.00
$1,137.00
$1,292.00
$1,527.00
$1,141.00
$1,191.00
$1,516.00
$1,428.00
$1,421.00
$1,527.00
$1,952.00
$911.00
$1,466.00
$1,568.00
$2,187.00
$1,093.00
$1,286.00
$1,497.00
$60.00
$3,996.00
$3,432.00
$2,420.00
----$674.00
$225.00
$376.00
$242.00
$243.00
$381.00
$427.00
$292.00
$511.00
$979.00
$1,266.00
$1,431.00
$889.00
$991.00
$1,269.00
$1,800.00
$2,288.00
$307.00
$295.00
$254.00
$193.00
$826.00
$248.00
$104.00
$241.00
$132.00
$186.00
$291.00
$1,063.00
$1,250.00
$1,187.00
$1,350.00
$1,596.00
$1,206.00
$1,244.00
$1,586.00
$1,493.00
$1,484.00
$1,596.00
$2,060.00
$957.00
$1,537.00
$1,639.00
$2,291.00
$1,143.00
$1,355.00
$1,557.00
$54.00
$718.00
$750.00
$459.00
----$437.00
$91.00
$134.00
$92.00
$128.00
$181.00
$228.00
$139.00
$290.00
$882.00
$1,141.00
$1,289.00
$629.00
$892.00
$1,143.00
$1,622.00
$2,060.00
$276.00
$265.00
$229.00
$75.00
$744.00
$181.00
$94.00
$151.00
$84.00
$164.00
$261.00
$956.00
$1,126.00
$1,069.00
$1,215.00
$1,437.00
$1,061.00
$1,120.00
$1,425.00
$1,344.00
$1,337.00
$1,438.00
$1,818.00
$852.00
$1,376.00
$1,476.00
$2,056.00
$1,028.00
$1,200.00
$1,413.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$57.00
$762.00
$795.00
$487.00
----$465.00
$97.00
$142.00
$98.00
$136.00
$192.00
$243.00
$147.00
$308.00
$937.00
$1,212.00
$1,369.00
$671.00
$948.00
$1,214.00
$1,722.00
$2,186.00
$294.00
$282.00
$243.00
$80.00
$791.00
$192.00
$100.00
$161.00
$89.00
$177.00
$279.00
$1,017.00
$1,197.00
$1,137.00
$1,292.00
$1,527.00
$1,141.00
$1,191.00
$1,516.00
$1,428.00
$1,421.00
$1,527.00
$1,952.00
$911.00
$1,466.00
$1,568.00
$2,187.00
$1,093.00
$1,286.00
$1,497.00
$60.00
$797.00
$832.00
$508.00
----$486.00
$101.00
$148.00
$102.00
$142.00
$201.00
$253.00
$154.00
$322.00
$979.00
$1,266.00
$1,431.00
$701.00
$991.00
$1,269.00
$1,800.00
$2,288.00
$307.00
$295.00
$254.00
$83.00
$826.00
$201.00
$104.00
$169.00
$93.00
$186.00
$291.00
$1,063.00
$1,250.00
$1,187.00
$1,350.00
$1,596.00
$1,206.00
$1,244.00
$1,586.00
$1,493.00
$1,484.00
$1,596.00
$2,060.00
$957.00
$1,537.00
$1,639.00
$2,291.00
$1,143.00
$1,355.00
$1,557.00
193
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
54390
54400
54401
54405
54406
54408
54410
54411
54415
54416
54417
54420
54430
54435
54440
54450
54500
54505
54512
54520
54522
54530
54535
54550
54560
54600
54620
54640
54650
54660
54670
54680
54690
54692
54699
54700
54800
54820
54830
54840
54860
54861
54900
54901
55000
55040
55041
55060
55100
55110
55120
55150
90 $1,635.00
90
$784.00
90
$892.00
90 $1,294.00
90
$687.00
90
$724.00
90
$856.00
90
$933.00
90
$510.00
90
$665.00
90
$819.00
90
$899.00
90
$799.00
90
$503.00
90
BR
0
$88.00
0
$102.00
10
$259.00
90
$519.00
90
$445.00
90
$589.00
90
$683.00
90
$922.00
90
$588.00
90
$842.00
90
$524.00
10
$373.00
90
$594.00
90
$861.00
90
$401.00
90
$485.00
90
$948.00
90
$825.00
90
$850.00
YYY
BR
10
$133.00
0
$257.00
90
$379.00
90
$411.00
90
$432.00
90
$503.00
90
$696.00
90
$969.00
90 $1,340.00
0
$109.00
90
$439.00
90
$634.00
90
$430.00
10
$156.00
90
$223.00
90
$350.00
90
$562.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,803.00
$763.00
$871.00
$1,093.00
$924.00
$977.00
$1,171.00
$1,289.00
$672.00
$918.00
$1,129.00
$984.00
$903.00
$575.00
----$110.00
$337.00
$298.00
$687.00
$442.00
$767.00
$702.00
$992.00
$636.00
$919.00
$570.00
$401.00
$570.00
$949.00
$431.00
$535.00
$1,040.00
$923.00
$970.00
----$529.00
$369.00
$438.00
$455.00
$439.00
$527.00
$707.00
$1,053.00
$1,434.00
$184.00
$443.00
$621.00
$457.00
$500.00
$467.00
$426.00
$599.00
$1,915.00
$810.00
$925.00
$1,161.00
$981.00
$1,038.00
$1,243.00
$1,365.00
$714.00
$973.00
$1,190.00
$1,047.00
$960.00
$611.00
----$117.00
$361.00
$317.00
$730.00
$470.00
$816.00
$746.00
$1,056.00
$676.00
$980.00
$606.00
$427.00
$608.00
$1,011.00
$459.00
$569.00
$1,110.00
$989.00
$1,032.00
----$566.00
$394.00
$466.00
$483.00
$467.00
$560.00
$750.00
$1,133.00
$1,542.00
$197.00
$471.00
$661.00
$486.00
$536.00
$496.00
$453.00
$637.00
$2,002.00
$847.00
$967.00
$1,214.00
$1,028.00
$1,087.00
$1,302.00
$1,423.00
$749.00
$1,014.00
$1,236.00
$1,095.00
$1,003.00
$638.00
----$122.00
$375.00
$332.00
$765.00
$492.00
$855.00
$781.00
$1,108.00
$708.00
$1,028.00
$635.00
$447.00
$638.00
$1,061.00
$481.00
$596.00
$1,166.00
$1,044.00
$1,083.00
----$590.00
$410.00
$488.00
$506.00
$488.00
$586.00
$784.00
$1,201.00
$1,636.00
$205.00
$494.00
$692.00
$510.00
$557.00
$519.00
$474.00
$667.00
$1,803.00
$763.00
$871.00
$1,093.00
$924.00
$977.00
$1,171.00
$1,289.00
$672.00
$918.00
$1,129.00
$984.00
$903.00
$575.00
----$84.00
$92.00
$298.00
$687.00
$442.00
$767.00
$702.00
$992.00
$636.00
$919.00
$570.00
$401.00
$570.00
$949.00
$431.00
$535.00
$1,040.00
$923.00
$970.00
----$336.00
$165.00
$438.00
$455.00
$439.00
$527.00
$707.00
$1,053.00
$1,434.00
$102.00
$443.00
$621.00
$457.00
$274.00
$467.00
$426.00
$599.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,915.00
$810.00
$925.00
$1,161.00
$981.00
$1,038.00
$1,243.00
$1,365.00
$714.00
$973.00
$1,190.00
$1,047.00
$960.00
$611.00
----$89.00
$98.00
$317.00
$730.00
$470.00
$816.00
$746.00
$1,056.00
$676.00
$980.00
$606.00
$427.00
$608.00
$1,011.00
$459.00
$569.00
$1,110.00
$989.00
$1,032.00
----$359.00
$174.00
$466.00
$483.00
$467.00
$560.00
$750.00
$1,133.00
$1,542.00
$108.00
$471.00
$661.00
$486.00
$293.00
$496.00
$453.00
$637.00
$2,002.00
$847.00
$967.00
$1,214.00
$1,028.00
$1,087.00
$1,302.00
$1,423.00
$749.00
$1,014.00
$1,236.00
$1,095.00
$1,003.00
$638.00
----$94.00
$103.00
$332.00
$765.00
$492.00
$855.00
$781.00
$1,108.00
$708.00
$1,028.00
$635.00
$447.00
$638.00
$1,061.00
$481.00
$596.00
$1,166.00
$1,044.00
$1,083.00
----$375.00
$183.00
$488.00
$506.00
$488.00
$586.00
$784.00
$1,201.00
$1,636.00
$114.00
$494.00
$692.00
$510.00
$305.00
$519.00
$474.00
$667.00
194
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
55175
55180
55200
55250
55300
55400
55450
55500
55520
55530
55535
55540
55550
55559
55600
55605
55650
55680
55700
55705
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55859
55860
55862
55865
55866
55870
55873
55899
56405
56420
56440
56441
56501
56515
56605
56606
56620
56625
56630
56631
56632
90
90
90
90
0
90
10
90
90
90
90
90
90
YYY
90
90
90
90
0
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
YYY
10
10
10
10
10
10
0
ZZZ
90
90
90
90
90
$426.00
$796.00
$310.00
$349.00
$167.00
$660.00
$391.00
$445.00
$446.00
$467.00
$496.00
$572.00
$486.00
BR
$486.00
$609.00
$853.00
$426.00
$183.00
$368.00
$555.00
$670.00
$1,331.00
$1,711.00
$1,989.00
$2,328.00
$1,153.00
$1,252.00
$1,705.00
$1,859.00
$2,222.00
$843.00
$1,012.00
$1,351.00
$1,890.00
$1,615.00
$166.00
$1,127.00
BR
$131.00
$130.00
$271.00
$183.00
$122.00
$200.00
$96.00
$49.00
$607.00
$735.00
$1,061.00
$1,400.00
$1,636.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$446.00
$877.00
$365.00
$554.00
$264.00
$693.00
$514.00
$476.00
$517.00
$475.00
$538.00
$638.00
$531.00
----$531.00
$674.00
$922.00
$450.00
$256.00
$407.00
$671.00
$754.00
$1,394.00
$1,747.00
$2,123.00
$2,324.00
$1,128.00
$1,226.00
$1,778.00
$1,898.00
$2,185.00
$1,011.00
$1,148.00
$1,445.00
$1,749.00
$2,207.00
$233.00
$1,505.00
----$193.00
$190.00
$329.00
$224.00
$196.00
$297.00
$116.00
$56.00
$661.00
$758.00
$1,071.00
$1,420.00
$1,649.00
$474.00
$934.00
$388.00
$593.00
$280.00
$735.00
$548.00
$509.00
$554.00
$505.00
$572.00
$685.00
$566.00
----$564.00
$717.00
$979.00
$479.00
$274.00
$433.00
$712.00
$801.00
$1,480.00
$1,854.00
$2,254.00
$2,466.00
$1,197.00
$1,302.00
$1,887.00
$2,015.00
$2,319.00
$1,073.00
$1,218.00
$1,535.00
$1,856.00
$2,327.00
$248.00
$1,593.00
----$207.00
$204.00
$354.00
$240.00
$210.00
$317.00
$124.00
$61.00
$711.00
$815.00
$1,151.00
$1,527.00
$1,773.00
$496.00
$979.00
$405.00
$616.00
$293.00
$769.00
$571.00
$535.00
$585.00
$529.00
$599.00
$725.00
$594.00
----$590.00
$752.00
$1,025.00
$500.00
$285.00
$452.00
$744.00
$837.00
$1,549.00
$1,941.00
$2,361.00
$2,582.00
$1,253.00
$1,362.00
$1,975.00
$2,109.00
$2,427.00
$1,122.00
$1,273.00
$1,608.00
$1,943.00
$2,424.00
$258.00
$1,663.00
----$218.00
$214.00
$372.00
$251.00
$221.00
$331.00
$131.00
$64.00
$752.00
$862.00
$1,218.00
$1,615.00
$1,879.00
$446.00
$877.00
$365.00
$321.00
$264.00
$693.00
$341.00
$476.00
$517.00
$475.00
$538.00
$638.00
$531.00
----$531.00
$674.00
$922.00
$450.00
$121.00
$407.00
$671.00
$754.00
$1,394.00
$1,747.00
$2,123.00
$2,324.00
$1,128.00
$1,226.00
$1,778.00
$1,898.00
$2,185.00
$1,011.00
$1,148.00
$1,445.00
$1,749.00
$2,207.00
$189.00
$1,505.00
----$141.00
$139.00
$269.00
$198.00
$149.00
$259.00
$85.00
$42.00
$661.00
$758.00
$1,071.00
$1,420.00
$1,649.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$474.00
$934.00
$388.00
$342.00
$280.00
$735.00
$362.00
$509.00
$554.00
$505.00
$572.00
$685.00
$566.00
----$564.00
$717.00
$979.00
$479.00
$128.00
$433.00
$712.00
$801.00
$1,480.00
$1,854.00
$2,254.00
$2,466.00
$1,197.00
$1,302.00
$1,887.00
$2,015.00
$2,319.00
$1,073.00
$1,218.00
$1,535.00
$1,856.00
$2,327.00
$200.00
$1,593.00
----$152.00
$149.00
$289.00
$212.00
$161.00
$276.00
$92.00
$46.00
$711.00
$815.00
$1,151.00
$1,527.00
$1,773.00
$496.00
$979.00
$405.00
$358.00
$293.00
$769.00
$378.00
$535.00
$585.00
$529.00
$599.00
$725.00
$594.00
----$590.00
$752.00
$1,025.00
$500.00
$135.00
$452.00
$744.00
$837.00
$1,549.00
$1,941.00
$2,361.00
$2,582.00
$1,253.00
$1,362.00
$1,975.00
$2,109.00
$2,427.00
$1,122.00
$1,273.00
$1,608.00
$1,943.00
$2,424.00
$209.00
$1,663.00
----$160.00
$157.00
$305.00
$223.00
$169.00
$289.00
$97.00
$48.00
$752.00
$862.00
$1,218.00
$1,615.00
$1,879.00
195
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
56633
56634
56637
56640
56700
56720
56740
56800
56805
56810
56820
56821
57000
57010
57020
57022
57023
57061
57065
57100
57105
57106
57107
57109
57110
57111
57112
57120
57130
57135
57150
57155
57160
57170
57180
57200
57210
57220
57230
57240
57250
57260
57265
57268
57270
57280
57282
57284
57287
57288
57289
57291
FUD 2003 MRA
90
90
90
90
10
0
10
10
90
10
0
0
10
90
0
10
10
10
10
0
10
90
90
90
90
90
90
90
10
10
0
90
0
0
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$1,350.00
$1,537.00
$1,806.00
$1,777.00
$227.00
$72.00
$321.00
$310.00
$1,349.00
$316.00
$119.00
$154.00
$237.00
$429.00
$118.00
$179.00
$290.00
$124.00
$251.00
$90.00
$132.00
$409.00
$1,467.00
$1,787.00
$1,015.00
$1,793.00
$1,907.00
$612.00
$220.00
$231.00
$50.00
$383.00
$67.00
$74.00
$124.00
$313.00
$395.00
$378.00
$442.00
$536.00
$485.00
$700.00
$902.00
$577.00
$867.00
$1,071.00
$734.00
$950.00
$685.00
$1,009.00
$879.00
$622.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,387.00
$1,547.00
$1,861.00
$1,857.00
$225.00
$59.00
$379.00
$347.00
$1,510.00
$367.00
$162.00
$210.00
$274.00
$525.00
$161.00
$243.00
$395.00
$176.00
$288.00
$121.00
$193.00
$546.00
$1,797.00
$2,046.00
$1,162.00
$2,132.00
$2,202.00
$645.00
$236.00
$291.00
$80.00
$533.00
$104.00
$119.00
$198.00
$374.00
$471.00
$407.00
$488.00
$529.00
$498.00
$720.00
$955.00
$601.00
$1,006.00
$1,226.00
$773.00
$1,061.00
$859.00
$1,005.00
$948.00
$708.00
$1,491.00
$1,663.00
$2,000.00
$1,997.00
$242.00
$63.00
$405.00
$372.00
$1,621.00
$394.00
$173.00
$224.00
$294.00
$563.00
$173.00
$261.00
$418.00
$190.00
$310.00
$129.00
$208.00
$585.00
$1,928.00
$2,180.00
$1,249.00
$2,292.00
$2,349.00
$693.00
$253.00
$313.00
$86.00
$572.00
$112.00
$128.00
$213.00
$402.00
$506.00
$437.00
$523.00
$567.00
$536.00
$774.00
$1,026.00
$645.00
$1,080.00
$1,316.00
$830.00
$1,138.00
$914.00
$1,068.00
$1,014.00
$761.00
$1,579.00
$1,760.00
$2,117.00
$2,116.00
$255.00
$67.00
$427.00
$393.00
$1,717.00
$417.00
$180.00
$234.00
$310.00
$595.00
$182.00
$275.00
$436.00
$199.00
$326.00
$136.00
$219.00
$618.00
$2,042.00
$2,293.00
$1,324.00
$2,431.00
$2,472.00
$734.00
$267.00
$329.00
$90.00
$604.00
$118.00
$134.00
$224.00
$424.00
$534.00
$461.00
$552.00
$598.00
$566.00
$819.00
$1,087.00
$682.00
$1,143.00
$1,392.00
$877.00
$1,202.00
$960.00
$1,120.00
$1,068.00
$804.00
$1,387.00
$1,547.00
$1,861.00
$1,857.00
$225.00
$59.00
$379.00
$347.00
$1,510.00
$367.00
$113.00
$156.00
$274.00
$525.00
$116.00
$243.00
$395.00
$128.00
$257.00
$91.00
$160.00
$546.00
$1,797.00
$2,046.00
$1,162.00
$2,132.00
$2,202.00
$645.00
$236.00
$255.00
$42.00
$533.00
$70.00
$68.00
$158.00
$374.00
$471.00
$407.00
$488.00
$529.00
$498.00
$720.00
$955.00
$601.00
$1,006.00
$1,226.00
$773.00
$1,061.00
$859.00
$1,005.00
$948.00
$708.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,491.00
$1,663.00
$2,000.00
$1,997.00
$242.00
$63.00
$405.00
$372.00
$1,621.00
$394.00
$121.00
$166.00
$294.00
$563.00
$124.00
$261.00
$418.00
$137.00
$276.00
$97.00
$172.00
$585.00
$1,928.00
$2,180.00
$1,249.00
$2,292.00
$2,349.00
$693.00
$253.00
$274.00
$46.00
$572.00
$75.00
$73.00
$170.00
$402.00
$506.00
$437.00
$523.00
$567.00
$536.00
$774.00
$1,026.00
$645.00
$1,080.00
$1,316.00
$830.00
$1,138.00
$914.00
$1,068.00
$1,014.00
$761.00
$1,579.00
$1,760.00
$2,117.00
$2,116.00
$255.00
$67.00
$427.00
$393.00
$1,717.00
$417.00
$127.00
$174.00
$310.00
$595.00
$132.00
$275.00
$436.00
$145.00
$291.00
$103.00
$181.00
$618.00
$2,042.00
$2,293.00
$1,324.00
$2,431.00
$2,472.00
$734.00
$267.00
$289.00
$48.00
$604.00
$80.00
$78.00
$180.00
$424.00
$534.00
$461.00
$552.00
$598.00
$566.00
$819.00
$1,087.00
$682.00
$1,143.00
$1,392.00
$877.00
$1,202.00
$960.00
$1,120.00
$1,068.00
$804.00
196
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
57292
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
57421
57452
57454
57455
57456
57460
57461
57500
57505
57510
57511
57513
57520
57522
57530
57531
57540
57545
57550
57555
57556
57700
57720
57800
57820
58100
58120
58140
58145
58146
58150
58152
58180
58200
58210
58240
58260
58262
FUD 2003 MRA
90
90
90
90
90
90
90
90
90
90
0
0
10
0
0
0
0
0
0
0
0
0
10
10
10
10
90
90
90
90
90
90
90
90
90
90
90
0
10
0
10
90
90
90
90
90
90
90
90
90
90
90
$925.00
$653.00
$995.00
$997.00
$769.00
$517.00
$612.00
$693.00
$916.00
$963.00
$70.00
$57.00
$75.00
$124.00
$162.00
$96.00
$125.00
$149.00
$141.00
$223.00
$333.00
$89.00
$105.00
$140.00
$159.00
$191.00
$359.00
$319.00
$386.00
$2,036.00
$815.00
$700.00
$486.00
$774.00
$718.00
$279.00
$328.00
$71.00
$182.00
$74.00
$297.00
$1,010.00
$677.00
$1,089.00
$1,110.00
$1,159.00
$1,118.00
$1,562.00
$2,080.00
$2,898.00
$926.00
$1,026.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,101.00
$664.00
$1,094.00
$1,271.00
$845.00
$579.00
$670.00
$682.00
$983.00
$1,486.00
$184.00
$221.00
$278.00
$169.00
$220.00
$165.00
$225.00
$203.00
$192.00
$404.00
$450.00
$154.00
$158.00
$254.00
$222.00
$233.00
$431.00
$369.00
$444.00
$2,225.00
$992.00
$1,060.00
$498.00
$780.00
$708.00
$319.00
$390.00
$81.00
$168.00
$152.00
$300.00
$1,170.00
$692.00
$1,495.00
$1,252.00
$1,634.00
$1,251.00
$1,741.00
$2,318.00
$3,073.00
$1,057.00
$1,196.00
$1,183.00
$712.00
$1,175.00
$1,367.00
$907.00
$616.00
$713.00
$728.00
$1,046.00
$1,591.00
$197.00
$237.00
$298.00
$180.00
$234.00
$176.00
$240.00
$216.00
$205.00
$435.00
$482.00
$165.00
$170.00
$273.00
$239.00
$251.00
$463.00
$397.00
$477.00
$2,383.00
$1,066.00
$1,140.00
$535.00
$839.00
$760.00
$342.00
$419.00
$88.00
$181.00
$161.00
$323.00
$1,258.00
$743.00
$1,595.00
$1,347.00
$1,743.00
$1,345.00
$1,871.00
$2,493.00
$3,301.00
$1,135.00
$1,284.00
$1,252.00
$752.00
$1,245.00
$1,449.00
$957.00
$645.00
$746.00
$765.00
$1,098.00
$1,681.00
$209.00
$248.00
$312.00
$188.00
$245.00
$184.00
$250.00
$226.00
$214.00
$456.00
$504.00
$173.00
$178.00
$286.00
$251.00
$263.00
$488.00
$418.00
$504.00
$2,517.00
$1,129.00
$1,207.00
$565.00
$887.00
$803.00
$361.00
$443.00
$92.00
$191.00
$168.00
$341.00
$1,333.00
$787.00
$1,679.00
$1,428.00
$1,832.00
$1,425.00
$1,983.00
$2,643.00
$3,497.00
$1,201.00
$1,359.00
$1,101.00
$664.00
$1,094.00
$1,271.00
$845.00
$579.00
$670.00
$682.00
$983.00
$1,486.00
$184.00
$147.00
$212.00
$120.00
$167.00
$113.00
$175.00
$152.00
$142.00
$221.00
$264.00
$79.00
$124.00
$181.00
$144.00
$181.00
$364.00
$312.00
$444.00
$2,225.00
$992.00
$1,060.00
$498.00
$780.00
$708.00
$319.00
$390.00
$67.00
$149.00
$118.00
$282.00
$1,170.00
$692.00
$1,495.00
$1,252.00
$1,634.00
$1,251.00
$1,741.00
$2,318.00
$3,073.00
$1,057.00
$1,196.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,183.00
$712.00
$1,175.00
$1,367.00
$907.00
$616.00
$713.00
$728.00
$1,046.00
$1,591.00
$197.00
$157.00
$228.00
$128.00
$177.00
$121.00
$186.00
$161.00
$151.00
$238.00
$282.00
$85.00
$134.00
$194.00
$154.00
$194.00
$392.00
$336.00
$477.00
$2,383.00
$1,066.00
$1,140.00
$535.00
$839.00
$760.00
$342.00
$419.00
$72.00
$160.00
$125.00
$303.00
$1,258.00
$743.00
$1,595.00
$1,347.00
$1,743.00
$1,345.00
$1,871.00
$2,493.00
$3,301.00
$1,135.00
$1,284.00
$1,252.00
$752.00
$1,245.00
$1,449.00
$957.00
$645.00
$746.00
$765.00
$1,098.00
$1,681.00
$209.00
$166.00
$239.00
$134.00
$185.00
$127.00
$194.00
$169.00
$159.00
$252.00
$298.00
$90.00
$141.00
$205.00
$163.00
$205.00
$414.00
$355.00
$504.00
$2,517.00
$1,129.00
$1,207.00
$565.00
$887.00
$803.00
$361.00
$443.00
$77.00
$170.00
$130.00
$321.00
$1,333.00
$787.00
$1,679.00
$1,428.00
$1,832.00
$1,425.00
$1,983.00
$2,643.00
$3,497.00
$1,201.00
$1,359.00
197
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
58263
58267
58270
58275
58280
58285
58290
58291
58292
58293
58294
58300
58301
58321
58322
58323
58340
58345
58346
58350
58353
58400
58410
58520
58540
58545
58546
58550
58552
58553
58554
58555
58558
58559
58560
58561
58562
58563
58578
58579
58600
58605
58611
58615
58660
58661
58662
58670
58671
58672
58673
58679
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
10
90
10
10
90
90
90
90
10
10
10
10
10
10
0
0
0
0
0
0
0
YYY
YYY
90
90
ZZZ
10
90
10
90
90
90
90
90
YYY
$1,120.00
$1,133.00
$1,019.00
$1,121.00
$1,132.00
$1,360.00
$1,089.00
$1,197.00
$1,268.00
$1,318.00
$1,168.00
$96.00
$71.00
$81.00
$90.00
$24.00
$87.00
$335.00
$408.00
$103.00
$225.00
$519.00
$752.00
$663.00
$923.00
$876.00
$1,104.00
$1,038.00
$853.00
$1,096.00
$1,085.00
$261.00
$340.00
$436.00
$482.00
$677.00
$339.00
$450.00
BR
BR
$337.00
$298.00
$47.00
$319.00
$793.00
$804.00
$807.00
$450.00
$463.00
$872.00
$928.00
BR
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,295.00
$1,369.00
$1,156.00
$1,266.00
$1,354.00
$1,769.00
$1,491.00
$1,640.00
$1,738.00
$1,804.00
$1,600.00
----$147.00
$99.00
$111.00
$39.00
$670.00
$342.00
$569.00
$151.00
$312.00
$551.00
$1,029.00
$964.00
$1,155.00
$1,206.00
$1,514.00
$1,158.00
$1,175.00
$1,500.00
$1,485.00
$292.00
$374.00
$481.00
$546.00
$777.00
$406.00
$482.00
--------$466.00
$425.00
$106.00
$373.00
$914.00
$885.00
$939.00
$493.00
$495.00
$1,044.00
$1,115.00
-----
$1,390.00
$1,467.00
$1,241.00
$1,359.00
$1,452.00
$1,892.00
$1,585.00
$1,746.00
$1,851.00
$1,919.00
$1,702.00
----$158.00
$106.00
$119.00
$42.00
$721.00
$365.00
$611.00
$163.00
$335.00
$592.00
$1,102.00
$1,035.00
$1,236.00
$1,296.00
$1,615.00
$1,245.00
$1,263.00
$1,595.00
$1,579.00
$314.00
$402.00
$517.00
$588.00
$836.00
$437.00
$518.00
--------$497.00
$452.00
$112.00
$402.00
$983.00
$951.00
$1,009.00
$530.00
$532.00
$1,120.00
$1,200.00
-----
$1,472.00
$1,549.00
$1,313.00
$1,439.00
$1,534.00
$1,996.00
$1,661.00
$1,832.00
$1,944.00
$2,011.00
$1,786.00
----$167.00
$112.00
$126.00
$44.00
$747.00
$384.00
$646.00
$170.00
$355.00
$626.00
$1,162.00
$1,097.00
$1,306.00
$1,372.00
$1,699.00
$1,320.00
$1,339.00
$1,672.00
$1,655.00
$332.00
$427.00
$549.00
$624.00
$887.00
$463.00
$550.00
--------$521.00
$473.00
$117.00
$424.00
$1,042.00
$1,009.00
$1,070.00
$560.00
$562.00
$1,185.00
$1,272.00
-----
$1,295.00
$1,369.00
$1,156.00
$1,266.00
$1,354.00
$1,769.00
$1,491.00
$1,640.00
$1,738.00
$1,804.00
$1,600.00
----$97.00
$71.00
$83.00
$18.00
$65.00
$342.00
$569.00
$108.00
$312.00
$551.00
$1,029.00
$964.00
$1,155.00
$1,206.00
$1,514.00
$1,158.00
$1,175.00
$1,500.00
$1,485.00
$262.00
$374.00
$481.00
$546.00
$777.00
$406.00
$482.00
--------$466.00
$425.00
$106.00
$373.00
$914.00
$885.00
$939.00
$493.00
$495.00
$1,044.00
$1,115.00
-----
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,390.00
$1,467.00
$1,241.00
$1,359.00
$1,452.00
$1,892.00
$1,585.00
$1,746.00
$1,851.00
$1,919.00
$1,702.00
----$104.00
$77.00
$90.00
$19.00
$70.00
$365.00
$611.00
$117.00
$335.00
$592.00
$1,102.00
$1,035.00
$1,236.00
$1,296.00
$1,615.00
$1,245.00
$1,263.00
$1,595.00
$1,579.00
$282.00
$402.00
$517.00
$588.00
$836.00
$437.00
$518.00
--------$497.00
$452.00
$112.00
$402.00
$983.00
$951.00
$1,009.00
$530.00
$532.00
$1,120.00
$1,200.00
-----
$1,472.00
$1,549.00
$1,313.00
$1,439.00
$1,534.00
$1,996.00
$1,661.00
$1,832.00
$1,944.00
$2,011.00
$1,786.00
----$110.00
$82.00
$95.00
$20.00
$74.00
$384.00
$646.00
$123.00
$355.00
$626.00
$1,162.00
$1,097.00
$1,306.00
$1,372.00
$1,699.00
$1,320.00
$1,339.00
$1,672.00
$1,655.00
$299.00
$427.00
$549.00
$624.00
$887.00
$463.00
$550.00
--------$521.00
$473.00
$117.00
$424.00
$1,042.00
$1,009.00
$1,070.00
$560.00
$562.00
$1,185.00
$1,272.00
-----
198
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
58700
58720
58740
58750
58752
58760
58770
58800
58805
58820
58822
58823
58825
58900
58920
58925
58940
58943
58950
58951
58952
58953
58954
58960
58999
59000
59001
59012
59015
59020
59025
59030
59050
59051
59100
59120
59121
59130
59135
59136
59140
59150
59151
59160
59200
59300
59320
59325
59350
59400
59409
59410
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
YYY
0
0
0
0
0
0
0
0
0
90
90
90
90
90
90
90
90
90
10
0
0
0
0
0
0
0
0
$544.00
$844.00
$508.00
$949.00
$893.00
$769.00
$763.00
$343.00
$509.00
$326.00
$603.00
$216.00
$469.00
$489.00
$571.00
$820.00
$592.00
$1,368.00
$1,170.00
$1,703.00
$1,876.00
$1,839.00
$1,999.00
$1,174.00
BR
$123.00
$167.00
$267.00
$168.00
$85.00
$54.00
$155.00
$71.00
$47.00
$633.00
$893.00
$768.00
$832.00
$1,083.00
$934.00
$461.00
$543.00
$690.00
$279.00
$79.00
$179.00
$196.00
$316.00
$375.00
$1,816.00
$1,019.00
$1,123.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$929.00
$925.00
$1,082.00
$1,203.00
$1,187.00
$1,072.00
$1,134.00
$445.00
$501.00
$394.00
$814.00
$294.00
$871.00
$509.00
$887.00
$915.00
$606.00
$1,506.00
$1,390.00
$1,819.00
$2,028.00
$2,556.00
$2,776.00
$1,227.00
----$172.00
$231.00
$292.00
$214.00
$85.00
$56.00
$175.00
$73.00
$61.00
$1,071.00
$1,006.00
$1,024.00
$1,163.00
$1,202.00
$1,138.00
$502.00
$978.00
$953.00
$338.00
$114.00
$250.00
$217.00
$347.00
$403.00
$2,211.00
$1,101.00
$1,230.00
$984.00
$994.00
$1,142.00
$1,295.00
$1,277.00
$1,153.00
$1,219.00
$477.00
$538.00
$420.00
$873.00
$312.00
$924.00
$546.00
$941.00
$983.00
$651.00
$1,620.00
$1,490.00
$1,954.00
$2,182.00
$2,751.00
$2,986.00
$1,319.00
----$187.00
$247.00
$321.00
$235.00
$95.00
$62.00
$192.00
$80.00
$67.00
$1,177.00
$1,106.00
$1,125.00
$1,280.00
$1,322.00
$1,251.00
$551.00
$1,053.00
$1,032.00
$369.00
$124.00
$274.00
$238.00
$382.00
$444.00
$2,427.00
$1,212.00
$1,354.00
$1,027.00
$1,054.00
$1,187.00
$1,373.00
$1,355.00
$1,222.00
$1,293.00
$501.00
$568.00
$439.00
$922.00
$326.00
$966.00
$577.00
$985.00
$1,042.00
$690.00
$1,717.00
$1,574.00
$2,070.00
$2,314.00
$2,919.00
$3,168.00
$1,397.00
----$200.00
$260.00
$348.00
$253.00
$103.00
$68.00
$208.00
$87.00
$73.00
$1,274.00
$1,197.00
$1,217.00
$1,389.00
$1,431.00
$1,354.00
$595.00
$1,117.00
$1,101.00
$394.00
$132.00
$295.00
$258.00
$414.00
$482.00
$2,616.00
$1,315.00
$1,469.00
$929.00
$925.00
$1,082.00
$1,203.00
$1,187.00
$1,072.00
$1,134.00
$444.00
$501.00
$394.00
$814.00
$294.00
$871.00
$509.00
$887.00
$915.00
$606.00
$1,506.00
$1,390.00
$1,819.00
$2,028.00
$2,556.00
$2,776.00
$1,227.00
----$115.00
$231.00
$292.00
$189.00
$85.00
$56.00
$175.00
$73.00
$61.00
$1,071.00
$1,006.00
$1,024.00
$1,163.00
$1,202.00
$1,138.00
$502.00
$978.00
$953.00
$273.00
$65.00
$197.00
$217.00
$347.00
$403.00
$2,211.00
$1,101.00
$1,230.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$984.00
$994.00
$1,142.00
$1,295.00
$1,277.00
$1,153.00
$1,219.00
$476.00
$538.00
$420.00
$873.00
$312.00
$924.00
$546.00
$941.00
$983.00
$651.00
$1,620.00
$1,490.00
$1,954.00
$2,182.00
$2,751.00
$2,986.00
$1,319.00
----$126.00
$247.00
$321.00
$208.00
$95.00
$62.00
$192.00
$80.00
$67.00
$1,177.00
$1,106.00
$1,125.00
$1,280.00
$1,322.00
$1,251.00
$551.00
$1,053.00
$1,032.00
$299.00
$71.00
$217.00
$238.00
$382.00
$444.00
$2,427.00
$1,212.00
$1,354.00
$1,027.00
$1,054.00
$1,187.00
$1,373.00
$1,355.00
$1,222.00
$1,293.00
$499.00
$568.00
$439.00
$922.00
$326.00
$966.00
$577.00
$985.00
$1,042.00
$690.00
$1,717.00
$1,574.00
$2,070.00
$2,314.00
$2,919.00
$3,168.00
$1,397.00
----$136.00
$260.00
$348.00
$226.00
$103.00
$68.00
$208.00
$87.00
$73.00
$1,274.00
$1,197.00
$1,217.00
$1,389.00
$1,431.00
$1,354.00
$595.00
$1,117.00
$1,101.00
$322.00
$78.00
$236.00
$258.00
$414.00
$482.00
$2,616.00
$1,315.00
$1,469.00
199
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
59412
59414
59425
59426
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622
59812
59820
59821
59830
59840
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
59898
59899
60000
60001
60100
60200
60210
60212
60220
60225
60240
60252
60254
60260
60270
60271
60280
60281
60500
60502
60505
60512
0
0
0
0
0
0
0
0
ZZZ
0
0
0
0
0
0
90
90
90
90
10
10
90
90
90
90
90
90
0
90
0
YYY
YYY
10
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
$141.00
$134.00
$414.00
$708.00
$140.00
$2,064.00
$1,199.00
$1,324.00
$591.00
$1,805.00
$1,113.00
$1,208.00
$2,035.00
$1,293.00
$1,397.00
$343.00
$389.00
$398.00
$496.00
$331.00
$443.00
$449.00
$464.00
$642.00
$477.00
$577.00
$711.00
$304.00
$348.00
$192.00
BR
BR
$114.00
$88.00
$96.00
$744.00
$872.00
$1,170.00
$851.00
$1,107.00
$1,228.00
$1,427.00
$1,911.00
$1,022.00
$1,468.00
$1,210.00
$546.00
$670.00
$1,232.00
$1,475.00
$1,631.00
$310.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$147.00
$131.00
$515.00
$905.00
$179.00
$2,510.00
$1,299.00
$1,468.00
$694.00
$2,335.00
$1,235.00
$1,358.00
$2,670.00
$1,424.00
$1,604.00
$415.00
$425.00
$461.00
$570.00
$380.00
$597.00
$499.00
$519.00
$733.00
$537.00
$649.00
$788.00
$323.00
$536.00
$229.00
--------$212.00
$133.00
$172.00
$854.00
$926.00
$1,304.00
$1,001.00
$1,179.00
$1,345.00
$1,694.00
$2,252.00
$1,470.00
$1,694.00
$1,411.00
$575.00
$781.00
$1,297.00
$1,619.00
$1,775.00
$333.00
$162.00
$145.00
$564.00
$990.00
$197.00
$2,754.00
$1,430.00
$1,615.00
$764.00
$2,563.00
$1,359.00
$1,495.00
$2,930.00
$1,568.00
$1,764.00
$450.00
$465.00
$505.00
$626.00
$415.00
$653.00
$549.00
$571.00
$805.00
$590.00
$714.00
$867.00
$356.00
$581.00
$251.00
--------$228.00
$142.00
$182.00
$916.00
$994.00
$1,400.00
$1,071.00
$1,264.00
$1,443.00
$1,810.00
$2,402.00
$1,570.00
$1,815.00
$1,509.00
$615.00
$835.00
$1,394.00
$1,740.00
$1,908.00
$358.00
$175.00
$157.00
$605.00
$1,062.00
$214.00
$2,969.00
$1,553.00
$1,750.00
$829.00
$2,764.00
$1,475.00
$1,621.00
$3,158.00
$1,702.00
$1,911.00
$480.00
$499.00
$543.00
$676.00
$443.00
$700.00
$595.00
$618.00
$871.00
$639.00
$773.00
$940.00
$387.00
$619.00
$269.00
--------$238.00
$147.00
$189.00
$965.00
$1,050.00
$1,480.00
$1,127.00
$1,336.00
$1,525.00
$1,905.00
$2,521.00
$1,652.00
$1,914.00
$1,588.00
$645.00
$877.00
$1,478.00
$1,844.00
$2,021.00
$380.00
$147.00
$131.00
$390.00
$674.00
$179.00
$2,510.00
$1,299.00
$1,468.00
$694.00
$2,335.00
$1,235.00
$1,358.00
$2,670.00
$1,424.00
$1,604.00
$362.00
$378.00
$415.00
$570.00
$295.00
$497.00
$499.00
$519.00
$733.00
$537.00
$649.00
$788.00
$323.00
$536.00
$176.00
--------$202.00
$70.00
$108.00
$854.00
$926.00
$1,304.00
$1,001.00
$1,179.00
$1,345.00
$1,694.00
$2,252.00
$1,470.00
$1,694.00
$1,411.00
$575.00
$781.00
$1,297.00
$1,619.00
$1,775.00
$333.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$162.00
$145.00
$429.00
$742.00
$197.00
$2,754.00
$1,430.00
$1,615.00
$764.00
$2,563.00
$1,359.00
$1,495.00
$2,930.00
$1,568.00
$1,764.00
$394.00
$415.00
$456.00
$626.00
$324.00
$546.00
$549.00
$571.00
$805.00
$590.00
$714.00
$867.00
$356.00
$581.00
$193.00
--------$217.00
$74.00
$114.00
$916.00
$994.00
$1,400.00
$1,071.00
$1,264.00
$1,443.00
$1,810.00
$2,402.00
$1,570.00
$1,815.00
$1,509.00
$615.00
$835.00
$1,394.00
$1,740.00
$1,908.00
$358.00
$175.00
$157.00
$466.00
$806.00
$214.00
$2,969.00
$1,553.00
$1,750.00
$829.00
$2,764.00
$1,475.00
$1,621.00
$3,158.00
$1,702.00
$1,911.00
$422.00
$447.00
$492.00
$676.00
$349.00
$589.00
$595.00
$618.00
$871.00
$639.00
$773.00
$940.00
$387.00
$619.00
$210.00
--------$227.00
$77.00
$118.00
$965.00
$1,050.00
$1,480.00
$1,127.00
$1,336.00
$1,525.00
$1,905.00
$2,521.00
$1,652.00
$1,914.00
$1,588.00
$645.00
$877.00
$1,478.00
$1,844.00
$2,021.00
$380.00
200
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
60520
60521
60522
60540
60545
60600
60605
60650
60659
60699
61020
61026
61050
61055
61070
61105
61107
61108
61120
61140
61150
61151
61154
61156
61210
61215
61250
61253
61304
61305
61312
61313
61314
61315
61316
61320
61321
61322
61323
61330
61332
61333
61334
61340
61343
61345
61440
61450
61458
61460
61470
61480
90
90
90
90
90
90
90
90
YYY
YYY
0
0
0
0
0
90
0
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$1,405.00
$1,591.00
$1,820.00
$1,272.00
$1,505.00
$1,477.00
$1,624.00
$1,340.00
BR
BR
$150.00
$138.00
$106.00
$143.00
$67.00
$503.00
$863.00
$959.00
$733.00
$1,389.00
$1,503.00
$795.00
$1,393.00
$1,473.00
$527.00
$637.00
$888.00
$1,042.00
$2,005.00
$2,419.00
$2,187.00
$2,207.00
$2,200.00
$2,393.00
$88.00
$2,118.00
$2,310.00
$1,779.00
$1,842.00
$1,706.00
$2,307.00
$2,231.00
$1,525.00
$1,584.00
$2,673.00
$2,259.00
$2,110.00
$2,173.00
$2,433.00
$2,426.00
$1,982.00
$1,922.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,443.00
$1,673.00
$1,978.00
$1,320.00
$1,567.00
$1,667.00
$2,047.00
$1,526.00
--------$160.00
$169.00
$146.00
$183.00
$101.00
$523.00
$482.00
$1,000.00
$856.00
$1,496.00
$1,631.00
$1,173.00
$1,424.00
$1,533.00
$553.00
$509.00
$996.00
$1,151.00
$2,027.00
$2,443.00
$2,310.00
$2,323.00
$2,127.00
$2,556.00
$126.00
$2,364.00
$2,586.00
$2,483.00
$2,568.00
$2,026.00
$2,418.00
$2,330.00
$1,647.00
$1,731.00
$2,764.00
$2,511.00
$2,445.00
$2,393.00
$2,523.00
$2,614.00
$2,345.00
$2,470.00
$1,556.00
$1,811.00
$2,140.00
$1,411.00
$1,678.00
$1,795.00
$2,208.00
$1,640.00
--------$175.00
$183.00
$157.00
$195.00
$109.00
$577.00
$532.00
$1,102.00
$945.00
$1,650.00
$1,800.00
$1,294.00
$1,572.00
$1,696.00
$610.00
$561.00
$1,097.00
$1,265.00
$2,236.00
$2,696.00
$2,551.00
$2,566.00
$2,329.00
$2,824.00
$143.00
$2,612.00
$2,847.00
$2,723.00
$2,811.00
$2,185.00
$2,638.00
$2,490.00
$1,802.00
$1,909.00
$3,053.00
$2,766.00
$2,707.00
$2,639.00
$2,780.00
$2,871.00
$2,576.00
$2,733.00
$1,651.00
$1,929.00
$2,280.00
$1,489.00
$1,772.00
$1,898.00
$2,336.00
$1,740.00
--------$188.00
$194.00
$165.00
$204.00
$115.00
$624.00
$577.00
$1,193.00
$1,025.00
$1,789.00
$1,954.00
$1,402.00
$1,706.00
$1,844.00
$661.00
$606.00
$1,187.00
$1,367.00
$2,426.00
$2,925.00
$2,769.00
$2,787.00
$2,510.00
$3,068.00
$160.00
$2,838.00
$3,083.00
$2,944.00
$3,033.00
$2,319.00
$2,832.00
$2,621.00
$1,940.00
$2,070.00
$3,316.00
$2,997.00
$2,946.00
$2,863.00
$3,013.00
$3,102.00
$2,784.00
$2,972.00
$1,443.00
$1,673.00
$1,978.00
$1,320.00
$1,567.00
$1,667.00
$2,047.00
$1,526.00
--------$160.00
$169.00
$146.00
$183.00
$101.00
$523.00
$482.00
$1,000.00
$856.00
$1,496.00
$1,631.00
$1,173.00
$1,424.00
$1,533.00
$553.00
$509.00
$996.00
$1,151.00
$2,027.00
$2,443.00
$2,310.00
$2,323.00
$2,127.00
$2,556.00
$126.00
$2,364.00
$2,586.00
$2,483.00
$2,568.00
$2,026.00
$2,418.00
$2,330.00
$1,647.00
$1,731.00
$2,764.00
$2,511.00
$2,445.00
$2,393.00
$2,523.00
$2,614.00
$2,345.00
$2,470.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,556.00
$1,811.00
$2,140.00
$1,411.00
$1,678.00
$1,795.00
$2,208.00
$1,640.00
--------$175.00
$183.00
$157.00
$195.00
$109.00
$577.00
$532.00
$1,102.00
$945.00
$1,650.00
$1,800.00
$1,294.00
$1,572.00
$1,696.00
$610.00
$561.00
$1,097.00
$1,265.00
$2,236.00
$2,696.00
$2,551.00
$2,566.00
$2,329.00
$2,824.00
$143.00
$2,612.00
$2,847.00
$2,723.00
$2,811.00
$2,185.00
$2,638.00
$2,490.00
$1,802.00
$1,909.00
$3,053.00
$2,766.00
$2,707.00
$2,639.00
$2,780.00
$2,871.00
$2,576.00
$2,733.00
$1,651.00
$1,929.00
$2,280.00
$1,489.00
$1,772.00
$1,898.00
$2,336.00
$1,740.00
--------$188.00
$194.00
$165.00
$204.00
$115.00
$624.00
$577.00
$1,193.00
$1,025.00
$1,789.00
$1,954.00
$1,402.00
$1,706.00
$1,844.00
$661.00
$606.00
$1,187.00
$1,367.00
$2,426.00
$2,925.00
$2,769.00
$2,787.00
$2,510.00
$3,068.00
$160.00
$2,838.00
$3,083.00
$2,944.00
$3,033.00
$2,319.00
$2,832.00
$2,621.00
$1,940.00
$2,070.00
$3,316.00
$2,997.00
$2,946.00
$2,863.00
$3,013.00
$3,102.00
$2,784.00
$2,972.00
201
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
61490
61500
61501
61510
61512
61514
61516
61517
61518
61519
61520
61521
61522
61524
61526
61530
61531
61533
61534
61535
61536
61538
61539
61541
61542
61543
61544
61545
61546
61548
61550
61552
61556
61557
61558
61559
61563
61564
61570
61571
61575
61576
61580
61581
61582
61583
61584
61585
61586
61590
61591
61592
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$1,687.00
$1,637.00
$1,353.00
$2,506.00
$2,981.00
$2,262.00
$2,253.00
$74.00
$3,163.00
$3,450.00
$4,349.00
$3,667.00
$2,415.00
$2,484.00
$3,918.00
$3,611.00
$1,344.00
$1,712.00
$1,535.00
$958.00
$2,862.00
$2,466.00
$2,660.00
$2,363.00
$2,533.00
$2,307.00
$2,271.00
$3,474.00
$2,695.00
$1,964.00
$1,141.00
$1,463.00
$1,760.00
$1,807.00
$2,085.00
$2,700.00
$2,175.00
$2,597.00
$1,975.00
$2,140.00
$2,992.00
$3,772.00
$2,383.00
$2,674.00
$2,557.00
$2,972.00
$2,830.00
$3,142.00
$2,097.00
$3,299.00
$3,491.00
$3,245.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,396.00
$1,685.00
$1,402.00
$2,643.00
$3,237.00
$2,356.00
$2,284.00
$102.00
$3,447.00
$3,789.00
$4,957.00
$4,065.00
$2,680.00
$2,543.00
$4,554.00
$3,917.00
$1,390.00
$1,837.00
$1,963.00
$1,128.00
$3,243.00
$2,492.00
$2,966.00
$2,631.00
$2,909.00
$2,719.00
$2,308.00
$3,997.00
$2,877.00
$1,982.00
$1,167.00
$1,519.00
$1,935.00
$2,104.00
$2,192.00
$3,052.00
$2,421.00
$3,072.00
$2,235.00
$2,431.00
$3,085.00
$4,438.00
$2,636.00
$2,707.00
$2,938.00
$3,372.00
$3,184.00
$3,442.00
$2,280.00
$3,620.00
$3,819.00
$3,633.00
$2,651.00
$1,851.00
$1,538.00
$2,920.00
$3,576.00
$2,602.00
$2,522.00
$108.00
$3,807.00
$4,180.00
$5,453.00
$4,488.00
$2,944.00
$2,794.00
$4,936.00
$4,259.00
$1,531.00
$2,024.00
$2,165.00
$1,243.00
$3,570.00
$2,751.00
$3,280.00
$2,898.00
$3,218.00
$3,008.00
$2,544.00
$4,417.00
$3,171.00
$2,170.00
$1,246.00
$1,604.00
$2,117.00
$2,327.00
$2,358.00
$3,376.00
$2,650.00
$3,401.00
$2,460.00
$2,682.00
$3,359.00
$4,756.00
$2,827.00
$2,907.00
$3,243.00
$3,714.00
$3,505.00
$3,763.00
$2,478.00
$3,895.00
$4,130.00
$4,001.00
$2,883.00
$1,998.00
$1,658.00
$3,171.00
$3,886.00
$2,825.00
$2,738.00
$113.00
$4,135.00
$4,536.00
$5,901.00
$4,873.00
$3,181.00
$3,018.00
$5,266.00
$4,556.00
$1,658.00
$2,192.00
$2,348.00
$1,345.00
$3,865.00
$2,986.00
$3,567.00
$3,140.00
$3,500.00
$3,272.00
$2,759.00
$4,801.00
$3,437.00
$2,337.00
$1,312.00
$1,670.00
$2,279.00
$2,530.00
$2,497.00
$3,673.00
$2,854.00
$3,704.00
$2,663.00
$2,911.00
$3,598.00
$5,019.00
$2,982.00
$3,081.00
$3,519.00
$4,022.00
$3,795.00
$4,047.00
$2,649.00
$4,124.00
$4,395.00
$4,334.00
$2,396.00
$1,685.00
$1,402.00
$2,643.00
$3,237.00
$2,356.00
$2,284.00
$102.00
$3,447.00
$3,789.00
$4,957.00
$4,065.00
$2,680.00
$2,543.00
$4,554.00
$3,917.00
$1,390.00
$1,837.00
$1,963.00
$1,128.00
$3,243.00
$2,492.00
$2,966.00
$2,631.00
$2,909.00
$2,719.00
$2,308.00
$3,997.00
$2,877.00
$1,982.00
$1,167.00
$1,519.00
$1,935.00
$2,104.00
$2,192.00
$3,052.00
$2,421.00
$3,072.00
$2,235.00
$2,431.00
$3,085.00
$4,438.00
$2,636.00
$2,707.00
$2,938.00
$3,372.00
$3,184.00
$3,442.00
$2,280.00
$3,620.00
$3,819.00
$3,633.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,651.00
$1,851.00
$1,538.00
$2,920.00
$3,576.00
$2,602.00
$2,522.00
$108.00
$3,807.00
$4,180.00
$5,453.00
$4,488.00
$2,944.00
$2,794.00
$4,936.00
$4,259.00
$1,531.00
$2,024.00
$2,165.00
$1,243.00
$3,570.00
$2,751.00
$3,280.00
$2,898.00
$3,218.00
$3,008.00
$2,544.00
$4,417.00
$3,171.00
$2,170.00
$1,246.00
$1,604.00
$2,117.00
$2,327.00
$2,358.00
$3,376.00
$2,650.00
$3,401.00
$2,460.00
$2,682.00
$3,359.00
$4,756.00
$2,827.00
$2,907.00
$3,243.00
$3,714.00
$3,505.00
$3,763.00
$2,478.00
$3,895.00
$4,130.00
$4,001.00
$2,883.00
$1,998.00
$1,658.00
$3,171.00
$3,886.00
$2,825.00
$2,738.00
$113.00
$4,135.00
$4,536.00
$5,901.00
$4,873.00
$3,181.00
$3,018.00
$5,266.00
$4,556.00
$1,658.00
$2,192.00
$2,348.00
$1,345.00
$3,865.00
$2,986.00
$3,567.00
$3,140.00
$3,500.00
$3,272.00
$2,759.00
$4,801.00
$3,437.00
$2,337.00
$1,312.00
$1,670.00
$2,279.00
$2,530.00
$2,497.00
$3,673.00
$2,854.00
$3,704.00
$2,663.00
$2,911.00
$3,598.00
$5,019.00
$2,982.00
$3,081.00
$3,519.00
$4,022.00
$3,795.00
$4,047.00
$2,649.00
$4,124.00
$4,395.00
$4,334.00
202
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
61595
61596
61597
61598
61600
61601
61605
61606
61607
61608
61609
61610
61611
61612
61613
61615
61616
61618
61619
61623
61624
61626
61680
61682
61684
61686
61690
61692
61697
61698
61700
61702
61703
61705
61708
61710
61711
61720
61735
61750
61751
61760
61770
61790
61791
61793
61795
61850
61860
61862
61870
61875
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
ZZZ
ZZZ
90
90
90
90
90
0
0
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
90
90
$2,350.00
$2,827.00
$3,046.00
$2,693.00
$2,039.00
$2,279.00
$2,299.00
$3,178.00
$2,961.00
$3,458.00
$798.00
$2,354.00
$584.00
$2,219.00
$3,375.00
$2,576.00
$3,535.00
$1,389.00
$1,682.00
$540.00
$1,073.00
$877.00
$2,758.00
$4,798.00
$3,341.00
$5,012.00
$2,556.00
$4,007.00
$3,231.00
$3,103.00
$4,037.00
$4,019.00
$1,444.00
$3,043.00
$2,546.00
$2,129.00
$3,150.00
$1,558.00
$1,664.00
$1,521.00
$1,628.00
$1,670.00
$1,867.00
$952.00
$1,205.00
$1,594.00
$371.00
$1,090.00
$1,197.00
$1,551.00
$616.00
$984.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,625.00
$3,138.00
$3,372.00
$2,983.00
$2,279.00
$2,589.00
$2,538.00
$3,532.00
$3,266.00
$3,862.00
$871.00
$2,376.00
$639.00
$2,297.00
$3,761.00
$2,915.00
$3,942.00
$1,601.00
$1,915.00
$739.00
$1,434.00
$1,167.00
$2,834.00
$5,575.00
$3,638.00
$5,853.00
$2,696.00
$4,672.00
$4,608.00
$4,415.00
$4,597.00
$4,414.00
$1,661.00
$3,229.00
$2,688.00
$2,355.00
$3,311.00
$1,594.00
$1,919.00
$1,690.00
$1,642.00
$1,847.00
$1,979.00
$957.00
$1,382.00
$1,627.00
$357.00
$1,161.00
$1,939.00
$1,818.00
$1,390.00
$1,366.00
$2,824.00
$3,392.00
$3,701.00
$3,241.00
$2,464.00
$2,850.00
$2,717.00
$3,875.00
$3,566.00
$4,261.00
$965.00
$2,569.00
$709.00
$2,490.00
$4,156.00
$3,172.00
$4,310.00
$1,754.00
$2,094.00
$781.00
$1,519.00
$1,233.00
$3,126.00
$6,168.00
$4,015.00
$6,472.00
$2,967.00
$5,156.00
$5,094.00
$4,883.00
$5,079.00
$4,876.00
$1,835.00
$3,553.00
$2,853.00
$2,518.00
$3,659.00
$1,763.00
$2,119.00
$1,867.00
$1,814.00
$2,049.00
$2,179.00
$1,049.00
$1,528.00
$1,797.00
$395.00
$1,275.00
$2,136.00
$2,009.00
$1,499.00
$1,493.00
$2,989.00
$3,608.00
$3,999.00
$3,464.00
$2,622.00
$3,085.00
$2,862.00
$4,182.00
$3,831.00
$4,625.00
$1,052.00
$2,740.00
$774.00
$2,660.00
$4,517.00
$3,395.00
$4,635.00
$1,889.00
$2,253.00
$815.00
$1,589.00
$1,287.00
$3,391.00
$6,713.00
$4,358.00
$7,041.00
$3,212.00
$5,598.00
$5,540.00
$5,313.00
$5,520.00
$5,298.00
$1,993.00
$3,847.00
$2,989.00
$2,653.00
$3,979.00
$1,915.00
$2,301.00
$2,028.00
$1,969.00
$2,240.00
$2,360.00
$1,131.00
$1,660.00
$1,950.00
$430.00
$1,376.00
$2,315.00
$2,182.00
$1,590.00
$1,605.00
$2,625.00
$3,138.00
$3,372.00
$2,983.00
$2,279.00
$2,589.00
$2,538.00
$3,532.00
$3,266.00
$3,862.00
$871.00
$2,376.00
$639.00
$2,297.00
$3,761.00
$2,915.00
$3,942.00
$1,601.00
$1,915.00
$739.00
$1,434.00
$1,167.00
$2,834.00
$5,575.00
$3,638.00
$5,853.00
$2,696.00
$4,672.00
$4,608.00
$4,415.00
$4,597.00
$4,414.00
$1,661.00
$3,229.00
$2,688.00
$2,355.00
$3,311.00
$1,594.00
$1,919.00
$1,690.00
$1,642.00
$1,847.00
$1,979.00
$957.00
$1,382.00
$1,627.00
$357.00
$1,161.00
$1,939.00
$1,818.00
$1,390.00
$1,366.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,824.00
$3,392.00
$3,701.00
$3,241.00
$2,464.00
$2,850.00
$2,717.00
$3,875.00
$3,566.00
$4,261.00
$965.00
$2,569.00
$709.00
$2,490.00
$4,156.00
$3,172.00
$4,310.00
$1,754.00
$2,094.00
$781.00
$1,519.00
$1,233.00
$3,126.00
$6,168.00
$4,015.00
$6,472.00
$2,967.00
$5,156.00
$5,094.00
$4,883.00
$5,079.00
$4,876.00
$1,835.00
$3,553.00
$2,853.00
$2,518.00
$3,659.00
$1,763.00
$2,119.00
$1,867.00
$1,814.00
$2,049.00
$2,179.00
$1,049.00
$1,528.00
$1,797.00
$395.00
$1,275.00
$2,136.00
$2,009.00
$1,499.00
$1,493.00
$2,989.00
$3,608.00
$3,999.00
$3,464.00
$2,622.00
$3,085.00
$2,862.00
$4,182.00
$3,831.00
$4,625.00
$1,052.00
$2,740.00
$774.00
$2,660.00
$4,517.00
$3,395.00
$4,635.00
$1,889.00
$2,253.00
$815.00
$1,589.00
$1,287.00
$3,391.00
$6,713.00
$4,358.00
$7,041.00
$3,212.00
$5,598.00
$5,540.00
$5,313.00
$5,520.00
$5,298.00
$1,993.00
$3,847.00
$2,989.00
$2,653.00
$3,979.00
$1,915.00
$2,301.00
$2,028.00
$1,969.00
$2,240.00
$2,360.00
$1,131.00
$1,660.00
$1,950.00
$430.00
$1,376.00
$2,315.00
$2,182.00
$1,590.00
$1,605.00
203
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
61880
61885
61886
61888
62000
62005
62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
62148
62160
62161
62162
62163
62164
62165
62180
62190
62192
62194
62200
62201
62220
62223
62225
62230
62252
62256
62258
62263
62264
62268
62269
62270
62272
62273
62280
62281
62282
62284
62287
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
ZZZ
0
0
0
0
0
90
90
90
10
90
90
90
90
90
90
0
90
90
10
0
0
0
0
0
0
10
10
10
0
90
$559.00
$262.00
$678.00
$331.00
$848.00
$1,282.00
$1,754.00
$1,962.00
$1,686.00
$1,928.00
$2,211.00
$1,898.00
$1,822.00
$1,221.00
$1,955.00
$1,011.00
$1,096.00
$1,566.00
$1,327.00
$1,566.00
$120.00
$172.00
$1,229.00
$1,578.00
$999.00
$1,706.00
$1,336.00
$1,695.00
$1,034.00
$1,146.00
$239.00
$1,625.00
$1,200.00
$1,215.00
$1,199.00
$488.00
$935.00
$85.00
$616.00
$1,308.00
$426.00
$593.00
$285.00
$271.00
$109.00
$137.00
$130.00
$199.00
$186.00
$211.00
$196.00
$784.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$661.00
$621.00
$808.00
$512.00
$961.00
$1,425.00
$1,857.00
$2,046.00
$1,952.00
$2,172.00
$2,471.00
$2,073.00
$1,905.00
$1,267.00
$1,411.00
$1,031.00
$1,248.00
$1,763.00
$1,508.00
$1,800.00
$168.00
$241.00
$1,718.00
$2,223.00
$1,408.00
$2,396.00
$1,861.00
$1,967.00
$1,074.00
$1,178.00
$420.00
$1,726.00
$1,386.00
$1,239.00
$1,229.00
$577.00
$1,018.00
$120.00
$684.00
$1,375.00
$991.00
$796.00
$389.00
$386.00
$245.00
$313.00
$253.00
$598.00
$530.00
$683.00
$331.00
$694.00
$729.00
$685.00
$891.00
$565.00
$1,023.00
$1,551.00
$2,051.00
$2,250.00
$2,162.00
$2,402.00
$2,734.00
$2,248.00
$2,056.00
$1,396.00
$1,553.00
$1,136.00
$1,375.00
$1,947.00
$1,656.00
$1,980.00
$187.00
$265.00
$1,893.00
$2,476.00
$1,571.00
$2,656.00
$2,039.00
$2,174.00
$1,184.00
$1,300.00
$452.00
$1,905.00
$1,518.00
$1,365.00
$1,356.00
$635.00
$1,123.00
$132.00
$754.00
$1,517.00
$1,061.00
$853.00
$413.00
$410.00
$262.00
$336.00
$270.00
$641.00
$567.00
$732.00
$354.00
$742.00
$789.00
$740.00
$965.00
$612.00
$1,074.00
$1,661.00
$2,228.00
$2,432.00
$2,355.00
$2,612.00
$2,974.00
$2,399.00
$2,184.00
$1,511.00
$1,680.00
$1,230.00
$1,488.00
$2,113.00
$1,789.00
$2,143.00
$205.00
$287.00
$2,053.00
$2,715.00
$1,724.00
$2,900.00
$2,201.00
$2,362.00
$1,281.00
$1,409.00
$478.00
$2,067.00
$1,634.00
$1,478.00
$1,470.00
$685.00
$1,216.00
$142.00
$815.00
$1,645.00
$1,104.00
$887.00
$432.00
$429.00
$272.00
$350.00
$282.00
$666.00
$589.00
$759.00
$368.00
$781.00
$661.00
$621.00
$808.00
$512.00
$961.00
$1,425.00
$1,857.00
$2,046.00
$1,952.00
$2,172.00
$2,471.00
$2,073.00
$1,905.00
$1,267.00
$1,411.00
$1,031.00
$1,248.00
$1,763.00
$1,508.00
$1,800.00
$168.00
$241.00
$1,718.00
$2,223.00
$1,408.00
$2,396.00
$1,861.00
$1,967.00
$1,074.00
$1,178.00
$420.00
$1,726.00
$1,386.00
$1,239.00
$1,229.00
$577.00
$1,018.00
$120.00
$684.00
$1,375.00
$454.00
$306.00
$389.00
$386.00
$85.00
$108.00
$145.00
$183.00
$179.00
$162.00
$114.00
$694.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$729.00
$685.00
$891.00
$565.00
$1,023.00
$1,551.00
$2,051.00
$2,250.00
$2,162.00
$2,402.00
$2,734.00
$2,248.00
$2,056.00
$1,396.00
$1,553.00
$1,136.00
$1,375.00
$1,947.00
$1,656.00
$1,980.00
$187.00
$265.00
$1,893.00
$2,476.00
$1,571.00
$2,656.00
$2,039.00
$2,174.00
$1,184.00
$1,300.00
$452.00
$1,905.00
$1,518.00
$1,365.00
$1,356.00
$635.00
$1,123.00
$132.00
$754.00
$1,517.00
$483.00
$325.00
$413.00
$410.00
$90.00
$116.00
$154.00
$194.00
$190.00
$171.00
$121.00
$742.00
$789.00
$740.00
$965.00
$612.00
$1,074.00
$1,661.00
$2,228.00
$2,432.00
$2,355.00
$2,612.00
$2,974.00
$2,399.00
$2,184.00
$1,511.00
$1,680.00
$1,230.00
$1,488.00
$2,113.00
$1,789.00
$2,143.00
$205.00
$287.00
$2,053.00
$2,715.00
$1,724.00
$2,900.00
$2,201.00
$2,362.00
$1,281.00
$1,409.00
$478.00
$2,067.00
$1,634.00
$1,478.00
$1,470.00
$685.00
$1,216.00
$142.00
$815.00
$1,645.00
$507.00
$342.00
$432.00
$429.00
$94.00
$123.00
$162.00
$204.00
$199.00
$180.00
$127.00
$781.00
204
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
62290
62291
62292
62294
62310
62311
62318
62319
62350
62351
62355
62360
62361
62362
62365
62367
62368
63001
63003
63005
63011
63012
63015
63016
63017
63020
63030
63035
63040
63042
63043
63044
63045
63046
63047
63048
63055
63056
63057
63064
63066
63075
63076
63077
63078
63081
63082
63085
63086
63087
63088
63090
0
0
90
90
0
0
0
0
90
90
90
90
90
90
90
0
0
90
90
90
90
90
90
90
90
90
90
ZZZ
90
90
ZZZ
ZZZ
90
90
90
ZZZ
90
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
ZZZ
90
$235.00
$232.00
$1,064.00
$821.00
$200.00
$201.00
$208.00
$203.00
$488.00
$782.00
$402.00
$195.00
$390.00
$517.00
$418.00
BR
BR
$1,882.00
$1,591.00
$1,390.00
$1,151.00
$1,568.00
$1,862.00
$1,788.00
$1,489.00
$1,395.00
$1,145.00
$280.00
$1,764.00
$1,620.00
BR
BR
$1,647.00
$2,117.00
$1,907.00
$367.00
$2,029.00
$1,960.00
$421.00
$2,200.00
$263.00
$1,720.00
$383.00
$1,828.00
$261.00
$2,203.00
$391.00
$2,416.00
$282.00
$2,930.00
$381.00
$2,490.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$580.00
$512.00
$683.00
$975.00
$342.00
$328.00
$380.00
$340.00
$564.00
$946.00
$442.00
$256.00
$475.00
$607.00
$509.00
--------$1,476.00
$1,496.00
$1,422.00
$1,241.00
$1,459.00
$1,824.00
$1,795.00
$1,515.00
$1,423.00
$1,173.00
$275.00
$1,744.00
$1,650.00
--------$1,561.00
$1,495.00
$1,402.00
$285.00
$2,033.00
$1,872.00
$449.00
$2,271.00
$288.00
$1,828.00
$357.00
$1,938.00
$279.00
$2,203.00
$384.00
$2,429.00
$275.00
$3,139.00
$376.00
$2,491.00
$621.00
$547.00
$730.00
$1,039.00
$366.00
$351.00
$406.00
$363.00
$605.00
$1,038.00
$473.00
$274.00
$510.00
$657.00
$549.00
--------$1,625.00
$1,645.00
$1,559.00
$1,334.00
$1,600.00
$2,012.00
$1,975.00
$1,664.00
$1,567.00
$1,288.00
$302.00
$1,914.00
$1,811.00
--------$1,719.00
$1,642.00
$1,538.00
$313.00
$2,236.00
$2,048.00
$490.00
$2,501.00
$318.00
$2,013.00
$394.00
$2,118.00
$304.00
$2,424.00
$423.00
$2,665.00
$302.00
$3,437.00
$413.00
$2,717.00
$646.00
$569.00
$769.00
$1,091.00
$380.00
$364.00
$422.00
$378.00
$640.00
$1,120.00
$499.00
$288.00
$538.00
$700.00
$580.00
--------$1,759.00
$1,779.00
$1,680.00
$1,411.00
$1,724.00
$2,181.00
$2,137.00
$1,796.00
$1,697.00
$1,389.00
$327.00
$2,066.00
$1,953.00
--------$1,861.00
$1,773.00
$1,658.00
$339.00
$2,419.00
$2,202.00
$527.00
$2,710.00
$345.00
$2,179.00
$428.00
$2,277.00
$327.00
$2,623.00
$459.00
$2,877.00
$327.00
$3,703.00
$447.00
$2,916.00
$227.00
$213.00
$683.00
$975.00
$128.00
$105.00
$136.00
$124.00
$564.00
$946.00
$442.00
$256.00
$475.00
$607.00
$509.00
--------$1,476.00
$1,496.00
$1,422.00
$1,241.00
$1,459.00
$1,824.00
$1,795.00
$1,515.00
$1,423.00
$1,173.00
$275.00
$1,744.00
$1,650.00
--------$1,561.00
$1,495.00
$1,402.00
$285.00
$2,033.00
$1,872.00
$449.00
$2,271.00
$288.00
$1,828.00
$357.00
$1,938.00
$279.00
$2,203.00
$384.00
$2,429.00
$275.00
$3,139.00
$376.00
$2,491.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$241.00
$226.00
$730.00
$1,039.00
$135.00
$111.00
$144.00
$132.00
$605.00
$1,038.00
$473.00
$274.00
$510.00
$657.00
$549.00
--------$1,625.00
$1,645.00
$1,559.00
$1,334.00
$1,600.00
$2,012.00
$1,975.00
$1,664.00
$1,567.00
$1,288.00
$302.00
$1,914.00
$1,811.00
--------$1,719.00
$1,642.00
$1,538.00
$313.00
$2,236.00
$2,048.00
$490.00
$2,501.00
$318.00
$2,013.00
$394.00
$2,118.00
$304.00
$2,424.00
$423.00
$2,665.00
$302.00
$3,437.00
$413.00
$2,717.00
$253.00
$237.00
$769.00
$1,091.00
$142.00
$117.00
$150.00
$138.00
$640.00
$1,120.00
$499.00
$288.00
$538.00
$700.00
$580.00
--------$1,759.00
$1,779.00
$1,680.00
$1,411.00
$1,724.00
$2,181.00
$2,137.00
$1,796.00
$1,697.00
$1,389.00
$327.00
$2,066.00
$1,953.00
--------$1,861.00
$1,773.00
$1,658.00
$339.00
$2,419.00
$2,202.00
$527.00
$2,710.00
$345.00
$2,179.00
$428.00
$2,277.00
$327.00
$2,623.00
$459.00
$2,877.00
$327.00
$3,703.00
$447.00
$2,916.00
205
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
63091
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63300
63301
63302
63303
63304
63305
63306
63307
63308
63600
63610
63615
63650
ZZZ
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
ZZZ
90
0
90
90
$249.00
$1,788.00
$1,672.00
$1,851.00
$1,486.00
$1,711.00
$1,347.00
$1,610.00
$1,444.00
$1,593.00
$1,603.00
$1,810.00
$1,725.00
$1,956.00
$2,258.00
$1,569.00
$3,182.00
$3,207.00
$3,319.00
$1,940.00
$2,053.00
$1,651.00
$1,469.00
$2,197.00
$2,401.00
$2,206.00
$2,012.00
$2,166.00
$2,135.00
$1,905.00
$1,877.00
$2,529.00
$2,496.00
$2,305.00
$2,041.00
$2,934.00
$3,003.00
$3,012.00
$3,073.00
$2,006.00
$2,209.00
$2,290.00
$2,357.00
$2,513.00
$2,574.00
$2,596.00
$2,522.00
$425.00
$797.00
$476.00
$1,348.00
$819.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$254.00
$1,916.00
$1,756.00
$2,115.00
$1,813.00
$1,886.00
$1,369.00
$1,645.00
$1,708.00
$1,875.00
$1,802.00
$2,088.00
$2,023.00
$2,146.00
$2,510.00
$1,836.00
$3,553.00
$3,722.00
$3,689.00
$2,010.00
$2,080.00
$1,691.00
$1,666.00
$2,483.00
$2,503.00
$2,346.00
$2,276.00
$2,193.00
$2,172.00
$1,942.00
$1,920.00
$2,620.00
$2,589.00
$2,441.00
$2,324.00
$3,284.00
$3,247.00
$3,355.00
$3,407.00
$2,261.00
$2,485.00
$2,526.00
$2,718.00
$2,696.00
$2,851.00
$2,652.00
$2,708.00
$459.00
$1,077.00
$651.00
$1,490.00
$514.00
$277.00
$2,111.00
$1,933.00
$2,326.00
$2,003.00
$2,066.00
$1,487.00
$1,798.00
$1,883.00
$2,072.00
$1,979.00
$2,310.00
$2,236.00
$2,381.00
$2,777.00
$2,020.00
$3,915.00
$4,104.00
$4,063.00
$2,218.00
$2,296.00
$1,864.00
$1,827.00
$2,742.00
$2,768.00
$2,589.00
$2,518.00
$2,419.00
$2,396.00
$2,140.00
$2,116.00
$2,896.00
$2,859.00
$2,696.00
$2,568.00
$3,630.00
$3,584.00
$3,709.00
$3,767.00
$2,493.00
$2,732.00
$2,781.00
$2,980.00
$2,944.00
$3,123.00
$2,829.00
$2,940.00
$507.00
$1,153.00
$688.00
$1,634.00
$547.00
$298.00
$2,285.00
$2,089.00
$2,513.00
$2,173.00
$2,225.00
$1,589.00
$1,933.00
$2,039.00
$2,248.00
$2,135.00
$2,512.00
$2,429.00
$2,603.00
$3,020.00
$2,182.00
$4,248.00
$4,453.00
$4,403.00
$2,406.00
$2,491.00
$2,019.00
$1,970.00
$2,977.00
$3,009.00
$2,811.00
$2,738.00
$2,625.00
$2,600.00
$2,318.00
$2,294.00
$3,147.00
$3,106.00
$2,928.00
$2,791.00
$3,946.00
$3,892.00
$4,032.00
$4,097.00
$2,703.00
$2,956.00
$3,013.00
$3,215.00
$3,163.00
$3,367.00
$2,973.00
$3,143.00
$551.00
$1,218.00
$718.00
$1,763.00
$575.00
$254.00
$1,916.00
$1,756.00
$2,115.00
$1,813.00
$1,886.00
$1,369.00
$1,645.00
$1,708.00
$1,875.00
$1,802.00
$2,088.00
$2,023.00
$2,146.00
$2,510.00
$1,836.00
$3,553.00
$3,722.00
$3,689.00
$2,010.00
$2,080.00
$1,691.00
$1,666.00
$2,483.00
$2,503.00
$2,346.00
$2,276.00
$2,193.00
$2,172.00
$1,942.00
$1,920.00
$2,620.00
$2,589.00
$2,441.00
$2,324.00
$3,284.00
$3,247.00
$3,355.00
$3,407.00
$2,261.00
$2,485.00
$2,526.00
$2,718.00
$2,696.00
$2,851.00
$2,652.00
$2,708.00
$459.00
$1,077.00
$651.00
$1,490.00
$514.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$277.00
$2,111.00
$1,933.00
$2,326.00
$2,003.00
$2,066.00
$1,487.00
$1,798.00
$1,883.00
$2,072.00
$1,979.00
$2,310.00
$2,236.00
$2,381.00
$2,777.00
$2,020.00
$3,915.00
$4,104.00
$4,063.00
$2,218.00
$2,296.00
$1,864.00
$1,827.00
$2,742.00
$2,768.00
$2,589.00
$2,518.00
$2,419.00
$2,396.00
$2,140.00
$2,116.00
$2,896.00
$2,859.00
$2,696.00
$2,568.00
$3,630.00
$3,584.00
$3,709.00
$3,767.00
$2,493.00
$2,732.00
$2,781.00
$2,980.00
$2,944.00
$3,123.00
$2,829.00
$2,940.00
$507.00
$1,153.00
$688.00
$1,634.00
$547.00
$298.00
$2,285.00
$2,089.00
$2,513.00
$2,173.00
$2,225.00
$1,589.00
$1,933.00
$2,039.00
$2,248.00
$2,135.00
$2,512.00
$2,429.00
$2,603.00
$3,020.00
$2,182.00
$4,248.00
$4,453.00
$4,403.00
$2,406.00
$2,491.00
$2,019.00
$1,970.00
$2,977.00
$3,009.00
$2,811.00
$2,738.00
$2,625.00
$2,600.00
$2,318.00
$2,294.00
$3,147.00
$3,106.00
$2,928.00
$2,791.00
$3,946.00
$3,892.00
$4,032.00
$4,097.00
$2,703.00
$2,956.00
$3,013.00
$3,215.00
$3,163.00
$3,367.00
$2,973.00
$3,143.00
$551.00
$1,218.00
$718.00
$1,763.00
$575.00
206
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
63655
63660
63685
63688
63700
63702
63704
63706
63707
63709
63710
63740
63741
63744
63746
64400
64402
64405
64408
64410
64412
64413
64415
64416
64417
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64450
64470
64472
64475
64476
64479
64480
64483
64484
64505
64508
64510
64520
64530
64550
64553
64555
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ZZZ
0
ZZZ
0
ZZZ
0
ZZZ
0
0
0
0
0
0
10
10
$1,064.00
$707.00
$615.00
$707.00
$1,340.00
$1,512.00
$1,708.00
$1,873.00
$1,041.00
$1,310.00
$1,165.00
$1,062.00
$741.00
$738.00
$529.00
$78.00
$75.00
$103.00
$120.00
$109.00
$89.00
$128.00
$109.00
$159.00
$105.00
$108.00
$89.00
$128.00
$116.00
$130.00
$114.00
$68.00
$165.00
$77.00
$152.00
$53.00
$206.00
$166.00
$183.00
$166.00
$224.00
$194.00
$206.00
$183.00
$104.00
$99.00
$103.00
$131.00
$135.00
$23.00
$137.00
$131.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$989.00
$534.00
$625.00
$496.00
$1,514.00
$1,538.00
$1,928.00
$2,177.00
$1,083.00
$1,354.00
$1,336.00
$1,089.00
$719.00
$777.00
$595.00
$155.00
$144.00
$154.00
$203.00
$198.00
$192.00
$173.00
$228.00
$217.00
$237.00
$201.00
$237.00
$349.00
$173.00
$182.00
$192.00
$215.00
$224.00
$106.00
$207.00
$132.00
$344.00
$168.00
$303.00
$144.00
$476.00
$198.00
$481.00
$204.00
$166.00
$294.00
$221.00
$294.00
$369.00
$37.00
$219.00
$241.00
$1,086.00
$575.00
$678.00
$537.00
$1,656.00
$1,641.00
$2,119.00
$2,403.00
$1,187.00
$1,484.00
$1,468.00
$1,197.00
$779.00
$854.00
$653.00
$165.00
$153.00
$165.00
$217.00
$211.00
$206.00
$185.00
$244.00
$227.00
$253.00
$214.00
$254.00
$374.00
$184.00
$195.00
$206.00
$229.00
$235.00
$112.00
$216.00
$141.00
$368.00
$179.00
$325.00
$154.00
$510.00
$211.00
$515.00
$218.00
$177.00
$314.00
$237.00
$315.00
$395.00
$40.00
$234.00
$257.00
$1,170.00
$609.00
$725.00
$572.00
$1,780.00
$1,723.00
$2,290.00
$2,609.00
$1,278.00
$1,598.00
$1,586.00
$1,294.00
$831.00
$922.00
$705.00
$172.00
$160.00
$172.00
$226.00
$220.00
$214.00
$193.00
$253.00
$234.00
$263.00
$223.00
$264.00
$388.00
$192.00
$204.00
$217.00
$238.00
$243.00
$117.00
$224.00
$147.00
$383.00
$187.00
$337.00
$160.00
$530.00
$220.00
$535.00
$226.00
$184.00
$326.00
$246.00
$327.00
$410.00
$41.00
$245.00
$267.00
$989.00
$534.00
$625.00
$496.00
$1,514.00
$1,538.00
$1,928.00
$2,177.00
$1,083.00
$1,354.00
$1,336.00
$1,089.00
$719.00
$777.00
$595.00
$77.00
$94.00
$91.00
$109.00
$97.00
$82.00
$98.00
$99.00
$217.00
$99.00
$89.00
$81.00
$113.00
$118.00
$105.00
$114.00
$98.00
$224.00
$106.00
$207.00
$89.00
$128.00
$86.00
$100.00
$65.00
$155.00
$107.00
$136.00
$91.00
$97.00
$85.00
$84.00
$93.00
$109.00
$12.00
$189.00
$152.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,086.00
$575.00
$678.00
$537.00
$1,656.00
$1,641.00
$2,119.00
$2,403.00
$1,187.00
$1,484.00
$1,468.00
$1,197.00
$779.00
$854.00
$653.00
$82.00
$99.00
$96.00
$116.00
$102.00
$88.00
$104.00
$104.00
$227.00
$105.00
$94.00
$86.00
$120.00
$126.00
$112.00
$123.00
$104.00
$235.00
$112.00
$216.00
$95.00
$136.00
$92.00
$106.00
$69.00
$165.00
$113.00
$144.00
$96.00
$103.00
$91.00
$89.00
$99.00
$115.00
$13.00
$202.00
$161.00
$1,170.00
$609.00
$725.00
$572.00
$1,780.00
$1,723.00
$2,290.00
$2,609.00
$1,278.00
$1,598.00
$1,586.00
$1,294.00
$831.00
$922.00
$705.00
$85.00
$104.00
$101.00
$122.00
$107.00
$92.00
$109.00
$109.00
$234.00
$110.00
$98.00
$90.00
$126.00
$132.00
$118.00
$131.00
$108.00
$243.00
$117.00
$224.00
$100.00
$143.00
$96.00
$111.00
$73.00
$173.00
$118.00
$151.00
$101.00
$108.00
$95.00
$93.00
$104.00
$120.00
$13.00
$212.00
$168.00
207
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
64560
64561
64565
64573
64575
64577
64580
64581
64585
64590
64595
64600
64605
64610
64612
64613
64614
64620
64622
64623
64626
64627
64630
64640
64680
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
64727
64732
64734
64736
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
64766
10
$197.00
10
$801.00
10
$121.00
90
$464.00
90
$367.00
90
$381.00
90
$343.00
90
$745.00
10
$37.00
10
$217.00
10
$153.00
10
$228.00
10
$319.00
10
$307.00
10
$188.00
10
$168.00
10
$200.00
10
$185.00
10
$333.00
ZZZ $113.00
10
$262.00
ZZZ $151.00
10
$202.00
10
$208.00
10
$180.00
90
$383.00
90
$402.00
90
$562.00
90
$678.00
90
$867.00
90
$715.00
90
$523.00
90
$558.00
90
$446.00
90
$439.00
90
$411.00
90
$271.00
ZZZ $261.00
90
$405.00
90
$432.00
90
$388.00
90
$475.00
90
$461.00
90
$517.00
90
$798.00
90
$494.00
90
$560.00
90 $1,042.00
90
$578.00
90
$495.00
90
$561.00
90
$713.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$248.00
$1,088.00
$252.00
$736.00
$389.00
$441.00
$416.00
$1,024.00
$287.00
$256.00
$194.00
$639.00
$833.00
$607.00
$216.00
$249.00
$331.00
$452.00
$577.00
$175.00
$591.00
$195.00
$378.00
$473.00
$496.00
$440.00
$425.00
$610.00
$681.00
$901.00
$766.00
$597.00
$616.00
$517.00
$545.00
$419.00
$398.00
$257.00
$449.00
$479.00
$421.00
$520.00
$495.00
$587.00
$522.00
$565.00
$638.00
$1,055.00
$579.00
$516.00
$694.00
$777.00
$265.00
$1,155.00
$269.00
$811.00
$417.00
$476.00
$442.00
$1,075.00
$311.00
$279.00
$210.00
$686.00
$895.00
$663.00
$229.00
$265.00
$352.00
$483.00
$618.00
$187.00
$633.00
$209.00
$403.00
$505.00
$531.00
$475.00
$460.00
$662.00
$726.00
$966.00
$813.00
$641.00
$669.00
$560.00
$590.00
$447.00
$432.00
$278.00
$491.00
$524.00
$459.00
$566.00
$529.00
$633.00
$573.00
$612.00
$689.00
$1,129.00
$617.00
$544.00
$748.00
$838.00
$277.00
$1,192.00
$279.00
$877.00
$439.00
$503.00
$460.00
$1,112.00
$329.00
$299.00
$223.00
$715.00
$937.00
$714.00
$238.00
$276.00
$365.00
$503.00
$641.00
$194.00
$658.00
$217.00
$419.00
$523.00
$551.00
$504.00
$490.00
$704.00
$761.00
$1,021.00
$852.00
$676.00
$714.00
$594.00
$624.00
$468.00
$460.00
$298.00
$528.00
$563.00
$493.00
$607.00
$555.00
$670.00
$618.00
$651.00
$732.00
$1,192.00
$648.00
$566.00
$791.00
$890.00
$164.00
$530.00
$126.00
$736.00
$389.00
$441.00
$416.00
$1,024.00
$224.00
$256.00
$194.00
$265.00
$414.00
$607.00
$154.00
$152.00
$167.00
$207.00
$219.00
$65.00
$269.00
$77.00
$221.00
$229.00
$200.00
$440.00
$425.00
$610.00
$681.00
$901.00
$766.00
$597.00
$616.00
$517.00
$529.00
$419.00
$398.00
$257.00
$449.00
$479.00
$421.00
$520.00
$495.00
$587.00
$522.00
$565.00
$638.00
$1,055.00
$579.00
$516.00
$694.00
$777.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$175.00
$555.00
$133.00
$811.00
$417.00
$476.00
$442.00
$1,075.00
$243.00
$279.00
$210.00
$283.00
$444.00
$663.00
$163.00
$161.00
$176.00
$220.00
$232.00
$69.00
$286.00
$81.00
$233.00
$241.00
$212.00
$475.00
$460.00
$662.00
$726.00
$966.00
$813.00
$641.00
$669.00
$560.00
$573.00
$447.00
$432.00
$278.00
$491.00
$524.00
$459.00
$566.00
$529.00
$633.00
$573.00
$612.00
$689.00
$1,129.00
$617.00
$544.00
$748.00
$838.00
$184.00
$571.00
$138.00
$877.00
$439.00
$503.00
$460.00
$1,112.00
$259.00
$299.00
$223.00
$298.00
$471.00
$714.00
$170.00
$167.00
$183.00
$230.00
$242.00
$72.00
$300.00
$86.00
$244.00
$251.00
$222.00
$504.00
$490.00
$704.00
$761.00
$1,021.00
$852.00
$676.00
$714.00
$594.00
$607.00
$468.00
$460.00
$298.00
$528.00
$563.00
$493.00
$607.00
$555.00
$670.00
$618.00
$651.00
$732.00
$1,192.00
$648.00
$566.00
$791.00
$890.00
208
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64804
64809
64818
64820
64821
64822
64823
64831
64832
64834
64835
64836
64837
64840
64856
64857
64858
64859
64861
64862
64864
64865
64866
64868
64870
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
90
90
90
90
ZZZ
90
ZZZ
90
90
ZZZ
90
90
90
0
90
90
90
90
90
90
90
90
90
ZZZ
90
90
90
ZZZ
90
90
90
90
ZZZ
90
90
90
90
90
90
90
ZZZ
ZZZ
ZZZ
90
90
90
90
90
90
90
90
90
$632.00
$636.00
$392.00
$390.00
$249.00
$482.00
$298.00
$751.00
$1,281.00
$458.00
$381.00
$884.00
$1,148.00
$247.00
$711.00
$1,202.00
$1,080.00
$845.00
$838.00
$609.00
$609.00
$703.00
$592.00
$171.00
$711.00
$834.00
$856.00
$480.00
$1,058.00
$1,063.00
$1,137.00
$1,313.00
$341.00
$1,524.00
$1,798.00
$970.00
$1,250.00
$1,238.00
$1,162.00
$1,313.00
$155.00
$230.00
$189.00
$1,382.00
$1,636.00
$1,112.00
$1,243.00
$1,177.00
$1,321.00
$1,500.00
$1,185.00
$1,419.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$729.00
$678.00
$483.00
$485.00
$256.00
$546.00
$310.00
$895.00
$1,414.00
$359.00
$436.00
$1,033.00
$1,303.00
$265.00
$781.00
$1,213.00
$1,056.00
$869.00
$959.00
$954.00
$954.00
$1,086.00
$901.00
$476.00
$942.00
$1,021.00
$1,017.00
$528.00
$1,116.00
$1,262.00
$1,323.00
$1,536.00
$356.00
$1,742.00
$1,734.00
$1,119.00
$1,346.00
$1,346.00
$1,250.00
$1,316.00
$168.00
$247.00
$259.00
$1,522.00
$1,791.00
$1,373.00
$1,278.00
$1,286.00
$1,388.00
$1,578.00
$1,691.00
$1,619.00
$799.00
$742.00
$521.00
$525.00
$277.00
$591.00
$336.00
$967.00
$1,539.00
$389.00
$471.00
$1,125.00
$1,411.00
$287.00
$838.00
$1,313.00
$1,125.00
$935.00
$1,035.00
$1,028.00
$1,028.00
$1,171.00
$974.00
$514.00
$1,018.00
$1,105.00
$1,099.00
$572.00
$1,188.00
$1,366.00
$1,431.00
$1,682.00
$385.00
$1,886.00
$1,879.00
$1,200.00
$1,443.00
$1,434.00
$1,344.00
$1,401.00
$182.00
$266.00
$280.00
$1,630.00
$1,917.00
$1,483.00
$1,368.00
$1,388.00
$1,498.00
$1,699.00
$1,812.00
$1,763.00
$861.00
$798.00
$553.00
$558.00
$295.00
$630.00
$359.00
$1,028.00
$1,646.00
$416.00
$500.00
$1,205.00
$1,504.00
$307.00
$886.00
$1,400.00
$1,181.00
$992.00
$1,097.00
$1,086.00
$1,086.00
$1,238.00
$1,034.00
$548.00
$1,082.00
$1,175.00
$1,168.00
$611.00
$1,244.00
$1,453.00
$1,521.00
$1,810.00
$410.00
$2,009.00
$2,002.00
$1,265.00
$1,522.00
$1,502.00
$1,421.00
$1,469.00
$194.00
$283.00
$298.00
$1,718.00
$2,018.00
$1,574.00
$1,443.00
$1,474.00
$1,590.00
$1,804.00
$1,914.00
$1,888.00
$729.00
$678.00
$483.00
$485.00
$256.00
$546.00
$310.00
$895.00
$1,414.00
$359.00
$436.00
$1,033.00
$1,303.00
$265.00
$781.00
$1,213.00
$1,056.00
$869.00
$959.00
$954.00
$954.00
$1,086.00
$901.00
$476.00
$942.00
$1,021.00
$1,017.00
$528.00
$1,116.00
$1,262.00
$1,323.00
$1,536.00
$356.00
$1,742.00
$1,734.00
$1,119.00
$1,346.00
$1,346.00
$1,250.00
$1,316.00
$168.00
$247.00
$259.00
$1,522.00
$1,791.00
$1,373.00
$1,278.00
$1,286.00
$1,388.00
$1,578.00
$1,691.00
$1,619.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$799.00
$742.00
$521.00
$525.00
$277.00
$591.00
$336.00
$967.00
$1,539.00
$389.00
$471.00
$1,125.00
$1,411.00
$287.00
$838.00
$1,313.00
$1,125.00
$935.00
$1,035.00
$1,028.00
$1,028.00
$1,171.00
$974.00
$514.00
$1,018.00
$1,105.00
$1,099.00
$572.00
$1,188.00
$1,366.00
$1,431.00
$1,682.00
$385.00
$1,886.00
$1,879.00
$1,200.00
$1,443.00
$1,434.00
$1,344.00
$1,401.00
$182.00
$266.00
$280.00
$1,630.00
$1,917.00
$1,483.00
$1,368.00
$1,388.00
$1,498.00
$1,699.00
$1,812.00
$1,763.00
$861.00
$798.00
$553.00
$558.00
$295.00
$630.00
$359.00
$1,028.00
$1,646.00
$416.00
$500.00
$1,205.00
$1,504.00
$307.00
$886.00
$1,400.00
$1,181.00
$992.00
$1,097.00
$1,086.00
$1,086.00
$1,238.00
$1,034.00
$548.00
$1,082.00
$1,175.00
$1,168.00
$611.00
$1,244.00
$1,453.00
$1,521.00
$1,810.00
$410.00
$2,009.00
$2,002.00
$1,265.00
$1,522.00
$1,502.00
$1,421.00
$1,469.00
$194.00
$283.00
$298.00
$1,718.00
$2,018.00
$1,574.00
$1,443.00
$1,474.00
$1,590.00
$1,804.00
$1,914.00
$1,888.00
209
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
64898
64901
64902
64905
64907
64999
65091
65093
65101
65103
65105
65110
65112
65114
65125
65130
65135
65140
65150
65155
65175
65205
65210
65220
65222
65235
65260
65265
65270
65272
65273
65275
65280
65285
65286
65290
65400
65410
65420
65426
65430
65435
65436
65450
65600
65710
65730
65750
65755
65770
65772
65775
90
ZZZ
ZZZ
90
90
YYY
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
0
0
0
90
90
90
10
90
90
90
90
90
90
90
90
0
90
90
0
0
90
90
90
90
90
90
90
90
90
90
$1,549.00
$865.00
$982.00
$1,059.00
$1,472.00
BR
$678.00
$712.00
$726.00
$769.00
$846.00
$1,305.00
$1,386.00
$1,456.00
$312.00
$730.00
$678.00
$738.00
$652.00
$862.00
$654.00
$45.00
$53.00
$58.00
$62.00
$627.00
$956.00
$1,104.00
$88.00
$223.00
$376.00
$75.00
$711.00
$1,177.00
$692.00
$519.00
$603.00
$142.00
$448.00
$534.00
$81.00
$88.00
$319.00
$52.00
$325.00
$1,124.00
$1,314.00
$1,381.00
$1,373.00
$1,461.00
$449.00
$595.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,734.00
$841.00
$964.00
$1,239.00
$1,665.00
----$891.00
$923.00
$936.00
$972.00
$1,045.00
$1,490.00
$1,740.00
$1,794.00
$457.00
$924.00
$944.00
$993.00
$854.00
$1,072.00
$859.00
$68.00
$82.00
$209.00
$87.00
$733.00
$1,181.00
$1,341.00
$294.00
$475.00
$473.00
$557.00
$776.00
$1,337.00
$720.00
$594.00
$728.00
$161.00
$614.00
$657.00
$484.00
$114.00
$505.00
$551.00
$442.00
$1,272.00
$1,325.00
$1,480.00
$1,469.00
$1,660.00
$579.00
$713.00
$1,885.00
$904.00
$1,035.00
$1,335.00
$1,788.00
----$948.00
$982.00
$995.00
$1,033.00
$1,110.00
$1,583.00
$1,853.00
$1,908.00
$487.00
$982.00
$1,003.00
$1,055.00
$909.00
$1,140.00
$915.00
$72.00
$86.00
$225.00
$92.00
$776.00
$1,253.00
$1,422.00
$313.00
$504.00
$501.00
$592.00
$822.00
$1,417.00
$765.00
$631.00
$773.00
$171.00
$654.00
$698.00
$518.00
$121.00
$536.00
$587.00
$471.00
$1,348.00
$1,402.00
$1,567.00
$1,556.00
$1,757.00
$616.00
$758.00
$2,016.00
$956.00
$1,094.00
$1,415.00
$1,888.00
----$983.00
$1,019.00
$1,032.00
$1,071.00
$1,151.00
$1,646.00
$1,931.00
$1,987.00
$506.00
$1,018.00
$1,040.00
$1,094.00
$942.00
$1,184.00
$948.00
$75.00
$90.00
$233.00
$96.00
$805.00
$1,300.00
$1,475.00
$325.00
$523.00
$520.00
$616.00
$853.00
$1,470.00
$793.00
$656.00
$802.00
$177.00
$678.00
$723.00
$536.00
$125.00
$556.00
$608.00
$488.00
$1,399.00
$1,455.00
$1,626.00
$1,615.00
$1,824.00
$639.00
$785.00
$1,734.00
$841.00
$964.00
$1,239.00
$1,665.00
----$891.00
$923.00
$936.00
$972.00
$1,045.00
$1,490.00
$1,740.00
$1,794.00
$237.00
$924.00
$944.00
$993.00
$854.00
$1,072.00
$859.00
$47.00
$59.00
$48.00
$63.00
$733.00
$1,181.00
$1,341.00
$213.00
$428.00
$473.00
$533.00
$776.00
$1,337.00
$661.00
$594.00
$657.00
$110.00
$560.00
$595.00
$111.00
$68.00
$458.00
$493.00
$250.00
$1,272.00
$1,325.00
$1,480.00
$1,469.00
$1,660.00
$530.00
$713.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,885.00
$904.00
$1,035.00
$1,335.00
$1,788.00
----$948.00
$982.00
$995.00
$1,033.00
$1,110.00
$1,583.00
$1,853.00
$1,908.00
$251.00
$982.00
$1,003.00
$1,055.00
$909.00
$1,140.00
$915.00
$49.00
$62.00
$51.00
$66.00
$776.00
$1,253.00
$1,422.00
$226.00
$455.00
$501.00
$566.00
$822.00
$1,417.00
$702.00
$631.00
$696.00
$116.00
$596.00
$631.00
$117.00
$72.00
$486.00
$525.00
$263.00
$1,348.00
$1,402.00
$1,567.00
$1,556.00
$1,757.00
$564.00
$758.00
$2,016.00
$956.00
$1,094.00
$1,415.00
$1,888.00
----$983.00
$1,019.00
$1,032.00
$1,071.00
$1,151.00
$1,646.00
$1,931.00
$1,987.00
$261.00
$1,018.00
$1,040.00
$1,094.00
$942.00
$1,184.00
$948.00
$51.00
$64.00
$53.00
$69.00
$805.00
$1,300.00
$1,475.00
$235.00
$472.00
$520.00
$590.00
$853.00
$1,470.00
$728.00
$656.00
$722.00
$121.00
$618.00
$655.00
$121.00
$75.00
$504.00
$544.00
$273.00
$1,399.00
$1,455.00
$1,626.00
$1,615.00
$1,824.00
$584.00
$785.00
210
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
65800
65805
65810
65815
65820
65850
65855
65860
65865
65870
65875
65880
65900
65920
65930
66020
66030
66130
66150
66155
66160
66165
66170
66172
66180
66185
66220
66225
66250
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
66710
66720
66740
66761
66762
66770
66820
66821
66825
66830
66840
66850
66852
FUD 2003 MRA
0
0
90
90
90
90
10
90
90
90
90
90
90
90
90
10
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
$88.00
$178.00
$516.00
$327.00
$813.00
$968.00
$441.00
$339.00
$540.00
$572.00
$597.00
$641.00
$945.00
$752.00
$700.00
$164.00
$160.00
$631.00
$798.00
$795.00
$942.00
$769.00
$1,089.00
$1,264.00
$1,313.00
$769.00
$711.00
$1,006.00
$602.00
$359.00
$359.00
$825.00
$1,136.00
$543.00
$623.00
$595.00
$526.00
$627.00
$506.00
$513.00
$506.00
$473.00
$506.00
$433.00
$483.00
$433.00
$275.00
$753.00
$651.00
$707.00
$805.00
$878.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$211.00
$211.00
$678.00
$709.00
$947.00
$1,042.00
$448.00
$383.00
$621.00
$672.00
$692.00
$734.00
$1,187.00
$833.00
$810.00
$199.00
$173.00
$766.00
$955.00
$953.00
$1,095.00
$931.00
$1,447.00
$1,530.00
$1,354.00
$831.00
$895.00
$1,037.00
$695.00
$423.00
$450.00
$878.00
$1,273.00
$642.00
$690.00
$644.00
$582.00
$693.00
$517.00
$502.00
$518.00
$488.00
$471.00
$501.00
$554.00
$605.00
$311.00
$931.00
$765.00
$746.00
$835.00
$902.00
$224.00
$224.00
$722.00
$754.00
$1,006.00
$1,103.00
$477.00
$406.00
$659.00
$713.00
$733.00
$778.00
$1,259.00
$882.00
$858.00
$212.00
$184.00
$812.00
$1,014.00
$1,011.00
$1,161.00
$988.00
$1,536.00
$1,621.00
$1,433.00
$880.00
$950.00
$1,097.00
$737.00
$449.00
$477.00
$930.00
$1,351.00
$682.00
$732.00
$682.00
$617.00
$735.00
$549.00
$532.00
$549.00
$516.00
$499.00
$532.00
$587.00
$644.00
$331.00
$987.00
$810.00
$789.00
$883.00
$954.00
$233.00
$233.00
$748.00
$782.00
$1,043.00
$1,145.00
$495.00
$421.00
$684.00
$739.00
$760.00
$807.00
$1,307.00
$915.00
$890.00
$220.00
$191.00
$843.00
$1,052.00
$1,048.00
$1,205.00
$1,025.00
$1,593.00
$1,682.00
$1,487.00
$913.00
$986.00
$1,139.00
$765.00
$465.00
$495.00
$965.00
$1,406.00
$707.00
$760.00
$708.00
$640.00
$763.00
$569.00
$552.00
$570.00
$536.00
$518.00
$552.00
$609.00
$668.00
$343.00
$1,024.00
$840.00
$819.00
$916.00
$990.00
$169.00
$170.00
$678.00
$651.00
$947.00
$1,042.00
$378.00
$337.00
$621.00
$672.00
$692.00
$734.00
$1,187.00
$833.00
$810.00
$158.00
$132.00
$722.00
$955.00
$953.00
$1,095.00
$931.00
$1,447.00
$1,530.00
$1,354.00
$831.00
$895.00
$1,037.00
$624.00
$423.00
$450.00
$878.00
$1,273.00
$592.00
$690.00
$644.00
$582.00
$693.00
$460.00
$437.00
$471.00
$488.00
$409.00
$435.00
$491.00
$605.00
$290.00
$931.00
$765.00
$746.00
$835.00
$902.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$179.00
$180.00
$722.00
$691.00
$1,006.00
$1,103.00
$401.00
$357.00
$659.00
$713.00
$733.00
$778.00
$1,259.00
$882.00
$858.00
$168.00
$140.00
$764.00
$1,014.00
$1,011.00
$1,161.00
$988.00
$1,536.00
$1,621.00
$1,433.00
$880.00
$950.00
$1,097.00
$661.00
$449.00
$477.00
$930.00
$1,351.00
$628.00
$732.00
$682.00
$617.00
$735.00
$487.00
$462.00
$499.00
$516.00
$433.00
$460.00
$520.00
$644.00
$308.00
$987.00
$810.00
$789.00
$883.00
$954.00
$186.00
$187.00
$748.00
$717.00
$1,043.00
$1,145.00
$416.00
$370.00
$684.00
$739.00
$760.00
$807.00
$1,307.00
$915.00
$890.00
$175.00
$145.00
$793.00
$1,052.00
$1,048.00
$1,205.00
$1,025.00
$1,593.00
$1,682.00
$1,487.00
$913.00
$986.00
$1,139.00
$685.00
$465.00
$495.00
$965.00
$1,406.00
$651.00
$760.00
$708.00
$640.00
$763.00
$506.00
$480.00
$518.00
$536.00
$449.00
$478.00
$540.00
$668.00
$320.00
$1,024.00
$840.00
$819.00
$916.00
$990.00
211
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
66920
66930
66940
66982
66983
66984
66985
66986
66990
66999
67005
67010
67015
67025
67027
67028
67030
67031
67036
67038
67039
67040
67101
67105
67107
67108
67110
67112
67115
67120
67121
67141
67145
67208
67210
67218
67220
67221
67225
67227
67228
67250
67255
67299
67311
67312
67314
67316
67318
67320
67331
67332
90
90
90
90
90
90
90
90
ZZZ
YYY
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
ZZZ
90
90
90
90
YYY
90
90
90
90
90
ZZZ
ZZZ
ZZZ
$785.00
$906.00
$819.00
$846.00
$763.00
$898.00
$744.00
$1,038.00
$84.00
BR
$639.00
$647.00
$637.00
$774.00
$1,089.00
$338.00
$485.00
$402.00
$1,384.00
$1,860.00
$1,490.00
$1,960.00
$767.00
$941.00
$1,350.00
$1,878.00
$1,040.00
$1,500.00
$496.00
$751.00
$962.00
$536.00
$514.00
$655.00
$779.00
$1,217.00
$894.00
$325.00
$44.00
$652.00
$1,025.00
$793.00
$872.00
BR
$616.00
$773.00
$688.00
$857.00
$663.00
$602.00
$560.00
$621.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$818.00
$961.00
$867.00
$1,157.00
$762.00
$913.00
$775.00
$1,066.00
$114.00
----$430.00
$518.00
$761.00
$1,178.00
$1,262.00
$642.00
$583.00
$393.00
$1,066.00
$1,874.00
$1,367.00
$1,572.00
$930.00
$759.00
$1,425.00
$1,961.00
$1,448.00
$1,654.00
$595.00
$1,098.00
$1,153.00
$665.00
$540.00
$761.00
$819.00
$1,734.00
$1,219.00
$437.00
$38.00
$791.00
$1,152.00
$1,027.00
$1,047.00
----$651.00
$802.00
$725.00
$886.00
$761.00
$326.00
$309.00
$339.00
$865.00
$1,017.00
$918.00
$1,223.00
$805.00
$965.00
$820.00
$1,127.00
$120.00
----$453.00
$546.00
$807.00
$1,256.00
$1,340.00
$687.00
$619.00
$417.00
$1,127.00
$1,981.00
$1,446.00
$1,662.00
$988.00
$804.00
$1,508.00
$2,075.00
$1,544.00
$1,751.00
$631.00
$1,171.00
$1,222.00
$707.00
$572.00
$807.00
$867.00
$1,830.00
$1,290.00
$464.00
$40.00
$840.00
$1,218.00
$1,091.00
$1,111.00
----$690.00
$849.00
$767.00
$938.00
$805.00
$344.00
$326.00
$357.00
$898.00
$1,056.00
$952.00
$1,271.00
$837.00
$1,003.00
$851.00
$1,170.00
$125.00
----$470.00
$568.00
$837.00
$1,301.00
$1,391.00
$711.00
$642.00
$432.00
$1,170.00
$2,057.00
$1,501.00
$1,725.00
$1,024.00
$835.00
$1,565.00
$2,153.00
$1,599.00
$1,817.00
$655.00
$1,213.00
$1,268.00
$733.00
$594.00
$837.00
$900.00
$1,893.00
$1,338.00
$481.00
$41.00
$871.00
$1,264.00
$1,132.00
$1,152.00
----$716.00
$882.00
$796.00
$974.00
$836.00
$357.00
$339.00
$371.00
$818.00
$961.00
$867.00
$1,157.00
$762.00
$913.00
$775.00
$1,066.00
$114.00
----$430.00
$518.00
$761.00
$727.00
$999.00
$190.00
$583.00
$347.00
$1,066.00
$1,874.00
$1,367.00
$1,572.00
$829.00
$661.00
$1,425.00
$1,961.00
$966.00
$1,654.00
$595.00
$662.00
$1,153.00
$613.00
$486.00
$701.00
$745.00
$1,734.00
$1,161.00
$303.00
$34.00
$696.00
$1,024.00
$1,027.00
$1,047.00
----$651.00
$802.00
$725.00
$886.00
$761.00
$326.00
$309.00
$339.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$865.00
$1,017.00
$918.00
$1,223.00
$805.00
$965.00
$820.00
$1,127.00
$120.00
----$453.00
$546.00
$807.00
$771.00
$1,058.00
$201.00
$619.00
$367.00
$1,127.00
$1,981.00
$1,446.00
$1,662.00
$879.00
$699.00
$1,508.00
$2,075.00
$1,025.00
$1,751.00
$631.00
$702.00
$1,222.00
$650.00
$514.00
$743.00
$787.00
$1,830.00
$1,227.00
$320.00
$36.00
$737.00
$1,080.00
$1,091.00
$1,111.00
----$690.00
$849.00
$767.00
$938.00
$805.00
$344.00
$326.00
$357.00
$898.00
$1,056.00
$952.00
$1,271.00
$837.00
$1,003.00
$851.00
$1,170.00
$125.00
----$470.00
$568.00
$837.00
$800.00
$1,099.00
$209.00
$642.00
$381.00
$1,170.00
$2,057.00
$1,501.00
$1,725.00
$912.00
$725.00
$1,565.00
$2,153.00
$1,064.00
$1,817.00
$655.00
$728.00
$1,268.00
$674.00
$533.00
$770.00
$818.00
$1,893.00
$1,274.00
$332.00
$37.00
$765.00
$1,122.00
$1,132.00
$1,152.00
----$716.00
$882.00
$796.00
$974.00
$836.00
$357.00
$339.00
$371.00
212
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
67334
67335
67340
67343
67345
67350
67399
67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67450
67500
67505
67515
67550
67560
67570
67599
67700
67710
67715
67800
67801
67805
67808
67810
67820
67825
67830
67835
67840
67850
67875
67880
67882
67900
67901
67902
67903
67904
67906
67908
67909
67911
67914
ZZZ
ZZZ
ZZZ
90
10
0
YYY
90
90
90
90
90
0
90
90
90
90
90
0
0
0
90
90
90
YYY
10
10
10
10
10
10
90
0
0
10
10
90
10
10
0
90
90
90
90
90
90
90
90
90
90
90
90
$447.00
$253.00
$559.00
$628.00
$275.00
$240.00
BR
$960.00
$799.00
$976.00
$909.00
$1,023.00
$146.00
$1,729.00
$1,203.00
$1,257.00
$1,269.00
$1,300.00
$75.00
$109.00
$53.00
$946.00
$936.00
$1,148.00
BR
$87.00
$117.00
$102.00
$119.00
$189.00
$208.00
$308.00
$133.00
$36.00
$130.00
$239.00
$500.00
$187.00
$143.00
$163.00
$442.00
$643.00
$487.00
$646.00
$650.00
$657.00
$720.00
$633.00
$550.00
$577.00
$517.00
$487.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$300.00
$188.00
$371.00
$730.00
$368.00
$247.00
----$1,170.00
$1,021.00
$1,256.00
$1,181.00
$1,388.00
$133.00
$2,041.00
$1,570.00
$1,500.00
$1,625.00
$1,527.00
$83.00
$89.00
$73.00
$1,187.00
$1,199.00
$1,561.00
----$435.00
$425.00
$92.00
$199.00
$485.00
$511.00
$405.00
$347.00
$103.00
$152.00
$629.00
$520.00
$491.00
$530.00
$617.00
$799.00
$954.00
$862.00
$702.00
$710.00
$935.00
$1,032.00
$835.00
$725.00
$772.00
$605.00
$814.00
$316.00
$198.00
$391.00
$773.00
$391.00
$261.00
----$1,244.00
$1,086.00
$1,337.00
$1,254.00
$1,476.00
$140.00
$2,164.00
$1,678.00
$1,594.00
$1,726.00
$1,622.00
$88.00
$95.00
$77.00
$1,263.00
$1,273.00
$1,661.00
----$466.00
$455.00
$97.00
$212.00
$519.00
$546.00
$429.00
$371.00
$109.00
$162.00
$674.00
$550.00
$525.00
$567.00
$662.00
$853.00
$1,019.00
$919.00
$745.00
$754.00
$999.00
$1,100.00
$891.00
$771.00
$822.00
$643.00
$871.00
$329.00
$205.00
$406.00
$803.00
$406.00
$272.00
----$1,292.00
$1,128.00
$1,387.00
$1,302.00
$1,531.00
$147.00
$2,247.00
$1,754.00
$1,655.00
$1,792.00
$1,683.00
$92.00
$98.00
$80.00
$1,312.00
$1,322.00
$1,728.00
----$483.00
$471.00
$101.00
$220.00
$537.00
$566.00
$446.00
$384.00
$113.00
$168.00
$697.00
$571.00
$543.00
$587.00
$685.00
$884.00
$1,055.00
$954.00
$774.00
$784.00
$1,040.00
$1,140.00
$928.00
$799.00
$853.00
$667.00
$902.00
$300.00
$188.00
$371.00
$730.00
$222.00
$247.00
----$1,170.00
$1,021.00
$1,256.00
$1,181.00
$1,388.00
$133.00
$2,041.00
$1,570.00
$1,500.00
$1,625.00
$1,527.00
$52.00
$54.00
$46.00
$1,187.00
$1,199.00
$1,561.00
----$100.00
$77.00
$92.00
$104.00
$142.00
$168.00
$405.00
$112.00
$66.00
$123.00
$193.00
$520.00
$154.00
$190.00
$173.00
$354.00
$493.00
$643.00
$702.00
$710.00
$695.00
$726.00
$679.00
$568.00
$608.00
$605.00
$369.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$316.00
$198.00
$391.00
$773.00
$235.00
$261.00
----$1,244.00
$1,086.00
$1,337.00
$1,254.00
$1,476.00
$140.00
$2,164.00
$1,678.00
$1,594.00
$1,726.00
$1,622.00
$54.00
$57.00
$48.00
$1,263.00
$1,273.00
$1,661.00
----$105.00
$81.00
$97.00
$110.00
$150.00
$177.00
$429.00
$118.00
$69.00
$131.00
$205.00
$550.00
$163.00
$201.00
$184.00
$374.00
$523.00
$683.00
$745.00
$754.00
$741.00
$771.00
$723.00
$602.00
$646.00
$643.00
$391.00
$329.00
$205.00
$406.00
$803.00
$244.00
$272.00
----$1,292.00
$1,128.00
$1,387.00
$1,302.00
$1,531.00
$147.00
$2,247.00
$1,754.00
$1,655.00
$1,792.00
$1,683.00
$57.00
$59.00
$50.00
$1,312.00
$1,322.00
$1,728.00
----$110.00
$85.00
$101.00
$115.00
$156.00
$184.00
$446.00
$123.00
$72.00
$136.00
$212.00
$571.00
$169.00
$209.00
$191.00
$389.00
$543.00
$710.00
$774.00
$784.00
$773.00
$800.00
$755.00
$625.00
$671.00
$667.00
$406.00
213
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
67915
67916
67917
67921
67922
67923
67924
67930
67935
67938
67950
67961
67966
67971
67973
67974
67975
67999
68020
68040
68100
68110
68115
68130
68135
68200
68320
68325
68326
68328
68330
68335
68340
68360
68362
68399
68400
68420
68440
68500
68505
68510
68520
68525
68530
68540
68550
68700
68705
68720
68745
68750
90
$252.00
90
$675.00
90
$631.00
90
$419.00
90
$243.00
90
$718.00
90
$605.00
10
$280.00
90
$520.00
10
$67.00
90
$584.00
90
$571.00
90
$645.00
90
$875.00
90 $1,126.00
90 $1,140.00
90
$681.00
YYY
BR
10
$106.00
0
$75.00
0
$137.00
10
$172.00
10
$248.00
90
$378.00
10
$146.00
0
$59.00
90
$502.00
90
$672.00
90
$654.00
90
$741.00
90
$488.00
90
$636.00
90
$413.00
90
$449.00
90
$691.00
YYY
BR
10
$154.00
10
$191.00
10
$96.00
90
$882.00
90
$921.00
0
$491.00
90
$687.00
0
$340.00
10
$379.00
90
$875.00
90 $1,107.00
90
$628.00
10
$176.00
90
$807.00
90
$704.00
90
$792.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$717.00
$1,051.00
$818.00
$786.00
$709.00
$1,038.00
$773.00
$791.00
$1,063.00
$529.00
$738.00
$747.00
$780.00
$886.00
$1,149.00
$1,140.00
$834.00
----$439.00
$404.00
$441.00
$514.00
$522.00
$372.00
$481.00
$62.00
$554.00
$689.00
$672.00
$768.00
$598.00
$647.00
$926.00
$551.00
$768.00
----$634.00
$682.00
$416.00
$1,060.00
$1,107.00
$844.00
$748.00
$335.00
$867.00
$1,009.00
$1,254.00
$672.00
$502.00
$854.00
$831.00
$857.00
$766.00
$1,122.00
$871.00
$840.00
$758.00
$1,107.00
$823.00
$845.00
$1,135.00
$567.00
$786.00
$795.00
$830.00
$938.00
$1,217.00
$1,206.00
$883.00
----$470.00
$433.00
$473.00
$551.00
$557.00
$392.00
$515.00
$66.00
$587.00
$729.00
$712.00
$814.00
$635.00
$684.00
$990.00
$586.00
$815.00
----$679.00
$731.00
$446.00
$1,126.00
$1,177.00
$900.00
$793.00
$353.00
$927.00
$1,069.00
$1,331.00
$713.00
$536.00
$904.00
$881.00
$908.00
$793.00
$1,162.00
$903.00
$870.00
$785.00
$1,147.00
$853.00
$876.00
$1,177.00
$587.00
$817.00
$825.00
$863.00
$974.00
$1,266.00
$1,253.00
$917.00
----$487.00
$448.00
$490.00
$570.00
$577.00
$407.00
$533.00
$68.00
$609.00
$758.00
$739.00
$848.00
$659.00
$710.00
$1,025.00
$607.00
$845.00
----$703.00
$756.00
$462.00
$1,174.00
$1,225.00
$933.00
$824.00
$367.00
$960.00
$1,111.00
$1,385.00
$740.00
$555.00
$939.00
$916.00
$943.00
$240.00
$541.00
$640.00
$343.00
$316.00
$575.00
$596.00
$341.00
$594.00
$96.00
$666.00
$583.00
$638.00
$886.00
$1,149.00
$1,140.00
$834.00
----$103.00
$64.00
$102.00
$159.00
$178.00
$372.00
$139.00
$37.00
$534.00
$689.00
$672.00
$768.00
$524.00
$647.00
$424.00
$485.00
$768.00
----$193.00
$241.00
$71.00
$1,060.00
$1,107.00
$349.00
$748.00
$335.00
$340.00
$1,009.00
$1,254.00
$672.00
$156.00
$854.00
$831.00
$857.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$253.00
$573.00
$679.00
$364.00
$335.00
$609.00
$632.00
$362.00
$630.00
$101.00
$709.00
$618.00
$678.00
$938.00
$1,217.00
$1,206.00
$883.00
----$109.00
$67.00
$108.00
$168.00
$188.00
$392.00
$146.00
$39.00
$565.00
$729.00
$712.00
$814.00
$556.00
$684.00
$449.00
$515.00
$815.00
----$205.00
$256.00
$75.00
$1,126.00
$1,177.00
$368.00
$793.00
$353.00
$360.00
$1,069.00
$1,331.00
$713.00
$164.00
$904.00
$881.00
$908.00
$263.00
$595.00
$705.00
$377.00
$348.00
$632.00
$655.00
$376.00
$655.00
$105.00
$737.00
$643.00
$706.00
$974.00
$1,266.00
$1,253.00
$917.00
----$114.00
$69.00
$112.00
$175.00
$195.00
$407.00
$152.00
$41.00
$587.00
$758.00
$739.00
$848.00
$577.00
$710.00
$466.00
$534.00
$845.00
----$213.00
$265.00
$78.00
$1,174.00
$1,225.00
$382.00
$824.00
$367.00
$375.00
$1,111.00
$1,385.00
$740.00
$171.00
$939.00
$916.00
$943.00
214
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
68760
68761
68770
68801
68810
68811
68815
68840
68850
68899
69000
69005
69020
69100
69105
69110
69120
69140
69145
69150
69155
69200
69205
69210
69220
69222
69300
69310
69320
69399
69400
69401
69405
69410
69420
69421
69424
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69550
69552
69554
69601
10
10
90
10
10
10
10
10
0
YYY
10
10
10
0
0
90
90
90
90
90
90
0
10
0
0
10
YYY
90
90
YYY
0
0
10
0
10
10
0
10
10
90
90
90
90
90
90
90
90
10
90
90
90
90
$109.00
$130.00
$634.00
$202.00
$290.00
$191.00
$399.00
$100.00
$76.00
BR
$52.00
$175.00
$109.00
$85.00
$87.00
$294.00
$274.00
$722.00
$248.00
$1,111.00
$1,680.00
$53.00
$110.00
$39.00
$78.00
$123.00
$522.00
$937.00
$1,434.00
BR
$76.00
$52.00
$176.00
$53.00
$117.00
$155.00
$84.00
$145.00
$182.00
$699.00
$525.00
$829.00
$1,118.00
$1,176.00
$1,221.00
$1,616.00
$2,824.00
$126.00
$998.00
$1,621.00
$2,600.00
$1,195.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$408.00
$218.00
$1,162.00
$91.00
$218.00
$241.00
$767.00
$142.00
$770.00
----$182.00
$240.00
$190.00
$121.00
$120.00
$360.00
$440.00
$830.00
$307.00
$1,288.00
$1,886.00
$112.00
$142.00
$61.00
$120.00
$185.00
$560.00
$1,065.00
$1,600.00
----$119.00
$103.00
$294.00
$87.00
$188.00
$221.00
$129.00
$196.00
$207.00
$770.00
$603.00
$891.00
$1,196.00
$1,243.00
$1,289.00
$1,768.00
$3,161.00
$177.00
$1,079.00
$1,763.00
$2,879.00
$1,301.00
$436.00
$233.00
$1,239.00
$97.00
$231.00
$256.00
$820.00
$151.00
$827.00
----$194.00
$256.00
$203.00
$129.00
$129.00
$385.00
$471.00
$886.00
$328.00
$1,378.00
$2,013.00
$120.00
$152.00
$66.00
$128.00
$198.00
$597.00
$1,137.00
$1,706.00
----$128.00
$110.00
$314.00
$93.00
$202.00
$237.00
$138.00
$210.00
$221.00
$822.00
$644.00
$951.00
$1,276.00
$1,326.00
$1,375.00
$1,885.00
$3,371.00
$189.00
$1,152.00
$1,880.00
$3,069.00
$1,388.00
$451.00
$241.00
$1,283.00
$100.00
$240.00
$265.00
$849.00
$156.00
$855.00
----$203.00
$268.00
$212.00
$134.00
$134.00
$402.00
$493.00
$927.00
$343.00
$1,446.00
$2,111.00
$125.00
$159.00
$69.00
$134.00
$207.00
$625.00
$1,190.00
$1,786.00
----$133.00
$115.00
$328.00
$97.00
$210.00
$247.00
$144.00
$219.00
$231.00
$860.00
$673.00
$996.00
$1,336.00
$1,389.00
$1,440.00
$1,974.00
$3,536.00
$197.00
$1,207.00
$1,970.00
$3,218.00
$1,452.00
$149.00
$118.00
$662.00
$77.00
$143.00
$241.00
$308.00
$111.00
$57.00
----$106.00
$214.00
$116.00
$63.00
$96.00
$324.00
$440.00
$830.00
$266.00
$1,288.00
$1,886.00
$79.00
$142.00
$45.00
$67.00
$160.00
$560.00
$1,065.00
$1,600.00
----$65.00
$51.00
$215.00
$26.00
$108.00
$188.00
$90.00
$125.00
$207.00
$770.00
$603.00
$891.00
$1,196.00
$1,243.00
$1,289.00
$1,768.00
$3,161.00
$144.00
$1,079.00
$1,763.00
$2,879.00
$1,301.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$158.00
$125.00
$701.00
$81.00
$151.00
$256.00
$326.00
$118.00
$60.00
----$113.00
$229.00
$124.00
$67.00
$103.00
$345.00
$471.00
$886.00
$284.00
$1,378.00
$2,013.00
$84.00
$152.00
$48.00
$71.00
$171.00
$597.00
$1,137.00
$1,706.00
----$69.00
$55.00
$229.00
$27.00
$115.00
$201.00
$97.00
$133.00
$221.00
$822.00
$644.00
$951.00
$1,276.00
$1,326.00
$1,375.00
$1,885.00
$3,371.00
$154.00
$1,152.00
$1,880.00
$3,069.00
$1,388.00
$164.00
$130.00
$727.00
$85.00
$157.00
$265.00
$339.00
$122.00
$63.00
----$119.00
$240.00
$130.00
$70.00
$108.00
$362.00
$493.00
$927.00
$297.00
$1,446.00
$2,111.00
$88.00
$159.00
$50.00
$74.00
$178.00
$625.00
$1,190.00
$1,786.00
----$73.00
$57.00
$240.00
$29.00
$121.00
$210.00
$101.00
$140.00
$231.00
$860.00
$673.00
$996.00
$1,336.00
$1,389.00
$1,440.00
$1,974.00
$3,536.00
$161.00
$1,207.00
$1,970.00
$3,218.00
$1,452.00
215
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
69602
69603
69604
69605
69610
69620
69631
69632
69633
69635
69636
69637
69641
69642
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69700
69710
69711
69714
69715
69717
69718
69720
69725
69740
69745
69799
69801
69802
69805
69806
69820
69840
69905
69910
69915
69930
69949
69950
69955
69960
90
90
90
90
10
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
0
90
90
90
90
90
90
90
90
90
YYY
90
90
90
90
90
90
90
90
90
90
YYY
90
90
90
$1,225.00
$1,264.00
$1,263.00
$1,526.00
$41.00
$651.00
$985.00
$1,166.00
$1,110.00
$1,207.00
$1,381.00
$1,370.00
$1,154.00
$1,519.00
$1,389.00
$1,529.00
$1,479.00
$1,620.00
$879.00
$1,072.00
$1,412.00
$1,386.00
$887.00
$887.00
$988.00
$828.00
$702.00
BR
$878.00
$961.00
$1,217.00
$996.00
$1,232.00
$1,307.00
$1,922.00
$1,274.00
$1,447.00
BR
$785.00
$1,115.00
$1,187.00
$1,123.00
$876.00
$869.00
$1,013.00
$1,228.00
$1,754.00
$1,498.00
BR
$2,017.00
$2,185.00
$2,116.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,297.00
$1,332.00
$1,327.00
$1,718.00
$448.00
$657.00
$988.00
$1,260.00
$1,207.00
$1,249.00
$1,468.00
$1,457.00
$1,226.00
$1,598.00
$1,473.00
$1,609.00
$1,559.00
$1,693.00
$940.00
$1,122.00
$1,468.00
$1,445.00
$948.00
$951.00
$1,121.00
$963.00
$718.00
----$1,020.00
$1,313.00
$1,671.00
$1,337.00
$1,679.00
$1,397.00
$2,269.00
$1,424.00
$1,525.00
----$851.00
$1,259.00
$1,283.00
$1,196.00
$999.00
$929.00
$1,082.00
$1,291.00
$1,929.00
$1,540.00
----$2,278.00
$2,389.00
$2,399.00
$1,383.00
$1,421.00
$1,416.00
$1,832.00
$478.00
$701.00
$1,054.00
$1,345.00
$1,289.00
$1,331.00
$1,566.00
$1,555.00
$1,308.00
$1,704.00
$1,572.00
$1,716.00
$1,664.00
$1,806.00
$1,003.00
$1,198.00
$1,566.00
$1,542.00
$1,012.00
$1,015.00
$1,196.00
$1,028.00
$765.00
----$1,086.00
$1,401.00
$1,784.00
$1,426.00
$1,792.00
$1,491.00
$2,420.00
$1,519.00
$1,622.00
----$908.00
$1,343.00
$1,369.00
$1,277.00
$1,064.00
$989.00
$1,154.00
$1,377.00
$2,058.00
$1,643.00
----$2,458.00
$2,547.00
$2,572.00
$1,448.00
$1,489.00
$1,482.00
$1,919.00
$501.00
$732.00
$1,103.00
$1,408.00
$1,348.00
$1,392.00
$1,640.00
$1,628.00
$1,369.00
$1,785.00
$1,646.00
$1,797.00
$1,742.00
$1,892.00
$1,050.00
$1,254.00
$1,640.00
$1,615.00
$1,059.00
$1,064.00
$1,251.00
$1,077.00
$801.00
----$1,133.00
$1,468.00
$1,870.00
$1,495.00
$1,879.00
$1,561.00
$2,536.00
$1,592.00
$1,694.00
----$950.00
$1,406.00
$1,434.00
$1,336.00
$1,112.00
$1,034.00
$1,208.00
$1,441.00
$2,158.00
$1,722.00
----$2,610.00
$2,669.00
$2,712.00
$1,297.00
$1,332.00
$1,327.00
$1,718.00
$408.00
$477.00
$988.00
$1,260.00
$1,207.00
$1,249.00
$1,468.00
$1,457.00
$1,226.00
$1,598.00
$1,473.00
$1,609.00
$1,559.00
$1,693.00
$940.00
$1,122.00
$1,468.00
$1,445.00
$948.00
$951.00
$1,121.00
$963.00
$718.00
----$1,020.00
$1,313.00
$1,671.00
$1,337.00
$1,679.00
$1,397.00
$2,269.00
$1,424.00
$1,525.00
----$851.00
$1,259.00
$1,283.00
$1,196.00
$999.00
$929.00
$1,082.00
$1,291.00
$1,929.00
$1,540.00
----$2,278.00
$2,389.00
$2,399.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$1,383.00
$1,421.00
$1,416.00
$1,832.00
$435.00
$508.00
$1,054.00
$1,345.00
$1,289.00
$1,331.00
$1,566.00
$1,555.00
$1,308.00
$1,704.00
$1,572.00
$1,716.00
$1,664.00
$1,806.00
$1,003.00
$1,198.00
$1,566.00
$1,542.00
$1,012.00
$1,015.00
$1,196.00
$1,028.00
$765.00
----$1,086.00
$1,401.00
$1,784.00
$1,426.00
$1,792.00
$1,491.00
$2,420.00
$1,519.00
$1,622.00
----$908.00
$1,343.00
$1,369.00
$1,277.00
$1,064.00
$989.00
$1,154.00
$1,377.00
$2,058.00
$1,643.00
----$2,458.00
$2,547.00
$2,572.00
$1,448.00
$1,489.00
$1,482.00
$1,919.00
$456.00
$533.00
$1,103.00
$1,408.00
$1,348.00
$1,392.00
$1,640.00
$1,628.00
$1,369.00
$1,785.00
$1,646.00
$1,797.00
$1,742.00
$1,892.00
$1,050.00
$1,254.00
$1,640.00
$1,615.00
$1,059.00
$1,064.00
$1,251.00
$1,077.00
$801.00
----$1,133.00
$1,468.00
$1,870.00
$1,495.00
$1,879.00
$1,561.00
$2,536.00
$1,592.00
$1,694.00
----$950.00
$1,406.00
$1,434.00
$1,336.00
$1,112.00
$1,034.00
$1,208.00
$1,441.00
$2,158.00
$1,722.00
----$2,610.00
$2,669.00
$2,712.00
216
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Surgery
CPT Code
FUD 2003 MRA
69970
69979
69990
90 $2,306.00
YYY
BR
ZZZ $262.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$2,582.00
----$300.00
$2,758.00
----$329.00
$2,899.00
----$354.00
$2,582.00
----$300.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,758.00
----$329.00
$2,899.00
----$354.00
217
Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2004 Edition
PART C
SCHEDULE OF MAXIMUM REIMBURSEMENT
ALLOWANCES
218
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
70010
70010-26
70010-TC
70015
70015-26
70015-TC
70030
70030-26
70030-TC
70100
70100-26
70100-TC
70110
70110-26
70110-TC
70120
70120-26
70120-TC
70130
70130-26
70130-TC
70134
70134-26
70134-TC
70140
70140-26
70140-TC
70150
70150-26
70150-TC
70160
70160-26
70160-TC
70170
70170-26
70170-TC
70190
70190-26
70190-TC
70200
70200-26
70200-TC
70210
70210-26
70210-TC
70220
70220-26
70220-TC
70240
70240-26
70240-TC
70250
$70.00
NC
NC
$58.00
NC
NC
$24.00
$10.00
$15.00
$29.00
$9.00
$19.00
$36.00
$12.00
$22.00
$32.00
$9.00
$22.00
$46.00
$17.00
$29.00
$45.00
$17.00
$28.00
$33.00
$9.00
$22.00
$42.00
$12.00
$29.00
$29.00
$8.00
$19.00
$52.00
NC
NC
$34.00
$10.00
$22.00
$43.00
$14.00
$29.00
$32.00
$8.00
$22.00
$42.00
$12.00
$29.00
$26.00
$9.00
$15.00
$35.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$240.00
$66.00
$174.00
$120.00
$65.00
$55.00
$27.00
$10.00
$17.00
$31.00
$10.00
$21.00
$39.00
$13.00
$25.00
$35.00
$10.00
$25.00
$50.00
$19.00
$32.00
$49.00
$19.00
$30.00
$36.00
$10.00
$25.00
$46.00
$14.00
$32.00
$30.00
$10.00
$21.00
$55.00
$16.00
$39.00
$37.00
$11.00
$25.00
$47.00
$15.00
$32.00
$35.00
$10.00
$25.00
$46.00
$14.00
$32.00
$27.00
$10.00
$17.00
$38.00
$261.00
$69.00
$191.00
$129.00
$69.00
$61.00
$29.00
$10.00
$19.00
$33.00
$10.00
$23.00
$42.00
$14.00
$28.00
$38.00
$10.00
$28.00
$55.00
$19.00
$35.00
$53.00
$19.00
$34.00
$39.00
$11.00
$28.00
$50.00
$15.00
$35.00
$33.00
$10.00
$23.00
$60.00
$17.00
$43.00
$40.00
$12.00
$28.00
$51.00
$16.00
$35.00
$38.00
$10.00
$28.00
$50.00
$15.00
$35.00
$30.00
$11.00
$19.00
$42.00
$274.00
$72.00
$202.00
$136.00
$71.00
$64.00
$30.00
$11.00
$20.00
$35.00
$11.00
$24.00
$44.00
$15.00
$29.00
$40.00
$11.00
$29.00
$57.00
$20.00
$37.00
$56.00
$20.00
$36.00
$41.00
$11.00
$29.00
$53.00
$16.00
$37.00
$35.00
$11.00
$24.00
$63.00
$18.00
$46.00
$42.00
$13.00
$29.00
$54.00
$17.00
$37.00
$40.00
$11.00
$29.00
$52.00
$15.00
$37.00
$31.00
$11.00
$20.00
$44.00
$240.00
$66.00
$174.00
$120.00
$65.00
$55.00
$27.00
$10.00
$17.00
$31.00
$10.00
$21.00
$39.00
$13.00
$25.00
$35.00
$10.00
$25.00
$50.00
$19.00
$32.00
$49.00
$19.00
$30.00
$36.00
$10.00
$25.00
$46.00
$14.00
$32.00
$30.00
$10.00
$21.00
$55.00
$16.00
$39.00
$37.00
$11.00
$25.00
$47.00
$15.00
$32.00
$35.00
$10.00
$25.00
$46.00
$14.00
$32.00
$27.00
$10.00
$17.00
$38.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$261.00
$69.00
$191.00
$129.00
$69.00
$61.00
$29.00
$10.00
$19.00
$33.00
$10.00
$23.00
$42.00
$14.00
$28.00
$38.00
$10.00
$28.00
$55.00
$19.00
$35.00
$53.00
$19.00
$34.00
$39.00
$11.00
$28.00
$50.00
$15.00
$35.00
$33.00
$10.00
$23.00
$60.00
$17.00
$43.00
$40.00
$12.00
$28.00
$51.00
$16.00
$35.00
$38.00
$10.00
$28.00
$50.00
$15.00
$35.00
$30.00
$11.00
$19.00
$42.00
$274.00
$72.00
$202.00
$136.00
$71.00
$64.00
$30.00
$11.00
$20.00
$35.00
$11.00
$24.00
$44.00
$15.00
$29.00
$40.00
$11.00
$29.00
$57.00
$20.00
$37.00
$56.00
$20.00
$36.00
$41.00
$11.00
$29.00
$53.00
$16.00
$37.00
$35.00
$11.00
$24.00
$63.00
$18.00
$46.00
$42.00
$13.00
$29.00
$54.00
$17.00
$37.00
$40.00
$11.00
$29.00
$52.00
$15.00
$37.00
$31.00
$11.00
$20.00
$44.00
219
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
70250-26
70250-TC
70260
70260-26
70260-TC
70300
70300-26
70300-TC
70310
70310-26
70310-TC
70320
70320-26
70320-TC
70328
70328-26
70328-TC
70330
70330-26
70330-TC
70332
70332-26
70332-TC
70336
70336-26
70336-TC
70350
70350-26
70350-TC
70355
70355-26
70355-TC
70360
70360-26
70360-TC
70370
70370-26
70370-TC
70371
70371-26
70371-TC
70373
70373-26
70373-TC
70380
70380-26
70380-TC
70390
70390-26
70390-TC
70450
70450-26
$12.00
$22.00
$50.00
$17.00
$33.00
$15.00
$5.00
$10.00
$24.00
$8.00
$15.00
$40.00
$11.00
$29.00
$28.00
$10.00
$18.00
$43.00
$12.00
$31.00
$107.00
NC
NC
$497.00
$72.00
$419.00
$24.00
$10.00
$14.00
$32.00
$10.00
$21.00
$24.00
$8.00
$15.00
$65.00
$16.00
$48.00
$122.00
$43.00
$79.00
$90.00
NC
NC
$34.00
$8.00
$24.00
$87.00
NC
NC
$221.00
$43.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$13.00
$25.00
$55.00
$19.00
$37.00
$17.00
$6.00
$11.00
$26.00
$9.00
$17.00
$44.00
$12.00
$32.00
$30.00
$10.00
$20.00
$47.00
$13.00
$34.00
$115.00
$30.00
$85.00
$534.00
$81.00
$452.00
$25.00
$10.00
$16.00
$34.00
$11.00
$23.00
$27.00
$10.00
$17.00
$70.00
$17.00
$53.00
$131.00
$46.00
$85.00
$96.00
$24.00
$72.00
$37.00
$10.00
$27.00
$93.00
$21.00
$72.00
$237.00
$47.00
$14.00
$28.00
$60.00
$19.00
$40.00
$19.00
$6.00
$12.00
$29.00
$10.00
$19.00
$48.00
$13.00
$35.00
$32.00
$10.00
$22.00
$51.00
$14.00
$38.00
$125.00
$31.00
$94.00
$583.00
$86.00
$497.00
$27.00
$10.00
$17.00
$37.00
$12.00
$26.00
$29.00
$10.00
$19.00
$76.00
$18.00
$58.00
$143.00
$49.00
$94.00
$105.00
$25.00
$80.00
$40.00
$10.00
$30.00
$102.00
$22.00
$80.00
$259.00
$49.00
$14.00
$29.00
$63.00
$20.00
$43.00
$20.00
$7.00
$13.00
$30.00
$10.00
$20.00
$51.00
$13.00
$37.00
$34.00
$11.00
$23.00
$54.00
$14.00
$40.00
$132.00
$32.00
$99.00
$615.00
$90.00
$525.00
$29.00
$11.00
$18.00
$40.00
$12.00
$27.00
$30.00
$11.00
$20.00
$80.00
$19.00
$61.00
$150.00
$51.00
$99.00
$111.00
$26.00
$85.00
$42.00
$11.00
$32.00
$108.00
$23.00
$85.00
$273.00
$51.00
$13.00
$25.00
$55.00
$19.00
$37.00
$17.00
$6.00
$11.00
$26.00
$9.00
$17.00
$44.00
$12.00
$32.00
$30.00
$10.00
$20.00
$47.00
$13.00
$34.00
$115.00
$30.00
$85.00
$534.00
$81.00
$452.00
$25.00
$10.00
$16.00
$34.00
$11.00
$23.00
$27.00
$10.00
$17.00
$70.00
$17.00
$53.00
$131.00
$46.00
$85.00
$96.00
$24.00
$72.00
$37.00
$10.00
$27.00
$93.00
$21.00
$72.00
$237.00
$47.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$14.00
$28.00
$60.00
$19.00
$40.00
$19.00
$6.00
$12.00
$29.00
$10.00
$19.00
$48.00
$13.00
$35.00
$32.00
$10.00
$22.00
$51.00
$14.00
$38.00
$125.00
$31.00
$94.00
$583.00
$86.00
$497.00
$27.00
$10.00
$17.00
$37.00
$12.00
$26.00
$29.00
$10.00
$19.00
$76.00
$18.00
$58.00
$143.00
$49.00
$94.00
$105.00
$25.00
$80.00
$40.00
$10.00
$30.00
$102.00
$22.00
$80.00
$259.00
$49.00
$14.00
$29.00
$63.00
$20.00
$43.00
$20.00
$7.00
$13.00
$30.00
$10.00
$20.00
$51.00
$13.00
$37.00
$34.00
$11.00
$23.00
$54.00
$14.00
$40.00
$132.00
$32.00
$99.00
$615.00
$90.00
$525.00
$29.00
$11.00
$18.00
$40.00
$12.00
$27.00
$30.00
$11.00
$20.00
$80.00
$19.00
$61.00
$150.00
$51.00
$99.00
$111.00
$26.00
$85.00
$42.00
$11.00
$32.00
$108.00
$23.00
$85.00
$273.00
$51.00
220
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
70450-TC
70460
70460-26
70460-TC
70470
70470-26
70470-TC
70480
70480-26
70480-TC
70481
70481-26
70481-TC
70482
70482-26
70482-TC
70486
70486-26
70486-TC
70487
70487-26
70487-TC
70488
70488-26
70488-TC
70490
70490-26
70490-TC
70491
70491-26
70491-TC
70492
70492-26
70492-TC
70496
70496-26
70496-TC
70498
70498-26
70498-TC
70540
70540-26
70540-TC
70542
70542-26
70542-TC
70543
70543-26
70543-TC
70544
70544-26
70544-TC
$176.00
$271.00
$58.00
$211.00
$332.00
$65.00
$264.00
$244.00
$65.00
$176.00
$284.00
$70.00
$211.00
$340.00
$74.00
$264.00
$236.00
$58.00
$176.00
$279.00
$66.00
$211.00
$339.00
$72.00
$264.00
$244.00
$65.00
$176.00
$284.00
$70.00
$211.00
$340.00
$74.00
$264.00
$366.00
$92.00
$270.00
$366.00
$92.00
$270.00
$482.00
$70.00
$413.00
$579.00
$82.00
$495.00
$1,029.00
$109.00
$916.00
$481.00
$61.00
$419.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$191.00
$290.00
$62.00
$228.00
$355.00
$70.00
$285.00
$261.00
$70.00
$191.00
$304.00
$76.00
$228.00
$364.00
$79.00
$285.00
$253.00
$62.00
$191.00
$300.00
$71.00
$228.00
$363.00
$77.00
$285.00
$261.00
$70.00
$191.00
$304.00
$76.00
$228.00
$364.00
$79.00
$285.00
$525.00
$96.00
$429.00
$525.00
$96.00
$429.00
$516.00
$73.00
$444.00
$620.00
$88.00
$532.00
$1,101.00
$116.00
$984.00
$518.00
$66.00
$452.00
$210.00
$316.00
$65.00
$251.00
$387.00
$73.00
$314.00
$284.00
$74.00
$210.00
$330.00
$80.00
$251.00
$397.00
$83.00
$314.00
$275.00
$66.00
$210.00
$326.00
$75.00
$251.00
$395.00
$82.00
$314.00
$283.00
$74.00
$210.00
$330.00
$80.00
$251.00
$397.00
$83.00
$314.00
$572.00
$101.00
$471.00
$573.00
$101.00
$471.00
$560.00
$76.00
$484.00
$673.00
$92.00
$581.00
$1,196.00
$122.00
$1,074.00
$566.00
$69.00
$497.00
$222.00
$333.00
$68.00
$265.00
$408.00
$77.00
$331.00
$299.00
$77.00
$222.00
$348.00
$83.00
$265.00
$418.00
$87.00
$331.00
$290.00
$69.00
$222.00
$343.00
$78.00
$265.00
$416.00
$85.00
$331.00
$299.00
$77.00
$222.00
$348.00
$83.00
$265.00
$418.00
$87.00
$331.00
$604.00
$105.00
$499.00
$604.00
$106.00
$499.00
$587.00
$79.00
$508.00
$705.00
$95.00
$609.00
$1,253.00
$127.00
$1,126.00
$597.00
$72.00
$525.00
$191.00
$290.00
$62.00
$228.00
$355.00
$70.00
$285.00
$261.00
$70.00
$191.00
$304.00
$76.00
$228.00
$364.00
$79.00
$285.00
$253.00
$62.00
$191.00
$300.00
$71.00
$228.00
$363.00
$77.00
$285.00
$261.00
$70.00
$191.00
$304.00
$76.00
$228.00
$364.00
$79.00
$285.00
$525.00
$96.00
$429.00
$525.00
$96.00
$429.00
$516.00
$73.00
$444.00
$620.00
$88.00
$532.00
$1,101.00
$116.00
$984.00
$518.00
$66.00
$452.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$210.00
$316.00
$65.00
$251.00
$387.00
$73.00
$314.00
$284.00
$74.00
$210.00
$330.00
$80.00
$251.00
$397.00
$83.00
$314.00
$275.00
$66.00
$210.00
$326.00
$75.00
$251.00
$395.00
$82.00
$314.00
$283.00
$74.00
$210.00
$330.00
$80.00
$251.00
$397.00
$83.00
$314.00
$572.00
$101.00
$471.00
$573.00
$101.00
$471.00
$560.00
$76.00
$484.00
$673.00
$92.00
$581.00
$1,196.00
$122.00
$1,074.00
$566.00
$69.00
$497.00
$222.00
$333.00
$68.00
$265.00
$408.00
$77.00
$331.00
$299.00
$77.00
$222.00
$348.00
$83.00
$265.00
$418.00
$87.00
$331.00
$290.00
$69.00
$222.00
$343.00
$78.00
$265.00
$416.00
$85.00
$331.00
$299.00
$77.00
$222.00
$348.00
$83.00
$265.00
$418.00
$87.00
$331.00
$604.00
$105.00
$499.00
$604.00
$106.00
$499.00
$587.00
$79.00
$508.00
$705.00
$95.00
$609.00
$1,253.00
$127.00
$1,126.00
$597.00
$72.00
$525.00
221
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
70545
70545-26
70545-TC
70546
70546-26
70546-TC
70547
70547-26
70547-TC
70548
70548-26
70548-TC
70549
70549-26
70549-TC
70551
70551-26
70551-TC
70552
70552-26
70552-TC
70553
70553-26
70553-TC
71010
71010-26
71010-TC
71015
71015-26
71015-TC
71020
71020-26
71020-TC
71021
71021-26
71021-TC
71022
71022-26
71022-TC
71023
71023-26
71023-TC
71030
71030-26
71030-TC
71034
71034-26
71034-TC
71035
71035-26
71035-TC
71040
$481.00
$61.00
$419.00
$914.00
$92.00
$820.00
$481.00
$61.00
$419.00
$481.00
$61.00
$419.00
$914.00
$92.00
$820.00
$497.00
$76.00
$419.00
$596.00
$91.00
$502.00
$1,055.00
$120.00
$931.00
$27.00
$9.00
$17.00
$30.00
$10.00
$19.00
$35.00
$11.00
$22.00
$41.00
$13.00
$28.00
$44.00
$16.00
$28.00
$49.00
$19.00
$29.00
$45.00
$16.00
$29.00
$79.00
$23.00
$54.00
$56.00
$19.00
$38.00
$34.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$518.00
$66.00
$452.00
$978.00
$99.00
$879.00
$518.00
$66.00
$452.00
$518.00
$66.00
$452.00
$978.00
$99.00
$879.00
$534.00
$81.00
$452.00
$640.00
$98.00
$542.00
$1,134.00
$129.00
$1,004.00
$29.00
$10.00
$19.00
$32.00
$11.00
$21.00
$37.00
$12.00
$25.00
$45.00
$15.00
$30.00
$48.00
$17.00
$30.00
$53.00
$21.00
$32.00
$48.00
$17.00
$32.00
$84.00
$26.00
$58.00
$31.00
$10.00
$21.00
$91.00
$566.00
$69.00
$497.00
$1,060.00
$104.00
$956.00
$566.00
$69.00
$497.00
$566.00
$69.00
$497.00
$1,060.00
$104.00
$956.00
$583.00
$86.00
$497.00
$699.00
$103.00
$595.00
$1,240.00
$136.00
$1,104.00
$31.00
$10.00
$21.00
$35.00
$12.00
$23.00
$40.00
$13.00
$28.00
$49.00
$15.00
$34.00
$52.00
$19.00
$34.00
$58.00
$23.00
$35.00
$53.00
$17.00
$35.00
$91.00
$27.00
$64.00
$33.00
$10.00
$23.00
$99.00
$597.00
$72.00
$525.00
$1,108.00
$109.00
$1,000.00
$597.00
$72.00
$525.00
$597.00
$72.00
$525.00
$1,108.00
$109.00
$1,000.00
$615.00
$90.00
$525.00
$737.00
$108.00
$629.00
$1,308.00
$142.00
$1,166.00
$33.00
$11.00
$22.00
$37.00
$13.00
$24.00
$43.00
$13.00
$29.00
$52.00
$16.00
$36.00
$55.00
$19.00
$36.00
$61.00
$24.00
$37.00
$55.00
$18.00
$37.00
$96.00
$28.00
$68.00
$35.00
$11.00
$24.00
$104.00
$518.00
$66.00
$452.00
$978.00
$99.00
$879.00
$518.00
$66.00
$452.00
$518.00
$66.00
$452.00
$978.00
$99.00
$879.00
$534.00
$81.00
$452.00
$640.00
$98.00
$542.00
$1,134.00
$129.00
$1,004.00
$29.00
$10.00
$19.00
$32.00
$11.00
$21.00
$37.00
$12.00
$25.00
$45.00
$15.00
$30.00
$48.00
$17.00
$30.00
$53.00
$21.00
$32.00
$48.00
$17.00
$32.00
$84.00
$26.00
$58.00
$31.00
$10.00
$21.00
$91.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$566.00
$69.00
$497.00
$1,060.00
$104.00
$956.00
$566.00
$69.00
$497.00
$566.00
$69.00
$497.00
$1,060.00
$104.00
$956.00
$583.00
$86.00
$497.00
$699.00
$103.00
$595.00
$1,240.00
$136.00
$1,104.00
$31.00
$10.00
$21.00
$35.00
$12.00
$23.00
$40.00
$13.00
$28.00
$49.00
$15.00
$34.00
$52.00
$19.00
$34.00
$58.00
$23.00
$35.00
$53.00
$17.00
$35.00
$91.00
$27.00
$64.00
$33.00
$10.00
$23.00
$99.00
$597.00
$72.00
$525.00
$1,108.00
$109.00
$1,000.00
$597.00
$72.00
$525.00
$597.00
$72.00
$525.00
$1,108.00
$109.00
$1,000.00
$615.00
$90.00
$525.00
$737.00
$108.00
$629.00
$1,308.00
$142.00
$1,166.00
$33.00
$11.00
$22.00
$37.00
$13.00
$24.00
$43.00
$13.00
$29.00
$52.00
$16.00
$36.00
$55.00
$19.00
$36.00
$61.00
$24.00
$37.00
$55.00
$18.00
$37.00
$96.00
$28.00
$68.00
$35.00
$11.00
$24.00
$104.00
222
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
71040-26
71040-TC
71060
71060-26
71060-TC
71090
71090-26
71090-TC
71100
71100-26
71100-TC
71101
71101-26
71101-TC
71110
71110-26
71110-TC
71111
71111-26
71111-TC
71120
71120-26
71120-TC
71130
71130-26
71130-TC
71250
71250-26
71250-TC
71260
71260-26
71260-TC
71270
71270-26
71270-TC
71275
71275-26
71275-TC
71550
71550-26
71550-TC
71551
71551-26
71551-TC
71552
71552-26
71552-TC
71555
71555-26
71555-TC
72010
72010-26
NC
NC
$108.00
NC
NC
$92.00
NC
NC
$33.00
$11.00
$21.00
$38.00
$13.00
$24.00
$43.00
$13.00
$29.00
$49.00
$16.00
$33.00
$35.00
$10.00
$24.00
$38.00
$11.00
$26.00
$282.00
$59.00
$220.00
$328.00
$63.00
$264.00
$402.00
$70.00
$330.00
$431.00
$100.00
$328.00
$490.00
$75.00
$415.00
$587.00
$88.00
$496.00
$1,029.00
$114.00
$911.00
$514.00
$92.00
$419.00
$62.00
$22.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$32.00
$59.00
$130.00
$40.00
$90.00
$99.00
$30.00
$69.00
$35.00
$12.00
$23.00
$42.00
$15.00
$27.00
$47.00
$15.00
$32.00
$54.00
$17.00
$37.00
$37.00
$11.00
$26.00
$41.00
$12.00
$29.00
$302.00
$63.00
$238.00
$353.00
$68.00
$285.00
$432.00
$76.00
$357.00
$592.00
$104.00
$488.00
$525.00
$79.00
$446.00
$628.00
$94.00
$534.00
$1,100.00
$123.00
$977.00
$552.00
$99.00
$452.00
$67.00
$25.00
$34.00
$65.00
$141.00
$42.00
$99.00
$108.00
$32.00
$76.00
$38.00
$13.00
$26.00
$45.00
$15.00
$30.00
$51.00
$15.00
$35.00
$59.00
$18.00
$40.00
$41.00
$12.00
$29.00
$44.00
$13.00
$32.00
$329.00
$67.00
$262.00
$385.00
$71.00
$314.00
$471.00
$80.00
$392.00
$641.00
$109.00
$532.00
$570.00
$82.00
$488.00
$682.00
$99.00
$584.00
$1,192.00
$129.00
$1,063.00
$601.00
$105.00
$497.00
$72.00
$27.00
$35.00
$69.00
$149.00
$44.00
$105.00
$113.00
$33.00
$80.00
$40.00
$13.00
$27.00
$48.00
$16.00
$32.00
$53.00
$16.00
$37.00
$62.00
$19.00
$43.00
$43.00
$12.00
$31.00
$46.00
$13.00
$33.00
$346.00
$69.00
$277.00
$405.00
$74.00
$331.00
$497.00
$83.00
$414.00
$670.00
$113.00
$558.00
$598.00
$85.00
$513.00
$716.00
$102.00
$614.00
$1,246.00
$134.00
$1,112.00
$634.00
$109.00
$525.00
$76.00
$28.00
$32.00
$59.00
$130.00
$40.00
$90.00
$99.00
$30.00
$69.00
$35.00
$12.00
$23.00
$42.00
$15.00
$27.00
$47.00
$15.00
$32.00
$54.00
$17.00
$37.00
$37.00
$11.00
$26.00
$41.00
$12.00
$29.00
$302.00
$63.00
$238.00
$353.00
$68.00
$285.00
$432.00
$76.00
$357.00
$592.00
$104.00
$488.00
$525.00
$79.00
$446.00
$628.00
$94.00
$534.00
$1,100.00
$123.00
$977.00
$552.00
$99.00
$452.00
$67.00
$25.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$34.00
$65.00
$141.00
$42.00
$99.00
$108.00
$32.00
$76.00
$38.00
$13.00
$26.00
$45.00
$15.00
$30.00
$51.00
$15.00
$35.00
$59.00
$18.00
$40.00
$41.00
$12.00
$29.00
$44.00
$13.00
$32.00
$329.00
$67.00
$262.00
$385.00
$71.00
$314.00
$471.00
$80.00
$392.00
$641.00
$109.00
$532.00
$570.00
$82.00
$488.00
$682.00
$99.00
$584.00
$1,192.00
$129.00
$1,063.00
$601.00
$105.00
$497.00
$72.00
$27.00
$35.00
$69.00
$149.00
$44.00
$105.00
$113.00
$33.00
$80.00
$40.00
$13.00
$27.00
$48.00
$16.00
$32.00
$53.00
$16.00
$37.00
$62.00
$19.00
$43.00
$43.00
$12.00
$31.00
$46.00
$13.00
$33.00
$346.00
$69.00
$277.00
$405.00
$74.00
$331.00
$497.00
$83.00
$414.00
$670.00
$113.00
$558.00
$598.00
$85.00
$513.00
$716.00
$102.00
$614.00
$1,246.00
$134.00
$1,112.00
$634.00
$109.00
$525.00
$76.00
$28.00
223
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
72010-TC
72020
72020-26
72020-TC
72040
72040-26
72040-TC
72050
72050-26
72050-TC
72052
72052-26
72052-TC
72069
72069-26
72069-TC
72070
72070-26
72070-TC
72072
72072-26
72072-TC
72074
72074-26
72074-TC
72080
72080-26
72080-TC
72090
72090-26
72090-TC
72100
72100-26
72100-TC
72110
72110-26
72110-TC
72114
72114-26
72114-TC
72120
72120-26
72120-TC
72125
72125-26
72125-TC
72126
72126-26
72126-TC
72127
72127-26
72127-TC
$38.00
$22.00
$7.00
$15.00
$34.00
$11.00
$22.00
$49.00
$16.00
$33.00
$61.00
$18.00
$42.00
$40.00
$17.00
$24.00
$36.00
$11.00
$24.00
$39.00
$11.00
$28.00
$45.00
$11.00
$34.00
$36.00
$11.00
$24.00
$39.00
$14.00
$24.00
$36.00
$11.00
$24.00
$50.00
$16.00
$34.00
$64.00
$18.00
$44.00
$45.00
$11.00
$33.00
$282.00
$59.00
$220.00
$328.00
$62.00
$264.00
$397.00
$65.00
$330.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$42.00
$25.00
$8.00
$17.00
$36.00
$12.00
$25.00
$54.00
$17.00
$37.00
$65.00
$20.00
$45.00
$33.00
$13.00
$20.00
$38.00
$12.00
$26.00
$42.00
$12.00
$30.00
$49.00
$12.00
$37.00
$40.00
$13.00
$27.00
$43.00
$16.00
$27.00
$40.00
$13.00
$27.00
$55.00
$17.00
$37.00
$68.00
$20.00
$48.00
$49.00
$13.00
$37.00
$302.00
$63.00
$238.00
$352.00
$66.00
$285.00
$426.00
$70.00
$357.00
$46.00
$28.00
$9.00
$19.00
$40.00
$13.00
$27.00
$59.00
$19.00
$40.00
$71.00
$21.00
$50.00
$35.00
$14.00
$22.00
$42.00
$13.00
$29.00
$46.00
$13.00
$34.00
$54.00
$13.00
$41.00
$44.00
$14.00
$30.00
$47.00
$17.00
$30.00
$44.00
$14.00
$30.00
$60.00
$19.00
$41.00
$74.00
$22.00
$52.00
$54.00
$14.00
$40.00
$329.00
$67.00
$262.00
$383.00
$70.00
$314.00
$465.00
$73.00
$392.00
$49.00
$29.00
$9.00
$20.00
$42.00
$13.00
$29.00
$62.00
$19.00
$43.00
$75.00
$22.00
$53.00
$37.00
$14.00
$23.00
$44.00
$13.00
$31.00
$49.00
$13.00
$36.00
$57.00
$13.00
$44.00
$46.00
$14.00
$32.00
$49.00
$18.00
$32.00
$46.00
$14.00
$32.00
$63.00
$19.00
$44.00
$78.00
$23.00
$55.00
$57.00
$14.00
$43.00
$346.00
$69.00
$277.00
$404.00
$73.00
$331.00
$491.00
$77.00
$414.00
$42.00
$25.00
$8.00
$17.00
$36.00
$12.00
$25.00
$54.00
$17.00
$37.00
$65.00
$20.00
$45.00
$33.00
$13.00
$20.00
$38.00
$12.00
$26.00
$42.00
$12.00
$30.00
$49.00
$12.00
$37.00
$40.00
$13.00
$27.00
$43.00
$16.00
$27.00
$40.00
$13.00
$27.00
$55.00
$17.00
$37.00
$68.00
$20.00
$48.00
$49.00
$13.00
$37.00
$302.00
$63.00
$238.00
$352.00
$66.00
$285.00
$426.00
$70.00
$357.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$46.00
$28.00
$9.00
$19.00
$40.00
$13.00
$27.00
$59.00
$19.00
$40.00
$71.00
$21.00
$50.00
$35.00
$14.00
$22.00
$42.00
$13.00
$29.00
$46.00
$13.00
$34.00
$54.00
$13.00
$41.00
$44.00
$14.00
$30.00
$47.00
$17.00
$30.00
$44.00
$14.00
$30.00
$60.00
$19.00
$41.00
$74.00
$22.00
$52.00
$54.00
$14.00
$40.00
$329.00
$67.00
$262.00
$383.00
$70.00
$314.00
$465.00
$73.00
$392.00
$49.00
$29.00
$9.00
$20.00
$42.00
$13.00
$29.00
$62.00
$19.00
$43.00
$75.00
$22.00
$53.00
$37.00
$14.00
$23.00
$44.00
$13.00
$31.00
$49.00
$13.00
$36.00
$57.00
$13.00
$44.00
$46.00
$14.00
$32.00
$49.00
$18.00
$32.00
$46.00
$14.00
$32.00
$63.00
$19.00
$44.00
$78.00
$23.00
$55.00
$57.00
$14.00
$43.00
$346.00
$69.00
$277.00
$404.00
$73.00
$331.00
$491.00
$77.00
$414.00
224
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
72128
72128-26
72128-TC
72129
72129-26
72129-TC
72130
72130-26
72130-TC
72131
72131-26
72131-TC
72132
72132-26
72132-TC
72133
72133-26
72133-TC
72141
72141-26
72141-TC
72142
72142-26
72142-TC
72146
72146-26
72146-TC
72147
72147-26
72147-TC
72148
72148-26
72148-TC
72149
72149-26
72149-TC
72156
72156-26
72156-TC
72157
72157-26
72157-TC
72158
72158-26
72158-TC
72159
72159-26
72159-TC
72170
72170-26
72170-TC
72190
$282.00
$59.00
$220.00
$328.00
$62.00
$264.00
$397.00
$65.00
$330.00
$282.00
$59.00
$220.00
$328.00
$62.00
$264.00
$391.00
$65.00
$323.00
$503.00
$82.00
$419.00
$604.00
$99.00
$502.00
$549.00
$82.00
$465.00
$603.00
$98.00
$502.00
$543.00
$76.00
$465.00
$597.00
$92.00
$502.00
$1,066.00
$131.00
$931.00
$1,066.00
$131.00
$931.00
$1,056.00
$121.00
$931.00
$563.00
$94.00
$465.00
$29.00
$8.00
$19.00
$35.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$302.00
$63.00
$238.00
$352.00
$66.00
$285.00
$426.00
$70.00
$357.00
$302.00
$64.00
$238.00
$352.00
$67.00
$285.00
$427.00
$70.00
$357.00
$540.00
$88.00
$452.00
$648.00
$106.00
$542.00
$589.00
$88.00
$501.00
$647.00
$106.00
$542.00
$583.00
$81.00
$501.00
$640.00
$99.00
$542.00
$1,145.00
$141.00
$1,004.00
$1,145.00
$141.00
$1,004.00
$1,134.00
$130.00
$1,004.00
------------$30.00
$10.00
$21.00
$39.00
$329.00
$67.00
$262.00
$383.00
$70.00
$314.00
$465.00
$73.00
$392.00
$329.00
$67.00
$262.00
$384.00
$71.00
$314.00
$466.00
$74.00
$392.00
$589.00
$92.00
$497.00
$707.00
$112.00
$595.00
$643.00
$92.00
$551.00
$707.00
$111.00
$595.00
$637.00
$86.00
$551.00
$699.00
$104.00
$595.00
$1,252.00
$148.00
$1,104.00
$1,252.00
$148.00
$1,104.00
$1,240.00
$137.00
$1,104.00
------------$33.00
$10.00
$23.00
$42.00
$346.00
$69.00
$277.00
$404.00
$73.00
$331.00
$491.00
$77.00
$414.00
$347.00
$70.00
$277.00
$405.00
$74.00
$331.00
$491.00
$77.00
$414.00
$621.00
$96.00
$525.00
$745.00
$117.00
$629.00
$678.00
$96.00
$582.00
$745.00
$116.00
$629.00
$671.00
$90.00
$582.00
$738.00
$109.00
$629.00
$1,321.00
$154.00
$1,166.00
$1,321.00
$154.00
$1,166.00
$1,309.00
$143.00
$1,166.00
------------$35.00
$11.00
$24.00
$44.00
$302.00
$63.00
$238.00
$352.00
$66.00
$285.00
$426.00
$70.00
$357.00
$302.00
$64.00
$238.00
$352.00
$67.00
$285.00
$427.00
$70.00
$357.00
$540.00
$88.00
$452.00
$648.00
$106.00
$542.00
$589.00
$88.00
$501.00
$647.00
$106.00
$542.00
$583.00
$81.00
$501.00
$640.00
$99.00
$542.00
$1,145.00
$141.00
$1,004.00
$1,145.00
$141.00
$1,004.00
$1,134.00
$130.00
$1,004.00
------------$30.00
$10.00
$21.00
$39.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$329.00
$67.00
$262.00
$383.00
$70.00
$314.00
$465.00
$73.00
$392.00
$329.00
$67.00
$262.00
$384.00
$71.00
$314.00
$466.00
$74.00
$392.00
$589.00
$92.00
$497.00
$707.00
$112.00
$595.00
$643.00
$92.00
$551.00
$707.00
$111.00
$595.00
$637.00
$86.00
$551.00
$699.00
$104.00
$595.00
$1,252.00
$148.00
$1,104.00
$1,252.00
$148.00
$1,104.00
$1,240.00
$137.00
$1,104.00
------------$33.00
$10.00
$23.00
$42.00
$346.00
$69.00
$277.00
$404.00
$73.00
$331.00
$491.00
$77.00
$414.00
$347.00
$70.00
$277.00
$405.00
$74.00
$331.00
$491.00
$77.00
$414.00
$621.00
$96.00
$525.00
$745.00
$117.00
$629.00
$678.00
$96.00
$582.00
$745.00
$116.00
$629.00
$671.00
$90.00
$582.00
$738.00
$109.00
$629.00
$1,321.00
$154.00
$1,166.00
$1,321.00
$154.00
$1,166.00
$1,309.00
$143.00
$1,166.00
------------$35.00
$11.00
$24.00
$44.00
225
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
72190-26
72190-TC
72191
72191-26
72191-TC
72192
72192-26
72192-TC
72193
72193-26
72193-TC
72194
72194-26
72194-TC
72195
72195-26
72195-TC
72196
72196-26
72196-TC
72197
72197-26
72197-TC
72198
72198-26
72198-TC
72200
72200-26
72200-TC
72202
72202-26
72202-TC
72220
72220-26
72220-TC
72240
72240-26
72240-TC
72255
72255-26
72255-TC
72265
72265-26
72265-TC
72270
72270-26
72270-TC
72275
72275-26
72275-TC
72285
72285-26
$10.00
$24.00
$413.00
$94.00
$315.00
$278.00
$56.00
$220.00
$317.00
$59.00
$256.00
$380.00
$62.00
$317.00
$491.00
$74.00
$415.00
$526.00
$84.00
$442.00
$1,037.00
$114.00
$919.00
$517.00
$95.00
$419.00
$29.00
$9.00
$19.00
$33.00
$9.00
$22.00
$30.00
$8.00
$21.00
$132.00
NC
NC
$129.00
NC
NC
$132.00
NC
NC
$176.00
NC
NC
$112.00
NC
NC
$101.00
NC
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$11.00
$27.00
$573.00
$98.00
$475.00
$298.00
$60.00
$238.00
$340.00
$63.00
$276.00
$408.00
$66.00
$342.00
$525.00
$79.00
$446.00
$628.00
$93.00
$534.00
$1,110.00
$123.00
$987.00
------------$30.00
$10.00
$21.00
$36.00
$10.00
$25.00
$33.00
$10.00
$23.00
$241.00
$49.00
$192.00
$223.00
$49.00
$174.00
$209.00
$45.00
$164.00
$319.00
$73.00
$246.00
$128.00
$39.00
$89.00
$401.00
$63.00
$12.00
$30.00
$620.00
$103.00
$517.00
$325.00
$63.00
$262.00
$370.00
$67.00
$304.00
$445.00
$70.00
$375.00
$571.00
$83.00
$488.00
$682.00
$98.00
$584.00
$1,207.00
$129.00
$1,078.00
------------$33.00
$10.00
$23.00
$39.00
$11.00
$28.00
$36.00
$10.00
$26.00
$263.00
$52.00
$211.00
$242.00
$51.00
$191.00
$228.00
$47.00
$180.00
$347.00
$77.00
$271.00
$141.00
$41.00
$100.00
$438.00
$67.00
$13.00
$32.00
$649.00
$107.00
$542.00
$343.00
$66.00
$277.00
$390.00
$69.00
$321.00
$469.00
$73.00
$397.00
$599.00
$86.00
$513.00
$715.00
$101.00
$614.00
$1,266.00
$134.00
$1,133.00
------------$35.00
$11.00
$24.00
$41.00
$11.00
$29.00
$38.00
$11.00
$27.00
$277.00
$54.00
$223.00
$255.00
$53.00
$202.00
$240.00
$49.00
$191.00
$366.00
$80.00
$286.00
$150.00
$43.00
$107.00
$462.00
$70.00
$11.00
$27.00
$573.00
$98.00
$475.00
$298.00
$60.00
$238.00
$340.00
$63.00
$276.00
$408.00
$66.00
$342.00
$525.00
$79.00
$446.00
$628.00
$93.00
$534.00
$1,110.00
$123.00
$987.00
------------$30.00
$10.00
$21.00
$36.00
$10.00
$25.00
$33.00
$10.00
$23.00
$241.00
$49.00
$192.00
$223.00
$49.00
$174.00
$209.00
$45.00
$164.00
$319.00
$73.00
$246.00
$128.00
$39.00
$89.00
$401.00
$63.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$12.00
$30.00
$620.00
$103.00
$517.00
$325.00
$63.00
$262.00
$370.00
$67.00
$304.00
$445.00
$70.00
$375.00
$571.00
$83.00
$488.00
$682.00
$98.00
$584.00
$1,207.00
$129.00
$1,078.00
------------$33.00
$10.00
$23.00
$39.00
$11.00
$28.00
$36.00
$10.00
$26.00
$263.00
$52.00
$211.00
$242.00
$51.00
$191.00
$228.00
$47.00
$180.00
$347.00
$77.00
$271.00
$141.00
$41.00
$100.00
$438.00
$67.00
$13.00
$32.00
$649.00
$107.00
$542.00
$343.00
$66.00
$277.00
$390.00
$69.00
$321.00
$469.00
$73.00
$397.00
$599.00
$86.00
$513.00
$715.00
$101.00
$614.00
$1,266.00
$134.00
$1,133.00
------------$35.00
$11.00
$24.00
$41.00
$11.00
$29.00
$38.00
$11.00
$27.00
$277.00
$54.00
$223.00
$255.00
$53.00
$202.00
$240.00
$49.00
$191.00
$366.00
$80.00
$286.00
$150.00
$43.00
$107.00
$462.00
$70.00
226
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
72285-TC
72295
72295-26
72295-TC
73000
73000-26
73000-TC
73010
73010-26
73010-TC
73020
73020-26
73020-TC
73030
73030-26
73030-TC
73040
73040-26
73040-TC
73050
73050-26
73050-TC
73060
73060-26
73060-TC
73070
73070-26
73070-TC
73080
73080-26
73080-TC
73085
73085-26
73085-TC
73090
73090-26
73090-TC
73100
73100-26
73100-TC
73110
73110-26
73110-TC
73115
73115-26
73115-TC
73120
73120-26
73120-TC
73130
73130-26
73130-TC
NC
$107.00
NC
NC
$28.00
$8.00
$19.00
$29.00
$8.00
$19.00
$26.00
$7.00
$17.00
$31.00
$9.00
$21.00
$68.00
NC
NC
$35.00
$10.00
$24.00
$30.00
$8.00
$21.00
$27.00
$7.00
$19.00
$30.00
$8.00
$21.00
$74.00
NC
NC
$28.00
$8.00
$19.00
$27.00
$8.00
$18.00
$29.00
$8.00
$19.00
$54.00
NC
NC
$27.00
$8.00
$18.00
$29.00
$8.00
$19.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$338.00
$362.00
$46.00
$316.00
$30.00
$9.00
$21.00
$30.00
$10.00
$21.00
$27.00
$8.00
$19.00
$33.00
$10.00
$23.00
$115.00
$30.00
$85.00
$39.00
$12.00
$27.00
$33.00
$10.00
$23.00
$29.00
$8.00
$21.00
$33.00
$10.00
$23.00
$115.00
$30.00
$85.00
$30.00
$9.00
$21.00
$29.00
$10.00
$20.00
$31.00
$10.00
$21.00
$94.00
$30.00
$64.00
$29.00
$9.00
$20.00
$31.00
$10.00
$21.00
$371.00
$395.00
$48.00
$347.00
$32.00
$9.00
$23.00
$33.00
$10.00
$23.00
$30.00
$9.00
$21.00
$36.00
$10.00
$26.00
$125.00
$31.00
$94.00
$42.00
$12.00
$30.00
$36.00
$10.00
$26.00
$32.00
$9.00
$23.00
$36.00
$10.00
$26.00
$126.00
$32.00
$94.00
$32.00
$9.00
$23.00
$32.00
$10.00
$22.00
$33.00
$10.00
$23.00
$103.00
$32.00
$71.00
$31.00
$10.00
$22.00
$33.00
$10.00
$23.00
$392.00
$417.00
$50.00
$367.00
$34.00
$10.00
$24.00
$35.00
$11.00
$24.00
$31.00
$9.00
$22.00
$38.00
$11.00
$27.00
$132.00
$33.00
$99.00
$45.00
$13.00
$32.00
$38.00
$11.00
$27.00
$33.00
$9.00
$24.00
$38.00
$11.00
$27.00
$133.00
$33.00
$99.00
$34.00
$10.00
$24.00
$34.00
$11.00
$23.00
$35.00
$11.00
$25.00
$108.00
$33.00
$75.00
$33.00
$10.00
$23.00
$35.00
$11.00
$25.00
$338.00
$362.00
$46.00
$316.00
$30.00
$9.00
$21.00
$30.00
$10.00
$21.00
$27.00
$8.00
$19.00
$33.00
$10.00
$23.00
$115.00
$30.00
$85.00
$39.00
$12.00
$27.00
$33.00
$10.00
$23.00
$29.00
$8.00
$21.00
$33.00
$10.00
$23.00
$115.00
$30.00
$85.00
$30.00
$9.00
$21.00
$29.00
$10.00
$20.00
$31.00
$10.00
$21.00
$94.00
$30.00
$64.00
$29.00
$9.00
$20.00
$31.00
$10.00
$21.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$371.00
$395.00
$48.00
$347.00
$32.00
$9.00
$23.00
$33.00
$10.00
$23.00
$30.00
$9.00
$21.00
$36.00
$10.00
$26.00
$125.00
$31.00
$94.00
$42.00
$12.00
$30.00
$36.00
$10.00
$26.00
$32.00
$9.00
$23.00
$36.00
$10.00
$26.00
$126.00
$32.00
$94.00
$32.00
$9.00
$23.00
$32.00
$10.00
$22.00
$33.00
$10.00
$23.00
$103.00
$32.00
$71.00
$31.00
$10.00
$22.00
$33.00
$10.00
$23.00
$392.00
$417.00
$50.00
$367.00
$34.00
$10.00
$24.00
$35.00
$11.00
$24.00
$31.00
$9.00
$22.00
$38.00
$11.00
$27.00
$132.00
$33.00
$99.00
$45.00
$13.00
$32.00
$38.00
$11.00
$27.00
$33.00
$9.00
$24.00
$38.00
$11.00
$27.00
$133.00
$33.00
$99.00
$34.00
$10.00
$24.00
$34.00
$11.00
$23.00
$35.00
$11.00
$25.00
$108.00
$33.00
$75.00
$33.00
$10.00
$23.00
$35.00
$11.00
$25.00
227
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
73140
73140-26
73140-TC
73200
73200-26
73200-TC
73201
73201-26
73201-TC
73202
73202-26
73202-TC
73206
73206-26
73206-TC
73218
73218-26
73218-TC
73219
73219-26
73219-TC
73220
73220-26
73220-TC
73221
73221-26
73221-TC
73222
73222-26
73222-TC
73223
73223-26
73223-TC
73225
73225-26
73225-TC
73500
73500-26
73500-TC
73510
73510-26
73510-TC
73520
73520-26
73520-TC
73525
73525-26
73525-TC
73530
73530-26
73530-TC
73542
$22.00
$7.00
$15.00
$242.00
$56.00
$185.00
$282.00
$59.00
$220.00
$342.00
$63.00
$277.00
$375.00
$94.00
$277.00
$482.00
$68.00
$413.00
$579.00
$82.00
$495.00
$520.00
$78.00
$442.00
$482.00
$68.00
$413.00
$579.00
$82.00
$495.00
$1,029.00
$109.00
$916.00
$513.00
$92.00
$419.00
$27.00
$8.00
$17.00
$32.00
$10.00
$21.00
$38.00
$12.00
$24.00
$84.00
NC
NC
$34.00
$14.00
$19.00
$108.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$24.00
$7.00
$17.00
$260.00
$60.00
$200.00
$302.00
$64.00
$238.00
$367.00
$67.00
$299.00
$533.00
$98.00
$434.00
$516.00
$73.00
$444.00
$620.00
$88.00
$532.00
$1,102.00
$117.00
$984.00
$516.00
$73.00
$444.00
$620.00
$88.00
$532.00
$1,101.00
$117.00
$984.00
------------$29.00
$10.00
$19.00
$35.00
$12.00
$23.00
$42.00
$15.00
$27.00
$115.00
$30.00
$85.00
$37.00
$16.00
$21.00
$116.00
$26.00
$8.00
$19.00
$282.00
$63.00
$219.00
$329.00
$67.00
$262.00
$400.00
$71.00
$329.00
$577.00
$103.00
$474.00
$560.00
$76.00
$484.00
$673.00
$92.00
$581.00
$1,197.00
$123.00
$1,074.00
$560.00
$76.00
$484.00
$673.00
$92.00
$581.00
$1,196.00
$122.00
$1,074.00
------------$31.00
$10.00
$21.00
$39.00
$13.00
$26.00
$46.00
$16.00
$30.00
$125.00
$31.00
$94.00
$40.00
$17.00
$23.00
$127.00
$28.00
$8.00
$20.00
$297.00
$66.00
$232.00
$347.00
$70.00
$277.00
$421.00
$74.00
$347.00
$604.00
$107.00
$498.00
$587.00
$79.00
$508.00
$705.00
$95.00
$609.00
$1,254.00
$128.00
$1,126.00
$587.00
$79.00
$508.00
$705.00
$95.00
$609.00
$1,253.00
$127.00
$1,126.00
------------$33.00
$11.00
$22.00
$41.00
$14.00
$27.00
$48.00
$17.00
$32.00
$132.00
$33.00
$99.00
$41.00
$17.00
$24.00
$134.00
$24.00
$7.00
$17.00
$260.00
$60.00
$200.00
$302.00
$64.00
$238.00
$367.00
$67.00
$299.00
$533.00
$98.00
$434.00
$516.00
$73.00
$444.00
$620.00
$88.00
$532.00
$1,102.00
$117.00
$984.00
$516.00
$73.00
$444.00
$620.00
$88.00
$532.00
$1,101.00
$117.00
$984.00
------------$29.00
$10.00
$19.00
$35.00
$12.00
$23.00
$42.00
$15.00
$27.00
$115.00
$30.00
$85.00
$37.00
$16.00
$21.00
$116.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$26.00
$8.00
$19.00
$282.00
$63.00
$219.00
$329.00
$67.00
$262.00
$400.00
$71.00
$329.00
$577.00
$103.00
$474.00
$560.00
$76.00
$484.00
$673.00
$92.00
$581.00
$1,197.00
$123.00
$1,074.00
$560.00
$76.00
$484.00
$673.00
$92.00
$581.00
$1,196.00
$122.00
$1,074.00
------------$31.00
$10.00
$21.00
$39.00
$13.00
$26.00
$46.00
$16.00
$30.00
$125.00
$31.00
$94.00
$40.00
$17.00
$23.00
$127.00
$28.00
$8.00
$20.00
$297.00
$66.00
$232.00
$347.00
$70.00
$277.00
$421.00
$74.00
$347.00
$604.00
$107.00
$498.00
$587.00
$79.00
$508.00
$705.00
$95.00
$609.00
$1,254.00
$128.00
$1,126.00
$587.00
$79.00
$508.00
$705.00
$95.00
$609.00
$1,253.00
$127.00
$1,126.00
------------$33.00
$11.00
$22.00
$41.00
$14.00
$27.00
$48.00
$17.00
$32.00
$132.00
$33.00
$99.00
$41.00
$17.00
$24.00
$134.00
228
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
73542-26
73542-TC
73550
73550-26
73550-TC
73560
73560-26
73560-TC
73562
73562-26
73562-TC
73564
73564-26
73564-TC
73565
73565-26
73565-TC
73580
73580-26
73580-TC
73590
73590-26
73590-TC
73600
73600-26
73600-TC
73610
73610-26
73610-TC
73615
73615-26
73615-TC
73620
73620-26
73620-TC
73630
73630-26
73630-TC
73650
73650-26
73650-TC
73660
73660-26
73660-TC
73700
73700-26
73700-TC
73701
73701-26
73701-TC
73702
73702-26
NC
NC
$30.00
$8.00
$21.00
$29.00
$8.00
$19.00
$31.00
$9.00
$21.00
$35.00
$11.00
$22.00
$28.00
$8.00
$18.00
$84.00
NC
NC
$29.00
$8.00
$19.00
$27.00
$8.00
$18.00
$29.00
$8.00
$19.00
$72.00
NC
NC
$27.00
$8.00
$18.00
$29.00
$8.00
$19.00
$26.00
$8.00
$17.00
$22.00
$7.00
$15.00
$242.00
$56.00
$185.00
$282.00
$61.00
$220.00
$341.00
$62.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$31.00
$85.00
$33.00
$10.00
$23.00
$31.00
$10.00
$21.00
$34.00
$10.00
$23.00
$38.00
$13.00
$25.00
$30.00
$10.00
$20.00
$136.00
$30.00
$106.00
$30.00
$10.00
$21.00
$29.00
$9.00
$20.00
$31.00
$10.00
$21.00
$115.00
$30.00
$85.00
$29.00
$9.00
$20.00
$31.00
$10.00
$21.00
$28.00
$9.00
$19.00
$24.00
$7.00
$17.00
$260.00
$60.00
$200.00
$302.00
$63.00
$238.00
$366.00
$66.00
$33.00
$94.00
$36.00
$10.00
$26.00
$34.00
$11.00
$23.00
$37.00
$11.00
$26.00
$42.00
$14.00
$28.00
$33.00
$11.00
$22.00
$148.00
$31.00
$117.00
$33.00
$10.00
$23.00
$31.00
$10.00
$22.00
$33.00
$10.00
$23.00
$126.00
$32.00
$94.00
$31.00
$10.00
$22.00
$33.00
$10.00
$23.00
$31.00
$10.00
$21.00
$26.00
$8.00
$19.00
$282.00
$63.00
$219.00
$329.00
$67.00
$262.00
$399.00
$70.00
$35.00
$99.00
$38.00
$11.00
$27.00
$36.00
$12.00
$24.00
$39.00
$12.00
$27.00
$44.00
$14.00
$29.00
$34.00
$12.00
$23.00
$156.00
$33.00
$123.00
$35.00
$11.00
$24.00
$33.00
$10.00
$23.00
$35.00
$11.00
$25.00
$133.00
$33.00
$99.00
$33.00
$10.00
$23.00
$35.00
$11.00
$25.00
$32.00
$10.00
$22.00
$28.00
$8.00
$20.00
$297.00
$66.00
$232.00
$346.00
$69.00
$277.00
$420.00
$73.00
$31.00
$85.00
$33.00
$10.00
$23.00
$31.00
$10.00
$21.00
$34.00
$10.00
$23.00
$38.00
$13.00
$25.00
$30.00
$10.00
$20.00
$136.00
$30.00
$106.00
$30.00
$10.00
$21.00
$29.00
$9.00
$20.00
$31.00
$10.00
$21.00
$115.00
$30.00
$85.00
$29.00
$9.00
$20.00
$31.00
$10.00
$21.00
$28.00
$9.00
$19.00
$24.00
$7.00
$17.00
$260.00
$60.00
$200.00
$302.00
$63.00
$238.00
$366.00
$66.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$33.00
$94.00
$36.00
$10.00
$26.00
$34.00
$11.00
$23.00
$37.00
$11.00
$26.00
$42.00
$14.00
$28.00
$33.00
$11.00
$22.00
$148.00
$31.00
$117.00
$33.00
$10.00
$23.00
$31.00
$10.00
$22.00
$33.00
$10.00
$23.00
$126.00
$32.00
$94.00
$31.00
$10.00
$22.00
$33.00
$10.00
$23.00
$31.00
$10.00
$21.00
$26.00
$8.00
$19.00
$282.00
$63.00
$219.00
$329.00
$67.00
$262.00
$399.00
$70.00
$35.00
$99.00
$38.00
$11.00
$27.00
$36.00
$12.00
$24.00
$39.00
$12.00
$27.00
$44.00
$14.00
$29.00
$34.00
$12.00
$23.00
$156.00
$33.00
$123.00
$35.00
$11.00
$24.00
$33.00
$10.00
$23.00
$35.00
$11.00
$25.00
$133.00
$33.00
$99.00
$33.00
$10.00
$23.00
$35.00
$11.00
$25.00
$32.00
$10.00
$22.00
$28.00
$8.00
$20.00
$297.00
$66.00
$232.00
$346.00
$69.00
$277.00
$420.00
$73.00
229
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
73702-TC
73706
73706-26
73706-TC
73718
73718-26
73718-TC
73719
73719-26
73719-TC
73720
73720-26
73720-TC
73721
73721-26
73721-TC
73722
73722-26
73722-TC
73723
73723-26
73723-TC
73725
73725-26
73725-TC
74000
74000-26
74000-TC
74010
74010-26
74010-TC
74020
74020-26
74020-TC
74022
74022-26
74022-TC
74150
74150-26
74150-TC
74160
74160-26
74160-TC
74170
74170-26
74170-TC
74175
74175-26
74175-TC
74181
74181-26
74181-TC
$277.00
$379.00
$98.00
$277.00
$482.00
$68.00
$413.00
$579.00
$82.00
$495.00
$520.00
$78.00
$442.00
$482.00
$68.00
$413.00
$579.00
$82.00
$495.00
$1,029.00
$109.00
$916.00
$515.00
$92.00
$419.00
$29.00
$9.00
$19.00
$33.00
$11.00
$21.00
$37.00
$13.00
$22.00
$44.00
$16.00
$28.00
$274.00
$60.00
$211.00
$322.00
$65.00
$256.00
$390.00
$71.00
$317.00
$418.00
$98.00
$315.00
$498.00
$85.00
$415.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$299.00
$537.00
$103.00
$434.00
$516.00
$73.00
$444.00
$620.00
$88.00
$532.00
$1,101.00
$117.00
$984.00
$516.00
$73.00
$444.00
$621.00
$88.00
$532.00
$1,101.00
$117.00
$984.00
$552.00
$100.00
$452.00
$31.00
$10.00
$21.00
$36.00
$13.00
$23.00
$40.00
$15.00
$25.00
$48.00
$17.00
$30.00
$293.00
$65.00
$228.00
$346.00
$70.00
$276.00
$419.00
$77.00
$342.00
$577.00
$103.00
$475.00
$526.00
$80.00
$446.00
$329.00
$582.00
$108.00
$474.00
$560.00
$76.00
$484.00
$673.00
$92.00
$581.00
$1,197.00
$123.00
$1,074.00
$560.00
$76.00
$484.00
$674.00
$93.00
$581.00
$1,196.00
$122.00
$1,074.00
$602.00
$105.00
$497.00
$33.00
$10.00
$23.00
$39.00
$13.00
$26.00
$43.00
$15.00
$28.00
$52.00
$18.00
$34.00
$319.00
$68.00
$251.00
$377.00
$73.00
$304.00
$456.00
$81.00
$375.00
$625.00
$108.00
$517.00
$572.00
$84.00
$488.00
$347.00
$609.00
$112.00
$498.00
$587.00
$79.00
$508.00
$705.00
$95.00
$609.00
$1,254.00
$128.00
$1,126.00
$587.00
$79.00
$508.00
$706.00
$97.00
$609.00
$1,253.00
$127.00
$1,126.00
$635.00
$109.00
$525.00
$35.00
$11.00
$24.00
$41.00
$14.00
$27.00
$45.00
$16.00
$29.00
$54.00
$19.00
$36.00
$336.00
$71.00
$265.00
$398.00
$77.00
$321.00
$481.00
$84.00
$397.00
$654.00
$112.00
$542.00
$600.00
$87.00
$513.00
$299.00
$537.00
$103.00
$434.00
$516.00
$73.00
$444.00
$620.00
$88.00
$532.00
$1,101.00
$117.00
$984.00
$516.00
$73.00
$444.00
$621.00
$88.00
$532.00
$1,101.00
$117.00
$984.00
$552.00
$100.00
$452.00
$31.00
$10.00
$21.00
$36.00
$13.00
$23.00
$40.00
$15.00
$25.00
$48.00
$17.00
$30.00
$293.00
$65.00
$228.00
$346.00
$70.00
$276.00
$419.00
$77.00
$342.00
$577.00
$103.00
$475.00
$526.00
$80.00
$446.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$329.00
$582.00
$108.00
$474.00
$560.00
$76.00
$484.00
$673.00
$92.00
$581.00
$1,197.00
$123.00
$1,074.00
$560.00
$76.00
$484.00
$674.00
$93.00
$581.00
$1,196.00
$122.00
$1,074.00
$602.00
$105.00
$497.00
$33.00
$10.00
$23.00
$39.00
$13.00
$26.00
$43.00
$15.00
$28.00
$52.00
$18.00
$34.00
$319.00
$68.00
$251.00
$377.00
$73.00
$304.00
$456.00
$81.00
$375.00
$625.00
$108.00
$517.00
$572.00
$84.00
$488.00
$347.00
$609.00
$112.00
$498.00
$587.00
$79.00
$508.00
$705.00
$95.00
$609.00
$1,254.00
$128.00
$1,126.00
$587.00
$79.00
$508.00
$706.00
$97.00
$609.00
$1,253.00
$127.00
$1,126.00
$635.00
$109.00
$525.00
$35.00
$11.00
$24.00
$41.00
$14.00
$27.00
$45.00
$16.00
$29.00
$54.00
$19.00
$36.00
$336.00
$71.00
$265.00
$398.00
$77.00
$321.00
$481.00
$84.00
$397.00
$654.00
$112.00
$542.00
$600.00
$87.00
$513.00
230
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
74182
74182-26
74182-TC
74183
74183-26
74183-TC
74185
74185-26
74185-TC
74190
74190-26
74190-TC
74210
74210-26
74210-TC
74220
74220-26
74220-TC
74230
74230-26
74230-TC
74235
74235-26
74235-TC
74240
74240-26
74240-TC
74241
74241-26
74241-TC
74245
74245-26
74245-TC
74246
74246-26
74246-TC
74247
74247-26
74247-TC
74249
74249-26
74249-TC
74250
74250-26
74250-TC
74251
74251-26
74251-TC
74260
74260-26
74260-TC
74270
$587.00
$88.00
$496.00
$1,037.00
$114.00
$919.00
$514.00
$92.00
$419.00
$73.00
NC
NC
$63.00
$18.00
$44.00
$68.00
$23.00
$44.00
$77.00
$27.00
$48.00
$160.00
NC
NC
$91.00
$35.00
$55.00
$91.00
$35.00
$56.00
$137.00
$46.00
$89.00
$97.00
$35.00
$61.00
$99.00
$35.00
$63.00
$144.00
$46.00
$96.00
$73.00
$23.00
$48.00
$85.00
$34.00
$48.00
$82.00
$25.00
$56.00
$100.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$628.00
$94.00
$534.00
$1,110.00
$123.00
$987.00
$551.00
$98.00
$452.00
$79.00
$26.00
$53.00
$68.00
$20.00
$48.00
$73.00
$25.00
$48.00
$82.00
$29.00
$53.00
$171.00
$65.00
$106.00
$97.00
$38.00
$59.00
$98.00
$38.00
$60.00
$146.00
$50.00
$96.00
$104.00
$38.00
$66.00
$106.00
$38.00
$69.00
$154.00
$50.00
$104.00
$79.00
$26.00
$53.00
$90.00
$38.00
$53.00
$87.00
$27.00
$60.00
$107.00
$682.00
$99.00
$584.00
$1,207.00
$129.00
$1,078.00
$601.00
$104.00
$497.00
$86.00
$27.00
$58.00
$73.00
$21.00
$52.00
$79.00
$27.00
$52.00
$88.00
$30.00
$58.00
$185.00
$69.00
$117.00
$105.00
$40.00
$65.00
$106.00
$40.00
$66.00
$158.00
$52.00
$106.00
$113.00
$40.00
$73.00
$115.00
$40.00
$76.00
$167.00
$52.00
$115.00
$85.00
$27.00
$58.00
$98.00
$40.00
$58.00
$95.00
$29.00
$66.00
$116.00
$716.00
$102.00
$614.00
$1,266.00
$134.00
$1,133.00
$633.00
$108.00
$525.00
$90.00
$29.00
$61.00
$77.00
$22.00
$55.00
$83.00
$28.00
$55.00
$93.00
$31.00
$61.00
$195.00
$71.00
$123.00
$110.00
$41.00
$69.00
$111.00
$41.00
$70.00
$167.00
$55.00
$112.00
$119.00
$41.00
$78.00
$121.00
$41.00
$80.00
$176.00
$55.00
$121.00
$90.00
$28.00
$61.00
$103.00
$41.00
$61.00
$100.00
$30.00
$70.00
$122.00
$628.00
$94.00
$534.00
$1,110.00
$123.00
$987.00
$551.00
$98.00
$452.00
$79.00
$26.00
$53.00
$68.00
$20.00
$48.00
$73.00
$25.00
$48.00
$82.00
$29.00
$53.00
$171.00
$65.00
$106.00
$97.00
$38.00
$59.00
$98.00
$38.00
$60.00
$146.00
$50.00
$96.00
$104.00
$38.00
$66.00
$106.00
$38.00
$69.00
$154.00
$50.00
$104.00
$79.00
$26.00
$53.00
$90.00
$38.00
$53.00
$87.00
$27.00
$60.00
$107.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$682.00
$99.00
$584.00
$1,207.00
$129.00
$1,078.00
$601.00
$104.00
$497.00
$86.00
$27.00
$58.00
$73.00
$21.00
$52.00
$79.00
$27.00
$52.00
$88.00
$30.00
$58.00
$185.00
$69.00
$117.00
$105.00
$40.00
$65.00
$106.00
$40.00
$66.00
$158.00
$52.00
$106.00
$113.00
$40.00
$73.00
$115.00
$40.00
$76.00
$167.00
$52.00
$115.00
$85.00
$27.00
$58.00
$98.00
$40.00
$58.00
$95.00
$29.00
$66.00
$116.00
$716.00
$102.00
$614.00
$1,266.00
$134.00
$1,133.00
$633.00
$108.00
$525.00
$90.00
$29.00
$61.00
$77.00
$22.00
$55.00
$83.00
$28.00
$55.00
$93.00
$31.00
$61.00
$195.00
$71.00
$123.00
$110.00
$41.00
$69.00
$111.00
$41.00
$70.00
$167.00
$55.00
$112.00
$119.00
$41.00
$78.00
$121.00
$41.00
$80.00
$176.00
$55.00
$121.00
$90.00
$28.00
$61.00
$103.00
$41.00
$61.00
$100.00
$30.00
$70.00
$122.00
231
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
74270-26
74270-TC
74280
74280-26
74280-TC
74283
74283-26
74283-TC
74290
74290-26
74290-TC
74291
74291-26
74291-TC
74300
74300-26
74300-TC
74301
74301-26
74301-TC
74305
74305-26
74305-TC
74320
74320-26
74320-TC
74327
74327-26
74327-TC
74328
74328-26
74328-TC
74329
74329-26
74329-TC
74330
74330-26
74330-TC
74340
74340-26
74340-TC
74350
74350-26
74350-TC
74355
74355-26
74355-TC
74360
74360-26
74360-TC
74363
74363-26
$35.00
$64.00
$136.00
$50.00
$84.00
$201.00
$103.00
$95.00
$44.00
$16.00
$28.00
$26.00
$10.00
$15.00
$31.00
NC
NC
BR
NC
NC
$51.00
NC
NC
$145.00
NC
NC
$103.00
NC
NC
$155.00
NC
NC
$155.00
NC
NC
$165.00
NC
NC
$121.00
NC
NC
$158.00
NC
NC
$137.00
NC
NC
$145.00
NC
NC
$274.00
NC
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$38.00
$69.00
$145.00
$54.00
$91.00
$214.00
$111.00
$104.00
$48.00
$17.00
$30.00
$28.00
$11.00
$17.00
----$20.00
--------$11.00
----$55.00
$23.00
$32.00
$156.00
$29.00
$127.00
$110.00
$38.00
$72.00
$165.00
$38.00
$127.00
$165.00
$38.00
$127.00
$176.00
$49.00
$127.00
$135.00
$29.00
$106.00
$168.00
$41.00
$127.00
$148.00
$41.00
$106.00
$157.00
$30.00
$127.00
$294.00
$48.00
$40.00
$76.00
$157.00
$57.00
$100.00
$231.00
$117.00
$114.00
$52.00
$18.00
$34.00
$31.00
$12.00
$19.00
----$21.00
--------$12.00
----$59.00
$24.00
$35.00
$170.00
$31.00
$140.00
$119.00
$40.00
$79.00
$180.00
$40.00
$140.00
$180.00
$40.00
$140.00
$192.00
$52.00
$140.00
$147.00
$31.00
$117.00
$183.00
$44.00
$140.00
$160.00
$44.00
$117.00
$171.00
$31.00
$140.00
$321.00
$51.00
$41.00
$81.00
$165.00
$59.00
$106.00
$242.00
$122.00
$121.00
$54.00
$19.00
$36.00
$32.00
$12.00
$20.00
----$22.00
--------$13.00
----$63.00
$25.00
$37.00
$179.00
$32.00
$148.00
$126.00
$42.00
$84.00
$190.00
$42.00
$148.00
$190.00
$42.00
$148.00
$202.00
$54.00
$148.00
$155.00
$32.00
$123.00
$193.00
$45.00
$148.00
$169.00
$45.00
$123.00
$180.00
$32.00
$148.00
$339.00
$53.00
$38.00
$69.00
$145.00
$54.00
$91.00
$214.00
$111.00
$104.00
$48.00
$17.00
$30.00
$28.00
$11.00
$17.00
----$20.00
--------$11.00
----$55.00
$23.00
$32.00
$156.00
$29.00
$127.00
$110.00
$38.00
$72.00
$165.00
$38.00
$127.00
$165.00
$38.00
$127.00
$176.00
$49.00
$127.00
$135.00
$29.00
$106.00
$168.00
$41.00
$127.00
$148.00
$41.00
$106.00
$157.00
$30.00
$127.00
$294.00
$48.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$40.00
$76.00
$157.00
$57.00
$100.00
$231.00
$117.00
$114.00
$52.00
$18.00
$34.00
$31.00
$12.00
$19.00
----$21.00
--------$12.00
----$59.00
$24.00
$35.00
$170.00
$31.00
$140.00
$119.00
$40.00
$79.00
$180.00
$40.00
$140.00
$180.00
$40.00
$140.00
$192.00
$52.00
$140.00
$147.00
$31.00
$117.00
$183.00
$44.00
$140.00
$160.00
$44.00
$117.00
$171.00
$31.00
$140.00
$321.00
$51.00
$41.00
$81.00
$165.00
$59.00
$106.00
$242.00
$122.00
$121.00
$54.00
$19.00
$36.00
$32.00
$12.00
$20.00
----$22.00
--------$13.00
----$63.00
$25.00
$37.00
$179.00
$32.00
$148.00
$126.00
$42.00
$84.00
$190.00
$42.00
$148.00
$190.00
$42.00
$148.00
$202.00
$54.00
$148.00
$155.00
$32.00
$123.00
$193.00
$45.00
$148.00
$169.00
$45.00
$123.00
$180.00
$32.00
$148.00
$339.00
$53.00
232
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
74363-TC
74400
74400-26
74400-TC
74410
74410-26
74410-TC
74415
74415-26
74415-TC
74420
74420-26
74420-TC
74425
74425-26
74425-TC
74430
74430-26
74430-TC
74440
74440-26
74440-TC
74445
74445-26
74445-TC
74450
74450-26
74450-TC
74455
74455-26
74455-TC
74470
74470-26
74470-TC
74475
74475-26
74475-TC
74480
74480-26
74480-TC
74485
74485-26
74485-TC
74710
74710-26
74710-TC
74740
74740-26
74740-TC
74742
74742-26
74742-TC
NC
$89.00
$24.00
$63.00
$98.00
$24.00
$72.00
$105.00
$24.00
$79.00
$117.00
$18.00
$97.00
$68.00
NC
NC
$48.00
NC
NC
$62.00
NC
NC
$101.00
NC
NC
$60.00
NC
NC
$75.00
NC
NC
$74.00
NC
NC
$181.00
NC
NC
$181.00
NC
NC
$146.00
NC
NC
$57.00
$17.00
$39.00
$68.00
NC
NC
$150.00
NC
NC
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$246.00
$95.00
$27.00
$69.00
$106.00
$27.00
$79.00
$113.00
$27.00
$86.00
$126.00
$20.00
$106.00
$73.00
$20.00
$53.00
$60.00
$18.00
$42.00
$66.00
$21.00
$45.00
$108.00
$62.00
$45.00
$77.00
$18.00
$59.00
$82.00
$18.00
$64.00
$80.00
$29.00
$51.00
$193.00
$29.00
$164.00
$193.00
$29.00
$164.00
$157.00
$30.00
$127.00
$61.00
$19.00
$42.00
$74.00
$21.00
$53.00
$160.00
$33.00
$127.00
$271.00
$104.00
$28.00
$76.00
$115.00
$28.00
$87.00
$123.00
$28.00
$95.00
$138.00
$21.00
$117.00
$79.00
$21.00
$58.00
$66.00
$19.00
$47.00
$72.00
$22.00
$50.00
$115.00
$65.00
$50.00
$84.00
$19.00
$65.00
$90.00
$19.00
$71.00
$86.00
$31.00
$56.00
$211.00
$31.00
$180.00
$211.00
$31.00
$180.00
$171.00
$31.00
$140.00
$67.00
$20.00
$47.00
$80.00
$22.00
$58.00
$174.00
$35.00
$140.00
$286.00
$110.00
$29.00
$80.00
$121.00
$29.00
$92.00
$129.00
$29.00
$100.00
$145.00
$22.00
$123.00
$83.00
$22.00
$61.00
$69.00
$20.00
$49.00
$76.00
$23.00
$53.00
$121.00
$68.00
$53.00
$89.00
$20.00
$69.00
$95.00
$20.00
$75.00
$91.00
$32.00
$59.00
$223.00
$32.00
$191.00
$223.00
$32.00
$191.00
$180.00
$33.00
$148.00
$70.00
$21.00
$49.00
$85.00
$23.00
$61.00
$184.00
$36.00
$148.00
$246.00
$95.00
$27.00
$69.00
$106.00
$27.00
$79.00
$113.00
$27.00
$86.00
$126.00
$20.00
$106.00
$73.00
$20.00
$53.00
$60.00
$18.00
$42.00
$66.00
$21.00
$45.00
$108.00
$62.00
$45.00
$77.00
$18.00
$59.00
$82.00
$18.00
$64.00
$80.00
$29.00
$51.00
$193.00
$29.00
$164.00
$193.00
$29.00
$164.00
$157.00
$30.00
$127.00
$61.00
$19.00
$42.00
$74.00
$21.00
$53.00
$160.00
$33.00
$127.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$271.00
$104.00
$28.00
$76.00
$115.00
$28.00
$87.00
$123.00
$28.00
$95.00
$138.00
$21.00
$117.00
$79.00
$21.00
$58.00
$66.00
$19.00
$47.00
$72.00
$22.00
$50.00
$115.00
$65.00
$50.00
$84.00
$19.00
$65.00
$90.00
$19.00
$71.00
$86.00
$31.00
$56.00
$211.00
$31.00
$180.00
$211.00
$31.00
$180.00
$171.00
$31.00
$140.00
$67.00
$20.00
$47.00
$80.00
$22.00
$58.00
$174.00
$35.00
$140.00
$286.00
$110.00
$29.00
$80.00
$121.00
$29.00
$92.00
$129.00
$29.00
$100.00
$145.00
$22.00
$123.00
$83.00
$22.00
$61.00
$69.00
$20.00
$49.00
$76.00
$23.00
$53.00
$121.00
$68.00
$53.00
$89.00
$20.00
$69.00
$95.00
$20.00
$75.00
$91.00
$32.00
$59.00
$223.00
$32.00
$191.00
$223.00
$32.00
$191.00
$180.00
$33.00
$148.00
$70.00
$21.00
$49.00
$85.00
$23.00
$61.00
$184.00
$36.00
$148.00
233
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
74775
74775-26
74775-TC
75552
75552-26
75552-TC
75553
75553-26
75553-TC
75554
75554-26
75554-TC
75555
75555-26
75555-TC
75600
75600-26
75600-TC
75605
75605-26
75605-TC
75625
75625-26
75625-TC
75630
75630-26
75630-TC
75635
75635-26
75635-TC
75650
75650-26
75650-TC
75658
75658-26
75658-TC
75660
75660-26
75660-TC
75662
75662-26
75662-TC
75665
75665-26
75665-TC
75671
75671-26
75671-TC
75676
75676-26
75676-TC
75680
$88.00
$32.00
$55.00
$503.00
$82.00
$419.00
$524.00
$100.00
$419.00
$517.00
$94.00
$419.00
$513.00
$91.00
$419.00
$497.00
NC
NC
$183.00
NC
NC
$143.00
NC
NC
$239.00
NC
NC
$445.00
NC
NC
$218.00
NC
NC
$540.00
NC
NC
$540.00
NC
NC
$560.00
NC
NC
$540.00
NC
NC
$219.00
NC
NC
$540.00
NC
NC
$207.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$94.00
$34.00
$59.00
$540.00
$88.00
$452.00
$562.00
$110.00
$452.00
$554.00
$101.00
$452.00
$550.00
$97.00
$452.00
$536.00
$28.00
$508.00
$571.00
$63.00
$508.00
$571.00
$62.00
$508.00
$629.00
$99.00
$530.00
$753.00
$131.00
$623.00
$590.00
$82.00
$508.00
$582.00
$74.00
$508.00
$580.00
$72.00
$508.00
$601.00
$93.00
$508.00
$581.00
$72.00
$508.00
$599.00
$91.00
$508.00
$581.00
$73.00
$508.00
$599.00
$101.00
$36.00
$65.00
$589.00
$92.00
$497.00
$612.00
$115.00
$497.00
$604.00
$107.00
$497.00
$600.00
$103.00
$497.00
$587.00
$29.00
$558.00
$625.00
$67.00
$558.00
$624.00
$66.00
$558.00
$687.00
$105.00
$582.00
$814.00
$137.00
$677.00
$644.00
$86.00
$558.00
$636.00
$78.00
$558.00
$634.00
$76.00
$558.00
$656.00
$98.00
$558.00
$635.00
$77.00
$558.00
$654.00
$96.00
$558.00
$635.00
$77.00
$558.00
$654.00
$107.00
$38.00
$69.00
$621.00
$96.00
$525.00
$645.00
$120.00
$525.00
$636.00
$111.00
$525.00
$632.00
$107.00
$525.00
$620.00
$30.00
$589.00
$659.00
$69.00
$589.00
$658.00
$69.00
$589.00
$724.00
$109.00
$615.00
$850.00
$143.00
$707.00
$680.00
$90.00
$589.00
$670.00
$81.00
$589.00
$669.00
$80.00
$589.00
$692.00
$102.00
$589.00
$670.00
$80.00
$589.00
$690.00
$101.00
$589.00
$670.00
$81.00
$589.00
$690.00
$94.00
$34.00
$59.00
$540.00
$88.00
$452.00
$562.00
$110.00
$452.00
$554.00
$101.00
$452.00
$550.00
$97.00
$452.00
$536.00
$28.00
$508.00
$571.00
$63.00
$508.00
$571.00
$62.00
$508.00
$629.00
$99.00
$530.00
$753.00
$131.00
$623.00
$590.00
$82.00
$508.00
$582.00
$74.00
$508.00
$580.00
$72.00
$508.00
$601.00
$93.00
$508.00
$581.00
$72.00
$508.00
$599.00
$91.00
$508.00
$581.00
$73.00
$508.00
$599.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$101.00
$36.00
$65.00
$589.00
$92.00
$497.00
$612.00
$115.00
$497.00
$604.00
$107.00
$497.00
$600.00
$103.00
$497.00
$587.00
$29.00
$558.00
$625.00
$67.00
$558.00
$624.00
$66.00
$558.00
$687.00
$105.00
$582.00
$814.00
$137.00
$677.00
$644.00
$86.00
$558.00
$636.00
$78.00
$558.00
$634.00
$76.00
$558.00
$656.00
$98.00
$558.00
$635.00
$77.00
$558.00
$654.00
$96.00
$558.00
$635.00
$77.00
$558.00
$654.00
$107.00
$38.00
$69.00
$621.00
$96.00
$525.00
$645.00
$120.00
$525.00
$636.00
$111.00
$525.00
$632.00
$107.00
$525.00
$620.00
$30.00
$589.00
$659.00
$69.00
$589.00
$658.00
$69.00
$589.00
$724.00
$109.00
$615.00
$850.00
$143.00
$707.00
$680.00
$90.00
$589.00
$670.00
$81.00
$589.00
$669.00
$80.00
$589.00
$692.00
$102.00
$589.00
$670.00
$80.00
$589.00
$690.00
$101.00
$589.00
$670.00
$81.00
$589.00
$690.00
234
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
75680-26
75680-TC
75685
75685-26
75685-TC
75705
75705-26
75705-TC
75710
75710-26
75710-TC
75716
75716-26
75716-TC
75722
75722-26
75722-TC
75724
75724-26
75724-TC
75726
75726-26
75726-TC
75731
75731-26
75731-TC
75733
75733-26
75733-TC
75736
75736-26
75736-TC
75741
75741-26
75741-TC
75743
75743-26
75743-TC
75746
75746-26
75746-TC
75756
75756-26
75756-TC
75774
75774-26
75774-TC
75790
75790-26
75790-TC
75801
75801-26
NC
NC
$160.00
NC
NC
$587.00
NC
NC
$194.00
NC
NC
$293.00
NC
NC
$206.00
NC
NC
$214.00
NC
NC
$530.00
NC
NC
$530.00
NC
NC
$540.00
NC
NC
$530.00
NC
NC
$540.00
NC
NC
$253.00
NC
NC
$530.00
NC
NC
$183.00
NC
NC
$80.00
NC
NC
$146.00
NC
NC
$245.00
NC
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$91.00
$508.00
$580.00
$72.00
$508.00
$629.00
$121.00
$508.00
$571.00
$63.00
$508.00
$580.00
$72.00
$508.00
$571.00
$63.00
$508.00
$592.00
$84.00
$508.00
$571.00
$62.00
$508.00
$571.00
$62.00
$508.00
$580.00
$72.00
$508.00
$571.00
$62.00
$508.00
$580.00
$72.00
$508.00
$599.00
$91.00
$508.00
$571.00
$62.00
$508.00
$573.00
$65.00
$508.00
$528.00
$20.00
$508.00
$156.00
$101.00
$55.00
$264.00
$45.00
$96.00
$558.00
$634.00
$76.00
$558.00
$685.00
$128.00
$558.00
$625.00
$67.00
$558.00
$634.00
$76.00
$558.00
$625.00
$67.00
$558.00
$646.00
$88.00
$558.00
$624.00
$66.00
$558.00
$624.00
$66.00
$558.00
$634.00
$76.00
$558.00
$624.00
$66.00
$558.00
$634.00
$76.00
$558.00
$653.00
$95.00
$558.00
$624.00
$66.00
$558.00
$626.00
$68.00
$558.00
$579.00
$21.00
$558.00
$167.00
$107.00
$61.00
$288.00
$48.00
$101.00
$589.00
$669.00
$79.00
$589.00
$723.00
$133.00
$589.00
$659.00
$70.00
$589.00
$669.00
$79.00
$589.00
$659.00
$69.00
$589.00
$680.00
$91.00
$589.00
$658.00
$69.00
$589.00
$658.00
$69.00
$589.00
$669.00
$79.00
$589.00
$658.00
$69.00
$589.00
$669.00
$79.00
$589.00
$689.00
$99.00
$589.00
$658.00
$69.00
$589.00
$660.00
$70.00
$589.00
$612.00
$22.00
$589.00
$175.00
$111.00
$64.00
$304.00
$50.00
$91.00
$508.00
$580.00
$72.00
$508.00
$629.00
$121.00
$508.00
$571.00
$63.00
$508.00
$580.00
$72.00
$508.00
$571.00
$63.00
$508.00
$592.00
$84.00
$508.00
$571.00
$62.00
$508.00
$571.00
$62.00
$508.00
$580.00
$72.00
$508.00
$571.00
$62.00
$508.00
$580.00
$72.00
$508.00
$599.00
$91.00
$508.00
$571.00
$62.00
$508.00
$573.00
$65.00
$508.00
$528.00
$20.00
$508.00
$156.00
$101.00
$55.00
$264.00
$45.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$96.00
$558.00
$634.00
$76.00
$558.00
$685.00
$128.00
$558.00
$625.00
$67.00
$558.00
$634.00
$76.00
$558.00
$625.00
$67.00
$558.00
$646.00
$88.00
$558.00
$624.00
$66.00
$558.00
$624.00
$66.00
$558.00
$634.00
$76.00
$558.00
$624.00
$66.00
$558.00
$634.00
$76.00
$558.00
$653.00
$95.00
$558.00
$624.00
$66.00
$558.00
$626.00
$68.00
$558.00
$579.00
$21.00
$558.00
$167.00
$107.00
$61.00
$288.00
$48.00
$101.00
$589.00
$669.00
$79.00
$589.00
$723.00
$133.00
$589.00
$659.00
$70.00
$589.00
$669.00
$79.00
$589.00
$659.00
$69.00
$589.00
$680.00
$91.00
$589.00
$658.00
$69.00
$589.00
$658.00
$69.00
$589.00
$669.00
$79.00
$589.00
$658.00
$69.00
$589.00
$669.00
$79.00
$589.00
$689.00
$99.00
$589.00
$658.00
$69.00
$589.00
$660.00
$70.00
$589.00
$612.00
$22.00
$589.00
$175.00
$111.00
$64.00
$304.00
$50.00
235
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
75801-TC
75803
75803-26
75803-TC
75805
75805-26
75805-TC
75807
75807-26
75807-TC
75809
75809-26
75809-TC
75810
75810-26
75810-TC
75820
75820-26
75820-TC
75822
75822-26
75822-TC
75825
75825-26
75825-TC
75827
75827-26
75827-TC
75831
75831-26
75831-TC
75833
75833-26
75833-TC
75840
75840-26
75840-TC
75842
75842-26
75842-TC
75860
75860-26
75860-TC
75870
75870-26
75870-TC
75872
75872-26
75872-TC
75880
75880-26
75880-TC
NC
$264.00
NC
NC
$271.00
NC
NC
$289.00
NC
NC
$54.00
NC
NC
$530.00
NC
NC
$72.00
NC
NC
$111.00
NC
NC
$194.00
NC
NC
$530.00
NC
NC
$54.00
NC
NC
$549.00
NC
NC
$531.00
NC
NC
$549.00
NC
NC
$531.00
NC
NC
$531.00
NC
NC
$530.00
NC
NC
$72.00
NC
NC
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$219.00
$283.00
$64.00
$219.00
$291.00
$45.00
$246.00
$310.00
$64.00
$246.00
$58.00
$26.00
$32.00
$571.00
$63.00
$508.00
$77.00
$38.00
$39.00
$118.00
$58.00
$60.00
$571.00
$63.00
$508.00
$570.00
$62.00
$508.00
$570.00
$62.00
$508.00
$590.00
$82.00
$508.00
$572.00
$63.00
$508.00
$590.00
$82.00
$508.00
$571.00
$63.00
$508.00
$571.00
$63.00
$508.00
$571.00
$62.00
$508.00
$77.00
$38.00
$39.00
$240.00
$308.00
$67.00
$240.00
$318.00
$47.00
$271.00
$338.00
$67.00
$271.00
$62.00
$27.00
$35.00
$625.00
$67.00
$558.00
$83.00
$40.00
$43.00
$127.00
$61.00
$66.00
$625.00
$67.00
$558.00
$623.00
$65.00
$558.00
$623.00
$65.00
$558.00
$644.00
$86.00
$558.00
$625.00
$67.00
$558.00
$644.00
$86.00
$558.00
$625.00
$67.00
$558.00
$625.00
$67.00
$558.00
$624.00
$66.00
$558.00
$83.00
$40.00
$43.00
$254.00
$324.00
$70.00
$254.00
$335.00
$49.00
$286.00
$356.00
$70.00
$286.00
$65.00
$28.00
$37.00
$659.00
$70.00
$589.00
$88.00
$42.00
$46.00
$134.00
$64.00
$70.00
$659.00
$70.00
$589.00
$658.00
$68.00
$589.00
$658.00
$68.00
$589.00
$680.00
$90.00
$589.00
$660.00
$71.00
$589.00
$679.00
$90.00
$589.00
$659.00
$70.00
$589.00
$659.00
$70.00
$589.00
$658.00
$69.00
$589.00
$88.00
$42.00
$46.00
$219.00
$283.00
$64.00
$219.00
$291.00
$45.00
$246.00
$310.00
$64.00
$246.00
$58.00
$26.00
$32.00
$571.00
$63.00
$508.00
$77.00
$38.00
$39.00
$118.00
$58.00
$60.00
$571.00
$63.00
$508.00
$570.00
$62.00
$508.00
$570.00
$62.00
$508.00
$590.00
$82.00
$508.00
$572.00
$63.00
$508.00
$590.00
$82.00
$508.00
$571.00
$63.00
$508.00
$571.00
$63.00
$508.00
$571.00
$62.00
$508.00
$77.00
$38.00
$39.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$240.00
$308.00
$67.00
$240.00
$318.00
$47.00
$271.00
$338.00
$67.00
$271.00
$62.00
$27.00
$35.00
$625.00
$67.00
$558.00
$83.00
$40.00
$43.00
$127.00
$61.00
$66.00
$625.00
$67.00
$558.00
$623.00
$65.00
$558.00
$623.00
$65.00
$558.00
$644.00
$86.00
$558.00
$625.00
$67.00
$558.00
$644.00
$86.00
$558.00
$625.00
$67.00
$558.00
$625.00
$67.00
$558.00
$624.00
$66.00
$558.00
$83.00
$40.00
$43.00
$254.00
$324.00
$70.00
$254.00
$335.00
$49.00
$286.00
$356.00
$70.00
$286.00
$65.00
$28.00
$37.00
$659.00
$70.00
$589.00
$88.00
$42.00
$46.00
$134.00
$64.00
$70.00
$659.00
$70.00
$589.00
$658.00
$68.00
$589.00
$658.00
$68.00
$589.00
$680.00
$90.00
$589.00
$660.00
$71.00
$589.00
$679.00
$90.00
$589.00
$659.00
$70.00
$589.00
$659.00
$70.00
$589.00
$658.00
$69.00
$589.00
$88.00
$42.00
$46.00
236
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
75885
75885-26
75885-TC
75887
75887-26
75887-TC
75889
75889-26
75889-TC
75891
75891-26
75891-TC
75893
75893-26
75893-TC
75894
75894-26
75894-TC
75896
75896-26
75896-TC
75898
75898-26
75898-TC
75900
75900-26
75900-TC
75901
75901-26
75901-TC
75902
75902-26
75902-TC
75940
75940-26
75940-TC
75945
75945-26
75945-TC
75946
75946-26
75946-TC
75952
75952-26
75952-TC
75953
75953-26
75953-TC
75954
75954-26
75954-TC
75960
$546.00
NC
NC
$546.00
NC
NC
$530.00
NC
NC
$530.00
NC
NC
$499.00
NC
NC
$972.00
NC
NC
$241.00
NC
NC
$124.00
$84.00
$39.00
$810.00
NC
NC
$98.00
NC
NC
$93.00
NC
NC
$151.00
NC
NC
$192.00
NC
NC
$108.00
NC
NC
BR
NC
NC
BR
NC
NC
BR
NC
NC
$600.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$587.00
$79.00
$508.00
$587.00
$79.00
$508.00
$570.00
$62.00
$508.00
$570.00
$62.00
$508.00
$538.00
$30.00
$508.00
$1,046.00
$72.00
$974.00
$919.00
$73.00
$847.00
$133.00
$90.00
$42.00
$873.00
$27.00
$846.00
$112.00
$27.00
$85.00
$106.00
$21.00
$85.00
$538.00
$30.00
$508.00
$207.00
$23.00
$184.00
$116.00
$23.00
$93.00
----$279.00
--------$109.00
--------$107.00
----$646.00
$641.00
$83.00
$558.00
$641.00
$83.00
$558.00
$623.00
$65.00
$558.00
$623.00
$65.00
$558.00
$589.00
$31.00
$558.00
$1,146.00
$77.00
$1,070.00
$1,007.00
$77.00
$930.00
$142.00
$95.00
$47.00
$958.00
$28.00
$930.00
$134.00
$28.00
$106.00
$129.00
$23.00
$106.00
$589.00
$31.00
$558.00
$227.00
$25.00
$203.00
$126.00
$24.00
$102.00
----$305.00
--------$128.00
--------$126.00
----$708.00
$676.00
$86.00
$589.00
$676.00
$86.00
$589.00
$658.00
$68.00
$589.00
$658.00
$68.00
$589.00
$622.00
$32.00
$589.00
$1,210.00
$80.00
$1,130.00
$1,063.00
$80.00
$983.00
$149.00
$99.00
$49.00
$1,012.00
$29.00
$983.00
$155.00
$29.00
$126.00
$150.00
$24.00
$126.00
$622.00
$33.00
$589.00
$240.00
$26.00
$214.00
$134.00
$25.00
$108.00
----$329.00
--------$148.00
--------$146.00
----$747.00
$587.00
$79.00
$508.00
$587.00
$79.00
$508.00
$570.00
$62.00
$508.00
$570.00
$62.00
$508.00
$538.00
$30.00
$508.00
$1,046.00
$72.00
$974.00
$919.00
$73.00
$847.00
$133.00
$90.00
$42.00
$873.00
$27.00
$846.00
$112.00
$27.00
$85.00
$106.00
$21.00
$85.00
$538.00
$30.00
$508.00
$207.00
$23.00
$184.00
$116.00
$23.00
$93.00
----$279.00
--------$109.00
--------$107.00
----$646.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$641.00
$83.00
$558.00
$641.00
$83.00
$558.00
$623.00
$65.00
$558.00
$623.00
$65.00
$558.00
$589.00
$31.00
$558.00
$1,146.00
$77.00
$1,070.00
$1,007.00
$77.00
$930.00
$142.00
$95.00
$47.00
$958.00
$28.00
$930.00
$134.00
$28.00
$106.00
$129.00
$23.00
$106.00
$589.00
$31.00
$558.00
$227.00
$25.00
$203.00
$126.00
$24.00
$102.00
----$305.00
--------$128.00
--------$126.00
----$708.00
$676.00
$86.00
$589.00
$676.00
$86.00
$589.00
$658.00
$68.00
$589.00
$658.00
$68.00
$589.00
$622.00
$32.00
$589.00
$1,210.00
$80.00
$1,130.00
$1,063.00
$80.00
$983.00
$149.00
$99.00
$49.00
$1,012.00
$29.00
$983.00
$155.00
$29.00
$126.00
$150.00
$24.00
$126.00
$622.00
$33.00
$589.00
$240.00
$26.00
$214.00
$134.00
$25.00
$108.00
----$329.00
--------$148.00
--------$146.00
----$747.00
237
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
75960-26
75960-TC
75961
75961-26
75961-TC
75962
75962-26
75962-TC
75964
75964-26
75964-TC
75966
75966-26
75966-TC
75968
75968-26
75968-TC
75970
75970-26
75970-TC
75978
75978-26
75978-TC
75980
75980-26
75980-TC
75982
75982-26
75982-TC
75984
75984-26
75984-TC
75989
75989-26
75989-TC
75992
75992-26
75992-TC
75993
75993-26
75993-TC
75994
75994-26
75994-TC
75995
75995-26
75995-TC
75996
75996-26
75996-TC
76000
76000-26
NC
NC
$616.00
NC
NC
$618.00
NC
NC
$333.00
NC
NC
$659.00
NC
NC
$333.00
NC
NC
$475.00
NC
NC
$617.00
NC
NC
$277.00
NC
NC
$303.00
NC
NC
$110.00
NC
NC
$180.00
NC
NC
$618.00
NC
NC
$333.00
NC
NC
$659.00
NC
NC
$658.00
NC
NC
$332.00
NC
NC
$58.00
$8.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$45.00
$601.00
$656.00
$232.00
$424.00
$665.00
$30.00
$635.00
$359.00
$20.00
$338.00
$708.00
$73.00
$635.00
$358.00
$20.00
$338.00
$511.00
$46.00
$465.00
$664.00
$29.00
$635.00
$297.00
$79.00
$219.00
$324.00
$78.00
$246.00
$118.00
$39.00
$79.00
$192.00
$65.00
$127.00
$665.00
$30.00
$635.00
$359.00
$20.00
$338.00
$708.00
$73.00
$635.00
$709.00
$74.00
$635.00
$358.00
$19.00
$338.00
$62.00
$9.00
$48.00
$660.00
$710.00
$244.00
$466.00
$730.00
$32.00
$698.00
$393.00
$21.00
$372.00
$775.00
$77.00
$698.00
$392.00
$21.00
$372.00
$560.00
$48.00
$511.00
$729.00
$31.00
$698.00
$323.00
$83.00
$240.00
$353.00
$82.00
$271.00
$128.00
$41.00
$87.00
$208.00
$68.00
$140.00
$729.00
$32.00
$698.00
$393.00
$21.00
$372.00
$775.00
$77.00
$698.00
$775.00
$78.00
$698.00
$392.00
$20.00
$372.00
$68.00
$10.00
$50.00
$697.00
$747.00
$254.00
$492.00
$771.00
$33.00
$738.00
$415.00
$22.00
$393.00
$818.00
$80.00
$738.00
$414.00
$21.00
$393.00
$591.00
$51.00
$540.00
$770.00
$32.00
$738.00
$340.00
$86.00
$254.00
$372.00
$86.00
$286.00
$135.00
$43.00
$92.00
$219.00
$71.00
$148.00
$770.00
$33.00
$738.00
$414.00
$22.00
$393.00
$818.00
$80.00
$738.00
$818.00
$81.00
$738.00
$414.00
$21.00
$393.00
$72.00
$10.00
$45.00
$601.00
$656.00
$232.00
$424.00
$665.00
$30.00
$635.00
$359.00
$20.00
$338.00
$708.00
$73.00
$635.00
$358.00
$20.00
$338.00
$511.00
$46.00
$465.00
$664.00
$29.00
$635.00
$297.00
$79.00
$219.00
$324.00
$78.00
$246.00
$118.00
$39.00
$79.00
$192.00
$65.00
$127.00
$665.00
$30.00
$635.00
$359.00
$20.00
$338.00
$708.00
$73.00
$635.00
$709.00
$74.00
$635.00
$358.00
$19.00
$338.00
$62.00
$9.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$48.00
$660.00
$710.00
$244.00
$466.00
$730.00
$32.00
$698.00
$393.00
$21.00
$372.00
$775.00
$77.00
$698.00
$392.00
$21.00
$372.00
$560.00
$48.00
$511.00
$729.00
$31.00
$698.00
$323.00
$83.00
$240.00
$353.00
$82.00
$271.00
$128.00
$41.00
$87.00
$208.00
$68.00
$140.00
$729.00
$32.00
$698.00
$393.00
$21.00
$372.00
$775.00
$77.00
$698.00
$775.00
$78.00
$698.00
$392.00
$20.00
$372.00
$68.00
$10.00
$50.00
$697.00
$747.00
$254.00
$492.00
$771.00
$33.00
$738.00
$415.00
$22.00
$393.00
$818.00
$80.00
$738.00
$414.00
$21.00
$393.00
$591.00
$51.00
$540.00
$770.00
$32.00
$738.00
$340.00
$86.00
$254.00
$372.00
$86.00
$286.00
$135.00
$43.00
$92.00
$219.00
$71.00
$148.00
$770.00
$33.00
$738.00
$414.00
$22.00
$393.00
$818.00
$80.00
$738.00
$818.00
$81.00
$738.00
$414.00
$21.00
$393.00
$72.00
$10.00
238
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
76000-TC
76001
76001-26
76001-TC
76003
76003-26
76003-TC
76005
76005-26
76005-TC
76006
76012
76012-26
76012-TC
76013
76013-26
76013-TC
76020
76020-26
76020-TC
76040
76040-26
76040-TC
76061
76061-26
76061-TC
76062
76062-26
76062-TC
76066
76066-26
76066-TC
76070
76070-26
76070-TC
76071
76071-26
76071-TC
76075
76075-26
76075-TC
76076
76076-26
76076-TC
76078
76078-26
76078-TC
76080
76080-26
76080-TC
76085
76085-26
$48.00
$134.00
$34.00
$97.00
$78.00
$28.00
$48.00
$79.00
$29.00
$48.00
$19.00
BR
NC
NC
BR
NC
NC
$29.00
$9.00
$19.00
$44.00
$14.00
$29.00
$61.00
$22.00
$37.00
$82.00
$27.00
$54.00
$58.00
$16.00
$41.00
$123.00
$13.00
$110.00
$121.00
$11.00
$110.00
$132.00
$15.00
$115.00
$40.00
$11.00
$29.00
$39.00
$10.00
$29.00
$67.00
NC
NC
$18.00
$3.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$53.00
$143.00
$37.00
$106.00
$83.00
$30.00
$53.00
$84.00
$31.00
$53.00
$25.00
----$83.00
--------$100.00
----$31.00
$10.00
$21.00
$48.00
$16.00
$32.00
$65.00
$25.00
$41.00
$88.00
$29.00
$58.00
$62.00
$17.00
$45.00
$133.00
$13.00
$119.00
$126.00
$12.00
$115.00
$142.00
$17.00
$125.00
$43.00
$12.00
$31.00
$42.00
$11.00
$31.00
$72.00
$29.00
$42.00
$20.00
$4.00
$58.00
$155.00
$39.00
$117.00
$90.00
$31.00
$58.00
$91.00
$33.00
$58.00
$27.00
----$91.00
--------$114.00
----$34.00
$11.00
$23.00
$52.00
$17.00
$35.00
$71.00
$26.00
$45.00
$95.00
$31.00
$64.00
$68.00
$19.00
$49.00
$145.00
$14.00
$131.00
$137.00
$13.00
$124.00
$155.00
$17.00
$138.00
$47.00
$13.00
$34.00
$46.00
$12.00
$34.00
$77.00
$31.00
$47.00
$22.00
$4.00
$61.00
$164.00
$40.00
$123.00
$94.00
$33.00
$61.00
$96.00
$35.00
$61.00
$29.00
----$99.00
--------$129.00
----$36.00
$11.00
$24.00
$55.00
$18.00
$37.00
$75.00
$27.00
$48.00
$100.00
$32.00
$68.00
$71.00
$19.00
$52.00
$153.00
$15.00
$138.00
$142.00
$13.00
$129.00
$163.00
$18.00
$145.00
$49.00
$13.00
$36.00
$48.00
$12.00
$36.00
$81.00
$32.00
$49.00
$23.00
$4.00
$53.00
$143.00
$37.00
$106.00
$83.00
$30.00
$53.00
$84.00
$31.00
$53.00
$25.00
----$83.00
--------$100.00
----$31.00
$10.00
$21.00
$48.00
$16.00
$32.00
$65.00
$25.00
$41.00
$88.00
$29.00
$58.00
$62.00
$17.00
$45.00
$133.00
$13.00
$119.00
$126.00
$12.00
$115.00
$142.00
$17.00
$125.00
$43.00
$12.00
$31.00
$42.00
$11.00
$31.00
$72.00
$29.00
$42.00
$20.00
$4.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$58.00
$155.00
$39.00
$117.00
$90.00
$31.00
$58.00
$91.00
$33.00
$58.00
$27.00
----$91.00
--------$114.00
----$34.00
$11.00
$23.00
$52.00
$17.00
$35.00
$71.00
$26.00
$45.00
$95.00
$31.00
$64.00
$68.00
$19.00
$49.00
$145.00
$14.00
$131.00
$137.00
$13.00
$124.00
$155.00
$17.00
$138.00
$47.00
$13.00
$34.00
$46.00
$12.00
$34.00
$77.00
$31.00
$47.00
$22.00
$4.00
$61.00
$164.00
$40.00
$123.00
$94.00
$33.00
$61.00
$96.00
$35.00
$61.00
$29.00
----$99.00
--------$129.00
----$36.00
$11.00
$24.00
$55.00
$18.00
$37.00
$75.00
$27.00
$48.00
$100.00
$32.00
$68.00
$71.00
$19.00
$52.00
$153.00
$15.00
$138.00
$142.00
$13.00
$129.00
$163.00
$18.00
$145.00
$49.00
$13.00
$36.00
$48.00
$12.00
$36.00
$81.00
$32.00
$49.00
$23.00
$4.00
239
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
76085-TC
76086
76086-26
76086-TC
76088
76088-26
76088-TC
76090
76090-26
76090-TC
76091
76091-26
76091-TC
76093
76093-26
76093-TC
76094
76094-26
76094-TC
76095
76095-26
76095-TC
76096
76096-26
76096-TC
76098
76098-26
76098-TC
76100
76100-26
76100-TC
76101
76101-26
76101-TC
76102
76102-26
76102-TC
76120
76120-26
76120-TC
76125
76125-26
76125-TC
76140
76150
76350
76355
76355-26
76355-TC
76360
76360-26
76360-TC
$14.00
$117.00
NC
NC
$161.00
NC
NC
$68.00
$17.00
$39.00
$85.00
$30.00
$48.00
$745.00
$83.00
$658.00
$980.00
$83.00
$894.00
$351.00
NC
NC
$79.00
NC
NC
$23.00
$8.00
$15.00
$77.00
$30.00
$46.00
$94.00
$36.00
$59.00
$95.00
$30.00
$65.00
$157.00
$56.00
$102.00
$49.00
$17.00
$33.00
$31.00
$15.00
BR
$372.00
$62.00
$308.00
$168.00
NC
NC
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$17.00
$126.00
$20.00
$106.00
$172.00
$25.00
$148.00
$81.00
$38.00
$42.00
$100.00
$47.00
$53.00
$800.00
$89.00
$711.00
$1,053.00
$89.00
$964.00
$377.00
$88.00
$289.00
$84.00
$31.00
$53.00
$26.00
$9.00
$17.00
$83.00
$32.00
$51.00
$90.00
$32.00
$58.00
$103.00
$32.00
$70.00
$63.00
$21.00
$42.00
$47.00
$15.00
$32.00
----$17.00
----$399.00
$67.00
$333.00
$396.00
$63.00
$333.00
$18.00
$138.00
$21.00
$117.00
$188.00
$26.00
$163.00
$87.00
$40.00
$47.00
$108.00
$50.00
$58.00
$875.00
$94.00
$781.00
$1,152.00
$94.00
$1,059.00
$410.00
$93.00
$317.00
$91.00
$33.00
$58.00
$29.00
$10.00
$19.00
$90.00
$34.00
$56.00
$97.00
$34.00
$63.00
$112.00
$34.00
$78.00
$69.00
$22.00
$47.00
$51.00
$16.00
$35.00
----$19.00
----$436.00
$71.00
$365.00
$432.00
$67.00
$365.00
$19.00
$145.00
$22.00
$123.00
$199.00
$27.00
$172.00
$91.00
$42.00
$49.00
$113.00
$52.00
$61.00
$923.00
$98.00
$825.00
$1,216.00
$98.00
$1,118.00
$433.00
$97.00
$335.00
$96.00
$34.00
$61.00
$30.00
$10.00
$20.00
$94.00
$35.00
$59.00
$103.00
$35.00
$67.00
$118.00
$35.00
$82.00
$73.00
$23.00
$49.00
$54.00
$16.00
$37.00
----$20.00
----$459.00
$74.00
$386.00
$455.00
$69.00
$386.00
$17.00
$126.00
$20.00
$106.00
$172.00
$25.00
$148.00
$81.00
$38.00
$42.00
$100.00
$47.00
$53.00
$800.00
$89.00
$711.00
$1,053.00
$89.00
$964.00
$377.00
$88.00
$289.00
$84.00
$31.00
$53.00
$26.00
$9.00
$17.00
$83.00
$32.00
$51.00
$90.00
$32.00
$58.00
$103.00
$32.00
$70.00
$63.00
$21.00
$42.00
$47.00
$15.00
$32.00
----$17.00
----$399.00
$67.00
$333.00
$396.00
$63.00
$333.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$18.00
$138.00
$21.00
$117.00
$188.00
$26.00
$163.00
$87.00
$40.00
$47.00
$108.00
$50.00
$58.00
$875.00
$94.00
$781.00
$1,152.00
$94.00
$1,059.00
$410.00
$93.00
$317.00
$91.00
$33.00
$58.00
$29.00
$10.00
$19.00
$90.00
$34.00
$56.00
$97.00
$34.00
$63.00
$112.00
$34.00
$78.00
$69.00
$22.00
$47.00
$51.00
$16.00
$35.00
----$19.00
----$436.00
$71.00
$365.00
$432.00
$67.00
$365.00
$19.00
$145.00
$22.00
$123.00
$199.00
$27.00
$172.00
$91.00
$42.00
$49.00
$113.00
$52.00
$61.00
$923.00
$98.00
$825.00
$1,216.00
$98.00
$1,118.00
$433.00
$97.00
$335.00
$96.00
$34.00
$61.00
$30.00
$10.00
$20.00
$94.00
$35.00
$59.00
$103.00
$35.00
$67.00
$118.00
$35.00
$82.00
$73.00
$23.00
$49.00
$54.00
$16.00
$37.00
----$20.00
----$459.00
$74.00
$386.00
$455.00
$69.00
$386.00
240
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
76362
76362-26
76362-TC
76370
76370-26
76370-TC
76375
76375-26
76375-TC
76380
76380-26
76380-TC
76390
76390-26
76390-TC
76393
76393-26
76393-TC
76394
76394-26
76394-TC
76400
76400-26
76400-TC
76490
76490-26
76490-TC
76496
76496-26
76496-TC
76497
76497-26
76497-TC
76498
76498-26
76498-TC
76499
76499-26
76499-TC
76506
76506-26
76506-TC
76511
76511-26
76511-TC
76512
76512-26
76512-TC
76513
76513-26
76513-TC
76516
$550.00
$203.00
$341.00
$155.00
$43.00
$110.00
$140.00
$8.00
$132.00
$182.00
$50.00
$131.00
$493.00
$71.00
$419.00
$496.00
NC
NC
$671.00
$216.00
$449.00
$503.00
$81.00
$419.00
$169.00
$106.00
$63.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$88.00
$33.00
$53.00
$96.00
$48.00
$48.00
$96.00
$36.00
$60.00
$96.00
$36.00
$60.00
$99.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$595.00
$219.00
$377.00
$166.00
$47.00
$119.00
$151.00
$9.00
$142.00
$194.00
$53.00
$141.00
------------$533.00
$83.00
$451.00
$726.00
$233.00
$493.00
$540.00
$87.00
$452.00
$285.00
$215.00
$70.00
------------------------------------------------$94.00
$36.00
$58.00
$140.00
$54.00
$87.00
$128.00
$38.00
$90.00
$138.00
$38.00
$100.00
$106.00
$661.00
$230.00
$431.00
$180.00
$49.00
$131.00
$166.00
$9.00
$156.00
$211.00
$56.00
$155.00
------------$582.00
$87.00
$495.00
$803.00
$245.00
$558.00
$589.00
$92.00
$497.00
$305.00
$225.00
$80.00
------------------------------------------------$101.00
$38.00
$63.00
$151.00
$56.00
$94.00
$138.00
$40.00
$98.00
$149.00
$40.00
$109.00
$115.00
$714.00
$240.00
$474.00
$190.00
$51.00
$138.00
$175.00
$10.00
$165.00
$222.00
$58.00
$163.00
------------$613.00
$91.00
$522.00
$862.00
$255.00
$607.00
$621.00
$96.00
$525.00
$321.00
$233.00
$89.00
------------------------------------------------$107.00
$40.00
$67.00
$157.00
$58.00
$99.00
$144.00
$41.00
$104.00
$156.00
$41.00
$115.00
$120.00
$595.00
$219.00
$377.00
$166.00
$47.00
$119.00
$151.00
$9.00
$142.00
$194.00
$53.00
$141.00
------------$533.00
$83.00
$451.00
$726.00
$233.00
$493.00
$540.00
$87.00
$452.00
$285.00
$215.00
$70.00
------------------------------------------------$94.00
$36.00
$58.00
$140.00
$54.00
$87.00
$128.00
$38.00
$90.00
$138.00
$38.00
$100.00
$106.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$661.00
$230.00
$431.00
$180.00
$49.00
$131.00
$166.00
$9.00
$156.00
$211.00
$56.00
$155.00
------------$582.00
$87.00
$495.00
$803.00
$245.00
$558.00
$589.00
$92.00
$497.00
$305.00
$225.00
$80.00
------------------------------------------------$101.00
$38.00
$63.00
$151.00
$56.00
$94.00
$138.00
$40.00
$98.00
$149.00
$40.00
$109.00
$115.00
$714.00
$240.00
$474.00
$190.00
$51.00
$138.00
$175.00
$10.00
$165.00
$222.00
$58.00
$163.00
------------$613.00
$91.00
$522.00
$862.00
$255.00
$607.00
$621.00
$96.00
$525.00
$321.00
$233.00
$89.00
------------------------------------------------$107.00
$40.00
$67.00
$157.00
$58.00
$99.00
$144.00
$41.00
$104.00
$156.00
$41.00
$115.00
$120.00
241
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
76516-26
76516-TC
76519
76519-26
76519-TC
76529
76529-26
76529-TC
76536
76536-26
76536-TC
76604
76604-26
76604-TC
76645
76645-26
76645-TC
76700
76700-26
76700-TC
76705
76705-26
76705-TC
76770
76770-26
76770-TC
76775
76775-26
76775-TC
76778
76778-26
76778-TC
76800
76800-26
76800-TC
76801
76801-26
76801-TC
76802
76802-26
76802-TC
76805
76805-26
76805-TC
76810
76810-26
76810-TC
76811
76811-26
76811-TC
76812
76812-26
$37.00
$63.00
$88.00
$31.00
$53.00
$86.00
$31.00
$53.00
$83.00
$31.00
$54.00
$78.00
$28.00
$48.00
$69.00
$31.00
$40.00
$116.00
$42.00
$73.00
$84.00
$30.00
$53.00
$112.00
$38.00
$73.00
$84.00
$30.00
$53.00
$112.00
$38.00
$73.00
$112.00
$61.00
$54.00
$93.00
$51.00
$42.00
$73.00
$43.00
$30.00
$131.00
$51.00
$79.00
$252.00
$100.00
$151.00
$243.00
$100.00
$142.00
$145.00
$94.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$31.00
$75.00
$99.00
$31.00
$67.00
$119.00
$33.00
$87.00
$88.00
$30.00
$58.00
$83.00
$30.00
$53.00
$72.00
$30.00
$42.00
$124.00
$45.00
$80.00
$90.00
$32.00
$58.00
$120.00
$40.00
$80.00
$90.00
$32.00
$58.00
$120.00
$40.00
$80.00
$118.00
$60.00
$58.00
$100.00
$55.00
$45.00
$79.00
$46.00
$32.00
$140.00
$55.00
$85.00
$105.00
$56.00
$49.00
$261.00
$109.00
$153.00
$158.00
$101.00
$33.00
$82.00
$107.00
$33.00
$74.00
$129.00
$34.00
$95.00
$95.00
$32.00
$63.00
$90.00
$32.00
$58.00
$78.00
$31.00
$47.00
$135.00
$47.00
$88.00
$98.00
$34.00
$63.00
$130.00
$42.00
$88.00
$97.00
$34.00
$63.00
$130.00
$42.00
$88.00
$126.00
$63.00
$63.00
$108.00
$58.00
$50.00
$86.00
$49.00
$37.00
$151.00
$57.00
$94.00
$116.00
$60.00
$57.00
$288.00
$116.00
$172.00
$176.00
$108.00
$34.00
$86.00
$111.00
$34.00
$78.00
$135.00
$35.00
$100.00
$100.00
$33.00
$67.00
$94.00
$33.00
$61.00
$82.00
$33.00
$49.00
$142.00
$49.00
$93.00
$103.00
$36.00
$67.00
$137.00
$44.00
$93.00
$103.00
$35.00
$67.00
$137.00
$44.00
$93.00
$133.00
$65.00
$67.00
$115.00
$60.00
$55.00
$91.00
$51.00
$40.00
$159.00
$60.00
$99.00
$125.00
$63.00
$63.00
$309.00
$122.00
$186.00
$192.00
$113.00
$31.00
$75.00
$99.00
$31.00
$67.00
$119.00
$33.00
$87.00
$88.00
$30.00
$58.00
$83.00
$30.00
$53.00
$72.00
$30.00
$42.00
$124.00
$45.00
$80.00
$90.00
$32.00
$58.00
$120.00
$40.00
$80.00
$90.00
$32.00
$58.00
$120.00
$40.00
$80.00
$118.00
$60.00
$58.00
$100.00
$55.00
$45.00
$79.00
$46.00
$32.00
$140.00
$55.00
$85.00
$105.00
$56.00
$49.00
$261.00
$109.00
$153.00
$158.00
$101.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$33.00
$82.00
$107.00
$33.00
$74.00
$129.00
$34.00
$95.00
$95.00
$32.00
$63.00
$90.00
$32.00
$58.00
$78.00
$31.00
$47.00
$135.00
$47.00
$88.00
$98.00
$34.00
$63.00
$130.00
$42.00
$88.00
$97.00
$34.00
$63.00
$130.00
$42.00
$88.00
$126.00
$63.00
$63.00
$108.00
$58.00
$50.00
$86.00
$49.00
$37.00
$151.00
$57.00
$94.00
$116.00
$60.00
$57.00
$288.00
$116.00
$172.00
$176.00
$108.00
$34.00
$86.00
$111.00
$34.00
$78.00
$135.00
$35.00
$100.00
$100.00
$33.00
$67.00
$94.00
$33.00
$61.00
$82.00
$33.00
$49.00
$142.00
$49.00
$93.00
$103.00
$36.00
$67.00
$137.00
$44.00
$93.00
$103.00
$35.00
$67.00
$137.00
$44.00
$93.00
$133.00
$65.00
$67.00
$115.00
$60.00
$55.00
$91.00
$51.00
$40.00
$159.00
$60.00
$99.00
$125.00
$63.00
$63.00
$309.00
$122.00
$186.00
$192.00
$113.00
242
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
76812-TC
76815
76815-26
76815-TC
76816
76816-26
76816-TC
76817
76817-26
76817-TC
76818
76818-26
76818-TC
76819
76819-26
76819-TC
76825
76825-26
76825-TC
76826
76826-26
76826-TC
76827
76827-26
76827-TC
76828
76828-26
76828-TC
76830
76830-26
76830-TC
76831
76831-26
76831-TC
76856
76856-26
76856-TC
76857
76857-26
76857-TC
76870
76870-26
76870-TC
76872
76872-26
76872-TC
76873
76873-26
76873-TC
76880
76880-26
76880-TC
$51.00
$88.00
$33.00
$53.00
$72.00
$30.00
$41.00
$96.00
$39.00
$57.00
$105.00
$40.00
$60.00
$101.00
$40.00
$60.00
$160.00
$65.00
$73.00
$71.00
$46.00
$27.00
$97.00
$35.00
$65.00
$72.00
$29.00
$42.00
$93.00
$35.00
$57.00
$95.00
$37.00
$57.00
$93.00
$35.00
$57.00
$59.00
$19.00
$39.00
$90.00
$33.00
$57.00
$93.00
$36.00
$57.00
$151.00
$68.00
$80.00
$85.00
$32.00
$54.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$57.00
$93.00
$36.00
$58.00
$92.00
$47.00
$45.00
$102.00
$41.00
$60.00
$125.00
$59.00
$66.00
$108.00
$43.00
$66.00
$172.00
$93.00
$80.00
$75.00
$46.00
$29.00
$103.00
$32.00
$71.00
$77.00
$32.00
$46.00
$100.00
$38.00
$62.00
$101.00
$39.00
$62.00
$100.00
$38.00
$62.00
$99.00
$21.00
$78.00
$97.00
$35.00
$62.00
$103.00
$38.00
$65.00
$172.00
$85.00
$87.00
$90.00
$32.00
$58.00
$69.00
$101.00
$38.00
$63.00
$98.00
$49.00
$49.00
$109.00
$43.00
$66.00
$134.00
$62.00
$72.00
$117.00
$44.00
$72.00
$185.00
$97.00
$88.00
$80.00
$48.00
$32.00
$112.00
$34.00
$78.00
$84.00
$33.00
$51.00
$108.00
$40.00
$68.00
$110.00
$41.00
$68.00
$108.00
$40.00
$68.00
$107.00
$22.00
$85.00
$105.00
$37.00
$68.00
$111.00
$40.00
$71.00
$186.00
$90.00
$96.00
$98.00
$34.00
$63.00
$79.00
$106.00
$39.00
$67.00
$103.00
$51.00
$52.00
$114.00
$45.00
$69.00
$141.00
$64.00
$77.00
$123.00
$46.00
$77.00
$194.00
$101.00
$93.00
$84.00
$50.00
$34.00
$118.00
$35.00
$83.00
$88.00
$34.00
$54.00
$114.00
$42.00
$72.00
$115.00
$43.00
$72.00
$114.00
$42.00
$72.00
$112.00
$23.00
$89.00
$111.00
$39.00
$72.00
$118.00
$42.00
$75.00
$196.00
$94.00
$102.00
$103.00
$36.00
$67.00
$57.00
$93.00
$36.00
$58.00
$92.00
$47.00
$45.00
$102.00
$41.00
$60.00
$125.00
$59.00
$66.00
$108.00
$43.00
$66.00
$172.00
$93.00
$80.00
$75.00
$46.00
$29.00
$103.00
$32.00
$71.00
$77.00
$32.00
$46.00
$100.00
$38.00
$62.00
$101.00
$39.00
$62.00
$100.00
$38.00
$62.00
$99.00
$21.00
$78.00
$97.00
$35.00
$62.00
$103.00
$38.00
$65.00
$172.00
$85.00
$87.00
$90.00
$32.00
$58.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$69.00
$101.00
$38.00
$63.00
$98.00
$49.00
$49.00
$109.00
$43.00
$66.00
$134.00
$62.00
$72.00
$117.00
$44.00
$72.00
$185.00
$97.00
$88.00
$80.00
$48.00
$32.00
$112.00
$34.00
$78.00
$84.00
$33.00
$51.00
$108.00
$40.00
$68.00
$110.00
$41.00
$68.00
$108.00
$40.00
$68.00
$107.00
$22.00
$85.00
$105.00
$37.00
$68.00
$111.00
$40.00
$71.00
$186.00
$90.00
$96.00
$98.00
$34.00
$63.00
$79.00
$106.00
$39.00
$67.00
$103.00
$51.00
$52.00
$114.00
$45.00
$69.00
$141.00
$64.00
$77.00
$123.00
$46.00
$77.00
$194.00
$101.00
$93.00
$84.00
$50.00
$34.00
$118.00
$35.00
$83.00
$88.00
$34.00
$54.00
$114.00
$42.00
$72.00
$115.00
$43.00
$72.00
$114.00
$42.00
$72.00
$112.00
$23.00
$89.00
$111.00
$39.00
$72.00
$118.00
$42.00
$75.00
$196.00
$94.00
$102.00
$103.00
$36.00
$67.00
243
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
76930
76930-26
76930-TC
76932
76932-26
76932-TC
76936
76936-26
76936-TC
76941
76941-26
76941-TC
76942
76942-26
76942-TC
76945
76945-26
76945-TC
76946
76946-26
76946-TC
76948
76948-26
76948-TC
76950
76950-26
76950-TC
76965
76965-26
76965-TC
76970
76970-26
76970-TC
76975
76975-26
76975-TC
76977
76977-26
76977-TC
76986
76986-26
76986-TC
76999
76999-26
76999-TC
77261
77262
77263
77280
77280-26
77280-TC
77285
$93.00
NC
NC
$93.00
NC
NC
$341.00
$102.00
$236.00
$128.00
NC
NC
$92.00
NC
NC
$93.00
NC
NC
$78.00
NC
NC
$77.00
NC
NC
$80.00
$30.00
$48.00
$281.00
$84.00
$208.00
$60.00
$20.00
$39.00
$99.00
NC
NC
$34.00
$3.00
$31.00
$162.00
$62.00
$97.00
BR
BR
BR
$73.00
$110.00
$163.00
$166.00
$36.00
$130.00
$264.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$99.00
$37.00
$62.00
$99.00
$37.00
$62.00
$365.00
$110.00
$254.00
$136.00
$75.00
$62.00
$154.00
$37.00
$117.00
$99.00
$37.00
$62.00
$83.00
$21.00
$62.00
$83.00
$21.00
$62.00
$85.00
$32.00
$53.00
$298.00
$74.00
$224.00
$65.00
$22.00
$42.00
$106.00
$45.00
$62.00
$37.00
$3.00
$33.00
$173.00
$67.00
$106.00
------------$79.00
$118.00
$175.00
$178.00
$38.00
$140.00
$282.00
$108.00
$39.00
$68.00
$108.00
$39.00
$68.00
$396.00
$117.00
$280.00
$147.00
$79.00
$68.00
$167.00
$40.00
$128.00
$107.00
$39.00
$68.00
$90.00
$22.00
$68.00
$90.00
$22.00
$68.00
$92.00
$34.00
$58.00
$324.00
$78.00
$246.00
$70.00
$23.00
$47.00
$115.00
$47.00
$68.00
$40.00
$4.00
$37.00
$187.00
$71.00
$117.00
------------$83.00
$125.00
$185.00
$194.00
$40.00
$154.00
$307.00
$113.00
$41.00
$72.00
$113.00
$41.00
$72.00
$417.00
$122.00
$296.00
$154.00
$82.00
$72.00
$175.00
$41.00
$134.00
$112.00
$40.00
$72.00
$95.00
$23.00
$72.00
$96.00
$23.00
$72.00
$97.00
$35.00
$61.00
$342.00
$81.00
$260.00
$74.00
$24.00
$49.00
$121.00
$49.00
$72.00
$43.00
$4.00
$39.00
$197.00
$74.00
$123.00
------------$86.00
$130.00
$192.00
$204.00
$42.00
$162.00
$324.00
$99.00
$37.00
$62.00
$99.00
$37.00
$62.00
$365.00
$110.00
$254.00
$136.00
$75.00
$62.00
$154.00
$37.00
$117.00
$99.00
$37.00
$62.00
$83.00
$21.00
$62.00
$83.00
$21.00
$62.00
$85.00
$32.00
$53.00
$298.00
$74.00
$224.00
$65.00
$22.00
$42.00
$106.00
$45.00
$62.00
$37.00
$3.00
$33.00
$173.00
$67.00
$106.00
------------$79.00
$118.00
$175.00
$178.00
$38.00
$140.00
$282.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$108.00
$39.00
$68.00
$108.00
$39.00
$68.00
$396.00
$117.00
$280.00
$147.00
$79.00
$68.00
$167.00
$40.00
$128.00
$107.00
$39.00
$68.00
$90.00
$22.00
$68.00
$90.00
$22.00
$68.00
$92.00
$34.00
$58.00
$324.00
$78.00
$246.00
$70.00
$23.00
$47.00
$115.00
$47.00
$68.00
$40.00
$4.00
$37.00
$187.00
$71.00
$117.00
------------$83.00
$125.00
$185.00
$194.00
$40.00
$154.00
$307.00
$113.00
$41.00
$72.00
$113.00
$41.00
$72.00
$417.00
$122.00
$296.00
$154.00
$82.00
$72.00
$175.00
$41.00
$134.00
$112.00
$40.00
$72.00
$95.00
$23.00
$72.00
$96.00
$23.00
$72.00
$97.00
$35.00
$61.00
$342.00
$81.00
$260.00
$74.00
$24.00
$49.00
$121.00
$49.00
$72.00
$43.00
$4.00
$39.00
$197.00
$74.00
$123.00
------------$86.00
$130.00
$192.00
$204.00
$42.00
$162.00
$324.00
244
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
77285-26
77285-TC
77290
77290-26
77290-TC
77295
77295-26
77295-TC
77299
77299-26
77299-TC
77300
77300-26
77300-TC
77301
77301-26
77301-TC
77305
77305-26
77305-TC
77310
77310-26
77310-TC
77315
77315-26
77315-TC
77321
77321-26
77321-TC
77326
77326-26
77326-TC
77327
77327-26
77327-TC
77328
77328-26
77328-TC
77331
77331-26
77331-TC
77332
77332-26
77332-TC
77333
77333-26
77333-TC
77334
77334-26
77334-TC
77336
77370
$53.00
$209.00
$325.00
$79.00
$243.00
$1,287.00
$232.00
$1,046.00
BR
BR
BR
$87.00
$36.00
$52.00
$1,473.00
$415.00
$1,046.00
$106.00
$36.00
$69.00
$142.00
$53.00
$87.00
$181.00
$79.00
$99.00
$200.00
$48.00
$150.00
$137.00
$47.00
$88.00
$202.00
$71.00
$130.00
$295.00
$106.00
$185.00
$64.00
$45.00
$18.00
$78.00
$27.00
$50.00
$115.00
$43.00
$70.00
$187.00
$63.00
$121.00
$111.00
$130.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$57.00
$225.00
$348.00
$85.00
$263.00
$1,376.00
$248.00
$1,128.00
------------$88.00
$34.00
$54.00
$1,571.00
$444.00
$1,128.00
$114.00
$38.00
$75.00
$152.00
$57.00
$94.00
$192.00
$85.00
$108.00
$214.00
$52.00
$163.00
$146.00
$51.00
$96.00
$216.00
$76.00
$140.00
$314.00
$114.00
$200.00
$68.00
$48.00
$20.00
$83.00
$29.00
$54.00
$123.00
$46.00
$77.00
$198.00
$68.00
$131.00
$120.00
$141.00
$60.00
$247.00
$378.00
$89.00
$289.00
$1,500.00
$261.00
$1,239.00
------------$95.00
$36.00
$59.00
$1,703.00
$464.00
$1,239.00
$123.00
$40.00
$83.00
$164.00
$60.00
$104.00
$208.00
$89.00
$118.00
$233.00
$55.00
$179.00
$158.00
$53.00
$105.00
$233.00
$80.00
$154.00
$340.00
$120.00
$219.00
$73.00
$50.00
$22.00
$90.00
$31.00
$59.00
$134.00
$49.00
$85.00
$215.00
$71.00
$144.00
$132.00
$154.00
$63.00
$261.00
$398.00
$93.00
$306.00
$1,581.00
$272.00
$1,310.00
------------$100.00
$37.00
$63.00
$1,789.00
$479.00
$1,310.00
$130.00
$42.00
$88.00
$173.00
$63.00
$110.00
$218.00
$93.00
$125.00
$245.00
$57.00
$189.00
$167.00
$55.00
$111.00
$245.00
$83.00
$162.00
$357.00
$125.00
$232.00
$76.00
$53.00
$23.00
$95.00
$32.00
$63.00
$141.00
$51.00
$90.00
$226.00
$74.00
$152.00
$140.00
$163.00
$57.00
$225.00
$348.00
$85.00
$263.00
$1,376.00
$248.00
$1,128.00
------------$88.00
$34.00
$54.00
$1,571.00
$444.00
$1,128.00
$114.00
$38.00
$75.00
$152.00
$57.00
$94.00
$192.00
$85.00
$108.00
$214.00
$52.00
$163.00
$146.00
$51.00
$96.00
$216.00
$76.00
$140.00
$314.00
$114.00
$200.00
$68.00
$48.00
$20.00
$83.00
$29.00
$54.00
$123.00
$46.00
$77.00
$198.00
$68.00
$131.00
$120.00
$141.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$60.00
$247.00
$378.00
$89.00
$289.00
$1,500.00
$261.00
$1,239.00
------------$95.00
$36.00
$59.00
$1,703.00
$464.00
$1,239.00
$123.00
$40.00
$83.00
$164.00
$60.00
$104.00
$208.00
$89.00
$118.00
$233.00
$55.00
$179.00
$158.00
$53.00
$105.00
$233.00
$80.00
$154.00
$340.00
$120.00
$219.00
$73.00
$50.00
$22.00
$90.00
$31.00
$59.00
$134.00
$49.00
$85.00
$215.00
$71.00
$144.00
$132.00
$154.00
$63.00
$261.00
$398.00
$93.00
$306.00
$1,581.00
$272.00
$1,310.00
------------$100.00
$37.00
$63.00
$1,789.00
$479.00
$1,310.00
$130.00
$42.00
$88.00
$173.00
$63.00
$110.00
$218.00
$93.00
$125.00
$245.00
$57.00
$189.00
$167.00
$55.00
$111.00
$245.00
$83.00
$162.00
$357.00
$125.00
$232.00
$76.00
$53.00
$23.00
$95.00
$32.00
$63.00
$141.00
$51.00
$90.00
$226.00
$74.00
$152.00
$140.00
$163.00
245
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
77399
77399-26
77399-TC
77401
77402
77403
77404
77406
77407
77408
77409
77411
77412
77413
77414
77416
77417
77418
77427
77431
77432
77470
77470-26
77470-TC
77499
77499-26
77499-TC
77520
77522
77523
77525
77600
77600-26
77600-TC
77605
77605-26
77605-TC
77610
77610-26
77610-TC
77615
77615-26
77615-TC
77620
77620-26
77620-TC
77750
77750-26
77750-TC
77761
77761-26
77761-TC
BR
BR
BR
$66.00
$66.00
$66.00
$66.00
$66.00
$78.00
$78.00
$78.00
$78.00
$87.00
$87.00
$87.00
$87.00
$21.00
$609.00
$166.00
$95.00
$417.00
$527.00
$106.00
$417.00
BR
BR
BR
BR
BR
BR
BR
$196.00
$80.00
$113.00
$263.00
$108.00
$151.00
$195.00
$79.00
$113.00
$262.00
$106.00
$151.00
$196.00
$80.00
$113.00
$299.00
$248.00
$49.00
$284.00
$188.00
$93.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
------------$72.00
$72.00
$72.00
$72.00
$72.00
$85.00
$85.00
$85.00
$85.00
$94.00
$94.00
$94.00
$94.00
$24.00
$694.00
$181.00
$102.00
$447.00
$564.00
$114.00
$450.00
----------------------------$209.00
$86.00
$123.00
$280.00
$116.00
$164.00
$208.00
$85.00
$123.00
$278.00
$114.00
$164.00
$208.00
$85.00
$123.00
$320.00
$266.00
$54.00
$304.00
$202.00
$102.00
------------$79.00
$79.00
$79.00
$79.00
$79.00
$93.00
$93.00
$93.00
$93.00
$104.00
$104.00
$104.00
$104.00
$27.00
$749.00
$190.00
$108.00
$471.00
$615.00
$120.00
$494.00
----------------------------$226.00
$91.00
$135.00
$303.00
$123.00
$180.00
$225.00
$90.00
$135.00
$300.00
$120.00
$180.00
$225.00
$90.00
$135.00
$339.00
$280.00
$59.00
$325.00
$213.00
$112.00
------------$84.00
$84.00
$84.00
$84.00
$84.00
$99.00
$99.00
$99.00
$99.00
$110.00
$110.00
$110.00
$110.00
$28.00
$776.00
$198.00
$112.00
$490.00
$648.00
$125.00
$523.00
----------------------------$238.00
$95.00
$143.00
$320.00
$129.00
$190.00
$237.00
$94.00
$143.00
$316.00
$125.00
$190.00
$236.00
$93.00
$143.00
$353.00
$290.00
$63.00
$340.00
$221.00
$119.00
------------$72.00
$72.00
$72.00
$72.00
$72.00
$85.00
$85.00
$85.00
$85.00
$94.00
$94.00
$94.00
$94.00
$24.00
$694.00
$181.00
$102.00
$447.00
$564.00
$114.00
$450.00
----------------------------$209.00
$86.00
$123.00
$280.00
$116.00
$164.00
$208.00
$85.00
$123.00
$278.00
$114.00
$164.00
$208.00
$85.00
$123.00
$320.00
$266.00
$54.00
$304.00
$202.00
$102.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
------------$79.00
$79.00
$79.00
$79.00
$79.00
$93.00
$93.00
$93.00
$93.00
$104.00
$104.00
$104.00
$104.00
$27.00
$749.00
$190.00
$108.00
$471.00
$615.00
$120.00
$494.00
----------------------------$226.00
$91.00
$135.00
$303.00
$123.00
$180.00
$225.00
$90.00
$135.00
$300.00
$120.00
$180.00
$225.00
$90.00
$135.00
$339.00
$280.00
$59.00
$325.00
$213.00
$112.00
------------$84.00
$84.00
$84.00
$84.00
$84.00
$99.00
$99.00
$99.00
$99.00
$110.00
$110.00
$110.00
$110.00
$28.00
$776.00
$198.00
$112.00
$490.00
$648.00
$125.00
$523.00
----------------------------$238.00
$95.00
$143.00
$320.00
$129.00
$190.00
$237.00
$94.00
$143.00
$316.00
$125.00
$190.00
$236.00
$93.00
$143.00
$353.00
$290.00
$63.00
$340.00
$221.00
$119.00
246
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
77762
77762-26
77762-TC
77763
77763-26
77763-TC
77776
77776-26
77776-TC
77777
77777-26
77777-TC
77778
77778-26
77778-TC
77781
77781-26
77781-TC
77782
77782-26
77782-TC
77783
77783-26
77783-TC
77784
77784-26
77784-TC
77789
77789-26
77789-TC
77790
77790-26
77790-TC
77799
77799-26
77799-TC
78000
78000-26
78000-TC
78001
78001-26
78001-TC
78003
78003-26
78003-TC
78006
78006-26
78006-TC
78007
78007-26
78007-TC
78010
$427.00
$289.00
$135.00
$605.00
$435.00
$167.00
$316.00
$233.00
$82.00
$540.00
$378.00
$158.00
$764.00
$568.00
$192.00
$847.00
$85.00
$759.00
$890.00
$127.00
$759.00
$956.00
$189.00
$759.00
$1,055.00
$284.00
$759.00
$74.00
$57.00
$16.00
$72.00
$53.00
$18.00
BR
BR
BR
$46.00
$9.00
$36.00
$62.00
$12.00
$48.00
$54.00
$17.00
$36.00
$115.00
$24.00
$89.00
$122.00
$25.00
$96.00
$89.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$456.00
$310.00
$146.00
$647.00
$466.00
$181.00
$322.00
$234.00
$89.00
$577.00
$406.00
$171.00
$817.00
$610.00
$207.00
$910.00
$91.00
$819.00
$955.00
$136.00
$819.00
$1,022.00
$203.00
$819.00
$1,124.00
$305.00
$819.00
$79.00
$61.00
$18.00
$77.00
$57.00
$20.00
------------$50.00
$11.00
$40.00
$67.00
$14.00
$53.00
$57.00
$18.00
$40.00
$123.00
$27.00
$96.00
$131.00
$27.00
$104.00
$96.00
$486.00
$326.00
$160.00
$688.00
$490.00
$199.00
$344.00
$246.00
$98.00
$615.00
$428.00
$188.00
$869.00
$642.00
$227.00
$995.00
$96.00
$900.00
$1,043.00
$143.00
$900.00
$1,113.00
$214.00
$900.00
$1,220.00
$321.00
$900.00
$84.00
$63.00
$20.00
$82.00
$60.00
$22.00
------------$55.00
$11.00
$44.00
$73.00
$15.00
$58.00
$62.00
$19.00
$44.00
$134.00
$28.00
$106.00
$143.00
$29.00
$115.00
$104.00
$508.00
$339.00
$169.00
$719.00
$509.00
$210.00
$361.00
$258.00
$104.00
$644.00
$446.00
$198.00
$908.00
$668.00
$240.00
$1,050.00
$100.00
$951.00
$1,099.00
$149.00
$951.00
$1,173.00
$222.00
$951.00
$1,284.00
$333.00
$951.00
$87.00
$66.00
$21.00
$86.00
$63.00
$23.00
------------$58.00
$12.00
$46.00
$77.00
$16.00
$61.00
$66.00
$19.00
$46.00
$142.00
$29.00
$112.00
$151.00
$30.00
$121.00
$110.00
$456.00
$310.00
$146.00
$647.00
$466.00
$181.00
$322.00
$234.00
$89.00
$577.00
$406.00
$171.00
$817.00
$610.00
$207.00
$910.00
$91.00
$819.00
$955.00
$136.00
$819.00
$1,022.00
$203.00
$819.00
$1,124.00
$305.00
$819.00
$79.00
$61.00
$18.00
$77.00
$57.00
$20.00
------------$50.00
$11.00
$40.00
$67.00
$14.00
$53.00
$57.00
$18.00
$40.00
$123.00
$27.00
$96.00
$131.00
$27.00
$104.00
$96.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$486.00
$326.00
$160.00
$688.00
$490.00
$199.00
$344.00
$246.00
$98.00
$615.00
$428.00
$188.00
$869.00
$642.00
$227.00
$995.00
$96.00
$900.00
$1,043.00
$143.00
$900.00
$1,113.00
$214.00
$900.00
$1,220.00
$321.00
$900.00
$84.00
$63.00
$20.00
$82.00
$60.00
$22.00
------------$55.00
$11.00
$44.00
$73.00
$15.00
$58.00
$62.00
$19.00
$44.00
$134.00
$28.00
$106.00
$143.00
$29.00
$115.00
$104.00
$508.00
$339.00
$169.00
$719.00
$509.00
$210.00
$361.00
$258.00
$104.00
$644.00
$446.00
$198.00
$908.00
$668.00
$240.00
$1,050.00
$100.00
$951.00
$1,099.00
$149.00
$951.00
$1,173.00
$222.00
$951.00
$1,284.00
$333.00
$951.00
$87.00
$66.00
$21.00
$86.00
$63.00
$23.00
------------$58.00
$12.00
$46.00
$77.00
$16.00
$61.00
$66.00
$19.00
$46.00
$142.00
$29.00
$112.00
$151.00
$30.00
$121.00
$110.00
247
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
78010-26
78010-TC
78011
78011-26
78011-TC
78015
78015-26
78015-TC
78016
78016-26
78016-TC
78018
78018-26
78018-TC
78020
78020-26
78020-TC
78070
78070-26
78070-TC
78075
78075-26
78075-TC
78099
78099-26
78099-TC
78102
78102-26
78102-TC
78103
78103-26
78103-TC
78104
78104-26
78104-TC
78110
78110-26
78110-TC
78111
78111-26
78111-TC
78120
78120-26
78120-TC
78121
78121-26
78121-TC
78122
78122-26
78122-TC
78130
78130-26
$19.00
$68.00
$114.00
$22.00
$90.00
$132.00
$34.00
$96.00
$173.00
$42.00
$130.00
$248.00
$44.00
$202.00
$35.00
$30.00
$5.00
$112.00
$36.00
$68.00
$242.00
$38.00
$202.00
BR
BR
BR
$106.00
$28.00
$77.00
$158.00
$39.00
$118.00
$194.00
$41.00
$152.00
$45.00
$9.00
$35.00
$108.00
$11.00
$96.00
$78.00
$11.00
$65.00
$125.00
$16.00
$108.00
$196.00
$22.00
$171.00
$139.00
$32.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$22.00
$74.00
$122.00
$25.00
$98.00
$141.00
$37.00
$104.00
$185.00
$45.00
$140.00
$266.00
$47.00
$219.00
$89.00
$33.00
$56.00
$119.00
$45.00
$74.00
$260.00
$41.00
$219.00
------------$113.00
$30.00
$83.00
$169.00
$41.00
$128.00
$208.00
$44.00
$164.00
$50.00
$11.00
$39.00
$116.00
$12.00
$104.00
$83.00
$13.00
$70.00
$135.00
$18.00
$117.00
$210.00
$25.00
$186.00
$149.00
$34.00
$23.00
$81.00
$133.00
$26.00
$107.00
$153.00
$39.00
$115.00
$202.00
$48.00
$154.00
$290.00
$50.00
$241.00
$97.00
$35.00
$63.00
$129.00
$47.00
$81.00
$284.00
$43.00
$241.00
------------$123.00
$32.00
$91.00
$184.00
$44.00
$140.00
$227.00
$46.00
$180.00
$54.00
$11.00
$43.00
$127.00
$13.00
$115.00
$91.00
$13.00
$78.00
$147.00
$19.00
$129.00
$230.00
$26.00
$204.00
$162.00
$36.00
$24.00
$86.00
$141.00
$27.00
$113.00
$162.00
$40.00
$121.00
$212.00
$50.00
$163.00
$306.00
$52.00
$254.00
$104.00
$36.00
$68.00
$135.00
$49.00
$86.00
$299.00
$45.00
$254.00
------------$130.00
$33.00
$97.00
$194.00
$45.00
$148.00
$239.00
$48.00
$191.00
$57.00
$12.00
$46.00
$135.00
$13.00
$121.00
$96.00
$14.00
$82.00
$155.00
$19.00
$136.00
$243.00
$27.00
$215.00
$171.00
$37.00
$22.00
$74.00
$122.00
$25.00
$98.00
$141.00
$37.00
$104.00
$185.00
$45.00
$140.00
$266.00
$47.00
$219.00
$89.00
$33.00
$56.00
$119.00
$45.00
$74.00
$260.00
$41.00
$219.00
------------$113.00
$30.00
$83.00
$169.00
$41.00
$128.00
$208.00
$44.00
$164.00
$50.00
$11.00
$39.00
$116.00
$12.00
$104.00
$83.00
$13.00
$70.00
$135.00
$18.00
$117.00
$210.00
$25.00
$186.00
$149.00
$34.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$23.00
$81.00
$133.00
$26.00
$107.00
$153.00
$39.00
$115.00
$202.00
$48.00
$154.00
$290.00
$50.00
$241.00
$97.00
$35.00
$63.00
$129.00
$47.00
$81.00
$284.00
$43.00
$241.00
------------$123.00
$32.00
$91.00
$184.00
$44.00
$140.00
$227.00
$46.00
$180.00
$54.00
$11.00
$43.00
$127.00
$13.00
$115.00
$91.00
$13.00
$78.00
$147.00
$19.00
$129.00
$230.00
$26.00
$204.00
$162.00
$36.00
$24.00
$86.00
$141.00
$27.00
$113.00
$162.00
$40.00
$121.00
$212.00
$50.00
$163.00
$306.00
$52.00
$254.00
$104.00
$36.00
$68.00
$135.00
$49.00
$86.00
$299.00
$45.00
$254.00
------------$130.00
$33.00
$97.00
$194.00
$45.00
$148.00
$239.00
$48.00
$191.00
$57.00
$12.00
$46.00
$135.00
$13.00
$121.00
$96.00
$14.00
$82.00
$155.00
$19.00
$136.00
$243.00
$27.00
$215.00
$171.00
$37.00
248
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
78130-TC
78135
78135-26
78135-TC
78140
78140-26
78140-TC
78160
78160-26
78160-TC
78162
78162-26
78162-TC
78170
78170-26
78170-TC
78172
78172-26
78172-TC
78185
78185-26
78185-TC
78190
78190-26
78190-TC
78191
78191-26
78191-TC
78195
78195-26
78195-TC
78199
78199-26
78199-TC
78201
78201-26
78201-TC
78202
78202-26
78202-TC
78205
78205-26
78205-TC
78206
78206-26
78206-TC
78215
78215-26
78215-TC
78216
78216-26
78216-TC
$106.00
$216.00
$33.00
$182.00
$179.00
$31.00
$147.00
$155.00
$17.00
$137.00
$143.00
$23.00
$119.00
$220.00
$20.00
$198.00
BR
$27.00
BR
$110.00
$20.00
$88.00
$272.00
$57.00
$214.00
$307.00
$31.00
$274.00
$216.00
$49.00
$152.00
BR
BR
BR
$112.00
$22.00
$88.00
$135.00
$26.00
$108.00
$259.00
$36.00
$220.00
$265.00
$46.00
$214.00
$135.00
$24.00
$109.00
$160.00
$29.00
$130.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$115.00
$232.00
$36.00
$197.00
$192.00
$34.00
$159.00
$167.00
$19.00
$148.00
$154.00
$26.00
$129.00
$237.00
$24.00
$214.00
----$29.00
----$118.00
$22.00
$96.00
$292.00
$61.00
$231.00
$329.00
$34.00
$295.00
$231.00
$66.00
$164.00
------------$120.00
$24.00
$96.00
$144.00
$28.00
$116.00
$278.00
$39.00
$238.00
$283.00
$53.00
$230.00
$145.00
$27.00
$118.00
$171.00
$31.00
$140.00
$126.00
$254.00
$38.00
$216.00
$210.00
$36.00
$174.00
$183.00
$21.00
$163.00
$168.00
$27.00
$142.00
$260.00
$25.00
$235.00
----$30.00
----$129.00
$23.00
$105.00
$318.00
$65.00
$253.00
$360.00
$36.00
$324.00
$250.00
$70.00
$180.00
------------$131.00
$25.00
$105.00
$157.00
$29.00
$127.00
$303.00
$41.00
$262.00
$305.00
$56.00
$249.00
$158.00
$28.00
$130.00
$187.00
$33.00
$154.00
$133.00
$268.00
$39.00
$228.00
$221.00
$37.00
$184.00
$193.00
$22.00
$172.00
$177.00
$28.00
$150.00
$275.00
$27.00
$248.00
----$31.00
----$136.00
$24.00
$111.00
$336.00
$68.00
$268.00
$380.00
$37.00
$342.00
$264.00
$73.00
$191.00
------------$138.00
$26.00
$111.00
$165.00
$31.00
$134.00
$320.00
$43.00
$277.00
$318.00
$58.00
$260.00
$166.00
$29.00
$137.00
$197.00
$34.00
$163.00
$115.00
$232.00
$36.00
$197.00
$192.00
$34.00
$159.00
$167.00
$19.00
$148.00
$154.00
$26.00
$129.00
$237.00
$24.00
$214.00
----$29.00
----$118.00
$22.00
$96.00
$292.00
$61.00
$231.00
$329.00
$34.00
$295.00
$231.00
$66.00
$164.00
------------$120.00
$24.00
$96.00
$144.00
$28.00
$116.00
$278.00
$39.00
$238.00
$283.00
$53.00
$230.00
$145.00
$27.00
$118.00
$171.00
$31.00
$140.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$126.00
$254.00
$38.00
$216.00
$210.00
$36.00
$174.00
$183.00
$21.00
$163.00
$168.00
$27.00
$142.00
$260.00
$25.00
$235.00
----$30.00
----$129.00
$23.00
$105.00
$318.00
$65.00
$253.00
$360.00
$36.00
$324.00
$250.00
$70.00
$180.00
------------$131.00
$25.00
$105.00
$157.00
$29.00
$127.00
$303.00
$41.00
$262.00
$305.00
$56.00
$249.00
$158.00
$28.00
$130.00
$187.00
$33.00
$154.00
$133.00
$268.00
$39.00
$228.00
$221.00
$37.00
$184.00
$193.00
$22.00
$172.00
$177.00
$28.00
$150.00
$275.00
$27.00
$248.00
----$31.00
----$136.00
$24.00
$111.00
$336.00
$68.00
$268.00
$380.00
$37.00
$342.00
$264.00
$73.00
$191.00
------------$138.00
$26.00
$111.00
$165.00
$31.00
$134.00
$320.00
$43.00
$277.00
$318.00
$58.00
$260.00
$166.00
$29.00
$137.00
$197.00
$34.00
$163.00
249
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
78220
78220-26
78220-TC
78223
78223-26
78223-TC
78230
78230-26
78230-TC
78231
78231-26
78231-TC
78232
78232-26
78232-TC
78258
78258-26
78258-TC
78261
78261-26
78261-TC
78262
78262-26
78262-TC
78264
78264-26
78264-TC
78267
78268
78270
78270-26
78270-TC
78271
78271-26
78271-TC
78272
78272-26
78272-TC
78278
78278-26
78278-TC
78282
78282-26
78282-TC
78290
78290-26
78290-TC
78291
78291-26
78291-TC
78299
78299-26
$165.00
$24.00
$139.00
$181.00
$43.00
$137.00
$106.00
$23.00
$82.00
$146.00
$27.00
$118.00
$157.00
$23.00
$132.00
$146.00
$38.00
$108.00
$190.00
$36.00
$152.00
$195.00
$35.00
$159.00
$195.00
$40.00
$154.00
BR
BR
$68.00
$10.00
$58.00
$72.00
$10.00
$61.00
$100.00
$14.00
$87.00
$234.00
$50.00
$182.00
BR
$19.00
BR
$149.00
$35.00
$113.00
$161.00
$45.00
$114.00
BR
BR
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$177.00
$27.00
$150.00
$194.00
$46.00
$148.00
$113.00
$25.00
$89.00
$157.00
$29.00
$128.00
$168.00
$26.00
$142.00
$157.00
$41.00
$116.00
$204.00
$38.00
$165.00
$209.00
$38.00
$172.00
$209.00
$43.00
$167.00
--------$74.00
$11.00
$63.00
$78.00
$11.00
$66.00
$109.00
$15.00
$94.00
$251.00
$54.00
$197.00
----$21.00
----$161.00
$38.00
$123.00
$172.00
$49.00
$123.00
---------
$193.00
$28.00
$165.00
$211.00
$49.00
$163.00
$124.00
$26.00
$98.00
$171.00
$30.00
$140.00
$183.00
$27.00
$156.00
$170.00
$43.00
$127.00
$222.00
$40.00
$182.00
$228.00
$40.00
$188.00
$228.00
$45.00
$183.00
--------$81.00
$12.00
$70.00
$85.00
$12.00
$73.00
$119.00
$16.00
$104.00
$273.00
$57.00
$216.00
----$23.00
----$175.00
$40.00
$135.00
$187.00
$51.00
$136.00
---------
$203.00
$29.00
$174.00
$223.00
$51.00
$172.00
$131.00
$27.00
$104.00
$180.00
$31.00
$148.00
$193.00
$28.00
$165.00
$179.00
$45.00
$134.00
$234.00
$42.00
$192.00
$240.00
$41.00
$199.00
$240.00
$47.00
$193.00
--------$86.00
$12.00
$74.00
$90.00
$12.00
$78.00
$126.00
$16.00
$110.00
$288.00
$59.00
$228.00
----$24.00
----$184.00
$41.00
$143.00
$197.00
$53.00
$143.00
---------
$177.00
$27.00
$150.00
$194.00
$46.00
$148.00
$113.00
$25.00
$89.00
$157.00
$29.00
$128.00
$168.00
$26.00
$142.00
$157.00
$41.00
$116.00
$204.00
$38.00
$165.00
$209.00
$38.00
$172.00
$209.00
$43.00
$167.00
--------$74.00
$11.00
$63.00
$78.00
$11.00
$66.00
$109.00
$15.00
$94.00
$251.00
$54.00
$197.00
----$21.00
----$161.00
$38.00
$123.00
$172.00
$49.00
$123.00
---------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$193.00
$28.00
$165.00
$211.00
$49.00
$163.00
$124.00
$26.00
$98.00
$171.00
$30.00
$140.00
$183.00
$27.00
$156.00
$170.00
$43.00
$127.00
$222.00
$40.00
$182.00
$228.00
$40.00
$188.00
$228.00
$45.00
$183.00
--------$81.00
$12.00
$70.00
$85.00
$12.00
$73.00
$119.00
$16.00
$104.00
$273.00
$57.00
$216.00
----$23.00
----$175.00
$40.00
$135.00
$187.00
$51.00
$136.00
---------
$203.00
$29.00
$174.00
$223.00
$51.00
$172.00
$131.00
$27.00
$104.00
$180.00
$31.00
$148.00
$193.00
$28.00
$165.00
$179.00
$45.00
$134.00
$234.00
$42.00
$192.00
$240.00
$41.00
$199.00
$240.00
$47.00
$193.00
--------$86.00
$12.00
$74.00
$90.00
$12.00
$78.00
$126.00
$16.00
$110.00
$288.00
$59.00
$228.00
----$24.00
----$184.00
$41.00
$143.00
$197.00
$53.00
$143.00
---------
250
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
78299-TC
78300
78300-26
78300-TC
78305
78305-26
78305-TC
78306
78306-26
78306-TC
78315
78315-26
78315-TC
78320
78320-26
78320-TC
78350
78350-26
78350-TC
78351
78399
78399-26
78399-TC
78414
78414-26
78414-TC
78428
78428-26
78428-TC
78445
78445-26
78445-TC
78455
78455-26
78455-TC
78456
78456-26
78456-TC
78457
78457-26
78457-TC
78458
78458-26
78458-TC
78459
78459-26
78459-TC
78460
78460-26
78460-TC
78461
78461-26
BR
$125.00
$32.00
$93.00
$181.00
$42.00
$137.00
$205.00
$44.00
$159.00
$233.00
$52.00
$179.00
$276.00
$53.00
$220.00
$40.00
$11.00
$29.00
$23.00
BR
BR
BR
BR
$23.00
BR
$126.00
$41.00
$84.00
$97.00
$28.00
$69.00
$187.00
$38.00
$148.00
$205.00
$49.00
$151.00
$140.00
$39.00
$99.00
$198.00
$46.00
$149.00
BR
$100.00
BR
$134.00
$44.00
$88.00
$294.00
$82.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----$135.00
$34.00
$101.00
$193.00
$45.00
$148.00
$220.00
$47.00
$172.00
$249.00
$56.00
$193.00
$296.00
$57.00
$238.00
$43.00
$12.00
$31.00
--------------------$25.00
----$135.00
$44.00
$91.00
$103.00
$27.00
$75.00
$201.00
$40.00
$161.00
$220.00
$55.00
$164.00
$150.00
$42.00
$108.00
$211.00
$50.00
$162.00
----$84.00
----$143.00
$47.00
$96.00
$259.00
$68.00
----$147.00
$36.00
$111.00
$210.00
$48.00
$163.00
$239.00
$50.00
$189.00
$271.00
$59.00
$212.00
$322.00
$60.00
$262.00
$47.00
$13.00
$34.00
--------------------$26.00
----$147.00
$46.00
$101.00
$112.00
$29.00
$83.00
$219.00
$42.00
$176.00
$240.00
$58.00
$182.00
$163.00
$44.00
$118.00
$230.00
$52.00
$178.00
----$88.00
----$154.00
$49.00
$105.00
$281.00
$72.00
----$155.00
$37.00
$118.00
$221.00
$50.00
$172.00
$252.00
$52.00
$200.00
$285.00
$61.00
$224.00
$339.00
$63.00
$277.00
$49.00
$13.00
$36.00
--------------------$27.00
----$154.00
$48.00
$107.00
$118.00
$30.00
$88.00
$231.00
$44.00
$186.00
$254.00
$60.00
$194.00
$171.00
$46.00
$125.00
$242.00
$54.00
$188.00
----$91.00
----$162.00
$51.00
$111.00
$296.00
$75.00
----$135.00
$34.00
$101.00
$193.00
$45.00
$148.00
$220.00
$47.00
$172.00
$249.00
$56.00
$193.00
$296.00
$57.00
$238.00
$43.00
$12.00
$31.00
--------------------$25.00
----$135.00
$44.00
$91.00
$103.00
$27.00
$75.00
$201.00
$40.00
$161.00
$220.00
$55.00
$164.00
$150.00
$42.00
$108.00
$211.00
$50.00
$162.00
----$84.00
----$143.00
$47.00
$96.00
$259.00
$68.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----$147.00
$36.00
$111.00
$210.00
$48.00
$163.00
$239.00
$50.00
$189.00
$271.00
$59.00
$212.00
$322.00
$60.00
$262.00
$47.00
$13.00
$34.00
--------------------$26.00
----$147.00
$46.00
$101.00
$112.00
$29.00
$83.00
$219.00
$42.00
$176.00
$240.00
$58.00
$182.00
$163.00
$44.00
$118.00
$230.00
$52.00
$178.00
----$88.00
----$154.00
$49.00
$105.00
$281.00
$72.00
----$155.00
$37.00
$118.00
$221.00
$50.00
$172.00
$252.00
$52.00
$200.00
$285.00
$61.00
$224.00
$339.00
$63.00
$277.00
$49.00
$13.00
$36.00
--------------------$27.00
----$154.00
$48.00
$107.00
$118.00
$30.00
$88.00
$231.00
$44.00
$186.00
$254.00
$60.00
$194.00
$171.00
$46.00
$125.00
$242.00
$54.00
$188.00
----$91.00
----$162.00
$51.00
$111.00
$296.00
$75.00
251
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
78461-TC
78464
78464-26
78464-TC
78465
78465-26
78465-TC
78466
78466-26
78466-TC
78468
78468-26
78468-TC
78469
78469-26
78469-TC
78472
78472-26
78472-TC
78473
78473-26
78473-TC
78478
78478-26
78478-TC
78480
78480-26
78480-TC
78481
78481-26
78481-TC
78483
78483-26
78483-TC
78491
78491-26
78491-TC
78492
78492-26
78492-TC
78494
78494-26
78494-TC
78496
78496-26
78496-TC
78499
78499-26
78499-TC
78580
78580-26
78580-TC
$213.00
$322.00
$56.00
$264.00
$519.00
$75.00
$441.00
$135.00
$36.00
$97.00
$180.00
$41.00
$137.00
$244.00
$47.00
$195.00
$259.00
$50.00
$206.00
$387.00
$75.00
$308.00
$91.00
$32.00
$58.00
$91.00
$32.00
$58.00
$248.00
$51.00
$195.00
$373.00
$77.00
$294.00
BR
$85.00
BR
BR
$100.00
BR
$324.00
$59.00
$262.00
$92.00
$24.00
$66.00
BR
BR
BR
$167.00
$38.00
$128.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$191.00
$345.00
$60.00
$285.00
$556.00
$81.00
$475.00
$144.00
$38.00
$106.00
$192.00
$44.00
$148.00
$261.00
$50.00
$210.00
$277.00
$54.00
$223.00
$413.00
$81.00
$333.00
$98.00
$34.00
$63.00
$98.00
$34.00
$63.00
$265.00
$54.00
$210.00
$399.00
$82.00
$317.00
------------------------$348.00
$65.00
$282.00
$310.00
$28.00
$282.00
------------$179.00
$41.00
$138.00
$210.00
$377.00
$63.00
$314.00
$607.00
$85.00
$522.00
$157.00
$40.00
$117.00
$209.00
$46.00
$163.00
$284.00
$53.00
$231.00
$302.00
$57.00
$245.00
$450.00
$85.00
$365.00
$106.00
$36.00
$70.00
$106.00
$36.00
$70.00
$288.00
$57.00
$231.00
$434.00
$86.00
$348.00
------------------------$378.00
$69.00
$309.00
$338.00
$30.00
$309.00
------------$195.00
$43.00
$152.00
$222.00
$397.00
$65.00
$331.00
$640.00
$88.00
$552.00
$165.00
$42.00
$123.00
$220.00
$48.00
$172.00
$299.00
$54.00
$244.00
$318.00
$59.00
$259.00
$474.00
$88.00
$386.00
$111.00
$37.00
$74.00
$111.00
$37.00
$74.00
$304.00
$59.00
$244.00
$457.00
$89.00
$368.00
------------------------$397.00
$71.00
$325.00
$356.00
$31.00
$325.00
------------$205.00
$45.00
$161.00
$191.00
$345.00
$60.00
$285.00
$556.00
$81.00
$475.00
$144.00
$38.00
$106.00
$192.00
$44.00
$148.00
$261.00
$50.00
$210.00
$277.00
$54.00
$223.00
$413.00
$81.00
$333.00
$98.00
$34.00
$63.00
$98.00
$34.00
$63.00
$265.00
$54.00
$210.00
$399.00
$82.00
$317.00
------------------------$348.00
$65.00
$282.00
$310.00
$28.00
$282.00
------------$179.00
$41.00
$138.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$210.00
$377.00
$63.00
$314.00
$607.00
$85.00
$522.00
$157.00
$40.00
$117.00
$209.00
$46.00
$163.00
$284.00
$53.00
$231.00
$302.00
$57.00
$245.00
$450.00
$85.00
$365.00
$106.00
$36.00
$70.00
$106.00
$36.00
$70.00
$288.00
$57.00
$231.00
$434.00
$86.00
$348.00
------------------------$378.00
$69.00
$309.00
$338.00
$30.00
$309.00
------------$195.00
$43.00
$152.00
$222.00
$397.00
$65.00
$331.00
$640.00
$88.00
$552.00
$165.00
$42.00
$123.00
$220.00
$48.00
$172.00
$299.00
$54.00
$244.00
$318.00
$59.00
$259.00
$474.00
$88.00
$386.00
$111.00
$37.00
$74.00
$111.00
$37.00
$74.00
$304.00
$59.00
$244.00
$457.00
$89.00
$368.00
------------------------$397.00
$71.00
$325.00
$356.00
$31.00
$325.00
------------$205.00
$45.00
$161.00
252
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
78584
78584-26
78584-TC
78585
78585-26
78585-TC
78586
78586-26
78586-TC
78587
78587-26
78587-TC
78588
78588-26
78588-TC
78591
78591-26
78591-TC
78593
78593-26
78593-TC
78594
78594-26
78594-TC
78596
78596-26
78596-TC
78599
78599-26
78599-TC
78600
78600-26
78600-TC
78601
78601-26
78601-TC
78605
78605-26
78605-TC
78606
78606-26
78606-TC
78607
78607-26
78607-TC
78608
78609
78610
78610-26
78610-TC
78615
78615-26
$171.00
$50.00
$119.00
$171.00
$36.00
$133.00
$118.00
$20.00
$96.00
$131.00
$24.00
$105.00
$239.00
$53.00
$192.00
$128.00
$20.00
$106.00
$151.00
$24.00
$126.00
$214.00
$27.00
$186.00
$332.00
$65.00
$264.00
BR
BR
BR
$131.00
$22.00
$108.00
$154.00
$26.00
$126.00
$155.00
$27.00
$126.00
$221.00
$45.00
$177.00
$311.00
$64.00
$245.00
BR
BR
$74.00
$15.00
$59.00
$166.00
$21.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$183.00
$54.00
$129.00
$288.00
$60.00
$228.00
$127.00
$22.00
$105.00
$140.00
$27.00
$113.00
$190.00
$60.00
$129.00
$137.00
$22.00
$115.00
$166.00
$27.00
$139.00
$230.00
$29.00
$201.00
$355.00
$70.00
$285.00
------------$141.00
$25.00
$116.00
$165.00
$28.00
$137.00
$167.00
$29.00
$137.00
$191.00
$35.00
$156.00
$333.00
$68.00
$265.00
--------$81.00
$17.00
$64.00
$179.00
$24.00
$199.00
$57.00
$142.00
$313.00
$63.00
$250.00
$139.00
$23.00
$115.00
$153.00
$28.00
$124.00
$206.00
$63.00
$142.00
$150.00
$23.00
$126.00
$181.00
$28.00
$153.00
$251.00
$31.00
$220.00
$387.00
$73.00
$314.00
------------$153.00
$26.00
$127.00
$181.00
$29.00
$151.00
$182.00
$31.00
$151.00
$209.00
$37.00
$172.00
$363.00
$72.00
$291.00
--------$88.00
$17.00
$71.00
$196.00
$25.00
$209.00
$59.00
$150.00
$330.00
$66.00
$264.00
$147.00
$24.00
$122.00
$161.00
$29.00
$131.00
$217.00
$66.00
$151.00
$158.00
$24.00
$133.00
$191.00
$29.00
$161.00
$265.00
$32.00
$233.00
$407.00
$76.00
$331.00
------------$161.00
$27.00
$134.00
$190.00
$31.00
$160.00
$192.00
$32.00
$160.00
$220.00
$39.00
$181.00
$382.00
$75.00
$308.00
--------$93.00
$18.00
$75.00
$207.00
$26.00
$183.00
$54.00
$129.00
$288.00
$60.00
$228.00
$127.00
$22.00
$105.00
$140.00
$27.00
$113.00
$190.00
$60.00
$129.00
$137.00
$22.00
$115.00
$166.00
$27.00
$139.00
$230.00
$29.00
$201.00
$355.00
$70.00
$285.00
------------$141.00
$25.00
$116.00
$165.00
$28.00
$137.00
$167.00
$29.00
$137.00
$191.00
$35.00
$156.00
$333.00
$68.00
$265.00
--------$81.00
$17.00
$64.00
$179.00
$24.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$199.00
$57.00
$142.00
$313.00
$63.00
$250.00
$139.00
$23.00
$115.00
$153.00
$28.00
$124.00
$206.00
$63.00
$142.00
$150.00
$23.00
$126.00
$181.00
$28.00
$153.00
$251.00
$31.00
$220.00
$387.00
$73.00
$314.00
------------$153.00
$26.00
$127.00
$181.00
$29.00
$151.00
$182.00
$31.00
$151.00
$209.00
$37.00
$172.00
$363.00
$72.00
$291.00
--------$88.00
$17.00
$71.00
$196.00
$25.00
$209.00
$59.00
$150.00
$330.00
$66.00
$264.00
$147.00
$24.00
$122.00
$161.00
$29.00
$131.00
$217.00
$66.00
$151.00
$158.00
$24.00
$133.00
$191.00
$29.00
$161.00
$265.00
$32.00
$233.00
$407.00
$76.00
$331.00
------------$161.00
$27.00
$134.00
$190.00
$31.00
$160.00
$192.00
$32.00
$160.00
$220.00
$39.00
$181.00
$382.00
$75.00
$308.00
--------$93.00
$18.00
$75.00
$207.00
$26.00
253
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
78615-TC
78630
78630-26
78630-TC
78635
78635-26
78635-TC
78645
78645-26
78645-TC
78647
78647-26
78647-TC
78650
78650-26
78650-TC
78660
78660-26
78660-TC
78699
78699-26
78699-TC
78700
78700-26
78700-TC
78701
78701-26
78701-TC
78704
78704-26
78704-TC
78707
78707-26
78707-TC
78708
78708-26
78708-TC
78709
78709-26
78709-TC
78710
78710-26
78710-TC
78715
78715-26
78715-TC
78725
78725-26
78725-TC
78730
78730-26
78730-TC
$143.00
$223.00
$35.00
$188.00
$129.00
$32.00
$95.00
$158.00
$29.00
$128.00
$268.00
$46.00
$220.00
$206.00
$31.00
$173.00
$107.00
$27.00
$79.00
BR
BR
BR
$137.00
$22.00
$113.00
$158.00
$24.00
$133.00
$187.00
$38.00
$147.00
$217.00
$49.00
$166.00
$231.00
$61.00
$166.00
$241.00
$68.00
$166.00
$256.00
$34.00
$220.00
$74.00
$15.00
$59.00
$87.00
$19.00
$66.00
$73.00
$18.00
$55.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$155.00
$241.00
$38.00
$203.00
$137.00
$34.00
$103.00
$169.00
$31.00
$138.00
$288.00
$50.00
$238.00
$221.00
$34.00
$187.00
$115.00
$29.00
$86.00
------------$148.00
$25.00
$123.00
$170.00
$27.00
$143.00
$200.00
$41.00
$160.00
$233.00
$53.00
$180.00
$247.00
$67.00
$180.00
$258.00
$77.00
$180.00
$275.00
$36.00
$238.00
$81.00
$17.00
$64.00
$93.00
$20.00
$72.00
$79.00
$20.00
$59.00
$171.00
$263.00
$40.00
$223.00
$149.00
$36.00
$113.00
$185.00
$33.00
$152.00
$314.00
$52.00
$262.00
$241.00
$35.00
$206.00
$125.00
$31.00
$95.00
------------$161.00
$26.00
$135.00
$185.00
$28.00
$157.00
$218.00
$43.00
$175.00
$253.00
$56.00
$198.00
$268.00
$70.00
$198.00
$279.00
$82.00
$198.00
$300.00
$38.00
$262.00
$88.00
$17.00
$71.00
$101.00
$21.00
$80.00
$86.00
$21.00
$65.00
$180.00
$277.00
$41.00
$236.00
$157.00
$37.00
$120.00
$194.00
$34.00
$161.00
$331.00
$54.00
$277.00
$254.00
$36.00
$217.00
$132.00
$32.00
$100.00
------------$170.00
$27.00
$143.00
$195.00
$29.00
$166.00
$230.00
$45.00
$185.00
$267.00
$58.00
$209.00
$282.00
$73.00
$209.00
$294.00
$85.00
$209.00
$317.00
$40.00
$277.00
$93.00
$18.00
$75.00
$107.00
$22.00
$85.00
$91.00
$22.00
$69.00
$155.00
$241.00
$38.00
$203.00
$137.00
$34.00
$103.00
$169.00
$31.00
$138.00
$288.00
$50.00
$238.00
$221.00
$34.00
$187.00
$115.00
$29.00
$86.00
------------$148.00
$25.00
$123.00
$170.00
$27.00
$143.00
$200.00
$41.00
$160.00
$233.00
$53.00
$180.00
$247.00
$67.00
$180.00
$258.00
$77.00
$180.00
$275.00
$36.00
$238.00
$81.00
$17.00
$64.00
$93.00
$20.00
$72.00
$79.00
$20.00
$59.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$171.00
$263.00
$40.00
$223.00
$149.00
$36.00
$113.00
$185.00
$33.00
$152.00
$314.00
$52.00
$262.00
$241.00
$35.00
$206.00
$125.00
$31.00
$95.00
------------$161.00
$26.00
$135.00
$185.00
$28.00
$157.00
$218.00
$43.00
$175.00
$253.00
$56.00
$198.00
$268.00
$70.00
$198.00
$279.00
$82.00
$198.00
$300.00
$38.00
$262.00
$88.00
$17.00
$71.00
$101.00
$21.00
$80.00
$86.00
$21.00
$65.00
$180.00
$277.00
$41.00
$236.00
$157.00
$37.00
$120.00
$194.00
$34.00
$161.00
$331.00
$54.00
$277.00
$254.00
$36.00
$217.00
$132.00
$32.00
$100.00
------------$170.00
$27.00
$143.00
$195.00
$29.00
$166.00
$230.00
$45.00
$185.00
$267.00
$58.00
$209.00
$282.00
$73.00
$209.00
$294.00
$85.00
$209.00
$317.00
$40.00
$277.00
$93.00
$18.00
$75.00
$107.00
$22.00
$85.00
$91.00
$22.00
$69.00
254
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
78740
78740-26
78740-TC
78760
78760-26
78760-TC
78761
78761-26
78761-TC
78799
78799-26
78799-TC
78800
78800-26
78800-TC
78801
78801-26
78801-TC
78802
78802-26
78802-TC
78803
78803-26
78803-TC
78805
78805-26
78805-TC
78806
78806-26
78806-TC
78807
78807-26
78807-TC
78810
78810-26
78810-TC
78890
78890-26
78890-TC
78891
78891-26
78891-TC
78990
78999
78999-26
78999-TC
79000
79000-26
79000-TC
79001
79001-26
79001-TC
$109.00
$29.00
$79.00
$135.00
$34.00
$99.00
$157.00
$36.00
$119.00
BR
BR
BR
$162.00
$34.00
$126.00
$199.00
$40.00
$158.00
$252.00
$44.00
$207.00
$303.00
$56.00
$245.00
$166.00
$38.00
$126.00
$286.00
$44.00
$241.00
$303.00
$57.00
$245.00
BR
$103.00
BR
$52.00
$3.00
$48.00
$104.00
$5.00
$97.00
BR
BR
BR
BR
$192.00
$92.00
$97.00
$104.00
$54.00
$48.00
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$117.00
$31.00
$86.00
$145.00
$36.00
$108.00
$168.00
$39.00
$129.00
------------$174.00
$36.00
$137.00
$214.00
$43.00
$170.00
$271.00
$47.00
$223.00
$325.00
$60.00
$265.00
$178.00
$40.00
$137.00
$307.00
$47.00
$260.00
$326.00
$61.00
$265.00
----------------------------------------------------$205.00
$99.00
$106.00
$110.00
$58.00
$53.00
$127.00
$32.00
$95.00
$157.00
$38.00
$119.00
$183.00
$41.00
$142.00
------------$189.00
$38.00
$151.00
$233.00
$46.00
$187.00
$295.00
$50.00
$246.00
$354.00
$63.00
$291.00
$193.00
$42.00
$151.00
$335.00
$50.00
$286.00
$355.00
$64.00
$291.00
----------------------------------------------------$220.00
$104.00
$117.00
$119.00
$61.00
$58.00
$134.00
$34.00
$100.00
$166.00
$40.00
$126.00
$193.00
$43.00
$150.00
------------$200.00
$40.00
$160.00
$245.00
$47.00
$198.00
$311.00
$52.00
$260.00
$374.00
$66.00
$308.00
$204.00
$44.00
$160.00
$354.00
$52.00
$302.00
$374.00
$66.00
$308.00
----------------------------------------------------$231.00
$108.00
$123.00
$124.00
$63.00
$61.00
$117.00
$31.00
$86.00
$145.00
$36.00
$108.00
$168.00
$39.00
$129.00
------------$174.00
$36.00
$137.00
$214.00
$43.00
$170.00
$271.00
$47.00
$223.00
$325.00
$60.00
$265.00
$178.00
$40.00
$137.00
$307.00
$47.00
$260.00
$326.00
$61.00
$265.00
----------------------------------------------------$205.00
$99.00
$106.00
$110.00
$58.00
$53.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$127.00
$32.00
$95.00
$157.00
$38.00
$119.00
$183.00
$41.00
$142.00
------------$189.00
$38.00
$151.00
$233.00
$46.00
$187.00
$295.00
$50.00
$246.00
$354.00
$63.00
$291.00
$193.00
$42.00
$151.00
$335.00
$50.00
$286.00
$355.00
$64.00
$291.00
----------------------------------------------------$220.00
$104.00
$117.00
$119.00
$61.00
$58.00
$134.00
$34.00
$100.00
$166.00
$40.00
$126.00
$193.00
$43.00
$150.00
------------$200.00
$40.00
$160.00
$245.00
$47.00
$198.00
$311.00
$52.00
$260.00
$374.00
$66.00
$308.00
$204.00
$44.00
$160.00
$354.00
$52.00
$302.00
$374.00
$66.00
$308.00
----------------------------------------------------$231.00
$108.00
$123.00
$124.00
$63.00
$61.00
255
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Radiology
CPT Code
2003 MRA
79020
79020-26
79020-TC
79030
79030-26
79030-TC
79035
79035-26
79035-TC
79100
79100-26
79100-TC
79200
79200-26
79200-TC
79300
79300-26
79300-TC
79400
79400-26
79400-TC
79420
79420-26
79420-TC
79440
79440-26
79440-TC
79900
79999
$192.00
$92.00
$97.00
$208.00
$107.00
$97.00
$230.00
$129.00
$97.00
$168.00
$68.00
$97.00
$203.00
$102.00
$97.00
BR
$83.00
BR
$201.00
$101.00
$97.00
BR
$77.00
BR
$204.00
$104.00
$97.00
BR
BR
Locality 01/02
Locality 03
Locality 04
Locality 01/02
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$205.00
$99.00
$106.00
$221.00
$115.00
$106.00
$245.00
$139.00
$106.00
$179.00
$73.00
$106.00
$216.00
$110.00
$106.00
----$89.00
----$214.00
$108.00
$106.00
----$83.00
----$217.00
$111.00
$106.00
---------
$220.00
$104.00
$117.00
$238.00
$121.00
$117.00
$263.00
$146.00
$117.00
$193.00
$77.00
$117.00
$232.00
$115.00
$117.00
----$94.00
----$231.00
$114.00
$117.00
----$87.00
----$234.00
$117.00
$117.00
---------
$231.00
$108.00
$123.00
$249.00
$126.00
$123.00
$275.00
$151.00
$123.00
$203.00
$80.00
$123.00
$243.00
$120.00
$123.00
----$98.00
----$242.00
$118.00
$123.00
----$90.00
----$245.00
$122.00
$123.00
---------
$205.00
$99.00
$106.00
$221.00
$115.00
$106.00
$245.00
$139.00
$106.00
$179.00
$73.00
$106.00
$216.00
$110.00
$106.00
----$89.00
----$214.00
$108.00
$106.00
----$83.00
----$217.00
$111.00
$106.00
---------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$220.00
$104.00
$117.00
$238.00
$121.00
$117.00
$263.00
$146.00
$117.00
$193.00
$77.00
$117.00
$232.00
$115.00
$117.00
----$94.00
----$231.00
$114.00
$117.00
----$87.00
----$234.00
$117.00
$117.00
---------
$231.00
$108.00
$123.00
$249.00
$126.00
$123.00
$275.00
$151.00
$123.00
$203.00
$80.00
$123.00
$243.00
$120.00
$123.00
----$98.00
----$242.00
$118.00
$123.00
----$90.00
----$245.00
$122.00
$123.00
---------
256
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
80048
80048-26
80048-TC
80050
80050-26
80050-TC
80051
80051-26
80051-TC
80053
80053-26
80053-TC
80055
80055-26
80055-TC
80061
80061-26
80061-TC
80069
80069-26
80069-TC
80074
80074-26
80074-TC
80076
80076-26
80076-TC
80100
80100-26
80100-TC
80101
80101-26
80101-TC
80102
80102-26
80102-TC
80103
80103-26
80103-TC
80150
80150-26
80150-TC
80152
80152-26
80152-TC
80154
80154-26
80154-TC
80156
80156-26
80156-TC
80157
$23.00
$4.00
$19.00
$45.00
$18.00
$26.00
$16.00
$6.00
$10.00
$29.00
$8.00
$21.00
$67.00
$21.00
$43.00
$31.00
$11.00
$19.00
$26.00
$6.00
$20.00
$107.00
$43.00
$64.00
$18.00
$7.00
$11.00
$38.00
$11.00
$26.00
$13.00
$3.00
$9.00
$23.00
$6.00
$16.00
$12.00
$4.00
$7.00
$40.00
$13.00
$26.00
$43.00
$14.00
$29.00
$49.00
$15.00
$34.00
$35.00
$11.00
$23.00
$22.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
257
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
80157-26
80157-TC
80158
80158-26
80158-TC
80160
80160-26
80160-TC
80162
80162-26
80162-TC
80164
80164-26
80164-TC
80166
80166-26
80166-TC
80168
80168-26
80168-TC
80170
80170-26
80170-TC
80172
80172-26
80172-TC
80173
80173-26
80173-TC
80174
80174-26
80174-TC
80176
80176-26
80176-TC
80178
80178-26
80178-TC
80182
80182-26
80182-TC
80184
80184-26
80184-TC
80185
80185-26
80185-TC
80186
80186-26
80186-TC
80188
80188-26
$8.00
$14.00
$35.00
$12.00
$22.00
$35.00
$12.00
$22.00
$13.00
$3.00
$9.00
$43.00
$14.00
$29.00
$35.00
$10.00
$24.00
$43.00
$17.00
$25.00
$18.00
$6.00
$11.00
$44.00
$13.00
$32.00
$33.00
$11.00
$22.00
$41.00
$12.00
$29.00
$35.00
$11.00
$23.00
$17.00
$6.00
$11.00
$43.00
$14.00
$29.00
$34.00
$10.00
$23.00
$36.00
$10.00
$25.00
$38.00
$11.00
$26.00
$35.00
$11.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
258
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
80188-TC
80190
80190-26
80190-TC
80192
80192-26
80192-TC
80194
80194-26
80194-TC
80196
80196-26
80196-TC
80197
80197-26
80197-TC
80198
80198-26
80198-TC
80200
80200-26
80200-TC
80201
80201-26
80201-TC
80202
80202-26
80202-TC
80299
80299-26
80299-TC
80400
80400-26
80400-TC
80402
80402-26
80402-TC
80406
80406-26
80406-TC
80408
80408-26
80408-TC
80410
80410-26
80410-TC
80412
80412-26
80412-TC
80414
80414-26
80414-TC
$23.00
$41.00
$13.00
$28.00
$44.00
$17.00
$26.00
$33.00
$10.00
$22.00
$13.00
$3.00
$9.00
$34.00
$11.00
$22.00
$20.00
$5.00
$15.00
$24.00
$7.00
$16.00
$33.00
$11.00
$21.00
$42.00
$14.00
$28.00
BR
BR
BR
$54.00
$18.00
$36.00
$138.00
$42.00
$95.00
$138.00
$42.00
$95.00
$213.00
$77.00
$136.00
$166.00
$54.00
$110.00
$533.00
$176.00
$355.00
$88.00
$26.00
$59.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
259
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
80415
80415-26
80415-TC
80416
80416-26
80416-TC
80417
80417-26
80417-TC
80418
80418-26
80418-TC
80420
80420-26
80420-TC
80422
80422-26
80422-TC
80424
80424-26
80424-TC
80426
80426-26
80426-TC
80428
80428-26
80428-TC
80430
80430-26
80430-TC
80432
80432-26
80432-TC
80434
80434-26
80434-TC
80435
80435-26
80435-TC
80436
80436-26
80436-TC
80438
80438-26
80438-TC
80439
80439-26
80439-TC
80440
80440-26
80440-TC
80500
$93.00
$28.00
$64.00
$256.00
$88.00
$166.00
$256.00
$88.00
$166.00
$934.00
$266.00
$666.00
$107.00
$33.00
$74.00
$62.00
$18.00
$43.00
$94.00
$26.00
$67.00
$232.00
$54.00
$176.00
$93.00
$19.00
$73.00
$99.00
$24.00
$74.00
$243.00
$56.00
$186.00
$161.00
$49.00
$110.00
$166.00
$49.00
$115.00
$119.00
$35.00
$85.00
$82.00
$24.00
$56.00
$176.00
$33.00
$144.00
$188.00
$36.00
$151.00
$34.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$24.00
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$25.00
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$26.00
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$22.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$23.00
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$23.00
260
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
80500-26
80500-TC
80502
80502-26
80502-TC
81000
81000-26
81000-TC
81001
81001-26
81001-TC
81002
81002-26
81002-TC
81003
81003-26
81003-TC
81005
81005-26
81005-TC
81007
81007-26
81007-TC
81015
81015-26
81015-TC
81020
81020-26
81020-TC
81025
81025-26
81025-TC
81050
81050-26
81050-TC
81099
81099-26
81099-TC
82000
82000-26
82000-TC
82003
82003-26
82003-TC
82009
82009-26
82009-TC
82010
82010-26
82010-TC
82013
82013-26
$34.00
BR
$72.00
$72.00
BR
$7.00
$3.00
$4.00
$7.00
$3.00
$4.00
$5.00
$3.00
$3.00
$5.00
$2.00
$3.00
$3.00
$1.00
$3.00
$5.00
$2.00
$4.00
$5.00
$3.00
$3.00
$8.00
$3.00
$5.00
$7.00
$4.00
$4.00
$33.00
$11.00
$21.00
BR
BR
BR
$24.00
$7.00
$17.00
$36.00
$10.00
$25.00
$10.00
$3.00
$6.00
$22.00
$7.00
$15.00
$24.00
$7.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
--------$80.00
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------$84.00
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------$87.00
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------$78.00
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
--------$82.00
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------$85.00
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
261
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82013-TC
82024
82024-26
82024-TC
82030
82030-26
82030-TC
82040
82040-26
82040-TC
82042
82042-26
82042-TC
82043
82043-26
82043-TC
82044
82044-26
82044-TC
82055
82055-26
82055-TC
82075
82075-26
82075-TC
82085
82085-26
82085-TC
82088
82088-26
82088-TC
82101
82101-26
82101-TC
82103
82103-26
82103-TC
82104
82104-26
82104-TC
82105
82105-26
82105-TC
82106
82106-26
82106-TC
82108
82108-26
82108-TC
82120
82120-26
82120-TC
$17.00
$26.00
$7.00
$18.00
$43.00
$17.00
$25.00
$11.00
$3.00
$7.00
$12.00
$3.00
$8.00
$14.00
$4.00
$10.00
$12.00
$4.00
$9.00
$33.00
$10.00
$22.00
$32.00
$10.00
$21.00
$24.00
$7.00
$17.00
$91.00
$28.00
$62.00
$59.00
$18.00
$41.00
$21.00
$7.00
$14.00
$22.00
$7.00
$15.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$45.00
$14.00
$32.00
$9.00
$3.00
$5.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
262
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82127
82127-26
82127-TC
82128
82128-26
82128-TC
82131
82131-26
82131-TC
82135
82135-26
82135-TC
82136
82136-26
82136-TC
82139
82139-26
82139-TC
82140
82140-26
82140-TC
82143
82143-26
82143-TC
82145
82145-26
82145-TC
82150
82150-26
82150-TC
82154
82154-26
82154-TC
82157
82157-26
82157-TC
82160
82160-26
82160-TC
82163
82163-26
82163-TC
82164
82164-26
82164-TC
82172
82172-26
82172-TC
82175
82175-26
82175-TC
82180
$33.00
$11.00
$22.00
$26.00
$6.00
$19.00
$57.00
$13.00
$44.00
$41.00
$13.00
$28.00
$38.00
$14.00
$23.00
$38.00
$14.00
$23.00
$40.00
$12.00
$28.00
$28.00
$8.00
$19.00
$35.00
$10.00
$24.00
$16.00
$5.00
$11.00
$34.00
$13.00
$20.00
$57.00
$17.00
$40.00
$67.00
$21.00
$43.00
$42.00
$12.00
$31.00
$32.00
$10.00
$21.00
$33.00
$10.00
$22.00
$48.00
$15.00
$33.00
$25.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
263
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82180-26
82180-TC
82190
82190-26
82190-TC
82205
82205-26
82205-TC
82232
82232-26
82232-TC
82239
82239-26
82239-TC
82240
82240-26
82240-TC
82247
82247-26
82247-TC
82248
82248-26
82248-TC
82252
82252-26
82252-TC
82261
82261-26
82261-TC
82270
82270-26
82270-TC
82273
82273-26
82273-TC
82274
82274-26
82274-TC
82286
82286-26
82286-TC
82300
82300-26
82300-TC
82306
82306-26
82306-TC
82307
82307-26
82307-TC
82308
82308-26
$8.00
$17.00
$24.00
$8.00
$16.00
$34.00
$10.00
$23.00
$43.00
$14.00
$29.00
$23.00
$8.00
$15.00
$49.00
$15.00
$34.00
$10.00
$3.00
$7.00
$10.00
$3.00
$7.00
$11.00
$3.00
$7.00
$38.00
$13.00
$24.00
$5.00
$2.00
$3.00
$8.00
$2.00
$6.00
BR
BR
BR
$12.00
$3.00
$8.00
$48.00
$15.00
$33.00
$79.00
$25.00
$52.00
$57.00
$19.00
$38.00
$62.00
$18.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
264
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82308-TC
82310
82310-26
82310-TC
82330
82330-26
82330-TC
82331
82331-26
82331-TC
82340
82340-26
82340-TC
82355
82355-26
82355-TC
82360
82360-26
82360-TC
82365
82365-26
82365-TC
82370
82370-26
82370-TC
82373
82373-26
82373-TC
82374
82374-26
82374-TC
82375
82375-26
82375-TC
82376
82376-26
82376-TC
82378
82378-26
82378-TC
82379
82379-26
82379-TC
82380
82380-26
82380-TC
82382
82382-26
82382-TC
82383
82383-26
82383-TC
$43.00
$11.00
$3.00
$7.00
$37.00
$11.00
$25.00
$14.00
$4.00
$10.00
$13.00
$4.00
$8.00
$31.00
$10.00
$20.00
$31.00
$10.00
$20.00
$31.00
$8.00
$21.00
$22.00
$7.00
$15.00
$16.00
$5.00
$11.00
$10.00
$3.00
$6.00
$26.00
$7.00
$18.00
$11.00
$3.00
$7.00
$31.00
$8.00
$21.00
$38.00
$13.00
$24.00
$21.00
$6.00
$15.00
$38.00
$12.00
$25.00
$62.00
$18.00
$43.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
265
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82384
82384-26
82384-TC
82387
82387-26
82387-TC
82390
82390-26
82390-TC
82397
82397-26
82397-TC
82415
82415-26
82415-TC
82435
82435-26
82435-TC
82436
82436-26
82436-TC
82438
82438-26
82438-TC
82441
82441-26
82441-TC
82465
82465-26
82465-TC
82480
82480-26
82480-TC
82482
82482-26
82482-TC
82485
82485-26
82485-TC
82486
82486-26
82486-TC
82487
82487-26
82487-TC
82488
82488-26
82488-TC
82489
82489-26
82489-TC
82491
$62.00
$18.00
$43.00
$34.00
$10.00
$23.00
$24.00
$7.00
$17.00
$22.00
$7.00
$15.00
$28.00
$8.00
$19.00
$8.00
$2.00
$6.00
$14.00
$4.00
$10.00
$13.00
$4.00
$8.00
$16.00
$5.00
$11.00
$8.00
$2.00
$6.00
$23.00
$6.00
$17.00
$23.00
$7.00
$15.00
$37.00
$8.00
$28.00
$42.00
$14.00
$27.00
$43.00
$14.00
$29.00
$57.00
$19.00
$38.00
$47.00
$15.00
$32.00
$58.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
266
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82491-26
82491-TC
82492
82492-26
82492-TC
82495
82495-26
82495-TC
82507
82507-26
82507-TC
82520
82520-26
82520-TC
82523
82523-26
82523-TC
82525
82525-26
82525-TC
82528
82528-26
82528-TC
82530
82530-26
82530-TC
82533
82533-26
82533-TC
82540
82540-26
82540-TC
82541
82541-26
82541-TC
82542
82542-26
82542-TC
82543
82543-26
82543-TC
82544
82544-26
82544-TC
82550
82550-26
82550-TC
82552
82552-26
82552-TC
82553
82553-26
$17.00
$41.00
$42.00
$13.00
$28.00
$48.00
$16.00
$32.00
$55.00
$16.00
$39.00
$26.00
$8.00
$18.00
$43.00
$17.00
$25.00
$34.00
$10.00
$23.00
$40.00
$13.00
$26.00
$38.00
$12.00
$25.00
$35.00
$10.00
$24.00
$10.00
$3.00
$6.00
$42.00
$13.00
$28.00
$42.00
$13.00
$28.00
$42.00
$13.00
$28.00
$42.00
$13.00
$28.00
$16.00
$4.00
$12.00
$33.00
$10.00
$22.00
$16.00
$5.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
267
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82553-TC
82554
82554-26
82554-TC
82565
82565-26
82565-TC
82570
82570-26
82570-TC
82575
82575-26
82575-TC
82585
82585-26
82585-TC
82595
82595-26
82595-TC
82600
82600-26
82600-TC
82607
82607-26
82607-TC
82608
82608-26
82608-TC
82615
82615-26
82615-TC
82626
82626-26
82626-TC
82627
82627-26
82627-TC
82633
82633-26
82633-TC
82634
82634-26
82634-TC
82638
82638-26
82638-TC
82646
82646-26
82646-TC
82649
82649-26
82649-TC
$11.00
$19.00
$6.00
$13.00
$13.00
$2.00
$11.00
$10.00
$2.00
$7.00
$25.00
$8.00
$17.00
$15.00
$3.00
$12.00
$31.00
$10.00
$21.00
$40.00
$12.00
$28.00
$38.00
$10.00
$27.00
$40.00
$13.00
$26.00
$17.00
$5.00
$12.00
$59.00
$19.00
$40.00
$37.00
$12.00
$24.00
$81.00
$23.00
$56.00
$81.00
$23.00
$56.00
$23.00
$7.00
$16.00
$37.00
$11.00
$25.00
$43.00
$17.00
$25.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
268
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82651
82651-26
82651-TC
82652
82652-26
82652-TC
82654
82654-26
82654-TC
82657
82657-26
82657-TC
82658
82658-26
82658-TC
82664
82664-26
82664-TC
82666
82666-26
82666-TC
82668
82668-26
82668-TC
82670
82670-26
82670-TC
82671
82671-26
82671-TC
82672
82672-26
82672-TC
82677
82677-26
82677-TC
82679
82679-26
82679-TC
82690
82690-26
82690-TC
82693
82693-26
82693-TC
82696
82696-26
82696-TC
82705
82705-26
82705-TC
82710
$43.00
$17.00
$25.00
$89.00
$25.00
$62.00
$37.00
$11.00
$25.00
$42.00
$13.00
$28.00
$42.00
$13.00
$28.00
$40.00
$13.00
$26.00
$58.00
$17.00
$41.00
$45.00
$14.00
$32.00
$61.00
$18.00
$42.00
$61.00
$17.00
$43.00
$57.00
$16.00
$41.00
$52.00
$17.00
$35.00
$70.00
$20.00
$48.00
$53.00
$21.00
$32.00
$23.00
$7.00
$16.00
$57.00
$19.00
$38.00
$14.00
$6.00
$9.00
$42.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
269
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82710-26
82710-TC
82715
82715-26
82715-TC
82725
82725-26
82725-TC
82726
82726-26
82726-TC
82728
82728-26
82728-TC
82735
82735-26
82735-TC
82742
82742-26
82742-TC
82746
82746-26
82746-TC
82747
82747-26
82747-TC
82757
82757-26
82757-TC
82759
82759-26
82759-TC
82760
82760-26
82760-TC
82775
82775-26
82775-TC
82776
82776-26
82776-TC
82784
82784-26
82784-TC
82785
82785-26
82785-TC
82787
82787-26
82787-TC
82800
82800-26
$13.00
$29.00
$33.00
$11.00
$21.00
$28.00
$8.00
$19.00
$42.00
$13.00
$28.00
$24.00
$7.00
$17.00
$36.00
$12.00
$23.00
$42.00
$13.00
$29.00
$39.00
$13.00
$25.00
$29.00
$10.00
$19.00
$36.00
$11.00
$24.00
$38.00
$12.00
$25.00
$26.00
$8.00
$18.00
$47.00
$14.00
$33.00
$14.00
$3.00
$11.00
$15.00
$5.00
$11.00
$33.00
$11.00
$21.00
$54.00
$17.00
$37.00
$22.00
$6.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
270
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82800-TC
82803
82803-26
82803-TC
82805
82805-26
82805-TC
82810
82810-26
82810-TC
82820
82820-26
82820-TC
82926
82926-26
82926-TC
82928
82928-26
82928-TC
82938
82938-26
82938-TC
82941
82941-26
82941-TC
82943
82943-26
82943-TC
82945
82945-26
82945-TC
82946
82946-26
82946-TC
82947
82947-26
82947-TC
82948
82948-26
82948-TC
82950
82950-26
82950-TC
82951
82951-26
82951-TC
82952
82952-26
82952-TC
82953
82953-26
82953-TC
$16.00
$53.00
$16.00
$37.00
$36.00
$10.00
$24.00
$28.00
$8.00
$19.00
$16.00
$5.00
$11.00
$20.00
$5.00
$15.00
$12.00
$4.00
$7.00
$48.00
$16.00
$32.00
$47.00
$15.00
$32.00
$38.00
$12.00
$25.00
$9.00
$3.00
$5.00
$29.00
$7.00
$21.00
$11.00
$3.00
$7.00
$5.00
$3.00
$3.00
$12.00
$4.00
$7.00
$22.00
$7.00
$15.00
$11.00
$3.00
$7.00
$41.00
$14.00
$26.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
271
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
82955
82955-26
82955-TC
82960
82960-26
82960-TC
82962
82962-26
82962-TC
82963
82963-26
82963-TC
82965
82965-26
82965-TC
82975
82975-26
82975-TC
82977
82977-26
82977-TC
82978
82978-26
82978-TC
82979
82979-26
82979-TC
82980
82980-26
82980-TC
82985
82985-26
82985-TC
83001
83001-26
83001-TC
83002
83002-26
83002-TC
83003
83003-26
83003-TC
83008
83008-26
83008-TC
83010
83010-26
83010-TC
83012
83012-26
83012-TC
83013
$25.00
$7.00
$18.00
$14.00
$4.00
$10.00
$5.00
$1.00
$4.00
$54.00
$17.00
$37.00
$16.00
$5.00
$11.00
$28.00
$8.00
$19.00
$16.00
$4.00
$12.00
$25.00
$7.00
$18.00
$18.00
$5.00
$13.00
$15.00
$3.00
$11.00
$41.00
$12.00
$29.00
$40.00
$12.00
$28.00
$42.00
$13.00
$29.00
$36.00
$10.00
$25.00
$34.00
$10.00
$23.00
$26.00
$8.00
$18.00
$36.00
$14.00
$21.00
$133.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
272
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
83013-26
83013-TC
83014
83014-26
83014-TC
83015
83015-26
83015-TC
83018
83018-26
83018-TC
83020
83020-26
83020-TC
83021
83021-26
83021-TC
83026
83026-26
83026-TC
83030
83030-26
83030-TC
83033
83033-26
83033-TC
83036
83036-26
83036-TC
83045
83045-26
83045-TC
83050
83050-26
83050-TC
83051
83051-26
83051-TC
83055
83055-26
83055-TC
83060
83060-26
83060-TC
83065
83065-26
83065-TC
83068
83068-26
83068-TC
83069
83069-26
$38.00
$94.00
$19.00
$6.00
$13.00
$51.00
$15.00
$36.00
$56.00
$16.00
$40.00
$24.00
$6.00
$18.00
$39.00
$13.00
$25.00
$8.00
$5.00
$3.00
$18.00
$6.00
$12.00
$15.00
$4.00
$11.00
$15.00
$5.00
$10.00
$13.00
$4.00
$8.00
$16.00
$5.00
$11.00
$16.00
$5.00
$11.00
$13.00
$4.00
$8.00
$22.00
$6.00
$16.00
$18.00
$6.00
$12.00
$20.00
$5.00
$15.00
$11.00
$3.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
------------------------------------------------$21.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------$22.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------$23.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------$21.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
------------------------------------------------$22.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------$23.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------
273
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
83069-TC
83070
83070-26
83070-TC
83071
83071-26
83071-TC
83080
83080-26
83080-TC
83088
83088-26
83088-TC
83090
83090-26
83090-TC
83150
83150-26
83150-TC
83491
83491-26
83491-TC
83497
83497-26
83497-TC
83498
83498-26
83498-TC
83499
83499-26
83499-TC
83500
83500-26
83500-TC
83505
83505-26
83505-TC
83516
83516-26
83516-TC
83518
83518-26
83518-TC
83519
83519-26
83519-TC
83520
83520-26
83520-TC
83525
83525-26
83525-TC
$7.00
$13.00
$4.00
$8.00
$18.00
$5.00
$13.00
$38.00
$11.00
$26.00
$59.00
$18.00
$41.00
$38.00
$13.00
$25.00
$49.00
$16.00
$33.00
$37.00
$11.00
$25.00
$35.00
$11.00
$23.00
$62.00
$20.00
$41.00
$51.00
$15.00
$36.00
$69.00
$21.00
$45.00
$77.00
$21.00
$54.00
$26.00
$8.00
$18.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$20.00
$6.00
$14.00
$31.00
$8.00
$21.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
274
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
83527
83527-26
83527-TC
83528
83528-26
83528-TC
83540
83540-26
83540-TC
83550
83550-26
83550-TC
83570
83570-26
83570-TC
83582
83582-26
83582-TC
83586
83586-26
83586-TC
83593
83593-26
83593-TC
83605
83605-26
83605-TC
83615
83615-26
83615-TC
83625
83625-26
83625-TC
83632
83632-26
83632-TC
83655
83655-26
83655-TC
83670
83670-26
83670-TC
83690
83690-26
83690-TC
83715
83715-26
83715-TC
83716
83716-26
83716-TC
83718
$35.00
$11.00
$23.00
$43.00
$14.00
$29.00
$16.00
$3.00
$13.00
$20.00
$5.00
$15.00
$23.00
$7.00
$16.00
$34.00
$8.00
$24.00
$38.00
$13.00
$24.00
$59.00
$18.00
$41.00
$19.00
$6.00
$13.00
$16.00
$5.00
$11.00
$23.00
$6.00
$17.00
$42.00
$14.00
$28.00
$31.00
$8.00
$21.00
$18.00
$5.00
$13.00
$18.00
$6.00
$12.00
$21.00
$5.00
$16.00
$54.00
$19.00
$35.00
$16.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
275
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
83718-26
83718-TC
83719
83719-26
83719-TC
83721
83721-26
83721-TC
83727
83727-26
83727-TC
83735
83735-26
83735-TC
83775
83775-26
83775-TC
83785
83785-26
83785-TC
83788
83788-26
83788-TC
83789
83789-26
83789-TC
83805
83805-26
83805-TC
83825
83825-26
83825-TC
83835
83835-26
83835-TC
83840
83840-26
83840-TC
83857
83857-26
83857-TC
83858
83858-26
83858-TC
83864
83864-26
83864-TC
83866
83866-26
83866-TC
83872
83872-26
$5.00
$11.00
$42.00
$14.00
$28.00
$16.00
$5.00
$11.00
$43.00
$14.00
$29.00
$15.00
$5.00
$10.00
$17.00
$5.00
$12.00
$58.00
$17.00
$41.00
$39.00
$13.00
$25.00
$39.00
$13.00
$25.00
$44.00
$15.00
$29.00
$34.00
$11.00
$22.00
$41.00
$12.00
$29.00
$42.00
$14.00
$28.00
$26.00
$8.00
$18.00
$37.00
$12.00
$24.00
$32.00
$8.00
$22.00
$26.00
$7.00
$19.00
$13.00
$4.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
276
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
83872-TC
83873
83873-26
83873-TC
83874
83874-26
83874-TC
83880
83880-26
83880-TC
83883
83883-26
83883-TC
83885
83885-26
83885-TC
83887
83887-26
83887-TC
83890
83890-26
83890-TC
83891
83891-26
83891-TC
83892
83892-26
83892-TC
83893
83893-26
83893-TC
83894
83894-26
83894-TC
83896
83896-26
83896-TC
83897
83897-26
83897-TC
83898
83898-26
83898-TC
83901
83901-26
83901-TC
83902
83902-26
83902-TC
83903
83903-26
83903-TC
$8.00
$54.00
$18.00
$36.00
$25.00
$8.00
$17.00
BR
BR
BR
$11.00
$3.00
$7.00
$45.00
$14.00
$32.00
$58.00
$17.00
$41.00
$7.00
$2.00
$5.00
$7.00
$2.00
$5.00
$7.00
$2.00
$5.00
$7.00
$2.00
$5.00
$7.00
$2.00
$5.00
$7.00
$2.00
$5.00
$9.00
$3.00
$5.00
$43.00
$14.00
$29.00
$44.00
$14.00
$29.00
$38.00
$13.00
$24.00
$44.00
$14.00
$29.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
277
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
83904
83904-26
83904-TC
83905
83905-26
83905-TC
83906
83906-26
83906-TC
83912
83912-26
83912-TC
83915
83915-26
83915-TC
83916
83916-26
83916-TC
83918
83918-26
83918-TC
83919
83919-26
83919-TC
83921
83921-26
83921-TC
83925
83925-26
83925-TC
83930
83930-26
83930-TC
83935
83935-26
83935-TC
83937
83937-26
83937-TC
83945
83945-26
83945-TC
83950
83950-26
83950-TC
83970
83970-26
83970-TC
83986
83986-26
83986-TC
83992
$44.00
$14.00
$29.00
$44.00
$14.00
$29.00
$44.00
$14.00
$29.00
$39.00
$11.00
$28.00
$31.00
$10.00
$20.00
$54.00
$18.00
$36.00
$41.00
$12.00
$29.00
$42.00
$12.00
$29.00
$37.00
$12.00
$25.00
$13.00
$3.00
$9.00
$11.00
$3.00
$7.00
$17.00
$5.00
$12.00
$29.00
$10.00
$19.00
$32.00
$11.00
$20.00
BR
BR
BR
$94.00
$31.00
$62.00
$8.00
$3.00
$5.00
$40.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------------------------------$21.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------$22.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------$23.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------$21.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------------------------------$22.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------$23.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
278
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
83992-26
83992-TC
84022
84022-26
84022-TC
84030
84030-26
84030-TC
84035
84035-26
84035-TC
84060
84060-26
84060-TC
84061
84061-26
84061-TC
84066
84066-26
84066-TC
84075
84075-26
84075-TC
84078
84078-26
84078-TC
84080
84080-26
84080-TC
84081
84081-26
84081-TC
84085
84085-26
84085-TC
84087
84087-26
84087-TC
84100
84100-26
84100-TC
84105
84105-26
84105-TC
84106
84106-26
84106-TC
84110
84110-26
84110-TC
84119
84119-26
$12.00
$28.00
$41.00
$13.00
$28.00
$11.00
$3.00
$7.00
$12.00
$3.00
$8.00
$20.00
$6.00
$14.00
$14.00
$4.00
$10.00
$18.00
$6.00
$12.00
$12.00
$3.00
$8.00
$19.00
$5.00
$14.00
$36.00
$11.00
$24.00
$45.00
$15.00
$31.00
$15.00
$5.00
$10.00
$25.00
$7.00
$18.00
$11.00
$3.00
$7.00
$11.00
$3.00
$7.00
$10.00
$2.00
$7.00
$21.00
$6.00
$15.00
$21.00
$6.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
279
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
84119-TC
84120
84120-26
84120-TC
84126
84126-26
84126-TC
84127
84127-26
84127-TC
84132
84132-26
84132-TC
84133
84133-26
84133-TC
84134
84134-26
84134-TC
84135
84135-26
84135-TC
84138
84138-26
84138-TC
84140
84140-26
84140-TC
84143
84143-26
84143-TC
84144
84144-26
84144-TC
84146
84146-26
84146-TC
84150
84150-26
84150-TC
84152
84152-26
84152-TC
84153
84153-26
84153-TC
84154
84154-26
84154-TC
84155
84155-26
84155-TC
$15.00
$38.00
$11.00
$26.00
$71.00
$20.00
$49.00
$18.00
$6.00
$12.00
$11.00
$3.00
$7.00
$11.00
$3.00
$7.00
$24.00
$7.00
$17.00
$57.00
$19.00
$38.00
$56.00
$18.00
$38.00
$41.00
$8.00
$33.00
$62.00
$20.00
$41.00
$38.00
$7.00
$31.00
$53.00
$17.00
$36.00
$69.00
$20.00
$47.00
$42.00
$14.00
$27.00
$33.00
$11.00
$21.00
$33.00
$11.00
$21.00
$12.00
$4.00
$7.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
280
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
84160
84160-26
84160-TC
84165
84165-26
84165-TC
84181
84181-26
84181-TC
84182
84182-26
84182-TC
84202
84202-26
84202-TC
84203
84203-26
84203-TC
84206
84206-26
84206-TC
84207
84207-26
84207-TC
84210
84210-26
84210-TC
84220
84220-26
84220-TC
84228
84228-26
84228-TC
84233
84233-26
84233-TC
84234
84234-26
84234-TC
84235
84235-26
84235-TC
84238
84238-26
84238-TC
84244
84244-26
84244-TC
84252
84252-26
84252-TC
84255
$5.00
$2.00
$2.00
$24.00
$8.00
$16.00
$29.00
$10.00
$19.00
$33.00
$11.00
$21.00
$39.00
$13.00
$25.00
$16.00
$5.00
$11.00
$32.00
$10.00
$21.00
$54.00
$16.00
$38.00
$24.00
$10.00
$15.00
$25.00
$8.00
$17.00
$32.00
$10.00
$21.00
$116.00
$35.00
$81.00
$116.00
$35.00
$81.00
$114.00
$34.00
$80.00
$97.00
$32.00
$65.00
$47.00
$15.00
$32.00
$47.00
$14.00
$33.00
$58.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------$21.00
--------$20.00
--------$22.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------$22.00
--------$21.00
--------$23.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------$23.00
--------$22.00
--------$23.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------$21.00
--------$20.00
--------$22.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------$22.00
--------$21.00
--------$23.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------$23.00
--------$22.00
--------$23.00
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
281
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
84255-26
84255-TC
84260
84260-26
84260-TC
84270
84270-26
84270-TC
84275
84275-26
84275-TC
84285
84285-26
84285-TC
84295
84295-26
84295-TC
84300
84300-26
84300-TC
84302
84302-26
84302-TC
84305
84305-26
84305-TC
84307
84307-26
84307-TC
84311
84311-26
84311-TC
84315
84315-26
84315-TC
84375
84375-26
84375-TC
84376
84376-26
84376-TC
84377
84377-26
84377-TC
84378
84378-26
84378-TC
84379
84379-26
84379-TC
84392
84392-26
$17.00
$41.00
$54.00
$16.00
$38.00
$36.00
$11.00
$24.00
$37.00
$11.00
$25.00
$59.00
$17.00
$42.00
$10.00
$3.00
$6.00
$10.00
$3.00
$6.00
BR
BR
BR
$34.00
$11.00
$22.00
$26.00
$8.00
$18.00
$11.00
$3.00
$7.00
$5.00
$2.00
$3.00
$37.00
$11.00
$25.00
$10.00
$3.00
$7.00
$10.00
$3.00
$7.00
$25.00
$8.00
$17.00
$25.00
$8.00
$17.00
$8.00
$2.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
282
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
84392-TC
84402
84402-26
84402-TC
84403
84403-26
84403-TC
84425
84425-26
84425-TC
84430
84430-26
84430-TC
84432
84432-26
84432-TC
84436
84436-26
84436-TC
84437
84437-26
84437-TC
84439
84439-26
84439-TC
84442
84442-26
84442-TC
84443
84443-26
84443-TC
84445
84445-26
84445-TC
84446
84446-26
84446-TC
84449
84449-26
84449-TC
84450
84450-26
84450-TC
84460
84460-26
84460-TC
84466
84466-26
84466-TC
84478
84478-26
84478-TC
$6.00
$72.00
$21.00
$49.00
$67.00
$19.00
$45.00
$54.00
$17.00
$37.00
$31.00
$10.00
$20.00
$28.00
$8.00
$19.00
$14.00
$3.00
$11.00
$13.00
$4.00
$8.00
$16.00
$4.00
$12.00
$25.00
$6.00
$19.00
$32.00
$7.00
$23.00
$98.00
$29.00
$69.00
$35.00
$11.00
$23.00
$38.00
$13.00
$24.00
$11.00
$3.00
$7.00
$13.00
$4.00
$8.00
$22.00
$7.00
$15.00
$12.00
$3.00
$8.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
283
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
84479
84479-26
84479-TC
84480
84480-26
84480-TC
84481
84481-26
84481-TC
84482
84482-26
84482-TC
84484
84484-26
84484-TC
84485
84485-26
84485-TC
84488
84488-26
84488-TC
84490
84490-26
84490-TC
84510
84510-26
84510-TC
84512
84512-26
84512-TC
84520
84520-26
84520-TC
84525
84525-26
84525-TC
84540
84540-26
84540-TC
84545
84545-26
84545-TC
84550
84550-26
84550-TC
84560
84560-26
84560-TC
84577
84577-26
84577-TC
84578
$15.00
$5.00
$10.00
$20.00
$6.00
$14.00
$33.00
$10.00
$22.00
$45.00
$15.00
$31.00
$21.00
$6.00
$15.00
$15.00
$4.00
$11.00
$15.00
$4.00
$11.00
$15.00
$4.00
$11.00
$26.00
$8.00
$18.00
$17.00
$5.00
$12.00
$12.00
$3.00
$8.00
$7.00
$2.00
$5.00
$13.00
$4.00
$8.00
$18.00
$5.00
$13.00
$12.00
$4.00
$7.00
$12.00
$3.00
$8.00
$34.00
$11.00
$22.00
$7.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
284
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
84578-26
84578-TC
84580
84580-26
84580-TC
84583
84583-26
84583-TC
84585
84585-26
84585-TC
84586
84586-26
84586-TC
84588
84588-26
84588-TC
84590
84590-26
84590-TC
84591
84591-26
84591-TC
84597
84597-26
84597-TC
84600
84600-26
84600-TC
84620
84620-26
84620-TC
84630
84630-26
84630-TC
84681
84681-26
84681-TC
84702
84702-26
84702-TC
84703
84703-26
84703-TC
84830
84830-26
84830-TC
84999
84999-26
84999-TC
85002
85002-26
$2.00
$5.00
$17.00
$5.00
$12.00
$11.00
$3.00
$7.00
$36.00
$11.00
$24.00
$42.00
$14.00
$27.00
$73.00
$23.00
$47.00
$33.00
$11.00
$21.00
$26.00
$9.00
$18.00
$37.00
$11.00
$25.00
$43.00
$13.00
$31.00
$29.00
$8.00
$20.00
$26.00
$8.00
$18.00
$52.00
$17.00
$35.00
$38.00
$11.00
$26.00
$22.00
$6.00
$15.00
$17.00
$5.00
$12.00
BR
BR
BR
$10.00
$3.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
285
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
85002-TC
85004
85004-26
85004-TC
85007
85007-26
85007-TC
85008
85008-26
85008-TC
85009
85009-26
85009-TC
85013
85013-26
85013-TC
85014
85014-26
85014-TC
85018
85018-26
85018-TC
85025
85025-26
85025-TC
85027
85027-26
85027-TC
85032
85032-26
85032-TC
85041
85041-26
85041-TC
85044
85044-26
85044-TC
85045
85045-26
85045-TC
85046
85046-26
85046-TC
85048
85048-26
85048-TC
85049
85049-26
85049-TC
85060
85060-26
85060-TC
$6.00
BR
BR
BR
$6.00
$3.00
$4.00
$5.00
$2.00
$3.00
$8.00
$3.00
$5.00
$3.00
$1.00
$2.00
$4.00
$1.00
$3.00
$5.00
$2.00
$3.00
$20.00
$6.00
$14.00
$15.00
$5.00
$10.00
BR
BR
BR
$7.00
$3.00
$4.00
$10.00
$3.00
$6.00
$6.00
$2.00
$4.00
$13.00
$4.00
$9.00
$7.00
$3.00
$4.00
BR
BR
BR
$25.00
$7.00
$18.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$26.00
---------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$27.00
---------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$29.00
---------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$26.00
---------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$27.00
---------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------$29.00
---------
286
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
85097
85097-26
85097-TC
85130
85130-26
85130-TC
85170
85170-26
85170-TC
85175
85175-26
85175-TC
85210
85210-26
85210-TC
85220
85220-26
85220-TC
85230
85230-26
85230-TC
85240
85240-26
85240-TC
85244
85244-26
85244-TC
85245
85245-26
85245-TC
85246
85246-26
85246-TC
85247
85247-26
85247-TC
85250
85250-26
85250-TC
85260
85260-26
85260-TC
85270
85270-26
85270-TC
85280
85280-26
85280-TC
85290
85290-26
85290-TC
85291
$59.00
$59.00
BR
$19.00
$6.00
$13.00
$7.00
$2.00
$5.00
$10.00
$3.00
$6.00
$31.00
$8.00
$21.00
$47.00
$15.00
$32.00
$47.00
$14.00
$33.00
$48.00
$15.00
$33.00
$49.00
$15.00
$34.00
$54.00
$18.00
$36.00
$54.00
$18.00
$36.00
$54.00
$18.00
$36.00
$49.00
$14.00
$35.00
$49.00
$14.00
$35.00
$49.00
$14.00
$35.00
$49.00
$14.00
$35.00
$44.00
$13.00
$32.00
$20.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$108.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
$115.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
$119.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
$54.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$57.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
$59.00
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
287
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
85291-26
85291-TC
85292
85292-26
85292-TC
85293
85293-26
85293-TC
85300
85300-26
85300-TC
85301
85301-26
85301-TC
85302
85302-26
85302-TC
85303
85303-26
85303-TC
85305
85305-26
85305-TC
85306
85306-26
85306-TC
85307
85307-26
85307-TC
85335
85335-26
85335-TC
85337
85337-26
85337-TC
85345
85345-26
85345-TC
85347
85347-26
85347-TC
85348
85348-26
85348-TC
85360
85360-26
85360-TC
85362
85362-26
85362-TC
85366
85366-26
$6.00
$14.00
$51.00
$17.00
$34.00
$51.00
$17.00
$34.00
$35.00
$12.00
$23.00
$29.00
$10.00
$19.00
$33.00
$11.00
$21.00
$26.00
$8.00
$18.00
$21.00
$7.00
$14.00
$29.00
$10.00
$19.00
$35.00
$12.00
$23.00
$21.00
$7.00
$14.00
$19.00
$6.00
$13.00
$10.00
$2.00
$7.00
$8.00
$2.00
$6.00
$10.00
$3.00
$6.00
$16.00
$4.00
$12.00
$18.00
$7.00
$11.00
$13.00
$3.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
288
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
85366-TC
85370
85370-26
85370-TC
85378
85378-26
85378-TC
85379
85379-26
85379-TC
85380
85380-26
85380-TC
85384
85384-26
85384-TC
85385
85385-26
85385-TC
85390
85390-26
85390-TC
85400
85400-26
85400-TC
85410
85410-26
85410-TC
85415
85415-26
85415-TC
85420
85420-26
85420-TC
85421
85421-26
85421-TC
85441
85441-26
85441-TC
85445
85445-26
85445-TC
85460
85460-26
85460-TC
85461
85461-26
85461-TC
85475
85475-26
85475-TC
$10.00
$20.00
$5.00
$15.00
$13.00
$4.00
$8.00
$18.00
$6.00
$12.00
BR
BR
BR
$11.00
$3.00
$7.00
$16.00
$5.00
$11.00
$10.00
$2.00
$7.00
$12.00
$3.00
$8.00
$12.00
$3.00
$8.00
$28.00
$10.00
$18.00
$16.00
$3.00
$13.00
$39.00
$12.00
$26.00
$7.00
$2.00
$5.00
$16.00
$5.00
$11.00
$15.00
$4.00
$11.00
$12.00
$3.00
$8.00
$15.00
$4.00
$11.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
--------------------------------------------------------------------------------$20.00
-----------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------$21.00
-----------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------$22.00
-----------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------$20.00
-----------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
--------------------------------------------------------------------------------$21.00
-----------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------$22.00
-----------------------------------------------------------------------------------------------------------------------------
289
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
85520
85520-26
85520-TC
85525
85525-26
85525-TC
85530
85530-26
85530-TC
85536
85536-26
85536-TC
85540
85540-26
85540-TC
85547
85547-26
85547-TC
85549
85549-26
85549-TC
85555
85555-26
85555-TC
85557
85557-26
85557-TC
85576
85576-26
85576-TC
85597
85597-26
85597-TC
85610
85610-26
85610-TC
85611
85611-26
85611-TC
85612
85612-26
85612-TC
85613
85613-26
85613-TC
85635
85635-26
85635-TC
85651
85651-26
85651-TC
85652
$22.00
$6.00
$16.00
$20.00
$6.00
$14.00
$39.00
$12.00
$26.00
$14.00
$4.00
$10.00
$24.00
$7.00
$17.00
$23.00
$6.00
$17.00
$45.00
$15.00
$31.00
$17.00
$5.00
$12.00
$34.00
$10.00
$23.00
$21.00
$5.00
$16.00
$32.00
$10.00
$21.00
$6.00
$3.00
$4.00
$6.00
$2.00
$4.00
$22.00
$6.00
$16.00
$15.00
$4.00
$11.00
$26.00
$8.00
$18.00
$8.00
$2.00
$6.00
$8.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------------------------------------------------------------------------------------------------------$21.00
---------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------$22.00
---------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------$23.00
---------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------$21.00
---------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------------------------------------------------------------------------------------------------------$22.00
---------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------$23.00
---------------------------------------------------------------------------------------------
290
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
85652-26
85652-TC
85660
85660-26
85660-TC
85670
85670-26
85670-TC
85675
85675-26
85675-TC
85705
85705-26
85705-TC
85730
85730-26
85730-TC
85732
85732-26
85732-TC
85810
85810-26
85810-TC
85999
85999-26
85999-TC
86000
86000-26
86000-TC
86001
86001-26
86001-TC
86003
86003-26
86003-TC
86005
86005-26
86005-TC
86021
86021-26
86021-TC
86022
86022-26
86022-TC
86023
86023-26
86023-TC
86038
86038-26
86038-TC
86039
86039-26
$2.00
$6.00
$10.00
$3.00
$6.00
$13.00
$3.00
$10.00
$13.00
$4.00
$8.00
$13.00
$4.00
$8.00
$11.00
$3.00
$7.00
$17.00
$5.00
$12.00
$19.00
$4.00
$15.00
BR
BR
BR
$16.00
$5.00
$11.00
$12.00
$4.00
$8.00
$6.00
$2.00
$3.00
$11.00
$4.00
$6.00
$41.00
$12.00
$29.00
$57.00
$18.00
$39.00
$28.00
$10.00
$18.00
$22.00
$7.00
$15.00
$19.00
$6.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
291
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86039-TC
86060
86060-26
86060-TC
86063
86063-26
86063-TC
86077
86077-26
86077-TC
86078
86078-26
86078-TC
86079
86079-26
86079-TC
86140
86140-26
86140-TC
86141
86141-26
86141-TC
86146
86146-26
86146-TC
86147
86147-26
86147-TC
86148
86148-26
86148-TC
86155
86155-26
86155-TC
86156
86156-26
86156-TC
86157
86157-26
86157-TC
86160
86160-26
86160-TC
86161
86161-26
86161-TC
86162
86162-26
86162-TC
86171
86171-26
86171-TC
$13.00
$13.00
$3.00
$10.00
$21.00
$6.00
$15.00
$91.00
$26.00
$64.00
$91.00
$26.00
$64.00
$79.00
$25.00
$52.00
$14.00
$4.00
$10.00
BR
BR
BR
$58.00
$19.00
$39.00
$53.00
$16.00
$36.00
$59.00
$21.00
$38.00
$26.00
$8.00
$18.00
$11.00
$3.00
$7.00
$13.00
$4.00
$8.00
$21.00
$5.00
$16.00
$21.00
$5.00
$16.00
$54.00
$18.00
$36.00
$25.00
$7.00
$18.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------------------$57.00
--------$58.00
--------$58.00
---------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------$60.00
--------$61.00
--------$61.00
---------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------$62.00
--------$63.00
--------$63.00
---------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------$55.00
--------$55.00
--------$55.00
---------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------------------$57.00
--------$57.00
--------$57.00
---------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------$60.00
--------$60.00
--------$60.00
---------------------------------------------------------------------------------------------------------------------------------------------------------
292
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86185
86185-26
86185-TC
86215
86215-26
86215-TC
86225
86225-26
86225-TC
86226
86226-26
86226-TC
86235
86235-26
86235-TC
86243
86243-26
86243-TC
86255
86255-26
86255-TC
86256
86256-26
86256-TC
86277
86277-26
86277-TC
86280
86280-26
86280-TC
86294
86294-26
86294-TC
86300
86300-26
86300-TC
86301
86301-26
86301-TC
86304
86304-26
86304-TC
86308
86308-26
86308-TC
86309
86309-26
86309-TC
86310
86310-26
86310-TC
86316
$19.00
$6.00
$13.00
$36.00
$12.00
$23.00
$36.00
$11.00
$24.00
$24.00
$8.00
$16.00
$33.00
$10.00
$22.00
$50.00
$15.00
$35.00
$25.00
$8.00
$17.00
$25.00
$8.00
$17.00
$41.00
$14.00
$26.00
$15.00
$3.00
$12.00
BR
BR
BR
$47.00
$15.00
$32.00
$47.00
$15.00
$32.00
$47.00
$15.00
$32.00
$8.00
$3.00
$5.00
$12.00
$3.00
$8.00
$19.00
$6.00
$13.00
$37.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------------------------------------------------------------------$22.00
--------$21.00
---------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------$23.00
--------$22.00
---------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------$23.00
--------$23.00
---------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------$22.00
--------$21.00
---------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------------------------------------------------------------------$23.00
--------$22.00
---------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------$23.00
--------$23.00
---------------------------------------------------------------------------------------------------------------------
293
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86316-26
86316-TC
86317
86317-26
86317-TC
86318
86318-26
86318-TC
86320
86320-26
86320-TC
86325
86325-26
86325-TC
86327
86327-26
86327-TC
86329
86329-26
86329-TC
86331
86331-26
86331-TC
86332
86332-26
86332-TC
86334
86334-26
86334-TC
86336
86336-26
86336-TC
86337
86337-26
86337-TC
86340
86340-26
86340-TC
86341
86341-26
86341-TC
86343
86343-26
86343-TC
86344
86344-26
86344-TC
86353
86353-26
86353-TC
86359
86359-26
$11.00
$25.00
$31.00
$10.00
$20.00
$23.00
$10.00
$14.00
$49.00
$19.00
$29.00
$49.00
$16.00
$33.00
$62.00
$19.00
$42.00
$37.00
$12.00
$24.00
$22.00
$6.00
$15.00
$54.00
$18.00
$36.00
$65.00
$18.00
$45.00
BR
BR
BR
$54.00
$18.00
$36.00
$39.00
$13.00
$25.00
$38.00
$13.00
$24.00
$33.00
$11.00
$21.00
$21.00
$7.00
$14.00
$102.00
$31.00
$72.00
$61.00
$19.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
------------------------------------$22.00
--------$21.00
--------$24.00
--------------------------------------------$21.00
-------------------------------------------------------------------------------------------------
------------------------------------$23.00
--------$22.00
--------$26.00
--------------------------------------------$22.00
-------------------------------------------------------------------------------------------------
------------------------------------$23.00
--------$23.00
--------$26.00
--------------------------------------------$23.00
-------------------------------------------------------------------------------------------------
------------------------------------$21.00
--------$21.00
--------$24.00
--------------------------------------------$21.00
-------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
------------------------------------$22.00
--------$22.00
--------$26.00
--------------------------------------------$22.00
-------------------------------------------------------------------------------------------------
------------------------------------$23.00
--------$23.00
--------$26.00
--------------------------------------------$23.00
-------------------------------------------------------------------------------------------------
294
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86359-TC
86360
86360-26
86360-TC
86361
86361-26
86361-TC
86376
86376-26
86376-TC
86378
86378-26
86378-TC
86382
86382-26
86382-TC
86384
86384-26
86384-TC
86403
86403-26
86403-TC
86406
86406-26
86406-TC
86430
86430-26
86430-TC
86431
86431-26
86431-TC
86485
86485-26
86485-TC
86490
86490-26
86490-TC
86510
86510-26
86510-TC
86580
86580-26
86580-TC
86585
86585-26
86585-TC
86586
86586-26
86586-TC
86590
86590-26
86590-TC
$41.00
$99.00
$33.00
$67.00
$66.00
$21.00
$43.00
$35.00
$11.00
$23.00
$45.00
$15.00
$31.00
$45.00
$14.00
$32.00
$24.00
$8.00
$16.00
$18.00
$3.00
$14.00
$21.00
$5.00
$16.00
$13.00
$4.00
$8.00
$17.00
$6.00
$11.00
$13.00
$4.00
$8.00
$17.00
$5.00
$12.00
$13.00
$4.00
$8.00
$13.00
$4.00
$8.00
$10.00
$3.00
$6.00
BR
BR
BR
$18.00
$6.00
$12.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------------------------------------------------------------------------------------------------------------------------------$12.00
--------$13.00
--------$11.00
--------$8.00
---------------------------------
----------------------------------------------------------------------------------------------------------------------------------------$13.00
--------$15.00
--------$12.00
--------$9.00
---------------------------------
----------------------------------------------------------------------------------------------------------------------------------------$14.00
--------$16.00
--------$13.00
--------$10.00
---------------------------------
----------------------------------------------------------------------------------------------------------------------------------------$12.00
--------$13.00
--------$11.00
--------$8.00
---------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------------------------------------------------------------------------------------------------------------------------------$13.00
--------$15.00
--------$12.00
--------$9.00
---------------------------------
----------------------------------------------------------------------------------------------------------------------------------------$14.00
--------$16.00
--------$13.00
--------$10.00
---------------------------------
295
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86592
86592-26
86592-TC
86593
86593-26
86593-TC
86602
86602-26
86602-TC
86603
86603-26
86603-TC
86606
86606-26
86606-TC
86609
86609-26
86609-TC
86611
86611-26
86611-TC
86612
86612-26
86612-TC
86615
86615-26
86615-TC
86617
86617-26
86617-TC
86618
86618-26
86618-TC
86619
86619-26
86619-TC
86622
86622-26
86622-TC
86625
86625-26
86625-TC
86628
86628-26
86628-TC
86631
86631-26
86631-TC
86632
86632-26
86632-TC
86635
$8.00
$2.00
$6.00
$11.00
$3.00
$7.00
$17.00
$5.00
$12.00
$20.00
$6.00
$14.00
$24.00
$8.00
$16.00
$20.00
$6.00
$14.00
$23.00
$8.00
$15.00
$21.00
$6.00
$15.00
$21.00
$6.00
$15.00
$29.00
$10.00
$19.00
$26.00
$8.00
$18.00
$21.00
$6.00
$15.00
$16.00
$5.00
$11.00
$21.00
$6.00
$15.00
$20.00
$6.00
$14.00
$20.00
$6.00
$14.00
$20.00
$6.00
$14.00
$18.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
296
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86635-26
86635-TC
86638
86638-26
86638-TC
86641
86641-26
86641-TC
86644
86644-26
86644-TC
86645
86645-26
86645-TC
86648
86648-26
86648-TC
86651
86651-26
86651-TC
86652
86652-26
86652-TC
86653
86653-26
86653-TC
86654
86654-26
86654-TC
86658
86658-26
86658-TC
86663
86663-26
86663-TC
86664
86664-26
86664-TC
86665
86665-26
86665-TC
86666
86666-26
86666-TC
86668
86668-26
86668-TC
86671
86671-26
86671-TC
86674
86674-26
$5.00
$13.00
$20.00
$6.00
$14.00
$21.00
$7.00
$14.00
$22.00
$7.00
$15.00
$28.00
$10.00
$18.00
$24.00
$8.00
$16.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$53.00
$17.00
$36.00
$29.00
$10.00
$19.00
$23.00
$8.00
$15.00
$17.00
$5.00
$12.00
$20.00
$6.00
$14.00
$23.00
$7.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
297
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86674-TC
86677
86677-26
86677-TC
86682
86682-26
86682-TC
86684
86684-26
86684-TC
86687
86687-26
86687-TC
86688
86688-26
86688-TC
86689
86689-26
86689-TC
86692
86692-26
86692-TC
86694
86694-26
86694-TC
86695
86695-26
86695-TC
86696
86696-26
86696-TC
86698
86698-26
86698-TC
86701
86701-26
86701-TC
86702
86702-26
86702-TC
86703
86703-26
86703-TC
86704
86704-26
86704-TC
86705
86705-26
86705-TC
86706
86706-26
86706-TC
$16.00
$24.00
$8.00
$16.00
$21.00
$7.00
$14.00
$24.00
$8.00
$16.00
$22.00
$7.00
$16.00
$20.00
$7.00
$14.00
$25.00
$8.00
$17.00
$22.00
$7.00
$15.00
$22.00
$7.00
$15.00
$21.00
$7.00
$14.00
$44.00
$14.00
$30.00
$20.00
$6.00
$14.00
$21.00
$7.00
$15.00
$21.00
$7.00
$14.00
$22.00
$7.00
$15.00
$33.00
$11.00
$21.00
$35.00
$11.00
$23.00
$24.00
$8.00
$16.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
298
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86707
86707-26
86707-TC
86708
86708-26
86708-TC
86709
86709-26
86709-TC
86710
86710-26
86710-TC
86713
86713-26
86713-TC
86717
86717-26
86717-TC
86720
86720-26
86720-TC
86723
86723-26
86723-TC
86727
86727-26
86727-TC
86729
86729-26
86729-TC
86732
86732-26
86732-TC
86735
86735-26
86735-TC
86738
86738-26
86738-TC
86741
86741-26
86741-TC
86744
86744-26
86744-TC
86747
86747-26
86747-TC
86750
86750-26
86750-TC
86753
$26.00
$8.00
$18.00
$32.00
$10.00
$21.00
$29.00
$10.00
$19.00
$22.00
$7.00
$15.00
$23.00
$7.00
$16.00
$20.00
$6.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$20.00
$6.00
$14.00
$19.00
$6.00
$13.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$23.00
$7.00
$16.00
$21.00
$7.00
$14.00
$20.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
299
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86753-26
86753-TC
86756
86756-26
86756-TC
86757
86757-26
86757-TC
86759
86759-26
86759-TC
86762
86762-26
86762-TC
86765
86765-26
86765-TC
86768
86768-26
86768-TC
86771
86771-26
86771-TC
86774
86774-26
86774-TC
86777
86777-26
86777-TC
86778
86778-26
86778-TC
86781
86781-26
86781-TC
86784
86784-26
86784-TC
86787
86787-26
86787-TC
86790
86790-26
86790-TC
86793
86793-26
86793-TC
86800
86800-26
86800-TC
86803
86803-26
$6.00
$14.00
$20.00
$6.00
$14.00
$44.00
$14.00
$30.00
$21.00
$7.00
$14.00
$22.00
$7.00
$15.00
$20.00
$6.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$23.00
$7.00
$16.00
$22.00
$7.00
$15.00
$23.00
$7.00
$16.00
$22.00
$7.00
$15.00
$21.00
$7.00
$14.00
$20.00
$6.00
$14.00
$21.00
$7.00
$14.00
$21.00
$7.00
$14.00
$26.00
$8.00
$18.00
$24.00
$8.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
300
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86803-TC
86804
86804-26
86804-TC
86805
86805-26
86805-TC
86806
86806-26
86806-TC
86807
86807-26
86807-TC
86808
86808-26
86808-TC
86812
86812-26
86812-TC
86813
86813-26
86813-TC
86816
86816-26
86816-TC
86817
86817-26
86817-TC
86821
86821-26
86821-TC
86822
86822-26
86822-TC
86849
86849-26
86849-TC
86850
86850-26
86850-TC
86860
86860-26
86860-TC
86870
86870-26
86870-TC
86880
86880-26
86880-TC
86885
86885-26
86885-TC
$16.00
$26.00
$8.00
$18.00
$97.00
$33.00
$64.00
$87.00
$28.00
$57.00
$74.00
$21.00
$51.00
$52.00
$15.00
$37.00
$108.00
$32.00
$75.00
$101.00
$29.00
$71.00
$64.00
$18.00
$44.00
$134.00
$39.00
$94.00
$123.00
$36.00
$86.00
$96.00
$32.00
$64.00
BR
BR
BR
$10.00
$3.00
$6.00
$44.00
$15.00
$29.00
$17.00
$6.00
$11.00
$13.00
$4.00
$8.00
$15.00
$4.00
$11.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
301
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86886
86886-26
86886-TC
86890
86890-26
86890-TC
86891
86891-26
86891-TC
86900
86900-26
86900-TC
86901
86901-26
86901-TC
86903
86903-26
86903-TC
86904
86904-26
86904-TC
86905
86905-26
86905-TC
86906
86906-26
86906-TC
86910
86910-26
86910-TC
86911
86911-26
86911-TC
86920
86920-26
86920-TC
86921
86921-26
86921-TC
86922
86922-26
86922-TC
86927
86927-26
86927-TC
86930
86930-26
86930-TC
86931
86931-26
86931-TC
86932
$14.00
$4.00
$10.00
$67.00
$11.00
$54.00
$91.00
$26.00
$64.00
$10.00
$3.00
$6.00
$10.00
$3.00
$6.00
$15.00
$5.00
$10.00
$19.00
$6.00
$13.00
$7.00
$1.00
$6.00
$11.00
$3.00
$7.00
$83.00
$24.00
$57.00
$19.00
$6.00
$13.00
$19.00
$3.00
$15.00
$23.00
$7.00
$16.00
$20.00
$6.00
$14.00
$21.00
$5.00
$16.00
$155.00
$45.00
$108.00
$155.00
$45.00
$108.00
$161.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
302
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
86932-26
86932-TC
86940
86940-26
86940-TC
86941
86941-26
86941-TC
86945
86945-26
86945-TC
86950
86950-26
86950-TC
86965
86965-26
86965-TC
86970
86970-26
86970-TC
86971
86971-26
86971-TC
86972
86972-26
86972-TC
86975
86975-26
86975-TC
86976
86976-26
86976-TC
86977
86977-26
86977-TC
86978
86978-26
86978-TC
86985
86985-26
86985-TC
86999
86999-26
86999-TC
87001
87001-26
87001-TC
87003
87003-26
87003-TC
87015
87015-26
$48.00
$111.00
$18.00
$5.00
$13.00
$31.00
$8.00
$21.00
$35.00
$11.00
$23.00
$99.00
$29.00
$70.00
$25.00
$7.00
$18.00
$41.00
$12.00
$29.00
$20.00
$5.00
$15.00
$20.00
$6.00
$14.00
$53.00
$16.00
$37.00
$53.00
$16.00
$37.00
$53.00
$16.00
$37.00
$65.00
$19.00
$44.00
$35.00
$12.00
$23.00
BR
BR
BR
$35.00
$11.00
$23.00
$40.00
$13.00
$26.00
$14.00
$5.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
303
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87015-TC
87040
87040-26
87040-TC
87045
87045-26
87045-TC
87046
87046-26
87046-TC
87070
87070-26
87070-TC
87071
87071-26
87071-TC
87073
87073-26
87073-TC
87075
87075-26
87075-TC
87076
87076-26
87076-TC
87077
87077-26
87077-TC
87081
87081-26
87081-TC
87084
87084-26
87084-TC
87086
87086-26
87086-TC
87088
87088-26
87088-TC
87101
87101-26
87101-TC
87102
87102-26
87102-TC
87103
87103-26
87103-TC
87106
87106-26
87106-TC
$9.00
$18.00
$6.00
$12.00
$18.00
$6.00
$11.00
$5.00
$2.00
$3.00
$14.00
$4.00
$10.00
$11.00
$3.00
$8.00
$11.00
$3.00
$8.00
$18.00
$6.00
$12.00
$24.00
$8.00
$16.00
$16.00
$5.00
$11.00
$12.00
$3.00
$8.00
$23.00
$7.00
$16.00
$14.00
$3.00
$11.00
$18.00
$6.00
$12.00
$20.00
$6.00
$14.00
$20.00
$6.00
$14.00
$32.00
$11.00
$20.00
$25.00
$7.00
$18.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
304
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87107
87107-26
87107-TC
87109
87109-26
87109-TC
87110
87110-26
87110-TC
87116
87116-26
87116-TC
87118
87118-26
87118-TC
87140
87140-26
87140-TC
87143
87143-26
87143-TC
87147
87147-26
87147-TC
87149
87149-26
87149-TC
87152
87152-26
87152-TC
87158
87158-26
87158-TC
87164
87164-26
87164-TC
87166
87166-26
87166-TC
87168
87168-26
87168-TC
87169
87169-26
87169-TC
87172
87172-26
87172-TC
87176
87176-26
87176-TC
87177
$23.00
$8.00
$15.00
$26.00
$8.00
$18.00
$23.00
$7.00
$15.00
$15.00
$3.00
$11.00
$28.00
$9.00
$20.00
$24.00
$7.00
$17.00
$34.00
$11.00
$22.00
$26.00
$8.00
$18.00
$46.00
$15.00
$31.00
$12.00
$4.00
$8.00
$5.00
$1.00
$3.00
$24.00
$8.00
$16.00
$24.00
$7.00
$17.00
$10.00
$3.00
$7.00
$10.00
$3.00
$7.00
$10.00
$3.00
$7.00
$16.00
$5.00
$11.00
$18.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------------------------------------------------------------------------------------------------------------------------------$20.00
---------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------$21.00
---------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------$21.00
---------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------$20.00
---------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------------------------------------------------------------------------------------------------------------------------------$21.00
---------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------$21.00
---------------------------------------------------------------------
305
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87177-26
87177-TC
87181
87181-26
87181-TC
87184
87184-26
87184-TC
87185
87185-26
87185-TC
87186
87186-26
87186-TC
87187
87187-26
87187-TC
87188
87188-26
87188-TC
87190
87190-26
87190-TC
87197
87197-26
87197-TC
87205
87205-26
87205-TC
87206
87206-26
87206-TC
87207
87207-26
87207-TC
87210
87210-26
87210-TC
87220
87220-26
87220-TC
87230
87230-26
87230-TC
87250
87250-26
87250-TC
87252
87252-26
87252-TC
87253
87253-26
$6.00
$12.00
$13.00
$3.00
$8.00
$13.00
$3.00
$10.00
$11.00
$3.00
$8.00
$16.00
$4.00
$12.00
$20.00
$3.00
$17.00
$18.00
$5.00
$13.00
$7.00
$2.00
$5.00
$29.00
$10.00
$19.00
$11.00
$3.00
$7.00
$15.00
$3.00
$12.00
$10.00
$3.00
$6.00
$8.00
$2.00
$6.00
$12.00
$4.00
$7.00
$35.00
$11.00
$23.00
$33.00
$13.00
$19.00
$44.00
$14.00
$31.00
$33.00
$10.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
------------------------------------------------------------------------------------------------------------------------------------$22.00
-------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------$23.00
-------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------$23.00
-------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------$22.00
-------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
------------------------------------------------------------------------------------------------------------------------------------$23.00
-------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------$23.00
-------------------------------------------------------------------------
306
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87253-TC
87254
87254-26
87254-TC
87255
87255-26
87255-TC
87260
87260-26
87260-TC
87265
87265-26
87265-TC
87267
87267-26
87267-TC
87270
87270-26
87270-TC
87271
87271-26
87271-TC
87272
87272-26
87272-TC
87273
87273-26
87273-TC
87274
87274-26
87274-TC
87275
87275-26
87275-TC
87276
87276-26
87276-TC
87277
87277-26
87277-TC
87278
87278-26
87278-TC
87279
87279-26
87279-TC
87280
87280-26
87280-TC
87281
87281-26
87281-TC
$22.00
$11.00
$3.00
$8.00
BR
BR
BR
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
BR
BR
BR
$26.00
$8.00
$18.00
BR
BR
BR
$26.00
$8.00
$18.00
$27.00
$9.00
$19.00
$26.00
$8.00
$18.00
$27.00
$9.00
$19.00
$26.00
$8.00
$18.00
$27.00
$9.00
$19.00
$26.00
$8.00
$18.00
$27.00
$9.00
$19.00
$26.00
$8.00
$18.00
$27.00
$9.00
$19.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
307
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87283
87283-26
87283-TC
87285
87285-26
87285-TC
87290
87290-26
87290-TC
87299
87299-26
87299-TC
87300
87300-26
87300-TC
87301
87301-26
87301-TC
87320
87320-26
87320-TC
87324
87324-26
87324-TC
87327
87327-26
87327-TC
87328
87328-26
87328-TC
87332
87332-26
87332-TC
87335
87335-26
87335-TC
87336
87336-26
87336-TC
87337
87337-26
87337-TC
87338
87338-26
87338-TC
87339
87339-26
87339-TC
87340
87340-26
87340-TC
87341
$27.00
$9.00
$19.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$13.00
$4.00
$9.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$27.00
$9.00
$19.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$27.00
$9.00
$19.00
$27.00
$9.00
$19.00
$27.00
$7.00
$20.00
$27.00
$9.00
$19.00
$20.00
$6.00
$14.00
$23.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
308
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87341-26
87341-TC
87350
87350-26
87350-TC
87380
87380-26
87380-TC
87385
87385-26
87385-TC
87390
87390-26
87390-TC
87391
87391-26
87391-TC
87400
87400-26
87400-TC
87420
87420-26
87420-TC
87425
87425-26
87425-TC
87427
87427-26
87427-TC
87430
87430-26
87430-TC
87449
87449-26
87449-TC
87450
87450-26
87450-TC
87451
87451-26
87451-TC
87470
87470-26
87470-TC
87471
87471-26
87471-TC
87472
87472-26
87472-TC
87475
87475-26
$8.00
$15.00
$20.00
$6.00
$14.00
$35.00
$11.00
$23.00
$26.00
$8.00
$18.00
$38.00
$13.00
$24.00
$38.00
$13.00
$24.00
$13.00
$4.00
$9.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$27.00
$9.00
$19.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$21.00
$6.00
$15.00
$19.00
$7.00
$12.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$40.00
$13.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
309
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87475-TC
87476
87476-26
87476-TC
87477
87477-26
87477-TC
87480
87480-26
87480-TC
87481
87481-26
87481-TC
87482
87482-26
87482-TC
87485
87485-26
87485-TC
87486
87486-26
87486-TC
87487
87487-26
87487-TC
87490
87490-26
87490-TC
87491
87491-26
87491-TC
87492
87492-26
87492-TC
87495
87495-26
87495-TC
87496
87496-26
87496-TC
87497
87497-26
87497-TC
87510
87510-26
87510-TC
87511
87511-26
87511-TC
87512
87512-26
87512-TC
$26.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$86.00
$28.00
$56.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$73.00
$23.00
$48.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$86.00
$28.00
$56.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
310
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87515
87515-26
87515-TC
87516
87516-26
87516-TC
87517
87517-26
87517-TC
87520
87520-26
87520-TC
87521
87521-26
87521-TC
87522
87522-26
87522-TC
87525
87525-26
87525-TC
87526
87526-26
87526-TC
87527
87527-26
87527-TC
87528
87528-26
87528-TC
87529
87529-26
87529-TC
87530
87530-26
87530-TC
87531
87531-26
87531-TC
87532
87532-26
87532-TC
87533
87533-26
87533-TC
87534
87534-26
87534-TC
87535
87535-26
87535-TC
87536
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$86.00
$28.00
$56.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$86.00
$28.00
$56.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$86.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
311
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87536-26
87536-TC
87537
87537-26
87537-TC
87538
87538-26
87538-TC
87539
87539-26
87539-TC
87540
87540-26
87540-TC
87541
87541-26
87541-TC
87542
87542-26
87542-TC
87550
87550-26
87550-TC
87551
87551-26
87551-TC
87552
87552-26
87552-TC
87555
87555-26
87555-TC
87556
87556-26
87556-TC
87557
87557-26
87557-TC
87560
87560-26
87560-TC
87561
87561-26
87561-TC
87562
87562-26
87562-TC
87580
87580-26
87580-TC
87581
87581-26
$28.00
$56.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$86.00
$28.00
$56.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
312
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87581-TC
87582
87582-26
87582-TC
87590
87590-26
87590-TC
87591
87591-26
87591-TC
87592
87592-26
87592-TC
87620
87620-26
87620-TC
87621
87621-26
87621-TC
87622
87622-26
87622-TC
87650
87650-26
87650-TC
87651
87651-26
87651-TC
87652
87652-26
87652-TC
87797
87797-26
87797-TC
87798
87798-26
87798-TC
87799
87799-26
87799-TC
87800
87800-26
87800-TC
87801
87801-26
87801-TC
87802
87802-26
87802-TC
87803
87803-26
87803-TC
$48.00
$86.00
$28.00
$56.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$86.00
$28.00
$56.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$86.00
$28.00
$56.00
$42.00
$13.00
$28.00
$73.00
$23.00
$48.00
$88.00
$28.00
$58.00
$46.00
$15.00
$31.00
$81.00
$26.00
$54.00
BR
BR
BR
BR
BR
BR
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
313
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
87804
87804-26
87804-TC
87810
87810-26
87810-TC
87850
87850-26
87850-TC
87880
87880-26
87880-TC
87899
87899-26
87899-TC
87901
87901-26
87901-TC
87902
87902-26
87902-TC
87903
87903-26
87903-TC
87904
87904-26
87904-TC
87999
87999-26
87999-TC
88000
88000-26
88000-TC
88005
88005-26
88005-TC
88007
88007-26
88007-TC
88020
88020-26
88020-TC
88025
88025-26
88025-TC
88027
88027-26
88027-TC
88036
88036-26
88036-TC
88037
BR
BR
BR
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$26.00
$8.00
$18.00
$594.00
$196.00
$398.00
BR
BR
BR
$1,126.00
$371.00
$755.00
$59.00
$20.00
$39.00
BR
BR
BR
$445.00
$445.00
BR
$500.00
$500.00
BR
$556.00
$556.00
BR
$556.00
$556.00
BR
$610.00
$610.00
BR
$666.00
$666.00
BR
$477.00
$477.00
BR
$389.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
314
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
88037-26
88037-TC
88040
88040-26
88040-TC
88045
88045-26
88045-TC
88099
88099-26
88099-TC
88104
88104-26
88104-TC
88106
88106-26
88106-TC
88107
88107-26
88107-TC
88108
88108-26
88108-TC
88125
88125-26
88125-TC
88130
88130-26
88130-TC
88140
88140-26
88140-TC
88141
88141-26
88141-TC
88142
88142-26
88142-TC
88143
88143-26
88143-TC
88147
88147-26
88147-TC
88148
88148-26
88148-TC
88150
88150-26
88150-TC
88152
88152-26
$389.00
BR
$1,445.00
$1,445.00
BR
BR
BR
BR
BR
BR
BR
$49.00
$37.00
$10.00
$54.00
$16.00
$38.00
$74.00
$57.00
$15.00
$59.00
$47.00
$11.00
$70.00
$20.00
$48.00
$25.00
$7.00
$18.00
$18.00
$5.00
$13.00
$33.00
NC
NC
$82.00
$21.00
$59.00
$94.00
$33.00
$59.00
$82.00
NC
$82.00
$104.00
$21.00
$82.00
$13.00
$3.00
$9.00
$46.00
$8.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
--------------------------------------------$54.00
$33.00
$22.00
$48.00
$33.00
$15.00
$71.00
$45.00
$26.00
$56.00
$33.00
$23.00
$23.00
$15.00
$7.00
------------------------$24.00
-----------------------------------------------------------------------------
--------------------------------------------$58.00
$34.00
$24.00
$51.00
$34.00
$17.00
$76.00
$47.00
$29.00
$60.00
$34.00
$25.00
$24.00
$16.00
$8.00
------------------------$26.00
-----------------------------------------------------------------------------
--------------------------------------------$61.00
$36.00
$25.00
$53.00
$36.00
$18.00
$79.00
$49.00
$30.00
$62.00
$36.00
$27.00
$25.00
$17.00
$9.00
------------------------$26.00
-----------------------------------------------------------------------------
--------------------------------------------$54.00
$33.00
$22.00
$48.00
$33.00
$15.00
$71.00
$45.00
$26.00
$56.00
$33.00
$23.00
$23.00
$15.00
$7.00
------------------------$24.00
-----------------------------------------------------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
--------------------------------------------$58.00
$34.00
$24.00
$51.00
$34.00
$17.00
$76.00
$47.00
$29.00
$60.00
$34.00
$25.00
$24.00
$16.00
$8.00
------------------------$26.00
-----------------------------------------------------------------------------
--------------------------------------------$61.00
$36.00
$25.00
$53.00
$36.00
$18.00
$79.00
$49.00
$30.00
$62.00
$36.00
$27.00
$25.00
$17.00
$9.00
------------------------$26.00
-----------------------------------------------------------------------------
315
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
88152-TC
88153
88153-26
88153-TC
88154
88154-26
88154-TC
88155
88155-26
88155-TC
88160
88160-26
88160-TC
88161
88161-26
88161-TC
88162
88162-26
88162-TC
88164
88164-26
88164-TC
88165
88165-26
88165-TC
88166
88166-26
88166-TC
88167
88167-26
88167-TC
88172
88172-26
88172-TC
88173
88173-26
88173-TC
88174
88174-26
88174-TC
88175
88175-26
88175-TC
88180
88180-26
88180-TC
88182
88182-26
88182-TC
88199
88199-26
88199-TC
$38.00
$82.00
$21.00
$59.00
$104.00
$21.00
$82.00
$14.00
$3.00
$10.00
$45.00
$14.00
$24.00
$64.00
$19.00
$37.00
$77.00
$22.00
$53.00
$54.00
$21.00
$33.00
$72.00
$33.00
$38.00
$82.00
$21.00
$59.00
$87.00
$26.00
$59.00
$70.00
$54.00
$14.00
$95.00
$95.00
$26.00
BR
BR
BR
BR
BR
BR
$88.00
$33.00
$54.00
$88.00
$33.00
$54.00
BR
BR
BR
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----------------------------------------$59.00
$29.00
$30.00
$57.00
$29.00
$28.00
$60.00
$45.00
$15.00
------------------------------------------------$52.00
$35.00
$17.00
$128.00
$81.00
$47.00
------------------------$62.00
$21.00
$41.00
$93.00
$45.00
$48.00
-------------
----------------------------------------$64.00
$31.00
$33.00
$62.00
$31.00
$31.00
$64.00
$47.00
$17.00
------------------------------------------------$56.00
$37.00
$19.00
$137.00
$85.00
$51.00
------------------------$66.00
$22.00
$44.00
$100.00
$48.00
$52.00
-------------
----------------------------------------$66.00
$32.00
$34.00
$64.00
$32.00
$32.00
$67.00
$49.00
$18.00
------------------------------------------------$58.00
$38.00
$20.00
$142.00
$89.00
$54.00
------------------------$69.00
$23.00
$46.00
$104.00
$50.00
$55.00
-------------
----------------------------------------$59.00
$29.00
$30.00
$57.00
$29.00
$28.00
$60.00
$45.00
$15.00
------------------------------------------------$52.00
$35.00
$17.00
$128.00
$81.00
$47.00
------------------------$62.00
$21.00
$41.00
$93.00
$45.00
$48.00
-------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----------------------------------------$64.00
$31.00
$33.00
$62.00
$31.00
$31.00
$64.00
$47.00
$17.00
------------------------------------------------$56.00
$37.00
$19.00
$137.00
$85.00
$51.00
------------------------$66.00
$22.00
$44.00
$100.00
$48.00
$52.00
-------------
----------------------------------------$66.00
$32.00
$34.00
$64.00
$32.00
$32.00
$67.00
$49.00
$18.00
------------------------------------------------$58.00
$38.00
$20.00
$142.00
$89.00
$54.00
------------------------$69.00
$23.00
$46.00
$104.00
$50.00
$55.00
-------------
316
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
88233
88233-26
88233-TC
88235
88235-26
88235-TC
88240
88240-26
88240-TC
88241
88241-26
88241-TC
88300
88300-26
88300-TC
88302
88302-26
88302-TC
88304
88304-26
88304-TC
88305
88305-26
88305-TC
88307
88307-26
88307-TC
88309
88309-26
88309-TC
88311
88311-26
88311-TC
88312
88312-26
88312-TC
88313
88313-26
88313-TC
88314
88314-26
88314-TC
88318
88318-26
88318-TC
88319
88319-26
88319-TC
88321
88321-26
88321-TC
88323
$243.00
$73.00
$170.00
$256.00
$76.00
$177.00
$21.00
$6.00
$15.00
$21.00
$6.00
$15.00
$24.00
$19.00
$5.00
$53.00
$42.00
$11.00
$70.00
$54.00
$14.00
$108.00
$86.00
$21.00
$210.00
$168.00
$41.00
$322.00
$258.00
$64.00
$23.00
$19.00
$4.00
$23.00
$7.00
$16.00
$23.00
$7.00
$16.00
$21.00
$6.00
$15.00
$33.00
$14.00
$18.00
$26.00
$13.00
$14.00
$43.00
$43.00
NC
$61.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
------------------------------------------------$16.00
$5.00
$10.00
$35.00
$8.00
$27.00
$45.00
$13.00
$32.00
$100.00
$44.00
$56.00
$172.00
$93.00
$79.00
$224.00
$133.00
$91.00
$18.00
$14.00
$4.00
$84.00
$32.00
$53.00
$56.00
$14.00
$42.00
$52.00
$26.00
$26.00
$46.00
$24.00
$22.00
$106.00
$31.00
$75.00
$85.00
--------$111.00
------------------------------------------------$17.00
$6.00
$11.00
$38.00
$8.00
$29.00
$48.00
$14.00
$34.00
$107.00
$46.00
$61.00
$184.00
$98.00
$87.00
$239.00
$140.00
$99.00
$19.00
$15.00
$4.00
$90.00
$33.00
$57.00
$60.00
$15.00
$45.00
$56.00
$28.00
$28.00
$49.00
$26.00
$23.00
$114.00
$33.00
$81.00
$90.00
--------$118.00
------------------------------------------------$18.00
$6.00
$12.00
$39.00
$9.00
$31.00
$50.00
$14.00
$36.00
$111.00
$47.00
$64.00
$192.00
$102.00
$91.00
$249.00
$145.00
$103.00
$20.00
$16.00
$5.00
$94.00
$34.00
$59.00
$63.00
$16.00
$47.00
$58.00
$29.00
$29.00
$51.00
$26.00
$24.00
$119.00
$34.00
$85.00
$93.00
--------$123.00
------------------------------------------------$16.00
$5.00
$10.00
$35.00
$8.00
$27.00
$45.00
$13.00
$32.00
$100.00
$44.00
$56.00
$172.00
$93.00
$79.00
$224.00
$133.00
$91.00
$18.00
$14.00
$4.00
$84.00
$32.00
$53.00
$56.00
$14.00
$42.00
$52.00
$26.00
$26.00
$46.00
$24.00
$22.00
$106.00
$31.00
$75.00
$76.00
--------$111.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
------------------------------------------------$17.00
$6.00
$11.00
$38.00
$8.00
$29.00
$48.00
$14.00
$34.00
$107.00
$46.00
$61.00
$184.00
$98.00
$87.00
$239.00
$140.00
$99.00
$19.00
$15.00
$4.00
$90.00
$33.00
$57.00
$60.00
$15.00
$45.00
$56.00
$28.00
$28.00
$49.00
$26.00
$23.00
$114.00
$33.00
$81.00
$79.00
--------$118.00
------------------------------------------------$18.00
$6.00
$12.00
$39.00
$9.00
$31.00
$50.00
$14.00
$36.00
$111.00
$47.00
$64.00
$192.00
$102.00
$91.00
$249.00
$145.00
$103.00
$20.00
$16.00
$5.00
$94.00
$34.00
$59.00
$63.00
$16.00
$47.00
$58.00
$29.00
$29.00
$51.00
$26.00
$24.00
$119.00
$34.00
$85.00
$82.00
--------$123.00
317
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
88323-26
88323-TC
88325
88325-26
88325-TC
88329
88329-26
88329-TC
88331
88331-26
88331-TC
88332
88332-26
88332-TC
88342
88342-26
88342-TC
88346
88346-26
88346-TC
88347
88347-26
88347-TC
88348
88348-26
88348-TC
88349
88349-26
88349-TC
88355
88355-26
88355-TC
88356
88356-26
88356-TC
88358
88358-26
88358-TC
88362
88362-26
88362-TC
88365
88365-26
88365-TC
88371
88371-26
88371-TC
88372
88372-26
88372-TC
88380
88380-26
$61.00
NC
$54.00
$54.00
NC
$51.00
$51.00
NC
$102.00
$70.00
$33.00
$53.00
$36.00
$17.00
$53.00
$36.00
$17.00
$96.00
$66.00
$28.00
$133.00
$99.00
$33.00
$191.00
$145.00
$44.00
$191.00
$145.00
$44.00
$108.00
$80.00
$26.00
$108.00
$80.00
$26.00
$108.00
$80.00
$26.00
BR
BR
BR
$24.00
$24.00
BR
$34.00
$10.00
$23.00
$38.00
$11.00
$26.00
BR
BR
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$79.00
$32.00
$204.00
--------$53.00
--------$90.00
$70.00
$20.00
$45.00
$35.00
$11.00
$86.00
$50.00
$37.00
$92.00
$50.00
$42.00
$108.00
$49.00
$58.00
$375.00
$88.00
$287.00
$393.00
$45.00
$349.00
$177.00
$108.00
$68.00
$236.00
$174.00
$62.00
$185.00
$164.00
$21.00
$266.00
$126.00
$140.00
$117.00
$54.00
$63.00
----$20.00
--------$22.00
-------------
$83.00
$35.00
$216.00
--------$56.00
--------$96.00
$73.00
$22.00
$48.00
$36.00
$12.00
$92.00
$52.00
$40.00
$99.00
$53.00
$46.00
$115.00
$52.00
$63.00
$402.00
$92.00
$310.00
$423.00
$47.00
$376.00
$189.00
$114.00
$75.00
$250.00
$183.00
$68.00
$197.00
$173.00
$24.00
$284.00
$132.00
$152.00
$125.00
$57.00
$68.00
----$21.00
--------$23.00
-------------
$87.00
$37.00
$224.00
--------$58.00
--------$100.00
$76.00
$24.00
$50.00
$38.00
$13.00
$96.00
$54.00
$42.00
$103.00
$55.00
$48.00
$120.00
$54.00
$66.00
$418.00
$96.00
$322.00
$439.00
$49.00
$390.00
$197.00
$118.00
$78.00
$261.00
$190.00
$71.00
$205.00
$179.00
$26.00
$295.00
$137.00
$158.00
$130.00
$59.00
$71.00
----$22.00
--------$23.00
-------------
$79.00
$32.00
$130.00
--------$39.00
--------$90.00
$70.00
$20.00
$45.00
$35.00
$11.00
$86.00
$50.00
$37.00
$92.00
$50.00
$42.00
$108.00
$49.00
$58.00
$375.00
$88.00
$287.00
$393.00
$45.00
$349.00
$177.00
$108.00
$68.00
$236.00
$174.00
$62.00
$185.00
$164.00
$21.00
$266.00
$126.00
$140.00
$117.00
$54.00
$63.00
----$20.00
--------$22.00
-------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$83.00
$35.00
$136.00
--------$41.00
--------$96.00
$73.00
$22.00
$48.00
$36.00
$12.00
$92.00
$52.00
$40.00
$99.00
$53.00
$46.00
$115.00
$52.00
$63.00
$402.00
$92.00
$310.00
$423.00
$47.00
$376.00
$189.00
$114.00
$75.00
$250.00
$183.00
$68.00
$197.00
$173.00
$24.00
$284.00
$132.00
$152.00
$125.00
$57.00
$68.00
----$21.00
--------$23.00
-------------
$87.00
$37.00
$142.00
--------$42.00
--------$100.00
$76.00
$24.00
$50.00
$38.00
$13.00
$96.00
$54.00
$42.00
$103.00
$55.00
$48.00
$120.00
$54.00
$66.00
$418.00
$96.00
$322.00
$439.00
$49.00
$390.00
$197.00
$118.00
$78.00
$261.00
$190.00
$71.00
$205.00
$179.00
$26.00
$295.00
$137.00
$158.00
$130.00
$59.00
$71.00
----$22.00
--------$23.00
-------------
318
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
88380-TC
88399
88399-26
88399-TC
88400
88400-26
88400-TC
89050
89050-26
89050-TC
89051
89051-26
89051-TC
89055
89055-26
89055-TC
89060
89060-26
89060-TC
89100
89100-26
89100-TC
89105
89105-26
89105-TC
89125
89125-26
89125-TC
89130
89130-26
89130-TC
89132
89132-26
89132-TC
89135
89135-26
89135-TC
89136
89136-26
89136-TC
89140
89140-26
89140-TC
89141
89141-26
89141-TC
89160
89160-26
89160-TC
89190
89190-26
89190-TC
BR
BR
BR
BR
$5.00
$2.00
$3.00
$10.00
$3.00
$6.00
$13.00
$4.00
$8.00
BR
BR
BR
$13.00
$5.00
$8.00
$51.00
$15.00
$36.00
$65.00
$19.00
$44.00
$14.00
$4.00
$10.00
$44.00
$13.00
$32.00
$20.00
$6.00
$14.00
$37.00
$11.00
$25.00
$43.00
$14.00
$29.00
$50.00
$16.00
$34.00
$56.00
$19.00
$37.00
$6.00
$2.00
$4.00
$10.00
$3.00
$6.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
--------------------------------------------------------------------$22.00
----$91.00
--------$108.00
--------------------$94.00
--------$75.00
--------$100.00
--------$77.00
--------$124.00
--------$142.00
---------------------------------
--------------------------------------------------------------------$23.00
----$97.00
--------$116.00
--------------------$101.00
--------$81.00
--------$106.00
--------$82.00
--------$132.00
--------$152.00
---------------------------------
--------------------------------------------------------------------$23.00
----$100.00
--------$120.00
--------------------$104.00
--------$84.00
--------$110.00
--------$85.00
--------$136.00
--------$157.00
---------------------------------
--------------------------------------------------------------------$22.00
----$33.00
--------$28.00
--------------------$24.00
--------$11.00
--------$43.00
--------$12.00
--------$49.00
--------$48.00
---------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
--------------------------------------------------------------------$23.00
----$35.00
--------$29.00
--------------------$25.00
--------$11.00
--------$45.00
--------$13.00
--------$52.00
--------$51.00
---------------------------------
--------------------------------------------------------------------$23.00
----$36.00
--------$30.00
--------------------$26.00
--------$12.00
--------$47.00
--------$13.00
--------$54.00
--------$53.00
---------------------------------
319
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Pathology
CPT Code
2003 MRA
89350
89350-26
89350-TC
89355
89355-26
89355-TC
89360
89360-26
89360-TC
89365
89365-26
89365-TC
89399
89399-26
89399-TC
$18.00
$6.00
$12.00
$10.00
$3.00
$6.00
$15.00
$4.00
$11.00
$24.00
$7.00
$17.00
BR
BR
BR
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$17.00
--------------------$18.00
---------------------------------
$18.00
--------------------$20.00
---------------------------------
$20.00
--------------------$21.00
---------------------------------
$17.00
--------------------$18.00
---------------------------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$18.00
--------------------$20.00
---------------------------------
$20.00
--------------------$21.00
---------------------------------
320
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
90471
90472
90473
90474
90632
90636
90675
90703
90718
90746
90749
90780
90781
90782
90783
90784
90788
90799
90801
90802
90804
90805
90806
90807
90808
90809
90810
90811
90812
90813
90814
90815
90816
90817
90818
90819
90821
90822
90823
90824
90826
90827
90828
90829
90845
90846
90847
90849
90853
90857
90862
90865
2003 MRA
$4.00
$4.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
$42.00
$20.00
$5.00
$15.00
$20.00
$6.00
BR
$140.00
$143.00
$62.00
$68.00
$94.00
$101.00
$144.00
$149.00
$69.00
$77.00
$101.00
$107.00
$143.00
$149.00
$64.00
$70.00
$96.00
$102.00
$144.00
$149.00
$73.00
$78.00
$103.00
$107.00
$146.00
$150.00
$85.00
$93.00
$110.00
$32.00
$32.00
$31.00
$50.00
$143.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$8.00
$6.00
------------------------------------$45.00
$23.00
$5.00
$17.00
$20.00
$5.00
----$159.00
$169.00
$69.00
$75.00
$103.00
$110.00
$154.00
$159.00
$74.00
$83.00
$112.00
$117.00
$161.00
$166.00
$69.00
$75.00
$104.00
$109.00
$154.00
$159.00
$74.00
$81.00
$110.00
$115.00
$161.00
$165.00
$96.00
$100.00
$122.00
$35.00
$34.00
$38.00
$54.00
$178.00
$9.00
$7.00
------------------------------------$50.00
$25.00
$5.00
$18.00
$22.00
$6.00
----$166.00
$177.00
$72.00
$79.00
$108.00
$115.00
$161.00
$166.00
$77.00
$86.00
$117.00
$122.00
$169.00
$173.00
$72.00
$78.00
$108.00
$114.00
$161.00
$166.00
$77.00
$85.00
$115.00
$120.00
$169.00
$172.00
$100.00
$104.00
$127.00
$36.00
$35.00
$40.00
$57.00
$187.00
$10.00
$7.00
------------------------------------$53.00
$27.00
$6.00
$20.00
$23.00
$6.00
----$172.00
$183.00
$74.00
$81.00
$111.00
$119.00
$166.00
$172.00
$80.00
$89.00
$121.00
$126.00
$174.00
$179.00
$75.00
$81.00
$112.00
$118.00
$166.00
$171.00
$80.00
$87.00
$119.00
$124.00
$174.00
$177.00
$103.00
$108.00
$132.00
$37.00
$36.00
$41.00
$59.00
$193.00
$8.00
$6.00
------------------------------------$45.00
$23.00
$5.00
$17.00
$20.00
$5.00
----$150.00
$161.00
$64.00
$72.00
$99.00
$107.00
$149.00
$156.00
$70.00
$78.00
$106.00
$113.00
$157.00
$162.00
$69.00
$75.00
$104.00
$109.00
$154.00
$159.00
$74.00
$81.00
$110.00
$115.00
$161.00
$165.00
$94.00
$100.00
$120.00
$33.00
$33.00
$36.00
$51.00
$150.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$9.00
$7.00
------------------------------------$50.00
$25.00
$5.00
$18.00
$22.00
$6.00
----$157.00
$168.00
$67.00
$76.00
$104.00
$112.00
$156.00
$163.00
$73.00
$82.00
$110.00
$118.00
$164.00
$169.00
$72.00
$78.00
$108.00
$114.00
$161.00
$166.00
$77.00
$85.00
$115.00
$120.00
$169.00
$172.00
$99.00
$104.00
$125.00
$35.00
$34.00
$38.00
$53.00
$157.00
$10.00
$7.00
------------------------------------$53.00
$27.00
$6.00
$20.00
$23.00
$6.00
----$162.00
$174.00
$69.00
$78.00
$107.00
$116.00
$161.00
$169.00
$76.00
$84.00
$114.00
$122.00
$169.00
$175.00
$75.00
$81.00
$112.00
$118.00
$166.00
$171.00
$80.00
$87.00
$119.00
$124.00
$174.00
$177.00
$102.00
$107.00
$129.00
$36.00
$35.00
$39.00
$55.00
$163.00
321
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
90870
90871
90875
90876
90880
90882
90885
90887
90889
90899
90901
90911
90921
90925
90935
90937
90939
90940
90945
90947
90997
90999
91000
91000-26
91000-TC
91010
91010-26
91010-TC
91011
91011-26
91011-TC
91012
91012-26
91012-TC
91020
91020-26
91020-TC
91030
91030-26
91030-TC
91032
91032-26
91032-TC
91033
91033-26
91033-TC
91052
91052-26
91052-TC
91055
91055-26
91055-TC
$94.00
$135.00
$74.00
$112.00
$112.00
$104.00
$49.00
$77.00
BR
BR
$46.00
$82.00
$259.00
$8.00
$76.00
$226.00
BR
BR
$80.00
$125.00
$115.00
BR
$43.00
$40.00
$2.00
$116.00
$76.00
$32.00
$141.00
$89.00
$39.00
$143.00
$95.00
$45.00
$60.00
$49.00
$9.00
$57.00
$47.00
$8.00
$108.00
$71.00
$30.00
$141.00
$82.00
$53.00
$67.00
$52.00
$12.00
$63.00
$46.00
$11.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$107.00
------------$130.00
--------------------$50.00
$71.00
----$9.00
$76.00
$125.00
--------$80.00
$127.00
$130.00
----$43.00
$40.00
$4.00
$160.00
$69.00
$91.00
$186.00
$82.00
$104.00
$190.00
$81.00
$109.00
$179.00
$79.00
$100.00
$137.00
$50.00
$87.00
$146.00
$67.00
$79.00
$160.00
$72.00
$88.00
$125.00
$43.00
$81.00
$123.00
$49.00
$74.00
$112.00
------------$136.00
--------------------$53.00
$75.00
----$10.00
$80.00
$131.00
--------$84.00
$134.00
$137.00
----$46.00
$42.00
$4.00
$171.00
$73.00
$99.00
$199.00
$86.00
$113.00
$204.00
$85.00
$119.00
$192.00
$83.00
$109.00
$146.00
$53.00
$94.00
$156.00
$70.00
$86.00
$172.00
$76.00
$96.00
$134.00
$46.00
$88.00
$132.00
$52.00
$80.00
$116.00
------------$140.00
--------------------$55.00
$78.00
----$11.00
$83.00
$135.00
--------$87.00
$138.00
$142.00
----$48.00
$44.00
$4.00
$179.00
$76.00
$103.00
$207.00
$90.00
$117.00
$213.00
$89.00
$124.00
$200.00
$87.00
$114.00
$152.00
$54.00
$97.00
$163.00
$73.00
$90.00
$180.00
$79.00
$102.00
$139.00
$47.00
$91.00
$137.00
$54.00
$83.00
$107.00
------------$116.00
--------------------$24.00
$51.00
----$9.00
$76.00
$125.00
--------$80.00
$127.00
$130.00
----$43.00
$40.00
$4.00
$160.00
$69.00
$91.00
$186.00
$82.00
$104.00
$190.00
$81.00
$109.00
$179.00
$79.00
$100.00
$137.00
$50.00
$87.00
$146.00
$67.00
$79.00
$160.00
$72.00
$88.00
$125.00
$43.00
$81.00
$123.00
$49.00
$74.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$112.00
------------$121.00
--------------------$26.00
$54.00
----$10.00
$80.00
$131.00
--------$84.00
$134.00
$137.00
----$46.00
$42.00
$4.00
$171.00
$73.00
$99.00
$199.00
$86.00
$113.00
$204.00
$85.00
$119.00
$192.00
$83.00
$109.00
$146.00
$53.00
$94.00
$156.00
$70.00
$86.00
$172.00
$76.00
$96.00
$134.00
$46.00
$88.00
$132.00
$52.00
$80.00
$116.00
------------$125.00
--------------------$27.00
$56.00
----$11.00
$83.00
$135.00
--------$87.00
$138.00
$142.00
----$48.00
$44.00
$4.00
$179.00
$76.00
$103.00
$207.00
$90.00
$117.00
$213.00
$89.00
$124.00
$200.00
$87.00
$114.00
$152.00
$54.00
$97.00
$163.00
$73.00
$90.00
$180.00
$79.00
$102.00
$139.00
$47.00
$91.00
$137.00
$54.00
$83.00
322
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
91060
91060-26
91060-TC
91065
91065-26
91065-TC
91100
91105
91122
91122-26
91122-TC
91123
91132
91132-26
91132-TC
91133
91133-26
91133-TC
91299
91299-26
91299-TC
92002
92004
92012
92014
92015
92018
92019
92020
92060
92060-26
92060-TC
92065
92065-26
92065-TC
92070
92081
92081-26
92081-TC
92082
92082-26
92082-TC
92083
92083-26
92083-TC
92100
92120
92130
92135
92135-26
92135-TC
92136
$35.00
$27.00
$8.00
$34.00
$23.00
$14.00
$57.00
$35.00
$169.00
$122.00
$37.00
BR
BR
$28.00
BR
BR
$34.00
BR
BR
BR
BR
$63.00
$98.00
$53.00
$75.00
$34.00
$80.00
$70.00
$31.00
$40.00
$32.00
$7.00
$34.00
$19.00
$6.00
$66.00
$32.00
$19.00
$6.00
$48.00
$24.00
$9.00
$59.00
$31.00
$14.00
$40.00
$32.00
$56.00
$69.00
$18.00
$49.00
$93.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$31.00
$24.00
$7.00
$158.00
$11.00
$147.00
$57.00
$19.00
$253.00
$99.00
$154.00
--------$29.00
--------$37.00
----------------$72.00
$131.00
$65.00
$97.00
----$142.00
$75.00
$50.00
$57.00
$39.00
$17.00
$37.00
$21.00
$16.00
$68.00
$49.00
$21.00
$28.00
$59.00
$25.00
$34.00
$73.00
$29.00
$44.00
$65.00
$64.00
$68.00
$65.00
$20.00
$45.00
$97.00
$34.00
$25.00
$8.00
$170.00
$12.00
$158.00
$60.00
$21.00
$272.00
$104.00
$167.00
--------$31.00
--------$39.00
----------------$76.00
$138.00
$69.00
$102.00
----$148.00
$79.00
$54.00
$60.00
$41.00
$19.00
$40.00
$22.00
$17.00
$72.00
$53.00
$22.00
$31.00
$63.00
$26.00
$37.00
$78.00
$30.00
$48.00
$69.00
$67.00
$72.00
$70.00
$21.00
$49.00
$105.00
$35.00
$26.00
$9.00
$176.00
$12.00
$164.00
$63.00
$21.00
$284.00
$109.00
$174.00
--------$33.00
--------$40.00
----------------$78.00
$142.00
$71.00
$106.00
----$153.00
$82.00
$55.00
$62.00
$42.00
$20.00
$41.00
$23.00
$18.00
$74.00
$55.00
$23.00
$32.00
$65.00
$27.00
$38.00
$81.00
$31.00
$50.00
$71.00
$69.00
$74.00
$73.00
$22.00
$50.00
$109.00
$31.00
$24.00
$7.00
$158.00
$11.00
$147.00
$57.00
$19.00
$253.00
$99.00
$154.00
--------$29.00
--------$37.00
----------------$49.00
$94.00
$38.00
$63.00
----$142.00
$75.00
$21.00
$57.00
$39.00
$17.00
$37.00
$21.00
$16.00
$41.00
$49.00
$21.00
$28.00
$59.00
$25.00
$34.00
$73.00
$29.00
$44.00
$52.00
$46.00
$48.00
$65.00
$20.00
$45.00
$97.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$34.00
$25.00
$8.00
$170.00
$12.00
$158.00
$60.00
$21.00
$272.00
$104.00
$167.00
--------$31.00
--------$39.00
----------------$51.00
$98.00
$40.00
$66.00
----$148.00
$79.00
$22.00
$60.00
$41.00
$19.00
$40.00
$22.00
$17.00
$43.00
$53.00
$22.00
$31.00
$63.00
$26.00
$37.00
$78.00
$30.00
$48.00
$54.00
$48.00
$50.00
$70.00
$21.00
$49.00
$105.00
$35.00
$26.00
$9.00
$176.00
$12.00
$164.00
$63.00
$21.00
$284.00
$109.00
$174.00
--------$33.00
--------$40.00
----------------$53.00
$101.00
$41.00
$68.00
----$153.00
$82.00
$23.00
$62.00
$42.00
$20.00
$41.00
$23.00
$18.00
$44.00
$55.00
$23.00
$32.00
$65.00
$27.00
$38.00
$81.00
$31.00
$50.00
$56.00
$49.00
$51.00
$73.00
$22.00
$50.00
$109.00
323
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
92136-26
92136-TC
92140
92225
92226
92230
92235
92235-26
92235-TC
92240
92240-26
92240-TC
92250
92250-26
92250-TC
92260
92265
92265-26
92265-TC
92270
92270-26
92270-TC
92275
92275-26
92275-TC
92283
92283-26
92283-TC
92284
92284-26
92284-TC
92285
92285-26
92285-TC
92286
92286-26
92286-TC
92287
92310
92311
92312
92313
92314
92315
92316
92317
92325
92326
92330
92335
92340
92341
$29.00
$63.00
$38.00
$45.00
$39.00
$58.00
$104.00
$46.00
$53.00
$132.00
$60.00
$67.00
$40.00
$24.00
$7.00
$20.00
$53.00
$37.00
$10.00
$64.00
$45.00
$19.00
$80.00
$56.00
$17.00
$24.00
$10.00
$5.00
$192.00
$151.00
$46.00
$26.00
$12.00
$6.00
$91.00
$53.00
$29.00
$99.00
$86.00
$78.00
$89.00
$70.00
$54.00
$44.00
$59.00
$39.00
$14.00
$44.00
$79.00
$65.00
$32.00
$43.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$31.00
$65.00
$58.00
$24.00
$22.00
$89.00
$139.00
$48.00
$91.00
$242.00
$64.00
$178.00
$78.00
$26.00
$52.00
$18.00
$106.00
$44.00
$62.00
$102.00
$47.00
$55.00
$118.00
$58.00
$60.00
$41.00
$10.00
$31.00
$98.00
$13.00
$84.00
$41.00
$12.00
$30.00
$137.00
$38.00
$99.00
$136.00
----$88.00
$95.00
$80.00
----$53.00
$64.00
$56.00
$16.00
$65.00
$84.00
$55.00
---------
$33.00
$72.00
$62.00
$25.00
$23.00
$95.00
$149.00
$50.00
$99.00
$259.00
$67.00
$192.00
$83.00
$27.00
$56.00
$19.00
$114.00
$46.00
$67.00
$109.00
$49.00
$60.00
$125.00
$60.00
$65.00
$44.00
$10.00
$33.00
$105.00
$14.00
$91.00
$45.00
$13.00
$32.00
$147.00
$40.00
$107.00
$145.00
----$93.00
$100.00
$84.00
----$56.00
$68.00
$60.00
$17.00
$71.00
$89.00
$58.00
---------
$34.00
$76.00
$64.00
$26.00
$24.00
$99.00
$155.00
$51.00
$103.00
$269.00
$69.00
$200.00
$86.00
$28.00
$58.00
$19.00
$118.00
$48.00
$70.00
$113.00
$51.00
$62.00
$130.00
$62.00
$68.00
$46.00
$11.00
$35.00
$109.00
$15.00
$94.00
$46.00
$13.00
$33.00
$152.00
$41.00
$111.00
$150.00
----$96.00
$103.00
$87.00
----$58.00
$70.00
$62.00
$18.00
$74.00
$92.00
$60.00
---------
$31.00
$65.00
$29.00
$22.00
$19.00
$32.00
$139.00
$48.00
$91.00
$242.00
$64.00
$178.00
$78.00
$26.00
$52.00
$12.00
$106.00
$44.00
$62.00
$102.00
$47.00
$55.00
$118.00
$58.00
$60.00
$41.00
$10.00
$31.00
$98.00
$13.00
$84.00
$41.00
$12.00
$30.00
$137.00
$38.00
$99.00
$45.00
----$58.00
$71.00
$48.00
----$25.00
$39.00
$24.00
$16.00
$65.00
$57.00
$25.00
---------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$33.00
$72.00
$30.00
$23.00
$20.00
$34.00
$149.00
$50.00
$99.00
$259.00
$67.00
$192.00
$83.00
$27.00
$56.00
$13.00
$114.00
$46.00
$67.00
$109.00
$49.00
$60.00
$125.00
$60.00
$65.00
$44.00
$10.00
$33.00
$105.00
$14.00
$91.00
$45.00
$13.00
$32.00
$147.00
$40.00
$107.00
$47.00
----$61.00
$74.00
$51.00
----$26.00
$41.00
$25.00
$17.00
$71.00
$60.00
$26.00
---------
$34.00
$76.00
$31.00
$23.00
$21.00
$35.00
$155.00
$51.00
$103.00
$269.00
$69.00
$200.00
$86.00
$28.00
$58.00
$13.00
$118.00
$48.00
$70.00
$113.00
$51.00
$62.00
$130.00
$62.00
$68.00
$46.00
$11.00
$35.00
$109.00
$15.00
$94.00
$46.00
$13.00
$33.00
$152.00
$41.00
$111.00
$49.00
----$63.00
$77.00
$52.00
----$27.00
$42.00
$25.00
$18.00
$74.00
$62.00
$27.00
---------
324
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
92342
92352
92353
92354
92355
92358
92370
92371
92390
92391
92392
92393
92395
92396
92499
92499-26
92499-TC
92502
92504
92506
92507
92508
92510
92511
92512
92516
92520
92526
92531
92532
92533
92534
92541
92541-26
92541-TC
92542
92542-26
92542-TC
92543
92543-26
92543-TC
92544
92544-26
92544-TC
92545
92545-26
92545-TC
92546
92546-26
92546-TC
92547
92548
$43.00
$31.00
$38.00
$221.00
$107.00
$24.00
$35.00
$18.00
$61.00
$83.00
$84.00
$264.00
$35.00
$52.00
BR
BR
BR
$101.00
$24.00
$63.00
$40.00
$42.00
$114.00
$81.00
$46.00
$36.00
$47.00
$48.00
$10.00
$14.00
$41.00
BR
$37.00
$25.00
$9.00
$33.00
$20.00
$10.00
$28.00
$19.00
$10.00
$26.00
$16.00
$8.00
$22.00
$14.00
$8.00
$29.00
$17.00
$9.00
$21.00
$92.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
--------------------------------------------------------------------$110.00
$27.00
$98.00
$81.00
$66.00
----$88.00
$65.00
$55.00
$53.00
$85.00
----------------$60.00
$24.00
$36.00
$60.00
$20.00
$41.00
$29.00
$6.00
$23.00
$49.00
$16.00
$33.00
$45.00
$14.00
$31.00
$99.00
$17.00
$82.00
$54.00
$179.00
--------------------------------------------------------------------$116.00
$29.00
$105.00
$87.00
$71.00
----$93.00
$69.00
$59.00
$56.00
$90.00
----------------$65.00
$26.00
$39.00
$65.00
$21.00
$44.00
$32.00
$7.00
$25.00
$53.00
$17.00
$36.00
$49.00
$15.00
$34.00
$107.00
$18.00
$88.00
$59.00
$194.00
--------------------------------------------------------------------$121.00
$30.00
$109.00
$90.00
$73.00
----$96.00
$71.00
$61.00
$58.00
$94.00
----------------$68.00
$27.00
$41.00
$68.00
$21.00
$46.00
$33.00
$7.00
$26.00
$55.00
$17.00
$38.00
$51.00
$15.00
$36.00
$111.00
$19.00
$92.00
$62.00
$203.00
--------------------------------------------------------------------$110.00
$11.00
$52.00
$31.00
$15.00
----$51.00
$30.00
$26.00
$47.00
$31.00
----------------$60.00
$24.00
$36.00
$60.00
$20.00
$41.00
$29.00
$6.00
$23.00
$49.00
$16.00
$33.00
$45.00
$14.00
$31.00
$99.00
$17.00
$82.00
$54.00
$179.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
--------------------------------------------------------------------$116.00
$12.00
$55.00
$32.00
$16.00
----$53.00
$31.00
$28.00
$49.00
$32.00
----------------$65.00
$26.00
$39.00
$65.00
$21.00
$44.00
$32.00
$7.00
$25.00
$53.00
$17.00
$36.00
$49.00
$15.00
$34.00
$107.00
$18.00
$88.00
$59.00
$194.00
--------------------------------------------------------------------$121.00
$12.00
$57.00
$34.00
$17.00
----$55.00
$32.00
$29.00
$51.00
$34.00
----------------$68.00
$27.00
$41.00
$68.00
$21.00
$46.00
$33.00
$7.00
$26.00
$55.00
$17.00
$38.00
$51.00
$15.00
$36.00
$111.00
$19.00
$92.00
$62.00
$203.00
325
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
92548-26
92548-TC
92551
92552
92553
92555
92556
92557
92560
92561
92562
92563
92564
92565
92567
92568
92569
92571
92572
92573
92575
92576
92577
92579
92582
92583
92584
92585
92585-26
92585-TC
92586
92587
92587-26
92587-TC
92588
92588-26
92588-TC
92589
92590
92591
92592
92593
92594
92595
92596
92597
92603
92604
92605
92606
92607
92608
$30.00
$59.00
$17.00
$16.00
$24.00
$14.00
$21.00
$46.00
$23.00
$27.00
$15.00
$14.00
$17.00
$15.00
$20.00
$14.00
$15.00
$14.00
$3.00
$13.00
$11.00
$17.00
$28.00
$28.00
$28.00
$34.00
$94.00
$114.00
$52.00
$70.00
$70.00
$58.00
$8.00
$49.00
$78.00
$20.00
$57.00
$54.00
$41.00
BR
BR
BR
BR
BR
$22.00
$96.00
$88.00
$60.00
BR
BR
$109.00
$22.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$31.00
$148.00
----$19.00
$28.00
$16.00
$24.00
$50.00
----$30.00
$17.00
$16.00
$20.00
$17.00
$22.00
$16.00
$17.00
$16.00
$4.00
$15.00
$13.00
$19.00
$31.00
$31.00
$31.00
$38.00
$103.00
$106.00
$29.00
$77.00
$77.00
$63.00
$8.00
$54.00
$83.00
$21.00
$62.00
$23.00
------------------------$25.00
$98.00
$93.00
$64.00
--------$114.00
$23.00
$33.00
$161.00
----$21.00
$31.00
$18.00
$27.00
$56.00
----$33.00
$19.00
$18.00
$22.00
$19.00
$25.00
$18.00
$19.00
$18.00
$4.00
$17.00
$14.00
$22.00
$34.00
$34.00
$34.00
$42.00
$115.00
$116.00
$31.00
$85.00
$85.00
$69.00
$9.00
$60.00
$91.00
$22.00
$68.00
$26.00
------------------------$28.00
$105.00
$101.00
$70.00
--------$124.00
$26.00
$34.00
$169.00
----$22.00
$33.00
$19.00
$29.00
$60.00
----$36.00
$21.00
$19.00
$24.00
$20.00
$27.00
$19.00
$21.00
$20.00
$5.00
$18.00
$15.00
$23.00
$37.00
$36.00
$36.00
$45.00
$123.00
$123.00
$32.00
$91.00
$91.00
$74.00
$9.00
$65.00
$96.00
$23.00
$73.00
$28.00
------------------------$30.00
$109.00
$106.00
$73.00
--------$129.00
$28.00
$31.00
$148.00
----$19.00
$28.00
$16.00
$24.00
$50.00
----$30.00
$17.00
$16.00
$20.00
$17.00
$22.00
$16.00
$17.00
$16.00
$4.00
$15.00
$13.00
$19.00
$31.00
$31.00
$31.00
$38.00
$103.00
$106.00
$29.00
$77.00
$77.00
$63.00
$8.00
$54.00
$83.00
$21.00
$62.00
$23.00
------------------------$25.00
$52.00
$93.00
$64.00
--------$114.00
$23.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$33.00
$161.00
----$21.00
$31.00
$18.00
$27.00
$56.00
----$33.00
$19.00
$18.00
$22.00
$19.00
$25.00
$18.00
$19.00
$18.00
$4.00
$17.00
$14.00
$22.00
$34.00
$34.00
$34.00
$42.00
$115.00
$116.00
$31.00
$85.00
$85.00
$69.00
$9.00
$60.00
$91.00
$22.00
$68.00
$26.00
------------------------$28.00
$55.00
$101.00
$70.00
--------$124.00
$26.00
$34.00
$169.00
----$22.00
$33.00
$19.00
$29.00
$60.00
----$36.00
$21.00
$19.00
$24.00
$20.00
$27.00
$19.00
$21.00
$20.00
$5.00
$18.00
$15.00
$23.00
$37.00
$36.00
$36.00
$45.00
$123.00
$123.00
$32.00
$91.00
$91.00
$74.00
$9.00
$65.00
$96.00
$23.00
$73.00
$28.00
------------------------$30.00
$57.00
$106.00
$73.00
--------$129.00
$28.00
326
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
92609
92610
92611
92612
92613
92614
92615
92616
92617
92700
92950
92953
92960
92961
92970
92971
92973
92974
92975
92977
92978
92978-26
92978-TC
92979
92979-26
92979-TC
92980
92981
92982
92984
92986
92987
92990
92992
92993
92995
92996
92997
92998
93000
93005
93010
93012
93014
93015
93016
93017
93018
93024
93024-26
93024-TC
93025
$59.00
$42.00
$46.00
$173.00
BR
$134.00
BR
$183.00
BR
BR
$203.00
$35.00
$162.00
$239.00
$201.00
$100.00
$174.00
$197.00
$400.00
$302.00
$269.00
$95.00
$170.00
$163.00
$76.00
$86.00
$952.00
$268.00
$705.00
$191.00
$1,222.00
$1,271.00
$974.00
BR
BR
$776.00
$210.00
$765.00
$331.00
$26.00
$16.00
$12.00
$90.00
$28.00
$104.00
$25.00
$63.00
$54.00
$111.00
$71.00
$42.00
$277.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$62.00
$45.00
$49.00
$182.00
----$141.00
----$193.00
--------$199.00
$18.00
$180.00
$258.00
$189.00
$107.00
$186.00
$171.00
$408.00
$326.00
$286.00
$102.00
$184.00
$174.00
$81.00
$93.00
$860.00
$239.00
$638.00
$170.00
$1,312.00
$1,364.00
$1,046.00
--------$702.00
$187.00
$696.00
$339.00
$28.00
$18.00
$10.00
$237.00
$29.00
$111.00
$25.00
$69.00
$17.00
$112.00
$66.00
$46.00
$446.00
$67.00
$50.00
$54.00
$195.00
----$151.00
----$205.00
--------$211.00
$20.00
$191.00
$271.00
$199.00
$112.00
$196.00
$181.00
$428.00
$359.00
$310.00
$107.00
$203.00
$187.00
$85.00
$102.00
$908.00
$252.00
$674.00
$179.00
$1,388.00
$1,444.00
$1,107.00
--------$741.00
$197.00
$736.00
$358.00
$30.00
$20.00
$10.00
$258.00
$30.00
$120.00
$26.00
$76.00
$18.00
$120.00
$69.00
$51.00
$481.00
$70.00
$53.00
$57.00
$202.00
----$157.00
----$213.00
--------$221.00
$20.00
$198.00
$282.00
$208.00
$116.00
$203.00
$189.00
$443.00
$380.00
$325.00
$111.00
$214.00
$196.00
$88.00
$108.00
$946.00
$263.00
$703.00
$187.00
$1,449.00
$1,507.00
$1,155.00
--------$773.00
$206.00
$768.00
$374.00
$32.00
$21.00
$11.00
$270.00
$31.00
$126.00
$27.00
$80.00
$18.00
$126.00
$72.00
$54.00
$499.00
$62.00
$45.00
$49.00
$73.00
----$73.00
----$106.00
--------$199.00
$18.00
$126.00
$258.00
$189.00
$107.00
$186.00
$171.00
$408.00
$326.00
$286.00
$102.00
$184.00
$174.00
$81.00
$93.00
$860.00
$239.00
$638.00
$170.00
$1,312.00
$1,364.00
$1,046.00
--------$702.00
$187.00
$696.00
$339.00
$28.00
$18.00
$10.00
$237.00
$29.00
$111.00
$25.00
$69.00
$17.00
$112.00
$66.00
$46.00
$446.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$67.00
$50.00
$54.00
$77.00
----$77.00
----$111.00
--------$211.00
$20.00
$132.00
$271.00
$199.00
$112.00
$196.00
$181.00
$428.00
$359.00
$310.00
$107.00
$203.00
$187.00
$85.00
$102.00
$908.00
$252.00
$674.00
$179.00
$1,388.00
$1,444.00
$1,107.00
--------$741.00
$197.00
$736.00
$358.00
$30.00
$20.00
$10.00
$258.00
$30.00
$120.00
$26.00
$76.00
$18.00
$120.00
$69.00
$51.00
$481.00
$70.00
$53.00
$57.00
$81.00
----$81.00
----$115.00
--------$221.00
$20.00
$137.00
$282.00
$208.00
$116.00
$203.00
$189.00
$443.00
$380.00
$325.00
$111.00
$214.00
$196.00
$88.00
$108.00
$946.00
$263.00
$703.00
$187.00
$1,449.00
$1,507.00
$1,155.00
--------$773.00
$206.00
$768.00
$374.00
$32.00
$21.00
$11.00
$270.00
$31.00
$126.00
$27.00
$80.00
$18.00
$126.00
$72.00
$54.00
$499.00
327
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
93040
93041
93042
93224
93225
93226
93227
93230
93231
93232
93233
93235
93236
93237
93268
93270
93271
93272
93278
93278-26
93278-TC
93303
93303-26
93303-TC
93304
93304-26
93304-TC
93307
93307-26
93307-TC
93308
93308-26
93308-TC
93312
93312-26
93312-TC
93313
93314
93314-26
93314-TC
93315
93315-26
93315-TC
93316
93317
93317-26
93317-TC
93318
93318-26
93318-TC
93320
93320-26
$14.00
$31.00
$9.00
$159.00
$46.00
$83.00
$50.00
$168.00
$57.00
$82.00
$55.00
$123.00
$97.00
$28.00
$109.00
$46.00
$90.00
$28.00
$58.00
$24.00
$44.00
$215.00
$70.00
$144.00
$114.00
$43.00
$73.00
$196.00
$56.00
$144.00
$118.00
$46.00
$75.00
$322.00
$140.00
$182.00
$76.00
$212.00
$65.00
$144.00
$287.00
$144.00
$141.00
$78.00
$236.00
$95.00
$141.00
BR
$114.00
BR
$86.00
$30.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$15.00
$6.00
$9.00
$169.00
$51.00
$90.00
$29.00
$180.00
$62.00
$89.00
$29.00
$131.00
$106.00
$25.00
$316.00
$51.00
$237.00
$29.00
$62.00
$14.00
$48.00
$229.00
$72.00
$157.00
$121.00
$42.00
$80.00
$208.00
$52.00
$157.00
$109.00
$30.00
$80.00
$278.00
$122.00
$156.00
$48.00
$226.00
$70.00
$156.00
----$154.00
----$49.00
----$102.00
--------$109.00
----$91.00
$21.00
$16.00
$7.00
$9.00
$186.00
$56.00
$99.00
$31.00
$197.00
$69.00
$98.00
$31.00
$143.00
$117.00
$26.00
$344.00
$56.00
$258.00
$30.00
$69.00
$15.00
$54.00
$248.00
$76.00
$173.00
$132.00
$44.00
$88.00
$227.00
$54.00
$173.00
$119.00
$32.00
$88.00
$301.00
$128.00
$173.00
$51.00
$246.00
$73.00
$173.00
----$162.00
----$52.00
----$107.00
--------$113.00
----$100.00
$22.00
$17.00
$7.00
$10.00
$197.00
$60.00
$105.00
$32.00
$209.00
$73.00
$104.00
$32.00
$150.00
$123.00
$27.00
$361.00
$60.00
$270.00
$31.00
$73.00
$16.00
$58.00
$261.00
$78.00
$183.00
$139.00
$45.00
$93.00
$239.00
$56.00
$183.00
$126.00
$33.00
$93.00
$318.00
$133.00
$185.00
$53.00
$260.00
$76.00
$185.00
----$168.00
----$54.00
----$111.00
--------$117.00
----$106.00
$23.00
$15.00
$6.00
$9.00
$169.00
$51.00
$90.00
$29.00
$180.00
$62.00
$89.00
$29.00
$131.00
$106.00
$25.00
$316.00
$51.00
$237.00
$29.00
$62.00
$14.00
$48.00
$229.00
$72.00
$157.00
$121.00
$42.00
$80.00
$208.00
$52.00
$157.00
$109.00
$30.00
$80.00
$278.00
$122.00
$156.00
$48.00
$226.00
$70.00
$156.00
----$154.00
----$49.00
----$102.00
--------$109.00
----$91.00
$21.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$16.00
$7.00
$9.00
$186.00
$56.00
$99.00
$31.00
$197.00
$69.00
$98.00
$31.00
$143.00
$117.00
$26.00
$344.00
$56.00
$258.00
$30.00
$69.00
$15.00
$54.00
$248.00
$76.00
$173.00
$132.00
$44.00
$88.00
$227.00
$54.00
$173.00
$119.00
$32.00
$88.00
$301.00
$128.00
$173.00
$51.00
$246.00
$73.00
$173.00
----$162.00
----$52.00
----$107.00
--------$113.00
----$100.00
$22.00
$17.00
$7.00
$10.00
$197.00
$60.00
$105.00
$32.00
$209.00
$73.00
$104.00
$32.00
$150.00
$123.00
$27.00
$361.00
$60.00
$270.00
$31.00
$73.00
$16.00
$58.00
$261.00
$78.00
$183.00
$139.00
$45.00
$93.00
$239.00
$56.00
$183.00
$126.00
$33.00
$93.00
$318.00
$133.00
$185.00
$53.00
$260.00
$76.00
$185.00
----$168.00
----$54.00
----$111.00
--------$117.00
----$106.00
$23.00
328
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
93320-TC
93321
93321-26
93321-TC
93325
93325-26
93325-TC
93350
93350-26
93350-TC
93501
93501-26
93501-TC
93503
93505
93505-26
93505-TC
93508
93508-26
93508-TC
93510
93510-26
93510-TC
93511
93511-26
93511-TC
93514
93514-26
93514-TC
93524
93524-26
93524-TC
93526
93526-26
93526-TC
93527
93527-26
93527-TC
93528
93528-26
93528-TC
93529
93529-26
93529-TC
93530
93530-26
93530-TC
93531
93531-26
93531-TC
93532
93532-26
$65.00
$50.00
$10.00
$42.00
$114.00
$4.00
$110.00
$216.00
$77.00
$66.00
$674.00
$160.00
$634.00
$187.00
$318.00
$248.00
$74.00
$698.00
$232.00
$469.00
$1,628.00
$247.00
$1,388.00
$1,629.00
$270.00
$1,350.00
$2,208.00
$525.00
$1,683.00
$2,150.00
$392.00
$1,766.00
$2,147.00
$363.00
$1,815.00
$2,186.00
$451.00
$1,766.00
$2,266.00
$482.00
$1,766.00
$2,032.00
$262.00
$1,766.00
$872.00
$250.00
$634.00
$2,268.00
$467.00
$1,815.00
$2,317.00
$569.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$70.00
$54.00
$9.00
$46.00
$124.00
$4.00
$119.00
$154.00
$82.00
$73.00
$861.00
$173.00
$689.00
$149.00
$332.00
$250.00
$82.00
$743.00
$235.00
$508.00
$1,755.00
$249.00
$1,506.00
$1,755.00
$289.00
$1,466.00
$1,869.00
$403.00
$1,466.00
$2,314.00
$399.00
$1,916.00
$2,312.00
$344.00
$1,968.00
$2,334.00
$418.00
$1,916.00
$2,434.00
$518.00
$1,916.00
$2,190.00
$274.00
$1,916.00
$927.00
$238.00
$689.00
$2,445.00
$476.00
$1,968.00
$2,486.00
$570.00
$78.00
$60.00
$9.00
$51.00
$137.00
$5.00
$132.00
$165.00
$85.00
$80.00
$942.00
$182.00
$759.00
$158.00
$356.00
$265.00
$91.00
$807.00
$249.00
$558.00
$1,923.00
$263.00
$1,661.00
$1,922.00
$306.00
$1,616.00
$2,042.00
$426.00
$1,616.00
$2,534.00
$422.00
$2,112.00
$2,534.00
$364.00
$2,170.00
$2,555.00
$443.00
$2,112.00
$2,661.00
$548.00
$2,112.00
$2,402.00
$289.00
$2,112.00
$1,011.00
$252.00
$759.00
$2,675.00
$504.00
$2,170.00
$2,716.00
$603.00
$83.00
$64.00
$10.00
$54.00
$146.00
$5.00
$140.00
$173.00
$88.00
$86.00
$996.00
$191.00
$805.00
$165.00
$374.00
$277.00
$97.00
$849.00
$260.00
$589.00
$2,036.00
$274.00
$1,761.00
$2,033.00
$319.00
$1,714.00
$2,159.00
$445.00
$1,714.00
$2,681.00
$440.00
$2,241.00
$2,682.00
$380.00
$2,302.00
$2,703.00
$462.00
$2,241.00
$2,813.00
$573.00
$2,241.00
$2,543.00
$302.00
$2,241.00
$1,069.00
$264.00
$805.00
$2,829.00
$527.00
$2,302.00
$2,871.00
$630.00
$70.00
$54.00
$9.00
$46.00
$124.00
$4.00
$119.00
$154.00
$82.00
$73.00
$861.00
$173.00
$689.00
$149.00
$332.00
$250.00
$82.00
$743.00
$235.00
$508.00
$1,755.00
$249.00
$1,506.00
$1,755.00
$289.00
$1,466.00
$1,869.00
$403.00
$1,466.00
$2,314.00
$399.00
$1,916.00
$2,312.00
$344.00
$1,968.00
$2,334.00
$418.00
$1,916.00
$2,434.00
$518.00
$1,916.00
$2,190.00
$274.00
$1,916.00
$927.00
$238.00
$689.00
$2,445.00
$476.00
$1,968.00
$2,486.00
$570.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$78.00
$60.00
$9.00
$51.00
$137.00
$5.00
$132.00
$165.00
$85.00
$80.00
$942.00
$182.00
$759.00
$158.00
$356.00
$265.00
$91.00
$807.00
$249.00
$558.00
$1,923.00
$263.00
$1,661.00
$1,922.00
$306.00
$1,616.00
$2,042.00
$426.00
$1,616.00
$2,534.00
$422.00
$2,112.00
$2,534.00
$364.00
$2,170.00
$2,555.00
$443.00
$2,112.00
$2,661.00
$548.00
$2,112.00
$2,402.00
$289.00
$2,112.00
$1,011.00
$252.00
$759.00
$2,675.00
$504.00
$2,170.00
$2,716.00
$603.00
$83.00
$64.00
$10.00
$54.00
$146.00
$5.00
$140.00
$173.00
$88.00
$86.00
$996.00
$191.00
$805.00
$165.00
$374.00
$277.00
$97.00
$849.00
$260.00
$589.00
$2,036.00
$274.00
$1,761.00
$2,033.00
$319.00
$1,714.00
$2,159.00
$445.00
$1,714.00
$2,681.00
$440.00
$2,241.00
$2,682.00
$380.00
$2,302.00
$2,703.00
$462.00
$2,241.00
$2,813.00
$573.00
$2,241.00
$2,543.00
$302.00
$2,241.00
$1,069.00
$264.00
$805.00
$2,829.00
$527.00
$2,302.00
$2,871.00
$630.00
329
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
93532-TC
93533
93533-26
93533-TC
93539
93540
93541
93542
93543
93544
93545
93555
93555-26
93555-TC
93556
93556-26
93556-TC
93561
93561-26
93561-TC
93562
93562-26
93562-TC
93571
93571-26
93571-TC
93572
93572-26
93572-TC
93580
93580-26
93580-TC
93581
93581-26
93581-TC
93600
93600-26
93600-TC
93602
93602-26
93602-TC
93603
93603-26
93603-TC
93609
93609-26
93609-TC
93610
93610-26
93610-TC
93612
93612-26
$1,766.00
$2,131.00
$352.00
$1,766.00
$45.00
$49.00
$38.00
$38.00
$213.00
$30.00
$240.00
$278.00
$42.00
$234.00
$414.00
$44.00
$368.00
$59.00
$47.00
$20.00
$46.00
$33.00
$13.00
$270.00
$93.00
$170.00
$222.00
$74.00
$155.00
$974.00
BR
BR
$1,303.00
BR
BR
$198.00
$129.00
$73.00
$159.00
$119.00
$42.00
$187.00
$127.00
$63.00
$578.00
$481.00
$101.00
$214.00
$166.00
$52.00
$224.00
$167.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$1,916.00
$2,296.00
$380.00
$1,916.00
$22.00
$24.00
$17.00
$17.00
$17.00
$14.00
$22.00
$300.00
$46.00
$254.00
$445.00
$47.00
$399.00
$49.00
$27.00
$22.00
$23.00
$9.00
$14.00
$288.00
$103.00
$184.00
$178.00
$85.00
$93.00
$1,049.00
--------$1,399.00
--------$202.00
$122.00
$80.00
$167.00
$122.00
$45.00
$190.00
$121.00
$69.00
$411.00
$300.00
$111.00
$228.00
$173.00
$55.00
$239.00
$173.00
$2,112.00
$2,516.00
$403.00
$2,112.00
$23.00
$25.00
$17.00
$17.00
$17.00
$15.00
$23.00
$327.00
$49.00
$279.00
$487.00
$49.00
$438.00
$53.00
$28.00
$25.00
$25.00
$9.00
$15.00
$312.00
$110.00
$203.00
$194.00
$92.00
$102.00
$1,114.00
--------$1,477.00
--------$217.00
$129.00
$88.00
$179.00
$129.00
$50.00
$204.00
$128.00
$76.00
$446.00
$323.00
$122.00
$245.00
$183.00
$61.00
$256.00
$183.00
$2,241.00
$2,664.00
$423.00
$2,241.00
$24.00
$26.00
$18.00
$18.00
$18.00
$16.00
$24.00
$345.00
$50.00
$295.00
$513.00
$51.00
$462.00
$57.00
$29.00
$27.00
$26.00
$10.00
$17.00
$329.00
$115.00
$214.00
$206.00
$98.00
$108.00
$1,168.00
--------$1,539.00
--------$228.00
$135.00
$94.00
$188.00
$135.00
$53.00
$214.00
$134.00
$80.00
$473.00
$344.00
$130.00
$257.00
$192.00
$65.00
$269.00
$192.00
$1,916.00
$2,296.00
$380.00
$1,916.00
$22.00
$24.00
$17.00
$17.00
$17.00
$14.00
$22.00
$300.00
$46.00
$254.00
$445.00
$47.00
$399.00
$49.00
$27.00
$22.00
$23.00
$9.00
$14.00
$288.00
$103.00
$184.00
$178.00
$85.00
$93.00
$1,049.00
--------$1,399.00
--------$202.00
$122.00
$80.00
$167.00
$122.00
$45.00
$190.00
$121.00
$69.00
$411.00
$300.00
$111.00
$228.00
$173.00
$55.00
$239.00
$173.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$2,112.00
$2,516.00
$403.00
$2,112.00
$23.00
$25.00
$17.00
$17.00
$17.00
$15.00
$23.00
$327.00
$49.00
$279.00
$487.00
$49.00
$438.00
$53.00
$28.00
$25.00
$25.00
$9.00
$15.00
$312.00
$110.00
$203.00
$194.00
$92.00
$102.00
$1,114.00
--------$1,477.00
--------$217.00
$129.00
$88.00
$179.00
$129.00
$50.00
$204.00
$128.00
$76.00
$446.00
$323.00
$122.00
$245.00
$183.00
$61.00
$256.00
$183.00
$2,241.00
$2,664.00
$423.00
$2,241.00
$24.00
$26.00
$18.00
$18.00
$18.00
$16.00
$24.00
$345.00
$50.00
$295.00
$513.00
$51.00
$462.00
$57.00
$29.00
$27.00
$26.00
$10.00
$17.00
$329.00
$115.00
$214.00
$206.00
$98.00
$108.00
$1,168.00
--------$1,539.00
--------$228.00
$135.00
$94.00
$188.00
$135.00
$53.00
$214.00
$134.00
$80.00
$473.00
$344.00
$130.00
$257.00
$192.00
$65.00
$269.00
$192.00
330
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
93612-TC
93613
93613-26
93613-TC
93615
93615-26
93615-TC
93616
93616-26
93616-TC
93618
93618-26
93618-TC
93619
93619-26
93619-TC
93620
93620-26
93620-TC
93621
93621-26
93621-TC
93622
93622-26
93622-TC
93623
93623-26
93623-TC
93624
93624-26
93624-TC
93631
93631-26
93631-TC
93640
93640-26
93640-TC
93641
93641-26
93641-TC
93642
93642-26
93642-TC
93650
93651
93652
93660
93660-26
93660-TC
93662
93662-26
93662-TC
$61.00
$377.00
$378.00
BR
$62.00
$49.00
$12.00
$94.00
$82.00
$12.00
$399.00
$258.00
$148.00
$717.00
$444.00
$290.00
$358.00
$272.00
$91.00
BR
$769.00
BR
BR
$771.00
BR
BR
$167.00
BR
$333.00
$256.00
$74.00
$651.00
$420.00
$239.00
$467.00
$230.00
$269.00
$613.00
$360.00
$269.00
$549.00
$295.00
$269.00
$639.00
$985.00
$1,044.00
$162.00
$103.00
$61.00
BR
$158.00
BR
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$66.00
$407.00
--------$64.00
$51.00
$13.00
$92.00
$79.00
$13.00
$406.00
$245.00
$161.00
$734.00
$420.00
$314.00
----$665.00
--------$123.00
--------$204.00
--------$163.00
----$357.00
$276.00
$81.00
$702.00
$441.00
$260.00
$493.00
$201.00
$291.00
$632.00
$341.00
$291.00
$566.00
$275.00
$291.00
$603.00
$933.00
$1,015.00
$172.00
$107.00
$65.00
----$173.00
-----
$73.00
$434.00
--------$68.00
$53.00
$15.00
$97.00
$83.00
$15.00
$437.00
$259.00
$178.00
$790.00
$444.00
$346.00
----$703.00
--------$131.00
--------$226.00
--------$173.00
----$381.00
$292.00
$90.00
$763.00
$472.00
$291.00
$533.00
$213.00
$321.00
$681.00
$360.00
$321.00
$609.00
$289.00
$321.00
$638.00
$987.00
$1,074.00
$182.00
$112.00
$70.00
----$188.00
-----
$78.00
$456.00
--------$71.00
$55.00
$16.00
$102.00
$86.00
$16.00
$459.00
$270.00
$189.00
$830.00
$464.00
$366.00
----$734.00
--------$137.00
--------$248.00
--------$180.00
----$400.00
$304.00
$95.00
$812.00
$499.00
$313.00
$562.00
$222.00
$340.00
$716.00
$376.00
$340.00
$639.00
$299.00
$340.00
$666.00
$1,031.00
$1,121.00
$189.00
$116.00
$73.00
----$203.00
-----
$66.00
$407.00
--------$64.00
$51.00
$13.00
$92.00
$79.00
$13.00
$406.00
$245.00
$161.00
$734.00
$420.00
$314.00
----$665.00
--------$123.00
--------$204.00
--------$163.00
----$357.00
$276.00
$81.00
$702.00
$441.00
$260.00
$493.00
$201.00
$291.00
$632.00
$341.00
$291.00
$566.00
$275.00
$291.00
$603.00
$933.00
$1,015.00
$172.00
$107.00
$65.00
----$173.00
-----
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$73.00
$434.00
--------$68.00
$53.00
$15.00
$97.00
$83.00
$15.00
$437.00
$259.00
$178.00
$790.00
$444.00
$346.00
----$703.00
--------$131.00
--------$226.00
--------$173.00
----$381.00
$292.00
$90.00
$763.00
$472.00
$291.00
$533.00
$213.00
$321.00
$681.00
$360.00
$321.00
$609.00
$289.00
$321.00
$638.00
$987.00
$1,074.00
$182.00
$112.00
$70.00
----$188.00
-----
$78.00
$456.00
--------$71.00
$55.00
$16.00
$102.00
$86.00
$16.00
$459.00
$270.00
$189.00
$830.00
$464.00
$366.00
----$734.00
--------$137.00
--------$248.00
--------$180.00
----$400.00
$304.00
$95.00
$812.00
$499.00
$313.00
$562.00
$222.00
$340.00
$716.00
$376.00
$340.00
$639.00
$299.00
$340.00
$666.00
$1,031.00
$1,121.00
$189.00
$116.00
$73.00
----$203.00
-----
331
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
93668
93701
93701-26
93701-TC
93720
93721
93722
93724
93724-26
93724-TC
93727
93731
93731-26
93731-TC
93732
93732-26
93732-TC
93733
93733-26
93733-TC
93734
93734-26
93734-TC
93735
93735-26
93735-TC
93736
93736-26
93736-TC
93740
93740-26
93740-TC
93741
93741-26
93741-TC
93742
93742-26
93742-TC
93743
93743-26
93743-TC
93744
93744-26
93744-TC
93760
93762
93770
93770-26
93770-TC
93784
93786
93788
BR
$36.00
$9.00
$27.00
$43.00
$27.00
$24.00
$411.00
$259.00
$148.00
$28.00
$43.00
$24.00
$18.00
$68.00
$48.00
$19.00
$38.00
$11.00
$28.00
$34.00
$21.00
$13.00
$30.00
$20.00
$7.00
$33.00
$10.00
$24.00
$17.00
$12.00
$5.00
$68.00
$33.00
$32.00
$77.00
$37.00
$43.00
$78.00
$43.00
$32.00
$88.00
$48.00
$43.00
$314.00
$378.00
NC
NC
NC
NC
NC
NC
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
----$51.00
$10.00
$41.00
$39.00
$30.00
$9.00
$439.00
$277.00
$161.00
$31.00
$46.00
$26.00
$20.00
$73.00
$52.00
$21.00
$40.00
$10.00
$31.00
$36.00
$21.00
$14.00
$61.00
$42.00
$19.00
$35.00
$9.00
$27.00
------------$72.00
$45.00
$27.00
$78.00
$51.00
$27.00
$88.00
$58.00
$30.00
$93.00
$66.00
$27.00
--------------------$45.00
$35.00
-----
----$55.00
$10.00
$45.00
$43.00
$33.00
$10.00
$469.00
$291.00
$178.00
$33.00
$50.00
$27.00
$22.00
$77.00
$54.00
$23.00
$44.00
$10.00
$34.00
$38.00
$22.00
$16.00
$65.00
$44.00
$21.00
$39.00
$9.00
$30.00
------------$77.00
$47.00
$30.00
$83.00
$53.00
$30.00
$93.00
$61.00
$33.00
$99.00
$69.00
$30.00
--------------------$49.00
$38.00
-----
----$58.00
$11.00
$47.00
$45.00
$35.00
$10.00
$491.00
$303.00
$189.00
$35.00
$52.00
$28.00
$24.00
$81.00
$56.00
$25.00
$47.00
$11.00
$36.00
$40.00
$23.00
$17.00
$68.00
$46.00
$22.00
$42.00
$10.00
$32.00
------------$80.00
$49.00
$32.00
$87.00
$55.00
$32.00
$97.00
$63.00
$35.00
$103.00
$72.00
$32.00
--------------------$51.00
$40.00
-----
----$51.00
$10.00
$41.00
$39.00
$30.00
$9.00
$439.00
$277.00
$161.00
$31.00
$46.00
$26.00
$20.00
$73.00
$52.00
$21.00
$40.00
$10.00
$31.00
$36.00
$21.00
$14.00
$61.00
$42.00
$19.00
$35.00
$9.00
$27.00
------------$72.00
$45.00
$27.00
$78.00
$51.00
$27.00
$88.00
$58.00
$30.00
$93.00
$66.00
$27.00
--------------------$45.00
$35.00
-----
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
----$55.00
$10.00
$45.00
$43.00
$33.00
$10.00
$469.00
$291.00
$178.00
$33.00
$50.00
$27.00
$22.00
$77.00
$54.00
$23.00
$44.00
$10.00
$34.00
$38.00
$22.00
$16.00
$65.00
$44.00
$21.00
$39.00
$9.00
$30.00
------------$77.00
$47.00
$30.00
$83.00
$53.00
$30.00
$93.00
$61.00
$33.00
$99.00
$69.00
$30.00
--------------------$49.00
$38.00
-----
----$58.00
$11.00
$47.00
$45.00
$35.00
$10.00
$491.00
$303.00
$189.00
$35.00
$52.00
$28.00
$24.00
$81.00
$56.00
$25.00
$47.00
$11.00
$36.00
$40.00
$23.00
$17.00
$68.00
$46.00
$22.00
$42.00
$10.00
$32.00
------------$80.00
$49.00
$32.00
$87.00
$55.00
$32.00
$97.00
$63.00
$35.00
$103.00
$72.00
$32.00
--------------------$51.00
$40.00
-----
332
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
93790
93797
93798
93799
93799-26
93799-TC
93875
93875-26
93875-TC
93880
93880-26
93880-TC
93882
93882-26
93882-TC
93886
93886-26
93886-TC
93888
93888-26
93888-TC
93922
93922-26
93922-TC
93923
93923-26
93923-TC
93924
93924-26
93924-TC
93925
93925-26
93925-TC
93926
93926-26
93926-TC
93930
93930-26
93930-TC
93931
93931-26
93931-TC
93965
93965-26
93965-TC
93970
93970-26
93970-TC
93971
93971-26
93971-TC
93975
NC
$17.00
$38.00
BR
BR
BR
$55.00
$17.00
$42.00
$176.00
$31.00
$144.00
$117.00
$21.00
$95.00
$215.00
$50.00
$162.00
$142.00
$33.00
$109.00
$60.00
$16.00
$44.00
$112.00
$28.00
$85.00
$122.00
$31.00
$92.00
$175.00
$31.00
$144.00
$117.00
$21.00
$96.00
$174.00
$26.00
$150.00
$118.00
$17.00
$101.00
$63.00
$26.00
$42.00
$189.00
$36.00
$154.00
$121.00
$23.00
$96.00
$277.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$10.00
$23.00
$31.00
------------$77.00
$12.00
$65.00
$205.00
$34.00
$171.00
$140.00
$23.00
$117.00
$237.00
$54.00
$183.00
$158.00
$35.00
$123.00
$88.00
$14.00
$74.00
$142.00
$26.00
$116.00
$174.00
$29.00
$145.00
$229.00
$33.00
$197.00
$156.00
$22.00
$135.00
$186.00
$26.00
$161.00
$132.00
$17.00
$114.00
$91.00
$19.00
$71.00
$201.00
$39.00
$163.00
$140.00
$25.00
$115.00
$322.00
$10.00
$24.00
$33.00
------------$84.00
$13.00
$72.00
$226.00
$36.00
$190.00
$154.00
$25.00
$129.00
$261.00
$57.00
$203.00
$174.00
$37.00
$137.00
$97.00
$15.00
$82.00
$156.00
$28.00
$129.00
$191.00
$31.00
$160.00
$252.00
$35.00
$218.00
$172.00
$23.00
$149.00
$207.00
$27.00
$179.00
$146.00
$19.00
$127.00
$99.00
$21.00
$79.00
$223.00
$41.00
$182.00
$155.00
$27.00
$129.00
$352.00
$11.00
$25.00
$34.00
------------$90.00
$13.00
$76.00
$241.00
$38.00
$204.00
$165.00
$26.00
$138.00
$278.00
$60.00
$218.00
$186.00
$39.00
$146.00
$104.00
$16.00
$87.00
$167.00
$29.00
$137.00
$203.00
$33.00
$170.00
$268.00
$36.00
$232.00
$183.00
$25.00
$158.00
$221.00
$29.00
$193.00
$156.00
$19.00
$136.00
$105.00
$22.00
$84.00
$239.00
$43.00
$196.00
$166.00
$28.00
$138.00
$374.00
$10.00
$10.00
$16.00
------------$77.00
$12.00
$65.00
$205.00
$34.00
$171.00
$140.00
$23.00
$117.00
$237.00
$54.00
$183.00
$158.00
$35.00
$123.00
$88.00
$14.00
$74.00
$142.00
$26.00
$116.00
$174.00
$29.00
$145.00
$229.00
$33.00
$197.00
$156.00
$22.00
$135.00
$186.00
$26.00
$161.00
$132.00
$17.00
$114.00
$91.00
$19.00
$71.00
$201.00
$39.00
$163.00
$140.00
$25.00
$115.00
$322.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$10.00
$11.00
$17.00
------------$84.00
$13.00
$72.00
$226.00
$36.00
$190.00
$154.00
$25.00
$129.00
$261.00
$57.00
$203.00
$174.00
$37.00
$137.00
$97.00
$15.00
$82.00
$156.00
$28.00
$129.00
$191.00
$31.00
$160.00
$252.00
$35.00
$218.00
$172.00
$23.00
$149.00
$207.00
$27.00
$179.00
$146.00
$19.00
$127.00
$99.00
$21.00
$79.00
$223.00
$41.00
$182.00
$155.00
$27.00
$129.00
$352.00
$11.00
$11.00
$17.00
------------$90.00
$13.00
$76.00
$241.00
$38.00
$204.00
$165.00
$26.00
$138.00
$278.00
$60.00
$218.00
$186.00
$39.00
$146.00
$104.00
$16.00
$87.00
$167.00
$29.00
$137.00
$203.00
$33.00
$170.00
$268.00
$36.00
$232.00
$183.00
$25.00
$158.00
$221.00
$29.00
$193.00
$156.00
$19.00
$136.00
$105.00
$22.00
$84.00
$239.00
$43.00
$196.00
$166.00
$28.00
$138.00
$374.00
333
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
93975-26
93975-TC
93976
93976-26
93976-TC
93978
93978-26
93978-TC
93979
93979-26
93979-TC
93980
93980-26
93980-TC
93981
93981-26
93981-TC
93990
93990-26
93990-TC
94010
94010-26
94010-TC
94014
94015
94016
94060
94060-26
94060-TC
94070
94070-26
94070-TC
94150
94150-26
94150-TC
94200
94200-26
94200-TC
94240
94240-26
94240-TC
94250
94250-26
94250-TC
94260
94260-26
94260-TC
94350
94350-26
94350-TC
94360
94360-26
$89.00
$181.00
$184.00
$59.00
$121.00
$177.00
$34.00
$143.00
$122.00
$23.00
$98.00
$183.00
$65.00
$105.00
$148.00
$25.00
$124.00
$110.00
$14.00
$96.00
$30.00
$12.00
$16.00
$39.00
$14.00
$26.00
$57.00
$18.00
$36.00
$32.00
$11.00
$19.00
$8.00
$6.00
$3.00
$17.00
$7.00
$9.00
$43.00
$15.00
$26.00
$12.00
$8.00
$5.00
$27.00
$8.00
$18.00
$36.00
$14.00
$20.00
$37.00
$11.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$100.00
$221.00
$197.00
$67.00
$131.00
$183.00
$37.00
$146.00
$130.00
$26.00
$105.00
$239.00
$69.00
$171.00
$216.00
$24.00
$192.00
$149.00
$14.00
$135.00
$42.00
$9.00
$33.00
$60.00
$32.00
$28.00
$73.00
$17.00
$57.00
$195.00
$32.00
$163.00
------------$30.00
$6.00
$24.00
$85.00
$14.00
$71.00
$32.00
$6.00
$26.00
$28.00
$7.00
$21.00
$87.00
$14.00
$74.00
$35.00
$14.00
$106.00
$246.00
$216.00
$70.00
$146.00
$203.00
$39.00
$164.00
$144.00
$27.00
$117.00
$262.00
$73.00
$189.00
$238.00
$25.00
$212.00
$164.00
$15.00
$149.00
$45.00
$10.00
$36.00
$64.00
$34.00
$29.00
$80.00
$17.00
$62.00
$211.00
$34.00
$177.00
------------$33.00
$6.00
$26.00
$92.00
$15.00
$78.00
$35.00
$6.00
$28.00
$31.00
$8.00
$23.00
$94.00
$15.00
$80.00
$39.00
$15.00
$112.00
$262.00
$230.00
$73.00
$157.00
$218.00
$42.00
$176.00
$155.00
$29.00
$126.00
$279.00
$76.00
$202.00
$252.00
$26.00
$225.00
$174.00
$16.00
$158.00
$48.00
$10.00
$37.00
$66.00
$36.00
$31.00
$84.00
$18.00
$66.00
$220.00
$35.00
$185.00
------------$34.00
$7.00
$28.00
$96.00
$15.00
$81.00
$36.00
$7.00
$30.00
$33.00
$8.00
$25.00
$98.00
$15.00
$83.00
$41.00
$15.00
$100.00
$221.00
$197.00
$67.00
$131.00
$183.00
$37.00
$146.00
$130.00
$26.00
$105.00
$239.00
$69.00
$171.00
$216.00
$24.00
$192.00
$149.00
$14.00
$135.00
$42.00
$9.00
$33.00
$60.00
$32.00
$28.00
$73.00
$17.00
$57.00
$195.00
$32.00
$163.00
------------$30.00
$6.00
$24.00
$85.00
$14.00
$71.00
$32.00
$6.00
$26.00
$28.00
$7.00
$21.00
$87.00
$14.00
$74.00
$35.00
$14.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$106.00
$246.00
$216.00
$70.00
$146.00
$203.00
$39.00
$164.00
$144.00
$27.00
$117.00
$262.00
$73.00
$189.00
$238.00
$25.00
$212.00
$164.00
$15.00
$149.00
$45.00
$10.00
$36.00
$64.00
$34.00
$29.00
$80.00
$17.00
$62.00
$211.00
$34.00
$177.00
------------$33.00
$6.00
$26.00
$92.00
$15.00
$78.00
$35.00
$6.00
$28.00
$31.00
$8.00
$23.00
$94.00
$15.00
$80.00
$39.00
$15.00
$112.00
$262.00
$230.00
$73.00
$157.00
$218.00
$42.00
$176.00
$155.00
$29.00
$126.00
$279.00
$76.00
$202.00
$252.00
$26.00
$225.00
$174.00
$16.00
$158.00
$48.00
$10.00
$37.00
$66.00
$36.00
$31.00
$84.00
$18.00
$66.00
$220.00
$35.00
$185.00
------------$34.00
$7.00
$28.00
$96.00
$15.00
$81.00
$36.00
$7.00
$30.00
$33.00
$8.00
$25.00
$98.00
$15.00
$83.00
$41.00
$15.00
334
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
94360-TC
94370
94370-26
94370-TC
94375
94375-26
94375-TC
94400
94400-26
94400-TC
94450
94450-26
94450-TC
94620
94620-26
94620-TC
94621
94621-26
94621-TC
94640
94642
94656
94657
94660
94662
94664
94667
94668
94680
94680-26
94680-TC
94681
94681-26
94681-TC
94690
94690-26
94690-TC
94720
94720-26
94720-TC
94725
94725-26
94725-TC
94750
94750-26
94750-TC
94760
94761
94762
94770
94770-26
94770-TC
$26.00
$33.00
$18.00
$12.00
$34.00
$16.00
$17.00
$40.00
$24.00
$14.00
$37.00
$20.00
$15.00
$91.00
$38.00
$54.00
$122.00
$71.00
$52.00
$19.00
BR
$75.00
$44.00
$54.00
$38.00
$18.00
$23.00
$16.00
$47.00
$23.00
$22.00
$60.00
$12.00
$43.00
$24.00
$4.00
$20.00
$49.00
$15.00
$31.00
$79.00
$14.00
$64.00
$37.00
$14.00
$21.00
$9.00
$20.00
$30.00
$21.00
$9.00
$12.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$21.00
$87.00
$14.00
$73.00
$39.00
$17.00
$23.00
$53.00
$21.00
$32.00
$44.00
$21.00
$22.00
$125.00
$34.00
$91.00
$144.00
$76.00
$68.00
$28.00
----$63.00
$44.00
$58.00
$40.00
$21.00
$33.00
$28.00
$86.00
$14.00
$72.00
$121.00
$11.00
$110.00
$86.00
$4.00
$82.00
$73.00
$14.00
$59.00
$114.00
$14.00
$100.00
$90.00
$12.00
$78.00
$4.00
$9.00
$32.00
$74.00
$8.00
$66.00
$24.00
$93.00
$15.00
$79.00
$42.00
$17.00
$25.00
$57.00
$22.00
$35.00
$47.00
$23.00
$25.00
$135.00
$36.00
$100.00
$154.00
$80.00
$75.00
$30.00
----$67.00
$46.00
$61.00
$42.00
$24.00
$36.00
$31.00
$94.00
$15.00
$79.00
$132.00
$12.00
$120.00
$94.00
$4.00
$89.00
$79.00
$15.00
$64.00
$124.00
$15.00
$110.00
$98.00
$13.00
$85.00
$5.00
$11.00
$37.00
$81.00
$8.00
$72.00
$26.00
$97.00
$15.00
$82.00
$44.00
$18.00
$26.00
$60.00
$23.00
$37.00
$49.00
$24.00
$26.00
$142.00
$37.00
$105.00
$162.00
$83.00
$79.00
$32.00
----$70.00
$48.00
$63.00
$43.00
$25.00
$39.00
$32.00
$98.00
$16.00
$83.00
$139.00
$12.00
$126.00
$98.00
$5.00
$93.00
$83.00
$15.00
$68.00
$131.00
$15.00
$116.00
$102.00
$13.00
$88.00
$6.00
$12.00
$40.00
$85.00
$9.00
$76.00
$21.00
$87.00
$14.00
$73.00
$39.00
$17.00
$23.00
$53.00
$21.00
$32.00
$44.00
$21.00
$22.00
$125.00
$34.00
$91.00
$144.00
$76.00
$68.00
$28.00
----$63.00
$44.00
$41.00
$40.00
$21.00
$33.00
$28.00
$86.00
$14.00
$72.00
$121.00
$11.00
$110.00
$86.00
$4.00
$82.00
$73.00
$14.00
$59.00
$114.00
$14.00
$100.00
$90.00
$12.00
$78.00
$4.00
$9.00
$32.00
$74.00
$8.00
$66.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$24.00
$93.00
$15.00
$79.00
$42.00
$17.00
$25.00
$57.00
$22.00
$35.00
$47.00
$23.00
$25.00
$135.00
$36.00
$100.00
$154.00
$80.00
$75.00
$30.00
----$67.00
$46.00
$43.00
$42.00
$24.00
$36.00
$31.00
$94.00
$15.00
$79.00
$132.00
$12.00
$120.00
$94.00
$4.00
$89.00
$79.00
$15.00
$64.00
$124.00
$15.00
$110.00
$98.00
$13.00
$85.00
$5.00
$11.00
$37.00
$81.00
$8.00
$72.00
$26.00
$97.00
$15.00
$82.00
$44.00
$18.00
$26.00
$60.00
$23.00
$37.00
$49.00
$24.00
$26.00
$142.00
$37.00
$105.00
$162.00
$83.00
$79.00
$32.00
----$70.00
$48.00
$44.00
$43.00
$25.00
$39.00
$32.00
$98.00
$16.00
$83.00
$139.00
$12.00
$126.00
$98.00
$5.00
$93.00
$83.00
$15.00
$68.00
$131.00
$15.00
$116.00
$102.00
$13.00
$88.00
$6.00
$12.00
$40.00
$85.00
$9.00
$76.00
335
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
94799
94799-26
94799-TC
95004
95010
95015
95024
95027
95028
95044
95052
95056
95060
95065
95070
95071
95075
95078
95115
95117
95120
95125
95130
95131
95132
95133
95134
95144
95145
95146
95147
95148
95149
95165
95170
95180
95199
95250
95805
95805-26
95805-TC
95806
95806-26
95806-TC
95807
95807-26
95807-TC
95808
95808-26
95808-TC
95810
95810-26
BR
BR
BR
$3.00
$11.00
$11.00
$3.00
$5.00
$8.00
$7.00
$9.00
$6.00
$13.00
$7.00
$82.00
$105.00
$82.00
$9.00
$10.00
$9.00
BR
BR
BR
BR
BR
BR
BR
$9.00
$17.00
$24.00
$33.00
$32.00
$36.00
$7.00
$13.00
$103.00
BR
$114.00
$334.00
$94.00
$237.00
$232.00
$109.00
$137.00
$367.00
$98.00
$256.00
$456.00
$149.00
$256.00
$521.00
$183.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
------------$4.00
$23.00
$21.00
$6.00
$6.00
$9.00
$8.00
$10.00
$7.00
$14.00
$8.00
$88.00
$112.00
$71.00
$11.00
$16.00
$20.00
----------------------------$12.00
$22.00
$26.00
$35.00
$34.00
$42.00
$11.00
$13.00
$143.00
----$124.00
$747.00
$103.00
$643.00
$239.00
$90.00
$149.00
$545.00
$89.00
$457.00
$629.00
$146.00
$483.00
$825.00
$192.00
------------$5.00
$25.00
$22.00
$7.00
$7.00
$10.00
$9.00
$11.00
$8.00
$16.00
$9.00
$95.00
$121.00
$75.00
$12.00
$18.00
$22.00
----------------------------$13.00
$23.00
$28.00
$37.00
$37.00
$45.00
$11.00
$14.00
$150.00
----$133.00
$806.00
$108.00
$698.00
$260.00
$94.00
$166.00
$592.00
$93.00
$499.00
$680.00
$153.00
$527.00
$890.00
$201.00
------------$5.00
$26.00
$23.00
$7.00
$7.00
$11.00
$10.00
$12.00
$8.00
$17.00
$10.00
$99.00
$126.00
$78.00
$13.00
$19.00
$23.00
----------------------------$14.00
$24.00
$29.00
$39.00
$38.00
$47.00
$12.00
$15.00
$155.00
----$138.00
$840.00
$112.00
$728.00
$275.00
$98.00
$178.00
$620.00
$96.00
$524.00
$711.00
$158.00
$553.00
$929.00
$209.00
------------$4.00
$9.00
$9.00
$6.00
$6.00
$9.00
$8.00
$10.00
$7.00
$14.00
$8.00
$88.00
$112.00
$54.00
$11.00
$16.00
$20.00
----------------------------$4.00
$4.00
$4.00
$4.00
$4.00
$4.00
$4.00
$4.00
$113.00
----$124.00
$747.00
$103.00
$643.00
$239.00
$90.00
$149.00
$545.00
$89.00
$457.00
$629.00
$146.00
$483.00
$825.00
$192.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
------------$5.00
$9.00
$9.00
$7.00
$7.00
$10.00
$9.00
$11.00
$8.00
$16.00
$9.00
$95.00
$121.00
$57.00
$12.00
$18.00
$22.00
----------------------------$4.00
$4.00
$4.00
$4.00
$4.00
$4.00
$4.00
$4.00
$119.00
----$133.00
$806.00
$108.00
$698.00
$260.00
$94.00
$166.00
$592.00
$93.00
$499.00
$680.00
$153.00
$527.00
$890.00
$201.00
------------$5.00
$10.00
$10.00
$7.00
$7.00
$11.00
$10.00
$12.00
$8.00
$17.00
$10.00
$99.00
$126.00
$59.00
$13.00
$19.00
$23.00
----------------------------$4.00
$4.00
$5.00
$4.00
$5.00
$5.00
$4.00
$4.00
$122.00
----$138.00
$840.00
$112.00
$728.00
$275.00
$98.00
$178.00
$620.00
$96.00
$524.00
$711.00
$158.00
$553.00
$929.00
$209.00
336
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
95810-TC
95811
95811-26
95811-TC
95812
95812-26
95812-TC
95813
95813-26
95813-TC
95816
95816-26
95816-TC
95819
95819-26
95819-TC
95822
95822-26
95822-TC
95824
95824-26
95824-TC
95827
95827-26
95827-TC
95829
95829-26
95829-TC
95830
95831
95832
95833
95834
95851
95852
95857
95858
95858-26
95858-TC
95860
95860-26
95860-TC
95861
95861-26
95861-TC
95863
95863-26
95863-TC
95864
95864-26
95864-TC
95867
$256.00
$644.00
$196.00
$423.00
$137.00
$58.00
$68.00
$177.00
$89.00
$68.00
$133.00
$54.00
$78.00
$115.00
$58.00
$56.00
$120.00
$58.00
$63.00
$51.00
$41.00
$10.00
$145.00
$59.00
$86.00
$328.00
$291.00
$6.00
$133.00
$26.00
$21.00
$34.00
$44.00
$18.00
$14.00
$40.00
$65.00
$56.00
$10.00
$73.00
$53.00
$15.00
$113.00
$86.00
$28.00
$138.00
$102.00
$35.00
$177.00
$114.00
$67.00
$66.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$633.00
$851.00
$206.00
$645.00
$230.00
$62.00
$168.00
$298.00
$99.00
$199.00
$189.00
$63.00
$127.00
$214.00
$63.00
$151.00
$246.00
$63.00
$183.00
----$44.00
----$154.00
$60.00
$93.00
$1,798.00
$352.00
$1,446.00
$207.00
$32.00
$29.00
$42.00
$47.00
$29.00
$23.00
$47.00
$107.00
$90.00
$17.00
$102.00
$56.00
$47.00
$121.00
$90.00
$31.00
$147.00
$109.00
$39.00
$189.00
$116.00
$73.00
$70.00
$689.00
$918.00
$217.00
$702.00
$248.00
$66.00
$182.00
$320.00
$104.00
$216.00
$204.00
$66.00
$138.00
$230.00
$66.00
$164.00
$265.00
$66.00
$199.00
----$47.00
----$166.00
$63.00
$103.00
$1,928.00
$372.00
$1,556.00
$220.00
$34.00
$31.00
$45.00
$50.00
$31.00
$25.00
$50.00
$113.00
$94.00
$19.00
$109.00
$59.00
$51.00
$129.00
$95.00
$34.00
$157.00
$114.00
$43.00
$202.00
$121.00
$81.00
$75.00
$720.00
$958.00
$225.00
$734.00
$259.00
$68.00
$191.00
$333.00
$108.00
$225.00
$213.00
$68.00
$144.00
$240.00
$68.00
$172.00
$277.00
$68.00
$209.00
----$49.00
----$175.00
$65.00
$109.00
$1,997.00
$388.00
$1,609.00
$228.00
$35.00
$32.00
$46.00
$51.00
$32.00
$26.00
$51.00
$118.00
$98.00
$20.00
$114.00
$61.00
$53.00
$135.00
$98.00
$37.00
$163.00
$118.00
$45.00
$211.00
$126.00
$86.00
$79.00
$633.00
$851.00
$206.00
$645.00
$230.00
$62.00
$168.00
$298.00
$99.00
$199.00
$189.00
$63.00
$127.00
$214.00
$63.00
$151.00
$246.00
$63.00
$183.00
----$44.00
----$154.00
$60.00
$93.00
$1,798.00
$352.00
$1,446.00
$99.00
$17.00
$17.00
$28.00
$35.00
$10.00
$7.00
$31.00
$107.00
$90.00
$17.00
$102.00
$56.00
$47.00
$121.00
$90.00
$31.00
$147.00
$109.00
$39.00
$189.00
$116.00
$73.00
$70.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$689.00
$918.00
$217.00
$702.00
$248.00
$66.00
$182.00
$320.00
$104.00
$216.00
$204.00
$66.00
$138.00
$230.00
$66.00
$164.00
$265.00
$66.00
$199.00
----$47.00
----$166.00
$63.00
$103.00
$1,928.00
$372.00
$1,556.00
$105.00
$17.00
$17.00
$29.00
$37.00
$11.00
$7.00
$32.00
$113.00
$94.00
$19.00
$109.00
$59.00
$51.00
$129.00
$95.00
$34.00
$157.00
$114.00
$43.00
$202.00
$121.00
$81.00
$75.00
$720.00
$958.00
$225.00
$734.00
$259.00
$68.00
$191.00
$333.00
$108.00
$225.00
$213.00
$68.00
$144.00
$240.00
$68.00
$172.00
$277.00
$68.00
$209.00
----$49.00
----$175.00
$65.00
$109.00
$1,997.00
$388.00
$1,609.00
$109.00
$18.00
$18.00
$30.00
$39.00
$11.00
$8.00
$34.00
$118.00
$98.00
$20.00
$114.00
$61.00
$53.00
$135.00
$98.00
$37.00
$163.00
$118.00
$45.00
$211.00
$126.00
$86.00
$79.00
337
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
95867-26
95867-TC
95868
95868-26
95868-TC
95869
95869-26
95869-TC
95870
95870-26
95870-TC
95872
95872-26
95872-TC
95875
95875-26
95875-TC
95900
95900-26
95900-TC
95903
95903-26
95903-TC
95904
95904-26
95904-TC
95920
95920-26
95920-TC
95921
95921-26
95921-TC
95922
95922-26
95922-TC
95923
95923-26
95923-TC
95925
95925-26
95925-TC
95926
95926-26
95926-TC
95927
95927-26
95927-TC
95930
95930-26
95930-TC
95933
95933-26
$43.00
$21.00
$96.00
$71.00
$26.00
$29.00
$21.00
$8.00
$29.00
$21.00
$8.00
$104.00
$81.00
$22.00
$43.00
$34.00
$7.00
$37.00
$24.00
$10.00
$43.00
$33.00
$9.00
$31.00
$20.00
$8.00
$168.00
$118.00
$48.00
$61.00
$46.00
$14.00
$65.00
$50.00
$14.00
$105.00
$47.00
$57.00
$94.00
$53.00
$41.00
$66.00
$34.00
$34.00
$67.00
$34.00
$34.00
$44.00
$25.00
$11.00
$62.00
$33.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$46.00
$24.00
$98.00
$69.00
$29.00
$31.00
$22.00
$9.00
$30.00
$21.00
$9.00
$111.00
$86.00
$25.00
$114.00
$64.00
$50.00
$61.00
$24.00
$37.00
$67.00
$35.00
$32.00
$51.00
$20.00
$32.00
$180.00
$127.00
$53.00
$66.00
$50.00
$16.00
$71.00
$55.00
$16.00
$150.00
$52.00
$98.00
$69.00
$31.00
$37.00
$69.00
$32.00
$37.00
$70.00
$33.00
$37.00
$60.00
$20.00
$40.00
$66.00
$34.00
$49.00
$26.00
$104.00
$72.00
$32.00
$33.00
$23.00
$10.00
$32.00
$22.00
$10.00
$118.00
$90.00
$28.00
$122.00
$67.00
$55.00
$65.00
$26.00
$40.00
$71.00
$37.00
$34.00
$55.00
$21.00
$34.00
$193.00
$135.00
$58.00
$70.00
$53.00
$17.00
$75.00
$58.00
$17.00
$160.00
$55.00
$106.00
$74.00
$33.00
$41.00
$74.00
$33.00
$41.00
$76.00
$35.00
$41.00
$64.00
$21.00
$43.00
$72.00
$36.00
$51.00
$28.00
$109.00
$75.00
$34.00
$34.00
$23.00
$11.00
$34.00
$23.00
$11.00
$123.00
$93.00
$30.00
$128.00
$70.00
$58.00
$68.00
$26.00
$42.00
$74.00
$38.00
$36.00
$57.00
$21.00
$36.00
$203.00
$142.00
$61.00
$73.00
$55.00
$18.00
$78.00
$60.00
$18.00
$166.00
$57.00
$110.00
$78.00
$34.00
$44.00
$78.00
$34.00
$44.00
$80.00
$36.00
$44.00
$67.00
$22.00
$45.00
$75.00
$37.00
$46.00
$24.00
$98.00
$69.00
$29.00
$31.00
$22.00
$9.00
$30.00
$21.00
$9.00
$111.00
$86.00
$25.00
$114.00
$64.00
$50.00
$61.00
$24.00
$37.00
$67.00
$35.00
$32.00
$51.00
$20.00
$32.00
$180.00
$127.00
$53.00
$66.00
$50.00
$16.00
$71.00
$55.00
$16.00
$150.00
$52.00
$98.00
$69.00
$31.00
$37.00
$69.00
$32.00
$37.00
$70.00
$33.00
$37.00
$60.00
$20.00
$40.00
$66.00
$34.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$49.00
$26.00
$104.00
$72.00
$32.00
$33.00
$23.00
$10.00
$32.00
$22.00
$10.00
$118.00
$90.00
$28.00
$122.00
$67.00
$55.00
$65.00
$26.00
$40.00
$71.00
$37.00
$34.00
$55.00
$21.00
$34.00
$193.00
$135.00
$58.00
$70.00
$53.00
$17.00
$75.00
$58.00
$17.00
$160.00
$55.00
$106.00
$74.00
$33.00
$41.00
$74.00
$33.00
$41.00
$76.00
$35.00
$41.00
$64.00
$21.00
$43.00
$72.00
$36.00
$51.00
$28.00
$109.00
$75.00
$34.00
$34.00
$23.00
$11.00
$34.00
$23.00
$11.00
$123.00
$93.00
$30.00
$128.00
$70.00
$58.00
$68.00
$26.00
$42.00
$74.00
$38.00
$36.00
$57.00
$21.00
$36.00
$203.00
$142.00
$61.00
$73.00
$55.00
$18.00
$78.00
$60.00
$18.00
$166.00
$57.00
$110.00
$78.00
$34.00
$44.00
$78.00
$34.00
$44.00
$80.00
$36.00
$44.00
$67.00
$22.00
$45.00
$75.00
$37.00
338
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
95933-TC
95934
95934-26
95934-TC
95936
95936-26
95936-TC
95937
95937-26
95937-TC
95950
95950-26
95950-TC
95951
95951-26
95951-TC
95953
95953-26
95953-TC
95954
95954-26
95954-TC
95955
95955-26
95955-TC
95956
95956-26
95956-TC
95957
95957-26
95957-TC
95958
95958-26
95958-TC
95961
95961-26
95961-TC
95962
95962-26
95962-TC
95965
95965-26
95965-TC
95966
95966-26
95966-TC
95967
95967-26
95967-TC
95970
95971
95972
$30.00
$36.00
$28.00
$8.00
$39.00
$30.00
$8.00
$40.00
$31.00
$9.00
$265.00
$84.00
$177.00
$34.00
$14.00
$20.00
$411.00
$165.00
$240.00
$208.00
$134.00
$23.00
$130.00
$59.00
$74.00
$541.00
$166.00
$314.00
$171.00
$104.00
$64.00
$296.00
$230.00
$66.00
$216.00
$166.00
$48.00
$227.00
$176.00
$48.00
BR
$420.00
BR
BR
$210.00
BR
BR
$184.00
BR
$22.00
$39.00
$78.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$32.00
$39.00
$30.00
$9.00
$41.00
$32.00
$9.00
$51.00
$37.00
$14.00
$342.00
$89.00
$253.00
----$347.00
----$437.00
$177.00
$260.00
$297.00
$142.00
$155.00
$138.00
$57.00
$82.00
$746.00
$178.00
$568.00
$185.00
$115.00
$70.00
$317.00
$245.00
$72.00
$231.00
$178.00
$53.00
$243.00
$190.00
$53.00
----$451.00
--------$225.00
--------$197.00
----$26.00
$45.00
$91.00
$36.00
$42.00
$32.00
$10.00
$44.00
$34.00
$10.00
$54.00
$39.00
$16.00
$374.00
$94.00
$280.00
----$365.00
----$473.00
$186.00
$287.00
$318.00
$150.00
$168.00
$151.00
$60.00
$91.00
$806.00
$187.00
$619.00
$198.00
$121.00
$77.00
$338.00
$258.00
$80.00
$247.00
$189.00
$58.00
$259.00
$201.00
$58.00
----$474.00
--------$236.00
--------$207.00
----$27.00
$48.00
$98.00
$38.00
$44.00
$33.00
$11.00
$46.00
$35.00
$11.00
$57.00
$40.00
$17.00
$396.00
$98.00
$298.00
----$378.00
----$498.00
$193.00
$305.00
$331.00
$156.00
$175.00
$160.00
$62.00
$97.00
$842.00
$194.00
$648.00
$208.00
$126.00
$82.00
$354.00
$269.00
$85.00
$259.00
$198.00
$61.00
$271.00
$210.00
$61.00
----$493.00
--------$246.00
--------$215.00
----$29.00
$50.00
$105.00
$32.00
$39.00
$30.00
$9.00
$41.00
$32.00
$9.00
$51.00
$37.00
$14.00
$342.00
$89.00
$253.00
----$347.00
----$437.00
$177.00
$260.00
$297.00
$142.00
$155.00
$138.00
$57.00
$82.00
$746.00
$178.00
$568.00
$185.00
$115.00
$70.00
$317.00
$245.00
$72.00
$231.00
$178.00
$53.00
$243.00
$190.00
$53.00
----$451.00
--------$225.00
--------$197.00
----$25.00
$43.00
$87.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$36.00
$42.00
$32.00
$10.00
$44.00
$34.00
$10.00
$54.00
$39.00
$16.00
$374.00
$94.00
$280.00
----$365.00
----$473.00
$186.00
$287.00
$318.00
$150.00
$168.00
$151.00
$60.00
$91.00
$806.00
$187.00
$619.00
$198.00
$121.00
$77.00
$338.00
$258.00
$80.00
$247.00
$189.00
$58.00
$259.00
$201.00
$58.00
----$474.00
--------$236.00
--------$207.00
----$27.00
$45.00
$94.00
$38.00
$44.00
$33.00
$11.00
$46.00
$35.00
$11.00
$57.00
$40.00
$17.00
$396.00
$98.00
$298.00
----$378.00
----$498.00
$193.00
$305.00
$331.00
$156.00
$175.00
$160.00
$62.00
$97.00
$842.00
$194.00
$648.00
$208.00
$126.00
$82.00
$354.00
$269.00
$85.00
$259.00
$198.00
$61.00
$271.00
$210.00
$61.00
----$493.00
--------$246.00
--------$215.00
----$28.00
$48.00
$101.00
339
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
95973
95974
95975
95990
95999
96000
96001
96002
96003
96004
96100
96105
96110
96111
96115
96117
96370
96400
96405
96406
96408
96410
96412
96414
96420
96422
96423
96425
96440
96445
96450
96520
96530
96542
96545
96549
96567
96570
96571
96900
96902
96910
96912
96913
96920
96921
96922
96999
97001
97002
97003
97004
2003 MRA
$47.00
$155.00
$88.00
$57.00
BR
$93.00
$111.00
$21.00
$20.00
$97.00
$68.00
$68.00
$88.00
$68.00
$68.00
$68.00
See formula
$20.00
$57.00
$86.00
$36.00
$5.00
$43.00
$50.00
$46.00
$46.00
$17.00
$54.00
$156.00
$157.00
$134.00
$33.00
$49.00
$126.00
BR
BR
$62.00
$69.00
$38.00
$17.00
$24.00
$21.00
$24.00
$53.00
$152.00
$155.00
$214.00
BR
$62.00
$29.00
$62.00
$29.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
$56.00
$177.00
$99.00
$60.00
----$99.00
$118.00
$23.00
$21.00
$121.00
$75.00
$75.00
----$75.00
$75.00
$75.00
----$39.00
$86.00
$130.00
$40.00
$63.00
$47.00
$54.00
$51.00
$50.00
$19.00
$58.00
$403.00
$395.00
$319.00
$37.00
$43.00
$211.00
--------$197.00
$60.00
$31.00
$20.00
----$62.00
$71.00
$108.00
$160.00
$164.00
$227.00
----$78.00
$42.00
$83.00
$51.00
$59.00
$187.00
$105.00
$65.00
----$103.00
$123.00
$25.00
$23.00
$127.00
$83.00
$83.00
----$83.00
$83.00
$83.00
----$42.00
$92.00
$138.00
$44.00
$69.00
$52.00
$60.00
$56.00
$56.00
$21.00
$64.00
$431.00
$422.00
$340.00
$40.00
$47.00
$225.00
--------$212.00
$63.00
$32.00
$22.00
----$67.00
$77.00
$118.00
$172.00
$176.00
$243.00
----$83.00
$44.00
$88.00
$54.00
$62.00
$195.00
$109.00
$69.00
----$106.00
$126.00
$26.00
$24.00
$132.00
$90.00
$90.00
----$90.00
$90.00
$90.00
----$44.00
$95.00
$143.00
$46.00
$73.00
$55.00
$64.00
$60.00
$59.00
$22.00
$68.00
$447.00
$437.00
$352.00
$43.00
$50.00
$233.00
--------$220.00
$65.00
$34.00
$23.00
----$70.00
$81.00
$124.00
$179.00
$183.00
$254.00
----$86.00
$46.00
$91.00
$56.00
$53.00
$177.00
$99.00
$60.00
----$99.00
$118.00
$23.00
$21.00
$121.00
$75.00
$75.00
----$75.00
$75.00
$75.00
----$39.00
$30.00
$44.00
$40.00
$63.00
$47.00
$54.00
$51.00
$50.00
$19.00
$58.00
$139.00
$129.00
$113.00
$37.00
$43.00
$80.00
--------$197.00
$60.00
$30.00
$20.00
----$62.00
$71.00
$108.00
$67.00
$68.00
$122.00
----$68.00
$34.00
$66.00
$32.00
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
$57.00
$187.00
$105.00
$65.00
----$103.00
$123.00
$25.00
$23.00
$127.00
$83.00
$83.00
----$83.00
$83.00
$83.00
----$42.00
$32.00
$46.00
$44.00
$69.00
$52.00
$60.00
$56.00
$56.00
$21.00
$64.00
$147.00
$136.00
$119.00
$40.00
$47.00
$84.00
--------$212.00
$63.00
$32.00
$22.00
----$67.00
$77.00
$118.00
$72.00
$73.00
$131.00
----$71.00
$36.00
$69.00
$34.00
$60.00
$195.00
$109.00
$69.00
----$106.00
$126.00
$26.00
$24.00
$132.00
$90.00
$90.00
----$90.00
$90.00
$90.00
----$44.00
$33.00
$48.00
$46.00
$73.00
$55.00
$64.00
$60.00
$59.00
$22.00
$68.00
$154.00
$141.00
$123.00
$43.00
$50.00
$87.00
--------$220.00
$65.00
$33.00
$23.00
----$70.00
$81.00
$124.00
$76.00
$77.00
$138.00
----$74.00
$37.00
$72.00
$35.00
340
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
97005
97006
97010
97012
97014
97016
97018
97020
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97260
97261
97504
97520
97530
97532
97533
97535
97537
97542
97545
97546
97601
97602
97703
97750
97752
97780
97781
97799
97802
97803
97804
97850
97851
97852
2003 MRA
NC
NC
$10.00
$16.00
$14.00
$15.00
$10.00
$10.00
$15.00
$10.00
$9.00
$10.00
$16.00
$16.00
$13.00
$11.00
$19.00
$15.00
$22.00
$23.00
$24.00
$21.00
$19.00
$15.00
$26.00
$18.00
$23.00
$17.00
$23.00
$23.00
$22.00
$22.00
$24.00
$23.00
$23.00
$17.00
$83.00
$41.00
$42.00
BR
$15.00
BR
$48.00
$32.00
BR
BR
$26.00
$17.00
$7.00
$54.00
$26.00
$54.00
Locality 01/02
Locality 03
Locality 04
(Non-Facility MRA)
(Non-Facility MRA)
(Non-Facility MRA)
(Facility MRA)
------------$16.00
----$15.00
$7.00
$5.00
$16.00
$5.00
$5.00
$6.00
$17.00
$22.00
$15.00
$13.00
$24.00
$13.00
$30.00
$31.00
$32.00
$26.00
$24.00
$17.00
$28.00
$20.00
--------$30.00
$29.00
$30.00
$26.00
$27.00
$33.00
$29.00
$29.00
--------$42.00
----$24.00
$31.00
----------------$19.00
$19.00
$7.00
-------------
------------$17.00
----$16.00
$8.00
$6.00
$17.00
$6.00
$6.00
$7.00
$18.00
$23.00
$16.00
$14.00
$26.00
$13.00
$32.00
$32.00
$34.00
$28.00
$25.00
$18.00
$30.00
$21.00
--------$32.00
$31.00
$32.00
$27.00
$28.00
$34.00
$30.00
$31.00
--------$45.00
----$25.00
$32.00
----------------$20.00
$20.00
$8.00
-------------
------------$17.00
----$17.00
$8.00
$6.00
$17.00
$6.00
$6.00
$7.00
$19.00
$24.00
$16.00
$14.00
$27.00
$14.00
$33.00
$34.00
$36.00
$29.00
$26.00
$19.00
$31.00
$22.00
--------$34.00
$32.00
$33.00
$28.00
$29.00
$36.00
$31.00
$32.00
--------$47.00
----$26.00
$34.00
----------------$21.00
$21.00
$9.00
-------------
------------$16.00
----$15.00
$7.00
$5.00
$16.00
$5.00
$5.00
$6.00
$17.00
$22.00
$15.00
$13.00
$24.00
$13.00
$30.00
$31.00
$32.00
$26.00
$24.00
$17.00
$28.00
$20.00
--------$30.00
$29.00
$30.00
$26.00
$27.00
$33.00
$29.00
$29.00
--------$42.00
----$24.00
$31.00
----------------$19.00
$19.00
$7.00
-------------
Cpt only © 2002 American Medical Association. All rights reserved.
Locality 01/02 Locality 03
Locality 04
(Facility MRA) (Facility MRA)
------------$17.00
----$16.00
$8.00
$6.00
$17.00
$6.00
$6.00
$7.00
$18.00
$23.00
$16.00
$14.00
$26.00
$13.00
$32.00
$32.00
$34.00
$28.00
$25.00
$18.00
$30.00
$21.00
--------$32.00
$31.00
$32.00
$27.00
$28.00
$34.00
$30.00
$31.00
--------$45.00
----$25.00
$32.00
----------------$20.00
$20.00
$8.00
-------------
------------$17.00
----$17.00
$8.00
$6.00
$17.00
$6.00
$6.00
$7.00
$19.00
$24.00
$16.00
$14.00
$27.00
$14.00
$33.00
$34.00
$36.00
$29.00
$26.00
$19.00
$31.00
$22.00
--------$34.00
$32.00
$33.00
$28.00
$29.00
$36.00
$31.00
$32.00
--------$47.00
----$26.00
$34.00
----------------$21.00
$21.00
$9.00
-------------
341
Florida's Workers' Compensation Health Care Provider Reimbursement Manual, 2004 Edition
Medicine
CPT Code
2003 MRA
97853
98925
98926
98927
98928
98929
98940
98941
98942
98943
99000
99001
99002
99025
99026
99027
99070
99071
99075
99078
99080
99082
99090
99091
99141
99142
99172
99173
99175
99183